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

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 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 her 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 of 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 of Xarelto daily. It was ceased last night but taken again today. 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 0.2 to 0.3 Gallons of water daily. We are just trying to gauge the significance of the blood in the urine. She has no specific urinary symptoms but is more sleepy overall.

Thank you.

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 to a few antibiotics, she does not tolerate them overall 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 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.

Hi doctor,

I checked my mother's urine again tonight as she had a pink stain on her underwear, and her 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, 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 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.

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 and noticeable pink tinge in the toilet and taking in mind my mother is 90.

Hello doctor,

Thank you for your suggestions. I will follow the same and will visit the urologist in person.