Antibacterial therapy for urinary tract infections. Urinary tract infection - treatment

One of the most common reasons for visiting a urologist today is genitourinary infections (UI), which should not be confused with STIs. The latter are transmitted sexually, while MPI is diagnosed at any age and occurs for other reasons.

Bacterial damage to the organs of the excretory system is accompanied by severe discomfort - pain, burning, frequent urge to empty the bladder, and the release of pathological secretions from the urethra. In severe cases of infection, intense febrile and intoxication symptoms may develop.

The optimal treatment option is the use of modern antibiotics, which allow you to get rid of the pathology quickly and without complications.

Genitourinary infections include several types of inflammatory processes in the urinary system, which includes the kidneys with the ureters (they form the upper sections of the urinary tract), as well as the bladder and urethra (lower sections):

• – inflammation of the parenchyma and pyelocaliceal system of the kidneys, accompanied by painful sensations in the lower back of varying intensity, as well as severe intoxication and febrile symptoms (lethargy, weakness, nausea, chills, muscle and joint pain, etc.).
• – an inflammatory process in the bladder, the symptoms of which are a frequent urge to urinate with an accompanying feeling of incomplete emptying, sharp pain, and sometimes blood in the urine.
• Urethritis is damage to the urethra (the so-called urethra) by pathogenic microorganisms, in which purulent discharge appears in the urine and urination becomes painful. There is also a constant burning sensation in the urethra, dryness and pain.

Urinary tract infections can have several causes. In addition to mechanical damage, pathology occurs against the background of hypothermia and decreased immunity, when opportunistic microflora is activated. In addition, infection often occurs due to poor personal hygiene, when bacteria enter the urethra from the perineum. Women get sick much more often than men at almost any age (with the exception of older people).

Antibiotics in the treatment of MPI

In the vast majority of cases, the infection is bacterial in nature. The most common pathogen is a representative of enterobacteria - Escherichia coli, which is detected in 95% of patients. Less common are S.saprophyticus, Proteus, Klebsiella, Entero- and.

The disease is also often caused by mixed flora (an association of several bacterial pathogens).

Thus, even before laboratory tests, the best option for genitourinary tract infections would be treatment with broad-spectrum antibiotics.

Modern antibacterial drugs are divided into several groups, each of which has a special mechanism of bactericidal or bacteriostatic action. Some drugs are characterized by a narrow spectrum of antimicrobial activity, that is, they have a detrimental effect on a limited number of varieties of bacteria, while others (broad spectrum) are designed to combat different types of pathogens. It is the antibiotics of the second group that are used to treat urinary tract infections.

Penicillins

The first antibiotics discovered by man were for quite a long time an almost universal means of antibiotic therapy. However, over time, pathogenic microorganisms mutated and created specific defense systems, which required the improvement of medications.

At the moment, natural penicillins have practically lost their clinical significance, and semi-synthetic, combined and inhibitor-protected penicillin antibiotics are used instead.

Urogenital infections are treated with the following drugs of this series:

• . A semi-synthetic drug for oral and parenteral use, acting bactericidal by blocking cell wall biosynthesis. It is characterized by fairly high bioavailability and low toxicity. Particularly active against Proteus, Klebsiella and Escherichia coli. In order to increase resistance to beta-lactamases, the combination drug Ampicillin/Sulbactam ® is also prescribed.
• . In terms of the spectrum of antimicrobial action and effectiveness, it is similar to the previous ABP, but is characterized by increased acid resistance (it is not destroyed in an acidic gastric environment). Its analogues and, as well as combined antibiotics for the treatment of the genitourinary system (with clavulanic acid) - Amoxicillin/Clavulanate ® , ® , are used.

Recent studies have revealed a high level of resistance of uropathogens to ampicillin and its analogues.

For example, the sensitivity of Escherichia coli is just over 60%, which indicates the low effectiveness of antibiotic therapy and the need to use antibiotics of other groups. For the same reason, the antibiotic sulfanilamide () is practically not used in urological practice.

Recent studies have revealed a high level of resistance of uropathogens to ampicillin ® and its analogues.

Cephalosporins

Another group of beta-lactams with a similar effect, differing from penicillins in increased resistance to the destructive effects of enzymes produced by pathogenic flora. There are several generations of these medications, most of them intended for parenteral administration. From this series, the following antibiotics are used to treat the genitourinary system in men and women:

• . An effective medicine for inflammation of all genitourinary organs for oral administration with a minimal list of contraindications.
• (Ceclor ® , Alphacet ® , Taracef ® ). It belongs to the second generation of cephalosporins and is also used orally.
• and its analogues Zinacef ® and. Available in several dosage forms. They can be prescribed even to children in the first months of life due to low toxicity.
• . Sold in powder form for the preparation of a solution, which is administered parenterally. Rocephin ® is also a substitute.
• (Cephobid ®). A representative of the third generation of cephalosporins, which is prescribed intravenously or intramuscularly for genitourinary infections.
• (Maxipim ®). The fourth generation of antibiotics of this group for parenteral use.

The listed drugs are widely used in urology, but some of them are contraindicated for pregnant and lactating women.

Fluoroquinolones

The most effective antibiotics to date for genitourinary infections in men and women. These are powerful synthetic drugs with bactericidal action (the death of microorganisms occurs due to disruption of DNA synthesis and destruction of the cell wall). They are considered highly toxic antibacterial agents. They are poorly tolerated by patients and often cause undesirable effects from the therapy.

Contraindicated in patients with individual intolerance to fluoroquinolones, patients with central nervous system pathologies, epilepsy, persons with kidney and liver pathologies, pregnant women, breastfeeding women, and patients under 18 years of age.

• . Taken orally or parenterally, it is well absorbed and quickly eliminates painful symptoms. It has several analogues, including Tsiprinol ®.
• ( , Tarivid ®). Antibiotic fluoroquinolone, widely used not only in urological practice due to its effectiveness and wide spectrum of antimicrobial action.
• (). Another drug for oral, as well as intravenous and intramuscular use. It has the same indications and contraindications.
• Pefloxacin ® (). It is also effective against most aerobic pathogens and is taken parenterally and orally.

These antibiotics are also indicated for mycoplasma, since they act on intracellular microorganisms better than the previously widely used tetracyclines. A characteristic feature of fluoroquinolones is their negative effect on connective tissue. It is for this reason that the drugs are prohibited from being used before reaching the age of 18, during pregnancy and breastfeeding, as well as by persons with diagnosed tendonitis.

Aminoglycosides

A class of antibacterial agents intended for parenteral administration. The bactericidal effect is achieved by inhibiting protein synthesis of predominantly gram-negative anaerobes. At the same time, drugs in this group are characterized by fairly high rates of nephro- and ototoxicity, which limits the scope of their use.

• . A drug of the second generation of aminoglycoside antibiotics, which is poorly adsorbed in the gastrointestinal tract and is therefore administered intravenously and intramuscularly.
• Netilmecin ® (Netromycin ®). Belongs to the same generation, has a similar effect and list of contraindications.
• . Another aminoglycoside that is effective for urinary tract infections, especially complicated ones.

Due to their long half-life, these drugs are used only once a day. Prescribed to children from an early age, but contraindicated for lactating women and pregnant women. First generation aminoglycoside antibiotics are no longer used in the treatment of urinary tract infections.

Nitrofurans

Broad-spectrum antibiotics for infections of the genitourinary system with a bacteriostatic effect, which manifests itself against both gram-positive and gram-negative microflora. At the same time, resistance in pathogens practically does not develop.

These drugs are intended for oral use, and food only increases their bioavailability. To treat UTI infections, Nitrofurantoin ® (trade name Furadonin ®) is used, which can be given to children from the second month of life, but not to pregnant and lactating women.

The antibiotic trometamol, which does not belong to any of the groups listed above, deserves a separate description. It is sold in pharmacies under the trade name Monural and is considered a universal antibiotic for inflammation of the genitourinary system in women.

This bactericidal agent for uncomplicated forms of inflammation of the urinary tract is prescribed in a one-day course - 3 grams of fosfomycin ® once (according to indications - twice). Approved for use at any stage of pregnancy, has virtually no side effects, and can be used in pediatrics (from 5 years of age).

Cystitis and urethritis

As a rule, cystitis and a nonspecific inflammatory process in the urethra occur simultaneously, so there is no difference in their treatment with antibiotics. For uncomplicated forms of infection, the drug of choice is.

Also, for uncomplicated infections in adults, a 5-7 day course of fluoroquinolones (Ofloxacin ® , Norfloxacin ® and others) is often prescribed. The reserve ones are Amoxicillin/Clavulanate ® , Furadonin ® or Monural ® . Complicated forms are treated similarly, but the course of antibiotic therapy lasts at least 1-2 weeks.

For pregnant women, the drug of choice is Monural ®; beta-lactams (penicillins and cephalosporins) can be used as an alternative. Children are prescribed a seven-day course of oral cephalosporins or Amoxicillin ® with potassium clavulanate.

Additional Information

It should be taken into account that complications and severe course of the disease require mandatory hospitalization and treatment with parenteral drugs. On an outpatient basis, medications are usually prescribed to be taken orally. As for folk remedies, they do not have any particular therapeutic effect and cannot be a substitute for antibiotic therapy. The use of herbal infusions and decoctions is permissible only in consultation with a doctor as an additional treatment.

Diseases of the urinary system are frequent companions of humanity. Special drugs are used to treat them. Antibiotics for diseases of the genitourinary system, prescribed by the attending physician, can be taken both at home and in the hospital. The therapeutic course is accompanied by periodic urine and blood tests.

For what diseases are antibacterial agents used?

Antibiotics are prescribed when an inflammatory process is detected in the kidneys. This is due to several factors. First of all, because antibiotics for diseases of the genitourinary system help relieve inflammation and pain caused by the process. These drugs can prevent the spread of infection through the bloodstream to neighboring organs of the urinary system and other systems.

Modern urologists use the universal term nephritis to refer to inflammatory processes of the kidneys. It includes diseases such as pyelonephritis, cystitis, and kidney tuberculosis. The effectiveness of influencing the cause of inflammation is determined by the degree of development of the disease. The sooner a person consults a doctor, the faster he will recover.

Important! Antibiotics are considered an effective treatment for all types of kidney, bladder and urinary tract diseases.

Antibacterial therapy: types of drugs

There are a large number of different drugs for the treatment of the genitourinary system.

The modern pharmaceutical market segment has a large number of different drugs. A consultation with a doctor is needed in order to find out what the cause is and select the appropriate medication to treat the problem in the genitourinary system. Experts use beta-lactams and some other antibiotics in practice to treat the genitourinary system.

Beta-lactams

These are anti-inflammatory drugs that have a strong effect on a wide range of bacteria. Drugs in this group are prescribed in combination with other drugs that improve the effect of the main drug. Antibiotics used to treat urinary tract infections have a detrimental effect on gram-negative and gram-positive organisms and kill staphylococci, which are resistant to many drugs. These include aminopenicillins and antipseudomonas pinicillins.

This also includes cephalosporins - a group of tablets created to treat urinary tract infections caused by various pathogens. The drug is offered in 4 types or generations, each of which has a specific range of effects and can help eliminate many serious kidney diseases. The group in question has proven itself on the positive side, especially the 4th generation.

Other antibiotics for the treatment of genitourinary tract infections

Different types of antibiotics are used for different diseases.

These are tablets that are just as effective for inflammation of the kidneys and bladder, in particular, antibiotics of the fluoroquinol group. These tablets are indicated in cases where the patient's life is in danger. They are also used to treat chronic diseases in acute stages. This group includes aminoglycosides used for urogenital dysfunction. But urethritis is treated with microlides. Tetracyclines are used to treat nephritis caused by atypical flora.

In addition, urologists recommend broad-spectrum antibiotics. These drugs are a way out of various situations and can eliminate the causes of kidney and urinary tract disease. To choose the most effective antibiotic used for a urinary tract infection, you need to consult a doctor and identify the true causative agent of the infection.

The main drugs for the treatment of the genitourinary system are antibiotics. Before the appointment, you need to submit a urine culture for sterility, and determine the reaction of microorganisms obtained from it to antibacterial drugs. Without sowing, it is better to use broad-spectrum medications. But some are characterized by nephrotoxicity (toxic effects on the kidneys), for example, Gentamicin, Polymyxin, Streptomycin.

Treating infections with antibiotics

For inflammation of the urinary tract, antibiotics of the cephalosporin group are used - Cephalexin, Cefaclor, Cefepime, Ceftriaxone. For kidney inflammation, semi-synthetic penicillin is also used - Oxacillin and Amoxicillin. But it is better for genitourinary infections to be treated with a fluoroquinolone - Ciprofloxacin, Ofloxacin and Gatifloxacin. The duration of antibiotic use for kidney diseases is up to 7 days. For complex treatment, drugs with sulfenylamide are used - “Biseptol” or “Urosulfan”.

Return to contents

Herbal uroantiseptics

"Canephron" for illness

In urology, herbal uroantiseptics are used both as the main healing substances and as auxiliary ones. « Canephron" is an excellent remedy for the treatment of diseases of the genitourinary system. It has anti-inflammatory and antimicrobial effects, causing a diuretic effect. It is used internally in the form of drops or tablets. Canephron contains rose hips, rosemary leaves, centaury and rosemary. For kidney inflammation, 50 drops of medicine or 2 tablets are prescribed 3 times a day. In men, it is considered the best remedy for the treatment of genitourinary infections.

Return to contents

"Phytolysin"

Herbal uroantiseptics are an excellent remedy for the treatment of diseases of the genitourinary system.

“Fitolysin” is a remedy for infections of the genitourinary system, promotes easier passage of stones and removes pathological agents from the urinary tract. Mint, pine, orange, sage and vanillin oils are added to the preparation. Take an anti-inflammatory after meals 3 times a day, 1 tsp. half a glass of warm water. Kidney disease goes away within a month. It is made in the form of a paste to obtain a solution. Composition of "Phytolysin" - extracts:

horsetail; parsley; birch leaves; wheatgrass rhizomes; fenugreek; hernia; onion bulbs; goldenrod; knotweed herb. Return to contents

Medicines to relieve symptoms of inflammation of the genitourinary system

Inflammation of the urinary tract begins to be treated with medications that relieve inflammatory symptoms and restore the functionality of the urinary tract. The main medications for the genitourinary system are “Papaverine” and “No-shpa”. Doctors recommend using antibacterial agents after a course of antispasmodics. At the same time, they are treated with tablets that do not have nephrotoxicity.

For diseases of the genitourinary system, paracetamol is used. Daily dose - 4 times 650 mg. When taking paracetamol, drink plenty of water to ensure normal hemodynamics. Instead of paracetamol, Ibuprofen is indicated. Daily dose - 4 times 1200 mg. Other medications for symptom relief: Ketanov, Nimesulide, Cefekon and Baralgin. The decision in therapy with nephrotoxic drugs is justified, and therapy is prescribed only after consulting a doctor.

Return to contents

Antispasmodics

Antispasmodics relieve pain, but do not affect the cause of the disease.

Antispasmodic medications improve urine flow and relieve pain. Popular tablets are the same “Papaverine” with “No-shpa” and “Benziclan” with “Drotaverine”. “No-spa” is available in the form of tablets and solution. Dosage - no more than 240 mg per day. It is strictly forbidden to take “No-shpu” in case of heart and liver failure. Additionally, it is allowed to take Canephron - it has both antispasmodic and antiseptic effects.

Return to contents

Diuretics

Diuretics are diuretics. Treatment with diuretics should be treated with caution. They can cause kidney failure and complicate the disease. Therapy is used only after a doctor's prescription. The main medications for urinary tract infections: Diuver, Hypothiazide, Furomesid and Aldactone. Dose - 1 tablet per week. To maintain water balance in the body, calcium, potassium, and saline solutions are taken in combination with diuretics, and hemosorption and hemodialysis are performed.

Return to contents

Immunostimulation for diseases of women and men

Often, in case of kidney disease, doctors prescribe multivitamin preparations to boost immunity.

When men and women have diseases of the kidneys and urinary tract, you need to drink decoctions that contain vitamins: rose hips, birch tree leaves, rowan, currant leaf, knotweed. Doctors also prescribe multivitamin preparations, which contain a complex of microelements and vitamins. Medicines to increase immunity for kidney diseases - “Alvittil”, “Aerovit”, “Ascorutin”, “Tetrafolevit”, “Milgamma”. Along with vitamins, minerals such as selenium and zinc are taken.

Urinary tract infection (UTI) is the growth of microorganisms in various parts of the kidneys and urinary tract (UT), which can cause an inflammatory process, localized corresponding to the disease (pyelonephritis, cystitis, urethritis, etc.).

UTI in children occurs in Russia with a frequency of about 1000 cases per 100,000 population. Quite often, UTIs tend to be chronic and recurrent. This is explained by the peculiarities of the structure, blood circulation, innervation of the MP and age-related dysfunction of the immune system of the growing child’s body. In this regard, it is customary to identify a number of factors contributing to the development of UTI:

• disturbance of urodynamics;
• neurogenic bladder dysfunction;
• severity of pathogenic properties of microorganisms (adhesion, release of urease);
• features of the patient’s immune response (decreased cell-mediated immunity, insufficient production of antibodies to the pathogen, production of autoantibodies);
• functional and organic disorders of the distal parts of the colon (constipation, imbalance of intestinal microflora).

In childhood, UTIs in 80% of cases develop against the background of congenital anomalies of the upper and lower bladders, in which there are urodynamic disturbances. In such cases, they speak of complicated UTI. In an uncomplicated form, anatomical disorders and urodynamic disorders are not determined.

Among the most common malformations of the urinary tract, vesicoureteral reflux occurs in 30-40% of cases. Second place goes to megaureter, neurogenic bladder dysfunction. With hydronephrosis, kidney infection occurs less frequently.

Diagnosis of UTI is based on many principles. It must be remembered that the symptoms of a UTI depend on the age of the child. For example, newborns do not have specific symptoms of UTI and the infection is rarely generalized.

Symptoms such as lethargy, restlessness, periodic rises in temperature, anorexia, vomiting and jaundice are typical for young children.

Older children are characterized by fever, back pain, abdominal pain and dysuria.

The list of questions when collecting anamnesis includes the following items:

• heredity;
• complaints when urinating (frequency, pain);
• previous episodes of infection;
• unexplained rises in temperature;
• presence of thirst;
• amount of urine excreted;
• in detail: straining during urination, diameter and intermittency of the stream, imperative urges, rhythm of urination, daytime urinary incontinence, nocturnal enuresis, frequency of bowel movements.

The doctor should always strive to more accurately determine the location of a possible source of infection: the type of treatment and prognosis of the disease depend on this. To clarify the topic of urinary tract damage, it is necessary to have a good knowledge of the clinical symptoms of lower and upper urinary tract infections. In case of upper urinary tract infection, pyelonephritis is significant, which accounts for up to 60% of all cases of hospitalization of children in hospital ( ).

However, the basis for diagnosing UTIs is the data of urine tests, in which microbiological methods are of primary importance. Isolation of the microorganism in urine culture serves as the basis for diagnosis. There are several ways to collect urine:

• intake from the middle portion of the stream;
• urine collection into a urinal (in 10% of healthy children up to 50,000 CFU/ml, at 100,000 CFU/ml the analysis should be repeated);
• catheterization through the urethra;
• suprapubic aspiration (not used in Russia).

A common indirect method for assessing bacteriuria is a nitrite test (nitrates normally found in urine are converted to nitrites in the presence of bacteria). The diagnostic value of this method reaches 99%, but in young children, due to the short stay of urine in the bladder, it is significantly reduced and reaches 30-50%. It must be remembered that in young boys a false positive result may occur due to the accumulation of nitrites in the preputial sac.

Most cases of UTI are caused by one type of microorganism. The detection of several types of bacteria in samples is most often explained by violations of the technique for collecting and transporting the material.

In chronic UTIs, in some cases it is possible to identify microbial associations.

Other methods for examining urine include collecting a general urine test, the Nechiporenko and Addis-Kakovsky tests. Leukocyturia is observed in all cases of UTI, but it must be remembered that it can also occur, for example, with vulvitis. Gross hematuria occurs in 20-25% of children with cystitis. In the presence of symptoms of infection, proteinuria confirms the diagnosis of pyelonephritis.

Instrumental examinations are carried out for children during the period of remission of the process. Their purpose is to clarify the location of the infection, the cause and extent of kidney damage. Examination of children with UTIs today includes:

• ultrasound scanning;
• voiding cystography;
• cystoscopy;
• excretory urography (obstruction in girls - 2%, in boys - 10%);
• radioisotope renography;
• nephroscintigraphy with DMSA (scar forms within 1-2 years);
• urodynamic studies.

Instrumental and x-ray examinations should be performed according to the following indications:

• pyelonephritis;
• bacteriuria under 1 year of age;
• increased blood pressure;
• palpable mass in the abdomen;
• spinal abnormalities;
• decreased urine concentrating function;
• asymptomatic bacteriuria;
• relapses of cystitis in boys.

The bacterial etiology of UTI in urological diseases has distinctive features depending on the severity of the process, the frequency of complicated forms, the age of the patient and the state of his immune status, the conditions of the infection (outpatient or in hospital).

Research results (data from the Scientific Center for Children's Diseases of the Russian Academy of Medical Sciences, 2005) show that in outpatients with UTI in 50% of cases there are E. coli, at 10 o'clock% - Proteus spp., in 13% - Klebsiella spp., at 3% - Enterobacter spp., at 2% - Morganella morg. and with a frequency of 11% - Enterococcus fac. ( ). Other microorganisms, accounting for 7% of the isolation and occurring at a frequency of less than 1%, were as follows: S. epidermidis — 0,8%, S. pneumoniae — 0,6%, Acinetobacter spp. — 0,6%, Citrobacter spp. — 0,3%, S. pyogenes — 0,3%, Serratia spp. — 0,3%.

In the structure of nosocomial infections, UTIs occupy second place, after respiratory tract infections. It should be noted that 5% of children in a urological hospital develop infectious complications caused by surgical or diagnostic intervention.

In inpatients, the etiological significance of E. coli is significantly reduced (up to 29%) due to the increase and/or addition of such “problematic” pathogens as Pseudomonas aeruginosa (29%), Enterococcus faec.(4%), coagulase-negative staphylococci (2.6%), non-fermenting gram-negative bacteria ( Acinetobacter spp. — 1,6%, Stenotrophomonas maltophilia- 1.2%), etc. The sensitivity of these pathogens to antibacterial drugs is often unpredictable, as it depends on a number of factors, including the characteristics of nosocomial strains circulating in a given hospital.

There is no doubt that the main objectives in the treatment of patients with UTIs are the elimination or reduction of the inflammatory process in the renal tissue and bladder, and the success of treatment is largely determined by rational antimicrobial therapy.

Naturally, when choosing a drug, the urologist is guided primarily by information about the causative agent of the infection and the spectrum of the antimicrobial action of the drug. An antibiotic may be safe, capable of creating high concentrations in the kidney parenchyma and urine, but if its spectrum does not have activity against a specific pathogen, prescribing such a drug is pointless.

A global problem in prescribing antibacterial drugs is the increasing resistance of microorganisms to them. Moreover, resistance most often develops in community-acquired and nosocomial patients. Those microorganisms that are not included in the antibacterial spectrum of any antibiotic are naturally considered resistant. Acquired resistance means that a microorganism that was initially sensitive to a particular antibiotic becomes resistant to its action.

In practice, people are often mistaken about acquired resistance, believing that its occurrence is inevitable. But science has facts that refute this opinion. The clinical significance of these facts is that antibiotics that do not cause resistance can be used without fear of its subsequent development. But if the development of resistance is potentially possible, then it appears quite quickly. Another misconception is that the development of resistance is associated with the use of antibiotics in large quantities. Examples from the world's most commonly prescribed antibiotic, ceftriaxone, as well as cefoxitin and cefuroxime, support the concept that the use of antibiotics with low resistance potential at any level will not lead to further increases in resistance.

Many people believe that the emergence of antibiotic resistance is typical for some classes of antibiotics (this opinion applies to third-generation cephalosporins), but not for others. However, the development of resistance is not related to the class of antibiotic, but to the specific drug.

If an antibiotic has the potential to develop resistance, signs of resistance to it appear within the first 2 years of use or even during clinical trials. Based on this, we can confidently predict problems of resistance: among aminoglycosides - gentamicin, among second generation cephalosporins - cefamandole, third generation - ceftazidime, among fluoroquinolones - trovofloxacin, among carbapenems - imipenem. The introduction of imipenem into practice was accompanied by the rapid development of resistance to it in P. aeruginosa strains; this process continues today (the appearance of meropenem was not associated with such a problem, and it can be argued that it will not arise in the near future). Among the glycopeptides is vancomycin.

As already indicated, 5% of hospitalized patients develop infectious complications. Hence the severity of the condition, and the increase in recovery time, hospital stay, and increase in the cost of treatment. In the structure of nosocomial infections, UTIs take first place, followed by surgical ones (wound infections of the skin and soft tissues, abdominal infections).

The difficulties of treating hospital-acquired infections are determined by the severity of the patient’s condition. Often there is an association of pathogens (two or more, with a wound or catheter-associated infection). Also of great importance is the increased resistance of microorganisms in recent years to traditional antibacterial drugs (penicillins, cephalosporins, aminoglycosides) used for infections of the genitourinary system.

To date, the sensitivity of hospital strains of Enterobacter spp. to Amoxiclav (amoxicillin + clavulanic acid) is 40%, to cefuroxime - 30%, to gentamicin - 50%, the sensitivity of S. aureus to oxacillin is 67%, to lincomycin - 56%, to ciprofloxacin - 50%, to gentamicin - 50 %. The sensitivity of P. aeruginosa strains to ceftazidime in different departments does not exceed 80%, and to gentamicin - 50%.

There are two potential approaches to overcome antibiotic resistance. The first is to prevent resistance, for example by limiting the use of antibiotics that have a high potential for developing resistance; Equally important are effective epidemiological control programs to prevent the spread of hospital-acquired infections caused by highly resistant microorganisms in a health care setting (inpatient monitoring). The second approach is to eliminate or correct existing problems. For example, if resistant strains are common in the intensive care unit (or in the hospital in general) P. aeruginosa or Enterobacter spp., then a complete replacement in the formularies of antibiotics with a high potential for the development of resistance with “cleaner” antibiotics (amikacin instead of gentamicin, meropenem instead of imipenem, etc.) will eliminate or minimize antibiotic resistance of gram-negative aerobic microorganisms.

In the treatment of UTIs, the following are currently used: inhibitor-protected penicillins, cephalosporins, aminoglycosides, carbapenems, fluoroquinolones (limited in pediatrics), uroantiseptics (nitrofuran derivatives - Furagin).

Let us dwell on antibacterial drugs in the treatment of UTIs in more detail.

1. Inhibitor-protected aminopenicillins: amoxicillin + clavulanic acid (Amoxiclav, Augmentin, Flemoklav Solutab), ampicillin + sulbactam (Sulbacin, Unazin).
2. II generation cephalosporins: cefuroxime, cefaclor.
3. Fosfomycin.
4. Nitrofuran derivatives: furazolidone, furaltadone (Furazolin), nitrofural (Furacilin).

For upper urinary tract infection.

1. Inhibitor-protected aminopenicillins: amoxicillin + clavulanic acid, ampicillin + sulbactam.
2. II generation cephalosporins: cefuroxime, cefamandole.
3. III generation cephalosporins: cefotaxime, ceftazidime, ceftriaxone.
4. IV generation cephalosporins: cefepime.
5. Aminoglycosides: netilmicin, amikacin.

For hospital infection.

1. Cephalosporins of the III and IV generations - ceftazidime, cefoperazone, cefepime.
2. Ureidopenicillins: piperacillin.
3. Fluoroquinolones: according to indications.
4. Aminoglycosides: amikacin.
5. Carbapenems: imipenem, meropenem.

For perioperative antibacterial prophylaxis.

1. Inhibitor-protected aminopenicillins: amoxicillin + clavulanic acid, ticarcillin/clavulanate.
2. Cephalosporins of the II and III generations: cefuroxime, cefotaxime, ceftriaxone, ceftazidime, cefoperazone.

For antibacterial prophylaxis during invasive procedures: inhibitor-protected aminopenicillins - amoxicillin + clavulanic acid.

It is generally accepted that antibiotic therapy in outpatients with UTI can be performed empirically, based on the antibiotic susceptibility data of the main uropathogens circulating in a particular region during a given observation period and the clinical status of the patient.

The strategic principle of antibiotic therapy in outpatient settings is the principle of minimal sufficiency. First-line drugs are:

• inhibitor-protected aminopenicillins: amoxicillin + clavulanic acid (Amoxiclav);
• cephalosporins: oral cephalosporins of the II and III generations;
• derivatives of the nitrofuran series: nitrofurantoin (Furadonin), furazidin (Furagin).

It is erroneous to use ampicillin and co-trimoxazole in outpatient settings due to increased resistance to them E. coli. The use of first generation cephalosporins (cephalexin, cefradine, cefazolin) is not justified. Derivatives of the nitrofuran series (Furagin) do not create therapeutic concentrations in the renal parenchyma, so they are prescribed only for cystitis. In order to reduce the growth of resistance of microorganisms, the use of third-generation cephalosporins should be sharply limited and the use of aminoglycosides in outpatient practice should be completely eliminated.

Analysis of the resistance of strains of pathogens of complicated urinary infections shows that the activity of drugs from the group of semisynthetic penicillins and protected penicillins can be quite high against Escherichia coli and Proteus, but against enterobacteria and Pseudomonas aeruginosa their activity is up to 42 and 39%, respectively. Therefore, drugs in this group cannot be drugs for empirical treatment of severe purulent-inflammatory processes of the urinary organs.

The activity of cephalosporins of the first and second generations against Enterobacter and Proteus also turns out to be very low and ranges from 15-24%; against E. coli it is slightly higher, but does not exceed the activity of semisynthetic penicillins.

The activity of cephalosporins of the III and IV generations is significantly higher than that of penicillins and cephalosporins of the I and II generations. The highest activity was observed against E. coli - from 67 (cefoperazone) to 91% (cefepime). Activity against Enterobacter ranges from 51 (ceftriaxone) to 70% (cefepime); high activity of drugs in this group is also noted against Proteus (65-69%). The activity of this group of drugs against Pseudomonas aeruginosa is low (15% for ceftriaxone, 62% for cefepime). The spectrum of antibacterial activity of ceftazidime is the highest against all current gram-negative pathogens of complicated infections (from 80 to 99%). The activity of carbapenems remains high - from 84 to 100% (for imipenem).

The activity of aminoglycosides is somewhat lower, especially against enterococci, but amikacin retains high activity against enterobacteria and Proteus.

For this reason, antibacterial therapy for UTIs in urological patients in a hospital should be based on data from microbiological diagnostics of the infectious agent in each patient and his sensitivity to antibacterial drugs. Initial empirical antimicrobial therapy for urological patients can be prescribed only until the results of a bacteriological study are obtained, after which it should be changed according to the antibiotic sensitivity of the isolated microorganism.

When using antibiotic therapy in a hospital, a different principle should be followed - from simple to powerful (minimum use, maximum intensity). The range of groups of antibacterial drugs used here has been significantly expanded:

• inhibitor-protected aminopenicillins;
• cephalosporins of III and IV generations;
• aminoglycosides;
• carbapenems;
• fluoroquinolones (in severe cases and in the presence of microbiological confirmation of sensitivity to these drugs).

Perioperative antibiotic prophylaxis (pre-, intra- and post-operative) is important in the work of a pediatric urologist. Of course, one should not neglect the influence of other factors that reduce the likelihood of developing an infection (reducing hospital stay, quality of processing of instruments, catheters, use of closed systems for urine diversion, staff training).

Major studies show that postoperative complications are prevented if a high concentration of antibacterial drug in the blood serum (and tissues) is created before the start of surgery. In clinical practice, the optimal time for antibiotic prophylaxis is 30-60 minutes before the start of surgery (subject to intravenous administration of the antibiotic), i.e. at the beginning of anesthesia. There was a significant increase in the incidence of postoperative infections if the prophylactic dose of antibiotic was not prescribed within 1 hour before surgery. Any antibacterial drug administered after closing the surgical wound will not affect the likelihood of complications.

Thus, a single administration of an adequate antibacterial drug for prophylactic purposes is no less effective than repeated administration. Only with long-term surgery (more than 3 hours) an additional dose is required. Antibiotic prophylaxis cannot last more than 24 hours, since in this case the use of an antibiotic is considered as therapy, and not as prevention.

An ideal antibiotic, including for perioperative prophylaxis, should be highly effective, well tolerated by patients, and have low toxicity. Its antibacterial spectrum should include probable microflora. For patients staying in hospital for a long time before surgery, it is necessary to take into account the spectrum of nosocomial microorganisms, taking into account their antibiotic sensitivity.

For antibiotic prophylaxis during urological operations, it is advisable to use drugs that create high concentrations in the urine. Many antibiotics meet these requirements and can be used, such as second-generation cephalosporins and inhibitor-protected penicillins. Aminoglycosides should be reserved for patients at risk or allergic to b-lactams. Third and fourth generation cephalosporins, inhibitor-protected aminopenicillins and carbapenems should be used in isolated cases when the surgical site is contaminated with multi-resistant nosocomial microorganisms. Still, it is desirable that the use of these drugs be limited to the treatment of infections with a severe clinical course.

There are general principles of antibacterial therapy for UTIs in children, which include the following rules.

In case of febrile UTI, therapy should be started with a broad-spectrum parenteral antibiotic (inhibitor-protected penicillins, cephalosporins of the second and third generations, aminoglycosides).

It is necessary to take into account the sensitivity of urine microflora.

The duration of treatment for pyelonephritis is 14 days, cystitis - 7 days.

In children with vesicoureteral reflux, antimicrobial prophylaxis should be long-term.

Antibacterial therapy is not indicated for asymptomatic bacteriuria.

The concept of “rational antibiotic therapy” should include not only the correct choice of drug, but also the choice of its administration. It is necessary to strive for gentle and at the same time the most effective methods of prescribing antibacterial drugs. When using step therapy, which consists of changing the parenteral use of an antibiotic to an oral one, after the temperature has normalized, the doctor should remember the following.

• The oral route is preferable for cystitis and acute pyelonephritis in older children, in the absence of intoxication.
• The parenteral route is recommended for acute pyelonephritis with intoxication in infancy.

Antibacterial drugs are presented below depending on the route of their administration.

Oral medications for the treatment of UTIs.

1. Penicillins: amoxicillin + clavulanic acid.
2. Cephalosporins:

   II generation: cefuroxime;

   III generation: cefixime, ceftibuten, cefpodoxime.

Drugs for parenteral treatment of UTI.

1. Penicillins: ampicillin/sulbactam, amoxicillin + clavulanic acid.
2. Cephalosporins:

   II generation: cefuroxime (Cefu-rabol).

   III generation: cefotaxime, ceftriaxone, ceftazidime.

   IV generation: cefepime (Maxi-pim).

Despite the availability of modern antibiotics and chemotherapy drugs that make it possible to quickly and effectively cope with infection and reduce the frequency of relapses by prescribing drugs in low prophylactic doses for a long period, treating recurrent UTIs is still a rather difficult task. This is due to:

• increased resistance of microorganisms, especially when repeated courses are used;
• side effects of drugs;
• the ability of antibiotics to cause immunosuppression of the body;
• decreased compliance due to long courses of taking the drug.

As is known, up to 30% of girls have a recurrent UTI within 1 year, 50% within 5 years. In boys under 1 year of age, relapses occur in 15-20%; in boys older than 1 year, there are fewer relapses.

Let us list the indications for antibiotic prophylaxis.

• Absolute:

  a) vesicoureteral reflux;

  B) early age; c) frequent exacerbations of pyelonephritis (three or more per year), regardless of the presence or absence of vesicoureteral reflux.

• Relative: frequent exacerbations of cystitis.

The duration of antibiotic prophylaxis is most often determined individually. The drug is discontinued in the absence of exacerbations during prophylaxis, but if an exacerbation occurs after discontinuation, a new course is required.

Recently, a new drug has appeared on the domestic market to prevent recurrent UTIs. This preparation is a lyophilized protein extract obtained by fractionating an alkaline hydrolyzate of certain strains E. coli and is called Uro-Vaxom. The tests have confirmed its high efficiency with the absence of significant side effects, which gives hope for its widespread use.

An important place in the treatment of patients with UTIs is occupied by clinical observation, which consists of the following.

• Monitor urine tests monthly.
• Functional tests for pyelonephritis annually (Zimnitsky test), creatinine level.
• Urine culture - according to indications.
• Measure blood pressure regularly.
• For vesicoureteral reflux - cystography and nephroscintigraphy once every 1-2 years.
• Sanitation of foci of infection, prevention of constipation, correction of intestinal dysbiosis, regular bladder emptying.

Literature

1. Strachunsky L. S. Urinary tract infections in outpatients // Proceedings of the international symposium. M., 1999. pp. 29-32.
2. Korovina N. A., Zakharova I. N., Strachunsky L. S. et al. Practical recommendations for antibacterial treatment of urinary system infections of community-acquired origin in children // Clinical microbiology and antimicrobial chemotherapy, 2002. T. 4. No. 4. C 337-346.
3. Lopatkin N. A., Derevyanko I. I. Antibacterial therapy program for acute cystitis and pyelonephritis in adults // Infections and antimicrobial therapy. 1999. T. 1. No. 2. P. 57-58.
4. Naber K. G., Bergman B., Bishop M. K. et al. Recommendations of the European Association of Urology for the treatment of urinary tract infections and infections of the reproductive system in men // Clinical microbiology and antimicrobial chemotherapy. 2002. T. 4. No. 4. P. 347-63.
5. Pereverzev A. S., Rossikhin V. V., Adamenko A. N. Clinical effectiveness of nitrofurans in urological practice // Men's health. 2002. No. 3. pp. 1-3.
6. Goodman and Gilman's The Pharmacological Basis of Therapeutics, Eds. J. C. Hardman, L. E. Limbird., 10th ed., New York, London, Madrid, 2001.

S. N. Zorkin, Doctor of Medical Sciences, Professor
SCCD RAMS, Moscow