The antibiotic-associated diarrhea
The antibiotic-associated diarrhea - a disease which is characterized by emergence of not properly executed chair in time or after reception of antibacterial medicines. The disease is followed by dispepsichesky symptomatology (ease of a chair, gas generation). Intensive belly-aches, weakness, fever appear in hard cases. Diagnostics is based on establishment of connection of reception of AB with development of diarrhea. In addition conduct the analysis a calla, an endoscopic research of intestines. Treatment assumes cancellation of AB, purpose of probiotics and dezintoksikatsionny medicines. At identification of an infecting agent carry out etiotropny antibacterial therapy.
The antibiotic-associated diarrhea
The antibiotic-associated diarrhea (AAD, nozokomialny colitis) - three and more episodes of a liquid chair repeating for not less than two days and connected with reception of antibacterial medicines (AB). Frustration can be shown within 4 weeks after cancellation of AB. In the developed countries damage of intestines is the most frequent reaction to antibiotic treatment: at the persons accepting antibiotics, AAD meets in 5-30% of cases. Pathology proceeds both in the easy self-stopped form, and in the form of heavy long colitis. In gastroenterology not less than 70% of cases are the share of idiopathic AAD, 30% - of Clostridium difficile-associated diarrhea. The disease equally affects men and women.
The reasons an antibiotic - the associated diarrhea
The disease develops after prescription of antibiotics of a penicillinic row, tetratsiklin, tsefalosporin more often. The way of introduction of drugs practically does not influence probability of emergence of diarrhea. At oral administration medicines influence a mucous layer of a GIT. At a parenteral way of introduction metabolites of AB are allocated with bile and saliva, exerting impact on obligate microflora. Taking into account the causes of a disease distinguish 2 AAD forms:
- Idiopathic (IAAD). Develops as a result of negative impact of AB on digestive tract. Influence of pathogenic microorganisms on a GIT is one of the possible reasons of development of this disease. Staphylococcus, proteas, enterokokk, klostridiya, mushrooms often occur among variety of activators. The risk of emergence of AAD increases at long (more than 10 days), frequent and wrong reception of AB (excess of a dose).
- Clostridium difficile-associated diarrhea (C. difficile-). Etiologicheski is connected with violation of microflora and excess settling of a GIT opportunistic bacteria of Clostridium difficile. Dysbacteriosis results from reception of AB from group of tsefalosporin, amoxicillin, lincomycin. Cases of development intra hospital an antibiotic - the associated infection by transfer of the activator through personal hygiene means (towels, soap, ware), medical tools are known at low-quality processing.
Besides direct influence of antibacterial funds for an intestines wall, there are risk factors increasing probability of development of a disease. Carry children's and advanced age, existence of heavy somatic pathology (a heart, renal failure), uncontrolled reception of antatsidny medicines, the congenital and acquired immunodeficiency, surgical interventions on an abdominal cavity to them, probe food. Chronic gastrointestinal diseases (a disease Krone, nonspecific ulcer colitis) also promote emergence an antibiotic - the associated colitis.
Antimicrobic medicines reduce growth and reproduction not only pathogenic, but also simbiontny microorganisms. There is a reduction of obligate intestinal microflora, dysbacteriosis develops. This fact is the cornerstone of pathogenesis of both types an antibiotic - the associated diarrhea. At an idiopathic form strengthening of motility of intestines, toxic damage of a mucous membrane or violation of exchange processes in intestines also plays a role.
The antibiotic-associated klostridialny colitis arises owing to change of structure of an endogenous normoflora of a GIT at reception of tsefalosporin III and IV generations, ftorkhinolon, penicillin. Dysbacteriosis promotes reproduction of C. Difficile which in a large number allocate 2 types of toxins (And yes In). Being in a gleam of a GIT, enterotoksina destroy epiteliotsita and cause inflammatory changes of a wall of intestines. Colitis mainly affects a large intestine with formation of diffusion hyperaemia and puffiness mucous. The wall of a GIT is thickened, the fibrin raids having an appearance of yellowish plaques (pseudo-membrane) are formed.
Allocate two forms idiopathic an antibiotic - the associated diarrhea: infectious and noninfectious. Klostridiya , golden staphylococcus, salmonellas, klebsiyella, sort mushrooms Candida often occur among activators of the AAD infectious form. Noninfectious IAAD is presented by the following types:
- Hyperkinetic. Klavulanat and his metabolites increase physical activity of a GIT, reception of macroleads causes reduction of a 12-perstny gut and antralny department of a stomach. These factors promote emergence of not properly executed chair.
- Giperosmolyarny. Develops due to partial absorption of AB (tsefalosporin) or at violation of carbohydrate exchange. In a gleam of intestines metabolites of carbohydrates which cause the increased secretion of electrolytes and waters collect.
- Sekretorny. It is formed due to violation of an eubioz of intestines and a dekonjyugation of bilious acids. Acids stimulate release of water and salts of chlorine in a gut gleam, the frequent not properly executed chair is a consequence of these processes.
- Toxic. It is formed because of negative impact of metabolites of penicillin and tetratsiklin on mucous intestines. Dysbacteriosis and diarrhea develops.
Manifestations of C. difficile- can vary from an asymptomatic carriage to immediately developing and severe forms. Depending on a clinical picture, data of endoscopy allocate the following types an antibiotic - the associated klostridialny infection:
- Diarrhea without colitis. It is shown by not properly executed chair without intoksikatsionny and abdominal syndromes. The mucous membrane of intestines is not changed.
- Colitis without pseudo-membranes. It is characterized by the developed clinical picture with moderate dehydration and intoxication. At an endoscopic research catarrhal inflammatory changes in a mucous membrane are observed.
- Psevdomembranozny colitis (PMK). It is characterized by the expressed intoxication, dehydration, a frequent watery chair and belly-aches. At a kolonoskopiya the fibrinozny raid and erosive and hemorrhagic changes of mucous is defined.
- Fulminantny colitis. The most severe form an antibiotic - the associated disorder of a GIT. Develops immediately (from several hours to one days). Causes serious gastroenterologichesky and septic violations.
Symptoms an antibiotic - the associated diarrhea
At IAAD the symptomatology arises in time (at 70% of patients) or after the treatment termination by antibiotics. As the basic, sometimes the only thing, display of a disease serves not properly executed chair to 3-7 times a day without impurity of blood and pus. Pains and feeling of a raspiraniye in a stomach, a meteorizm owing to the strengthened work of a GIT are seldom noted. The disease proceeds without temperature increase of a body and symptoms of intoxication.
Unlike an idiopathic form, the clinical range of manifestations of Clostridium difficile-AD varies from asymptomatic colitis to severe fatal forms of a disease. Bakterionositelstvo is expressed by lack of symptomatology and allocation to the environment of klostridiya with a stake. The easy course of a disease is characterized only by a liquid chair without fever and the expressed abdominal syndrome. It is more often observed by C. the difficile-associated colitis of moderate severity which is shown by temperature increase of a body, periodic skhvatkoobrazny pains in okolopupochny area, repeated diarrhea (10-15 times/days).
The heavy course of disease (PMK) is characterized frequent (to the 30th times/days) by the plentiful watery chair having a fetid smell. Kal may contain impurity of slime and blood. The disease is followed by intensive abdominal pains which disappear after the act of defecation. At patients deterioration in the general state, the expressed weakness and temperature increase to 38-39 °C is noted. In 2-3% of cases the fulminantny form of a disease which is shown by rapid increase of symptoms, the expressed intoxication and emergence of early heavy complications an antibiotic - the associated diarrhea is registered.
Idiopathic AAD will well respond to treatment and does not cause complications in patients. The diarrhea caused by S. difficile leads to a persistent lowering of arterial pressure, development of electrolytic violations and dehydration of an organism. Losses of protein and water promote developing of hypostases of the lower extremities and soft fabrics. Further development of a disease provokes emergence of megacolon, expressions of a mucous membrane of a GIT up to perforation of a thick gut, peritonitis and sepsis. Lack of timely diagnostics and pathogenetic treatment in 15-30% of cases leads to a lethal outcome.
At emergence of a plentiful liquid chair and discomfort in a stomach it is necessary to visit the gastroenterologist. The expert by means of studying of the anamnesis of life and a disease, fizikalny survey, these laboratory and tool inspections will make the corresponding conclusion. For diagnostics idiopathic the antibiotic - the associated diarrhea is enough to reveal communication between reception of AB and the beginning of diarrhea, to exclude the accompanying GIT pathology. In this case laboratory indicators remain normal, changes of a mucous membrane of intestines are absent.
At suspicion on Clostridium difficile-associated diarrhea for confirmation of the diagnosis the following methods are used:
- Laboratory blood tests. In the general blood test increase in SOE, anemia is noted ; in biochemical - a gipoproteinemiya.
- Research calla. In a koprogramma leukocytes and erythrocytes are found. As the main diagnostic criterion of a disease serves identification of the activator in Calais. Diagnostics of the choice are the cytopathogenic test (CT) and the toxin neutralization reaction (TNR) which define toxin B. The method of the immunofermental analysis (IFA) is sensitive to And yes V-endotoksinam. The Polymerase Chain Reaction (PCR) is used for identification of the genes coding toxins. A cultural method the calla allows to find klostridiya in crops.
- Endoscopy of a thick gut. To Kolonoskopy carry out for visualization of pathological changes of intestines (pseudo-membranes, fibrinous films, erosion). Endoscopic diagnostics at heavy colitis can constitute danger in connection with risk of a perforation of a gut.
Diagnostics an antibiotic - the associated frustration of a chair usually does not cause difficulties. The idiopathic form of a disease is differentiated with food toksikoinfektion of easy degree. Clinic of C. the difficile-associated diarrhea, namely psevdomembranozny colitis, can remind the course of cholera, disease Krone, ulcer colitis and serious food poisoning. Carry in addition out a survey X-ray analysis of an abdominal cavity, KT of a large intestine.
Treatment an antibiotic - the associated diarrhea
Treatment of idiopathic AAD assumes cancellation or decrease in a dose of antibacterial means, purpose of antidiarrheal medicines (loperamide), eubiotik and probiotics (a lactobacillus, a bifidobacterium). At repeated episodes of a liquid chair it is expedient to carry out normalization of water-salt balance.
Identification of klostridiya to a diffitsila is the indication for cancellation of AB and purpose of etiotropny, symptomatic and dezintoksikatsionny therapy. Choice medicine for treatment of a disease is metronidazole. In hard cases and at intolerance of metronidazole appoint . Correction of dehydration and intoxication is carried out by parenteral introduction of water-salt solutions (, Ringer's solution, , etc.). Complex therapy of klostridialny colitis includes use of enterosorbents, probiotics. The last are appointed after performing etiotropny therapy for restoration intestines normoflor a course to 3-4 months. At PMK complications (perforation of a gut, megacolon, the recidivous progressing course of colitis) surgical treatment is shown. Carry out a resection of a part or all thick gut (a gemikolektomiya, a kolektomiya).
Forecast and prevention
Forecast of idiopathic AAD favorable. The disease can independently be stopped after cancellation of antibiotics and not demand specific treatment. At timely diagnosis and adequate treatment of psevdomembranozny colitis it is possible to achieve an absolute recovery. Severe forms of diarrhea, ignoring of symptoms of a disease can entail complications as from a GIT, and all organism. Rational antibiotic treatment assumes reception of medicines according to strict indications only at appointment as the doctor and under his careful control. Prevention an antibiotic - the associated diarrhea includes application of probiotics for maintenance of normal microflora of a GIT, a balanced diet and maintaining active lifestyle.