Algorithm for the treatment of acute intestinal infections in children. On the approval of the standard of specialized medical care for acute intestinal infections of unknown etiology of severe severity Undergo treatment in Korea, Israel, Germany, USA

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols MH RK - 2017

Viral and other specified intestinal infections (A08), Diarrhea and gastroenteritis of suspected infectious origin (A09), Other bacterial intestinal infections (A04), Other salmonella infections (A02), Cholera (A00), Shigellosis (A03)

Infectious diseases in children, Pediatrics

general information

Short description

Approved
Joint Commission on the Quality of Medical Services
Ministry of Health of the Republic of Kazakhstan
dated August 18, 2017
Protocol No. 26

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

INTRODUCTORY PART

ICD-10 code (s):

ICD-10
The code	Name
A00	cholera
A00.0	Cholera caused by Vibrio cholera 01, biovar cholerae
A00.1	Cholera caused by Vibrio cholera 01, biovar eltor
A00.9	Cholera, unspecified
A02	Other salmonella infections
A02.0	Salmonella enteritis
A02.1	Salmonella septicemia
A02.2	Localized salmonella infection
A02.8	Other specified salmonella infections
A02.9	Salmonella infection, unspecified
A03	Shigellosis
A03.0	Shigellosis due to Shigella dysenteriae
A03.1	Shigellosis due to Shigella flexneri
A03.2	Shigellosis due to Shigella boydii
A03.3	Shigellosis due to Shigella sonnei
A03.8	Another shigellosis
A03.9	Shigellosis, unspecified
A04	Other bacterial intestinal infections
A04.0	Enteropathogenic Escherichia coli infection
A04.1	Enterotoxigenic Escherichia coli infection
A04.2	Enteroinvasive Escherichia coli infection
A04.3	Enterohaemorrhagic Escherichia coli infection
A04.4	Other intestinal infections with Escherichia coli
A04.5	Campylobacter enteritis
A04.6	Yersinia enterocolitica enteritis
A04.7	Clostridium difficile enterocolitis
A04.8	Other specified bacterial intestinal infections
A04.9	Bacterial intestinal infection, unspecified
A08	Viral and other specified intestinal infections
A09	Diarrhea and gastroenteritis of suspected infectious origin

Date of development / revision of the protocol: 2017 year.

Abbreviations used in the protocol:

Digestive tract	-	gastrointestinal tract
IU	-	international units
UAC	-	general blood analysis
OAM	-	general urine analysis
IMCI	-	Integrated Management of Childhood Illness
ELISA	-	linked immunosorbent assay
OKI	-	acute intestinal infections
OBO	-	general danger signs
OPC	-	oral rehydration agents
ESPGHAN	-	European Society of Pediatric Gastroenterology, Hepatology and Nutrition
PCR	-	polymerase chain reaction
GP	-	general doctor
ESR	-	erythrocyte sedimentation rate
ICE	-	disseminated intravascular coagulation

Protocol users: general practitioners, pediatric infectious disease specialists, pediatricians, paramedics, emergency doctors.

Evidence level scale:

AND	High quality meta-analysis, systematic review of RCTs, or large RCTs with very low likelihood (++) of bias that can be generalized to the relevant population.
IN	High quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with a very low risk of bias or RCTs with a low (+) risk of bias that can be generalized to the relevant population ...
FROM	A cohort or case-control study or controlled trial without randomization with a low risk of bias (+), the results of which can be generalized to the relevant population, or RCTs with a very low or low risk of bias (++ or +), the results of which cannot be directly extended to the relevant population.
D	Description of a series of cases or uncontrolled research or expert opinion.
GPP	Best Pharmaceutical Practice.

Classification

Classification :

By etiology:	... cholera; ... shigellosis; ... salmonellosis; ... escherichiosis; ... campylobacteriosis and other AEI caused by anaerobic pathogens; ... Yersinia enterocolitica; ... OCI caused by opportunistic microorganisms (staphylococci, Klebsiella, citrobacter, Pseudomonas aeruginosa, Proteus, etc.).
By severity	light, medium and severe forms
On the topic of gastrointestinal tract damage	... gastritis; ... enteritis; ... gastroenteritis; ... gastroenterocolitis; ... enterocolitis; ... colitis.
With the flow	... acute (up to 1 month); ... protracted (1-3 months); ... chronic (over 3 months).

Salmonellosis classification:

Shigellosis classification:

Classification of Escherichiosis:

Classification of intestinal yersiniosis:

Cholera classification:

Classification of opportunistic intestinal infection:

Diagnostics

DIAGNOSTIC METHODS, APPROACHES AND PROCEDURES

Diagnostic criteria

Complaints:
Fever;
· nausea, vomiting;
Lethargy;
· stomach ache;
• loose stools 3 or more times during the day;
Flatulence.

Anamnesis:

Physical examination:

Epidemiological history: the use of low-quality products; reports of local outbreaks of intestinal infections, including stays in other hospitals; family members or community members have similar symptoms.
Medical history:
The presence of symptoms of intoxication, fever, gastritis, gastroenteritis, enterocolitis, colitis.

General intoxication syndrome:
... violation of the general condition;
... fever;
... weakness, lethargy;
... decreased appetite;
... vomiting;
... nausea;
... lamination of the tongue.
Dyspeptic syndrome:
... nausea, vomiting, bringing relief associated with food intake, in young children, persistent regurgitation;
... the appearance of pathological stools with enteritis - abundant, odorless, with undigested lumps, possibly with greens, with colitis: scanty loose stools with mucus, greens, streaks of blood;
... rumbling along the small and / or large intestine;
... flatulence;
... irritation of the skin around the anus, on the buttocks, perineum.
Pain syndrome:
... with gastritis - pain in the upper abdomen, mainly in the epigastrium;
... with enteritis - constant pain in the umbilical region or throughout the abdomen;
... with colitis - pain in the sigmoid colon.
Exicosis:
... signs of dehydration in the form of dry mucous membranes and skin, thirst or refusal to drink, decreased skin elasticity and tissue turgor, sunken eyes;
... retraction of the large fontanelle (in infants);
... violation of consciousness;
... weight loss;
... decrease in urine output.
Neurotoxicosis:
... fever that does not respond well to antipyretic drugs;
... the appearance of vomiting, not associated with food intake and does not bring relief;
... convulsions;
... violation of peripheral hemodynamics;
... tachycardia.
The syndrome of metabolic (metabolic) disorders:
... signs of hypokalemia - muscle hypotension, weakness,
... hyporeflexia, intestinal paresis;
... signs of metabolic acidosis - marbling and cyanosis of the skin, noisy toxic breathing, confusion.

Causative agents	The main symptoms
Cholera	Abdominal pain is uncommon. The stool is watery, odorless, the color of rice water, sometimes with the smell of raw fish. Vomiting occurs after diarrhea. Rapid development of exicosis. Little or no intoxication, normal body temperature.
Salmonellosis	Watery, foul-smelling stools, often green and marsh-colored. Prolonged fever, hepatosplenomegaly.
Intestinal yersiniosis	Prolonged fever. Intense pain around the navel or right iliac region. Abundant, offensive, often mixed with mucus and blood, stools. In the general analysis of blood, leukocytosis with neutrophilia.
OCI caused by opportunistic microorganisms	The main variants of lesions of the gastrointestinal tract in children over a year old are gastroenteritis and enteritis, less often - gastroenterocolitis, enterocolitis. In children of the first year of life, the clinic depends on the etiology and timing of infection. In patients with the first year of life, the intestinal form is often accompanied by the development of toxicosis and exicosis of I-II degree. Diarrhea is predominantly secretory-invasive.
Shigellosis	Symptoms of intoxication, frequent, scanty, with a lot of cloudy mucus, often green and blood, loose stools.
Enteropathogenic Escherichia (EPE) Enteroinvasive Escherichia (EIE) Enterotoxigenic Escherichia (ETE)	EPE: early age of the child; gradual start; infrequent but persistent vomiting; flatulence; copious watery stools; ETE: The onset of the disease is usually acute, with the appearance of repeated vomiting, "watery" diarrhea. Body temperature is most often within normal limits or subfebrile. Feces are devoid specific fecal odor, pathological impurities in them are absent, reminiscent of rice water. Exicosis develops rapidly. EIE: in older children, the disease begins, as a rule, acutely, with a rise in body temperature, headache, nausea, often - vomiting, moderate abdominal pain. Simultaneously or after a few hours, a liquid stool with pathological impurities appears.

WHO and ESPGHAN / ESPID criteria (2008, 2014):

Assessment of fluid deficiency in a child according to WHO:

The severity of dehydration as a percentage of the child's body weight before illness

ESPGHAN recommends using the Clinical Dehydration Scale (CDS), where 0 points - no dehydration, 1 to 4 points - mild dehydration, 5-8 points correspond to severe dehydration.

Clinical Dehydration Scale (CDS):

Sign	Points
Sign	0	1	2
Appearance	Normal	Thirst, anxiety, irritability	Lethargy, drowsiness
Eyeballs	Not sunken	Slightly sunken	Sunken
Mucous membranes	Wet	dryish	Dry
Tears	Lacrimation is normal	Lacrimation is reduced	No tears

The severity of dehydration in children according to IMCI in children under 5 years of age:
NB! If there are signs of severe dehydration, check for shock symptoms: cold hands, capillary filling time\u003e 3 seconds, weak and fast pulse.

Types of dehydration and clinical symptoms:

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

Clinical criteria for assessing the degree of exicosis :

Symptoms	Excosis degree
Symptoms	1	2	3
Chair	infrequent	up to 10 times a day, enteric	frequent, watery
Vomiting	1-2 times	repeated	multiple
General state	moderate	moderate to severe	heavy
Weight loss	up to 5% (\u003e 1 year up to 3%)	6-9% (\u003e 1 year to 3-6%)	more than 10% (\u003e 1 year to 6-9%)
Thirst	moderate	pronounced	may be absent

Turgor of tissues	saved	the fold straightens slowly (up to 2 s.)	the fold straightens very slowly (more than 2 s.)
Mucous membrane	wet	dryish, slightly hyperemic	dry, bright
Large fontanelle	At the level of the bones of the skull	slightly sunken	pulled in
Eyeballs	norm	sink	sink
Heart tones	loud	slightly muted	Muted
Blood pressure	normal or slightly increased	systolic normal, diastolic increased	reduced
Cyanosis	no	Moderate	pronounced
Consciousness, reaction to others	norm	Agitation or drowsiness, lethargy	Lethargic or unconscious
Pain response	expressed	Weakened	absent
Vote	norm	Weakened	often aphonia
Diuresis	saved	Reduced	Significantly reduced
Breath	norm	moderate shortness of breath	toxic
Body temperature	norm	often increased	often below normal
Tachycardia	no	Moderate	expressed

Laboratory research :
KLA - leukocytosis, neutrophilia, accelerated ESR;
· Coprogram: the presence of undigested fiber, mucus, leukocytes, erythrocytes, neutral fats;
· Bacteriological examination of vomit or gastric lavage and feces, release of pathogenic / opportunistic pathogenic flora.

Additional laboratory and instrumental studies:
B / x blood test: concentration of electrolytes in blood serum, urea, creatinine, residual nitrogen, total protein (with dehydration);
· Coagulogram (with DIC syndrome);
· Bacteriological examination of blood and urine - isolation of pathogenic / conditionally pathogenic flora;
· RPHA (RNGA) blood with specific antigenic diagnostics - an increase in antibody titers with a repeated reaction by 4 or more times.
· PCR - determination of the DNA of intestinal infections of bacterial etiology.

Indications for specialist consultation:
· Consultation with a surgeon - if you suspect appendicitis, intestinal obstruction, intestinal intussusception.

Diagnostic algorithm:

Differential diagnosis

Differential diagnosis and justification for additional research:

Diagnosis	Rationale for differential diagnosis	Surveys	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 RNA of enteroviruses in feces.	Herpangina, exanthema, gastroenteritis.
Intestinal intussusception	Loose stools, abdominal pain.	Consultation with a surgeon	Crying attacks, with pale skin of the infant. Blood in the stool ("raspberry" or "currant jelly") without stool impurities 4-6 hours after the onset of the disease. Bloating, induration in the abdomen. soft-elastic consistency. In dynamics, repeated vomiting.
Adenovirus infection	Fever, vomiting, loose stools.	PCR - determination of DNA of adenoviruses in feces.	Prolonged fever. Pharyngitis, tonsillitis, rhinitis, conjunctivitis, enteritis, hepatosplenomegaly.
Acute appendicitis	Fever, vomiting, loose stools.	Consultation with a surgeon.	Pain in the epigastrium with movement to the right iliac region. The pain is constant, aggravated by coughing. The stool is liquid, without pathological impurities, up to 3-4 times, often constipation.

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Treatment

Preparations (active ingredients) used in treatment

Groups of drugs according to ATC used in treatment

Treatment (outpatient clinic)

TACTICS OF TREATMENT AT THE AMBULATORY LEVEL

On an outpatient basis, children with mild and moderate forms (children over 36 months old) receive treatment for AEI of bacterial etiology.
The principles of treatment of patients with AEI include: regimen, rehydration, diet, means of pathogenetic and symptomatic therapy.
In case of ineffectiveness of outpatient treatment or its impossibility, the issue of hospitalization of the child in a specialized hospital is considered.

Non-drug treatment:
· Half-bed mode (during the entire period of fever);
· Diet - depending on the child's age, food preferences and eating habits before the onset of the illness;
· Breastfed babies should be breastfed as often and for as long as they want;
· Children who are bottle-fed, continue to feed their usual food;
· Children aged 6 months to 2 years - table number 16, from 2 years and older - table number 4;

Drug treatment
For relief of hyperthermic syndrome over 38.5 0 С:
... paracetamol 10-15 mg / kg with an interval of at least 4 hours, no more than three days by mouth or per rectum, or ibuprofen at a dose of 5-10 mg / kg no more than 3 times a day by mouth.

For diarrhea without dehydration - plan A:
· Breastfeed more often and increase the duration of each feed if the baby is exclusively breastfed, give additional ORS or clean water in addition to breast milk.
· If the baby is mixed or formula fed, give the following fluids in any combination: ORS solution, liquid food (eg soup, rice water) or clean water.
Explain to the mother how much fluid should be given in addition to the usual intake:
· Up to 2 years 50-100 ml after each loose stool;
2 years and older 100-200 ml after each loose stool.
· Continue feeding;
Advise the mother to take the baby back to hospital immediately if any of the following symptoms appear:
· Cannot drink or suckle;
· The child's condition worsens;
• fever has appeared;
The child has blood in his stool or does not drink well.

For diarrhea with moderate dehydration - plan B:
The required ORS volume (in ml) can be calculated by multiplying the child's weight (in kg) by 75.
· To drink the calculated volume of liquid for 4 hours.
· If the child eagerly drinks the ORS solution and asks for more, more than the recommended amount can be given. Breastfeeding should be continued at the request of the baby. For formula-fed infants, the feeding is canceled and oral rehydration is administered for the first 4 hours.
· After 4 hours, reassess the child's condition and determine the hydration status: if 2 or more signs of moderate dehydration persist, continue plan B for another 4 hours and feed according to age.
· In the absence of the effect of oral rehydration on an outpatient basis, the patient is referred for inpatient treatment.
With a replacement purpose for the correction of exocrine pancreatic insufficiency, pancreatin 1000 U / kg / day with meals for 7-10 days.
For the purpose of etiotropic therapy of acute intestinal infections: azithromycin on the first day 10 mg / kg, from the second to the fifth day, 5 mg / kg once a day by mouth;
· Children over six years old - ciprofloxacin 20 mg / kg / day in two oral doses for 5-7 days.

List of essential medicines:

Pharmacological group		Mode of application	UD
Anilides	Paracetamol	Syrup for oral administration 60 ml and 100 ml, 5 ml - 125 mg; tablets for oral administration, 0.2 g and 0.5 g; rectal suppositories; solution for injection (in 1 ml 150 mg).	AND
	Dextrose + potassium chloride + sodium chloride + sodium citrate		FROM
	Azithromycin		IN

List of additional medicines:

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

Surgical intervention: no.

Further management[ 1-4,19 ] :
· Discharge to the children's team in case of clinical and laboratory recovery;
· A single bacteriological examination of convalescents after dysentery and other acute diarrheal infections is carried out after clinical recovery, but not earlier than two calendar days after the end of antibiotic therapy;
· In case of a relapse of the disease or a positive result of laboratory examination, persons who have had dysentery again undergo treatment. After the end of treatment, these individuals undergo monthly laboratory examinations for three months. Persons who have been carrying bacteria for more than three months are treated as patients with a chronic form of dysentery;
· Persons with chronic dysentery are on dispensary observation throughout the year. Bacteriological examinations and examination by an infectious disease doctor of persons with chronic dysentery are carried out monthly;
· Children who continue to excrete Salmonella after the end of treatment are suspended by the attending physician from visiting the organization of preschool education for fifteen calendar days; during this period, a three-time study of feces is carried out with an interval of one to two days. In case of a repeated positive result, the same procedure for removal and examination is repeated for another fifteen days.

[ 1-4,7 ] :

· Negative results of bacteriological studies;
· Stool normalization.

Treatment (hospital)

STATIONARY TREATMENT TACTICS
The basis of therapeutic measures for acute intestinal infections of bacterial etiology is therapy, including: regimen, rehydration, diet, etiotropic, pathogenetic and symptomatic therapy.

Oral rehydration is a two-step process:
Stage I - in the first 6 hours after admission of the patient, the water-salt deficiency that occurs before the start of treatment is eliminated;
· With dehydration of the I st. the volume of liquid is 40-50 ml / kg, and with dehydration of the II stage - 80-90 ml / kg of body weight in 6 hours;
Stage II - supportive oral rehydration, which is carried out for the entire subsequent period of the disease in the presence of continued loss of fluid and electrolytes. The approximate volume of solution for maintenance rehydration is 80-100 ml / kg of body weight per day. The effectiveness of oral rehydration is assessed according to the following criteria: a decrease in the volume of fluid loss; reducing the rate of weight loss; the disappearance of clinical signs of dehydration; normalization of diuresis; improving the general condition of the child.

Indications for parenteral rehydration and detoxification:
· Severe forms of dehydration with signs of hypovolemic shock;
· Infectious toxic shock;
· Neurotoxicosis;
· Severe forms of dehydration;
· Combination of exicosis (of any degree) with severe intoxication;
Indomitable vomiting;
Ineffectiveness of oral rehydration therapy within 8 hours with plan B or transition from moderate dehydration to severe dehydration.

The program for conducting parenteral rehydration therapy on the first day is based on calculating the required amount of fluid and determining the qualitative composition of rehydration solutions. The required volume is calculated as follows:
Total volume (ml) \u003d FP + PP + D, where FP is the daily physiological need for water; PP - pathological losses (with vomiting, loose stools, perspiration); D - fluid deficiency that the child has before the start of infusion therapy.
The amount of fluid required to compensate for the existing fluid deficit depends on the severity of dehydration and is roughly determined based on the body weight deficit. With exicosis of the first degree, 30-50 ml / kg per day is required to compensate for the deficiency, with exicosis of the second degree - 60-90 ml / kg per day, and with dehydration of the third degree - 100-150 ml / kg per day. The volume of the existing deficit is corrected gradually, only with dehydration of the 1st degree it is possible to compensate for the deficit within one day. For a more accurate accounting of pathological losses, it is necessary to carefully record all external losses (vomiting, loose stools) by measuring or weighing them. Replenishment of current pathological losses is carried out with pronounced massive losses every 4-8 hours, with moderate losses - every 12 hours.
The choice of starting solution for infusion therapy is determined by the degree of hemodynamic disturbance and the type of dehydration. Severe hemodynamic disorders in all types of dehydration are corrected with balanced isoosmolar saline solutions (saline, Ringer's solution, etc.), and, if necessary, in combination with colloidal solutions. The basic principle of infusion therapy for dehydration syndrome is that the loss must be reimbursed with an infusion medium similar to the lost one.
Do not use any low osmolarity solutions (5% dextrose solutions, low osmolarity polyionic solutions) as a starting solution. In this regard, 5% dextrose solutions are the most dangerous. First, because of their hypo-osmolarity; secondly, the utilization of glucose is accompanied by the formation of "free" water, which further enhances intracellular hyperhydration (danger of cerebral edema); thirdly, under-oxidation of glucose under conditions of tissue hypoperfusion leads to even greater lactic acidosis.

Patient observation chart, patient routing:

Drug-free treatment[ 1-4 ] :
... semi-bed mode (during the entire period of fever);
... diet - depending on the child's age, food preferences and eating habits before the onset of the illness;
... breastfed babies should be breastfed as often and for as long as they want;
... children who are bottle-fed, continue to feed their usual food;
... children aged 6 months to 2 years - table number 16, from 2 years and older - table number 4;
... children with lactose deficiency are prescribed low / lactose-free mixtures.

Drug treatment:
for relief of hyperthermic syndrome over 38.5 o C, it is prescribed:
Paracetamol 10-15 mg / kg with an interval of at least 4 hours, no more than three days by mouth or per rectum;
· or
Ibuprofen at a dose of 5-10 mg / kg no more than 3 times a day by mouth;

For diarrhea without dehydration - plan A, with moderate dehydration - plan B.

For severe dehydration - plan B: IV fluids for the child<12 мес. 30 мл/кг в течение 1 часа, затем введите 70 мл/кг за 5 часов. Если ребенок ≥ 12 мес. в/в за 30 мин 30 мл/кг, затем 70 мл/кг за 2,5 часа. Повторяйте оценку через каждые 15-30 мин. Если статус гидратации не улучшается, увеличьте скорость капельного введения жидкостей. Также давайте растворы ОРС (около 5 мл/кг/ч) как только ребенок сможет пить: обычно через 3-4 ч (младенцы) или 1-2 ч (дети более старшего возраста). Повторно оцените состояние младенца через 6 ч, а ребенка старше одного года - через 3 ч. Определите степень обезвоживания. Затем выберите соответствующий план (А, Б или В) для продолжения лечения.

For the purpose of detoxification therapy, intravenous infusion at the rate of 30-50 ml / kg / day with the inclusion of solutions:
10% dextrose (10-15 ml / kg);
0.9% sodium chloride (10-15 ml / kg);
Ringer's (10-15 ml / kg).

With a replacement purpose for the correction of exocrine pancreatic insufficiency, pancreatin 1000 U / kg / day during meals for 7-10 days.
Antibacterial drugs are prescribed in age-specific dosages, taking into account the etiology of AEI. When choosing an antibacterial drug, the severity of the disease, the age of the child, the presence of concomitant pathology and complications are taken into account. If the temperature in a patient with a confirmed AEI does not decrease within 46-72 hours, alternative antimicrobial methods should be considered.

Etiotropic antibacterial therapy[ 1-5 ] :

Etiology of OCI	First line antibiotics			Second line antibiotics
Etiology of OCI	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 by mouth;
· Children over six years of age ciprofloxacin 20-30 mg / kg / day in two oral doses for 5-7 days;
· Ceftriaxone 50-75 mg / kg per day IM or IV, up to one gram - once a day, more than one gram - twice a day. The course of treatment is 5-7 days; or
· Cefotaxime 50-100 mg / kg per day intramuscularly or intravenously, in two or three doses. The course of treatment is 5-7 days; or
· Amikacin 10-15 mg / kg per day intramuscularly or intravenously in two divided doses. The course of treatment is 5-7 days; or
· Cefuroxime 50-100 mg / kg per day intramuscularly or intravenously in two or three doses. The course of treatment is 5-7 days.

Essential Medicines List[1- 5 ,11-18 ]:

Pharmacological group	International non-proprietary drug name	Mode of application	UD
Anilides	paracetamol	Syrup for oral administration 60 ml and 100 ml, 5 ml - 125 mg; tablets for oral administration, 0.2 g and 0.5 g; rectal suppositories;	AND
Solutions affecting the water-electrolyte balance	dextrose + potassium chloride + sodium chloride + sodium citrate*	Powder for solution preparation inside.	FROM
Systemic antibacterial drugs	azithromycin.	powder for preparation of suspension for oral administration 100 mg / 5 ml, 200 mg / 5 ml; tablets 125 mg, 250 mg, 500 mg; capsules 250 mg, 500 mg	IN

List of complementary medicines :

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

Surgical intervention: no.

Further management :
· Discharge of convalescents after dysentery and other acute diarrheal infections (except for salmonellosis) is carried out after complete clinical recovery.
A single bacteriological examination of convalescents of dysentery and other acute diarrheal infections (with the exception of toxin-mediated and caused by opportunistic pathogens such as Proreus, Citrobacter, Enterobacter, etc.) is carried out on an outpatient basis within seven calendar days after discharge, but not earlier two days after the end of antibiotic therapy.
· Dispensary observation is carried out within one month, after which a single bacteriological examination is required.
· The frequency of visits to the doctor is determined by clinical indications.
· Dispensary observation is carried out by a GP / pediatrician at the place of residence or a doctor in the office of infectious diseases
· In case of a relapse of the disease or a positive result of laboratory examination, persons who have had dysentery again undergo treatment. After the end of treatment, these persons undergo monthly laboratory examinations for three months. Persons who have been carrying bacteria for more than three months are treated as patients with a chronic form of dysentery.
· Persons with chronic dysentery are on dispensary observation throughout the year. Bacteriological examinations and examination by an infectious disease doctor of these persons are carried out monthly.
· The discharge of salmonellosis convalescents is carried out after complete clinical recovery and a single negative bacteriological examination of feces. The study is carried out no earlier than three days after the end of treatment.
· Only the decreed contingent is subject to dispensary observation after a disease.
· Children who continue to excrete Salmonella after the end of treatment are suspended by the attending physician from visiting the organization of preschool education for fifteen days; during this period, a three-time study of feces is carried out with an interval of one to two days. In case of a repeated positive result, the same procedure for removal and examination is repeated for another fifteen days.

Treatment effectiveness indicators[ 1-4 ] :
· Normalization of body temperature;
· Restoration of water and electrolyte balance;
Relief of symptoms of intoxication;
· Relief of gastrointestinal syndrome;
· Stool normalization.

Hospitalization

INDICATIONS FOR HOSPITALIZATION WITH INDICATION OF THE TYPE OF HOSPITALIZATION

Indications for planned hospitalization: no

Indications for emergency hospitalization:
· Children with severe and moderate forms (up to 36 months) of viral gastroenteritis;
· All forms of the disease in children under the age of two months;
· Forms of the disease with severe dehydration, regardless of the age of the child;
Lingering diarrhea with dehydration of any degree;
· Chronic forms of dysentery (with exacerbation);
· Burdened premorbid background (prematurity, chronic diseases, etc.);
Fever\u003e 38 ° C in children<3 месяцев или> 390 C for children from 3 to 36 months;
· Severe diarrheal syndrome (frequent and significant stool volume);
Persistent (repeated) vomiting;
· Lack of effect from oral rehydration;
· No effect of outpatient treatment within 48 hours;
· Clinical symptom complex of a severe infectious disease with hemodynamic disorder, organ failure;
· Epidemiological indications (children from "closed" institutions with round-the-clock stay, from large families, etc.);
· Cases of the disease in medical institutions, boarding schools, orphanages, children's homes, sanatoriums, boarding schools for the elderly and disabled, summer health organizations, rest homes;
· Inability to provide adequate home care (social problems).

Information

Sources and Literature

Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2017
1. 1) Roberg M. Kliegman, Bonita F. Stanton, Joseph W. St. Geme, Nina F. Schoor / Nelson Textbook of Pediatrics. Twentieth edition. International Edition.// Elsevier-2016, vol. 2-th. 2) Uchaikin V.F., Nisevich N.I., Shamshieva O.V. Infectious diseases in children: textbook - Moscow, GEOTAR-Media, 2011 - 688 p. 3) Treatment of diarrhea. Manual for doctors and other categories of senior health workers: World Health Organization, 2006 4) Provision of inpatient care for children (WHO Guidelines for the management of the most common diseases in primary hospitals, adapted to the conditions of the Republic of Kazakhstan) 2016. 450 s. Europe. 5) Farthing M., Salam M., Lindberg G. et al. Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organization, 2012 // www.worldgastroenterology.org/ 6) World Gastroenterology Organization (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World Gastroenterology Organization (WGO); 2008 Mar.28p. 7) Implementation of new guidelines for the clinical management of diarrhea. Guidelines for decision makers and program managers, WHO, 2012 // www.euro.who.int/__data/assets/pdf_file/0007/.../9244594218R.pdf. 8) National Collaborating Center for Women "s and Children" s Health. Diarrhoea and vomiting in children. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Apr 9) Centers for Disease Control and Prevention. Salmonella Senftenberg Infections, Serbia. Emerging Infectious Diseases 2010; 16 (5): 893-894. 10) Majowicz SE, Musto J, Scallan E, Angulo FJ, Kirk M, O'Brien SJ, et al; International Collaboration on Enteric Disease ‘Burden of Illness’ Studies. The global burden of nontyphoidal Salmonella gastroenteritis. Clin Infect Dis. 2010; 50: 882-9. http://dx.doi.org/ 10.1086/ 650733 11) Petrovska L, Mather AE, AbuOun M, Branchu P, Harris SR, Connor T, et al. Microevolution of monophasic Salmonella Typhimurium during epidemic, United Kingdom, 2005-2010. Emerg Infect Dis. 2016; 22: 617-24. http://dx.doi.org/10.3201/ eid2204.150531 12) Samuel J. Bloomfield, Jackie Benschop, Patrick J. Biggs, Jonathan C. Marshall, David T.S. Hayman, Philip E. Carter, Anne C. Midwinter, Alison E. Mather, Nigel P. FrenchLu J, Sun L, Fang L, Yang F, Mo Y, Lao J, et al. Genomic Analysis of Salmonella enterica Serovar Typhimurium DT160 Associated with a 14-Year Outbreak, New Zealand, 1998–2012 Emerging Infectious Diseases www.cdc.gov/eid Vol. 23, No. 6, June 2017 13) G. Gigante, G. Caracciolo, M. Campanale, V. Cesario, G. Gasbarrini, G. Cammarota, A. Gasbarrini Ospedale Gemelli, Rome, Italy; Fondazione Italiana Ricerca in Medicina, Rome, Italy Gelatine Tannate reduces antibiotics associated side-effects of anti-helicobacter pylori first- line therapy Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 14) Gelatin tannate for treating acute gastroenteritis: a systematic review Center for Reviews and Dissemination Original Author (s): Ruszczynski M, Urbanska M and Szajewska H Annals of Gastroenterology, 2014, 27 (2), 121-124 15) Esteban Carretero J , Durbán Reguera F, López-Argüeta Ál - varez S, López Montes J. A comparative analysis of response to ORS (oral rehydration solution) vs. ORS + gelatin tannate in two cohorts of pediatric patients with acute diarrhea. Rev Esp Enferm Dig 2009; 101: 41-49. 16) Large reference book of medicines / ed. L. E. Ziganshina, V. K. Lepakhina, V. I. Petrov, R. U. Khabrieva. - M .: GEOTAR-Media, 2011. - 3344 p. 17) BNF for children 2014-2015 18) Order of the Minister of National Economy of the Republic of Kazakhstan dated March 12, 2015 No. 194. Registered with the Ministry of Justice of the Republic of Kazakhstan on April 16, 2015 No. 10741 About approval of the Sanitary Rules "Sanitary and Epidemiological Requirements for the Organization and Conduct of Sanitary and Antiepidemic (Preventive) Measures to Prevent Infectious Diseases"

Information

ORGANIZATIONAL ASPECTS OF THE PROTOCOL

List of protocol developers:
1) Efendiev Imdat Musa oglu - Candidate of Medical Sciences, Head of the Department of Pediatric Infectious Diseases and Phthisiology, State Medical University of Semey City.
2) Baesheva Dinagul Ayapbekovna - Doctor of Medical Sciences, Associate Professor, Head of the Department of Children's Infectious Diseases, JSC "Astana Medical University".
3) Kuttykuzhanova Galiya Gabdullaevna - Doctor of Medical Sciences, Professor, Professor of the Department of Pediatric Infectious Diseases of the Republican State Enterprise at the REM “Kazakh National Medical University named after S. D. Asfendiyarov.
4) Devdariani Khatuna Georgievna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, Republican State Enterprise at the REM "Karaganda State Medical University".
5) Zhumagalieva Galina Dautovna - Candidate of Medical Sciences, Associate Professor, Head of the Course of Children's Infections, Republican State Enterprise at the REM “West Kazakhstan State University named after Marat Ospanov ".
6) Mazhitov Talgat Mansurovich - Doctor of Medical Sciences, Professor, Professor of the Department of Clinical Pharmacology, JSC "Astana Medical University".
7) Umesheva Kumuskul Abdullaevna - Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Infectious Diseases, RSE at the REM “Kazakh National Medical University named after S. D. Asfendiyarov ".
8) Alshynbekova Gulsharbat Kanagatovna - Candidate of Medical Sciences, Acting Professor of the Department of Children's Infectious Diseases, Republican State Enterprise at the REM "Karaganda State Medical University".

No Conflict of Interest Statement:no .

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

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

Attached files

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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 Basics of Health Protection 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 of severe severity according to the appendix.

Minister
V.I.Skvortsova

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

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

application
to order
Ministry of Health
Russian Federation
dated November 9, 2012 N 732н

Floor: any

Phase: acute

Stage: severe severity

Complications: regardless of complications

Type of medical assistance: specialized medical care

Conditions for the provision of medical care: stationary

Medical assistance form: urgent, emergency

Average terms of treatment (number of days): 10


	Code byICD 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 the diagnosis of disease, condition


Reception (examination, consultation) of 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 medical care, which can take values \u200b\u200bfrom 0 to 1, where 1 means that this event is carried out by 100% of patients corresponding to this model, and the numbers are less 1 - the percentage of patients specified in the standard of medical care with appropriate medical indications.
	Appointment (examination, consultation) of an obstetrician-gynecologist, primary
	Appointment (examination, consultation) of an infectious disease doctor, primary
	Appointment (examination, consultation) of a surgeon primary



The code medical services	Medical service name	Average rendering frequency	Average frequency of application
	Study of the level of stercobilin in the feces
	Stool study for protozoa and helminth eggs
	Carrying out the Wasserman reaction (RW)
	Study of intestinal microbiocenosis (dysbiosis)
	Determination of antigen to hepatitis B virus (HBsAg Hepatitis B virus) in 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 in the blood
	Determination of antibodies of classes M, G (IgM, IgG) to human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2) in blood
	Bacteriological examination of feces for the causative agent of dysentery (Shigella spp.)
	Bacteriological examination of feces for Salmonella (Salmonella spp.)
	Microscopic examination of feces for protozoa
	Microscopic examination of stool for Cryptosporidium (Cryptosporidium parvum)


	General urine analysis
	Scatological examination



The code medical services	Medical service name	Average rendering frequency	Average frequency of application
	Esophagogastroduodenoscopy
	Colonic endoscopy


	Digital fluorography of lungs

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


Reception (examination, consultation) and supervision of a specialist doctor
The code medical services	Medical service name	Average rendering frequency	Average frequency of application
	Daily examination by an infectious disease doctor with supervision and care of nursing and junior medical personnel in the hospital department


Laboratory research methods
The code medical services	Medical service name	Averaged index frequency providing	Average frequency of application
	General (clinical) blood test
	General therapeutic biochemical blood test
	General urine analysis


Instrumental research methods
The code medical services	Medical service name	Average rendering frequency	Average frequency of application
	Esophagogastroduodenoscopy
	Ultrasound examination of the abdominal organs (complex)
	Registration of an electrocardiogram
	Radiography of the lungs

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


	Anatomical therapeutic chemical classification	Name of the medicinal product **	Average neat show tel frequency pre- placing	Units of measurement rhenium
_______________ International non-proprietary 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 amine esters
		Platyphyllin
	Papaverine and its derivatives
		Drotaverine
		Drotaverine
	Coal preparations
		Activated carbon
	Other absorbent intestinal preparations
		Hydrolytic lignin
	Antidiarrheal microorganisms
		Bifidobacterium bifidum
	Enzyme preparations
		Pancreatin
	Calcium preparations
		Calcium gluconate
	Solutions, affecting the water-electrolyte balance
		Dextrose + Potassium chloride + Sodium chloride + Sodium citrate
		Potassium chloride + Sodium acetate + Sodium chloride

4. Types of health food, including specialized health food products


The name of the type of medical food	Average rendering frequency	amount
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. Prescription and use of medicinal products for medical use, medical devices and specialized medical food products that are not included in the standard of medical care are allowed in 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 basics 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 text of the document
prepared by Kodeks CJSC and verified by:
official website of the Ministry of Justice of Russia
www.minjust.ru (copy scanner)
as of 01.24.2013

ICD-10 code:

A 0.2. - salmonellosis

A 0.3. - shigellosis

A 0.4. - escherichiosis

enterocolitis caused by opportunistic flora
Definition.Acute intestinal infections (AEI) represent a large group of independent infectious diseases, united by the presence of a common clinical syndrome for them - diarrhea. The causative agents of OCI are pathogenic, opportunistic pathogens, viruses and fungi. Among the pathogenic bacteria that cause diseases mainly in older children, Shigella, Salmonella, Escherichia are of the greatest importance. 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 old, are 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 of the first 3 months of life.

Criteria for the severity of AEI.The volume and quality of the therapy performed depends on the severity of the disease.

Lightweight form.There are practically no general infectious symptoms, the body temperature is subfebrile, it can remain normal. In children of the first year of life, rare regurgitation is noted, while there is no drop in body weight. The stool becomes more frequent up to 4-6 times a day and, depending on the localization of the inflammatory process, becomes enteric, colitis or enterocolitis.

Moderate form.From the first days of the disease, general infectious symptoms are expressed: body temperature is 38-39 ° C, there is a decrease in appetite, lethargy, vomiting, often repeated, peripheral circulation is disturbed in the form of pallor or marbling of the skin, acrocyanosis. Children in the first year of life have a flat weight curve. Chair 8-10 times a day.

Severe form.The main criteria of severity include: hyperthermia (body temperature 39 ° C and above), repeated vomiting, increased stool frequency up to 10-15 times or more per day, hemocolitis. The stool loses its fecal character and when the distal part of the intestine is damaged, it is defined as "rectal spitting"; when the small part of the intestine is damaged, the stool is abundant with a large amount of water without admixture of feces. The development of one of the syndromes is characteristic: toxicosis, toxicosis with exicosis, neurotoxicosis, disseminated intravascular coagulation, accompanied by severe disorders of the central and cardiovascular systems, water-electrolyte metabolism, acid-base state, hemostatic system.

The scope of examination of patients with AEI.

Light form - general analysis of peripheral blood, general analysis of urine, coprogram 1-3 times, tank. sowing 3 times, feces for rotaviruses once.

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

Severe form - general blood test, general urine analysis, coprogram 1-3 times tank. sowing 3 times, hematocrit, blood coagulation time, blood electrolytes, acid base balance, liver function tests, urea, total protein, immunogram.

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

Table 8

Classification of dysentery

Table 9

Salmonellosis classification

Table 10

Classification of Escherichiosis

Table 11

Rotavirus gastroenteritis classification

Table 12

Classification of enterocolitis caused by

conditionally pathogenic flora

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

The algorithm for choosing therapeutic tactics in AEI begins with the establishment of the etiopathogenetic group of diarrhea. The most optimal is to determine the etiology of the disease using express diagnostic methods (for example, tests for the diagnosis of viral AEI SD BIOLINE Rotavirus, RIDA Quick Rotavirus R-Biopharm AG, Cito Test Rota and others), allowing you to quickly identify the pathogen and choose a further therapy algorithm ...

Unfortunately, in routine clinical practice, the etiology of AEI in most cases remains unclear and the therapeutic tactics are determined based on the etiopathogenetic group of diarrhea, which is diagnosed on the basis of clinical and epidemiological data. So, watery diarrhea in most cases is caused by viral agents and requires the appointment of antiviral drugs as etiotropic therapy, invasive - bacterial, which implies antibiotic therapy in the presence of appropriate indications.

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

Epidemiological data on the etiological structure of AEI are currently characterized by the prevalence of viral agents over bacterial and the presence of combined forms in 26.0 ± 1.6% of patients with viral-bacterial and viral-viral etiology.

Among viral agents in children with primary infection, the first place is occupied by rotavirus infection (87.6 ± 1.4% among intestinal monoinfections of viral etiology), among bacterial agents - salmonella, and, as a consequence, the most common form of combined forms is the combined form of rotavirus infection and salmonellosis (9.2% ± 1.1% in the general structure of decoded AEI). Among viral AEI, the most significant etiological factors are rotavirus and norovirus infections, which determines this combination as the most frequent not only with simultaneous infection with two viral agents, but also with infection with a large number of pathogens (4.8 ± 0.8% in the total structure of decrypted OKI).

Evaluation of the epidemiological history of the disease is carried out according to the following scheme (Table 2). It is necessary for the doctor to speculate about the etiology of the disease. So, food and water transmission routes are more typical for bacterial OCI, contact-household - for viral agents. In the autumn-winter period, there is an increase in the incidence of viral AEI, in the summer - bacterial.

When conducting a clinical and epidemiological analysis of a patient, it is necessary to take into account the age structure of the AEI. For children at all age periods, rotavirus infection is significantly more often recorded, while its share of patients under 3 years old accounts for 83% of all patients with established rotavirus infection (р< 0,01) (рис.). Для норовирусной инфекции характерно наибольшее количество пациентов в возрасте от 3 до 7 лет — 43,6 ± 6,7%.

According to the form of severity, AEI is subdivided into mild, moderate and severe. Establishing the form of the severity of the disease is carried out by an integral analysis of clinical data:

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

Determination of the form of severity can be carried out visually: the more points are noted in block 1 and the greater the total number of points in blocks 2 and 3, the more severe the form of the disease is observed in the patient.

However, it is more preferable to calculate the integral index of clinical symptoms, which is carried out according to the formula:

where indicator A is the sum of positive values \u200b\u200bfor each item of block 1; В and С - the sum of positive values \u200b\u200bfor each item of blocks 2 and 3, respectively.

The values \u200b\u200bof this indicator in the range from 1% to 35% refer to the mild form of the disease, from 36% to 70% to the moderate form, and 71% or more to the severe form of the disease.

The severity of acute intestinal infection in children is largely determined depending on the volume of fluid loss by the patient, while the correctness of the assessment of the degree of dehydration in a child with acute intestinal infections is of particular importance.

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

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

Abroad, the scale of characteristics of M. H. Gorelick is widely used:

change in the general condition (type) of the patient;
the presence of tears;
capillary reperfusion\u003e 2 seconds;
sunken eyes;
decreased urine output;
condition (dryness, turgor) of the skin and mucous membranes;
basic hemodynamic parameters (heart rate and heart rate);
breathing disorders.

Assessment of the form of dehydration according to this scale implies counting the number of signs that the patient has:

lung (< 5%) обезвоживание ≤ 2 признаков;
moderate (6-9%) dehydration 3-5 signs;
severe (\u003e 10%) dehydration - 6-7 signs.

However, the significance of each of the symptoms of dehydration in clinical practice may not always be high enough, especially with exsicosis of the first degree (Table 4).

Therapeutic tactics for AEI in a particular patient is based on knowledge or assumption (based on clinical features, data from the epidemiological history) about the etiology of the disease: bacterial or viral infection. In addition, it is necessary to take into account the age of the patients, the features of its premorbid background and the period of the disease.

The scheme of therapeutic tactics for AEI, depending on the type of diarrhea and the period of the disease, is shown in Table. 6.

Sorbents (carbon, synthetic, mineral, fibrous) should be prescribed to all patients, regardless of the etiology and severity of the disease, as one of the important aspects of etiotropic therapy. Currently, the Russian pharmaceutical market has a fairly large number of drugs with sorption properties to varying degrees. The appointment of enterosorbents is shown as early as possible of the disease - before the identification of the pathogen, which makes it possible to achieve an "interrupting" effect on the course of AEI. The use of enterosorbents in the late stages of the disease (after 5-7 days), especially with invasive AII, has less effect on the diarrheal syndrome, but has a pronounced detoxification and enteroprotective effect. The important positive aspects of the use of enterosorbents include the absence of the effect of these drugs on the composition of the obligate intestinal microbiota. The course of treatment with enterosorbents is usually 5-7 days. The criterion for early withdrawal of drugs is stable stool normalization or stool delay for 2 days.

Antiviral drugs are recommended for viral AEI. Antiviral drugs recommended for AEI and proven to be effective in clinical trials: affinity purified antibodies to human interferon gamma, interferon alfa-2b in combination with taurine, umifenovir.

The issues of antibacterial therapy of OCI for the practicing physician remain one of the most urgent. Unfortunately, most doctors approach the issue of prescribing antibiotics in a stereotyped manner, without taking into account the etiology of the disease, recommending them even for viral AEI, and without knowing the data on the sensitivity and resistance of the main bacterial pathogens.

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

Absolute indications for the appointment of antibiotic therapy are absolutely valid - antibiotic therapy is indicated for all patients in whom they are installed. The presence of the main indications in combination with one of the additional points is an indication for the appointment of antibiotic therapy. The presence of only additional indications is not an indication for the appointment of antibiotic therapy.

Antibacterial agents recommended for acute intestinal infections are divided into two types: intestinal antiseptics and drugs intended for systemic action. The first group can be recommended for prescription in outpatient practice, where the most justified tactic of starting therapy for AEI is the use of nitrofurans (nifuroxazide, nifurantel). Quinolones (nalidixic acid, ciprofloxacin) have proven themselves well in the treatment of salmonellosis. Cephalosporins are recommended for systemic antibiotic therapy in moderate and severe acute infections in a hospital setting. Perhaps the appointment of tetracyclines, metronidazole, aminoglycosides, chloramphenicol.

In the case of a diagnosis of campylobacteriosis, macrolides (erythromycin, azithromycin, clarithromycin) are the most optimal for starting etiotropic therapy.

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

It should be emphasized that in recent years, most of the causative agents of invasive AEI have resistance to furazolidone. Salmonella remain highly sensitive to fluoroquinolones (for example, cypro-phloxacin - 96.7% of the strains are sensitive, but 23.3% are moderately resistant to pefloxacin and 17.2% are resistant), but their use in pediatric practice is limited; nalidixic acid (53.1%), amikacin (61.1%), netilmicin (63.9%), some cephalosporins II (cefoxitin, cefuroxime) - 86.7-57.9%, III (ceftriaxone, cefotaxime, ceftazidime ) - 84.4%, 85.0%, 81.7% and IV generation (cefepime) - 91.3% of sensitive strains.

An obligatory component of antibiotic therapy from the moment of its appointment and during the period of convalescence is the appointment of probiotics.

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

Oral rehydration therapy is a necessary component of therapy, included in the list of therapeutic measures recommended by the World Health Organization, and is prescribed for all patients with AEI. For oral rehydration, the most justified use of ready-made solutions is balanced in terms of electrolyte composition and osmolarity (75 meq / l sodium and 75 meq / l glucose and osmolarity 245 mosm / l).

Oral rehydration is a two-step process.

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

Stage 2 - supportive rehydration, the task of which is to replenish the current fluid loss in AEI. 80-100 ml / kg of fluid is prescribed per day. The duration of the second stage of oral rehydration continues until the moment of recovery or the appearance of indications for parenteral correction of dehydration.

It should be borne in mind that correction of dehydration is impossible without the use of salt-free solutions, among which preference should be given to drinking water (not mineral!), It is possible to use pectin-containing decoctions (apple compote without sugar, carrot-rice broth). The ratio of glucose-saline solutions to drinking water should be 1: 1 for watery diarrhea, 2: 1 for severe vomiting, 1: 2 for invasive diarrhea.

Severe forms of acute intestinal infections, lack of effect from oral rehydration or the presence of profuse vomiting, edema, development of functional (acute) renal failure are indications for parenteral rehydration, which can be carried out using one of the modern domestic solutions - 1.5% sodium meglumine succinate solution , which has proven its effectiveness in the intensive care of these conditions.

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

AEI of any form of severity is the cause of significant changes in the microbiocenosis of the gastrointestinal tract - for example, with Zonne's dysentery in 67.8-85.1% of patients, with salmonellosis - in 95.1%, yersiniosis - in 94.9%, rotavirus infection - in 37, 2-62.8% of patients.

Probiotics should be prescribed as part of a comprehensive starting therapy, regardless of the etiology of the disease, as early as possible. These drugs are also indicated for all patients in the period of convalescence in order to restore the parameters of microbiocenosis. Their use in AEI in children is not only pathogenetically justified, but also belongs to the highest level of evidence A - in accordance with the principles of evidence-based medicine.

The modern view of probiotic therapy implies a strain-specific approach, which means establishing in clinical trials the therapeutic effects characteristic of certain genetically certified strains and their further use, taking into account the strain-specific properties of probiotics in various clinical situations.

In relation to acute intestinal infections in children, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Working Group in 2014 based on the analysis of published systematic reviews and the results of randomized clinical trials, including placebo-controlled, published a memorandum in which it recommended (despite the low level of evidence base according to experts) several probiotic strains in the treatment of acute intestinal infections: Lactobacillus GG, Saccharomyces boulardii, Lactobacillus reuteri strain DSM 17938 (original strain ATCC 55730), as well as a thermally inactivated strain was assigned to this group of probiotics Lactobacillus acidophilus LB, which formally cannot be classified as probiotics as living microorganisms with specified beneficial properties, however, has shown its effectiveness in acute infectious gastroenteritis.

Currently probiotic strains Bifidobacterium lactis BB-12, Escherichia coli Nissle 1917, Lactobacillus acidophilus, Bacillus clausii belong to the group of microorganisms for which there is not enough data on the effectiveness of their use in the acute period of acute respiratory infections. However, previously conducted studies have shown the presence of clinically significant positive properties, the efficacy and safety of their use in AEI, post-infectious bacterial overgrowth syndrome and prevention of gastrointestinal microbiocenosis disorders against the background of antibacterial therapy. Thus, the spectrum of strains that can be recommended in the treatment of AII requires further study.

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

Among such probiotic strains, microorganisms of the genus Bifidobacterium... Bifidobacteria belong to the dominant species in the microbiocenosis of the human gastrointestinal tract - their proportion in the composition of microbiocenoses ranges from 85% to 98%. This genus is characterized by a high adhesion capacity, a leading role in ensuring the colonization resistance of the organism, regulating the metabolism of fats, proteins and minerals, and the synthesis of biologically active substances, including vitamins. The most studied are strains Bifidobacterium longum and Bifidobacterium animalis lactis.

One of the lines of probiotic drugs that can be recommended for the complex therapy of AEI in children are probiotic drugs Bifiform.

Bifiform Baby includes BifidobacteriumBB-12 1 × 10 8 CFU and Streptococcus thermophilusTH-4 1 × 10 7 CFU.

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

For this strain, antagonistic activity is shown to a whole spectrum of pathogenic pathogens ( Bacillus cereus, Clostridium difficile, Clostridium perfringens Type A, Escherichia coli, Listeria monocytogenes, Pseudomonas aeruginosa, Salmonella enterica subsp enterica serovar Typhimurium, Salmonella enterica subsp. enterica serovar Typhi, Shigella flexneri, Shigella sonnei, Campylobacter jejuni and Candida albicans), which makes it preferable for AEI of bacterial etiology.

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

Patients who require therapy with antibacterial drugs deserve special attention. The changes in the gastrointestinal tract microbiota caused by the course of the infectious process can be aggravated by antibiotics. Therefore, this category of patients needs to be included in the complex therapy of AEI with probiotic drugs aimed at maintaining the microbiocenosis. Bifidobacterium lactis BB-12 is resistant to antibiotics such as gentamicin, streptomycin, polymyxin B, nalidixic acid, kanamycin, neomycin, cycloserine, tetracycline, which makes it the strain of choice when prescribing these antibacterial agents to patients, for example, for acute intestinal infections (salmonellosis, shigellosis) ...

Placebo-controlled studies have shown that, in addition to the therapeutic properties, the strain Bifidobacterium lactis BB-12s are inherent and preventative. In particular, its use reduces the risk of developing gastrointestinal infections, including rotavirus, associated with the provision of medical care.

It should be noted that the high safety profile of this strain was approved by regulatory authorities in Europe - in 2008 the European Food Safety Authority (EFSA) awarded it the status of Qualified Presumption of Safety (unconditional safety) - and in the USA, where Generally Regarded As Safe (GRAS) is recognized by the Food and Drug Administration (FDA).

Streptococcus thermophilus, which is part of Bifiform Baby, has shown antagonistic action against the causative agents of AEI in studies, in particular, its effectiveness in preventing traveler's diarrhea has been shown.

For this strain, a symbiotic relationship with Lactobacillus bulgariсus.

Bifiform Baby is intended for children from the first days of life to 2 years. The daily dose (the mark on the pipette corresponds to 1 dose) is 0.5g ~ 0.5ml. It is applied once a day with meals. The most optimal is to use it when carrying out antibacterial therapy for OCI, during the period of convalescence, as well as for prophylactic purposes (for example, when traveling with a child on vacation, attending social events, a swimming pool).

Bifiform capsules include Bifidobacterium longum, which is also a donor strain and is characterized by pronounced antagonistic activity against pathogenic and opportunistic microorganisms. The inclusion of apathogenic Enterococcus faecium, not related to those not recommended for use in pediatric practice, but normally colonizing the small intestine, allows you to have a positive effect on the condition and digestive functions of not only the large, but also the small intestine, especially in the presence of fermentative dyspepsia and flatulence phenomena.

The drug is indicated for children over 2 years old. For acute diarrhea, the drug is taken 1 capsule 4 times a day until the stool is normalized. Then, taking the drug should be continued at a dose of 2-3 capsules per day until the symptoms disappear completely. To normalize the intestinal microbiota and support the immune system, the drug is prescribed in a dose of 2-3 capsules per day for 10-21 days. Children from 2 years old take 1 capsule 2-3 times a day.

Symptomatic therapy includes therapy for febrile conditions. Antipyretic drugs are not indicated for all patients, since an increase in temperature is an adaptive response of the body to an infection, which creates optimal conditions for the body's immune restructuring. The appointment of this category of drugs is 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, exacerbation of chronic pathology of the pancreas is often observed during the period of repair and convalescence of the OCI. It should be noted that with norovirus infection, damage to the pancreas is noted more often than with AII of other etiology. In such cases, the appointment of enzyme preparations is indicated, preferably in a minimicrospherical form. It should be noted that in the acute period of AEI, enzyme preparations are not indicated. The most optimal period for their appointment, if indicated, is 5-6 days, the appointment criterion is the appearance of the patient's appetite.

To stop persistent vomiting, you can use prokinetics and antiemetic drugs: metoclopramide, domperidone, promethazine, 0.25% novocaine - 1 spoon (tea, dessert, table by age).

Criteria for evaluating the effectiveness of treatment:

clinical (relief of intoxication syndrome, normalization of temperature, relief of vomiting, diarrhea and other symptoms);
clinical and laboratory (stable normalization of hemogram, coprocytogram, negative results in bacteriological and PCR examination).

Due to the fact that sanitation from the pathogen, complete repair of the intestine and restoration of its impaired functions occur much later than the clinical manifestations of the disease disappear, it is advisable to conduct dynamic monitoring of patients who have undergone AEI.

Thus, acute intestinal infections require special approaches to diagnosis, management and therapy from the doctor. When curating patients with acute intestinal infections, it should be borne in mind that even mild forms lead to significant changes in the microbiota of the gastrointestinal tract in children, which requires the use of probiotic drugs not only in the acute period of the disease, but also in the period of convalescence.

Literature

A. A. Ploskireva 1, candidate of Medical Sciences
A. V. Gorelov, doctor of Medical Sciences, Professor

FBSI Central Research Institute of Epidemiology of Rospotrebnadzor, Moscow