Microbial inflammatory diseases of the urinary system take the second place among childhood infections and are the largest group in nephrological practice. They are characterized not only by a high frequency of occurrence, but also by a tendency to relapse, especially against the background of urinary tract abnormalities. That is why microbial damage to the kidneys is the most common cause of the development of chronic renal failure in childhood.
Conventionally, all infections of the urinary system, depending on the localization of the process, can be divided into two groups: infections of the lower urinary tract and upper. Infections of the lower urinary tract involve the urethra and bladder (urethritis, urethral syndrome,) in the inflammatory process. Microbial damage to the upper urinary tract leads to the development of a and lumped processes, for example, a or a kidney. The ureters, as the connecting link between the kidneys and the bladder, are almost not involved in the inflammatory process in isolation. The main differential diagnostic sign that distinguishes lower urinary tract infections from the upper ones is the severity of the body's response to inflammation. When the lower urinary tract is affected, local reactions to the introduction of the microbe prevail without significant changes in the blood and the development of intoxication. There are also some differences in the urinary syndrome.
Lower urinary tract infections
Urethritis and urethral syndrome - an inflammatory process caused by microbial effects on the mucous membrane of the urethra. In boys, the inflammatory process is more often localized in the lower urethra, i.e. typical develops. In girls, due to the short length of the urethra, the infection spreads rapidly and, as a rule, clinic a joins within one to two days. Given the uncertainty of the localization of the pathological process in girls, the diagnosis is often made - urethral syndrome. Infection enters the urinary tract most often in an ascending way.
Predisposing factors in boys are balanitis, and in girls - synechia of the labia minora. Depending on the duration of the disease, acute urethral syndrome or (up to 3 weeks) and chronic urethral syndrome (urethritis) are distinguished. The latter in pediatric practice occurs mainly in adolescence in boys and is associated, as a rule, with the presence of sexually transmitted diseases. Clinically and urethral syndrome are characterized by pain at the beginning of urination, imperative (forced) urges and increased urination, as well as discharge from the urethra.
The criteria for the chronic course are the duration of the process (more than 6 months) or the presence of urinary tract obstruction. The latter can be functional (neurogenic urination disorder, vesicoureteral reflux of the I-II degree) and organic (due to stone, ju, ohm, aberrant artery, cystic dysplasia). Depending on the degree of impaired renal function, excrete without impairment or impaired renal function (acute and chronic renal).
Relapse a is documented in the presence of clinical and laboratory symptoms and the allocation of the same pathogen that occurred in the previous episode of the disease. Reinfection is diagnosed when a different serotype of the pathogen or another microbial agent is detected during urine culture. In the primary case, the causative agent of the disease enters the kidney, as a rule, through the hematogenous pathway, and in the secondary pathogen, through the ascending route, rising from the bladder. The most common causative agent of a is Escherichia coli and other intestinal flora (often on background a). Bladder-ureter reflux, bladder sphincter dysfunction, and recurrence of lower urinary tract infections are risk factors for microbial damage to the kidneys.
A is characterized by the presence of extrarenal symptoms: febrile temperature, intoxication, abdominal pain (in young children) or lower back (in older children). In blood tests, neutrophilic, an increase in acute phase indicators and ESR are detected. Urinary syndrome is represented by bacteriuria of more than 10 4 Mt / ml, neutrophilic leukocyturia and microproteinuria. In the case of papillary necrosis, erythrocytes are present in the urinary sediment, sometimes exceeding the number of leukocytes. In contrast to lower urinary tract infection, a neutral or alkaline reaction of urine is observed with e, which is associated with massive multiplication of bacteria in the kidney. For the same reason, a positive reaction to leukocyte esterase and a nitrite test is noted (gram-negative flora, which is the most common cause of a, converts nitrates to nitrites). It should be remembered that enterococci do not give a positive test for nitrites, and taking phenazopyridine causes a false positive test for nitrites. Unlike microproteinuria observed in infections of the lower urinary tract, with e, the protein in the urinary sediment is of tubular origin. Therefore, the degree of proteinuria correlates with the degree of kidney damage by microbial agents. In recent years, the informativeness and accessibility of urine test methods has increased markedly. So, you can get information about various indicators using test strips, which are recorded in manual or automatic modes for 2-10 indicators. Modern test strips also allow you to evaluate the ratio of protein / creatinine, which reflects the total function of the kidneys. To identify the pathogen, you can use not only traditional urine cultures (5-7 days), but also express methods. Tests for 18-24-hour recording of the degree and type of bacteriuria are available in Ukraine. They represent a nutrient medium deposited on a plastic plate stored in a special container. After immersion in the test urine plate for 18-24 hours. placed in a thermostat (37 o C), then the identification of crops. Automated urine culture systems allow identification of the causative agent on differential diagnostic media within 48 hours, determining the sensitivity of the microbe to 20-30 antimicrobial agents.
Mandatory examinations in a child with ohm are ultrasound of the kidneys and mycic cystogram (especially in children under the age of 5 years). If there are signs of obstruction detected by ultrasound, it is advisable to conduct an excretory urogram or computed tomography of the kidneys and urinary tract with amplification by the magnevist. Immaturity of the urinary tract in children, the latent course of infections often determine the presence of asymptomatic bacteriuria. The latter is documented when microbial bodies of 1 ml are detected in an average portion of morning urine 104 and above in the absence of other clinical and laboratory manifestations of diseases of the urinary system. In 1% of girls of preschool age and in 5% of girls under 15 years of age, bacteriuria is detected during routine urinalysis. Three variants of the course and outcome of asymptomatic bacteriuria can be distinguished: a manifestation of a disease of the urinary system (pyelonephritis or om) - 10%, self-elimination of bacteriuria - 80-70% and transient preservation of bacteriuria - 10-20%. Risk factors for the manifestation of asymptomatic bacteriuria are functional and organic abnormalities in the development of the kidneys and urinary tract. It should be remembered that 2/3 of women who had persistent bacteriuria during childhood also develop a manifest infection of the urinary system during pregnancy. In most cases, asymptomatic bacteriuria is caused by E. Coli., Klebsiella, Proteus, Pseudomonas, Enterococcus and Staphylococcus epidermalis (more often in newborns).
Modern treatment approaches
In the treatment of acute a, a short 10-12-day regimen or standard 2-3-week treatment is used. A short treatment regimen involves triple therapy. The first component (antimicrobial) is an antibiotic selected taking into account the sensitivity of the microorganism and administered intravenously for the period of fever. As a rule, preference is given to cephalosporin of the 2-3rd generation, penicillin of the 3-4th generation, or fluoroquinolone (in adolescents). The second component (detoxification, metabolic) is lipin at the rate of 10-20 mg / kg of body weight per day intravenously in 5% glucose solution for 2-4 days. Hemodesis, neohaemodesis are currently not used in nephrological patients.
The third component (anti-inflammatory, antipyretic) is paracetamol or a selective COX-2 inhibitor, for example nimesulide. The use of other non-steroidal anti-inflammatory drugs is undesirable. The criterion for the effectiveness of the therapy is the normalization of temperature on the 2nd-4th day, the elimination of bacteriuria on the 4th-5th day, the normalization of urinalysis on the 5th-7th day and blood tests on the 9th-10th day of treatment. The use of this treatment regimen (with the participation of a nephrologist) is advisable in cases of acute primary a (secondary is treated in the urology department).
With a 2-3-week treatment (standard regimen), two pairs of antimicrobials (antibiotic + uroantiseptic) are used sequentially. For example: cefataxime + co-trimoxazole, cefuroxime + co-trimoxazole or ceftriaxone + co-trimoxazole. If necessary, supplement therapy with metronidazole. One of the drugs is administered parenterally. Bactericidal preparations (or bactericidal concentrations) are preferred. The dose for second-fourth generation cephalosporins is 75-50 mg / kg per day in 2 divided doses, for gentamicin and netilmicin 3-5 mg / kg in 3 divided doses. It is also possible to use the entire daily dose of aminoglycoside in one injection, which significantly reduces the nephrotoxicity of the drug and the negative effect on the VIII pair of cranial nerves. Cephalosporins and aminoglycosides should not be combined due to a possible increase in their nephrotoxicity.
If a hospital strain of the pathogen is detected, IV generation cephalosporin is prescribed - cefepime 1-2 g twice a day in combination with fluoroquinolones. It is possible to use carbapenems (imipenem in combination with cilastatin, meronem). Macrolides are used as second-line drugs and only those that give significant concentrations in the kidneys and urine: roxithromycin, clarithromycin, josamycin, midecamycin, fosfomycin and azithromycin. The use of erythromycin, rovamycin is not justified in connection with their low concentration in the urinary tract and bacteriostatic effect. An insufficient concentration of the drug in the renal parenchyma is observed when using nitrofurantoin, nalidixic acid, pipemidic acid, nitroxoline, which limits their purpose during the period of active manifestations a. Penicillins of the 1st and 2nd generations, cephalosporins of the 1st generation should not be prescribed in connection with their low activity against gram-negative flora.
In cases where it is caused by specific pathogens, for example, Corynebacterium Urealiticum (pyelonephritis with a sharply alkaline reaction of urine, red blood cells, struvite crystals and inlay of the pyelocaliceal system) or tubercle bacillus (abacterial leukocyturia), the use of appropriate drugs (vancomycin, anti-TB drugs) is required. Given the duration of antibiotic therapy, it is advisable to use probiotics (linex, bactisubtil, yogurt, hilak, bifiform) and, according to indications, prebiotics (fructose, lactulose).
After completing the main course of antibiotic therapy, girls are prescribed 1 / 3-1 / 4 doses of uroantiseptic once a night for one month. In case of relapse a, secondary process, this prophylactic dose can be used for a long time, up to 2 years, with a change of the drug every 3-6 months. It should be remembered that after acute acute, the barrier properties of kidney tissue are restored within a year, which makes it vulnerable to contaminating bacteria. For prophylactic purposes, co-trimoxazole (trimethoprim + sulfamethaxazole), furazidine, nitrofurantoin, nitroxoline, amoxicycline are prescribed. If there is an intimate relationship for adolescents, it is advisable to recommend the use of a single dose of uroantiseptic after intercourse. In secondary e, prophylactic treatment can be carried out with two antimicrobials (antibiotic + uroantiseptic) for 10-12 days a month in combination with physiotherapeutic methods (electrophoresis with 0.33% aspirin, paraffin applications on the bladder or amplipulse). The schedule for the appointment of a daily preventive dose should be agreed with the urologist.
Prophylactic treatment with short (10-12-day) courses can be recommended when prescribing physiotherapeutic procedures. This is due to the fact that physiotherapy can provoke an exacerbation of latent processes. It should be emphasized that preventive therapy is effective in preventing reinfection rather than relapse a. That is, the manifestation of the disease against the background of preventive therapy, for example, when conducting electrical procedures on the bladder, indicates the preservation of asymptomatic bacteriuria and the inefficiency of the main course of antimicrobial therapy. The unresolved question is about the treatment of foci of bacterial excretion, which are distinguished from the surrounding tissues. Despite the high doses of antibacterial drugs, it is not possible to achieve a therapeutic concentration of the drug in the focus of infection. One of the promising methods is the use of auto vaccines. It is also possible to use official vaccines (Uro-Vaxom, ribomunyl, bronchomunal). Our experience shows that the use of an auto vaccine in two courses of 10 days allows to increase the effectiveness of therapy in more than half of patients. A slightly lower efficiency was observed when using the official vaccine against Escherichia coli (Uro-Vaxom), which was administered once a day for three months, and then 10 days a month for three months. In general, the eradication of the pathogen when using vaccines reaches 75-85%. Symptomatic agents, membrane stabilizing and vitamin preparations can to some extent provide a more comfortable state for the affected organ. However, all these drugs are not leading in the treatment of a, and a lasting effect can be expected only with adequately selected antibacterial treatment. Therefore, all other measures that are usually mentioned in complex treatment and do not have a significant impact on the effectiveness of therapy are not considered in this article.
Depending on the achieved treatment results, three groups of patients can be conditionally distinguished. The first includes patients with a persistent therapeutic effect (absence of complaints and relapses of the microbial process for 3 years, which is regarded as recovery). In the second group of patients, partial remission is achieved, which requires active management and observation of the patient. The third group consists of patients in whom, despite treatment, the disease progresses and loss of kidney function develops with the formation of chronic renal failure. In conclusion, it can be noted that the problem of infections of the urinary system in children goes beyond the urological and is wide pediatric due to the prevalence of the disease in the pediatric population. In addition, in the presence of predisposing factors, the kidneys often turn out to be the target organ for infection against the background of more frequent hypoimmune conditions.
- a group of microbial inflammatory diseases of the urinary system: kidneys, ureters, bladder, urethra. Depending on the location of the inflammation, a urinary tract infection in children can manifest itself as dysuric disorders, pain in the bladder or lower back, leukocyturia and bacteriuria, and a temperature reaction. Examination of children with a suspected urinary tract infection includes urine tests (general, bacterial culture), ultrasound of the urinary system, cystoureterography, excretory urography, cystoscopy. The basis for the treatment of urinary tract infections in children is the appointment of antimicrobials, uroantiseptics.
General information
Urinary tract infection in children is a general term for inflammatory processes in various parts of the urinary tract: infections of the upper urinary tract (pyelitis, pyelonephritis, ureteritis) and lower urinary tract (cystitis, urethritis). Urinary tract infections are extremely common in childhood - by 5 years, 1-2% of boys and 8% of girls have at least one episode of the disease. The prevalence of urinary tract infections depends on age and gender: for example, among newborns and infants, boys are more likely to get sick, and girls aged 2 to 15 years. Most often in the practice of pediatric urology and pediatrics, one has to deal with cystitis, pyelonephritis and asymptomatic bacteriuria.
Causes of urinary tract infection in children
The spectrum of microbial flora that causes urinary tract infections in children depends on the gender and age of the child, the conditions of infection, the state of intestinal microbiocenosis and general immunity. In general, enterobacteria are the leaders among bacterial pathogens, primarily E. coli (50-90%). In other cases, Klebsiella, Proteus, enterococci, Pseudomonas aeruginosa, Staphylococci, Streptococci, etc. are sown. Acute urinary tract infections in children are usually caused by one type of microorganism, however, with frequent relapses and malformations of the urinary system, microbial associations are often detected.
Urinary tract infections in children can be associated with urogenital chlamydia, mycoplasmosis and ureaplasmosis and combined with vulvitis, vulvovaginitis, balanoposthitis. Fungal infections of the urinary tract often occur in weakened children: premature, suffering from malnutrition, immunodeficiency, anemia. There is an assumption that a viral infection (infection with Coxsackie viruses, influenza, adenoviruses, herpes simplex virus type I and II, cytomegalovirus) acts as a factor contributing to the layering of a bacterial infection.
The development of a urinary tract infection in children is predisposed by conditions accompanied by a violation of urodynamics: neurogenic bladder, urolithiasis, bladder diverticula, vesicoureteral reflux, pyeloectasia, hydronephrosis, polycystic kidney disease, kidney dystopia, ureterocele, urechosis, phychosis girls. Often, urinary tract infections in children develop against a background of gastrointestinal diseases - dysbiosis, constipation, colitis, intestinal infections, etc. Exchange risk (dysmetabolic nephropathy in children, glucosuria, etc.) can be a risk factor.
The introduction of infection into the urinary tract can occur with insufficient hygiene of the external genitalia, improper washing technique for the child, lymphogenous and hematogenous routes, during medical procedures (catheterization of the bladder). Boys who have passed through circumcisio suffer from urinary tract infections 4-10 times less often than uncircumcised.
Classification
According to the localization of the inflammatory process, infections of the upper urinary tract - the kidneys (pyelonephritis, pyelitis), the ureters (ureteritis) and the lower parts - the bladder (cystitis) and the urethra (urethritis) are distinguished.
According to the period of the disease, urinary tract infections in children are divided into the first episode (debut) and relapse. The course of a recurring urinary tract infection in children can be supported by an unresolved infection, persistence of the pathogen, or reinfection.
The severity of clinical symptoms distinguish between mild and severe urinary tract infections in children. With a mild course, the temperature reaction is moderate, dehydration is negligible, the child follows the treatment regimen. The severe course of a urinary tract infection in children is accompanied by high fever, persistent vomiting, severe dehydration, and sepsis.
Symptoms in children
The clinical manifestations of a urinary tract infection in a child depend on the localization of the microbial inflammatory process, the period and severity of the disease. Consider the signs of the most common urinary tract infections in children - pyelonephritis, cystitis, and asymptomatic bacteriuria.
Pyelonephritis in children occurs with febrile temperature (38-38.5 ° C), chills, symptoms of intoxication (lethargy, pallor of the skin, decreased appetite, headache). At the height of intoxication, frequent regurgitation, vomiting, diarrhea, neurotoxicosis, meningeal symptoms may develop. The child is concerned about pain in the lumbar region or abdomen; the striking symptom is positive. At an early age, infections of the upper urinary tract in children can hide under the mask of pylorospasm, dyspeptic disorders, acute abdomen, intestinal syndrome, etc .; in older children - flu-like syndrome.
Treatment of urinary tract infections in children
The main place in the treatment of urinary tract infections in children belongs to antibiotic therapy. Prior to establishing a bacteriological diagnosis, starting antibiotic therapy is prescribed on an empirical basis. Currently, in the treatment of urinary tract infections in children, preference is given to inhibitor-protected penicillins (amoxicillin), aminoglycosides (amikacin), cephalosporins (cefotaxime, ceftriaxone), carbapenems (meropenem, imipenem), uroantrofurantinptine (nitro-antifurantin). The duration of antimicrobial therapy should be 7-14 days. After completion of the course of treatment, a second laboratory examination of the child is carried out.
Vaccination of children is carried out during periods of clinical and laboratory remission.
Primary prevention of urinary tract infections in children should include inculcation of proper hygiene skills, rehabilitation of chronic foci of infection, and elimination of risk factors.
One of the most common diseases of the girls' reproductive system is inflammatory genital diseases, which make up more than 50% of all visits to the gynecologist by parents and teenage girls. Inflammatory diseases of the genitals in girls include: vulvitis, vulvovaginitis, salpingitis and salpingo-oophoritis.
In the structure of gynecological diseases of girls under 8 years old, vulvitis and vulvovaginitis account for 60-70%, which is associated with some physiological characteristics of the child's body. From the first days after birth, the girl’s vagina is populated by opportunistic microorganisms. They play a significant role in protecting the health of the vulva and vagina.
A decrease in the reactivity of the child’s body, which most often occurs after a disease or in a chronic inflammatory process, leads to an imbalance between the child’s body and the vaginal microflora. Therefore, it is not surprising that the appearance of vaginal discharge in a child is usually preceded by a disease, most often a cold.
Signs of the inflammatory process of the vulva and vagina are the appearance of redness of the mucous membranes and skin of the external genital organs and vaginal discharge. Girls may be concerned about itching or burning in the external genital area.
The data of the anamnesis and gynecological examination do not always allow to clarify the cause of vulvovaginitis. For this purpose, additional research methods are used: microscopy of vaginal smears, microbiological examination and many others.
The degree of damage to the vagina is determined using vaginoscopy or examination of the vagina in children's vaginal mirrors with lighting. In patients, hyperemia (redness) of the walls of the vagina, cheesy plaque, discharge is detected.
Vaginoscopy allows you to see a foreign body, take material for microscopic and other types of research from the posterior fornix of the vagina or from the cervical canal.
In the vaginal smears of healthy girls 5-8 years old, a small number of leukocytes (up to 5 in the field of view) and epithelial cells (1-3 in the field of view) are found, the flora is scarce, often coccal. The vaginal microflora of girls of preschool age does not contain lactobacilli, they appear with the onset of puberty.
In menstruating girls, the vaginal microflora becomes more abundant, and coincides with the microflora of women of reproductive age.
It should be emphasized that children are not always associated with inflammatory processes of the vulva and vagina. Quite often, vulvitis is observed - a defeat by the microorganisms entering the vagina.
Vulvitis is more often observed in girls with a pathology of the urinary system, ingestion of an infected beginning from the intestines, infection from outside, if the rules of the medical-hygienic regimen are not followed.
Provoking factors of vulvitis and vulvovaginitis in children:
- non-compliance with sanitary standards (34%),
- urinary tract infection (20%),
- introduction of intestinal flora (16%),
- helminthic invasion (12%),
- infection from outside, including a foreign body (10%),
- allergy (8%).
In recent years, the role of sexually transmitted infections (STIs) in girls has increased in the genesis of vulvovaginitis - chlamydia, myco- and ureaplasmas, trichomonas, genital herpes, gonorrhea, etc.
Specific vulvovaginitis requires complex treatment using immunobiological preparations and physiotherapy, using means aimed at eliminating intestinal and vaginal dysbacterioses with the mandatory use of etiotropic therapy (long-term treatment with several antibiotics to which a specific pathogen is sensitive).
Salpingitis and salpingo-oophoritis in girls and girls
In girls who do not live sexually, in the pre-pubertal period, inflammation of the uterine appendages is a casuistic phenomenon. In most cases, inflammation of the appendages is secondary, i.e. the infection is transmitted by hematogenous or lymphogenous route from the organ affected by the inflammatory process to the fallopian tubes and ovaries.
What are the causes of genital tract infections in children? How are sexually transmitted infections in children? How to treat such diseases? You will find answers to questions in this article.
The child’s body has not yet managed to get stronger, so the immunity in children is much weaker than in adults. And for this reason, babies are quite often exposed to various infections. There are many varieties of them, but in this article we will talk about genital infections, namely, how they arise, proceed and what are the features of their treatment.
So, it is generally accepted that sexually transmitted infections are sexually transmitted, but in the case of babies, this route is almost impossible. So how then do infections get into the body? This happens most often due to errors in care and personal hygiene. Such errors occur due to ignorance or irresponsibility and carelessness of parents. In addition, often the subject of infection is various hygiene items that the patient first used, and then the child.
Very often, a genital tract infection in children gets even from the body of the child, namely, from the intestines. This happens when, for example, the girl’s mother does not follow the rules of personal hygiene. Thus, bacteria are transferred from the anus into the vagina and spread in the reproductive system. To avoid sexually transmitted infections, you must follow all the rules for caring for the child and regularly carry out all necessary procedures.
Now about how sexual infections in children manifest. This depends, firstly, on the sex of the child, and secondly, on the location of bacteria that have fallen into the reproductive system.
For example, in boys, the foreskin of the penis often suffers, since very often the mothers of the boys do not pay due attention to care or do not know how to do it. The reproductive system of girls is more complicated.
Most often, infections of the external genital organs, namely, the vagina, are found. This also happens more often due to improper hygiene. As for treatment, most often it involves taking antibiotics.
But the best treatment is prevention, which in this case comes down to observing the rules of personal hygiene of the child. Such features have sexually transmitted infections in children.
