Professor Xie Hong
Deputy chief physician of the Department of Urology, MD, PhD. Master’s supervisor in Shanghai Jiao Tong University School of Medicine and Medical College of Suzhou University. Member of the Andrology Branch and the Chinese and Western Medicine Branch of the Shanghai Medical Association. He was involved in research projects funded by The Science and Technology Commission of Shanghai Municipality (STCSM), the Shanghai Municipal Health Commission, and the National Natural Science Foundation of China. His contributions earned him a second prize in the Shanghai Medical Science and Technology Award and a third prize in the Shanghai Science and Technology Progress Award, respectively. He is currently serving as the principal investigator, overseeing a project funded by the Science and Technology Commission of Shanghai Municipality and two projects sponsored by the Shanghai Municipal Health Commission. He has authored over 30 papers in both domestic and international professional journals, with over 10 of them included in SCI, and has contributed to the compilation of five specialist publications.

Introduction: Urinary tract infections are highly prevalent among women. How do we diagnose and treat them? What are the current clinical challenges?

Urinary tract infections (UTIs) are common ailments that occur when bacteria and other pathogens invade the urothelium, typically affecting the lower urinary tract, namely the bladder and the urethra. Patients with UTIs often experience inconvenient and uncomfortable symptoms such as bacteriuria and pyuria. ‘Medical Community’ has invited Professor Xie Hong from Shanghai Sixth People’s Hospital to discuss key aspects of UTIs treatment and medication.

The Prevalence of UTIs and Multifaceted Challenges in Treatment
UTIs are common, particularly among women. The annual incidence of UTIs in women is approximately 10%. ¹ Women are more vulnerable to UTIs due to their physiological features, such as having a shorter urethra that is more susceptible to bacterial invasion. UTIs manifest across all age groups, but they are more prevalent in young women, while both the elderly and paediatric populations have relatively lower incidence rates. UTIs are usually caused by bacterial infections, such as Escherichia coli, proteus spp, Proteus mirabilis, etc.

Professor Xie Hong highlighted that antibiotic resistance constitutes a significant challenge in the clinical treatment of UTIs worldwide. Overuse or improper use of antibiotics can lead to increased bacterial resistance. Patients may also experience recurring infections; recurrence may be associated with patients’ physiological anatomical structure, immune status, and other potential risk factors. For instance, individuals with diabetes exhibit an increased susceptibility to UTIs. Hence, comprehensive consideration of the aforementioned factors is imperative in the management of the patient’s disease trajectory. Thus, care and attention are required when administering treatment to elderly patients or those with a history of diabetes.

Furthermore, diagnosing UTIs can be challenging, as its symptoms are similar to other urinary system diseases. Clinicians must carefully consider the patient’s medical history, physical examination and laboratory tests results, as well as other factors, to make a careful diagnosis, rather than relying solely on the patient’s subjective description.

Precise Diagnosis and Holistic Team-Based Treatment
Complicated UTIs(cUTIs) are more complicated to diagnose and treat because the disease mechanism is multifactorial. Professor Xie Hong pointed out that patients with cUTIs may still experience recurring infections and persistent symptoms after receiving conventional treatment. They may also present with atypical UTI symptoms, such as abdominal discomfort, backache, or fever, rather than typical symptoms such as frequent urination, urgency, and pain during urination.

Professor Xie Hong also stated that during the diagnosis and treatment process, an initial mid-stream urine culture is required to determine the pathogen’s sensitivity to antibiotics and to select the most effective treatment. In addition, during clinical practice, practitioners may encounter the challenge of infections caused by multiple pathogens, especially in immunodeficient patients. Relatively rare pathogenic infections also need to be considered. Moreover, imaging examinations play a crucial role in ruling out underlying issues such as stones, hydrops, congenital malformations, etc., thereby contributing significantly to the UTI treatment.

To help address these challenges, Professor Xie Hong highlighted that it is important for physicians to possess solid basic skills and to conduct comprehensive analyses. For example, physicians need to consider that targeted drugs or hormone therapies may cause UTIs in women with lung tumours. In such cases, they need to communicate with the oncologist and consider adjusting the prescription. Furthermore, Professor Xie Hong emphasised the necessity of a multidisciplinary team consisting of doctors from different specialisations such as urology, oncology, laboratory, and other clinical departments, to achieve more effective treatment results. Lastly, it is necessary to fully understand the patients’ history of antibiotics use to avoid misuse.

Prevalence of Drug Resistance and the Necessity for Comprehensive, Personalised Treatment
In recent years, concurrent with advancements in medical technology and the pervasive utilisation of broad-spectrum antibacterial agents, drug-resistant bacteria associated with UTIs have increased in prevalence. The profiles of such pathogenic bacteria are constantly changing, necessitating adaptations in treatment approaches and methods for UTIs. Professor Xie Hong has shared a treatment plan for cUTIs based on his extensive clinical experience.

Professor Xie Hong emphasised that effectively treating cUTIs in settings with high drug resistance requires a comprehensive and personalised treatment plan. The primary consideration should involve selecting appropriate antibiotics and assessing the need for combination treatments. In cases of cUTIs or when antibiotics adjustments are needed, it is recommended to conduct two to three urine cultures and drug sensitivity tests to increase the likelihood of positive outcomes and to provide a foundation for personalised treatment. Employing combination therapy is a crucial approach in managing cUTIs. Additionally, in highly drug-resistant environments, it is essential to administer higher antibiotic doses to ensure adequate drug concentration for improved efficacy. Furthermore, he underscored the importance of switching antibiotic types during treatment to mitigate the development and progression of drug resistance.

Personalised treatment requires developing a plan based on the patient’s age, medical history, immune status, and other factors. Professor Xie Hong provided an example to illustrate this concept. If the laboratory tests detect the presence of bladder stones or ureteral stones in a patient experiencing recurrent UTIs, it indicates that the stones are causative. In such cases, antibiotic therapy alone may be insufficient, necessitating consideration of surgical intervention.

For patients with immunodeficiency, physicians must consider treatment that strengthens the immune system. Drugs such as thymosin can be used to provide immune support, thereby reducing the incidence of UTIs. In addition, Professor Xie Hong emphasised the importance of health education for patients. It is necessary to encourage the rational use of antibiotics in accordance with medical education to reduce the risk of drug resistance. Patients must also be reminded to cultivate healthy lifestyle habits, such as staying adequately hydrated, urinating in a timely manner, and maintaining good personal hygiene.

The 2022 version of the Chinese Urology Association’s guidelines for the diagnosis and treatment of UTIs has introduced new medication guidance for patients with cUTIs. Sitafloxacin has been added to the fluoroquinolones category ², as it has a broad-spectrum antibacterial effect and can be used for strains that are potentially resistant to other antibiotics. It has also been found to have an augmentation effect when used in combination therapy for UTIs. Professor Xie Hong recommended starting with 50 mg of sitafloxacin twice daily, which can be adjusted to 50 mg once a day during subsequent consolidation treatment. Coupled with monitoring patient symptoms and laboratory indicators, it can effectively improve the patient’s condition and their compliance.

Summary
UTIs represent a common clinical infectious disease, particularly among young females. The cornerstone of treatment lies in a judicious antibiotic selection, with a dedicated focus on averting antibiotic resistance. Patients are advised to complement medical interventions with a positive mindset and a healthy lifestyle to mitigate recurrent infections and attain a favourable prognosis.

References：

1. China Medical Women’s Association Special Committee on Kidney Disease and Blood Purification. Consensus of Chinese experts on the diagnosis and treatment of female urinary tract infection [J]. Natl Med J Chin,2017,97(36):2827-2832.
2. Huang J. and Zhang X. (editors). Diagnosis and Treatment Guidelines for Urology and Andrology Diseases in China, 2022 Edition.[M]. Beijing: Science and Technology Press,2022:647-649.