00:00 – Dr. Kumar: When we replace estrogen in the vagina, we have growth of healthy lactobacilli strains and that
00:07 – can help with repopulation of healthy bacteria in the urethra and the bladder as well.
00:27 – Melissa: Is there any research at the moment around what different types of antibiotic treatment
00:31 – do to the urinary microbiome – so short courses of antibiotics or prophylactic doses, versus long term full dose antibiotics?
00:39 – Dr. Kumar: That’s a great question. I think there’s
00:44 – early research into that. I think we certainly suspect that antibiotic exposure
00:52 – does alter the urinary microbiome and it does make women
00:59 – more prone to getting another infection by reducing the amount of protective bacteria.
01:08 – But I think there are no conclusive studies that I know of right now, but certainly
01:15 – that is a big question that everyone’s asking. I think it makes sense that antibiotic
01:22 – exposure does alter the urinary microbiome because you get certain populations of
01:31 – bacteria, like let’s say, I think we were talking about this, you can have E. coli which is
01:37 – sensitive to cephalosporins and you might have a little bit of enterococcus which is sitting around
01:42 – doing absolutely nothing. Now you’ve taken cephalosporins to
01:48 – get rid of the E. coli and suddenly the enterococcus has no competitor for nutrients or
01:55 – space and that enterococcus is going to flourish. So I think number one, you
02:01 – can get overgrowth of competing pathogens and then you can get a decrease in the population
02:08 – of protective bacteria. I think that we’re going to start seeing that as
02:14 – we further characterize what the microbiome looks like in antibiotic treated patients and it is definitely an area of interest.
02:22 – Melissa: Okay, and so you deplete the existing microbiome, and what is
02:27 – left behind after the treatment, do you think that has more antibiotic resistance given the treatment that you’ve just been through?
02:33 – Dr. Kumar: Yeah, it’s certainly possible that the bacteria which
02:40 – are not aimed to be treated start developing resistance to whatever antibiotic they become exposed to.
02:47 – Melissa: And is that a long-term issue or is that something that kind of just changes over time?
02:56 – Dr. Kumar: Well, you know it depends. I think to an extent it is a long-term issue because
03:04 – bacteria, when they get exposed to an antibiotic they can develop
03:08 – resistance very quickly and one example is, we see these strains of
03:13 – what are called ESBL or extended spectrum beta-lactamase bacteria and they develop
03:21 – resistance to most antibiotics orally. You can treat it with nitrofurantoin or bactrim
03:28 – but if it’s not sensitive then the patients only option at that point is
03:33 – a really big gun antibiotic like imipenem or carbapenem and usually patients who
03:40 – are developing those ESBL infections have had exposure to other antibiotics prior.
03:48 – Melissa: Do you think there is any way that we can help replenish the urinary microbiome after treatment?
03:55 – Dr. Kumar: That’s a great question and I think that there is a role for both estrogen and
04:06 – probiotics. One of the most important bacteria that we have in the vagina and also in the bladder
04:12 – is lactobacillus and when we take oral probiotics there are some studies to show that
04:20 – the lactobacillus actually does populate in the vagina. We have a vaginal probiotic on
04:30 – the market now which has good strains of lactobacillus, like lactobacillus
04:38 – crispatus which you can use directly in the vagina. And when you have those strains of
04:43 – lactobacillus in the vagina it’s from there that they can repopulate inside the
04:49 – bladder. The other important aspect of that is estrogen. When we replace estrogen in the vagina
04:58 – we have growth of healthy lactobacilli strains and again that can help with repopulation
05:05 – of healthy bacteria in the urethra and the bladder as well.
05:11 – Melissa: When it comes to urinary antiseptics like Hiprex, do they have the same problem
05:16 – of depleting the healthy microbiome and causing antibiotic resistance?
05:21 – Dr. Kumar: I don’t know. It’s a great question. I don’t know of any study where they’ve looked at
05:28 – the variety of bacteria in the bladder before and after Hiprex. Hiprex
05:37 – works by basically converting, it makes ammonia and formaldehyde in the bladder
05:45 – and so I think if you have a large amount of bacteria, you have a bacteria
05:52 – which is trying to cause an infection in the bladder, the Hiprex is essentially working
05:59 – to prevent it from being able to replicate, because the formaldehyde is bacteriostatic.
06:04 – So unless the bacteria is attempting to be metabolically active
06:12 – then I don’t know that having Hiprex is going to make a difference. The other thing is
06:19 – that Hiprex works only when the urine is acidic and I think a lot of people who take it,
06:25 – they’re not monitoring their urine pH. So if the urine pH is six or above it’s not really
06:30 – doing anything. So it’s really important, that’s why we use it with vitamin C. And if
06:35 – a person is taking, let’s say one gram of vitamin C a day,
06:41 – and their urine is not acidic, then we increase it, because otherwise the Hiprex is not doing anything.
06:46 – Melissa: Talking about non-antibiotic approaches, there have been some studies that have
06:51 – indicated that ibuprofen could be an appropriate alternative to taking antibiotics for an acute UTI.
06:56 – Do you think that’s an actual problem, and could lead to increased recurrence rates, or is it safe for some patients to try that?
07:04 – Dr. Kumar: I think that there are a large number of women who get UTIs and
07:10 – their immune systems are incredibly efficient at clearing them, and there
07:20 – was recently a really fascinating talk by Dr. Abraham, who’s a professor at Duke, where he
07:28 – was on the UTI global alliance and know he went into the way in which the immune
07:35 – system and the bladder clears infection. And the first response is to get rid of bacteria, and
07:43 – the second response is then to repair the damaged tissue. So I think you’re going to get women
07:50 – where their immune system gets in very quickly and is very efficient at clearing the bacteria
07:56 – and so when they take ibuprofen for the symptoms and let their immune system do the rest, it works.
08:01 – I think that there are other women in whom you are going to allow that bacteria to hang around
08:08 – for a longer period of time and that’s where you may start getting these intracellular
08:14 – reservoirs. He was showing that if the immune system’s response
08:23 – is to switch from bacterial clearance to tissue repair too quickly, you actually get bacteria
08:30 – embedded in the lamina propria, which is a deeper layer of the mucosa in the bladder,
08:37 – because the tissue starts to repair before the bacteria is fully cleared. And there you’ve got
08:44 – truly what we would consider an embedded situation. So I mean I think for myself
08:52 – and my patients, if you have a UTI I favor treating it because I
09:00 – think that if we’re just relying on your immune system to clear it, we’re rolling the dice.
09:05 – Melissa: It sounds like your body might actually help it become worse in that case, if that mechanism occurs.
09:12 – Dr. Kumar: Right, if it occurs that way, you may be favoring the bacteria embedding into a deeper layer of the the bladder tissue, yes
09:22 – Melissa: Do you think for a lot of people that do experience recurrent
09:27 – UTI, that it is actually an embedded UTI, where the symptoms just flare intermittently over time?
09:34 – Dr. Kumar: Yeah I do. I think that there is definitely a population of women where
09:41 – the bacteria has formed a quiescent reservoir in the bladder and it re-emerges from time to
09:48 – time. I think when that happens, we have actually been able to prove on culture that
09:55 – it’s the same bacteria that’s coming back. You have to be very careful because
10:01 – there are a lot of women who have symptoms from genital urinary syndrome of menopause
10:07 – and that can really mimic the symptoms of a urinary tract infection where it’s that
10:11 – burning, that irritation, the increased frequency, the pressure, and so you really have to pay
10:18 – attention to whether it’s something that’s like waxing and waning. Like, I
10:23 – was noticing I had to urinate more. I had this increased awareness of my bladder and urethra
10:29 – and then as the day went on I sort of drank more water and and then the
10:33 – feeling sort of went away, versus it progressed, I was running to the bathroom
10:38 – every five minutes, the pain was so bad that I was taking Advil and Tylenol and Pyridium.
10:44 – So you really have to be in tune to whether it’s waxing and waning and it kind
10:48 – of just goes away versus whether when it comes on it actually progresses to full-fledged symptoms.