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1
., ., ., .
, ,
Karpov I.A., Gorbich Y.L., Stoma I.O., Solovey N.V.
Belarusian State Medical University, Minsk, Belarus
« C.difficile-
».
Review of the recommendations of the European Society of Clinical Microbiology
and Infectious Diseases "Update of the Treatment Guidance Document for Clostridium
dif cile Infection".
.
C.difficile –
. , C.difficile,
.
C.difficile-
,
.
: C.difficile, ,
, .
Resume.
C.difficile - one of the key agents of nosocomial infection and prevalent cause of
antibiotic-associated diarrhea and pseudomembranous colitis. Infections caused by C.difficile are
characterized by the highest mortality compared to other pathogens of intestinal infections. This
publication describes the main clinical and epidemiological features of C.difficile-associated
infections, and gives recent recommendations of the European Society of Clinical Microbiology
and Infectious Diseases on the management of this nosology of varying severity.
Keywords: C.difficile, antibiotic-associated diarrhea, pseudomebranous colitis,
antibacterial therapy.
2
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12 . Miller
,
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5 ,
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3. ( 133 1,5
) IIht).
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) IIr), (B IIht),
, (B IIht),
.
,
C. difficile, :
1. (>65 ) IIrh).
2. ( -C. difficile )
IIrh).
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IIh).
4. ( ) IIt).
5. (
) (B IIrh).
6. (B IIht).
, CLOSTRIDIUM DIFFICILE
12
, C. difficile,
. : 1)
; 2)
; 3) ; 4)
; 5) ; 6) ; 7) /
, , ; 8)
; 9) .
, C. difficile,
, R.P. Vonberg
[6].
:
- ;
- ;
- ,
;
- .
,
,
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.
.
2011 15 ,
, C. difficile, , 12
.
CDI [7].
,
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( 1).
13
,
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. , C. difficile.
. ,
C. difficile.
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:
1. .
2. .
3. .
4. .
5. .
. , C. difficile: ..
.
.
,
( ).
( ),
,
[8–10].
79% , ,
71% , (3 ; n=335 ; 0,91; 95
% 0,81-1,03; p 0,14) [7].
( ),
( . . )
, [11].
(81,8 %
72,7 %; 1,681; 95 % 1,114-2,537; p 0,0134).
(p<0,01)
, (3,0
14
, n=22), (4,6 , n=28) [12].
,
, C. difficile [13–16].
C. difficile, 027 [17].
, in vitro ,
( ) C.
difficile . Brazier et al. ,
C. difficile
, , (027, 106
001) [18]. ,
C. difficile [19].
; E-
[19,20].
[21,22]. ,
,
C. difficile
[19,23,24]. « »
,
C. difficile,
[25].
( ),
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, C. difficile
[25].
), , ,
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[12,22]. , .
15
, ,
0,25 9,5 ,
[26]. ,
.
,
[10].
( ).
,
, C.
difficile, [27].
, C. difficile, ,
,
, .
,
(n=17) (n=17), ,
, [28].
, C. difficile,
[29].
, C. difficile,
.
(VanA)
20 .
VanA , ,
,
, C. difficile [29].
, C. difficile, ,
.
, . difficile,
16
, Candida spp.
,
[30], ,
.
Candida spp.
, C. difficile, .
[31].
, [9,32].
, [7,32]. in vitro
C. difficile [33]. 2013
, C. difficile,
. ,
.
,
,
.
[34]. ,
[35]
[36].
.
,
,
[37].
[38].
.
,
.
.
17
, C. difficile,
.
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,
. .
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( )
,
48 ,
.
.
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4.
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, 500 3 – 10 I
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, 200 2 – 10 I
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48 II
4.
1.
, .
2. [7,10]
.
18
3. :
[7].
4.
( C. difficile 027 ) –
III [39].
5.
125 4 500 4 [40].
6.
.
.
, C.
difficile.
.
, C. difficile,
.
( ).
,
[15,41]. ,
, .
,
[15].
[42].
, C. difficile,
,
[43]. , ,
,
, C.
difficile [44].
-
, C. difficile,
.
19
(Saccharomyces boulardii) [45,46]. ,
[47].
.
,
, C. difficile.
B. , C. difficile.
. 6 17
. , 4 6
.
.
,
C. difficile, [10,22].
500 4 ) , C.
difficile, [14]
. ,
>125 4
[40].
, C. difficile,
[39,48].
, C.
difficile, 5.
5.
, Clostridium difficile,
, 125 4 – 10 I
, 500 4 – 10 III (Ia)
20
, 200 2 – 10 I
, 500 3 – 10 D (
)
I
a – , ,
.
5.
1.
,
[40].
2.
( III) [39,48].
3.
, C. difficile,
.
4.
0,125 4
C. difficile 027) [39].
5.
,
[10].
6.
[49].
, C. difficile.
. ,
C. difficile,
,
[15].
19 % 71 %
[50].
. ,
21
,
[51]. ,
[52].
, , , :
( ),
(>5 mM), ,
[50,53–56].
,
.
[52].
,
,
.
.
3350 ,
, .
.
10 [57].
.
. :
1. .
2.
,
,
. , ,
, . ,
, (
, 5,0 mM).
22
,
(
).
. , C.
difficile.
. 3 17
, C. difficile,
.
.
.
[48,58,59].
,
( n=79 n=80) [59].
,
. ,
, C. difficile
027, C. difficile
[48]. , ,
, C. difficile,
(B-I)
.
, C. difficile,
6.
6.
, Clostridium difficile,
, 125 4 – 10 B I
23
, 200 2 –
10
I
, 500 3 –
10
C I
, 500 4 – 10 III
6.
1.
[7,9,32].
2.
III) [39,48].
3.
[59].
4.
, [7,10,32,60].
[61].
5.
,
[40].
D. ..
. ( )
.
, ,
[30,59]. ,
,
, .
,
.
24
:
– –
[62].
7 8.
. ,
..
,
[63]. (500 3
) ,
[15,64].
, , .
, ,
.
,
. ,
,
[65,66].
, , ,
[67,68].
7.
( , ).
125 4 10 ,
(125-500
2-3 ) 3
IIt
125 4 10 ,
:
125
IIt
25
200 10 IIrt
500 4 10 IIrt
500 3 10 D IIrt
8. ( )
( )
, ).
500 4
, 4 +
+
I
+
Saccharomyces boulardii
D I
+
Lactobacillus spp.
D I
D I
9.
.
500 3
10
IIu
500 3
IIru
26
10 +
500 100 0,9%
NaCl 4 10 B III
500 3
10 +
500
100 0,9% NaCl 4
/
10
IIru
III
50 2 14
III
.
,
, ,
.
( ).
.
. , ,
C.difficile , .
,
, .
, .
: , .
5-7 ,
24 , , .
27
:
,
.
:
(>6 )
.
:
( )
,
, ,
.
:
- ( > 15 109 )
- (< 30 )
- (> 133 1,5
)
. , <
8 , , ,
.
. ,
, ,
( , ,
) .
3 , , .
, , 3-5
.
.
.
(SoE: I-III) (SoR: -D)
. – 1.
. : .
.
28
( ) ,
,
48 ,
,
( -II).
.
500 3 10 ( -I).
125 4 10 ( -I).
200 2 10 ( -I).
. .
.
125 4 10 ( -I).
200 2 10 ( -I).
:
- 500 4 10
(B-III)
- ,
(D-III)
(D-I).
.
:
-
- ,
; ,
.
. , ,
( 5,0 ).
, (
).
. .
29
.
200 2 10 ( -I).
125 4 10 (B-I).
500 3 10 ( -I).
:
, .difficile 027 -027 .
D. .
.
200 2 10 ( -II).
125 4 10 , (B-II)
125 4 10 ,
( -II).
.
,
,
( -I).
. , .
: 500 3 10 ( -
II).
: 500 3 10 ( -II)
500 100 0,9%
4 500
4 10 ( -III).
,
(QoE: I-III) (SoR: A-D)
1.
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