How to Treat Antibiotic Resistant UTI in Diabetics?

Treating UTI in diabetics is challenging when the organism is resistant to antibiotics, in patients with recurrent UTIs, and in those with concomitant autonomic neuropathy or prostatic enlargement resulting in bladder outlet obstruction or urinary retention.

Here are a few definitions before discussing the topic.

Urinary tract infections (UTIs) are generally more common among people with diabetes. According to research, UTI is the most common bacterial infection among the diabetic population.

There can be multiple reasons for repeated UTIs, including immunologic dysfunctions or simply high glucose concentrations that create a favorable environment for bacteria.

Whatever the reason, UTI in diabetics is severe and requires proper treatment.

Moreover, the frequent antibiotic use, even that of broad-spectrum antibiotics, creates resistance. That is why diabetics often require prolonged and potent treatments.

Diabetes and UTI:

Diabetes mellitus refers to an impaired glucose tolerance in the body. Various problems link diabetes to UTI, making diabetics more prone to these infections.

A weakened immune system, poor metabolic control, or incomplete emptying of the urinary bladder due to neuropathy can be the major causes.

In addition, high glucose levels in the renal parenchyma are suitable for promoting bacterial growth. All these factors are involved in the recurrence of UTI in diabetics.

Furthermore, there has been a growing concern that diabetic medications might be a contributing factor to UTI due to hyperglucosuria. Increased glucose present in the urine can improve bacterial growth.

Common glucose-lowering drugs, such as SGLT2 inhibitors, are linked to a 3 to 5-fold increased incidence of UTI.

Another reason can be the low levels of the natural antimicrobial peptide psoriasin.

It is a protein that reduces bacteria’s attachment to the cells in the bladder. High glucose levels reduce the levels of this peptide in the body, contributing to UTI.

Besides this, UTIs are more frequent in female diabetics, and the longer the duration of diabetes, the more exposed you are to urinary tract infections.

According to research, the most common factors associated with UTI are female gender, high HbA1C values, and older age. [Ref]

UTI Diagnostic Criteria in Diabetics

Diabetic patients might present with complex symptoms that can easily be confused with other common conditions, such as diabetic neuropathy. However, the typical clinical manifestations include:

• Frequent urination
• Dysuria
• Hematuria
• Abdominal pain
• Pelvic pain (common in females)

For appropriate diagnosis, urine culture, urine analysis, and antimicrobial susceptibility testing can be used. In diabetics, it is recommended to examine urine cultures before starting antibiotic therapy.

 Urine dipstick examination is usually positive for “Leukocyte esterase” and “nitrites”.

However, a positive midstream urine culture of 1 × 105 CFU/L or more is diagnostic of UTI.

Treatment Options for Resistant UTI in Diabetics

Antibiotics are usually prescribed to kill the bacteria causing the infection. The type of antibiotic depends specifically on the urine culture results.

In people with diabetes, a regular UTI can become a reason for severe issues if prompt treatment isn’t provided.

Moreover, intermittent catheterization or urethral catheterization is the best way to reduce urinary tract infections in case of neurogenic bladder dysfunction.

Some of the commonly prescribed antibiotics for UTI include:

• Ceftriaxone
• Doxycycline
• Fosfomycin
• Cephalexin
• Nitrofurantoin
• Trimethoprim-sulfamethoxazole
• Quinolones and B-lactams

Treatment and antibiotic selection are essential to avoid interactions between diabetes and UTI medication. That is why I always seek professional advice and avoid self-treatments.

Besides drug interactions, UTI treatment varies depending on factors such as age, gender, infection sites, and underlying conditions.

Moreover, 60 to 80% of bacteria are resistant to common antimicrobials making it difficult to treat.

Protective Effects of Estrogen against UTIs

Estrogen has been known to have specific protective effects against urinary tract infections. That is why postmenopausal women are greatly exposed to recurrent infections.

Estrogen plays a major defensive role in preventing UTIs. It induces the expression of antimicrobial peptides, such as psoriasin.

Thereby it increases the epithelium’s antimicrobial capacity in the urinary bladder. Which in turn reduces bacterial growth.

Secondly, estrogen promotes the expression and distribution of cell contact proteins. In this way, it strengthens the epithelial wall and prevents the loss of cells during infection.

According to one study, vaginal estrogen (via ring or cream) in 35 postmenopausal women resulted in decreased urinary tract infections within six months. [Ref]

A meta-analysis of eight studies with 4702 participants concluded that vaginal estrogen treatment reduced recurrent UTIs and decreased the vaginal pH in postmenopausal women. [Ref]

Antibiotics for UTI in Postmenopausal Women

The resistance to all antimicrobial agents is higher in postmenopausal women due to the declined estrogen levels.

Ampicillin, ciprofloxacin, and trimethoprim-sulfamethoxazole combinations should be avoided among common antibiotics.

Although drug resistance patterns and distribution of pathogens are important indicators in drug selection, cephalosporins are preferred as initial treatment in postmenopausal women.

Antibiotics for UTI during Pregnancy

UTIs are a major problem during pregnancy due to changes in the urinary tract and increased bacterial growth.

UTI in pregnancy is even more serious because an uncontrolled infection can lead to preterm births or low-birth-weight infants.

The first line of treatment for asymptomatic bacteriuria and acute cystitis during pregnancy are nitrofurantoin and fosfomycin.

However, for acute pyelonephritis, the preferred choice is cefuroxime and ceftriaxone.

But still, the treatment plan varies according to antimicrobial resistance and varies among patients.

Antibiotics for UTI in Older Adults

Longer duration of diabetes puts older adults at a risk of recurrent UTIs. Along with this, age adds a double burden in the form of dysfunctional bladders and poor immune responses.

Treatment of UTI in older adults can be challenging as it comes with a risk of compromised health and even mortality.

Broad-spectrum antibiotics might be prescribed for complicated UTIs, or sometimes it is impossible to cure the infection with antibiotics, and catheterization might be required.

For uncomplicated UTIs, the treatment is often easier and can be covered with narrow-spectrum antibiotics.

Most older diabetic men have concomitant autonomic neuropathy or prostatic enlargement which can cause urinary retention.

Adding an α-blocker such as Tamsulosin or Silodosin can relieve obstruction and improve urinary flow.

Furthermore, the duration of antibiotics is usually longer than compared to non-diabetic individuals and healthy diabetic individuals.

How to Prevent UTI in Diabetics?

The best strategy to prevent UTI in diabetic people is to have good control of blood glucose levels. This can be done by taking dietary precautions and by doing regular physical activity.

Moreover, personal hygiene also contributes to how recurrent your infection can be. Therefore, maintain good hygiene and avoid cross infections.

A good hydration status also plays a significant role in UTI prevention, mostly because it keeps constipation at bay.

If you get constipated, it is likely for bacteria to transfer from the rectum to the bladder. Treating constipation may help some people.

UTI in older diabetic individuals may also be prevented by adding alpha-blockers such as tamsulosin and silodosin to improve urinary flow and reduce urinary retention.