Effects Of Random Rotation Of Antibiotics: A Case Report

Claims on Rotation of different antibiotics, within a period of 1-3 weeks and achieving high cure rates have been posted in Prostatitis News Groups. However our research group on Chronic Prostatitis,have not been able to find valid peer  reviewed material on this approach.

Misuse of antibiotics has become rampant worldwide,resulting to the  emergence of bugs that has not only become stubborn to treatment but also  lead to the development of multi-drug resistant strains.

Reports in valid medical journals have documented the disadvantages of short  term use of antimicrobials in acute cases of urinary tract infection,stating that the  only advantage is “patient compliance” the major disadvantage is “recurrences.”

Traditional treatment of CP cases recommends antimicrobial treatment for a  duration of 4-12 weeks, which is far superior than short term treatment.In spite of this fact the success rate of this approach is documented to be only 30-40%. Long term cure rates are unknown.

Claims on cures for cases of CP with in 1-3 weeks have been posted in both  CPPS and Prostatitis discussion group. Science defies such claims. However effective treatment for CP cases still have to be found.

Published in the medical journal of treatment for CP cases with durable results  even after 2 years was documented at earliest of 16 days and as long as 32 days. This study showed that complete eradication rate of bugs both culturable  and difficult to culture organisms with the traditional isolation techniques disproved that cures for true CP cases was not possible within 1-2 weeks. More  so with random selection and rotation of antimicrobials.

The case to be presented by our research group intends to show the ill effects of  short term,random selection of antimicrobials.

A 53 year old, single male, appearing depressed, residing in the US. consulted  because of an intermittent urethral discomfort and testicular pain of one year duration.

His previous medical record about a year PTC showed treatment with 7 different  antimicrobials rotated in a period of 10 days. His drug cocktail also consisted of  an antifungal drug given on the second day of his treatment for 5 days.

On the first visit, Gram Stains of the urethra, EPS, Semen, Urinalysis and a  Semen analysis were done. Genozyme and Chlamydiazyme was also done on the urethra And Semen. Finally Cultures for “9” organism were done on the Urethra  and Semen

Gram Stains results showed the following: Urethra, No WBC,but presence of  gram positive cocci,gram positive bacilli,and gram negative bacilli. EPS, 0-1  WBC. Semen, 0-2 WBC

Urinalysis,was interpreted as Normal. Semen Analysis was unremarkable except  for leukocytosis of 7

On the same visit he was prescribed Ciprofloxacin 500mg Single dose and  Azithromycin 1 gram single dose.

He was followed up the following day (second day). The patient reported “slight  improvement of his symptoms”.

Gram Stains;Urethra showed no WBC but some gram positive cocci was  reported. Gram Stains;EPS showed 0-4 WBC.

He was then prescribed Ciprofloxacin 500 mg.BID , Doxycycline 100 mg. BID, for  2 days and Fluconazole at 50mg OD for 5 days.

On the third day, He reported “recurrence of his symptoms”.

Gram Stain;Urethra revealed no WBC and no organism.EPS showed 3-12  WBC.

The 3 medicines were continued.

On the fourth day(daily visit).The patient reported “lesser symptoms.”

Gram Stain of the EPS showed 8-36. WBC.Cultures done on the first visit  including Ureaplasma Urealyticum(urethra and semen)reported negative.

The 3 medications were continued.

On the fifth visit (Fifth day),The patient reported further improvement of his  symptoms. Gram Stain of the EPS showed a count greater than 60  WBC. Cultures for Mycoplasma done on the urethra and semen (collected  during the first visit) reported negative. Cultures for “9” organism was done on  the EPS.

Cipro and Doxy was stopped,and Shifted to Cefuroxime 500mg.,Fleroxacin  400mg. to be taken for 3 days,Additionally he was also given Azithromycin 1 gram single dose.

On the sixth visit (sixth day), patient reported improved symptoms (compared to the first visit). Gram stain of the EPS showed 8-30. WBC. Cefuroxime and Fleroxacin was continued.

On the seventh visit (Eighth day),Patient reported symptoms recurrence, Gram stain of the urethra showed 0-1 wbc,EPS showed 12-42 WBC. Cultures done on the EPS (collected on the fifth day) reported negative including Ureaplasma urealyticum.Semen analysis was done again,found to be unremarkable except for leukocytosis of 5-10. Gram stain of the semen showed 0-3 WBC.

His present medication was stopped and Shifted to Co-tri/Sulfa 800mg BID, Co- Amoxiclav 625 TID and Azithromycin 500mg BID given for 2 days.

The eight visit (ninth day) No report on symptoms was recorded, Gram stain of the EPS showed, 10-38 WBC. Cultures of the EPS for Mycoplasma reported negative (collected on the fifth visit) Both Gonozyme and chlamydiazyme on the urethra and semen also reported negative (collected on the first visit). Gram Stain of the EPS showed 10-38 WBC. His present meds were continued.

On the ninth visit (tenth day) No report of symptomatology was recorded, Gram stains of the EPS showed 10-40 WBC. Present medication was continued. Patient was then lost to follow up by the first managing team.

Later on this patient was treated,by a second team. They were able to identify “bugs”and treated with target specific meds given until proof of bacterial eradication was achieved. Symptom score of the patient dropped by 100%. Leukocytosis dropped to normal values. Total microbial eradication was achieved. (Results of the on how the patient was managed using the Manila Protocol will later be Posted.)

Points to note in this case:

1. Patient was rotated on 7 different antibiotic and 1 course of antifungal in period of 10 days.
2. WBC count in the initial visit showed normal values.This places the patient in CPPS category 3b,or prostatodynia.
3. Med were initiated without any indication,cultures later on was taken even while the patient the patient was on antimicrobials given by the first group. (See, 1st and 5th day)
4. Serial monitoring of his EPS showed a significant increase in WBC count including the semen analysis.This increase was persistently high throughout the treatment course (from a base line of normal values) Serial “extensive” microbiology work up including use of the Gonozyme and Chlamydiazyme never isolated any pathogen. Both Gonozyme and Chlamydiazyme were done also done in the semen sample.(This should have never been done in the first place because what is needed in valid samples are infected epithelial cells) No amount of testing with semen sample using the Gonozyme and Chlamydiazyme will isolate this pathogen.Results will always be negative,unless PCR is used
5. Shifting of antimicrobials had no valid basis,ie in spite of a significant Increase in WBC counts by the 4th day present meds were continued Yet on the 5th and 7th day, there was a significant Decrease in WBC count (theoretical improvement) meds were again Shifted.
6. No significant improvement, was noted on the symptoms of the patient.
7. This approach converted the patient from non- inflammatory to inflammatory(CPPS category 3b -3a)

Our contention is that, as stated in Harrison`s Textbook of Internal Medicine “one of the most common errors when such a patient is Not responding is to add more antimicrobial agents Indiscriminately,when the correct course would be to discontinue therapy and observe the patient” Perhaps the latter is more valid than the former.
When this patient came in to our service we did not administer any antimicrobials Until we were able to isolate, using careful isolation techniques of both culturable and difficult to culture microorganisms. Misuse of antimicrobials was therefore avoided and the intended end point was reached to our satisfaction. (To be posted soon)