Medical-Social Aspects of Prevention of Urinary Tract Infections in Children at the Outpatient-Polyclinic Stage

The dissertation is devoted to the study of the medical-social aspects of the prevention of urinary tract infections in children under conditions of the outpatient-polyclinic link of the health care system. The research encompasses the analysis of the prevalence of diseases of the urinary system organs among the pediatric population, the identification of risk factors influencing the development of renal pathology, and the evaluation of the organization of medical care for children with these diseases. Special attention is given to the medical-social characteristics of families having children with urinary tract infections and to the development of predictive instruments for early diagnosis of the pathology.

The work examines modern medical-social factors contributing to the formation of urinary tract infections in children, including social-hygienic and medical-biological components of risk. A model of continuity between district and specialized services has been proposed, aimed at the optimization of preventive care and rehabilitation of children with kidney pathology. The practical significance of the research consists in the introduction of a predictive table for individual risk and a methodology for assessing the risk of occurrence of urinary tract infections into the practice of pediatricians and nephrologists.

Urinary tract infections constitute an urgent problem, both for nephrology and general pathology [7, 54, 61, 66; 67]. Over the past decade, an increase in the prevalence of this pathology has been observed, particularly among the pediatric population, reaching 30 cases per 1,000 children by the year 2000 [43]. Acute forms of the disease are frequently accompanied by concomitant pathology that is not timely detected and acquires a chronic course. Furthermore, a distinctive feature of urinary tract infections is their latent course, which also contributes to the delay in diagnosis and medical-social assistance. Chronic pathology requires prolonged therapeutic and rehabilitative measures, the insufficient efficacy of which often leads to functional impairments of the kidneys at pediatric age.

Urinary tract infections are a collective concept encompassing the following diseases according to the ICD-10 of 1998: chronic pyelonephritis (N 11) and acute pyelonephritis (N 10) (section: tubulointerstitial kidney diseases), acute cystitis (N 30.1), chronic cystitis (N 30.2), urinary tract infection without established localization (N 39.0) (section: other diseases of the urinary system).

At present, an entire array of etiological factors has been identified (E. Coli, Proteus, Klebsiella, Enterococci, and others). Pathogenetic mechanisms have been thoroughly studied, in which significant importance is attributed to membrane-pathological processes, in particular: processes of lipid peroxidation, activity of endogenous phospholipases, and antioxidant deficiency. These issues are addressed in the works of N. I. Kazenko, 1990; V. I. Krylov, Yu. E. Vel'tisheva, 1988; A. A. Ovchinikov, 1992. On the basis of these data, criteria for early diagnosis and treatment of the principal diseases have been developed.

Measures aimed at optimizing the observation of children with urinary tract infections consist in clarifying the risk factors of various forms of pathology [9,100], in substantiating various forms of observation: specialized consultations, specialized departments, and diagnostic centers [61,117], as well as in improving the system of organization of the rehabilitation stage [40,97,114].

To date, the scientifically grounded technology of medical care for children with urinary tract infections, implementing the principles of prevention of these disorders at the outpatient-polyclinic level, has not been sufficiently developed. There are deficiencies in the continuity between the district service and specialists—nephrologists—in the conduct of preventive work, dynamic observation, and treatment of these diseases, and the system of document circulation is not clearly developed.

The above determines the relevance of the present research, directed toward evaluating the state of nephrological care for children under conditions of the outpatient-polyclinic link and developing scientifically grounded recommendations for improving the quality of medical provision for patients with urinary tract infections.

The objective of the research: to develop and substantiate proposals for early diagnosis of urinary tract infections in children and optimization of the prevention system at the outpatient-polyclinic stage, taking into account medical-social characteristics and analysis of the organization of medical care for this category of patients, so as to reduce the risk of disease relapses and the need for hospitalization of children with this pathology.

In accordance with the set objective, the tasks of the research were as follows:

1. To conduct an analysis of morbidity by referral rates of children for urinary tract infections.

2. To provide a modern medical-social characterization of families having children with urinary tract infections and to develop a predictive table for early diagnosis of this pathology.

3. To identify medical-organizational defects of outpatient-polyclinic care for children with urinary tract infections.

4. To develop proposals for optimization of prevention of urinary tract infections in children at the outpatient stage.

The scientific novelty of the work consists in the fact that, for the first time:

1. Modern features of the lifestyle and living conditions of children with urinary tract infections have been identified, which made it possible to obtain a characterization of a number of social-hygienic and medical-biological risk factors influencing the development of the pathology.

2. The influence of medical-organizational defects of outpatient care on the progression of urinary tract infections in children has been determined, including the lack of continuity of observation and staging of treatment, irregular dispensary observation by district pediatricians and narrow specialists, and insufficient work on the formation of medical activity of the family of the ill child.

3. A model of continuity between district and specialized services for the optimization of medical-organizational provision of prevention of urinary tract infections and rehabilitation of children with kidney pathology has been created, including clinical-diagnostic criteria for early detection of this pathology.

The practical significance of the research consists in the fact that:

1) a predictive table for assessing the individual risk of urinary tract infections in children has been developed, recommendations have been proposed for the formation of risk groups among children with respect to the development of urinary tract infections, and scientifically grounded proposals have been made for the organization of therapeutic and preventive care for children with this pathology;

2) The methodology for assessing the risk of occurrence of urinary tract infections using a predictive table and the selection of measures for its correction have been introduced into the practice of pediatricians and nephrologists of the children's diagnostic and treatment center of the city of Ivanovo, pediatricians of the Ivanovo Central District Hospital, and the sanatorium "Ivantsevo".

Publications and presentation of the research results. Five scientific articles and an informational letter for health care organizers have been published on the dissertation topic. The materials of the research were presented at:

- scientific-practical conferences "Actual Problems of Regional Health Care" (Ivanovo, 2003); "Health, Lifestyle, and Education" (Shuya, 2005);

- the Eighth International Conference "Ecology and Life" (Penza, 2005).

The principal provisions of the dissertation to be defended:

1. A modern characterization of the medical-social risk factors in the formation of urinary tract infections in children.

2. The technology of individual prediction of the development of urinary tract infections in children taking into account the diagnostic significance of risk factors.

3. A complex of measures for the optimization of therapeutic and preventive care for children with urinary tract infections at the outpatient-polyclinic stage.