Methodical Instruction for Lectures

Ministry of Public Health of Ukraine Ukrainian Medical Stomatological Academy

Approved at the meeting of the department Infection diseases and epidemiology «28» August 2019 protocol № 1 from «28» August 2019 the Head of the Department ______Koval T.I.

Methodical Instruction for lectures

Study discipline Infectious diseases and epidemiology Module № Infectious diseases and epidemiology Topic Acute respiratory viral infections. Clinical characteristics and prevention of influenza. Course 4 Faculty Stomatological Number of teaching hours: 2

Poltava -2019

1. Scientific and methodological substantiation of the topic. Infectious diseases today remain extremely relevant. In the past decades, previously unknown infections — HIV infection, Lyme disease, campylobacteriosis, SARS, and others — have spread, and the achieved reduction in the incidence of diphtheria and measles has not been maintained. There is an increase in the incidence of viral hepatitis, acute intestinal infectious diseases, tuberculosis among the population of Ukraine and other countries. The clinical manifestations of infectious diseases can be different, often atypical, can lead to hospitalization of the patient in a medical institution of any profile. The ability to recognize infectious pathology, correctly conduct differential diagnosis, prescribe appropriate treatment, ensure that the necessary preventive measures are taken that are necessary for a doctor of any specialty. In our country, the classification of infectious diseases, academician L.V. Gromashevsky, has become most widespread. The classification is based on the principle of the predominant localization of the pathogen in the body, which is due to a certain transmission mechanism. One of the most important components in the treatment of patients for infectious diseases is inpatient treatment. Infectious Diseases Hospital is a special medical institution, which has a number of structural and functional units in order to ensure effective treatment, examination and isolation of patients. The features of the infectious diseases hospital, which are related to the possibility of transmission of the infection from person to person, determine not only the special structure of the infection departments, but also the particularities of maintaining medical documentation - emergency messages to the epidemiological service institutions and related records, sanitary treatment of patients things, etc. . Currently, influenza is the most common infection in the world and is registered on all continents. A feature of this infection is the incredible spread rate - a large place is covered by the disease in 1.5-2 weeks, a large country in 3-4 weeks. During epidemic outbreaks, up to 30-50 people in the affected region are affected, which leads to large epidemic losses. In the calmest years, nearly 30 million people are affected by the flu. Currently, the flu remains an uncontrolled and little controlled infection. The mortality rate of uncomplicated influenza is low and amounts to 0.01-0.2, but it increases sharply in the case of influenza in the elderly and weakened people, especially in those who have chronic heart disease, lungs, and young children. During an influenza epidemic, mortality from cardiovascular, pulmonary diseases always increases. It is estimated that uncomplicated influenza and other respiratory infections take a person’s life for at least 1 year. Annually (according to the WHO), 40 million people are infected with infectious diseases in the world, 90% of them account for ARVI. Each adult on average 2 times a year has the flu, or SARS, a schoolboy - 3 times, a preschooler - 6. In practical medicine, acute respiratory viral infections occupy a special place among other human diseases for another reason. As with other common diseases, an acute respiratory viral infection is often diagnosed without good reason. The error rate for the diagnosis of acute respiratory viral infections is 50%. At the same time, the diagnosis of acute respiratory viral infections can only take place if, during the examination of the patient, the doctor determines the signs of airway impression. However, it must be remembered that not only viruses can cause respiratory syndrome, but also bacteria, mycoplasmas, chlamydia, and rickettsia. 2. The educational goals of the lecture. To analyze the characteristics of infectious diseases, the patterns of the course of the infectious and epidemiological process of various infectious diseases, the principles of their diagnosis, treatment and prevention; types of infectious diseases hospitals, requirements for the territory of infectious diseases hospitals; structural subdivisions, purposes and tasks of the sanitary inspection room, the purpose and components of the boxes and semi-boxes, auxiliary sections, the principles of disinfection in an infectious diseases hospital; principles of preventing nosocomial infection, infection of medical personnel; rules for maintaining medical documentation in the infectious diseases ward; rules for discharge of patients from the infectious diseases hospital; features of infectious diseases, phases of the infectious process, factors that affect its course, the role of immunity in infectious diseases; principles for classifying infectious diseases ; general characteristics of different groups of infectious diseases - intestinal, respiratory, blood, wound infections, infectious diseases with multiple transmission mechanisms. Explain the etiology of influenza and SARS, pathogenicity factors of the pathogen; epidemiology of influenza; pathogenesis, clinical manifestations of influenza, SARS; the period of occurrence and clinical manifestations of complications of influenza, SARS; diagnosis of influenza, SARS; principles of treatment and prevention; categories of people to whom vaccination is shown first; treatment of influenza, indications for the appointment of antibacterial drugs; indications for hospitalization of patients with influenza. Analyze the rules for staying in an infectious diseases hospital and, in particular, near the patient’s bed; collect an epidemiological history, separate the possible ways and factors of infection transmission; decide on the necessity and place of hospitalization of the patient for an infectious disease; draw up and submit the appropriate documentation to the SES; adhere to the rules for discharge of the patient with infection department. Explain the basic rules of work near the bed of a patient with influenza, SARS; to collect a medical history with an assessment of epidemiological data; examine the patient and detect the main symptoms and flu syndromes, substantiate the clinical diagnosis, determine the need for hospitalization in a hospital; conduct differential diagnosis of influenza, SARS; on the basis of a clinical examination, in a timely manner to identify possible complications of influenza, urgent conditions, draw up medical documentation on the fact of the establishment of a previous diagnosis of influenza (emergency report to the district epidemiological department); make a plan for laboratory and additional examination of the patient; interpret the results of a laboratory examination; to draw up an individual treatment plan taking into account the syndromes of the disease, the presence of complications, the severity of the condition, allergic history, concomitant pathology; provide emergency care at the prehospital stage; draw up a plan of anti-epidemic and preventive measures in the focus of infection; give recommendations regarding the regimen, diet, examination, supervision, during the period of convalescence. 3. The goals of the personality development of the future specialist (educational goals), relevant aspects: deontological, environmental, legal, professional responsibility, psychological, ethical, patriotic, etc.

4. Learning outcomes: Autonomy and No. Competence Awareness Skill Communication responsibility Integral Competency 1. Ability to solve typical and complex specialized tasks and practical problems in professional activities in the field of healthcare or in the learning process, which involves research and / or innovation and is characterized by the complexity and uncertainty of conditions and requirements. General competencies 1. Ability for abstract To know the To be able to To establish To be responsible thinking, analysis and methods of analyze appropriate for the timely synthesis. analysis, synthesis information, make links to achieve acquisition of and further informed goals. modern knowledge. modern learning decisions, be able to acquire modern knowledge 2. Ability to learn and master To know current To be able to To establish To be responsible modern knowledge. industry trends analyze appropriate for the timely and analyze them professional links to achieve acquisition of information, make goals. modern knowledge. informed decisions, acquire modern knowledge 3. Ability to apply knowledge To have To be able to solve Clear and Responsible for in practical situations specialized complex issues and unambiguous decision making in conceptual problems arising in reporting of difficult conditions knowledge professional their own acquired in the activities. conclusions, learning process. knowledge and explanations that substantiate them, to specialists and non-specialists. 4. Knowledge and To have deep To be able to carry The ability to To be responsible understanding of the knowledge of the out professional effectively for development, subject area and structure of activities that formulate a the ability to further understanding of professional require updating communication professional professional activities activity. and integration of strategy in training with a high knowledge. professional level of autonomy. activities 5. Ability to adapt and act in a To know the types To be able to use To establish To be responsible new situation. and methods of means of self- appropriate for the timely use of adaptation, the regulation, to be relationships to self-regulation principles of able to adapt to achieve results. methods. action in a new new situations situation (circumstances) of life and activity. 6. Ability to make informed To know the To be able to make To use To be responsible decisions tactics and an informed communication for the choice and communication decision, choose strategies and tactics of the strategy, laws and ways and strategies interpersonal communication methods of of communication skills method. communicative to ensure effective behavior teamwork Autonomy and No. Competence Awareness Skill Communication responsibility

7. Able to work in a team To know the To be able to make To use To be responsible environment tactics and an informed communication for the choice and communication decision, choose strategies tactics of the strategy, laws and ways and strategies communication methods of of communication method. communicative to ensure effective behavior teamwork 8. Interpersonal To know the laws To be able to To use To be responsible communication skills and methods of choose methods interpersonal for the choice and interpersonal and strategies for communication tactics of the communication interpersonal skills communication communication method. 9. Ability to communicate in To have perfect To be able to apply To use the To be responsible the state language both knowledge of the knowledge of the official for fluency in the orally and in writing. state language state language, language in state language, for both orally and in professional and the development of writing business professional communication knowledge. and in the preparation of documents. 10. Ability to communicate in To have basic To be able to To use a foreign To be responsible a foreign language knowledge of a communicate in a language in for the foreign language foreign language. professional development of activities professional knowledge using a foreign language. 11. Skills to exploit To have in-depth To be able to use To use To be responsible information and knowledge in the information and information and for the communication technology field of communication communication development of information and technologies in the technologies in professional communication professional professional knowledge and technologies used industry, which activities skills. in professional requires updating activities and integration of knowledge. 12. Certainty and perseverance To know the To be able to To establish Responsible for the regarding tasks and responsibilities determine goals interpersonal quality responsibilities and ways to and objectives, to relationships to performance of accomplish tasks be persistent and effectively assigned tasks conscientious in complete tasks the performance of and duties responsibilities 13. Ability to act responsibly To know your To form your civic Ability to Responsible for and consciously in the social and civil consciousness, to convey your civic position and social dimension rights and be able to act in social and social activities responsibilities accordance with it position 14. The pursuit of To know the To be able to To submit To be responsible environmental problems of formulate proposals to for the conservation. environmental requirements for relevant implementation of conservation and yourself and others authorities and environmental how to preserve regarding the issue institutions on protection environment of environmental measures to measures within conservation preserve and own competence. Autonomy and No. Competence Awareness Skill Communication responsibility protect the environment 15. Ability to plan and manage To know the To be able to To establish To be responsible time principles of consistently carry appropriate for the appropriate planning, to know out the actions in relationships to procedure and the requirements accordance with achieve results. timing of actions for the timing of the requirements an action for the timing of their implementation 16. Ability to act ethically To know the To be able to apply Ability to To be responsible basics of ethics ethical and convey their for the and deontology deontological professional implementation of norms and position to ethical and principles in patients, deontological professional members of norms and activities their families, principles in colleagues professional activities Special (professional) competencies 1. Skills of interrogation1 and To have To be able to To form a To be responsible . clinical examination of the specialized conduct a communication for the quality patient knowledge about conversation with strategy when collection of the human body, the patient; communicating information its organs and physical with the patient received on the systems, to know examination, effectively. To basis of an the standard palpation, enter interview, survey, patterns of percussion, information examination and questioning and auscultation based about the state for a timely physical on algorithms and of human health assessment of the examination of standards. in medical patient’s general the patient. records health

2. Ability to 2determine the To have To be able to To formulate To be responsible . necessary list of laboratory specialized analyze the results and convey to for making and instrumental studies knowledge about of laboratory and the patient and decisions regarding and evaluate their results the human body, instrumental specialists the evaluation of its organs and studies and on conclusions laboratory and systems, standard their basis to regarding the instrumental methods for evaluate necessary studies. conducting information about list of laboratory and the patient's laboratory and instrumental condition instrumental studies defined by studies. the program. 3. Ability to 3conduct To have To be able to To formulate Responsible for . differential diagnosis knowledge of the conduct and convey to timely and correct clinical differential the patient and diagnosis. manifestations of diagnosis between specialists the various diseases infectious and results of other diseases differential diagnosis 4. Ability to 4establish a To have To be able to Based on Following ethical . diagnosis of the disease specialized conduct a physical regulatory and legal standards, knowledge about examination of the documents, to to be responsible Autonomy and No. Competence Awareness Skill Communication responsibility the human body, patient; be able to keep medical for making its organs and make an informed records of the informed decisions systems, standard decision regarding patient and actions examination the definition of a (inpatient card, regarding the techniques; leading clinical etc.). correctness of the disease diagnosis symptom or established algorithms; syndrome; be able diagnosis of the algorithms for to prescribe a disease determining laboratory and leading symptoms instrumental and syndromes; examination of the laboratory and patient by using instrumental standard methods examination methods; knowledge regarding the assessment of human condition. 5. Ability to 5prescribe To have To be able to To formulate To be responsible . treatment specialized choose the and convey to for the timeliness knowledge necessary complex the patient and and correctness of regarding of therapeutic specialists the the choice of algorithms and measures, appropriate treatment program treatment depending on the complex of for the patient schemes for clinical form of the treatment for infectious disease the patient. To diseases be able to record prescribtions in medical records 6. Ability to 6diagnose of To have To be able, in Under any To be responsible . emergency conditions specialized conditions of lack circumstances, for the timeliness knowledge about of information, adhering to the and effectiveness of the human body, using standard relevant ethical medical measures its organs and methods, by and legal regarding the systems, to know making an standards, to diagnosis of the standard informed decision make an emergency techniques for to assess a informed conditions physical person’s condition decision examination of and the need for regarding the the patient. emergency care assessment of the condition of a person and the organization of necessary medical measures, depending on the condition of the person 7. Skills of emergency7 To have To be able to To explain the To be responsible . medical care specialized provide emergency need and for the timeliness knowledge about medical care in procedure for and quality of the human body, case of emergency conducting emergency medical its organs and emergency care Autonomy and No. Competence Awareness Skill Communication responsibility systems, the medical algorithm for treatment providing measures emergency medical care in case of emergency 8. Skills of medical8 To have To be able to To formulate To be responsible . manipulation specialized perform medical and convey for the quality of knowledge about manipulations conclusions to medical procedures the human body, provided by the the patient and its organs and program specialists about systems; the need for knowledge of medical medical procedures manipulation algorithms provided by the program 9. Ability to 9keep medical To know the To be able to To otain the To be responsible . records system of official determine the necessary for the workflow in the source and location information completeness and professional work of the necessary from a specific quality of the of medical information source and, analysis of personnel, depending on its based on its information and including modern type; be able to analysis, to conclusions based computer process form relevant on its analysis. information information and conclusions technologies analyze the information received 10. Ability to 1conduct To know the To have skills in To know the To be responsible 0. sanitary-hygienic and system of organizing the principles of for the timely and preventive measures sanitary-hygienic sanitary-hygienic presenting high-quality and preventive and medical- information implementation of measures when protective regime about the measures to ensure working with of the main units sanitary- the sanitary- patients with of medical hygienic hygienic and infectious institutions. To be condition of the medical-protective diseases. able to organize premises and regime of the main To know the the promotion of a compliance units of medical principles and healthy lifestyle. with the institutions, methods of hospital-wide promoting a promoting a and medical- healthy lifestyle; healthy lifestyle protective regimes; to use lectures and interviews. 5. Interdisciplinary integration. Names of previous Acquired skills disciplines Anatomy The structure of the oropharynx, nose, larynx, trachea, bronchi, lungs, heart, nervous system Histology The structure of the mucous membrane of the nose, larynx, oropharynx, trachea Microbiology Properties of the influenza virus, methods for the specific diagnosis of influenza Physiology The parameters of the physiological norm of human organs and systems; laboratory examination parameters are normal (total blood, urine, blood biochemistry, parameters of WWTP, electrolytes, etc.). Pathophysiology The mechanism of violation of the functions of organs and systems in pathological conditions of different genesis. Pathological anatomy Changes in the structure of the mucous membrane of the oropharynx, tonsils, nose, l / u, renal tubule epithelium, the structure of the central and peripheral NS, myocardium. Pharmacology Groups of drugs that are used to treat the disease, dosing (single and daily), their side effects, contraindications and so on Propaedeutics of Methods and main stages of a clinical examination of a patient. internal diseases Symptoms and syndromes of the disease. Clinical Famakokinetics and pharmacodynamics, side effects of chloramphenicol, Pharmacology ciprofloxacin, pathogenetic therapy. Neurology Pathogenesis, clinical signs of toxic brain edema, arachnoiditis, syndrome, Hyena-Barre, polyneuritis, Reye's syndrome 6. Plan and organizational structure of the lecture

Influenza Aetiology. The disease is caused by the virus belonging to the family Orthomyxoviridae. Three serotypes of the influenza virus are distinguished: A, B, and C. Virus A is of greatest epidemiologic danger. Its antigen structure is constantly changing. Four subtypes of virus A have been established: AO, Al, A2 and A3. Virus B has a more stable antigen structure. Virus C is the most stable influenza virus. Two various antigens are contained in the outer envelope of the influenza virus: haemagglutinin (H) and neuraminidase (N). Haemagglutinin (H) has four independent subtypes: HO, HI, H2 and H3, which relate to viruses AO, Al, A2 and A3, respectively. The other antigen of the influenza virus of the envelope, neuraminidase (N), has two subtypes: Nl (common for viruses AO and Al) and N2 (common for viruses A2 and A3). Depending on the presence of particular surface antigens, influenza A virus is designated A(HONl), A(H1N1), A(H2N3), A(H3N2), etc. Influenza viruses are intracellular parasites. The virus is unstable in the environment, is rapidly destroyed on heating, drying, and by various disinfectants; it withstands frosting. Influenza viruses are cultivated and isolated on chick embryo. Among laboratory animals, hamsters, mice and pole cats are most susceptible to the influenza virus. Epidemiology. Diseased humans, especially during the first days of the disease, are the main source of infection. The virus is released from the patient during sneezing, coughing and talking till the 4-7th day of the disease. If influenza is complicated by pneumonia, the virus is liberated for 10-12 days. Patients with abortive and asymptomatic diseases are dangerous for the surrounding, because the quantity of such patients is much greater than of patients with clinical symptoms, and they continue actively infecting people. Infection is transmitted by air-borne route in enclosures where an influenza patient is present. Infection spread is facilitated by inadequate living conditions, overcrowding that promotes close contacts with the patient, nadequate labour conditions, intensive migration of population. Since the influenza virus is unstable in the external environment, fomites (dishes, toys, towels, etc.) are not substantially important. Influenza occurs as sporadic infections and epidemic outbreaks, pandemics. Influenza A epidemic is characterized by a rapid spread, which is due to generation of new antigenic variants of the virus. During an epidemic outbreak, the number of influenza cases and acute respiratory diseases increases 10-20 times. Within a short lapse of time (1- 11/2 months) residents of many cities and countries become involved (the sick rate from 30 to 40 per cent). People of almost all age groups are equally involved. The duration of circulation of all new virus A serotypes is 10-11 years. During this period, each serotype gives 3-4 antigenic variants, which, in turn, become the cause of new epidemic outbreaks of influenza every 2 or 3 years. During the past seventy years, virus A changed its antigenic structure five times. One virus type superseded the other: A0-A1-A2-A3. Late in 1977, when cases with influenza A3 were still reported, a new influenza appeared due to serotype A(H1N1). Since the last pandemic caused by this serotype was in 1956, people aged under 25 years were mostly afflicted. Stable immunity to serotype A(H1N1) in persons who sustained this infection in the past was thus discovered. Epidemics due to virus B develop slowly and involve to 10-25 per cent of population; they occur every 2 or 3 years. Virus C causes sporadic infections mostly among children. The spread of influenza is thus promoted by the instability of the antigenic structure of virus A under the influence of immunity in those who sustained the disease in the past. The spread is also promoted by high natural susceptibility of population, by a considerable proportion of asymptomatic (abortive) forms of the disease, by the short-lasting incubation period, and by the easiness of infection transmission through the droplet mechanism. The influenza incidence increases during the autumn and winter, and also in the spring. Pathogenesis. The portal of infection is mucosa of the upper airways. Columnar epithelium of the trachea is afflicted selectively. As the virus multiplies in the epithelium it causes its degeneration and necrosis. The underlying tissues are affected by oedema, the vessels become permeable to cause epistaxis, blood in the sputum, etc. Toxaemia evokes the lesion of the nervous and cardiovascular system. Suppressed immunity facilitates development of secondary complications due to exogenic and endogenic microorganisms; chronic diseases are exacerbated. Miltiplication of the virus is inhibited by interferon that is formed from the very first hours of the disease in the infected cells. By the end of the first week, the titre of the specific antibodies increases. The type-specific immunity after the sustained disease persists for 20 years. Clinical course. The incubation period lasts 1-2 days with variations from a few hours to 3 days. Influenza can be mild, moderate and severe. The disease can have a typical or atypical clinical manifestations. A typical influenza begins acutely with elevation of body temperature and chilliness. In 4-5 hours the body temperature can be as high as 38.7-40 °C. If the disease is mild, the body temperature can be subfebrile. The condition of the patient worsens. He complains of headache, mostly frontal and retro-ocular, which is accentuated by the movement of the eyes, pain in the muscles and bones, insomnia, cough, nasal obstruction, dry throat, sneezing, sweating, and weakness. Examination reveals hyperaemic face and neck, and injected scleral vessels. There are also tachypnoea and arterial hypotension; the heart sounds are dull; the pulse is slow (disagrees with body temperature). Nosebleed is possible. Among the respiratory symptoms are catarrh of the upper airways: stuffy nose, sneezing, hoarse voice, dry cough. The fauces are hyperaemic, the tongue is coated. Cough can persist in the young for 10-12 days, and in the elderly for longer time. The influenza virus and its toxins affect the peripheral nervous system and bone marrow, which is manifested by neuralgia, neuritis and symptoms of encephalitis. If influenza is not aggravated by complications, fever persists for 2-4 days, less frequently 5 days, or it may be as short as 1 day. A severe (toxic) form of influenza is characterized by marked symptoms of toxaemia: severe headache, hyperpyrexia (to 40 °C), dyspnoea, cyanosis, hypotension, weak and fast pulse, insomnia or somnolence, sometimes delirium, nausea, vomiting, loss of consciousness, muscular cramping, symptoms of meningitis; haemorrhages in the skin can develop. Severe forms of influenza usually occur during the first two weeks of an epidemic. Influenza is characterized by specific leucopenia with relative lymphocytosis and a neutrophilic shift to the left, and aneosinophilia. Complications. The chief complications are pneumonias due to the virus or secondary bacterial infection (pneumococci, staphylococci, haemolytic streptococci, etc.). Acute cardiovascular failure, laryngitis, tracheobronchitis, bronchitis, bronchiolitis, frontal sinusitis, maxillary sinusitis, otitis and various haemorrhages, from epistaxis to haemorrhagic oedema of the lungs, are also complications of influenza. Diagnosis. It is not difficult to establish the diagnosis of influenza during an epidemic outbreak. During the interepidemic period, when the course of influenza is mild, it should be differentiated from other acute respiratory viral infections. Influenza is characterized by an acute onset, marked toxaemia, mild catarrhal phenomena, and leucopenia. A final and accurate diagnosis of influenza and other acute viral respiratory infections can be established in the laboratory by serologic, virologic and immunofluorescent methods. The first specimen of serum is taken not later than on the third day of the disease, the second not earlier than in three weeks. A four-fold increase in the titre is considered as a decisive diagnostic evidence. Serologic reactions are used to confirm the clinical diagnosis. The influenza virus can be isolated from the pharyngeal washings obtained during the first days of the disease or when the disease is in its full swing. The filtrate of the washings is mixed in the laboratory with a 2 per cent suspension of hen or guinea pig erythrocytes. The mixture is kept on ice for 20-30 minutes and the erythrocytes are precipitated by centrifuging. An isotonic sodium chloride solution and antibiotics are added to the precipitated erythrocytes with the virus adsorbed on them. The obtained material is used to inoculate chick embryos, cell cultures, and experimental animals. The isolated pure virus culture is used for serologic identification of the virus type. The result is ready only in 72-96 hours. The immunofluorescent method can confirm the diagnosis of influenza or differentiate it from other acute viral respiratory diseases. To that end, a smear is taken from the mucosa of the inferior concha (after preliminary cleaning of the nose from mucus and crusts). The cotton tampon with a smear is placed in a test tube containing 2-3 ml of physiological saline solution and delivered immediately to the laboratory. Fluorescent antibodies help detect the virus in 3-4 hours in the cells of columnar epithelium of the patient's nose. The disadvantage of this method is that it is impossible to identify the serotype of the circulating virus. Treatment. Regardless of severity of the disease, the patient must keep bed until his body temperature normalizes and symptoms of toxaemia subside. Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who:  is hospitalized;  has severe, complicated, or progressive illness; or  is at higher risk for influenza complications. Decisions about starting antiviral treatment should not wait for laboratory confirmation of influenza. Figure: Guide for considering influenza testing and treatment when influenza viruses are circulating in the community (regardless of influenza vaccination history)

The recommended treatment course for uncomplicated influenza is oral oseltamivir 75 mg twice daily or two 5-mg inhalations twice daily of inhaled zanamivir for 5 days, or one 600 mg dose of intravenous peramivir or oral baloxavir (40 to <80 kg: one 40 mg dose; >80 kg: one 80 mg dose) for 1 day. Amantadine and rimantadine are antiviral drugs in a class of medications known as adamantanes, which target the M2 ion channel protein of influenza A viruses. Therefore, these medications are active against influenza A viruses, but not influenza B viruses. As in recent past seasons, there continues to be high levels of resistance (>99%) to adamantanes among circulating influenza A(H3N2) and influenza A(H1N1)pdm09 (“2009 H1N1”) viruses. Therefore, amantadine and rimantadine are not recommended for antiviral treatment or chemoprophylaxis of currently circulating influenza A viruses. Drinking of great amount of hot liquid (tea with lemon, jam or honey; warm milk) is recommended. Polyvitamins should be taken 3 times a day. If the nose is stuffy, a 2 per cent ephedrine (naphthyzine, or sanorine) solution should be instilled into the nose. Codeine, libexin preparations and steam inhalations are useful for cough. Analgin, amidopyrin, ascophen should be given to lessen headache and myalgia. Anti-influenza donor immunoglobulin is an effective specific preparation. It is given in severe forms of influenza, preferably during the first days of the disease. Immunoglobulin should be given to children intramuscularly, 0.15-0.2 ml/kg body weight. Adults should be given 6 ml. Influenza due to virus. Severe forms of influenza should be treated by repeated administrations of anti-influenza immunoglobulin, detoxicating fluids (isotonic sodium chloride solution, haemodez, polyglucin, rheopolyglucin), 800-1000 ml a day, with an obligatory administration of lasix, brinaldix (saluretics), or urea and mannitol. Development of complications is an indication for antibiotic therapy. Prevention and control. CDC recommends a yearly flu vaccine as the first and most important step in protecting against influenza and its potentially serious complications. Inactivated influenza vaccine [IIV], recombinant influenza vaccine [RIV], or live attenuated influenza vaccine (LAIV) are used for specific prophylaxis of influenza. Everyone 6 months and older should get an influenza (flu) vaccine every season with rare exception. Vaccination to prevent flu is particularly important for people who are at high risk of developing serious flu complications. The seasonal flu vaccine protects against the influenza viruses that research indicates will be most common during the upcoming season. Trivalent vaccines are made to protect against three flu viruses; an influenza A (H1N1) virus, an influenza A (H3N2) virus, and an influenza B virus. Quadrivalent vaccines protect against four viruses; the same viruses as the trivalent vaccine as well as an additional B virus. Prophylactic vaccination should be completed 1-2 months before the expected rise of the morbidity. Chemoprophylaxis: Recommended duration is 7 days (after last known exposure). For control of outbreaks in institutional settings (e.g. long-term care facilities for elderly people and children) and hospitals, CDC recommends antiviral chemoprophylaxis with oral oseltamivir or inhaled zanamivir for a minimum of 2 weeks and continuing up to 1 week after the last known case was identified. Antiviral chemoprophylaxis is recommended for all residents, including those who have received influenza vaccination. General hygiene is important for control of influenza spread. Adequate airing and intensive insolation of enclosures, using ultraviolet radiation (especially in children's and medical institutions), adequate washing of dishes in hot water, proper individual hygiene (washing hands, using separate dishes, towels, linen, etc.) are important prophylactic measures. Patients with non-complicated influenza in the focus of infection should be isolated in home conditions. Patients with severe forms of the disease and complications, and also first patients with acute respiratory infections at closed children's institutions (sanatoria, children's homes, etc.) and in big families, should be hospitalized. The patients should be isolated until complete recovery. Rooms where influenza patients are kept should be regularly aired and cleaned. Patients are given their individual towels and dishes. Persons who take care of influenza patients must wear masks (respirators). Contacts of patients with the rest of the family must be restricted. Asthenic infants (aged under 1 year) should be given anti-influenza immunoglobulin intramuscularly in a dose of 0.2 ml/kg body weight. Passive immunity lasts for 18- 20 days. After recovery of the patient, the room should be aired thoroughly and cleaned with soap- soda solution. Especially strict sanitary and hygienic regimen must be ensured during epidemic in children's institutions, policlinics, hospitals, maternity houses, etc. Personnel of lying-in hospitals, children's medical and prophylactic institutions should wear respirators in order to prevent infection and its spread. Rooms for isolation of influenza patients must be provided at hostels and other places where people live in close communities. Children attending schools or preschool institutions should be isolated at home. If the disease is severe or home conditions are suboptimal, the patient should be hospitalized. After isolation of the patient from the rest of the group, the room should be aired properly and cleaned with a 0.5 per cent chloramine solution. The personnel must wear respirators. All healthy children must be examined every day in order to reveal timely new patients. The rooms must be treated with ultraviolet radiation when the children are out-of-doors.

Acute respiratory tract infection - is an illness caused by an acute infection, which involves the upper respiratory tract, including the nose, sinuses, pharynx, or larynx. This commonly includes nasal obstruction, sore throat, tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold. Most infections are viral in nature, and in other instances, the cause is bacterial. URTIs can also be fungal or helminthic in origin, but these are less common. In 2015, 17.2 billion cases of URTIs are estimated to have occurred.[1] As of 2014, they caused about 3,000 deaths, down from 4,000 in 1990. Table 1. Differential diagnosis between URI and Influenza Symptoms URI Influenza Itchy, watery Rare (conjunctivitis may occur Soreness behind eyes, sometimes eyes with adenovirus) conjunctivitis Nasal Common Common discharge Nasal Common Sometimes congestion Sneezing Very common Sometimes Sore throat Very common Sometimes Cough Common (mild to moderate, Common (dry cough, can be severe) hacking) Headache Rare Common Fever Rare in adults, possible in Very common children 100–102 °F (or higher in young children), lasting 3–4 days; may have chills Malaise Sometimes Very common Fatigue, Sometimes Very common (can last for weeks, extreme weakness exhaustion early in course)

Muscle pain Slight Very common (often severe)

Parainfluenza Aetiology. The disease is caused by the virus belonging to the family of Paramyxoviridae. The parainfluenza virus contains RNA. Four serotypes are known that afflict humans. In laboratory conditions they are cultivated in cells of human embryo kidney. The viruses are unstable in the environment. Epidemiology. The source of infection is a diseased human. Infection is transmitted by air-borne route. Infants are mostly affected, although adults can also develop the disease. A sufficiently stable immunity to a specific virus is produced in those who sustained the disease. Parainfluenza occurs during the whole year as sporadic infection, but seasonal rise in the morbidity (during the spring and the cold season) is also observed. Pathogenesis. This is the same as in influenza. Clinical course. The incubation period lasts from 3 to 4 days with variations from 2 to 7 days. As a rule, the disease develops gradually and runs a sluggish course of 3-5 days. Catarrhal phenomena are not pronounced: cough, mild rhinorrhoea, less frequently subfebrile temperature. The patient complains of chilliness, headache, and slight fatigue. Hoarseness and chest pain are due to laryngitis (the most common symptom of parainfluenza) and laryngotracheitis. Nasal breathing is impeded. Serous nasal discharge gradually thickens and becomes mucous or mucopurulent due to secondary infection. Children, and especially infants, develop severe laryngitis, which is often attended by the clinical symptoms of laryngeal stenosis and croup. The entire respiratory tract can be involved in parainfluenza. Bronchitis runs a severer course and is attended by lesion of small ronchi (bronchiolitis) and lung parenchyma (pneumonia). Complications. Croup, pneumonia, acute tonsillitis, sinusitis, otitis and some other diseases develop; these usually occur in infants with rickets, anaemia and other disease due to secondary infection. Diagnosis. As distinct from influenza, toxaemia is not manifest in parainfluenzal infection. Cardiovascular and nervous lesions are absent; involvement of the larynx and the lower airways is more pronounced. The diagnosis is verified in the laboratory by virologic tests (isolation of the parainfluenza virus from nasopharyngeal washings), serologic (blood serum tests) and immunofluorescence. Treatment. Treatment is symptomatic. Anti-influenza immunoglobulin can be administered intramuscularly for therapeutic and prophylactic purposes. Antibiotics, sulpha drugs and inhalations should be given for complications. Prophylaxis is the same as in influenza.

Adenoviral Infections Aetiology. The causative agent belongs to the family of Adenoviridae. Among the 32 types of adenovirus isolated from man, types 3, 4, 7, 14, and 21 cause severe diseases. Type 8 causes keratoconjunctivitis in susceptible persons. Adenoviruses contain DNA. They are more stable in the environment than the influenza virus. Epidemiology. The source of infection is a diseased person, who liberates adenoviruses with nasal, nasopharyngeal mucus, sputum, and conjunctival discharge during the first 5-6 days of the disease. Virus carriers are another source of infection. At later terms of the disease adenoviruses are shed with faeces. The infection is mainly transmitted by the air-borne route. Since the virus is stable in the environment, infection can spread by contact, food or water (bathing in swimming pools, ponds, lakes, etc.). Infants aged from 6 months to 3 years are usually afflicted. Type-specific immunity is produced in convalescents. Adenovirus infections occur as sporadic cases and epidemic outbreaks in children's institutions. The morbidity rises in the autumn and winter. Since the incubation period lasts from 3 to 12 days, outbreaks of adenoviral infection last longer than those of influenza. Pathogenesis. Adenoviruses mostly affect respiratory mucosa, and less frequently conjunctiva. They can multiply in the intestinal mucosa as well. The lymphoid tissue of the regional lymph nodes is damaged, the vegetative nervous and endocrine systems are also upset with subsequent vascular disorders (pallor, tachycardia). Clinical course. The incubation period lasts from 3 to 12 days, most frequently from 5 to 6 days. Acute adenoviral infection is characterized by the following clinical symptoms: rhinopharyngitis, rhinopharyngotonsillitis, rhinopharyngobronchitis, pharyngoconjunctival fever, membranous or follicular conjunctivitis, and pneumonia. Rhinopharyngotonsillitis and rhinopharyngoconjunctivitis are more common. The incubation period lasts 5-6 days. The disease onset is usually gradual (2-3 days). The general symptoms are marked: malaise, chilliness, fever, headache. Local symptoms develop early: stuffy nose, hyperaemia of the fauces and the posterior wall of the pharynx, difficult swallowing, cough (dry or with expectoration of sputum) and chest pain. Some patients complain of abdominal pain, intestinal disorders, sometimes hepatic enlargement. Fever lasts from 2 to 7 days. Malaise and other general symptoms abate with normalization of body temperature, but catarrh can persist for 1-2 days more. Acute rhinopharyngoconjunctivitis is characterized by a moderate impairment of the general condition, inflammation of the respiratory mucosa, the fauces, and the eyes (rhinitis, tonsillitis, pharyngitis, nasopharyngitis, laryngitis, tracheitis, bronchitis, conjunctivitis). The internal organs can be involved separately or in various combinations. Respiratory mucosa and the mucosa of the eyes can be involved simultaneously, but sometimes only pharyngitis or only conjunctivitis can develop. Conjunctivitis lasts from several days to 2 weeks and longer. The eyelid mucosa and the eyeballs are injected, the conjunctiva can be affected with oedema and gentle granularity (catarrhal or follicular conjunctivitis). Membranous conjunctivitis is also possible. The eye secretion is meagre and serous in character. The cornea and the iris remain usually uninvolved. Among rare symptoms are nosebleed, nausea, vomiting and diarrhoea. In addition to the mentioned symptoms, small round foci of corneal opacity develop in several days (to 2 weeks) after the onset of keratoconjunctivitis. The foci sometimes fuse together. The disease lasts 2-4 weeks and usually ends in complete recovery. Pneumonia is the most severe form of adenoviral infection. It usually afflicts infants under 1 year of age. Pneumonia can occur with other forms of adenoviral infection. Pneumonia is usually focal (bronchopneumonia). The body temperature can remain high for 1-2 weeks and longer. Dyspnoea, cyanosis, and symptoms of toxaemia develop. Complications. The condition can be complicated by otitis, sinusitis, pneumonia, pleuritis, arthritis, which are due to secondary infections. Adenoviral infection can be the cause of exacerbation of chronic diseases. Diagnosis. Adenoviral infection is characterized by pronounced exudation; toxaemia is absent; conjunctivitis, especially membranous, is typical of the infection. An accurate diagnosis can be established only in the laboratory: virologically (isolation of the adenovirus in tissue culture), serologically, and by the immunofluorescent method. Treatment. Symptomatic treatment is used: analgesics, cardiacs, antitussives. Severe cases should be treated with immunoglobulin, interferon, desoxyribonuclease. To prevent complications, the patient must remain in bed. Food must be adequate and rich in vitamins. Prevention and control. Cases with severe course of the disease should only be hospitalized. The other patients should be isolated in home conditions till complete recovery. Chlorination of water in swimming pools is used to prevent outbreaks of the infection. For other preventive measures see "Influenza". 8. Materials for activating students during a lecture: 1. Which group of infectious diseases by source of infection does the influenza and ARVI belong to? 2. To characterize the causative agent of influenza, aggression factors, different serotypes of the virus and antigenic variants, to define antigenic drift and shift. 3. The mechanism of transmission of influenza and SARS. 4. The pathogenesis of influenza and acute respiratory viral infections and the main clinical symptoms. 5. Classification of influenza and SARS. 6. Describe the main clinical symptoms and name the criteria for the severity of influenza and SARS. 7. Name the possible complications of influenza and SARS and their diagnostic criteria. 8. The effects of influenza and SARS. 9. The plan for the examination of the patient with influenza and SARS. 10. Methods of specific diagnosis of influenza and SARS. 11. Etiotropic therapy of influenza and SARS and the principles of basic therapy. 12. Duration and indications for the appointment of antibiotic therapy for influenza and SARS. 13. Nonspecific and specific prophylaxis of influenza and SARS. 14. Categories of persons to whom vaccination is shown first.

Task 1 The patient turned to FD on the 3rd day of illness. The disease developed acutely. It began with the fever to 39 ° C, chills, severe headache with localization in the forehead, eyebrows, aches in the body. On the 2nd day there was a dry painful cough, dryness and sore throat, nasal congestion. On examination: temperature 38.5, sluggish answers, hyperemia of the face and upper body skin, vascular injection of the sclera, hyperemia, granularity and dryness of the mucous membrane of the oropharynx, blood pressure 100/60, pulse 90 / min., BH 20 in 1 min. 1. Formulate a preliminary diagnosis. 2. Diagnostics 3. Treatment.

Task 2 Patient P., 28 years old, fell ill suddenly. The disease began with chills, muscle pain, intense headache in the frontal region, eyeballs. The temperature rose to 39 ° C. On the second day of the disease, a dry, annoying cough, nasal congestion appeared. On examination, the temperature is 39.2 ° C, the face is hyperemic, edematous. Injection of vascular sclera. Bright hyperemia of the tongue, soft palate, granularity of the posterior pharyngeal wall. Auscultatory: vesicular breathing. Heart sounds are deaf, pulse 100 / min. 1. Formulate a preliminary diagnosis. 2. Diagnostics 3. Treatment.

Test control. 1. When antibacterial drugs for flu patient should be prescribed? A. in the presence of a chronic focus of infection; B. from the first day of illness C. in the presence of signs of bacterial complications, regardless of the duration of the disease; D. in cases of prolonged fever (more than 5 days) with severe intoxication; E. regardless of the duration of the disease in the presence of high fever and signs of tracheitis.

2. What are the complications of influenza caused by the action of the virus: A. pneumonia B. hemorrhagic pulmonary edema C. glomerulonephritis D. arachnoiditis E. sinusitis

3. Clinical signs of the toxic effect of the virus on the vascular and nervous system: A. headache, dizziness, meningism; B. nosebleeds, gum bleeding, toxic hemorrhagic pulmonary edema С. blood pressure lability, a tendency to collapse, tachycardia and bradycardia, sweating, hyperemia of the face and mucous membranes; D. cough

4. Basic symptom of influenza: A. high body temperature; B. hepato-lienal syndrome C. spotted rash on the face D. dry painful cough E. liquid bowel movements

5. Flu fever without complications in a typical course: A. Generally high or moderate B. constant C. wave D. grows during the first 3 days E. observed for 3 to 5 days

6. Characteristic of Guillain-Barre syndrome: A. peripheral paralysis with preservation of superficial sensitivity; B. ascending nature of paralysis; C. the descending nature of paralysis; D. protein-cell dissociation in the cerebrospinal fluid; E. cell-protein dissociation in the cerebrospinal fluid.

7. Etiotropic drugs for the treatment of patients with influenza: A. lamivudin B. oseltamivir C. zanamivir D. acyclovir E. influenza immunoglobulin

8. The main means of pathogenetic therapy in patients with influenza: A. heavy drinking; B. glucocorticoids; C. antibiotics D. crystalloid solutions intravenously under the control of CVP E. decongestants, expectorant, antihistamines.

9. The fly patient should be discharged from the hospital: A. according to the clinical signs of recovery; B. regardless of the results of specific diagnosis B. 5 days after normalization of body temperature; G. after receiving negative results of specific diagnostic methods D. after control radiography of the lungs

10. Vaccination against influenza indicated primarily for: A. All persons over 50 B. persons with chronic diseases of the cardiovascular, respiratory systems, kidneys, diabetes mellitus, immunodeficiency of various origins C. Newborns D. persons with 2 or 4 blood groups E. family members of an influenza patient

9. Materials for self-training of students for a lecture: - on the topic outlined in the lecture (see paragraph 8) - on the topic of the next lecture 1. Characterization of the causative agent of diphtheria. 2. Source, mechanism, transmission pathways for diphtheria. 3. The nature of immunity in diphtheria. 4. What organs are affected by diphtheria? 5. Classification of diphtheria. 6. What is combined diphtheria, give an example. 7. Classification of diphtheria croup. 8. Features of the films with diphtheria of the larynx. 9. In what infectious diseases, besides diphtheria and tonsillitis, is the impression of tonsils. 10. Name the main factors of aggression of diphtheria bacillus. 11. The main links in the pathogenesis of diphtheria. 12. Clinic of general intoxication syndrome with diphtheria. 13. Clinic of localized membranous diphtheria of tonsils. Changes in the oropharynx with islet diphtheria of the tonsils. 14. Characteristic changes in the oropharynx in patients with localized diphtheria of the tonsils and lacunar tonsillitis. Indicate changes. 15. Features of the course of diphtheria of the larynx. 16. Specific laboratory diagnosis of diphtheria. Nonspecific laboratory tests for diphtheria. 17. List the complications that can occur with diphtheria. Specific complications of diphtheria. 18. Causes of death with diphtheria. 19. The principles of treatment of diphtheria. Etiotropic therapy of diphtheria. Rules for the introduction of antidiphtheria serum. 20. Prevention of diphtheria. What anti-epidemic measures are carried out in the focus of diphtheria? 21. To which group of infectious diseases do herpes virus infections belong? 22. Routes of transmission of herpes virus infections. 23. Stages of the pathogenesis of various manifestations of herpes virus infections. 24. Clinical classification of herpes virus infections. 25. The main symptoms of various nosological forms of herpes virus infections. 26. Features of the course of various manifestations of herpes virus infections in AIDS patients. 27. Complications of various manifestations of herpes virus infections. 28. The main causes of death in various nosological forms of herpes virus infections. 29. Plan for examination of a patient with various forms of herpes virus infections. 30. Changes in cerebrospinal fluid with lesions of the nervous system caused by herpes viruses. 31. Methods of specific diagnosis of herpes virus infections. 32. Interpretation of results depending on the duration of the disease and the study material. 33. Etiotropic therapy of herpes virus infections: doses, routes of administration, duration of treatment. 34. Principles of the pathogenetic treatment of herpes virus infections 35. Rules for extracting convalescents from the hospital. 36. The etiological structure of infectious mononucleosis. 37. Classification of infectious mononucleosis. 38. Clinical variants of the course of infectious mononucleosis. 39. Complications and consequences of infectious mononucleosis. 40. Features of the defeat of the oropharynx with infectious mononucleosis. 41. Features of liver damage in infectious mononucleosis. 42. The main clinical manifestations of infectious mononucleosis. 43. The nature of the changes in the hemogram with infectious mononucleosis. 44. Criteria for the severity of infectious mononucleosis. 45. Ultrasound diagnosis for infectious mononucleosis. 46. The main stages of pathogenesis in infectious mononucleosis. 47. The principles of treatment of infectious mononucleosis. 48. Rules for discharge of patients with infectious mononucleosis.

LITERATURE

BASIC

1. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases E-Book: 2- Volume Set/ by John E. Bennett (Author), Raphael Dolin (Author), Martin J. Blaser (Author). – Elsevier; 9 edition, 2019. – 4176 p.

2. Comprehensive Review of Infectious Diseases/ by Andrej Spec (Author), Gerome V. Escota (Author), Courtney Chrisler (Author), Bethany Davies (Author). - Elsevier; 1 edition, 2019. – 776 p.

3. Harrison's Infectious Diseases, Third Edition (Harrison's Specialty)/ by Dennis L. Kasper (Author), Anthony S. Fauci (Author). - McGraw-Hill Education / Medical; 3 edition, 2016. – 1328 p.

4. Infectious Diseases: textbook / O.A. Holubovska, M.A. Andreichyn, A.V. Shkurba et al.; edited by O.A. Holubovska. — Kyiv: AUS Medicine Publishing, 2018. — 664 p. + 12 p. colour insert.

ADDITIONAL

1. Infectious Diseases in Context Set / by Brenda Wilmoth Lerner (Editor), Adrienne Wilmoth Lerner (Editor). – Gale Research Inc; 1 edition, 2007 – 1078 р. 2. Human Emerging and Re-emerging Infections / by Sunit K. Singh (Editor). - Wiley- Blackwell; 1 edition, 2015. – 1008 p. 3. Essentials of Clinical Infectious Diseases/ by MPH Wright, William F., DO (Editor). - Demos Medical; 2 edition, 2018 – 485 p.

INFORMATIONAL RESOURCES

1. Сайт МОЗ України: www.moz.gov.ua 2. Сайт ВООЗ: www.who.int 3. Centers for Disease Control and Prevention (Центр з контролю та профілактики захворювань, США): http://www.cdc.gov/

Methodical instruction is prepared by V.A. Bodnar ______O. H. Marchenko ______

Approved at a meeting of the Department of Infectious Diseases and Epidemiology «___» ______2019, Protocol No. ______Head of the Department T. I. Koval

Approved at a meeting of the Department of Infectious Diseases and Epidemiology «___» ______2020, Protocol No. ______Head of the Department T. I. Koval

Approved at a meeting of the Department of Infectious Diseases and Epidemiology «___» ______2021, Protocol No. ______Head of the Department T. I. Koval

Approved at a meeting of the Department of Infectious Diseases and Epidemiology «___» ______2022, Protocol No. ______Head of the Department T. I. Koval

Approved at a meeting of the Department of Infectious Diseases and Epidemiology «___» ______2023, Protocol No. ______Head of the Department T. I. Koval

Approved at a meeting of the Department of Infectious Diseases and Epidemiology «___» ______2024, Protocol No. ______Head of the Department T. I. Koval

Approved at a meeting of the Department of Infectious Diseases and Epidemiology «___» ______2025, Protocol No. ______Head of the Department T. I. Koval

Ministry of Public Health of Ukraine Ukrainian Medical Stomatological Academy

Approved at the meeting of the department Infection diseases and epidemiology «28» August 2019 protocol № 1 from «28» August 2019 the Head of the Department ______Koval T.I.

Methodical Instruction for lectures

Study discipline Infectious diseases Module № Introduction to infectology. Infectious diseases with foodborne transmission. Topic The concept of infectious process and infectious diseases. Diarrheal syndrome in infectology. Course 5 Faculty Foreign students (Medical) Number of teaching hours: 2

Poltava -2019

1. Scientific and methodological substantiation of the topic. Acute diarrhea is defined as the abrupt onset of 3 or more loose stools per day. The augmented water content in the stools (above the normal value of approximately 10 mL/kg/d in the infant and young child, or 200 g/d in the teenager and adult) is due to an imbalance in the physiology of the small and large intestinal processes involved in the absorption of ions, organic substrates, and thus water. A common disorder in its acute form, diarrhea has many causes and may be mild to severe. Acute diarrhea is usually caused by infection of the small and/or large intestine; however, numerous disorders may result in diarrhea, including a malabsorption syndrome and various enteropathies. Acute-onset diarrhea is usually self-limited; however, an acute infection can have a protracted course. By far, the most common complication of acute diarrhea is dehydration. Although the term "acute gastroenteritis" is commonly used synonymously with "acute diarrhea," the former term is a misnomer. The term gastroenteritis implies inflammation of both the stomach and the small intestine, whereas, in reality, gastric involvement is rarely if ever seen in acute diarrhea (including diarrhea with an infectious origin); in addition, enteritis is also not consistently present. Examples of infectious acute diarrhea syndromes that do not cause enteritis include Vibrio cholerae– induced diarrhea and Shigella -induced diarrhea. Thus, the term acute diarrhea is preferable to acute gastroenteritis. Diarrheal episodes are classically distinguished into acute and chronic (or persistent) based on their duration. Acute diarrhea is thus defined as an episode that has an acute onset and lasts no longer than 14 days; chronic or persistent diarrhea is defined as an episode that lasts longer than 14 days. The distinction, supported by the World Health Organization (WHO), has implications not only for classification and epidemiological studies but also from a practical standpoint because protracted diarrhea often has a different set of causes, poses different problems of management, and has a different prognosis. 2. The educational goals of the lecture. To analyze the characteristics of infectious diseases, the patterns of the course of the infectious and epidemiological process of various infectious diseases, the principles of their diagnosis, treatment and prevention; types of infectious diseases hospitals, requirements for the territory of infectious diseases hospitals; structural subdivisions, purposes and tasks of the sanitary inspection room, the purpose and components of the boxes and semi-boxes, auxiliary sections, the principles of disinfection in an infectious diseases hospital; principles of preventing nosocomial infection, infection of medical personnel; rules for maintaining medical documentation in the infectious diseases ward; rules for discharge of patients from the infectious diseases hospital; features of infectious diseases, phases of the infectious process, factors that affect its course, the role of immunity in infectious diseases; principles for classifying infectious diseases ; general characteristics of different groups of infectious diseases - intestinal, respiratory, blood, wound infections, infectious diseases with multiple transmission mechanisms. Explain the etiology of infectious diseases , pathogenicity factors of the pathogen; epidemiology; pathogenesis, clinical manifestations; the period of occurrence and clinical manifestations of diseases complications; diagnosis; principles of treatment and prevention; indications for antibacterial treatment. Analyze the rules for staying in an infectious diseases hospital and, in particular, at the patient’s bedside; collect an epidemiological history, separate the possible ways and factors of infection transmission; decide on the necessity and place of hospitalization; draw up and submit the appropriate documentation to the sanitary and epidemiological service (SES); adhere to the rules for discharge of the patient with infection department. Explain the basic working rules at the patient’s bedside; to collect a medical history with an assessment of epidemiological data; examine the patient and detect the main symptoms and syndromes, substantiate the clinical diagnosis, determine the need for hospitalization; conduct differential diagnosis of disease; on the basis of a clinical examination, to identify possible complications, urgent conditions in time, draw up medical documentation on the fact of the establishment of a previous diagnosis of (emergency report to the district epidemiological department); make a plan for laboratory and additional examination of the patient; interpret the results of a laboratory examination; to draw up an individual treatment plan taking into account the syndromes of the disease, the presence of complications, the severity of the condition, allergic history, concomitant pathology; provide emergency care at the prehospital stage; draw up a plan of anti- epidemic and preventive measures in the focus of infection; give recommendations regarding the regimen, diet, examination, supervision, during the period of convalescence. 3. The goals of the personality development of the future specialist (educational goals), relevant aspects: deontological, environmental, legal, professional responsibility, psychological, ethical, patriotic, etc.

The concept of infectious process and infectious diseases. The etiology of infectious diarrhea. Pathophysiology of infectious diarrhea. Clinical presentation of acute diarrhea. Management of acute diarrhea.

THE CONCEPT OF INFECTIOUS PROCESS AND INFECTIOUS DISEASES. An infectious process is the interaction of a pathogenic microorganism with a macroorganism under certain environmental and social conditions. The concept 'infectious disease' means the condition manifested by a disease state of a patient and the so-called carrier state. The specific properties of infective agents, various pathogenicity and virulence of these agents, as well as the quantity of microorganisms that enter the macroorganism, resistance of the macroorganism and duration of specific immunity account for the multitude of clinical manifestations of infection. Infection can be clinically pronounced or it may be asymptomatic, which is known as the carrier state (parasite, bacterium, virus carrier state). A clinically manifest infection can run a typical or atypical course. Patients with a typical form of infection demonstrate all symptoms specific for a given disease. One or several symptoms of a given disease are absent from the clinical picture of an atypical form, or the symptoms can be modified. A disease can be acute or run a protracted or even a chronic course. A clinically manifest disease is usually classed as mild, moderate, and severe; according to the duration, the disease can be acute or chronic. An acute infection (smallpox, measles, plague) is characterized by a short stay of the causative agent in the body and development of specific immunity in the patient toward the given infection. A chronic infection (brucellosis, tuberculosis) can last for years. Asymptomatic infections can be subclinical and latent. A person with a subclinical infection (acute and chronic) looks in full health, and the disease can only be diagnosed by detecting the causative agents, specific antibodies, and functional and morphological changes in the organs and tissues that are specific for a given disease. Such patients (or carriers) are a special danger for the surrounding people since they are the source of infection. At the same time, a repeated subclinical infection in poliomyelitis, diphtheria, influenza, and some other acute infections promotes formation of an immune group of people (herd immunity). Acute and chronic subclinical forms (carrier state) are more common in typhoid fever, paratyphoid B, salmonellosis, viral hepatitis B, etc. Latent or persistent forms of human and animal infections are a prolonged asymptomatic interaction of macroorganisms with the pathogenic agents which are present in modified ('defective') forms. These are defective interfering particles in latent viral infections, and L forms, spheroplasts, etc. in bacterial infections. Being inside the host cell, these forms survive for long periods of time and are not released into the environment. Under the action of various provoking factors (such as thermal effects, injuries, psychic trauma, transplantation, blood transfusion, various disease states), persistent infection can be activated and become clinically manifest. The microbe regains its pathogenic properties. Persistence of virus has been studied best of all, but at the present time, persistence of other pathogenic factors has been intensively studied as well, e.g. of the L forms of streptococci, staphylococci, meningococci, cholera vibrio, typhoid fever bacilli, microbes causing diphtheria, tetanus, etc. Protozoa and rickettsia can also persist. For example, latent epidemic recrudescent typhus infection is manifested by relapses of epidemic recrudescent typhus (Brill's disease).

In the 19th century, infectious diseases were classed as contagious (transmissible from person to person), miasmatic (transmitted through air), and contagious-miasmatic. Late in the 19th century, in view of advances made in bacteriology, the diseases were classified according to their aetiology. These classifications could not satisfy clinicians or epidemiologists since diseases with different pathogenesis, clinical course and epidemiologic characteristics were united in one group. Classifications based on clinical and epidemiologic signs proved ineffective too. The classification proposed by Gromashevsky seems to be more reasonable than many others. It is based on the location of infection in the macroorganism. In accordance with the main sign, that determines the transmission mechanism, all infectious diseases are divided by the author into Jour groups: 1. intestinal infections; 2. respiratory infections; 3. blood infections; 4. skin infections. According to Gromashevsky, each group is subdivided into anthroponoses and zoonoses; their epidemiology and prevention differ substantially. Intestinal infections. Intestinal infections are characterized by location of the causative agents in the intestine and their distribution in the environment with excrements. If the causative agent circulates in the blood (typhoid fever, paratyphoid A and B, leptospirosis, viral hepatitis, brucellosis, etc.), it can also be withdrawn through various organs of the body, e. g. the kidneys, lungs, the mammary glands. As a microbe is released into the environment with faeces, urine, vomitus (cholera), it can cause disease in a healthy person only after ingestion with food or water. In other words, intestinal infections are characterized by the faecal-oral mechanism of transmission. Maximum incidence of intestinal infections occurs usually during the warm seasons. The anthroponoses include typhoid fever, paratyphoid, bacterial and amoebic dysentery, cholera, viral hepatitis A, poliomyelitis, helminthiasis (without the second host). The zoonoses include brucellosis, leptospirosis, salmonellosis, botulism, etc. The main means of control of intestinal infection are sanitary measures that prevent possible transmission of the pathogenic microorganisms with food, water, insects, soiled hands, etc. Timely detection of the diseased and carriers, their removal from food catering and the like establishments is also very important. Specific immunization is only of secondary importance in intestinal infections. Respiratory infections. This group includes diseases whose causative agents parasitize on the respiratory mucosa and are liberated into the environment with droplets of sputum during sneezing, cough, loud talks, or noisy respiration. People get infected when the microbes contained in sputum get on the mucosa of the upper airways. If the causative agent is unstable in the environment, a person can only be infected by close contact with the sick or carrier (pertussis). Pathogenic microorganisms causing some diseases can persist for a period of time in an enclosure where the sick is present. Infected particles of sputum or mucus can dry and be suspended in the air. Some diseases of this group can spread through contaminated linen, underwear, utensils, toys, etc. Since susceptibility of people, and especially of children to respiratory infection is very high, and since the infection is easily transmitted from the diseased (or carriers) to healthy people, almost entire population of a given area usually gets infected, and some people can be infected several times. Some diseases of this group form a special subgroup of children's infections (diphtheria, scarlet fever, measles, pertussis, epidemic parotitis, chickenpox, rubella). A durable immunity is usually induced in children who sustained these diseases. The main measure to control respiratory infections is to increase non-susceptibility of population, especially of children, by specific immunization. It is important to timely reveal the sick and carriers, and also to break the mechanism of infection transmission: control of overcrowding, proper ventilation and isolation of enclosures, using UV-lamps, wearing masks, respirators, disinfection, and the like. Blood infections. The diseases of this group are transmitted by blood-sucking insects, such as fleas, mosquitoes, ticks, etc., which bite people and introduce the pathogenic agent into the blood. Tick-borne encephalitis, Japanese B encephalitis and some other infections are characterized by natural nidality which is due to specific geographic, climatic, soil and other conditions of infection transmission. The morbidity is the highest during the warm season which coincides with the maximum activity of the transmitters - ticks, mosquitoes, etc. Control of blood infections includes altering natural conditions, improvement of soils, draining swamps, destroying sites where the insects multiply, disinsection measures against mosquitoes, ticks, etc., detoxication of sources of infection by their isolation and treatment, carrying out preventive measures. If the source of infection are rodents, measures to control them are taken. Active immunization is also effective. Skin infections. The diseases of this group occur as a result of contamination of the skin or mucosa with the pathogenic microorganisms. They can remain at the portal of infection (tetanus, dermatomycoses), or affect the skin, enter the body and be carried to various organs and tissues with the circulating blood (erysipelas, anthrax). The transmitting factors can include bed linen, clothes, plates and dishes and other utensils, that can be contaminated with mucus, pus or scales. Pathogenic microorganisms causing venereal diseases, rabies, AIDS, and some other diseases are transmitted without the agency of the environmental objects. Wound infections are characterized by damage to the skin as a result of injury (tetanus, erysipelas). The main measures to control skin infections include isolation and treatment of the source of infection, killing diseased animals, homeless dogs and cats, improving sanitation and living conditions of population, personal hygiene, control of traumatism, and specific prophylaxis. A nosocomial infection is an infection that develops in a patient inside a hospital in a lapse of time that exceeds the duration of the incubation period of a given infection, or an infection that develops in a patient after his discharge from the hospital in a period of time that is shorter than the incubation period for a given infection. Extrahospital infection implies cases of infection before hospitalization (the patient is admitted to the hospital during the incubation period of a given infection). Among nosocomial infections, most common are air-borne infections, such as influenza and acute respiratory diseases, chickenpox, rubella, epidemic parotitis, scarlet fever, or measles. Nosocomial infections result from admittance to the hospital of patients with unrevealed diseases. Anti-epidemic measures should be taken in cases of development of nosocomial infections. These measures are aimed at prevention of infection spread. Quarantine should be established whenever necessary. During this period, only those patients can be admitted to the hospital who have already sustained this particular disease. The first patient with a nosocomial infection should be isolated from the others or placed in a mixed-infection ward, while the room and objects that were used by this patient must be disinfected. Other patients and personnel who had contacts with the nosocomial infection patient should be observed during the incubation period. Depending on the disease, they should be given immunoglobulin (prophylactic therapy) and tested for the carrier state.

DIARRHEAL SYNDROME IN INFECTOLOGY. «Diarrhea» is an alteration in a normal bowel movement characterized by an increase in the water content, volume, or frequency of stools. A decrease in consistency (i.e., soft or liquid) and an increase in frequency of bowel movements to>3stools per day have often been used as a definition for epidemiological investigations. “Infectious diarrhea” is diarrhea due to an infectious etiology, often accompanied by symptoms of nausea, vomiting, or abdominal cramps. “Acute diarrhea” is an episode of diarrhea of<14 days in duration. “Persistent diarrhea” is diarrhea of >14 days in duration. Although we will not categorize persistent diarrhea further here, some experts refer to diarrhea that lasts>30 days as chronic.

Etiology. Viral, bacterial, and parasitic infections are the most common cause of diarrhea, and they are typically spread through the fecal-oral route. This occurs when an individual comes into contact with a contaminated surface (doorkob, button, counter top, or handshake) or by ingesting contaminated food or beverages. There are also non-infectious reasons that a patient might develop diarrhea, and these are often related to medical conditions affecting the digestive, immune, or endocrine (hormone) systems. These conditions include irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), celiac disease, hyperthyroidism, and lactose intolerance.2 The term gastroenteritis typically refers to bacterial of viral infections the affect both the stomach and small/large intestines. These patients present with nausea, vomiting, and abdominal pain, as well as diarrhea. "Dysentery" refers to patients with infectious or inflammatory diarrheal diseases that result in the frequent passage of smaller stools containing varying amounts of mucus and/or blood. Viral Causes Viruses are the most common cause of diarrhea and are related predominately to four specific types:  Norovirus, also known as the "cruise ship virus," is the most common cause of food-borne gastroenteritis in the U.S.  Rotavirus is the most common cause of diarrhea in American children and a leading cause of death of children in the developing world.  Adenoviruses include a family of more than 50 subtypes. Types 40 and 41 are primarily responsible for causing diarrhea in humans. (Other adenoviral subtypes include cold viruses).  Astroviruses are common causes of diarrhea in the elderly, children, and people with compromised immune systems. Bacterial Causes Bacterial diarrhea is a major contributor to illness and death worldwide. Although less common than viral diarrhea, bacterial diarrhea disorders more often lead to dysenteric disease due to the development of ulcers and inflammation in the intestines. Among the most common causes:  Salmonella enteritidis can cause diarrhea, fever, and abdominal cramps within 12 to 72 hours of consuming contaminated food or beverage.  Escherichia coli (especially E. coli 0157) is spread through contaminated food and dairy products and can lead to a condition known as hemorrhagic colitis.  Shigella is common both in the U.S. and around the world and can often cause bloody diarrhea, particularly in children of preschool age.  Campylobacter is among the most common bacterial food-borne infections and can cause bloody diarrhea due to acute intestinal inflammation  Vibrio infection is often associated with eating raw seafood or sushi.  Staphylococcus aureus can cause explosive diarrhea due to toxins released by the bacteria.  Clostridium difficile is unique in that the rise of the infection is frequently linked to prior or concurrent antibiotic use. It is today the most common cause of hospital-acquired diarrhea.  Yersinia is a species of bacteria that can cause a number of different diseases in humans. Yersinia enterocollitica is a common cause of infectious diarrhea. In contrast, Yersinia pestis has been isololated as a primary cause of the bubonic plague. Humans typically encounter Yersinia species in dairy products. Parasitic Causes Protozoa are the primary cause of parasitic diarrhea around the world. These single-celled organisms come in many forms and are often transmitted through infected drinking water. Among the three most common causes of parasitic diarrhea:4  Giardia lamblia is passed through contaminated food or by person-to-person contact and can result in explosive diarrhea within two days of infection.  Entamoeba histolytica is related to fecal-oral transmission and can cause bloody diarrhea as these invasive parasites bore their way into the intestinal wall.  Cryptosporidium is known to cause both respiratory and gastrointestinal illness and is characterized by the development of watery stools. Pathophysiology Diarrhea is the reversal of the normal net absorptive status of water and electrolyte absorption to secretion. Such a derangement can be the result of either an osmotic force that acts in the lumen to drive water into the gut or the result of an active secretory state induced in the enterocytes. In the former case, diarrhea is osmolar in nature, as is observed after the ingestion of nonabsorbable sugars such as lactulose or lactose in lactose malabsorbers. Instead, in the typical active secretory state, enhanced anion secretion (mostly by the crypt cell compartment) is best exemplified by enterotoxin-- induced diarrhea. In osmotic diarrhea, stool output is proportional to the intake of the unabsorbable substrate and is usually not massive; diarrheal stools promptly regress with discontinuation of the offending nutrient, and the stool ion gap is high, exceeding 100 mOsm/kg. In fact, the fecal osmolality in this circumstance is accounted for not only by the electrolytes but also by the unabsorbed nutrient(s) and their degradation products. The ion gap is obtained by subtracting the concentration of the electrolytes from total osmolality (assumed to be 290 mOsm/kg), according to the formula: ion gap = 290 – [(Na + K) × 2]. In secretory diarrhea, the epithelial cells’ ion transport processes are turned into a state of active secretion. The most common cause of acute-onset secretory diarrhea is a bacterial infection of the gut. Several mechanisms may be at work. After colonization, enteric pathogens may adhere to or invade the epithelium; they may produce enterotoxins (exotoxins that elicit secretion by increasing an intracellular second messenger) or cytotoxins. They may also trigger release of cytokines attracting inflammatory cells, which, in turn, contribute to the activated secretion by inducing the release of agents such as prostaglandins or platelet-activating factor. Features of secretory diarrhea include a high purging rate, a lack of response to fasting, and a normal stool ion gap (ie, 100 mOsm/kg or less), indicating that nutrient absorption is intact.

Clinical presentation Acute diarrhea is defined as the abrupt onset of 3 or more loose stools per day and lasts no longer than 14 days; chronic or persistent diarrhea is defined as an episode that lasts longer than 14 days. The distinction has implications not only for classification and epidemiologic studies but also from a practical standpoint, because protracted diarrhea often has different etiologies, poses different management problems, and has a different prognosis.

The clinical presentation and course of diarrhea therefore depend on its cause and on the host. Consider the following to determine the source/cause of the patient’s diarrhea:

 Stool characteristics (eg, consistency, color, volume, frequency)  Presence of associated enteric symptoms (eg, nausea/vomiting, fever, abdominal pain)  Food ingestion history (eg, raw/contaminated foods, food poisoning)  Water exposure (eg, swimming pools, marine environment)  Camping history (possible exposure to contaminated water sources)  Travel history (common pathogens affect specific regions; also consider rotavirus and Shigella, Salmonella, and Campylobacter spp regardless of specific travel history, as these organisms are prevalent worldwide)  Animal exposure (eg, young dogs/cats: Campylobacter spp; turtles: Salmonella spp)  Predisposing conditions (eg, hospitalization, antibiotic use, immunocompromised state)

Signs and symptoms of diarrhea may include the following:

 Dehydration: Lethargy, depressed consciousness, sunken anterior fontanel, dry mucous membranes, sunken eyes, lack of tears, poor skin turgor, delayed capillary refill  Failure to thrive and malnutrition: Reduced muscle/fat mass or peripheral edema  Abdominal pain/cramping  Borborygmi  Perianal erythema

Knowledge of the characteristics of consistency, color, volume, and frequency can be helpful in determining whether the source is from the small or large bowel. Table 1 outlines these characteristics and demonstrates that an index of suspicion can be easily generated for a specific set of organisms. Table 1. Stool Characteristics and Determining Their Source Stool Small Bowel Large Bowel Characteristics Appearance Watery Mucoid and/or bloody Volume Large Small Frequency Increased Highly increased Blood Possibly positive but never Commonly grossly bloody gross blood pH Possibly < 5.5 >5.5 Reducing Possibly positive Negative substances WBCs < 5/high power field Commonly >10/high power field Serum WBCs Normal Possible leukocytosis, bandemia Organisms Viral Invasive bacteria  Rotavirus  Escherichia Coli (enteroinvasive,  Adenovirus enterohemorrhagic)  Calicivirus  Shigella species  Astrovirus  Salmonella species  Norovirus  Campylobacter species  Yersinia species  Aeromonas species  Plesiomonas species Enterotoxigenic bacteria Toxic bacteria  E coli  Clostridium difficile  Klebsiella  Clostridium perfringens  Cholera species  Vibrio species Parasites Parasites  Giardia species  Entamoeba organisms  Cryptosporidium species

Management. Fecal laboratory studies include the following:

 Examination for ova and parasites  Leukocyte count  pH level: A pH level of 5.5 or less or the presence of reducing substances indicates carbohydrate intolerance, which is usually secondary to viral illness  Examination of exudates for presence/absence of leukocytes  Cultures: Always culture for Salmonella, Shigella, and Campylobacter spp and Y enterocolitica in the presence of clinical signs of colitis or if fecal leukocytes are present; look for Clostridium difficile in those with diarrhea characterized by colitis and/or bloody stools; assess for Escherichia coli, particularly O157:H7, with bloody diarrhea and a history of eating ground beef; screen for Vibrio and Plesiomonas spp with a history of eating raw seafood or foreign travel  Enzyme immunoassay for rotavirus or adenovirus antigens  Latex agglutination assay for rotavirus

Figure 1.Recommendations for the diagnosis and management of diarrheal illnesses.

Acute-onset diarrhea is usually self-limited; however, an acute infection can have a protracted course. Management is generally supportive: In most cases, the best option for treatment of acute- onset diarrhea is the early use of oral rehydration therapy (ORT). Although many patients with mild diarrhea can prevent dehydration by ingesting extra fluids (such as clear juices and soups), more severe diarrhea, postural light-headedness, and reduced urination signify the need for more rehydration fluids. Oral rehydration solutions approaching the WHO-recommended electrolyte concentrations (e.g., Ceralyte, Pedialyte, or generic solutions) can be purchased at local pharmacies or obtained from pediatricians. WHO-recommended oral rehydration solutions can also be prepared by a pharmacy by mixing 3.5 g of NaCl, 2.5 g of NaHCO3 (or 2.9 g of Na citrate), 1.5 g of KCl, and 20 g of glucose or glucose polymer (e.g., 40 g of sucrose or 4 tablespoons of sugar or 50–60 g of cooked cereal flour such as rice, maize, sorghum, millet, wheat, or potato) per liter (1.05 qt) of clean water. This makes a solution of approximately Na 90 mM, K 20 mM, Cl 80 mM, HCO3 30 mM, and glucose 111 mM. Therapeutic considerations. Because of increasing threats from antimicrobial-resistant infections, side effects of treatment with antimicrobial agents, suprainfections when normal flora are eradicated by antimicrobial agents, and the possibility of induction of disease-producing phage by antibiotics (such as Shiga-toxin phage induced by quinolone antibiotics, any consideration of antimicrobial therapy must be carefully weighed against unintended and potentially harmful consequences. One situation in which empirical antibiotics are commonly recommended without obtaining a fecal specimen is in cases of traveler's diarrhea, in which enterotoxigenic E. coli or other bacterial pathogens are likely causes, and prompt treatment with fluoroquinolone or, in children, trimethoprim- sulfamethoxazole (TMP-SMZ) can reduce the duration of an illness from 3–5 days to <1–2 days (A- I). Some also consider empirical treatment of diarrhea that lasts longer than 10–14 days for suspected giardiasis, if other evaluations are negative and, especially, if the patient's history of travel or water exposure is suggestive. Otherwise, for patients with febrile diarrheal illnesses, especially those believed to have moderate to severe invasive disease, empirical treatment should be considered (after a fecal specimen is obtained for the performance of the studies noted above). This empirical treatment can be with an agent such as a quinolone antibiotic or, for children, TMP-SMZ, which can reduce the duration and shedding of organisms in infections with susceptible Shigella species and possibly in infections with susceptible Campylobacter species.

Table 9.Recommendations for therapy against specific pathogens Pathogen Recommendations Shigella species TMP-SMZ, 160 and 800 mg, respectively (pediatric dose, 5and 25 mg/kg, respectively) b.i.d.33 d (if susceptible) or fluoroquinolone (e.g., 300 mg ofloxacin, 400 mg norfloxacin, or 500 mg ciprofloxacin); nalidixic acid, 55 mg/kg/d (pediatric) or 1 g/d(adults)35 d or ceftriaxone; azithromycin Non-typhi species of Not recommended routinely, but if severe or patient is <6mo or Salmonella >50 y old or has prostheses, valvular heart disease, severe atherosclerosis, malignancy, or uremia, TMP-SMZ (if susceptible) or fluoroquinolone as above, b.i.d.35–7 d; ceftriaxone, 100mg/kg/d in 1 or 2 divided doses Campylobacter species Erythromycin, 500 mg b.i.d.35d Escherichia coli species TMP-SMZ, 160 and 800 mg, respectively, b.i.d.,33 d (if susceptible), or fluoroquinolone (e.g., 300 mg ofloxacin,400 mg norfloxacin, or 500 mg ciprofloxacin b.i.d.33d Vibrio cholerae Doxycycline, 300-mg single dose; or tetracycline, 500 mgq.i.d.33 d; or TMP-SMZ, 160 and 800 mg, respectively,b.i.d.33 d; or single-dose fluoroquinolone Toxigenic Clostridium Offending antibiotic should be withdrawn if possible; difficile metronidazole, 250 mg q.i.d. to 500 mgt.i.d.310 d

Complications Common complications include the following:  Campylobacter species -Bacteremia, meningitis, cholecystitis, urinary tract infection, pancreatitis, Reiter syndrome (RS)  C difficile - Chronic diarrhea  C perfringens serotype C - Enteritis necroticans  Enterohemorrhagic E coli - Hemorrhagic colitis  Enterohemorrhagic E coli O157:H7 - HUS  Salmonella species - Seizures, HUS, perforation, RS  Vibrio species - Rapid dehydration  Rotavirus - Isotonic dehydration, carbohydrate intolerance  Giardia species - Chronic fat malabsorption  Cryptosporidium species - Chronic diarrhea Enteric fever is caused by S typhi. This syndrome has an insidious onset of malaise, fever, abdominal pain, and bradycardia. Diarrhea and rash (rose spots) appear after 1 week of symptoms. Bacteria may have disseminated at that time, and treatment is required to prevent systemic complications such as hepatitis, myocarditis, cholecystitis, or GI bleeding. HUS is caused by damage to vascular endothelial cells by verotoxin (released by enterohemorrhagic E coli and by Shigella organisms). Thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure characterize HUS. Symptoms usually develop one week after onset of diarrhea, when the organism may be absent. RS can complicate acute infections and is characterized by arthritis, urethritis, conjunctivitis, and mucocutaneous lesions. Individuals with RS usually do not demonstrate all features. Carrier states are observed after some bacterial infections.  After diarrhea caused by Salmonella organisms, 1-4% of individuals with nontyphoid and enteric fever infections become carriers. The carrier stage for Salmonella organisms is more likely for females, infants, and individuals with biliary tract disease.  Asymptomatic C difficile carriage may be observed in as many as 20% of hospitalized patients receiving antibiotics and in 50% of infants.  Rotavirus is excreted asymptomatically in feces of children who were previously infected, typically for as long as 1-2 weeks.

8. Materials for activating students during a lecture: 1. Define the concepts: infection, infectious process, infectious disease. 2. Define the concept: exacerbation, remission, relapse of an infectious disease. 3. Define the concept: co-infection, superinfection, reinfection, autoinfection. 4. Give a definition of the concept: nosocomial, ubiquitous, natural focal infection. 5. Features of infectious diseases. 6. What does the term «diarrhea» means? 7. What is the difference between acute, persistent and chronic diarrhea? 8. Which causes of infectious diarrhea do you know? 9. Which are the pathophysiological types of diarrhea? 10. What are the typical symptoms of diarrhea? 11. What is the difference between small and large bowel diarrhea? 12. What is the role of lab testing in the diagnosis of diarrhea? 13. Which drugs have been approved for the treatment of diarrhea? 14. What is the role of antimicrobial treatment of diarrhea?

Task 1 The patient, 32 years old, was admitted to the infectious department with complaints of fever, abdominal pain, diarrhea, nausea, vomiting. The illness began in the morning with chills, diffuse abdominal pain, nausea and vomiting, followed by short-term relief. An hour later, diarrhea joined. Diarrhea and vomiting were repeated at least 8 times, there was a pronounced weakness, cramps in the calf muscles. He ate meat salad, scrambled eggs, and homemade sausage for dinner. Objectively: moderate condition, body T - 38.9oC. The skin is pale, dry, its turgor is reduced, acrocyanosis, isolated cramps of the calf muscles. Blood pressure - 100/50 mm, pulse 102 beats / min, weak. Heart tones are muffled. The tongue is dry, covered with white plaque. The abdomen is soft, moderately painful around the navel, in the epigastric and iliac regions. There are no symptoms of peritoneal irritation. Stools - abundant, liquid, smelly, greenish, without mucus and blood. 1. Formulate a preliminary diagnosis. 2. Diagnostics 3. Treatment.

Task 2 Patient K., 27 years old, a cook, was admitted to an infectious disease hospital on the second day of illness with complaints of headache, frequent (up to 15 times a day) loose stools, nausea, vomiting, lower abdominal pain, false calls to the bottom. The disease began acutely with chills, fever up to 39˚C, repeated vomiting. After 5-7 hours, there was severe cramping pain in the abdomen, which worsened before defecation, loose stools with mucus and streaks of blood. Volume: 38.2˚C, sluggish. The skin is pale, turgor is preserved. Heart tones are weakened. Blood pressure 100/60 mm Hg. Pulse 104 beats / min. The tongue is dry, covered with a gray plaque. The abdomen is soft, hurts on palpation, there is a "growl" along the colon and sigmoid spasm. Liver at the edge of the costal arch. Stools fecal, semi-liquid, with mucus, up to 10 times a day. Urination is not disturbed. 1. Preliminary diagnosis. 2. Survey plan. 3. Treatment.

Task 3 A 29 year-old man was admitted to the hospital because of fatigue, anorexia, malaise, occipital headache, fever and difficulty concentrating. On physical examination he appeared tired and thin. His temperature was 40 oC. The liver edge was tender and palpated 3 cm below the right costal margin, with diffuse abdominal tenderness. An abdominal computed tomographyc scan showed thickening of the terminal ileum wall and clumped-enlarged mesenteric lymph nodes in the right lower quadrant. Laboratory test: white cells count, 4,600/mm3; aspartate-aminotransferase, 790 U/L; lactate-dehydrogenase, 1,562 U/L. He also had roseola spots distributed on the trunk. 1. Formulate a preliminary diagnosis. 2. Diagnostics 3. Treatment. Test control. 1. The main sources of salmonellosis are: A. Ducks B. Fish C. Dogs D. Cows E. Pigs 2. Signs of subclinical form of salmonellosis are following: A. Disposable diarrhea B. Increase in titers of anti-salmonella antibodies in paired serum samples C. The presence of ulcers of the intestinal mucosa during rectoromanoscopy D. Isolation of salmonella from feces E. Isolation of salmonella from food samples 3. Complications of the localized form of salmonellosis A. Dehydration shock B. Formation of liver abscesses C. Infectious and toxic shock D. Sepsis E. Chronic bacterial excretion 4. Which clinical variant of salmonellosis is generalized? A. Typhoid B. Gastric C. Colitis D. Gastroenteritic E. Gastroenterocolytic 5. Specific therapy of shigellosis includes: A. Nifuroxazide B. Doxycycline C. Ampicillin D. Intetrix E. Ciprofloxacin 6. Which type of Shigellas produces an exotoxin? A. Sonne B. Flexner C. Grigorieva-Shiga D. Large-Sachs E. All pathogens of shigellosis 7. The main transmission factors of cholera are following: A. milk and dairy products B. eggs of waterfowl C. water D. confectionery E. seafood 8. Dehydration of the III degree (according to Pokrovsky VI) corresponds to what percentage of loss of liquid from body weight: A. 1-2% of body weight B. 2-4% of body weight C. 5-7% of body weight D. 7-9% of body weight E. 10% or more by body weight 9. Which of the transmission pathways is leading in Sonne's shigellosis infection: A. Contact and household B. Dusty C. Water D. Sexual E. Food 10. Features of vomiting typical for cholera patients are following: A. occurs suddenly, without nausea B. accompanied by nausea, abdominal pain C. vomiting brings relief D. occurs before diarrhea E. occurs after diarrhea

9. Materials for self-training of students for a lecture: - on the topic outlined in the lecture (see paragraph 8) - on the topic of the next lecture 1. What is the role of antigenic drift and shift in the pathogenesis of influenza? 2. How are influenza viruses transmitted? 3. What is the incubation period of influenza? 4. How is influenza diagnosed? 5. What are the signs and symptoms of influenza? 6. Which physical findings suggest influenza? 7. How is primary influenza pneumonia characterized? 8. What are the possible complications of influenza pneumonia? 9. What are the differential diagnoses for Influenza? 10. What is the role of lab testing in the diagnosis of influenza? 11. What is the criterion standard for confirming influenza? 12. Which drugs have been approved for the treatment of influenza? 13. How is influenza prevented? 14. What are recommendations for influenza vaccination?