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Äëèòåëüíîñòü ëå÷åíèÿ àìèêàöèíîì ïðè õðîíè÷åñêîé ìî÷åïîëîâîé èíôåêöèè (ýøåðèõèè)
Æåíùèíà äåòîðîäíîãî âîçðàñòà èç ÑÏá, ÐÔ. Ä-ç: ðåöèäèâèðóþùèå öèñòèòû è âóëüâîâàãèíèòû íà ïðîòÿæåíèè ïîñëåäíèõ 3-4 ëåò. Îíà ìåäñåñòðà, ïîýòîìó óïîòðåáëÿëà ìíîãî ðàçíûõ àíòèáèîòèêîâ.  ìàçêå â àïðåëå çëàÿ ýøåðèõèÿ, êîòîðàÿ ÷óâñòâèòåëüíà òîëüêî ê ìåðîïåíåì, àìèêàöèí, òèãåöèêëèí, ïèïåðàöèëëèí òàçîáàêòàì è öåôîêñèòèí. Ïîñëåäíèé ïî÷åìó-òî îòñóòñòâóåò â ÐÔ â ïðîäàæå (çà÷åì òîãäà íà íåãî ñåÿòü?). Î÷íûå âðà÷è ñêëîíÿþòñÿ ê àìèêàöèíó. Ïîíÿòíî, ÷òî îáîèì ñóïðóãàì (õîòÿ ó ìóæà, ñî ñëîâ, ñèìïòîìîâ íèêàêèõ íåò) îäíîâðåìåííî â îäèíàêîâûõ äîçàõ. Ó ìåíÿ âîïðîñ ïî äëèòåëüíîñòè àíòèáàêòåðèàëüíîãî êóðñà, ó÷èòûâàÿ, ÷òî õðîíü, à îäíîçíà÷íûõ ñîâåòîâ ïî äëèòåëüíîñòè â ðóêîâîäñòâàõ íå íàøåë.  îäíèõ ïèøóò 10 äíåé, â äðóãèõ 2 ìåñÿöà. Ëå÷åíèå ïëàíèðóåòñÿ àìáóëàòîðíîå, ò.å. çà ñâîè äåíüãè. Èì íå õî÷åòñÿ ïðîäåøåâèòü, íî è ïåðåñòðàõîâî÷íî äîëãî êîëîòüñÿ è ïåðåïëà÷èâàòü òîæå íåò æåëàíèÿ. ×òî ïîñîâåòóåòå?
Çàðàíåå áëàãîäàðåí çà ëþáûå ñîâåòû.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#2
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Óâàæàåìûé Àëåêñàíäð Èâàíîâè÷,
Âîò çäåñü ïèøóò, ñêîëüêî ñëåäóåò äàâàòü ìã ïðè êîíêðåòíîì âåñå (â òàáëèöå): [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] ýôôåêòîò ëå÷åíèÿ äîëæåí áûòü â ïåðâûå 2-3 äíÿ, åñëè â òå÷åíèå 3-5 äíåé íåò ýôôåêòà, òî ïåðåïðîâåðÿòü íà ÷óâñòâèòåëüíîñòü, êóðñ ëå÷åíèÿ 7-10 äíåé, ìàêñèìóì 14 äíåé, ñâûøå ýòîãî ïåðèîäà áåçîáàñíîñòü àìèêàöèíà íåèçâåñòíà. Îçíàêîìüòå ïàðó ñ àíòèýøåðèõèàëüíûì äåéñòâèåì ýêñòðàêòà êëþêâû - âñå æå åãî ïðèíèìàòü ïðîôèëàêòèöêè ïîñëå êóðñà áóäåò ïîïðèÿòíåå, ÷åì ïðîäîëæàòü èñêàòü ÷óâñòâèòåëüíûé ÀÁ: Recurrent urinary tract infection and urinary Escherichia coli in women ingesting cranberry juice daily: a randomized controlled trial. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] îôô-òîïîì è âíå ÅÁÌ - ïîðåêîìåíäóéòå ìåäñåñòðå èñêëþ÷èòü æåëåçîäåôèöèò: ïîðîé åãî êîððåêöèÿ äàåò íåïëîõèå ðåçóëüòàòû íà ðåöèäèâèð. èíôåêöèè: Eur J Clin Microbiol Infect Dis. 2013 Oct;32(10):1253-8. Iron deficiency and susceptibility to infections: evaluation of the clinical evidence. Tansarli GS, Karageorgopoulos DE, Kapaskelis A, Gkegkes I, Falagas ME. Iron is a fundamental nutrient for human and microbial life. We sought to examine the association of iron deficiency versus normal iron status with the susceptibility to infections. A systematic search in the PubMed and Scopus databases was performed to identify relevant clinical studies. Six studies (including a total of 1,422 participants) met the inclusion criteria: four prospective cohort (859 participants), one retrospective case-control (115 participants), and one retrospective cohort study (448 participants). Intensive care unit (ICU)-acquired and postoperative infections were more common in patients with iron deficiency than among those with normal iron status in two studies, while no difference was reported in another study. In one study examining pregnant women with normal mean iron values, higher soluble transferrin receptor values independently predicted vaginosis-like microflora. Iron deficiency anemia was an independent predictor of respiratory tract infections in one study, and postoperative urinary tract infections were more common in patients with iron deficiency anemia in another. The limited available evidence suggests that individuals with iron deficiency and those with iron deficiency anemia may be more susceptible to infections than patients with normal iron status. Future studies should elucidate further these findings.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#3
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Åùå èç íåäàâíåãî ïî ðåöèäèâèð. ÌÂÏ-èíôåêöèÿì:
Prescrire Int. 2014 Feb;23(146):47-9. Recurrent uncomplicated cystitis in women: allowing patients to self-initiate antibiotic therapy. Acute uncomplicated cystitis is a lower urinary tract infection occurring in the absence of anatomic or functional abnormalities of the urinary tract or any other complicating factors.The organism responsible is often an enterobacterium, especially Escherichia coli. What is the role of antibiotic therapy for non-pregnant women with recurrent acute uncomplicated cystitis? We reviewed the available evidence using the standard Prescrire methodology. A single oral dose of fosfomycin trometamol is the antibiotic of choice for treating an episode of acute uncomplicated cystitis. Alternative antibiotics are certain fluoroquinolones or co-trimoxazole (a fixed-dose combination of sulfamethoxazole and trimethoprim). For recurrent acute uncomplicated cystitis, cranberry juice has modest efficacy in reducing the frequency of episodes. A number of non-drug measures are typically proposed, although their effects are unproven: drinking sufficient fluids and urinating regularly; urinating after sexual intercourse; and avoiding spermicides. The strategy that results in the lowest antibiotic exposure is a short course of antibiotics for each episode of urinary tract infection, initiated as soon as clinical symptoms appear. Long-term antibiotic therapy is sometimes offered. According to one systematic review, women taking long-term prophylactic antibiotic therapy had about 6 times fewer clinical recurrences than with placebo. According to one randomised trial, 3 g of fosfomycin trometamol taken as a single dose every ten days reduced the frequency of recurrence, resulting in 0.14 episodes of infection per year on average versus about 3 episodes with placebo (p < 0.001). The amount of antibiotic used when fosfomycin trometamol is taken every 10 days for 6 months is equivalent to treatment of 18 acute episodes of cystitis. When cystitis appears to be associated with sexual intercourse, two small randomised trials suggest that routine postcoital antibiotic treatment is more effective than placebo and as effective as long-term antibiotic therapy. Adverse effects, some of which can be serious, depend on the antibiotic used. The development of resistance among enterobacteria is one argument for limiting the use of antibiotics, in order to preserve their efficacy in serious infections. In practice, the strategy that uses the fewest antibiotics is to treat each episode as soon as the first clinical symptoms appear. Cases in which the frequency of recurrence warrants regular antibiotic prophylaxis are rare. The optimal antibiotic regimen in these cases has not been determined, either in clinical trials or by consensus. BMC Urol. 2013 Jun 5;13:28. doi: 10.1186/1471-2490-13-28. Cysticlean® a highly pac standardized content in the prevention of recurrent urinary tract infections: an observational, prospective cohort study. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Cranberries vs antibiotics to prevent urinary tract infections: a randomized double-blind noninferiority trial in premenopausal women. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Recurrent Urinary Tract Infections in Women: Diagnosis and Management [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#4
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Áîëüøîå ñïàñèáî, óâàæàåìûé Âàäèì Âàëåðüåâè÷!
Ïðî äîçû àìèêàöèíà çíàþ, ïðî äëèòåëüíîñòü ñ ïîçèöèé àìèêàöèíà âðîäå òîæå. Ñèëüíî ñìóùàåò ðåöèäèâèðîâàíèå, ìîæåò î÷àã ñèäèò ãäå-òî ãëóáîêî, íàïðèìåð, ó ìóæ÷èíû â ïðîñòàòå, äà åùå áåññèìïòîìíî. Òîãäà ýôôåêò òåðàïèè íå îöåíèòü íà 3-é äåíü... À õðîíè÷åñêèé ïðîñòàòèò ïî ðóêîâîäñòâó øóðóþò àíòèáèîòèêàìè àæ 2 ìåñÿöà èëè çàáèâàþò íà ôàêò åãî ñóùåñòâîâàíèÿ. ß ìîãó èì ïîñëàòü ïîñûëêó ñ öåôîêñèòèíîì, åãî-òî ìîæíî äîëãî ââîäèòü. Îñòàëüíûå èç ïåðå÷èñëåííûõ - âíóòðèâåííûå-ìåäëåííûå è òðåõêðàòíûå, ò.å. äîìà ìàëîâåðîÿòíî ïîêîëîòü. P.S. Çà êëþêâó ñïàñèáî. P.P.S. Áóäåòå ñìåÿòüñÿ, íî àíåìèÿ - ýòî ïåðâîå, ÷òî ÿ ïðåäëîæèë ïîèñêàòü. Îíà ñ ÿíâàðÿ ïüåò ôåððåòàá, â êîíöå ìàðòà ïî æåëåçó âñå â àíàëèçàõ íîðìàëèçîâàëîñü.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#5
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Óâàæàåìûé Àëåêñàíäð Èâàíîâè÷,
äàæå ïðè îñëîæíåííîé ðåöèäèâèð. èíôåêöèè ÌÂÏ ñëåäóþùèå ðåêîìåíäàöèè (èç ñàìîé ïîñëåäíåé ññûëêè): Parenteral antimicrobial therapy is indicated if patients are unable to tolerate oral therapy, have impaired gastrointestinal absorption, have hemodynamic instability, or if the infecting organism is known or suspected to be resistant to oral agents. The duration of therapy should be seven days for patients with lower urinary tract symptoms, and 10 to 14 days for patients with upper urinary tract symptoms or sepsis syndrome. Òîëüêî ïóñòü ïðîáóþò ïðîâåðåííûå ñîêè/ýêñòðàêòû êëþêâû, à òî îò ïîääåëîê òîëêó ìíîãî îæèäàòü íå ïðèõîäèòñÿ (åñëè â Ãåðìàíèè åñòü, òî ëó÷øå âûøëèòå åãî âìåñòî öåôîêñèòèíà). Åñëè ó íåå ôåððèòèí ñòàë áîëåå 70 (âíå âîñïàëåíèÿ/ðåöèäèâà, à åñëè áûë îïðåäåëåí â ïåðèîä ðåöèäèâà èíôåêöèè, òî áîëåå 100), òî äåôèöèò æåëåçà â îðãàíèçìå ëèêâèäèðîâàí.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#6
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è åùå îòòóäà: In cases of recurrence, a test-of-cure urine culture performed approximately one to two weeks after completion of antibiotic therapy may be considered to confirm clearance.
òå æå ðåêîìåíäàöèè è îò áðèòàíöåâ - 3 äíåâíûé êóðñ ìàëîýôôåêòèâåí; 7 äíåé - îïòèìàëüíî äëÿ ðåöèäèâèð. èíôåêöèè íèæíèõ ÌÂÏ, 10-14 äíåé - äëÿ èíôåêöèé âåðõíèõ ÌÂÏ: Complicated urinary tract infections: practical solutions for the treatment of multiresistant Gram-negative bacteria [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#7
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Ñ ÷èñòî ìèêðîáèîëîãè÷åñêèõ ïîçèöèé: åñëè ýíòåðîáàêòåðèÿ (â äàííîì ñëó÷àå E.coli) óñòîé÷èâà õîòÿ áû ê îäíîìó öåôàëîñïîðèíó 3-ãî ïîêîëåíèÿ, òî îíà ÿâëÿåòñÿ êðàéíå ïîäîçðèòåëüíîé íà ïðîäóêöèþ áåòà-ëàêòàìàç ðàñøèðåííîãî ñïåêòðà (ÁËÐÑ, îíè æå ESBL). Âàðèàíòîâ 2 - ëèáî îïðåäåëÿòü íàëè÷èå ýòèõ ñàìûõ ÁËÐÑ â ðåôåðåíòíîé ëàáîðàòîðèè, ëèáî ñîãëàñèòüñÿ ñ òåì, ÷òî îíè åñòü.
Ïðîáëåìà â òîì, ÷òî ïðîäóêöèÿ ÁËÐÑ àññîöèèðóåòñÿ ñ óñòîé÷èâîñòüþ íå òîëüêî ê áåòà-ëàêòàìàì, íî è ê äðóãèì êëàññàì àíòèáèîòèêîâ, â ò.÷. àìèíîãëèêîçèäàì (ïðè ñîõðàíåííîé ÷óâñòâèòåëüíîñòè in vitro). Ïðåïàðàòàìè âûáîðà îñòàþòñÿ òîëüêî êàðáàïåíåìû. Òàéãåöèêëèí, öåôîïåðàçîí/ñóëüáàêòàì, ïèïåðàöèëëèí/òàçîáàêòàì, êîëèñòèí ìîãóò áûòü ýôôåêòèâíû ñ ðàçíîé âàðèàáåëüíîñòüþ. Åùå ê áåòà-ëàêòàìàçàì óñòîé÷èâ ôîñôîìèöèí (ìîíóðàë), íî îí ïëîõî ïðîíèêàåò â òêàíè è ñîçäàåò âûñîêèå êîíöåíòðàöèè òîëüêî â ìî÷å.  îáùåì, ïðîñòîãî ðåøåíèÿ êàê-òî íå íàáëþäàåòñÿ. Ðàçâå ÷òî êëþêâà, íî îïÿòü-òàêè - òîëüêî â îòíîøåíèè ìî÷è. Ñàíèðîâàòü ìî÷ó îñîáî áîëüøîé ïðîáëåìû íåò, íî ìàçîê-òî, êàê ÿ ïîíèìàþ, áðàëè èç âëàãàëèùà? ß ïðåäëàãàþ îáðàòèòüñÿ â ÍÈÈÄÈ ê ïðîô. Ñèäîðåíêî Ñ.Â., ñäåëàòü ïîñåâû òàì è ïîïðîñèòü åãî èíòåðïðåòèðîâàòü ðåçóëüòàòû. Îí, êîíå÷íî, áàêòåðèîëîã, íå ïðàêòè÷åñêèé âðà÷, íî ãðàìîòíåå íåãî â áàêòåðèîëîãèè â Ïèòåðå, ÈÌÕÎ, íåò. Âîò åñëè ÎÍ ñêàæåò, ÷òî ÷òî ê àìèêàöèíó ýòà êèøïàëêà äåéñòâèòåëüíî ÷óâñòâèòåëüíà, òî òîãäà ìîæíî áóäåò èì ëå÷èòüñÿ.  ïðîòèâíîì ñëó÷àå åñòü âîçìîæíîñòü îãðåñòè âñå ïîáî÷íûå ýôôåêòû, íå ïîëó÷èâ ïîëîæèòåëüíîãî ðåçóëüòàòà. ß ÷óòü ïîçæå ñêèíó Âàì êîîðäèíàòû Ñ.Â.Ñèäîðåíêî, åñëè íàäî. |
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#8
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Èñòî÷íèê ìîèõ ñîìíåíèé ïî ñðîêàì ëå÷åíèÿ:
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ñòðàòåãèþ î ïðèåìå àíòèáèîòèêà ïðè íà÷àëå ñèìïòîìîâ èëè ñðàçó ïîñëå êîèòóñà äîíåñ òîæå ðàíåå, ïîìîãàåò, ïîêà ïðî ýòî íå çàáûâàþò... P.S. Åñëè ïëîõî âèäíî, òî òðè êàðòèíêè âûøå êëèêàáåëüíû (óâåëè÷èâàþòñÿ â íîâîì îêíå).
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#9
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#10
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À åùå ÿ î÷åíü ñèëüíî ñîìíåâàþñü â íåîáõîäèìîñòè îäíîâðåìåííîãî ëå÷åíèÿ ñóïðóãà, ïî êðàéíåé ìåðå äî òåõ ïîð, ïîêà íå äîêàçàíî, ÷òî ó íåãî åñòü òà æå ñàìàÿ E.coli. Âñå-òàêè íåñïåöèôè÷åñêèå êîëüïèòû è öèñòèòû íå îòíîñÿòñÿ ê ÈÏÏÏ.
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#11
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Ðàçíèöà â ñðîêàõ ëå÷åíèÿ ðàçíûìè ïðåïàðàòàìè îáúÿñíÿåòñÿ ðàçíîé ñòåïåíüþ ïðîíèêíîâåíèÿ â òêàíè ïðîñòàòû è òåì, ÷òî ÔÕ - áàêòåðèöèäíûå, à ÒÌÏ-ÑÌ - áàêòåðèîñòàòèê. Êñòàòè, â Ðîññèè ïðî ïîñëåäíèé ïðåïàðàò ìîæíî âîîáùå çàáûòü - íå ðàáîòàåò (êðîìå ïíåâìîöèñò è MRSA).
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#12
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Äà, áèñåïòîë â ÐÔ ïîãèá ïîä ìàññîâîé áåçðåöåïòóðíîñòüþ...
×óâñòâèòåëüíîñòü ê öåôîêñèòèíó òîæå ìîæåò áûòü òîëüêî in vitro? È, åñëè êàðáàïåíåìû, òî êàêèå ñðîêè ëå÷åíèÿ? È âîçìîæíî ëè êàðáàïåíåìû ïîäåëàòü àìáóëàòîðíî (ó ìåíÿ ïî íèì îïûò îãðàíè÷åí, íî ââîäÿòñÿ æå â/â íå áûñòðî è òðè ðàçà â ñóòêè)? ÈÌÕÎ, âñå-òàêè íóæíî ëå÷èòü îáîèõ. Óâåðåí, ÷òî îáìåíÿëèñü îíè ýòîé ýøåðèõèåé. Äà è â÷åðà ïîïûòàë èõ íåìíîãî: ìóæ÷èíà è ïî íî÷àì âñòàåò â òóàëåò è ææåíèå â óðåòðå òàêè áûâàåò...
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#13
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#14
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Öèòàòà:
Êàðáàïåíåìû. Ñàìûé äåøåâûé (îòíîñèòåëüíî) è ïðîñòîé âàðèàíò - ýðòàïåíåì (Èíâàíç). Ââîäèòñÿ îäèí ðàç â ñóòêè, â/â èëè â/ì. Äëèòåëüíîñòü... Áîþñü, ÷òî äëÿ òàêèõ ñèòóàöèé ñõåìû åùå íå ðàçðàáîòàíû. ßâíî íå ìåíüøå 7-è äíåé (öèñòèò è êîëüïèò). |
#15
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Åùå ðàç áîëüøîå ñïàñèáî, Äìèòðèé Âëàäèìèðîâè÷!
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |