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Morgan DJ, Scherer L, Pineles L, Baghdadi J, Magder L, Thom K, Koch C, Wilkins N, LeGrand M, Stevens D, Walker R, Shirrell B, Harris AD, Korenstein D. Game-based learning to improve diagnostic accuracy: a pilot randomized-controlled trial. Diagnosis (Berl) 2024; 11:136-141. [PMID: 38284830 PMCID: PMC11075046 DOI: 10.1515/dx-2023-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Perform a pilot study of online game-based learning (GBL) using natural frequencies and feedback to teach diagnostic reasoning. METHODS We conducted a multicenter randomized-controlled trial of computer-based training. We enrolled medical students, residents, practicing physicians and nurse practitioners. The intervention was a 45 min online GBL training vs. control education with a primary outcome of score on a scale of diagnostic accuracy (composed of 10 realistic case vignettes, requesting estimates of probability of disease after a test result, 0-100 points total). RESULTS Of 90 participants there were 30 students, 30 residents and 30 practicing clinicians. Of these 62 % (56/90) were female and 52 % (47/90) were white. Sixty were randomized to GBL intervention and 30 to control. The primary outcome of diagnostic accuracy immediately after training was better in GBL (mean accuracy score 59.4) vs. control (37.6), p=0.0005. The GBL group was then split evenly (30, 30) into no further intervention or weekly emails with case studies. Both GBL groups performed better than control at one-month and some continued effect at three-month follow up. Scores at one-month GBL (59.2) GBL plus emails (54.2) vs. control (33.9), p=0.024; three-months GBL (56.2), GBL plus emails (42.9) vs. control (35.1), p=0.076. Most participants would recommend GBL to colleagues (73 %), believed it was enjoyable (92 %) and believed it improves test interpretation (95 %). CONCLUSIONS In this pilot study, a single session with GBL nearly doubled score on a scale of diagnostic accuracy in medical trainees and practicing clinicians. The impact of GBL persisted after three months.
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Affiliation(s)
- Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- VA Maryland Healthcare System, Baltimore, MD, USA
| | - Laura Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Denver, CO, USA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jon Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kerri Thom
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christina Koch
- Division of General Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Deborah Stevens
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Renee Walker
- Visual Communication Design, Thomas Jefferson University, Philadelphia, PA, USA
| | - Beth Shirrell
- Visual Communication Design, Thomas Jefferson University, Philadelphia, PA, USA
| | - Anthony D. Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah Korenstein
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Advani SD, Ratz D, Horowitz JK, Petty LA, Fakih MG, Schmader K, Mody L, Czilok T, Malani AN, Flanders SA, Gandhi TN, Vaughn VM. Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria. JAMA Netw Open 2024; 7:e242283. [PMID: 38477915 PMCID: PMC10938177 DOI: 10.1001/jamanetworkopen.2024.2283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/23/2024] [Indexed: 03/14/2024] Open
Abstract
Importance Guidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB), including among patients with altered mental status (AMS) and no systemic signs of infection. However, ASB treatment remains common. Objectives To determine prevalence and factors associated with bacteremia from a presumed urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB. Design, Setting, and Participants This cohort study assessed patients hospitalized to nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023. Main Outcomes and Measures The primary outcome was prevalence of bacteremia from a presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine culture). To determine factors associated with bacteremia, we used multivariable logistic regression models. We estimated each patient's risk of bacteremia and determined what percentage of patients empirically treated with antibiotics had less than 2% estimated risk of bacteremia. Results Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595 female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients [1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia. No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia. Conclusions and Relevance In patients with ASB, bacteremia from a presumed urinary source was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to empiric therapy could decrease unnecessary ASB treatment.
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Affiliation(s)
- Sonali D. Advani
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - David Ratz
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | - Lindsay A. Petty
- Division of Infectious Diseases, University of Michigan, Ann Arbor
| | | | - Kenneth Schmader
- Division of Geriatrics, Duke University School of Medicine, and Durham Veterans Affairs Healthcare System, Durham, North Carolina
| | - Lona Mody
- Division of Geriatrics, University of Michigan, Ann Arbor
| | - Tawny Czilok
- Division of Hospital Medicine, University of Michigan, Ann Arbor
| | | | | | - Tejal N. Gandhi
- Division of Infectious Diseases, University of Michigan, Ann Arbor
| | - Valerie M. Vaughn
- Division of Hospital Medicine, University of Michigan, Ann Arbor
- Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City
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3
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Scott IA, Crock C, Twining M. Too much versus too little: looking for the "sweet spot" in optimal use of diagnostic investigations. Med J Aust 2024; 220:67-70. [PMID: 38146617 DOI: 10.5694/mja2.52193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/23/2023] [Indexed: 12/27/2023]
Affiliation(s)
- Ian A Scott
- Centre for Health Services Research, University of Queensland, Brisbane, QLD
- Princess Alexandra Hospital, Brisbane, QLD
| | - Carmel Crock
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC
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Schinas G, Dimopoulos G, Akinosoglou K. Understanding and Implementing Diagnostic Stewardship: A Guide for Resident Physicians in the Era of Antimicrobial Resistance. Microorganisms 2023; 11:2214. [PMID: 37764058 PMCID: PMC10537711 DOI: 10.3390/microorganisms11092214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Antimicrobial resistance (AMR) poses a significant global health challenge, exacerbated by the COVID-19 pandemic. Antimicrobial stewardship programs (ASPs) are crucial in managing this crisis, with diagnostic stewardship (DS) emerging as a key component. DS refers to the appropriate use of diagnostic tests to optimize patient outcomes, improve antimicrobial use, and combat multi-drug-resistant (MDR) organisms. Despite its potential, understanding and application of DS remain ambiguous in multiple respects, which, however, do not directly implicate the implementation of such initiatives. DS is particularly important for resident physicians who are often at the forefront of patient care and can significantly influence future AMR strategies. This review provides a comprehensive overview of DS, discussing its importance, potential challenges, and future directions. It emphasizes the need for resident physicians to understand DS principles and integrate them into their clinical practice from the beginning of their careers. The review also highlights the role of various stakeholders in implementing DS and the importance of continuous education and training. Ultimately, DS is not just a clinical tool but a philosophy of care, essential for a more responsive, humane, and effective healthcare system.
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Affiliation(s)
| | - George Dimopoulos
- 3rd Department of Critical Care, EVGENIDIO Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Karolina Akinosoglou
- School of Medicine, University of Patras, 26504 Patras, Greece;
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
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Baghdadi JD, Tripathi R, Pineles L, Harris AD, Palacio D, Charles D, Claeys KC, Heil E, Bork J, Morgan DJ. Developing a diagnosis calculator to estimate the probability of bacterial pneumonia. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e137. [PMID: 37592970 PMCID: PMC10428145 DOI: 10.1017/ash.2023.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 08/19/2023]
Abstract
Misdiagnosis of bacterial pneumonia increases risk of exposure to inappropriate antibiotics and adverse events. We developed a diagnosis calculator (https://calculator.testingwisely.com) to inform clinical diagnosis of community-acquired bacterial pneumonia using objective indicators, including incidence of disease, risk factors, and sensitivity and specificity of diagnostic tests, that were identified through literature review.
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Affiliation(s)
- Jonathan D. Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ravi Tripathi
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- VA Maryland Healthcare System, Baltimore, MD, USA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anthony D. Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Danica Palacio
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Drew Charles
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kimberly C. Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Emily Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jackie Bork
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- VA Maryland Healthcare System, Baltimore, MD, USA
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- VA Maryland Healthcare System, Baltimore, MD, USA
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Navanandan N, McNulty MC, Suresh K, Freeman J, Scherer LD, Tyler A. Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics. Clin Pediatr (Phila) 2022; 62:329-337. [PMID: 36199256 PMCID: PMC10073349 DOI: 10.1177/00099228221128074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.
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Affiliation(s)
- Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Monica C McNulty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Krithika Suresh
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, CO, USA
| | - Julia Freeman
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura D Scherer
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Tyler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Section of Pediatric Hospital Medicine, Children's Hospital of Colorado, Aurora, CO, USA
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7
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Kenaa B, O’Hara NN, O’Hara LM, Claeys KC, Leekha S. Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e120. [PMID: 36483413 PMCID: PMC9726546 DOI: 10.1017/ash.2022.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Ventilator-associated pneumonia (VAP) can be overdiagnosed on the basis of positive respiratory cultures in the absence of clinical findings of pneumonia. We determined the perceived diagnostic importance of 6 clinical attributes in ordering a respiratory culture to identify opportunities for diagnostic stewardship. DESIGN A discrete choice experiment presented participants with a vignette consisting of the same "stem" plus variations in 6 clinical attributes associated with VAP: chest imaging, oxygenation, sputum, temperature, white blood cell count, and blood pressure. Each attribute had 3-4 levels, resulting in 32 total scenarios. Participants indicated whether they would order a respiratory culture, and if yes, whether they preferred the bronchoalveolar lavage or endotracheal aspirate sample-collection method. We calculated diagnostic utility of attribute levels and relative importance of each attribute. SETTING AND PARTICIPANTS The survey was administered electronically to critical-care clinicians via a Qualtrics survey at a tertiary-care academic center in the United States. RESULTS In total, 59 respondents completed the survey. New radiograph opacity (utility, 1.15; 95% confidence interval [CI], 0.99-1.3), hypotension (utility, 0.88; 95% CI, 0.74-1.03), fever (utility, 0.76; 95% CI, 0.62-0.91) and copious sputum (utility, 0.75; 95% CI, 0.60-0.90) had the greatest perceived diagnostic value that favored ordering a respiratory culture. Radiograph changes (23%) and temperature (20%) had the highest relative importance. New opacity (utility, 0.35; 95% CI, 0.17-0.52) and persistent opacity on radiograph (utility, 0.32; 95% CI, 0.05-0.59) had the greatest value favoring bronchoalveolar lavage over endotracheal aspirate. CONCLUSION Perceived high diagnostic value of fever and hypotension suggest that sepsis vigilance may drive respiratory culturing and play a role in VAP overdiagnosis.
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Affiliation(s)
- Blaine Kenaa
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan N. O’Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lyndsay M. O’Hara
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kimberly C. Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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8
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Baghdadi JD, Korenstein D, Pineles L, Scherer LD, Lydecker AD, Magder L, Stevens DN, Morgan DJ. Exploration of Primary Care Clinician Attitudes and Cognitive Characteristics Associated With Prescribing Antibiotics for Asymptomatic Bacteriuria. JAMA Netw Open 2022; 5:e2214268. [PMID: 35622364 PMCID: PMC9142875 DOI: 10.1001/jamanetworkopen.2022.14268] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/11/2022] [Indexed: 01/21/2023] Open
Abstract
Importance Antibiotic treatment for asymptomatic bacteriuria is not recommended in guidelines but is a major driver of inappropriate antibiotic use. Objective To evaluate whether clinician culture and personality traits are associated with a predisposition toward inappropriate prescribing. Design, Setting, and Participants This survey study involved secondary analysis of a previously completed survey. A total of 723 primary care clinicians in active practice in Texas, the Mid-Atlantic, and the Pacific Northwest, including physicians and advanced practice clinicians, were surveyed from June 1, 2018, to November 26, 2019, regarding their approach to a hypothetical patient with asymptomatic bacteriuria. Clinician culture was represented by training background and region of practice. Attitudes and cognitive characteristics were represented using validated instruments to assess numeracy, risk-taking preferences, burnout, and tendency to maximize care. Data were analyzed from November 8, 2021, to March 29, 2022. Interventions The survey described a male patient with asymptomatic bacteriuria and changes in urine character. Clinicians were asked to indicate whether they would prescribe antibiotics. Main Outcomes and Measures The main outcome was self-reported willingness to prescribe antibiotics for asymptomatic bacteriuria. Willingness to prescribe antibiotics was hypothesized to be associated with clinician characteristics, background, and attitudes, including orientation on the Medical Maximizer-Minimizer Scale. Individuals with a stronger orientation toward medical maximizing prefer treatment even when the value of treatment is ambiguous. Results Of the 723 enrolled clinicians, 551 (median age, 32 years [IQR, 29-44 years]; 292 [53%] female; 296 [54%] White) completed the survey (76% response rate), including 288 resident physicians, 202 attending physicians, and 61 advanced practice clinicians. A total of 303 respondents (55%) were from the Mid-Atlantic, 136 (25%) were from Texas, and 112 (20%) were from the Pacific Northwest. A total of 392 clinicians (71% of respondents) indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria in the absence of an indication. In multivariable analyses, clinicians with a background in family medicine (odds ratio [OR], 2.93; 95% CI, 1.53-5.62) or a high score on the Medical Maximizer-Minimizer Scale (indicating stronger medical maximizing orientation; OR, 2.06; 95% CI, 1.38-3.09) were more likely to prescribe antibiotic treatment for asymptomatic bacteriuria. Resident physicians (OR, 0.57; 95% CI, 0.38-0.85) and clinicians in the Pacific Northwest (OR, 0.49; 95% CI, 0.33-0.72) were less likely to prescribe antibiotics for asymptomatic bacteriuria. Conclusions and Relevance The findings of this survey study suggest that most primary care clinicians prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria in the absence of risk factors. This tendency is more pronounced among family medicine physicians and medical maximizers and is less common among resident physicians and clinicians in the US Pacific Northwest. Clinician characteristics should be considered when designing antibiotic stewardship interventions.
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Affiliation(s)
- Jonathan D. Baghdadi
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
- Veterans Affairs (VA) Maryland Healthcare System, Baltimore
| | - Deborah Korenstein
- Division of General Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
| | - Laura D. Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Aurora
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Denver, Colorado
| | - Alison D. Lydecker
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
| | - Deborah N. Stevens
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
- Veterans Affairs (VA) Maryland Healthcare System, Baltimore
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