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Bacterial intestinal infections in children. Algorithm for the treatment of acute intestinal infections in children Standards of medical care for intestinal infections

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2017

Viral and other specified intestinal infections (A08), Diarrhea and gastroenteritis of presumably 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 Healthcare Quality
Ministry of Health of the Republic of Kazakhstan
dated August 18, 2017
Protocol No. 26

Bacterial intestinal infections is a group of human infectious diseases with an enteral (fecal-oral) mechanism of infection, caused by pathogenic (Shigella, Salmonella, etc.) and opportunistic bacteria (Proteus, Klebsiella, Clostridia, etc.), characterized by predominant damage to the gastrointestinal tract and manifested by intoxication and diarrhea syndromes.

INTRODUCTORY PART

ICD-10 code(s):

ICD-10
Code	Name
A00	cholera
A00.0	Cholera caused by Vibrio cholerae 01, biovar cholerae
A00.1	Cholera caused by Vibrio cholerae 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 caused by Shigella dysenteriae
A03.1	Shigellosis caused by Shigella flexneri
A03.2	Shigellosis caused by Shigella boydii
A03.3	Shigellosis caused by Shigella sonnei
A03.8	Other shigellosis
A03.9	Shigellosis, unspecified
A04	Other bacterial intestinal infections
A04.0	Enteropathogenic 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	Enteritis caused by Campylobacter
A04.6	Enteritis caused by Yersinia enterocolitica
A04.7	Enterocolitis caused by Clostridium difficile
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 protocol development/revision: 2017

Abbreviations used in the protocol:

Gastrointestinal tract	-	gastrointestinal tract
ME	-	international units
UAC	-	general blood analysis
OAM	-	general urine analysis
IMCI	-	Integrated Management of Childhood Illnesses
ELISA	-	linked immunosorbent assay
OKI	-	acute intestinal infections
OPO	-	general danger signs
ORS	-	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.

Level of evidence scale:

A	A high-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate 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, the results of which can be generalized to an appropriate population .
WITH	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 RCT with a very low or low risk of bias (++ or +), the results of which cannot be directly distributed to the relevant population.
D	Case series or uncontrolled study or expert opinion.
GPP	Best pharmaceutical practice.

Classification

Classification :

By etiology:	. cholera; . shigellosis; . salmonellosis; . Escherichiosis; . campylobacteriosis and other acute infections caused by anaerobic pathogens; . Yersinia enterocolitica; . OCI caused by opportunistic microorganisms (staphylococci, Klebsiella, Citrobacter, Pseudomonas aeruginosa, Proteus, etc.).
By severity	light, medium and heavy forms
According to the topic of gastrointestinal lesions	. gastritis; . enteritis; . gastroenteritis; . gastroenterocolitis; . enterocolitis; . colitis.
With the flow	. acute (up to 1 month); . prolonged (1-3 months); . chronic (over 3 months).

Salmonellosis classification:

Classification of shigellosis:

Classification of Escherichiosis:

Classification of intestinal yersiniosis:

Classification of cholera:

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: consumption of low-quality products; reports of local outbreaks of intestinal infections, including stays in other hospitals; family members or children's team have similar symptoms.
History of the disease:
The presence of symptoms of intoxication, fever, gastritis, gastroenteritis, enterocolitis, colitis.

General intoxication syndrome:
. violation of general condition;
. fever;
. weakness, lethargy;
. decreased appetite;
. vomit;
. nausea;
. coated tongue.
Dyspeptic syndrome:
. nausea, vomiting, which brings relief, associated with food intake, persistent regurgitation in young children;
. the appearance of pathological stool with enteritis - copious, odorless, with undigested lumps, possibly with greens; with colitis: scanty liquid stool with mucus, greens, streaks of blood;
. rumbling along the small and/or large intestines;
. 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 area 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, and sunken eyes;
. retraction of the large fontanel (in infants);
. disturbance of consciousness;
. weight loss;
. decrease in diuresis.
Neurotoxicosis:
. fever that responds poorly to antipyretic drugs;
. the appearance of vomiting that is not associated with food intake and does not bring relief;
. convulsions;
. disturbance of peripheral hemodynamics;
. tachycardia.
Syndrome of metabolic disorders:
. signs of hypokalemia - muscle hypotonia, adynamia,
. hyporeflexia, intestinal paresis;
. signs of metabolic acidosis - marbling and cyanosis of the skin, noisy toxic breathing, confusion.

Pathogens	Main symptoms
Cholera	Abdominal pain is not typical. The stool is watery, the color of rice water, odorless, sometimes with the smell of raw fish. Vomiting occurs after diarrhea. Rapid development of exicosis. Intoxication is minor or absent, body temperature is normal.
Salmonellosis	Watery stools with an unpleasant odor, often mixed with green and the color of swamp mud. Prolonged fever, hepatosplenomegaly.
Intestinal yersiniosis	Prolonged fever. Intense pain around the navel or right iliac region. Copious, foul-smelling stools, often mixed with mucus and blood. A general blood test revealed leukocytosis with neutrophilia.
OCI caused by opportunistic microorganisms	The main types of damage to the gastrointestinal tract in children over one year of age are gastroenteritis and enteritis, less often - gastroenterocolitis, enterocolitis. In children of the first year of life, the clinical picture depends on the etiology and timing of infection. In patients in the first year of life, the intestinal form is often accompanied by the development of toxicosis and exicosis of I-II degrees. Diarrhea is predominantly secretory-invasive in nature.
Shigellosis	Symptoms of intoxication: frequent, scanty, with a large amount of cloudy mucus, often green and bloody, loose stools.
Enteropathogenic Escherichia (EPE) Enteroinvasive Escherichia (EIE) Enterotoxigenic Escherichia (ETE)	EPE: early age of the child; gradual onset; infrequent but persistent vomiting; flatulence; copious watery stools; ETE: The onset of the disease is usually acute, with the appearance of repeated vomiting and “watery” diarrhea. Body temperature is most often within normal limits or low-grade. Bowel movements are devoid specific fecal odor, no pathological impurities in them, reminiscent of rice water. Exicosis develops quickly. EIE: In older children, the disease usually begins acutely, with a rise in body temperature, headache, nausea, and often vomiting, and moderate abdominal pain. At the same time or after a few hours, loose stools with pathological impurities appear.

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 indicate no dehydration, 1 to 4 points indicate mild dehydration, and 5 to 8 points indicate severe dehydration.

Clinical Dehydration Scale (CDS):

Sign	Points
Sign	0	1	2
Appearance	Normal	Thirst, restlessness, irritability	Lethargy, drowsiness
Eyeballs	Not sunken	Slightly sunken	Sunken
Mucous membranes	Wet	somewhat dry	Dry
Tears	Tear production is normal	Tear production is reduced	There are no tears

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 signs of shock: cold hands, capillary refill time greater than 3 seconds, weak and rapid pulse.

Types of dehydration and clinical symptoms:

sector	type of violation	clinical picture
intracellular	dehydration	thirst, dry tongue, agitation
intracellular	overhydration	nausea, aversion to water, death
interstitial	dehydration	folds, sclerema, sunken eyes, pointed facial features are poorly straightened
interstitial	overhydration	swelling
vascular	dehydration	hypovolemia, collapsed veins, ↓CVP, tachycardia, microcirculation disorder, cold extremities, marbling, acrocyanosis
vascular	overhydration	BCC, central venous pressure, vein swelling, shortness of breath, wheezing in the lungs

Clinical criteria for assessing the degree of exicosis :

Symptoms	Degree of exicosis
Symptoms	1	2	3
Chair	infrequent	up to 10 times a day, enteritis	frequent, watery
Vomit	1-2 times	repeated	multiple
General state	moderate severity	moderate to severe	heavy
Weight loss	up to 5% (> 1 year up to 3%)	6-9% (> 1 year to 3-6%)	more than 10% (> 1 year to 6-9%)
Thirst	moderate	pronounced	may be missing

Tissue turgor	saved	the fold straightens out slowly (up to 2 s.)	the fold straightens out very slowly (more than 2 sec.)
Mucous membrane	wet	dry, slightly hyperemic	dry, bright
Great fontanelle	At the level of the skull bones	slightly sunken	pulled in
Eyeballs	norm	sink	sink
Heart sounds	loud	slightly muted	Muted
Arterial pressure	normal or slightly increased	systolic normal, diastolic increased	reduced
Cyanosis	No	Moderate	sharply expressed
Consciousness, reaction to others	norm	Excitement or drowsiness, lethargy	Lethargic or unconscious
Reaction to pain	expressed	Weakened	absent
Voice	norm	Weakened	often aphonic
Diuresis	saved	Reduced	Significantly reduced
Breath	norm	moderate shortness of breath	toxic
Body temperature	norm	often elevated	often below normal
Tachycardia	No	Moderate	expressed

Laboratory research :
· UAC - leukocytosis, neutrophilia, accelerated ESR;
· coprogram: the presence of undigested fiber, mucus, leukocytes, erythrocytes, neutral fats;
· bacteriological examination of vomit or gastric lavage and feces, identification of pathogenic/conditionally pathogenic flora.

Additional laboratory and instrumental studies:
· used blood test: concentration of electrolytes in blood serum, urea, creatinine, residual nitrogen, total protein (in case of dehydration);
· coagulogram (for DIC syndrome);
· bacteriological examination of blood and urine - isolation of pathogenic/conditionally pathogenic flora;
· RPGA (RNGA) of blood with specific antigen diagnosticums - an increase in antibody titers with a repeated reaction by 4 or more times.
· PCR - determination of DNA of intestinal infections of bacterial etiology.

Indications for consultation with specialists:
· consultation with a surgeon - if appendicitis, intestinal obstruction, or intussusception is suspected.

Diagnostic algorithm:

Differential diagnosis

Differential diagnosis and rationale for additional studies:

Diagnosis	Rationale for differential diagnosis	Surveys	Diagnosis exclusion criteria
Rotavirus infection		ELISA - determination of rotavirus antigens in feces.	Watery stools, vomiting, short-term fever.
Enterovirus infection	Fever, vomiting, loose stools.	PCR - determination of enterovirus RNA in feces.	Herpangina, exanthema, gastroenteritis.
Intussusception	Loose stools, abdominal pain.	Surgeon consultation	Attacks of crying with paleness of the baby's skin. Blood in the stool (“raspberry” or “currant jelly”) without stool impurities 4-6 hours after the onset of the disease. Bloating, tightness in the abdominal cavity. soft elastic consistency. Dynamics of repeated vomiting.
Adenovirus infection	Fever, vomiting, loose stools.	PCR - determination of adenovirus DNA in feces.	Prolonged fever. Pharyngitis, tonsillitis, rhinitis, conjunctivitis, enteritis, hepatosplenomegaly.
Acute appendicitis	Fever, vomiting, loose stools.	Surgeon consultation.	Pain in the epigastrium with movement to the right iliac region. The pain is constant, worsens when coughing. The stool is liquid, without pathological impurities, up to 3-4 times, most often constipation.

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Treatment

Drugs (active ingredients) used in treatment

Groups of drugs according to ATC used in treatment

Treatment (outpatient clinic)

OUTPATIENT TREATMENT TACTICS

At the outpatient level, children with mild and moderate forms (children over 36 months) of acute intestinal infections of bacterial etiology receive treatment.
The principles of treatment of patients with acute intestinal infections include: regimen, rehydration, diet, pathogenetic and symptomatic therapy.
If outpatient treatment is ineffective or impossible, the issue of hospitalizing the child in a specialized hospital is considered.

Non-drug treatment:
· semi-bed rest (during the entire period of fever);
· diet - depending on the child’s age, his food preferences and eating habits before the onset of the disease;
· Breastfed babies should be fed breast milk as often and for as long as they want;
· Children who are bottle-fed should continue to be fed their usual diet;
· children aged from 6 months to 2 years - table No. 16, from 2 years and older - table No. 4;

Drug treatment
To relieve hyperthermic syndrome above 38.5 0 C:
. 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 child is mixed or bottle-fed, give the following liquids in any combination: ORS solution, liquid food (for example, soup, rice water) or clean water.
· Explain to the mother how much fluid should be given in addition to her 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 child back to the hospital immediately if the child develops any of the following signs:
· cannot drink or breastfeed;
· the child’s condition worsens;
· fever appeared;
· the child has blood in his stool or is not drinking well.

For diarrhea with moderate dehydration - plan B:
The volume of ORS required (in ml) can be calculated by multiplying the child’s weight (in kg) by 75.
· Give the calculated volume of liquid for 4 hours.
· If the child drinks the ORS solution eagerly and asks for more, you can give more than the recommended amount. Breastfeeding should be continued if the baby wishes. For bottle-fed infants, food is stopped during the first 4 hours and oral rehydration is given.
· After 4 hours, reassess the child and determine hydration status: if 2 or more signs of moderate dehydration persist, continue Plan B for another 4 hours and provide age-appropriate nutrition.
· If there is no effect from oral rehydration in an outpatient setting, the patient is referred to inpatient treatment.
· for replacement purposes to correct exocrine pancreatic insufficiency, pancreatin 1000 IU/kg/day with meals for 7-10 days.
· for the purpose of etiotropic treatment 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 orally;
· children over six years old - ciprofloxacin 20 mg/kg/day in two doses orally 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 (150 mg in 1 ml).	A
	Dextrose+potassium sodium chloride+ chloride+sodium citrate		WITH
	Azithromycin		IN

List of additional medicines:

Pharmacological group	International nonproprietary name of the drug	Mode of application	UD
Propionic acid derivatives	Ibuprofen	Suspension and tablets for oral administration. Suspension 100mg/5ml; tablets 200 mg;	A
Enzymatic preparations	Pancreatin		IN
	Ciprofloxacin	tablets 0.25 g and 0.5 g; in infusion bottles of 50 ml (100 mg) and 100 ml (200 mg)	A

Surgical intervention: No.

Further management[ 1-4,19 ] :
· discharge to the children's team during clinical and laboratory recovery;
· a one-time 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 the event of a relapse of the disease or a positive result of a laboratory examination, persons who have had dysentery are treated again. After completion of treatment, these individuals undergo monthly laboratory examinations for three months. Persons who carry the bacteria for more than three months are treated as patients with chronic dysentery;
· persons with chronic dysentery are monitored at the dispensary for a year. Bacteriological examinations and examination by an infectious disease specialist 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 preschool education organization for fifteen calendar days, during which time three stool examinations are carried out with an interval of one or two days. If the result is positive again, the same procedure for removal and examination is repeated for another fifteen days.

[ 1-4,7 ] :

· negative results of bacteriological tests;
· normalization of stool.

Treatment (inpatient)

TREATMENT TACTICS AT THE INPATIENT LEVEL
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 carried out in two stages:
· Stage I - in the first 6 hours after the patient’s admission, the water-salt deficiency that occurs before the start of treatment is eliminated;
· With dehydration stage I. the volume of liquid is 40-50 ml/kg, and with stage II dehydration - 80-90 ml/kg body weight in 6 hours;
· Stage II - maintenance oral rehydration, which is carried out throughout the subsequent period of illness in the presence of ongoing losses of fluid and electrolytes. The approximate volume of solution for maintenance rehydration is 80-100 ml/kg body weight per day. The effectiveness of oral rehydration is assessed by the following criteria: reducing the volume of fluid loss; reducing the rate of weight loss; 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 (any degree) with severe intoxication;
· uncontrollable vomiting;
· failure of oral rehydration within 8 hours of 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) = 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 deficiency depends on the severity of dehydration and is approximately determined based on the body weight deficit. In case of exicosis of the first degree, 30-50 ml/kg per day is required to compensate for the deficiency, in case of exicosis of the second degree - 60-90 ml/kg per day, and in case of dehydration of the third degree - 100-150 ml/kg per day. The amount of existing deficiency is corrected gradually; only with grade I dehydration is it possible to compensate for the deficiency 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 disorders and the type of dehydration. Severe hemodynamic disorders in all types of dehydration are corrected with balanced isosmolar saline solutions (saline, Ringer's solution, etc.), and, if necessary, in combination with colloidal solutions. The basic principle of infusion therapy for dehydration syndrome is that compensation for losses must be done with an infusion medium similar to that lost.
No low osmolarity solutions (5% dextrose solutions, low osmolarity polyionic solutions) should be used as a starting solution. In this regard, 5% dextrose solutions are the most dangerous. Firstly, due to their hypoosmolarity; secondly, the utilization of glucose is accompanied by the formation of “free” water, which further enhances intracellular hyperhydration (danger of cerebral edema); thirdly, underoxidation of glucose under conditions of tissue hypoperfusion leads to even greater lactic acidosis.

Patient observation card, patient routing:

Non-drug treatment[ 1-4 ] :
. semi-bed rest (during the entire period of fever);
. diet - depending on the child’s age, his food preferences and eating habits before the onset of the disease;
. Breastfed babies should be fed breast milk as often and for as long as they want;
. Children who are bottle-fed should continue to be fed their usual diet;
. children aged from 6 months to 2 years - table No. 16, from 2 years and older - table No. 4;
. Children with lactose intolerance are prescribed low/lactose-free formulas.

Drug treatment:
to relieve hyperthermic syndrome above 38.5 o C, the following is prescribed:
· paracetamol 10-15 mg/kg with an interval of at least 4 hours, no more than three days, orally or per rectum;
· or
· ibuprofen in 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 including solutions:
· 10% dextrose (10-15 ml/kg);
· 0.9% sodium chloride (10-15 ml/kg);
· Ringer's (10-15 ml/kg).

For replacement purposes to correct exocrine pancreatic insufficiency, pancreatin 1000 units/kg/day with meals for 7-10 days.
Antibacterial drugs are prescribed in age-specific dosages, taking into account the etiology of acute intestinal infections. When choosing an antibacterial drug, the severity of the disease, the age of the child, the presence of concomitant pathologies and complications are taken into account. If the temperature of a patient with confirmed ACI does not improve within 46 to 72 hours, alternative antimicrobial methods should be considered.

Etiotropic antibacterial therapy[ 1-5 ] :

Etiology of acute intestinal infections	First line antibiotics			Second line antibiotics
Etiology of acute intestinal infections	Antibiotic	Daily dose (mg/kg)	Days	Antibiotic	Daily dose(mg/kg)	Days
Shigellosis	azithromycin		5	ciprofloxacin	20- 30	5-7
Shigellosis	azithromycin		5	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	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
Intestinal yersiniosis	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
Staphylococcal infection	azithromycin		5	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 orally;
· for children over six years old, ciprofloxacin 20-30 mg/kg/day in two doses orally 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 IM or IV, 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 doses. The course of treatment is 5-7 days; or
· Cefuroxime 50-100 mg/kg per day IM or IV in two or three doses. The course of treatment is 5-7 days.

List of essential medicines[1- 5 ,11-18 ]:

Pharmacological group	International nonproprietary name of the drug	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;	A
Solutions affecting water-electrolyte balance	dextrose+potassium sodium chloride+ chloride+sodium citrate*	Powder for preparing an oral solution.	WITH
Systemic antibacterial drugs	azithromycin.	powder for the 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 additional medicines :

Other irrigation solutions	dextrose	Solution for infusion 5% 200 ml, 400 ml; 10% 200 ml, 400 ml	WITH
Saline solutions	sodium chloride solution	Solution for infusion 0.9% 100 ml, 250 ml, 400 ml	WITH
Saline solutions	Ringer's solution*	Solution for infusion 200 ml, 400 ml	WITH
Second generation cephalosporins	cefuroxime	powder for solution for injection 250 mg, 750 mg and 1500 mg	A
	ceftriaxone	powder for preparing a solution for intravenous and intramuscular administration 1 g.	A
Third generation cephalosporins	cefixime	film-coated tablets 200 mg, powder for oral suspension 100 mg/5 ml	A
Third generation cephalosporins	cefotaxime	powder for preparing a solution for intravenous and intramuscular administration 1 g	A
Other aminoglycosides	amikacin	powder for solution for injection 500 mg; injection solution 500 mg/2 ml 2 ml each	A
Antibacterial drugs - quinolone derivatives	ciprofloxacin	film-coated tablets 250 mg, .500 mg for oral administration	A
Antibacterial drugs - quinolone derivatives	norfloxacin	Tablets 400, 800 mg for oral administration	A
Enzymatic preparations	pancreatin	Capsules 10,000 and 25,000 units for oral administration.	IN

Surgical intervention: No.

Further management :
· Prescription of convalescents after dysentery and other acute diarrheal infections (except salmonellosis) is carried out after complete clinical recovery.
· A one-time 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 for one month, after which a single bacteriological examination is required.
· The frequency of visits to the doctor is determined according to clinical indications.
· Dispensary observation is carried out by a GP/pediatrician at the place of residence or a doctor at the office of infectious diseases.
· If the disease relapses or the laboratory test results are positive, people who have had dysentery are treated again. After completion of treatment, these individuals undergo monthly laboratory examinations for three months. Persons who carry the bacteria for more than three months are treated as patients with chronic dysentery.
· Persons with chronic dysentery are under clinical observation for a year. Bacteriological examinations and examination by an infectious disease specialist of these individuals are carried out monthly.
· Convalescents of salmonellosis are discharged after complete clinical recovery and a single negative bacteriological examination of stool. The study is carried out no earlier than three days after the end of treatment.
· Only the decreed contingent is subject to clinical observation after an illness.
· Children who continue to excrete salmonella after treatment are suspended by the attending physician from attending preschool education for fifteen days; during this period, stool examinations are performed three times with an interval of one or two days. If the result is positive again, the same procedure for removal and examination is repeated for another fifteen days.

Indicators of treatment effectiveness[ 1-4 ] :
· normalization of body temperature;
· restoration of water and electrolyte balance;
· relief of symptoms of intoxication;
· relief of gastrointestinal syndrome;
· normalization of stool.

Hospitalization

INDICATIONS FOR HOSPITALIZATION, INDICATING 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 two months of age;
· forms of the disease with severe dehydration, regardless of the child’s age;
· prolonged diarrhea with dehydration of any degree;
· chronic forms of dysentery (with exacerbation);
· burdened premorbid background (prematurity, chronic diseases, etc.);
· fever > 38°C for children<3 месяцев или>390 C for children from 3 to 36 months;
· severe diarrhea syndrome (frequent and large stools);
· persistent (repeated) vomiting;
· lack of effect from oral rehydration;
· lack of 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 stays, from large families, etc.);
· cases of disease in medical organizations, boarding schools, orphanages, children's homes, sanatoriums, boarding homes for the elderly and disabled, summer health organizations, rest homes;
· inability to provide adequate care at home (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. 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. 2nd. 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. Training manual for doctors and other categories of senior health workers: World Health Organization, 2006. 4) Providing inpatient care to children (WHO Guide to the management of the most common diseases in primary hospitals, adapted to the conditions of the Republic of Kazakhstan) 2016. 450 pp. 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 recommendations for the clinical management of diarrhea. A guide 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. Diarrhea 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. Emerging 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. Petrova, 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 implementation of sanitary and anti-epidemic (preventive) measures to prevent infectious diseases”

Information

ORGANIZATIONAL ASPECTS OF THE PROTOCOL

List of protocol developers:
1) Efendiev Imdat Musa ogly - Candidate of Medical Sciences, Head of the Department of Children's Infectious Diseases and Phthisiology, RSE at the State Medical University of Semey.
2) Baesheva Dinagul Ayapbekovna - Doctor of Medical Sciences, Associate Professor, Head of the Department of Children's Infectious Diseases, Astana Medical University JSC.
3) Kuttykuzhanova Galiya Gabdullaevna - Doctor of Medical Sciences, Professor, Professor of the Department of Children's Infectious Diseases of the RSE at the PVC "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, RSE at the Karaganda State Medical University.
5) Zhumagalieva Galina Dautovna - Candidate of Medical Sciences, Associate Professor, head of the course of childhood infections, RSE at the West Kazakhstan State University named after. Marat Ospanov."
6) Mazhitov Talgat Mansurovich - Doctor of Medical Sciences, Professor, Professor of the Department of Clinical Pharmacology, Astana Medical University JSC.
7) Umesheva Kumuskul Abdullaevna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, RSE at the PVC "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, RSE at the Karaganda State Medical University.

Disclosure of no conflict of interest: No .

Reviewers:
1) Kosherova Bakhyt Nurgalievna - Doctor of Medical Sciences, Professor of the RSE at Karaganda State Medical University, Vice-Rector for Clinical Work and Continuing Professional Development, Professor of the Department of Infectious Diseases.

Indication of the conditions for reviewing the protocol: review of the protocol 5 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.

Attached files

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MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

ORDER

In accordance with Article 37 of the Federal Law of November 21, 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation” (Collected Legislation of the Russian Federation, 2011, N 48, Art. 6724; 2012, N 26, Art. 3442, 3446)

I order:

To approve the standard of specialized medical care for acute intestinal infections of unknown etiology and severe severity in accordance with the appendix.

Minister
V.I.Skvortsova

Registered
at the Ministry of Justice
Russian Federation
January 21, 2013,
registration N 26608

Application. Standard of specialized medical care for acute intestinal infections of unknown etiology and severe severity

Application
to the order
Ministry of Health
Russian Federation
dated November 9, 2012 N 732n

Floor: any

Phase: acute

Stage: severe severity

Complications: regardless of complications

Type of medical care: specialized medical care

Conditions for providing medical care: stationary

Form of medical care: urgent, emergency

Average treatment time (number of days): 10


	Code by ICD X * Nosological units		Diarrhea and gastroenteritis of suspected infectious origin
	_______________ * International statistical classification of diseases and related health problems, X revision.

1. Medical measures for diagnosing a disease or condition


Appointment (examination, consultation) with a specialist doctor
Medical service code
The probability of providing medical services or prescribing drugs for medical use (medical devices) included in the standard of care, which can take values from 0 to 1, where 1 means that this activity is carried out by 100% of patients corresponding to this model, and numbers less 1 - the percentage of patients with appropriate medical indications specified in the standard of medical care.
	Primary appointment (examination, consultation) with an obstetrician-gynecologist
	Primary appointment (examination, consultation) with an infectious disease specialist
	Primary appointment (examination, consultation) with a surgeon



Code medical services	Name of medical service	Average frequency of provision	Average frequency of application
	Study of the level of stercobilin in feces
	Examination of stool for protozoa and helminth eggs
	Carrying out the Wasserman reaction (RW)
	Study of intestinal microbiocenosis (dysbacteriosis)
	Determination of antigen to the hepatitis B virus (HBsAg Hepatitis B virus) in the blood
	Determination of antibodies of classes M, G (IgM, IgG) to viral hepatitis C (Hepatitis C virus) in the blood
	Determination of antibodies of classes M, G (IgM, IgG) to the human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1) in the blood
	Determination of antibodies of classes M, G (IgM, IgG) to the human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2) in the blood
	Bacteriological examination of stool for the causative agent of dysentery (Shigella spp.)
	Bacteriological examination of stool for salmonella (Salmonella spp.)
	Microscopic examination of stool for protozoa
	Microscopic examination of stool for cryptosporidium (Cryptosporidium parvum)


	General urine analysis
	Scatological research



Code medical services	Name of medical service	Average frequency of provision	Average frequency of application
	Esophagogastroduodenoscopy
	Colon endoscopy


	Digital fluorography of the lungs

2. Medical services for the treatment of disease, condition and treatment monitoring


Reception (examination, consultation) and observation of a specialist doctor
Code medical services	Name of medical service	Average frequency of provision	Average frequency of application
	Daily examination by an infectious disease specialist with observation and care of nursing staff in the hospital department


Laboratory research methods
Code medical services	Name of medical service	Average index frequencies providing	Average frequency of application
	General (clinical) blood test
	General therapeutic biochemical blood test
	General urine analysis


Instrumental research methods
Code medical services	Name of medical service	Average frequency of provision	Average frequency of application
	Esophagogastroduodenoscopy
	Ultrasound examination of the abdominal organs (comprehensive)
	Electrocardiogram registration
	X-ray of the lungs

3. List of medicinal products for medical use registered on the territory of the Russian Federation, indicating average daily and course doses


	Anatomy therapeutic chemical classification	Name of the medicinal product**	Average shown freq. fre- quency setting	Units of measurement Rhenia
_______________ International generic or chemical name of the medicinal product, and in cases of their absence - the trade name of the medicinal product. * Average daily dose. **** Average course dose.
	Synthetic anticholinergics, tertiary amino esters
		Platifillin
	Papaverine and its derivatives
		Drotaverine
		Drotaverine
	Coal preparations
		Activated carbon
	Other intestinal absorbent drugs
		Hydrolytic lignin
	Antidiarrheal microorganisms
		Bifidobacterium bifidum
	Enzyme preparations
		Pancreatin
	Calcium preparations
		Calcium gluconate
	Solutions, affecting water-electrolyte balance
		Dextrose+ Potassium chloride+ Sodium chloride+ Sodium citrate
		Potassium chloride+ Sodium acetate+ Sodium chloride

4. Types of medical nutrition, including specialized medical nutrition products


Name of the type of medical nutrition	Average frequency of provision	Quantity
Diet option with mechanical and chemical sparing

Notes:

1. Medicines for medical use registered on the territory of the Russian Federation are prescribed in accordance with the instructions for use of the medicinal product for medical use and the pharmacotherapeutic group according to the anatomical-therapeutic-chemical classification recommended by the World Health Organization, as well as taking into account the method of administration and use medicinal product.

2. The prescription and use of drugs for medical use, medical devices and specialized medical nutrition products that are not included in the standard of medical care are allowed in the case of medical indications (individual intolerance, for health reasons) by decision of the medical commission (part 5 of article 37 of the Federal Law of November 21, 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation” (Collected Legislation of the Russian Federation, 2011, N 48, Art. 6724; 2012, N 26, Art. 3442, 3446)).

Electronic document text
prepared by Kodeks JSC and verified against:
official website of the Russian Ministry of Justice
www.minjust.ru (scanner copy)
as of 01/24/2013

In the general structure of infectious diseases, acute intestinal infections (AI) account for more than 40% of all hospitalized patients, and in the structure of infectious morbidity they occupy second place after acute respiratory viral infections (ARVI) and influenza, representing a serious problem in pediatric practice.

The algorithm for choosing therapeutic tactics for acute intestinal infections begins with establishing the etiopathogenetic group of diarrhea. The most optimal way is to determine the etiology of the disease using express diagnostic methods (for example, tests for diagnosing viral acute intestinal infections 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 treatment algorithm .

Unfortunately, in routine clinical practice, the etiology of acute intestinal infections in most cases remains unidentified and therapeutic tactics are determined based on the etiopathogenetic group of diarrhea, the diagnosis of which is carried out on the basis of clinical and epidemiological data. Thus, watery diarrhea in most cases is caused by viral agents and requires the use of antiviral drugs as etiotropic therapy, while invasive diarrhea is caused by bacterial agents, which implies antibacterial therapy if there are appropriate indications.

Clinical differential diagnosis of DCI is based on the clinical features of the leading syndromes (Table 1).

Epidemiological data on the etiological structure of acute intestinal infections are currently characterized by the predominance of viral agents over bacterial ones and the presence of combined forms in 26.0 ± 1.6% of patients of viral-bacterial and viral-viral etiology.

Among viral agents in children during 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 overall structure of deciphered OKI). Among viral acute infections, the most significant etiological factors are rotavirus and norovirus infections, which determines this combination as the most common not only when infected with two viral agents at the same time, but also when infected with a large number of pathogens (4.8 ± 0.8% in the overall structure of deciphered OKI).

The epidemiological history of the disease is assessed according to the following scheme (Table 2). It is necessary for the doctor to make assumptions about the etiology of the disease. Thus, food and water transmission routes are more typical for bacterial acute infections, while contact and household transmission are more typical for viral agents. In the autumn-winter period, there is an increase in the incidence of viral acute intestinal infections, and in the summer - bacterial ones.

When conducting clinical and epidemiological analysis of a patient, it is necessary to take into account the age structure of ACI. For children of all ages, rotavirus infection is recorded significantly more often, while in patients under 3 years of age it accounts for 83% of all patients with established rotavirus infection (p< 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, OCI is divided into mild, moderate and severe. Establishing the severity of the disease is carried out through an integral analysis of clinical data:

1) the prevalence of damage to the gastrointestinal tract (GIT) and other organs;
2) intensity of manifestation of the main clinical symptoms of the disease;
3) intensity of manifestation of the patient’s main complaints (Table 3).

The form of severity can be determined 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 for each item in block 1; B and C are the sum of positive values for each item in blocks 2 and 3, respectively.

Values of this indicator ranging from 1% to 35% refer to a mild form of the disease, from 36% to 70% to a moderate form of the disease, and 71% or more to a 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, and the correct assessment of the degree of dehydration in a child with ACI is of particular importance.

To diagnose dehydration, the “gold” standard is to assess the patient’s body weight dynamics. Thus, degree I exicosis corresponds to a loss of up to 5% of body weight, which is up to 50 ml/kg of fluid, degree II exicosis corresponds to a loss of 6-10% of body weight (60-100 ml/kg), degree III exicosis corresponds to a loss of more than 10%. body weight (110-150 ml/kg). Dehydration, characterized by a loss of body weight of more than 20%, is not compatible with life.

However, for pediatric practice, the use of a method for assessing body weight loss is not always acceptable. In this case, clinical assessment of the symptoms of dehydration comes first.

The M. H. Gorelick trait scale is quite widely used abroad:

change in the general condition (type) of the patient;
presence of tears;
capillary reperfusion > 2 seconds;
sunken eyes;
decreased diuresis;
condition (dryness, turgor) of the skin and mucous membranes;
basic hemodynamic parameters (pulse rate and filling);
breathing disorders.

Assessing the form of dehydration on this scale involves counting the number of signs a patient has:

lung (< 5%) обезвоживание ≤ 2 признаков;
moderate (6-9%) dehydration 3-5 signs;
severe (> 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 with grade I exicosis (Table 4).

Therapeutic tactics for acute intestinal infections in a particular patient are based on knowledge or assumption (based on clinical characteristics, epidemiological history data) about the etiology of the disease: bacterial or viral infection. In addition, it is necessary to take into account the age of the patient, the characteristics of his premorbid background and the period of the disease.

The scheme of therapeutic tactics for acute intestinal infections depending on the type of diarrhea and the period of the disease is given in table. 6.

All patients, regardless of the etiology and severity of the disease, should be prescribed sorbents (carbon, synthetic, mineral, fibrous) as one of the important aspects of etiotropic therapy. Currently, there is a fairly large number of drugs on the Russian pharmaceutical market that have sorption properties to varying degrees. The administration of enterosorbents is indicated as early as possible in the course of the disease - before identification of the pathogen, which makes it possible to achieve a “terminating” effect on the course of acute intestinal infections. The use of enterosorbents in the late stages of the disease (after 5-7 days), especially with invasive acute intestinal infections, has less effect on diarrheal syndrome, but has a pronounced detoxification and enteroprotective effect. Important positive aspects of the use of enterosorbents include the lack of influence 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 drug withdrawal is stable normalization of stool or its delay within 2 days.

Antiviral drugs are recommended for viral acute intestinal infections. Antiviral drugs recommended for acute intestinal infections and proven effective in clinical studies: affinity purified antibodies to human interferon gamma, interferon alpha-2b in combination with taurine, umifenovir.

The issues of antibacterial therapy for acute intestinal infections remain among the most pressing for the practicing physician. Unfortunately, most doctors approach the issue of prescribing antibiotics in a formulaic manner, without taking into account the etiology of the disease, recommending them even for viral acute intestinal infections, and without knowledge of data on the sensitivity and resistance of the main bacterial pathogens.

Indications for the prescription of antibacterial drugs are divided into absolute, basic and additional (Table 7).

Absolute indications for prescribing antibacterial therapy have absolute force - antibacterial therapy is indicated for all patients for whom they are established. The presence of main indications in combination with one of the additional points is an indication for antibiotic therapy. The presence of additional indications alone is not an indication for 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 use in outpatient clinics, where the most justified tactics for initial treatment of acute intestinal infections is the use of nitrofurans (nifuroxazide, nifurantel). Quinolones (nalidixic acid, ciprofloxacin) have proven themselves in the treatment of salmonellosis. Cephalosporins are recommended for systemic antibacterial therapy for moderate and severe acute intestinal infections in a hospital setting. It is possible to prescribe tetracyclines, metronidazole, aminoglycosides, chloramphenicol.

If a diagnosis of campylobacteriosis is made, the most optimal for initial etiotropic therapy are macrolides (erythromycin, azithromycin, clarithromycin).

The duration of the course of antibacterial therapy in the acute phase of localized acute intestinal infections is determined by the clinical situation and, as a rule, is at least 5-7 days. The generally accepted indications for changing the drug are clinical ineffectiveness of the drug within 3 days.

It should be emphasized that in recent years, most pathogens of invasive acute intestinal infections have resistance to furazolidone. Salmonella remain highly sensitive to fluoroquinolones (for example, ciprofloxacin - 96.7% of strains are sensitive, but 23.3% are moderately resistant and 17.2% are resistant to pefloxacin), 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 antibacterial therapy from the moment of its prescription and during the convalescence period is the administration of probiotics.

Among the pathogenetic methods of therapy, the most important are rehydration agents (oral, parenteral), drugs that affect dehydration processes (gelatin tanate), and probiotics.

Oral rehydration is a necessary component of therapy, included in the list of therapeutic measures recommended by the World Health Organization, and is prescribed to all patients with ACI. For oral rehydration, the most justified is the use of ready-made solutions that are balanced in electrolyte composition and osmolarity (75 mEq/L sodium and 75 mEq/L glucose and osmolarity 245 mOsm/L).

Oral rehydration is carried out in two stages.

Stage 1 - primary rehydration is the replenishment of losses that occurred before seeking medical help, and is calculated for 6 hours. A total amount of liquid of 50-80 ml/kg is prescribed for 6 hours.

Stage 2 - maintenance rehydration, the task of which is to replenish current fluid losses during acute intestinal infections. 80-100 ml/kg of liquid is prescribed per day. The duration of the second stage of oral rehydration continues until recovery or the appearance of indications for parenteral correction of dehydration.

It must be taken into account 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 infusions (apple compote without sugar, carrot-rice infusion). The ratio of glucose-salt solutions and 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% solution of meglumine sodium succinate , which has proven its effectiveness in intensive therapy of these conditions.

The use of antidiarrheals (loperamide) in acute intestinal infections is not pathogenetically justified, since the mechanism of action of these drugs involves a decrease in gastrointestinal motility (increased motility is the body’s protective reaction in acute infectious intestinal lesions) and can contribute to the aggravation of intoxication syndrome in acute intestinal infections.

OKI of any severity are the cause of significant changes in the microbiocenosis of the gastrointestinal tract - for example, with Sonne'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 complex initial therapy, regardless of the etiology of the disease, as early as possible. These drugs are also indicated for all patients during the period of convalescence in order to restore microbiocenosis parameters. Their use for acute intestinal infections in children is not only pathogenetically justified, but also refers 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 studies 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.

With regard to acute intestinal infections in children, the working group of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition, ESPGHAN in 2014, based on an 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), and a heat-inactivated strain was also included in this group of probiotics Lactobacillus acidophilus LB, which formally cannot be classified as probiotics as living microorganisms with specified beneficial properties, however, it 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 insufficient data on the effectiveness of their use in the acute period of acute intestinal infections. However, previous studies have shown the presence of clinically significant positive properties, the effectiveness and safety of their use in acute intestinal infections, post-infectious bacterial overgrowth syndrome and the prevention of gastrointestinal microbiocenosis disorders against the background of antibacterial therapy. Thus, the range of strains that can be recommended in the treatment of acute intestinal infections requires further study.

In this regard, the most promising probiotic strains are microorganisms characterized by a high ability of adhesion, resistance to the action of aggressive environments of the human gastrointestinal tract (hydrochloric acid, bile) and belonging to the donor category.

Among such probiotic strains one can distinguish 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 ability for adhesion, a leading role in ensuring colonization resistance of the body, regulating the metabolism of fats, proteins and minerals, and the synthesis of biologically active substances, including vitamins. The most studied strains are Bifidobacterium longum and Bifidobacterium animalis lactis.

One of the lines of probiotic preparations that can be recommended for complex therapy of acute intestinal infections in children is the probiotic preparations Bifiform.

Bifiform Baby contains: Bifidobacterium BB-12 1 x 108 CFU and Streptococcus thermophilus TH-4 1 × 10 7 CFU.

Preclinical studies Bifidobacterium lactis BB-12, which is a component of the natural intestinal biofilm of healthy people, has been demonstrated to have high-level adhesion to surfaces with mucin (polycarbonate well plates were used), without mucin, and cell culture films (Caco-2, HT29?MTX), including on background of rotavirus infection and after it.

This strain has shown antagonistic activity against 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 its use preferable for acute intestinal infections of bacterial etiology.

Bifidobacterium lactis BB-12 is resistant to the action of aggressive environments in the human body - hydrochloric acid and bile, due to the synthesis of pH-dependent ATPase, which regulates the acid-base balance inside the bacterium and the presence of bile salt hydrolase, which allows the bacterium to remain active in the presence of bile.

Patients who require treatment with antibacterial drugs deserve special attention. Changes in the gastrointestinal microbiota caused by the course of the infectious process can be aggravated by the action of antibiotics. Therefore, this category of patients needs to include probiotic drugs aimed at maintaining microbiocenosis in the complex therapy of acute intestinal infections. 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 therapeutic properties, the strain Bifidobacterium lactis BB-12 is also inherently preventive. 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 it is recognized by the Food and Drug Administration (FDA) as Generally Regarded As Safe (GRAS).

Streptococcus thermophilus, which is part of Bifiform Baby, has demonstrated in studies an antagonistic effect against pathogens of acute intestinal infections; in particular, its effectiveness in the prevention of traveler's diarrhea has been shown.

This strain has been shown to have a symbiotic relationship with Lactobacillus bulgaricus.

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 0.5 g ~ 0.5 ml. Used once a day during meals. It is most optimal to use it during antibacterial therapy for acute intestinal infections, during the period of convalescence, as well as for preventive purposes (for example, when going on vacation with a child, visiting public 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. Inclusion in the preparation of an apathogenic Enterococcus faecium, which is not classified as not recommended for use in pediatric practice, but normally colonizes the small intestine, allows for a positive effect on the condition and digestive functions of not only the large intestine, but also the small intestine, especially in the presence of fermentative dyspepsia and flatulence.

The drug is indicated for children over 2 years of age. For acute diarrhea, the drug is taken 1 capsule 4 times a day until stool normalizes. Then 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: 1 capsule 2-3 times a day.

Symptomatic therapy includes treatment of febrile conditions. Antipyretics are not indicated for all patients, since an increase in temperature is an adaptive response of the body to an infection, creating optimal conditions for immune restructuring of the body. The prescription of this category of drugs is indicated for 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 and exacerbation of chronic pancreatic pathology is often observed during the period of repair and convalescence of acute intestinal infections. It should be noted that with norovirus infection, damage to the pancreas is observed more often than with acute intestinal infections of other etiologies. In such cases, the administration of enzyme preparations is indicated, preferably in minimicrosphere form. It should be noted that in the acute period of AII, enzyme preparations are not indicated. The most optimal period for their prescription, if indicated, is 5-6 days; the criterion for prescription is the appearance of appetite in the patient.

To relieve persistent vomiting, you can use prokinetics and antiemetic drugs: metoclopramide, domperidone, promethazine, 0.25% novocaine - 1 spoon (teaspoon, dessert spoon, table spoon according to age).

Criteria for assessing the effectiveness of treatment:

clinical (relief of intoxication syndrome, normalization of temperature, relief of vomiting, diarrhea and other symptoms);
clinical and laboratory tests (persistent normalization of hemogram, coprocytogram, negative results during bacteriological and PCR examinations).

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 carry out dynamic monitoring of patients who have suffered acute intestinal infections.

Thus, acute intestinal infections require special approaches from the doctor to diagnosis, management tactics and therapy. When supervising patients with acute intestinal infections, it should be taken into account that even mild forms lead to significant changes in the gastrointestinal microbiota in children, which requires the use of probiotic preparations 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

Federal Budgetary Institution Central Research Institute of Epidemiology of Rospotrebnadzor, Moscow

ICD-10 code:

A 0.2. – salmonellosis

A 0.3. – shigellosis

A 0.4. – Escherichiosis

enterocolitis caused by opportunistic flora
Definition. Acute intestinal infections (AI) represent a large group of independent infectious diseases, united by the presence of a common clinical syndrome - diarrhea. The causative agents of acute intestinal infections are pathogenic, conditionally pathogenic microorganisms, viruses and fungi. Among pathogenic bacteria that cause diseases mainly in older children, the most important are Shigella, Salmonella, and Escherichia. Conditionally pathogenic enterocolitis, dominant among children in the first year of life, is caused by various variants of staphylococcus, enterococcus, Escherichia coli, Proteus, etc. Viral diarrhea, recorded mainly in children from 6 months to 2 years, is caused by rotavirus. Intestinal candidiasis, where fungi of the genus appear as the main pathogen Candida, and in particular Candida albicans, occurs mainly in children in the first 3 months of life.

Criteria for the severity of acute intestinal infections. The volume and quality of therapy depends on the severity of the disease.

Light form. General infectious symptoms are practically absent, body temperature is subfebrile, but can remain normal. In children of the first year of life, rare regurgitation is observed, but no loss of body weight is observed. Stools become more frequent up to 4-6 times a day and, depending on the location of the inflammatory process, become enteritic, colitis or enterocolitis.

Moderate form. From the first days of the disease, general infectious symptoms are expressed: body temperature is 38-39ºC, there is a decrease in appetite, lethargy, vomiting, often repeated, peripheral circulation is impaired in the form of pallor or marbling of the skin, acrocyanosis. In children of the first year of life, a flat weight curve is observed. Stool 8-10 times a day.

Severe form. The main criteria for severity include: hyperthermia (body temperature 39ºC and above), repeated vomiting, increased frequency of stools up to 10-15 times or more per day, and hemocolitis. The stool loses its fecal character and, if the distal part of the intestine is affected, is determined in the form of “rectal spitting”; if the small part of the intestine is affected, the stool is copious with a large amount of water without admixture of feces. The development of one of the syndromes is characteristic: toxicosis, toxicosis with exicosis, neurotoxicosis, DIC syndrome, accompanied by severe disorders of the central and cardiovascular systems, water-electrolyte metabolism, acid-base state, hemostasis system.

Scope of examination of patients with acute intestinal infections.

Light form– general peripheral blood test, general urine test, coprogram 1-3 times, tank. culture 3 times, stool for rotavirus once.

Moderate form– general blood test, general urine test, coprogram 1-3 times, bacteriological culture 3 times, feces for rotaviruses, blood electrolytes, liver tests.

Severe form– general blood test, general urine test, coprogram 1-3 times tank. culture 3 times, hematocrit, blood clotting time, blood electrolytes, acid-base balance indicators, liver tests, urea, total protein, immunogram.

The classification of acute intestinal infections is presented in tables 8-12.

Table 8

Classification of dysentery

Table 9

Classification of salmonellosis

Table 10

Classification of Escherichiosis

Table 11

Classification of rotavirus gastroenteritis

Table 12

Classification of enterocolitis caused by

conditionally pathogenic flora