Anaerobic infection general surgery. What is anaerobic infection

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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 angioneuropathy. 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 involved in infectious processes not 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 causative agents 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, the participation of which 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 primarily 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 of 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, injuries, invasive manipulations, decay of tumors, translocation of bacteria from the intestine in acute diseases of the 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 of 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 both as a result of general causes (shock, blood loss, etc.), and local tissue hypoxia in conditions of insufficient arterial blood flow (occlusive vascular disease), the presence of a large the 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 microcirculation are accompanied by increased vascular permeability, erythrocyte sludge, microthrombosis with the development of immunocomplex 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 inhabit the oral cavity, colon, upper respiratory tract, and 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 the large intestine of humans 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, in particular with streptococci, bacteria of the Enterobacteriaceae family, non-fermenting gram-negative bacteria, makes it possible 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:

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.
The infectious process in the clinical course practically does not differ from the usual purulent processes, proceeds favorably, like the usual phlegmon with moderately pronounced symptoms of intoxication.
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 in different conditions can cause different 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 of soft tissue and bone injuries 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 mellitus. 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 diseases of the vessels of the lower extremities, the chances of a favorable outcome of the disease are less, since in the form of cellulite 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. The duration of the 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 growing 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 in the early stages of predominantly serous, 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 involved in the inflammatory process for the second time. 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 is detected at once in the form of necrotic 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 in anaerobic necrotizing fasciocellulitis or myositis, when only moderate hyperemia or tissue edema in the absence of fluctuation 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 dermatoses, 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 in the early stages of the disease (at the stage of purulent complications, the addition of anaerobic infection is usually determined);
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 a different etiology associated with pneumothorax, pneumoperitoneum, perforation of hollow abdominal organs into the retroperitoneal tissue, surgical interventions, washing wounds and cavities with a solution of hydrogen peroxide, etc. Moreover, 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. In the acute form of the disease, 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 infection can definitely 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, acridine yellow staining of preparations for the detection of bacteria or their antigens in the blood, 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 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.

Nevertheless, in addition to academic interest, the identification of anaerobic microflora is of great clinical importance both in determining the etiology of the primary purulent-necrotic focus and sepsis, and in building treatment 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 rapid 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: seeding 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:

on freshly poured 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);
on 5% blood agar for aerobic culture;
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 greatly facilitates the use of commercial test systems containing more than 20 biochemical tests, which allow determining not only the genus, but also the type of microorganism.

Micropreparations of some anaerobic species isolated in pure culture are presented below.

Detection and identification of an anaerobic pathogen from the blood is possible in rare cases, such as cultures of P. niger 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. Such results of bacteriological examination are 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 anaerobic isolation, 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-treatments of an extensive 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 progressive nature of the course of anaerobic infection is an indication for emergency or urgent surgical treatment, which should be performed after a short-term preliminary preoperative preparation, which consists in the elimination of hypovolemia and gross violations of homeostasis. In patients with septic shock, surgical intervention is possible only after stabilization of 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. The maximum pathological changes in 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. A wide dilution of skin-fat flaps, a circular exposure of a group of affected muscles with a dilution of intermuscular fiber is sufficient to stop the process with adequate intensive detoxification and targeted 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 the 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 in this situation, amputation or disarticulation of the limb is indicated. 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 in the case of 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 complex surgical treatment of patients with anaerobic infection is local wound treatment.

The use of one or another dressing 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 by 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 surgery of a purulent 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 underwent late surgery, 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 an 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.

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Anaerobic infection from the very beginning should be considered generalized, since the toxins of anaerobic microbes have an extraordinary ability to penetrate protective barriers and aggressiveness towards living tissues.

Clinical forms of anaerobic infection. In practice, only clostridia and anaerobic gram-positive cocci can cause monoinfection. Much more often, the anaerobic process proceeds with the participation of several species and genera of bacteria, both anaerobic (bacteroids, fusobacteria, etc.) and aerobic, and is designated by the term "synergistic". The following forms of anaerobic wound infection:

1) Anaerobic monoinfections:

- clostridial cellulitis, clostridial myonecrosis;

Anaerobic streptococcal myositis, anaerobic streptococcal cellulitis.

2) Polymicrobial synergistic (aerobic-anaerobic) infections:

Synergistic necrotizing fasciitis;

Synergistic necrotic cellulitis;

Progressive synergistic bacterial gangrene;

Chronic perforating ulcer.

Regardless of the form of anaerobic infection, a zone of putrefactive fusion, a zone of necrosis and phlegmon, and an extensive zone of serous edema, represented by living tissues abundantly saturated with toxins and anaerobic enzymes, are formed in the wound, without clear boundaries.

Diagnosis of anaerobic infection. Anaerobic character wound infection is detected in the presence of at least one of the pathognomonic local signs:

1) fetid putrid smell of exudate;

2) the putrefactive nature of necrosis - structureless detritus of gray, gray-green or brown color;

3) gas formation, detected by palpation, auscultation (crepitus) and radiography (cellular pattern with cellulite, pinnate - with myositis);

4) discharge of the wound in the form of a liquid exudate of a gray-green or brown color with droplets of fat;

5) microscopy of Gram-stained smears of wound discharge reveals a large number of microorganisms and absence of leukocytes:

the presence of large gram-positive rods with a well-defined capsule indicates a clostridial infection;
gram-positive cocci in the form of chains or clusters cause anaerobic coccal monoinfection;
small gram-negative rods, including spindle-shaped, are bacteroids and fusobacteria.

Symptoms characteristic of any form of wound infection during the development of anaerobic infection have the following features:

The nature of the pain: increases rapidly, ceases to be stopped by analgesics;

The absence, especially in the initial period of development, of pronounced external signs of inflammation against the background of severe toxicosis: slight hyperemia of the skin, pastosity, absence of purulent formation, serous nature of inflammation of the tissues surrounding the necrosis zone, dull and pale appearance of the tissues in the wound;

Signs of toxicosis: pallor of the skin, icterus of the sclera, severe tachycardia (120 beats per minute or more) always “overtaking” the temperature, euphoria is replaced by lethargy, anemia and hypotension are rapidly growing;

Dynamics of signs: having appeared, the symptoms increase rapidly within one day or night (anemia, symptom of "ligature", tachycardia, etc.).

Surgical treatment of anaerobic infection. Choice method in the surgical treatment of anaerobic infections is secondary debridement. It has the following features:

Radical necrectomy within the affected area (limb segment) with mandatory wide Z-shaped fasciotomy throughout the affected area (case, limb segment);

Additional drainage of a non-sutured wound through counter-openings in the lowest parts of the region with 2-3 thick (more than 10 mm in diameter) tubes;

Filling the wound with napkins constantly wetted with a 3% hydrogen peroxide solution, carbon sorbents;

On the limbs, additionally, fasciotomy of all muscle cases outside the affected area is performed in a closed way to decompress the muscles, improve blood circulation in the tissues; "lamp incisions" are not performed, because they do not solve the problem of detoxification, they are additional entrance gates of infection and cause severe injury;

Performing incisions at the border of the serous edema zone to ensure the outflow of tissue fluid with a high concentration of exotoxins and prevent their spread.

With the established non-viability of the segment (s) of the limb affected by the anaerobic process, its amputation, which can be performed in two versions:

Amputation according to the type of surgical treatment of the wound in compensated and subcompensated (according to the scale "VPH-SP or SG") the state of the wounded and the possibility of preserving the overlying joint;

Amputation or disarticulation within healthy tissues in a minimally traumatic way is performed in an extremely severe (decompensated according to the “VPH-SP or SG” scale) condition of the wounded, unable to endure a longer and more thorough surgical treatment.

Features of amputation in case of anaerobic infection:

With a non-viable limb, the level of amputation is determined by the level of dead muscles, the operation is performed with elements of surgical treatment in order to preserve viable tissues necessary for the subsequent closure of the wound;

Be sure to perform a wide opening of all fascial cases of the affected muscle groups on the stump;

It is advisable to pre-tie up the main vessels at a level that preserves the blood circulation of the stump, and if possible, do not use a tourniquet;

The operation is performed only under general anesthesia;

Regardless of the type of operation, suturing the wound is unacceptable;

Repeated scheduled daily surgical revisions (under anesthesia) of the wound with necrectomy are required up to the complete cleansing of the wound.

Intensive conservative therapy of anaerobic infection.

1. Preoperative preparation. Stabilization of hemodynamics and elimination of hypovolemia is achieved by introducing crystal-like solutions with 10-15 million units of penicillin, polyglucin in combination with cardiovascular analeptics in a total volume of 1.0-1.5 liters within 0.5-1.5 hours.

Neutralization of toxins: enzyme inhibitors (gordox 200-300 thousand U, countercal 50-60 thousand ATR); stabilization and protection of biological membranes: corticosteroids (prednisolone 90–120 mg), pyridoxine 3–5 ml of a 5% solution; introduction into the circumference of the focus of a large amount of a solution (250–500 ml or more) containing novocaine, antibiotics (penicillin, clindamycin), nitroimidazoles (mepidazole 100.0 5% solution), enzyme inhibitors (gordox 200–300 thousand units), corticosteroids (hydrocortisone 250-375 mg, prednisolone 60-90 mg) to slow down the spread of the inflammatory-exudative process.

2. Intraoperative therapy. Infusion and transfusion therapy continues, providing an antitoxic effect (protein preparations, albumin, plasma) and eliminating anemia. The operation ends with the repeated introduction of the solution into the area of inflammatory tissue edema. A large amount of liquid injected to wash the tissues affected by exotoxins performs an essential antitoxic function. wound cavity loosely it is drained with gauze strips soaked in a solution of hydrogen peroxide, detergents or antiseptics with a two-three change of the drug during the day. A highly effective means of conservative treatment is the use of carbon sorbents in a similar way.

Guidelines for military surgery

One of the most serious wound complications in war is anaerobic infection. During the Second World War, it was observed on average in 1-2% of the wounded. On the lower extremities, it occurred 5 times more often than on the upper ones, the lethality reached 20-55%. Amputations were performed in 40-60% of the wounded. Academician N.N. Burdenko, Chief Surgeon of the Red Army during the Second World War wrote:

“The past war posed a number of theories and practical problems in the medical field. As such, I consider: 1) early diagnosis of anaerobic infection; 2) introduction of toxoid in case of anaerobic infection; 3) the problem of deep antiseptics”.

It is assumed that in the conditions of modern combat operations, complications of anaerobic infection are observed even more often, due to the special severity of injuries during the use of nuclear missile weapons and new types of firearms, the use of bacteriological weapons, incl. containing and pathogens of gas infection. These factors may acquire particular importance in conditions of mass sanitary losses.

Information about gas infection has been available since ancient times. Vivid descriptions of the clinic of this severe complication confirmed the unified picture that we are currently observing. In 1835, Mesonnet isolated the disease into an independent form and aptly named it "fulminant gangrene". The name not only survived until recently, but also served as the basis for the modern definition - "gas gangrene". The merit of N.I. Pirogov. He associated anaerobic infection with warfare and gave an exhaustive analysis of the causes contributing to its spread during "traumatic epidemics".

Wound anaerobic infection has more than 70 names.

At the same time, for a clearer idea of the essence of the process and a more complete definition of it, the term “anaerobic infection of wounds” should be preferred at present. This term has the advantage that it reflects the presence of a complication associated with tissue infection and indicates the etiology of the disease (presence of anaerobic infection). A.N. Berkutov suggested calling this disease "a particularly dangerous wound infection", given in this case the high contagiousness of the complication.

Etiology, pathogenesis and classification of anaerobic infection

The leading role in the pathogenesis of anaerobic infection belongs to the localization of the wound and the characteristics of the entrance gate of infection, the nature of microbial pathogens. Of great importance is the reduction of the body's immunological defenses (exhaustion, beriberi, blood loss, traumatic shock, overwork, etc.).

It has been established that gunshot shrapnel wounds are most often complicated by anaerobic infection. Gunshot wounds are known to

3 damage zones: wound channel, zone of primary necrosis, zone of molecular shaking. In the last zone, in areas located closer to the zone of primary necrosis, secondary tissue necrosis develops due to irreversible changes in them due to the action of a temporary pulsating cavity. It is also very important that along with the fragments, pieces of clothing and shoes, pieces of earth get into the wound. The degree of microbial contamination of such wounds is very significant. In addition, the wound channel is most often geometrically complex, with multiple blind pockets in the muscles. The contents of the wound channel and dead tissue in the areas of primary and secondary necrosis are an excellent nutrient medium for microbes that have entered the wound. On the other hand, tissue resistance is sharply reduced.

In the action of microbes and toxins, the phases of edema, gas formation are conditionally distinguished, and then muscle necrosis follows. Edema and gas spread in the muscle, subcutaneous tissue, carrying microbes with them, moving them far into healthy tissues. The process spreads rapidly in the muscle layer and hardly passes through the fascia, which serves as a natural barrier to its spread. The transfer of bacteria can occur through the lymphatic pathways and blood vessels. The demarcation line, as a rule, is not marked.

Classification of anaerobic infection(according to A.N. Berkutov, 1955):

I. By the rate of spread - a) rapidly spreading;

b) slowly spreading.

II. According to clinical and morphological parameters -

a) gas forms;

b) gas-edematous forms;

c) putrid-purulent forms.

III. According to anatomical features -

a) deep (subfascial);

b) superficial (epifascial).

The advantage of this classification is that using it, you can always formulate a dynamic diagnosis that can serve as a guide to action.

Currently, all clostridia are divided into 3 groups:

I gr. - cl. perfringens, cl. edematiens and cl. septicum, which have pronounced toxicogenic and proteolytic properties, causing the "classic" form of gas gangrene.

II gr. - cl. sporogenes, cl. histoliticum, cl. falax. They have a more pronounced proteolytic effect, but less toxicogenic properties.

III gr. - polluting microorganisms (contaminants) - class. tertium, cl. butricum, cl. Sartagoforum, etc.

A three-degree classification of anaerobic infection has become widespread:

Simple hyperculomic process

2. Clostridial cellulitis.

3. Clostridial myonecrosis or gas gangrene.

Traditionally the term "anaerobic infection" applied only to infections caused by Clostridium. However, in modern conditions, the latter are involved in infectious processes not 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.

Anaerobic infection occupies a special place due to the exceptional severity of the course of the disease, high mortality (14-80%), and frequent cases of severe disability in patients.

By and large, anaerobic infections include infections 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 natural habitat of Clostridia is the soil and the large intestine of humans and animals.

Anaerobic endogenous infection develops when conditionally pathogenic anaerobes appear in places that are unusual for their habitat. Penetration of anaerobes into tissues and the bloodstream occurs during surgical interventions, injuries, invasive manipulations, decay of tumors, translocation of bacteria from the intestine in acute diseases of the abdominal cavity and sepsis.

For all anaerobic infections, regardless of the location of the focus, there are a number of very characteristic clinical signs):

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 soluble products of anaerobic metabolism of bacteria in water (hydrogen, nitrogen, methane, etc.).

Most anaerobic infections have a violent onset. Symptoms of severe endotoxicosis (high fever, chills, tachycardia, tachypnea (rapid breathing), 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 pre-hospital, and sometimes in-hospital, 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 the treatment of anaerobic infections, surgery and complex intensive care are of primary importance. Surgical treatment is based on radical CHO with subsequent re-treatment of an extensive wound and its closure with available plasty methods.

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.

With CHOGO, it is necessary to remove all non-viable tissues, regardless of the extent of the lesion. 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. Do 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, the development of sepsis and worsening of the prognosis of the disease.

The department of purulent surgery of GKB29 has accumulated global experience in the treatment of this nosology. Timely diagnosis, adequate amount of surgical intervention are the basis for a favorable outcome in the management of patients with anaerobic infection. Given the severity of the condition of the patients, the specialists of the intensive care unit provide great assistance in the treatment. The presence of modern antibacterial drugs, dressings, qualified paramedical and junior medical personnel, as well as a competent attending physician, as the head of the treatment process, create the conditions for a comprehensive and adequate fight against this formidable disease. Also, the department performs the whole range of reconstructive plastic surgery after stopping the purulent process.

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 non-clostridial infection has no tendency to intrahospital spread, therefore, the sanitary and hygienic regimen for patients with this pathology must comply with the general requirements adopted 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; elevated oxygen pressure. 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 aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

Anashism

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