Survey shows most PCPs prescribe unnecessary antibiotics for asymptomatic bacteriuria

Roughly seven out of 10 primary care clinicians would inappropriately prescribe antibiotic treatment for asymptomatic bacteriuria, even for patients without risk factors, according to researchers.

Jonathan Baghdadi, MD, PhD, an infectious disease physician and hospital epidemiologist at the University of Maryland Medical Center and informatics hospital epidemiologist at the Baltimore VA, and colleagues reported their findings in JAMA Network Open.

For the study, the researchers surveyed 551 primary care clinicians in the United States from June 1, 2018, to Nov. 26, 2019, to assess their approach to a hypothetical patient with asymptomatic bacteriuria.

Typically, in cases without specific risk factors, antibiotic treatment for asymptomatic bacteriuria is not indicated and not recommended in guidelines, Baghdadi and colleagues wrote. Still, antibiotic treatment is commonly prescribed for these patients, the researchers added.

Overall, 392 clinicians — or 71% of respondents — indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria, even in “the absence of an indication,” the researchers wrote.

Multivariable analyses suggested that other clinician factors, such as location of a practice, might contribute to one’s willingness to prescribe antibiotics in these scenarios, with clinicians in the Pacific Northwest being less likely to prescribe antibiotics than those in other regions (OR = 0.49; 95% CI, 0.33-0.72).

In addition, the researchers found that clinicians with a background in family medicine were more likely to prescribe antibiotics than internists (OR = 2.93; 95% CI, 1.53-5.62), and resident physicians were less likely to prescribe antibiotics than attending physicians (OR = 0.57; 95% CI, 0.38-0.85).

However, most clinicians, regardless of other factors, reported that they were willing to prescribe inappropriate antibiotics, which suggests that “the Choosing Wisely campaign recommending against antibiotic treatment for asymptomatic bacteriuria has failed to make an impact in the U.S.,” Baghdadi and colleagues wrote.

Inappropriate prescribing could come from clinicians misinterpreting the meaning of diagnostic test results. The researchers noted that “willingness to prescribe inappropriate antibiotics among our study sample likely reflects a knowledge gap.” Many clinicians who said they would prescribe antibiotics when given the hypothetical case believed that the patient had a high probability of having a UTI, despite the case details not supporting this diagnosis.

On their own, knowledge gaps probably do not explain everything, though. Clinicians have stated several reasons for inappropriate prescribing, like “a desire to meet their patient’s perceived expectations,” according to the researchers. It also may come from diagnostic uncertainty, like when a patient cannot provide an accurate symptom history, they added.

These results “suggest that most primary care clinicians would contradict widely accepted guidelines by prescribing antibiotics for asymptomatic bacteriuria in the absence of risk factors,” the researchers concluded.