J. Curtis Nickel, MD, FRCSC, discusses the antibiotic stigma associated with recurrent UTIs in a recent interview. In addition to dissecting the problem, it provides advice to practicing urologists on prescribing treatment and highlights research that could potentially transform treatment for recurrent UTIs for good. Nickel is Professor of Urology at Queen’s University and Research Chair in Urological Pain and Inflammation at Kingston Health Sciences Center, Kingston, Ontario, Canada.
How serious are the problems surrounding recurrent urinary tract infections?
We have all understood that recurrent UTIs in women are a major health problem.
Depending on the literature you read, between 40% and 60% of women suffer from a urinary tract infection in their lifetime. Many of these women have recurrences, and these recurrences can occur within 6 months in about 20% of patients who have a chance UTI.
One in 5 women overall suffers from recurrent urinary tract infections defined as being greater than or equal to 3 urinary tract infections per year. However, many of these women suffer much more, the average being 6 UTIs per year in this population of women with recurrent UTIs.
To sum up, over the course of a year, 11% of women will suffer from a urinary tract infection while 3 in 100 will suffer from recurrent urinary tract infections. So, this is really a major health problem.
How is the personal burden surrounding recurrent UTIs a problem for patients?
We generally think of recurrent UTIs as simple, uncomplicated infections that will resolve with our standard antibiotic therapy. However, in reality, recurrent urinary tract infections can lead to serious debilitating health consequences.
Patients suffer from recurrent bladder and urinary pain and bothersome urinary symptoms whenever they contract an infection. These women have a disability, and by disability I mean problems in activities of life, including employment.
Studies have shown that women with recurrent UTIs have significantly poorer mental health than the normal population. And it is even more important in certain aspects of physical health, but in particular physical sexual health. We also note that in this setting, patients have issues with their overall social well-being. This results in a very poor quality of life for women with recurrent urinary tract infections.
And then we look at the impact of the treatment they have to endure. There are many short and long term side effects of antibiotics, including serious and irreversible side effects that many of these women end up having. They may develop intolerances or allergies to standard antibiotics prescribed, which can make it more difficult to treat subsequent infections.
Many of these women, due to the long-term build-up of antibiotics from episodic or multiple prophylactic doses that may be prescribed for 3 months or up to 12 months, develop a personal reservoir of resistant uropathogens in their gut that can make the treatment of subsequent UTIs very difficult, sometimes requiring parental or intravenous antibiotics for simple, recurrent and uncomplicated UTIs.
And again, there’s the problem – rare, but it does happen – that patients can transition or develop complicated UTIs, severe episodes of pyelonephritis, and even urosepsis. Some of these consequences are associated with the threat of hospitalization and, in rare cases, death.
And finally, the frequent use of episodic antibiotics or long-term prophylactic antibiotics to treat or prevent urinary tract infections, changes the patient’s personal microbiome into an unhealthy state.
Our gut microbiome is important in keeping us healthy. It impacts our response to stress, anxiety, sleep, and well-being, and changing that into a dysbiotic or somewhat polluted gut microbiome with less diversity caused by antibiotics can be a very unhealthy state. for these women. It also impacts the microbiome of the vagina, leading to increased yeast overgrowth and yeast vaginitis. Additionally, it can impact the bladder microbiome, leading to decreased diversity, awareness, and even chronic pain states between episodes of recurrent urinary tract infections.
So, as you can see, there is a huge personal burden associated with diagnosing recurrent UTIs, despite the fact that it appears that we have effective treatment with the use of antibiotics.
Are there any stigmas associated with this condition?
Yes there are, and this is becoming increasingly evident with our knowledge of the growing importance of global antimicrobial resistance evolving in this patient population and in society as a whole.
Antibiotic therapy and prophylaxis are the only treatments recommended by guidelines in North America. It works, but it comes with all kinds of problems. We have discussed the mild, moderate, severe and even irreversible adverse events associated with the use of antibiotics. But overall, the 1 major problem we see from a people’s perspective is the fact that it promotes antimicrobial resistance.
So the stigma is that the massive use of antibiotics in this population contributes to increasing the overall cost, the difficulty of treating the infection and the transition to serious UTIs and even mortality, not only in these patients but in those patients. other patients due to this huge use of antibiotics in this population.
This really is the only stigma and it’s not the fault of patients with recurrent UTIs, and most of us in the medical profession realize that this stigma is more the result of our treatment alone than we have for this condition.
What can urologists do about this stigma?
We can do something for our patient population and for this stigma of promoting antibiotic resistance in our community. The most important thing is the management of antibiotics. We need to be very careful with the antibiotics we prescribe for UTIs, try to stick to the first-line antimicrobial treatment recommended by the guidelines, try to keep the antimicrobial treatment as short as possible, but long enough to treat and eradicate bacteria, and be careful how we use prophylaxis. Perhaps a postcoital antibiotic management program will achieve the same results in sexually active young women as long-term prophylaxis of 3 to 12 months.
Alternate-day prophylactic therapy works in many patients. Keep the dose and duration as low as possible with planned medication time off. And then we can recommend conservative measures. We’ve always done this, including post-intestinal hygiene, not using showers, tubs versus showers, and the type of clothing patients wear, but none of this really benefits the patient. In fact, they can cause self-guilt and personal anxiety.
The only conservative measure that is really proven is to increase water consumption. If patients increase their water intake to 2 liters per day, yes they will urinate a little more often, but this lower urinary tract dilution keeps uropathogenic bacteria at bay and we reduce urinary tract infections.
For postmenopausal patients, the evidence-based use of intravaginal estrogen reduces UTIs in this population. It’s not a panacea and it doesn’t work for everyone, but it certainly reduces recurrent UTIs in susceptible patients.
We can use a variety of supplements, like cranberry extract, but it’s important that we use those with a described dose of proanthocyanidins (PACS). We can use D-mannose, especially in patients with E. coli recurrent urinary tract infections. Probiotics could help improve or regenerate the gut and vaginal microbiome.
And prebiotics, trying to feed the good bacteria in our microbiome can be accomplished through good healthy eating. There are a number of dietary improvements that can be made in many of our patients, which will help their microbiome fight infection.
Finally, I believe science will help. I recently presented, at the last abstracts session of the American Urological Association annual meeting in 2021, the exciting potential of a new very safe sublingual vaccine, MV140, which significantly reduces recurrent urinary tract infections. in this population of women; in fact, preventing it in almost 60% of women who had previously had a median of 6 UTIs increasing to a median of 0 UTIs within a 9-month efficacy period. This particular vaccine is used as part of special access or compassionate drug programs in Europe, Australia, New Zealand and the UK.
And to date, over 40,000 patients have received this vaccine and it has been shown to be safe and appears, in observational studies and this most recent pivotal trial, to be effective. So, I believe there is something physicians will be able to offer beyond these conservative measures and antibiotic management in the future. I think our goal is to reduce the use of antibiotics in this population, while reducing the problem of recurrent urinary tract infections in our female population.
Is there anything else our audience should know about this topic in your opinion?
I think it’s important to address the issue of the burden these patients carry. We need to address the fact that overuse of antibiotics in this population is a major health problem and see what we can do with antibiotic management. We need to explore all the conservative measures we can in this population to reduce overall antibiotic use.
The perceived stigma that this population promotes antibiotic resistance is not the patient’s fault. It is our responsibility as physicians and urologists to find the answers for our patients. And I think evolving science, as I mentioned, is going to help us help our patients. Any burden or stigma associated with this condition will gradually improve as we better approach the underlying problem by reducing the risk of developing recurrent UTIs.
This article originally appeared on Urology TimesÂ®.