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Antimicrobial Stewardship uUTIs
Not Always an Easy Task: Antimicrobial Stewardship for Uncomplicated UTIs

Released: November 02, 2023

Lilian Abbo
Lilian Abbo, MD, MBA, FIDSA
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Key Takeaways
  • Resistance to first-line antimicrobial agents is increasing and has the potential to exceed several leading causes of mortality by the year 2050.
  • Practicing responsible prescribing and incorporating antimicrobial stewardship principles can help preserve the efficacy of currently available and emerging therapeutic options.

Being a Responsible Steward
If we are not mindful about antimicrobial stewardship now, by the year 2050, antimicrobial resistance will be a global crisis. We are now calling this risk “the silent pandemic” because if left unchecked, antimicrobial resistance has the potential to kill more people than cancer, traffic accidents, and even HIV. Widespread antimicrobial resistance could be a major cost to society because it affects people of all ages, of all races, and in all parts of the world.

Preventing microbial resistance involves not only developing new drugs and new agents, but also practicing responsible stewardship of the therapies we have now. Stewardship means understanding how to choose the right drug for the right bug, for the right duration in the right scenario, and for the right reasons.

So, when we talk about urinary tract infections (UTIs), why does this matter? It matters because uncomplicated UTIs compose a large portion of antimicrobial prescribing, and healthcare professionals (HCPs) need to understand how to prescribe responsibly. This includes being able to identify when NOT to treat.

To make this decision, HCPs should strive to accurately classify asymptomatic bacteriuria, uncomplicated UTIs, complicated UTIs, and pyelonephritis and distinguish them from other potential conditions. It is important for HCPs to ask themselves, “Does this patient really have a UTI? Do I need to prescribe a medication?”

If the answer to both those questions is yes, the next factors to consider are: What diagnostic tests are appropriate for this case? Should new diagnostic tests be used? How should I pick the right agent? How should I confirm a UTI?

Antimicrobial stewardship may seem daunting, but it is critical to remember that a good medical history and physical exam are key!

The Importance of an Accurate History and Physical Exam
A comprehensive medical history and physical exam will go a long way toward making an accurate diagnosis. HCPs can use screening questionnaires in the office or have clinical staff triage patients to help with collecting a thorough history.

The most common presentation will include acute onset of symptoms, including dysuria and frequent urination. Patients may also have fever or chills.

Other important historical information to collect includes:

  • From where the patient is presenting (eg, home, assisted living facility, skilled nursing facility)
  • Potential triggers for the symptoms
  • Sexual history
  • Daily lifestyle behaviors:
    • Is the patient holding their urine for long periods of time?
    • Is the patient drinking enough fluids?
  • History of similar episodes, if applicable
  • Recent history of antimicrobial use
  • Relevant medication allergies or intolerances (eg, sulfa, β-lactam) and information related to those reactions

It is important to ensure that you are not missing a complicated UTI or pyelonephritis. On exam, HCPs should rule out abdominal pain and retroperitoneal or rebound pain and assess for a history of kidney stones. 

In my practice, a urine culture is usually not ordered for a patient’s first episode of an uncomplicated UTI. The exception is if the patient has recently been on antibiotics. If patients say that they had an infection a few weeks ago and were prescribed an antibiotic, or if they report having taken courses of antibiotics recently for other reasons, they may be dealing with a resistant bacterium.

In addition, HCPs should ask about travel history. Depending on their recent locations, patients can acquire organisms with different mechanisms of resistance. Their environment will also affect their microbiome, which may affect therapy needs.

Using Antibiograms in Family Practice
Another important tool for antibiotic stewardship is the antibiogram. Many healthcare systems design antibiograms to summarize local resistance patterns. Outpatient family practice offices may not have the resources to design their own clinic-specific antibiogram, but there are options to obtain them.

It is important to refer to the correct antibiogram version, as isolates for patients in the medical ICU, the pediatric ICU, the general acute care floor, and the emergency department may differ. Antibiograms summarizing recent data on urinary isolates from local emergency departments or urgent care clinics are the most applicable to outpatient settings, as these patient populations are most similar.

In general, if working within or near a large health system, HCPs can reach out to the infection control or antimicrobial stewardship team(s), or the microbiology lab to request a current antibiogram or the data to create one.

Another option is to request the data from local diagnostic labs and companies. Some of these labs may even have the capacity to produce an antibiogram specific to your practice. If you are in a private practice using a send-out lab, they also may be able to share general information on common regional patterns of resistance.

Emerging Therapies for Uncomplicated UTI
Extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae and carbapenem-resistant organisms are unfortunately becoming more common. Newer agents offer much-needed options to combat resistant cases, especially as resistance grows to commonly used agents such as fluoroquinolones and, in some places, trimethoprim/sulfamethoxazole.

Many new drugs have been investigated for uncomplicated UTIs, with some, like gepotidacin and sulopenem, potentially coming onto the market soon. There are vaccines in development to prevent and treat recurrent UTIs. However, like all agents, these have pros and cons and are unlikely to be a magic “cure all” agent for UTIs.

In patients with recurrent infections, family medicine providers have an important role in understanding the risk factors (eg, menopause), providing counseling, and using nonantimicrobial preventive strategies such as behavioral modifications or referral to an infectious diseases specialist when appropriate.

Ultimately, I believe responsible prescribing practices, whether with current or emerging agents, are the key to preserving the UTI armamentarium. I always suggest preventive and nonantibiotic strategies when feasible, picking the agent with the narrowest possible spectrum and shortest duration of therapy (less is more), focusing on killing the pathogen, and preserving the rest of the microbiome, because those effects are long lasting.

Finally, we must remember to choose not to test asymptomatic patients and only treat with the right drug for the right duration when clinically indicated.

Your Thoughts?
How do you incorporate antimicrobial stewardship principles into the treatment of uncomplicated UTIs? Leave a comment below to join the discussion.