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Ophthalmology Case No 2. Leptospira

তোমার চোখ দুটো লাল কেন?

দেখতে চিকন সুতোর মত (Lepto) , স্ক্রু এর মত প্যাঁচানো (Spiral) যে Bacteria টি আপনারা দেখতে পাচ্ছেন

এর নাম Leptospira,

এইরকম আকৃতির একটা সুবিধা হচ্ছে : MOTILITY

ঠিক তেমনি Leptospira ও অনেক motile একটা অর্গানিজম,

খুব সহজেই আপনার Skin penetrate করে ঢুকে যাবার ক্ষমতা আছে তার, সেই সাথে skin এ যদি কোনো cut বা abrasion থাকে তাহলে  সেটা আরো সহজ হয়ে যায়।

বসতবাড়ি মূলত Rat 🐁এর Nephron এর PCT তে,

সে থেকে urine এর মাধ্যমে পানিতে ছড়িয়ে পড়ে,

Immersive water এ যারা কাজ করে তাই সেরকম মানুষ বেশি আক্রান্ত হয়ে থাকে।

শরীরে ঢুকার পর সপ্তাহখানেক এর মত Incubation period শেষ করে সে তার লক্ষণ দেখানো শুরু করে।

✅মূলত 4 টা সিন্ড্রোম এ তাদের লক্ষণ কে আমরা ভাগ করতে পারি।

১. প্রথমত শরীরে ঢুকার কারণে একটা Non specific reaction দেখা যায়,

গায়ে গায়ে ব্যথা, বিশেষ করে Calf muscle এ tenderness, high grade fever, headache, muscle ache, photophobia ইত্যাদি থাকতে পারে।

সেই সাথে চোখে থাকতে পারে conjunctival congestion,

অনেক ক্ষেত্রে এতটুকুতেই রোগটা ভালো হয়ে যায়।

আবার অনেকের ক্ষেত্রে ছড়িয়ে পড়তে পারে আরো বেশি।

এইটুকু Phase কে বলা হয় Bactaremic phase

২. ক্ষেত্র বিশেষে L. canicola এর ক্ষেত্রে আক্রান্ত হতে পারে meninges,

আগের মতই high grade fever, headache, photophobia এর ফিচার থাকবে। CSF study দেখে মনে হবে যেন Viral Meningitis,

যদিওবা CBC তে neutrophilic leukocytosis পাওয়া যাবে,

আর চোখে থাকবে typical conjunctival congestion,

Congestion কেনো হয়, এটার কিছু থিওরী আছে,

১. Vasculitis হয়ে এমন হতে পারে

২. Systemic inflammation এর জন্যে হয়

৩. ব্যাকটেরিয়ার টক্সিন এর জন্যে এমন হয়

সোজা কথা বললে, vessel এর permeability বেড়ে গিয়ে কিছু জায়গায় congestion হতে পারে। সেজন্যে কখনো কখনো শরীরে rash ও পাওয়া যায়।

৩. তবে একদম পরিচিত যেই রূপটা আমরা চিনি, সেটা হচ্ছে Weils diseases

যেখানে একই সাথে রোগীর Fever ,Hemorrhage,Jaundie, AKI, Conjunctival congestion একত্রে থাকবে,

এরকম চোখের চাহনি একবার দেখলে এই ডায়াগনসিস আর মিস হবার কথা না।

AKI এর কারণ হিসেবে মূলত acute interstitial nephritis কেই চিন্তা করি আমরা,

অন্যদিকে Hepatitis থেকেই hepatomegaly & jaundice , eventually encephalopathy ও পাওয়া যেতে পারে।

Life threatening event বলে এই অবস্থা খুব সিরিয়াসলি ডিল করতে হবে।

বিশেষত রোগীর urine output,albumin level ইত্যাদি মনিটর করতে হবে। কেনোনা দীর্ঘ সময় AKI থেকে ATN হয়ে যেতে পারে।

এছাড়াও weils disease এ Meningitis, encephalitis, myocarditis ইত্যাদি ও associated থাকতে পারে

৪. কিছু কিছু ক্ষেত্রে রোগীদের ARDS এর মত ফিচার দেখা যেতে পারে, সে সাথে থাকবে Hemoptysis, infiltration in CXR ইত্যাদি।

✅ইনভেস্টিগেশন বলতে গেলে,

শুরুতেই আমরা CBC দেখব,

যেহেতু ব্যাকটেরিয়াল ইনফেকশন তাই Neutrophil & WBC বেশি থাকবে স্বাভাবিক,

সে সাথে Endothelial reaction এর কারণে প্লেটলেট কমে গিয়ে Thrombocytopenia হতে পারে,

বাড়তে পারে Bilirubin, Creatinine, Creatinine kinase,

CSF এ প্রোটিন খুব সামান্য বাড়লেও, নরমাল থাকবে গ্লুকোজ,

স্পেসিফিক ভাবে এটা leptospira কিনা সেটা শিউর হবার জন্যে আমাদের অপেক্ষা করতে হবে প্রায় ৭ দিন,

1st week এর শেষের দিকে থেকে Leptospira Ag urine এর সাথে বের হলে তখন আমরা Ab টেস্ট করতে পারি,

Ab titer 4 fold rise হলে ডায়াগনসিস করা সহজ,

অথবা,

8th day থেকে urine দিয়ে Leptospira DNA pass করলে সেটাকেও PCR করে identify করার সুযোগ থাকবে,

✅চিকিৎসা হিসেবে Spirochete এর জন্যে ভালো অপশন Doxy & Penicillin

তাই আমরা Penicillin কিংবা Ceftriaxone 1g/d যেমন দিতে পারি,

আবার 100mg করে Doxy ও দিতে পারি।

অনেকসময় এগুলো দিলে একটু জ্বর বাড়তে পারে যেটা Jarisch–Herxheimer reaction এর কারণে হয়ে থাকে।

মূলত মৃত Spirochete এর প্রতি একধরনের রেসপন্স থেকে এটা হয়ে থাকে…

এইতো বলা হয়ে গেল leptospira এর গল্প,

ঝটপট এবার রোগীর রিপোর্ট আর অন্য সবকিছুর সাথে মিলিয়ে ফেলুন পড়াটা..

Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Indications of Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Doxacil is indicated in the following infections caused by susceptible microorganisms:

  • Respiratory tract infections: Pneumonia, influenza, sinusitis, bronchitis, tonsillitis, tracheitis.
  • Gastrointestinal tract infections: Cholera, traveler’s diarrhea, shigella dysentery, acute intestinal amebiasis.
  • Chlamydial infections: Lympho-granuloma venereum, psittacosis, trachoma.
  • Sexually transmitted diseases: Non gonococcal urethritis, acute pelvic inflammatory disease, uncomplicated urethral and endocervical or rectal infections, gonorrhoea, syphilis, pyelonephritis, cystitis.
  • Other infections: Impetigo, furunculosis, inclusion conjunctivitis, brucellosis, tularemia, cellulitis, acne and Q-fever.

Description Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Doxacil is a highly active broad-spectrum antibiotic of tetracycline group. It is effective against a wide range of Gram-positive and Gram-negative bacteria, spirochete, mycoplasma, rickettsia and mycobacteria. Doxacil is used as an alternate to penicillin in the treatment of gonorrhoea and syphilis. Doxacil has its main mechanism of action on protein synthesis. Inside the bacterial cell, it inhibits protein synthesis.

Pharmacology Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Doxycycline Hydrochloride is a semisynthetic tetracycline antibiotic with broad spectrum activity. It is primarily a bacteriostatic antibiotic. It has a similar spectrum of activity to other tetracyclines but in particular is more active against Staphylococcus aureus and Nocardia. The drug is often active against penicillin-resistant strains of Staphylococcus aureus and against strains of those organisms that are resistant to other Tetracyclines. Certain Gram-negative strains of E. coli, Proteus mirabilis and Klebsiella, which are often resistant to Tetracycline, may be sensitive to Doxycycline. In addition, 70-90% of the various anaerobes are sensitive to Doxycycline and Bacteroides fragilis is more likely to be sensitive to Doxycycline than to other tetracyclines.

Doxycycline is active against most strains of Haemophilus influenzaeand is particularly useful for infections with H. ducreyi, Actinomyces, Brucella and Vibrio cholerae. It is also active against Nocardia, Chlamydia, Mycoplasma and a wide range of Rickettsiae. Doxycycline is active against spirochetes such as Borellia recurrentis, Treponema pallidum and Treponema pertenue. It is also active against Plasmodium falciparum.

Dosage Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Usual dose: 200 mg on first day, then 100 mg daily for 7-10 days.
Severe infections (including refractory urinary tract infections): 200 mg daily for 10 days.
Acne: 100 mg daily.
Uncomplicated genital chlamydia, non-gonococcal urethritis: 100 mg twice daily for 7-21 days (14-21 days in pelvic inflammatory disease).

Administration Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Capsules should be swallowed whole with plenty of fluid during meals while sitting or standin

Interaction Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Absorption of tetracyclines is impaired by antacid containing aluminium, calcium or magnesium, and iron containing preparation. Absorption of tetracyclines is also impaired by bismuth salicylate. Barbiturates, carbamazepine and phenytoin decrease half-life of doxycycline. Concurrent use of tetracyclines may render oral contraceptive less effective. Patients who are on anticoagulant therapy may require downward adjustment of their anticoagulant dosages. It is advisable to avoid giving tetracyclines in conjunction with penicillin.

Contraindications Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Doxycycline is contraindicated to the patients who have shown hypersensitivity to any of the tetracyclines. Doxycycline is contraindicated to the children under 8 years of age. It is also contraindicated to pregnant women and to the lactating mothers.

Side Effects Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Nausea, vomiting, diarrhoea, skin rashes, hemolytic anaemia, eosinophilia may be reported.

Pregnancy & Lactation Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Doxycycline should be avoided in pregnant women, because of the risk of both staining and effect on bone growth in the foetus. Doxycyclines enter breast milk, and mothers taking these drugs should not breastfeed their child.

Precautions & Warnings Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

use of drugs of the tetracycline class during tooth development (last half of pregnancy, infancy and childhood to the age of 8 years) may cause permanent discoloration of teeth. Tetracyclines drugs, therefore should not be used in this age group.

Therapeutic Class Capsule 1.Doxacil 100mg (AS A Doxycycline Hydrochloride AS A Tetracycline group of drugs).

Tetracycline group of drugs.

OR,Group Of Penicilline :-

1.Cloxacillin Sodium:-

Capsule 1.A-Clox 500mg (AS A (Cloxacillin Sodium) AS A Penicillinase-resistant penicillins).

Injection 2.Cloxin IM/IV 500mg/vial 500mg vial (AS A (Cloxacillin Sodium) AS A Penicillinase-resistant penicillins).

Syrup 3.Hi-Clox 125 mg/5ml 100ml Bottle  (AS A (Cloxacillin Sodium) AS A Penicillinase-resistant penicillins).

2.Flucloxacillin Sodium:-

Descriptition:-

Indications of (Flucloxacillin Sodium):-

Flucloxacillin is indicated for the treatment of infections due to Gram-positive organisms, including infections caused by penicillinase producing staphylococci. These indications include:

  • Skin and soft tissue infections: Boils, abscess, carbuncles, infected skin conditions (e.g. ulcer, eczema, acne, furunculosis, cellulitis, infected wounds, infected burns, otitis media and externa, impetigo).
  • Respiratory tract infections: Pneumonia, lung abscess, empyema, sinusitis, pharyngitis, tonsillitis, quinsy.
  • It is also used for the treatment of other infections i.e. osteomyelitis, enteritis, endocarditis, urinary tract infection, meningitis, septicaemia caused by Flucloxacillin-sensitive organisms.
  • As a prophylactic agent, it is used during major surgical procedures where appropriate; for example, cardiothoracic and orthopedic surgery.

Pharmacology of (Flucloxacillin Sodium):-

Flucloxacillin is active against Gram-positive organisms including penicillinase producing strains. It has little activity against Gram-negative bacilli. Flucloxacillin acts by inhibiting the formation of cell wall of bacteria. Flucloxacillin is isoxazolyl penicillin which combined the properties of resistance to hydrolysis by penicillinase, gastric acid stability and activity against gram-positive bacteria. Flucloxacillin is a bactericidal antibiotic that is particularly useful against penicillinase-producing staphylococci. Flucloxacillin kills bacterial cellwall, thus interfering with peptidoglycan synthesis. Peptidoglycan is a heteropolymeric structure that provides the cell wall with its mechanical stability. The final stage of peptidoglycan synthesis involves the completion of the cross-linking with the terminal glycine residue of the pentaglycin bridge linking to the fourth residue of the pentapeptide (D-alanine). The transpeptidase enzyme that performs this step is inhibited by Flucloxacillin. As a result the bacterial cellwall is weakened, the cell swells and then ruptures. Flucloxacillin resists the action of bacterial penicillinase probably because of the steric hindrance induced by the acyl side chain which prevents the opening of the β- lactam ring.

Dosage of (Flucloxacillin Sodium):-

Oral administration:

  • Adult: 250 mg four times daily. Dosage may be doubled in severe infections. In osteomyelitis and endocarditis, up to 8 gm daily is used in 6-8 hourly divided doses.
  • Children (2-10 years): 1/2 of adult dose.
  • Children (Under 2 years): 1/4 of adult dose.

Parenteral administration:
Adult or Elderly:

  • Intramuscular Injection: 250 mg four times daily.
  • Intravenous Injection: 250 mg-1 g four times daily by slow injection over 3 to 4 minutes or by intravenous infusion.
  • All systemic doses may be doubled in severe infections: doses up to 8 g daily have been suggested for endocarditis or osteomyelitis.

Children:

  • 2-10 years: half of the adult dose.
  • Under 2 years: a quarter of the adult dose.

Administration of (Flucloxacillin Sodium):-

Oral doses should be administered 1 hour before meal.

Interaction of (Flucloxacillin Sodium):-

Concurrent use of Flucloxacillin and may result in increased level of Flucloxacillin in blood for prolonged period.

Contraindications of (Flucloxacillin Sodium):-

Flucloxacillin is contraindicated in penicillin hypersensitive patients.

Side Effects of (Flucloxacillin Sodium):-

There have been some common side effects of gastrointestinal tract such as nausea, vomiting, diarrhoea, dyspepsia and other minor gastrointestinal disturbances. Besides these rashes, urticaria, purpura, fever, interstitial nephritis, hepatitis and cholestatic jaundice have been reported.

Pregnancy & Lactation of (Flucloxacillin Sodium):-

US FDA Pregnancy Category of Flucloxacillin is B. There are, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. Flucloxacillin have been shown to be excreted in human milk. So, caution should be exercised when Flucloxacillin is administered to a lactating mother.

Precautions & Warnings of (Flucloxacillin Sodium):-

Flucloxacillin should be used with caution in patients with evidence of hepatic dysfunction. Caution should also be exercised in the treatment of patients with an allergic diathesis.

Use in Special Populations of (Flucloxacillin Sodium):-

In severe renal failure (creatinine clearance <10 ml/min), a reduction in dose or an extension of dose interval should be considered.

Therapeutic Class of (Flucloxacillin Sodium):-

Penicillinase-resistant penicillins

OR (Ceftriaxne Third generation Cephalosporins).

Injection 1.Ceftron IM Injection 1gm/vial 1gm vial (AS A Ceftriaxone Sodium AS A Third generation Cephalosporins).

Indications

Ceftron injection is indicated for the treatment of the following major infections:

  • Lower respiratory tract infections
  • Acute Bacterial Otitis Media
  • Skin and skin structure infections
  • Urinary tract infections
  • Gonorrhea
  • Bacterial Septicemia
  • Bone and joint infections
  • Meningitis
  • Prevention of postoperative infections
  • Perioperative prophylaxis of infections associated with surgery

Pharmacology

Ceftriaxone is a 3rd generation broad-spectrum parenteral cephalosporin antibiotic. It has potent bactericidal activity against a wide range of Gram-positive and Gram-negative organisms. Like other cephalosporins and penicillins, Ceftriaxone kills bacteria by interfering with the synthesis of the bacterial cell wall. Ceftriaxone has a high degree of stability in the presence of beta lactamases. A remarkable feature of Ceftriaxone is its relatively long plasma elimination half-life of about 6 to 9 hours, which makes single or once-daily dosage of the drug appropriate for most patients. Ceftriaxone is not metabolized in the body. About 40-65% of a dose of Ceftriaxone is excreted unchanged in the urine; the remainder is excreted in the bile and ultimately found in the feces as unchanged drug and microbiologically inactive compound. The drug is highly protein bound (95%).

Dosage

Adult: The usual dose is 1 to 2 gm by intravenous or intramuscular administration once a day (or in equally divided doses twice a day).

  • Pneumonia, Bronchitis, Acute bacterial otitis media, Skin and skin structure infection, Urinary tract infections, Bacterial Septicemia, Bone and joint infections, Meningitis: 1 to 2 g IV or IM once a day (or in equally divided doses twice a day); Maximum dose: 4 gm/day
  • Uncomplicated gonococcal infections: 250 mg IM as a single dose
  • Surgical prophylaxis: 1 g IV as a single dose 30 to 120 minutes before surgery

Infants and Children (01 month or older): The usual dose is 50 to 75 mg/kg intravenous or intramuscular administration once a day (or in equally divided doses twice a day).

  • Pneumonia, Bronchitis, Skin and skin structure infection, Urinary tract infections, Bacterial Septicemia, Bone and joint infections: 50 to 75 mg/kg IV or IM once a day (or in equally divided doses twice a day); Maximum dose: 2 gm/day
  • Acute bacterial otitis media: 50 mg/kg IM in single dose; Maximum dose: 1 gm/day
  • Meningitis: 100 mg/kg IV or IM in single daily dose or (or in equally divided doses twice a day); Maximum dose: 4 gm/day

Duration of therapy: Continue for more than 2 days after signs and symptoms of infection have disappeared. Usual duration is 4 to 14 days; in complicated infections, longer therapy may be required.

Administration

Preparation of Solutions for Intramuscular / Intravenous Injections:

  • For Intramuscular Injection: 250 mg or 500 mg Ceftriaxone should be dissolved in 2 ml Lidocaine HCI 1% injection or 1 g Ceftriaxone in 3.5 ml of Lidocaine HCI 1% injection.
  • For Intravenous Injection: 250 mg or 500 mg Ceftriaxone should be dissolved in 5 ml of Water for injection or 1 g Ceftriaxone in 10 ml of Water for injection USP or 2 g Ceftriaxone in 20 ml of Water for injection.

The injection should be administered over 2-4 minutes, by Intramuscular or Intravenous injection or by tubing infusion over a period of 30 minutes at concentration between 10 mg/mL and 40 mg/mL. Before starting treatment through Ceftriaxone injection, patient tolerance test should be checked by administration of a test dose. (The use of freshly reconstituted solution is recommended. However, it maintains potency for at least 6 hours at room temperature or 24 hours at 5°C).

Interaction

No drug interactions have been reported.

Contraindications

Ceftriaxone should not be given to patients with a history of hypersensitivity to cephalosporin antibiotics.

Side Effects

Ceftron is generally well tolerated. A few side effects such as gastro-intestinal effects including diarrhea, nausea and vomiting, stomatitis and glossitis; cutaneous reactions including rash, pruritus, urticaria, edema and erythema multiforme; hematologic reactions including eosinophilia, thrombocytopenia, leucopenia, anemia and neutropenia; hepatic reactions including elevations of SGOT or SGPT, bilirubinemia; CNS reactions including nervousness, confusion, sleep disturbances, headache, hyperactivity, convulsion, hypertonia and dizziness were reported. Local phlebitis occurs rarely following intravenous administration but can be minimized by slow injections over 2-4 minutes.

Pregnancy & Lactation

Its safety in human pregnancy has not been established. Therefore, it should not be used in pregnancy unless absolutely indicated. Low concentrations of Ceftriaxone are excreted in human milk. Caution should be exercised when Ceftriaxone is administered to a lactating mother.

Precautions & Warnings

As with other cephalosporins, anaphylactic shock cannot be ruled out even if a thorough patient history is taken. Anaphylactic shock requires immediate countermeasures such as intravenous epinephrine followed by a glucocorticoid. In rare cases, shadows suggesting sludge have been detected by sonograms of the gallbladder. This condition was reversible on discontinuation or completion of Ceftron therapy. Even if such findings are associated with pain, conservative, nonsurgical management is recommended. During prolonged treatment the blood picture should be checked at regular intervals.

Use in Special Populations

Ceftron must not be given to neonates if the neonates is premature and newborn (up to 28 days of age).

Overdose Effects

There is no specific antidote. Treatment of overdosage should be symptomatic.

Therapeutic Class

Third generation Cephalosporins

Raiyyan tahsan Date:05-02-2025 Wednesday Time:-10-43-45 Am

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