What is anaerobic infection. Anaerobic surgical infection (etiology, pathogenesis, clinic)

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 initial 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 the likelihood of recurrence of the infection during this period.

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 gemodez, 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.

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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 aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

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See what "Anaerobic infection" is in other dictionaries:

See Gas gangrene... Big Encyclopedic Dictionary

Anaerobic infection is one of the most severe infections that leads to the development of severe endogenous intoxication with damage to vital organs and systems and maintains a high percentage of mortality. Anaerobes are divided into 2 ... ... Wikipedia

See gas gangrene. * * * ANAEROBIC INFECTION ANAEROBIC INFECTION, see Gas gangrene (see GAS GANGRENE) ... encyclopedic Dictionary

ANAEROBIC INFECTION- (wound) - an infectious process caused by anaerobes. It is characterized by rapidly emerging and progressive tissue necrosis with the formation of gases in them and the absence of pronounced inflammatory phenomena, severe intoxication. There are two groups... Encyclopedic Dictionary of Psychology and Pedagogy

ANAEROBIC INFECTION

The beginning of the study of anaerobes dates back to 1680, when Leeuwenhoek first described the existence of microbes without air access. Almost two centuries later, in 1861-1863, L. Pasteur scientifically explained lactic acid fermentation in the absence of oxygen by the multiplication of microorganisms and called this process anaerobiosis. The discovery of L. Pasteur served as an impetus for numerous studies, which are primarily associated with the discovery of various types of anaerobic flora that are the causative agents of botulism, tetanus, appendicitis, wound suppuration and many other diseases.

A new "flourishing" of this problem falls on the 70s of the twentieth century and is associated with the use of more advanced methods of bacteriological research, which make it possible to isolate and accurately identify anaerobic microorganisms.

Not so long ago, many doctors under anaerobic infection meant purulent-septic inflammation caused by spore-forming microorganisms of the genus Clostridium, with extremely severe clinical course, with extensive necrotic changes in tissues and gas formation. However, now there is no doubt that in most cases the causative agents of these diseases are non-clostridial anaerobes. Late diagnosis and incorrectly chosen treatment tactics cause high, up to 60%, mortality in this pathology.

Epidemiology. Anaerobic flora occupies 11 out of 19 parts of the entire diversity of the microbial microcosm. This is due to the fact that microorganisms are among the most ancient creatures, the appearance of which on Earth dates back to times when the atmosphere did not have oxygen. Microbiological characteristics of anaerobes, which currently have the highest clinical significance, is presented in the table.

Causative agents of anaerobic infections

Depending on the ability to sporulate, anaerobic microorganisms are classified into spore-forming (clostridial) and non-spore-forming (non-clostridial). The share of the former is 5% of the total number of anaerobes.

Anaerobic microorganisms are conditionally pathogenic saprophytes, which, under certain conditions, cause purulent diseases. The main habitat of anaerobes is the digestive tract, and their maximum number is in the large intestine.

Pathogenesis. For the occurrence of anaerobic infection, a prerequisite is the appearance of anaerobes in unusual habitats for them. This is facilitated by trauma, surgery, tumor decay and other circumstances.

Equally important is the combination of conditions that create a favorable environment for the development of anaerobic microorganisms, including blood loss, shock, starvation, overwork, hypothermia, local circulatory disorders, weakened immunity against the background of malignant and systemic diseases, diabetes mellitus and radiation therapy.

Anaerobes produce enzymes, including collagenase, hyaluronidase, deoxyribonuclease, which cause tissue destruction and thus increase the pain potential. The endotoxin present in the microbial cell determines antigenicity and toxigenicity. The capsule of the pathogen, in addition to antigenic properties, has a pronounced weakening of phagocytosis. Such metabolic factors as fatty acids, indole, hydrogen sulfide, ammonia, in addition to suppressing other microflora, have a toxic effect on the cells of the macroorganism.

Clostridial pathogens produce exotoxin with a complex colloidal structure and its active fractions. Among them are: a-toxin (lecithinase), which has a necrotizing and hemolytic effect; b-toxin (hemolysin), which is considered a "lethal" factor due to its specific cardiotoxic effect; k-toxin (collagenase), which lyses protein structures; h-toxin (hyaluronidase), which potentiates the spread of wound infection and inflammation; m-toxin that affects the genetic apparatus of macroorganism cells; fibrinolysin; neuraminidase, which destroys the immunoreceptor apparatus of erythrocytes; hemagglutinin, inactivating factor A on erythrocytes and inhibiting phagocytosis.

Classification. The most complete classification of surgical anaerobic infections is presented by A.P. Kolesov et al. (1989):

• according to microbial etiology: fusobacterial, clostridial, peptostreptococcal, bacteroid, etc.;
• by the nature of the microflora: monoinfections, polyinfections (several anaerobes), mixed (aerobic-anaerobic);
• on the affected part of the body: soft tissue infection (fasciitis, myositis), infection internal organs(liver abscess), infection of the serous cavities (peritonitis), infection of the bloodstream (sepsis);
• by distribution: local (limited), unlimited - with a tendency to spread (regional), systemic or generalized;
• by source: exogenous, endogenous;
• by origin: out-of-hospital, nosocomial;
• by causes of occurrence: traumatic, spontaneous; iatrogenic.

However, this classification is not very acceptable in the clinic, since, on the one hand, it is quite cumbersome, on the other hand, in some sections, for example, according to the affected part of the body, according to distribution, pathological conditions are unequal and incomparable in clinical characteristics.

From the point of view of a practical doctor, the classification of B.V. Petrovsky, G.I. Lyskina (1984), who proposed to single out two criteria that determine the tactics of therapeutic actions.

• according to the pace of development - fulminant, acute and subacute forms of the course;
• according to the depth of tissue damage - cellulitis, fasciitis, myositis and mixed infection.

This division of labeling of anaerobic infections has the same clinical relevance as for clostridial infections.

Identification of anaerobic microflora. A certain help in the diagnosis of anaerobic infection is provided by a rather simple in technical execution and, therefore, a microscopic examination method accessible to any doctor.

When microscopy of native material stained by Gram within 40-60 minutes after its delivery to the laboratory, by the presence of a number of morphological characteristics of cell types, it is possible to reject or confirm the presence of anaerobes in the studied smears. Here, a relative quantitative assessment of seeding is also possible. A significant disadvantage of this method is the inability to distinguish aerobic cocci from anaerobic ones. This diagnosis of gram-negative anaerobes coincides with the results of bacteriological culture in 73% of cases [Kuzin M.I. et al., 1987].

Another method of express diagnostics is the study of pathological material in ultraviolet light, while the color of a cotton swab soaked in exudate changes to red. This phenomenon is based on the discovery in the material of vitamins produced by bacteria of the Bacteroides melaninogenicus/assacchoroliticus group [Kuzin M.I. et al., 1987].

Bacteriological analysis of wound exudate or wound tissues reveals more etiologically accurate data.

The method of paraphase (haed-spece) analysis is also acceptable in the clinic, in which the chromatographic spectrum of substances contained above the object of study is studied. Isolation of propionic, normal valeric and isomeric butyric, caproic acids allows identification of the anaerobic pathogen.

Full verification of the pathogen is carried out with the help of a targeted microbiological study. However, classical microbiological methods for the determination of anaerobes require a lot of time and strict adherence to special conditions for their implementation. Therefore, these methods are of little use for wide use in surgical practice, especially since they are unacceptable for fast-flowing infections, which include anaerobic inflammation.

Clinic of non-clostridial anaerobic infection. Non-clostridial anaerobic infection often develops in individuals with secondary immune deficiency against the background of:

1. 1. prolonged and indiscriminate use of broad-spectrum antibiotics, as a result of which normal microbial biocenoses are disturbed;
2. 2. use of cytostatics;
3. 3. use of immunosuppressants;
4. 4. long-term undiagnosed or uncompensated diabetes;
5. 5. malignant tumors;
6. 6. chronic atherosclerotic ischemia;
7. 7. chronic cardiovascular diseases with severe decompensation of cardiac activity;
8. 8. blood diseases.

Both gram-positive and gram-negative non-clostridial anaerobes cause the most various diseases- from superficial phlegmon and extensive necrotic soft tissue lesions to lung abscesses, peritonitis and sepsis.

At the same time, a non-clostridial anaerobic infection is united by a number of clinical signs that cause specific symptomatic and syndromic disorders, on the basis of which the diagnosis is based.

One of the most constant signs of an anaerobic non-clostridial infection should be considered a predominantly initially putrefactive nature of tissue damage that acquires a dirty gray or gray-green hue. In some cases, foci of black or brown color are diagnosed. The boundaries of the lesion are usually without clear contours and are not visually traceable. The spread rate of such necrosis reaches 15-20 cm in diameter per day.

No less important diagnostic value is the appearance and smell of wound exudate. A putrid odor is usually due to the specific substrates of microbial activity. At the same time, not all anaerobes produce such substances, and, therefore, the absence of a fetid odor is not a basis for an absolute denial of the involvement of non-clostridial anaerobic infection in the development of the wound process.

Signs of non-clostridial anaerobic infection are also swelling of the soft tissues along the periphery of the wound with signs of an inflammatory shaft up to 2-3 cm, the disappearance of pain in the center of the focus and an increase in pain along the periphery of the wound.

A feature of the course of wounds in anaerobic lesions can also be considered a sharp slowdown in the first phase of the course of the wound process.

In 65% of patients with anaerobic non-clostridial infection of soft tissues, the pathological focus can be characterized as necrotic cellulitis, which quite often captures the superficial fascia and loose connective tissue layers leading to the muscle fascia. Anaerobic non-clostridial myositis with a predominant lesion of the intermuscular connective tissue layers or with the capture of muscle tissue in the pathological process (own myonecrosis).

Reliable signs of anaerobic abscesses in the lungs can be considered:

1. 1. The putrid smell of the released air in the first days of the disease before it breaks into the bronchi.
2. 2. Dirty-gray color of the separated sputum and pus from the abscess cavity.
3. 3. Progressive destruction of the lung tissue and a tendency to become chronic.
4. 4. Progressive anemia.
5. 5. Progressive weight loss.
6. 6. Localization of abscesses on radiographs in 2-6 lung segments.
7. 7. Single-focal decay with an average cavity of 3 to 15 cm.

With peritonitis in adults, reliable signs of anaerobic non-clostridial infection are:

1. 1. The presence of brown or gray exudate;
2. 2. Sluggish course of peritonitis (4-5 days without pronounced spread) and with eventration developed against this background;
3. 3. Formation of intra-abdominal abscesses in the area of ​​ischemic tissues (bandaged stumps of the mesentery, greater omentum, mesentery of intestinal loops).
4. 4. Organizing intraperitoneal abscesses that do not manifest themselves as severe clinical symptoms.

However, in children, anaerobic non-clostridial peritonitis has a more violent and threatening course. As a rule, the following symptoms can serve as reliable signs of it:

1. 1. Inhibited or soporous state alternating with euphoria;
2. 2. Exudate from the abdominal cavity always has a fetid odor, and sometimes a brown tint;
3. 3. Bowel loops are often soldered into large conglomerates with multiple multi-chamber abscesses with a tendency to spread throughout the abdominal cavity;
4. 4. The presence of abundant fibrinous deposits on the parietal and visceral peritoneum is often gray-black;
5. 5. Severe intestinal paralysis.

As a classic feature of anaerobes, it should be noted flatulence. It is mainly due to the fact that in the process of anaerobic metabolism, gaseous products that are poorly soluble in water, including nitrogen, hydrogen and methane, are released. There are several clinical signs of gas formation. On palpation of the affected area, the so-called “crepitus” or “crunching” often occurs. During the operation, when dissecting tissues, you can get a similar sensation of crunching snow crust. Sometimes, during the opening of a purulent cavity, gas comes out of it with noise, in some cases, gas is released in the form of small bubbles as inclusions in the wound exudate.

Symptoms of gas accumulation can be detected radiographically. In abscesses, the level of liquid and gas above it is determined. When soft tissues are affected with the involvement of fiber in the process, the inclusion of gas is detected as a symptom of "honeycombs". In cases where the muscles are affected, when the gas spreads, the muscle fibers are stratified, which causes the x-ray symptom of the “herringbone pattern”. It is these features that allow differential diagnosis infectious emphysematous tissue changes from non-infectious emphysema, in which there is a uniform increased airiness. However, the symptoms of gas formation are more pronounced with clostridial lesions.

Since in the vast majority of observations anaerobic infection is of endogenous origin, among the characteristic features it is legitimate to indicate the proximity of the focus of inflammation to the natural habitats of anaerobes. Often their localization with the digestive tract, upper respiratory tract and genital organs, which are known to be the areas where the largest amount of normal human anaerobic microflora lives.

Given the presence of these specific features, their knowledge makes it possible to diagnose anaerobic infection clinically with a high degree of probability. In order to have no doubts about the participation of anaerobic microorganisms in the infectious process, it is enough to detect two of the described signs [Kolesov A.P. et al., 1989].

Clinic of anaerobic clostridial infection. Among the first signs of an infectious process, one should focus on the general symptoms of intoxication: weakness, headache, inappropriate behavior, agitation or lethargy of the patient, sleep disturbance. There is a rise in body temperature to 38-39 ° C with a range between evening and morning indicators of 1 or more degrees. There is anemia, leukocytosis with a neutrophilic shift of the leukocyte formula to the left.

Locally there is intense pain in the area of ​​the wound or pathological focus. In this case, the patient may experience a feeling of fullness or compression of the limb with a bandage. This symptomatology is explained by severe swelling of the tissues. The presence of edema is indicated by swelling of the muscles, traces of impression of the bandage, incision of sutures, retraction of the skin in the area hair follicles. In some cases, the swelling is so pronounced that the skin becomes white and shiny. Somewhat later, due to hemolysis and tissue necrosis, it acquires a brownish color. Of great importance is the rate of increase in edema, the degree of which can be judged by the symptom of A.V. Melnikov. To detect it, a thread is placed circularly around the limb proximal and distal to the focus of inflammation. When observing the thread in dynamics, the speed of ligature cutting into soft tissues is determined.

On palpation, the symptom of crepitus is often determined. A number of radiological signs help to confirm the presence of gas in the tissues - the “honeycomb pattern” symptom (distribution of gas through the fiber) and the “herringbone pattern” symptom (gas fragmentation of muscle fibers).

The predominance in the clinic of signs of gas formation and edema traditionally characterize clostridial anaerobic infection.

With cellulite, subcutaneous fat is damaged. The skin is usually bluish-white in color. In some cases, there is a slight hyperemia without clear boundaries. Edema in the area of ​​the pathological focus is very dense. It is noteworthy that skin manifestations do not reflect the true extent of the spread of the inflammatory process. It goes far beyond these changes. During the dissection of tissues, the subcutaneous tissue has a gray or dirty gray color with areas of hemorrhage. It is saturated with a serous fluid with an unpleasant fetid odor.

With the rapid spread of the process with a progressive increase in hyperemia, the appearance of areas of necrosis, as well as when necrosis of the subcutaneous tissue and presenting fascia is detected during the operation, one can confidently speak of fasciitis.

With myositis, there is damage to muscle tissue. Muscles take on the appearance of boiled meat, dull, saturated with serous-hemorrhagic exudate. Unlike fasciitis, in which only the superficial layers of muscles are involved in the pathological process, myositis is characterized by damage to the entire thickness of the muscle mass. Granulations are often visible on the wound surface, but their appearance does not correspond to the severity of anaerobic inflammation. In this regard, if myositis is suspected, muscle tissue is dissected and a biopsy specimen is taken for urgent histological examination, which allows you to determine the degree and depth of muscle damage.

With a combination of myositis and fasciitis during surgical treatment, areas of dark-dirty fascia with many perforations are found in the wound, through which a brownish-gray or serous-hemorrhagic exudate with a sharp unpleasant odor is released. Cellulose in such cases suffers less, and necrotic changes in the skin, as a rule, are absent.

The most common combination of cellulite, fasciitis and myositis is a mixed lesion. At the same time, local symptoms are observed, which are characterized by signs of all forms of anaerobic infection, and an intoxication syndrome, which determines the severity of the patient's condition and the possible development of sepsis.

Thus, a vivid clinical picture of anaerobic inflammation of soft tissues allows, with a fairly high degree of probability, to make a correct diagnosis even before laboratory express diagnostics.

Treatment of anaerobic infection. Variety of shapes and clinical manifestations anaerobic infection is one of the main causes individual approach in the treatment of this category of patients. First of all, we note that one hundred individuality of choice belongs to one of the decisive directions complex therapy- sanation therapy of the primary focus of infection.

In non-clostridial anaerobic infection, radical excision of all non-viable tissues with adequate drainage should be considered optimal. Repeated surgical treatments aim to prevent a possible expansion of the boundaries of destruction. From these positions, control notches 1.5-2 cm long along the periphery of the wound are sometimes appropriate (for necrotizing fasciitis). If during the initial surgical treatment it is not possible to reliably excise all necrotic tissues, then subsequent treatments should be carried out daily until the desired effect is achieved. Of course, suppurative lung diseases and peritonitis with the participation of non-clostridial anaerobic flora present the greatest difficulties. Staged surgical debridement of purulent foci in this case, and with peritonitis, debridement relaparotomy is always justified.

With anaerobic clostridial infection, stripe incisions were previously widely declared. However, the staff of the school B.V. Petrovsky and, in particular, G.I. Lyskin (1984), who has experience in the treatment of gas infection, found that stripe incisions exacerbate wound depletion, and therefore it is more expedient to use small incisions up to 7-8 cm along the periphery of the wound.

The surgical allowance is only a part of the sanation measures, the implementation of which is undoubtedly necessary at the first stage. Any surgical intervention can be supplemented with vacuum treatment, laser irradiation, ultrasonic cavitation, etc. Among medicinal preparations, oxidizing agents (hydrogen peroxide, potassium permanganate, pervomur, etc.), adsorbents, polyethylene glycol-based ointments with high osmotic activity should be widely used.

Among general biological, pathogenetically substantiated, therapeutic measures, hyperbaric oxygenation should be widely used. HBO allows you to narrow the scope of tissue destruction, promotes the demarcation of necrosis in a shorter time, stimulates the growth of granulation tissue. The general biological orientation of HBO contributes to the stimulation of immunity and the reactivity of the body as a whole.

Among the general drug therapy for anaerobic infections, metronidazole derivatives should be used (metragil, flagyl, up to 1.5 g per day intravenously; tinidazole - tricanix up to 1.5 g per day intravenously after 8 hours for 5-8 days), 1% dioxidine solution 120.0 IV. These drugs have sufficient antiseptic properties against gram-negative rods and anaerobic cocci.

Mandatory components of the treatment of anaerobic infections are detoxification, antibiotic therapy, immunotherapy, correction of life support systems, energy supply of patients. These issues will be covered by us in more detail in the "sepsis" section.

test questions

1. 1. What are the causative agents of anaerobic infections?
2. 2. What are the features of anaerobic microflora?
3. 3. How can anaerobic infection be classified?
4. 4. What conditions are necessary for the development of anaerobic infection?
5. 5. What are the factors of pathogenicity of anaerobic microorganisms?
6. 6. What are the clinical features of anaerobic infection?
7. 7. What additional methods are used in the diagnosis of anaerobic infection?
8. 8. Classification of anaerobic infection of soft tissues.
9. 9. What is the clinical picture of anaerobic infection of soft tissues?

10. What are the main directions of therapeutic measures for anaerobic infections?

11. What is the scope of surgical treatment of anaerobic soft tissue infections?

Situational tasks

1. A 28-year-old patient was delivered to the clinic with an extensive crushed wound of the right thigh, received 4 days ago in a road accident. The victim is lethargic, hardly answers questions, is adequate. Locally, a wound of 15x25 cm is noted, the edges are scalped, the muscles presenting are dull, the discharge is meager, serous-purulent, the symptom of “crepitus” is determined by palpation of the tissues of the near-wound zone, tissue infiltration is expressed, the skin is tense, pale in color. What is your preliminary diagnosis? What additional examination methods should be used in this situation? What is the treatment strategy?

2. A 38-year-old woman came to the emergency room with complaints of pain in the left thigh, where 2 weeks before this, magnesium sulfate injections were performed for hypertensive crisis. A pronounced swelling of the tissues of this zone is visually noted, the skin is brown, tense, pain on palpation is moderate, movements of the left leg are significantly limited. X-ray examination of the left thigh is determined by the symptom "herringbone pattern". What is your preliminary diagnosis? How to explain and how to interpret radiological data? What is the treatment strategy?

3. During the operation of surgical treatment of a purulent focus for post-injection phlegmon of the right gluteal region, a symptom of crepitus was noted during the dissection of soft tissues. Soft tissues are saturated with brownish serous exudate with a fetid odor, the fiber is dirty-gray, dull. What nature of the inflammatory process can be thought of in this case? What is your diagnosis? What research methods will help clarify the diagnosis? What therapeutic measures should be used in this situation?

Answers

1. The preliminary diagnosis is formulated as follows: purulent wound of the right thigh. Wound infections are most likely caused by anaerobic microorganisms. To clarify the nature of the bacterial flora and determine its sensitivity to antibiotics, a bacteriological examination of the wound is necessary. In this case, the surgical treatment of the purulent focus (secondary surgical treatment of the wound) and the mandatory conduct of rational antibiotic therapy are indicated.

2. The patient has post-injection anaerobic phlegmon of the left thigh. The X-ray detected symptom "herringbone pattern" indicates that the causative agent of this surgical infection belongs to the group of anaerobes. They, as you know, in the process of life are able to release gas, which, spreading along the muscle fibers, exfoliates them and thereby determines the radiological symptoms. The patient is shown surgical treatment, including surgical treatment of the purulent focus.

3. In this case, it can be assumed that anaerobic microorganisms are the causative agent of surgical infection. In this regard, the diagnosis can be formulated as follows: post-injection anaerobic phlegmon of the right gluteal region. To confirm the anaerobic etiology of the pathogen, it is advisable to conduct a microbiological study of the wound to determine the sensitivity of the flora to antibiotics. In the postoperative period, the complex of treatment should include local and general rational antibiotic therapy and symptomatic measures.

LITERATURE

1. 1. Anaerobic non-clostridial infection in surgery (guidelines). - M, 1987. - 28 p.
2. 2. Grigoriev E. G., Kogan A. S. Surgery of severe purulent processes. - Novosibirsk: Nauka, 2000. - 314 p.
3. 3. Kolesov A. P., Stolbovoy A. V., Kocherovets V. I. Anaerobic infection in surgery. - L .: Medicine, 1989. - 160 p.
4. 4. Larichev A. B. Anaerobic infections in purulent surgery (educational manual) Yaroslavl, 1995. - 31 p.
5. 5. Proceedings of the All-Union Symposium "Anaerobic non-clostridial infection in purulent surgery: Ternopil, 1989. - 200 p.
6. 6. Wounds and wound infection (Edited by M.I. Kuzin and B.M. Kostyuchenko). - M.: Medicine, 1990. - 592 p.

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 by predominantly 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 on early stages diseases.

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 Institute of Surgery named after Vishnevsky, 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 surgery resulting in festering wound, 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 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.

- an infectious process caused by spore-forming or non-spore-forming microorganisms under conditions favorable for their vital activity. characteristic clinical signs anaerobic infections are the predominance of symptoms of endogenous intoxication over local manifestations, the putrefactive nature of the exudate, gas-forming processes in the wound, and rapidly progressive tissue necrosis. Anaerobic infection is recognized on the basis of the clinical picture, confirmed by the results microbiological diagnostics, gas-liquid chromatography, mass spectrometry, immunoelectrophoresis, PCR, ELISA, etc. Treatment of anaerobic infection involves radical surgical treatment of a purulent focus, intensive detoxification and antibiotic therapy.

General information

Anaerobic infection is a pathological process, the causative agents of which are anaerobic bacteria that develop under conditions of anoxia (lack of oxygen) or hypoxia (low oxygen tension). Anaerobic infection is a severe form of the infectious process, accompanied by damage to vital organs and a high percentage of mortality. In clinical practice, anaerobic infections are faced by specialists in the field of surgery, traumatology, pediatrics, neurosurgery, otolaryngology, dentistry, pulmonology, gynecology and other medical areas. Anaerobic infection can occur in patients of any age. The proportion of disease caused by anaerobic infection is not exactly known; from purulent foci in soft tissues, bones or joints, anaerobes are sown in about 30% of cases; anaerobic bacteremia is confirmed in 2-5% of cases.

Causes of anaerobic infection

Anaerobes are part of the normal microflora of the skin, mucous membranes, gastrointestinal tract, organs genitourinary system and by their virulent properties are conditionally pathogenic. Under certain conditions, they become causative agents of endogenous anaerobic infection. Exogenous anaerobes are present in the soil and decaying organic masses and cause a pathological process when they enter the wound from the outside. Anaerobic microorganisms are divided into obligate and facultative: the development and reproduction of obligate anaerobes is carried out in an oxygen-free environment; facultative anaerobes are able to survive both in the absence and in the presence of oxygen. Facultative anaerobic bacteria include Escherichia coli, Shigella, Yersinia, Streptococcus, Staphylococcus, etc.

Obligate pathogens of anaerobic infection are divided into two groups: spore-forming (clostridia) and non-spore-forming (non-clostridial) anaerobes (fusobacteria, bacteroids, veillonella, propionibacteria, peptostreptococci, etc.). Spore-forming anaerobes are the causative agents of clostridiosis of exogenous origin (tetanus, gas gangrene, botulism, food poisoning, etc.). Non-clostridial anaerobes in most cases cause purulent-inflammatory processes of an endogenous nature (abscesses of internal organs, peritonitis, pneumonia, phlegmon of the maxillofacial region, otitis media, sepsis, etc.).

The main factors of pathogenicity of anaerobic microorganisms are their number in the pathological focus, the biological properties of pathogens, the presence of associated bacteria. In the pathogenesis of anaerobic infection, the leading role belongs to enzymes produced by microorganisms, endo- and exotoxins, and nonspecific metabolic factors. So, enzymes (heparinase, hyaluronidase, collagenase, deoxyribonuclease) are able to enhance the virulence of anaerobes, the destruction of muscle and connective tissues. Endo- and exotoxins cause damage to the vascular endothelium, intravascular hemolysis and thrombosis. In addition, some clostridial toxins have nephrotropic, neurotropic, cardiotropic effects. Nonspecific factors of anaerobic metabolism - indole, fatty acids, hydrogen sulfide, ammonia - also have a toxic effect on the body.

Conditions favorable for the development of anaerobic infection are damage to anatomical barriers with the penetration of anaerobes into tissues and the bloodstream, as well as a decrease in the redox potential of tissues (ischemia, bleeding, necrosis). The entry of anaerobes into tissues can occur during surgical interventions, invasive manipulations (punctures, biopsies, tooth extraction, etc.), perforation of internal organs, open injuries, wounds, burns, animal bites, prolonged compression syndrome, criminal abortions, etc. Factors contributing to the emergence of anaerobic infections are massive contamination of wounds with earth, the presence of foreign bodies in the wound, hypovolemic and traumatic shock, concomitant diseases (collagenoses, diabetes mellitus, tumors), and immunodeficiency. In addition, irrational antibiotic therapy aimed at suppressing the accompanying aerobic microflora is of great importance.

Depending on the localization, anaerobic infection is distinguished:

• central nervous system(brain abscess, meningitis, subdural empyema, etc.)
• head and neck (periodontal abscess, Ludwig's angina, otitis media, sinusitis, neck cellulitis, etc.)
• respiratory tract and pleura (aspiration pneumonia, lung abscess, pleural empyema, etc.)
• female reproductive system (salpingitis, adnexitis, endometritis, pelvic peritonitis)
• abdominal cavity (abdominal abscess, peritonitis)
• skin and soft tissues (clostridial cellulitis, gas gangrene, necrotizing fasciitis, abscesses, etc.)
• bones and joints (osteomyelitis, purulent arthritis)
• bacteremia.

Symptoms of anaerobic infection

Regardless of the type of pathogen and the localization of the focus of anaerobic infection, various clinical forms have some common features. In most cases, anaerobic infection has an acute onset and is characterized by a combination of local and general symptoms. The incubation period can range from several hours to several days (about 3 days on average).

A typical sign of anaerobic infection is the predominance of symptoms of general intoxication over local inflammatory phenomena. Sharp deterioration general condition the patient usually occurs even before the onset of local symptoms. A manifestation of severe endotoxicosis is high fever with chills, severe weakness, nausea, headache, lethargy. Arterial hypotension, tachypnea, tachycardia, hemolytic anemia, icteric skin and sclera, acrocyanosis are characteristic.

With a wound anaerobic infection, an early local symptom is a strong, growing pain of a bursting nature, emphysema and soft tissue crepitus, caused by gas-forming processes in the wound. Among the constant signs is the fetid ichorous smell of exudate associated with the release of nitrogen, hydrogen and methane during anaerobic oxidation of the protein substrate. The exudate has a liquid consistency, serous-hemorrhagic, purulent-hemorrhagic or purulent in nature, heterogeneous color with inclusions of fat and the presence of gas bubbles. The putrid nature of the inflammation is also indicated by the appearance of the wound, which contains gray-green or gray-brown tissues, sometimes black scabs.

The course of anaerobic infection can be fulminant (within 1 day from the moment of surgery or injury), acute (within 3-4 days), subacute (more than 4 days). Anaerobic infection is often accompanied by the development of multiple organ failure (renal, hepatic, cardiopulmonary), toxic shock, severe sepsis, which are the cause of death.

Diagnostics

For the timely diagnosis of anaerobic infection, the correct assessment is of great importance. clinical symptoms allowing timely provision of the necessary medical care. Depending on the localization of the infectious focus, clinicians of various specialties can be engaged in the diagnosis and treatment of anaerobic infections - general surgeons, traumatologists, neurosurgeons, gynecologists, otolaryngologists, maxillofacial and thoracic surgeons.

Methods for rapid diagnosis of anaerobic infection include bacterioscopy of wound discharge with Gram smear staining and gas-liquid chromatography. In the verification of the pathogen, the leading role belongs to the bacteriological culture of the discharged wound or the contents of the abscess, analysis of the pleural fluid, blood culture for aerobic and anaerobic bacteria, enzyme immunoassay, PCR. In the biochemical parameters of the blood during anaerobic infection, a decrease in the concentration of proteins, an increase in the level of creatinine, urea, bilirubin, transaminase and alkaline phosphatase activity are found. Along with clinical and laboratory studies, radiography is performed, which reveals the accumulation of gas in the affected tissues or cavities.

Anaerobic infection must be differentiated from erysipelas of soft tissues, polymorphic exudative erythema, deep vein thrombosis, pneumothorax, pneumoperitoneum, perforation of the hollow organs of the abdominal cavity.

Treatment of anaerobic infection

An integrated approach to the treatment of anaerobic infections involves radical surgical treatment of a purulent focus, intensive detoxification and antibiotic therapy. The surgical stage should be performed as early as possible - the life of the patient depends on it. As a rule, it consists in a wide dissection of the lesion with the removal of necrotic tissues, decompression of surrounding tissues, open drainage with washing of cavities and wounds with antiseptic solutions. Features of the course of anaerobic infection often require repeated necrectomy. The outcome of anaerobic infection largely depends on the clinical form of the pathological process, premorbid background, timeliness of diagnosis and initiation of treatment. The mortality rate in some forms of anaerobic infection exceeds 20%. Prevention of anaerobic infection consists in timely and adequate PST of wounds, removal of foreign bodies of soft tissues, compliance with the requirements of asepsis and antisepsis during operations. For extensive wounds and high risk development of anaerobic infection requires specific immunization and antimicrobial prophylaxis.

"5" (excellent) - the absence of errors in the technique of performing the manipulation and a complete, detailed justification of the sequence of its implementation

"4" (good) - no more than 2 minor errors were made in the manipulation technique. Gives a complete, detailed justification for the sequence of its implementation. The mistakes made do not lead to complications and do not threaten the life of the patient's body.

"3" (satisfactory) - when performing the manipulation technique, more than 2 minor errors were made (violation of the technique), which can lead to complications. The student eliminates them with the help of the teacher

"2" (unsatisfactory) - when performing the manipulation technique, gross (more than 2) mistakes were made. The student cannot correct them with the help of the teacher.

GENERAL QUESTIONS OF SURGICAL INFECTION, OSTEOMYELITIS. GENERAL PURULENT INFECTION

Surgical infections include diseases caused by the introduction of pyogenic microbes into the body, accompanied by purulent-inflammatory and purulent-necrotic processes in organs and tissues that require surgical treatment. The development of purulent-inflammatory diseases depends on 3 reasons: 1. On the state of the macroorganism (the body's defenses, immunity); 2. From virulence, i.e. the body's ability to cause purulent-inflammatory diseases; 3. From timely preventive measures(asepsis and antisepsis), lack of entry gates of infection.

The main causative agents of purulent surgical infections are staphylococci, streptococci, Pseudomonas aeruginosa, different kinds protea and Escherichia coli. Microbes penetrating the body cause purulent inflammation, which has local and general manifestations: local symptoms of inflammation - edema or dense formation - infiltration, redness, local fever, pain and impaired function of the affected organ. The main component in the focus of inflammation is pus, the constituent components of which are leukocytes, destroyed tissues and bacteria. With a staphylococcal infection, pus is yellow, thick, odorless; with staphylococcal infection, it is liquid, slimy, of a light shade. Pseudomonas aeruginosa gives various shades - from bluish to greenish with a sweet smell. E. coli - brown pus with the smell of feces.

General symptoms:

1. The general reaction is clinically manifested by an increase in body temperature, which depends on the general reactivity, on the other hand, on the severity of the manifestation of purulent inflammation.

2. General intoxication: weakness, headache, chills, increased heart rate.

3. In blood tests: leukocytosis (increase in stab forms) and neutrophils, with a shift of blood to the left, a decrease in erythrocytes, accelerated ESR. In the analysis of urine - protein.

Principles of treatment: 1. Local treatment: 1. Creation of functional rest of the affected area. 2. Opening of the abscess. 3. Wound drainage. 4. Washing the wound antiseptic solutions and hypertensive wound dressing. After the appearance of granulations - ointment bandages.

General treatment:1. Antibiotic therapy and chemotherapy. 2. Infusion therapy and detoxification therapy (hemodez, neocompensan, polyvinylpyrramidone, etc.)

3. Stimulation of immunity (hemostimulin, vit. B 12, ATP, vitreous body, aloe, antistaphylococcal gamma globulin, leukocyte mass, thymosin, T-activin, levomisole, decaris 1 tab. per day for 3 days, thymalin in / m 5-10 mg for 5-10 days, ultraviolet irradiation of blood.

SEPARATE TYPES OF LOCAL PURULENT DISEASES:

FURUNCLE- this is an acute purulent-necrotic inflammation of the hair follicle and surrounding tissue. Localization - the back of the neck, forearm, back of the hand, buttocks, face, etc. The causative agent is staphylococcus aureus. Furuncle, purplish, painful, cone-shaped nodule with tissue infiltration around it. At the top there is a site of purulent necrosis (size from 0.5 -1.5-2). Furunculosis - the appearance of several boils simultaneously or sequentially. Treatment: outpatient initial stages, the skin around the boil is treated with alcohol, ether, 2% salicylic alcohol. Dry heat, UHF, UVI, novocaine blockade 0.25% solution around the focus and under it. General treatment - vitamin therapy, autovaccine, autohemotherapy, physiotherapy, ultraviolet irradiation.

CARBUNCLE- this is an acute purulent-necrotic inflammation of several hair follicles and adjacent sebaceous glands, spreading to the entire thickness of the skin and underlying tissues. The inflammatory process extends to the lymphatic vessels and nodes. Necrotic rods within 3-5 days are combined into a single purulent-necrotic conglomerate, which is rejected. A wound is formed, which granulates, scars within 3-4 weeks. General symptoms of intoxication: fever, chills,

HYDRADENITIS- This is a purulent inflammation of the apocrine, sweat glands. The infection penetrates through the excretory ducts of the sweat glands (armpits, inguinal folds, mammary glands, perianally). Clinic: the appearance of a dense, painful, cone-shaped formation of a reddish, purple color, 1-3 cm in size. An abscess appears on 2-3 days - melting of the sweat glands. Treatment: local - bandages with levomikol. With an abscess - an autopsy. Antibiotic therapy, sulfonamides, immunotherapy.

ABSCESS- this is a limited form of purulent inflammation, which is characterized by the formation of a cavity filled with pus. (Pathogens - staphylococcus aureus, streptococcus, E. coli, etc.) Causes - complications of a boil, carbuncle, wounds, microtraumas, foreign bodies, after injections, hematoma infection. Metastatic abscesses, with a general purulent infection, enter the organs and tissues through the blood. Abscesses may be non-specific purulent, putrefactive, specific and anaerobic. Diagnosis - with a diagnostic needle puncture, air can be introduced - pneumoabscessography or radiopaque substance - radiopaque abscessography. Treatment - surgical, opening of the abscess. Antibiotic therapy.

PHLEGMON- this is an acute unlimited, diffuse inflammation of the cellular spaces. M.b. phlegmon superficial (epifascial), deep (subfascial), more often putrefactive and anaerobic flora. Clinic - acute onset, local and general inflammation. When placed on the surface. sharply increasing soreness, swelling, hyperemia, increased body temperature, chills with sweat, violation of the function of the affected area. On palpation - infiltrate, + s-m "fluctuations". Treatment - surgery under general anesthesia, opening of cavities, drainage. Antibiotic therapy, sulfonamides, infusion therapy.

erysipelas- this is an acute serous-purulent inflammation of the skin, mucous membranes (causative agent - streptococcus). Entrance gates - violation of the integrity of the skin, the contact route of transmission through tools, material, hands; secondary infection penetrates if there is a streptococcal infection. Localization - on the lower extremities, face, torso, scalp. There are 4 forms of erysipelas: 1. erythematous, 2. bullous, 3. necrotic, 4. phlegmonous. Clinic: common signs of intoxication: increase in temperature up to 38-40, nausea, vomiting, confusion, rapid pulse, against this background, there is a sharply limited reddening of the skin in the form of "tongues of flame" with edematous edges. Regional lymph nodes are enlarged, painful, bands of hyperemic nodes (lymphangitis) are more often visible - an erythematous form. Bullous f-ma - blisters appear, filled with serous, serous-hemorrhagic exudate. Necrotic - areas of necrosis are noted against the background of altered skin. Phlegmonous - (pyogenic flora joins streptococcus), an unlimited form of purulent inflammation of the skin and subcutaneous tissue. Treatment: stationary, locally 2-3 times the skin is treated with antiseptic solutions (96% ethyl alcohol + 20% ammonia 2:1). Antibiotics IV. With phlegmonous f-me - opening of abscesses, with necrotic - excision of areas of dead skin - necrectomy, antiseptic ointment dressings with 10% hypertonic sodium chloride solution, levomikol.

ERYZIPELOID is an erysipelas-like disease caused by a porcine erysipelas bacillus that affects the skin of the fingers and less often the parts of the hand (contingent - butchers, cooks, housewives, tanners), the infection penetrates through the skin, microtrauma. Clinic - serous inflammation of all layers of the skin with swelling, redness. The incubation period is from 2-5 days. Skin itching, hyperemia from one finger passes to neighboring areas, the phenomenon of lymphadenitis, lymphangitis is noted. T-ra is normal. Treatment: a / b (penicillin 250 thousand units - 4-5 times), novocaine blockade 0.25% solution of novocaine, UVI.

FELON- purulent inflammation of the fingers (with abrasion, injection, scratch, splinter). Structural features of the skin, subcutaneous tissue of the fingers, which have a large number of connective tissue partitions, determine the specifics. 1. Skin felon - accumulation of pus under the epidermis, easily displaced by pressure, moderate pain. Treatment: cut off the exfoliated epidermis with scissors. On the wound with an ointment bandage with antibiotics. 2. Subcutaneous panaritium - reinforced pain due to compression of nerve endings. Treatment: initially conservative warm baths, alcohol compresses, novocaine blockade. The operation under local anesthesia according to Oberst-Lukashevich, on both sides at the base of the finger with a tourniquet previously applied, is anesthetized with 1% 10 ml solution of novocaine (or intravenous anesthesia-barbiturates), two parallel incisions are made along the edge of the phalanx. For a better outflow of pus, the incisions are connected, drainage is placed. Subungual panaritium - the cause is trauma to the periungual bed, manicure. Clinic: pain, pus under the nail plate. Operation - under anesthesia, the nail is removed, the ointment bandage is removed. 4. Paronychia - an abscess under the root of the nail. The clinic is pain, swelling, hyperemia of the skin roller at the base of the nail. Operation - two parallel incisions are made at the base of the nail on the rear of the terminal phalanx along the edges of the periungual roller, they are separated and pulled back. 5. Tendon panaritium (purulent tendovaginitis), a complication of other forms, with injuries. The finger is bent, thickened, pain on movement, intoxication. Pus accumulates in the tendon synovial sheaths, from where it breaks into soft tissues, with the formation of deep phlegmon of the hand and forearm.

Treatment: surgery for tendinous panaritiums of 2-4 fingers, two parallel incisions are made on the lateral surface of the main and middle phalanges, drainage. At 1-5 finger-cuts on the palmar surface in the area of ​​elevation. Immobilization with a back plaster splint: the brushes are given a half-bent position. Antibiotics. 6. Bone panaritium - primarily when the infection penetrates deep under the periosteum, secondary - running subcutaneous panaritium. There comes a necrosis of a section of the bone - a sequester. The clinic - severe pain, purulent fistulas, necrosis of the entire phalanx of the finger. Sequesters are separated on the 8-10th day. Treatment: under anesthesia, a wide lateral or arcuate incision of the soft tissues is made to the bone. Sequesters are removed, the wound is washed with H2O2, drainage, a swab with Vishnevsky's ointment. Immobilization of the finger and hand with a plaster splint. With necrosis, amputation of the fingers. 7. Articular panaritium - half-bent position of the finger, soreness in the joint, pathological mobility, as a result of the destruction of the ligaments and joint capsule. Treatment: open with two lateral incisions, washed with solutions of antiseptics, antibiotics, immobilization with a plaster bandage. Disability in violation of the function of 1 finger.

THROMBOPHLEBITIS- acute inflammation the walls of a vein with the formation of a thrombus (blood clot) in the lumen of its lumen. Causes - violation of the integrity of the inner lining of the vein, slowing down the blood flow, increased blood clotting. Clinic: thrombophlebitis of superficial veins lower extremities, the reason is varicose veins n / a. acute onset, the appearance of intense pain, hyperemia along the veins, sharply painful bands under the skin. Edema of the limb, difficulty in movement, increased body temperature. With purulent thrombophlebitis, with general intoxication, dense infiltrate along the vein, suppuration, abscesses, phlegmon. Deep vein thrombophlebitis is a serious illness, sudden severe pain, swelling of the entire limb. A complication is an embolism (blockage) of the pulmonary arteries, which can lead to death. Dangerous septic thrombophlebitis, sepsis. Treatment: conservative - a / b and anti-inflammatory therapy, hospitalization in a hospital.

OSTEOMYELITIS- purulent inflammation of the bone marrow, usually spreads to a compact, spongy bone and periosteum. The causative agents are pyogenic microbes (Staphylococcus aureus 80%). There are 2 ways of spread: 1. The infection gets into the bone through damaged skin and mucous membranes (exogenous way); 2. The infection is introduced into the bone with blood flow from another purulent source (endogenous route); A predisposing moment, a decrease in the general, protective forces of the body, injuries, local and general cooling, beriberi, infections. Tubular bones, metaphysis are affected. infection once in the bone causes inflammation of the bone marrow, with the development of serous, and then purulent exudate. The dead area of ​​the bone is called a sequester, a foreign body, a demarcation shaft is formed around the ktr, it separates the living tissue from the dead. Pus breaks into soft tissues (purulent streaks) outward, forming purulent fistulas. Sequesters also keep the fistula alive. Gradually, the granulation tissue around the sequester is replaced by bone, and the sequester is demarcated. Fistulas can close, reopen during exacerbation (the disease acquires a chronic process). The clinic is a sudden onset, an increase in body temperature, pain in the affected limb. the condition worsens, breathing becomes more frequent, tachycardia 100-120 beats. in min. The pains are arching, palpation, active, passive movement intensify. Soft tissue edema appears, the lymph nodes are enlarged, skin hyperemia and a local increase in body temperature. The appearance of edema of the limb indicates the formation of a subperiosteal abscess. In the center of hyperemia, fluctuation. With a breakthrough of pus, the condition improves. M.b. purulent metastases.

Changes in the bone are observed on the x-ray within 2-3 weeks. hospitalization and treatment in a hospital: transportation with immobilization of the limb and the introduction of analgesics. Operation: opening of subperiosteal abscesses with bone trepanation.

SEPSIS- heavy pathological condition, ktr is caused by a variety of microorganisms, their toxins (0.1% - 0.15%). The reason is pathogenic, conditionally pathogenic bacteria: staphylococcus aureus, streptococcus, Pseudomonas aeruginosa, Escherichia coli, Proteus vulgaris, anaerobes, etc. Development mechanism (3 factors): 1. Microbial (monoinfection, polyinfection, mixed, virulence; 2. Type of input gate (the nature of the destroyed tissues, the size of the purulent focus, its location, the state of blood circulation); 3. The reactivity of the body (the state of immunity).

Classification of sepsis: 1. By type of pathogen - staphylococcal, streptococcal, coli-bacillary, non-clostridial, clostridial, mixed; 2. According to the location of the entrance gate of infection - surgical, urological, gynecological, otogenic, etc.; 3. By the presence or absence of a visible focus of infection - primary (cryptogenic - sepsis, with CTR, the primary focus of purulent inflammation cannot be recognized due to reasons), secondary; 4. By the presence or absence of purulent metastases - septicemia, septicopyemia; 5. By clinical picture- fulminant, acute, subacute, chronic.

Clinic: septicemia is characterized by a sharp deterioration in the condition, chills, T-ra 40-41C; hemodynamic dis-vatachycardia, rapid Ps, drop in blood pressure, muffled heart sounds, Ps - soft, not countable, rapid breathing 25-30 per minute, cyanosis, acrocyanosis. From the side of the National Assembly - excitation, inhibition, hallucinations, anxiety. The skin and sclera are icteric, there are rashes on the skin (vasculitis). the spleen is enlarged, painful on palpation, subcutaneous hemorrhages, t-ra in the terminal state decreases to normal, pulse - 120-140 beats. in minutes ("scissors effect", between the swarm and the pulse, there are discrepancies, then this is a bad prognostic sign). Sepsis lasts 1-2 days, there is a high mortality rate. For septicopyemia, an acute and subacute course is characteristic: bacterioemia, purulent metastases, high t-tour of the body, with periodic remission (during the day, t-ra falls within 2-4 C, when measuring t-ry every 2 hours - a remitting type curve ). The duration of the course is from several weeks to several months. Symptoms of intoxication, pain in muscles, joints, headaches, tachycardia, pulse rate corresponds to that. UAC - anemia, leukocytosis (15.0 - 25.0 x 10 9 / l, shift to the left, sticks, accelerated ESR. OAM - anuria, decrease in the amount of urine, protein, renal epithelium, cylinders. The spleen is enlarged, rashes on the skin Skin and mucous membranes are jaundiced Metastases in the liver, kidneys, lungs, brain - death (subacute - 2-3 weeks, chronic - months) Septic shock is a complication of sepsis: hemodynamic and respiratory races, impaired liver function , kidneys, brain (cerebral coma).Renal and liver failure develops, with impaired thrombosis and intravascular coagulation (hyper- and hypocoagulation).Treatment: in intensive care and intensive care.Principles of treatment: 1. Active surgical treatment of primary and secondary purulent foci 2. General intensive care: antibiotics, detoxification therapy, immunocorrection, specific immunization, correction of blood clotting, maintenance of cardiovascular system, respiration, liver, kidneys.

ACUTE ANAEROBIC SURGICAL INFECTION. GAS GANGRENE.

Anaerobes are microorganisms that can reproduce in the absence of oxygen.

gas gangrene- pathogens Cljstridium perfringens, Cl. Septicus, Cl. Oedematiens, Cl. Histolyticum. Gas gangrene develops with extensive crushed tissues (gunshot, lacerations, lacerated wounds), contaminated with earth, the more tissues (especially muscles) are destroyed, the more favorable conditions are. Clinical features depend on the type of bacteria: Clostridium perfringens - toxic-hemolytic, fibrinolytic, necrotic action. Clostridium septicum causes bloody-serous edema of tissues, hemolysis of red blood cells. Clostridium oedematiens - rapidly increasing edema with the release of a large amount of gas. Clostridium hystoliticum - dissolves living tissues, melts muscles, connective tissue.

Local symptoms of gas gangrene are swelling, the presence of gas in the tissues, muscle breakdown and the absence of symptoms characteristic of inflammation.

General symptoms: incubation period(2-3 days), tachycardia, low blood pressure, agitation of the patient, talkativeness, depressed mood, insomnia. Tem-ra - 38-39C, intoxication, dehydration, rapid breathing, P-120-140 beats per minute, in the blood - hemolysis of erythrocytes, anemia, hemoglobin-70-100 g / l, erythrocytes - 1-1.5x10 12 / l, leukocytosis-15-20x10 9 /l, shift of the leukocyte formula to the left, p / i and young forms, in the urine - oliguria, anuria, hematuria. If treatment is not started within 2-3 days, death occurs.

Prevention: primary surgical treatment of the wound - excision of non-viable tissues under anesthesia and local anesthesia.

Treatment: surgical-PHO: non-viable tissues are excised, with wide parallel (lamp) incisions, fascia and soft tissues are dissected to the full depth, the wounds are drained and left open. Inject antibiotics into the wound. Hyperbaric oxygenation (3 atm) is prescribed, the patient is placed in a chamber with high atmospheric pressure: 1 day - 3 times for 2-2.5 hours, then 1 time per day. If gangrene spreads, then amputation or disarticulation of the limb. Intensive infusion therapy is prescribed: albumin, plasma, electrolytes, proteins, transfusion of freshly prepared whole blood, erythrocyte mass. Antigangrenous serum is prescribed (monovalent if the pathogen is detected, polyvalent if the pathogen is not identified) intravenously at a dose of 150 thousand AU (active units). The serum is dissolved in an isotonic sodium chloride solution and heated to 36-37C. Patient care: patients should be isolated, linen, tools are processed in a dry-heat cabinet at T-re-150C, in a steam sterilizer-2 atm. Dressings are done with gloves, the dressings are burned.

TETANUS- an acute specific anaerobic infection caused by the introduction of a virulent tetanus bacillus (Clostridium tetani) into the body. The stick is common in nature, on the surface of the body (spores), soil, street dust, clothes, earth, in the intestines of humans, animals. Entrance gate - mouth, foreign bodies. The causative agents of tetanus secrete toxins that are characterized by a neurotropic effect, act on the central nervous system, causing convulsive contractions of the striated muscles.

Clinic: incubation period from 2 days to 3 weeks or more. Headache, sweating, fever, photophobia, then quickly appear tension and rigidity of the masticatory muscles (trismus), which do not allow you to open your mouth, not an arbitrary convulsive contraction of the facial muscles "sardonic smile". The occipital muscles, back and abdominal wall are also involved in the process, clonic convulsions of the entire skeletal muscles appear. Attacks are accompanied by severe pain. Light, sound, mechanical irritations lead to an attack of convulsions. The patient's head tilts back, the spine bends forward, the patient leans on the back of the head and on the heels (opisthotonus). The muscles of the abdominal wall are tense. Consciousness is completely preserved, the duration of the attack is 1-2 minutes (in severe condition, the attack is repeated after 30 minutes - 1 hour). The transition of convulsions to the muscles of the larynx creates a threat of suffocation, spasms of the intercostal muscles are dangerous, which makes it difficult to exhale. The spread of convulsions to the diaphragm leads to respiratory arrest. Strong seizures. lead to fractures of the ribs, muscle ruptures.

Prevention- wound treatment, immunization (passive): introduction of antitoxic serum. All patients with damage are given Bezredko 3000 AU (active units) of tetanus toxoid. Before the introduction of the entire dose, an intradermal test of 1:100 serum is placed in the forearm area and the patient is observed for 20 minutes. In case of a “negative” reaction, undiluted serum is administered s.c. in an amount of 0.1 ml; if there is no reaction, the entire dose of serum is administered after 30 minutes-1 hour. For active immunization, tetanus toxoid is used sc (1 ml; after 3 weeks - 1.5 ml; after another 3 weeks - 1.5 ml of toxoid). Early immunized persons who have the appropriate certificate are injected with 0.5 ml of toxoid. Serum must be administered separately from the toxoid.

Treatment. It is necessary to introduce large doses of tetanus toxoid - 100-150 thousand AU for adults, 20-80 thousand AU for older children, to neutralize toxins, they are injected intramuscularly, intravenously, into the spinal canal.

At the same time, active immunization is carried out: 2-3 hours before the start of the serum infusion, 2 ml of toxoid is injected under the skin. A week later, the introduction of toxoid is repeated. Toxoid is injected 3 times (in a week) at a dose of 4 ml. The patients are in the intensive care unit. Exclude sound, light, mechanical irritants. Rigidity of muscles, convulsive attacks are removed by the introduction of substances that reduce the excitability of the National Assembly: 10 ml of 20% magnesium sulfate solution, hypnotics, bromides; intravenous drip preparations of barbituric acid: sodium thiopental, hexenal, pentothal; muscle relaxers.