URINARY TRACT INFECTIONS (DRUG-RESISTANT):

URINARY TRACT INFECTIONS (DRUG-RESISTANT):

Dear Sumner:

I’d like your help. It involves a 26 year old sexually active woman, Anne Smith, who has had many recurrent urinary tract infections. She has been treated with various medications and, unfortunately, has had allergic reactions from both trimethoprim-sulfa and nitrofurantoin. Culture and sensitivity studies of the current infection reveal an organism which is sensitive only to injectable antibiotics. I’m reluctant to give these meds because of their toxicity potential. Anne’s only symptom now is mild discomfort during urination. I do not know how aggressively I should try to sterilize her urine. Anne will be making an appointment to see you shortly.

Dear Glenda:

It was a pleasure seeing your patient, Anne Smith, although disconcerting that it has been so difficult to clear her infections. There was nothing unusual in her sexual history: She is currently monogamous. Her partner is circumcised and he has not had any symptoms suggestive of infections. They engage in vaginal intercourse about 4 times per week. No abnormalities were noted on physical exam. Culture and sensitivities of a catheterized urine specimen confirmed your findings of an organism resistant to all of the oral medications tested. Given this situation of the many recurrent infections, particularly when dealing with the accompanying resistant organisms, I obtained a renal ultrasound. Happily no obvious anatomical abnormalities of the urinary tract were found.

I discussed with Anne the pros and cons of trying to render her infection free with the use of injectable antibiotics (as per the results of the sensitivity studies). Since she has not been unduly distressed by the infectious process, and the infection seems to be limited to the lower urinary tract (no fevers, back pain and grossly normal renal ultrasound--as per her request, we did not do a voiding cystourethrogram), we opted, for the time being, to delay active treatment of the infection and treat the symptoms of discomfort only.

This plan is particularly expedient when dealing with a resistant organism and a strong allergic history. I have found that, with the passage of time, possibly a few weeks or longer, there is often a shift in the sensitivity pattern, with the emergence of an organism which can be eradicated with less toxic medications. (Sometimes the “flushing” effect of a high fluid intake alone can actually clear up the infection without the use of antibiotics!) Assuming we can, indeed, clear the current infection, post-coital voiding and appropriate post coital meds for a few months may help prevent recurrent infections by reestablishment of a more healthy urethral-vaginal area, providing a less susceptible environment for the offending organisms. There is, of course, the possibility that we are still unable to clear the infection without treating her with injectable medications. We would the have to decide whether her clinical situation warranted such an approach. (The body can live in a symbiotic relationship with many organisms: The cure must never be worse than the disease!)