Bacterial and viral gastrointestinal infections Prof. MUDr. Petr Husa, CSc. Klinika infekčních chorob LF MU a FN Brno Acute gastroenteritis •Acute gastroenteritis is an inflammatory infection of the stomach and gut •Gastrointestinal infections encompass a wide variety of symptoms and recognized infectious agents •The most common symptoms associated with acute gastroenteritis are nausea, vomiting and diarrhoea •Estimates are that over 1.8 million children still die each year (more than 6000/day) due to GI infections •Diarrhoea is estimated to account for 18% of all death in children younger than 5 years •The second most common infections in developed countries (after respiratory infections) •Clostridium difficile infection is still serious problem in many well-developed countries – it is a typical hospital-acquired infection 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Campylobacter 20 175 20 371 21 164 18 811 18 412 18 389 20 903 21 102 24291 24508 23780 23169 Salmonella 11 009 10 805 8 622 8 752 10 507 10 280 13 633 12 739 11912 11779 11359 13314 Shigella 229 178 450 164 266 257 92 88 70 168 145 134 Bacterial other 3 305 3 178 3 343 4 607 5 168 5 797 6 763 8 146 7563 7371 8116 8137 Viral 6 639 6 066 8 517 9 955 6 877 7 778 9 438 18 858 9491 9986 9694 12056 Food poisoning 84 106 100 381 14 203 177 793 127 3 237 38 j0178242 Gastrointestinal infections in CR 2008-2019 Gastrointestinal infections •bacterial • •viral • •parasitic Bacterial GI infections •transmission of pathogenic microbes •- zoonosis •- human • •food-poisoning (toxins in food) Zoonosis • •campylobacteriosis (C. jejuni) •salmonellosis (S. Enteritidis) •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, Guillain-Barré syndrome – possible immune-mediated complications •rehydration, diet, complicated forms: macrolides, doxycycline, cotrimoxazole, for septic forms: 3rd generation cephalosporins, carbapenems, aminoglycosides • Campylobacteriosis in Southern Moravia 2015-2019 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 •according to the current Salmonella nomenclature system of CDC and WHO the full taxonomic designation Salmonella enterica subspecies enterica serotype Enteritidis (Typhimurium) can be shortened to Salmonella Enteritidis (Typhimurium) •gastroenteritidis •enterotoxin production and active penetration into intestinal epithel •septic form (extraintestinal abscesses) in IS patients •reactive arthritis, erythema nodosum, Guillain-Barré syndrome – possible immune-mediated complications •rehydration, diet, complicated forms: cotrimoxazole, ampicillin, aminoglycosides, 3rd generation cephalosporins Salmonellosis in Southern Moravia 2015-2019 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, Guillain-Barré syndrome - possible immune-mediated complications •rehydration, diet, complicated forms: cotrimoxazole, doxycycline, aminoglycosides, and 3rd generation cephalosporines • • Human bacterial infections •cholera •shigellossis •E.coli enterocolitis (except for EHEC – zoonosis) •Clostridium difficile infection • Cholera •Historically 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 is now endemic in more than 50 countries •There an estimated 3 to 5 million cholera cases , resulting in approximately 100 000 death each year 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 (cotrimoxazole, doxycycline, ampicillin, chloramphenicol, or fluoroquinolones) •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:(cotrimoxazole, ampicillin, chloramphenicol, or fluoroquinolones • 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 2007-2018 Source: Epidat, ISIN 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 – thickness of the wall of the gut fig 3 CDI therapy •termination of initial 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 - diarrhoea •Bacillus cereus •Clostridium perfringens type A • •absence of fever, small 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 2015-2019 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 husa-tenisky Thank you for your attention! Husa.petr@fnbrno.cz