Gastrointestinal infections Prof. MUDr. Petr Husa, CSc. Klinika infekčních chorob LF MU a FN Brno Global significance of GI infections •Estimates are that over 1.8 million children still die each year (more than 6000/day) •The second most common infections in developed countries (after respiratory infections) j0286672 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Campylobacter 20 175 20 371 21 164 18 811 18 412 18 389 20 903 21 102 24291 24508 23780 Salmonella 11 009 10 805 8 622 8 752 10 507 10 280 13 633 12 739 11912 11779 11359 Shigella 229 178 450 164 266 257 92 88 70 168 145 Bacterial other 3 305 3 178 3 343 4 607 5 168 5 797 6 763 8 146 7563 7371 8116 Viral 6 639 6 066 8 517 9 955 6 877 7 778 9 438 18 858 9491 9986 9694 Food poisoning 84 106 100 381 14 203 177 793 127 3 237 j0178242 Gastrointestinal infections in CR 2008-2018 Gastrointestinal infections •bacterial • •viral • •parasitic Bacterial GI infections •transmission of pathogenic microbs •- zoonosis •- human • •food-poisoning (toxins in food) Zoonosis •salmonellosis (S. Enteritidis) • •campylobacteriosis (C. jejuni) • •yersiniosis (Y. enterocolitica) • •EHEC (E. coli) Campylobacteriosis •now the most common zoonosis in CR a many other European countries (especially undercooked poultry) •Campylobacter jejuni •clinical course – from inaparent to serious acute enterocolitis with right lower abdominal quadrant pain, fever, and bloody diarrhoea •sepsis is possible in IS patients •reactive arthritis, erythema nodosum – possible immune-mediated complications •rehydration, diet, complicated forms: macrolides • Campylobacteriosis in Southern Moravia 2014-2018 C:\Users\33550\Pictures\Image Library One\My Images\Lékařské\Amébovýabsces jater\bakteriální abscesy jater\P1010005.JPG C:\Users\33550\Pictures\Image Library One\My Images\Lékařské\Amébovýabsces jater\bakteriální abscesy jater\P1010001.JPG Salmonellosis •the second most common zoonosis in CR and most European countries •at present in CR minimally 90 % cases caused by S. Enteritis, rarely S. Typhimurium •gastroenteritidis •enterotoxin production and active penetration into intestinal epithel •septic form (extraintestinal abscesses) in IS patients •reactive arthritis, erythema nodosum – possible immune-mediated complications •rehydration, diet, complicated forms: fluoroquinolones, co-trimoxazol, ampicilin, chloramphenicol Salmonellosis in Southern Moravia 2014-2018 Yersiniosis •worldwide zoonosis, relatively more common in Nothern Europe •Yersinia enterocolitica •more often in winter •fever, diarrhea, often bloody, syndrome of the lower right quadrant (mesenterial lymphadenitis) •complication: sepsis, metastatic abscesses (esp. liver) •reactive arthritis, erytema nodosum - possible immune-mediated complications •rehydration, diet, complicated forms: fluoroquinolones, co-trimoxazol, ampicilin, chloramphenicol • • Human bacterial infections •cholera •shigellossis •E.coli enterocolitis (except for EHEC – zoonosis) •Clostridium difficile infection • Cholera •endemic in South and South-East India •Vibrio cholerae faecally contaminated water – drinking water, undercooked animals from this water •boiling destroys this bacteria •at least 7 cholera pandemics worldwide during last 200 years •1st-6th pandemics - classic type (1817-1923) •7th pandemic - biotyp El Tor (since 1960s) •8th pandemic - O139 Bengal (since 1992) cholera mapka Cholera – 7th and 8th pandemics Cholera •enterotoxin production - profuse diarrhea, vomiting and rapid dehydration (especially when is the infection caused by classic type) •the collection of stool by special swabs and culture •the necessity of quick rehydration •antibiotics – above all epidemiological significance (fluroquinolones, co-trimoxazol, doxicycline, chloramphenicol) •vaccination available (combinated vaccine with ETEC), not generally recommended – low efficacy, short duration of protection cholera scan cholera stolice Shigellosis •one of the most contagious intestinal infections •associated with poor hygiene conditions – war conflicts, natural catastrophes •Shigella sonnei, S. flexneri •colitis (tenesmus, often mucus, pus, and blood in stool) •rehydration, diet, complicated forms: fluoroquinolones, co-trimoxazol, ampicilin, chloramphenicol • E. coli enterocolitis •Enterotoxigenic - ETEC •Enteroinvasive - EIEC •Enteropathogenic - EPEC •Enterohemorrhagic - EHEC •Enteroagregative - EAEC •Diffuse adherent Clostridium difficile infection (CDI) •C. difficile - G+ anaerobic spore-forming bacteria •spores survive for many months outside an organism – extremely resistant •common nosocomial infections in developed countries •development of vegetative forms in the colon •production of exotoxins (usually both at once) •- toxin A (enterotoxin – necrotic) •- toxin B (cytotoxin) •- binary toxin (unknown mechanism) CDI in CR 2007-2016 Source: Epidat c Important factors for CDI •presence of toxigenic strain of C.difficile •antibiotic treatment – aminopenicilins, cephalosporins, lincosamides… •less frequently without antibiotic treatment – oncologic patients •age ≥ 65 years, comorbities, IS •function of GI tract – peristalsis, only parenteral nutrition, disturbances of mucous immunity Long-term impacts of antibiotic exposure on the human intestinal microbiota. Jernberg C., Löfmark S, Edlund Ch. et al. Microbiology (2010), 156, 3216–3223 CDI – clinical forms •a) asymptomatic carriers (2-3 % of adults, in children much more, prevalence is increasing with the length of hospitalization - 10-25 % or more) •b) uncomplicated colitis (diarrhea, fever, no pseudomembranes) •c) pseudomembranous colitis - PMC (sepsis, leucocytosis, abdominal pain, and bloody stool) •d) toxic megacolon (paresis and necrosis of the gut, possible perforation, infectious shock) C:\Users\33550\Pictures\Image Library One\My Images\Lékařské\Clostridium difficile\rektum.JPG C:\Users\33550\Pictures\Image Library One\My Images\Lékařské\Clostridium difficile\P1010006.JPG Diagnosis of CDI •antibiotics in history •clinical findings •microbiological testing – detection of toxins (ELISA), specific antigen (GDH), culture, cytotoxic test, PCR •coloscopy (pseudomembranes) •ultrasound, CT – auxilliary methods fig 3 CDI therapy •termination of ATB therapy •colitic diet, rehydration, rehabilitation •do not use antimotility drugs - danger of toxic megacolon •pharmacotherapy – 10-14 days •vancomycin 4 × 125 mg oral •fidaxomicin 2 × 200 mg oral •faecal bacteriotherapy – faecal transplant •colectomy • • • Food poisining •with short incubation period (1-6 hours)-termostabile toxins – nausea, vomiting •Staphylococcus aureus •Bacillus cereus •with long incubation period (6-18 hours)- termolabile toxins - diarrhea •Bacillus cereus •Clostridium perfringens A •absence of fever, outbreaks •rehydration, diet Viral gastroenteritis •noroviruses (Norwalk, Norwalk-like virus) – older children, adults •rotaviruses (small children- 6-24 months, seniors) – fecal-oral, air-borne infection, vaccine available •adenoviruses •astroviruses •coronaviruses • •symptomatic therapy Viral GI infections in Southern Moravia 2014-2018 C:\Users\33550\Pictures\norovirus.jpg Norovirus Incubation periods of GI infections Pathogen Incubation period Campylobacter 1-7 days Salmonella 6-48 hours Yersinia 4-10 days Shigella 1-5 days Clostridium difficile 3-30 days Staphylococcus aureus 1-6 hours Bacillus cereus termostabile toxin 1-6 hours Bacillus cereus termolabile toxin 8-16 hours Clostridium perfringens A 8-16 hours Rotavirus 1-2 days Adenovirus 1-2 days Norovirus 18-72 hours Parasitic infection of GI tract •protozoal •helmintic •fungal Protozoal infections •Human •Amebiasis (Entamoeba histolytica) •Lambliasis = girardiasis (L., G. intestinalis) •Zoonotic •cryptosporidiosis (Cryptosporidium parvum) •isosporosis (Isospora belli) •microsporidiosis (Enterocytozoon bineusi) •cyclosporosis (Cyclospora cayetanensis) • Amebiasis_LifeCycle Amebiasis Entamoeba histolytica améba - střevo Amebic colitis absces pred drenazi CT – day 0 Amebic abscess absces drenaz CT – drainage of 2 abscesses – day 2 Amebic abscess absces uvodni UZ US – day 0 absces posledni UZ US – day 5 břicho 1 pytlík zkumavka 3 amépa punkce abscesu Amebic abscess – transcutaneus punction Giardia_LifeCycle Lambliasis, girardiasis Lamblia, Giardia intestinalis lamblie mikro Lambliasis microscopy lamblie scan Lambliasis scan Helmintic GI infections •Roundworms (Nematodes) - ascariosis, enterobiosis=oxyuriosis, trichuriosis •Tapeworms (Cestodes) - teniosis, diphylobotriosis, hymenolepsiosis, echinococcosis, alveococcosis •Flukes (Trematodes) - schistosomosis Roundworms (Nematodes) •Ascaris lumbricoides •Enterobius, Oxyuris vermicularis •Trichuris trichiura • Ascariasis_LifeCycle Ascariosis Ascaris lumbricoides škrkavka škrkavky ze zadku škrkavka žlučovod škrvka ileus Trichuris_LifeCycle Trichuriosis Trichuris trichiura trichuris trichuris prolaps rekta Enterobius_LifeCycle Enterobiosis, oxyuriosis Enterobius, Oxyuris vermicularis roupy vyšetření Enterobiosis, oxyuriosis Tapeworms (Cestodes) •Man as final host •Taenia saginata •Taenia solium •Diphyllobotrium latum, D. pacificum •Hymenolepsis nana • •Animal as final host •Echinococcus granulosus •Echinococcus (Alveococcus) multilocularis • • • Taenia_LifeCycle Taeniosis Taenia saginata Taenia solium Cysticercosis_LifeCycle Cysticercosis Taenia solium hlavičky tasemnic Taenia solium Taenia saginata taenia saginata červ Taenia solium taenia saginata červ2 Taenia saginata cysticerkóza u prasete Cysticercosis (pig) cysticerkóza člověk Cysticercosis (man) cysticerkóza kráva Cysticercosis (cow) Echinococcus_LifeCycle Echinococcosis Alveococcosis E. granulosus, E.multilocularis echinokok červ Echinococcus granulosus (dog) echinokok CT Echinococcus granulosus – liver cysts (man) echinokok cysta Echinococcus granulosus – liver cysts (man) Flukes (Trematodes) •schistosomiasis (bilharsiasis) •S. hematobium •S. intestinalis (mansoni) •S. japonicum •S. mekongi • Schistomes_LifeCycle Schistosomosis, bilharziosis schistosoma šneci schistosoma koupání Katayama fever schistosoma ascites schistosoma kalcifikace Fungal GI infections •about all candidiasis •different members of Candida sp. (mostly C.albicans) •mounth cavity, oesophagus, anorectal •mostly IS patients •fluconazol, itraconazol, ketoconazol, amphotericin B husa-tenisky Thank you for your attention! Husa.petr@fnbrno.cz