TREATMENT OF URINARY TRACT INFECTIONS

     Urinary tract infection (UTI) - non-specific infectious processes that affect the urinary system. According to statistics, in the U.S. they are the cause of more than 8 million annual visits to physicians and more than 100 thousand hospitalizations per year. In this pathology is about 50 times more common in women and is generally about 5% of the population morbidity. At the same time for the older age groups (60 and older), UTI found among both sexes with approximately equal frequency [1, 2].

     Urinary tract infection includes all types of infectious processes that affect various anatomical urinary tracts: kidneys, ureters, bladder and urethra. Traditionally they are divided into UTI lower divisions (urethritis, cystitis), which are found in most cases, and the top (jade). Brackets for this publication intentionally bred fairly specific topic of drug treatment nephritis. The aim of the work was to analyze the patterns of modern drug therapy UTI is not applicable to the renal parenchyma. Similarly, out of discussion in this publication has been Sexually Transmitted Diseases (STD), which are defined as infectious diseases, the most common route of infection that is sexual. These include gonorrhea, syphilis, chancroid, lymphogranuloma venereum, chlamydia, trichomoniasis, genital herpes, and genital warts.

     At present there are important factors that significantly increase the risk of UTI. For women, there are many more, as determined by the anatomical structure of the body (the shorter urethra and perineum, which facilitates the penetration of bacteria into the urinary tract). Sexually active women have a higher frequency of UTI, because of increased irritation of mucous membranes, including the urethra. In menopausal UTI becomes more frequent due to the overall decline in estrogen due to the background increased vulnerability of mucous vagina, urethra and lower parts of the bladder. Studies show that virtually every other woman suffering from a UTI of at least one in their lifetime, and most of them get sick much more frequently [2-4].

     Other significant risk factors are: a) the presence of obstacles to the flow of urine (BPH, nephrolithiasis, etc.), b) diabetes and other chronic diseases, leading to a decrease in the intensity of immune system, and c) medications that suppress the immune system (corticosteroids, antineoplastic agents, etc.) d) the use of catheters for urine excretion (episodic and permanent).

     Signs and symptoms. Not every patient with a UTI recorded to recognize the symptoms of infection, but most of them are. In this particular lesion of urinary tract provides its own specific symptoms. Thus, in cystitis often a feeling of pressure or discomfort in the abdomen, and urethritis is usually seen burning during urination. In men with chronic course it often causes erectile dysfunction and more. Other typical symptoms UTI are:

     - Strong and almost constant urge to urinate (cystitis, urethritis)

     - Frequent urination in small quantities of urine (more common in cystitis)

     - The presence of blood in the urine (hematuria), which makes it darker or odor (often marked cystitis).

     The symptoms of lesions of the upper urinary tract include pain in the side or back, a significant (up to 38.5 ºC or more) of fever, malaise, chills, nausea and vomiting. In the presence of this symptom in UTI, in any case, you should seek medical attention. Only a specialist can eliminate the (differentiated) lesion of the upper and lower urinary tract, the presence of possible complications and the right to assign drug treatment [3, 4].

     Diagnosis. To confirm the diagnosis UTI is commonly used clinical urine analysis. It is a urine test, supplemented by microbiological analysis, is in most cases sufficient to diagnose this disease and use of adequate therapy.

     UTI complications if treatment is started promptly and properly carried out are quite rare. At the same time, left untreated, it can cause acute or chronic kidney disease (pyelonephritis more often). As the data in the literature, such an outcome is realistic for most children and patients of older age groups. To risk of complications should also include women with a UTI during pregnancy [3, 5, 6].

     Treatment. The use of antibiotics is currently the method of choice in most applications of drug therapy UTI in recent years. At the same time in some countries, like Britain, retained the recommendation for the use of combinations of initial treatment with trimethoprim/sulfamethoxazole (TMP-SMX).

     Appropriate selection of the drug and possible alternatives in UTI depends on many factors, including the availability of treatment-resistant infections, its primacy and related diseases. UTI taken in this regard in practice divided into uncomplicated (trivial) and hospital (nosocomial). For uncomplicated, usually caused by susceptible strains of antimicrobial E.coli, is in practice about 70% of infections. Hospital UTI are the main cause virulent strains of E. coli, Pseudomonas, Staphylococcus (usually coagulase-negative Staphylococcus saprophyticus) and different combinations of microorganisms. Their common problem is drug resistance. According to special studies, and often a predisposing etiologic agent of this type of infection is the use of medical instruments (catheters, cystoscope, etc.). It is worth noting that some authors in the number of complications included UTI and all their cases in men younger and middle age, which this pathology is extremely rare. This is due to the need an additional medical examination this patient population and is mainly organizational in nature [2, 4, 7].

     To a large extent the choice of antibiotic depends on the patient (gender, pregnancy, age, place of treatment - a hospital or at home, etc.), as well as the presence of diabetes and other chronic diseases, other factors mentioned above on progression UTI.

     The main goals of drug therapy of all forms of UTI are quick and effective response to treatment, relapse prevention, and preventing or at least delay the development of resistance of microorganisms to antimicrobial drugs. Currently used previously rejected for the appointment and monitoring of the treatment effect parameters titer of bacteria in the urine. For example, if a woman has symptoms, even at low UTI bacterial titer, it still shows the use of antibiotics [1, 8].

     It should be noted that the prevalence of antibiotic-resistant strains of E. coli, which are the most common cause of UTI, is constantly growing. Experts believe this is a consequence of widespread use of antibiotics in food production. As the literature in 2003, 42% of isolates E. coli were resistant to one or more of the 12 investigated antibiotics. This has caused a departure from standard up to that time in the U.S. treatment of UTI using the TMP-SMX (trimethoprim/sulfamethoxazole) recommended the use of fluoroquinolones. Statistics in 2006 shows that their practical use for this condition has already surpassed the number of appointments TMP-SMX. And now traced the likely emergence of resistance is the microflora to these drugs [1, 9].

     Currently, UTI is used for the treatment of drugs that can be separated in four groups (see table).

     Treatment of uncomplicated UTI. The overwhelming frequency of this type of UTI observed in women younger and middle-aged and treated successfully in the "background", i.e. without changing the normal rhythm of life. In such cases, are now recommended to appoint a three-day course of antibiotics. Usually, even without the analysis of urine. This approach is recommended only for women at low risk for recurrent infections (outside the above-mentioned risk factors for their development and without concomitant diseases) and those who have not revealed signs of other infectious processes, the pelvis, such as vaginitis. An antibiotic in this case provides approximately 94% of success, although the relapse rate is also quite high [2, 6]. For this type of therapy is usually used the following drugs:

     Standard three-day mode TMP-SMX (Biseptol, Bactrim, Septra, Co-trimoxazole). In some cases, using a single dose of TMP-SMX, but the results of treatment it is usually worse.

    Fluoroquinolones are the second option. In geographic areas where high frequency resistance of microorganisms to the TMP-SMX, the fluoroquinolones are first-line. The most frequently used ciprofloxacin (Cipro). Fluoroquinolones are usually prescribed for 3-4 days.

      Nitrofurantoin (furadonin, furadantin, macrodantin) - the third option of choice. The drug must be taken longer than 6 days.

     Fosfomycin (Monural, Urofosfabol) - less effective than other antibiotics, but can be used during pregnancy. The incidence of resistant strains to him is very low.

     Other antibiotics, including amoxicillin (in combination with or without clavulanate) and cephalosporins. Doxycycline is not administered to children and pregnant women.

     If the symptoms do not disappear in UTI during the first two or three days of treatment, it is recommended to stop and do urine culture to determine the composition and the sensitivity of microflora.

Modes of use of antibiotics for acute uncomplicated cystitis

     Treatment of recurrent infection. Recurrent infection (usually after treatment failure) occurs in approximately 10% of women and is rare in men. Relapse is treated as UTI and prior disease, but the duration of antibiotic therapy increases, until at least two weeks. The probability of relapse is significantly increased against the background of structural urinary tract abnormalities, concretions, etc. In this regard, a survey (consulting gynecologist, an ultrasound, etc.). Preventive treatment with antibiotics, according to current regulations, is required for women who suffer from UTI two or more times in six months or three or more times per year. The implication is that they do need to use preventive measures for possible recurrence.      Many women with recurrent UTI, in consultation with a physician, can effectively use the antibiotic the next time the appearance of symptoms, UTI alone. In these cases it is recommended to do a urine test for the microflora. In the English literature to refer to this regimen often used the term "self", which is unlikely in this sense applies here. Regular consultation with a physician is needed in the following cases:

     - If symptoms have not been entirely UTI within 48 hours

     - If there are changes in the usual symptoms of UTI

     - If a patient is suspected in a pregnancy

     - If the patient has a UTI of more than four cases per year

     Not suitable for this mode of treatment are those with weakened immune systems, structural urinary tract abnormalities, with a history of nephritis, and antibiotic-resistant infections.

     Postcoital antibiotics. If recurrent infection is associated with sexual activity and UTI have relapses over two times in six months, proved the feasibility and efficacy of a single prophylactic dose of the drug immediately after intercourse. Besides the TMP-SMX, in such cases, the use of nitrofurantoin, cephalexin, or fluoroquinolone (e.g. ciprofloxacin) [3, 11].

     Prophylactic antibiotics. This treatment is a method of treatment for some women who do not help other measures. At the same antibiotics at a relatively low dose taken continuously for 6 months or more. Typical for this type of therapy includes a daily dose of a single dose of nitrofurantoin (50 mg), 1/2 tablets TMP-SMX or cephalexin (250 mg). Reception at bedtime is more effective. Recent studies suggest that prolonged prophylaxis reduces relapse rate of infection by 95% and prevent possible infection of the kidneys. Side effects of this therapy include dyspepsia, and various fungal infections. However, concomitant use of probiotics or yogurt, as shown by data from the studies, particularly of infection reduces the yeast fungi. There is an opinion that such use of antibiotics increases the number of drug-resistant bacteria. However, a significant increase of over 5 years of observation is not observed [4, 8, 9].

     Treatment of specific categories of patients

     Treatment of pregnant women. According to statistics, even in asymptomatic bacteriuria during pregnancy a woman has a 30% increased risk of acute pyelonephritis in the second or third trimester of her. In this regard, such states should be promptly identified and treated. In most cases, treatment involves a short course of antibiotics (3-5 days). These drugs are used during pregnancy include amoxicillin, ampicillin, nitrofurantoin or oral cephalosporins. Fosfomycin (Monural) is less effective than others, but the safest during pregnancy. Fluoroquinolones and TMP-SMX (C on effects on the fetus) in the tapping contraindicated [5,12].

     Treatment of patients with diabetes. The presence of diabetes causes more frequent and more severe in its manifestations and prognosis in terms of shape UTI. Most experts recommend that such patients, even in cases of uncomplicated infections treated with antibiotics for 7 to 14 days. People with diabetes have a higher incidence of asymptomatic bacteriuria, but among the experts as long as there is no consensus about their obligatory identification and treatment of this feature. The 2003 study showed that treatment of this condition is practically no influence on the prognosis and UTI did not prevent infection [7].

     Treatment of urethritis in men. Until now, standard treatment for UTI (urethritis) in men is a seven-day course of doxycycline. Some research suggests that this rate is similar to the effectiveness of a single dose of azithromycin, which also causes fewer side effects. And with compliance, the results of treatment with azithromycin may be even much better. However, the propagation of infection to the prostate, the effect of azithromycin was leveled. In this regard, most physicians prefer a longer treatment. It should also be remembered that patients with urethritis should be checked for disease, sexually transmitted diseases (gonorrhea, chlamydia, etc.).

     Treatment of children. Children with a UTI usually treated using the scheme TMP-SMX or cephalexin (Keflex). Medications taken by mouth and effect of treatment usually occur a few days. At the same time, as noted in the literature, resistance to cephalosporins (cephalexin) has recently been growing, prompting doctors to use the aminoglycoside antibiotics. The most effective among them are now considered to gentamicin (Garamycin), which in this patient group is commonly used intravenously.

     The mechanism of development of complications UTI in children is essential presence vesicoureteral reflux (WSSD) in which urine from the bladder enters the kidney and renal pelvis can infect them with the development of pyelonephritis. About one-third of children have WSSD, which most experts recommend treatment for relapsing forms of UTI surgery. And it expressed its degree. The grounds are extensive 2006 study which showed that even prolonged use of antibiotics does not prevent complications of WSSD. But it was also found that the average and moderate degree of WSSD did not increase the frequency of UTI or pyelonephritis [6, 10].

     Treatment of patients using a catheter to remove urine. The main problem of the treatment UTI in this group of patients is the constant variability of microflora. In this regard, experts recommend the use of antibiotics with a broad spectrum of antimicrobial action. First of all fluoroquinolones and combinations such as ampicillin plus gentamicin plus/or imipinem/cilastatin. The use of prophylactic antibiotics during catheter use is not currently recommended.

     For the prevention of UTI in these cases, as a general rule, you should use catheters only by absolute necessity. They need to be removed as quickly as possible and, if possible, use only the periodic introduction. Special coatings for catheters (lapis, antibiotics, etc.) to some extent play a preventive role, but very little. The most modern approach is a hydrophilic coating of polyvinylpyrrolidone, which ensured, according to research by 2003, reducing the frequency of UTI [7, 8].

     Thus, modern arsenal of antimicrobial agents can successfully treat various forms of UTI. But in some categories of patients this type of infection may present a significant health difficulties and non-medical. In this regard, a skilled and timely advice the pharmacist can help the overall success of therapy and, most importantly, prevent its recurrence.

     Tips for a patient with a UTI. Symptoms usually disappear in UTI within a few days of starting treatment. But you may need to continue taking medication for a week or more. Take the full course of drug treatment recommended by your doctor to ensure that the disease is completely eliminated.

     While antibiotics do not suppress the infection, you can take steps to help their treatment. In this regard:

     - Drink plenty of fluids. Drinking large amounts of water dilutes the urine and helps remove bacteria from the urinary tract.

     - Avoid coffee, alcohol and soft drinks, which contain components of citrus fruits and caffeine. They irritate the bladder and can cause frequent urination.

     UTI in its normal course can give pain, but you can take steps to consult with your doctor to help you here. To do this:

     - Use an electric heating pad. Sometimes the heater placed on the bottom of the stomach, completely eliminates the debilitating feeling of pressure and pain.

     - Use non-prescription drugs. The best effect for UTI usually provide a number of nonsalicylate NSADs containing paracetamol (Efferalgan, Daleron, Tylenol, etc.).

In the case of recurrent UTI is important to respect some simple rules that are important and without symptoms of the disease:

     - Careful "toilet bubble" (drink 2-3 liters of fluid daily and always urinate before bedtime and after sex).

     - Can be a useful decision 250-500 ml of cranberry juice daily. This gives the prevention of bladder and overflow has an adverse effect on the microflora (in conjunction with warfarin - is contraindicated!).

     - It is necessary to empty the bladder completely and often as possible.

     - Use a shower instead of baths and carefully wipe after its adoption. Additional moisture, promoting the development of recurrence UTI.

     - Carefully follow the purity of the perineum, including after using the toilet. You must use a bidet.

     - Avoid using intimate cosmetics in the crotch. Deodorants and gels can irritate the urethra, contributing to UTI relapse.

Reference.

1. Urinary tract infections // In: Beuben D., Herr K., Pacala J., Potter J., Semla T., Small G., eds. Geriatrics at Your Fingertips. – New York: American Geriatrics Society. – 2000. – P.70-73.

2. Мазо Е.Б., Попов С.В. Эффективность пефлоксацина в лечении урологических инфекций // РМЖ. – 2005. – Т.13, №.25. – С.1679-1682

3. Desai S. Dysuria (women). // In: Desai S. Clinician's Guide to Diagnosis. – Hudson, Ohio: Lexi-Comp, Inc. – 2001. – P.189-206.

4. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines 2002 // MMWR. – 2002. – V.51, No. RR-6. – P.36-52.

5. Иремашвили В.В. Инфекции мочевыводящих путей: современный взгляд на проблему // РМЖ. – 2007. – Т. 15, № 29. – С.471-475

6. Vachvanichsanong P., Dissaneewate P., Thongmak S., Lim A. Primary vesicoureteral reflux mediated renal scarring after urinary tract infection in Thai children // Nephrology. – 2008. – V.13, No.1. – P.38-42.

7. Hilbert D.W., Pascal K.E., Libby E.K., Mordechai E., Adelson M.E., Trama J.P. Uropathogenic Escherichia coli dominantly suppress the innate immune response of bladder epithelial cells by a lipopolysaccharide- and Toll-like receptor 4-independent pathway // Microbes Infect. – 2007. – № 10. – P.894-899.

8. Hamill T.M., Gilmore B.F., Jones D.S., Gorman S.P. Strategies for the development of the urinary catheter // Expert Rev Med Devices. – 2007. – V.4, No.2. – P.215-225.

9. Prelog M, Schiefecker D, Fille M, Wurzner R, Brunner A, Zimmerhackl LB. Risk Factors for Community-Acquired Urinary Tract Infection Due to Quinolone-Resistant E. coli // Infection. – 2008. – V.12, No.6.

10. Saul P. Managing UTIs in children // Practitioner. – 2007. – V.251, No.1698. – P.7-10.

11. Мороз В.А., Ланько Л.Г. Современные подходы к лечению инфекций мочевыводящего тракта // Провизор.- 2008.– №19. – С.42-48

12. Hale T. Medications and Mothers' Milk. 10th ed. – Amarillio, Texas: Pharmasoft Medical Publishing. – 2002.