Bringing UTI Conversations to Boynton: An Antibiotic Stewardship

[December 2018] Reem Elbasher, Rachel Grushan, Chetana Guthikonda, and Victoria Skolnick are working to prevent antibiotic resistance by increasing awareness about UTIs and how to treat them. Their first stop: Boynton Health.

Can you explain your project to bring UTI education to Boynton?

Rachel: We’ve been referring to this as a stewardship project, because it’s focused around the idea of antibiotic stewardship, which is making sure that antibiotics are used responsibly for the betterment of everyone as opposed to just individuals.

Rachel: The GCC class that we took was about antibiotic resistance, which is a growing issue across the world. We had the idea to focus in on UTIs, which are very common.

Reem: 50% of women will get at least one UTI in their lifetime. And I think it’s ⅓ of those will get recurring ones.

Rachel: Right, so UTIs- being Urinary Tract Infections- are pretty much always resolved by prescribing an antibiotic. The personal experience I’ve had is that I've always been prescribed a lot of antibiotics for UTIs, and I didn’t realize that was problematic until I took this class. We learned about patterns of resistance, and how your body can become resistant to the drugs if you’re taking too many of them too frequently. So we decided to look more into that.

Chetana: We learned that UTIs were common, recurrent, and antibiotics were almost always the only thing prescribed for them. There are other methods, but the physicians that we talked to often times weren’t aware of those methods, or considered them not as effective.  

Reem: The worst case scenario with a UTI is that it would develop into a new kidney infection. Providers are worried about that, so just to be safe they prescribe antibiotics.

Rachel: Our actual project is a hand out. It’s like a conversation starter, like a tool that the patient brings with them into the office when they see their provider with a UTI. It has questions listed that are meant to spark a conversation about responsible antibiotic use with their provider. So there’s some questions about “What do my test results mean? Do they confirm the presence of the bacteria that causes UTIs?” Some of the tests that are done don’t necessarily mean you have a UTI. There’s something called a urinalysis that basically confirms bacteria but does not confirm the UTI. We include these questions so that the patient can have shared decision-making with their provider about whether an antibiotic is the best course.

Victoria: To add on to that, it’s not meant to be a list of questions that providers can go through. I know that some providers were a little uncertain if they would have time to do it. It’s more so a tool to stimulate that conversation that needs to happen.


How did you come up with the idea of a handout?

Chetana: This actually wasn’t our first idea. We had something different, but then we realized a handout as a tool for communication was more effective. Through our research and in our interviews with other physicians, we’ve come to realize that it’s not that patients aren’t aware or don’t want to know all of their options; most of the time patients are intimidated when they are sitting with their physician, and they are telling them things but don’t really know what to ask. We found existing research in something called "shared decision making," which looked at conversations between physicians and patients. These conversations resulted in a decrease in prescriptions of antibiotic use without any negative effects and without a decrease in patient satisfaction. Our solution would be a conversational tool to promote shared decision making between the patient and physician.


Why are you testing this handout as a conversational tool at Boynton?

Rachel: We wanted to work with Boynton because first of all, UTIs are really common among college-aged women. This is the perfect microcosm to focus on. We spoke with the Director of Public Health at Boynton, Dave Golden, about how prescriptions for UTIs are contributing to antibiotic resistance. He said the first step at Boynton would be to create some buy-in with the providers, because antibiotic resistance is something that providers are thinking about. However, it's not always at the forefront of providers' minds. When you see a patient, you want to resolve the issue that patient is having, but you don’t always consider the bigger picture. Dave said that to create some buy-in, we could have Dr. James Johnson come in and do a Continued Medical Education lecture. Dr. Johnson is a professor of medicine here, though right now he works at the VA. He’s done a lot of research on E. Coli, which is the bacteria that causes UTIs.

Chetana: The lecture will be on January 24th [2019] from 12-1 in the ROEN room at Boynton.

Rachel: Dr. Johnson will be talking about resistance and UTIs, along with management. Hopefully after that we can move on with the project and see if there’s anything we can do with students for Boynton, or if there’s any way they want to utilize our handout.


Would you say your goal is to spread awareness and open up a conversation about antibiotic resistance?

Victoria: The patients don’t really want to bring up this issue and neither do the providers. The handout is mostly just to stimulate that conversation, and to emphasize that this is something that needs to be talked about. Then, if patients have a different clinic that they go to later on, maybe they’ll bring it up there too. Our main goal is to show that this is something that needs to be addressed in an appointment.

Rachel: I think it’s also about investing patients in their own care. College-aged patients have likely heard about resistance before, so it’s more about seeing how your personal health relates to these larger issues and really investing in that.

Chetana: It’s also empowering when you know what’s going on and can make decisions and take control of your own health. Again, if the patient wants to talk about it, the physician will talk about it.

Reem: We’re not necessarily pushing our flier idea; we just want to be able to play some role in addressing this issue from the student’s perspective. We learned from talking with Dave Golden that staff does tend to talk about it, but it's not really addressed from the student perspective. I think that’s where we’re coming from, is as students and as representatives of the population. We just want to be able to help in whatever way that we can.


Do you have a way that you’re going to be measuring your results?

Rachel: Best-case scenario is we would run a pilot study. Dave Golden said that before we do anything like a pilot, we need to create that buy-in with the providers at Boynton first. It would be awesome if we could just give a laminated handout to patients that come into Boynton with a UTI. We could measure if there are recurrences in patients who received the handout. We don’t know yet if we can access data about people that were actually prescribed antibiotics, but that’s best case scenario. We do not even know if the handout is what we’d end up working with. It’s just a matter of getting involved.


What made you want to work on antibiotic resistance related to the treatment of UTIs specifically?

Reem: We were in GCC 3016/5016, which that talked about antibiotic resistance, and our group specifically was working on stewardship. We were just brainstorming ideas, and I think it started with Rachel talking about her experience at Boynton.

Rachel: I had gone in with three recurrent UTIs and I got prescribed three different antibiotics for it. And like I said, I didn’t think that was an issue because from my perspective, whenever I got another UTI, I was like “Oh, super easy, I just go into Boynton and they give me this drug and then it goes away in a couple of days. This must not be a big deal because it’s so easily resolved.”After taking GCC 3016/5016 and learning that if you’re switching from one antibiotic to another, then that can build antibiotic resistance.

Reem: Rachel's personal experience helped direct us to the specific population of students going in for UTIs at Boynton. I think that without her personal experience, we would have done it at a much broader level that maybe wasn’t as realistic or applicable. It was a good starting point for us.


Is there a chance your message won't make a long-lasting impact?

Reem: I think that’s always going to be a possibility, and we've talked about it with Dave Golden. He mentioned that in the past, Boynton has addressed the issue of antibiotic resistance in regards to upper respiratory infections. When they started addressing that, they noticed prescription rates at Boynton going down for that type of infection. That could be applicable to us if we’re lucky enough to get access to that information.

Chetana: Having partners like Dave definitely increases our chances of getting the message across. He’s also very invested, which is exciting for us to see, because it means that we will have more access to track whatever comes after our efforts.

Rachel: Our whole model of having a list of questions to bring in with the provider, that’s not something that’s particularly new. We based that off of handouts that exist in clinics that are not specific to UTIs, but just talk about responsible antibiotic use in general. There are copies of those handouts online, and we know that they’re being used in clinics. It’s not a particularly new idea, it’s just that we’re catering it specifically to UTIs because we know that on a college campus, it’s a really common infection.  

Chetana: We were also talking about sending out a follow-up email along with the handout. The email could be used as a conversational tool or a satisfaction survey to track the effectiveness some way. These are all ideas that might sustain it in the long term if it’s embedded long enough.


Are all of you from different majors?

Reem: Yes. I’m a Biology major.

Rachel: I’m in Child Psychology.

Victoria: I’m Biology, Society, and Environment.

Chetana: I’m Neuroscience.


Wow, so quite a range. How is it working together on something?

Reem: It worked really well because we all have similar long-term goals. We’re all pre-health students so I think we have similar interests. Also, us three have hard, physical biological science majors, but Rachel’s perspective is different. It's always nice to hear Rachel's persepctive, because sometimes it’s hard to get different ideas when you’re around science students all the time.

Rachel: I feel lucky that we ended up in this group together. I feel like a lot of times, group projects do not pan out this way, and you’ll never see those kids again after the class is over. So it was really nice that we randomly got put together and got to meet each other and work on this even after the class was over.

Reem: We were all very invested in it from the beginning, which I think is why it’s been contuing on past the class.

Rachel: And because we realized our idea was actually doable.

Chetana: I think we’re also very invested in being holistic future health care professionals, so learning about an issue like this and knowing we can use these resources from now on for personal development is great, too.

Victoria: We all want to be physicians, and we know we would have to deal with antibiotic resistance in the future, so we might as well start now!


What has been your favorite part of working together, or of doing this project?

Reem: My favorite part of this project was talking to Dr. Jim Johnson at the VA. I thought that was a really interesting conversation. We got to hear a lot from the perspective of someone who treats UTIs regularly. It was interesting to hear his opinion on how things work right now in regards to treating UTIs versus how he thinks they could be. Without that conversation, I don’t think we would have come up with the idea of the flier, because that stemmed from that interview.

Victoria: I think the conversation with Dr. Johnson was a turning point in the project where we actually started to accelerate into our specific goal. And it was very interesting to learn from him.

Rachel: It’s also been fun to find something in medicine that hasn’t really been solved yet. There isn’t an easy answer to this, people have different ideas, and physicians disagree about how UTIs should be handled. It’s kind of cool to be in that grey area where science hasn’t figured everything out yet. We’re trying to find a way to deal with that and make sure that patients are healthy and happy.

Chetana: Over the summer we talked with CIDRAP, which is the Center for Infectious Disease. It was really cool because they’re located at the University of Minnesota campus, but they’re a national organization. It’s their job to collect the most recent information about the antibiotic resistance project, which is one of their specific goals. They compile information every single day to put together the latest research. We have access to an entire database with all this research, and it was really helpful.

Rachel: They were super nice to talk to. We talked to a couple of reporters from CIDRAP, and they encouraged us to keep going with our project. They said, because we sounded knowledgeable and that we cared about this, Boynton would be on board if we talked to them.

Reem: For me it’s really fun to address this issue from the social side of things, rather than just the science side. It’s something that I don’t get to experience a lot. I think it’s a really interesting perspective to address it from, rather than trying to get into the science of everything.


Is there anything else you want people to know?

Rachel: If students find something they are passionate about, don’t be afraid to be persistent and try. Try it even if it doesn’t pan out the way you were expecting.

Reem: Be open to your ideas changing. You don't have to be stuck to one thing.