Should i kill Pseudomonas or leave it be?

[crispy1981]

I came down with a Pseudomonas bladder infection which is only sensitive to several IV anti biotics (from a C & S) - no oral Anti Biotics. My urologist put me on oral Fosfomycin for 12 days. It seems to have helped some but i'm still unable to return to draining into my condom cath without AD (my normal function).

If the post 12 day fosfomycin treatment shows the bug in the follow up C $ S (just submitted that today) should i consider the IV options? Or is that a recipe for developing more resistance?

thanks

[SCI-Nurse]

Have you had other recent UTIs (not just colonization) with pseudomonas? If so, have you been evaluated for urinary stones recently? The two are commonly linked.

How many days after you finished the antibiotic did you submit the urine C&S? It should be at least 2 days later. Too soon and the results will be tainted by the excreted antibiotics. Was the choice to use fosfomycin based on a urine C&S originally?

Are you still symptomatic for a UTI (fever, chills, AD, malaise, etc.)?

(KLD)

[crispy1981]

Hello KLD! thanks for your reply/input!

to my knowledge i haven't had this bug before. I haven't had a UTI since 2016 and it was Staphyloccous (sp). And i don't think the kidney stone discussion has come up yet with my urologist but they did consider prostate (i'm 56) but ruled it out based on my recent physical bloodwork.

My last dose of Fosfomycin was last friday Nov 22nd. Yes the original choice to use Fosfomycin was based on the culture results which indicated only IV options. The urologist did not offer the rationale of using it. I did find out however that Anti Biotic cannot be tested in C & S. Not sure why.

I do not have any UTI symptoms at present (i did before starting the AB therapy) other than elevated AD when voiding neurogenically? And with that AD comes some minor chills, sweating and slight headache and elevated BP (about 155).

I'm quite puzzled by how to manage UTIs in the face of resistance. As best i can understand resistance comes from repeated use of the same Anti Biotic?...same family of Anti Biotic? So if i have several IV choices that i've never used before am i risking anything? I think i can see how this plays out though...what about the next bug? And what if i need to use IV from the same family? And of course i always try every other option. I'm currently trying 4-6grams of Vitamin C since learning Pseudomonas does not survive in an acidic environment.

[SCI-Nurse]

Are you testing your urine pH? 4-6 gm. of vitamin C is a very high dose; generally no more than 1 gm. daily is recommended.

How much residual urine do you carry after voiding? When did you last have urodynamics? Have you been assessed for kidney function and the absence of hydronephrosis recently?

(KLD)

[hlh]

You can check urine cultures for sensitivity to Fosfomycin.

It is just a very old antibiotic that is rarely used these days, so most hospitals don't routinely check for sensitivity to this antibiotic. The doctor needs to ask ahead of time to add on this antibiotic to their test, or call and ask the lab once they have the sample to add it.

My Dad also recently had a resistant UTI that wouldn't go away, even after using the appropriate IV antibiotic. So we checked a culture for Fosfomycin sensitivity, and it was susceptible, so my Dad took it for 3 doses and things look good so far for him.

Your dose of Fosfomycin is unusual. Are you taking it every day for 12 days? It is normally given as a one time dose for simple UTIs (not you....) or 3 doses for more complicated UTIs, and each dose is given every other day. What kind of doctor prescribed this 12 day course for you? Infectious disease doctors like this antibiotic, but most urologists don't know much about it.

in general, the more you use one antibiotic of the same family of antibiotics, the higher the chance of developing resistance. It is not a bad thing to use an IV antibiotic if that is the appropriate treatment, especially if it is not one you take often. IV antibiotics are just inconvenient, often more expensive, and more potent is some cases so you may have more side effects. However, in my Dad's case, his doctors know him well and quickly set up Home Health services and he got the IV antibiotic at home and never had to be admitted to the hospital first.

Because of my Dad's history of resistant UTIs, he is followed by an infectious disease (ID) doctor now. That means that be a good thing for you. Unfortunately, the ID docs don't tend to know much about SCI but they can give advice on antibiotics.

i agree with the nurse that you should talk with your urologist/ID/physiatrist about having an ultrasound or CT of your bladder and kidneys to look for stones, signs of chronic retention of urine and possibly uro dynamics if the infection isn't going away.

[crispy1981]

No i have not been testing my urine PH but i shall if that is something i can do. What would i be looking for regarding PH testing?

Question about the Vitamin C, is the dosage of 1 gram the recommendation for a general supplement for UTI maintenance/avoidance? I was under the impression a higher dosage is better for battling a UTI, especially a bug known to have succeptibility to vitamin C?

I have never emptied completely (except i do cath currently morning and night when i need to/battling a UTI etc) otherwise i don't mess with the natural flora and it seems to have worked until now but that's a longer story). Yes, i tried switching to intermittent cath but no drugs could prevent leakage so urologist said i might not be a candidate.

I haven't had Urodynamics done since 2016 and at that time i also had a scope. I am supposed to be scheduled soon to have kidney analysis done...i think an ultrasound? My creatinine levels are fine however and have not changed since my records have been kept online (2012) so they aren't specifically focussed there. I can press vigorously on my flanks and zero discomfort so i'm also not suspecting anything there at this time.

I do not know anything about hydronephrosis...i can research/ask about it.

I think i know what you are focussed on...ruling out any other problems that typically come with this type of bug and i think we've been also looking at what would have been the source...but of course this forum/your input is much more targetted for us SCI folks so i appreciate the full spectrum of considerations!

thanks

[SCI-Nurse]

Anyone using reflex voiding for bladder management should have urodynamics done every 1-2 years, as your bladder can change. A high pressure bladder can both damage your kidneys and lead to more frequent UTIs.

Annual ultrasound should be done for your kidneys, ureters, and bladder to screen for stones, hydronephrosis, and other structural problems in the urinary tract. Usually a gall bladder ultrasound should be included in this as you are also higher risk for gall stones if you have a SCI.

pH testing can tell you if you are taking the right amount of vitamin C. According to the American Association for Clinical Chemistry, the average value for urine pH is 6.0, but it can range from 4.5 to 8.0. Urine under 5.0 is acidic, and urine higher than 8.0 is alkaline, or basic. It is generally recommended to avoid more than 2,000 mg. daily. Here is some information on the side effects commonly found with higher dosage.
https://www.healthline.com/nutrition...min-c#section2

(KLD)

[crispy1981]

You can check urine cultures for sensitivity to Fosfomycin.

It is just a very old antibiotic that is rarely used these days, so most hospitals don't routinely check for sensitivity to this antibiotic. The doctor needs to ask ahead of time to add on this antibiotic to their test, or call and ask the lab once they have the sample to add it.

My Dad also recently had a resistant UTI that wouldn't go away, even after using the appropriate IV antibiotic. So we checked a culture for Fosfomycin sensitivity, and it was susceptible, so my Dad took it for 3 doses and things look good so far for him.

Your dose of Fosfomycin is unusual. Are you taking it every day for 12 days? It is normally given as a one time dose for simple UTIs (not you....) or 3 doses for more complicated UTIs, and each dose is given every other day. What kind of doctor prescribed this 12 day course for you? Infectious disease doctors like this antibiotic, but most urologists don't know much about it.

in general, the more you use one antibiotic of the same family of antibiotics, the higher the chance of developing resistance. It is not a bad thing to use an IV antibiotic if that is the appropriate treatment, especially if it is not one you take often. IV antibiotics are just inconvenient, often more expensive, and more potent is some cases so you may have more side effects. However, in my Dad's case, his doctors know him well and quickly set up Home Health services and he got the IV antibiotic at home and never had to be admitted to the hospital first.

Because of my Dad's history of resistant UTIs, he is followed by an infectious disease (ID) doctor now. That means that be a good thing for you. Unfortunately, the ID docs don't tend to know much about SCI but they can give advice on antibiotics.

i agree with the nurse that you should talk with your urologist/ID/physiatrist about having an ultrasound or CT of your bladder and kidneys to look for stones, signs of chronic retention of urine and possibly uro dynamics if the infection isn't going away.

Perfect! This is exactly what i was looking for! thanks HLH!

Yes, i have learned of AB resistance the hard way. My docs would throw cipro at me everytime i had a UTI and i even asked for it...now that family of ABs is not an option for me. I think it might be the only one...now that i have learned more i can research - good to know how all this resistance stuff works. Good because the medical systems don't keep track of our history of AB use so we have to be our own advocates/MD!

And yes the oncall urologist actually told me that you cannot test Fosfomycin! Now i know.

The Fosfomycin (Monural) therapy they prescribed was to drink once every 3 days (it's a powder for others that might read this), 4 doses for a total of 12 days. I wonder if the cadence SHOULD have been every 2 days having read your post? I noticed my urine symptoms would clear up day 2 then return on day 3!

I just did a quick search and it seems the cadence is not set in stone so i probably should have done every 2 days! Ugh!

My uro prescribed it. I had never heard of such a product before.

Yes, i just made a connection with a Infectious Disease doc so now i hopefully can use him to run any therapy's by before starting etc.

Sounds like your Dad and i have much in common. I hope all is going well for him.

[crispy1981]

Anyone using reflex voiding for bladder management should have urodynamics done every 1-2 years, as your bladder can change. A high pressure bladder can both damage your kidneys and lead to more frequent UTIs.

Annual ultrasound should be done for your kidneys, ureters, and bladder to screen for stones, hydronephrosis, and other structural problems in the urinary tract. Usually a gall bladder ultrasound should be included in this as you are also higher risk for gall stones if you have a SCI.

pH testing can tell you if you are taking the right amount of vitamin C. According to the American Association for Clinical Chemistry, the average value for urine pH is 6.0, but it can range from 4.5 to 8.0. Urine under 5.0 is acidic, and urine higher than 8.0 is alkaline, or basic. It is generally recommended to avoid more than 2,000 mg. daily. Here is some information on the side effects commonly found with higher dosage.
https://www.healthline.com/nutrition...min-c#section2

(KLD)

KLD, much appreciated! All good maintenance suggestions and some of them i hadn't had done prior nor even knew of (eg. scan ureters, nor had i heard of we SCI being more succeptible to gall bladder problems - add it to the list! ). I'll pursue them with my urologist.

And just ordered PH strips. Thanks for that tip! I am open to prevention ideas. I much prefer effort spent on prevention than recovery!

I do know my bladder retention has not changed in the 30 plus years of SCI (hasn't increased in the amount i can hold etc). And the only thing that changed (thankfully) in the past 10 years is i do not have AD when i void anymore. And that brings me back to the reason for my post. I'm not yet back to voiding/draining automatically without AD. So is that enough to use one of the IV bullets in my gun or should i stay the course and perhaps i can eventually overcome this bug? Or is pseudomonas one of those bugs you don't want to be colonized with?

thanks!

[crispy1981]

My follow up culture was this:

MIXED UROGENITAL AND OR SKIN MICROBIOTA, ALL ISOLATES <10,000 CFU/ML

I've always been curious. I think the result means i still could have Pseudomonas or some other microbes that you might not consider a healthy flora but if it's under the threshold they don't offer any specifics/details about if there is anything present that you should be aware of? Can we request feedback about what IS present despite the CFU?

[SCI-Nurse]

Was this specimen collected by catheterization, or voided? If the latter, did you take the specimen from your leg or bedside bag?

(KLD)

[crispy1981]

Hi KLD, the specimen was catherization. They usually won't accept a bag sample.

But switching gears...despite my BUN/Creatine levels being normal i do think i'm showing symptoms of Kidney problems so i'm going make a follow up appointment to look at that closer.

I have several symptoms on this list from this link...
https://www.kidney.org/news/ekidney/...Kidney_Disease

- I have noticed very dry skin and some itchiness which i originally dismissed as possible Anit Biotic side affects.
- Traces of blood in urine (dip stick tests indicated this...i did not see any)
- Left foot has been swelling a little more than usual, intermittently. Under control now but has been happening intermittently.
- And muscles have been cramping too...didn't know until i read about symptoms that this could be kidney related.


Another thing of note is:

those with kidney disease tend not to experience symptoms until the very late stages, when the kidneys are failing or when there are large amounts of protein in the urine. This is one of the reasons why only 10% of people with chronic kidney disease know that they have it,? says Dr. Joseph Vassalotti, Chief Medical Officer at the National Kidney Foundation.

• You're more tired, have less energy or are having trouble concentrating. A severe decrease in kidney function can lead to a buildup of toxins and impurities in the blood. This can cause people to feel tired, weak and can make it hard to concentrate. Another complication of kidney disease is anemia, which can cause weakness and fatigue.
• You're having trouble sleeping. When the kidneys aren't filtering properly, toxins stay in the blood rather than leaving the body through the urine. This can make it difficult to sleep. There is also a link between obesity and chronic kidney disease, and sleep apnea is more common in those with chronic kidney disease, compared with the general population.
• You have dry and itchy skin. Healthy kidneys do many important jobs. They remove wastes and extra fluid from your body, help make red blood cells, help keep bones strong and work to maintain the right amount of minerals in your blood.Dry and itchy skin can be a sign of the mineral and bone disease that often accompanies advanced kidney disease, when the kidneys are no longer able to keep the right balance of minerals and nutrients in your blood.
• You feel the need to urinate more often. If you feel the need to urinate more often, especially at night, this can be a sign of kidney disease. When the kidneys filters are damaged, it can cause an increase in the urge to urinate. Sometimes this can also be a sign of a urinary infection or enlarged prostate in men.
• You see blood in your urine. Healthy kidneys typically keep the blood cells in the body when filtering wastes from the blood to create urine, but when the kidney's filters have been damaged, these blood cells can start to "leak" out into the urine. In addition to signaling kidney disease, blood in the urine can be indicative of tumors, kidney stones or an infection.
• Your urine is foamy. Excessive bubbles in the urine ? especially those that require you to flush several times before they go away?indicate protein in the urine. This foam may look like the foam you see when scrambling eggs, as the common protein found in urine, albumin, is the same protein that is found in eggs.
• You're experiencing persistent puffiness around your eyes. Protein in the urine is an early sign that the kidneys? filters have been damaged, allowing protein to leak into the urine. This puffiness around your eyes can be due to the fact that your kidneys are leaking a large amount of protein in the urine, rather than keeping it in the body.
• Your ankles and feet are swollen. Decreased kidney function can lead to sodium retention, causing swelling in your feet and ankles. Swelling in the lower extremities can also be a sign of heart disease, liver disease and chronic leg vein problems.
• You have a poor appetite. This is a very general symptom, but a buildup of toxins resulting from reduced kidney function can be one of the causes.
• Your muscles are cramping. Electrolyte imbalances can result from impaired kidney function. For example, low calcium levels and poorly controlled phosphorus may contribute to muscle cramping.

[HACKNSACK44]

The Fosfomycin (Monural) therapy they prescribed was to drink once every 3 days (it's a powder for others that might read this), 4 doses for a total of 12 days. I wonder if the cadence SHOULD have been every 2 days having read your post? I noticed my urine symptoms would clear up day 2 then return on day 3!

Did you follow these directions when taking it?

MONUROL should be taken orally. Pour the entire contents of a single-dose sachet of MONUROL into 3 to 4 ounces of water (? cup) and stir to dissolve. Do not use hot water. MONUROL should be taken immediately after dissolving in water.

[SCI-Nurse]

Cripsy, do you have a annual 24 hour urine collection for creatinine clearance? That is a much better test for overall kidney function than a simple creatinine level on a urinalysis. You must collect every drop of urine for 24 hours, then have a blood test during that 24 hour period as well.

(KLD)

[crispy1981]

Cripsy, do you have a annual 24 hour urine collection for creatinine clearance? That is a much better test for overall kidney function than a simple creatinine level on a urinalysis. You must collect every drop of urine for 24 hours, then have a blood test during that 24 hour period as well.

(KLD)

Hm, i will ask. Never heard of this before and not sure i'm following. I did not know you can test urine for BUN/Creatinine levels. I thought that was only done via a blood test. But i can ask my urologist about this.