As much as any practitioner does, Dr. Joseph Bartges enjoys an engaging challenge that tests his veterinary skills. But if diagnosis and treatment dissolve into the “antibiotic alphabet game,” count him out.
When treating recurrent lower urinary tract infections, he notes it’s easy to get caught up in such an A-to-Z game. You know the potential progression: Start with amoxicillin and hope to hit on something effective before working through to Zeniquin.
“The practitioner may not even have proved that the patient has an infection,” says Dr. Bartges, DVM, Ph.D., Dipl. ACVIM, Dipl. ACVN. Dr. Bartges is professor of medicine and nutrition and the Acree Chair of Small Animal Research in the College of Veterinary Medicine at the University of Tennessee.
If what has been diagnosed as a lower urinary tract infection is not responding initially, “Changing antibiotics is not the way to go,” he counsels. “Looking harder is a better option.”
It’s time to do a urine culture by cystocentesis (to help ensure its accuracy), as well as perhaps take radiographs, do an ultrasound or MRI and get a full blood workup, say both Dr. Bartges and Ronald Lyman, DVM, Dipl. ACVIM, founder and president of the Animal Emergency and Referral Center in Fort Pierce, Fla.
“The urine culture is still the gold standard,” Bartges notes.
Both doctors see many patients who have been diagnosed as having recurrent and chronic lower urinary tract infection as referrals from general practitioners. So they get the cases that aren’t easily solved.
They know that the sooner they start looking for underlying causes and the more they do to get patients on the right antibiotics, as needed, the greater their chance of breaking the cycle of recurrence.
The first thing Dr. Lyman does when he sees a new case is to look into the patient’s history, he says.
“I want to see if there have been any adverse reactions to antibiotics,” he says. “And I want to know what antibiotics the pet has been on, for any reason, in the recent past, so I can stay away from those.”
If he’s able to choose a course of antibiotic therapy based on a cystocentesis urine culture, then Lyman will often prescribe seven days of a quinolone, a potentiated penicillin-type or a potentiated amoxicillin drug while he waits for the culture results.
“Or 14 days, at least, if I’m not able to obtain a culture, for whatever reason,” he says.
A quinolone of choice is Baytril, because it combines broad-spectrum bactericidal activity against most uropathogens with once-daily dosing.
“It can be very effective, especially since as a once-a-day choice it brings a higher chance of compliance,” Dr. Lyman says.
If the infection persists despite appropriate treatment, “then there are underlying causes that the clinician needs to look for,” he adds.
Lyman’s list of potential causative factors includes bladder stones, which a radiograph or ultrasound can reveal, and vaginal infections, which persistently reintroduce the bacteria to the urinary tract. Other possibilities are a hormonal disorder such as Cushing’s syndrome, as well as a congenital anomaly such as a pelvic-positioned bladder or a diverticulum of the bladder.
Bartges adds some other possible underlying factors to the list: diabetes, kidney failure or a tumor.
“These and other predisposing conditions may be the reason for the failure of your antibiotic therapy,” Lyman says.
As clinicians take a step back to begin rooting out the cause of the recurrent problem, it’s a good point to invest time with the client to explain the next steps in the process, Bartges and Lyman say.
The case may have started with the pet owner not even recognizing the clinical signs of urinary tract infection. And now she or he is hearing that a new round of tests is needed to uncover something else so far unseen.
By communicating with clients up front and throughout the course of treatment, clinicians often learn that clients are more receptive to new options than may have been first assumed, Bartges notes.
“What I’ll often do is take advantage of the digital imaging systems to show examples of some of the things that might be occurring in their pet,” Lyman adds. “Here’s another female dog that had some stones in her bladder, which is why she kept getting infections. The stones were holding the bacteria, and the antibiotics could never completely get rid of them.
“These tools can help to suggest why we do X-ray, ultrasound or scope the vagina. If more veterinarians would take that extra bedside time to visually show the client why they’re suggesting something, then they would probably get a higher percentage of compliance.”
Of course, there’s always the occasional client who isn’t a picture person.
“I had a woman this morning who just didn’t want to see the inside of her dog,” Lyman says. “And that’s why I always ask first.”
Lyman considers compliance and follow-up as so important that his emergency and referral center employs two people solely as communication coordinators. “They’re not receptionists, not technicians and not managers,” he says. “Their only job is to make reminders for people, then to tailor them to the way they are best reminded to follow up, whether it’s by phone, text, email or letter.”
Communication with primary-care clinicians is just as important, Lyman adds.
“They need to be in the loop every time we communicate,” he says. “We try to make things as simple as possible to be more compatible with the way people live and interact today.
“We want to find the best path to success for everyone involved.”
This Education Series article was underwritten by Bayer Animal Health of Shawnee Mission, Kan.