E D I T O R I A L C O M M E N T A R Y

Doing the Right Thing for Asymptomatic Bacteriuria:Knowing Less Leads to Doing Less

Aanand D. Naik1,2 and Barbara W. Trautner1,2

1Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and 2Department of Medicine, Baylor College ofMedicine, Houston, Texas

(See the Brief Report by Leis et al on pages 980–3.)

Keywords. clinical practice guidelines; asymptomatic bacteriuria; asymmetric paternalism; behavioral economics; decisionpsychology.

Clinical practice guidelines are thepreferred method among professionalsocieties for defining safe and effectivehealthcare. Despite widespread dissemina-tion by professional societies, the impactof guidelines on routine clinical practiceremains suboptimal [1]. The InfectiousDiseases Society of America guidelinesfor asymptomatic bacteriuria (ASB) area particularly salient example [2], withone-third to two-thirds of patients withASB inappropriately receiving treatmentwith antimicrobial agents [3, 4]. Urinecultures are often ordered reflexivelywhen patients are admitted to the hospitalor have any change in status in long-termcare, regardless of the absence of urinarysymptoms [3–5]. Clinicians react topositive results on these cultures byprescribing unnecessary antimicrobialagents, frequently swayed by guidelines-

discordant cognitive biases regardingolder age and frailty, pyuria on urinalysis,and the particular types of bacterial organ-isms (eg, gram-negative rods) on urineculture results [3, 5].In this context, the very simple inter-

vention by Leis et al [6] published in thisedition of Clinical Infectious Diseases isparticularly elegant. The authors exploredthe effectiveness of suppressing reportingof urine culture results when ordered fornoncatheterized patients. Instead of re-ceiving urine culture results as the defaultoption, clinicians received a standardizedstatement declaring, “The majority ofpositive urine cultures from inpatientswithout an indwelling urinary catheterrepresent asymptomatic bacteriuria” [6].They were encouraged to call the microbi-ology laboratory if they “strongly suspect-ed” a urinary tract infection. The positiveresults of this study are provocative onmany levels. First, they confirm the signif-icantly higher prevalence of ASB (86%) vsurinary tract infections (14%) among the74 cultures from patients without urinarycatheters. Second, in patients whose urinecultures were reported openly, as per thestandard approach, nearly half of all pa-tients with confirmed ASB received anti-biotics. Third, the intervention design

had a strong effect on clinician behavior.When the default of reporting culture re-sults was removed, the rate of guidelines-discordant treatment for ASB droppedfrom 48% to 12%, and clinicians calledthe microbiology laboratory for only14% (5 of 37) of suppressed culture re-sults. Only 4 urinary tract infections oc-curred in noncatheterized patients, andin each of these cases clinicians had em-pirically started therapy, with the pre-sumption that clinically significantsymptoms of urinary tract infection werepresent. Furthermore, no untreated pa-tients had clinically significant signs ofsepsis or urinary tract infection 72 hoursafter urine culture collection.

The study has limitations that shouldbe addressed prior to conducting alarge-scale evaluation. The investigatorsacknowledge that they studied a smallsample of patients and clinicians at onlyone institution. The rationale for usingpatients with urinary catheters as thecomparison group to the interventionsample of noncatheterized patients isnot clear. Treatment decisions may differbetween these groups in ways that are bet-ter explained by clinical factors ratherthan customary and default decision er-rors. Finally, any large-scale intervention

Received 13 December 2013; accepted 29 December 2013;electronically published 26 February 2014.

Correspondence: Barbara Trautner, MD, PhD, HoustonHealth Services Research and Development Center of Excel-lence (152), Michael E. DeBakey VAMC, 2002 HolcombeBlvd, Houston, TX 77030 (trautner@bcm.edu).

Clinical Infectious Diseases 2014;58(7):984–5Published by Oxford University Press on behalf of the InfectiousDiseases Society of America 2014. Thiswork iswritten by (a) USGovernment employee(s) and is in the public domain in the US.DOI: 10.1093/cid/ciu011

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trial will encounter both safety and ethi-cal challenges requiring tight oversight bya data and safety management board tofollow the outcomes of patients who donot receive therapy after a urine cultureis ordered but not reported [7].

Interventions to improve concordancewith clinical practice guidelines are oftencomplex, with multiple components and/or clinical targets. An alternative ap-proach adapted from behavioral eco-nomics advocates the selective use of“asymmetric paternalism to improvehealth behaviors [8].” Asymmetric pater-nalism is a policy approach that attemptsto help individuals achieve their owngoals, especially when individuals areprone to decisional biases and errors,without actually limiting choices or free-doms. The most common strategy con-sists of reframing the description ofchoices to bias decision making in favorof more beneficial options [8, 9]. Inother words, the provider is presentedwith information selectively in a mannerthat makes the right choice the most ob-vious and easy one to select [7]. For ex-ample, the microbiology laboratory atour institution only displays the sensitiv-ities of an organism for antibiotics on ourformulary, so that providers will choosefrom among agents readily available atour hospital.

Asymmetric paternalism is new termbut an old concept. A poem by EmilyDickinson (1830–1886) exhorts us to“Tell all the Truth,” but to reveal thetruth gradually rather than all at once,lest the full truth “dazzle” the recipient’seyes. The study by Leis et al [6] representsan interesting proof-of-concept study forthe use of asymmetric paternalism to re-duce inappropriate treatment of ASB. Be-cause positive results from urinalysis andurine cultures for ASB are likely to triggercognitive biases favoring initiation vswithholding treatment, it may be prudentto change the standard and default prac-tices regarding ordering and reporting of

urine culture results in patients with like-ly ASB. The study’s change in the defaultoption likely forced clinicians to more de-liberately reassess the pretest probabilityof urinary tract infection vs ASB. If phy-sicians do not really want the results,there is no need to present them with apositive urine culture that will blindthem to the lack of urinary-associatedsymptoms and trigger inappropriate pre-scribing behavior [7].Behavioral economics approaches have

limitations [9].Changes to default optionsare effective at avoiding biases and errors,but they need to be coupled with an inter-vention that can correct the source ofthese errors to ensure a more lasting effect.Clinicians make errors (treat ASB with an-tibiotics) when they use the wrong clinicalcues (patient is a frail older adult) or rulesof thumb (treat when pyuria is present onurinalysis) to guide their decisions [5].We are currently testing a brief “fastand frugal” algorithm [10] to alert clini-cians to guidelines-concordant symp-toms of urinary tract infections andembedding the algorithm within anaudit and feedback intervention to reducetreatment for ASB [5, 11]. Our study, likethe one by Leis et al [6], highlights theimportance of integrating evidence-based theories from the social and behav-ioral sciences to ensure safe and effectivehealthcare. In the bigger picture, inter-ventions that lead to fewer courses of un-necessary antibiotics given in hospitalsettings may in turn decrease the ratesof Clostridium difficile and multidrug-resistant infections. Now, that in truthwould be a dazzling result.

Notes

Disclaimer. The opinions expressed arethose of the authors and do not necessarily repre-sent those of the Department of Veterans Affairs.The funding source had no role in the prepara-tion, review, or approval of the manuscript.Financial support. This work was supported

in part by the Center for Innovations in Quality,

Effectiveness and Safety (CIN 13–413) at the Mi-chael E. DeBakey VAMC.Potential conflicts of interest. Both authors:

No reported conflicts.Both authors have submitted the ICMJE Form

for Disclosure of Potential Conflicts of Interest.Conflicts that the editors consider relevant to thecontent of the manuscript have been disclosed.

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