In reconstructive urology, preventing infection often means prolonged antibiotic exposure, raising important questions about stewardship and long-term harm. In this episode of BackTable Urology, Joshua Sterling of Yale University joins host George Koch to examine how antibiotic stewardship and emerging insights into the urinary microbiome are reshaping infection management in reconstructive practice.

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SYNPOSIS

The discussion centers on real-world clinical challenges, particularly in high-risk populations such as patients with neurogenic bladder, chronic catheterization, or prior reconstruction - groups in whom antibiotics are frequently used prophylactically or indefinitely. Drs. Sterling and Koch explore how well-intentioned prescribing patterns can contribute to resistance, dysbiosis, and recurrent infection, while often failing to address the underlying drivers of disease.

Rather than framing infection control solely around eradication, the conversation considers a shift toward modulation of the urinary microbiome, drawing on lessons from gastroenterology, infectious disease, and transplant medicine. The episode concludes by outlining how a more nuanced, multidisciplinary approach may better serve reconstructive urology patients in the long term.

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TIMESTAMPS

00:00 - Introduction
02:22 - Antibiotic Stewardship in Urology
06:34 - Current Landscape of Antibiotic Use
13:44 - Protocols and Practices in Reconstruction
18:24 - Antibiotic Overuse and Misuse
21:02 - Shifting the Microbiome
25:12 - Chlorhexidine Irrigations
32:38 - Future Directions
38:27 - Implementing Antibiotic Protocols
40:48 - Conclusions

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RESOURCES

STOP-IT Trial
https://www.nejm.org/doi/full/10.1056/NEJMoa1411162