Complicated urinary tract infections are a group of bacterial infections that occur due to structural and functional lesions of the urinary tract or on the background of comorbidities (e.g. diabetes or immunodeficiency) that affect the protective mechanisms of macroorganism and increase the risk of infection or treatment ineffectiveness.
The purpose of the study was to optimize the treatment of patients with complicated urinary tract infections by determining the impact of immune status disorders and the intestine dysbiotic changes on the progression of superinfection, reinfection, disease recurrence and developing comprehensive antibacterial therapy.
The first step was a retrospective analysis of 80 medical records of patients who died from urosepsis development in order to determine the risk factors for complicated urinary tract infections and assess their impact on the development of septic conditions in patients.
The second step was in performing a prospective examination of 120 patients with complicated urinary tract infection. These patients were divided into 2 groups: group 1 (n = 60) included patients who underwent a short course of antibiotic therapy, group 2 (n = 60) patients were prescribed a prolonged course of antibiotic therapy. Each group was subdivided into subgroup A, where patients received antibiotic monotherapy, and subgroup B, where patients were prescribed immunomodulator and probiotic in addition to antibiotic therapy.
The activity and severity of the inflammatory process in patients was assessed using the results of comprehensive examination, namely: study of complaints and case history; physical examination of the patient; ultrasound; general and biochemical blood tests; general and microbiological urine tests; determination of sensitivity of selected cultures; immunological research, research of dysbiotic intestine changes.
The retrospective analysis results showed that urolithiasis was the most common risk factor (70%) for the development of complicated urinary tract infections. Severe course of the disease and mortality in patients occurred due to high correlation and significant impact of cardiac pathology (r = 0.80, p = 0.00003), diabetes (r = 0.90, p <0.001), and obesity (r = 0.93, p = 0.02). We noted that the most common surgical interventions that complicated the course of urinary tract infections were the imposition of puncture nephrostomy (43%), performing nephrectomy (17.5%), and kidney decapsulation (13.8%).
When considering the relationship of factors complicating urinary tract infection with comorbidities depending on the type of sepsis we noted a high direct correlation of cardiac pathology with the Charlson comorbidity index (r = 0.71, p = 0.000006) in septic shock, and moderate correlation (r = 0.54; p = 0.01) in acute course of sepsis.
In the prospective study, patients with complicated urinary tract infections (n=120) in anamnesis (>6 months) were performed transurethral resection of the prostate (28.3%), ureterolithotripsy (22.5%), and plastic of the pelvic-ureteral segment (13.3%). Factors impeding the course of complicated urinary tract infections were urinary tract obstruction in 40.8% of patients, previous surgery – in 33.3% and diabetes – in 27.5% of patients. We determined that complicated urinary tract infections were caused by the following uropathogens: E. coli was diagnosed in 36.7% of patients, Klebsiella – in 26.7%, Enterococcus faecalis and Pseudomonas aeruginosa – in 10%.
The obtained results showed that 30% of patients receiving a short course of antibiotic therapy and 33.3% of patients with prolonged course of antibiotics showed a change in the response of urine pH from alkaline to acidic on the background of microbiological examination of urine, which determined mixed infections, namely the combination of Klebsiella pneumoniae + Pseudomonas aeruginosa and Staphylococcus epidermidis + Candida caused changes in urine response in 8 patients (26.7%) of group 1, and 12 patients (40%) of group 2.
On the 15th day of treatment, the concentration of IgA almost reached control values of 2.32 ± 0.21 (р=0,05), increased by 33.3% in group 2В patients. While there was a tendency to reduce the level of IgG (by 55.8%, р=0,83) and IgM (by 37.4%, р=0,06), which almost reached the values obtained in almost healthy people. That is, there was a significant improvement in controlled indicators.
Complex therapy of complicated urinary tract infections leads to normalization of the level of immunocompetent cells and immunoglobulins, increases the functional (phagocytic) activity of segmental neutrophils, improves
cellular and humoral immunity, but the values are significantly closer to the control values only if the duration of treatment is 15 days.
