Rx for Doctors: Stop With the Urine Tests

By Paula Span, The New York Times, October 14, 2019.

It’s such a common routine in a doctor’s office or clinic or hospital that patients tend to comply without thinking: Step on the scale, roll up your sleeve for the blood pressure cuff, urinate into a cup.

But that last request should prompt questions, at the least. The urine test is the first step into what’s sometimes called “the culture of culturing.”

In patients who have none of the typical symptoms of a urinary tract infection — no painful or frequent urination, no blood in the urine, no fever or lower abdominal tenderness — lab results detecting bacteria in the urine don’t indicate infection and thus shouldn’t trigger treatment.

Older people, and nursing home residents in particular, often have urinary systems colonized by bacteria; they will have a positive urine test almost every time, but they’re not sick.

Yet such test results, signifying what’s known in doctor-talk as asymptomatic bacteriuria, frequently lead to unnecessary treatment with antibiotics. Public health leaders and researchers have battled for years to persuade providers to stop reaching for their prescription pads every time a urine test comes back positive.

They have been only modestly successful. A recent study in 46 Michigan hospitals, for instance, found that of 2,733 patients with asymptomatic bacteriuria (average age: 77), almost 83 percent received a full course of antibiotics. The odds of this overtreatment rose 10 percent with each decade of age.

“We now recognize that there’s a strong cognitive bias,” said Dr. Christine Soong, head of hospital medicine at Sinai Health System in Toronto and co-author of a recent editorial on the subject in JAMA Internal Medicine. “Once a clinician sees bacteria in the urine, the reflex is, you can’t ignore it. You want to treat it.”

Now, the campaign has changed from trying to prevent needless treatment to trying to curtail the testing that prompts it. If concerned doctors can’t dissuade their colleagues from treating these non-infections, they’re trying to discourage them from ordering urine tests in the first place.

The very reserved headline on Dr. Soong’s editorial was: “De-adoption of Routine Urine Culture Testing — A Call to Action.” It probably should have been: “For Crying Out Loud, Stop With the Pee in the Cup.”

What’s raising this issue once more are the latest guidelines from the United States Preventive Services Task Force, the independent expert panel that reviews medical evidence and advises on prevention and screenings.

The task force concluded last month that for virtually everyone except pregnant women, screening for and treating asymptomatic bacteriuria provides no benefit and has potential harms. This didn’t come as news — the task force reached essentially the same determination in 1996, in 2004 and in 2008.

The Infectious Diseases Society of America, which updated its recommendations this spring, also cautioned against screening and treating, except for pregnant women and patients about to undergo invasive urologic procedures. The Choosing Wisely campaign has similarly weighed in against routine urine testing in older adults.

Why this strenuous effort? All of it is aimed at reducing the persistent overuse of antibiotics.

They’re lifesaving drugs, useful when patients actually have urinary or other bacterial (not viral) infections. But studies have shown that with asymptomatic bacteriuria, withholding antibiotics doesn’t endanger patients. Providing the drugs, however — especially to older people — definitely does pose risks.
“The public thinks it’s good to take an antibiotic,” said Dr. Heidi Wald, a geriatrician and chief quality and safety officer at SCL Health in Denver. “People don’t understand the risks of overuse.”

Antibiotics can cause side effects ranging from nausea and rashes to impaired kidney function and interactions with other commonly used drugs, like cardiac medications and antidepressants.

“The problem I worry about most in the frail elderly is C. difficile,” Dr. Wald said, referring to a virulent, hard-to-eradicate infection that has rampaged through the Medicare population.

Antibiotics affect the human microbiome, wiping out the protective microbes in the gastrointestinal tract and increasing people’s vulnerability to C. difficile, which the Centers for Disease Control and Prevention has called an “urgent threat.”

In the Michigan hospital study, patients treated for asymptomatic bacteriuria fared no better on a variety of measures than those who weren’t treated. “But they stayed in the hospital a day longer,” said Dr. Lindsay Petty, the study’s lead author and an infectious disease specialist at the University of Michigan.

She theorized that their doctors were awaiting urine culture results. The patients, meanwhile, faced additional risks of disrupted sleep, infections, physical deconditioning from time spent in bed and other hazards, while generating needlessly higher hospital bills.

Beyond its effect on individuals, “antibiotic resistance is one of the greatest public health crises of our time,” Dr. Petty said. When bacteria develop resistance to overused drugs, doctors are left with fewer and riskier weapons with which to fight infections.

Because U.T.I.s occur so commonly — 40 percent to 60 percent of women, in whom they’re far more common than in men, will experience at least one in their lifetimes — it’s easy for doctors and patients to engage in so-called scapegoating, blaming a supposed U.T.I. for problems that may have little to do with the urinary tract.

In older patients, particularly, confusion and hospital delirium can lead family members to urge doctors to order urine cultures, especially when dementia makes it difficult for patients to describe their symptoms.

But “the idea of attributing delirium to a U.T.I. is losing ground,” Dr. Wald said. When older patients grow confused, “maybe they’re dehydrated,” she said. “Maybe it’s a new medication.” Hospitalization itself might be to blame.

Doctors understand, after vigorous education efforts, that they need to prescribe fewer antibiotics; virtually every hospital has an antimicrobial stewardship program aimed at that goal. “This isn’t a knowledge gap,” Dr. Soong said.

But since many doctors can’t seem to overlook positive tests, even in asymptomatic patients — fearful, perhaps, of missing an infection — health care systems are working to curb their impulse to treat.

Some organizations have created pop-up alerts in electronic records when health care professionals attempt to order urine tests, reminding them of the proper criteria.

At Dr. Soong’s hospital, withholding the results of urine cultures, unless doctors actually called the microbiology lab to request them, reduced prescriptions for asymptomatic bacteriuria to 12 percent from 48 percent of non-catheterized patients, with no loss of safety.

“The extra step of having the clinician call eliminated a lot of frivolous testing,” Dr. Soong said.

Similarly, another Toronto emergency room reported success using containers with a preservative, allowing urine specimens to be held at room temperature for 48 hours, processed only at a doctor’s request. That two-step approach cut antibiotic prescriptions for emergency room patients in half.

There’s a role here for patients and families, as well. What if we asked why we were being asked to urinate into a cup?

“Asking further questions is always appropriate,” Dr. Petty said. “’Why do you think I need this test? What would you do with the results?’”

(Hint: “It’s just routine” is not a good answer. “The symptoms you’ve described could mean a urinary tract infection” is a better one.)

“Such questions should be welcome,” Dr. Petty said. “It’s a way for patients to protect themselves.”