THE ANTIBIOTIC DILEMMA
The recurrent, uncomplicated urinary tract infection is extremely common in Canada. Somewhere around eight to 10 per cent of women will have rUTIs. It’s also the most common use of antibiotics for Canadian women. But antibiotics cause a lot of damage, not only to the individual but also to society, through the creation of resistant organisms, said Dr. Curtis Nickel.
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Things have gotten out of hand between this and the long-term use of antibiotics to treat chronic cases. And what was once a miracle drug is turning into the cause.
The problem with heavy use of generalized antibiotics in the bladder is they don’t just kill the specific bacteria that caused the infection. In many cases, it kills much more than that.
And this would work under the assumption that the bladder is a sterile environment—therefore, killing all bacteria would seem like a sensible choice.
But what Dr. Nickel, professor and research chair for the department of urology, Queen’s University, is finding is that the bladder is not sterile at all.
He said the constant use of antibiotics, the on, off patterns that recurrent sufferers see, can cause the microbiome (the collective genetic material) to be dysbiotic (imbalanced or polluted), causing a person to become susceptible to more and more infections.
Additionally, he cautions against the already controversial, long-term use of antibiotics used sometimes for chronic cases.
“There's a trend right now for patients to be put on long-term antibiotics, you know, for months, or even a year,” he said. “It's going to be a very problematic issue.”
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“It's sort of like the battle of the bladder. If you carpet bomb the bladder, wipe out everything, what happens is you might feel better for the year you're on antibiotics or for a short period of time after. But after that, what happens is you have resistant organisms that come in dysbiotic and are less diversified.”
“The way I explained to my patients is that
antibiotics are poison. And as such, they
kill things, they kill living organisms,
bacteria, so they can't be good for us.”
-Dr. Curtis Nickel
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Long-term antibiotic use has been associated with significant problems with patients’ health, a predisposition to cancer, chronic diseases such as arthritis, impacted mental cognitive function, anxiety and even suicidal tendencies.
“The way I explained to my patients is that antibiotics are poison. And as such, they kill things, they kill living organisms, bacteria, so they can't be good for us.”
But don’t get it twisted. Dr. Nickel concedes that antibiotics have done more for human civilization than any other medical advancement. Although it has not wiped out infection as once thought, it does allow us to control it.
But the widespread use of antibiotics will create further resistant organisms. Organisms that killed 14,000 Canadians last year. This is a losing battle. Each year we’re running out of effective antibiotics, and Dr. Nickel said we might run out within this decade—we already see this in places with unthrottled use of antibiotics, like India, Mexico and Spain.
“People dying from resistant organisms that only five years ago, we would have given him a pill, and they would have gotten better. And that caused by overuse of antibiotics, poor stewardship, using antibiotics without sound scientific rationale.”
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They’re a necessary evil. How Dr. Nickel makes the best out of a piss-poor situation is to pin-point the bacteria that needs treatment and respond with a surgical strike of antibiotics for as short and high doses as possible. The goal in mind is to eradicate that particular bacteria and leave those that do no harm.
In his clinic, for complicated UTI patients, he gives high concentrations of antibiotics through a catheter directly into the bladder for an hour before the patient “goes.” This avoids absorption into the body and negative long-term health impacts.
TESTING
A barrier to striking with surgical accuracy is the testing. The test commonly relied on for recurring and chronic UTIs is the culture test, which shows the predominant and most abundant organisms. The culture is also 125-year-old technology and hasn’t changed much since.
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“We know it's a veritable microbial jungle.
And like all jungles, the jungle can be
very healthy. If the right bacteria are
there in the right proportions.”
-Dr. Curtis Nickel
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“We only grow in our culture techniques, maybe one per cent of the bacteria that we know are in the blood. So with using more sophisticated and sensitive genetic testing for bacteria, we know that the bacteria is not just you know, if you find a bacteria, it's an infection.”
“We know it's a veritable microbial jungle. And like all jungles, the jungle can be very healthy. If the right bacteria are there in the right proportions.”
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Urine, by his account, is an untapped spring of knowledge. But first thing’s first, he needs to find out what a normal bladder looks like, then figure out how to go from abnormal to normal.
All he knows for sure is that antibiotics don’t cut it.
“Antibiotics will give some patients minor, moderate, or even major short-term benefits for really long term pain, in terms of their general health and well being.”
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To avoid overusing antibiotics and maintain stasis in the bladder, Dr. Nickel would like to ditch the turn-of-the-century culture for next-generation genetic sequencing.
Rather than grow a culture of only the most common types of bacteria that may or may not be causing symptoms in the individual, genetic sequencing of the urine can determine the species, type, abundance, resistance and diversity in the sample.
“Now we can do whole-genome sequencing, so we can look for bugs we didn't even know existed. And we'd look for interrelationships of different bacteria in the bladder,” said Dr. Nickel.
“We're starting to understand what a normal healthy microbiome looks like. And that microbiome is one that doesn't have antibiotics for long term.”
Better yet, unlike the 72-hour turn-around for a urine culture, genetic sequencing takes anywhere from 20 hours to 12 depending on the case, and because it’s becoming automated, it’s getting better and faster all the time.
“This science is just on the cusp of revolutionizing our treatment of infections across the board. But I'm particularly interested in the way it's going to change the way we deal with urinary tract infections.”
SOLUTIONS
But, for the uncomplicated UTIs, Dr. Nickel has found that in a lot of cases, it can be managed like the common cold: supportive therapy, diet, ibuprofen as needed and lots of water.
In fact, through randomized testing, those on antibiotics did better on days three to seven. But by 14 days, there wasn’t much difference, and most symptoms were gone without any antibiotics. And those without the antibiotics had better long-term bladder symptoms.
He said cranberry capsules and probiotics might also help to reduce UTI and UTI-like symptoms.
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“Antibiotics are wonderful. I mean, I use too
many because I see too many infections.
And I hate using too much. But they're not
the panacea, they are not the cure..."
-Dr. Curtis Nickel
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For complicated UTIs, Dr. Nickel emphasizes that each patient has to be taken on their own merits, and each patient is looked at individually to determine their clinical picture.
“What's happening to them? How do you think it happened? And use all the tools at our disposal, including old culture and urinalysis results, modern next-generation genetic sequencing to determine what we believe might be causing their symptoms, and then we treat them. We put together a treatment plan for the individual.”
The most exciting of all, within a year, at most 16 months, Canadian women can expect a vaccine to treat recurrent and even chronic UTIs and avoid antibiotics altogether, said Dr. Nickel. It works for acute and chronic UTIs, UTI prevention and works well for the frail elderly. And he’s running studies right now that have vaccinated 20,000 patients to date, and the results are strong, safe and effective.
“I think vaccines are going to be the game-changer,” he said.
“Antibiotics are wonderful. I mean, I use too many because I see too many infections. And I hate using too much. But they're not the panacea, they are not the cure, all they do is a stop-gap-effort, you bomb out, and you kill everything. It's like pointing a flamethrower to something to try and cure a patient. It's not the best approach. But right now, it's the best approach we have.”
