UTIs: increasing drug-resistant bugs

since i am doing a few blogs on antibiotic overuse and concerns about increasing drug-resistant bacteria, i thought i would add another one on antibiotic-resistant E. coli causing urinary tract infections, per the NY Times on 7/14/19 (see https://www.nytimes.com/2019/07/13/health/urinary-infections-drug-resistant.html?smid=nytcore-ios-share )

Details/Comments:

--UTIs are among the most common infections in the world

--the number of hospitalizations from UTIs has increased 52% from 1998-2011, especially for women and older patients (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5414046/ )

--there has been increasing E coli resistance to trimethoprim/sulfamethoxazole (TMP/SMX), with the NY City Dept of Health reporting 1/3 are resistant (as we have certainly seen in Boston over the past few decades) and 1/5 are resistant to 5 other common treatments

    --a Lancet editorial on the 2018 NICE (National Institute for Health and Care Excellence in the UK) draft guidelines for UTI treatment (see https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31077-8/fulltext , and https://www.nice.org.uk/guidance/NG109 for the guidelines themselves), also comments that 1/3 of UTIs are resistant to key antibiotics, suggesting that: 

        --for nonpregnant women:

            -- sometimes UTIs remit spontaneously, so if not so bad symptoms, reasonable to try acetaminophen or ibuprofen with lots of fluids, then to take a backup antibiotic if symptoms worsen or do not improve in 48 hours

            -- meds: either trimethoprim or nitrofurantoin as first-line antibiotics [they do not use TMP/SMX, but instead just trimethoprim 200mg bid for 3 days.  seems like a good idea to me, since it does work, and may spare patients from the not-so-uncommon adverse effects of a sulfa drug. The Infectious Disease Society of America guidelines for acute bacterial cystitis treatment in women notes that TMP/SMX and trimethoprim alone are equivalently effective (see cystitis guidelines ISDA1999 in dropbox, or Warren JW. Clin Infect Des 1999; 29: 745-58)]

            --use pivmecillinam and fosfomycin as second-line [pivmecillinam is not available inthe US].  NOTE: they do not even include fluoroquinolones in their algorithm!! And these should be avoided whenever possible, since overuse leads to resistant bugs (and a study found that E coli resistance to fluoroquinolones is already in the 12% range overall and the 30% range for elderly outpatients: see https://aac.asm.org/content/60/5/2680), fluoroquinolones have profound microbiome effects (including increased risk of C diff) as well as other serious adverse effects (eg tendon rupture etc etc etc: see https://www.fda.gov/news-events/press-announcements/fda-updates-warnings-fluoroquinolone-antibiotics-risks-mental-health-and-low-blood-sugar-adverse for example)

            -- if there is a urine culture with antibiotic sensitivities and the patient is on empiric antibiotics but the bug is not sensitive to the prescribed antibiotic, speak with the woman after the results come back and change antibiotics "if symptoms are not already improving", and then "using a narrow-spectrum antibiotic whenever possible" [ie, do not change the antibiotic if the patient is improving, even if the bug is resistant,!!!]

        --and, do not test for or treat asymptomatic bacteriuria in nonpregnant women, men, young people or children

        --if patients are given antibiotic and do not respond, consider alternative diagnoses

        --for those with recurrent UTIs: can use D-mannose, or vaginal estrogens if post-menopausal. but no benefit from cranberry juice (and, by the way, that does have a pretty significant sugar load) or urinary alkalinizing agents

        --for info about the other UTI treatment recommendations from NICE, including those for men, pregnant women, and kids under 16yo, see the full document: https://www.nice.org.uk/guidance/NG109

--an ED study in Northern California found that 6% of 1045 patients with culture-proven UTIs had resistance to extended-spectrum b-lactamase (ESBL) producing Enterobacteriaceae (see https://www.ncbi.nlm.nih.gov/pubmed/29980462 )

--there are quite troubling accounts of pan-resistant E coli emerging: see http://gmodestmedblogs.blogspot.com/2016/06/e-coli-superbug-is-spreading.html

--a CDC-funded study found that 12 strains of E coli in poultry match common human uropathogenic strains (see uti e coli from poultry msphere2018 in dropbox, or DOI: 10.1128/mSphere.00179-18; this is the journal of the American Society for Microbiology), which suggests that poultry may be a source of human E. coli infections, advancing the possibility that the inappropriate use of antibiotics in livestock is associated with antibiotic-resistant human disease. For example, it is estimated that 1.0 million kg of antibiotics are used in poultry (eg, see https://www.ncbi.nlm.nih.gov/books/NBK216502/ )

So, another example of increasing bacterial antibiotic resistance.  See blog from yesterday for more general comments on this subject (http://gmodestmedblogs.blogspot.com/2019/07/copd-crp-guided-antiobiotic-prescribing.html ). A few other comments:

-- I do think that the NICE guidelines are pretty on-target, suggesting strategies for minimizing antibiotic use (esp for non-pregnant women) and, when necessary, using the narrowest-spectrum ones around.

-- it probably is reasonable to change from TMP/SMX to just trimethoprim as the first-line drug

-- the article cited above on poultry includes several references which further suggest the linkage between poultry and community-acquired human UTIs.  We really need stronger regulations against antibiotic usage in livestock, especially in light of the rapid emergence of antibiotic resistance in the setting of the huge overcrowding of large numbers of animals in highly industrialized commercial farming…

geoff​

If you would like to be on the regular email list for upcoming blogs, please contact me at gmodest@uphams.org

  

to get access to all of the blogs:

1. go to http://gmodestmedblogs.blogspot.com/ to see them in reverse chronological order

2. click on 3 parallel lines top left, if you want to see blogs by category, then click on "labels" and choose a category​

3. or you can just click on the magnifying glass on top right, then  type in a name in the search box and get all the blogs with that name in them

please feel free to circulate this to others. also, if you send me their emails, i can add them to the list