Many patients dealing with a recurrent UTI, chronic UTI, or the diagnosis of Interstitial Cystitis are familiar with bladder instillations. But what about antibiotic bladder instillations? How are they administered? How do they work? Are they effective?
Ruth Kriz, APRN, answers your questions about antibiotic bladder instillations and more in part 3 of our interview. Also discussed are the varied oral antibiotic treatment approaches, non-antibiotic options for UT, and the importance of identifying primary pathogens over time.
Watch the video or read the full transcript below to learn more.
Jump To Section:
- Antibiotic Bladder Instillations And Other Chronic UTI Treatment Methods >>>>
- Targeting the Biggest Player First >>>>
- Potential Risk of Long-Term Antibiotics >>>>
- Alternatives to Oral Antibiotics >>>>
- Non-Antibiotic Treatment Approaches >>>>
Ruth Kriz Video 3 Transcript: Antibiotic Bladder Instillations And Other Chronic UTI Treatment Methods
Melissa Now that we’ve talked about antibiotic resistance maybe you can tell us a little bit more about your general approach to treatment for chronic infection.
Ruth: A while back I mentioned that things have causes and if you don’t address the root cause and eliminate it then you will never get rid of the problem. And so when we have bacteria that are not just free floating in the urine, they’re not just attached to the bladder wall, they have invaded the bladder wall.
If they’re in the interstitial spaces, which is the space between the cells, that’s bathed with lymphatic fluid and I have seen pathology slides of bladder wall biopsies in which you can see the bacteria, so we know it gets there. When it’s in the interstitial spaces it causes swelling, inflammation, pressure on the nerves and pain. And that’s where the definition interstitial cystitis came from, was the inflammation in those interstitial spaces.
When you see that, you have a lot of work to do. We have to diminish the infectious load sufficiently that the bladder wall can do its repair job. It takes about four month months for damaged bladder wall tissue to regenerate after you’ve reduced the infectious load sufficiently that it can seriously start the healing and repair process.
So we know that this problem didn’t start as a one time, out of the blue thing, and then go away. It’s been there for some time whether you’re talking months or years. The longer the process has gone on pretty much the more damage there is and the longer it’s going to take to eliminate the infections and then begin the healing and repair process.
Targeting the Biggest Player First
Ruth: My approach is to see who is the big player – which infection is the highest amount on one of these reports and target the biggest part of the problem. Now bacteria kind of are classified in a couple different categories: Gram-positive, which has to do with the type of stain they take when you put it on a microbiology slide and look at it under a microscope, or Gram-negative.
Most antibiotics address either Gram-positive or Gram-negative bacteria. There’s only a few that will kind of do an okay job with both. By selecting which antibiotic is the best one for the majority of the infection that’s come out of the biofilm currently, is going to knock back the most infection.
And when we knock that one back, because the biofilms have lots of inhabitants, lots of different bacteria, then we retest and see who’s the next biggest player that’s now causing the most problem and we go after that one. This necessitates that you treat each infection that comes out.
And I like to do, most protocols are two weeks long. It’s a little bit longer than you’d routinely be given for an acute infection because the acute infections haven’t gotten as embedded. And yet it’s not long term because if you give only one antibiotic long term and the other infections aren’t covered by that one antibiotic you’re given long term then it’s not going to work.
It’s only going to take care of some of the infection that happened to come out of the biofilm at that point in time. And they’re left with a lot of infections still in the bladder wall, still doing their damage.
Hunner’s Ulcers Harbor Bacteria
Melissa We do have some other questions about long-term antibiotics but I wanted to go back briefly to the infection embedded in the bladder wall. I wanted to ask if that is what you believe is the cause for the ulcers that are sometimes referred to as Hunner’s lesions, and if so, can those then be treated in the same way?
Ruth: Well Hunner’s ulcers remind me of stomach ulcers. In the stomach you have H. pylori as a causative agent. It gets embedded in the lining and if it goes for a long time untreated the lining ulcerates. I think it’s the same process in the bladder wall.
Hunner’s ulcers are infection and I have had several patients that we have successfully healed by treating the bacteria that are responsible for damaging the bladder wall in that location to that extent.
Now some people have procedures in which they go in with a laser and they actually treat that area and that resolves a lot of the pain issues a whole lot faster. So that is an option but I think that’s only a temporary solution because if there’s still a lot of infection throughout the bladder wall, the propensity is going to be to form more ulcers down the road if you fail to treat the infections that are responsible in the first place.
Potential Risks of Long-Term Antibiotics
Melissa Okay, thanks. So back to long-term antibiotics. Do you see any risks in this type of treatment aside from what you already mentioned with the potential mis-targeting of the antibiotics over time?
Ruth: We know that long-term antibiotics have other consequences for the gut flora and yeast issues and other long-term side effects. Now do the benefits outweigh the risks? We have that problem with every decision we make.
By treating long term I have a concern that you’re not treating all the bacteria that’s there in a biofilm community and I have a concern about the long-term effects. When you test and treat and retest and treat you are essentially giving your body an antibiotic holiday and the gut flora does have a chance to repopulate.
Fun fact – they finally found a purpose for an appendix. It turns out that that’s a reservoir for the healthy bacteria so if you have a GI bug or you’ve been on an antibiotic and you’ve wiped out a considerable percentage of your normal gut flora, the role of the appendix is to repopulate that in your GI tract.
So taking drug holidays or antibiotic holidays does allow that repopulation to take place in a healthier way than to be on one antibiotic continuously month after month after month after month.
The Risks of Prophylactic Antibiotics
Melissa Okay so that was more on the the long term high dose antibiotics but what about prophylactic doses – so low doses that are just used preventatively either after sex or on a daily basis or after other triggers?
Ruth: I have had a number of patients who have been put on those protocols and pretty universally they say it helped for some period of months and then it quit working. And the reason it quit working is because you have successfully given your bacteria enough exposure to a sub-therapeutic dose of an antibiotic that it now has developed drug resistance.
So I think it’s important that just like they advocate that you take a full course of an antibiotic for other infections such as sinus infections or throat infections or kids and ear infections, lest you produce drug resistant strains, that the same principle applies to bladder infections.
You want to take a full course of a therapeutic level and so to do sub-therapeutic quote-unquote prophylactic dosages doesn’t make sense to me. Because number one, you don’t know what you’re treating and number two you’re ensuring that you will get drug-resistant strains.
Alternatives to Oral Antibiotics
Melissa Do you always use oral antibiotics for treatment or do you take other approaches for some patients?
Ruth: I do have concerns about only using oral antibiotics, particularly when we have someone whose infections are deeply embedded long term. I’m not naive to think that they’re harmless. I know that there are consequences, but we come back to the benefit-risk problem.
If your body has been unsuccessful in getting rid of these infections on their own and your body needs some help then the benefit of the antibiotics becomes a quality of life issue. If you can get rid of the infections, let the bladder wall heal and have a normal healthy life, which I consider I have for the past 30 years, I know that bladder walls can be healed.
I was told I had one of the most damaged ones and most severe cases of IC the chief of urology at this prestigious university hospital declared. My claim to fame back then I guess. And so I do know that this can be successfully treated with antibiotics.
How Compounded Antibiotic Bladder Instillations Differ From Standard Instillations
Ruth: Now how do you do this? Well we mentioned earlier that you need to look at what infection is the predominant player at that time. But there are alternatives to oral antibiotics. I’ve been working with a compounding pharmacy for about eight years now in having them compound IV antibiotics into bladder instillations.
Instead of the one size fits all Gentamicin bladder instillation, which is assuming that what you have is Gram-negative like E. coli, and only doing it once a week, which once again is another recipe for developing drug resistance.
These bladder instillations are instilled by the patient through a small pediatric catheter. It’s pre-lubricated into the bladder twice a day for a period of nine days to two weeks and there are certain issues that determine how long of course you need.
These antibiotics are ones that generally the bacteria have never seen before. They’re put in the bladder so we don’t have to have the risks of disrupting the normal gut flora and we generally don’t have to worry about the side effects of any medication because very little if any of the antibiotic is absorbed systemically from the bladder. Although if you have a significantly damaged bladder wall you will have more leakage into the general circulation.
The bladder instillations oftentimes can be combined with a biofilm disruptor and that makes the antibiotic work better. And faster, because you’re not only breaking down biofilms right where they are but the antibiotic is able to get in a higher concentration directly where the infection is present in the bladder wall versus having to be systemically absorbed, metabolized, cleared through the bladder and then whatever gets to the bladder is the part that can work.
The Limitations of Compounded Antibiotic Bladder Instillations
Melissa I imagine for some people it’s difficult to hold the instillation in their bladder when they have urgency, frequency symptoms. Is it still helpful if they can just hold it for a little bit of time? What’s the ideal amount of time to hold it in?
Ruth: Longer is better. I have many patients who can’t hold it very long but as we reduce the amount of infection and get the bladder wall to start healing they become more successful holding it for more periods of time.
This is done twice a day, so of course in the morning when you’re drinking and you have more fluid in your bladder you don’t hold it as long as you can overnight. Many patients may make it three to four hours or even sometimes all night long and the more you can get the antibiotic to have come in contact with the bladder wall of course it’s going to work better.
Melissa Is this a type of treatment approach that a patient can ask their own doctor to work with the compounding pharmacy on and access?
Ruth: A little bit harder at this point in time. The compounding pharmacy that I work with has determined what concentration of antibiotic is appropriate for the bladder wall tissue and that isn’t information that most compounding pharmacies have access to. And likewise, this is sterile compounding which many compounding pharmacies aren’t equipped to do.
Melissa So they really need to work with a specialist compounding pharmacist that has this experience.
Ruth: It needs to be a compounding pharmacy that does sterile compounding. I’m in the process of doing training modules for other practitioners and then those trained practitioners will have access to those concentrations and are able to work with more local compounding pharmacies.
Non-Antibiotic Treatment Approaches
Melissa For people that are unable to continue taking antibiotics for one reason or another, are there other non-antibiotic treatment approaches that they could consider?
Ruth: I wish we had more. I’ve had a number of people try herbal treatments. I know that Stephen Buhner’s book on herbal antibiotics is something that many people have looked to as a reference.
I’ve had a number of patients try his protocols based on which bacteria the DNA testing was identifying and we’ve not had terribly good success in reducing the infectious load of those organisms.
I don’t know whether it’s because the urine dilutes the herbals. I don’t know if it’s because they just need to do it longer and haven’t. And I don’t know what those variables are. That being said, there are some alternatives that are more promising on the horizon.
Hiprex / Methenamine
Ruth: I know that people have been given and have tried Hiprex and I have to say I am less than enthusiastic about that one because the Hiprex itself interacts with the urine and produces formaldehyde. And formaldehyde, if you’ve ever seen the pictures of labs with brains and other organs floating in a jar, they’re floating in jars of formaldehyde.
It basically pickles the organ. Formaldehyde is also known to be carcinogenic and I could not find any studies looking at the long-term effect of formaldehyde being produced by a person’s body in the bladder and then remaining there for months at a time.
Because I know that some of the antibiotics when we give them in the bladder by instillation do have some small amount that gets into the systemic circulation I am concerned that particularly someone with a damaged bladder wall will be absorbing some of that formaldehyde.
Ruth: In place of that I’ve recently started using some methylene blue. It’s an old urinary tract infection remedy that does not disrupt normal gut flora and give people yeast issues. And we’re starting to see some good success on eradication of multi-drug resistant pathogens in several of my patients. But I don’t have enough data on it yet to say that it’s the new answer to antibiotics.
Melissa Right, and is that an over-the-counter compound or prescription?
Ruth: Unfortunately not. It gets compounded by compounding pharmacies into capsules that you take twice a day and it does make your urine blue. It’s not known to have any side effects in particular.
If any of you have used Uribel for pain management, it does have a small amount of methylene blue in it. Once again I don’t think it’s enough to go after some of the pathogens that we’ve been finding. It may help discourage the growth of them but it doesn’t seem to eradicate them the way the higher doses do.
Melissa We’ve received a lot of questions from people on different UTI products like Uqora, uva ursi products, Utiva, Marshmallow root and other natural products for UTIs. People want to know your thoughts on those, but also on ozone instillations as another non-antibiotic approach.
Ruth: Some of those actually have some good merit, some of them may not be well tolerated with a damaged bladder wall and some of them have very limited application.
The Marshmallow root and aloe vera may give good symptom management but I do have some concerns about that because they’re mucilaginous. They put sort of an artificial coating on the bladder wall which was the goal of Elmiron.
They are for symptom management. They’re not going to heal or cure anything as long as the infection is still embedded in the bladder wall. So all of those products should be stopped a week before you send off any testing by DNA. Patients who’ve been on those products and send off a specimen oftentimes get negative or no pathogens found on the DNA test. So that tells me that basically those are effective barriers but they also prevent good diagnosis and treatment.
D-Mannose, Uqora, and Uva Ursi
Ruth: D-mannose is really stunningly brilliant. It comes from mannitol which is a plasma volume expander, and some brilliant person observed that when it was being given it would attract Gram-negative bacteria, particularly E. coli, and like a magnet link up with it. And then basically that infection would be cleared out of the urinary tract.
It is not effective for Gram-positive organisms and therefore you may find that D-mannose works for one person and not for another person. D-mannose is fairly effective when it’s a low level of E. coli but I have been unsuccessful in making it work well for people with a medium or a high load of that pathogen.
If you look at the Uqora product it does have some D-mannose in it. It has some vitamin C in it, which if it’s ascorbic acid could be a further bladder irritant. However, they do buffer it with some magnesium which may or may not be enough. Natural lemon and potassium and citric acid which is in that product could potentially be an irritant as well, so I think it depends upon how damaged your bladder wall is as to whether that product would be helpful or a further irritant.
The uva ursi is interesting because it actually does go after Gram-positive pathogens and may be more effective than D-mannose if the Gram-positives are what infections you tend to be harboring primarily.
Ruth: The ozone treatment is becoming more and more popular. We’ve noticed on the Microgen report they have a little category that says respiration. And it will talk about aerobic – needing oxygen, anaerobic – not needing oxygen and something called FAN – facultative anaerobic, meaning that it’s a very smart bug that can live with or without oxygen.
So when you’re talking about putting ozone or free oxygen into someone’s bladder, some of the bacteria, if they can only live as an anaerobe and you give them oxygen, may not like that,
curl up and die. But if you have bacteria that thrive in oxygen or have the capability of thriving in oxygen they may just laugh and say, you know, I’m going to party, thank you for the extra oxygen.
So I don’t know at what concentrations the oxygen would help the bacteria grow or discourage its growth. I do have a number of patients who have done it and I guess my warning is you need to be very careful and go at much lower concentrations than what is typically given if you have chronic urinary tract infections or have been diagnosed with IC and there’s significant damage to the bladder wall.
I have had a number of patients who said that it made their bladder worse so I’m not saying not to try it. I’m for anything that will help people get rid of infections. I’m just not seeing it deliver consistently for my patients who have tried it.
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The idea of antibiotic bladder instillations can be frightening. However, when UTI patients are unable to tolerate oral antibiotics, antibiotic instills may prove to be an alternative. As more clinicians become familiar with alternative treatment options, more avenues for patients become available. We want to thank Ruth Kriz for generously donating her time to speak with us and share her knowledge with the UTI community.
Watch the rest of our video series with Ruth Kriz, APRN, or subscribe to Live UTI Free on YouTube.