Cipro for enterococcus?

[Sandra G]

I'm confused. My doctor did a urinalysis for my UTI that showed
enterococcus, susceptible to Cipro (as well as Macrobid, penicillin,
and Levaquin). So I'm taking Cipro. However, I've done some research on
the web and found many resources to suggest the fluoroquinolones aren't
the best choice against enterococcus.

Did the fact that the lab found susceptibility mean I have a strain of
it that is not resistant?

[JEDilworth]

The only two drugs our lab reports on Group D enterococci are ampicillin and vancomycin, and nitrofurantoin on urinary isolates. Ciprofloxacin resistant enterococci are fairly common. Our drug panel includes it, but we only report it upon doctor request and to one of our clients. It's kept in "hide" mode on all other reports. I'm not sure whether Cipro concentrates in the urine well - this would be a question for a pharmacist.

I don't have our current antibiogram report, but in 2000, we had 637 enterococcus isolates. Of those 93% were sensitive to ampicillin, 94% were sensitive to Vancomycin, and 98% were sensitive to Nitrofurantoin (trade name Macrobid). Ciprofloxacin is not listed as a drug of choice for enterococcus. I'm sure that we have had a trend to more resistant strains in the last five years, as well as more isolates, as we have far more specimens now than we did in 2000.

Yes, Cipro, in your case, tested in vitro (outside the body) as sensitive. Sometimes, however, the in vivo (inside the body) results are not necessarily always the same as in vitro. If you are still having symptoms, by all means talk to your doctor about a repeat culture and a possible change in antibiotic therapy.

Judy Dilworth, M.T. (ASCP)
Microbiology 32 years

Post by Sandra G
I'm confused. My doctor did a urinalysis for my UTI that showed
enterococcus, susceptible to Cipro (as well as Macrobid, penicillin,
and Levaquin). So I'm taking Cipro. However, I've done some research on
the web and found many resources to suggest the fluoroquinolones aren't
the best choice against enterococcus.
Did the fact that the lab found susceptibility mean I have a strain of
it that is not resistant?

[John Gentile]

On 2006-02-09 01:24:00 -0500, "JEDilworth"

The only two drugs our lab reports on Group D enterococci are ampicillin =
and vancomycin, and nitrofurantoin on urinary isolates. Ciprofloxacin =
resistant enterococci are fairly common. Our drug panel includes it, but =
we only report it upon doctor request and to one of our clients. It's =
kept in "hide" mode on all other reports. I'm not sure whether Cipro =
concentrates in the urine well - this would be a question for a =
pharmacist.
I don't have our current antibiogram report, but in 2000, we had 637 =
enterococcus isolates. Of those 93% were sensitive to ampicillin, 94% =
were sensitive to Vancomycin, and 98% were sensitive to Nitrofurantoin =
(trade name Macrobid). Ciprofloxacin is not listed as a drug of choice =
for enterococcus. I'm sure that we have had a trend to more resistant =
strains in the last five years, as well as more isolates, as we have far =
more specimens now than we did in 2000.=20
Yes, Cipro, in your case, tested in vitro (outside the body) as =
sensitive. Sometimes, however, the in vivo (inside the body) results are =
not necessarily always the same as in vitro. If you are still having =
symptoms, by all means talk to your doctor about a repeat culture and a =
possible change in antibiotic therapy.
Judy Dilworth, M.T. (ASCP)
Microbiology 32 years

Post by Sandra G
I'm confused. My doctor did a urinalysis for my UTI that showed
enterococcus, susceptible to Cipro (as well as Macrobid, penicillin,
and Levaquin). So I'm taking Cipro. However, I've done some research =

on

Post by Sandra G
the web and found many resources to suggest the fluoroquinolones =

aren't

Post by Sandra G
the best choice against enterococcus.
=20
Did the fact that the lab found susceptibility mean I have a strain of
it that is not resistant?

I don't recall our latest antibiogram (the list of organisms and the %
susceptible to various antibiotics), but I think that last year the
fluoroquinolones were reported as S about 60% for Enterococcus sp.

My wife had a UTI caused by E. coli recently and even though I
"strongly" suggested that an antibiotic other than cipro or levo be
used her doc wrote a script for levo. I think there is evidence that
fluoroquinolones do work for UTIs, but I always have reservations about
them since it only took 6 months for our MRSA to become cipro resistant
in most cases.

The proof of the pudding is did the infection clear up after taking the
drugs? And a follow up would be does it reoccur? And if it does is it
the same organism and is it resistant to cipro?

[Sandra G]

60%? That's it? I think I made a mistake not taking Macrobid...

I don't know if I can wait to see if it clears up! I'm afraid it might
spread during that time, if I wait too long. I've already had it over a
month.

[JEDilworth]

If you've had it for over a month you need to get back with your doctor
PRONTO. Print out what John and I wrote to you.

If it's only 60% that may be why we don't report it at all....

Good luck.

Judy Dilworth, M.T. (ASCP)
Microbiology

Post by Sandra G
60%? That's it? I think I made a mistake not taking Macrobid...

[Sandra G]

Since it's Saturday, I can't get in to see the Dr. until Monday. I have
Macrobid, though. I had filled the prescription a while ago but didn't
take it because I read scary things about it. Would you recommend I
switch immediately?

I've been on Cipro since Monday, and while a lot of my flank pain is
better, my urine is still cloudy and smells funny. (I have no other UTI
symptoms besides that)

[Sandra G]

BTW, do you know how to read my susceptibility results? They said the
following:

Cipro S=1
Levofloxacin S<=1
Nitrofurantonin S<=32
Penicillin S=2
Vancomycin S<=0.5

Thanks.

[JEDilworth]

S = sensitive.

The numbers are MIC's. MIC = minimum inhibitory concentration.

http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/mic.html

The "S" is the interpretation of the MIC for that antibiotic. Don't
worry about the MIC's, just the interpretation.

http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/amt.html

Yes, I would start the Macrodantin right away, but wait until you
normally would have taken your next Cipro. Drink with lots of water.
This drug concentrates in the bladder and you need a lot of liquid to
flush it down there. You will pee yellow :-).

Be sure to tell the doctor you have switched drugs. Do you have a whole
course of Macrobid or only a part of one? If only a part of one, be sure
to get enough to take a whole course. Stopping in the middle, even if
you're asymptomatic, is what leads to drug resistance.

Judy Dilworth, M.T. (ASCP)
Microbiology

Post by Sandra G
BTW, do you know how to read my susceptibility results? They said the
Cipro S=1
Levofloxacin S<=1
Nitrofurantonin S<=32
Penicillin S=2
Vancomycin S<=0.5

[Sandra G]

Thanks. I still don't quite understand what the urinalysis
susceptibility results mean. My isolate is susceptible to ALL those
drugs I mentioned, right?

I guess you can't apply a clear-cut rule, like if the numbers are less
than 20, the bacteria is resistant...

[Sandra G]

Hi Judy,

Please check out this page

http://dentistry.ouhsc.edu/intranet-web/Courses/DMI_8351/ZoneStds.html

Do these numbers apply to my test?? If so, it looks like my isolate is
resistant to everything but Macrobid?? I'm so confused...

[John Gentile]

Post by Sandra G
Hi Judy,
Please check out this page
http://dentistry.ouhsc.edu/intranet-web/Courses/DMI_8351/ZoneStds.html
Do these numbers apply to my test?? If so, it looks like my isolate is
resistant to everything but Macrobid?? I'm so confused...

That chart has been a source of confusion for even some experienced
laboratory technologists. My advice is don't look at it!

Every bacteria species and every antibiotic drug have different
interpretive standards. An MIC of <8 may be susceptible for one germ,
but resistant for another. Judy's advice was correct - don't worry
about the MIC levels, just the interpretation.

In your case the interpretation was S for all the drugs tested.

The MIC is actually an indicator for the blood level of the drug - in
other words, if the blood level Levofloxacin can reach a level of 1
microgram/liter of blood then it would be considered inhibitory to that
bacteria. It might not kill it, but it will not allow it to multiply
further. This would then allow your immune system to marshal it's
forces and attack the germ and kill it off.

But none of that applies to bladder infections since the concentration
of certain antibiotic is much higher in the urine than it is in the
blood. The same principle does apply, the cloudiness is actually your
white blood cells (pus) attacking the infection.

I find that people are surprised that laboratory technologists (or
clinical laboratory scientists) actually have to have a 4 year BS
degree. It is subjects like these that bring the point home. I still
remember the frustration our computer specialist had when we tried to
set up our sensitivity reports in our computer system. He just could
not grasp the "fuzzy logic" of it all.

[JEDilworth]

We used to make jokes about just finding microbiologists "on the
street" - like it was an easy thing to do. Some excellent techs have a
difficult time grasping micro and hate it, but love other parts of the
lab. I myself recoil in panic just thinking about doing blood
banking....which is an extremely complicated department to learn in
depth, and can come with adrenalin rushes and ulcer-creating
circumstances that I would do anything to avoid. Some techs just like
those STAT rushes they get for uncrossmatched blood, though, and I'm
just thankful for that, as it was never my favorite department. I'm sure
they think of micro in a likewise fashion.

Judy Dilworth, M.T. (ASCP)
Microbiology

Post by John Gentile
I find that people are surprised that laboratory technologists (or
clinical laboratory scientists) actually have to have a 4 year BS
degree. It is subjects like these that bring the point home.

[Mike McWilliams]

Post by John Gentile
I find that people are surprised that laboratory technologists (or
clinical laboratory scientists) actually have to have a 4 year BS
degree. It is subjects like these that bring the point home. I still
remember the frustration our computer specialist had when we tried to
set up our sensitivity reports in our computer system. He just could not
grasp the "fuzzy logic" of it all.

Where I live, the tech program is one year on top of lab assistant which
is two years.

lab assistants take blood, perform ecgs, eegs


techs run the equipment

up here I would guess that third year is friggin intense.

I got a four year degree in cell biology and wasn't qualified to be a
tech...

up here it is a great program with high pay out of the gate, I would
recommend it to anyone who wants a rewarding day job.

[JEDilworth]

The numbers listed are ZONE sizes used with the Kirby Bauer method of
performing sensitivities. Zone sizes are based on the organism and the
disc used for testing. The numbers in your result are MIC's. These are
NOT the same as zone sizes. Why are you worrying about this :-)? Leave
this to the microbiologists.

Your sensitivity was probably done on an automated instrument which was
either Vitek or Microscan - two commercial methods for performing
sensitivities in an automated fashion. That is why your results are
reported in an MIC format with the interpretation of that MIC. They are
both legitimate, and quality control is required. Some labs don't use
automated methods, and use the manual method of Kirby Bauer testing. We
use KB for backup on some organisms that either won't grow in Vitek or
to double check Vitek results if they're flagged. This gets into
complexities that are too hard to explain unless you're a micro tech
(sorry).

John Gentile posted an excellent summary of MIC's. Microbiology is a
very complex subject. I tell new techs it will take them a year just to
feel comfortable with the basics of it all. Don't fret that you're
having a hard time. If you've never taken a course in medical micro it's
going to be very confusing.

The most important thing for you to worry about is to get your UTI
treated. Consult with your doctor Monday.

Judy Dilworth, M.T. (ASCP)
Microbiology

Post by Sandra G
Do these numbers apply to my test?? If so, it looks like my isolate is
resistant to everything but Macrobid?? I'm so confused...

[Sandra G]

Thanks. I saw something on the FDA insert with Macrobid about "tell
your doctor if you're taking a fluoroquinolone." But it doesn't say
WHY. is there some interaction you know about between Macrobid and FQs?
I guess I should ask the doctor! I will call her tomorrow.

Do you think it is dangerous that I've been treating the UTI with
possibly the wrong antibiotic? I've now had the UTI a month and a half.
Ugh.

[JEDilworth]

Sandra! Call your doctor! If they can't help you, ask for a referral to
a urologist. Complicated UTI's sometimes call for a specialist. We see
urines from Urology patients all the time.

Judy Dilworth, M.T. (ASCP)
Microbiology

[Mike McWilliams]

Post by Sandra G
60%? That's it? I think I made a mistake not taking Macrobid...
I don't know if I can wait to see if it clears up! I'm afraid it might
spread during that time, if I wait too long. I've already had it over a
month.

I looked at the options you originally gave... Penicillins are dirt
cheap where I come from... I had an ear infection recently, and I think
the whole treatment course cost something like 18$

[Sandra G]

I'm allergic to penicillin!

[John Gentile]

Post by Sandra G
60%? That's it? I think I made a mistake not taking Macrobid...
I don't know if I can wait to see if it clears up! I'm afraid it might
spread during that time, if I wait too long. I've already had it over a
month.

For any UTI I'll always recommend nitrofurantoin as the first line of
defense. It is cheap and concentrates very well in the urine. Not many
organisms are resistant to it.
Any infection that does not resolve in the first few days of antibiotic
treatment must be reevaluated for resistant organisms.

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