The stigma surrounding antibiotics for recurrent urinary tract infections

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J. Curtis Nickel, MD, FRCSC, in a recent interview, discussed the antibiotic stigma associated with recurrent urinary tract infections. In addition to analyzing the problem, he advises practicing urologists on prescribing treatments and highlights research that may ultimately change the way we treat recurrent urinary tract infections. Nickel is Professor of Urology at Queen’s University and Research Professor of Urological Pain and Inflammation at Kingston Health Sciences Center, Kingston, Ontario, Canada.

How extensive are the problems associated with recurrent urinary tract infections?

We all understand that recurring urinary tract infections are a major health concern in women.

Depending on the literature you read, between 40 and 60% of women will develop a urinary tract infection at some point in their life. Many of these women have relapses, and these relapses can occur in approximately 20% of patients who have an accidental urinary tract infection within 6 months.

Overall, one in five women has recurrent urinary tract infections, which are defined as 3 UTIs per year or greater. However, many of these women suffer much more, with an average of 6 urinary tract infections per year in this group of women with recurring urinary tract infections.

In summary, over the course of a year, 11% of women will develop a urinary tract infection, while 3 in 100 will have recurrent urinary tract infections. So this is really a big health problem.

How is personal exposure associated with recurrent urinary tract infections a problem for patients?

We usually think of recurrent urinary tract infections as straightforward, simple infections that go away with our standard antibiotic therapy. In reality, however, recurring urinary tract infections can have serious health consequences.

With every infection, patients suffer from recurring bladder and urinary tract pain and annoying urinary tract problems. These women have a disability, and by disability I mean problems with performing life activities, including employment.

Studies have shown that women with recurring urinary tract infections have significantly poorer mental health compared to a normal population. And it’s even more important in some aspects of physical health, particularly physical sexual health. We also find that patients experience problems with their general social wellbeing. This leads to a very poor quality of life for women who suffer from recurring urinary tract infections.

And then we look at the effects of the treatment they have to endure. There are several short- and long-term side effects of antibiotics, including serious, irreversible side effects that many of these women end up experiencing. You may develop intolerance or allergies to the prescribed standard antibiotics, which can make treatment of subsequent infections more difficult.

Many of these women, due to the long-term accumulation of antibiotics from multiple episodic or prophylactic doses that can be prescribed for 3 months or up to 12 months, develop a personal reservoir of resistant uropathogens in their gut that can make treatment for subsequent urinary tract infections very difficult, sometimes simple recurring uncomplicated urinary tract infections require parental or intravenous antibiotics.

And then there is the problem again – rarely, but it does happen – that patients can develop or develop complicated urinary tract infections, severe episodes of pyelonephritis, and even urosepsis. Some of these consequences are linked to impending hospitalization and, in rare cases, even death.

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 to an unhealthy state.

Our gut microbiome is important to keep us healthy. It affects our response to stress, anxiety, sleep, and wellbeing, and switching to a dysbiotic or slightly polluted gut microbiome with less diversity from antibiotics can be a very unhealthy condition for these women. It also affects the microbiome of the vagina, which leads to increased yeast growth and yeast vaginitis. In addition, it can affect the bladder’s microbiome, resulting in lower diversity, awareness, and even chronic pain conditions between episodes of recurrent urinary tract infections.

As you can see, diagnosing recurrent urinary tract infections comes with an enormous personal burden, even though we seem to have effective antibiotic therapy.

Are there any stigmas associated with this condition?

Yes, there is, and it becomes more and more evident as we understand the increasing importance of antimicrobial resistance as a whole that is evolving in this patient population and in society at large.

Antibiotic treatment and prophylaxis the only therapy recommended by guidelines in North America. It works, but it comes with all sorts of problems. We talked about the mild, moderate, severe, and even irreversible side effects associated with antibiotic use. But overall, the most important problem that we see from a population perspective is the fact that it promotes antimicrobial resistance.

So the stigma is that the massive use of antibiotics in this population adds to the overall cost, difficulty in treating infection and transition to severe urinary tract infections, and even mortality not only in these patients but also in other patients as a result of this massively increasing use of antibiotics in this population.

That really is the only stigma and it is not the fault of the patients with recurrent urinary tract infections and most of us in medicine know that this stigma is more the result of our only treatment we have for the 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 antibiotic stewardship. We have to be very careful about what antibiotics we prescribe for urinary tract infections, try to stick to the first-line antimicrobial therapy recommended by the guidelines, try to keep the antimicrobial therapy course as short as possible but long enough to treat the bacteria and eradicate, and be careful how we apply prophylaxis. Perhaps a stewardship program of post-coital antibiotics in sexually active young women will produce the same results as long-term prophylaxis over 3 to 12 months.

Prophylactic therapy on the alternative day works for many patients. Keep the dose and duration as low as possible on planned drug vacations. And then we can recommend conservative measures. We have always done this, including post-bowel hygiene, avoiding showering, bathing versus showering, and the types of clothing patients wear, but none of these really benefit the patient. They can actually cause self-guilt and personal anxiety.

The only conservative measure that really works is to increase your water intake. If patients increase their water intake to 2 liters per day, yes, they will void a little more often, but this thinning of the lower urinary tract keeps the uropathogenic bacteria in check and we reduce urinary tract infections.

In postmenopausal patients, evidence-based use of intravaginal estrogen reduces urinary tract infections in this population. It’s not the panacea and it doesn’t work for everyone, but it certainly reduces recurring urinary tract infections in the susceptible patients.

We can use various dietary supplements such as cranberry extract, but it is important that we use those with a prescribed dose of proanthocyanidins (PACS). We can use D-mannose, especially in patients with E. coli recurring urinary tract infections. Probiotics can help improve or regenerate the microbiome of the gut and vagina.

And prebiotics, which try to feed the good bacteria in our microbiome, can be achieved through a good, healthy diet. Many of our patients can make a number of nutritional enhancements that will help their microbiome fight infection.

After all, I believe science will help. I recently unveiled the exciting potential of a new, very safe sublingual vaccine, MV140, that could significantly reduce recurring urinary tract infections in this group of women in the latest abstract session at the American Urological Association’s 2021 annual meeting; In fact, this was prevented in nearly 60% of women who had a median of 6 urinary tract infections once, up to a median of 0 urinary tract infections over a 9 month period of effectiveness. This particular vaccine is used in Special Access or Compassionate drug programs in Europe, Australia, New Zealand and the UK.

To date, over 40,000 patients have received this vaccine and it has been shown to be safe and appears to be effective in observational studies and this most recent pivotal study. So I believe that in the future, doctors can offer something beyond these conservative measures and antibiotic stewardship. I think our goal is to reduce antibiotic use in this population while reducing the problem of recurrent urinary tract infections in our female population.

Is there anything else you think our audience should know about this topic?

I think it is important to deal with the burden these patients carry. We need to face the fact that antibiotic overuse is a major health concern in this population and see what we can do through antibiotic stewardship. We need to explore all conservative measures in this population group to reduce antibiotic consumption overall.

The perceived stigma that this population promotes antibiotic resistance is not the patient’s fault. It is our responsibility as doctors and urologists to find the answers for our patients. And I think evolving science, as I mentioned earlier, will help us to help our patients. Any stress or stigma associated with this condition will gradually improve as we better address the underlying problem by reducing the risk of developing recurring urinary tract infections.

This article was originally published in the Urology Times®.


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