Antibiotics in the treatment and prevention of urinary tract infections (UTI) in children


treatment and prevention of urinary tract infectionsUrinary tract infection (UTI) - the growth of microorganisms in various parts of the kidneys and urinary tract (MP), capable of causing inflammation, localization corresponding to the disease (pyelonephritis, cystitis, urethritis, etc.).

Impact of children occurs on average with a frequency of about 1000 cases per 100 000 population. Quite often, UTIs tend to have a chronic, recurrent course. This is due to the peculiarity of the structure, blood circulation, innervation of the MP and age-related dysfunction of the immune system of the growing child's body.

In connection with this, it is customary to single out a number of factors that contribute to the development of UTI:

1. Violation of urodynamics;

2. Neurogenic bladder dysfunction;

3. Expression of pathogenic properties of microorganisms (adhesion, urease isolation);

4. Features of the immune response in the patient (reduction of cell-mediated immunity, inadequate production of antibodies to the pathogen, production of autoantibodies);

5. Functional and organic disorders of the distal colon (constipation, imbalance of intestinal microflora).

In childhood, UTI in 80% of cases develop against a background of congenital anomalies of the upper and lower MP, in which there are violations urodynamics. In such cases, one speaks of a complicated UTI. Uncomplicated form of anatomical disorders and disorders of urodynamics is not determined.

Among the most common malformations of the urinary tract, vesicoureteral reflux occurs in 30-40% of cases. The second place is occupied by a megaureter, neurogenic dysfunction of the bladder. With hydronephrosis, infection of the kidney occurs less frequently.

Diagnosis of UTI is based on many principles. It must be remembered that the symptomatology of UTI depends on the age of the child. For example, newborn children lack specific symptoms of UTIs and the infection is rarely generalized.

Young children are characterized by symptoms such as lethargy, anxiety, periodic temperature rises, anorexia, vomiting and jaundice.

For older children, fever, back pain, stomach and dysuric phenomena are common.

The list of questions in the collection of anamnesis includes the following items:

1. Heredity;

2. Complaints with urination (frequent, pain);

3. Previous episodes of infection;

4. Unexplained temperature rises;

5. The presence of thirst;

6. The amount of excreted urine;

7. In detail: straining with urination, the diameter and discontinuity of the jet, imperative urges, the rhythm of urination, urinary incontinence during the day, nocturnal enuresis, the frequency of emptying the intestine.

The doctor should always strive to establish more precisely the localization of a possible foci of infection: the type of treatment and the prognosis of the disease depend on this.

To clarify the topic of the urinary tract lesion, it is necessary to know well the clinical symptoms of infections of the lower and upper urinary tract. When infection of the upper urinary tract is significant pyelonephritis, which is up to 60% of all hospitalizations of children in the hospital.

However, the basis for the diagnosis of UTI is the data of urinalysis, in which microbiological methods are of primary importance. The isolation of the microorganism in the urine culture serves as the basis for the diagnosis.

There are several ways to take urine:

1. Selection from the average portion of the jet;

2. Taking urine into urine collection (in 10% of healthy children up to 50 000 cfu / ml, with 100 000 cfu / ml, the analysis should be repeated);

3. Sutterization through the urethra;

4. Suprapubic aspiration.

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

In most cases, UTI is caused by one type of microorganism. The determination in the samples of several species of bacteria is most often explained by violations of the technique of collecting and transporting the material.

In the chronic course of UTI in some cases, it is possible to identify microbial associations.

Other methods of urinalysis include the collection of a general urinalysis, the Nechiporenko and Addis-Kakovski test. Leukocyturia is observed in all cases of UTI, but it must be remembered that it can be, for example, and with vulvitis. Macrogematuria occurs in 20-25% of children with cystitis. In the presence of symptoms of infection, proteinuria confirms the diagnosis of pyelonephritis.

Instrumental examinations are performed for children during remission of the process. Their goal is to clarify the location of the infection, the cause and extent of damage to the kidneys.

The examination of children with UTIs today includes:

1. Ultrasound scanning;

2. Mictorial cystography;

3. Cystoscopy;

4. Excretory urography (obstruction in girls - 2%, in boys - 10%);

5. Radioisotope renography;

6. Nephroscintigraphy with DMSA (the scar is formed within 1-2 years);

7. Urodynamic studies.

The instrumental and radiological examination should be performed according to the following indications:

1. Pyelonephritis;

2. Bacteriuria before the age of 1 year;

3. Increased blood pressure;

4. Palpable formation in the abdomen;

5. Anomalies of the spine;

6. Decrease in the function of urine concentration;

7. Asymptomatic bacteriuria;

8. Relapses of cystitis in boys.

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

There is no doubt that the main tasks in the treatment of patients with UTI are the elimination or reduction of the inflammatory process in the kidney tissue and MP, while 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 pathogen and the spectrum of the antimicrobial effect of the drug. An antibiotic can be safe, capable of creating high concentrations in the parenchyma of the kidneys and urine, but if its spectrum is not active against a particular pathogen, the purpose of such a drug is meaningless.

The global problem in the appointment of antibacterial drugs is the growth of resistance of microorganisms to them. And most often, resistance develops in community-based and nosocomial patients. Those microorganisms that are not part of the antibacterial spectrum of any antibiotic, naturally, are considered resistant. Acquired resistance means that the microorganism initially sensitive to a particular antibiotic becomes resistant to its action.

In practice, often mistaken for acquired resistance, believing that its occurrence is inevitable. But science has facts that disprove 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 quickly enough.

Another misconception is that the development of resistance is associated with the use of antibiotics in large volumes. Examples with the world's most commonly prescribed antibiotic ceftriaxone, as well as with cefoxitin and cefuroxime, support the concept that the use of antibiotics with a low resistance development potential in any volumes will not lead to its growth thereafter.

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

If the antibiotic has the potential for developing resistance, signs of resistance to it appear already during the first 2 years of use or even at the stage of clinical trials. Proceeding from this, we can confidently forecast the problems of resistance: among aminoglycosides - it is gentamicin, among cephalosporins of the second generation - cefamandole, III generation - ceftazidime, among fluoroquinolones - trovafloxacin, among carbapenems - imipenem.

The introduction of imipenem into practice was accompanied by a rapid development of resistance to P. aeruginosa strains, this process continues even now (the appearance of meropenem was not associated with such a problem, and it can be asserted that it will not occur in the near future). Among the glycopeptides is vancomycin.

As already indicated, 5% of patients in hospital develop infectious complications. Hence the severity of the condition, and the increase in the terms of recovery, stay on the bed, increasing the cost of treatment. In the structure of nosocomial infections, UTIs occupy the first place, in the second place - surgical (wound infections of the skin and soft tissues, abdominal).

The complexity of treating hospital infections is due to 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 important is the increased resistance of microorganisms to traditional antibacterial drugs (to penicillins, cephalosporins, aminoglycosides) used in the infection of the genitourinary system in recent years.


To date, the sensitivity of hospital strains 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 strains of P. aeruginosa to ceftazidime in different compartments does not exceed 80%, to gentamicin - 50%.


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There are two potential approaches to overcome resistance to antibiotics. The first is the prevention of resistance, for example by limiting the use of antibiotics, which have a high potential for its development; equally important are effective programs of epidemiological control to prevent the spread of hospital infections caused by highly resistant microorganisms (stationary monitoring) in the hospital.

The second approach is to eliminate or correct existing problems. For example, if resistant strains of P. aeruginosa or Enterobacter spp. Are spread in the intensive care unit (or in the hospital at all), then a complete replacement in the formulations of antibiotics with a high potential for development of resistance to antibiotics- "cleaners" (amikacin instead of gentamicin, meropenem instead of imipenem and etc.) will eliminate or minimize the antibiotic resistance of gram-negative aerobic microorganisms.

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

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

Recommended drugs for infection of the lower urinary tract (UTI)

1. Inhibitor-protected aminopenicillins: Аmoxicillin + clavulanic acid (Amoxiclav, Augmentin, Flemoclav Solutab), ampicillin + sulbactam (Sulbacin, Unazin).

2. Cephalosporins of the second generation: Сefuroxime, Сefaclor.

3. Fosfomycin.

With infection of the upper urinary tract.

1. Inhibitor-protected aminopenicillins: Аmoxicillin + clavulanic acid (Amoxiclav, Augmentin), ampicillin + sulbactam.

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2. Cephalosporins of the second generation: Cefuroxime, Cefamandole.

3. Cephalosporins of the third generation: Сefotaxime, Сeftazidime, Сeftriaxone.

4. Cephalosporins of the IV generation: Сefepime.

5. Aminoglycosides: Netilmicin, Amikacin.

6. Carbapenems: Imipenem, Meropenem.

With hospital infection.

1. Cephalosporins III and IV generations - Ceftazidime, Cefoperazone, Cefepime.

2. Ureidopenicillins: Piperacillin.

3. Fluoroquinolones: according to the indications.

4. Aminoglycosides: Amikacin.

5. Carbapenems: Imipenem, Meropenem.

For perioperative antibacterial prophylaxis.

1. Inhibitor-protected aminopenicillins: Amoxicillin + clavulanic acid (Amoxiclav, Augmentin), Ticarcillin / Clavulanate.

2. Cephalosporins II and III generations: Cefuroxime, Cefotaxime, Ceftriaxone, Ceftazidime, Cefoperazone.

For antibacterial prophylaxis in invasive manipulations: inhibitor-protected aminopenicillins - Amoxicillin + clavulanic acid.

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

The principle of minimum sufficiency is the strategic principle of antibiotic therapy in outpatient settings.

Preparations of the first row are:

1. Inhibitor-protected aminopenicillins: Amoxicillin + clavulanic acid (Amoxiclav);

2. Cephalosporins: oral cephalosporins of II and III generations;

3. Derivatives of the nitrofuran series: Nitrofurantoin (Furadonin), Furazidin (Furagin).

The main studies show that postoperative complications are prevented if the high concentration of antibacterial drug in the blood serum (and in the tissues) is created by the beginning of the surgical intervention. In clinical practice, the optimal time for antibiotic prophylaxis is 30-60 minutes before the start of the operation (under the condition of intravenous antibiotic administration), i.e. at the beginning of anesthesia.

There was a significant increase in the incidence of postoperative infections if a prophylactic dose of an antibiotic was prescribed not within 1 h before the operation. Any antibacterial drug introduced after the closure of the operating wound will not affect the likelihood of complications.

Thus, a single administration of an adequate antibacterial drug for prevention is no less effective than multiple. Only with prolonged surgery (more than 3 hours) requires an additional dose. Antibiotic prophylaxis can not last more than 24 hours, since in this case the use of an antibiotic is already considered as therapy, and not as prevention.

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

For antibiotic prophylaxis in urological operations it is desirable to use drugs that create a high concentration in the urine. Many antibiotics meet these requirements and can be used, for example, second generation cephalosporins and inhibitor-protected penicillins. Aminoglycosides should be reserved for patients at risk or with allergies to b-lactams.

Cephalosporins of III and IV generations, inhibitor-protected aminopenicillins and carbapenems should be used in single cases when the site of operation is seeded with multidrug-resistant nosocomial microorganisms. Still, it is desirable that the purpose of these drugs is limited to the treatment of infections with severe clinical course.

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

With a febrile course of UTI, therapy should begin with a parenteral broad-spectrum antibiotic (inhibitor-protected penicillins, cephalosporins II, III generations, aminoglycosides).

The sensitivity of the urine microflora must be considered.

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

In children with vesicoureteral reflux, antimicrobial prophylaxis should be prolonged.

With asymptomatic bacteriuria, antibiotic therapy is not indicated.

The concept of "rational antibiotic therapy" should include not only the correct choice of the drug, but also the choice of its administration. It is necessary to strive for sparing and at the same time the most effective methods of prescribing antibacterial drugs. When using stepwise therapy, which consists in changing the parenteral use of the antibiotic for oral administration, after normalizing the temperature, the doctor should remember the following.

1. The oral route is preferable for cystitis and acute pyelonephritis in older children, in the absence of intoxication.

2. The parenteral route is recommended for acute pyelonephritis with intoxication, in infancy.

Below are the antibacterial drugs, depending on the route of administration.

Preparations for oral treatment of UTI

1. Penicillins: amoxicillin + clavulanic acid.

2. Cephalosporins:

• 2nd generation: cefuroxime;

• 3rd generation: cefixime, ceftibutene, cefpodoxime.

Preparations for parenteral treatment of UTI

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

2. Cephalosporins:

• 2nd generation: cefuroxime (Cefurabol).

• 3rd generation: cefotaxime, ceftriaxone, ceftazidime.

• 4th generation: cefepime (Maxipim).

Despite the availability of modern antibiotics and chemotherapeutic drugs that allow to quickly and effectively cope with the infection and reduce the frequency of relapses by prescribing drugs at low prophylactic doses for a long period, treatment of recurrent UTIs is still a rather difficult task.

The duration of antibiotic prophylaxis is usually determined individually. The drug is withdrawn in the absence of exacerbations during the prophylaxis, but if there is an exacerbation after the abolition, a new course is required.

Important place in the treatment of patients with UTI is dispensary observation, which is as follows.

1. Control of urinalysis every month.

2. Functional tests for pyelonephritis annually (Zimnitsky's trial), level of creatinine.

3. Sowing of urine - according to indications.

4. Measure blood pressure regularly.

5. With vesicoureteral reflux - cystography and nephroscintigraphy 1 time in 1-2 years.

6. Sanitation of foci of infection, prevention of constipation, correction of intestinal dysbiosis, regular emptying of the bladder.


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