Coded as K98.1 in ICD 10, antibiotic-associated diarrhea (AAD) is a disorder of the stool that is not associated with infection or other causes. Antibacterial drugs precede this condition. Diarrhea is said to be if loose stools are observed three times two days in a row or more often. Sometimes AAD is fixed some time after the passage of the therapeutic course - up to eight weeks.
General view
Encrypted with K98.1 symbols in the ICD, antibiotic-associated diarrhea in rare cases can develop against the background of infection, but is more often explained by the direct effect of medications on intestinal motility or by an indirect effect. In addition, the drugs act quite strongly on different parts of the digestive system, which can also cause unformed pathological stools. A good example is macrolides that have a motilin-like effect. The course of treatment with ceftriaxone preparations can provoke sludge syndrome. Manifestations of a pathological condition with this form of the disorder disappear on their own after some time after stopping the drug. A specific patient correction program is not required.
K98.1 - code in the ICD 10 of antibiotic-associated diarrhea, that is, stool disorders due to the therapeutic course of antimicrobial agents. As can be seen from the clinical data, medical statistics, almost 37% of patients forced to take medicines of this group experience manifestations of AAD, which is recorded in the personal history of the disease. The indicated frequency is the minimum estimate of those suffering from gastrointestinal disorders, but some experts are convinced that the problem is much more common. A not entirely accurate estimate of the number of cases is associated with a tolerant assessment of manifestations - both patients and doctors do not perceive the phenomenon as a pathology. This is especially characteristic if stool disorder is observed in a mild form or moderate in severity.
Forms and Nuances
The antibiotic-associated diarrhea code K98.1 used in the ICD includes several clinical forms of a pathological condition. Recently, a widespread use has been made of a classification system involving the evaluation of manifestations. There are AAD without signs of colitis, AA colitis and pseudomembranous. When infected with certain forms of clostridia, AMA are classified as having no signs of colitis, and three types of it are distinguished: fulminant, pseudomembranous and non-pseudomembrane form.
Up to 20% of all cases are attributed to difficile clostridia. The K98.1 code used in the ICD for antibiotic-associated diarrhea also includes other cases, which account for (total) about 80% of all patients. These are situations in which stool disorder is associated with other forms of clostridia, fungal microflora, cocci, salmonella, and Klebsiella. The latter, as established, most often cause segmental hemorrhagic pathological conditions of the gastrointestinal tract.
Diagnoses and classification
In 2009, specialists in infectious infections, microbiologists, members of the European Union of Physicians, published clinical recommendations relevant to antibiotic-associated diarrhea. An impressive amount of scientific work was devoted primarily to the most common forms of microflora - clostridia difficile. The problems of diagnosis and treatment of such cases were considered. Special attention was given by experts to assessing the severity of the patient's condition and the formulation of the prognosis. American epidemiologists a year later issued practical recommendations for the observation and treatment of patients with AMA, in which the indicated form of microflora dominates.
The relevance of the problem of diarrhea after antibiotics in adults and children is associated with insufficient study of the issue. In particular, for the aforementioned type of pathological life form, only recently discovered a new strain, which is characterized by significantly more active production of toxic components in comparison with previously known. The difference reaches 23 times. Infection with such a strain becomes the cause of severe AMA. Among the substances generated by microflora is a binary toxin. The measures taken so far have not allowed to clarify what effect this substance has on a person. A specific feature of the identified type is increased resistance to fluoroquinolones. From this, the doctors concluded that the use of fluoroquinolones may be one of the factors that trigger AAD.
Nuances and manifestations
Antibiotic-associated dysbiosis, AAD can develop in various forms. Some patients have mild diarrhea that quickly resolves. Others are diagnosed with severe colitis, associated with the danger of death. In a predominant percentage of cases, the manifestation is expressed by a weakening of secretions, weak manifestations of colitis. General symptoms are absent. Stool per day is up to four times, accompanied by moderate soreness, reminiscent of contractions, in the abdomen. The temperature remains normal. On palpation, you can determine the increased sensitivity, but not always. Gas formation is also more active than the norm, but the difference from a healthy state is not very large.
Antibiotic-associated diarrhea in children and adults does not manifest itself as a marker of inflammation in the circulatory system. Symptoms are usually stopped by taking specific drugs, by canceling the course of antimicrobial agents. For rapid improvement, it is recommended to use probiotics, anti-diarrhea drugs. Doctors have determined for sure: this condition is associated with an imbalance in the composition of the intestinal microflora, a violation of the functionality of beneficial bacteria. Proliferation of pathological microscopic life forms does not occur.
Cases: sometimes harder
The treatment of diarrhea after antibiotics is significantly different if the clinical manifestations of the AMA associated with difficile clostridia are disturbed in case of colitis. This condition can be suspected by a strong, unpleasantly smelling discharge, in which mucous inclusions are noticeable. The chair is profuse. Bowel movements are accompanied by tenesmus. The patient is concerned about pains resembling contractions in the abdomen. On palpation, this area is soft, separate areas respond with increased sensitivity (colon). Listening allows you to determine: noise in the intestine is more than normal.
If diarrhea after taking antibiotics is associated with the specified form of life, the patient has fever (a state of moderate severity). General dehydration of the body is observed, the patient is sick, vomits. A blood test shows inconsequential leukocytosis, even if there are no typical manifestations of diarrhea. Colitis is most often localized in the right part of the colon, points to foci of pain, an increase in the content of white blood cells in the blood, and a fever. Diarrhea is moderate or completely absent.
Options and Cases
Sometimes diarrhea after taking antibiotics is severe. A toxic megacolon is accompanied by a rare stool. In clinical practice, cases of inadequate assessment of such progress in the patient's condition are known - sometimes doctors (and the patients themselves) take the symptom as a sign of improvement. At the same time, gases are trapped in the intestinal tract, the peritoneal region is irritated, the person is in fever, studies reveal the distention of the colon. A detailed study of the patient's condition helps to detect effusion in the peritoneum, pelvic area. In the circulatory system, an increased level of white blood cell count is established, and the concentration of albumin, on the contrary, is below normal. In addition, hypovolemia is detected. The indicated manifestations are a typical clinical picture.
If antibiotic-associated diarrhea progresses in this form, the patient should be referred for an x-ray. With a poisonous megacolon, the colon expands. Studies help identify intestinal pneumatosis. After CT, you can establish a thickening of the intestinal wall, narrowing of the lumens, densification of the fatty structures surrounding the intestine, as well as ascites. The condition is quite serious, therefore, deterioration to such a level of diarrhea after antibiotics should be avoided. What to do if progress has nevertheless reached this stage, qualified doctors know: an urgent operation is indicated to the patient. However, as can be seen from medical practice, the predominant percentage of patients are faced with rather serious complications, negative consequences of the intervention. The percentage of deaths has been increased.
Problem: typical cases
If previously antibiotic-associated diarrhea was mainly explained by relatively safe forms of pathological microflora, recently there have been more frequent cases of occurrence of the most dangerous clostridial strain - BI / NAPI. Most often, outbreaks of this type of ADA are observed in hospital walls, where patients are forced to undergo prolonged courses of antimicrobial treatment. Such AMA is significantly more severe than other types and forms of pathology.
Typically, symptoms begin to be detected on the fifth day after the start of the antimicrobial program, sometimes twice as much time passes before the initial manifestations. Isolated cases of the detection of symptoms of AAD are known already on the second day of taking the medicine, but there are also late options when the first manifestations occurred in the tenth week from the end of the course of antibiotic treatment.
BI / NAPI: Lightweight AMA
Antibiotic-associated diarrhea of this type is manifested by a decrease in the functionality of the small intestine and the contamination of this organ. Oral digestion of food is weakened, fermentation, rotting with the participation of bacteria are activated. The acidity of the contents of the intestinal tract decreases, as a result of which lipase activity is disrupted. The patient has steatorrhea, soap compounds, fatty structures are formed in the intestinal tract. Fat-soluble vitamin substances are absorbed much worse, which provokes endogenous polyhypovitaminosis.
Since adsorption and digestive processes in the small intestine are disturbed, antibiotic-associated diarrhea causes active gas formation and imbalance of intestinal motility, which results in a persistent syndrome of dyspepsia. Too active production of organic acids due to reactions activated by microflora leads to an increase in the osmolarity of the obsessed gastrointestinal tract. The consequences of the phenomenon are bloating, flatulence, diarrhea, bursting soreness, which comes with attacks. Dysbiosis provokes a high level of permeability of the intestinal barrier, which initiates the allergic response of the body. Excessive development of microflora in the small intestine can cause the weakening of the functionality of other parts of the gastrointestinal tract, as a result - increased pressure, duodenostasis, IBS, pseudo-obstruction. The start of inflammatory processes due to prolonged contamination, deconjugation is possible. Enteritis or duodenitis is recorded in the patient's card.
Continuing consideration
Treatment of antibiotic-associated diarrhea associated with difficile clostridia does not require if it is mild. It is not necessary to adjust the patient's condition if the pain is moderate, and defecation is fixed up to four times a day, while there is no general symptomatology, laboratory studies show that there are no significant changes. If this condition develops at home, it is strictly forbidden to use antibacterial drugs to get rid of AMA.
As a rule, diarrhea completely disappears on its own when the patient completes the therapeutic course that caused it. In some cases, the doctor may recommend taking probiotics. Without a medical recommendation, you should not use any medications, so as not to provoke a worsening of the condition.
BI / NAPI: severe AMA
In some cases, AMA proceeds according to a more negative scenario, and colitis develops. Two main forms are distinguished: with and without pseudomembranes. Without pseudomembranes, the process is usually systemic. AAD manifests itself in a febrile state, general poisoning of the body, and abdominal pain. The patient is sick and vomits. The chair is frequent, watery. Emptying up to twenty times is possible per day. There is dehydration.
Pseudomembranous colitis initially indicates similar symptoms. Colonoscopy reveals pseudomembranes. In the course of coproscopy, red blood cells, leukocytes can be detected. An analysis of occult blood in a predominant percentage of cases gives a positive result. Hematochezia is sometimes observed.
The most severe variant of the pathological condition is fulminant type colitis. It occurs in approximately 3% of patients. The condition can cause obstruction of the intestinal tract, megacolon against the background of poisoning, intestinal perforation, inflammation in the abdominal cavity, blood poisoning. You can suspect fulminant colitis if the patient suffers from a bright, pronounced pain in the stomach and bloating. Colitis is accompanied by dehydration, fever, hypotension, depression of consciousness or agitation. Toxin A, generated by pathological microflora, directly poisons the central nervous system, which can cause severe encephalopathy.
Case development: attention to the nuances
With AAD, manifestations can be observed that make it possible to suspect irritation of the peritoneal tissues. Perhaps muscle tension in certain areas. Such phenomena are the basis for suggesting intestinal perforation. In laboratory studies, you can establish an increased concentration of white blood cells in the blood, azotemia.
Gastrointestinal obstruction, toxic megacolon, into which the condition can progress, lead to more rare stools. Sometimes colitis is manifested by abdominal syndrome in acute form, but is not accompanied by diarrhea. This is also possible with megacolon against the background of poisoning the body.
Not always by pattern
Perhaps the development of atypical AMA. With this form of the disease, the patient suffers from colitis, the integrity and health of the small intestine is violated. There is a loss of protein structures, enteropathy. Monitoring the patient's condition reveals extraintestinal symptoms.
Clarification
With symptoms of AAD, colitis, including suspicion of cases associated with the new and most dangerous strains of clostridia, the medical history should be studied. If in the last two months a person has used antimicrobial drugs, one must proceed from the fact that the likelihood of AAD is significantly higher than average. In differential diagnosis, it is necessary to determine the nuances of the course of the case. It is important to take samples of feces, blood, urine, and conduct laboratory diagnostics. It is necessary to verify the fact of clostridial infection. On the AMA indicate a lack of albumin, azotemia, the content of leukocytes - 15-16 thousand per mm cubic meter.
If colitis is suspected, it is first necessary to take an X-ray, to assess the condition of the abdominal organs. The diagnosis is confirmed when perforation, megacolon, pneumatosis, ileus are detected. CT can show an increased thickness of the intestinal walls in certain areas, ascites. Obliteration, perforation of the intestine are somewhat less common.
The most accurate and fastest method of diagnosis is to analyze feces for the presence of pathogens. To do this, studies are conducted to identify the content of toxin A. Immunological enzymes are used. The accuracy and sensitivity of modern testing systems is estimated at an average of 75-85%. Methods have been developed for simultaneously detecting toxins A and B. This approach is considered more accurate.
Endoscope to clarify the condition
Such a study is most carefully carried out if there is reason to believe that treatment is required for antibiotic-associated diarrhea that has progressed to colitis. With such progress, the procedure is considered dangerous, since it increases the likelihood of intestinal perforation. This is more typical of severe cases.
If pseudomembranous colitis has developed, colonoscopy is recognized as the most reliable way to finally confirm the diagnosis.Given the high risks associated with such an event, the examination is carried out only in the case when you need to extremely quickly and extremely accurately determine the diagnosis, as well as with ileus. Colonoscopy is necessary to differentiate the condition and exclude other pathological conditions of the intestinal tract that threaten the patient's life.
What to do?
, , . , . , . , . , .
Formulating recommendations on how to treat diarrhea after antibiotics with carriage of clostridia of the genus difficile without typical symptoms, doctors from the American Union concluded that it was not necessary to give the patient medications to specifically correct the condition. In the general case, they complete the antibacterial course and do not use means to prevent secretory activity, peristalsis of the intestinal tract - they can provoke active reproduction of pathological microflora.
The main treatment is the use of probiotics, that is, living microorganisms that restore the balance of microflora in the intestinal tract. These are a variety of bacteria: lacto-, bifido-, sticks, cocci, fungal cultures. A number of scientists are convinced that probiotics can be used to prevent AAD. This question is currently open, numerous studies are underway to confirm the hypothesis or its refutation.