Cystitis should not happen again! Getting rid of disease without antibiotics

Our expert is urologist-oncologist surgeon, candidate of medical sciences Hovhannes Dilanyan.

If cystitis occurs more than twice a year, the process can be considered chronic. However, this does not mean that you did not treat acute cystitis or were treated incorrectly. Acute cystitis does not become chronic, even if the disease is not treated. Of course, antibiotics speed up recovery, but if a person does not have serious immune disorders (for example, AIDS), as a rule, cystitis completely goes away on its own over time, even if you do not take medications. Therefore, if the disease returns again and again, it is necessary to look for the reason why the bladder inflammation occurs. Among them:

Urolithiasis disease

Clinical case. A woman complains of pain and pain when urinating. A urine test shows the presence of Pseudomonas aeruginosa, so the doctor prescribes antibiotics. The symptoms gradually subside, but cystitis returns a few days after stopping antibiotics. As a result of the examination, the patient was diagnosed with kidney stones. An operation was performed to remove the stones, after which the cystitis disappeared.

What happened? On any foreign body, which is a stone, three to four days after its formation, a microfilm (microbiofilm) of bacteria begins to form. Bacteria constantly end up in the bladder, causing inflammation, which can be successfully treated with antibiotics. But, since the source of bacteria has not been eliminated, as soon as the patient stops taking the medication, cystitis returns.

Kidneys without stones. How to avoid urolithiasis Read more

STDs: why don't antibiotics help?

There are many stories about how couples were unsuccessfully treated for sexually transmitted infections. They changed doctors and clinics, went to “grandmothers” and homeopaths, despaired and offended. Yes, treatment often does not help even with strict adherence to all rules and conditions. The relationship is strictly monogamous, the partners are treated at the same time, carefully follow the recommendations, hope, but recovery does not occur. What's the matter?

The problem of ineffective antibacterial therapy is much broader than cases of unsuccessful attempts to treat STDs. Back in 2000, WHO experts drew attention to the growing resistance of microorganisms to antibiotics: “Our great-grandfathers lived without antibiotics, and it may happen that our great-grandchildren will live without them - these drugs simply will not work. We still have the opportunity to maintain their effectiveness, but we are late. Time is running out for our interventions..."

Read also: Treatment of STIs with one tablet?

Humanity will have to admit that we are hopelessly losing this war.

Back in the 80s of the 20th century, it became known that the gonorrhea pathogen was resistant to tetracycline and penicillin. In 2007, fluoroquinolones were removed from CDC guidelines for the treatment of gonorrhea for the same reason. Today, the drugs of choice for the treatment of gonococcal infections include cephalosporins, but here the situation is heating up - there are more and more strains resistant to them: for example, the number of N. gonorrhoeae strains resistant to cefixime has increased 7 times, and to ceftriaxone, the “gold standard” for the treatment of gonorrhea , - 3 times. In the very near future, the possibility of treating gonococcal infections with cephalosporins may be completely lost.

Background

In 1928, Scottish scientist Alexander Fleming returned to his London laboratory from vacation, where, amid the usual chaos for a researcher, he found Petri dishes that he had left unwashed before leaving. Imagine the scientist’s surprise when he discovered that some colonies of Staphylococcus aureus died and the reason for this was the well-known “bread” mold - Penicillium notatum. A year later, the scientist proved that the “mushrooms” he studied produced an antibacterial compound, which the researcher called penicillin.

The revolution devours its children

The first antibiotic made a real revolution! In those days, any wound, even a minor one, could lead to death as a result of infection. Humanity has received powerful weapons to combat pathogens. However, the victory was short-lived. Already in 1945, at the Nobel Prize ceremony, Alexander Fleming said: “It is not at all difficult to make microbes resistant to penicillin - this requires small doses of the antibiotic, insufficient to kill the microbes. Such conditions can be reproduced not only in the laboratory, but also in the human body.” Fleming's prophecy turned out to be ominous: penicillin-resistant strains of Staphylococcus aureus appeared in hospitals a year after the release of the first drug.

"Arms race"

As soon as a new miracle drug appeared on the market, the microbial world came up with a new way to avoid the misfortune. By the beginning of the 21st century, it became obvious that we are inventing new antibiotics much more slowly than microbes have time to adapt to them. Adaptation to the toxic effects of drugs is a classic example of natural selection according to Darwin. However, bacteria have an additional feature: they can pass on resistance to antibiotics not only to their offspring, but also to each other. In this case, it does not matter at all that the person has never taken this or that antibiotic. If bacteria resistant to a drug are present in the microbiome of one of the family members, they are highly likely to pass on the resistance genes to other “relatives”.

Bacteria strike again

In 2009, the microbial world “shot” with a new mutation that could turn any microorganism into a superbug, resistant to absolutely all antibiotics. In the English-language literature, such bacteria were called “superbug”. In November 2013, at the Infections and Infection Control forum, the case of the death of a young woman in the postpartum period from sepsis caused by such a superbug was discussed in detail.

In April 2014, WHO published the horrifying results of epidemiological surveillance. Every year, millions of people around the world die from superinfections. If we take specific figures, in Thailand it is more than 30,000 per year, and in the USA - 99,000.

The question “What to do?” very important

The situation in our country is alarming. 83.6% of Russian families take antimicrobial drugs uncontrollably. Moreover, many try to independently treat ARVI with antibiotics, in the holy confidence that antibiotics definitely act on viruses. The course of self-medication is, at best, limited to one package of the drug, although more often antibiotics are taken until the general condition improves.

In 2013, Prime Minister of the Russian Federation D.A. Medvedev recognized antibiotic resistance of bacteria as a matter of national security. The uncontrolled use of antibiotics should be treated in the same way. The sale of antibiotics by prescription only should become the absolute norm.

In November 2013, progressive obstetricians and gynecologists adopted the “Code of the Doctor Prescribing Antibiotics,” which, among other things, requires explaining to patients why antibiotics should not be purchased without a doctor’s prescription.

It is necessary to “do more, recognizing the scale of the coming catastrophe,” the WHO states. Of course, personal hygiene, access to clean water, infection control in medical institutions, and vaccination are important.

With regard to chronic urogenital infections, only monogamous relationships and love will save the world. A condom is the only barrier to sexual infection. It protects like a bulletproof vest, but does not guarantee anything to anyone. Therefore, only love can create real miracles.

Literature: Dobretsova T.A., Makletsova S.A. WHO: the world has entered a post-antibiotic era. — Status praesens, No. 3 (20), 2014. — P.11-20

Oksana Bogdashevskaya

Main photo: thinkstockphotos.com

Anatomical features

Clinical case. A young woman complains of acute cystitis, which appears the day after each sexual intercourse. An examination by a urologist showed that the patient’s urethra was located too low. An operation was performed to transpose (move) the urethra, after which the symptoms of cystitis disappeared.

What happened? Due to the incorrect position of the urethra during sexual intercourse, the penis pushes bacteria that live on the head of the penis into the vagina and bladder. As a result, acute cystitis occurs within 24–36 hours after sexual intercourse.

• Magazine archive /
• 2019 /

Treatment of acute uncomplicated cystitis in women with allergies or intolerance to antibiotics

DOI: https://dx.doi.org/10.18565/urology.2019.5.64-71

M.I. Davidov, D.A. Voitko, N.E. Bunova

1) Federal State Budgetary Educational Institution of Higher Education “Perm State Medical University named after. acad. E. A. Wagner" of the Ministry of Health of Russia; 2) Research Institute of Urology and Interventional Radiology named after. N. A. Lopatkina – branch of the Federal State Budgetary Institution “National Medical Research Center of Radiology” of the Ministry of Health of Russia

Purpose of the study: comparative assessment of the effectiveness and safety of the drugs Canephron N and Cyston in monotherapy for acute uncomplicated cystitis in women with allergies or intolerance to antibiotics. Materials and methods. In three urological centers in Perm in 2016–2019. A prospective randomized controlled trial of the drug Canephron N as a monotherapy for acute uncomplicated cystitis was conducted in 51 women with a history of allergy or intolerance to antibiotics. Patients in the main group received Canephron N for 30 days, the comparison group received Cyston. We used the assessment of disease symptoms using the ACSS scale, urine analysis by microscopy, bacteriological examination of urine and other methods. Results were assessed 3, 6, 30 days and a year after the start of treatment. Results. In the main group, monotherapy with Canephron N for 30 days led to a decrease in the sum of characteristic ACSS symptoms from the initial 12.9 to 0.3 points; in the Cyston group, the reverse dynamics of the development of symptoms on the ACSS scale was slightly worse: from the initial 12.8 points, symptoms decreased to 1.4 (p0.05), bacteriuria in the main group - to 7.7%, in the comparison group - to 20% (p>0.05), and the number of days of disability in the main group was 4.9±0 .4 days, in the comparison group – 7.4±0.6. In the Canephron N group, relapses of the disease within a year were observed in only 7.7%, in the Cyston group - in 16% of patients. Conclusion. The results of the study indicate that Canephron N is an effective and safe monotherapy for acute uncomplicated primary cystitis, which allows it to be considered the treatment of choice for the treatment of women with allergies or intolerance to antibiotics.

Key words: allergy to antibiotics, conservative treatment, acute uncomplicated cystitis, Canephron N, herbal medicine, urinary tract infections

The full text of the article is available in the Doctor's Library

Literature

1. Grigoryan L., Zoorob R., Wang H., Trautner BW Low Concordance With Guidelines for Treatment of Acute Cystitis in Primary Care. Open Forum Infect Dis. 2015; 2(4): 159. Doi: 10.1093/ofid/ofv 159.

2. Wagenlehner FM, Weidner W., Naber KG An update on uncomplicated urinary tract infections in women. Curr Opin Urol. 2009;19:368–374.

3. Foxman B. The epidemiology of urinary tract infection. Nat Rev Urol 2010;7:653–660.

4. Zaitsev AV, Kasyan GR, Spivak LG Cystitis. Urologiia. 2017; 1(Suppl. 1): 34–44. Russian (Zaitsev A.V., Kasyan G.R., Spivak L.G. Cystitis. Urology. 2017;1(Suppl. 1):34–44).

5. Alyaev Yu.G., Glybochko P.V., Pushkar D.Yu. Urology. Russian Clinical guidelines. M.:GEOTAR-Media. 2021. 480 rub. Russian (Alyaev Yu.G., Glybochko P.V., Pushkar D.Yu. Urology. Russian clinical guidelines. M.: GEOTAR-Media; 2021. 480 p.).

6. Perepanova TS, Kozlov RS, Rudnov VA, Sinyakova LA Antimicrobial therapy and prevention of infections of the kidneys urinary tract and male genital organs. Federal clinical guidelines. M., 2015: 23–29. Russian (Perepanova T.S., Kozlov R.S., Rudnov V.A., Sinyakova L.A. Antimicrobial therapy and prevention of infections of the kidneys, urinary tract and male genital organs. Federal clinical recommendations. M., 2015: 23– 29).

7. EAU Guidelines. Edn. Presented at the EAU Annual Congress Copenhagen 2021. ISBN 978-94-92671-01-1. www.https://uroweb.org/guideline/urological-infections/

8. Rationale for drug therapy of kidney and urinary tract disorders. Editors NA Lopatkin, TS Perepanova. M.: Litterra; 2012. 800 p. Russian (Rational pharmacotherapy in urology. Edited by N.A. Lopatkin, T.S. Perepanova. M.: Litterra; 2012. 800 pp.).

9. Kunin CM Urinary tract infections: detection, Prevention and Management. 5 th ed. Baltimore: Williams and Wilkins; 1997. 340 p.

10. Reese RE, Betts RF, Gumustop B. Handbook of antibiotics 3 ed. Philadelphia: Williams and Wilkins; 2000.415.

11. Scholar EM, Pratt WB The antimicrobial drugs. 2 ed. Oxford: University Press; 2000.

12. Gagyor I., Bleidorn J., Kochen MM, Schmiemann G., Wegscheider K., Hummers-Pradier E. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomized controlled trial. BMJ. 2015;351:h6544.

13. Kronenberg A., Butikofer L., Odutayo A., Muhlemann K., da Costa BR, Battaglia M., Meli DN, Limacher A., ​​Reichenbach S., Juni P. Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomized, double blind trial. BMJ 2017;359:j4784.

14. Alyaev Yu.G., Amosov AV, Sultanova EA Canephron N. Review of pharmacological and clinical data. M.; 2015. 128 p. Russian (Alyaev Yu.G., Amosov A.V., Sultanova E.A. Canephron N. Review of pharmacological and clinical data. M.; 2015. 128 p.).

15. Haloui M., Louedec JB, Michel JB, Lyoussi B. Experimental diuretic effects of Rosmarinus officinalis and Centauriumerythraea. J Ethnopharmacol. 2000;71:465–472.

16. Künstle G., Brenneis C., Haunschild J. Efficacy of Canephron N against bacterial adhesion inflammation and bladder hyperactivity. Eur Urol. Suppl 2013;12:e671.

17. Künstle G., Brenneis C., Pergola C., Werz O., Haunschild J. Anti-inflammatory effects of Canephron N and effectiveness in a model of interstitial cystitis. Urologe 2013;52(Suppl. 1):e97.

18. Alidjanov JF, Abdufattaev UA, Makhsudov SA, Pilatz A., Akilov FA, Naber KG, Wagenlehner FM New self-reporting guestionnaire to assess urinary tract infections and differential diagnosis: acute cystitis symptom score. Urol Int.2014;92(2):230–236. Doi: 10.1159/000356177.

19. Amdiy RE, Al-Shukri S.Kh., Kuzmin IV, Sorokin NV, Chaplitskiy EA, Skvortsov MV, Alekseev AS, Okunchaev A.Sh., Turbin AA, Timaeva GR, Bulaev DV, MoskalevaYu.S. Use of Kanefron in treatment of acute uncomplicated cystitis in women. Urologicheskie vedomosti. 2016;6(2):16–22. Russian (Amdiy R.E., Al-Shukri S.H., Kuzmin I.V., Sorokin M.V., Chaplitsky E.A., Skvortsov M.V., Alekseev A.S., Okunchaev A.Sh. ., Turbin A.A., Timaeva G.R., Bulaev D.V., Moskaleva Yu.S. Experience of using canephron in the treatment of acute uncomplicated cystitis in women. Urological Gazette. 2016;6(2):16–22) .

20. Davidov MI, Bunova NE Comparative assessment of Canephron N and ciprofloxacin as monotherapy of acute uncomplicated cystitis in women. Urologiia.2018;4:24–32. Russian (Davidov M.I., Bunova N.E. Comparative assessment of monotherapy with Canephron N and ciprofloxacin for acute uncomplicated cystitis in women. Urology. 2018;4:24–32). Doi: https://dx.doi.org/10.18565/urology.2018.4.24.32.

21. Ivanov D., Abramov-Sommariva D., Moritz K., Eskotter H., Kostinenko T., Martynyuk L., Kolesnik N., Naber KG An open label, non-controlled, multicentre, interventional trial to investigate the safety and efficacy of Canephron N in the management of uncomplicated urinary tract infections (uUTls). Clinical Phytoscience. 2015;1:7. Doi:10.1186/s40816-015-0008-x.

22. Kulchavenya EV, Breusov AA, Brizhatyuk EV, Shevchenko S.Yu. Acute cystitis - do we need antibiotikalways? Urologiia. 2016;1:25–28. Russian (Kulchavenya E.V., Breusov A.A., Brizhatyuk E.V., Shevchenko S.Yu. Acute cystitis - is an antibiotic always needed? Urology. 2016;1:25–28).

23. Veshkina AA, Zhuravlev OV, Semakov DV, KuzubI.I., Bazhenov IV The possibilities of using herbal medicine in urinary tract infections treatment. Ural. Med. J. 2017;2:130–132. Russian (Veshkina A.A., Zhuravlev O.V., Semakov D.V., Kuzub I.I., Bazhenov I.V. Possibilities of herbal medicine in the treatment of uncomplicated urinary tract infections. Ural Medical Journal. 2017;2:130– 132).

24. Wagenlehner F.M., Abramov-Sammariva D., Holler M., Steindl H., Naber KGNon-antibiotic herbal therapy (BNO 1045) versus antibiotic therapy (Fosfomycin trometamol) for the treatment of acute lower uncomplicated urinary tract infections in women: A double-blind, parallel-Group, randomized, multicentre, non-inferiority phase III trial. Urologia Internationalis. 2018;101:327–336. Doi: 10.1159/000493368.

About the authors / For correspondence

AUTHORIZATION: M. I. Davidov – urologist of the highest category, candidate of medical sciences, associate professor of the department of faculty surgery and urology of the Perm State Medical University. acad. E. A. Wagner", Perm, Russia; e-mail: [email protected]

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Disturbance of urine outflow

Clinical case. A 60-year-old woman complains of constant episodes of cystitis. The examination revealed uterine prolapse. An operation was performed, after which cystitis stopped bothering the patient.

What happened? Pelvic organ prolapse leads to difficulty emptying the bladder. Bacteria begin to multiply in the remaining urine, which leads to constant relapses of cystitis.

As a rule, pelvic organ prolapse occurs in women after a difficult birth or with age, when the tissues that support the organs in a normal state lose their elasticity. Tumors and diverticula (hernias) of the bladder can also lead to disruption of the outflow of urine.

Stop, infection! How to fight back against “winter” ailments Read more

Consequences of childbirth, injuries and operations

Clinical case . Chronic cystitis occurred in a woman after removal of the uterus. As a result of the examination, a fistula was discovered between the bladder and rectum. An operation was performed to eliminate the fistula, after which a cure for cystitis occurred.

What happened? Particles of feces entered the bladder from the rectum, causing inflammation. Typically, this kind of fistula is not difficult to diagnose - often the patient himself notices the release of urine from the anus during bowel movements. But if the patient suffers from frequent constipation, this may not be noticeable - urine does not flow out of the anus, but simply softens the stool.

Changes in the mucosa

Clinical case. After treatment of acute cystitis, the patient complains that the symptoms of the disease have blurred, but have not completely disappeared. When urinating, discomfort occurs, which quickly passes. The patient's urine analysis is normal, but cystoscopy and biopsy revealed vaginal metaplasia of the bladder mucosa. An operation for vaporization (steam treatment) of the altered area of ​​the mucosa has been proposed.

What happened? In acute cystitis, the mucous membrane of the bladder is damaged. The body directs all its efforts to repair the problem area, however, since the mucous membrane needs to be restored quickly, it happens that the “patch” turns out to be of poor quality. The altered area of ​​the mucous membrane cannot fully perform its protective function, so a small part of the urine ends up on the nerve endings, which causes pain.

Since changes in the mucosa do not cause any harm to health, they can be left without treatment. Such changes do not develop into cancer, so there is no need to worry about this.

Important!

Diagnosis of chronic cystitis includes examination by a urologist, ultrasound of the kidneys and bladder, and cystoscopy. During this procedure, the doctor uses a special instrument to examine the inside of the bladder. The procedure is performed under local anesthesia or sedation - light general anesthesia. Sedation is preferred as cystoscopy can be quite painful. If after a standard examination the cause of cystitis remains unknown, CT and MRI of the kidneys and bladder may be prescribed.

Answers on questions

Lecture transcript

XXV All-Russian Educational Internet Session for doctors.
Total duration: 16:26

00:00

Oksana Mikhailovna Drapkina, Secretary of the Interdepartmental Scientific Council on Therapy of the Russian Academy of Medical Sciences, Doctor of Medical Sciences, Professor:

— We are coming to the end of the section that is dedicated specifically to functional diseases of the intestine. Listening to the reports, I think many practicing doctors have a question.

What is the clinical portrait of a patient (adult, child) who should use Trimebutin? Who is this - man, woman, with abdominal pain, without pain, with constipation, with diarrhea? When should you see a psychotherapist? Can you briefly describe the clinical portrait that makes you reach for this drug?

Elena Aleksandrovna Poluektova, Candidate of Medical Sciences:

— Oksana Mikhailovna, you asked a very interesting question. A very interesting topic for discussion. Among adult patients, the drug "Trimebutin" has proven itself quite well. Why? This drug is soft and delicate. If this drug is prescribed, then somewhere on the next day (in extreme cases - every other day) the effect occurs.

What else is the trick of this drug? It initially works because it affects peripheral opioid receptors, which are located directly in the intestinal wall.

Among our questions was the following question (I saw it somewhere): does addiction set in, do the receptors cease to be sensitive? They do not cease to be sensitive, because somewhere towards the end of the first month of treatment, the second mechanism of action comes into play. This drug also acts on glutamate receptors at the level of the spinal cord.

If the drug "Trimebutin" helps the patient, the patient can take it for as long as desired - two months, three months. We have such patients in our clinic. Moreover, any gender differences (more men or more women) do not play a role here. If a patient complains of abdominal pain or abnormal bowel movements, then by prescribing this drug, we simply relieve several symptoms at once. Considering that these are able-bodied working people, it is easier for them to take one drug than to take several drugs.

02:40

Oksana Drapkina: Svetlana Ilinichna, your opinion?

Svetlana Ilyinichna Erdes, professor:

- Thank you. First of all, I would like to say that when talking about the genesis of all gastrointestinal disorders in pediatric practice (this is generally known to all pediatricians), we assign the leading role to motor disorders. Discussing the mechanisms of Trimebutin, of course, I am very impressed by its ability to influence these motor disorders.

If you ask about the portrait of the patient to whom this drug is intended, then it seems to us that this is a patient (probably a child too) with motor disorders. But at the same time, it should be noted that today, if we talk specifically about pediatric studies, their number is small. I think that so far there is simply a huge deficit in our understanding of how this drug will work in pediatric practice.

Determine exactly the points of its action. What will it be? Upper sections or will it still be intestinal motility? Which parts of the intestine? Accordingly, access to specific nosological forms.

The mechanisms that are announced seem very attractive. This is very important for the genesis of all inflammatory or functional disorders in pediatrics. But, I want to say again, clinical practice will judge us.

Oksana Drapkina: Time and practice. Marina Fedorovna, what questions do you have?

Marina Fedorovna Osipenko, professor:

— I have a few questions.

Oksana Drapkina: Questions? Let us ask questions then.

Marina Osipenko: Reply now?

Oksana Drapkina: Let's do it. Yes.

04:35

Marina Osipenko: Question about the doses and duration of use of Trimebutin for duodenogastric reflux.

I must say that the question of the duration of use of any drugs (especially for functional pathology) from the perspective of evidence-based medicine is generally a question that does not have a clear answer. I emphasize once again - from the standpoint of evidence-based medicine!

We, first of all, rely on our empirical practice, based on the research that has been conducted. Did you notice that in the vast majority of cases it was about the month of prescription of this drug. The second point is based on common sense. Especially when it comes to gastroduodenal reflux, for the diagnosis of which there are no strict standards at all today.

When treating any pathology (primarily functional), we focus on a month or more, let’s say. In any case, a shorter prescription usually does not bring lasting improvement. Regarding the longer term, I think you need to approach it individually.

Second question.

Are there combination drugs that include prokinetics and antispasmodics or prokinetics with different effects? Are there similar drugs on the domestic market?

Combination drugs (prokinetics and antispasmodics) do not exist not only on the domestic market, but also in the world in general. The mechanism of almost all prokinetics (we demonstrated this today) is, in the vast majority of cases, multicomponent.

“Trimebutin”, which everyone present has extensive experience in using (we often use it and treat it well). It has an excellent evidence base. We demonstrated in an experiment that in clinical use it acts on different parts of motor dysfunction, therefore, in its essence, it is already a combined drug.

Again, the question is about the duration of use for diseases accompanied by impaired motor skills. A question has been asked here regarding gastroesophageal reflux disease. "Trimebutin" does not affect the condition of the lower esophageal sphincter: at least, so far there have been no such studies. For isolated gastroesophageal reflux disease, there is, frankly speaking, no information in the world that it can be effective.

In the event that GERD is aggravated, for example, by impaired piloantral motility (for example, gastroparesis or some kind of gastric outlet disorder) - yes, the combined use of drugs that either affect the lower esophageal sphincter or make reflux less acidic (that is, inhibitors acidity), with Trimebutin is quite justified. But it is not suitable as monotherapy for the treatment of GERD.

Regarding non-ulcer dyspepsia, duodenogastric reflux - essentially, I have already answered this question.

07:39

One more question.

In what situation is it preferable to use Trimedat, and in what situation are drugs like Dicetel and Buscopan?

The question is very good because it compares the application points of these drugs. By and large, we often consider them in one group, because the indications for their use (Elena Aleksandrovna and Svetlana Ilyinichna demonstrated this quite remarkably) are nosological. They are close.

Here we must clearly understand the strengths of each of the drugs that are asked in this question (groups of drugs).

Antispasmodics are still drugs that are aimed at relieving pain. This is their first priority. In this regard, the strength of the same “Buscopan” is any abdominal pain of any origin. “Dicetel” has a greater tendency (or tropism) to the smooth muscles of the intestine, therefore it is used more (mainly) for functional intestinal pathology.

As for Trimedat, its strength, along with the antispasmodic effect, is its normalizing effect on motor skills, when abdominal pain is accompanied by either pathological reflux, or a violation of passage, or some other manifestations in addition to pain.

Thank you.

09:08

Oksana Drapkina: Thank you very much! Let us then answer the questions that came to us. Elena Alexandrovna, do you still have questions?

Elena Poluektova: Yes, I have two questions. First question.

What is the significant difference between the drugs Trimedat and Loperamide? How can one explain the benefits of Trimedat in patients with dyspepsia?

The difference between Loperamide and Trimedat: Loperamide affects µ-opioid peripheral receptors, Trimedat affects µ, ? and ?-receptors. Accordingly, Loperamide inhibits motor skills, and Trimedat regulates it. This is the difference.

How can one explain the benefits of Trimedat in patients with dyspepsia?

I think it can be explained by the fact that this drug acts throughout the gastrointestinal tract. As a rule, the patient does not have only functional dyspepsia or only irritable bowel syndrome. If the motility of the gastrointestinal tract is disturbed, then it is disturbed throughout. A drug that restores it throughout its entire length has advantages.

How often in your practice do you resort to the use of anxiolytics and antidepressants in the treatment of patients with functional dyspepsia? Which drugs should be preferred?

What do I want to say about this? Previously (probably 5 years ago) I was more categorical: if symptomatic treatment does not help the patient, I referred him to a psychiatrist. We tried to prescribe psychotropic drugs.

Now I still try to change the symptomatic treatment regimen twice, sometimes three times. If the patient and I are convinced that this treatment regimen is not working and another is not working and another is not working, then we discuss why that might be. What is the reason? Maybe there are some deeper processes that prevent these drugs from working. Then we discuss together the question of whether we should also involve a psychiatrist in the alliance between doctor and patient.

If the patient agrees with this, then we invite a psychiatrist. We already then jointly develop a concept - will it be psychopharmacotherapy or will it be psychotherapy. Here it is difficult to say that we give preference to any one drug, because everything depends on the patient, on his individual characteristics.

What else would I like to say here? Let's say if we take 100% of all patients for whom consultation with a psychiatrist is indicated. I guide them. Only 60% reach a psychiatrist (they agree to a consultation out of those 100% for whom this consultation is indicated). About half of those who have reached a psychiatrist agree to treatment with psychotropic drugs. What will you do about it? Probably nothing. This is a difficult group of our functional patients.

16:26

Oksana Drapkina: I see. Thanks a lot. Svetlana Ilyinichna, do you also have questions?

Svetlana Erdes: Yes. Regarding age indications. This drug is registered in Russia and is approved for use in children starting from the age of three. I talked about this. Doses vary (this was also in my report) depending on age.

To be fair, it should be said that world practice indicates the possibility of using it from a very early age, since there are also forms in the form of sachets. But for Russia not yet. We must, working within the certified indications, use this drug only in children starting from the age of three.

Regarding side effects. According to general statistics and in pediatrics too, there is a very small, almost insignificant effect of adverse reactions in the form of allergic ones. Less than 2%. No other undesirable effects were recorded.

Oksana Drapkina: Thank you very much, Svetlana Ilyinichna. Thank you very much Elena Alexandrovna, Svetlana Ilyinichna. Marina Fedorovna, you are receiving questions.

Marina Osipenko: Should patients with risk factors for gallstone disease take ursodeoxycholic acid preparations as a preventive measure?

Yes, I have listed specifically those situations for which there is a good evidence base. In relation to other situations, of course, it is necessary to approach individually, but this is quite possible. In some cases it is advisable.

Oksana Drapkina: Is the dosage the same?

Marina Osipenko: Dosage 10 – 15 mg per kilogram of body weight.

Do essential phospholipids affect bile formation?

They don't influence.

Can biliary sludge lead to the development of gallstones? Does this condition require medication correction?

Of course, biliary sludge gives us reason to consider the pre-culculous stage of cholelithiasis. If we talk about conservative treatment of this pathology, then this is exactly the situation that requires conservative treatment, and the effectiveness of which is extremely high.

Regarding the prescription of drugs from the group of antispasmodics. The attitude towards them should be restrained. The effectiveness of ursodeoxycholic acid increases with good contractility of the gallbladder. We prescribe antispasmodics only if we prove the presence of functional disorders, namely hypertonicity of the sphincter of Oddi.

14:55

Oksana Drapkina: We still have two last minutes until twenty minutes. Marina Fedorovna, we have a patient who has all the indications for the use of ursodeoxycholic acid. After all, there is a lot of ursodeoxycholic acid (I mean - different drugs).

As I understand it, what you told us and your studies that showed were done on Ursosan. How do you approach this difficult problem of choosing a quality drug?

Marina Osipenko: Indeed, there are quite a lot of ursodeoxycholic acid preparations on the market. One of the first to appear was “Ursosan”. We have been working with him for a very long time - he has never let us down. I can’t say anything bad about a number of other drugs: Ursofalk and emerging domestic drugs.

Just to choose and use, of course, there must be a good evidence base. We must use these drugs ourselves and have experience in using them. A drug that is well tolerated (essentially a group of drugs). The only side effect that we encounter is a certain loosening of the stool (tendency to diarrhea). But in some cases, on the contrary, we achieve this.

Oksana Drapkina: Many do.

Marina Osipenko: Yes. In the event that there are opposite problems with passage through the intestines. Here, by prescribing one drug, we can solve issues not only related to the biliary system.

Oksana Drapkina: Thank you very much! Thank you for your lectures and for coming to us today. Thanks a lot!

16:26

Is it true?

+ To avoid cystitis, you need to wear warm underwear. Hypothermia can actually cause cystitis. When hypothermia occurs, local immunity suffers, and bacteria that live in the anus and vagina and for the time being do not cause any harm begin to actively multiply. But where exactly the hypothermia occurred is not so important. Therefore, cystitis can appear even if you are wearing warm underwear, but you go outside without a hat.

— For cystitis, douching with potassium permanganate or furatsilin is needed. But this is definitely not necessary! When douching, the antiseptic solution does not penetrate the bladder, but can cause a burn to the mucous membrane of the vagina and urethra.

— Thongs and tight underwear lead to cystitis. This connection has not been proven, so choose the underwear that you like.

— To prevent cystitis, you need to drink as much cranberry juice as possible. Morse has no effect on the occurrence of cystitis, so drinking or not drinking is a matter of personal preference. However, if cystitis has already appeared, it is really necessary to maintain a drinking regime and drink at least 1.5 liters of clean water per day - the bladder must be emptied on time.

— If you have cystitis, you need to sit in a bath with warm water. It relieves spasms and alleviates the condition, but does not cure the disease.

+ If you have cystitis, you should not eat spicy food or drink alcohol. Both irritate the mucous membrane of the bladder, so it is really better to avoid these products during illness.

ANTIBACTERIAL THERAPY OF UNCOMPLICATED ACUTE CYSTITIS AND PYELONEPHRITIS IN ADULTS

MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

COMMISSION ON ANTIBIOTIC POLICY OF THE MINISTRY OF HEALTH OF THE RF AND RAMS

Research Institute of Urology of the Ministry of Health of the Russian Federation

Research Institute of Antimicrobial Chemotherapy of SMOLENSK STATE MEDICAL ACADEMY

MOSCOW STATE MEDICAL AND DENTAL UNIVERSITY

ST. PETERSBURG MILITARY MEDICAL ACADEMY

Toolkit

The manual provides basic information about the classification, risk factors for urinary tract infections; modern domestic data on the etiology and antibiotic resistance of pathogens of uncomplicated acute cystitis and pyelonephritis. The tactics of antibacterial therapy for patients with acute cystitis and pyelonephritis are discussed in detail: choice of antibiotic, route of administration, duration of therapy, main errors in therapy. Recommendations are given for prophylactic antibacterial chemotherapy for recurrent urinary tract infections. A comparative description of the main antibiotics used to treat these infections is provided.

For general practitioners, urologists, obstetricians-gynecologists, clinical pharmacologists.

Authors' team:

Institute of Urology of the Ministry of Health of the Russian Federation (academician of the Russian Academy of Medical Sciences, Doctor of Medical Sciences, Professor N.A. Lopatkin, I.I. Derevyanko), Research Institute of Antimicrobial Chemotherapy of the Smolensk State Medical Academy (Doctor of Medical Sciences, Professor L.S. Strachunsky , Candidate of Medical Sciences V.V. Rafalsky, Candidate of Medical Sciences G.K. Reshedko, S.V. Sekhin), Department of Urology, Moscow Medical and Dental University (Doctor of Medical Sciences, Prof. O B. Laurent), Department of Urology, St. Petersburg Military Medical Academy (MD, Prof. S.B. Petrov, MD, P.A. Babkin, Ph.D., Associate Professor E.I. Veliev).

Contact address:

V.V. Rafalsky Tel.: (0812) 611301, 611327 Fax: (0812) 611294 Email. mail

Content

• Introduction
  Classification of urinary tract infections
• Epidemiology
• Risk factors for developing UTIs

• Etiology of NSTI
• Sensitivity of pathogens to antibiotics
• Antibacterial therapy of acute cystitis and pyelonephritis
• Goals of antibiotic therapy
• Choice of antibiotics
Choice of antibiotics for the treatment of NUTI in pregnant women
• Route of administration of antibiotics
• Duration of therapy
Acute cystitis
• Acute pyelonephritis
• Indications for hospitalization
• Prophylactic use of antibiotics for recurrent NSTIs
• Errors in antibiotic therapy in patients with NIMP
• Bibliography
• Applications
• Appendix 1. Algorithm for the management of patients with urinary tract infection.
• Appendix 2. Doses of antibacterial drugs for the treatment of NUTI.
• Appendix 3. Basic antibacterial drugs recommended for the treatment of uncomplicated urinary tract infections.

INTRODUCTION

1.1. Classification of urinary tract infections.

According to the anatomical classification, UTIs are divided into lower and upper urinary tract infections. Lower urinary tract infections include acute cystitis (AC) and urethritis. Infections of the upper sections include acute and chronic pyelonephritis. Based on the nature of their course, urinary tract infections (UTIs) are divided into complicated and uncomplicated (Fig. 1).

Rice. 1.

Classification of urinary tract infections

Uncomplicated UTI

(NIMP) occur in the absence of obstruction in the kidneys and urinary tract, urolithiasis, polycystic kidney disease, anomalies in the development and location of the kidneys, ureteral strictures, urethral strictures, vesicoureteral reflux, benign prostatic hyperplasia with impaired passage of urine from the upper urinary tract, etc. etc.), as well as in patients without serious concomitant diseases.

Only AC and acute pyelonephritis (AP) in non-pregnant women, without stricture uropathy and neurological disorders, fully qualify as NIMP.

Complicated UTIs

occur in patients with various obstructive uropathy, against the background of instrumental (invasive) methods of examination and treatment, with serious concomitant diseases (diabetes mellitus, neutropenia). Complicated UTIs can lead to the development of severe purulent-septic complications, bacteriuria, and sepsis.

The importance of distinguishing between complicated and uncomplicated UTIs is determined by different treatment approaches. It is necessary to take into account that NIMP can occur not only in mild and moderate, but also in severe form, with severe symptoms of intoxication.

1.2. Epidemiology.

UTIs are among the most common diseases, both in the clinic and in the hospital. The most common presentation of uncomplicated UTI is AC. The incidence of OC in women is 0.5-0.7 episodes of the disease per woman per year. The prevalence of AC in Russia, according to estimates, is 26-36 million cases per year. The incidence of AC in adult men is extremely low and amounts to 6-8 episodes per year per 10,000 men aged 21-50 years.

AP is the most common kidney disease in all age groups. In general, women predominate among patients with AP. The incidence of AP is significantly lower than AC, and in Russia, according to estimates, is 0.9-1.3 million cases annually.

1.3. Risk factors for developing UTI.

The risk of developing a UTI depends on the age, gender of the patient, the presence of concomitant diseases and pathology of the urinary tract. Women are 30 times more likely to have a UTI than men. Between the ages of 2 and 15, girls suffer from UTIs 6 times more often than boys, almost the same ratio between men and women is observed in young and middle age, while in old age UTIs occur more often in men. A significant risk factor for OC in young women is the frequency of sexual intercourse and the nature of the contraceptives used: the incidence of OC is higher when using diaphragms and spermicides. During pregnancy, the risk of UTIs increases, which develop in 4-10% of pregnant women; bacteriuria is detected in 25-30% of women in labor. In postmenopausal women, the incidence of NUTI is 20%.

ETIOLOGY OF NUMP

Typically, NSTIs are caused by a single microorganism. The detection of several bacteria in the samples is explained by violations of the technique for collecting and transporting the material. The most common pathogens are gram-negative enterobacteriaceae, mainly E. coli

- 70-95%.
The second most frequently isolated organism is S. saprophyticus
(5-20% of NSTI cases), which is more often isolated in young women. Much less frequently, NSTIs are caused by other gram-negative bacteria (Klebsiella, Proteus, etc.). In 1-2%, the causative agents are gram-positive microorganisms (streptococci, enterococci).

2.1. Sensitivity of pathogens to antibiotics.

Pathogens of NSTIs, primarily E.coli

, have natural (primary) sensitivity to many antibiotics, for example, sulfonamides, tetracyclines, chloramphenicol, ampicillin and many others. However, most bacteria have now become resistant to a number of antibiotics.

Rice. 2.

Antibiotic resistance of
E. coli
isolated from patients with acute cystitis in Russia

Studies on the sensitivity of UTI pathogens in Russia (Fig. 2) show that the prevalence of uropathogenic E. coli

resistant to ampicillin and co-trimoxazole is very high and amounts to 33.3% and 18.4%, respectively.
Modern fluoroquinolones (ciprofloxacin and norfloxacin) are the most active drugs against E. coli
isolated from UTIs. Resistance to them is 2.6%. In addition, ciprofloxacin and norfloxacin are active against E. coli strains resistant to nalidixic acid and pipemidic acid. In general, the main problem is resistance of uropathogens to ampicillin and co-trimoxazole.

ANTIBACTERIAL THERAPY OF ACUTE CYSTITIS AND PYELONEPHRITIS

3.1. Goals of antibiotic therapy.

The main goals of NIMP therapy are: – rapid relief of symptoms, – restoration of ability to work and social activity, – prevention of complications, – prevention of relapses.

3.2. Choice of antibiotics.

The choice of drug in the vast majority of cases is carried out empirically, based on data on the predominant pathogens (mainly E. coli

), their resistance in the region and the severity of the patient’s condition.

Taking into account the characteristics of antibiotic resistance of the main uropathogens, pharmacokinetics and safety, the drugs of choice for NSTI are fluoroquinolones - norfloxacin, ofloxacin, pefloxacin, ciprofloxacin, etc. Alternative drugs - amoxicillin/clavulanate, fosfomycin trometamol, co-trimoxazole (Table 2, Appendix 1, Appendix 2) .

When choosing antibiotics for the treatment of NSTI, it is important to weigh the possible risk of adverse reactions and the severity of the patient's condition. Because NSTIs are self-limiting, the use of drugs that may cause severe adverse reactions may not be justified. For example, aminoglycosides should not be used in patients with non-severe NSTIs due to the nephrotoxicity of these drugs.

3.2.1. The choice of antibiotics for the treatment of NUTI in pregnant women.

The choice of antibiotics in pregnant women depends not only on the activity of the drugs, but also on their safety. These requirements are met by aminopenicillins and cephalosporins, which can be prescribed with a high degree of safety throughout pregnancy. If there is no alternative, pregnant women may be prescribed co-trimoxazole and nitrofurantoin.

3.3. Route of administration of antibiotics.

For NIMP, the preferred route of administration is oral. It is necessary to take into account the pharmacokinetics of the antibiotic

and use drugs that provide high (above the MIC of the pathogen) concentrations in the urine when taken 1-2 times a day. Antibiotics with a long half-life can be prescribed 1-2 times a day, thereby increasing patient compliance. Parenteral administration of antibiotics is used for severe acute pyelonephritis and the inability to take drugs orally.

3.4. Duration of therapy

3.4.1. Acute cystitis.

The main criterion for choosing the duration of antibiotic therapy is the presence or absence of risk factors (Table 1). In the absence of risk factors, a 3-5 day course is carried out, and if risk factors are identified, it is rational to use a 7-day course of therapy.

Conducting short courses (3-5 days) of antibiotic therapy in patients with AC is highly effective. Lengthening the course of antibiotic administration does not lead to a significant increase in effectiveness, but may increase the risk of adverse reactions. During the first 2-3 days of therapy, there may be no relief of symptoms; therefore, it is necessary to explain to patients the features of the course of acute cystitis.

Table 1.

Contraindications to treatment of acute cystitis in short (3-5 days) courses

– Pregnancy, – Age > 65 years, – UTI in men, – Duration of symptoms > 7 days, – Recurrence of infection, – Use of diaphragms and spermicides, – Diabetes mellitus.

Treatment with a single dose of the drug is generally less effective than a short course and should only be prescribed to patients without risk factors. In this case, it is necessary to use antibiotics with a sufficiently long half-life, for example, fluoroquinolones fosfomycin trometamol.

Table 2.

Antibacterial treatment regimens for uncomplicated urinary tract infections

	E.coli S.saprophyticus Less commonly, other enterobacteria	No	Orally for 3-5 days: fluoroquinolone (norfloxacin, ofloxacin, perfloxacin, ciprofloxacin, etc.), amoxicillin/clavulanate. Fosfomycin trometamol
Diabetes Symptoms persist > 7 days Recurrent UTI Use of diaphragms and spermicides Age > 65 years		Oral for 7 days: fluoroquinolone or amoxicillin/clavulonate
Pregnancy1		Orally for 10-14 days: cephalosporin, amoxicillin, nitrofurantoin, co-trimoxazole
Acute uncomplicated pyelonephritis in women	E.coli P.mirabilis K.pneumoniae	Mild or moderate course, without pronounced symptoms of intoxication	Oral for 10-14 days: fluoroquinolone (norfloxacin, ofloxacin, perfloxacin, ciprofloxacin) or amoxicillin/clavulonate
		Severe course, need for hospitalization	Parenterally until fever disappears: fluoroquinolone2, IZP3, cephalosporin II-IV, acrbopenem or ampicillin + aminoglycoside; then oral fluoroquinolone for 14 days
		Pregnancy – hospitalization recommended	Parenterally until fever disappears: cephalosporin II-III, IZP4, ampicillin + aminoglycoside, aztreonam, co-trimoxazole; then orally for 14 days: amoxicillin, cephalosporin or co-trimoxazole.
1 Fluoroquinolones should not be prescribed. Co-trimoxazole should not be prescribed in the third trimester. Gentamicin can be used with caution - damage to the VIII cranial nerve in the fetus is possible. 2 Ciprofloxacin, pefloxacin, ofloxacin 3 IPPs - inhibitor-protected penicillins (amoxicillin/clavulanate, ampicillin/sullbactam, ticarcillin/clavulanate) 4 amoxicillin/clavulanate

3.4.2. Acute pyelonephritis.

It is more difficult to achieve eradication of the pathogen with damage to the kidney parenchyma than with superficial damage to the mucous membrane. Therefore, in AP, antibiotics are prescribed for a longer period than in AC.

For mild to moderate cases, without pronounced symptoms of intoxication, antibiotics are prescribed orally for 10-14 days. If the 14-day course is ineffective, a longer prescription of antibiotics is used - for 4-6 weeks (Table 2).

In severe cases of AP and the presence of severe symptoms of intoxication, parenteral administration of antibiotics is necessary until the fever disappears. Then it is possible to switch to oral antibiotics for 10-14 days. If relapses occur, preventive treatment is used for 6-12 months.

3.5. Indications for hospitalization.

Patients with AC and mild/moderate AP are usually treated on an outpatient basis and hospitalization is not required. In severe cases of AP and the presence of severe symptoms of intoxication, hospitalization of the patient is necessary.

Rice. 3.

Management tactics for patients with recurrent uncomplicated urinary tract infections.

3.6. Prophylactic use of antibiotics for recurrent NSTIs.

Patients with frequently recurrent NSTI (more than 2 exacerbations within 6 months, or more than 3 exacerbations within a year) should receive preventive therapy (Fig. 3). For this purpose, long-term prophylactic administration of low doses of fluoroquinolones, nitrofurantoin, co-trimoxazole, or, in adolescents, pregnant and lactating women, an oral cephalosporin (for example, cephalexin) is used (Table 2, Fig. 3). In patients with recurrent NSTIs associated with sexual intercourse, a single dose of the drug after coitus is recommended. With this prophylaxis regimen, the dose of the drug, the number of adverse reactions and the risk of selection of resistant strains are reduced.

Table 3.

Typical mistakes when choosing antibiotics for the treatment of uncomplicated urinary tract infections

First generation cephalosporins	Insufficiently high activity against the main pathogens of NSTIs
Sulfonamides Ampicillin Amoxicillin	Risk of Stevens-Johnson and Lyell syndromes High level of uropathogen resistance
Use of fluoroquinolones in pregnant women	Contraindicated (risk of damage to connective tissue in the fetus)
Route of administration
Gentamicin IM for AC or mild AP	For AC or non-severe NUTI, oral antibiotics are sufficient.
Parenteral administration of antibiotics in outpatient settings	Modern oral antibiotics, for example, fluoroquinolones, are not inferior in effectiveness to parenteral drugs
Duration of therapy
Long courses of antibiotics for AC	In the absence of risk factors, 3-5 days, and in their presence, 7-day courses of therapy are sufficient. Increasing the duration of therapy does not significantly affect the effectiveness of treatment, but increases the risk of adverse reactions.
Use of an antibiotic to treat AC for 1-3 days in the presence of risk factors	If there are risk factors, treatment should be carried out for at least 7 days.

In case of rare relapses of NUMP and the inability to seek medical help, it is possible to recommend self-administration of an antibiotic when symptoms of NUMP appear. At the same time, to confirm the elimination of the pathogen, a bacteriological examination of urine 1-2 weeks after taking the drug is desirable.

In postmenopausal women, antibiotics play a lesser role than in young women. Periurethral and intravaginal use of hormonal creams containing estrogen (0.5 mg/g) at night for 2 weeks, followed by twice a week for several months, significantly reduces the frequency of exacerbations of UTIs and should be recommended before prophylactic use of antibacterial drugs.

Errors in antibiotic therapy in patients with NIMP

When conducting antibacterial therapy for UTIs, doctors often make mistakes, primarily related to the choice of drug, the route and frequency of administration, and the duration of therapy (Table 3). To a certain extent, such errors can be avoided by standardizing treatment and using diagnostic and therapy algorithms (Appendix 1).

LITERATURE

1. Lopatkin N.A., Derevyanko I.I. Uncomplicated and complicated urinary tract infections. Principles of antibacterial therapy. RMJ 1997;24:1579-1589.
2. Laurent O.B. Epidemiological aspects of urinary tract infections. Proceedings of the symposium: “Urinary tract infections in outpatients” February 16, 1999, Moscow 1999. P.5-9.
3. Naber K.G. Optimal treatment of urinary tract infections. Clinical microbiology and antimicrobial chemotherapy. 1999; 1:23-30.
4. Strachunsky L.S. Norfloxacin in the treatment of urinary tract infections. Proceedings of the symposium: “Urinary tract infections in outpatients” February 16, 1999, Moscow 1999. P.29-32.
5. Strachunsky L.S., Rfalsky V.V., Sekhin S.V., Abrarova E.R. Practical approaches to the choice of antibiotics for uncomplicated urinary tract infections // Urology. - 2000. - No. 2. - P. 8-15.
6. Bacheller CD, Bernstein JM Urinary tract infections. Med Clin North Am. 1997;81:719-729.
7. Hooton TM, Stamm WE Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am. 1997;11:551-581.
8. Kunin KM Urinary tract infections: Detection, prevention, and management. Fifth edition, 1997. p.139.

Applications

Annex 1.

Algorithm for the management of patients with urinary tract infection.

Appendix 2.

Doses of antibacterial drugs for the treatment of NSTI.

Appendix 3.

The main antibacterial drugs recommended for the treatment of uncomplicated urinary tract infections.