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Cystitis and its treatment (by Prof. Glickman)

I ask you to start the new year with a fresh look at cystitis and its management.

While all the following are true:

• The bladder is a soluble waste storage “bin.”

• Urine is liquid metabolic waste dross.

• Cystitis is a scourge. 

• Antibiotic stewardship must protect against over-use and

• Symptom relief and clinical recovery are treatment goals.

These facts haven’t helped us address cystitis recurrences, urosepsis or reduce AMR, so consider these facts, too:

• Cystitis treatment targets are either intravesical planktonic bacteria or they’re attached to the urothelial outer membrane surface, so oral antibiotics are distant from them.

•Cystitis treatment’s antibiotic bath medium is urine, not urothelium’s capillary-system delivered extracellular fluid.

•Urinary pH influences an antibiotic’s hydrophilicity/ionisation, thus adsorption to bacterial envelopes and uptake internally, in vivo MIC and treatment efficacy, but also is highly variable (urinary pH range: 4.4-9.9, >300,000fold).

• Urinary pools receiving the antibiotic dilute the initially arriving drug molecules very substantially, potentially provoking the bacterial invaders to react in defence quickly.

• Symptom relief, without bacterial eradication included in the treatment goals, can effect recurrences, compromise many future treatments and lead to poverty of antibiotics, thus constituting poor antibiotic stewardship.

• Experience to date indicates recurrences and AMR following treatments remain unchecked.

In light of rising infection recurrences and AMR attributed to current treatments, where do you suspect the main problem lies in?

  • Diagnosis

  • Antibiotic inefficacy

  • Route of administration

  • Over-use

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