ACUTE ANAEROBIC NONSPECIFIC AND SPECIFIC INFECTION

Anaerobic infection is a number of diseases which, as a rule, arise in a wound, caused by microbes which develop during anaerobic conditions. The typical features of this infection: weak inflammatory reaction, tissue hypostasis, dead tissue, formation of gas in tissue, significant intoxication.

More often this infection is a complication of battle wounds. In the course of its history it had different interpretations, described in literature as “hospital gangrene”, “gas gangrene,” “malignant hypostasis”, “bronze mallow”, “blue gangrene”, etc.

Concerning the clinical picture of open fractures Hyppocrates gave the description of a fatal complication with strong hypostasis of tissue and jaundice and, as a rule, with fatal outcome.

Describing the death of prince Romadanovsky in a letter to Alexander Menshikov, his son represented this complication as follows: “Yesterday prince Romadanovsky died from print disease. Anton’s fire appeared on the leg. Enormous fever was upon the whole body and the leg began to swell, the swelling almost reached the moon within two days”. Dupuytren (1815), Velpeau (1844), Pyrogov (1848) described this disease in details in the XIX century.

In 1835 Mezanov allocated this disease into an independent illness and named it a lightning gangrene. It is known that anaerobic infections is more often observed during the war. According to Terebinsky’s data during the World War I the gas infection affected 7– 8% of the wounded. In the English army at this time, about 1,115 amputations were done. In the Russian army, there are 200,000 of people suffered from this infection, according to Burdenko’s data. During the Great Patriotic War — 0.2–0.3% of the wounded had gas infection. In the peace time this complication is also observed but much less often.

Sources of the causative agent of anaerobic infections are the intestines of mammals and people, microbes excrete into the environment, locate in the upper layers of ground and can appear with the pollution of the wound. A number of conditions are necessary for their development, first of all oxygen-free space, formed during “blind” wounds, lacerations, and also the presence of glycogen; because of this anaerobic infection appears more often with damage to muscles. It is known that 90% of wounds contain anaerobic agents. However, with the absence of conditions for their growth clinical signs are not observed.

Today it is considered that agents of anaerobic infection are bacteria of the genus Clostridium, so-called clostridium anaerobic infections. Representatives of the genus Clostridium, dangerous and pathogenetic for people are the following: Cl. Perfringens (types A, B, C, etc.), Cl. Edematiens (types A, B, C, etc.), Cl. Septicum, Cl. Hystoliticum.

Each kind of an agent of anaerobic infections has qualitative and structural features, and also has a certain action on a person’s organism.

Cl. Perfringens are observed more often, causing gas formation. The agent’s toxins have proteolytic, haemolytic, glycogenolytic action. The pathoanatomical picture appears as necrosis of tissue, especially muscular, porosis of vessels and expressive interstitial hypostasis of the connective tissue, oppression of red blood growth.

Today the following classifications are used:

1. After the speed of spreading:

lightning;

acute.

2. After the pathoanatomical picture:

emphysemic;

hydropic;

phlegmonous;

necrotic;

mixed.

3. After the depth of the process:

epifascial;

subfascial.

From the moment of entering the wound to the clinical displays of anaerobic infections, as a rule, several hours or 1–2 days up to 7 days pass.

The incidence of various has a wide range. The hydropic form is observed in 37.7%, mixed forms — in 29.2%, emphysemic forms — in 19.7%, the necrotic form — in 9.3% of the cases,  phlegmonous — in 7.1%.

More often the anaerobic infection is caused by damage to the muscles of the extremities. In due time, M. I. Pyrogov described the development of this infection: “the damaged part without any attributes of reaction dies within first 24–28 h after the injury. The skin is flushed, gases quickly develop, a rattle during palpation. The wounded weakens, and sometimes does not complain of pain, he is pale with a yellowish shade, anxious, cloudy eyes, cold sweat, small, quivering, frequent pulse and hiccups, which shows that death is close”.

Today in the clinical picture of anaerobic infection local signs are distinguished — growing bursting pain in the wound, edema, which spreads upwards on the legs. First the skin is pale, and then it gets a dark-purple. The wound is dry; insignificant secretion, unpleasant odour, pronounced necrosis of the muscles (color of cooked meat), a crunch of the tissue in places where gas (crepitation) has accumulated is determined during palpation. The general picture appears as paleness, accentuation of features of the face, frequent pulse (120–140 beats per minute), high temperature. Arterial pressure decreases. Patients are euphoric. Decrease in haemoglobin and erythrocytes is observed; diuresis decreases.

Many clinical physicians describe a characteristic specific putrefactive odour which spreads through the air. Victor Hugo describes his visit to Onore Balzac. It is known that O. Balzac suffered from hydrops: having wounded his leg with a table, he felt relief, because from the wound a lot of tissue liquid flew out. However, later anaerobic infection developed in the wound. Having visited the patient, Victor Hugo described his condition: “I called, a house maid appeared and lead me to the living-room, we came to Balzac’s bedroom. I heard ominous snoring. An intolerable odour came from the bed. I lifted the blanket and took Balzac’s hand. It was wet from sweat. He did not answer my handshake. When I arrived home, I found a few men and told them: Sirs, Europe is now losing a genius”.

Besides of the clinical picture, the diagnosis is based on radiological exam, which reveals the presence of gas in the tissue. More often bacteriological methods are used.

Smear-prints, sometimes inoculation of wound excretion on the Kit—Taroci medium is used, and also hyaluronidase and lecithinase are determined in the wound excretion. However, all the methods of diagnosis lag behind clinical displays by the hour factor, that is why in the clinic treatment is started when anaerobic infection in the wound is suspected, without waiting for laboratory confirmation.

Aggression of clostridium toxins has been investigated in details by employees of the faculty of microbiology of our university. The essential contribution was made by the works of prof. S. N. Minevrina, A. V. Tselukha, etc. It is proved that aggression of clostridium toxins increases during the combination of several kinds of agents both anaerobic and aerobic. That is why it is necessary to not allow the development of purulent process in the wound.

Treatment of anaerobic infection includes some components. It is specific therapy. Antigangrenous serums, containing 30,000 IU (10,000 IU against Cl. Perfringens, Cl. Edematiens and Cl. Septicum) are applied. The dose — 30,000 IU is applied for preventive measures, during treatment 10–15 preventive doses are used. Serum is entered intravenously. Recently it is considered that numerous complications of serotherapy make it inexpedient to enter antigangrenous serum. However, being based upon experience of the clinic, we consider this idea to be erroneous. The application of hyperbaric oxygenation is effective. Sessions of hyperbaric oxygenation are conducted 2–4 times a day with the pressure of 2.5–3.0 atm. It is necessary to apply also antibiotics (penicillin group) and to combine them with tetracyclin and erythromycin.

Surgical treatment consists of duly surgical processing of the wound with the opening of blind pockets, removal of dead tissues, washing of the wound with hydrogen peroxide, kalium permanganate, boric acid. Patients should be isolated in case of the development of anaerobic infection. The material which is applied for dressings, is burnt, the wound is widely opened (incisions). More often amputation of the extremities is conducted. With anaerobic infection, the amputation is done in the “guillotine” type, i.e. do not form a stump and do not sew up the wound. It is necessary to actively carry out nonspecific therapy which consists in the methods of detoxification and stimulations of the parenchymatous organs function. They transfuse blood, blood substitutes, stimulate diuresis, carry out vitamin therapy, and apply cardiac drugs.

Unfortunately, modern complex therapy not always gives positive results, and today the rate ranges from 20 up to 30%.

Last years, due to M. I. Kuzin’s and B. M. Kostyuchenko’s works, microbiologists established that anaerobic infection is caused not only by clostridia but also by a whole group of non-clostridium anaerobes: gram-negative bacilli of the bacteroid family and fusobacteria, gram-positive cocci of the peptococcum and peptostreptococcus family, gram-positive asporous bacilli.

Under usual conditions these agents are in the oral cavity, intestines. For a long time they could not be released, because when they collide with air they quickly perish. In clinic non-clostridium pathogenic organisms frequently complicate the wound process and cause a number of diseases: phlegmons of the subcutaneous fat with injury foci, the tissues around the wound are saturated with serousbloody brownish liquid with an unpleasant odour. The process spreads more deeply, damaging muscles against a background of toxemia, growing edema and disintegration of muscles. It increases because of local thrombogenesis of fine vessels, inflammatory reaction is insignificant.

Diagnosis is difficult, however, recently thanks to gas-liquid chromatography it is possible to find crotonic, oil, valerian and other fatty acids, in the surrounding tissue which form during anaerobic infections and are absent during purulent. Treatment of anaerobic non-clostridium infection includes surgical interventions such as wide incisions (removing) necrotic tissue, antibiotics usage: lincomycin, siptomisin, metronidazole, etc. It is necessary to carry out detoxification. Unfortunately, lethality rate is high during this infection and ranges within 16–60%.

ACUTE SPECIFIC ANAEROBIC INFECTION

Tetanus, anthrax, wound diphtheria and rabies belong to anaerobic infection.

Tetanus is observed more often in surgical practice. The disease was described in ancient times. Tetanus was known still by ancient hindus. It was described by Hyppocrates, who lost his son because of tetanus, and only in 1884 Monastirsky and Nicolaer found its causative agents.

The agent of tetanus is revealed in war conditions, but in peace time it is also observed. During the Great Patriotic War tetanus was marked in 6–7 cases in 10,000 wounded. M. І. Pyrogov considered that during the Crimean and Caucasian wars (1854–1858) the tetanus incidence ranges from 0.3 up to 0.6%.

The agents of tetanus — Cl. tetani — as saprophyte is in the intestines of animals (sheep, horned cattle) and people. When excrements enter the ground, it can be kept for a long time in the surrounding environment. With dust it gets to the skin, and then to the wound. It does not require special conditions and can develop under the blood crust from 4 days to 4–5 months.

Cl. tetani intensively divides and releases exotoxin, which contains tetanospasmin and tetanohemolysin. The toxin gets into the central nervous system through the perineural spaces, damaging the anterior grey substance of the spinal cord, causes tonic and clonic muscle spasms. Tetanohemolysin destroys erythrocytes.

According to the place of the infection entering different kinds of tetanus are distinguished:

— wound;

— burn;

— postinfection;

— postoperative; — postnatal, etc.

According to the character of spreading and localization:

— local tetanus

— generalized tetanus.

According to the clinical course:

— acute tetanus;

— chronic tetanus;

— vague tetanus.

The clinical picture of tetanus appears as general weakness, rise in the body temperature, uncertain pains, and then convulsive muscular contraction follows at the wound site or old scars. Further there is damage to the chewing muscles — masticatory spasm and mimic muscles as a smile — “sardonic smile”, convulsive contractions spreads to muscles which surround the wound, and then to muscles of the whole thorax — the patient is curved as an arch, from time to time leaning on the bed by the heals and occiput (opistotonus). The frequency of the convulsive attacks increases. The process spreads to the respiratory muscles, asphyxia occurs, during this the muscles can rupture, bones can fracture, atelectasis of the lungs can occur.

Treatment of patients with tetanus is carried out in specialized resuscitation department and contains the following measures: centralization of the tetanus toxin, elimination of spasms, lung ventilation, as well strengthening and symptomatic therapy. The patient is given intravenous or intralumbar antitetanic serum in the dose of 100,000–150,000 IU daily, as well as muscle relaxants. Artificial lung ventilation is carried out by the method of tracheotomy or tracheostomy. Introduction of great amount of liquids — vitamins, parenteral nutrition are carried out.

Thus, surgeons during treatment of tetanus are consulting physicians, but they are responsible for preventive measures of this disease.

Preventive measures of tetanus may be elective and emergency.

Elective preventive measures begin at an early age with the observance of certain terms. Immunization of children is conducted with adsorbed diphtheria, tetanus toxoids and pertussis vaccine, and immunization of adults — tetanus anatoxin. Immunization is started at 6–7 months of age and continues till 15 years. Elective preventive measures for adults are conducted during excavations and for service men.

Emergency preventive measures are carried out with the infringement of the skin, burns and frostbites, abortions and operations on the large intestines. Emergency preventive measures contain the introduction of tetanus anatoxin 1.0 ml, 3,000 AO antitetanic serum. They enter by the scheme. Nonspecific preventive measures of tetanus are primary surgical processing of wounds.

Anthrax is an acute specific pathology. It belongs to especially dangerous infections because of high contageousness. The disease is caused by the anthrax bacillum which is capable of forming spores. It is very resistant to conditions of adverse environment. It can be kept for decades in the ground. Source: animals — sheep, cattle. Earlier this illness was named illness of furriers because a person could catch it from animal skin and also by eating their meat.

Treatment is carried out by doctors-infectionists. However, it is necessary to remember this disease because in clinic it can appear as a furuncule, and also damage the intestines and lungs, stimulate tumoural process. Malignant carbuncle locates on open surfaces of the body; the focus is black, pronounce oedema, weak pain syndrome, but the top is surrounded with two lines of fine blisters filled with an amber color liquid. Any operative interventions are impossible. Treatment is conducted with specific serums and antibiotics.

Diphtheria. There can be diagnostic mistakes with acute disease for diphtheria. The pathogenic organism — the Löffler bacillus — can develop in the wound, thus, its toxin results in significant morphofunctional changes in the cardiac muscle, cortex of the adrenal glands, kidneys. With treatment no antiseptics, except for specific serum, work. That is why it is important to remember that wound diphtheria presents in the wound grey films, soldered with surrounding tissues. When attempting to remove them there are dot bleedings. Thus, during the treatment of tetanus, diphtheria of wounds and sibirea surgeons are not the leading doctors, but for the introduction of preventive measures for tetanus and determining differential diagnosis of sibirea and diphtheria surgeons need to have corresponding knowledge.

Rabies. Surgeons are responsible for preventive measures of one more disease — rabies. It is caused by virus as a result of a bite from a wild animal or pets with rabies. The disease is connected to damage to the CNS by the rabies virus. In clinic general intoxication prevails, the patient cannot swallow, accept food and water as a result of pharyngospasm, the development of spasms and paralyses is observed. The prognosis is adverse, lethality reaches 100%.

Prophylaxis consists in gamma-globulin and antirabic vaccine according to special schemes.