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Ruchika Talwar: Hi, everyone and welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar, and today I'm joined by George Koch, who is a urologic reconstructive fellow at the University of Washington. We'll be doing an in-depth conversation on antibiotic stewardship and what it means for urology. Thanks so much, Dr. Koch, for joining us.

George Koch: Thank you for having me, Dr. Talwar. I appreciate it.

Ruchika Talwar: So let's dive right in. Tell me a bit about how you got interested in the space of antibiotic stewardship in urology.

George Koch: Absolutely. I first got interested in really treating surgical infections. Fournier's gangrene was a clinical interest of mine, and over the past few years, trying to reduce those patients' antibiotic load essentially after they've been debrided was kind of a priority of a lot of research groups. After having done some of that work, moving further into other urologic infections. Antibiotic stewardship has been very popular recently, as it should be, and there's just been a lot of interesting work done in trying to minimize unnecessary antibiotics, and just got interested from there.

Ruchika Talwar: Great. So you bring up a couple of important points. First, antibiotic stewardship in the context of recurrent UTIs I think is something that urologists are a bit more comfortable with. We see those patients longitudinally, so we understand the importance of culture-directed antibiotics to avoid leading to resistant infections, but I think the picture in Fournier's historically has been a little less clear.

We know that surgical debridement and particularly in an emergent manner is a mainstay of the algorithm of treating Fournier's effectively, but a lot of times we do want to throw our strongest antibiotics, and one would imagine for a prolonged period of time, to help fight off such a severe infection. But you mentioned that it's been a focus of research lately to kind of narrow and shorten those courses. So tell me more about that.

George Koch: Yeah, so you're absolutely right. When you come in with an infection that's life-threatening, throwing the kitchen sink at those infections is often the way to go. But getting those patients who have been appropriately debrided, which does happen pretty quickly, off of antibiotics, as long as they don't have complicating factors like bacteremia or osteomyelitis, can be pretty effective in treating them.

And you can kind of move to local wound care pretty quickly. Overtreating with antibiotics is something that we do because we care. We want our patients to do well. It's not something that's done irresponsibly, it's something that's done out of a feeling of responsibility. But doing the research to understand those places like Fournier's, where we have to go heavy early and then we can back off quicker, is I think really the key to antibiotic stewardship and using the big guns appropriately.

Ruchika Talwar: Yeah. Tell me about some other conditions other than Fournier's and recurrent UTIs where antibiotic stewardship is particularly important in urology.

George Koch: Yeah. So recently there have been a couple of articles in the Journal of Urology and in the Gold Journal about perioperative prophylaxis. We know that even one dose of antibiotics that's inappropriate causes a selection pressure on bacteria that can kind of push them towards resistance. So even when we're giving single dose perioperative prophylaxis, it's important to make sure that we're giving the appropriate antibiotics for the appropriate amount of time.

There have been a couple of articles in bladder cancer and in stone disease recently where patients are being given longer courses of antibiotics than 24 hours, which is what the AUA best practice statement would recommend for those procedures. And those patients are actually coming back with more hospital acquired infections, more C diff, more emergency department visits following their discharge. There's certainly not a causal relationship in those data sets, but there is an association that we need to look into further.

Ruchika Talwar: Yeah, great point, especially in those high risk surgeries. I think, again, we try to throw the antibiotics at the patients because we care and we want them to do well and reduce their risk of infection, particularly with dirty procedures like a cystectomy. But the point you bring up about C diff is really important, because that leads to longer length of stay, readmissions, higher healthcare related costs. Since I focus on health policy, I think this is a very important area that we need to explore as it relates to getting our patients home faster, avoiding those readmissions and prolonged length of stays and saving the health system money overall.

Let's talk about a particular interest of yours as a reconstructive urologist. Another area where I think people tend to overuse antibiotics is definitely with prosthetics. So tell me a bit about what your practice is and what the evidence shows in this space.

George Koch: Yeah, so I've been at Vanderbilt and now at the University of Washington recently where we follow the best practice guidelines and give people doses of perioperative vancomycin and gentamycin. We tend not to give extended courses of prophylactic antibiotics after the implant goes in. There have been a couple of studies, one out of Vanderbilt notably, that showed that there was no decrease in complications with giving even high risk patients antibiotics afterward.

And the devices themselves are coated with antibiotics, so those patients are getting locally dosed antibiotics just having an implant in anyway. So I think that generally just following the best practice statements is the way to go unless you have a concern. And with implants specifically, generally if you have a concern that maybe you should be treating the infection that you're worried about prior to, and then coming back and fighting that battle another day.

I think recently there's been more interest in potentially covering patients for fungal infections. There was a paper recently in JU about that, and the data's still mixed on it. We know that patients who have infections that are cultured from their devices and explant, we know that a significant proportion of them are fungal infections. But in today's day and age, the risk of a device infection from your implant surgery is about or less than 1%.

So whether it's enough that we should be giving everybody a dose of antifungal is still kind of up in the air, and some people advocate for it and some people don't. I haven't been at an institution yet that does give that antifungal coverage, but we try to be thoughtful about the antibiotics that we're using. And like I said, if we have a concern, usually the best practice is to wait and implant another day.

Ruchika Talwar: Where I trained for residency, we did give fungal coverage, but I think I've heard a lot of people not give any fungal coverage at all or give fungal coverage in very specific cases, such as in a patient with well-controlled diabetes who is an appropriate candidate for implanting, but you want to tend to be on the safe side. So I think that evidence, like you alluded to, is forthcoming and will become a little more clear as we look at these studies that are in progress.

But I think even these conversations are important because I know there's a lot of variations, surgeon to surgeon and site to site, but it becomes difficult when all of these patients are out in the community and they have resistant bugs and we're faced with using the really big gun antibiotics then, and that might require an admission or a PICC line or what have you.

So as we wrap up, let's think about what urologists can take home, some messages for them as they kind of embark on their day-to-day practices. What are some things to keep in mind when treating patients either with a urologic infection or to try to avoid a urologic infection in the setting of a procedure?

George Koch: Yeah, in the setting of the procedure, I think you need to make sure that when we're giving patients antibiotics, they're culture directed and they're given for a specific reason. You should be thinking, "What's my indication for this medication?" And if the indication is it's going to make me feel better, it'll make the patient feel better, thinking twice about some of those antibiotics could certainly be helpful for community urologists.

I think any research that we can do in this space is welcome and needed, especially around perioperative prophylaxis. It's not the most exciting area to research sometimes, but it's something that almost every patient that gets surgery is going to interact with. And trying to reduce the selection pressure for those bacteria is certainly really, really important.

But for the everyday urologists looking to just be thoughtful about their antibiotics, just remembering that all medications have side effects, and while you may be trying to do your best to keep that patient out of the emergency department by giving them antibiotics, you could be starting a cascade that could end them up in the emergency department more.

Ruchika Talwar: Absolutely. Absolutely. I think another point to keep in mind is also your local antibiogram. Reaching out to your infectious disease department, understanding what your local bacterial makeup is and what antibiotics tend to be effective in your specific population is very important.

George Koch: Absolutely. As much of that data as you can collect, I think the better, because we don't all have the same microbiome and the same concerning flora that we're taking care of, and local experience can be huge.

Ruchika Talwar: Well, thanks so much, Dr. Koch. I really appreciate you doing a deep dive into this important topic. As you actually mentioned earlier, it may not be the most exciting area of research, but it is really important, and I think that it's an area where we can go a long way in improving the health of our urologic patient population, and I really encourage everyone to use the resources available through the AUA guidelines or best practice statements, as well as some of those local charts on antibiotic effectiveness that we alluded to.

George Koch: Absolutely. Thanks for having me. I appreciate it.

Ruchika Talwar: Great, and thanks to our audience for tuning in. We'll see you next time.