Что нового в диагностике и лечении антибиотикоассоциированных диарей у детей?

Для цитирования: Захарова И.Н., Бережная И.В., Зайденварг Г.Е. и др. Что нового в диагностике и лечении антибиотикоассоциированных диарей у детей? Consilium Medicum. Педиатрия (Прил.). 2016; 2: 52–59.

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Zakharova I.N., Berezhnaya I.V., Zaydenvarg G.E. et al. What's new in the diagnosis and treatment of antibiotic-associated diarrhoea in children?
Consilium Medicum. Pediatrics (Suppl.). 2016; 2: 52–59.

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Аннотация

Широкое, часто необоснованное применение антибиотиков (АБ) в педиатрической практике может способствовать развитию разнообразных осложнений. У детей, особенно первых 5 лет жизни, на фоне приема АБ очень высок риск развития антибиотикоассоциированной диареи (ААД), проявляющейся как 3 и более эпизодов неоформленного стула, возникающих на фоне лечения или в течение 8 нед после отмены препарата. Наиболее значимым возбудителем ААД является Clostridium difficile, с которой, по различным данным, связано от 10 до 25% всех ААД и от 90 до 100% случаев псевдомембранозного колита. Учитывая опасность развития псевдомембранозного колита, особое внимание стоит обращать на снижение частоты бесконтрольного использования АБ, а детям из группы риска по развитию ААД необходимо назначать такие пробиотики, как Saccharomyces boulardii, обладающие протективным действием на кишку и имеющие высшую степень доказательности при данной патологии.

Ключевые слова: антибиотики, антибиотикоассоциированная диарея, псевдомембранозный колит, диарея, жидкий стул, дети, пробиотики, Saccharomyces boulardii, Энтерол.

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Widespread, often unjustified use of antibiotics (AB) in paediatric patients may contribute to the development of a variety of complications. The children, especially in their first 5 years of life, are at very high risk of developing antibiotic-associated diarrhoea (AAD), which manifests itself as a 3 or more episodes of unformed stools that occur during treatment or within 8 weeks after discontinuation of the drug. The most important causative agent of AAD is Clostridium difficile, which, according to various sources, connected from 10 to 25% of all AMA and from 90 to 100% of the cases of pseudomembranous colitis. Given the risk of the development of pseudomembranous colitis, special attention should be paid to the reduction of the frequency of uncontrolled use of AB, and children at risk for the development of the AMA should be administered probiotics such as Saccharomyces boulardii, have a protective effect on the gut and have a high degree of evidence in this pathology.

Key words: antibiotics, antibiotic diarrhoea, pseudomembranous colitis, diarrhoea, loose stools, children, probiotics, of Saccharomyces boulardii, Enterol.

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1. Omelianskii V.L. Osnovy mikrobiologii. L.: OGIZ, Biomedgiz, 1936. [in Russian]
2. Goossens H, Ferech M, Vander Stichele R, Elseviers M. ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005; 365: 579–87.
3. Tatochenko V.K. Antibiotiko- i khimioterapiia infektsii u detei. M., 2008. [in
Russian]
4. Van Boeckel TP, Gandra S, Ashok A et al. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. Lancet Infect Dis 2014; 14: 742–50.
5. Guarino А, Albano F, Ashkenazi S et al. European society for paediatric gastroenterology, hepatology, and nutrition/european society for paediatric infectious diseases evidence-based guidelines for the management of acute gastroenteritis in children in europe: executive summary. J Pediatr Gastroenterology Nutr 2008; 46 (5): 619–21.
6. VOZ. Lechenie diarei. 2006. [in Russian]
7. Hempel S, Newberry SJ, Maher AR et al. Probiotics for the Prevention and Treatment of Antibiotic-Associated Diarrhea. JAMA 2012; 307 (18): 1959–69.
8. Zakharova I.N., Mazankova L.N. i dr. Antibiotik-assotsiirovannye diarei u detei: problema i reshenie. M., 2011. [in Russian]
9. Alam S, Muchatad M. Antibiotic associated diarrhea in children. Indian Pediatr 2009; 46 (6): 491–6.
10. Zilberberg MD et al. Risk factors for recurrent Clostridium difficile infection (CDI) hospitalization among hospitalized patients with an initial CDI episode: a retrospective cohort study. BMC Infect Dis 2014; 14: 306. http://www.biomedcentral.com/1471-2334/14/306
11. Sheviakov M.A. Antibiotik-assotsiirovannaia diareia i kandidoz kishechnika: vozmozhnosti lecheniia i profilaktiki. Antibiotiki i khimioterapiia. 2004; 49 (10): 26–9. [in Russian]
12. Parfenov A.I., Osipov G.A., Ruchkina I.N. Diareiu, assotsiirovannuiu s antibiotikami, mozhet vyzyvat' Cl. perfringens. Eksperim. i klin. gastroenterologiia. 2002; 1: 159. [in Russian]
13. Hedge DD, Strain JD, Heins JR, Farver DK. New advances in the treatment of Clostridium difficile infection (CDI). Ther Clin Risk Manag 2008: 4 (5).
14. Lowy I, Molrine DC, Leav BA et al. Treatment with Monoclonal Antibodies against Clostridium difficile Toxins. N Engl J Med 2010; 362: 197–205.
15. Barakat M, El-Kady Z, Mostafa M et al. Antibiotic-associated Bloody Diarrhea in Infants: Clinical, Endoscopic, and Histopathologic Profiles. JPGN 2011; 52 (1).
16. Kirgizov K.I, Shul'ga S.Iu., Pristanskova E.A. i dr. Enterokolit, sviazannyi s Clostridium difficile, v detskoi gematologii-onkologii – reshennaia problema? Obzor literatury i sobstvennyi opyt. Ros. zhurn. detskoi gematologii i onkologii. 2014; 1: 25–31. [in Russian]
17. Vaishnavi C, Bhassin D, Kochhar R, Singh K. Clostridium difficile toxin and faecal lactoferrin assays in adult patients. Microbes Infect 2000; 2: 1827–30.
18. Lupse M, Flonta M, Cioara A et al. Predictors of First Recurrence in Clostridium difficile-Associated Disease. A Study of 306 Patients Hospitalized in a Romanian Tertiary Referral Center. J Gastrointestin Liver Dis 2013; 22 (4): 397–403.
19. Schwartz KL et al. Severe clinical outcome is uncommon in Clostridium difficile infection in children: a retrospective cohort study. BMC Pediatr 2014; 14: 2810.1038/ajg.2013.4; published online 26 February 2013.
20. Curtin BF, Zarbalian Y, Flasar МH, von Rosenvinge E. Clostridium difficile-associated disease: Adherence with current guidelines at a tertiary medical center. World J Gastroenterol 2013; 19 (46): 8647–51.
21. Johnson S et al. Interruption of recurrent Clostridium difficile-associated diarrhea episodes by serial therapy with vancomycin and rifaximin. Clin Infect Dis 2007; 44 (6): 846–8.
22. Edward O’Rourke. Harvard University – Harvard Medical School. Нospital epidemiology. 2014.
23. Cohen SH, Gerding DN, Johnson S et al; Society for Healthcare Epidemiology of America; Infectious Diseases Society of America. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Disases Society of America (IDSA). Infect Contr Hosp Epidem 2010; 5: 431–55.
24. Hsu J, Abad C, Dinh M, Safdar N. Prevention of Endemic Healthcare-Associated Clostridium difficile Infection: Reviewing the Evidence. Am J Gastroenterol 2010; 105: 2327–39. doi: 10.1038/ajg.2010.254; published online 6 July 2010.
25. Bossuyt P, Verhaegen J, van Assche G et al. Increasing incidence of Clostridium difficile-associated diarrhea in inflammatory bowel disease. J Chrohns Colits 2009; 3 (Issue 1): 4–7.
26. Clostridium difficile. In: Red Book. 2000.
27. Gerding DN. Clindamycin, cephalosporins, fluoroguinolones, and Clostridium difficile-associated diarrhea: this is an antimicrobial resistance problem. Clin Infect Dis 2004; 38: 646–8.
28. Szajewska H et al. J Pediatr Gastroenterol Nutr. 2016 (online).
29. Goulet O. Saccharomyces boulardii. Arch Pediatrie 2009; 16 (1): 1–14.
30. Poutanen SM, Simor AE. Clostridium difficile-associated diarrhea in adults. CMAJ 2004; 171: 51–8.
31. Aas J, Gessert CE, Bakken JS. Recurrent Clostridium difficile colitis: case series involving 18 patients treated with donor stool administered via a nasogastric tube. Clin Infect Dis 2003; 36: 580–5.
32. Lobzin Iu.V., Zakharenko S.M., Ivanov G.A. Sovremennye predstavleniia ob infektsii Clostridium difficile. Klin. mikrobiologiia i antimikrobnaia khimioterapiia. 2002; 4 (3): 200–32. [in Russian]
33. Surawicz CM, Brandt LJ, Binion DG et al. Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections. Am J Gastroenterol 2013; 108: 478–98.
34. Szajewska H, Mrukowicz J. Aliment Pharmacol Ther 2005; 22 (5): 365–72.

Авторы

И.Н.Захарова*1, И.В.Бережная1, Г.Е.Зайденварг1, А.Н.Плац-Колдобенко2, А.Ю.Дараган2

1 ГБОУ ДПО Российская медицинская академия последипломного образования Минздрава России. 125993, Россия, Москва, ул. Баррикадная, д. 2/1;
2 ГАУЗ МО Химкинская центральная клиническая больница. 141407, Россия, Химки, Куркинское ш., вл. 11
*zakharova-rmapo@yandex.ru

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I.N.Zakharova*1, I.V.Berezhnaya1, G.E.Zaydenvarg1, A.N.Plats-Koldobenko2, A.Yu.Daragan2

1 Russian Medical Academy of Postgraduate Education of the Ministry of Health of the Russian Federation. 125993, Russian Federation, Moscow, ul. Barrikadnaia, d. 2/1;
2 Khimki Central Clinical Hospital. 141407, Russian Federation, Khimki, Kurkinskoe sh., vl. 11
*zakharova-rmapo@yandex.ru

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