Vibrio Choleaae(V. Cholerae) 감염증의 치료.

Treatment of Vibrio Cholerae infection.

 

참고자료 : http://www.cdc.gov/cholera/treatment/antibiotic-treatment.html

 

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본인도 회, 생굴을 먹고 비브리오 콜레라에 감염된 적이 몇번 있는데,

마침 임상 증상으로 보았을 때, V. Cholerae가 의심되는 환자가 찾아온고로,

V. Cholerae 감염의 치료에 대해 자료를 찾아서 읽어보았다.

 

V. Cholerae 감염의 비특이적 증상은 일단 잦은 설사 등으로 대표되는

일반적인 장염증상, 미열 등의 감기 증상과 비슷하나.

특이적 증상으로 몇가지가 있다. 기억할 만한 것은,

 힘을 주지 않고 괄약근에 힘만 조금 풀어도 마구마구 쏟아지는 쌀뜨물 같은 설사증상(watery diarrhea),

*덩어리가 없이 오로지 물만 쏟아지는 게 참 신기하다.

그리고 하루종일 그렇게 설사를 쏟아내면서 휴지로 항문을 닦는데도

항문에 별로 쓰린 증상이 없다는 점도 특이한 것 같다.

 

보통 장염이면,

복통이나 부글부글 끓는 느낌이나 항문이 닳아질 것 같은 느낌 때문에 고생을 했던 것 같은데,

비브리오 콜레라 장염은 내가 겪어본 장염 중에는 탈수증으로 나를 가장 고생시켰던 장염인 것 같다.

아오!!! 생각만 해도 끔찍하다.

 

여튼 그건 그렇게 치료를 알아보자!

http://www.cdc.gov/cholera/treatment/antibiotic-treatment.html

이것저것 많이는 안 찾아봤고, 일단 이것만 그냥 읽어봤다.

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원본 출처는 링크를 해 뒀으니 내용을 긁어와서 밑줄 좀 그어보자.

Antibiotic Treatment

Recommendations for the Use of Antibiotics for the Treatment of Cholera

 

Summary Recommendations

1. Oral or intravenous hydration is the mainstay of cholera treatment. (역시 장염에서 가장 중요한 치료는 뭐니뭐니해도 수분공급!!!)
2. In conjunction with hydration, treatment with antibiotics is recommended for severely ill patients. It is particularly recommended for patients who are severely or moderately dehydrated and continue to pass a large volume of stool during rehydration treatment. Antibiotic treatment is also recommended for all patients who are hospitalized.(여튼 증상이 심하면 항생제도 쓰긴 써야된다)
3. Antibiotic choices should be informed by local antibiotic susceptibility patterns. In most countries, Doxycycline is recommended as first-line treatment for adults, while azithromycin is recommended as first-line treatment for children and pregnant women. During an epidemic or outbreak, antibiotic susceptibility should be monitored through regular testing of sample isolates from various geographic areas. (성인에서 first-line은 Doxycycline)
4. None of the guidelines recommend antibiotics as prophylaxis for cholera prevention, and all emphasize that antibiotics should be used in conjunction with aggressive hydration. (예방적 항생제 요법은 비추!!!)
5. Education of health care workers, assurance of adequate supplies, and monitoring of practices are all important for appropriate dispensation of antibiotics.

Background

1. Mainstay of cholera treatment is hydration
   Intravenous ¹ and oral ² hydration are both associated with greatly decreased mortality and remain the mainstay of treatment for cholera.

1. Antibiotic effectiveness for the treatment of cholera
2. Antibiotics have been used as an adjunct to hydration treatment for cholera since 1964. Findings from randomized controlled trials evaluated the effectiveness of selected antibiotics on three main outcomes: stool output, duration of diarrhea, and bacterial shedding.These studies compared outcomes for cholera patients who were given both intravenous (IV) fluids and antibiotic treatment with those given IV fluids only. Findings indicate that antibiotics reduced volume of stool output by 8-92%, duration of diarrhea by 50-56%, and duration of positive bacterial culture by 26-83% ^3–7.

• Antibiotic use for moderately and severely ill patients is also likely to reduce resource requirements. By decreasing duration of diarrhea and stool volume, antibiotics result in more rapid recovery and shorter lengths of inpatient stay, both of which contribute to optimizing resource utilization in an outbreak setting.
• The majority of published studies exploring effectiveness of antibiotics for cholera patients have been done in patients who were adequately rehydrated. In these studies, there was no mortality and therefore the impact of antibiotics on mortality cannot be assessed. In the absence of adequate rehydration, antibiotics alone are not sufficient to prevent cholera mortality.

1. Antibiotic regimens for the treatment of cholera
   Tetracycline has been shown to be effective treatment for cholera ², ³ and is superior to furazolidone ⁸, cholamphenicol ⁹ and sulfaguanidine ⁹ in reducing cholera morbidity. Treatment with a single 300mg dose of doxycycline has shown to be equivalent to tetracycline treatment ¹⁰. Erythromycin is effective for cholera treatment, and appropriate for children and pregnant women ¹¹. Orfloxacin ¹², trimethoprim-sulfamethoxazole (TMP-SMX) ¹³, and ciprofloxacin ¹⁴ are effective, but doxycycline offers advantages related to ease of administration and comparable or superior effectiveness. Recently, azithromycin has been shown to be more effective than erythromycin and ciprofloxacin ¹⁵, ¹⁶ and is an appropriate first line regimen for children and pregnant women.(Tetracycline이 1st-line이긴 하나, single dose의 Doxycycline 300mg도 비등한 효과가 있다!!!)
2. Antibiotic resistance
   Resistance to tetracycline and other antimicrobial agents among V. cholerae has been demonstrated in both endemic and epidemic cholera settings. Resistance can be acquired through the accumulation of selected mutations over time, or the acquisition of genetic elements such as plasmids, introns, or conjugative elements, which confer rapid spread of resistance. A likely risk factor for antimicrobial resistance is widespread use of antibiotics, including mass distribution for prophylaxis in asymptomatic individuals. Antibiotic resistance emerged in previous epidemics in the context of antibiotic prophylaxis for household contacts of cholera patients ¹⁷, ¹⁸.
3. Unanswered questions
   Inadequate information still exists with respect to antibiotics in the following areas:
4. Effect of antibiotics on secondary transmission:
   • There are insufficient data examining the effect of antibiotics on secondary transmission of cholera. However, in published studies to date antibiotics have not been shown to decrease secondary transmission of cholera within households ¹⁹, ²⁰.
5. Utility of antibiotics when aggressive rehydration is not possible:
   • Because studies on antibiotic treatment for cholera were conducted in patients who received adequate rehydration, the effect of antibiotics in settings where this is not possible remains unclear.
6. Summary of Antibiotic Treatment Guidelines
   Various organizations that participate in cholera responses recommend the use of antibiotics in cholera-infected patients with moderate or severe illness and who have begun IV hydration. None of the guidelines recommend antibiotics as prophylaxis for cholera prevention, and all emphasize that antibiotics should be used in conjunction with aggressive hydration. In addition, the guidelines recommend that antimicrobial susceptibility testing should inform local drug choices. Available guidelines are summarized below.

Guidelines for Cholera Treatment with Antibiotics
Organization	Recommendation	First-line drug choice	Alternate drug choices	Drug choices for special populations
World Health Organization 21	Antibiotic treatment for cholera patients with severe dehydration only	Doxycycline	Tetracycline	Erythromycin is recommended drug for children
Pan American Health Organization 22	Antibiotic treatment for cholera patients with moderate or severe dehydration	Doxycycline	Ciprofloxacin Azithromycin	Erythromycin or azithromycin recommended as first-line drugs for pregnant women and children Ciprofloxacin and doxycycline recommended as second-line drugs for children
International Centre for Diarrhoeal Disease Research, Bangladesh 23	Antibiotic treatment for cholera patients with some or severe dehydration	Doxycycline	Ciprofloxacin Azithromycin Cotrimoxazole	Erythromycin recommended as first-line drug for children and pregnant women
Medicins Sans Frontieres 24	Antibiotic treatment for severely dehydrated patients only	Doxycycline	Erythromycin Cotrimoxazole Chloramphenicol Furazolidone

 

* Please note, due to space constraints, dosage information is not included in this table. Dosage guidance can be found by following the website links to the treatment guidance documents provided in the references section below (references 21-24).

7. Considerations
   • Over-emphasizing antibiotics for treatment of cholera could divert resources from oral and intravenous rehydration.
   • Doxycycline costs approximately $0.02 per 100mg tablet. Azithromycin costs approximately $0.16 per 250mg tablet.
   • Antibiotics can cause nausea and vomiting. Gastrointestinal side effects should be carefully monitored, especially in dehydrated patients.
   • Antibiotics are not needed and should not be given to patients with cholera who have only mild or no diarrhea and dehydration.
   • Prospective surveillance for antibiotic resistance among bacterial isolates from any outbreak is essential for understanding and minimizing the spread of resistance.

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1년에 비브리오 콜레라 환자가 한명 올까 말까 하는 이 조그마한 보건소에

비브리오 콜레라 환자가 언제 또 올지 아무도 알 수 없으니....ㅋㅋ(2012년의 비브리오 콜레라 환자는 바로 본인....ㅠㅠ)

우선은 이거라도 기억해보자.

single dose of Doxycycline 300mg