Have questions relating to my 89 year old mother who

Patient

Q: Have questions relating to my 89 year old mother who had reoccurring bladder infections for over 5 years. Was on preventative antibiotics such as nitro with elevated liver enzymes etc.
Anyhow - she had apprx 4 utis a year.
About half a year ago - she began 2000mg daily mannose sugar and has been uti free.
See uro study below

https://www.ncbi.nlm.nih.gov/pubmed/23633128

I believe for her its been effective. She historically has suffered from ecoli causing her incontinence, urgency and pain.
However, I just wanted to know the loading a sugar like this might have on the kidneys..
She began the sugar in April and 2.5 months later, her lab test
showed eGFR of 65 and creatinine of 71 (range of 60 -115)

Her CBC and urine tests were normal and the sugar is not metabolized in the body.

Deeming that the sugar comes from a good supplier - and contaminant free - how DOES one guage that the 2000mg daily wont cause taxing to the kidneys?
Please provide a succinct accurate answer showing some knowledge in this area or payment will be refuted

Doctor

A:   Hi,
D mannose is a natural sugar as you know and has few side effects like diarrhea.

The upper limit dose is not specified clearly but in the research paper quoted by you, the dose is 2000 mg per day and the research was done for 6 months and at the end of it there was no alarming side effect in the patients.

In the absence of detailed studies, some doctors recommend taking d mannose in a dose of 500 mg twice daily for longer durations.

If kidney function tests are not showing any specific abnormal kidney function test results then 2000 mg d mannose daily has not caused any kidney associated dysfunction in your mother when she took it for 2 1/2 months.

It is important to know that since d mannose is a natural sugar therefore it is less likely to cause any kidney problems unless taken many times over recommended dose and over a longer duration.

I am sorry to state that an accurate answer is not available in context to consuming d mannose in recommended doses and kidney dysfunction however eGFR and creatinine are recommended tests for kidney function analysis.

It is important to know that GFR will decrease in the elderly population over 70 years and is a physiological variation.

Hope I could answer at least a part of your query.
Please do write back if you have any doubts.

Regards,

Comments / Follow Ups

Patient: May I ask a number of followup questions
1. What kind of specialist are you? - your years of experience and country of practice?
2. So where do you get the 500mg twice a day from? I have only read that long term use
of high doses of this sugar may harm the kidneys but amounts are never specified
3. Am pondering reducing the amount to 1500mg daily and wait a few weeks but I dont
want a new full blown uti as she already is resistant to a couple of primary antibiotics
It has been difficult sometimes to treat the ecoli initially so 6 months has been her longest duration she has been ecoli free, I dont wish to jeopardize that. Your opinion
on staying at 2000mg than reducing at all?
4. How often should blood and urine testing be done to do checks?
5. I am attaching two uro reports August 12 and 16 - any comments to the results?
She also applies premarin twice a week 0.5 grams
Patient: 2 lab reports - urine 4 days apart in August 2016
Doctor: Hi,
Thanks for writing back with an update.

1. I am a doctor physician with over a decade of experience. I cannot provide more personal details myself as a part of employee guidelines at askthedoctor.com However you can write in to our support team and they are authorized to send you the details.

2. I have read numerous medical literature on the subject of d mannose used in preventing UTIs. One such article used a 1500 mg dose twice daily for nearly 6 months and there was no issues related to side effects.

You can read through the link below for complete details
http://uro.sagepub.com/content/7/3/208

In the above study the subjects were in the age range of 22 to 54 years. Therefore keeping in mind that your mother is 89 years old, it is suggested to go for a lower than normal adult dose and 500 mg twice daily fits in well.

3. In my opinion 2000 mg should not cause any problems but if she develops diarrhea then it should be reconsidered.

A 1500 mg daily is also acceptable. I suggest you start with 1500 mg a day and then if there is no problems in the coming 3 months then you can make it 1000 mg daily. This should not cause any problems.


4. Urine tests can be done once in 12 weeks and blood test only when she develops symptoms of fever and suspected high grade infections.

5. I feel there was contamination of the urine sample tested 12 August 2016. The test result of 16 August 2016 is acceptable.

D mannose should not cause any interactions with primarin.

Hope your query is answered.
Please do write back if you have any doubts.

Regards,
Patient: The article you site above WAS NOT 1500mg twice a day but actually
"1 g 3 times a day, every 8 hours for 2 weeks, and subsequently 1 g twice a day for 22 weeks"
So that information is wrong.
I dont know where you get only 500mg twice a day.
I shall potentially try 1500mg a day vs 2000mg at the risk of a rebound ecoli infection.
In a way, it appears you have some knowledge about this supplement but when articles are poorly cited - it puts all information provided in doubt Dr UK
Doctor: Hi Sir,
Thanks for pointing out the error.

I agree it should have read 1000 mg when citing from the article, it is regretted. I honestly wanted to share the article with you.

It is to be noted that d mannose capsules are available in 500 mg dose to be given to children. Since your mother is 89 years old, therefore taking the lowest dose of 500 mg twice a day was suggested so that the kidney is safe.

However, 1500 mg a day is something which you can try since the kidney function is normal and I pray it works for her and prevents rebound infection.

Regards,
Patient: Can you provide me the article which cites 1000mg a day whether in 1 dose or spilt up in 2 - 500mg. If 1000mg is what is deemed okay for a child but is that not enough for an adult body
Doctor: Hi Sir,
Please find the required information in the link below

https://www.google.ch/patents/US20040147459

It is a patent information and is quoted "The maintenance dosage for prophalaxis is one-half teaspoon (1 gram) 1 to two times per day."

Therefore my previous reply concerning 500 mg twice daily is the same which is mentioned above.

Regards,
Patient: You provided the advice about reducing the mannose from 2000mg daily to 1500mg in a 90 year old woman. I did this for the last 6 weeks. Her last urinalysis on Dec 3rd was negative - I have my own strips. My mothers predominant ecoli symptoms are incontinence, urgency and atypical tingling pain that shoots up to her shoulders when she urinates. The only two symptoms have been a bit of tingling in the vagina and today abdominal fullness which got better by days end. When I did the urinalysis strips this evg
- her leukocytes was negative but the distinctive pink was there for nitrites. I am sending a urine sample tomorrow for culture as my home tests are not 100 percent accurate.
I am hoping she can clear this but doubt it. Also am hoping its not another organism
She had a bad diarrhea last week and whether 2000mg would have been the magic bullet.
Regardless she was about 8 months uti free - your advice???
Doctor: Hi Sir,
Thanks for writing back with an update.

I guess the mannose is working for her. As we are experiencing a winter in Hamilton CA, it is important to know if your mother is taking adequate amount of water and fluids. Inadequate intake can precipitate UTIs in some patients during winter and I guess she is getting enough water each day.

If she has no other specific symptoms then the chances of another organism are less however I support you in getting a urine culture done tomorrow.

Mannose usually does not help in treating diarrhea but is working for the UTIs.

My suggestion is go proceed with the urine culture and take care of her dailg fluid requirements during the winter.

Hope your query is answered.
Please do write back if you have any doubts.

Regards,
Patient: No, I meant she had 2 diarrhea incidents and thus this what may have caused the uti.
She slept through the night. However, her urine this morning was still positive for nitrites
which it hasnt been for months. I am still submitting a urine sample for culture in the event she becomes incontinent or with urgency. My key question hinges on what the maximum mannose would be for a few days to TREAT vs prevent. And mannose is reported to cause diarrhea. And yes, her fluid intake is down in the winter. She drinks apprx 1 litre a day of fluids
Patient: Also the aspect of being positive for nitrites but low count of leukocytes - what constitutes a true infection - both these parameters positive PLUS symptoms.
Doctor: Hi Sir,
Thanks for writing back with an update.

It is possible that a female patient can have UTI following diarrhea due to transmission of bacteria from anal opening to the vagina.

Researches have shown that positive nitrites is specific for an infection in and in 1 percent of cases the result can be false positive in case of asymptomatic patients.

There is information stating that for acute UTI treatment 1 tea spoon d mannose can be given every 3 hours (during the day) for 2 days and 1 teaspoon 3 times a day for 3 days however the credibility of this information is not verified.

For prevention the dose is one-half teaspoon (1 gram) 1 to two times per day which has been stated in a previous reply.

Hope your query is answered.
Please do write back if you have any doubts.

Regards,

Doctor: Please encourage your mother to drink more fluids and water, about nearing 1.5 to 2 litres a day.

Regards,
Patient: So you stated 2grams (teaspoon) every 3 hours during the day - that's 16 grams a day.
That's way too much especially for a senior. Even if its lets say its 15 hours wake times during the day - its 10grams.....sounds way too much.
How can you just provide this type of info again - Also you avoided the aspect if a leukocyte count is low what does that mean if a person is symptom free
Patient: So the lab urinalysis results have come in - 0.3 ethroyctyes, 500 leukocytes and positive nitrites. She had no urgency or incontinence but had the distinctive tingling pain today.
She releases urine and feels this radiating pain extending up. Its been the key symptom for years. She took 1000mg mannose 3 times today. I doubt it will clear it now.
I cannot subject her to higher doses of mannose. A young woman can guzzle down litres of water with sugar but not a 90 year old woman. I am awaiting the urine culture report. Here a urologist has recommended fosfomycin. She took it for over a year preventatively that was 2 years ago. She has never tested resistant for her ecoli to this drug. Nitro causes elevated liver enzymes, cipro seems too strong (tendonitis risk) and Bactrim is no longer effective. I am truly hoping its not another organism and it can be treated with an antibiotic and she resume the 2grams daily mannose. Whether the less 500mg daily made a difference, I don't know. Its been very frustrating as she has endured many ecoli utis over the years due to hygiene with spinal arthritis and having bowel movements
Doctor: Hi Sir,
Thanks for writing back with an update.

I do agree that 10 grams of mannose is too much for your mother an it is good that you have given 3 grams and let us hope for the best outcome. You can take a decision on resuming 2 grams of mannose after 2 more days.

Right now the urinalysis shows 500 leukocytes which is abundant and therefore it is important to wait for the culture report.

Fosfomycin is a good antibiotic and works in many patients.

Treating UTIs in the elderly is a challenge and I would like to share an article on that. Please read it from the link below.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079031/

Regards,
Patient: So my mother had initially signs of a bladder infection on Monday - distinctive tingling symptom - she had been taking 1500mg mannose daily. By Tuesday, it was lab confirmed - positive nitrites, 500 leukocytes, and 0.3 ethrocytes. She took 2500, 3000, 3000mg daily mannose for the last three days. She had no symptoms yesterday, other than a 1 urgency episode. However this morning, my own dipstick test still showed positive nitrites, leukocytes and rbcs (200+). The first day with my own test strip it was only the nitrites. So the lab culture report will be coming in today and most likely ecoli
-how do you balance taking an antibiotic in absence of true historical symptoms but the rbcs seems pretty high. She is resistant to Bactrim and ampicillin already. She is only drinking 1L daily so I don't wish to be giving any additional mannose as discussed before
Thankyou for your advice
Doctor: Hi Sir,
Once the culture report is obtained then we can know the organism and which antibiotics will work best against the bacteria causing the infection. Based on this information we can eliminate bactrim and ampicillin and look forwards are the options we have. It is particularly difficult to choose an antibiotic only based on the RBCs and without historical symptoms. For this the culture and sensitivity report is important and I will not suggest to start an antibiotic without having a look at the report.

She can try increasing water fro 1.0 to 1,5 litres a day for few weeks . This will help flush out the bacteria and antibiotics from her system. You may with hold extra mannose for now.

Regards,
Patient: I can post the culture report once its available...however I imagine it will be ecoli and not hopefully resistant to fosfomycin which I have been given the okay to give...its 3grams at 1 time. However, in lieu of not giving antibiotics too readily, I have held off.
She has no obvious symptoms. Other than the higher rbcs (200) this morning on my urinalysis - is that significant to give ANY antibiotic at this time. Do you understand
Patient: I have posted the culture - so this was collected two days ago. On that morning, my urinalysis showed only positive for nitrites. Their analysis showed both wbc/rbc elevation.
So in the last three days - she has had no obvious symptoms - urgency, loss or the tingling sensation which shoots up into the upper torso when releasing urine. But my primary concern stems on having a high rbcs 200 on this mornings urinalysis which included leukocytes and still nitrites. She has been given today already 2000mg mannose.
The culture report is yet to confirm the fosfomycin but imagine it will still be sensistive
She had it sensitive in one of her cultures a 9 months ago. She tolerates it well. It looks like this ecoli is sensitive to bactrim too again. She doesnt want to take an antibiotic but fosfomycin has been easiest to tolerate but it hasnt been given recently when mannose was used. My primary concern truly hinges even if she has no real symptoms - is the indication of blood.
Patient: Imagine if she does develop symptoms - she will take the fosfomycin but the significance of the blood in the interim. Also I am also careful in not wasting antibiotics and using them carelessly. Her Egfr in June was 65
Patient: Also of note - with a previous ecoli infection, she had blood in the urine which resolved eventually but she was truly symptomatic. She also takes daily 15mg xarelto.
Patient: You are in a different time zone.....my mothers family GP has minimum knowledge of utis and thinks its okay to be incontinent and brushes it off as a nuisance. It takes months to see a urologist in Canada. So my mother will go to bed tonight having only taken 2000 mg mannose after 2 days of 3000mg and first day of 2500mg. I shall take another dipstick test. Blood but with no true symptoms to date..
Patient: My second last comment where it resolved meant - she took 3.5 days of cipro (April 2016) before going on 200mg mannose
Patient: 2000mg mannose..............................
Doctor: Dear Sir,
Thanks for writing back with an update.

I understand your concern about starting antibiotics without real symptoms, the only obvious abnormality being RBCs. The report shows E.coli and probably a second organism which is not clear. If she had a previous UTI caused by E.coli and which was symptomatic, then I suspect this UTI attack to be a milder form of UTI which is showing RBCs but no obvious symptoms.

Mannose can be continued as a supportive treatment. After discussing with your urologist you can start 3 grams of fosfomycin should there be continuing positive dipstick results or appearance of symptoms..

Xarelto does not cause interactions with fosfomycin.

Regards,
Patient: I wont be getting an appointment anytime soon with a urologist for her. He already confirmed that fosfomycin could be given once a uti develops. But that's all under the umbrella - there are symptoms. You provide neutral responses using fosfo for EITHER positive dipstick or symptoms? Which one is it? She was symptom free today and will take another dipstick tomorrow am. I have taken 3 mornings, and today was the 1st with rbcs. I only stated xarelto as the connection if bleeding is more evident then.
I shall give the site here a favourable opinion about you as you have provided a humane response. Canadian public healthcare stinks
Patient: Also how one staggers off the mannose if the fosfomycin is given. My original question was posed about kidney loadings with substances taken as mannose isn't really metabolized in the body. I do strongly believe when my mother took cipro for 3.5 days only in April - she remained uti free for 8 months as she quickly started mannose shortly after or even on her last few doses of cipro consumption. Perhaps the mannose allows the antibiotic to get better at the ecoli than it digging into the bladder walls?
Doctor: Dear Sir,
You can wait until tomorrow and repeat the dip stick test. If RBCs are still found then you can give fosfomycin 3 grams as suggested.

Mannose can be safely continued as a supportive measure.

Since there is no macrosopic hematuria, the connection with xarelto is unlikely.

Thanks for your positive feedback

Regards,
Patient: Isnt there a danger with overloading the kidneys - 2grams mannose PLUS 3grams of fosfo, doesnt this drug linger in the bladder for at least 3 days. Goodnight
Doctor: Dear Sir,
Fosfomycin is eliminated in urine as 38 percent unchanged drug. The elimination half life is around 8 hours and with mild kidney impairment it can go up to 50 hours.
Concerning about mannose and fosfomycin together, the danger for a singe 3 gram dose overloading the kidneys is unlikely.
Good night
Patient: My mothers urinalysis this morning only showed a trace of nitrites but still stronger dipstick reading for leukocytes and rbcs 200's. She reports no symptoms. The urine is cloudy but not truly foul smelling. I know historically with a symptomatic ecoli - she had white fragments almost resembling the white of an egg in the urine sample. She still has no symptoms - to date. The lab wrote wrote just an initial predictory statement that fostomycin should be sensitive but I see results are pending and they will probably confirm today that the ecoli is sensitive. I typically have given her the fosfomycin before she goes to bed. Is there any merit of holding off a day or so more or give the fosfomycin today - tonight. I thought it was positive that the nitrites was a trace but obviously you would know better the significance of the blood reading.
Doctor: Dear Sir,
I see that your mothers infection is resolving slowly. If the nitirites have decreased and the urine had leukocytes and RBCs then there are signs of the infection being under control, besides she is not having symptoms. In this situation you can with hold fosfomycin for another night and then check on the dip stick result tomorrow.

Regards,
Patient: She has no obvious bladder infection but more tired/fatigued. Another doctor advised me once a senior gets a bladder infection - they will not be able to clear it themselves unless an antibiotic is given. I don't want her to belabour in the bigger pix but realize after 5 years with over 20 utis - all ecoli. That antibiotics are not to be dispensed like candies. I am hoping she can clear this by herself with the mannose. You are the first global doctor who has recognized this sugar as a potential aid. We will see tomorrow
Doctor: Dear Sir,
Thanks for your words.

I support your views that giving an antibiotic every time will increase the tendency of resistance and this will mean the bacteria is getting more stronger after each cycle of antibiotics.

Your mother seems to be having an uncomplicated UTI and therefore of she is responding to mannose and the test results are improving then we should make use of the full potential of non antibiotic treatment.

A single dose of fosfomycin can be given if she starts getting symptoms. Till then you can wait and watch. I am hoping the mannose she is taking will benefit her and help in complete resolution of the infection.

Regards,
Patient: Hello - you dont have to call me Sir....I realize you get paid peanuts for providing guidance.
Your only reward is that you are helping a 90 year old lady somewhere in the world so hopefully you get have some good fortune cast upon you. I truly wish I wouldnt have to be solving this online. My mother drank about 1.25 litres today and didnt have the urge to urinate for 5 hours where she released quite a volume of urine at that point..... I knew thus the urine had been in the bladder a few hours and thus the nitrite parameter would be more accurate. So this morning, it appeared to be a "trace" but tonight it was a darker shade between trace and positive. Same higher levels for RBCs - but that coloured square
was instead of 200 was half a shade lighter green indicating perhaps 80 to 200. How truly accurate the dipstick tests are or my specific brand? I know on Monday the lab identified both wbcs/rbcs and nitrites and mine only showed nitrites. Regardless what stock value the tests are? So again - she is symptom free to this point. I know back in APril when she first started mannose, she was still getting over another ecoli episode. She was nitrite postive for a week based on the dipstick and eventually became symptomatic.
So if no symptoms appear - the readings of higher rbcs can continue for a few more days?
It would be day 4 if Tuesday was the first day. I did cease the 15mg xarelto this evg. Cardiologist has given approval for other reasons for up to 3 days - you indicated it wouldnt be related. If one didnt have the dipstick tests - you wouldnt know otherwise
Since she has no real symptoms - she doesnt take it serious to drink a bit more fluid
Anyhow, goodnight
Patient: Also the last two days have only been 2000mg mannose whereas the two days before were 3000mg. What I have read from younger women they do in fact load up with much higher quantites and with larger water amounts.......its simply not going to happen with my mother
Patient: I have posted a new question - can you please answer. So two urinalysis tests were done this morning - one is negative for nitrites and then again a trace. However the rbcs is still 200 and you can see the pinkish stain in the urine....
Doctor: Hi,
Thanks for writing in.

From the observations in the two tests, it is good to know that the nitrites have decreased. The important thing is that she is not having symptoms and it means the infection by e coli is uncomplicated.

The RBCs in urine can be from injury of the urinary tract by bacteria. If there is no increase in RBCs then the situation is stable and she might be resolving.

Holding the bladder for 5 hours is bit too much. In the day she can void rhe bladder every 3 hours and this will help recurrent infection.

The error in dip stick can range from 5 to 10 percent.

Regards,
Patient: So thankyou for responding back. I entered some additional information on a new question but you may not have access. At 430am this morning - her nitrite was negative but rbcs was 200. By 9am apprx - the nitrite was a trace and rbcs was also 200. I imagine you are familiar with the test strips. The next stage is non-hemoloysis (sp>)
What bothers me is that the urine sample really had a pink tinge to it. She urinated just in the last 30 minutes but wasn't able to see the toilet bowl and it was a large void. She used to take estrogren cream regularly but not as much. The fosfomycin was confirmed to be sensitive. So you inferring unless she has real symptoms -no need to provide. She will get her second 1000mg mannose dosage in the next few hours. I simply don't know if the situation is stable. She has no pain as I mentioned otherwise. I recall over a year ago when she had a full fledged uti infection when she was on vitamin c and then took the fosfomycin, it caused some irritation when urinating. If I didn't have the strips - one wouldn't know any better. She is 90. Its also the weekend and local hospitals are housed with interns that have no true knowledge of urinary issues
Patient: So you inferred before - if one has a uti, taking xarelto would not worsen it during that time. Doesn't a blood thinner increase bleeding even at this level. Is applying topical estrogen at this time recommended as well? She has an incident of blood spotting a few months ago which was attributed to vaginal dryness and a blood drop was noticed in the underwear. But imagine this is more internal...hopefully you can provide more insight to this overall and what "stable" meant. I am only going to make her do 1 urine sample a day. The toilet bowl upon her last urination had no distinct pink or red tinge to it.
She was given today 2 - 1000mg mannose doses and no fosfomycin.
Patient: Hello? A number of hours have passed by - thankyou!
Patient: So you are aware, I paid additional funds today to ask for you. However apparently they locked the new question and this question remains open as it contains all the historical info
Patient: Will you be assisting......
Doctor: Hi,
Thanks for writing back with an update.

You can continue this thread.

By stable I meant the dip stick parameters are not worsening day after day.

Application of estrogen is recommended to prevent recurrent UTIs. This takes care of thinning mucosa in the genital tract of elderly women.

In UTI the RBCs are found due to elimination from tiny blood vessels during infection by e coli. As such this will not be affected by xarelto.

I guess mannose is working for her and controlling the infection.

Regards,
Doctor: Please write back with your additional questions on this thread.

Regards,
Patient: I imagine you are familiar with the strips. The RBCS is the third one from the far right. The far right is the most severe - instead of a green square - its a yellow square with green specks. So are you inferring if she has no symptoms to the urinary tract - she could continue to have high rbc's (200) for a few more days. Theoretically, if the nitrites are getting less, the ecoli are reducing in numbers but she is a 90 year old woman and not a 20 year old. Can estrogen be applied at this time - doesn't she have technically an open wound somewhere.
Doctor: Hi,
I have got the new query unlocked and given my reply over there.

You may post new queries in the new thread.

For your information, the answer to the above last query is as follows.

You have written:
I imagine you are familiar with the strips. The RBCS is the third one from the far right. The far right is the most severe - instead of a green square - its a yellow square with green specks. So are you inferring if she has no symptoms to the urinary tract - she could continue to have high rbc's (200) for a few more days. Theoretically, if the nitrites are getting less, the ecoli are reducing in numbers but she is a 90 year old woman and not a 20 year old. Can estrogen be applied at this time - doesn't she have technically an open wound somewhere.
....................................................................................................

I understand you are talking about non hemolyzed blood in urine which is seen as yellow with green specks and in probably between the moderate and severe ranges which is between 50 and 200 RBCs. Therefore you can continue to monitor over the weekend and look for improvements.

Estrogen can be applied now.

Hope your query is answered.

Regards,



Patient: So she is in actually the worst category with 200 plus RBCs - I thought the further you go to the right, the worse the count. You are advising otherwise. I never knew this but I don't understand non-hemolyzed vs hemolyzed. I hope that the higher blood count somehow doesn't create a false negative for the nitrites with some cross interference.
So internal bleeding even if painless cant be good in the long run in the urinary tract.
Doctor: Hi,
Thanks for writing back with an update.

Non hemolyzed blood is found in UTIs where the hemoglobin in RBCs is intact.

Urine dipsticks can differ from one manufacturer to another. Therefore it is best to refer to the package for accurate interpretation of results. What I have mentioned is a general information followed in most clinics.

There can newer dipsticks with a wider spectrum of low to high categories for RBCs in urine and it is requested that you cross check this point.

Please find a sample urine dipstick chart using the link below

http://learn.parallax.com/support/reference/urinalysis-test-strip-color-chart

You will find a similar chart in the urine dipstick container.

You can see green specks on yellow can mean trace (if few) or moderate (if many)

Blood count usually will not interfere with nitirites.

Internal bleeding is not good and needs to be controlled and treated aggressively if persisting beyond a week.

Regards,
Patient: So another urinalysis this morning showed negative nitrites, trace or negative leukocytes but solid dark green 200+ for RBCs. As to remind you - on the day of the lab sample - they reported 0.3 ethrocytes, 500 leukocytes and positive nitrites whereas my strip was only positive for nitrites. It was only til Thursday where my daily urinalysis strip showed leukocytes and the 200+ RBCs. So its been 4 consecutive days for the RBCS with my strips.
I have 2 other lab sample forms from the urologist who has seen her a few months ago but it takes months to see him. I could take another urine sample tomorrow and submit and request a followup but there is no gurantee...her family GP has limited knowledge.
I dont know how ethrocytes reporting compares with the rbc count on mine. I know on Dec 13ths lab submission, the urine didnt have that pink tinge as it has now. Its not a coca cola darkness but the urine is different than early in the week. My mother also had a diarrhea incident yesterday and since I do the laundry is why she gets these utis.
Is there any merit in giving the fosfomycin at this point? How would the bleeding be stopped exactly and identified from where? The weather is poor today and the local ERs have young doctors who have no real knowledge than just administer a random antibiotic
Patient: You also have stated xarelto has no impact. It was taken Friday night but resumed yesterday
Patient: It WAS NOT taken Friday night - correction
Patient: Hopefully you can answer today on Sunday -thankyou
Patient: She seems overall more tired today and doesn't wish to go to an urgent care clinic today either..
Doctor: Hi,
Thanks for writing back with an update.

Since she is feeling bit tired today, it is important to give her adequate liquids and water. The reason for feeling tired can be inadequate fluids, an increase in the intensity of infection or the weather itself. If there have been RBCs for 4 consecutive days then giving fosfomycin 3 grams might help.

Regards,
Patient: Dr Kumar - I realize you probably don't get paid much for answering these questions.
I would have appreciated your guidance today. My mothers initial urinalysis tests
this morning were negative for wbcs and nitrites. But tonight again, it showed strong 200rbcs and returning trace of nitrites and leukocytes. SHe also had pink staining in her underwear. So to rule on the side of error - fosfomycin was given. Another online doctor stated that xarelto may indeed increase bleeding if a uti is experienced. I had no other choice to give her the sachet. Hopefully things calm down. You are still a young guy, I presume. It shows
Doctor: Hi,
If the nitrites and leukocytes are returning with a strong number of RBCs think you have done the right by giving fosfomycin. There is a chance of the infection flaring up. Hopefully fosfomycin will fight out the bacteria since it is sensitive.

Regards,
Patient: Thanks for responding back today. I shall be calling the Urology clinic tomorrow. Another online source stated today - that the blood thinner itself is the reason.
She had bleeding last April too with a symptomatic ecoli. Whether its a lingering ecoli or the blood thinner which was stopped today again. I saw the toilet bowl had a stronger pink tinge. What has to be done now exactly diagnostically and what did you mean bleeding to treated aggressively
Doctor: Hi,
Thanks for writing back.

Good to know that you are calling the urology clinic tomorrow.

Blood thinners usually cause a severe bleeding and since there are nitrits and leukocytes on the rise, I feel the return of the infection is a more likely cause. The blood thinner possibility is rare in my opinion.

Diagnostically, she may require another lab confirmation of infection or any improvement from the previous result. Treating aggressively means giving the antibiotics to which any growing bacteria is maximally responsive.

Please write in your next follow up in the new thread. This is a directive I have received from the support team.

Thanks,

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