Antimicrobial therapy

The problem of optimal choice uroseptics in treating a specific patient requires answers to many questions. First, you need to find out the localization of urinary tract infection, to determine the type of pathogen and its sensitivity to the selected uroseptics, acute inflammation, renal function. In addition, you must have a clear understanding of the pharmacokinetics and pharmacodynamics of the drug.

Only after answering these questions, drug choice is really optimal.

Talking about the localization of infection, we must not forget that even in the same patient may be different microflora in the parenchyma of the kidneys and urinary tract.

As a rule, in the early stages of the disease is detected monoinfection, at a long process, in case of brand cialis inadequate antimicrobial therapy, there are microbial associations, including up to two and three species of pathogens, often as a Gram-negative and gram-positive.

The most common pathogens are E. coli and enterococci (ie, obligate intestinal flora), as well as hemolytic variant of Escherichia coli, Proteus, Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella. In this case, the association of different types of pathogens in pyelonephritis occur in 20-45,5% of cases. Approximately 15% of cases of pyelonephritis can not identify the causative agent in the usual way or in urine culture, or in crops of kidney tissue. Pathogens, transform into a form devoid of cell walls (L-shape), and mycoplasmas require for their detection difficult diagnostic media and techniques.

Identification of agent can choose the most effective uroseptics. Currently, there are clear guidelines for choosing uroseptics depending on the pathogen, and the literature information on this subject quite a lot. In situations where one can not expect the results of urine culture and sensitivity of flora, may be used standardized schemes of antibacterial therapy. For example, perhaps the use of gentamicin, as appropriate, in combination with cephalosporins, or a combination of carbenicillin (piopena) with nalidixic acid, kolimitsina with nalidixic acid.

Currently in severe urological disease - pyelonephritis, urosepsis, with resistance to other classes of antimicrobial substances in the presence of multi-drug resistant strains of bacteria - is recommended to use antibiotics the fluoroquinolones.

When the need for therapy uroseptics long, with the change agents every 7-10 days, it is advisable to consistently apply drugs acting on the bacterial wall and the metabolism of bacterial cells. Recommended that the consistent application of penicillin and erythromycin, cephalosporins and chloramphenicol, cephalosporins and nitrofuranov to prevent survival protoplastnyh and L-forms of bacteria.

All of these groups uroseptics well into the tissue of the urogenital system and urine, which are sufficient to produce the therapeutic effect of concentration. At the same time check of renal excretory function is required in each case. When expressed sclerotic changes and lesions of the glomerular apparatus of the kidneys success of treatment decreases with decrease in glomerular filtration rate of 30 ml / min to carry out antibiotic therapy does not make sense, since it is impossible to obtain a therapeutic concentration of therapeutic drugs in the renal parenchyma. In addition, dramatically increases the risk of toxic effects. Reduced functional capacity of the kidneys makes pay particular attention to the nephrotoxicity of the means.

Almost no nephrotoxicity fluoroquinolones, oxacillin, methicillin, carbenicillin from the group of penicillins, macrolides, cephalosporins, chloramphenicol.

Have negligible nephrotoxicity of ampicillin, lincomycin, nitrofurans, nalidixic acid, some sulfonamides of prolonged action. In the presence of renal failure become nephrotoxic tetracyclines. Always highly nephrotoxic aminoglycosides (gentamicin, streptomycin, torbamitsin, kanamycin).

Nephrotoxic effects of drugs are enhanced in severe dehydration while taking diuretics.

One of the most important criteria for selecting a drug is the pH of urine. Maximum efficiency in alkaline medium at pH = 7,5-9,0 show aminoglycosides and macrolides, the lower the pH of the urine of their activity decreases. Does not depend on the pH of urine efficacy of cephalosporins, quinolones, glycoproteins, tetracycline, chloramphenicol. In an acidic medium at pH ≤ 5,5 most effective penicillins derived naftiridina, nitrofuran, a quinolone, 8-oksihinolona, metepamin. All of these drugs significantly reduce its activity as alkalinization of the medium.

In order to increase the alkalinity of urine possible appointment of lacto-vegetarian diet, sodium bicarbonate. To reduce the urine pH (acidification) increases the consumption of bread and flour products, meat and eggs. Assign ammonium chloride, ascorbic order brand levitra acid, methionine, hippuric acid (which contains, for example, cranberry juice). Any substance that reduces urine pH below 5.5, inhibits the growth of bacteria in the urine.

In the presence of microbial associations may use a combination of two uroseptics.

Good compatibility with most antimicrobial agents and the absence of adverse reactions with combination antibiotic therapy are the fluoroquinolones.

β-lactams (penicillins, cephalosporins), aminoglycosides and polypeptides have a synergistic action, they can be combined with severe forms of infection. In this case, all of these groups of antibiotics in conjunction with tetracyclines, macrolides, lincomycin show antagonism.

Chloramphenicol, tetracyclines and macrolides in the joint appointment of showing indifference. Nitrofurantoin nalidixic acid reduces the effect. Considered inappropriate to appoint the following combinations: furagin with chloramphenicol, furagin with sulfonamides, chloramphenicol with sulfonamides, metenamina with sulfonamides.

How to choose a combination of drugs and the necessary duration of the course of therapy and route of administration of drugs depend on the localization of infection, the severity of the process, the causative agent.

Doses for course therapy are listed in Table. 2. With treatment should be aware that some drugs develop resistance of microorganisms. Especially it should be considered, if necessary intermittent therapy. Preference should be given drugs to which resistance develops relatively slowly: it fluoroquinolones, ampicillin, chloramphenicol, sulfonamides depot. Particularly slowly develops resistance to furagin, so this drug is important during prolonged intermittent treatment.

Rather quickly, and often develops resistance of microorganisms to nalidixic acid, oxolinic acid, tetracycline, streptomycin, cephalosporin.

Having said that, you should always find out what drugs were used under previous therapy, and evaluate their effectiveness.

It is also necessary to specify the side effects that occurred against the background of previous therapy, and to take into account the possibility of their appearance on the background of the treatment.

All the above indicates that even in the presence of mass advisory literature from a large number of different schemes of therapy - an approach to the treatment of urinary tract infection can not be mechanical and requires an individual choice of tactics of therapy for each patient.