What is anaerobic infection. Anaerobic surgical infection Causative agents of surgical infections anaerobes and aerobes

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Wound anaerobic infection attracts close attention of surgeons, infectious disease specialists, microbiologists and other specialists. This is due to the fact that anaerobic infection occupies a special place due to the exceptional severity of the disease, high mortality (14-80%), and frequent cases of severe disability in patients. Anaerobes and their associations with aerobes currently hold one of the leading places in human infectious pathology.

Anaerobic infection can develop as a result of injuries, surgical interventions, burns, injections, as well as in the complicated course of acute and chronic purulent diseases of soft tissues and bones, vascular diseases against the background of atherosclerosis, diabetic angio-neuropathy. Depending on the cause of an infectious disease of soft tissues, the nature of the damage and its localization, anaerobic microorganisms are found in 40-90% of cases. So, according to some authors, the frequency of isolation of anaerobes during bacteremia does not exceed 20%, and with phlegmon of the neck, odontogenic infection, intra-abdominal purulent processes, it reaches 81-100%.

Traditionally, the term "anaerobic infection" referred only to infections caused by Clostridium. However, in modern conditions, the latter are not involved in infectious processes so often, only in 5-12% of cases. The main role is assigned to non-spore-forming anaerobes. Both types of pathogens are united by the fact that the pathological effect on tissues and organs is carried out by them under conditions of general or local hypoxia using the anaerobic metabolic pathway.

ICD-10 code

A48.0 Gas gangrene

Causative agents of anaerobic infections

By and large, the pathogens of anaerobic infections include pathological processes caused by obligate anaerobes, which develop and exert their pathogenic effect under conditions of anoxia (strict anaerobes) or at low oxygen concentrations (microaerophiles). However, there is a large group of so-called facultative anaerobes (streptococci, staphylococci, proteus, Escherichia coli, etc.), which, when exposed to hypoxic conditions, switch from aerobic to anaerobic metabolic pathways and are capable of causing the development of an infectious process clinically and pathomorphologically similar to a typical anaerobic one.

Anaerobes are ubiquitous. More than 400 species of anaerobic bacteria have been isolated in the human gastrointestinal tract, which is their main habitat. The ratio of aerobes to anaerobes is 1:100.

Below is a list of the most common anaerobes, whose participation in infectious pathological processes in the human body is proven.

Microbiological classification of anaerobes

• Anaerobic gram-positive rods
  • Clostridium perfringes, sordellii, novyi, histolyticum, septicum, bifermentans, sporogenes, tertium, ramosum, butyricum, bryantii, difficile
  • Actinomyces israelii, naeslundii, odontolyticus, bovis, viscosus
  • Eubacterium limosum
  • Propionibacterim acnes
  • Bifidobacterium bifidum
  • Arachnia propionica
  • Rothia dentocariosa
• Anaerobic gram-positive cocci
  • Peptostreptococcus anaerobius, magnus, asaccharolyticus, prevotii, micros
  • Peptococcus niger
  • Ruminococcus flavefaciens
  • Coprococcus eutactus
  • Gemella haemolysans
  • Sarcina ventriculi
• Anaerobic gram-negative rods
  • Bacteroides fragilis, vulgatus, thetaiotaomicron, distasonis, uniformis, caccae, ovatus, merdae,
  • stercoris, ureolyticus, gracilis
  • Prevotella melaninogenica, intermedia, bivia, loescheii, denticola, disiens, oralis, buccalis, veroralis, oulora, corporis
  • Fusobacterium nucleatum, necrophorum, necrogenes, periodonticum
  • Porphyromonas endodontalis, gingivalis, asaccharolitica
  • Mobiluncus curtisii
  • Anaerorhabdus furcosus
  • Centipeda periodontii
  • Leptotrichia buccalis
  • Mitsuokella multiacidus
  • Tissierella praeacuta
  • Wolinella succinogenes
• Anaerobic gram-negative cocci
  • Veillonella parvula

In most pathological infectious processes (92.8-98.0% of cases), anaerobes are detected in association with aerobes and, above all, with streptococci, staphylococci and bacteria of the Enterobacteriaceae family, non-fermenting gram-negative bacteria.

Among the many classifications of anaerobic infections in surgery, the classification proposed by A.P. Kolesov et al. should be considered the most complete and meeting the needs of clinicians. (1989).

Classification of anaerobic infection in surgery

According to microbial etiology:

• clostridial;
• non-clostridial (petostreptococcal, peptococcal, bacteroid, fusobacterium, etc.).

By the nature of the microflora:

• monoinfections;
• polyinfections (caused by several anaerobes);
• mixed (anaerobic-aerobic).

For the affected body part:

• soft tissue infections;
• infections internal organs;
• bone infections;
• infections of the serous cavities;
• bloodstream infections.

By prevalence:

• local, limited;
• unlimited, tending to spread (regional);
• systemic or generalized.

According to the source of infection:

• exogenous;
• endogenous.

Origin:

• out-of-hospital;
• nosocomial.

For reasons of occurrence:

• traumatic;
• spontaneous;
• iatrogenic.

Most anaerobes are natural inhabitants of human skin and mucous membranes. More than 90% of all anaerobic infections are endogenous. Exogenous infections include only clostridial gastroenteritis, clostridial post-traumatic cellulitis and myonecrosis, infections after human and animal bites, septic abortion, and some others.

Endogenous anaerobic infection develops in the event of the appearance of opportunistic anaerobes in places that are unusual for their habitat. Penetration of anaerobes into tissues and the bloodstream occurs during surgical interventions, with injuries, invasive manipulations, decay of tumors, with translocation of bacteria from the intestine during acute diseases abdominal cavity and sepsis.

However, for the development of an infection, it is still not enough to simply get bacteria into unnatural places of their existence. For the introduction of anaerobic flora and the development of an infectious pathological process, the participation of additional factors is necessary, which include large blood loss, local tissue ischemia, shock, starvation, stress, overwork, etc. Concomitant diseases play an important role (diabetes mellitus, collagenoses, malignant tumors, etc.). ), long-term use hormones and cytostatics, primary and secondary immunodeficiencies against the background of HIV infection and other chronic infectious and autoimmune diseases.

One of the main factors in the development of anaerobic infections is a decrease in the partial pressure of oxygen in tissues, which occurs as a result of common causes(shock, blood loss, etc.), and local tissue hypoxia in conditions of insufficient arterial blood flow (occlusive vascular disease), the presence of a large number of shell-shocked, crushed, non-viable tissues.

Irrational and inadequate antibiotic therapy, aimed mainly at suppressing the antagonistic aerobic flora, also contributes to the unhindered development of anaerobes.

Anaerobic bacteria have a number of properties that allow them to show their pathogenicity only when favorable conditions appear. Endogenous infections occur when the natural balance between the body's immune defenses and virulent microorganisms is disturbed. Exogenous anaerobic infection, and especially clostridial, is more pathogenic and clinically more severe than infection caused by non-spore-forming bacteria.

Anaerobes have pathogenicity factors that contribute to their invasion into tissues, reproduction and manifestation of pathogenic properties. These include enzymes, waste products and decay of bacteria, cell wall antigens, etc.

So bacteroids, which mainly live in various parts of the gastrointestinal tract, upper respiratory tract and lower genitourinary tract, are able to produce factors that promote their adhesion to the endothelium and damage it. Severe disorders of microhemocirculation are accompanied by increased vascular permeability, erythrocyte sludge, microthrombosis with the development of immune complex vasculitis, which cause the progressive course of the inflammatory process and its generalization. Anaerobic heparinase contributes to the occurrence of vasculitis, micro- and macrothrombophlebitis. The capsule of anaerobes is a factor that sharply increases their virulence, and even brings them to the first place in associations. The secretion of neuraminidase, hyaluronidase, fibrinolysin, superoxide dismutase by bacteroids, due to their cytotoxic effect, leads to tissue destruction and the spread of infection.

Bacteria of the genus Prevotella produce endotoxin, the activity of which exceeds the action of lipopolysaccharides of bacteroids, and also produce phospholipase A, which disrupts the integrity of epithelial cell membranes, which leads to their death.

The pathogenesis of lesions caused by bacteria of the genus Fusobacterium is due to the ability to secrete leukocidin and phospholipase A, which exhibit a cytotoxic effect and facilitate invasion.

Gram-positive anaerobic cocci normally colonize oral cavity, colon, upper respiratory tract, vagina. Their virulent and pathogenic properties have not been sufficiently studied, despite the fact that they are often detected during the development of very severe purulent-necrotic processes of various localization. It is possible that the pathogenicity of anaerobic cocci is due to the presence of a capsule, the action of lipopolysaccharides, hyaluronidase and collagenase.

Clostridia can cause both exogenous and endogenous anaerobic infections.

Their natural habitat is the soil and colon man and animals. The main genus-forming feature of clostridia is spore formation, which determines their resistance to adverse environmental factors.

In C. perfringens, the most common pathogen, at least 12 enzyme toxins and an enterotoxin have been identified that determine its pathogenic properties:

• alpha-Toxin (lecithinase) - exhibits dermatonecrotizing, hemolytic and lethal effects.
• beta-toxin - causes tissue necrosis and has a lethal effect.
• sigma-Toxin - exhibits hemolytic activity.
• theta-Toxin - has a dermatonecrotic, hemolytic and lethal effect.
• e-Toxins - cause a lethal and dermatonecrotizing effect.
• k-Toxin (collagenase and gelatinase) - destroys the reticular muscle tissue and connective tissue collagen fibers, has a necrotizing and lethal effect.
• lambda-toxin (proteinase) - breaks down denatured collagen and gelatin like fibrinolysin, causing necrotic properties.
• gamma and nu-toxins - have a lethal effect on laboratory animals.
• mu- and v-toxins (hyaluronidase and deoxyribonu-clease) - increase tissue permeability.

Anaerobic infection is extremely rare in the form of monoinfection (less than 1% of cases). Anaerobic pathogens manifest their pathogenicity in association with other bacteria. Symbiosis of anaerobes with each other, as well as with some types of facultative anaerobes, especially with streptococci, bacteria of the Enterobacteriaceae family, non-fermenting gram-negative bacteria, allows you to create synergistic associative bonds that facilitate their invasion and manifestation of pathogenic properties.

How does anaerobic soft tissue infection manifest itself?

Clinical manifestations of anaerobic infections occurring with the participation of anaerobes are determined by the ecology of pathogens, their metabolism, pathogenicity factors, which are realized in conditions of a decrease in the general or local immune defenses of the macroorganism.

Anaerobic infection, regardless of the location of the focus, has a number of very characteristic clinical signs. These include:

• erasure of local classic signs of infection with a predominance of symptoms of general intoxication;
• localization of the focus of infection in the usual habitat of anaerobes;
• an unpleasant putrid odor of exudate, which is a consequence of anaerobic oxidation of proteins;
• the predominance of processes of alterative inflammation over exudative with the development of tissue necrosis;
• gas formation with the development of emphysema and crepitus of soft tissues due to the formation of poorly water-soluble products of anaerobic metabolism of bacteria (hydrogen, nitrogen, methane, etc.);
• serous-hemorrhagic, purulent-hemorrhagic and purulent exudate with a brown, gray-brown color of the discharge and the presence of small droplets of fat in it;
• staining of wounds and cavities in black;
• development of infection against the background of long-term use of aminoglycosides.

If a patient has two or more of the signs described above, the likelihood of participation of anaerobic infection in the pathological process is very high.

Purulent-necrotic processes occurring with the participation of anaerobes can be conditionally divided into three clinical groups:

1. The purulent process is local in nature, proceeds without severe intoxication, quickly stops after surgical treatment or even without it, patients usually do not need intensive additional therapy.
2. The infectious process clinical course practically does not differ from the usual purulent processes, proceeds favorably, like the usual phlegmon with moderately pronounced symptoms of intoxication.
3. Purulent-necrotic process proceeds rapidly, often malignantly; progresses, occupying vast areas of soft tissues; severe sepsis and PON develop rapidly with a poor prognosis of the disease.

Anaerobic infection of soft tissues is characterized by heterogeneity and diversity both in the severity of the pathological processes they cause and in the pathomorphological changes that develop in the tissues with their participation. Various anaerobes, as well as aerobic bacteria, can cause the same type of disease. At the same time, the same bacteria under different conditions can cause various diseases. However, despite this, several main clinical and pathomorphological forms of infectious processes involving anaerobes can be distinguished.

Various types of anaerobes can cause both superficial and deep purulent-necrotic processes with the development of serous and necrotic cellulitis, fasciitis, myositis and myonecrosis, combined lesions of several structures of soft tissues and bones.

Clostridial anaerobic infection is characterized by severe aggressiveness. In most cases, the disease proceeds severely and rapidly, with the rapid development of sepsis. Clostridial anaerobic infection develops in patients with various types injuries of soft tissues and bones in the presence of certain conditions, which include massive contamination of tissues with earth, the presence in the wound of areas of dead and crushed tissues deprived of blood supply, the presence of foreign bodies. Endogenous clostridial anaerobic infection occurs in acute paraproctitis, after operations on the abdominal organs and lower extremities in patients with obliterating vascular diseases and diabetes. Less common is an anaerobic infection that develops as a result of a bite of a person or animals, injections of drugs.

Clostridial anaerobic infection occurs in the form of two main pathomorphological forms: cellulitis and myonecrosis.

Clostridial cellulitis (crepitating cellulitis) is characterized by the development of necrosis of the subcutaneous or intermuscular tissue in the wound area. It's running relatively well. A wide timely dissection of the wound and excision of non-viable tissues in most cases ensures recovery.

In patients with diabetes mellitus and obliterating vascular diseases lower extremities there are less chances for a favorable outcome of the disease, since in the form of cellulitis the infectious process occurs only at the first stages, then the purulent-necrotic tissue damage quickly passes to deeper structures (tendons, muscles, bones). A secondary gram-negative anaerobic infection joins with involvement in the purulent-necrotic process of the entire complex of soft tissues, joints and bone structures. Wet gangrene of the limb or its segment is formed, in connection with which it is often necessary to resort to amputation.

Clostridial myonecrosis (gas gangrene) is the most severe form of anaerobic infection. Duration incubation period ranges from several hours to 3-4 days. There is a strong, arching pain in the wound, which is the earliest local symptom. The state thus remains without visible changes. Later, progressive edema appears. The wound becomes dry, there is a fetid discharge with bubbles of gas. The skin takes on a bronze color. Rapidly formed intradermal blisters with serous-hemorrhagic exudate, foci of wet necrosis of the skin of purple-cyanotic and brown color. Gas formation in the tissues is a common sign of anaerobic infection.

In parallel with local signs, the general condition of the patient worsens. Against the background of massive endotoxicosis, the processes of dysfunction of all organs and systems are rapidly increasing with the development of severe anaerobic sepsis and septic shock, from which patients die if surgical care is not provided in full on time.

A characteristic sign of infection is the defeat of the necrotic process of the muscles. They become flabby, dull, bleed poorly, do not contract, acquire a dirty brown color and have the consistency of "boiled meat". With the progression of the process, anaerobic infection quickly passes to other muscle groups, neighboring tissues with the development of gas gangrene.

A rare cause of clostridial myonecrosis is injection of medicinal drugs. Treatment of such patients is a difficult task. Only a few patients manage to save lives. One such case is evidenced by the following case history.

Anaerobic streptococcal cellulitis and myositis occur as a result of various soft tissue injuries, surgical operations and manipulations. They are caused by gram-positive facultative anaerobes Streptococcus spp. and anaerobic cocci (Peptostreptococcus spp., Peptococcus spp.). The disease is characterized by the development of predominantly serous in the early stages, and in the later stages of necrotic cellulitis or myositis and proceeds with symptoms of severe intoxication, often turning into septic shock. Local symptoms of infection are erased. Tissue edema and hyperemia are not expressed, fluctuation is not determined. Gas formation rarely occurs. With necrotic cellulitis, the fiber looks faded, bleeds poorly, is gray in color, and is abundantly saturated with serous and serous-purulent exudate. The skin is involved in the inflammatory process for the second time: cyanotic spots with uneven edges appear, blisters with serous contents. The affected muscles look edematous, contract poorly, and are saturated with serous, serous-purulent exudate.

Due to the paucity of local clinical signs and the prevalence of symptoms of severe endotoxicosis, surgery is often carried out late. Timely surgical treatment of the inflammatory focus with intensive antibacterial and detoxification therapy quickly interrupts the course of anaerobic streptococcal cellulitis or myositis.

Synergistic necrotizing cellulitis is a severe, rapidly progressive purulent-necrotic cellular disease caused by an associative non-clostridial anaerobic infection and aerobes. The disease proceeds with irrepressible destruction of cellular tissue and secondary involvement in the purulent-necrotic process of neighboring tissues (skin, fascia, muscles). The skin is most often involved in the pathological process. Purple-cyanotic confluent spots appear without a clear boundary, later turning into moist necrosis with ulceration. With the progression of the disease, vast arrays of various tissues and, above all, muscles are involved in the infectious process, non-clostridial gangrene develops.

Necrotizing fasciitis is a synergistic anaerobic-aerobic rapidly progressive purulent-necrotic process with damage to the superficial fascia of the body. In addition to anaerobic non-clostridial infection, the causative agents of the disease are often streptococci, staphylococci, enterobacteria and Pseudomonas aeruginosa, usually determined in association with each other. In most cases, the underlying areas of fiber, skin, and superficial layers of muscles are secondary involved in the inflammatory process. Necrotizing fasciitis usually develops after soft tissue injury and surgery. Minimal external signs of infection usually do not correspond to the severity of the patient's condition and those massive and widespread tissue destruction that are detected intraoperatively. Delayed diagnosis and late surgical intervention often lead to a fatal outcome of the disease.

Fournier's syndrome (Fournier J., 1984) is a type of anaerobic infection. It is manifested by progressive necrosis of the skin and deeper tissues of the scrotum with rapid involvement of the skin of the perineum, pubis, and penis into the process. Often formed wet anaerobic gangrene of perineal tissues (Fournier gangrene). The disease develops spontaneously or as a result of a small injury, acute paraproctitis or other purulent diseases of the perineum and proceeds with severe symptoms of toxemia and septic shock. Often it ends in the death of patients.

In a real clinical situation, especially in the late stages of the infectious process, it can be quite difficult to distinguish between the clinical and morphological forms of diseases described above, caused by anaerobes and their associations. Often, during surgery, a lesion of several anatomical structures in the form of necrotizing fasciocellulitis or fasciomyositis. Often, the progressive nature of the disease leads to the development of non-clostridial gangrene involving the entire thickness of soft tissues in the infectious process.

The purulent-necrotic process caused by anaerobes can spread to soft tissues from the side of the internal organs of the abdominal and pleural cavities affected by the same infection. One of the factors predisposing to this is inadequate drainage of a deep purulent focus, for example, in pleural empyema and peritonitis, in the development of which anaerobes are involved in almost 100% of cases.

Anaerobic infection is characterized by a rapid onset. Symptoms of severe endotoxicosis (high fever, chills, tachycardia, tachypnea, lack of appetite, lethargy, etc.) usually come to the fore, which often precede the development of local signs of the disease by 1-2 days. At the same time, part of the classic symptoms of purulent inflammation (edema, hyperemia, soreness, etc.) disappears or remains hidden, which makes it difficult to timely prehospital, and sometimes nosocomial, diagnosis of anaerobic phlegmon and delays the start of surgical treatment. It is characteristic that often the patients themselves, until a certain time, do not associate their "malaise" with the local inflammatory process.

In a significant number of observations, especially with anaerobic necrotizing fasciocellulitis or myositis, when only moderate hyperemia or tissue edema in the absence of fluctuations prevails in local symptoms, the disease proceeds under the guise of another pathology. These patients are often hospitalized with a diagnosis of erysipelas, thrombophlebitis, lymphovenous insufficiency, ileofemoral thrombosis, deep vein thrombosis of the lower leg, pneumonia, etc., and sometimes in non-surgical departments of the hospital. Late diagnosis of a severe soft tissue infection is fatal for many patients.

How is anaerobic infection recognized?

Anaerobic infection of soft tissues is differentiated with the following diseases:

• purulent-necrotic lesions of soft tissues of another infectious etiology;
• various forms of erysipelas (erythematous-bulous, bullous-hemorrhagic);
• soft tissue hematomas with symptoms of intoxication;
• cystic dermatosis, severe toxic dermatitis (polymorphic exudative erythema, Steven-Johnson syndrome, Lyell's syndrome, etc.);
• deep vein thrombosis of the lower extremities, ileofemoral thrombosis, Paget-Schretter syndrome (subclavian vein thrombosis);
• syndrome of prolonged tissue crushing on early stages diseases (at the stage purulent complications accession of anaerobic infection is determined, as a rule);
• frostbite II-IV degree;
• gangrenous-ischemic changes in soft tissues against the background of acute and chronic thrombobliterating diseases of the arteries of the extremities.

Infectious soft tissue emphysema, which develops as a result of the vital activity of anaerobes, must be differentiated from emphysema of another etiology associated with pneumothorax, pneumoperitoneum, perforation of hollow abdominal organs into retroperitoneal tissue, surgical interventions, washing wounds and cavities with a solution of hydrogen peroxide, etc. In this case, in addition to crepitus soft tissues usually lack local and general signs of anaerobic infection.

The intensity of the spread of the purulent-necrotic process during anaerobic infection depends on the nature of the interaction of the macro- and microorganism, on the ability of the immune defense to resist the factors of bacterial aggression. A fulminant anaerobic infection is characterized by the fact that already during the first day a widespread pathological process develops that affects tissues over a large area and is accompanied by the development of severe sepsis, uncorrectable MOF and septic shock. This malignant variant of the course of infection leads to the death of more than 90% of patients. At acute form diseases such disorders in the body develop within a few days. Subacute anaerobic infection is characterized by the fact that the relationship between the macro- and microorganism is more balanced, and with timely complex surgical treatment, the disease has a more favorable outcome.

Microbiological diagnostics of anaerobic infection is extremely important not only due to scientific interest, but also necessary for practical needs. Until now, the clinical picture of the disease is the main method for diagnosing anaerobic infections. However, only microbiological diagnostics with the identification of the causative agent of the infection, it is able to give an answer about the participation of anaerobes in the pathological process. Meanwhile, the negative answer of the bacteriological laboratory by no means rejects the possibility of the participation of anaerobes in the development of the disease, since, according to some data, about 50% of anaerobes are uncultivated.

Anaerobic infection is diagnosed by modern high-precision indication methods. These primarily include gas-liquid chromatography (GLC) and mass spectrometry, based on the registration and quantitative determination of metabolites and volatile fatty acids. The data of these methods correlate with the results of bacteriological diagnostics in 72%. The sensitivity of GLC is 91-97%, the specificity is 60-85%.

Other promising methods for isolating anaerobic pathogens, including those from blood, include the Lachema, Bactec, Isolator systems, staining preparations for the detection of bacteria or their antigens in the blood with acridine yellow, immunoelectrophoresis, enzyme immunoassay, and others.

An important task of clinical bacteriology at the present stage is the expansion of studies of the species composition of pathogens with the identification of all species involved in the development of the wound process, including anaerobic infection.

It is believed that most soft tissue and bone infections are of a mixed, polymicrobial nature. According to V.P. Yakovlev (1995), with extensive purulent diseases of soft tissues, obligate anaerobes occur in 50% of cases, in combination with aerobic bacteria in 48%, in monoculture anaerobes are detected only in 1.3%.

However, it is difficult to determine the true ratio of the species composition with the participation of facultative anaerobic, aerobic and anaerobic microorganisms in practice. To a large extent, this is due to the difficulty of identifying anaerobic bacteria due to some objective and subjective reasons. The former include the capriciousness of anaerobic bacteria, their slow growth, the need for special equipment, highly nutritious media with specific additives for their cultivation, etc. The latter include significant financial and time costs, the need for strict adherence to protocols for multi-stage and multiple studies, and a shortage of qualified specialists.

However, in addition to academic interest, the identification of anaerobic microflora is of great clinical significance both in determining the etiology of the primary purulent-necrotic focus and sepsis, and in constructing medical tactics including antibiotic therapy.

Below are standard schemes for studying the microflora of a purulent focus and blood in the presence of clinical signs of anaerobic infection, used in the bacteriological laboratory of our clinic.

Each study begins with a Gram-stained smear-imprint from the deep tissues of the purulent focus. This study is one of the methods for express diagnosis of wound infections and can give an approximate answer about the nature of the microflora present in the purulent focus within one hour.

Be sure to use means to protect microorganisms from the toxic effects of oxygen, for which they use:

• microanaerostat for cultivating crops;
• commercial gas packs (GasPak or HiMedia) to create conditions for anaerobiosis;
• indicator of anaerobiosis: sowing P. aeruginosa on Simons citrate under anaerobic conditions (P. aeruginosa does not utilize citrate, while the color of the medium does not change).

Immediately after the operation, smears and biopsy specimens from the deep sections of the wound taken from one locus are delivered to the laboratory. For the delivery of samples, special transport systems of several types are used.

If bacteremia is suspected, blood is sown in parallel in 2 vials (10 ml each) with commercial media for testing for aerobic and anaerobic microorganisms.

Sowing is carried out with disposable plastic loops for several media:

1. on freshly spilled Schedler blood agar with the addition of vitamin K + hemin complex - for cultivation in a microanaerostat. At primary seeding, a kanamycin disk is used to create elective conditions (most anaerobes are naturally resistant to aminoglycosides);
2. on 5% blood agar for aerobic culture;
3. on the enrichment medium for cultivation in a microanaerostat (the probability of pathogen isolation increases, thioglycol or iron-sulfite if clostridial infection is suspected.

The microanaerostat and a dish with 5% blood agar are placed in a thermostat and incubated at +37 C for 48-72 hours. Smears delivered on glasses are Gram-stained. It is advisable to take several swabs of the wound discharge during the operation.

Already with microscopy, in some cases it is possible to make a presumptive conclusion about the nature of the infection, since certain types of anaerobic microorganisms have a characteristic morphology.

Obtaining a pure culture confirms the diagnosis of clostridial infection.

After 48-72 hours of incubation, the colonies grown under aerobic and anaerobic conditions are compared by their morphology and by the results of microscopy.

Colonies grown on Schedler agar are tested for aerotolerance (several colonies of each type). They are seeded in parallel sectors on two plates: with Schaedler agar and 5% blood agar.

Colonies grown on the respective sectors under aerobic and anaerobic conditions are considered indifferent to oxygen and are examined according to existing methods for facultative anaerobic bacteria.

Colonies that have grown only under anaerobic conditions are regarded as obligate anaerobes and are identified based on:

• morphology and size of colonies;
• the presence or absence of hemolysis;
• the presence of pigment;
• ingrowth into agar;
• catalase activity;
• generic sensitivity to antibiotics;
• cell morphology;
• biochemical features of the strain.

The identification of microorganisms is greatly facilitated by the use of commercial test systems containing more than 20 biochemical tests, which make it possible to determine not only the genus, but also the type of microorganism.

Micropreparations of some types of anaerobes isolated in pure culture are presented below.

Detection and identification of an anaerobic pathogen from the blood is possible in rare cases, such as P. niger culture isolated from the blood of a patient with a picture of severe wound anaerobic sepsis on the background of phlegmon of the thigh.

Sometimes, microorganism associations may contain contaminants that do not have an independent etiological role in the infectious and inflammatory process. The isolation of such bacteria in monoculture or in association with pathogenic microorganisms, especially when analyzing biopsy specimens from deep wounds, may indicate a low nonspecific resistance of the organism and, as a rule, is associated with a poor prognosis of the disease. Similar results bacteriological research not uncommon in severely debilitated patients, in patients with diabetes mellitus, with immunodeficiency states against the background of various acute and chronic diseases.

In the presence of a purulent focus in soft tissues, bones or joints and a clinical picture of anaerobic infection (clostridial or non-clostridial), the overall frequency of isolation of anaerobes, according to our data, is 32%. The frequency of detection of obligate anaerobes in the blood in these diseases is 3.5%.

How is anaerobic infection treated?

Anaerobic infection is mainly treated with surgical intervention and complex intensive care. The surgical treatment is based on radical HOGO with subsequent re-treatment of a large wound and its closure with available plasty methods.

The time factor in the organization of surgical care plays an important, sometimes decisive, role. Delaying the operation leads to the spread of infection over large areas, deterioration of the patient's condition and an increase in the risk of the intervention itself. The steadily progressing nature of the course of anaerobic infection is an indication for emergency or urgent surgical treatment, which should be performed after a short preliminary preoperative preparation, which consists in the elimination of hypovolemia and gross violations of homeostasis. In patients with septic shock, surgery is possible only after stabilization blood pressure and resolution of oligoanuria.

Clinical practice has shown that it is necessary to abandon the so-called “lamp” incisions, widely accepted several decades ago and not forgotten by some surgeons so far, without performing necrectomy. Such tactics lead to the death of patients in almost 100% of cases.

During surgical treatment, it is necessary to perform a wide dissection of the tissues affected by the infection, with the incisions reaching the level of visually unchanged areas. The spread of anaerobic infection is characterized by pronounced aggressiveness, overcoming various barriers in the form of fascia, aponeuroses and other structures, which is not typical for infections that occur without the dominant participation of anaerobes. Pathological changes in the focus of infection can be extremely heterogeneous: areas of serous inflammation alternate with foci of superficial or deep tissue necrosis. The latter can be separated from each other by considerable distances. Maximum pathological changes tissues in some cases are detected far from the entrance gate of infection.

In connection with the noted features of the spread in anaerobic infections, a thorough revision of the focus of inflammation should be carried out with a wide mobilization of skin-fat and skin-fascial flaps, dissection of the fascia and aponeuroses with a revision of intermuscular, paravasal, paraneural fiber, muscle groups and each muscle separately. Insufficient revision of the wound leads to an underestimation of the prevalence of phlegmon, the volume and depth of tissue damage, which leads to insufficiently complete CHO and the inevitable progression of the disease with the development of sepsis.

With CHOGO, it is necessary to remove all non-viable tissues, regardless of the extent of the lesion. Skin lesions of pale cyanotic or purple color are already deprived of blood supply due to vascular thrombosis. They should be removed as a single block with the underlying fatty tissue. All affected areas of the fascia, aponeuroses, muscles and intermuscular tissue are also subject to excision. In areas adjacent to the serous cavities, large vascular and nerve trunks, joints, with necrectomy, it is necessary to exercise some restraint.

After radical XOGO, the edges and bottom of the wound should be visually unchanged tissues. The area of ​​the wound after surgery can occupy from 5 to 40% of the body surface. One should not be afraid of the formation of very large wound surfaces, since only a complete necrectomy is the only way out to save the patient's life. Palliative surgical treatment inevitably leads to the progression of phlegmon, systemic inflammatory response syndrome and worsening of the prognosis of the disease.

With anaerobic streptococcal cellulitis and myositis in the stage of serous inflammation, surgical intervention should be more restrained. Wide dilution of skin-fat flaps, circular exposure of the group of affected muscles with dilution of intermuscular fiber is sufficient to stop the process with adequate intensive detoxification and directed antibiotic therapy. With necrotic cellulitis and myositis, surgical tactics are similar to those described above.

With clostridial myositis, depending on the volume of the lesion, a muscle, a group or several muscle groups, non-viable areas of the skin, subcutaneous fat and fascia are removed.

If, during revision of the surgical wound, a significant amount of tissue damage (gangrene or the possibility of the latter) is revealed with little prospect of preserving the functional ability of the limb, then amputation or disarticulation of the limb is indicated in this situation. Radical intervention in the form of limb truncation should also be resorted to in patients with extensive damage to the tissues of one or more segments of the limb with symptoms of severe sepsis and uncorrectable MOF, when the prospect of saving the limb is fraught with the loss of the patient's life, as well as with a fulminant course of anaerobic infection.

Amputation of a limb in anaerobic infection has its own characteristics. It is carried out in a circular way, without the formation of musculocutaneous flaps, within healthy tissues. To obtain a longer limb stump, A.P. Kolesov et al. (1989) propose to perform amputation at the border of the pathological process with dissection and dilution of the soft tissues of the stump. In all cases, the wound of the stump is not sutured, it is carried out openly with loose tamponade with water-soluble ointments or iodophor solutions. The group of patients who underwent limb amputation is the most severe. Postoperative mortality, despite ongoing complex intensive therapy, remains high - 52%.

Anaerobic infection is characterized by the fact that the inflammation is of a prolonged nature with a slowdown in the change of phases of the wound process. The phase of cleansing the wound from necrosis is sharply prolonged. The development of granulations is delayed due to the polymorphism of the processes occurring in soft tissues, which is associated with gross microcirculatory disorders, secondary infection of the wound. Associated with this is the need for repeated surgical treatment of a purulent-necrotic focus (Fig. 3.66.1), in which secondary necrosis is removed, new purulent streaks and pockets are opened, thorough debridement of the wound using additional methods of exposure (ultrasonic cavitation, treatment with a pulsating jet antiseptic, ozonation, etc.). The progression of the process with the spread of anaerobic infection to new areas is an indication for an emergency repeated CHOGO. Refusal of staged necrectomy is possible only after persistent relief of the local purulent-inflammatory process and SIRS phenomena.

The immediate postoperative period in patients with severe anaerobic infection takes place in the intensive care unit, where intensive detoxification therapy, antibiotic therapy, treatment of multiple organ dysfunction, adequate pain relief, parenteral and enteral tube nutrition, etc. are carried out. dynamics during the wound process, completion of the stage of repeated surgical treatment of the purulent focus, and sometimes plastic interventions, persistent clinical and laboratory elimination of PON phenomena.

Antibiotic therapy is an important link in the treatment of patients with a disease such as anaerobic infection. Given the mixed microbial etiology of the primary purulent-necrotic process, first of all, broad-spectrum drugs are prescribed, including anti-anaerobic drugs. The following drug combinations are most commonly used: II-IV generation cephalosporins or fluoroquinolones in combination with metronidazole, dioxidine or clindamycin, carbapenems in monotherapy.

Monitoring the dynamics of the course of the wound process and sepsis, microbiological monitoring of discharge from wounds and other biological media make it possible to make timely adjustments to the change in the composition, dosage and methods of antibiotic administration. Thus, during the treatment of severe sepsis against the background of anaerobic infection, antibiotic therapy regimens can change from 2 to 8 or more times. Indications for its cancellation are persistent relief of inflammation in the primary and secondary purulent foci, wound healing after plastic surgery, negative results of blood cultures and the absence of fever for several days.

An important component of the complex surgical treatment of patients with anaerobic infection is local treatment wounds.

The use of one or another dressing agent is planned depending on the stage of the wound process, pathomorphological changes in the wound, the type of microflora, as well as its sensitivity to antibiotics and antiseptics.

In the first phase of the wound process in case of an anaerobic or mixed infection, the drugs of choice are hydrophilic-based ointments with anti-anaerobic action - dioxicol, streptonitol, nitacid, iodopyrone, 5% dioxidine ointment, etc. In the presence of gram-negative flora in the wound, they are used as hydrophilic-based ointments, and antiseptics - 1% solutions of iodophors, 1% solution of dioxidine, solutions of miramistin, sodium hypochlorite, etc.

In recent years, we have widely used modern application-sorption therapy of wounds with biologically active swelling sorbents of multicomponent action on the wound process such as lysosorb, colladia-sorb, diotevin, anilodiotevin, etc. These agents cause a pronounced anti-inflammatory, hemostatic, anti-edematous, antimicrobial effect on almost all types bacterial flora, allow necrolysis, turn the wound discharge into a gel, absorb and remove toxins, decay products and microbial bodies outside the wound. The use of biologically active draining sorbents makes it possible to stop the purulent-necrotic process, inflammation in the wound area in the early stages and prepare it for plastic closure.

The formation of extensive wound surfaces resulting from the surgical treatment of a widespread purulent focus creates the problem of their speedy closure with various types of plastic surgery. It is necessary to perform plastic surgery as early as possible, as far as the condition of the wound and the patient allows. In practice, it is possible to carry out plastic surgery not earlier than the end of the second - the beginning of the third week, which is associated with the above-described features of the course of the wound process in anaerobic infection.

Early plastic festering wound is considered one of the most important elements of the complex surgical treatment of anaerobic infections. The rapid elimination of extensive wound defects, through which a massive loss of proteins and electrolytes occurs, contamination of the wound with hospital polybiotic-resistant flora with the involvement of tissues in the secondary purulent-necrotic process, is a pathogenetically justified and necessary surgical measure aimed at treating sepsis and preventing its progression.

In the early stages of plasty, it is necessary to use simple and least traumatic methods, which include plasty with local tissues, dosed tissue stretching of tissues, ADP, a combination of these methods. Complete (simultaneous) skin grafting can be performed in 77.6% of patients. In the remaining 22.4% of patients, the wound defect, due to the peculiarities of the course of the wound process and its vastness, can only be closed in stages.

Mortality in the group of patients who underwent a complex of plastic interventions is almost 3.5 times lower than in the group of patients who did not undergo plastic surgery or were performed at a later date, respectively, 12.7% and 42.8%.

The overall postoperative mortality in severe anaerobic infection of soft tissues, with the prevalence of purulent-necrotic focus on an area of ​​more than 500 cm 2 is 26.7%.

Knowledge of the clinical features of the course allows a practical surgeon to identify such a life-threatening disease as anaerobic infection at an early stage and plan a set of response diagnostic and therapeutic measures. Timely radical surgical treatment of a large purulent-necrotic focus, repeated staged necrectomy, early skin grafting in combination with multicomponent intensive therapy and adequate antibacterial treatment can significantly reduce mortality and improve treatment outcomes.

Anaerobic infection (synonyms: gas infection, gas gangrene, anaerobic myositis; old names: Antonov fire, malignant edema, local stupor - N. And Pirogov) is a complex complex reaction of the body in response to damage and infection by specific pathogens. It is one of the heaviest and dangerous complications wounds.

Anaerobic infection is rare, its occurrence is usually associated with a violation of the requirements of antisepsis and asepsis when performing surgical and general medical procedures.

Etiology. The causative agents of anaerobic infection (clostridial form) are specific pathogens - Clostridium of the so-called "Group of Four": Clostridium perfringens, Clostridium oedematiens, Vibrion septicum, Clostridium hystolitium. All of these microorganisms are spore-bearing obligate anaerobes that secrete strong exotoxins. They are widely distributed in the environment; in large quantities they saprophytize in the intestines of mammals, from where they enter the soil with feces, seeding it. Clostridial anaerobe spores are highly resistant to chemical and thermal factors.

The most important is Clostridium perfringens, the frequency of which in anaerobic infections reaches 90%.

Pathogenesis. The first link in the development of the considered pathological process is the presence of favorable conditions for the mass reproduction of clostridial microflora. These conditions include: the nature and localization of the wound, the state of the central and peripheral circulation, the individual characteristics of the body, specific environmental conditions.

When considering these conditions, it is apparently necessary to remember that Clostridia of the "group of four", being obligate anaerobes, cannot multiply not only in living, normally oxygenated tissues, but also in dead tissues freely in contact with the outside air. Therefore, the main local factors in the wound that contribute to the development of anaerobic gangrene are: a) a large volume of necrotic and poorly oxygenated tissues and b) a deep wound channel, a wound cavity that does not communicate well with the external environment. Each of these factors should be considered in more detail.

The volume of necrosis in the wound depends primarily on the characteristics of the injury. Stab and cut wounds are almost never complicated by anaerobic gangrene.

The greatest amount of necrosis in the wound occurs when large muscle masses are damaged, which, due to the peculiarities of their structure, are damaged by the action of a side impact over a large area. In addition, muscles are rich in glycogen, which, under anaerobic conditions, is perfectly absorbed by clostridia. In general, any features of damage that contribute to circulatory disorders in the wound and its circumference and, therefore, increase the amount of necrosis, contribute to the development of anaerobic gangrene.

Damage to the main vessels of the extremities increases the frequency of anaerobic gangrene by 8 times. The rarity of anaerobic gangrene in case of injuries to the body, including those abundantly seeded with pathogenic anaerobes, is explained to a greater extent by the fact that the muscles there, unlike the muscles of the limbs, are supplied with blood not from the main vessel, but from many sources.

General circulatory disorders in wounds, mainly associated with blood loss and leading to a significant deterioration in microcirculation, in particular in damaged tissues and around the wound, also significantly increase the risk of anaerobic gangrene. Often, an increase in the volume of necrosis and, consequently, gas infection is facilitated by cooling (frostbite) of the injured limb.

The second factor in the wound, contributing, as already mentioned, to the development of anaerobic infection, is the significant depth of the wound channel and its insufficient communication with the external environment.

The communication of the wound channel with the external environment is prevented by its primary and secondary deviations, primary traumatic edema, tight tamponade of an untreated or poorly treated wound for the purpose of hemostasis, a tight bandage and some other factors.

At the heart of pathoanatomical changes in anaerobic infection is acute serous-alternative inflammation, accompanied by progressive tissue necrosis in the circumference of the wound channel and severe general intoxication.

Reproduction of causative agents of anaerobic infection begins in areas of traumatic necrosis and is accompanied by the rapid formation of microbial exotoxins (hemolysin, myotoxins, neurotoxins, etc.), which have a detrimental effect on tissues around the wound and cause severe general poisoning of the body.

Clostridia, causing progressive necrosis, primarily muscle tissue, with the help of exotoxins, as if preparing a new substrate for their development, as a result of which the process spreads rapidly.

As a result of exposure to microbial toxins, profuse serous hemorrhagic edema rapidly develops, leading to an increase in pressure inside the fascial sheaths, resulting in ischemia of the muscle tissue. In addition, as a result of toxic effects on the vascular wall, vein thrombosis quickly sets in, which also impairs blood circulation.

As a result of exposure to toxins in the affected area, hemolysis develops, the products of which, together with the breakdown products of muscles (myoglobin), imbibe fiber and skin, causing the appearance of brown, bronze or bluish spots.

The rapidly progressing local process in the wound area is accompanied by intensive resorption of microbial toxins and tissue decay products into the bloodstream. As a result, general intoxication and dysfunction of a number of vital organs and systems develop. The phenomena of intoxication are supplemented by severe disorders of the water and electrolyte balance, to a greater extent dependent on abundant exudation in the affected area. As a result of intoxication and dehydration of the body, death occurs.

In cases where, under the influence of therapeutic measures, anaerobic gangrene is stopped and the spread of the process stops, dead muscles begin to disintegrate under the influence of putrefactive microflora or purulently melt under the influence of pyogenic microorganisms. Demarcation inflammation develops (absent during the progression of anaerobic infection), the wound is gradually cleared and heals by secondary intention. Wound cleansing after anaerobic infection under the influence of pyogenic microflora usually proceeds clinically more favorably, however, in this case, the process can proceed with severe purulent-resorptive fever, and sometimes with the development of sepsis, sharply weakened by the previous complication.

When examining blood, a rapidly growing anemia is determined, due to intravascular hemolysis, under the influence of toxins and suppression of the function of hematopoietic organs. A high leukocytosis with a degenerative shift of the leukocyte formula to the left is characteristic. In especially severe cases, leukopenia occurs. Diuresis usually decreases despite heavy drinking. Protein and casts appear in the urine.

When removing the bandage and examining the area of ​​damage, the dry, lifeless appearance of the wound attracts attention. Damaged muscles have a "boiled" or sometimes even "smoked" appearance. They are edematous and, as if they do not fit in the wound, they bulge out of the wound defect. Cellulose is also edematous, has a jelly-like appearance, and is imbibed with blood.

In the circles of the wound, there is a pronounced and rapidly spreading edema in the proximal direction. The entire segment of the limb, and sometimes the entire limb, increases in volume. On the skin, traces of the bandage that has become tight and embedded are visible.

The skin is usually cold to the touch, pale. Often, bronze or bluish spots are visible on it due to imbibition by hemoglobin transformation products. Often translucent bluish network of dilated and thrombosed superficial veins.

With emphysematous forms of anaerobic infection under the fingers of the examiner, a characteristic crunch, crepitus are determined. When shaving the skin around the wound, a high-pitched metallic sound is heard (“razor symptom”). Tapping with a spatula or other instrument reveals a characteristic, also with a metallic tint, tympanitis (“spatula symptom”). The accumulation of gas in the wound channel can cause the typical popping sound when the tampon is removed from the wound (“champagne cork symptom”).

So, the characteristic pathogenetic and clinical features of anaerobic surgical infection are:

1. Toxin formation, which suppresses the protective response of the body;

2. Weak inflammatory response (short-term or absent);

3. Development of progressive edema in the proximal direction as a result of the influence of specific toxins (develops within a few hours).

4. Rapidly developing tissue necrosis due to progressive gas formation, increased interstitial pressure, and circulatory disorders.

5. Absence of cellular and granulation barriers (instant generalization of the process).

6. Isolation of ichorous exudate from the wound cavity in the form of "meat slops" with a putrid odor.

7. Rapidly growing intoxication.

8. Suppressed antitoxic function of the liver, immunogenesis.

9. A sharp decrease in the number of red blood cells, up to 1 million; the decrease in the amount of hemoglobin is less by 20-60%.

10 Oppression general condition, temperature increase (by 1.5 - 2.5 ° C), increased heart rate and respiration.

By clinical manifestation anaerobic infection in animals occurs in the form of gas abscess, gas gangrene, gas phlegmon and malignant edema (these are clinical forms of anaerobic infection).

Gas abscess develops more often in cattle and pigs after stab wounds or injections. It is formed quickly, without signs of inflammation, but at a high general body temperature.

Gas gangrene is caused in 92% of cases by B. perfingens, in 35% of cases by B. oedematiens. They can be combined with putrefactive infection (B. purtrificus, B. sporogenus). The muscles are predominantly affected. 24-48 hours after infection of the wound, cold edema develops, progressive necrosis, blood circulation stops, blood clots form - gangrene develops, and body parts die in 2-3 days and sepsis occurs (usually 3-5 days after the onset of the disease). Characteristic: painless, cold edema, gaseous crepitus, blue-purple spots on the skin, fetid exudate, with gas. Swollen muscles have a lifeless appearance, dull color, lack elasticity, brittle, disintegrate when captured with tweezers, bloodless and without discharge, sometimes there is a scanty, brownish exudate.

Gas phlegmon is caused by the same pathogens in combination with streptococci and staphylococci. Loose tissue is mainly affected. At the beginning, it develops as a purulent phlegmon, i.e., inflammatory edema, local pain, but then the inflammatory reaction with phagocytosis is suppressed (due to the action of anaerobic toxins) and gangrenous decay and accumulation of gases develop in the center of the swelling. Due to the absence of a granulation barrier, diffuse fusion of the tissue occurs. Rapidly increasing edema, moderate inflammatory reaction and soreness are characteristic. They are observed along the periphery, and in the center - progressive necrosis.

Malignant edema - more common in sheep after shearing and castration. Pathogens: Vibrion septicus (toxic edema) and B. oedematiens (gas edema stick) - causes hemolysis of erythrocytes, inhibits phagocytosis, causes bloody-serous edema and toxicosis. Characteristic: after a few hours, or 1-2 days, the appearance of progressive edema, at the beginning of a warm, then cold, painless. An odorless exudate flows from the wound. With a high body temperature and a sharp depression, death occurs within 1 to 2 days.

A putrefactive infection develops under the influence of facultative anaerobes B. coli, B. putrificus, B. proteus vulgaris, etc., often found in association with streptococci and staphylococci. This infection is characterized by the putrefaction of tissues with the formation of a hemorrhagic, foul-smelling exudate called ichor. At first, it has a gray-bloody color, and then acquires the color of meat slops.

Pathogenesis. Putrefactive microbes of the intestinal tract with dysbacteriosis and violation of the intestinal barrier can penetrate into the internal environment of the body and cause endogenous putrefactive infection. This is observed with intussusceptions, infringements of the intestine and its wounds. Exogenous putrefactive infection occurs in severe wounds with crushing of tissues and the formation of significant niches and pockets. Putrefactive microbes live and multiply in dead tissues; they do not penetrate into healthy tissues. Thus, for the development of a putrefactive infection, first of all, dead tissues or decomposing blood clots are needed in case of impaired blood circulation and lack of oxygen in the wound environment. Under such conditions, under the influence of enzymes secreted by putrefactive microbes, the decay of dead tissues occurs. This is accompanied by the accumulation of extremely poisonous protamines and toxalbumins, gas and ichor in the focus of infection. The products of tissue decay sharply reduce the inflammatory response, phagocytosis, the protective function of the local tissue and completely suppress the life of cells in the zone of direct impact; absorbed into the blood, they cause severe intoxication of the body, sharply reduce the function nervous system and internal organs, causing degenerative degeneration and necrosis in the latter.

Clinical signs . Initially putrefactive infection manifests itself in the form of progressive inflammatory edema. In the presence of a wound, liquid ichor begins to stand out from it on the second day. Dead tissues are flabby. Sprawling, greenish-gray and black-brown. Arrosional bleeding is observed. The granulations formed before the development of the infection are necrotic, and the process passes to the deeper tissues and organs. In a short time, tendons, tendon sheaths, muscles die, and the process, expanding, captures more and more new parts of the body; hooves and phalanges of fingers fall off on the limbs. All these changes are accompanied by severe intoxication of the body, high temperature body, rapid pulse and breathing; the state of the animal is severely depressed.

The prognosis is cautious or unfavorable. In advanced cases, treatment does not bring positive results.

Treatment of anaerobic and putrefactive infections must necessarily be complex and must include surgical intervention. Surgical treatment for anaerobic and putrefactive infections should be combined with the most active general treatment directed: a) to suppress the vital activity of infectious agents; b) to increase the body's resistance, c) to eliminate the pathological changes caused by the disease.

Surgical intervention for anaerobic gangrene should be performed immediately after the diagnosis is established, since even a delay of one or two, and even more so, for several hours, significantly reduces the chances of recovery.

Features of surgical treatment of anaerobic and putrefactive infections:

Wide, so-called "lamp" incisions, carried out longitudinally through the entire affected segment of the limb. Usually, depending on the spread of the lesion, 2-3 such incisions are made, and one of them must pass through the wound, opening it to its full depth. Incisions can play a certain role in terms of ensuring the outflow of edematous fluid containing toxic products. However, their significance in this respect is limited, since exudate in anaerobic gangrene, in contrast to what occurs with purulent infection, is closely associated with tissues and cannot flow freely from them.

Carrying out "lamp" incisions ends with infiltration of the tissues of the affected limb segment with a solution of penicillin or its durant preparations and loose tamponade of wounds with gauze, which most authors recommend moistening with oxidizing agents (solutions of potassium permanganate, hydrogen peroxide, etc.).

Excision of affected muscles and other tissues is a more radical operation than incisions. However, feasible only with a limited distribution of the process.

Amputations and disarticulations of the extremities are the most radical methods of treatment of anaerobic infections, which give a favorable result in terms of saving life in cases where they are carried out early enough, before the spread of the infectious process to the trunk. Therefore, this type of surgical treatment should be used only in cases where it is absolutely necessary.

Antimicrobial treatment for anaerobic gangrene consists primarily in passive penicillin therapy. Topically, penicillin is used to infiltrate tissues in the area of ​​the wound or stump during amputation. In this case, penicillin is administered intramuscularly and intravenously in large doses (600 million units or more per day). Regional administration of antibiotics is also recommended.

To maintain homeostasis, sharply disturbed by the anaerobic process, it is necessary to carry out massive infusion therapy, which aims to replenish large fluid losses, as well as detoxification by stimulating diuresis and excreting toxic products in the urine.

To combat the growing anemia, repeated blood transfusions are also carried out.

Prevention: Anaerobic infection is of the utmost importance. It is based, as it should be clear from the section on pathogenesis, early radical surgical treatment of wounds with opening of the wound channel and possibly more complete excision of non-viable tissues, which are the substrate for the start of mass reproduction of pathogenic anaerobes.

Anaerobic infection in surgery

1. Historical background

2. Information on etiology and pathogenesis

3. Clinical data

4. Diagnostics (bacteriological, GLC)

5. Treatment

6. Conclusion

In 1952, Ambroise Pare first described an anaerobic infection, calling it hospital gangrene. In the domestic literature, N.I. Pirogov described in detail its clinical picture. Synonyms for the term "anaerobic infection" are: gas gangrene, anaerobic gangrene, hospital gangrene, blue or bronze mug, anton fire, etc. By the way, the famous literary hero Bazarov, judging by the description, died precisely from anaerobic gangrene. According to recent studies published in the journal "Clinical Surgery" in 1987, 1 A.S. Pushkin also died from a gas infection as a result of a gunshot wound with crushing of the right iliac and sacral bones and damage to a large array of muscles.

According to modern concepts, anaerobes and their associations with aerobes occupy one of the leading places in human infectious pathology. Until recently, one of the most pressing problems was the fight against staphylococcus aureus. Over time, the role of gram-negative opportunistic microflora was revealed. Suppurations caused by anaerobic-aerobic microflora require slightly different approaches. Strict anaerobes are elusive by conventional bacteriological methods, doctors are little familiar with them. Without taking into account anaerobes, the etiological diagnosis becomes inaccurate, distorted, and a large group of unregistered infections appears. So, without taking into account the sowing of material from wounds on special media, Staphylococcus aureus is mainly sown / about 70% /, while its true frequency is about 4%.

More than a century and a quarter have passed since Louis Pasteur published materials devoted to the study of anaerobic microorganisms. Emerged at the end of the nineteenth century. clinical microbiology was born as the microbiology of aerobes and anaerobes equally. At the beginning of the twentieth century. diseases caused by anaerobes were separated into an independent section, which included 3 groups of diseases. The largest of them were "banal" purulent-putrefactive processes. The 2nd group according to the characteristics of pathogens and clinics were represented by tetanus and botulism. The 3rd group united clostridial / gas / gangrenes of soft tissues, which then gradually became the dominant form of anaerobic lesions in the view of doctors over many decades. And the vast experience of World Wars 1 and 2 consolidated this, in general, an erroneous position. Now, when discussing anaerobic infections, in the imagination of doctors, fed by the current textbooks and guidelines, gas gangrene occurs, caused by anaerobic gram-positive rods: Clostridium perfringens, Clostridium edematens, Clostridium septicum, Clostridium sporogenes, etc. Extreme severity of the course, the vastness of necrotic changes are attributed to this clostridial infection , gas formation and high lethality.

In fact, clostridia make up only a very small part of the anaerobes found in humans (about 5%/). At the same time, there is a much larger group of anaerobes pathogenic for humans that do not form spores. Among them, representatives of the genera Bacteroides, Fusobacterium (gram-negative rods), Peptococcus & Peptostreptococcus (gram-positive cocci), Enterobacterium, Vellonella, Actinomyces (gram-positive rods), etc. have the greatest clinical significance.

The diseases they cause are often referred to as non-clostridial anaerobic infections. It must be said right away that patients with these infections are not uncommon and often do not have any clinical uniqueness. They represent the majority of everyday surgical infections and may be characterized mainly by local manifestations and a benign course, or have a clinic of severe processes with an unfavorable prognosis.

The role of anaerobes in the occurrence of a wide range of surgical infections has so far been little touched upon in Russian literature. This is due to the difficulties of working with anaerobes. Experience shows that the bulk of infections that occur with the participation of anaerobes are not monomicrobial. Most often they are caused by a combination of anaerobes with aerobes. The predominance of anaerobic microflora becomes quite understandable if we remember that microorganisms belong to the most ancient living beings and they appeared back in those days when the Earth's atmosphere was deprived of oxygen. Therefore, anaerobic metabolism for a long time was the only possible one. Most microorganisms are facultative and moderately obligate anaerobes.

PREVALENCE OF PATHOGENIC ANAEROBES

Anaerobic microorganisms make up the vast majority of normal microflora human body. The skin is populated with anaerobes ten times more than aerobes. The main habitat of anaerobes is the digestive tract, where there are no sterile sections. The flora in the mouth is 99% anaerobic, which is close to the large intestine. The large intestine is the main habitat of anaerobes due to the lack of oxygen and a very low redox potential /-250 mV/. The content of the intestine at 20-405 consists of microorganisms. Of these, 975 are severe anaerobes. The share of Escherichia coli is, contrary to popular belief, only 0.1-0.45.

PATHOGENESIS OF INFECTIONS

As the main conditions for the life of non-spore anaerobes, the following are necessary: ​​1. Negative redox potential of the environment / This potential, or redox potential, determines or is the sum of all redox processes, reactions taking place in a given tissue, environment. It decreases significantly in the presence of blood, hence it is clear that the presence of blood in the abdominal cavity, in the presence of infection, is a very dangerous factor.

2. Oxygen-free atmosphere.

3. The presence of growth factors. For example, in diabetes mellitus, PO2 in soft tissues is 405 below normal. The redox potential of healthy tissue is about +150 mV, while in dead tissue and abscesses it is about -150 mV. In addition, aerobes patronize anaerobes / contribute to the creation of an oxygen-free environment /.

PATHOGENIC FACTORS

1. Specific toxic substances.

2. Enzymes

3. Antigens.

Anaerobic heparinase contributes to the occurrence of thrombophlebitis. The capsule of anaerobes sharply increases their virulence and even brings them to the 1st place in associations. Disease factors have their own characteristic features. The diseases they cause have a number of pathogenetic features.

THE SHARE OF ANAEROBES IN THE MICROBIAL LANDSCAPE OF SURGICAL

INFECTIONS

The largest proportion of anaerobic infections in those areas where anaerobes are more common. They are: 1. Surgery of the gastrointestinal tract

2. Maxillofacial surgery. 3. Neurosurgery 4. ENT diseases

5. Gynecology 6. Soft tissue infections.

For example: brain abscesses - anaerobes in 60%, neck phlegmon in 100%. Aspiration pneumonia - 93%. Lung abscesses - 100%. Abscesses in the abdominal cavity - 90% Appendicular peritonitis - 96%. Gynecological infections - 100% Soft tissue abscesses - 60%.

CLINICAL FEATURES OF ANAEROBIC INFECTIONS

Regardless of the localization of the focus, there are common and very characteristic clinical features of infectious processes that occur with the participation of anaerobes. Many clinical features of this type of infection are explained by the peculiarities of the metabolism of anaerobes, namely, the putrefactive nature of the lesion, gas formation. It is known that putrefaction is a process of anaerobic oxidation of a tissue substrate.

Most persistent symptom: unpleasant, putrid smell of exudate. It was known as early as the end of the 19th century. but as a result of the aerobic shift in clinical microbiology over the years, this symptom has been attributed to Escherichia coli. In fact, not all anaerobes form unpleasantly smelling substances, and the absence of this feature does not yet allow us to completely reject the presence of anaerobes. On the other hand, the stench always indicates its anaerobic origin.

The 2nd sign of anaerobic damage is its putrefactive nature.

Lesions contain dead tissue of a gray, gray-green color.

3rd sign - the color of the exudate - gray-green, brown.

The color is heterogeneous, contains droplets of fat. Pus is liquid, often diffusely impregnating inflamed tissues. Whereas with aerobic suppuration, the pus is thick, the color is uniform, dark yellow, there is no smell. It should be noted that the distinguishing features of certain infections are more clearly manifested in the early stages of the disease.

4th sign - gas formation.

Due to the fact that hydrogen, nitrogen and methane, which are poorly soluble in water, are released during anaerobic metabolism. Gas formation can be in 3 versions:

a/ soft tissue emphysema - crepitus. This symptom is not common.

b/ X-ray determined level at the border of gas-liquid in the abscess.

Most anaerobic infections are endogenous, hence their clinical feature - proximity to the natural habitats of anaerobes - zh.k.t., vdp, genitals. Usually it is possible to trace not only the proximity of the foci to the mucous membranes, but also the damage to these membranes.

Typically, there is also the occurrence of mixed infections at the sites of animal and human bites, as well as on the hand after a blow to the teeth.

Anaerobic infections should be suspected when the pathogen cannot be isolated by conventional methods or when the number of isolated bacteria does not match what is seen under the microscope.

If the patient has two or more of the described signs, then the participation of anaerobes in the process should not be questioned. Bacteriological data only clarify the composition of pathogens. One more important circumstance should be noted.

The proximity of the foci of infection to the mucous membranes makes them hidden. Therefore, the external manifestations of the disease often do not correspond to the extent of the lesion in depth and the general signs of the disease. Clinically, anaerobic phlegmon of soft tissues is a phlegmon, the severity and course of which largely depends on the volume of the affected tissues. The infection may be predominantly localized in

1. subcutaneous tissue,

2. fascia,

3. muscles,

4. hit these structures at the same time.

With damage to the subcutaneous tissue, the skin over this area is usually little changed. There is its dense edema and hyperemia without a clear delimitation. A relatively small change in the skin does not reflect the true extent of damage to the underlying tissues. The pathological process can spread far beyond the primary focus. Adipose tissue appears as foci of melting of a gray-dirty color, the exudate is brown, often with an unpleasant odor, freely flowing into the wound. The presence of dense infiltration of the subcutaneous tissue and areas of darkening or necrosis of the skin due to thrombosis of small vessels indicates the transition of the process to the fascia. The presence in the wound of molten, gray-dirty areas of necrotically altered fascia, brown exudate makes it possible to consider the diagnosis of non-clostridial infection as undoubted. Perhaps a combined lesion of the subcutaneous tissue, fascia and muscles. In this case, the process often goes far beyond the boundaries of the primary focus. Muscles are dull, boiled, saturated with serous-hemorrhagic exudate.

This form of non-clostridial infection is significantly different from clostridial myonecrosis, when there is an acute onset, severe toxemia, gas in the tissues, and pain in the affected area. At the same time, the muscles are swollen, dull, disintegrate when touched, bloodless. Scanty brown exudate with an unpleasant odor. The subcutaneous tissue does little. Skin necrosis usually does not occur. It should be emphasized that in the presence of non-clostridial wound infection, there is almost always a pronounced and combined lesion of the skin, subcutaneous tissue, fascia and muscles. With a process limited only to the area of ​​the wound, the general signs of the disease are usually not very pronounced. General weakness, sometimes pain in the wound area, subfebrile condition. However, in many cases anaerobic non-clostridial infection is acute and spreads fairly quickly. In this case, there is a pronounced intoxication.

Morphological differential diagnosis of clostridial and non-clostridial infections is based on the absence of gas bubbles in the latter, less severity of necrotizing myositis, and the predominance of sero-leukocyte infection of the subcutaneous tissue. The presence of numerous microabscesses indicates the addition of an aerobic infection. With clostridial anaerobic infection, the leukocyte reaction is inhibited, and part of the PMN is in a state of destruction. The inflammatory process is of a prolonged nature, the phases of suppuration and cleansing are significantly prolonged. The formation of granulations slows down.

Anaerobic and mixed soft tissue infections develop in different ways. At the same time, in advanced cases, individual clinical and etiological differences between them are erased and much is lost for the doctor. Therefore, there are many connections between anaerobic infection, putrefactive infection and other suppurations.

Diagnosis and treatment of these potentially fatal diseases are often delayed due to misleading initial manifestations. The clinical diversity of surgical infections requires a unified approach in the early period of diagnosis and treatment. In view of the fact that for the isolation and identification of non-clostridial microflora during bacteriological examination, special equipment is required and a period of 3-5 days in everyday surgical practice to confirm the diagnosis, it is advisable to focus on the results of 1/ Gram-stained smear microscopy and 2/ gas-liquid chromatography / GLC /. These results can be obtained on average within 1 hour. When diagnosing gram-negative anaerobes, the coincidence of the results of microscopy of a native smear with the results of bacterial cultures was noted in 71% of cases. At the same time, it is practically excluded

the possibility of obtaining data on the presence of anaerobic cocci, tk. their morphology is identical to that of anaerobic cocci. In bac.study, anaerobic microorganisms were found in 82% of patients in the presence of clinical data, which indicates a high degree of correlation between clinical and bacteriological data. Acute surgical soft tissue infection involving non-clostridial anaerobes has a predominantly polymicrobial etiology. As for the non-spore-forming anaerobes themselves, 2-3 different types of these bacteria were found in almost half of the patients.

If there is an association of anaerobes and anaerobes, to establish the leading role of world organisms, it is necessary to conduct quantitative studies and additional studies.

GAS-LIQUID CHROMATOGRAPHY

In recent years, it has been established that anaerobic microorganisms in the process of metabolism produce volatile fatty acids - propionic, butyric, isobutyric, valeric, isovvaleric, etc., into the growth medium or into pathologically altered tissues, while aerobic microorganisms do not form such compounds. These volatile metabolites can be detected by GLC within 1 hour providing an answer for the presence of anaerobes. The method makes it possible to judge not only the presence of anaerobes, but also their metabolic activity and, consequently, the real participation of anaerobes in the pathological process.

ISOLATION OF ANAEROBES IN THE LABORATORY

The most acceptable method in the clinic now is the cultivation of anaerobes in anaerostats. 2 requirements must be met: 1/ Avoid accidental contamination; 2/ Prevent loss of the agent from the moment the material is collected.

It is easier to protect anaerobes from the action of oxygen when transporting the material in disposable syringes, but it is better in special sealed vials, such as penicillin. The material is placed in the bottle when punctured. In the vial - transport medium or without it, but mandatory filling with an oxygen-free mixture consisting of 80% nitrogen, 10% hydrogen and 10% carbon dioxide, nitrogen alone can be used.

TREATMENT

In the treatment of patients with anaerobic infection, the statement is more appropriate than ever: "Being restrained in choosing patients for antibacterial chemotherapy, one must be generous in prescribing doses."

Surgical intervention and intensive care with the targeted use of antibiotics are the basis for the treatment of patients with anaerobic infection. Most authors believe that when a clinical diagnosis of "anaerobic infection" is established, an operation is indicated urgently. Publications lack data on a single, unified method of surgical treatment.

According to the Vishnevsky Institute of Surgery, the institution that has perhaps the most experience in the treatment of such patients, urgent surgical intervention is the decisive factor. It should be performed at the first suspicion of a non-clostridial infection without waiting for the results of a complete bacterial study. Postponing intervention while waiting for the action of antibiotics is unacceptable. This will inevitably lead to the rapid spread of infection and the inevitable deterioration of the patient's condition and an increase in the volume and risk of surgical intervention. With the traditional "clostridial" understanding of anaerobic infection, stripe incisions are used as an operational aid. This method has a limited right to exist and is purely auxiliary. In principle, the surgeon should strive for a radical treatment of the focus, which consists, if possible, in obtaining a clean wound. Palliative surgeries resulting in a purulent wound are the least favorable. In non-clostridial soft tissue infection, surgery consists of radical surgical debridement with excision of all non-viable tissues. During surgery, it is necessary to make a wide incision of the skin, starting from the border of its changed color, as well as tissues of the entire affected area with complete removal of the pathologically altered subcutaneous tissue, fascia, muscle without fear of the appearance of an extensive wound surface.

ness. It is important to stop the progression of the infection and save the life of the patient. Skin flaps along the edges of the surgical wound must be widely deployed, placed on sterile gauze rolls and sutured with separate shvamik to nearby areas of unaffected skin. This provides the best aeration of the wound and visual control over the course of the wound process. With such wound management in the postoperative period, it is easy to detect areas of affected tissues that have not been removed during the intervention, which must be removed immediately. Incomplete removal of non-viable tissues leads to the progression of the disease. The surgeon must be guided by the principle of radical excision of all affected tissues, which is the only way to save the patient's life without fear of the formation of an extensive wound surface after the operation. If the entire thickness of the muscles is affected, it is necessary to raise the question of their excision. With the defeat of the limbs - about their amputation. With extensive deep wounds with streaks, it is recommended to use osmotically active ointments, before the transition of the wound process to the II phase. In the future, with positive dynamics of the course of the wound process /usually 8-11 days, it is advisable to close the wound by applying early secondary sutures with flow drainage or perform plastic surgery with soft tissues or autodermoplasty with a free mesh flap.

An obligatory component of treatment is antibiotic therapy. The ideal condition for conducting targeted AB-therapy is the knowledge of the pathogen and its sensitivity to antimicrobial agents and the creation of a therapeutic concentration of the drug in the focus of infection under laboratory control. However, in practice this is not always possible. It is difficult to isolate and identify anaerobes, but it is even more difficult to identify them.

sensitivity to antibiotics. The latter is now within the power of many well-equipped institutions. Therefore, clinicians need to be guided by published literature data. In addition, one should not forget that infections involving anaerobes are usually polymicrobial and require the simultaneous administration of several antibacterial drugs. They are most often prescribed on an emergency basis, in maximum doses and in / in.

In the literature, the judgment that one of the most active and having a wide range of effects on anaerobes is an amntibiotic is clindamycin /hereinafter C/. Therefore, it is recommended for empirical use in anaerobic infections. But given that most of these infections are mixed, therapy is usually carried out with several drugs. For example, crindamycin with an aminoglycoside. Moreover, an aminoglycoside should be prescribed only when prescribing drugs specific to anaerobes. Many strains of anaerobes are suppressed by rifampin, lincomycin, although the latter antibiotic is about 4 times less

active than clindamycin. Benzylpenicillin works well against gram-positive and gram-negative anaerobic cocci. However, there is often intolerance to it. Its substitute is erythromycin, but it has a bad effect on B. fragis and fusobacteria and therefore its use is not recommended for the treatment of these infections. Antibiotic Fortum /England/ is effective against anaerobic cocci and rods. It is combined with aminoglycosides.

Dose: children over 2 months. 30-100 mg/kg per day for 2-3 injections. Up to 2 months 25-60 mg/kg per day for 2c intravenous, intramuscular injections. Cefobid /cephalosporin/ /Belgium/ is also an effective antibiotic against anaerobic cocci and rods. F.v. vials of 1 g. Dose for children: 50-200 mg / kg per day for 2 injections in / in, in / m. Lincocin / contains lincomycin / - is also effective against cocci and anaerobic bacilli. It is prescribed inside, in / m, in / in. 10 mg/kg per day for 2 injections. /F.V. capsules, ampoules of 1 ml soda. 300 mg/. A special place among the drugs used to influence the anaerobic microflora is occupied by metronidazole and other imidazoles close to it. Metronidazole is a metabolic poison for many strict anaerobes and acts bactericidal on Gram-negative rods related to them. Metranidazole also acts on gram-positive forms of bacteria, but much weaker, and its use in such pathogens is not justified.

Metronidazole is recommended to be administered from an initial dose of 15 mg / kg and then at 7.5 mg / kg after 6 hours. Due to its properties, metronidazole, like clindamycin, constitutes another standard chemotherapeutic combination with aminoglycosides in the treatment of anaerobic infection.

Metronidazole is not an AB and many of the problems associated with the determination of sensitivity and the emergence of resistance to it are of relatively minor importance. The dose for adults is 0.75-2.0 g / day. Usually prescribed 0.5-3-4 times a day.

Flagyl /metrogil/ - 300 mg / day.

The plasma concentration of metronidazole after IV administration is approximately equal to that achieved by oral and rectal routes of administration, so parenteral administration is not advantageous when other methods can be used. The IV form is the most expensive and inaccessible. However, it must be borne in mind that with all the advantages of this drug, it penetrates well into all organs and tissues, is not toxic, acts quickly and efficiently, and there are reports of its teratogenicity.

Other imidazoles - ornidazole, tinidazole /tricanix/, niridazole - were close in action to trichopol. Niridazole is more active than metronidazole.

A 1% solution of dioxidine up to 120 ml IV for adults is also used, as well as carbenicillin 12-16 g/day IV for adults. Drugs with a targeted action on anaerobes are used for 5-7 days under the control of GLC.

In the complex treatment of patients with anaerobic infection with beneficial HBO. The positive effect of the use of oxygen is that it helps to achieve delimitation of the process, complements the surgical and antibacterial effects. But you can't put him in 1st place.

With a non-spore-forming infection of soft tissues, there is no need for a special sanitary and hygienic regimen, since there are no specific epidemiological pathways for the spread of infection characteristic of gas gangrene. Therefore, it is believed that patients with this pathology can be treated in the department of purulent surgery. Another thing is that it is not always immediately possible to establish the type of infection.

Summarizing the above, we can conclude that adequate therapy of anaerobic infections is a difficult complex task of an etiotropic, pathogenetic and symptomatic nature. Therapeutic measures should be of a general and local nature, and their core is made up of timely and complete operations, AB therapy. The entire process of managing a patient with a surgical infection can be divided into several stages.

1. Diagnostic. It starts when the patient arrives. Obtaining an accurate and complete etiological and morphological diagnosis of the infection (ideally).

2. Preparatory. Preparing the patient for surgery, and the hospital /department/ - for his treatment. Neglect of such preparation and reliance on incision and drainage leads to tragic consequences. Correction of the patient's homeostasis.

3. Surgical treatment of the focus /central link/. The use of AB, HBO. Surgical treatments are often multiple. When it is possible to quickly and correctly establish the diagnosis and apply adequate treatment, even in severe patients there is a rapid positive trend, and after 5-7 days you can start suturing.

4. Reconstructive stage. Closure of extensive wound surfaces. Mortality in non-clostridial infection according to the literature data ranges from 48 to 60%. Data from the Vishnevsky Institute - 16%. We have 16% for the last 5 years.

Anaerobic infection is a rapidly developing pathogenic process that affects various organs and tissues in the body and often leads to death. It affects all people, regardless of gender or age. Timely diagnosis and treatment can save a person's life.

What it is?

Anaerobes are always present in normal microflora, mucous membranes of the body, in the gastrointestinal tract and genitourinary system. They are classified as conditionally pathogenic microorganisms, since they are natural inhabitants of the biotopes of a living organism.

With a decrease in immunity or the influence of negative factors, bacteria begin to actively multiply uncontrollably, and microorganisms turn into pathogens and become sources of infection. Their waste products are dangerous, toxic and rather aggressive substances. They are able to easily penetrate cells or other organs of the body and infect them.

In the body, some enzymes (for example, hyaluronidase or heparinase) increase the pathogenicity of anaerobes, as a result, the latter begin to destroy muscle fibers and connective tissue, which leads to disruption of microcirculation. Vessels become fragile, erythrocytes are destroyed. All this provokes the development of immunopathological inflammation of blood vessels - arteries, veins, capillaries and microthrombosis.

The danger of the disease is associated with a large percentage of deaths, so it is extremely important to notice the onset of the infection in time and immediately begin its treatment.

Causes of infection

• Creation of suitable conditions for the vital activity of pathogenic bacteria. This may happen:
• when an active internal microflora gets on sterile tissues;
• when using antibiotics that have no effect on anaerobic gram-negative bacteria;
• in case of circulatory disorders, for example, in the case of surgery, tumors, injuries, foreign bodies, vascular diseases, tissue necrosis.
• Infection of tissue by aerobic bacteria. They, in turn, create the necessary conditions for the vital activity of anaerobic microorganisms.
• Chronic diseases.
• Some tumors that are localized in the intestines and head are often accompanied by this disease.

Types of anaerobic infection

Surgical infection or gas gangrene

• increasing pain with a feeling of fullness, since the process of gas formation takes place in the wound;
• fetid smell;
• exit from the wound of a purulent heterogeneous mass with gas bubbles or inclusions of fat.

Anaerobic surgical infection is rare, and its occurrence is directly related to the violation of antiseptic and sanitary standards during surgical operations.

anaerobic clostridial infections

In this case, the pathogen enters the human body from the external environment. For example, these are such pathogens:

• tetanus;
• botulism;
• gas gangrene;
• toxicoinfections associated with the use of low-quality contaminated food.

Anaerobic non-clostridial infections

• (spherical bacteria);
• shigella;
• escherichia;
• yersinia.

In gynecology

Penetration of anaerobic infection into female body contribute to:

• injuries of the soft tissues of the vagina and perineum, for example, during childbirth, during abortions or instrumental studies;
• various vaginitis, cervicitis, cervical erosion, tumors of the genital tract;
• remnants of membranes, placenta, blood clots after childbirth in the uterus.

Qualification of anaerobic infections according to the localization of its focus

There are the following types of anaerobic infections:

• Soft tissue and skin infections. The disease is caused by anaerobic Gram-negative bacteria. These are superficial diseases (cellulitis, infected skin ulcers, consequences after major diseases - eczema, scabies and others), as well as subcutaneous infections or postoperative ones - subcutaneous abscesses, gas gangrene, bite wounds, burns, infected ulcers in diabetes, vascular diseases. With a deep infection, soft tissue necrosis occurs, in which there is an accumulation of gas, gray pus with a vile odor.
• Bone infection. Septic arthritis is often the result of neglected Vincent, osteomyelitis - a purulent-necrotic disease that develops in the bone or bone marrow and surrounding tissues.
• Infections of the internal organs, including women, bacterial vaginosis, septic abortion, abscesses in the genital apparatus, intrauterine and gynecological infections may occur.
• Infections of the bloodstream- sepsis. It spreads through the bloodstream;
• Serous cavity infections- peritonitis, that is, inflammation of the peritoneum.
• bacteremia- the presence of bacteria in the blood, which get there in an exogenous or endogenous way.

Aerobic surgical infection

• diplococci;
• sometimes ;
• intestinal and typhoid coli.

• furuncle;
• furunculosis;
• carbuncle;
• hydradenitis;
• erysipelas.

Diagnostics

Only microbiological studies can confirm for sure the participation of anaerobic bacteria in the pathological process. However, a negative answer about the presence of anaerobes in the body does not reject their possible participation in the pathological process. According to experts, about 50% of the anaerobic representatives of the microbiological world today are uncultivated.

High-precision methods for indicating anaerobic infection include gas-liquid chromatography and mass spectrometric analysis, which determines the amount of volatile liquid acids and metabolites - substances that form during metabolism. No less promising methods are the determination of bacteria or their antibodies in the patient's blood using enzyme immunoassay.

They also use express diagnostics. The biomaterial is studied in ultraviolet light. Spend:

• bacteriological seeding of the contents of the abscess or detachable part of the wound in a nutrient medium;
• blood cultures for the presence of bacteria of both anaerobic and aerobic species;
• blood sampling for biochemical analysis.

When diagnosing, it is necessary to exclude the presence in the patient's body of erysipelas - a skin infectious disease, deep vein thrombosis, purulent-necrotic tissue lesions by another infection, pneumothorax, exudative erythema, frostbite stage 2-4.

Treatment of anaerobic infection

Surgical intervention

Medical therapy

• taking painkillers, vitamins and anticoagulants - substances that prevent clogging of blood vessels by blood clots;
• antibacterial therapy - taking antibiotics, and the appointment of a particular drug occurs after an analysis has been carried out for the sensitivity of pathogens to antibiotics;
• administration of antigangrenous serum to the patient;
• transfusion of plasma or immunoglobulin;
• the introduction of drugs that remove toxins from the body and eliminate their negative effects on the body, that is, they detoxify the body.

Physiotherapy

Prevention

What will be the result of the treatment? This largely depends on the type of pathogen, the location of the focus of infection, timely diagnosis and the right treatment. Doctors usually give a cautious but favorable prognosis for such diseases. In the advanced stages of the disease, with a high degree of probability, we can talk about the death of the patient.

Next article.

anaerobic infection

Treatment both clostridial and non-clostridial anaerobic wounds operational: a wide lesion and necrotic tissue. Decompression of edematous, deeply located tissues contributes to the wide. Sanitation of the hearth is carried out as radically as possible, combining it with antiseptic treatment and drainage. In the immediate postoperative period, the wound is left open, it is treated with osmotically active solutions and ointments. If necessary, areas of necrosis are removed again. If a wound infection develops against the background of a fracture of the bones of the limb, then plaster may be the preferred method of immobilization. In some cases, already during the primary revision of the wound of the limb, such extensive tissues are revealed that it becomes the only method of surgical treatment. It is carried out within healthy tissues, but sutures are applied to the wound of the stump no earlier than 1-3 days after the operation, controlling during this period the likelihood of recurrence of the infection.

The main objectives of infusion therapy A. and. are the maintenance of optimal hemodynamic parameters, the elimination of microcirculation and metabolism disorders, the achievement of a replacement and stimulating result. Particular attention is paid to detoxification, using preparations such as hemodez, neogemodez, etc., as well as various extracorporeal sorption methods - hemosorption, plasmasorption, etc.

Prevention A. i. effective under the condition of adequate and timely surgical treatment of wounds, careful observance of asepsis and planned surgical interventions, preventive use of antibiotics, especially in severe injuries and gunshot wounds. In cases of extensive damage or severe contamination of wounds, a polyvalent anti-gangrenous serum is administered prophylactically at an average prophylactic dose of 30,000 IU.

The sanitary and hygienic regime in the ward where the patient with clostridial wound infection stays should exclude the possibility of contact spread of infectious agents. To this end, it is necessary to adhere to the relevant requirements for the disinfection of medical instruments and equipment, premises and toiletries, dressings, etc. (see Disinfection) .

Anaerobic nonclostridial infection has no tendency to nosocomial spread, therefore, the sanitary and hygienic regimen for patients with this pathology must comply with general requirements taken in the department of purulent infection.

Bibliography: Arapov D.A. Anaerobic gas infection, M., 1972, bibliogr.; Kolesov A.P., Stolbovoy A.V. and Kocherovets V.I. in surgery, L., 1989; Kuzin M.I. etc. Anaerobic non-clostridial infection in surgery, M., 1987; high blood pressure oxygen, . from English, ed. L.L. Shika and T.A. Sultanova, p. 115, M., 1968

Rice. 5a). Patient with non-clostridial anaerobic infection of odontogenic origin. The lesion in the right eye socket before treatment.

Rice. 3. X-ray of the lower leg with an open fracture of the bones, complicated by clostridial infection: accumulations of gas are visible, fragmenting the muscles of the lower leg.

skin coloring">

Rice. 2. Clostridial infection of the femoral stump with an inadequate level of limb amputation due to ischemic gangrene: a characteristic spotty-marble color of the skin.

1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First health care. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

• Anashism

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