Symptoms and treatment of intestinal infection in children. Intestinal infections in young children - Kharchenko G.A. Intestinal infections pediatrics

Acute respiratory viral infections (ARVI) Acute respiratory viral infections constitute a group of diseases caused by viruses, transmitted by airborne droplets and characterized by damage to various parts of the upper respiratory tract. To this group

Acute respiratory viral infections Etiology The causative agents of the disease are influenza viruses (A, B, C), parainfluenza, respiratory syncytial virus, adenovirus, rhinoviruses. The highest incidence of acute respiratory viral infections (ARVI) is observed in

Acute respiratory viral infections Etiology The causative agents of the disease are influenza viruses (A, B, C), parainfluenza, respiratory syncytial virus, adenovirus, rhinoviruses. The highest incidence of acute respiratory viral infections (ARVI) is observed in

Acute gastrointestinal infectious diseases Typhoid and paratyphoid There are typhoid fever, paratyphoid A and B - these are infectious diseases that are caused by typhoid and paratyphoid bacilli. Clinically characterized by high fever, severe general condition,

Gastrointestinal diseases Fungal gastritis. Fungal infections of the stomach are observed quite often in ostriches. This can either be a consequence of stomach damage foreign bodies, or as a result of feeding ostriches with poor-quality feed, heavily contaminated

Acute intestinal infections (AI) are a large group of infectious diseases of various etiologies, characterized by damage to the gastrointestinal tract, diarrhea, symptoms of intoxication and dehydration.

Diarrhea in children is one of the most common reasons parental health-seeking behavior in both developed and developing countries. According to WHO, more than 1 billion people in the world suffer from acute intestinal infections every year, and more than half of them are children. Acute diarrhea kills 2 million to 5 million children per year.

According to the Ministry of Health and Social Development of the Russian Federation, the incidence of acute respiratory infections in adults and children in our country is high. Thus, in 2004, 372,834 cases were officially registered infectious diarrhea in children. The incidence of dysentery is 147.5 per 100,000, salmonellosis - 78.05 per 100,000, ACI of established etiology - 424.7 per 100,000, ACI of unknown etiology - 961.3 per 100,000 children.

Young children are most susceptible to ACI. This is due to the anatomical and physiological characteristics of their digestive organs (for example, low acidity of gastric juice) and the imperfection of protective mechanisms (for example, low concentration of IgA). Artificial feeding and lack of sanitary and hygienic skills in a child increase the likelihood of illness. Young children suffer from acute intestinal infections more severely than the rest of the patient population. Their disease leads to malnutrition, decreased immunity, the development of dysbacteriosis and secondary enzymatic deficiency. Frequently recurring episodes of diarrhea have a negative impact on the physical and neuropsychological development of children. Therefore, the problems of reducing the incidence of acute intestinal infections, improving treatment results, and rehabilitating children after suffering from diarrhea are very relevant for the health care of many countries around the world.

ETIOLOGY

The most common causative agents of acute diarrhea are gram-negative pathogenic enterobacteria [Shigella (Shigella flexneri,

S. sonneietc.), salmonella (Salmonella typhimurium, S. enteritidis etc.), campylobacter (Campylobacter jejuni, C. coli, C. laridis, C. fetus etc.), Escherichia (enteropathogenic, enterotoxigenic, enteroinvasive, etc.), Yersinia (Yersinia enterocolitica 03, 05, 06, 09)] and opportunistic microorganisms (Klebsiella, Proteus, Clostridia, Enterobacter, Pseudomonas aeruginosa). Diarrhea caused by viruses (enteroviruses, rotaviruses, adenoviruses, caliciviruses), protozoa (cryptosporidium, coccidia, giardia, dysenteric amoebas) and fungi are also detected. The range of pathogens is constantly expanding; in recent years, the etiological role of Aeromonas, Plesiomonas and halophilic vibrios in the occurrence of ACI.

The etiological structure of acute intestinal infections is different in children of different age groups. Thus, in young children, diseases caused by salmonella, pathogenic Escherichia, campylobacter, opportunistic microorganisms and rotaviruses are more often detected, while in older children shigellosis, salmonellosis and yersiniosis predominate.

EPIDEMIOLOGY

AEI in children have common epidemiological features:

High contagiousness of pathogens (widespread);

Fecal-oral mechanism of infection, realized through food, water, contaminated hands, household items, etc.;

High resistance of pathogens to various environmental factors;

Long-term persistence of pathogens in soil, water, and various food products.

Infection of children occurs through contaminated hands (both of the child and the mother), dishes, toys, pacifiers, and underwear; non-heat-treated food (milk, dairy and meat products, fish, vegetables), water, fruit juices. Insects (for example, flies) and rodents (mice, rats) play a certain role in the contamination of food and dishes. Domestic and farm animals, birds, and fish serve as natural reservoirs for pathogens of many acute infections. In children, food and contact routes of infection predominate. OCI caused by viruses and salmonella can also be spread by airborne droplets. In weakened young children, due to low immunological protection, the possibility of endogenous infection by opportunistic microorganisms cannot be excluded. In the vast majority of cases of acute intestinal infection, the source of infection is a patient with a manifest or erased form of the disease, a carrier or animals.

Sporadic incidence of acute intestinal infections is most often recorded; epidemic outbreaks and pandemics (for example, with cholera) are less common. There are some implementation specifics different mechanisms infection of children: with contact and household transmission of infection, sporadic cases occur more often, with food - group cases, and with water - epidemic outbreaks. Currently, a flattening of seasonal peaks is observed in most OCIs. Clear seasonality is recorded only for some bacterial and viral infections. For example, dysentery is characterized by a summer-autumn rise, while for rotavirus infection- winter.

Immunity in acute intestinal infections is species-specific and unstable.

PATHOGENESIS

The severity of the disease and the duration of the incubation period of AEI depend on the number of pathogens that have entered the body (infectious dose), their pathogenicity, serotype, and the state of the macroorganism. The leading pathogenicity factors of bacterial pathogens of acute intestinal infections include their ability to adhere and synthesize endo- and exotoxins (enterotoxins).

Enteropathogenic effects of pathogens acute diarrhea may be different.

In some cases, the enteropathogenicity of a microorganism is due to its invasion into the intestinal wall and intracellular reproduction (for example, in enterocytes, macrophages) with the release of enterotoxins. The latter destroy the membranes of epithelial cells, promoting the invasion of infectious agents and the development of inflammatory and necrotic changes in the intestinal mucosa. Shiga toxin and Shiga-like toxins (verotoxin) belong to this group. OCI that occurs when infected with invasive microorganisms is clinically manifested by loose stools with pathological impurities (mucus, blood). These include shigellosis, salmonellosis, yersiniosis, campylobacteriosis, escherichiosis (caused by enteroinvasive and enterohemorrhagic escherichia), as well as acute intestinal infections of unknown etiology, occurring with damage to the mucous membrane of the colon.

In secretory diarrhea, the pathogen colonizes only the surface of the enterocytes, and the local inflammatory process is weakly expressed. The leading role in the pathogenesis of diarrhea is played by impaired secretion and reabsorption of water and salts in the intestine under the influence of enterotoxins, such as cholera and cholera-like toxins (thermolabile and thermostable). The toxin stimulates adenylate cyclase in intestinal epithelial cells, as a result of which the co-

retention of intracellular cAMP, which leads to secretion into the lumen small intestine a large amount of isotonic fluid that does not have time to be reabsorbed in the colon. With such diarrhea, the stool is fecal in nature at first and then becomes watery and may contain a small amount of clear or greenish mucus. This group includes cholera, escherichiosis (caused by enterotoxigenic and enteropathogenic escherichia) and diseases caused by opportunistically pathogenic flora.

The division into secretory and invasive diarrhea is very arbitrary, since with the same infections both mechanisms are possible, but usually one of them predominates.

Endotoxins (lipopolysaccharides) formed as a result of the death of gram-negative pathogens also increase the secretion of fluid and electrolytes in the intestine. When endotoxins penetrate through protective barriers into the blood (endotoxemia), an intoxication syndrome occurs (fever, vomiting, hypotension, etc.), which can lead to the development of endotoxin shock.

In acute intestinal infections of viral etiology (rotavirus, calicivirus, etc.), pathogens attach to the receptors of epithelial cells covering the upper part of the villi of the mucous membrane of the small intestine and penetrate the cells. Reproduction of the virus inside cells leads to their destruction. The free surface of the upper part of the villi is exposed and the cells that absorb fluid from the intestine and synthesize disaccharidases are lost. Unsplit disaccharides accumulate in the intestinal contents, increasing osmotic pressure, which attracts fluid into the intestinal lumen and leads to diarrhea. In recent years, enterotoxigenic activity has been discovered in rotaviruses. The nonstructural protein NSP-4 of rotaviruses acts similarly to the enterotoxins of gram-negative enterobacteria.

With all mechanisms of development of diarrhea in children, intestinal functions (secretion, absorption, motility), as well as the synthesis and secretion of enzymes and hormones by the intestines are disrupted.

CLINICAL PICTURE

The duration of the incubation period for AEI ranges from several hours (with foodborne infection) to 7 days, most often 2-3 days. The onset of the disease is usually acute. Subacute

the development of the disease is noted in young children with salmonellosis, yersiniosis, some escherichiosis and diseases caused by opportunistic pathogens.

At the height of the disease, most ACIs are characterized by fever, lethargy, decreased appetite, abdominal pain, vomiting and/or diarrhea. OCI is characterized by a wide variety of forms: from latent (erased) to extremely severe. There are typical (mild, moderate and severe) and atypical (erased, hypertoxic) forms. The severity of the disease is assessed according to three main parameters: the severity of intoxication, dehydration and the degree of damage to the gastrointestinal tract.

Clinical manifestations of local syndrome in acute intestinal infections largely depend on the characteristics of the pathogen (its tropism, ability to secrete exotoxins, degree of invasiveness), routes of infection and location greatest defeat Gastrointestinal tract (stomach, small or large intestine). According to the topic of gastrointestinal tract damage, gastritis, enteritis, gastroenteritis, enterocolitis, gastroenterocolitis, colitis are distinguished.

A distinctive feature of the course of acute intestinal infections in children, especially infants and weakened children, is the development of not only localized, but also generalized forms with the spread of the pathogen beyond the intestine (for example, with salmonellosis, yersiniosis, Grigoriev-Shiga dysentery, campylobacteriosis).

According to the course of ACI in children, it is customary to distinguish abortive, acute (up to 1.5 months), prolonged (more than 1.5 months) and chronic (more than 5-6 months) forms. In recent years in Russia the term “ prolonged diarrhea", adopted abroad to indicate dysfunction of a child’s intestines for 2-2.5 months or more.

Below are the clinical signs of acute intestinal infections most commonly reported in children.

Dysentery (shigellosis)

Most often children from 3 to 10 years old who attend children's groups get sick. The incidence is year-round with an increase in July and August. Specific immunity is unstable.

The duration of the incubation period is 1-7 days. The disease begins acutely with an increase in body temperature (up to 38.5-40.0? C), increasing weakness, lethargy and headache. Against the background of fever, chills are noted, disturbances of consciousness, delirium, convulsions, and symptoms of meningism are possible. Appetite is reduced or absent. In the first days there may be vomiting. Characterized by cramping pain in the abdomen, localized in the left iliac region, and symptoms of distal colitis: spasm and tenderness of the sigmoid colon, excruciating nagging pain in the abdomen, tenesmus (false painful

urge to defecate), sphincteritis and anal compliance. The stool is thin, scanty, mixed with cloudy mucus and streaks of blood (like “rectal spit”).

In children of the first year of life, who rarely suffer from dysentery, a dyspeptic form of the disease usually develops: subacute or gradual onset, moderate increase in body temperature, pasty or loose stools, often without pathological impurities. Distal colitis syndrome is not expressed. The severity of the disease is due to disturbances in hemodynamics, water-salt and protein metabolism.

Dysentery in children older than one year is characterized by the simultaneous development of symptoms of intoxication and local syndrome, as well as the short duration of the disease. With Sonne dysentery, the duration of vomiting is usually 1 day, fever - 1-2 days, diarrhea - no more than 1 week, blood discharge with feces - 1-3 days. With Flexner's dysentery, the duration of all symptoms and the severity of the local syndrome are greater: more frequent bowel movements, clearer signs of distal colitis and hemorrhagic syndrome, up to intestinal bleeding. Grigoriev-Shiga dysentery in children is recorded extremely rarely.

Salmonellosis

In the last two decades, salmonellosis has become an acute infection, widespread in children. This is due to the emergence of new hospital strains of salmonella (S. typhimurium), possessing drug resistance and the ability to cause outbreaks (including nosocomial ones) through contact and household transmission. Salmonellosis caused by hospital strains S. typhimurium, Children of the first year of life are more often ill. Second dominant strain S. enteritidis Causes the disease mainly in older children, most often transmitted through eggs and poultry meat. The clinical picture of the disease, to a greater extent than with other acute intestinal infections, depends on the age of the patient, the route of infection, the type and properties of the pathogen.

In children of the first year of life, the onset of the disease is usually subacute or gradual, with the maximum development of all symptoms by the 3-7th day from the onset of the disease. Symptoms of intoxication (fever, lethargy, pallor, decreased appetite, tachycardia) and intestinal disorders (enterocolitis, gastroenterocolitis) gradually increase. Persistent vomiting can begin either from the first day of illness or later. The stool is copious, liquid, fecal in nature, green-brown in color (like “swamp mud”), mixed with blood (on the 5th-7th day of illness). The stool may also be watery. Flatulence, enlargement of the liver and spleen are pronounced. Disease

lasts for a long time, the flow is wavy. The severity of the condition depends on the degree of intoxication and disturbance of the water-salt balance (exicosis of I-III degrees). Generalization of the process is possible with the formation of secondary foci and the development of complications (pneumonia, meningitis, osteomyelitis, etc.), as well as long-term (up to 1 year) bacterial carriage in convalescents.

In children older than one year, the disease is less severe, mainly in two clinical variants - PTI type (with a predominance of gastroenteritis or gastroenterocolitis) or enterocolitis. In older children, the disease may be limited to the development of gastritis with its main symptoms: pain in the epigastric region, repeated vomiting, etc. The disease usually begins acutely with an increase in body temperature to 38-40? C (fever persists for 1-5 days, rarely has a wave-like character), vomiting, often repeated, symptoms of intoxication, moderate abdominal pain and profuse loose stools with pathological impurities. Hepatolienal syndrome occurs rarely. For moderate and severe forms toxicosis with exicosis and cardiovascular failure develop. With timely initiation of therapy, the symptoms of the disease quickly stop.

In some cases, a typhoid-like form develops, characterized by a long-term (up to 10-14 days) fever of a constant, wave-like or irregular type. Lethargy, adynamia, severe headache, muscle and joint pain, sleep disturbance, arterial hypotension, and bradycardia are noted. Upon examination, an enlarged liver and spleen and bloating are revealed. The stool can be pathological, sometimes constipation occurs. A blood test may show leukopenia.

Septic and respiratory (flu-like) forms of salmonellosis rarely develop in children.

Escherichiosis (coli infection)

According to the existing WHO classification, all Escherichia that cause diseases in humans are divided into 6 subgroups. In children, the most common escherichiosis is caused by enteropathogenic and enterotoxigenic escherichia, which occupies a leading position in the etiological structure of acute intestinal infections in children of the first year of life. Non-pathogenic Escherichia are common inhabitants of the intestines.

Escherichiosis caused by enteropathogenic Escherichia(most often serovars 018, 026, 055, 0111). The incubation period lasts 2-7 days. Subacute, less often acute onset of the disease is typical. Body temperature is normal or subfebrile. Lethargy, weakness, and loss of appetite are noted. Persistent vomiting

(regurgitation) and flatulence are the most constant symptoms; they appear from the first day of illness. Characteristic chair type watery diarrhea(splashy, abundant, yellow color, with a moderate amount of mucus). The frequency of bowel movements increases by the 5-7th day of illness. Loss of fluid through vomiting and loose stools quickly leads to the development of exicosis I (loss of body weight 5%), II (loss of body weight up to 10%) and III (loss of body weight more than 10%) degrees. Dry skin and mucous membranes develop, a decrease in tissue turgor and skin elasticity up to the formation of the symptom of a “standing skin fold”, retraction of the large fontanel and eyeballs. The activity of the cardiovascular system is disrupted (tachycardia, muffled heart sounds, drop in blood pressure), diuresis decreases (oliguria or anuria). The central nervous system suffers, which is expressed in the child’s anxiety, which in case of exicosis of II-III degree is replaced by inhibition up to the development of coma. In older children, this type of escherichiosis can occur as PTI.

Escherichiosis caused by enterotoxigenic Escherichia(the most significant serovars are 06, 08, 09, 020, 075). The incubation period lasts from several hours to 3 days. In older children, the disease begins acutely and proceeds according to the PTI type. Characterized by persistent, uncontrollable vomiting, pain in the epigastric region, and loose, loose stools. Recovery occurs by the end of the first week of the disease. In young children, escherichiosis, caused by enterotoxigenic escherichia, occurs as cholera-like diarrhea: acute or subacute onset of the disease, repeated vomiting, frequent watery stools; development of exicosis is possible. Temperature reaction is not typical.

Escherichiosis caused by enteroinvasive Escherichia(serovars 028, 0124, 0144, 0151). The duration of the incubation period is on average 1-3 days. The disease clinically resembles acute shigellosis and begins acutely with a rise in body temperature to febrile or subfebrile values. Patients complain of cramping abdominal pain (occasionally tenesmus). During an objective examination, a spasmodic, painful area is palpated sigmoid colon. The stool is scanty, with mucus and greens, and streaks of blood may appear.

Escherichiosis caused by enterohemorrhagic Escherichia, are classified as little-studied infections. Among the etiological agents, Escherichia serogroup 0157:H7 dominates. Children of all age groups are affected, with the exception of children in the first months of life. Usually the onset of the disease is acute, regardless of age. There are cramping pains in the abdomen and short-term watery diarrhea, turning into bloody. At the height of the disease, stool is frequent,

copious, liquid, containing significant admixtures of blood and mucus. Symptoms of intoxication are moderate, body temperature is normal or subfebrile, 50% of patients complain of nausea and repeated vomiting. The severity of the disease is due to the frequent development of hemolytic-uremic syndrome, manifested by a sharp decrease in Hb and platelet levels, an increase in the concentration of creatinine and blood urea, the development of anemia and acute renal failure. The development of hemolytic-uremic syndrome is indicated by the “ominous” triad: anemia, anuria, thrombocytopenia. With the development of hemolytic-uremic syndrome, transfer to hemodialysis is indicated.

Diseases caused by enteroadhesive And diffusely attached Escherichia, It is not registered in Russia yet.

Yersiniosis

Yersiniosis is detected among patients with acute intestinal infections in 3-9% of cases. The disease is characterized by polymorphism of clinical manifestations. Children aged 2-7 years are most often affected. Localized and generalized forms of the disease are recorded. The incubation period lasts 5-19 days.

In localized forms, general manifestations of intoxication (fever, headache, weakness, sleep disturbances) are expressed moderately; the clinical picture of the disease is dominated by local manifestations with the development of gastrointestinal, abdominal, catarrhal forms and yersinia hepatitis.

The main clinical manifestations of generalized forms: fever, exanthema, prolonged abdominal pain, repeated vomiting, moderate diarrhea. Symptoms of intoxication (lethargy, adynamia, lethargy, sleep disturbances, pallor or marbling skin, shortness of breath, tachycardia) determine the severity of the disease and prevail over the symptoms of gastrointestinal tract damage, which most often occurs as gastroenterocolitis (in children under one year old) and gastroenteritis or enteritis (in children over one year old). Stools are usually up to 10 times a day, profuse, foamy, foul-smelling, brown-green in color, sometimes streaked with blood.

Exanthema is a symptom pathognomonic for yersiniosis. The rash is often maculopapular, less often punctate, sometimes with hemorrhagic elements; in some children it is scalloped, anular, and confluent. Favorite localization is the skin of the trunk and limbs, less often - on the face. Characteristic is the appearance of a rash on the skin of the hands and feet, up to their diffuse hyperemia. The rash appears on the 2-4th day of illness, grows over 1-2 days and disappears after 2-5 days. Possible development of yersinia hepatitis (usually anicteric),

erythema nodosum, arthritis. The duration of the disease is usually no more than 2 weeks.

The abdominal form is accompanied by severe fever, intoxication and abdominal pain. Clinical manifestations of this form of yersiniosis are determined by the development of mesadenitis, appendicitis, terminal ileitis or pancreatitis, which explains different character localization and severity pain syndrome. Peritonitis is possible; interintestinal abscesses and adhesions are less common.

Generalized forms with a predominance of symptoms of general intoxication include typhus-like, septic and mononucleosis-like forms.

Campylobacteriosis

Campylobacteriosis is a zooanthroponotic disease caused by Campylobacter (Campylobacter jejuni, C. coli, C. laridis). The share of campylobacteriosis in the structure of ACI is 6-8%, in the summer months up to 24%.

The disease begins acutely and is manifested by fever, intoxication, diarrhea and abdominal syndrome (intense constant paroxysmal abdominal pain localized in the periumbilical and right iliac regions). Often the disease occurs as an IPT, especially in older children. In this case clinical picture includes increased body temperature, repeated vomiting, weakness, headache, decreased appetite, abdominal pain, loose, watery stools without pathological impurities, less often with streaks of blood. In young children, campylobacteriosis is characterized by an acute onset of the disease, subfebrile body temperature and the development of hemocolitis against the background of moderate intoxication. Stools are frequent (7-10 times a day), copious, liquid, mixed with mucus, greens and streaks of blood. In some children, an enlargement of the liver is noted, less often the spleen. The development of ulcerative-necrotic appendicitis, peritonitis and the appearance of extraintestinal foci (parenchymal anicteric hepatitis, reactive pancreatitis, mesadenitis, arthritis, myocarditis) are possible.

Cryptosporidiosis

Cryptosporidiosis is an infection caused by members of the genus cryptosporidium, characterized by chronic diarrhea. The share of cryptosporidiosis in the etiological structure of acute intestinal infections in children is 3-8%.

The incubation period lasts from 3 to 8 days. The onset is acute, similar to enteritis or gastroenteritis, with frequent (up to 10 times a day) copious watery stools, often mixed with

mucus. Diarrhea is most pronounced on the first day of the disease, less often on the 2-3rd day. At the same time, repeated persistent vomiting appears and ketoacidosis develops. A decrease in appetite up to anorexia, pain in the epigastric region, and flatulence are noted. Body temperature is often subfebrile. In most patients, the disease occurs in a mild form. Possible asymptomatic carriage. In immunocompromised children, cryptosporidiosis can become chronic or severe, with profuse watery diarrhea leading to cachexia.

Rotavirus infection

Species pathogenic to humans cause acute enteritis in newborns and young children. These species belong to the genus Rotavirus families Reoviridae. Rotavirus infection is one of the leading causes of infectious gastroenteritis, especially in children under 3 years of age.

The incubation period ranges from 15 hours to 3-5 days, more often 1-3 days. The onset is acute, all symptoms of the disease develop within one day. In 60-70% of patients, a combination of damage to the gastrointestinal tract and respiratory organs is detected, and sometimes catarrhal phenomena precede diarrhea. Respiratory syndrome is manifested by moderate hyperemia and granularity of the walls of the pharynx, soft palate and palatine arches, nasal congestion, and coughing. In parallel, gastroenteritis develops. The stool is liquid, watery, foamy, slightly colored, without pathological impurities or with a small admixture of mucus. The frequency of bowel movements usually does not exceed 4-5 times a day, but in young children it can increase up to 15-20 times. The duration of diarrhea in older children is up to 3-7 days, in infants it is often up to 10-14 days. Vomiting often occurs simultaneously with diarrhea or precedes it, is repeated and continues for 1-2 days. Body temperature usually does not exceed 38.5-39? C and normalizes by the 3-4th day of illness. The most typical signs of general intoxication include weakness, lethargy, adynamia, headache, and dizziness. The severity of the disease is determined by the development of exicosis I-II, less often III degree.

Intestinal infections caused by opportunistic microorganisms

The role of conditionally pathogenic microflora as an etiological factor of acute intestinal infections is most significant in children in the first 3 months of life, especially in newborns. In this group, the disease begins gradually. The body temperature may be low-grade, vomiting and loose stools may occur. Symptoms get worse over several days

days, dehydration increases. Following gastroenteritis, colitis or hemocolitis may develop; generalization of the infectious process with severe prolonged fever, diarrhea, persistent vomiting, bacteremia, the appearance of extraintestinal foci and the development of complications is possible. In children over 1 year of age, the disease often occurs in the form of IPT with repeated vomiting and severe intoxication. At the beginning of the disease, gastroenteritis occurs, then enterocolitis may develop.

Staphylococcal intestinal infection

The prevalence of staphylococci, including pathogenic ones, is high both among healthy children and among patients with other laboratory-confirmed acute intestinal infections. However, the etiological role of staphylococcus in the occurrence of acute intestinal infections is insignificant, which is associated with the presence of specific antitoxic immunity in most children at the time of infection.

There is a primary staphylococcal intestinal infection and a secondary one, developing against the background staphylococcal sepsis or pneumonia, as well as as a result of dysbacteriosis with long-term anti- bacterial treatment any other diseases. In addition, staphylococci can cause PTI.

COMPLICATIONS

In severe acute intestinal infections, patients may develop grade II-III exicosis, hypovolemic shock, pulmonary edema, disseminated intravascular coagulation syndrome, acute renal failure, hemolytic-uremic syndrome, acute heart failure, etc. In generalized forms of the disease, pneumonia, otitis, meningitis, pyelonephritis, hepatitis, infectious-toxic shock. The consequences of a history of acute intestinal infections may include secondary disaccharidase deficiency (for example, lactase deficiency), intestinal dysbiosis, etc. Rectal prolapse, arthritis, neuritis, and encephalitis are recorded as rare complications of dysentery.

DIAGNOSTICS AND DIFFERENTIAL DIAGNOSTICSThe etiological deciphering of OKI from clinical data in sporadic cases is difficult. During the initial examination, only a preliminary diagnosis is possible based on a set of clinical and epidemiological data: time of year, age of the patient, suspected source of infection, presence of acute intestinal infections in the patient’s environment, leading clinical syndrome, combination of symptoms and sequence of their appearance, localization of the pathological process (gastritis, enteritis, colitis and their combinations), etc.

In a preliminary diagnosis, the main syndrome is most often identified, indicating the localization of the process in the gastrointestinal tract, etiology, stage (phase) of the disease and the nature of its course (if admitted late in the disease), as well as the degree and type of dehydration (dehydration) and the presence of complications . If the loss of water and electrolytes occurs in physiological proportions, an isotonic type of dehydration occurs. Depending on the predominance of losses of water or electrolytes, primarily K+ and Na+, water- and salt-deficient types of dehydration are distinguished.

The final diagnosis is based in most cases on data from clinical and laboratory studies: further dynamics of the disease, severity of symptoms, isolation of the pathogen or its Ag, detection of specific antibodies in the patient’s blood. In case of group outbreaks of the disease with an established etiology, the diagnosis is made on the basis of clinical and epidemiological data.

The main method of confirming the diagnosis is bacteriological (virological) examination of stool. The collection of material for research must be carried out as quickly as possible. early dates, before starting etiotropic therapy.

Traditional serological methods (RPGA, RSK, etc.) also have diagnostic value. When used, the accuracy of laboratory diagnostics of acute intestinal infections increases by 1.5-2 times. It must be remembered that the patient’s blood is tested for the presence of antibodies to the causative agent of the disease no earlier than the 5th day from the onset of the disease.

Latex agglutination, coagglutination, as well as modern highly sensitive methods - PCR, ELISA can be used as simple, accessible and informative express methods for diagnosing AEI.

Microscopic examination of stool (coprogram and coprocytogram) and blood is of auxiliary importance in making a diagnosis.

The differential diagnosis of OCI is presented in Table. 29-1. TREATMENT

Treatment of acute intestinal infections in children should be comprehensive and staged. An individual approach to the selection of medications is required, taking into account the etiology, severity, phase, clinical form disease, the age of the child and the state of the macroorganism at the time of the disease. The outcome of acute intestinal infections, especially in young children, largely depends on the timeliness and adequacy of therapy. Currently, mild forms of acute intestinal infections are often treated on an outpatient basis, in which case daily visits by the local pediatrician and nurse to the patient are required.

Table 29-1.Main differential diagnostic criteria for acute intestinal infections in children

* UPMF is a conditionally pathogenic microflora.

Etiotropic therapy

Etiotropic therapy includes the use of antibiotics and synthetic antimicrobial drugs (strictly according to indications), specific bacteriophages and enterosorbents. Antibiotics and synthetic antimicrobials are indicated for invasive acute intestinal infections in the following cases:

In severe OCI - to all children (regardless of age);

For moderate acute intestinal infections - children under 2 years of age;

In case of a mild form of the disease - children under one year old who are at risk (with congenital pathology Central nervous system and other organs and systems, immunodeficiencies, sick children from closed children's groups, etc.), as well as hemocolitis.

When choosing a drug, it is necessary to take into account the characteristics of its pharmacokinetics, the spectrum of antimicrobial action, possible adverse reactions and drug resistance of the causative agents of acute intestinal infections. All antibiotics and synthetic antimicrobial drugs prescribed to children are usually divided into the following groups.

First-line drugs (usually prescribed on an outpatient basis in the first days of the disease): kanamycin, polymyxin, nifuroxazide, furazolidone, co-trimoxazole, Intetrix.

Second-line drugs: nalidixic acid, rifampicin, amikacin, netilmicin, amoxicillin + clavulanic acid. Second-line drugs are indicated for patients with moderate and severe forms of the disease, as well as when first-line drugs are ineffective.

Third-line drugs (reserve drugs): ceftibuten, ceftazidime, meropenem, imipenem + cilastatin, norfloxacin, ciprofloxacin (the last two drugs are only for children over 12 years of age); they are used for severe and generalized forms of acute intestinal infections in the intensive care unit.

Narrow-spectrum drugs are also used. Chloramphenicol, widely used previously, is recommended only for the treatment of yersiniosis and typhoid fever, and erythromycin for campylobacteriosis and cholera. Antimicrobial drugs are prescribed in age-specific doses. The duration of the course usually does not exceed 5-7 days. The drugs are used for a longer period of time for yersiniosis and typhoid fever. If there is no effect within 2-3 days, one drug is replaced by another.

When reseeding pathogenic pathogens, as well as for the treatment of mild and erased forms of acute intestinal infections, it is advisable to use specific bacteriophages, lactoglobulins (Salmonella, dysentery, coliproteus, Klebsiella, etc.) and Ig (rotavirus, yersinia, etc.).

In the treatment of rotavirus infection and yersiniosis, the drug “Anaferon for children” is effective, prescribed according to the following regimen: up to 8 doses on the 1st day, then 1 tablet 3 times a day, for a course of 5 days.

Indications for antibacterial therapy have been narrowed in recent years due to the widespread use of enterosorbents that have a sanitizing, detoxifying and antiallergic effect. Natural enterosorbents (for example, dioctahedral smectite, etc.) are most often prescribed. Their effectiveness increases when taken early (from the first hours of illness).

Pathogenetic and symptomatic therapy

In the treatment of acute intestinal infections, much attention is paid to pathogenetic therapy, which necessarily includes oral rehydration in combination with proper nutrition of patients.

Oral rehydration. One of the main methods of treating acute intestinal infections occurring with exicosis I, I-II, and in some cases, degree II. Oral rehydration is aimed at restoring water-salt metabolism, disturbed as a result of increased secretion and reduced reabsorption of water and electrolytes in the intestines. For this purpose, glucose-saline solutions containing glucose, sodium and potassium salts in different ratios are used (for example, dextrose + potassium chloride + sodium chloride + sodium citrate - “Rehydron”) (the choice of ratio depends on the type of dehydration). Glucose promotes the transition of sodium and potassium ions into epithelial cells, restoration of disturbed water-salt balance and normalization of metabolic processes. Oral rehydration is most effective when administered early (from the first hours of illness). To avoid dehydration, the child should be given drinking plenty of fluids(slightly sweetened tea, dried fruit compote, rosehip infusion, rice, etc.) followed by a mandatory transition to a standard glucose-saline solution with a salt composition that is optimal for a given patient. At home, as a temporary substitute, you can prepare the following medicinal solution: in 1 liter of boiled water, dissolve 4 tablespoons of granulated sugar, 1 teaspoon table salt and 1 teaspoon of baking soda.

Oral rehydration is carried out in two stages. Stage I (the first 6 hours from the start of treatment) is aimed at eliminating the water-salt deficiency that the child had at the start of treatment. Calculation of the amount of liquid for primary rehydration at the first stage is carried out according to the formula:

where V is the volume of fluid administered to the patient per hour, ml/hour; P is the patient’s weight, kg; n - child’s body weight deficit, %; 10 - proportionality coefficient.

I degree of exicosis corresponds to a loss of 5% of body weight, II degree - 7-9%, III degree - 10% or more. In the absence of accurate data on the child’s weight loss during illness, the degree of dehydration can be determined by clinical and laboratory data. You can also use approximate data on the volume of fluid needed by the patient during the first 6 hours of rehydration, depending on the child’s body weight and the degree of dehydration (Table 29-2).

Table 29-2.Approximate volumes of fluid for oral rehydration in children of different ages

Stage II - maintenance therapy. It is carried out depending on the ongoing loss of fluid and salts through vomiting and bowel movements. On average, the volume of fluid administered at this stage is 80-100 ml/kg per day. The duration of rehydration is until fluid loss stops.

The effectiveness of oral rehydration largely depends on correct technique its implementation. The basic principle is the fractional administration of liquid. At stage I, the child takes the amount of liquid calculated for each hour of administration in fractions, depending on age, a teaspoon or a tablespoon every 5-10 minutes. If there is single or double vomiting, rehydration is not stopped, but interrupted for 5-10 minutes and then continued again. It is equally important to correctly determine the optimal composition of the liquid. Thus, in children under 3 years of age, it is advisable to combine glucose-saline solutions with salt-free solutions (for example, tea, water, rice broth, rosehip broth, etc.) in the following ratios: 1:1 - for severe watery diarrhea; 2:1 - with loss of fluid mainly through vomiting; 1:2 - with fluid loss mainly with perspiration (with hyperthermia against the background of moderate diarrhea). The administration of saline and salt-free solutions alternates (they cannot be mixed!).

Oral rehydration can be carried out not only in the hospital, but also at home (under the supervision of a doctor and nurse).

Oral rehydration should not be stopped at night, while the child is sleeping. At this time, the liquid can be administered through the nipple with a syringe or pipette. If you refuse to drink, oral rehydration can be done using a system intravenous administration liquid by attaching it to a gastric tube or nipple. Criteria for the effectiveness of oral rehydration:

Disappearance or reduction of symptoms of dehydration;

Stopping watery diarrhea or reducing the volume of bowel movements;

Weight gain in a sick child;

Normalization of diuresis, acid-basic acid indicators, Hb concentration and hematocrit;

Improvement of the child's condition.

Correctly and timely oral rehydration allows you to avoid parenteral rehydration in 80-90% of patients with ACI and reduce the number of children requiring hospitalization by at least 2 times. After the widespread introduction of this treatment method, mortality from acute intestinal infections among children decreased by 2-14 times.

Diet therapy.Currently, it is not recommended to prescribe a water-tea break and a fasting diet, since it has been proven that even with severe forms of acute intestinal infections, the digestive function of most of the intestines is preserved, and a fasting diet significantly weakens the body’s protective functions and slows down the repair processes. The volume and composition of food depends on child's age, the nature of previous feeding, the severity of the disease and the presence of concomitant diseases.

Breastfed children, while undergoing oral rehydration, continue to be breastfed or expressed milk 6-8 times a day, applied to the breast for a shorter period than usual. Children who are on artificial feeding, receive their usual breast milk substitutes, with fermented milk mixtures being preferred. If before the disease the child received age-appropriate complementary foods, in the following days complementary foods are gradually introduced in an age-appropriate amount. The same principles apply to the nutrition of children over one year of age: increasing the frequency of meals, reducing the amount of food per meal, using fermented milk products, porridge and puree with vegetable broth, grated or baked apples, omelet, and later cottage cheese. The meat is subjected to special processing and served in the form of soufflés and quenelles. By the 3-5th day of illness, in most cases, it is possible to switch to a physiological, age-appropriate diet with a limitation of chemical and mechanical irritants of the gastrointestinal mucosa. Avoid dishes that increase fermentation and stimulate secretions.

tion and bile secretion (whole milk, rye bread, raw vegetables, sour fruits and berries, meat broths, etc.).

With prolonged post-infectious diarrhea (more often in infants), additional nutritional correction is necessary, depending on functional disorders.

In the complex therapy of acute intestinal infections, lysozyme, pancreatin, antihistamines (chloropyramine, clemastine, cyproheptadine, ketotifen), symptomatic drugs (indomethacin, Tanalbin, etc.) are also widely used. During the period of convalescence, dysbacteriosis is corrected [bifidobacteria, "Linex", lactobacilli acidophilus + kefir fungi ("Acipol"), "Hilak-forte", lactulose, etc.], and herbal infusions are also prescribed (chamomile, St. John's wort, cinquefoil, oak bark, alder cones, etc.), vitamins and physiotherapeutic procedures.

PREVENTION

Prevention of acute intestinal infections is based on sanitary and hygienic measures. At home, these should include the correct heat treatment and storage of meat and dairy products, separate processing of raw and cooked meat, as well as vegetables; refusal of creams and dishes that include raw eggs; water protection and food products from pollution and infection; keeping the home clean; early detection and isolation of patients, etc. A mother caring for a child must observe basic hygiene rules (cleaning the mammary glands before feeding, washing hands after washing and swaddling the child, and before picking up a pacifier, feeding bottle, etc.).

In children's institutions, the main place in the prevention of acute intestinal infections is occupied by the correct organization of the sanitary regime. In the environment of patients (in children's institutions, at home or in a hospital), current or final disinfection is carried out. Children who have had contact with a patient with acute intestinal infections are subject to medical observation for 7 days and a single bacteriological examination. Similar measures are applied to employees of food enterprises and other persons of designated groups.

Intestinal infections are common in children. Symptoms and treatment should not be treated without medical supervision, as children quickly become dehydrated.

One of current problems In pediatrics, for many years there has been an intestinal infection in children, the symptoms and treatment of which should be known to every parent. After ARVI, infections affecting the gastrointestinal tract (GIT) occupy one of the leading positions in the structure of morbidity among children.

All ACIs (acute intestinal infections) are characterized as intoxication with elevated temperature body, damage to the gastrointestinal tract and the development of dehydration (dehydration) due to pathological losses liquids.

In children, intestinal infections are mostly acute diseases infectious nature, which and/or viruses. Susceptibility to pathogens of acute intestinal infections in childhood significantly higher (2.5–3 times) than in adults.

Every year, sporadic outbreaks are recorded that provoke intestinal infections. The high likelihood of OCI in a child is explained by the immaturity of protective mechanisms, unstable microbial flora in babies (especially premature babies), frequent contacts in closed groups (kindergartens, nurseries, schools), and neglect of hygiene.

The variety of pathogens that cause intestinal infections in childhood determines a large number of clinical signs and treatment methods in which tablets, solutions, syrups, and suppositories are used. All this dictates the need for every parent to understand this topic in more detail.

Symptoms of intestinal infections in childhood

Any OCI is accompanied by fever, poor general health, diarrhea and vomiting. Loss of water as a result of these disease manifestations can lead to severe dehydration. A high lack of fluid in the body of a small child is still the cause of death from intestinal infections. There are many microbes that can cause damage to the gastrointestinal tract; the main diseases to which they contribute are discussed below.

Dysentery

This intestinal infection is caused by bacteria of the genus Shigella (shigellosis). The pathogen enters the child’s body from unwashed hands, household items and toys. The frequency of occurrence in the pediatric population is quite high.

The characteristic features of dysentery are as follows:

• the incubation period of the pathogen (time from infection to the appearance of the clinic) is 1–7 days;
• high fever (up to 40°C);
• severe intoxication (weakness, chills, lack of appetite, headaches);
• in severe cases, loss of consciousness and convulsions, delirium are possible;
• vomiting is a variable symptom;
• the pain is cramping and localized in the lower abdomen;
• frequency of bowel movements per day from 4 to 20 times;
• tenesmus (false urge to defecate);
• stool of a liquid consistency, with cloudy mucus, streaks of blood;
• As the disease progresses, stool becomes scanty and takes on the appearance of “rectal spit.”

Salmonellosis

This disease affects children of any age; its most dangerous occurrence is in infants. Infection with salmonella is possible through consumption of milk, meat, eggs, or through contact with objects contaminated with the feces of a sick person (furniture, toys, towels, pots).

The main clinical manifestations of salmonellosis are different.

1. It begins acutely with the appearance of a feverish state.
2. Vomiting can be repeated.
3. Rumbling in the right iliac region.
4. The pain is localized depending on the level of the pathological process, in any part of the abdomen.
5. When the stomach is affected, gastritis develops, the small intestine - enteritis, the large intestine - colitis, and there may be a combination of these forms.
6. Severe intoxication.
7. Reactive enlargement of the liver and spleen (hepatosplenomegaly).
8. Feces are liquid, with mucus, greens, sometimes streaked with blood, watery (like “swamp mud”, “frog spawn”).

Escherichiosis

A group of infections that are caused various types coli. It occurs more often in children under the first 3 years of age. The incidence of this infection increases in the summer. The following types of escherichiosis are distinguished (depending on microbiological properties): enteropathogenic, enterotoxic and enteroinvasive.

Symptoms characteristic of infections caused by E. coli are:

• intoxication syndrome (decreased appetite, lethargy, headache, weakness);
• fever up to febrile levels;
• vomiting is not repeated, but persistent, in infants - regurgitation;
• severe bloating;
• watery diarrhea;
• stools are yellow-orange, spattering, with mucus - a hallmark of escherichiosis;
• dehydration (exicosis), which is very difficult to treat.

Clinical manifestations that indicate the development of exicosis:

• dry skin, visible mucous membranes (the spatula sticks to the tongue);
• sunken and dry eyes;
• crying without tears;
• decrease in tissue turgor (elasticity), skin elasticity;
• the large fontanel in infants sinks;
• diuresis (urine output) decreases.

Rotavirus infection

A viral infection that occurs more often in winter. It is transmitted by consuming contaminated dairy products, water, or contact with sick people.

The symptoms caused by rotavirus intestinal infection in children are as follows:

• the incubation period lasts 1–3 days;
• severe intoxication syndrome and fever;
• the disease occurs in the form of gastroenteritis;
• catarrhal phenomena (hyperemia of the pharynx tissue, runny nose, sore throat);
• repeated vomiting is a mandatory symptom of rotavirus;
• the stool is watery and foamy and persists for a long time during treatment;
• the frequency of bowel movements reaches 15 per day.

Treatment of acute intestinal infections in childhood

As usual, children should begin with routine activities and organizing a treatment table. Medications(tablets, suppositories, solutions, suspensions) and the routes of their administration into the body are selected depending on the age and severity of the condition.

At mild form During the course of the disease, treatment should begin with the establishment of semi-bed rest, for moderate cases - bed rest, and with the development of dehydration - strict bed rest for the entire period while rehydration (replenishment of lost fluid) continues.

The child's nutrition is based on a dairy-vegetable diet, with the exception of rotavirus infection, where the consumption of milk is prohibited.

The portions are small, the frequency of meals increases up to 6 times. The food is mechanically and chemically gentle. Infants should receive mother's milk or an adapted milk formula (preferably lactose-free). Complementary foods are not introduced during illness.

It is very important to give your child water to prevent dehydration. Drinking should be plentiful, at a temperature close to body temperature. You need to offer liquid in small sips (a teaspoon), often. It is important not to give large volumes at once, as this will lead to overdistension of the stomach and provoke vomiting. You can drink sweet, weak tea, compote, raisin decoction, or slightly alkaline mineral water without gas.

The main directions of drug therapy for acute intestinal infections.

1. Rehydration (oral - through the mouth) with glucose-saline solutions (Regidron, Citroglucosolan, Gidrovit) should begin with the appearance of the first symptoms.
2. with an established bacterial pathogen (Ampicillin, Ceftriaxone, Gentamicin, Erythromycin).
3. Enterosorbents – enveloping the intestinal mucosa and excreting toxic substances and pathogenic microbes with feces(Smecta, Enterosgel, Polyphepan). These drugs, along with rehydration, should occupy the bulk of treatment.
4. At high temperature, antipyretic drugs are necessarily prescribed for any indicator, since fever contributes to even greater fluid loss (syrup and suppositories with ibuprofen can be alternated with Paracetamol).
5. Antispasmodic therapy is designed to relieve spasm from the smooth muscles of the intestine and relieve pain (No-shpa, Papaverine suppositories for children older than six months).
6. A complex product containing immunoglobulin and interferon - Kipferon suppositories for children.

The effectiveness of treatment measures determines how many days the illness lasts and how quickly the symptoms go away. In children, treatment should be comprehensive and carried out under the supervision of a doctor, especially in children in the first years of life.

Causes of OKI in children

All children's intestinal infections are highly contagious and, if they enter the baby's body, are likely to cause pathological processes. But there are still predisposing factors that increase the child’s chances of getting sick, these are:

• chronic pathologies of the gastrointestinal tract that a child may suffer from;
• reduction of local and general protective forces;
• prematurity (determines susceptibility to infections);
• lack of breastfeeding;
• lack of care and poor hygiene skills;
• intestinal dysbiosis;
• visiting places where there are large concentrations of children.

The main causes of ACI in childhood are presented below.

1. Gram-negative enterobacteria - affecting the gastrointestinal tract (Shigella, Campylobacter, Escherichia, Salmonella, Yersinia).
2. Opportunistic flora that lives in the intestines and disease-causing only when the balance of the intestinal biocenosis is disturbed (Klebsiella, Proteus and staphylococci, clostridium).
3. Viral agents (rota-, entero-, adenoviruses).
4. Protozoa (giardia, coccidia, amoeba).
5. Fungal pathogens (candida, aspergillus).

Carriers and excretors of pathogens of intestinal infections can be: domestic animals, insects (flies, cockroaches), a sick person with an erased form of the disease or with clear signs diseases.

Harmful microbes can enter a child’s body through fecal-oral (the infectious agent enters through water, food, unwashed hands) and contact-household (use of contaminated dishes, household items, toys) routes.

In childhood, endogenous (internal) infection often occurs with opportunistic bacteria, which are typical representatives of intestinal microbiocenosis.

Any illness of a child is a serious cause for concern for parents. If you experience symptoms indicating damage to the gastrointestinal tract, you should definitely consult a doctor. Only by establishing the correct cause of the disease can treatment begin effectively. Therapy should continue until the symptoms causing dehydration begin to subside.