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Q. My mom is suffering blood in urine. Is it due to UTI or Xarelto?

Answered by
Dr. Shahil Khant
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Dec 11, 2017

Hi doctor,

This deals with my mother, who has a history of chronic E. coli bladder infections. She has been on preventative antibiotics and topical estrogen. Recently, she was eight months UTI free with being on 2000 mg mannose sugar daily. Her eGFR was 65 around six months ago. I reduced the sugar down to 1500 mg. About a week ago, she developed some UTI symptoms. Historically, she would get incontinence, urgency and a distinctive radiating pain shooting up torso when she peed. However, this week, she had only the symptom lightly once in two days in a row. Otherwise, she had no other symptoms. I have attached the urine sample report. I also have urinalysis strips.

On the day of the laboratory sample, the strip was positive for nitrites, but nothing for RBCs or leukocytes. We increased her mannose to 3 g for two days and then 2 g for three days. Then, the dipstick test showed leukocytes, nitrites and RBCS 200. Today, two tests showed traces or negative nitrites (3 hours bladder retention). However, the RBCs are still high at 200 and the urine sample showed a pink tinge. I have been given approval by a urologist to give my mother Fosfomycin. My mother's E. coli in the past have shown resistance to Bactrim, Amoxicillin, Ampicillin, etc. She has no symptoms at this point other than being more tired and she is 90. Someone told me if nitrites are getting less, she might be able to get over this incident without a formal antibiotic. She does take 15 mg Xarelto daily. It was ceased last night, but taken today again. Is Xarelto playing a factor here? She also used to take estrogen cream more regularly, but now once a week if she remembers it. She had spot bleeding on her underwear a few months ago around once or twice and an ultrasound showed nothing. She has an ovarian cyst.She drinks 1 to 1.25 liters of water daily. We are just trying to gauge the significance of the blood in the urine. She has no specific urinary symptoms, but more sleepy overall. Thank you.

Dr. Shahil Khant

Andrology General Surgery Urology
#

Hi,

Welcome to icliniq.com.

I have gone through the history and the reports sent by you (attachment removed to protect patient identity).

  • According to me, it is because of her age her bladder power is weak. So, her voiding efficiency is less, which would be the cause of UTI. To know that, get an ultrasound abdomen with post-void residual urine.
  • Her bleeding is because of Xarelto (Rivaroxaban), which is an anticoagulant drug and not due to urinary infection. Though it was stopped once in between, but its effect stays for seven days in the body.
  • If she does not have a fever, then there is no need to give Fosfomycin at present. Also, she does not require urgent clinic care at present.
  • Her urine culture, which you had sent, shows Escherichia coli infection with sensitivity to many drugs.
  • I suggest her tablet Nitrofurantion 100 mg in the morning and in the evening for seven days and repeat urine culture after 10 days. Consult your specialist doctor, discuss with him or her and take the treatment with consent.

For further information consult a urologist online -->https://www.icliniq.com/ask-a-doctor-online/urologist


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Hi doctor,

My mother had elevated liver enzymes after being on Nitrofuran 100 mg for 2.5 years. They dropped after ceasing the drug. Even for treatment episodes such as 10 days on Nitro she would have a rebound infection within two weeks. She has tolerated Fosfomycin well. This morning the urinalysis was negative for leukocytes and nitrites, but still positive for 200 plus RBCs. Does the bleeding potential increase as she is on Xarelto and going through an asymptomatic E. coli incident? You infer it is strictly the blood thinner. She had a symptomatic E. coli episode eight months ago where she also had higher RBCs. She will be stopping Xarelto for a couple of days. She takes it for atrial fib and can do so periodically when she gets spinal injections. Though she is sensitive for a few antibiotics, she does not tolerate them over all well and Fosfomycin is the last in the toolbox. The mannose sugar kept her UTI free for eight months. She does have some post urine void and the spinal arthritis has resulted in poor hygiene. She lives with me. I am grateful that the mannose has worked overall and hopefully she can clear this episode. I hope that today's urinalysis negative for nitrites and leukocytes is a positive sign.

Dr. Shahil Khant

Andrology General Surgery Urology
#

Hi,

Welcome back to icliniq.com.

  • Yes, I think bleeding is due to Xarelto only and not because of UTI.
  • There is no need to give Fosfomycin at present, if she does not have a fever. Because, I feel that she should not get resistant to Fosfomycin also, which is the last drug available in our hands. So, save it for later.
  • She should also increase her fluid intake up to 2 liters per day.
  • We will treat her only when she gets a fever, which is a sign of a UTI and not based on nitrites or leukocyte esterase or pus cells.

For further information consult a urologist online -->https://www.icliniq.com/ask-a-doctor-online/urologist


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Hi doctor,

I checked my mother's urine tonight again as she had pink stain on her underwear and RBCs were 200 plus. Her leukocytes and nitrates were back again. In the absence of any real life medical assistance, another doctor stated that in light of an existing UTI coupled with taking Xarelto could induce bleeding. As I stated, Before also she had a symptomatic E. coli back with bleeding though she was on Xarelto as well. It was treated with Cipro and she went on Mannose for eight months without any problem. She has ceased the Xarelto for the time being. I would have preferred if I did not have to give the Fosfomycin, but it is too much of a gamble. You never gave that direction to stop the Xarelto temporarily, but I have done this for a couple of days and will have to consult the cardiologist. Even though she had no symptoms this time, I did not wish to rely on the mannose any longer. It was not getting any better. The high RBCS, but you put it solely on the Xarelto. It cannot be a coincidence as it happened this week with the E. coli.

Dr. Shahil Khant

Andrology General Surgery Urology
#

Hi,

Welcome back to icliniq.com.

  • As per her clinical condition, I am saying that bleeding is due to Xarelto and not due to UTI as she do not have fever.
  • Leukocyte esterase and nitrites positive does not mean infection always. To prove if presently any infection is there or not, we need urine culture and sensitivity.
  • If you want to rule out infection, then it is better to get done urine culture and sensitivity.
  • I cannot suggest to stop Xarelto, because I do not know about her present heart condition and you need to consult your cardiologist.
  • So, get a urine culture and if it shows positive for infection, then we will treat her for UTI.

For further information consult a urologist online -->https://www.icliniq.com/ask-a-doctor-online/urologist


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Hi doctor,

I posted her urine culture and sensitivity. It cannot be a coincidence that she has had this bleeding now for four consecutive days and it had nothing to do with initial E. coli. She has gotten the Fosfomycin now because of the continuous bleeding, noticeable pink tinge in the toilet and taking in mind my mother is 90.

Dr. Shahil Khant

Andrology General Surgery Urology
#

Hi,

Welcome back to icliniq.com.

  • Based on that urine culture only I asked to take Nitrofurantion before, because it shows sensitivity to Nitrofurantion.
  • I still say that without fever there is no need to take Fosfomycin antibiotics. It is very powerful and you are making her resistant to Fosfomycin. Kindly get an opinion for another urologist and proceed with the treatment.

For further information consult a urologist online --> https://www.icliniq.com/ask-a-doctor-online/urologist


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