Enterococcus bacteria/UTI (UPDATE-Now Streptococcus!)

[carolynandlatte]

Hello,
Latte was diagnosed with her zillionth UTI over the years. She has two types of bacteria...e coli and enterococcus. I had the test dont at the University of MN, and she was seen by a internal medicine specialist. My understanding from our conversation is that the later bateria (enterococcus) is pretty much resistant to a/b's. He said something about it sometimes coming and going w/little symptoms. Other times clinical diseases will develop from it.

I did get a copy of the sensitivity. Below is what I wrote yesterday about how I understood the results:

I did get her labs emailed to me. The sensitivity lists a bunch of a/b's. Next to them it states if it is resistant, intermediate, or susceptible to the bacteria. The e coli is susceptible to all a/bs on the list. The other infection (enterococcus) lists orbax (which she is on) and baytril as intermediate. This is probably why he suggested sticking with it for now...to see if it works as we get rid of the ecoli. I assume, intermediate means a slight chance? There were 2 listed as susceptible....ampicillin and clavamox. Clavamox is NOT well tolerated by Latte. I think if it was a short course, and very hopeful I would consider it for sure. Long term, boy :YMSIGH: ...Im not sure how fair it would be to give her something that would make her feel crappy everyday (vomiting and not eating) for an undetermined amount of time and not be 100% sure it will clear it. KWIM? That may be where I have to draw a line in the sand. Ampicillin sounds like it is not absorbed well orally, so another injection (fine). I have read that bacteria often builds resistance to it. It also has potential to react with antacids (latte is on pepcid)). This must be why the IM was not to hip on giving it a try.

viewtopic.php?f=9&t=17546

I got the sense from speaking with the IM dr that this infection would likely be resistant to anything, and due to her being 'geriatric' with all her underlying conditions it would be difficult to treat. His final words to me were "good luck". Didnt make me feel to optimistic. Anyway, I have an appt with her regular vet for a recheck of urine on Tuesday. Im thinking of questions to ask and clarification as to how bad this is, or is not. I also have a call into her kidney specialist (also at the UofM). He is out of town, so I dont know when he will be able to get back to me.

I cant find much practical information online. Most of it relates to humans and not cats. I guess the main thing I need to know is how serious this is. There are already a number of QOL issues I toss around more and more these days. Is this less grim than the IM leads me to believe, or is he being realistic.

Thanks for any help you can offer.

Oh! I should add..I have a link in our signature to Latte's profile. If you are curious about her medications and/or various conditions I welcome you to look it over! She has too many too list each time I post...and often times they are ever changing. :?

 

[Jess & Earl]

Re: Enterococcus bacteria/UTI

Hi Carolyn

Just a few questions first. Is she symptomatic for the UTI, or were you doing a UA/urine culture as part of a regular workup? Has she had a recent ultrasound?

Edited to add: one more question. What kind of growth did the culture show? (Amounts) Can you post it?

 

[JJ & Gwyn [GA]]

Re: Enterococcus bacteria/UTI

Gwyn also had an infinite number of UTIs over the years -- she was steroid-dependent, which had the dual effect of making her diabetes somewhat unstable as well as suppressing her immune system

Can I ask how the urine sample was collected? The one time Gwyn had a UTI that tested resistant to most abx, it turned out that the sample had been contaminated. Fortunately, my vet suspected that was the problem, collected another sample and re-ran the C&S.


> intermediate means a slight chance?

I believe intermediate means that it has some resistance to it and that you may have to give somewhat higher-than-normal doses, or continue the medication for an extended period of time, in order to clear out all of the infection. Because Gwyn was immune-suppressed, even when her UTI was fully susceptible to an antibiotic, we usually had to keep her on it for an extended period of time to make sure the infection cleared up.


Am I correct in the following?
1. The e. coli is susceptible to all the abx tested? (In which case, I'd just worry about the enterococcus and let the e. coli clear up with whatever you use on that.)
2. The enterococcus is susceptible to ampicillin and clavamox, and intermediate to orbax and baytril.

If (2) is true, then your options would appear to be to continue with the Orbax (because that's what Latte is already on) and trying to clear the infection out that way, or switching her to a course of ampicillin, which looks like it should clear things up.


> It also has potential to react with antacids (latte is on pepcid)).

I'd also consider what medications you can give to lessen potential side effects. For example, ampicillin *may* react with antacids; that doesn't mean that it *will* react to Pepcid in Latte. If it does, you could switch to another stomach-calming drug, say, reglan / metoclopramide. If not-eating may become an issue, I'd consider cyproheptadine or mirtazapine.

Also, when Gwyn had UTIs, I'd frequently give her L-Lysine, increase her B-12 injections, and I'd increase the amount of sub-Q fluids I gave. Not sure whether any of those might be indicated in Latte's case, but I pass them on FWIW.


> I have read that bacteria often builds resistance to it.

This should only happen if any bacteria survive the antibiotic+immune system assault. The majority of the time, antibiotic resistance occurs because the antibiotic isn't given at the recommended intervals, is given in too small of a dose, or isn't continued for long enough. You can greatly reduce the possibility of the bacteria becoming resistant by giving the full dose over the full period at the recommended intervals.


Unrelated to the above:
Checked out Latte's profile. Good to see that you're doing B-12 for IBD. Stupid question: it's light-sensitive; you *are* keeping it in a dark cabinet or something, yes? Could the sudden loss of rear leg use in '09 have been a saddle thrombus? If so, that could indicate underlying heart problems.

 

[carolynandlatte]

Re: Enterococcus bacteria/UTI

I will have to come back in the a.m. with more specific answers, but yes Jess it was sterile. Symptomatic ispecific to uti is hard to say. She has had wildly fluctuating bgs from 100-600+. I took her in on an urgent basis because she was stuck above 500- 600 for about 2 days. She had been off a/'s for maybe 3 weeks from an earlier infection...probably aggravated by an increase in pred around that time.

Gwen, she is pretty much on all the meds you suggested (or some form).
She had another episode of the inability to walk around the time of last uti a month or so ago. Xrays done showed she had nothing inbetween the last two vertebrae. She is mobile now, but with many adaptations and often times the use of bupe. no NSAIDS due to kidney failure from them, so we are limited.

Her ss is most up to date on med, behavioral, symptom changes, if you dare to be blinded by the rainbow of colors.

Oh...and the orbax as of right now will be given for 24 days. We are on day 9.

Thanks. Back in the a.m. when I am on puter vs phone.

 

[carolynandlatte]

Re: Enterococcus bacteria/UTI

Edited to add: one more question. What kind of growth did the culture show? (Amounts) Can you post it?

Too Many too count! (thats what it says, and what they told me! :shock: )

EDITED: Had to take out attachment with Labs due to address/phone listed on them...sorry. :?

Labs were done to see if there was anything going on that would contribute to her crazy blood sugars (large drops, bounces, higher range numbers than usual, etc).

Last u/s was a year and a half ago. It required a lot of time saving up for it. I dont think I could ever afford another one. So...nothing recent.

 

[carolynandlatte]

Re: Enterococcus bacteria/UTI

Can I ask how the urine sample was collected? The one time Gwyn had a UTI that tested resistant to most abx, it turned out that the sample had been contaminated. Fortunately, my vet suspected that was the problem, collected another sample and re-ran the C&S.

However its done with the needle (forget the terminology). This was done at the University of MN animal hospital. I completely trust their process being top notch. I believe if the IM felt their was any possibility he would want to redo it. BUT, I could ask him just to put it out there.

Am I correct in the following?
1. The e. coli is susceptible to all the abx tested? (In which case, I'd just worry about the enterococcus and let the e. coli clear up with whatever you use on that.)
2. The enterococcus is susceptible to ampicillin and clavamox, and intermediate to orbax and baytril.

If (2) is true, then your options would appear to be to continue with the Orbax (because that's what Latte is already on) and trying to clear the infection out that way, or switching her to a course of ampicillin, which looks like it should clear things up.

That is correct. So far, that is the plan. Other than discussing her reaction to clavamox (which Im sure would be similar to ampicillin), neither has been placed higher on the list to start first. It was suggested to do a longer course of orbax and see what happens, to start.

I'd also consider what medications you can give to lessen potential side effects. For example, ampicillin *may* react with antacids; that doesn't mean that it *will* react to Pepcid in Latte. If it does, you could switch to another stomach-calming drug, say, reglan / metoclopramide. If not-eating may become an issue, I'd consider cyproheptadine or mirtazapine.

:lol: I only laugh, because this is a cat who reacts to practically EVERY drug! :roll: IF there could be a reaction between the ampicillin and pepcid...she would be the one to have it! :YMSIGH: She does get ondansetron 2x/daily, and cerenia as needed. I think the pepcid is a key med for her early a.m. stomach acid/vomit.

Also, when Gwyn had UTIs, I'd frequently give her L-Lysine, increase her B-12 injections, and I'd increase the amount of sub-Q fluids I gave. Not sure whether any of those might be indicated in Latte's case, but I pass them on FWIW.

I can ask about the L-Lysine. She already gets b12 injections. Ive slightly increased her fluids because she was apparently a tad dehydrated at this last visit. Thats not typical for her. It will be a topic of conversation with her regular vet on Tuesday as to how much I may want to increase on a regular basis.

Unrelated to the above:
Checked out Latte's profile. Good to see that you're doing B-12 for IBD. Stupid question: it's light-sensitive; you *are* keeping it in a dark cabinet or something, yes? Could the sudden loss of rear leg use in '09 have been a saddle thrombus? If so, that could indicate underlying heart problems.

Yup, b12 and other light sensitive drugs all stored in a drawer and in a dark container.
As I mentioned in above post, loss of rear leg use last fall was almost identical to what happened about a month ago. Xrays showed nothing between last 2 vertebraes (ouch!). We are doing the best we can with managing pain for it, but not knocking her out 100% of the time. When she gets the bupe its only .02-.03ml...much more than that and she will not sleep for a 24 hr period. Very sensitive gal!

 

[Jess & Earl]

Re: Enterococcus bacteria/UTI

Hi Carolyn

Darn, I was disappointed to see so much enterococcal growth. Your IM vet is right -- sometimes enterococcus infections don't need to be treated; they colonize the bladder for various reasons but don't seem to cause symptoms and they seem to be unlikely to ascend to the kidneys. Her recent culture shows E. coli, too, though, which may be helping fuel growth of the other. Personally I would actually stick to the current treatment i.e. treat the E. coli and retest.

A few lifestyle things:
* Are you sure she's emptying her bladder completely? I wonder if she isn't, perhaps because pain during squatting. Are you seeing nice big pee balls in the litter? A continually-partially-empty bladder is a slow cooker for bacteria.
* Does she need help in cleaning her bottom? I know she has mobility issues. These are both 'poop' bacteria and I wonder if they are sitting on the fur and getting a chance to crawl up the urethra.
* Have you considered a supplement like Uromaxx to make her bladder less hospitable to growth?
* Obviously--and you know this--the less sugar in the urine, the less food for the bacteria. I know you are working on it so I mention it just to be thorough.

I can't find any reference to ampicillin being an issue with Pepcid. Some members of the penicillin family need an acidic gastric environment but ampicillin isn't one of them. The oral version of ampicillin is amoxicillin, BTW. Again, personally, I would not use this because you may just be helping the enterococcus gaining a new resistance. I'd go for treating the E. coli and then see.

Her kidney vet needs to discuss with you the risk of pyleonephritis here. From the little that I know, the E. coli is more of a danger, pyleo-wise, and is the better target.

Hope this helps. Keep us posted.

 

[carolynandlatte]

Re: Enterococcus bacteria/UTI

A few lifestyle things:
* Are you sure she's emptying her bladder completely? I wonder if she isn't, perhaps because pain during squatting. Are you seeing nice big pee balls in the litter? A continually-partially-empty bladder is a slow cooker for bacteria.

She gets IN her box and pees outside of it onto pee pads. Only time that is better is when she has lower BG #'s. She pee's probably a dozen times or more a day, and most cover close to the entire pad. Very rarely is it a small bit.

* Does she need help in cleaning her bottom? I know she has mobility issues. These are both 'poop' bacteria and I wonder if they are sitting on the fur and getting a chance to crawl up the urethra.

Her bottom is shaved as of the last UTI about 5 weeks ago. Its starting to grow a little bit of fuzz. I have not noticed anything back there. Always looks pretty clean to me. I *try* to wipe it and put a little shea butter on it from time to time, just in case. I should probably have them reshave it when she is seen on Tuesday. I suspect with her inability to clean back there it might be best for her to have a new permanent look. :YMSIGH: (this getting old thing is hard, ya know?! :sad: )

* Have you considered a supplement like Uromaxx to make her bladder less hospitable to growth?

I can ask about it. thanks for the suggestion.

* Obviously--and you know this--the less sugar in the urine, the less food for the bacteria. I know you are working on it so I mention it just to be thorough.

Strangest thing, unless I totally misunderstood and you see it in the labwork...the student who called told me there was NO sugar in her urine. I asked her to repeat what she just said, and she said NO sugar in the urine...very strange. I dont understand how that could be with how high her numbers were and had been the days prior to the visit.

Problem is Jess, I think today brought me one step closer to coming to terms with the fact that I will likely not be able to maintain, let alone get her BG's to a point under renal threshold for a reasonable amount of time to prevent the sugar dump or other damage.

Also, dont forget she has the prednisolone in her. I started decreasing it last night and hope to get her down from 10mg back to 5mg in the very near future....like, by the end of the week.

Her kidney vet needs to discuss with you the risk of pyleonephritis here. From the little that I know, the E. coli is more of a danger, pyleo-wise, and is the better target.

I will ask her regular vet and her renal specialist. Ive wondered if she doesnt have a kidney infection already. Im surprised the other IM didnt mention it.

You have explained, just like the vet, that it may go away on its own....or show no symptoms. I dont mean to sound negative, or morbid, but as Im weighing quality of life issues Im just wondering what I might expect in terms of the infection not going away. What type of clinical disease are we looking at, and how might I differenciate it from her other issues?

Thanks a lot Jess.

 

[Jess & Earl]

Re: Enterococcus bacteria/UTI

You have explained, just like the vet, that it may go away on its own....or show no symptoms. I dont mean to sound negative, or morbid, but as Im weighing quality of life issues Im just wondering what I might expect in terms of the infection not going away. What type of clinical disease are we looking at, and how might I differenciate it from her other issues?

I would treat the E. coli and then re-evaluate.

You are sure of your numbers with your meter, right? do you have another meter to double-check?

 

[carolynandlatte]

Re: Enterococcus bacteria/UTI

You are sure of your numbers with your meter, right? do you have another meter to double-check?

Yup! Changed batteries about a month or so ago, occassional spot checks with back up meter, usually spot on with what vet gets when comparing. Behavior is very consistant with what numbers she is sitting in, or big drop she is having.

Will let you know what kind of results we get after recheck tomorrow.

Thanks Jess!

 

[carolynandlatte]

Just got a call from regular vet and culture came back with NO e coli or enterococcus. But it did come back with streptococcus (am I spelling all these right?!?! :roll: ). He is not sure what is going on. I asked him to run a sensitivity because I dont want to mess around with guessing on a/b's at this point. he is also putting a call into the specialist she saw at the University last week to see what he thinks. I should know more on the sensitivity and hopefully what the two talk about in the consult by Friday.

What her regular vet did say, is that the University sends their cultures out to a lab in Wisconsin. Sometimes if there are multiple bacteria, some of them will cloud others if they are not cultured immediately. This may have been the case, and the streptococcus was there all along. They do the cultures immediately at her regular clinic, so its less likely to happen. Makes sense I guess.

So the orbax got the enterococcus??? Or is it probably just temporary? Does the a/b (she is still taking it) cover up the bacteria? Could its still be there, but we wont see until she is off a/b's?

And what is this new one?!?!? Where are all these coming from? :YMSIGH: Very frustrating. My poor girl. :cry:

We did discuss the possibility of a kidney infection. I brought it up because Ive noticed the last 2 times she has showed a UTI in a u/a, a week later she has that problem walking due to back/walking issues. I know she has something that can specifically be causing the back/walking issues. But it seems so coincedental, that I wonder if they are related and this is a kidney infection as well. Would that cause continuous bladder infections if it has not been treated properly? Add the steroid and high bg's in there, and????