Anaerobic infections. Anaerobic infections: treatment, symptoms, causes, signs, prevention Anaerobic infections general surgery

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

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

1) Anaerobic monoinfections:

- clostridial cellulitis, clostridial myonecrosis;

Anaerobic streptococcal myositis, anaerobic streptococcal cellulitis.

2) Polymicrobial synergistic (aerobic-anaerobic) infections:

Synergistic necrotizing fasciitis;

Synergistic necrotizing cellulite;

Progressive synergistic bacterial gangrene;

Chronic boring ulcer.

Regardless of the form of anaerobic infection, a zone of putrefactive fusion, a zone of necrosis and phlegmon, and an extensive zone of serous edema, represented by living tissues richly impregnated with toxins and anaerobic enzymes, which has no clear boundaries, are formed in the wound.

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

1) fetid putrid odor of exudate;

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

3) gas formation, detected by palpation, auscultation (crepitus) and radiography (cellular pattern for cellulite, feathery pattern for myositis);

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

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

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

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

Nature of pain: increases rapidly, ceases to be relieved by analgesics;

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

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

Dynamics of symptoms: once symptoms appear, they rapidly increase over the course of one day or night (anemia, “ligature” symptom, tachycardia, etc.).

Surgical treatment of anaerobic infection. By selection method in the surgical treatment of anaerobic infection is secondary surgical treatment of the wound. It has the following features:

Radical necrectomy within the affected area (limb segment) with the obligatory implementation of a wide Z-shaped fasciotomy throughout the entire affected area (case, limb segment);

Additional drainage of an unsutured wound through counter-openings in the lowest parts of the area with 2-3 thick (more than 10 mm in diameter) tubes;

Filling the wound with napkins constantly moistened with a 3% solution of hydrogen peroxide and carbon sorbents;

On the limbs, an additional fasciotomy of all muscle sheaths outside the affected area is performed in a closed manner to decompress the muscles and improve blood circulation in the tissues; “Lampas incisions” are not performed because they do not solve the problem of detoxification, are an additional entry point for infection and cause serious injury;

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

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

Amputation according to the type of surgical treatment of a wound in compensated and subcompensated (according to the “VPH-SP or SG” scale) condition of the wounded person and the possibility of preserving the overlying joint;

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

Features of amputation for anaerobic infection:

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

A wide opening of all fascial sheaths of the affected muscle groups on the stump is required;

It is advisable to preligate the great vessels at a level that preserves blood circulation to the stump, and if possible, do not use a tourniquet;

The operation is performed only under general anesthesia;

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

Repeated planned daily surgical revisions (under anesthesia) of the wound with necrectomy are required until the wound is completely cleansed.

Intensive conservative therapy of anaerobic infection.

1. Preoperative preparation. Stabilization of hemodynamics and elimination of hypovolemia is achieved by administering crystalline solutions containing 10–15 million units of penicillin, polyglucin in combination with cardiovascular analeptics in a total volume of 1.0–1.5 liters over 0.5–1.5 hours.

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

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

Instructions for military field surgery

Anaerobic infections are infections that occur as complications of various injuries. Aerobic pathogens are gram-negative bacteria, for which an oxygen-free environment or oxygen supplied in minimal volumes is favorable. Toxic substances, which are waste products of harmful microorganisms, are quite dangerous. They can easily penetrate cells and attack various organs.

Treatment of anaerobic infections may be associated not only with such areas as surgery and traumatology. A similar pathology is found in gynecology, dentistry, pediatrics, pulmonology and other areas. Statistics show that anaerobic bacteria are detected in thirty cases out of a hundred associated with purulent formations.

Anaerobic microorganisms make up the microflora of the mucous membranes of the gastrointestinal tract, skin, and genitourinary system. During periods of decreased body resistance, they become the cause of illnesses. When the immune system malfunctions, the reproductive process of bacteria gets out of control. This is why infection occurs. Being in a favorable environment in the form of organic matter and soil and subsequently getting on open wound surfaces, they become the cause of exogenous infection.

Classification regarding susceptibility to oxygen divides bacteria into three types. Anaerobic organisms include:

Facultative bacteria. They can exist safely in the presence of oxygen, as well as without.
Microaerophilic organisms. These bacteria require a minimum amount of oxygen to live.
Obligate bacteria are either clostridial or non-clostridial. The first are external and manifest themselves in such ailments as toxic food infections.

"Anaerobic microorganism"

The second group provokes internal purulent phenomena with an inflammatory nature. Such ailments include peritonitis, sepsis, abscess and other diseases.

The cause of infectious diseases associated with anaerobes is tissue injury, which helps microorganisms to virtually freely enter the weakened zone. Anaerobic infection is also facilitated by partial or complete lack of immunity, bleeding, ischemia and some of the chronic diseases.

Anaerobic infection can result from tooth extraction, as well as biopsy. Often the disease manifests itself as an acute surgical aerobic infection. Quite often, infection occurs through soil and other elements of foreign origin. An ill-chosen antibiotic treatment strategy, having a detrimental effect on the vital activity of positive microflora, can also become the cause of an infectious disease.

Infections of an anaerobic nature cause the growth of obligate bacteria and microaerophilic microorganisms. In the case of optional representatives, the principle of influence is slightly different. The most common causes of infection are the following bacteria:

propionibacteria;
peptococci;
sarcins;
fusobacteria;
clostridia;
bifidobacteria;
peptostreptococci;
bacteroides.

Basically, an infectious disease develops with the participation of both anaerobic and aerobic organisms. These are mainly enterobacteria, staphylococci, and streptococci.

The infectious process can be localized in bone tissue, serous cavities, in the blood, as well as in internal organs. According to localization, pathology is divided into:

Local variety. Its action is limited to a certain area.
Regional form. Its peculiarity lies in the ability to capture new locations.
Generalized.

Symptoms

Despite the variety of forms of this disease, it has many manifestations that are reflected in any of the infections. A typically bright onset of the disease. Subsequently, the symptoms intensify. Sometimes a few hours are enough for an anaerobic infection to develop. In three days the disease is in full force.

During the development of the disease, among symptoms such as intoxication and inflammation in the pathological area, the first symptom is dominant. Most often, the patient first experiences a deterioration in his general condition, and only over time do symptoms of inflammation appear in a certain area. Symptoms of endotoxicosis include:

headaches;
weakness;
nausea;
feverish condition;
increase in breathing rate;
increased heart rate;
state of chills;
slowness in reaction;
blue limbs.

Among the first manifestations of a wound type of infection:

bursting pain;
characteristic sounds when diagnosing soft tissues;
emphysema.

Painkillers, even narcotic ones, are not able to relieve pain. A temperature jump occurs, pulsation increases to one hundred and twenty blows. Liquid-like pus is released from the wound area. Exudate with several shades of impurities can also be separated. It contains gas bubbles and fatty particles.

The characteristic putrefactive odor indicates the synthesis of methane, hydrogen and nitrogenous components. Gradually, as the disease progresses, a disorder of the central nervous system, in some cases, coma, may occur. There is a decrease in blood pressure. With the non-clostridial type of the disease, purulent brown discharge appears, as well as diffuse tissue necrosis.

Non-clostridial processes, like clostridial forms, can manifest themselves in acute or subacute form. Sometimes the infection can manifest itself just a day after infection. This occurs as a consequence of surgery or injury. This form has a corresponding name - lightning. The acute form appears after four days. It takes four days or more for the subacute form to develop.

Diagnostics

In most cases, a specialist makes a diagnosis based on symptoms. The unpleasant odor characteristic of the disease, cell damage and the location of the pathological zone make it possible to accurately diagnose the disease.

In the case of the subacute form, the unpleasant odor appears gradually as the disease develops. Diseased tissues accumulate gas. One indication of the presence of an anaerobic infection is the absence of changes during antibiotic therapy.

In order for the study on the bacteriological component to be objective, you will need to take a sample from the affected area. The material being tested should not come into contact with air.

Materials obtained by puncture will also help to identify the predominance of harmful flora in the body. Blood, urine, and cerebrospinal fluid can be used for analysis. In order to obtain an accurate research result, the material should be immediately delivered to the laboratory, because the obligate form of anaerobes dies upon contact with oxygen. Also, this form of bacteria can be replaced by any of the other two varieties.

Therapy

In order to cope with the bacterial attack on the body, a comprehensive treatment strategy is necessary. Antibacterial therapy may include surgical methods as well as conservative treatment.

The surgical block must be implemented without delay, since a timely operation can prevent death.

During surgery, the task is to clean the affected area. It will be necessary to open the inflamed area and remove the affected tissue. Also in this case, drainage and cleaning with antiseptic medications are performed. Sometimes additional surgery is possible.

There are also very difficult situations when the only option to solve the problem is removal of the pathological area. This method is used in extreme cases, when amputation is performed in order to prevent other even more serious and life-threatening complications.

When carrying out conservative treatment, drugs are used that help increase the patient’s body’s resistance, achieve a detoxification effect, and also cope with harmful bacteria. For this purpose, antibiotics are used, as well as infusion treatment. If necessary, the doctor prescribes anti-gangrenosis serum. Extracorporeal hemocorrection, hyperbaric oxygenation and ultraviolet irradiation of blood are performed.

The sooner a patient goes to a medical facility with this problem, the greater his chances of recovery. The form of the disease also greatly affects the effectiveness of treatment.

Prevention

Prevention includes the removal of foreign elements, the use of antiseptics during surgery, as well as primary surgical treatment. In cases where there is a possibility of the body being attacked by harmful bacteria, the doctor may prescribe antimicrobial drugs, as well as drugs that enhance immunity.

Symptoms depend on the location of the infection. Anaerobes are often accompanied by the presence of aerobic organisms. Diagnosis is clinical, along with Gram staining and culture to identify anaerobic cultures. Treatment with antibiotics and surgical drainage and debridement.

Hundreds of varieties of non-spore-forming anaerobes are part of the normal flora of the skin, mouth, gastrointestinal tract and vagina. If these relationships are disrupted (eg, by surgery, other trauma, compromised blood supply, or tissue necrosis), some of these species can cause infections with high morbidity and mortality. Once established at a primary site, organisms can reach distant sites hematogenously. Because aerobic and anaerobic bacteria are often present in the same infected site, appropriate identification and culture procedures are necessary to avoid overlooking anaerobes. Anaerobes may be a major cause of infection in the pleural cavities and lungs; in the intrabdominal area, gynecological area, central nervous system, upper respiratory tract and skin diseases, and in bacteremia.

Causes of anaerobic infections

The major anaerobic gram-negative bacilli include Bacteroides fragilis, Prevotella melaninogenica, and Fusobacterium spp.

Pathogenesis of anaerobic infections

Anaerobic infections can usually be characterized as follows:

They tend to appear as localized collections of pus (abscesses and cellulitis).
The reduction in O2 and low oxidation reduction potential that predominates in avascular and necrotic tissues are critical for their survival,
When bacteremia occurs, it does not usually lead to disseminated intravascular coagulation (DIC).

Some anaerobic bacteria have obvious virulence factors. The virulence factors of B. fragilis are likely to be somewhat exaggerated due to their frequent detection in clinical specimens, despite their relative rarity in normal flora. This organism has a polysaccharide capsule, which apparently stimulates the formation of a purulent focus. An experimental model of intraabdominal sepsis showed that B. fragilis can cause an abscess on its own, whereas other Bactericides spp. a synergistic effect of another organism is required. Another virulence factor, a potent endotoxin, has been implicated in septic shock associated with severe Fusobacterium pharyngitis.

Morbidity and mortality in anaerobic and mixed bacterial sepsis are as high as in sepsis caused by a single aerobic microorganism. Anaerobic infections are often complicated by deep tissue necrosis. The overall mortality rate in severe intraabdominal sepsis and mixed anaerobic pneumonia is high. B. fragilis bacteremia has a high mortality rate, especially among the elderly and patients with cancer.

Symptoms and signs of anaerobic infections

Fever, chills, and severe critical illness are common in patients; incl. infectious-toxic shock. DIC can develop with Fusobacterium sepsis.

For specific infections (and symptoms) caused by mixed anaerobic organisms, see GUIDELINES and Table. 189-3. Anaerobes are rare in urinary tract infections, septic arthritis, and infective endocarditis.

Diagnosis of anaerobic infections

Clinical suspicion.
Gram stain and culture.

Clinical criteria for anaerobic infections include:

Infection adjacent to mucosal surfaces that have anaerobic flora.
Ischemia, tumor, penetrating trauma, foreign body or perforated internal organ.
Spreading gangrene affecting the skin, subcutaneous tissue, fascia and muscles.
Unpleasant odor of pus or infected tissue.
Abscess formation.
Gas in tissues.
Septic thrombophlebitis.
Lack of response to antibiotics that do not have significant anaerobic activity.

Anaerobic infection should be suspected when the wound has a foul odor or when a Gram stain of pus from the infected site reveals mixed pleomorphic bacteria. Only samples collected from normally sterile sites are used for culture because other organisms present can easily be mistaken for pathogens.

Gram stains and aerobic cultures should be obtained for all specimens. Gram stains, especially in the case of bacteroides infection, and cultures for all anaerobes may be falsely negative. Antibiotic susceptibility testing of anaerobes is difficult and data may not be available >1 week after initial culture. However, if the variety is known, the susceptibility pattern can usually be predicted. Therefore, many laboratories do not routinely test anaerobic organisms for sensitivity.

Treatment of anaerobic infections

Drainage and sanitation
The antibiotic is selected depending on the location of the infection

When infection is established, the pus is drained and dead tissue, foreign bodies and necrotic tissue are removed. Organ perforations should be treated by wound closure or drainage. If possible, blood supply should be restored. Septic thrombophlebitis may require vein ligation along with antibiotics.

Since test results for anaerobic flora may not be available for 3-5 days, antibiotics are started. Antibiotics sometimes work even when several bacterial species in a mixed infection are resistant to the antibiotic, especially if surgical debridement and drainage are adequate.

Oropharyngeal anaerobic infections may not respond to penicillin and thus require a drug effective against penicillin-resistant anaerobes (see below). Oropharyngeal infections and lung abscesses should be treated with clindamycin or β-lactam antibiotics with β-lactamase inhibitors such as amoxicillin/clavulanate. For patients allergic to penicillin, it is good to use clindamycin or metronidazole (plus a drug active against aerobes).

Gastrointestinal tract infections or female pelvic anaerobic infections are likely to contain anaerobic gram-negative bacilli such as B. fragilis plus facultative gram-negative bacilli such as Escherichia coir; the antibiotic must be active against both species. The resistance of B. fragilis and other obligatory gram-negative bacilli to penicillin and 3rd and 4th generation cephalosporins differs. However, the following drugs have superior activity against B. fragilis and in vitro efficacy: metronidazole, carbapenems (eg, imipenem/cilastatin, meropenem, ertapenem), combination inhibitor, tigecycline, and moxiflocacin. No single drug can be given preference. Drugs that appear to be somewhat less active against B. fragilis in vitro are generally effective, including clindamycin, cefoxitin, and cefotetan. All but clindamycin and metronidazole can be used as monotherapy because these drugs also have good activity against facultative anaerobic gram-negative bacilli.

Metronidazole is active against clindamycin-resistant B. fragilis, has unique anaerobic bactericidal ability, and is not usually prescribed for the pseudomembranous colitis sometimes associated with clindamycin. Concerns about the potential mutagenicity of metronidazole have not been clinically supported.

Because many options are available for the treatment of gastrointestinal or female pelvic anaerobic infections, the use of a combination of a potentially nephrotoxic aminoglycoside (to target intestinal gram-negative bacilli) and an antibiotic active against B. fragilis is no longer advocated.

Prevention of anaerobic infections

Metronidazole plus gentamicin or ciprofloxacin.

Before undergoing colorectal surgery, patients must have their intestines prepared for the procedure, which is achieved by the following:

Laxative.
Enema,
Antibiotic.

Most surgeons give both oral and parenteral antibiotics. For emergency colorectal surgery, only parenteral antibiotics are used. Examples of oral are neomycin plus erythromycin or neomycin plus metronidazole; these drugs are given no more than 18-24 hours before the procedure. Examples of preoperative parenterals are cefotetan, cefoxitin, or cefazolin plus metronidazole. Preoperative parenteral antibiotics control bacteremia, reduce secondary or metastatic suppurative complications, and prevent the spread of infection around the surgical site.

For patients with documented allergy or adverse reaction to β-lactams, clindamycin plus gentamicin, aztreonam, or ciprofloxacin is recommended; or metronidazole plus gentamicin or ciprofloxacin.

Anaerobic infection is a pathology caused by bacteria that can grow and multiply in the complete absence of oxygen or its low voltage. Their toxins are highly penetrating and are considered extremely aggressive. This group of infectious diseases includes severe forms of pathologies, characterized by damage to vital organs and a high mortality rate. In patients, manifestations of intoxication syndrome usually prevail over local clinical signs. This pathology is characterized by predominant damage to connective tissue and muscle fibers.

Anaerobic infection is characterized by a high rate of development of the pathological process, severe intoxication syndrome, putrid, foul-smelling exudate, gas formation in the wound, rapid necrotic tissue damage, and mild inflammatory signs. Anaerobic wound infection is a complication of injuries - wounds of hollow organs, burns, frostbite, gunshot, contaminated, crushed wounds.

Anaerobic infection in origin can be community-acquired and; by etiology – traumatic, spontaneous, iatrogenic; by prevalence - local, regional, generalized; by localization - with damage to the central nervous system, soft tissues, skin, bones and joints, blood, internal organs; along the flow - lightning, acute and subacute. According to the species composition of the pathogen, it is divided into monobacterial, polybacterial and mixed.

Anaerobic infection in surgery develops within 30 days after surgery. This pathology is hospital-acquired and significantly increases the patient’s time in the hospital. Anaerobic infection attracts the attention of doctors of various specialties due to the fact that it is characterized by a severe course, high mortality and disability of patients.

Causes

The causative agents of anaerobic infection are inhabitants of the normal microflora of various biocenoses of the human body: skin, gastrointestinal tract, genitourinary system. These bacteria are opportunistic due to their virulent properties. Under the influence of negative exogenous and endogenous factors, their uncontrolled reproduction begins, bacteria become pathogenic and cause the development of diseases.

Factors causing disturbances in the composition of normal microflora:

Prematurity, intrauterine infection,
Microbial pathologies of organs and tissues,
Long-term antibiotic, chemotherapy and hormonal therapy,
Radiation, taking immunosuppressants,
Long-term hospital stays of various profiles,
Prolonged presence of a person in a confined space.

Anaerobic microorganisms live in the external environment: in the soil, at the bottom of reservoirs. Their main characteristic is lack of oxygen tolerance due to insufficiency of enzyme systems.

All anaerobic microbes are divided into two large groups:

Pathogenicity factors of anaerobes:

Enzymes enhance the virulent properties of anaerobes and destroy muscle and connective tissue fibers. They cause severe microcirculation disorders, increase vascular permeability, destroy red blood cells, promote microthrombosis and the development of vasculitis with generalization of the process. Enzymes produced by bacteroids have a cytotoxic effect, which leads to tissue destruction and the spread of infection.
Exotoxins and endotoxins damage the vascular wall, cause hemolysis of red blood cells and trigger the process of thrombus formation. They have nephrotropic, neurotropic, dermatonecrotizing, cardiotropic effects, disrupt the integrity of epithelial cell membranes, which leads to their death. Clostridia secrete a toxin, under the influence of which exudate is formed in the tissues, the muscles swell and die, become pale and contain a lot of gas.
Adhesins promote the attachment of bacteria to the endothelium and its damage.
The anaerobic capsule enhances the virulent properties of microbes.

Exogenous anaerobic infection occurs in the form of clostridial enteritis, post-traumatic cellulite and myonecrosis. These pathologies develop after the penetration of the pathogen from the external environment as a result of injury, insect bites, or criminal abortion. Endogenous infection develops as a result of the migration of anaerobes within the body: from their places of permanent residence to foreign loci. This is facilitated by operations, traumatic injuries, therapeutic and diagnostic procedures, and injections.

Conditions and factors that provoke the development of anaerobic infection:

Contamination of the wound with soil, excrement,
Creation of an anaerobic atmosphere by necrotic tissues deep in the wound,
Foreign bodies in the wound,
Violation of the integrity of the skin and mucous membranes,
Penetration of bacteria into the bloodstream,
Ischemia and tissue necrosis,
Occlusive vascular diseases,
Systemic diseases
Endocrinopathies,
Oncology,
Great blood loss
Cachexia,
Neuropsychic stress,
Long-term hormone therapy and chemotherapy,
Immunodeficiency,
Irrational antibiotic therapy.

Symptoms

Morphological forms of clostridial infection:

Non-clostridial anaerobic infection causes purulent inflammation of internal organs, the brain, often with abscess formation of soft tissues and the development of sepsis.

Anaerobic infection begins suddenly. In patients, symptoms of general intoxication prevail over local inflammation. Their health deteriorates sharply until local symptoms appear, the wounds become black in color.

The incubation period lasts about three days. Patients experience fever and chills, they experience severe weakness and weakness, dyspepsia, lethargy, drowsiness, apathy, blood pressure drops, heart rate increases, and the nasolabial triangle turns blue. Gradually, lethargy gives way to excitement, restlessness, and confusion. Their breathing and heart rate increase. The condition of the gastrointestinal tract also changes: patients' tongue is dry, coated, they experience thirst and dry mouth. The skin of the face turns pale, acquires an earthy tint, and the eyes become sunken. The so-called “mask of Hippocrates” – “fades Hippocratica” - appears. Patients become inhibited or sharply agitated, apathetic, and depressed. They cease to navigate space and their own feelings.

Local symptoms of pathology:

Severe, unbearable, increasing pain of a bursting nature, not relieved by analgesics.
Swelling of the tissues of the limb progresses quickly and is manifested by sensations of fullness and distension of the limb.
Gas in affected tissues can be detected using palpation, percussion and other diagnostic techniques. Emphysema, soft tissue crepitus, tympanitis, slight crackling, box sound are signs of gas gangrene.
The distal parts of the lower extremities become inactive and practically insensitive.
Purulent-necrotic inflammation develops rapidly and even malignantly. If left untreated, soft tissues are quickly destroyed, which makes the prognosis of the pathology unfavorable.

Diagnostics

Diagnostic measures for anaerobic infection:

Microscopy of smears from wounds or wound discharge makes it possible to determine long polymorphic gram-positive “rough” rods and the abundance of coccal microflora. Bacteriods are polymorphic, small gram-negative rods with bipolar coloring, mobile and immobile, do not form spores, strict anaerobes.
In the microbiological laboratory they carry out bacteriological examination of wound discharge, pieces of affected tissue, blood, urine, liquor. The biomaterial is delivered to the laboratory, where it is inoculated on special nutrient media. The dishes with the crops are placed in an anaerostat, and then in a thermostat and incubated at a temperature of +37 C. In liquid nutrient media, microbes grow with rapid gas formation and acidification of the environment. On blood agar, colonies are surrounded by a zone of hemolysis and in air they acquire a greenish color. Microbiologists count the number of morphologically different colonies and, after isolating a pure culture, study the biochemical properties. If the smear contains gram+ cocci, check for the presence of catalase. When gas bubbles are released, the sample is considered positive. On Wilso-Blair medium, clostridia grow in the form of black colonies in the depths of the medium, spherical or lenticular in shape. Their total number is counted and their belonging to clostridia is confirmed. If microorganisms with characteristic morphological signs are detected in the smear, a conclusion is made. Bacteriodes grow on nutrient media in the form of small, flat, opaque, grayish-white colonies with jagged edges. Their primary colonies are not reseeded, since even short-term exposure to oxygen leads to their death. When bacteriodes grow on nutrient media, a disgusting smell attracts attention.
Express diagnostics – study of pathological material in ultraviolet light.
If bacteremia is suspected, the blood is inoculated onto nutrient media (Thioglycolate, Sabouraud) and incubated for 10 days, periodically inoculating the biomaterial onto blood agar.
Enzyme immunoassay and PCR help to establish a diagnosis in a relatively short time.

Treatment

Treatment of anaerobic infection is complex, including surgical treatment of the wound, conservative and physical therapy.

During surgical treatment, the wound is widely dissected, non-viable and crushed tissue is excised, foreign bodies are removed, and then the resulting cavity is treated and drained. The wounds are loosely packed with gauze swabs with a solution of potassium permanganate or hydrogen peroxide. The operation is performed under general anesthesia. When decompressing edematous, deeply located tissues, a wide fasciotomy is performed. If an anaerobic surgical infection develops against the background of a limb fracture, it is immobilized with a plaster splint. Extensive tissue destruction can lead to amputation or disarticulation of the limb.

Conservative therapy:

Physiotherapeutic treatment consists of treating wounds with ultrasound and laser, conducting ozone therapy, hyperbaric oxygenation, and extracorporeal hemocorrection.

Currently, specific prevention of anaerobic infection has not been developed. The prognosis of the pathology depends on the form of the infectious process, the state of the macroorganism, the timeliness and correctness of diagnosis and treatment. The prognosis is cautious, but most often favorable. Without treatment, the outcome of the disease is disappointing.

Anaerobic infection is a severe toxic wound infection caused by anaerobic microorganisms, primarily affecting connective and muscle tissue.

Anaerobic infection is often called anaerobic gangrene, gas gangrene, or gas infection.

The causative agents are clostridia - CI. perfringens, CI. oedomatien, C.I. septicum, CI. hystolyticus. These bacteria are anaerobic spore-bearing rods. Pathogenic anaerobes are common in nature, saprophyte in the intestines of mammals, and enter the soil with feces. Together with the soil, they can get into the wound. Pathogens are resistant to thermal and chemical factors. Anaerobic bacteria produce strong toxins that cause necrosis of connective tissue and muscles. They also cause hemolysis, vascular thrombosis, damage to the myocardium, liver, and kidneys. For the development of anaerobic infection, the lack of free access of oxygen with impaired blood circulation in injured tissues is of great importance.

The reasons contributing to the development of anaerobic infection in the wound are: extensive damage to muscles and bones; deep closed wound channel; the presence of a wound cavity that has poor communication with the external environment; impaired tissue circulation due to vascular damage; large necrotic areas with poor oxygenation.

Clinically, anaerobic infection is divided into the following forms: classical; edematous-toxic; gas-purulent mixed.

Clinical picture. The patient's condition is serious, intoxication is progressing, manifested by weakness, nausea, vomiting, poor sleep, lethargy, delirium, the skin is pale with a jaundiced tint, facial features become sharpened. The pulse is significantly increased and does not correspond to the temperature, blood pressure is reduced, body temperature ranges from low-grade to high. A blood test reveals anemia, high leukocytosis with a shift in the leukocyte formula to the left. Diuresis is reduced, leukocytes, casts and protein are detected in the urine.

In the area of the wound, the patient notes the appearance of severe arching pain. The skin around it is cyanotic, cold to the touch, with dilated bluish veins. The limb is swollen; upon palpation, crepitus of the soft tissues is determined (due to the presence of air in them). When dressing or opening a wound, a scanty discharge with an unpleasant odor and air bubbles is released from it. An X-ray examination reveals areas of gas accumulation and disintegrating muscles.

To clarify the diagnosis, it is necessary to conduct a bacteriological study.

Treatment. The patient is urgently hospitalized in the purulent-septic department of the surgical hospital in a separate box.

After the diagnosis is made, surgical intervention is performed - wide and deep opening of the wound, excision of necrotic tissue and drainage. A bandage with hydrogen peroxide is applied to the wound. If the general condition worsens and local symptoms increase, they resort to radical surgery - amputation of the limb.

General treatment includes the use of mixtures of anti-gangrenous serums, infusion therapy, blood transfusions, plasma and blood substitutes, antibacterial therapy, high-calorie nutrition, and symptomatic treatment. Hyperoxybarotherapy (pressure chamber for saturating the body with oxygen) is highly effective.

To prevent anaerobic infection, early and radical primary surgical treatment of wounds is necessary; drainage of crushed, contaminated, gunshot and festering wounds; good transport and therapeutic immobilization on a limb with damaged tissues; early antibiotic therapy for large wounds.

Rules for patient care. The patient is hospitalized in a specialized box and medical personnel are assigned to care for him. When entering the room, the nurse puts on a clean gown, scarf, mask, shoe covers and rubber gloves. Dressings are made with separate instruments intended only for a given patient, which are then immersed in a disinfectant solution. The dressing material is burned after disinfection. The ward is cleaned 2-3 times a day using a 6% hydrogen peroxide solution and a 0.5% detergent solution, after which the bactericidal irradiator is turned on. Bed and underwear are disinfected in a 2% solution of soda ash, followed by boiling and sending to the laundry.

After use, dishes are disinfected in a 2% solution of sodium bicarbonate, boiled and washed in running water.

The paramedic monitors the patient’s condition hourly on the first day, and 3-4 times a day on the following days: measures blood pressure, body temperature, counts pulse, and respiratory rate. An oilcloth with a diaper is placed under the affected limb, which is changed as often as possible. The wound with drainage is left open. If it becomes very wet with blood or bursting pain appears, immediately inform the doctor.

Putrid infection

Putrefactive infection is caused by various representatives of anaerobic non-clostridial microflora in combination with anaerobic microorganisms.

Clinical picture. Putrefactive infection is observed with lacerations, crushed wounds, and open fractures. The general condition worsens in the same way as with an aerobic infection. In the wound area, the process of necrosis prevails over the processes of inflammation. The edges and bottom of the wound with necrotic areas of tissue of a hemorrhagic, dirty gray color and foul-smelling discharge. There is pronounced swelling and hyperemia around the wound. Lymphangitis and lymphadenitis are often observed.

Treatment. Treatment is carried out in the purulent-septic department of a surgical hospital without isolating the patient in a box.

Urgent radical surgical treatment of the wound with wide dissection of tissue and removal of necrosis, antibacterial, detoxification therapy, and immunotherapy are carried out.

Tetanus

Tetanus is an acute specific infection. According to the World Health Organization (WHO), more than 1 million people fall ill with tetanus every year, and the mortality rate reaches 50–80%.

The causative agent of tetanus (CL tetani) - tetanus bacillus - is an anaerobic, spore-forming, gram-positive microorganism, the spores of which are very resistant to environmental factors. Bacteria can exist under normal conditions for many years. The toxin released by the tetanus bacillus damages the nervous system and destroys red blood cells.

Infection occurs only through damaged tissue. The incubation period lasts from 4 to 40 days. During the incubation period, a person complains of headache, insomnia, increased irritability, general malaise, profuse sweating, pain and twitching of tissue in the wound area. Tendon reflexes increase and pathological reflexes appear on the injured side.

Clinical picture. The leading symptom of the disease is the development of toxic and clonic spasms of skeletal muscles. First, muscle spasms and cramps begin around the site of injury, then move to the chewing and facial muscles. The patient's face twists into a so-called “sardonic smile.” The spread of spasms to the neck muscles leads to throwing back the head. Convulsive contractions of the respiratory muscles cause breathing problems up to asphyxia, and contractions of the heart muscles cause it to stop. Due to tonic contraction of all skeletal muscles, opisthotonus develops - the torso arches, and the patient touches the bed only with the back of the head and heels (Fig. 10.5). Such convulsions can be accompanied by retraction of the tongue, fractures of bones, spine, ruptures of organs, muscles, and neurovascular bundles.

Frequent cramps are combined with profuse sweating, high body temperature, respiratory and cardiovascular disorders. The severity of the disease is determined not only by convulsions, but also by intoxication, suppuration of the wound, the characteristics of the course of the wound process, the number and virulence of the pathogen, and the reactivity of the body.

Treatment. Necrotic tissue in and around the wound is carefully removed, leaving the wound open to allow air access to the tissue.

For local treatment, proteolytic enzymes are used, which accelerate necrolysis, clean the wound, and stimulate the regeneration process.

General treatment consists of specific serotherapy (administration of PSS, tetanus toxoid, antitetanus human immunoglobulin), anticonvulsant therapy (aminazine, droperidol, muscle relaxants with mechanical ventilation), hyperbaric oxygenation, antibiotic therapy, symptomatic therapy aimed at maintaining the functions of the cardiovascular and respiratory systems, infusion therapy to compensate for fluid loss and normalize water and electrolyte balance. In severe forms of the disease, when providing first aid, the patient during hospitalization is placed horizontally on a stretcher with straps attached to it, aminazine with diphenhydramine is administered intravenously, an air duct is inserted into the oral cavity, and, if necessary, mechanical ventilation is performed.

Rules for patient care. A patient with tetanus is treated in the same conditions as a patient with sepsis, but the room must be darkened to eliminate unnecessary irritation to the patient. The patient must be provided with a medical and protective regime, an individual nursing station, constant medical supervision and careful care. The patient is placed on a soft bed. Staff must maintain silence: sharp sounds and bright lights cause seizures in the patient. All manipulations and feeding are carried out after the administration of anticonvulsants. Significant dehydration of the patient, administration of large amounts of fluid and the inability to urinate on his own necessitates the need to release urine with a catheter 2 times a day after preliminary anesthesia of the urethra (dicaine, novocaine), if the patient is not under anesthesia.

You can give fluids enterally and feed via a sippy cup, through a thin gastric tube inserted through the nose, or as a nutritional enema. Food should be liquid. All measures must be carried out carefully, since any careless impact on the patient can lead to the development of a convulsive attack.

When the frequency and duration of seizures increases, long-acting muscle relaxants are administered and the patient is transferred to mechanical ventilation through an endotracheal tube or tracheostomy.

When monitoring a patient, it is necessary to measure blood pressure, count pulse, respiratory rate, monitor renal function (calculate daily diuresis), gastrointestinal tract, blood composition (general analysis).

Emergency prevention. Emergency prevention of tetanus is carried out in case of injury with violation of the integrity of the skin and mucous membranes, frostbite and burns of II - IV degrees; penetrating wounds, out-of-hospital abortions, childbirth outside of medical institutions, gangrene or tissue necrosis of any type, long-term abscesses, carbuncles and other purulent infections, animal bites.

Emergency prevention of tetanus consists of primary surgical treatment of the wound and simultaneous immunoprophylaxis. Prevention should be carried out as early as possible. Contraindications to the use of specific means of emergency prophylaxis of tetanus are hypersensitivity to the drug and pregnancy.

When a patient consults a doctor about an injury, the issue of emergency tetanus prophylaxis must be decided.

Prevention is not carried out for patients who have documented evidence of routine preventive vaccinations in accordance with age or a full course of immunization no more than 5 years ago in an adult; patients in whom, according to emergency immunological control, the titer of tetanus antitoxin in the blood serum is higher than 1: 160 according to the passive hemagglutination reaction. The titer of tetanus antitoxin in the blood serum can be determined within 1.5 -2.0 hours from the moment the patient contacts the health care facility for assistance.

For emergency immunoprophylaxis, adsorbed tetanus toxoid, adsorbed diphtheria-tetanus toxoid with reduced antigen content (ADS-m), purified concentrated horse PSS, and human tetanus immunoglobulin (HAT) are used. If the patient's tetanus antitoxin titer is within the range of 1: 20... 1: 80 (0.01-0.1 IU/ml), then for the purpose of prevention, only 0.5 ml of tetanus toxoid or 0.5 ml of ADS- m.

If the patient has a tetanus antitoxin titer of less than 1:20 (0.01 IU/ml), then 1 ml of tetanus toxoid and 3,000 IU of PSS are administered after the test (or 250 IU of PSS).

Antitetanus serum is administered according to the usual method: 0.1 ml intradermally, if there is no reaction within 20 - 30 minutes - another 0.1 ml subcutaneously, after 20 - 30 minutes if there is no reaction - the entire dose is intramuscular. Revaccination at a dose of 0.5 ml of tetanus toxoid is carried out after 1 month and 1 year. In this case, immunity is developed for 10 years.

Before administering the drugs, the paramedic carefully examines the ampoule (label, expiration date, presence of sediment in the ampoule or cracks), shakes until a homogeneous suspension is obtained, and treats the skin at the injection site with 70% alcohol. The drugs are taken with one needle, and another needle is used for injection. Antitetanus serum is stored, covered with a sterile napkin, for no more than 30 minutes.

Osteoarticular tuberculosis

Tuberculosis of bones and joints occurs in patients of any age, is characterized by a long chronic course and is a manifestation of general tuberculosis. It is caused by the tuberculosis bacillus. With bone tuberculosis, flat and short bones are most often affected, as well as small tubular ones - fingers and toes, ribs, vertebrae, wrist joints.

The process begins in the spongy bone and gradually leads to the destruction of the bone structure, the formation of small sequesters, fistulas and cavities, from which pus leaks into the soft tissue. Tuberculous abscesses are called “cold”, since they have no signs of inflammation, and the pus contains almost no leukocytes. When thinned, the abscess wall can break through and a long-term non-healing fistula is formed.

Clinical picture. Symptoms of the disease appear gradually, so it is difficult to determine the onset of the disease. From the moment of infection to the symptoms of the disease, it takes from 3 months to 3 years, depending on the location of the process. The process can move from the bones to the joints, or it can remain only in the bones.

If the process is localized in the spine (tuberculous spondylitis), then the focus is in the spongy substance of the anterior part of the vertebral body. The muscles in the area of the affected vertebra become tense and it collapses. Several vertebrae may also be destroyed, causing the spine to bend and form a hump. This creates a danger to the spinal cord, the likelihood of developing paresis and paralysis.

Tuberculosis most often affects the hip joint, causing tubular coxitis. When the knee joint is damaged, tubular gonitis occurs. An effusion forms in the joint cavity, the contours of the joint are smoothed, and it takes the shape of a spindle. The skin becomes white and shiny, muscle atrophy occurs above and below the joint. This process happens very slowly. The joint capsule, ligaments, and cartilage are destroyed, and the function of the joint is impaired. In this case, the patient has no inflammatory symptoms. The body temperature is normal, pain is characteristic of the later stages of the disease, although sometimes it can be present in the initial stages. They occur during movement and stress on the joint (the patient is asked to stand on one leg). The diagnosis is confirmed by x-ray.

Treatment. Treatment is carried out in anti-tuberculosis dispensaries. It can be specific and non-specific. Anti-tuberculosis antibiotics, vitamins, restoratives and immunity boosters are prescribed. The regimen and proper nutrition of the patient are very important. The joint must be

at rest, so the patient is prescribed bed rest and special orthopedic devices or a plaster cast.

Surgical treatment is indicated in the final period of treatment to correct the deformity and restore joint function.

In case of abscesses, pus is removed by puncture of the joint cavity. Treatment of abscesses lasts several months. As a complication, bone deformation, curvature, and pathological fractures may occur.

After inpatient treatment, patients are recommended to undergo sanatorium-resort treatment. General treatment of patients with osteoarticular tuberculosis lasts several years.

Professional examinations and fluorographic examination are of great importance for identifying early forms of the disease.