Clostridial and non-clostridial infections have attracted the attention of scientists around the world for more than a century. Diseases provoked by anaerobes are difficult to tolerate by humans and are highly likely to lead to severe complications and death. In modern medical literature, clostridial infection is also referred to under a number of other names. Let us consider in more detail what kind of pathological condition it is.
Terms and concepts
Clostridial infection is gas gangrene. In some sources it is called gas phlegmon. Another common name for the pathological condition is malignant edema. In total, in the medical literature, you can find about 70 different terms denoting the same condition - an infectious process caused by Clostridium. These microorganisms are anaerobes and are highly pathogenic.
Clostridial infection in dogs, cats, humans is characterized by a rapid course. The disease is characterized by active necrotic processes that quickly spread throughout the body. organic tissuesbreak up and form a gaseous atmosphere. The patient suffers from a hard-tolerated general poisoning of the body. At the same time, clostridial infection does not cause the phenomena characteristic of a typical inflammatory process.
History and Science
Clostridial anaerobic infections are mentioned in scientific works that have come down to our days from ancient times. Even Galen, Hippocrates knew about this phenomenon. Information about him can also be found in the works of Ambroise Pare. In 1854, the first classical description of the disease was formulated. Its author, the scientist Pirogov, used the term "mephitic gangrene". Work on the description was carried out during the Crimean military campaign. Since at that moment clostridial infection in surgery was quite common, Pirogov considered the pathological condition in his significant work on surgical care in the field.
In the classical description of the pathology, there are references to the first signs that make it possible to suspect that an anaerobic disease is beginning. Acute serous process, as noted by Pirogov, purulent infiltrate cause subcutaneous crepitus. This phenomenon indicates that the course of the pathology has changed, the gangrenous stage has begun.
Nuances of the phenomenon
Studying clostridial anaerobic infections, Pattol, Welsh in 1892 established which microscopic life form provokes a pathological condition. It was found that the cause is Clostridia from the genus Perfringens. From statistics it is known that outside of hostilities this disease occursrelatively rare. Mostly, the statistical base on clostridial infections accumulated during the period of hostilities. The survival rate and the nuances of the course of cases vary significantly from period to period. This is due to the progress of medical support, the conditions for the evacuation of victims, as well as the nuances of prevention. On average, the incidence of clostridial infection varies between 0.5-15%. The probability of death is estimated at 15-20%.
From the history of medicine it is known that in 1938 during a military campaign near Lake Khasan, clostridial infection occurred in 1.5% of the victims. Similar figures (one tenth of a percent less) were characteristic of the battles near the Khalkhin-Gol River. The frequency was even less during the battles of the Soviet and Finnish forces - about 1.25%.
Infection and treatment
As practice has shown, the likelihood of formation of clostridial infection of the intestines, limbs, and other organs largely depends on the quality and speed of primary medical care for the wounded. It is known that during the Second World War, among those American soldiers who entered the surgical department of a field hospital in the first 24 hours after receiving a wound, the incidence rate was estimated at 8%. For French troops operating on wounded persons in the first 48 hours of the event, the risks were 13%. Among the German soldiers who were taken prisoner, this figure was more than half of the victims - about 51%. This difference is explained by the fact that prisoners of war received qualified assistance only 3-4 days aftergetting injured.
It is known that among Soviet sailors, clostridial infection developed only if patients from the landing force were admitted to surgery.
Localization and nuances
According to the accumulated information over a long period of observation in surgery, clostridial anaerobic infection is more often observed if the wound is received in the leg area. The incidence for such lesions is estimated at 58-77%. The risks are higher if the hip is broken due to a gunshot wound and the lower leg. The first variant of the wound accounts for up to 46% of all recorded cases, the second - about 35%. In 1943, statistics were compiled, from which it followed that bullet wounds were the cause of about 55.3% of cases. Significantly higher risks of developing the condition under consideration when injured by shrapnel - up to 83% of patients encountered a pathological process.
Categories and types
Due to the high level of mortality due to untimely medical care, the described pathological state attracted the attention of scientists from various fields of knowledge, and especially surgery. Anaerobic clostridial infection, as it was found out, is formed by clostridium capable of generating spores. These are Gram-positive pathological forms of life. Clarifying the nuances of the etiology and pathology of the disease, it was revealed that there are about 90 types of dangerous microorganisms in total. Among them, four forms were found that are more common than others. According to Kuzin, these are histolyticum, septicum, oedematiens, perfringens. Themthe code name "Group of Four" was given.
Research perfringens allowed to establish six varieties of microflora that form 12 toxic compounds, enzymes. One of the toxins is a neurolytic, hemolytic, which has pronounced necrotic qualities. It is he who has the strongest influence in the formation of clostridial infection.
4 types have been identified in oedematiens, generating 8 hazardous substances. The most harmful is capillary poison, which changes the permeability of the walls of blood vessels. This causes swelling of muscle fibers, fiber under the skin.
Septicum has two types, forms four or more poisons, toxic to the blood. They provoke a rapidly growing edema, muscles and fiber are saturated with serous-hemorrhagic substance.
Histolyticum generates three hazardous substances that melt muscle tissue. This turns the cells into an amorphous jelly mass.
Features of pathogens
Treatment of clostridial infection is difficult due to the fact that anaerobic life forms are normally found in the intestinal tract of humans and animals. To a greater extent, this is inherent in herbivores. They penetrate the ground with intestinal secretions. It has been established that general, local factors can cause infection.
When considering the causes, one should first of all pay attention to wounds: fragments and bullets with a high degree of probability lead to such a complication. This factor is considered local. There is a high probability of infection when injured, since modernprojectiles, when hitting a target, cause numerous necrotic foci. In addition, local factors are blind wounds in which the earth fell, as well as wounds in which the integrity of the pelvic bones, lower leg, and thigh was violated.
Since the disease in question is characteristic not only of humans, but also of animals, scientists also considered the causes of clostridial infection in cats and dogs. It has been established that the disease is often observed against the background of injuries. Higher probability with soil contamination. An animal can get injured due to various factors, including an accident involving a vehicle.
About Factors: Continuing Consideration
Statistics show that the incidence of clostridial infection is directly related to the quality of medical care. The worse the processing was carried out, the more defects were made, the higher the risks. Anaerobic infections are more likely to develop if medical attention is delayed.
Of the common factors that can provoke a pathological condition, there is extensive blood loss and shock. In addition, the likelihood of infection is greater if a person is starving or too tired, lacks vitamins in the body. General hypothermia may play a role.
The likelihood of clostridial infection is exceptionally high if there are already necrotic areas of tissue in the body. The risks are greater if the tissue's potential to oxidize and regenerate is reduced. The studies that confirmed this were organized in 1991.
Clostridia can exist in symbiosis withaerobic life forms and other infectious pathogens, due to which virulence increases, and the course of the process becomes more difficult. The absorption of oxygen by aerobes creates conditions that are comfortable for anaerobic life forms, the infection actively spreads with the blood and lymph flow, as well as by contact. Due to toxic poisoning, there is spasm and stasis in small blood vessels. The condition gradually progresses to paralysis, increasing the anemization of organic structures.
Categories and flow
In 1962 it was proposed to divide all cases into two types: cellulitis and myositis accompanied by necrosis. In 1951, another classification was developed in Russia - it was she who was used recently. This system was formed taking into account the speed of progress, the clinical picture and the anatomical nuances of the case. All situations were divided into instant, fast, slow. Each of them refers to gas, edematous or mixed form. It was taken into account that the process can be superficial or deep.
It is known that with an instantaneous form, serious complications form a couple of hours after receiving a wound. In a day or two, death is possible. With the rapid progress of the disease, the first symptoms of clostridial infection (intestines, limbs or other areas) appear 2-3 days after the wound is received. Without adequate assistance, the patient dies within 4-6 days. With slow progress, on the 5th-6th day, the first manifestations of the pathology can be seen, and death is possible by the end of the third week.
Nuances of symptoms
The first symptoms of clostridial infection are agitation, a tendency to talkatively, and the patient's anxiety. The pulse becomes frequent (120 beats per minute and above), there is a fever up to 39 degrees.
One of the main signs of the disease, appearing almost immediately and constantly disturbing - pain in the wound area. Narcotic painkillers don't help. The sensations are described as bursting, some complain of intense pressure under the bandage. To control the spread of edema, it has been suggested that silk thread be used to tie the affected area. Based on the insertion of the thread, it is possible to determine how much the condition progresses. Nowadays, this method is not practiced, since the symptom, as established, is characteristic not only of clostridial infection, but also of fractures. In addition, this is a rather slow diagnostic method, which means that valuable time is wasted.
At the beginning of the development of clostridial infection, signs of general poisoning of the body are expressed. When examining damage, crepitus, a specific sound, is detected. At a late stage, erythrocyte hemodialysis can cause subicteric sclera. Severe poisoning is accompanied by a euphoric state and a change in the face, described in medicine as fades hyppocratica.
Manifestations and specifics
When examining the area of injury, you can see multi-colored spots. This also indicates the development of clostridial infection. The spots are explained by hemorrhagic impregnation, and the shade depends on the progress of decomposition processes. Based on the shades of the spots, the condition is assessed as brown, blue,bronze phlegmon. It is taken into account that the appearance of the wounded area is largely determined by the damage measurements. If the wound is small, the discharge is usually small in volume, bloody, sometimes foamy. With large wounds, muscle tissue resembles wax, over time it acquires a gray tint of boiled meat. With strong skin, fascial defects, the swollen muscle may protrude above the surface of the wound.
In any form, infection with Clostridium is accompanied by the formation of a grayish coating. Diseased tissues are lifeless in appearance, the muscles are dull-colored, fragile, inelastic. Examination reveals bleeding in the area.
Status update
A fairly accurate way to diagnose is an x-ray. Instrumental examination helps to identify small gas formations that cannot be determined by palpation, percussion. In addition, it is with the help of x-rays that the condition can be clarified if pseudopolyps exist. With clostridial infection, such a complication is not always observed, and in other ways, except for x-rays, it is not detected.
Bacteriological analysis can show an abundance of coarse rods in muscle tissues. For the accuracy of the study, it is necessary to take samples in an environment without oxygen.
Bacterioscopy, developed in 1988, can detect clostridial infection in just 40 minutes.
What to do?
The therapeutic course for anaerobic infection is required to be comprehensive. The main element is an urgent operation. Conservative treatment in 100% of cases leads tolethal outcome. The main task of the surgeon is to prevent the vital activity of the pathological microflora, to remove the shifts provoked by the disease. In addition, as part of the course of treatment, it is necessary to increase the patient's resistance to microflora.
During the operation, stripe incisions are made, fascial sheaths are opened. It is known that during the Second World War such incisions were practiced in 37% of cases, and up to 8% of patients were subjected to the procedure of excision of other tissues. With the spread of the infectious process, amputation of the limb, disarticulation is required. Amputation is indicated if the main blood vessel is affected, the fracture is accompanied by serious integrity violations, sparing interventions have not shown an effect. In addition, the indication for amputation is a total wound, an active spread of the process that threatens the torso. About 45% of the wounded during the Second World War survived the amputation. Up to 37% of cases occurred on the day of death or the day before.
Nuances of treatment
Surgery on the background of clostridial infection should be completed with loose tamponade. Potassium permanganate and hydrogen peroxide should be used. The wound should be opened as wide as possible. Soft tissues should be liberally treated with antimicrobial agents and any movement of the affected limb should be prevented. The best results are observed with continuous injection of clindamycin into the muscle. The frequency of procedures is every 8 hours. Dosage - 0.3-0.6 g. Also, the patient should receive 1 g of metronidazole daily. It is possible to use reserve antibiotics: doxycycline, carbapenem, cefoxitin.
Recently, hyperbaric oxygen therapy has proven itself well for clostridial infections. The approach is used strictly as an element of complex treatment. It is chosen because hyperoxia has an antibacterial effect. This is indicated if hypoxia is among the clinical manifestations.
How to prevent?
Prevention of clostridial infection involves the timely provision of assistance to a patient with hemorrhagic shock, traumatic. Surgical intervention should be early, in some cases radical, if the risks are high. Important aspects of preventing gas gangrene are responsible immobilization of the affected limb and adequate use of antimicrobials.
