Antibiotic Bladder Instill for Lower Urinary Tract Symptoms

Introduced in the 1970s, bladder instillations, or instill, for urinary tract symptoms has been a long regarded concept. With the ability to insert medications directly into the bladder, an instill may serve as an alternative treatment. Antibiotic, antifungals and other medications may be used to treat UTIs or offer other solutions for lower urinary tract symptoms. 

Today, a primary feature of instill treatment for UTI is the use of this treatment alongside enhanced UTI testing. With more sensitive testing methods and detailed reports, the recommendations for compounded drug treatments have become more defined. 

Quick Links

• Compounded Antibiotic and Antifungal Instill for UTI >>>
• The Significance of DNA Tests and Compounded Instill >>>
• Identifying Other Bacterial and Fungal Reservoirs >>>
• Additional Benefits of Compounded Medications >>>
• Instill Safety and Practicality  >>>

With conventional lab techniques, organisms are often missed due to limitations around standard testing methods. Many organisms do not grow well in standard urine cultures, resulting in a negative UTI test. But thankfully, times have changed. Newer testing methods have given us a more focused look into what kind of bacteria, fungi, and corresponding biofilms may be located in the bladder. 

Benefits of this individualized approach include developing, or compounding, specialized instill medications to target specific organisms, address biofilms, and promote healing of the bladder. Armed with this information, better guided treatment decisions can be made.

With more sensitive testing methods, lab assessments now provide detailed information that may result in more suitable treatment options. For patients diagnosed with a chronic or recurrent UTI, polymicrobial infection, or interstitial cystitis in which other treatments have failed or continuously come up short, instill treatments may be an alternative. 

So, what is a bladder instill? It is a sterile antibiotic or antifungal solution prepared in specific concentrations, then inserted through a catheter into someone’s bladder. Despite the obvious invasive nature of the instill, there are many reasons this method of administration may be beneficial. 

One of the more notable benefits of a compounded bladder instill is the introduction of antibiotics and antifungals that organisms have not been exposed to previously. 

Despite being inserted into the body, an instill is still considered a topical treatment. A topical treatment is something that is applied directly to a surface of the body. A bladder instill qualifies as topical because when inserted, the compounded solution coats the internal surface of the bladder. 

The topical nature of the treatment combined with limited absorption into other areas of the body presents a unique treatment alternative. 

Antibiotics and antifungals that can’t be used orally or are difficult to access via IV treatment may be compounded and used as an instill. 

Compounded Instill for Biofilm Infections

While commonly used to target specific organisms within the bladder, compounded instills have the benefit of addressing biofilms. If needed, biofilm busting items like EDTA may be added to the solution. This gives the antibiotics an advantage when dealing with particularly difficult to eradicate organisms.

Biofilms form a complex barrier that both antimicrobials and natural immune system defenses have a hard time overcoming. The introduction of biofilm dissolvers directly into the bladder with an instill may result in this biofilm barrier being penetrated. As biofilm are broken down, microbial organisms can be more directly targeted. 

"Breaking through these biofilms has been a key to success, as they appear to exist in layers. As each layer is addressed, the organisms seen in the lab work shift, providing direction for treating the next layer." Randy Breton, RPh, BS Pharm

Biofilms are regarded as their own ‘ecosystem’ within an environment and have been well studied. Periodontitis, cystic fibrosis, and non-healing wounds are all conditions in which biofilms have been identified. 

Thus, biofilms have been associated with polymicrobial, chronic, hard to treat infections for quite some time. But novel treatments for addressing biofilms have taken time to be accepted and effectively incorporated. 

Some organisms are surprisingly difficult to grow in traditional cultures. This is what makes standard testing difficult for rare organisms and often gives inaccurate or incomplete results. It’s not uncommon to receive a negative UTI test when using this type of testing, even when symptoms are present. 

Standard culture testing of organisms involves variables such as: nutrients, temperature, and humidity, all of which have to be exactly right for growth to occur. Even when all of these are in alignment, there are species that simply cannot be grown. These organisms are known as viable but nonculturable (VBNC). 

Newer lab techniques have opened the door to removing some of the limitations associated with standard testing methods. The most researched enhanced testing methods include DNA PCR and NGS (Next Generation Sequencing). In the past, enhanced testing was only available to large universities and hospitals. Being extraordinarily expensive, it was rarely used. 

Today, thanks to affordability and other factors, this type of testing is more widely accessible than it was years ago. DNA testing identifies organisms by their DNA signature and gives a better look at what might be brewing in the biofilm layer. 

The comprehensive information about organisms and antimicrobial resistance obtained from DNA tests can provide clinicians with more informed treatment options, guiding compounded instill recommendations. 

Identification is this testing method’s strong point, but there is one downside to some DNA tests: they may lack sufficient antimicrobial sensitivity tests. 

Identifying Antimicrobial Sensitivities

A sensitivity test is when small, known concentrations of antimicrobials are dripped onto a growing plate in a laboratory. The growing plate contains an organism, and the organism’s response to the antimicrobial is observed. As part of a standard urine culture, an organism that has been identified in the urine is exposed to a variety of antibiotics, one at a time. Depending on how the organism responds to the antibiotic, it may be deemed either sensitive or resistant to the antibiotic.

Although enhanced UTI tests often do not test sensitivity in this way, this limitation can be overcome with good communication between the clinician and the compounding pharmacy. Quality research regarding the species of the organisms, previous treatments, and product availability can help direct treatment.   

Due to the interconnectedness of the vaginal and urinary microbiomes, it can be helpful to examine how surrounding areas may be influencing symptoms. And in certain situations, testing a sexual partner can also be useful. 

Testing a sexual partner in regards to vaginal, prostate, or UTI symptoms differs from testing for STIs. Testing a partner can be beneficial in detecting organisms that may be causing symptoms in one partner while the other does not experience symptoms.

Aside from the bladder, the main reservoirs for bacteria and fungi are the vagina, nearby external areas, and the urethra itself. Watch our interview with Mary Cotter to find out more about bacteria in the urinary tract.

The good news is that the same lab technology used to test urine samples can also provide more information about the surrounding areas as well. Once there is an indication of what organisms are present, treatments can be compounded as vaginal gels and suppositories. 

"When it comes to bacterial reservoirs, the urethra deserves special attention. Clinically, we have noticed that the urethra can harbor organisms for a long period. There is also evidence that the cells in that area can harbor the bacteria. This process allows the organisms to embed into the wall of the bladder, making treatment more difficult." Randy Breton, RPh, BS Pharm

To combat this, gels that are applied directly to the urethra, known as intraurethral gels, have been developed. These gels may include antibiotics, antifungals or both. Intraurethral gels are stickier than vaginal gels, so they have more contact time with the urethra and the surrounding area. They can be used alongside bladder instills, allowing a combined treatment approach.

Because a bladder instill is considered an invasive procedure, some patients and clinicians have understandable reservations. Gradually over the past decade, more clinicians have come to understand the practical benefits to using bladder instill to treat recurrent and chronic UTI. 

Patients who have successfully used bladder instill treatments range in age from 20 to 90 years. Some patients may choose to visit their doctor’s office or hire a home health nurse to help instill the compounded medication, as the process can be intimidating in the beginning. 

However, many patients find that with proper instruction and practice, the process of inserting a small catheter and instilling the medication at home becomes a simple process.

"We’ve taken care to streamline the process, making it as simple as possible for patients to complete in their own home. From both clinician feedback and pharmacy experience, instills are a safe method for treating polymicrobial infections." Randy Breton, RPh, BS Pharm

To decrease discomfort as much as possible, it’s recommended to use smaller 8 french pre-lubricated catheters and lidocaine gels for placement of the catheter. Once familiar with the procedure, it becomes fairly quick to insert the catheter, instill the medication, and remove the catheter.

Check out our interview with Dr. Sachin Malde to learn more about his experience prescribing compounded instill treatments for recurrent UTI.

Can an Instill Cause Another Infection?

The question of re-infection often arises regarding the use of catheters and bladder instill treatment. “Am I going to reintroduce bacteria into my bladder?” The short answer is no.  

"Throughout the time our pharmacy has been providing bladder instills, finding bacteria that are known as ‘skin contaminants’, which would indicate re-infection, has been incredibly rare." Randy Breton, RPh, BS Pharm

Pharmacies involved in drug studies are required to adhere to exceptional sterilization procedures. Because time in transit and temperature during shipping can impact the quality of medications, enacting superior packing and shipping procedures are crucial. Medications, such as a compounded instill, are sterilized through the moment of use. This packing method also means instills can be shipped almost anywhere within the country of origin.

Once accustomed to inserting a catheter on your own, bladder instills open up other opportunities for compounded medications. Solutions of heparin, lidocaine, and steroids can be infused into the bladder to reduce pain and help the GAG (glycosaminoglycans) layer of the bladder heal. 

Other solutions like hyaluronic acid can be used to decrease the pain response and to assist the healing of the GAG layer by acting as a barrier along the inner surface of the bladder. 

Compounded vaginal treatments also extend beyond antimicrobials. Specific vaginal suppositories for pain and spasms have also been developed. They include ingredients such as baclofen, gabapentin, and diazepam. These, along with the vaginal gels, suppositories and the intraurethral gels, may allow your clinician more options to treat and manage your symptoms. 

Instill as Alternative to Oral and IV Antimicrobials for UTI

Overall, the use of compounded instill treatments appear to have some distinct advantages over oral and intravenous routes of administration. Since the bladder instill medication is put directly in contact with the organisms, a unique advantage in targeting pathogens exists.

Additionally, there is little to no drug absorbed into the bloodstream through systemic circulation. Because the instill stays in the bladder, the likelihood of common side effects of the medications is significantly decreased. Neither patients nor clinicians have reported any de-population of normal bowel or vaginal flora and no stomach upset, such as can occur with oral administration. 

Overall a compounded instill approach may allow clinicians to use antibiotics and antifungals that the organisms have never been exposed to before, thus increasing the opportunity for recovery and healing.  

Learn more about antibiotic bladder instills in our expert video series.

If you have questions or comments about antibiotics instills for UTI, you’re welcome to share them below. To get answers to other commonly asked questions about chronic and recurrent UTI, visit our FAQ page.