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Dr. Joey
Dr. Joey, Board Certified
Category: Dog Veterinary
Satisfied Customers: 4695
Experience:  15 yrs in practice, specialist canine/feline medicine
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I urgently need some advice. I have a 14 year old rescue

Customer Question

I urgently need some advice. I have a 14 year old rescue ***** *****/terrier mix who has always had to be sedated to go to the vet. He has been on phenobarbital for years 1.5 pills per day. On 6/17 I brought him as he had been coughing for a few days....he was sedated for about 5 min and the doctor found he had tonsillitis. Started him on Baytril - made him extremely sick. So on 6/21 we started him on Amoxicillin. He seemed to be getting worse so on 6/25 it was switched to cefpodoxime Proxetil. This past Tuesday, I brought him back in and he was sedated again for approx. 10 min and they did a culture of this tonsil and also now heard a murmur. They did xrays and he is in congestive heart failure. They started Encard 5mg per day and Lasix 20mg 1/2 pill 2x per day. He was struggling on Friday am so when I called they added Pimobenden 5mg 1/2 pill 2x per day. By Friday night the culture came back as Stenotrophomonas maltophilia and was started on Trimethprini-Sulfa 480mg 1/2 pill every 12 hours. It is now Sunday evening and I feel his cough is not much better. I have also looked this bacteria up and not sure he is on the right antibiotic or how long would it take to start to work. In human cases I see that that bacteria can cause the congestive heart failure. I am trying to get another professionals thoughts on the meds he is on as I can't just take him easily to the vet without being sedated and/or the stress on his poor little heart. Please help.
Submitted: 5 months ago.
Category: Dog Veterinary
Expert:  Dr. Joey replied 5 months ago.

Hello I am Dr. Joey. Thanks for trusting me to help you and your pet today. I am a licensed veterinarian with over 16 years of experience. I look forward to working with you.

I am so sorry your dog is going through this and that it sounds to be very stressful to have him seen which makes it very difficult to do testing and rechecks.
The tricky part is knowing if the cough is due to pneumonia (sounds unlikely), an upper respiratory infection (also unlikely) or the congestive heart failure (most likely). Dogs with congestive heart failure can cough for two different reasons. First is if there is fluid accumulation in the lungs, which would be treated with the furosemide (Lasix); some dogs require multiple diuretics like this to get it under control. Second would be if his heart is enlarged and pushing on his airway. This latter would be my top suspicion for the cause of the cough. Did a board certified radiologist read his x-rays (if not then I highly advise this to know if he is truly severely in failure or only mildly and get an opinion on the size of his heart and if this could be pushing on his airway)?

Usually we treat airway irritation with a different medication (codeine) to suppress the cough.

As well, was his blood pressure taken? We need to know if this was high and if so then it would need to be rechecked next week to ensure the enacard is the right dose. As a final very important diagnostic test would be for him to have an echocardiogram (can your vet arrange for this to be done in-house? I know it requires he be sedated again but very important to know what type of heart failure we are contending with). If you prefer not to have him seen right away again, then I recommend you pursue having the films read by a radiologist, if not already done.

As to this culture, I am afraid swabs of the throat really are not useful. There is so much contaminant bacteria (from the mouth) back there that it really doesn't give us much information. Now if he had a tracheal wash or bronchoscopy to get a sample directly from his airways then this is different. Either way, I am skeptical if he truly has congestive heart failure that the cough is related to an antibiotic infection; so I would not expect much benefit from this medication.

Also, as a side note, pimobendan is a fantastic drug but we have to be sure this is needed (this is where the echocardiogram is very useful) and one of its top side effects is to worsen coughing. I have had this occur in a few patients. So, you need to try to gauge if the coughing worsened after you started, and if so then discontinuing for 24-48 hours should see improvement in the cough.

I am at a point I need to know what questions you have.I hope that the information I provided has been helpful.

Please let me know if for any reason you need further clarification, have more questions, or were expecting a different type of answer.

If you received all the information you needed, then kindly submit a rating.

Customer: replied 5 months ago.
As I put in the first part - they did xrays this past Wednesday. His heart is enlarged and pressing on the airway. They did see fluid in the lung. They did the culture of his tonsils as the 2nd time they checked it (this past wed) there was a white puss pocket on his tonsil - the culture of that came back as Stenotrophomonas maltophilia. I will be going back this week with him of course but really wanted another opinion on all the meds he is currently taking. The cough has seemed to get a little better but not near enough- he is struggling when coughing. As for the Stenotrophomonas maltophilia - do you feel the Trimethprini-Sulfa 480mg 1/2 pill every 12 hours is the proper medicine? And if the fluid in his lungs is pneumonia will that antibiotic help with that? I looked up this bacteria and in many articles I read in human cases it caused pneumonia. The first time I brought him approx. 2 weeks ago, he was diagnosed with tonsillitis - I saw the tonsil it was huge - the 2nd time there was the white puss looking pocket on it - almost like strep.
Expert:  Dr. Joey replied 5 months ago.

I would recommend asking about the addition of a drug to suppress the cough associated with the tracheal compression from the enlarged heart (hydrocodone, codeine etc).

I assume a culture & sensitivity panel was performed on the sample that was taken. If so and this was indicated as sensitive to SMZ/TMP, then this is appropriate. It takes time for tonsillitis to improve, but I would expect improvement if we think this is the cause of the cough within a week. In some cases SMZ/TMP is not good enough to clear the bug. I think our complicating factor is that he got sick on Baytril (so this category which is excellent is not going to be useful for him) and Amoxicillin & Cefpodoxime didn't seem to cause improvement. That doesn't leave us with a lot of antibiotic choices. Our selection of drugs would then be based on the culture/sensitivity report.

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