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Suggest Treatment For Recurrent Bladder Infection Of Enterococcus Faecalis
Question: Please do not tell me to simply go and get a positive urinalysis!!! After 12 weeks of initial continuing infection, it moved into the bladder wall/biofilms and defied culturing. Thank you
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I contracted a bladder infection of Enterococcus faecalis after being in hospital and having had urinary catheters. It was positively cultured and prescribed Augmentin, 1.5gm p/d for 10 days (they did one IV of augmentin and gentamycin). After 2 months the infection returned worse than before, I was prescribed 10 days 1.5gm p/day Amoxicillin, when at this stage I think the returning infection should have been considered more seriously. (only nitrofurantoin and amoxicillin were ever checked for sensitivity). Infection returned worse in 5 days after end of course, but could **no longer be cultured in urine** (the previous positive culture took 48 hours to grow). Specialist refused more treatment with no culture. After a further 12 months of continuing significant bladder pain, the pain has spread to the flanks, backs of knees, back and left chest with pain and acute muscle weakness. Now I have excruciating vas genital pain, both sides and rising.
No medical professional will offer treatment without positive urinalysis. BUT positive urinalysis has not been possible for over 12 months and no other techniques will be tried (eg, fine needle aspirates from prominent infected vas)
I am taking 3 x 200gm ibuprofen and 5gm VitC per day which has slowed progression.
What else can I do?
How do I get our medical system to properly manage this condition?
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I contracted a bladder infection of Enterococcus faecalis after being in hospital and having had urinary catheters. It was positively cultured and prescribed Augmentin, 1.5gm p/d for 10 days (they did one IV of augmentin and gentamycin). After 2 months the infection returned worse than before, I was prescribed 10 days 1.5gm p/day Amoxicillin, when at this stage I think the returning infection should have been considered more seriously. (only nitrofurantoin and amoxicillin were ever checked for sensitivity). Infection returned worse in 5 days after end of course, but could **no longer be cultured in urine** (the previous positive culture took 48 hours to grow). Specialist refused more treatment with no culture. After a further 12 months of continuing significant bladder pain, the pain has spread to the flanks, backs of knees, back and left chest with pain and acute muscle weakness. Now I have excruciating vas genital pain, both sides and rising.
No medical professional will offer treatment without positive urinalysis. BUT positive urinalysis has not been possible for over 12 months and no other techniques will be tried (eg, fine needle aspirates from prominent infected vas)
I am taking 3 x 200gm ibuprofen and 5gm VitC per day which has slowed progression.
What else can I do?
How do I get our medical system to properly manage this condition?
Brief Answer:
The culture results are needed!
Detailed Answer:
Hello,
I've read your question and understand how annoyed you may feel after such a long time without a permanent solution to your problem.
Unfortunately in order to choose the right antibiotic (particularly after having used broad spectrum potent antibiotics) an antibiogram is essential. Taking samples during treatment (or right after it) may result in false negatives. The biofilm you've mentioned may make eradication more difficult but the diagnostic and treatment approach remains the same.
Men with urinary tract infection need radiological investigation of the urinary tract and when the infection is persistent consideration for the probability of spread to the epididymis or prostate.
Have you consulted a urologist? Do you have radiological investigation results? Fever is absent I suppose.
Two months after a supposedly successful treatment of a urinary tract infection are enough to consider the possibility that another pathogen (not the same that caused the first cystitis) could be implicated. Since you've received treatment with beta-lactam antibiotic and aminoglycoside, most pathogens should have been eradicated.
So in conclusion, since you're not taking any antibiotics for some time now, an antibiogram would be very helpful to guide treatment and is worth a try (and perhaps more tries). Also consulting a urologist for investigation of potential structural abnormalities in your urinary tract and exclusion of the possibility for epididymititis or prostatitis is essential.
I hope you find my answer helpful!
Contact me again, if you'd like to discuss something in more detail.
Kind Regards!
The culture results are needed!
Detailed Answer:
Hello,
I've read your question and understand how annoyed you may feel after such a long time without a permanent solution to your problem.
Unfortunately in order to choose the right antibiotic (particularly after having used broad spectrum potent antibiotics) an antibiogram is essential. Taking samples during treatment (or right after it) may result in false negatives. The biofilm you've mentioned may make eradication more difficult but the diagnostic and treatment approach remains the same.
Men with urinary tract infection need radiological investigation of the urinary tract and when the infection is persistent consideration for the probability of spread to the epididymis or prostate.
Have you consulted a urologist? Do you have radiological investigation results? Fever is absent I suppose.
Two months after a supposedly successful treatment of a urinary tract infection are enough to consider the possibility that another pathogen (not the same that caused the first cystitis) could be implicated. Since you've received treatment with beta-lactam antibiotic and aminoglycoside, most pathogens should have been eradicated.
So in conclusion, since you're not taking any antibiotics for some time now, an antibiogram would be very helpful to guide treatment and is worth a try (and perhaps more tries). Also consulting a urologist for investigation of potential structural abnormalities in your urinary tract and exclusion of the possibility for epididymititis or prostatitis is essential.
I hope you find my answer helpful!
Contact me again, if you'd like to discuss something in more detail.
Kind Regards!
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello Dr Zografakis, thank you for the reply and detail/thought you put into it.
Fever, after 17 months of initial infection is absent. When the infection had run 12 weeks it became chronic and not culturable from urine. Our system relies on urine as the SOLE determinate unless a person is in critical care.
1/ I recently underwent a cystoscopy for exactly what you state, detection and lab work on a bladder wall biopsy. However the urologist was apparently on a different course to what he told me he would do (and the exact reason I went to him). He looked for physical abnormalities, did bladder extension etc., passed on doing the wall biopsy and did massage the prostate. At the initial consultation he laughed that repeat infections don't happen and that it's impossible for E.f. to infect beyond the bladder.
2/ For 7 months now there's been a relentless march of pain and acute muscle weakness first to the flanks, then to the back of knees, back and over into the left chest muscles. Without ibuprofen I cannot stand straight or walk without support. 6 weeks ago it moved into the epididymis both sides and moved up to the lower abdomen; excruciating pain. I have almost stopped it in its tracks with 5gms of VitC a day.
3/ Regarding the antibiotic courses. The first failed probably after reinfection from the prostate (it was successful until the first ejaculation more than 2 months later). Then a Specialist decided that a course of amoxicillin (no beta-lactamase inhibitor) was correct procedure. This was where more serious intervention should have been taken. The amoxicillin was insufficient right from the start, never fully reduced the infection and was back in full within days. The recent augmentin was targeting the rising infection from the epididymis(2) and from what I've read, penetration is difficult.
Please remember this is a nosocomial infection and only 2 sensitivities were determined for the cheapest drugs. The correct treatment was the initial IV augmentin and gentamycin which should have run as a day patient for a week. We have a free health care system and penny-pinching is widespread.
I think it is reasonable to say that the original infection was never correctly targeted/treated after the first treatment.
4/ ? No antibiogram is now possible. The cystoscopy was a waste of time, nothing will be isolated from the soft tissue spread (because "the infection COULD not spread outside the bladder") and find needle aspirates from the swollen painful front genital vessels are impossible because "this just doesn't happen", in spite of visual evidence.
Again thank you for your professional well-thought out answer, however ALL my attempts for the last 9 months to get a specimen to a lab. have failed.
If you can make any more helpful comments from what I've written, please do so. Tks again (ps - I'm not annoyed, I'm extremely upset that mediocre medicine has allowed a potentially dangerous pathogen like E.faecalis to disseminate like this, with no end in sight and no experienced capable available Doctors).
Fever, after 17 months of initial infection is absent. When the infection had run 12 weeks it became chronic and not culturable from urine. Our system relies on urine as the SOLE determinate unless a person is in critical care.
1/ I recently underwent a cystoscopy for exactly what you state, detection and lab work on a bladder wall biopsy. However the urologist was apparently on a different course to what he told me he would do (and the exact reason I went to him). He looked for physical abnormalities, did bladder extension etc., passed on doing the wall biopsy and did massage the prostate. At the initial consultation he laughed that repeat infections don't happen and that it's impossible for E.f. to infect beyond the bladder.
2/ For 7 months now there's been a relentless march of pain and acute muscle weakness first to the flanks, then to the back of knees, back and over into the left chest muscles. Without ibuprofen I cannot stand straight or walk without support. 6 weeks ago it moved into the epididymis both sides and moved up to the lower abdomen; excruciating pain. I have almost stopped it in its tracks with 5gms of VitC a day.
3/ Regarding the antibiotic courses. The first failed probably after reinfection from the prostate (it was successful until the first ejaculation more than 2 months later). Then a Specialist decided that a course of amoxicillin (no beta-lactamase inhibitor) was correct procedure. This was where more serious intervention should have been taken. The amoxicillin was insufficient right from the start, never fully reduced the infection and was back in full within days. The recent augmentin was targeting the rising infection from the epididymis(2) and from what I've read, penetration is difficult.
Please remember this is a nosocomial infection and only 2 sensitivities were determined for the cheapest drugs. The correct treatment was the initial IV augmentin and gentamycin which should have run as a day patient for a week. We have a free health care system and penny-pinching is widespread.
I think it is reasonable to say that the original infection was never correctly targeted/treated after the first treatment.
4/ ? No antibiogram is now possible. The cystoscopy was a waste of time, nothing will be isolated from the soft tissue spread (because "the infection COULD not spread outside the bladder") and find needle aspirates from the swollen painful front genital vessels are impossible because "this just doesn't happen", in spite of visual evidence.
Again thank you for your professional well-thought out answer, however ALL my attempts for the last 9 months to get a specimen to a lab. have failed.
If you can make any more helpful comments from what I've written, please do so. Tks again (ps - I'm not annoyed, I'm extremely upset that mediocre medicine has allowed a potentially dangerous pathogen like E.faecalis to disseminate like this, with no end in sight and no experienced capable available Doctors).
Brief Answer:
I've added some comments on your thoughts
Detailed Answer:
Hello,
let me comment on your reply and hope to be helpful...
First of all Enterococcus faecalis may indeed cause upper urinary tract infections and other serious infections as well. This is a well known fact.
The bladder wall biopsy may show signs of chronic cystitis while the direct visualization of your bladder wall during cystoscopy should be enough for the detection of any "acute" signs.
Recurrent infections with E. faecalis are not rare particularly in men (and particularly when prostatitis or epididymitis coexist).
I cannot relate the symptoms you've mentioned (muscle weakness with bladder pain). If muscle weakness is objectively detected then investigation for neurologic causes is warranted. And I don't know of any infection getting better with vitamin C supplementation. It's definitely not indicated as a treatment neither as an adjunct to treatment!
Perhaps you're right about antibiotic treatment although I gather that your doctors studied the antibiogram before administering treatment, so I suppose that the antibiotic choice should have been right. Regarding treatment duration I would have gone for a longer treatment in a man. Women can benefit faster from urinary tract infection treatments.
One last comment about the "12 week" rule. I've never heard of it or read about it in any medical books or article. If you do have any related resource I'll be grateful if you could share it with me. I suppose it must be a misunderstanding because during my primary medical studies (and after them) I've studied the infectious diseases a lot and never came across such a rule.
Judging from your description your current problem seems to be the dissemination of the infection to the male organs. I'd be really curious to read test reports you may have (radiological, urinalysis, blood tests etc). And I'm also curious to know what the urologist's opinion was about your case, since he/she was the one that examined you last.
Kind Regards!
I've added some comments on your thoughts
Detailed Answer:
Hello,
let me comment on your reply and hope to be helpful...
First of all Enterococcus faecalis may indeed cause upper urinary tract infections and other serious infections as well. This is a well known fact.
The bladder wall biopsy may show signs of chronic cystitis while the direct visualization of your bladder wall during cystoscopy should be enough for the detection of any "acute" signs.
Recurrent infections with E. faecalis are not rare particularly in men (and particularly when prostatitis or epididymitis coexist).
I cannot relate the symptoms you've mentioned (muscle weakness with bladder pain). If muscle weakness is objectively detected then investigation for neurologic causes is warranted. And I don't know of any infection getting better with vitamin C supplementation. It's definitely not indicated as a treatment neither as an adjunct to treatment!
Perhaps you're right about antibiotic treatment although I gather that your doctors studied the antibiogram before administering treatment, so I suppose that the antibiotic choice should have been right. Regarding treatment duration I would have gone for a longer treatment in a man. Women can benefit faster from urinary tract infection treatments.
One last comment about the "12 week" rule. I've never heard of it or read about it in any medical books or article. If you do have any related resource I'll be grateful if you could share it with me. I suppose it must be a misunderstanding because during my primary medical studies (and after them) I've studied the infectious diseases a lot and never came across such a rule.
Judging from your description your current problem seems to be the dissemination of the infection to the male organs. I'd be really curious to read test reports you may have (radiological, urinalysis, blood tests etc). And I'm also curious to know what the urologist's opinion was about your case, since he/she was the one that examined you last.
Kind Regards!
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello Dr Zografakis, the recent urologist's view is that all symptoms are psyschomatic! I did not intend to create a 12 week rule. The 2nd positive culture after some 10 weeks took 48 hrs to culture, I had to request them to extend the culture as they discard at the 24hr mark usually. When symptoms returned worse than ever after the disastrous course of amoxicillin, nothing could be cultured. The original Infectious Diseases Specialist simplistically KNOWS this means no infection, however the severe symptoms said otherwise. (He's a young guy who it turns out deals with pediatric issues normally, however he's the only ID in private practice, one day a week, in a city of 1million)
The reality right now is that nobody will investigate anything further, even if they saw me in obvious pain and unable to walk unsupported. Enterococcus does have a history of disseminating through soft tissues.
Ibuprofen and vitC definitely have a substantial suppressive action, at least in my case (a number of published studies are available online)
The original E.faecalis infection very probably went like this:
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0000
which would also explain the "epithelial contamination" comment of the first sample (I presume you can see the first two lab. results I sent with my question?, I'l try to upload again), I certainly know what MSU means. By 12 weeks when nothing could be cultured by urinalysis, it's near-certain that what the above article describes (intra-cellular invasion by E.f.) is a strong possibility.
If you could please answer one more question:
Do you know of any respected institution(s) (in or out-patient care) around the world with extensive experience treating infectious diseases?
Thank you, XXXXXXX
The reality right now is that nobody will investigate anything further, even if they saw me in obvious pain and unable to walk unsupported. Enterococcus does have a history of disseminating through soft tissues.
Ibuprofen and vitC definitely have a substantial suppressive action, at least in my case (a number of published studies are available online)
The original E.faecalis infection very probably went like this:
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0000
which would also explain the "epithelial contamination" comment of the first sample (I presume you can see the first two lab. results I sent with my question?, I'l try to upload again), I certainly know what MSU means. By 12 weeks when nothing could be cultured by urinalysis, it's near-certain that what the above article describes (intra-cellular invasion by E.f.) is a strong possibility.
If you could please answer one more question:
Do you know of any respected institution(s) (in or out-patient care) around the world with extensive experience treating infectious diseases?
Thank you, XXXXXXX
Brief Answer:
Perhaps you should give a try to your doctor's suggestion
Detailed Answer:
Hello XXXXXXX
I read the culture and urinalysis reports. Unfortunately they didn't add much to what you've already said. And I've skimmed through the medical paper you've mentioned. The paper actually gives an explanation to the fact that Enterococcal infections may recur.
The infectious diseases specialist should be able to give you reliable advice. Even if a big part of the specialist's practice has to do with children, I'm sure he/she won't have any problem to treat adults. Besides the fact that infectious diseases specialists are trained to treat adults too, urinary tract infections in adults and children are not that different. It's the etiology that may be different.
Although bladder infections are the most common causes of bladder pain and discomfort during urination, there are other potential causes that the urologist may detect and I'm sure he's tried to do so already.
Anyway, since you've suffered for such a long time and continue to suffer, why not try your doctor's suggestion? A psychiatrist is the right person to diagnose a psychosomatic problem. If your problem is organic indeed, talking to the psychiatrist won't do you any harm. If it's not then treating it the right way, could be life-saving.
Regarding your question: I can't speak about New Zealand, because I practice medicine in Greece.
Reputable infectious diseases departments operate in the following hospitals of XXXXXXX (Greece):
- Attikon Hospital (http://www.attikonhospital.gr)
- Evaggelismos Hospital (http://www.evaggelismos-hosp.gr)
- Gennimatas Hospital (http://www.gna-gennimatas.gr)
- "Red Cross" Hospital (http://www.korgialenio-benakio.gr/)
I'm sure you can find similar departments much closer to you! The internet is full of information, although some filtering is usually required.
Kind Regards!
Perhaps you should give a try to your doctor's suggestion
Detailed Answer:
Hello XXXXXXX
I read the culture and urinalysis reports. Unfortunately they didn't add much to what you've already said. And I've skimmed through the medical paper you've mentioned. The paper actually gives an explanation to the fact that Enterococcal infections may recur.
The infectious diseases specialist should be able to give you reliable advice. Even if a big part of the specialist's practice has to do with children, I'm sure he/she won't have any problem to treat adults. Besides the fact that infectious diseases specialists are trained to treat adults too, urinary tract infections in adults and children are not that different. It's the etiology that may be different.
Although bladder infections are the most common causes of bladder pain and discomfort during urination, there are other potential causes that the urologist may detect and I'm sure he's tried to do so already.
Anyway, since you've suffered for such a long time and continue to suffer, why not try your doctor's suggestion? A psychiatrist is the right person to diagnose a psychosomatic problem. If your problem is organic indeed, talking to the psychiatrist won't do you any harm. If it's not then treating it the right way, could be life-saving.
Regarding your question: I can't speak about New Zealand, because I practice medicine in Greece.
Reputable infectious diseases departments operate in the following hospitals of XXXXXXX (Greece):
- Attikon Hospital (http://www.attikonhospital.gr)
- Evaggelismos Hospital (http://www.evaggelismos-hosp.gr)
- Gennimatas Hospital (http://www.gna-gennimatas.gr)
- "Red Cross" Hospital (http://www.korgialenio-benakio.gr/)
I'm sure you can find similar departments much closer to you! The internet is full of information, although some filtering is usually required.
Kind Regards!
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
My only psychological problem is the existence of a mismanaged infectious illness. Thank you for your help and persistence, XXXXXXX
Brief Answer:
I hope you find the right solution
Detailed Answer:
Hi,
I did not imply that you do have a psychological problem because I couldn't possibly judge that by talking to you for a while, without having reviewed your medical history in detail. I'm just suggesting that if everything else failed either by mismanaging the actual illness or for any other reason, and since you've not any ready solutions for the problem, perhaps you should give a try to the proposed solution (by your doctor). Anyway, this is your choice and I respect that.
I really hope you can find the right solution for you!
I'll be glad to help, should you need a medical opinion in the future!
Kind Regards!
I hope you find the right solution
Detailed Answer:
Hi,
I did not imply that you do have a psychological problem because I couldn't possibly judge that by talking to you for a while, without having reviewed your medical history in detail. I'm just suggesting that if everything else failed either by mismanaging the actual illness or for any other reason, and since you've not any ready solutions for the problem, perhaps you should give a try to the proposed solution (by your doctor). Anyway, this is your choice and I respect that.
I really hope you can find the right solution for you!
I'll be glad to help, should you need a medical opinion in the future!
Kind Regards!
Note: Consult a Urologist online for consultation about prostate and bladder problems, sexual dysfunction, kidney stones, prostate enlargement, urinary incontinence, impotence and erectile dysfunction - Click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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