One Thing You Can Do to Be a Better Antimicrobial Steward

Roni K. Devlin, MD, MBS


September 01, 2022

We all know that antibiotics are commonly misused in medical practice. We frequently give them to patients for noninfectious diagnoses (see my previous blog discussing pseudocellulitis as an example). We often underdose or overdose them, both of which have unfavorable outcomes (less likely to be curative in the former and more likely to cause harmful side effects in the latter). We use longer durations than necessary and are quick to offer ineffective refills. And we even prescribe them without first looking at a patient's allergy list or researching potential harmful drug interactions.

Despite our casualness with antibiotics, the consequences of misuse are serious. Treating a patient for a diagnosis that is noninfectious or using antibiotics inappropriately is not only expensive, but can result in side effects, toxicities, or even death. An unnecessary antibiotic course can lead to hospital admission or prolong a hospital stay. And, over time, misuse of antibiotics increases the risk for antimicrobial resistance.

The World Health Organization has declared that antimicrobial resistance is one of the top ten global public health threats facing humanity. In our lifetime, we may reach a point where we have no effective treatment for gonorrhea. In some countries, carbapenems already do not work in more than half of the patients treated for resistant Klebsiella pneumoniae infections. Less than 60% of those treated for multidrug-resistant/rifampin-resistant tuberculosis are successfully cured. And I haven't even mentioned any antiviral-, antifungal-, or antiparasitic-resistance issues.

Without a reduction in antimicrobial misuse, prevention of resistance, and improved access to novel antimicrobials, more of our patients will fail treatment or die from their infections.

So what can you do today to become a better antimicrobial steward?

Certainly, you can update your knowledge about antimicrobials and the pathogens that they treat. In your everyday clinical practice, though, there is an easy thing you can do to decrease the risk for further antimicrobial resistance: Stop treating asymptomatic bacteriuria (ASB).

An easy way to stop treating ASB is to avoid ordering urinalyses and urine cultures in women and men without symptoms of a urinary tract infection (UTI); of note, the exceptions to this rule are pregnant women and patients who will undergo endoscopic urologic procedures associated with mucosal trauma. This sounds deceptively simple, but I suspect nearly all of us have ordered urine samples and offered antibiotics for many patients who didn't need them.

As a reminder, here are the patients who don't need urinary screening or antibiotic treatment for ASB:

  • Infants and children

  • Healthy premenopausal, nonpregnant women

  • Healthy postmenopausal women

  • Older, community-dwelling persons who are functionally impaired

  • Older persons who reside in long-term care facilities

  • Patients with diabetes

  • Patients s/p renal transplant more than 1 month prior

  • Patients with nonrenal solid organ transplant

  • Patients with high-risk neutropenia

  • Patients with spinal cord injury

  • Patients with indwelling urethral catheters

  • Patients undergoing elective nonurologic surgery

  • Patients planning to undergo surgery for an artificial urine sphincter or penile prosthesis implantation

  • Patients living with implanted urologic devices

Hospitalized aseptic patient with a Foley and funny-smelling urine? Not a candidate for urinalysis or culture. Healthy patient admitted for elective total knee arthroplasty? Not a candidate for urinalysis or culture. Diabetic patient seen in the office for a routine check? Not a candidate for urinalysis or culture. Delirious nursing home resident without a fever or urinary symptoms? Not a candidate for urinalysis or culture.

Certainly, if a patient has the defining signs and symptoms of UTI, then obtaining a urinalysis and urine culture would be appropriate, as would consideration for antibiotic treatment. Unfortunately, as clinicians, we're not so good at getting this right, either. A recent study published in Open Forum Infectious Diseases suggests that in over 670,000 young women diagnosed with UTI, almost half received an antibiotic that was inappropriate and more than 75% were prescribed antibiotics for a longer duration than was considered necessary.

In addition to avoiding inappropriate treatment of ASB, we have a lot of room for improvement when it comes to the diagnosis and management of true UTI — I'll save that discussion for another blog entry. In the meantime, the Infectious Disease Society of America has a clinical practice guideline for the management of asymptomatic bacteriuria — it's a great place to start as you strive to become a better antimicrobial steward.

Comments to this blog post are welcomed and encouraged. If you have an infectious disease topic you'd be interested in reading about here, please don't hesitate to mention it.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube

About Dr Roni Devlin
Roni K. Devlin, MD, MBS, is an infectious diseases physician currently residing in the Midwest. She is the author of several scholarly papers and two books on influenza. With a longstanding interest in reading and writing beyond the world of medicine, she has also owned an independent bookstore, founded a literary nonprofit, and published articles and book reviews for various online and print publications. You can reach her via LinkedIn.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.