For many years now, health authorities around the world have been trying to reduce the overuse of antibiotics in cases where they're not strictly needed, but a new study shows the message still isn't getting through – even within the medical community.
The problem is a serious one. In addition to the risk of side effects when antibiotics are prescribed unnecessarily, the specter of antibiotic resistance is a growing concern in global health, already constituting the third leading cause of death worldwide by some estimates.
Against that backdrop, it's easy to understand why organizations like the Centers for Disease Control and Prevention (CDC) are mounting efforts to improve antibiotics awareness, as overuse of these medications is helping to spur the more than 2.8 million antibiotic-resistant infections that take place annually in the US, thousands of which become fatal.
Unfortunately, we still have a long way to go, as the results of a new survey conducted by researchers at the University of Maryland School of Medicine reveal.
In the survey, which was completed by 551 primary care clinicians in active practice at medical facilities in Texas, the Mid-Atlantic, and the Pacific Northwest, the participants were presented with a number of hypothetical clinical scenarios.
One of these hypothetical scenarios involved Mr. Williams, a 65-year-old patient, who presents with asymptomatic bacteriuria: a medical condition in which large numbers of bacteria are present in the urine, but there are no symptoms to suggest a urinary tract infection.
Clinical practice guidelines in the US stipulate that in the absence of specific risk factors, a patient like Mr. Williams shouldn't be given antibiotics.
But in the survey, a clear majority (71 percent) of the respondents who completed the survey indicated that they would prescribe antibiotics to Mr. Williams.
"Our study suggests that primary care clinicians do not follow widely accepted recommendations against prescribing antibiotics for asymptomatic bacteriuria," says lead author of the study and epidemiologist Jonathan Baghdadi.
"Some primary clinicians may be unaware of these recommendations, but a culture of inappropriate prescribing is also likely a contributing factor."
According to the researchers, the tendency to prescribe antibiotics was most common among attending physicians, family medicine physicians, and clinicians who lived outside the Pacific Northwest.
"However, most clinicians, regardless of degree type, years in practice, or geographic region, reported being willing to prescribe inappropriate antibiotics," the authors write, noting that campaigns to advise doctors not to treat asymptomatic bacteriuria with antibiotics appear to have failed.
There are a number of reasons why a doctor might inappropriately prescribe an unnecessary antibiotic, the team says.
Previous studies have shown physicians may feel a need to meet their patient's expectations, or feel that the public health argument to not prescribe antibiotics does not translate to the bedside.
In other cases, a doctor might simply misdiagnose the patient based on the facts available, thinking that antibiotics are required for a condition, when in fact they are not recommended.
"Overwhelmingly, clinicians who indicated they would prescribe antibiotics estimated that the patient had a high probability of having a UTI, although the case details did not support this diagnosis," the researchers explain in their paper.
"We suspect that many clinicians in our sample were not aware of what constitutes UTI symptoms or were not aware that symptoms are required to substantiate a UTI diagnosis."
Current residents – medicine graduates still in training in hospitals – were less likely to prescribe antibiotics in the survey, suggesting that, as more recent students of the medical training system, they may have better absorbed more recent information on the appropriate management of asymptomatic bacteriuria.
But clinicians' attitudes and cognitive characteristics also play a part, the researchers say, with doctors who function as 'medical maximizers' more likely to inappropriately prescribe antibiotics in the hypothetical scenario.
"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 researchers explain.
For this reason, the researchers think future interventions designed to discourage over-prescription of antibiotics might benefit from targeting the mindset of medical maximizers more specifically, who may be more resistant to the current messaging used in campaigns.
Of course, there are a number of limitations to be aware of here, which the researchers acknowledge in their study – chiefly, that their survey only involved a hypothetical clinical scenario, and how the respondents answered the question doesn't necessarily reflect how they would treat a living patient in front of them.
Even so, it seems there's clearly a lot more work to be done in educating professional physicians on the issue of appropriate antibiotic use, at least in this one medical context, if not in others.
When seven out of 10 doctors get the same thing wrong, we have a job ahead of us.
The findings are reported in JAMA Network Open.