Urinary tract infections - symptoms and signs, treatment
Symptoms and signs, treatment of infections of the urinary system.
Infections of the urinary system
Infections of the urinary system are defined as the presence of more than 5 × 104colonies / ml when taking a urine with a catheter or at the end of the adolescent period, with repeated urine culture, urine released during urination more than 105colonies / ml. In young children, IC often develops against the background of developmental abnormalities. IMS can be manifested by febrile fever, a violation of weight gain, side pain and lumbar region, as well as symptoms of sepsis, especially in young children. Treatment is carried out with antibiotics. In the future, conduct ultrasound and x-ray examination.
Mechanisms that support sterility of the urinary tract include acidic and free flow of urine, normal emptying of the bladder, intact ureterovesical and urethral sphincters, and immunological and mucous barriers.Violation of any of these mechanisms predisposes to the development of IC.
Urinary tract infections - etiology and pathophysiology
In 1–2% of newborns, IC is developed, and the ratio of girls to the boy’s urinary system, the most common pathogens are Escherichia coli strains with particular adhesion factors to the transitional epithelium of the bladder and ureters. E. coli causes more than 75% of all IC in children of any age group. The remaining cases are caused by other gram-negative enterobacteria, especially Klebsiella, Proteus mirabilis, Pseudomonas aeruginosa. Enterococci and coagulase-negative staphylococci are the most common gram-positive microorganisms. Fungal and mycobacterial etiology are very rare, mainly in the case of an immune deficiency condition. Adenoviruses rarely cause ICI, primarily causing hemorrhagic cystitis.
Infections of the urinary system - symptoms and signs
In newborns, symptoms and signs are nonspecific and include refusal to eat, diarrhea, impaired weight gain, vomiting, mild jaundice, drowsiness, fever. Neonatal sepsis may develop.
In children of the first years of life, there may also be not very localized local symptoms, such as fever, symptoms of the gastrointestinal tract, or urine with an unpleasant odor.
In children older than 2 years, a more classical picture of cystitis or pyelonephritis can already develop. Symptoms of cystitis include dysuric phenomena, hematuria, urinary retention, pain in the suprapubic area, frequent, painful urination, urinary incontinence, unpleasant smell of urine and enuresis. Symptoms of pyelonephritis include high fever, chills, pain in the lumbar region.
Urine Tests for Urinary Infection
For diagnosis, it is necessary to detect a high titer of bacteriurii, while observing the rules for collecting urine. The majority of doctors in children in the first years of life take urine for sowing with a transurethral catheter, leaving urine in reserve using the suprapubic bladder puncture, which can be used in boys with moderate or severe phimosis. Both procedures require appropriate technical skills, however, catheterization is less invasive and somewhat safer, for example, its safety is 95% and specificity is 99% compared to suprapubic puncture.Urine samples collected in the urinal do not give reliable results and should not be used for diagnosis.
If urine is obtained by suprapubic puncture, the presence of any number of microorganisms is diagnostically significant. When taking a urine catheter, the presence of 5 × 10 is diagnostically significant.4colonies / ml. You can also sow a medium portion of urine when urinating collected in a sterile tube, while bacteriuria is diagnostically significant in the presence of more than 105colonies / ml of microorganisms of the same species. Urine is examined and sown on the medium as soon as possible after taking or placed in a refrigerator and stored at 4 ° C, if you intend to postpone the study. Sometimes, with IMS, there may be a lower incidence of gnostic infection in children with borderline urinalysis results than those cited. Some specialists determine urea nitrogen and creatinine in the blood during the first episode of IC. Blood cultures are shown to children of the first year of life with IC, as well as children older than 1-2 years with signs of intoxication.
Instrumental examination methods for urinary tract infection
Many malformations of the kidneys and urinary tract today are diagnosed in utero with routine prenatal ultrasound. At the same time, the high incidence of congenital malformations still justifies the need for instrumental examination methods in all children aged 2 months to 2 years after the first episode of IC. If the 1st episode of IC is developing after 2 years of age, most experts recommend a survey; however, some doctors postpone taking pictures until the 2nd episode of the IC in girls older than 2 years. Methods include mictorial cystography, radionuclide cystography using technetium-99tpertechnetate and ultrasound.
It is better to use MC and RNC, rather than ultrasound, to detect MTCT and developmental abnormalities. At the RSC, the radiation load on the gonads is approximately 1% of that at MC; this method is sensitive in the detection of MTCT, and some recommend it as a test, which should be done first. At the same time, most specialists prefer to carry out MC first because of the better visualization of anatomical features, and the RSC is used in dynamic control to determine if reflux has disappeared or not. Modern radiology equipment has reduced the difference in the radiation load between the MC and RNC.These examinations are recommended as early as possible after clinical improvement, as a rule, at the end of therapy, when urinary bladder reactivity decreases and urine sterility is restored.
This may be due to prior antibacterial therapy, diluted urine, or obstruction of urine outflow with severe inflammatory events. Sterile cultures usually exclude the diagnosis of IC, unless the child receives antibiotics or an antiseptic is used in the urine to treat the hands.
Microscopic examination of urine is useful, but not determinative. The sensitivity of pyuria is approximately 70%. Leukocyturia sensitivity over 10 / µl in non-centrifuged urine is 90%, but this method is not used by many laboratories. The sensitivity of the presence of bacteria in the urine for Gram staining of centrifuged or non-centrifuged urine is about 80%. Specificity of microscopy is also approximately 80%.
Dipstick tests of urine are usually performed to detect bacteriurii or leukocytes; if any of these are positive, the diagnostic sensitivity for IC is about 93%.The specificity of the nitrite test is relatively high; The prognostic value of a positive result in the study of fresh urine is very high. The specificity of leukocyte esterase is much lower.
Difficulties may arise during the differential diagnosis between pyelonephritis and urinary tract infection. High fever, tenderness in the lumbar region and massive pyuria with cylindruria indicate pyelonephritis. However, many children have pyelonephritis without these symptoms. Examination to establish the exact localization of the process is not shown in most cases, since this does not change the treatment.
Blood test for urinary tract infection
Complete blood count and acute-phase indices can help diaaprytic antibacterial drugs in prophylactic doses before exclusion of MTCT.
Ultrasound helps to eliminate obstruction and hydronephrosis and is usually performed within a week after making a diagnosis of IC in infants, especially if they do not respond very quickly to antibiotic therapy. Otherwise, ultrasound can be postponed until the MC.
Infections of the urinary system - prognosis
Children receiving adequate treatment rarely develop renal failure unless they have uncorrected urinary system abnormalities. However, the recurrence of infection, especially against the background of VUR, can cause the formation of Cicatricial changes of the kidneys, which can lead to the appearance of hypertension and terminal CRF. With high degrees of MTCT, there is a 4-6 times higher rate of development of Cicatricial changes of the kidneys with long-term observation than with MUR of low degrees, and 8-10 times higher frequency than with children without CID. Extreme cicatricial changes in MTCT lead to the development of terminal CRF in 3–10% of patients, although this data is rather somewhat biased, since other kidney abnormalities may also occur in children with MTCT.
Urinary tract infections - treatment
The treatment is aimed at stopping the acute inflammatory process, preventing urosepsis and preserving renal functions. Antibacterial therapy is begun empirically for all children with symptoms of intoxication, as well as for children without intoxication with probable IC. In other cases, you can wait for the results of urine culture.
Children from 2 months to 2 years with intoxication, dehydration, or inability to take antibiotics are prescribed parenteral antibiotics, usually 3rd generation cephalosporins.Cephalosporins of the 1st generation can be used if it is known that local typical pathogens are sensitive to them. Amy-slickosides, despite being potentially nephrotoxic, are effective in treating IMS caused by potentially resistant gram-negative bacteria, such as Pseudomonas, against urinary system abnormalities, with a permanent catheter, recurrent IC. If blood cultures are negative and a good clinical result is obtained, you can switch to taking the appropriate oral antibiotic [cephalosporin, trimethoprim-sulfamethoxazole, amoxicillin], selected based on the sensitivity of the pathogen to antibiotics, until the end of the 10-14 day treatment regimen. A bad clinic response may indicate resistance of the pathogen or the presence of obstructive uropathy and the need for an emergency ultrasound examination and re-sowing of urine.
In the absence of intoxication, dehydration in infants and children who can metabolize orally, you can take antibiotics inside from the very beginning. The drug of choice is TMP-SMK, 3-6 mg / kg 2 times a day.Alternative drugs are cephalosporins, such as cedinir, 7 mg / kg, 2 times a day, cefprozil, 15 mg / kg, 2 times a day, cefixime, 4 mg / kg, 2 times a day, and cephalexin, 12.5-25 mg / kg 4 times a day. Therapy is corrected on the basis of the results of planting and the sensitivity of the pathogen to antibiotics. Treatment usually lasts more than 10 days, although many older children with uncomplicated IC can be treated for 7 days. Urine cultures are repeated 2-3 days after the start of therapy, if its clinical effectiveness is not obvious.
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