Approximately half of women and more than one in ten men may have a urinary tract infection (UTI) at some point in their lives, with many enduring repeated UTIs. These frequent bacterial infections, which can cause painful urination, have been treated and cured with antibiotics with relative ease for decades.
As per Scientific American, however, as a result of antibiotic resistance — when bacteria grow resistant to the drugs used to treat them — a number of antibiotics frequently used to treat UTIs have become ineffective, resulting in more severe sickness, hospitalizations, and deaths while also increasing medical expenses.
Antibiotic resistance is a natural phenomenon, but the use and misuse of antibiotics in humans and animals have expedited its development. More than 92% of bacteria that cause urinary tract infections are resistant to at least one common antibiotic, and over 80% are resistant to at least two. Escherichia coli is the most prevalent cause of urinary tract infections (UTIs).
“Because UTIs are so prevalent, antibiotic resistance is a major issue in comparison to other illnesses. According to Lisa Bebell, an infectious disease physician at Massachusetts General Hospital, “we see the effects of antibiotic resistance much more quickly and with a higher frequency.”
Drug-resistant UTIs are a consequence of antimicrobial resistance (AMR), which occurs when bacteria, viruses, fungi, and parasites no longer respond to the medications used to treat them. In 2019, around 4.95 million deaths were attributed to AMR, and at least 1.27 million deaths were directly attributable to antibiotic-resistant bacterial infections, according to a Lancet study published in 2022.
According to the study, AMR killed more people in 2019 than HIV or malaria and was the leading cause of mortality worldwide. In 2021, the World Health Organization (WHO) identified AMR as one of the top ten worldwide hazards to public health.
The bacteria that cause urinary tract infections have developed resistance for numerous reasons. One is selection pressure, Bebell explains. Theoretically, when the correct antibiotic is administered in the correct quantity for a sufficient amount of time, it eradicates all of the targeted germs. However, antibiotics are not always prescribed or administered properly. If the dose is insufficient or the antibiotic is not taken long enough, the bacteria are subjected to selective pressure but are not eradicated. Those who survive adapt and develop more resistance.
Even when antibiotics are given and used appropriately, each time a person takes them, they alter the makeup of bacteria in the body and exert selective pressure on those that reside in the gastrointestinal tract, including E. coli and other bacteria that cause UTIs. According to Bebell, there is a correlation between taking antibiotics in general and the risk of acquiring a drug-resistant UTI in the future.
According to Ramanan Laxminarayan, an epidemiologist and chair of the WHO’s Global Antibiotic Research & Development Partnership (GARDP), a non-profit organization that develops cures for drug-resistant illnesses, people can potentially be exposed through consuming animals. He says that inadequately cooked meat can cause a drug-resistant strain of E. coli to develop. This bacterium can cause intestinal illness, which may result in a UTI resistant to antibiotics.
When a urinary tract infection (UTI) does not react to a conventional antibiotic, physicians use broad-spectrum medicines, which are effective against a wider range of germs. These are frequently only available intravenously, necessitating hospitalization for five to fourteen days and significant medical costs. Some individuals have passed away from UTIs that migrated to the bloodstream and caused sepsis, and drug-resistant infections could make this more prevalent.
Recently, Bebell treated a patient with a drug-resistant UTI who was hospitalized occasionally for several months. The patient’s blood and urine were cultured multiple times to discover which germs were resistant to which antibiotic, allowing his healthcare personnel to administer the most effective treatment. This raises the question of whether routine bacterial culture testing for UTIs should become the standard. In such cultures, bacteria in the urine are identified and cultivated in the laboratory to determine their kind and antibiotic resistance.
Bebell believes that bacteria cultures are simply a short-term treatment, despite the likelihood that they will become increasingly common, particularly in complex instances. Bebell notes that although culture-based diagnostics are essential, they are both costly and time-consuming (taking between three and five days), which might postpone therapy. “I would like to see the development of more point-of-care assays that can identify the implicated bacteria and its genetic makeup. She says, “I believe the long-term plan is to improve diagnosis and abandon culture-based methods.”
Bebell would like to see testing that can identify the primary bacteria responsible for the infection and assess if it has genetic mutations that signal drug resistance. Such tests, which might be performed in 15 minutes at the patient’s bedside by someone with no training, are in development, according to Bebell. However, she is unaware of any available for therapeutic use to treat UTIs.
But improved diagnostics alone will not fix the issue; new therapeutic approaches are also required. Researchers discovered in October 2010 that a combination of the antibiotics cefepime and enmetazobactam was successful in treating certain drug-resistant UTIs. Enmetazobactam protects cefepime from being degraded by enzymes produced by antibiotic-resistant bacteria. Combining one medicine with another that “protects” it is a typical tactic, according to Bebell. “It is hopeful in the long run because that is how many of our combination antibiotics have proven successful. “However, this particular antibiotic [combination] will be one among several, and therefore a temporary remedy,” she notes.
New antibiotics may be useful. However, Laxminarayan does not feel that new medication development is the only solution to drug resistance, a worldwide problem with no simple solution, as he states. “It is imperative that we use fewer antibiotics while growing chickens and pigs. It necessitates reducing the amount of antibiotics sprayed on trees. It necessitates improved infection management in hospitals. “It’s a variety of things,” explains Laxminarayan. “This is not a problem that can be solved with a single solution, where you do one thing and then you’re done.”
“New antibiotics are in development. But they will be quite expensive,” he adds. “We are accustomed to paying $5, $10, and $20 for antibiotics. Do we really want to spend $5,000 on antibiotics? Because that would mean that many individuals could not afford them. It places a tremendous burden on the health care system. However, this is where we are headed.”
According to Bebell, there aren’t many evidence-based strategies for preventing UTIs. (Drinking cranberry juice, for example, does not provide a clear advantage.) Keeping hydrated to flush the system continuously and practicing regular genital hygiene are the few evidence-based measures of prevention. (Bebell recommends avoiding excessive washing and strong soaps.) She suggests that those with a female urinary tract may benefit from urinating after sexual activity.
Due to the paucity of evidence-based preventative techniques, according to Bebell, the focus should be on antibiotic stewardship: a reduction in overall antibiotic use—not only in humans but also in commercial agriculture—and improved infection control in hospitals and among the general population. The World Health Organization adds that some basic techniques for preventing infections include “frequently washing hands, preparing food hygienically, avoiding close contact with sick individuals, [engaging in] safer sex, and maintaining up-to-date vaccines.”
“Antibiotics are often legitimately required, but we all need to be advocates for [appropriate] antibiotic use, and everyone has a duty,” adds Bebell. “And I would advise patients to ask their doctor just one basic question: ‘Do I need this antibiotic?'”
