RU2724186C1 - Method of treating infants with recurrent urinary infection - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to pediatric urology and nephrology, and can be used for treating children aged 6 months to 3 years old with recurrent urinary infection. Antibacterial therapy is prescribed. Content of procalcitonin in morning urine is determined in children with urinary recurrence more than once in 6 months by immunochromatographic method. If its level is more than 1.5 ng/ml, an antibacterial therapy is prescribed in age dosages of 10 days. That is followed by repeated determination of procalcitonin content in morning urine by an immunochromatographic method, and if observing a decrease in its level, the uroseptic therapy is prescribed for at least two times within 14 days. If the previous level is maintained or decreased less than twice, the antibacterial therapy is continued for 5 more days with the following prescription of the uroseptic therapy within 14 days. After the uroseptic therapy, the content of procalcitonin in the morning urine is again determined by an immunochromatographic method and if level is 0.6 ng/ml or more, the indications for the surgical correction of vesicoureteral reflux are determined.EFFECT: method provides the possibility of preventing developing renal parenchymal involvement, including reflux-nephropathy, chronic renal disease in treating recurrent urinary tract infections in children under three years old, creation of individual therapeutic regimens for the given category of patients, based on the objective assessment of the inflammatory process in the kidneys, providing conditions for surgical correction of manifested vesicoureteral reflux by developing an algorithm for treating recurrent urinary tract infections in infants taking into account an objective index characterizing the course of an inflammatory process, a level of procalcitonin in the urine.1 cl, 2 ex

Description

The invention relates to medicine, namely to pediatric urology and nephrology, can be used in the treatment of young children with a recurring infection of the urinary system.

As a result of the constant recurrent course of the infectious and inflammatory process, chronic pyelonephritis is formed in the urinary system, which is complicated by vesicoureteral reflux during intermittent dilatation of the uretero-vesical anastomosis.

A known method of treating young children with recurrent infection of the urinary system, including the appointment of a short course of antibiotic therapy (Infection of the urinary tract in children. Clinical recommendations, 2017, p. 24) (prototype).

However, as a rule, a short course of antibiotic therapy is not enough. Inadequate sanitation of the urinary tract against the background of persisting vesicoureteral reflux leads to the progression of the disease, the development of nephropathy. This problem is especially relevant in young children under three years of age, who have contraindications for the use of many informative diagnostic instrumental methods of research, and limitations for invasive surgical interventions. Due to scarring of the kidney tissue, they begin to develop arterial hypertension and a decrease in renal function, which lead to chronic kidney disease, which, as a rule, is a contraindication to surgical correction of vesicoureteral reflux. Timely and adequate treatment of recurrent urinary tract infection, in our opinion, will be able to ensure the prevention of reflux nephropathy, the development of tubulointerstitial kidney fibrosis. The individually selected treatment of this pathology can be based on the results of a dynamic study of objective biomarkers characterizing the state of the urinary system of the child.

A known marker of urinary tract infection is procalcitonin (PCT) (Zaykova N., Long V., Sinitsyna L. Procalcitonin in urine as a marker of renal tissue damage in children with vesicoureteral reflux. Nephrology, 2012, Volume 16, No. 4, p. . 69-74).

PCT is a calcitonin precursor molecule, a glycoprotein with a molecular weight of about 14.5 k Yes. Normal plasma levels of PCT are less than 0.2 ng / ml. Procalcitonin is produced by thyroid C cells. In infectious pathology of any localization, it is stimulated by endoxins and pro-inflammatory cytokines and appears in a high titer in blood plasma and correlates with its severity. The diagnostic value of this marker in the blood was established in children with varying degrees of vesicoureteral reflux in chronic pyelonephritis.

However, a study of PCT in the blood is not sufficiently informative in determining renal damage. There is no data on the use of the results of a study of the level of PCT in both blood and urine for the selection of individual treatment regimens for children with recurrent infection of the urinary system.

Known recommendations for the diagnosis of urinary tract infections (RU 2611371 C2), based on the use of the ratio of PCT in blood and urine, also do not allow choosing the appropriate therapy for this particular child, especially with negative results of DMSA-scintigraphy, which will prevent a reduction in the volume of already begun damage to the parenchyma the kidneys.

The medical and technical problem is to develop an algorithm for the treatment of recurrent urinary tract infections in young children, which can prevent kidney damage (reflux nephropathy), taking into account an objective indicator of the course of the inflammatory process.

The technical result achieved by the implementation of the invention is to prevent the development of damage to the renal parenchyma, including reflux nephropathy, chronic kidney disease in the treatment of recurrent urinary tract infections in children under three years of age; the creation of individual treatment regimens for this category of patients, based on an objective assessment of the state of the inflammatory process in the kidneys; providing conditions for surgical correction of severe vesicoureteral reflux.

We established objective criteria (certain levels of PCT in the urine), which turned out to be informative for the choice of treatment regimens for recurrent urinary tract infections in children under three years of age. This allowed us to begin early adequate treatment of this pathology, which in turn ensured long-term sanitation of the urinary tract. The latter allowed in some cases to be limited only to therapeutic treatment and to exclude kidney damage. Preservation of renal function made it possible to perform operative correction of vesicoureteral reflux in other cases.

The invention consists in the following.

In the treatment of children aged 6 months to three years with a recurring infection of the urinary system when a relapse of urinary infection occurs more than 1 time in 6 months, the content of PCT in morning urine is determined by immunochromatographic method. At a PCT level of more than 1.5 ng / ml, antibiotic therapy is prescribed in age-related dosages for a course of 10 days. Then re-determine the content of procalcitonin in the morning urine by the immunochromatographic method. With a decrease in its level, at least two times prescribed uroseptic therapy for 14 days. While maintaining the previous level of procalcitonin or reducing it by less than half, antibiotic therapy is continued for another 5 days, followed by the appointment of uroseptic therapy for 14 days. After conducting uroseptic therapy, the procalcitonin content in morning urine is again determined by the immunochromatographic method, and at its level of 0.6 ng \ mmol or more, indications for surgical correction of vesicoureteral reflux are determined.

The method is as follows. In children aged 6 months to three years with a recurring infection of the urinary system, when a recurrence of urinary infection occurs more than 1 time in 6 months, the content of PCT in morning urine is determined by immunochromatographic test - Brachms PCT-Q method. The set of reagents is a rectangular rectangular plastic tablet containing an immunochromatographic rapid test strip to view the results of the analysis - the test and control lines. A sticker in the medical history with a comparative scale is attached to the kit.

A relapse of urinary infection is characterized by a temperature above 37.8C, in the analysis of urine bacteriuria (more than 10 * 5), leukocyturia (20-30 in s / sp).

At a PCT level of more than 1.5 ng / ml, antibiotic therapy is prescribed in age-related dosages for a course of 10 days. For antibiotic therapy can be used, for example, the following drugs amoxiclav, ceftriaxone in age dosages.

Then re-determine the content of procalcitonin in the morning urine by the immunochromatographic method. With a decrease in the level of PCT, at least two times prescribed uroseptic therapy for 14 days.

While maintaining the initial level of PCT or reducing it by less than two times, antibiotic therapy is continued for another 5 days, followed by the appointment of uroseptic therapy for 14 days.

For uroseptic therapy, the following drugs can be used - furazidine (furagin), nitroxoline (5-NOC), trimethoprim (biseptol) in age dosages.

After uroseptic therapy, the procalcitonin content in morning urine is again determined by the immunochromatographic method, and at its level of 0.6 ng / ml or more, indications for surgical correction of vesicoureteral reflux are determined.

To conduct an in-depth urological examination in order to identify severe vesicoureteral reflux, the following methods can be used: conducting cystography, excretory urography, and static nephroscintigraphy.

Clinical example 1.

Child A, 3 years old, was admitted for the first time to the nephrology department with complaints of abdominal pain, changes in urine tests in the form of a moderate degree of leukocyturia, enlargement of the heart rate on both sides according to the ultrasound picture of the kidneys.

The anamnesis is burdened by kidney diseases: the mother has a doubled kidney on the left, recurrent cystitis; father has urolithiasis. The girl from III uncomplicated pregnancy, delivery on time, with a weight of 3000, length - 53 cm, screamed right away, applied to her breast on the first day, breast-fed for the first month, then on artificial feeding. Developed according to age. Vaccinated by age. Two siblings (13 and 9 years old) are healthy.

Anamnesis of the disease: for the first time at the age of 1 year before vaccination, a moderate degree of leukocyturia was revealed in urine tests, according to the ultrasound picture - CLS up to 4-5 mm on both sides, the parenchyma was not thickened. Received uroseptic therapy (furazidine at a dose of 8 mg / kg - 14 days) with a positive effect. It was further observed by a nephrologist with a diagnosis of infection of the urinary system (recurrence of urinary infection 2 times over 6 months). She received uroseptic courses, and her mother refused hospitalization.

On examination, the physical development is harmonious average (50-75 percentile). The skin is pale pink, on the elbows and knees signs of atopy. HELL for single measurements of 85/50 mm Hg The abdomen is soft, painful on palpation in the bladder. Urinates painlessly, freely, 9-10 times a day in portions of 150-200 ml, excretes 1.5 liters of urine per day.

During the examination: in the clinical analysis of urine, white blood cells up to 30 in s / sp, Er - single; urine culture is negative; in the clinical analysis of blood: Hb - 118 g / l, Le - 9.3 × 10 ⁹ , ESR - 12 mm / h; in the biochemical analysis of blood: urea - 3.7 mmol / l, blood creatinine - 0.038 mmol / l. The functional parameters of the kidneys are normal: GFR - 112.9 ml / min (CKD 1 tbsp), the concentration function of the kidneys in the Zimnitsky sample is not impaired (1018-1021). The level of PCT is 1.6 ng / ml.

Ultrasound: dilatation of both pelvis up to 9-10 mm, clear kidney contour, right kidney 78 × 45 mm, left kidney 92 × 47 mm, signs of inflammation, the parenchyma is not thickened, differentiated.

According to cystourethrography: vesicoureteral reflux of 1 degree to the left. On excretory urography, the fornixes are clear, the pyelocaliceal system is not expanded, the function, according to visual assessment, is not broken.

Dopplerographic study of the kidneys was carried out: an increase in IR (more than 0.8) at all levels of branching of the renal artery, blood flow rate increased Vmax - 58.7 mm / s.

The diagnosis was made: Secondary pyelonephritis, active stage 1 tbsp. Vesicoureteral reflux of the I degree on the left. CKD 1 tbsp.

She received antibacterial therapy (amoxiclav) for 10 days (PCT level on day 11 - 0.7 ng / ml), followed by uroseptic therapy (furazidine) for 14 days.

On an outpatient examination on the 14th day of TSI administration - the level of PCT is 0.5 ng / ml, somatically the child is healthy. Monitoring of the clinical analysis of urine and ultrasound of the kidneys, the level of PCT in the urine after a month. When observed in the long term for 2 years, there is no relapse of urinary infection, no reflux nephropathy.

Clinical example 2.

Child N, 6 months old, was admitted to the nephrology department with complaints of febrile temperature, changes in urine and blood tests.

From the anamnesis: from I pregnancy, the pregnancy proceeded against the background of toxicosis of the first and second trimester, was born at 41 weeks, birth weight - 4200 g, length - 55 cm, screamed right away, breast-fed up to 3 months. Developed according to age. Not vaccinated (parental denial). Mother’s grandfather has urolithiasis.

From the anamnesis of the disease: throughout life, from the moment of birth four times relapse of urinary infection, twice the attack of pyelonephritis. Ultrasound of the kidneys was carried out: enlargement of the CSF, increased echogenicity of the renal parenchyma. Periodically in urinalysis leukocyturia without fever. He was treated at the place of residence, received short courses of antibacterial and uroseptic therapy with a short-term positive effect. On examination, The skin is pale, dry. The abdomen is soft, painless on palpation.

Urinary syndrome presented: Le 20-30 in the field of view, Er 3-4 in the field of view, protein 0.14 g / l; albuminuria 44.54 mg / l. Blood test: Hb - 102 g / l, Le - 15.3 × 10 ⁹ , ESR - 32 mm / hour. There was a decrease in glomerular filtration, which corresponded to stage II of CKD (urea - 6.7 mmol / L, blood creatinine - 0.074 μmol / L, GFR - 89.2 ml / sec) and violation of tubular function in the Zimnitsky test (hypoisostenuria - 1003-1007). The level of PCT in urine is 13.7 ng / ml.

With echolocation of the kidneys, the expansion of the CHS on both sides was determined, the contour of the kidneys is clear. Renal parenchyma is differentiated into cortical and medullary layers, echogenicity is increased, comparable with liver echogenicity.

He received antibacterial therapy (ceftriaxone) for 10 days, but the level of PCT decreased slightly - 8.7 ng / ml. Antibacterial therapy was continued for another 5 days, followed by the addition of uroseptic therapy (nitroxoline) for up to 14 days. The content of procalcitonin in morning urine is 0.5 ng / ml.

At the control examination - somatically the child is healthy, clinical urine tests are normal. When observed in the long term for 3 years, there are no recurrences of urinary infection, no reflux nephropathy.

In accordance with the proposed method, 44 children aged 6 months to 3 years were treated with a recurrent infection of the urinary system with a relapse rate of urinary infection from 2 to 5 over 6 months. 21 children received antibiotic therapy for 10 days (followed by uroseptic therapy). 23 patients received antibiotic therapy for 15 days, followed by uroseptic therapy, of which two underwent surgical correction of vesicoureteral reflux confirmed by instrumental methods (in one child, the level of PCT after antibiotic therapy was 15 days, uroseptic therapy for 14 days, the content of PCT in the urine was 0.6 ng / ml and the other 0.8 ng / ml). In all cases, when observed in a long period of recurrence of urinary infection, no reflux nephropathy was noted.

Claims (1)

A method of treating children aged 6 months to three years with a recurring infection of the urinary system, including the appointment of antibiotic therapy, characterized in that in children with a recurrence of urinary infection more than 1 time in 6 months, the content of procalcitonin in morning urine is determined by immunochromatographic method and at its level of more than 1.5 ng / ml, antibiotic therapy is prescribed in age-related dosages for a course of 10 days; then re-determine the content of procalcitonin in morning urine by the immunochromatographic method and, when its level is reduced by at least two times, uroseptic therapy is prescribed for 14 days, and if the previous level is maintained or its decrease is less than two times, antibacterial therapy is continued for another 5 days followed by the appointment of uroseptic therapy for 14 days; after uroseptic therapy, the procalcitonin content in morning urine is again determined by the immunochromatographic method and, at its level of 0.6 ng / ml or more, indications for surgical correction of vesicoureteral reflux are determined.