Urology Case No10. Sterile Pyuria

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Urology Case No10. Sterile Pyuria

Sterile_pyuria

সাজেদা ২২ বছর বয়স- পুরো সুস্থ মানুষ, রুটিন ইনভেসটগেশন হিসাবে কিছু Test করলো- CBC, CRP, Urine R/E.

CBC তে ESR and WBC count নরমাল রেঞ্জের মধ্যে আছে-CRP ও normal. Urine R/E তে দেখা গেলো 15 pus cell /HPF. তার কোন UTI এর উপসর্গ নাই- No fever, No burning sensation and frequency of Micturation ও নাই–

এখন GP practitioner হিসাবে আপনার করনীয় কি?

ডায়াগনোসিস কি হবে?

এইটার differential diagnosis হচ্ছে

1..Sterile pyuria

2. Asymptomatic bacteriuria

Sterile pyuria কাকে বলে-

Sterile pyuria হচ্ছে পেশেন্টের ইউরিন স্যাম্পলের মধ্যে PUS cell থাকবে, কিন্ত Culture করলে কোনো organism/bacteria পাওয়া যাবেনা–

মানে Urine R/E = Pus cell

Urine C/S = No growth of any organism

এই অবস্থাকে sterile pyuria বলে,

এখন এই ধরনের পেশেন্ট এর যদি কোনো উপসর্গ না থাকে, তাহলে তার কোনো চিকিৎসা লাগবেনা..

Asymptomatic sterile pyuria এর কারণ কি?

recent যদি পেশেন্ট UTI এর জন্য এন্টিবায়োটিক পেয়ে থাকে, তাহলে এন্টিবায়োটিক কোর্সের পরে পেশেন্ট এর URINE R/E করলে PUS cell পাওয়া যাবে-

এই ক্ষেত্রে পেশেন্ট এর যদি উপসর্গ না থাকে, তাহলে তাকে এন্টিবায়োটিক দেওয়ার দরকার নাই–

সিনারিও–

জোবায়দা ৩৪ বছর UTI এর উপসর্গ নিয়ে আপনাকে দেখালেন- URINE R/E করে দেখলেন, plenty of Pus cell–

আপনি 7 দিনের জন্য এন্টিবায়োটিক দিলেন, আর পেশেন্ট কে ৭-১০ দিন পর ফলোআপে আসতে বললেন-

পেশেন্ট ৫ দিন এন্টিবায়োটিক খেয়েই সুস্থ – তাও ৭ দিন পর আপনার কাছে আসলো –

আপনি এখন তাকে আবার URINE R/E করতে দিলেন–

Urine R/E রিপোর্টে দেখা গেলো-

15 pus cell-

এখন আপনার করনীয় কি?

আবার ৭ দিনের এন্টিবায়োটিক দিবেন?

উত্তর হচ্ছে না– তার এন্টিবায়োটিকের আর কোন দরকার নাই- পেশেন্ট কে এই মূহুর্তে আরেকটা Urine R/E কর‍তে দেওয়ার ও কোনো দরকার ছিলোনা–

এখন যে pus cell দেখা যাচ্ছে, তা হচ্ছে sterile pyuria –

মানে পেশেন্ট এন্টিবায়োটিক ব্যবহার এর ফলে তার ইনফেকশন ভালো হয়ে গিয়েছে, যদিও ইনফেকশন এর বিরুদ্ধে ফাইট করা কিছু WBC বা pus cell ইউরিনের সাথে বের হচ্ছে– এখানে এন্টিবায়োটিকের কোন দরকার নাই–

2.. Asymptomatic Pyruia এর আরো কিছু কারণ আছে-

যদি কোনো পেশেন্ট এর urine R/E তে PUS cell আসে, তার যদি কোন উপসর্গ না থাকে, তখন Nephrogenic কোন কারণ আছে কিনা, সেটা exclude করার জন্য Urinary protein and serum creatinine দেখবেন, যদি দুইটাই নরমাল থাকে, তাহলেও পেশেন্টের কোনো চিকিৎসা লাগবেনা-

৩… পেশেন্ট এর urinary pus cell positive + সেরাম ক্রিয়েটিনিন বেড়ে গেছে, কিন্ত কোনো উপসর্গ নাই, তাহলে পেশেন্ট কে Nephrologist এর কাছে রেফার করুন—

আর কি কি কারণে sterile pyuria হতে পারে–

1.. NSAID exposure (এইটা থেকে interstitial nephritis হয়ে Urinary pus cell) পজিটিভ আসতে পারে.

2.. Chronic PPI intake

3.. Moxaclav exposure

4.. Diuretics এর কারণে

5.. Aspirin ট্যাবলেট এর কারণে

6.. Autoimnuno disease (R/A, SLE, etc)

এখন যদি পেশেন্ট এর উপরের কোনো কারণ থাকে, তাহলে সেই মেডিসিন বন্ধ করতে হবে,

ধরুন কোনো ড্রাগ হিস্ট্রি নাই-

উপসর্গ নাই- সেরাম ক্রিয়েটিনিন নরমাল, তাহলে এই পেশেন্টের কোনো চিকিৎসা লাগবেনা,

Urinary culture করারও দরকার হবেনা-

কখন চিকিৎসা লাগবে–

পেশেন্ট এর Pyuria আছে, + পেশেন্ট এর উপসর্গ নাই, কিন্ত পেশেন্ট প্রেগন্যান্ট, তখন পেশেন্ট এর একটা Urine C/S করে দেখুন- যদি bacteria থাকে, তাহলে এইটাকে Asymptomatic bacteriuria বলে–

উপসর্গ নাই+ Pus cell positive + C/S positve– যদি এমন পেশেন্ট আসে, তাহলে পেশেন্ট প্রেগন্যান্ট হলে কিংবা patient কোনো urological procedure এ গেলে এন্টিবায়োটিক পাবে,

কালচারের সুযোগ নাই, তবে পেশেন্ট প্রেগন্যান্ট, সেই ক্ষেত্রেও এন্টিবায়োটিক দিতে পারেন

আর পেশেন্ট যদি healthy হয়, তাহলে কোনো এন্টিবায়োটিক লাগবেনা–

সারকথা-

Asymptomatic bacteriuria /Sterile pyuria তে healthy patient এ কোনো এন্টিবায়োটিকের দরকার নাই—

Jodi tarpor o valo na hoi patient Tahole 2^ND Generation Cephalosporin OR Broad spectrum penicillins Antibiotic Use kora jai

IN that case we 1^st go 1^st line Antibiotic

Second generation Cephalosporins:-

Tablet 1:- Cefotil plus 500mg +100 mg (AS a (Cefuroxime Axetil + Clavulanic Acid) AS A Second generation Cephalosporins.)

Indications of Tablet :- Cefotil plus 500mg +100 mg (AS a (Cefuroxime Axetil + Clavulanic Acid) AS A Second generation Cephalosporins.)

Cefotil Plus is indicated for the treatment of infections caused by sensitive bacteria.

Pharyngitis/Tonsillitis caused by Streptococcus pyogenes.
Acute Bacterial Otitis Media caused by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis (beta-lactamase producing strains) or Streptococcus pyogenes.
Acute bacterial maxillary sinusitis caused by Streptococcus pneumoniae or Haemophilus influenzae (non beta-lactamase producing strains)
Lower respiratory tract infections including pneumoniae, caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta lactamase-producing strains), Klebsiella spp., Staphylococcus aureus (penicillinase- and non-penicillinase-producing strains), Streptococcus pyogenes, E. coli.
Acute bacterial exacerbation of chronic bronchitis and secondary bacterial infections of Acute bronchitis caused by Streptococcus pneumoniae, Haemophilus influenzae (beta-lactamase negative strains) or Haemophilus parainfluenzae (beta-lactamase negative strains).
Uncomplicated skin and skin-structure infections caused by Staphylococcus aureus (including beta-lactamase producing strains) or Streptococcus pyogenes.
Uncomplicated urinary tract infections caused by E.coli or Klebsiella pneumoniae.
Bone and Joint Infections caused by Staphylococcus aureus (penicillinase- and non-penicillinase-producing strains).
Uncomplicated Gonorrhoea caused by penicillinase-producing and non-penicillinase producing strains of Neisseria gonorrhoeae.
Early Lyme Disease (erythema migrans) caused by Borrelia burgdorferi.
Septicemia caused by Staphylococcus aureus, Streptococcus pneumoniae, E.coli, Haemophilus influenzae (including ampicillin-resistant strains) & Klebsiella spp.
Meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae (including ampicillin-resistant strains), Neisseria meningitidis & Staphylococcus aureus (penicillinase and non-penicillinase producing strains)
Switch therapy (Injectable to oral)

Pharmacology of Tablet :- Cefotil plus 500mg +100 mg (AS a (Cefuroxime Axetil + Clavulanic Acid) AS A Second generation Cephalosporins.)

Cefuroxime is a bactericidal second generation cephalosporin antibiotic which is active against a wide range of Gram-positive and Gram-negative susceptible organisms including many beta-lactamase producing strains. Cefuroxime inhibits bacterial cell wall synthesis by interfering with the transpeptidation process.

Clavulanic acid is a naturally derived beta lactamase inhibitor produced by Streptomyces clavuligerus. It has similar structure to beta lactam antibiotics which binds irreversibly to beta-lactamase enzymes and inactivates them. Clavulanic acid gives protection of Cefuroxime from degradation by beta lactamase enzymes and provides a solution for the treatment of bacterial infections caused by beta lactam resistant bacteria.

Dosage & Administration of Tablet :- Cefotil plus 500mg +100 mg (AS a (Cefuroxime Axetil + Clavulanic Acid) AS A Second generation Cephalosporins.)

Adolescents and adults (13 years and older)-

Pharyngitis/tonsillitis: 250 mg b.i.d. for 5-10 days
Acute bacterial maxillary sinusitis: 250 mg b.i.d. for 10 days
Acute bacterial exacerbation of chronic bronchitis: 250-500 mg b.i.d. for 10 days
Secondary bacterial infections of acute bronchitis: 250-500 mg b.i.d. for 5-10 days
Uncomplicated skin and skin structure infections: 250-500 mg b.i.d. for 10 days
Uncomplicated urinary tract infections: 250 mg b.i.d. for 7-10 days
Uncomplicated Gonorrhoea: 1000 mg b.i.d. Single dose
Community acquired pneumonia: 250-500 mg b.i.d. for 5-10 days
MDR Typhoid Fever: 500 mg b.i.d. for 10-14 days
Early Lyme disease: 500 mg b.i.d. for 20 days

Paediatric Patients (3 months to 12 years)-

Pharyngitis/Tonsillitis: 20 mg/kg/day b.i.d for 5-10 days
Acute otitis media: 30 mg/kg/day b.i.d for 10 days
Acute bacterial maxillary sinusitis: 30 mg/kg/day b.i.d for 10 days
Impetigo: 30 mg/kg/day b.i.d for 10 days

Cefuroxime-Clavulanic Acid tablet may be taken without regard of food.

Side Effects of Tablet :- Cefotil plus 500mg +100 mg (AS a (Cefuroxime Axetil + Clavulanic Acid) AS A Second generation Cephalosporins.)

Generally Cefuroxime-Clavulanic Acid is well tolerated. However, a few side effects like nausea, vomiting, diarrhea, abdominal discomfort or pain may occur. As with other broad-spectrum antibiotics, prolonged administration of Cefuroxime and Clavulanic acid combination may result in overgrowth of nonsusceptible microorganisms. Rarely (<0.2%) renal dysfunction, anaphylaxis, angioedema, pruritis, rash and serum sickness like urticaria may appear.

Pregnancy & Lactation of Tablet :- Cefotil plus 500mg +100 mg (AS a (Cefuroxime Axetil + Clavulanic Acid) AS A Second generation Cephalosporins.)

While all antibiotics should be avoided in the first trimester if possible. However, Cefuroxime-Clavulanic Acid can be safely used in later pregnancy to treat urinary and other infections. Cefuroxime-Clavulanic Acid is excreted into the breast milk in small quantities. However, the possibility of sensitizing the infant should be kept in mind.

Therapeutic Class of Tablet :- Cefotil plus 500mg +100 mg (AS a (Cefuroxime Axetil + Clavulanic Acid) AS A Second generation Cephalosporins.)

Second generation Cephalosporins, Vaccines, Anti-sera & Immunoglobulin

Broad spectrum penicillins Antibiotic:-

Tablet 2:-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Indications of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Co-amoxiclav is indicated for short-term treatment of bacterial infections at the following sites:

Upper respiratory tract infections (including ENT) e.g.tonsillitis,sinusitis,otitis media.
Lower respiratory tract infections e.g.acute and chronic bronchitis, lobar and bronchopneumonia.
Genito-urinary tract infections e.g.cystitis,urethritis,pyelonephritis.
Skin and soft tissue infections.
Bone and joint infections e.g.osteomyelitis.
Other infections e.g.septic abortion,puerperal sepsis,intra-abdominal sepsis etc.

Composition

375 mg tablet: Each film coated tablet contains Amoxicillin 250 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 125 mg as Diluted Potassium Clavulanate BP.
625 mg tablet: Each film coated tablet contains Amoxicillin 500 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 125 mg as Diluted Potassium Clavulanate BP.
1 gm tablet: Each film coated tablet contains Amoxicillin 875 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 125 mg Diluted Potassium Clavulanate BP.
Powder for Suspension: Each 5 ml reconstituted suspension contains Amoxicillin 125 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 31.25 mg as Diluted Potassium Clavulanate BP.
Powder for Suspension (Forte): Each 5 ml reconstituted suspension contains Amoxicillin 400 mg as Amoxicillin Trihydrate BP and Clavulanic Acid 57.5 mg as Diluted Potassium Clavulanate BP.
1.2 gm Injection: Each vial contains sterile mixture of Amoxicillin Sodium BP (equivalent to Amoxicillin 1 gm) and Clavulanate Potassium USP (equivalent to Clavulanic Acid 200 mg).
0.6 gm injection: Each vial contains sterile mixture of Amoxicillin Sodium BP (equivalent to Amoxicillin 500) and Clavulanate Potassium USP (equivalent to Clavulanic Acid 100 mg).

Pharmacology of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Pharmacodynamic properties: Co-amoxiclav is an antibacterial combination consisting of the antibiotic Amoxicillin and the (3-lactamase inhibitor Clavulanic Acid. Amoxicillin has a broad spectrum of bactericidal activity against many Gram-positive & Gram-negative microorganisms but it is susceptible to degradation by (3-lactamases and therefore the spectrum of activity does not include microorganisms, which produce these enzymes. Clavulanic acid possesses the ability to inactivate a wide range of beta-lactamase enzymes commonly found in microorganisms resistant to penicillins and cephalosporins. Thus Clavulanic acid in this preparation protects Amoxicillin from degradation by (3-lactamase enzymes and effectively extends the antibiotic spectrum to embrace a wide range of microorganisms.

Pharmacokinetic properties: The pharmacokinetics of the two components of Co-amoxiclav is closely matched. Peak serum levels of both occur about one hour after oral administration. Absorption of Co-amoxiclav is optimized at the start of a meal. Both clavulanate and Amoxicillin have low levels of serum binding; about 70% remains free in the serum. Doubling the dosage of Co-amoxiclav approximately doubles the serum levels achieved.

Dosage of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Adults and children over 12 years:

Tablet:

The usual adult dose is one 625 mg Tablet every 12 hours or one 375 mg Tablet every 8 hours.
For more severe infections and infections of the respiratory tract, the dose should be one 1 gm Tablet every 12 hours or one 625 mg Tablet every 8 hours.

Suspension:

Children 6-12 years: 2 teaspoonful every 8 hours.
Children 1-6years: 1 teaspoonful every 8 hours.
Children below 1 year: 25 mg/kg/day in divided doses every 8 hours, for example a 7.5 kg child would require 2 ml suspension t.i.d, Treatment should not be extended beyond 14 days without review.

Forte suspension:

The usual recommended daily dosage: 25/3.6 mg/kg/day in mild to moderate infections (upper respiratory tract infections e.g. recurrent tonsilitis, lower respiratory infections, and skin and soft tissue infections)।
For serious infections: 45/6.4 mg/kg/day for the treatment of more serious infections (upper respiratory tract infections, e.g. otitis media and sinusitis, lower respiratory infections e.g. bronchopneumonia, and urinary tract infections).

Children of 2 to 12 years:
Mild to moderate infections:

25/3.6 mg/kg/day (Suspension)
2-6 years (13-21 kg) 2.5 ml suspension b.i.d
7-12years (22-40kg) 5 ml suspension b.i.d

Serious infections:

45/6.4 mg/kg/day (Forte Suspension)
2-6 years (13-21 kg) 5 ml suspension b.i.d
7-12 years (22-40 kg) 10 ml suspension b.i.d

IV Injection

Adults-

Usually, 1.2 gm every 8 hours
Increased in more serious infections to 1.2 gm every 6 hours
For surgical prophylaxis: The usual dose is 1.2 gm at induction, for high risk procedures (eg. colorectal surgery) up to 2-3 gm may be given every 8 hours.

Children-

0 to 3 months: 30 mg/kg every 8 hours. (every 12 hours in the perinatal period and in premature infants.
3 months to 12 years: Usually 30 mg/kg every 8 hours increased in more serious infection to 30 mg/kg every 6 hours.

Administration of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Oral dosage form: This may be taken without regard to meals; however, absorption of clavulanate potassium is enhanced when Amoxicillin and Clavulanic acid are administered at the start of a meal. To minimize the potential for gastrointestinal intolerance, Amoxicillin and Clavulanic acid should be taken at the start of the meal.

IV injection is not suitable for intramuscular or subcutaneous administration. The reconstituted vial can be administered intravenously by injection (over 2 minutes) or slow intravenous infusion (30 minutes). The contents of the content of the vial must be used within 20 minutes and thereafter any unused material should be discarded.

Interaction of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Prolongation of bleeding time and prothrombin time have been reported in some patients receiving Co-amoxiclav. In common with other broad-spectrum antibiotics, Co-amoxiclav may reduce the efficacy of oral contraceptives and patients should be warned accordingly. Concomitant use of allopurinol during treatment with amoxicillin can increase the likelihood of allergic skin reactions. There are no data on the concomitant use of Co-amoxiclav and allopurinol.

Contraindications of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

History of Penicillin hypersensitivity. Attention should be paid to possible cross-sensitivity with other beta-lactam antibiotics e.g. cephalosporins. Also contraindicated for patients with a previous history of Co-amoxiclav or Penicillin-associated cholestatic jaundice.

Side Effects of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Side effects, as with Amoxicillin, are uncommon and mainly of a mild and transitory nature. Diarrhoea, pseudomembranous colitis, indigestion, nausea, vomiting and candidiasis have been reported, if gastrointestinal side effects occur with oral therapy, that may be reduced by taking Co-amoxiclav at the start of meals. Hepatitis and cholestatic jaundice have been reported rarely but are usually reversible. Urticarial and erythematous rashes sometimes occur. Rarely erythema multiforme, Stevens-Johnson Syndrome and exfoliative dermatitis have been reported. In common with other beta-lactam antibiotics, angioedema and anaphylaxis have been reported.

Pregnancy & Lactation

Animal studies with orally and parenterally administered Co-amoxiclav have shown no teratogenic effect. The drug has been used orally in human pregnancy in a limited number of cases with no untoward effect; however, the use of Co-amoxiclav in pregnancy is not recommended unless considered essential by the physician. During lactation, trace quantities of Amoxicillin can be detected in breast milk.

Precautions & Warnings of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Co-amoxiclav should be used with care in patients on anticoagulation therapy or with severe hepatic dysfunction. In patients with moderate or severe renal impairment, dosage should be adjusted. During the administration of a high dose of Co-amoxiclav adequate fluid intake and urinary output should be maintained to minimize the possibility of crystalluria.

Use in Special Populations of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

The dose should be adjusted in case of patients with renal impairment

Adult:

Mild impairment (Creatinine clearance> 30ml/minute): No changein dosage.
Moderate impairment (Creatinine clearance 10-30 ml/minute): One 375 Tablet or one 625 Tablet 12 hourly or 1.2 gm IV followed by 0.6 gm IV 12 hourly.
Severe impairment (Creatinine clearance <10 ml/minute): Not more than one 375 mg tablet 12 hourly or 1.2 gm IV followed by 0.6 gm IV 24 hourly. Dialysis decreases serum concentrations of Moxaclav and an additional 0.6 gm IV dose may need to be given during dialysis and at the end of dialysis.

Children:

A similar reduction in dosage should be made for children.
Administration hepatic impairment: Dose with caution; monitor hepatic function at regular intervals.

Overdose Effects of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Problems of overdose with Co-amoxiclav are unlikely to occur, if encountered gastrointestinal symptoms and disturbance of the fluid and electrolyte balances may be evident. Co-amoxiclav may be removed from the circulation by haemodialysis.

Therapeutic Class of Tablet :-Moxaclav (500mg+125mg) As A ( Amoxacilline+Clavulanic Acid) (AS A Broad spectrum penicillins).

Broad spectrum penicillins

Raiyyan Tahsan Date:24-01-2025 Friday Time:- 9-08-25 PM

Raiyyan Tahsan

Raiyyan Tahsan