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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3256_Библиотеки_им_академика_М_И_Перельмана
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bacteremia observed in CKD, unlike urinary tract infections of other
localizations, the antibiotic should create high serum concentrations.
The eectiveness of antibacterial therapy depends on: the etiotro-
pic therapy, the dose of the drug, taking into account the pharmaco-
kinetics of the drug and the course of the disease. The concentration
of the antibiotic in the blood should exceed the minimum suppressive
concentration for the pathogen by at least four times. On the timeliness
of therapy and the rational duration of course treatment and the use of
combinations of antibiotics in order to expand the spectrum of action
and enhance the antibacterial eect.
Repeated microbiological examination of urine should be carried
out 3-4 days after the start of antibacterial therapy and several days
after the end of treatment. Catheterization of the bladder is used only
for strict indications, most often with acute urinary retention.
For the treatment of severe and moderate forms of CKD, semi-
synthetic penicillins are prescribed (more often aminopenicillins, in-
cluding beta-lactamase inhibitors), cephalosporins, aminoglycosides,
less often carbapenems. Biosynthetic penicillins and phenicols are
not used.
Antibiotics of other groups, in particular tetracyclines, macro-
lides. rifampicins are used to treat lower urinary tract infections caused
by chlamydia, ureoplasma and mycoplasma infections.
Combined antibacterial therapy for CKD is used in:
1. Severe septic course in order to increase the synergism of the
action of antibacterial drugs.
2. Severe course of urinary system infection caused by micro-
bial associations.
3. The need to overcome the polyresistance of microorganisms
to antibiotics (especially in the treatment of “problematic” infections
caused by proteus, Pseudomonas aeruginosa, klebsiella, etc.).
4. The presence of signs of intracellular location of microorgan-
isms (chlamydia, mycoplasma, ureaplasma).
Semi- synthetic penicillin:
1) aminopenicillins: amoxicillin - inside 1.5-3.0 g / day for 3 dos-
es;
t.me/medicina_free
292
2) carboxypenicillins: carbenicillin - in / m 4-8 g / day for 4 injec-
tions; ticarcillin - in / m 12-18 g / day for 4-6 injections;
3) ureidopenicillins: azlocillin - in / m 8-12 g / day for 3-4 injec-
tions;
4) piperacillin IV or IV 4-6 g / day for 2-3 injections.
Semi-synthetic penicillin combined with B-lactamase inhibitors:
1)
augmentin (amoxicillin + clavulanic acid) inside 1,125-1,875
g / day in 3 doses or in / in 3-6 g / day for 3 injections;
2) unazine (ampicillin + sulbactam) inside 0.375-0.75 g / day for
2 doses;
3) thimentin (ticarcillin + clavulanic acid) - in / in 12.4-18.6 g /
day for 4 injections;
4) tazocin (piperacillin + tazobactam) - in / in 13.5 g / day for
3 injections.
A wide spectrum of antibacterial action, low toxicity of augmen-
tin allow it to be used as monotherapy for pyelonephritis and urinary
tract infections as an empirical starting treatment when the pathogen
has not yet been identied. In severe cases, a combination of it with
aminoglycosides is possible.
Cephalosporins:
I generation: cefazolin (kefzol) in / m or in / in 2 g / day for 2 in-
jections, cephalexin - inside 0.5-1.0 g / day in 2 doses;
II generation: cefuroxime axetil - 0.25-0.5 g / day in 2 doses, ce-
faclor inside - 0.75 g / day in 3 doses;
III generation: cefotaxime (claforan) in / in 2-4 g / day for 2 injec-
tions; ceftazidim (fortum) in / in 1-2 g / day for 2 injections, ceftriax-
one in / m or in / in 1-2 g / day once.
Aminoglycosides:
I generation: gentamicin I/m 3-4 mg/kg;
II generation: amikacin - i / m or I / v 10 mg / kg / day;
III generation - netromycin in / m 4-6 mg / kg / day for 2-3 injec-
tions.
Carbopenems:
1) meronem (meropenem) - in / in 1.5 g / day for 3 injections;
t.me/medicina_free
293
2) thienam (imipenem + celastatin sodium) -- in / in / or in /
m 1.5 g / day for 3 injections.
Fluoroquinolones:
1) peoxacin (abactal) – inside 0.8-1.2 g / day;
2) ooxacin (tarivit) - inside 0.4 g / day in 2 doses;
3) ciprooxacin inside 0.25-1.0 g / day;
4) noroxacin (nolicin) inside 0.4 g / day in two doses;
5) lomeoxacin (maxaquin) inside 0.4 g / day once.
Naphthyridine derivatives:
1) nalidixic acid (negram) inside 2-4 g / day in 4 doses;
2) pipemidic acid (palin) 0.8 g / day in 2 doses.
Non-uorinated uoroquinolones: Nitroxoline - 5-NOK are cur-
rently not used due to the low sensitivity of microorganisms and the
development of side eects (prolonged use of nitroxoline leads to the
development of optic neuritis).
4. Medical and labor expertise. Dispensary observation.
Examination of working capacity. Temporary disability (TD) is
established with an exacerbation of the disease; the occurrence of
a hypertensive crisis or a signicant increase in blood pressure; the
addition of an intercurrent infection; an increase in renal failure. TD
depends on the form: acute, acute, subacute, latent.
Acute form: TD is 2-2.5 months, of which 35-40 days in hospi-
tal; acute - 1.5-2 months, of which 30-35 days in hospital; subacute
- 1 month; latent course - 15-18 days.
In the case of a signicant increase in blood pressure without ob-
vious signs of exacerbation of pyelonephritis, severe neurological and
cardiovascular complications, the duration of TD is 10-12 days.
Able-bodied patients with chronic pyelonephritis with rare exac-
erbations, in the remission phase, in the absence of pronounced com-
plications, working in accessible professions and working conditions.
The criteria for the restoration of working capacity are: reduction
of proteinuria and hematuria to insignicant, reduction of blood pres-
sure to the initial level, disappearance or reduction of edema, increase
t.me/medicina_free
294
in glomerular ltration, normalization of total protein and acute phase
reactions, as well as general blood analysis.
Contraindicated working conditions: 1) work associated with sig-
nicant physical stress; 2) work at the prescribed pace (on the con-
veyor); 3) work in unfavorable microclimatic and meteorological con-
ditions; 4) contact with nephrotoxic poisons.
Indications for referral to MSE:
TD > 4 months. with the 3rd degree of activity of the process and
a favorable labor prognosis (CKD no more than stage IB).
TD < 4 months. with the 3rd degree of activity and an unfavorable
labor prognosis (CKD IIA and more severe stage).
TD < 4 months. in the case of a continuously recurrent course of
the disease with high activity (2-3 degrees), pronounced arterial hy-
pertension.
TD < 4 months. with rapid progression of CKD or the addition of
extrarenal complications that are not amenable to conservative thera-
py.
For the rst time, chronic pyelonephritis was detected outside of
exacerbation with CKD 0 or stage I and the impossibility of rational
employment according to the conclusion of the MC of medical and
preventive institutions.
The necessary minimum of examination when referring patients
to MSE is urine tests (repeated); clinical blood analysis, thrombocytes;
daily loss of protein in urine; Rehberg test; creatinine, urea, choles-
terol, electrolytes, total protein and fractions; if CKD ABC indicators,
bone radiography, alkaline phosphatase; ultrasound, scintigraphy, ra-
diography and kidney biopsy according to indications.
Additional research methods: urine culture with colony counting;
ultrasound and radioisotope scanning; intravenous urography; consul-
tation of a urologist.
Criteria for disability in pyelonephritis in adults
Disability is not established if the patient has:
Stage 1 CKD, GFR more than 90 ml/min/1.73 m2;
Stage 2 CKD, GFR within 89 - 60 ml/min/1.73 m2
Stage 3A CKD, GFR 59 - 45 ml/min/1.73 m2
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295
Disability of the 3rd group is established if the patient has: Stage
3 CKD, GFR 44-30 ml/min/1.73 m2. Nephrotic / nephritic syndromes
with ineective treatment with moderate impairment of body func-
tions.
Disability of the 2nd group is established if the patient has: Stage
4 CKD, GFR 29-15 ml/min/ 1.73 m2, preparation for dialysis. Stage
5 CKD (GFR below 15 ml/min/1.73 m2) in the absence of dialy-
sis complications.
Disability of the 1st group is established if the patient has: Stage
5 CKD, GFR below 15 ml/min / 1.73 m2, in the presence of complica-
tions with signicant impairment of body functions.
Dispensary observation. The patient is under lifelong observation
by a urologist. Annually, the frequency of observations should be at
least 2 visits per year or, if necessary, according to indications. A gen-
eral blood test, a general urine test, a urine test according to Nechipo-
renko, urine culture for ora and sensitivity to antibiotics – 2 times
a year. Biochemical blood test: total protein, albumin, urea, creatinine
- 2 times a year. GFR – 2 times a year. Ultrasound of the kidneys -
1 time per year. ECG – 1 time per year. Measurement of blood pres-
sure at each visit, that is, 2 times a year. Urine analysis according to
Zimnitsky, daily proteinuria for medical reasons.
Clinical case No. 7
1. What is the preliminary diagnosis?
Preliminary diagnosis: Urolithiasis (right ureter stone), obstruc-
tive right-sided acute purulent pyelonephritis.
2. What additional tests would you recommend to the patient,
and what are the expected results?
Laboratory tests. The gold standard of diagnosis is the detec-
tion of bacteriuria and leukocyturia in combination with anamnestic
and physical signs of pyelonephritis. GBT: increased ESR, neutro-
philic leukocytosis, anemia (in some patients with CKD). Biochemi-
cal blood test: proteinogram - in the acute phase, pathological shifts
t.me/medicina_free
296
with hypoalbuminemia, hyper-α1, α2-globulinemia are observed, in
the late stages with hypogammaglobulinemia. Concentration of ni-
trogenous slags - there is an increase in creatinine levels, as a result
of a decrease in glomerular ltration and impaired excretory function
of the kidneys. Electrolyte homeostasis: hypokalemia, hyponatremia,
hypocalcemia, which sometimes reach signicant severity, are caused
by polyuria and a large loss of ions in the urine.
Urine examination: (detection of leukocyturia, proteinuria and
bacteriuria) - general analysis, analysis by Nechiporenko. Proteinuria
is usually insignicant and does not exceed, with rare exceptions,
1.0 g / l (most often traces), and the daily excretion of protein in the
urine is less than 1.0 g. Leukocyturia can be of varying severity, but
more often the number of leukocytes is 5-10, 15-20 in the eld of
vision, less often reaches 50-100 or more. Occasionally, single hya-
line and granular cylinders are found in the urine. Hematuria, more
often microhematuria and occurs in 30% of cases. In the absence of
proteinuria and leukocyturia, it is necessary to conduct urine tests in
dynamics repeatedly, including according to Nechiporenko, for active
leukocytes, as well as urine culture for microora and the degree of
bacteriuria. If the protein content in the daily amount of urine exceeds
70-100 mg, in the Nechiporenko study more than 2.5 × 106 / l, then
this may speak in favor of CP. The diagnosis of pyelonephritis be-
comes more convincing if active leukocytes or Sternheimer -Malbin
cells are found in the urine of patients. However, their importance
should not be overestimated, since it has been established that they are
formed at low osmotic pressure of urine and again turn into ordinary
leukocytes with an increase in its osmotic activity.
Bacteriuria. The basis for the diagnosis of urinary tract infections
is the determination of reliable bacteriuria by quantifying bacteria in
an average portion of urine obtained by free urination. A culture study
of urine (sowing on nutrient media, isolation of a pure culture of the
pathogen and determination of its sensitivity to drugs) is desirable to
be carried out in a hospital in all patients. If bacteremia is suspected
(high fever, chills), a hemoculture study is required. A necessary con-
dition for the reliability of the results of a bacteriological study is the
t.me/medicina_free
297
correctness of urine and blood sampling. Urine for microbiological
examination should be collected before the start of antibacterial thera-
py. If the patient receives antibacterial drugs, they should be canceled
2-3 days before the study.
A study of the concentration capacity of the kidneys (urine anal-
ysis according to Zimnitsky) - polyuria with hypo- and isostenuria
is observed.
Instrumental research. Ultrasound: unequal kidney sizes, irregu-
larity of their contours, unusual location, deformation and expansion
of the cup-pelvic systems, asymmetry of sizes and contours, size re-
duction. Radiation diagnostics. R-graph overview: it is possible to
identify X-ray-positive stones. Excretory urography: provides infor-
mation about the violation of the structure and function of the kid-
neys, the state of the calyx-pelvic system and upper urinary tract. It
reveals changes in the size and shape of the kidneys, their location,
the presence of concretions in the cups, pelvis or ureters. Allows you
to judge the state of the total excretory function of the kidneys. Excre-
tory urography is carried out only in the inactive phase, in the active
phase only for vital indications if urological intervention is necessary,
it is contraindicated in CKD. In favor of CKD, there are: spasm or pin-
shaped expansion of the cups, violation of their tone, deformities and
expansion of the pelvis, changes in the shape and tone of the ureters,
anomalies of their development, strictures, extensions, kinks, twists,
wrinkling of the kidney or kidneys (reduction in size).
Retrograde pyelography is performed with severe CKD, since the
contrast of renal tissue and urinary tract in these patients is sharply
reduced. If the contours of the kidneys are not clearly detected during
overview and excretory urography, as well as if a kidney tumor is sus-
pected, a pneumoretroperitoneum (pneumoren) is used.
Radioisotope renography and scintigraphy: kidney sizes are nor-
mal or reduced, isotope accumulation is reduced, the secretory and
excretory phases of the renography curve are lengthened.
Computed tomography is an informative but expensive diagnos-
tic method used in complex dierential diagnostic cases.
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298
A lifetime puncture biopsy of the kidney is also performed in
terms of dierential diagnosis, but it is rarely used in CKD.
3. What is the patient’s management?
When conrming the diagnosis, the traditional treatment is urgent
surgical intervention: nephrostomy + decapsulation of the kidney +
ureter lithotomy (with localization of the stone in the upper or middle
third of the ureter), with localization of the stone in the lower third
of the ureter, only nephrostomy + decapsulation of the kidney. Af-
ter surgery, intensive antibacterial, anti-inammatory and detoxica-
tion therapy.
Diet for chronic kidney disease. Patients should observe a gentle
regime, avoid colds and hypothermia. All intercurrent diseases require
antibacterial therapy and monitoring of urine test data. In all forms and
at all stages of CKD, spicy dishes, spices, alcoholic beverages, coee,
meat and sh broths should be excluded from the diet.
Treatment of CKD is conditionally divided into two stages: stage
I – treatment of exacerbation (active phase of the disease); stage II –
anti-relapse treatment.
Treatment of the active phase. The initial continuous course of an-
tibacterial treatment is 6-8 weeks, since during this time it is necessary
to suppress the infectious agent in the kidney and resolve the purulent
inammatory process in it without complications in order to prevent
the formation of scar connective tissue. The rapid development of mi-
crobial ora resistance to antibacterial drugs, changes in the spectrum
of microorganisms that cause microbial-inammatory process in the
urinary system, the production of beta-lactamases by many of them,
create diculties in choosing an antibacterial drug and make tradi-
tional therapy ineective.
An important condition for the eectiveness of antibacterial ther-
apy of CKD is the creation of bactericidal concentrations of antibiotics
in urine and kidney tissues. In addition, given the high percentage of
bacteremia observed in CKD, unlike urinary tract infections of other
localizations, the antibiotic should create high serum concentrations.
t.me/medicina_free
299
The eectiveness of antibacterial therapy depends on: the etiotro-
pic therapy, the dose of the drug, taking into account the pharmaco-
kinetics of the drug and the course of the disease. The concentration
of the antibiotic in the blood should exceed the minimum suppressive
concentration for the pathogen by at least four times. On the timeliness
of therapy and the rational duration of course treatment and the use of
combinations of antibiotics in order to expand the spectrum of action
and enhance the antibacterial eect.
Repeated microbiological examination of urine should be carried
out 3-4 days after the start of antibacterial therapy and several days
after the end of treatment. Catheterization of the bladder is used only
for strict indications, most often with acute urinary retention.
For the treatment of severe and moderate forms of CKD, semi-
synthetic penicillin are prescribed (more often aminopenicillins, in-
cluding beta-lactamase inhibitors), cephalosporins, aminoglycosides,
less often carbapenems. Biosynthetic penicillin and phenicol are
not used.
Antibiotics of other groups, in particular tetracyclines, macro-
lides. rifampicins are used to treat lower urinary tract infections caused
by chlamydia, ureoplasma and mycoplasma infections.
Combined antibacterial therapy for CKD is used in:
1. Severe septic course in order to increase the synergism of the
action of antibacterial drugs.
2. Severe course of urinary system infection caused by micro-
bial associations.
3. The need to overcome the polyresistance of microorganisms
to antibiotics (especially in the treatment of “problematic” infections
caused by proteus, Pseudomonas aeruginosa, klebsiella, etc.).
4. The presence of signs of intracellular location of microorgan-
isms (chlamydia, mycoplasma, ureaplasma).
Semi- synthetic penicillin:
1) aminopenicillins: amoxicillin - inside 1.5-3.0 g / day for 3 dos-
es;
2) carboxypenicillins: carbenicillin - in / m 4-8 g / day for 4 injec-
tions; ticarcillin - in / m 12-18 g / day for 4-6 injections;
t.me/medicina_free
300
3) ureidopenicillins: azlocillin - in / m 8-12 g / day for 3-4 injec-
tions;
4) piperacillin IV or IV 4-6 g / day for 2-3 injections.
Semi-synthetic penicillin combined with B-lactamase inhibitors:
1) augmentin (amoxicillin + clavulanic acid) inside 1,125-1,875
g / day in 3 doses or in / in 3-6 g / day for 3 injections;
2) unazine (ampicillin + sulbactam) inside 0.375-0.75 g / day for
2 doses;
3) thimentin (ticarcillin + clavulanic acid) - in / in 12.4-18.6 g /
day for 4 injections;
4) tazocin (piperacillin + tazobactam) - in / in 13.5 g / day for
3 injections.
A wide spectrum of antibacterial action, low toxicity of augmen-
tin allow it to be used as monotherapy for pyelonephritis and urinary
tract infections as an empirical starting treatment when the pathogen
has not yet been identied. In severe cases, a combination of it with
aminoglycosides is possible.
Cephalosporins:
I generation: cefazolin (kefzol) in / m or in / in 2 g / day for 2 in-
jections, cephalexin - inside 0.5-1.0 g / day in 2 doses;
II generation: cefuroxime axetil - 0.25-0.5 g / day in 2 doses, ce-
faclor inside - 0.75 g / day in 3 doses;
III generation: cefotaxime (claforan) in / in 2-4 g / day for 2 injec-
tions; ceftazidim (fortum) in / in 1-2 g / day for 2 injections, ceftriax-
one in / m or in / in 1-2 g / day once.
Aminoglycosides:
I generation: gentamicin I/m 3-4 mg/kg;
II generation: amikacin - i / m or I / v 10 mg / kg / day;
III generation - netromycin in / m 4-6 mg / kg / day for 2-3 injec-
tions.
Carbopenems:
1) meronem (meropenem) - in / in 1.5 g / day for 3 injections;
2) thienam (imipenem + celastatin sodium) -- in / in / or in /
m 1.5 g / day for 3 injections.
Fluoroquinolones:
t.me/medicina_free
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