00:00 – Dr. Malcolm Starkey: Urinary tract infection, as we know now, doesn’t really fit into those boxes
00:04 – and yes/no questions and it’s a lot more complicated.
00:07 – And this has really been impacted by the diagnostic tests and as you say, you know, the midstream urine culture in particular.
00:26 – Melissa Kramer: Dr. Malcolm Starkey is an Australian scientist dedicated to improving
00:30 – the lives of people affected by urinary tract infections and related bladder and kidney conditions.
00:34 – He leads the Urinary Tract Disease Research Group at Monash University and founded
00:38 – the Bladder and Kidney Health Discovery Program to drive new treatments and diagnostics where they’re most needed.
00:43 – His research explores why some people are more vulnerable to recurrent UTIs and
00:47 – kidney problems focusing on the role of microbes and the immune system.
00:51 – Beyond the lab, he works with global alliances, women’s health networks
00:54 – and patient advocacy groups and is passionate about inspiring
00:57 – the next generation of scientists through teaching and mentoring.
01:00 – Thanks so much for taking the time to answer in our community’s questions.
01:03 – Dr. Starkey: Hi Melissa, thanks so much for having me in and thank you so much for this great initiative.
01:07 – I think it’s really fantastic to engage with researchers and connect with the community and it’s a real pleasure to be here.
01:13 – Melissa: It’s been exciting for our community to see so much more research happening.
01:16 – And when I started Live UTI Free eight years ago, I could hardly find
01:19 – anybody working in the space that was willing to engage with patients.
01:22 – But now every time I speak to someone, they recommend
01:24 – other researchers in the space and most of them are happy to chat with us.
01:27 – So that’s been really encouraging and I’d love to hear more about your
01:31 – background and how you came to be working in the UTI space.
01:35 – Dr. Starkey: Sure. And look, it’s fantastic to hear.
01:37 – And as I was saying to you before, I think this community now in this space is really fantastic.
01:42 – And I’m really excited about this next generation of researchers and the impact that we can have together.
01:47 – And thank you again for the initiative.
01:50 – So originally, I was a respiratory immunologist and microbiologist.
01:55 – And I came about looking at urinary tract diseases when I sort of, I guess, became an independent researcher.
02:03 – And at that point in time, when I was setting up my own independent laboratory at Monash University,
02:07 – I asked the question of what’s something I can do that’s really impactful
02:12 – and important and something that I’m really passionate about
02:15 – that can combine my existing expertise in immunology and microbiology.
02:19 – And so I settled on urinary tract diseases and perhaps there’s a little bit of a background story there, Melissa,
02:24 – because I actually have a chronic kidney disease and I received a transplant – kidney transplant in January 2024.
02:31 – And so whilst I’m not researching the diseases that affected me,
02:34 – I think it made me acutely aware of the lack of awareness and education within the community,
02:41 – within our governments and within our health sector and also within the scientific fields of urinary tract diseases more
02:47 – broadly. So when I decided what can I do that’s going to have the most impact?
02:51 – That’s what made me land in this space and of course, urinary tract infections is a major component of understanding
02:57 – host-microbe interactions, so microbiology and immunology in the urinary tract. And so that’s how I got here.
03:03 – Melissa: It’s always interesting to hear how people arrived here because they’re so different, all the backgrounds
03:07 – and personal experience is how I ended up here doing the health psychology research that I’m doing.
03:13 – Interesting to hear that you also have an experience that led you here.
03:16 – One of the things that we talk about a lot in our community and I think it’s the thing that’s behind a lot of these
03:21 – prolonged experiences with UTI is the flaws with standard UTI testing.
03:26 – And so we have covered that a lot in our content, but we have a lot of new viewers and a lot of patients that are new to the
03:30 – topic. And I would love to hear from you, your thoughts on why standard urine cultures are just not the right test for this illness.
03:39 – Dr. Starkey: Sure. I mean, this is one of my favorite things to talk about and one of my favorite things to,
03:45 – you know, to bring up to the undergraduate students,
03:47 – you know, in medicine and science as they’re coming through because there’s just such a stigma around this testing.
03:53 – And I think it’s really important to sort of bring it back to some basic principles around medicine.
03:58 – So medicine love to have boxes and names and criteria and they love to
04:03 – have tests that basically say yes or no or have some kind of a threshold.
04:08 – And then that allows them to say yes/no. And then they follow guidelines for treatment.
04:12 – Of course, urinary tract infections, as we know now, doesn’t really fit into those boxes and yes/no questions.
04:18 – And it’s a lot more complicated. And this has really been, you know, impacted by the diagnostic tests.
04:25 – And as you say, you know, the midstream urine culture in particular.
04:29 – So when we think about these bacteria that we can culture, it’s predominantly E. coli.
04:33 – So they’re the bacteria that really become dominant in these detection assays that we use in the diagnostic labs.
04:41 – And so there’s the potential that we lose lots of other uropathogens that might be causing the infection.
04:46 – Of course, it also relies on detecting bacteria in the urine. Now, these bacteria are very clever.
04:53 – And of course, they’ve evolved to be able to embed themselves within the unary bladder lining,
04:58 – which is called the urothelium. And so they hide out here. And so when they’re not in the urine, when
05:04 – they’re hiding out in the bladder lining, we just can’t see them in the urine. So then the test comes back as negative.
05:11 – The other problem is for many diagnostic labs, they have a very high threshold of diagnosing infection,
05:18 – which is often around 100,000 colony forming units of bacteria per milliliter.
05:23 – And this number came about because of a study from the 1950s that was looking at infection in pregnant women
05:31 – that developed a kidney infection called pyelonephritis, which can be quite serious, both for mum and baby.
05:37 – And even in that study, they recognized that this is an arbitrary sort of cutoff.
05:41 – It’s okay for looking at this kind of infection in pregnancy, but it’s not to be used for standard UTI.
05:48 – However, if you look fast forward to now and you look at every single guideline across the entire world,
05:53 – everybody’s using this threshold as their diagnostic threshold.
05:56 – So even the original study suggests that this shouldn’t be done. And then we get variation in this threshold.
06:03 – So even here in Melbourne, we have some hospitals that lower that a little bit, some that keep it 10 to the 5.
06:07 – And so it’s inconsistent, which makes it really difficult for patients to understand.
06:12 – On top of that, a lot of diagnostic labs will exclude tests that have human cells called epithelial cells in that sample.
06:22 – Because the assumption is that that’s contamination from the skin and that therefore you could be culturing bacteria from
06:29 – the skin. Of course, we know that the urinary bladder is one of its first line defenses to the pathogen.
06:34 – And it will actually shed the bladder lining, which are epithelial cells.
06:38 – And so when we see those cells in the urine, it’s very likely that’s a very strong indicator of an active infection.
06:46 – However, the diagnostic labs will say that’s contamination and therefore that’ll come back as no positive result.
06:53 – We now know that if we culture the bacteria out of those cells or even stain for bacteria within those cells and urine,
06:59 – we can see them packed full of uropathogenic E. coli, these main bugs that cause the infection.
07:05 – So really, everything’s there. We’re just not looking in the right place. So I think the key message is don’t just test the urine.
07:12 – We need to test the cells as well. And of course, we’re not doing that.
07:15 – And so I think we have some fairly simple things that we could do to change diagnostics.
07:20 – But we kind of have to go against decades and decades of inertia in medicine,
07:25 – which is, as you’re aware, Melissa, a very difficult thing to change.
07:29 – Melissa: It’s so frustrating though. I know this information and every time I hear it, I just can’t help thinking,
07:33 – how do we still have this test as the gold standard up to 70 odd years?
07:37 – And even the test itself wasn’t designed for this purpose
07:40 – in the first place. They knew the threshold was arbitrary and we’ve just stuck with it.
07:44 – And instead of changing the test, patients are just told that this is all in their head and the test is clear.
07:50 – Therefore, you don’t have a UTI or therefore nothing is wrong with you, which is, it gets me even more.
07:55 – Your symptoms are imaginary. What do you think a new test in the future might look like?
08:03 – Dr. Starkey: Look, I think there’s lots of ways we can pursue this.
08:05 – And this is something we’re doing in the lab as well as many others internationally.
08:09 – So I think we need to be identifying non-bacteria related factors.
08:14 – So what we call biomarkers, so factors that are coming from us, the host.
08:19 – So often what happens in the field, typically over the past decades, is that all the research is largely focused on for a
08:25 – long period of time, the bugs, so the bacteria and the drug, the antibiotic.
08:30 – And so it’s not just all about the bug and the drug. We’re the thing that’s getting infected.
08:36 – And so what our body has to say to that is really important.
08:40 – And so looking at the factors that we produce in response to that infection could be really important
08:45 – because we could identify host factors in the urine, for example, even though we can’t see bacteria
08:51 – that shouldn’t be there unless we’re really trying to fight off an infection.
08:55 – So that would give us a really good indication. So we can look at that and we’re doing that.
08:59 – And we can do that via all sorts of really complicated processes.
09:03 – And so we’re trying to narrow that down. I also alluded to before in answering your previous question,
09:08 – I think really some of the answers already there, like if we just stain for or
09:13 – bust open those cells and culture them or don’t even exclude those cultures that have the contamination,
09:19 – then we’re already going in the right direction. I think the other thing we can do immediately is to just standardize and
09:25 – realize that it doesn’t have to be such a high cutoff.
09:28 – You’got symptomology even with 10 to the 2 or 10 to the 3 bacteria, it’s very likely to be an infection.
09:35 – So there’s some low hanging fruit there Melissa that we could look at in the diagnostic labs, of course. And then there’s also
09:41 – some higher end scientific approaches that we can do looking for biomarkers of host factors that we can detect in the urine.
09:48 – Melissa: And it seems like a lot of the problems with the test not being accurate is this chronic UTI concept,
09:54 – which I think is fairly well established in the research, but not so much in a medical sense.
09:59 – In clinic, there’s no consensus around the definition of chronic UTI. What do you think it should be defined as?
10:06 – Dr. Starkey: And again, this is the problem generally with medicine, right?
10:09 – And as we were saying before with our personal experiences being a transplant recipient and being on the other end as a
10:15 – patient, I’m constantly frustrated by the process of medicine, which is this boxing characterization and guidelines.
10:23 – And if things don’t fit into those boxes, people just don’t know what to do, even though these are extremely clever people.
10:29 – And also there’s a lot of pressure for them to not prescribe antibiotics and to also follow guidelines.
10:34 – And so it can be difficult now for people to really be thinking outside the box.
10:38 – Of course, you do get champions that are capable of doing this. Yeah, diagnosis of this sort of thing. It’s tricky.
10:44 – You know, some people see it as a distinct disease. Some people see it as a form of recurrent infection.
10:50 – I see it as probably, you know, an over an umbrella term that really probably encompasses a number of different types of
10:57 – diseases. So you could have these chronic or embedded infections that are persistent
11:01 – and they stay within the urinary bladder. Or you could have these infections that are highly recurrent.
11:06 – And so it’s hard to define that. I think we really do need very large longitudinal, you know, multinational studies to
11:13 – really sort of identify the patterns of what this looks like and to come up with some high criteria that could be used medically.
11:20 – It’s also tricky because we know that an infection, even if it is resolving, it can leave behind a signature that changes the
11:28 – bladder lining and changes the neurons or the nervous system within the bladder and how it responds.
11:35 – So even though the infection may be gone, the consequence of the infection can lead to
11:41 – things like chronic pain, chronic inflammation. And so there’s a lot of things there that really need
11:47 – to be teased out from basic discovery research such as researches like myself
11:51 – as well as doing large clinical studies to try to understand that.
11:55 – But look, I mean, I would think it’s going to look something like having frequent episodes within a period of time.
12:01 – You know, like we know recurrent UTI is, you know, two UTIs in six months or three in a year.
12:06 – And so, you know, it’s probably going to look like increased numbers within that time frame of symptomology or infections.
12:14 – It might also look like the sort of number of infections with persistent symptoms throughout that time.
12:20 – So there’s no sort of relapse or recovery period. But like I said, we really need large studies to convince the field to do that.
12:29 – You know, medicine’s not going to move unless we have very large studies to prove it.
12:33 – And of course, we need the funding and we need the awareness to be able to get these sort of studies done.
12:38 – And we’ve got to convince our funding agencies and the community that this is something that’s critical to and of a
12:44 – critical need for women’s health.
12:46 – Melissa: Yeah, I think patients get it.
12:47 – One of the main reasons that people find our website is because they have had a standard culture, gotten a negative
12:52 – result, have clear symptoms of the UTI. For people who do have that experience over and over, do you have any advice
12:58 – for what they could discuss with their doctor to try to find answers?
13:02 – Dr. Starkey: Yeah, I mean, look, it’s tricky.
13:04 – I think, you know, trying to find people that have experience in dealing with these problems.
13:08 – So here in Australia, we have some really great pediatric urologists and we work with them.
13:13 – We’ve established the first pediatric chronic UTI clinic, but there’s nothing that exists for for adult women in Australia.
13:20 – And so, you know, doing your research, finding the doctors that are actually willing to go outside of the typical norms and
13:27 – really work with you to understand this, I think it’s important. Being educated about the diagnosis, so challenging that.
13:35 – So for example, saying, do we know whether this is reported as contamination?
13:39 – For example, if it is contamination, can we actually get the results next time? They will – what is the bacteria anyway?
13:48 – Even though there is contamination. Would I then have an infection? Just being aware of these sorts of things
13:53 – can really help to leverage those discussions. And again, from my personal experience, being educated in that space in
14:00 – relation to your condition can really help you to educate your doctors.
14:05 – But also more importantly, I would say it’s critical to work collaboratively.
14:09 – You don’t want to be telling them what to do, but you want to be working collaboratively and saying, this is my health.
14:14 – And this is my understanding or my concerns, could we explore it in this way together?
14:19 – So I think reaching out and finding what’s available to you in your area at that point in time
14:25 – by finding specialists that are skilled in this space for which there are a few, unfortunately.
14:30 – And then also providing evidence based information and working collaboratively
14:35 – with your medical team, I think it’s probably the best way to pursue this at this point in time.
14:40 – Melissa: Yeah, and I know Chronic UTI Australia has some information about clinicians
14:44 – for Australian residents and Live UTI Free can share information about a lot of countries as well.
14:49 – But you’re right, it’s difficult to find those types of clinicians and we’re always trying
14:52 – to find the types of clinicians that want to work with patients in that way.
14:56 – And so if you do hear of any, send them in our direction too,
14:58 – because we’d love to be able to share them with other patients. What you mentioned about –
15:03 – Dr. Starkey: I think what you find happens, sorry, Melissa, is that it’s sort of a condition where people don’t know what to do.
15:07 – Like it’s outside of GP’s realm, it doesn’t fit within typical infectious disease because they’re normally dealing with
15:14 – severe life threatening infections or chronic infections like HIV in the hospital setting. It’s not something that
15:20 – you’re typically hospitalized for. So those sort of clinical microbiologists, infectious disease physicians aren’t seeing it.
15:27 – A lot of urologists tend to be dealing more with sort of bladder cancer and structural problems and they’re not really dealing
15:32 – with this. Urogynecologists are typically dealing with other important women’s health issues.
15:39 – And so they kind of fall in between again, these baskets that medicine have.
15:44 – Sometimes it’s nephrology, if it’s recurrent kidney infection. So it’s kind of, there’s sort of no clear path of where to go.
15:51 – And the primary general practitioners really don’t know where to refer people to and that’s part of the problem.
15:57 – And then they’re doing their best within the guidelines of what they know.
16:00 – But it’s really tricky because there’s a lack of education within the field and there’s also a lack of where do I go?
16:06 – There’s no clear specialty for dealing with this infection.
16:09 – Melissa: Yeah, you’ve kind of described the exact problem that we come up against all the time.
16:12 – There isn’t a specialty for recurrent and chronic UTI patients and it’s not taken seriously.
16:18 – It’s seen as a benign condition that nobody really wants to deal with and that there’s just patients all over the world trying
16:23 – to find the right type of clinician. And we always say there isn’t a specialty for it. It’s whether
16:28 – the clinician takes an interest in the topic and that could be any specialty. And that’s what makes them so hard to find.
16:35 – Dr. Starkey: Exactly, totally agree.
16:37 – Melissa: You mentioned the contamination thing, which kind of leads to the next question.
16:41 – We know now that the bladder isn’t sterile, that there is a urinary microbiome. But do we have
16:45 – enough information to understand what would be considered good versus bad in the bladder in terms of microbes?
16:52 – Dr. Starkey: You know, it’s always a bit of a black box, right? I mean, it’s really hard to know.
16:56 – I mean, we’re talking about thousands of different microbes that are existing within this community.
17:03 – And unless you sort of systematically test every single one of them in various different systems, it’s very hard to know that.
17:10 – I think what’s important is that any pathogen has the potential to be pathogenic,
17:15 – whether it’s naturally occurring or whether it’s something that’s sort of invaded into that space, depending on what
17:21 – the host is doing, right? So are you immunocompromised like me because you’ve had a transplant?
17:27 – Are you a post-menopausal woman? Are you somebody with a structural abnormality?
17:31 – Then in all of these sort of circumstances, these pathogens could become problematic.
17:35 – But for the most part, it’s hard to distinguish.
17:38 – So if we take something like E. coli, which is the main bacteria that cause these infections, as you know, right?
17:44 – And we talk about something like chronic UTI, which we’ve already discussed is this embedding of these pathogens
17:49 – within to the bladder lining, right? You would assume that only the bad bacteria do that.
17:54 – But the interesting thing is the good bacteria do that too.
17:58 – It’s part of what bacteria do to replicate and survive and just do their bacteria things, right?
18:04 – But how do we then distinguish which is good and which is bad? Again, we can’t look at the bug.
18:09 – We’ve got to look at the host because the difference in that context, even though the bugs, the good ones can still get
18:15 – inside and hide inside the bladder lining, that’s not necessarily the bad thing is having bacteria there.
18:22 – The trick is, are those bacteria actually causing problems? Are they causing activation of the immune response?
18:29 – Are they causing inflammation? Are they causing death and shedding of that epithelial lining?
18:35 – Are they causing remodeling of the bladder? These are the things that are important.
18:40 – And they’re difficult questions to answer that we can’t just get from microbiome analysis.
18:45 – We need to do a lot of functional studies to understand that.
18:48 – And of course, the only way to really test that is to test one pathogen at a time.
18:52 – But in reality, these pathogens exist in very complex microbial communities.
18:59 – And so I don’t think we’ll ever really have a distinctive answer other than when we have very clear cases of diagnosed
19:08 – infection in humans where we could say, this is the pathogen that we think has caused that.
19:12 – But it’s always a bit of we think, which is also why antibiotics are a bit tricky because they’re often generalized.
19:20 – They’re not very specific. They don’t really get to the urinary bladder as well as they do to other tissues.
19:26 – And then they’re potentially disrupting the balance of the bacteria or the good bacteria if there are good bacteria in there
19:34 – and not just targeting the bad bacteria that are causing the infection.
19:38 – So it’s – you can see why it’s just so complicated and even for scientists to try to dissect this. It’s a bit of a nightmare.
19:44 – Melissa: Yeah, it really is. And we also can’t look at the bladder in isolation.
19:47 – And can you explain how the microbiomes of the gut, vagina, and the bladder are all interconnected?
19:53 – Dr. Starkey: Yeah. So again, this is another really interesting topic. And one of the things that really frustrates me is that
20:00 – people tend to just blame women. So they say anatomically, you have a shorter urethra.
20:06 – Anatomically, your urethra is closer to your anal opening.
20:11 – And anatomically, you know, you’ve got the vaginal opening in that space too.
20:15 – And you guys don’t wipe properly and you’re unhygienic
20:18 – so it’s all your whole fault, which just drives me absolutely mad, right?
20:22 – Because in older men, we see significant increases in infection and in very young boys, we see very large numbers of
20:30 – infections. So it’s not just urethral length because these things don’t really just change as you get older, right?
20:36 – Anatomically, you are the same.
20:38 – What’s changing is what you do as a host, your immune response and the way you deal with these infections.
20:44 – So I think there’s a lot of naivety there in terms of these sort of things.
20:48 – Having said that, there is important evidence to suggest that bacteria that come from the gastrointestinal tract,
20:55 – so these uropathogenic E. coli can be detected in the gastrointestinal tract and it’s thought that they can bloom and
21:01 – replicate there. And then essentially, they can colonize the urethra and they can ascend from there.
21:09 – So it is, there is thoughts thinking that the gut microbiome, so the bacteria there in the gut could be an important source of
21:16 – these uropathogens. In terms of the vaginal microbiome, we know that particular bacteria, so particular
21:22 – species of a lactobacilli are important for protection. And so I don’t think it’s just as simple as the bacteria again, like the
21:30 – lactobacilli, but it’s sort of what they’re doing in the host.
21:34 – I think, you know, they’re probably creating more of a protective environment or a healthier microbiome environment
21:40 – or a healthier lining environment that just is less likely to be infected by these pathogens.
21:45 – Now, of course, it’s not just that some women are unfortunate and come across these pathogens.
21:49 – They’re there all the time, even healthy people can have them in their urine and even at high levels,
21:56 – that would be diagnostic of an infection, but they have no symptoms.
21:59 – Melissa: Right.
22:00 – Dr. Starkey: So that’s the other problem with these diagnostics is that
22:03 – you can have the level of bacteria in your urine to say you got infection,
22:06 – but you got no symptoms, so do you really have an infection? So it’s complicated. But in terms of the how they’re connected,
22:13 – I think, in summary, the gut can be a source of some of these uropathogens and the vaginal microbiome we know from
22:20 – some evidence has some protective species that can help to reduce the likelihood of having UTI.
22:27 – Melissa: You mentioned earlier that an infection leaving a signature in the bladder
22:31 – that could be related to this next question. Could antibiotics disrupt the urinary microbiome
22:37 – and repeated antibiotics use make someone more susceptible to future infection?
22:43 – Dr. Starkey: Yeah, I mean, I think it’s very feasible and plausible, right?
22:46 – I mean, I don’t know that there’s really good, hard evidence to say that that’s what’s happening.
22:52 – So we have to be careful how we interpret that, but it makes physiological sense.
22:56 – You know, you have a community of bacteria that exist in harmony under homeostasis or normal conditions.
23:03 – And so if you disrupt that, then you’re essentially removing some of your frontline defenses.
23:08 – You know, your soldiers at the front of the castle, the castle being your bladder lining.
23:12 – You know, if you get rid of those guys, you’ve moved a defense mechanism and allows the bad guys to come in and
23:17 – sort of attack that castle wall sooner. And so when you think about it like that, it’s very plausible.
23:23 – And obviously, if you have ongoing, you know, courses of antibiotics,
23:26 – not only are you going to disrupt the microbiome that’s in your urinary bladder,
23:30 – but also in your gastrointestinal tract and that’s going to affect your gastrointestinal health as well as your vaginal health
23:36 – as well. And we know, for example, you know, having fungal infections such a thrush is really common after antibiotics.
23:42 – And so that’s obviously disrupting the vaginal microbiome and potentially these protective lactobacilli as well.
23:48 – So we use these antibiotics with the intention of getting rid of the pathogen that’s causing infection.
23:53 – But of course, it’s a bit like an atomic bomb.
23:55 – We kind of doing it to all the other path — all the other bacteria, good or bad, across the entire body that are responsive to that
24:03 – particular antibiotic. So of course, that’s going to cause disruption. Whenever there’s disruption,
24:08 – whether that’s anatomical, older age, hormonal changes, transplantation, immunosuppression,
24:15 – whenever there’s a disruption, whether it be antibiotics or any of those things I just mentioned,
24:19 – that’s going to make us vulnerable in some way. So yeah, it’s feasible and plausible, but is it proven? No.
24:25 – Melissa: Do you think still we might move away from antibiotics as the future of UTI treatment?
24:29 – Dr. Starkey: I would love that to be the case. Yeah. Or at least as a combination therapy.
24:34 – I think antibiotics is probably great for the vast majority of uncomplicated infections occurring for the first time.
24:42 – I think it has a really important place there.
24:45 – We’re certainly not going to be moving to really complicated, expensive immunotherapies for everyone.
24:51 – Because I think of it a bit like a spectrum with COVID and COVID is a great example
24:54 – because people can understand that. It has such an impact on the community.
24:58 – Some people had the infection, no idea they had it. They’re asymptomatic, right?
25:03 – Some people it’s like a mild cold.
25:04 – Some people sort of got more like flu-like symptoms right up to being hospitalized, right up to ventilation, right up to death.
25:12 – And of course, UTI is exactly the same. It has that whole spectrum. It’s not sort of a yes/no infection, right?
25:18 – And so I think that’s really important. So on that lower end of the spectrum or even the high end of the spectrum
25:23 – where you’re in with urosepsis and it’s life threatening, then of course we need antibiotics in that case.
25:29 – And of course we need antibiotics as a first line therapy.
25:32 – But where things like immunotherapy come in, so non-antibiotic therapies that target the host rather than just the bug,
25:40 – that’s going to be important in the sort of conditions we’re talking about.
25:43 – So these highly recurrent infections or these chronic embedded infections where antibiotics aren’t working,
25:50 – is there something that we can do to target the host that can rebalance the host immune system or the host just in general?
25:57 – So that we can then clear the infection or so that then antibiotics might actually be effective.
26:05 – So I think antibiotics need to always be there, but I don’t think they should be the only weapon we have.
26:11 – I think we need to have additional tools.
26:13 – Melissa: There’s a lot of patient interest in non-antibiotic approaches.
26:16 – One thing that people often ask us about is fecal microbiota transplant or FMT
26:21 – do you think that could become something that is used for recurrent UTI patients more frequently?
26:26 – I know some patients already seek out this type of treatment, but it’s not something that’s offered as a standard approach.
26:32 – Dr. Starkey: Yeah, I mean, look, it could.
26:34 – I mean, it really depends, I guess, for that individual of where the pathogens are coming from.
26:39 – If for them, their disease is being caused because it’s, you know, their gastrointestinal tract is the source of these
26:45 – uropathogenic E. coli. And for that individual that’s happening, then this could well be a great treatment.
26:51 – So I think before that, we probably need ways of trying to distinguish or subset patients as to what’s causing it.
26:56 – So is there some kind of abnormality in the bladder or vaginal disruption or hormonal disruption
27:03 – or anatomical abnormality, immunosuppression, genetic cause, whatever it might be.
27:08 – But for a subset of patients, sure, I mean, it could be that they just happen to harbor these bacteria
27:13 – and you just constantly get in these blooms and that’s happening.
27:16 – But to assume that would work for everybody, I think would be tricky because I doubt that
27:20 – everybody’s going to have that cause of infection, even though it might be a common cause of infection.
27:26 – So could it work if you have, you know, disrupted microbiome and you have other gastrointestinal diseases
27:33 – and these bacteria are out competing other bacteria in your gut, then it could well be a therapy.
27:40 – Does everybody need to be pursuing it? I mean, it’s tricky.
27:42 – I don’t think that there’s the evidence there, right? But it’s always fun to joke about these things.
27:47 – You know, you’re going to get poo shakes or poo fusions or even craptuals or whatever you want to call these things.
27:53 – You know, like, you know, it’s an interesting and engaging topic. So you can see why people kind of navigate towards that.
28:01 – But I think we need to know how to stratify patients to make sure we give them the best care.
28:07 – So really, we need to move Melissa towards personalized medicine where we’re identifying
28:11 – like we do for other diseases. What kind of treatment? So if we take respiratory disease like asthma that I used to work in,
28:18 – we know that there’s these really great new immunotherapies.
28:21 – If we just give it to all asthmatics, it doesn’t work. And the clinical trials show that.
28:25 – But when you stratify those patients based on whether they have high levels of the sort of immune factors that are driving
28:33 – disease and then you use immunotherapy against that, of course, it works really well in that subset of patients.
28:40 – So that’s a great example of we can’t – it’s not just a one size fits all. We really need to understand more about subsets
28:46 – and individual patients through personalized medicine and then have targeted approaches for those individuals.
28:53 – Melissa: Thanks so much for watching. I hope you found this expert video helpful.
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