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UDC 616.34-002.1-053.2-07-08
SYNDROME OF HEMORRHAGIC COLITIS BY ACUTE INTESTINAL INFECTIONS IN CHILDREN: CLINICAL AND LABORATORY CHARACTERISTICS
Altai State Medical University, Barnaul Municipal hospital №12, Barnaul
I.V. Ivanov, O.S. Sidorova, G.M. Filippova, O.Ye. Yefimenko, A.M. Masneva
There were examined 94 children with acute intestinal infections with developing hemorrhagic colitis. Hemorrhagic colitis syndrome developed primarily in children at the age under 4 years (61%). The main etiological agents of hemorrhagic colitis were salmonella and campylobacteriae (47% in each case), in single cases - Shigella, Yersinia, staphylococcus, Escherichia, Pseudomonas Aureginosa. In all patients with campilobacteriosis and in 34% of patients with salmonellosis, the etiology was determined by detection of causative agent's DNA from the stool, but no by bacteriological examination. In patients with salmonellosis, hemorrhagic colitis developed in later terms since the disease onset and had a harder response to therapy, by campilobacteriosis, on the contrary, it was characterized by earlier development and quicker reduction on the background of therapy. Cefixime, as a drug of etiotropic treatment, showed enough efficiency by campilobacteriosis, while by salmonellosis 22,7% of patients needed the second course of treatment (ceftriaxone). Key words: acute intestinal infections, hemorrhagic colitis, children.
In the etiological structure of acute intestinal infections in children, the leading position is occupied by virus diarrheas. Nevertheless, bacterial intestinal infections, such as shigellosis, salmo-nellosis, klebsiellosis, proteose, enterobacteriosis and infections causes by other opportunistic pathogenic agents, still retain their relevance [1, 2, 3].
This is explained by a number of reasons, among which is the severity of the disease course at an early age, possibility of long-term bacterial excretion [4]. The diarrhea syndrome developing by these conditions has an invasive character and can lead to hemorrhagic colitis.
Considering the etiological structure of only bacterial intestinal infections in children, there is commonly observed the reduction of shigellosis share by preserving significance of salmonellosis and potentially opportunistic microorganisms [5, 6]. While the spread of new methods of diagnostics in everyday practice allowed to determine the role of Campylobacter spp. microorganisms as a substantive cause bacterial diarrheas in children affected by hemorrhagic colitis syndrome.
The change of etiological structure of acute intestinal infections (AII) affected by hemorrhagic colitis not only reduced, but also increased the role of its differential diagnostics among the broad range of diseases of both infectious and noninfec-tious genesis.
The importance of studying clinical, epidemio-logical and laboratory characteristics of intestinal infections accompanied by hemorrhagic colitis is still present.
Objective: to study clinical and laboratory characteristics of hemorrhagic colitis syndrome developed in children with acute intestinal infections.
Materials and methods
The current research presents the analysis of AII course in 94 children at the age from 1 month to 14 years being hospitalized to the infectious disease department of FSBHI "Municipal hospital №12, Barnaul" in 2016. The inclusion criteria was the development of hemorrhagic colitis.
The study included the following methods:
1. General laboratory tests - general blood analysis, general urine analysis, coprogram.
2. Biochemical tests - serum electrolytes, urine ketones.
3. Bacteriological fecal tests for obligate and opportunistic pathogenic microflora.
4. Polymerase chain reaction for detection of RNA od rotaviruses, noroviruses and astrovirus-es and DNA of salmonella and campylobacteriae.
5. Microscopic investigation of fecal matter for detection of protozoans.
6. The statistical analysis was performed by means of Biostat 2009 Professional data analysis package.
To estimate the statistical significance of the differences there was used Mann-Whitney U test.
Results and discussion
The age structure of patients in the clinical picture of intestinal infection with developing hemor-rhagic colitis is presented in Diagram 1.
According to Diagram 1, the development of hemorrhagic colitis was more often registered in infants and young children (61%) in comparison with the older children.
The number of boys among the examined patients - 48, girls - 46.
The etiological structure of intestinal infections affected by hemorrhagic colitis in the studied children is presented in Diagram 2.
Diagram 1
Age structure of examined patients (%)
■ under 1 year ■ 1-3 years □ 4-6 years ■ 7-14 years
Diagram 2
Etiology of hemorrhagic colitis in examined patients (%)
■ salmonella
■ campylobacteriae □ shigella
■ others
According to Diagram 2, the main causes of hemorrhagic colitis development in children were salmonella and campylobacteriae (47% of children in each case). Rather rarely the cause of intestinal infection was shigella (only 2%). Among other infection agents causing hemorrhagic colitis in single patients were Yersinia, staphylococcus, Escherichia, Pseudomonas Aureginosa (1% each respectively). In 63% of patients, the local syndrome was presented by enterocolitis, in 37% - gastroenterocolitis.
Taking into account the small number of patients with shigella, Yersinia, staphylococcus, Esch-erichia and Pseudomonas Aureginosa as a causative agent of hemorrhagic colitis, a more detailed analysis was performed only for salmonellosis and campilobacteriosis.
In all patients with campilobacteriosis and 34% of patients with salmonellosis, the diagnosis was established on the basis of DNA detection from the stool by means of PCR, but not on the basis of conventionally used bacteriological methods of examination.
Salmonellosis proceeding in children with hemorrhagic colitis in 48% of patients was associated with rotavirus. By campilobacterious hemorrhagic colitis, such association was registered not more than in 16% of cases.
On the basis of concomitant pathology, there was noticed high frequency of anemia development - 41%, moreover, on the background of campilobacteriosis, it developed 1,6 times often-er than by salmonellosis *25% and 16% respectively, the difference is statistically significant, P(0,001).
Nearly three quarters of children (74,5%) were admitted to hospital during first three days of the disease. The average term of disease duration for the moment of admission constituted 3,2 ± 0,3 days. In all children intestinal infection proceeded in moderate form.
Hemorrhagic colitis manifestations by the moment of hospital admission were registered in 42 children (44,7%), while by campilobacteriosis it took place in 64% of children, by salmonellosis - only in 29,5% of children. It would be interesting to analyze the terms of hemorrhagic colitis development according to the days of illness, which is presented in Diagram 3.
The data of Diagram 3 demonstrate, that intensive formation of hemorrhagic colitis in patients with campilobacteriosis occurred on the 2nd-3rd day of illness, by the 4th day this syndrome was present already in 73% of patients. By salmonellosis the occurrence of hemorrhagic colitis syndrome was observed in later terms, primarily after the 5th day of illness.
Manifestations of hemorrhagic colitis had a moderately expressed character and were characterized by the presence of mucus and blood streaks in the fecal matter. Coprological examination revealed the presence of mucus, erythrocytes and increased concentration of leucocytes in all children.
The intensity of diarrhea syndrome at the ambulatory stage (frequency of defecation per day) by campilobacteriosis constituted 9,6±0,7, by salmonellosis - 7,3±0,7 (the difference is statistically significant, P<0,001). On the contrary, during the hospital treatment its manifestations were opposite: diarrhea syndrome was more intensive by salmonellosis - 12,7±1,1 defecation events, against 9,3±0,7 events by campilobacteriosis.
The duration of hemorrhagic colitis at the hospital stage of treatment constituted aver-agely 2,4 ± 0,1 days. In spite of the similar duration of hemorrhagic colitis in patients with salmonello-sis and campilobacteriosis, the dynamics of its reduction on the background of the conducted antibacterial therapy turned out to be different, which is presented in Diagram 4. Hemorrhagic colitis was reduced slower in patients with salmonellosis than in patients with campilobacteriosis. The data of Diagram 4 show, that already in 3 days after the conducted antibacterial therapy, by campilobacteriosis
it retained only it 20% of patients, while by salmonellosis - in 50%, in 4 days - 7% and 27% respectively (the difference during these days is statistically significant, P<0,001).
The total duration of diarrhea syndrome constituted 5,7±0,4 days by salmonellosis and 4,2±0,3 days by campilobacteriosis (the difference is statistically significant, P<0,001).
Terms of hemorrhagic colitis development according to etiology
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Diagram 3
(lav of illness
■salmonellosis
- campilobacteriosis
Reduction of hemorrhagic colitis in relation to the duration of antibacterial treatment
Diagram 4
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The general infectious syndrome was manifested in patients in the temperature rise, loss of appetite, reduction of physical activity, disturbance of sleep. The temperature rise was registered practically in all patients (94,7%). Its degree constituted 38,7 ± 0,1°C irrespective of the etiology of the intestinal infection. The duration of temperature response in patients with salmonellosis constituted 4,4 ± 0,3 days, while by campilobacteriosis - 3,7 ± 0,2 days (the difference is statistically significant, P<0,001).
3 4 5
day of treatment
■ campilobacteriosis
The general blood analysis at the acute stage of the disease in patients with salmonellosis showed leukocytosis in 61,4% patients, neutrocy-tosis - 54,5%, ESR boost - 20,4%, by campilobacteriosis the same indexes were registered with a different frequency: 34,1% - 38,8% - 9,0% respectively (the difference is statistically significant for all indexes, P<0,001).
The etiotropic treatment in children included cefixime as a starting drug, moreover, by campi-lobacteriosis treatment the change of antibiotic
treatment and administration of the second course of etiotropic therapy (ceftriaxone) was required only in 9% of patients, while by salmonellosis the same changes took place in 22,7% of cases (the difference is statistically significant, P<0,001).
The pathogenic therapy included oral, enteral (diosmectit octahedral) and infusion detoxication. According to the indications, the patients received enzymes (creon), probiotics (saccharomyces bou-lardii).
The average bed day by campilobacteriosis constituted 5,5±0,2 days, by salmonellosis - 7,2±0,5 days.
Conclusion
1. The main etiological factors of intestinal infections affected by hemorrhagic colitis syndrome in children at the current stage are salmonella and campylobacteria.
2. The hemorrhagic colitis syndrome develops primarily in children at the age under 4 years, the rational antibacterial therapy allows to reduce it not later than the 4th day of treatment.
3. In patients with salmonellosis, hemorrhag-ic colitis developed at later stages since the disease onset and had a harder response to therapy, by campilobacteriosis, on the contrary, it was characterized by earlier development and quicker reduction on the background of therapy.
4. Parallel use of bacteriological examination and methods of agent's DNA detection allows to improve the etiological diagnostics of intestinal infections.
5. Cefixime, which had shown high efficiency, is recommended as an etiotropic means by treatment of acute intestinal infections in children affected by hemorrhagic colitis.
References
1. Kessayeva I.K., et al. Informational value of fecal calprotectin in acute intestinal infections diagnostics in children. Fundamental research. 2015; 1: 87-91. Available at: https://fundamental-research.ru/ru/article/ view?id=36773. Accessed March 6, 2017.
2. Rettabi El Kbir. Modern clinical and epidemi-ological peculiarities of invasive diarrheas in children and improvement of their treatment [extended abstract of dissertation]. Perm, 2004.
3. Chashchina S.Ye., Startseva Ye.V. Entero-sorption therapy of acute intestinal infections with invasive diarrhea in children of early age. Lechashchy vrach. 2014; Available at: www.lvrach.ru https://www.lvrach. ru/2014/01/ 15435868/. Accessed March 7, 2017.
4. Menzairov V.F., et al. The structure of severe forms of acute intestinal infections in children. I All-Russian annual congress on infectious diseases. Moscow, 2009.
5. Khayertynov Kh.S., Semenova D.R., Sush-nikov K.V. Clinical and epidemiological features of acute intestinal infections with hemorrhagic colitis in children. Kazan Medical Journal. 2013; 94(2): 208-211.
6. Tikhomirova O.V., et al. Implementation of peroral from of cephalosporin III in the therapy of bacterial intestinal infections in children. Consilium-medicum. 2006; 8(2). Available at: http://old.consilium-medi-cum.com/ media/pediatr/ 06_02/68.shtml. Accessed on March 7, 2017.
7. Khaliulina S.V. Modeern principles of diagnostics and treatment of acute intestinal infections in children. [extended abstract of dissertation]. Kazan, 2016.
Contacts:
Corresponding author - Ivanov Igor Valeryevich, Candidate of Medical Sciences, Associate Professor of the Department of pediatrics with the course of further vocational education of the FSBEI HE Altai State Medical University of the Ministry of Health of the Russian Federation, Barnaul. 656038, Barnaul, Lenina Prospekt, 40. Tel.: (3852) 566868. Email: opus07tv@gmail.com
