Urinary system infection in children: current approaches to diagnosis and treatment. Urinary tract infections - symptoms and signs, treatment

Every year, a huge number of patients, both adults and children, regardless of gender, are faced with such a serious medical problem as urinary tract infection. Women suffer from this infection much more often than men, but men with the development of a urinary tract infection are expected to have a propensity for a protracted and even severe course of the disease.

Urinary tract infections are inflammatory diseases of the human urinary system caused by infectious microorganisms that have a relapsing course with the possible development of complications.

The urinary system (urinary tract) is a single complex of organs for the formation of urine and its excretion from the body. The urinary tract consists of the bean-shaped kidneys (they produce urine), the ureters (the urine enters the bladder through them), the bladder (urine reservoir), the urethra or urethra (the release of urine out).

The urinary tract plays a significant role in maintaining the body's water-salt balance, the production of a number of hormones (erythropoietin, for example), and the release of a number of toxic substances from the body. On average, up to 1.5-1.7 liters of urine is excreted per day, the amount of which may vary depending on the fluid consumed, salt, and urinary tract diseases.

Risk groups for urinary tract infections:

Female sex (women suffer from such infections 5 times more often than men, this is due to the physiological feature of the woman's body - a short and wide urethra, and therefore the infection penetrates the urinary tract more easily).
- Children under 3 years of age (inadequate immunity, in particular, infections of the urinary system are the most common cause of fever of unknown origin among boys under 3 years of age).
- Elderly people due to the development of age-related immunodeficiency.
- Patients with structural features of the urinary system (for example, an enlarged prostate gland can make it difficult for urine to drain from the bladder).
- Patients with renal pathology (for example, urolithiasis, in which stones are an additional risk factor for the development of infections).
- Patients of resuscitation and intensive care units (such patients require urinary catheter excretion for some period of time - this is the entrance gate of infection).
- Patients with chronic diseases (for example, diabetes mellitus, in which there is a high risk of developing urinary tract infections due to a decrease in body resistance).
- Women using some methods of contraception (eg diaphragm ring).

Factors predisposing to urinary tract infections are:

1) hypothermia (most problems of this nature occur in the cool season),
2) the presence of a respiratory infection in a patient (frequent activation of urological
infections during cold season)
3) decreased immunity,
4) violations of the outflow of urine of various nature.

Causes of urinary tract infections

In the kidneys, urine is formed absolutely sterile from microorganisms, it contains only water, salts and various metabolic products. The infectious agent first penetrates into the urethra, where favorable conditions are created for its reproduction - urethritis develops. Then it spreads higher to the bladder, in which inflammation of its mucous membrane occurs - cystitis. In the absence of adequate medical care, the infection enters the kidneys through the ureters with the development of pyelonephritis. This is the most common ascending type of infection.

Pathogens that cause urinary tract infections:

1) E. coli (Escherichia coli). This pathogen is a representative of the normal flora of the large intestine, and its entry into the urethra is mainly due to non-compliance with the rules of personal hygiene. Also, E. coli is almost always present on the external genitalia. 90% of all urinary tract infections are associated with Escherichia coli.
2) Chlamydia and mycoplasmas are microorganisms that mainly affect the urethra and ducts of the reproductive system. They are mainly transmitted sexually and affect the genitourinary system.
3) Klebsiella, Pseudomonas aeruginosa can be the causative agents of urinary tract infections in children.
4) Periodically there are streptococci of serogroups A and B.

How can microorganisms enter the urinary tract:

1) If the rules of personal hygiene are not observed after visiting the toilet room.
2) During sexual intercourse and during anal sex.
3) When using certain methods of contraception (diaphragmatic ring, spermicides).
4) In children, these are inflammatory changes due to stagnation of urine in the pathology of the urinary tract of a different nature.

Symptoms of urinary tract infections

What clinical forms of urinary tract infections are found in medical practice? This is an infection of the urethra or urethra - urethritis; bladder infection - cystitis; infection and inflammation in the kidneys - pyelonephritis.

There are also two main types of infection spread - this is an ascending infection and a descending one. With an ascending infection, the inflammatory process affects the anatomically lower organs of the urinary system, and then the infection process spreads to the higher organs. An example is cystitis and the subsequent development of pyelonephritis. One of the causes of ascending infection is the so-called functional problem in the form of vesicoureteral reflux, which is characterized by the reverse flow of urine from the bladder to the ureters and even the kidneys. The descending infection by origin is more understandable. In this case, the pathogen spreads from the higher parts of the urinary system to the lower ones, for example, from the kidneys to the bladder.

Many cases of infectious pathology of the urinary system are asymptomatic. But still, for specific clinical forms, there are certain symptoms that patients most often complain about. Most patients are characterized by nonspecific symptoms: weakness, feeling unwell, fatigue, irritability. Such a symptom as seemingly unreasonable fever (temperature) is in the vast majority of cases a sign of an inflammatory process in the kidneys.

With urethritis, patients are worried: pain during urination, pain and burning at the beginning of the process of urination, discharge from the urethra of a mucopurulent nature, having a specific smell.

With cystitis there is frequent urination, which can be painful, accompanied by pain in the lower abdomen, a feeling of insufficient emptying of the bladder, sometimes the temperature may rise.

Pyelonephritis characterized by the appearance of pain in the lumbar region, fever (with an acute process), chills, symptoms of intoxication (weakness, body aches), urination disorders, the patient may not feel. Only with an ascending infection, pain during urination, frequent urination can be disturbed at first.

Summarizing the above, we list the symptoms characteristic of urinary tract infections that require a visit to a doctor:

1) pain, burning and cramps during urination;
2) frequent urination;
3) pain in the lower abdomen, in the lumbar region;
4) pain in the suprapubic region in women;
5) temperature and symptoms of intoxication without cold symptoms;
6) discharge from the urethra of a mucopurulent nature;
7) change in the color of urine - it becomes cloudy, the appearance of mucus, flakes, streaks of blood;

Features of urinary tract infections in children

Common causes of urinary tract infections in children are obstruction of the genitourinary tract, various functional disorders, phimosis, congenital anomalies of the genitourinary tract, and rare emptying of the bladder.

Symptoms of urinary tract infections in babies may be blurred. Children under 1.5 years old with such an infection can become irritable, whiny, refuse to eat, there may not be a very high, but unreasonable temperature, which is poorly controlled by conventional antipyretic drugs. Only from the age of two, the child will complain of pain in the abdomen or back, pain in the lower abdomen, you will notice frequent urination, urination disorders, body temperature rises more often than remains normal.

The outcome of a urinary tract infection in a child is often favorable, but there are such consequences as sclerosis of the kidney tissue, arterial hypertension, protein in the urine, and functional disorders of the kidneys.

Features of urinary tract infection in pregnant women

Up to 5% of pregnant women suffer from inflammatory kidney disease. The main reasons for this include hormonal changes in the body during pregnancy, a decrease in the body's immunological defenses, and a change in the location of certain organs associated with a growing fetus. For example, due to the increase in the size of the uterus, there is pressure on the bladder, congestion occurs in the urinary organs, which will eventually lead to the multiplication of microorganisms. Such changes require frequent monitoring of this system in a pregnant woman.

Features of urinary tract infection in men

First of all, the causes leading to urinary tract infections in men are different from those in women. This is mainly such a pathology as urolithiasis and an increase in the size of the prostate gland. Hence the disturbed outflow of urine and inflammatory changes in the urinary system. In this regard, the treatment program for men includes such an item as the removal of an obstruction to the outflow of urine (a stone, for example). Also, certain problems are caused by a chronic inflammatory process in the prostate gland, which requires massive antibiotic therapy.

Diagnosis of urinary tract infections

A preliminary diagnosis is made on the basis of the patient's clinical complaints, but this is not enough in all cases to make a correct diagnosis. For example, pyelonephritis can be accompanied only by fever and symptoms of intoxication, lower back pain does not appear on the first day of the disease. Therefore, without additional laboratory research methods, it is difficult for a doctor to make a diagnosis.

Laboratory diagnostics includes:

1) general clinical tests: complete blood count, general urinalysis, biochemical blood tests (urea, creatinine) and urine (diastasis).
The most informative at the initial stage is a general urine test. For research, an average portion of morning urine is taken. In the study, the number of leukocytes, erythrocytes is counted, due to which bacteriuria (a bacterial inflammatory process) can be suspected. Also informative are indicators such as protein, sugar, specific gravity.
2) bacteriological method (sowing urine on special nutrient media in order to detect the growth of certain types of microorganisms in them), in which the average portion of morning urine is taken into a sterile dish;
3) PCR method (with negative culture and ongoing urinary tract infection) - to detect microorganisms such as chlamydia, mycoplasma.
4) Instrumental diagnostic methods: ultrasound of the kidneys and bladder, cystoscopy, radiopaque examination or intravenous urography, radionuclide studies and others.

Basic principles of treatment of urinary tract infections

1. Regime events: home half-bed treatment for infections of the urinary system, and according to indications, hospitalization in the therapeutic or urological department of the hospital. Compliance with a dietary regimen with salt restriction and sufficient fluid intake in the absence of renal failure. For kidney diseases, diets No. 7, 7a, 7b according to Pevzdner are shown.

2. Etiotropic treatment(antibacterial) includes various groups of drugs that
are prescribed ONLY by a DOCTOR after a correct diagnosis has been made. SELF-TREATMENT will lead to the formation of resistance to antibiotics of the infectious agent and the occurrence of frequent relapses of the disease. For treatment, the following are used: primetoprim, bactrim, amoxicillin, nitrofurans, ampicillin, fluoroquinolones (ofloxacin, ciprofloxacin, norfloxacin), if necessary, combinations of drugs. The course of treatment should be 1-2 weeks, less often longer (with concomitant pathology, the development of septic complications, anomalies of the urinary system). After the end of treatment, the effectiveness of treatment is monitored by a complete laboratory examination prescribed by the attending physician.

Advanced cases of urinary tract infections with the formation of a protracted course sometimes require longer courses of etiotropic treatment with a total duration of several months.

Doctor's recommendations for the prevention of a protracted course of urinary tract infections:

Drinking regimen (sufficient fluid intake during the day);
- timely emptying of the bladder;
- hygiene of the perineal area, daily shower instead of taking a bath;
- meticulous hygiene after sexual intercourse;
- avoid self-medication with antibiotics;
- avoid spicy and salty foods, coffee intake;
- drink cranberry juice;
- sharply reduce up to the complete exclusion of smoking;
- for the period of treatment to avoid sexual intimacy;
- Eliminate alcohol.

Features of therapeutic measures in pregnant women:

When registering urinary tract infections in a pregnant woman, therapeutic measures are taken without delay to prevent more serious problems (premature birth, toxicosis, arterial hypertension). The choice of an antibacterial drug remains with the doctor and depends on the duration of pregnancy, assessment of its effectiveness and possible risks to the fetus. The appointment of drugs is strictly individual.

3. Posyndromal therapy(antipyretic at temperature, urological preparations, herbal
uroseptics, for example, phytolysin, immunomodulators and others).

4. Phytotherapy for urinary tract infections: use herbal infusions (birch leaves, bearberry, horsetail grass, dandelion root, juniper fruits, fennel fruits, black elderberry, parsley fruits, chamomile flowers and others).

The main problem of urinary tract infections is the frequent development of a recurrent form of infection. This problem is typical mainly for women, every 5th woman after the initial debut of an infection of the urinary system meets with a recurrence of all symptoms, that is, the development of a relapse, and sometimes frequent relapses. One of the important properties of relapses is the formation of new modified strains of microorganisms with an increase in the frequency of relapses. These modified strains of bacteria are already acquiring resistance to specific drugs, which will certainly affect the quality of treatment for subsequent exacerbations of the infection.

Recurrent urinary tract infections may be associated with:

1) with an incomplete primary infection (due to incorrect low doses of antibacterial drugs, non-compliance with the treatment regimen, the development of resistance of the pathogen to drugs);
2) with prolonged persistence of the pathogen (the ability of the pathogen to attach to the mucous membrane of the urinary tract and stay in the focus of infection for a long time);
3) with the occurrence of re-infection (reinfection with a new pathogen of the periurethral space, rectum, perineal skin).

Prevention of urinary tract infections

1) The importance of preventive measures is given to the timely rehabilitation of chronic foci
bacterial infection (tonsillitis, sinusitis, cholecystitis, dental caries, and others), from which the infection can spread through the bloodstream and affect the urinary system.
2) Compliance with hygiene rules for the care of intimate areas, especially girls and
women, pregnant women.
3) Avoid overwork, hypothermia of the body.
4) Timely correction of changes in the human immune system.
5) Timely treatment of diseases of the urinary system (urolithiasis, prostatitis, developmental anomalies).

Infectious disease specialist Bykova N.I.

Urinary tract infections are caused by bacteria and are 10 times more common in women than men. More than 50% of women have experienced these diseases at least once during their lives. About 30-40% of infections recur within 6 months of the first diagnosis. Relapses can occur both due to incomplete sanitation of the focus, and in case of re-infection with other strains of pathogenic microflora.

Signs and symptoms of the disease

Symptoms of urinary tract infections in women begin to appear 12 to 72 hours after infection. The time of the incubation period depends on the microflora and the degree of tolerance of the immune system. Symptoms may include:

• Pain or burning when urinating.
• The need to urinate more often than usual.
• Feeling of urgency during urination.
• Blood or pus in the urine.
• Cramping and pain in the lower abdomen.
• Chills or fever (fever may be the only symptom in infants and children).
• Strong smell of urine.
• Pain during intercourse.
• Nausea, vomiting, malaise.

The clinical picture of the disease may include the entire complex of the listed symptoms or their individual combinations. Therefore, if you have at least 2 of these signs, you should immediately consult a doctor.

Causes of infections

The main causes of urinary tract infections in women lie in violation of the rules of personal hygiene, a decrease in the level of the body's defenses, and an unhealthy lifestyle. Risk factors include:

• New sexual partner or multiple partners.
• More frequent and intense sexual intercourse.
• Diabetes.
• Pregnancy.
• Penetration into the urethra of Escherichia coli (E.coli).
• Infection with Staphylococcus saprophyticus.
• Use of irritating products such as strong skin cleaners.
• Use of irritating contraceptives such as diaphragms and spermicides.
• Use of birth control pills.
• Intensive uncontrolled use of antibiotics.
• Blockage of urine in the urinary tract (by benign or malignant tumors, small stones).

Diagnostics

When making a diagnosis, it is important not only to determine the focus of the inflammatory process, but also the degree of its prevalence. Urine culture is important to identify pathogenic microflora and its sensitivity to antibiotics. Therefore, the diagnosis begins with the appointment:

• general urine analysis;
• general blood test;
• ultrasound examination of the pelvic organs;
• culture of urine for sensitivity to antibacterial agents.

After a course of antibiotic therapy, all tests must be repeated to monitor the success of treatment. If the infection recurs, urine culture is repeated.

Treatment

The mainstay of treatment for urinary tract infections in women is antibiotic therapy. Depending on the type of pathogen and the degree of damage to the mucous membranes, the course of treatment can vary from 3 days to 2 weeks. Antibacterial therapy is not recommended without supervision by the attending physician. In most cases, cystitis occurs due to infection with a pathogenic form of fungi of the genus Candida. Modern antibiotics only exacerbate the situation, causing the rapid growth of these pathogens. There are also forms of medicines that allow the treatment of urinary tract infections in women in record time, in 2 to 3 days.

Nalidixic acid preparations and other urosulfates can be used to sanitize the urinary tract. nutrition, diet and water balance are also important.

1. Drink plenty of fluids, such as herbal teas and water. Avoid sweetened fruit juices and other sugary drinks.
2. Cranberries and blueberries contain substances that inhibit bacteria from binding to bladder tissues.
3. Try to eliminate potential food allergens, which may include milk, wheat (gluten), corn, preservatives, and food additives.
4. Eat antioxidant foods, including fruits and vegetables in your daily diet.
5. Eat more high fiber foods, including beans, oats, and root vegetables.
6. Avoid refined foods such as white bread, pasta, and especially sugar.
7. Drink 6-8 glasses of filtered water a day.

How to treat infections in pregnant women?

The period of pregnancy is a time of increased risk of pathogenic microflora in the urinary tract in a woman, the natural balance of the acid-base reaction is disturbed. There is a favorable soil for the rooting of various forms of microorganisms. In connection with changes in the hormonal background, there is a risk of developing thrush. Therefore, it is important to observe the rules of personal hygiene, visit a doctor regularly, and take urine tests in a modern way.

If symptoms occur, seek medical attention. During pregnancy, urinary tract infections in women are treated without the use of antibacterial agents.

The main task of treating urinary tract infections is to eliminate the pathogen and suppress infectious inflammation. To solve it, various antibacterial drugs are used. The question of choosing the optimal drug is not easy. And only a doctor can make the right choice. Judge for yourself how many factors need to be taken into account: the total duration of the disease (including episodes of urinary tract infection in childhood), the body's response to antibiotic therapy during previous exacerbations, the state of kidney function, urinary tract patency, existing concomitant diseases (for example, diabetes mellitus, cardiovascular diseases, diseases of the stomach and intestines), medications taken, etc. It is also important to know the type of pathogen and its sensitivity to antibiotics. You are unlikely to be able to answer many of these questions, and self-medication is more likely to hurt yourself than help. We will give you some tips on how to properly take the drugs prescribed by your doctor.

Several groups of antibacterial drugs are currently used to treat urinary tract infections.

Antibiotics

Many drugs in this group have nephrotoxicity, that is, the ability to damage kidney tissue. Some drugs always show this property (absolutely nephrotoxic), others - under certain conditions: in the presence of renal failure, against the background of dehydration of the body or its sharp weakening due to severe concomitant pathology. Based on this, absolutely nephrotoxic antibiotics for the treatment of urinary tract infections are not prescribed. Semi-synthetic combined penicillin derivatives, cephalosporins and fluoroquinolone preparations are recognized as optimal antibiotics today. It is pointless to list the names of drugs, since their list can take more than one page. And only the attending physician can give you recommendations on how to take a particular remedy, this is his prerogative.

The duration of antibiotic treatment is 10-14 days. The strict timing of their intake is due to the ability of antibiotics to influence the life expectancy and the reproduction cycle of microorganisms. Interruption of the course of treatment is fraught with unpleasant consequences, primarily the transition of the disease to a latent (hidden) form due to the “addiction” of bacteria to the drug and their loss of sensitivity to the drug and its analogues. A properly selected antibiotic leads to an improvement in the condition, the disappearance of urination disorders (polyuria and nocturia) by 3-4 days of treatment. However, this does not mean the elimination of the infection. Complete destruction of the pathogen is observed only by the 10-14th day of treatment. Clinical cure will be indicated not only by a significant improvement in the condition, but also by the absence of changes in urine and blood tests.

Due to the possible risk of kidney failure, antibiotics should always be combined with sufficient fluids (of course, except in cases of severe heart failure and high blood pressure, when fluid intake is limited).

Sulfanilamide preparations

Perhaps this group of antibacterial agents is the most popular among the people. The slightest cold, cough, malaise pushes us to the pharmacy to buy Biseptol. The medicine is cheap, effective (alas, it used to be), easy to use. Why "alas"? The wide availability of the drug led to the fact that most of the pathogens that were successfully destroyed by biseptol and its analogues adapted to the drug, learned to integrate it into their metabolism, and therefore lost sensitivity to it. We prescribe medicine to treat, but we see the opposite result.

Of course, this does not mean that it is useless to take sulfonamides. Exacerbation of chronic urinary tract infection is not always caused by the same pathogen. In addition, there are people who rarely resort to the use of antibacterial agents during their lives. In such cases, biseptol can be very effective.

Duration of treatment sulfonamides is less than the duration of antibiotic treatment. When prescribing sulfonamides, there is a danger of their falling into a crystalline precipitate in the lumen of the renal tubules. To exclude this possibility, sulfonamides must be washed down with a large amount of alkaline mineral water. The water must be degassed. In renal failure, sulfa drugs are not prescribed.

However, we repeat once again that the effectiveness of sulfonamides is low due to the high resistance of pathogens to them, and therefore today this group of drugs is practically not used to treat urinary tract infections.

Nitrofuran preparations

This group of drugs includes furadonin, furagin, furazolidone, blacks, negramon, etc. They are moderately effective in chronic sluggish urinary tract infections in elderly and senile people. Restriction to their use is also renal failure. Medium duration of treatment nitrofuran means - from 7 to 10 days.

Oxolinic acid derivatives

Special mention should be made of these medicines. Popular rumor ascribes nitroxoline(5-NOC) miraculous properties and 100% effectiveness. Where this conviction came from is anyone's guess. Firstly, the main pathogens of pyelonephritis have extremely low sensitivity to oxolinic acid derivatives. Secondly (more importantly), the drugs of this group do not create the necessary therapeutic concentrations in the kidney tissue, urine and blood serum. And if so, then one should not expect miracles: 5-NOC and its analogues are not able to eliminate the infectious focus in the kidney. Therefore, most countries around the world have abandoned the use of these drugs for the treatment of urinary tract infections.

Pipemidic acid preparations

Antibacterial drugs of this group (palin, urotractin, pimidel, pipemidine, pipemidic acid) are quite effective in men suffering from a urinary tract infection against the background of prostate adenoma. Usually the drug is prescribed 1 capsule 2 times a day after meals. Duration of treatment- 10-14 days.

Herbal uroantiseptics

Herbal medicines are widely used in urological practice. They are prescribed during the period of exacerbation of infectious diseases of the urinary system as an auxiliary antiseptic, anti-inflammatory agent. In addition, they are used for prophylactic purposes to prevent recurrence of the disease.

Of the herbal preparations that have the ability to disinfect urine at the level of the urinary tract, Canephron, Uroflux, Fitolizin, kidney collections and teas are prescribed.

Kanefron

"Kanefron" - a combined preparation of plant origin. It has antimicrobial, antispasmodic and anti-inflammatory effects. It has a pronounced diuretic effect. Produced "Kanefron" in the form of dragees or drops for oral administration.

The drug "Canephron"

The dragee includes powders of centaury herb, rosehip peel, lovage root, rosemary leaves. Drops are prepared on the basis of extracts of the same plants. Usually, for the treatment of urinary tract infections, 2 tablets or 50 drops of the drug are prescribed 3 times a day. The duration of taking "Kanefron" is determined by the nature of the course of the disease.

Phytolysin

"Fitolizin" has indications and medicinal properties similar to those of "Canephron". In addition, it facilitates the passage of stones. The drug is available in the form of a paste for the preparation of a solution. It contains plant extracts: parsley root, wheatgrass rhizomes, horsetail herb, birch leaves, knotweed herb, onion bulbs, fenugreek seed, goldenrod herb, hernia herb. It also includes oils - mint, sage, pine, orange and vanillin. Take Fitolizin 1 teaspoon in 1/2 cup of warm, sweetened water 3 times a day after meals.

Other herbal uroantiseptics can be prepared at home. When choosing herbal medicine, one should take into account the presence of kidney-friendly effects of medicinal plants: diuretic, anti-inflammatory, tanning and hemostatic.

The alternation of plant fees is considered optimal. And another important point. No need to condemn yourself to lifelong intake of kidney teas and fees. It is necessary to be treated only if there are indications: either during an exacerbation, or prophylactically to prevent a re-exacerbation of a urinary tract infection during colds, with an increase in signs of urination disorders, etc.

Treatment of an exacerbation of a urinary tract infection is considered effective if, at the end of it, there are no signs of the disease for the next six months, and there are no leukocytes and bacteria in the urine tests.
Antibacterial treatment is aimed at eliminating the infection - the cause of inflammation. Therefore, it is also called etiotropic (“etios” - the reason, “tropic” - having an affinity, relation; related to the reason).

The main properties of medicinal plants used in diseases of the urinary tract.

Symptomatic treatment

To eliminate signs of infectious intoxication, normalize blood pressure, correct anemia, symptomatic treatment is prescribed (“symptom” is a sign of the disease; symptomatic treatment is treatment aimed at eliminating the manifestations of the disease).

I would like to make one caveat. Sometimes, to enhance the diuretic effect of herbal preparations, patients take diuretics - diuretics(hypothiazide, furosemide, etc.). The consequence of such self-medication may be acute renal failure. Its reason is simple: diuretics cause forced urination, and the renal tubules are inflamed, their lumen is narrowed, contains bacteria, desquamated epithelium, leukocytes, and mucus. Because of this, sometimes, the tubules become completely impassable for urine. And "the puck is already thrown in." The diuretic works by pushing urine toward the tubules. The result is sad - an acute violation of kidney function, that is, acute renal failure.

What about diuretics? Don't take them at all? Only a doctor can make a decision. He knows when, at what dose, and with what frequency to prescribe a certain diuretic. Specifically, because each diuretic works in different parts of the renal tubules.

And one more knot for memory. Many people, when the slightest pain appears, take analgesics (analgin, paracetamol, diclofenac, aspirin, etc.). All painkillers with uncontrolled use have a detrimental effect on the medulla of the kidney: on the tubules and interstitium. And pyelonephritis is a disease of precisely these structures of the kidney. Therefore, the question of the use of analgesics in pyelonephritis should be decided carefully and always by a doctor.

vitamin therapy

To activate the immune forces of the body, the speedy elimination of inflammatory disorders, vitamin preparations are necessarily included in the treatment of urinary tract infections. There can be no specific recommendations here. All vitamins sold in the pharmacy chain are good. No need to chase expensive, imported vitamins. The composition and effectiveness of domestic drugs are similar to those of foreign drugs, but they are much cheaper. It is advisable to take multivitamins with trace elements - complex preparations, which include all the vitamins and trace elements necessary for the human body (iron, iodine, calcium, potassium, magnesium, manganese, copper). For elderly and senile people, domestic multivitamins "Dekamevit" may be optimal (take 1 yellow and 1 orange tablet 1-2 times a day after meals; the duration of the course of treatment is 20 days), "Undevit" (2 tablets 3 times a day within 20-30 days).

Physiotherapy

Prevention of pyelonephritis

In addition to the preventive measures described in the article “Acute and chronic cystitis”, it is recommended to drink fluids in an amount of at least 2 liters / day, regular urination, mandatory urination at night, if there is an urge to urinate, fighting constipation. In some people, pyelonephritis worsens several times a year, has a protracted, severe course. In such cases, anti-relapse courses are necessarily added to general preventive measures, including several antibacterial drugs, vitamins, diuretics, herbal uroantiseptics, and agents that stimulate the immune system. The scheme of anti-relapse treatment and its duration is chosen only by

One of the very serious problems and a common cause of hospitalization in childhood is a urinary tract infection. Why it occurs, how it manifests itself and what parents should do in this case, you will learn in this article.

Urinary tract infections develop in children of any age, but are more common in children under 3 years of age. This is predisposed to the features of the structure and work of the urinary system of the child. I will dwell on them in more detail - as I consider it important.

The organs of the urinary system are the kidneys, ureters, bladder and urethra (urethra). The kidneys act as a natural filter that removes toxins and excess fluid from the body, and also ensures the balance of the internal environment of the body. The bladder is the main storage reservoir for urine. It gradually fills with urine, and when its volume is more than half full, a person has an urge to urinate, that is, there is a desire to urinate, and urine from the bladder is expelled through the urethra.

By the time a baby is born, each kidney contains at least a million glomeruli and renal tubules. After birth, new glomeruli can form only in premature babies. As intrauterine and extrauterine development, the kidneys tend to descend.

In a newborn child, the maturation of the kidneys is not yet completed. The kidneys in young children are relatively larger than in adults, located below the iliac crest (up to 2 years), their structure in the early years is lobed, and the fatty capsule is poorly expressed, therefore the kidneys are more mobile and are palpable until the age of 2. (that is, the doctor can feel them), especially the right one.

The cortical layer of the kidneys is underdeveloped, the pyramids of the medulla therefore reach almost to the capsule. The number of nephrons in young children is the same as in adults (1 million in each kidney), but they are smaller in size, their degree of development is not the same: the juxtamedullary ones are better developed, the cortical and isocortical ones are worse. The epithelium of the basement membrane of the glomerulus is high, cylindrical, which leads to a decrease in the filtration surface and a higher resistance at the same time. The tubules in young children, especially in newborns, are narrow, short, the loop of Henle is also shorter, and the distance between the descending and ascending knees is greater.

The differentiation of the epithelium of the tubules, the loop of Henle and the collecting ducts has not yet been completed. The juxtaglomerular apparatus in young children is not yet formed. Morphological maturation of the kidney as a whole ends by school age (by 3-6 years). The renal pelvis is relatively well developed, in young children they are located mainly intrarenal, and the muscle and elastic tissue in them is poorly developed. A feature is the close connection of the lymphatic vessels of the kidneys with similar intestinal vessels, which explains the ease of infection from the intestines to the renal pelvis and the development of pyelonephritis.

The kidneys are the most important organ for maintaining balance and relative constancy of the internal environment of the body (homeostasis). This is achieved by filtration in the glomerulus of water and residual products of nitrogen metabolism, electrolytes, active transport of a number of substances in the tubules. The kidneys also perform an important secretory function, producing erythropoietin (this substance helps to synthesize red blood cells), renin (maintains blood pressure), urokinase and local tissue hormones (prostaglandins, kinins), and also convert vitamin D into its active form. Although the ureters in young children are relatively wider than in adults, they are more tortuous, hypotonic due to the weak development of muscle and elastic fibers, which predisposes to stagnation of urine and the development of a microbial-inflammatory process in the kidneys.
The bladder in young children is located higher than in adults, so it can be easily felt above the pubis, which, in the absence of urination for a long time, makes it possible to differentiate its reflex delay from the cessation of urination. The bladder has a well-developed mucous membrane, weakly elastic and muscular tissue. The capacity of the bladder of a newborn is up to 50 ml, in a one-year-old child - up to 100-150 ml.

The urethra in newborn boys is 5-6 cm long. Its growth is uneven: it slows down somewhat in early childhood and accelerates significantly during puberty (increases to 14-18 cm). In newborn girls, its length is 1-1.5 cm, and at 16 years old - 3-3.3 cm, its diameter is wider than in boys. In girls, due to these features of the urethra and proximity to the anus, an easier infection is possible, which must be taken into account when organizing care for them. The mucous membrane of the urethra in children is thin, delicate, easily vulnerable, its folding is weakly expressed.
Urination is a reflex act, which is carried out by congenital spinal reflexes. The formation of a conditioned reflex and neatness skills should begin at the age of 5-6 months, and by the age of one, the child should already be asking for a potty. However, in children under 3 years of age, involuntary urination can be observed during sleep, exciting games, and excitement. The number of urination in children during the neonatal period is 20-25, in infants - at least 15 per day. The amount of urine per day in children increases with age. In children older than a year, it can be calculated by the formula: 600+ 100 (x-1), where x is the number of years, 600 is the daily diuresis of a one-year-old child.

The most common nephrological problems in children are the expansion of the pelvis of the kidney (hydronephrosis), infections of the urinary system, dysmetabolic nephropathy, bladder dysfunction. A nephrologist is a specialist in the prevention, diagnosis and treatment of kidney diseases.

Urinary infection is a microbial-inflammatory process in any segment of the mucous membrane of the urinary tract throughout its entire length (in the urethra, bladder, pelvis, calyces), which also captures the kidney tissue itself.
Despite the fact that this does not give an accurate idea of ​​the localization of the focus of inflammation, the term is widely used by pediatricians, because it corresponds to the modern point of view on the diffusion (prevalence) of the pathological process in the urinary system. This is explained by the fact that in children, especially younger ones, due to insufficient maturity of the renal tissue, as well as reduced immunity compared to adults, there is almost never isolated urethritis (inflammation of the urethra), pyelitis (inflammation of the calyx of the kidney) and even cystitis ( inflammation of the bladder).

The term "urinary system infection" includes all infectious and inflammatory diseases of the urinary system (OMS) and includes pyelonephritis (PN), cystitis, urethritis, and asymptomatic bacteriuria.
The first signs of infectious and inflammatory diseases of the CMI, as a rule, are detected at the preclinical stage (outpatient service, emergency service), when, in most cases, it is not possible to establish the exact localization of the process. Therefore, the diagnosis of "urinary tract infection or urinary system infection" is legitimate. In the future, in a specialized hospital, the diagnosis is specified.

Urinary infection occurs especially often in newborns and children under 3 years of age, and then the number of patients gradually decreases. Its second peak falls on people over 20 years old. Among newborns and children of the first months of life, boys and girls get sick with the same frequency, later the incidence is observed mainly in girls.

Causes of infection.

Most often, the inflammatory process in the urinary system is caused by Escherichia coli, it belongs to the normal saprophytic flora of the large intestine, but when it enters the kidneys (where it should not be), it can cause a pathological process.

Less often, various strains of Proteus, Pseudomonas aeruginosa and other gram-negative microorganisms, sometimes also gram-positive microbes, can be the cause of the pathological process. Among the latter, Staphylococcus aureus is most often found, entering the bloodstream from an inflammatory focus in some organ, and from there to the kidney. Such a source in newborns can be purulent omphalitis (inflammation of the navel), abscess pneumonia, abscesses on the skin. The emergence and further development of the infection is facilitated by helminthic invasions and inflammatory diseases of the external genital organs.

Development mechanism.

There are 3 ways of getting the infection into the kidney: hematogenous (through the blood), urinogenous (up from the urethra along the urinary tract) and lymphogenous, in which the pathogen enters the kidney through the lymphatic vessels coming from the bladder along the ureters (many authors reject this path). The hematogenous route is the most common in newborns and children in the first months of life. In older children, the ascending (urinogenous) path becomes of primary importance, when infection occurs from the lower urinary tract. The predominant incidence among girls is the result of an easier ascent of the infection through the urethra, since it is relatively wider and shorter in them. At the same time, hygienic care of the child is important. Especially easily and often, the infection penetrates along with urine from the bladder into the overlying sections and kidneys in the presence of vesicoureteral reflux (reverse reflux of urine), which is a pathological phenomenon resulting from insufficiency of the valvular mechanism of the ureters or vesicoureteral anastomosis. Neurogenic bladder dysfunction may also play a role. The presence of reflux, as well as other obstructions to the outflow of urine due to congenital malformations of the formation of the urinary system or formed stones, contributes to the development of pyelonephritis. Above the obstacle, mechanical retention of bacteria in the urine occurs.

In newborns, the development of the disease is facilitated by the structural and functional immaturity of the urinary tract and tubular nephron. Also important are the infectious process in the mother during pregnancy, late preeclampsia (contributes to metabolic disorders in the child in the early postnatal period), asphyxia of the child during childbirth, sepsis during the neonatal period.

In children of the first years of life, severe gastrointestinal disorders with dehydration, inflammatory lesions of the external genital organs (vulvitis, vulvovaginitis), pneumonia, malnutrition, rickets, hypervitaminosis D predispose to the development of pyelonephritis.

In preschool age, the development of urinary tract infection is facilitated by helminthic invasions, the presence of foci of chronic infection.
An important role is assigned to hereditary metabolic disorders, fermentopathies. Favorable conditions for the development of the disease are created with metabolic disorders, accompanied by increased urinary excretion of oxalates, urates, phosphates, cystine and calcium. Along with the listed factors in the development of pyelonephritis, the immunological reactivity of the organism, factors of local cellular protection are of great importance.

Most often, acute urinary infection occurs in the form of pyelonephritis (primary non-obstructive and secondary obstructive) or cystopyelonephritis. Less often, its forms such as cystourethritis and cystitis are observed.
Pyelonephritis (PN) is a non-specific, acute or chronic microbial inflammation in the pelvicalyceal system and interstitial tissue of the kidneys with the involvement of tubules, blood and lymphatic vessels in the pathological process.

Cystitis is a microbial-inflammatory process in the wall of the bladder (usually in the mucous and submucosal layer).

Asymptomatic bacteriuria is a condition when, in the complete absence of clinical manifestations of the disease, bacteriuria is detected by one of the following methods:
- 10 or more microbial bodies in 1 ml of urine;
- or more than 105 colonies of microorganisms of the same species, grown when sowing 1 ml of urine taken from the middle stream;
- or 103 or more colonies of microorganisms of the same species when inoculating 1 ml of urine taken with a catheter;
- or any number of colonies of microorganisms when sowing 1 ml of urine obtained by suprapubic puncture of the bladder. The presence of bacteria in the general analysis of urine is not a reliable criterion for bacteriuria.

Predisposing factors and risk groups.

The development of an infectious-inflammatory process in the urinary system, as a rule, occurs in the presence of predisposing factors on the part of the baby's body, the main of which is an obstruction to the flow of urine at any level.

This allows you to identify conditional risk groups for the development of infection of the urinary system:
- children with urodynamic disorders (urinary obstruction): anomalies in the development of the urinary system, vesicoureteral reflux, nephroptosis, urolithiasis, etc.;
- children with metabolic disorders in the urinary system: glucosuria, hyperuricemia, dysmetabolic nephropathy, etc.;
- motility disorders of the urinary tract (neurogenic dysfunction);
- children with reduced general and local resistance: premature babies, frequently ill children, children with systemic or immune diseases, etc.;
- children with a possible genetic predisposition: UMS infection, anomalies in the development of UMS, vesicoureteral reflux, etc. in relatives, UMS infection in the history of the child himself;
- children with constipation and chronic bowel disease;
- female children, children with III (B0) or IV (AB) blood groups.

In the prenatal period, the kidneys do not function as an excretory organ - this role is performed by the placenta. However, a minimal amount of urine is still formed and accumulates in the pelvis of the kidney (a kind of funnel attached to each kidney where small portions of urine collect). As a result, even before the birth of the child, the pelvis expands. Such changes are detected during pregnancy by ultrasound or in the first months of a child's life. In most cases, the size of the pelvis returns to normal by 1 - 1.5 years. Sometimes the expansion of the pelvis occurs due to the reverse reflux of urine into them from the bladder, called vesicoureteral reflux. This is a serious pathology that can lead to changes in the kidney tissue. Therefore, all children in the first months of life should undergo ultrasound of the kidneys and urinary tract. If an expansion of the pelvis is detected, you need to constantly monitor their size and monitor urine tests.

Dysmetabolic nephropathies are various metabolic disorders, which are characterized by an increased amount of salts in the urine. Most often in the urine there are salts of oxalates, phosphates and urates. Their appearance in most cases is associated with the peculiarities of the child's nutrition and the inability of his kidneys to dissolve large amounts of salts. The predominance of foods rich in oxalic acid and vitamin C (cocoa, chocolate, spinach, celery, beets, parsley, currants, radishes, sour apples, broths, cottage cheese, etc.) in the diet can increase the amount of oxalates in the urine. Foods rich in purines (strong tea, cocoa, coffee, chocolate, sardines, liver, pork, organ meats, broths, oily fish, tomatoes, acidic mineral waters) can cause an increase in urates. Phosphorus-rich food (beef liver, cheese, cottage cheese, caviar, fish, beans, peas, chocolate, oatmeal, barley, buckwheat and millet cereals, alkaline mineral waters, etc.) contributes to an increase in the level of phosphates in the urine. However, some children have dysmetabolic disorders are caused by deeper, sometimes hereditary causes and depend on the nature of nutrition to a lesser extent. Salt crystals are dangerous because they can damage kidney tissue, causing inflammation; in addition, they can serve as a background for the development of urinary tract infections and accumulate in the kidney and pelvis, forming stones. The basis for the correction of dysmetabolic disorders is a specific diet with the exclusion of foods rich in appropriate salts, and the intake of large amounts of fluid.

Violations of the bladder activity in young children are mainly associated with the immaturity of its regulation by the nervous system. As a rule, they pass as the child grows. However, functional disorders can serve as a background for the development of deeper organic disorders; in addition, they deliver psycho-emotional discomfort to the child, contribute to a negative mood. The most common in children are enuresis, daytime urinary incontinence, urinary incontinence, neurogenic bladder.

Urinary incontinence is involuntary urination without an urge; enuresis is bedwetting. Incontinence should be distinguished from incontinence, in which there is an urge to urinate, but the child cannot hold urine, “run to the toilet”. Often, incontinence manifests as panty sagging or wet panty syndrome, where at first a small amount of urine is poured into the panties, and then the bladder sphincter is triggered and urination stops. In young children, a clear reflex to urination has not yet been fully formed, so they easily “forget” about the urge, switch their attention, “flirt”. The child should be offered to urinate periodically. Otherwise, urination disorders and overdistension of the bladder may occur, which can lead to the appearance of vesicoureteral reflux (reverse reflux of urine from the bladder into the ureters).

Variants of the course of urinary tract infection

In children, three variants of its course can be conditionally distinguished.
Option one. There are no clinical manifestations of the disease. Urinalysis reveals: bacterial leukocyturia, abacterial leukocyturia, isolated bacteriuria. Possible causes: infectious lesions at any level of the genitourinary system - asymptomatic bacteriuria, latent infection of the lower urinary tract, latent PN, vulvitis, balanitis, phimosis, etc.

Option two. Clinical manifestations in the form of dysuria (pain when urinating, pollakiuria, incontinence or urinary incontinence, etc.); pain or discomfort in the suprapubic region. Urinary syndrome in the form of bacterial leukocyturia (possibly in combination with hematuria of varying severity) or abacterial leukocyturia. Possible causes: cystitis, urethritis, prostatitis.

Option three. Clinical manifestations in the form of fever, symptoms of intoxication; pain in the lower back, side, abdomen, radiating to the groin, inner thigh. Urinary syndrome in the form of bacterial leukocyturia or abacterial leukocyturia, sometimes moderate hematuria. Changes in the blood: leukocytosis, neutrophilia with a shift to the left, accelerated ESR. Possible causes: pyelonephritis, pyelonephritis with cystitis (with dysuria).

Features of the course of pyelonephritis.

In the clinic of pyelonephritis in young children, symptoms of intoxication predominate. Perhaps the development of neurotoxicosis, the appearance of meningeal symptoms, frequent regurgitation and vomiting at the height of intoxication. Often in children of the first year of life, a complete refusal to eat with the development of malnutrition is possible. On examination, attention is drawn to the pallor of the skin, periorbital cyanosis, pastosity of the eyelids is possible.

Often, pyelonephritis at an early age occurs under a variety of "masks": dyspeptic disorders, acute abdomen, pylorospasm, intestinal syndrome, septic process, etc. When such symptoms appear, it is necessary to exclude the presence of a urinary tract infection.

In older children, “general infectious” symptoms appear less sharply, “unreasonable” rises in temperature are often possible against the background of normal well-being. They are characterized by fever with chills, symptoms of intoxication, persistent or intermittent pain in the abdomen and lumbar region, a positive symptom of tapping. Perhaps the course of pyelonephritis under the "mask" of influenza or acute appendicitis.

Features of the course of cystitis.

In older children and adults, cystitis most often occurs as a "local suffering", without fever and symptoms of intoxication. With hemorrhagic cystitis, hematuria, sometimes macrohematuria (urine of the color of meat slops), will be leading in the urinary syndrome. In infants and young children, cystitis often occurs with symptoms of general intoxication and fever. They are characterized by the frequent development of stranguria (urinary retention).

Kidney stone disease in children develops less frequently than in adults. Stones are formed from salt crystals, which are dissolved in normal urine; they can be located in the tissue of the kidney, the renal pelvis and their calyces, the bladder. The formation of stones is associated with metabolic disorders (in particular, mineral), non-compliance with the diet, as well as with difficulty in the outflow of urine with various malformations of the urinary system. Often, kidney stone disease is combined with pyelonephritis, as the stone creates the conditions for the development of infection. The disease is usually manifested by bouts of acute pain in the lower back, radiating to the lower abdomen.

Attacks of renal colic are often accompanied by vomiting, fever, gas and stool retention, and impaired urination. Blood is found in the urine (this is due to the fact that when a stone passes through the urinary tract, their mucous membrane is damaged). Treatment in most cases is surgical.

Diagnosis of infection.

Often, diseases of the urinary system are hidden, so any unusual symptoms that appear in a child should alert parents and the attending physician. Fortunately, these symptoms are easy to spot.
Symptoms of kidney disease:
Unmotivated fever (without symptoms of SARS);
Periodic pain in the lower abdomen or in the lumbar region;
daytime "letting" of urine;
nocturnal and daytime enuresis;
frequent or infrequent urination.

For the diagnosis of infection of the urinary system, laboratory instrumental methods of research are used.

To identify the activity and localization of the microbial-inflammatory process. It is necessary to conduct mandatory laboratory tests, such as a clinical blood test and a biochemical blood test (total protein, protein fractions, creatinine, urea, fibrinogen, CRP). General urine analysis; quantitative urine tests (according to Nechiporenko); urine culture for flora with a quantitative assessment of the degree of bacteriuria; urine antibiogram (sensitivity to antibiotics); biochemical study of urine (daily excretion of protein, oxalates, urates, cystine, calcium salts, indicators of membrane instability - peroxides, lipids, anti-crystal-forming ability of urine).

In some cases, additional laboratory tests will be required, such as quantitative urine tests (according to Amburge, Addis-Kakovsky); urine sediment morphology; urine test for chlamydia, mycoplasma, ureaplasma (PCR, cultural, cytological, serological methods), fungi, viruses, mycobacterium tuberculosis (urine culture, express diagnostics); study of immunological status (sIgA, state of phagocytosis).

In addition to analyzes, special studies are also carried out to characterize the functional state of the kidneys, tubular apparatus and bladder.
Laboratory tests are obligatory: the level of creatinine, urea in the blood; Zimnitsky test; clearance of endogenous creatinine; study of pH, titratable acidity, ammonia excretion; diuresis control; rhythm and volume of spontaneous urination.

Mandatory and instrumental studies, such as measuring blood pressure; Ultrasound of the urinary system; X-ray contrast studies (micting cystoscopy, excretory urography) - with repeated episodes of UTI and only in the phase of minimal activity or remission.

Additionally, a nephrologist may prescribe Doppler ultrasound (USDG) of renal blood flow; excretory urography, cystoureteroscopy; radionuclide studies (scintigraphy); functional methods for studying the bladder (uroflowmetry, cystometry); electroencephalography; echoencephalography; CT scan; Magnetic resonance imaging.
Mandatory consultations of specialists: children's gynecologist or urologist. If necessary: ​​neurologist, otorhinolaryngologist, ophthalmologist, cardiologist, dentist, surgeon.

Principles of treatment of infectious diseases of the urinary system.

In an acute period or during an exacerbation, the child should be treated in a hospital or at home under the supervision of a doctor. After the child is discharged from the hospital, a nephrologist or urologist periodically observes for a certain time, the appointments of which must be strictly followed. Any infection can cause an exacerbation of the disease, so try to protect your child from contact with patients with the flu, sore throat, and acute respiratory infections. Much attention should be paid to the elimination of chronic foci of infection (timely treat teeth, eliminate foci in the pharynx, paranasal sinuses). Children who have had kidney disease should avoid overwork and hypothermia, significant physical exertion. After discharge from the hospital, the child is allowed to engage in physiotherapy exercises, but classes in sports sections and participation in competitions are prohibited. These restrictions will be lifted over time. Measures aimed at strengthening the body, the reasonable use of natural factors of nature - the sun, air and water, will help prevent kidney diseases and related complications. To prevent the spread of infection from the lower urinary tract, especially in girls, it is necessary to strictly observe the hygiene of the external genital organs. Of great importance is the removal of obstacles that disrupt the normal outflow of urine.

Treatment of microbial-inflammatory diseases of the urinary system involves not only antibacterial, pathogenetic and symptomatic therapy, but also the organization of the correct regimen and nutrition of a sick child.

The issue of hospitalization is decided depending on the severity of the child's condition, the risk of complications and the social conditions of the family - the younger the child, the more likely it is to be treated in a hospital. During the active stage of the disease, in the presence of fever and pain, bed rest is prescribed for 5–7 days. Cystitis and asymptomatic bacteriuria usually do not require hospitalization. In the acute period, table No. 5 according to Pevzner is used: without salt restriction, but with an increased drinking regimen, 50% more than the age norm. The amount of salt and fluid is limited only if the kidney function is impaired. It is recommended to alternate protein and plant foods. Products containing extractives and essential oils, fried, spicy, fatty foods are excluded. Detected metabolic disorders require special corrective diets.
Drug therapy for UTIs includes antibacterial drugs, anti-inflammatory, desensitizing and antioxidant therapy.

Conducting antibiotic therapy is based on the following principles: before the start of treatment, it is necessary to conduct a urine culture (later the treatment is changed based on the results of the culture); exclude and, if possible, eliminate factors that contribute to infection; improvement does not mean the disappearance of bacteriuria; Treatment results are considered a failure if there is no improvement and/or persistence of bacteriuria.
Primary lower urinary tract infections (cystitis, urethritis) usually respond to short courses of antimicrobial therapy; infections of the upper urinary tract (nephritis and pyelonephritis) - require long-term therapy.

Treatment of pyelonephritis includes several stages:
- suppression of the active microbial-inflammatory process with the use of antibiotics and uroseptics (here, urine culture for sensitivity to antibiotics is taken into account).
- against the background of the subsidence of the process, stimulation of antioxidant protection and immunocorrection are carried out,
- the stage of anti-relapse treatment.
Therapy of an acute process, as a rule, is limited to the first two stages, in chronic cases all three stages of treatment are included.

When choosing antibacterial drugs, the following requirements must be taken into account: the drug must be active against the most common pathogens of urinary tract infections, not be nephrotoxic (like gentamicin, for example), create high concentrations in the focus of inflammation (in urine, kidney tissue), and have a predominantly bactericidal effect. action, have activity at the pH values ​​of the patient's urine, when several drugs are combined, drug interactions should be observed.
The duration of antibiotic therapy should be optimal, ensuring complete suppression of the activity of the pathogen; usually is about 3-4 weeks in the hospital with a change of antibiotic every 7-10 days (or replacement with a uroseptic).

Starting antibiotic therapy is prescribed empirically (without waiting for sowing), based on the most likely infectious agents. In the absence of a clinical and laboratory effect after 2-3 days, it is necessary to change the antibiotic. In severe and moderate PN, drugs are administered mainly parenterally (intravenously or intramuscularly) in a hospital setting. With mild and in some cases moderate course of PI, inpatient treatment is not required, antibiotics are administered orally, the course of treatment is from 14 to 20 days.

In the first days of the disease, against the background of increased water load, fast-acting diuretics are used, which increase renal blood flow, ensure the elimination of microorganisms and inflammatory products, and reduce swelling of the interstitial tissue of the kidneys. The composition and volume of infusion therapy depend on the severity of the intoxication syndrome, the patient's condition, indicators of hemostasis, diuresis and other kidney functions.
The combination with anti-inflammatory drugs is used to suppress the activity of inflammation and enhance the effect of antibiotic therapy. Non-steroidal anti-inflammatory drugs are recommended. The course of treatment is 10-14 days.

Desensitizing agents (Tavegil, Suprastin, Claritin, etc.) are prescribed for acute or chronic PN in order to stop the allergic component of the infectious process, as well as with the development of the patient's sensitization to bacterial antigens.
The complex of PN therapy includes drugs with antioxidant and antiradical activity: Tocopherol acetate, Unithiol, Beta-carotene, etc. Of the drugs that improve kidney microcirculation, Trental, Cinnarizine, Eufillin are prescribed.

Anti-relapse therapy involves long-term treatment with antibacterial drugs in small doses and is usually carried out on an outpatient basis. For this purpose, use: Furagin for 2 weeks, then with normal urine tests, the transition to 1/2-1/3 doses for 4-8 weeks; the appointment of one of the drugs pipemidic acid, nalidixic acid or 8-hydroxyquinoline for 10 days of each month at the usual dosages for 3-4 months.

Treatment of cystitis.

Treatment of cystitis provides for general and local effects. Therapy should be aimed at normalizing urination disorders, eliminating the pathogen and inflammation, and eliminating the pain syndrome. In the acute stage of the disease, bed rest is recommended until the dysuric phenomena subside. The general warming of the patient is shown. Dry heat is applied to the area of ​​the bladder.

Diet therapy provides for a sparing regimen with the exception of spicy, spicy dishes, spices and extractives. Dairy and vegetable products, fruits, which contribute to the alkalization of urine, are shown. It is recommended to drink plenty of water (weakly alkaline mineral water without gas, of course, fruit drinks, weakly concentrated compotes) after the pain syndrome is relieved. An increase in diuresis reduces the irritating effect of urine on the inflamed mucous membrane, promotes the washing out of inflammation products from the bladder. Reception of mineral water (Slavyanovskaya, Smirnovskaya, Essentuki) at the rate of 2-3 ml/kg 1 hour before meals has a weak anti-inflammatory and antispasmodic effect, changes the pH of the urine. Drug therapy of cystitis includes the use of antispasmodic, uroseptic and antibacterial agents. With pain syndrome, the use of age doses of No-shpa, Papaverine, Belladona, Baralgin is indicated.

In acute uncomplicated cystitis, it is advisable to use oral antimicrobials, which are excreted mainly by the kidneys and create the maximum concentration in the bladder. The minimum course of treatment is 7 days. In the absence of sanitation of urine against the background of antibiotic therapy, additional examination of the child is required. Uroseptic therapy includes the use of drugs of the nitrofuran series (Furagin), non-fluorinated quinolones (drugs of nalidixic and pipemidic acids, derivatives of 8-hydroxyquinoline).
In recent years, fosfomycin (Monural) has been widely used to treat cystitis, which is taken once and has a wide antimicrobial spectrum of action. In the acute period of the disease, phytotherapy is carried out with an antimicrobial, tanning, regenerating and anti-inflammatory effect. Cowberry leaf and fruits, oak bark, St. John's wort, calendula, nettle, coltsfoot, plantain, chamomile, blueberries, etc. are used as an anti-inflammatory agent. Barley, nettle, lingonberry leaf have a regenerating effect.

Management of children with asymptomatic bacteriuria.

The decision to use antibiotic therapy for asymptomatic bacteriuria is always a difficult one for the physician. On the one hand, the absence of a clinic and a pronounced urinary syndrome does not justify the use of a 7-day course of antibiotics and uroseptics due to possible side effects. In addition, the doctor often has to overcome parental prejudice against the use of antibacterial drugs.
On the other hand, shorter courses are ineffective, since they only shorten the period of bacteriuria, creating "imaginary well-being", and do not prevent the subsequent development of clinical symptoms of the disease. Also, short courses of antibiotics contribute to the emergence of resistant strains of bacteria. In most cases, asymptomatic bacteriuria does not require treatment. Such a patient needs further examination and clarification of the diagnosis.

Antibacterial therapy is necessary in the following situations:
- in newborns and infants and young children (up to 3-4 years), since they may develop PN rapidly;
- in children with structural anomalies of OMS;
- if there are prerequisites for the development of PN or cystitis;
- with chronic PN (cystitis) or transferred earlier;
- with the appearance of clinical symptoms of UTI.
Most often, uroseptics are used for asymptomatic bacteriuria.

Dynamic observation of children suffering from infections of the urinary system:

The child should be observed by a pediatrician together with a nephrologist.
During the period of exacerbation, the nephrologist looks - 1 time in 10 days; remission on the background of treatment - 1 time per month; remission after the end of treatment for the first 3 years - 1 time in 3 months; remission in subsequent years until the age of 15 years - 1-2 times a year, then the observation is transferred to therapists.

Clinical and laboratory studies:
- general urinalysis - at least 1 time per month and against the background of SARS;
- biochemical analysis of urine - 1 time in 3-6 months;
- Ultrasound of the kidneys - 1 time in 6 months.

According to indications - cystoscopy, cystography and intravenous urography. Removal from the dispensary of a child who has had acute UTI is possible while maintaining clinical and laboratory remission without therapeutic measures (antibiotics and uroseptics) for more than 5 years, after a complete clinical and laboratory examination. Patients with chronic IMVS are observed before transfer to the adult network.

Urinary tract infections (UTIs) rank 2-3 among all infections (second only to diseases of the respiratory tract and / or intestines) and lead in children under 2 years of age (level of evidence: 2a). In the first year of life, for the most part, the first 3 months, they are more common in boys (3.7%) than in girls (2%), after a year, on the contrary - 3% in girls and 1.1% in boys. UTIs are the most common cause of fever of unknown origin in boys under 3 years of age. It is estimated that 5% of their girls and 0.5% of boys at school age carry the disease. Progression of UTI with frequent recurrences or developmental anomalies leads to proteinuria, increased blood pressure, and is the most common cause of chronic renal failure in childhood (level of evidence: 2a).

Etiology

In the etiology of UTI, the leading role belongs to E. coli- 90% of all uropathogens. Gram-positive microorganisms make up only 5-7%. Anomalies in the development of the urinary system create the prerequisites for the colonization of the urinary system in an ascending way, and dysbacteriosis and constipation - in the hematogenous way. Bladder dysfunction contributes to recurrent UTIs. The presence of vesicoureteral reflux, both in combination with an infectious agent and without it (for example, in utero), can lead to the development of obstructive nephropathy, the appearance of scars and foci of sclerosis of the renal tissue.

According to the Order of the Ministry of Health of Ukraine No. 627 of 03.11.2008. “On the approval of the protocol for the treatment of children with infections of the sich system and tubulointerstitial nephritis” (Working group: academician Antipkin Yu.G., prof. Ivanov D.D., prof. Bagdasarova I.V., prof. Berezhnoy V.V., Prof. Borisova T.P., Associate Professor Kushnirenko S.V.), in our country the following is used IC classification (picture). It should be emphasized that complicated infections usually require emergency hospital care.

The European Guide EAU, 2010 also highlights:

• unresolved infection due to the resistance of the pathogen to the antibacterial drug;
• bacterial carriage , due to the presence of a focus of bacterial excretion;
• reinfection - the presence of a new infection with a pathogen different from the previous process.

Diagnosis and treatment of urinary tract infections (UTIs) in children are regulated by the above-mentioned order of the Ministry of Health of Ukraine. Based on this, the material below uses the latest updates of Guidelines on Urological Infections, 2010, Cochrane collaboration, 2010, National Guideline Clearinghouse, 2010.

Diagnostics

In the clinical picture in young children, nonspecific manifestations of inflammation predominate, and only the absence of a visible cause for fever is often the reason for examining a urine test. At a younger age, against the background of hyperthermia, vomiting and diarrhea, diffuse pains in the abdomen can be noted. The differential diagnostic sign of cystitis and pyelonephritis is the presence in the latter case of a generalized reaction of the body: hyperthermia, intoxication, leukocytosis with a shift of the formula to the left, increased ESR and positive CRP. On the contrary, cystitis is characterized by the presence of normal body temperature (less than 37.2 ° C), dysuric disorders, imperative urge to urinate, pain at the end of urination, often leading to the child's refusal to urinate. When examining a child, attention should be paid to the presence of phimosis, synechia, vulvitis, which are often the cause of leukocyturia not associated with UTI.

Urinary catheterization or suprapubic puncture is now rarely used to collect urine. For small children, special plastic bags are used, glued to the genitals. A urinalysis is collected completely, at the risk of contamination and for urine culture, a medium jet is used. The presence of more than 10 leukocytes in the field of view (more than 6 for boys) is considered a pathognomonic sign of UTI and does not require confirmation by Nechiporenko urinalysis.

The presence of other biochemical markers in the urine sample allows for the diagnosis of UTI. So, a positive reaction to nitrites (except Pseudomonas aeruginosa, Pseudomonas enterococci) with a sensitivity of 45-60% and a specificity of 85-98%, the presence of CRP at a concentration above 20 μg / ml, an increase in N-acetyl-ß-glucosaminidase are in favor of pyelonephritis. The clinical significance of interleukin-6 is currently not definitively determined.

The criteria for the diagnosis of UTI according to the IDSA/ESCMID protocols are presented in Table. one.

Table 1

Criteria for the diagnosis of UTI according to the IDSA/ESCMID protocols

Imaging methods for UTI include mandatory Ultrasound of the kidneys and bladder, voiding cystogram from the first episode of infection for boys and from the second for girls (grade of recommendation: B), performance CT or excretory urography only if an obstructive process is suspected (level of evidence: 2a). To identify scars and foci of sclerosis, renoscintigraphy with Tc-99m DMSA (specificity 100% and sensitivity 80%, level of evidence: 2a), the functional state of the kidneys with suspected obstructive damage - with Tc-99m DTPA/MAG-3 .

Treatment

In the treatment of IMS, 4 main tasks are pursued:

1. Elimination of symptoms and elimination of bacteriuria (recovery).
2. Prevention of scarring of renal tissue and the development of renal failure.
3. Prevention of recurrence of UTIs.
4. Correction of associated urological disorders.

Treatment of cystitis

At the first episode of cystitis in children antimicrobial therapy is prescribed for 5 days with a uroantiseptic (furamag, sulfamethoxazole / trimethoprim, furagin, furadonin) or for 3 days with a cephalosporin antibiotic of 2-3 generations (cefuroxime, cefixime, cefpodoxime). Riabal is used to reduce urgency. In the presence of risk factors (vulvitis, diathesis), only in girls it is possible to use prophylactic therapy at a dose of 1/3-1/4 of the daily dose once a night for 1-3 months with one of the listed drugs, but not with the one that was treated or with a phytopreparation, for example, kanefron N.

With recurrence of cystitis an additional examination is indicated, including a consultation with a gynecologist / urologist, determination of the carriage of pathogens by the presence of Ig to Ureapl. Urealiticum, Chlamyd. Trachomatis, Mycoplasma Genitalium (Hominis) and Trichom. Vaginalis. Treatment with a uroantiseptic is carried out for 7 days or with an antibiotic (cefix, cefuroxime) for 5 days with a change in the drug prescribed for the first episode of cystitis. Preventive treatment is usually carried out for at least 3 months.

For treatment infection carriers drugs of first choice in treatment Ureapl. Urealiticum are roxithromycin, clarithromycin with a course of 7-10 days, Chlamyd. Trachomatis- azithromycin, levofloxacin - 7 days, Mycoplasma Genitalium (Hominis)- xytrocin, clarithromycin, moxifloxacin - 7 days, Trichom. Vaginalis- ornidazole or naxojin - 5-7 days. Accompanying therapy for chronic cystitis in the form of instillations is prescribed by a urologist after cystoscopy with a solution of dimexide (3-15%) in combination with an antiseptic (ciprofloxacin, lefloxacin, decasan, dioxidine, an aqueous solution of 0.02% chlorhexidine, ectericide, metronidazole) or 2% protargol. Therapy for neurogenic urinary disorders is determined by the urologist.

For pregnant women the drugs of choice are cefix, nitrofurantoin, biseptol for a course of 7 days, fosfomycin or azithromycin - once with a possible combination with phytotherapy (Canephron N).

With an overactive bladder use oxybutynin or riabal. In the presence of reflux and no need for surgical correction (according to the opinion of the urologist), long-term use of furamag or trimethoprim/sulfamethaxosole is prescribed prophylactically (grade of justification: B).

Treatment asymptomatic bacteriuria in pregnant women carried out with fosfomycin 3 g once, amoxy / clavulanate or nitrofurantoin - 7 days; incomplete infection or persistence of bacteria requires prescriptions according to the antibiogram, taking into account the need for bladder instillations.

Treatment of pyelonephritis

In the presence of severe pyelonephritis (vomiting, dehydration, hyperthermia, preschool age), treatment is carried out in a hospital, in other cases, outpatient treatment is possible (degree of justification: A) - Table. 2.

Empiric antibiotic therapy lasts 10-14 days. The drugs of first choice are cephalosporins, mainly of the third generation (cefuroxime, ceftriaxone (preferably with sulbactam), cefotaxime, ceftazidime, cefoperazone, cefixime, ceftibuten) - Table. 3. Treatment should be carried out in the form step therapy : parenteral cephalosporin 3-4 days (children under 3 years 5-7 days) and then after normalization of temperature - cefuroxime or cefexime up to 7-10 days. "Protected penicillins" (amoxicillin/clavulonate, amoxicillin/sulbactam) are not a choice group and are indicated only when Gram-positive flora is expected. Fluoroquinolones 2-3 generations (levofloxacin, ciprofloxacin, moxifloxacin) are reserve drugs.

Table 3

Classification of cephalosporins

Generation

If intoxication, hyperthermia, urinary syndrome persist for more than 3 days, the drug is replaced (preferably taking into account sensitivity). Alternative drugs include IV generation cephalosporins (cefpirome, cefepime), aminoglycosides (netromycin, amikacin, gentamicin, tobramycin).

Combined antibiotic therapy is not used in routine practice.

For pregnant women the drugs of choice are 2-3 generation cephalosporins, protected aminopenicillins, macrolides, aminoglycosides (the latter only for a course of up to 7 days). The duration of treatment is 14 days. Furadonin and cephalexin are used postcoitally in the presence of previous UTIs (level of evidence: 2b, grade of recommendation: B).

Preventive therapy is used as an outpatient stage of treatment (after taking therapeutic doses of antibacterial drugs) for young children who have already had an episode of pyelonephritis, at risk of scarring, with infected urolithiasis, at risk of recurrent UTIs, chronic UTIs, in the presence of congenital malformations of the urinary system, concomitant urogenital infection, neurogenic bladder, diabetes mellitus, prolonged immobilization. The drugs of choice are furamag, sulfamethoxazole / trimethoprim, furagin, furadonin or canephron N. Except for the last one, all of the listed drugs are used once at night in 1/3-1/4 of the daily dose for 3-6 months each with a total duration of up to 2 years.

Pregnant women are usually not prescribed prophylactic treatment. If UTIs often recur during pregnancy, monural can be used as a prophylactic once every 10 days or postcoital.

In addition to antibiotic therapy in patients with pyelonephritis, post-syndrome therapy . Treatment of dehydration is carried out with a water load, detoxification - with the use of rheosorbilact, xylitol (with concomitant acetonemic syndrome) or through the mouth with stimol. With hyperthermia, antipyretics are used: paracetamol, nimesulide (from 12 years old). In cases of pain syndrome, riabal is prescribed, the appearance of diarrhea (or for the purpose of its prevention) - enterol. Biologics and antihistamines are not routinely used.

In the period of hyperthermia, bed mode is recommended, then room mode. During the period of remission - the general regimen by age, with the limitation of long-term orthostatic load, hypothermia should also be avoided. Diet therapy involves the appointment of table No. 5 and only in case of impaired renal function - table 7a, 7. Salt restriction is necessary only in the presence of impaired renal function and / or arterial hypertension.

A water load is recommended at the rate of 25-50 ml/kg/day (sufficiency of the drinking regimen is estimated by the amount of diuresis - at least 1.5 l) under the control of timely emptying of the bladder (at least 1 time for 2-3 hours). The drinking regime includes tea, alkaline mineral water, pure water, compotes (from dried fruits). With an alkaline reaction of urine, an increase in acid valences is shown (fruit drink, drinks from cranberries or lingonberries).

Thus, the basis for the treatment of pyelonephritis in a hospital is based on scheme "3+":

1. Gradual antibiotic therapy (for example, ceftriaxone / sulbactam 100 mg / kg / day in 2 injections / in 3 days, then cefix 8 mg / kg / day by mouth for 7 days), if necessary - enterol.
2. Rehydration through the mouth and detoxification intravenously (rheosorbilact 5 ml / kg / day in two injections) or through the mouth (stimol).
3. Antipyretic and anti-inflammatory: paracetamol 3-4 days and nimesulide.

At home (non-severe pyelonephritis, does not have dehydration and hyperthermia):

1. For example, cefix once a day No. 10.
2. Stimol 3-5 days.
3. Antipyretic and anti-inflammatory: paracetamol 3-4 days and nimesulide up to 10 days.

"+" - prevention of relapse: prophylactic treatment with furamag 25 mg at night for 3-6 months.

Thus, the treatment of UTIs in children is based on modern protocols with a rather limited list of drugs used. The appointment of other aids has no evidence base to date and therefore is considered as a doctor's initiative.