Kat (not her real name), a banking executive in Saint Petersburg, Florida, started getting urinary tract infections about 20 years ago, when she was in college. The urge to pee was so relentless that she resorted to lining a wastebasket with a plastic bag and sitting on her makeshift commode for hours at a time. “I had three roommates and only one bathroom,” she says, “so I couldn’t usurp the only toilet.”
A quick visit to Kat’s primary care doctor almost always ended in a prescription for the antibiotic Ciprofloxacin, commonly shortened to Cipro. Kat was able to identify certain triggers: A UTI reliably popped up whenever she began having sex with someone new. But she couldn’t break the cycle. Her next UTI was never too far away.
UTIs are bacterial infections of the bladder, kidneys or urethra. They’re notoriously uncomfortable and extremely common — more than half of women will have at least one in their lifetimes, and a 2015 paper estimated that “uncomplicated” UTIs account for 10 million doctors’ visits a year. Too many of these visits, experts worry, result in patients taking antibiotics that are unnecessarily strong and sometimes just unnecessary. This could be contributing to the growing problem of antibiotic resistance, in which bacterial infections evolve to withstand the drugs developed to take them down. Experts say both providers and patients need a better understanding of which antibiotics are appropriate for UTIs, and for how long.
“I do think in the future, UTIs will become harder to treat, because the antibiotics we have will become less and less able to treat them,” says Dr. Abbye Clark, an internal medicine resident at the Washington University School of Medicine in St. Louis and coauthor of a recent review of antibiotic use for UTIs. “Researchers are always trying to find new antibiotics, but they can only develop them so fast.”
Where UTIs come from
Women are more susceptible to UTIs because they have short urethras compared to men, which makes it easier for bacteria to reach the bladder, explains Dr. R. Mark Ellerkmann, assistant professor at Johns Hopkins School of Medicine and director of the Center for Urogynecology at Mercy Medical Center in Baltimore. Also, the urethra is pretty close to the vagina and anus, which is partly why “increased sexual activity” tends to be a major UTI risk factor.
UTIs vary; “uncomplicated” infections, which affect healthy, nonpregnant and premenopausal women with normally functioning urinary tracts, tend to be more common. According to the latest clinical practice guidelines, an uncomplicated UTI should be treated with one of three mild antibiotics: nitrofurantoin (taken for five days), trimethoprim-sulfamethoxazole (taken for three days) or a single dose of Fosfomycin.
Although seemingly straightforward, these recommendations are often ignored. The review Clark coauthored analyzed 670,450 women ages 18 to 44 treated for uncomplicated UTIs between 2010 and 2015. Just over three-quarters of these women, study authors found, were put on antibiotics for longer than necessary. About half took antibiotics considered inappropriate.
Twenty years ago, a seven- or even nine-day course of a strong antibiotic like Cipro was considered appropriate for an uncomplicated UTI. Now it’s discouraged unless other options fail or nothing milder is likely to work. Repeated exposure to antibiotics gives resistant bacteria a chance to adapt and multiply. As a result, subsequent infections are harder to treat than those caused by nonresistant bacteria. Yet Cipro still finds its way into UTI patients’ hands, as do other strong antibiotics. Not only do doctors prescribe the wrong antibiotics too often, but they prescribe them for too long — and don’t always make sure patients need antibiotics in the first place.
Why the confusion? A few factors appear to be at play, and the doctors I interviewed feel patients bear some of the responsibility. Ellerkmann says it’s common for patients with viruses like a cold or the flu to demand antibiotics, even though antibiotics are only effective against bacterial infections.
“A huge number of young women are prescribed multiple courses of antibiotics in part because many physicians are under a lot of pressure from patients who call and say, ‘I’m really uncomfortable,’” says Dr. Michael Tahery, a Los Angeles-based ob-gyn with a subspecialty in urogynecology and minimally invasive surgery.
That pressure can contribute to patients taking unnecessary antibiotics, after which they may attribute any positive health developments to their treatment choice. If a patient actually has a different kind of infection and it resolves on its own, the antibiotics may still get credit, Tahery says. Vaginitis and an irritable bladder can both be mistaken for a UTI, as can other conditions. Recently, a patient of Tahery’s was sure she had a UTI because it burned so badly when she peed. Tahery discovered a herpes outbreak on her vulva; her pain was caused by urine hitting the lesion.
Care over urgency
If a patient feels certain they have a UTI, it might seem like a waste of time to go see a doctor in person just to make sure. But useless courses of antibiotics can have negative health consequences, Tahery says. Over time, antibiotics can destroy helpful bacteria in the vaginal microbiome, setting the stage for more infections.
“Patients don’t want to wait,” agrees Houston ob-gyn Dr. Vonne Jones, a fellow of the American Congress of Obstetricians and Gynecologists. “That part is tough, and I try to educate my patients as much as possible. You have people who just want antibiotics, and we’ll talk about resistance and they’ll say, ‘I don’t care, I’d be fine with antibiotic resistance.’”
If those antibiotics stop working, the next step might be taking a stronger antibiotic, administered intravenously, instead of a conventional oral pill. But an antibiotic-resistant infection that proves untreatable can do serious damage.
Clinical practice guidelines don’t change annually, but they are updated every few years. Ellerkmann says doctors who aren’t up to date on the current guidelines might still prescribe Cipro, simply because it was a standby for so long. They might even tell patients to take it for seven days because a week is easy to remember.
Physicians speculate that it’s common for patients to see PCPs about UTIs or head to urgent care or the ER when their doctor’s office is closed. Compared to ob-gyns, these generalists might be less likely to know the latest treatment recommendations, Clark says, leading them to prescribe an overly strong antibiotic or an unnecessarily long course of treatment, or both.
“Ob-gyns are generally quite good at making sure they’re giving the right first-line treatment, [because] they see more UTIs in their clinics,” Clark says.
Clark and her colleagues also suspect that logistical concerns might play a role in UTI mistreatment, especially in rural areas. If a patient with a UTI lives an hour away, a doctor might prescribe a strong antibiotic that can swiftly knock out the infection in the hopes of sparing the patient a follow-up visit.
Still, pointing fingers at patients won’t stem the rise of antibiotic-resistant UTIs. “Patient demand for antibiotics is part of it, but we can also do a better job of explaining the risks of antibiotic resistance,” Clark says. “It’s our job to treat, but also to make sure patients understand their options and why we give one thing over another.”
What actually helps
Current clinical practice guidelines recommend a urinalysis for women who are considered low-risk for antibiotic resistance and experiencing an uncomfortable frequent and urgent need to urinate without other UTI symptoms, such as discharge or blood in the urine. A urinalysis can be done fairly quickly by examining a patient’s urine sample for bacteria and white blood cells, which indicates an infection. A urine culture, on the other hand, requires sending out a urine sample to a lab so that technicians can identify the specific bacteria or yeast causing an infection.
With more specific information, doctors can better determine which drug would be the most appropriate treatment, Ellerkmann says. Most UTIs are bladder infections, which don’t require a urine culture to figure out a treatment. Making a patient wait for the results of a culture may also get in the way of offering patients immediate relief.
“If a patient calls and says she’s uncomfortable and can’t come in, then you prescribe a short [antibiotic] course; three days should usually take care of the problem or reduce symptoms significantly,” Tahery says. “But if symptoms persist, two things are happening: It’s not a UTI or there’s antibiotic resistance. Then the patient should come in and get a urine culture to make sure nothing else is going on. Those are the best ways to avoid recurrent infections.”
Jones says it’s also helpful to give recurrent UTI patients Pyridium, a medication that’s not an antibiotic but will calm UTI symptoms and reduce pain while waiting for the results of a urine culture.
Patients with recurrent UTIs should talk to their doctors about their diagnosis and treatment approach. Clark suggests asking if you might need a urine culture to figure out which antibiotic might be most effective to treat your infection. If you have discharge, she says, you might need a pelvic exam to make sure you’re not missing a different issue.
Kat blames recent recurrent yeast infections on antibiotic overtreatment when she was younger. But she finally stopped getting UTIs, after doing her own research and working with her doctors.“My best cure thus far, after 20 years of dealing with this shit,” Kat says, “has simply been D-Mannose, an over-the-counter supplement that costs about $14 — along with always, always peeing after sex.”