TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

PYELONEPHRITIS (KIDNEY INFECTIONS) AND

 

URINARY TRACT INFECTIONS (UTIS)

 

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What are They?


Why They Are Important


Frequency


Causes


Complicated Versus Uncomplicated


Symptoms


Diagnosis


Problems with Diagnosis


Treatments


Prognosis


 

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Home > Key Issues > Pyelonephritis and Urinary Tract Infections

 


Overview


  • Urinary tract infections are relatively common in CKD cats because the dilute urine seen in CKD allows bacteria to thrive.

  • In the worst case, the bacteria may travel up to the kidneys and cause infection there.

  • It is extremely important to treat these infections because they may make the CKD progress faster (in some cases, they may even cause CKD), and may make the cat feel very uncomfortable or downright ill.


What Are They


 

Most people have heard of or experienced an infection of the urinary tract, but may not be entirely clear exactly where it happens.

 

The urinary tract consists of:

  • two kidneys

  • two ureters: thin tubes, each of which leads from a kidney to the bladder

  • the bladder

  • the urethra: a tube which carries urine from the bladder to outside the body

The bladder and urethra are considered to be the lower urinary tract.

 

The kidneys and ureters are considered to be the upper urinary tract.

 

The expression "urinary tract infection" or "UTI" is normally (but not always) used to refer to infections in the lower urinary tract.

 

Inflammation in the upper urinary tract, particularly in the form of bacterial infections in the kidneys themselves, is often referred to as pyelonephritis or a kidney infection.

 

Cats are also prone to a condition commonly known as FLUTD (Feline Lower Urinary Tract Disease), which can have a variety of causes. Most  cases of FLUTD are not caused by bacterial infection, which is what this page addresses.

 


Importance


 

It is extremely important to treat infections in the urinary tract because they may make the CKD progress faster, and may make the cat feel very uncomfortable or downright ill.

 

In some cases, these infections may even cause CKD. Bacterial urinary tract infections (2016) Dowling PM Merck Veterinary Manual says "The consequences of untreated UTI include lower urinary tract dysfunction, urolithiasis, prostatitis, infertility, septicemia, and pyelonephritis with scarring and eventual kidney failure."

 


Frequency


 

Urinary tract infections are relatively common in CKD cats. Problem urinary tract infections (2012) Chew DJ & Westropp JL American College of Veterinary Surgeons Proceedings states "UTI occurs in approximately 30% of all cats with chronic renal failure (CRF ), many within one year of diagnosis of CRF."

 

Since most cats with CKD are older, they are at additional risk. Managing the E coli UTI (2011) KuKanich KS NAVC Clinician's Brief Aug 2011 pp61-66 says "cats older than ten years of age are predisposed and usually have concurrent illness."

 


Causes


 

Lower Urinary Tract Infections


These are usually caused by bacteria gaining access to the bladder. Urinary tract infections are relatively common in CKD cats because the dilute urine seen in CKD allows bacteria to thrive.

 

Around two thirds of UTIs in cats are caused by e Coli. Managing the E coli UTI (2011) KuKanich KS NAVC Clinician's Brief Aug 2011 pp61-66 says "Other bacteria associated with UTI include Staphylococcus, Streptococcus, Enterococcus, Proteus, and Klebsiella."

 

Overview of infectious diseases of the urinary system in small animals (2016) Brown SA Merck Veterinary Manual discusses the bacteria that may be seen.

 

Kidney Infections (Pyelonephritis)


In  some cases, the bacteria involved rise further into the upper urinary tract and cause kidney inflammation, also known as pyelonephritis. In cats, the cause is usually bacterial. Chronic Renal Failure (2001) Polzin DJ Delaware Valley Academy of Veterinary Medicine states that "infection at one location potentially places the entire urinary tract at risk for infection."

 

Sometimes pyelonephritis has other causes. Kidney stones can cause pyelonephritis, as may polycystic kidney disease (PKD). It may also be caused by bacteria carried via the bloodstream. Veterinary Partner says pyelonephritis is "caused by a bacterial invasion. The kidney infection may have come from the bladder through the ureters, the bloodstream, or have invaded via other organs. Infection via the bladder/ureters is the most common route. Urinary stasis, urethral obstruction, kidney stones, trauma, and depressed immunity may predispose the pet to pyelonephritis. The bloodstream route of infection may be caused by bacterial endocarditis, diskospondylitis, abscesses, and dental disease."

 

The Feline Patient (4th Ed.) (2010) Norsworthy GD (ed.) Wiley-Blackwell states ""Pyelonephritis is inflammation of the renal pelvis and parenchyma. The etiology in cats is typically bacterial…The infection may arise hematogenously (i.e., bacterial endocarditis, abscesses, or dental disease); however, experimental evidence favors ascension of bacteria from the lower urinary tract in most cases."

 


Complicated Versus Uncomplicated


 

Vets often divide these infections into two categories, uncomplicated and complicated. This plays a part in deciding on the most appropriate treatment plan, see below.

 

Uncomplicated


Uncomplicated or simple urinary tract infections mean that the cat is normally healthy, and there are no problems with the cat's bodily defence mechanisms or any structural problems, so the infection should respond fully to antibiotic therapy.

 

Complicated


Complicated urinary tract infections occur when there are other factors which increase the likelihood of an infection arising, persisting or recurring. Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the international society for companion animal infectious diseases (2011) Weese JS, Blondeau JM, Boothe D, Breitschwerdt EB, Guardabassi L, Hillier A, Lloyd DH, Papich MG, Rankin SC, Turnidge JD & Sykes JE Veterinary Medicine International 2011 pp1-9 state "“A complicated UTI is an infection that occurs in the presence of an anatomic or functional abnormality or a comorbidity that predisposes the patient to persistent infection, recurrent infection, or treatment failure.”

 

A comorbidity means the presence of other illnesses. As you might expect (particularly so since the kidneys are part of the urinary tract), chronic kidney disease means that UTIs in CKD cats are considered complicated, but cats with other diseases such as diabetes also qualify.

 

Other factors include anatomic or functional problems, for example a cat with polycystic kidney disease (PKD) forms cysts in the kidneys which can be a breeding ground for infection.

 

Cats with kidney stones or dental problems are also at increased risk, and if they develop an infection, it would be considered complicated.

 

Kidney infections are always complicated, even in otherwise healthy cats.

 


Symptoms


 

Urinary Tract Infections


Cats with a UTI often do not show any symptoms. Bacterial urinary tract infections Dowling PM Merck Veterinary Manual says "Unlike humans, veterinary patients are often asymptomatic, and the UTI may be an incidental finding.'

 

Pyelonephritis


Cats with acute pyelonephritis will often be obviously ill, e.g. not eating, sensitive to the touch in the lower back or abdomen (which your vet may detect during palpation), and/or have a fever. Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says "Animals with acute pyelonephritis may exhibit kidney or flank pain, fever, malaise, and sometimes vomiting, polyuria, and polydipsia."

 

Unfortunately, cats with chronic pyelonephritis may not be obviously ill or the signs may be subtle, such as increased urination, increased drinking, or vomiting, all of which are not uncommon in CKD cats anyway. Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says "Chronic pyelonephritis is more difficult to recognize, because clinical signs may be subtle or absent. Polyuria and polydipsia are frequent. In many cases, the disease goes unrecognized until kidney failure occurs."

 

One of our cats was prone to pyelonephritis, maybe because he had PKD (in PKD cats, the bacteria can enter the cysts in the kidneys and cause a deep-rooted infection), and initially he would simply be a little subdued. Fortunately, he also became incontinent every time, so we were able to recognise the problem and get treatment started promptly.

 


Diagnosis


 

The usual method of diagnosis is a urine test, but for pyelonephritis in particular other tests may also be appropriate.

Blood Tests


Cats with pyelonephritis may experience a worsening of their kidney bloodwork. In the worst case, this may be so severe that it leads to acute kidney injury. One member of Tanya's CKD Support Group had a cat who was diagnosed with pyelonephritis whose creatinine level was 26 mg/dl at diagnosis. Your cat's case will hopefully not be as severe, but if your cat's bloodwork worsens suddenly, speak to your vet about the possibility of your cat having an infection.

 

The presence of an infection is sometimes indicated in the white blood cell readings of a blood test, particularly if pyelonephritis is present.

 

CKD cats with chronic infections may also have anaemia.

 

Ultrasound


For cases of pyelonephritis, your vet may also wish to have an ultrasound performed to look at the renal pelvis. The renal pelvis is the top of the ureters (the tubes that lead to the bladder) and it may be dilated if pyelonephritis is present (this is known as pyelectasis), which should be visible on ultrasound (though this may not occur in the case of acute infections).

 

Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says "Other useful diagnostic tests include abdominal ultrasonography and IV pyelography. Both studies may show dilation of one or both renal pelvises secondary to inflammation and partial obstruction."

 

Feline chronic renal disease - acute presentation (2007) Zwingenberger A Veterinary Radiology says "Kidneys with pyelonephritis also tend to enlarge because of inflammation."

 

Urine Tests


The usual method to check for UTIs initially is via a urine sample. Cystocentesis is the best way to obtain a urine sample if you want to check for infection because the sample is sterile. Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the international society for companion animal infectious diseases (2011) Weese JS, Blondeau JM, Boothe D, Breitschwerdt EB, Guardabassi L, Hillier A, Lloyd DH, Papich MG, Rankin SC, Turnidge JD & Sykes JE Veterinary Medicine International 2011 pp1-9 state "Cystocentesis should be used for sample collection. Catheterized samples can be evaluated for culture but cystocentesis samples are preferred. Free-catch (midstream voiding or manual expression) samples should not be used. It is imperative that a quantitative culture be performed."

 

Urinary tract infection: how to diagnose and treat correctly (2003) is a presentation by Claudio Brovida to the World Small Animal Veterinary Association World Congress 2003 which explains why cystocentesis is the ideal method of urine collection, but not always possible.

 

Once the urine sample has been obtained, usually the vet will test it by dipping a test strip into the urine sample or by looking at a few drops of urine under a microscope. If bacteria are present in a clean urine sample, this is indicative of an infection. If no bacteria are seen, the result will usually say "none seen" or "negative" or "NSF" (an abbreviation for "no significant findings").

 

A negative test for bacteria does not mean no infection is present. Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says of chronic pyelonephritis "Although abnormalities in the urinalysis are present, they are often less dramatic than with acute kidney infection. A single urine culture can be negative if bacterial numbers are low."

 

Therefore even if the initial result is negative, it is important to run a culture and sensitivity test (see below), especially in a CKD cat, in whom these infections do not always show in standard urine tests (see below).

 

Elevated white blood cells are sometimes a sign of infection, but you cannot rely on checking white blood cells in the urine: FLUTD: a diagnostic approach (2011) Bovens C Feline Update (Langford Veterinary Centre University of Bristol) states  "Urine dipstick is frequently positive for leukocytes [white blood cells] in cats; this is unreliable and does not indicate the presence of inflammation or infection."

 

Urine tests may also find blood in the urine. Blood in urine may be a sign of infection, but there are other possible causes as discussed here.

 

Culture and Sensitivity (C&S) Test


A culture and sensitivity (or susceptibility) test means that the laboratory tries to grow the bacteria obtained from the urine sample over a few days (3-4).

 

If they are successful in growing the bacteria, they then treat each batch with a different antibiotic to ascertain to which antibiotic the bacteria are most sensitive (i.e. which antibiotic is most likely to kill the bacteria). Veterinary Partner explains more about these tests.

 

Some vets will only run a C&S test if they suspect pyelonephritis. However, Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the international society for companion animal infectious diseases (2011) Weese JS, Blondeau JM, Boothe D, Breitschwerdt EB, Guardabassi L, Hillier A, Lloyd DH, Papich MG, Rankin SC, Turnidge JD & Sykes JE Veterinary Medicine International 2011 pp1-9 state that even for uncomplicated UTIs, "Aerobic bacterial culture and susceptibility testing should be performed in all cases, to confirm the presence of infection, identify the presence of resistant bacteria that may not respond to initial therapy, to help differentiate reinfection from relapse should a UTI return."

 

It is particularly important to run a C&S test for a CKD cat because the dilute urine typically seen in CKD can make it hard to detect infections in other types of urine test. Cat Hospital of Chicago says "Performing urine cultures on cats with CKD is important. Since the urine is dilute, it can make identification of bacterial in the urine difficult. Thus, bacterial urinary tract infections can be missed by running just a simple analysis of the urine. A culture is the ‘gold standard’ test for determining if a kidney infection is a cause or complicating factor in the kidney failure."

 

A C&S test measures colony forming units (CFUs). Diagnostic caveats for difficult bacterial urinary tract  infections (2005) Osborne CA DVM News Magazine discusses UTIs and includes a table (Table 7) which shows what the levels of bacteria found in a urine sample obtained by various methods probably indicate. Problem urinary tract infections (2012) Chew DJ & Westropp JL American College of Veterinary Surgeons Proceedings has a similar table, though the values given differ somewhat. Overview of the urinary system (2016) Sanderson SL Merck Veterinary Manual states "If the sample is collected by spontaneous micturition [urination] or manual compression, significant numbers of bacteria are present if ≥10,000 CFU/mL of urine in cats are detected. Samples with >1,000–10,000 CFU/mL in cats are suspicious for a UTI. If the sample is collected by catheterization, ≥1,000 CFU/mL in cats is significant, whereas samples containing 100–1,000 CFU/mL in cats are suspicious for a UTI."

 

Generally speaking, for a cat whose urine was obtained by cystocentesis, a level over 1000 cfu/ml indicates probable infection, whereas for a mid stream urine sample, the level would probably need to be over 100,000 cfu/ml. A level below 20000 cfu/ml from a mid stream urine sample is probably contaminated.

 

Cultures are also often performed either after a cat has been treated with antibiotics to check that the infection has gone. You normally have to wait seven days after stopping antibiotics before you can do this (to give any surviving bacteria time to grow), but for a cat on a lengthy course of antibiotics, or a cat with recurring or resistant infections, it may be appropriate to run a C&S test every seven days to make sure the treatment is working. IDEXX Laboratories offer a Urine Culture and MIC Susceptibility, Low Colony Count (test code is 4033) which is "Recommended for patients with recent or current antibiotic therapy or when a low level of infection is suspected." This may also be of use for CKD cats where low levels of bacteria may be present.

 

RapidBac Vet is a new test that takes only 20 minutes to perform and costs a lot less than a culture. Diagnostic accuracy of a rapidimmunoassay for point-of-care detection of canine urinary tract infection (2016) Jacob ME, Crowell MD, Fauls MB, Griffith EH, and Ferris K American Journal Veterinary Research 77 pp162 reports that it was 95% accurate in tests with dogs. The manufacturer says recent tests in cats indicate sensitivity of 100% and a negative predictive value of 99%. I do not know of anyone who has used this test in a cat yet.

 


Diagnosis Difficulties


 

It is quite common for tests to indicate that your CKD cat does not appear to have a urinary tract infection when in fact one is present. Unfortunately not every vet accepts that this is the case. It does not help that cats do not always show any symptoms. Urinary tract infections in cats with chronic kidney disease (2013) White JD, Stevenson M, Malik R, Snow D & Norris JM Journal of Feline Medicine & Surgery 15(6) pp459-65 found that 72% of the cats in the study had occult (hidden) UTIs, i.e. a positive urine culture but no clinical signs of infection.

 

One human study, Establishment of a persistent Escherichia coli reservoir during the acute phase of a bladder infection (2001) Mulvey MA, Schilling JD & Hultgren SJ Infection and Immunity 69(7) pp 4572-9, found that in some cases the bacteria that cause urinary tract infections can burrow so deep into the bladder lining that they cannot be detected in the usual tests. In a later (2004) study reported by Science Daily, researchers found that the bacteria commonly involved in UTIs pass through four distinct developmental stages, including a dormant stage in some cases, which may help explain why UTIs often recur.

 

It is also quite common for nothing to grow in a culture if the cat has pyelonephritis rather than a lower urinary tract infection, particularly if the infection is chronic rather than acute. Some types of bacteria do not grow in a culture, or levels are too low to measure easily. Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says of chronic pyelonephritis "Although abnormalities in the urinalysis are present, they are often less dramatic than with acute kidney infection. A single urine culture can be negative if bacterial numbers are low."

 

The Feline Patient (4th Ed.) (2010) Norsworthy GD (ed.) Wiley-Blackwell states "The etiology in cats is typically bacterial (…) However, urine cultures do not always recover an organism. Usually, the affected cat is presented for chronic renal failure after many months or years of subclinical pyelonephritis; by this time, it is abacteriuric."

 

Pyelonephritis in small animals (2005) Parry NMA UK Vet 10(6) pp1-5 says "Absence of urinary changes does not rule out pyelonephritis as infection can localise to the renal parenchyma, producing no abnormalities on urinalysis and negative urine cultures. (...) The presence of urinary leucocyte casts is consistent with renal inflammation. Positive bacterial culture from urine obtained by cystocentesis is yielded in most acute cases, although in chronic cases cultures are often negative, and multiple cultures may be required to confirm UTI. Unfortunately, the leucocytosis may resolve with chronicity, making chronic pyelonephritis difficult to diagnose. Similarly serum chemistry profile is usually normal unless CRF develops."

 

Ultrasound may be helpful in diagnosing the existence of pyelonephritis, though this can be of limited value in cats with PKD, whose kidneys already look abnormal. Ultrasound may also help with detecting lower urinary tract infections, but only if the bladder is full. In both cases you need an experienced operator.

 


Treatments


 

The main treatment for urinary tract infections is antibiotics, though D-mannose may also be helpful.

 

Infections may sometimes lead to anaemia. If your cat has anaemia and an infection, and the anaemia is not life-threatening, you may be able to wait before starting an ESA for the anaemia because often anaemia caused by infection or inflammation will resolve once the infection has gone.

 

Humans with cystitis are sometimes advised to take cranberries. However, cranberries are not appropriate for CKD cats (see Holistic Treatments for more information on this). The active ingredient in cranberries is D-mannose, so you could consider giving this by itself, see below.

 

The British Medical Journal has information about a human study which showed that lactulose (which is normally used for constipation) may help prevent urinary tract infections in humans. However, I would not give only give lactulose if my cat needed it for constipation.

When to Start Treatment


Your vet may be reluctant to treat for an infection if test results come back normal. This may well be an appropriate response for healthy cats. Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the international society for companion animal infectious diseases (2011) Weese JS, Blondeau JM, Boothe D, Breitschwerdt EB, Guardabassi L, Hillier A, Lloyd DH, Papich MG, Rankin SC, Turnidge JD & Sykes JE Veterinary Medicine International 2011 pp1-9 state "Treatment may not be necessary in animals that have no clinical signs of UTI and no evidence of UTI based on examination of urine sediment."

 

However, this does not apply to CKD cats because of the fact that infections do not always show (see above) and the risks of leaving possible infections untreated. The working group goes on to say "In some circumstances, treatment may be considered if there is concern that there is a particularly high risk of ascending or systemic infection (e.g., immunocompromised patients, patients with underlying renal disease) or that the bladder may be a focus of extraurinary infection. Diagnosis and management of the underlying cause is critical and treatment should not be used as a replacement for proper diagnosis and management."

 

This is particularly important if your cat's kidney values have recently worsened, because an infection may be the cause. Management and treatment of chronic kidney disease in cats (2016) Caney S In Practice Oct 2016 pp10-13 says of lower urinary tract infections "Current recommendations are that these should be treated if the patient shows clinical signs (systemic and/or lower urinary), if pyuria is present, where ultrasound evidence of pyelonephritis is present and/or if renal function has recently deteriorated."

 

The International Renal Interest Society (2015) says "any urinary tract infection should be regarded as a potential pyelonephritis and treated appropriately."

 


Intravenous Fluids


 

Intravenous fluid therapy may also be necessary, particularly for cats who have a fever or who are not eating, or whose kidney values have worsened. Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says "Animals that are febrile, anorectic, dehydrated, or azotemic should be hospitalized to provide IV antibiotics and fluid therapy. Fluid therapy may prevent acute pyelonephritis from progressing to azotemic acute kidney injury and will improve renal perfusion and uremic signs in animals already experiencing uremia."

 


Antibiotics


 

UTIs and pyelonephritis are usually treated with antibiotics. Lower urinary tract infections are usually relatively easy to treat, but pyelonephritis can be trickier: Managing complicated urinary tract infections (2008) Grauer GF CVC in San Diego Proceedings says "Most bacterial infections of the lower urinary tract respond quickly to antimicrobial treatment; however, urinary tract infections (UTI) associated with defects in the host immune system (complicated UTI) often fail to respond or recur after antibiotic withdrawal and can be a therapeutic challenge."

Antibiotics: Choice of Medication


 

Uncomplicated


There is some debate about which antibiotic to use in these cases. For an uncomplicated urinary tract infection many vets start with amoxicillin, which can be a good choice. Managing the E coli UTI (2011) KuKanich KS NAVC Clinician's Brief Aug 2011 pp61-66 has a table that may assist with antibiotic selection and says that for simple UTIs, "E coli strains are susceptible to amoxicillin, amoxicillin clavulanic acid, or cephalexin. Enrofloxacin should be avoided as first-line treatment because of resistance."

 

Managing complicated urinary tract infections (2008) Grauer GF CVC in San Diego Proceedings says with regard to simple UTIs "Without benefit of bacterial sensitivity testing, the following are the drugs of choice for the bacteria listed: E. coli - enrofloxacin; Proteus - amoxicillin-clavulanic acid; Staph - amoxicillin-clavulanic acid; Strep - amoxicillin-clavulanic acid; Enterobacter - tetracyclines; Klebsiella - enrofloxacin; Pseudomonas - tetracycline. If bacterial identification is unknown, treatment is best based on the gram-staining characteristics, i.e., ampicillin/amoxicillin or amoxicillin-clavulanic acid for gram-positive bacteria and trimethoprim-sulfa or enrofloxacin for gram-negative bacteria."

 

There is currently some debate as to whether enteroccocus needs to be treated immediately. Diagnosing and treating urinary tract infection in cats (2015) Kovalik D Veterinary Medicine says "Treatment is not currently recommended for asymptomatic cats with isolates of Enterococcus species, as this infection commonly resolves without intervention."

 

In the UK you may be offered cefovecin (Convenia), because this is approved in Europe for the treatment of UTIs in cats. However, bacteria can develop resistance to cefovecin over time, so it should normally only be used a maximum of around three times.

 

Complicated


For complicated infections (which is what CKD cats have, or are deemed to have - The International Renal Interest Society (2015) says "any urinary tract infection should be regarded as a potential pyelonephritis and treated appropriately"), your vet will choose the most appropriate treatment based on the results of the culture and sensitivity test. Normally a broad spectrum antibiotic will be chosen because although one bacterium may dominate (usually E coli), it is not uncommon for more than one to be present.

 

My cat with repeated pyelonephritis did not respond to amoxicillin but enrofloxacin (Baytril) worked every time. Chronic Renal Failure (2001) Polzin DJ Delaware Valley Academy of Veterinary Medicine states "Enrofloxacin's excellent in vitro activity combined with good serum, renal tissue, and urine concentrations following oral or parenteral administration make it an excellent choice for these patients. Further, fluoroquinolones may ultimately supplant use of aminoglycosides for managing pyelonephritis in most patients because of their effectiveness of in achieving both renal and urine concentrations with minimal toxicity."

 

Antibiotics: Length of Treatment


 

Uncomplicated


Just like humans, healthy cats with lower urinary tract infections are usually given quite short causes of antibiotics, for perhaps 3-7 days, and these are usually very effective.

 

Complicated


Since cats with CKD are not healthy, they usually need a longer course of treatment in order to be sure that the bacteria are completely eradicated and the infection completely cured.

 

Cats with pyelonephritis in particular are usually given a prolonged course of antibiotics. The course of treatment will usually be for at least four weeks and may be as long as eight weeks, or occasionally even longer. This lengthy period is necessary because blood flow to the site of most kidney infections is poor, so it can take a while for the antibiotics to reach and kill the bacteria.

 

Unfortunately not every vet is aware of this recommendation so here are some links to share if necessary.

 

Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says "Pyelonephritis should be treated aggressively with broad-spectrum antibiotics, based on urine culture and antimicrobial susceptibility testing, for 4–8 wk."

 

Urinary tract infection (UTI): how to diagnose correctly and treat (2003), Brovida C Presentation to the 28th World Congress of the World Small Animal Veterinary Association mentions that antibiotic treatment should continue for 4-8 weeks in the case of kidney infections.

 

Management and treatment of chronic kidney disease in cats (2016) Caney S In Practice Oct 2016 pp10-13 says "Typically a prolonged course of treatment (eg, four to six weeks) is needed to eliminate the infection."

 

Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the international society for companion animal infectious diseases (2011) Weese JS, Blondeau JM, Boothe D, Breitschwerdt EB, Guardabassi L, Hillier A, Lloyd DH, Papich MG, Rankin SC, Turnidge JD & Sykes JE Veterinary Medicine International 2011 pp1-9 state "Treatment of 4–6 weeks is often recommended. A shorter duration of therapy might be effective; however there is currently inadequate evidence to provide objective recommendations, and 4–6 weeks of treatment is recommended at this time.”

 

Chronic Renal Failure (2001) Polzin DJ Delaware Valley Academy of Veterinary Medicine states "It is recommended that acute, uncomplicated UTIs and some reinfections be treated for a period of 10 to 14 days whereas most recurrent UTI, complicated infections, pyelonephritis, and prostaitis should be treated for at least 4 to 6 weeks. Infections involving the kidney(s) and prostate gland may require even more prolonged therapy."

 

In cases of pyelonephritis, the dose may also need to be increased or given more frequently: Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says "The infection may respond to the same antibiotics recommended for cystitis, but more frequent administration (eg, amoxicillin tid rather than bid) and/or higher dosages are indicated."

 

Diagnosing and treating urinary tract infection in cats (2015) Kovalik D Veterinary Medicine states "Antimicrobials should be given not just for seven to 14 days, but until a bacteriologically sterile urine can be confirmed both during administration of medication and for a protracted time after cessation of treatment."

 

Monitoring


Uncomplicated


If you are giving antibiotics for a short period (3-14 days), your vet should check the urine again and run another culture 7-14 days after stopping the antibiotic to make sure the infection has completely gone. With a 14 day course, some vets also like to check the urine about three days before the end of the course.

 

Complicated


If, as is more likely, you are giving a lengthy course of 4-8 weeks, then your cat's progress should be monitored via urine culture once or twice a week during the therapy and again after completion. Management and treatment of chronic kidney disease in cats (2016) Caney S In Practice Oct 2016 pp10-13 says "Repeat urine culture is recommended during the treatment period and seven to 10 days after treatment has concluded to confirm treatment success."

 

The purpose of monitoring is to make sure there is a response, in case you need to change to a different antibiotic. If the antibiotics seem to be working (i.e. culture counts are reducing), you do not normally stop the antibiotics, but give the complete course to be sure you are eradicating the infection.

 

Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the international society for companion animal infectious diseases (2011) Weese JS, Blondeau JM, Boothe D, Breitschwerdt EB, Guardabassi L, Hillier A, Lloyd DH, Papich MG, Rankin SC, Turnidge JD & Sykes JE Veterinary Medicine International 2011 pp1-9 state "Urine culture should be considered 5–7 days after initiation of therapy, particularly in patients with a history of relapsing or refractory infection, or those considered at high risk for ascending or systemic infection. Any bacterial growth during treatment indicates potential treatment failure and should prompt immediate re-evaluation. Referral or consultation with a specialist is recommended. Urine culture is recommended 7 days after cessation of therapy in all cases."

 

Pyelonephritis in small animals (2005) Parry NMA UK Vet 10(6) pp1-5 says "Unfortunately since there is often poor antibiotic penetration into the renal medullary parenchyma, chronic pyelonephritis may be difficult to treat. A urine sample may be cultured seven to ten days after treatment initiation, and then repeated one week post-antibiotic therapy, and monthly thereafter until three consecutive negative cultures are obtained."

 

 Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says "A urinalysis and culture should be repeated 3–7 days after therapy, and then monthly for 3 consecutive months. If all of these cultures are negative, the interval between urine cultures may be gradually lengthened. Animals with pyelonephritis are at high risk of persistence or recurrence of infection and for secondary infections at other sites (eg, bacterial endocarditis and discospondylitis)."

Recurrence: Relapses and Reinfection


Unfortunately it is not uncommon for urinary tract infections to relapse or recur, especially if too short a course of antibiotics has been given. A recurring urinary tract infection is often classified as:

  • Relapsing

    The infection returns, usually a few days after stopping treatment, and it is caused by the same bacteria that caused the first infection.

  • Reinfection

    The cat develops another infection but this time it is caused by a different bacterium. This will usually happen some time after the antibiotics used to treat the initial infection were stopped. This can occur because often the cat is infected with more than one infective agent. Bacterial urinary tract infections (2016) Dowling PM Merck Veterinary Manual says "In dogs and cats, UTI are caused by more than one pathogen 30% of the time. In immunocompromised patients, funguria from Candida spp may be seen."

It can be difficult to tell if an infection is relapsing or recurring. I am guessing with my cat who had repeated infections that it was relapsing, because the antibiotic we used did always do the trick.

 

Antibiotic sensitivity profiles do not reliably distinguish relapsing or persisting infections in cats with chronic renal failure and multiple diagnoses of Escherichia coli urinary tract infection (2006) Freitag T, Squires RA, Schmid J, Elliott J & Rycroft AN Journal of Veterinary Internal Medicine 20(2) pp245-9 states that it can be hard to tell if a cat has a new infection or a recurring one.

 

Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the international society for companion animal infectious diseases (2011) Weese JS, Blondeau JM, Boothe D, Breitschwerdt EB, Guardabassi L, Hillier A, Lloyd DH, Papich MG, Rankin SC, Turnidge JD & Sykes JE Veterinary Medicine International 2011 pp1-9 state "Aerobic bacterial culture and susceptibility testing should be performed in all cases, to confirm the presence of infection, identify the presence of resistant bacteria that may not respond to initial therapy, to help differentiate reinfection from relapse should a UTI return."

 

Managing the E coli UTI (2011) KuKanich KS NAVC Clinician's Brief Aug 2011 pp61-66 states "Recurrence of UTI with the same organism warrants fur ther investigation of potential problems with antimicrobial treatment and/or reevaluation for a source of the infection (uroliths or neoplasia). Recurrence of UTI with a different organism warrants further investigation for a cause of immunosuppression."

 

Pulse Dosing


Because of the risk of recurrence, some vets choose to put CKD cats on a low level dose of antibiotics on an ongoing basis, or recommend pulse dosing, where the cat is given antibiotics at regular intervals for several days at a time, e.g. for the first five days of every month.

 

Managing complicated urinary tract infections (2008) Grauer GF CVC in San Diego Proceedings states "For animals with frequent infections, which cannot be cured, low dose (1/3 to 1/2 of the conventional daily dose) antimicrobial administration at bedtime may be recommended after the urinary tract has been sterilized with standard dose antibiotic treatment. This allows the drug to be present in the bladder overnight supplementing the animal's defense mechanisms. Low (sub therapeutic) dosages of antibiotic may reduce infections by interfering with bacterial fimbria production and therefore uroepithelial attachment. For recurrences due to gram-positive bacteria, penicillins are recommended; while for recurrences caused by gram-negative bacteria, trimethoprim-sulfa or enrofloxacin is recommended."

 

There may be risks in doing this because it can increase the chance of antibiotic resistance, but if your vet wishes to do this, discuss it and decide whether you think it is a reasonable treatment for your cat: infections can be hard for the weakened immune system of a CKD cat to cope with and to recover from, so in some cases this is not an unreasonable option.

 

I did not try pulse dosing for my cat, but since he used to let us know whenever he had a kidney infection by becoming incontinent, my vet gave me an emergency supply of enrofloxacin (Baytril) so I could start antibiotics immediately whenever the problem arose.


D-mannose


 

D-mannose is a simple sugar, in fact it is actually the active ingredient in cranberry but without the downsides associated with cranberry.

 

A human study at the Washington University in St Louis School of Medicine, Establishment of a persistent Escherichia coli reservoir during the acute phase of a bladder infection (2001) Mulvey MA, Schilling JD & Hultgren SJ Infection and Immunity 69(7) pp 4572-9, found that in some cases the bacteria that cause urinary tract infections can burrow so deep into the bladder lining that they cannot be detected in the usual tests. D-mannose appears to be very helpful when dealing with this sort of infection.

 

It does not kill the bacteria as an antibiotic does; rather, it works by attracting the bacteria to bind with itself rather than with the bladder wall; the bacteria can then be passed out of the body via urination.

 

D-mannose will only work for urinary tract infections caused by E coli (and not all of them), and possibly for infections caused by Klebsiella bacteria. Klebsiella infections are rare, but E coli accounts for around 67% of urinary tract infections in cats.

 

I am not aware of any research into the use of D-mannose in cats but Effect of D-mannose and D-glucose on Escherichia coli bacteriuria in rats (1983) Michaels EK, Chmiel JS, Plotkin BJ & Schaeffer AJ Urological Research 11(2) pp97-102 found that it significantly reduced levels of E coli in rats. I have heard from a number of people who have tried this treatment on their cat, and all of them thought it was effective.

 

Although D-mannose is a type of sugar, it does not get absorbed by the digestive tract. Therefore it should be safe for diabetic cats, but check with your vet before using if your cat has diabetes.

 

Although D-mannose appears to be effective, it seems to work best for cats with a recurring UTI. If your CKD cat is prone to persistent, ongoing or repeated UTIs, speak to your vet about using

 

D-mannose is not intended to take the place of antibiotics. If your vet prescribes antibiotics, you must use them, because untreated urinary tract infections can rise into the kidneys and cause permanent damage, which is the last thing a CKD cat needs. See Treatments for more information on treating urinary tract infections.

 

D-mannose Dosage


  • A commonly used dose is 250-500mg twice a day. Managing the E coli UTI (2011) KuKanich KS NAVC Clinician's Brief Aug 2011 pp61-66 mentions a dose of 250-1000mg twice daily.

  •  With most (but not all) brands, a ¼ of a teaspoon of the powder is 500mg, so if you are giving 250-500mg, you would give ⅛-¼ teaspoon twice a day, but check with your vet.

  • Some people find it works better if they divide the total amount over 3-4 doses a day.

  • Keep giving it for a week after the symptoms have disappeared.

Since it is a type of sugar, D-Mannose has a pleasant taste. It can be easily mixed with wet food or mixed with water and syringed into the cat's mouth.

 

Where to Buy D-mannose


D-mannose is widely available from health food shops such as Vitamin Shoppe and Wholefoods (it is often in the women's health section). You want pure D-mannose. It can also be bought online:

 

USA


Amazon

sells the Now brand at US$17.33 for 3 oz. Some people are reporting (April 2016) a possible problem with one batch with an expiry date of 11 2018.

Iherb

sells the Now brand. 3 oz cost US$20.38.

 

Vitacost

sells 2.5 oz of the Kal brand for US$27.33. This brand is stronger than some others so the dosages mentioned above need to be amended accordingly.

 

UK


Amazon UK

sells the Now brand at £20.37 for 3 oz.

D-Mannose UK

sells 50g for £17.50. This company will ship to other countries.

 


Prognosis


 

Urinary tract infections can be very worrying, particularly so since they can trigger CKD or acute kidney injury, or cause CKD to worsen. They can also be challenging to treat.

 

Do not give up hope. My cat did not have CKD but he had PKD and frequent kidney infections, yet he never developed CKD. One member of Tanya's CKD Support Group had a cat whose creatinine level was 26 mg/dl at diagnosis. He was diagnosed with pyelonephritis, and although he needed a twelve week course of antibiotics, he made a full recovery with no permanent kidney damage. Although you may not see a full recovery in a cat who already has CKD, the bloodwork may improve once the infection is under control. Urinary tract infections may sometimes lead to anaemia, which should also improve once the infection has gone.

 

Pyelonephritis in small animals (2016) Brown SA Merck Veterinary Manual says "Animals with acute pyelonephritis may recover normal renal function, depending on the amount of damage that occurred before treatment. In cases of chronic pyelonephritis with a severely hydronephrotic, nonfunctional kidney, a nephrectomy may be the treatment of choice once the animal has been stabilized. This will remove the source of infection and hopefully save the opposite kidney. IV pyelography and/or renal scintigraphy are useful to assess the relative function of each kidney. If both kidneys are severely affected, medical management alone is the only alternative. Recovery to chronic, stable renal failure is possible in many cases."

 

Case report: pyelonephritis and chronic renal insufficiency in a cat (2013) DeVictoria TM Urology 34(4) reports on a young cat with both CKD and pyelonephritis.

 

Advanced Veterinary Care Center describes the case of a seven month old cat with CKD who developed acute kidney injury on top of the CKD because of a kidney infection.

 

 

 

 

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This page last updated: 04 May 2017

Links on this page last checked: 04 May 2017

 

   

*****

 

TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE EXTREMELY DANGEROUS.

 

I have tried very hard to ensure that the information provided in this website is accurate, but I am NOT a vet, just an ordinary person who has lived through CKD with three cats. This website is for educational purposes only, and is not intended to be used to diagnose or treat any cat. Before trying any of the treatments described herein, you MUST consult a qualified veterinarian and obtain professional advice on the correct regimen for your cat and his or her particular requirements; and you should only use any treatments described here with the full knowledge and approval of your vet. No responsibility can be accepted.

 

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