Successful EDTA-Tris treatment of Pseudomonas aeruginosa infection of urinary bladder secondary to urolithiasis in a dog

大韓獸醫學會誌(2006) 第46卷 第1號

Korean J Vet Res

83

Successful EDTA-Tris treatment of Pseudomonas aeruginosa infection of urinary bladder secondary to urolithiasis in a dog

Sang-Gwan Lee

, Woo-Pil Hoh

, Ki-Dong Eom, Keun-Woo Lee, Tae-Ho Oh*

1

Joeun Animal Hospital, Daegu 706-808, Korea

College of Veterinary Medicine, College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea

(Accepted: January 27, 2006)

Abstract : About 8 year-old castrated male Yorkshire terrier was presented for evaluation of dysuria, stranguria, hemtauria, and pollakiuria. On history taking, dysuria first was observed three months ago and these signs were waxed and waned. Physical examination revealed mild left perineal swelling. On routine laboratory examination, no significant findings were identified. Positive contrast urogram identified peritoneal herniation of urinary bladder. Urinalysis showed proteinuria and hematuria. Urine sediment revealed epithelial cells, white blood cells and rod-shaped bacteria. Pseudomonas aeroginosa was isolated from urine obtained through cystocentesis, and had resistance against fourteen antibiotics. Cystitis caused by P. aeruginosa concurrent with cystolithiasis and perineal hernia was diagnosed. Cystotomy, herniorrhaphy and EDTA-Tris solution lavage of bladder were performed. The patient was recovered to normal condition 2 days after treatment. Two weeks later, bacterial culture of urine was negative and any abnormality in ultrasonogram and urinalysis was not observed except calcium oxalate dihydrate crystals.

Keywords : cystitis, Pseudomonas aeruginosa , EDTA-Tris, perineal hernia, dog

Introduction

Urinary tract infections (UTIs) are more common in dogs than in cats. Most UTIs in dogs involve bacterial inflammation of the lower urinary tract. The most common pathogens are E. coli (45%), Staphylococcus (13%), and Proteus (10%). Enterococcus, Klebsiella, Streptococcus, Enterbacter , and Pseudomonas are patho- gens isolated in less than 10% [2, 17].

Pseudomonas aeruginosa is known as avirulent organism and an opportunistic infection in a compro- mised urinary tract, but it tends to be exceedingly resistant to antimicrobial agents [17]. UTIs caused by resistant Pseudomonas aeruginosa are difficult to treat so that colonization and subsequent bacterial tissue invasion recur soon after cessation of antimicrobial treatment [8].

EDTA-Tris showed specific synergic effects with tetracycline, quinolone, aminoglycoside, macrolide and b-lactam antibiotics against resistant Gram positive and

negative bacteria [7, 22, 23]. Irrigations with EDTA- Tris solution have been successfully used in combination with antimicrobial agents against soft tissue infections in small animals caused by resistant pathogens [1, 8, 18].

This case report describes the management of cystitis caused by resistant Pseudomonas aeruginosa infection in a dog with urolithiasis.

Case Report

About 8 year-old castrated male Yorkshire terrier weighing 2.8 kg was presented for dysuria, stranguria, hemtauria, and pollakiuria. The patient was vaccinated, dewormed, and prevented from heartworm infection. On history taking, dysuria and mild hematuria was observed three months ago. Since then, clinical signs had been wax and wane, and became suddenly worsen 3 days ago before presentation. Physical examination revealed mild left perineal swelling (Fig. 1). On routine laboratory examination, no significant findings were identified.

*Corresponding author: Tae-Ho Oh

College of Veterinary Medicine, Kyungpook National University, Daegu 702-701, Korea

[Tel: +82-53-950-5959, Fax: +82-53-244-2367, E-mail: [email protected]]

84 Sang-Gwan Lee et al.

In survey radiography, gas-filled structures and soft mass opacity were observed in perineal area and urinary bladder was not observed in caudoventral abdomen (Fig. 2). Calculi in urinary bladder and focal thickened caudodorsal part of urinary bladder wall were observed in ultrasonographic examination (Fig. 3).

Positive contrast urogram confirmed perineal herniation of urinary bladder (Fig. 4).

For urinalysis urine collected from cystocentesis.

Urine pH was 5.0 and specific gravity was 1.050 in urinalysis. Protein and blood were detected in urine.

Also, urine sediment test revealed many epithelial cells, calcium oxalate dihydrate crystals, white blood cells, and rod-shaped bacteria. The urine culture and sensitivity test was pending. Finally cystitis caused by P.

aeruginosa concurrent with cystolithiasis and perineal hernia was diagnosed.

Urinary bladder calculi were removed by cystotomy and perineal herniation of urinary bladder was corrected by herniorrhaphy. The calculi were sent for the

analysis. Calcium oxalate was identified in urolith analysis. Ampicillin (20 mg/kg IV q12hrs) was admini- stered for the prevention of post operation and urinary catheter was inserted for 3 days after surgery. And then, amoxicillin (20 mg/kg PO bid) was administered for 7 days. However, the heamturia was not completely disappeared. During the therapy urine culture and sensitivity results came out and revealed that Pseudo- monas aeruginosa had resistance against fourteen antibiotics. After suture removed, EDTA-tris solution (TrizEDTA, Dermapet) lavage was performed for 15 minutes, two times per day for 5 days through the urethral catheter after the urinary bladder emptied as treatment of cystitis.

Clinical signs included dysuria, pollakiuria and stran- guria were improved 2 days after surgery except hamturia. Two weeks later, heamturia was completely disappeared. The bacterial culture was negative. Any abnormality was not observed in ultrasonogam, urina- lysis, and urine sediment test.

Fig. 1. Mild left perineal swelling was observed at.

Fig. 2. Gas-filled structures and soft mass opacity were observed in perineal area and urinary bladder was not observed in caudoventral abdomen in survey radiography.

Fig. 3. Ultrasonographic findings showed calculi in urinary bladder (A), and focal thickened caudodorsal part of urinary bladder wall (B).

Fig. 4. Positive contrast urogram confirmed perineal

herniation of urinary.

EDTA-Tris treatment of Pseudomonas aeruginosa infection of urinary bladder in a dog 85

Discussion

In this case we assumed that urolithiasis and perineal herniation of urinary bladder were underlying problems to cause the urinary tract infections. Therefore, this case managed with the surgical treatment of these problems followed by irrigation of urinary bladder with EDTA- Tris solutions, and the patient recovered successfully.

Interestingly clinical signs were suddenly worsen after perineal swelling was observed in this case.

Perineal hernia was identified by radiographic exami- nation. Perineal hernia occurs when pelvic diaphragm muscles fail to support the rectal wall, allowing persistent rectal distension and impaired defecation.

The cause of pelvic diaphragm weakening is poorly understood but believed to be associated with male hormones, straining, and congenital or acquired muscle weakness or atrophy. Any condition included prostatitis, cystitis, urinary tract obstruction, colorectal obstruction, rectal deviation and/or dilation, perianal inflammation, anal sacculitis, diarrhea, and constipation that causes straining may stress the pelvic diaphragm [14]. In this case, it was thought that perineal hernia was caused by cystitis and/or cystolithiasis, which could cause the opportunistic infection of Pseudomonas aeruginosa in urinary tract. Pseudomonas aeruginosa infection could be a factor of perineal hernia thorough the deterioration of urinary bladder inflammation.

Pseudomonas aeruginosa is considered as a relatively avirulent opportunistic pathogen of urinary tract, capable only invading a compromised urinary tract, but may be exceedingly resistant to antimicrobial resistant to antimicrobial agents. When is isolated from a urine culture, the host defenses are probably compromised.

This indicate that the need for a more extensive diagnostic evaluation in practice [17]. In this case, P.

aeruginosa isolated from urine obtained by cystocentesis and had resistance to 14 antibiotics including especially fluoroquinolones. Therefore, we thought that this case should be treated another therapeutic agent except antibiotics or surgical correction of cystolithiasis and perineal hernia of urinary bladder.

EDTA-Tris can damage the cell surface of Gram- negative bacteria. And EDTA-Tris increase permeability of cell wall to extracellular solutes and induce leakage of intracellular solute leading to rapid lysis of bacterial cell wall leading to sensitization to lysozyme, bactero- cides, and antibiotics [4, 6, 9, 11-13, 16, 19]. Particularly

EDTA-Tris is active against Pseudomonas aeruginosa and cause the death of organism by rapid lysis [6, 12].

EDTA-Tris has been applied for the treatment of bacterial rhinitis in dog [21] and metritis caused by Pseudomonas aeruginosa in mare [25]. In human medicine, combinations of EDTA-Tris and lysozyme have been used as lavage in persistent bladder infection caused by Gram-negative bacteria [10]. The combina- tions of EDTA-Tris and lysozyme or antibiotics have been used to treat otitis externa and cystitis experi- mentally induced by P. aeruginasa in dogs [3, 8, 24], keratitis in rabbits [5, 20]. The adverse tissue reactions were not noticed in the use of EDTA-Tris in the bladder, ear, or eye [3, 5, 15, 20]. In this case EDTA- Tris lavage of urinary bladder was applied after cystotomy and herniorrhaphy. And then, the dog was completely recovered from cystitis and culture of P.

aeruginosa was negative. Also, any adverse effects were not occurred.

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