Clinical management of patients with chronic inflammatory diseases of urogenital organs in an outpatient setting

Over the last decade has seen awareness of the role of sexually transmitted infections (STIs), as factors of reproductive health conditions and chronic inflammatory diseases of the urinary organs.

The contribution of this group of agents in the formation of tubal factor infertility, ovarian cystic changes, miomatoza uterus, endometrial hyperplastic processes, adhesions in the pelvis, menstrual function in women and reproductive health in men. Among all the agents belonging to a group of sexually transmitted infections, the leading role in the pathogenesis of these changes is given chlamydia and mycoplasma infection.

In recent years, formed the algorithm of patients with inflammatory diseases of the urinary tract:

∙ Evaluation of the history of the disease, in women - obstetrics and gynecology, subjective symptoms, gynecological and urological examination.

∙ Microbiological examination: identification of N. gonorrhoeae, T. vaginalis by microscopic and culture methods, C. trachomatis using two different methods of research, U. urealyticum and M. hominis - a quantification of microorganisms, identification of conditionally pathogenic microorganisms in quantitative determination of their.

∙ If there are complaints of dysuria and / or guidance to a history of urinary tract disease (cystitis, urethritis, pyelonephritis, urolithiasis) - an additional examination in urological institutions: uretrotsistoskopiya (with biopsy if indicated), ureteroscopy, ultrasonic, etc.

∙ An analysis of clinical and microbiological (and special) surveys and risk assessment of future invasive (operative) procedures, including the establishment of an intrauterine device, planned pregnancy or planned pregnancy outcome available (birth, abortion), and other invasive diagnostic or therapeutic manipulation.

∙ Evaluation of anamnestic data and clinical and microbiological survey of urogenital positive partner.

∙ Diagnosis (ICD-10 and clinical); concomitant diagnosis (if indicated - consultation of experts: gynecologist-endocrinologist, a gynecologist-oncologist, andrology, urology, etc.).

∙ Treatment, control of cure

The main directions of STI:

∙ a medical examination to detect sexually transmitted infections in high-risk groups: prostitutes, homosexuals, women of childbearing age with chronic inflammatory diseases of the urogenital tract, pregnant with a complicated obstetric history and disadvantaged during this pregnancy.

∙ examination of pregnant women at different stages of pregnancy. In case of urogenital mycoplasmosis they can prevent the development of intrauterine infection by Mycoplasma readjustment pregnant woman and her husband.

∙ observation of high-risk groups among urological patients.

STI in the generality of the modes of transmission of pathogens in the majority of cases occur as mixed pathogens (gonorrhea, trichomonas, herpes simplex virus) and opportunistic infections (ureaplasma, mycoplasma, anaerobes). For the STI is characterized by:

∙ a tendency to long-term chronic course, often latent;
∙ No persistent immunity;
∙ long-term carrier state;
∙ recurrent nature of the disease;
∙ mnogosimptomnost;
∙ presence of atypical or asymptomatic forms;
∙ a tendency to spread infection;
∙ similarities and severity of complications;
∙ sexual route of transmission;
∙ the possibility of transplacental transmission of these infections to the fetus and newborn.

: A major problem faced by the specialist in the treatment of STIs is a rational choice of antibiotic, which is carried with the following criteria:

∙ the spectrum of activity, corresponding to the expected pathogen;
∙ pharmacokinetics, which determines the penetration of antibiotic into the inflammatory focus, dose frequency and duration of treatment;
∙ Effectiveness in urogenital infections, proven in randomized clinical trials;
∙ contraindications, and frequency of side effects;
∙ Ease of use for the patient (increases accuracy of adherence);
∙ cost-effectiveness.

The optimal therapy for the treatment of patients with sexually transmitted infections for many years, macrolide antibiotics are a number. They are safe and have a high therapeutic efficacy. One of the most well-known macrolide is clarithromycin, in RB - Klarikar production of "Farmakar." The drug belongs to a semi-synthetic 14-membered macrolide, erythromycin A. The presence of derivatives of the methoxy group at position 6-lactone ring gives it a higher kislotostabilnost and improved, compared with erythromycin, antibacterial and pharmacokinetic properties. Stability to hydrolysis by the action of clarithromycin hydrochloric acid is 100 times higher than that of erythromycin, however, the maximum antibacterial effect of the drug is in an alkaline environment. The antimicrobial effect is due to a violation of protein synthesis by ribosomes of microbial cells. Clarithromycin is highly soluble in lipids, and therefore is widely distributed in tissues and organs. This antibiotic penetrates well into various cell microorganism. The maximum concentration of clarithromycin in mononuclear leukocytes and polymorphic exceeds that in serum at 10-40 times, more preferably in comparison with erythromycin, roxithromycin and dzhozamitsinom. The most important differences of clarithromycin azithromycin include the fact that the activity of clarithromycin is independent of the pH of the medium, does not create long-term clarithromycin subingibiruyuschih concentrations, and its absorption is independent of food intake. Under the influence of clarithromycin in the body into active metabolite - 14-gidroksiklaritromitsin, which is not inferior to (and for a number of pathogens and superior) on the antimicrobial action of the main drug. For many pathogens and antibiotic metabolite showing an additive effect, and the pathogens such as H. influenzae, M. catarrhalis, Legionella spp., some streptococci and staphylococci, act synergistically.

At the most micro-organisms clarithromycin bakteriostaticheski, but may be bactericidal effect against S. pneumoniae, H. influenzae, L. pneumophila and M. avium. Active against pathogens that are both outside and subcellular localization. Almost equivalent to erythromycin activity against M. catarrhalis. Gonococci possess moderate sensitivity to clarithromycin. This antibiotic is about 8 times higher for erythromycin activity against S. trashomatis. In addition, it is stronger than erythromycin acts on C. psittaci. The activity of clarithromycin against M. pneumoniae is almost equivalent to that of erythromycin. but on U. Urealyticum he is stronger. Clarithromycin has postantibioticheskim effect against S. pyogenes, S. aureus, S. pneumoniae (including strains penitsillinrezistentnye), H. influenzae, M. catarrhalis, and L. pneumophila, which can last from 2 to 10 hours. The active metabolite - 14-gidroksiklaritromitsina - also marked postantibiotichesky effect against S. pneumoniae, H. influenzae and M. catarrhalis.

Clarithromycin is able to interact with the host's immune system. It increases the phagocytic activity of macrophages and neyrofilov, and to a greater extent than erythromycin and dzhozamitsin. Revealed a synergistic bactericidal effect of clarithromycin in combination with serum complement. In addition, in the presence of clarithromycin increases the activity of T-killers, which probably has implications for the treatment of bacterial infections, complicated by viral superinfection.

Clarithromycin penetrates well into prostatic tissue and create a concentration sufficient for the treatment of chronic prostatitis caused by Chlamydia or ureaplasmas. Clarithromycin is a high concentration inside the cell, which is the basis for the suppression of intracellular pathogens proliferating as Chlamydia, Legionella and Toxoplasma. Accumulating in immunocompetent cells, an antibiotic, as noted above, increasing their phagocytic function. Clarithromycin is approximately 78% metabolized in the liver by demethylation and hydroxylation, with the participation of cytochrome P450. When using high doses may saturate the enzyme systems and reducing the metabolism, which is accompanied by increased bioavailability of the antibiotic. The main metabolite is microbiologically active 14-gidroksiklaritromitsin partially formed already in the process of first-pass biotransformation of clarithromycin, so when ingested antibiotic concentration of 14 gidroksiklaritromitsina in plasma is higher than when administered intravenously.

Clarithromycin is out of the body in two ways: through the kidneys and through the biliary system. In general, renal function is more important for the elimination of clarithromycin, since it is excreted in the urine in combination with its active metabolite. While taking the drug orally at a dose of 250 mg every 12 hours about 20% of the excreted in the urine unchanged and 10-15% - in the form of the active metabolite, when administered a dose of 500 mg over intervals similar proportion of unchanged antibiotic in the urine of 30% in maintaining the same amount of metabolite (10-15%). Excretion in the stool is 40%.

The effectiveness of clarithromycin in the treatment of urogenital infections was studied in several controlled studies. The best clinical effect was observed in chlamydial urethritis and cervicitis. In patients with urethritis caused by the U. urealyticum, the use of this antibiotic is also very effective. Study the sensitivity of C. trachomatis to antibiotics in ambulatory patients (unpublished data OE Orlova, IBC "Pasteur", Moscow, 2000) demonstrated the presence of sensitive strains to clarithromycin chlamydia in 98% of cases, compared with azithromycin - 76% , roxithromycin - 93% spiramycin - 72%.

We were treated 151 patients with urogenital infections chlamydia, ureaplasma and mixed etiology. As a means of antibiotic drug used Klarikar a dose of 500 mg twice daily by mouth. Duration of antibiotic therapy was determined by the clinical form of the disease and the duration of infection and was on average 10-14 days. Microbiological cure was achieved in 100% of patients with chlamydial infection and 91.2% of patients ureaplazmozom.

Currently discussing the use of macrolides in the treatment of sexually transmitted infections in pregnant women. The most promising drugs found clarithromycin and azithromycin. According to some researchers, the most appropriate treatment for bacterial STIs among pregnant women is a macrolide clarithromycin [Popkov, AM, AL Vertkin, Kolobov, SV, 2000]. Its advantage over other macrolides is that transplacental passage of this drug is somewhat higher, which is essential to prevent the implementation of intrauterine infection in the fetus and newborn. In addition, clarithromycin inhibits the cytochrome P450 system in the liver is reversible, that is acceptable to the appointment of pregnant patients.

The greatest difficulty for the treatment of pregnant women are ureaplasmosis. So according to SI Mikhalevich and MN Ismail clarithromycin in the treatment of mycoplasmosis in children born of complications was observed in 3.4 times less than in the group after treatment with erythromycin.

To carry antibiotic myco-ureaplazmozom pregnant, the following indications:

∙ The threat of miscarriage during pregnancy of less than 12 weeks
∙ Leukocytosis in smears
∙ The presence of mixed infection (detection in smears gardnerella, chlamydia, herpes infections)
∙ The presence of abundant smears coccal flora
∙ Identification of clinical symptoms endocervicitis, ectopic cervix, the presence of abundant mucus, inflammatory disease of the pelvic organs
∙ The number of ureaplasmas in bacteriological examination of more than 1000 CFU

Thus, Klarikar (clarithromycin) is a highly effective antimicrobial therapy of STIs in children and adults, including pregnant women. High efficiency and komplaentnost drug determine its choice for the treatment of sexually transmitted infections in the outpatient setting.