sasarde sistemis infeqciis martva mozrdil pacientebsi pirvelad … · 2017. 6. 5. · gamoyenebuli...

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danarTi 1

saSarde sistemis infeqciis

marTva mozrdil pacientebSi

pirvelad jandacvaSi

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris 2010 wlis 24 seqtembris

# 306/o brZanebiT

miRebulia “klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo

standartebis (protokolebi) SemuSavebis, Sefasebisa da danergvis erovnuli sabWos"

2009 wlis 30 dekembris #2 sxdomis gadawyvetilebis Sesabamisad

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saSarde sistemis infeqciis marTva mozrdil

pacientebSi pirvelad jandacvaSi

1. aavadebis ganmarteba, sinonimebi, klasifikacia da

terminologia

ganmarteba

saSarde sistemis mwvave, gaurTulebeli infeqcia gulisxmobs mwvave cistitisa da mwvave pielonefritis epizodebs sxvamxriv janmrTel pirebSi. aseTi pacientebis marTva pirveladi jandacvis dawesebulebaSi ojaxis eqimis mier SesaZlebelia, mowodebuli empiriuli mkurnalobis sqemebi efeqturia.

saSarde gzebis garTulebuli infeqciebis dros aRiniSneba damamZimebeli faqtorebi, ris gamoc standartuli mkurnaloba xSirad araefeqturia da maRalia iseTi SemTxvevebis Camoyalibebis riski, rogoricaa: emfizematozur pielonefriti, Tirkmlis kortikomedularuli abscesi, perinefruli abscesi, papilaruli nekrozi da urosefsisi. aseTi pacientebis gamokvleva da mkurnaloba mizanSewonilia specializebul dawesebulebebSi.

garTulebuli saSarde gzebis infeqciis arsebobis albaToba maRalia mamakacebSi (saSarde gzebis infeqciis klinikuri suraTiT vlindeba mwvave an qronikuli prostatiti; saSarde gzebis infeqcia Tan axlavs Sard-kenWovan davadebas, prostatis keTilTvisebiani hiperplaziiT gamowveuli obstruqciis fonze xSirad viTardeba saSarde gzebis infeqcia).

gaurTulebeli da garTulebuli infeqciis gamijvna mizanSewonilia, upirveles yovlisa, imis gamo, rom, es gansazRvravs daavadebis mimdinareobis Taviseburebebs, antibaqteriuli mkurnalobis saxesa da xangrZlivobas, Sesabamisad, specializebul klinikaSi referalis aucileblobas.

saSarde gzebis infeqciis (sgi) klsifikacia

saSarde gzebis gaurTulebeli infeqciis saxeebia:

1. mwvave gaurTulebeli cistiti premenopauzis periodSi araorsul qalebSi;

2. mwvave gaurTulebeli pielonefriti premenopauzis periodSi araorsul qalebSi;

3. asimptomuri baqteriuria;

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4. mwvave cistiti orsulebSi;

5. mwvave pielonefriti orsulebSi;

6. asimptomuri baqteriuria orsulebSi;

7. morecidive cistiti qalebSi;

8. saSarde gzebis infeqcia postmenopauzis periodSi qalebSi;

9. saSarde gzebis infeqcia mamakacebSi – gaurTulebeli, funqciur-anatomiuri anomaliebis dasabuTebulad gamoricxvis SemTxvevaSi.

gamoyenebuli terminebi

sgi gaurTulebeli – cistitisa da pielonefritis epizodebi sxvamxriv janmrTel pirebSi.

sgi garTulebuli – cistitisa da pielonefritis epizodebi saSarde gzebis funqciur-anatomiuri anomaliebis arsebobisas (Tandayolili anomaliebi, Sard-kenWovani daavadeba, prostatis keTilTvisebiani hiperplazia, Sardis Sekaveba, da a.S.).

asimptomuri baqteriuria – asimptomuri pacienti Sardis dadebiTi kulturiT. uropaTogenis raodenoba am dros >10 ml 1 .

piuria – sul mcire 8 000 leikocitis arseboba 1 ml daucentrifugirebel SardSi (Seesabameba mxedvelobis areSi 8-10 leikocitis arsebobas), sxva mosazrebiT piuriis dros leikocitebis raodenoba >20 000 (hemocitometriiT) 1 ml SardSi 2. zemoT aRniSnuli imaze miuTiTebs, rom es meTodi ar aris zusti da upiratesoba diagnostikaSi eniWeba leikocitebis daTvlas. baqteruria piuriis gareSe Sardis kontaminaciaze miuTiTebs.

steriluri piuria _ maSin rodesac saSarde gzebis infeqcia piuriis gareSe warmoudgenelia, Tavad piuria SeiZleba iyos infeqciisgan damoukideblad, gansakuTrebiT im pacientebSi, romlebmac Caitares antimikrobuli mkurnaloba (ZiriTadad - TviTmkurnaloba). steriluri piuriis sxva mizezebia Sardis nimuSis kontaminacia sasterilizacio xsnariT, vaginaluri gamonadeniT, ureTruli steriluri piuria SeiZleba aRiniSnos qronikuli intersticiuli nefritis dros (mag., analgeziuri saSualebebis Warbi moxmarebiT gamowveuli nefropaTia), nefroliTiazis, uroepiTeluri simsivnis da specifikuri infeqciis (mag: tuberkulozi) SemTxvevaSi.

Dipstick-testi – am meTodiT xdeba leikocitebis esterazas da nitritis aRmoCena SardSi. pirveli miuTiTebs piuriaze, xolo meore enterobaqteriebis arsebobaze, romlebic Sardis nitrats

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gardaqmnian nitritad 3 , 4 .Sardis rutinuli analizisa da Dipstick meTods axasiaTebs cru uaryofiTi da cru dadebiTi Sedegebi

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2. epidemiologia

sgi (gaurTulebeli) – gavrcelebuli problemaa pirveladi jandacvis sistemaSi. is gansakuTrebiT xSiria qalebSi. gaurTulebeli sgi 20-dan 40 wlamde qalebis 25-30%-s aReniSneba.

axalgazrda qalebSi Catarebuli kohortuli da SemTxveva-kontrolis kvlevis mixedviT, mwvave cistitis ganviTarebis riski mkveTradaa dakavSirebuli sqesobriv urTierTobasTan, kontraceptivis gamoyenebasTan (kerZod, diafragmis gamoyenebasTan spermicidTan erTad), manamde arsebul baqteriuriasTan, morecidive sgi-Tan anamnezSi, sgi ganviTarebis pirveli epizodis dros qalis asaksa da pacientis dedis anamnezSi sgi-is arsebobasTan.

morecidive sgi-s sixSire matulobs, Tu gogonas sgi pirveli epizodi aReniSneboda 15 wlamde asakSi. morecidive sgi-s ganviTarebis riski maRalia menopauzis periodSi, vinaidan am dros adgili aqvs saSos lorwovanis funqciur cvlilebas, rac estrogenebis donis daqveiTebiT aris gamowveuli.

amerikuli, evropuli da avstraliuri kvlevebis mixedviT, asimptomuri baqteriuriis gavrceleba orsulebSi 4-7 %-s Seadgens. asimptomuri baqteriuria dakavSirebulia sqesobriv aqtivobasTan da misi sixSire izrdeba asakisa da orsulobis vadis matebasTan erTad. is aseve maRalia dabali socialur-ekonomikuri statusis mqone pacientebSi. infeqciis simptomebi orsulTa 1-2 %-Si vlindeba.

qalebis umravlesobas asimptomuri baqteriuria orsulobamde aReniSneba. pirvel vizitze orsulebSi asimptomuri baqteriuria iseTive sixSiriT gvxvdeba, rogorc araorsulebSi. asimptomuri baqteriuriis mqone skolis moswavle gogonebis 37-57%-s orsulobisas sgi uviTardeba6 (III).

SvedeTSi Catarebuli kvlevis mixedviT, baqteriuriis ganviTarebis riski matulobs orsulobis vadis zrdasTan erTad, maqsimums

aRwevs gestaciuri vadis 9-17 kviraze 7 (III). orsulTa asimptomur baqteriuriasTan dakavSirebulia axalSobilis mcire wona (< an = 2500g), naadrevi mSobiaroba (<37 kviraze) da neonataluri sikvdiloba. asimptomuri baqteriuriis mqone qalebis 20-40%-s orsulobisas uviTardeba pielonefriti. mwvave pielonefriti ufro xSirad viTardeba orsulobis mesame trimestrSi. Gilstrap da misi Tanaavtorebis mimoxilviT, 24 000 orsulidan 2%-s aReniSneboda

mwvave pielonefriti8.

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sgi axalgazrda (15-dan 50 wlamde), sxvamxriv janmrTel mamakacebSi sakmaod iSviaTia. norvegiaSi 21-dan 50 wlamde asakis 10 000 mamakacidan sgi 6-8-s aReniSneba.

prognozi

qveda sgi garTulebebi, Cveulebriv, iSviaTia da gamowveulia rezistentuli mikroorganizmebiT. zogjer garTulebebis mizezi aradiagnostirebuli struqturuli an urodinamikuri/funqciuri cvlilebaa.

saSarde gzebis infeqcias, Cveulebriv, keTilsaimedo prognozi aqvs. ucxo sxeulis arsebobis fonze ganviTarebuli garTulebuli sgi rTuli samkurnaloa. sgi, romelic viTardeba meqanikuri an funqciuri obstruqciis fonze, prognozulad ufro arakeTilsaimedoa, vidre gaurTulebeli sgi.

gadaudebel referals moiTxovs perinefruli da Tirkmlis abscesi, vinaidan SesaZlebeli gamoiwvios Tirkmlis funqciis gauareseba, septiuri Soki.

3. etiopaTogenezi

saSarde sistemaSi mikroorgamizmebis gavrcelebis 3 gza arsebobs: aRmavali, hematogenuri da limfogenuri. klinikurad da eqsperimentulad dadasturebulia, rom ureTraSi e.w `nawlavuri mikroorganizmebis~ gavrceleba dasabams aZlevs saSarde gzebis infeqcias. amiT aixsneba is, rom sgi ufro xSirad gvxvdeba ureTris kaTeterizaciis an instrumentuli Carevis Semdeg, agreTve qalebSi (anatomiuri mdebareoba). dadgenilia, rom ureTris erTjeradi kaTeterizaciis Semdeg ambulatoriuli pacientebis 1-2 %-s sgi uviTardeba. ureTraSi mudmivi kaTeteris Cadgmidan (Tu igi Ria sistemiTaa drenirebuli) me-3-4 dRes sgi aRmocendeba SemTxvevebis 100%-Si. drenirebisTvis daxSuli sistemis gamoyenebisas infeqcia mogvianebiT viTardeba. kaTeterizebul pacientebSi infeqcia aRmavali gziT viTardeba. savaraudod, baqteriebi kaTetersa da ureTras Soris arsebuli gziT (mikopurulenturad) vrceldeba, rasac sabolood daaxloebiT 4 kviris ganmavlobaSi baqteriuria mosdevs. SardmimRebSi steriluri Sardis arseboba, SardmimRebidan kaTeterSi Sardis retrograduli dinebis ar arseboba, antibaqteriuli Terapia ver abrkolebs infeqciis ganviTarebasa da gavrcelebas.

infeqcia saSarde gzebSi SeiZleba gavrceldes organizmSi arsebuli pirveladi kerebidan hematogenurad. am infeqciis gamomwvevebia: Staphyloccocus aureus, Candida spp., Salmonela spp.,Mycobacterium

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tuberculosis. hematogenuri da aRmavali infeqciis iSviaTi gamomwvevia Candida albicans, ufro xSirad ureTruli kaTeteris gamoyenebisa da antibiotikoTerapiis Semdeg.

sgi infeqciis ganviTarebis aucilebeli pirobaa organizmis zogadi damcavi meqanizmebis daTrgunva. arc Tu umniSvneloa baqteriis virulentobis xarisxic. garkveul baqteriebs axasiaTebT e.w ”specializebuli virulentoba”, rac uadvilebs maT nawlavuri floridan, saSodan an ureTris mimdebare aredan aRmavali gziT Sardis buStisken, iSviaTad ki Tirkmlebiskenac ki gavrceldnen da sistemuri anTebiTi procesi Camoayalibon. amgvari virulentobiT gamoirCeva E.coli.

gaurTulebeli saSarde gzebis (rogorc zeda, aseve qveda) infeqciis uxSiresi gamomwvevia E.coli (70-95%) da Staphylococcus

saprophyticus (5-10%). es ukanaskneli mwvave pielonefritis dros ufro naklebad gvxdeba, vidre mwvave cistitis SemTxvevaSi.

zogjer sxva enterobaqteriebis gamoyofac xdeba, esenia: Proteus

mirabilis, Klebsiella spp. da enterokokic ki (kombinirebuli kontaminacia). simptomuri pacientebis 10-15 %-Si baqteriuriis dadgena ver

xerxdeba rutinuli meTodebiT 9 , 10 . orsulobis dros sgi

ganviTarebas xels uwyobs Tirkmlebisa da saSarde gzebis anatomiur-fiziologiuri cvlilebebis ganviTareba, romelic damaxasiaTebelia orsulobisTvis: SardsawveTebi farTovdeba, xolo gadidebuli saSvilosno gadaadgilebs Sardis buSts win da zemoT. Tirkmlebis sisxliT momarageba da gorglovani filtracia izrdeba 30-40%-iT, Tirkmlebi mcired matulobs zomaSi da xdeba hiperemiuli. Sardis nakadi xdeba dune da SeiZleba Sardis buSti arasrulad daicalos.

mamakacebisgan gansxvavebiT, qalebSi Sardsadeni milis gareTa xvreli axlo mdebareobaSia swori nawlavis xvrelTan, rac zrdis kontaminaciis risks. garda amisa, gasaTvaliswinebelia mamakacis ureTris Taviseburebebi da misi sigrZe, agreTve prostatis wvenis antibaqteriuli moqmedebac. sgi ganviTarebas mamakacebSi xels uwyobs dasnebovnebuli partnioris arseboba, analuri seqsi da

CuCis arseboba11, Tumca es faqtorebi yoveTvis ar aRiniSneba.

sgi ganviTareba postmenopauzis periodis mqone qalebSi dakavSirebulia vaginaluri ph-is momatebasTan (normis farglebSi mcire raodenobiT gram uaryofiTi baqteriebi aRiniSneba vaginalurad, rasac xels uwyobs adgilobrivi mikroflora. laqtobacilebi amcireben vaginalur ph, magram maTi raodenoba mcirdeba menopauzisa da antibiotikoTerapiis Semdeg. estrogenebi xels uwyoben laqtobacilebis zrdas, amcireben vaginalur ph

12 (II b) da Sesabamisad aqvT damcavi funqcia). nawlavuri gram uaryofiTi

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flora kolonizacias ganicdis postmenopauzis periodis qalebSi morecidive sgi SemTxvevaSi 13 (IIb). aqedan gamomdinare,

postmenopauzalur qalebSi oraluri 14 , 15 an intravaginaluri

estriolis16 gamoyeneba mkveTrad amcirebs sgi recidivs (Ib A).

sgi FgarTulebis xelSemwyobi faqtorebia:

mamrobiTi sqesi (mamakacebSi saSarde infeqciis klinikuri suraTiT vlindeba mwvave an qronikuli prostatiti, saSarde infeqcia Tan axlavs Sard-kenWovan ddavadebas, prostatis keTilTvisebiani hiperplaziiT gamowveuli obstruqciis fonze xSirad viTardeba saSarde infeqcia);

xanSiSesuli asaki;

hospitaluri infeqcia (moiTxovs mkurnalobas specialuri antibaqteriuli preparatebiT da specialuri sqemiT / xangrZlivobiT);

orsuloba;

ureTruli kaTeteri;

ukanasknel xans Catarebuli intervencia saSarde gzebze;

saSarde gzebis funqciuri an anatomiuri paTologia;

Saqriani diabeti;

imunosupresia.

4. klinikuri simptomatika

simptomebi

mwvave cistiti premenopauzis periodis araorsul qalebSi xasiaTdeba gamoxatuli dizuriiT, tkiviliT, daWimulobiT boqvenzeda areSi.

mwvave pielonefrits araorsul premenopauzis periodis qalebSi axasiaTebs tkivili welis areSi, gulisreva, Rebineba, Semcivneba, sxeulis temperaturis mateba (>38 ºC), tkivili kostovertebrul areSi. am dros cistitis niSnebi SesaZloa arc aRiniSnebodes.

mwvave pielonefriti orsulebSi ZiriTadad mesame trimestrSi viTardeba. xSiria loginobis xanaSic. xasiaTdeba SemcivnebiT, maRali temperaturiT, tkiviliT welis areSi.

mwvave cistiti mamakacebSi SeiZleba arsebobdes rogorc damoukideblad, ise pielonefritTan da prostatitTan erTad. klinikuri suraTi iseTivea, rogorc qalebSi. morecidive sgi dros,

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unda vivaraudoT qronikuli prostatitis arseboba. asimptomuri baqteriuria ufro xSiria xanSiSesul mamakacebSi, Tumca ufro iSviaTia, vidre xanSiSesul qalebSi 17

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garTulebebi

mwvave pielonefritis garTuleba - saSarde gzebis infeqciis progresirebis sicocxlisTvis saSiSi garTulebebia: emfizematozuri pielonefriti (ZiriTadad diabetiT daavadebulebSi), Tirkmlis kortikomeduluri abscesi-karbunkuli, perinefruli abscesi (paranefriti) da papilaruli nekrozi.

garTulebebi da sikvdilianoba dabalia, rodesac pacienti itarebs Sesabamis mkurnalobas. mwvave pielonefritis ganviTarebis mizezi orsulebSi ZiriTadi urologiuri darRvevebi da imunitetis daqveiTebaa, rac maRali riskis qveS ayenebs orsulisa da nayofis janmrTelobas, axasiaTebs: toqsemia, hipertenzia, naadrevi mSobiaroba da perinataluri sikvdiloba. antibaqteriuli Terapia imdenad efeqturia, rom baqteriemiis SemTxvevaSic ki TiTqmis yvela pacienti gaurTulebeli mwvave pielonefritiT ukeTesad grZnobs Tavs da afebriluri xdeba mkurnalobis dawyebidan ramdenime dReSi.

5. daavadebis diagnozi

I mwvave gaurTulebeli cistitis diagnozi premenopauzis

periodis mqone araorsul qalebSi:

araorsul, premenopauzis periodis qalebSi mwvave dizuriul movlenebs iwvevs sami ZiriTadi infeqcia:

mwvave cistiti

mwvave ureTriti, gamowveuli C.trachomatis, Neissseria gonorrhoeae, an

herpes simplex virusiT

vaginiti, gamowveuli Candida spp. an Trichomonas vaginalis-iT.

am sami paTologiis diferencireba sakmaod maRali sarwmunoobiT SeiZleba anamneziTa da fizikuri gasinjviT.

mwvave cistiti savaraudoa im SemTxvevaSi, rodesac qali uCivis tkivils an daWimulobas boqvenzeda midamoSi da dizurias, aris diafragmisa da spermicidebis momxmarebeli, msgavsi Civilebi warsulSic aReniSneboda da bolo dros Catarebuli aqvs urologiuri manipulaciebi (cistoskopia, Sardsadeni milisa da SardsawveTis kaTeterizacia, invaziuri uro-rentgenologiuri

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diagnostikuri procedurebi). miuxedavad imisa, rom cistitis mqone qalebis daaxloebiT 40% aReniSneba hematuria, is ar SeiZleba CaiTvalos garTulebis maCveneblad. im SemTxvevaSi, rodesac dizurias Tan axlavs hematuria da infeqciis niSnebi ar aris gamoxatuli, saWiroa Sardis citologiuri kvleva da cistoskopia Sardis buStis karcinomis gamosaricxad. C.trachomatis an Neissseria

gonorrhoeae–iT gamowveuli ureTriti savaraudoa im SemTxvevaSi, Tu: qals axali sqesobrivi partniori hyavs bolo ramdenime kviris ganmavlobaSi an mis sqesobriv partniors aReniSneba ureTruli niSnebi (simptomebi). anamnezSi aRiniSneboda sqesobrivi gziT gadamdebi daavadebis arseboba, simptomebis TandaTan ganviTareba da Tanmxlebi saSosmxrivi simptomebi (gamonadeni saSodan an suni); vaginitze miuTiTebs vaginaluri gamonadeni, suni, qavili, tkivili sqesobrivi urTierTobisas, wva ureTris gareTa xvrelis midamoSi Sardvis sixSiris gazrdisa da moSardvis imperatiuli survilis gaCenis gareSe.

Sardis analizi (dipstick meTodiT)- sgi SemTxvevaSi piuriis, hematuriisa da nitritebis aRmosaCenad. mwvave, simptomuri sgi dros piuria yovelTvisaa (iseT SemTxvevaSi, rodesac gamoxatulia infeqciis klinikuri suraTi, magram ar aRiniSneba leikocituria, aucilebelia ganmeorebiTi kvleva, baqteriologia, kvlevis damatebiTi meTodebi – sonografia, rentgeni), iseve rogorc C.trachomatis an Neissseria gonorrhoeae–iT gamowveuli ureTritis dros. piuriis ar arseboba sxva diagnozze miuTiTebs. sgi diagnozi ismeba mniSvnelovani baqteriuriis SemTxvevaSi. am ukanasknelis definicia sadavoa. tradiciuli standartiT 4 dekadis win mniSvnelovani baqteriuriis qveS igulisxmeboda uropaTogenebis raodenoba ≥ 10 1

ml Sardis Sua ulufaSi, dafuZnebuli im qalebis SeswavliT, romlebsac hqondaT mwvave pielonefriti da asimptomuri baqteriuria 8. bolo ramdenime kvleviT dadginda, rom qalebis daaxloebiT naxevars mwvave cistitis dros aReniSneba baqteriuria

< 10 1 ml Sardis Sua ulufaSi 18 (II). praqtikuli miznebidan

gamomdinare mwvave gaurTulebeli cistitis diagnozis dasma SesaZlebelia, rodesac uropaTogenebis raodenoba ≥ 10³ 1 ml Sardis

Sua ulufaSi 19, 20.

Sardis baqteriologiuri (kulturuli kvleva) ar aris aucilebeli mwvave gaurTulebeli cistitis SemTxvevaSi, vinaidan gamomwvevisa da antimikrobuli mgrZnobelobis gansazRvra SesaZlebelia winaswar, maRali albaTobiT. garda amisa, baqteriologiuri kvlevis Sedegi cnobili xdeba maSin, rodesac pacientis simptomebi qreba an mkveTrad mcirdeba. Tu pacientis simptomebi ar aris sgi-Tvis damaxasiaTebeli, aseT SemTxvevaSi saWiroa Sardis Sua ulufis gamokvleva an kaTeteriT miRebuli Sardis (iRebs

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daxelovnebuli samedicino personali) baqteriologiuri kvleva. aseT SemTxvevaSi laboratorias egzavneba Setyobineba dafiqsirdes baqteriis umniSvnelo raodenobac ki.

menjis organoebis gasinjva naCvenebia, rodesac saeWvoa ureTritis an vaginitis arseboba an saeWvoa diagnozi (ver xerxdeba diagnozis dasma). menjis gasinjva moicavs vaginitis dadgenas, ureTruli gamonadenis an herpesuli dazianebis gamokvlevas. cervikaluri daTvaliereba da cervikaluri da ureTruli nacxis kulturaluri kvleva saWiroa C.trachomatis da Neissseria gonorrhoeae- aRmosaCenad (an polimerazas jaWvuri reaqcia dilis Sardis pirvel ulufaSi).

II mwvave gaurTulebeli pielonefritis diagnostika

premenopauzs periodis araorsul qalebSi:

mwvave pielonefritis diagnozi efuZneba klinikur suraTs: tkivili welis areSi, gulisreva/Rebineba, cxeleba (>38ºC) an daWimuloba kostovertebrul kuTxeSi, romelTac SeiZleba Tan axldes mwvave cistitis simptomebi. mwvave gaurTulebeli pielonefritis mimdinareoba msubuqidan zomieramde meryeobs.

Sardis analizSi sayuradReboa piuria da hematuria. cistitisgan gansxvavebiT pielonefritis SemTxvevaTa 80-95% -Si uropaTogenebis

raodenoba > 10 1 ml SardSi 21 , xolo rutinuli diagnozisaTvis

uropaTogenis 10 raodenobac sakmarisia 1 ml SardSi 22 , 23 . zeda

saSarde gzebis obstruqciis sanaxavad naCvenebia ultrabgeriTi

kvleva 24 . damatebiTi kvlevis meTodebi sonografia, eqskretoruli

urografia, kompiuteruli tomografia 25 naCvenebia Tu pacienti mkurnalobis dawyebidan 72 saaTis Semdegac febriluria, raTa gamoiricxos iseTi garTulebebi, rogoricaa uroliTiazi, Tirkmlis an perinefruli abscesi. rutinulad eqskretoruli urografiis gamoyeneba araRirebulia, vinaidan pacientTa umravlesobas mwvave gaurTulebeli pielonefritiT zeda saSarde gzebi ucvleli aqvT.

III sgi-is diagnostika orsul qalebSi:

mwvave cistitis diagnozi orsulebSi iseve ismeba, rogorc araorsulebSi.

mwvave pielonefritis diagnostika orsulebSi efuZneba klinikur suraTs: maRali cxeleba, leikocitozi, tkivili kostovertebrul kuTxeSi. xSiria baqteriemia.

asimptomuri baqteriuriis mqone qalebis 20-40% orsulobisas uviTardeba pielonefriti 26 ,asimptomuri baqteriuriis mkurnaloba ki amcirebs misi ganviTarebis risks 27 (II a), aqedan gamomdinare,

11

rekomendebulia yvela orsulis skriningi baqteriuriis aRmosaCenad Sardis baqteriologiuri kvlevis meTodiT erTxel mainc orsulobis adreul vadaze da dadebiTi pasuxis SemTxvevaSi mkurnalobis kursis Catareba 28 (IA). asimptomuri baqteriuriis

skriningi xarjTefeqturia, rodesac misi gavrceleba >2 % 29 .

socialurad stabilur populaciaSi ki, sadac misi gavrceleba dabalia, ar aris aucilebeli skrininguli programis muSaoba

30 (IIIB). TumcaRa, yovelwliurad pielonefritis SemTxvevaTa

Semcireba pirdapir kavSirSia asimptomuri baqteriuriis

skriningTan da mis mkurnalobasTan orsulebSi 31 (IIaB).

IV asimptomuri baqteriuriis diagnostika

asimptomuri baqteriuria sakmaod xSiria. Sardsasqeso sistemis funqciuri an anatomiuri anomaliis mqone pirebSi Zalian maRalia misi gavrcelebis sixSire, Tumca janmrTel populaciaSic aRiniSneba Sardis dadebiTi kultura. asimptomuri baqteriuria iSviaTadaa dakavSirebuli cud gamosavalTan. misi skriningi da mkurnaloba rekomendebulia mxolod Semdeg pirebSi:

orsulebi (IbA)

prostatis transureTruli rezeqciis Catarebis win (IbA)

sxva urologiuri Carevis SemTxvevaSi (III B)

arasaWiro mkurnalobis Tavidan acilebis mizniT saWiroa asimptomuri baqteriuriis diagnostika - ori Tanmimdevruli dadebiTi kultura erTidaigive saxeobis uropaTogenze.

cru dadebiTi Sedegis sixSire Sardis mxolod erTi Sua ulufidan >40 % (II b). qalebi Sardis dadebiTi kulturiT ganmeorebiT unda iqnen gamokvleulni 1-2 kviris Semdeg, amisaTvis xdeba vulvis gulmodgine damuSaveba, Sardis meore Sua ulufis aReba an kaTeteriT Sardis miReba da am masalis kvleva (II aB).

V morecidive sgi-is diagnostika

morecidive sgi diagnozi ismeba, Tu pacients bolo 12 Tvis manZilze 3 an 6 Tvis manZilze sgi 2 epizodi aReniSneboda.

VI mwvave gaurTulebeli sgi-is diagnostika axalgazrda

mamakacebSi

mwvave sgi simptomatika axalgazrda mamakacebSi msgavsia qalebSi mimdinare sgi-sa. ureTriti savaraudoa sqesobrivad aqtiur mamakacebSi. ureTritis gamosaricxad sqesobrivad aqtiur

12

mamakacebSi, iReben Sardis pirveli ulufis nimuSs ureTruli leikocitozis dasadgenad an mimarTaven gramis wesiT SeRebvas. gramiT SeRebvisas leikocitebisa da gram-uaryofiTi floris naxva miuTiTebs E. coli inficirebaze, romelic win uZRvis an Tan axlavs sgi. yvela mamakaci mwvave cistitiT Sefasebuli inda iqnas gamomwvev mizezze. Tu risk faqtori ar aris gamokveTili (mag: Sardis buStis kaTeteri), saWiroa pacientis urologiuri Sefaseba. morecidive sgi dros savaraudoa qronikuli prostatitis arseboba.urologiuri Sefaseba SesaZloa saWiro ar iyos axalgazrda, janmrTel mamakacebSi, romelTac ar aqvT gamokveTili garTulebis maCvenebeli faqtori, aqvT cistitis pirveli epizodi da antimikrobul Terapiaze Sedegi swrafad miiReba.

referalis Cvenebebi:

Semdegi faqtorebis arsebobis SemTxvevaSi aucilebelia vifiqroT garTulebuli saSarde infeqciis arsebobasa da referalis Cvenebebze.

urgentul referals moiTxovs perinefruli da Tirkmlis abscesi, vinaidan mas SeuZlia gamoiwvios Tirkmlis funqciis gauareseba da septiuri Sokic ki.

referalis pirdapiri Cvenebaa:

saSarde gzebis funqciuri an anatomiuri paTologia (Tandayolili anomaliebi, Sard-kenWovani daavadeba, prostatis keTilTvisebiani hiperplazia, Sardis Sekaveba, da a.S.);

saSarde sistemaSi kaTeteris arseboba (ureTruli, epicistostoma, nefrostoma);

imunosupresia;

adekvaturi mkurnalobis miuxedavad mkurnalobis dawyebidan 72 sT-Si klinikuri gaumjobesebis ararseboba;

orsuloba.

referalis Cvenebaa agreTve Semdegi mdgomareobebi:

1. roca pacienti mamrobiTi sqesisaa* da ojaxis eqims ar aqvs SesaZlebloba (sadiagnozo saSualebebis xelmiuwvdomloba) gamoricxos:

*

mamakacebSi: (a) saSarde infeqciis klinikuri suraTiT vlindeba mwvave an qronikuli prostatiti (b) saSarde gzebis infeqcia Tan axlavs Sard-kenWovan daavadebas (g) prostatis keTilTvisebiani hiperplaziiT gamowveuli obstruqciis fonze xSirad viTardeba sgi.

13

axalgazrda mamakacebSi mwvave cistitze saeWvo klinikis SemTxvevaSi ureTriti, prostatiti, SardkenWovani daavadeba;

axalgazrda mamakacebSi pwvave pielonefritze saeWvo klinikis SemTxvevaSi Sard-kenWovani daavadeba da Tandayolili obstruqciuli anomaliebi;

xanSiSesul mamakacebSi cistitze saeWvo klinikis SemTxvevaSi prostatiti, prostatis keTilTvisebiani hiperplaziis gamo an sxva mizeziT moSardvis darRvevebi, Sardis Sekaveba, Sardis buStis kenWi;

xanSiSesul mamakacebSi mwvave pielonefritze saeWvo klinikis SemTxvevaSi Sard-kenWovani daavadeba, Sardis Sekaveba da Tandayolili obstruqciuli anomaliebi.

2. roca pacienti asakovania

xanSi Sesuli asaki pirdapir Cvenebas referalisaTvis ar warmoadgens. Tumca im SemTxvevaSi, rodesac mdgomareoba ar umjobesdeba mkurnalobis dawyebidan 72 sT-Si, rekomendebulia referali.

3. roca pacients aReniSneba hospitaluri infeqcia†

aseT SemTxvevaSi sasurvelia Tanmxlebi urologiuri paTologiebis gamoricxva, Sardis baqteriologiuri kvleva da mkurnalobis adekvaturi (ufro efeqturi) reJimis gamoyeneba.

4. roca pacients ukanasknel xans Catarebuli aqvs intervencia saSarde gzebze (kaTeterizacia, cistoskopia, operacia).

urologiuri paTologiis arseboba referalis pirdapiri Cvenebaa; Catarebuli kvlevebiT urologiuri paTologiis gamoricxvis SemTxvevaSi ki referalis mizania Sardis baqteriologiuri kvleva da mkurnalobis ufro efeqturi reJimis gamoyeneba.

5. roca pacients aReniSneba Saqriani diabeti

am dros sasurvelia Tanmxlebi urologiuri paTologiis gamoricxva da aqtiuri monitoringi. Tu mkurnalobidan 72 sT-Si klinikuri gaumjobeseba ar aRiniSneba, saWiroa referali.

† moiTxovs mkurnalobas specialuri antibaqteriuli preparatebiT da specialuri sqemiT / xangrZlivobiT.

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6. roca pacients bolo xans Catarebuli aqvs antibiotikoTerapia, rac SeiZleba mianiSnebdes antibiotikebisadmi rezistentuli floris arsebobaze.

sasurvelia Tanmxlebi urologiuri paTologiis gamoricxva, Sardis baqteriologiuri kvleva da mkurnalobis adekvaturi (ufro efeqturi) reJimis gamoyeneba mgrZnobelobis gansazRvramde, Semdeg ki _ mkurnaloba antibiotikogramis mixedviT.

7. roca pacients aReniSneba daavadebis 7 dReze meti mimdinareoba

mkurnalobis gareSe izrdeba garTulebis riski. amitom sasurvelia Tanmxlebi urologiuri paTologiis gamoricxva da aqtiuri monitoringi. Tu mkurnalobidan 72 sT-Si klinikuri gaumjobeseba ar aRiniSneba, saWiroa referali.

15

sqema 1. sgi diagnostikuri algoriTmi mozrdil pacientebSi: mozrdilTa sgi

diax ara

asimptomuri baqteriuria

garTulebis xelSemwyobi faqtorebi

diax ara

garTulebuli sgi

ganmeorebiTi epizodi

morecidive sgi

diax ara

zeda sg simptomebi

diax ara

pielonefriti cistiti, ureTriti an vaginiti.

mozrdilTa sgi-is simptomebis arseboba

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6. mkurnaloba:

qveda sgi (50-70%) TviTlimitirebadia, Tumca simptomebi SeiZleba ramdenime Tvec darCes. prospeqtul, placebo kontrolirebad kvlevaSi 32 (I b), 288 pacienti Rebulobda placebos 7 dRis manZilze, 39 % pirveli vizitis Semdeg gamovarda kvlevidan (8-10) dRe. simptomebis spontanuri gankurneba aRiniSna 28 % pacientSi erTi kviris Semdeg, xolo 37 % aRar aReniSneboda arc simptomebi da

arc baqteriuria 5-7 kviris Semdeg. sxva kvlevis mixedviT 33 (I b),

simptomuri gaumjobeseba da gankurneba aReniSna 33 placebo mkurnalobis mqone pacientTa 52% mkurnalobidan 1 kviraSi, romelTac dadasturebuli hqondaT sgi baqteriologiurad, magram am pacientTa mxolod 20% hqonda baqteriuli eradikaciac. orive parametri mniSvnelovnad dabali iyo im pacientebTan SedarebiT, romlebic mkurnalobdnen nitrofurantoiniT (100 mg 4-jer dReSi 3 dRis manZilze).

gaurTulebeli sgi gamomwvevi uropaTogenebis antimikrobeli mgrZnobelobis codna ama Tu im populaciaSi gansazRvravs mkurnalobis mimarTulebas, TumcaRa, mwvave gaurTulebeli cistitis mqone pacientTa kulturaluri kvleva ar aris rutinuli meTodi da es monacemebic Sesabamisad mwiria.

I mwvave cistitis mkurnaloba premenopauzis periodis

araorsul qalebSi

antimikrobuli mkurnalobis xanmokle kursi maRal efeqturia

mwvave cistitis dros premenopauzian, araorsul qalebSi 34 , 35 (I a).

xanmokle kursis upiratesobaa mkurnalobis xelmisawvdomoba (siiafe) da arasasurveli gverdiTi movlenebis simcire. Tumca SeiZleba mkurnalobis xanmokle kursis Semdeg aRiniSnos recidivi an mkurnalobis araefeqturoba. aseve gasaTvaliswinebelia pacientis mxridan potenciuri fsiqologiuri aspeqtebi erTjeradi doziT mkurnalobisas, 2-3 dRiani kursis araefeqturobisas am kursis ”arasworad” CaTvla misi mxridan da zedmeti vizitebisa Tu zarebis ganxorcieleba.

sgi samkurnalod sxvadasxva antimikrobuli preparatebis sxvadasxva jgufebi, dozebi, reJimebi da xangrZlivoba iyo mowodebuli. maTi analizis Sedegad IDSAA komitetma da sgi samuSao jgufma Seqmna da ganaaxla sgi mkurnalobis gaidlaini.

sgi samkurnalod mowodebulia Semdegi preparatebi: trimetoprimi (TMP), trimetroprim-sulfametoqsazoli (TMP-SMX), ftorqinolo-nebi (ciprofloqsacini, enoqsacini, norfloqsacini, ofloqsacini,

17

pefloqsacini, rufloqsacini), beta-laqtamebi da cefalosporinebi (amoqsicilini, ampicilini, cefaleqsini, cefuroqsim aqsetili, cefpodoqsim proqsetili, ceftibuteni, pivmecilinami, ritipenemi), fosfomicin trometamoli da nitrofurantoini.

mkurnalobis xangrZlivoba: gaurTulebeli, mwvave cistitis mqone mozrdil, sxvamxriv janmrTel, araorsul qalebSi erTjeradi doziT mkurnaloba mniSvnelovnad nakleb efeqturia sawyisi baqteriuriis eradikaciisaTvis, vidre igive preparatis xangrZlivi gamoyenebisas, es preparatebia: trimetoprimi (TMP), trimetroprim-sulfametoqsazoli (TMP-SMX), ciprofloqsacini, norfloqsacini, ß

laqtamebi. TumcaRa, trimetoprimis (TMP), trimetroprim-sulfametoqsazolis (TMP-SMX), ciprofloqsacinis, norfloqsacinisa da fleroqsacinis miReba 3 dRis manZilze iseTive efeqts iZleva, rogorc misi gamoyeneba xangrZlivi droiT. am ukanasknelis dros xSiria gverdiTi reaqciebi (I b). S. saprophyticus-

iT gamowveuli cistiti SeiZleba ukeT ganikurnos mkurnalobis 7 dRiani kursiT 36 (III B).

trimetoprimi, kotrimoqsazoli-trimetoprim-sulfametoqsa-zoli (TMP-SMX) yvelaze Seswavlili preparatia (30 kvleva). mkurnalobis 3 dRiani kursi TMP-SMX–iT standartuli Terapiis kursad aris miCneuli (I aA). calke aRebuli TMP ekvivalenturia TMP-SMX-sa eradikaciisa da gverdiTi movlenebis mixedviT. sulfanilamidebis mier gamowveuli iSviaTi, magram seriozuli gverdiTi movlenebis gamo calke trimetoprimi ufro miRebuli preparatia, vidre TMP-

SMX (III C). TMP da TMP-SMX rekomendebulia pirveli rigis preparatad empiriuli mkurnalobisTvis im populaciaSi, sadac uropaTogenebis rezistentoba TMP mimarT < 10-20 %-ze (erTis mxriv mgrZnobelobisa da E. coli eradikaciisa da meore mxriv rezistentobisa da uropaTogenebis persistenciis mWidro

korelaciis gamo 37 38 (Ib). pivmecilinamsa da

ciprofloqsacins 39 naklebad axasiaTebs recidivis dros

rezistentuli floris warmoqmna, vidre TMP-s (III).

ftorqinolonebi - ciprofloqsacini, norfloqsacini, ofloqsacini da fleroqsacini TMP-SMX ekvivalenturni arian 3 dRiani kursis Catarebisas (I bA). erTdRiani mkurnaloba pefloqsaciniTa da rufloqsaciniT SeiZleba TMP-SMX ekvivalenturi iyos baqteriuriis eradikaciisa da recidivebis TvalsazrisiT. ar aris garkveuli am agentebiT sargeblobisas gverdiTi movlenebis matebis Sesaxeb sxva rekomendebul TerapiasTan SedarebiT 40 (Ib B).

ftorqinolonebi ZviradRirebuli preparatebia TMP da TMP-SMX –Tan SedarebiT da amdenad ar aris rekomendebuli maTi gamoyeneba empiriuli TerapiisTvis, garda im SemTxvevebisa, rodesac

18

populaciaSi uropaTogenebis rezistentoba TMP mimarT >10-20 %. ftorqinilonebisadmi rezistentobis ganviTarebis safrTxis gamo ar aris mizanSewonili maTi rutinuli gamoyeneba gaurTulebeli, mwvave sgi dros, Tumca ar aris gamoqveynebuli kvlevis monacemebi mwvave cistitis SemTxvevaSi am jgufis preparatebis mimarT

rezistentuli floris Sesaxeb41 ,42 ,43 (III). zogierT qveyanaSi E. coli

rezistentoba ftorqinolonebis mimarT ukve gaizarda da >10 %. aseT SemTxvevaSi alternatiuli preparatebi unda iqnen gamoyenebuli empiriuli mkurnalobisTvis (cxr. #2, #3). am preparatebis gamoyenebisas baqteriuriis eradikacia 90%-ze meti unda iyos.

ß laqtamebi - am jgufis preparatebi zemoT CamoTvlil preparatebTan SedarebiT nakleb efeqturia (III). ar moipoveba farTomasStabiani kvleva zemoT xsenebul reJimebsa (3 dRiani kursi TMP an TMP-SMX an ftorqinolonebiT) da meore da mesame Taobis cefalosporinisa an aminopenicilins plius ßlaqtamebis inhibitorebis SedarebiTi moqmedebis Sesaxeb 44 . mxolod erTma kvlevam Seadara laqtamebis (pivmecilinami) 3 dRiani kursi

SedarebiT xangrZliv kurss 45 (Ib). Sedegad aRmoCnda, rom 3 dRiani

kursi 7 dRiani kursis ekvivalenturia sawyisi baqteriuriis eradikaciis mixedviT, Tumca, xanmokle kursi dakavSirebuli iyo recidivis matebasTan. pivmecilinamiT 7 dRiani kursi (200 mg orjer dReSi) da 3 dRiani kursi norfloqsaciniT (400 mg orjer) erTnair

Sedegs iZleva 46 , 47 (IaB). pivmecilinamis gamoyenebisas vaginaluri

kandidozis sixSire mniSvnelovnad dabali iyo, vidre norfloqsacinis gamoyenebisa 48 (IB). pivmecilinams aseve axasiaTebs dabali rezistentoba E. coli sa da sxva enterobaqteriebis mimarT sgi samkurnalod gamoyenebuli sxva preparatebis mimarT jvaredini

rezistentobis gareSe 49 , 50 (IIb). pirveli da meore Taobis

cefalosporinebiT 3 dRiani kursi ar aris rekomendebuli pirveli

rigis samkurnalo reJimad gaurTulebeli sgi dros 51 ,52,53 (Ib A). 133

Sefasebul pacientSi mesame Taobis oraluri cefalosporinebidan 3 dRiani kursi cefpodoqsim-proqsetiliT (200 mg orjer dReSi)

iseTive usafrTxo da efeqturi iyo, rogorc TMP-SMX 54 (Ib A). amis

sawinaaRmdegod, 370 qalSi 3 dRiani kursi amoqsicilin-klavulanatiT (500 mg/125 mg orjer dReSi) ar iyo iseTi efeqturi, rogorc 3 dRiani kursi ciprofloqsaciniT (250 mg orjer dReSi). es sxvaoba SesaZloa gamowveuli iyos amoqsicilin-klavulanatis susti eradikaciuli moqmedebiT vaginaluri E. coli mimarT.

fosfomicini - farTo kvleviT 55 (IbA) 547 qalze fosfomicin-trometamolis erTjeradi doziT mkurnaloba (3 g) Sedarebuli iqna

19

trimetoprimiT 5 dRian mkurnalobis kursTan (200 mg dReSi orjer), Sedegad nanaxi iqna ekvivalenturi gankurnebis sixSire (83 % orive preparatis gamoyenebisas). es preparati gamoiyeneba evropis ramdenime qveyanaSi da rezistentoba E. coli mimarT Zalian dabalia sgi samkurnalod gamoyenebuli sxva preparatebis mimarT jvaredini

rezistentobis gareSe 56, 57, 58 (II b).

nitrofurantoini - 50-100 mg 4-jer dReSi an 100 mg 2-jer dReSi ar SeiZleba mowodebuli iqnas xanmokle mkurnalobisTvis gaurTulebeli cistitis SemTxvevaSi. sasurvelia misi daniSvna 5-7 dRiani kursiT mwvave cistitis samkurnalod 59 (IIa B). miuxedavad am preparatis wlebis manZilze gamoyenebisa, rezistentoba E. coli –sa da S.saprophyticus mimarT jer kidev dabalia evropaSi 60 (II b), Tumca, zogierT regionSi SeiniSneba nitrofurantoinis mimarT E. coli rezistentobis gazrda bolo 10 wlis manZilze 61 . es preparati araefeqturia P.mirabilis da Klebsiella spp. mimarT, romlebic rigiT meore da mesame gram uaryofiTi uropaTogenebi arian 62 (II b). garda amisa, gansakuTrebiT safrTxiloa maTi daniSvna, vinaidan axasiaTebT iseTi seriozuli gverdiTi movlenebi rogoricaa mwvave da qronikuli pulmonaruli sindromi, gansakuTrebiT xanSiSesul

asakSi 63 , 64 . es seriozuli reaqcia ar aRiniSneba am preparatis

xangrZlivi droiTa da dabali doziT gamoyenebisas (sgi profilaqta gogonebsa da qalebSi) 65,66 (III).

cxrili #2

mwvave gaurTulebeli cistitis mkurnalobis reJimi premenopauzis periodis araorsul qalebSi

medikamenti doza mkurna-lobis xangr-Zlivoba

mtkicebulebis done, rekomendaciis xarisxi

SeniSvna

cefpodoqsimi 100mg X2 3 dRe Ib A

cefpodoqsimi 3dRe iseTive efeqturia, rogorc TMP-SMX 3dRe

ciprofloqsacini* 250mg X 2 3 dRe Ib A gamoiyeneba post menopauzian qalebSic

ciprofloqsacinis gaxangrZlivebuli moqmedis formebi

500 mg erTjer

3 dRe Ib A

efeqturoba da tolerantoba gaxangrZlivebuli moqmedebis ciprofloqsacinisa (500 mg erTjer) ekvivalenturia 3-dRiani kursisa

20

ciprofloqsaciniT 250 mg 2-jer dReSi

fosfomicini 3000 mg erTjeradi doza

1 dRe Ia, b A E

levofloqsacini* 250 mgX 2 3 dRe Ib A iseTive efeqturia, rogorc ofloqsacini

nitrofurantoini

50-100 mg X4; 100 mg gaxangrZlivebuli moqmedebis

5-7 dRe II aB

5-7 dRiani mkurnaloba ufro efeqturi iyo, vidre 3 dRiani kursi.

norfloqsacini* 400 mgX2 3 dRe Ib A

recidivi 3 dRiani mkurnalobisas metia, vidre 7 dRiani kursis dros.

ofloqsacini* 200mg X2 3 dRe Ib A

ekvivalenturia TMP-

SMX 3 dRiani mkurnalobis kursisa.

pivmecilinami 200mg X2 7 dRe Ib A

iseTive efeqturia, rogorc norfloqsacini, iSviaTia sokovani vaginitis ganviTareba

trimetoprimi* 200mg X2 5-7 dRe Ib A

standartuli Terapiaa, rodesac TMP rezistentuli

E.coli<10-20%; 5-7 dRiani mkurnaloba ufro efeqturia, vidre 3 dRiani.

trimetoprim-sulfametoqsazoli*

160/800 mg X2 3 dRe Ib A

mxolod empiriuli mkurnalobisTvis, roca rezistentuli

E.coli<10-20%

* E.coli rezistentoba gansxvavebulia evropis qveynebSi. es medikamentebi rekomendebulia empiriuli mkurnalobisTvis, rodesac E.coli rezistentobis sixSire<10-20 %.

mkurnalobis sxva meTodebi - iseTi analgeziuri saSualebebi, rogoricaa fenazopiridini (200 mg 3-jer dReSi) SeiZleba dainiSnos im pacientebSi, romelTac aReniSnebaT seriozuli dizuria 1-2 dRis

21

manZilze. qalebs cistitiT, maT Soris dizuriiTa da moSardvis imperatiuli surviliT mdgomareobis gaumjobeseba Cveulebriv aReniSnebaT mkurnalobis dawyebidan 2-3 dReSi. es informacia unda miewodos pacients. aqedan gamomdinare, analgeziuri Terapiis saWiroebisa da xangrZlivobis gansazRvra individualuria.

miuxedavad imisa, rom zogadad rekomendebulia pacientebma sgi dros miiRon Warbi raodenobiT siTxe Sardvis matebisa da uropaTogenebis eliminaciis mizniT, ar aris cnobili am meTodis ziani/sargeblobis Sesaxeb 67.

II mwave cistitis mkurnaloba orsulebSi

orsulebSi rekomendebulia 7 dRiani mkurnalobis kursis Catareba mag: pivmecilinamiT 68 (IbA). xanmokle mkurnalobis kursi ar aris ise mowodebuli orsulebSi, rogorc araorsulebSi, magram mcire kvlevebiTa da eqspertTa mosazrebiT SeiZleba am reJimis gamoyenebac 69 (IIaB). fosfomicin trometamoli (3 g erTjeradi doza) an meore, mesame Taobis cefalosporinebi (mag: ceftibuteni 400 mg erTjeradad) SeiZleba ganixilos xanmokle reJimis alternativad 70 (IIaB). sxva SemTxvevaSi rekomendebulia amoqsicilinis, cefaleqsinisa an nitrofurantoinis daniSvna (IV C).

III sgi mkurnaloba axalgazrda mamakacebSi

gamomdinare iqidan, rom sgi axalgazrda asakis mamakacebSi ar aris xSiri, ar arsebobs mkurnalobis kontrolis Semswavleli kvlevebi. rekomendebulia im preparatebis gamoyeneba, romlebic naCvenebia sgi samkurnalod qalebSi (III). nitrofurantoini ar gamoiyeneba sgi samkurnalod axalgazrda mamakacebSi, vinaidan ver aRwevs saTanado koncentracias qsovilebSi (IV C). mwvave gaurTulebeli pielonefritis samkurnalod im populaciaSi sadac am preparatebisadmiEE. coli s rezistentoba dabalia (<10%) ftorqinolonebia rekomendebuli rogorc sawyisi empiriuli mkurnaloba (IIa B). sxva SemTxvevaSi gamoiyeneba alternatiuli medikamentebi. mamakacebSi febriluri sgi an pielonefritiT unda vivaraudoT prostatis CarTvac procesSi, mkurnalobis mizani ki ara mxolod SardSi baqteriebis eradikaciaa, aramed prostatis infeqciis aRmofxvrac. amitom, mizanSewonilia iseTi medikamentebis gamoyeneba, romelTac axasiaTebT prostatis qsovilsa da siTxeSi maRali SeRwevadoba. mag: ftorqinolonebi 71 (II bB). SesaZloa mkurnalobis xanmokle kursi efeturi iyos mamakacebSi gaurTulebeli mwvave cistitis samkurnalod, magram ar arsebobs amis damadasturebeli kvlevebi. rekomendebulia minimum 7 dRiani mkurnalobis kursi, vinaidan mamakacebSi qalebisgan gansxvavebiT metia garTulebis xelSemwyobi faqtoris arsebobis Sansi (III B).

22

garda amisa, xangrZliv mkurnalobas SeuZlia prostatis savaraudod arsebuli infeqciis Semcirebac. febriluri sgi epizodis periodSi an mis Sedeg 6 Tve ar aris rekomendebuli plazmis prostatis specifiuri antigenis gansazRvra. im mamakacTa urologiuri Semowmeba, romelTac mxolod erTxel aReniSnebodaT gaurTulebeli sgi ar aris aucilebeli. urologiuri Sefaseba rutinulad tardeba mozardebsa da mamakacebSi febriluri sgi-iT, pielonefritiTa da morecidive infeqciiT, agreTve, rodesac savaraudoa garTulebis xelSemwyobi faqtoris arseboba (III B).

IV sgi mkurnaloba post menopauzis periodis qalebSi

mwvave sgi mkurnaloba post menopauzis periodis qalebSi iseTivea, rogorc premenopauzis periodis araorsul qalebSi. TumcaRa, mkurnalobis xanmokle kursi ar aris ise mowodebuli, rogorc premenopauzis periodis qalebSi. ormagi brma kvlevis72 (I B) Sedegad nanaxi iqna, rom 183 post menopauzis periodis qalSi, romelTa asaki minimum 65 weli iyo, oraluri 3 dRiani da 7 dRiani kursi ciprofloqsaciniT (250 mg orjer dReSi) erTnairad efeqturi aRmoCnda (baqteriuli eradikaciis maCvenebeli mkurnalobis damTavrebidan 2 dReSi 98% da 93%), Tumca xanmokle kursi pacientisTvis ufro asatani iyo. baqteriis eradikaciis maCvenebeli sakmaod maRali, xolo ciprofloqsacinisadmi rezistentoba dabali iyo. igive ar SeiZleba iTqvas xanSiSesul pacientebze, romelTac aReniSnebaT Tanmxlebi daavadebebi, gram uaryofiTi da rezistentuli mikroorganizmebiT gamowveuli sgi. morecidive sgi dros saWiroa urologiuri an ginekologiuri Sefaseba simsivnis, obstruqciuli problemis, detruzoris ukmarisobisa an genitaliebis infeqciis gamosaricxad (IV C).

V mwvave pielonefritis mkurnaloba premenopauzis

periodis araorsul qalebSi

prospeqtuli, randomizebuli, kontrolirebadi kvlevebis 73 , 74 75

analizis Sedegad sawyisi Terapiis Sesaxeb gamoqveynda mxolod 5 76,

77 publikacia.

TMP-SMX gaaCnia upiratesoba ampicilinTan SedarebiT (Ib A)

(mxolod TMP –ze ar arsebobs kvleva).

TMP-SMX gamoyeneba mwvave gaurTulebeli pielonefritis samkurnalod 2 kviris manZilze adekvaturia qalebis umravlesobisTvis (I bA). zogierT SemTxvevaSi sxvadasxva antibiotikebis mag: aminoglikozidebis daniSvna SeiZleba xanmokle droiT (5-7 dReE) (III B). populaciaSi, sadac E. colis rezistentoba TMP mimarT>10 %, ftorqinolonebia naCvenebi arCevis preparatad

23

empiriuli mkurnalobisTvis. 7 dRiani kursi ciprofloqsaciniT (500 mg dReSi orjer) baqteriebis eradikaciis da naklebi gverdiTi movlenebis gamo ufro efeqturi aRmoCnda, vidre 14 dRiani kursi

TMP-SMX–iT (960 mg orjer dReSi) 78 (IbA). ciprofloqsacinis aseTi maRali efeqturoba E. colis Stamebis TMP mimarT rezistentobiT iqna gamowveuli.

ar arsebobs sarwmuno monacemebi SedarebiTi kvlevisa ftorqinolonebis an TMP-SMX moqmedebis efeqturobisa aminopenicilinebs plius laqtamebis inhibitorebis an meore da mesame Taobis oraluri cefalosporinebTan mimarTebaSi. prospeqtuli, randomizebuli kvleviT 10 dRiani mkurnaloba cefpodoqsim-aqsetiliT (200 mg dReSi orjer) iseTive efeqturi iyo, rogorc ciprofloqsaciniT (500 mg orjer dReSi) 79 (IbA).

im SemTxvevebSi, rodesac E. coli rezistentoba ftorqinolonebisadmi >10 % da rodesac es preparatebi ukunaCvenebia (orsuloba, laqtacia, mozardi asaki), aminopenicilinebs plius ß laqtamebis inhibitorebi an mesame Taobis oraluri cefalosporinebia rekomendebuli, rogorc sawyisi TerapiisTvis, aseve oralur reJimze gadayvanis dros (III B).

miRebul monacemebze dayrdnobiT EAU gaidlainebis sgi samuSao jgufi rekomendacias uwevs msubuqi da zomieri SemTxvevis dros oraluri ftorqinolonebis gamoyenebas 7 dRis manZilze pirveli rigis preparatad. ftorqinolonebis gamoyenebis ukuCvenebis dros (ix. zemoT) mesame Taobis cefalosporinebi SeiZleba ganvixiloT empiriuli mkurnalobis arCevis preparatad (B). gram dadebiTi organizmebis aRmoCenisas nacxSi aminopenicilinebs plius ß laqtamebis inhibitorebia naCvenebi (B). gaurTulebeli pielonefritis ufro seriozuli SemTxvevebi saWiroebs pacientis gadagzavnas saavadmyofoSi da oraluri mkurnalobis Sesrulebis SeuZleblobisas parenteruli reJimiT Terapias ftorqinolonebiT, aminopenicilinebs plius ß laqtamebis inhibitorebiT, mesame Taobis cefalosporinebiT an aminoglikozidebiT (B). mdgomareobis gaumjobesebasTan erTad pacienti gadadis oralur Terapiaze zemoT CamoTvlili erTerTi antibiotikis gamoyenebiT (gamomwvevis mimarT aqtiuri Tu aris), raTa dasruldes mkurnalobis 1-2 kviriani kursi (B). hospitalizebuli pacientebis daaxloebiT 12 % baqteriemia aReniSneba, daavadebis simZime gansazRvravs maTSi sisxlis baqteriologiuri kvlevis Catarebis aucileblobas 80 . ar arsebobs mtkicebulebebi aqvs Tu ara baqteriemias prognozuli mniSvneloba da misi arsebobisas saWiroa Tu ara ufro xangrZlivi mkurnalobis kursi pielonefritis mqone, sxvamxriv janmrTel pirebSi.

24

cxrili #3

mwvave gaurTulebeli pielonefritis mkurnalobis reJimi premenopauzis periodis araorsul qalebSi

medikamenti doza mkurnalobis xangrZlivoba

Mtkicebulebis done, rekomendaciis xarisxi

SeniSvna

ciprofloqsacini 500 mg X2

7 dRe Ib A mniSvnelovnad efeqturia, vidre TMP-SMX da gverdiTi efeqti naklebia

ciprofloqsacinis gaxangrZlivebuli moqmedis formebi

1000 mg erTjer

7-10 dRe Ib A iseTive efeqturia, rogorc ciprofloqsacini 10 dRe

cefpodoqsimi* 200 mg X2

10 dRe Ib B klinikurad ekvivalenturia ciprofloqsacinisa (500 mg X2)

gatifloqsacini 400mg erTjer

10 dRe Ib A ekvivalenturia ciprofloqsacinisa (500 mg X2)

levofloqsacini 250 mg erTjer

10 dRe Ib A ekvivalenturia ciprofloqsacinisa (500 mg X2)

lomefloqsacini 400 mg erTjer

10 dRe Ib B

trimetoprim-sulfametoqsazoli

160/800 mg X2

14 dRe Ib B xolod TMP

mgrZnobiare uropaTogenebis arsebobisas

25

cxrili #4

mwvave pielonefritis marTvis algoriTmi

ara diax

Sardis saerTo da baqteriologiuri kvleva, ultrasonografia, ambulatoriuli mkurnaloba, oraluri Terapia 7-14 dRe

ftorqinolonebi

aminopenicilini+ ß laqtamebis inhibitorebiT

cefalosporinebi (III Taobis)

TMP-SMX (dadasturebuli mgrZnobelobiT)

Sardis saerTo, Sardisa da sisxlis baqteriologiuri kvleva ultrasonografia hospitaluri mkurnaloba daiwyeT parenterulad 1-3 dRe

ftorqinolonebi

aminopenicilini+ ß laqtamebis inhibitorebiT

cefalosporinebi (III Taobis)

aminoglikozidebi

mdgomareobis gaumjobeseba 72 saaTSi

mkurnalobis mTliani kursi 14-21 dRe

mdgomareoba ar umjobesdeba an gauaresebaa

oraluri Terapia

Sardis baqteriologia mkurnalobis dawyebidan me-4 da damTavrebidan me-10 dRes

saWiroebisas urologiuri Sefaseba

ganmeorebiTi hospitalizacia

baqteriologiisa da mgrZnobelobis gadamowmeba

urologiuri Sefaseba garTulebis xelSemwyobifaqtorebze

obstruqciis an abscesis drenireba

pielonefritis simptomebi an niSnebi (tkivili welis areSi, cxeleba, piuria, leikocitozi),

gulisreva, Rebineba an septiuri mdgomareoba

26

VI mwvave pielonefritis mkurnaloba orsulebSi

rekomendebulia meore da mesame Taobis cefalosporinebis, aminopenicilins plius ß laqtamebis inhibitorebisa da aminoglikozidebis gamoyeneba. qinolonebisa da tetraciklinis gamoyeneba ar aris rekomendebuli, xolo TMP ar gamoiyeneba pirveli trimestris, sulfanilamidebi ki mesame trimestris dros

81,82. garTulebul SemTxvevebSi, gansakuTrebiT zeda saSarde gzebis

dilataciisas saWiro xdeba stentis Cadgma da antibaqteriuli profilaqtika mSobiarobamde da loginobis xanaSi (C).

VII asimptomuri baqteriuriis mkurnaloba orsulebSi

mkurnaloba dafuZnebuli unda iyos antibiotikebisadmi mgrZnobelobaze da Cveulebriv moicavs 5-7 dRian kurss 83 (III). Tumca, zogierTi avtori rekomendacias uwevs mkurnalobis xanmokle kurss, rogorsac mimarTaven mwvave cistitis dros 84 (II aB). ganmeorebiTi baqteriologiuri kvleva unda Catardes mkurnalobis dasrulebidan 1-4 kviraSi da sul mcire erTxel mainc mSobiarobamde (III B).

VIII morecidive sgi mkurnaloba

ar aris cnobili romeli antibiotikis reJimis gamoyenebaa umjobesi profilaqtikurad an ra xangrZlivobiT, agreTve gverdiTi movlenebis sixSire da recidivis ganviTarebis albaToba profilaqtikuri mkurnalobis Sewyvetis Semdeg.

morecidive sgi prevenciisTvis mowodebulia sxvadasxva meTodi, maT Soris arafarmakologiuri: moSardva sqesobrivi aqtis Semdeg an StoSis wvenis daleva 85 , seqsualurad aqtiur qalebSi ki antibiotikebis regularuli an post koitaluri profilaqtikuri miReba. mniSvnelovania Zilis win dabali doziT antimikrobuli preparatis miReba xangrZlivi droiT. antimikrobuli mkurnalobis gamoyenebis SemTxvevaSi sgi recidivi erT pacientze weliwadSi 95%-iT Semcirda. profilaqtikuri mkurnalobis xangrZlivoba 6 Tvidan 1 wlamde iyo. Tumca, kotrimoqsazolisTvis (TMP_SMX) mkurnalobis kursi 2-dan 5 wlamde darCa efeqtur meTodad 86 , 87 . xangrZlivi mkurnalobis drosac ki, mkurnalobis Sewyveta iwvevs reinfeqcias 3-4 TveSi qalebis daaxloebiT 60%-Si.

trimetoprimi, kotrimoqsazoli an nitrofurantoini jer kidev standartul reJimadaa miRebuli. fosfomicin trometamoli 3g yovel 10 dReSi 6 Tvis manZilze ganixileba alternatiul meTodad 88 (IB).

27

cxrili #5

morecidive, gaurTulebeli sgi profilaqtikuri mkurnaloba qalebSi

preparati Ddoza

standartuli reJimi

nitrofurantoini 50 mg dReSi (98)

nitrofurantoinis makrokristalebi 100 mg dReSi (101,106)

trimetoprim-sulfametoqsazoli 40/200 mg dReSi (97) an samjer kviraSi (110)

trimetoprimi 100 mg dReSi (103)

fosfomicini 3g/10 dRe (109)

gamwvaveba profilaqtikuri mkurnalobis fonze

ciprofloqsacini 125 mg dReSi (105)

norfloqsacini 200-400 mg dReSi (101,111)

pefloqsacini 800 mg/kviraSi (104)

orsulobis periodSi

cefaleqsini 125 mg dReSi (99)

cefaklori 250 mg dReSi (100)

qalebSi, romlebSic infeqciis epizodis ganviTareba ukavSirdeba sqesobriv aqtivobas, saWiroa mkurnaloba yoveli sqesobrivi aqtis Semdeg 89, 90, 91 (IbA). am SemTxvevaSi, igive preparatebi da igive doziT gamoiyeneba, rac xangrZlivi mkurnalobisas.

alternatiuli profilaqtikuri meTodebi: Sardis acidifikacia (gamJavianeba) 92 , StoSis wvenis miReba 93 , simindis ulvaSis nayenis

miReba da vaginalurad laqtobacilis 94 , 95 gamoyeneba sxvadasxva

efeqturobiT xasiaTdeba. diurezis gazrda siTxis Warbi miRebiT zogierT pacientSi SeiZleba efeqturi iyos. qalebs unda erCioT moSardon yoveli sqesobrivi aqtis Semdeg. imunoTerapia (IaB) da probiotikuli Terapia (IIa C) naklebad efeqturia, vidre antibiotikoTerapia.

28

7. reabilitacia / meTvalyureoba

mwvave cistitis mkurnalobis Semdgomi meTvalyureoba: rutinuli meTvalyureobisTvis sakmarisia Sardis analizi (mag; dipstick meTodi). mkurnalobis Semdeg asimptomur pacientebSi baqteriologiuri kvleva ar aris mizanSewonili, vinaidan asimptomuri baqteriuriis mkurnaloba aucilebelia mxolod orsulebSi, urologiuri Carevisa da operaciis win. im qalebSi, romlebSic simptomebi ar alagdeba mkurnalobis bolos an alagdeba da ganmeirebiT iCens Tavs 2 kviris manZilze, unda Catardes Sardis baqteriologiuri kvleva mgrZnobelobiT. am SemTxvevaSi igulisxmeba, rom gamoyenebuli preparatisadmi gamomwvevi ar iyo mgrZnobiare da saWiroa sxva preparatiT 7 dRiani mkurnalobis kursis Catareba (IV C).

mwvave cistitis mkurnalobis Semdgomi meTvalyureoba orsulebSi:

mkurnalobis Semdeg saWiroa Sardis baqteriologiuri kvleva baqteriebis eradikaciis dasadastureblad. am SemTxvevaSic, iseve rogorc araorsulebSi, ar aris sasargeblo xangrZlivi droiT profilaqtika, garda morecidive infeqciisa. dabali doziT cefaleqsini (125-250 mg) an nitrofurantoini (50 mg) Zilis win rekomendebulia reinfeqciis profilaqtikisaTvis, loginobis xanis CaTvliT, Tu aris amis Cveneba. postkoitaluri profilaqtika

alternatiuli midgomaa 96, 97 (IIaB).

mwvave pielonefritis mkurnalobis Semdgomi meTvalyureoba premenopauzis periodis araorsul qalebSi:

mkurnalobis Semdgomi Sardis baqteriologiuri kvleva ar aris rutinuli meTodi asimptomur pacientebSi. sakmarisia Sardis analizi dipstick meTodiT. qalebSi, romelTac mkurnalobidan 3 dReSi ar aReniSnebaT mdgomareobis gaumjobeseba an simptomebi qreba da 2 kviraSi kvlav Cndeba, saWiroa Sardis ganmeorebiTi baqteriologiuri kvleva, antibaqteriologiuri mgrZnobelobis gansazRvra da sxva kvlevebis Catareba: Tirkmlebis ultrabgera da skanireba. pacientebSi urologiuri anomaliis gareSe unda CaiTvalos rom infeqciuri agenti ar iyo mgrZnobiare antibiotikisadmi da ganmeorebiTi mkurnalobis kursi Catardes sxva preparatiT 2 kviris manZilze. xolo im pacientebSi, romlebSic recidivi paTogenis igive StamiT xdeba, saWiroa mkurnalobis ufro xangrZlivi kursi.

mkurnalobis Semdgomi meTvalyureoba mamakacebSi:

im mamakacTa urologiuri Semowmeba, romelTac mxolod erTxel aReniSnebodaT gaurTulebeli sgi ar aris aucilebeli. urologiuri Sefaseba rutinulad tardeba mozardebsa da mamakacebSi febriluri sgi-iT, pielonefritiTa da morecidive

29

infeqciiT, agreTve, rodesac savaraudoa garTulebis xelSemwyobi faqtoris arseboba (III B).

8. eTikur-samarTlebrivi sakiTxebi

sgi marTva samedicino eTikis principebis dacviT unda ganxorcieldes. mniSvnelovania pacientis avtonomiis dacva da pacientis Tanamonawileoba problemis gadaWris gzebis Ziebisas.

9. praqtikaSi adaptaciis da protokolis

SemuSavebis rekomendaciebi

gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi

donori organizaciebis, dargobrivi asociaciebis, Sjsd saministros Tanadgoma da finansuri mxardaWera.

diplomamdeli da diplomisSemdgomi ganaTlebis umaRlesi saswavleblebis mxardaWera saswavlo programebSi gaidlainis CarTvis sakiTxSi.

mosalodneli barierebi gaidlainis danergvis procesSi

damkvidrebuli praqtika da tradiciebi samedicino personals Soris

klinikuri praqtikis auditis kriteriumebi:

mwvave cistitis mqone ramden pacients Cautarda sam dRiani mkurnalobis kursi?

mwvave pielonefritis mqone ramden pacients Cautarda Svid dRiani mkurnalobis kursi?

ramdeni orsuli iqna Sefasebuli asimptomur baqteriuriaze?

ramden pacientSi iqna daniSnuli pirveli rigis medikamentebi mwvave cistitis samkurnalod?

ramden pacientSi iqna daniSnuli pirveli rigis medikamentebi mwvave pielonefritis samkurnalod?

simptomuri baqteriuriis mqone ramden orsuls Cautarda mkurnaloba?

30

10. gaidlainis gadasinjvis da ganaxlebis vada - 2 weli.

11. gaidlainis miRebis xerxi/wyaro

gaidlaini warmoadgens sxvadasxva gaidlainebis (Guidelines on Urological

Infections M. Grabe (Chairman), M.C. Bishop, T.E. Bjerklund-Johansen,

H. Botto, M. Çek, B. Lobel, K.G. Naber, J. Palou, P. Tenke, F. Wagenlehner 2009 weli) (ix. literatura) Sejerebis da adaptaciis Sedegs.

mtkicebulebis done da rekomendaciebis xarisxi

done mtkicebulebis done xaris-

xi rekomendaciis xarisxi

Ia

mtkicebuleba, romelic eyrdnoba swori dizainis mqone randomizebuli kvlevis meta analizs.

A

eyrdnoba maRali xarisxis klinikur klinikur kvlevebs da sul mcire erT randomizebul kvlevas, mtkiced rekomendebulia.

Ib mtkicebuleba, miRebuli sul mcire erTi randomizebuli kvleviT

B

eyrdnoba sworad Catarebul klinikur kvlevebs randomizaciis gareSe.

IIa

mtkicebuleba eyrdnoba sul mcire erT, swori dizainis mqone kontrolirebad kvlevas randomizaciis gareSe.

C

rekomendebulia, miuxedavad gamoyenebadi maRali xarisxis klinikuri kvlevebis ar arsebobisa.

IIb

mtkicebuleba eyrdnoba sul mcire erT, swori dizainis mqone sxva tipis eqsperimentul kvlevas.

III

mtkicebuleba eyrdnoba swori dizainis mqone, ara-eqsperimentul kvlevebs, rogoricaa SedarebiTi da SemTxveva kontrolis kvlevebi.

IV mtkicebuleba eyrdnoba eqspertTa mosazrebebsa da klinikur gamocdilebas.

31

12. alternatiuli gaidlaini ar arsebobs

13. gamoyenebuli literatura

Guidelines on Urological Infections M. Grabe (Chairman), M.C. Bishop, T.E. Bjerklund-Johansen, H. Botto, M. Çek, B. Lobel, K.G. Naber, J. Palou, P. Tenke, F. Wagenlehner 1 Wilson, ML, Gaido, L. Laboratory diagnosis of urinary tract infections in adult patients. Clin

Infect Dis 2004; 38:1150. 2 Stamm, WE, Wagner, KF, Amsel, R, et al. Causes of the acute urethral syndrome in women. N

Engl J Med 1980; 303:409). 3 Pfaller, MA, Koontz, RP. Laboratory evaluation of leukocyte esterase and nitrite tests for the

detection of bacteriuria. J Clin Microbiol 1985; 21:840. 4 Hurlbut, TA 3rd, Littenberg, B. The diagnostic accuracy of rapid dipstick tests to predict urinary

tract infeciton. Am J Clin Pathol 1991; 96:582. 5 Koeijers, JJ, Kessels, AG, Nys, S, et al. Evaluation of the nitrite and leukocyte esterase activity

tests for the diagnosis of acute symptomatic urinary tract infection in men. Clin Infect Dis 2007;

45:894. 6 Kass EH. Bacteriuria and pyelonephritis of pregnancy. Arch Intern Med 1960;105:194-8.

http://www.ncbi.nlm.nih.gov/pubmed/14404662 7 Stenqvist K, Dahlen-Nilsson I, Lidin-Janson G, Lincoln K, Oden A, Rignell S, Svanborg-Eden

C.Bacteriuria in pregnancy. Frequency and risk of acquisition. Am J Epidemiol 1989;129(2):372-

http://www.ncbi.nlm.nih.gov/pubmed/2912046 8

Gilstrap LC 3rd, Cunningham FG, Whalley PJ. Acute pyelonephritis in pregnancy: a

anterospective study. Obstet Gynecol 1981;57(4):409-13.

http://www.ncbi.nlm.nih.gov/pubmed/7243084 9 Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection.

Infect DisClin North Am. 1997;11:(3)551-81.

http://www.ncbi.nlm.nih.gov/pubmed/9378923. Kahlmeter G; ECO.SENS. An international

survey of the antimicrobial susceptibility of pathogens from 10

uncomplicated urinary tract infections: the ECO.SENS Project. J Antimicrob Chemother

2003;51(1):69-76. http://www.ncbi.nlm.nih.gov/pubmed/12493789 11

Stamm WE. Urinary tract infections in young men. In: Bergan T (ed). Urinary tract infections.

Basel, Switzerland: Karger, 1997;pp.46-47.

http://content.karger.com/ProdukteDB/produkte.asp?Doi=61396 12

Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with

recurrent urinary tract infections. N Engl J Med 1993;329(11):753-6.


Pfau A, Sacks T. The bacterial flora of the vaginal vestibule, urethra and vagina in the normal

premenopausal woman. J Urol 1977;118(2):292-5.


Privette M, Cade R, Peterson J, Mars D. Prevention of recurrent urinary tract infections in

postmenopausal women. Nephron 1988;50(1):24-7.


prophylactic treatment of recurrent urinary tract infections in postmenopausal women. Scand J

Primary Health Care 1992;10(2):139-42.

http://www.ncbi.nlm.nih.gov/pubmed/1641524


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16

Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with

recurrent urinary tract infections. N Engl J Med 1993;329(11):753-6.

http://www.ncbi.nlm.nih.gov/pubmed/8350884 17 Wilson, ML, Gaido, L. Laboratory diagnosis of urinary tract infections in adult patients.

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15. avtorTa jgufi

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avtorebi:

guram kiknaZe, nino gelaSvili, givi javaSvili (redaqtori).

eqspertebi:

zaza Wanturaia _ saqarTvelos urologTa asociacia, saojaxo medicinis profesionalTa kavSiri

saqarTvelos saojaxo medicinis profesionalTa kavSiri;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tamar ZagniZe _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti.

sasarde sistemis infeqciis martva mozrdil pacientebsi pirvelad … · 2017. 6. 5. · gamoyenebuli...

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