Question: Hello
I am posting this as a new inquiry

About two weeks ago my mother had mild bladder symptoms.
She had positive for nitrites/leukocytes
Her symptoms resided as the week went on but her rbcs were 200 more and pink tinge to urine in toilet bowl.
A lab culture showed ecoli sensitive to fosfomycin.
She was given this past Sunday and her 15mg xarelto was stopped.
Within three days or this past Wednesday, she was negative for rbcs, wbcs and nitrites.
She resumed xarelto Wednesday evg and the preventative 2000mg mannose.
As of this morning, her urinalysis was negative for rbcs but positive for nitrites and leukcocytes - she has no symptoms.

How do you handle this?

Dr XXXXXXX

She took the fosfomycin this Sunday.
She was negative then for nitrites, wbcs for 2 consecutive days.

And it took three days for the rbcs to be negative?

Are you implying this is still from the previous infection?
Or is the beginning of a new one?

I think its the latter.

The primary reason she was given fosfomycin was the rbcs which was not resolving. Was it the ecoli infection or the xarelto

If she has no real symptoms now - I imagine the rbcs will become an issue again.

She had an ecoli back in April - it was treated 10 days nitro and 4 days later another sympt ecoli which was still sensitive to nitro

I dont wish to be giving her antibiotics easily

She was months symptom free with 2000mg mannose. It helps to prevent but not treat

I think this new episode is going to build again like it did over a week back.

She might hopefully not have any symptoms but will have high RBCS which wont resolve on its own?

No one can provide a clear answer on the significance of the xarelto.

She was off it for 3 days on Sunday and I dont wish to keep her off it either long
but she resumed Wednesday

Hopefully it was a typo on your part.
Leukocytes don't produce nitrite but is the actual ecoli that produce nitrites from nitrates

I went to see the family doctor as the local uro is a surgeon who finds ecoli infections trivial.

Family doctor gave a prescription for nitro.
I havent given it yet.

As of this afternoon, she is still positive for nitrites/leukocytes but no rbcs
which was the primary concern before the fosfomycin was given.

Your primary comment hinged ON that the urinalysis results today are from last weeks episode - I say its a new one or beginning of new one
But at this point - no nitro.

I am hoping she remain symptom free but a 90 year old shouldnt be having pink stained urine indefiintely

Dr XXXXXXX

My mother has atrial fib - she was off three days off the xarelto.

SHe is still symptom free to date and no RBC's

However there is the nitrites/leukocytes -

How can you get two days negative for these 2 parameters and then positive again
You are inferring its from last weeks episode????

She stopped xarelto for 3 days and has been back the last three days.

I thought temporarily stop the xarelto again to prevent the bleeding

I dont wish to give the antibiotic but perhaps have no other choice.

I am hoping with 40 years of experience you have seen all situations.

My point is - I dont think she will have symptoms.

However will she now develop blood in the urine.
And being proactive stopping the xarelto now.
It has already been taken tonight because there are no RBCS

However, ceasing it - hoping she can eventually beat this 2nd ecoli episode
solo without a 2nd antibiotic

Do you understand the mechanics of this

Thankyou for your insight.

My mother only drinks 1 to 1.25 litres fluid daily and we have daily arguments about this

My mother has been fortunate to have been uti symptom free for 8 months - mannose I imagine.

However this past weeks episode had no lagging symptoms - incontinence, urgency, radiating pain.

ONLY was the elevated RBCS and pink urine about 6 days in.
Fosfomycin was given and xarelto stopped.
She was ALL CLEAR only two days ago for all applicable parameters.

Today, leukocytes and nitrites...
So if the key problem is bloodloss - I thought ceasing xarelto would have merit.

You inferred an antibiotic would be needed a second time

But you also stated in your first entry - this might just be remnants of the first fofsomycin episode.

I simply dont wish to over-use antibiotics as even though the culture report from Dec 13th only had two resistant antibiotics - she has had in the last 5 years wher almost all the antibiotics lost their effectiveness.

Do you understand Dr P

I contacted a hospital uro clinic to discuss this and got brushed off because of the holidays.

Stay clear of Canada!

I guess the next day will tell.

You believe the nitrites/leukocytes are from last weeks episode.
I think its the beginning of a new one.

Why have two days of negative readings and then all of a sudden - its back.

A new culture was taken today already.

If the urinalysis shows high RBCS - then guess nitro will have to be used which I have.

I have strong beliefs in the mannose but it may prevent, it wont eliminate it once it sets in.

Like I mentioned before, this is one of the first episodes she had no true symptoms other than the blood.

Anyhow, thankyou for your opinion. I hope you are correct with the remnants arugument.

Its truly tough to deal with a 90 year old health care needs in a system thats broken. Goodnight sir

I have uploaded the 2nd urine sample yesterday

Is the nitrites/leukocytes - vaginal contamination

But I had two similiar urinalysis strips yesterday

Neg - RBCS
Positive- Nitrites/Leukocytes

The toilet water this morning still had no pink as was the case about a week ago

Thankyou

Correction this morning - the toilet water had no pink tinge today contrary to last week which it did. Then the fosfomycin was given.
The urinalysis strip was still negative for rbcs this morning but positive for the nitrites/leukocytes. But visually the urine sample looks a bit better than yesterday.
I shall hold off the nitro for the time being but your insight to the significance of the urine microscopy

Dr XXXXXXX
You helped out over a week back.
Unfortunately this site did not allow me to post more questions.

As you may recall the 1st ecoli episode was not resolved by the fosfomycin.

Though the nitro has suppressed the ecoli since Dec 25th and xarelto was stopped for three days, after it was begun again for 1 evg, she showed hemolyzed rbcs 200plus the following morning. She has now been off the xarelto for three nights
and the morning urinalysis Dec 30,31, Jan1st have been negative.
However she has been on and off xarelto three times now since Dec 19th.
Another online source has stated stay off it for 5 consecutive days
You made the initial comment that a weeks time would not be a big concern

However, I dont know if the combination of days on and off make a big difference.
I am getting paranoid about this as far as the atrial fib risk

I have chronicled the events below

Dec 13 - Mild bladder symptoms - Urine sample taken with culture
showing > 100 * E6 cfu/L and sensitivity to fosfomycin and
nitrofuran, lab urinalysis showing already 0.3 mg/L ethrocytes
Bladder symptoms resolve within a couple of days

Dec 18 -Home urinalysis strips showing 200 RBC's,
nitrites/wbcs positive - brown urine
Fosfomycin 3grams given, xarelto 15mg stopped

Dec 21 -Nitrites and rbcs negative, xarelto resumed after 3 days

Dec 23 -Nitrites/leukcocytes positive, rbcs negative
Urine culture shows same high ecoli count and sensitivity
to fosfomycin/nitrofuran later on

Dec 25 -RBC >200, strong pink urine tinge, Nitrofuran 200mg daily started for 10 days
Xarelto stopped again

Dec 28 - RBCs, Nitrites, WBCs - Negative, Xarelto resumed

Dec 29 Nitrites/WBCs - negative, RBCs >200, brown urine
Stop xarelto

Dec 30, Dec 31st - Urinalysis negative for all parameters

Dr XXXXXXX
I see the family doctor tomorrow. Urology clinic - who knows when they show interest. I respect your opinion as I imagine with a few decades worth of experience - you have seen a few issues.
Two other online cardiologists mirror the same 7 day window to stay off the blood thinner to let the tissue heal.

However, one younger urologist inferred that the pink or brown tinged urine regardless of the > 200 RBC count is not significant. Gross hematuria is really only true blood (red) coming out with pain which would warrant stopping the blood thinner regardless of the cardiac risk.

He implied it would settle on its own.

My mother basically had two bouts since Dec 13th where the original fosfomycin sensitive eoli resurfaced and then treated with nitro. It appeared the second round of blood tinge came on stronger/faster.

She began the nitro and ceased the xarelto for three days where rbcs were negative. She began the 15mg in the evg again and by morning, the urine was brown tinged with 200 plus RBCs

Did that warrant then ceasing what is now day 5 without it. As the urine rbcs was again negative only 1 day after stopping it which seems also a bit unusual
that it went from 200RBC to negative within 1 day.

Anyhow, imagine your experience implies you dont gamble that pink tinged urine could all of a sudden become true blood.

I am going to receive criticism tomorrow from the family doctor I imagine.

goodnight