Dr. Pk Gupta  Jan 04 2016

What Is The Treatment For Resistant Urinary Tract Infection
Nephrology Internal Medicine UrologyVotes(0) Answers(6) Viewed 120 Times

One 72 year old male, hypertensive non-diabetic, non-smoker patient presented with sleepiness and confusion 5 years ago. On investigation he had urinary tract infection with pus cell count of over 100 per hpf. He also had elevated serum creatinine . Repeated ultrasound abdomen revealed slight prostatomegaly with PVR of 50 to 70 ml, no calculi. kidney normal. cystoscopy was normal. Following culture and sensitivity of urine specimen which revealed klebsella infection anti biotics were started which included sulfamethoxazole and trimethoprim, ciprofloxacin and others but to no avail.
Kidney failure worsened. Polymerase chain reaction for mycobacterium tuberculosis revealed a positive and a negative specimen. rifampin, ethambutol and ciprofloxacin were started and after long period he started improving. serum creatinine and urine parameters became normal.
The problem was that on reducing ATT the urine started again showing 100 pus cells per hpf. Rifampcin had to be continued for 5 years. lately, he started showing signs of agitation and it did not improve with dothiepin and Lorazepam but improved with haloperidol. so a diagnosis of psychosis was made and rifampicin stopped. Again his urine is full of pus cells and shows resistance to most antibiotics. He is showing resistant klebsiella infection. MRI brain is normal.
What should be the choice of antibiotics and should his prostatomegaly be operated.it only shows 50 ml PVR.
I shall be grateful. The case has been managed by many internists and nephrologist. quite a puzzle
Is he resistant UTI with compromised renal function. or prostatitis. or infection in seminal vesicles? Urine also shows lots of rbc recurrently or obstructive uropathy or tuberculosis of lower urinary tract, bladder wall is thick.
What treatment should be given?
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Dr. Pk Gupta

Jan 04 2016

is he resistant uti with compromised renal function. or prostatitis. or infection in seminal vescicles. urine also shows lots of rbc recurrently.or obstructive uropathy. or tuberculosis of lower urinary tract. bladder wall is thick

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Dr. Suhas Bavikar

9:45 AM

Before starting treatment would like to assess his immun system , urine culture with sensitivity for additional fungus , as it seems he has mixed infection suggesting immunocompromised status ! How about anatomical utinary tract evaluation , as obstruction will perpetuate infection n vice versa

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Dr. Sameer Chaubey

9:57 AM

I think a TURP should help. It sure did in my 2 patients.

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Dr. Rai Chand Nagar

5:59 PM

TURP may help,possibility of prostate obstruction……….evaluate more………

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Dr. Pk Gupta

10:21 PM

urine c & s has been done and shows sensitivity to nitrofuranoin trimethoprim levifloxaxicillin. levofloxacillin helped but was stopped. internist say it should not be given for more that 2 weeks. I don’t know. cystoscopy has been done as well as uroflowmetry 2 years back. was not of much help.

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Dr. Purva Shoor

10:52 AM

microhaematuria or macrohaematuria ie destroyed rbcs or frank. How are the kidneys is it ckd….antibiotics which get excreted through the kidneys cant be used for treatment. Klebsiella indicates hospital aquired injection. Is there dysuria? If that is there treat with pain killers and treat the kidney pathology. In old age muscle mass becomes atrophied which increase creatinine. Sr urea great needs to be measured, controlled diuresis, and after that treatment of klebsiella unless septic condition arises.

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Dr. Pk Gupta

10:25 PM

thanks . frank rbc are seen .kidneys are normal on ultrasound and kidney function which were deranged for few months initially. after uti was successfully treated kidney funtion came to normal

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Dr. Satish Kumar Gupta

2:10 PM

Chronic UTI with granulomatous menifestations indicates multiple infections and in urogenital tract non-specific infections like Ureaplasma urealyticum and many more nonconventional bacteria are known to occur along with chronic fungal infection. Moreover intracellular bacteria are not killed by most of antibiotics.Fast development of resistance is also a problem. Effect of antibiotics is also reduced by presence of blood and pus. Unhealthy, macerated and abraised epithelium of Uro-Gental tract is also responsible for recurrent urinary infections.

There are some tips from my side which may be useful in the treatment.

1. Give several short coures each of 7-10days

2. Use antibiotics used for non-specfic uro-gental infectionas along with specific antibiotic used for Klebsiella or classical UTI pathgens.

These are Azithromycin, Ornidazole or Metronidazole and Fluconazole

Neuforce 3 Kit may be given once every week for 3-4 weeks to cover both atypical bacteria, fungus and protozoa subject to tolerance by the patient.

3. Use those antibiotic that enter inside cell and act on intracellular bacteria like:

Moxifloxacin

Azithromycin

Rifampicin

4. To prevent resistance use Rifampicin along with others

5.If 2 or more antibiotics are individually resistant, their combination may not be resistant. So plan combination.

6. Search some new anti-biotic which is recently approved or is in Phase-3 clinical research

7. Always give low dose Vitamin A therapy with antibiotic therapy (Aquasol 10,000 units BD or Becadexamin 1BD for 1 week, followed by Becadexamin 1 daily for 2-3 months. Vitamin A shall promote growth and differentiation of epithelium of Uro-genital tract.

Please give me full clinical details of the patient. May be I could give better advice.

 

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Dr. Pk Gupta

10:27 PM

thanks. i will send more details

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Dr. Purnanandam Yedavally

2:27 PM

The problems here are 2 fold. A.1.Reinfection with m.tb.2. Mixed secondary bacterial infection B. Anatomically significant lesions tending to perpetuate the infection – enlarged prostate .

The patient should have a bacterial culture, fungal culture and afb culture of the urine. The longer the afb culture is incubated the higher is the positivity rate.And of course sensitivity antibiogram as well. It is also llikey that patient must have got resistant to longterm use of rifamycin and hence a MDR Tb should be kept in mind and assessed as well both for isolation of organism and sensitivity.

Longterm use of antibacterials and antibiotics surely can and do result in fugal superinfection – so a fungal culture is in order.

Since the patient is 70+, a Uroflowmentry is in order.In fact not only a UROFLOWMETRY but a Full Urodynamic assessment is called for.As the U/S of the bladder suggests thickwalled bladder – may be due to tb, may be due to obstruction.If the cause is T.B then even reflux to ureters and kidneys should be kept in mind.The urodynamics will tell us if th bladder capacity is decreased, any ODCs,and the outflow obstruction present.

It would not be wise to attempt any surgical procedure without all this basic info.

Ther are many brave surgeons and pathetic patients. All surgeons are brave at the expense of the patients.

Once all this data is available, let us know and the course of action can be charted out.

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Dr. Purnanandam Yedavally

2:29 PM

Premature Detrusor Contractions, not ODCs

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Dr. Pk Gupta

10:38 PM

thanks fungal culture was normal. uroflowmetry was done and not of much help as no definite indications for surgery came out.i will send more details

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Dr. Gafur Mansuri

3:40 PM

Resistant Urinary Tract Infection is a very big problem for the patient & doctor both specially in elderly men,pregnant lady,paediatrics patients & women complicated further by other associated diseases like benign prostatic hypertrophy in elderly male and sex worker in female using medicated diaphram & spermicidal drugs.

Urine culture & sensitivity test may give you some important clue for the diagnosis and treatment.Intravenous route may have better results.Injection Fosfomycin 3 gm Intrvenously Monotherapy,can be repeated on third day is widely used in United States of America.

Previously used wonder drugs like Trimethoprim + Sulphamethoxazole have no role today.Other commonly used medicines nowadays are Ciproflaxacin, Chloramphenicol & Nitrofurntoin in Escherichia Coli (mostly 80% ),Klebsiella & Proteus (rare) Gram Negative organisms causing resistant UTI.

The Cycloserine 250 – 500 mg 1 BiD for 14 – 21 days may be helpful.

No cure is there. Cure rate is poor.

Recurrence is usual in resistant UTI

 

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Dr. Pk Gupta

10:35 PM

thanks .we have tried out ciprofloxacillin chloramphenicol and nitrofuranoin but he seems to have got resistant to it.we will try cycloserine. many good sensitive antibiotics and limited by the fact of his history of renal impairment in past

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Dr. Bakul P. Dhruva

3:53 PM

Nitrofurantoin has been found to be one of the best drugs when most of the oral drugs have been found to be resistant.

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Dr. Ranjit Jain

9:05 PM

Yes

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Dr. Ranjit Jain

9:06 PM

Tb

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Dr. Pk Gupta

10:31 PM

thanks . nitrofuranoin was found to be sensitive and has been used allready. it helped previously but now he is resistant to it

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