The Superbug Apocalypse: The Danger of Antibiotic Use In Urinary Tract Infections (UTIs

Inappropriate use and duration of antibiotics in treating urinary tract infections (UTIs)­–also known as acute cystitis or bladder infection­– is becoming a major problem in the US.   Consequently, it creates the “superbug” catastrophe–an event in which the bugs outsmart antibiotics in conformity with Darwin’s survival of the fittest theory.  UTI is one of the most common infection in women, resulting in millions of office visits and hospitalization each year.  The threat materializes as antibiotics are being overused in UTI prophylaxis and treatment.  Subsequently, it leads to undesirable patient outcomes and substantial increases in the cost of healthcare.  A recent study published by South Medicine Journal found that “antibiotic regimens prescribed for various UTIs diagnosed did not align with the IDSA recommendation” in ambulatory care and inpatient settings.1

Screen Shot 2015-09-28 at 8.18.31 PM

The statistics for having at least one UTI incidence in women’s lifetime is about 50% and of those, one in three will develop some kind of recurrence.  The most notorious causes of UTIs is Escherichia coli (E. coli)–approximately 75-95%–and primarily other gram-negative microorganisms, followed by Staphylococcus.  Other players in the field include much broader range of pathogens.  As you can see in the figure below, outpatient and inpatient involving microorganisms are almost identical–with the exception of Staphylococcus and Candida spp.  Not all UTIs are the same.  The most common–also known as the uncomplicated kind– are your typical bladder infections, or acute cystitis. Uncomplicated infections are usually without functional/structural damages.  More serious ones–complicated infections– involves your kidney­ (pyelonephritis­­), prostate (acute or chronic prostatitis), and sperm producing factories (epididymitis).  Complicated UTIs are usually with functional/structural damages and interruption of urine flow or voiding.

In the working example, even some of the most qualified physicians are too quick to suspect and treat UTIs.  Take this patient’s case during my last week of Hospital rotation for example.

Patient C, 70/F, a previous stroke patient, was admitted to the hospital for sudden and increasing weakness of to the left side of her body.  Urinary tract infection (UTI) were suspected and screened.  Culture resulted in Enterococcus faecalis with colony count of 40,000 CFU/ml.  Urinalysis revealed negative results for both nitrite, leukocyte esterase, and hematuria.   The patient was experiencing no pain, no apparent elevation in temperature, or any symptoms for urinary tract infection.  Urine cultures grew Enterococcus faecalis sensitive to nitrofurantoin; therefore, the hospital physician ordered nitrofurantoin 50 mg capsules to be taken four times daily.  Do you agree with the MD’s decision on the use of nitrofurantoin?

Generally, asymptomatic bacteriuria–patients with the absence of frequent urination, dysuria, suprapubic tenderness, hematuria, and foul smell urine­–do not require antibiotics.  In the hospitalized patient population, UTIs are also subjected to medical procedures like catheterization–which only requires the removal of the catheters and monitoring of patients for symptoms.  A common misconception is the interpretation of bacteria colonization as a cue to treat.  Cultures of <100,000 CFU/ml are not usually an indication for treatment, unless the patient is symptomatic.

Screen Shot 2015-09-28 at 8.18.46 PM

The general rule of thumb is to use the narrowest spectrum antibiotics with the least side effects–like Bactrim–should antibiotics be used.  In addition, uncomplicated UTI should be treated using shorter course regimens–3 days’ duration–while you may choose a longer course regimen for complicated UTI.  The point to make here is that under-treatment normally will not result in undesired outcomes­–but over-treating will surely add burden to the already distressing issue of “the superbug takeover”.  The superbugs are trending in prevalence in the US and–worse– across the world.  Don’t believe me? Pick up your site’s antibiogram and carefully examine the trends in ciprofloxacin sensitivity and resistance.  A recent study done at George Washington University and Providence Hospital found that E. coli antimicrobial resistance to ciprofloxacin–the most commonly prescribed antibiotic for UTIs–have increased five-fold over the last decade.2 

It all comes to–what can you do as pharmacist students to prevent–what some scientists believe will lead to–a superbug apocalypse, and at the same time, still provide adequate healthcare for patients? Practice communication and intervention.  Be knowledgeable, proactive, and professional on your approach–and be aware that not all physicians will accept your recommendations.  Communicate with your patients, counsel properly so that they understand the importance of antibiotic adherence and the risks involved for the patient and others if they are non-adherence.   Furthermore, provide your patients with alternatives and advise on UTI preventions such as:

  • Urinating right away when feeling the urge to urinate. Do not try to hold in urges to urinate
  • Stay hydrated, drink plenty of fluids
  • Take precautions when engaging in sexual activities (high correlations between STDs and UTIs)
  • Exercise appropriate bowel habits (especially for ladies, remember to wipe front to back)
  • Ingestion of good bacteria (probiotics)
  • Prevent the adherence of bacteria to the bladder walls with
    • Cranberry juice or products
      • **most research has shown that cranberry extract can lower the risks of repeated UTIs in some patient, and no strong evidence for the treatment of UTIs.4
      • **No clear evidence in the difference in the effectiveness of preventing repeated UTIs in cranberry juice and cranberry extracts4
    • FimH inhibitors (the new approach) but are still years away from being available to the public. FimH is the binding site of E. coli, responsible for it’s stickiness to the vaginal wall. FimH inhibitors is a synthetic compound used to inhibit FimH, taking away its capabilities to stick.  The Journal of Infectious Disease published a study and established that FimH Inhibitors can potentially be an alternative to multidrug-resistant E. Coli related UTIs.3

References

  1. M, Totsika. “A FimH Inhibitor Prevents Acute Bladder Infection and Treats Chronic Cystitis Caused by Multidrug-resistant Uropathogenic Escherichia Coli ST131.” Journal of Infectious Disease6 (2013): 921-28. Print.
  2. Guillermo V. Sanchez, Ronald N. Master, James A. Karlowsky and Jose M. Bordon. In Vitro Antimicrobial Resistance of Urinary Escherichia coli Isolates among U.S. Outpatients from 2000 to 2010. Antimicrobial Agents and Chemotherapy, April 2012 DOI: 1128/%u200BAAC.06060-11
  3. M, T. (2013). A FimH inhibitor prevents acute bladder infection and treats chronic cystitis caused by multidrug-resistant uropathogenic Escherichia coli ST131. Journal of Infectious Disease, 208(6), 921-928. doi:0.1093/infdis/jit245
  4. Hisano M , Bruschini H,Nicodemo AC, Srougi M. Cranberries and lower urinary tract infection prevention. Clinics (Sao Paulo). 2012;67(6):661-8.
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