1. Acute Intestinal Infections. Lecturer: ass.prof. Gorishna I.L.

2. Plan of the lecture 1.Definition of Acute intestinal diseases 2.Reasons of Acute Intestinal Diseases 3.Clinical, Epidemiological Peculiarities, Differential Diagnosis, Treatment of Escherichiosis 4.Clinical, Epidemiological Peculiarities, Differential Diagnosis, Treatment of Shigellosis 5.Clinical, Epidemiological Peculiarities, Differential Diagnosis, Treatment of Salmonellosis 6.Toxicosis And Exicosis. Pathogenesis, Clinical Features, 7.Toxicosis And Exicosis. Treatment

3. Definitions Acute intestinal diseases – the group of disorders with diarrhea syndrome which can accompanied with toxicosis and dehydration

4. Actuality Diarrheal diseases cause one billion episodes of illness and 3-5 million deaths annually. They range from 1.3 to 2.3 episodes of diarrhea per year in children under five years of age. Infectious gastroenterocolitis account for about 10-15% of the diarrheal illnesses of children presenting to the emergency department.

5. common causes of diarrhea Functional digestive disorders Inborn errors of metabolism Some surgical disorders Acute intestinal diseases

6. Etiology of Acute Intestinal Diseases bacterial agents –Escherichia coli –Shigella, – Salmonella, –Campylobacter jejuni –Yersinia enterocolitica. –Clostridium difficile –Vibrio cholerae enteroviruses (infectio enteroviralis) –Rotavirus –Coxsackie viruses –ECHO (Enteric Cytopathogenic Human Orphan) viruses –Astrovirus Parvovirus - Parasites Giardia lamblia Cryptosporidium

7. Escherichia Coli Infection is an acute infectious disease mainly of early age children, caused by different pathogenic strains of Escherichia coli (Enterotoxigenic, Enteropathogenic, Enteroinvasive, Enterohemorrhagic, Enteroaggregative)

8. Etiology Escherichia coli, a facultatively anaerobic gram-negative bacillus, is a major component of the normal intestinal flora and ubiquitous in the human environment.

9. Transmission The way of transmission Contact Alimentary (by water, milk, food)

10. Source of infection Contagious patient Bacillus carrier

11. Pathogenesis Enteropathogenic E.coli strains destroy the microvilli, lover the disaccharidases, and cause inflammation of the small bowel and malabsorption. Enterotoxigenic strains results in derangement of electrolytes and water absorption, similar to that of V.cholerae. Enteroinvasive strains colonize the colon and distal part of the small intestine and cause damage to the epithelium. Enterohemorrhagic E.coli O157H7 has been shown to produce diarrhea and hemorrhagic colitis Enteroaggregative E coli is not good studied

12. Localisation of the process – in small intestinum

13. Incubation period Short (from a few hours to 8 days)

14. Enteropathogenic E.coli infection Gradual growth of symptoms up to 5-7 days. Subfebril temperature. Vomits, regurgitation from the disease beginning. The watery massive yellow-orange feces with the two-bit of mucus, green color admixtures, up to 10-15 times per day. Toxicosis with dehydration of 2-3 degree

15. Enteropathogenic E coli metheorism (abdominal distension)

16. Enteropathogenic E coli infection, typical color of feces

17. Enteroinvasive E.coli infection Acute beginning with the severe toxic syndrome, fever (1-3 days), rarer vomits. Diarrhea in the 1st day of the disease: feces with the admixtures of mucus and green, blood 3-5 times per day. Abdomen is tender by the colon way, infiltrated sigmoid colon, tenesms are absent. Rapid recovery, normalization of feces in 3-5 days.

18. Enterotoxigenic E.coli infection Acute beginning from the repeated vomiting, watery diarrhea. Intoxication is absent; body temperature is normal or subfebrile. grumbling along thin intestine during palpation. Feces 15-20 time per days, watery without pathological admixtures, of rice-water character. Development of severe dehydration Duration of the disease 5-10 days.

19. Enterohemorrhagic E.coli infection severe abdominal cramps, low – grade fever, grossly bloody stools, nausea and vomiting. hemolytic uremic syndrome (HUS)

20. Mild form Consists or acute onset of diarrhea Stool is watery, yellow or golden in colour. The temperature is normal Loss of appetites Duration of the disease is up to 1 week

21. Moderate form Acute onset of diarrhea Stool is watery, yellow or golden in colour with mucous and blood. The temperature is 38-39°C Anorexia Symptoms of toxicosis

22. Severe form Acute onset of diarrhea Symptoms of toxicosis Dehydration 2 nd -3 rd degree Stool is watery, yellow or golden in colour with mucous and blood. Defecation up to 20 times per day Intractable vomiting The temperature is 39-40°C Anorexia

23. Diagnosis example E.coli infection (caused by Enterotoxigenic strain), typical form, severe degree. Complication: hypertonic dehydration, 2 nd degree.

24. DIFFERENTIALS should be performed among acute non infectious diarrheas, salmonellosis, shigellosis, staphylococcal diarrhea, viral diarrhea, and cholera.

25. Lab Studies: Routine stool cultures Rapid enzyme immunoassays for E coli 0157:H7 Stool test (koprogram): inflammatory changes, intestinal enzymopathy Electrolyte changes in blood Full blood count

26. stool cultures

27. Shigellosis (dysentery) An acute human infectious diseases with enteral infection that is characterized by colitic syndrome and symptoms of general intoxication, quite often with development of primary neurotoxicosis.

28. Etiology of Shigella Infection Shigella dysenteriae Shigella sonnei Shigella flexneri Shigella boydii

29. Transmission Shigella is spread through fecal-oral mechanism of transmission. The way of transmission Contact Alimentary Watery

30. Source of infection Contagious patient Bacillus carrier Susceptibility: 60-70% especially infants and preschoolers. Seasonality: is summer-autumn.

31. Pathogenesis: Entering Shigella to gastrointestinal tract. Destruction of them by the enzymes. Toxemia. Toxic changes in organs and systems (especially in CNS). Local inflammatory process (due to colonizing of distal part of the colon). Diarrhea.

32. Incubation period Short (from a few hours to 7 days)

33. Localisation of the process

34. Classification of Shigella Infection I.Clinical Form With dominance of toxicosis with dominance of local inflammation II. Severity (mild, moderate and severe) III.Course acute (up to 1.5 mo) subacute (up to 3 mo) chronic (about 3 mo) –recurrent –constantly recurring IV. Complicated or uncomplicated V. Bacterium carrying

35. With dominance of toxicosis Toxicosis is the first sing may be neurotoxicosis (headache, vomiting, hallucinations, seizures, febrile temperature 39-40  C). Distal Colitis is secondary (abdominal pain, tenesmus, false urge to defecate, sigmoid colon is tender, anus is gaping in severe cases. Feces in the form of a rectal spit. Dehydration isn’t developed (except infants).

36. Toxicosis, marble skin

37. With dominance of local inflammation Sudden onset of high-grade fever abdominal cramping abdominal pain, tenesmus, and large-volume watery diarrhea → fecal incontinence, and small-volume mucoid diarrhea with frank blood

38. Peculiarities of shigellosis in infants: Acute beginning with slow development of signs and symptoms (for 3-5 days). Distal colitis is less common Enterocolitis is more often with enterocolitic feces, hemocolitis is rare. Hepato- and splenomegaly Crying, anxiety, red face during defecation is equivalent to tenesmus. Always occurs gaping anus, sphincteritis Dehydration is more often Prolonged duration of the disease

39. Sunken abdomen, dehydration

40. Shigella Infection false urge to defecate

41. Stools with greenish and mucous

42. Rectal spit

43. Rectal prolapse

44. Mild form Consistent or acute onset of diarrhea Stools are 5-8 times per day with mucous and blood Not permanent pain in abdominal region. The temperature is normal Loss of appetites May be vomiting

45. Moderate form Acute onset of diarrhea Symptoms of toxicosis The temperature is 38-39°C Anorexia Crampy abdominal pain Stools are 10-15 times per day Pain during palpation in left inguinal region hepatomegaly

46. Severe form Multiple vomiting not only after meal, but also independent, can be with bile, sometimes - as coffee lees, slools - more 15 times per day, sometimes - with each diaper, with much mucus, there is blood, sometimes - an intestinal bleeding General condition is sharply worsened, quite often - sopor, loss of the consciousness, cramps, changes in all organs and systems, severe toxicosis, may be dehydration (in infants), significant weight loss

47. Lab Studies: The white blood cell count is often within reference range, with a high percentage of bands. Occasionally, leukopenia or leukemoid reactions may be detected. If HUS, anemia and thrombocytopenia occur. Stool examination Increasing of red blood sells and leukocytes Stool culture Specimens should be plated lightly onto MacConkey, xylose-lysine-deoxycholate, or eosin-methylene blue agars. Serological test in dynamics with fourfold title increasing in 10-14 days

48. Shigella colonies

49. DIFFERENTIALS should be performed with: salmonellosis, escherichiosis, acute appendicitis, bowel invagination, Krohn’s disease, nonspecific necrotizing colitis.

50. Diagnosis example Shigellosis (Sh. sonnei), typical form (with dominance of toxicosis), severe degree, acute duration. Shigellosis (Sh. flexneri), typical form (with dominance of local inflammation), moderate degree, constantly recurring duration, complicated by the rectum prolapse

51. Salmonellosis an acute infectious disease of human and animals, that is caused by the numerous strains of Salmonella and more frequent courses as gastro- intestinal, rare – as typhoid or septic form

52. Etiology of Salmonella Infection S. typhimurium S. enteritidis S. java S. anatum

53. Transmission The way of transmission Contact Alimentary (by water, food) Droplet

54. Source of infection Domestic animals, birds Contagious patient Bacillus carrier

55. Pathogenesis Entering the salmonella into gastro- intestinal tract. Bacteria destruction of in the upper parts of gastro-intestinal tract. Toxemia. Bacteria which remain, enter bowel, colonize epitheliocytes. Local inflammatory process  diarrhea,  dehydration. Bacteriemia in newborns  Septic focci of salmonellosis.

56. Incubation period Short (from a few hours to 3 days)

57. Classification 1.Local form  Gastrointestinal form  Bacterium carrying 2.General form  Like typhoid fever  Sepsis 3.Asymptomatic form II.Severity (mild, moderate and severe) III.Course  acute (up to 1.5 mo)  subacute (up to 3 mo)  chronic (about 3 mo) IV. Complicated or uncomplicated

58. Salmonella Infection (gastrointestinal form) acute beginning from: intoxication (nausea, vomiting, high body temperature, headache); abdominal pain; diarrhea, usually appears secondary, stools are “muddy”, may be with blood and mucus, abdomen is tender; dehydration is moderate.

61. Salmonella Infection typical color of feces, hemocolitis

62. Salmonella Infection, severe hemocolitis

63. Typhoid form acute beginning from high temperature (39-40˚ C) lasting for 1-2 weeks, vomiting, hallucinations; “Typhoid” tongue; hepato-, splenomegaly from the 5-6 th day of disease; skin rash (roseols) on the trunk; diarrhea; tenderness in the right inguinal region.

64. Salmonella Infection Typhoid form

65. Septic form Etiology - antibiotic resistant, nosocomeal strains of Salmonella; contact transmittion. Incubation period is long (5-10 days). Usually occurs in newborns fever becomes hectic Septic focci: meningitis, pneumonia, osteomyelitis, pyelonephritis, enterocolitis); hepatosplenomegaly; thrombocytopenia; development of toxic-dystrophic syndrome; relapses, bacterial carrying high mortality;

66. Salmonella Infection septic form

67. Lab Studies: Complete blood count with differential Cultures: fecal, blood, urine, or bone marrow. Stools examination: hemoccult positive and positive for fecal polymorphonuclear cells. Chemistry: Electrolyte tests may reveal abnormalities consistent with dehydration. Serologic tests in dynamics with fourfold title increasing in 10-14 days

68. Diagnosis example Salmonellosis (S. enteritidis), typical local gastrointestinal form (enterocolitis), moderate degree, acute duration. Complication: isotonic dehydration, 1st degree. Salmonellosis (S. typhimurium), typical generalized septic form (enterocolitis, meningitis, bilateral pneumonia, left humeral bone osteomyelitis), severe degree, subacute duration. Complication: malnutrition, 2nd degree.

69. Differentials should be performed with: functional diarrhea, shigellosis, escherichiosis, klebsiellosis, typhoid fever, and sepsis of different etiology.

70. Dehydra tion

72. Symptom, signHypertonic dehydration Isotonic dehydration Hypotonic dehydration Body temperature Highly increased Normal, subfebril subnormal ThirstSevereModerateRefusal of water CNS reactionExitingSome exiting or dullness Adynamia Concentration of the sodium in blood IncreasedNormalDecreased Loss of body weight 5-10 %Less than 5 %More than 10 %

73. General principals of intestinal infections treatment  Dietary treatment  Specific treatment  Antibacterial treatment  Rehydration  Enterosorption  Symptomatic treatment

74. Hygienic regimen

75. Diet 4 In the acute period it is recommended to decrease daily food volume on 1/3 – 1/4. In infants and in case of urges to vomit numbers of food intake may increase up to 8- 10 per day. It is necessary to eliminate all dairy foods (including cheese), fish, hard sausage, chocolate, fried, greasy and spicy foods. Limit intake of meat, fats and foods containing gluten (barley, rye).

76. Diet 4 Hypochloric diet; milk and foods rich with fiber must be excluded. Stimulators of bile secretion are not recommended. Diet with low carbohydrate and fat content is administered. prepared in puree form and warm are acceptable. Food taking is 5-6 times a day. Nonacidic fresh or cooked vegetables are recommended as well as plenty of liquids.

77. Breast feeding In infants breast feeding must continue, those, who are bottle feeding – receive adopted milk formulas, better with low lactose content

78. Lactose- free or dairy formulas

79. Rice and oat flakes

80. Specific treatment Bacteriophage Coliphage, Salmonella phage, Shigella phage –Infant younger 6 mo 10 ml twice a day per os 20 ml a day per enema -Infant from 6 mo up to 12 mo 20 ml twice a day per os 40 ml a day per enema -Children older then 12 mo 30 ml twice a day per os 60 ml a day per enema

81. Etiotrope therapy for 5-7 days is used: in all severe cases, in case of hemocolitis, in moderate cases: »children before 1 year, »immune deficiency »shigellosis, amebiasis »secondary bacterial complications in mild cases in case of: »immune deficiency »hemolytic anemia »shigellosis, amebiasis »secondary bacterial complications

82. Antibacterial treatment Mild or moderate form – furazolidone 10 mg/kg day in 4 doses, or ercefuril (niphuroxazide); –Nalidixic acid (NegGram) - Pediatric Dose 55 mg/kg/d PO in 4 divided doses for 5 d. in severe cases – –amoxiclav 25-50 mg/kg, –or netylmycin 6-8 mg/kg, amikacin 10-15 mg/kg –or cefotaxim 100-150 mg/kg, –or ceftriaxon 100 mg/kg, –or ciprophloxacin 10-20 mg/kg per day in 2 equal doses.

84. Probiotics during acute period and for 3-4 weeks in the recovery period

85. Home treatment of dehydration The best fluid replacement for children younger than 2 years is Rehydron,Elektrolyt, Gastrolyte, ORS-200, Pedialyte, Rehydralyte, Pedialyte, or any similar product designed to replace fluids, sugar, and electrolytes. You can make your own oral rehydration fluid by following this recipe: one-half teaspoon table salt one-half teaspoon potassium chloride (lite salt) one-half teaspoon baking soda 4 tablespoons sugar dissolved in 1 liter of water Give a few sips every few minutes.

86. Oral rehydration is effective in case of 1 st - 2 nd degre. of dehydration in 80-95%. It is performed in 2 steps by glucose- saline fluids: first — water-electrolyte deficiency liquidation for the first 4-6 hours after hospitalization (50-100 ml/kg). second — maintenance therapy of the fluid loss (80-100 ml/kg for 18-20 hours). Oral intakes should be small –– 1-2 tea spoon every 5-10 minutes. water and saline fluids correlation is 1:1, in neonates –– 2:1.

88. Adequate rehydration criteria: Improvement of the clinical status; Progressive decreasing of dehydration symptoms; Peroral rehydration should be stopped when it is ineffective, and edema and oliguria is developing.

89. Parenteral rehydration should be performed in case of: Severe dehydration with hypovolemic shock; Toxic shock syndrome; Combination of dehydration with severe intoxication; Oliguria, anuria; Nonstop vomiting; Ineffective peroral rehydration during 4-6 hours.

90. Accounting of the fluids for rehydration (in ml) per 1 kg of the body weight stageFluid deficit, %Before 1 yr old 1-5 years6-10 years І5 %130-150100-12575-100 ІІ5-10 %170-200130-170100-125 ІІІ> 10%200-230170-200125-150

91. Correlation of IV fluids (water to saline): In case of isotonic dehydration –– 1:1; In case of hypertonic dehydration –– 2:1 or 3:1; In case of hypotonic dehydration –– 1:2.

92. Start fluids: In case of hypertonic dehydration –– 5 % glucose; In case of hypotonic dehydration –– 0,9 % NaCl; In case of isotonic dehydration –– 10 % glucose.

93. Correction of the electrolytes: Na, Cl deficit – by 0,9 % NaCl not more 100 ml/kg, К deficit – 4 % KCl 2-5 ml/kg, or 1-2 ml/kg 7,5 % KCl (1 ml of which is adequate to 1 mmol/l К) Mg deficit – 25 % MgSO 4 0,75-1,0 ml/kg.

94. Correction of the toxicosis: in case of neurotoxicosis Lytic suspension 0,1 ml/kg, seduxen 0,3 mg/kg, prednisone 2-3 mg/kg, dehydration – lasix 1-2 mg/kg hormones IV 5-20 mg/kg per day in 2-4 takes (by prednisone), toxic shock syndrome albumin 5-15 ml/kg, rheopolyglucin 10-20 ml/kg, trental 0,1-0,2 ml/kg, contrical 1000 U/ kg, heparin 100- 200 U/ kg; hemodyalis (in case of HUS).

95. Parenteral infusion in toddler

96. Parenteral infusion in the newborn

97. Enterosorption For 5-7 days, in case of stools normalization or constipation development enterosorption should be discontinued. –Smecta –Enterosgel –Polysorb

98. Other treatment antipyretics antidiarrheal Enzymes in the recovery period in case of enzymopathy no more than 2-3 weeks

99. Primary Prophylaxis Sanitary disposal of human feces Protection, purification and boiling of water Correct preparing and saving of foodstuffs Person hygiene

100. Secondary Prophylaxis Ill Person Isolation period –until the stool culture taken 3 days after stopping treatment is negative Current and terminal disinfection Medical supervision for 1-3 mo Contact children Stool culture

101. Thanks for attention!