How are urinary tract infections treated?

Later, the onset of adequate antimicrobial therapy in children with a urinary tract infection leads to serious consequences: damage to the kidney parenchyma (with possible formation of wrinkles) and sepsis. An analysis of the results of scintigraphy carried out within 120 hours from the start of treatment showed that antimicrobial therapy prescribed for children with fever and suspected urinary tract infection in the first 24 hours of the disease completely eliminates focal defects in the kidney parenchyma. The beginning of treatment at a later date (2-5 days) leads to the appearance of parenchyma defects in 30-40% of children.

[1], [2], [3], [4], [5], [6]

Indication for appointment

Parenteral (intravenous or intramuscular) administration of antimicrobial agents is indicated in children with fever, toxicosis, inability to conduct oral therapy, and to ensure optimal antimicrobial concentrations in the blood, eliminate acute infection, prevent urosepsis, and reduce the likelihood of renal damage. With intravenous administration of medications, children with urinary tract infection are recommended a single daily dose of ceftriaxone, with intramuscular - in accordance with official recommendations. After clinical improvement (usually 24-48 hours after the beginning of treatment) and in the absence of vomiting, the child can be transferred to receive the drug through the mouth (stepwise therapy).

Choice of antimicrobial therapy

The initial choice of therapy for urinary tract infection is always empirical. It is based on the knowledge of prevailing uropathogens in children of this age group, the suspected antibacterial sensitivity of the microflora and the clinical status of the child. In most cases, the empirical choice of protected penicillins, cephalosporins of the third generation (eg, cefixime) or aminoglycosides is justified. According to Allen UD et al. (1999), the sensitivity of E. Coli to aminoglycosides can reach 98%. The drugs of choice include amoxiclav or augmentin. The main problem in the selection of antimicrobial therapy for urinary tract infection is associated with the development of resistance of urine microflora. Resistance is more likely to develop with abnormalities of the urinary tract, as a result of this change in antibiotic therapy should be guided by the proven sensitivity of the microflora of urine to an antimicrobial agent.

Antimicrobial agents recommended for the treatment of urinary tract infections in children

A drug	Sensitivity of microflora	Mode of administration and dose
Amoxicillin	E. Coli, Klebsiella	In the mouth: for children under 2 years - 20 mg / kg three times; 2-5 years - 125 mg three times; 5-10 years - 250 mg three times; over 10 years - 250-500 mg three times W / m: 50 mg / kg per day in 2 injections
Augmentin (amoksiklav)	E. Coli, Proteus mirabilis, Proteus vulgaris, Klebsiella, Salmonella	In / in: children of the first 3 months of life 30 mg / kg for administration with an interval of 12 hours; at the age of 3 months to 12 years - 30 mg / kg for administration every 6-8 hours; over 12 years, a single dose of 1.2 g every 6-8 hours. In the mouth: children under the age of 9 months are not prescribed; Children under the age of 12 are given in the form of a syrup; children aged 9 months to 2 years - 2.5 ml (0.156 g / 5 ml) for admission; from 2 to 7 years - 5 ml (0.156 g / 5 ml) for admission; from 7 to 12 years - 10 ml (0.156 g / 5 ml) for admission; over 12 years old - 0.375 g per reception (in the form of syrup or tablets)
Cephalexin	E. Coli	In the mouth: children weighing up to 40 kg - 25-50 mg / kg per day in 4 sessions; more than 40 kg - 250-500 mg every 6-12 hours
Cefotaxime	E. Coli, Citrobacter, Proteus mirabilis, Klebsiella, Providencia, Serratia, Haemophilus influenzae, Pseudomonas aeruginosa	In / m and / in: 50-180 mg / kg per day
Ceftriaxone	E. Coli, Citrobacter, Proteus, Klebsiella, Pseudomonas aeruginosa, Enterobacter	In / m and / in: newborns up to 2 weeks - 20-50 mg / kg per day once; older than 2 weeks of age, 50-100 mg / kg per day once
Cefixim	E. Coli, Proteus mirabilis, Moraxella (Branhamella) catarrhalis, N. Gonorrhoeae, Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus pyogenes	In the mouth: for children from 6 months to 12 years - 4 mg / kg every 12 hours; children over 12 years of age and weighing more than 50 kg - 400 mg once a day or 2 mg 2 times a day
Cefaclor	E. Coli, Haemophilus influenzae, Proteus mirabilis, Klebsiella	In the mouth: 20 mg / kg per day in 3 divided doses. When conducting anti-relapse treatment: 5-10 mg / kg per day in 1-3 doses
Gentamicin	E. Coli, Proteus, Klebsiella, Pseudomonas aeruginosa, Enterobacter	In / m and in / in: newborn and prematurely - 2-5 mg / kg per day in 2 injections; Children younger than 2 years - 2-5 mg / kg per day in 2 injections, children over 2 years - 3-5 mg / kg per day in 2 injections (once daily dose of gentamycin IV)
Amikacin	E. Coli, Klebsiella, Pseudomonas aeruginosa, Enterobacter	In / m and / in: the first injection - 10 mg / kg, the subsequent - 7.5 mg / kg (interval of introduction 12 h); a single daily dose of amikacin IV is allowed
Nethylmycin	E. Coli, Proteus, Klebsiella, Pseudomonas aeruginosa, Enterobacter	In / m and in / in: preterm and newborn under 7 days - 6 mg / kg per day in 2 injections; newborns older than 7 days, children under 2 years of age - 7.5-9 mg / kg per day in 2 injections; children over 2 years of age - 6-7.5 mg / kg per day in 2 injections; allow single administration of a daily dose of netilmicin IV
Nalidixic acid	E. Coli , Proteus, Klebsiella	In the mouth: 15-20 mg / kg per day once a night (for the prevention of recurrence of IC)
Trimethoprim	E. Coli , Proteus, Klebsiella	In the mouth: 2-3 mg / kg per day once a night (to prevent recurrence of infections of the urinary system)
Furagin	E. Coli, Proteus, Klebsiella, Enterobacter	In the mouth: 2-3 mg / kg per day once a night (for the prevention of recurrence of infections of the urinary system); 6-8 mg / kg per day (therapeutic dose)

[7], [8], [9], [10], [11]

The duration of antimicrobial therapy

Numerous studies have shown that the duration of antimicrobial therapy in children with urinary tract infection should not be less than 7 days. The optimal duration of antibiotic therapy for pyelonephritis is 10-14 days.

Evaluation of the effectiveness of antibiotic therapy

Clinical improvement within 24-48 hours from the start of treatment. With properly selected treatment, urine becomes sterile after 24-48 hours. Decrease or disappearance of leukocyturia on the 2-3 day from the beginning of treatment.

Efficacy and safety of some antibacterial drugs in children with urinary tract infection

A drug	Efficiency,%	Safety (frequency of side effects and complications),%
Ethymycin (Zhao C. Et al., 2000)	85.3	8.6
Nethylmycin (Zhao C. Et al., 2000)	83.9	9.4
Sulbactam (Li JT et al., 1997)	85	5
Cefotaxime (Li JT et al., 1997)	81	10
Norfloxacin (Goettsch W. Et al., 2000)	97.6	-
Trimethoprim (Goettsch W. Et al., 2000)	74.7	-
Nitrofurantoin (Goettsch W. Et al., 2000)	94.8	-
Amoxicillin (Goettsch W. Et al., 2000)	65.2	-

The absence of remission after the 14th day of treatment is possible in patients with an abnormal development of the urinary tract. The question of the need to continue antibiotic therapy should be resolved after a re-examination of the child, determination of the culture in the urine and its sensitivity to antimicrobial drugs, microscopy of urine. The consultation of a children's nephrologist and urologist is shown.

Necessary studies during the period of antibiotic therapy.

• On the 2nd-3rd day of treatment, urine microscopy should be performed. Indication for the re-determination of the degree of bacteriuria and the sensitivity of the microflora of urine to antimicrobial agents is the lack of clinical improvement during the first 48 hours of therapy.
• After the completion of antibacterial therapy, a urinalysis and a general blood test should be performed.

[12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22],

Prevention of recurrence of urinary tract infections

The main indication for the appointment of anti-relapse therapy is an abnormality of the genitourinary system, metabolic disorders that determine the development of relapses. Currently, for the anti-relapse treatment of infections of the urinary system, the following medicines are recommended.

• Furagin 2-3 mg / kg per day once a night in the absence of bacteriuria.
• Cotrimoxazole 2 mg of trimethoprim + 10 mg of sulfamethoxazole per kg / day once a night.
• Nalidixic acid at 15-20 mg / kg per day once a night.

The duration of anti-relapse therapy is at least 3 months.

As part of the complex therapy of exacerbations and as a prophylaxis of relapses, it is advisable to prescribe a herbal medicine. Kanefron N. The drug has a complex action: anti-inflammatory, mild diuretic, antimicrobial, antispasmodic, increases the effectiveness of antibacterial therapy and reduces the number of repeated exacerbations of the disease. It is used for a long time: in infants - 10 drops 3 times a day; in preschool children - 15 drops 3 times a day; in children of school age - 25 drops or 1 dragee 3 times a day.

Clinical follow-up of patients with pyelonephritis is carried out for 5 years. Vaccination of children is carried out during the period of clinical and laboratory remission.