Medical Alchemy: The Treatment of Asymptomatic Bacteriuria

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Original story posted on: August 22, 2018

Alchemy, whether medieval or medical, is an irrational process.

Alchemy was a protoscientific practice with a long, fabled history starting with the ancient Greek’s rudimentary art of ‘k’hēmeía’ through the more advanced Arab practice of ‘al-kimiya’ climaxing with its formal Medieval name ‘alchemy’ from the Latin alkimia.

In the Middle Ages its goal was discovering the legendary alchemical substance known as the ‘Philosopher’s Stone’ which was capable of transmuting base metals, like lead, into noble ones, like gold. With the onset of the Scientific Revolution starting with Copernicus in the mid-1500s, progressing through Boyle in the mid-1600s, and climaxing with Lavoisier in the mid-1700s alchemy fell into disrepute as a pseudoscience, replaced by the modern science of chemistry.

In the 20st century the craft of alchemy has been revived in America and has become nationwide. It is performed every day in every hospital in the United States. It is still a pseudoscience but is now the practice of a reverse alchemy called Medical Alchemy which is the art of turning noble health into base disease. The alchemist’s ‘Philosopher’s Stone’ has been discovered - it is antibiotics. Doctors have become Antimicrobial Alchemists turning a non-disease, Asymptomatic Bacteriuria, into a real disease, C. difficile colitis. Sometimes this Medical Alchemy has changed noble life into base death.

Medical Alchemy spans generations of doctors using generations of antibiotics to treat generations of patients with Asymptomatic Bacteriuria which normally needs no treatment whatsoever. Medically, there are a few indications for the treating an asymptomatic patient with an abnormal urinalysis suspicious for infection. These exceptions are: patients undergoing urologic surgery or instrumentation, pregnancy, and in the very sick who cannot give a coherent history and a urinary tract infection is suspected. These cases make up a very small minority of those treated for Asymptomatic Bacteriuria.  

Indeed, Asymptomatic Bacteriuria is an epidemic without symptoms that is raging across the United States. The risk factors for this non-disease are being an elderly patient and being in an ER bed. These patients without symptoms or signs of a urinary tract infection (UTI), such as, dysuria, frequency, back pain, cloudy urine or hematuria needlessly get a urinalysis (UA) and then are needlessly being given antibiotics when white cells and bacteria are seen in their urine. With the exception of the exceptions noted above, if there are no symptoms of a UTI a UA is simply not indicated much less treating any findings of an unneeded test.

Nonetheless, daily, and likely hourly, across our country many, many senior citizens are being groundlessly tested for and groundlessly treated for a UTI when their only problem is Asymptomatic Bacteriuria. This is how Medical Alchemy can transform a harmless condition into a harmful one: treatment with gratuitous antibiotics. This turns a harmless situation into a perilous one – the risk of being swept up in a symptomatic epidemic that is also raging across America, the epidemic of C. difficile colitis.

Very recently, NASA launched a space probe that will take more than seven years to spiral towards the sun eventually to pass within 4 million miles of its surface. The goal is to detail the properties of “solar eruptions.” Amazingly, while astrophysicists can get close to the sun’s atmosphere, Medicine cannot get close to resolving this asymptomatic epidemic. More incredibly, while science can develop a program that will help to accurately understand the contents of the solar wind in outer space, medicine cannot develop a program to accurately understand the contents of patient’s urine in Emergency Rooms.

The findings of medieval alchemists spread very slowly, initially by handwritten manuscripts and after the mid-1400s by Gutenberg’s primitive printing presses. Modern alchemists initially spread their findings by handwritten medical records but after the mid-1980s they have been instantaneously transmitting them via the EMR. Their medical alchemical powers have been greatly enhanced by the use of an electronic preservative called copy/paste. Once the mis-documentation of Asymptomatic Bacteriuria as a real UTI is entered into the chart, it gets copy/pasted and the misdiagnosis is promulgated from one day to another. The clinical documentation then drives the clinical management rather than the other way around – the way it is supposed to happen: treatment driving documentation.

Alchemy whether medieval or medical is an irrational process. However, in the Middle Ages alchemists were guided by the hope of finding a cure for disease, while Medical Alchemists are guided by the fear of missing a diagnosis. This unfounded worry of missing something leads unfortunately to unfounded treatment. It is simply more important to assuage the fear than to thoughtfully consider whether treatment is necessary.

If the problem was just ignorance, it should have been corrected with education, but it hasn’t. If the problem was misunderstanding, it should have been remedied by explanation, but it hasn’t been. The problem is fear. It is very hard to educate fear or to explain to fear because fear only listens to itself. Fear is dreadful and baseless fears are made scarier by stress. It is the synergy between two epidemics: the symptomatic epidemic of physician burnout magnifies the asymptomatic epidemic of the unnecessary treatment of Asymptomatic Bacteriuria.

From our 21st century perch we can look back at the specious practices of medieval alchemists attempting to transmute the valueless into the valuable. But we needn’t look back in time to see such spurious practices. In every hospital there are modern Medical Alchemists changing health into disease, and worst of all, sometimes transforming a cheerful life into a sorrowful death by the unnecessary treatment of Asymptomatic Bacteriuria.

Medieval alchemists couldn’t know better; Medical alchemists should.

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Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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