Dysentery (bacterial dysentery, shigellosis). Medical examination and rehabilitation of infectious patients. Clinical observation of patients with infectious diseases.
All military personnel who have suffered generalized forms of meningococcal infection are subject to dynamic observation (Table 7).
Duration of dispensary dynamic observation is established: for conscript military personnel - twelve months, for military personnel serving under a contract - two years.
The frequency of mandatory control examinations by a doctor of the unit (polyclinic) is: once a month during the first three months after discharge from the hospital, subsequently - once every three months for one year, subsequently (for contract military personnel) once every six months.
The frequency of consultations with specialists is determined: for a neurologist, therapist, ophthalmologist - immediately after sick leave, then once a year or when complaints and signs of disorders of the nervous, cardiovascular systems and organ of vision appear; for other specialists - according to indications.
Laboratory and special studies include: clinical analysis blood and general urine analysis - once a year; EEG, ECG, MRI and other special studies - as indicated.
The main activities are carried out in accordance with the Guidelines for medical examination of military personnel in the Armed Forces Russian Federation (2010).
Table 7
Methodology for dispensary dynamic observation and content of basic treatment and preventive measures for major diseases of military personnel of the Armed Forces of the Russian Federation, reserve officers (retired)
| Nosological forms diseases | Frequency of mandatory control examinations by a doctor of the unit (polyclinic) | Duration of observation | Frequency of specialist consultations | List and frequency of laboratory, x-ray and other special studies (all studies are performed to the maximum extent possible) | Basic treatment and preventive measures | Clinical criteria effectiveness of clinical examination during the calendar year |
| Those who have had generalized forms of meningococcal infection, meningitis and other meningoencephalitis bacterial etiology | Once a month for the first three months after discharge from the hospital, subsequently - once every three months for one year, subsequently (for contract military personnel) once every six months. | For conscripted servicemen - twelve months, for contract servicemen - two years. | Examination by a neurologist, therapist, or ophthalmologist immediately after sick leave, if complaints and signs of disorders of the nervous, cardiovascular systems, or visual organs appear, then once a year. | General tests blood, urine – once a year; | EEG, ECG, MRI - according to indications. 1. Work and rest schedule: during the first 3-6 months after illness, exemption from work related to special conditions service, 3 months exemption from night duty and long business trips. 2. Prohibition of smoking and drinking alcohol. 3. Drug therapy | restorative, adaptogenic and vitamin preparations. |
4. Exercise therapy.
5. Spa treatment in those who have suffered severe and complicated forms of the disease. 6. If neurological symptoms appear and increase, hospitalization in the neurological department of the hospital. Recovery No complaints or violations of objective and laboratory indicators.
Deterioration Increase in subjective and objective manifestations of the disease, development of complications.
6. MILITARY MEDICAL EXAMINATION Convalescents after nasopharyngitis are given an exemption from drill training, assignments for 3 days and from physical training for 2 weeks. Persons who have had meningococcal infection in a generalized form, sick leave is provided for 30–60 days. In the future, the degree of their suitability for
military service determined by military medical examination. Military personnel who have recovered from meningococcal infection can be presented at the IHC and discharged from the hospital upon completion of treatment and rehabilitation in the hospital with a determined outcome of the disease, normalization of the cerebrospinal fluid and after one negative culture of mucus from the nasopharynx for meningococcus.), are presented at the VVK. The degree of their suitability for military service is determined based on the presence and severity of residual changes and the nature of military labor in accordance with the current order of the Ministry of Defense of the Russian Federation “On the procedure for conducting military medical examinations in the Armed Forces of the Russian Federation.”
When making an expert decision, the nature of residual effects past illness and the degree of dysfunction of the nervous system - indicated clinical syndrome(syndromes), which is noted at the time of examination and affects the expert prognosis.
Military personnel serving under conscription are recognized as unfit for service in the Airborne Forces, naval personnel, marine corps, as well as for working with radioactive substances (RS), sources of ionizing radiation (IRS), rocket fuel components (RFC), microwave generators and in special structures. The suitability of persons serving under a contract to work with radioactive materials, research institutes, SRT, microwave generators and in special structures is determined individually.
Military personnel serving in the Airborne Forces under a contract are considered temporarily unfit for parachute jumps for three to six months. After this period, the question of their admission to parachute jumps, as well as their suitability for service in the Airborne Forces, is decided individually.
Contract servicemen of the Navy should be recognized as requiring exemption for three months from night duty, long business trips, and for six months from going to sea and long autonomous cruises. They are not suitable for service on submarines. Their suitability for service on surface ships is determined individually.
Candidates for military educational institutions of the Ministry of Defense of the Russian Federation are recognized as unfit for admission.
Cadets and listeners (who have not signed the contract), certified according to paragraph 1 of the corresponding order of the Ministry of Defense of the Russian Federation “On the procedure for conducting military medical examination in the Armed Forces of the Russian Federation”, in case of changes in the state of health of a temporary nature, need to be granted sick leave.
1st year cadets of military educational institutions of the RF Ministry of Defense for the training of aviation flight personnel of the Armed Forces are recognized as unfit for flight training. Starting from the second year of training, the question of suitability (unsuitability) for flight training is decided individually.
In relation to flight personnel, a decision is made to grant sick leave, after which their suitability for flight work is determined individually by the medical flight commission.
Conscripts who have had meningococcal infection are granted a deferment from conscription due to illness if less than six months have passed since the end of hospital treatment. At the end of the deferment, the question of their suitability for military service and assignment to the branches of the Armed Forces, branches of the armed forces and military specialties is decided depending on the severity and persistence of dysfunction of the nervous system. In the absence of residual phenomena or in the presence of only scattered organic signs not accompanied by dysfunction, conscripts are fit for combat service, for service in the Airborne Forces, border troops, sailing personnel, marines, for work in special structures, in training units.
The content of the article
Dysentery (shigellosis)- spicy infectious disease with a fecal-oral transmission mechanism, caused by various types of Shigella, characterized by symptoms of general intoxication, damage to the large intestine, mainly its distal section, and signs of hemorrhagic colitis. IN in some cases becomes protracted or chronic.Historical data of dysentery
The term “dysentery” was proposed by Hippocrates (5th century BC), but it meant diarrhea accompanied by pain. Translated from Greek. dys - disorders, enteron - intestines. The disease was first described in detail by the Greek physician Aretaeus (1st century AD) under the name “strain diarrhea.” In 1891, military doctor-prosector A.V. Grigoriev isolated gram-negative microorganisms from the mesenteric lymph nodes of people who died from dysentery and studied their morphology . Japanese microbiologist K. Shiga studied these pathogens in more detail. Later, various causative agents of dysentery were described, which were collectively called “Shigella.” S. Flexner, J. Boyd, M. I. Shtutser, K. Schmitz, W. Kruse, C. Sonne, E. M. Novgorodskaya and others worked on their discovery and study.Etiology of dysentery
. The causative agents of bacterial dysentery belong to the genus Shigella, family Enterobacteriaceae. These are immobile gram-negative rods measuring 2-4X0.5-0.8 microns, not forming spores and capsules, they grow well on ordinary nutrient media, and are facultative anaerobes. Among the enzymes that determine the invasiveness of Shigella are hyaluronidase, plasmacoagulase, fibrinolysin, hemolysin, etc. Shigella is able to penetrate the epithelial cells of the intestinal mucosa, where they can be stored and multiply (endocytosis). This is one of the factors determining the pathogenicity of microorganisms.The combination of enzymatic, antigenic and biological properties of Shigella forms the basis for their classification. According to international classification(1968) distinguish 4 subgroups of Shigella. Subgroup A (Sh. dysenteriae) covers 10 serovars, including Shigella Grigoriev-Shig - serovars 1, Stutzer-Schmitz - serovars 2, Large-Sachs - serovars 3-7. Subgroup B (Sh. flexneri) includes 8 serovars, including Shigella Newcastle - serovars 6. Subgroup C (Sh. boydii) has 15 serovars. Subgroup D (Sh. sonnei) has 14 serovars for enzymatic properties and 17 for colicinogenicity. Our country has adopted a classification according to which there are 3 subgroups of Shigella (subgroups B and C are combined into one - Sh. Flexneri).Sh. dysenteriae (Grigorieva-Shiga) are capable of producing a strong heat-stable exotoxin and heat-labile endotoxin, while all other Shigella excrete only endotoxin.
The pathogenicity of different types of Shigella varies. The most pathogenic are Shigella Grigoriev-Shiga. Thus, the infectious dose for this shigellosis in adults is 5-10 microbial bodies, for Flexner's Shigella - about 100, Sonne's - 10 million bacterial cells.
Shigella has significant resistance to environmental factors. They are stored in moist soil for about 40 days, in dry soil - up to 15. In milk and dairy products they can be stored for 10 days, in water - up to 1 month, and in frozen foods and ice - about 6 months. Shigella can survive on contaminated laundry for 6 months. They quickly die from exposure to direct sunlight(after 30 minutes), but in the shade they remain viable for up to 3 months. At a temperature of 60 ° C, Shigella die within 10 minutes, and when boiled, they die immediately. All disinfectants kill Shigella within 1-3 minutes.
The resistance of Shigella in the external environment is higher, the weaker its pathogenicity.
In the 20th century the etiological structure of dysentery changes. Until the 30s, the vast majority of patients were diagnosed with Shigella Grigoriev-Shiga (about 80% of cases), from the 40s - Shigella Flexner, and from the 60s - Shigella Sonne. The latter is associated with greater stability of the pathogen in the external environment, as well as with the frequent course of the disease in the form of erased and atypical forms, which creates conditions for further spread of the pathogen. Noteworthy is the fact of a significant increase in the 70-80s of cases of Grigoriev-Shiga dysentery in the countries of Central America, where large epidemics took place, and its spread to the countries of Southeast Asia, which gives grounds to talk about a modern pandemic of Grigoriev Prokofiev-Shiga dysentery .
Epidemiology of dysentery
The source of infection is patients with acute and chronic forms of the disease, as well as bacteria carriers. Patients with the acute form are most contagious in the first 3-4 days of illness, and with chronic dysentery - during exacerbations. The most dangerous sources of infection are bacteria carriers and diseased mild and erased forms of the disease, which may not manifest themselves.Based on the duration of bacterial excretion, they are distinguished: acute bacterial carriage (within 3 months), chronic (over 3 months) and transient.
The mechanism of infection is fecal-oral, occurring through water, food and household contact. Transmission factors, as with other intestinal infections, are food, water, flies, dirty hands, household items contaminated with feces of the patient, etc. With Sonne's dysentery, the main route of transmission is food, with Flexner's dysentery - water, Grigoriev - Shiga - contact and household. However, we must remember that all types of shigellosis can be transmitted in different ways.
Susceptibility to dysentery is high, depends little on gender and age, but the highest incidence is observed among children preschool age due to their lack of sufficient hygiene skills. Intestinal dysbiosis and other chronic diseases of the stomach and intestines increase susceptibility.
Like other acute intestinal infections, dysentery is characterized by summer-autumn seasonality, which is associated with the activation of transmission routes, the creation of favorable external conditions for the preservation and reproduction of the pathogen, the peculiarities of the morphofunctional properties of the digestive canal during this period.
The transferred disease leaves a fragile (for a year), and with Grigoriev-Shiga shigellosis - a longer (about two years), strictly type- and species-specific immunity.
Dysentery is a common infectious disease that is registered in all countries of the world. The most common shigellosis in the world is D (Sonne). Shigellosis A (Grigorieva-Shiga), in addition to the countries of Central America, Southeast Asia, and certain regions of Africa, also occurs in European countries. In our country, shigellosis A occurred only in the form of isolated “imported” cases. Recently, the incidence of dysentery caused by this subtype of pathogen has gradually begun to increase.
Pathogenesis and pathomorphology of dysentery
The mechanism of development of the pathological process in dysentery is quite complex and requires further study. Infection occurs only orally. This is evidenced by the fact that it was impossible to contract dysentery when Shigella was administered through the rectum in experiments.The passage of a pathogen through the digestive canal can lead to:
a) until the complete death of Shigella with the release of toxins and the occurrence of reactive gastroenteritis,
b) transient passage of the pathogen through the digestive canal without clinical manifestations - transient bacterial carriage;
c) to the development of dysentery. In addition to the premorbid state of the organism, a significant role in this case belongs to the pathogen: its invasiveness, colicinogenicity, enzymatic and antiphagocytic activity, antigenicity, foreignness, etc.
Penetrating into the digestive canal, Shigella is influenced by digestive enzymes and antagonistic intestinal flora, as a result of which a significant part of the pathogen dies in the stomach and small intestine with the release of endotoxins, which are absorbed through the intestinal wall into the blood. Some of the dysentery toxins bind to cells of various tissues (including cells of the nervous system), causing intoxication in the initial period, and the other part is released from the body, including through the wall of the colon. In this case, the toxins of the causative agent of dysentery sensitize the intestinal mucosa and cause trophic changes in the submucosal layer. Provided that the pathogen remains viable, it penetrates the intestinal mucosa sensitized by toxins, causing destructive changes in it. It is believed that foci of reproduction in the epithelium of the intestinal mucosa are formed due to the invasiveness of Shigella and their ability to endocytose. At the same time, during the destruction of the affected epithelial cells, Shigella penetrates into the deep layers of the intestinal wall, where they are phagocytosed by neutrophil granulocytes and macrophages. Defects (erosions, ulcers) appear on the mucous membrane, often with a fibrinous coating. After phagocytosis, Shigella dies (completed phagocytosis), toxins are released that infect small vessels, cause swelling of the submucosal layer and hemorrhages. In this case, pathogen toxins stimulate the release of biologically active substances- histamine, acetylcholine, serotonin, which, in turn, further disrupt and discoordinate the capillary blood supply of the intestine and increase the intensity of the inflammatory process, thereby deepening disorders of the secretory, motor and absorption functions of the colon.
As a consequence of the hematogenous circulation of toxins, a progressive increase in intoxication is observed, irritation of the receptor apparatus of the renal vessels and their spasm increases, which, in turn, leads to disruption of the excretory function of the kidneys and an increase in the concentration of nitrogenous wastes, salts, end products of metabolism in the blood, and a deepening of homeostasis disorders. In case of such disorders excretory function take over the replacement (vicar) excretory organs (skin, lungs, digestive canal). The colon bears the maximum load, which aggravates destructive processes in the mucous membrane. Since in children the functional differentiation and specialization of various parts of the digestive canal is lower than in adults, the mentioned process of releasing toxic substances from the body does not occur in any separate segment of the colon, but diffusely, along the course of the entire digestive canal, which causes a more severe course diseases in young children.
Due to endocytosis, toxin formation, disturbances of homeostasis, the release of thick waste and other products, trophic disturbances progress, due to deprivation of tissues of nutrition and oxygen, erosions and ulcers appear on the mucous membrane, and more extensive necrosis is also observed. In adults, these lesions are usually segmental according to the needs of elimination.
The result of irritation by dysentery toxin of the nerve endings and nodes of the abdominal plexus are disorders of the secretion of the stomach and intestines, as well as incoordination of the peristalsis of the small and especially large intestine, spasm of the stiff muscles of the intestinal wall, which causes paroxysmal abdominal pain.
Due to edema and spasm, the diameter of the lumen of the corresponding segment of the intestine decreases, so the urge to defecate occurs much more often. Based on this, the urge to defecate does not end with emptying (i.e., it is not real), is accompanied by pain and the release of only mucus, blood, and pus (“rectal spitting”). Changes in the intestines are gradually reversed. Due to the death of part nerve formations intestines from hypoxia long time morphological and functional disorders which may progress.
In acute dysentery, pathomorphological changes are divided into stages according to the severity of the pathological process. Acute catarrh- swelling of the mucous membrane and submucosal layer, hyperemia, often minor hemorrhages, sometimes superficial necrotization of the epithelium (erosion); on the surface of the mucous membrane between the folds there is mucopurulent or mucohemorrhagic exudate; hyperemia is accompanied by lymphocytic-neutrophilic infiltration of the stroma. Fibrinous-necrotic inflammation is much less common, characterized by dirty-gray dense layers of fibrin, necrotic epithelium, leukocytes on the hyperemic edematous mucous membrane, necrosis reaches the submucosal layer, which is intensively infiltrated with lymphocytes and neutrophilic leukocytes. The formation of ulcers is the melting of the affected cells and the gradual removal of necrotic masses; the edges of superficial ulcers are quite dense; in the distal part of the colon there are confluent ulcerative “fields”, between which islands of unaffected mucous membrane are sometimes preserved; very rarely, penetration or perforation of the ulcer with the development of peritonitis is possible. Healing of ulcers and their scarring.
In chronic dysentery during remission, the intestines may be visually almost unchanged, but histologically they reveal sclerosis (atrophy) of the mucous membrane and submucosal layer, degeneration of intestinal crypts and glands, vascular disorders with inflammatory cell infiltrates and dystrophic changes. During an exacerbation, changes similar to those observed in the acute form of the disease are observed.
Regardless of the form of dysentery, changes in the regional lymph nodes (infiltration, hemorrhage, swelling), and intramural nerve plexuses are also possible. The same changes occur in the abdominal plexus, cervical sympathetic ganglia, and vagus nerve ganglia.
Dystrophic processes are also observed in the myocardium, liver, adrenal glands, kidneys, brain and its membranes.
Dysentery Clinic
Dysentery is marked by polymorphism of clinical manifestations and is characterized as local defeat intestines, and general toxic manifestations. This clinical classification of dysentery has become widespread.1. Acute dysentery (lasts about 3 months):
a) typical (colic) form,
b) toxicoinfectious (gastroenterocolitic) form.
Both forms can be light, medium-heavy, heavy, or erased.
2. Chronic dysentery (lasts more than 3 months):
a) recurrent;
b) continuous.
3. Bacterial carriage.
Dysentery has a cyclical course. Conventionally, the following periods of the disease are distinguished: incubation, initial, height, extinction of the manifestations of the disease, recovery or, much less often, transition to a chronic form.
Acute dysentery.
The incubation period lasts from 1 to 7 days (usually 2-3 days). In most cases, the disease begins acutely, although in some patients prodromal phenomena in the form of general malaise, headache, lethargy, loss of appetite, drowsiness, and a feeling of discomfort in the abdomen. As a rule, the disease begins with chills and a feeling of heat. Body temperature quickly rises to 38-39 ° C, intoxication increases. The duration of fever ranges from several hours to 2-5 days. Possible course of the disease with low-grade fever or without raising it.
From the first day of illness, the leading symptom complex is spastic distal hemorrhagic colitis. Paroxysmal spasmodic pain occurs in the lower abdomen, mainly in the left iliac region. Cramping pain precedes each bowel movement. Tenesmus, typical for distal colitis, also occurs: a nagging pain in the otkhodnik during defecation and for 5-10 minutes after it, which is caused by the inflammatory process in the area of the rectal ampulla. The feces have a liquid consistency, at first they have a fecal character, which changes after 2-3 hours. The amount of feces decreases each time, and the frequency of stool increases, an admixture of mucus appears, and with subsequent bowel movements - blood, and later manure.
Feces look bloody-mucous, less often a mucopurulent mass (15-30 ml) - lumps of mucus streaked with blood ("rectal spit"). There can be from 10 to 100 or more urges per day, and the total amount of feces in typical cases is at the beginning of the disease does not exceed 0.2-0.5 liters, and in subsequent days it is even less. In cases (especially in children), there may be prolapse of the rectum, gaping of the posterior one due to paresis of its sphincter from “overwork.”
On palpation of the abdomen, sharp pain is noted in its left half, sigmoid colon spasmodic and palpated in the form of a dense, inactive, painful cord. Often palpation of the abdomen increases intestinal spasm and provokes tenesmus and false urges to defecation. Soreness and spasticity are also detected in other parts of the colon, especially in its descending part.
Already at the end of the first day the patient is weakened, adynamic, apathetic. The skin and visible mucous membranes are dry, pale, sometimes with bluish tint, the tongue is covered with a white coating. Anorexia and fear of pain is the reason for refusing food. Heart sounds are weakened, pulse is labile, arterial pressure reduced. Sometimes disturbances in the rhythm of heart contractions and systolic murmur above the apex are detected. Patients are restless and complain of insomnia. Sometimes there is pain along the nerve trunks, skin hyperesthesia, and hand tremor.
In patients with dysentery, all types of metabolism are disrupted. In young children, metabolic disorders can cause the development of secondary toxicosis and especially severe cases- adverse consequences. In some cases, toxic proteinuria is observed.
Blood tests revealed neutrophilic leukocytosis with a shift in the leukocyte formula to the left, monocytosis, and a moderate increase in ESR.
During sigmoidoscopy (colonoscopy), inflammation of the mucous membrane of the rectum and sigmoid colon of varying degrees is determined. The mucous membrane is hyperemic, swollen, and easily injured by the slightest movements of the sigmoidoscope. Hemorrhages, mucopurulent, and in some cases fibrinous and diphtheritic plaques (similar to diphtheria) are often observed. different sizes erosions and ulcerative defects.
High period The illness lasts from 1 to 7-8 days, depending on the severity of the course. Recovery occurs gradually. Normalization of intestinal function does not yet indicate recovery, since, according to sigmoidoscopy, restoration of the mucous membrane of the distal colon occurs slowly.
Most often (60-70% of cases) a mild colitic form of the disease is observed with short-term (1-2 days) and mildly expressed dysfunction of the digestive system without significant intoxication. Defecation is rare (3-8 times a day), with a small amount of mucus streaked with blood. Abdominal pain is not sharp, there may be no tenesmus. Sigmoidoscopy allows you to identify catarrhal, and in some cases catarrhal-hemorrhagic proctosigmoiditis. Patients, as a rule, remain able to work and do not always seek help. The disease lasts 3-7 days.
Moderate colic form(15-30% of cases) is characterized by moderate intoxication in the initial period of the disease, an increase in body temperature to 38-39 ° C, which persists for 1-3 days, spastic pain in the left half of the abdomen, tenesmus, and a false urge to defecate. The frequency of stools reaches 10-20 per day, feces are in small quantities, quickly lose their fecal character - impurities of mucus and streaks of blood (“rectal spit”). Sigmoidoscopy reveals catarrhal-hemorrhagic or catarrhal-erosive proctosigmoiditis. The disease lasts 8-14 days.
Severe colic form(10-15% of cases) has a violent onset with chills, increased body temperature to 39-40 ° C, and significant intoxication. There is a sharp, paroxysmal pain in the left iliac region, tenesmus, frequent (about 40-60 times a day or more) bowel movements, feces of a mucous-bloody nature. The sigmoid colon is sharply painful and spasmodic. In severe cases, intestinal paresis with flatulence is possible. Patients are adynamic, facial features are sharpened, blood pressure is reduced to 8.0/5.3 kPa (60/40 mm Hg), tachycardia, heart sounds are muffled. During sigmoidoscopy, catarrhal-hemorrhagic-erosive, catarrhal-ulcerative proctosigmoiditis is determined; fibrinous-necrotic changes in the mucous membrane are less often observed. The recovery period lasts 2-4 weeks.
TO atypical forms dysentery includes gastroenterocolitic (toxicoinfectious), hypertoxic (especially severe) and erased. Gastroenterocolitic form observed in 5-7% of cases and has a course similar to food poisoning.
Hypertoxic (especially severe) form characterized by severe intoxication, collaptoid state, development of thrombohemorrhagic syndrome, acute failure kidney Due to the lightning-fast course of the disease, changes in the gastrointestinal tract do not have time to develop.
Erased form characterized by the absence of intoxication, tenesmus, intestinal dysfunction is insignificant. Sometimes palpation reveals mild tenderness of the sigmoid colon. This form of the disease does not lead to changes in normal lifestyle, so patients do not seek help.
The course of dysentery, depending on the type of pathogen, has some features. Thus, Grigoriev-Shiga dysentery is characterized by a severe course, most often with severe colitic syndrome, against the background of general intoxication, hyperthermia, neurotoxicosis, and sometimes convulsive syndrome. Flexner's dysentery is characterized by a slightly milder course, but severe forms with severe colitic syndrome and longer release from the pathogen are observed relatively often. Sonne dysentery usually has mild course, often in the form of food toxic infection (gastroenterocolitic form). More often than with other forms, the cecum and ascending colon are affected. The overwhelming majority of cases of bacterial carriage are caused by Shigella Sonne.
Chronic dysentery
Recently it has been observed rarely (1-3% of cases) and has a recurrent or continuous course. More often it acquires a recurrent course with alternating phases of remission and exacerbation, during which, as with acute dysentery, signs of damage to the distal colon predominate. Exacerbations can be caused by dietary disorders, disorders of the stomach and intestines, acute respiratory diseases and are often accompanied by moderate symptoms of spastic colitis (sometimes hemorrhagic colitis), but prolonged bacterial excretion.During objective research You can detect spasm and tenderness of the sigmoid colon, rumbling along the colon. During the period of exacerbation of sigmoidoscopy, the picture resembles the changes typical of acute dysentery, however, the pathomorphological changes are more polymorphic, areas of the mucous membrane with bright hyperemia border on areas of atrophy.
With a continuous form of chronic dysentery, there are practically no periods of remission, the patient’s condition gradually worsens, profound digestive disorders, signs of hypovitaminosis, and anemia appear. A constant companion of this form of chronic dysentery is intestinal dysbiocenosis.
Patients with a long course of chronic dysentery often develop post-dysenteric colitis, which is the result of deep trophic changes in the colon, especially its nervous structures. The dysfunction persists for years, when pathogens are no longer excreted from the colon, and etiotropic treatment is ineffective. Patients constantly feel heaviness in the epigastric region, constipation and flatulence are periodically observed, which alternate with diarrhea. Sigmoidoscopy reveals total atrophy of the mucous membrane of the rectum and sigmoid colon without inflammation. The nervous system suffered to a greater extent - patients are irritable, their performance is sharply reduced, headaches, sleep disturbances, and anorexia are frequent.
Feature of modern The course of dysentery is a relatively large proportion of mild and subclinical forms (which, as a rule, are caused by Shigella Sonne or Boyd), long-term stable bacterial carriage, greater resistance to etiotropic therapy, as well as the rarity of chronic forms.
Complications have recently been observed extremely rarely. Relatively more often, dysentery can be complicated by exacerbation of hemorrhoids and anal fissures. In weakened patients, mainly children, complications may occur (bronchopneumonia, urinary tract infections) caused by the activation of opportunistic low-, conditionally and non-pathogenic flora, as well as rectal prolapse.
The prognosis is generally favorable, but in some cases the course of the disease becomes chronic. Lethal outcome in adults is rare; in weakened young children with an unfavorable premorbid background it is 2-10%.
Diagnosis of dysentery
Reference symptoms clinical diagnostics dysentery there are signs of spastic terminal hemorrhagic colitis: paroxysmal pain in the left half of the abdomen, especially in the iliac region, tenesmus, frequent false urge to defecate, mucous-bloody discharge (“rectal spitting”), spastic, sharply painful, sedentary sigmoid colon, sigmoidoscopy picture of catarrhal, catarrhal-hemorrhagic or erosive-ulcerative proctosigmoiditis.In establishing a diagnosis, epidemiological history data play an important role: the presence of an outbreak of the disease, cases of dysentery in the patient’s environment, seasonality, etc.
Specific diagnosis of dysentery
. The most reliable and widespread method of laboratory diagnosis of dysentery is bacteriological, which consists of isolating coprocultures of Shigella, and in case of Grigoriev-Shiga dysentery, in some cases, blood cultures. It is advisable to take the material for research before starting antibacterial therapy, repeatedly, which increases the frequency of excretion of the pathogen. The material is sown on selective media of Ploskirev, Endo, Levin, etc. The frequency of pathogen isolation during bacteriological studies is 40-70%, and this figure is higher, the earlier the studies were conducted and the greater their frequency.Along with bacteriological examination, serological methods are used. Identification of specific antibodies is carried out using the RNGA reaction, less often RA. The diagnostic titer in the RNGA is considered to be 1: 100 for Sonne’s dysentery and 1: 200 for Flexner’s dysentery. Antibodies in dysentery appear at the end of the first week of illness and reach a maximum on the 21-25th day, so it is advisable to use the method of paired sera.
Skin allergy test with dysenterin (Tsuverkalov reaction) is rarely used because it does not have sufficient specificity.
Coprological examination is of auxiliary importance in establishing the diagnosis, during which mucus, pus, a large number of leukocytes, mainly neutrophils, and red blood cells are often detected.
Differential diagnosis of dysentery
Dysentery should be differentiated from amoebiasis, foodborne toxic infections, cholera, sometimes with typhoid fever and paratyphoid A and B, exacerbation of hemorrhoids, proctitis, colitis of non-infectious origin, nonspecific ulcerative colitis, neoplasms of the colon. and Unlike dysentery, amebiasis is characterized by a chronic course and the absence of a significant temperature reaction. Feces retain their fecal character, mucus is evenly mixed with blood (“raspberry jelly”), and amoebas, the causative agents of the disease, or their cysts, eosinophils, and Charcot-Leyden crystals are often found in them.At foodborne diseases the disease begins with chills, repeated vomiting, and pain mainly in the epigastric region. Lesions of the colon are rare, so patients do not have spastic pain in the left iliac region or tenesmus. In the case of salmonellosis, the feces are greenish in color (a type of swamp mud).
For cholera signs of spastic colitis are not typical. The disease begins with profuse diarrhea, which is accompanied by vomiting with a large amount of vomit. The feces look like rice water, signs of dehydration quickly increase, which often reaches alarming levels and causes the severity of the condition. For cholera, tenesmus, abdominal pain, high body temperature (usually even hypothermia) are atypical.
For typhoid fever in some cases, the large intestine is affected (colotypha), but it is not typical spastic colitis, there is a prolonged fever, pronounced hepatolienal syndrome, and a specific roseola rash.
Bloody discharge due to hemorrhoids observed in the absence inflammatory changes in the large intestine, blood is mixed into the stool at the end of a bowel movement. Review of otkhodniks and sigmoidoscopy help to avoid diagnostic errors.
Colitis non-infectious nature often occurs in cases of poisoning with chemical compounds (“lead colitis”), with some internal medicine(cholecystitis, hypoacid gastritis), pathologies of the small intestine, uremia. This secondary colitis is diagnosed taking into account the underlying disease and is not contagious or seasonal.
Nonspecific ulcerative colitis begins in most cases gradually, has a progressive long course, typical rectoromaioscopic and x-ray picture. Characterized by resistance to antibacterial therapy.
Colon neoplasms in the stage of decay may be accompanied by diarrhea with blood against the background of intoxication, but are characterized by a longer course, the presence of metastasis to regional The lymph nodes and distant organs. To find out the diagnosis, you should use a digital examination of the rectum, sigmoidoscopy, irrigography, and coprocytoscopic examination.
Treatment of dysentery
The basic principle of treating patients with dysentery is to begin therapeutic measures as early as possible. Treatment of patients with dysentery can be carried out both in an infectious diseases hospital and at home. sick light forms Dysentery, in the case of satisfactory sanitary and living conditions, can be treated at home. This is reported by sanitary and epidemiological institutions. Patients with moderate and severe forms of dysentery, decreed contingents and in the presence of epidemiological indications are subject to mandatory hospitalization.Diet therapy is of great importance. IN acute phase The disease is prescribed diet No. 4 (4a). They recommend pureed mucous soups from vegetables, cereals, dishes from pureed meat, cottage cheese, boiled fish, wheat bread, etc. food should be taken in small portions 5-6 times a day. After stool normalization, diet No. 4c is prescribed, and later diet No. 15.
Etiotropic therapy involves the use of various antibacterial drugs, taking into account the sensitivity of the pathogen to them and after taking the material for bacteriological examination. Recently, the principles and methods of etiotropic treatment of patients with dysentery have been revised. It is recommended to limit the use of broad-spectrum antibiotics, which contribute to the formation of intestinal dysbiocenosis and prolong recovery time.
It is advisable to treat patients with mild forms of dysentery without the use of antibiotics. The best results are obtained when using nitrofuran drugs in these cases (furazolidone 0.1-0.15 g 4 times a day for 5-7 days), 8-hydroxyquinoline derivatives (enteroseptol 0.5 g 4 times a day, intestopan 3 tablets 4 times a day), sulfonamide drugs with non-resorptive action (phthalazol 2-3 g 6 times a day, phthazin 1 g 2 times a day) for 6-7 days.
Antibiotics are used for moderate and severe colic forms of dysentery, especially in the elderly and in young children. In this case, it is advisable to shorten the course of treatment to 2-3 days. Apply the following drugs(in daily doses): chloramphenicol (0.5 g 4-6 times), tetracycline (0.2-0.3 g 4-6 times), ampicillin (0.5-1.0 g 4 times) , monomycin (0.25 g 4-5 times), biseptol-480 (2 tablets 2 times), etc. In case of severe forms of the disease and in the treatment of young children, it is advisable parenteral administration antibiotics.
Among the means of pathogenetic therapy in severe and moderate cases of dysentery, polyglucin, reopolyglucin, polyionic solutions, “Quartasil”, etc. are used for detoxification. In especially severe cases, glycocorticosteroids are prescribed for infectious-toxic shock. For mild and partially moderate forms, you can limit yourself to drinking a glucose-saline solution (oralite) of the following composition: sodium chloride - 3.5 g, sodium bicarbonate - 2.5, potassium chloride - 1.5, glucose - 20 g per 1 liter of drinking water boiled water.
Pathogenetically justified is the prescription of antihistamines and vitamin therapy. In cases of prolonged dysentery, immunostimulants (pentoxyl, sodium nucleinate, methyluracil) are used.
In order to compensate for the enzyme deficiency of the digestive canal, natural gastric juice, chlorohydrochloric (hydrochloric) acid with pepsin, Acidin-pepsin, oraza, pancreatin, panzinorm, festal, etc. are prescribed. If there are signs of dysbacteriosis, bactisubtil, colibacterin, bifidumbacterin, lactobacterin and others are effective. within 2-3 weeks. They prevent the process from becoming chronic and relapse of the disease, and are also effective in cases of prolonged bacterial carriage.
Treatment of patients with chronic dysentery includes anti-relapse treatment and treatment for exacerbations and includes diet, antibacterial therapy with a change in drugs according to the sensitivity of Shigella to them, vitamin therapy, the use of immunostimulants and bacterial preparations.
Prevention of dysentery
Priority is given to early diagnosis of dysentery and isolation of patients in an infectious diseases hospital or at home. Current and final disinfection is required in outbreak areas.Persons who have had acute dysentery are discharged from the hospital no earlier than 3 days after clinical recovery and a single, and in decreed contingents - a double negative bacteriological study, which is carried out no earlier than 2 days after the completed course of antibacterial therapy. If the pathogen was not isolated during the illness, patients are discharged without a final bacteriological examination, and decreed contingents are discharged after a single bacteriological examination. In case of chronic dysentery, patients are discharged after the exacerbation has subsided, stable normalization of stools and a negative single bacteriological examination. If the result of the final bacteriological examination is positive, such persons are given a second course of treatment.
Persons who have had dysentery with an established type of pathogen, carriers of Shigella, as well as patients with chronic dysentery are subject to dispensary observation in the KIZ. Clinical examination is carried out within 3 months after discharge from the hospital, and for patients with chronic dysentery from among the decreed contingents - within 6 months.
Strict compliance with sanitary-hygienic and sanitary-technical standards and rules at catering establishments, food industry facilities, preschool institutions, schools and other facilities is important in the prevention of dysentery.
For the specific prevention of dysentery, a dry lyophilized live anti-dysenteric vaccine (orally) made from Shigella Flexner and Sonne has been proposed, but its effectiveness has not been fully clarified.
15. Dispensary observation after an acute dysentery subject to:
1) employees of public catering facilities, food trade, food industry;
2) children of orphanages, children's homes, boarding schools;
3) employees of psychoneurological dispensaries, orphanages, children's homes, boarding homes for the elderly and disabled.
16. Dispensary observation is carried out for one month, at the end of which a single bacteriological examination is required.
17. The frequency of visits to the doctor is determined by clinical indications.
18. Dispensary observation is carried out by a local doctor (or family doctor) at the place of residence or by a doctor in the office of infectious diseases.
19. If the disease relapses or the laboratory test results are positive, persons who have had dysentery are treated again. After completion of treatment, these individuals undergo monthly laboratory examinations for three months. Persons who carry the bacteria for more than three months are treated as patients with chronic form dysentery.
20. Persons from the decreed group of the population are allowed by the employer to work in their specialty from the moment they provide a certificate of recovery. A certificate of recovery is issued by the attending physician only after full recovery, confirmed by the results of clinical and bacteriological examination.
Persons with chronic dysentery are transferred to work where they do not pose an epidemiological danger.
21. Persons with chronic dysentery are under clinical observation for a year. Bacteriological examinations and examination by an infectious disease specialist of persons with chronic dysentery are carried out monthly.
6. Sanitary and epidemiological requirements for the organization and implementation of sanitary and anti-epidemic (preventive) measures for prevention salmonellosis
22. The following categories of people in the population are subject to mandatory bacteriological examination for salmonellosis:
1) children under two years of age admitted to hospital;
2) adults hospitalized in a hospital to care for a sick child;
3) women in labor, postpartum women, in the presence of intestinal dysfunction at the time of admission or during the previous three weeks before hospitalization;
4) all patients, regardless of diagnosis, upon presentation intestinal disorders during a hospital stay;
5) persons from among the decreed groups of the population who are presumably the source of infection in the outbreak of salmonellosis.
23. An epidemiological survey of salmonellosis foci is carried out in the event of illness among persons belonging to a decreed group of the population or children under two years of age.
24. Hospitalization of patients with salmonellosis is carried out according to clinical and epidemiological indications.
25. Convalescents after salmonellosis are discharged after complete clinical recovery and a single negative bacteriological examination of stool. The study is carried out no earlier than three days after the end of treatment.
26. Only decreed groups of the population are subject to clinical observation after an illness.
27. Dispensary observation of persons who have had salmonellosis is carried out by a doctor at the office of infectious diseases or local (family) doctors at the place of residence.
Persons from decreed groups of the population are allowed by the employer to work in their specialty from the moment they provide a certificate of recovery.
28. Convalescents from among the decreed population groups are allowed by the employer to work in their specialty from the moment they provide a certificate of recovery.
Convalescents who continue to excrete salmonella after the end of treatment, as well as identified bacteria carriers from among the decreed population groups, are suspended from their main work by the territorial divisions of the government agency in the field of sanitary and epidemiological welfare of the population for fifteen calendar days. The employer transfers them to a job where they do not pose an epidemiological danger.
If suspended, a three-time stool examination is carried out within fifteen calendar days. If the result is positive again, the procedure for removal from work and examination is repeated for another fifteen days.
If bacterial carriage is established for more than three months, persons, as chronic carriers of salmonella, are suspended from work in their specialty for twelve months.
After the expiration of the period, stool and bile are examined three times with an interval of one or two calendar days. If negative results are obtained, they are allowed to return to work. If they receive one positive result, such persons are considered as chronic bacteria carriers, and the territorial departments of the government agency in the field of sanitary and epidemiological welfare of the population are removed from work where they pose an epidemiological danger.
29. Children who continue to excrete salmonella after treatment are suspended by the attending physician from attending preschool education for fifteen calendar days; during this period, three stool examinations are carried out with an interval of one or two days. If the result is positive again, the same procedure for removal and examination is repeated for another fifteen days.
Sanitary and epidemiological requirements for the organization and implementation of sanitary and anti-epidemic (preventive) measures to prevent typhoid fever and paratyphoid fever
30. State sanitary and epidemiological surveillance of the incidence of typhoid and paratyphoid fever in the population includes:
1) analysis of information on the sanitary condition of settlements, especially those disadvantaged by the incidence of typhoid paratyphoid infections among the population;
2) implementation of state sanitary and epidemiological surveillance and identification of risk groups among the population;
3) determination of phagotypes of isolated cultures from patients and bacteria carriers;
4) registration and dispensary observation of those who have had typhoid fever and paratyphoid fever in order to identify and sanitize bacteria carriers, especially from among workers of food enterprises and other decreed groups of the population;
5) planning preventive and anti-epidemic measures.
31. Preventive actions typhoid paratyphoid diseases are aimed at carrying out sanitary and hygienic measures to prevent the transmission of pathogens through water and food. State sanitary and epidemiological supervision is carried out over the sanitary and technical condition of the following facilities:
1) water supply systems, centralized, decentralized water supply sources, main water intake structures, sanitary protection zones of water sources;
2) food processing industry, food trade, public catering;
3) sewer system.
32. Before being allowed to work, persons from among the decreed groups of the population, after a medical examination, are subjected to a serological examination by performing a direct hemagglutination reaction with blood serum and a single bacteriological examination. Persons are allowed to work if negative results serological and bacteriological examinations and in the absence of other contraindications.
In case of a positive result of the direct hemagglutination reaction, an additional five-fold bacteriological examination of native feces is carried out with an interval of one to two calendar days. If the results of this examination are negative, a single bacteriological examination of bile is performed. Persons who have received negative data from bacteriological examination of stool and bile are allowed to work.
Persons who have positive results of serological and bacteriological examination are considered as bacteria carriers. They are treated, registered, and are under medical supervision. Territorial divisions of the department of the state body in the field of sanitary and epidemiological welfare of the population exclude bacteria carriers from work where they pose an epidemic danger.
33. According to the Decree of the Government of the Republic of Kazakhstan dated December 30, 2009 No. 2295 “On approval of the list of diseases against which preventive vaccinations are carried out, the Rules for their implementation and population groups subject to routine vaccinations,” sewer and sewer workers are subject to vaccination against typhoid fever treatment facilities.
34. In the focus of typhoid fever or paratyphoid fever, the following measures are taken: 1) identification of all patients through questioning, examination, thermometry, laboratory examination;
2) timely isolation of all patients with typhoid fever, paratyphoid fever;
3) identifying and conducting laboratory examinations of persons who have previously had typhoid fever and paratyphoid fever, decreed groups of the population, persons exposed to the risk of infection (who consumed food or water suspected of being infected, or who had contact with patients);
4) in an outbreak with a single disease in persons from among the decreed population groups, a single bacteriological examination of feces and a study of blood serum in a direct hemagglutination reaction is carried out. In persons with a positive result of the direct hemagglutination reaction, a repeated five-fold bacteriological examination of stool and urine is carried out;
5) in the event of group diseases, a laboratory examination of persons who are presumably the source of infection is carried out. Laboratory examination includes three-time bacteriological examination of stool and urine with an interval of at least two calendar days and a single examination of blood serum using the direct hemagglutination reaction. In persons with a positive result of the direct hemagglutination reaction, an additional five-fold bacteriological examination of stool and urine is carried out with an interval of at least two calendar days, and if the results of this examination are negative, the bile is examined once;
6) persons from among the decreed groups of the population who have contact or communication with a patient with typhoid fever or paratyphoid fever at home, territorial divisions of the department of the state body in the field of sanitary and epidemiological welfare of the population are temporarily suspended from work until the patient is hospitalized, final disinfection is carried out and negative results of a single test are obtained bacteriological examination of stool, urine and direct hemagglutination reaction;
7) persons exposed to the risk of infection, along with laboratory examination are under medical supervision with daily medical examinations and thermometry for twenty-one calendar days for typhoid fever and fourteen calendar days for paratyphoid fever from the moment of isolation of the last patient;
8) identified patients and bacteria carriers of typhoid and paratyphoid fever are immediately isolated and sent to medical organizations for examination and treatment.
35. Emergency prevention in areas of typhoid fever and paratyphoid fever, it is carried out depending on the epidemiological situation. In areas of typhoid fever, a typhoid bacteriophage is prescribed in the presence of typhoid fever; in case of paratyphoid fever, a polyvalent salmonella bacteriophage is prescribed. The first appointment of a bacteriophage is carried out after collecting material for bacteriological examination. The bacteriophage is also prescribed to convalescents.
36. In areas of typhoid fever and paratyphoid fever, disinfection measures must be carried out:
1) current disinfection is carried out during the period from the moment of identification of the patient to hospitalization, for convalescents within three months after discharge from the hospital;
2) current disinfection is organized by a medical worker medical organization, and carried out by the person caring for the patient, the convalescent himself or the bacteria carrier;
3) final disinfection is carried out by disinfection stations or disinfection departments (departments) of bodies (organizations) of the sanitary and epidemiological service, in rural areas - rural medical hospitals, outpatient clinics;
4) final disinfection in urban areas populated areas carried out no later than six hours, in rural areas - twelve hours after hospitalization of the patient;
5) if a patient with typhoid fever or paratyphoid fever is identified in a medical organization, after isolating the patient in the premises where he was located, final disinfection is carried out by the personnel of this organization.
Typhoid fever, paratyphoid fevers A and B are infectious diseases. They are similar in clinical manifestations and pathogenesis and are caused by typhoid or paratyphoid bacillus. These diseases are accompanied by a temperature reaction, severe condition, enlargement of the liver and spleen, digestive disorders, damage to the lymphatic system, and often a roseolous rash.
Etiology
The causative agents of typhoid fever and paratyphoid fevers A and B belong to the Salmonella group, a family of intestinal bacteria.
Typhoparatyphoid bacteria can persist in soil and water from several days to several months.
They are also well preserved and multiply in foods such as minced meat, cottage cheese, sour cream and jelly. Well tolerated low temperatures, but are easily destroyed when exposed to high temperatures (at 100 °C - instantly).
Epidemiology
The source of infection is a sick person or a bacteria carrier.
The pathogen is found in the patient's feces, saliva and urine. There is an oral-fecal route of transmission.
The massive nature of outbreaks occurs when consuming food products in which typhoid paratyphoid infection persists for a long time and multiplies well.
The peak incidence occurs in the summer-autumn period.
The pathogenesis of typhoid fever is clearly shown in Table. 1.
Table 1
Pathogenesis of typhoid fever
Main clinical symptoms
There are 4 periods of the disease: initial, peak period, development of the disease and recovery.
The incubation period lasts from 7 to 23 days, and on average is 10–14 days.
The disease begins gradually with the appearance of weakness, general malaise, weakness throughout the body, headaches and loss of appetite. This period (prodrome) lasts from several hours to several days, then the actual period of illness begins. Characteristic is a stepwise increase in temperature, which reaches 38–39 °C by the 4th–5th day of illness, and remains at this level for several days.
Already from the first days of the disease, general weakness, indifference to everything around, apathy and adynamia are noted, as well as loss of appetite and disturbed sleep. Main complaints: headache, insomnia and lack of appetite.
The patient’s appearance is also characteristic: an indifferent look, pallor skin and mucous membranes, and intoxication increases every day.
Very characteristic symptom is a roseola rash that appears on the 8th–10th day of illness and is localized on the abdomen, chest, and back in the form of pink spots with a diameter of up to 3 mm. When pressed they disappear. Typhoid bacteria are located in the center of roseola, and acute inflammatory allergic changes form around it. With the appearance of roseola, the peak period begins. Usually, in the first 6–7 days from the onset of the disease, a characteristic appearance of the tongue is noted: it is enlarged, swollen, difficult to fit into the oral cavity, and tooth marks are visible along the edges. The tongue is usually coated with a dirty gray coating. Later it becomes dry, and the plaque acquires a brown tint, and sometimes cracks appear in the mucous membrane. The abdomen is swollen due to gas formation. There is pain in the right iliac region. Stool may be retained, and sometimes there is loose stool resembling pea soup. From 4–5 days the spleen begins to be palpated, and then an enlargement of the liver is observed.
If untreated, the febrile period lasts from 2 to 5 weeks. The temperature curve reflects the beginning, height and extinction of the pathological process. The temperature decreases gradually over 3–4 days, and sometimes decreases in steps, after which recovery begins.
Complications of typhoid fever are often pneumonia; thrombophlebitis may occur on days 16–20. Perforation of an intestinal ulcer, accompanied by peritonitis, is especially dangerous.
Diagnostics
Recognition of typhoid fever is based on clinical symptoms taking into account epidemiological data (the presence of diseases in a given locality).
For typhoparatyphoid diseases, diagnosis in the first 5–7 days of illness is important.
Laboratory methods used are bacteriological and serological. The pathogen is isolated from the blood in the 2nd week from the onset of the disease, from the feces - in the 2-3rd week, and throughout the entire disease - from the duodenal contents. In addition, it can be isolated from scrapings of roseolae, bone marrow, pus and sputum.
During the entire febrile period, blood for blood culture is taken sterilely from a vein in an amount of 5–10 ml, followed by inoculation on bile broth or Rappoport medium.
To obtain copro and urine cultures, sowing is carried out on Ploskirev’s medium.
As a serological diagnosis, from the 5th to 7th day, a PHRA study is performed with erythrocyte diagnostics (O-, H-, Vi-antigens).
Much depends on proper care, including complete rest and sufficient influx fresh air. Skin where it happens highest pressure(on the shoulder blades, buttocks and sacrum), it is necessary to wipe with alcohol. In addition, care should be taken to care for the oral mucosa and skin.
Bed rest is prescribed until the 7th day of normal temperature, after which it is allowed to sit, and from the 11th day of this condition it is allowed to walk.
In the acute period, table 4 or 4b is prescribed.
Of the medications, the most effective is chloramphenicol, which is prescribed during the fever period and the first 10 days of normal temperature at 0.5 mg 4 times a day. And if it is intolerant, ampicillin is prescribed.
In case of perforation of the intestinal wall, surgical intervention is necessary. And in case of severe intoxication, it is recommended to administer hemodez and rheopolyglucin.
Activities in the outbreak
Isolation of contacts is not carried out; they are under medical observation for 21 days with thermometry, a one-time test of stool for typhus, and a blood test in the RPGA. In addition, triple phaging is prescribed.
Specific prevention of typhoid fever is carried out by epidemic indications in areas disadvantaged by typhoid fever, starting from the age of 7. It is also prescribed to persons traveling to Asian and African countries with high level morbidity and workers of infectious diseases hospitals and bacteriological laboratories.
Admission to the team
Convalescents of typhoid and paratyphoid fever are allowed into the team without additional examination, except for workers of food enterprises and persons equivalent to them, who are not allowed to work for 1 month, during which five times the examination of feces and urine is carried out.
If bacilli are excreted, they are not allowed to work. In this case, for another 3 months, their stool and urine are examined five times with an interval of 1–2 days and bile once. If the result is negative, they are allowed to work in their specialty with a monthly bacteriological examination for 2 months and a one-time bile test and RPGA.
Preschool children who carry bacteria are sent for inpatient examination.
Monitoring those who have been ill
Those who have recovered from the disease are observed for 3 months; in the first 2 months, medical examinations and thermometry are carried out weekly, in the 3rd month – once every 2 weeks. Bacteriological examination is performed monthly, bile examination - after 3 months simultaneously with the staging of RPGA.
If the result is negative, those who have recovered from the disease are removed from the register, and if the result is positive, they are treated and further examined. Food facility workers are monitored for 2 years and examined quarterly, and then 2 times a year.
Other salmonella infections
Other Salmonella infections – acute intestinal infections, which are caused by various types of microbes from the genus Salmonella and occur typhoid-like in the form of acute and protracted gastrointestinal diseases and by type of generalized forms.
The Salmonella group contains over 600 types, which are divided into 3 groups:
– Group I causes typhoid fever;
– Group II causes disease in both humans and animals;
– Group III consists of pathogens isolated from reptiles and turtles; the disease is rarely caused in humans.
Salmonella is well preserved in dairy and meat products.
Epidemiology and pathogenesis
The source of salmonella infection is sick people and animals. The pathogen is excreted in urine, feces and milk and is observed in cats, dogs, rodents and many species of wild animals. Birds can also be a source of infection (when eating their meat, entrails and eggs).
The main route of transmission is food. Having reached the intestines, microorganisms cause a local inflammatory process, then they penetrate into lymphatic system, and in severe cases - into the bloodstream. Intoxication with salmonellosis occurs under the influence of endotoxin. When salmonella enters the internal organs, purulent foci can form.
There are gastrointestinal (gastritis, gastroenteritis, gastroenterocolitis, etc.) and generalized forms (typhoid-like and septic).
The course of the disease can be acute or chronic (more than 3 months).
Main clinical symptoms
The gastrointestinal form is characterized by increased temperature, pain in the epigastric region, symptoms of intoxication, and loose and watery stools of a dark green color.
With enterocolitis, long-term severe toxicosis, exicosis and intestinal dysfunction are observed.
The generalized form is characterized by an acute onset with the appearance of headache, fever, delirium and motor agitation. When examining the patient, pallor, a thickened, densely coated tongue, enlarged liver and spleen, roseola rash and enteric stool are noted.
The septic form is characterized by a severe condition, prolonged hectic fever, jaundice, chills and embolism of capillaries on the skin. The remaining symptoms are associated with the location of the purulent focus.
Complications may include vascular collapse, hypovolemic shock, acute cardiac and renal failure, purulent erythritis, endocarditis, abscesses of the brain, spleen and liver, as well as peritonitis and pneumonia.
Diagnostics
The final diagnosis is made on the basis of clinical symptoms, epidemiological history and bacteriological and serological examination methods.
In the first days of the disease, stool examinations are carried out three times, preferably before the start of etiotropic therapy. In addition, food debris, vomit and gastric lavage are subjected to bacteriological examination. If you suspect septic condition Blood (from the first days) and urine (from the 2nd week) are examined for bile broth or media for enterobacteria.
At intervals of 7–10 days, the agglutination reaction and the indirect hemagglutination reaction are determined.
For salmonellosis, the main thing is pathogenetic therapy, which includes detoxification agents, normalization of water-salt metabolism and other symptomatic agents.
Activities in the outbreak
Isolation of contacts is not carried out; they are under medical observation for 7 days to identify repeated diseases in the hearth. Children preschool institutions and catering department employees are subject to a one-time bacteriological examination. And in case of group diseases, all groups are examined.
In the event of a nosocomial outbreak, the patient is hospitalized, admission of patients to this department is stopped for 7 days, and contacts are examined once.
If several cases appear in the department and positive swabs for salmonella, the department is closed.
Admission to the team
Children are not allowed into nurseries and orphanages for 15 days after discharge from the hospital; they undergo three bacteriological examinations every 1–2 days. The same is prescribed for food service workers.
Dispensary observation
It is carried out for 3 months in relation to catering workers, children under 2 years old and preschoolers. They are examined monthly for salmonellosis.
Prevention
Held specific prevention, which consists of administering a polyvalent bacteriophage to contact.
Shigellosis
Shigellosis (dysentery) is an infectious disease caused by dysentery bacilli of the genus Shigella, which occurs with damage to the mucous membrane of the large intestine, intoxication and frequent mucous, purulent, bloody stools, accompanied by tenesmus.
Etiology and pathogenesis
There are 4 groups of Shigella: – Group I of 7 types (Grigorieva – Shiga and 5 representatives of the Laraj – Sachs subgroup);
– Group II (Shigella Flexner) 6 types and 2 subtypes;
– Group III (Shigella boydi) 15 types;
– IV group – 1 type with 2 options.
The highest pathogenicity is observed in Shigella Grigoriev-Shiga, associated with the presence of enterotoxin and neurotoxin.
Dairy products are a favorable environment for dysentery microbes. They tolerate drying well, but quickly die under the influence of direct sun rays and heating. Disinfectants usually kill dysentery bacteria within minutes.
The source of infection is a sick person; there are oral-fecal, food and contact-household transmission routes (through hands, household items, water or food). Dysentery most often affects preschool children. A higher incidence is observed in the autumn-summer period. When entering the body, a certain number of bacteria die in the gastrointestinal tract, and the remaining ones reach the middle layer of the mucous membrane of the large intestine and cause symptoms of colitis, accompanied by the appearance of superficial erosions on it. The pathogen and its toxins, when affecting the cells of the mucous membrane, promote the release of biologically active substances, which increase the degree of the inflammatory process and lead to intestinal dysfunction.
In the case of severe dysentery, the phenomena of toxicosis and exicosis occur.
The severity of the disease is determined by the type of pathogen.
Main clinical symptoms
The incubation period lasts from 1 day to 7 days. Dysentery can be acute or chronic. There are 4 periods during the course of the disease: initial, peak, extinction of symptoms and recovery (or transition to a chronic form).
Usually there is an acute onset of the disease with fever, intoxication and abdominal pain (mainly on the right). Subsequently, tenesmus appears - painful nagging pain. On palpation, a spasmodic colon is noted. The frequency of stool can reach 20 times a day with a small amount of feces. At first the stool is copious, but then it consists of clear mucus with the appearance of blood. Severe clinical manifestations last 1–1.5 weeks. The severe form is characterized by a violent onset with high temperature and intoxication, loss of consciousness may occur, convulsive syndrome. Facial features become sharpened, infection of the scleral vessels and frequent stools, sometimes mixed with blood and pus, are noted. There are also erased forms of dysentery. The acute form can also become chronic, in which periods of remission and exacerbation alternate.
Complications: toxic-infectious shock and exacerbation of pre-existing diseases.
Diagnostics
Based on clinical data and results of laboratory bacteriological examination of the patient. In the first 3 days, a three-fold study is carried out to identify the pathogen.
The first examination is performed before prescribing antibacterial therapy. From the 2nd week of the disease, a serological method is used - the indirect hemagglutination reaction (IRHA), which determines the increase in titers above 1: 200 during the height of the disease.
Mandatory hospitalization for severe forms of children under 3 years of age, as well as catering workers and dormitory residents.
Treatment is carried out with antibiotics, sulfonamide drugs, nitrofuran derivatives, furazolidone, furadolin are prescribed 0.1 g 4 times a day for 6–7 days.
Antibiotics are prescribed ampicillin 1 g 4–6 times a day or chloramphenicol 0.5 g 4 times a day for 5–7 days. During antibacterial therapy, lactobacterin, colibacterin, and bificol are used to prevent dysbacteriosis for 4–6 weeks.
Of the sulfonamide drugs, sulfadimethoxine is prescribed according to the regimen: 1st day - 2 g, 1 g on days 2-3.
In addition, antispasmodics, antihistamines, enzymes (pepsin, pancreatin, etc.), vitamins and adsorbents, as well as herbal remedies based on herbs such as St. John's wort, bird cherry, blueberry and burnet are used.
At severe course Isotopic and colloidal solutions are used intravenously (Trisol, Acesol, hemodez, reopoliglyukin, etc.).
Activities in the outbreak
Contacts are not isolated; they are under medical observation for 7 days. Children attending child care institutions, catering workers and persons equivalent to them are subject to a one-time examination.
If several cases occur, all contacts are examined.
Discharge from the hospital is carried out after clinical recovery and a single bacteriological examination 3 days after the end of treatment.
Clinical examination
Preschoolers attending children's institutions are observed for 1 month with a single study at the end of the month. For patients with chronic dysentery, bacteria carriers and persons with unstable stools, observation is established for 3 months.
Employees of food enterprises with chronic dysentery are observed for 6 months with a monthly bacteriological examination and only after this period can they be allowed to work in their specialty.
Prevention
Specific prevention is carried out, which consists of the use of a polyvalent specific bacteriophage in preschool institutions that are disadvantaged in terms of morbidity.
17. All patients who have had typhoid fever and paratyphoid fever after discharge from the hospital are subject to medical supervision with thermometry once every 2 weeks. 10 days after discharge from the hospital, examination of convalescents for bacterial carriage begins, for which feces and urine are examined five times with an interval of at least 2 days. A single bacteriological examination of feces and urine is carried out monthly for 3 months.
If the result of a bacteriological examination is positive within 3 months after discharge from the hospital, the subject is regarded as an acute carrier.
In the fourth month of observation, bile and blood serum are bacteriologically examined in a direct hemagglutination reaction with cysteine. If the results of all studies are negative, the patient is removed from treatment. dispensary observation.
If the result of a serological test is positive, a five-fold bacteriological study of feces and urine is performed. In case of negative results, remain under observation for 1 year.
1 year after discharge from the hospital, stool and urine and blood serum are examined once bacteriologically in a direct hemagglutination reaction with cysteine. If the test results are negative, the patient is removed from dispensary observation.
18. After being discharged from the hospital, those who have been ill and belong to the maternity leave are suspended from work for 1 month, where they may pose an epidemic danger. During this period, they are carried out five times bacteriological examination (examination of feces and urine).
If the test results are negative, they are allowed to work, and over the next two months, bile and blood serum are examined monthly using a direct hemagglutination reaction with cysteine. Then they are examined quarterly for two years, and subsequently throughout their working career 2 times a year (stool and urine are examined).
If the result is positive (1 month after recovery), they are transferred to work unrelated to food products and water. After three months, bacteriological examination of feces and urine is carried out five times and bile once. If the result is negative, they are allowed to work and examined like the previous group.
If the result of direct hemagglutination reaction with cysteine is positive, a five-fold additional study of feces and urine is performed, and if the results are negative, a single study of bile is performed. If the result is negative, they are allowed to work. If, during any examination carried out three months after recovery, typhoid or paratyphoid pathogens were isolated from such persons at least once, they are considered chronic bacteria carriers and are removed from work where they may pose an epidemic danger.
19. Among the identified carriers of typhoid and paratyphoid bacteria, the following measures are taken:
1) in transient carriers, five-fold bacteriological examination of feces and urine is carried out within three months. If the result is negative, the bile is examined once. At the end of the observation, blood serum is examined once in a direct hemagglutination reaction with cysteine. If the results of all studies are negative, by the end of the third month of observation they are removed from the register. If the results of bacteriological and serological tests are positive, they are regarded as acute carriers;
2) acute carriers are subject to medical observation with thermometry for two months after detection, and a bacteriological examination of feces and urine is carried out once every month for three months. At the end of the third month, a bacteriological examination of feces and urine is carried out - five times, bile - once, and a serological study of blood serum in a direct hemagglutination reaction with cysteine. If the results of bacteriological and serological tests are negative, the subject is removed from dispensary observation. If the result of a serological study is positive and the results of a bacteriological study of feces and urine are negative, observation is continued for 1 year. After 1 year, it is necessary to examine feces and urine with cysteine once, and feces and urine - bacteriologically, once. If the result of a serological test is positive, feces and urine are examined five times, bile once. If the test results are negative, the subject is removed from dispensary observation. If the result is positive, the subject is regarded as a chronic carrier;
3) chronic carriers are registered with the territorial body of the sanitary-epidemiological service, the procedure for their examination during their lifetime is determined by the epidemiologist. They are taught the rules for preparing disinfectant solutions, ongoing disinfection, and proper hygienic behavior;
4) carriers from among the decreed contingent are permanently registered with the territorial body of the sanitary and epidemiological service. During the first month of observation, they are removed from work, where they may pose an epidemic danger. If after a month the excretion of the pathogen continues, the subjects are suspended from work for another 2 months. After three months, if the results of the bacteriological examination are negative, they are allowed to return to work. If the bacteriological test results are positive, they are regarded as chronic carriers and are not allowed to work, where they may pose an epidemic danger.
20. In cases of detection of chronic bacterial carriage in one of the family members of workers in the food processing industry, food trade, public catering and other designated contingent, the latter are not suspended from work and are not subject to special observation.
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