Barbara Trautner: Professor of Medicine, Co-Chief, Infectious Diseases Division, Washington University School of Medicine, St. Louis, Missouri, USA
Citation: Microbiol Infect Dis AMJ. 2025;3[1]. https://doi.org/10.33590/microbiolinfectdisam/QAJK1579
What are the most practice-changing updates that were introduced in the session, ‘What’s New in Urinary Tract Infection (IDSA cUTI Guideline Panel and the UTI WikiGuideline Panel)’? Are there any that frontline clinicians should be applying immediately?
I think that the most practice changing update was for us to simply agree with clinical practice for the classifications of urinary tract infection (UTI). People were already using, in their minds, the distinction between uncomplicated and complicated UTI (cUTI) based on whether the infection has gone beyond the bladder or not, since that changes which antibiotics you’re going to use, and often the location of treatment, inpatient versus outpatient. We didn’t invent this idea; we just aligned our definitions with how people were practicing medicine. I think people were excited that we included the possibility that men could have an uncomplicated UTI because we all know what a burden it is to try to keep people on antibiotics longer than necessary. It is also practice changing that we included men.
Which parts of the guidance do you think will most improve real-world decision-making?
I really hope that our four-step process of choosing an empiric antibiotic for cUTI will help frontline clinicians. I’m going to give a shout out to panelists, Nico Cortés-, and everyone on the panel for helping us develop this concept. If we were to recommend three best drugs, that would be outdated in just a few years, and that recommendation might not even apply in certain places where they have different resistance patterns.
It’s a four-step process that you apply to individualize the empiric antibiotic choice to the patient in front of you. You apply the four steps and then you choose among the remaining drugs that are in the preferred category, rather than just starting by giving everyone this one drug.
It’s codifying what people were already doing and making decision-making a little more formal for them. The first step is severity of illness, sepsis versus no sepsis, shock versus no shock. That decision puts you on different paths to preferred antibiotic groups. The next step is to consider what risk factors the patient has for an organism resistant to the antibiotic that you’re thinking about. The third step is what antibiotic can the patient take? That’s kind of the art of medicine. Can they take oral or intravenous? What drug interactions may impact your choice? And the fourth step, only with septic patients, is to use the antibiogram to prevent excess mortality related to not choosing a broad enough antibiotic.
What guidance emerged to help clinicians avoid overtreatment without compromising outcomes when balancing antimicrobial stewardship with patient expectations for rapid relief?
I don’t think we’re thinking so much in terms of rapid relief for cUTI, we’re thinking of preventing mortality. It’s a balance between antibiotic stewardship and preventing mortality, particularly in the septic patients where the risk of mortality is higher. We’re very proud of the modeling that we did for the impact of choosing the wrong drug initially versus the right drug initially. That’s how we were able to set our modeling thresholds for using the antibiogram in sepsis with shock, to choose an antibiotic for which the suspected organism is 90% likely to be susceptible to. In sepsis without shock, you’re looking for an antibiotic for which the suspected organism has a predicted 80% susceptibility. There’s your balance, if you apply the antibiogram in the strictest sense to every single patient.
When we initially including the antibiogram step 4 in all cases, in a draft version of the recommendations, every patient ended up on a carbapenem when we applied it to real world cases. So there had to be some kind of balance. That’s how we modeled the antibiogram use as a specific way to prevent excess mortality.
What parts of UTI guidance still need development or updating?
In the cUTI guidelines, we focused on cUTI empiric treatment, length of treatment, and intravenous-to-oral switch. We’re missing some pieces of UTI guidance like updating the uncomplicated UTI guidelines, and then we probably need diagnostic guidelines because we don’t touch on how you diagnose UTI in these guidelines. The WikiGuideline group, which we shared the session with, used a different methodology and was surprised by the lack of evidence for many key clinical questions in UTI. This is not a simple infection that should be neglected, it’s something that merits much more study, and I hope we can expand and do more guideline updates.
These guidelines represent a huge collaborative effort. Is there anyone you would like to recognize for their contributions?
First, the panelists who represented emergency medicine, hospital medicine, pharmacists, obstetrics, gynecology, and primary care. We wanted a representative panel of the people who would need to apply the guidelines. I want to thank all the panelists for all their intelligent suggestions that led us to the guidelines that we have. I particularly want to thank my co-chair, Valéry Lavergne [Vancouver General Hospital, Canada], who is our GRADE methodologist, and who has an IDSA appointment to support guidelines development. The second and third authors, Nico Cortés-Penfield and Kal Gupta, spent a lot of time looking at different revisions of the documents. Other people who made these better were our reviewers. Because we had so many different reviewers, different societies doing reviews, and public comments, all of that helped contribute and make the guidelines more practical. And, to the patients that participated as volunteers in all aspects of the guideline development, I am appreciative of their work.
What did it mean for you personally to present these new guidelines?
I’d be glad to share that. When I was an infectious diseases fellow, I was obsessed with the wonderful IDSA catheter-associated UTI guidelines. So much that Mac Hooten [University of Miami, Florida, USA], who was the lead author, let me review a draft and be one of their external reviewers. I’m actually named in the acknowledgments and that meant so much to me, as I had pored over every word. A few years later, I was invited to join the IDSA Asymptomatic Bacteriuria Guidelines panel as a co-author, and that was super exciting. That project actually carried me through a period when I was being treated for breast cancer, as I had something very positive to work on and contribute to, and that was meaningful. I then volunteered to co-chair the IDSA UTI guidelines, and this experience has definitely been a career milestone for me. Seeing them finally out and hearing how people are putting them into practice and exploring how they can best make those guidelines fit their specific practice has been an incredibly meaningful experience.
Your long-standing research has focused on preventing recurrent catheter-associated UTIs and reducing antimicrobial overuse. What strategies do you see as the most promising for reducing recurrence in high-risk populations?
I’m going to sound a little solemn here because I think we are failing our patients in what we currently have available to prevent recurrence, because antibiotics are not preventing recurrence. A lot of the things sold on the internet are not preventing recurrence, and if cranberry helps, and there’s some evidence that it does, it’s a minor help. I think that we need a lot of strategies for preventing recurrence. There’s a big difference between patients with a catheter and those without a catheter.
For the ‘without catheter’ population, people are predisposed to recurrent UTI. It’s either something about their immune systems, their bladder mucosa adhesins, the specific organisms they get, or other things, but they keep getting these UTIs again and again. It’s going to be multifactorial: vaccines are probably going to be one approach, urinary antiseptics will have a role, and bacteriophage, the living predators on bacteria, may have a role too. I’m envisioning multifaceted strategies to try to help prevent recurrent UTI.
How can clinicians better integrate patient education and behavioral interventions to improve UTI outcomes?
Clinicians need to listen to the patients. We had patient representatives who experience extreme forms of UTI symptoms. Their distress is real and their lives are impaired. The fullness of their life is impaired by this non-stop bladder pain. I think people can dismiss that and say, “No, it’s not something they need antibiotics for, they’re just confused.” We need to come together and listen to people. Our job is to relieve the suffering and find out what the suffering is caused by. To better design the research studies that need to be done, I think we need to gain people’s trust by listening to what they have to say.
What are the current biggest gaps in equitable UTI management, given presentation, diagnostic access, and antimicrobial resistance patterns can vary across populations?
In our current well-resourced healthcare setting, when a woman or man gets an acute symptomatic UTI, even in the best of circumstances, they have trouble accessing care in a timely fashion. If it happens at night, how do they get in and provide a urine specimen for culture? You don’t know if you can be seen the next morning. If I have trouble getting a urine culture for my own family member in a timely manner, how will someone who can’t get to healthcare, doesn’t have a regular doctor, or doesn’t have insurance, actually get tested? That probably drives emergence of more pyelonephritis from untreated UTIs. That’s in the United States. In other parts of the world, antibiotics are sold over the counter, because otherwise, how will the person ever get any treatment? Then you’re creating resistant organisms over time through self-treatment. People are empowered, they can have antibiotics when they need, but we don’t know what they’re treating, and then they get resistant organisms.
Which emerging areas excite you most from a translation-to-bedside perspective in the expanding field of UTIs?
I’m trying to start a bacteriophage trial for chronic bladder colonization with Escherichia coli in persons with neurogenic bladders from spinal cord injury. I’m very interested in phage as an adjunct to antibiotics to prevent recurrent UTI, with the idea that the phage would help root out persistent organisms in different parts of the genitourinary tract. The trial is registered with ClinicalTrials.gov (NCT06559618).1 We enrolled one patient before I moved institutions, but we plan to restart it here. It’s for people with neurogenic bladders from spinal cord injury or spinal cord related disorders. It’s a Phase I trial, so I’m not trying to relieve symptoms of UTI, just trying to see if we can get rid of the E. coli colonizing people’s bladders. This trial is funded by the Craig H. Neilsen Foundation.
Congratulations on your leadership appointment at Washington University! What do you hope to achieve in this role?
So, I’m at Washington University in St. Louis, Missouri, US, and I’m Co-Chief of Infectious Diseases. This is a thriving division, and I hope to take really good care of my people, the division and infectious diseases practitioners in general. I was motivated to make the switch for several reasons, one of which is I felt that infectious diseases as a field hasn’t quite recovered from the pandemic. We got overworked, we got sad, and now we’re dealing with people who don’t want vaccines and we’re sad about that too. It’s a time to stand up and support infectious diseases practitioners, and I thought one of the best ways I could do that was in a leadership role of a strong division at a major academic institution.
