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15.04.2019

Dysentery. Clinical examination of patients with acute intestinal infections (AI)

SHIGELLOSIS (DYSENTERY)

Dysentery – anthroponotic infectious disease, characterized by predominant damage to the distal part of the large intestine and manifested by intoxication, frequent and painful defecation, loose stools, in some cases with mucus and blood.

Etiology. The causative agents of dysentery belong to the genus Shigella families Enterobacteriaceae. Shigella are gram-negative bacteria 2-4 microns long, 0.5-0.8 microns wide, non-motile, do not form spores or capsules. Shigella is divided into 4 subgroups - A, B, C, D, which correspond to 4 types - S. dysenteriae, S. flexneri, S. boydii, S. sonnei. In the population S. dysenteriae 12 serological variants are identified (1-12); population S. flexneri divided into 8 serovars (1-5, 6, X, Y-variants), while the first 5 serovars are divided into subserovars ( 1 a, 1 b, 2 a, 2 b, 3 a, 3 b, 4 a, 4 b, 5 a, 5 b); population S. boydii differentiates into 18 serovars (1-18). S. sonnei do not have serovars, but they can be divided into a number of types according to biochemical properties, relation to typical phages, ability to produce colicins, and resistance to antibiotics. The dominant position in the etiology of dysentery is occupied by S. sonnei And S. flexneri 2 a.

The causative agents of the main etiological forms of dysentery have unequal virulence. The most virulent are S. dysenteriae 1 (pathogens of Grigoriev-Shiga dysentery), which produce a neurotoxin. The infectious dose of Shigella Grigoriev-Shiga is tens of microbial cells. Infectious dose S. flexneri 2 a, which caused disease in 25% of infected volunteers, amounted to 180 microbial cells. Virulence S. sonnei significantly lower - the infectious dose of these microorganisms is at least 10 7 microbial cells. However S. sonnei have a number of properties that compensate for the deficiency of virulence (higher resistance during external environment, increased antagonistic activity, more often produce colicins, greater resistance to antibiotics, etc.).

Shigella (S. sonnei, S. flexneri) are relatively stable in the external environment and remain viable in tap water for up to one month, in waste water for 1.5 months, in moist soil for 3 months, in food products for several weeks. Shigella Grigoriev-Shiga are characterized by less resistance.

The causative agents of dysentery die within 10 minutes at a temperature of 60°C, and instantly when boiled. Disinfectant solutions in normal working concentrations (1% chloramine solution, 1% phenol solution) have a detrimental effect on these pathogens.

Source of infection. Sources of infection are patients with acute forms, convalescents, as well as patients with protracted forms and bacteria carriers. In the structure of sources of infection in Sonne dysentery, 90% are in patients with the acute form, in whom in 70-80% of cases the disease occurs in a mild or erased form. Convalescents account for 1.5-3.0% of infections, patients with protracted forms - 0.6-3.3%, persons with subclinical forms - 4.3-4.8%. In Flexner's dysentery, the leading role in the structure of sources of infection also belongs to patients with acute forms, however, with this form of dysentery, the importance of convalescents (12%), patients with protracted and chronic forms (6-7%), and persons with subclinical infection (15%) increases. .

The period of infectiousness of patients corresponds to the period of clinical manifestations. Maximum infectivity is observed in the first 5 days of illness. In the vast majority of patients with acute dysentery, as a result of treatment, the release of pathogens stops in the first week and only occasionally continues for 2-3 weeks. Convalescents release pathogens until the restoration of the colon mucosa is completed. In some cases (up to 3% of cases), carriage can continue for several months. The tendency to a protracted course is more typical for Flexner's dysentery and less so for Sonne's dysentery.

Incubation period– is 1-7 days, on average 2-3 days.

Transmission mechanism– fecal-oral.

Pathways and factors of transmission. Transmission factors are food products, water, household items. In the summer, the “fly” factor is important. A certain relationship has been established between transmission factors and etiological forms of dysentery. In Grigoriev-Shiga dysentery, the leading factors in the transmission of Shigella are household items. S. flexneri transmitted mainly through the water factor. Dietary factor plays a major role in the spread S. sonnei. As transmission factors S. sonnei, the main place is occupied by milk, sour cream, cottage cheese, kefir.

Susceptibility and immunity. The human population is heterogeneous in susceptibility to dysentery, which is associated with factors of general and local immunity, frequency of infection with Shigella, age and other factors. Factors of general immunity include serum antibodies of the classes IgA, IgM, IgG. Local immunity associated with the production of secretory immunoglobulins of the class A (IgA s ) and plays a major role in protection against infection. Local immunity is relatively short-lived and after an illness provides immunity to re-infections for 2-3 months.

Manifestations of the epidemic process. Dysentery is widespread. IN last years in Belarus, the incidence of Sonne's dysentery ranges from 3.0 to 32.7, Flexner's dysentery - from 14.1 to 34.9 per 100,000 population. Most cases of dysentery are classified as sporadic; outbreaks in different years account for no more than 5-15% of diseases. Risk time– periods of ups and downs with Sonne’s dysentery alternate at intervals of 2-3 years, with Flexner’s dysentery the intervals are 8-9 years; the incidence of dysentery increases in the warm season; in the structure of causes leading to morbidity, seasonal factors account for 44 to 85% of annual morbidity rates; In cities, two seasonal increases in the incidence of dysentery are often detected - summer and autumn-winter. At-risk groups– children aged 1-2 years and 3-6 years attending preschool institutions. Territories at risk– the incidence of dysentery in the urban population is 2-3 higher than in the rural population.

Risk factors. Lack of conditions for fulfilling hygienic requirements, insufficient level of hygienic knowledge and skills, violation of hygienic and technological standards at epidemically significant facilities, reorganization of preschool institutions.

Prevention. In the prevention of dysentery, measures aimed at breaking the transmission mechanism occupy a leading place. First of all, these are sanitary and hygienic measures arising from the results of a retrospective epidemiological analysis to neutralize the spread of Shigella through milk and dairy products. An important section of sanitary and hygienic measures is to provide the population with good quality and epidemically safe drinking water. Compliance with sanitary standards and rules at enterprises Food Industry and public catering, as well as in preschool institutions, makes a significant contribution to the prevention of dysentery. The disruption of the fecal-oral transmission mechanism of Shigella is facilitated by disinfestation measures aimed at destroying flies, as well as preventive disinfection at epidemically significant objects.

Considering the significant contribution of seasonal factors to the formation of the incidence of dysentery, advance measures should be taken to neutralize them.

Anti-epidemic measures- Table 1.

Table 1

Anti-epidemic measures in areas of dysentery

Event name

1. Measures aimed at the source of infection

Revealing

Carried out:

    when seeking medical help;

    during medical examinations and when observing persons who interacted with patients;

    in the event of an epidemic problem related to the acute respiratory infection in a given territory or facility, extraordinary bacteriological examinations of decreed contingents may be carried out (the need for them, frequency and volume is determined by the specialists of the Center for State Examination);

    among children of preschool institutions, orphanages, boarding schools, summer health institutions during examination before registration in this institution and bacteriological examination in the presence of epidemic or clinical indications; when receiving children returning to the listed institutions after any illness or long-term (3 days or more excluding weekends) absence (reception is carried out only if there is a certificate from the local doctor or from the hospital indicating the diagnosis of the disease);

    when a child is admitted to the preschool in the morning (parents are surveyed about the general condition of the child, the nature of the stool; if there are complaints and clinical symptoms characteristic of OKI, the child is not admitted to the preschool, but is sent to a health care facility).

Diagnostics

It is carried out according to clinical, epidemiological data and laboratory research results.

Accounting and registration

The primary documents for recording information about the disease are: medical record of an outpatient patient (form 025u); history of the child’s development (form 112 y), medical record (form 026 y). The case of the disease is registered in the infectious diseases register (form 060 y).

Emergency notification to the Center for State Examination

Patients with dysentery are subject to individual registration in territorial CSE. Doctor who registered case of illness, sends an emergency notification to the Central State Examination Center (f. 058u): primary - orally, by telephone in the city in the first 12 hours, in rural areas - 24 hours, final - in writing, after a differential diagnosis has been carried out and the results of a bacteriological or serological study have been received, no later than 24 hours from the moment of their receipt.

Insulation

Hospitalization in an infectious diseases hospital is carried out according to clinical and epidemic indications.

Clinical indications:

    all severe forms of infection, regardless of the patient’s age;

    moderate forms in children early age and in persons over 60 years of age with a burdened premorbid background;

    diseases in persons who are severely weakened and burdened with concomitant diseases;

    protracted and chronic forms of dysentery (with exacerbation).

Epidemic indications:

    if there is a threat of infection spreading at the patient’s place of residence;

    workers of food enterprises and persons equivalent to them if they are suspected of being a source of infection (mandatory for a full clinical examination).

Workers of food enterprises and persons equivalent to them, children attending preschool institutions, boarding schools and summer health institutions are discharged from the hospital after complete clinical recovery and a single negative result of a bacteriological examination carried out 1-2 days after the end of treatment. In case of a positive result of the bacteriological examination, the course of treatment is repeated.

Categories of patients not related to the above-mentioned contingent are discharged after clinical recovery. The need for bacteriological examination before discharge is decided by the attending physician.

Procedure for admission to organized teams and work

Employees of food enterprises and persons equivalent to them are allowed to work, and children attending kindergartens, brought up in orphanages, orphanages, boarding schools, vacationing in summer health institutions, are allowed to visit these institutions immediately after discharge from hospital or treatment for home on the basis of a certificate of recovery and in the presence of a negative result of a bacteriological analysis. Additional bacteriological examination is not carried out in this case.

Food workers and persons equivalent to them, with positive results of a control bacteriological examination carried out after a second course of treatment, are transferred to another job not related to the production, storage, transportation and sale of food and water supply (until recovery). If their isolation of the pathogen continues for more than three months after the illness, then they, as chronic carriers, are transferred for life to work unrelated to food and water supply, and if transfer is impossible, they are suspended from work with the payment of social insurance benefits.

Children who have suffered an exacerbation of chronic dysentery are admitted to the children's group if their stool has normalized for at least 5 days, their general condition is good, and their temperature is normal. Bacteriological examination is carried out at the discretion of the attending physician.

Dispensary observation

Employees of food enterprises and persons equivalent to them who have had dysentery are subject to dispensary observation for 1 month. At the end of the clinical observation, the need for a bacteriological examination is determined by the attending physician.

Children attending preschool institutions and boarding schools who have had dysentery are subject to dispensary observation for 1 month after recovery. Bacteriological examination is prescribed to them according to indications (presence of long-term unstable stool, excretion of a pathogen after a completed course of treatment, weight loss, etc.).

Food workers and persons equivalent to them, with positive results of a control bacteriological examination carried out after a second course of treatment, are subject to dispensary observation for 3 months. At the end of each month, a single bacteriological examination is carried out. The need for sigmoidoscopy and serological studies is determined by the attending physician.

Persons diagnosed with chronic dysentery are subject to dispensary observation for 6 months (from the date of diagnosis) with monthly examination and bacteriological examination.

At the end of the established period of clinical examination, the observed person is removed from the register by an infectious disease doctor or local doctor, subject to complete clinical recovery and epidemic well-being in the outbreak.

2. Activities aimed at the transmission mechanism

Current disinfection

At home, it is carried out by the patient himself or those caring for him. It is organized by the medical professional who made the diagnosis.

Sanitary and hygienic measures: the patient is isolated in a separate room or a fenced-off part of it (the patient’s room is subjected to daily wet cleaning and ventilation), contact with children is excluded, the number of objects with which the patient can come into contact is limited, personal hygiene rules are observed; provide a separate bed, towels, care items, and utensils for food and drink for the patient; Dishes and care items for the patient are stored separately from the utensils of family members. The patient's dirty linen is kept separately from the linen of family members. Maintain cleanliness in rooms and common areas. In the summer, flies are systematically controlled. In apartment foci of dysentery, it is advisable to use physical and mechanical methods disinfection, as well as use household detergents and disinfectants, soda, soap, clean rags, washing, ironing, airing, etc.

In preschool institutions, it is carried out during the maximum incubation period by staff under the supervision of a medical worker.

Final disinfection

In apartment outbreaks, after hospitalization or recovery of the patient, it is performed by his relatives using physical methods of disinfection and the use of household detergents and disinfectants. Instructions on the procedure for their use and disinfection are carried out by medical workers of health care facilities, as well as an epidemiologist or an assistant to an epidemiologist of the territorial Central State Epidemiology Center.

In kindergartens, boarding schools, orphanages, dormitories, hotels, health institutions for children and adults, nursing homes, in apartment centers where large and socially disadvantaged families live, it is carried out upon registration of each case by the CDC or by the disinfection department of the territorial Center for State Examination during the first days from the receipt of an emergency notification at the request of an epidemiologist or assistant epidemiologist. Chamber disinfection is not carried out. Various disinfectants are used - solutions of chloramine (0.5-1.0%), sulfochloranthine (0.1-0.2%), chlordesine (0.5-1.0%), hydrogen peroxide (3%), desam (0.25-0.5%), etc.

Laboratory study of the external environment

As a rule, samples of food residues, water samples and swabs from environmental objects are taken for bacteriological research.

3. Measures aimed at persons who communicated with the source of infection

Revealing

Those who communicated in the kindergarten are children who attended the same group at the approximate time of infection as the sick person, staff, catering staff, and in the apartment - those living in this apartment.

Clinical examination

It is carried out by a local doctor or an infectious disease specialist and includes a survey, assessment of general condition, examination, palpation of the intestines, and measurement of body temperature. The presence of symptoms of the disease and the date of their onset are clarified.

Collection of epidemiological anamnesis

The presence of similar diseases at the place of work/study of the sick person and their contacts is determined, and the fact that the sick person and the contacts consumed food products that are suspected as a transmission factor.

Medical observation

Set for 7 days from the moment the source of infection is isolated. In a collective center (preschool, hospital, sanatorium, school, boarding school, summer health institution, food enterprise and water supply enterprise) it is performed by a medical worker of the specified enterprise or territorial health care facility. In apartment outbreaks, “food workers” and equivalent persons, children attending kindergartens, are subject to medical supervision. It is carried out by medical workers at the place of residence of those communicating. Scope of observation: daily (in preschool education 2 times a day - morning and evening) survey about the nature of stool, examination, thermometry. The results of the observation are entered in the observation log of those who communicated, in the history of the child’s development (form. 112u), in the patient’s outpatient card (form. 025u) or in medical card child (form. 026u), and the results of observation of catering workers - to the magazine “Health”.

Regime-restrictive measures

Activities are carried out within 7 days after isolation of the patient. The admission of new and temporarily absent children to the preschool group from which the patient is isolated is stopped. It is prohibited to transfer children from this group to other groups after isolation of the patient. Communication with children of other groups is not allowed. Participation of the quarantine group in general cultural events is prohibited. Walks for the quarantine group are organized and they return from them last, group isolation is observed at the site, and food is received last.

Emergency prevention

Not carried out. You can use dysentery bacteriophage.

Laboratory examination

The need for research, its type, volume, frequency is determined by an epidemiologist or an assistant epidemiologist.

As a rule, in an organized team, a bacteriological examination of communicating persons is carried out if a child under 2 years of age, attending a nursery, an employee of a food enterprise, or an equivalent person falls ill. In apartment outbreaks, “food workers” and persons equivalent to them, children attending kindergartens, boarding schools, and summer health institutions are examined. Upon receipt of a positive result of a bacteriological examination, persons belonging to the category of “food workers” and equivalent to them are suspended from work related to food products or from visiting organized groups and sent to the clinical health center of the territorial clinic to resolve the issue of their hospitalization.

Health education

A conversation is held about the prevention of infection with intestinal pathogens.

The content of the article

Dysentery (shigellosis)- an acute infectious disease with a fecal-oral transmission mechanism, caused by various types of Shigella, characterized by symptoms of general intoxication, damage to the colon, mainly its distal part, and signs of hemorrhagic colitis. In some cases, it 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 or capsules, and grow well on ordinary nutrient media, 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 the international classification (1968), there are 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.
Pathogenicity various types Shigella is not the same. 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 dissemination 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 increases susceptibility, others chronic diseases stomach and intestines.
Like other spicy ones 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, and 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

Development mechanism pathological process for 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) to the 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 affect small vessels, causing swelling of the submucosal layer and hemorrhages. At the same time, the toxins of the pathogen 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 the 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 the case of such disorders, the excretory function is taken over by substitute (vicarious) excretory organs (skin, lungs, digestive canal). The colon bears the maximum load, which aggravates the 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 large intestine, but diffusely, along the course of the entire digestive canal, which causes 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.
Result of irritation by dysentery toxin nerve endings and nodes of the abdominal plexus are disorders of the secretion of the stomach and intestines, as well as incoordination of peristalsis of the small and especially large intestine, spasm of the inflexible 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, pus (“rectal spitting”). Changes in the intestines undergo reverse development gradually. Due to the death of part of the nerve formations of the intestines from hypoxia long time Morphological and functional abnormalities are observed that can progress.
In acute dysentery, pathomorphological changes are divided into stages according to the severity of the pathological process. Acute catarrhal inflammation - 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 neutrophil 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 during acute form diseases.
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 a polymorphism of clinical manifestations and is characterized by both local intestinal damage and general toxic manifestations. This has become widespread clinical classification dysentery.
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 some patients may experience prodromal symptoms in the form of general malaise, headache, lethargy, loss of appetite, drowsiness, and a feeling of abdominal discomfort. 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. The course of the disease is possible with low-grade fever or without increasing it.
From the first day of illness, the leading symptom complex is spastic distal hemorrhagic colitis. Paroxysmal spasmodic pain occurs in lower parts abdomen, mainly in the left iliac region. Cramping pain precedes each bowel movement. Tenesmus, typical for distal colitis, also occurs: nagging pain in otkhodniks 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 even less. The pain in the left half of the abdomen intensifies, tenesmus and false (false) urge to lower the body become more frequent, which does not result in defecation and does not provide relief. In some cases 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 defecate. 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 a 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 reveal neutrophilic leukocytosis with shift leukocyte formula to the left, monocytosis, moderate increase in ESR.
During sigmoidoscopy (colonoscopy), inflammation of the mucous membrane of the rectum and sigmoid colon is determined. varying degrees. 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 kidney failure. 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, 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 an objective examination, spasm and tenderness of the sigmoid colon, rumbling along the colon can be detected. 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 large intestine, especially its nerve 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. Death in adults it is rarely observed; 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 important role epidemiological history data play a 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 laboratory diagnostics dysentery is bacteriological, which consists of isolating a coproculture of Shigella, and with Grigoriev-Shiga dysentery, in some cases, a blood culture. It is advisable to take the material for research before the start of antibacterial therapy, repeatedly, which increases the frequency of pathogen isolation. 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, they use serological methods. 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.
The dysenterine allergy skin test (Tsuverkalov reaction) is rarely used because it does not have sufficient specificity.
Coprological examination is of auxiliary importance in establishing a diagnosis, during which mucus, pus, a large number of leukocytes, mainly neutrophils, and erythrocytes.

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, amoebiasis is characterized chronic course, lack of significant temperature response. 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.
For food poisoning 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. Feces have the appearance of rice water, signs of dehydration quickly increase, which often reaches alarming levels and causes the severity of the condition. For cholera, atypical tenesmus, abdominal pain, heat body (more often even hypothermia).
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 of inflammatory changes in the colon, blood is mixed with the feces at the end of the act of defecation. Review of otkhodniks and sigmoidoscopy help to avoid diagnostic errors.
Colitis non-infectious nature often occurs in cases of poisoning chemical compounds(“lead colitis”), with some internal medicine(cholecystitis, hypoacid gastritis), pathologies small intestine, uremia. This secondary colitis is diagnosed taking into account the underlying disease and is not contagious or seasonal.
Non-specific ulcerative colitis In most cases, it begins gradually, has a progressive long-term course, and a typical rectoromaioscopic and radiological picture. Characterized by resistance to antibacterial therapy.
Colon neoplasms in the decay stage they 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 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. Patients with mild forms of dysentery, in 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.
Great importance given to diet therapy. In the acute phase of the disease, diet No. 4 (4a) is prescribed. They recommend pureed mucous soups from vegetables, cereals, dishes from pureed meat, cottage cheese, boiled fish, wheat bread and so on. 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 antibiotics wide range actions that promote 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), sulfa drugs 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 severe forms diseases and in the treatment of young children, parenteral administration of antibiotics is advisable.
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 appointment antihistamines, 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 early diagnosis 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 been ill 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 in enterprises is important in the prevention of dysentery Catering, food industry facilities, children's preschool institutions, schools and other facilities.
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 according to 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 complete recovery, confirmed by the results of a 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 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, with the appearance of intestinal disorders during their 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 prescribed 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. Dispensary observation after past illness Only decreed groups of the population are exposed.
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. When receiving one positive result, such persons are considered as chronic bacteria carriers, and the territorial divisions 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 the end of treatment are suspended by the attending physician from attending preschool education for fifteen calendar days, during which time three stool examinations are carried out with an interval of one or two days. If the result is positive again, the same procedure for removal and examination is repeated for another fifteen days.

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 the results of serological and bacteriological examinations are negative 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 subject to 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 and paratyphoid fever 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) organizes ongoing disinfection 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.

DYSENTERY

SHIGELLOSES

Bacterial infection - most often caused by Sonne and Flexner's shigella, less often by Grigoriev-Shig and Schmitz-Stutzer. Incubation 1-7 (2-3) days. They usually occur as hemocolitis, the Sonne form also occurs as gastroenterocolitis (food infection). Accompanied by toxicosis of varying degrees with vomiting, cardiovascular disorders, and in infants - also exicosis and acidosis.

Definition - a group of anthroponotic bacterial infectious diseases with a fecal-oral transmission mechanism. It is characterized by predominant damage to the mucous membrane of the distal colon and general intoxication.

Pathogen - a group of microorganisms of the family Tnterobacteriaceae of the genus Shigella, including 4 species: 1) group A - Sh.dysenteriae, which included bacteria Sh.dysenteriae 1 - Grigoriev-Shigi, Sh.dysenteriae 2 - Stutzer-Schmitz and Sh.dysenteriae 3-7 Large - Sachs ( serovars 1-12, of which 2 and 3 are dominant); 2) group B - Sh.flexneri with subspecies Sh.flexneri 6 - Newcastle (serovars 1-5, each of which is divided into subserovars a and b, as well as serovars 6, X and Y, of which 2a, 1b and 6 dominate) ; 3) group Sh.boydii (serovars 1-18, of which 4 and 2 are dominant) and 4) group D - Sh.sonnei (biochemical variants Iie, IIg and Ia dominate). The most common types are Sonne (up to 60-80%) and Flexner.

Shigella are gram-negative, non-motile rods, facultative aerobes. Grigoriev's bacillus - Shigi produces Shigitoxin, or exotoxin, while other species produce heat-labile endotoxin. The highest infectious dose is typical for Grigoriev-Shiga bacteria. Large for Flexner bacteria and largest for Sonne bacteria. Representatives of the last two species are the most stable in the environment: on dishes and wet linen they can persist for months, in soil - up to 3 months, on food - several days, in water - up to 2 months; when heated to 60° They die after 10 minutes, when boiled - immediately, in disinfectant solutions - within a few minutes.

Reservoir and sources of pathogen: a person suffering from acute or chronic form of dysentery, as well as a convalescent or transient carrier.

Period of infectiousness of the source equal to the entire period of clinical manifestations of the disease plus the period of convalescence while the pathogen is excreted in the feces (usually from 1 to 4 weeks). Carriage sometimes lasts several months.

Pathogen transmission mechanism fecal-oral; transmission routes - water, food (transmission factors - a variety of food products, especially milk and dairy products) and household (transmission factors - hands, dishes, toys, etc. contaminated with the pathogen).

Natural sensitivity of people high. Post-infectious immunity is unstable, reinfections are possible.

Basic epidemiological signs. The disease is widespread, but the incidence predominates in developing countries among populations with unsatisfactory socio-economic and sanitary-hygienic status. Children most often fall ill during the first 3 years of life. City dwellers get sick 2-4 times more often than rural residents. Summer-autumn seasonality is typical. Outbreak morbidity is not uncommon, and in water outbreaks, Shigella Flexner predominates as the etiological agent, and in food (dairy) outbreaks, Shigella Sonne predominates.

Incubation period from 1 to 7 days, more often 2-3 days.

Main clinical signs. In typical cases (colitic form), the disease begins acutely. Cramping pain appears in the left iliac region. False urge to defecate. The stool is scanty, mucous-bloody. Body temperature can rise to 38-39° C. There is a loss of appetite, headache, dizziness, weakness, and a coated tongue. The sigmoid colon is spasmodic and painful on palpation. In atypical cases, acute dysentery occurs in the form of gastroenteritis or gastroenterocolitis with symptoms of intoxication, pain in the epigastric region, loose stools. Chronic shigellosis can occur in recurrent or protracted (continuous) forms: exacerbation usually occurs after 2-3 months. after discharge from the hospital, sometimes later - up to 6 months. Subclinical forms are usually detected only during bacteriological examinations for epidemiological indications.

Laboratory diagnostics is based on the isolation of the pathogen from feces with the establishment of its species and genus, antibiotic resistance, etc. In order to identify the dynamics of dysentery antibodies in the blood, tests are performed RSK, RPGA with paired sera, however, this reaction is of little use for early diagnostic purposes.

Dispensary observation of the ill person. Procedure and terms of dispensary observation:

Persons suffering from chronic dysentery, confirmed by the release of the pathogen, and carriers who secrete the pathogen for a long time, are subject to observation for 3 months. with a monthly examination by an infectious disease specialist at a clinic or a local doctor and a bacteriological examination. During the same period, an examination is carried out for persons who have been suffering from unstable stool for a long time;

Employees of food enterprises and persons equivalent to them, after discharge to work, remain under dispensary observation for 3 months. with a monthly examination by a doctor, as well as bacteriological examination; persons suffering from chronic dysentery are subject to dispensary observation for 6 months. with monthly bacteriological examination. After this period, with clinical recovery, they can be allowed to work in their specialty;

Persons with long-term carriage are subject to clinical trial and repeated treatment until recovery.

At the end of the observation period, the completion of research, with clinical recovery and epidemiological well-being in the environment, the observed person is removed from the register. Deregistration is carried out on commission by an infectious disease specialist at a clinic or a local doctor together with an epidemiologist. The commission's decision is recorded in a special entry in the medical documentation.
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