2-3. UTI. Svetlana Paunova (eng)

404 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
404
On SlideShare
0
From Embeds
0
Number of Embeds
32
Actions
Shares
0
Downloads
7
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

2-3. UTI. Svetlana Paunova (eng)

  1. 1. EVIDENCE-BASED INVESTIGATIONS AND TREATMENT OF URINARY TRACT INFECTIONS
  2. 2. ESRF CAUSES FOREMAN JW,CHAN JCM. J PEDIATR 1988,113,793-800 ERA-EDTA ANNUAL REPORT 2005, REGISTERED CHARITY №1060134 Другие Васкулиты Наследственные нефропатии Cong. NP ПМР/ РН Обструкция UTI, VUR, ИМП RN Гломерулопатии Glomerulopath. 0 10 20 30 40
  3. 3. State Statistic Survice – last decade- incidence of renal diseasesin children under increased in 1,6 times, theenagers – in 2 times  Russian (http://www.gks.ru )
  4. 4.  Stable increasing of UTI in children  In children of 1-3 years of life UTI is more frequent than acute respir. infection -Соматичекие болезни у детей, Руководство для врачей // Под ред. М.С. Игнатовой / Москва-Оренбург.-2002.- 669 с, -Bhat RG, Katy TA, Place FC. Pediatric urinary tract infections. Emerg Med Clin North Am. 2011 Aug;29(3):637-53
  5. 5.  UTI is possible in neonates.  In mature neonates with fever and malaise –UTI in 1,1 - 7% cases Beetz R.Evaluation and management of urinary tract infections in the neonate. Curr Opin Pediatr. 2012 Jan 5.
  6. 6.  1/3 of 1-st year babies (36,4%)renal scarring after first episode of UTI. Lin D.S., Huang S.H., Lin C.C. et al. Urinary tract infection in febrile infants younger than eight weeks of age. // Pediatrics. -2000. –v.105, №2. –P.E20, Remington J.S, Klein J. Infectious diseases of the fetus and newborn. 5th edition Philadelphia: WB Saunders, 2001
  7. 7. UTI (inflammation) -CD14 –macrofage marker -Co-receptor of CD14/TLR4/MD2 complex -NF-κB –transcription factor (I-kB- inhibitor) - Controls gene expression of immune response, apoptosis and cellular cycle -TLR4- binds LPS of bacter. wall -the most ancient in antibacter. protect. system -similar to IL-1
  8. 8. UTI (urodynamics) Abnormal urodynamics  High intrapelvic pressure  Intrarenal reflux 
  9. 9. RENAL SCARRING IN UTI       Abnormal urodynamics (IRR) UTI- p-fimbria E. сoli, number of PN relapses ang age of debuite GeГенетическая предрасположенность (DD-генотип АПФ - почечный фиброз, делеция 13q хромосомы – тяж. ПМР, РН, ХПН, полиморфизм гена ТФР-β1 – у 82% больных с РН, Нарушение равновесия ФНО-а, ИЛ-6, ИЛ-8, ИЛ-10 Гиперпродукция ТФР, ФРФ, ИФР-1 Нарушение механизма апоптоза
  10. 10. МЕТА-ANALYSIS - RENAL SCARRING RISK IN UTI Shaikh N, et al.. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics 2010, Dec;126(6):1084-91 Medline и Embase (english-, french-, spanish) Kea words: "Technetium (99m)Tc dimercaptosuccinic acid (DMSA)," "DMSA," "dimercaptosuccinic," "scintigra*," "pyelonephritis," and "urinary tract infection." Children of 0-18 years with 1st episode of UTI ©2010 by American Academy of Pediatrics Shaikh N et al. Pediatrics 2010;126:1084-1091
  11. 11. Risk of acute pyelonephritis according to the presence or absence of VUR. ©2010 by American Academy of Pediatrics Shaikh N et al. Pediatrics 2010;126:1084-1091
  12. 12. Risk of renal scarring according to the grade of VUR. ©2010 by American Academy of Pediatrics Shaikh N et al. Pediatrics 2010;126:1084-1091
  13. 13.  Vesicoureteral reflux associated renal damage: congenital reflux nephropathy and acquired renal scarring. Peters C, Rushton HG. J Urol. 2010 Jul;184(1):265-73. Microflora virulence  Local and general inflam. response pecularities  Tissue ability to restoration  Sterile reflux dose not lead to RN 
  14. 14. ЗАВИСИМОСТЬ РАСПРОСТРАНЕННОСТИ НЕФРОСКЛЕРОЗА ОТ ГОДА ПУБЛИКАЦИЙ (хорошая диагностическая база, качественное лечение и наблюдение) ©2010 by American Academy of Pediatrics Shaikh N et al. Pediatrics 2010;126:1084-1091
  15. 15. DIAGNOSIS OF UTI  Clinical manifestations  Laboratory methods of urine examination: -urinary sediment, -bacteriuria, -urine osmolality, -daily excretion of β2-microglobulin, etc Blood count, ESR  Visual methods of voiding system evaluation:  -Renal US with doppler imaging of intrarenal hemodynamics, -Nuclear examination
  16. 16. CLINICAL MANIFESTATIONS OF UTI  In neonates-the only sign of the UTI-prolonged jaundice  Patients under the age of 2 years-general toxic symptoms: fever, anxiety, insomnia, decreased appetite, vomiting, dyspepsia, etc.  Children under 5 years-common abdominal pain without a specific localization.  Only after 5 years of age-specific symptoms of the urinary system lesions appear
  17. 17. АНАЛИЗ МОЧИ  До назначения лечения  Сбор мочи «clean catch», а не в мочеприемник!!!  Бактериурия истинная (рост боле 100 000 колониеобразующих единиц в свежевыделенной моче) У детей раннего возраста – 50 000 КОЕ (малая экспозиция мочи в мочевом пузыре) Вид микрофлоры (протей, клебсиела, с/г палочка)  Симптоматическая, асимптоматическая
  18. 18. DIAGNOSTIC ALGORITHM
  19. 19. US OF VOIDING SYSTEM Screening or an additional assessment method of anatomofunctional status of VS  Modern digital ultrasound devices with high resolution and Doppler of renal hemodynamics- early detection of scaring and foci-infiltrative changes in renal parenchyma  Contrast voiding urosonographia, where instead of iodine used gas bubbles (Levovist "drug")  In 70% of cases, this method has a higher degree of detected reflux than was revealed by MCUG (Darge K. Pediatr Radiol. 2008 Jan;38(1):40 53.)
  20. 20. Эхографическая картина мочевого пузыря и расширенного дистального отдела левого мочеточника у ребенка 5 лет с левосторонним смешанным ПМР 2-3 степени и левосторонней РН.
  21. 21. RENAL US OF 3-mo CHILD
  22. 22. ТЯЖЕЛАЯ РЕФЛЮКС-НЕФРОПАТИЯ Резкое обеднение интраренального кровотока Маленькая сморщенная почка с толстостенной расширенной собирательной системой и почти полным отсутствием функционирующей паренхимы
  23. 23. Visual diagnostic methods Imaging Studies after a First Febrile Urinary Tract Infection in Young Children Alejandro Hoberman, M.D., Martin Charron, M.D., Robert W. Hickey, M.D., Marc Baskin, M.D., Diana H. Kearney, R.N., and Ellen R. Wald, M.D. N Engl J Med 2003; 348:195-202January 16, 2003
  24. 24. РЕНОГРАФИЯ С ПЕНТАТЕХОМ Right kidney Left kidney К., 10 years, right VUR 3 grade, left VUR 2 grade, rightside RN (X-Ray MCUG, IVU) Obstructive curve right kidney Arrows - VUR of
  25. 25. НЕПРЯМАЯ (MAG-3) ЦИСТОГРАФИЯ
  26. 26. НЕПРЯМАЯ (MAG-3) ЦИСТОГРАФИЯ
  27. 27. DMSA Не ранее 6 мес. после стихания ИМС
  28. 28. MCUG Children younger than 6 months-whith atypical or recurring UTI+  The boys from 6 months to 3 years-high risk of VUR+/ Дети 3-5-7 лет – visual changes of kidneys (US, nuclear invest), familial history of VUR or RN (CAKUT), relapses of UTI   Children over 7 years – ИНДИВИДУАЛЬНО !!! выраженные изменения верхних отделов мочевой системы, ранее выявленные нарушения уродинамики
  29. 29. Treatment and prevention of UTI the most complicated and controversial issue of pediatric nephrology (What, how, how long to treat?)
  30. 30. MODERN ANTIBACTERIAL DRUGS     Protected 3-4 generation of Penicillins (Tikarcillin, Mecillinam), aminoglycosides, cephalosporins, fluoroquinolones, karbopenems Cyclic lipopeptide (daptomycin-kubicin)-, Gram+ Oxazolidinons (linezolid, Zyvox) – Gram+/- (~ 20.000 rub=620 – 10 tablets) Antagonists of Н-fimbria (J Med Chem. 2010 Dec 23;53(24):8627-41. FimH antagonists for the oral treatment of urinary tract infections: from design and synthesis to in vitro and in vivo evaluation. Klein T, с соавт., Швейцария)  - Products based on plant extracts: Cress and horseradish (Curr Med Res Opin. 2007 Oct;23(10):2415-22. A randomised, double-blind, placebo-controlled trial of a herbal medicinal product containing Tropaeoli majoris herba (Nasturtium) and Armoraciae rusticanae radix (Horseradish) for the prophylactic treatment of patients with chronically recurrent lower urinary tract infections. Albrecht U, Goos KH, Schneider B., Германия) - Solidago- семейство Астровых, Ortosophones- почечный чай, Birch (Cai T, Caola I, Tessarolo F, Piccoli F, et al. Solidago, orthosiphon, birch and cranberry extracts can decrease microbial colonization and biofilm development in indwelling urinary catheter: a microbiologic and ultrastructural pilot study. World J Urol. 2013 Oct 4. [Epub ahead of print] - Canephron– lovage, wild rose, centaury, Rosemary
  31. 31. WHAT? in low dosage – strong proapoptotic effect  Aminoglycosides (El Mouedden M., et al, Apoptosis in renal proximal tubules of rats treated with low doses of aminoglycosides, Antimicrobial Agents and Chemotherapy 2000, March 44 (3):665-675).  Penicillin acid inhibits induced-apoptosis Fas- (Bando M., Hasegawa M., Tsuboi Y. et al. The Mycotoxin Penicillin Acid inhibits Fas Ligand-iduced apoptosis by blocking self-processing of caspase-8 in death-inducing signaling complex. J Biol Chem 2003, 278(8):5786-5793
  32. 32.  Ceftriaxone associated nephrolithiasis: a prospective study in 284 children. Mohkam M, Karimi A, Gharib A, Daneshmand H, Khatami A, Ghojevand N, Sharifian M. Pediatr Nephrol. 2007 May;22(5):690-4. Ceftriaxone-associated biliary pseudolithiasis in children. [J Clin Ultrasound. 2006]  Nephrolithiasis associated with ceftriaxone therapy: a prospective study in 51 children. [Arch Dis Child. 2004] –8% of patients - stones d=2 мм in 7 mo after treatment  Ceftriaxone-associated nephrolithiasis and biliary pseudolithiasis in a child. [Pediatr Radiol. 2003] 
  33. 33. PLANT DERIVATES    Cranberry juice (Orange, pineapple) prevents the adhesion of E. Coli strains to uroepitelial cells (Pfimbriae and L-fimbriae) Damage of Р-fimbriae-polymer of E. сoli cover и reduction of its length in 3 times (from 148 to 48 nm) Cranberry Proanthocyanidins selective action on the urinary tract microflora (safety of oropharyngeal and intestinal biocenosis) Zafriri D., Ofek I., Adar R., Pocino M., Sharon N. Inhibitory activity of cranberry juice on adherence of type 1 and type P fimbriated Escherichia coli to eucaryotic cells // Antimicrob Agents Chemother. -1989.- v.33,№1.Р.92–98 Kontiokari Т., Salo J., Eerola E., Uhari U. Cranberry juice and bacterial colonization in children—A placebocontrolled randomized trial // Clinical Nutrition.- 2005.- v.24,№6.- Р.1065-1072 Liu Y, Black M.A., Caron L., Camesano T.A. Role of cranberry juice on molecular-scale surface characteristics and adhesion behavior of Escherichia coli // Biotechnol Bioeng.- 2006.- v.93,№2.- Р.297-305
  34. 34.  Does early treatment of urinary tract infection prevent renal damage? Doganis D, et al. Pediatrics. 2007 Oct;120(4):e922-8. Greece. 278 infants (153 males, 125 females) age-0.5 to 7.5 mo. with acute pyelonephritis  Early in the first 24 hours adequate treatment reduces the possibility of the kidneys involvement in acute inflammation,  but does not prevent the development of nephrosclerosis 
  35. 35. HOW AND FOR HOW LONG? SCHEME OF ANTIMICROBIAL THERAPY     Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled noninferiority trial (BMJ. 2007 August 25; 335(7616): 386 ) 28 pediatric clinics of North Italy 502 child (age 1-7 years) with pyelonephritis Oral co-amoxyclav (50 mg/kg/day in 3 admission for 10 days) or parenteral ceftriaxone (50 mg/kg/day once for 3 days) switch on to oral co-amoxyclav (50 mg/kg/day in 3 admission for 7 days)
  36. 36. Criteria of efficiency : signs of nephrosclerosis on scintigramms through 12 months  The result: no reliable differences between groups (13.7 vs 17.7%) 
  37. 37. PREVENTION OF RECURRING UTI (1)  The main task-appropriate antibacterial prevention of recurring UTI amoxicillin in infants and trimethoprim in senior schildren Update on Vesicoureteral Reflux: Pathogenesis, Nephropathy, and Management Ross M Decter, MD Rev Urol. 2001 Fall; 3(4): 172–178
  38. 38. PREVENTION OF RECURRING UTI (2)  Long-term antibiotics for preventing recurrent urinary tract infection in children Cochrane Database Syst Rev. 2006 Jul 19;3:CD001534  Total - 8 researches (618 children) 5 of them (406 children)-comparison of antibiotics and placebo Duration of treatment-from 10 weeks to 12 months 1 study-nitrofurantoin is more effective than trimethoprim, but poor compliance of nitrofurantoina   
  39. 39. AUTHORS' CONCLUSIONS: Large, properly randomised, double blinded studies are needed !!!! to determine the efficacy of long-term antibiotics for the prevention of UTI Cochrane Database Syst Rev. 2006 Jul 19;3:CD001534
  40. 40. MODERN DATA ON THE A/B PREVENTION OF UTI  Randomized controlled study (over 2 years) a/b prevention of UTI relapses by TRIMETHOPRIM  100 children under 30 mo with VUR 2-4 grade  4 years follow-up  The equal frequency of UTI relapses and RN the formation Pennesi M et al, Is antibiotic profylaxis in children with VUR effective in preventing pyelonephritis and renal scars ? A randomized controlled trial, PEDIATRICS Vol. 121, № 6, 2008, pp.e1489-1494
  41. 41. MODERN DATA ON THE A/B PREVENTION OF UTI  Specialists from UK [National Institute for Health and Clinical Excellence (NICE), UK]  10 randomized controlled trials – antibacterial prevention of UTI relapses and NS development in children with VUR, based on Medline, EMBASE, CINAHL и Cochrane Library.  No reliable data from the point of view of evidence-based medicine Verier-Jones K et al. Effectiveness of antibiotic prophylaxis for children at risk of developing UTI and renal scarring: Results of systematic review carried out on behalf of the National Institute for Health and Clinical Excellence (NICE), UK, Pediatric Nephrol 2008, v23, n9, p1595
  42. 42.       Since 1975, the 11 major comparative studies (1550 children with UTI)effectiveness of prolonged antibacterial therapy (an equatorial comparison with placebo) There is no reliable differences in the frequency of exacerbations after 12 months. treatment-20% develop recurrence: 3 studies (394 ch)- the efficiency of cranberry derivatives 2 researches (252 ch)- the efficiency of vitamin A Conclusion: the largest evidence basesmall efficiency of prolonged antibiotic therapy. Possible efficiency of cranberry derivatives. Finnell SM, Carroll AE, Downs SM; Subcommittee on Urinary Tract Infection. - Technical report— Diagnosis and management of an initial UTI in febrile infants and young children. Pediatrics. 2011 Sep;128(3):e749-70 Williams GJ, Craig JC, Carapetis JR. Preventing urinary tract infections in early childhood. Adv Exp Med Biol. 2013;764:211-8. Review
  43. 43. HOME MESSAGE NICE UTI Guidelines, 2008  NEED FOR A WELL-DESIGNED STUDY !!! Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR): Background Commentary of RIVUR Investigators Russell W. Chesney, MDa, Myra A. Carpenter, PhDb, Marva Moxey-Mims, MDc, Leroy Nyberg, MDc, Saul P. Greenfield, MDd, Alejandro Hoberman, MD, MPHe, Ron Keren, MD, MPHf, Ron Matthews, MDg, Tej K. Matoo, MDh, members of the RIVUR Steering Committee Pediatrics. 2008 Dec;122 Suppl 5:S233-9. Adv Chronic Kidney Dis. 2011 Sep;18(5):348-54. Vesicoureteral reflux and reflux nephropathy. Mattoo TK. (USA)  The need to establish of the national programme?
  44. 44. INDICATIONS FOR CLINICAL URINE ANALYSIS !!!!!!! Т >380С or long subfebrilitet for no apparent reason (all children, in particular, young children)  Unexplained vomiting and abdominal pain  Frequent urination, dysuria, enuresis  Decrease or loss of appetite  Prolonged jaundice in neonates  Vague signs of well-being  Hematuria (visually) and hypertension 

×