Diabetic nephropathy as a complication of diabetes mellitus. Treatment of diabetic nephropathy A new drug for the treatment of diabetic nephropathy

Diabetes is a silent killer, regularly elevated sugar levels have little effect on well-being, so many diabetics do not pay special attention to periodically high numbers on the glucometer. As a result, the health of most patients after 10 years is undermined due to the consequences of high sugars. So, kidney damage and a decrease in their functionality, diabetic nephropathy, is diagnosed in 40% of diabetic patients who take insulin, and in 20% of cases - in those who drink hypoglycemic agents. Currently, this disease is the most common cause of disability in diabetes mellitus.

Reasons for the development of nephropathy

The kidneys filter our blood from toxins around the clock, during the day it is cleared many times. The total volume of fluid entering the kidneys is about 2 thousand liters. This process is possible due to the special structure of the kidneys - they are all permeated with a network of microcapillaries, tubules, and vessels.

First of all, accumulations of capillaries into which blood enters suffer from high sugar. They are called renal glomeruli. Under the influence of glucose, their activity changes, the pressure inside the glomeruli increases. The kidneys begin to work in an accelerated mode, proteins enter the urine, which now do not have time to be filtered. Then the capillaries are destroyed, connective tissue grows in their place, and fibrosis occurs. The glomeruli either completely stop their work, or significantly reduce their productivity. Renal failure occurs, urine output decreases, intoxication of the body increases.

In addition to the increase in pressure and destruction of blood vessels due to hyperglycemia, sugar also affects metabolic processes, causing a number of biochemical disorders. Glycosylated (react with glucose, candied) proteins, including those inside the renal membranes, the activity of enzymes increases, which increase the permeability of the walls of blood vessels, and the formation of free radicals increases. These processes accelerate the development of diabetic nephropathy.

In addition to the main cause of nephropathy - an excessive amount of glucose in the blood, scientists identify other factors that affect the likelihood and rate of development of the disease:

• genetic predisposition. It is believed that diabetic nephropathy appears only in individuals with genetic prerequisites. In some patients, there are no changes in the kidneys even with a long absence of compensation for diabetes mellitus;
• high blood pressure;
• infectious diseases of the urinary tract;
• obesity;
• male gender;
• smoking.

Symptoms of DN

Diabetic nephropathy develops very slowly, for a long time this disease does not affect the life of a diabetic patient. Symptoms are completely absent. Changes in the glomeruli of the kidneys begin only after a few years of life with diabetes. The first manifestations of nephropathy are associated with mild intoxication: lethargy, nasty taste in the mouth, poor appetite. The daily volume of urine increases, urination becomes more frequent, especially at night. The specific gravity of urine decreases, a blood test shows low hemoglobin, elevated creatinine and urea.

At the first sign, contact a specialist so as not to start the disease!

Symptoms of diabetic nephropathy increase as the stage of the disease increases. Obvious, pronounced clinical manifestations occur only after 15-20 years, when irreversible changes in the kidneys reach a critical level. They are expressed in high pressure, extensive edema, severe intoxication of the body.

Classification of diabetic nephropathy

Diabetic nephropathy refers to diseases of the genitourinary system, ICD-10 code N08.3. It is characterized by renal insufficiency, in which the glomerular filtration rate (GFR) decreases.

GFR underlies the division of diabetic nephropathy into stages of development:

1. With initial hypertrophy, the glomeruli become larger, the volume of filtered blood increases. Sometimes there may be an increase in the size of the kidneys. There are no external manifestations at this stage. Analyzes do not show an increased amount of proteins in the urine. GFR >
2. The appearance of changes in the structures of the glomeruli is observed several years after the onset of diabetes mellitus. At this time, the glomerular membrane thickens, the distance between the capillaries increases. After exercise and a significant increase in sugar, protein in the urine can be determined. GFR falls below 90.
3. The onset of diabetic nephropathy is characterized by severe damage to the vessels of the kidneys, and as a result, a constant increase in the amount of protein in the urine. In patients, pressure begins to rise, at first only after physical labor or exercise. GFR falls sharply, sometimes up to 30 ml/min, indicating the onset of chronic renal failure. Prior to this stage at least 5 years. All this time, changes in the kidneys can be reversed with proper treatment and strict adherence to the diet.
4. Clinically significant DN is diagnosed when changes in the kidneys become irreversible, protein in the urine is detected > 300 mg per day, GFR< 30. Для этой стадии характерно высокое артериальное давление, которое плохо снижается лекарственными средствами, отеки тела и лица, скопление жидкости в полостях тела.
5. Terminal diabetic nephropathy is the last stage of this disease. The glomeruli almost cease to filter urine (GFR< 15), в крови растут уровни холестерина, мочевины, падает гемоглобин. Развиваются массивные отеки, начинается тяжелая интоксикация, которая поражает все органы. Предотвратить смерть больного на этой стадии диабетической нефропатии могут только регулярный диализ или трансплантация почки.

General characteristics of the stages of DN

Diagnosis of nephropathy

The main thing in the diagnosis of diabetic nephropathy is to detect the disease at the stages when the kidney dysfunction is still reversible. Therefore, diabetics who are registered with an endocrinologist are prescribed tests once a year to detect microalbuminuria. With the help of this study, it is possible to detect protein in the urine, when it is not yet determined in the general analysis. The analysis is prescribed annually 5 years after the onset of type 1 diabetes and every 6 months after the diagnosis of type 2 diabetes.

If the protein level is higher than normal (30 mg / day), a Reberg test is performed. With its help, it is assessed whether the renal glomeruli are functioning normally. For the test, the entire volume of urine that the kidneys produced per hour (as an option, the daily volume) is collected, and blood is also taken from a vein. Based on data on the amount of urine, the level of creatinine in the blood and urine, the level of GFR is calculated using a special formula.

To distinguish diabetic nephropathy from chronic pyelonephritis, general urine and blood tests are used. With an infectious kidney disease, an increased number of blood leukocytes and bacteria in the urine is found. Renal tuberculosis is distinguished by the presence of leukocyturia and the absence of bacteria. Glomerulonephritis is differentiated on the basis of an x-ray examination - urography.

The transition to the next stages of diabetic nephropathy is determined on the basis of an increase in albumin, the appearance of protein in the OAM. The further development of the disease affects the level of pressure, significantly changes blood counts.

If changes in the kidneys occur much faster than the average numbers, the protein grows strongly, blood appears in the urine, a kidney biopsy is performed - a sample of kidney tissue is taken with a thin needle, which makes it possible to clarify the nature of the changes in it.

Drugs to lower blood pressure in diabetes

At stage 3, hypoglycemic agents can be replaced with those that will not accumulate in the kidneys. At stage 4, type 1 diabetes usually requires an adjustment in insulin. Due to poor kidney function, it takes longer to be removed from the blood, so less is needed now. At the last stage, the treatment of diabetic nephropathy consists in detoxifying the body, increasing the level of hemoglobin, replacing the functions of non-functioning kidneys through hemodialysis. After stabilization of the state, the question of the possibility of transplantation with a donor organ is being considered.

In diabetic nephropathy, anti-inflammatory drugs (NSAIDs) should be avoided, as they worsen kidney function if taken regularly. These are such common medicines as aspirin, diclofenac, ibuprofen and others. Only a doctor who is informed of the patient's nephropathy can treat with these drugs.

There are some peculiarities in the use of antibiotics. For the treatment of bacterial infections in the kidneys in diabetic nephropathy, highly active agents are used, the treatment is longer, with the obligatory control of creatinine levels.

The need for a diet

Treatment of nephropathy in the initial stages largely depends on the content of nutrients and salt that enter the body with food. The diet for diabetic nephropathy is to limit the intake of animal proteins. Proteins in the diet are calculated depending on the weight of the patient with diabetes - from 0.7 to 1 g per kg of weight. The International Diabetes Federation recommends that the calorie content of proteins should be 10% of the total nutritional value of food. It is also worth reducing the amount of fatty foods in order to lower cholesterol and improve the functioning of blood vessels.

Nutrition for diabetic nephropathy should be six times a day so that carbohydrates and proteins from dietary food enter the body more evenly.

Allowed products:

1. Vegetables are the basis of the diet, they should make up at least half of it.
2. Berries and fruits with low GI are allowed only for breakfast.
3. Of the cereals, buckwheat, barley, yachka, brown rice are preferred. They are put in the first courses and used as part of side dishes along with vegetables.
4. Milk and dairy products. Butter, sour cream, sweet yoghurts and curds are contraindicated.
5. One egg per day.
6. Legumes as garnishes and in soups in limited quantities. Plant protein is safer for dietary nephropathy than animal protein.
7. Lean meat and fish, preferably 1 time per day.

Starting from stage 4, and if there is hypertension, then even earlier, salt restriction is recommended. They stop adding salt to food, exclude salted and pickled vegetables, mineral water. Clinical studies have shown that reducing salt intake to 2 g per day (half a teaspoon) reduces pressure and swelling. To achieve such a reduction, you need not only to remove salt from your kitchen, but also to stop buying ready-made convenience foods and bread products.

• High sugar is the main cause of the destruction of the vessels of the body, so it is important to know -.
• - if they are all studied and eliminated, then the appearance of various complications can be postponed for a long time.

Diabetic nephropathy is a complex of disorders of the functional functioning of the kidneys in diabetes mellitus. It is accompanied by damage to the circulatory system in the tissues of the glomeruli and tubules of the kidneys, leading to chronic renal failure.

Kidney nephropathy in diabetes develops gradually and is rather a general term for various kinds of diseases of this organ, from a violation of its basic functions, to some external damage to tissues, the vascular system, and other things.

The validity of this decision lies in the fact that with an elevated blood sugar level, a cellular disruption of many vital systems of the body occurs, which, like a chain reaction, provokes the development of multiple complications that, of course, affect cardiovascular activity. Hence arterial hypertension, which provokes pressure surges, passively regulating the filtering ability of the kidneys.

If a diabetic has problems with the kidneys, then this will be indicated by the results of a blood test for creatinine and which must be systematically taken in a planned manner once a month, and if there are serious disorders, more often.

The fundamental factor that is the foundation of the further well-being of a diabetic is normoglycemia!

That is why blood glucose monitoring is so important in the success of the treatment of endocrine disease. For the treatment of almost all, the achievement of stable glycemic compensation is the key to the health of a diabetic.

So with nephropathy, the main factor that triggers its progression is an increased level of sugar in the blood. The longer it is kept, the higher the chance of developing various kidney problems that will lead to chronic kidney failure (according to the new standards of 2007 - chronic kidney disease).

The higher the hyperglycemia, the higher the hyperfiltration.

Unused glucose in the blood is toxic and literally poisons the entire body. It damages the walls of blood vessels, increasing their permeability. Therefore, when diagnosing, special attention is paid not only to the biochemical parameters of urine and blood, but also to monitor blood pressure.

Very often, the development of the disease occurs against the background when the peripheral nervous system of the body is affected. Affected vessels are converted into scar tissue, which is unable to perform basic tasks. Hence all the problems with the kidneys (difficulty urinating, poor filtration, blood purification, frequent infections of the genitourinary system, etc.).

Along with impaired carbohydrate metabolism in diabetes, there are often problems with lipid metabolism, which also adversely affects the patient's health. The problem of obesity becomes the root cause of the development that develops against the background. All this together leads to diabetes mellitus, atherosclerosis, kidney problems, blood pressure, disorders in the central nervous system and cardiovascular system, etc. It is not surprising that when making a diagnosis, diabetics also have to take and, on the basis of which one can judge the quality of the treatment provided.

Thus, the main reasons for the development of neuropathy:

• hyperglycemia
• obesity
• metabolic syndrome
• prediabetes
• elevated blood cholesterol (including triglycerides)
• signs of anemia (with a decrease in hemoglobin concentration)
• hypertension (or arterial hypertension)
• bad habits (especially smoking,)

Signs and symptoms

The symptomatic picture is rather blurred, and all because diabetic nephropathy does not manifest itself at the initial stage.

A person who has lived with diabetes for 10 or more years may not notice any unpleasant symptoms. If he notices the manifestations of the disease, then only when the disease has developed into renal failure.

Therefore, in order to talk about some symptomatic manifestations, it is worth distinguishing them according to the stages of the disease.

Stage I - hyperfunction of the kidneys or hyperfiltration.

What is it?

Clinically, it is quite difficult to determine, because the cells of the renal vessels increase somewhat in size. There are no external signs. There is no protein in the urine.

II stage - microalbuminuria

It is characterized by thickening of the walls of the vessels of the kidneys. The excretory function of the kidneys is still normal. After passing the urine test, the protein may still not be detected. It usually occurs 2 to 3 years after diagnosing diabetes.

III stage - proteinuria

After 5 years, "rudimentary" diabetic nephropathy may develop, for which the main symptom is microalbuminuria, when a certain amount of protein elements (30 - 300 mg / day) is detected in the urine test. This indicates significant damage to the renal vessels and the kidneys begin to filter urine poorly. There are problems with blood pressure.

This is manifested as a result of a decrease in glomerular filtration (GFR).

However, we note that a decrease in GFR and an increase in albuminuria at an early stage of the development of the disease are separate processes and cannot be used as a diagnostic factor.

If the pressure increases, then the glomerular filtration rate is somewhat increased, but as soon as the vessels are severely damaged, the filtration rate drops sharply.

Until the third stage (inclusive) of the development of the disease, all the consequences of its impact are still reversible, but it is very difficult to make a diagnosis at this stage, since the person does not feel any discomfort, therefore, he will not go to the hospital for "nothing" (given that the tests in generally remain normal). The disease can be detected only through special laboratory methods or through a kidney biopsy, when a part of the organ is taken for analysis. The procedure is very unpleasant and quite expensive (from 5,000 rubles and more).

Stage IV - severe nephropathy with symptoms of nephrotic syndrome

Comes after 10 - 15 years lived with diabetes. The disease manifests itself quite clearly:

• excessive excretion of protein in the urine (proteinuria)
• decrease in blood protein
• multiple edema of the extremities (first in the lower extremities, on the face, then in the abdominal, chest cavities and myocardium)
• headache
• weakness
• drowsiness
• nausea
• loss of appetite
• intense thirst
• high blood pressure
• heartache
• severe shortness of breath

Since there is less protein in the blood, a signal is received to compensate for this condition due to the processing of its own protein components. Simply put, the body begins to destroy itself, cutting out the necessary structural elements in order to normalize the protein balance of the blood. Therefore, it is not surprising that a person begins to lose weight with diabetes, although before that he suffered from excess weight.

But the volume of the body still remains large due to the ever-increasing swelling of the tissues. If earlier it was possible to resort to help (diuretics) and remove excess water, then at this stage their use is ineffective. The fluid is removed surgically by puncture (a needle is punctured and the fluid is artificially removed).

Stage V - renal failure (kidney disease)

The final, terminal stage is already renal failure, in which the renal vessels are completely sclerosed, i.e. a scar is formed, the organ parenchyma is replaced by a dense connective tissue (renal parenchyma). Of course, when the kidneys are in this state, a person is in danger of death, unless more effective methods are used, since the glomerular filtration rate drops to critically low rates (less than 10 ml / min) and blood and urine purification is practically not carried out.

Renal replacement therapy includes several types of techniques. It consists in peritoneal dialysis, hemodialysis, in which the compensation of minerals, water in the blood, as well as its actual purification (removal of excess urea, creatinine, uric acid, etc.) is carried out. Those. everything that the kidneys are no longer able to do is done artificially.

That is why it is also called more simply - "artificial kidney". To understand whether the technique used in the treatment is effective, they resort to the derivation of the urea coefficient. It is by this criterion that one can judge the effectiveness of therapy to reduce the perniciousness of metabolic nephropathy.

If these methods do not help, then the patient is put on a waiting list for a kidney transplant. Very often, diabetics have to transplant not only a donor kidney, but also “replace” the pancreas. Of course, there is a high risk of mortality during and after the operation if the donor organs do not take root.

Diagnostics

As we have already mentioned, diagnosing the disease in the early stages is an extremely difficult task, since it is asymptomatic and it is impossible to notice changes in the analyzes.

Therefore, indicative signs are the presence of albuminuria in the patient's urine (increased excretion of albumin (a simple protein soluble in liquid) and a decrease in glomerular filtration rate, which manifest themselves in the last stages of diabetic nephropathy, when kidney disease is already diagnosed.

There are less effective methods of rapid tests using test strips, but they give quite frequent false results, therefore, they resort to using several analyzes at once, taking into account the albumin excretion rate (SEA) and the albumin / creatinine ratio (Al / Cr), which for completeness the pictures are repeated after a few months (2 - 3 months).

Albuminuria in the presence of kidney disease

In nephrotic syndrome, albumin excretion is usually >2200 mg/day and Al/Cr >2200 mg/g or >220 mg/mmol.

There is also a change in urinary sediment, tubular dysfunction, histological changes, structural changes in visual research methods, glomerular filtration rate < 60 ml / min / 1.73m 2 (its definition indirectly indicates the presence of nephropathy and reflects an increase in pressure in the renal vessels).

An example of a diagnosis

A 52-year-old woman with type 2 diabetes mellitus, controlled arterial hypertension, chronic heart failure, according to the results of tests: HbA1c - 8.5%, Al from 22 g / l, 6 months SEB 4-6 g / day, GFR 52 ml / min /1.73m2.

Diagnosis: Diabetes mellitus type 2. diabetic nephropathy. nephrotic syndrome. Stage III arterial hypertension, risk 4. Target HbA1c<8.0%. ХБП С3а А3.

Treatment

Treatment of diabetic nephropathy consists of several stages, among which the achievement of stable compensation for diabetes mellitus and glycemia, reduction, and prevention of cardiovascular diseases stand apart.

If there are already signs of microalbuminuria, it is recommended to switch to a special diet with limited protein intake.

If there are all signs of proteinuria on the face, then the main task is to slow down the development of kidney disease as much as possible and severe restriction of protein foods (0.7 - 0.8 g of protein per 1 cell of body weight) is introduced. With such low volumes of food proteins, in order to prevent the compensatory breakdown of one's own biological protein, for example, ketosteril is prescribed.

They also continue to monitor blood pressure, which, if necessary, is controlled by medication.

Diuretics such as furosemide, indapamide are prescribed to reduce swelling. When taking diuretics, it is important to monitor the amount of water you drink to prevent dehydration.

Upon reaching GFR<10 мл/мин прибегают к помощи более жестких мер с заместительной почечной терапией. Однако при такой терминальной стадии нефропатии лучшим выходом из ситуации по спасению жизни пациента является пересадка не только почки, но и поджелудочной железы. Такие операции стоят крайне дорого, и в России (в рамках государственной программы) нет специализированных центров, которые бы проводили подобные операции.

But do not forget that you need to radically change your lifestyle! Give up smoking, alcohol, increase physical activity. You don't have to sign up for a gym. It is enough to devote 30 minutes a day of your free time to simple exercises that you will repeat 5 times a week.

Be sure to review the diet and sign up for a consultation with a nutritionist who will recommend not only reducing the amount of protein foods, but also reducing the amount of salt, phosphates, and potassium to prevent swelling.

Medical treatment

Drugs used in the treatment of diabetic nephropathy are most often prescribed together with other drugs as part of combined antihypertensive therapy, since along with type 1 and type 2 diabetes, there are often other diseases such as arterial hypertension, cardiovascular complications, neuropathy, etc. d.

Do not take any medications without consulting a doctor!

Drugs that have a nephroprotective effect

During pregnancy, many women are frightened by the results of the tests, since the main diagnostic indicator of nephropathy (glomerular filtration rate) is several times higher than normal. This happens due to the fact that the female body during the bearing of a child undergoes a lot of changes and begins to work, as they say, for two. Consequently, the excretory function of the kidneys also increases due to the increasing load on the heart, which distills twice as much blood.

Therefore, during normal pregnancy, GFR and blood flow in the kidneys increase by an average of 40-65%. In an uncomplicated pregnancy (without, for example, metabolic abnormalities and infections of the genitourinary system), hyperfiltration is not associated with renal (renal) damage and, as a rule, after the birth of a baby, the glomerular filtration rate quickly returns to normal.

If you find an error, please select a piece of text and press Ctrl+Enter.

Diabetes negatively affects the immune system, so the patient gets sick more often. Antibiotics for diabetes are used in extreme cases when antimicrobial treatment is needed. The immune barrier is reduced, so the patient's body reacts to all pathogenic viruses. The appointment of such serious drugs is done exclusively by the doctor, with disturbed metabolic processes, the effect is the opposite of the expected one or is not achieved at all.

When are antibiotics used?

The body of a diabetic is vulnerable, so the infection can affect any part of the body. When diagnosing a disease, immediate intervention is required. More often, antibiotics are prescribed in the presence of such pathologies:

• dermatological diseases;
• infections in the urinary system;
• diseases of the lower respiratory tract.

First of all, the effect occurs on organs with an increased load. The kidneys do not cope with their functions by 100%, so infectious lesions can lead to nephropathy. Antibiotics and diabetes mellitus are concepts that are combined with caution. Appointment occurs in extreme cases, when there is a risk of developing hypoglycemia. The acute course of the disease should take place under the supervision of a doctor in a hospital.

Respiratory tract pathologies

Antibiotics for type 2 diabetes are prescribed according to the standard scheme. The cause is bronchitis or pneumonia. X-ray monitoring is regularly carried out, since the course of the disease is complicated by an initially weakened immune system. In the treatment, protected penicillins are used: Azithromycin, Grammidin in combination with symptomatic therapy. Before use, carefully study the instructions, pay attention to the sugar content. With high blood pressure, antibiotics with a decongestant effect are prohibited. Combine reception with probiotics and dietary supplements that preserve the microflora and prevent adverse reactions, especially in type 1 diabetics.

Skin infections

To eliminate symptoms, diabetics should pay attention to the level of sugar, as a high level prevents healing and blocks the action of antibiotics. The most common infectious diseases of the skin:

• furunculosis and carbuncle;
• necrotizing fasciitis.

diabetic foot

When treating a diabetic foot, you need to prepare for a long and painful healing process. Bleeding ulcer formations are formed on the extremities, which are divided into 2 groups of severity. For diagnosis, samples are taken from the detachable sequester, an X-ray of the foot is performed. Antibiotics for diabetic foot are prescribed topical and oral. If there is an increased risk of limb amputation, for outpatient treatment are used: "Cefalexin", "Amoxicillin". Medications can be combined with a complex course of the disease. Course treatment is carried out for 2 weeks. The therapy is carried out in a complex and consists of several stages:

• compensation for diabetes;
• reduction in the load of the lower extremities;
• regular treatment of wounds;
• limb amputation with purulent-necrotic lesions, otherwise death.

Treatment of furunculosis and fasciitis

Furunculosis and carbuncle are recurrent diseases. The inflammatory process is localized on the scalp. Occurs in violation of carbohydrate metabolism and non-compliance with a therapeutic diet, accompanied by purulent-necrotic wounds in the deep layers of the skin. Antibacterial treatment: "Oxacillin", "Amoxicillin", the course of treatment is 1-2 months.

With necrotizing fasciitis, immediate hospitalization is required, as there is a high risk of infection spreading throughout the body. The soft tissues of the shoulder, anterior thigh, and abdominal wall are affected. Treatment is carried out in a complex manner, antibiotic therapy is only an addition to surgical intervention.

Diabetes mellitus (DM) is one of the most common chronic endocrine diseases. It is generally accepted to combine changes in the feet in patients with DM into DIABETIC FOOT SYNDROME (DFS), which is a complex of anatomical and functional changes in the foot caused by diabetic neuropathy, angiopathy, osteo- and arthropathy, complicated by the development of purulent-necrotic processes. The frequency of amputations in patients with DM is 40 times higher than among other groups with non-traumatic injuries of the lower extremities. Meanwhile, adequate and timely treatment of SDS in 85% of cases allows avoiding a mutilation operation.

Given the need to unify the infection in patients with DFS, a classification is currently widely used that combines various clinical manifestations of the process in accordance with the severity of the disease.

Etiology of infection in diabetic patients

The depth of the lesion, the severity of the disease and the previous use of antibiotics affect the nature of the infection in patients with DFS. Aerobic gram-positive cocci that colonize the skin are the first to contaminate a wound or skin defects. S. aureus and beta-hemolytic streptococci of groups A, C and C are most often sown in patients with infectious complications on the background of DFS. Long-term ulcers and their accompanying infectious complications are characterized by a mixed microflora, consisting of gram-positive cocci (staphylococci, streptococci, enterococci), representatives of Enterobacteriaceae, obligate anaerobes and, in some cases, non-fermenting gram-negative bacteria (Pseudomonas spp., Acinetobacter spp.). In patients repeatedly treated in the hospital with broad-spectrum antibiotics and subjected to surgical interventions, multi-resistant strains of pathogens, in particular, methicillin-resistant staphylococci, enterococci, non-fermenting gram-negative bacteria, and enterobacteria, are often sown.

Often infectious lesions of the feet are caused by microorganisms with low virulence, such as coagulase-negative staphylococci, diphtheroids. It is noted that acute forms of infections are caused mainly by gram-positive cocci; polymicrobial associations, which include 3-5 pathogens, are isolated mainly in chronic processes. Streptococci, S. aureus and enterobacteria predominate among aerobes (Proteus spp., Escbericbia coli, Klebsiella spp., Enterobacter spp.); in 90% of cases, the microbial landscape in SDS is supplemented by anaerobes.

General principles of treatment of patients with SDS

Currently, there are the following indications for hospitalization of patients with SDS:

• systemic manifestations of infection (fever, leukocytosis, etc.),
• the need to correct glucose levels, acidosis;
• rapidly progressive and / or deep infection, areas of necrosis on the foot or gangrene, clinical signs of ischemia;
• the need for urgent examination or intervention;
• inability to independently follow doctor's orders or home care.

Normalization of the metabolic status is the basis for further successful therapy of patients with DFS. It is supposed to restore the water-salt balance, correct hyperglycemia, hyperosmolarity, azotemia and acidosis. Of particular importance is the stabilization of homeostasis in severely ill patients who require emergency or urgent surgery. A vicious circle is known in patients with diabetes: hyperglycemia supports the infectious process; normalization of glucose levels contributes to the speedy relief of manifestations of infection and eradication of pathogens; at the same time, rational treatment of infection contributes to easier correction of blood sugar. Most patients with foot infections due to DFS require antibiotic therapy.

Surgical interventions are one of the defining methods of treating infection in patients with DFS. The task of the surgeon is to choose an operative tactic based on clinical data and the form of infection. Options for surgical interventions can be very different: from surgical treatment and drainage of foci to operations on blood vessels and nerve trunks. Purulent foci located in the deep layers of soft tissues, fascia damage can be the cause of secondary ischemia.

Characteristically, early surgical debridement in some cases makes it possible to avoid mutilating operations or amputations of the lower extremities at a more proximal level. In patients without severe systemic signs of infection and limited involvement, with a stable metabolic status, delayed debridement is warranted; in the preoperative period, it is possible to conduct a full range of examinations, determine the scope of the operation (necrectomy, revascularization operations). Taking into account the peculiarities of the course of the wound process in patients with DM, the surgeon needs to assess the degree of tissue vascularization and the depth of lesions in order to determine the methods of wound closure or the level of amputation.

Very often, in patients with SDS, surgical treatment has several stages. The most careful attention should be paid to the course of the wound process and wound care in patients with SDS. The goal of daily debridement is limited necrectomy, with a surgical technique using scalpel and scissors being preferred over applications of chemical and biological agents. Mandatory dressings, preferably wet, with the conditions of daily dressings and medical control of the condition of the wound; it is also necessary to unload the affected areas of the foot.

Among other methods, a number of innovations are currently proposed, such as topical application of recombinant growth factor, dressings with antibiotics and the latest antiseptics, vacuum wound drainage systems or "artificial skin".

Antibacterial therapy in patients with diabetes mellitus

The most important element of the complex treatment of patients with SDS is rational antibiotic therapy. The drug and dosing regimen, method and duration of antibiotic administration are selected based on clinical data or microbiological data. Taking into account the pharmacokinetics of the antibiotics used is an important element in the preparation of a future treatment regimen. Thus, for cephalosporin antibiotics, the difference in distribution in the tissues of healthy and affected limbs in patients with DFS has not been proven. Attention deserves the need to adjust the doses and regimens of antibiotic therapy in patients with diabetes and diabetic nephropathy. Therapy with nephrotoxic antibiotics in such patients is highly undesirable.

Antimicrobial therapy is indicated for all patients with DFS and infected foot wounds, however, systemic or topical antibiotics do not replace careful debridement and daily care of the lesion.

For patients with mild and, in some cases, moderate course of acute forms of infections, the use of antibiotics active against gram-positive cocci is considered optimal. In the absence of severe disorders of the gastrointestinal tract, it is preferable to use oral forms with high bioavailability. With a mild course of infection, amoxicillin / clavulanate, clindamycin, cephalexin per os or parenteral cefazolin are prescribed mainly for cellulitis monotherapy. With a probable or proven gram-negative etiology, it is advisable to use fluoroquinolones (levofloxacin), possibly in combination with clindamycin.

Severe systemic manifestations of infection require hospitalization. In the hospital, parenteral therapy is carried out with cefazolin, oxacillin or, in case of allergy to beta-lactams, clindamycin. At high risk or a proven role for MRSA in the etiology of the disease, vancomycin or linezolid are prescribed (the advantages of the latter are the possibility of stepwise therapy). In cases of severe, as well as for most patients with moderate infection, hospitalization is indicated.

The empirical choice of a drug for initial therapy, especially for long-term, chronic ulcers, should be based on antibiotics with a wide spectrum of activity, which should be administered parenterally at least in the first days of treatment.

When prescribing antibacterial therapy for infections of polymicrobial etiology, there is no need for combinations of antibiotics that are active against all, both identified during microbiological examination, and suspected pathogens. The drugs should be active against the most virulent pathogens: S. aureus, beta-hemolytic streptococci, enterobacteria and some anaerobes. The importance of less virulent bacteria, such as coagulase-negative staphylococci and enterococci, in the development of the infectious process may be small. In patients with widespread cellulitis associated with a superficial ulcer, especially if broad-spectrum antibiotics have been previously used, the likelihood of a polymicrobial etiology of infection is high; it is also impossible not to take into account the resistance of the microflora, which is especially characteristic of gram-negative bacteria and / or staphylococci. Therefore, the appointment of antibiotics with a wide spectrum of action, active not only against aerobes, but also anaerobes, is preferable.

Modern standards based on data from clinical studies suggest the widespread use of cefamycins (cefoxitin, cefotetan), which have good antianaerobic activity.

The development of severe soft tissue infection against the background of a long-term ulcer, purulent-necrotic processes that threaten the viability of the limb in patients with impaired metabolic status is due to polymicrobial aerobic-anaerobic associations. In such cases, inhibitor-protected beta-lactams, the most important of which are cefoperazone / sulbactam (Sulperacef), and carbapenems are the basis of de-escalation antibiotic therapy.

Reserve drugs are third-generation cephalosporins - ceftriaxone, cefotaxime and cefoperazone. These antibiotics are active against gram-negative bacteria, as well as staphylococci and streptococci, but do not act on anaerobic pathogens. Therefore, in the treatment of severe infections, it is recommended to use their combinations with anti-anaerobic antibiotics.

Evaluation of the effectiveness of an empirically chosen regimen should usually be made on days 1 (severe infection) - 3 days. With positive clinical dynamics, empirical therapy is continued for up to 1-2 weeks, depending on the severity of the process. If the initial therapy turned out to be ineffective, and it is not possible to conduct a microbiological study, then antibiotics with a wider spectrum of activity are prescribed (mainly against gram-negative bacteria and anaerobes - cefoperazone / sulbactam, carbapenems) and / or drugs active against MRSA are added. .

When one or more courses of antibiotic therapy in somatically stable patients are ineffective, it is recommended to stop all antibacterial drugs and after 5-7 days to conduct a microbiological study to identify the etiology of the disease.

outcomes

The effectiveness of rational therapy of infections in patients with DFS is, according to various authors, from 80-90% in mild and moderate forms to 60-80% in severe cases and osteomyelitis. The main risk factors for adverse outcomes are systemic manifestations of infection, severe disorders of regional blood flow to the limbs, osteomyelitis, the presence of areas of necrosis and gangrene, unskilled surgical care, and the spread of infection to more proximal segments of the limb. Recurrent infections, with an overall incidence of 20–30%, are typically associated with patients with osteomyelitis.

Literature

1. Akalin H.E. The role of beta-lactam/beta-lactamase inhibitors in the management of mixed infections. IntJ Antimicrobial Agents. 1999; 12 Suppl 1:515-20 Armstrong D.G., Lavery L.A., Harkless L.B. Who is at risk for diabetic foot ulceration? Clin Podiatr Med Surg 1998;15(1):11-9.
2. Bowler P.G., Duerden B.I., Armstrong DG. Wound microbiology and associated approaches to wound management. Clin Microbiol Rev 2001; 14:244-69.
3. Caputo G.M., Joshi N., Weitekamp M.R. foot infections in patients with diabetes. Am Fam Physician 1997 Jul; 56(1): 195-202.
4. Chaytor E.R. Surgical treatment of the diabetic foot. Diabetes Metab Res Rev 2000; 16(Suppl 1):S66-9.
5. Cunha B.A. Antibiotic selection for diabetic foot infections: a review. J Foot Ankle Surg 2000; 39:253-7.
6. EI Tahawy AT. Bacteriology of diabetic foot. Saudi Med J 2000; 21:344-7. Edmonds M., Foster A. The use of antibiotics in the diabetic foot. Am J Surg 2004; 187:255-285.
7. Joseph W.S. Treatment of lower extremity infections in diabetics. Drugs 1991;42(6):984-96.
8. Fernandez-Valencia J.E., Saban T, Canedo T., Olay T. Fosfomycin in osteomyelitis. Chemotherapy 1976; 22:121-134.
9. International Working Group on the Diabetic Foot. International consensus on the diabetic foot. Brussels: International Diabetes Foundation, May 2003.
10. Lipsky B.A., Berendt A.R., Embil J., De Lalla F. Diagnosing and treating daibetic foot infections. Diabetes Metab Res Rev 2004; 20(Suppl 1): S56-64.
11. Lipsky B.A., Berendt A.R., Deery G. et al. Guidelines for Diabetic Foot Infections. CID 2004:39:885-910.
12. Lipsky B.A., Pecoraro R.E., Wheat L.J. The diabetic foot: soft tissue and bone infection. Infect Dis Clin North Am 1990; 4:409-32.
13. Lipsky B.A. Evidence-based antibiotic therapy of diabetic foot infections. FEMSImmunol Med Microbiol 1999; 26:267-76.
14. Lobmann R, Ambrosch A, Seewald M, et al. Antibiotic therapy for diabetic foot infections: comparison of cephalosporins with chinolones. Diabetes Nutr Metab 2004; 17:156-62.
15. Shea K. Antimicrobial therapy for diabetic foot infections /A practical approach. Postgrad Med, 1999, 106(1): 153-69.
16. The Sanford Guide to Antimicrobial Therapy/Thirty-fifths edition. Ed by O. Gilbert, M. Sande. - Antimicrobial Therapy Inc. - 2005.

Infectious complications in patients with "sweet disease" are very common. It is necessary to quickly begin active antimicrobial therapy for the timely elimination of the pathological focus. Many patients are interested in what antibiotics can be used for diabetes.

It should be immediately clarified that the intake of this group of medicines should be carried out only under the supervision of the attending physician and with his appointment. alters the normal metabolic process. In most cases, the effect of the drug may differ from the same in a relatively healthy body.

Few people know about such nuances. Therefore, undesirable side reactions often appear after the use of antimicrobial agents for a "sweet illness".

Antibiotics and diabetes

Before the direct use of drugs, it is necessary to study all the risks that may lie in wait for the patient when using drugs.

These include:

1. Decompensated course of the disease.
2. Elderly age.
3. Already formed late ones (micro- and macroangiopathy, retinopathy, nephro- and neuropathy).
4. Duration of illness (˃10 years).
5. The presence of changes in the work of some components of the immune system and the whole organism as a whole (reduced activity of neutrophils, phagocytosis and chemotaxis).

When the doctor takes into account all these aspects, he will be able to more accurately determine the drug necessary for the patient and prevent a number of undesirable consequences.

Also, do not forget the following important points:

1. Different antibiotics in diabetes mellitus affect the effectiveness of hypoglycemic drugs (and pills that reduce serum glucose) differently. So, sulfonamides and macrolides inhibit enzymes that are responsible for the breakdown of the active substances of drugs. As a result, more active compounds enter the blood, and the effect and duration of their work increases. Rifampicin, on the contrary, inhibits the quality of the effects of hypoglycemic drugs.
2. Microangiopathy leads to sclerosis of small vessels. Therefore, it is advisable to start antibiotic therapy with intravenous injections, and not with injections into the muscles, as usual. Only after saturation of the body with the required dose, you can switch to oral forms of medicines.

When to use antibiotics?

Microorganisms can potentially affect almost all areas of the body.

Most often suffer:

• Urinary system;
• Integuments;
• lower respiratory tract.

Urinary tract infections (UTIs) are caused by the formation of nephropathy. The renal barrier does not cope with its function by 100% and bacteria actively attack the structures of this system.

Examples of UTIs:

• Abscess of the perirenal adipose tissue;
• Pyelonephritis;
• papillary necrosis;
• Cystitis.

Antibiotics for diabetes in this case are attributed to the following principles:

1. The drug should have a broad spectrum of action for initial empiric therapy. While the causative agent is not exactly identified, cephalosporins and fluoroquinolones are used.
2. The duration of treatment for complex forms of UTI is about 2 times longer than usual. Cystitis - 7-8 days, pyelonephritis - 3 weeks.
3. If the patient progresses nephropathy, it is necessary to constantly monitor the excretory function of the kidneys. To do this, regularly measure creatinine clearance and glomerular filtration rate.
4. If there is no effect from the antibiotic used, you need to change it.

Skin and soft tissue infections

Such a lesion most often manifests itself in the form of:

• Furunculosis;
• carbuncle;
• Diabetic foot syndrome;
• Fasciitis.

First of all, to eliminate symptoms, it is necessary to normalize glycemia. It is elevated blood sugar that causes the progression of the disease and slows down the process of regeneration of soft tissues.

Additional principles of therapy remain:

1. Ensuring complete rest and maximum unloading of the injured limb (if we are talking about a diabetic foot).
2. The use of powerful antimicrobials. The most commonly prescribed are 3rd generation cephalosporins, carbapenems, and protected penicillins. The choice of medication depends on the sensitivity of the pathogen and the individual characteristics of the patient. The duration of the course of treatment is not less than 14 days.
3. The use of surgical procedures (removal of dead tissue or drainage of purulent foci).
4. Constant monitoring of vital functions. With the active spread of the process, there may be a question of removing a limb.

Respiratory tract infections

Antibiotics with concomitant pneumonia or bronchitis are prescribed according to the standard scheme of the unified clinical protocol. You should start with protected penicillins (Amoxiclav), further according to the situation. It is important to constantly conduct x-ray monitoring of the condition of the lungs. Additional symptomatic therapy is used.

Prescribing antibacterial drugs for diabetes mellitus requires great attention and care from the doctor. Since microbes are always actively attacking the body of a person with a “sweet disease”, it is worth considering the use of a variety of probiotics and drugs that prevent the death of their own microflora.

With this approach, it will be possible to neutralize the side effects of most aggressive drugs.