TomTom update -- pyelonephritis

I just spoke to the university vet and TomTom's diagnosis is pyelonephritis. (Original thread: viewtopic.php?f=29&t=1862 )

He has discharge from the area which is bacterial in nature; they took a swab. The C&S from the most recent cysto is pending but is already growing something -- it appears to be either staph or enterococcus -- and there's concern that it might be antibiotic resistant (since his last blockage in July 09, Tom has been on multiple courses of antibiotics including clavamox, baytril, and gentomycin). We should know more in the next 24-48 hours.

He's still in ICU on fluids, but the urinary cathether has been removed as he started leaking around it. He's urinating freely now but is leaking urine steadily.

He is still not eating well and his attitude is somewhat depressed. His blood panel still shows normal liver enzymes and the doc is talking about a possible appetite stimulant.

He's staying in ICU for a few more days for monitoring and so that we can start IV antibiotics as soon as the culture results are back. He presents a potential risk to my Cushing's dog in the interim, especially if the bacteria is antibiotic resistant, so he's staying at the university until they get definitive answers.

I'm kicking myself as I knew something was up with Tom the last few months and that I should probably pursue more detailed diagnostics. But, my vet doesn't do cystos and TomTom, being a stray whom I never intended to keep, kept getting relegated to the bottom of the to-do list. Charlie had multiple issues that required micromanaging, Chip was being difficult, I have a dog with Cushings who was requiring attention, another dog with liver disease and two forms of cancer who recently underwent surgery...so I simply went with the doc's recommendations to fly blind on giving antibiotics even though I know better. *smacking self on side of head*

Does anyone have experience with pyelonephritis? If so, I'm interested in your thoughts and experiences. And, as usual, good thoughts are greatly appreciated.

Yeah, I guess TomTom is officially here to stay now.

(((JL)))

I have no specific experience, but a quick search of the old board revealed that 1.) Linda and Bear has been dealing with it, and 2.) Jojo gave her this link about a year ago: http://www.merckvetmanual.com/mvm/index ... 130503.htm. Maybe that will contain some helpful information?

Robin had to deal with it with both Tigger and Nikita, and here are two of the threads in which she discussed it:

http://www.felinediabetes.com/phorum5/read.php?8,771008

http://www.felinediabetes.com/phorum5/read.php?8,179536

-- Janet

He has discharge from the area which is bacterial in nature; they took a swab.

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?? What area? Did they scope his bladder and see discharge from the ureters?

Where/what did they swab?

I am curious....did they talk about doing a renal aspirate?

Maybe this is all on the old thread....sorry if it is!

Lisa dvm said:

He has discharge from the area which is bacterial in nature; they took a swab.

Click to expand...

?? What area? Did they scope his bladder and see discharge from the ureters? Where/what did they swab?

Click to expand...

From the prepuce area. That's the area they swabbed. I went to look up the spelling of the word and never came back and inserted it into the sentence...

No, they haven't scoped him yet...nor has it been recommended. The C&S that was run on the initial sample (upon admittance) didn't grow anything, but he had just received a gentomycin injection 24 hours earlier, so that might have impacted the results. The sample they pulled via cysto yesterday is what is growing something. They also did an abdominal US yesterday, which is one of the sources for the pyelonephritis diagnosis.

Lisa dvm said:

I am curious....did they talk about doing a renal aspirate?

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Not today. It was mentioned in passing by the ER vet upon admittance, but at that point we only knew he was blocked and were talking hypotheticals. It hasn't been brought up since.

Are there any additional tests that you think I should encourage them to run before bringing him home? I'm somewhat limited as to what I can do locally, so the time to do it is probably while he's at the university.

From the prepuce area.

Click to expand...

Hmmm.....awfully contaminated area with oral bugs, etc.......

Tests mentioned in the earlier thread - contrast studies if they are putting a PU on the table.

And, of course, x-rays and U/S.

I have not read the entire thread so I can't speak in great specifics.

(((TomTom))) Linda's Bear has it, and he's on Baytril for life b/c he just can't get rid of it. (He's blind, so the Baytril/blindness link isn't a concern). Cultures were all negative IIRC, but they've had multiple u/s to dx (I think). I'll send her a PM to look in on this thread.

I have had experience with two cats and pyelonephritis. My comments are based on my own layman's experience and my notes, but I have no special knowledge of the medical issues.

Most recently, my civie Emily suddenly started going in and out of the litter box, straining to pass urine, and leaking blood and urine on her bedding. I took her to the vet, who started her on Baytril. Her urea and creatinine were elevated, in addition to her WBC. The urine itself looked suspicious. Her clinical signs improved almost immediately after starting Baytril. A C & S was also done on her initial visit, which came back positive for e coli. After 3 weeks of treatment with Baytril, another C&S was done, which came back no growth, showing that the Baytril was working. After a total of 6 weeks on Baytril, we stopped the antibiotic. One week after that, a repeat C & S was done to confirm that she was still clear (which she was). Four months previously, she had also been treated with Baytril for a UTI.

My diabetic Bear, who has multiple health issues, became very ill suddenly in Oct 2008. He was lying flat out on the floor, vomiting, inappetant, and almost unresponsive. At the vet, his bloodwork showed his WBC extremely high. His kidney area appeared very painful on palpation. Other b/w eventually ruled out pancreatitis. Kidney values were high. Because he had a long history of steroids which lowered his immunity, the vet suspected pyelonephritis and started him on Baytril. His C & S came back no growth, but my vet said that it is possible for the infection to be primary in the kidney, and not show growth in the urine (please forgive my very hazy understanding of the science here). He was treated for 6 weeks on Baytril. He had another in a long series of urine cultures, which all came back negative. We relied on clinical signs, CBC, and renal values to gauge progress. One month after tx with Baytril, his creatinine was back in normal range.

A few weeks after stopping Baytril, he became ill again. He was making frequent unproductive trips in and out of the litterbox, crying in the litter box, lying by the water bowl, and drinking huge amounts of water. A non-sterile urine catch looked like his October urine, and looked suspicious for infection (copying from my notes: Ph 6.5, no blood, large amount of free flow bacteria, WBC 0-3, bacteria w/in WBC). He was restarted on Baytril for a planned course of at least 4 months. The vet said, again copying from my notes here, that there is a well documented syndrome of repeated negative urine cultures – bacteria in local glomeruli and don’t shed into urine. (Non bacteriogenic urine syndrome???). Stopping and restarting antibiotics is thought to promote antibiotic resistance.

Two months later, his renal threshold, which is already low, became even lower. He was acting unwell again. All of his kidney indicators were much worse again, which the vet felt was due to pyelonephritis being uncontrolled by the Baytril. Pancreatitis was ruled out, but he does have IBD with cramping, which could also make him feel ill. Another culture came back no growth. He had a kidney ultrasound, which showed the kidneys scarred down, consistent with current or previous pyelonephritis, interstitial cystitis, or exposure to nephrotoxic drugs. Quote from ultrasound report: The left and right kidneys (3.8 cm and 3.9 cm long, respectively), had mildly irregular contours, hyperechoic mildly heterogeneous cortices with moderate loss of normal cortico-medullary junction delineation. One 4 mm cyst noted in the left kidney cortex.

We decided at that point to continue Baytril treatment "for life", and based on the other ultrasound findings, to make other adjustments to his meds for his IBD/pancreas issues. Six months later, he urinated a couple of times on the floor, and was unwell. Urine cultures were done, and were negative, renal values were up, there was blood in the urine. Another ultrasound showed no major changes. Treatments were started for other issues (hyperthyroid, potassium supplementation, anemia).

In November/09 he started urinating regularly on the floor. His urine sample had a large amount of blood in it, and clumps of white blood cells. The vet was concerned that another bacteria was growing through the Baytril. His urine culture was negative. He was started on the antibiotic Suprax, which was a disaster. He developed terrible diarrhea, and was pooping and urinating on the floor. He developed a circling behaviour, worsened by his blindness. he walked around and around in circles, tracking through the urine and feces on the floor. Several meds failed to clear up the diarrhea. He stopped the Suprax. He stopped the Baytril, in case it was causing neuro toxicity.

Present day: the diarrhea has somewhat improved. He still urinates and poops on the floor. He is back on Baytril. The circling behaviour continues. There has been no cause identified for the foul looking urine. The last idea the vet had would be to give Convenia, which I refused out of fear of starting the diarrhea again. Renal values are back up, possibly due to an incident involving overdosing of his thyroid medication. His last urine culture showed no growth.

His history of pyelonephritis is complicated by steroid use, and many other concurrent diseases. It is a juggling act, to be sure. There don't seem to be many antibiotic treatments that he can tolerate (as noted above, he has been blind since birth). The main points I came away with are that there can be infection present despite negative urine cultures, that you have to use other tests and symptoms to gauge the success of treatment, that stopping and restrating antibiotic treatment can aggravate the condition, and that antibiotic treatment may have to be very long term.

Again, I have no veterinary knowledge, so I can't vouch for the accuracy of any of my comments above.