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Inappropriate antibiotic prescribing can lead to emergence of antibiotic resistance, adverse drug reactions, development of opportunistic infections like C. diff, and add to unnecessary healthcare costs. Hence, the need for antibiotic stewardship programs.
One area of inappropriate antibiotic prescribing where attention has been focused is asymptomatic bacteriuria. Guidelines from the Infectious Diseases Society of America (Nicolle 2019) and Choosing Wisely recommend we do not treat asymptomatic bacteriuria with antibiotics.
But University of Maryland researchers recently identified a disturbing trend regarding how physicians approach asymptomatic bacteriuria. Baghdadi and colleagues (Baghdadi 2022) reported the results of a survey of 723 primary care clinicians (physicians and advanced practice clinicians) in active practice regarding their approach to a hypothetical patient with asymptomatic bacteriuria. Results were striking. 71% of respondents indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria in the absence of an indication. The tendency was more pronounced among family medicine physicians and those with a high score on the Medical Maximizer-Minimizer Scale (individuals with a stronger orientation toward medical maximizing prefer treatment even when the value of treatment is ambiguous). The tendency was less common among resident physicians and clinicians in the US Pacific Northwest.
The authors suggest that clinician characteristics should be considered when designing antibiotic stewardship interventions. Specifically, physician culture (rather than urine culture) may be an important determinant of inappropriate prescribing. The concept of medical maximizers was especially of interest. Medical maximizers favor errors of commission over errors of omission, preferring to treat even when treatment has uncertain value and may introduce a chance of harm. The authors note that their finding of an association between medical maximizing and inappropriate antibiotic prescribing is important because it suggests that certain tendencies among clinicians may pose a barrier to initiatives, such as Choosing Wisely, that are intended to combat the emergence of antimicrobial resistance.
Though not specifically addressing the issue of prescribing antibiotics for asymptomatic bacteriuria, there have been several other recent studies addressing physician characteristics related to inappropriate antibiotic prescribing. In our May 24, 2022 Patient Safety Tip of the Week Requiring Indication for Antibiotic Prescribing we noted a study (Neels 2020) citing many factors that contribute to inappropriate antibiotic prescribing in general practice. These include automatic repeat prescriptions, inappropriate durations and quantities and the extended period of time during which a prescription may be filled. In addition, some prescriptions are dispensed more than 60 days after the prescription date, suggesting likely usage for an alternate indication to that intended by the prescriber. Patient expectations may also lead to inappropriate antibiotic prescribing. They implemented an educational intervention in a large general practice clinic in Australia. It included face-to-face education sessions with physicians on antimicrobial stewardship principles, antimicrobial resistance, current prescribing guidelines and microbiological testing. This resulted in a significant reduction in prescriptions without a listed indication for antimicrobial therapy, prescriptions without appropriate accompanying microbiological tests and the provision of unnecessary repeat prescriptions. There were significant improvements in appropriate antimicrobial selection, appropriate duration, and compliance with guidelines. And two recent studies in BMJ Quality & Safety discussed factors related to long-term and repeat antibiotic prescriptions in primary care in the UK (Krockow 2022, Van Staa 2022).
Some of our prior columns on antibiotic stewardship:
Our other columns on urinary catheter-associated UTIs:
· May 8, 2007 Tip of the Week Doctor, when do I get this red rubber hose removed?
· January 8, 2008 Tip of the Week Urinary Catheter-Associated Infections
·
April 2008 Whats New in the Patient Safety
World column More
on Nosocomial UTIs
· June 24, 2008 Tip of the Week Urinary Catheter-Related UTIs: Bladder Bundles
· April 21, 2009 Tip of the Week Still Futzing with Foleys?
· June 9, 2009 Tip of the Week CDC Update to the Guideline for Prevention of CAUTI
· March 2010 IDSA CAUTI Guidelines
· February 2011 Whats New in the Patient Safety World column Catheters Not Needed in C-Sections?
·
January
2012 CAUTIs Still Get No Respect
·
May 2012
Foley Catheter Hazards
·
November
2012 CAUTI
Conundrum
·
December
18, 2012 Unintended Consequences of the CAUTI Measure?
·
January
2013 Silver-Coated Urinary Catheters Dont Reduce
CAUTIs
·
June
2013 Barriers to CAUTI Prevention
·
November
2013 Further Reducing Urinary Catheter Use
·
June
2014 Updated HAI Prevention Guidelines from
SHEA/IDSA
·
June 30,
2015 What Are Appropriate Indications for Urinary
Catheters?
·
December
2015 CAUTI
Prevention Tools
·
July
2016 Holy
Moly, My Patient has a FOLEY!
·
December
2016 The
Joint Commission NPSG for CAUTIs
·
April 3,
2018 Cost
of a CAUTI
·
September
25, 2018 Foley
Follies
·
April
30, 2019 Reducing Unnecessary Urine
Cultures
·
March 2,
2021 Barriers to Timely Catheter
Removal
·
March
2022 Urinary Catheter Reinsertion
References:
Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis 2019; 68(10): e83-e110
https://academic.oup.com/cid/article/68/10/1611/5481760
Choosing Wisely Campaign. Infectious Diseases Society of America. Dont treat asymptomatic bacteruria with antibiotics. Released February 23, 2015
Baghdadi JD, Korenstein D, Pineles L, et al. Exploration of Primary Care Clinician Attitudes and Cognitive Characteristics Associated With Prescribing Antibiotics for Asymptomatic Bacteriuria. JAMA Netw Open 2022; 5(5): e2214268
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792752?resultClick=3
Neels AJ, Bloch AE, Gwini SM, Athen E. The effectiveness of a simple antimicrobial
stewardship intervention in general practice in Australia: a pilot study. BMC Infectious Diseases 2020; 20: 586
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05309-8
Krockow EM, Harvey EJ, Ashiru-Oredope D. Addressing long-term and repeat antibiotic prescriptions in primary care: considerations for a behavioural approach. BMJ Quality & Safety 2022; Published Online First: 15 June 2022
https://qualitysafety.bmj.com/content/early/2022/06/14/bmjqs-2022-014821
Van Staa T, Li Y, Gold N, et al. Comparing antibiotic prescribing between clinicians in UK primary care: an analysis in a cohort study of eight different measures of antibiotic prescribing. BMJ Quality & Safety 2022; Published Online First: 03 March 2022
https://qualitysafety.bmj.com/content/early/2022/03/02/bmjqs-2020-012108
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