“At ����ý, we are fortunate to have many outstanding antimicrobial stewardship allies who do an incredible job promoting thoughtful antimicrobial use in their areas of work, ” said Nikolaos Mavrogiorgos, MD, CASP medical director.  “Through these awards, we want to celebrate such individuals, recognize their efforts, and highlight the fact that we at CASP really depend on them.” He, along with CASP pharmacists Ashley Marx and Travis Jones, recognized the fourth cohort of awardees.

Erin Brown’s work to improve inpatient access to RSV vaccines was recognized with an award. Brown worked with CASP on making RSV vaccines available for pregnant patients who cannot be discharged prior to delivery, who would otherwise have received them as part of outpatient prenatal care. This is important to reduce the number of infants who become ill with RSV, since they are protected by their parent’s antibodies, and infants are at high risk for severe disease. Brown also contributed to the standardization of perioperative prophylaxis in gynecologic surgery; surgical site infection prevention is part and parcel of antimicrobial stewardship.  “She is always happy to help with antimicrobial stewardship interests, and diligently works to improve her patients’ care,” one nominator wrote.

Bobby Ijeoma is a third-year resident in Internal Medicine at ����ý Hospitals and is already an antimicrobial stewardship star. As one nominator wrote, Ijeoma “routinely provides exceptionally thoughtful care for patients both as an internal medicine resident and as an internal medicine consultant. In a recent rotation on the internal medicine consult service, he identified multiple patients for whom involvement of the Infectious Diseases consult service was both beneficial and contributed to safe and effective use of antimicrobials.” Ijeoma integrates aspects of antimicrobial and testing stewardship into his day-to-day practice and sets an example for others.

Nominators for Donna Krzastek, a pharmacist at ����ý Hospitals’ Hillsborough campus, shared that she is an enthusiastic and proactive antimicrobial steward, working to optimize antimicrobial therapy in her clinical role at Hillsborough and collaborating with CASP on projects that positively impact patients across the Hospitals’ two campuses. Krzastek has conducted numerous penicillin allergy assessments this year, which improved the accuracy of penicillin allergy labeling and allowed patients to receive optimal antibiotic therapies. She also involves students in this process, taking time to provide stewardship education for our future pharmacists and instill best practices. Additionally, Krzastek worked with other CASP team members this year to develop a new guidance document on Gram-Negative Bacteremia.

CASP congratulates the three awardees and looks forward to an ongoing partnership.

Brian Conlon’s lab is looking at ways to help antibiotics fight deadly “persister” bacteria.

Nikolaos Mavrogiorgos, MD, CASP Medical Director

“CASP created these awards to recognize colleagues’ efforts to support the appropriate and effective use of antimicrobials,” said Nikolaos Mavrogiorgos, MD, CASP medical director. “Each of us can make meaningful changes that improve patient care and fight antimicrobial resistance. We value those contributions and want to recognize individuals’ efforts that surpass expectations. We all can be stewards, whatever our roles.”

Antimicrobial stewardship requires partnership across disciplines and across ����ý Medical Center. Antimicrobial stewardship programs are intended to both lead to improvements in patient care and slow antimicrobial resistance. They do this by ensuring antimicrobial therapies are only used when needed, and when needed, that patients receive the right drug, at the right dose, for the right durations, via the right route of administration. The Carolina Antimicrobial Stewardship Program (CASP) is charged with optimizing the use of antimicrobials at the Medical Center. To do that, it relies on a broad partnership of stakeholders from microbiology, pharmacy, nursing, medicine, information technology, and more.

CASP launched the Super Steward Awards in 2022 to underline the vital role of these partnerships in successful antimicrobial stewardship. See previous awardees.

Awardees will demonstrate leadership in one or more ways. Some examples include:

• Routinely speaking up about and/or using antimicrobials judiciously
• Innovation / Quality Improvement
• Infection Prevention to Conserve Antimicrobials
• Infectious Diseases Diagnostic Stewardship: avoiding unnecessary tests that could lead to antibiotic overuse
• Mentorship / Education

CASP welcomes nominations (including self-nominations) of ����ý Hospitals or University employees who demonstrate what it means to be an antimicrobial steward. Nominees must be employees of ����ý Hospitals or the University with a role at the Medical Center and not paid employees of CASP. Awardees will be recognized in May and receive a token of thanks.

Nominations may be submitted via Super Steward Awards Nomination Form | Carolina Antimicrobial Stewardship Program.

Consider posting the flyer in your work area.

Nick Mavrogiorgos, MD is the medical director of the Carolina Antimicrobial Stewardship Program at ����ý Hospitals.

Avoid Treating Asymptomatic Pyuria and Bacteriuria

To establish the diagnosis of a UTI, patients generally need to have urinary symptoms and compatible diagnostic data, such as the presence of pyuria in the urinalysis (UA) and a positive urine culture. Pyuria and bacteriuria are very common, especially in older adults, and their presence (without urinary symptoms) does not generally warrant treatment. This is because antibiotic treatment of asymptomatic pyuria or bacteriuria is of no benefit to the patient, with a few exceptions for asymptomatic bacteriuria, such as during pregnancy or preceding invasive urological procedures.

How about patients who present with sepsis? And how about patients who do not have a functional bladder, such as patients with spinal cord injury or neurogenic bladder due to another etiology?

Patients with Suspected Sepsis

Cystitis does not present with sepsis unless there is progression to acute pyelonephritis. Patients with acute pyelonephritis typically also have a picture of sepsis (fever, leukocytosis, tachycardia), which in some cases can progress to septic shock. Patients with chronic indwelling catheters can also present with sepsis in the setting of a UTI; it is reasonable to assume that these patients, too, have acute pyelonephritis when they present with sepsis due to a UTI. Most patients with sepsis due to a UTI, who have a normal urinary system, also have urinary symptoms, such as dysuria, urinary urgency/frequency, and flank pain. These urinary symptoms point towards the diagnosis. Occasionally, patients with acute pyelonephritis may present with “undifferentiated sepsis” (i.e., without localizing symptoms), but this is less common. In patients presenting with sepsis without urinary symptoms, a workup for possible UTI is indicated if there is no other obvious source of infection. If another infection source is obvious, there is generally no need to send urine for testing in the absence of urinary symptoms.

It can be easy to assume that sepsis is due to a UTI and miss the true cause.

Patients without Normal Bladder Function

Diagnosis of urinary tract infections in patients who do not have normal bladder function can be very challenging. This includes patients with neurogenic bladder (for example, in the setting of spinal cord injury or diseases such as multiple sclerosis) who often have a chronic indwelling Foley catheter or suprapubic catheter or need in-and-out catheterization. It also includes patients with a chronic indwelling Foley catheter or suprapubic catheter due to another cause of bladder dysfunction, such as bladder outlet obstruction. They often do not have typical lower urinary symptoms, such as dysuria, urgency, and suprapubic pain. In these scenarios, pyuria and bacteriuria are also more likely, so a “dirty” UA or positive urine culture may represent their baseline status and not a new infection requiring antibiotic treatment.

Caring for such patients necessitates several considerations. If they are asymptomatic and in their usual state of health, there is generally no need to investigate for a urinary tract infection (malodorous or cloudy urine are non-specific symptoms that do not warrant further evaluation).

If patients present with sepsis, workup for possible UTI is indicated, especially if there is no other obvious source of infection. Still, it is important to remember that an abnormal UA does not establish the diagnosis (given that the UA is often abnormal in these patients at baseline), so one should keep one’s mind open to other diagnostic possibilities. It can be easy to assume that sepsis is due to a UTI and miss the true cause.

It may be appropriate to proceed with a watchful waiting approach in stable patients.

Patients with Spinal Cord Injuries

Patients with neurological conditions such as spinal cord injury and associated quadriplegia or paraplegia and neurogenic bladder may have some additional symptoms in the setting of a urinary tract infection. These include increased spasticity or autonomic dysreflexia. It is important to remember that these symptoms are not specific to a urinary tract infection and can have multiple etiologies, including other infections or non-infectious causes. Because these patients often have pyuria/bacteriuria at baseline, it is important to also think of other possible explanations for these symptoms. Sometimes it may be appropriate to proceed with a watchful waiting approach in stable patients, addressing another more likely cause of the symptoms and watching for improvement to decide if patients may need evaluation for a possible UTI).

Patient Scenarios

Below are some examples and suggested management.

For additional clinical resources for UTI diagnosis and management, consider reviewing the UTI tool kit, including the adult and pediatric clinical pathways.