Infectious and non-infectious diseases of the skin of newborns. Purulent-septic diseases of newborns: etiology, clinic, treatment, prevention
INFECTIOUS DISEASES OF THE NEWBORN
Pyoinflammatory diseases include localized purulent infection and sepsis. In newborns, the line between local and generalized forms of purulent infection is arbitrary, since there is often a rapid transition of the local inflammatory process to a generalized infection. For the development of a purulent-inflammatory disease, certain conditions are necessary: reduced immunological reactivity of the child, the presence of an entrance gate and the massiveness of the infection, the virulent properties of microbes. The causative agents of diseases can be various microorganisms. Most often, purulent-inflammatory diseases are caused by gram-negative flora, staphylococcus aureus, streptococcus, often by a microbial association. Infection can occur in utero, during the birth of a child, or after childbirth.
Sources of infection are patients (medical staff, mothers, children), healthy bacteria carriers, as well as care items, medical equipment and tools. The infection is spread by airborne, contact, alimentary routes, in utero. The spread of infection is facilitated by violations of the sanitary and hygienic regime.
LOCALIZED PURULENT-INFLAMMATORY DISEASES
Localized purulent infection. It is a purulent-inflammatory process, limited to the limits of one organ. Localized purulent infections include: diseases of the navel (omphalitis), skin forms of purulent-inflammatory diseases (pyoderma), glandular lesions (mastitis), inflammatory diseases of the mucous membranes (conjunctivitis, etc.).
Omphalitis - inflammation of the skin and subcutaneous tissue in the navel. Allocate primary and secondary omphalitis. Primary omphalitis develops as a result of early infection of the umbilical wound; secondary - associated with the addition of infection against the background of congenital anomalies (incomplete umbilical, yolk or urinary fistula). Secondary omphalitis manifests itself at a later date and proceeds for a long time. By the nature of the inflammatory process, catarrhal, phlegmonous and necrotic omphalitis are distinguished.
Catarrhal omphalitis develops with delayed epithelialization of an infected umbilical wound. It is clinically characterized by limited hyperemia and swelling of the umbilical ring, proliferation of granulation tissue at the bottom of the umbilical wound with serous-purulent discharge. The general condition of the child remains satisfactory, the blood test remains unchanged.
Phlegmonous omphalitis develops when the inflammatory process spreads to tissues adjacent to the umbilical ring. The disease often begins with symptoms of catarrhal omphalitis. A few days later, a purulent discharge appears from the umbilical wound. The skin around the navel becomes hyperemic, edematous, the umbilical region protrudes somewhat above the surface of the abdomen. Characteristic is the expansion of the vessels of the anterior abdominal wall (strengthening of the venous network) and the appearance of red stripes due to the addition of lymphangitis. Sometimes the process passes to the umbilical vessels (vein and arteries), which become thickened and are palpated in the form of tourniquets above and below the umbilical ring. The patient's condition is disturbed. The child becomes lethargic, sucks badly at the breast, burps, there is a change in body weight (stop or fall). Body temperature is elevated. In the peripheral blood - signs of an inflammatory reaction.
With the spread of inflammation along the umbilical vessels, the development of thrombosis of the umbilical veins and the generalization of the process with the transition to sepsis are possible. Omphalitis can lead to phlegmon of the abdominal wall and peritonitis.
Necrotic omphalitis is rare, is a complication of phlegmon of the umbilical region in children with low immunity. The skin becomes purple-cyanotic. Tissue necrosis quickly spreads to all layers with the formation of a deep wound. This form of omphalitis is the most severe, accompanied by severe intoxication and ends in most cases with sepsis.
pyoderma- a group of acute and chronic, superficial and deep purulent-inflammatory diseases of the skin.
Vesiculopustulosis- one of the most common forms of pyoderma. The disease is characterized by the appearance on the skin of superficially located small vesicles 1-3 mm in size, filled with transparent exudate. The contents of the bubbles quickly become purulent - a pustule is formed. After 2-3 days, the elements are opened, surface erosions appear, which dry out and epithelialize. Elements are located mainly in the back of the head, neck, skin folds, on the back, buttocks.
The number of pustules may vary. With small rashes, the general condition of the child is not disturbed. Untimely treatment and a decrease in immunity can lead to generalization of the infection.
Pemphigus of newborns is a special form of skin lesions and refers to highly contagious diseases. It is characterized by the appearance on the skin of superficial, flaccid blisters of various sizes (usually 0.5 - 2 cm in diameter) with a red rim at the base. Bubbles can be located on any part of the body, with the exception of the palms of the feet. The number of rashes ranges from single to multiple. Elements tend to quickly spread or merge. The serous contents of the blisters after 1-2 days takes on a serous-purulent character. Rashes occur in jolts, so the rash is polymorphic: some blisters soon dry up, others, exfoliating the epidermis, increase in size, and others open, exposing the eroded surface. The epithelialization of eroded areas proceeds rapidly, pale pink spots with scalloped or rounded outlines remain in their place for a long time. The general condition of the child is not disturbed, and with a favorable course of the disease, recovery occurs in 2-3 weeks. With abundant rashes, the condition may worsen: the temperature rises, anxiety appears, the child sucks sluggishly, there is a stop increase or decrease in body weight. The disease can take a septic course.
Exfoliative dermatitis of the newborn (Ritter's disease)) is the most severe form of neonatal pemphigus. The disease begins with redness and maceration of the skin in the navel, inguinal folds, around the mouth. Within 1-2 days, erythema spreads throughout the body, then patchy detachment of the epidermis occurs with the formation of extensive eroded surfaces. The process develops rapidly, the skin of the face, trunk and extremities comes off in layers. The general condition is severe due to the septic course of the disease. Sometimes there is no erythema, the skin has a normal appearance, but with the slightest friction, the epidermis easily exfoliates (positive Nikolsky's symptom).
With multiple skin abscesses (pseudofurunculosis) the inflammatory process develops in the excretory ducts of the sweat glands. Abscesses are localized in places subject to friction and pollution (skin of the scalp, back of the neck, back, buttocks, limbs). In the beginning, pustules appear, prone to reverse development. Then, in their place or nearby, bluish-purple nodes appear, ranging in size from a pea to a hazelnut. In the center of the inflammatory focus fluctuation is planned. When an abscess is opened, thick greenish-yellow pus is released. After healing, a scar remains. Multiple abscesses are accompanied by severe intoxication. The disease proceeds for a long time and in waves.
Phlegmon of newborns- severe purulent-inflammatory disease of the skin and subcutaneous tissue. The chest, lumbosacral and gluteal regions are most commonly affected. In the first hours of the disease, a limited area of hyperemia forms on the skin, it increases in size, edema and induration appear. On the 2-3rd day, a softening area appears in the center of the infiltrate, the skin over it becomes cyanotic. At the site of softening, fistulas form, through which shoy is released. Extensive tissue necrosis develops rapidly. From the 5th - 6th day, necrotic areas are torn off, and an extensive wound with undermined edges is formed. In severe cases, muscles are involved in the process. Surgical treatment.
Purulent mastitis- usually occurs against the background of physiological engorgement of the mammary glands. Contribute to the development of the disease pyoderma, mechanical irritation (squeezing out the secret). In most cases, there is a unilateral enlargement of the gland. The inflammatory process is accompanied by edema, hyperemia, often softening in the center. Pus is secreted from the excretory ducts of the breast. The process can be complicated by phlegmon.
G.V. Yatsyk, E.P. Bombardirova, Yu.S. Akoev
Diseases of this group are among the most frequent in children of the neonatal period. Their share in the structure of diagnoses in neonatal pathology departments approaches 70-80%, which is due to the immaturity of the barrier functions of the skin and mucous membranes of the newborn, reduced resistance to bacterial infection.
The group of local purulent-inflammatory foci conditionally combines the so-called small infections - omphalitis, navel fistula, dacryocystitis, pustular rashes, as well as serious diseases - phlegmon and pemphigus of newborns, osteomyelitis. The etiology of most of these diseases is gram-positive microorganisms (staphylo- and streptococci), in 1/4-1/3 cases - gram-negative microbes (Klebsiella, Escherichia coli, Pseudomonas, etc.).
Omphalitis (“weeping navel”) is a purulent or serous inflammation of the umbilical wound, accompanied by the appearance of a serous or purulent discharge, infiltration and hyperemia of the umbilical ring, delayed epithelialization of the wound. Perhaps a combination with an incomplete fistula and fungus of the navel.
Local treatment: treatment with aqueous and alcoholic solutions of antiseptics (furatsilin, chlorophyllipt, brilliant green, potassium permanganate), lysozyme; the use of a helium-neon laser, with significant infiltration - Vishnevsky's ointment, with necrotic changes - sea buckthorn and rosehip oil. The fungus of the navel is cauterized once a day with a lapis stick. Antibiotics can be used both locally (irrigation, ointments) and parenterally, taking into account the sensitivity of the flora sown from the umbilical wound and the severity of the inflammatory process.
Fistula of the navel
Fistula of the navel is a congenital anomaly of development, which is the result of non-closure of the vitelline duct or urinary tract, existing in the early embryonic period and obliterating by the time of birth. The fistula is complete and incomplete.
clinical picture. After the umbilical cord falls off, a fistulous opening is found, from which the mucous membrane of a bright red color protrudes and the intestinal contents are released (complete fistula of the vitelline duct). With a complete fistula of the urinary tract, there is no spherical protrusion of the mucous membrane at the bottom of the umbilical fossa, but there is an area of weeping surface with a fistulous opening in the center. Urine is expelled from this opening when straining. Incomplete fistulas proceed with the phenomena of slight weeping of the navel, the skin around which may be macerated.
Diagnosis. Suspicion of a congenital fistula of the navel occurs in all cases of prolonged non-healing of the umbilical wound, the presence of discharge from it. Often, an incomplete fistula is difficult to determine visually. For specification of the diagnosis and differentiation of full and incomplete fistula the X-ray fistulography can be shown.
Treatment. A complete fistula is subject to surgical treatment upon diagnosis, an incomplete fistula - at the age of over 1 year.
Vesiculopustulosis
Vesiculopustulosis - superficial staphyloderma of newborns. The process is localized in the mouths of the eccrine sweat glands. Asthenization and immune deficiency are important in formula-fed children. Contributing factors are most often overheating, excessive sweating, maceration.
clinical picture. Follicular pustules the size of a millet grain or pea are located throughout the skin, but are more often localized on the back, in the folds of the skin, on the neck, chest, in the buttocks and on the scalp, accompanied by subfebrile body temperature. Possible complications such as otitis, bronchopneumonia, pyelonephritis.
Treatment. During the period of illness, it is not recommended to wash and bathe the child. Lesions and visible healthy skin are treated with antiseptic agents: a solution of furacilin 1: 5000, a 0.1% solution of rivanol (ethacridine lactate), a 0.1-0.2% solution of potassium permanganate, aniline dyes. Pastes with 1% erythromycin, 1% lincomycin, ointments (erythromycin, heliomycin, lincomycin, rivanol, streptocid) are applied directly to the foci of pustular elements.
Epidemic pemphigus of the newborn (pemphigoid of the newborn)
Epidemic pemphigus in newborns is caused by pathogenic Staphylococcus aureus, sometimes (in 1.6% of cases) by Staphylococcus aureus in association with other microorganisms (strepto-, diplococci). The disease is a generalized purulent lesion in children of the first days of life with insufficient immune reserves, an unfavorable prenatal history, and the possible presence of foci of chronic infection in parents.
clinical picture. A multiple disseminated polymorphic rash is found. Evolutionary polymorphism of elements is characteristic: blisters, pustules-conflicts, erosion at the site of opened blisters, layering of serous-purulent crusts. Localization - the skin of the trunk, limbs, large folds. The process extends to the mucous membranes of the mouth, nose, eyes and genitals, accompanied by hyperthermia, asthenia, diarrhea, reactive changes in the blood and urine. Severe septic complications are possible.
Exfoliative dermatitis of the newborn (Ritter's disease)
Exfoliative dermatitis of the newborn is a severe form of epidemic pemphigus of the newborn. It is characterized by a state of erythroderma with multiple blisters, extensive erosive surfaces. Nikolsky's symptom is positive. Deprived of the epidermis, areas of the skin resemble a second-degree burn. There are three stages of the disease: erythematous, exfoliative and regenerative. In severe cases, the process proceeds septically with weight loss, toxicosis, gastrointestinal disorders, anemia, and dysproteinemia.
The contagiousness of staphyloderma in newborns is high. Infection is possible in the presence of a nosocomial infection, as well as in utero through the placental circulation.
Treatment. Perhaps parenteral administration of semi-synthetic penicillins (methicillin, oxacillin, etc.), which have the ability to inhibit the production of epidermolytic toxin and microbial flora resistant to penicillase. Fusidin sodium, lincomycin hydrochloride and cephalosporin derivatives - cephaloridine (ceporin), cephalexin and cefazolin (kefzol) are used as antibiotics with a specific antistaphylococcal action. Sulfanilamide drugs are rarely prescribed due to their lack of effectiveness and possible toxic-allergic complications. Simultaneously with antibiotics, intravenous immunoglobulins (nitraglobin, octagam, sandoglobin) are used. For the purpose of detoxification, intravenous albumin, native plasma, 10% glucose solution are administered dropwise, hemosorption or plasmapheresis is carried out. With intestinal dysbacteriosis, eubiotics are prescribed (bifidumbacterin, bifikol, bactisubtil, lactobacterin, etc.). Vitamin therapy is indicated, especially ascorbic acid, pyridoxal phosphate, calcium pantothenate or pangamate, vitamins A and E.
Bubbles open or suck their contents with a syringe. The skin around the blisters is treated with aniline dyes, 0.1-0.2% alcohol solution of sanguirythrin, 1-2% salicylic alcohol. The resulting erosions are subjected to UV irradiation followed by treatment with ointments and pastes containing antibiotics: Dioxycol, Dioxifen, Levosin, heliomycin, erythromycin, lincomycin.
Of particular importance due to the contagiousness of the process is child care, including daily change of linen, daily baths with a solution of potassium permanganate (1:10,000). Careful observance of the hygienic regime is necessary, ultraviolet irradiation of the wards is mandatory. If possible, children suffering from staphyloderma are placed in boxes. Breastfeeding is maintained or, in case of hypogalactia in the mother, the child is transferred to donor breast milk.
Staphylococcal pyoderma
Distinguish superficial and deep forms. Superficial include ostiofolliculitis, folliculitis; to deep ones - hydradenitis, furuncle, carbuncle.
Ostiofolliculitis is a purulent inflammation of the mouth of the hair follicle with the formation of a superficial conical pustule pierced in the center by a hair. When suppuration spreads deep into the follicle, folliculitis occurs. A deeper purulent-necrotic inflammation of the hair follicle and surrounding tissues with the formation of a necrotic rod is called a furuncle. The furuncle of the face is dangerous due to the possible metastasis of the infection with the development of a septic condition and meningitis.
Hidradenitis is a purulent inflammation of the apocrine sweat glands, more often in the axillary fossa, as well as in the anus, genitals. Pathogenetic factors are the same as for all staphylococcal processes, but increased sweating and an alkaline reaction of sweat have an additional effect.
streptococcal pyoderma
Streptococcal pyoderma is manifested by the main primary pustular element - conflict. The most common types of pyoderma in children are superficial streptococcal lesions - impetigo and deep - ecthyma. Streptococcal impetigo is manifested by a superficial bubble - conflict. Localization: face, skin of the trunk, limbs. In the corners of the mouth, conflicts quickly open up, and the erosive surface transforms into a longitudinal crack (jam). On the nail phalanges of the hands, conflicts surround the nail in a horseshoe-like manner, forming periungual impetigo (tourniole). With combined superficial streptostaphylococcal infection, impetigo vulgaris occurs, which is characterized by significant contagiousness, a tendency to dissemination in various parts of the skin.
Treatment. With widespread superficial and deep streptostaphyloderma, antibiotics are prescribed (taking into account the data of the antibiogram and individual tolerance) in combination with intravenous immunoglobulin preparations, as well as immunomodulators, vitamins A, E, C. Externally - aniline dyes, 2% salicylic camphor alcohol, 2-5 % levomycetin alcohol, followed by the application of pastes and ointments with antibiotics and antibacterial drugs. Physiotherapy is indicated: UV irradiation, magneto-laser therapy, light therapy with a polarized light lamp "Bioptron".
In the prevention of pyoderma in children, a rational diet, sanitary and hygienic measures in the ante-, inter- and postnatal periods are most effective.
Middle exudative otitis media
Otitis media is characterized by the presence of serous exudate in the middle ear cavity. The cause may be allergic processes in the nasopharynx, improper use of antibiotics. The accumulation of serous exudate limits the mobility of the auditory ossicles and the tympanic membrane, which leads to the development of conductive hearing loss. On otoscopy, the eardrum has a hazy gray-yellow to purple color, depending on the color of the exudate.
Treatment: sanitation of the nasopharynx, restoration of the patency of the auditory tube. In the absence of effect, puncture of the tympanic membrane, evacuation of exudate and the introduction of hormonal drugs are indicated.
Acute osteomyelitis
Acute osteomyelitis is a purulent inflammation of the bone tissue, the causative agent of which can be any pyogenic microorganism.
The disease begins acutely. The first symptom is a sharp pain in the limb, from which the child screams and avoids any movement. Older children localize the pain strictly, in younger children it manifests itself with particular anxiety when they are picked up or shifted. Body temperature rises to 39-40°C. Vomiting, diarrhea are observed. External signs of osteomyelitis may initially be absent. On palpation, the place of greatest pain can be established only in older children. As the process develops, when it passes to soft tissues, local swelling appears, the configuration of the limb changes. The skin becomes edematous and hyperemic. The adjacent joint is deformed.
The clinical course of acute osteomyelitis depends on the virulence of the microorganism and the reactivity of the child's body, the age of the patient, etc. There are three forms of the disease: toxic, septic-pyemic, local. The first is characterized by a stormy onset, the phenomena of sepsis predominate, and the patient often dies before local changes have had time to manifest themselves. The second form is observed more often than others. Local phenomena are clearly expressed, combined with a general septic reaction; sometimes several bones are affected at once, purulent metastases are observed in other organs.
Recognition is difficult in young children, especially newborns. If osteomyelitis is suspected, the ends of long tubular bones and joints are especially carefully examined, an X-ray examination is performed. Early radiological signs appear in young children on the 7-10th day, in older children - on the 10-12th day of illness. At the beginning of the disease in the blood - leukocytosis, shift of the leukocyte formula to the left; in severe cases, leukopenia is often observed. Surgical treatment.
Dacryocystitis of the newborn
Dacryocystitis in newborns is an inflammation of the lacrimal sac caused by incomplete opening of the nasolacrimal duct by the time of birth. It is manifested by lacrimation, mucopurulent discharge at the inner corner of the eye. When pressing on the area of the lacrimal sac, purulent contents are released from the lacrimal openings.
Treatment: massage the area of the lacrimal sac from top to bottom to break the film and restore the patency of the nasolacrimal duct. In cases where the patency of the nasolacrimal duct is not restored within a week, the ophthalmologist probing and washing the lacrimal ducts.
PURULENT-INFLAMMATORY DISEASES AND SEPSIS IN NEWBORN AND INFANT CHILDREN.
Lecture for 5th year students of the Medical Faculty of RUDN University
Despite the expansion of the range of antibacterial drugs used, the improvement of nursing and a number of other organizational and therapeutic and preventive measures, the incidence of purulent-inflammatory diseases (PID) in newborns has practically not decreased over the past few decades. According to the literature, in 1995, out of 126 million children born alive, 8 million (6%) died in the first year of life, with 5 million in the neonatal period and a significant part in the 2nd and 3rd months of life ( B. J. Stoll, 1997). A large share in the structure of neonatal mortality is occupied by severe HL, and the main causes of death in almost all countries of the world are severe pneumonia, meningitis and sepsis.
One of the causes of deaths in severe HL is the imperfection of the immune system of newborns and children in the first months of life, known as transient immunodeficiency. Another objective reason is a certain range of HL pathogens in newborns and its change. The latter is due to both medical interventions (immunization, the use of antibiotics, immunomodulators, new methods of nursing newborns, as well as an increase in the number of premature, especially very premature newborns, etc.), and biological evolutionary changes in the microflora.
Purulent-inflammatory diseases in newborns and young children occur in children in 2 forms - localized and generalized. Localized purulent-inflammatory diseases include lesions of various organs and are the most common pathological manifestations. The generalized form includes sepsis, which can occur in the form of septicemia with a clinic of infectious toxicosis and septicopyemia with manifestations of infectious toxicosis in combination with local purulent foci, often multiple.
Most often in newborns and infants, purulent-inflammatory diseases affect those organs that are in contact with the environment (skin and mucous membranes, gastrointestinal tract, respiratory tract), which is associated with the immaturity of barrier functions and reduced resistance of children of these age groups to to bacterial infection. The etiology of most of these diseases is gram-positive microorganisms (staphylococci and streptococci), in 1/4-1/3 cases - gram-negative microbes (Klebsiela, Escherichia coli, Pseudomonas).
It was noted that the spectrum of causative agents of severe HL in newborns differs significantly in developing and industrialized countries. In particular, in developing countries, the etiology of neonatal sepsis is characterized by a large role of pathogens such as Staphylococcus aureus,Streptococcuspyogenes And Escherichia coli. Quite often, the causative agents of sepsis are Pseudomonas spp.. And Salmonella spp.. In the same time S. agalactiae,Klebsiella spp.(whose role is high in the development of sepsis in newborns in industrialized countries) are rarely detected.
In newborns, localized purulent-inflammatory diseases were classified in the presented table ...
Purulent-inflammatory lesions of the skin or pyoderma are divided into staphyloderma and streptoderma, although some of these forms can be caused by both microorganisms.
Vesiculopustulosis- superficial staphyloderma of newborns. The process is localized in the mouths of the eccrine sweat glands (staphylococcal periporitis)
Pseudofurunculosis(multiple abscesses) - staphylococcal lesion of the entire eccrine sweat gland. It differs from a boil in the absence of a dense infiltrate and a characteristic necrotic "rod"
Pemphigus- epidemic pemphigus of newborns - one of the types of staphylococcal skin lesions, occurring in benign and malignant forms.
The benign form is characterized by the appearance at the end of the first week of life or later, against the background of redness, vesicles and flaccid blisters 0.2-0.5 cm in size, filled with a translucent fluid containing pus. Localization - the lower abdomen, arms, legs, inguinal, cervical and other folds of the skin, less often - other parts of the body. All layers of the skin are affected to granular. More often, pustules are multiple, rashing in groups, but there may be single ones. Nikolsky's symptom is negative.
The malignant form also develops at the end of the first week of life, but with it there are multiple flaccid blisters (conflicts) ranging in size from 0.5 to 2-3 or more cm in diameter, the skin between them is exfoliated. Nikolsky's symptom is positive. The temperature is above 38 degrees C, the condition is serious - in addition to lethargy, lack of appetite, intoxication phenomena are expressed - pallor, increased respiration, palpitations, vomiting. The disease is highly contagious and usually ends in sepsis.
It is necessary to differentiate pemphigus from bullous epidermolysis and syphilitic pemphigus of newborns. Epidermolysis bullosa is a hereditary disease, blisters appear from birth on apparently healthy skin, mainly on protruding areas subjected to friction, filled with serous, serous-purulent or hemorrhagic contents. In dystrophic forms, cicatricial atrophy remains at the site of the blisters.
Syphilitic pemphigus can be detected already at birth or appear in the first days of life. Blisters are localized on the palms and soles, occasionally - on other parts of the skin. At the base of the blisters there is a specific infiltrate, so the blisters are surrounded by a reddish-purple rim. When the bubbles open, the eroded surface is exposed.
Ritter's exfoliative dermatitis- a severe form of epidemic pemphigus of the newborn. It is caused by hospital strains of Staphylococcus aureus, which produce exotoxin - exfoliatin. It begins at the end of the 1st beginning of the 2nd week of life with redness, weeping of the skin and the formation of cracks, then flaccid blisters. St. Nikolsky is positive. The child has the appearance of being burned with boiling water. The process proceeds septically with weight loss, toxicosis, gastrointestinal disorders, anemia, dysproteinemia. Similar to this disease, but in children of older age groups, staphylococcal scalded skin syndrome (SSSS) occurs.
The contagiousness of staphyloderma in newborns is high. Infection is possible in the presence of a nosocomial infection, as well as in utero through the placental circulation.
Epidemic pemphigus, EPDR, SSS must be differentiated from congenital hereditary skin diseases that occur with epidermal detachment (epidermolysis bullosa, congenital ichthyosis), where the process affects all layers of the skin, including the basal, and skin lesions of a non-purulent nature (Stevens Johnson and -m Lyell - toxic epidermal necrolysis), having an allergic, or toxic-allergic etiology. These diseases can occur at any age.
Impetigo- one of the forms of pyoderma, a highly contagious disease, it is caused by both streptococci and staphylococci. Eczema, pediculosis, scabies and fungal infection predispose to the development of impetigo. Purulent blisters first appear on the face - around the mouth and nose - and very quickly spread to other parts of the body. The blisters dry up and form crusts. Streptococcal impetigo differs from staphylococcal impetigo in the golden color of the crusts. The causative agent of ordinary (non-bullous) impetigo, as a rule, is Streptococcus pyogenes, but in this case, staphylococci can cause superinfection.
Impetigo can occur as a primary (on clean skin) and as a secondary infection (against the background of another dermatosis). Superficial pustules are characteristic, which, after opening, become covered with yellowish-brown (honey) crusts. Staphylococci sometimes cause bullous impetigo. bullous impetigo- Superficial skin infection (tense blisters with clear contents) caused by Staphylococcus aureus. Under the action of Staphylococcus aureus exfoliatins, epidermal detachment and the formation of blisters 1-2 cm in diameter occur, in the contents of which neutrophils and staphylococci are found. At first, the rash appears around the nose and mouth, then quickly spreads to other parts of the body, blisters with purulent contents appear. After the bubbles open, crusts form. Children under 5 years of age are especially susceptible to the disease; dissemination of the infection can lead to death.
One of the manifestations of impetigo is slit-like impetigo (angular stomatitis, seizure).
Intertriginous streptoderma - occurs on the contact surfaces of large skin folds. In mild cases, a fairly common finding during routine checkups, requiring nothing more than good wrinkle hygiene and simple zinc paste preparations. In severe cases, conflicts up to 1 cm in size are formed, merging with each other. After opening, erosive weeping surfaces of red or pink color with scalloped edges form, infection occurs, requiring the use of topical antibiotics, sometimes with very short-term use of mild corticosteroid ointments to relieve swelling.
With poor care in children, mixed staphylococcal streptococcal intertrigo often occurs, characterized by a greater degree of hyperemia and swelling of the affected skin. So it is very important to carefully examine the folds, especially in children with paratrophy, with excessive sweating, diabetes.
Ectima- ulcerative form of streptoderma, sometimes of mixed etiology. The disease is facilitated by a decrease in the overall reactivity of the body due to past infections and severe general diseases.
Ecthyma develops as a result of streptococci getting into the depths of the skin, under the epidermis. In this regard, not a conflict is formed, but a deep, against the background of an inflammatory infiltrate, a bubble or an epidermal-dermal pustule the size of a large pea or more. A bubble or pustule quickly shrinks into a serous-hemorrhagic or purulent-hemorrhagic crust, immersed in the thickness of the skin and bordered by a zone of soft hyperemia. After removal of the crust, an ulcer with sheer edges is found, which fills with granulations over time. In the natural course of ecthyma, granulations develop under the crust, which is gradually forced out of the ulcer, then disappears, leaving a scar surrounded by a border of hyperpigmentation.
The penetration of streptococci into the depths of the skin is due to microtraumas, itchy dermatoses. Ecthymas are usually multiple, often linear (in the course of scratching).
erysipelas- acute recurrent infectious disease of the skin and subcutaneous tissue caused by streptococcus. Erysipelas in children proceeds similarly to adults.
In newborns, erysipelas begins most often with the navel or fingers. Very quickly, erysipelas migrates ("traveling erysipelas", "stray erysipelas"). Erythema in erysipelas in newborns may not be as intense as in older children or adults, but swelling, infiltration of the skin, subcutaneous tissue is always present. The edges of the lesion have a zigzag contour, but the restrictive roller is not expressed. Newborns may also have the so-called "white" erysipelas, when there is no redness, and blisters, subcutaneous abscesses and necrosis sometimes appear in the affected area.
The disease begins with high fever and chills. At the same time, dense areas of reddening of the skin appear, warm to the touch and with jagged edges.
Sometimes the onset of the disease can be insidious - without or with a slight increase in temperature. Then the general condition progressively worsens, the body temperature remains at 39-40 ° C, the child becomes lethargic, refuses to breastfeed, digestive disorders appear, myocarditis, nephritis, meningitis, sepsis develops. The death rate of newborns from erysipelas is extremely high. Erysipelas are just as dangerous for children of the first year of life.
Infectious diseases of the umbilical wound occur in the form of catarrhal omphalitis(weeping navel), purulent omphalitis - bacterial inflammation of the bottom of the umbilical wound, umbilical ring, subcutaneous fatty tissue around the umbilical vessels. Positive symptom of Krasnobaev.
Phlegmon of newborns- one of the most severe purulent-inflammatory diseases of the skin and subcutaneous adipose tissue of newborns, starting with the appearance of a red spot on a small area of the skin, usually dense to the touch, in the future, 4 stages can be distinguished in its development. initial stage It is characterized by the rapid spread of the process deep into the subcutaneous fatty tissue, the purulent expansion of which is ahead of the rate of skin change. Alternative necrotic stage occurs after 1-1.5 days - the color of the affected area of the skin acquires a purple-bluish hue, softening occurs in the center. The rejection stage is characterized by the necrosis of exfoliated skin. In the stage of repair, the development of granulations, epithelialization of the wound surface, followed by the formation of scars.
Mastitis in newborns- a serious disease that begins against the background of physiological engorgement of the mammary glands. It is clinically manifested by an increase in one gland, its infiltration, redness, then fluctuation appears. A purulent discharge appears from the excretory ducts.
Osteomyelitis- inflammation of the bone marrow, spreading to the compact and spongy substance of the bone. Staphylococci enter the bone hematogenously from foci in the skin or nasopharynx, often the gates of infection cannot be identified. Children are more likely to suffer from osteomyelitis, the usual localization is the metaphyses of long tubular bones, in newborns the epiphyses of the femur and humerus are more often affected. A predisposing factor is a recent limb injury. Initially, symptoms of intoxication predominate, with high fever and confusion; later there are severe pains in the affected limb, aggravated by movement. At an early stage, the number of leukocytes in the blood is within the normal range or lower, later neutrophilic leukocytosis develops. X-ray changes usually appear after 2-3 weeks from the onset of the disease, bone scintigraphy allows you to make a diagnosis faster. With a breakthrough of pus from under the periosteum into the soft tissues, skin hyperemia and fluctuation appear.
Sepsis.
A generalized form of purulent-inflammatory infection with an acyclic course, caused by opportunistic bacterial microflora, the basis of the pathogenesis of which is the rapid development of a systemic (generalized) inflammatory response of the body (SVR) in response to a primary septic focus.
SVR is a general biological non-specific immunological reaction of the human body in response to the action of a damaging endogenous or exogenous factor.
The systemic inflammatory response is characterized by an increase in the production of pro-inflammatory cytokines and, to a lesser extent, anti-inflammatory cytokines produced by almost all cells of the human body, including immunocompetent ones. This direction of the SVR mediator response to a stimulus is referred to as SVR with a predominantly pro-inflammatory orientation.
The main clinical manifestations of adequate SVR include: an increase in body temperature (hyperthermia), an increase in the number of heart contractions (tachycardia), an increase in the number of breaths (tachypnea), hyperventilation of the lungs, an increase in the number of leukocytes in the peripheral blood (leukocytosis), an increase in the number of immature leukocytes (metamyelocytes, myelocytes , stab) in peripheral blood
Along with it, SVR with a predominantly anti-inflammatory orientation of the mediator response can be observed. One of the most severe and least managed is a mixed antagonistic reaction or SVR dysregulation, the so-called "mediator storm", "mediator chaos". Rapid, inadequate action of the damaging factor, the development of SVR ultimately contributes to induced apoptosis and, in some cases, cell necrosis, which determines the damaging effect of SVR on the body.
The regulation of SVR is carried out through the activation of the hypothalamic-pituitary-adrenal system, which normally provides the body's response to stress. In this regard, pronounced manifestations of SIRS are accompanied by an increase in the secretion of adrenocorticotropic hormone (ACTH) in the adenohypophysis with a corresponding stimulation of the hormonal activity of the adrenal cortex and an increase in the level of cortisol in the blood.
Thus, sepsis is a systemic inflammatory response of the body to infection. In children of senior school age and adults, sepsis syndrome (sepsis without PON), severe sepsis as a manifestation of sepsis with multiple organ failure, septic shock (sepsis with hypotension) are distinguished. Newborns and young children, due to the physiological characteristics of the immune system, tend to generalize the body's reactions to excessive exposure to damaging factors (infections), sepsis always occurs with multiple organ failure. In newborns, congenital sepsis is also isolated, which is divided into early, which occurred in the first 72 hours from birth and late, the symptoms of which appeared on days 4–6, and also acquired, with onset after 7 days. Downstream, lightning is distinguished - 1 - 7 days, acute 4-8 weeks and protracted more than 8 weeks.
The frequency of sepsis.
According to T. E. Ivanovskaya in 1978-1982. sepsis was found in 4.5% of the dead children, among them newborns (92.3%) and, in particular, premature babies predominated.
According to the results of autopsies conducted in the Leningrad Regional Children's Pathological and Anatomical Bureau (LODPAB), the frequency of sepsis in the structure of total child mortality was 1% in 2000, 1.4% in 2001 and 1% in 2002, 9%, while the proportion of newborns among children who died from sepsis did not exceed 50%.
According to foreign authors, the frequency of sepsis among newborns ranges from 0.1 to 0.8%. Of particular concern are children in intensive care units and premature newborns, among whom the incidence of sepsis is on average 14% (from 8.6% among premature infants with a gestational age of 31 to 38 weeks to 25% among premature infants). with a gestational age of 28 to 31 weeks).
In the Russian Federation, in the structure of neonatal mortality, sepsis has occupied the 4-5th place over the past decades, averaging 4-5 cases per 1000 live births. Mortality rates from sepsis are also fairly stable at 30-40%.
Among older children, sepsis occupies 7-10 places in the structure of mortality.
Features of the status of newborns, causing increased sensitivity to infections:
1. Reduced chemotaxis, low bactericidal activity of phagocytes, low level of properdin, C3, IgM, IgA
2. Low expression of HLA-2 class molecules → immaturity of presentation mechanisms, including by dendritic cells.
4. Propensity to differentiate in the direction of T-x 2 → IL4, IL13 → increased sensitivity to infections
5. Low production of IL12, IL15 in response to stimulation → low production of IL2, γIFT cells → low cellular cytotoxicity
6. Low production of TNFα,GM-CSF,M-CSF
7. The NK function is suppressed.
8. Low expression of CD21 on neonatal B-lymphocytes
High risk factors for neonatal sepsis:
Death of previous children in the family from systemic bacterial infections under the age of 3 months (suspicion of hereditary immunodeficiency).
Numerous abortions in history, preeclampsia in the mother, which lasted more than 4 weeks.
Clinically diagnosed bacterial vaginosis in the mother during pregnancy and childbirth.
Clinically pronounced bacterial infectious processes in the mother immediately before and during childbirth, including pyelonephritis, chorioamnionitis.
Detection of streptococcus B or its antigens in the mother in the birth canal.
Anhydrous interval more than 12 hours.
The birth of a child with very low and especially extremely low body weight.
Fetal tachycardia without maternal fever, hypotension, blood loss, or medication that causes tachycardia.
Birth asphyxia or other pathology that required resuscitation benefits and prolonged abstinence from enteral nutrition.
Surgical operations, especially with extensive tissue trauma.
Congenital malformations with damaged skin, burns.
Type 1 SDR and pulmonary edema.
Multi-day catheterization of the umbilical and central veins.
intrauterine infections.
Multiple malformations or stigmas of dysembryogenesis.
classification of sepsis.
|
Time and conditions of development |
Entrance gate (localization of the primary septic focus) |
Clinical forms |
Manifestations of multiple organ failure |
|
Neonatal sepsis: Late out-of-hospital hospital Against the background of immunodeficiency states |
Umbilical Pulmonary Intestinal rhinopharyngeal Rhinoconjunctival Otogenic Urogenic Abdominal Post-catheterization |
Septicemia Septicopyemia |
Septic shock Acute pulmonary failure Acute heart failure Acute renal failure Acute intestinal obstruction Acute adrenal insufficiency cerebral edema Secondary immune dysfunction, etc. |
Etiology of sepsis
Etiology of early neonatal sepsis
Streptococcus agalactiae (group B beta-hemolytic streptococcus)
Listeria monocytogenes
Etiology of late neonatal sepsis
representatives of the Enterobacteriaceae family (E.coli, Klebsiellaspp., Serratia marcescens, Proteus spp., Citrobacter diversus and others)
Rarely found: Pseudomonasaeruginosa, Flavobacterium meningosepticum, Staphylococcusaureus, Staphylococcus epidermidis, Enterococcus spp. and fungi of the genus Candida
Extremely rare: Streptococci belonging to serological groups A, D and E; and Streptococcus pneumoniae, which are highly sensitive to natural penicillins and all other beta-lactams
The pathogenesis of sepsis
The development of organosystemic damage in sepsis is primarily associated with the uncontrolled spread of pro-inflammatory mediators of endogenous origin from the primary focus of infectious inflammation, followed by activation under their influence of macrophages, neutrophils, lymphocytes and a number of other cells in other organs and tissues, with secondary release of similar endogenous substances, damage to the endothelium. and decreased organ perfusion and oxygen delivery.
Dissemination of microorganisms may be absent altogether or be short-lived and subtle. However, even this breakthrough can trigger the release of pro-inflammatory cytokines at a distance from the focus. Exo and endotoxins of bacteria can also activate their hyperproduction from macrophages, lymphocytes, endothelium.
The total effects exerted by mediators form a systemic inflammatory response syndrome.
There are three main stages in its development.
Stage 1 - local production of cytokines in response to the action of microorganisms. Cytokines act in the focus of inflammation and on the territory of reacting lymphoid organs, ultimately performing a number of protective functions, participating in the processes of wound healing and protecting body cells from pathogenic microorganisms.
Stage 2 - the release of a small amount of cytokines into the systemic circulation. A small amount of mediators can activate macrophages, platelets, the release of adhesion molecules from the endothelium, and the production of growth hormone. The developing acute phase reaction is controlled by pro-inflammatory mediators (IL1,6, 8, TNF (tumor necrosis factor) and anti-inflammatory cytokines (IL4, 10.13, TGF (transforming growth factor)). As a result of their balance, prerequisites are created for wound healing, destruction of pathogenic microorganisms The systemic adaptive changes in acute inflammation include stress reactivity of the neuroendocrine system, fever, release of neutrophils into circulation from the vascular and bone marrow depot, increased leukocytopoiesis in the bone marrow, overproduction of acute phase proteins in the liver, and the development of generalized forms of the immune response.
Stage 3 - generalization of the inflammatory response.
With severe inflammation, some cytokines (TNF, TGF, Il 1, 6, 10) accumulate in the systemic circulation, cause destructive changes in the microcirculatory bed, impaired capillary permeability, hypoxia, trigger DIC, multiple organ failure and the formation of distant metastatic foci.
Options for the course of sepsis:
Hyperergic variant of sepsis
Acute intranatal asphyxia of moderate severity during childbirth
Clinical data for IUI, long and massive courses of antibiotics, surgery, HDN, BPD, long-term parenteral nutrition, catheter care defects
Early, violent onset, acute course, deep depression of the central nervous system up to coma, with short-term signs of arousal, meningoencephalitis is possible.
Early arterial hypotension, short-term inotropic support in medium doses.
Persistent hyperthermia is typical.
"marbling", spotty-petechial rashes
Often - respiratory distress syndrome of the adult type, pneumonia lobar, sometimes destructive.
Characterized by vomiting and regurgitation, a rapid drop in body weight.
Foci of infection are often one or almost simultaneous appearance of several.
Urinary tract infections are not common.
DIC early, "overcompensated", undulating course
In laboratory tests:
Anemia normochromic, regenerative erythrocytes > 3.0x1012/l, Hb-110 g/l.
Leukocytosis (in 90%) neutrophilia (in 85%) with a regenerative shift, in 18% - leukemoid reaction (up to 65 thousand per 1 μl.) toxic granularity.
Absolute monocytosis from the first days
80% have eosinophilia.
Hyperbilirubinemia (97 µmol/l) during the first day of life, unconjugated bilirubin significantly increased in dynamics.
Fluctuations in hemostatic parameters with a pronounced tendency to hypercoagulability (shortening of APTT, PT, PTT), an increased content of the main anticoagulants (AT III and α1 AT), plasminogen, fibrinogen, higher platelet aggregation with adrenaline.
7. Vitamin therapy.
2. Sanitation of foci of infection.
studfiles.net
Purulent-septic diseases in infants
PURULENT-SEPTIC DISEASES
For the development of purulent-septic diseases, several factors are of great importance.
The first factor: Phagocytic activity is significantly reduced, phagocytosis is incomplete, in children passive immunity is mainly associated with IgG, which are transferred to the child from the mother through the placental barrier (for other immunoglobulins it is impassable), the active response is quickly depleted.
The second factor: all internal organs of excretion take part in the elimination of bacteria and toxins from the body (purulent foci easily appear).
The third factor: the protective barriers of the skin and mucous membranes are imperfect: the thickness of the epidermis is reduced by almost 30% of that of adults; the basement membrane between the epidermis and the dermis is poorly developed, so the epidermis is easily separated from the dermis (bubbles quickly appear during infection); protective functions are poorly developed during stretching, trauma, compression; a significant amount of toxins and metabolic products are released.
Bacterial infections in children mainly occur with local lesions, primarily of the skin, conjunctiva and umbilical wound, and then other organs. Generalization of the process occurs only in the presence of an unfavorable background, at present it is mainly with concomitant intrauterine infection or postnatal infection with especially virulent pathogens or their significant number.
Typical pathogenic microorganisms that infect and cause diseases in the perinatal period:
group B beta hemolytic streptococci
Escherichia coli
Streptococcus pneumoniae
Staphylococcus aureus
Chlamydia trachomatis and others
Typical pathogens that cause diseases in the postnatal period:
Enterococcus, etc.
Staphylococcus aureus
Staphylococcus epidermidis
Pseudomonas aerugenosa
candida albicans
Esphericia coli
Klebsiella pneumoniae
LOCAL PURULENT-SEPTIC DISEASES
It is observed in newborns, in children of the first month of life and at an early age. The pustule is the size of a pinhead, sometimes larger, localized in the natural folds of the skin on the trunk, scalp, limbs. The temperature is normal, the general condition is rarely disturbed. The duration of the disease is from several days to several months. Vesiculopustulosis can cause multiple skin abscesses and cellulitis.
Treatment: elements of vesiculopustulosis are removed, the erosive surface is treated with a 1% solution of aniline dyes (brilliant green, methyl violet) or a 2% solution of potassium permanganate. Antibacterial therapy, as a rule, is not carried out.
VEMBULOSIS OF THE NEWBORN
It develops more often at 1-2 weeks of life. Bubbles appear in diameter from 0.5 to 2 cm, from single to many tens. There is a red rim around the bubble. The contents are initially transparent, but soon cloudy. The integrity of the blisters is quickly broken and an erosive surface is exposed, often bleeding. Frequent localization - neck, abdomen, limbs. Rashes in jerks, the rash is polymorphic. The general condition of the child worsens, symptoms of infectious toxicosis appear. The severity corresponds to the degree of skin damage: temperature up to 38-40. The child becomes lethargic, takes the breast poorly, loose stools appear, poor weight gain. The duration of the disease is up to 2-3 weeks. Pemphigus is the most contagious form of staphyloderma.
Treatment: local - the blisters are opened, the erosive surface is treated with aniline dyes (as with vesiculopustulosis); general - antibiotic therapy, taking into account the sensitivity of microorganisms in the usual therapeutic doses, usually in one course of 7-10 days.
Ritter's exfoliative dermatitis
The most severe form of pemphigus in newborns. It starts on the 4th-6th day, sometimes on the 2nd-3rd day of life. Hyperemia and maceration of the skin around the mouth and navel appear, the process spreads very quickly to the trunk and limbs, the epidermis exfoliates, blisters form, they quickly burst, exposing extensive erosions. On the extremities, the skin comes off in layers in the form of stockings or gloves. The prognosis for this disease is extremely poor. Rarely seen at present.
Treatment: local - treatment with antiseptic drugs, antibacterial suspensions, ointments. General - active antibacterial combination therapy (the best combination is 3-4 generation cephalosporins + aminoglycosides); septic doses (2 times higher than therapeutic); repeated courses until the effect is achieved. Infusion therapy for the purpose of detoxification and correction of hypovolemia (a large amount of fluid is lost from the erosive surface) - plasma, plasma substitutes, klistalloids.
phlegmon of newborns
A very serious disease with damage not only to the skin, but also to the subcutaneous tissue. This is a purulent-necrotic lesion. Infection occurs either through the skin or hematogenously. Initially, a spot appears - an area of hyperemia, surrounded by a purple ring. Reminds me of erysipelas. The spot increases, the skin and subcutaneous tissue are torn off, and a site of necrosis is formed. The most common localization of phlegmon is the back surface of the body, less often the limbs, neck, and chest are affected. The main feature in this disease is the extremely rapid spread of necrosis (several hours, days) and an increase in the size of the lesion. The general condition is very difficult. Symptoms of infectious toxicosis are expressed. With phlegmon, early diagnosis and urgent surgical intervention are necessary. In severe cases, muscles can be involved in the process, tissues become dead, torn away right down to the bones. The prognosis in such cases is unfavorable.
Treatment: local - the affected area is opened (cuts are made in a checkerboard pattern of 1.5-2 cm within healthy tissues, drainage); then a bandage is applied with a hypertonic solution (25% solution of magnesium sulfate, changed every 8-12 hours). General - combined antibiotic therapy, taking into account the sensitivity of microorganisms, if this is not possible - starting therapy with 3-4 generation cephalosporins + aminoglycosides (septic doses, 2 times higher than therapeutic doses with the maximum possible frequency of administration, preferably intravenously). Infusion therapy for the purpose of detoxification and correction of metabolic disorders. This disease very often leads to the development of a generalized process (sepsis) with a skin entrance gate.
pseudofurunculosis
It often develops in children after the neonatal period. The inflammatory process is localized in the excretory ducts of the sweat glands, which are relatively wide in young children, most often it is the scalp. It is more correct to speak of a multiple abscess of the skin.
Nodules of a bluish-purple color are formed, ranging in size from a pea to a hazelnut. In the center of the inflammatory focus, fluctuation is quickly outlined. When the abscess is opened, thick greenish-yellow pus is released. After healing, a scar is formed. Multiple abscesses in children are sometimes accompanied by symptoms of infectious toxicosis.
Treatment: local - hair is shaved, the head is well washed with soap and treated with antiseptic aniline dyes, abscesses are opened and bandages are applied with hypertonic solution. General - antibacterial parenteral therapy is carried out with extensive damage and always in the presence of symptoms of infectious toxicosis. Course 7-10 days. Doses are normal.
PURULENT MASTITIS OF NEWBORN
As a rule, a consequence of unreasonable manipulations during the period of physiological engorgement of the mammary glands (which does not require external influences). The mammary gland becomes infected, engorgement, edema, induration, hyperemia appear. Then fluctuation is determined, sometimes regional lymph nodes increase. General condition or normal, but worsens more often; there are symptoms of infectious toxicosis.
Treatment: local - opening with the help of incisions in a checkerboard pattern with the capture of soft tissues, then a bandage with hypertonic solution, drainage. General - antibiotic antibiotic therapy, taking into account sensitivity, 7-10 days, in usual doses.
DISEASES OF THE UMBILIC WOUND
Physiology. With the modern method of processing the umbilical cord residue (imposing a metal bracket), the umbilical cord residue falls off on 3-5 days, less often later. In a healthy child, the wound is covered with epithelium within a few days. Fully epithelialization occurs by 12-14 days. Infection can occur both during the initial treatment of the umbilical cord, and during further care of the umbilical cord and umbilical wound. It should also be recalled that after the initial treatment of the umbilical cord, 2 thrombi form in the umbilical arteries, which are the most common localization of infection.
weeping navel
The umbilical wound becomes wet, a serous or serous-purulent discharge is formed, which dries into crusts.
Pyorrhea of the navel.
Discharge from the umbilical wound acquires a purely purulent character and accumulates in large quantities in the umbilical fold.
Purulent omphalitis.
The most severe form of the disease of the umbilical wound. The inflammatory process extends to the skin and subcutaneous tissue around the navel. The skin around the navel turns red, infiltrated, the umbilical region noticeably protrudes, pus is released, and ulceration is sometimes observed. There are symptoms of infectious toxicosis, fever.
General principles of treatment: proper treatment of the umbilical wound; it is good to expand the umbilical ring and treat with a solution of hydrogen peroxide, then with a cotton flagellum, abundantly moistened with a solution of antiseptic liquids (use a 1% solution of brilliant green, or a 3-5% solution of potassium permanganate), treat the walls and bottom of the umbilical wound). With purulent omphalitis, after treatment with hydrogen peroxide, a bandage is applied with 25% magnesium sulfate, and after 2-3 hours - a bandage with an antibiotic emulsion. Physiotherapy is used on the navel area: UHF, UVI. If the infiltration is significant and captures the umbilical region, fluctuation is determined, incisions are made in a checkerboard pattern, then hypertonic saline, drainage. General therapy - antibiotics, taking into account the sensitivity of 7-10 days. at the usual dose, however, given that the umbilical wound is most often the entrance gate for sepsis, it is necessary to very accurately determine the effectiveness of the therapy, possibly with the replacement of the drug with low treatment productivity.
PURULENT CONJUNCTIVITIS
In a newborn and children of the first months of life, this is a fairly common disease. As a rule, it is associated with infection during childbirth, or postnatally in the maternity hospital. The physiological basis is the presence in a significant part of newborns of a violation of the patency of the nasolacrimal canal.
Symptoms: lacrimation on one or both sides and purulent discharge from slight to copious.
Treatment: in the absence of dacryocystitis - instillation into the conjunctiva or a 20% solution of sodium sulfacyl, and preferably a 0.25% solution of chloramphenicol. With congenital dacryocystitis - probing the nasolacrimal canal to restore patency, followed by instillation of the above solutions.
phlegmon of the lacrimal sac
Complication of congenital dacryocystitis. There is hyperemia and edema in the area of the lacrimal sac on the side of the lesion or on both sides, the tissues are infiltrated. In the corner of the eye appears profuse purulent discharge, thick, like a paste from a tube. The child cannot open his eyes in the morning. The general condition is disturbed: symptoms of infectious toxicosis appear.
Treatment: local: as with dacryocystitis, sometimes an additional antibiotic is introduced into the infiltration area (preferably ampicillin). The nasolacrimal canal is probed. General: parenteral administration of antibiotics is carried out, taking into account the sensitivity of 7-10 days, under the control of the condition, since if the treatment is ineffective, the disease quickly passes into:
PHEGMON OF THE ORBIT
Inflammatory process in the area of retrobulbar tissue. Exophthalmos appears, the condition is very serious, severe symptoms of infectious toxicosis with high fever. Treatment: the same, but antibiotics are injected into the area of retrobulbar tissue, and parenterally, combined therapy with the most optimal antibacterial drugs is started. With severe intoxication, infusion therapy is also carried out for the purpose of detoxification.
ETMOIDITIS
Inflammation of the ethmoid sinuses. As a rule, a complication of orbital phlegmon or orbital phlegmon. Exophthalmos, a very serious condition, severe toxicosis with hemodynamic disturbances. Treatment in conjunction with an otolaryngologist, who opens the ethmoid sinuses to ensure the outflow of purulent contents. Antibiotics are prescribed taking into account their accumulation in bone tissue (fortum, klaforan, longocef, dardum, etc.). Infusion therapy is carried out for detoxification and correction of metabolic disorders.
For the development of sepsis, certain conditions are necessary:
unfavorable premorbid background (intrauterine infection, both viruses and bacteria;
postnatal infection with especially virulent microorganisms or their large number;
morpho-functional immaturity; prematurity;
prolonged presence of local foci of infection, etc.),
failure of the immune system (secondary or primary immunodeficiencies),
irrational antibiotic therapy in the early neonatal period (suppression of the dominant flora and growth of the subdominant), etc.
The development of the septic process takes time: with intranatal and postnatal infection, the process develops after the interaction of macro and microorganism after about 2 weeks. However, with intrauterine infection - it can be lightning fast.
Sepsis classification
1. Depending on the entrance gate: - skin, pulmonary, umbilical, otogenic, intestinal, renal, cryptogenic (with unidentified entrance gate)
2. By etiology: - staphylococcal, streptococcal, pneumococcal, caused by opportunistic flora, meningococcal, etc.
3. According to the clinical picture:
Septicopyemia (presence of purulent foci),
Septicemia (toxemia),
4. Downstream:
Sluggish (subacute, protracted).
Criteria for a generalized process.
Signs and symptoms of a bacterial infection:
1. Clinical signs of sepsis:
respiratory distress syndrome of unknown etiology,
feeding intolerance of unclear etiology (frequent regurgitation, vomiting, anorexia, flattening of the weight curve, malnutrition),
temperature instability,
drowsiness, irritability,
discoloration of the skin (pallor, subicteric, gray coloration),
bloating, dyspeptic disorders,
hepatosplenomegaly,
depression of the functions of the central nervous system.
For clinical practice, the totality of these manifestations is important, each individual cannot be the basis for asserting the presence of an infection.
2. Laboratory signs of sepsis.
1. Peripheral blood:
leukocytosis or leukopenia,
neutrophilia, shift to the left,
early anemia,
thrombocytopenia,
accelerated ESR.
2. Hemorrhagic syndrome (vitamin K deficiency, DIC, thrombocytopenia):
hematuria, etc.
increased bleeding at the injection site,
3. Biochemical blood test:
hypoproteinemia,
hypoalbuminemia,
dysproteinemia,
increased ALT, AST in hepatitis,
increase in C-reactive protein, DPA.
4. Positive results of the study of blood culture at the height of fever.
5. The presence of several foci of inflammation.
6. Edema syndrome: edema mainly in the area of the anterior abdominal wall, pubis and lower extremities.
7. Change in parenchymal organs:
hepatomegaly (toxic liver damage, or hepatitis with direct hyperbilirubinemia),
splenomegaly - less often.
8. Temperature reaction is not typical.
UMBILICAL SEPSIS
Entrance gate: umbilical wound. As mentioned earlier, in a child, blood clots form in the umbilical arteries (2) after separation of the umbilical cord. Let me remind you that the umbilical arteries carry venous blood. Under adverse conditions, infection occurs, thromboembolism of the umbilical vessels develops, a local process, and then generalization.
Clinical picture:
1. Symptoms of infectious toxicosis, listed earlier.
2. Local symptoms:
damage to the umbilicus and blood vessels,
a symptom of a “secondarily” opened navel,
bloating (venous network, shiny surface of the anterior abdominal wall),
Krasnobaev's symptom (tension of the rectus abdominis muscle on the side of the affected vessel),
palpation of the umbilical vessels,
the appearance of pus in the umbilical wound (tube symptom).
Diagnosis is established on the basis of local symptoms, the previously listed criteria for the septic process and laboratory parameters.
PRINCIPLES OF TREATMENT OF THE SIPTIC PROCESS
After the diagnosis of sepsis is established, a treatment program is developed. First of all, this concerns the nutrition of the child, given the presence of dyspeptic disorders.
1. Breastfeeding if mother's milk is sterile. In all other cases, feeding with adapted, better sour-milk mixtures.
a) the number of feedings 8-10 times a day (50 ml each), every 2-2.5 hours. Water load - up to 150-200 ml fractionally between feedings with boiled water.
b) after stopping the dyspeptic syndrome, a rapid transition to the physiological rhythm of nutrition.
2. Infection control:
broad-spectrum antibiotics, taking into account sensitivity, if it is defined, or combination therapy with 2 antibiotics (semi-synthetic penicillins + aminoglycosides or 3-4 generation cephalosporins + amiglycosides); doses are 2 times higher than therapeutic (septic); the maximum frequency of administration, taking into account the pharmacokinetics for this drug (at the half-life level, the concentration of the antibiotic should be bactericidal); the route of administration is intravenous (large doses of antibiotics are not absorbed from the muscles and bactericidal concentration is not created). Duration as needed (2-3 courses).
3. Pathogenetic therapy:
a) infusion therapy for the purpose of detoxification (combating infectious-toxic shock), correcting metabolic disorders (combating metabolic tissue acidosis, electrolyte disorders), improving hemodynamic parameters (eliminating symptoms of centralization of blood circulation), stopping DIC:
fresh frozen plasma
plasma substitutes,
polarizing mixture,
crystalloids,
KKB, vitamins, drugs stabilizing vascular and membrane permeability.
4. Passive immunization:
hyperimmune plasma intravenous drip every 3-4 days.
toxoids,
antitoxic serums.
immunoglobulins intravenously, drip.
It should be noted that it is impossible to immunize with vaccines in this state, since the child cannot synthesize antibodies in this situation.
5. Sanitation of foci of infection (this was mentioned earlier).
PREVENTION OF PURULENT-SEPTIC DISEASES
Before pregnancy - sanitation of foci of infection.
Constant monitoring of a pregnant woman with correction of identified violations (toxicosis, viral and bacterial diseases, etc.).
Prevention of infection in the hospital.
Refusal of uncontrolled prescription of antibiotics.
Careful care of the child in the neonatal period.
studfiles.net
17. Purulent-septic diseases of newborns.
Etiology: Escherichia coli, Klebsiella, Enterobacteria, Proteus, Pseudomonas aeruginosa. Infection of a child in the postnatal period occurs through the hands of personnel, the mother and through direct contact with a source of infection in the environment (diapers, equipment, infusion solutions, nutrient mixtures, etc. ).
The source of an intestinal infection can be a sick child, infected from the mother or from a bacillus carrier from among the medical staff.
1. Vesiculopustulosis is a skin form of purulent-inflammatory diseases of newborns. On the skin of natural folds, head, buttocks, small superficially located vesicles up to several millimeters in size appear, filled with transparent, and then cloudy contents due to inflammation in the mouths of the merocrine sweat glands. Vesicles burst 2-3 days after the appearance, and erosions are covered with dry crusts that do not leave scars or pigmentation after falling off. The course of the disease is usually benign. The general condition of children is not disturbed, but generalization of the infection is possible.
2. Pemphigus (pemphigus) of newborns is characterized by the appearance of vesicles up to 0.5-1 cm in diameter against the background of erythematous spots, filled with serous-purulent contents. Bubbles can be at different stages of development, have a slightly infiltrated base with a halo of hyperemia around the bubble. They are usually localized in the lower half of the abdomen, near the navel, on the extremities, in the area of natural folds. After opening the bubbles, erosions form. The condition of newborns may not be disturbed. Body temperature subfebrile. Recovery occurs in 2-3 weeks. With a malignant form of pemphigus, a lot of flaccid vesicles of predominantly large sizes appear on the skin - up to 2-3 cm in diameter. The condition of children is severe, symptoms of intoxication are expressed. The disease often ends in sepsis. Treatment consists in piercing the blisters and treating them with alcohol solutions of aniline dyes. Ultraviolet irradiation of the skin is advisable. If necessary, antibacterial and infusion therapy is carried out.
3. Pseudofurunculosis - inflammation of the mouths of the hair follicles with the further spread of the process to the entire sweat gland - an abscess occurs. The most common localization: the scalp, back of the neck, back, buttocks, limbs. As the size of abscesses increases (up to 1-1.5 cm), fluctuation appears, and pus appears at opening. Characterized by an increase in body temperature, symptoms of intoxication, possible lymphadenitis, the development of sepsis.
4. Mastitis of newborns develops against the background of physiological engorgement of the mammary glands. It is clinically manifested by enlargement and infiltration of the mammary gland. Hyperemia in the early days may be absent or mildly pronounced. Soon, hyperemia of the skin over the gland increases, fluctuation appears. From the excretory ducts of the mammary gland, when pressed or spontaneously, purulent contents are released. Palpation is accompanied by pain. The child's condition worsens: body temperature rises, symptoms of intoxication appear. The child cries, sucks badly, becomes restless. The disease is dangerous purulent-septic complications.
5. Erysipelas of newborns - streptoderma, begins more often in the navel, in the lower third of the abdomen, inguinal region, on the inner thighs, on the skin of the face. The disease quickly spreads to other areas of the skin through the lymphatic tract. It begins with the appearance of local hyperemia, infiltration of the skin and subcutaneous fatty tissue. The edges of the lesion are zigzag, there is no restrictive ridge. Altered skin is warm to the touch. Newborns may have a "white erysipelas", in which there is no hyperemia, and blisters with hemorrhagic contents, subcutaneous abscesses and necrosis appear in the affected area. The course of the disease is usually severe, the body temperature reaches 39-40 ° C, the condition of the children deteriorates rapidly, the child becomes lethargic, refuses to eat, diarrhea, myocarditis, and meningitis appear. Infectious-toxic shock may develop.
6. Phlegmon of newborns - acute purulent inflammation of the subcutaneous tissue. It can occur as a simple or necrotic phlegmon and as lymphadenitis. The most severe form of purulent-inflammatory process in the neonatal period is necrotic phlegmon of newborns. More often localized on the back and side of the chest, lumbar and sacral region, buttocks. The disease begins with the appearance at first of a small area of redness and swelling of the skin, dense and painful to the touch, without clear contours. The lesion is rapidly spreading. The skin acquires a purple-cyanotic hue, softening is noted in the center. By the end of the second day, the fluctuation becomes more pronounced, the nutrition of the exfoliated skin area is disturbed, signs of its necrosis appear - gray-cyanotic areas alternate with pale ones. After rejection of necrotic skin areas, wound defects are formed with undermined edges and purulent pockets. As a rule, with such a course of phlegmon, sepsis develops. The development of granulations and epithelialization of the wound proceed slowly, followed by the formation of scars.
The disease begins acutely. There are signs of intoxication: vomiting, dyspepsia, the occurrence of metastatic foci of infection.
7. Omphalitis of a newborn - inflammation of the skin and subcutaneous tissue in the navel. By the nature of the inflammatory process, it can be catarrhal, purulent and gangrenous.
a) Catarrhal omphalitis is characterized by the presence of serous discharge from the umbilical wound and a slowdown in the timing of its epithelization. Slight hyperemia and slight infiltration of the tissues of the umbilical ring are possible. The condition of the newborn is usually not disturbed. Local treatment: treatment of the umbilical wound 3-4 times a day with 3% hydrogen peroxide solution, then 70% ethyl alcohol solution and potassium permanganate solution, as well as UVI on the umbilical wound area.
b) Purulent omphalitis usually begins by the end of the first week of a child's life, often with symptoms of catarrhal omphalitis. A few days later, a purulent discharge from the umbilical wound appears, swelling and hyperemia of the tissues of the umbilical ring, infiltration of the subcutaneous tissue around the navel, as well as symptoms of an infectious lesion of the umbilical vessels. On the wall of the abdomen, red stripes are visible, characteristic of the attached lymphangitis. Superficial veins are dilated. With thrombophlebitis of the umbilical vein, a round cord is palpated along the midline of the abdomen above the navel, with thromboarteritis - on both sides below the navel and on the side. In the case of periphlebitis and periarteritis, the skin over the affected vessels is edematous, hyperemic. The disease is characterized by the presence of symptoms of intoxication of varying severity. Omphalitis can be complicated by the formation of purulent metastatic foci (osteomyelitis, ulcerative necrotic enterocolitis), the development of sepsis. In addition to local treatment, antibiotic therapy is mandatory.
c) Gangrenous omphalitis - practically does not occur in obstetric institutions.
8. Conjunctivitis and dacryocystitis of newborns - acute inflammation of the conjunctiva and lacrimal sac, characterized by edema, hyperemia of the conjunctiva and lacrimal sac with purulent or serous discharge from the eyes. When treating the disease, it is necessary to carefully remove purulent discharge with a separate cotton swab for the right and left eyes, with a slight movement from the lateral corner of the eye to the medial one. The conjunctival sac is washed several times a day with an antibiotic solution or isotonic sodium chloride solution. After washing, it is necessary to put an eye ointment (penicillin, erythromycin, etc.). In the presence of general manifestations of the disease, antibiotic therapy is performed.
9. Acute rhinitis of newborns - inflammation of the mucous membrane of the nasal cavity. It is characterized by profuse mucopurulent discharge from the nose. The accumulation of mucopurulent secretion makes it difficult for the child to breathe through the nose, which leads to the impossibility of sucking the mother's breast. The child becomes restless, sleep is disturbed, weight loss is observed. The inflammatory process from the nasal cavity easily spreads to the posterior pharynx, Eustachian tube and middle ear. When a secret accumulates in the nose, it is sucked off with a rubber balloon or an electric suction. Nasal passages can also be cleaned of secretions with swabs of sterile vaseline oil. Solutions of antibacterial drugs are instilled into the nose or gauze wicks moistened with them are inserted into each nasal passage for 5-10 minutes.
10. Acute otitis media of newborns - inflammation of the mucous membranes of the middle ear cavities in newborns. Serous otitis media is characterized by the appearance of a transudate in the tympanic cavity as a result of the spread of the inflammatory process from the nasal cavity or nasopharynx. Purulent otitis is accompanied by a sharp edema, infiltration of the mucous membrane of the tympanic cavity and the formation of purulent exudate in it. Clinically, otitis media in newborns proceeds imperceptibly at first. Inspection of the tympanic membrane is difficult. It may not change, but with increasing pressure in the cavity of the middle ear, it swells slightly. There is pain when pressing on the tragus of the auricle, the lymphatic nodule on the mastoid process increases. Babies are unable to suck due to pain when swallowing. Body temperature in purulent otitis media is almost always elevated, with serous otitis media it can be normal. Treatment is carried out in conjunction with an otolaryngologist. Apply dry heat and UHF to the area of the mastoid process (2-3 sessions). If necessary, parenteral antibiotics are administered.
11. Pneumonia of newborns - an inflammatory process of lung tissue.
Neonatal pneumonia begins in the first days of life. Characterized by poor sucking, lethargy, pallor of the skin, fever. Then signs of respiratory failure join. Percussion is determined by the shortening of the sound over individual sections of the lungs. Auscultation reveals small bubbling rales, inspiratory crepitus, and dry rales on exhalation. Tachycardia, muffled heart sounds are observed.
Pneumonia in premature babies is characterized by symptoms of intoxication, respiratory failure. Pronounced respiratory-metabsiptesky acidosis, hypoxia and hypercapnia. There is a drop in body weight, depression of the central nervous system, a decrease in muscle tone and reflexes, regurgitation, and vomiting. Arrhythmias and breath holding are characteristic. Auscultation always reveals an abundance of small moist rales, crepitus, congestion in the lungs.
Treatment includes the creation of a medical-protective regimen.
1. Infusion therapy. Colloidal solutions (albumin, plasma) are administered at the rate of 10-15 ml/kg per day. With acidosis, a 4% solution of sodium bicarbonate is administered.
2. Antibiotic therapy. Antibiotics are prescribed in accordance with the suspected or identified microflora.
3. Passive immunization - the appointment of immunoglobulin 0.2 ml / kg 3-4 times with an interval of 3-4 days and other immunomodulators. Interferon is instilled into the nasal passages every 2 hours.
4. Oxygen therapy is carried out through isotonic solutions of sodium bicarbonate or sodium chloride.
5. Physiotherapy in the acute period of the disease is reduced to the use of electrophoresis with aminophylline, novocaine, calcium preparations.
6. If a large amount of sputum accumulates, the respiratory tract is sanitized.
7. Vitamin therapy.
12. Newborn enterocolitis - inflammation of the mucous membrane of the small and large intestine. Etiology: Escherichia coli, Salmonella, Klebsiella, Proteus, Staphylococcus aureus. Infection occurs through the hands of adults caring for children. The source of infection can be the mother, the staff of the department, as well as other children who excrete the corresponding pathogen. Clinic: increased peristalsis, loose green stools with mucus. The child refuses to suck, becomes lethargic. Later, vomiting with an admixture of bile, swelling of the lower abdomen and genitals, constant flatulence, pain reaction of the child during palpation of the abdomen, stool retention or a rare stool that becomes less watery, but contains an abundance of mucus, often blood, appear. With frequent stools, regurgitation and vomiting, signs of dehydration develop. There is a significant loss of initial body weight.
Treatment: rational nutrition, adequate hydration therapy, antibiotic therapy, bifidumbacterin and bactisubtil,
13. Sepsis of newborns. The disease occurs due to the continuous or periodic penetration of a large number of bacteria into the blood with a defect in natural barriers against the background of a reduced or perverted immunity of the body.
Infection of the newborn can occur during pregnancy, at birth or in the early neonatal period. Depending on the period of infection, congenital septicemia and postnatal sepsis are distinguished.
Predisposing factors: carrying out resuscitation at the birth of a child; inhibition of immunological reactivity; increased risk of massive bacterial contamination; the appearance of a purulent-inflammatory disease in a child in the first week of life.
Etiology: opportunistic hospital strains - Escherichia and Pseudomonas aeruginosa, Proteus, Klebsiella, Enterobacter, Staphylococcus aureus and epidermal, Group B streptococci, Listeria, anaerobes.
Entrance gates: umbilical wound, injured skin and mucous membranes, intestines, lungs, less often urinary tract, middle ear, eyes.
Clinic. With septicemia, symptoms of intoxication are observed - changes in the behavior of the child, lethargy, weight loss, loss of physiological reflexes, fever, refusal of the breast, regurgitation, vomiting. General exhaustion develops. The skin acquires a gray, earthy color, yellowness of the skin and mucous membranes appears. Characterized by edematous syndrome (swelling of the anterior abdominal wall, limbs), hemorrhages on the skin, mucous membranes and serous membranes. Temperature from subfebrile to febrile. The liver is enlarged, the spleen is enlarged less frequently. Very often with sepsis, omphalitis phenomena are noted. An infected wound after the umbilical cord falls off does not heal well, gets wet, crusts form, which periodically fall off. The septicopyemic form is characterized by the appearance of purulent foci in various tissues and organs with a corresponding clinical manifestation.
The course of sepsis is fulminant (1-3 days), acute (up to 6 weeks), protracted (more than 6 weeks). Diagnosis: clinical examination, obtaining the growth of bacteria in blood cultures and other body fluids, laboratory parameters.
1. Organization of optimal care and feeding.
2. Sanitation of foci of infection.
3. The use of broad-spectrum antibiotics or the combined use of cephalosporins with aminoglycosides. In the future, the choice of antibacterial drugs is based on the results of sowing and determining the sensitivity of the isolated flora to antibiotics. With a protracted course of sepsis, metronidazole is included in the complex antibiotic treatment. Simultaneously with antibacterial drugs, it is recommended to use bifidum or lactobacterin 2-3 doses 3 times a day, as well as polyvalent pyobacteriophage or monovalent bacteriophages, antimycotic agents (nystatin, levorin, amphotericin B). 4. Vitamin therapy.
5. Immunocorrection - hyperimmune (specific and non-specific) plasma, 10-20 ml / kg of body weight; hyperimmune or conventional immunoglobulin; other immunomodulators (pentoxyl, licopid, sodium nucleinate).
6. Neutralization of toxins, maintaining water and electrolyte homeostasis, improving the rheological properties of blood, hemodynamics, increasing diuresis, restoring the acid-base state, replenishing energy and plastic needs, eliminating disturbed gas exchange and hypoxia.
Prevention: carrying out recreational activities among women, preventing miscarriage, monitoring the sanitary and epidemiological regime in maternity hospitals and child care facilities, timely identification of newborns at risk and increasing their resistance to infections, sanitation of identified foci of infection.
studfiles.net
Purulent-septic diseases in young children
Recently, purulent-septic infections have been leading in the structural distribution of morbidity and mortality rates in newborns. Most often, purulent-septic diseases in infants are caused by various pathogens, but more often by Staphylococcus aureus, which has a high resistance to environmental influences and rapid adaptation to drugs.
Infections enter the body of a newborn through the wound surface of the skin and mucous membranes, conjunctiva and gastrointestinal tract, umbilical vessels, umbilical wound. The causative agents of purulent-septic diseases, having penetrated into the body, provoke the formation of a primary septic focus. The primary septic focus during intrauterine infection is often localized in the placenta, in the organs of the pregnant woman.
The skin of newborns is most often infected. The clinical forms of such lesions are united under the general name pyoderma, which develops under the influence of such pyogenic microorganisms as gonococci, staphylococci, Pseudomonas aeruginosa, streptococci and others.
Purulent-septic diseases of newborns are divided into the following forms: generalized (sepsis and its complications) and local.
The most common purulent-septic diseases include vesiculopustulosis, also called superficial staphyloderma of newborns. The causes of the disease include maceration, excessive sweating, overheating. Localization of the process occurs at the mouth of the exocrine sweat glands, follicular pustules spread throughout the skin of the child.
With pseudofurunculosis, the inflammatory process covers the merocrine sweat glands (Finger's pseudofurunculosis, numerous abscesses of the sweat glands). The development of this disease is facilitated by immunodeficiency states, prematurity, and insufficient care. The disease is accompanied by fever, a violation of the general condition, rashes on the body.
Phlegmon of newborns belongs to severe forms of purulent-inflammatory diseases of the skin, often leading to the development of sepsis. The inflammatory process of the subcutaneous tissue is caused by infections that have entered the child's body through the skin or umbilical wound. Phlegmon begins with an increase in temperature, the formation of a limited painful area of compaction (usually on the chest, neck, in the sacrococcygeal region) with further formation in the center of the fistula area. With phlegmon, emergency surgical treatment is required.
Epidemic pemphigus, or neonatal pemphigoid, is the most contagious form of staphyloderma. This generalized skin lesion is manifested by a multiple polymorphic disseminated rash on the body, limbs, large folds, with further spread to the mucosa. The process can cause severe septic complications.
Such diseases also include purulent mastitis, which occurs with physiological engorgement (especially with pyoderma) of the mammary glands; omphalitis, an inflammatory process in the umbilical fossa; conjunctivitis (inflammation of the mucous membrane of the eyes); gonorrheal conjunctivitis.
Sepsis refers to independent infectious diseases. It is characterized by bacteremia, a variety of pathogens, a malignant course due to concomitant immunosuppression. Risk factors are a long anhydrous interval, premature birth, low birth weight of the newborn, birth asphyxia and other complications.
Prevention of diseases is best to start with antenatal protection of the fetus, timely detection and treatment of acute and chronic diseases of the future mother, systematic monitoring of the pregnant woman and the course of pregnancy. A significant role is given to the personal hygiene of the mother and medical staff in the maternity hospital, antiseptics, full breastfeeding.
The nose of a newborn does not breathe what to do
G.V. Yatsyk, E.P. Bombardirova, Yu.S. Akoev
Local purulent-inflammatory diseases of newborns
Diseases of this group are among the most frequent in children of the neonatal period. Their share in the structure of diagnoses in neonatal pathology departments approaches 70-80%, which is due to the immaturity of the barrier functions of the skin and mucous membranes of the newborn, reduced resistance to bacterial infection.
The group of local purulent-inflammatory foci conditionally combines the so-called small infections - omphalitis, navel fistula, dacryocystitis, pustular rashes, as well as serious diseases - phlegmon and pemphigus of newborns, osteomyelitis. The etiology of most of these diseases is gram-positive microorganisms (staphylo- and streptococci), in 74-1/3 cases - gram-negative microbes (Klebsiella, Escherichia coli, Pseudomonas, etc.).
Omphalitis
Omphalitis (“weeping navel”) is a purulent or serous inflammation of the umbilical wound, accompanied by the appearance of a serous or purulent discharge, infiltration and hyperemia of the umbilical ring, delayed epithelialization of the wound. Perhaps a combination with an incomplete fistula and fungus of the navel.
Local treatment: treatment with aqueous and alcoholic solutions of antiseptics (furatsilin, chlorophyllipt, brilliant green, potassium permanganate), lysozyme; the use of a helium-neon laser, with significant infiltration - Vishnevsky's ointment, with necrotic changes - sea buckthorn and rosehip oil. The fungus of the navel is cauterized once a day with a lapis stick. Antibiotics can be used both locally (irrigation, ointments) and parenterally, taking into account the sensitivity of the flora sown from the umbilical wound and the severity of the inflammatory process.
Fistula of the navel
Fistula of the navel is a congenital anomaly of development, which is the result of non-closure of the vitelline duct or urinary tract, existing in the early embryonic period and obliterating by the time of birth. The fistula is complete and incomplete.
clinical picture. After the umbilical cord falls off, a fistulous opening is found, from which the mucous membrane of a bright red color protrudes and the intestinal contents are released (complete fistula of the vitelline duct). With a complete fistula of the urinary tract, there is no spherical protrusion of the mucous membrane at the bottom of the umbilical fossa, but there is an area of weeping surface with a fistulous opening in the center. Urine is expelled from this opening when straining. Incomplete fistulas occur with phenomena of slight weeping of the navel, the skin around which may be macerated.
Diagnosis. Suspicion of a congenital fistula of the navel occurs in all cases of prolonged non-healing of the umbilical wound, the presence of discharge from it. Often, an incomplete fistula is difficult to determine visually. For specification of the diagnosis and differentiation of full and incomplete fistula the X-ray fistulography can be shown.
Treatment. A complete fistula is subject to surgical treatment upon diagnosis, an incomplete fistula - at the age of over 1 year.
Vesiculopustulosis
Vezi kul o pustules ez - superficial staphyloderma of newborns. The process is localized in the mouths of the eccrine sweat glands. Asthenization and immune deficiency are important in formula-fed children. Contributing factors are most often overheating, excessive sweating, maceration.
clinical picture. Follicular pustules the size of a millet grain or pea are located throughout the skin, but are more often localized on the back, in the folds of the skin, on the neck, chest, in the buttocks and on the scalp, accompanied by subfebrile body temperature. Possible complications such as otitis, bronchopneumonia, pyelonephritis.
Treatment. During the period of illness, it is not recommended to wash and bathe the child. Lesions and visible healthy skin are treated with antiseptic agents: a solution of furacilin 1: 5000, a 0.1% solution of rivanol (ethacridine lactate), a 0.1-0.2% solution of potassium permanganate, aniline dyes. Pastes with 1% erythromycin, 1% lincomycin, ointments (erythromycin, heliomycin, lincomycin, rivanol, streptocid) are applied directly to the foci of pustular elements.
Epidemic pemphigus of the newborn (pemphigoid of the newborn)
Epidemic pemphigus in newborns is caused by pathogenic Staphylococcus aureus, sometimes (in 1.6% of cases) by Staphylococcus aureus in association with other microorganisms (strepto-, diplococci). The disease is a generalized purulent lesion in children of the first days of life with insufficient immune reserves, an unfavorable prenatal history, and the possible presence of foci of chronic infection in parents.
clinical picture. A multiple disseminated polymorphic rash is found. The evolutionary polymorphism of the elements is characteristic: blisters, pustules - conflicts, erosion at the site of the opened blisters, layering of serous-purulent crusts. Localization - the skin of the trunk, limbs, large folds. The process extends to the mucous membranes of the mouth, nose, eyes and genitals, accompanied by hyperthermia, asthenia, diarrhea, reactive changes in the blood and urine. Severe septic complications are possible.
Exfoliative dermatitis of the newborn (Ritter's disease)
Exfoliative dermatitis of the newborn is a severe form of epidemic pemphigus of the newborn. It is characterized by a state of erythroderma with multiple blisters, extensive erosive surfaces. Nikolsky's symptom is positive. Deprived of the epidermis, areas of the skin resemble a second-degree burn. There are three stages of the disease: erythematous, exfoliative and regenerative. In severe cases, the process proceeds septically with weight loss, toxicosis, gastrointestinal disorders, anemia, and dysproteinemia.
The contagiousness of staphyloderma in newborns is high. Infection is possible in the presence of a nosocomial infection, as well as in utero through the placental circulation.
Treatment. Perhaps parenteral administration of semi-synthetic penicillins (methicillin, oxacillin, etc.), which have the ability to inhibit the production of epidermolytic toxin and microbial flora resistant to penicillase. Fusidin sodium, lincomycin hydrochloride and cephalosporin derivatives - cephaloridine (ceporin), cephalexin and cefazolin (kefzol) are used as antibiotics with a specific antistaphylococcal action. Sulfanilamide drugs are rarely prescribed due to their lack of effectiveness and possible toxic-allergic complications. Simultaneously with antibiotics, intravenous immunoglobulins (nitraglobin, octagam, sandoglobin) are used. For the purpose of detoxification, intravenous albumin, native plasma, 10% glucose solution are administered dropwise, hemosorption or plasmapheresis is carried out. In intestinal dysbacteriosis, eubiotics are prescribed (bifidumbacterin, bifikol, bactisubtil, lactobacterin, etc.). Vitamin therapy is indicated, especially ascorbic acid, pyridoxal phosphate, calcium pantothenate or pangamate, vitamins A and E.
Bubbles open or suck their contents with a syringe. The skin around the blisters is treated with aniline dyes, 0.1-0.2% alcohol solution of sanguirythrin, 1-2% salicylic alcohol. The resulting erosions are subjected to UV irradiation followed by treatment with ointments and pastes containing antibiotics: Dioxycol, Dioxifen, Levosin, heliomycin, erythromycin, lincomycin.
Of particular importance due to the contagiousness of the process is child care, including daily change of linen, daily baths with a solution of potassium permanganate (1:10 LLC). Careful observance of the hygienic regime is necessary, ultraviolet irradiation of the wards is mandatory. If possible, children suffering from staphyloderma are placed in boxes. Breastfeeding is maintained or, in case of hypogalactia in the mother, the child is transferred to donor breast milk.
Staphylococcal pyoderma
Distinguish superficial and deep forms. Superficial ones include ostiofolliculitis, folliculitis; to deep ones - hydradenitis, furuncle, carbuncle.
Ostiofolliculitis is a purulent inflammation of the mouth of the hair follicle with the formation of a superficial conical pustule pierced in the center by a hair. When suppuration spreads deep into the follicle, folliculitis occurs. A deeper purulent-necrotic inflammation of the hair follicle and surrounding tissues with the formation of a necrotic rod is called a furuncle. The furuncle of the face is dangerous due to the possible metastasis of the infection with the development of a septic condition and meningitis.
Hidradenitis is a purulent inflammation of the apocrine sweat glands, more often in the axillary fossa, as well as in the anus, genitals. Pathogenetic factors are the same as for all staphylococcal processes, but increased sweating and an alkaline reaction of sweat have an additional effect.
streptococcal pyoderma
Streptococcal pyoderma is manifested by the main primary pustular element - conflict. The most common types of pyoderma in children are superficial streptococcal lesions - impetigo and deep - ecthyma. Streptococcal impetigo is manifested by a superficial bubble - conflict. Localization: face, skin of the trunk, limbs. In the corners of the mouth, conflicts quickly open up, and the erosive surface transforms into a longitudinal crack (jam). On the nail phalanges of the hands, conflicts surround the nail in a horseshoe-like manner, forming periungual impetigo (tourniole). With combined superficial streptostaphylococcal infection, vulgar impetigo occurs, which is characterized by significant contagiousness, a tendency to dissemination in various parts of the skin.
Treatment. With widespread superficial and deep streptostaphyloderma, antibiotics are prescribed (taking into account the data of the antibiogram and individual tolerance) in combination with intravenous immunoglobulin preparations, as well as immunomodulators, vitamins A, E, C. Externally - aniline dyes, 2% salicylic-camphoric alcohol , 2-5% levomycetin alcohol, followed by the application of pastes and ointments with antibiotics and antibacterial drugs. Physiotherapy is indicated: UV irradiation, magneto-laser therapy, light therapy with a polarized light lamp "Bioptron".
In the prevention of pyoderma in children, a rational diet, sanitary and hygienic measures in the ante-, inter- and postnatal periods are most effective.
Middle exudative otitis media
Otitis media is characterized by the presence of serous exudate in the middle ear cavity. The cause may be allergic processes in the nasopharynx, improper use of antibiotics. The accumulation of serous exudate limits the mobility of the auditory ossicles and the tympanic membrane, which leads to the development of conductive hearing loss. On otoscopy, the eardrum has a hazy gray-yellow to purple color, depending on the color of the exudate.
Treatment: sanitation of the nasopharynx, restoration of the patency of the auditory tube. In the absence of effect, puncture of the tympanic membrane, evacuation of exudate and the introduction of hormonal drugs are indicated.
Acute osteomyelitis
Acute osteomyelitis is a purulent inflammation of the bone tissue, the causative agent of which can be any pyogenic microorganism.
The disease begins acutely. The first symptom is a sharp pain in the extremity, from which the child screams and avoids any movement. Older children localize the pain strictly, in younger children it manifests itself with particular anxiety when they are picked up or shifted. The body temperature rises to 39- 40 ° C. Vomiting, diarrhea are observed. External signs of osteomyelitis may be absent at first. On palpation, the place of greatest pain can only be established in older children. As the process develops, when it passes to soft tissues, local swelling appears, the configuration of the limb changes. The skin becomes edematous and hyperemic, the adjacent joint is deformed.
The clinical course of acute osteomyelitis depends on the virulence of the microorganism and the reactivity of the child's body, the age of the patient, etc. There are three forms of the disease: toxic, septic-pyemic, local. The first is characterized by a stormy onset, the phenomena of sepsis predominate, and the patient often dies before local changes have had time to manifest themselves. The second form is observed more often than others. Local phenomena are clearly expressed, combined with a general septic reaction; sometimes several bones are affected at once, purulent metastases are observed in other organs.
Recognition is difficult in young children, especially newborns. If osteomyelitis is suspected, the ends of long tubular bones and joints are especially carefully examined, an X-ray examination is performed. Early radiological signs appear in young children on the 7-10th day, in older children - on the 10-12th day of illness. At the beginning of the disease in the blood - leukocytosis, shift of the leukocyte formula to the left; in severe cases, leukopenia is often observed. Surgical treatment.
Dacryocystitis of the newborn
Dacryocystitis in newborns is an inflammation of the lacrimal sac caused by incomplete opening of the nasolacrimal duct by the time of birth. Manifested by lacrimation, mucopurulent discharge at the inner corner of the eye. When pressing on the area of the lacrimal sac, purulent contents are released from the lacrimal openings.
Treatment: massage the area of the lacrimal sac from top to bottom to break the film and restore the patency of the nasolacrimal duct. In cases where the patency of the nasolacrimal duct is not restored within a week, the ophthalmologist probing and washing the lacrimal ducts.
paraproctitis
Paraproctitis is an inflammation of pararectal tissue. In children, it is less common than in adults, and usually has the character of a subcutaneous abscess. The introduction of infection is facilitated by maceration of the skin and diaper rash.
In a limited area of the skin near the anus, induration and hyperemia appear, accompanied by pain during defecation. The child becomes restless, sometimes his general condition is disturbed, the body temperature rises to 38-39°C. The patient avoids sitting down or leans only on one half of the buttocks. Pains gradually increase. Paraproctitis is easily recognized during examination of the perineum. A sharp increase in pain with pressure is characteristic, sometimes pus is released from the anus.
Treatment consists in opening the abscess as quickly as possible. In some cases, spontaneous opening of the abscess occurs, and after the inflammatory phenomena subside, a fistula with purulent discharge is formed - chronic paraproctitis. At times, the fistula closes, but after another exacerbation it opens again. In the presence of a fistula, surgical treatment is indicated in the cold period.
Phlegmon of newborns
Phlegmon of newborns is a kind of inflammation of the subcutaneous tissue, observed in the first month of life. The causative agent can be any pyogenic microorganism, more often staphylococcus aureus.
The disease begins acutely. The child is restless, loses appetite, body temperature rises to 39-40°C. A limited area of redness and induration appears on the skin, painful to the touch. The most common localization is the sacrococcygeal region, chest, neck. The area of the inflammatory focus rapidly increases, the skin over it becomes purple, and then cyanotic. On the 2-3rd day, a softening area appears in the center of the lesion: the skin quickly melts and a fistula forms, through which necrotic tissues are torn off. Along the edges, skin detachment occurs, which undergoes melting, and an extensive wound with uneven edges is formed. Often, necrosis spreads deep and wide, bones are exposed. The newborn requires emergency care and treatment in a surgical hospital.
Neonatal sepsis
Sepsis is a generalized polyetiological infectious disease with an acyclic course, the presence of a primary purulent-inflammatory focus, the occurrence and course of which are determined by the state of the macroorganism and the properties of the pathogen.
In recent years, taking into account the latest achievements in immunology, a new, refined definition of the concept of "Sepsis" has been proposed - this is a bacterial infectious polyetiological disease with a cyclic course, the presence of a focus of purulent inflammation and / or bacteremia, a systemic inflammatory response (SIR or SIRS - systemic inflammatory syndrome). response, SIRS) and multiple organ failure (MOF).
The presence of PON implies at least one symptom that characterizes the dysfunction of each of the body systems. Clinical criteria for SVR are violations of thermoregulation, disturbances in the hemogram, DIC, signs of hypercatabolism.
In the pathogenesis of sepsis in newborns, high-risk factors from the side of the macroorganism retain their leading role - urogenital infections of the mother, a long anhydrous period and postpartum endometrium in her; prematurity, severe perinatal damage to the central nervous system, mechanical ventilation and prolonged vascular catheterization in a child. In recent years, the significance of microbial pathogenicity factors - endotoxins, proteases, exotoxins, neuraminidase, etc. - has been clarified. These factors provide a breakthrough in the barrier systems of an immature organism and the activation of inflammatory mediators that damage the vascular endothelium (TNF, IL-1, -4, -6, -8; RAF, prostaglandins and prostacyclins) - through which the systemic inflammatory reaction is realized. With adequate treatment and sufficient opportunities for the child in the period of sepsis repair, anti-inflammatory activation of macrophages and the synthesis of anti-inflammatory cytokines - IL-10 are noted; TNF and IL-1 receptors.
According to the time of occurrence, intrauterine and postnatal sepsis are distinguished. Intrauterine sepsis is understood as a disease that has already developed in utero (antenatal) in an intrauterine infected fetus. Moreover, in this case, the primary purulent-inflammatory focus (chorionitis, chorioamnionitis, placentitis, etc.) is outside the child's body. Intrauterine infection is a condition characterized by microbial contamination (contamination) of the fetus. Contamination of the fetus with microorganisms can occur antenatal (rarely noted) or intranatally (during childbirth), which is much more common.
Professor N.P.Shabalov proposed a classification of sepsis, highlighting the so-called. early and late neonatal sepsis - this largely corresponds to intrauterine and postnatal sepsis.
Depending on the state of reactivity of the macroorganism, virulence and the degree of colonization (microbial colonization), during intranatal intrauterine infection in the postnatal period of a child’s life, processes of gradual displacement of this microflora by saprophytes occur or the carriage of this microflora is formed, or when the compensatory protective mechanisms of the macroorganism are disrupted, localized purulent inflammatory disease or sepsis. It should be emphasized that the disease, as such, develops in the postnatal period and, if it is sepsis, it is considered as postnatal.
In postnatal sepsis, there is always a primary purulent-inflammatory focus. Depending on its localization, umbilical, otogenic, skin, pulmonary, intestinal, urosepsis, etc. are distinguished. In newborns and infants, umbilical sepsis is more common with a primary focus in the umbilical wound and / or umbilical vessels. In recent years, the primary septic focus is often infected thrombi, thrombophlebitis arising in connection with vein catheterization for infusion therapy, as well as the mucous membrane of the esophagus and intestines.
Almost all types of opportunistic and some pathogenic microorganisms can be the cause of sepsis: staphylo- and streptococci, bacteria of the intestinal group, pseudomonad groups, anaerobes, etc. The leading place (up to 50%) is occupied by staphylococci, in second place (36%) is microflora, mainly enterobacteria. A certain value (up to 10%) has a mixed etiology of the disease. The etiology of the disease leaves a certain imprint on the clinical picture of the disease, its outcome, determines the choice of antibiotic therapy. Therefore, the establishment of the etiological diagnosis of sepsis is mandatory.
Most authors distinguish two clinical forms of sepsis - septicemia (sepsis without metastases) and septicopyemia (sepsis with purulent metastases).
Septicemia. With septicemia, clinical symptoms may not have strict specificity, because. depend on the properties of the microorganism, as well as on the degree of violation of homeostasis parameters.
Bacteremia in the process of settling the body of a newborn with microbial flora can occur as a short-term episode in almost every child, including a practically healthy one (the so-called asymptomatic bacteremia, detected on average in 15% of newborns at the 1st week of life). The development of septicemia depends not so much on the very fact of the circulation of bacteria, but on the ability to purify the blood and lymph from microbes by the elimination systems of the body and the speed of this process.
Septicemia, which has developed as a result of intrauterine infection, is already in the first 1-3 days of life accompanied by a severe general condition, progressive depression of the central nervous system, hypothermia, less often - hyperthermia, pale or dirty gray skin coloration, early onset and rapidly growing jaundice, progressive edematous syndrome, enlargement of the liver and spleen, respiratory failure in the absence of pronounced radiographic changes. Regurgitation, vomiting, hemorrhagic syndrome may be noted.
Sepsis that develops after birth is more often characterized by a more gradual onset. After the introduction of an infectious agent, the latent period is 2-5 days; in premature babies, its duration increases to 3 weeks.
The harbingers of the disease include a decrease in the activity of the child, appetite, regurgitation, local symptoms. Assessment of the state of the umbilical wound, as the site of the primary introduction of infectious agents, presents the greatest difficulty, because. the gram-negative flora prevailing now does not give the expressed local inflammatory reaction. The later falling off of the umbilical cord is taken into account (after the 6th day in full-term and the 10th in premature), the state of the bottom of the wound (compaction, protrusion or sharp retraction), the nature and duration of the discharge, the preservation of a dense crust after 16-18 days of life. The presence of an inflammatory process is evidenced by pastosity of the tissue in the lower segment of the umbilical ring, the appearance or strengthening of the venous network on the anterior abdominal wall, especially on the right, tension of the rectus abdominis muscles above or below the umbilical ring. With thrombophlebitis, it is possible to palpate the compacted umbilical vein. On palpation of the vessels (veins, arteries) from the periphery to the center, a purulent discharge may appear at the bottom of the umbilical wound. Symptoms of damage to the umbilical wound and blood vessels, being an almost constant manifestation of umbilical sepsis, do not in themselves serve as a criterion for the generalization of infection.
The development of sepsis is characterized by the appearance of infectious toxicosis - lethargy or anxiety, temperature reaction (hyper- or hypothermia), regurgitation, dyspepsia, edematous syndrome or, conversely, exsicosis, dysreflexia, dystonia. During the height of the disease, toxicosis intensifies. Toxic damage to individual organs is detected, for example, liver function disorders (hepatomegaly, jaundice, increased levels of direct bilirubin and transaminases), a reaction from the kidneys (oliguria, proteinuria, leukocyturia, erythrocyturia), i.e. multiple organ failure.
Septicemia can be complicated by the addition of pneumonia, an independent intercurrent disease with aerobronchogenic infection. Against the background of septicemia, respiratory disorders are also possible due to impaired microcirculation in the lungs, metabolic changes in the myocardium.
Septicopyemia is characterized by the presence of purulent metastases (screening out centers) in the meninges, lungs, bones, liver, and less often in other organs. The current change of the pathogen to gram-negative flora has affected the features of metastasis: cases of purulent meningitis with poor clinical and liquorodynamic symptoms at the onset of the disease have become more frequent, which requires repeated spinal punctures. With a decrease in the frequency of such metastatic foci as epiphyseal osteomyelitis, which is more typical for staphylococcus, metaphyseal and epimetaphyseal lesions became more frequent: sluggish, difficult to diagnose, often occurring without distinct arthritis, with scanty and indistinct radiological changes. In such cases, the leading symptoms are hyperextension of the limb in the joint and pain during passive movements. Only on the 3rd week, a periosteal reaction may appear, determined by touch and radiologically.
Allocate a fulminant course of sepsis, leading to a fatal outcome within 3-7 days, acute lasting 4-8 weeks and protracted. The fulminant course of sepsis is characterized by the development of septic shock, which usually serves as the direct cause of the death of the patient.
Septic shock
Septic shock can occur in both septicopyemia and septicemia. It is characterized by profound suppression of cellular immunity. At the heart of the pathogenesis of this variant of sepsis is an inadequate response of the body to the infectious process, the breakdown of defense mechanisms. The role of hormonal imbalance (pituitary gland - thyroid gland - adrenal glands) in the origin of septic shock has been established. The development of septic shock is most likely in case of gram-negative infection (Klebsiella, Pseudomonas aeruginosa) in cases of massive seeding (colonization) of the newborn organism with highly virulent strains, for example, during nosocomial outbreaks.
In the pathogenesis of septic shock, a significant role belongs to the hyperactivation of the defense systems of the child's body with microbial endotoxins of gram-negative flora and the disruption of defense systems with massive capillary damage, neuroendocrine and
metabolic disorders.
Clinically, septic shock is manifested by a catastrophic increase in the severity of the condition, a sharp pallor of the skin, increasing in the distal sections, a decrease in body temperature to subnormal numbers, a rapid change from tachycardia to bradycardia, an increase in the deafness of heart sounds, the occurrence and rapid generalization of sclerema, the appearance of oliguria, bleeding, progressive respiratory insufficiency, the development of a picture of pulmonary edema (“shock lung”) due to deep microcirculation disorders, microcirculatory blockade of the kidneys, which is accompanied by acute renal failure.
The course of sepsis
In the acute course of sepsis (4-8 weeks), the initial period, periods of peak, recovery and recovery are distinguished. The clinical picture of the initial period in the acute course of sepsis is characterized by the presence of a primary focus and gradually increasing general changes (toxicosis). In the peak period, the manifestations of toxicosis are most pronounced, its characteristic features are violations of thermoregulation, functions of the central nervous system, respiration, hemodynamics and the gastrointestinal tract. In children of the first 10 days of life, hypothermia is often noted; icteric syndrome is characteristic in the first month of life. GA Samsygina noted edematous syndrome in 46% of sick newborns, the genesis of which is associated with functional disorders in the pituitary - thyroid gland system (transient hypothyroidism). For the septicopyemic form of sepsis in the peak period, the formation of pyemic foci is characteristic.
The recovery period is characterized by the sanitation of metastatic foci, the gradual subsidence of toxicosis. At the same time, an increase in the liver and spleen remains, a flat weight curve. In the period of convalescence, there is a restoration of the functions of all organs and systems, normalization of skin color and tissue turgor, and an increase in body weight.
A protracted course of sepsis (more than 2 months) is characterized not only by a more sluggish dynamics of clinical symptoms, but also by low levels of adaptive hormones, as well as manifestations of immunological deficiency (combined impairment of cellular, humoral immunity and phagocytosis).
Features of sepsis caused by gram-negative flora
In recent years, outbreaks of nosocomial infections caused by opportunistic gram-negative microorganisms (Klebsiella, Pseudomonas aeruginosa, etc.) have been described. The clinical picture of these diseases is different, local intestinal lesions are mainly described - gastroenteritis and enterocolitis (when infected through water, milk). With massive seeding and the presence of a complicated premorbid background, the development of severe intestinal sepsis is possible. In addition, sepsis caused by gram-negative flora quite often develops due to intrauterine infection (chronic urogenital pathology in the mother is a risk factor). ?
The clinical peculiarity of sepsis of this etiology is due to the toxicity of pathogens and their resistance to antibiotics. The disease often occurs in the form of septic shock (fulminant course); in acute course, even in premature infants, septicopyemia is more often observed with a predominant metastatic lesion of bones and joints (osteoarthritis), as well as meninges (meningitis and melajimcjiDnDie neonatal leukemia
ningoencephalitis). Often, especially in premature babies, such formidable complications develop as necrotizing ulcerative enterocolitis, DIC. Purulent foci are usually characterized by a more persistent and prolonged course than those caused by staphylococcal infection, a tendency to tissue necrosis. Osteomyelitis in Klebsiella sepsis is characterized by a "creeping" course, successive lesions of large joints, frequent disability in the outcome of the process. Mortality in sepsis caused by gram-negative flora is the highest (up to 60%).
"Fungal sepsis" (generalized candidiasis)
The change in the etiological structure of sepsis in recent years has led to an increase in the frequency of cases caused by fungi, generalized purulent-inflammatory diseases, which can be conditionally called sepsis. The lesion caused by fungi of the genus Candida is most often noted. The morphological feature of candidiasis is the formation of granulomas in the internal organs, as well as frequent damage to the gastrointestinal tract, meninges, and joints. Infection occurs, as a rule, in utero from a mother suffering from genital candidiasis or being a carrier of fungi. The entrance gates are the mucous membrane of the gastrointestinal tract, skin, veins after catheterization.
There are fungal dermatitis around the anus, candidiasis of the mucous membranes of the oral cavity, genital organs, fungal diaper rash in the axillary areas. At the same time or after 3-5 days, symptoms of a generalization of the process appear, as evidenced by the development of toxicosis and the formation of septicopyemic foci (more often meningitis, osteoarthritis, kidney damage, thromboendocarditis).
The clinical picture is characterized by moderately severe symptoms of toxicosis. Unlike bacterial sepsis, the skin remains pink or pale pink throughout the course of the disease; microcirculation disorders and respiratory disorders are usually noted. Only in some patients, pronounced manifestations of toxicosis can be observed: some increase in the pallor of the skin or the appearance of a cyanotic (but not grayish) shade, marbling, distal cyanosis, as well as shortness of breath, tachycardia, regurgitation, and bloating. As a rule, these patients have a febrile fever, the rest of the patients have subfebrile condition. Characterized by anorexia, lack of weight gain, enlarged spleen. At the 2-3rd week of the disease, there is a tendency to some increase in the size of the liver.
The course of the disease is in most cases protracted. The hemogram in generalized candidiasis is characterized by the development of moderate normochromic anemia, which is detected as early as the 1st week of the disease and persists throughout the disease until recovery. The appointment of vitamins (group B, folic acid) and blood transfusions do not have a significant effect on red blood counts. The content of leukocytes in most patients is moderately increased (12-18 x 107 l, on average 13.2 ± 1.4 x 107 l), the shift of the formula to the left is not typical. Eosinophilia is almost always observed.
Hemorrhagic syndrome in sepsis
Hemorrhagic syndrome in sepsis is polyetiological. It can be caused, firstly, by a violation of the synthesis of vitamin K-dependent factors in blood plasma in severe lesions of the upper parts of the small intestine, liver (secondary hemorrhagic disease); secondly, thrombocytopenia due to increased adhesion on the exposed subendothelial structures of platelets vessels and a decrease in their bone marrow production during the height of gram-negative sepsis.
One of the most serious manifestations of sepsis in children is the syndrome of disseminated intravascular coagulation (DIC), which is characterized by multiple thrombus formation in microcirculation vessels. Clinically, it is manifested by deterioration, increased pallor of the skin, its marbling, gray color, cold extremities. A rash and edema are the consequences of impaired peripheral blood flow. Deterioration of microcirculation in the vessels of the kidneys can lead to the development of acute renal failure (oliguria, increased blood urea). As a result of multiple microthrombosis, cerebral edema develops (impaired consciousness, convulsions, vomiting).
In some cases, microangiopathic anemia occurs, which is manifested by jaundice, a drop in hemoglobin levels, reticulocytosis (more than 1%), and the appearance of damaged red blood cells (lysocytes) in the blood.
The circulation in the blood of coagulation factors released during the breakdown of erythrocytes and platelets, in turn, enhances coagulation processes, during which there is an active consumption of fibrinogen, proaccelerin, and other factors. Violation of microcirculation causes a compensatory increase in the activity of the fibrinolytic system, the excessive severity of which leads to the development of thrombohemorrhagic syndrome (hypocoagulation phase). This condition is caused by the consumption of coagulation factors, thrombocytopenia, which has developed in connection with the shortening of the life of platelets, a decrease in their production, consumption in the process of coagulation. Disseminated intravascular coagulation often develops in shock and in the preterminal period of sepsis.
Hemorrhagic syndrome manifests itself in different ways: petechial rash, hemorrhage, sometimes coffee grounds vomiting, tarry stools. This condition develops more often and is more severe in children with a burdened obstetric history and preterm infants. In sepsis, the hypocoagulation phase often indicates the irreversibility of the process and precedes death.
Intestinal dysbacteriosis (dysbiosis) in the clinical picture of sepsis
Violation of the intestinal biocenosis in infants and, especially, in newborns and premature babies, on the one hand, is an important link in the pathogenesis of the development of sepsis (because it contributes to intestinal dysfunction, the introduction of the pathogen through the intestinal epithelium due to a decrease in local immunity), on the other hand, dysbacteriosis develops and aggravates as a consequence of an already ongoing septic process, as its complication. In addition to sepsis itself, massive antibiotic therapy contributes to the development of dysbacteriosis.
Any clinical manifestations of dysfunction of the gastrointestinal tract in sepsis - increased frequency and change in the nature of the stool, the appearance of pathological impurities in it, regurgitation, flatulence, partial paresis of the intestine - should be considered not only as a result of intoxication, but also dysbacteriosis (as evidenced by the data of microflora studies) . The appearance of mucus and blood in the stool should alert the doctor in terms of the development of necrotizing ulcerative enterocolitis, especially in premature babies.
Features of the clinical picture of sepsis in premature newborns
Babies born prematurely develop sepsis 10 times more often than full-term babies. This is due to the peculiarities of immunological reactivity and the immaturity of protective barriers. In premature babies, sepsis occurs, as a rule, in the form of septicemia.
The onset of the disease is usually gradual; the course is more sluggish, prolonged (with the exception of sepsis due to massive seeding with nosocomial strains of gram-negative microorganisms). In the recovery period, severe anemia and malnutrition often develop; more pronounced dysbacteriosis. A complication of sepsis is necrotizing ulcerative enterocolitis with perforation of ulcers and peritonitis, specific for preterm infants.
Laboratory diagnosis of sepsis
The results of paraclinical studies are not the main ones, since in any localized purulent disease they have much in common with sepsis. The most informative changes in peripheral blood. In the early period of sepsis, as a rule, there is a moderate leukocytosis (up to 15 x 107 l), anemia is most often insignificant or absent. At the height of the disease, the number of leukocytes increases, a shift of the leukocyte formula to the left is noted, myelocytes appear, toxic granularity of neutrophils. During this period, anemia is constant.
In premature newborns, especially with a gram-negative etiology of the disease, leukopenia (up to 4 x 107l) may be observed. Thrombocytopenia is also not an absolute criterion for sepsis. Of some practical value are studies of the enzymatic status of leukocytes, especially neutrophil alkaline phosphatase, the indicators of which increase with sepsis. However, this test is not absolute, as it can also be positive in localized purulent diseases.
In recent years, in addition to determining the level of CP protein, additional immunological criteria for sepsis can be used - an increase in the concentration of cytokines: IL-1, IL-6, IL-8 and TNF in serum.
The introduction of immunocytological diagnostic methods into clinical practice has made it possible to develop methods for the early diagnosis of sepsis. These include:
a decrease of more than 2 times the percentage of digestion in neutrophils and monocytes of peripheral blood (in the study of phagocytic activity);
an increase of over 70% in the number of neutrophils and monocytes that give a positive reaction to nitro-blue tetrazolium (NST-test);
a more than 2-fold decrease in the quantitative and functional parameters of T-lymphocytes.
An important role in the diagnosis of sepsis is played by blood cultures, thanks to the results of which the etiology of the disease is established. The informativeness of this method depends on the strict observance of the examination technique and the correct interpretation of the results obtained.
Rules for the study of blood culture:
sowing should be carried out before the appointment of antibiotics and again during the period of severe febrile condition;
manipulation must be performed in a special (procedure) room, near the burner;
carefully sterilize the instrument, the hands of the staff, the skin of the child; after antiseptic treatment, do not palpate the skin;
take blood by venipuncture (even if there is a catheter in the main vessels);
avoid taking a clot;
the amount of blood is not less than 2 ml;
ratio of nutrient medium to blood 25:1.
Blood culture data alone is not a decisive criterion for the diagnosis of sepsis. A single bacteremia that is not associated with toxicosis may be transient. Bacteremia accompanying the toxic state is an indication for antibiotic therapy, but the question of the diagnosis of sepsis is decided depending on the dynamics of the disease. When repairing a purulent focus with synchronous elimination of toxicosis, bacteremia can be interpreted as symptomatic, with persistent toxicosis - as a manifestation of sepsis.
Given the possibility of a negative blood culture result, the following criteria can be considered sufficient for making a diagnosis of sepsis in general practice:
bacterial focus or thromboangiitis against the background of the current and past purulent process;
toxicosis, aggravated during the period of bacteremia, the severity of which is inexplicable only by the existing purulent focus;
pyrogenic febrile condition;
hypothermia in newborns;
a pronounced reaction of white and red blood (leukocytosis> 15-30 x 109 / l or leukopenia; asynchrony in the elimination of febrile condition, a local process with a delay in daily recovery of body weight for 1-2 weeks of normothermia.
In the presence of a complete syndrome complex, a reliable confirmation of sepsis can be the receipt of a blood culture identical to the microorganism isolated from a purulent focus, as well as the development of secondary foci of infection of hematogenous origin, which have a common etiology with the primary focus and isolated blood culture (a sign of septicopyemia).
With a localized infectious disease, as the local process subsides, the patient's condition improves synchronously: febrile condition disappears, activity increases, appetite improves, vomiting becomes rare or absent, normal skin color is restored, and an increase in body weight is noted. The dynamics of hematological parameters is also synchronous: leukocytosis decreases, neurophilia disappears and the formula shifts to the left, absolute lymphocytosis and monocytosis appear, anemia is absent or quickly eliminated.
In the case of sepsis, the level of intoxication exceeds the severity of the local process and possible hematological changes with it, since the toxic syndrome is caused not only by toxemia emanating from the purulent focus, but also by periodic or constant bacteremia, impaired homeostasis, etc. In these patients, even with the elimination of the local process and the disappearance of febrile condition, hyporegenerative anemia remains for another 1-3 months, and the weight curve does not correspond to nutritional loads, i.e. the discrepancy between the dynamics of general and local symptoms with a flat weight curve testifies in favor of sepsis. That is why, after 1-2 weeks from the start of adequate therapy, it is necessary to review the clinical diagnosis and retrospectively confirm or reject sepsis.
Differential diagnosis of sepsis
Differential diagnosis is difficult, since it is at an early age that various infectious and somatic diseases appear, the symptoms of which resemble sepsis. Prolonged toxicosis in the absence of a purulent process requires the exclusion of serious diseases of non-infectious origin (systemic, genetic, hematological, infectious-allergic, etc.).
Since the general symptoms characteristic of sepsis can be observed in any infectious diseases that occur with toxicosis (abscess pneumonia, purulent meningitis, enterocolitis, phlegmon, etc.), they must be excluded.
Principles of therapy
When treating patients with sepsis, it is necessary to take into account the history, the degree of maturity of the child at birth, his age, the duration of the disease, the localization of the pyemic focus, the severity and nature of the course of the disease, and comorbidities. General plan of events:
active antibiotic therapy;
detoxification, corrective and stimulating treatment;
vigorous topical therapy.
Antibiotics. In the treatment of sepsis, targeted antibiotic therapy is of primary importance, taking into account the sensitivity of the isolated or suspected microbial flora. Before obtaining an antibiogram, a combination of agents aimed at penicillin-resistant staphylococci and gram-negative flora is advisable. Upon receipt of the results of the study of blood culture and the contents of the IE focus, treatment with one of the drugs is acceptable or the issue of replacing antibiotics is being decided.
The most effective in / in the introduction of drugs. The duration of the first course of treatment is 1-2 weeks. An early criterion of effectiveness, regardless of the duration of the disease, can be a decrease in toxicosis or a decrease in febrile condition by 1-1.5 ° C within a few hours (at least the first day) of treatment. For a final judgment on the adequacy of therapy, 2-3 days are sufficient, during which a positive dynamics of the disease is noted.
Possible algorithms for the use of antibiotics in neonatal sepsis include:
starting therapy with a combination of 2 antibiotics - 3rd generation zeporin + aminoglycoside - or monotherapy with carbopreparations;
reserve therapy - 4th generation zeporin + one of the new aminoglycosides or glycopeptide monotherapy (vancomycin);
deep reserve therapy - thienam, according to vital indications - fluoroquinolones.
Recovery of body weight indicates the beginning of recovery and the possibility of discontinuation of antibiotics, the total duration of treatment is 3-4 weeks.
Given the possibility of developing dysbacteriosis, when conducting antibiotic therapy for newborns and premature infants, it is advisable to early prescribe antifungal agents (mycosyst, diflucan), biological products, phages, vitamins A, C, PP, group B, bifidumbacterin. Treatment is carried out under the control of blood tests, urine and feces for the presence of fungi, the nature of the microflora.
Detoxification, immune, corrective therapy. In the period of toxicosis, early use of detoxification agents is necessary. For this purpose, a 10% glucose solution is prescribed, plasma (5-10 ml / kg), and specific passive immunotherapy is also carried out - intravenous infusions of immunoglobulin preparations (sandoglobin, intraglobin, pentaglobulin, etc.) - for a course of 5-7 infusions.
The detoxification effect is exerted by direct blood transfusions, including from donors immunized with staphylococcal toxoid. A single dose of heparinized blood is 5-10 ml/kg. This therapy, being a method of passive specific immunotherapy, simultaneously improves non-specific protective factors and cellular immunity. Gamma globulin, plasma, preserved blood do not have a pronounced effect on nonspecific resistance and cellular immunity and should not be used for this purpose. With leukopenia, 1-2-fold transfusions of leukocyte mass are indicated.
In recent years, research has begun on new immunotropic drugs for severe infections in newborns (immunomodulators such as bacterial lysates and their genetically engineered analogues, stimulants of interferonogenesis and colony-stimulating factors). In the future, it is possible to use monoclonal antibodies to inflammatory mediators and antagonists of the receptors of these mediators in therapy.
The appointment of glucocorticoids is considered justified only in septic shock. The dose of prednisolone for oral administration should not exceed 1-2 mg / kg, hydrocortisone - 5-10 mg / kg / day. The duration of therapy is 5-7 days, including days of dose reduction. Hormone therapy is carried out against the background of the appointment of antibiotics, vitamins, potassium preparations, under the control of electrolyte balance.
Correction of homeostasis disorders in sepsis is carried out by prescribing cocarboxylase, vitamin C, 5-10% albumin solution, plasma (with hypoproteinemia), glucose-salt solutions in various ratios (with exicosis). In order to prevent hypokalemia during total parenteral nutrition, the daily dose of potassium should be 2-3 mmol/kg. With partial parenteral nutrition, the volume of a 3% potassium chloride solution decreases proportionally. In the presence of hypokalemia, an additional correction is performed.
Infusion therapy depends on the child's age and body weight, the nature of toxicosis, the degree and type of exicosis, etc. Nutrition, fractional drinking, detoxifying, corrective and symptomatic agents are taken into account, the rest is administered intravenously by drip using an infusion pump. Infusion therapy is carried out under the control of blood pressure, acid-base status, ECG, electrolyte balance, hematocrit, blood sugar.
In therapy, it is necessary to take into account indications for the appointment of cardiac glucosides, insulin (1 unit per 4-5 g of dry glucose), dehydration agents (lasix - 1-3 mg / kg per day for 2-3 doses, mannitol 15% - 1 g of dry matter per 1 kg/day, etc.). Diuretics are contraindicated in renal failure, anuria.
Convulsions, hyperpyrexia, cardiovascular and respiratory failure are treated according to general rules.
If there is evidence in favor of hypercoagulability, measures aimed at restoring peripheral circulation are recommended. For this purpose, limbs are warmed (hot pads, half-alcohol rubbing), reopoliglyukin, antiaggregants (curantil) are prescribed. The main pathogenetic agent is heparin at a dose of 150-300 U/kg. The daily dose is administered 4-6 times in / in or s / c into fatty tissue. Heparin therapy is carried out under the control of the results of laboratory tests and continues until the signs of hypercoagulability disappear. The dose is reduced gradually, within 2-3 days, while maintaining the frequency of administration.
The appearance of the first signs of hemorrhagic syndrome (hypocoagulation phase) is not an indication to reduce heparin doses; with increased bleeding, the daily dose should be reduced to 50-100 U / kg. Simultaneously with the replacement purpose, heparinized blood (5-10 ml/kg) or fresh frozen native plasma (5 ml/kg) is administered.
¦ |.".
In the presence of DIC, prednisolone should be used with caution, as it enhances the coagulating properties of the blood.
In the complex therapy of sepsis, local, surgical and physiotherapeutic treatment is important.
After the elimination of toxicosis, treatment of concomitant diseases and stimulating therapy are carried out. In the recovery period, massage, gymnastics, therapeutic baths are connected.
Forecast. According to various authors, mortality from sepsis varies from 10 ds to 80%. Such a wide range, apparently, is due to the arbitrariness of the interpretation of the diagnosis of sepsis. In most of the country's leading clinics and according to foreign> researchers, mortality from neonatal sepsis is 30-40%.
Depending on the localization of the septic process, recovered children may experience various conditions (delayed physical development, frequent intercurrent diseases, anemia, hepatosplenomegaly, CNS damage, etc.), which should be considered not as a chronic course, but as a consequence of sepsis or a manifestation of treatment of independent diseases. Practice shows that the allocation of latent, protracted and chronic sepsis is not justified, since these diagnoses most often hide various undeciphered conditions.
Dispensary supervision. All patients who have undergone sepsis are observed for 12 months. At the age of up to 1 year, examinations are carried out monthly, older than 1 year - quarterly. At the same time, attention is paid to the general condition of the child, muscle and emotional tone, appetite, body weight dynamics, daily routine and feeding. Peripheral blood parameters are monitored 1 month after discharge, then 1 time in 3 months. Medication prescriptions depend on the condition of the child. Prevention and treatment of rickets, anemia and other diseases are carried out according to general rules. With complete well-being of the somatic status of children, they are removed from the register after 12 months. After sepsis that has developed from the first days of life, BCG vaccination and other vaccinations are carried out strictly individually.
Fundamentals of sepsis prevention in newborns and infants
Prevention of sepsis begins long before the birth of a child and includes a wide range of measures to improve the health of adolescent girls, sanitary and hygienic education of the population (combating smoking, alcohol consumption, hygiene of sexual life). Of great importance is the work of antenatal clinics to improve the health of women, prevent abortions, and sanitize pregnant women.
In terms of preventing fungal infections, women using intrauterine contraceptives and hormonal contraceptives require attention. Strict adherence to the sanitary and hygienic regime in the maternity hospital, the rules for processing the umbilical cord (secondary processing on the 2nd-3rd day of life), early attachment to the breast, and the joint stay of the mother and newborn remain important in the prevention of sepsis.
Since nosocomial strains of gram-negative microorganisms have played an important role in the etiology of sepsis in recent years, an important role in preventing their spread is given to limiting the use of antibiotics (especially penicillin) in the maternity hospital and preventing dysbacteriosis.
Important in the prevention of purulent-septic diseases in newborns and infants are natural feeding, prevention of mastitis.
