Antibiotics in the treatment and prevention of urinary tract infections in children

Antibiotics and children

Parents need to know that giving antibiotics to children without a doctor's prescription is dangerous. The doctor finds out whether certain antibiotics are suitable for the child, and only then prescribes them.

These questions and their answers will help you understand such a difficult topic as antibiotics:

1. My child has a serious cold. Why doesn't the doctor prescribe antibiotics?

Acute respiratory infections occur due to viruses. And antibiotics are used to treat infections caused by bacteria. Most cold symptoms are not dangerous and your child will get better without medication.

2. Doesn’t a cold often turn into a bacterial infection? Why wait for this when you can take antibiotics right away?

In most cases, bacterial infections do not follow viral ones. If you treat viruses with antibiotics, you can get bacteria that are resistant to antibiotics. In addition, your child may have diarrhea and other side effects from antibiotics.

3. If yellow or green mucus comes from your nose, is this a sign of a bacterial infection?

A change in the color of nasal discharge is characteristic of the natural course of viral infections. A runny nose can last up to 10-14 days.

Inflammation of the paranasal sinuses (sinusitis) is most often caused by a virus. In some cases, bacteria may be the cause.

If sinusitis is caused by bacteria, this is indicated by the following signs:

- cough and yellow or green nasal discharge lasting more than 10-14 days

- high body temperature, poor health, pain in the projection of the paranasal sinuses lasts 3-4 days

Bacterial sinusitis may require antibiotics. Before prescribing antibiotics, the doctor will definitely examine the child to make sure they are necessary.

4. Are antibiotics prescribed to treat ear infections?

Antibiotics are prescribed for ear infections, but not always. In most cases, ear infections clear up without the use of antibiotics.

If a child (over 2 years old) does not have a high fever, it is worth waiting and observing the development of the disease. You can give your child over-the-counter pain relievers for ear pain. The doctor prescribes antibiotics if the temperature does not decrease and the pain lasts more than 48 hours.

5. Do I need to take antibiotics for a sore throat?

No. In more than 80% of cases, sore throat is caused by viruses, and as we remember, viruses are not treated with antibiotics.

Antibiotics should only be used to treat sore throat caused by group A streptococci.

If the doctor suspects that the child has a streptococcal infection, he or she recommends a strep test. If the result is positive, antibiotics are prescribed.

6. Do antibiotics have side effects?

Side effects after taking antibiotics occur in 1 in 10 children. This may include a rash, nausea, diarrhea, or abdominal pain.

Be sure to tell your pediatrician if your child has a reaction to antibiotics.

7. How long does it take for antibiotics to work?

Most symptoms of bacterial infections begin to subside within 48 to 72 hours after taking antibiotics. If there is no improvement during this time, you should consult a doctor.

It is also important to complete the course of antibiotic treatment to the end. Otherwise, the infection may not heal completely and symptoms may return.

8. Can antibiotic resistance develop?

Improper use of antibiotics can lead to the development of resistant bacteria. These are bacteria that are no longer killed by antibiotics.

Therefore, it is important to take antibiotics that are most specific for the infection, rather than a broad spectrum one.

9. What are antiviral drugs?

Antiviral medications can speed up recovery from the flu (there are also antiviral medications to treat the herpes virus, hepatitis C, and HIV). For other viral infections, antiviral drugs are not effective.

Safe use of antibiotics.

Remember the following if your child is sick:

— Antibiotics are not always the best treatment if a child is sick. The pediatrician will tell you which treatment is best.

— Antibiotics are used to treat bacterial infections. They do not work against influenza and other viral infections.

— Ask your doctor about the best antibiotics to treat your child's bacterial infection.

- Make sure you give the medicine as directed.

— The same antibiotics may not be suitable for two different children, and that is, cause harm.

— Throw away unused antibiotics. Expired medications can be harmful.

Taking antibiotics in early childhood increased the risk of long-term health problems

“Welcome, or No Trespassing” / Mosfilm, 1964

Children who received at least one course of antibiotic therapy during the first two years of life have an increased risk of developing asthma, allergic rhinitis, atopic dermatitis, celiac disease, obesity, and attention deficit hyperactivity disorder. As reported in the journal Mayo Clinic Proceedings

, these associations were influenced by the amount, type, and timing of antibiotic therapy. In addition, when multiple drugs were prescribed, the likelihood of combinations of these conditions increased.

Since the bacterial communities that colonize the human body play a significant role in the development of immunity, metabolism and behavior, disturbances in their formation (including those caused by antibiotics) can lead to various diseases. Due to the increasing prevalence of childhood-onset diseases such as asthma, food allergies, obesity, and attention deficit hyperactivity disorder (ADHD), scientists have already hypothesized that antibiotic exposure to children's microbiome may be a risk factor for the development of these conditions. However, most studies examining the relationship between early life antibiotic exposure and later health outcomes have focused on a single disease.

Zaira Aversa and colleagues at the Mayo Clinic conducted a retrospective review of the medical records of nearly every person living in Olmsted County, Minnesota, over more than 50 years, and also analyzed available data on diagnoses, surgeries, and prescriptions to to evaluate whether exposure to antibiotics in the first two years of life is associated with the incidence of various immunological, metabolic and neurobiological diseases in children.

The sample included all children born in Olmsted County between January 1, 2003 and December 31, 2011. The exceptions were children whom doctors observed for less than two years, children with congenital pathologies, children from multiple pregnancies, as well as those whose parents did not give permission for the study. In total, the researchers analyzed data from 14,572 children (7,026 girls and 7,546 boys) who were followed for an average of 8.8 years. 3,374 children (23 percent) were born by caesarean section.

About 70 percent of children (10,220 children) were prescribed at least one antibiotic by age two, although most received multiple antibiotics. Most often, children received penicillins, cephalosporins and macrolides (including lincomycin). Nitrofurantoin, quinolones, and other antibiotics (aminoglycosides, antituberculosis drugs, and chloramphenicol) together accounted for less than one percent of prescriptions. Most antibiotics (99 percent) were prescribed orally.

In separate analyses, both girls and boys who were prescribed at least one course of antibiotics had higher cumulative rates of asthma, allergic rhinitis, overweight, and ADHD. Girls exposed to antibiotics were more susceptible to atopic dermatitis and celiac disease, and boys were more likely to be obese.

Then the scientists studied the dependence of the risk of developing pathological conditions on the number of antibiotics prescribed in the first two years of life. Among children who received one or two courses of antibiotic therapy, girls had a significantly higher risk of developing asthma (p < 0.001) and celiac disease (p < 0.047) than those who did not receive them. Taking 3-4 courses was associated with a higher incidence of asthma, atopic dermatitis and overweight in both sexes (all p < 0.05 or less).

Both girls and boys who received 5 or more courses of antibiotic therapy had a significantly higher risk of developing asthma, allergic rhinitis, overweight, obesity, and ADHD (all p < 0.025 or less), and girls also had a higher risk of developing celiac disease ( p < 0.017).

At the same time, exposure to cephalosporins was associated with an increased risk of developing the largest number of diseases and, most importantly, autism (p < 0.032) and food allergies (p < 0.001). Penicillins increased the risk of asthma (p < 0.001) and overweight in both sexes (p < 0.021 for girls and p < 0.007 for boys), celiac disease (p < 0.011) and ADHD (p < 0.003) in girls, and obesity (p < 0.007 for boys). 0.007) in boys. However, they were also associated with a reduced risk of developing autism in girls (p < 0.038).

Sulfonamides increased the risk of overweight in boys (p < 0.033), and macrolides increased the risk of asthma (p < 0.006 for girls and p < 0.001 for boys) and overweight (p < 0.002 for girls and p < 0.027 for boys) in both gender, allergic rhinitis (p < 0.001) and obesity (p < 0.022) in boys, but reduced the risk of developing atopic dermatitis in girls (p < 0.021) and learning disability in boys (p < 0.028).

Antibiotics prescribed before 6 months of age were significantly associated with the risk of developing atopic dermatitis, overweight, and ADHD in both sexes. Girls had an increased risk of developing asthma, allergic rhinitis and obesity; and in boys, the risk of food allergies. Antibiotics prescribed between six months and one year of life greatly increased the risk of developing asthma, allergic rhinitis, overweight and obesity in both sexes. Antibiotics given between one and two years of age increased the chances of developing asthma and becoming overweight in both sexes, increasing the risk of ADHD in girls and allergic rhinitis in boys.

To avoid confusion in risk estimates, scientists also examined infant and maternal risk factors for these diseases. Thus, boys had a significantly higher risk of developing asthma, allergic rhinitis, food allergies, overweight, obesity, ADHD, autism and learning disabilities than girls. Birth by cesarean section increased the risk of allergic rhinitis, atopic dermatitis, overweight, obesity and ADHD. Higher birth weight was associated with overweight, obesity and celiac disease, but there was a lower risk of asthma and learning disabilities.

In addition, taking antibiotics during pregnancy increased the risk of asthma, allergic rhinitis, overweight, obesity, ADHD and learning disabilities in children. Smoking during pregnancy increased the risk of asthma, overweight, obesity, ADHD and learning disabilities.

Given such a strong influence of infant and maternal factors on the development of diseases, scientists conducted a multivariate analysis to better characterize the risks associated specifically with taking antibiotics. After adjustment for all infant and maternal risk factors, the effect of early antibiotic treatment on the development of asthma, allergic rhinitis, atopic dermatitis, celiac disease, overweight, obesity, ADHD and learning disability remained significant.

Cumulative probability of developing one, two, three, or more health conditions in antibiotic-exposed and unexposed children, stratified by number of prescriptions

Zaira Aversa et al. / Mayo Clinic Proceedings, 2020

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In addition, children exposed to antibiotics had a higher likelihood of developing more than one pathology, and, in general, they had two or more diagnoses on their charts. The most common pairings were obesity with asthma, ADHD and learning disability, and asthma with allergic rhinitis. However, similar combinations were also observed in children who did not take antibiotics. Combinations of asthma, obesity and atopic dermatitis or ADHD have been observed more frequently in children exposed to antibiotics in early childhood.

Although these results reflect associations rather than causation, they generate testable hypotheses about the effects of antibiotic class and dose on early childhood health. Despite the diversity of antibiotic prescribing patterns in childhood, further research is needed to develop clinical guidelines to optimize the benefits and minimize the risks of antibiotic use in children.

Despite the incomparable benefits of antibiotics, their irrational use leads to problems both for a specific person and for all of humanity. Many descendants of penicillin can no longer cope with multi-resistant bacteria, but scientists are trying to invent new classes of these chemotherapy drugs that could kill “unkillable bacteria.” We have already told you that scientists have discovered an antibacterial substance that does not cause resistance in bacteria and even treats gonorrhea in mice.

Vyacheslav Gomenyuk

Antibiotics for children

Antibiotics are medicines used to treat infections in children caused by bacteria, such as sore throat, otitis media, pneumonia (pneumonia). Widespread and not always justified prescription of antibiotics to children can lead to the development of side effects such as allergies and dysbacteriosis.

But the biggest problem with misuse of antimicrobials is resistance (antibiotic resistance), when bacteria change so much that the antibiotics needed to fight the infection no longer have any effect on the child's body. Therefore, serious reasons are required for prescribing antibiotics to children.

What Antibiotics DO NOT Do

• Does not affect viruses. Antibiotics kill bacteria or stop their growth, but have no effect on viruses, so they are not used for ARVI, influenza, or bronchitis.
• Does not reduce body temperature. Antibiotics are neither antipyretics nor pain relievers. They fight bacteria that cause inflammation, and not an increase in temperature. The duration of fever is not a determining indication for prescribing an antibiotic;
• Not used for acute intestinal infections - acute intestinal infections with watery diarrhea, regardless of the child’s age (WHO recommendations);
• They do not prevent the development of bacterial complications , therefore they should not be used for ARVI, colds and coughs as a prophylaxis, since their use does not prevent the penetration of microorganisms (bacteria) into the body, an antibiotic is a medicinal drug and has nothing other than a therapeutic (medicinal) effect. The task of the child’s parents is to detect in time a possible deterioration in the child’s well-being and inform the doctor.

Finnish scientists from the Helsinki Institute argue that treating children at an early age with antibiotics increases the risk of demineralization of molars (leaching of mineral substances from the tooth enamel). Scientists came to these conclusions from observations of children under one year of age who took antibiotics from the penicillin and macrolide group, and children under three years of age who took antibiotics from the amoxicillin group. It is these children, unlike children who have not been treated with antibiotics, who have an increased risk of developing defects in tooth enamel.

Antibiotics for children with cough

There are many causes of cough : viral infections, allergies (cough occurs when the upper respiratory tract is exposed to allergens), bronchial asthma, cough due to nasal congestion when mucus flows into the respiratory tract and many others. But only some types of cough are associated with a bacterial infection and require pediatricians to prescribe an antibiotic, such as whooping cough.

The use of antibiotics for cough is justified and necessary only if the form of microflora that has affected the respiratory tract and caused the cough is precisely known (after receiving tests, for example, a swab from the throat or nose to identify the pathogen with culture for susceptibility to antibiotics).

Therefore, prescribing antibiotics for the treatment of cough is allowed only after additional examinations or empirically immediately after examining the child by a doctor.

Antibiotics for ARVI

As a general rule, antibiotics are not prescribed or used for ARVI . Antibiotics for ARVI in children can only be used if there are signs of a bacterial infection. If it is impossible to conduct an examination (blood, urine, smear), there are certain criteria to determine this condition:

• at the age of up to 3 months of the baby’s life, a high temperature (above 38) persists for 3 days;
• if after improvement on days 5-6 there is a deterioration in health - the temperature rises again to 38-39 ° C, the cough intensifies;
• submandibular lymph nodes enlarge;
• cough persists for more than 10-14 days (whooping cough);
• discharge from the nasal passages becomes purulent;
• A white or purulent coating appears on the tonsils (tonsillitis, scarlet fever, diphtheria, infectious mononucleosis).

As a rule, with a viral infection, body temperature returns to normal by 3 days from the onset of symptoms. The cough is sporadic, there is no wheezing in the lungs or hard breathing. Discharge from the nasal passages is transparent and lacks white and green (purulent) inclusions.

Also, antimicrobial drugs can be prescribed by a pediatrician for acute respiratory viral infections and influenza to children with chronic lung pathology, immunodeficiencies, who are at risk of exacerbation of the bacterial process; their choice of antibiotic is usually predetermined in advance by the nature of the flora.

And it is important to remember that who is monitoring (pediatrician, ENT) can prescribe an antibacterial agent for a child with ARVI

To confirm their hypothesis, the Finns decided to conduct an examination of the oral cavity of schoolchildren in 2nd and 5th grades. Having compared the examination data with the data from the medical records of schoolchildren for the first three years, they were convinced that their hypothesis was confirmed: taking antibiotics does indeed increase the risk of enamel demineralization.

Antibiotics in the treatment and prevention of urinary tract infections in children

Urinary tract infection (UTI) is the growth of microorganisms in various parts of the kidneys and urinary tract (UT), which can cause an inflammatory process, localized corresponding to the disease (pyelonephritis, cystitis, urethritis, etc.).

UTI in children occurs in Russia with a frequency of about 1000 cases per 100,000 population. Quite often, UTIs tend to be chronic and recurrent. This is explained by the peculiarities of the structure, blood circulation, innervation of the MP and age-related dysfunction of the immune system of the growing child’s body. In this regard, it is customary to identify a number of factors contributing to the development of UTI:

• disturbance of urodynamics;
• neurogenic bladder dysfunction;
• severity of pathogenic properties of microorganisms (adhesion, release of urease);
• features of the patient’s immune response (decreased cell-mediated immunity, insufficient production of antibodies to the pathogen, production of autoantibodies);
• functional and organic disorders of the distal parts of the colon (constipation, imbalance of intestinal microflora).

In childhood, UTIs in 80% of cases develop against the background of congenital anomalies of the upper and lower bladders, in which there are urodynamic disturbances. In such cases, they speak of complicated UTI. In an uncomplicated form, anatomical disorders and urodynamic disorders are not determined.

Among the most common malformations of the urinary tract, vesicoureteral reflux occurs in 30–40% of cases. Second place goes to megaureter, neurogenic bladder dysfunction. With hydronephrosis, kidney infection occurs less frequently.

Diagnosis of UTI is based on many principles. It must be remembered that the symptoms of a UTI depend on the age of the child. For example, newborns do not have specific symptoms of UTI and the infection is rarely generalized.

Symptoms such as lethargy, restlessness, periodic rises in temperature, anorexia, vomiting and jaundice are typical for young children.

Older children are characterized by fever, back pain, abdominal pain and dysuria.

The list of questions when collecting anamnesis includes the following items:

• heredity;
• complaints when urinating (frequency, pain);
• previous episodes of infection;
• unexplained rises in temperature;
• presence of thirst;
• amount of urine excreted;
• in detail: straining during urination, diameter and intermittency of the stream, imperative urges, rhythm of urination, daytime urinary incontinence, nocturnal enuresis, frequency of bowel movements.

The doctor should always strive to more accurately determine the location of a possible source of infection: the type of treatment and prognosis of the disease depend on this. To clarify the topic of urinary tract damage, it is necessary to have a good knowledge of the clinical symptoms of lower and upper urinary tract infections. In case of upper urinary tract infection, pyelonephritis is significant, which accounts for up to 60% of all cases of hospitalization of children in the hospital (table).

However, the basis for diagnosing UTIs is the data of urine tests, in which microbiological methods are of primary importance. Isolation of the microorganism in urine culture serves as the basis for diagnosis. There are several ways to collect urine:

• intake from the middle portion of the stream;
• urine collection into a urinal (in 10% of healthy children up to 50,000 CFU/ml, at 100,000 CFU/ml the analysis should be repeated);
• catheterization through the urethra;
• suprapubic aspiration (not used in Russia).

A common indirect method for assessing bacteriuria is a nitrite test (nitrates normally found in urine are converted to nitrites in the presence of bacteria). The diagnostic value of this method reaches 99%, but in young children, due to the short stay of urine in the bladder, it is significantly reduced and reaches 30–50%. It must be remembered that in young boys a false positive result may occur due to the accumulation of nitrites in the preputial sac.

Most cases of UTI are caused by one type of microorganism. The detection of several types of bacteria in samples is most often explained by violations of the technique for collecting and transporting the material.

In chronic UTIs, in some cases it is possible to identify microbial associations.

Other methods for examining urine include collecting a general urine test, the Nechiporenko and Addis-Kakovsky tests. Leukocyturia is observed in all cases of UTI, but it must be remembered that it can also occur, for example, with vulvitis. Gross hematuria occurs in 20–25% of children with cystitis. If symptoms of infection are present, proteinuria confirms the diagnosis of pyelonephritis.

Instrumental examinations are carried out for children during the period of remission of the process. Their purpose is to clarify the location of the infection, the cause and extent of kidney damage. Examination of children with UTIs today includes:

• ultrasound scanning;
• voiding cystography;
• cystoscopy;
• excretory urography (obstruction in girls - 2%, in boys - 10%);
• radioisotope renography;
• nephroscintigraphy with DMSA (scar forms within 1–2 years);
• urodynamic studies.

Instrumental and x-ray examinations should be performed according to the following indications:

• pyelonephritis;
• bacteriuria under 1 year of age;
• increased blood pressure;
• palpable mass in the abdomen;
• spinal abnormalities;
• decreased urine concentrating function;
• asymptomatic bacteriuria;
• recurrence of cystitis in boys.

The bacterial etiology of UTI in urological diseases has distinctive features depending on the severity of the process, the frequency of complicated forms, the age of the patient and the state of his immune status, the conditions of the infection (outpatient or in hospital).

Research results (data from the Scientific Center for Disease Control of the Russian Academy of Medical Sciences, 2005) show that in outpatients with UTI, E. coli is isolated in 50% of cases, Proteus spp. in 10%, Klebsiella spp. in 13%, Enterobacter spp. in 3%, in 2% - Morganella morg. and with a frequency of 11% - Enterococcus fac. (drawing). Other microorganisms, accounting for 7% of the isolation and occurring at a frequency of less than 1%, were as follows: S. epidermidis - 0.8%, S. pneumoniae - 0.6%, Acinetobacter spp. — 0.6%, Citrobacter spp. - 0.3%, S. pyogenes - 0.3%, Serratia spp. - 0.3%.

In the structure of nosocomial infections, UTIs occupy second place, after respiratory tract infections. It should be noted that 5% of children in a urological hospital develop infectious complications caused by surgical or diagnostic intervention.

In hospitalized patients, the etiological significance of E. coli is significantly reduced (up to 29%) due to the increase and/or addition of such “problematic” pathogens as Pseudomonas aeruginosa (29%), Enterococcus faec. (4%), coagulase-negative staphylococci (2.6%), non-fermenting gram-negative bacteria (Acinetobacter spp. - 1.6%, Stenotrophomonas maltophilia - 1.2%), etc. The sensitivity of these pathogens to antibacterial drugs is often unpredictable, as it depends from a number of factors, including the characteristics of nosocomial strains circulating in a given hospital.

There is no doubt that the main objectives in the treatment of patients with UTIs are the elimination or reduction of the inflammatory process in the renal tissue and bladder, and the success of treatment is largely determined by rational antimicrobial therapy.

Naturally, when choosing a drug, the urologist is guided primarily by information about the causative agent of the infection and the spectrum of the antimicrobial action of the drug. An antibiotic may be safe, capable of creating high concentrations in the kidney parenchyma and urine, but if its spectrum does not have activity against a specific pathogen, prescribing such a drug is pointless.

A global problem in prescribing antibacterial drugs is the increasing resistance of microorganisms to them. Moreover, resistance most often develops in community-acquired and nosocomial patients. Those microorganisms that are not included in the antibacterial spectrum of any antibiotic are naturally considered resistant. Acquired resistance means that a microorganism that was initially sensitive to a particular antibiotic becomes resistant to its action.

In practice, people are often mistaken about acquired resistance, believing that its occurrence is inevitable. But science has facts that refute this opinion. The clinical significance of these facts is that antibiotics that do not cause resistance can be used without fear of its subsequent development. But if the development of resistance is potentially possible, then it appears quite quickly. Another misconception is that the development of resistance is associated with the use of antibiotics in large quantities. Examples from the world's most commonly prescribed antibiotic, ceftriaxone, as well as cefoxitin and cefuroxime, support the concept that the use of antibiotics with low resistance potential at any level will not lead to further increases in resistance.

Many people believe that the emergence of antibiotic resistance is typical for some classes of antibiotics (this opinion applies to third-generation cephalosporins), but not for others. However, the development of resistance is not related to the class of antibiotic, but to the specific drug.

If an antibiotic has the potential to develop resistance, signs of resistance to it appear within the first 2 years of use or even during clinical trials. Based on this, we can confidently predict problems of resistance: among aminoglycosides - gentamicin, among second generation cephalosporins - cefamandole, third generation - ceftazidime, among fluoroquinolones - trovofloxacin, among carbapenems - imipenem. The introduction of imipenem into practice was accompanied by the rapid development of resistance to it in P. aeruginosa strains; this process continues today (the appearance of meropenem was not associated with such a problem, and it can be argued that it will not arise in the near future). Among the glycopeptides is vancomycin.

As already indicated, 5% of hospitalized patients develop infectious complications. Hence the severity of the condition, and the increase in recovery time, hospital stay, and increase in the cost of treatment. In the structure of nosocomial infections, UTIs take first place, followed by surgical ones (wound infections of the skin and soft tissues, abdominal infections).

The difficulties of treating hospital-acquired infections are determined by the severity of the patient’s condition. Often there is an association of pathogens (two or more, with a wound or catheter-associated infection). Also of great importance is the increased resistance of microorganisms in recent years to traditional antibacterial drugs (penicillins, cephalosporins, aminoglycosides) used for infections of the genitourinary system.

To date, the sensitivity of hospital strains of Enterobacter spp. to Amoxiclav (amoxicillin + clavulanic acid) is 40%, to cefuroxime - 30%, to gentamicin - 50%, the sensitivity of S. aureus to oxacillin is 67%, to lincomycin - 56%, to ciprofloxacin - 50%, to gentamicin - 50 %. The sensitivity of P. aeruginosa strains to ceftazidime in different departments does not exceed 80%, and to gentamicin - 50%.

There are two potential approaches to overcome antibiotic resistance. The first is to prevent resistance, for example by limiting the use of antibiotics that have a high potential for developing resistance; Equally important are effective epidemiological control programs to prevent the spread of hospital-acquired infections caused by highly resistant microorganisms in a health care setting (inpatient monitoring). The second approach is to eliminate or correct existing problems. For example, if resistant strains of P. aeruginosa or Enterobacter spp. are common in the intensive care unit (or in the hospital in general), then completely replacing antibiotics with a high potential for resistance development in the formulary with “cleaner” antibiotics (amikacin instead of gentamicin, meropenem instead of imipenem and etc.) will eliminate or minimize antibiotic resistance of gram-negative aerobic microorganisms.

In the treatment of UTIs today the following are used: inhibitor-protected penicillins, cephalosporins, aminoglycosides, carbapenems, fluoroquinolones (limited in pediatrics), uroantiseptics (nitrofuran derivatives - Furagin).

Let us dwell on antibacterial drugs in the treatment of UTIs in more detail.

Recommended medications for lower urinary tract infections.

1. Inhibitor-protected aminopenicillins: amoxicillin + clavulanic acid (Amoxiclav, Augmentin, Flemoklav Solutab), ampicillin + sulbactam (Sulbacin, Unazin).
2. II generation cephalosporins: cefuroxime, cefaclor.
3. Fosfomycin.
4. Nitrofuran derivatives: furazolidone, furaltadone (Furazolin), nitrofural (Furacilin).

For upper urinary tract infection.

1. Inhibitor-protected aminopenicillins: amoxicillin + clavulanic acid, ampicillin + sulbactam.
2. II generation cephalosporins: cefuroxime, cefamandole.
3. III generation cephalosporins: cefotaxime, ceftazidime, ceftriaxone.
4. IV generation cephalosporins: cefepime.
5. Aminoglycosides: netilmicin, amikacin.
6. Carbapenems: imipenem, meropenem.

For hospital infection.

1. Cephalosporins of the III and IV generations - ceftazidime, cefoperazone, cefepime.
2. Ureidopenicillins: piperacillin.
3. Fluoroquinolones: according to indications.
4. Aminoglycosides: amikacin.
5. Carbapenems: imipenem, meropenem.

For perioperative antibacterial prophylaxis.

1. Inhibitor-protected aminopenicillins: amoxicillin + clavulanic acid, ticarcillin/clavulanate.
2. Cephalosporins of the II and III generations: cefuroxime, cefotaxime, ceftriaxone, ceftazidime, cefoperazone.

For antibacterial prophylaxis during invasive procedures: inhibitor-protected aminopenicillins - amoxicillin + clavulanic acid.

It is generally accepted that antibiotic therapy in outpatients with UTI can be performed empirically, based on the antibiotic susceptibility data of the main uropathogens circulating in a particular region during a given observation period and the clinical status of the patient.

The strategic principle of antibiotic therapy in outpatient settings is the principle of minimal sufficiency. First-line drugs are:

• inhibitor-protected aminopenicillins: amoxicillin + clavulanic acid (Amoxiclav);
• cephalosporins: oral cephalosporins of the II and III generations;
• derivatives of the nitrofuran series: nitrofurantoin (Furadonin), furazidin (Furagin).

It is erroneous to use ampicillin and co-trimoxazole in outpatient settings, due to the increased resistance of E. coli to them. The use of first generation cephalosporins (cephalexin, cefradine, cefazolin) is not justified. Derivatives of the nitrofuran series (Furagin) do not create therapeutic concentrations in the renal parenchyma, so they are prescribed only for cystitis. In order to reduce the growth of resistance of microorganisms, the use of third-generation cephalosporins should be sharply limited and the use of aminoglycosides in outpatient practice should be completely eliminated.

Analysis of the resistance of strains of pathogens of complicated urinary infections shows that the activity of drugs from the group of semisynthetic penicillins and protected penicillins can be quite high against Escherichia coli and Proteus, but against enterobacteria and Pseudomonas aeruginosa their activity is up to 42 and 39%, respectively. Therefore, drugs in this group cannot be drugs for empirical treatment of severe purulent-inflammatory processes of the urinary organs.

The activity of cephalosporins of the first and second generations against Enterobacter and Proteus also turns out to be very low and ranges from 15–24%; against Escherichia coli it is slightly higher, but does not exceed the activity of semisynthetic penicillins.

The activity of cephalosporins of the III and IV generations is significantly higher than that of penicillins and cephalosporins of the I and II generations. The highest activity was observed against E. coli - from 67 (cefoperazone) to 91% (cefepime). Activity against Enterobacter ranges from 51 (ceftriaxone) to 70% (cefepime); high activity of drugs in this group is also noted against Proteus (65–69%). The activity of this group of drugs against Pseudomonas aeruginosa is low (15% for ceftriaxone, 62% for cefepime). The spectrum of antibacterial activity of ceftazidime is the highest against all current gram-negative pathogens of complicated infections (from 80 to 99%). The activity of carbapenems remains high - from 84 to 100% (for imipenem).

The activity of aminoglycosides is somewhat lower, especially against enterococci, but amikacin retains high activity against enterobacteria and Proteus.

For this reason, antibacterial therapy for UTIs in urological patients in a hospital should be based on data from microbiological diagnostics of the infectious agent in each patient and his sensitivity to antibacterial drugs. Initial empirical antimicrobial therapy for urological patients can be prescribed only until the results of a bacteriological study are obtained, after which it should be changed according to the antibiotic sensitivity of the isolated microorganism.

When using antibiotic therapy in a hospital, a different principle should be followed - from simple to powerful (minimum use, maximum intensity). The range of groups of antibacterial drugs used here has been significantly expanded:

• inhibitor-protected aminopenicillins;
• cephalosporins of III and IV generations;
• aminoglycosides;
• carbapenems;
• fluoroquinolones (in severe cases and in the presence of microbiological confirmation of sensitivity to these drugs).

Perioperative antibiotic prophylaxis (pre-, intra- and post-operative) is important in the work of a pediatric urologist. Of course, one should not neglect the influence of other factors that reduce the likelihood of developing an infection (reducing hospital stay, quality of processing of instruments, catheters, use of closed systems for urine diversion, staff training).

Major studies show that postoperative complications are prevented if a high concentration of antibacterial drug in the blood serum (and tissues) is created before the start of surgery. In clinical practice, the optimal time for antibiotic prophylaxis is 30–60 minutes before the start of surgery (subject to intravenous administration of the antibiotic), i.e., at the beginning of anesthesia. There was a significant increase in the incidence of postoperative infections if the prophylactic dose of antibiotic was not prescribed within 1 hour before surgery. Any antibacterial drug administered after closing the surgical wound will not affect the likelihood of complications.

Thus, a single administration of an adequate antibacterial drug for prophylactic purposes is no less effective than repeated administration. Only with long-term surgery (more than 3 hours) an additional dose is required. Antibiotic prophylaxis cannot last more than 24 hours, since in this case the use of an antibiotic is considered as therapy, and not as prevention.

An ideal antibiotic, including for perioperative prophylaxis, should be highly effective, well tolerated by patients, and have low toxicity. Its antibacterial spectrum should include probable microflora. For patients staying in hospital for a long time before surgery, it is necessary to take into account the spectrum of nosocomial microorganisms, taking into account their antibiotic sensitivity.

For antibiotic prophylaxis during urological operations, it is advisable to use drugs that create high concentrations in the urine. Many antibiotics meet these requirements and can be used, such as second-generation cephalosporins and inhibitor-protected penicillins. Aminoglycosides should be reserved for patients at risk or allergic to b-lactams. Third and fourth generation cephalosporins, inhibitor-protected aminopenicillins and carbapenems should be used in isolated cases when the surgical site is contaminated with multi-resistant nosocomial microorganisms. Still, it is desirable that the use of these drugs be limited to the treatment of infections with a severe clinical course.

There are general principles of antibacterial therapy for UTIs in children, which include the following rules.

In case of febrile UTI, therapy should be started with a broad-spectrum parenteral antibiotic (inhibitor-protected penicillins, cephalosporins of the second and third generations, aminoglycosides).

It is necessary to take into account the sensitivity of urine microflora.

The duration of treatment for pyelonephritis is 14 days, cystitis - 7 days.

In children with vesicoureteral reflux, antimicrobial prophylaxis should be long-term.

Antibacterial therapy is not indicated for asymptomatic bacteriuria.

The concept of “rational antibiotic therapy” should include not only the correct choice of drug, but also the choice of its administration. It is necessary to strive for gentle and at the same time the most effective methods of prescribing antibacterial drugs. When using step therapy, which consists of changing the parenteral use of an antibiotic to an oral one, after the temperature has normalized, the doctor should remember the following.

• The oral route is preferable for cystitis and acute pyelonephritis in older children, in the absence of intoxication.
• The parenteral route is recommended for acute pyelonephritis with intoxication in infancy.

Antibacterial drugs are presented below depending on the route of their administration.

Oral medications for the treatment of UTIs.

1. Penicillins: amoxicillin + clavulanic acid.
2. Cephalosporins:
   • II generation: cefuroxime;

   • III generation: cefixime, ceftibuten, cefpodoxime.

Drugs for parenteral treatment of UTI.

1. Penicillins: ampicillin/sulbactam, amoxicillin + clavulanic acid.
2. Cephalosporins:
   • II generation: cefuroxime (Cefurabol).

   • III generation: cefotaxime, ceftriaxone, ceftazidime.

   • IV generation: cefepime (Maxipim).

Despite the availability of modern antibiotics and chemotherapy drugs that make it possible to quickly and effectively cope with infection and reduce the frequency of relapses by prescribing drugs in low prophylactic doses for a long period, treating recurrent UTIs is still a rather difficult task. This is due to:

• increased resistance of microorganisms, especially when repeated courses are used;
• side effects of drugs;
• the ability of antibiotics to cause immunosuppression of the body;
• decreased compliance due to long courses of taking the drug.

As is known, up to 30% of girls have a recurrent UTI within 1 year, 50% within 5 years. In boys under 1 year of age, relapses occur in 15–20%; in boys older than 1 year, there are fewer relapses.

Let us list the indications for antibiotic prophylaxis.

• Absolute:
  a) vesicoureteral reflux;

  b) early age; c) frequent exacerbations of pyelonephritis (three or more per year), regardless of the presence or absence of vesicoureteral reflux.

• Relative: frequent exacerbations of cystitis.

The duration of antibiotic prophylaxis is most often determined individually. The drug is discontinued in the absence of exacerbations during prophylaxis, but if an exacerbation occurs after discontinuation, a new course is required.

Recently, a new drug has appeared on the domestic market to prevent recurrent UTIs. This drug is a lyophilized protein extract obtained by fractionating an alkaline hydrolyzate of certain strains of E. coli and is called Uro-Vaxom. The tests have confirmed its high efficiency with the absence of significant side effects, which gives hope for its widespread use.

An important place in the treatment of patients with UTIs is occupied by clinical observation, which consists of the following.

• Monitor urine tests monthly.
• Functional tests for pyelonephritis annually (Zimnitsky test), creatinine level.
• Urine culture - according to indications.
• Measure blood pressure regularly.
• For vesicoureteral reflux - cystography and nephroscintigraphy once every 1-2 years.
• Sanitation of foci of infection, prevention of constipation, correction of intestinal dysbiosis, regular bladder emptying.

Literature

1. Strachunsky L. S. Urinary tract infections in outpatients // Proceedings of the international symposium. M., 1999. pp. 29–32.
2. Korovina N. A., Zakharova I. N., Strachunsky L. S. et al. Practical recommendations for antibacterial treatment of urinary system infections of community-acquired origin in children // Clinical microbiology and antimicrobial chemotherapy, 2002. T. 4. No. 4. C 337–346.
3. Lopatkin N. A., Derevyanko I. I. Antibacterial therapy program for acute cystitis and pyelonephritis in adults // Infections and antimicrobial therapy. 1999. T. 1. No. 2. P. 57–58.
4. Naber K. G., Bergman B., Bishop M. K. et al. Recommendations of the European Association of Urology for the treatment of urinary tract infections and infections of the reproductive system in men // Clinical microbiology and antimicrobial chemotherapy. 2002. T. 4. No. 4. P. 347–63.
5. Pereverzev A. S., Rossikhin V. V., Adamenko A. N. Clinical effectiveness of nitrofurans in urological practice // Men's Health. 2002. No. 3. pp. 1–3.
6. Goodman and Gilman's The Pharmacological Basis of Therapeutics, Eds. J.C. Hardman, L.E. Limbird., 10th ed., New York, London, Madrid, 2001.

S. N. Zorkin , Doctor of Medical Sciences, Professor of the Scientific Center for Children's Diseases of the Russian Academy of Medical Sciences, Moscow

Side effects after taking antibiotics

In 86.1% of cases these were allergic skin reactions .

Fleming-Dutra notes that side effects always manifest themselves differently. In the most severe cases, it can be anaphylaxis , a severe and life-threatening condition that is also often caused by peanut or bee sting allergies. According to the study, 70% of allergic reactions did not pose a threat to the child's life.

Side effects may also include:

• diarrhea
• rash (in young children)
• problems with the gastrointestinal tract (nausea, vomiting, abdominal pain in older children)
• severe headache and light sensitivity

Who's at risk

Researchers note that most often side effects during antibiotic treatment are observed in children aged 1 to 2 years. The older the child, the less likely he is to have a negative reaction to antibiotics.

Pediatrician Mark Sawyer, a member of the American Association of Pediatrics' Infectious Diseases Association, emphasizes that young children are most susceptible to infections and are therefore more likely to be prescribed antibiotics. However, they are much more likely to experience allergic reactions.

Why is it important

In reality, the number of side effects associated with antibiotics is much higher because parents are more likely to take their children to the pediatrician rather than to the hospital, or not seek help at all if symptoms are mild. The study took into account only those adverse reactions to antibiotics that caused hospital visits.

Doctors believe that the final decision about which medicine to prescribe to a child always rests with the treating pediatrician. However, parents should always discuss the potential risks and appropriateness of using an antibiotic to treat their child.