Clostridial and non-clostridial infections have attracted the attention of scientists around the world for more than a century. Diseases caused by anaerobes are poorly tolerated by humans and are very likely to lead to serious 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 this is.
Terms and concepts
Clostridial infection is gas gangrene. In some sources, it is called a gas phlegmon. Another common name for a pathological condition is malignant edema. In total, in the medical literature you can find about 70 different terms denoting the same condition - the infectious process caused by clostridia. These microorganisms are anaerobes and are highly pathogenic.
Clostridial infection in dogs, cats, humans is characterized by a rapid course. Active necrotic processes that spread rapidly throughout the body are characteristic of the disease. Organic tissues decay, a gas atmosphere is formed. The patient suffers from severely tolerated general poisoning of the body. In this case, clostridial infection does not cause 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 be found in the works of Ambroise Paré. 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 common enough, Pirogov examined the pathological condition in his significant work devoted to surgical care in the field.
In the classic description of pathology, there are references to the first signs that make it possible to suspect that anaerobic disease is beginning. An acute serous process, as Pirogov noted, purulent infiltrate cause subcutaneous crepitation. This phenomenon indicates that the course of the pathology has changed, the gangrenous stage has begun.
The nuances of the phenomenon
Studying clostridial anaerobic infections, Pattol, Welch in 1892 established which microscopic form of life provokes a pathological condition. It was revealed that the cause is clostridia from the genus Perfringens. From statistics it is known that outside the war this disease is relatively rare. Mostly the statistical base for clostridial infections accumulated during the war. The survival rate and nuances of the course of cases vary 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%.
It is known from the history of medicine that in 1938 during the military campaign near Lake Hassan, clostridial infection occurred in 1.5% of the victims. Similar indicators (less than one tenth of a percent) were characteristic of battles near the Khalkhin-Gol river. The frequency was even lower during the battles of the Soviet and Finnish forces - about 1.25%.
Infection and treatment
As practice has shown, the likelihood of clostridial infection of the intestine, limbs, and other organs depends largely on the quality and speed of primary medical care for the wounded. It is known that during World War II, 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 the French troops during the operation of persons injured in the first 48 hours from the moment of the event, the risks amounted to 13%. Among German soldiers captured, this figure was more than half the victims - about 51%. This difference is explained by the fact that prisoners of war provided qualified assistance only 3-4 days after the person received the wound.
It is known that among Soviet sailors, clostridial infection developed only if patients from the landing entered the surgery.
Localization and nuances
According to accumulated information for a long observation period in surgery, a clostridial anaerobic infection is more often observed if a wound is received in the leg area. The frequency of cases for such injuries is estimated at 58-77%. Higher risks if a hip is broken due to a gunshot wound and 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. The risks of developing the condition in question when injured by fragments are significantly higher - up to 83% of patients experienced a pathological process.
Categories and types
Due to the high mortality rate with untimely medical care, the described pathological condition attracted the attention of scientists from different fields of knowledge and especially surgery. It was found that anaerobic clostridial infection is formed due to clostridia, which can generate spores. These are gram-positive pathological life forms. Clarifying the nuances of the etiology and pathology of the disease, it was revealed that in total there are about 90 types of dangerous microorganisms. Among them, four forms were found, which are more common than others. According to the works of Cousin, these are histolyticum, septicum, oedematiens, perfringens. They were given the code name "group of four."
Research perfringens have identified six varieties of microflora, forming 12 toxic compounds, enzymes. One of the toxins is a neurolytic, hemolytic with pronounced necrotic qualities. It is he who has the most powerful influence in the formation of clostridial infection.
In oedematiens, 4 types were identified that generate 8 hazardous substances. The most harmful is capillary poison, which changes the permeability of the walls of blood vessels. This becomes the cause of swelling of muscle fibers, fiber under the skin.
Septicum is of two types, forms four or more poisons toxic to blood. They provoke rapidly growing edema, muscles and fiber are saturated with serous hemorrhagic substance.
Histolyticum generates three dangerous 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 normally occur in the intestinal tract of humans and animals. To a greater extent this is inherent in herbivores. They penetrate the earth with intestinal secretions. It has been established that common, local factors can cause infection.
Considering the reasons, you should first pay attention to wounds: fragments and bullets with a high degree of probability lead to such a complication. This factor is considered local. The likelihood of infection when wounded is high, since modern shells when the target is hit become the cause of numerous necrotic foci. In addition, local factors are blind wounds that hit the ground, as well as wounds in which the integrity of the pelvic bones, lower leg, and thighs is impaired.
Since the disease in question is characteristic not only of humans, but also of animals, scientists also examined the causes of clostridial infection in cats and dogs. It is established that often the disease is observed against the background of wounds. Higher chance of land pollution. An animal can get injured due to various factors, including an accident involving vehicles.
About factors: continuing consideration
Statistics show that the incidence of clostridial infection is directly related to the quality of care. The worse the treatment, the more defects were made, the higher the risks. Anaerobic infection is more likely to develop if medical attention is late.
Of the common factors that can provoke a pathological condition, there is an extensive loss of blood and shock. In addition, the likelihood of infection is greater if a person is starving or too tired, experiencing a lack of vitamins in the body. General hypothermia can play its role.
An extremely high probability of clostridial infection if the body already has necrotic tissue sites. The risks are greater if the potential of tissues to oxidize and regenerate is reduced. Studies confirming this were organized in 1991.
Clostridia can exist in symbiosis with aerobic life forms and other infectious pathogens, due to which virulence increases, and the process becomes heavier. Aerobic oxygen absorption forms conditions that are comfortable for the anaerobic life form, the infection actively spreads with blood and lymph flow, as well as by contact. Due to toxic poisoning, spasm and stasis are observed in small blood vessels. The condition gradually progresses to paralysis, increasing the anemization of organic structures.
Categories and course
In 1962, it was proposed to divide all cases into two types: cellulite and myositis, accompanied by necrosis. In 1951, another classification was developed in Russia - it has been 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 a gas, edematous or mixed form. It was considered that the process can be superficial or deep.
It is known that with an instant form, serious complications form in a couple of hours after receiving a wound. In a day or two, a fatal outcome is possible. With the rapid progression of the disease, the first symptoms of clostridial infection (intestines, limbs or other areas) appear 2-3 days after receiving the wound. Without adequate help, the patient dies on 4-6 days. With slow progress on the 5-6th day, the first manifestations of the pathology can be seen, and death is possible by the end of the third week.
Symptoms nuances
The first symptoms of clostridial infection are agitation, a tendency to talkativeness, and a patient's concern. The pulse becomes frequent (120 beats per minute and higher), there is a fever up to 39 degrees.
One of the main signs of the disease, appearing almost immediately and constantly disturbing is pain in the wound area. From her do not help narcotic painkillers. Sensations are described as bursting, some complain of strong pressure under the bandage. To control the spread of edema, it was proposed to use a silk thread to tie the diseased area. Based on the incision of the thread, you can determine how much the condition progresses. Nowadays, such a method is not practiced, since the symptom has been established to be characteristic not only of clostridial infection, but also of fractures. In addition, this is a rather slow diagnostic method, which means that such valuable time is wasted.
At the beginning of the development of clostridial infection, signs of general poisoning of the body are expressed. In the study of damage revealed crepitus, a specific sound. In the late stage, erythrocyte hemodialysis can cause sclerotic subicterosis. Severe poisoning is accompanied by a euphoric state and a face change, described in medicine as fades hyppocratica.
Manifestations and specifics
Studying the area of injury, you can see colorful spots. This also indicates the development of clostridial infection. Stains 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 evaluated as brown, blue, bronze phlegmon. Take into account that the appearance of the wounded area is largely determined by measurements of damage. If the wound is small, the discharge is usually small in volume, bloody, sometimes foamy. With large wounds, muscle tissues resemble wax, over time they acquire a gray shade of boiled meat. With severe skin, fascial defects, the swelling muscle can protrude above the surface of the wound.
In any form, infection with clostridia is accompanied by the formation of a grayish plaque. Sick tissues are lifeless in appearance, muscles are dullly colored, fragile, inelastic. During the examination, the bloodlessness of the area is noticeable.
Status Update
A fairly accurate diagnostic method is an X-ray. Instrumental research helps to identify small gas formations that can not be determined by palpation, percussion. In addition, it is with the help of X-rays that one can clarify the state if pseudo-polyps exist. With clostridial infection, this complication is not always observed, and is not detected by other methods, except for X-rays.
Bacteriological analysis can show an abundance of coarse sticks in muscle tissue. For the accuracy of the study, it is necessary to take samples in a medium without oxygen.
Bacterioscopy, developed in 1988, allows you to establish a clostridial infection in just 40 minutes.
What to do?
The therapeutic course for infection with anaerobes is mandatory comprehensive. The main element is an urgent operation. Conservative treatment in 100% of cases leads to death. The main task of the surgeon is to prevent the vital activity of 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, strip 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 underwent excision of other tissues. With the spread of the infectious process, amputation of the limb, exarticulation is required. Amputation is indicated if the main blood vessel is affected, the fracture is accompanied by serious integrity disorders, sparing interventions have not shown an effect. In addition, the indication for amputation is a total injury, the active spread of the process, threatening the torso. About 45% of the wounded during the Second World War survived amputation. Up to 37% of cases occurred on the day of death or the day before this moment.
The nuances of treatment
Operation against a background of clostridial infection should result in loose tamponade. Potassium permanganate and hydrogen peroxide should be used. The wound should be opened as wide as possible. Soft tissues should be abundantly treated with antimicrobial compounds and any movement of the affected limb should be prevented. The best results are observed with the continuous introduction 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, carbopenems, cefoxitin.
Recently, with clostridial infection, hyperbaric oxygenation has proven itself well. The approach is used strictly as an element of complex treatment. It is chosen because hyperoxia has an antibacterial effect. This is indicated if there is hypoxia among the clinical manifestations.
How to prevent?
The prevention of clostridial infection involves the timely provision of assistance to a patient with a hemorrhagic shock state, traumatic. Surgical intervention should be early, in some cases - radical, if the risks are high. Important aspects of the prevention of gas gangrene are responsible immobilization of the affected limb and the adequate use of antimicrobial agents.