The 2019 USPSTF Report on Screening for Asymptomatic Bacteriuria—Lessons From History

In the September 24, 2019, issue of JAMA,^1,2 more than a decade after the last statement,³ the US Preventive Services Task Force (USPSTF) released their 2019 recommendations for screening and treatment of asymptomatic bacteriuria (ASB) in adults. Likewise, the Infectious Diseases Society of America recently updated their guidelines⁴ on ASB after more than a decade. Although there are some important changes, the recommendations are still against screening and treatment of ASB in most settings except pregnancy. With the back-to-back release of these authoritative and evidence-driven guidance statements, one would anticipate strong momentum for modification of the common practice of testing for and treating bacteriuria in asymptomatic patients.

However, if history does indeed repeat itself, then the expertise and new evidence will not easily translate into clinical practice change. Multiple studies since 2008 have described treatment of ASB in patients for whom the USPSTF recommended against treatment (grade D recommendation).⁵ Notably, these are not usually rogue clinicians giving out antibiotics in direct opposition to the guidelines. Instead, there is true concern among clinicians that their patients are different from or more seriously ill than those covered by USPSTF guidelines.⁶ Clinicians’ fear of adverse outcomes when withholding antibiotics for a urine culture that is positive for bacteriuria is well documented. Per a 2017 systematic review and meta-analysis,⁵ 45% of ASB is treated with antibiotics. In short, the 2019 USPSTF statement² will likely have the same effect as the 2008 statement³ and the one 10 years before that unless the chasm between guidance and practice is bridged with an implementation plan.

The newly updated USPSTF guidelines^1,2 have 2 major recommendations. First, women who are pregnant should continue to receive screening for ASB during pregnancy by urine culture (grade B recommendation, moderate net benefit), while the USPSTF recommends against screening for ASB in adults who are not pregnant (grade D).^1,2 The grade B recommendation in support of screening in women who are pregnant is a change from the prior grade A recommendation, issued in 2008.³ Factors that went into this change include data from a 2015 study⁷ in the Netherlands suggesting limited benefit from screening and treating ASB in pregnant women who were closely followed prepartum and were at low risk for urinary tract infection and preterm birth or other complications. The applicability of this new information to a more diverse population of women who are pregnant is unclear. In addition, the 2019 update^1,2 took into account concerns about overuse of antibiotics and potential harm to the microbiome, thus further shifting the risk vs benefit analysis and contributing to the downgrading from A to B of the recommendation to screen women who are pregnant for ASB.

Second, they gave a grade D recommendation against screening for ASB in adults who are not pregnant, ie, no net benefit. This is a powerful buttress for the myriad of antibiotic stewardship programs that seek to reduce unnecessary screening for and treatment of ASB.⁸ Overdiagnosis of urinary tract infection in patients who instead have ASB is a major contributor to antibiotic overuse in outpatient clinics, hospitals, long-term care facilities, and emergency departments. The fact that the USPSTF discourages screening urine cultures in asymptomatic patients means Medicare could cease paying for unnecessary urine tests. The 2008 policy change by which Medicare ceased reimbursing for hospital-acquired infections, such as catheter-associated urinary tract infections (CAUTI), launched nationwide CAUTI-reduction programs that were associated with lasting and sustained reduction in rates of this health care–associated infection.

The USPSTF reviewed 5 randomized clinical trials that evaluated treatment of ASB in adults who were not pregnant; these included participants from the community and independent living facilities, mostly women. There was no benefit to treating ASB and thus no role for screening in this population. One limitation is that the populations addressed by the USPSTF recommendations^1,2 are limited to those included in the evidence base, and the recommendations exclude people who are hospitalized, people who reside in a health care institution (eg, a nursing home), people who have chronic medical or urinary tract conditions, people who are transplant recipients, people with urinary catheters or urinary stents, and people with spinal cord injury. And therein lies the rub—the excluded populations are exactly those who are most likely to have ASB and at the most risk of receiving unnecessary antibiotics to treat ASB.

How can we extend and implement these important recommendations from the USPSTF? Studies have found that education, combined with audit and feedback, can change clinician behavior.⁹ Interventions that incorporate behavioral theory to nudge clinicians toward the right course of action or that replace reflexive prescribing with evidence-based activities have demonstrated effectiveness. For example, the Kicking CAUTI¹⁰ campaign has successfully decreased antibiotic treatment of ASB through focus on decreasing unnecessary urine cultures in asymptomatic patients. In addition, a deimplementation initiative, The ABCs of ASB, (K. Gupta, MD, MPH, et al, unpublished data, October 2019) was associated with a 50% reduction in intended antibiotic use for ASB in preoperative and nursing home settings. Clinicians were taught substitution actions in lieu of antibiotic use to improve outcomes in their patients identified as having ASB, with the most important message being, next time, do not screen. Clearly, these strategies are outside the scope of the USPSTF, but need to be delivered alongside the recommendations in a user-friendly, scalable, and adaptable package. Only then will we reach the ever-elusive goal of influencing clinician behavior with every patient and in every clinic room.

Another barrier to reducing antibiotic use for ASB is that it is a poorly defined concept clinically (eg, whether it requires 1 culture or 2, what counts as a symptom, and how to evaluate a patient with delirium with ASB). Clinicians rely on laboratory testing to diagnose urinary tract infection; the identification of pyuria or high colony counts of bacteriuria prompts higher rates of antibiotic treatment in asymptomatic patients.¹¹ Reducing the number of urine cultures by requiring pyuria to reflex a urine culture for testing has been shown to reduce antibiotic use.¹² However, overreliance on the urinalysis results also drives antimicrobial use, and thus diagnostic stewardship needs to extend to not only urine cultures but also the screening urinalyses.¹⁰ Future directions include development of performance metrics, nonpayment for inappropriate urine testing, and ongoing research on the harms vs benefits of screening in diverse populations.

As we contemplate the challenges of moving from recommendations to practice, the medical community needs to emulate the approach of Alexander Hamilton, “a sparkling theoretician and masterful executive [who took] principles and infused them with expansive life.”¹³ As such, the well-evidenced guidance of the USPSTF^1,2 and Infectious Diseases Society of America⁴ on ASB needs to be infused into clinical practice, shifting our current culture of culturing away from routine urine testing and toward actions that benefit our patients.

Published: September 24, 2019. doi:10.1001/jamanetworkopen.2019.12522

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Gupta K et al. JAMA Network Open.

Corresponding Author: Kalpana Gupta, MD, MPH, Department of Medicine, Veterans Affairs Boston Healthcare System, 1400 VFW Pkwy, MED 111, West Roxbury, MA 02312 (Kalpana.gupta@va.gov).

Conflict of Interest Disclosures: Dr Gupta reported receiving grants from Pfizer; personal fees from Paratek Pharmaceuticals, Nabriva Therapeutics, Rebiotix, Shionogi, Ocean Spray, First Light Diagnostics, Tetraphase Pharmaceuticals, and Iterum Therapeutics; and personal fees and royalties from UpToDate outside the submitted work; additionally, Dr Gupta reported serving as a coauthor of the 2019 Infectious Diseases Society of America guidelines on asymptomatic bacteriuria, for which no compensation was received. Dr Trautner reported receiving grants from the Agency for Healthcare Research and Quality, US Department of Veterans Affairs Health Services Research and Development, National Institutes of Health, US Centers for Disease Control and Prevention, Zambon Pharma, and Antibacterial Resistance Leadership Group and personal fees from Paratek Pharmaceuticals outside the submitted work.

Funding/Support: Dr Trautner’s work is supported in part by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413).

Role of the Funder/Sponsor: The funder had no role in the preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.