Theme Shigellae infections. Salmonellae infections. Escherichia infections. Yersiniosis. Rotaviral infection Theme Viral hepatitis A, B, С, d et al. Gastrointestinal infections: guidance, data and analysis
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- Bu səhifədəki naviqasiya:
- For the calculation of physiologic fluid’s requirement
- The calculation of fluid’s deficit
- The expected volume of fluid
- Concentration of ions in crystalloid solutions Concentration of the ion, mmol/l Osmolarity
- Current pathological losses
- Rehydration depends on the type of dehydration
- An isotonic rehydration
- Signs of different forms of dehydration
- Hypertonic dehydration
- Hypotonic dehydration
- Speed of infusion during the rehydration
- Antibacterial therapy Antibacterial therapy in case of invasive diarrhea
- Antibacterial therapy in case of secretory diarrhea
- Antibacterial medicines which are recommended to children in case of an acute intestinal infection of the known etology
- Antibacterial medicines dosing for children in case of acute intestinal infections Preparation Dose Number of
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The 2nd step of rehydration is supportive therapy, which correlates with the fluid losses with vomiting and emptying, that continue. Method of the 2nd step: Supportive oral rehydration means that for the next 6 hours as many solutions are entered, as the child has lost during the previous 6 hours. An acceptable volume of solution for supportive rehydration for infants and toddlers is 50-100 ml, children elder than 2 yrs – 100-200 ml or 10 ml/kg of solution after each emptying. It is possible to alternate oral rehydration solution with sugar free fruit or vegetable decoctions, or green tea during this step of rehydration. In case of vomiting, rehydration therapy is continued in 10 minutes. If the child refuses to drink or vomits repeatedly an enteral rehydration with nasogastric tube is possible in the hospital. This type of rehydration could be done continuously with a help of the tube for intravenous infusion, with a speed no more than 10 ml/min.
Oral rehydration is combined with the parenteral rehydration in case of acute intestinal infections with 3rd degree of dehydration, multiple vomiting, anorexia, if patient refuse to drink oral rehydration solutions. Solutions for parenteral rehydration: • Ringer’s lactat solution, • Ringer’s acetate solution, • Isotonic glucose solution, • Isotonic sodium chloride solution. It is better not to use 0.9 % NaCl for children younger than 3 months as it has relatively plenty of chlorine (154 mmol/l) and relatively high osmolarity (308 mosmol/l). Monotherapy with glucose solution is not effective. Composition and correlation of solutions depends on the type of dehydration. It is necessary to eliminate solutions, which contain plenty of sodium, chlorine, glucose (Disol, Trisol, Quartasol, Acesol, Laktasol, Chlosol and others like that) for rehydration of infants and toddlers because of possible hypernatremia and intracellular edema
development. Also it is needed to correct ions deficiency (sodium, potassium, magnesium, calcium) in plasma and acid-base imbalance. Before starting parenteral rehydration, it is necessary to evaluate: • daily requirements of fluids and electrolytes, • type and degree of dehydration, • fluid current losses. Principle of volume calculation for the IV infusion: Daily volume of fluid in case of dehydration consists of: • deficit of fluid before the treatment (a loss of body weight during the disease), • physiologic fluid’s requirement, • current pathological losses. a)
For the calculation of physiologic fluid’s requirement the method of Holiday Segar that is used all over the world is recommended (Table 3). Table 3
1-10 kg
100 ml/kg 10.1-20 kg 1000 ml + 50 ml/kg for the every kilogram over 10 kgs more than 20 kg 1500 ml + 20 ml/kg for the every kilogram over 20 kgs b)
by the clinical signs or weight lost in %: - 1 % of weight lost = 10 ml/kg - 1 kg of weight loss = 1 liter So, daily deficit of fluid is 50 ml/kg/day in case of the 1st degree of dehydration (5 % of weight loss); 100 ml/kg/day – in case of 2nd degree (10 % of weight loss). The expected volume of fluid is entered during a day. The fluid is infused into peripheral veins for 4-8 hours; infusion could be repeated in 12 hours, if it is necessary. So a patient gets intravenously 1/6 of daily volume for 4 hours, or 1/3 – for 8 hours). A rest of volume is given through a mouth! Fluid’s requirement is more physiologic when it is calculated per hour of the infusion: New-born: 1-st day of life – 2 ml/kg/hour; 2-nd day of life – 3 ml/kg/hour; 3-rd day of life – 4 ml/kg/hour; Elder children: weight up to 10 kg – 4 ml/kg/hour; weight from 10 to 20 kg – 40 ml/hour + 2 ml for every kg over 10 kg; weight more than 20 kg – 60 ml/hour + 1 ml for every kg over 20 kg. Calculation of electrolytes requirements: Special attention should be paid to the correction of sodium and potassium deficit, losses of which can be considerable. It is necessary to remember that a child will receive sodium from crystalloid solutions which are infused in certain correlations with glucose solution depending type and severity of dehydration. If laboratory control is not done, potassium is entered according the physiologic necessity (1-2 mmol/kg/day). Maximal daily amount should not exceed 3-4 mmol/kg/day. Medicine, mainly potassium chloride, is entered intravenously dripply in 5% of glucose solution. Nowadays, is not recommended to add insulin to these solutions. Concentration of potassium chloride in prepared solution should not exceed 0.3-0.5 % (maximally 6 ml 7.5 % KCl on 100 ml of glucose). 1 ml of 7.5 % KCl solution contains 1 mmol of K
+ . It is necessary to restore urination before entering potassium, as anuria or severe oliguria is a contra-indication for intravenous potassium infusion. 6.5 mmol/l of potassium in plasma is threatened to the life, 7 mmol/l require hemodialysis. Presence of electrolytes deficit may be proven with blood boichemistry. Acute intestinal infections in children are mainly accompanied with isotonic type of dehydration, that’s why measuring of blood electrolytes for all the children with diarrhea is not obvious. Measurement of Na + and K + is necessary for children with the 3rd degree of dehydration and those with the 2nd degree of dehydration, whose general condition does not correspond to the diarhea severity, anamnesis is complicated, and oral rehydration was ineffective. A calculation of sodium and potassium deficit is done by the following formula: Ion deficit = (normal Ion concentration – patient’s Ion concentration) * M * К, where M is weight of the patient, K is a coefficient of intracellular fluid volume, K = 0.3 for children under 1 year, K = 0.2 for children elder than 1 year and adults. So it is necessary to evaluate the amount of sodium and potassium in solutions which are infused, volume and correlations of which are already expected. Electrolytes concentrations in solutions which are often used are represented in a table. It is necessary to check sodium and potassium concentration in plasma after an urgent intravenous rehydration. Table 4
SOLUTION Na+ K
Cl - Ca ++ Acetate (bicarbonate) mosmol/l Physiological solution 154 -
- - 308 Ringer’s solution 147
4 155 2 - 308 Ringer’s lactat 130 4 109
1,5 28 (bicarbonate) 273 4 % NaHCO 3
500 - - - 500 (bicarbonate) 1000
5 % dextrose solution with 0.45 % solution of NaCl 77 -
- - 252 A 25 % solution of magnesium is given in the dose of 0.5-0.75 mmol/kg (1 ml of solution = 1 mmol of magnesium) on the first stage of rehydration therapy taking into account importance of magnesium for the child’s organism, and also that the magnesium is usually lost together with potassium. In children with a severe malnutrition daily necessity in potassium and magnesium is enlarged (up to 3-4 mmol of potassium and 0.4-0.6 mmol of magnesium). c)
diapers, measuring the amount of the vomit or with a help of calculations: 10 ml/kg/day for every degree of body temperature over 37.0 °C; 20 ml/kg/day in case of vomiting; 20-40 ml/kg/day in case of intestinal paresis; 25-75 ml/kg/day in case of diarhea; 30 ml/kg/day for perspiration.
for a correct rehydration. Rehydration depends on the type of dehydration It is necessary to take into account the type of dehydration to choose solutions and their correlations for the rehydration therapy. There are 3 types of dehydration: isotonic, hypertonic (water deficient) and hypotonic (salt deficient) (Table 5). An isotonic rehydration (Na 130-150 mmol/l) occurs as a result of equal losses of electrolytes and water; it is the most frequent type of dehydration in children with an acute intestinal infection. Initially (in case of microcirculation maintenance) rehydration is
performed with 5% of glucose solution in combination with 0.9% of sodium chloride or Ringer’s lactate solution in correlation (2:1) with parallel correction of electrolytes. Glucose-saline solutions in a volume which balances the physiologic fluid’s requirements, the rest volume of dehydration, current pathological losses, plasma electrolytes are given the next day.
Table 5
Breathing No peculiarities Hypoventilation Hyperventilation Blood pressure Decreased or Increased a bit Low Stays normal for a long time Temperature of the body Subfebrile Normal, tendency to the hypothermia Febrile Skin
Cold, dry, elasticity is decreased a bit Cold with a cyanotic tint,
elasticity is decreased Elasticity is stored, warm Nervous system Malaise Sleepiness, possible seizures Agitation, sleeplessness Diuresis Reduced a bit Reduced
Stays normal for a long time Specific gravity of the urine Normal or insignificantly encreased
Decreased to 1010 or low Increased to 1035 and more Osmolality of plasma Normal Decreased Increased A level of electrolytes in the blood Normal
Decreased Increased
of electrolytes, in inadequate rapid infusion of saline solutions. Rehydration should be done with a 5 % glucose solution in combination with 0.9% sodium chloride solution in correlation (3:1). During the rehydration therapy for patients with hypertonic dehydration it is need to take into account daily sodium requirements (2-3 mmol/kg). Thus sodium in solutions for infusion should be taken into account. If the level of sodium is 140-150 mmol/l, the amount of sodium should be decreased 2 times in comparesment with a physiologic necessity; and if it is higher than 150 mmol/l solutions which contain sodium are forbidden, except for colloids. It is necessary to measure a potassium level and correct if it is needed. A control of plasma osmolarity and body weight is needed to prevent cerebral edema. A speed of infusion should be 15-20 ml per hour on this stage.
are above the fluid loses, excessive infusion of solutions with a small concentration of electrolytes. It is typical for intestinal infections which are accompanied with frequent vomiting or in case of oral rehydration with solutions that contain small amount of electrolytes. Rehydration therapy is done with 5 % glucose solution in combination with 0.9 % sodium chloride in correlation (1:1). If the level of sodium is less than 129 mmol/l, it is needed to be corrected (calculate it by formula described before). Sodium hypertyonic solutions are forbidden. Their infusion can result in an acute intracellular dehydration, first of all cerebral. Except this,
anaphylactic reactions can develop. The correction of sodium is done by 0.9 % NaCl, Ringer’s lactat. If it is impossible to investigate blood electrolytes, glucose-saline solutions are infused in correlation 1:1. By the WHO recommendations (if the fast rehydration is necessary in case of laboratory control absence) the volume and speed of 0.9 % NaCl, Ringer’s lactat infusion on the first rehydration stage should be the following (Table 6):
Table 6
Age of the child Speed of infusion Speed of infusion Under 12 months 30 ml/kg for the first 1 hour 70 ml/kg for the next 5 hours Elder than 12 months 30 ml/kg for the first 30 minutes 70 ml/kg for the next 2.5 hours
The condition of the child is checked every 15-30 minutes up to normal pulse on a radial artery. If the condition of the child does not improve, a speed of infusion should be increased. After that, the condition of the child is estimated hourly (abdominal skin fold, consciousness, possibility to drink). After all the volume is infused the child’s condition should be evaluated again: • If the signs of severe dehydration are still present, the infusion should be repeated again according the table 6. • If the child’s condition gets better, but signs of moderate dehydration are present, oral rehyderation should be continued according the table 2. If a child is breast fed, it is recommended to continue feeding; numbers of feeding should be increased. • If signs of dehydration are absent, the duration of feeding should be increased. 50- 100 ml of oral rehydration solution is given to the children younger than 2 yrs for supportive rehydration simultaneously at presence of diarrhea, 100-200 ml – to children elder than 2 yrs or 10 ml/kg additionally after every emptying (up to 1/3 of an expected volume for oral rehydration). Children, who are bottle fed, are fed as usual, by lactose free formulas. Supervision for children with a severe malnutrition and dehydration during the rehydration therapy should be done every 30 minutes for the first 2 hours, and then hourly for the next 4-10 hours. Rehydration should be stopped when signs of hyperhydration appear (increase of pulse rate on 15 per minute, respiratory rate on 5 per minute). Than the child’s condition through an hour should be evaluated.
A speed of the IV fluid infusion must not exceed 15 ml/kg/hour for those children, and for children with pneumonia or toxic encephalopathy. A daily weight gain in these cases must not exceed 1-3 % in the first 3 days of treatment. If dehydration is absent but infectious toxic shock develops, resuscitative measures should be done according the guidelines. Antibacterial therapy Antibacterial therapy in case of invasive diarrhea is given to: 1. Children with severe and moderate forms of the disease. 2. Children younger than 3 months independently of the disease severity. 3. Children with the immune deficiency, HIV-infection, those who receive immune suppressive therapy, corticosteroid therapy for a long time, children with hemolytic anemia, hemoglobinopathies irrespectively of their age and the disease severity. 4. Children with hemocolitis independently of their age and the disease severity. 5. Children with the secondary bacterial complications independently of their age. Antibacterial therapy in case of secretory diarrhea is given to: 1. Children, younger than 6 months, with severe and moderate form of the disease . 2. Children with the immune deficiency, HIV-infection, those who receive immune suppressive therapy, corticosteroid therapy for a long time, children with hemolytic anemia, hemoglobinopathies. 3. Cholera, parasitic diarrhea irrespectively of their age and the disease severity. 4. Children with the secondary bacterial complications irrespectively of their age.
1. Children with mild, subclinical and moderate forms of infections, except for those which are listed above. 2. Children-bacteriocarriers of any etiology (transitory, postinfectional). 3. Children with alimentary dysfunction, as a result of an acute intestinal infection (intestine dysbiosis, lactase intolerance, celiac syndrome, secondary enzymopathy etc.). Table 8
Ciprofloxacin* Nifuroxazide Ceftriaxone Trimethoprim/sulfamethoxazole Azythromycin Salmonella Ceftriaxone Cefotaxime Nifuroxazide Trimethoprim/sulfamethoxazole Ciprofloxacin Ampycillin** Chlorampheniсol** Azythromycin
Trimethoprim/sulfamethoxazole Doxycycline (to the children elder
than 8 years) Aminoglycosides** Nifuroxazide
Nifuroxazide Ciprofloxacin Trimethoprim/sulfamethoxazole Ceftriaxone Azythromycin
Erythromycin Ciprofloxacin Aminoglycosides** Amoxicillin/сlavulanate Carbapenems (imipenem, carbapenem)
enterocolitica Ceftriaxone Cefotaxime Ciprofloxacin Trimethoprim/sulfamethoxazole Doxycycline (for children elder than 8 years) Aminoglycosides** Chloramphenicol**
Trimethoprim/sulfamethoxazole Doxycycline (for children elder than 8 years)
Nifuroxazide Furazolidone Ciprofloxacin Clostridium deficile Methronidazole Ornidazole Vancomycin (through a mouth) Giardia Lamblia Methronidazole Furazolidone Ornidazole Amoeba hystolitica Methronidazole Intetrix Tinidazole * – other fluoroquinolones, except for Ciprofloxacin, are not recommended for children. ** – only in case of sensitivity to this antibiotic. *** – antibiotics can provoke hemolytic-uremic syndrome in case of Entherohemorrhagic E.coli. Table 9
Nifuroxazide (through a mouth) Suspension: children aged 2-6 months 2.5-5 ml (110-220 mg) 6 month to 6 years – 5 ml (220 mg) elder than 6 years – 5 ml (220 mg) Pills: children aged before 6 yrs – 0.2 g elder than 6 years – 0.2 g A course of treatment is 5-7 days 2times daily 3 times daily 4 times daily 3times daily 4 times daily
Children aged 2-5 years – 200 mg of sulfamethoxazole/ 40 mg of trimethoprim Children aged 5-12 years – 400 mg of sulfamethoxazole/ 80 mg of trimethoprim Children elder than 12 years – 800 mg of sulfamethoxazole/ 160 mg of trimethoprim A course of treatment is 3-5 days
2 times daily Ciprofloxacin (through a mouth) 15 mg/kg (maximal dose is 500 mg) A course of treatment is 3 days 2 times daily Ceftriaxone (IM, IV) 50-100 mg/kg daily dose (a maximal dose is 1-2 g) A course of treatment is 2-5 days onse a day Cefotaxime (IM, IV) 50-100 mg/kg daily dose (a maximal dose is 1-2 g) A course of treatment is 3-5 days 2 times daily Azythromycin (through a mouth) 6-20 mg/kg A course of treatment is 1-5 days once a day 1-1.5 hours before meal
Erythromycin (through a mouth) Children aged 1-3 years – 0.4 g daily children aged 4-6 years – 0.5-0.75 g children aged 6-8 years – 0.75 g children aged 6-8 years – 1 g A course of treatment is 7-10 days 4 times daily 1-1.5 hours before meal
Through a mouth (suspension) children aged 1-2 years – 78 mg children aged 2-7 years – 156 mg children aged 7-12 years – 312 mg IV – 30 mg/kg A course of treatment is 5-10 days
3 times daily 3-4 times daily
Gentamicin 2-3 mg/kg/day Amikacin 15 mg/kg/day Netilmicin: children under 1 year – 7.5-9 mg/kg children elder than 1 year – 6-7.5 mg/kg A course of treatment is 5-7 days 2 times daily 2-3 times daily 3 times daily
3 times daily Furazolidone (through a mouth) 8-10 mg/kg daily dose A course of treatment is 10 days 4 times daily Doxycycline (through a mouth) for children elder than 8 yrs Children aged 9-12 years daily dose for the first day is 4 mg/kg, then 2 mg/kg A course of treatment is 7-10 days 2 times daily
40 mg/kg daily dose A course of treatment is 7-10 days 3-4 times daily
Through a mouth children before 3 yrs – 10-15 mg/kg children aged 4-8 years – 0.15-0.2 g children elder than 8 yrs – 0.2-0.3 g IM children under 1 year, daily dose – 25-30 mg/kg children elder than 1 year, daily dose – 50 mg/kg A course of treatment is 5-10 days 3-4 times daily 30 min before meal
2-3 injections daily
Methronidazole (through a mouth) Amebiasis: children aged 2-5 years – 0.25 g children aged 6-10 years – 0.375 g children aged 11-15 years – 0.5 g A course of treatment is 10 days Giardiasis: children aged 2-5 years – 0.2 g children aged 6-10 years – 0.3 g children aged 11-15 years – 0.4 g A course of treatment is 5-7 days
Once a day while eating
mouth) Giardiasis - 40 mg/kg A course of treatment is 1-3 days Amebiasis – 25-30 mg/kg A course of treatment is 1-3 days
Once a day Albendazole (through a mouth) Giardiasis children elder than 2 yrs – 400 mg A course of treatment is 5 days
Once a day Tinidazole (through a mouth) Amebiasis – 30 mg/kg A course of treatment is 3 days Once a day
Children elder than 12 years – 1 capsule A course of treatment is 10 days 4 times daily
Carbapenems Imipenem/cilastatin (IM, IV) children with body weight less than 40 kg – 15 mg/kg (maximal daily dose is 2 g) children with body weight more than 40 kg – 500-1000 mg, maximal daily dose is 2 g)
Meropenem (IV) 10-12 mg/kg children with body weight more than 50 kg – 500 mg A course of treatment is according the evidences
4 times daily 2-4 times daily
In case of the unknown etiology in inflammatory diarrhea, it is recommended to prescribe Nifuroxazide, or Trimethoprim/sulfamethoxazole, or Cefotaxime, or Ceftriaxone, or Ciprofloxacin for an empiric therapy of an acute intestinal infection. Cefalosporins of the 3-4th generations are used for the empiric antibacterial therapy of a secretory diarrhea, if it is necessary. Yüklə 3,37 Mb. Dostları ilə paylaş:
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