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Gastroenterita cu rotavirus (GERV)
Prof.dr.Nicolae Miu
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Sumar Gastroenterita cu rotavirus (GERV) patogeneza
transmitere si evolutie clinica tratamentul actual al bolii profilaxia actuala a bolii Gastroenterita cu RV- particularitati epidemiologice Importanta gastroenteritei cu RV nosocomiale Concluzii
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Infectia cu Rotavirusuri
95% dintre copii la nivel mondial sunt infectati pana la varsta de 3–5 ani1 Cea mai comuna cauza de spitalizare prin gastroenterita severa2 Varful de incidenta: intre 6–24 luni1 Rotaviruses are the most common enteric pathogen to infect infants and young children throughout the world.3 By the age of 3–5 years, virtually all children have been infected—the younger the child, the higher the risk of severe gastroenteritis, hospitalisation or death.1 (However, rotavirus disease is uncommon in neonates, suggesting a protective role for placentally transferred maternal antibody among infants less than 3 months old).1 The incidence of clinical illness peaks among children aged 6–24 months. Infants within this age range are also at the greatest risk from severe RVGE requiring hospitalisation.2 Rotavirus is the most common cause of diarrhoea in children and is estimated to be responsible for one third of diarrhoea-associated hospitalisations per year.1 Rotavirus infections of adults are often subclinical but occasionally cause illness. For example, parents of children with rotavirus diarrhoea, immunocompromised patients (including those with HIV), the elderly population or travellers to developing countries who are exposed to unfamiliar serotypes may be affected.3 1Parashar et al, Emerg Infect Dis 1998;4(4):561–570 2Linhares and Bresee, Pan Amer J Public Health 2000;8(5):305–330 3 Kapikian AZ, Chanock RM. Rotaviruses. In: Fields Virology 3rd ed. Philadelphia, PA: Lippincott-Raven; 1996:1659 1Linhares AC and Bresee JS, Pan Am J Public Health 2000;8(5):305–330 2Parashar UD et al, Emerg Infect Dis 1998;4(4):561–570 Image: Service Urgences Pédiatriques Hôpital Armand Trousseau Paris, France.
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Patogeneza Rotavirusurile adera la celulele epiteliale ale mucoasei tractului gastrointestinal Multiplicarea virionilor are loc predominant la nivelul enterocitelor mature ale vililor din portiunea superioara a intestinului subtire 1,2 Pe durata a 1-2 zile,dupa replicarea virala – infectia disemineaza de-a lungul intestinului (de la nivelul partii superioare a IS catre ileum) 1,2 1.Linhares AC et al.Rev Panam Salud Publica 2000;8(5):305-31 2 Parashar UD et al, Emerg Infect Dis 1998;4(4):561–570
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Patogeneza Rotavirusul adera la epiteliul tractului gastrointestinal (mucoasa jejunala) Atrofiere microvili Activarea sistemului nervos enteric Enterotoxina virala Scaderea suprafetei de absorbtie Rotaviruses adhere to gastrointestinal (GI) tract epithelia, infecting the surface of cells of the villi in the upper parts of the small intestine.1 Following viral replication, the infection spreads further along the intestine, producing mucosal lesions by selectively destroying the tips of the villi of the gut and extensive viral shedding in the faeces. Although infection is superficial, it is sufficient to trigger local and systemic immune responses. The damage is reversible but diarrhoea continues until the villi have regenerated. Hence, the seriousness of the lesions determine the time course of symptoms. Diarrhoea results from the loss of absorptive area and the flux of water and electrolytes across the damaged surface. Rotavirus infection is also more likely to produce vomiting, dehydration and fever than other diarrhoea-producing viral pathogens. There are three broad types of virulence traits found in diarrhoeal pathogens, which allow the organism to: (ii) adhere to the cells lining the gut (ii) penetrate the cells lining the gut (viruses) (iii) produce toxins. There is evidence that one of the rotavirus proteins acts as an exotoxin which causes fluid loss from infected cells, in a similar way to shigella and cholera. However, this is the first time that an exotoxin has been associated with a virus.2 Another recent study suggested that the virus activates the enteric nervous system, triggering nerves that control the peristaltic movement of the intestines and the extent to which they can absorb fluid.3 1Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996: p. 1657–1708 2Carnell, BMJ 1996;312: 927 3WHO Int J Pub Health, 2000 Eflux de apa si electroliti VARSATURI SI DIAREE *Rotavirus infection in an animal model of infection. Photographs are from an experimentally infected calf. Reproduced with permission from Zuckerman et al, eds. Principles and Practice of Clinical Virology. 2nd ed. London: John Wiley & Sons; 1990:182. Micrographs courtesy of Dr. Graham Hall, Berkshire, UK. Lundgren et al. Science 2000; 287: ; Boshnizen et al, J Virol 2004; 78:
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Patogeneza mecanisme de producere a diareei
Mecanism principal : scaderea absorbtiei de apa si electroliti (in urma distructiei epiteliului mucoasei intestinale) 1,2,3 Inlocuirea celulelor epiteliale cu rol major de absorbtie cu celule secretorii din criptele vililor intestinali → diaree secretorie 1,2,3 Dupa distructie epiteliala →scaderea nivelului dizaharidelor → malabsorbtie de carbohidrati si diaree osmotica 1,2,3 1.Blacklow NR et al.N engl J of Med1991;325(4): 2.Mavromichialis J et al..Arch Dis Child 1977;52(7): 3.Kerzner B et al.gastroenterology 1977;72(3):457-61
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Patogeneza – leziunile intestinale
Initial la nivelul portiunii superioare a IS si ulterior progreseaza catre ileum sunt situate selectiv la nivelul varfurilor vilozitare 1,2 sunt complet reversibile 3,4 severitatea leziunilor dicteaza evolutia si durata simptomelor3,4 1.Linhares AC et al.Rev Panam Salud Publica 2000;8(5):305-31 2 Parashar UD et al, Emerg Infect Dis 1998;4(4):561–570 3.Blacklow NR et al.N engl J of Med1991;325(4): 4.Kerzner B et al.gastroenterology 1977;72(3):457-61
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Patogeneza - actiunea enterotoxinei si activarea sistemului nervos enteric
Studii de histologie au demonstrat ca: diareea poate aparea si-n absenta leziunilor epiteliului mucoasei ↓ Implicarea altor mecanisme in patogeneza GERV: 1.Actiunea enterotoxica a glicoproteinei NSP4 * 1,2 Productia NSP4 → cresterea nivelelor de calciu → diaree secretorie 2.Stimularea sistemului nervos enteric 3 * proteina RV nonstructurala, codificata de gena 10) 1.Ball JM et al.Science 1996;272(5258): 2.Morris AP et al.Am J Physiol 1999;277(2pt1):G431-44 3.Lundgren O et al.Science 2000;287(5452):
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DIAREEA ACUTĂ VIRALĂ Vârf Criptă Secreţie ++ Hipersecreţie Distrugerea enterocitelor din vârful vilozităţilor Deficit de absorbţie datorat atacului viral Absorbţie ++ În cazul diareilor virale, hipersecreţia apare prin 3 mecanisme Iniţial se distrug enterocitele din vărful vilozităţilor, cele însărcinate cu absorbţia. Apoi, această distrugere accelerează migrarea enterocitelor secretoare din cripte care îşi conservă funcţia În plus virusii secretă toxine care provoacă hipersecreţie « Orice diaree, indiferent de mecanismul iniţial de producere, determină o pierdere excesivă de apă şi electroliţi »
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Patogeneza diareei cu rotavirus
Procesul cheie Mecanism patogenetic Consecinţe Distrugerea vilozităţilor Distrugere citoschelet, liza celulară Malabsorbţie, diaree osmotică Proliferarea criptelor Proliferare compensatorie a celulelor secretoare Diaree secretorie Enterotoxina NSP4 Creşterea Ca intracelular, secreţiei de Cl Malabsorbţia glucozei induse de NSP4 Inhibiţia SGLT-1 (Na-glucoza simport) (Simportul Na-glucoză SGLT1 şi posibil ATP-aza Na K dependentă) Diaree osmotică Ischemie vasculară neuromediată Dereglarea neurotransmiţătorilor microcirculaţiei Inflamaţie NF-kB, IL-8, Rantes Diaree osmotică/secretorie
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Simptome şi semne ale gastroenterocolitelor acute în funcţie de agentul etiologic la pacienţi sub 2 ani; infecţiile combinate sunt excluse Rotavirus (n=189) Adenovirus (n=35) Astrovirus (n=34) Norwalk-like virus (n=115) Sapporo-like virus (n=44) Durata diareei (zile) 4 5 1 2 3 Număr maxim/24h 6 Durată vărsături Temperatura 38,8 38,4 37,9 37,8 Scor severitate 10 7 8
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ENKEFALINELE: neurotransmiţători antisecretori
Neuron enteric enkefalinergic enkefaline enkefalinaze Receptor delta antisecretor Enterocite Absorbţie accentuată Enkefalinaze (excesiv) Dupa cum spuneam enkefalinele sunt neurotransmitatori antisecretori. Prin modularea nivelului de enkefaline poate fi influentata absorbtia si secretia de apa si electroliti Secreţie accentuată
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Hipersecreţia mecanismul principal al diareei acute
Descoperirea Racecadotril, inhibitor de enkefalinază, enzima responsabilă de degradarea rapidă a enkefalinelor, vine să confirme aceste date şi să aducă o armă cu totul originală în tratamentul diareei. Acţiunea sa specifică la nivel digestiv şi acţiunea pură antisecretorie diferenţiază Racecadotril de alte antidiareice.
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Tratamentul diareei acute
Igieno-dietetic Etiologic Patogenic Simptomatic
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Transmiterea CONTAGIOZITATE INALTA 4
Facilitata si de excretia asimptomatica a virusului inainte de aparitia simptomelor (50% din cazuri) si inca o saptamana dupa terminarea simptomatologiei(30% din cazuri) 5 Virus stabil in conditiile de mediu ( supravietuieste ore pe maini si zile/saptamani pe suprafete solide Transmiterea apare chiar in conditii de igiena imbunatatite4 Rotaviruses are highly contagious and are predominantly transmitted via the faecal-oral route. Only a very small number of infective organisms are needed to initiate infection (1012 particles/g of stool can be shed. The infective dose in a child can be as little as 10 particles)3. The virus can survive for hours on hands and for days on solid surfaces such as toys or food preparation counters2. It remains stable and infective in human faeces for up to 1 week. Person-to-person spread via contaminated hands is probably the most important means by which rotaviruses are spread in close communities, including family homes2. In addition, respiratory transmission is also suspected to occur via air droplets, as is transmission via contaminated environmental surfaces1,2. Transmission occurs regardless of sanitary conditions3. Improved socio-economic conditions have not significantly reduced the incidence of rotavirus diarrhoea in industrialised countries and further improvements in water quality, sewage disposal or hygiene are unlikely to have a substantial impact1,3,4. Transmission among non-toilet trained children in kindergartens and day-care centers is facilitated by direct close contact as well as sharing contaminated food, drinks or toys2. 1Fischer et al Vaccine2004; 22S:S49-S54 2Dennehy Pediatr Infect Dis J, 2000;19:S103–5 3Linhares AC et al, Pan Am J Public Health.2000;8(5):305–331 4Parashar et al, Emerg Infect Dis 1998;4:561–570 5Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996: p. 1657–1708 1 Fischer TK et al Vaccine 2004; 22S:S49-S54, 2Dennehy PH Pediatr Infect Dis J, 2000;19:S103–5; 3Linhares AC and Bresee JS, Pan Am J Public Health 2000;8(5):305–330; 4Parashar UD et al, Emerg Infect Dis 1998:4(4):561–570 Image: Ross Whitaker/Getty Images 5.Richardson S et al.Lancet 1998;35(9119):
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Transmiterea Modul predominant de transmitere este pe cale fecal - orala 1,2,3 Pana la 1012 particule virale sunt eliminate per gram de materii fecale obiectele contaminate (ex. jucarii) raman infectioase mai multe zile/saptamani Posibila si transmiterea respiratorie 4,5 Rotaviruses are highly contagious and are predominantly transmitted via the faecal-oral route. Only a very small number of infective organisms are needed to initiate infection (1012 particles/g of stool can be shed. The infective dose in a child can be as little as 10 particles)3. The virus can survive for hours on hands and for days on solid surfaces such as toys or food preparation counters2. It remains stable and infective in human faeces for up to 1 week. Person-to-person spread via contaminated hands is probably the most important means by which rotaviruses are spread in close communities, including family homes2. In addition, respiratory transmission is also suspected to occur via air droplets, as is transmission via contaminated environmental surfaces1,2. Transmission occurs regardless of sanitary conditions3. Improved socio-economic conditions have not significantly reduced the incidence of rotavirus diarrhoea in industrialised countries and further improvements in water quality, sewage disposal or hygiene are unlikely to have a substantial impact1,3,4. Transmission among non-toilet trained children in kindergartens and day-care centers is facilitated by direct close contact as well as sharing contaminated food, drinks or toys2. 1Fischer et al Vaccine2004; 22S:S49-S54 2Dennehy Pediatr Infect Dis J, 2000;19:S103–5 3Linhares AC et al, Pan Am J Public Health.2000;8(5):305–331 4Parashar et al, Emerg Infect Dis 1998;4:561–570 5Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996: p. 1657–1708 1 Fischer TK et al Vaccine 2004; 22S:S49-S54, 2Dennehy PH Pediatr Infect Dis J, 2000;19:S103–5; 3Linhares AC and Bresee JS, Pan Am J Public Health 2000;8(5):305–330; 4Parashar UD et al, Emerg Infect Dis 1998:4(4):561–570 Image: Ross Whitaker/Getty Images 5. Fragoso M et al.Diagn Microbiol Infect Dis 1986;4(1) : 87-8
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Evolutia clinica Primul episod de gastroenterita cu rotavirus este de obicei cel mai sever1 Tabloul clinic cuprinde: Diaree apoasa, varsaturi, febra, durere abdominala, deshidratare2 Evolutia clinica: Perioada de incubatie 0,5 – 4 zile Durata simptomelor 4–8 zile Considering the clinical course of rotavirus disease: Newborn infants rarely suffer from severe rotavirus disease as a consequence of breast feeding and passive transfer of maternal antibodies2. Children less than 5 years old present with a clinical spectrum of symptoms ranging from mild watery diarrhoea of short duration to severe GE with life-threatening dehydration and, if not promptly and adequately treated, death2. For children with a normal healthy immune system, and an adequate level of nutrition, rotavirus infections generally result in a self-limiting diarrhoeal disease lasting for a few days. However, severe disease may rapidly progress to cause life-threatening dehydration, requiring urgent rehydration therapy. After an incubation period of 0.5 to 4 days (most commonly 2 days), vomiting and profuse watery diarrhoea lasting for 4–8 days are noted. Fever and abdominal pain are common. Rotavirus diarrhea has an insidious onset and the symptoms last slightly longer than bacterial diarrhoeas. The first infection with rotavirus is usually the most severe and subsequent infections cause progressively milder symptoms1. Most patients are cared for at home and recover quickly without long-term effects. Hospitalisation is required for patients with severe disease in order to correct dehydration and electrolyte imbalance. In developing countries, infants may not receive adequate rehydration therapy and the dehydration may consequently become life-threatening. In the industrialised world, rotavirus infection is often less life-threatening but causes extensive morbidity and is associated with a substantial public health burden. 1Velázquez et al. N Engl J Med 1996; 335: 2Linhares and Bresee. Pan Am J Public Health 2000; 8(5):305–331 3Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996: p. 1657–1708 Semne de deshidratare 1Velázquez FR et al. N Engl J Med 1996; 335: Linhares AC and Bresee JS. Pan Am J Public Health 2000; 8(5): 305–331; Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996:p. 1657–1708; Image: JAMA 2001;285:362
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Asociat simptomelor digestive, copiii pot prezenta simptome respiratorii. Astfel, din 150 copii spitalizaţi pentru gastroenterită acută cu Rotavirus au prezentat: 26 % - rinită 8 % - raluri în căile aeriene 49 % - eritem faringian 18 % - adenopatie cervicală palpabilă 19 % semne de otită medie Simptomele infecţiei rotavirale sunt mult mai severe la pacienţii cu malnutriţie preexistentă.
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Evolutia clinica Varsaturile apar precoce, urmate ulterior de diaree si deshidratare2 Varsaturile si febra pot persista pana la 9 zile Durata diareei pana la 21 de zile Alte trasaturi clinice ale GERV includ: Exacerbarea anorexiei Depresie Tulburari circulatorii si respiratorii 1.Kaipikian A et al.Field Virology.Lippincott 4th Edition 2001: 2.Robert B.Textbook of human virology 2nd Ed.1990
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Consecintele gastroenteritei severe cu rotavirus (GERV)
Consecintele potentiale ale unei GERV severe netratate cuprind: Deshidratare severa Dezechilibru electrolitic Hipovolemie Colaps circulator Deces Considering the clinical course of rotavirus disease and consequences of severe untreated rotavirus gastroenteritis: Complications of RV infection include dehydration prompting hospitalisation, electrolyte imbalance (base-deficit acidosis and potassium depletion) and the psychological trauma of hospitalisation for infants and their families. Severe dehydration can lead to hypovolemia, circulatory collapse and death, if not immediately and adequately managed1. 1D’Agostino Clin Pediatr 2006;45: D’Agostino J. Clin Pediatr 2006;45: ; Image: Dr. D. Mahalanabis, World Health Organization
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GERV - recomandari terapeutice
Pentru sugarii imunocompetenti gastroenterita cu rotavirusuri(GERV) este o boala cu evolutie autolimitata Nu se recomanda de rutina un tratament antiviral specific pentru GERV esential tratamentul simptomatic de reechilibrare hidroelectrolitica *ESPGHAN - European Society of Paediatric Gastroenterology Hepatology and Nutrition **AAP- American Academy of Pediatrics 1Sandhu et al. J Pediatr Gastroenterol Nutr 2001; 33: S36-39; 2Szajewska et al. J Pediatr Gastroenterol Nutr 2000; 30:552–527; AAP. 3 AAP Policy. Pediatrics 2004; 114:507; 4King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16.
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GERV - recomandari terapeutice
Obiectivele principale ale tratamentului simptomatic pentru gastroenterita (ESPGHAN1,2*, AAP3,4**): Preventia si tratamentul deshidratarii: Terapie de rehidratare orala (ORT), solutii hipotonice Inlocuirea deficitului in 3-4 ore Terapie de intretinere apoi cu saruri de rehidratare orala (ORS) Continuarea hranirii normale Successful management of gastroenteritis in children relies chiefly on the maintenance or restoration of adequate hydration and electrolyte balance together with maintenance of an adequate nutritional intake Until recently it has been established practice in Europe that children with acute diarrhoea should be starved for 24 hours, in the belief that this would decrease the severity and duration of the diarrhoea3. However, firm evidence has now emerged favouring early re-feeding of children during oral rehydration therapy4. Treatment recommendations (WHO, ESPGHAN, AAP) for gastroenteritis include:1,2 Prevent and treat dehydration: ORS, hypotonic (Na 60, glu mmol/L) replace deficit in 3-4 hrs. maintenance therapy thereafter with ORS Resume normal feeding following successfuly completed rapid rehydration phase (3-4 h) continuation breastfeeding at all times no diluted or special formulas no unnecessary medications The ESPGHAN working group has recently completed a study comparing the effects of (a) complete resumption of child's normal feeding with a lactose-containing formula after 4 hrs of rehydration with oral rehydration solution and (b) sole use for 24 h of oral rehydration solution and then resumption of normal feeding1. This study showed that early feeding did result in significant weight gain compared with the late feeding group but did not result in worsening of diarrhoea, prolongation of the duration of diarrhoea, increased vomiting, or lactose intolerance. It is hoped that this ESPGHAN recommendation will help to establish this practice of early feeding in the management of gastroenteritis for children in Europe. 1Sandhu BK, Isolauri E, Walker-Smith JA, et al. J Pediatr Gastroenterol Nutr 1997;24:522-7 2Szajewska et al. J Pediatr Gastroenterol Nutr 2000; 30:552–527 3International Study Group on reduced-osmolarity ORS solutions. Lancet 1995;4;34:282-5 4Brown KH, Gastanaduy AS, Saavedra JM, et al. J Pediatr 1988;112: *ESPGHAN - European Society of Paediatric Gastroenterology Hepatology and Nutrition **AAP- American Academy of Pediatrics 1Sandhu et al. J Pediatr Gastroenterol Nutr 2001; 33: S36-39; 2Szajewska et al. J Pediatr Gastroenterol Nutr 2000; 30:552–527; AAP. 3 AAP Policy. Pediatrics 2004; 114:507; 4King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16.
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Dieta NU se va întrerupe alimentaţia naturală.
Unii autori au renunţat la dieta clasică în enterocolitele copilului, recomandând, după o scurtă periodă de dietă “hidrică“, realimentarea precoce cu formula folosită înainte de boală, renunţând la dieta de tranziţie. Perioada de regim hidric nu trebuie să depăşească 24 h. Se administrează 150 –200 ml/kg/24h fără a depăşi 1000 ml/zi la sugar.
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Se folosesc soluţii polielectrolitice:
- Humana Elektrolyt, supliment oral de minerale şi lichide Serveşte la echilibrarea rapidă a pierderilor de substanţe minerale şi de lichide în caz de diaree (tratament oral de rehidratare). Conţinutul unui plic (6,25 g pulbere) se dizolvă în 250 ml apă fiartă/ceai neîndulcit/Humana Baby Wasser. Se poate consuma caldă sau rece.
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(soluţie gata de consumare)
Conţinut (soluţie gata de consumare) La 100 ml La 250 ml Valoare calorică 34 kJ/8 kcal 84 kJ/20 kcal Glucoză 1,6 g 8,9 mmol 4 g Maltodextrină 0,28 g 1,7 mmol 0,7 g Sodiu 139 mg 6 mmol 347 mg Potasiu 78 mg 2 mmol 195 mg Clor 176 mg 5 mmol 440 mg Citrat 187 mg 1 mmol 467 mg Osmolaritate 230 mosmol/l
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Dozaj În primele 6-12 ore se recomandă: 1-3 luni: ml/kg, aproximativ ml, divizaţi în 3-8 biberoane 4-5 luni: ml/kg, aproximativ ml, divizaţi în 3-8 biberoane 6-12 luni: ml/kg, aproximativ ml, divizaţi în 3-8 biberoane copii mici şi şcolari: ml/kg, aproximativ 2-8 biberoane sau ceşti a 200 ml
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Alte soluţii polielectrolitice - GESOL conţine la 1 l apă:
3,5 g NaCl 2,5 g NaHCO3 1,5 g KCl 20 g glucoză - Pedyalite (la 1 l apă): 45 mEq Na 20 mEq K 35 mEq Cl 30m Eq citrat 25 g dextroză - Lytren (la 1 l apă): ∙ 9 g glucoză ∙ 42 g dextrin maltoză ∙ 42 mEq Na ∙ 25 mEq K ∙ 40 mEq Cl ∙ 19 g citrat
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În primele ore se administrează 50 – 100 ml/kg apoi, în urmatoarele 12 ore, restul, suplimentându-se cu 10 ml/kg pentru fiecare scaun lichid. Realimentarea se va face treptat respectând principiul reintroducerii progresive a alimentaţiei anterioare îmbolnăvirii. La profilul etiologic al enterocolitelor acute ale copilului în Romania considerăm necesară menţinerea dietei de tranziţie.
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GERV - recomandari terapeutice
Medicamentele antiperistaltice sau antisecretorii, administrate pt a limita diareea - pot genera efecte adverse importante 1 Tratamentul antibiotic nu este necesar 2 Este foarte utilă administrarea de Biotics, Ecoflorină, Enterolactil... Successful management of gastroenteritis in children relies chiefly on the maintenance or restoration of adequate hydration and electrolyte balance together with maintenance of an adequate nutritional intake Until recently it has been established practice in Europe that children with acute diarrhoea should be starved for 24 hours, in the belief that this would decrease the severity and duration of the diarrhoea3. However, firm evidence has now emerged favouring early re-feeding of children during oral rehydration therapy4. Treatment recommendations (WHO, ESPGHAN, AAP) for gastroenteritis include:1,2 Prevent and treat dehydration: ORS, hypotonic (Na 60, glu mmol/L) replace deficit in 3-4 hrs. maintenance therapy thereafter with ORS Resume normal feeding following successfuly completed rapid rehydration phase (3-4 h) continuation breastfeeding at all times no diluted or special formulas no unnecessary medications The ESPGHAN working group has recently completed a study comparing the effects of (a) complete resumption of child's normal feeding with a lactose-containing formula after 4 hrs of rehydration with oral rehydration solution and (b) sole use for 24 h of oral rehydration solution and then resumption of normal feeding1. This study showed that early feeding did result in significant weight gain compared with the late feeding group but did not result in worsening of diarrhoea, prolongation of the duration of diarrhoea, increased vomiting, or lactose intolerance. It is hoped that this ESPGHAN recommendation will help to establish this practice of early feeding in the management of gastroenteritis for children in Europe. 1Sandhu BK, Isolauri E, Walker-Smith JA, et al. J Pediatr Gastroenterol Nutr 1997;24:522-7 2Szajewska et al. J Pediatr Gastroenterol Nutr 2000; 30:552–527 3International Study Group on reduced-osmolarity ORS solutions. Lancet 1995;4;34:282-5 4Brown KH, Gastanaduy AS, Saavedra JM, et al. J Pediatr 1988;112: 1.Subbotina MD et al.Pediatr Infect Dis J 2003; 22(8):706-11 2. AAP Policy. Pediatrics 2004; 114:507;
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Preventia gastroenteritei cu rotavirus
Masurile preventive curente sunt limitate ! I.Alaptarea hranirea la san protejeaza nounascutii prin transfer pasiv de anticorpi materni 1 Prima infectie cu RV apare dupa disparitia anticorpilor materni 1 Alimentatia artificiala este asociata cu risc crescut de infectie 2 Considering methods of preventing transmission of rotavirus1,2: Evidence from a number of studies have shown that breast feeding does not prevent rotavirus infection but there is some evidence to suggest that breast feeding can decrease the severity of RVGE3 1Linhares and Bresee, Pan Amer J Public Health 2000;8(5):305–330 2Dennehy Pediatr Infect Dis J, 2000;19:S 3Sterling LM and Richardson J Fam Practice 2003; 52:10 4Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996: p. 1657–1708 5Parashar et al, Emerg Infect Dis 2003:9(5):565–572 1 Linhares AC and Bresee JS, Pan Am J Public Health 2000;8(5):305–330; 2Dennehy, Pediatr Infect Dis J, 2000;19:S 2.Sethi D et al.Pediatr Infect Dis J 2001;126(!): 63-70 Image Credit: pd-usgov-usda
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Preventia gastroenteritei cu rotavirus
Masurile preventive curente sunt limitate ! II.Masuri de control a infectiilor in colectivitati de copii si spitale pediatrice 1: dezinfectie sistematica a locurilor de joaca si a jucariilor spalarea frecventa a mainilor practici igienice riguroase in mediul de spital Considering methods of preventing transmission of rotavirus1,2: Rigorous hygiene practices in hospital wards can help prevent nosocomial rotavirus infection in young or otherwise compromised patients In day-care centers and kindergartens, regular disinfection of play areas and toys limits the exposure risk Frequent hand washing of staff and children The similar incidence of RVGE between industrialised and developing countries suggests that improvements in water supply, hygiene and sanitation will not impact the control of the disease.4,5 This conclusion, along with the dramatic disease burden associated with rotavirus, underscores the urgent need for intervention measures such as vaccination, particularly to prevent childhood deaths in developing nations4 and decrease morbidity associated with disease in Europe. 1Linhares and Bresee, Pan Amer J Public Health 2000;8(5):305–330 2Dennehy Pediatr Infect Dis J, 2000;19:S 3Sterling LM and Richardson J Fam Practice 2003; 52:10 4Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996: p. 1657–1708 5Parashar et al, Emerg Infect Dis 2003:9(5):565–572 1.Dennehy, Pediatr Infect Dis J, 2000;19:S
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Preventia gastroenteritei cu rotavirus
Aceste masuri de profilaxie nu sunt suficiente pentru reducerea morbiditatii si mortalitatii legate de gastroenterita cu RV 1,2 The similar incidence of RVGE between industrialised and developing countries suggests that improvements in water supply, hygiene and sanitation will not impact the control of the disease.4,5 This conclusion, along with the dramatic disease burden associated with rotavirus, underscores the urgent need for intervention measures such as vaccination, particularly to prevent childhood deaths in developing nations4 and decrease morbidity associated with disease in Europe. 1Linhares and Bresee, Pan Amer J Public Health 2000;8(5):305–330 2Dennehy Pediatr Infect Dis J, 2000;19:S 3Sterling LM and Richardson J Fam Practice 2003; 52:10 4Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996: p. 1657–1708 5Parashar et al, Emerg Infect Dis 2003:9(5):565–572 1.Glass RI et al.J Infect Dis 2005;192(suppl 1):S160-6 2. Kapikian A and Chanock R. Rotaviruses. In: Fields B et al, editors. Fields Virology, 3rd ed; 1996: p. 1657–1708
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Gastroenterita cu RV particularitati epidemiologice
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Tari in curs de dezvoltare
Infectia cu RV afectiune frecventa si “democratica” Infectia cu RV→ o treime din cazurile de diaree acuta la nivel global /an 1 Incidenta GERV la sugari si copii mici → SIMILARA in tarile industrializate si in curs de dezvoltare1 Bacterii Necunoscuta ROTAVIRUS Calicivirus Escherichia coli Paraziti Alte bacterii Tari dezvoltate Adenovirus Astrovirus Tari in curs de dezvoltare Diarrhoeal diseases are the second most common cause of death in infants under 5 years old, second only to lower respiratory infections.2 Globally, rotaviruses are the most common cause of severe diarrhoea, responsible for one third of cases of severe diarrhoea globally each year1 with a similar incidence of disease in both industrialised and developing countries.3 The similar incidence of rotavirus disease between industrialised and developing countries suggests that improvements in water supply, hygiene and sanitation will not impact the control of the disease.3 1Parashar et al, Emerg Infect Dis 1998;4(4):561–570 2World Health Report, 2005 3Linhares and Bresee, Pan Am J Public Health 2000;8(5): 4Parashar et al, Emerg Infect Dis 2003;9(5):565–572 5De Zoysa and Feachem, Bull WHO 1985;63:569–583 6Kosek et al, Bull WHO 2003;81(3):197–204 7Parashar et al, Bull WHO 2003;81(4):236 8 Soriano-Gabarro M et al. Pediatr infect Dis J ; 2006;25(1):Suppl S7-S11 1Parashar UD et al, Emerg Infect Dis 1998;4(4):561–570 Figure:Kapikian AZ, Chanock RM. Rotaviruses. In: Fields Virology 3rd ed. Philadelphia, PA: Lippincott-Raven; 1996:1659
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Sezonalitatea gastroenteritei cu RV
Jan-1997 Cazuri Jul-1997 Jan-1998 Jul-1998 Jan-1999 Jul-1999 Jan-2000 Jul-2000 Jan-2001 Jul-2001 Jan-2002 Jul-2002 Jan-2003 Jul-2003 Jan-2004 200 400 600 800 1000 cazuri Medie Seasonality of rotavirus disease Seasonality is an important but poorly understood feature of rotavirus diarrhoea. “Winter gastroenteritis” and “winter vomiting disease” were recognized illnesses of early childhood before rotavirus was identified and found to be their cause. In temperate climates of the developed world, rotavirus infections have a predominantly winter seasonal pattern and epidemics usually occur between November and April.1 Rendi-Wagner and colleagues observed seasonality of hospitalised cases of RVGE in children <15 years of age in Austria over a 7 year period (1997 and 2003) with a maximum number of cases being notified in February (18%) with the lowest incidence reported in July. 2 Seasonality was observed over a 14-year period ( ) in Spain (Basque Country). In the period, a clear seasonality was not observed but in the second period of the study (1991-7), seasonality was marked, with peak activity in winter.3 Gomara and colleagues noted that in the UK between 1995 and 1998, notable numbers of infections began in December or January, peaking in March or April and falling to almost zero by July.4 The seasonal occurrence of RVGE during the winter months results in competition for limited healthcare resources (mainly hospital beds) when epidemics of respiratory syncytial virus (RSV), influenza, and RVGE coincide. 1Cook SM et al. Bulletin of the WHO 1990;68: 2 Rendi-Wagner, et al., Wien Klin Wochenschr 2006;118/9-10 ; 3Cilla G et al. Epidemiol Infect 2000;125(3):677-83 4Iturriza-Gomara M et al. J Clin Microbiol 2000;38(12): Distributia sezoniera a cazurilor de GERV la copii <15 ani in Austria in (n= 26,500) Adapted from Rendi-Wagner P et al., Wien Klin Wochenschr 2006;118/9-10 ;
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Infectiile cu RV in Europa
Un review 2006 al mai multor studii realizate in Europa: Infectiile comunitare: prevalenta crescuta la varsta de 6 – 23 luni 1 Infectiile nosocomiale: prevalenta crescuta la varsta de sub 5 luni 1 RV implicat in 31-87% din cazurile de diaree nososcomiala pediatrica 1 1.Gleizes O et al.Ped Infect Dis J 2006;25 (1 suppl)S 12-21
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Importanta GERV nosocomiale
Infectia cu rotavirus este una dintre principalele cauze de infectii nosocomiale la copii1 In medie 21% dintre toate cazurile de GERV internate in spital sunt datorate GERV nosocomiale2 GERV poate creste durata spitalizarii cu 3 – 5 zile in aproximativ 50% dintre cazuri2 Cost estimat asociat unui episod de GERV nosocomiala, in Europa: 2500 euro 1 Rotavirus is one of the leading causes of hospital-acquired (nosocomial) infections in children younger than 5 years of age1 Nosocomial rotavirus infection usually becomes apparent between the second and sixth day of hospitalisation4. Nosocomial rotavirus is generally introduced in paediatric wards after hospitalisation of children with rotavirus community-acquired infection and/or following a stay in the emergency room before hospitalisation. Children who acquire nosocomial rotavirus infections potentially have the length of their hospital stay increased3. A median of 21% of all RV cases detected in hospital are from nosocomial infections2. Based on these data and national data in hospitals, the number of nosocomial cases could be estimated by dividing by 5. Range of nosocomial cases is 5-51%2. 1Gleizes O et al PIDJ, 2006; 25: S12-21 2 PROTECT Epidemiol & Infection 2006; 134: 3Thuret A at al Pathologie Biologie (Paris) 2004; 52(3):131-7 4Languepin J. Pediatric nosocomial diarrhea. Patho Biol (Paris). 2000:48(8):764-9 1Gleizes O et al PIDJ, 2006; 25: S12-21; 2The Pediatric ROTavirus European CommitTee (PROTECT). Epidemiol Infect 2006; 134:
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Concluzii
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Concluzii Rotavirus - urile sunt ubicuitare - 95% dintre copiii din toata lumea sunt infectati pana la varsta de 3 – 5 ani1 GERV o boala cu patogenie complexa Incidenta maxima a bolii clinice apare la copiii cu varste intre 6 si 24 luni 2 Cu cat apare la varsta mai mica, cu atat este mai mare riscul de boala severa, spitalizare sau deces2 1Parashar et al, Emerg Infect Dis (4) 561–570; 2Linhares and Bresee, Pan Amer J Public Health (5) 305–330
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Concluzii Vaccinarea la o varsta cat mai mica este o interventie eficienta pentru scaderea numarului de cazuri de gastroenterita cu rotavirus
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