Rx for Change: Changing the Culture Around Urinary Tract Infections

Article taken from page 10 of the March/April 2019 Newsletter

By Nancy Worcester and Mariamne Whatley

Many women may be surprised to discover that what they know about Urinary Tract Infection (UTI) treatment and what, previously, seemed to serve them well is being questioned and may no longer be recommended.

Most UTIs are caused by bacteria and can be treated by antibiotics. Until recently, the identification of bacteria in the urine (by dipstick test or urinalysis) followed by an antibiotic prescription was the usual treatment protocol. UTI management was so routine that women with recurring UTIs (rUTIs) were sometimes given low-dose antibiotic prescriptions for extended time-periods, or single doses of antibiotics to take after sex (if that activity resulted in rUTIs).[1] Some women were allowed to self-diagnose for an antibiotic prescription. There’s even a website that promises 24-hour UTI diagnosis and antibiotic prescriptions without a doctor’s appointment.[2]

But, as one researcher noted, UTI is “an ambiguous, expensive, overused diagnosis that can lead to marked, harmful antibiotic overtreatment.”[3]  Now, UTIs are helping change our culture of antibiotic over-prescription, since they are a very common reason for antibiotic use,[4] they often are healthily resolved without antibiotics, and there are new scientific findings about UTIs’ complex nature.

 

Antibiotic resistance and antibiotics’ overuse and misuse

Antibiotic overuse and misuse include: Using antibiotics to treat illnesses, like colds and influenza, which are virally caused and unresponsive to antibiotics; using antibiotics for infections that are self-resolving or can be treated without antibiotics; using a less-appropriate antibiotic to treat bacterial infections; treating with antibiotics longer than necessary; and stopping antibiotics too early.

Overuse/misuse can cause side-effects, unnecessary expense, and, most significantly, increased antibiotic resistance. Bacteria that are exposed to antibiotics can develop resistance to those antibiotics. As antibiotics kill non-resistant bacteria, the resistant survivors continue multiplying without competition and become a dominant strain among bacteria in any given system. Eventually, antibiotics that were effective in fighting specific disease-causing bacteria may become less effective or ineffective. Bacteria can develop resistance to several antibiotics, causing multidrug-resistance that eliminates antibiotic treatment options. Bacterial infections that cannot be controlled by antibiotics become more common and potentially very dangerous.

The more often someone with a UTI is treated with antibiotics, the more likely she is to experience a recurrence due to the reservoir of antibiotic-resistant bacteria. In addition, since antibiotic treatment disrupts the urinary tract’s healthy balance of microorganisms, the environment can become more conducive to the growth of disease-causing bacteria. Many women are familiar with vaginal yeast infections that can develop due to changes in the vaginal flora following antibiotic treatment.

A widespread misunderstanding is that individuals become resistant to antibiotics. Individuals who have often been treated with antibiotics may have high levels of antibiotic-resistant bacteria in their systems, but they themselves are not resistant to antibiotics.

 

New understandings

The urinary tract is comprised of the kidneys, ureters, bladder, and urethra, and hosts many bacteria as part of its healthy environment. These communities of microorganisms (microbiome, or microbiota) are increasingly a focus for our understanding of appropriate health care for the urinary tract as well as UTI prevention and treatment.

Our urine normally contains bacteria (bacteriuria), so its mere presence (asymptomatic bacteriuria) is no longer used to diagnose UTIs and generally does not require treatment. As one researcher noted, “From this perspective, most people who are treated for a ‘UTI’ would probably be better without treatment,”[5] although there are some exceptions. The distinction between asymptomatic bacteriuria and UTI is crucial. It is necessary to know which specific bacteria are involved and, if treatment is necessary, to which antibiotics they are susceptible.

Minimizing unnecessary antibiotic use is one way to avoid disrupting the microbiome. Using probiotics may help restore the right balance of microorganisms, thereby reducing rUTIs.[6] These approaches have helped reduce serious gastrointestinal infections including life-threatening C.diff, which often develops after antibiotic use. Recurring and persistent C.diff has been treated by doing a fecal transfer from a healthy person to restore the sick person’s microbiome. A similar approach holds promise for persistent UTIs, such as by instilling health-promoting bacteria into the bladder.[7]

New research is identifying how UTI-causing bacteria can invade urinary tract cells and attach to those cells and each other, creating an intracellular community that forms a matrix (biofilm) in which the bacteria are embedded and protected. This could explain why UTIs are so hard to eradicate in some women, and offers hope for better solutions.[8] [9]

 

Now what?

The crisis of antibiotic overuse is being addressed through an emphasis on “Antimicrobial Stewardship” in every health care setting.[10] [11] Consumers may notice the Centers for Disease Control and Prevention’s public education materials from the “Get Smart about Antibiotics” campaign and “Antibiotic Awareness Week.”

On a deeper level, all patients and providers need to help change our culture and expectations that antibiotics are always the answer. Many patients have positive attitudes about antibiotic use, and poor knowledge about what antibiotic resistance means—resulting in reduced patient satisfaction when antibiotics are discouraged.[12] [13] Providers report that discussing antibiotic resistance with patients is time-consuming, but that their comfort with not prescribing antibiotics increased over time.[14]

Changing attitudes toward antibiotics gives women’s health activists new roles in the public health arena. Since UTIs often resolve themselves within a short time (especially with good hydration and over-the-counter treatments) and usually don’t result in more serious issues, many women may welcome the news that it’s responsible and safe to wait about 48 hours before contacting a health care provider. (People who are pregnant or have UTI symptoms accompanied by chills, fever, vomiting, and/or kidney pain should not wait to contact their health provider.)

UTIs’ enormous discomforts are a painful reminder that it’s time to think through all of UTIs’ potential causes and what we know works in our own bodies and lives for prevention and treatment. Thank goodness we think of ourselves as informed consumers and active patients! We can question whether antibiotics are necessary and discuss alternatives. The prescription for change, as in other situations, may be fewer prescriptions. (For more information, see the UTI Fact Sheet at www.nwhn.org.)

 

References are available from info@nwhn.org.

 

Nancy Worcester and Mariamne Whatley are Professors Emeritae of Gender and Women’s Studies at the University of Wisconsin-Madison. They are long-time women’s health educators, writers, and activists who have both served on the NWHN’s Board.

 

[1] Mayo Clinic, Urinary Tract Infection (UTI) – Diagnosis and Treatment, Rochester (MN): Mayo Clinic, 2017. Available online at: https://www.mayoclinic.org/diseases-conditions/urinary-tract-in…

[2] UTItreatment.com, Physician-Approved UTI Treatment Online for Only $59  (advertisement). Online at: https://www.utitreatment.com/?msclkid=a4ed078a1209108036

[3] Finucane TE, “’Urinary Tract Infection’ – Requiem for a Heavyweight,” J Am Geriatr Soc 2017; 65(8): 1650-1655.

[4] Sihra N, Goodman A, Zakri R, et. al., “Nonantibiotic prevention and management of recurrent urinary tract infection,” Nat Rev Urol. 2018; Dec 15 (12): 750-776.

[5] Finucane TE, “’Urinary Tract Infection’ – Requiem for a Heavyweight,” J Am Geriatr Soc 2017- August; 65(8): 1650-1655.

[6] Hanson L, VandeVusse L, Jerme M, et. al., “Probiotics for Treatment and Prevention of Urogenital Infections in Women: A Systematic Review,” J Midwifery Women’s Health 2016; 61(3): 339-355.

[7] Lee SJ, “Recent advances in managing lower urinary tract infections,” 2018 Dec. Retrieved January 16, 2019 from: https://www-ncbi-nlm-nih-gov.ezproxy.library.wisc.edu/pme/pmc/art…

[8] Stamm WE, “Theodore E. “Woodward Award: Host–Pathogen Interactions in Community-Acquired Urinary Tract Infections,” Trans Am Clin Climatol Assoc 2006; 117: 75-84.

[9] Soto SM, “Importance of Biofilms in Urinary Tract Infections: New Therapeutic Approaches,” Advances in Biology 2014, Article ID 543974, 13 pages.

[10] Manning ML, “Antimicrobial Stewardship and Infection Prevention – leveraging the synergy: A position paper update,” American Journal of Infection Control 2018; 46 (4); 364-368.

[11]  Trautner BW, Greene MT, Krein SL, et. al., “Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel, Infect Control Hosp Epidemiol 2017 Jan; 38 (1): 83-88.

[12] Duane S, Domegan C, Callan A, et. al., “Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections” BMJ Open 2016; 6(1): e008894.

[13]  Averbeck MA, Rantell A, Ford A, et. al., “Current controversies in urinary tract infections: ICI-RS 2017. Wiley Online Library. Online at: https://onlinelibrary-wiley-com.ezproxy.library.wisc.edu/doi/10

[14] Duane S, Domegan C, Callan A, et. al., “Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections” BMJ Open 2016; 6(1): e008894.