ACUTE PYELONEPHRITIS

Acute pyelonephritis - a nonspecific acute exudative inflammation of the kidneys and

pyelocaliceal system with a strong fever, pain, pyuria and renal dysfunctions.

Clinical picture

Leading disease syndromes in older children in the acute period are shown in Table
16-1.

Table 16-1. Leading syndromes of acute pyelonephritis in children older

Syndrome Symptoms
Pain Abdominal pain (often without a definite localization) and the
lumbar region, reinforced by physical effort. Positive symptom
Dizurichesky (when Pasternatskogo Frequent urge to urinate, pain or burning
involved in the sensation (especially at the end of urination) may neuderzhanie
pathological process of the urine
lower urinary tract)
Increased body temperature (sometimes up to febrile digits)
Intoxication with chills, headache, weakness, anorexia, pale skin

Features of the clinical picture of acute pyelonephritis in young children, in particular

the prevalence of extrarenal symptoms, due to morphological immaturity of the
urinary system and the tendency to generalization of the inflammatory process. The
disease begins with hyperthermia, increasing signs of toxicosis and exsicosis. The
rapid start is especially true for children with post-hypoxic encephalopathy. Excitation
characteristic of the first days of illness, quickly replaced adinamii. Pseudomeningitis
There phenomenon. The child's body weight is reduced because of severe anorexia,
persistent regurgitation and vomiting, loose stool. Dyspeptic phenomena may prevail
over dizuricheskimi. Sometimes a careful observation of the child may be noted
anxiety before or during urination. In general, the clinical picture of acute urinary
infections in young children resembles sepsis, and is accompanied by changes not
only in the kidney, but also in the liver, adrenal glands and central nervous system.

Fever relapsing-remitting type, sometimes with chills and sweating, still about a
week. In the next 1-2 weeks all manifestations gradually disappearing. If the disease is
delayed by more than 3 months, or relapse, the diagnosis of acute pyelonephritis
should be reviewed in order to avoid exacerbation of a chronic process.

Complications. Among the complications should be allocated sepsis, apostematozny

nephritis (interstitial nephritis, characterized by the formation of multiple purulent
foci, especially in the cortical layer of the kidneys), renal carbuncle, paranefrit,
pionefroz and necrosis of renal papillae. Complications more common for young
children.

Laboratory studies

The most characteristic pathological pyelonephritis inclusion in the urine. It often

becomes turbid, may contain small amounts of protein. In the draft reveal numerous
white blood cells, sometimes - leukocyte cylinders, a large number of epithelial cells,
may be red blood cells, possible hematuria (with papillary necrosis), or clots of fresh
blood, reflecting an acute inflammation of the bladder. Leucocytes are usually
represented by neutrophils. Almost always reveal a great number of microorganisms
(50 000-100 000 microbial bodies in 1 ml, taken from the middle portion allocated
urine - a reliable sign of bacterial inflammation in older children, 10000 of microbial
bodies in 1 ml - in the younger age group).

In the study of blood detected moderate anemia, leukocytosis with a shift to the left of
leukocyte formula, erythrocyte sedimentation rate increased, the concentration of C-
reactive protein, dysproteinemia. Varying index of the immune system: the number of
T-and B-lymphocytes, the content of Ig. Define high titer of serum AT to bacteria
isolated from urine.

Diagnosis

Diagnosis of acute pyelonephritis has been particularly difficult in young

children. Acute pyelonephritis should be excluded in any child's first years of life
when unmotivated fever, intoxication, dyspeptic phenomena. For the older children in
typical cases, oriented to a set of characteristics such as fever, dysuria and pain in the
back or abdomen.The main symptoms - changes in the urine (bacteriuria and
leykotsituriya), diagnosis should contain the following information.

Defining the essence of the pathogenetic process (primary or secondary

pyelonephritis), indicating predisposing to its development factors (abnormalities,
reflux, stones, metabolic disorders, etc.).

The period of the disease (active, reverse the development of symptoms, complete
clinical and laboratory remission).

Condition of kidney function.

The presence or absence of complications.

If you suspect pyelonephritis necessarily prescribe ultrasound of urine to clarify the
size, position, characteristics of the anatomical structure of the kidneys (doubling,
hypoplasia, etc.) and the state of the composite system, the possible detection of
kidney stones or bladder, assessment of renal blood flow.

Differential Diagnosis

Acute pyelonephritis primarily differentiated from acute glo-merulonefrita arising not

in the acute phase of bacterial or viral disease, but after 2-3 weeks after streptococcal
infection. Glomerulonephritis almost always develops in the background is a normal
body temperature and is rarely accompanied by dizuricheskimi disorders. Edema or
pastoznost tissue, arterial hypertension, observed in the majority of patients with
glomerulonephritis, is also not characteristic of pyelonephritis. Oliguria initial period
of glomerulonephritis contrasts with polyurethane it often is detected in the first days
of acute pyelonephritis. In glomeruli nephritis-dominant hematuria, in the urinary
sediment always reveal the cylinders, but the number of leukocytes slightly, some of
them are lymphocytes, bacteriuria absent. Reduction of concentration ability of
kidneys (in a sample of urine Zimnitskiy maximum density of less than 1,020 in
diuresis less than 1000 ml / day), and ammoniogeneza atsidogeneza combined with
pyelonephritis with normal creatinine clearance (for those last-glomerulonephritis
reduced).

In addition, it is necessary to carry out differential diagnosis of acute pyelonephritis

with sepsis (if pyelonephritis does not become a consequence of sepsis), as well as
acute appendicitis, which is atypical for the location of the appendix may be
accompanied by dizuricheskimi phenomena in the absence of symptoms of irritation
of the peritoneum. In the latter case to establish the correct diagnosis are important
study per rectum, allowing to identify the painful infiltrate in the right iliac region,
and repeated urine. With persistent absence of bacterial flora in the urine showed her
study of mycobacteria.

In each case, acute urinary infection is extremely important to resolve the issue is
limited to whether the pathological process of the lower urinary track, or apply to the
pelvisand tubulointerstitial kidney tissue, ie determine the disease as pyelonephritis,
or cystitis pyelocystitis. Pyelonephritis is much greater cystitis. In addition, cystitis no
change in urine, defined as absolute indications of pyelonephritis: leukocyte cylinders,
high enzyme activity, characteristic of epithelial tubules, and a high concentration of
p 2microglia-bowline, the presence of bacteria coated with AT (revealed using
fluorescence microscopy) . In contrast to cystitis, pyelonephritis accompanied by an
increase in titer of antibacterial AT in serum, decrease in concentration ability of the
kidneys, and ammoniogeneza atsidogeneza.
Treatment

Treatment is directed at fighting infections, intoxication, the restoration of

urodynamics and kidney function, increased reactive position of the body.

In the acute period of bed rest is needed, particularly at high body temperature, chills,
severe intoxication, dizuricheskih disorders and pain. A diet with restriction of
extractive substances, excreted epithelial tubules and have an irritant (pepper, onion,
garlic, rich broth, meats, coffee, etc.). In order to force a diuresis in the diet is
advisable to include fresh fruits and vegetables with diuretics (water-melons, melons,
squash, cucumbers). It is recommended to increase fluid intake by 50% compared
with the age norm. Young children, as well as more older children with severe course
of the disease shows a transfusion, rehydration, and detoxification therapy.

All patients with acute pyelonephritis prescribe antibiotics. In severe disease course
therapy begins with parenteral administration of antibacterial agents (preferably
bactericidal). Most patients starting antibiotic therapy prescribed empirically, since
the results of bacteriological studies and determination of the sensitivity of the
microbial flora can be obtained only through 48-72 h, and therapy should begin
immediately. In the absence of the effect of treatment after 3 days of empirical
therapy hold its adjustment to the change of the antibiotic in accordance with
antibiotikogrammoy. For the empirical (homepage) antibiotic therapy in the acute
phase of illness in severe and moderate course you can use these drugs.

"Protected" Penicillins [amoxicillin + clavulanic acid (eg, amoxiclav, Augmentin),

ampicillin + sulbactam (eg, unazin)].

II generation cephalosporin (cefuroxime, etc.).

III generation cephalosporin (cefotaxime, etc.).

Aminoglycosides (amikacin, etc.).

Drugs injected parenterally, by decreasing the activity of the process is administered

orally. In the development of sepsis or exposure
19-3029

to intracellularly located microorganisms (Chlamydia, mikoplaz-mu, ureaplasma) use

a combination of antibiotics, macrolides. Allow the appointment of fluoroquinolones,
including children and the younger age group, both as monotherapy and in
combination with antibiotics.
After a course of antibiotics (7-14 days) designate uroseptiki. Of the group
nitrofuranov increasingly using furazidin (Furagin) at a dose of 5-8 mg / day. When
reducing the activity of the preparation process can be assigned to 1 time per day at
night at half the daily dose. Applied also nalidixic acid (eg, nevigramon, 60 mg / kg /
day), oxolinic acid (eg, gramurin; 20-30 mg / kg / day), pipemidovuyu acid (15 mg /
kg / day), nit-roksolin (eg , 5-NOK, 8-10 mg / kg / day).

Duration of treatment for acute pyelonephritis is 1-3 months - until the complete
rehabilitation of urine. After antibiotic therapy can assign herbs with antiseptic,
regenerative and diuretic properties. Shown alkaline mineral water (Smirnovskaya
Essentuki 20 and others).

Forecast

Weather favorable for life, healing occurs in 80% of cases. Deaths are rare, mostly
young children in the development of complications such as sepsis, apostematozny
jade, emerald kidneys, inflammation of the perirenal fat. All the children had suffered
an acute pyelonephritis, at least 3 years is registered with the monthly control study of
urine.