periods of cholera. Causes of cholera
- This is an acute intestinal infection that occurs when a person is affected by cholera vibrio. Cholera is manifested by severe frequent diarrhea, profuse repeated vomiting, which leads to significant fluid loss and dehydration. Dryness is a sign of dehydration skin and mucous membranes, decreased tissue turgor and wrinkling of the skin, sharpening of facial features, oligoanuria. The diagnosis of cholera is confirmed by the results of bacteriological culture of feces and vomit, serological methods. Treatment includes isolation of the cholera patient, parenteral rehydration, and tetracycline antibiotic therapy.
Cholera is transmitted by household ( dirty hands, objects, utensils), food and by water by the fecal-oral mechanism. Currently, a special place in the transmission of cholera is given to flies. The waterway (contaminated water source) is the most common. Cholera is an infection with a high susceptibility, most easily infecting people with hypoacidosis, some anemia, infected with helminths, and alcohol abusers.
Symptoms of cholera
The incubation period for infection with Vibrio cholerae lasts from several hours to 5 days. The onset of the disease is acute, usually at night or in the morning. The first symptom is intense painless urge to defecation, accompanied by discomfort in the abdomen. Initially, the stool has a liquefied consistency, but retains a fecal character. Quite quickly, the frequency of bowel movements increases, reaches 10 or more times per day, while the stool becomes colorless, watery. In cholera, stools are usually not offensive, unlike other infectious diseases intestines. Increased secretion of water into the intestinal lumen contributes to a marked increase in the amount of excreted stool. In 20-40% of cases, the feces acquire the consistency of rice water. Usually the stools are greenish liquid with white loose flakes, similar to rice.
Often there is rumbling, seething in the abdomen, discomfort, transfusion of fluid in the intestines. The progressive loss of fluid by the body leads to the manifestation of symptoms of dehydration: dry mouth, thirst, then there is a feeling of cold extremities, ringing in the ears, dizziness. These symptoms are indicative of significant dehydration and require emergency measures to restore the water-salt homeostasis of the body.
Diagnosis of cholera
Severe cholera is diagnosed on the basis of clinical presentation and physical examination. The final diagnosis is established on the basis of bacteriological culture of feces or vomit, intestinal contents (sectional analysis). The material for sowing must be delivered to the laboratory no later than 3 hours from the moment of receipt, the result will be ready in 3-4 days.
There are serological methods for detecting vibrio cholerae infection (RA, RNGA, vibrocidal test, ELISA, RCA), but they are not sufficient for final diagnosis, being considered methods of accelerated approximate determination of the pathogen. Accelerated methods for confirming a preliminary diagnosis can be considered luminescent-serological analysis, dark field microscopy of vibrios immobilized with O-serum.
cholera treatment
Since the main danger in cholera is the progressive loss of fluid, its replenishment in the body is the main task of treating this infection. Treatment of cholera is carried out in a specialized infectious diseases department with an isolated ward (box) equipped with a special bed (Philips bed) with scales and utensils for collecting feces. For exact definition degrees of dehydration keep records of their volume, regularly determine the hematocrit, the level of ions in the serum, the acid-base index.
Primary rehydration measures include replenishment of existing fluid and electrolyte deficits. In severe cases, it is intravenous administration polyion solutions. After that, compensatory rehydration is performed. The introduction of fluid occurs in accordance with its losses. The occurrence of vomiting is not a contraindication to continued rehydration. After the restoration of the water-salt balance and the cessation of vomiting, antibiotic therapy is started. With cholera, a course of tetracycline drugs is prescribed, and in case of repeated isolation of bacteria, chloramphenicol.
There is no specific diet for cholera, in the early days they can recommend table number 4, and after subsiding severe symptoms and restoration of intestinal activity (3-5th treatment laziness) - nutrition without features. Those who have had cholera are recommended to increase potassium-containing foods in the diet (dried apricots, tomato and orange juice, bananas).
Forecast and prevention of cholera
With timely and complete treatment, after the suppression of the infection, recovery occurs. Currently modern drugs effectively act on cholera vibrio, and rehydration therapy contributes to the prevention of complications.
Specific prevention of cholera consists of a single vaccination with cholera toxin before visiting regions with high level the spread of this disease. If necessary, revaccination is performed after 3 months. Non-specific measures Prevention of cholera implies the observance of sanitary and hygienic standards in populated areas, at food establishments, in areas where water is taken for the needs of the population. Individual prevention It consists in maintaining hygiene, boiling the water used, washing food and their proper cooking. When a case of cholera is found epidemiological focus is subject to disinfection, patients are isolated, all contact persons are observed for 5 days to identify possible infection.
Cholera(from other Greek χολή “bile” and ῥέω “flow”) is an acute intestinal saprozoonotic infection caused by bacteria of the species Vibrio cholerae. It is characterized by the fecal-oral mechanism of infection, damage to the small intestine, watery diarrhea, vomiting, rapid loss of body fluids and electrolytes with the development varying degrees dehydration up to hypovolemic shock and death.
3.2 Etiology
The causative agent Vibrio cholerae has more than a hundred serogroups. It was discovered by Koch in the 19th century and looks like a comma. Vibrio cholerae can survive on surfaces food products and in cooked food up to 5 days, can be stored in water, kept for 1 minute in boiling water.
The infection is anthroponotic and has an epidemic character. Of particular importance in the epidemiology of the disease are healthy carriers, that is, people infected with Vibrio cholerae without clinical symptoms of the disease and capable of infecting other people. The greatest danger in terms of infection with cholera is drinking non-disinfected water, eating contaminated food, including those that do not undergo heat treatment. A contact-household transmission route is also possible. An epidemic danger is stagnant reservoirs with warm water, into which sewage waste flows, as they create favorable conditions for the reproduction of cholera pathogens.
3.3 Epidemiology
According to the World Health Organization, in 2010 there were from 3 to 5 million cases of cholera in the world and 100-130 thousand deaths. These diseases occurred mainly in developing countries. In the early 1980s, the death rate was estimated to be in excess of 3 million a year. The exact number of cases is difficult to estimate because many are not reported due to concerns that cholera outbreaks could negative effect on the influx of tourists in these countries. Currently, cholera continues to be epidemic and endemic in many regions of the world.
All modes of transmission of cholera are variants of the fecal-oral mechanism. The source of infection is a person - a cholera patient and a healthy (transient) vibrio-carrier, releasing Vibrio cholerae into the environment with feces and vomit.
Healthy vibrio carriers are of great importance for the spread of the disease. The carrier/patient ratio can be as high as 4:1 with Vibrio cholerae O1 and 10:1 with non-O1 Vibrio cholerae (NAG vibrios).
Infection occurs mainly when drinking non-disinfected water, swallowing water when swimming in polluted reservoirs, while washing, and also when washing dishes with contaminated water. Infection can occur when eating food contaminated during cooking, storing, washing or distributing it, especially foods that are not subjected to heat treatment (shellfish, shrimp, dried and lightly salted fish). Contact-household (through contaminated hands) transmission route is possible. In addition, V. cholerae can be carried by flies.
When the disease spreads, poor sanitary and hygienic conditions, overcrowding of the population, and large migration of the population play an important role. Here it should be noted endemic and imported foci of cholera. In endemic areas (Southeast Asia, Africa, Latin America), cholera is recorded throughout the year. Imported epidemics are associated with intensive migration of the population. In endemic areas, children are more likely to get sick because adult population already possesses naturally acquired immunity. In most cases, an increase in the incidence is observed in the warm season.
Approximately 4-5% of recovered patients develop chronic vibrio carriage in the gallbladder. This is especially true for the elderly. After the illness, immunity is developed in the body of those who have been ill, which does not exclude infection with other serotypes of Vibrio cholerae.
Clinical picture (symptoms and signs). The incubation period is from several hours to 5 days, more often 2-3 days. There are several clinical forms of cholera: enteric, gastroenteric, algid. There is also a gastric form of cholera, when diarrhea is preceded by. The onset of the disease is acute - with sudden, uncontrollable urge to go down with copious discharge from the intestines. At first, the discharge is liquid, fecal, then watery, odorless. The color of the discharge also changes: at first they resemble bean, pea, then milk soup, later rice water. The stools can sometimes contain mucus, undigested food debris, and blood. This first phase - cholera, cholera, or diarrhea - lasts from several hours to 1-2 days. Sometimes the disease can be limited to only these phenomena.
Subsequently, cholera gastroenteritis develops - the second phase. There is repeated and profuse vomiting without nausea. The diarrhea continues. Huge fluid losses (up to 10% or more of the patient's body weight) lead to dehydration of the body, loss of sodium salts, etc. The patient's condition is extremely serious, he is exhausted by continuous vomiting and diarrhea. Tongue covered with white coating, dry. Painful thirst. The phenomena of intoxication are growing. deaf, blood pressure decreases sharply. Acrocyanosis is observed. Decreased or completely stopped urine output. Sunken belly. Moderate pains in the abdomen are sometimes noted, more often - a feeling of heaviness. When in the intestine is determined by a large amount of fluid. In this period, painful and painful clonic, tonic or mixed character appear.
The third phase is algid. The patient is in prostration, agonizing thirst, hoarse voice (exicosis), up to aphonia. Consciousness is preserved. Acrocyanosis progresses. Facial features are sharpened, cheekbones protrude, eyes sink, sclera fade, are injected. The skin decreases - it easily gathers into folds, becomes wrinkled, cold to the touch, covered with sticky sweat. The temperature is sharply reduced (up to 35-34° and below). continue. An excruciating hiccup appears. Pulse is thready, frequent. Heart sounds are muffled, blood pressure is not determined. Urination may stop completely (cholera anuria). Due to thickening of the blood, the amount rises to 6-8 million or more per 1 mm 3. Leukocytosis up to 10,000-15,000 and above. The algidic phase passes into the asphyxic (fourth phase), in which shortness of breath joins. Consciousness is darkened, and convulsions intensify. With symptoms of increasing shortness of breath and collapse, the patient dies.
The described phases (forms) of cholera are not observed in all patients. Lighter (enteric, gastroenteric) forms are more often noted, especially in cholera caused by the El Tor biotype. Lightning and "dry" are described, when death occurs from sudden intoxication even before the development of diarrhea and vomiting.
Clinical picture and course
The duration of the incubation period ranges from several hours to 6 days (usually 2-3 days), rarely a little longer. The onset of the disease is acute, with sudden urge to descend, often appearing at first at night. The urge is irresistible, with copious discharge. Defecation usually proceeds without pain and tenesmus. Allocations are initially liquid, fecal, and then after several bowel movements acquire a liquid watery consistency, lose their smell. The color of the allocated masses also changes; at first they look like bean soup, then like milk soup, and later like rice water. Sometimes the stools contain mucous masses, undigested food residues, very, rarely, an admixture of blood.
The general condition of the patient in this first phase - cholera enteritis, cholera diarrhea, or diarrhea - is slightly disturbed, the disease is carried on the legs, which poses a great epidemiological threat to others. Patients report general weakness, thirst, lack of appetite. The temperature is not elevated or there is a subfebrile temperature. The duration of the first period is 1-2 days (G. P. Rudnev, A. G. Podvarko). Sometimes the disease can be limited to only these phenomena.
With the continuation of the disease, the second phase develops - cholera gastroenteritis. Vomiting occurs, multiple and copious portions, without prior nausea, diarrhea continues. Vibrio cholerae are easily detected in feces and vomit (3. V. Ermolyeva, N. N. Zhukov-Verezhnikov, L. M. Yakobson). The patient, as it were, is likened to a "fountain of infection", which is very dangerous in epidemiological terms (G. P. Rudnev). In connection with profuse diarrhea and repeated vomiting, progressive dehydration of the body occurs.
With a relatively short duration of this period (36-48 hours), some patients lose up to 7 liters of fluid with vomit and up to 30 liters with feces (N. K. Rozenberg). Fluid is removed from the body a large number protein and a number of salts (especially sodium chloride).
The patient's condition becomes severe, he is exhausted by continuous vomiting and diarrhea. The vomit, containing food impurities at first, then becomes watery. Tongue covered with white coating, dry. Restless thirst. The phenomena of intoxication are growing. Heart sounds are muffled arterial pressure reduced, acrocyanosis appears, the amount of urine decreases. The abdomen is soft, sunken. The temperature is normal or drops significantly. In this period of the disease, painful and excruciating convulsions of a clonic, tonic or mixed nature appear.
Diarrhea, vomiting, dehydration (loss of salts), convulsions are the main symptoms in the clinic of cholera gastroenteritis. However, gastric symptoms (nausea, vomiting) in cholera can sometimes precede the onset of diarrhea (ID Ionin). This is also noted in connection with wide application antibiotics and in cholera caused by a variant of Vibrio El Tor.
The third phase is an algid with a dominant clinic of the consequences of the second period (G. P. Rudnev). The patient is in prostration, agonizing thirst, hoarse voice (exicosis) to complete aphonia. Consciousness is preserved.
Acrocyanosis progresses. Facial features are sharpened, cheekbones protrude, eyes sink, sclera fade, are injected. Skin turgor is lost, it easily folds, becomes wrinkled, cold to the touch, covered with sticky sweat. The temperature is sharply reduced (up to 36-35-34° and below). The cramps become more common, affecting the muscles of the arms, abdomen, chest, chewing muscles, and especially the calf muscles. Diarrhea stops, but vomiting is still possible. Excruciating hiccups appear ( clonic convulsions aperture).
Pulse is thready, frequent. Heart sounds are deaf, arrhythmia, blood pressure is sharply reduced. When listening - friction noise of the pleura, pericardium (exicosis). Urination is reduced and may stop completely (cholera anuria). Due to thickening of the blood, the number of red blood cells rises to 6-7-8 million and more in 1 mm 3. Moderate leukocytosis (up to 10,000-15,000, sometimes higher).
The duration of the algid period is from several hours to 3-4 days.
The algid phase passes into the asphyxial phase, in which shortness of breath appears (up to 40-45 breaths per minute), uremic and azotemic states develop. Consciousness is darkened, cyanosis and convulsions intensify. With symptoms of increasing shortness of breath and collapse, the patient dies. Death can also occur in the algid period during convulsive attack. Mortality in algid form in recent years has reached 90%, although the average mortality from cholera is not higher than 50%, and with El Tor cholera is much lower.
The described phases are observed not at all patients; with timely diagnosis and proper treatment, the transition of the disease after the first three phases into the so-called reactive phase is possible.
The division into phases served as the basis for the development by G. P. Rudnev of the following classification of the clinical forms of typical cholera.
Classification of clinical forms of cholera
1. Cholera enteritis
2. Cholera gastroenteritis
3. Algid period
Reactive phase Asphyxic phase
recovery cholera coma
Death
Possible lighter atypical forms cholera, as well as fulminant and "dry" cholera. Death in these forms of the disease occurs from severe intoxication even before the development of diarrhea and vomiting.
Of the complications, especially often developing in seriously ill patients, it is necessary to note pneumonia, erysipelas, phlegmon, abscesses, sepsis, etc.
To specific complications diseases include cholera typhoid, in the pathogenesis of which Escherichia coli plays a certain role. Patients have a high temperature, consciousness is darkened (status typhosus), rashes of a roseolous nature appear on the skin. Nausea, vomiting, and offensive diarrhea are characteristic, as in colitis with ichorous stools. It's heavy and dangerous complication cholera, the lethality from which reached 80-90% in the past.
Cholera is an acute infectious disease, the epidemic spread of which is observed in the summer-autumn period. Characteristic are fast loss fluids as a result of the occurrence of profuse watery diarrhea and vomiting, disturbances in the water and electrolyte balance. Refers to especially dangerous infections.
Etiology. The causative agent is Vibrio cholerae. It is a gram-negative, curved rod with a polarly located flagellum, providing high mobility of the pathogen. Does not form spores or capsules. Long survives in open water, resistant to low temperatures, may overwinter in frozen water sources. Deactivates quickly when exposed to disinfectants and when boiling. Under the influence of cholera vibrio exotoxin on the epithelium of the mucous small intestine loss of body fluid occurs. Morphological changes in the cells of the epithelium and underlying tissues of the intestine are not observed.
Pathogenesis, clinic. The incubation period varies from a few hours to 5 days. The disease begins acutely, with the appearance of diarrhea and the subsequent addition of vomiting. The stool becomes more and more frequent, the stools lose their fecal character and smell, and become watery. The urge to defecate is imperative, patients cannot control the act of defecation. Discharge from the intestines looks like rice water or is a liquid dyed yellow or yellow by bile. green color. Often in the discharge there is an admixture of mucus and blood. The vomit is similar in chemical composition with intestinal secretions. It is a liquid colored yellow, without sour smell. Fluid loss during vomiting and diarrhea quickly leads to dehydration of the body, the patient's appearance changes, facial features become sharper, the mucous membranes are dry, the voice loses its sonority, the usual skin turgor decreases, and it easily folds, cyanosis develops. There is tachycardia, shortness of breath, heart sounds become muffled, blood pressure decreases, urination decreases. Often there are tonic convulsions, as well as cramps in the muscles of the limbs. Palpation of the abdomen reveals fluid transfusion, increased rumbling, and in some cases fluid splash noise is detected. Palpation is painless. Body temperature is normal. The progress of the disease in a patient is characterized by a serious condition, which is accompanied by a decrease in body temperature to 34-35.5 ° C, extreme dehydration (patients lose 8-12% of body weight), hemodynamic disturbances, shortness of breath. The color of the skin in such patients has an ashy tint, the voice is absent, the eyes are sunken, the sclera is dull, the gaze is inactive. The abdomen is retracted, there is no stool and urine emission. In the blood, due to the thickening of the elements, high leukocytosis, an increase in the content of hemoglobin and erythrocytes, the hematocrit index, and an increase in the relative density of the plasma are noted.
Diagnosis of the disease in the focus in the presence of characteristic signs of the disease is not difficult. The first cases of cholera in areas where it has not previously been observed are often difficult and require mandatory bacteriological confirmation.
Treatment is carried out in a hospital, but in certain cases, according to urgent indications it can be started at home. Sick with extreme dehydration and phenomena of hypovolemic shock (falling blood pressure, severe tachycardia or absence of a palpable pulse, shortness of breath, cyanosis, lack of urine) to compensate for the volume of lost fluid and electrolytes, immediately inject a jet into / into a warm (38-40 ° C) sterile saline solution type "Trisol" (1000 ml of sterile pyrogen-free water, 5 g of sodium chloride, 4 g of sodium bicarbonate, 1 g of potassium chloride). In some cases, if venipuncture is difficult, venesection is performed. During the first hour of treatment, patients with symptoms of hypovolemic shock are injected with a saline solution in an amount equal to 10% of body weight (with a patient weighing 75 kg - 7.5 liters of solution), and then the patient is transferred to drip injection of the solution at a rate of 80-100 drops in 1 min. The total volume of the saline solution to be replenished is determined by the amount of fluid released during diarrhea and with vomit (for example, if 2 hours after the end of the jet injection of the solution, the patient lost 3 liters of fluid, he needs an equal amount of saline at the same time). In case of a pyrogenic reaction to the injected saline solution (with chills, an increase in body temperature), the liquid is administered more slowly and administered through the infusion system in / in 1-2 ml of a 2% solution of promedol and a 2.5% solution of pipolfen or 1% solution of diphenhydramine. With more pronounced reactions, 30-60 mg of prednisolone is administered intravenously. When vomiting stops, patients are prescribed tetracycline 0.3 g orally 4 times a day for 5 days. Material for bacteriological analysis taken before antibiotics are prescribed. Cardiac glycosides, pressor amines, plasma, blood components, colloidal solutions are not used to remove patients from hypovolemic shock in cholera.
The prognosis for timely treatment of patients with cholera, including those with extremely severe course, is favorable.
Prevention. If cholera is suspected, patients should be immediately hospitalized. If such patients are detected at home, in hotels and under other circumstances, the doctor, before their hospitalization, must take measures to isolate the sick from others and immediately report the disease to the head doctor of his institution. Chief Physician informs the sanitary-epidemiological station and the department (city, district) of health about the case of the disease. At the same time, a list of persons who have been in contact with the patient is compiled, after the patient is hospitalized, they must be placed in the contact department. In the room in which there was a patient with cholera, after his hospitalization, the final disinfection is carried out.
2. Typhoparatyphoid diseases
Typhoid and paratyphoid diseases (typhoid fever, paratyphoid A and B) are a group of acute infectious diseases with fecal-oral transmission caused by salmonella and similar in clinical presentation. They are manifested by fever, general intoxication, bacteremia, enlargement of the liver and spleen, enteritis and a peculiar lesion of the intestinal lymphatic apparatus. They are classified as intestinal anthroponoses. The main source of infection in recent years is considered to be chronic Salmonella bacteria carriers.
Etiology. The causative agents of the disease are several types of Salmonella - Salmonella typhi, S. Paratyphi A, S. schottmulleri. Activators are sensitive to chloramphenicol and ampicillin. The infectious dose ranges from 10,000,000 to 1,000,000,000 microbial cells.
Pathogenesis. The causative agent enters the small intestine, where it causes a picture of specific enteritis. The process involves the lymphatic formations of the small intestine and mesenteric The lymph nodes. From the first days of the disease, pathogens can be isolated from the blood. With the breakdown of salmonella, endotoxin is released, which causes symptoms of general intoxication and plays important role in the genesis of ulcers of the small intestine, leukopenia and can cause the development of infectious-toxic shock.
Clinic. The incubation period lasts from 1 to 3 weeks. The disease develops gradually with a typical course. Symptoms appear and increase: weakness, headache, signs of intoxication, body temperature rises steadily, reaching the highest numbers by the 7-9th day of illness. The delay of a chair and the phenomena of a meteorism are more often observed. With paratyphoid in the initial period, symptoms of acute gastroenteritis may appear. Paratyphoid A can cause symptoms of catarrh respiratory tract. During the peak of the disease, patients experience lethargy, headache, loss of appetite, slight cough. Examination reveals typical typhoid exanthema. It is expressed in single roseola with a diameter of up to 3-6 mm, plus the tissue has clear boundaries. After 3-5 days, the exanthema disappears without a trace. New rashes may appear from time to time. Relative bradycardia and dicrotia of the pulse, a decrease in blood pressure, muffled heart sounds are noted. On auscultation, scattered dry rales are heard. The tongue is dry, there is a thick brownish coating. The edges and tip of the tongue are clean, with imprints of teeth. The abdomen is swollen, a rough rumbling in the region of the caecum and pain in the right iliac region are determined. The liver and spleen are enlarged. At the height of the disease, the number of leukocytes in peripheral blood especially neutrophils and eosinophils. ESR is moderately elevated (up to 20 mm/h). In the analysis of urine - traces of protein. Complications: perforation of intestinal ulcers and intestinal bleeding. Pneumonia, infectious psychosis, acute cholecystitis are possible, less often other complications. Intestinal perforation may occur in 0.5-8% of patients during the period from the 11th to the 25th day of illness. In recent years, intestinal damage has been associated with normal temperature and well-being of the patient, often with expansion motor activity. The onset of perforation is acute: there are abdominal pains, muscle tension, symptoms of peritoneal irritation, free gas in the abdominal cavity, size reduction hepatic dullness. These initial manifestations perforations may vary. As a result, it becomes difficult to diagnose early stage. If the operation is not performed in the first 6 hours, it is possible to develop diffuse peritonitis. Its signs: frequent vomiting, increased flatulence, increased body temperature, rapid pulse, increased symptoms of peritoneal irritation, the appearance of free fluid in the abdominal cavity, leukocytosis. Intestinal bleeding may coincide with perforation intestinal ulcer and is diagnosed when an admixture of altered blood appears in the feces or according to the clinical picture of an acutely developing internal bleeding. Recurrence is possible in some cases 1-2 weeks after normalization of body temperature. Chronic bacteriocarrier remains in 3-5% of recovered patients. Diagnostics initial period typhoid and paratyphoid diseases is difficult, especially in mild and atypical cases. During this period, it is important to identify the presence of pathogens in the blood (detection using bile broth culture, immunofluorescent method). With a typical clinical picture, the diagnosis is not difficult. In later periods, stool cultures can be used and serological methods(Vidal reaction, RNGA).
Treatment. Antibacterial therapy is prescribed (chloramphenicol 0.5-0.75 g 4 times a day until the 10-12th day of normal temperature). In severe forms, antibiotic therapy is combined with a short course (5-7 days) of glucocorticoids (prednisolone 30-40 mg / day). Pathogenetic therapy is used (vitamins, oxygen therapy, vaccines). Bed rest should be observed at the same time until the 7-10th day of normalization of temperature. With intestinal bleeding, the patient is prescribed strict bed rest, cold on the stomach, vikasol (1 ml of a 1% solution), aminocaproic acid (200 ml of a 5% solution). In intestinal perforation - urgent surgical intervention to prevent intestinal bleeding and associated complications. Treatment of chronic bacteriocarrier has not been developed.
The prognosis is favorable with timely treatment. In severe forms and the presence of complications (especially intestinal perforation), the prognosis is worse. Ability to work is restored after 1.5-2 months from the onset of the disease.
Prevention. Sanitary supervision of food and water supply. Convalescents are discharged after a triple negative bacteriological examination of feces and urine and a single study of bile (portions B and C).
Those who have been ill are registered with the sanitary and epidemiological station for 2 years (workers in food enterprises - 6 years). Isolation of patients is terminated from the 21st day of normal body temperature. According to the indications, specific immunization is carried out. The final disinfection is carried out in the hearth.
Cholera (cholera) - acute anthroponotic infectious disease with a fecal-oral mechanism of transmission of the pathogen, which is characterized by massive diarrhea with rapid development of dehydration. In connection with the possibility of mass distribution, it refers to quarantine diseases dangerous to humans.
ICD codes -10 A00. Cholera.
A00.0. Cholera caused by Vibrio cholerae 01, biovar cholerae.
A00.1. Cholera caused by vibrio cholerae 01, biovar eltor.
A00.9. Cholera, unspecified.
Etiology (causes) of cholera
The causative agent of cholera Vibrio cholerae belongs to the Vibrio genus of the Vibrionaceae family.
Vibrio cholerae is represented by two biovars, similar in morphological and tinctorial properties (the cholera proper biovar and the El Tor biovar).
The causative agents of cholera are short curved Gram-negative rods (1.5–3 µm long and 0.2–0.6 µm wide), highly mobile due to the presence of a polarly located flagellum. They do not form spores and capsules, they are located in parallel, in a smear they resemble a flock of fish, they are cultivated on alkaline nutrient media. Vibrio cholerae El Tor, in contrast to the classic biological variants are able to hemolyze sheep erythrocytes.
Vibrios contain heat-stable O-antigens (somatic) and heat-labile H-antigens (flagella). The latter are group, and according to O-antigens, cholera vibrios are divided into three serological types: Ogawa (contains antigenic fraction B), Inaba (contains fraction C) and intermediate type Gikoshima (contains both fractions - B and C). In relation to cholera phages, they are divided into five main phage types.
Pathogenic factors:
· mobility;
chemotaxis, by which the vibrio overcomes slime layer and interacts with the epithelial cells of the small intestine;
· adhesion and colonization factors, with the help of which the vibrio adheres to the microvilli and colonizes the mucous membrane of the small intestine;
enzymes (mucinase, protease, neuraminidase, lecithinase) that promote adhesion and colonization, as they destroy the substances that make up the mucus;
exotoxin cholerogen - main factor, which determines the pathogenesis of the disease, namely, it recognizes the enterocyte receptor and binds to it, forms an intramembrane hydrophobic channel for the passage of subunit A, which interacts with nicotinamide adenine dinucleotide, causes hydrolysis of adenosine triphosphate, followed by the formation of cAMP;
factors that increase capillary permeability;
endotoxin - thermostable LPS, which does not play a significant role in the development of clinical manifestations of the disease. Antibodies that are formed against endotoxin and have a pronounced vibriocidal effect - important component post-infection and post-vaccination immunity.
Vibrio cholerae survive well at low temperatures; kept on ice for up to 1 month sea water- up to 47 days, in river water- from 3–5 days to several weeks, in soil - from 8 days to 3 months, in feces - up to 3 days, on raw vegetables- 2-4 days, on fruit - 1-2 days. Vibrio cholerae at 80 ° C die after 5 minutes, at 100 ° C - instantly; highly sensitive to acids, drying and direct sun rays, under the action of chloramine and other disinfectants, they die after 5-15 minutes, they are well and long preserved and even multiply in open water and Wastewater ah, rich in organic matter.
Epidemiology of cholera
Source of the infectious agent- a person (sick and vibrio-carrier).
Especially dangerous are those who preserve social activity patients with erased and mild forms of the disease.
Mechanism of transmission- fecal-oral. Ways of transmission - water, alimentary, contact-household. The waterway has crucial for the rapid epidemic and pandemic spread of cholera. At the same time, not only drinking water, but also using it for household needs (washing vegetables, fruits, etc.), swimming in an infected reservoir, as well as eating fish, crayfish, shrimp, oysters caught there and not passed heat treatment can lead to cholera infection.
Susceptibility to cholera is universal. The most susceptible to the disease are people with reduced acidity of gastric juice (chronic gastritis, pernicious anemia, helminthic invasions, alcoholism).
After the illness, antimicrobial and antitoxic immunity is developed, which lasts from 1 to 3 years.
The epidemic process is characterized by acute explosive outbreaks, group diseases and individual imported cases. Thanks to wide transport links, cholera is systematically brought into the territory of countries free from it. Six pandemics of cholera have been described. Currently, the seventh pandemic, caused by vibrio El Tor, is ongoing.
Classical cholera is common in India, Bangladesh, Pakistan, El Tor cholera - in Indonesia, Thailand and other countries of Southeast Asia. On the territory of Russia, mainly imported cases are recorded. Over the past 20 years, more than 100 cases of importation into seven regions of the country have been noted. The main reason for this is tourism (85%). There have been cases of cholera among foreign citizens.
The most severe was the cholera epidemic in Dagestan in 1994, where 2359 cases were registered. The infection was brought by pilgrims who made the Hajj to Saudi Arabia.
Like for everyone intestinal infections, for cholera in countries with a temperate climate, summer-autumn seasonality is characteristic.
Measures to prevent cholera
Non-specific prophylaxis
It is aimed at providing the population with good-quality drinking water, disinfecting wastewater, sanitary cleaning and improvement of populated areas, and informing the population. Employees of the epidemiological surveillance system are working to prevent the introduction of the pathogen and its spread on the territory of the country in accordance with the rules of sanitary protection of the territory, as well as a planned study of the water of open reservoirs for the presence of cholera vibrio in the sanitary protection zones of water intakes, places of mass bathing, port waters, etc. d.
Analysis of data on the incidence of cholera, examination and bacteriological examination (according to indications) of citizens who arrived from abroad are being carried out.
According to international epidemiological rules, persons arriving from cholera-prone countries are subject to a five-day observation with a single bacteriological examination.
A comprehensive plan of anti-epidemic measures is being carried out in the outbreak, including hospitalization of sick people and vibrio carriers, isolation of those who contacted and medical supervision followed by them for 5 days with a 3-fold bacteriological examination. Carry out current and final disinfection.
Emergency prevention includes the use antibacterial drugs(Table 17-9).
Table 17-9. Schemes for the use of antibacterial drugs in emergency prevention cholera
| A drug | Single dose inside, g | Multiplicity of application per day | Daily dose, g | Heading dose, g | Course duration, days |
| Ciprofloxacin | 0,5 | 2 | 1,0 | 3,0–4,0 | 3-4 |
| Doxycycline | 0.2 on day 1, then 0.1 each | 1 | 0.2 on day 1, then 0.1 each | 0,5 | 4 |
| Tetracycline | 0,3 | 4 | 1,2 | 4,8 | 4 |
| Ofloxacin | 0,2 | 2 | 0,4 | 1,6 | 4 |
| Pefloxacin | 0,4 | 2 | 0,8 | 3,2 | 4 |
| Norfloxacin | 0,4 | 2 | 0,8 | 3,2 | 4 |
| Chloramphenicol (levomycetin) | 0,5 | 4 | 2,0 | 8,0 | 4 |
| Sulfamethoxazole / biseptol | 0,8/0,16 | 2 | 1,6 / 0,32 | 6,4 / 1,28 | 4 |
| Furazolidone + kanamycin | 0,1+0,5 | 4 | 0,4+2,0 | 1,6 + 8,0 | 4 |
Note. When isolating vibrio cholerae sensitive to sulfamethoxazole + trimethoprim and furazolidone, pregnant women are prescribed furazolidone, children - sulfamethoxazole + trimethoprim (biseptol).
Specific prophylaxis
For specific prophylaxis, cholera vaccine and cholerogen anatoxin are used. Vaccination is carried out according to epidemic indications. A vaccine containing 8-10 vibrios per 1 ml is injected under the skin, the first time 1 ml, the second time (after 7-10 days) 1.5 ml. Children aged 2-5 years old are administered 0.3 and 0.5 ml, 5-10 years old - 0.5 and 0.7 ml, 10-15 years old - 0.7-1 ml, respectively. Cholerogen-anatoxin is injected once a year strictly under the skin below the angle of the scapula. Revaccination is carried out according to epidemic indications no earlier than 3 months after primary immunization.
Adults need 0.5 ml of the drug (also 0.5 ml for revaccination), children from 7 to 10 years old - 0.1 and 0.2 ml, respectively, 11–14 years old - 0.2 and 0.4 ml, 15– 17 years old - 0.3 and 0.5 ml. The International Certificate of Vaccination against Cholera is valid for 6 months after vaccination or revaccination.
cholera pathogenesis
The portal of entry for infection is digestive tract. The disease develops only when pathogens overcome the gastric barrier (usually observed in the period of basal secretion, when the pH of the gastric contents is close to 7), reach the small intestine, where they begin to multiply intensively and secrete exotoxin. Enterotoxin or cholerogen determines the occurrence of the main manifestations of cholera. Cholera syndrome is associated with the presence of two substances in this vibrio: protein enterotoxin - cholerogen (exotoxin) and neuraminidase. Cholerogen binds to a specific enterocyte receptor - ganglioside. Under the action of neuraminidase, a specific receptor is formed from gangliosides. The cholerogen-specific receptor complex activates adenylate cyclase, which initiates the synthesis of cAMP.
Adenosine triphosphate regulates by means of an ion pump the secretion of water and electrolytes from the cell into the intestinal lumen. As a result, the mucous membrane of the small intestine begins to secrete a huge amount of isotonic fluid, which does not have time to be absorbed in the large intestine - isotonic diarrhea develops. With 1 liter of feces, the body loses 5 g of sodium chloride, 4 g of sodium bicarbonate, 1 g of potassium chloride. The addition of vomiting increases the amount of fluid lost.
As a result, the volume of plasma decreases, the volume of circulating blood decreases and it thickens. The fluid is redistributed from the interstitial to the intravascular space. There are hemodynamic disorders, microcirculation disorders, resulting in dehydration shock and acute renal failure. Metabolic acidosis develops, which is accompanied by convulsions. Hypokalemia causes arrhythmias, hypotension, myocardial changes, and intestinal atony.
Clinical picture (symptoms) of cholera
Incubation period from several hours to 5 days, more often 2–3 days.
cholera classification
According to the severity of clinical manifestations, blurred, mild, moderate, severe and very severe form cholera, determined by the degree of dehydration.
IN AND. Pokrovsky distinguishes the following degrees of dehydration:
I degree, when patients lose a volume of fluid equal to 1-3% of body weight (erased and mild forms);
II degree - losses reach 4–6% (moderate form);
III degree - 7–9% (severe);
· IV degree of dehydration with a loss of more than 9% corresponds to a very severe course of cholera.
Currently, I degree of dehydration occurs in 50-60% of patients, II - in 20-25%, III - in 8-10%, IV - in 8-10% (Tables 17-10).
Table 17-10. Assessing the severity of dehydration in adults and children
| sign | Degree of dehydration, % weight loss | |||
| worn and light | moderate | heavy | very heavy | |
| 1–3 | 4–6 | 7–9 | 10 or more | |
| Chair | Up to 10 times | up to 20 times | Over 20 times | Without an account |
| Vomit | Up to 5 times | Up to 10 times | up to 20 times | Multiple (indomitable) |
| Thirst | Weak | Moderately pronounced | Pronounced | Insatiable (or cannot drink) |
| Diuresis | Norm | lowered | Oliguria | Anuria |
| convulsions | Not | Calf muscles, short-term | Prolonged and painful | Generalized clonic |
| State | Satisfactory | Medium | heavy | Very heavy |
| eyeballs | Norm | Norm | Sunken | sharply sunken |
| Mucous membranes of the mouth, tongue | Wet | dryish | Dry | Dry, sharply hyperemic |
| Breath | Norm | Norm | moderate tachypnea | Tachypnea |
| Cyanosis | Not | Nasolabial triangle | acrocyanosis | Pronounced, diffuse |
| Skin turgor | Norm | Norm | Decreased (skin fold expands >1 s) | Dramatically reduced (skin fold expands >2 s) |
| Pulse | Norm | Up to 100 per minute | Up to 120 min | Above 120 per minute, filiform |
| BP system, mm Hg | Norm | Up to 100 | 60–100 | Less than 60 |
| blood pH | 7,36–7,40 | 7,36–7,40 | 7,30–7,36 | Less than 7.3 |
| Voice sound | Saved | Saved | Hoarseness | Aphonia |
| Relative plasma density | Norm (up to 1025) | 1026–1029 | 1030–1035 | 1036 and more |
| Hematocrit, % | Norm (40–46%) | 46–50 | 50–55 | Above 55 |
The main symptoms and dynamics of their development
The disease begins acutely, without fever and prodromal phenomena.
First clinical signs are a sudden urge to defecate and discharge of mushy or watery stools from the very beginning.
Subsequently, these imperative urges are repeated. The stools lose their fecal character and often have the appearance of rice water: translucent, cloudy white in color, sometimes with floating flakes gray color, odorless or odorless fresh water. The patient notes rumbling and discomfort in the umbilical region.
In patients with mild form cholera defecation is repeated no more than 3-5 times a day, general well-being remains satisfactory, slight sensations of weakness, thirst, dry mouth. The duration of the disease is limited to 1-2 days.
With moderate severity(dehydration II degree) the disease progresses, vomiting joins the diarrhea, increasing in frequency. The vomit has the same rice water appearance as the stool. It is characteristic that vomiting is not accompanied by any tension and nausea. With the addition of vomiting, exsicosis progresses rapidly. Thirst becomes excruciating, the tongue is dry, with a "chalky coating", the skin, mucous membranes of the eyes and oropharynx turn pale, skin turgor decreases. Stool up to 10 times a day, plentiful, does not decrease in volume, but increases. Arise single convulsions calf muscles, brushes, stop, chewing muscles, unstable cyanosis of the lips and fingers, hoarseness.
Moderate tachycardia, hypotension, oliguria, hypokalemia develop.
The disease in this form lasts 4-5 days.
Severe form of cholera(III degree of dehydration) is characterized by pronounced signs of exsicosis due to abundant (up to 1–1.5 liters per defecation) stool, which becomes so already from the first hours of illness, and the same profuse and repeated vomiting. Patients are concerned about painful cramps in the muscles of the limbs and abdomen, which, as the disease progresses, change from rare clonic to frequent and even give way to tonic convulsions. The voice is weak, thin, often barely audible. The turgor of the skin decreases, the skin gathered in a fold does not straighten out for a long time. The skin of the hands and feet becomes wrinkled ("the washerwoman's hand"). The face takes on the appearance characteristic of cholera: pointed features, sunken eyes, cyanosis of the lips, auricles, earlobes, nose.
Palpation of the abdomen determines the transfusion of fluid through the intestines, the noise of splashing fluid. Palpation is painless. Tachypnea appears, tachycardia increases to 110–120 per minute. Pulse of weak filling (“thread-like”), heart sounds are muffled, blood pressure progressively falls below 90 mm Hg, first maximum, then minimum and pulse. Body temperature is normal, urination decreases and soon stops. The thickening of the blood is expressed moderately. Indicators of relative plasma density, hematocrit index and blood viscosity on upper bound norms or moderately increased. Pronounced hypokalemia of plasma and erythrocytes, hypochloremia, moderate compensatory hypernatremia of plasma and erythrocytes.
A very severe form of cholera(previously called algid) is characterized by a stormy sudden development disease that begins with massive continuous bowel movements and profuse vomiting. After 3-12 hours, the patient develops a severe condition of algid, which is characterized by a decrease in body temperature to 34-35.5 ° C, extreme dehydration (patients lose up to 12% of body weight - IV degree dehydration), shortness of breath, anuria, and hemodynamic disturbances by type hypovolemic shock. By the time the patients arrive at the hospital, they develop paresis of the muscles of the stomach and intestines, as a result of which the patients stop vomiting (replaced by convulsive hiccups) and diarrhea (gaping anus, free flow of "intestinal water" from the anus with light pressure on the anterior abdominal wall). Diarrhea and vomiting reappear during or after rehydration. The patients are in a state of prostration. Breathing is frequent, superficial, in some cases Kussmaul breathing is observed.
The color of the skin in such patients acquires an ashy hue (total cyanosis), "dark glasses around the eyes" appear, the eyes are sunken, the sclera is dull, the gaze is unblinking, the voice is absent. The skin is cold and clammy to the touch, easily folds and long time(sometimes within an hour) does not straighten out ("cholera fold").
Severe forms are more often noted at the beginning and in the midst of an epidemic. At the end of the outbreak and during the inter-epidemic period, mild and erased forms, indistinguishable from forms of diarrhea of a different etiology. Children under the age of 3 have the most severe cholera: they are less able to tolerate dehydration. In addition, children have a secondary lesion of the central nervous system: adynamia, clonic convulsions, impaired consciousness, up to the development of coma are observed. It is difficult to determine the initial degree of dehydration in children. In such cases, it is impossible to focus on the relative density of the plasma due to the large extracellular fluid volume. Therefore, it is advisable to weigh patients at the time of admission in order to most reliably determine their degree of dehydration. The clinical picture of cholera in children has some features: body temperature often rises, apathy, adynamia, a tendency to epileptiform seizures due to the rapid development of hypokalemia are more pronounced.
The duration of the disease ranges from 3 to 10 days, its subsequent manifestations depend on the adequacy of replacement treatment with electrolytes.
Complications of cholera
Due to violations of hemostasis and microcirculation in older patients age groups observed myocardial infarction, mesenteric thrombosis, acute insufficiency cerebral circulation. Phlebitis is possible (with vein catheterization), pneumonia often occurs in severe patients.
Diagnosis of cholera
Clinical diagnostics
Clinical diagnosis in the presence of epidemiological data and a characteristic clinical picture (the onset of the disease with diarrhea followed by the addition of vomiting, the absence pain syndrome and fever, the nature of vomit) is not complicated, however, mild, erased forms of the disease, especially isolated cases are often viewed. In these situations, laboratory diagnosis is crucial.
Specific and non-specific laboratory diagnostics
Main and decisive method laboratory diagnosis of cholera is bacteriological examination. Feces and vomit are used as material, feces are examined for vibrio-carrying; in persons who died from cholera, a ligated segment of the small intestine and gallbladder is taken.
When conducting a bacteriological study, it is necessary to observe three conditions: as soon as possible, sow the material from the patient (cholera vibrio remains in the feces for a short time); · the dishes in which the material is taken should not be disinfected with chemicals and should not contain traces of them, since Vibrio cholerae is very sensitive to them; Eliminate the possibility of contamination and infection of others.
The material must be delivered to the laboratory within the first 3 hours; if this is not possible, preservative media are used (alkaline peptone water, etc.).
The material is collected in individual vessels washed from disinfectant solutions, on the bottom of which a smaller vessel, disinfected by boiling, or sheets of parchment paper are placed. During shipment, the material is placed in a metal container and transported in a special vehicle with an attendant.
Each sample is provided with a label, which indicates the name and surname of the patient, the name of the sample, the place and time of taking, the alleged diagnosis and the name of the person who took the material. In the laboratory, the material is inoculated on liquid and solid nutrient media to isolate and identify a pure culture.
The results of express analysis are obtained after 2-6 hours (indicative response), accelerated analysis - after 8-22 hours (preliminary response), complete analysis - after 36 hours (final response).
Serological methods are of secondary importance and can be used mainly for retrospective diagnosis. For this purpose, microagglutination in phase contrast, RNHA can be used, but it is better to determine the titer of vibriocidal antibodies or antitoxins (antibodies to cholerogen are determined by ELISA or immunofluorescent method).
Differential Diagnosis
Differential diagnosis is carried out with other infections that cause diarrhea. Differential signs are given in table. 17-11.
Table 17-11. Differential Diagnosis cholera
| Epidemiological and clinical signs | Nosological form | ||||
| cholera | PTI | dysentery | viral diarrhea | traveler's diarrhea | |
| Contingent | Residents of endemic regions and visitors from them | No specifics | No specifics | No specifics | Tourists to developing countries with a hot climate |
| epidemiological data | The use of non-disinfected water, washing vegetables and fruits in it, bathing in polluted water bodies, contact with the patient | The use of food products prepared and stored in violation of hygiene standards | Contact with the patient, the use of mainly lactic acid products, violation of personal hygiene | Contact with the patient | Drinking water, food purchased from street vendors |
| focality | Often according to general epidemiological signs | Often among users of the same suspect product | Possible among contact persons who used a suspicious product | Often among contacts | Possible due to general epidemiological signs |
| First symptoms | loose stool | Epigastric pain, vomiting | Abdominal pain, loose stools | Epigastric pain, vomiting | Epigastric pain, vomiting |
| Subsequent symptoms | Vomit | loose stool | Tenesmus, false urges | loose stool | loose stool |
| Fever, intoxication | Missing | Often, simultaneously with dyspeptic syndrome or before it | Often, at the same time or earlier than dyspeptic syndrome | Often, moderately expressed | Characteristic, simultaneously with dyspeptic syndrome |
| Chair character | Calcium-free, watery, no characteristic odor | Fecal, liquid, offensive | Fecal or non-fecal (“rectal spit”) with mucus and blood | Fecal, liquid, frothy, with a sour odor | Fecal liquid, often with mucus |
| Stomach | Swollen, painless | Swollen, painful in the epi- and mesogastrium | Retracted, painful in the left iliac region | Swollen, slightly painful | moderately painful |
| Dehydration | II–IV degree | I-III degree | Possibly 1st or 2nd degree | I-III degree | I–II degree |
Diagnosis example
A 00.1. Cholera (coproculture of Vibrio eltor), severe course, III degree dehydration.
Indications for hospitalization
All patients with cholera or with suspicion of it are subject to mandatory hospitalization.
cholera treatment
Mode. diet for cholera
A special diet for cholera patients is not required.
Medical therapy
Basic principles of therapy: compensation for fluid loss and restoration of the electrolyte composition of the body; influence on the pathogen.
Treatment must begin in the first hours from the onset of the disease.
Pathogenic agents
Therapy includes primary rehydration (replacement of water and salt losses prior to treatment) and corrective compensatory rehydration (correction of ongoing water and electrolyte losses). Rehydration is seen as resuscitation event. In the emergency room, during the first 5 minutes, the patient must measure the pulse rate, blood pressure, body weight, take blood to determine the hematocrit or relative density of the blood plasma, electrolyte content, acid-base state, coagulogram, and then start inkjet introduction saline solutions.
The volume of solutions administered to adults is calculated using the following formulas.
Cohen formula: V \u003d 4 (or 5) × P × (Ht 6 - Htn), where V is the determined fluid deficit (ml); P - body weight of the patient (kg); Ht 6 - patient's hematocrit; Htn - hematocrit is normal; 4 - coefficient for a hematocrit difference of up to 15, and 5 - for a difference of more than 15.
Phillips formula: V = 4(8) × 1000 × P × (X – 1.024), where V is the determined fluid deficit (ml); P - body weight of the patient (kg); X is the relative density of the patient's plasma; 4 - coefficient at the density of the patient's plasma up to 1.040, and 8 - at a density above 1.041.
In practice, the degree of dehydration and, accordingly, the percentage of body weight loss is usually determined by the criteria presented above. The resulting figure is multiplied by body weight and the volume of fluid loss is obtained. For example, body weight 70 kg, dehydration III degree (8%). Therefore, the loss volume is 70,000 g 0.08 = 5600 g (ml).
Polyionic solutions, preheated to 38–40 °C, are administered intravenously at a rate of 80–120 ml/min at II–IV degrees of dehydration. Various polyionic solutions are used for treatment. The most physiological are Trisol® (5 g of sodium chloride, 4 g of sodium bicarbonate and 1 g of potassium chloride); acesol® (5 g sodium chloride, 2 g sodium acetate, 1 g potassium chloride per 1 liter of pyrogen-free water); chlosol® (4.75 g sodium chloride, 3.6 g sodium acetate and 1.5 g potassium chloride per 1 liter of pyrogen-free water) and lactasol® solution (6.1 g sodium chloride, 3.4 g sodium lactate, 0, 3 g of sodium bicarbonate, 0.3 g of potassium chloride, 0.16 g of calcium chloride and 0.1 g of magnesium chloride per 1 liter of pyrogen-free water).
Jet primary rehydration is carried out using catheterization of central or peripheral veins. After replenishment of losses, increase in blood pressure to the physiological norm, restoration of diuresis, cessation of seizures, the infusion rate is reduced to the required level in order to compensate for ongoing losses. The introduction of solutions is decisive in the treatment of seriously ill patients. As a rule, 15–25 minutes after the start of administration, pulse and blood pressure begin to be determined, and after 30–45 minutes shortness of breath disappears, cyanosis decreases, lips become warmer, and a voice appears. After 4-6 hours, the patient's condition improves significantly, he begins to drink on his own. Every 2 hours, it is necessary to monitor the patient's hematocrit (or relative density of blood plasma), as well as the content of blood electrolytes to correct infusion therapy.
Enter error large quantities 5% glucose solution®: not only does this not eliminate the electrolyte deficiency, but, on the contrary, reduces their concentration in plasma. Also transfusion of blood and blood substitutes is not shown. It is unacceptable to use colloidal solutions for rehydration therapy, as they contribute to the development of intracellular dehydration, acute renal failure and shock lung syndrome.
Oral rehydration is needed for cholera patients who do not vomit.
The WHO Expert Committee recommends the following composition: 3.5 g sodium chloride, 2.5 g sodium bicarbonate, 1.5 g potassium chloride, 20 g glucose, 1 l boiled water(solution screams). The addition of glucose® promotes the absorption of sodium and water in the intestines. WHO experts have also proposed another rehydration solution, in which bicarbonate is replaced by more stable sodium citrate (Rehydron®).
Glucosolan® has been developed in Russia and is identical to the WHO glucose-saline solution.
Water-salt therapy is stopped after the appearance of fecal stools in the absence of vomiting and the predominance of the amount of urine over the number of stools in the last 6-12 hours.
Etiotropic therapy
Antibiotics - additional remedy therapy, they do not affect the survival of patients, but reduce the duration of clinical manifestations of cholera and accelerate the cleansing of the body from the pathogen. Recommended drugs and schemes for their use are presented in Table. 17-12, 17-13. Apply one of the listed drugs.
Table 17-12. Schemes of a five-day course of antibacterial drugs for the treatment of patients with cholera (I-II degree of dehydration, no vomiting) in tablet form
| A drug | Single dose, g | Medium daily dose, G | Heading dose, g | |
| Doxycycline | 0,2 | 1 | 0,2 | 1 |
| Chloramphenicol (levomycetin®) | 0,5 | 4 | 2 | 10 |
| Lomefloxacin | 0,4 | 1 | 0,4 | 2 |
| Norfloxacin | 0,4 | 2 | 0,8 | 4 |
| Ofloxacin | 0,2 | 2 | 0,4 | 2 |
| Pefloxacin | 0,4 | 2 | 0,8 | 4 |
| Rifampicin + trimethoprim | 0,3 0,8 |
2 | 0,6 0,16 |
3 0,8 |
| Tetracycline | 0,3 | 4 | 1,2 | |
| 0,16 0,8 |
2 | 0,32 1,6 |
1,6 8 |
|
| Ciprofloxacin | 0,25 | 2 | 0,5 | 2,5 |
Table 17-13. Schemes of a 5-day course of antibacterial drugs for the treatment of patients with cholera (presence of vomiting, III-IV degree of dehydration), intravenous administration
| A drug | Single dose, g | Frequency of application, per day | Average daily dose, g | Heading dose, g |
| Amikacin | 0,5 | 2 | 1,0 | 5 |
| Gentamicin | 0,08 | 2 | 0,16 | 0,8 |
| Doxycycline | 0,2 | 1 | 0,2 | 1 |
| Kanamycin | 0,5 | 2 | 1 | 5 |
| Chloramphenicol (levomycetin®) | 1 | 2 | 2 | 10 |
| Ofloxacin | 0,4 | 1 | 0,4 | 2 |
| Sizomycin | 0,1 | 2 | 0,2 | 1 |
| Tobramycin | 0,1 | 2 | 0,2 | 1 |
| trimethoprim + sulfamethoxazole | 0,16 0,8 |
2 | 0,32 1,6 |
1,6 8 |
| Ciprofloxacin | 0,2 | 2 | 0,4 | 2 |
Clinical examination
Discharge of patients with cholera (vibrion carriers) is carried out after their recovery, completion of rehydration and etiotropic therapy and receiving three negative bacteriological examination results.
Those who have undergone cholera or vibrio-carrying after being discharged from hospitals are allowed to work (study), regardless of profession, they are registered in the territorial departments of epidemiological surveillance and QIZ of polyclinics at the place of residence. Dispensary observation is carried out for 3 months.
Those who have had cholera are subject to a bacteriological examination for cholera: in the first month, a bacteriological examination of feces is carried out once every 10 days, then once a month.
If vibrio carriers are detected in convalescents, they are hospitalized for treatment in infectious diseases hospital, after which dispensary observation of them is resumed.
Those who have undergone cholera or vibrio-carrying are removed from the dispensary record if cholera vibrios are not isolated during the dispensary observation.
