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Suggest Treatment For High Grade UTI And Lower Back Pain
Question: I am a 59 year old post menopausal woman who developed a high grade UTI (leukocytes 500, nitrites greater than 100,000, and blood in urine). I have not had a UTI since age 28 nor have I taken an antibiotic to treat any illness since 1992. The physician who evaluated me for the UTI prescribed Macrobid (100 mg./2 per day). After finishing a seven day (yesterday--12.21.15), I continued to feel discomfort (I believe emanating from the urethra and perhaps bladder). Another 7 days of Macrobid were dispensed. I had a urinalysis done 12.18 which showed leukocytes down to 75 and no nitrites or blood. I do not wish to continue the antibiotic any longer than necessary (taking probiotics) and am wondering if the discomfort I continue to experience is due to residual inflammation. The lower back pain that I was experiencing upon diagnosis has largely resolved. I am concerned that I have developed interstitial cystitis. Any guidance offered would be greatly appreciated. Thank you! Bea
Brief Answer:
Before considering interstitial cystitis, it is important to get a culture.
Detailed Answer:
Hello and welcome,
I'm sorry you are still having trouble after the course of Macrobid. You mentioned a couple of urinalyses but no culture. It's possible that the causative bacteria is only partly sensitive to nitrofurantoin so that you have a low grade UTI.
It is best, when you have signs and symptoms of a UTI to get, in addition to a urinalysis, a "culture and sensitivity" test. The culture grows out whatever bacteria are present and identifies the causative bacteria. The sensitivity test uses several antibiotics against that bacteria and provides a rating of "sensitive", "intermediate/partial" and "resistant". In this way, the most effective antibiotics can be used.
A culture and sensitivity should DEFINITELY be done if you have any symptoms of pyelonephritis (low back or flank pain, fever, nausea). Nitrofurantoin (Macrobid) is not a good choice for pyelonephritis.
At this point a culture and sensitivity may not be as accurate as there may not be enough bacteria present for the test to work, but if it hasn't been done previously, ask for a culture and sensitivity to be done anyway. The best timing for this is 1- 2 weeks after you are off of antibiotics. You may still have a low grade infection. I would explore this before considering interstitial cystitis.
A few thoughts, now that you are sexually active:
- If you get recurrent UTIs or urethritis or have considerable vaginal dryness, consider talking with your doctor about topical estrogen (Estrace cream) or vaginal suppository. After menopause, there is increased susceptibility to getting UTIs, and topical estrogen can increase the health of genitourinary tissues, making you more resistant to infections.
- Urinate as soon as you can after intercourse to flush out bacteria that may have gotten into the urethra.
- Consider giving your bottom a quick rinse after intercourse to help remove semen and bacteria that may be near your urethra and may be an irritant.
- Consider taking cranberry powder supplements. Or drink a lot of cranberry juice. But I recommend making your own or use concentrate and reconstitute with water and apple juice. In this way you'll avoid the excessive sugar that are in products like Ocean Spray.
Before considering interstitial cystitis, it is important to get a culture.
Detailed Answer:
Hello and welcome,
I'm sorry you are still having trouble after the course of Macrobid. You mentioned a couple of urinalyses but no culture. It's possible that the causative bacteria is only partly sensitive to nitrofurantoin so that you have a low grade UTI.
It is best, when you have signs and symptoms of a UTI to get, in addition to a urinalysis, a "culture and sensitivity" test. The culture grows out whatever bacteria are present and identifies the causative bacteria. The sensitivity test uses several antibiotics against that bacteria and provides a rating of "sensitive", "intermediate/partial" and "resistant". In this way, the most effective antibiotics can be used.
A culture and sensitivity should DEFINITELY be done if you have any symptoms of pyelonephritis (low back or flank pain, fever, nausea). Nitrofurantoin (Macrobid) is not a good choice for pyelonephritis.
At this point a culture and sensitivity may not be as accurate as there may not be enough bacteria present for the test to work, but if it hasn't been done previously, ask for a culture and sensitivity to be done anyway. The best timing for this is 1- 2 weeks after you are off of antibiotics. You may still have a low grade infection. I would explore this before considering interstitial cystitis.
A few thoughts, now that you are sexually active:
- If you get recurrent UTIs or urethritis or have considerable vaginal dryness, consider talking with your doctor about topical estrogen (Estrace cream) or vaginal suppository. After menopause, there is increased susceptibility to getting UTIs, and topical estrogen can increase the health of genitourinary tissues, making you more resistant to infections.
- Urinate as soon as you can after intercourse to flush out bacteria that may have gotten into the urethra.
- Consider giving your bottom a quick rinse after intercourse to help remove semen and bacteria that may be near your urethra and may be an irritant.
- Consider taking cranberry powder supplements. Or drink a lot of cranberry juice. But I recommend making your own or use concentrate and reconstitute with water and apple juice. In this way you'll avoid the excessive sugar that are in products like Ocean Spray.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Berger-Durnbaugh,
Thank you for the thorough reply to my inquiries/concerns. Both urinalyses were cultured and the offending bacterium is e. coli, which I understand Macrobid efficiently targets.
Regarding pyelonephritis, when I was initially seen at the urgent care two Sundays ago, I was experiencing lower back pain. The physician who examined me palpated my bladder, which was tender (more so on the right side). He also palpated my kidneys, which were not reactive to touch (i.e. no pain).
Normal body temperature for me is 96.6, but I felt fevered during the initial visit and the nurse reported a temp of 98.1. That evening and again yesterday, I spoke with the urgent care physician and inquired about whether or not he thought the infection had gone to one or both kidneys. He did not think this was the case.
I do not have a fever today and the highest my temperature XXXXXXX was a week ago Monday--99--after two doses of Macrobid. For several days it hovered around 97.8 or so. I stopped taking Ibuprofen last Monday because I awoke with an elevated heart rate, which I presumed was likely linked to an Ibuprofen-induced rise in BP.
As of this evening, the lower back pain has largely subsided, but I just now felt my back for kidney sensitivity to touch and do notice sensation on the right side beneath the ribs. I can't say it is 'pain.' That having been said, I left work early today because of the urethral pain I have described and have been sitting in bed working on my computer for a considerable length of time. Absent a fever, nausea, or vomiting, may I assume that my position in bed has not been the best in terms of muscle support and accounts for what I described above? I also feel a similar sensation in my upper back beneath my shoulder.
My questions for you follow:
1. With an e. coli count > 100,000, leukocytes at 500, and blood in the urine (outcomes of the first urinalysis) and then leukocytes down to 50 and nitrite count at 75 Friday (second urinalysis--12.18), is the pain I have described attributable to residual inflammation? Pyridium helps, but yesterday and today I have tried to reduce my intake of it, in part to gauge my pain and establish from where it is coming.
2. Is it safe to assume I do not have pyelonephritis?
3. Given my severe sensitivities to penicillin and cephalosporins, which antibiotic would be best to treat pyelonephritis? I am also very attentive to the safety profiles of all drugs, especially those that are hard on the liver and are known to cause Stevens-Johnson in some cases.
4. For how much longer should I continue the Macrobid? I have read about the pulmonary issues this drug can cause (tops the list of side effects on WebMD). I am a non-smoker and have not had influenza or any other respiratory infection since 1992. I am looking for some kind of metric regarding my vulnerability to this side pneumonitis if I take six days' more Macrobid.
Again--thank you in advance for your careful consideration of my questions/concerns. Looking forward to your guidance.
XXXXXXX (Bea)
Thank you for the thorough reply to my inquiries/concerns. Both urinalyses were cultured and the offending bacterium is e. coli, which I understand Macrobid efficiently targets.
Regarding pyelonephritis, when I was initially seen at the urgent care two Sundays ago, I was experiencing lower back pain. The physician who examined me palpated my bladder, which was tender (more so on the right side). He also palpated my kidneys, which were not reactive to touch (i.e. no pain).
Normal body temperature for me is 96.6, but I felt fevered during the initial visit and the nurse reported a temp of 98.1. That evening and again yesterday, I spoke with the urgent care physician and inquired about whether or not he thought the infection had gone to one or both kidneys. He did not think this was the case.
I do not have a fever today and the highest my temperature XXXXXXX was a week ago Monday--99--after two doses of Macrobid. For several days it hovered around 97.8 or so. I stopped taking Ibuprofen last Monday because I awoke with an elevated heart rate, which I presumed was likely linked to an Ibuprofen-induced rise in BP.
As of this evening, the lower back pain has largely subsided, but I just now felt my back for kidney sensitivity to touch and do notice sensation on the right side beneath the ribs. I can't say it is 'pain.' That having been said, I left work early today because of the urethral pain I have described and have been sitting in bed working on my computer for a considerable length of time. Absent a fever, nausea, or vomiting, may I assume that my position in bed has not been the best in terms of muscle support and accounts for what I described above? I also feel a similar sensation in my upper back beneath my shoulder.
My questions for you follow:
1. With an e. coli count > 100,000, leukocytes at 500, and blood in the urine (outcomes of the first urinalysis) and then leukocytes down to 50 and nitrite count at 75 Friday (second urinalysis--12.18), is the pain I have described attributable to residual inflammation? Pyridium helps, but yesterday and today I have tried to reduce my intake of it, in part to gauge my pain and establish from where it is coming.
2. Is it safe to assume I do not have pyelonephritis?
3. Given my severe sensitivities to penicillin and cephalosporins, which antibiotic would be best to treat pyelonephritis? I am also very attentive to the safety profiles of all drugs, especially those that are hard on the liver and are known to cause Stevens-Johnson in some cases.
4. For how much longer should I continue the Macrobid? I have read about the pulmonary issues this drug can cause (tops the list of side effects on WebMD). I am a non-smoker and have not had influenza or any other respiratory infection since 1992. I am looking for some kind of metric regarding my vulnerability to this side pneumonitis if I take six days' more Macrobid.
Again--thank you in advance for your careful consideration of my questions/concerns. Looking forward to your guidance.
XXXXXXX (Bea)
Brief Answer:
Here are some answers:
Detailed Answer:
Hello Bea,
I'll respond to each question:
1. If I understand your history correctly, the second urinalysis and culture was done less than a week from when you finished the Macrobid. So that may make it inaccurate to evaluate whether bacteria are causing the inflammation (elevated white count). Regarding interstitial cystitis, given that you had a bacterial cause to this initially, I would still go with that it is either not adequately treated yet, or there is residual post UTI pain. For a diagnosis of interstitial cystitis, you need a cystoscopy and usually we see if there are chronic symptoms particularly lasting 6 or more weeks. But we don't always wait for that to evaluate for interstitial cystitis: if you have recurrent urinalyses and cultures with just elevated leukocytes and no bacteria, then it would be time for a referral to a urologist. Here is some information that might help: http://www.aafp.org/afp/2001/1001/p1199.html There are other causes for urinary tract inflammation/elevated urinary white blood cells, too, other than interstitial cystitis.
2. It's hard to say if you initially had pyelonephritis - if you did it would have been mild as people with kidney infections usually feel pretty ill. Without fever or nausea now, and without a deep ache right in the kidney area, I think pyelonephritis is less likely.
3. Antibiotics that treat pyelo, that are not penicillins or cephalosporins, are fluoroquinolones, carbapenems, and aminoglycosides. I would skip the aminoglycosides as they have a high risk of side effects. The fluoroquinolones, such as Ciprofloxin, have a lower rate of side effects, but are not without risks. There is some resistance to fluoroquinolones, so it would have to be one that was originally effective on the sensitivity test of your first culture.
4. Regarding the statistical risk of pulmonary complications from Macrobid, I had a hard time finding relevant numbers and would advise you talk with a pharmacist at the pharmacy where you got your prescription filled. If you call and tell them what you are looking for and that they can look it up and call you back when they have time, most will do so. Ask if there is data to show reaction rates in different age groups, or other variables that increase the likelihood of pulmonary complications. And if there is data on the duration of taking nitrofurantoin when these complications occurred. They have access to databases and manufacturer information that I don't. I do know that pulmonary problems from nitrofurantoin are considered rare.
5. From what you wrote, it sounds like the Macrobid helped lessen the white count and nitrites, blood in the urine, but did not actually make the symptoms better? Or made the symptoms somewhat better? If the pharmacist does not give you frightening data, and I don't think it will be frightening for a 14 day course of Macrobid, I would continue it for the duration your doctor recommended which I imagine was another 7 days. But if after a few more days on it you find that you are still having considerable urinary pain and no improvement, it is time to talk with your doctor again.
Here are some answers:
Detailed Answer:
Hello Bea,
I'll respond to each question:
1. If I understand your history correctly, the second urinalysis and culture was done less than a week from when you finished the Macrobid. So that may make it inaccurate to evaluate whether bacteria are causing the inflammation (elevated white count). Regarding interstitial cystitis, given that you had a bacterial cause to this initially, I would still go with that it is either not adequately treated yet, or there is residual post UTI pain. For a diagnosis of interstitial cystitis, you need a cystoscopy and usually we see if there are chronic symptoms particularly lasting 6 or more weeks. But we don't always wait for that to evaluate for interstitial cystitis: if you have recurrent urinalyses and cultures with just elevated leukocytes and no bacteria, then it would be time for a referral to a urologist. Here is some information that might help: http://www.aafp.org/afp/2001/1001/p1199.html There are other causes for urinary tract inflammation/elevated urinary white blood cells, too, other than interstitial cystitis.
2. It's hard to say if you initially had pyelonephritis - if you did it would have been mild as people with kidney infections usually feel pretty ill. Without fever or nausea now, and without a deep ache right in the kidney area, I think pyelonephritis is less likely.
3. Antibiotics that treat pyelo, that are not penicillins or cephalosporins, are fluoroquinolones, carbapenems, and aminoglycosides. I would skip the aminoglycosides as they have a high risk of side effects. The fluoroquinolones, such as Ciprofloxin, have a lower rate of side effects, but are not without risks. There is some resistance to fluoroquinolones, so it would have to be one that was originally effective on the sensitivity test of your first culture.
4. Regarding the statistical risk of pulmonary complications from Macrobid, I had a hard time finding relevant numbers and would advise you talk with a pharmacist at the pharmacy where you got your prescription filled. If you call and tell them what you are looking for and that they can look it up and call you back when they have time, most will do so. Ask if there is data to show reaction rates in different age groups, or other variables that increase the likelihood of pulmonary complications. And if there is data on the duration of taking nitrofurantoin when these complications occurred. They have access to databases and manufacturer information that I don't. I do know that pulmonary problems from nitrofurantoin are considered rare.
5. From what you wrote, it sounds like the Macrobid helped lessen the white count and nitrites, blood in the urine, but did not actually make the symptoms better? Or made the symptoms somewhat better? If the pharmacist does not give you frightening data, and I don't think it will be frightening for a 14 day course of Macrobid, I would continue it for the duration your doctor recommended which I imagine was another 7 days. But if after a few more days on it you find that you are still having considerable urinary pain and no improvement, it is time to talk with your doctor again.
Note: For further queries related to kidney problems and comprehensive renal care, talk to a Nephrologist. Click here to Book a Consultation.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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