Urinary tract infections and stewardship practices – For a urologist (KIDNEY-AMSP model)

Urinary tract infections (UTIs) account for a major proportion of infectious disease consultations in hospitals. Tertiary centers report that UTIs account for 25%–30% of the bacterial isolates and drive major antibiotic use.[1] The burden spans uncomplicated cystitis, pyelonephritis, complicated infections in patients with diabetes or renal failure, catheter-associated UTIs (CAUTI), and post-operative or post-instrumentation infections following transurethral procedures or stenting.[2] India faces a dual challenge: high prevalence of infection and rising antimicrobial resistance (AMR) in uropathogens. National surveillance reports consistently reveal increasing resistance to fluoroquinolones, third-generation cephalosporins, carbapenems, and colistin.[3] Many hospitals continue extended prophylaxis after procedures, and misinterpret colonising flora as infection, along with delayed or omitted diagnostic sampling, amplifying the antimicrobial misuse. Integrated antimicrobial stewardship frameworks, such as the 42 practice statements of the Society of Antimicrobial Stewardship Practices (SASPI) in India, provide context-specific guidance to counter these challenges.[4] For urologists, stewardship is not limited to rational antimicrobial selection; it encompasses diagnostic precision, procedural asepsis, device care, and patient education. URINARY TRACT INFECTION SPECTRUM CONTRIBUTING TO ANTIMICROBIAL RESISTANCE AND ITS CONCERN Community-acquired UTIs: are caused by Escherichia coli, Klebsiella spp., and Enterococcus faecalis. Increasing resistance to fluoroquinolones and β-lactams has reduced the reliability of empirical regimens.[5] Over-the-counter antimicrobial use and incomplete courses further sustain reservoirs of resistance Complicated and recurrent UTIs: Patients with diabetes, chronic kidney disease (CKD), or anatomical abnormalities frequently receive prolonged broad-spectrum therapy without culture guidance. Lack of periodic culture testing leads to repeated exposure to ineffective drugs[6] CAUTIs: account for 40% of the nosocomial infections in tertiary hospitals.[7] Biofilm-forming Gram-negatives and Candida spp. dominate. Poor adherence to catheter-care bundles, indiscriminate prophylaxis, and delayed device removal perpetuate these infections Post-surgical and instrumentation-related infections: Transurethral resection of the prostate, ureteroscopy, and percutaneous nephrolithotomy are frequent triggers for perioperative antimicrobial misuse. Despite guidelines recommending prophylaxis limited to 24–48 h, many centers extend therapy for several days.[8] Such practices heighten selective pressure and contribute to hospital AMR clusters Fungal UTIs: Excessive use of broad-spectrum antibacterials and catheterization predispose to Candida colonization, which is often misinterpreted as infection. Unnecessary antifungal use follows, driving azole resistance.[9] Together, these patterns reflect how empiricism, prolonged prophylaxis, and misinterpretation of cultures drive a self-perpetuating cycle of AMR and treatment failure. STEWARDSHIP: UROLOGISTS AS PROBLEM-SOLVERS Diagnostic stewardship The cornerstone of rational management is accurate pathogen identification. While culture is not required in all the uncomplicated infections, it is essential in complicated, recurrent, or healthcare-associated UTIs and prior to initiating or changing broad-spectrum therapy.[6] Proper specimen collection: clean-catch or catheter-derived urine before antimicrobial exposure, and timely transport to the laboratory are crucial. In India, insufficient training in collection often leads to contamination and misleading reports.[10] Microbiologists and clinicians must jointly standardize protocols to reduce false positives. The urinary tract may be colonized by non-pathogenic flora; therefore, culture positivity alone does not necessarily indicate infection. As emphasized by Panda et al.,[11] diagnostic stewardship must distinguish pathogen from nonpathogen through clinical correlation, quantitative thresholds, and assessment of inflammatory response. Uncritical reporting or treatment of colonizers in asymptomatic patients constitutes misuse. Rapid diagnostics, such as urine flow cytometry, MALDI-TOF (Matrix-Assisted Laser Desorption/Ionization Time-of-Flight) identification, and molecular resistance assays, should supplement, not replace, clinical reasoning. Therapeutic stewardship Empiric regimens should be tailored to local antibiograms and patient context. For uncomplicated cystitis, narrow-spectrum oral agents such as nitrofurantoin or Fosfomycin remain the preferred first-line options.[2] Fluoroquinolones, cephalosporins, and carbapenems should be reserved for specific indications. Source control is a vital yet often delayed component of therapy. Early source control reduces both the duration of antimicrobial therapy and the risk of relapse.[12] Duration must be standardized: 3–5 days for uncomplicated infections, 5–7 days for pyelonephritis or complicated cases, and culture-directed modification thereafter.[6] Unnecessary combination therapy should be actively discouraged. Surgical and procedural stewardship Evidence indicates that a single pre-procedure dose or prophylaxis limited to 24–48 h is sufficient for most endourological interventions.[8] Routine continuation “until catheter removal” lacks justification and promotes resistance. Regular audits should be part of the departmental quality indicators. Minimally invasive procedures have improved recovery times but increased reliance on indwelling catheters and monitoring lines. Therefore, asepsis and catheter care bundles are essential to balance minimal invasion with maximal infection control.[13] Preventive stewardship Infection-prevention strategies must focus on: Strict catheter-care bundles Hydration counseling, especially for elderly or CKD patients Vaccination where indicated (e.g., influenza to prevent secondary infections), and Promoting hygiene and appropriate antimicrobial use in community settings helps reduce the reservoir of resistant organisms entering hospitals. Educational and organizational stewardship Ongoing staff education on collection methods, prophylaxis policies, and AMS updates is essential. New trainees should undergo induction on IAS (Integrated Antimicrobial Stewardship) practices led by microbiologists and infection-control nurses. Departmental AMS champions (urologist, microbiologist, and pharmacist) can monitor antimicrobial audits, surgical prophylaxis compliance, and infection trends.[4] Community education is equally important; patients must understand the risks of self-medication and incomplete courses. One health connection One Health recognizes that misuse of antimicrobials in humans, animals, and agriculture fuels shared resistance ecosystems. Urologists contribute by ensuring judicious use in hospitals and by sharing AMR data with national surveillance systems such as NCDC’s Bulletin and ICMR-AMRSN towards a better one-health strategy.[14] SOCIETY OF ANTIMICROBIAL STEWARDSHIP PRACTICES PRACTICE POINTS FOR UROLOGISTS The SASPI consensus offers a pragmatic structure to each tertiary care hospital, adaptable to urinary-tract infections.[4] Key aligned recommendations [Box 1] include: Integrate diagnostic-stewardship standard operating procedures for sampling Implement audit systems for perioperative prophylaxis Restrict carbapenem and colistin use to culture-proven MDR pathogens (rule out non-pathogens first) Ensure pharmacist involvement in antimicrobial monitoring Develop outpatient parenteral antimicrobial therapy (OPAT) pathways for complicated UTIs requiring prolonged IV therapy. Box 1: The 10 core elements of the integrated antimicrobial stewardship framework – the “KIDNEY-AMSP model”Recent Indian data show that <30% of hospitals have functional AMS audits and only ~15% have OPAT protocols;[4] the urology department must lead the improvement. UTIs exemplify the intersection of high infection prevalence and escalating resistance. For urologists, stewardship is integral to patient safety, not an adjunct responsibility. From obtaining a reliable sample to choosing, dosing, and discontinuing the therapy, every step influences AMR dynamics. Embedding the SASPI practice framework within departmental protocols can transform stewardship from policy to practice (KIDNEY-AMSP Model). Declaration regarding use of AI/AI tools The author/s have not used AI and AI-assisted technologies, including large language learning models, in the preparation of the manuscript. The author/s confirm that they have reviewed the manuscript and take/s full responsibility for the contents in the article. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.