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Revision as of 13:05, 13 August 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

To view a comprehensive algorithm of common findings of urine composition and urine output, click here

Overview

Pyuria refers to urine which contains pus. Defined as the presence of 10 or more neutrophils per high power field of unspun, voided mid-stream urine. It can be a sign of a bacterial urinary tract infection. Pyuria may be present in the septic patient, or in an older patient with pneumonia.

Sterile pyuria is urine which contains white blood cells (pus) while appearing sterile by standard culture techniques. Sterile pyuria is listed as a side-effect from some medications such as paracetamol (acetaminophen).

Causes

In Alphabetical Order^[1]^[2]

Causes by Organ System

Cardiovascular	No underlying causes
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Thalidomide
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	No underlying causes
Musculoskeletal/Orthopedic	No underlying causes
Neurologic	No underlying causes
Nutritional/Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	No underlying causes

Treatment

Antimicrobial regimen

Sterile pyuria

1. Definitions

1.1 Pyuria: the presence of 10 or more white cells per cubic millimeter in a urine specimen, 3 or more white cells per high-power field of unspun urine, a positive result on Gram’s stain of an unspun urine specimen, or a urinary dipstick test that is positive for leukocyte esterase^[3]
1.2 Sterile pyuria: the persistent finding of white cells in the urine in the absence of bacteria, as determined by means of aerobic laboratory techniques (on a 5% sheep-blood agar plate and MacConkey agar plate)^[4]
1.3 Bacteriuria: bacterial colony counts of more than 1000 colony-forming units (CFU) per milliliter in urine^[5]

2. Causes^[6]

2.1 Infectious etiologies

Gynecologic infection
Urethritis due to chlamydia, Neisseria gonorrhoeae, mycoplasma, or ureaplasma
Prostatitis
Balanitis
Appendicitis
Viral infection of the lower genitourinary tract
Genitourinary tuberculosis
Fungal infection
Parasitic disease such as trichomoniasis or schistosomiasis

2.2 Non-infectious etiologies

Current use of antibiotics
Recently treated urinary tract infection (within past 2 weeks)
Presence or recent use of a urinary catheter
Recent cystoscopy or urologic endoscopy
Urinary tract stones
Foreign body such as surgical mesh in the urethra or a retained stent
Urinary tract neoplasm
Pelvic irradiation
Urinary fistula
Polycystic kidney
Rejection of a renal transplant
Renal-vein thrombosis
Interstitial nephritis or analgesic nephropathy
Papillary necrosis
Interstitial cystitis
Inflammatory disease such as systemic lupus erythematosus or Kawasaki’s disease

3. Pathogen-directed antimicrobial therapy^[7]

3.1 Tuberculosis

Preferred regimen: Isoniazid AND Rifampin AND Ethambutol AND Pyrazinamide for 3–6 months

3.2 Gonorrhea

Preferred regimen: Ceftriaxone 250 mg IM in a single dose, THEN (Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days)

3.3 Chlamydia

Preferred regimen: Azithromycin 1 g PO in single dose OR Doxycycline 100 mg PO bid for 7 days
Alternative regimen: Erythromycin base 500 mg PO qid for 7 days

3.4 Mycoplasma and ureaplasma

Preferred regimen: Azithromycin OR Levofloxacin OR Moxifloxacin

3.5 Genital herpes

Preferred regimen: Acyclovir 400 mg PO tid for 7–10 days or Acyclovir 200 mg PO five times a day for 7–10 days OR Famciclovir 250 mg PO tid for 7–10 days OR Valacyclovir 1 g PO bid for 7 days

3.6 Trichomoniasis

Preferred regimen: Metronidazole 2 g PO in a single dose OR Tinidazole 2 g PO in a single dose

Note: Treat patient’s sex partner if trichomoniasis is diagnosed in patient.

3.7 Fungal infections

Preferred regimen: Fluconazole OR posaconazole OR Echinocandins OR Amphotericin B

3.8 Schistosomiasis

Preferred regimen: Praziquantel 20 mg/kg PO bid for 1–2 days

References

↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
↑ Horan, Teresa C.; Andrus, Mary; Dudeck, Margaret A. (2008-06). "CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting". American Journal of Infection Control. 36 (5): 309–332. doi:10.1016/j.ajic.2008.03.002. ISSN 1527-3296. PMID 18538699. Check date values in: |date= (help)
↑ Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.
↑ Kwon, Jennie H.; Fausone, Maureen K.; Du, Hongyan; Robicsek, Ari; Peterson, Lance R. (2012-05). "Impact of laboratory-reported urine culture colony counts on the diagnosis and treatment of urinary tract infection for hospitalized patients". American Journal of Clinical Pathology. 137 (5): 778–784. doi:10.1309/AJCP4KVGQZEG1YDM. ISSN 1943-7722. PMID 22523217. Check date values in: |date= (help)
↑ Dieter, R. S. (2000). "Sterile pyuria: a differential diagnosis". Comprehensive Therapy. 26 (3): 150–152. ISSN 0098-8243. PMID 10984817.
↑ Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.

Template:WH Template:WS

[1] Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016

[2] Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X

[3] Horan, Teresa C.; Andrus, Mary; Dudeck, Margaret A. (2008-06). "CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting". American Journal of Infection Control. 36 (5): 309–332. doi:10.1016/j.ajic.2008.03.002. ISSN 1527-3296. PMID 18538699. Check date values in: |date= (help)

[4] Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.

[5] Kwon, Jennie H.; Fausone, Maureen K.; Du, Hongyan; Robicsek, Ari; Peterson, Lance R. (2012-05). "Impact of laboratory-reported urine culture colony counts on the diagnosis and treatment of urinary tract infection for hospitalized patients". American Journal of Clinical Pathology. 137 (5): 778–784. doi:10.1309/AJCP4KVGQZEG1YDM. ISSN 1943-7722. PMID 22523217. Check date values in: |date= (help)

[6] Dieter, R. S. (2000). "Sterile pyuria: a differential diagnosis". Comprehensive Therapy. 26 (3): 150–152. ISSN 0098-8243. PMID 10984817.

[7] Wise, Gilbert J.; Schlegel, Peter N. (2015-03-12). "Sterile pyuria". The New England Journal of Medicine. 372 (11): 1048–1054. doi:10.1056/NEJMra1410052. ISSN 1533-4406. PMID 25760357.

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@@ Line 140: / Line 140: @@
 |-
 |}
+==Treatment==
+===Antimicrobial regimen===
+* '''Sterile pyuria'''
+:*1. '''Definitions'''
+::*1.1 '''Pyuria''': the presence of 10 or more white cells per cubic millimeter in a urine specimen, 3 or more white cells per high-power field of unspun urine, a positive result on Gram’s stain of an unspun urine specimen, or a urinary dipstick test that is positive for leukocyte esterase<ref>{{Cite journal| doi = 10.1016/j.ajic.2008.03.002| issn = 1527-3296| volume = 36| issue = 5| pages = 309–332| last1 = Horan| first1 = Teresa C.| last2 = Andrus| first2 = Mary| last3 = Dudeck| first3 = Margaret A.| title = CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting| journal = American Journal of Infection Control| date = 2008-06| pmid = 18538699}}</ref>
+::*1.2 '''Sterile pyuria''': the persistent finding of white cells in the urine in the absence of bacteria, as determined by means of aerobic laboratory techniques (on a 5% sheep-blood agar plate and MacConkey agar plate)<ref>{{Cite journal| doi = 10.1056/NEJMra1410052| issn = 1533-4406| volume = 372| issue = 11| pages = 1048–1054| last1 = Wise| first1 = Gilbert J.| last2 = Schlegel| first2 = Peter N.| title = Sterile pyuria| journal = The New England Journal of Medicine| date = 2015-03-12| pmid = 25760357}}</ref>
+::*1.3 '''Bacteriuria''': bacterial colony counts of more than 1000 colony-forming units (CFU) per milliliter in urine<ref>{{Cite journal| doi = 10.1309/AJCP4KVGQZEG1YDM| issn = 1943-7722| volume = 137| issue = 5| pages = 778–784| last1 = Kwon| first1 = Jennie H.| last2 = Fausone| first2 = Maureen K.| last3 = Du| first3 = Hongyan| last4 = Robicsek| first4 = Ari| last5 = Peterson| first5 = Lance R.| title = Impact of laboratory-reported urine culture colony counts on the diagnosis and treatment of urinary tract infection for hospitalized patients| journal = American Journal of Clinical Pathology| date = 2012-05| pmid = 22523217}}</ref>
+:*2. '''Causes'''<ref>{{Cite journal| issn = 0098-8243| volume = 26| issue = 3| pages = 150–152| last = Dieter| first = R. S.| title = Sterile pyuria: a differential diagnosis| journal = Comprehensive Therapy| date = 2000| pmid = 10984817}}</ref>
+::*2.1 '''Infectious etiologies'''
+:::* Gynecologic infection
+:::* Urethritis due to chlamydia, Neisseria gonorrhoeae, mycoplasma, or ureaplasma
+:::* Prostatitis
+:::* Balanitis
+:::* Appendicitis
+:::* Viral infection of the lower genitourinary tract
+:::* Genitourinary tuberculosis
+:::* Fungal infection
+:::* Parasitic disease such as trichomoniasis or schistosomiasis
+::*2.2 '''Non-infectious etiologies'''
+:::* Current use of antibiotics
+:::* Recently treated urinary tract infection (within past 2 weeks)
+:::* Presence or recent use of a urinary catheter
+:::* Recent cystoscopy or urologic endoscopy
+:::* Urinary tract stones
+:::* Foreign body such as surgical mesh in the urethra or a retained stent
+:::* Urinary tract neoplasm
+:::* Pelvic irradiation
+:::* Urinary fistula
+:::* Polycystic kidney
+:::* Rejection of a renal transplant
+:::* Renal-vein thrombosis
+:::* Interstitial nephritis or analgesic nephropathy
+:::* Papillary necrosis
+:::* Interstitial cystitis
+:::* Inflammatory disease such as systemic lupus erythematosus or Kawasaki’s disease
+:*3. '''Pathogen-directed antimicrobial therapy'''<ref>{{Cite journal| doi = 10.1056/NEJMra1410052| issn = 1533-4406| volume = 372| issue = 11| pages = 1048–1054| last1 = Wise| first1 = Gilbert J.| last2 = Schlegel| first2 = Peter N.| title = Sterile pyuria| journal = The New England Journal of Medicine| date = 2015-03-12| pmid = 25760357}}</ref>
+::*3.1 '''Tuberculosis'''
+:::* Preferred regimen: [[Isoniazid]] {{and}} [[Rifampin]] {{and}} [[Ethambutol]] {{and}} [[Pyrazinamide]] for 3–6 months
+::*3.2 '''Gonorrhea'''
+:::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose, {{then}} ([[Azithromycin]] 1 g PO in a single dose {{or}} [[Doxycycline]] 100 mg PO bid for 7 days)
+::*3.3 '''Chlamydia'''
+:::* Preferred regimen: [[Azithromycin]] 1 g PO in single dose {{or}} [[Doxycycline]] 100 mg PO bid for 7 days
+:::* Alternative regimen: [[Erythromycin|Erythromycin base]] 500 mg PO qid for 7 days
+::*3.4 '''Mycoplasma and ureaplasma'''
+:::* Preferred regimen: [[Azithromycin]] {{or}} [[Levofloxacin]] {{or}} [[Moxifloxacin]]
+::*3.5 '''Genital herpes'''
+:::* Preferred regimen: [[Acyclovir]] 400 mg PO tid for 7–10 days or [[Acyclovir]] 200 mg PO five times a day for 7–10 days {{or}} [[Famciclovir]] 250 mg PO tid for 7–10 days {{or}} [[Valacyclovir]] 1 g PO bid for 7 days
+::*3.6 '''Trichomoniasis'''
+:::* Preferred regimen: [[Metronidazole]] 2 g PO in a single dose {{or}} [[Tinidazole]] 2 g PO in a single dose
+:::: Note: Treat patient’s sex partner if trichomoniasis is diagnosed in patient.
+::*3.7 '''Fungal infections'''
+:::* Preferred regimen: [[Fluconazole]] {{or}} [[posaconazole]] {{or}} [[Echinocandins]] {{or}} [[Amphotericin B]]
+::*3.8 '''Schistosomiasis'''
+:::* Preferred regimen: [[Praziquantel]] 20 mg/kg PO bid for 1–2 days
 ==References==