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Bacteria, Antibiotics & current prostatitis studies.
Featuring: Dr. Michael Pontari, Temple University.

Moderator: Jill Osborne, ICN Founder
Date: December 2, 1998

<introduction> We are pleased to have a very special speaker tonight, Dr. Michael Pontari of Temple University (Philadelphia, PA). Many of you will recognize the work of Dr. Pontari. In addition to writing the "Interstitial Cystitis Update" that we've referred to so frequently on the Medscape website, he also was coauthor of "Logical and Systematic Approach to the Evaluation and Management of Patients Suspected of Having Interstitial Cystitis," Urology, Vol. 49(5A), May 1997. He is also the co-author of Chapter 22 "Oral Therapies for IC" in Sants book "Interstitial Cystitis," which was released last year. Dr. Pontari is also one of the primary researchers of the new NIDDK Prostatitis Study. Greetings Dr. Pontari... and welcome to the ICN Chat. We thank you for visiting with us tonight and for helping us understand... the difficult controversy around the use of antibiotics to treat IC as well as the role of bacteria and IC.

<mpontari> Thanks... for having me here tonight!

<icnjill> How did you first get involved in IC?

<mpontari> Back in 1992, when I joined the faculty at Temple University, my boss was Phillip Hanno, who is one of the premier IC world researchers. I also have to credit Michael Ruggieri who was (and still is) the lab director at Temple, who has done a lot of basic science work on IC

<icnjill>One of the things that we first recognized in your publications is a very open minded approach to exploring the many potential causes of ic, including bacterial origins. How do you stand on the theory that IC could be caused by an infection.. and if so, what type of infection is proposed?

<mpontari> You have to break it into several points. The first question you have to consider is where could an infection be? It could be in the bladder or in the nerves going to the bladder. It is also possible that there could be a bacteria that we have not identified. To our knowledge, we only a small fraction of bacteria have actually been identified and classified, so, it's possible that there is an organism that we haven't even discovered yet. It's also possible there is an organism that we can't culture and that we can't get antibiotics too because of it's natural defense mechanism. Lastly.. there may be part of a bacteria there..a lipopolyssacharide .. a piece of the cell wall of the bacteria that could be causing the problem. My favorite theory is that there was an infection of some point that caused an inflammmatory reaction and today, though the infection may be gone, its inflammation could still be present.

<icnjill> Fascinating. As patients, we're hampered by so many differing opinions on the role of bacteria and IC including research studies which, in some cases, find no bacteria, and others which do find some bacterial remnant. What research studies do you find the most intriguing on the potential role of bacteria and IC?

<mpontari> I find the polymerase chain reaction research interesting, which look for 16s ribosomal RNA, which is essentially a fingerprint of a bacteria, interesting. Dr. Susan Keay's in Maryland, the group at Northwestern and G. Domingues research at Tulane (even though he has officially retired to France) are all worth further study. One thing that we've learned recently is that there are problems with technique in bacterial studies. Dr. Keay just published a study in which in which they found false positive bacterial results in their earlier studies, because they found bacteria on the biopsy forceps. This is interesting because even though they were sterilized as they would have been in the OR, bacteria continued to be found on the equipment.

<icnjill> Dr. Pontari, this is fascinating because we have so many IC patients who have developed symptoms after either a hospital stay or some kind of surgery. What was it about Dr. Domingue's research that you found so interesting?

<mpontari> First of all, he got positive results and discovered a little uncharacterized organism... that is possibly some microorganism that we haven't been able to identify. The fact that he found something consistent with the theory even though we haven't identified it yet... doesn't mean it's not there...and that it doesn't mean that it doesn't exist...

<icnjill> Can you walk us through... what can be happening in the bladder due to the presence of bacteria?

<mpontari> Essentially, you're setting up an inflammatory response which is normally found for a short period of time and then goes away. White blood cells come in to help fight the bacteria and release substances which can help fight the bacteria but, in excess amounts, can be damaging to the bladder, such as nitric oxide. With this response, there is also the induction of new enzymes such as inducible nitric oxide and cyclooxygenase 2. The INOS can be causing local damage to the bladder, the cox2 produces prostaglandins that can be involved in causing pain. There is also localized inflammation of the afferent nerves which carry bladder sensation.

<icnjill> One of the topics about bacteria continue to be the presence of fastidious infections... that.. perhaps... can burrow inside of epithelial cells... or just cling to the epithelium... so muich so.. that they can't be found in urinalysis. What's your take on the role of fastidious infections in IC?

<mpontari> One of the things that argue against that is the cultures of biopsied tissues. Susan Keay did this, in which they found fastidious organisms. The problem with that is that we don't know if it's causing the symptoms. There are definite pros and cons to that argument.

<icnjill> So, as patients, we're faced with an unusual dilemma. We have some doctors (and patients) who firmly believe firmly in IC as a sterile condition and a few others, perhaps a minority, who want to treat IC with very long term antibiotics. How do we figure out what's the right thing to do??

<MPontari> The main thing you have to do is to make sure you can't be hurt by it. If you can find evidence both for and against the treatment, at least make sure that you are safe doing it. I wouldn't recommend prolonged antibiotics for months and months on end and at full strength. We do extended antibiotics for recurrent utis, but we do it at half strength. I think you should set a limit on how long you treat with antibiotics.

<icnjill> What are some of the risks of antibiotic usage?

<mpontari> #1.. resistent infections...#2.. allergic reactions.. certain side effects specific to medications, such as severe rashes from bactrim, GI upset from erythromycin. Also, we see resistent vaginal yeast infections. The development of resistent infections is the primary concern.

<icnjill> Any comments on alternative strategies?

<mpontari> We don't have an official policy for alternative medicines at Temple. Let me just say that alternative medications are not FDA regulated and even though they may have some good ingredients, there is no standardization about how much of that ingredient is going to be in the products as well as what effective level of that ingredient is required to produce results.

<icnjill> Let's switch gears for a moment and talik about men with bladder problems and prostatitis. You are one of the national researchers for the NIDDK Study on Prostatitis. We are so happy to see this research move forward. Can you tell us about this study, what you have done and what you hope to do in the next year?

<mpontari>We've done a couple things. First of all, we have come up with a research definition for prostatitis similar to what was developed for ic ten years ago. It allows us to monitor a relatively homogenous population of patients. Secondly, we've also come up with an outcome measure, The Chronic Prostatitis Symptom Index, that will be used as a international standard to measure the outcome of prostatitis treatment trials. We started seeing patients as of November 9th and we're doing a couple of things. We are trying to determine if chronic prostatitis is caused by an infection. So, we are doing five day cultures of urine, prostatic secretions, semen and a urethral swab to see if anything grows, that would not grow in the standard culture. We're also trying to look at the natural history of prostatitis, what happens with the symptoms as well as an analysis of past history, so that we can identify risk factors for prostatitis. We had the first meeting of the international treatment group three weeks ago and we hope to start treatment trials possibly next year or the year after

------------------- Audience Question & Answer Session Begins -------------------

<icnjill> Pooh has the first question. She wants to know what you think of chronic candidiasis syndrome resulting from the overuse of antibiotics?

<mpontari> Usually, chronic implies that it's going to be there for a while but usually, if you stop the antibiotics or use an antifungal agent, it should be reversible...but I don't think it would be that persistent.

<icnjill> Next question, someone wants to know what you think of Dr. Fuggazottos culturing techniques??

<mpontari> I think his culturing technique is valid and fine. I'm against.. though.. using antibiotics for a year at a time without a clear endpoint.

<icnjill> Is enterococcus, as typically found in Dr. Fuggazotto's work, a pathogen or is does it naturally live in the bladder. Many patients are confused by this. Have you found enterococcus in any of your current studies with prostatitis patients?

<mpontari> Not so far.

<icnjill> The next question is about BCG (Bacillus Calmette Guerin). Any comments?

<mpontari> Yes, I think it has a lot of promise. The research data has been very good and it seems to have held up in their long term follow up studies. I'm not sure if we know exactly how BCG works yet and, if we can figure that out, it should help us understand IC more clearly.

<icnjill> The next question is about Elmiron. Do you have any comments on this treatment?

<mpontari> I think that elmiron has a place in the overall IC treatment strategy because it does seem to work in some patients. As an oral therapy with a reasonable side effect profile, it is definitely something I try to use before we consider more invasive procedures, such as instillations.

<icnjill> Dr. Pontari, do you have any comments about direct sacral nerve stimulation and/or SANS.

<mpontari> We haven't done it here so I don't have any comments either way.

<icnjill> Julie.. wants to know what you think of chlorpactin as a treatment for IC? Is it on the way out?? Or.. do you see this continuing to be a major treatment for IC?

<mpontari> We're still doing it in selected patients. My approach is to do the least invasive treatment first. I would try oral therapies first (less invasive) before I would put patients under anesthesia to do the treatment. It does seem to work for some patients, however.

<icnjill> Charlie asks "Why is prostatitis so easily accepted in men that have chronic symptoms... with no infection found as opposed to calling it IC?

<mpontari> Excellent question! It's probably semantics and .. as far as I can see.. there's not much difference between the two. The one time.. you might diagnose a man with ic typically as opposed to prostatitis is if he had severe urgency, frequency and nocturia and no pain. Basically, it seems to be just chronic pelvic pain and it doesn't really matter what it's called

<icnjill>Charlie asks: But why are the treatments different then?

<mpontari> They aren't different in my clinic.

<icnjill> One last question from the floor. Is elmiron considered less invasive than BCG?

<mpontari> Yes.. because you don't have to be catheterized for it..

<icnjill> Folks.. we're going to end the session now. Let's give Dr. Pontari our gratitude for his presence tonight. You helped us to understand some of these very confusing and complex issues around treatments for IC and.. especially antibiotics.

<mpontari> It was a pleasure to be here!

------------------- Audience Question & Answer Session Ends -------------------

The necessary disclaimer: Active and informed IC patients understand implicitly that no patient, or website or presentation on a web site should be considered medical advice. We strongly encourage you to discuss your medical care and treatments with a trusted medical care provider. Only your personal provider can and should give you medical advice. The opinions expressed by our speaker may not represent the opinions of the IC Network.

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