Antibiotic stewardship
Urologists can play an important role in avoiding misuse and overuse of antibiotics.
The discovery of antibiotics is one of the greatest scientific milestones of the 20th century. Yet, growing concerns over antibiotic resistance and responsible use are driving renewed education over being good stewards of the drugs.
The term “antibiotic stewardship” originated in the 1990s, but today is supported by evidence-based strategies to control it, according to E. Ann Gormley, MD, MSc, FRCS(C), FACS, a professor of surgery (urology) at the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. Dr. Gormley is the speaker at Monday morning’s Plenary session, “State-of-the-Art Lecture: Update on Antibiotic Stewardship.”
“Urologists prescribe a significant number of antibiotics in both the inpatient and outpatient setting. Most antibiotics in the outpatient setting are prescribed for infections of the respiratory tract, skin and urinary tract,” Dr. Gormley said. “Antibiotic stewardship is ensuring that we make efforts to improve antibiotic use so that we prescribe and use them in a way that will provide a clear benefit. This includes monitoring the choice, dose and duration of an antibiotic.”
In fact, the Centers for Disease Control and Prevention (CDC) recognizes that although there is no one-size-fits-all approach to optimize antibiotic use for all settings, the “complexity of medical decision-making surrounding antibiotic use and the variability in facility size and types of care in U.S. health care settings require flexible programs and activities.”
According to Dr. Gormley, antibiotics are commonly prescribed, with 252 million outpatient prescriptions dispensed in 2023 in the U.S. This represents 756 prescriptions per 1,000 people. Approximately 28% of prescriptions are unnecessary, she said, and this does not include antibiotics that are the wrong choice, wrong dose or prescribed for the wrong duration.
Misuse and overuse of antibiotics lead to antibiotic resistance (AR) and toxicity. Antibiotic resistance is estimated to result in 35,000 deaths annually in the U.S. and five million deaths worldwide, Dr. Gormley said.
“Antibiotic resistance leads to higher mortality, worse outcomes, longer hospital stays and higher health care costs,” she said. “Patients with AR may need to be prescribed antibiotics that are less effective and have more adverse events.”
For example, exposure to some antibiotics, such as fluroquinolones, or third- or fourth-generation cephalosporins, alter the gut microbiome and increase the risk of C. difficile infection. Such an infection is contagious, morbid and can be deadly, Dr. Gormley said.
Unfortunately, urologists face unique challenges when deciding to prescribe antibiotics, she said.
“We deal with patients with poor bladder emptying and those with catheters and stents, which can increase the risk of bacteriuria and may or may not cause symptoms that require treatment,” Dr. Gormley said. “We often recommend against routine cultures and treatment of the asymptomatic patient, but our patients may often be tested and treated by other physicians, including their primary care providers, ER or infectious disease physicians. We may have to balance disparate recommendations by one patient’s care team.”
There are certain factors urologists should consider when prescribing an antibiotic. For example, pending culture results, urologists should choose an appropriate antibiotic by examining prior culture results and using local antibiograms that show local resistance patterns. Additionally, clinicians should stop antibiotics if cultures are negative.
Dr. Gormley said many health care institutions have antibiotic stewardship programs in place that address duration and drug selection. Because urologists prescribe a large number of antibiotics, she said they have a critical role in shaping antibiotic stewardship.
“Urologists should be mindful when prescribing antibiotics in terms of the correct indications, correct dose and appropriate length of treatment. We should educate our learners and staff about antibiotic stewardship and teach our patients when and how to take antibiotics,” Dr. Gormley said.
