Infectious Diseases Society of America

Five Things Physicians and Patients Should Question

Released February 23, 2015; Last reviewed 2021

  1. 1

    Don’t treat asymptomatic bacteruria with antibiotics.

    Inappropriate use of antibiotics to treat asymptomatic bacteruria (ASB), or a significant number of bacteria in the urine that occurs without symptoms such as burning or frequent urination, is a major contributor to antibiotic overuse in patients. With the exception of pregnant patients, patients undergoing prostate surgery or other invasive urological surgery, and kidney or kidney pancreas organ transplant patients within the first year of receiving the transplant, use of antibiotics to treat ASB is not clinically beneficial and does not improve morbidity or mortality. The presence of a urinary catheter increases the risk of bacteruria, however, antibiotic use does not decrease the incidence of symptomatic catheter-associated urinary tract infection (CAUTI), and unless there are symptoms referable to the urinary tract or symptoms with no identifiable cause, catheter-associated asymptomatic bacteruria (CA-ASB) does not require screening and antibiotic therapy. The overtreatment of ASB with antibiotics is not only costly, but can lead to C. difficile infection and the emergence of resistant pathogens, raising issues of patient safety and quality.

  2. 2

    Avoid prescribing antibiotics for upper respiratory infections.

    The majority of acute upper respiratory infections (URIs) are viral in etiology and the use of antibiotic treatment is ineffective, inappropriate and potentially harmful. However, proven infection by Group A Streptococcal disease (Strep throat) and pertussis (whooping cough) should be treated with antibiotic therapy. Symptomatic treatment for URIs should be directed to maximize relief of the most prominent symptom(s). It is important that health care providers have a dialogue with their patients and provide education about the consequences of misusing antibiotics in viral infections, which may lead to increased costs, antimicrobial resistance and adverse effects.

  3. 3

    Don’t use antibiotic therapy for stasis dermatitis of lower extremities.

    Stasis dermatitis is commonly treated with antibiotic therapy, which may be a result of misdiagnosis or lack of awareness of the pathophysiology of the disease. The standard of care for the treatment of stasis dermatitis affecting lower extremities is a combination of leg elevation and compression. Elevation of the affected area accelerates improvements by promoting gravity drainage of edema and inflammatory substances. The routine use of oral antibiotics does not improve healing rates and may result in unnecessary hospitalization, increased health care costs and potential for patient harm.

  4. 4

    Avoid testing for a Clostridium difficile infection in the absence of diarrhea.

    Testing for C. difficile or its toxins should be performed only on diarrheal (unformed) stool, unless ileus due to C. difficile is suspected. Because C. difficile carriage is increased in patients on antimicrobial therapy, and patients in the hospital, only diarrheal stools warrant testing. In the absence of diarrhea, the presence of C. difficile indicates carriage and should not be treated and therefore, not tested.

  5. 5

    Avoid prophylactic antibiotics for the treatment of mitral valve prolapse.

    Antibiotic prophylaxis is no longer indicated in patients with mitral valve prolapse for prevention of infective endocarditis. The risk of antibiotic-associated adverse effects exceeds the benefit (if any) from prophylactic antibiotic therapy. Limited use of prophylaxis will likely reduce the unwanted selection of antibiotic-resistant strains and their unintended consequences such as C. difficile-associated colitis.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The Infectious Diseases Society of America (IDSA) is proud to partner with the Choosing Wisely® campaign to raise awareness of inappropriate, wasteful clinical actions that harm patients and lead to costly health care. Supporting the aims ofChoosing Wisely, IDSA is committed to evidence-based medicine and develops clinical practice guidelines that inform the use of high-quality, truly necessary medicine. Founded in 1963, IDSA represents more than 10,000 infectious diseases physicians and scientists devoted to patient care, prevention, population health, education and research in the area of infectious disease (ID). Our members care for patients of all ages with serious infections, including meningitis, pandemic influenza, pneumonia, tuberculosis, surgical infections, immunocompromised cancer or transplant patients who have life- threatening infections caused by uncommon or drug-resistant microorganisms, HIV and AIDS patients, and new and emerging infections, such as Middle East respiratory syndrome (MERS), and Ebola.

For more information on infectious diseases specialists and IDSA, please visit the IDSA website,

How This List Was Created

The Infectious Diseases Society of America’s (IDSA) Quality Improvement Committee (QIC) directed the development of IDSA’s Choosing Wisely®list of Five Things Physicians and Patients Should Question. The Committee identified a preliminary list of inappropriate and overused clinical practices. A list of five items was drafted and then vetted by the QIC and revisions were made according to a workgroup consensus. The finalized list was then submitted for approval to the IDSA Board of Directors.

IDSA’s disclosure and conflict of interest policy can be found at


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