Monday, September 12, 2011

SUNDAY'S INTERESTING CASE. Sep 11, 2011. Urine test shows bacteria 3+

When the urine is collected directly from a dog peeing outdoors, there is the possibility of bacterial contamination. In this case of one dog who had fits for the 3rd time 2 days ago, I reviewed the record of one urine sample collected and tested showing bacteria +++. However, no antibiotics was prescribed by Vet 1. Vet 1 received the urine sample and handled the case accordingly.

I know that the owner works in a human medical polyclinic and knows what to do when it comes to urine collection.

She collected the urine "mid-stream", that is, let the dog pass some urine first and then collect directly the next flow. The urine was collected in a container provided by the Lab. She sent the urine in to Toa Payoh Vets for analysis. As I was not around, Vet 1 took the responsibility of handling this urine sample.

The urine showed 3+.

Now, in veterinary medicine, each vet has his or her own interpretation of the laboratory results and come to a decision.

Vet 1 judged that the bacteria was not from the urine. Therefore no antibiotics were prescribed.

In my opinion, I would have prescribed antibiotics for a suspected urinary tract infection. A bacterial culture would have been advised too but due to financial considerations for the owners, this is often not asked of the owner.



I asked Vet 1 who said that the owner did not wish to have antibiotics.
The owner came on this Sunday to see her dog. I asked why she did not want antibiotics. She said: "Vet 1 said that no antibiotics were necessary as the urine was contaminated."

Now there was a difference of reply. I needed to investigate what happened, being the licensee and shouldering the responsibilities of sustaining a practice.

So, I had a meeting with Vet 1, the owner and myself present inside the consultation room to clarify the matter immediately, as to why the owner did not want antibiotics. There are some Singapore owners who don't want antibiotics nowadays and so Vet 1's explanation would be logical had I not asked the owner's side of the story. The vet on the spot has to judge. And be responsible for the judgment.

At the meeting on this busy Sunday morning, the owner denied having said she did not want antibiotics. "Why would I reject antibiotics when my cat's urine has bacteria 3+?" she protested.

Vet 1 said: "It is a mis-communication." It was an emotional meeting to clear the air as the owner was very upset over the allegations. A dog with three fits is a very stressful to any owner. The dog had a sudden attack, ran to her father screaming. Foam spilled out of the dog's mouth. When the dog was calmed down, the dog started pooping and peeing all over the apartment. She phoned me for a house-call but I told her it would be better to send the dog down for my examination. She had not told me of the 2nd fit episode.

I had a blood test, urine test, X-ray of the chest and abdomen done with permission from the owner. I reviewed the urine test result done some 3 weeks ago and noted that Vet 1 had not prescribed any antibiotics. Hence, the situation arose when I found this out.

A vet has to be responsible for his judgment. Sometimes, I do not prescribe antibiotics if I deem it unnecessary. In one case, I spayed a female dog and had given an antibiotic and pain-killer injection. As the spay was a smooth short surgery, I did not deem it necessary to give antibiotics and pain-killers at home. However, the owner's wife wanted the medication. The harassed husband came for them. It does not matter what I think. I prescribed the antibiotics and pain-killers for the next 4 days.

The husband came for the medication. He gave me a feedback, saying he wanted to bash Vet 1's up. "Why?" I asked. He said: "Vet 1 shouted at me from inside the consultation room when I asked a question how long the pain-killer injection lasted. Sitting on his chair and shouting from inside the room. So rude!"

I said: "From my knowledge of Vet 1 over the years, Vet 1 has a gentle personality."

Later, I asked Vet 1 what had happened. Vet 1 said that Vet 1 was busy consulting and therefore shouted out the reply.

Much could have been avoided had I prescribed antibiotics and pain-killers for 4 days after the operation as I usually do. You can say it was a lapse of judgment, but I find that dogs and cats who had one post-op injection of antibiotics and pain-killers do well.

Sometimes, it is best to prescribe antibiotics as it is hard to tell whether the infection will set in. In any case, a dog urine with bacteria +++ definitely requires antibiotics and failure to give them may constitute an act of negligence in a court of law if a "reasonable man" (i.e. a vet) will prescribe antibiotics in such a situation. Singapore owners are much more sophisticated. They will check the internet first to do research before consulting the vet.

In this case of the dog with the 2nd fit, the owner did not inform me about the incident till Sunday. As to the cause of the fit, most of the causes are idiopathic, ie. unknown.

However, based on the fact that the dog had urinary bladder stones removed and had fits after the surgery (first episode) a few months ago, there could be a relationship to urinary stone formation. In the 3rd episode, the dog had passed blood, blood was 4+, White cells very high, the pH was 8.0 (alkaline) and struvite crystals (2+) was detected in the urine.

The owner had fed rawhide as she felt that the dog's quality of life must be poor, eating SD diet every day. Would this be the cause of recurrence of urinary bladder crystals and high pH? It is hard to say. X-ray did not show any radio-opaque struvite stones.

More urine and other test need to be done monthly or 3-monthly. But few owners do bother. Till another episode of fits.

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