Huey - Head Tilt

Question
QUESTION: Hi Randy - I wanted to follow up with you about your answer to my lop rabbit's head tilt.  Thank you for getting back to me.

The reason we have not done a culture for Huey's infection is because there is no discharge.  In order to do a culture, we would need to do surgery at this point, and it is just too risky right now.

I gave him a dose of Bonamine a couple of hours ago, but he is still not able to walk.  He just rolls over and over and over.  Again, it seems as though the Zithromax has helped in that he is a bit more alert and eating better, but I really don't know how long it is until I should see him at least get his balance back.  I know that head tilt can be permanent, but do those bunnies always have no balance?

Can Pen G be safely administered with Zithro?  And what dosage should he be on with the Zithro?  He is approx. 4 pounds and is getting 1.5ml per day.  You had mentioned it should be much higher than with a cat or dog.  Any futher information you can provide would be greatly appreciated.

Thank you!
Karen

ANSWER: Hi Karen,

There does not have to be visible discharge nor is surgery required to perform a culture for the ear.  We have done hundreds of them.  Many times with vestibular infections, there is no visible sign of infection.  We base treatment on symptoms such as tilt, vertigo, nystagmus and elevated body temp and what the culture identifies.  In some cases, we have all the symptoms but still not grow anything in a petri dish...that is when we treat for pasteurella.

Some rabbits do not respond to meclizine (the active ingredient in motion sickness meds).  Sometimes it takes a few days to get the drug levels up to a working level.  And it is important (as with any drug) to make every effort to administer it in an evenly times fashion to keep the level on an even keel.  How much and how often are you giving it?  And sometimes the damage in the ear is such that they are never fully stable again...but they can still lead a good life and we have several like that.

You can give Pen G with Zithromax....and I do that all the time.  Pen G stings like crazy going in so I usually buffer it with either lactated ringers or saline.  The amount of zithromax depends on the concentration of the drug.  I assume this is a liquid.  Look on the side of the bottle and it should have the concentration on the label.  It will be written something like this (just an example) 50mg/ml.  That will tell me how much drug is in one mil of suspension....I can calculate the correct dosing with that information.  And it is always possible that this could be a bacteria, primarily pseudomonas, that will not be affected by either of these drugs.  That misstep can cause more ear damage. And unless that concentration of the suspension is unusually high, that dosing sounds quite low for zithromax.

I am free tomorrow most all day.  If your vet would be willing to do so, I am always happy to discuss these things with him/her.  Since I am not a licensed vet (I am licensed to do wildlife)..some will not talk about cases and I respect that and understand completely.  But many try to learn as much as they can...and I can give them references from professional colleagues.

Randy


---------- FOLLOW-UP ----------

QUESTION: Randy - you are so incredibly helpful.  I have been reading everything here on the head tilt cases and it made me feel much better that you said you haven't lost your rabbits because of it.

I will check into the dosages of everything.  My vet did not want to combine the Pen G and Zithro, but perhaps I should?

How can a culture be done?  It is CERTAINLY something I would like to do.  I was told that if there is no discharge, they just can't do it - what are the facts?

Thanks again,
Karen :)

ANSWER: Hi Karen,

You are seeing why I have been so aggressive in learning everything I can about rabbits.  And I live near a major vet school that does have an exotics focus type training and the vets involoved are some of the best in the world.  In fact, this is a little OT, but check out this link.  It is a show for NOVA on PBS.  It deals with the money spent to treat pets.  This is a video documenting a new surgical procedure on a fish.  That fish, Comet, was in retirement swimming around in a very large tank right here in our house.  That is our fish.  The video is a couple of years old and Comet died a few months ago from old age.  And some people question why research money is spent on things like this...but the lessons learned are also applied to humans.  The fish you see on the surgical table on the opening page is our Comet.  You can also watch the segment that was broadcast.

http://www.pbs.org/wgbh/nova/sciencenow/3214/04.html

Having that vet school so close is a real asset.  But it has also allowed me to see that the primary focus of small animal medicine has always been dogs and cats.  Many vets, especially if they haven't graduated in the last few years, received little, if any, training on "exotics" or avian.  That really puts them "behind the eight ball" so to speak.  Many rely on the older manuals that were not based on clinical investigation but mostly "hear say" from breeders.  No slam on breeders at all because they had to try something to treat their sick animals since they got no help from the veterinary community.  But certain things are just "pounded into" the heads of people.  One is the myth of "snuffles".  That is a joke.  There are other publications that warn "never acidify the digestive systems of rabbits" and then they turn around and say to use acidophilus for digestive system issues...look at the first four letters..acid.  My point in all of this rambling is that there is still a long way to go as far as veterinary care for rabbits and exotics as a group.  No flaming intended to your vet at all.  There is a condition known as E Cuniculi that is very common in rabbits.  But probably 99% of the vets in the US have never seen a case and wouldn't know it if they saw it.  I have the utmost respect for vets.  The intelligence and drive they have to learn is unmatched...but every species is different and that is a lot to learn.  But we'll get back on topic now.

It might help if your vet could perform a cytology.  It is something like a mini-culture.  It won't identify the pathogen, but it will show if there is bacteria or yeast or both or neither.  I usually swab the waxy stuff deep inside the ear canal just above the ear drum.  If you culture the pus discharge, you are culturing dead bacteria and skin tissue.  I like to know what is alive down there.  It can be a little tricky to get a swab especially in the down side..which is always the side with the primary infection.  If bacteria is found, a full culture and sensitivity is in order.

As far as using Pen G and Zithromax together....that alliance of drugs is a huge and powerful weapon against pasteurella.  I'm sure you have heard of jaw abscess in rabbits.  The most popular treatment is surgery and implanting antibiotic laced beads inside the abscess.  It doesn't work, it's expensive and very painful.  I have developed a drug protocol that uses Pen G and Zithromax together and for long term.  I have used these drugs in tandem for over 60 consecutive days.  This combination seems to be particularly well suited to penetrate the very thick pus in the core of the abscess and attacks and controls the anaerobic bacteria (this type of bacteria does not require oxygen to live) that is so hard to get to.  But these two drugs when used together are a powerful treatment which gives good coverage across a lot of, but not all, bacteria.  And like I have mentioned, the Zithromax should be dosed at a much higher concentration than for dogs/cats.  Another powerful drug that can be use against most bacteria is Chloramphenicol.  This is an awesome drug.  It is something that has fallen out of favor due to some side effects....not for the rabbit but for the humans giving the drug.  There have been some reports of severe bone marrow suppressions in some humans that have had direct contact with this drug.  To administer it, you need to "suit up" so that none of the drug comes into direct contact with your skin.  The chances of problems are extremely rare, but still a possibility.

I don't know if this information is available on the VIN (your vet will understand that one) but it is worth a look.  If not, I would be happy to provide dosing and comments on my experiences in using this protocol to your doctor.  Ear infections need to be hit hard and hit fast to prevent long term issues.

Just wondering...has an x-ray of the skull been performed?  Sometimes we have seen issues with either the roots of the upper arcade molars or "spurs" from the lower arcade cause secondary infections in the upper respiratory or the ears.  The teeth can actually either invade or abscess in the "sinus" (rabbits don't technically have a sinus, I just use the term since we are all familiar with it and can relate to the position) and cause some unusual things....just like with humans, all of that stuff up there is connected.  If this infection doesn't start to resolve soon, I would start seriously searching for something like this.  Dental issues are quite common in some breeds...mostly the flat faced rabbits like Netherland Dwarfs and Holland Lops.  Just a thought for your vet to consider.

Keep me posted.

Randy



---------- FOLLOW-UP ----------

QUESTION: Randy - thank you again.  It's so helpful to have you as a resource because Head Tilt is such a nasty thing.

One thing I love about my vet is that she encourages me to get 2nd opinions.  There is a VERY knowledgeable vet in Guelph, Ontario, that I will be checking in with this week.

As for the Zithro, Huey's medication says it is 200mg/5ml.  I have no idea what that means, but i have the feeling that you do.  He has been on it 5 days, taking 1.5ml per day.  It is upsetting his tummy a bit, but he is eating well still.  He is showing some signs of improvement, but I am not sure how much I should be seeing at this point.  What about the Pen G?  I am a bit nervous to go against what my vet says, but am definitely open to suggestions.

Huey has not had an Xray done because he is too unstable.  They would most likely have to sedate and at this point, I don't want to risk it.  I do wonder about the dental thing though.  My vet took the best look she could with her equipment and everything looked ok, but she couldn't see too far back.  I know there are scopes that can be used and I think I will ask the new clinic to do that for me.

I do want to knock this one out of the park and i know that they need to be treated for a long time.  I am so willing to do that, but I want to treat for the right thing!

From what you mentioned, I just want to make sure i am clear... Please tell me if I am correct in taking it from your answer that the wax can basically be cultured?  He definitely has wax in his ears, but no pus.  A culture would be the best thing in the world, so I am hoping I do have that option.

How long should he be on the Zithro before I should see more improvement?  He is supposed to be on for 7 days and then I am to consult with my vet.

Thanks again Randy - I can't tell you how much I appreciate this.

Karen :)

Answer
Hi Karen,

I like it when vets are OK with second opinions.  Everyone thinks I know so much...but what I know is a combination of the ideas of others and taking the best and combining them...just as people take my ideas and expand on them.  That is how we get improved treatments.

That dosing is about right for a four pound rabbit.  It will need to be given for much longer than 7 days.  And if your vet is willing to speak with me, I would be happy to talk to her about using the Pen G/Zithromax in tandem.  My vet was "concerned" when I told her of what I did.  I did it because it was basically a "Hail Mary"...a last resort, but it worked and I have used it successfully many times since then.  Her comment was that "you certainly have coverage".  But she has since used the same treatment for other clients...so that is quite a validation.  I can also ask my vet to talk directly to your vet if that is preferred.  Vets do that kind of stuff all the time....they have to learn too.

As far as an x-ray...that might be one of those "lesser of the evils" we encounter way too often.  If the infection doesn't respond quickly...things need to move along as far as diagnostics.  And he shouldn't need to be fully sedated.  Ketamine might be something that would do just the trick.....maybe even some diazapam.

I would at least do a cytology on any wax debris you can get from deep in the ear canal.  It's worth a shot.  But we have never had to sedate or perform any surgery to do this.  We had one rabbit that had ongoing bacterial infections due to E Cuniculi....and he had numerous cultures from his ears.

Expect to continue using the Zithromax for long term.  We have never had any GI upset whatsoever but it's not impossible by any means.  Make sure unlimited amounts of grass hays are being eaten.  Keep a close watch on hydration.  And it wouldn't hurt to give a probiotic.  I prefer using a product called Bene-Bac.  It contains millions of colony forming bacteria...but it's not the strain of bacteria found naturally in a rabbit's gut.  But it does help stabilize the pH in the gut which supports the beneficial bacteria.  Bene-Bac contains a particularly helpful strain of bacteria known as L Casei (this is also found in many yogurts and some may suggest yogurt...not a good idea).  Bene-Bac comes both in a paste and in a powdered form.  About a gram per day usually does good things when using antibiotics.

There is also another drug that you might discuss with your vet.  It does have some possible side effects for you, not so much the rabbit.  It's Chloramphenicol.  An awesomely effective drug.  Are you doing an ear drop?  This might be a situation when drops such as Tresaderm might be considered.  A very powerful drug. It does contain a steroid.  Steroids can be very effective weapons in situations like this...but like all other treatments, they do carry some negative side effects that are worse in rabbits than most other species.  Doctors pick their spots for using steroids effectively..but regardless of the side effects, they should always be considered.

Randy