Слайд 1Acute intestinal infections.
Dehydration.
Principles of rehydration therapy
Слайд 2General characteristic of infectious diseases
with fecal-oral mechanism of transmission
particular localization of the causative agent GIT
(small or
large intestine, rectum, mesenterium)
the movement of the agent with feces or vomiting mass
penetrate in a susceptible organism in a special ways of transmission (watery, alimentary, contact-household)
various factors of transmission (foodstuff, water, hands, insects, toys, soil)
different localization of the causative agent in the intestine: in lumen of intestine, intestinal epithelium, on the mucous membrane, in lymphatic tissue of intestine
causative agent can constantly be in intestine (cholera, dysentery, some helminthic invasion) or temporarily,
the ability to penetrate from the intestine to the blood and other tissue (ascariasis, amebiasis, strongyloidiasis, trichinosis, echinococcosis)
Слайд 3 - The incidence of infectious diseases is higher:
- in the warm and/or rainy periods
(in
moderate climatic zones is more often registered during
a summer or autumn);
- in countries with low socio-economic level of development;
- among people of risk-groups:
- age - children and the elderly,
- chronic GIT-pathology - patients with
gastritis, duodenitis, peptic ulcer, cholecystitis;
- profession - sanitary workers, plumbers, teachers,
medical personal;
- occupation – fishermen, water-rescuers,
veterinarians, animal trainers
Слайд 4Diarrhea - disorder of frequency, volume and consistency of stool
accompanied with abdominal pains.
Diseases with diarrhea syndrome are divided on
3 types:
Type A - proceeding without an inflammation of intestine
Type B - proceeding with an inflammation of intestine
Type C - caused by the short-term penetration of infectious agents through
mucous membrane of intestine without damage
Слайд 5Type A
In the small intestine;
disorder of water and electrolyte
absorption;
-Mucous membrane of intestine is not involved
in the inflammation
(at biopsy of intestine –
morphological changes are insignificant
or not find);
-General symptoms:
fever, malaise, anorexia - are moderate or absent;
-Typical symptoms:
1) pain in mesogastrium;
2) plentiful, watery stool, meteorism;
3) in coprocytogramm – leucocytes are not found;
-This type of diarrhea can be caused by:
- viruses ( Rotavirus, Parvovirus etc.);
- toxicogenic bacteria (V. cholerae, E.coli, S.aureus, B. cereus);
- parasites (Giardia intestinalis, Ascaris lumbricoides, Cestodes,
Ancylostoma duodenale, Strongyloides stercoralis, Trichinella
spiralis, Cryptosporidium parvum and etc.)
Слайд 6Type B
– large intestine is involved and affected;
- inflammation
of intestinal wall;
- infectious agents are implanted in a mucous
membrane
of the large intestine and damage it;
- General symptoms:
fever, malaise, anorexia - are moderate or severe;
- Typical symptoms (colitis):
- pain in hypogastrium, painful spasms of large intestine, tenesmus;
- in coprocytogramm – leucocytes, admixture of mucus and blood;
- stool is scanty, brown or pink
- This type of diarrhea is caused by:
- bacteria ( Shigellae, Salmonellae, S. V. Parahaemoliticus, Yersinia
enterocolitica, E. coli, Campylobacter jejuni, Clostridium difficile)
- parasites (E. histolytica, Balantidium coli, Schistosomae)
Слайд 7Type C
- caused by penetration of infectious agent in
mucous membrane and lymphatic tissue of intestine (usually small intestine)
without damage.
- General symptomes:
fever, chills, headache, malaise, disorded sleep;
- Typical symptomes:
diarrhea or constipation, mesadenitis,
roseola-spot rash, bradycardia,
hepatosplenomegaly,
leukopenia,
- in coprocytogramm: -macrophages
The classical examples - Salmonella typhi, more rare - Yersinia enterocolitica, Campylobacter jejuni, Pseudomonas aeruginosa
Слайд 8Factors contributing to the development of diarrhea
- the reduced acidity
of gasric juice;
- nonactive intestinal peristaltics;
- imbalance of intestinal microflora;
-
insufficien level of coproantibodies;
Sometimes diarrhea can develop as nonspecific response of human organism on the severe infection proceeding outside of the intestine (more often - in newborns, but can be in adults, caused by Gram-negative microflora).
The reasons of noninfectious secretory diarrhea:
1. Exogenous: - after some medicine:
purgatives
antacids
of diuretics, antiasthmatic, cholinergic, cardiac, thyroid, antimetabolitic
drugs
prostaglandines
toxins
errors of a diet
- hypersensitivity of the intestine (without structural damage)
Слайд 92. Endogenous
Congenital enzymopathy,
B. Na+diarrhea – absence of sodium (hydrogen
in enterocytes)
D. The functional distresses of intestine
E. Colo-enteritis
(ulcerous, ischemia, necrotization, hemorrhage )
F. Pellagra
Metabolic diseases - hyperthyroidism, insufficiency of adrenal
glands and pancreas
H. Allergy, purpura Schonlein- Henoch
Слайд 12Criteria of degree of dehydration in cholera
Слайд 13Criteria of degree of dehydration in cholera
Слайд 14Criteria of degree of dehydration in cholera
Слайд 15Rehydration
Primary
Compensatory
Replacement fluids
lost before
hospitalization
Recovery
of continuing
water and electrolyte
losses
during hospitalization
Слайд 16Rules of primary rehydration
Duration - 2-4 hours
(except for elderly, children, patients with chronic pathology of
the cardiovascular system, alimentary cachexia: 6-8 hours);
To restore the balance of electrolytes, it is necessary to determine the volume of the lost liquid (V);
To do this, you need to know the body weight (m) and the degree of dehydration in percent (%)
To weigh the patient (body mass - m);
Regarding the existing clinical symptoms (see table) to determine the degree of dehydration (according to WHO classification) (%);
Слайд 174. The volume of the lost fluid is calculated by
the formula:
m × %
V=
100%
5. To determine the method of introduction of fluid: oral or parenteral:
- oral: 1-st and 2-nd degree of dehydration without vomiting
V×1,5
1,5 - a constanta characterizes the ratio between volume of fluid introduced in intestine and absorbed into the blood
Oral solutions: rehydron, glucosolan, citroglucosolan;
Слайд 18 Mixed (1-st and 2-nd degree, vomiting till 3 times/day)
- oral – 2/3
of V×1,5;
- parenteral – 1/3 of V (i/v);
Parenteral (1-st and 2-nd degree with vomiting more then 3 t/d or 3-d degree of dehydration) - V;
6. Choice of infusion solutions depends on the level
of potassium (K+) in the blood of the patient:
…….. ≤ 2 ≤ 3 ≤ 3,5-5,5 mmol/l (normal
level of K+)
Qartasol Trisol Disol
Слайд 197. To determine the speed of intravenous infusion:
1-st degree – 60-80 drops/min (usual);
2-nd degree
– 100-120 drops/min;
3-d degree – by stream;
8. To stop i/v rehydration is possible, if there:
- no vomiting,
- constant, and normal pulse and blood pressure,
- daily diuresis exceeds the daily stool volume
in 1,5 times
Слайд 20
Salmonellosis
- acute intestinal zoo-anthroponotic infection with fecal-oral mechanism of transmission,
described by a preferred lesion of small intestine and development
of severe intoxication and diarrhea in the clinic.
ETIOLOGY:
- Family Enterobacteriaceae, genus Salmonella
Includes 1 species, 7 subspecieses, 2300 serotypes
Gram (-) motile rods without spors
Has 4 antigenes: O – somatic antigene (lipopolysaccharid )
H- a flagellar antigene
K – a capsula antigene – facilitates infiltration
salmonella inside of enterocytes
Vi – virulence antigene
Слайд 21Produces: - enterotoxin – causes a diarrhea
(activation a cAMP)
- cytotoxin - destroys the membrane of the cell,
disrupting the synthesis of proteins
- hyaluronidasum, neuraminidase,
R-plasmide (resistance)
Releases: - endotoxin - (lipopolysaccharid the complex
cellular of a wall) causes a set of toxic
symptoms
Grows well on usual mediums
Stable in environment: - in water – 5 months
- in milk – 300 days
- at 18-24 dg C – 80 days
Sensitive: - usual concentrations of desinfectants inactivate
in 30 min
- at boiling perish immediatly
Слайд 22The factors of pathogenicity
- Ability to endocellular parasitism
K –
antigene, promoting the infiltration
R-plasmide – resistance to a/b
Presence of aggressive
enzymes
Ability to cause a bacteriemia, sepsis
Ability to reproduce in many bodies
Ability to cause disbiosis
Ability to derivate L-of the form
Presence of toxins
Слайд 23EPIDEMIOLOGY
Source of an infection – warm-blooded animals, swimming birds
- patient with manifested form of the disease
- carriers (especially chronic)
Mechanism of transmission – fecal-oral
Routs of transmission – alimentary, watery, contact
Factors of transmission – foodstuffs (meat, lactic products, eggs, fish)
- contaminated water
- dust (at processing skins animal)
- contact with subjects of environment
-Risk groups – children till 2-5 years
- old people
- patient with chronic GIT-pathology
- immunocompromised patient
- Seasonal prevalence – summer-autumn
Слайд 24PATHOGENY
1. Penetration of S. through a mouth in stomach
2. Mass
destruction with excretion endo- and exotoxin –
toxemia
3.
Entering in small intestine, infiltration through
enterocytes, colony, reproduction, accumulation
4. Activation of cAMP, appearance of a secretory diarrhea
The destruction all S. at this stage causes only localized
form with subsequent recovery
5. Bacteriemia at gastrointestinal form is short-term, at
incompetence of immunity S. can penetrate into a blood,
causing hematosepses
Слайд 25CLINICAL CLASSIFICATION
Localized
Generalized
Gastritic
Gastroenteric
Gastroenterocolitic
Enterocolitic
Influenza-like
Typhus-like
Septicopyemic
mild
moderate
severe
Слайд 27LABORATORY INSPECTION
SPECIFIC TESTS (for confirmation):
1. Bacteriologic research:
material – feces, vomitive masses, gastric
lavage (localized form)
- blood, urine, bile, liquor (generalized form)
medium – cholic broth, selenitic nutrition, bismuth-zinci sulfas
2. Serological test: - IHA test
- CF test
- ELISA
3. Immunofluorescence
4. Detection of antigenes S. in coprofiltrates (express-diagnosis)
NONSPESIFIC INVESTIGATION:
1. CBC- neutrophilia, eosinipenia, shift to the left, acceleration ESR
2. Urinalysis – signs of a set of symptoms “toxic kidney”
Слайд 28TREATMENT
SPESIFIC THERAPY
Not indicated for the localized forms
Antibiotics should be given
the patient of risk-groups and at generalized form :
- quinolones (ciprofloxacin 0,5g×2t/d; ofloxacin 0,4×2t/d)
- chloramphenicol 0,5×4t/d
- cephalosporins of 3-rd generation
- ampicillinum, amoxicillin,amikacinum
NONSPESIFIC THEAPY
Detoxication PO or IV (lavage stomach and intestine; enterosorbents, plentiful drink
Rehydration PO or IV
Metabolites, angioprotectors
Ferment drugs
Biologic preparations
At TIS - glucocorticosteroids
Слайд 29
DISCHARGE FROM HOSPITAL ONLY AT CLINICAL CONVALESCENCE:
1 negative bacteriological test
of a feces in 2 days after ending
treatment
Decree group
2 negative bacteriological testes with the subsequent observation
3 month with monthly
bacteriological testing
Слайд 30Cholera
- Acute intestinal infectious disease with fecal-oral mechanism of
transmission, saproantroponosis, characterized by functional disorder of enterocytes, development of
dehydration and demineralization, clinically manifested by severe diarrhea-syndrome.
It is the typical disease with a diarrhea of Type A.
Etiology
Vibrio cholerae is presented in 2 species:
- Vibrio cholerae biovar cholerae;
- Vibrio cholerae biovar El-Tor;
The new strain Bengal O139, causes diarrhea of people, but not agglutinate with 01 group antiserum (it is resistant to streptomycin and co-trimoxazole), now it belongs to the 3rd biotype.
Слайд 32Characteristics:
small Gram “—” comma-shaped rods (size 1.5 - 4 microns
of length and 0.2 – 0.4 microns);
mobile, have flagella (the
most mobile between pathogenic infectious agents);
has no spores and capsules;
facultative aerobes, gallophile;
grows on the simple alkaline media with pH of 7.8-8.0;
Feature:
thermostable endotoxin;
thermolabile exotoxin – cholerogen – provides a development of
dehydration;
factors of aggression:- neuraminidase, lipase, protease;
H-antigen, O-antigen (serogroup O1 is divided into:
-Inaba, - Ogava,- Higoshima);
Resistance:
high in water, humid environment (a few months), in food stuffs (2-5 days);
Sensitivity: - to the dryness, ultraviolet irradiation;
- disinfection, high temperature, boiling;
- antibiotics – tetracycline, ampicillin, chloramphenicol.
Слайд 33Halofeels (optimal pH of nutrient medium from 7.8 to 8.0)
- they are easily colouring by all aniline stains.
-
well grow on the simple medium (1 % of peptonic water)
Stability in the external environment – survival rate:
- in sea water - 10 - 60 days (Eltor)
- on subjects of use - 3 - 7 days
- in fresh water - 7 - 18 days
- in milk - 7 - 14 days
- on vegetables - 1 - 10 days
- in a fish and sea products - 2 - 14 days
- in the freezer - 21 days
Слайд 34
Epidemiology
Source: - vibrio-carrier (more dangerous in epidemiological – chronic
form);
- patients with
clinically manifested form (especially in the first 4-5 d);
- patients with obliterated form,
- convalescents (within 2-4 weeks).
In the first days of the disease the patient discharges about more then 1 million of vibrios.
Mechanism of transsmition:
fecal-oral realized by:- watery way – is leading (drinking, bathing),
- alimentary (milk, rice),
- contact
Susceptibility: general and high, depends on the:
- season (active drinking, bathing, flies),
- age (elderly and children),
- persons with GIT-pathology ( hypoacid gastritis, anemia and
helminthiasis),
Immunity: resistant, specific, antitoxic
Morbidity: high (due to fast distribution) - 1 - 3 %.
Слайд 35Due to the wide application of pathogenic treatment (rehydration), the
mortality from cholera has decreased significantly;
But prognosis is always serious
at the dehydration of III-IV degree.
Recently, the mortality rate decreased from 6% to 1%.
Слайд 38The factors of vibrio pathogenicity facilitating the process colonisation
- flaggella
- adds mobility to vibrioes;
- the mucinase - dilutes slime
on a surface of enterocytes, facilitating fixation of
exotoxin on receptors (Gm1-ganglioside);
hyaluronidase and neuraminidase – facilitate infiltration of exotoxin in
enterocytes;
- other toxic components (hemolysins for eltor etc.)
Слайд 39Pathogenesis
Scheme of the pathogenesis of cholera has the following steps:
Ingestion
of Vibrio cholerae in the intestine, reproduction in an alkaline
environment and destruction, the release and accumulation of toxins, including cholerogen;
Increased secretion of isotonic fluid:
a) cholerogen activates the cAMF on membranes of enterocytes,
increases a permeability of enterocyte membranes for sodium and
water;
b) blocks the sodium pump and reduces of resorption of
isotonic fluid;
Dehydration (in a severe form);
Haemoconcentration, slowing blood flow,
hypoxemia, hypoxia;
Metabolic acidosis with the accumulation
of toxic products;
Extrarenal urinary disorders up to anuria
in severe cases or extrarenal coma.
Слайд 40Pathomorfology
Biopsy of the small intestine:
- swelling of
the basal layer of the mucosa and the endothelium of
blood vessels,
- structure of enterocytes is not violated,
- signs of functional hyperactivity – (enteritis ) are not developed;
At the autopsy:
severe dehydration of all tissues, ischemia of mucosa in stomach, small intestine and colon, it is swollen, with small hemorrhages,
in all parenchymatous organs expressed dystrophic changes
Слайд 41Clinical classification
Hemorrhagic
Subclinical
erased
Mixed
Gastric
“Dry”
Severe
Complicated
Uncomplicated
Typical
Atypical
Mild
Moderate
Слайд 421. Incubation - 2 - 3 days (from some hours
to 5 days)
2. Prodrome is not typical, but sometimes may
be:
- feeling of anxiety, weakness,
- rumbling in abdomen, pain in chewing and
calf muscles,
- sweating, dizziness, cold extremities.
3. Climex –
1) In typical cases disease begins suddenly, more often at the night or
before morning with acute diarrhea but without abdominal pain and
tenesmus.
2) Stool quickly becomes watery and then resembles a rice water, loses its
odor and becomes the smell of raw fish or grated potatoes.
3) The patient feels:
- discomfort in epigastric and paraumbilical area,
- rumbling around the navel, murmurs in abdomen, feeling of
bloating,
- insuperable desire on defecation;
- after a few hours, sometimes a day, diarrhea accompanied with
repeated vomiting, sometimes a fountain, without nausea.
Vomit quickly becomes watery and resembles rice water.
Слайд 43 Profuse diarrhea, repeated vomiting lead to dehydration
4) Intoxication (have
endogenous character), weakness, thirst,
dryness of the mouth;
5)
The skin becomes bluish, cold and loses its elasticity, turgor;
6) Tongue is dry, abdomen is retracted, painless, possible meteorism
(hypokalemia);
7) Voice becomes hoarse, breathing quickens (tachypnea);
8) Tachycardia and decreased blood pressure;
9) Reduced diuresis, convulsions of some groups of muscles;
10) Consciousness is not changed, patient indifferent, feels fear;
11) Body temperature remains normal;
12) CBC without significant changes;
Severity of the disease is determined by the degree of dehydration,
hemodynamic and metabolic disorders.
Слайд 44Atypical forms:
Fulminant cholera (due to reproduction and accumulation of
Vibrio in the biliary tract, small intestine and penetration of
its toxins in the blood in high concentrations):
- sudden onset and rapid development of dehydration,
- fast development of hypovolemic shock,
- convulsions of all muscle groups,
- symptoms of encephalitis and coma;
Dry cholera (cholera sicca) is very severe (“tragic”) form of the disease
with a malignant course:
- severe weakness,
- rapid development of collapse,
- dyspnea, convulsions,
- cyanosis, coma.
This form of the disease is rare, usually in malnourished patients.
Obliterated cholera is characterized by unclear symptoms and mild
severity (often observed in the case of cholera El-Top).
Слайд 45The basic clinical diagnostic symptoms of cholera:
Classic tetrad - diarrhea,
vomiting, dehydration (isotonic dehydration),
seizures,
Acute onset
of illness with diarrhea and following vomiting
(without nausea, abdominal pain, tenesmus), vomit and feces in the form of rice-water,
3. Subnormal or normal body temperature,
Acrocyanosis (total cyanosis), the symptoms of “cholera face”, “hands
of washerwoman”, cholera folds, “cholera glasses”,
Hoarse voice (aphonia), tachypnea,
Tachycardia, decreased blood pressure (collapse), oligoanuria.
Слайд 46Specific diagnosis of cholera
Bacteriological method – classical, main in laboratory
diagnosis of cholera. For bacteriological study using feces and vomit
(10-20 ml) and 1% peptone water;
Serologic method –
- immobilized reaction (RI),
- microagglutination of Vibrio cholera by O-serum
(contrast microscopy) (result in a few minutes),
- reaction of immunofluorescence (results in 2 - 4 hours),
- RIHA, RN, ELISA.
Nonspesific diagnostic
CBC+Ht – relative leukocytosis, shift of formula to the left, increased ESR
and Ht, hemoconcentration;
2) Urinalysis - leukocyturia, proteinuria, microhematuria, admixture
Слайд 48Treathment
Nonspecific therapy:
Rehydration – oral and parenteral;
The use of cardiac glycosides
is contraindicated, due to increased disturbance of microcirculation, assisting in
the development of kidney failure;
Diet №4, and in 3-4 days - with a predominance of foods that contain a lot of potassium (e.g. potatoes);
Pro – and eubiotics, sorbents;
Specific therapy:
The principles of antibiotic therapy of cholera:
Administration of antibiotic after obtaining material for bacteriological
examination,
b) Continuity of the drug (including night hours),
c) Parenteral using of a/b till disappearance of vomiting, after that – in oral form,
Determine susceptibility to antibiotics,
Treatment with antibiotics regardless of the degree of dehydration should be at least 5 days.
Слайд 49Woman undergoing treatment at a cholera unit in Lima, Peru
Слайд 50Antibacterial therapy:
- doxycyclin
0.1g × 2t/d PO
- tetracyclinum
0.5g × 3t/d PO
- biseptolum 960 mg × 3-4 t/d PO
- furazolidonum 0.1 – 0.15g × 4t/d PO
- ciprofloxacin 0.5g -1.0g × 2-3t/d PO
quinolones and cephalosporins of 3-rd generation
Rules of discharging from the hospital:
Patients discharged from hospital after receiving negative results of bacteriological examination, which is taking before discharge, 24-36h after the treatment with antibiotics.
- complete convalescence;
+ 3 negative tests of a feces;
+ 1 negative test of bile;
Слайд 51Prophylaxis:
- personal hygiene;
- improvement of sanitary conditions of
the external environment;
- use only of high-quality WATER;
vaccination forms
antibacterial and antitoxic immunity
(does not influence onspreading of cholera and consequently in the
present the time widly does not be used!);
Persons who were in close contact with cholera patients need in emmediate prevention.
For this purpose, use tetracycline in dose - 0,3g × 3 t/day for 4 days.
The dose for children is reduced in accordance with age.