Antibiotic Resistant UTI is a common and valid concern for many patients treating recurrent or chronic UTIs with antibiotics.
Ruth Kriz, APRN, lays out some of the factors that contribute to antibiotic resistance in the second part of our video interview. She also discusses the significance of biofilm and steps patients can take to help overcome these UTI hurdles.
Watch the video or read the full transcript below to learn more.
- Ruth Kriz on Antibiotic Resistant UTI >>>>
- Factors that Contribute to Chronic UTI >>>>
- Biofilms – The Big ‘B’ Word >>>>
- Disrupting Biofilm in Antibiotic Resistant UTI >>>>
- How Biofilms Contribute to Antibiotic Resistant UTI >>>>
- Horizontal Gene Transfer in Antibiotic Resistant UTI >>>>
Transcript Video 2: Ruth Kriz on Antibiotic Resistant UTI
Melissa: How do you explain why some people have infrequent UTIs while others have frequent symptoms or just continuous symptoms at a certain point?
Ruth: This is a hard question I think everyone struggles with. We all have friends, neighbors, family members, they get a UTI. They take a couple days of antibiotics and they’re fine for another three, five, ten years. And they have another one. Whereas we are in the camp of people who tend to get a UTI repeatedly and sometimes the symptoms don’t go away. And therefore we’ve moved from the acute urinary tract infection to the chronic UTI to the now IC label.
I think there’s several reasons that this happens and there are some commonalities among people who have these conditions that other people don’t have. When I started looking at the genetics based on some testing some of my patients did, I found some interesting commonalities.
Factors that Contribute to Chronic UTI
Vitamin D Receptor Mutation
Ruth: The first one is a vitamin D receptor mutation. Now we’ve all heard about vitamin D, the sunshine vitamin, and how important it is for bone health. But it has a key role in preventing urinary tract infections, if you have enough vitamin D.
I want to qualify that the way they get a normal reference range is you get your thousand people. You check their vitamin D level, you find the mean. You go out two standard deviations and that is declared to be the normal. And in the United States that goes from 30 to 100.
However, if you have a vitamin D receptor mutation, even though you can make vitamin D as well as other people, you can’t hold on to it as well. And because that reference range did not throw out of their normal reference range those people, it was falsely skewed to the bottom. So instead of going out two standard deviations, if you only go out one that cutoff is 50.
So I like my patients to keep their vitamin D level between 50 and 80. This provides enough vitamin D for the bladder wall to secrete a protein or a peptide called cathelicidin, that actually helps prevent urinary tract infections. If you have enough vitamin D that will help your body prevent urinary tract infections and if you don’t then you’ll be more prone to them.
Melissa: Does this mean for those people they’ll need to supplement with vitamin D forever?
Ruth: Absolutely because their bodies will never hold on to it as well as other people and d3 is a preferable form than the d2 because it’s more bioavailable.
Cysteine Beta Synthase Mutation
Ruth: The other commonality that I found was mutation called CBS – cysteine beta synthase. And that enzyme is important in the methylation pathway in breaking one of the chemicals down into cysteine that helps your body detox and taurine which your heart muscle uses. If you have a CBS mutation, which 100 percent of the patients who did the testing have, instead of making cysteine and taurine you make a truck load of ammonia.
And what’s the big deal about ammonia? Well it turns out that ammonia then goes over to the urea cycle, it’s in the urine. In the veterinary literature there are some excellent studies that talk about ammonia destroying the gag layer of the bladder wall. And that’s basically what happens when you get an IC diagnosis. They look through the cystoscope they see the damage to that bladder lining, that gag layer.
So if you can keep the ammonia level down, if you can help the body clear it then that will help reduce the damage to the bladder wall itself. And there’s a supplement called ornithine. It’s over the counter, it’s marketed to help you sleep. So I’ve started asking my patients to take one of those at bedtime.
I can’t prove that it will help 5% or 20% or 50%. But theoretically if you can help stop the damage to the bladder wall then the bacteria won’t have a happy home.
Biofilms – The Big ‘B’ Word
Melissa: You mentioned happy home. So maybe that’s a good place to segue into biofilms because this is a topic that comes up a lot.
Ruth: Absolutely. So let’s talk about biofilms. The big B word. Biofilms are kind of like slime. They attach to a surface and bacteria live inside these structures. And periodically pieces of these break off. When your body has an infection it causes inflammation and inflammation triggers fibrin. Fibrin is sort of that spider web stuff that things attach to.
We see that with making a clot, for instance It’s part of the body’s normal defense to try to wall off an infection so it doesn’t spread wildly or reproduce quickly. When you have an infection in the bladder we know that those bacteria like to attach to the bladder wall. They encase themselves in that structure which utilizes fibrin and they slowly continue to reproduce.
This also means that they don’t shed off into the urine as readily. So when you do a urine specimen there’s some sort of an assumption that all the infection is free floating in your urine and that isn’t really the reality. It’s walled off on the bladder wall. And so taking a substance that would help that biofilm to be broken down or disrupted should help that bacteria spill out into the urine so it could be found on a urine test and then more effectively treated, for instance with an antibiotic.
Can we Confirm Whether or Not Biofilm is Present?
There isn’t any specific test to confirm that you have a biofilm. If on a test they report multiple pathogens that’s a pretty good sign you have a biofilm community. They kind of live like in an apartment building with lots of different residents. The problem with urine cultures is that if they find more than two pathogens they report it as contaminated.
If there’s a fungal component that is found on a culture plate they throw it away and report it as contaminated. Whereas with the DNA testing we know that there are multiple pathogens and some of those can be fungal as well as bacterial.
How to Collect a Urine Sample When Dealing with a Biofilm Infection
Melissa: So given that the bacteria can live in these protected biofilms, does that mean the best time to collect a urine sample is actually when you’re experiencing symptoms?
Ruth: Probably it is. We did an interesting study some years ago in which we had patients collect urine specimens in the morning and the evening and then MicrogenDX tested those two specimens separately.
We discovered that the type of bacteria that are shed at one time in a day is different than either the quantity or the kind that is secreted in or able to be found at a different time of day.
And for me that explains why some patients will say oh I don’t have that much frequency during the day but I go to bed at night and I’m up four times. Another person will say oh I’m just miserable all day long. I’m going every half hour but I sleep through the night.
I think that can be explained by the different bacteria that are able to flourish at one time of day versus another time a day and some of that is dependent upon the urinary environment. When we go to bed at night we put out antidiuretic hormones. If you have the CBS mutation you’re collecting and concentrating a lot of ammonia in the urine and that’s a pH change that favors the growth of some bacteria over other types of bacteria.
Currently MicrogenDX will have you collect specimens at both times a day and send them in separate transport tubes they get combined by the lab 50/50 and that way we get a more realistic view of which bacteria is really present no matter which time of day you’re shedding it.
How to Collect Urine Samples Using Ruth Kriz’s Method
Melissa: Is that true for all practitioners or have you got a special set up with MicrogenDX for that?
Ruth: Currently we have a special set up and so practitioners are able to contact my sales rep and he is able to supply them and his patients or her and her patients with the kits that are set up to do the two collections. I think this is important for anybody with chronic urinary tract infections or an IC diagnosis because otherwise it’s very possible that the main pathogen will be totally missed.
Disrupting Biofilm in Antibiotic Resistant UTI
Melissa: You mentioned being able to disrupt biofilms in certain ways are there particular supplements that you use to do that?
Ruth: There are. There’s not a one size fits all. It turns out that when you make this extra fibrin, a person’s body tries to break it down, sort of the breaks and the accelerator on a car and those
substances are called thrombin anti-thrombin or TAT, T-A-T complexes. Some people are better able to make TAT complexes than other people depending upon their genetics.
About 20 percent of the population genetically are known as hypercoagulant. This means that they make a lot of fibrin which goes into atherosclerotic plaque causing blood clots, heart attacks and strokes. And then they aren’t able to break that fibrin down in the biofilms as efficiently as other people.
Those same set of genetics that apply to that population are the same ones that I’m finding in my chronic urinary tract infection and IC population. Only instead of 20% it’s closer to 55 or 60 percent. And so I think this is a huge, huge player in knowing how to break down the biofilms and how to more effectively treat because we can actually get to the infection.
Depending upon whether you have one of those genetic issues or not would dictate which biofilm disruptor would work better for you. So there can’t be a one-size-fits-all. Also some of the biofilm disruptors work by actually punching holes in the biofilm.
Some of them are enzymes that break down the fibrin, some of them have substances that prevent the bacteria themselves from making their own biofilms. So it can be fairly complex figuring out which biofilm disruptor your body needs.
How do Biofilm Disruptors Affect the Rest of the Body?
Melissa: Do you have any concerns about disrupting biofilms in other parts of the body that are meant to be there?
Ruth: Not significantly. First of all, I haven’t seen a problem in giving biofilm disruptors to essentially 100% of my patients. Secondly, if you have one of the genetic issues that doesn’t allow you to break down biofilms efficiently by supplementing a biofilm disruptor, all we’re doing is helping your body work as well as everybody else’s. And finally, biofilms are involved in any infection so people with those chronic infections would benefit from a biofilm disruptor.
I don’t care if we’re talking about chronic sinus infections, chronic prostatitis in men, chronic urinary tract infections. I believe fibromyalgia is also connected to the buildup of fibrin in the microvasculature, the small blood vessels. So I think the benefits far outweigh any risks. Finally, the enzymes that are used…Some of them are the ones that are used to help digest food. Some of their enzymes do work in that way as well but the majority of them aren’t the same enzymes.
How Biofilms Contribute to Antibiotic Resistant UTI
Melissa: That’s good to know, that’s a question that comes up quite a lot. You talked about biofilms and the way they can protect organisms from the body’s natural defenses but what does that mean for antibiotic resistance in general and also their ability to avoid antibiotic treatment?
Ruth: Biofilms do have the added problem that they can contribute to antibiotic resistance. Bill Costerton, who’s considered the father of biofilms published an article in 2011 that had demonstrated that the presence of biofilms is a major contributor to antibiotic resistance.
Not only can pieces of the natural immune system have difficulty getting to where the infection is and attacking it, likewise antibiotics have difficulty getting to where the infection is and dealing with it.
So you end up with partial penetration of the antibiotics through the biofilm and the bacteria get just enough of a dose, kind of like a vaccine, that it becomes very smart and has developed drug resistance.
This is an important part, a big point because, when you’re told that you have an antibiotic resistance to a certain antibiotic people are concerned that now they can never take that antibiotic again and if they get an infection they can’t treat it adequately because they’re resistant to an antibiotic.
What really is being said is that the bacteria has developed resistance to that antibiotic.
If you have let’s say a resistance to penicillin by the organism they find in your urine, that doesn’t mean that you can’t take penicillin for a sinus infection or a strep throat, because the bacteria in your bladder are most certainly different than what you’re finding with your throat infection or your sinus infection.
Is Antibiotic Resistance Permanent?
The other good news is that antibiotic resistance is not permanent.
Two years ago Scientific American in August, that would have been I guess 2018, had a brilliant article in which they talked about the price that bacteria pay for developing resistant strains. And that price is they do not reproduce as readily. And so if they don’t see that antibiotic or that family, that class of antibiotics for a number of months, they die out.
I see that all the time with my patients. They may have a urine specimen and they may have an organism that has multi-drug resistance but if we don’t give them any of those antibiotics for four months six months, sometimes it takes as long as a year, lo and behold when they come back with future tests that resistance is no longer an issue.
Melissa: Which means they may then have more treatment options than they did previously.
Ruth: Absolutely, and that’s one reason why it’s important to rotate antibiotics, to not keep giving the same one over and over again. Because with repeated exposures the bacteria are more likely to develop resistance to that particular family of antibiotics or the ones that work that particular way.
Horizontal Gene Transfer in Antibiotic Resistant UTI
Melissa: You also mentioned that in a biofilm it’s usually a community of different types of bacteria. Do they actually share antibiotic resistance traits so that one can help another become resistant to antibiotics?
Ruth: Unfortunately, yes. These critters are much smarter than we ever used to give them credit for. It turns out that there’s something called quorum sensing which is a very fancy term in physics that I don’t fully understand. It means that these bacteria are able to communicate with one another and they are able to transfer some resistance characteristics between species.
One of the labs that I use, Pathnostics, has gotten a very clever trick together in which they actually test for pooled antibiotic resistance. They have demonstrated that bacteria behave very differently in their resistance patterns when they have a community than if you’re only separating out each organism and checking each of those individually for drug resistance characteristics.
This testing is only PCR – they only check for 48 pathogens but it’s very helpful when you have multi-drug resistance because you can get actual drug sensitivities not just what the literature says should work.
Choosing Which Testing Method is Appropriate
Melissa: So they’re looking at what may be effective treatment for the bacterial community as a whole instead of individuals which gives you a better picture potentially.
Ruth: Absolutely. So there’s pros and cons of the different companies that do the testing. Some check for more organisms, some do actual sensitivity testing, and so it’s pretty much a judgment call as to what’s the more appropriate test for you at that time based on which pathogens have been treated and which ones haven’t and whether you have multi-drug resistance or not.
Melissa: That’s good to know. We do get that question a lot: What is the best test? But it can really depend on your situation, it sounds like.
Ruth: Absolutely. It’s like everything else in life. There isn’t a one size fits all either in the testing nor in the treatment protocols.
The idea of an antibiotic resistant UTI can be scary. However, with the guidance of an experienced clinician, factors contributing to resistance can be addressed, and resistance can be reversed. 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.
- Chronic UTI And IC Testing
- Antibiotic Bladder Instillations And Other Chronic UTI Treatment Methods
- How To Prevent Recurrent UTI