Q. I’m in my tenth year as a C7 quadriplegic. I manage my bladder with intermittent catheterization. When I have signs of an impending bladder infection — cloudy or smelly urine, feeling a bit run down — I try to flush it out by drinking lots of water. This usually does the trick, but if it continues or gets worse, my primary care doc has me drop off a urine sample before she will start me on antibiotics.

I have friends whose doctors keep them stocked with Cipro or Levaquin and they take one or two at the first sign of a UTI. Recently a friend complained that his doctor had stopped writing him scripts for preemptive antibiotics, saying “Why would he do this? Cipro is harmless, it isn’t addicting.” I try to explain this type of antibiotic use is setting them up for trouble, but they say it is better than getting a UTI. Am I overreacting? Does taking antibiotics at the first sign of a UTI cause problems?
— Jenny

A. Jenny, you are right on the mark. Antibiotics are amazing drugs that can be lifesaving when used properly. But taking them haphazardly every time you are feeling run down or have cloudy or smelly urine is akin to playing Russian roulette. It can cause serious, often life-threatening complications, including severe stomach problems and antibiotic-resistant strains of bacteria.

All antibiotics should only be used under a doctor’s care and according to a pharmacist’s instructions. Ciprofloxacin (Cipro) and Levaquin are very powerful broad spectrum antibiotics (they kill a wide range of bacteria) known as fluoroquinolones. A June 5, 2014 article in La Revue de Medicine Interne explains that fluoroquinolones are among the most frequently prescribed antibiotics in the world. They are lifesaving when needed and used properly. But fluoroquinolone-resistant strains of bacteria are on the rise, and these bacteria are also resistant to other classes of antibiotics. The article says in order to maintain their usefulness, it is crucial that fluoroquinolones only be used when essential, must be taken properly, and the entire prescription must be finished.

Kathleen Dunn, clinical nurse specialist and rehab case manager, adds: “Broad spectrum antibiotics are very much overused. If you don’t take them as prescribed, and don’t finish the entire prescription, you significantly increase your chance of developing antibiotic-resistant strains of bacteria.” She says people put pressure on their doctors to prescribe antibiotics for everything from early stages of a UTI to viral infections like the flu. “A health provider caves in and issues a prescription. This is especially bad when somebody thinks they have a UTI but doesn’t get appropriate lab tests. This sets the person up to develop antibiotic resistance.”

Another reason to use antibiotics carefully and wisely is they play havoc with the gut. A 2013 Stanford School of Medicine study explains that the intestines of an average healthy person have over 1,000 different microbes that coexist and work in conjunction to break down food into vital nutrients and fight off bacteria that can make us sick. The study found that as few as two five-day courses of fluoroquinolones in a year destroy certain beneficial bacteria, and the damage is cumulative. The more courses taken, the more the damage. Researchers found the change is subtle, and the effect isn’t noticed for years — until perhaps the body is invaded by a bad bacteria, one that would normally be handled by good bacteria, except the good bacteria have been killed off by repeated antibiotic use.

This appears to be the mechanism behind clostridium difficile (C. diff) — a serious, sometimes life-threatening infection caused by spores that lay dormant in many people’s gut, held in check by good bacteria. When an antibiotic kills the good bacteria, the C. diff spores come alive and run rampant, causing high fever, abdominal cramping and severe, bloody diarrhea.

There have also been studies looking at a link between long-term antibiotic use and the development of celiac disease — something that hits close to home. In the late ’90s and early ’00s this author was guilty of taking Cipro whenever I felt a UTI coming on. I figured I found a way to beat the system. I was wrong! A few years ago I developed celiac disease.

But what do you do when you have SCI and are more likely to get certain maladies that require antibiotic treatment in a timely manner? The best plan is to develop a good relationship with a local primary care doc. Tell the doc about the infections that are prevalent with SCI, such as UTI, cellulitis, etc. Explain that you may need to drop off a urine sample, and if you have a fever, to get started on an antibiotic right away, or be seen right away if you have signs of cellulitis (see resources). Dunn explains that if a person with SCI is symptomatic with a UTI and the provider collects a pre-antibiotic urine specimen for culture, it is OK to start an antibiotic and then wait for the culture to come back — and then change to the correct antibiotic or a narrower spectrum antibiotic when the test shows the specific bacteria the antibiotic is sensitive to. Of course, you also need to make sure you are versed in bladder care and UTI prevention — see resources for a refresher courses and options.

Even with the best health routine, having an SCI means you are likely to require antibiotics at some point. A way to “replant” the good gut microbes is by taking probiotics, which are good bacteria. Nutritionist Joanne Smith, co-author of Eat Well, Live Well with Spinal Cord Injury, says when antibiotics are necessary, you can still protect/help the bacterial balance in your gut by simultaneously taking probiotics. She says when doing so, it’s important to take them at least two hours after taking the antibiotic.  And after an antibiotic course is complete, in order to re-inoculate the gut, take probiotic supplements that have a minimum of 8 billion micro-organisms per dose for at least two to three months. Smith says that since SCI compromises immune function, she recommends a probiotic supplement every day to continuously support the immune system and help reduce infection risk associated with the urinary tract, respiratory system and pressure sores.

Figuring out which probiotic to take can be a task. Anecdotally, to combat the possibility of developing C. Diff, NEW MOBILITY editor Tim Gilmer’s favorite is Florastor [Note: Always see a physician if you suspect C Diff]. This writer likes VSL #3, which has 112-billion micro-organisms per capsule.

Resources
• Bladder Care Education Modules, Craig Hospital: www.craighospital.org/Left-Nav/Specialty-Services/SCI—TBI-Health-Info/Education-Modules/Bladder-Care
• Florastor Probiotic: www.florastor.com
• Neosporin Gu: www.newmobility.com/2011/04/neosporin-gu/
• Para/Medic: Gluten Sensitivity, Celiac Disease and SCI: www.newmobility.com/2013/05/paramedic-gluten-sensitivity-celiac-disease-and-sci/
• Para/Medic: Understanding Cellulitis: www.newmobility.com/2011/05/paramedic-understanding-cellulitis/
• VSL #3 Probiotic: www.vsl3.com
• When to Treat a UTI with Antibiotics: www.newmobility.com/2010/04/when-to-treat-a-uti-with-antibiotics/

Advice in this column is supported by Craig Hospital’s SCI Nurse Advice Line, a toll-free hotline for people living with SCI, a community service partially funded by the PVA Education Foundation, Craig H. Nielsen Foundation and Caring for Colorado Foundation. For non-emergency nursing info about SCI health, call 800/247-0257 between 9 a.m. and 4 p.m. Mountain time.