Organization of dispensary observation of recovered infectious diseases - general principles, definitions, theory, practice, methods. Dysentery (shigellosis) Viral hepatitis A

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Diarrhea and gastroenteritis of suspected infectious origin (A09)

Short description

Approved
minutes of the meeting of the Expert Commission
on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 18 dated 19.09.2013

Diarrhea represents the excretion of pathologically loose stools, usually at least three times within 24 hours.

I. INTRODUCTION

Protocol name: Diarrhea and gastroenteritis of suspected infectious origin
Protocol code:

ICD codeX:
A01 - Other Salmonella infections
A02 - Salmonella infections
A03 - Shigellosis
A04 - Other bacterial intestinal infections
A05 - Other bacterial food poisoning
A06 - Amoebiasis
A07 - Other protozoal intestinal diseases
A08 - Viral and other specified enteric infections
A-09-Diarrhea and gastroenteritis of suspected infectious origin

Protocol development date: 2013

Abbreviations used in the protocol:
GP - general practitioner
GIT - gastrointestinal tract
ischemic heart disease
ITSH - infectious-toxic shock
ELISA- enzyme immunoassay
ACS - acute coronary syndrome
PHC - primary health care
RNGA - reaction of indirect hemagglutination
RPHA - passive hemagglutination reaction
Ultrasound - ultrasonography
ECG - electrocardiography
E - Escherichia
V. - Vibrio
Y.-Yersinia

Patient category: adult patients of polyclinics and infectious diseases hospitals / departments, multidisciplinary and specialized hospitals, pregnant women, women in labor and puerperas of maternity hospitals / perinatal centers.

Protocol Users:
- PHC GP, primary health care physician, primary health care infectious disease specialist;
- an infectious disease specialist at an infectious diseases hospital/department, a therapist at multidisciplinary and specialized hospitals, an obstetrician-gynecologist at maternity hospitals/perinatal centers.

Classification

Clinical classification

The World Gastroenterological Organization defines the following possible causes of acute diarrhea

According to the etiological factor

Infectious causes of acute diarrhea

According to the topical diagnosis of gastrointestinal lesions: gastritis, enteritis, colitis, gastroenteritis, enterocolitis, gastroenterocolitis.

According to the severity of the disease(mild, moderate, severe form) in accordance with the severity of intoxication and / or exsicosis syndromes. With the maximum severity of these syndromes, this is defined in the diagnosis as a complication (ITS, hypovolemic shock).

salmonellosis
I. Gastrointestinal form(localized):
Flow options:
1. Gastritis
2. Gastroenteric
3. Gastroenterocolitic

II. Generalized form
Flow options:
1. With intestinal phenomena
2. Without intestinal phenomena:
a) typhoid
b) septicopyemic

III. Bacteriocarrier of Salmonella(permanent, transient, convalescent).

shigellosis
I. Acute shigellosis:
1. Colitis form (mild, moderate, severe, very severe, erased)
2. Gastroenterocolitic form (mild, moderate, severe, very severe, obliterated)

II. Shigella bacteria carrier

III. Chronic shigellosis:
1. Recurrent
2. Continuous

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of diagnostic measures

Main
1. Complete blood count
2. Urinalysis
3. Coprological examination
4. Bacteriological examination of feces

Additional
1. Bacteriological examination of vomit
2. Bacteriological examination of blood and urine
3. RPHA (RNHA, ELISA) of blood with specific antigenic diagnosticums
4. Concentration of electrolytes in blood serum
5. Bacteriological examination of feces to isolate Vibrio cholerae
6. Endoscopic examination of the intestinal cavity: sigmoidoscopy, colonoscopy (in the differential diagnosis of acute bacterial diarrhea with protozoan intestinal invasions, ulcerative colitis, Crohn's disease, neoplastic diseases).
7. Plain radiography of the abdominal organs
8. ECG
9. Ultrasound of the abdominal organs
10. Ultrasound of the pelvic organs
11. Virtual CT Colonoscopy
12. Surgeon's consultation
13. Consultation with a gynecologist
14. Consultation with a cardiologist

Diagnostic criteria

Complaints and anamnesis:
- acute onset of diarrhea;
- fever;
- nausea, vomiting;
- stomach ache;
- voiced and short intestinal noises;
- nature of bowel movements: loose stools more than 3 times a day;
- there may be blood in the stool;
- in some cases - tenesmus, false urges.
- the use of suspicious products;
- the duration of diarrhea is not more than 14 days;
- members of the family or team at work have similar symptoms;
- with an incubation period of less than 18 hours, toxin-mediated food poisoning is suspected;
- if symptoms appear on the 5th day or later, it can be assumed that diarrhea is caused by protozoa or helminths.

Physical examination:
In acute diarrheal (intestinal) infections, the following syndromes are distinguished:
1. Intoxication (fever, tachycardia / bradycardia);

2. Lesions of the gastrointestinal tract.

gastritis syndrome:
- heaviness in the epigastrium;
- nausea;
- vomiting, bringing relief;

Enteritis syndrome:
- pain in the umbilical and right iliac region;
- profuse, watery, frothy, fetid stools, there may be lumps of undigested food;
- the color of the stool is light, yellow or greenish;
- in severe cases, stools may look like a translucent whitish turbid liquid with flaky suspended particles;
- on palpation, there is a "noise of splashing intestines";

Colitis Syndrome:
- cramping pains in the lower abdomen, left iliac region;
- false urge to defecate, tenesmus, feeling of incomplete emptying of the intestine;
- stools are scanty, mushy or liquid with an admixture of mucus, blood, pus;
- with severe colitis, stools with each bowel movement become more and more scarce, lose their fecal character (“rectal spit”);
- with the development of a hemorrhagic process in the terminal sections of the colon, the stool consists of mucus with streaks of blood, when hemorrhages are localized mainly in the right half of the colon, the mucus is evenly colored red or brown-red;
- palpation of the sigmoid colon has the character of a dense, painful, rigid cord.

3. Dehydration (dehydration, exicosis)

Clinical and laboratory characteristics of the dehydration syndrome in acute diarrheal infections (according to V.I. Pokrovsky, 2009) .

At moderate form - the temperature rises to 38-39 ° C, the duration of fever is up to 4 days, repeated vomiting, stools up to 10 times a day, the duration of diarrhea is up to 7 days; tachycardia, a decrease in blood pressure are noted, dehydration of the I-II degree, fluid loss up to 6% of body weight may develop.

Severe course disease characterized by high fever (above 39°C), which lasts 5 or more days, severe intoxication. Vomiting is repeated, observed for several days; stools more than 10 times a day, copious, watery, fetid, may be mixed with mucus. Diarrhea lasts up to 7 days or more. There is cyanosis of the skin, tachycardia, a significant decrease in blood pressure. Changes in the kidneys are revealed: oliguria, albuminuria, erythrocytes and casts in the urine, the content of residual nitrogen increases. Acute renal failure may develop. Violated water-salt metabolism (dehydration II-III degree), which manifests itself in dry skin, cyanosis, aphonia, convulsions. Fluid loss reaches 7-10% of body weight. In the blood, the level of hemoglobin and erythrocytes increases, moderate leukocytosis is characteristic with a shift of the leukocyte formula to the left.

Laboratory research

General blood analysis:
- normo-, leukocytosis (normal indicators of leukocytes in the blood: 4-9 10 9 / l);
- shift of the leukocyte formula to the left (normal values ​​of neutrophils in the blood: stab 1-6%; plasma cells - absent; segmented - 47-72%);
- relative erythrocytosis, relative hyperchromia, with a change in hematocrit develops with large fluid losses and thickening of the blood (normal blood counts: erythrocytes: male 4-5 10 12 / l, female 3-4 10 12 / l; color index is calculated according to the formula: hemoglobin (g/l) / number of erythrocytes 3 = 0.9-1.1 hematocrit: male 40-54%, female 36-42%, hemoglobin: male 130-150 g/l, female 120-140 g/l);
- thrombocytopenia in severe cases (normal platelet counts in the blood: 180-320 10 9 /l);
- ESR within the normal range or slightly increased (normal ESR values ​​are 6-9 mm / h).

General urine analysis:
- toxic albuminuria and cylindruria in severe cases (normal urine values: total protein less than 0.033 g/l; casts are absent).

Coprogram:
- an admixture of mucus and leukocytes, erythrocytes;
- detection of protozoa and helminth eggs.

Bacteriological examination of feces- sowing feces on nutrient media to isolate the pathogen.

If there is vomiting bacteriological examination of vomit- inoculation of vomit on nutrient media to isolate the pathogen.

If you suspect salmonellosis, or bacteremia of another etiology - bacteriological examination of blood and urine- sowing blood and urine on nutrient media to isolate the pathogen.

RPGA (RNGA) blood with specific antigenic diagnosticums - the study is carried out twice with an interval of 5-7 days. Diagnostic value has an increase in antibody titers by 2-4 times with repeated reactions.

AT ELISA diagnostic value have IgM.

Serum electrolyte concentration - decreases (normal blood counts: potassium 3.3-5.3 mmol/l, calcium 2-3 mmol/l, magnesium 0.7-1.1 mmol/l, sodium 130-156 mmol/l, chlorides 97-108 mmol/l) .

Instrumental Research
Sigmoidoscopy, colonoscopy:
Indications: if a tumor is suspected, ulcerative colitis, Crohn's disease; preservation of pathological impurities in the feces of patients with diarrhea, intestinal bleeding, intestinal obstruction, the presence of foreign bodies.
Contraindications: extremely serious condition of the patient, late stages of heart and lung failure, fresh myocardial infarction, acute typhoid-paratyphoid disease, acute diverticulitis, peritonitis, abdominal surgery, severe forms of ulcerative and ischemic colitis, fulminant granulomatous colitis, technical difficulty in carrying out research (rectal cancer), pregnancy.

Ultrasound of the abdominal organs - in differential diagnostic cases, free fluid (ascites, peritonitis), the size of the liver and spleen, portal hypertension, volumetric processes are detected.

Ultrasound of the pelvic organs- in case of suspected acute gynecological pathology.

ECG- if there is a suspicion of damage to the heart muscle of a toxic, inflammatory or ischemic nature.

Plain radiography of the abdominal organs- in case of suspected intestinal obstruction in order to detect "Cloiber bowls".

Virtual CT Colonoscopy- for differential diagnosis of somatic and oncological colon and rectosigmoid junction.

Indications for expert advice:
Consultation of the surgeon - if you suspect appendicitis, thrombosis of mesenteric vessels, intestinal obstruction.
Consultation of a gynecologist - in case of suspected ectopic pregnancy, ovarian apoplexy, salpingo-oophoritis.
Consultation with a cardiologist - in case of suspected acute coronary syndrome.

Differential Diagnosis

The main differential diagnostic signs of acute intestinal infections

Diagnosis examples:
A02.0. Salmonellosis, gastrointestinal form, gastroenteric variant, severe severity (Salmonellae enteritidis from feces dated 22.08.2013). Complication. ITSH II degree.
A03.1 Acute shigellosis, colitis variant, moderate severity (Shigella flexneri from feces dated 22.08.2013).

Treatment

Treatment goals:
1. Relief of symptoms of intoxication
2. Restoration of water and electrolyte balance
3. Normalization of the stool
4. Eradication of the pathogen

Treatment tactics

Non-drug treatment:
Mode - bed with severe intoxication and fluid loss.
Diet - table number 4.

Medical treatment

Ambulatory treatment:
1. Oral rehydration(with dehydration of I-II degree and absence of vomiting): glucosolan, citroglucosolan, rehydron. Oral rehydration with 2 liters of rehydration fluid for the first 24 hours. On the next day, 200 ml after each regular stool or vomiting. Rehydration therapy is carried out in two stages, the duration of stage I (primary rehydration - replenishment of fluid losses that developed before the start of therapy) - up to 2 hours, stage II (compensatory rehydration - replenishment of ongoing losses) - up to 3 days. Volume 30-70 ml/kg, speed 0.5-1.5 l/h.

2. Sorbents(smectite, smectite, activated carbon, polyphepan).

3. Pro-, pre-, eubitoics

Hospital treatment:
1. Oral rehydration.

2. Parenteral rehydration therapy crystalloid solutions: chlosol, acesol, trisol. It is carried out in two stages, the duration of stage I is up to 3 hours, stage II - according to indications up to several days (in the absence of vomiting, a transition to oral fluid intake is possible). Volume 55-120 ml/kg, average speed 60-120 ml/min.

3. Sorbents(Smectite, smectite, activated carbon, polyphepan).

4. Pro-, pre-, eubitoics(sterile concentrate of metabolic products of intestinal microflora 30-60 drops 3 times a day for up to 10 days; Bifidobacterium longum, Enteroccocus faetcium capsules 1 capsule 3 times for 3-5 days; Linex 1 capsule 3 times for 3-5 days ).

5. Indications for antibiotic therapy:
1. severe symptoms of the disease (if diarrhea is accompanied by fever that does not stop within 6-24 hours);
2. colitis with shigellosis, severe salmonellosis, escherichiosis:
First choice drug:
- Preparations of the fluoroquinolone series (ciprofloxacin 500 mg 2 times a day for 5 days);
Alternative drugs:
- Antibiotics of the tetracycline series (doxycycline 0.1 g 1-2 times a day for 5 days);
- Metronidazole (for suspected amebiasis) 750 mg 3 times a day for 5 days (10 days for severe form).

6. Antiemetics only with persistent nausea and severe intractable vomiting: methaclopromide 10 mg / m or 1 tb (10 mg).

7. In the presence of vomiting, gastric lavage probeless method, if the patient's condition allows. Symptoms of damage to the cardiovascular system require a mandatory ECG study before gastric lavage in order to exclude ACS.

Avoid prescribing drugs that suppress intestinal motility (loperamide), due to the possible development of severe colitis, toxic dilatation of the large intestine (megacolon), bacterial contamination of the small intestine.

List of basic and additional medicines

List of essential medicines:
1. Salts for the preparation of oral glucose-electrolyte solutions, powder;
2. Smectite, smectite, powder for suspension, activated charcoal tablets for oral administration;
3. Sterile concentrate of metabolic products of intestinal microflora drops for oral administration 30 ml, 100 ml;
4. Bifidobacterium longum, Enteroccocus faetcium capsules.
5. Linex capsules.

List of additional medicines:
1. Drotaverine tablets 40 mg, 80 mg; solution for injection 40 mg/2 ml, 20 mg/ml, 2%;
2. Pancreatin enteric-coated tablets 25 IU, 1000 IU, 3500 IU; enteric-coated capsule containing minimicrospheres 150 mg, 300 mg; powder; dragee;
3. Glucose solution for infusions 5%;
4. Sodium chloride - 6.0; potassium chloride - 0.39, magnesium chloride - 0.19; sodium bicarbonate - 0.65; sodium phosphate monosubstituted - 0.2; glucose - 2.0 solution for infusion;
5. Sodium chloride solution for infusion;
6. Sodium acetate for infusion;
7. Potassium chloride for infusions.
8. Ciprofloxacin tablets, film-coated 250 mg, 500 mg, 750 mg, 1000 mg;
9. Metronidazole coated tablets 250 mg, 400 mg, 500 mg;
10. Salmonella bacteriophage tablets with acid-resistant coating.

Other types of treatment: no.

Surgical intervention: no.

Preventive actions :
- early detection and isolation of patients and bacteria carriers,
- clinical and laboratory examination of contact persons,
- epidemiological examination and disinfection in the focus of infection,
- strict observance of the rules for the discharge of convalescents,
- dispensary observation of patients who have been ill in the office of infectious diseases in the clinic.

Further management
The discharge of convalescents after dysentery and other acute diarrheal infections (except for salmonellosis) is carried out after a complete clinical recovery.

A single bacteriological examination of convalescents of dysentery and other acute diarrheal infections (with the exception of toxin-mediated and opportunistic pathogens such as Proreus, Citrobacter, Enterobacter, etc.) is carried out on an outpatient basis within seven calendar days after discharge, but not earlier than two days after the end of antibiotic therapy.

Dispensary observation after acute dysentery is subject to:
1) employees of public catering facilities, food trade, food industry;
2) employees of psycho-neurological dispensaries, orphanages, orphanages, nursing homes for the elderly and disabled.

Dispensary observation is carried out within one month, at the end of which a single bacteriological examination is obligatory.

The frequency of visits to the doctor is determined by clinical indications.

Dispensary supervision is carried out by a local doctor (or family doctor) at the place of residence or by a doctor in the office of infectious diseases.

With a recurrence of the disease or a positive result of a laboratory examination, people who have had dysentery are treated again. After the end of treatment, these persons undergo monthly laboratory examinations for three months. Persons whose bacteriocarrier continues for more than three months are treated as patients with a chronic form of dysentery.

Persons with chronic dysentery are on dispensary observation during the year. Bacteriological examinations and examination by an infectious disease doctor of these persons are carried out monthly.

An extract of salmonellosis convalescents is carried out after a complete clinical recovery and a single negative bacteriological examination of feces. The study is carried out no earlier than three days after the end of treatment.

Dispensary observation after the illness is subject only to the decreed contingent.

Dispensary observation of persons who have been ill with salmonellosis is carried out by a doctor in the office of infectious diseases or district (family) doctors at the place of residence.

Treatment effectiveness indicators:
- normalization of body temperature;
- disappearance of symptoms of intoxication;
- disappearance of nausea and vomiting;
- normalization of the stool;
- restoration of water and electrolyte balance.

Hospitalization

Indications for hospitalization indicating the type of hospitalization

Emergency hospitalization - severe degree, presence of complications, ineffectiveness of outpatient treatment (persisting vomiting; fever lasting more than 24 hours; increasing degree of dehydration).

Clinical indications for hospitalization of patients with acute intestinal infections:
1) forms of the disease, aggravated by concomitant pathology;
2) prolonged diarrhea with dehydration of any degree;
3) chronic forms of dysentery (with exacerbation).

Epidemiological indications for hospitalization of patients with acute intestinal infections:
1) the inability to comply with the necessary anti-epidemic regime at the place of residence of the patient (socially disadvantaged families, hostels, barracks, communal apartments);
2) cases of disease in medical organizations, boarding schools, orphanages, orphanages, sanatoriums, nursing homes for the elderly and disabled, summer recreational organizations, rest homes.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Treatment of diarrhea. Manual for physicians and other senior health workers: World Health Organization, 2006. 2. Acute diarrhea. Practical recommendations of the World Gastroenterological Organization (WGO), 2008. // http://www.omge.org/globalguidelines/guide01/guideline1.htm 3. Infectious and skin diseases / ed. Nicholas A. Boone, Nicky R. College, Brian R. Walker, John A. A. Hunter; per. from English. ed. S.G.Pak, A.A.Erovichenkov, N.G.Kochergina. - M .: Reed Elsiver LLC, 2010. - 296 p. – (Series “Internal Diseases according to Davidson” / under the general editorship of N.A. Mukhin). – Translation of ed. Davidson "s Principles and Practice of Medicine, 20th edition / Nicolas A. Boon, Nicki R. Colledge, Brain R. Walker, John A. A. Hunter (eds). 4. Sanitary rules "Sanitary and epidemiological requirements for the organization and conduct of sanitary and anti-epidemic (preventive) measures to prevent infectious diseases "Approved by the Decree of the Government of the Republic of Kazakhstan dated January 12, 2012 No. 33. 5. General medical practice: the diagnostic value of laboratory tests: Textbook / Edited by S.S. Vyalov, S.A. Chorbinskaya - 3rd ed. - M.: MEDpress-inform, 2009. - 176 pp. 6. Infectious diseases: national guidelines / Edited by N.D. Yushchuk, Yu.Ya. Vengerov. - M .: GEOTAR-Media, 2010. - 1056 pp. - (Series "National Guidelines") 7. Bogomolov B.P. Infectious diseases: emergency diagnosis, treatment, prevention. - Moscow, Publishing House NEWDIAMED, 2007.- P.31 -45 8 Evidence Based Medicine Annual Quick Reference Guide Issue 3 2004 9 Clinical Guidelines and for practitioners based on evidence-based medicine, 2002.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers with qualification data:
1. Imambaeva G.G. - Candidate of Medical Sciences, Associate Professor, Acting head Department of Infectious Diseases with Epidemiology JSC "Astana Medical University"
2. Kolos E.N. - Candidate of Medical Sciences, Associate Professor of the Department of Gastroenterology with the Course of Infectious Diseases FNPR and DO JSC "Astana Medical University"

Reviewers:
1. Baesheva D.A. - MD, Head of the Department of Children's Infectious Diseases of JSC "Astana Medical University".
2. Kosherova B.N. - Freelance infectious disease specialist of the Ministry of Health of the Republic of Kazakhstan, Doctor of Medical Sciences, Professor, Vice-Rector for Clinical Work and Research and Development Department of the Karaganda State Medical University.
3. Doskozhaeva S.T. - d.m.s., head. Department of Infectious Diseases, Almaty State Institute for Postgraduate Medical Education.

Indication of no conflict of interest: no.

Indication of the conditions for revising the protocol:
- changes in the legal framework of the Republic of Kazakhstan;
- revision of WHO clinical guidelines;
- availability of publications with new data obtained as a result of proven randomized trials.

Attached files

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Clinically, the diagnosis of shigellosis can only be established in cases of a typical colitis variant of the course of the disease. To clarify the diagnosis in cases not confirmed by laboratory, sigmoidoscopy is performed, which in all cases of shigellosis reveals a picture of colitis (catarrhal, hemorrhagic or erosive-ulcerative) with damage to the mucous membrane of the distal colon, often sphincteritis. Gastroenteritis and gastroenterocolitic variants are diagnosed only in case of laboratory confirmation.

The most reliable method of laboratory diagnosis of shigellosis is the isolation of coproculture of shigella. For the study, stool particles containing mucus and pus (but not blood) are taken, it is possible to take material from the rectum with a rectal tube. For inoculation, 20% bile broth, Kaufman's combined medium, and selenite broth are used. The results of bacteriological examination can be obtained no earlier than 3-4 days from the onset of the disease. Isolation of blood culture is important in Grigoriev-Shiga shigellosis.

In some cases of gastroenteritis, presumably of shigellosis etiology, a bacteriological study of gastric lavage is performed.

The diagnosis can also be confirmed by serological methods. Of these, the most common method is with standard erythrocyte diagnosticums.

An increase in antibodies in paired sera taken at the end of the first week of illness and after 7–10 days, and a fourfold increase in titer are considered diagnostic.

ELISA, RKA are also used, it is possible to use aggregation hemagglutination and RSK reactions. An auxiliary diagnostic method is a coprological study, in which an increased content of neutrophils, their accumulations, the presence of erythrocytes and mucus in a smear are detected.

Of the instrumental methods, endoscopic (sigmoidoscopy and colonofibroscopy) are of primary importance, which confirm the characteristic changes in the colon mucosa.

Ultrasound and radiological research methods are used for the purpose of differential diagnosis.

Differential Diagnosis

Most often performed with other diarrheal infections, acute surgical pathology of the abdominal organs, UC, tumors of the distal colon. The most relevant differential diagnosis with diseases presented in Table. 17-6.__

Salmonellosis presents difficulties for differential diagnosis in the presence of colitis syndrome, acute appendicitis - in atypical course (diarrhea, unusual localization of pain), mesenteric thrombosis - in the presence of blood in the stool, acute or subacute variants of UC - in cases with fever, a rapid increase in diarrhea and the appearance blood in feces, cancer of the distal colon - with an asymptomatic course of the disease, if diarrhea and intoxication develop due to infection of the tumor.

Diagnosis example

Acute shigellosis, colitis variant, moderate course.

Indications for hospitalization

• Clinical: severe and moderate course of the disease, the presence of severe concomitant diseases.
• Epidemiological: persons of decreed groups.

Mode. Diet

In severe and moderate course, bed rest is indicated, in mild cases, a ward regimen. In the acute period, with significant intestinal disorders, table No. 4 according to Pevzner is prescribed. With an improvement in the condition, a decrease in intestinal dysfunction and the appearance of appetite, patients are transferred to table No. 2 or No. 13, and 2-3 days before discharge from the hospital - to the general table No. 15.

Medical therapy

Etiotropic therapy

• It is necessary to prescribe an antibacterial drug to a patient taking into account information about the territorial landscape of drug resistance, i.e. about

sensitivity to it of Shigella strains isolated from patients in the area recently.

• The duration of the course of etiotropic therapy is determined by the improvement of the patient's condition. With a moderate form of infection, the course of etiotropic therapy is limited to 3-4 days, with a severe form - 5-6 days.
• Combinations of two or more antibiotics (chemotherapy) should be strictly limited to severe cases.
• In the gastroenteric variant of shigellosis, etiotropic treatment is not indicated.

Patients with a mild form of shigellosis at the height of the disease are prescribed furazolidone at a dose of 0.1 g four times a day. In moderate shigellosis, drugs of the fluoroquinolone group are prescribed: ofloxacin at a dose of 0.2-0.4 g twice a day or ciprofloxacin at a dose of 0.25-0.5 g twice a day; in severe cases - ofloxacin at a dose of 0.4 g twice a day or ciprofloxacin 0.5 g twice a day; fluoroquinolones in combination with cephalosporins II generation (cefuroxime at a dose of 1 g three times a day) or III generation (ceftazidime or cefoperazone 1 g three times a day). In the first 2-3 days of treatment, the drugs are administered parenterally, then they switch to oral administration.

For the treatment of shigellosis Grigorieva-Shigi recommend ampicillin and nalidixic acid. Ampicillin is administered intramuscularly at a daily dose of 100–150 mg/kg every 4–6 hours for 5–7 days. Nalidixic acid is prescribed at a dose of 1 g four times a day for 5-7 days.

With shigellosis Flexner and Sonne, a polyvalent dysenteric bacteriophage is effective. The drug is produced in liquid form and in tablets with an acid-resistant coating. Take 1 hour before meals orally at a dose of 30-40 ml three times a day or 2-3 tablets three times a day. Rectal administration of liquid bacteriophage is possible. In severe cases, the drug is not indicated due to the danger of massive lysis of Shigella and worsening of intoxication.

Pathogenic agents

• Carry out rehydration therapy. With a mild form - oral administration of oralit, rehydron, cycloglucosolan solutions. The rate of administration of solutions is 1–1.5 l/h. In moderate and severe cases, intravenous administration of crystalloid solutions of chlosol, quartasol, trisol is used, taking into account the degree of dehydration and body weight of the patient at a rate of 60-100 ml / min and above.
• In the absence of severe dehydration and signs of intoxication, a 5% glucose solution and plasma substitutes (hemodez, reopoliglyukin) are used.

In the gastroenteric variant of acute shigellosis, the provision of medical care to the patient should begin with gastric lavage with water or 0.5% sodium bicarbonate solution, using a gastric tube for this.

• To bind and remove the toxin from the intestine, one of the enterosorbents is prescribed: polyphepan♠ one tablespoon three times a day, activated charcoal at a dose of 15–20 g three times a day, enterodez♠ 5 g three times a day, polysorb MP♠ 3 g three times a day, smectu♠ one sachet three times a day.
• Intestinal antiseptics: oxyquinoline (one tablet three times a day), enterol♠ - an antidiarrheal drug of biological origin (yeast Saccharomyces boulardii) appoint 1-2 capsules twice a day.
• To correct and compensate for digestive insufficiency, enzyme preparations are used: acidin-pepsin♠, pancreatin, panzinorm♠ in combination with calcium preparations (at a dose of 0.5 g twice a day).
• In the acute period, for the relief of spasm of the colon, drotaverine hydrochloride (no-shpa♠) is prescribed at a dose of 0.04 g three times a day, belladonna preparations (bellastezin♠, besalol♠).
• During the entire period of treatment, a vitamin complex is recommended, consisting of ascorbic (500-600 mg / day), nicotinic acid (60 mg / day),

thiamine and riboflavin (9 mg / day).

• In order to correct the intestinal biocenosis, patients with severe colitis syndrome upon admission are prescribed drugs based on

microorganisms of the genus bacillus: biosporin♠, bactisporin♠ two doses twice a day for 5-7 days. When choosing a drug, preference should be given to modern complex drugs: probifor♠, linex♠, bifidumbacterin-forte♠, florin forte♠, etc.__

Dispensary observation
Patients with chronic dysentery, employees of food enterprises and persons equated to them (within 3 months, and in case of chronic dysentery - within 6 months) are subject to dispensary observation.

1. Measures aimed at the source of infection

1.1. Detection is carried out:
when seeking medical help;
during medical examinations and when observing persons who have interacted with patients;
in case of epidemic trouble for acute intestinal infection (AII) in a given territory or object, extraordinary bacteriological examinations of decreed contingents can be carried out (the need for their conduct, the frequency and volume are determined by the CGE specialists);
among children attending preschool institutions, brought up in orphanages, boarding schools, vacationing in summer recreational institutions, during examination before registration in this institution and bacteriological examination in the presence of epidemic or clinical indications; when receiving children returning to the listed institutions after any illness or a long (3 days or more, excluding weekends) absence (admission is carried out only if there is a certificate from a local doctor or from a hospital indicating the diagnosis of the disease);
when a child is admitted to a kindergarten in the morning (a survey of parents is conducted about the general condition of the child, the nature of the stool; if there are complaints and clinical symptoms characteristic of OKA, the child is not allowed in the kindergarten, but is sent to a health care facility).

1.2. Diagnosis is based on clinical, epidemiological data and laboratory results

1.3. Accounting and registration:
Primary documents for recording information about the disease:
outpatient card (f. No. 025/y); history of the child's development (form No. 112/y), medical record (form No. 026/y).
The case of the disease is registered in the register of infectious diseases (f. No. 060 / y).

1.4. Emergency notification to the CGE
Patients with dysentery are subject to individual registration in the territorial CGE. The doctor who registered the case of the disease sends an emergency notification to the CGE (f. No. 058 / y): primary - orally, by phone, in the city in the first 12 hours, in the countryside - 24 hours; final - in writing, after the differential diagnosis and the results of bacteriological examination
or serological examination, no later than 24 hours from the moment of their receipt.

1.5. Insulation
Hospitalization in an infectious disease hospital is carried out according to clinical and epidemic indications.
Clinical indications:
all severe forms of infection, regardless of the age of the patient;
moderate forms in young children and in persons over 60 years of age with a aggravated premorbid background;
diseases in persons who are sharply weakened and burdened with concomitant diseases;
protracted and chronic forms of dysentery (with exacerbation).

Epidemic indications:
with the threat of the spread of infection at the place of residence of the patient;
employees of food enterprises and persons equated to them, if suspected as a source of infection (mandatory for a full clinical examination)

1.7. Extract
Employees of food enterprises and persons equated to them, children attending preschool institutions, boarding schools and summer health institutions are discharged from the hospital after a complete clinical recovery and a single negative result of a bacteriological examination conducted 1-2 days after the end of treatment. In the case of a positive result of bacteriological examination, the course of treatment is repeated.
Categories of patients who do not belong to the above-mentioned contingent are discharged after clinical recovery. The question of the need for bacteriological examination before discharge is decided by the attending physician.

1.8. The procedure for admission to organized teams and work
Employees of food enterprises and persons equated to them are allowed to work, and children attending kindergartens, being brought up in orphanages, orphanages, boarding schools, vacationing in summer recreational institutions, are allowed to visit these institutions immediately after discharge from the hospital or treatment at home on the basis of a certificate of recovery and in the presence of a negative result of bacteriological analysis. Additional bacteriological examination in this case is not carried out.

Patients who do not belong to the above categories are allowed to work and to organized teams immediately after clinical recovery.

Employees of food enterprises and persons equated to them, with positive results of a control bacteriological examination conducted after a second course of treatment, are transferred to another job not related to the production, storage, transportation and sale of food and water supply (until recovery). If the release of the pathogen continues for more than 3 months after the disease, then as chronic carriers they are transferred for life to work not related to food and water supply, and if the transfer is impossible, they are suspended from work with the payment of social insurance benefits.

Children who have had an exacerbation of chronic dysentery are admitted to the children's team if the stool has been normalized for at least 5 days, in good general condition, and at normal temperature. Bacteriological examination is carried out at the discretion of the attending physician.

1.9. Dispensary supervision.
Employees of food enterprises and persons equated to them who have had dysentery are subject to dispensary observation for 1 month. At the end of dispensary observation, the need for bacteriological examination is determined by the attending physician.

Children who have had dysentery and attend preschool institutions, boarding schools are subject to dispensary observation within 1 month after recovery. A bacteriological examination is prescribed by him according to indications (the presence of a long unstable stool, the release of a pathogen after a completed course of treatment, weight loss, etc.).

Employees of food enterprises and persons equated to them, with positive results of a control bacteriological examination conducted after a second course of treatment, are subject to dispensary observation for 3 months. At the end of each month, a single bacteriological examination is carried out. The need to perform sigmoidoscopy and serological studies is determined by the attending physician.

Persons with a diagnosis of chronic are subject to dispensary observation for 6 months (from the date of diagnosis) with a monthly examination and bacteriological examination.

At the end of the established period of medical examination, the observed person is removed from the register by an infectious disease specialist or a local doctor, provided that he has made a full clinical recovery and is in an epidemic state of well-being in the outbreak.

2. Activities aimed at the transmission mechanism

2.1 Current disinfection

In apartment centers, it is carried out by the patient himself or by persons caring for him. It is organized by the medical worker who made the diagnosis.
Sanitary and hygienic measures: the patient is isolated in a separate room or a fenced off part of it (the patient's room is subjected to wet cleaning and ventilation daily), contact with children is excluded;
the number of objects with which the patient can come into contact is limited;
the rules of personal hygiene are observed;
a separate bed, towels, care items, dishes for food and drink of the patient are allocated;
utensils and items for patient care are stored separately from the utensils of other family members;
dirty linen of the patient is kept separately from the linen of family members.

Maintain cleanliness in rooms and common areas. In the summer, indoor activities are systematically carried out to combat flies. In apartment foci of dysentery, it is advisable to use physical and mechanical methods of disinfection (washing, ironing, airing), as well as to use detergents and disinfectants, soda, soap, clean rags, etc.

It is carried out during the maximum incubation period by the personnel under the supervision of a medical worker in the kindergarten.

2.2. Final disinfection
In apartment outbreaks, after hospitalization or treatment of the patient, it is performed by his relatives using physical methods of disinfection and detergents and disinfectants. Instruction on the procedure for their use and disinfection is carried out by medical workers of the LPO, as well as an epidemiologist or an assistant epidemiologist of the territorial CGE.

In kindergartens, boarding schools, orphanages, dormitories, hotels, health-improving institutions for children and adults, nursing homes, in apartment centers where large and socially disadvantaged families live, it is carried out upon registration of each case by a disinfection and sterilization center (CDS) or disinfection department of the territorial CGE within the first day from the moment of receiving an emergency notification at the request of an epidemiologist or his assistant. Chamber disinfection is not carried out. Use disinfectants approved by the Ministry of Health

2.3. Laboratory studies of the external environment

The question of the need for research, their type, volume, multiplicity is decided by the epidemiologist or his assistant.
For bacteriological research, as a rule, sampling of food residues, water and washings from environmental objects is done.

3. Activities aimed at persons who have been in contact with the source of infection

3.1. Revealing
Persons who communicated with the source of infection in preschools are children who visited the same group as the sick person at the approximate time of infection; staff, employees of the catering unit, and in the apartment - living in this apartment.

3.2. Clinical examination

It is carried out by a local doctor or an infectious disease specialist and includes a survey, assessment of the general condition, examination, palpation of the intestine, measurement of body temperature. Specifies the presence of symptoms of the disease and the date of their occurrence

3.3. Collecting an epidemiological history

The presence of such diseases at the place of work (study) of the sick person and those who communicated with him, the fact that the sick person and those who communicated with food, which are suspected as a transmission factor, are being found out.

3.4 Medical surveillance

It is set for 7 days from the moment of isolation of the source of infection. In a collective focus (child care center, hospital, sanatorium, school, boarding school, summer health institution, food and water supply enterprise) is carried out by a medical worker of the specified enterprise or territorial healthcare facility. In apartment centers, food workers and persons equated to them, children attending kindergartens are subject to medical supervision. It is carried out by medical workers at the place of residence of those who communicated.

Scope of observation: daily (in kindergarten 2 times a day - in the morning and in the evening) a survey about the nature of the stool, examination, thermometry. The results of the observation are entered in the journal of observations of those who communicated, in the history of the development of the child (form No. 112 / y), in the outpatient card (form No. 025 / y); or in the child's medical record (f. No. 026 / y), and the results of monitoring the workers of the catering department - in the Health magazine.

3.5. Regime-restrictive measures

Conducted within 7 days after isolation of the patient. The admission of new and temporarily absent children to the DDU group, from which the patient is isolated, is stopped.
After isolation of the patient, it is prohibited to transfer children from this group to others. Communication with children of other groups is not allowed. Participation of the quarantine group in general cultural events is prohibited.
Quarantine group walks are organized subject to group isolation at the site; leaving and returning to the group from a walk, as well as getting food - last.

3.6. Emergency prevention
Not carried out. You can use a dysenteric bacteriophage

3.7. Laboratory examination
The question of the need for research, their type, volume, multiplicity is determined by the epidemiologist or his assistant.
As a rule, in an organized team, a bacteriological examination of communicating persons is performed if a child under 2 years of age who attends a nursery, a worker in a food enterprise or equivalent to him falls ill.

In apartment centers, “food workers” and persons equated to them, children attending kindergartens, boarding schools, and summer recreational institutions are examined. Upon receipt of a positive result of a bacteriological examination, persons belonging to the category of “food workers” and equated to them are suspended from work related to food products or from visiting organized groups and are sent to the KIZ of the territorial polyclinic to resolve the issue of their hospitalization

3.8. Health education
A conversation is being held on the prevention of infection with pathogens of intestinal infections

General principles of organizing dispensary observation of recovered infectious diseases, methods of nonspecific prophylaxis at the medical site, in teams.

Dysentery.

Persons to be observed directly related to the production, storage, transportation and sale of food products and equated to them, who have had dysentery with an established type of pathogen and bacteria carriers. Of the remaining groups of the population, only patients with chronic dysentery and persons with long-term unstable stools who are employees of food enterprises and are equated to them are covered by observation.

The following procedure and terms of dispensary observation are established:

1. Persons suffering from chronic dysentery, confirmed by the release of the pathogen, bacteriocarriers, long-term excretion of the pathogen, are subject to observation for 3 months with a monthly examination by a CIZ doctor or a district doctor. Bacteriological examination of the listed contingents is carried out once a month. At the same time, persons who suffer from unstable stools for a long time are examined.
2. Employees of food enterprises and persons equated to them who have suffered from acute dysentery, after being discharged from work, remain in the dispensary for 3 months. During this period, they are monthly examined by a KIZ doctor or a district doctor, and once a month a bacteriological examination of feces is performed.
3. Employees of food enterprises and persons equated to them, suffering from chronic dysentery, are subject to dispensary observation for 6 months with a monthly bacteriological examination of feces. After this period, in case of complete clinical recovery, these persons are allowed to work in their specialty.
4. In all cases of long-term bacteriocarrier, these individuals undergo a clinical examination and re-treatment until recovery.

Salmonellosis.

Employees of food and equivalent facilities are subject to observation in the KIZ of the polyclinic with acute forms of the disease. The follow-up period was 3 months with monthly examination and bacteriological examination of feces. In generalized forms, bacteriological examination is carried out similarly to that of typhoid convalescents.

Convalescents - employees of food enterprises and persons equated to them, who continue to isolate pathogens after discharge from the hospital or who isolated them during a three-month dispensary observation, are not allowed to work for 15 days. During this time, a five-time bacteriological study of feces, a single - bile, as well as a clinical examination are carried out. With a positive result of bacteriological examination, the examination is repeated within 15 days.

When establishing bacterial excretion for more than 3 months these persons (chronic carriers) are suspended from their main work for at least a year and remain on dispensary records all this time. During this period, they undergo clinical and bacteriological studies 2 times a year - in spring and autumn. After this period and in the presence of negative results of bacteriological examination, a fourfold bacteriological examination is carried out, which includes three examinations of feces and one bile. Upon receipt of negative test results, these persons are allowed to work in their specialty. If at least one positive test result is obtained after a year of observation, they are considered as chronic bacteria carriers and are removed from work in their specialty. They must be registered with the KIZ and SES at the place of residence for life.

Escherichiosis.

Employees of food and equivalent facilities are subject to supervision within 3 months. Monthly bacteriological examination of feces and examination of the patient by a KIZ doctor or a local doctor are carried out. Other contingents are not subject to dispensary observation.

Helminthiases.

KIZ organizes work on the detection of helminthiases among the population, carries out accounting and control over medical and preventive work to identify and improve the infested, dispensary observation of them.

Research on helminthiases is carried out in clinical diagnostic laboratories of medical institutions.

SES employees are responsible for organizing work on surveying the population for helminthiases; methodological guidance; selective quality control of medical and preventive work; examination of the population for helminthiases in the foci according to epidemiological indications; study of elements of the external environment (soil, products, washouts, etc.) in order to establish ways of infection.

The effectiveness of the treatment of patients with ascariasis is determined by a control study of feces after the end of treatment after 2 weeks and 1 month, enterobiasis - according to the results of a study of perianal scraping after 14 days, trichuriasis - according to a negative triple scatological study every 5 days.

Infested with pygmy tapeworm(hymenolepiasis) after treatment are observed for 6 months with a monthly study of feces for eggs of worms, and in the first 2 months - every 2 weeks. If during this time all tests are negative, they are removed from the register. If helminth eggs are found, repeated treatment is carried out, observation continues until complete recovery.

Patients with taeniasis after successful treatment are registered at the dispensary for at least 4 months., and patients with diphyllobothriasis - 6 months. Monitoring the effectiveness of treatment should be carried out after 1 and 2 months. Analyzes should be repeated after another 3-5 days. At the end of the observation period, a study of feces is performed. In the presence of a negative result, as well as in the absence of complaints about the discharge of the segments, these persons are removed from the register.

It must be especially emphasized that deworming in diphyllobothriasis combined with pathogenetic therapy especially in the treatment of anemia. A six-month clinical observation after deworming is carried out in parallel with a monthly laboratory study of feces for helminth eggs and blood in case of diphyllobothriasis anemia, which is combined with invasion with essential pernicious anemia.

Trichinosis.

Due to prolonged convalescence, those who have recovered from trichinosis are subject to dispensary observation for 6 months, and according to indications - for 1 year. In cities, it is carried out by doctors of the KIZ, and in rural areas - by district doctors. Terms of dispensary examination: 1-2 weeks, 1-2 and 5-6 months after discharge.

Dispensary examination methods:

1. clinical (detectionmuscle pain, asthenic phenomena, cardiovascular and possible other pathologies);
2. electrocardiographic;
3. laboratory (calculation of the number of eosinophils, determination of the level of sialic acid, C-reactive protein).

Those who have been ill are removed from the dispensary register in the absence of muscle pain, cardiovascular and asthenic phenomena, a significant decrease in the T wave on the ECG and the normalization of other laboratory parameters.

Viral hepatitis.

Viral hepatitis A.

Dispensary observation of patients who have been ill is carried out no later than 1 month after discharge by the attending physician of the hospital. In the absence of any clinical and biochemical abnormalities in convalescents, they can be deregistered. convalescents,having residual effects, after 3 months they are registered in the KIZ, where they are re-examined.

Parenteral viral hepatitis (C, B).

Dispensary observation for patients who recovered from acute hepatitis C, B, chronic hepatitis C and “carriers” of anti-HCV and HBsAg carried out by infectious disease doctors in:

• dispensary (advisory) offices of city (regional) infectious diseases hospitals;
• KIZakh outpatient organizations at the place of residence (place of stay) of the patient.
• In the absence of KIZ, dispensary observation is carried out by a local general practitioner or pediatrician.

Persons subject to dispensary observation:

• those who have had an acute form of HCV, HBV (OGC, OGV);
• with a chronic form of HCV, HBV (CHC, CHB);
• "carriers" of the hepatitis C virus (anti-HCV). At the same time, the term "carrier" of the hepatitis C virus should be taken as a statistical one until the diagnosis is deciphered (more often CHC).

Dispensary observation consists of a medical examination and laboratory examinations. Medical examination includes:

• examination of the skin and mucous membranes (pallor, jaundice, vascular changes, etc.);
• a survey for the presence of characteristic complaints (loss of appetite, fatigue, abdominal pain, nausea, vomiting, etc.);
• palpation and percussion determination of the size of the liver and spleen, determination of consistency and pain.

Laboratory examination includes the definition:

• the level of bilirubin and its fractions;
• activity of alanine aminotransferase (hereinafter - ALT).

Other laboratory examinations, medical consultations are carried out as prescribed by the attending physician conducting dispensary observation.

The primary medical examination and laboratory examination is carried out 10 days after discharge from the health care organization in which medical care was provided, to resolve the issue of the terms of temporary disability for workers and students in educational institutions.

The results of the primary medical examination and laboratory examination performed in a hospital organization are attached to the discharge summary and transferred in accordance with the legislation of the Republic of Belarus on health care to an outpatient organization at the place of residence (place of stay) of the sick person.

Based on the results of the initial medical examination and laboratory examination, a decision is made on the closure or extension of a temporary disability certificate and recommendations are given.

Dispensary observation of those who have been ill with acute hepatitis C, acute hepatitis C is carried out 3, 6, 9, 12 months after the completion of the course of treatment in order to control the period convalescence, timely detection of patients with a chronic course of the disease, selection of tactics for etiotropic therapy.

Dispensary supervision includes:

• medical checkup;
• laboratory blood tests for bilirubin, ALT, and for patients who have undergone OCS and who have not received antiviral therapy, it is recommended to test the blood for the presence of HCV RNA or HBV DNA by PCR 3 and 6 months after diagnosis;
• ultrasound examination (hereinafter referred to as ultrasound) of the abdominal organs.

Those who have been ill with acute hepatitis C and OGV are removed from dispensary observation12 months after discharge from the hospital for:

1. absence of complaints;
2. stably normal indicators of biochemical samples;
3. elimination of HCV RNA or HBV DNA;
4. the presence of two negative results of HCV RNA or HBV DNA in the blood by PCR.

With positive results after 3 months, a study on the genotype of the virus, the level of viral load is recommended to make a decision on the tactics of antiviral treatment.

Depending on the clinical course of the infectious process There are four groups of dispensary observation of patients with CHC (including those with variants of mixed hepatitis B, D, C).

The first group includes persons in whom the disease occurs without signs of biochemical and (or) morphological activity. Dispensary observation of patients of this group is carried out at least once a year.

The dispensary observation program includes:

1. medical checkup;
2. blood test for bilirubin, AlAT, AsAT, y-GTP;
3. Ultrasound of the abdominal organs;
4. determination of viral load (the number of copies of HCV RNA or HBV DNA) in dynamics (if it increases, a decision is made to prescribe antiviral therapy).

The second group includes persons in whom the disease occurs with signs of biochemical and (or) morphological activity of the pathological process, fibrosis of the liver parenchyma. The dispensary observation program includes:

• medical checkup;
• blood test for bilirubin, ALT, AST, y-GTP - 1 time per quarter;
• blood test for a-fetoprotein - 1 time per year;
• Ultrasound of the abdominal organs - 1 time per year;
• determination of the level of viral load (RNA HCV or DNA CHBV) indynamics. With its increase, a decision is made on the appointment of antiviral therapy.

The frequency and volume of laboratory tests can be expanded according to medical indications.

The third group includes persons undergoing antiviral (etiotropic) therapy.

Taking into account the tolerability of antiviral drugs The follow-up program includes:

• medical examination - at least once a month;
• study of hemogram parameters with platelet count - at least 1 time per month;
• Ultrasound of the abdominal organs - at least 1 time in 3 months;
• determination of the level of viral load - at least 1 time in 3 months. The frequency and scope of laboratory tests can be expandedfor medical reasons.

Decision to discontinue antiviral therapy, regimen changes are usually taken in the first 3 months of treatment.

After completing the course of antiviral therapy and stable remission of the pathological process dispensary observation continues for a period of 3 years with the frequency of observation:

1. in the first year - 1 time per quarter;
2. second and third - 2 times a year.

During this period, the follow-up program includes:

1. at each visit: medical examination, researchbiochemical parameters, complete blood count, ultrasound of the abdominal organs;
2. PCR - at least 1 time per year.

The frequency and volume of laboratory tests can be expanded according to medical indications.

After 3 years of dispensary observation, a patient who has had CHC, CHB is removed from dispensary observation if:

• absence of complaints;
• satisfactory results of the medical examination;
• normalization of the size of the liver;
• stably normal values ​​of biochemical samples
• two negative blood PCR results for HCV RNA or DNA

The frequency and volume of laboratory tests can be expanded according to medical indications.

In the absence of positive dynamics the patient is transferred to the fourth group of dispensary observation.

The fourth group of dispensary observation includes individuals with viral cirrhosis of the liver with Child-Pugh cirrhosis, MELD. The frequency of dispensary observation of such patients is determined by the infectious disease specialist who carries out dispensary observation, depending on the clinical course of the disease and the degree of liver cirrhosis.

The program of examination of patients with viral cirrhosis of the liver includes:

1. at each visit: complete blood count with platelet count - biochemical blood test (AlAT, AsAT, y-GTP, bilirubin, urea, creatinine, iron, total protein, proteinogram);
2. blood for a-fetoprotein - at least 1 time per year;
3. dopplerography - at least 1 time per year;
4. fibrogastroduadenoscopy (hereinafter - FGDS) in the absence of contraindications - at least 1 time per year;
5. Ultrasound of the abdominal organs - at least 2 times a year;
6. blood sugar level - according to clinical indications;
7. prothrombin index (hereinafter - PTI) and (or) international normalized ratio (hereinafter - INR) - according to clinical indications;
8. thyroid hormones - according to clinical indications;
9. consultation of a surgeon (to resolve the issue of surgical treatment) - according to clinical indications.

If necessary, consultations (conciliums) are organized on the basis of dispensary (advisory) offices of city (regional) infectious diseases hospitals for adjusting the tactics of antiviral therapy, planning liver transplantation (inclusion on the transplantation waiting list).

Patients of the fourth group are not removed from dispensary observation.

Children born to women with CHC, CHB are subject to dispensary observation by a pediatrician together with an infectious disease specialist in an outpatient clinic at the place of residence (place of stay).

Laboratory examinations of such children in order to establish a clinical diagnosis are carried out taking into account the timing of the circulation of maternal HCV markers: children born to women infected with HCV, CHB are examined for RNA or DNA of the virus by PCR 3 and 6 months after birth, for anti-HCV 18 months after birth, then according to clinical and epidemic indications.

If HCV or HBV markers are detected dispensary observation of such children is carried out on the basis of dispensary (advisory) offices of city (regional) infectious diseases hospitals.

1. Pregnant. When registering for pregnancy, with a negative result of the initial examination, additionally in the III trimester of pregnancy, then according to clinical and epidemic indications(vaccinated against hepatitis B are tested for anti-HCV)
2. Blood donors and its components of human organs and (or) tissues, sperm, other biological materials. With each donation, collection of 1 biological materials, substrates, organs and (or) human tissues
3. Pre-conscription. When registering (not vaccinated against hepatitis B for HBsAg and anti-HCV, vaccinated for anti-HCV), then according to clinical and epidemic indications
4. Contact with infected parenteral hepatitis viruses. When registering a focus, then according to clinical and epidemic indications; for chronic lesions at least once a year (vaccinated against hepatitis B are examined for anti-HCV, when deciding whether to revaccinate for anti-HBsAg titer)
5. Contained in places of deprivation of liberty. When placed in places of deprivation of liberty, released from places of deprivation of liberty, according to clinical and epidemic indications
6. Health care workers(outpatient clinics, hospitals, sanatoriums and others) performing medical interventions with violation of the integrity of the skin, mucous membranes, work with biological material, medical devices or medical equipment contaminated with biological material. At a preliminary medical examination, then 1 time per year - not vaccinated against hepatitis B for HBsAg and anti-HCV, vaccinated - for anti-HCV, additionally according to clinical and epidemic indications
7. Newborns from women infected with HCV, HBV age 3, 6 months by 1 PCR method for the presence of HCV markers, HBV at the age of 18 months for anti-HCV, HBsAg, then according to paragraph 4
8. Patients of centers and departments of hemodialysis. During the initial clinical and laboratory examination, then according to clinical and epidemic indications, but at least twice a year
9. Recipients of blood and its components, other biological materials, organs and (or) human tissues. 6 months after the last transfusion, transplantation, then according to clinical and epidemic indications
10. Patients with chronic diseases(oncological, neuropsychiatric, tuberculosis and others). During the initial clinical and laboratory examination, then according to clinical and epidemic indications
11. Patients with suspected liver disease, biliary tract(hepatitis, cirrhosis, hepatocarcinoma, cholecystitis, etc.). During the initial clinical and laboratory examination according to clinical and epidemic indications
12. Patients with infections sexually transmitted. When detected, then according to clinical and epidemic indications
13. Patients of narcological dispensaries, offices, people who use drugs (with the exception of people who use drugs for medical reasons). Upon detection, after - at least 1 time per year, then according to clinical and epidemic indications
14. Patients admitted to healthcare organizations for planned surgical interventions. When conducting a clinical and laboratory examination in preparation for surgery
15. Children and adults from residential institutions. Upon admission to a residential institution, then according to clinical and epidemic indications
16. Contingents having promiscuous sex. Upon detection, seeking medical help, then according to clinical and epidemic indications

Flu and SARS.

Persons who have had complicated forms of influenza are subject to observation. The terms of clinical examination are determined by the health status of convalescents and are at least 3-6 months. With influenza complications that have taken on the character of chronic diseases (bronchitis, pneumonia, arachnoiditis, sinusitis, etc.), the duration of dispensary observation increases.

Erysipelas.

Carried out by a KIZ doctor or a district therapist after primary erysipelas within one year with an examination once a quarter, with recurrent - for 3-4 years. Bicillin prophylaxis is carried out once a month for 4-6 months in the presence of residual effects in primary erysipelas and for 2-3 years in recurrent ones. If there are consequences of erysipelas (lymphostasis, skin infiltration, increased regional lymph nodes) shows outpatient treatment of physiotherapy, exercise therapy, massage, etc.

meningococcal infection.

Observation by a neuropathologist is subject to persons, who have undergone a generalized form of infection (meningitis, encephalitis). Duration of observation - 2-3 years with a frequency of examinations 1 time in 3 months during the first year, then - 1 time in six months.

Tick-borne encephalitis.

It is carried out by a neuropathologist for 1-2 years (until the permanent disappearance of all residual phenomena).

Leptospirosis.

Persons who have recovered from leptospirosis are subject to dispensary observation for 6 months. with a mandatory clinical examination by an ophthalmologist, neuropathologist and therapist, and children - by a pediatrician. Control general blood and urine tests are necessary, and those who have undergone an icteric form of leptospirosis - a biochemical blood test. The survey is carried out 1 time in 2 months. Dispensary observation is carried out by the doctor of the CIH of the polyclinic at the place of residence, in the absence of the CIH - by the local or shop therapist.

Deregistration is carried out after the expiration of the period of dispensary observation after complete clinical recovery (normalization of laboratory and clinical parameters). If necessary, the terms of dispensary observation can be extended until complete clinical recovery.

In the presence of persistent residual effects patients are observed by specialists in the profile of clinical manifestations (oculists, therapists, neuropathologists, nephrologists, etc.).

Yersiniosis.

It is carried out by doctors of the KIZ, and in their absence - by district doctors.

After icteric forms, dispensary observation lasts up to 3 months with a double study of liver function tests after 1 and 3 months, after other forms - 21 days (the most common time for relapses).

Malaria.

After discharge from the hospital, convalescents are observed in the KIZ by an infectious disease specialist or a local therapist for 2 years with a periodic medical examination and a blood test for malarial plasmodia. Clinical and laboratory examinations are carried out monthly from May to September, in the rest of the year - quarterly, as well as at any visit to the doctor throughout the entire period of medical examination. With positive results of laboratory examination, along with the appointment of specific treatment, the period of dispensary observation is extended. All persons who have had malaria and are on dispensary records, annually in April May undergo anti-relapse treatment with primaquine (0.027 g in one dose after meals) for 14 days. After a two-year dispensary observation, the grounds for deregistration are the absence of relapses or recurrence of the disease and the negative results of laboratory tests of a smear or a thick drop of blood for the presence of the causative agent of malaria.

Persons who were abroad in the territories who are unfavorable for malaria, after their return they are subject to dispensary observation also for two years. During the initial examination, they specify the time of departure and arrival from abroad, the place of stay (country, city, district), the diseases transferred abroad, the treatment carried out, the date of malaria chemoprophylaxis and the drug used. On clinical examination, attention is drawn to the enlargement of the liver and spleen. Then a smear and a thick drop of blood are examined for malarial plasmodia.

Foreigners who arrived from tropical and subtropical countries Africa, Asia, Central and South America for a long time (students of higher and secondary educational institutions, vocational schools, graduate students, various specialists) are also subject to registration, primary clinical and laboratory examination and further dispensary observation.

HIV infection.

Dispensary observation of HIV-infected people patients are carried out in the offices of infectious diseases of territorial outpatient clinics, consultative and dispensary offices of the regions, the consultative and dispensary department for HIV infection of the City Infectious Diseases Clinical Hospital of Minsk, and the City Infectious Children's Clinical Hospital of Minsk.

The purpose of dispensary observation of HIV-infected patients is to increase the duration and improve their quality of life. To reduce the burden on the doctor, a specially trained nurse can conduct nursing appointments.

Dispensary observation for HIV-infected patients includes:

• Primary HIV testing with confirmation of test results and post-test crisis counseling with a diagnosis of HIV infection;
• Clinical assessment of the patient's condition;
• Patient counseling;
• Monitor the patient's health status;
• Initiation and maintenance of APT;
• Prevention and treatment of OI and other concomitant infections and diseases;
• Psychological support;
• Treatment adherence support;
• Referral to appropriate services to ensure continuity of care

The initial examination should include:

• careful history taking (personal, family and medical history);
• objective examination;
• laboratory and instrumental studies;
• special studies and consultations of other specialists.

The planned examination includes:

Determining the clinical stage of HIV infection and changes in comparison with the previous survey;

Determination of the dynamics of markers of the progression of HIV infection:

• Identification of indications for APT;
• Monitoring of opportunistic infections;
• Identification of concomitant diseases and indications for their therapy;
• Psychosocial adaptation of the patient;
• Appointment APT;
• Monitoring the effectiveness of APT;

The doctor who carries out medical examination and treatment of an HIV-infected patient maintains the following medical documentation: outpatient card (f-025/y); control card of dispensary observation (f-030 / y).

In the regional consultative and dispensary offices of the region, the following is carried out:

• conducting consultations for persons living in the regional center;
• diagnosis of HIV infection with crisis counseling for people living in the regional center;
• dispensary observation of persons living in the regional center;
• outpatient treatment of opportunistic infections;
• analysis of work and submission of reports on clinical examination to the regional infectious disease specialist - quarterly, a statistical report to the Center for Disease Control and Prevention and the health department of the regional executive committee - monthly;
• registration of documents for MREK residents of the regional center;
• methodological assistance to infectious disease specialists of the CIS and doctors of medical and preventive institutions on HIV infection;
• organizing consultations to determine the clinical stage of HIV infection and prescribe antiretroviral therapy;
• cooperation with departments of medical universities;
• preparation of applications for the need for antiretroviral drugs according to the information of the medical and preventive institution of the region to the regional CT and E, the health department of the regional executive committees and the chief infectious disease specialist of the Ministry of Health of the Republic of Belarus.

Scheme of clinical examination of HIV-infected and AIDS patients

Initial examination of an HIV-infected patient. The anamnesis of life and disease is specified: past infectious diseases: childhood infections, infectious diseases in adolescence and in adults, previous visits to specialists, hospitalizations (time, hospital, profile); smoking and alcoholism; vaccination history.

General condition of the patient: complaints, well-being, assessment of severity, identification of ongoing symptoms. Drug history: taking prescribed by a doctor and Affordable medication, alternative methods of treatment; taking narcotic drugs: intravenous, injection drug addiction; Other ways of administering drugs.

In the absence of a clinic of the disease:

• clinical examination - 1-2 times a year;
• laboratory and instrumental studies: complete blood count (1-2 times a year); biochemical blood test (1-2 times a year); general urinalysis (1-2 times a year); chest x-ray (1 time per year); examination for markers of parenteral viral hepatitis (1 time in 2 years).

In the presence of concomitant diseases and conditions (not related to the manifestation of HIV) - treatment by highly specialized specialists.

In the presence of a clinic of the disease - determination of the stage:

Consultative examination by an infectious disease doctor of a consultative and dispensary office for HIV / AIDS - according to clinical indications, but at least 2 times a year.

Laboratory and instrumental studies:

• study of the level of CD4;
• determination of HIV viral load;
• determination of a group of opportunistic diseases (CMV, toxoplasmosis, HSV, R. sappp, etc.) on the basis of laboratories that diagnose infectious diseases;
• general blood test with the obligatory determination of platelets;
• biochemical analysis of blood (AlAt, AsAt, bilirubin, sedimentary samples, glucose, total protein and protein fractions), as well as markers of hepatitis viruses (1 time per year) on the basis of territorial health facilities;
• general urine analysis;
• sowing feces on pathogenic and conditionally pathogenic flora;
• chest x-ray (annually);
• ECG - upon registration;
• Ultrasound of the abdominal organs 1 time per year;
• consultative examination of narrow specialists (cardiologist, neuropathologist, ophthalmologist, etc.) using instrumental research methods.

After the examination on commission, with the participation of an infectious disease specialist of the HIV / AIDS consultative and dispensary office and / or the chief infectious disease specialist of the region, and / or an employee of the department of infectious diseases, the stage of the disease is determined and, if necessary, antiretroviral therapy is prescribed, further patient management tactics are determined, including preventive treatment of opportunistic diseases. Clinical examination with a known level of CD4:

The level of CO4 is less than 500, but more than 350 in 1 µl of blood:

1. clinical examination every 6 months;
2. laboratory research:

• determination of the level of CD4 cells - after 6 months, examination for a group of opportunistic infections (when clinical manifestations appear); determination of viral load - every 6 months;
• on the basis of territorial polyclinics - a general blood test with the obligatory determination of platelets; biochemical blood test (AlAt, AsAt, bilirubin, sedimentary samples, glucose, urea, total protein, protein fractions); general urine analysis; sowing feces for pathogenic and conditionally pathogenic flora. Frequency - 1 time in 6 months.

Determination of markers of viral hepatitis 11 times a year; tuberculin test 11 times a year;

If necessary, examination of narrow specialists according to the profile of clinical manifestations and treatment in day hospitals.

Emergency assistance is provided according to the general rules, depending on the pathology.

If necessary, examination of narrow specialists in the profile of clinical manifestations and treatment.

CD 4 level less than 350 in 1 µl of blood:

1. clinical examination every 3 months;
2. laboratory research:

• determination of the level of CD 4 after 3 months; examination for a group of opportunistic infections when clinical manifestations appear; determination of viral load - every 6 months;
• on the basis of territorial polyclinics: a general blood test with the obligatory determination of platelets; biochemical blood test (AlAt, AsAt, bilirubin, sedimentary samples, glucose, urea, total protein and protein fractions); general urine analysis; sowing feces for pathogenic and conditionally pathogenic flora. Frequency - 1 time in 6 months.

Determination of markers of viral hepatitis - 1 time per year; tuberculin test - 1 time per year (at the level of CD4+< 200/мкл - не проводится); ECG - at dispensary registration, before the start of APT, every 6 months during APT;X-ray of the chest organs - upon registration, then according to indications;Ultrasound of the abdominal organs = 1 time per year, in the presence of concomitant parenteral hepatitis - 1-2 times a year;FGDS, colonoscopy - according to indications. Interpretation (decoding) of the diagnosis of infectious diseases, emergency conditions for major infections - wording, examples - 17/08/2012 09:08

Rehabilitation of an infectious patient is understood as a complex of medical and social measures aimed at faster recovery of health and impaired performance by the disease.

Rehabilitation is aimed primarily at maintaining the vital activity of the body and adapting it to conditions after illness, and then to work and society.

As a result of medical rehabilitation, a person who has had an infectious disease must fully restore both health and working capacity.

Rehabilitation often begins even during the stay of an infectious patient in a hospital. The continuation of rehabilitation, as a rule, takes place at home after discharge from the hospital, when a person is not yet working, having a "sick leave" (disability certificate) in his hands. Unfortunately, centers and sanatoriums for the rehabilitation of infectious patients are still rarely created in our country.

The general principles of rehabilitation are refracted through the prism of what disease the patient has suffered (viral hepatitis, meningococcal infection, dysentery, acute respiratory infections, etc.)

Among the treatment and rehabilitation measures, the following should be distinguished: regimen, nutrition, physiotherapy exercises, physiotherapy, interviews with those who have been ill, and pharmacological agents.

The regime is the main one for the implementation of medical and rehabilitation measures.

Training of the main body systems should lead to the realization of the main goal - a return to work. With the help of the regime conditions for treatment and rest are created.

The diet is prescribed taking into account the severity and clinical manifestations of an infectious disease, taking into account the predominant damage to organs: the liver (viral hepatitis), kidneys (hemorrhagic fever, leptospirosis), etc. Specifically, the diet is recommended by the doctor before discharge from the hospital. All patients are prescribed multivitamins at a dose that is 2-3 times the daily requirement.

Therapeutic physical education contributes to the fastest recovery of the physical performance of the patient. The simplest objective indicator of appropriate physical activity is the recovery of heart rate (pulse) 3-5 minutes after exercise.

Physiotherapy is carried out according to the doctor's prescription according to the indications: massage, UHF, solux, diathermy, etc.

It is advisable to conduct conversations with convalescents: about the dangers of alcohol after suffering viral hepatitis, about the need to avoid hypothermia after suffering erysipelas, etc. Such educational conversations (reminders) on medical topics can also be held at home by the relatives of the patient.

Pharmacological therapy with drugs that contribute to the restoration of functions and performance of those who have recovered from infectious diseases exists and is prescribed by a doctor before discharge of patients from the hospital.

The main stages of medical rehabilitation of infectious patients are: 1. Infectious hospitals. 2. Rehabilitation center or sanatorium. 3. Polyclinic at the place of residence - an office of infectious diseases (KIZ).

The first stage is the acute period of the disease; the second stage is the recovery period (after discharge); the third stage is in KIZ, where the issues of medical and social expertise (former VTEK) related to employment are mainly resolved.

In the KIZ, dispensary (active dynamic) monitoring of those recovering from infectious diseases is also carried out in accordance with the orders and guidance documents of the Ministry of Health (Reg. N 408 of 1989, etc.). where they are observed by an infectious disease specialist. Observation is carried out after the patient has suffered the following infections: dysentery, salmonellosis, acute intestinal infections of unknown nature, typhoid fever, paratyphoid fever, cholera, viral hepatitis, malaria, tick-borne borreliosis, brucellosis, tick-borne encephalitis, meningococcal infection, hemorrhagic fevers, leptospirosis, pseudotuberculosis, diphtheria, ornithosis.