What
do we mean by Mycoplasma genitalium ??? What may happen in rec urethritis in non preg woman?? In
fact we often come across such cases at least twice a week. Explanation: These patients often represent
“problem cases” in the clinic. Frequently, different kinds of antibiotics are
prescribed before the patients are cured. In a few women, antibiotics have only
a limited effect, but most of these women are spontaneously cured after a
varying time. Therefore, may refer her to an Urologist if
tr under your care seems ineffective by two months time. The uncommon organism
responsible for recurrent urethritis in euglycemic women are 1) Mycoplasma genitalium: a common cause of
persistent urethritis more amongst men than women usually treated with
doxycycline 2) Resistant Fungal. Infection 3) Urethral diverticulitis 4)
Trichomonal Urethritis .5) condom moistener covered over the outer aspect of
male condom 6) Contraceptive sponge / Pessary. However Doxycycline is the first
choice for treatment of non‐gonococcal urethritis (NGU)-à followed by Azithromycin. According to current recommendations
treatment is initiated after establishing or excluding sexually transmitted
infection (STI) , How the lab diag of Rec urethritis is done . Treatment is
usually initiated when urethritis is diagnosed on the basis of microscopy of a
stained smear from the urethra. The number of polymorphonuclear leucocytes –WBC
(PMNLs) defining urethritis but usually >4 PMNLs per high power field
(×1000) (hpf) is considered significant. PMNL counts between
5/hpf and 10/hpf are often considered low grade or borderline, and can in some
patients represent a sign of infection, but may among other cases be normal.
Many researchers have time and again showed that the number of leucocytes
is a strong predictor of infection with Chlamydia trachomatis although
more than one third of the patients did not have urethritis. In contrast,
some studies showed that 90% of all patients with C trachomatis or Mycoplasma genitalium infection
had urethritis and all of those with NGU (nongonococcal ) had >10 PMNLs/hpf.
Can
N Gono cause UTI?? Yes . Few points on Neisseria gonorrhoeae: It is a common cause of urethritis. However,
gonorrhoea has become a very uncommon disease in globally and not all reported
though the majority of the patients have NGU. B) Few points on the second common cause of rec urethritis
C trachomatis and this infection is
on the rise. \ Though many studies reports that more than half of the NGU patients are C trachomatis negative.(nonspecific
urethritis (NSU). C) . Few points on the Ureaplasmas
may have a role in some patients but its high isolation rate in men without
urethritis has given rise to much controversy.
M genitalium has been most thoroughly studied as a cause of
urethritis and cervicitis, but it is most likely also a cause of
upper genital tract infections. Tetracyclines are usually
suboptimal, whereas azithromycin is likely to be the most effective
antibiotic, when given as a total dose of 1.5 g over 5 days. Polymerase
chain reaction (PCR) tests detecting M genitalium,
which currently are the only diagnostic tools, have recently been introduced
D)
Few points on Trichomonas vaginalis might
give rise to symptoms in some patients whereas E) Few points on M hominis. ,& M genitalium has been shown to
be an important aetiological agent in non‐chlamydial, non‐gonococcal urethritis (NCNGU) accounting for approximately
20% of symptomatic urethritis F) Few points on Viruses, such as
adenovirus, herpes simplex, and human papillomavirus, might be important
in some cases, but the majority remains unexplained
.Not do harm to such women
by prescribing second line drugs used for Kochs:-What we should not
prescribe in the treatement of long standing Urethritis:- :--Doxycycline may
be prescribed However, the choice of antibiotic for NSU is usually the same as
that for NGU in general—that is, doxycycline. Despite appropriate antibiotic
therapy, 10%–20% of women return to the clinic because of persisting symptoms
and show signs of dysuria. Second line drugs of
Kochs for ordinary UTI!! What are second
line drugs for Kochs ?? This group of second line drugs is
therefore considered to be the most important component of the core MDR-TB
regimen. The benefits from their use outweighs the potential risks. So they
should always be included unless there is an absolute contra-indication for
their use.
The
order of preference for the inclusion of the later generation fluoroquinolones
in MDR-TB regimens is:
high-dose
levofloxacin
, all Fluoroquinolones (levofloxacin or moxifloxacin), bed aquiline and
linezolid are strongly recommended for use in longer regimens, which are
completed with other drugs ranked by their relative balance of effectiveness to
potential toxicity.
moxifloxacin
&
gatifloxacin
It
is recommended that ofloxacin is phased out from MDR-TB regimens and that
ciprofloxacin is never used due to the limited evidence for their effectiveness
Second Line Drugs - Fluoroquinolones, second line injectable drugs
WHO
recommendations on the treatment of drug resistant TB
In
December 2018 the World Health Organisation (WHO) changed their recommendations
on the second line drugs to be used for the treatment of drug resistant TB.1 As the
treatment provided for many patients will lag behind the guidelines produced by
WHO, a summary of the 2016 recommendations are also provided here for
reference.
The
guidelines published by WHO provide extensive information, so the information
provided here is just a summary.
Second
line drugs, recommendations after December 2018
The
second line drugs to be used for the treatment of drug resistant TB after 2018
are shown in the table below.
The
new guidelines mark a major change in the recommended treatment to be provided
for those on "longer regimens". Longer MDR-TB regimens are treatments
for MDR/RR-TB which last 18 months or more and which may be standardized or
individualized. These regimens are usually designed to include a minimum number
of second line TB medicines considered to be effective based on patient history
or drug resistance patterns. The term "conventional" was previously
used to refer to such regimens but was discontinued in 2016 when WHO first
issued a recommendation for the use of a shorter MDR-TB regimen.
Injectable
agents are no longer among the priority medicines to be used when designing
longer MDR-TB regimens and WHO recommends that oral regimens should become the
preferred option for most patients. It is a major step forward in the treatment
of patients with drug resistant TB that patients are no longer required to have
injectable drugs.
Fluoroquinolones
(levofloxacin or moxifloxacin), bed aquiline and linezolid are strongly recommended for use in
longer regimens, which are completed with other drugs ranked by their relative
balance of effectiveness to potential toxicity.
|
Group
A :
|
Group
B :
|
Group
C :
|
|
Levofloxacin
(Lfx) or
Moxifloxacin (Mfx) |
Clofazimine
(Cfz)
|
Ethambutol
(E)
|
|
Bedaquiline
(Bdq)
|
Cycloserine
(Cs)
or Terizidone (Trd) |
Delamanid
(Dlm)
|
|
Linezolid
(Lzd)
|
Pyrazinamide
(Z)
|
|
|
Imipenem-cilastatin
(Ipm-Cln) or
Meropenem (Mpm) |
||
|
Amikacin
(Am) (or Streptomycin)
|
||
|
Ethionamide
(Eto) or Prothionamide (Pto)
|
||
|
p-aminosalicylic
acid (PAS)
|
||
|
Second
line drugs used to treat rifampicin resistant and multi drug
resistant TB after December 2018
|
||
If
a plus sign is shown, clicking on it will show more columns.
All
three medicines in Group A should be included.
In group B one or both medicines should be included
Group C medicines should be included to complete the regimen when medicines from Groups A and B cannot be used.
In group B one or both medicines should be included
Group C medicines should be included to complete the regimen when medicines from Groups A and B cannot be used.
There
is some further information about this on the page on the Treatment of Drug
Resistant TB,
and there is extensive information which should be consulted in the WHO
guidelines document.
Second
line drugs, recommendations after 2016 and before 2018
In
2016 WHO changed their recommendations on the second line drugs to be used for
the treatment of drug resistant TB.2. The second line drugs to be used for
the treatment of drug resistant TB after 2016 were as follows.
|
Group
A : Fluoroquinolones
|
Group
B : Second line injectable drugs
|
Group
C : Other core second line drugs
|
Group
D : Add-on drugs (not part of the core MDR-TB regimen)
|
|
Levofloxacin
(Lfx)
|
Amikacin
(Am)
|
Ethionamide/Prothionamide
(Eto/Pto)
|
D1
Pyrazinamide
|
|
Moxifloxacin
(Mfx)
|
Capreomycin
(Cm)
|
Cycloserine
/ Terizidone (Cs Trd)
|
D1
Ethambutol (E)
|
|
Gatifloxacin
(Gfx)
|
Kanamycin
(Km)
|
Linezolid
(Lzd)
|
D1
High-dose isoniazid (Hh)
|
|
(Streptomycin)
|
Clofazimine
(Cfz)
|
D2
Bedaquiline (Bdq)
|
|
|
D2
Delamanid (Dlm)
|
|||
|
D3 p-aminosalicylic
acid PAS)
|
|||
|
D3
imipenem-cilastatin (lpm)
|
|||
|
D3
Meropenem (Mpm)
|
|||
|
D3
Amoxicillin-clavulanate (Amx-Clv)
|
|||
|
D3
Thioacetazone (T)
|
|||
Groups
A, B & C are the core second line drugs.
If
a plus sign is shown, clicking on it will show more columns.
What is ASB:
Is rec urethritis is a sequel??Few points on Asymptomatic
bacteriuria (ASB) : It is worth remembering that Asymptomatic bacteriuria
(ASB) is the
presence of bacteria within the urinary tract, excluding the distal urethra,
without signs or symptoms of infection. ASB is associated with low-birth-weight
infants and preterm delivery, and its treatment in pregnancy is indicated. The
prevalence of ASB during pregnancy ranges from 2% to 7%. If left: untreated,
20% to 30% of ASB in pregnant women progresses to pyelonephritis; treatment
reduces this to 3%.
Screening
for bacteriuria with a urine culture is recommended at the first prenatal
visit. Women with sickle cell trait have a twofold increased risk of ASB and
can be screened every trimester. A clean-catch urine culture with >100,000
colonics/mL or catheterized urineculture with >100 colonics/mL warrants
treatment. Escherichia
coli accounts for 75% to 90% of infections. Klebsiella, Proteus, Pseudomonas, Enterobacter, and coagulase-negative
Staphylococcus are other common pathogens.
Initial
therapy is usually empiric and may be altered based on urine culture
sensitivities. Repeat urine culture is obtained 1 to 2 weeks after
treatment and again each trimester. If bacteriuria persists after two or more
treatment courses, suppressive therapy should be considered for the remainder
of the pregnancy.
Acute cystitis occurs in approximately 1% to 3% of pregnant women. Symptoms
include urinary frequency, urgency, dysuria, hematuria, and/or suprapubic discomfort.
Empiric treatment regimens arc the same as for ASB. If possible, a urine
culture should be sent prior to initiating antibiotic therapy.
Urethritis is usually caused by Chlamydia trachomatis, and it should be suspected in
patients with symptoms of acute cystitis and a negative urine culture. Mucopurulent
cervicitis may also be present. The treatment of choice is azithromycin 1 g as
a single oral dose for both the patient and her partner. A test of cure should
be sent 3 to 4 weeks after treatment.
E. coli that have adhesins such as S- or P-fimbriae. These
appendages enhance bacterial virulence, and indeed, 90% of E. coli isolates from women with acute pyelonephritis have these
fimbriae.
Under
certain conditions, covert bacteriuria can cause symptomatic cystitis or
pyelonephritis. Normal pregnancy-induced urinary stasis and vesicoureteral
reflux predispose to these infections. The invading organisms are those from
the normal perineal flora, and about 10% of women have perineal colonization
with strains of E. coli that have adhesins such as S- or P-fimbriae. These
appendages enhance bacterial virulence, and indeed, 90% of E. coli isolates from women with acute pyelonephritis have these
fimbriae.
Because
one-fourth of pregnant women with untreated asymptomatic bacteriuria go on to
develop acute pyelonephritis, early prenatal screening and eradication is
recommended by most, including the American College of Obstetricians and
Gynecologists. When the prevalence is low, standard urine cultures may not be
cost effective and other test systems such as the dipstick culture technique
have been reported to be accurate.
ASB:-Cystitis
typically is characterized by dysuria, urgency and frequency with minimal
manifestations. Infection is confirmed by pyuria, hematuria and bacteriuria.
The upper urinary tract may also become involved by ascending infection, either
with or without concomitant cystitis. The incidence of acute pyelonephritis
during pregnancy is reported to be as high as 4%. Because of this, renal
infection is a leading cause of sepsis syndrome (see Protocol 26).
Pyelonephritis is more common after midpregnancy and it is right-sided in
about half of cases and bilateral in another fourth. The onset is usually
abrupt with fever, shaking chills and pain in one or both lumbar regions. There
may be anorexia, nausea and vomiting. Tenderness usually can be elicited by
percussion in one or both costovertebral angles. The urinary sediment usually
contains many leukocytes, frequently in clumps, and numerous bacteria. E. coli strains are isolated from urine cultures in 75 to 80% of
women with pyelonephritis. The other isolates include Klebsiella, Enterobacter or Proteus species or group B streptococci.
Women with acute pyelonephritis usually appear quite ill, and bacteremia is
confirmed in 15 to 20%.
Bacteriuria
or cystitis are treated empirically with any of several antimicrobial regimens
that include single-dose or 3-day treatment with ampicillin or amoxicillin; one
of the cephalosporins or quinolones; nitrofurantoin; or
trimethoprim-sulfamethoxazole. Regardless of the regimen chosen, the recurrence
rate is about 30% after completion of any of these regimens. For women with a
recurrent infection, a second course with the same or another one of these
agents is given. For women with persistent bacteriuria, or those with frequent
recurrences, suppressive therapy for the remainder of pregnancy can be given
with nitrofurantoin, 100 mg at bedtime.
Most major
complications encountered with antepartum pyelonephritis are caused by the
sepsis syndrome. Between 5 and 20% of women will manifest reversible acute
kidney injury manifest by elevated serum creatinine levels. In some of these,
it may be necessary to modify dosing with potentially nephrotoxic
antimicrobials such as amnioglycosides. Up to 5 to 10% of women with acute
pyelonephritis develop varying degrees of acute respiratory distress syndrome.
In some of these, tracheal intubation with mechanical ventilation is
lifesaving. After midpregnancy, septicemia may cause uterine activity, but
caution is urged for co-administration of tocolytics that may increase the risk
of permeability pulmonary edema. Finally, persistence of the sepsis syndrome
should prompt a search for ureteral obstruction as well as for a perinephric
phlegmon or abscess. Endotoxin-induced hemolysis causes anemia in about a third
of women.
Management of acute Pyelonephritis:
Hydration
with intravenous crystalloid solutions and antimicrobials is the cornerstone of
therapy and is begun promptly at diagnosis. Therapy is empirical, and
ampicillin plus gentamicin; cefazolin or ceftriaxone; or an extended-spectrum beta-lactam
have been found to be 95% effective in randomized trials. Ongoing surveillance
in an acute care unit is recommended in order to recognize worsening of sepsis
syndrome. To do so, frequent determinations of vital signs and urinary output
are monitored. Clinical response is usually relatively prompt and clinical
symptoms usually resolve within 2 days and 95% of women are afebrile by 72
hours. As discussed, for those who do not respond promptly and appropriately,
consideration is given for urinary tract obstruction, usually from stone
disease, and imaging studies may be indicated. At discharge, oral antimicrobial
therapy is given for 7 to 10 days.
Recurrent
covert bacteriuria develops in about a third of women following treatment for
pyelonephritis. Because a third of these will again develop recurrent
symptomatic infection, then asymptomatic bacteriuria is treated again as
Management
of the pregnant woman with acute pyelonephritis
Hospitalization
Urine
culture; blood culture if overtly septic
Hemogram,
serum creatinine and electrolytes
Monitor
vital signs frequently, including urinary output with indwelling bladder
catheter
Intravenous
crystalloid to establish urinary output to &50 ml/h
Intravenous
antimicrobial therapy
Chest x-ray
if there is dyspnea or tachypnea
Repeat
hemogram and creatinine in 48 hours
Switch to
oral antimicrobials when afebrile
Discharge
when afebrile 24 hours, give antimicrobial therapy for 7 to 10 days
Urine
culture 1 to 2 weeks after antimicrobial therapy completed
described
above. Unless urine culture surveillance is performed to ensure urine
sterility, then nitrofurantoin, 100 mg at bedtime, is given for the remainder
of the pregnancy. Avoid using
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