In the general structure of infectious diseases, acute intestinal infections (AEIs) account for more than 40% of all hospitalized patients, and in the structure of infectious morbidity they rank second after acute respiratory viral infections (ARVI) and influenza, representing a serious problem in pediatric practice.
The algorithm for choosing therapeutic tactics in AEI begins with the establishment of the etiopathogenetic group of diarrhea. The most optimal is to determine the etiology of the disease using express diagnostic methods (for example, tests for the diagnosis of viral AEI SD BIOLINE Rotavirus, RIDA Quick Rotavirus R-Biopharm AG, Cito Test Rota and others), allowing you to quickly identify the pathogen and select a further therapy algorithm ...
Unfortunately, in routine clinical practice, the etiology of AEI in most cases remains unclear and the therapeutic tactics are determined based on the etiopathogenetic group of diarrhea, which is diagnosed on the basis of clinical and epidemiological data. So, watery diarrhea in most cases is caused by viral agents and requires the appointment of antiviral drugs as etiotropic therapy, invasive - bacterial, which implies antibiotic therapy in the presence of appropriate indications.
Clinical differential diagnosis of AEI is based on the clinical features of the leading syndromes (Table 1).
Epidemiological data on the etiological structure of AEI are currently characterized by the prevalence of viral agents over bacterial and the presence of combined forms in 26.0 ± 1.6% of patients with viral-bacterial and viral-viral etiology.
Among viral agents in children with primary infection, the first place is occupied by rotavirus infection (87.6 ± 1.4% among intestinal monoinfections of viral etiology), among bacterial agents - salmonella, and, as a consequence, the most common form of combined forms is the combined form of rotavirus infection and salmonellosis (9.2% ± 1.1% in the general structure of decoded AEI). Among viral AEI, the most significant etiological factors are rotavirus and norovirus infections, which determines this combination as the most frequent not only with simultaneous infection with two viral agents, but also with infection with a large number of pathogens (4.8 ± 0.8% in the total structure of decrypted OKI).
Evaluation of the epidemiological history of the disease is carried out according to the following scheme (Table 2). It is necessary for the doctor to speculate about the etiology of the disease. So, food and water transmission routes are more typical for bacterial OCI, contact-household - for viral agents. In the autumn-winter period, there is an increase in the incidence of viral AEI, in the summer - bacterial.
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When conducting a clinical and epidemiological analysis of a patient, it is necessary to take into account the age structure of the AEI. For children of all age periods, rotavirus infection is significantly more often recorded, while its share of patients under 3 years old accounts for 83% of all patients with established rotavirus infection (р< 0,01) (рис.). Для норовирусной инфекции характерно наибольшее количество пациентов в возрасте от 3 до 7 лет — 43,6 ± 6,7%.
According to the form of severity, AEI is subdivided into mild, moderate and severe. Establishing the form of the severity of the disease is carried out by an integral analysis of clinical data:
1) the prevalence of damage to the gastrointestinal tract (GIT) and other organs;
2) the intensity of the manifestation of the main clinical symptoms of the disease;
3) the intensity of the manifestation of the patient's main complaints (Table 3).
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Determination of the form of severity can be carried out visually: the more points are noted in block 1 and the greater the total number of points in blocks 2 and 3, the more severe the form of the disease is observed in the patient.
However, it is more preferable to calculate the integral index of clinical symptoms, which is carried out according to the formula:
where indicator A is the sum of positive values \u200b\u200bfor each item of block 1; В and С - the sum of positive values \u200b\u200bfor each item of blocks 2 and 3, respectively.
The values \u200b\u200bof this indicator in the range from 1% to 35% refer to the mild form of the disease, from 36% to 70% - to the moderate form, and 71% or more - to the severe form of the disease.
The severity of acute intestinal infection in children is largely determined depending on the volume of fluid loss by the patient, while the correctness of the assessment of the degree of dehydration in a child with acute intestinal infections is of particular importance.
For the diagnosis of dehydration, the gold standard is the assessment of the dynamics of the patient's body weight. So, exicosis I degree corresponds to a loss of up to 5% of body weight, which is up to 50 ml / kg of fluid, exicosis II degree - loss of 6-10% of body weight (60-100 ml / kg), exicosis III degree - loss of more than 10% body weight (110-150 ml / kg). Dehydration, characterized by a weight loss of more than 20%, is not compatible with life.
However, for pediatric practice, the use of the method for assessing body weight loss is not always acceptable. In this case, the clinical assessment of the symptoms of dehydration comes first.
Abroad, the M. H. Gorelick trait scale is widely used:
- change in the general condition (type) of the patient;
- the presence of tears;
- capillary reperfusion\u003e 2 seconds;
- sunken eyes;
- decreased urine output;
- condition (dryness, turgor) of the skin and mucous membranes;
- basic hemodynamic parameters (heart rate and heart rate);
- breathing disorders.
Assessment of the form of dehydration according to this scale implies counting the number of signs that the patient has:
- lung (< 5%) обезвоживание ≤ 2 признаков;
- moderate (6-9%) dehydration 3-5 signs;
- severe (\u003e 10%) dehydration - 6-7 signs.
However, the significance of each of the symptoms of dehydration in clinical practice may not always be high enough, especially in case of exsicosis of the first degree (Table 4).
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Therapeutic tactics for AEI in a particular patient is based on knowledge or assumption (based on clinical features, data from the epidemiological history) about the etiology of the disease: bacterial or viral infection. In addition, it is necessary to take into account the age of the patients, the peculiarities of its premorbid background and the period of the disease.
The scheme of therapeutic tactics for AEI, depending on the type of diarrhea and the period of the disease, is given in Table. 6.
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Sorbents (carbon, synthetic, mineral, fibrous) should be prescribed to all patients, regardless of the etiology and severity of the disease, as one of the important aspects of etiotropic therapy. Currently, the Russian pharmaceutical market has a fairly large number of drugs with sorption properties to varying degrees. The appointment of enterosorbents is shown as early as possible of the disease - before the identification of the pathogen, which makes it possible to achieve an "interrupting" effect on the course of AEI. The use of enterosorbents in the late stages of the disease (after 5-7 days), especially with invasive AEI, has less effect on diarrheal syndrome, but has a pronounced detoxification and enteroprotective effect. The important positive aspects of the use of enterosorbents include the absence of the effect of these drugs on the composition of the obligate intestinal microbiota. The course of treatment with enterosorbents is usually 5-7 days. The criterion for early withdrawal of drugs is stable stool normalization or its delay for 2 days.
Antiviral drugs are recommended for viral AEI. Antiviral drugs recommended for AEI and proven to be effective in clinical trials: affinity purified antibodies to human interferon gamma, interferon alfa-2b in combination with taurine, umifenovir.
The issues of antibiotic therapy of OCI for the practicing physician remain one of the most urgent. Unfortunately, most doctors approach the issue of prescribing antibiotics in a stereotyped manner, without taking into account the etiology of the disease, recommending them even for viral AEI, and without knowing the data on the sensitivity and resistance of the main bacterial pathogens.
Indications for the appointment of antibacterial drugs are divided into absolute, basic and additional (Table 7).
Absolute indications for the appointment of antibiotic therapy are absolutely valid - antibiotic therapy is indicated for all patients in whom they are installed. The presence of the main indications in combination with one of the additional points is an indication for the appointment of antibiotic therapy. The presence of only additional indications is not an indication for the appointment of antibiotic therapy.
Antibacterial agents recommended for acute intestinal infections are divided into two types: intestinal antiseptics and drugs intended for systemic action. The first group can be recommended for prescription in outpatient practice, where the most justified tactic of starting therapy for AEI is the use of nitrofurans (nifuroxazide, nifurantel). Quinolones (nalidixic acid, ciprofloxacin) have proven themselves well in the treatment of salmonellosis. Cephalosporins are recommended for systemic antibiotic therapy in moderate and severe acute infections in a hospital setting. Perhaps the appointment of tetracyclines, metronidazole, aminoglycosides, chloramphenicol.
In the case of a diagnosis of campylobacteriosis, macrolides (erythromycin, azithromycin, clarithromycin) are the most optimal for starting etiotropic therapy.
The duration of the course of antibiotic therapy in the acute phase of localized AEI is determined by the clinical situation and, as a rule, is at least 5-7 days. The indications for changing the drug are generally accepted - the clinical ineffectiveness of the drug within 3 days.
It should be emphasized that in recent years, most of the causative agents of invasive AEI have resistance to furazolidone. Salmonella remain highly sensitive to fluoroquinolones (for example, cypro-phloxacin - 96.7% of the strains are sensitive, but 23.3% are moderately resistant to pefloxacin and 17.2% are resistant), but their use in pediatric practice is limited; nalidixic acid (53.1%), amikacin (61.1%), netilmicin (63.9%), some cephalosporins II (cefoxitin, cefuroxime) - 86.7-57.9%, III (ceftriaxone, cefotaxime, ceftazidime ) - 84.4%, 85.0%, 81.7% and IV generation (cefepime) - 91.3% of sensitive strains.
An obligatory component of antibiotic therapy from the moment of its appointment and during the period of convalescence is the appointment of probiotics.
Among the pathogenetic methods of therapy, the most important are the means of rehydration (oral, parenteral), drugs that affect the processes of dehydration (gelatin thanat), and probiotics.
Oral rehydration therapy is a necessary component of therapy, included in the list of therapeutic measures recommended by the World Health Organization, and is prescribed for all patients with AEI. For oral rehydration, the most justified is the use of ready-made solutions, balanced in electrolyte composition and osmolarity (75 meq / l sodium and 75 meq / l glucose and osmolarity 245 mosm / l).
Oral rehydration is a two-step process.
Stage 1 - primary rehydration is the replenishment of losses that occurred before the moment of seeking medical help, and is calculated for 6 hours. A total amount of fluid of 50-80 ml / kg is prescribed for 6 hours.
2nd stage - supportive rehydration, the task of which is to replenish the current fluid loss in AEI. 80-100 ml / kg of fluid is prescribed per day. The duration of the second stage of oral rehydration continues until the moment of recovery or the appearance of indications for parenteral correction of dehydration.
It should be borne in mind that correction of dehydration is impossible without the use of salt-free solutions, among which preference should be given to drinking water (not mineral!), It is possible to use pectin-containing decoctions (apple compote without sugar, carrot-rice broth). The ratio of glucose-saline solutions to drinking water should be 1: 1 for watery diarrhea, 2: 1 for severe vomiting, 1: 2 for invasive diarrhea.
Severe forms of acute intestinal infections, lack of effect from oral rehydration or the presence of profuse vomiting, edema, development of functional (acute) renal failure are indications for parenteral rehydration, which can be carried out using one of the modern domestic solutions - 1.5% meglumine sodium succinate solution , which has proven its effectiveness in the intensive care of these conditions.
The use of antidiarrheal agents (loperamide) for acute intestinal infections is pathogenetically not justified, since the mechanism of action of these drugs implies a decrease in gastrointestinal motility (increased motility is a protective reaction of the body in acute intestinal infectious lesions) and can contribute to the aggravation of intoxication syndrome in acute intestinal infections.
AEI of any form of severity is the cause of significant changes in the microbiocenosis of the gastrointestinal tract - for example, with Zonne's dysentery in 67.8-85.1% of patients, with salmonellosis - in 95.1%, yersiniosis - in 94.9%, rotavirus infection - in 37, 2-62.8% of patients.
Probiotics should be prescribed as part of a comprehensive starting therapy, regardless of the etiology of the disease, as early as possible. These drugs are also indicated for all patients in the period of convalescence in order to restore the parameters of microbiocenosis. Their use in AEI in children is not only pathogenetically justified, but also belongs to the highest level of evidence A - in accordance with the principles of evidence-based medicine.
The modern view of probiotic therapy implies a strain-specific approach, which means establishing in clinical trials the therapeutic effects characteristic of certain genetically certified strains and their further use, taking into account the strain-specific properties of probiotics in various clinical situations.
In relation to acute intestinal infections in children, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Working Group in 2014 based on the analysis of published systematic reviews and the results of randomized clinical trials, including placebo-controlled, published a memorandum in which it recommended (despite the low level of evidence according to experts) several probiotic strains in the treatment of acute intestinal infections: Lactobacillus GG, Saccharomyces boulardii, Lactobacillus reuteri strain DSM 17938 (original strain ATCC 55730), as well as a thermally inactivated strain was assigned to this group of probiotics Lactobacillus acidophilus LB, which formally cannot be classified as probiotics as living microorganisms with specified beneficial properties, however, has shown its effectiveness in acute infectious gastroenteritis.
Currently probiotic strains Bifidobacterium lactis BB-12, Escherichia coli Nissle 1917, Lactobacillus acidophilus, Bacillus clausii belong to the group of microorganisms for which there is not enough data on the effectiveness of their use in the acute period of acute respiratory infections. However, previously conducted studies have shown the presence of clinically significant positive properties, the efficacy and safety of their use in AEI, post-infectious syndrome of bacterial overgrowth and prevention of gastrointestinal microbiocenosis disorders against the background of antibacterial therapy. Thus, the spectrum of strains that can be recommended in the treatment of AEI requires further study.
In this regard, the most promising probiotic strains are microorganisms characterized by a high adhesion ability, resistance to aggressive media of the human gastrointestinal tract (hydrochloric acid, bile) and belonging to the donor category.
Among such probiotic strains, microorganisms of the genus Bifidobacterium... Bifidobacteria belong to the dominant species in the microbiocenosis of the human gastrointestinal tract - their proportion in the composition of microbiocenoses ranges from 85% to 98%. This genus is characterized by a high adhesion capacity, a leading role in ensuring the colonization resistance of the organism, regulating the metabolism of fats, proteins and minerals, and the synthesis of biologically active substances, including vitamins. The most studied are strains Bifidobacterium longum and Bifidobacterium animalis lactis.
One of the lines of probiotic drugs that can be recommended for the complex therapy of AEI in children is the probiotic Bifiform.
Bifiform Baby includes BifidobacteriumBB-12 1 × 10 8 CFU and Streptococcus thermophilusTH-4 1 × 10 7 CFU.
Preclinical studies Bifidobacterium lactis BB-12, which is a component of the natural intestinal biofilm of healthy people, demonstrated its ability for high-level adhesion to surfaces with mucin (polycarbonate well plates were used), without mucin and cell culture films (Caco-2, HT29 × MTX), including on the background of rotavirus infection and after it.
For this strain, antagonistic activity has been shown to a whole range of pathogenic pathogens ( Bacillus cereus, Clostridium difficile, Clostridium perfringens Type A, Escherichia coli, Listeria monocytogenes, Pseudomonas aeruginosa, Salmonella enterica subsp enterica serovar Typhimurium, Salmonella enterica subsp. enterica serovar Typhi, Shigella flexneri, Shigella sonnei, Campylobacter jejuni and Candida albicans), which makes it preferable for AEI of bacterial etiology.
Bifidobacterium lactis BB-12 is resistant to aggressive environments of the human body - hydrochloric acid and bile, due to the synthesis of a pH-dependent ATP-ase, which regulates the acid-base balance within the bacterium and the presence of bile salt hydrolase, which allows the bacteria to remain active in the presence of bile.
Patients who need antibacterial drug therapy deserve special attention. The changes in the gastrointestinal tract microbiota caused by the course of the infectious process can be aggravated by antibiotics. Therefore, this category of patients needs to be included in the complex therapy of AEI with probiotic drugs aimed at maintaining the microbiocenosis. Bifidobacterium lactis BB-12 is resistant to antibiotics such as gentamicin, streptomycin, polymyxin B, nalidixic acid, kanamycin, neomycin, cycloserine, tetracycline, which makes it the strain of choice when prescribing these antibacterial agents to patients, for example, for acute intestinal infections (salmonellosis, shigellosis) ...
Placebo-controlled studies have shown that, in addition to the therapeutic properties, the strain Bifidobacterium lactis BB-12s are inherent and preventative. In particular, its use reduces the risk of developing gastrointestinal infections, including rotavirus, associated with the provision of medical care.
It should be noted that the high safety profile of this strain was approved by regulatory authorities in Europe - in 2008 the European Food Safety Authority (EFSA) awarded it the status of Qualified Presumption of Safety (unconditional safety) - and in the USA, where Generally Regarded As Safe (GRAS) is recognized by the Food and Drug Administration (FDA).
Streptococcus thermophilus, which is part of Bifiform Baby, demonstrated antagonistic action against the pathogens of AEI in studies, in particular, its effectiveness in preventing traveler's diarrhea was shown.
For this strain, a symbiotic relationship with Lactobacillus bulgariсus.
Bifiform Baby is intended for children from the first days of life to 2 years. The daily dose (the mark on the pipette corresponds to 1 dose) is 0.5g ~ 0.5ml. It is applied once a day with meals. The most optimal is to use it when carrying out antibacterial therapy of OCI, during the period of convalescence, as well as for preventive purposes (for example, when traveling with a child on vacation, attending social events, a swimming pool).
Bifiform capsules include Bifidobacterium longum, which is also a donor strain and is characterized by pronounced antagonistic activity against pathogenic and opportunistic microorganisms. The inclusion of apathogenic Enterococcus faecium, not related to those not recommended for use in pediatric practice, but normally colonizing the small intestine, allows you to have a positive effect on the condition and digestive functions of not only the large, but also the small intestine, especially in the presence of fermentative dyspepsia and flatulence phenomena.
The drug is indicated for children over 2 years old. For acute diarrhea, the drug is taken 1 capsule 4 times a day until the stool is normalized. Then, taking the drug should be continued at a dose of 2-3 capsules per day until the symptoms disappear completely. To normalize the intestinal microbiota and support the immune system, the drug is prescribed in a dose of 2-3 capsules per day for 10-21 days. Children from 2 years old take 1 capsule 2-3 times a day.
Symptomatic therapy includes therapy for febrile conditions. Antipyretic drugs are not indicated for all patients, since an increase in temperature is an adaptive response of the body to an infection, which creates optimal conditions for the body's immune restructuring. The appointment of this category of drugs is shown to all patients with hyperthermia, and in the presence of severe concomitant pathology - with a fever of more than 38.5 ° C.
The development of secondary pancreatic insufficiency, exacerbation of chronic pathology of the pancreas is often observed during the period of repair and convalescence of the OCI. It should be noted that with norovirus infection, damage to the pancreas is noted more often than with AII of a different etiology. In such cases, the appointment of enzyme preparations is indicated, preferably in a minimicrospherical form. It should be noted that in the acute period of AEI, enzyme preparations are not indicated. The most optimal period for their appointment, if indicated, is 5-6 days, the appointment criterion is the appearance of the patient's appetite.
To stop persistent vomiting, prokinetics and antiemetic drugs can be used: metoclopramide, domperidone, promethazine, 0.25% novocaine - 1 spoon (tea, dessert, table by age).
Criteria for evaluating the effectiveness of treatment:
- clinical (relief of intoxication syndrome, normalization of temperature, relief of vomiting, diarrhea and other symptoms);
- clinical and laboratory (stable normalization of hemogram, coprocytogram, negative results in bacteriological and PCR examination).
Due to the fact that sanitation from the pathogen, complete repair of the intestine and restoration of its impaired functions occur much later than the clinical manifestations of the disease disappear, it is advisable to conduct dynamic monitoring of patients who have undergone AEI.
Thus, acute intestinal infections require special approaches to diagnosis, management and therapy from the doctor. When supervising patients with acute intestinal infections, it should be taken into account that even mild forms lead to significant changes in the microbiota of the gastrointestinal tract in children, which requires the use of probiotic drugs not only in the acute period of the disease, but also in the period of convalescence.
Literature
A. A. Ploskireva 1, candidate of Medical Sciences
A. V. Gorelov, doctor of Medical Sciences, Professor
FBSI Central Research Institute of Epidemiology of Rospotrebnadzor, Moscow
CHIEF STATE SANITARY DOCTOR OF THE RUSSIAN FEDERATION
RESOLUTION
About the approval of SP 3.1.1.3108-13 "Prevention of acute intestinal infections"
Document with changes made:
(Official Internet portal of legal information www.pravo.gov.ru, 28.12.2017, N 0001201712280059).
____________________________________________________________________
In accordance with the Federal Law of 30.03.99 N 52-FZ "On the sanitary and epidemiological well-being of the population" (Collected Legislation of the Russian Federation, 1999, N 14, Article 1650; 2002, N 1 (Part I), Article 2; 2003, No. 2, article 167; No. 27 (part 1), article 2700; 2004, No. 35, article 3607; 2005, No. 19, article 1752; 2006, No. 1, article 10; No. 52 (part I), article 5498; 2007 N 1 (part I), article 21; N 1 (part I), article 29; N 27, article 3213; N 46, article 5554; N 49, art. 6070; 2008, N 24, art. 2801; N 29 (part I), art. 3418; N 30 (part II), art. 3616; N 44, art. 4984; N 52 (part I), Article 6223; 2009, No. 1, Article 17; 2010, No. 40, Article 4969; 2011, No. 1, Article 6; No. 30 (part I), Articles 4563, 4590, 4591 , 4596; N 50, Art. 7359; 2012, N 24, Art. 3069; N 26, Art. 3446; 2013, N 27, Art. 3477; N 30 (part I), Art. 4079 and the decree of the Government of the Russian Federation of July 24, 2000 N 554 "On approval of the Regulations on the State Sanitary and Epidemiological Service of the Russian Federation and the Regulations on State Sanitary and Epidemiological Standards" (Collected Legislation of the Russian Federation, 2000, 31, Article 3295; 2004, No. 8, art. 663; 47, Article 4666; 2005, N 39, Art. 3953)
i decree:
1. To approve the sanitary and epidemiological rules of the joint venture 3.1.1.3108-13 "Prevention of acute intestinal infections" (Appendix).
2. To recognize as invalid the sanitary and epidemiological rules "Prevention of acute intestinal infections. SP 3.1.1.1117-02"
________________
Registered with the Ministry of Justice of the Russian Federation on May 8, 2002, registration N 3418.
G.G. Onischenko
Registered
at the Ministry of Justice
Russian Federation
registration N 31602
Application. Sanitary and Epidemiological Rules SP 3.1.1.3108-13. Prevention of acute intestinal infections
application
3.1.1. Prevention of infectious diseases
Intestinal infections
Prevention of acute intestinal infections
Sanitary and Epidemiological Rules
SP 3.1.1.3108-13
I. Scope
1.1. These sanitary and epidemiological rules establish requirements for a complex of organizational, preventive, sanitary and anti-epidemic measures, the implementation of which ensures the prevention of the occurrence and spread of cases of acute intestinal infections (AEI) among the population of the Russian Federation.
1.2. Compliance with sanitary and epidemiological rules is mandatory throughout the Russian Federation by state bodies, local governments, legal entities, officials, citizens, individual entrepreneurs.
1.3. Control over the implementation of these sanitary rules is carried out by bodies authorized to exercise federal state sanitary and epidemiological supervision.
II. General Provisions
2.1. Sanitary rules apply to infections (poisoning of microbial etiology), manifested by diarrheal syndrome at the stage of preliminary diagnosis - before the onset of characteristic symptoms of diseases or in the absence of an epidemiological history indicating the connection of the disease with registered foci of infectious diseases or before establishing the type of pathogen.
2.2. When establishing the etiology of a disease or a probable diagnosis on the basis of clinical and epidemiological data, to implement the necessary measures, sanitary and epidemiological rules are applied for certain types of infectious diseases (cholera, typhoid fever, salmonellosis, yersiniosis, campylobacteriosis, enterovirus infections, and others).
2.3. In the absence of sanitary and epidemiological rules for certain nosological forms of diseases manifested by diarrheal syndrome, or in the absence of detection of the pathogen (OCI with an unknown etiology), measures are carried out in accordance with these sanitary and epidemiological rules.
2.4. For OCI, the predominant transmission mechanism is fecal-oral, realized by household (contact-household), food and water transmission of the pathogen. For certain diseases (viral infections), an aerosol transmission mechanism is possible.
2.5. According to the forms of the course of the infectious process, manifest cyclical forms of the course of diseases are distinguished, in which the incubation period, the acute phase of the disease and the period of convalescence and submanifest (asymptomatic) forms are distinguished. Isolation of the pathogen can be observed in the acute phase of the disease (the most active), in the period of convalescence after a previous illness, in asymptomatic forms of infection and, in a number of nosologies, in cases of the formation of a chronic release of the pathogen.
2.6. The epidemic process of AEI is manifested by outbreak and sporadic morbidity. Depending on the type of pathogen, seasonal and epidemic rises in the incidence are observed in certain territories or in climatic zones.
III. Measures to ensure federal state sanitary and epidemiological surveillance of acute intestinal infections
3.1. In order to ensure federal state sanitary and epidemiological surveillance, continuous monitoring of the epidemic process of AEI is carried out in order to assess the situation, make timely management decisions, develop and adjust sanitary and anti-epidemic (preventive) measures to prevent the occurrence and spread of AEI cases among the population, and the formation of epidemic foci with group morbidity.
3.2. Measures to ensure federal state sanitary and epidemiological surveillance of AEI include:
- morbidity monitoring;
- monitoring the circulation of AEI pathogens in the human population and in the environment;
- analysis of the parameters of environmental factors that can serve as factors for the transmission of OCI;
- assessment of the effectiveness of the ongoing sanitary and anti-epidemic (preventive) measures;
- retrospective and operational analysis of the dynamics of the incidence of AEI;
- forecasting the development of the epidemiological situation.
IV. Identifying cases of acute intestinal infections in humans
4.1. The detection of cases of AEI diseases, as well as cases of carriage of pathogens of AEI, is carried out by workers of medical organizations during outpatient appointments, home visits, and medical examinations.
4.2. The collection of clinical material from the patient (for example: feces, blood, vomit, gastric lavage) is carried out by specialists from medical organizations who identified the patient on the day of treatment and before the start of etiotropic treatment. Clinical material from a patient with a clinic of acute intestinal infections is sent to the laboratory for laboratory research in order to determine the causative agent of the infection.
(Clause as amended, entered into force on January 8, 2018 by the decree of the Chief State Sanitary Doctor of the Russian Federation of December 5, 2017 N 149.
4.3. When treating a patient at home, the collection of material for research is carried out by the personnel of medical organizations assigned geographically or departmental.
4.4. In the foci of AEI with group morbidity, the selection and laboratory examination of material from patients is carried out both by employees of medical organizations and by employees of institutions providing state sanitary and epidemiological surveillance.
4.5. Material from contact persons and persons from among the employees of catering units, organizations for the production and sale of food products, children's institutions and medical organizations (hereinafter referred to as the decreed contingent) in epidemic foci is examined in the laboratories of institutions providing state sanitary and epidemiological surveillance. The volume and list of material are determined by the specialist responsible for conducting the epidemiological investigation.
4.6. Delivery of clinical material to the laboratory in order to establish the etiology of the pathogen and its biological properties is carried out within 24 hours.
If it is impossible to deliver the material to the laboratory on time, it is preserved using methods determined taking into account the requirements of the planned diagnostic tests.
4.7. The diagnosis is established on the basis of clinical signs of the disease, the results of laboratory tests, and an epidemiological history.
4.8. In case of admission of a patient from an epidemic focus of AEI with proven etiology, the diagnosis can be made on the basis of a clinical and epidemiological history without laboratory confirmation.
4.9. In large foci of AEI (more than 100 cases of diseases) with multiple cases of diseases, a sample of patients who fell ill at the same time with the same symptomatology (at least 20% of the number of cases) was examined to detect the etiological agent.
In epidemic foci of up to 20 cases of diseases, all patients are subject to laboratory research.
In epidemic foci from 20 to 100 cases of diseases, at least 30% of cases are subject to laboratory research.
V. Laboratory diagnostics of OCI
5.1. Laboratory diagnostics of OCI is carried out in accordance with current regulatory and methodological documents, depending on the type of suspected pathogen.
5.2. Laboratory research of materials from patients with acute intestinal infections is carried out by laboratories that have permits for work with microorganisms of III-IV pathogenicity groups.
5.3. Studies on the isolation of pathogens or its genome from the material from patients, associated with the accumulation of pathogens of I-II pathogenicity groups (microbiological, molecular-genetic studies), are carried out in laboratories licensed to work with pathogens of I-II pathogenicity groups.
5.4. Serological studies, molecular genetic studies without the accumulation of the pathogen for microorganisms of the II pathogenicity group can be carried out in bacteriological laboratories that have permits for working with pathogens of the III-IV pathogenic groups.
5.5. One of the conditions for the qualitative conduct of bacteriological and molecular genetic research is the correct sampling of material and its preliminary preparation for research in accordance with the current regulatory methodological documents.
5.6. Confirmation of the etiology of AEI is carried out by any methods available to the laboratory.
5.7. To diagnose AEI, diagnostic systems registered in the Russian Federation in the prescribed manner are used.
5.8. Methods for confirming the etiology of OCI are isolation and identification of the pathogen using nutrient media and biochemical tests, polymerase chain reaction (PCR), serological research methods (RPHA, ELISA and others) and other methods that allow for the indication and identification of pathogens and toxins.
5.9. Stool, vomit, gastric and intestinal washings, and blood can serve as material for research on the detection of AEI pathogens.
5.10. In case of lethal outcomes of diseases, materials obtained during pathological and anatomical research (tissue samples of the intestine, spleen, liver and others) are examined. Research can be carried out both in a medical organization and in institutions providing state sanitary and epidemiological supervision.
In case of suspicion of a disease caused by microorganisms of I-II groups of pathogenicity, the pathological and anatomical material is selected in the presence of specialists from institutions providing federal state sanitary and epidemiological surveillance, and is examined in laboratories of institutions providing federal state sanitary and epidemiological surveillance.
Vi. Anti-epidemic measures for acute intestinal infections
6.1. In the epidemic foci of AEI during the period of epidemic rises in the incidence of AEI in certain territories, anti-epidemic measures are organized and carried out aimed at localizing the focus and preventing further spread of the infection.
6.2. A medical organization that has identified a patient or a carrier of AEI pathogens (including when the diagnosis is changed) is obliged to take measures to isolate the patient and send an emergency notification to the territorial authority exercising federal state sanitary and epidemiological supervision.
When detecting patients with AEI in schools, preschool organizations, recreation organizations for children and adults, social institutions (boarding schools), the responsibility for timely informing the territorial bodies of the federal executive body exercising federal state sanitary and epidemiological supervision is assigned to the head of the organization. The medical worker of the organization, who identified the patient, is obliged to take measures to isolate the patient and organize disinfection.
6.3. Epidemiological investigation of the AEI epidemic focus is carried out by the bodies exercising federal state sanitary and epidemiological surveillance in order to establish the boundaries of the outbreak, identify the AEI causative agent and its source, persons at risk of infection, determine the pathways and factors of transmission of the pathogen, as well as the conditions that contributed to the emergence of the outbreak.
The purpose of the epidemiological investigation is to develop and take measures to eliminate the focus and stabilize the situation.
6.4. Epidemiological investigation includes examination (epidemiological examination) of the outbreak, collection of information (interview) from victims, persons at risk of infection, personnel, study of documentation, laboratory tests. The volume and list of necessary information are determined by the specialist responsible for organizing and conducting the epidemiological investigation.
6.5. In the course of an epidemiological investigation, a preliminary and final epidemiological diagnosis is formulated, on the basis of which measures are developed to localize and eliminate the focus.
The epidemiological investigation ends with the drawing up of an epidemiological investigation act with the establishment of a causal relationship between the formation of a focus of the established form.
6.6. In the case of registration of epidemic foci of up to 5 cases of diseases, the epidemiological examination of the outbreak is carried out by specialists of the institutions that ensure the conduct of state sanitary and epidemiological surveillance with the preparation of an epidemiological survey card in the established form and submitting it to the authorities authorized to carry out state sanitary and epidemiological surveillance.
Epidemiological examination of family (apartment) foci with isolated cases of diseases is carried out in case of illness (carriage) of OCI officials and employees of organizations whose activities are related to the production, storage, transportation and sale of food and drinking water, education and training of children, communal and consumer services population (decreed contingent), as well as in case of illness of persons (children and adults) living with them. In addition, all multiple family (apartment) epidemic foci with simultaneous or repeated occurrence of several cases of AEI are examined.
6.7. In the event that an increase in the incidence of AEI is registered in the territory by the bodies authorized to carry out state sanitary and epidemiological surveillance, measures are taken to identify the causes and conditions of epidemic trouble, and a set of measures is organized to stabilize the situation.
6.8. Anti-epidemic measures in the foci of AEI and with an epidemic rise in the incidence of AEI should be directed to:
to the source of infection (isolation, hospitalization);
to stop the transmission of infection;
to increase the body's defenses of persons at risk of infection.
6.9. Individuals with AEI symptoms should be isolated.
6.10. Hospitalization of identified patients (patients with suspected AEI) and carriers of AEI pathogens is carried out according to clinical and epidemiological indications.
Hospitalization should include patients with severe and moderate forms of AEI in children under 2 years of age and in children with a burdened premorbid background, patients of all ages with concomitant diseases, patients with protracted and chronic (with exacerbation) forms of the disease, patients with AEI in various forms if it is impossible to comply anti-epidemic regimen at the place of residence (identification of the patient), patients with AEI from among the decreed contingent, patients with AEI of various ages, who are in closed institutions.
6.11. The identified patients with symptoms (or a sample of patients with the same symptoms who fell ill during the same incubation period), persons who communicated with patients, persons from the decreed contingent are subject to compulsory laboratory examination for AEI in the epidemic focus.
The list and volume of laboratory tests in the epidemic focus or during an epidemic rise in incidence is determined by the specialist responsible for conducting the epidemiological investigation.
6.12. In the epidemic focus, in order to identify the ways and factors of transmission of the pathogen, a laboratory study of environmental samples is also carried out, including the remains of food or dishes, raw materials, water, washings from kitchen equipment, inventory, and others.
Laboratory studies of environmental objects (water, food products, etc.) are carried out by organizations that provide federal state sanitary and epidemiological supervision. The scope and list of laboratory tests is determined by the specialist responsible for conducting the epidemiological investigation.
6.13. Examination and identification of patients in epidemic foci are carried out by doctors of clinical specialties (infectious disease specialists, therapists, pediatricians and others).
Observation of persons at risk of infection in epidemic foci (contact persons) is carried out by medical workers at the place of residence or at the place of work of the contact person.
For contact persons related to the decreed contingent, children attending preschool organizations and summer health organizations, medical supervision is carried out not only at the place of residence, but also at the place of work (study, rest).
The results of medical supervision are reflected in outpatient records, in the child's development histories, in hospitals - in the medical records (when registering the outbreak in the hospital).
The duration of medical supervision is 7 days and includes a survey, examination, observation of the nature of the stool, thermometry.
6.14. In the event that the water quality does not comply with the current hygienic standards, there is information about interruptions in the supply of water to the population, emergency situations by the bodies exercising federal state sanitary and epidemiological supervision, an order is issued to legal entities and individual entrepreneurs to conduct an audit of water use systems (water supply and sewerage), taking measures to eliminate technical malfunctions, introduce a hyperchlorination regime and a drinking regime in organizations, supply drinking water to the population.
In case of pollution of open water bodies, measures are taken to clean them, if necessary, restrictions on water use are introduced.
6.15. The transmission factor (a specific food or water suspected of being infected) is excluded from use until the entire complex of anti-epidemic measures in the outbreak is completed.
6.16. Persons at risk of infection can receive emergency prophylaxis with the appointment of bacteriophages, immunomodulators, antiviral and antibacterial agents in accordance with the instructions for use of the drugs.
In the presence of vaccines against the causative agent of infection, immunization of persons at risk of infection, or certain contingents from among the decreed groups, can be carried out.
6.17. For the period of laboratory examinations, persons at risk of infection and not belonging to the decreed contingent are not suspended from work and visiting the organization in the absence of clinical symptoms of the disease, unless other requirements for certain pathogens are provided for by sanitary legislation.
6.18. In the event that, based on the results of an epidemiological investigation, a food route for the implementation of the transmission mechanism is assumed, measures are taken to temporarily suspend the activity of the facility with which group morbidity is associated, or to temporarily suspend personnel associated with the preparation and sale of food products, assumed as a factor in the transmission of infection ( pending laboratory results).
6.19. When a potential threat of the spread of AEI arises, in particular, against the background of extreme natural (sharp increases in air temperature, floods, floods, downpours, and others) and social (power outages in cities and towns, epidemically significant objects, movement of refugees and other), anti-epidemic measures should be aimed at:
- strengthening of measures for the supervision of epidemically significant objects, primarily food industry organizations, public catering, water use and others in a specific area using laboratory control methods;
- organization of sanitary and epidemiological control at points of temporary location of the affected population;
- active identification of patients (carriers) among persons belonging to the decreed categories;
- carrying out immunization according to epidemic indications;
- the appointment of emergency prophylaxis to persons at risk of infection;
- carrying out disinfection, disinsection and deratization treatments of epidemically significant objects;
- explanatory work with the population.
Vii. The procedure for discharge, admission to work and dispensary observation of persons who have undergone AEI
7.1. Persons from among the decreed categories after clinical recovery and a single laboratory examination with a negative result, carried out 1-2 days after the end of treatment in a hospital or at home, unless other requirements for individual pathogens are provided for by the current regulatory methodological documents. With an unknown etiology of AEI, patients belonging to this category are discharged from the hospital upon clinical recovery (no fever, normalization of stool, cessation of vomiting).
7.2. When carriers of AEI pathogens are identified, which can be sources of infection (decreed categories), as well as persons with diseases associated with opportunistic flora (pustular diseases, pharyngitis, tonsillitis and others), they are temporarily suspended from work and sent to medical organizations for diagnosis and treatment (sanitation). Admission to work is carried out on the basis of the conclusion (certificate) of the attending physician on clinical recovery, taking into account the data of the control laboratory study.
7.3. Persons who have undergone acute intestinal infections and who do not belong to the prescribed contingents are discharged after clinical recovery. The need for their laboratory examination before discharge is determined by the attending physician, taking into account the characteristics of the clinical course of the disease and the healing process.
7.4. In the case of a positive result of laboratory examinations carried out before discharge, the course of treatment is repeated with therapy adjustments prescribed in accordance with the characteristics of the pathogen. If the results of the control laboratory examination carried out after the repeated course of treatment of persons from the decreed contingent are positive, dispensary observation is established for them with a temporary transfer, with their consent, to another job not associated with an epidemic risk.
Patients with a chronic form of intestinal infection are not allowed to work related to the preparation, production, transportation, storage, sale of food and the maintenance of water supply facilities.
7.5. When discharging persons who have had acute intestinal infections, the hospital doctor draws up and sends to the polyclinic an extract from the medical history, including the diagnosis of the disease, data on the treatment performed, the results of the patient's examination, recommendations for medical examination.
7.6. Persons of the decreed category who have had acute forms of AEI are allowed to work after discharge from the hospital or treatment at home on the basis of a certificate of recovery issued by a medical organization, and in the presence of a negative laboratory test result, unless other requirements for individual pathogens are provided for by current regulations.
Persons from among the decreed categories who have undergone AEI of unknown etiology are allowed to work no earlier than 7 days from the onset of the disease.
7.7. Children and adolescents studying in educational organizations who are in summer health institutions, boarding schools for two months after a previous illness are not allowed on duty at the catering unit.
7.8. Persons from among the decreed categories who are carriers of AEI pathogens, with their consent, are temporarily transferred to another job that is not associated with the risk of AEI spread. If it is impossible to transfer on the basis of decisions of the chief state sanitary doctors and their deputies, they are temporarily suspended from work with the payment of social insurance benefits (clause 2 of article 33 of the Federal Law "On the sanitary and epidemiological welfare of the population").
7.9. Persons from among the decreed contingent who have had AEI and who are carriers of the pathogens of AEI are subject to dispensary observation for 1 month with a clinical examination and laboratory examination carried out at the end of the observation.
7.10. Children and adolescents who have had OCI, attending preschool organizations, boarding schools, summer health organizations and other types of closed institutions with round-the-clock stay, are subject to dispensary observation within 1 month after recovery with a daily medical examination. Laboratory examination is prescribed according to indications (presence of intestinal dysfunctions during the period of dispensary observation, weight loss, unsatisfactory general condition).
7.11. Persons - convalescents of chronic forms of AEI are subject to dispensary observation within 3 months from the date of diagnosis with monthly examination and laboratory examination. If necessary, the terms of dispensary observation are extended.
7.13. Removal from dispensary observation is carried out by a doctor of a medical organization, subject to the complete clinical recovery of the convalescent and a negative laboratory test result.
VIII. Disinfection measures for acute intestinal infections
8.1. With OCI, prophylactic and focal (current and final) disinfection is carried out.
8.2. Preventive disinfection measures in organized groups of children and adults, as well as in organizations of the food industry, public catering, grocery trade, transport for transporting food products, water supply facilities are carried out in combination with other preventive and anti-epidemic measures carried out in accordance with the current sanitary rules for arrangement and maintenance of these places.
8.4. All items that have contact with the patient and are factors in the transmission of OCI are subject to disinfection (tableware, underwear, bed linen, towels, handkerchiefs, napkins, personal hygiene items, patient's discharge and utensils from discharge, surfaces in rooms, hard furniture, sanitary equipment, soil and others).
8.5. Particular attention is paid to hand hygiene, including their protection with rubber gloves when caring for the patient and contact with objects in the patient's environment; thoroughly washing hands with soap and water, treating them with skin antiseptics after any contact with patients, their clothes, bedding and other potentially contaminated objects (door handles of wards and boxes, stair railings, switches). To disinfect the hands of medical workers, skin antiseptics are used that are effective against pathogens of intestinal bacterial and viral infections.
8.7. It is necessary to monitor the timely implementation of preventive pest control aimed at combating flies, cockroaches and ants, which are mechanical carriers of AEI pathogens.
8.8. If the epidemiological examination reveals objective signs of colonization of the structure by rodents, in the AII focus (with salmonellosis, leptospirosis, intestinal yersiniosis, pseudotuberculosis, campylobacteriosis, etc.), deratization is carried out in order to prevent contamination of water and food products with AII pathogens, stages of implementation to the population, as well as to prevent the entry of pathogens into finished food products.
Disinsection and deratization in the OCI focus is carried out in accordance with the current sanitary legislation.
IX. Anti-epidemic measures for nosocomial foci of AEI
9.1. Employees of a medical organization should conduct operational tracking and timely detection of cases of drift or nosocomial infection of AEI among patients, staff or nurses.
It is forbidden to hospitalize new patients for 7 days in the ward with the identified patient.
9.2. If a patient is identified with AEI, the following is performed:
9.2.1. immediate sending of an emergency notification to the territorial body authorized to carry out state sanitary and epidemiological supervision;
9.2.2. immediate isolation, transfer of the patient to the infectious diseases ward or diagnostic boxes (half boxes) in the specialized department;
9.2.3. medical observation within 7 days from the moment the patient was identified and a single laboratory examination (to detect carriage or asymptomatic course of the disease) for persons at risk of infection;
9.2.4. final disinfection;
9.2.5. epidemiological investigation of the case (s) of the importation or nosocomial infection of patients, staff or persons caring for patients with salmonellosis with the identification of factors and routes of transmission of the pathogen; analysis of information, making administrative decisions.
9.3. With a group incidence of acute intestinal infections in one or more departments of a medical organization:
9.3.1. isolate patients in the infectious diseases department;
9.3.2. stop admitting patients to the department (s) where group morbidity is registered, and conduct medical observation of the contact within 7 days from the moment of isolation of the last patient.
9.3.3. conduct laboratory examination of personnel (contact - by decision of the specialist in charge of the epidemiological investigation) to determine the source of infection;
9.3.4. carry out emergency prevention;
9.3.5. prohibit the movement of patients from ward to ward, as well as reducing the number of patients due to early discharge, taking into account the general condition of patients;
9.3.6. the closure of the department (s) is carried out by order of the body exercising federal state sanitary and epidemiological supervision.
9.4. The opening of the department (s) is carried out after a complex of anti-epidemic measures and the completion of medical supervision of contact persons.
X. Preventive measures
10.1. The bodies authorized to conduct federal state sanitary and epidemiological surveillance exercise control over compliance with the requirements of the sanitary legislation of the Russian Federation, aimed at preventing contamination by pathogens of OCI:
- food products both in the process of their storage and production, and at all stages of sale to the population, as well as to prevent pathogens from entering the finished food products and the accumulation of microorganisms in them;
- drinking water;
- utility facilities in populated areas;
- household items and environment in organized groups of children and adults, medical organizations and others.
10.2. Legal entities and individual entrepreneurs are obliged to comply with the requirements of the sanitary legislation of the Russian Federation and carry out production control, including using laboratory tests.
10.3. The objects of production control in organizations and individual entrepreneurs are raw materials, products and environmental objects that can be contaminated with AEI pathogens.
10.4. The production control program is drawn up by a legal entity, an individual entrepreneur and approved by the head of the organization or authorized persons.
10.5. For preventive purposes, clinical and laboratory examinations and restrictive measures are carried out among certain groups of the population.
10.6. Persons applying for work in:
a) food enterprises, catering and food trade enterprises, dairy kitchens, dairy farms, dairy factories and others directly involved in the processing, storage, transportation of food and the delivery of prepared food, as well as the repair of inventory and equipment;
b) children's and medical organizations engaged in direct service and nutrition of children;
c) organizations operating water supply facilities, delivery and storage of drinking water.
In case of isolation of pathogens of acute intestinal infections in the patient, he is not allowed to work and is sent to a doctor's consultation.
10.6.1. Laboratory examination of persons before admission to hospitals and sanatoriums is carried out according to clinical and epidemiological indications.
When registering persons for inpatient treatment in psychoneurological (psychosomatic) hospitals (departments), nursing homes, boarding schools for people with chronic mental illness and central nervous system damage, in other types of closed organizations with round-the-clock stay, a single bacteriological examination is carried out for the presence of microorganisms of the genus Shigella spp. and Salmonella spp. A one-time examination is also carried out when patients are transferred to institutions of a neuropsychiatric (psychosomatic) profile.
10.6.2. A single laboratory examination in order to determine the causative agents of acute intestinal infections of bacterial and viral etiology in health organizations for children before the start of the health season (also when applying for work during the health season) is subject to:
employees who come to work in the catering units;
employees whose activities are related to the production, storage, transportation, sale of food products and drinking water;
persons operating water supply facilities.
(The item is additionally included from January 8, 2018 by the resolution of the Chief State Sanitary Doctor of the Russian Federation of December 5, 2017 N 149)
10.7. Prevention of acute intestinal infections, in which the causative agent is a pyogenic and opportunistic flora, is carried out by suspension from work related to the direct processing of food products and their manufacture, persons with pustular diseases, pharyngitis, tonsillitis and other manifestations of chronic infection.
10.8. Persons belonging to the decreed contingent are obliged to inform the management about the symptoms of AEI and immediately consult a doctor.
XI. Hygienic education and training of the population on the prevention of AEI
11.1. Hygienic education of the population is one of the methods of preventing acute intestinal infections.
11.2. Hygienic education of the population includes: providing the population with detailed information about AEI, the main symptoms of the disease and preventive measures using the media, leaflets, posters, bulletins, conducting an individual conversation.
11.3. The organization of information and explanatory work among the population is carried out by the bodies exercising federal state sanitary and epidemiological supervision, health authorities, medical prevention centers, medical organizations.
application
to SP 3.1.1.3108-13
Nosological forms with ICD-10 codes, the clinic of which may be manifested by diarrheal syndrome
A00-A09 Block (A00-A09) - Intestinal infections
A00 Cholera
A00.0 Cholera caused by vibrio 01, biovar cholerae
A00.1 Cholera caused by vibrio 01, biovar eltor
A00.2 Cholera, unspecified
A01 Typhus and paratyphoid
A01.0 Typhoid fever
A01.1 Paratyphoid A
A01.2 Paratyphoid B
A01.3 Paratyphoid C
A01.4 Paratyphoid, unspecified
A02 Other salmonella infections
A02.0 Salmonella enteritis
A02.1 Salmonella septicemia
A02.2 Localized salmonella infection
A02.8 Other specified salmonella infection
A02.9 Salmonella infection, unspecified
A03 Shigelez
A03.0 Shigellosis due to Shigella dysenteriae
A03.1 Shigellosis due to Shigella flexneri
A03.2 Shigellosis due to Shigella boydii
A03.3 Shigellosis due to Shigella sonnei
A03.8 Other shigellosis
A03.9 Shigellosis, unspecified
A04 Other bacterial intestinal infections
A04.0 Enteropagogic infection caused by Escherichia coli
A04.1 Enterotoxigenic infection caused by Escherichia coli
A04.2 Enteroinvasive infection caused by Escherichia coli
A04.3 Enterohemorrhagic infection caused by Escherichia coli
A04.4 Other intestinal infections caused by Escherichia coli
A04.5 Campylobacter enteritis
A04.6 Enteritis caused by Yersinia enterocolitica
A04.7 Clostridium difficile enterocolitis
A04.8 Other specified bacterial intestinal infections
A04.9 Bacterial intestinal infection, unspecified
A05 Other bacterial food poisoning
A05.0 Staphylococcal food poisoning
A05.1 Botulism
A05.2 Food poisoning due to Clostridium perfringens (Clostridium welchii)
A05.3 Food poisoning due to Vibrio parahaemolyticus
A05.4 Food poisoning due to Bacillus cereus
A05.8 Other specified bacterial foodborne intoxications
A05.9 Bacterial food poisoning, unspecified
A06 Amoebiasis
A06.0 Acute amoebic dysentery
A06.1 Chronic intestinal amebiasis
A06.2 Amebic nondysenteric colitis
A06.3 Intestinal amoeba
A06.4 Amebic liver abscess
A06.5 Amebic lung abscess (J99.8 *)
A06.6 Amebic abscess of the brain (G07 *)
A06.7 Cutaneous amebiasis
A06.8 Amebic infection of other localization
A06.8 Amoebiasis, unspecified
A07 Other protozoal intestinal diseases
A07.0 Balantidiasis
A07.1 Giardiasis (giardiasis)
A07.2 Cryptosporidiosis
A07.3 Isosporosis
A07.8 Other specified protozoal intestinal diseases
A07.9 Protozoal intestinal disease, unspecified
A08 Viral and other specified intestinal infections
A08.0 Rotavirus enteritis
A08.1 Acute gastroenteropathy caused by Norwalk pathogen
A08.2 Adenoviral enteritis
A08.3 Other viral enteritis
A08.4 Viral intestinal infection, unspecified
A08.5 Other specified intestinal infections
A08 Diarrhea and gastroenteritis of suspected infectious origin
Document revision taking into account
changes and additions prepared
JSC "Codex"
RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols MH RK - 2017
Viral and other specified intestinal infections (A08), Diarrhea and gastroenteritis of suspected infectious origin (A09), Other bacterial intestinal infections (A04), Other salmonella infections (A02), Cholera (A00), Shigellosis (A03)
Infectious diseases in children, Pediatrics
general information
Short description
Approved
Joint Commission on the Quality of Medical Services
Ministry of Health of the Republic of Kazakhstan
dated August 18, 2017
Protocol No. 26
Bacterial intestinal infectionsis a group of human infectious diseases with an enteral (fecal-oral) infection mechanism caused by pathogenic (Shigella, Salmonella, etc.) and opportunistic bacteria (Proteus, Klebsiella, Clostridia, etc.), characterized by a predominant lesion of the gastrointestinal tract and manifested by syndromes of intoxication and diarrhea.
INTRODUCTORY PART
ICD-10 code (s):
| ICD-10 | |
| The code | Name |
| A00 | cholera |
| A00.0 | Cholera caused by Vibrio cholera 01, biovar cholerae |
| A00.1 | Cholera caused by Vibrio cholera 01, biovar eltor |
| A00.9 | Cholera, unspecified |
| A02 | Other salmonella infections |
| A02.0 | Salmonella enteritis |
| A02.1 | Salmonella septicemia |
| A02.2 | Localized salmonella infection |
| A02.8 | Other specified salmonella infections |
| A02.9 | Salmonella infection, unspecified |
| A03 | Shigellosis |
| A03.0 | Shigellosis due to Shigella dysenteriae |
| A03.1 | Shigellosis due to Shigella flexneri |
| A03.2 | Shigellosis due to Shigella boydii |
| A03.3 | Shigellosis due to Shigella sonnei |
| A03.8 | Another shigellosis |
| A03.9 | Shigellosis, unspecified |
| A04 | Other bacterial intestinal infections |
| A04.0 | Enteropathogenic Escherichia coli infection |
| A04.1 | Enterotoxigenic Escherichia coli infection |
| A04.2 | Enteroinvasive Escherichia coli infection |
| A04.3 | Enterohaemorrhagic Escherichia coli infection |
| A04.4 | Other intestinal infections with Escherichia coli |
| A04.5 | Campylobacter enteritis |
| A04.6 | Yersinia enterocolitica enteritis |
| A04.7 | Clostridium difficile enterocolitis |
| A04.8 | Other specified bacterial intestinal infections |
| A04.9 | Bacterial intestinal infection, unspecified |
| A08 | Viral and other specified intestinal infections |
| A09 | Diarrhea and gastroenteritis of suspected infectious origin |
Date of development / revision of the protocol: 2017 year.
Abbreviations used in the protocol:
| Gastrointestinal tract | - | gastrointestinal tract |
| IU | - | international units |
| UAC | - | general blood analysis |
| OAM | - | general urine analysis |
| IMCI | - | Integrated Management of Childhood Illness |
| ELISA | - | linked immunosorbent assay |
| OKI | - | acute intestinal infections |
| OBO | - | general danger signs |
| OPC | - | oral rehydration agents |
| ESPGHAN | - | European Society of Pediatric Gastroenterology, Hepatology and Nutrition |
| PCR | - | polymerase chain reaction |
| GP | - | general doctor |
| ESR | - | erythrocyte sedimentation rate |
| ICE | - | disseminated intravascular coagulation |
Protocol users: general practitioners, pediatric infectious disease specialists, pediatricians, paramedics, emergency doctors.
Evidence level scale:
| AND | High quality meta-analysis, systematic review of RCTs, or large RCTs with very low likelihood (++) of bias that can be generalized to the relevant population. |
| IN | High quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias that can be generalized to the relevant population ... |
| FROM | A cohort or case-control study or controlled trial without randomization with a low risk of bias (+), the results of which can be generalized to the relevant population, or RCTs with a very low or low risk of bias (++ or +), the results of which cannot be directly extended to the relevant population. |
| D | Description of a case series or uncontrolled study or expert opinion. |
| GPP | Best Pharmaceutical Practice. |
Classification
Classification :
| By etiology: |
... cholera; ... shigellosis; ... salmonellosis; ... escherichiosis; ... campylobacteriosis and other AEI caused by anaerobic pathogens; ... Yersinia enterocolitica; ... OCI caused by opportunistic microorganisms (staphylococci, Klebsiella, citrobacter, Pseudomonas aeruginosa, Proteus, etc.). |
| By severity | light, medium and severe forms |
| On the topic of gastrointestinal tract damage |
... gastritis; ... enteritis; ... gastroenteritis; ... gastroenterocolitis; ... enterocolitis; ... colitis. |
| With the flow |
... acute (up to 1 month); ... protracted (1-3 months); ... chronic (over 3 months). |
Salmonellosis classification:
Shigellosis classification:
Classification of Escherichiosis:
Classification of intestinal yersiniosis:
Cholera classification:
Classification of opportunistic intestinal infection:
Diagnostics
DIAGNOSTIC METHODS, APPROACHES AND PROCEDURES
Diagnostic criteria
Complaints:
Fever;
· nausea, vomiting;
Lethargy;
· stomach ache;
• loose stools 3 or more times during the day;
Flatulence.
| Anamnesis: | Physical examination: |
|
Epidemiological history: the use of low-quality products; reports of local outbreaks of intestinal infections, including stays in other hospitals; family or children's community members have similar symptoms. Medical history: The presence of symptoms of intoxication, fever, gastritis, gastroenteritis, enterocolitis, colitis. |
General intoxication syndrome: ... violation of the general condition; ... fever; ... weakness, lethargy; ... decreased appetite; ... vomiting; ... nausea; ... overlapping tongue. Dyspeptic syndrome: ... nausea, vomiting, bringing relief associated with food intake, in young children, persistent regurgitation; ... the appearance of pathological stools with enteritis - abundant, odorless, with undigested lumps, possibly with greens, with colitis: scanty loose stools with mucus, greens, streaks of blood; ... rumbling along the small and / or large intestine; ... flatulence; ... irritation of the skin around the anus, on the buttocks, perineum. Pain syndrome: ... with gastritis - pain in the upper abdomen, mainly in the epigastrium; ... with enteritis - constant pain in the umbilical region or throughout the abdomen; ... with colitis - pain in the sigmoid colon. Exicosis: ... signs of dehydration in the form of dry mucous membranes and skin, thirst or refusal to drink, decreased skin elasticity and tissue turgor, sunken eyes; ... retraction of the large fontanelle (in infants); ... violation of consciousness; ... weight loss; ... decrease in urine output. Neurotoxicosis: ... fever that does not respond well to antipyretic drugs; ... the appearance of vomiting, not associated with food intake and does not bring relief; ... convulsions; ... violation of peripheral hemodynamics; ... tachycardia. The syndrome of metabolic (metabolic) disorders: ... signs of hypokalemia - muscle hypotension, weakness, ... hyporeflexia, intestinal paresis; ... signs of metabolic acidosis - marbling and cyanosis of the skin, noisy toxic breathing, confusion. |
| Causative agents | The main symptoms |
| Cholera | Abdominal pain is uncommon. The stool is watery, odorless, the color of rice water, sometimes with the smell of raw fish. Vomiting occurs after diarrhea. Rapid development of exicosis. Little or no intoxication, normal body temperature. |
| Salmonellosis | Watery, foul-smelling stools, often green and marsh-colored. Prolonged fever, hepatosplenomegaly. |
| Intestinal yersiniosis | Prolonged fever. Intense pain around the navel or right iliac region. Abundant, offensive, often mixed with mucus and blood, stools. In the general analysis of blood, leukocytosis with neutrophilia. |
| OCI caused by opportunistic microorganisms | The main variants of lesions of the gastrointestinal tract in children over a year old are gastroenteritis and enteritis, less often - gastroenterocolitis, enterocolitis. In children of the first year of life, the clinic depends on the etiology and timing of infection. In patients with the first year of life, the intestinal form is often accompanied by the development of toxicosis and exicosis of I-II degree. Diarrhea is predominantly secretory-invasive. |
| Shigellosis | Symptoms of intoxication, frequent, scanty, with a lot of cloudy mucus, often green and blood, loose stools. |
|
Enteropathogenic Escherichia (EPE) Enteroinvasive Escherichia (EIE) Enterotoxigenic Escherichia (ETE) |
EPE: early age of the child; gradual start; infrequent but persistent vomiting; flatulence; copious watery stools; ETE: The onset of the disease is usually acute, with the appearance of repeated vomiting, "watery" diarrhea. Body temperature is most often within normal limits or subfebrile. Feces are devoid specific fecal odor, pathological impurities in them are absent, reminiscent of rice water. Exicosis develops rapidly. EIE: in older children, the disease begins, as a rule, acutely, with a rise in body temperature, headache, nausea, often vomiting, and moderate abdominal pain. Simultaneously or after a few hours, a liquid stool with pathological impurities appears. |
WHO and ESPGHAN / ESPID criteria (2008, 2014):
Assessment of fluid deficiency in a child according to WHO:
Severity of dehydration as a percentage of the child's body weight before illness
ESPGHAN recommends using the Clinical Dehydration Scale (CDS), where 0 points - no dehydration, 1 to 4 points - mild dehydration, 5-8 points correspond to severe dehydration.
Clinical Dehydration Scale (CDS):
| Sign | Points | ||
| 0 | 1 | 2 | |
| Appearance | Normal | Thirst, anxiety, irritability | Lethargy, drowsiness |
| Eyeballs | Not sunken | Slightly sunken | Sunken |
| Mucous membranes | Wet | dryish | Dry |
| Tears | Lacrimation is normal | Lacrimation is reduced | No tears |
The severity of dehydration in children according to IMCI in children under 5 years of age:
NB! If there are signs of severe dehydration, check for shock symptoms: cold hands, capillary filling time\u003e 3 seconds, weak and fast pulse.
Types of dehydration and clinical symptoms:
| sector | type of violation | clinical picture |
| intracellular | dehydration | thirst, dry tongue, agitation |
| overhydration | nausea, aversion to water, death | |
| interstitial | dehydration | folds, sclera, sunken eyes, pointed facial features are poorly straightened |
| overhydration | swelling | |
| vascular | dehydration | hypovolemia, venous collapse, ↓ CVP, tachycardia, microcirculation disorder, cold extremities, marbling, acrocyanosis |
| overhydration | BCC, CVP, vein swelling, shortness of breath, wheezing in the lungs |
Clinical criteria for assessing the degree of exicosis :
| Symptoms | Excosis degree | ||
| 1 | 2 | 3 | |
| Chair | infrequent | up to 10 times a day, enteric | frequent, watery |
| Vomiting | 1-2 times | repeated | multiple |
| General state | moderate | moderate to severe | heavy |
| Weight loss | up to 5% (\u003e 1 year up to 3%) | 6-9% (\u003e 1 year to 3-6%) | more than 10% (\u003e 1 year to 6-9%) |
| Thirst | moderate | pronounced | may be absent |
| Turgor of tissues | saved | the fold straightens slowly (up to 2 s.) |
the fold straightens very slowly (more than 2 s.) |
| Mucous membrane | wet | dryish, slightly hyperemic | dry, bright |
| Large fontanelle | At the level of the bones of the skull | slightly sunken | pulled in |
| Eyeballs | norm | sink | sink |
| Heart tones | loud | slightly muted | Muted |
| Blood pressure | normal or slightly increased | systolic normal, diastolic increased | reduced |
| Cyanosis | no | Moderate | pronounced |
| Consciousness, reaction to others | norm | Agitation or drowsiness, lethargy | Lethargic or unconscious |
| Pain response | expressed | Weakened | absent |
| Vote | norm | Weakened | often aphonia |
| Diuresis | saved | Reduced | Significantly reduced |
| Breath | norm | moderate shortness of breath | toxic |
| Body temperature | norm | often increased | often below normal |
| Tachycardia | no | Moderate | expressed |
Laboratory research :
KLA - leukocytosis, neutrophilia, accelerated ESR;
· Coprogram: the presence of undigested fiber, mucus, leukocytes, erythrocytes, neutral fats;
· Bacteriological examination of vomit or gastric lavage and feces, isolation of pathogenic / conditionally pathogenic flora.
Additional laboratory and instrumental studies:
B / x blood test: concentration of electrolytes in blood serum, urea, creatinine, residual nitrogen, total protein (with dehydration);
· Coagulogram (with DIC syndrome);
· Bacteriological examination of blood and urine - isolation of pathogenic / conditionally pathogenic flora;
· RPHA (RNGA) blood with specific antigenic diagnostics - an increase in antibody titers with a repeated reaction by 4 or more times.
· PCR - determination of the DNA of intestinal infections of bacterial etiology.
Indications for specialist consultation:
· Consultation with a surgeon - if you suspect appendicitis, intestinal obstruction, intestinal intussusception.
Diagnostic algorithm:
Differential diagnosis
Differential diagnosis and justification for additional research:
| Diagnosis | Rationale for differential diagnosis | Surveys | Criteria for excluding a diagnosis |
| Rotavirus infection | ELISA - determination of rotavirus antigens in feces. | Watery stools, vomiting, short-term fever. | |
| Enterovirus infection |
Fever, vomiting, loose stools. |
PCR - determination of RNA of enteroviruses in feces. | Herpangina, exanthema, gastroenteritis. |
| Intestinal intussusception | Loose stools, abdominal pain. | Consultation with a surgeon | Crying attacks, with pale skin of the infant. Blood in the stool ("raspberry" or "currant jelly") without stool impurities 4-6 hours after the onset of the disease. Bloating, induration in the abdomen. soft-elastic consistency. In dynamics, repeated vomiting. |
| Adenovirus infection |
Fever, vomiting, loose stools. |
PCR - determination of DNA of adenoviruses in feces. | Prolonged fever. Pharyngitis, tonsillitis, rhinitis, conjunctivitis, enteritis, hepatosplenomegaly. |
| Acute appendicitis |
Fever, vomiting, loose stools. |
Consultation with a surgeon. | Pain in the epigastrium with movement to the right iliac region. The pain is constant, aggravated by coughing. The stool is liquid, without pathological impurities, up to 3-4 times, often constipation. |
Treatment abroad
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Treatment
Preparations (active ingredients) used in treatment
Groups of drugs according to ATC used in treatment
Treatment (outpatient clinic)
TACTICS OF TREATMENT AT THE AMBULATORY LEVEL
On an outpatient basis, children with mild and moderate forms (children over 36 months old) receive treatment for AEI of bacterial etiology.
The principles of treatment of patients with acute respiratory infections include: regimen, rehydration, diet, pathogenetic and symptomatic therapy.
In case of ineffectiveness of outpatient treatment or its impossibility, the issue of hospitalization of the child in a specialized hospital is considered.
Non-drug treatment:
· Semi-bed mode (during the entire period of fever);
· Diet - depending on the child's age, food preferences and eating habits before the onset of the illness;
· Breastfed babies should be breastfed as often and for as long as they want;
· Children who are bottle-fed, continue to feed their usual food;
· Children aged 6 months to 2 years - table number 16, from 2 years and older - table number 4;
Drug treatment
For relief of hyperthermic syndrome over 38.5 0 С:
... paracetamol 10-15 mg / kg with an interval of at least 4 hours, no more than three days by mouth or per rectum, or ibuprofen at a dose of 5-10 mg / kg no more than 3 times a day by mouth.
For diarrhea without dehydration - plan A:
· Breastfeed more often and increase the duration of each feeding if the baby is exclusively breastfed, give additional ORS or clean water in addition to breast milk.
· If the baby is mixed or formula fed, give the following fluids in any combination: ORS solution, liquid food (eg soup, rice water) or clean water.
Explain to the mother how much fluid should be given in addition to the usual intake:
· Up to 2 years 50-100 ml after each loose stool;
2 years and older 100-200 ml after each loose stool.
· Continue feeding;
Advise the mother to take the baby back to hospital immediately if any of the following symptoms appear:
· Cannot drink or suckle;
· The child's condition worsens;
• fever has appeared;
The child has blood in his stool or does not drink well.
For diarrhea with moderate dehydration - plan B:
The required ORS volume (in ml) can be calculated by multiplying the child's weight (in kg) by 75.
· To drink the calculated volume of liquid for 4 hours.
· If the child eagerly drinks the ORS solution and asks for more, more than the recommended amount can be given. Breastfeeding should be continued at the request of the baby. For formula-fed infants, the feeding is canceled and oral rehydration is administered for the first 4 hours.
· After 4 hours, reassess the child's condition and determine the hydration status: if 2 or more signs of moderate dehydration persist, continue with plan B for another 4 hours and feed according to age.
· In the absence of the effect of oral rehydration on an outpatient basis, the patient is referred for inpatient treatment.
With a replacement purpose for the correction of exocrine pancreatic insufficiency, pancreatin 1000 U / kg / day with meals for 7-10 days.
For the purpose of etiotropic therapy of acute intestinal infections: azithromycin on the first day 10 mg / kg, from the second to the fifth day, 5 mg / kg once a day by mouth;
· Children over six years old - ciprofloxacin 20 mg / kg / day in two oral doses for 5-7 days.
List of essential medicines:
| Pharmacological group | Mode of application | UD | |
| Anilides | Paracetamol | Syrup for oral administration 60 ml and 100 ml, 5 ml - 125 mg; tablets for oral administration, 0.2 g and 0.5 g; rectal suppositories; solution for injection (in 1 ml 150 mg). | AND |
|
Dextrose + potassium chloride + sodium chloride + sodium citrate |
FROM | ||
| Azithromycin | IN |
List of additional medicines:
| Pharmacological group | International non-proprietary drug name | Mode of application | UD |
| Propionic acid derivatives | Ibuprofen | Suspension and tablets for oral administration. Suspension 100mg / 5ml; tablets 200 mg; | AND |
| Enzymatic preparations | Pancreatin | IN | |
| Ciprofloxacin | tablets 0.25 g and 0.5 g; in bottles for infusion of 50 ml (100 mg) and 100 ml (200 mg) | AND |
Surgical intervention: no.
Further management[
1-4,19
]
:
· Discharge to the children's team in case of clinical and laboratory recovery;
• a single bacteriological examination of convalescents after dysentery and other acute diarrheal infections is carried out after clinical recovery, but not earlier than two calendar days after the end of antibiotic therapy;
· In case of a relapse of the disease or a positive result of laboratory examination, persons who have had dysentery again undergo treatment. After the end of treatment, these individuals undergo monthly laboratory examinations for three months. Persons who have been carrying bacteria for more than three months are treated as patients with a chronic form of dysentery;
· Persons with chronic dysentery are on dispensary observation throughout the year. Bacteriological examinations and examination by an infectious disease doctor of persons with chronic dysentery are carried out monthly;
· Children who continue to excrete Salmonella after the end of treatment are suspended by the attending physician from visiting the organization of preschool education for fifteen calendar days; during this period, a three-time study of feces is carried out with an interval of one to two days. In case of a repeated positive result, the same procedure for removal and examination is repeated for another fifteen days.
[
1-4,7
]
:
· Negative results of bacteriological studies;
· Stool normalization.
Treatment (hospital)
STATIONARY TREATMENT TACTICS
The basis of therapeutic measures for acute intestinal infections of bacterial etiology is therapy, including: regimen, rehydration, diet, etiotropic, pathogenetic and symptomatic therapy.
Oral rehydration is a two-step process:
Stage I - in the first 6 hours after admission of the patient, the water-salt deficiency that occurs before the start of treatment is eliminated;
· With dehydration of the I st. the volume of liquid is 40-50 ml / kg, and with dehydration of the II stage - 80-90 ml / kg of body weight in 6 hours;
Stage II - supportive oral rehydration, which is carried out for the entire subsequent period of the disease in the presence of ongoing loss of fluid and electrolytes. The approximate volume of solution for maintenance rehydration is 80-100 ml / kg of body weight per day. The effectiveness of oral rehydration is assessed by the following criteria: a decrease in the volume of fluid loss; reducing the rate of weight loss; the disappearance of clinical signs of dehydration; normalization of diuresis; improving the general condition of the child.
Indications for parenteral rehydration and detoxification:
· Severe forms of dehydration with signs of hypovolemic shock;
· Infectious toxic shock;
· Neurotoxicosis;
· Severe forms of dehydration;
· Combination of exicosis (of any degree) with severe intoxication;
Indomitable vomiting;
Ineffectiveness of oral rehydration therapy within 8 hours with plan B or transition from moderate dehydration to severe dehydration.
The program for parenteral rehydration therapy on the first day is based on calculating the required amount of fluid and determining the qualitative composition of rehydration solutions. The required volume is calculated as follows:
Total volume (ml) \u003d FP + PP + D, where FP is the daily physiological need for water; PP - pathological losses (with vomiting, loose stools, perspiration); D - fluid deficiency that the child has before the start of infusion therapy.
The amount of fluid required to compensate for the existing fluid deficit depends on the severity of dehydration and is roughly determined based on the deficit in body weight. In case of exicosis of the 1st degree, 30-50 ml / kg per day is required to compensate for the deficiency, with exicosis of the II degree - 60-90 ml / kg per day, and with dehydration of the III degree - 100-150 ml / kg per day. The volume of the existing deficit is corrected gradually, only with dehydration of the first degree it is possible to compensate for the deficit within one day. For a more accurate accounting of pathological losses, it is necessary to carefully record all external losses (vomiting, loose stools) by measuring or weighing them. Replenishment of current pathological losses is carried out with pronounced massive losses every 4-8 hours, with moderate losses - every 12 hours.
The choice of starting solution for infusion therapy is determined by the degree of hemodynamic disturbance and the type of dehydration. Severe hemodynamic disorders in all types of dehydration are corrected with balanced isoosmolar saline solutions (saline, Ringer's solution, etc.), and, if necessary, in combination with colloidal solutions. The main principle of infusion therapy for dehydration syndrome is that the loss must be reimbursed with an infusion medium similar to the lost one.
Do not use any low osmolarity solutions (5% dextrose solutions, low osmolarity polyionic solutions) as a starting solution. In this regard, the most dangerous 5% dextrose solutions. First, because of their hypo-osmolarity; secondly, the utilization of glucose is accompanied by the formation of "free" water, which further enhances intracellular hyperhydration (danger of cerebral edema); thirdly, under-oxidation of glucose under conditions of tissue hypoperfusion leads to even greater lactic acidosis.
Patient observation chart, patient routing:
Drug-free treatment[
1-4
]
:
... semi-bed mode (during the entire period of fever);
... diet - depending on the child's age, food preferences and eating habits before the onset of the illness;
... breastfed babies should be breastfed as often and for as long as they want;
... children who are bottle-fed, continue to feed their usual food;
... children aged 6 months to 2 years - table number 16, from 2 years and older - table number 4;
... children with lactose deficiency are prescribed low / lactose-free mixtures.
Drug treatment:
for relief of hyperthermic syndrome over 38.5 o C, it is prescribed:
Paracetamol 10-15 mg / kg with an interval of at least 4 hours, no more than three days by mouth or per rectum;
· or
Ibuprofen at a dose of 5-10 mg / kg no more than 3 times a day by mouth;
For diarrhea without dehydration - plan A, with moderate dehydration - plan B.
For severe dehydration - plan B: IV fluids for the child<12 мес. 30 мл/кг в течение 1 часа, затем введите 70 мл/кг за 5 часов. Если ребенок ≥ 12 мес. в/в за 30 мин 30 мл/кг, затем 70 мл/кг за 2,5 часа. Повторяйте оценку через каждые 15-30 мин. Если статус гидратации не улучшается, увеличьте скорость капельного введения жидкостей. Также давайте растворы ОРС (около 5 мл/кг/ч) как только ребенок сможет пить: обычно через 3-4 ч (младенцы) или 1-2 ч (дети более старшего возраста). Повторно оцените состояние младенца через 6 ч, а ребенка старше одного года - через 3 ч. Определите степень обезвоживания. Затем выберите соответствующий план (А, Б или В) для продолжения лечения.
For the purpose of detoxification therapy, intravenous infusion at the rate of 30-50 ml / kg / day with the inclusion of solutions:
10% dextrose (10-15 ml / kg);
0.9% sodium chloride (10-15 ml / kg);
Ringer's (10-15 ml / kg).
With a replacement purpose for the correction of exocrine pancreatic insufficiency, pancreatin 1000 U / kg / day with meals for 7-10 days.
Antibacterial drugs are prescribed in age-specific dosages, taking into account the etiology of AEI. When choosing an antibacterial drug, the severity of the disease, the age of the child, the presence of concomitant pathology and complications are taken into account. If the temperature in a patient with a confirmed AEI does not decrease within 46-72 hours, alternative antimicrobial methods should be considered.
Etiotropic antibacterial therapy[
1-5
]
:
| Etiology of OCI | First line antibiotics | Second line antibiotics | ||||
| Antibiotic | Daily dose (mg / kg) | Days | Antibiotic | Daily dose(mg / kg) | Days | |
| Shigellosis | azithromycin | 5 | ciprofloxacin | 20- 30 | 5-7 | |
|
norfloxacin |
15 |
5-7 |
||||
| Salmonellosis | Ceftriaxon | 50-75 | 5-7 |
azithromycin |
1 day - 10 mg / kg, then 5-10 mg / kg | 5 |
| Cefotaxime | 50-100 | 5-7 | ||||
| norfloxacin | 15 | 5-7 | ||||
| Escherichiosis | azithromycin | 1 day - 10 mg / kg, then 5-10 mg / kg | 5 | cefixime | 8 | 5 |
| Cholera | azithromycin | 1 day - 10 mg / kg, then 5-10 mg / kg | 5 | ciprofloxacin | 20-30 | 5-7 |
| Intestinal yersiniosis | Ceftriaxon | 50-75 | 5-7 | ciprofloxacin | 20-30 | 5-7 |
| Cefotaxime | 50-100 | 5-7 | norfloxacin |
15 |
5-7 |
|
| Campylobacteriosis | azithromycin | 1 day - 10 mg / kg, then 5-10 mg / kg | 5 | ciprofloxacin | 20-30 | 5-7 |
| Staphylococcal infection | azithromycin | 5 | cefuroxime | 50-100 | 5-7 | |
| amikacin | 10-15 | 5-7 | ||||
| OCI caused by UPF | azithromycin | 1 day - 10 mg / kg, then 5-10 mg / kg | 5 | ceftriaxone | 50-75 | 5-7 |
|
cefotaxime |
50-100 | 5-7 | ||||
| amikacin | 10-15 | 5-7 | ||||
· Azithromycin on the first day 10 mg / kg, from the second to the fifth day, 5 mg / kg once a day by mouth;
· Children over six years of age ciprofloxacin 20-30 mg / kg / day in two oral doses for 5-7 days;
· Ceftriaxone 50-75 mg / kg per day IM or IV, up to one gram - once a day, more than one gram - twice a day. The course of treatment is 5-7 days; or
· Cefotaxime 50-100 mg / kg per day intramuscularly or intravenously, in two or three doses. The course of treatment is 5-7 days; or
Amikacin 10-15 mg / kg per day IM or IV in two divided doses. The course of treatment is 5-7 days; or
· Cefuroxime 50-100 mg / kg per day intramuscularly or intravenously in two or three doses. The course of treatment is 5-7 days.
Essential Medicines List[1-
5
,11-18
]:
| Pharmacological group | International non-proprietary drug name | Mode of application | UD |
| Anilides | paracetamol | Syrup for oral administration 60 ml and 100 ml, 5 ml - 125 mg; tablets for oral administration, 0.2 g and 0.5 g; rectal suppositories; | AND |
| Solutions affecting the water-electrolyte balance |
dextrose + potassium chloride + sodium chloride + sodium citrate* |
Powder for solution preparation inside. | FROM |
| Systemic antibacterial drugs | azithromycin. | powder for preparation of suspension for oral administration 100 mg / 5 ml, 200 mg / 5 ml; tablets 125 mg, 250 mg, 500 mg; capsules 250 mg, 500 mg | IN |
List of complementary medicines :
| Other irrigation solutions | dextrose | Solution for infusion 5% 200 ml, 400 ml; 10% 200 ml, 400 ml | FROM |
| Saline solutions | sodium chloride solution |
Solution for infusion 0.9% 100 ml, 250 ml, 400 ml |
FROM |
| Saline solutions | ringer's solution * |
Solution for infusion 200 ml, 400 ml |
FROM |
| Second generation cephalosporins | cefuroxime |
powder for solution for injection 250 mg, 750 mg and 1500 mg |
AND |
| ceftriaxone | powder for preparation of solution for intravenous and intramuscular administration of 1 g. | AND | |
| Third generation cephalosporins | cefixime | coated tablets 200 mg, powder for oral suspension 100 mg / 5 ml | AND |
| Third generation cephalosporins | cefotaxime | powder for preparation of a solution for i / v and i / m administration 1 g | AND |
| Other aminoglycosides | amikacin |
powder for solution for injection 500 mg; solution for injection 500 mg / 2 ml, 2 ml |
AND |
| Antibacterial drugs - quinolone derivatives | ciprofloxacin | film-coated tablets 250 mg, .500 mg for oral administration | AND |
| Antibacterial drugs - quinolone derivatives | norfloxacin | Tablets 400, 800 mg for oral administration | AND |
| Enzymatic preparations | pancreatin | Capsules 10,000 and 25,000 IU for oral administration. | IN |
Surgical intervention: no.
Further management :
· Discharge of convalescents after dysentery and other acute diarrheal infections (except for salmonellosis) is carried out after complete clinical recovery.
A single bacteriological examination of convalescents of dysentery and other acute diarrheal infections (with the exception of toxin-mediated and caused by opportunistic pathogens such as Proreus, Citrobacter, Enterobacter, etc.) is carried out on an outpatient basis within seven calendar days after discharge, but not earlier two days after the end of antibiotic therapy.
· Dispensary observation is carried out within one month, after which a single bacteriological examination is required.
· The frequency of visits to the doctor is determined by clinical indications.
· Dispensary observation is carried out by a GP / pediatrician at the place of residence or a doctor in the office of infectious diseases.
· In case of a relapse of the disease or a positive result of laboratory examination, persons who have had dysentery again undergo treatment. After the end of treatment, these individuals undergo monthly laboratory examinations for three months. Persons who carry bacteria for more than three months are treated as patients with chronic dysentery.
· Persons with chronic dysentery are on dispensary observation throughout the year. Bacteriological examinations and examination by an infectious disease doctor of these persons are carried out monthly.
· The discharge of salmonellosis convalescents is carried out after complete clinical recovery and a single negative bacteriological examination of feces. The study is carried out no earlier than three days after the end of treatment.
· Dispensary observation after the transferred disease is subject only to the decreed contingent.
· Children who continue to excrete Salmonella after the end of treatment are suspended by the attending physician from visiting the organization of preschool education for fifteen days; during this period, a three-time study of feces is carried out with an interval of one to two days. With a repeated positive result, the same procedure for removal and examination is repeated for another fifteen days.
Treatment effectiveness indicators[
1-4
]
:
· Normalization of body temperature;
· Restoration of water and electrolyte balance;
· Relief of symptoms of intoxication;
· Relief of gastrointestinal syndrome;
· Stool normalization.
Hospitalization
INDICATIONS FOR HOSPITALIZATION WITH INDICATION OF THE TYPE OF HOSPITALIZATION
Indications for planned hospitalization: no
Indications for emergency hospitalization:
· Children with severe and moderate forms (up to 36 months) of viral gastroenteritis;
· All forms of the disease in children under the age of two months;
· Forms of the disease with severe dehydration, regardless of the age of the child;
Lingering diarrhea with dehydration of any degree;
· Chronic forms of dysentery (with exacerbation);
· Burdened premorbid background (prematurity, chronic diseases, etc.);
Fever\u003e 38 ° C in children<3 месяцев или> 390 C for children from 3 to 36 months;
Severe diarrheal syndrome (frequent and significant stools in volume);
Persistent (repeated) vomiting;
· Lack of effect from oral rehydration;
· No effect of outpatient treatment within 48 hours;
· Clinical symptom complex of a severe infectious disease with hemodynamic disorder, organ failure;
· Epidemiological indications (children from "closed" institutions with round-the-clock stay, from large families, etc.);
· Cases of illness in medical organizations, boarding schools, orphanages, children's homes, sanatoriums, boarding schools for the elderly and disabled, summer health organizations, rest homes;
· Inability to provide adequate home care (social problems).
Information
Sources and Literature
- Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2017
- 1) Roberg M. Kliegman, Bonita F. Stanton, Joseph W. St. Geme, Nina F. Schoor / Nelson Textbook of Pediatrics. Twentieth edition. International Edition.// Elsevier-2016, vol. 2-th. 2) Uchaikin V.F., Nisevich N.I., Shamshieva O.V. Infectious diseases in children: textbook - Moscow, GEOTAR-Media, 2011 - 688 p. 3) Treatment of diarrhea. A textbook for doctors and other categories of senior health workers: World Health Organization, 2006 4) Provision of inpatient care for children (WHO Guidelines for the management of the most common diseases in primary hospitals, adapted to the conditions of the Republic of Kazakhstan) 2016. 450 s. Europe. 5) Farthing M., Salam M., Lindberg G. et al. Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organization, 2012 // www.worldgastroenterology.org/ 6) World Gastroenterology Organization (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology Organization (WGO); 2008 Mar.28p. 7) Implementation of new guidelines for the clinical management of diarrhea. Guidelines for decision makers and program managers, WHO, 2012 // www.euro.who.int/__data/assets/pdf_file/0007/.../9244594218R.pdf. 8) National Collaborating Center for Women "s and Children" s Health. Diarrhoea and vomiting in children. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Apr 9) Centers for Disease Control and Prevention. Salmonella Senftenberg Infections, Serbia. Emerging Infectious Diseases 2010; 16 (5): 893-894. 10) Majowicz SE, Musto J, Scallan E, Angulo FJ, Kirk M, O'Brien SJ, et al; International Collaboration on Enteric Disease ‘Burden of Illness’ Studies. The global burden of nontyphoidal Salmonella gastroenteritis. Clin Infect Dis. 2010; 50: 882-9. http://dx.doi.org/ 10.1086/ 650733 11) Petrovska L, Mather AE, AbuOun M, Branchu P, Harris SR, Connor T, et al. Microevolution of monophasic Salmonella Typhimurium during epidemic, United Kingdom, 2005-2010. Emerg Infect Dis. 2016; 22: 617-24. http://dx.doi.org/10.3201/ eid2204.150531 12) Samuel J. Bloomfield, Jackie Benschop, Patrick J. Biggs, Jonathan C. Marshall, David T.S. Hayman, Philip E. Carter, Anne C. Midwinter, Alison E. Mather, Nigel P. FrenchLu J, Sun L, Fang L, Yang F, Mo Y, Lao J, et al. Genomic Analysis of Salmonella enterica Serovar Typhimurium DT160 Associated with a 14-Year Outbreak, New Zealand, 1998–2012 Emerging Infectious Diseases www.cdc.gov/eid Vol. 23, No. 6, June 2017 13) G. Gigante, G. Caracciolo, M. Campanale, V. Cesario, G. Gasbarrini, G. Cammarota, A. Gasbarrini Ospedale Gemelli, Rome, Italy; Fondazione Italiana Ricerca in Medicina, Rome, Italy Gelatine Tannate reduces antibiotics associated side-effects of anti-helicobacter pylori first- line therapy Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 14) Gelatin tannate for treating acute gastroenteritis: a systematic review Center for Reviews and Dissemination Original Author (s): Ruszczynski M, Urbanska M and Szajewska H Annals of Gastroenterology, 2014, 27 (2), 121-124 15) Esteban Carretero J , Durbán Reguera F, López-Argüeta Ál - varez S, López Montes J. A comparative analysis of response to ORS (oral rehydration solution) vs. ORS + gelatin tannate in two cohorts of pediatric patients with acute diarrhea. Rev Esp Enferm Dig 2009; 101: 41-49. 16) Large reference book of medicines / ed. L. E. Ziganshina, V. K. Lepakhina, V. I. Petrov, R. U. Khabrieva. - M .: GEOTAR-Media, 2011. - 3344 p. 17) BNF for children 2014-2015 18) Order of the Minister of National Economy of the Republic of Kazakhstan dated March 12, 2015 No. 194. Registered with the Ministry of Justice of the Republic of Kazakhstan on April 16, 2015 No. 10741 About approval of the Sanitary Rules "Sanitary and Epidemiological Requirements for the Organization and Conduct of Sanitary and Antiepidemic (Preventive) Measures to Prevent Infectious Diseases"
Information
ORGANIZATIONAL ASPECTS OF THE PROTOCOL
List of protocol developers:
1) Efendiev Imdat Musa oglu - Candidate of Medical Sciences, Head of the Department of Pediatric Infectious Diseases and Phthisiology, State Medical University of Semey State Medical University.
2) Baesheva Dinagul Ayapbekovna - Doctor of Medical Sciences, Associate Professor, Head of the Department of Children's Infectious Diseases, JSC "Astana Medical University".
3) Kuttykuzhanova Galiya Gabdullaevna - Doctor of Medical Sciences, Professor, Professor of the Department of Pediatric Infectious Diseases of the Republican State Enterprise at the REM “Kazakh National Medical University named after S. D. Asfendiyarov.
4) Devdariani Khatuna Georgievna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, Republican State Enterprise at the RHV "Karaganda State Medical University".
5) Zhumagalieva Galina Dautovna - Candidate of Medical Sciences, Associate Professor, Head of the Course of Children's Infections, Republican State Enterprise at the REM “West Kazakhstan State University named after Marat Ospanov ".
6) Mazhitov Talgat Mansurovich - Doctor of Medical Sciences, Professor, Professor of the Department of Clinical Pharmacology, JSC "Astana Medical University".
7) Umesheva Kumuskul Abdullaevna - Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Infectious Diseases, RSE at the REM “Kazakh National Medical University named after S. D. Asfendiyarov ".
8) Alshynbekova Gulsharbat Kanagatovna - Candidate of Medical Sciences, Acting Professor of the Department of Children's Infectious Diseases, Republican State Enterprise at the REM "Karaganda State Medical University".
No Conflict of Interest Statement:no .
Reviewers:
1) Kosherova Bakhyt Nurgalievna - Doctor of Medical Sciences, Professor of the Republican State Enterprise at the Karaganda State Medical University, Vice-Rector for Clinical Work and Continuous Professional Development, Professor of the Department of Infectious Diseases.
Indication of the conditions for revision of the protocol:revision of the protocol 5 years after its publication and from the date of its entry into force or if there are new methods with a level of evidence.
Attached files
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