BackTable Urology
Ep. 286 Antibiotic Stewardship in Reconstructive Urology with Dr. Joshua Sterling
27 Jan 2026
Chapter 1: What is the main topic discussed in this episode?
This week on the Backtable podcast.
I think the future is really going to be being able to tailor a pre, peri, and post-operative antibiotic course to a patient.
Chapter 2: What is antibiotic stewardship in reconstructive urology?
Understanding where they are, how their other health parameters play into it, you know, instead of just saying, regardless of what else is going on in the patient, if this comes back, this is what we're going to do. Taking into account, you know, are they immunocompromised? Is there a reason where, you know, maybe they don't have as much reserve as another patient?
So we should err on the more cautious side in terms of treating things.
Chapter 3: How is the current landscape of antibiotic use in urology?
And then really, bacteria do help us. And so, you know, again, moving the conversation away from sterilization and complete cleaning of the GU tract to restoring that balance so that everything is functioning the way that it should be.
Welcome to Backtable Urology, everyone. I'm George Koch from The Ohio State University, and I'm really excited to introduce Dr. Joshua Sterling from Yale University today to discuss antibiotic stewardship in reconstructive urology. Thanks so much for being here, Josh.
Yeah, thanks for having me. I'm really excited about what we're going to talk about today.
Chapter 4: What protocols and practices are used in reconstructive procedures?
Yeah, very much so. You know, you and I have had a bunch of conversations about antibiotic stewardship and, you know, really put our heads together about some projects. So I'm very excited to go over it with you today. Could you start by telling us a little bit about yourself and your path to reconstructive urology?
Yeah, so I didn't have a very straight path to reconstructive urology.
Chapter 5: What are the risks of antibiotic overuse and misuse?
I kind of tried a bunch of other things and ended up there. My background is in engineering. Growing up, I was always a tinkerer, building stuff with my dad and things like that.
Chapter 6: How can we shift the urinary microbiome for better outcomes?
And when I got to residency, I... The only thing I knew I didn't want to do was oncology and then slowly kind of realize that there was this world where not everything was set, where you can kind of, for lack of a better word, play with what you're going to do for the patients and really, you know, kind of personalize the treatment that you're giving them.
And that's kind of really what sucked me in. And once I figured that and it just approached everything like it's an engineering problem and a problem set, I was hooked and there was no going back.
Chapter 7: What role do chlorhexidine irrigations play in infection management?
Yeah, no, definitely a field where, I mean, your word, where you can tinker. So it sounds like it was a good fit. And about antibiotic stewardship, could you tell me a little bit about kind of what your interest is in antibiotic stewardship and the urinary microbiome and reconstructive urology?
Yeah, so I think I really got... I didn't pay much attention to it in training. I was just kind of, you know, your culture would pop up, you're treated. We had our standard protocol at SUNY Upstate and never really questioned it.
Chapter 8: What future directions are there for antibiotic protocols in urology?
And then probably the first year I was in practice, I got a culture for a bacteria I'd never heard of before. They started like subspeciating our different species of Klebsiello and looked into that and realized that What we think of as, you know, bacteria and then positive urine cultures is probably the tip of the iceberg.
And if there are actual, you know, ribosomal differences and enzyme differences in the bacteria, maybe there are clinical differences as well. And so kind of really tried to dig into it and realize that there wasn't much there, at least in the urology literature, which is kind of, you know, UA reflects the positive culture. If culture there, then treat.
And I realized that there's a wide world where we could really be doing a lot more for patients. I think that's when I started talking to people about it and getting interested in and realizing that I wasn't the only one having these thoughts.
Yeah. I think a lot of us have that moment. So I was a chief resident at Vanderbilt and We had a couple of patients who had like urosepsis and bacteremia. And, you know, one went home on, needed to pick IV antibiotics for, you know, two weeks. One person went home on like five days of Bactrim.
like it was very different and i remember saying okay well i'll do one of our like education sessions on you know urosepsis and bacteremia so that you know when these patients come in we won't have to consult id we'll just take care of the the bacterium ourselves it shouldn't be that that big of a an issue so i reached out to one of the infectious disease doctors and they were like that's not how bacteremia works like it's not it's not just like
bacteria in blood, this is your antibiotic duration. And I, and I was, I was, you know, I was a little hell bent on it. I was like, I am going to figure this out. So I go and I get the ID textbook, like they're, they're Campbell Walsh. And I find out that each bacteria, like each subspecies of bacteria in this book, has its own chapter. Like that's how they broke it down.
And I was like, oh, this is not a disease process thing. This is a bacteria thing. And I am never going to, I had to like abandon the idea because it was just, it was preposterous, I think, of me to think that we could just like, oh no, I know we get ID consults, but let me just like cover this in a lecture real quick.
And it was the first time that I, you know, similarly started thinking about we are in a little bit of a data free zone and then going into recon, you know, it was it was more of a data free zone. But we deal, you know, unlike maybe andrology and infertility, although they have implant infections or, you know, stones and urosepsis from endoscopic procedures.
I feel like every single one of my patients has a tube and it's not like some patients who I treat.
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