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Thread: +VRE = vancomycin resistant enterococcus UTI

  1. #1

    +VRE = vancomycin resistant enterococcus UTI

    My Dad is in a string of 5 symptomatic UTIs in a row, every bug different, all requiring antibiotics. He does CIC. Now he has +VRE (Vancomycin resistant enterococcus). His urologist isn't sure what to use to treat it, as most of the antibiotics it is susceptible to are bugger guns or IV meds, so wants him to see an Infectious Disease doctor for advice next week.

    Just curious - has anyone had success beating +VRE with nitrofurantoin in the past? What antibiotic did you use in the past? Of course, he will use what is recommended based on the culture sensitivities. It doesn't appear that the data isn't great for getting rid of this bug with nitrofurantoin, even when the bacteria is susceptible to it. But this is what he will be taking 4 times per day until we see ID next week.

  2. #2
    Excerpt from uptodate.com (aka the physicians wikipedia)

    "If susceptibility is documented, the best options for oral therapy of enterococcal lower UTIs areamoxicillin, nitrofurantoin, or fosfomycin; dosing is outlined in the Table (table 4) [82]. Nitrofurantoin achieves excellent therapeutic levels in the urine and renal parenchyma but is not adequate for treatment of infection at other sites"

    *btw table 4 just recommends that nitrofurantoin be dosed at 100mg BID (twice daily)

    Your question seems to be "do I need to go to the infectious disease doc?" and the answer is yes.

    For further online speculation it would be nice to know if the data you refer to as not being great for nitrofurantoin getting rid of this bug is the sensitivities or just local prevalence of resistance. If sensitivities are back, please let us know. Also nitrofurantoin is pretty good at destroying most bacteria from the kidneys down, but if your father has pyelonephritis (an infection of the kidney) nitrofurantoin is basically garbage (not high enough concentrations as the second sentence of my uptodate quote suggests).

  3. #3
    On second look I found this article...

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC90284/

    "The activity of nitrofurantoin was tested against 300 isolates of Enterococcus faecium, Enterococcus faecalis, and Enterococcus gallinarum. No isolates tested were resistant to nitrofurantoin (MIC, ≥128 μg/ml), including vancomycin-resistant E. faecium isolates with vanA- and vanB-positive genotypes and vancomycin-resistant E. gallinarum isolates. We conclude that nitrofurantoin may provide effective treatment of urinary tract infections caused by vancomycin-resistant enterococci."

    which suggests that there might have never been found a nitrofurantoin resistant strain of VRE, which should be reassuring, however you should still see the ID doc, because this is a serious infection and your urologist clearly does not feel confident enough to treat it on his or her own. (the ID doc went through 9 years of medical education just to study those bugs... they'll know what's up).

  4. #4
    I agree with the advice above.

    (KLD)

  5. #5
    Thanks. We're definitely going to see ID. I was just curious what others have used in the past if they have had resistant enterococcus infections. Nitrofurantion is the only oral antibiotic that this bug is susceptible to except for Linezolid.

    I think the main concern is that Nitrofurantoin is bacteriostatic... not bacteriocidal, and his physiatrist is concerned that it wont be sufficient for this complicated UTI. Susceptibility in a petri dish is one thing.... effectiveness in a person is sometimes another. Most of the data for the effectiveness of Nitrofurantoin in patients is actually not in patients with complicated UTIs... and definitely not with complicated VRE UTIs. All people with SCI who are cathing etc.. are complicated UTIs.

    I will try to find the reference where this was pulled (below), but even in uncomplicated UTIs in this example there wasn't great clearance of the bug. My Dad's also immunocompromised and with all the recent infections it makes things a bit complex. I'm just hoping that Nitrofurantoin will keep him stable until we get to ID next week....

    Clinical Studies

    Controlled clinical trials comparing Macrobid 100 mg p.o. q12h and Macrodantin 50 mg p.o. q6h in the treatment of acute uncomplicated urinary tract infections demonstrated approximately 75% microbiologic eradication of susceptible pathogens in each treatment group.



  6. #6
    http://www.activistpost.com/2013/05/...ibit-drug.html

    And a garlic and ginger supplement can't hurt the situation either.

  7. #7
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    I agree with seeing Infectious disease, and wanted to add that my husband takes Methenamine Hippurate daily to control UTI's. He used to have them chronically (one after another, after another) until starting it.. and now usually only gets one if he misses too many doses of it. It would be a matter of the risks outweighing the benefits , but for us there seems no other choice. We have actually cured UTI's with it before , though it takes longer than an antibiotic - but it differs from antibiotics in the way that it covers any bacteria and not just some.

  8. #8
    Linezolid- it is by mouth. Use it all the time. Nitrofurantoin is not effective against most and has bad side effects. You have to go with the culture not what other people have tried.
    Any other antibiotic? Ohters can be given IM daily.
    CWO

  9. #9
    Hi JacksonsGirl,

    Thanks for your input. He did see the Infectious disease doctor, who has helpful.... yet, not helpful (see below).

    My Dad has also started the Methenamine 1g twice a day, taking with 1000mg Vitamin C twice a day. So far we have not had good luck at getting his urine to the optimal pH for methenamine to work (<6 acidic). So I am worried this will not be a magic bullet for him. But we are continuing it for now. Maybe his urine is staying at a higher pH because he is on a proton pump inhibitor for multiple stomach issues twice a day, and some calcium for his osteoporosis. He also takes cranberry pills, and drinks the juice as well. Those were the only things his docs suggested, although they all admit they don't use methenamine much.

    What dose are you guys taking? Do you only take it in between infections, or do you continue to take it while on an antibiotic? Have you had any trouble keeping an acidic pH? Are you only using this, or are you using Hydrocleanse as well? My father is starting to activate his hydrophilic catheters with Hydroclenase.

  10. #10
    Thanks CWO for your input. I was curious if others had used Linezolid, since no one mentions it on this website, so I appreciate your input.

    My Dad saw the ID doctor this week. He just said to continue with Nitrofurantoin 100mg 4x a day for 2 weeks, and if the symptoms continue, we would re-culture and re-assess. Pretty much as I expected. I know it may not work, as my Dad is already having increasing UTI symptoms after 1 week of Nitro. I asked the ID doctor what he would likely try "next" if the VRE is still there, and he said maybe Fosfomycin. It surprised me that he didn't say Linezolid, as the VRE is susceptible to this and I thought he would want to try something stronger.

    Fosfomycin is another antibiotic that I almost never hear about people taking. Nurse CWO - do you use it often?!? From my reading it is more for simple UTIs and not complicated ones like my Dad's situation.

    I realize that most ID doctors want to start with the simplest antibiotic possible, but none of the other docs (or us.... ) are optimistic this will work. And even more frustrating, the ID doctor said.... "If there are any signs of systemic infection like fever/chills, take him immediately to the ER as the bug will likely be highly resistant and he will need to be admitted for IV antibiotics..." Well, if this is the case, then shouldn't we be trying to nip the infections in the bud earlier with a better oral antibiotic, rather than try simple one after simple one.......

    Of course, I realize the pros/cons to the ID approach. But he also didn't want to schedule a follow-up appointment. Never a good sign....

    So CWO - do you ever use fosfomycin as a second line antibiotic in a patient like my Dad?

    And he suggested as the next step in trying to break this cycle of infections to try prophylactic nitrofurantoin or fosfomycin, or keeping nitro at home and taking it "empirically' at the sign of "any" UTI symptom for 5-7 days (which is just bizarre to me....). Any thoughts?

    The urologists are favoring circumcision to help avoid self-contamination while cathing (the most likely contributor) vs. superpubic (as my father has not had the greatest history of good cathing habits). Of course, surgeons want to do surgery.... but his physiatrist hesitates to do either and wanted him to see ID and maybe get another urologist's opinion. My Dad wants to avoid surgery. He wants to keep trying to optimize his technique, try different catheters, and maybe try Hydrocleanse.....
    Last edited by hlh; 02-18-2015 at 11:49 AM.

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