Recommendation For Microbiologist

[ELLHNAS]

Hello,

I was diagnosed with the bacteria Enterococcus Faecalis a few days ago and currently taking antibiotics. This seems to be causing an infection of the urinary tract. This is quite new to me and from my research in the internet it seems that this bacteria can be proved difficult and long to kill and has a capacity to develop easily antibiotic resistance. I am currently taking cipro tabs for 10 days as recommended by a urologist. Selection of the right antibiotics or combination of them is crucial to kill the bacteria and I have doubts that a urologist has enough experience dealing with this. I think that a microbiologist is more appropriate for my case. However, it seems to be very hard to find information about this. I tried to browse through the forum but I found absolutely nothing for recommendations of microbiologists or even if it exists as a specialty in Thai hospitals. Could please someone point me to the right direction or does anyone know a microbiology specialist that would recommend? This is causing me great anxiety. Thank you for your help.

[Sheryl]

Microbiologists do not work directly with patients or prescribe treatment. They are in the labs, and all the large hospitals have them.

There is no need to worry about finding a microbiologist...you just need to be sure that your doctor sent a urine sample for "culture and sensitivity". Since they know that your infection was caused by e. faecolis,they must have done a culture at minimum and probably did a sensitivity test as well. To be sure, just request a copy of the urine test results. By law, patients are entitled to any and all of their medical records on demand.

The report will show the name of the organism and a numerical indication of how many bacteria you had. It should also have a section that lists various antibiotics followed by an indication of whether the organism responds to it. May be abbreviated as "R", "S" and "I". S = sensitive, r= resistant, i= in between (partially resistant).

If ciprofloxacin does not show as "S", obviously you should question the doctor. If it shows as sensitive, then continue the treatment with confidence but do insist on a repeat culture and sensitivity towards the end of the tretament to make sure there is no lingering infection.

Enterococcus Faecalis is actually not an uncommon cause of urinary tract infection, especially among people who acquired the infection while in a hospital and in men with prostate or other urinary tract conditions.

It does tend to be resistant to many antibiotics and often requires a combination of two drugs to effectively treat, so do check on that lab report to make sure your strain is sensitive to the cipro. It often (in fact, usually) happens that doctors start a patient on a drug before the lab report is back. When the report comes in, they should check the sensitivity report and change medication if necessary but sometimes things fall through the cracks at that stage.

[ELLHNAS]

Dear Sheryl,

Thank you so much for your informative post. This is actually the kind of info that I was looking for. I got confused because if I remember right in my country it is possible to see a microbiologist in the same way that you visit any other doctor. However, what you say makes complete sense. My symptoms that prompted me to go to the doctor were often urination that I usually do not have and small pain/discomfort in the rear of my right testicle (maybe scrotum). I am suspecting that based on those symptoms I may have prostatitis or epididymitis due to the bacteria. My doctor did a semen culture test and I believe a sensitivity report test also because the document I received looks very similar to the one you describe (name of bacteria and list of antibiotics with the indication "S", "R" and "I").The document does not have a numerical indication about the number of bacteria. It only says "moderate growth". I have a few questions and I would appreciate yours or anyone's help.

1) I would like to know a little more about the way they do the sensitivity test. Does it apply to my specific strain of bacteria found in THIS SPECIFIC semen or as soon as the microbiologist establishes that I have a e.faecalis he checks through a pre-established list of bacteria and relevant antibiotics and creates this list. In a way I am asking this because I want to know if the "S" and "R" indications on my test are based on generic pre-established conclusions or apply directly to my SPECIFIC strain of e.faecalis. In other words I would like to know without getting too technical and overload the thread how they run those sensitivity reports. Do they actually try every antibiotic on the list in the culture and see how the specific bacteria on the specific semen responds? I hope my question is clear.

2) Ciprofloxacin is not inside the sensitivity list of antibiotics. So I do not know if it has an "R" or "S" indication. I failed to ask the doctor about this. However, I find it hard to believe that this is a mistake from the doctor. I know that Cipro belongs to the quinolones family of the antibiotics. The names I have for antibiotics in the list are (ampicillin, benzylpenicillin, erythromycin, gentamicin high level, imipenem, levofloxacin, linezolid, moxifloxacin, quinupristin/dalfopristin, cefuroxime-axetil, cefuroxime, ampicilin/sulbactam, streptomycin high level, tetracycline, tigercycline, teicoplanin, vancomycin). Any idea where ciprofloxacin belongs here so that I can check the indicator? I know that moxifloxacin (S indicator on my list) and levofloxacin (S indicator on my list) are also fluoroquinolone like the cipro but stronger with adverse side-effects so could it be that the doctor wanted to start with a "lighter" antibiotic of the same family and see if it works. Actually I think that already after 3 days of treatment, cipro seems to give me light arthritis in the lower back which is one of its side-effects and I hope it does not increase as I would like to finish this treatment (10 days).

3) From those 17 antibiotics, 10 have the indication "S" on the list. Does that mean that the specific strain of bacteria I have is not so resistant so maybe there is hope?

4) Under the line that describes the bacteria there is another line that says "antimicrobial agent: MIC 1". Under the MIC column some antibiotics have numbers like 4, 0.5 and 1. Any idea what this means?

I am actually a healthy person, normal weight, 38 years old and I hardly ever get sick. I do not smoke and drink only moderately. I guess I got worried because I spent too much time online researching about this bacteria and I did not like what I read about its high resistance. But maybe the strain I have is not so strong. Thank you again for your help and I hope someone can answer the above questions.

[Sheryl]

1) The sensitivity test is done by putting small amounts of the bacteria that grew on your culture onto petri dishes treated with various antibiotics. So it is specific to exactly the bacteria in your sample.

2) Indeed cipro is closely related to levoflaxacin & moxifloxacin so if it is sensitive to these, odds are it will be sensitive to cipro. Levofloxacin and moxifloxacin are newer quinilones and much more expensive whereas cipro is made locally and cheap. This probably accounts for the doctor's choice. If your urinary symptoms are improving/gone, then that together with the sensitivity to other quinolones would suggest you are on the right drug.

3) Yes, the strain of e. faecolis you have seems much less antibiotic-resistant than it often is. To keep things that way, be sure to finish the full course of treatment and also insist on a repeat culture to be sure no organisms remain as if not 100% treated, in future it will likely be quinolone resistant.

4. MIC is the "minimum inhibitory concentration", that is the minimum concentration of antibiotic needed to prevent the organism from growing. The lower the number, the more potent the antibiotic is against this organism (there will not be an MIC number for drugs to which it is resistant). In some cases an organism may be sensitive to an antibiotic but only at higher doses than can safely be given. The doctor can see this from the MIC value, so it os of use in selecting from among the antibiotics to which there is sensitivity. It can also be helpful in deciding on dosage to give especially for patients in whom giving the smallest necessary dose is important (e.g. people with impaired kidney or liver function).

In your case other than being sure to complete the full course of antibiotics and get a repeat culture, the point of concern I see is that you got the infection in the first place. Women readily get such infections because their urethras are very short in length, it is very easy for bacteria to climb up. Men on the other hand seldom get such infections unless they either had required a urinary catheter for some reason (e.g. after surgery), had undergone some type of urethral procedure (cystoscopy etc) or have some other urinary tract disease process such as enlarged prostate, bladder stones etc. You say you are only 38 and healthy. So unless there was a history of being catheterized or undergoing some procedure which involved an instrument into the urethra, I'd be puzzled as to how/why you got this infection, and I'd recommend seeing a urologist to rule out an underlying cause.

[Jowels]

Sorry, to bump an old thread, but I fear I've contracted an acute bacterial prostatatis infection and I would like to have a semen and sensitivity test. Does anyone know if this is available at all the major hospitals throughout Thailand, or would it be limited to BKK? Also, as I'm currently taking antibiotics, how long before the test would I need to stop?

[Sheryl]

culture and sensitivity testing is available in all larger hospitals but may not be in in small ones.

Also Thai doctors have a marked tendency not to order them and instead opt use a "shot gun" treatment approach.

Prostatitis can be hard to clear up. if you are on a course of antibiotics, do not go if it without first consulting a doctor (risk of develkoing resistance).

[Jowels]

culture and sensitivity testing is available in all larger hospitals but may not be in in small ones.

Also Thai doctors have a marked tendency not to order them and instead opt use a "shot gun" treatment approach.

Prostatitis can be hard to clear up. if you are on a course of antibiotics, do not go if it without first consulting a doctor (risk of develkoing resistance).

Sheryl – Thanks for the advice and information. It’s much appreciated.

Unfortunately, I’m already experiencing the Thai doctors ‘shotgun’ approach. The first urologist I saw put it down to a simple UTI and put me on a course of Ciprofloxacin for 1 week. There was no improvement, so he then decided it was an STD (which is very unlikely) and instructed me to take 1mg of azithromycin and 500mg of levofloacin. I understand these are the recommended doses for uncomplicated gonorrhea and Chlamydia so presumably he had these in mind (even though I’ve never had any penile discharge).

After 10-12 days there was no improvement, so I saw another urologist who decided the infection had reached my prostate and I should go back onto the Ciprofloxacin for 2 weeks. He didn’t seem concerned that the original 1-week course may have made the bacteria resistant, so I followed his advice.

That was about a week ago, and as there’s been no improvement, I spoke with another urologist yesterday, and he’s recommended I stop taking the Ciprofloxacin and change to Bactrim. At this stage, I’m really not sure what to do.

In retrospect I wish the first uro had ordered a semen and sensitivity test, so I could have got the correct antibiotics from the start. Now, I’ve started the Ciprofloxacin course, I think I should finish it just to make sure the bacteria doesn’t become resistant (if indeed it isn’t already). If the Cipro doesn’t work, I’m inclined to stop all medication for one week, and then have a semen test to see what bacteria is present and which antibiotics they’re sensitive to.

Sheryl, does this sound a sensible course of action, or do you have any alternative suggestions?

Although, I’m not based in BKK, I’ve only been to the best local private hospitals and I feel a little let down by the advice I’ve received. I know that once an infection has taken ‘root’ in the prostate it’s very difficult to treat with antibiotics, so I’m keen to resolve my problems before they become worse. Any advice you, or any other members could offer, would be gratefully received.

[Sheryl]

My advice: continue the cipro but t also insist ion a culture & sensitivity.

Alternatively, if symptoms are at least not worsening, wait a while and then get the culture if symptoms have persisted.

Do not stop the cipro unless (1) a c&s indicates resistance/partial resistance OR (2) you have completed 6 weerks of treatment (or develop serious side effects from the drug)

If you have a bug not sensitive or only partially sensitive to cipro it will show, allowing for a change of antibiotic

BTW the culture and sensitivity test is usually done urine. The usual procedure is first to test a regular sample and then, if not sign of infection, get a repeat sample after first massaging the prostate.

Sometimes prostatitis is not bacterial in origin.

I don't know where you are located/where you've gone, but the quality of private hospitals upcountry is far below that of Bangkok; indeed in most locations it is well below the level of the tertiary level government facilities.

If it is not too hard to arrange, you might do well to come to Bkk and consult one of the urologists recommended on the pinned thread.

[Jowels]

Sheryl - Again, thanks for the advice.

I agree continuing with the Cipro seems the best course of action, and I'll do so for another 4-5 weeks. I've already had a urine culture, and while no bacteria was detected this is apparently quite common if the infection is in the prostate. With prostate infections, I'm told a semen culture is far more reliable. To ensure I'm using the correct meds, I'm keen to organize a test, but I'll need to be off antibiotics for at least a week beforehand, so this won't happen for another month and a half.

Hopefully, Cipro is the correct medicine, if not the next 4-5 weeks will be wasted, and in that time the bacteria will presumably multiply and penetrate the prostate further. It's a pity Thai urologists adopt this 'shotgun' approach, rather than taking a more measured approach and properly dentifying the cause of the infection before they prescribe meds.

The main hospital I've gone to is affilitated with the Bangkok group of hospitals. It costs an arm and a leg, but I accept this doesn't always guarantee quality. If things don't improve with the Cipro, perhaps I'll organize a consultation in BKK.