Kaufman starts by challenging the idea that urine is sterile. She presents work by Curtis Nickel, MD that shows the existence of a urinary microbiome. This microbiome has a diverse population of organisms which are seen on enhanced quantitative urine culture. This microbiome may play a role in urinary incontinence, pelvic pain, and rUTIs. The bacteria responsible for rUTIs are not necessarily pathogens. Rather, dysbiosis, or a change in composition of resident commensal communities, may account for UTIs, and this may be unique for each person.
Genetics, diet, infections, and medical interventions all disrupt homeostasis and promote dysbiosis. The #1 medical intervention that disrupts homeostasis is antibiotics, and judicious use of antibiotics is very important. Dr. Kaufman advises that patients should not control their own antibiotic administration. Antibiotic resistance accounts for 23,000 deaths per year, and few new agents are in development. Fluoroquinolone resistance, for example, has a 33% prevalence, with geographical prescribing patterns matching geographical resistance rates.
Dr. Kaufman shows data that demonstrates resistance patterns emerge and are persistent for one year after a single course of antibiotics for a UTI. Coordinated interventions are needed to improve distribution of antibiotics, and she describes Vanderlbilt’s program for antibiotic stewardship oversight.
Finally, Dr. Kaufman discusses traditional treatment strategies and challenges the classically accepted mechanisms of action. For example, transvaginal estrogen is thought to work by repopulating lactobacilli bacilli in the vagina, but she shows that estrogens actually affect the gut microbiome, and may not work the way we think.
Probiotics, a newer strategy in UTI prevention, may help with re-establishing a healthy microbial community. Dr. Kaufman describes the “ultimate priobiotic” is a fecal transplant, and shows evidence from one study where fecal transplants reduced rUTI at one year.
Overall, this was a fascinating session that identified major gaps in knowledge for rUTIs. It emphasized the need to advocate for very selective use of antibiotics. Future treatment strategies may work toward restoring the natural microbiome of the urinary tract.
Presented by: Melissa Kaufman, MD, PhD, Vanderbilt University Medical Center
Written by: Dena Moskowitz, MD; Fellow, Female Pelvic Medicine and Reconstructive Surgery, Virginia Mason Medical Center, Twitter: @demoskowitz, at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA