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Acute infectieuze diarree (AID)

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AID door Blastocystis species

Beoordeeld: 01-02-2014

Uitgangsvraag

Acute Infectieuze Diarree als gevolg van Blastocystis parasieten.

Aanbeveling

Behandeling van een vermeende Blastocystis spp. infectie kan worden overwogen bij langdurige klachten en bij uitsluiting van andere oorzaken. Metronidazol is dan het middel van eerste keuze (1dd 1500 mg gedurende 10 dagen).

Overwegingen

Er zijn voor deze richtlijn geen overwegingen opgesteld.

Onderbouwing

Niveau 2

Metronidazol kan mogelijk symptoomvermindering in combinatie met parasitologische genezing geven.

 

A2 Nigro 237

B Moghaddam 238

Blastocystis spp. (voorheen Blastocystis hominis) zijn anaerobe protozoaire intestinale parasieten. Ze behoren tot de meest aangetroffen micro-organismen in feces monsters wereldwijd. Bij mensen worden tenminste 9 verschillende subtypes gevonden waarbij 1, 2, 3 en 4 het meest voorkomen. De prevalentie in ontwikkelingsgebieden lijkt hoger te zijn dan in westerse landen. Ook bij reizigers naar tropische landen wordt deze parasiet frequent in de ontlasting aangetroffen. Net als bij D. fragilis wordt verondersteld dat de transmissie feco-oraal verloopt.[236]

Een blastocystis infectie wordt wel geassocieerd met buikpijn, flatulentie en met acute zowel als chronische diarree.[236] In een Nederlandse studie bij kinderen leek co-infectie met D. fragilis veel voor te komen en kon geen verschil gevonden worden in intestinale klachten tussen kinderen met en zonder positieve PCR op intestinale parasieten.[223] Een door het RIVM uitgevoerde case-control studie naar gastroenteritis en verwekkers liet zien dat er bij volwassenen in de controle groep vaker B. hominis werd gedetecteerd dan in de groep met intestinale klachten.[222] Terughoudendheid met betrekking tot antibiotische behandeling wordt daarom aanbevolen. Bij persisterende klachten waarbij geen andere oorzaak voor de klachten gevonden kan worden, kan therapie wellicht zinvol zijn.
Hoewel metronidazol wordt gezien als de behandeling van 1e keuze, lijkt eradicatie met dit middel verre van gegarandeerd te zijn. Er zijn 2 placebo-gecontroleerde studies met metronidazol die concluderen dat symptoom vermindering is geassocieerd met parasitaire genezing, hoewel bij de studie van Moghaddham eradicatie in de meeste gevallen niet optreedt.[237; 238] TMP-SMZ lijkt in één studie mogelijk een alternatief te zijn voor metronidazol, maar dit werd nooit bevestigd in andere studies.[239] Een Nederlandse retrospectieve cohort studie vond dat behandeling met paromomycine vaker tot parasitologische genezing leidde dan behandeling met clioquinol of metronidazol, maar meer data zijn nodig om de superioriteit van dit middel te bevestigen en om het effect van behandeling op klinische symptomen te bestuderen.[240]
In afwezigheid van voldoende bewijslast voor pathogeniciteit bestaat er geen consensus over of, hoe en wie er behandeld zou moeten worden. Het lijkt echter redelijk om een behandeling te overwegen wanneer andere oorzaken van diarree goed zijn onderzocht, de patiënt klachten blijft houden en blastocystis spp. als enige mogelijke verwekker kunnen worden aangemerkt. In afwachting van prospectieve data met paromomycine, wordt metronidazol vooralsnog gezien als het middel van eerste keuze, hoewel bij persisterende klachten en het uitblijven van parasitologische genezing een behandeling met paromomycine kan worden overwogen. Aangeraden wordt om metronidazol voor te schrijven in een dosering van 1dd 1500 mg gedurende 10 dagen.[237]

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Autorisatiedatum en geldigheid

Laatst beoordeeld  : 01-02-2014

Laatst geautoriseerd  : 01-02-2014

Geplande herbeoordeling  :

De geldigheid van de richtlijn is 5 jaar; in 2019 of zoveel eerder als nodig is zal de richtlijn ge-reëvalueerd worden.

Initiatief en autorisatie

Initiatief:
  • Stichting Werkgroep Antibioticabeleid

Algemene gegevens

De richtlijn is opgesteld en goedgekeurd door vertegenwoordigers van de in de inleiding en methoden genoemde beroepsverenigingen, en verwoordt de geldende professionele standaard in februari 2014. De richtlijn bevat aanbevelingen van algemene aard. Het is mogelijk dat deze aanbevelingen in een individueel geval niet van toepassing zijn. De toepasbaarheid van de richtlijn in de praktijk is de verantwoordelijkheid van de behandelend arts. Er kunnen zich feiten of omstandigheden voordoen waardoor, in het belang van een goede zorg voor de patiënt, afwijking van de richtlijn wenselijk is.

 

De totstandkoming van deze richtlijn werd gefinancierd door subsidie van het Ministerie van VWS/RIVM-CIb aan de SWAB.

Doel en doelgroep

Doel

De Stichting Werkgroep Antibioticabeleid (SWAB) ontwikkelt richtlijnen voor het gebruik van antibiotica bij volwassenen in het ziekenhuis met als doel het antibioticabeleid te optimaliseren en zo een bijdrage te leveren aan de beheersing van kosten en resistentieontwikkeling.

 

Doelgroep

De richtlijnen dienen als raamwerk voor de commissies die antibioticaformularia opstellen in ziekenhuizen.

Samenstelling werkgroep

Voorbereidingscommissie:

  • Mw. drs. J.C. Bos (internist-infectioloog)
  • Mw. dr. C. Schultsz (arts-microbioloog)
  • Dr. T. Van Gool (arts-microbioloog, parasitoloog)
  • Drs. M. P. Bauer (internist-infectioloog)
  • Prof. dr. J.M. Prins (internist-infectioloog)

 

Wij zijn dank verschuldigd aan mevr. Heleen Dyserinck, (voormalig) bibliothecaresse van de Medische Bibliotheek van het AMC voor haar bijdrage aan de tot stand koming van de zoekstrategie.

Belangenverklaringen

De leden van de voorbereidingscommissie hebben de volgende potentiële belangenconflicten gemeld: M. Bauer heeft op uitnodiging van Astellas een Clostridium-symposium bezocht in Londen, UK. De overige auteurs hebben gemeld geen belangenconflicten te hebben.

Methode ontwikkeling

Evidence based

Werkwijze

Tabel 1. Methodologische kwaliteit van individuele studies [2]

Classificatie

Definitie

A1

A2

Systematische review obv tenminste twee onafhankelijke A2 studies

Randomised Controlled Trial (RCT) van voldoende methodologische kwaliteit en power

of

Prospectieve cohort studie met voldoende power en adekwate correctie voor confounders

B

Vergelijkende studie zonder de methodologische kwaliteit zoals genoemd bij A2 (inclusief patient gecontroleerde studies en cohort studies)

of

Prospectieve cohort studie zonder de methodologische kwaliteit zoals genoemd bij A2, retrospectieve cohort studie of patient gecontroleerde studie

C

Niet vergelijkende studie

D

Bewijs obv de mening van leden van de richtlijn commissie

* NethMap/ISIS surveillance data zijn niet goed te graderen omdat geen gebruik gemaakt kan worden van levels of evidence zoals gebruikt in deze richtlijn. Er wordt echter wel veel gewicht aan de methodologische kwaliteit van deze data toegekend, omdat ze betrekking hebben op zo’n 30% van de Nederlandse bevolking. Ditzelfde geldt voor de MARAN data.

 

Tabel 2. Bewijsniveaus

Bewijsniveaus

Definitie

Niveau 1

Één A1 studie of tenminste twee onafhankelijke A2 studies

Niveau 2

Één A2 studie of tenminste twee onafhankelijke B studie

Niveau 3

Één B of C studie

Niveau 4

Expert opinion

Zoekverantwoording

Zoekacties zijn opvraagbaar. Neem hiervoor contact op met de Richtlijnendatabase.

Volgende:
Empirische therapie bij AID