On approval of guidelines for antenatal and postnatal prediction of risk groups for newborns and determination of health groups for children in the neonatal period. Health groups and risk groups of newborns Risk of child infection

Every pregnant woman registered with the antenatal clinic must be tested for HIV twice - at the first visit and in the third trimester. If a positive or doubtful test for antibodies to HIV is detected, the woman is immediately sent for a consultation to the AIDS Center to clarify the diagnosis.

Transmission of HIV from mother to child is possible during pregnancy, more often in late pregnancy, during childbirth and while breastfeeding.

Without preventive measures, the risk of HIV transmission is up to 30%. The risk of infection of the child increases if the mother was infected within six months before the onset of pregnancy or during pregnancy, and also if the pregnancy occurred in the late stages of HIV infection. The risk increases with a high viral load (the amount of virus in the blood) and low immunity. An increase in the risk of infection of the child occurs with repeated pregnancies.

With proper preventive measures, the risk of transmitting HIV infection from mother to child is reduced to 2%.

In this brochure you will find information on how to reduce the risk of infection in your child and how long dispensary observation child at the AIDS Center.

Reducing the risk of mother-to-child transmission of HIV

When contacting the AIDS Center, a pregnant woman receives advice from an infectious disease specialist, an obstetrician-gynecologist, a pediatrician; passes all the necessary tests (viral load, immune status, etc.), after which the issue of prescribing antiretroviral (ARV) drugs to the woman is decided. When ARV drugs are taken correctly, the amount of virus in the blood decreases and the risk of passing HIV to an unborn child is reduced. The choice of the regimen and the term of prescription of ARV drugs is decided individually. The safety of their use for the fetus and the pregnant woman herself has been proven. The medicines are given out free of charge according to the prescriptions of the doctors of the AIDS Center.

The effectiveness of drugs should be checked by the end of pregnancy ( laboratory research for viral load).

A pregnant woman must continue to be observed at the antenatal clinic at the place of residence.

Preventing mother-to-child transmission of HIV involves 3 steps:

Stage 1. Taking medication by a pregnant woman. Prevention should be started as early as possible, preferably from 13 weeks of gestation, with three drugs and continued until delivery.

Stage 2. Intravenous administration ARV drug for a woman during childbirth (“dropper”).

Stage 3. Taking drugs for a newborn baby. Taking drugs by a child begins in the first 6 hours after birth (no later than 3 days). Most children receive zidovudine syrup at a dose of 0.4 ml per 1 kg of body weight twice a day (every 12 hours) for 28 days. In special cases, the doctor can add 2 more drugs to the child for prevention: viramune suspension - 3 days, epivir solution - for one week.

Births take place in maternity hospitals at the woman's place of residence. Maternity hospitals in the Moscow region are provided with all the necessary ARV drugs for prevention. The method of delivery (natural childbirth or caesarean section) is chosen by the general decision of the infectious disease specialist and obstetrician-gynecologist.

Breastfeeding is one of the ways of transmission of HIV infection (not only breastfeeding itself, but also feeding with expressed milk). Without exception, all women with HIV infection should not breastfeed!

Timing of examination of children
born to HIV-infected mothers in the first year of life.

Up to 1 year of life, the child is examined three times:

• In the first 2 days after birth, blood is taken in the maternity hospital for examination for HIV method PCR (detects virus particles) and ELISA (detects antibodies - protective proteins produced by the human body in the presence of infection) for delivery to the AIDS Center.
• At 1 month of life - blood is taken for HIV PCR method in a children's polyclinic or hospital, in an HIV prevention room at the place of residence (if you have not donated blood at the place of residence, this will need to be done at the AIDS Center in 2 months).
• At 4 months of life - it is necessary to come to the AIDS Center of the Moscow Region for a pediatrician to examine the child and to test the blood for HIV by PCR. Also, the doctor may prescribe additional tests for your child (immune status, hematology, biochemistry, hepatitis C, etc.).

If you miss one of the examination dates, do not postpone it until a later time. At the age of 1 month and up to 1 year of life, the child must be tested for HIV by PCR at least 2 times!

What do the test results mean?

Positive blood test for HIV antibodies

All children of HIV-positive mothers are also positive from birth, and this is normal! The mother passes on her proteins (antibodies) in an attempt to protect the baby. Maternal antibodies should leave the blood of a healthy child by 1.5 years (on average).

Positive PCR result

This study directly detects the virus itself, which means that a positive PCR may indicate a possible infection of the child. An urgent appearance of the child in the AIDS Center for rechecking is required.

Negative PCR

A negative result is the best result! Virus not detected.

• A negative PCR on the second day of a child's life indicates that most likely the child did not become infected during pregnancy.
• Negative PCR at 1 month of life says that the child was not infected during childbirth. The reliability of this analysis at the age of one month is about 93%.
• Negative PCR over the age of 4 months - the child is not infected with a probability of almost 100%.

Examinations of children from 1 year.

If a child already has negative results of blood tests for HIV by PCR, the main research method from the age of 1 year is the determination of antibodies to HIV in the child's blood. Average age when the child's blood is completely "cleared" of maternal proteins - 1.5 years.

• At the age of 1, the child donates blood for antibodies to HIV at the AIDS Center or at the place of residence. If a negative test result is obtained, repeat after 1 month and the child can be deregistered ahead of schedule. A positive or questionable result for HIV antibodies requires a retake after 1.5 years.
• At the age of over 1.5 years - one negative result for antibodies to HIV is enough to remove the child from the register in the presence of previous examinations.

Deregistration of children

• The age of the child is over 1 year old;
• The presence of two or more negative PCR at the age of over 1 month;
• Having two or more negative test results for HIV antibodies over the age of 1 year;
• No breastfeeding in the last 12 months.

Confirmation of the diagnosis of HIV infection in a child

Confirmation is possible at any age from 1 to 12 months with two positive HIV PCR results.

In children older than 1.5 years, the criteria for making a diagnosis are the same as for adults (presence of a positive blood test for antibodies to HIV).

The diagnosis is confirmed only by specialists of the AIDS Center.

Children with HIV infection are constantly under the supervision of a pediatrician of the AIDS Center, as well as in a children's polyclinic at the place of residence. HIV infection may be asymptomatic, but there comes a time when the doctor will prescribe treatment for the child. Modern medications allow you to suppress the immunodeficiency virus, thereby eliminating its effect on the body of a growing child. Children with HIV can lead a full life, visit any children's institutions on a general basis.

Vaccination

Children of positive mothers are vaccinated like all other children according to the national calendar, but with two special features:

• The polio vaccine must be inactivated (not live).
• Permission for the BCG (tuberculosis) vaccination, which is usually given in the maternity hospital, you will receive from the pediatrician of the AIDS Center

Phone of the pediatric department: 8-9191397331 (from 0900 to 1500 except Thursdays).

We are waiting for you with your children only on Thursdays from 8 00 to 14 00, on other days (except weekends) you can get a consultation from a pediatrician, find out the results of the child's tests from 09 00 to 16 00.

Your child's health is in your hands!

If you are HIV-positive and plan to have healthy children, you must visit the AIDS Center before you become pregnant!

If you are diagnosed with HIV infection during pregnancy, contact the AIDS Center as soon as possible in order to timely start preventive measures aimed at reducing the risk of HIV infection in future babies!

HIV infection is not transmitted to most children born to HIV-positive mothers

Risk of HIV transmission from mother to child

20% - during pregnancy.
60% - during childbirth.
20% - at breastfeeding.

What does it take for an HIV-infected woman to give birth to a healthy baby?

Prevention of vertical transmission (PVT) is a set of measures aimed at preventing the transmission of HIV from mother to child at all possible stages (pregnancy, childbirth, feeding).

Algorithm of preventive measures:

• If a pregnant woman is diagnosed with HIV infection, she must register with a gynecologist at the AIDS Center.
• From 24-28 weeks of gestation, an HIV-positive pregnant woman should start taking antiviral drugs (according to the approved protocol) until the time of delivery. The drugs will be given to her at the regional AIDS center free of charge.
• The method of delivery is chosen in conjunction with gynecologist AIDS center individually, according to the approved protocol, depending on the viral load (the amount of virus in the woman's blood).
• If prophylactic ART is started late (in labor) or if the viral load is high, delivery by caesarean section to avoid as much as possible the baby's contact with the mother's blood and vaginal secretions.
• Immediately after birth, each child born to an HIV-positive mother is given the antiviral drug Zidovudine in syrup for 7 or 28 days. The drug is issued in maternity hospital for the entire course.
• Breastfeeding is not recommended. Immediately after birth, the child is transferred to artificial feeding with adapted milk mixtures.

When carrying out all the above activities, the risk of HIV transmission from mother to child is no more than 1-2%.

Risk factors for mother-to-child transmission of HIV

1. Mother's stage of HIV infection.
2. Absence preventive treatment during pregnancy.
3. Multiple pregnancy.
4. Long dry period.
5. premature birth.
6. Independent childbirth.
7. Bleeding, aspiration during childbirth.
8. Breast-feeding.
9. Injection drug use, alcohol abuse during pregnancy.
10. Co-infection (tuberculosis, hepatitis).
11. Extragenital pathology.

Peculiarities of management of a child born from an HIV-positive mother at a pediatric site

1. Carefully study the extract from the maternity hospital.
2. Pay attention to: vaccination of the child (vaccination against hepatitis B - carried out, BCG not carried out); prophylactic treatment regimen with Zidovudine (7 or 28 days).
3. Check the presence of Zidovudine syrup in the mother and whether she knows about the mode and duration of the drug (2 times a day at the rate of 4 mg / kg for each dose, for 7 or 28 days). Once again explain to the mother why it should be taken (prevention of HIV infection in the newborn).
4. All children, until the HIV status is clarified, are under the supervision of the pediatrician of the AIDS center, the district pediatrician and the pediatric phthisiatrician.
5. The child is examined and treated for all concomitant diseases, at the place of residence, on a general basis.
6. medical documentation the child must be kept separately in an inaccessible place for other persons and remember that information about the status of the child and his parents is strictly confidential.
7. After a child is removed from the register for HIV infection, it is recommended to replace his outpatient card with a new one, which will not contain information that the child was registered with an AIDS center.

Criteria for registration and deregistration at the AIDS center

For the first examination and examination of the child, it is necessary to receive a referral to the regional AIDS center at the age of 1 month, where he will be taken blood for the determination of HIV RNA by PCR and for the determination of antibodies to HIV by ELISA. Further tactics of conducting a child depends on the results of the study.

Examination for the determination of PCR HIV RNA at 1 month

The main clinical symptoms of HIV infection in children

1. Delayed weight gain and growth. Anthropometry is obligatory monthly.
2. Delayed psychomotor and physical development. Mandatory observation by a neurologist.
3. Painless enlargement lymph nodes(over 0.5 cm) in two or more groups (cervical, axillary, etc.)
4. Enlargement of the liver and spleen for no apparent reason.
5. Recurrent parotitis (enlarged salivary glands).
6. Relapses of thrush or manifestations of thrush in children older than 6 months.
7. Candidiasis of the skin and mucous membranes.
8. Recurrent bacterial infections: pneumonia, otitis, sinusitis, pyoderma, etc.
9. Relapses of herpes simplex and herpes zoster.
10. Relapses of chicken pox.
11. Common molluscum contagiosum.
12. Angular cheilitis, "zaed".

Features of monitoring, nutrition and vaccination of HIV-positive children

1. All HIV-positive children are registered with the pediatrician of the AIDS Center, district pediatrician, pediatric phthisiatrician.
2. Examination of an HIV-positive child by a pediatrician of the AIDS Center and a district pediatrician is carried out at least once every 3 months.
3. Anthropometry, examination by a pediatrician, assessment of the state of immunity (blood sampling to determine the number of CD4-lymphocytes), determination of viral load are carried out at the reception at the AIDS center.
4. Vaccination of HIV-positive children is carried out in the polyclinic at the place of residence in accordance with Order No. 48 of 03.02.06 and Order No. 206 of 07.04.06.
5. HIV-positive children are recommended to increase the caloric intake by an average of 30% of the age norm.
6. At the pediatric site at the place of residence, the mandatory examination of an HIV-positive child includes:
   • Anthropometry (up to 6 months - 1 time per month), after 6 months 1 time in 3 months.
   • Examination by a phthisiatrician 1 time in 6 months.
   • Mantoux reaction 1 time in 6 months.
   • Examination by an ophthalmologist with a description of the fundus once every 12 months.
   • KLA, OAM, biochemical blood test, blood sugar - 1 time in 6 months.

IMPORTANT: HIV-positive children attend kindergartens and schools on a general basis. With the consent of the parents, only the medical staff of the children's institution or school can be informed about the child's HIV status.

IMPORTANT: HIV-positive children undergo annual rehabilitation in children's health institutions of the appropriate profile.

Principles and approaches to the treatment of HIV infection in children

1. For the treatment of HIV infection, highly active antiretroviral therapy (HAART) is used - a combination of several antiretroviral drugs that are prescribed simultaneously, continuously and for life.
2. The appointment of HAART for an HIV-infected child is carried out on a commission basis by specialists from the AIDS Center. with the written consent of the parents (guardians).
3. Preparations for the treatment of HIV infection are given to the child's parents in their hands when visiting the AIDS center with recommendations for taking and doses.
4. HAART leads to the suppression of the reproduction of the virus, but does not completely remove it from the body.
5. The use of monotherapy (one ARV drug) or bitherapy (two ARV drugs) is not allowed, as it leads to the formation of HIV resistance to ARV drugs and the ineffectiveness of further treatment.
6. It is important to strictly adhere to the regimen of taking drugs (dose, time, frequency of doses) - a violation of the treatment regimen can quickly lead to its ineffectiveness.
7. If inpatient treatment is required, an HIV-infected child can be hospitalized in a specialized department or in any health facility (in accordance with the indications).

Excerpts from the main document regulating this issue:

RESOLUTION of October 22, 2013 N 58 ON APPROVAL OF SANITARY AND EPIDEMIOLOGICAL RULES SP 3.1.3112-13 "PREVENTION OF VIRAL HEPATITIS C"

7.6. Children born from mothers infected with the hepatitis C virus are subject to dispensary observation in medical organization at the place of residence with a mandatory examination of blood serum (plasma) for the presence of anti-HCV IgG and hepatitis C virus RNA. Detection of anti-HCV IgG in such children has no independent diagnostic value, since antibodies to the hepatitis C virus obtained from the mother can be detected during pregnancy. The first examination of the child is carried out at the age of 2 months. In the absence of hepatitis C virus RNA at this age, the child is re-examined for the presence of anti-HCV IgG and hepatitis C virus RNA in the serum (plasma) at the age of 6 months. The detection of hepatitis C virus RNA in a child at the age of 2 months or 6 months indicates the presence of AHS. Further examination of the child is carried out at the age of 12 months. Re-detection of hepatitis C virus RNA at this age indicates CHC as a result of perinatal infection, and the subsequent dispensary observation of the child is carried out in accordance with paragraph 7.4 of these sanitary rules. With the initial detection of hepatitis C virus RNA at the age of 12 months, it is necessary to exclude infection of the child in more than late dates when implementing other routes of transmission of the hepatitis C virus. In the absence of hepatitis C virus RNA at the age of 12 months (if hepatitis C virus RNA was detected earlier at 2 or 6 months), the child is considered a convalescent AHC and is subject to examination for the presence of anti-HCV IgG and hepatitis virus RNA C at 18 and 24 months of age. A child who does not have hepatitis C virus RNA at the age of 2 months, 6 months and 12 months is subject to withdrawal from dispensary observation if he does not have anti-HCV IgG at 12 months of age. A child who does not detect hepatitis C virus RNA at the age of 2 months, 6 months and 12 months, but anti-HCV IgG is detected at the age of 12 months, is subject to an additional examination for the presence of anti-HCV IgG and virus RNA in the blood serum (plasma) hepatitis C at 18 months of age. In the absence of anti-HCV IgG and hepatitis C virus RNA at the age of 18 months, the child is subject to removal from dispensary observation. Detection of anti-HCV IgG at the age of 18 months and older (in the absence of hepatitis C virus RNA) may be a sign of acute hepatitis C in the first months of life. Diagnosis of hepatitis C in children born to hepatitis C-infected mothers who have reached the age of 18 months is carried out in the same way as in adults.

7.7. Obstetric organizations should transfer information about children born to mothers infected with the hepatitis C virus to the children's polyclinic at the place of registration (or residence) for further observation.

Statistics show an annual increase in the number of HIV-infected people. The virus, which is very unstable in the external environment, is easily transmitted from person to person during sexual intercourse, as well as in childbirth from mother to child and breastfeeding. The disease is controllable, but a complete cure is impossible. Therefore, pregnancy with HIV infection should be under the supervision of a doctor and with appropriate treatment.

About the pathogen

The disease is caused by the human immunodeficiency virus, which is represented by two types - HIV-1 and HIV-2, and many subtypes. It infects cells immune system– CD4 T-lymphocytes, as well as macrophages, monocytes and neurons.

The pathogen multiplies rapidly and infects a large number of cells during the day, causing their death. To compensate for the loss of immunity, B-lymphocytes are activated. But this gradually leads to the depletion of protective forces. Therefore, opportunistic flora is activated in HIV-infected people, and any infection proceeds atypically and with complications.

The high variability of the pathogen, the ability to lead to the death of T-lymphocytes allows you to get away from the immune response. HIV quickly forms resistance to chemotherapy drugs, so at this stage in the development of medicine, it is not possible to create a cure for it.

What signs indicate the disease?

The course of HIV infection can be from several years to decades. The symptoms of HIV during pregnancy do not differ from those in the general population of those infected. Manifestations depend on the stage of the disease.

At the stage of incubation, the disease does not manifest itself. The duration of this period is different - from 5 days to 3 months. Some already after 2-3 weeks are worried about the symptoms of early HIV:

• weakness;
• flu-like syndrome;
• enlarged lymph nodes;
• a slight unreasonable increase in temperature;
• rash on the body;

After 1-2 weeks, these symptoms subside. Quiet period may continue long time. For some it takes years. The only signs may be recurrent headaches and permanently enlarged, painless lymph nodes. Can also join skin diseases- Psoriasis and eczema.

Without the use of treatment, the first manifestations of AIDS begin in 4-8 years. In this case, the skin and mucous membranes are affected by a bacterial and viral infection. Patients lose weight, the disease is accompanied by candidiasis of the vagina, esophagus, pneumonia often occurs. Without antiretroviral therapy, after 2 years, the final stage of AIDS develops, the patient dies from an opportunistic infection.

Management of pregnant women

AT last years the number of pregnant women with HIV infection is increasing. This disease can be diagnosed long before pregnancy or during the gestational period.

HIV can pass from mother to child during pregnancy, childbirth, or breast milk. Therefore, planning pregnancy with HIV should be done in conjunction with a doctor. But not in all cases, the virus is transmitted to the child. The following factors influence the risk of infection:

• the immune status of the mother (the number of viral copies is more than 10,000, CD4 is less than 600 in 1 ml of blood, the CD4/CD8 ratio is less than 1.5);
• clinical situation: the presence of an STI in a woman, bad habits, drug addiction, severe pathologies;
• genotype and phenotype of the virus;
• the condition of the placenta, the presence of inflammation in it;
• gestational age at infection;
• obstetric factors: invasive interventions, duration and complications in childbirth, anhydrous time;
• condition skin newborn, the maturity of the immune system and digestive tract.

The consequences for the fetus depend on the use of antiretroviral therapy. In developed countries, where women with infection are monitored and instructions are followed, the effect on pregnancy is not pronounced. In developing countries, HIV can develop the following conditions:

• spontaneous miscarriages;
• antenatal fetal death;
• accession of STIs;
• premature;
• low birth weight;
• postpartum infections.

Examinations during pregnancy

All women give blood for HIV when they register. A re-examination is carried out at 30 weeks, a deviation up or down by 2 weeks is allowed. This approach makes it possible to identify at an early stage pregnant women who are already registered as infected. If a woman becomes infected on the eve of pregnancy, then the examination before childbirth coincides in time with the end of the seronegative period, when it is impossible to detect the virus.

A positive HIV test during pregnancy warrants referral to an AIDS center for further diagnosis. But only one express test for HIV does not establish a diagnosis; this requires an in-depth examination.

Sometimes an HIV test during gestation turns out to be a false positive. This situation can scare the expectant mother. But in some cases, the features of the functioning of the immune system during gestation lead to such changes in the blood, which are defined as false positive. And this may apply not only to HIV, but also to other infections. In such cases, additional tests are also prescribed, which allow an accurate diagnosis.

The situation is much worse when a false-negative analysis is obtained. This can happen when blood is taken during the seroconversion period. This is the period of time when infection occurred, but antibodies to the virus have not yet appeared in the blood. It lasts from several weeks to 3 months, depending on the initial state of immunity.

A pregnant woman who tests positive for HIV and further testing confirms the infection is offered a legal termination of pregnancy. If she decides to keep the child, then further management is carried out simultaneously with the specialists of the AIDS Center. The need for antiretroviral (ARV) therapy or prophylaxis is decided, the time and method of delivery are determined.

Plan for women with HIV

For those who were already registered as infected, as well as with a detected infection, in order to successfully bear a child, it is necessary to adhere to the following observation plan:

1. When registering, except for the main scheduled examinations required ELISA for HIV, immune blotting reaction. The viral load is determined, the number of CD lymphocytes. The specialist of the AIDS Center gives advice.
2. At 26 weeks, the viral load and CD4 lymphocytes are re-determined, the general and biochemical analysis blood.
3. At 28 weeks, a specialist from the AIDS Center consults a pregnant woman, selects the necessary AVR therapy.
4. At 32 and 36 weeks, the examination is repeated, the AIDS Center specialist also advises the patient on the results of the examination. At the last consultation, the term and method of delivery are determined. If there are no direct indications, then preference is given to urgent delivery through the natural birth canal.

Throughout pregnancy, procedures and manipulations that lead to a violation of the integrity of the skin and mucous membranes should be avoided. This applies to holding and. Such manipulations can lead to contact of the mother's blood with the baby's blood and infection.

When is urgent analysis needed?

In some cases, an express HIV test at the maternity hospital may be prescribed. This is necessary when:

• the patient was never examined during pregnancy;
• only one analysis was passed when registering, there was no second test at 30 weeks (for example, a woman comes with a threat of preterm birth at 28-30 weeks);
• pregnant women were tested for HIV the right time but it has an increased risk of infection.

Features of HIV therapy. How to give birth to a healthy child?

The risk of vertical transmission of the pathogen during childbirth is up to 50-70%, while breastfeeding - up to 15%. But these figures are significantly reduced by the use of chemotherapeutic drugs, with the refusal of breastfeeding. With a properly selected scheme, a child can get sick only in 1-2% of cases.

Antiretroviral drugs for prevention are prescribed to all pregnant women, regardless of clinical symptoms, viral load and CD4 count.

Prevention of transmission of the virus to the child

Pregnancy in HIV-infected people takes place under the guise of special chemotherapy drugs. To prevent infection of the child, use the following approaches:

• prescribing treatment for women who were infected before pregnancy and are planning to conceive;
• use of chemotherapy for all infected;
• during childbirth, drugs for ARV therapy are used;
• prescribed after childbirth similar medicines for a child.

If a woman has a pregnancy from an HIV-infected man, then ARV therapy is prescribed to the sexual partner and to her, regardless of the results of her tests. Treatment is carried out during the period of bearing a child and after his birth.

Particular attention is paid to those pregnant women who use drugs and have contacts with sexual partners with similar habits.

Treatment at the initial detection of the disease

If HIV is detected during gestation, treatment is prescribed depending on the time when this happened:

1. Less than 13 weeks. ART drugs are prescribed if there are indications for such treatment until the end of the first trimester. For those who are at high risk of fetal infection (with a viral load of more than 100,000 copies / ml), treatment is prescribed immediately after the tests. In other cases, in order to exclude a negative effect on the developing fetus, with the start of therapy, it is timed until the end of the 1st trimester.
2. Term from 13 to 28 weeks. If the disease is detected in the second trimester or an infected woman applied only in this period, treatment is prescribed urgently immediately after receiving the results of tests for viral load and CD
3. After 28 weeks. Therapy is prescribed immediately. Use the scheme of three antiviral drugs. If treatment is first started after 32 weeks with a high viral load, a fourth drug may be added to the regimen.

A highly active antiviral therapy regimen includes certain groups of drugs that are used in a strict combination of three of them:

• two nucleoside reverse transcriptase inhibitors;
• a protease inhibitor;
• or a non-nucleoside reverse transcriptase inhibitor;
• or an integrase inhibitor.

Preparations for the treatment of pregnant women are selected only from groups whose safety for the fetus has been confirmed. clinical research. If it is impossible to use such a scheme, you can take drugs from the available groups, if such treatment is justified.

Therapy in patients previously treated with antiviral drugs

If HIV infection was detected long before conception and the expectant mother underwent appropriate treatment, then HIV therapy is not interrupted even in the first trimester of gestation. Otherwise, this leads to a sharp increase in viral load, worsening test results and the risk of infection of the child during the gestation period.

With the effectiveness of the scheme used before gestation, there is no need to change it. The exception is drugs with a proven danger to the fetus. In this case, the replacement of the drug is made on an individual basis. Efavirenz is considered the most dangerous of those for the fetus.

Antiviral treatment is not a contraindication for pregnancy planning. It has been proven that if a woman with HIV consciously approaches the conception of a child, follows the medication regimen, then the chances of giving birth to a healthy baby increase significantly.

Prevention in childbirth

The protocols of the Ministry of Health and WHO recommendations define the cases when it is necessary to prescribe a solution of Azidothymidine (Retrovir) intravenously:

1. If antiviral treatment was not used with a pre-delivery viral load of less than 1000 copies / ml or more than this amount.
2. If a rapid HIV test in the maternity hospital gave a positive result.
3. If there are epidemiological indications, contact with a sexual partner infected with HIV within the last 12 weeks while injecting drugs.

Choice of method of delivery

To reduce the risk of infection of the child during childbirth, the method of delivery is determined on an individual basis. Childbirth can be performed through the natural birth canal in the case when the woman in labor received ART during pregnancy and the viral load at the time of delivery is less than 1000 copies/ml.

Be sure to detect the time of the outflow of amniotic fluid. Normally, this occurs in the first stage of labor, but sometimes prenatal effusion is possible. Considering the normal duration of labor, this situation will result in an anhydrous gap of more than 4 hours. For an HIV-infected woman in labor, this is unacceptable. With such a duration of the anhydrous period, the probability of infection of the child increases significantly. A long waterless period is especially dangerous for women who have not received ART. Therefore, a decision can be made to complete the birth by.

In childbirth with a living child, any manipulations that violate the integrity of tissues are prohibited:

• amniotomy;
• episiotomy;
• vacuum extraction;
• application of obstetrical forceps.

Also do not carry out labor induction and labor intensification. All this significantly increases the chances of infection of the child. It is possible to carry out the listed procedures only for health reasons.

HIV infection is not an absolute indication for caesarean section. But it is highly recommended to use the operation in the following cases:

Caesarean section completely excludes the contact of the child with the discharge of the mother's genital tract, therefore, in the absence of HIV therapy, it can be considered an independent method of preventing infection. The operation can be performed after 38 weeks. Planned intervention is performed in the absence of labor. But it is possible to carry out a caesarean section and according to emergency indications.

In childbirth through the natural birth canal, at the first examination, the vagina is treated with a 0.25% solution of chlorhexidine.

A newborn after childbirth must be bathed in a bath with aqueous chlorhexidine 0.25% in an amount of 50 ml per 10 liters of water.

How to prevent infection during childbirth?

To prevent infection of the newborn, it is necessary to carry out HIV prevention during childbirth. Drugs are prescribed and administered to a woman in labor and then to a newborn child only with written consent.

Prevention is necessary in the following cases:

1. Antibodies to HIV were detected during testing during pregnancy or using a rapid test in a hospital.
2. According to epidemic indications, even in the absence of a test or the impossibility of conducting it, in the case of a pregnant woman injecting drugs or her contact with an HIV-infected person.

The prevention scheme includes two drugs:

• Azitomidine (Retrovir) intravenously, is used from the moment of onset of labor until the umbilical cord is cut, it is also used within an hour after childbirth.
• Nevirapine - one tablet is drunk from the moment of the onset of labor. With a duration of labor of more than 12 hours, the drug is repeated.

In order not to infect the child through breast milk, it is not applied to the chest either in the delivery room or subsequently. Also, bottled breast milk should not be used. Such newborns are immediately transferred to adapted mixtures. A woman is prescribed Bromkriptine or Cabergoline to suppress lactation.

Mother in the postpartum period antiviral therapy continue with the same drugs as during the gestation period.

Prevention of infection in the newborn

A child born to an HIV-infected mother is given drugs to prevent infection, regardless of whether the woman has been treated. It is optimal to start prophylaxis 8 hours after birth. Until this period, the drug that was administered to the mother continues to act.

It's important to start giving. medicines in the first 72 hours of life. If a child becomes infected, then for the first three days the virus circulates in the blood and does not penetrate into the DNA of cells. After 72 hours, the pathogen is already attached to the host cells, so infection prevention is ineffective.

For newborns, liquid forms of drugs have been developed for use by mouth: Azidothymidine and Nevirapine. The dosage is calculated individually.

Such children are under dispensary registration up to 18 months. The criteria for deregistration are as follows:

• no antibodies to HIV in the study by ELISA;
• no hypogammaglobulinemia;
• no symptoms of HIV.

The term "urinary system infection" (UTI) refers to an inflammatory process in the urinary system without a special indication of the etiology and localization (urinary tract or renal parenchyma) and definition of its nature.

The term "urinary system infection" includes all infectious and inflammatory diseases of the urinary system (OMS) and includes pyelonephritis (PN), cystitis, urethritis, and asymptomatic bacteriuria. Thus, it is a group concept, but not a nosological form. Accordingly, the diagnosis of "urinary system infection" is possible only at the initial stages of the examination, when changes in the urine (leukocyturia and bacteriuria) are detected, but there is no indication of localization inflammatory process. In the future, such children require a full-fledged nephrourological examination and determination of the level of damage to the OMS, after which a more accurate diagnosis is established (cystitis, PN, etc.). This approach is also justified because it corresponds to the stages of pathology detection adopted in the pediatric service of our country. The first signs of infectious and inflammatory diseases of the OMS, as a rule, are detected at the preclinical stage (outpatient service, emergency service), when, in most cases, it is not possible to establish the exact localization of the process. Therefore, the diagnosis of "urinary tract infection or urinary system infection" is legitimate. In the future, in a specialized hospital, the diagnosis is specified.

In the domestic literature, there are various terms for designating the infectious process in the CHI: “CMA infection”, “urinary infection”, “urinary tract infection”, etc. At the same time, a certain meaning is put into each name. For example, "infection of the UMS" and "urinary infection" implies the possibility of localization of the infection in any department of the UMS or a total lesion of the kidneys and urinary tract; "urinary tract infection" means infection only of the urinary tract, but not of the kidneys, etc. Such a variety of terms introduces some confusion, especially since any of these diagnoses still requires examination and clarification of localization. In our opinion, for convenience, it is advisable to consider the terms "urinary tract infection", "URI infection", etc. as synonyms, while implying that any of them cannot be final and requires clarification.

However, this approach is not entirely consistent with ICD-10 (1995). According to the recommendation of WHO experts, which is the basis of ICD-10, urinary tract infection is an independent nosological entity and implies a disease in which there is no evidence of damage to the kidney parenchyma, but there are signs of transient inflammation of the lower urinary tract, which cannot be localized at the time of examination. Thus, the concept of "urinary tract infection" narrows down to lesions Bladder and urethra and excludes PN, which, according to ICD-10, belongs to the group of tubulo-interstitial nephritis.

This narrow interpretation of the term has its consequences. Firstly, this implies that the diagnosis of "urinary tract infection" can only be established in a hospital after a comprehensive nephrourological examination. Secondly, treatment can and should be prescribed even without an established localization of the infectious and inflammatory process. Thirdly, in fact, "urinary tract infection" is reduced to transient leukocyturia and bacteriuria against the background of the main intercurrent disease (bronchitis, pneumonia, SARS, tonsillitis, etc.) and quickly disappears during the treatment of the underlying disease and antibiotic therapy. Therefore, the courses of antibacterial drugs should be short (5-7 days).

Without pretending to be objective, we consider it more convenient to use the term "urinary tract infection" in accordance with the domestic tradition, since such an understanding is widespread among pediatricians in our country and is more consistent with the structure of the pediatric and pediatric nephrological service. In addition, infectious lesions of the urinary system are associated with a common etiopathogenesis and therapeutic tactics.

Epidemiology

The prevalence of UTI in the population is quite high and accounts for up to 80% of all OMS diseases. Among all diseases of infectious etiology, UTI ranks second after SARS.

The prevalence of UTI depends on age and gender (Table 1). If in the neonatal period, boys get sick one and a half times more often than girls, then in the following months these indicators are equalized, by the age of 1 year, the frequency of UTIs among girls is already 4 times higher, and after a year of life, the frequency of UTIs in girls is ten times higher than that in boys. Among patients of childbearing age, UTI is 50 times more common in women than in men (excluding urethritis and prostatitis). This leads us to the conclusion that, in fact, PN and cystitis are "female" diseases. AT childhood the prevalence of PN reaches 20-22 cases per 1000 children (M. V. Erman, 1997).

Terminology

PN is a nonspecific, acute or chronic microbial inflammation in the pyelocaliceal system and interstitial tissue of the kidneys with involvement of the tubules, blood and lymphatic vessels in the pathological process.

Cystitis is a microbial-inflammatory process in the wall of the bladder (usually in the mucous and submucosal layers).

Asymptomatic bacteriuria is a condition in which total absence clinical manifestations diseases bacteriuria is detected by one of the following methods: 10 or more microbial bodies in 1 ml of urine; or more than 105 colonies of microorganisms of the same species that have grown when sowing 1 ml of urine taken from the middle stream; or 103 or more colonies of microorganisms of the same species when inoculating 1 ml of urine taken with a catheter; or any number of colonies of microorganisms when sowing 1 ml of urine obtained by suprapubic puncture of the bladder.

The presence of bacteria in the general analysis of urine is not a reliable criterion for bacteriuria.

Ways of penetration of infection into the urinary system

The causative agent can enter the OMS in three ways: hematogenous, lymphogenous and ascending.

Hematogenous way the spread of the pathogen is of particular importance during the neonatal period and infancy. At an older age, its role is insignificant, although the significance of the hematogenous entry of the pathogen into the MMS cannot be denied in diseases such as furunculosis, bacterial endocarditis, sepsis, etc. In this case, the nature of pathogens can be different, but representatives of gram-positive flora and fungi are most common.

Lymphogenic pathway the entry of pathogens is associated with the general system of lymphatic circulation between the OMS and the intestines. Normally, lymph flows from the kidneys and urinary tract to the intestines, so the spread of bacteria from the intestinal cavity to the OMS along lymphatic vessels excluded; moreover, the intestinal mucosa itself is a barrier to the penetration of microorganisms into the blood and lymph. However, in conditions of violation of the barrier properties of the intestinal mucosa and lymphostasis, the probability of infection with OMS by the intestinal flora increases many times over. This situation occurs with long-term dyspepsia (diarrhea and, especially, chronic constipation), colitis, infectious diseases of the intestine, impaired motility and dysbacteriosis. With the lymphogenous route of infection, representatives of the intestinal microflora will be sown from the urine.

ascending path the spread of infection is dominant. The anatomical proximity of the urethra and anus leads to the fact that in the periurethral zone there is always a large number of bacteria that enter from the anus. The structural features of the external genital organs in girls and the shorter urethra create the most favorable conditions for the penetration of bacteria into the OMS in an ascending way, which leads to a higher frequency of UTIs. Therefore, it is very important to have a correct and regular toilet of the perineum (washing from the vulva to the anus), instilling a girl with early childhood personal hygiene skills. The main pathogens in the ascending path are representatives of the intestinal microflora.

Etiological structure of IMS

The representatives of the Enterobacteriacae family are sown most often with UTI, and among them - coli(E. coli), the proportion of which, according to different authors, ranges from 40 to 90%.

The multicenter study of ARMID, conducted in various centers of our country in 2000-2001, revealed that in 57% of cases the causative agent of community-acquired UTI in children is Escherichia coli, in 9% - Proteus, in 9% - enterococci, in 9% - Klebsiella , in 6% - enterobacters, in 6% - Pseudomonas aeruginosa and in 4% - staphylococci (Strachunsky L. S., Korovina N.A., Papayan A. V. et al., 2001).

It should also take into account the change in the composition of pathogens with the age of the patient. So, if in newborns and children of the first year of life in 75-85% of the causative agent in PN is Escherichia coli, then in boys its share further decreases to 33% and the role of Proteus increases (up to 33%) and St. aureus (up to 12%); whereas in girls under 10 years of age, Escherichia coli (up to 85%) is also often sown, and after 10 years - Escherichia coli (up to 60%) and St. aureus (up to 30%). Summary data on the etiological structure of PN in children are given in Table. 2.

The composition of the seeded microflora at chronic course PN has some special features. At the same time, the role of microbial associations increases, the presence of which can be considered as one of the factors of chronicity (Table 3). In addition, a feature of the culture results in chronic PN is a lower number of sown microorganisms than in acute PN. According to some authors, diagnostically significant bacteriuria is detected in acute PN twice as often as in chronic. However, the proportion of gram-positive flora in children with chronic PN is higher. In addition, L-forms of bacteria are much more often found in chronic PN.

Viruses (adenovirus, influenza, Coxsackie A, etc.) play a certain role in the genesis of UTIs. Acute viral infection or the persistence of viruses in the renal tissue causes damage to the uroepithelium, a decrease in local resistance, a violation of microcirculation, etc., thus facilitating the penetration of bacteria into the MMS.

Predisposing factors and risk groups

The development of an infectious-inflammatory process in the urinary system, as a rule, occurs in the presence of predisposing factors from the macroorganism, the main of which is obstruction of the urine flow at any level.

Normal urodynamics is one of the factors preventing the upward spread of microorganisms and their adhesion to the surface of the epithelium. Therefore, any anatomical or functional impairment urine flow can be considered as a favorable factor for the development of infection.

Urinary obstruction occurs in all variants of anomalies in the development and structure of the organs of the urinary system, with crystalluria and urolithiasis, etc.

Functional disorders of the motility of the urinary tract (hypo-, hyperkinesia), even short-term, contributes to stagnation of urine, creating conditions for the adhesion of microorganisms and the colonization of the epithelium. Functional obstruction can occur with an absolutely normal structure of the organs of the urinary system, it is provoked by hypothermia, bowel disease, intoxication, stress, etc.

In addition to urinary obstruction, the development of UTI will be promoted by genetic factors, metabolic disorders, chronic bowel disease, a decrease in general and local immunity, etc.

Representatives of III (B0) and IV (AB) blood groups have a greater tendency to develop UTIs, since they have receptors for fixing bacteria on the surface of the uroepithelium.

All this allows us to identify conditional risk groups for the development of infection of the urinary system:

Children with urodynamic disorders (urinary obstruction): anomalies in the development of the urinary system, vesicoureteral reflux, nephroptosis, urolithiasis disease and etc.;

Children with metabolic disorders in the urinary system: glucosuria, hyperuricemia, dysmetabolic nephropathy, etc.;

Urinary tract motility disorders (neurogenic dysfunctions);

Children with reduced general and local resistance: premature babies, frequently ill children, children with systemic or immune diseases, etc.;

Children with a possible genetic predisposition: UMS infection, anomalies in the development of UMS, vesicoureteral reflux, etc. in relatives, UMS infection in the history of the child himself;

Children with constipation and chronic diseases intestines;

Children exposed to iatrogenic factors: hospitalizations, instrumental methods OMS studies, treatment with steroids and cytostatics;

Female children, children with III (B0) or IV (AB) blood groups.

IMS flow options

With all the variety of clinical and laboratory manifestations of infection of the urinary system, three variants of its course can be conditionally distinguished.

Option 1

There are no clinical manifestations of the disease. Urinalysis reveals: bacterial leukocyturia, abacterial leukocyturia, isolated bacteriuria. Possible reasons: infectious lesion at any level of the genitourinary system - asymptomatic bacteriuria, latent infection of the lower urinary tract, latent PN, vulvitis, balanitis, phimosis, etc.

Option 2

Clinical manifestations in the form of dysuria (pain when urinating, pollakiuria, incontinence or urinary incontinence, etc.); pain or discomfort in the suprapubic region. Urinary syndrome in the form of bacterial leukocyturia (possibly in combination with hematuria varying degrees severity) or abacterial leukocyturia. Possible causes: cystitis, urethritis, prostatitis.

Option 3

Clinical manifestations in the form of fever, symptoms of intoxication; pain in the lower back, side, abdomen, radiating to the groin, inner thigh. Urinary syndrome in the form of bacterial leukocyturia or abacterial leukocyturia, sometimes moderate hematuria. Changes in the blood: leukocytosis, neutrophilia with a shift to the left, accelerated ESR. Possible causes: PN, PN with cystitis (with dysuria).

Features of the course of PN

In the PN clinic for children early age symptoms of intoxication predominate. Perhaps the development of neurotoxicosis, the appearance of meningeal symptoms, frequent regurgitation and vomiting at the height of intoxication. Often in children of the first year of life, a complete refusal to eat with the development of malnutrition is possible. On examination, attention is drawn to the pallor of the skin, periorbital cyanosis, pastosity of the eyelids is possible.

Often PN at an early age proceeds under a variety of "masks": dyspeptic disorders, acute abdomen, pylorospasm, intestinal syndrome, septic process, etc. If such symptoms appear, it is necessary to exclude the presence of an infection of the urinary system.

In older children, “general infectious” symptoms appear less sharply, “unreasonable” rises in temperature are often possible against the background of normal well-being. They are characterized by fever with chills, symptoms of intoxication, persistent or intermittent pain in the abdomen and lumbar region, a positive symptom of tapping. Perhaps the course of PN under the "mask" of influenza or acute appendicitis.

Features of the course of cystitis

In older children and adults, cystitis most often occurs as a "local suffering", without fever and symptoms of intoxication. With hemorrhagic cystitis, hematuria, sometimes macrohematuria, will be leading in the urinary syndrome.

In infants and young children, cystitis often occurs with symptoms of general intoxication and fever. They are characterized by the frequent development of stranguria (urinary retention).

IC diagnostics

For the diagnosis of infection of the urinary system, laboratory instrumental methods of research are used.

Studies to identify the activity and localization of the microbial-inflammatory process.

Clinical blood test;

Biochemical blood test (total protein, protein fractions, creatinine, urea, fibrinogen, CRP);

General urine analysis;

Quantitative urine tests (according to Nechiporenko);

Urine culture for flora with a quantitative assessment of the degree of bacteriuria;

Urine antibioticogram;

Biochemical research urine (daily excretion of protein, oxalates, urates, cystine, calcium salts, indicators of membrane instability - peroxides, lipids, anti-crystal-forming ability of urine).

Quantitative urine tests (according to Amburge, Addis-Kakovsky);

Morphology of urine sediment;

Urinalysis for chlamydia, mycoplasma, ureaplasma (PCR, cultural, cytological, serological methods), fungi, viruses, mycobacterium tuberculosis (urine culture, express diagnostics);

Study of immunological status (sIgA, state of phagocytosis).

Studies to characterize the functional state of the kidneys, tubular apparatus and bladder.

Mandatory laboratory tests:

The level of creatinine, urea in the blood;

Zimnitsky's test;

Clearance of endogenous creatinine;

Study of pH, titratable acidity, ammonia excretion;

diuresis control;

Rhythm and volume of spontaneous urination.

Additional laboratory tests:

Urinary excretion of beta-2 microglobulin;

Osmolarity of urine;

urine enzymes;

Sample with ammonium chloride;

Zimnitsky test with dry food.

Instrumental research.

Mandatory:

Measurement of blood pressure;

Ultrasound of the urinary system;

X-ray contrast studies (micting cystoscopy, excretory urography) - with repeated episodes of UTI and only in the phase of minimal activity or remission.

Additional:

Doppler ultrasound (USDG) of renal blood flow;

Excretory urography with furosemide test;

cystoureteroscopy;

Radionuclide studies (scintigraphy);

Functional methods of examination of the bladder (uroflowmetry, cystometry);

Electroencephalography;

echoencephalography;

CT scan;

Magnetic resonance imaging.

Expert advice:

Mandatory: gynecologist, urologist.

If necessary: ​​neurologist, otorhinolaryngologist, ophthalmologist, cardiologist, dentist, surgeon.

Principles of treatment of infectious diseases of the urinary system

Treatment of microbial-inflammatory diseases of the urinary system involves not only antibacterial, pathogenetic and symptomatic therapy, but also the organization of the correct regimen and nutrition of a sick child. The tactics of treatment will be considered on the example of PN as the most severe infectious disease OMS.

The issue of hospitalization for PI is decided depending on the severity of the child's condition, the risk of complications and the social conditions of the family. During the active stage of the disease, in the presence of fever and pain, bed rest is prescribed for 5-7 days. Cystitis and asymptomatic bacteriuria usually do not require hospitalization. During this period, Pevzner table No. 5 is used: without salt restriction, but with an increased drinking regimen, 50% more than the age norm. The amount of salt and fluid is limited only if the kidney function is impaired. It is recommended to alternate protein and plant foods. Exclude products containing extractives and essential oils, fried, spicy, fatty foods. Detected metabolic disorders require special corrective diets.

Medical therapy IMS includes antibacterial drugs, anti-inflammatory desensitizing and antioxidant therapy.

Antibacterial therapy is based on the following principles:

Prior to treatment, it is necessary to conduct a urine culture (later the treatment is changed based on the results of the culture);

Eliminate and, if possible, eliminate factors that contribute to infection;

Improving the condition does not mean the disappearance of bacteriuria;

The results of treatment are regarded as a failure in the absence of improvement and / or persistence of bacteriuria;

Early recurrences (up to 2 weeks) represent a recurrent infection and are due either to the survival of the pathogen in the upper urinary tract or to continued colonization from the intestine. Late relapses are almost always re-infection;

pathogens community-acquired infections urinary tract usually sensitive to antibiotics;

Frequent relapses, instrumental interventions on the urinary tract, recent hospitalization make us suspect an infection caused by resistant pathogens.

PI therapy includes several stages: the stage of suppression of the active microbial-inflammatory process using an etiological approach, the stage pathogenetic treatment against the background of the subsidence of the process with the use of antioxidant protection and immunocorrection, the stage of anti-relapse treatment. Therapy for acute PN, as a rule, is limited to the first two stages, in chronic PN all three stages of treatment are included.

When choosing antibacterial drugs, the following requirements must be taken into account: the drug must be active against the most common pathogens of the urinary system, not be nephrotoxic, create high concentrations in the inflammation focus (in the urine, interstitium), have a predominantly bactericidal effect, be active at pH values urine of the patient (tab. 4); when several drugs are combined, synergism should be observed.

The duration of antibiotic therapy should be optimal, ensuring complete suppression of the activity of the pathogen; usually is about 3-4 weeks in the hospital with a change of antibiotic every 7-10 days (or replacement with a uroseptic).

Starting antibiotic therapy is prescribed empirically, based on the most likely infectious agents. In the absence of a clinical and laboratory effect, it is necessary to change the antibiotic after 2-3 days. In case of manifest severe and moderate PN, drugs are administered mainly parenterally (intravenously or intramuscularly) in a hospital setting. With mild and in some cases moderate course of PI, inpatient treatment is not required, antibiotics are administered orally, the course of treatment is from 14 to 20 days.

Some antibiotics used in the initial treatment of PN:

Semi-synthetic penicillins in combination with beta-lactomase inhibitors:

Amoxicillin and clavulanic acid:

Augmentin - 25-50 mg / kg / day, inside - 10-14 days;

Amoxiclav - 20-40 microns / kg / day, inside - 10-14 days.

Cefuroxime (Zinacef, Ketocef, Cefurabol), cefamandol (Mandol, Cefamabol) - 80-160 mg / kg / day, IV, IM - 4 times a day - 7-10 days.

Cefotoxime (Klaforan, Clafobrin), ceftazidime (Fortum, Vicef), ceftizoxime (Epocelin) - 75-200 mg / kg / day, IV, IM - 3-4 times a day - 7-10 days;

Cefoperazone (Cefobide, Cefoperabol), ceftriaxone (Rocefin, Ceftriabol) - 50-100 mg/kg/day, IV, IM - 2 times a day - 7-10 days.

Aminoglycosides:

Gentamicin (Garamycin, Gentamicin sulfate) - 3.0-7.5 mg / kg / day, intramuscularly, intravenously - 3 times a day - 5-7 days;

Amikacin (Amycin, Lykacin) - 15-30 mg / kg / day, IM, IV - 2 times a day - 5-7 days.

During the period of subsiding PN activity, antibacterial drugs are administered mainly orally, while “step therapy” is possible, when the same drug is given orally as it was administered parenterally, or a drug of the same group.

The most commonly used during this period are:

Semi-synthetic penicillins in combination with beta-lactamase inhibitors:

Amoxicillin and clavulanic acid (Augmentin, Amoxiclav).

2nd generation cephalosporins:

Cefaclor (Ceclor, Vercef) - 20-40 mg / kg / day.

3rd generation cephalosporins:

Ceftibuten (Cedex) - 9 mg / kg / day, once.

Nitrofuran derivatives:

Nitrofurantoin (Furadonin) - 5-7 mg / kg / day.

Quinolone derivatives (non-fluorinated):

Nalidixic acid (Negram, Nevigramone) - 60 mg / kg / day;

Pipemidic acid (Palin, Pimedel) - 0.4-0.8 g / day;

Nitroxoline (5-NOC, 5-Nitrox) - 10 mg / kg / day.

Sulfamethoxazole and trimethoprim (Co-trimoxazole, Biseptol) - 4-6 mg / kg / day for trimethoprim.

In severe septic course, microbial associations, multidrug resistance of microflora to antibiotics, when exposed to intracellular microorganisms, as well as to expand the spectrum of antimicrobial action in the absence of culture results, combined antibiotic therapy is used. In this case, bactericidal antibiotics are combined with bactericidal, bacteriostatic with bacteriostatic antibiotics. Some antibiotics are bactericidal for some microorganisms and bacteriostatic for others.

Bactericidal include: penicillins, cephalosporins, aminoglycosides, polymyxins, etc. Bacteriostatic - macrolides, tetracyclines, chloramphenicol, lincomycin, etc. Potentiate the action of each other (synergists): penicillins and aminoglycosides; cephalosporins and penicillins; cephalosporins and aminoglycosides. Are antagonists: penicillins and chloramphenicol; penicillins and tetracyclines; macrolides.

From the point of view of nephrotoxicity, erythromycin, drugs of the penicillin group and cephalosporins are non-toxic or low-toxic; moderately toxic are gentamicin, tetracycline, etc.; kanamycin, monomycin, polymyxin, etc. have pronounced nephrotoxicity.

Risk factors for aminoglycoside nephrotoxicity are: duration of use for more than 11 days, maximum concentration above 10 μg / ml, combination with cephalosporins, liver disease, high creatinine levels. After a course of antibiotic therapy, treatment should be continued with uroantiseptics.

Nalixidic acid preparations (Nevigramon, Negram) are prescribed for children older than 2 years. These agents are bacteriostatics or bactericides depending on the dose in relation to gram-negative flora. They can not be administered simultaneously with nitrofurans, which have an antagonistic effect. The course of treatment is 7-10 days.

Gramurin, a derivative of oxolinic acid, has a wide spectrum of activity against gram-negative and gram-positive microorganisms. It is used in children aged 2 years and over in a course of 7-10 days. Pipemidic acid (Palin, Pimidel) affects most gram-negative bacteria and staphylococci. It is prescribed for a short course (3-7 days). Nitroxoline (5-NOC) and nitrofurans are broad bactericidal preparations. The reserve drug is ofloxacin (Tarivid, Zanocin). It has a wide spectrum of action, including on the intracellular flora. Children are prescribed only in case of ineffectiveness of other uroseptics. The use of Biseptol is possible only as an anti-relapse agent in the latent course of PI and in the absence of obstruction in the urinary organs.

In the first days of the disease, against the background of increased water load, fast-acting diuretics (Furosemide, Veroshpiron) are used, which increase renal blood flow, ensure the elimination of microorganisms and inflammatory products, and reduce swelling of the interstitial tissue of the kidneys. The composition and volume of infusion therapy depend on the severity of the intoxication syndrome, the patient's condition, indicators of hemostasis, diuresis and other kidney functions.

The stage of pathogenetic therapy begins when the microbial-inflammatory process subsides against the background of antibacterial drugs. On average, this occurs 5-7 days after the onset of the disease. Pathogenetic therapy includes anti-inflammatory, antioxidant, immunocorrective and anti-sclerotic therapy.

The combination with anti-inflammatory drugs is used to suppress the activity of inflammation and enhance the effect of antibiotic therapy. It is recommended to take non-steroidal anti-inflammatory drugs - Ortofen, Voltaren, Surgam. The course of treatment is 10-14 days. The use of indomethacin in pediatric practice is not recommended due to a possible deterioration in the blood supply to the kidneys, a decrease in glomerular filtration, water and electrolyte retention, and necrosis of the renal papillae.

Desensitizing agents (Tavegil, Suprastin, Claritin, etc.) are prescribed for acute or chronic PN in order to stop the allergic component of the infectious process, as well as with the development of the patient's sensitization to bacterial antigens.

The complex of PN therapy includes drugs with antioxidant and antiradical activity: Tocopherol acetate (1-2 mg/kg/day for 4 weeks), Unithiol (0.1 mg/kg/day IM one-time, for 7-10 days ), Beta-carotene (1 drop per year of life 1 time per day for 4 weeks), etc. Of the drugs that improve the microcirculation of the kidneys, Trental, Cinnarizine, Eufillin are prescribed.

Anti-relapse therapy of PN involves long-term treatment antibacterial drugs in small doses and is carried out, as a rule, on an outpatient basis. For this purpose, use: Furagin at the rate of 6-8 mg / kg for 2 weeks, then with normal tests urine transition to 1/2-1/3 doses for 4-8 weeks; the appointment of one of the preparations of pipemidic acid, nalidixic acid or 8-hydroxyquinoline for 10 days of each month in the usual dosages for 3-4 months.

Treatment of cystitis

Treatment of cystitis provides for general and local effects. Therapy should be aimed at normalizing urination disorders, eliminating the pathogen and inflammation, and eliminating the pain syndrome. AT acute stage disease, bed rest is recommended until the dysuric phenomena subside. The general warming of the patient is shown. Dry heat is applied to the area of ​​the bladder.

Diet therapy provides for a sparing regimen with the exception of spicy, spicy dishes, spices and extractives. Dairy and vegetable products, fruits, which contribute to the alkalization of urine, are shown. It is recommended to drink plenty of water (slightly alkaline mineral waters, fruit drinks, weakly concentrated compotes) after pain relief. An increase in diuresis reduces the irritating effect of urine on the inflamed mucous membrane, promotes the washing out of inflammation products from the bladder. Reception mineral water(Slavyanovskaya, Smirnovskaya, Essentuki) at the rate of 2-3 ml / kg 1 hour before meals has a weak anti-inflammatory and antispasmodic effect, changes the pH of the urine. Drug therapy of cystitis includes the use of antispasmodic, uroseptic and antibacterial agents. With pain syndrome, the use of age doses of No-shpa, Papaverine, Belladona, Baralgin is indicated.

In acute uncomplicated cystitis, it is advisable to use oral antimicrobials, which are excreted mainly by the kidneys and create a maximum concentration in the bladder. Starting drugs for the treatment of acute uncomplicated cystitis can be "protected" penicillins based on amoxicillin with clavulanic acid. Oral 2-3 generation cephalosporins can be used as an alternative. When identifying atypical flora, macrolides are used, fungi - antimycotic drugs.

The minimum course of treatment is 7 days. In the absence of sanitation of urine against the background of antibiotic therapy, additional examination of the child is required. Uroseptic therapy includes the use of drugs of the nitrofuran series (Furagin), non-fluorinated quinolones (drugs of nalidixic and pipemidic acids, derivatives of 8-hydroxyquinoline).

In recent years, fosfomycin (Monural) has been widely used to treat cystitis, which is taken once and has a wide antimicrobial spectrum of action. In the acute period of the disease, phytotherapy is carried out with an antimicrobial, tanning, regenerating and anti-inflammatory effect. Cowberry leaf and fruits, oak bark, St. John's wort, calendula, nettle, coltsfoot, plantain, chamomile, blueberries, etc. are used as an anti-inflammatory agent. Barley, nettle, lingonberry leaf have a regenerating effect.

Antibacterial therapy for chronic cystitis is carried out for a long time and is often combined with local treatment in the form of bladder instillations. For catarrhal cystitis, an aqueous solution of Furacilin, sea buckthorn and rosehip oil, synthomycin emulsion are used. Instillations of antibiotics and uroseptics are used for hemorrhagic cystitis. In the treatment of bullous and granular forms, the solution of Collargol and silver nitrate is used. The duration of the course is 8-10 procedures with a volume of 15-20 ml, with catarrhal cystitis, 1-2 courses of instillations are required, with granular and bullous - 2-3 courses, the interval between courses is 3 months.

At frequent relapses possible use of immunomodulatory drugs. Instillations with Tomicid (a waste product of non-pathogenic streptococcus), which also has a bactericidal effect, can be used. Tomicid increases the content of sIgA in the bladder mucosa.

As physiotherapy, electrophoresis, currents of supratonal frequency, an electric field of ultrahigh frequency, applications of Ozokerite or paraffin are used. Physiotherapy treatment is recommended to be repeated every 3-4 months.

Management of children with asymptomatic bacteriuria

The decision to use antibiotic therapy for asymptomatic bacteriuria is always a difficult one for the physician. On the one hand, the absence of a clinic and a pronounced urinary syndrome does not justify the use of a 7-day course of antibiotics and uroseptics due to possible side effects. In addition, the doctor often has to overcome parental prejudice against the use of antibacterial drugs.

On the other hand, shorter courses are ineffective, because they only shorten the period of bacteriuria, creating "imaginary well-being", and do not prevent the subsequent development of clinical symptoms of the disease. Also, short courses of antibiotics contribute to the emergence of resistant strains of bacteria. In most cases, asymptomatic bacteriuria does not require treatment. Such a patient needs further examination and clarification of the diagnosis.

Antibacterial therapy is necessary in the following situations:

In newborns and infants and young children (up to 3-4 years), since they may develop PN rapidly;

In children with structural anomalies of OMS;

If there are prerequisites for the development of PN or cystitis;

In chronic PN (cystitis) or previously transferred;

When clinical symptoms of UTI appear.

Most often, uroseptics are used for asymptomatic bacteriuria.

Dynamic observation of children suffering from PN:

Frequency of examination by a nephrologist:

- exacerbation - 1 time in 10 days;

- remission against the background of treatment - 1 time per month;

- remission after the end of treatment for the first 3 years - 1 time in 3 months;

- remission in subsequent years until the age of 15 years - 1-2 times a year, then the observation is transferred to therapists.

Clinical and laboratory studies:

— general analysis urine - at least 1 time per month and against the background of SARS;

- biochemical analysis of urine - 1 time in 3-6 months;

- Ultrasound of the kidneys - 1 time in 6 months.

According to the indications, cystoscopy, cystography and intravenous urography are performed. Removal from the dispensary of a child who has had acute PN is possible while maintaining clinical and laboratory remission without therapeutic measures (antibiotics and uroseptics) for more than 5 years, after a complete clinical and laboratory examination. Patients with chronic PN are observed before transfer to the adult network.

A. V. Malkoch, Candidate of Medical Sciences RSMU, Moscow