SIU 2018: Urologists vs. Urinary Bugs: Time for a Truce?

Seoul, South-Korea (UroToday.com) J. Curtis Nickel, MD gave a talk on the history and future of infections in urology. When looking at the history of infections and the treatment of urinary tract infections in the 1800s, bacteria was then discovered as the cause of inflammation. Dr. Nickel presented a relevant anonymous quote, stating that “In the 19th century men lost their fear of God and acquired a fear of microbes”. Various strange treatments with questionable benefit were offered to patients with urinary tract infections. This included Hexylresorcinol (caprokol), lead, strychnine, and others.

In the 1930s antibiotics were first introduced for the treatment of urinary tract infections with sulfanilamide. In the 1950s Nitrofurantoin was available, and then in the 1970s beta-lactams were started to be used. In the 1980s quinolones were introduced to the market. With the introduction of the different antibiotics, it was believed in the 1950s that urinary tract infections will soon be relegated to the waste basket of medical history. The surgeon general in the US in 1967 stated that: “The time has come to close the book on infectious diseases. We have basically wiped out infection in the United States.” Because of this unrealistic belief in antibiotics, they were used on a regular basis, and given prophylactically to everyone, including adding them to the food people had consumed.

Unfortunately, the era of infectious disease has not gone away from this world, and is probably here to stay for a long time… There is a growing number of resistant pathogens, and the issue of antibiotic resistance is real and getting worse. Some of these resistant pathogens include CRE, ESBL, MRSA and VRSA, MDR and XDR and others. These are encountered in our hospitals on a daily basis, and we have no real response to this.

In the battle between microbes and man, man is unfortunately losing. Man has developed vaccines, expanded public health with clean running water and sanitary sewers, and has also invented new antibiotics. However, the microbes have done much better, demonstrating pleomorphism, genetic heterogeneity, and genomic plasticity, horizontal gene transfer, and demonstrate short generation times with high replicative power. Microbes can produce 72 generations in 24 hours! And 272 organisms in one day.

According to Dr. Nickel, we are currently entering the “Post-Antibiotic era”. Our understanding of microbes is gradually changing, and with the use of next-generation sequencing, we can attempt to battle the microbes.

Our body is replete with bacteria with most of them living in harmony with us. The urinary bladder is a veritable microbial jungle. We need to try to understand which microbes are our allies and which are our enemies. The antibiotics we use commonly cause dysbiosis (microbial imbalance) which is most probably a cause of a lot of morbidities we encounter.

In the last part of his discussion, Dr. Nickel discussed the possible alternatives to antibiotic therapy. In the past, physicians used a plethora of alternative treatments for infectious diseases, including bloodletting, leeches, purging, and various tonics with questionable benefit. However, nowadays, there are several recommendations that we can give patients with simple urinary tract infections, aside from hydration, rest, hot water bottle, and avoiding spermicides, douching, genital hygiene products, and bubble baths. Some of the possible treatments include cranberry, but only in the form of oral supplements since we need a minimum of 30 gram to make it effective. Reaching this amount with cranberry juice is not possible. For older women, vaginal estrogen can help fight the infection as well. Other helpful treatments include phenazopyridine1, non-steroidal anti-inflammatory drugs2, urine alkalization with sodium citrate or sodium bicarbonate, methenamine Hippurate3, and proposed various herbal therapies. These herbs with unknown efficacy include goldenseal root, Uva Ursi, Cleavers, Buchu, Corn sil, Horsetail, and Usnea Lichen. Lastly, the diet approach is also important, using nature’s natural antibiotics, including garlic, honey, ginger, grapefruit seed, turmeric, olive oil, echinacea, Neem, apple cider, blueberries, and pineapple.

Dr. Nickel concluded his talk describing a hint of what the future might hold in this field. Immune therapy in the form of vaccination may be utilized. Various immunizations are currently being developed including Uromune4, and Uro-Vaxom5. There is a possibility, that we might even treat simple urinary tract infections like we treat the common cold, without any antibiotics, but only time will tell.

Presented by: J. Curtis Nickel, Queen’s University, Kingston, Canada

References:
1. Ann Pharmacother 1996 Jul-August ; 30 (7-8): 866-8
2. BMJ 2017 NOV 7; 359: j4784
3. Cochrane Database Sys Rev 2012 Oct 17
4. BJU Int. 2018; 121:289-292
5. Eur Urol 1994;26:137-140

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre  Twitter: @GoldbergHanan at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea
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