00:00 – Dr. Ana Lidia Flores-Mireles: When you have uncomplicated UTIs, there is the majority one pathogen, the uropathogenic E. coli, right? But when we look at catheter associated UTIs, the rules have changed.
00:22 – Melissa Kramer: Today, I’m joined by Dr. Ana Flores-Mireles, a microbiologist whose research focuses on understanding how urine re-catheterization
00:29 – leads to inflammation, which in turn makes patients susceptible to catheter-associated urinary tract infections,
00:35 – urosepsis and bladder cancer. Her work aims to develop innovative antibiotic-free strategies
00:40 – to prevent and treat these common hospital-acquired infections. It’s intended to inform future clinical guidelines for catheterization
00:47 – by focusing on reducing inflammation and limiting the opportunities for microbial colonization.
00:52 – Thanks for taking the time to share your expertise with our community. Dr. Flores-Mireles: Well, thank you so much for this invitation.
00:58 – And I think it’s a major problem that we have. And if more people were working on it, we would find solutions.
01:07 – Melissa: There’s been a lot of interest in our patient community over the last few years in the topic of catheterization. So I’m so glad that you were referred to us so that we could reach out
01:15 – and learn more about your work. But I noticed in your bio that you actually started out in marine biology.
01:20 – So I’m interested to hear more about how you went from that to your current field of research. Dr. Flores-Mireles: Yeah, so and I actually, you will know in a few seconds
01:28 – that thanks to being a marine biologist, I was able to figure out what’s happened in the catheterized bladder.
01:34 – So just to tell you that when I was eight years old, I decided I was going to be a marine biologist.
01:40 – I don’t know why. I just decided, well, I know why, but it’s a long story. And I started working with marine environments and great whales and sharks and everything.
01:51 – And then at one point we were trying to look whether great whales were healthy enough, right?
01:59 – Because they were hunted in the 40s and we have really low numbers. And then we didn’t know whether all of them were clone of themselves.
02:07 – And then when they are going from Alaska to Mexico, they have to go through different ports. They are totally contaminated. So the question, can they survive an infection? Right – or an epidemic
02:17 – like the one we had just a few years ago, right?
02:25 – And by doing that, we were looking at the specific genes of the great whale.
02:30 – So we had to use microbes to bind those genes, to clone those genes, right? And I hated that.
02:38 – And I actually put it in my notebook, Who Cares About Micros? Right? Because I was working with these big things. And then I had to focus on that. But actually I became really interested in them.
02:48 – And one of my mentors said, like, you should do microbiology. So then is when I did my master in marine biotechnology, working with microbes to understand which microbes are good,
03:00 – which microbes are bad for the environment in marine ecosystems. And then there is when I realized that they can actually communicate between each other.
03:10 – And for me, that was mind blowing. Like how these tiny, tiny things can coordinate behaviors to kill a plant,
03:17 – to infect something, right? How can they organize? So then I went to Cornell, the University of Cornell, to do my PhD to understand that on there Dr. Steve Winans.
03:28 – And there I was looking at plant pathogens and how they can manipulate the host or the plant to create a tumor.
03:38 – So these crown galls that you see in the plants or trees is basically tumors,
03:43 – that these microbes cause, and they do this by coordinating themselves with these signals.
03:49 – So then the question is, like, if they can manipulate things so well,
03:56 – how can we know that our good microbes can become bad microbes?
04:02 – And that’s when I started looking at urinary tract infections, specifically catheter-associated urinary tract infections,
04:09 – because the majority of the pathogens, they are good in our gut.
04:15 – But if you move them from the gut to the bladder, that’s a different story. How our immune response can differentiate that? When they got friends, so they are enemies, right?
04:26 – So then is when I went to Dr. Scott Hultgren, which is the guy of UTIs.
04:31 – And nobody was paying attention to catheter-associated UTI. Nobody cares about it.
04:39 – And I ask, like, why not more people are doing this? Like, well, it’s because it’s difficult. Most of the times what we have is just prevalence, right?
04:47 – Different clinical reports and say, these are the pathogens in this place, these are the pathogens in the other place. And we have many people developing novel catheters.
04:56 – But they were not really successful in the clinic. So is when I start working on this, it worked out. It was a big gamble.
05:06 – Melissa: Yeah. Dr. Flores-Mireles: But the reason they were able to figure it out is because I was an environmental biologist.
05:15 – Melissa: Interesting. And it’s such a fascinating area of work and so needed, as we’ve seen from the questions that we get from our community.
05:21 – So I’d love to jump into some of the questions that were submitted. And first of all, it would be great if you can explain in simple terms
05:28 – why urinary catheterization makes someone more susceptible to infection.
05:33 – Dr. Flores-Mireles: Yeah. So one of the things when I start working on this, the question is when probably many of your audience have seen different talks about uncomplicated UTIs, right?
05:47 – The first thing that we need to understand is these are not the same. Melissa: Yeah. Dr. Flores-Mireles: Right? Everybody in the clinic treat them the same
05:53 – because they’re affecting the same organ, but they are not the same. So when you have uncomplicated UTIs, it mostly affects women.
06:01 – There is specific age bias when they’re really young or for some menopausal. And there is the majority one pathogen, uropathogenic E. coli, right?
06:12 – But when we look at catheter associated UTIs, the rules have changed. First of all, we don’t have age bias. If you have a urinary catheter, if you’re small or old,
06:22 – you have similar predisposition to develop the infection. If you – so we don’t have age bias. We don’t have gender bias. And other thing is that we have many
06:34 – microbes causing the disease. And 76% of them are polymicrobial.
06:41 – So we’re talking about different pathophysiologists, a different story. So when I start looking at that, I was focusing on the pathogens,
06:50 – not in the one that is able to cause infection like uropathogenic E. coli, because it can cause infection in both of the types of disease,
06:58 – but the ones that cannot – what is special with these ones? They cannot do that.
07:04 – If you put these pathogens to grow in urine, they don’t grow. They don’t grow well. So how they can infect the bladder?
07:11 – If you put them in a healthy bladder without the catheter, they don’t cause infection. So what is the advantage
07:19 – that the catheter is providing for these microbes to infect. So it’s when the marine biology hit in.
07:29 – And I was thinking, this is the environment. The environment have changed. If you’re in a marine environment and they say,
07:37 – oh, do not eat oysters this season because we have red tide. It’s because probably there was a contamination in the lagoon.
07:43 – And you have this red tide that these oysters are eating, right? It’s the same thing that’s happening in the bladder.
07:48 – When you introduce the catheter in the bladder, can you imagine the bladder is really flexible
07:56 – because in one moment, you will have half of a liter there and you have to go to the bathroom and then come back
08:02 – and it goes back to normal. So if you put the catheter, the bladder goes all over
08:07 – and imagine that you’re walking and this is moving, you move. So we move a lot. The bladder moves a lot all the time, right? Imagine that you have a new shoes,
08:18 – you’re going to a conference, a new job, you have a new shoes and you’re walking. What happens? You start rubbing your skin and then you have blisters.
08:26 – You have bleeding. It’s exactly the same thing that happened in the bladder. Now we have this huge inflammation and what the bladder wants to do is, let’s heal the damaged tissue.
08:36 – So by bringing proteins from the bloodstream, they will help us to basically to coagulate and heal the damage, right?
08:44 – That’s what happens. So if you put these catheters just in urine with none of the inflammation proteins,
08:54 – they barely form biofilms because the urine has high salinity, low pH
09:01 – as urea, it changes the environment, how the pathogen reacts to the environment.
09:08 – But now, if you have all these tons of proteins that’s coming from the bloodstream, to heal the damaged tissue,
09:14 – they deposit on the catheter and now there is something that they can cling on, right?
09:20 – Not only on the catheter, but also in the bladder walls. So before they couldn’t infect. But now you bring those resources.
09:29 – I always call these a bed and breakfast. They have a place to stay and a place to eat
09:36 – because now they are eating all these proteins and nutrients that are coming from the bloodstream.
09:41 – That’s the difference, that’s the main key. Now the catheter damage or the inflammation caused
09:49 – by the catheter provides an advantage to these pathogens that normally do not cause damage
09:55 – or do no cause an infection in the bladder. Melissa: It’s really interesting to think about it from that perspective and it makes so much sense because often when we’re talking in the patient community,
10:05 – people are focusing on the surface of the catheter and they know that this can have biofilms on it, but why and why does it happen there or not in a lab environment?
10:12 – And that kind of raises the question. People also assume that the organisms that cause catheter associated UTI come somehow in with the catheter, but you’re saying that they could be there.
10:23 – They just weren’t a problem until the catheter was put into that environment. Are there other ways that those organisms can come when the catheter has been inserted?
10:31 – Dr. Flores-Mireles: I have facts and theories that I haven’t tested, but it’s a really amazing question. And it’s a question that I still have. Right.
10:40 – So, people, most of the time we have the same pathogens. We have many, but we have the same pathogens coming in.
10:48 – We have early pathogens, E. coli, E. faecalis, Candida albicans, they are in colonizers.
10:54 – And then people that have the catheter for the prolonged periods of time, they are seeing pseudomonas,
11:00 – proteus mirabilis, other ones. So there is definitely a succession in the ecosystem, right?
11:06 – First we have these ones that they can stay there for long periods of time, but then we have another one
11:12 – that’s coming in. So the three ones that I’m just telling you, they are common microbes in our gut.
11:21 – Proteus mirabilis is not in our gut. It’s environmental. Pseudomonas is environmental.
11:27 – That is not a part of our microflora. So the question is if we think about the early colonizers,
11:33 – the idea is that they, since the urinary tract is so close to the gastrointestinal tract, we may have some contamination.
11:41 – Right? Could be by inserting the catheter, we may have other type of contamination.
11:48 – And actually that’s something that we’re seeing lately. And I was talking with different neurologists, and I just gave a talk in Berlin about this. We have a new player in these infections.
12:00 – Candida auris, which is a fungal pathogen, highly resistant to antifungals. We don’t have that many antifungals.
12:08 – And it’s a nightmare right now in the hospitals. And we’re seeing a high correlation of this pathogen.
12:15 – when factors are present. There are no studies. So it’s just correlations what we can see. Melissa: Right.
12:20 – Dr. Flores-Mireles: And high mortality on those patients. So those are believed to be,
12:29 – that they can disseminate through the hospital. So that could be true contamination, because they are not part of our microflora, skin
12:36 – microflora, gut microflora. So we have those ones that can come from us. One that can be due to contamination, due to insertion, like are not really aseptic conditions.
12:48 – And the other ones that could be environmental. Right. So when catheters are there for really long periods of time, you’re walking with that, you’re touching things,
13:01 – dust is in the house or things like that, those things can end up in the bladder, because you have basically a road
13:09 – that they can go in. And when we look at one of the main proteins that provide this platform for biofilm formation,
13:17 – and actually I think it’s the key protein is fibrinogen, which this protein is critical for you. If you don’t have fibrinogen, you die.
13:27 – you bleed to death. So fibrinogen is the one that helps to coagulate. So when I was getting the first urinary catheter for patients,
13:35 – I can see the accumulation of fibrinogen coming from where the place they was inside of the bladder,
13:40 – all the way to the back. So if you think about that these microbes can use these proteins, including fibrinogen, they can climb.
13:49 – And it will take time, but they will get there. Right. So we have those situations.
13:54 – So those are the three things that we can think about evidence or like a more, not as theoretical.
14:02 – My hypothesis that I hope I can test soon is that they may come within. You don’t need to have a contamination or anything.
14:12 – So there are many reports from different colleagues. They show that when people take antibiotics,
14:19 – if you’re going to a surgery, you need to take antibiotics, right? To make sure that you don’t have an infection. There are three populations, they spike in the gut. Candida auris, sorry, Candida albicans, not Candida auris, sorry.
14:34 – Candida albicans, because it’s part of our gut and the antimicrobials are not going to kill them. It’s just killing bacteria. E. coli increase and E. faecalis increase.
14:48 – Also, they got reports that there are specific antibiotics that cause inflammation in the gut, which may, it becomes leaky.
14:57 – So pathogens can actually translocate from the gut to the bloodstream.
15:02 – So if they’re in the bloodstream and there are many proteins getting into the catheter because we have an inflammation, you may think that they
15:10 – may end up seeding their bladder and then they can reflux back. Right. So that’s the theory that I have that I have not tested, but it could make sense.
15:22 – Melissa: It seems really important to know the whole creating a road for bacteria to climb into the bladder is pretty terrifying, especially for people
15:30 – who have chronic UTI or recurrent UTI. So there’s always this concern about having a catheter during surgery,
15:35 – which is understandable. And people have asked whether you can just refuse to have a catheter in
15:40 – surgery, if you could use an adult diaper. But I know there are medical reasons for using a catheter during surgery.
15:46 – And it would be really helpful if you can walk us through some of those. Dr. Flores-Mireles: Yeah. So actually that was the first thing when I have my C-section.
15:53 – I know that I’m sharing too much information. Melissa: It’s never too much information.
15:59 – Dr. Flores-Mireles: Like can I have a diaper? And they said no, because there are many issues. So when you, you need to, you require having a catheter if the procedure is more than three hours.
16:12 – Also, it helps, if it’s something in the abdomen, they help the physician to see the bladder.
16:18 – The bladder is so small that you can injure the bladder without knowing. Also, it helps you to monitor the activity of the bladder. The last thing that you want to have is retention.
16:29 – You’re under anesthesia. So that means the muscles have paralyzed, right? A diaper is not going to help you to remove or avoid the urine. So actually medically, they are really, really important.
16:43 – And yeah, so they are critical for us, right? And mostly because we don’t want to cause damage to the kidneys that we don’t
16:52 – have any, that we’re not releasing the urine because the urine can then reflux and then you may have like a kidney infection.
17:00 – Since there are many, something they didn’t mention before, there are really good data about having a urobiome, right?
17:08 – So we don’t know whether if by pushing a microbe from the bladder to the kidneys, they may cause an infection, right?
17:16 – So it’s important to actually be healthy. So when I told the doctor, hey, can I have a diaper?
17:23 – He said, no, these are the reasons. They were really good to me. And I said, okay, can then I have my catheter to study my own catheter. And I did.
17:31 – So I think they use it for something. So it was great. Melissa: Yeah. Good to have access. Dr. Flores-Mireles: But yeah, they are really like, there are many things that definitely are
17:41 – critical to maintain the, to monitor the urine output and to make sure that
17:48 – we don’t damage the bladder when you’re working in something really close to the bladder. Yeah. Melissa: Yeah. And it makes a lot of sense. I also have a personal experience with this.
17:57 – When I had endometriosis surgery, I had a much longer surgery than expected. I had a catheter during the surgery. Then I required a catheter for a week afterwards because of the surgical damage. And I just couldn’t pee basically.
18:08 – And that was a nightmare for me because I knew this could be a problem. I could get a catheter associated UTI and I did.
18:14 – And that was something that has taken me a long time to get over. And so I completely understand the fear around this, but also it’s so risky.
18:23 – And you just wouldn’t be allowed to have surgery without having a catheter in that kind of way. Dr. Flores-Mireles: Yeah. And I, that’s why I believe that actually understanding the situation,
18:31 – like for example, before I was explaining, before I started working on this and I’m really grateful that my PI really believed on me and I said, yeah, go ahead and do whatever you need to do.
18:44 – The question is that when we get really good solutions is when we understand a system. We understand that the catheter is
18:52 – needed. But now we understand the catheter could be the perpetrator in the whole situation.
18:58 – How can we minimize that? That we don’t use antibiotics and we reduce inflammation.
19:04 – We know that is the main cause. So I think that by looking in details, what is the mechanistic factors that
19:14 – play role in infection, we can actually develop efficient intervention strategies.
19:19 – But we cannot do that until we don’t study. So when people before they were creating all these coatings with antimicrobials
19:27 – and everything, they don’t work. They have super inconclusive data. They test everything in vitro. They don’t think about the host. They don’t think about how you’re responding to it.
19:38 – And that’s the problem. Melissa: Yeah. And we can talk more about that in the next section. There’s one more question before moving on to risk reduction.
19:46 – And that is, are there comorbidities that make some people more vulnerable to catheter associated UTIs?
19:51 – Dr. Flores-Mireles: Yeah, no, that’s something that’s in my mind all the time. So one of the problems that we have, as I told you, if you have a urinary catheter,
19:59 – you’re predisposed. But there are patients that can go for a long period of time and they don’t really develop an infection. But there are patients that are 24 hours and they have already an infection.
20:10 – So the question is, what makes you more susceptible? We know, yes, indeed, the catheter will predispose you.
20:18 – But are there any other factors that may affect that? So our journey to trying to understand if there are comorbidities that can exacerbate
20:28 – the situation was by looking at fibrinogen. Right? So as I mentioned, fibrinogen is the key protein for coagulation. Something that we see all the time in the blood.
20:39 – That is that we have these fibers, right? So fibrinogen is soluble in your bloodstream. It’s always running in your bloodstream.
20:47 – As soon as you cut yourself, it will go there, it will coagulate and everything will be perfect. Right?
20:53 – It will go back to normal. So you have the coagulation, you fold basically the scab and then suddenly the scab falls off.
21:01 – Everything has been healed. So there is a system which is coagulation and fibrinolytic system, which is like the
21:09 – waste removal, right? Okay, we don’t need this anymore. Let’s take it out. So the question that we have, since we see these fibers, I don’t know if you can see them right there in green.
21:19 – Those are the fibers that the pathogens in red are attaching to and that’s a bladder. Those are two bladders.
21:25 – Melissa: I see. I like your choice in artwork. Dr. Flores-Mireles: So the question is, can fibrinogen play a role in exacerbating the infection? Right?
21:40 – So by having different transgenic mice, will have – they don’t have fibrinogens or they have just soluble fibrinogens.
21:48 – Because something that I forgot to mention before is that I say it’s soluble, right? But as soon as they arrive to the damaged tissue, it will activate it to form these fibers.
21:57 – It will help to heal the damaged tissue, right? So is soluble fibrinogen sufficient or you need to have fibrin formation? Is accumulation of fibrin deleterious for us or not?
22:12 – So the coagulation cascade is super complicated. I never thought that I would be diving into it, but we did.
22:20 – And we have all these different mutations that will allow us to understand what predispose the patient.
22:28 – Well, in this case, the mouse, the mouse, not only to a persistent CAUTI, but also a dissemination,
22:36 – urosepsis, right? So we found if we have soluble fibrinogen, the infection decrease.
22:44 – Because if the fibrinogen doesn’t have time to attach, it’s a really sticky molecule. It doesn’t have time to attach to a surface, the pathogen will bind and will go out with the urine.
22:56 – Right? So you basically study co-molecules. However, over time, that doesn’t happen.
23:01 – So if they start sticking, then they will attach to everything. However, the problem was when you have accumulation of these fibrin,
23:12 – so that means that the waste system, the fibrinolytic system that removes everything is not working.
23:18 – That not only increase the amount of pathogen that is in the bladder, but it goes systemically really fast.
23:27 – And actually when we did infections over time, that we look from one day to 14 days,
23:32 – we saw that at one point when they have found the max colonization in the bladder is
23:38 – when they start disseminating to other organs, right? So the question is who is more susceptible?
23:43 – Well, the pathogen has to build a community in the bladder to then go to the bloodstream.
23:49 – But then the question is, what is going to promote this to be more persistent to have higher amounts?
23:55 – So basically what we have found, either you have genetic issues like thrombosis
24:01 – that many people in our population suffers from, or who have coagulopathies that end up
24:08 – in accumulation of fibrin in the bladder, that makes you more susceptible,
24:13 – not only for monomicrobial infections, but polymicrobial. Melissa: Right. Dr. Flores-Mireles: And actually that’s, and this is just early on, like nobody have found that before.
24:23 – Like nobody have studied this before, nobody have figured it out that that could be something. Then let’s think during a hospital, you have many patients. The nurses and the doctors
24:33 – are really overwhelmed, like what we have with COVID. The incidents of CAUTIs, the catheter associated UTIs, increased during COVID
24:42 – because the patients were in an ICU. They have a catheter, they were intubated. So they have two infections,
24:49 – one for the intubation into the lungs, and the other one through the urinary catheter.
24:56 – You have many patients. Which ones do you pay attention the most, right?
25:02 – And by understanding if there are other factors that may affect that, we may say, okay, this person has history of thrombosis.
25:11 – Let’s keep an eye on this one. And why? So probably when you were during the surgery and everything, and many people have had that.
25:20 – You have many medications, different type of medications that will mask the symptoms of an uncomplicated UTI.
25:27 – You will have painkillers, you will have anti-fever medications, so then when they see that
25:32 – they actually you have a really severe infection, it may have already jumped to the bloodstream. So we don’t have a way to know because you’re not feeling everything.
25:44 – It’s not like an uncomplicated UTI that is in the community that you say, I feel weird, like when I go to the bathroom, I feel like it’s burning. No, in this case, you’re bypassing all these symptoms.
25:54 – So there is any way that we can say, okay, we know that these patients may be more susceptible.
26:00 – Let’s pay attention to them, right? So right now I’m working with the Lucy Institute right here in Notre Dame which is for artificial intelligence.
26:10 – And we’re trying to work with the VA, the Veteran’s Affairs in the U.S. and also in a hospital
26:15 – in Mexico, where we can collect all the data, medication. We don’t know if a specific medication make you more susceptible or not.
26:24 – Patient history, the type of surgery, how long the catheter was there, did they develop an infection,
26:30 – did they went to the bloodstream, did they, that results in mortality. By gathering all this data, we can actually form clusters of information and say, hey,
26:38 – we have seen that these specific patients may be more susceptible because they use this type of medication.
26:45 – They use, they have genetic problem, not genetic problem, but genetic markers
26:54 – that may induce thrombosis or something like that. And then we can have a better understanding how to treat the patients, right,
27:01 – and how to pay attention to them and how to monitor them. And that will go a little bit with like a more personalized idea for the patient because each patient is important, right?
27:13 – So the other thing that I was gonna, I lost my train of thoughts, but yes.
27:22 – Basically, that’s one of the things that we want to do. Are there any other factors that may allow us to understand? I got it.
27:31 – If the type of medication, let’s say somebody that has diabetes and they use a specific medication,
27:39 – they will increase the glucose input in the urine. Does that select for more Gram-negative pathogens, Gram-positive pathogens or fungal pathogens? We don’t know.
27:54 – Melissa: Yeah, it’s all so complicated, but it sounds like you need to build this big picture and able – to be able to help people or to predict who might actually get infections.
28:03 – There are some things that I think we know about catheters and I’m hoping you can fill us in. And so we’re talking about the risk factors. One of the questions was are
28:12 – intermittent catheters less risky than indwelling catheters in terms of infection risk? Dr. Flores-Mireles: They are in the in between. In fact, there are many people that will suffer from
28:23 – these infections if they have intermittent catheterization. Most of the time, the pathophysiology will be more like an uncomplicated UTI’s
28:34 – because the majority of the pathogen that you will find there is E. coli. And because you get in, you avoid the bladder and then remove it, there’s no constant damage in the bladder.
28:47 – But every insertion is causing a little bit of damage. So that’s why I say it’s the in between.
28:53 – So since we have not changed the ecosystem completely, the bladder environment completely,
28:59 – so the pathogens end up being really efficient to infect is E. coli.
29:05 – The problem with this is that, and actually we have a paper about this with intermittent catheterization and one of the
29:12 – companies that were developing a system to clean intermittent catheters.
29:18 – So I don’t know how the rules have changed now, but like before you,
29:24 – Medicaid or Medicare can pay for a specific amount of urinary catheters.
29:30 – So that means that they say that it’s single use. But people don’t have money to be paying for all of that every single time.
29:40 – So what normally happens is that they go to the bathroom, they wash it in the faucet,
29:45 – they put it back in a pocket, you’re touching it, you’re getting some microbes right there.
29:52 – And actually we did a test. We just put in the urine with a really low amount of microbes and we let it sit for six hours.
30:01 – We see a biofilm buildup. So we were testing this system where they would clean it and
30:10 – they were able to prove that you’re able to clean that every single time. So reducing again contamination of the environment because there’s so many silicone catheters.
30:21 – Not only that, you were able efficiently to clean every single thing. Just imagine like how many times do you go to the bathroom?
30:29 – If you have only three catheters per day or one catheter per day, you’re not going to go just one time to the bathroom.
30:36 – Sometimes we go 12 times depending how much hydration we have. So in low like going back to the question, yes, they may be less risky in developing infection,
30:50 – but that doesn’t mean that you’re not going to develop an infection. And it looks more like an uncomplicated UTI.
30:56 – And there is no more, no much research about it. So we cannot talk more about the incident,
31:02 – like what kind of uropathogen E. coli has to be able to infect. Some research have found that if you get an infection with a really pathogenic microbe,
31:13 – then the next time a less pathogenic is able to infect. So you’re even changing the bladder behavior.
31:20 – So I think that this is one of the few research that we have and it’s just, and it’s not even in the animal. It’s just testing in vitro.
31:30 – Melissa: It is kind of amazing the lack of research around some of these questions because patients ask them all the time.
31:36 – So they’re thinking about these kinds of mechanisms. There are other two types of catheters that people ask about infection risk differences is a suprapubic catheter and an
31:45 – indwelling catheter. Can you share any insights about that? Dr. Flores-Mireles: So they are pros and cons in every single one.
31:52 – So with a suprapubic catheter, they are really good in managing long term catheterization.
31:58 – However, it’s surgically inserted, right? You have to go through the skin, which also that may lead to an infection.
32:08 – There are really contradictory data. We don’t have like a really big cohort of patients to study, but there is
32:17 – contradictory data whether reduce the amount of infections. There are some places that say, yes, it’s less likely. It doesn’t mean that it’s not,
32:28 – but it’s like you won’t have as many infections as a urethral catheter.
32:36 – So, but again, one of the important things that they have the same issues. They will clog, they need to be changed.
32:46 – And again, until we don’t understand the patient population, it could be that patient population will be really good at having suprapubic catheters.
32:54 – And that will be the goal. They will reduce infections and everything. And it could be for another ones that does not, that may be not an option, but there is no data about it.
33:06 – But there are pros and cons in every single one. Melissa: Okay. So it’s disappointing to know that we don’t know enough yet to help patients, but I think this is
33:15 – why all the questions come up, because patients have also not found that information online. We did get a few questions about for people who do need to use intermittent catheterization multiple times a day.
33:26 – What are the basic things they can be doing to help prevent infection? I think most of them already have a basic hygiene routine. And I’m wondering if there’s more they can be doing.
33:35 – Dr. Flores-Mireles: Yeah, so one of the main things is hygiene. That’s the main thing that when you’re putting the catheter, like to not just rinse it with water.
33:45 – Like you actually have to clean it very well, right? And the problem is that you have, like, this is the problem, right?
33:52 – I cannot say with confidence that if you wash it very well, you’re going
33:58 – to reduce completely the amount of infections you will have. Because you just need a little bit of the catheter touching a surface or something for microbes to be there.
34:11 – But hygiene is important. Probably using gloves or something like that that may help to reduce the colonization from your own microbes.
34:22 – There is this system. I don’t know if it’s in the market. I was a consultant and a contractor. I just tested. And I tested so many
34:31 – times because I, like I say, if the data doesn’t work, I’m sorry, but it didn’t work, right?
34:37 – But this system was, again, I don’t know if it’s in the market. They were able to wash
34:44 – the catheters very well. And we tested and nothing grew on them. So we may need more innovation. We may need something that’s more sustainable
34:54 – because also we’re contaminating so much with so many medical trash, right?
35:00 – So, so far what I can say, and I feel so bad because I cannot speak,
35:06 – I cannot give recommendations without actually having the proper scientific data that will allow me to say, yes, if you do this, you’re going to be fine. Yeah.
35:14 – Melissa: It’s tricky. Maybe if we can find the system that you’re talking about and we’ll share a link in the video description if it is available.
35:20 – Dr. Flores-Mireles: Yes, yes, yes, it’s available and I can look for it and send it to you. Melissa: Yeah, that would be great. At least we can share it for people who are interested.
35:28 – There was one more question that why are indwelling catheters typically changed at four weeks when the guidelines say they’re designed to last for up to 12?
35:36 – Dr. Flores-Mireles: So actually, if you go to the CDC, it says that you need to change it every two weeks. Melissa: Okay.
35:42 – Dr. Flores-Mireles: So, yeah, so obviously I think it’s convenient if we reduce the amount of changing of the catheter,
35:49 – like, you know, like if you have the many, like even in nursing homes, right? How often do you have to change the catheter? The patient is probably not as lucid as other ones.
35:59 – They don’t understand what is happening. It’s a traumatic event. So leave it for long periods of time.
36:06 – It would be easier for them. However, the problem is they develop infection,
36:13 – like, they would develop microbial colonization. And based on our studies, depending how much of that microbe –
36:23 – the amount of those microbes in the bladder they make result in and going them to urosepsis.
36:32 – The longer you have the catheter more built up of fibrinogen and other proteins that may help the pathogen to attach, it will be there.
36:41 – Again, the recommendation is to remove every two weeks for those people that need it. But people will go to four months and even we have patients that have the catheter for 49 days or even more.
36:56 – In my opinion, you asked me, I think you should change it more often. Melissa: Yeah.
37:01 – Dr. Flores-Mireles: That you need. Melissa: It makes sense based on everything you’ve already explained during this interview.
37:07 – But again, it comes back to cost for some people, I’m sure. Dr. Flores-Mireles: Exactly. Exactly. So and again, if we’re able to understand which patients are going to be really susceptible,
37:18 – can we develop better guidelines to say, okay, this patient is super susceptible.
37:23 – It could be two weeks. Good for them to reduce the incidence. Right.
37:28 – Melissa: Yeah. Dr. Flores-Mireles: And remember, we’re talking about most of these patients, they are outpatients, they are not in the hospital.
37:38 – That they need the catheterization for long periods of time. And they are doing the daily things. Right. So we don’t know whether more contamination will –
37:50 – it’s a higher probability of contamination by being in your home than in a more sterile environment in a hospital.
37:57 – But I think if we can understand comorbidities, what makes them susceptible,
38:03 – because we don’t know even again, these patients may have a specific medication. They may have neurogenic bladder. They don’t feel pain or they don’t have something that can give you an idea.
38:12 – We may have catheters that can detect if microbes are there. We don’t know. What we need this more innovation.
38:19 – Right. And I believe me, I’m suffering with everybody else because when I started this, we didn’t know anything about it.
38:31 – But yeah, so it’s cost effective. At the end, it’s going to be, if you don’t have the money, you need to have it there.
38:37 – Right. So you need to, sometimes you would, uncertainty.
38:42 – Melissa: Yeah. Well, I think you are working on solutions so we can talk about some of them. Thanks so much for watching. I hope you found this expert video helpful.
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