Hospital salmonellosis. Salmonellosis Properties of Salmonell Natural Range

Salmonellosis - acute zoonous-anthroponous bacterial infection With the fecal-oral transmission mechanism of the pathogen. It is characterized mainly by the damage to the gastrointestinal tract and intoxication, which occurs most often in the form of gastrointestinal, less frequently generated forms.

Historical information .

Etiology .

Salmonella - wands with a size of (2-4) x 0.5 μm, movable due to the presence of flagella, anaeroba. The dispute and capsules do not form, gram-negative. Grow on ordinary nutrient media. Salmonella is resistant in an external environment, in the water they live up to 120 days, in feces - from 80 days to 4 years.

In some products (milk, meat), Salmonella can even multiply. Low temperature is carried out well, with high perish instantly. Salmonellas are capable of producing exotoxins: enterotoxins (thermolabile and thermostable), reinforcing the secretion of liquid and salts into the intestinal lumen, and cytotoxin, disturbing protein-synthetic processes in the intestinal mucosa cells and affecting cytomembranes. In the destruction of the bacteria, endotoxin is distinguished, with which the development of intoxication syndrome is associated.

The antigenic structure of Salmonella is complex: they contain O- and H-antigens. The antigenic structure of Salmonelle is based on the international serological classification of Salmonelle (Kaufman-White scheme). Differences in the structure of o-antigens made it possible to allocate serological groups A, B, C, D, E, and others. Inside each serological group on H-antigen, serological versions differ. More than 2,300 Serovarov Salmonell is currently described, of which a person has more than 700. The most commonly found by Salmonella: Typhimurium, Heidelberg, Enteritidis, Anatum, Derby, London, Panama.

Epidemiology .

Salmonellosis can occur both in the form of separate sporadic cases and in the form of flashes. Currently, the incidence of salmonellosis remains relatively high throughout the year with some rise in the warm season. Animals and people can be sources of infection, and the role of animals in epidemiology is the main one. Salmonellosis in animals is found in the forms of clinically pronounced disease and bacterias. Being externally healthy, bacteria carriers can highlight pathogens with urine, feces, milk, noseal mucus, saliva. The greatest epidemiological hazard is infected with cattle, pigs, sheep, cats, house rodents (mice and rats). Salmonella is found in many species of wild animals: foxes, beavers, wolves, sands, bears, seals, monkeys. A significant place in the epidemiology of Salmonelleza is occupied by birds, especially waterfowl. Salmonella detect not only in meat and internal organs of animals and birds, but also in eggs.

The main way of infection with salmonellosis is alimentary, and the factors of transmission of infection are different food products (animal meat, fish, frogs, oysters, crabs, eggs and egg products, milk and dairy products, vegetable dishes). Water often acts as a direct factor of transmission of infection. Cases of air-dropleted infection in children's teams are described. There are cases of direct contamination of people from sick animals when leaving them. Salmonellazes can be patients with salmonelles People or bacteriasels. Salmonellosis is found throughout the year, but more often in the summer months, which can be explained by the deterioration of food storage conditions.

The incidence of salmonellosis in general has increased. The reason for this phenomenon, according to most researchers, is associated with the intensification of animal husbandry on an industrial basis, a changed character and scope of food products, a significant increase in export-import links between countries, intensification of migration processes, etc.

Another epidemiological feature of Salmonellez is currently mainly a sporadic nature of its distribution. It has been established that sporadic morbidity is substantially a consequence of the outbreaks of salmonellosis, the nature of which has changed, as a result of which epidemiological decoding of them is difficult. They arise mainly as a result of admission to a trading network of various foods infected with salmonells.

Describes water outbreaks of salmonellosis. The air-dust transmission path of infection is discusted. The air-drip transmission path is not legalized, but there are increasingly outbreaks that have a flu-like type of flow of the infectious process. It is possible to infect a child during childbirth, transplacentating transmission of infection is allowed.

One of the important problems of modern medicine becomes salmonellosis as a nosocomial (internal hospitality, hospital) infection. Salmonella, causing nosocomial diseases, received the name of hospital strains, as it is believed that their biological features (no sensitivity to typical bacteriophages, multiple drug stability, etc.) are formed in the hospital. Inthossed outbreaks are characterized by high contagiousness, rapid distribution and weight clinical flow.

Pathogenesis .

For the development of manifest forms of the disease, it is necessary to penetrate into the gastrointestinal tract not only salmonelle toxins, but also live pathogens. The massive intake of living bacteria (with an alimentary path of infection) is accompanied by the destruction of them in the upper sections of the gastrointestinal tract (in the stomach and mainly in the intestine), as a result of which a large amount of endotoxin is released, which, sucking into the blood, causes the occurrence of endotoxic syndrome that determines the clinical Picture of the initial period of the disease. The severity of toxmia depends on both infecting doses and the bactericidal properties of the gastrointestinal tract. At this stage, the infectious process may end. The clinically disease will flow according to the type of toxicoinfection (gastroenteritic form).

If the intensity of bacteriolization is insufficient, specific immunity is absent, and factors non-specific protection The gastrointestinal tract is imperfect, salmonells overcome the epithelial barrier of the small intestine and penetrate the tissue thickness (in enterocytes and its own layer of the intestinal mucous membrane), where they are captured (phagocyt) neutrophils and macrophages. Arises inflammatory process In all departments of the gastrointestinal tract (gastroenterocolitical form).

Depending on the state immune system The organism either occurs only the local process, or there is a breakthrough of intestinal and lymphatic barriers and the next stage of the infectious process - bacteremia occurs.

The sallimell accumulation process in the body is simultaneously accompanied by intense their death and decay, and therefore, a significant emission of toxins, which marks the end of the incubation period and denotes the beginning of intoxication syndrome. The result of the cumulative effect of endotoxin and bacterial bodies on enterocytes is a diarrhea syndrome.

The local reaction is the development of enteritis. Inflammatory phenomena in the mucous membrane occurs after salmonellas pass through the epithelial barrier and are captured by macrophages and leukocytes. As a result, the death of not only the pathogen, but also the part of the phagocytes and other cells under the action of endotoxin and the metabolism products of Salmonell, as well as the release of additional portions of toxins, histamine and other biologically active substances: serotonin, catecholamines, kininov, etc. Salmonelle toxins cause activation of the synthesis of foremeaddines and cyclic nucleotides, which leads to a sharp increase in the secretion of liquid and potassium and sodium ions into the gastrointestinal lumen. Diarrhea develops with subsequent disorders of the water-electronic balance. The total response of the body on endotoxins is characterized by a violation of functional adaptive processes in many organs and systems.

Large fluid losses lead to a reduction in the volume of circulating blood, a decrease in blood pressure, compensatory spasm of peripheral vessels and the development of hypoxia. Hypoxia in turn leads to the development of acidosis. Further strengthening of intoxication occurs mainly due to the violation of metabolic processes, which causes an increase in the blood of unsophisticated products and the level of histamic-like substances and ultimately leads to the expansion of capillaries, blocking their reaction to adrenaline. As a result of enteritis, the processes of digestion and suction in the intestine are disturbed, there is a deficiency of lipase and lactase, which is preserved about 4 weeks after the disappearance of clinical manifestations of the disease. The composition of the intestine microflora is often disturbed - dysbacteriosis develops.

In generalized forms, the accumulation and reproduction of Salmonelle occur in internal organs and lymphatic formations. In these cases, the disease proceeds along a typhoid version or septicopemia develops.

Pathological anatomy .

With the most common gastrointestinal form of salmonellosis, there is an edema, hyperemia, small hemorrhages and ulcerations in the mucous membrane of the gastrointestinal tract. Histologically detected excessive secretion of mucus and desquamation of epithelium, surface necrosis of the mucous membrane, vascular disorders, nonspecific cell infiltration. In addition to these changes, in severe and septic forms of illness, signs of dystrophy and foci of necrosis in the liver, kidney and other organs are often observed. The reverse development of morphological changes in most patients occurs in the 3rd week of the disease.

Clinical picture .

The incubation period at salmonellosis is 12-24 hours. Sometimes it shorten up to 6 hours or lengthens up to 2 days. The following forms and options for the flow of salinelosis infection are distinguished:

I. Gastrointestinal shape:

- gastritic option;

- gastroenteritudic version;

- Gastroenterocolithic option.

II. Generalized form:

- typhoid version;

- Septicopyemic option.

III. Bacterialization:

- acute;

- chronic;

- transit.

Most often, the gastrointestinal form of salmonellosis is recorded, which can flow under the specified options, and in gravity is divided into light, medium-heavy and severe flow. The severity of the disease is established according to the degree of dehydration and the severity of intoxication.

The gastritic option (salmonellosis gastritis) is rare, clinically accompanied by moderate inxication phenomena, pain in the epigastric region, nausea, re-vomiting. Diarrhea with this form of the course of the disease does not happen.

The gastroenteritudic option is the most frequent clinical option of salinelosis infection. Start sharp. In the initial period, both signs of damage to the gastrointestinal tract and signs of intoxication are noted. Nausea and vomiting are noted in many patients. Vomiting is one-time, sometimes indomitable. The chair is liquid, abundant, as a rule, retains a wheelchair character, sometimes can resemble rice decoction. Most often, the chair happens with an admixture of mucus, less often - watery, without pathological impurities. Sometimes stealing has a greenish color. The belly will usually be moderately, when Palpation is painful in epigastrics, around the navel, in the Ileocecal region, the rumbling in the area of \u200b\u200bthe loop of the thin intestinal deposit is detected. The normalization of the feces in most patients occurs in the first week of the disease, and only in some cases the diarrhea is maintained for more than 10 days.

The gastroenterocolitic version of salmonellosis can begin as gastroenteritis, but then more clearly in the clinic is the symptoms of colitis. In this case, the salmonellosis for its flow resembles acute dysentery. The disease begins sharply, the temperature rises, other symptoms of intoxication appear. From the first days of the disease Chair frequent, liquid, with admixture of mucus, sometimes blood. There may be tenesses and false uiles. Under the reorganososcopy, such patients detect inflammatory changes in various intensity - catarrhal, catarrhal-hemorrhagic, orphan-erosive.

With gastrointestinal form of salmonellosis, there is no characteristic type of temperature curve. It is found permanent, less often a remitting or intermitting type of fever. Sometimes the disease occurs during normal or subfebrile temperature. Often the pancreas is involved in the process, appear clinical symptoms pancreatitis. With salmonellosis, liver may be affected. Symptoms of damage to the pancreas and liver are usually transient. Characteristic for Salmonellosis is defeat of cardio-vascular systemThe degree of its lesion depends on the severity of the total toxicosis. The frequency, filling and tension of the pulse change, decreases blood pressure, collapse occurs in severe cases. Myocardians are affected. Toxic damage to the renal parenchyma manifests itself, as a rule, the symptom of "infectious toxic kidney": proteinuria, microhematuria, cylindruria. Disturbance of the Kidney Circulation Along with the changes in the water and electrolyte balance may cause the development of acute functional renal failure. In the midst of the disease, water-salt metabolism is disturbed, leading to dehydration and demineralization of the body. Shifts of acid-alkaline equilibrium are found, especially in severe cases. In the blood, the level of hemoglobin and erythrocytes occurs; Moderate leukocytosis with a neutrophilic shift, soe, as a rule, does not change.

Long flow of gastrointestinal forms middle severity Little. The temperature is reduced to the norm within 2-4 days; Even earlier, intoxication disappears, the chair is normalized to the 3-7th day of the disease. Normalization of the intestinal functional state occurs significantly later clinical recovery. A number of patients with impaired suction and digestive function can persist for several months.

The generalized form of salmonellosis can occur in two versions: typhoid and septico-federic.

The typhoid version of salmonellosis usually begins with the lesion of the gastrointestinal tract, but maybe from the very beginning to flow and without the intestinal dysfunction. Clinically, this form is very similar to the abdominal typhoid and especially parathy. Incication syndrome is pronounced and accompanied by the oppression of the functions of the central nervous system.

Patients complain of headaches, sleep disturbance (sleepiness day and insomnia at night), lethargy, sharp weakness. In severe cases, adamius, inhibition, are possible, nonsense and hallucinatory syndrome are possible. Fever reaches 39-40 OS, it is often constant and lasts 10-14 days. On the skin of the chest and abdomen sometimes a roseless rash appears. There is an increase in the liver and spleen. The pulse is more often slowed, blood pressure is reduced. In some cases, there are phenomena from the upper respiratory tract, bronchitis and pneumonia develop. In peripheral blood, they find leukopenia, but there may be moderate leukocytosis.

The septic-fired version represents essentially sepsis of salinelese etiology. After a short initial period of gastroenteritis, a typical picture of septicopemia is developing with a hectic temperature, headache and pain in the muscles of feet, chills, sweat, tachycardia. There may be nonsense and excitement. Skin Covers Pale, sometimes greenish yellow, with petehel or hemorrhagic rash. The formation of secondary septic focal foci of various localization (pneumonia, pleurisy, endocarditis, abscesses, soft fabrics, pylitis, periostitis, arthritis, osteomyelitis, iridocyclite) and an increase in liver and spleen.

The septic-federic option may also flow by the type of chroniapsis with a local lesion of individual organs. Typically long and severe flow, an unfavorable outcome is possible.

Bacterialization as a result of suspended salmonellosis can be sharp and chronic.

Acute bacterial excretion, in which the pathogen continues to stand out to 3 months after clinical recovery, is much more common.

In chronic bacterial release, the causative agent is found in the feces of more than 3 months after clinical recovery.

Transient bacterial excretion is diagnosed in cases where there is only one-time or twofold selection of salmonell with subsequent multiple negative results of bacteriological studies of Cala and urine.

In addition, the necessary diagnostic conditions are the absence of any clinical manifestations of the disease at the time of the examination and during the preceding 3 months, as well as the negative results of serological studies in the dynamics.

Features of the flow of salmonellosis in children .

Salmonellosis - intestinal infection in children in the past two decades in the last two decades in connection with the advent of new, so-called "hospital" Salmonella Typhimururium strains, which have medicinal stability and capable of causing outbreaks (including intra-community) with contact-domestic transmission. Unlike the dysentery, the children of the first year of life are much more often sick, mainly with a burdened premorbid background and are on artificial feeding. In recent years, Samonella has become the second dominant strain enteritidisextending mainly among older children through eggs and chicken meat. Seasonality of diseases caused by Salmonells group B, more often than spring-summer (with the maximum number of ills in May-June). Salmonellosis caused by pathogens of other serological groups (C, D, E) are found with different frequencies in different seasons of the year.

The clinical picture of the disease is determined by the age of the sick and the properties of the pathogen, as well as by infection. In the children of the first year of life, salmonelles are caused in the overwhelming majority of cases by the "hospital" strains of Salmonella Timururium, it spreads most often by a contact-household, including in hospitals, and has a characteristic clinical picture. The beginning of the disease is usually subacute or gradually with the maximum development of all the symptoms by the 3-7th day of the disease. Characterized by the combination of symptoms of intoxication ( febral temperature, lethargy, pallor, cyanosis of the nasolabile triangle, decline in appetite, tachycardia) with the symptoms of the lesion of the gastrointestinal tract (more often by the type of enterocolitis and gastroenterocolitis, less often enteritis). Vomiting is noted in half of the patients, it can appear both from the first day of the disease, and to join later, and in a third of the patients wealthing is stubborn. The chair is abundant, liquid, caal, brown-green (type "swamp tina"), with an admixture of mucus and greens, and in 2/3 patients - and blood, which, as a rule, appears in the feces for the 5-7th day Diseases. Frequent manifestations are also a water diarrhea syndrome, meteorism, an increase in liver and spleen. Salmonellosis in this group of children is characteristic of the medium-heavy and serious flow, often prolonged and recurrent, it is possible to generalize the infectious process. The severity of the disease is defined as symptoms of intoxication and disorders of water-mineral metabolism (Exicosis II- III degree), as well as the emergence of secondary focal complications (pneumonia, meningitis, osteomyelitis, anemia, DVS syndrome). Salmonellosis, caused by multi-pre-antibacterial drugs in biovar, is particularly adversely adversely S. Typhimurium Kopengagen.in children from closed children's institutions (children's houses, psychoneurological hospitals) suffering from various immunodeficiency. They often take a protracted latter (up to 3-4 months) bacterial excretion (from feces and urine).

Differential diagnosis of salmonellosis with dysentery in young children is significant due to the similarity of clinical manifestations:

- the possibility of both acute and gradual onset of the disease;

- frequent of the development of hemocolithic under both infections and the possibility of the appearance of blood impurities in feces not from the first day of the disease;

- the rare the occurrence of distal colitis syndrome.

Differences in clinical manifestations of dysentery and salmonellosis are as follows:

- greater severity of the flow of salmonellosis compared with dysentery at this age (with a more pronounced and long-term fever and more frequent development of hemodynamic disorders during salmonellosis);

- hepatolyenal syndrome - although not an early, but reliable differential diagnostic characteristic characteristic of salmonellosis;

- greater severity with saloonelles of water diarrhea and meteorism syndromes;

- A much greater duration of the flow of salmonellase, often with exacerbation waves, as well as with the development of generalization of the disease.

Epidemiological data obtained when collecting anamnesis (indication on staying in another hospital or to an extract from it 2-4 days to the present disease during salmonelles), as well as different seasonality and the frequency of distribution of these infections in young children .

Salmonellosis in children older than a year is often caused by the antibiotics strains of Salmonelle of various servers with mainly food by infection and flows in two clinical versions.

I option - the most frequent - proceeds along the type of food toxicoinfection (gastritis, gastroenteritis, gastroenterocolitis). Characterized by the acute principle of the disease with an increase in temperature to febrile numbers, the appearance of vomiting, often re-, symptoms of intoxication ( headache, weakness, decrease in appetite, hemodynamic disorder) and the appearance of a ridiculous liquid calmic chair with an admixture of mucus and greens, moderate pain in the stomach (more often in the epigastric area and around the navel). Half children's chairs frequency exceeds 10 times a day. Upon timely start of therapy, the disease quickly fits, the infectious process is not further developed, and in such cases salmonellosis is difficult to differentiate with the food toxicinosis of other etiologies.

II option - dysenter-like - meets in a third of children of this age. As with dysentery, there is an acute beginning of the disease with an increase of 1-3 days of temperature, the appearance of symptoms of intoxication and the development of signs of colitis.

With the differential diagnosis of salmonellosis from dysentery, children over one year should consider:

- rare development at salmonellosis isolated colitis and more frequent - enterocolitis and gastroenterocolitis, while the chair remains abundant, watery, despite the mixture of mucus and even blood, while in the dysentery of the chair by the end of the first day the disease usually acquires a typical view " rectal spit ";

- in contrast to dysentery with salmonellosis in most patients, the blood flow in the chair appears not in the first, but only on the 3-5th day of the disease and persists more for a long time (especially often - with tithimurium salmonellosis);

- distal colitis syndrome Even if there is blood impurities in the chair, as a rule, it is not characteristic of salmonellosis, and meteorism is much more common;

- An increase in liver during salmonellosis in older children is observed although less often than in young children, but much more often than in dysentery, therefore, the presence of this symptom can help in differential diagnosis.

In the coprogram with salmonellosis, unlike dysentery, there is no specific features, and the nature of the change depends on the localization of the infectious process and the degree of severity of digestion disorders. When involving mucosa of thin and colon in the inflammatory process in feces appear forming elements Blood (leukocytes and erythrocytes), and with functional disorders of digestion, many undue neutral fat, starch, muscle fibers are found.

Complications .

Complications of salmonellosis are numerous and diverse. In the gastrointestinal form of the disease, the development of vascular collapse, hypovolemic shock, acute cardiac and renal failure is possible. Salmonellosis patients are prone to septic complications: purulent arthritis, osteomyelitis, endocarditis, brain abscess, spleen, liver and kidney, meningitis, peritonitis, appendicitis. In addition, pneumonia may arise, ascending infection urinary tract (cystitis, pyelitis), infectious toxic shock. At all clinical shapesah disease is possible to develop recurrences.

The forecast for gastrointestinal form and the typhoid version of Salmonellosis is favorable, especially in cases of early diagnosis and proper treatment. The outlook forecast is always serious, mortality is 0.2-0.3%.

Diagnosis and Differential Diagnostics .

Salmonellosis is diagnosed on the basis of epidemiological data, characteristic clinical signs and results of laboratory research. Salmonellosis begins acutely from chills, nausea, vomiting; The pain in the epigastric and umbilical areas appears, the abundant watery stool of dark brown or green with a sharp slicer smell is joined later.

From epidemiological data, the group nature of the disease is important, communication with the use of poor-quality products.

Under the conditions of sporadic morbidity, the diagnosis of salmonellosis is authorized only in the presence of a complex of characteristic clinical and epidemiological data and laboratory confirmation. Bacteriological and serological are most important from laboratory methods. Bacteriological research is subject to feces of patients, lots of mass, washing water stomach, urine, blood, bile, suspected products. To confirm the "hospital" properties of Salmonella Typhimurium, it is recommended to determine their antibiogram.

RA and Ring applied from serological methods. In recent years, highly sensitive serological methods for determining specific salmonell antigens in the blood and other biosubstrats of patients with the method of latex agglutination, coaglutination, immuno-immimensional analysis have been used.

The differential diagnosis of salmonellosis should be carried out with a large group of infectious diseases - food toxicoinfections of other etiology, acute dysentery, cholera, virus gastroenteritis, abdominal typhoid, flu, meningitis, therapeutic and surgical diseases (myocardial infarction, acute appendicitis, cholecystitis, subarachnoid hemorrhage), as well as with poisoning poisons and salts of heavy metals.

Treatment .

The complexity of pathogenetic mechanisms for salmonellosis, the variety of clinical forms of the disease dictates the need for an individual approach to treatment. The choice of treatment method depends on the shape and severity of the disease. Patients with a subclinical form of salmonellosis and persons with acute bacterial idle are not required medical events. The bacterial excretion, as a rule, ceases independently, and the purpose of any drugs only extends the period of rejection. The main method of treating patients with a gastrointestinal form of the disease is the pathogenetic therapy, which includes measures aimed at disinfecting, restoration of water-electrolyte balance and hemodynamics, eliminate local lesions of the gastrointestinal tract. At the same time, it is necessary to treat concomitant diseases.

Common for these forms of salmonellosis is the need to comply with the diet and the refusal to use etiotropic therapy. The diet must be mechanically and chemically gentle, which corresponds to the Table No. 4 of therapeutic nutrition. From the diet, one-piece milk and refractory fats are excluded, limit carbohydrates. Oatmeal and rice porridge on water, boiled fish, steam cutlets, meatballs, fruit kisins, cottage cheese, light cheese varieties. The diet is expanding gradually, and with full clinical recovery, the coming usually on the 28-30th day from the beginning of the disease, go to the diet of a healthy person.

The use of antibacterial drugs with these forms is contraindicated, as it leads to later clinical recovery, delay in the normalization of the functional activity of the gastrointestinal tract, lengthens the duration of the body's sanitation from Salmonelle and contributes to the formation of dysbacteriosis.

Treatment of patients start from washing the stomach in order to remove infected products, pathogens and their toxins. For washing, a 2% sodium bicarbonate solution is used in an amount of 2-3 liters with a temperature of 18-20 OS. In light cases of salmonellosis infection without signs of dehydration of stomach washing, the entire amount of medical care is exhausted.

The fight against dehydration in cases of diseases of the average and light gravity occurring with dehydration of the I-II degree is carried out by rehydration solutions that are administered orally: glucosolyan, oralitis, reciprons are used. The volume of administered oral solutions should be determined by the dehydration dehydration, the severity of intoxication and the mass of the patient's body. Typically, the salty salmonellosis of medium severity with dehydration II solutions are prescribed in a volume of 40-70 ml / kg, patients with severe intoxication, but in the absence of dehydration - in a volume of 30-40 ml / kg.

Oral rehydration is carried out in two stages:

- I Stage - primary rehydration in order to eliminate dehydration, loss of salts, intoxication. Its duration is usually 2-4 hours;

- II Stage - supporting therapy aimed at eliminating the continuing losses of liquid and salts, as well as the preserving intoxication syndrome. It is carried out over the next 2-3 days.

In most cases, with oral rehydration therapy, a good therapeutic effect is observed.

With repeated vomiting, increasing dehydration, the treatment of patients start with intravenous administration of polyionic solutions, such as Quartasol, Glosol, Azesol, Trisole, and others, heated to a temperature of 38-40 OS. The amount of fluid administered to rehydrate the fluid depends on the degree of dehydration and body weight of the patient. After reimbursement of the initial loss of fluid go to oral reception liquids.

In order to disinfect and restore hemodynamics, synthetic colloidal solutions are used: hemodez, polyglyukin, refooliglukin. However, their use is permissible only in the absence or after the elimination of dehydration.

With severe disease with dehydration of III-IV degree, treatment should be started with intravenous inkjet (80-120 ml / min) administration of said polyionic rabbers. The volume of solutions administered to rehydrate is determined by the dehydration and mass of the patient's body. The transition to oral fluid intake can be recommended after stabilizing hemodynamic parameters, stopping vomiting and restoring the excretory function of the kidneys. In cases of the development of metabolic acidosis, the estimation of the calculated dose of 4% sodium bicarbonate solution is recommended.

In the presence of toxic-infectious shock medical events Start from intravenous infusion of polyionic solutions (at a rate of 100-120 ml / min). The volume of injected solutions is determined by the state of hemodynamics and biochemical blood parameters. For the purpose of disintellation with insignificant dehydration together with salt solutions Synthetic colloidal solutions (hemodes, polyglyukin, refooliglukin) can be used in a volume of 400-1000 ml.

In the development of adrenal insufficiency, the introduction of glucocorticoids is shown. The initial dose (60-90 mg of prednisiolone, 125-250 mg of hydrocortisone) is administered intravenously, the subsequent dose - intravenously drip in 4-6 hours. At the same time, the deoxyticosterone acetate is injected intramuscularly - at 5-10 mg every 12 hours. Intensive therapy continues to a rack Normalization of hemodynamic indicators and urinary recovery. Purpose with a gastrointestinal form of such drugs like Meston, Noradrenalin, Ephedrine, contraindicated due to their ability to cause a spasm of kidney vessels. In the development of acute renal failure, the edema of the lungs or brain is carried out targeted therapy with the inclusion of diuretics (mannitol, furosemide). In order to restore the functional activity of the gastrointestinal tract, enzyme preparations should be applied (Panzinorm, Festal, Mezim-Forte, Abomin, Holenzim). To bind infectious aggressors, the use of enterosorbents - smects, enterodesis, etc. In order to normalize the intestinal motor-evacuator activity, it is shown the appointment of antispasmodic and binder (papaverine, noszpa, belladonna, atropine, bismuth, tanalbin, branch of oak bark, blueberry fruits, bark Pomegranate, cherry).

In generalized forms of salmonellosis, along with pathogenetic therapy, it is necessary to appoint antibacterial agents - Levomycetin, ampicillin. In the typhoid version, Levomycetin is prescribed 0.5 g 4 times a day for 10-12 days. It is preferable to introduce levomycetin succinate at the rate of 30-50 mg / kg per day. Ampicillin is prescribed for the same period of 0.5-1.0 g 3 times a day orally or 500-1000 mg 4 times a day intravenously. In the septic-federic variant, ampicillin is prescribed at the rate of 200-300 mg / kg in the knock, and the dose of levomycetin succinate is increased to 70-100 mg / kg.

Sanation of chronic bacteriasels Salmonella must be complex. The use of funds acting on the overall reactivity of the body is paramount: the use of pyrimidine series (pentoxyl and methyluracyl), treatment of accompanying diseases of the gastrointestinal tract, intestinal dysbiosis. It is advisable to appoint salinellase bacteriophage.

Extract from the hospital is made after clinical recovery in the presence of a negative result of a bacteriological study of Cala. The control examination of persons from the decreed population is carried out three times. Persons who do not distinguish salmonella, after discharge from the hospital, are not allowed to work and dispensary observation.

Prevention and events in the hearth .

Veterinary and sanitary control over the scope of livestock, for the technology of treatment of carcasses, preparing and storing meat and fish dishes. After hospitalization, the patient is observed behind the hearth during the week. Employees of food enterprises are subject to one-time bacteriological survey. After discharge from the hospital, food enterprises and children visiting the nursery are observed within 3 months with bacteriological studies of Cala (1 time per month). Bacteriders are not allowed to work in food and equivalent enterprises.

Salmonelles – prevention of nosocomial infection.

Salmonellosis diseases are a group of various clinical manifestations and severity of the flow of paratyphoid diseases caused by microorganisms from the genus Salmonella.

The proportion of salinellious patients in the group of acute intestinal diseases is growing.

Currently, the number of Salmonella microbes, highlighted in humans, domestic and wild animals, birds, insects, is over 2000. Salmonella paratif in, mouse title (Breslau), Heidelberg, Parastif from Kinddorf, Newport, Enteitidis (Gerder ), pork plague, paratif N 1, N 2, and a number of others.

Salmonella have high resistance to the effects of various environmental factors, they remain in soil, water, various food products for a long time. In dust saves from 80 days to 4 years. In milk - up to 20 days in the refrigerator. In the egg - on the surface of 2-3 weeks, and when penetrating inside up to 13 months. In dairy and meat products not only persist, but also multiply, without changing the appearance and product taste.

Solving and smoking have a weak effect on Salmonella.

Salmonella is resistant to the most common disinfectants in medical preventive institutions.

The main tank of salmonellosis infection is different types of animals, as well as a sick person and a bacteria carrier. Infectness can occur in animals in vigenous, and may also be associated with slaughter conditions, cutting, storage of meat, storage and meat processing.

Salmonella's human body penetrate with infected food products - meat, fish, vegetables, dairy products. The greatest danger is presented boiled sausages, sausages, sausages, meat stuffs, cutlets, jelly, if they were infected and storage rules were not respected.

Unlike food toxicoinfections, with sporadic cases of salmonellosis, the main way of infection is fecal-oral.

There is also a contact-household path of transmission of infection, when the source of infection can be patients, especially with the structures and unrecognized forms of the disease, the bacillos, the objects of care, toys, the hands of the service personnel. The contact form of salmonelles is observed more often in children.

Narcyboomic transmission of infection is proved:

1. Continated household - through the hands of the hospital caring staff, through the objects of patient care, through bed linen.

2. Conitamination of medicines, recreational breast milk.

3. Failure to comply with food storage rules in the hospital.

4. Dusty path - when comparing the current and general cleaning mode.

Salmonellosis diseases are registered throughout the year, but the maximum rise in disease is observed in the summer months. In the warm season, cases of the disease are rapidly and possible as sporadic and group outbreaks of the disease.

Pathogenesis.

The penetration of pathogens and their endotoxins into the human body leads to an acute inflammatory process in the stomach and intestines. The endotoxins that were visible to the blood of water and electrolyte metabolism, violate the activity of the cardiovascular system, kidneys and adrenal glands. Along with the toxins in the development of pathological processes, the microbes themselves are involved, localized by intracellular in the mucous membrane and submucosal shell of the gastrointestinal tract. It is possible to generalize Salmonell with hematogenic drift to various organs and tissues.

Clinic Salmonellites is characterized by a large polymorphism, which is expressed in various shape of the severity of the flow, degree of damage to individual organs and systems of organs, in the emergence of complications, different timing recovery and relapses.

The incubation period is from 6 hours to 7 days after receiving infected food.

Regardless of the etiological factor, all food toxicoin intakes proceed with a similar clinical picture. The general condition of the patient is disturbed, nausea appears, re-vomiting, abdominal pain, the body temperature rises, a liquid chair appears, which resembles a rice decoction, sometimes with an admixture of a small amount of mucus. The symptoms of sharp dehydration are developing.

In group diseases in most patients, salmonellonese infection proceeds easily - quickly passing nausea, an infrequent liquid chair, the general condition is not noticeably violated. For 2-3 days of treatment, disturbed functions are completely restored.

In the food toxicoinfection of salmonellonese etiology (salmonellosis), the following clinical forms are distinguished: Gastrointestinal shape is divided into

gastric (rarely observed)

gastroenteric (over 60% of all cases of food toxicoinfection)

gastroenterocolitical

enterocolitical.

Generalized forms of salmonellosis are also isolated - typhoid and septic shape.

Gastroenteric form.

With a gastroenteric form, the beginning of the disease is always sharp: vomiting (often repeated vomiting), 1-2 hours later or at the same time - diarrhea, photo transmission, rapid temperature rise to 38.5 ° - 40 ° C, total weakness, indisposition, pain in the upper half of the abdomen, hot to the touch leather, a rapid liquid chair with a milder smell containing in the liquid carriage masses of greens make up the characteristic signs of the initial period of the disease.

When examining the patient on the first day, there is an increase in the pulse, respectively, the temperature level, muffling of the heart tones, some decrease in the level of blood pressure, uniformly covered with white rod, spangled, reducing the skin of the skin, seizures. The amount of urine distinguished patients is sharply decreasing.

On the second day, all these symptoms can intensify in their intensity, after timely effective treatment, quickly disappear.

With a serious flow - already in the first hours of the beginning of the disease, it is possible to quickly drop the level of blood pressure, the appearance of symptoms of significant dehydration with the subsequent collapse.

Enterocolitic form It is characterized by diarrhea, separation of liquid carriage masses containing an abundant impurity of mucus, and sometimes streams of blood. When palpation of the sigmoid intestine, the sensitivity, spasm of the sigmoid intestine, which is palpable as a tight severity is determined in the left iliac region. The clinical course of this form is very similar to the dysentery zone.

The typhoid form of salmonellosis.

The duration of the incubation period is 3-10 days.

In most patients, the disease begins sharply, with an increase in temperature to 38 ° -39 ° C, headaches, sometimes chills, less often vomiting, nausea. Notes lethargy, anorexia, muscle and articular pain. The fevering period lasts about two weeks, sometimes up to 3-4 weeks. Quite often observed the symptoms of meningism, dimming consciousness, nonsense. Abdominal pain appear, liquid chair, watery, infrequent, without pathological impurities, the language is densely covered.

Most patients have hepatosplenegaly. From 3-4 days of the disease, some patients may appear poorly pronounced rash in the form of single roseol, fun, erythema. In severe cases, the deafness of the tones of the heart, bradycardia, decrease in blood pressure. We are more often observed leukopenia, aezinophilia, an enlarged ESR.

Septic shape of Salmonellia It is rare. It is characterized by a long fever, pronounced signs of intoxication. Jaundice may be observed, the phenomena of hemorrhagic syndrome in the form of hematuria, bleeding, hemorrhages in the conjunction, fucked hemorrhagic rashes on the skin.

From the side of the cardiovascular system, tachycardia is observed, the deafness of heart tones, rarely - the expansion of the heart boundaries, the appearance of systolic noise.

There is an increase in liver, spleen.

The chair is infrequent, liquid, sometimes with an admixture of mucus, rare blood. Anorexia, re-vomiting, flatulence can be observed. There is a violation of the kidney activities with various forms of kidney parenchyma damage.

Multiple complications are characteristic - pneumonia, pleurisy, otitis, pyelonephritis, meningitis, pericarditis.

In the blood - leukocytosis, aezinophilia, anemia, an increase in ESO.

All listed clinical forms of salmonellonese infection can be not only in sporadic diseases, but also in food toxicoinfections and proceed in a heavy, median and light form.

Diagnosis.

The disease is recognized on the basis of anamnesis (a disease of several people who consumed the same product), a clinical picture, data of laboratory studies.

The clinical picture of food toxicoinfection, with its various etiologies, is so complicated that it does not allow, without the results of laboratory research, to put an ethiological diagnosis.

Originally put the diagnosis of food toxicoinfection (indicating its shape, severity).

Of great importance in the diagnosis of salmonellosis have laboratory methods Research.

Bacteriological research is the main method. In addition to the detergents, bacteriological research is subjected to urine, vomit masses, washing water, duodenal content, blood, as well as food residues eaten by a sick person (with food toxicoinfection), washes from dishes, from tables.

The greatest percentage of excessability of Salmonelle from feces is mainly in the 1st week of the disease, but the seedability is also celebrated on the 4th - 5th week of the disease.

The selection of hemoculture during blood crops is the earliest and valuable diagnostic method, which is used for all forms of the disease from the 1st day and throughout the feverish period at any age. From serological studies use agglutination reaction with salinellonese diagnosticum, which is positive since the 5-7th day of the disease. And the reaction of indirect hemagglutination (rng) with a diagnostic titer 1:80 and above.

Hospital salmonellas, salmonella strains, most often Salmonella typhimurium are the pathogens of intrabrouting salmonellosis. Unlike the "wild" (natural) strains of the same species, they do not cause the death of mice in infecting through the mouth, but more pathogenic for humans, and have multiple drug resistance due to the presence of R-plasmid. "Hospital" strains are also discovered among S. Enteritidis.

Disease in humans.The source of infection is sick people. The distribution of noselnichny salmonellel occurs contact-domestic, air-dust and food.

Disease manifestations are diverse: asymptomatic bacteriampsities, light shapes, severe intestinal disorders with intoxication, bacteremia, sometimes with septic complications. Personal diseases in young children occurs.

Laboratory diagnostics.Studies are investigated, blood. Selected pure cultures are identified by morphology, biochemical properties, antigenic structure.

Prevention and treatment.Compliance with the sanitary and hygienic regime in medical institutions, in catering establishments; Identification of Salmonella carriers and their reservation. For the purpose of emergency prevention of the nosocomial infection, polyvalent salmonellic bacteriophage is prescribed to children in contact with patients and carriers, as well as mothers.

Antibacterial drugs (levomycetin, ampicillin) are used to treat patients with generalized salmonellase forms.

Shigella

The pathogens of the dysenter (Shigellize) are several types of bacteria combined into the genus Shigella. One of them first discovered in 1891. The Russian doctor A. Grigoriev and studied during the epidemic in Japan in 1898. Shiga. Subsequently, other types of Shigell were isolated and described. According to the modern classification, the genus Shigella includes 4 groups, respectively, 4 types. All kinds, except S. Sonnei, are divided into serovars, S. Flexneri - still on the subservoir (Table 8).

In recent decades, the dysentery is most often caused by Schigella Flexner and Zonne, less often Schigella Boyd. S. Dysenteriae (Grigoriev-Shiga) in Russia is not found.

Shigellas are short gram-negative sticks, they do not form a dispute and capsules, unlike salmonelle do not have flavors.

Optional anaerobes. They grow on simple nutrient media, the optimum temperature of 37 ° C, pH 6.8-7.2. According to biochemical properties, it is distinguished (Table 5) Frequent glucose, lactose in the first day is not fermented (Shigella Zonne - a few days), man-thread fermented all types, except S. dysenteriae.

Antigens.Shigella contain o-antigens, some serovas have to-antigen. Among the antigens there are specific and group.

Toxicosis.An exotoxin with a neurotropic effect is produced by S. Dysenteriae, and this species causes a disease in the hardest form. All Schigella contain thermostable endotoxin.

Stability.The most resistant in the external environment S. Sonnei. Boiling kills Schigella immediately, at 60 ° C, they are dying after 10-20 minutes, but there are thermal resistant S. Sonnei, die only at 70 ° C for 10 minutes, that is, capable of surviving during milk pasteurization. In water, soil, in food products, on items, in the dishes of Shigella are persisted viable for one or two weeks. S. Sonnei can multiply in milk. In the intestines of flies and on their paws, Shigella survive for 2-3 days. Flying with sewage and garbage on food, flies can carry pathogens.

At the same time, Shigella is very unstable in facal samples, since they die under the influence of antagonist microbes and an acidic reaction of the medium. Therefore, samples taken for research should be immediately sought at the nutrient medium.

Disease in humans.The source of infection is a person - a family or carrier. Mechanism of transmission fecal-oral. Infection occurs through the mouth. The incubation period lasts from 2 to 7 days.

The pathogen penetrates the cells of the epithelium of the gum mucosa and multiply in them. This leads to inflammation (colitis) and the formation of an ulcer. The main symptoms: an increase in body temperature, pain at the bottom of the abdomen, vomiting, frequent chair, in severe cases impose in the chair of mucus and blood; Characteristic sign - tenesms (false painful urges). The disease lasts 8-10 days. Patients with light shapes of the disease often do not pay for qualified help, engaged in self-medication. The trouble-free dysentery can go into a chronic form.

Immunity.After the suffering disease, immunity is unstable. During the disease, antibodies are formed, the detection of which has a diagnostic value.

Laboratory diagnostics.Material for bacteriological research are faces (faeces). The sample should be taken before the start of antibacterial therapy, sowing immediately or place a sample in a preservative liquid (30% glycerol and 70% buffer solution) no more than one day. For sowing to take the mucus lumps. The number of Schigell in the sample can be very scarce, so sowing is made on the plane selection environment or on the enrichment environment - selenite.

The isolated pure culture is identified by morphology, biochemical properties and in the reaction of agglutination with adsorbed species serums. Determine the sensitivity to antibiotics. Shigella belongs to the number of bacteria that quickly acquire resistance to antibiotics, in most cases associated with R plasmids. In addition, Shigell's antigens reveal in feces using ELISA.

For the purpose of diagnostics use serological reactions: agglutination, Riga. Antibodies appear in the second third week of the disease.

Medical preparations.Specific prophylaxis has not been developed. In the foci of morbidity use dysenteric bacteriophage.

Treatment with antibiotics should be carried out, taking into account the sensitivity to them of the causative agents. Used Levomycetin, tetracycline; Nitrofuran drugs are effective, polyvalent bacteriophage. In chronic dysentery, vaccine therapy is used using a chemical vaccine introduced through the mouth.

Klebsiella

The genus Klebsiella got its name in honor of the German scientist E. Klebsa. Among the representatives of this kind: Klebsiella Pneumoniae, Klebsiella Ozaenae, Klebsiella Rhinoscleromatis.

Morphology, culture properties.Klebsiella - short, thick sticks. In the preparation are arranged by one, pairs and short chains of flavors do not have, the dispute is formed. A characteristic feature of Klebsiell is the formation of capsules both in the body and on nutritional media.

Grow on simple nutritional media, on dense media Forming mucous colonies. Differentiation of them is carried out according to biochemical features.

Antigens.Klebsiella contain lipopolisaccharide o-antigens and polysaccharide capsule antigens, based on serotyping. Some antigens are common with Escherichia and Salmonella antigens.

Pathogenicit is connected with Klebsiell with the presence of a capsule that prevents phagocytosis and endotoxins.

Stability.Klebsiellas are resistant in an external environment, are durable in water, on items, in dairy products can be multiplied at room temperature and in the refrigerator. Dying when boiling and under the action of disinfectants.

Disease in humans.Chlebseyella pneumonia cause inflammation of the lungs (bronchopneumonia), sometimes also sepsis, cystitis, acute intestinal infections; Frequently found with mixed infections.

Chlebseyellalas are causative agents of the chronic diseases of the left of the upper respiratory tract with the allocation of a viscous secret and the formation of crusts, emitting a malicious smell. The disease is contagious, transmitted by air-droplet.

Klebsiella Rinostclerians cause a chronic inflammatory process of the mucous membranes of the upper respiratory tract, with the formation of nodules (granulom).

Immunity.Antibodies are formed during diseases, but they do not provide immunity. Chronic course of the disease is associated with the development of the PCF.

Laboratory diagnostics.The studied materials: at pneumonia - sputum, during ozone - mucus from the zea, nose, trachea, during rhinicler - pieces of tissues from the granuloma. The study is based on the allocation of pure cultures and identification of morphology, cultural, biochemical properties and the definition of the Serovar.

RSK is set to detect the antibodies in the blood serum patients.

Medical preparations.Vaccinoprophylaxis has not been developed. Antibiotics (streptomycin, leftomycetin, neomycine, tetracycline), antimony preparations are used for treatment.

Proteins

Among the bacteria of the genus Proteus causative agents of food toxicoin intakes and purulent-inflammatory processes can be Proteus vulgaris and Proteus Mirabilis.

Morphology, culture, biochemical properties.Proteues - polymorphic sticks, short, long, filamentous, disputes and capsules do not form, have flavored flagellations. Gram is negative.

Good grow on simple nutrient media. For protev, the "creeping" growth in the form of a bluish laid on dense nutrient media, which form sulfate n-forms. Stamps that have lost flames and the ability to roll, form colonies with smooth edges (O-forms). When sowing the Schuhevich method into condensation water at the bottom of the test tube with a beveled agar of the protein quickly covers the entire surface.

Proteues have well-pronounced proteolytic properties: they dilute gelatin and rolled serum, rolls milk, divert the urea, form hydrogen sulfide, indole, ammonia. Enzyme many carbohydrates.

Antigens.Proves have o-antigens and n-antigens, some of them are common with other enterobacteriums.

Toxicosis.Exotoxin is not produced, contain lipopolysaccharide endotoxin of the cell wall.

Stability and distribution.Bacteria genus Proteus is widespread in the external environment. They are found in soil, water, in the intestines of man and animals. Participate in the processes of rotting, breeding in garbage containing organic matter.

Disease in humans.Protees - Conditional and pathogenic microbes. Can cause purulent-inflammatory diseases in humans: the suppuration of the Russian Academy of Sciences, otitis, peritonitis, pyelonephritis, cystitis. When eating foods containing a large number of these bacteria, food toxicoinfection occurs. P. Mirabilis causes purulent-inflammatory diseases of the urinary system. They may result from driving bacteria with urological instruments. In the newborn, the penetration in the umbilical wreck leads to a septic process.

Laboratory diagnostics.The materials under study serve, depending on the disease, pus, urine, vomit, foods. Sowing method for Schukevich is used. Selected pure cultures are identified by culture and biochemical properties and in the reaction of agglutination.

Medical preparations.Collective bacteriophage, on-lidixic acid, antibiotics are used.

Iracinia

Among the bacteria belonging to the genus Yersinia, human diseases cause Yersinia Peslis (the pathogen of the plague), Yersinia Pseudotuberculosis and Yersinia Enterocolitica.

Jersey Chuma

Yersinia Pestis was opened in 1894 by A. Iersen and S. Kitazato during the plague epidemic in Hong Kong.

Morphology, cult-rally, biochemical properties.Y. Pestis is a gram-negative small ovoid shape of a 1-2 microns of 1-2 microns, fixed. The dispute does not form, have a capsule. In strokes of pathological material, methylene blue is most intense at the ends - bipolar (Fig. 31). In reproduction on dense nutrient media, have the type of elongated sticks.

Optional anaerobes. They grow on a simple nutrient medium at a temperature of 28 ° C, can grow at lower temperatures (up to + 5 ° C), which can be used in the selection of pure culture. In the liquid nutrient media of the chopsticks of the plague form a film on the surface and down from it down the threads similar to the stalactites, and the precipitate in the form of flakes. In a dense nutrient medium, colonies are formed, resembling a "lace handkerchief" - with a dense center and festral edges. Such R-forms of the colonies form virulent strains, and s-forms are unwarf. The characteristic cultural properties of the plague of the plague are used when identifying.

Fresh carbohydrates with the formation of acid. Proteolytic activity is poorly pronounced (Table 9).

Antigens.The plague sticks contain a somatic thermostable antigen, common with other rations, as well as an antigen, common with erythrocytes of people of the O-Group. Viruble strains have a capsule thermolabile antigen, with which the immunogenicity of the pathogen is connected.

Factors of pathogenicity.The plague sticks form toxic substances that are contained in the body of the bacteria and in the capsule and have properties of exo- and endotoxin. Virulence is also due to superficially located substances with anti-phaganic activity, and enzymes: hyaluronidase, fibrinolysin, hemolyns, plasmoagulase.

Stability.In the external environment can continue to be kept well, low temperatures are well tolerated, in frozen corpses, fleas - a year or more, in milk - 3 months. When boiling dying for 1 minute. Sensitive to disinfectants. The direct sunlight kills them for 2-3 hours.

Disease in humans.The main reservoir of Iracinium plague in nature is rodents (gopters, tarbagans, rats, etc.). Plague is a zoonotic disease. The source of infection for humans are animals and man. From animals, infection occurs in transmissive pathway - with the bite of an infected flea, contact path. In this case, the microbe penetrates through the skin. From a person, a patient with a pulmonary chumay, the pathogen is passed through the air. The clinical form of plague depends on the entrance gate of infection. The bubonic form develops with the penetration of the pathogen through the skin, followed by the lesion of the region-onar lymph nodes, which increasing, turn into the bellows. Hence the pathogens can spread over lymphatic or blood vessels, cause the defeat of other lymph nodes, lead to the development of septic shape, secondary pulmonary pneumonia.

When infected through the air, the primary pulmonary plague is developing. With all the forms of the plague, the pathological process amazes all organs and systems.

Immunity.After the suffering disease, immunity is resistant.

Laboratory diagnostics.Plague is a particularly dangerous infection. Everything

studies are carried out in special regime laboratories, prepared by the personnel of the material for the study serve the contents of the bubon, sputum, blood, feces, pieces of died organs, animal corpses. If gram-negative oval bipolar stained wands are detected from the material from the bacterioscopy from the material, the final diagnosis is made on the basis of the selection. Clean culture and its identification of but morphology, culture, biochemical, antigenic properties, for sensitive to plague bacteriophage on these features differentiate them from other types of Iersinium put a biological sample on guinea pigs The reef is also used in materials from the injected animal corpses. It is possible to detect a plague antigen with Precipient reactions

Preventive and medicinal preparations.Specific prophylaxis is carried out in epidemic indications, a lively plane vaccine containing EV strain

Of therapeutic agents are effective, streptomycin, tetracyclines Jersey pseudotuberculeza

Yersmm Pseudotuberculosis - Pseudotuberculeza causative agent - Opened L Mary and Vinyal in 1883

Causes diseases characterized by formation in the bodies of the nodules, externally similar to tuberculosis one of the forms of pseudotuberculosis, observed in Vladivostok, is described as "Far Eastern Scarlantine-like fever"

Morphology, culture, biochemical properties.Gram-negative kokcobacteria, do not form a dispute, have flagella and capsule optional anaerobes, well multiply on simple nutrient media. Important for the epidemiology of the disease The property of pathogens is their psychroid. The optimal reproduction temperature of 20-28 ° C is also multiplied at 0 - + 4 ° C

Ferimentary frames, urea (Table 9)

Antigens.Contain O-somatic and n-flavored antigens Serovars and subservories are distinguished by O- and N-Atigenam

Factors of pathogenic.Pseudotuberculosis Iranin contains endotoxin, released with their death. Some serovars produce exotoxins.

Stability.In the external environment resistant to psychrophyls, can accumulate in large quantities in food products stored for a long time in the refrigerator

When boiling dying after a few seconds, sensitive to disinfectants

Disease in humans.The source of the infection is rodents infection of people occurs in an alimentary path of transmission factors most often there are vegetable dishes (salads, winegres) and dairy products.

Designations: "+" - the presence of a sign, "-" - the absence of a sign, "±" - a sign of non-permanent products that are not subjected to heat treatment. It matters and the water transfer path.

The pathogens fall into the human body through the mouth. Overcoming the protective barrier of the stomach, fall into the small intestine, as a result, the gastroenteritis develops. The penetration of pathogens into mesenterical nodes leads to the development of lymphadenitis with signs of peritonean irritation and the formation of infiltration (pseudo-tuberculosis appendicitis). In the breakthrough of Iersini in the blood, generalized forms arise with the lesions of the joints, with the manifestations of the scarlatin-like fever.

Immunity.Antibodies are found during the disease, but they do not have a protest effect.

Laboratory diagnosticsdue to the wide variety of manifestations of the disease is crucial. The material for bacteriological research serves blood, feces and vomit. Cultivation of pathogens and the release of pure culture is carried out with the optimal temperature for them. Pure culture is differentiated from other heersinis on biochemical properties. For serological diagnostics, paired serums, taken at the beginning and in the third week of the disease, in the reaction of agglutination and rland are investigated.

Medical preparations.Specific prophylaxis has not been developed. Levomycetin and other antibiotics, nitrofuran drugs are applied to treatment.

Salmonelles - a classic oral, acute infectious disease of animals and a person, characterized by the development of gastrointestinal, less often with typhorate and septic forms.

Etiology. According to a modern generally accepted representation, the term "salmonelles" combines a group of diseases characterized by a variety of clinical manifestations caused by multiple serovars (about 2000) bacteria and combined in genus Salmonella. Enterobacteriaceae.

The whole group of bacteria is divided into pods, serovars, bivars and phagelovars.

Salmonella - gram-negative small sticks (2-4 x 0.5 μm), movable due to the presence of flagellas, with the exception of S.Gallina-Rum and S.Pullorum species, as well as low-propelled mutants.

Salmonellet's pathogens represent an extensive group of bacteria, of which Berelau bacteria are most often found (pathogel of mouse title), Gerder (pathogen of rat tit), Suipess-Tifer (microbe, detected by pigs). The whole group of salmonell refers to the same family as the bacteria of the abdominal typhoid, parasips A and V.

Salmonella is sufficiently stable in the external environment. In a dry fell, they can maintain viability up to 4 years, in manure - up to 3 months. When cooking infected meat for 2.5 hours, salmonella dies only in small pieces (no more than 200 g). In milk, they not only persist, but also multiply, and it does not change its appearance and taste.

Resistant to the effects of physicochemical factors (moisture, low and high temperatures, UV rays, disinfectants, etc.), among which are most viable S.typhimurium and S.Neritidis. Optimum growth - 35-37 ° C, aerogenic.

Classification

Typical.

1. Gastrointestinal (gastritis, enteritis, gastroenteritis, gastroenterocolite, enterocolitis, colitis). 2. Typhoid. 3. Meningoencephalitic. 4. Septic.

Atypical.

1. erased. 2. Subclinic. 3. Bacteridation.

II. The severity of the process:

1. Easy. 2. Medium-heavy. 3. Heavy.

III. The course of the disease:

1. Acute (up to 1 month). 2. Started (up to 3 months). 3. Chronic (over 3 months). 4. Smooth (without complications). 5. With complications. 6. Mikst-infection.

Diagnosis design examples:

1. Salmonellic gastroenteritis (S.Neritidis), typical, medium-haul form, sharp flow. 2. Major disease: Salmoneclone enterocolitis (s.typhimurium), typical, medium-haul form, sharp flow.

Complication: subcompensated intestinal dysbiosis.

Symptoms

The variety of clinical forms of salmonellosis can be explained by the peculiarities of the pathogenesis of this disease. In particular, the pathogen's pathogen to all departments of the gastrointestinal tract, with the development of invasive diarrhea, as well as the presence of bacteremia with the damage to immunocompetent systems and internal organs.

The incubation period lasts from 6 to 14 hours, less often 1-2 days. The disease begins acutely.

With a slight course of the disease, nausea appears, sometimes vomiting, liquid chair several times a day, abdominal pain. The general condition of the patients is not enough, the temperature is normal or subfebrile. Recovery occurs after 1-2 days even without treatment.

In severe flow, symptoms of acute gastroenteritis are prevailing with pronounced inxication phenomena due to toxins poisoning: strong pain in the abdomen, abundant vomiting, diarrhea, the phenomena of dehydration of the body, the general weakness, anouria, the convulsions of the limbs; Blood pressure drops, pulse frequent, weak filling and voltage. The feces, initially watery and stencil, with a severe course of the disease, may lose their own character and resemble rice decoction. Temperature 38-39 °. Sometimes in severe course, patients appear non-corrosive vomiting, profuse diarrhea; Blood pressure and body temperature decreases, cyanosis, convulsions, anouria appear, the voice becomes a sip, which is reminded by the flow of cholere.

In some cases, salmonellosis occurs in the form of generalized (typhoid) and septic forms. The generalized form can begin with gastroenteritis phenomena or with fever without signs of this disease and clinical flow to resemble a condition for abdominal typhoids or parathy.

Gastritis, pancreatites, cholecystitis, cholants, chronic colitis are possible from complications.

In addition, the possibility of the formation of generalized forms of salmonellet is influenced by the age of children, the presence of background immune deficiency, as well as adverse premorbid factors (perinatal damage to the central nervous system, exudative diathesis, enzympathy, intrauterine infections, etc.).

In addition, the probability of severe forms of the disease is influenced by the virulence of Salmonella.

The greatest proportion is children with a gastrointestinal form of the disease - 90%. The typhoid version is registered in 1.8% of patients, septic - in 0.6% of children. The share of documented atypical forms accounts for about 10% of salmonellosis patients.

Maintenance clinical manifestations Gastrointestinal shape of salmonellosis can be grouped into the following syndromes:

1. Inxication syndrome, or infectious toxicosis. 2. Excicosis syndrome. 3. Diarrhea syndrome in the type of invasive. 4. Hepatoslenomegaly syndrome (in children breast-age).

The criteria of gravity of Salmonølzez are:

I. General manifestations:

1. The degree of severity of intoxication. 2. The presence and degree of severity of infectious toxicosis. 3. The presence, degree of severity and the nature of the excocose. 4. Generalization of the process.

II. Local manifestations:

1. Chair frequency. 2. The presence and number of pathological impurities in feces.

The gastrointestinal form of salmonellosis is registered in 90% of children.

In older patients, gastroenteritis develops more often, in patients of breast-age - enterocolit. Depending on the degree of severity of intoxication, toxicosis and excocosis, the stool frequency is distinguished by a lightweight, medigative and severe forms of the disease.

Light form Salmonelleza is usually developing in older children and is due to the predominantly salmonells of rare groups and S.Neritidis.

The disease begins acutely accompanied by a light malaise, a decrease in appetite, an increase in body temperature to 37.2-38 ° C. Patients can disturb minor abdominal pain. With this form of vomiting a single or absent. The chair is read up to 3-5 times a day, it is cascidious or liquid, without pathological impurities or with a small amount of mucus and greenery. There are no changes from the internal organs.

The patient's condition is quickly (after 3-5 days) normalizes.

A medium-haul form is the most frequent option for Salmonellsee.

The disease begins acutely after 6 hours - 3 days after eating an infected product or after 3-7 days with a contact path of infection.

The first symptoms of the disease include weakness, lethargy, adamina, a decrease in appetite, abdominal pain that are localized in the epigastric and communal regions are moderately expressed.

TO early signs Diseases also include nausea, vomiting. Repeated vomiting is characteristic of the food route of infection. In this case, it is often the first sign of the disease, but is preserved for a short time - 1-2 days. With the development of the gastroenterocolitical version of vomiting may appear in the 1st day, it is infrequent - 1-2 times a day, but it lasts 2-3 days and more, that is, it is stubborn.

The average heavy form of salmonellosis is accompanied by fever. It fails to identify some patterns. It is possible to increase body temperature up to 38-39 ° C from one day. However, the temperature growth is not excluded to the maximum digits of the 2-3rd day. Increased temperature is saved 4-5 days.

The participation of the chair usually begins on the first day, but the most expressed diarrhea syndrome on the 2-3rd day from the beginning of the disease. The character of the chair depends on the variant of the flow of the gastrointestinal form of salmonellosis. So, with the enterito version, the chair is rich, watery, foam, folin, with greens (often like "swamp tina"). With the development of enterocolitis, impurities of mucus, blood appear in a rich stool.

With the moderate form of the disease, the frequency of the chair reaches 7-10 times, and the duration of diarrhea is 7-10 days.

When palpation of the belly in patients, spilled soreness are determined, a rumbling along the thick bowel, bloating.

Patients in the first year of life is possible a minor liver increase.

Due to the development of dehydration in children, a decrease in tone tone, skin elasticity, dryness of mucous membranes, diurea reduction, body weight loss is 3-7%.

The medium-haul form of the disease is usually without serious complications and after 7-12 days ends with recovery.

The heavy form of salmonellosis is more often developing in young children, with unfavorable factors of the premorbid state, with non-hospitality infection, and is predominantly s.typhimurium.

The disease begins violently, accompanied by a sharp increase in body temperature to 39-40 ° C, often marked chills.

The patient's condition deteriorates significantly, they become very sluggish, survive, the reaction to the surrounding is reduced. Children refuse food and drink. Patients are disturbed by painful nausea, repeated, sometimes indomitable vomiting.

The frequency of the chair usually exceeds 10 times a day. It is abundant, malicious, green. Most patients in the feces are found mucus and blood.

Skin covers in children are very pale, possibly cooling limbs, the appearance of cyanosis. Tour tissues and skin elasticity are sharply reduced, mucous membranes dry, dry tongue, covered with thick white bloom.

Violations of cardiovascular activities are developing in all patients. The frequency, voltage and tension of the pulse change, decreases arterial and central venous pressure. Heart tones are significantly muted. The development of infectious-toxic shock I-II degree is possible.

It is often affected by the nervous system, which is manifested by a headache, dizziness (among older children), drowsiness or sleep disturbance, convulsions (in young children).

Children determine the bloating of the abdomen, the possibility of the development of the intestinal paresis is not excluded. Most patients have an increase in liver and spleen (less often).

In early age children develop dehydration of II-III degree in hypotonic or isotonic type.

With a severe form of salmonellosis, the complications are developing in most patients, and recovery comes in 2-3 weeks.

The typhoid form of Salmonellez is observed in older children and is 1.8% of the total number of patients with salmonellosis.

This form may have a beginning similar to a gastrointestinal form, that is, it is beginning to begin with a deterioration in the overall state, an increase in body temperature, the appearance of pain in the abdomen, vomiting, liquid stool. However, the disease does not end with recovery after 3-7 days, but acquires traits characteristic of abdominal typhoid.

The fever of wave-like or irregular type up to 38-39 ° C, 10-14 days and more continues. The lethargy, adamiya increase, sleep disorder appears, headache. Stably marked the bloating, an increase in the liver, spleen. Sometimes the belly skin appears on the skin of the belly. Bradycardia develops, systolic noise is detected, blood pressure decreases.

In other cases, the disease can begin with the symptoms of intoxication, and the gastroenterocolitis syndrome is expressed weakly or is completely absent. Recurrements are rarely noted.

The duration of this form of salmonellosis infection is 3-4 weeks.

The septic form is a sepsis of salmonellosis etiology, the development of which is due to a sharp decrease in immunity, therefore it is common in children of early age, newborns, patients with IDC and other "risk groups" are usually caused by high-surplus, poly-resistant strains of s.typhimurium.

The disease begins with gastroenteritis phenomena, after which the typical picture of septicopemia is developing. The condition of the patients is significantly worse. The body temperature is incorrect, with large daily swings, repeated chills, abundant sweating. It is often observed by examine in the form of petechia and / or large hemorrhages, piedermia. From the first days of the disease, signs of damage to the nervous and cardiovascular systems are determined.

Secondary septic foci can be formed in various organs, while there is no regularity.

Purulent foci is often developing in the lungs, in the musculoser (osteomyelitis, arthritis): cholecisto-cholants, meningitis, tonsillites, lymphadenites, and urinary tract infection occur relatively often. Sometimes septic endocarditis, aortitis is observed.

The specific character of multiple lesions is confirmed by the detection of Salmonelle in spinal fluid (purulent meningitis), sputum (pneumonia), urine (urinary tract infection). In parallel with this, Salmonella is sown from blood and feces.

The septic version of salmonellosis is characterized by a long, heavy flow and may end to death.

Meningoencephalitic form relates to generalized salmonellaz forms. It differs from the septic form by the fact that meningoencephalitis is the only secondary septic focus. It is found in children of early age, newborns, patients with the background ids and the defeat of the nervous system.

The disease usually begins with gastroenteritis phenomena, after which the condition deteriorates due to the enhancement of intoxication and neurological symptoms. Headache or its equivalents (anxiety, a monotonous cry) appear, vomiting is increasing, swelling, voltage, ripple of a large springs are revealed. Cramps may occur. In later dates, meningeal symptoms are found, focal signs, loss of consciousness.

This form of salmonellosis proceeds very hard, it can end with a fatal outcome or formation of intracranial complications.

The erased form of salmonellosis is a very light gastrointestinal form of the disease, which is usually developing in older children and causes S.Neritidis and Salmonellas of rare groups.

With erased form, the general condition does not suffer, the body temperature remains normal. Against the background of a satisfactory general condition, a 1-2-fold liquefied chair without pathological impurities appears. Sometimes there are short-term abdominal pain.

The disease ends with recovery (often by self-physician) after 1-2 days.

Subclinical form clinically does not manifest. This is essentially salmonellosis. However, the increase in the titer of specific antibodies and morphological changes in the intestines are noted (catarrhal inflammation of the mucous membrane of the small intestine).

Carrying. After the suffered salmonellosis, it can be formed sharp (from 15 days to 3 months) or chronic (more than 3 months) bacteridation. It is observed in children less often than adults.

Adverse premorbium states contribute to the development of carriage. The slow release of the body from salmonella occurs when acute salmonellosis occurs against the background of exudative enteropathy, disfernosis, intestinal dysbiosis.

In addition, there is transient, or "healthy", carriage. It is said about this type of carrier if the detection of the causative agent in the feces was not preceded by an acute form of salmonellosis. In addition, the results of serological surgery (RING) with salinelose diagnosis in dynamics should be negative.

Features of Salmonellet's course in newborns and children of the first year of life.

Newborn and breast-age children have the highest sensitivity to Salmonellam. It is for this age group that is characterized by a non-hospital infection and contact path of infection.

Clinical manifestations of salmonellosis in young children are very diverse.

In the development of gastrointestinal shape, the enterocolitic option is more often registered. In this situation, it is characterized by a gradual increase in all symptoms, expressed toxicosis, dehydration, frequent developing hemolyte, hepatomegaly. The disease often occurs hard.

It is for these age groups that the septic form of salmonellosis is characterized.

In early age children, the disease is often accompanied by the formation of complications: enzymesopathy, intestinal dysbacteriosis, malabsorption syndrome, pneumonia, otitis, anemia, urinary tract infections, etc.

In 35% of patients, salmonellosis occurs in the form of a mixed infection (with rotavirus gastroenteritis, UPI, chiegelosis, sharp respiratory infections).

Heavy forms are more often observed in children with a burdened premorbid state. Especially adverse effects are accompanying herpesvirus and chlamydial infection. In this case, a fatal outcome is possible.

Features of the flow of Salmonellize, depending on the sulfur of the pathogen. The microbial landscape of Salmonella, isolated from people (patients and carriers), diverse. Every year it stands out from 15 to 39 servants, but the prevailing is S.Typhimurium - 65% of the number of all selected crops, in second place S.NERITIDIS - 23%.

Diseases caused by various Salmonella Serows have their own characteristics.

Thus, under salmonellosis, due to S.Neritidis, the prevailing version of the gastrointestinal form of the disease is gastroenteritudic. Infection occurs in an alimentary pathway and registered in patients of various age groups. The disease occurs in light and medium-free forms, quickly ends with recovery.

When Salmonellosis caused by S.Typhimurium, the prevailing means is the contact. The disease may occur in different age groups, but more often sick children of the breast. For this salmonellosis is characterized by nosocomial infection. The clinically disease is characterized by the development of enterocolitis (in 80-20% of patients), the greater frequency of the occurrence of hemocolithic (in 50-70% of patients), long intestinal dysfunction (within 10-15 days), the development of toxicosis, excocose, complications. The possibility of generatization of infection is not excluded.

The more severe flow of salmonellosis due to S.typhimurium is associated with both the pathogen features (primarily with poly-resistance to antibiotics) and with a high frequency of internal hospitality infection.

Salmonella have a complex identification system, including the definition of the following features:

- enzymatic activity in relation to carbohydrates; - serological properties - the establishment of an antigenic formula (CE-Rovar); - the stability of bacteriophage relative to the host microorganism (the definition of the phagelovar).

The bacteria of the genus Salmonella also possess a wide range of enzymatic properties that F. Kaufman (F. Kaufman) were based on the division of 4 trees:

I Podzhod - S.Kaufmani; II Podzhod - S.Salamae; III Podzhod - s.arizonae; IV Podzhod - S.Houtenae.

Salmonella have 3 main antigen:

O - somatic (thermostable); H - flagella (thermolabile); K - capsule (superficial).

A certain set of antigenic factors is a structure characteristic of each serovara. According to Kaufman-White's classification, all Salmonella are divided into 5 serological groups - A, B, C, D, E and Rare Groups (F-Z), in each of which serovas differ in H-antigen. Each antigen may have variations (VI-antigen - A-antigen variation).

An important meaning is to identify software for o-bacteriophage, which lies more than 97.55% of Salmonella strains. Known typical phages to s.typhimurium, s.enteritidis, s.dublin, etc.

S.TYPHIMURIUM includes 90 phageotypes caused to 90% of human diseases.

The person, as a rule, causes diseases of about 100 serovars, among which s.typhimurium, S.Londonis, S.Helderberg, S.London, S.Neuuport, S.Derbi, S.Moskau, S.Natum and others are most often registered. .

The owner adapted is able to cause a disease, mainly in humans or only in individual species of animals and birds.

So, S.Gallinarum, as a rule, cause disease from chickens, S.abortus-OVIS - sheep, S.Abortus-Equi - in horses, S.Cholerae-Suis - in pigs.

However, it is known that these same serovas cause diseases not only in other animal species, but also a person.

S.TYPHI, S.Paratyphi A and S.paratyphi C cause diseases only in humans. Serovar S.Paratyphi, as a predominantly causative agent of infection in people, is able to cause a disease and cattle, causing epizootia in young and chickens.

Pathogenesis of salmonellosis is due to a number of pathogenic factors, among which the decisive, most significant are adhesion, invasion and toxigencies.

Adhesion- element of colonization, i.e. the ability of a microorganism to reproduction on the surface of the epithelium of the macroorganism. Salmonella not detected special factors of adhesion.

Adhesive functions are performed by fibrils, pectins and lipopolysaccharide complex.

Invasiveness - The ability of Salmonelle to overcome the glycochaleks and without substantial damage to the brush kayma to be introduced into the cells of the epithelium, without destroying the cell membrane, which, surrounding salmonella, forms a vacuole. The latter are initially transferred to the basal part of the epithelial cell, then to the tissue to be tissue. Salmonella, absorbed by the macrophages, not only not subjected to phagocytosis, but are preserved and even multiply; According to lymphatic paths, they fall into the blood, which ultimately leads to the generalization of the infectious process.

Salmonelle toxins are subdivided into 2 types: ex- and endotoxins.

Exoto-toxins include vital products, actively secreted (produced) during bacteria (most often with the lesion function); Endotoxins include those biologically active substances that are released only with lysis of the bacterial cell.

In the pathogenesis of Salmonellez, a decisive role is generally accepted: endo- and exotoxin.

Endotoxin is a complex molecular complex consisting of protein, polysaccharide and lipid A.

The toxicity of the molecular complex has a dual nature:

- primary, due to the action of polysaccharide and lipid molecules (LPS); Lipid and protein (cytotoxic, membrancing); - secondary, which is the result of the occurrence of slow-type hypersensitivity (the phenomenon of the hypersensitivity of Schwarzman-Sanarelly) and immediate type (anaphylactic shock at endotoxinemia). The result of the toxic complex is the suppression of the degranulation process of neutrophilles, the release of biologically active substances, the effect on the rolling system of blood, which leads to the development of inflammation and DVS syndrome. The effect of toxin is cascade; - causes a sharp increase in enzyme activity, including adenylate cyclase, which leads to an increase in the level of CAMF; - stimulates the synthesis of prostaglandins, which in turn also activate the adenylate cyclase system.

High level The CAMF activates the enzyme systems affecting the permeability of membranes, causing increased secretion of electrolytes and liquid.

Exotoxins - they include enterotoxins:

- Thermolabile (high molecular weight protein), in structure and biological effects are close to cholerogen and thermolabile E. coli thermolabile enterotoxin and other enterobacteria. The mechanism of its action is carried out through the activation of the adenylate cyclase system directly or through the prostaglandins; - thermostable (low molecular weight protein), which has no antigenic kinship with thermolabile, but also causing the accumulation of fluid in the intestine through the guanillatocyclame system, causes the phenomenon of fast vascular permeability; - cytotoxin, damage epithelial cells.

Salmonella antigens include endotoxin complex, VI antigen, thermolabile and thermal staple enterotoxins, cytotoxin.

The correlation between the severity of the course of the disease, the frequency and the level of antigens in the blood, urine, coproiltrates, the detection of which has diagnostic and prognostic value.

Epidemiology.The features of Salmonellez epidemiology should include widespread distribution in the form of sporadic cases and epidemic outbreaks. The incidence of salmonellosis remains high both among adults and children. In 2005, 42,174 patients with salmonellosis were registered in the Russian Federation (incidence of 29.17 per 100 thousand population). Among the sick 17,449 children under 14 years of age (41.4%). Especially high susceptibility to salmonellosis are different children under 2 years old (they account for from 43.5 to 58.3%) and persons with different types of immunodeficiency.

The main sources of infection are homemade farm animals (cattle, pigs), poultry (chickens, geese, ducks), cats, dogs, pigeons, wild birds, fish, etc.

The disease is more often evolving when eating meat and meat products, fish, abundant with salmonellas. Meat infection can occur in a lotumely with bastard of patients, improper cutting of a carcass, when the meat is contaminated by the bowel content, or when the rules of transportation and storage of meat and meat products are violated, if they are contaminated with rodent secretions.

The person is very sensitive to the toxins of Salmonellez's causative agents, and therefore massive diseases may arise among those who used the infected product, massively amized by these microbes and their toxins.

The causative agents of infection can multiply and accumulate in infected milk and dairy products, confectionery, etc. with their improper storage.

Salmonellosis disease is most often observed in a warm and especially hot season, which depends on availability favorable conditions For reproduction of pathogens in food products and greater prevalence of these diseases among livestock.

The greatest epidemiological danger is agricultural animals and birds, in which salmonellosis can take the character of epizooty.

An important role in the spread of infection belongs to both a person. The source of infection may be both a patient and a bacteria carrier. Infectness of children comes from adults in the process of care of the child.

The main way of infection is an alimentary, in which the leading transmission factors are the food products of animal origin (meat, meat products, eggs, milk and dairy products), fish, vegetables, fruits, berries. Salmonella products products do not change their appearance, taste.

As a direct or indirect transmission factor, the infection is often acting water. Aerogenic path of infection and contact-household, which is mainly implemented among young children. The transfer of the pathogen in this case occurs through the hands of people who caregoes for children, bed linen, objects of care, equipment, etc.

Salmonellosis is registered throughout the year, but more often in the summer months, which can be explained by the deterioration of food storage conditions.

A special epidemic shape of the disease represents the "intrabolese" salmonellosis. Most often, the "hospital" salmonellosis arises in intensive care and children's infectious offices. It is possible to infect children during their stay in their maternity homes, somatic and surgical hospitals. The "intra-tram" salmonellosis occurs in young children, especially from the "risk groups", but may develop in older patients with severe somatic pathology.

The feature of the "noso-community" salmonellosis is monoethiology: the main pathogen is s.typhimurium, sulfur r ", characterized by multiple resistance to antibacterial agents. The source of infection in these cases is only a person, most often sick children, less often - personnel, mother. The main way of transmitting infection in these situations is a contact. The foci of the "hospital" salmonellosis is characterized by gradual development, long-term existence, the emergence of the emergence in the cold season.

One of the features of Salmonellosis is the variability of the etiological structure. Until 1986, Serovar S.Typhimurium dominated, while the incidence in the overwhelming majority was due to hospital strains.

Since 1986, a significant proportion of S.Neritidis belongs to S.Neritidis, with a number of outbreaks and group diseases.

S.Neritidis and caused by their diseases were widespread against the background of intense industrial poultry. In the overwhelming majority of cases, the source of infection is chickens, and the leading factor in transmission of infection - chickens meat, eggs.

The disease develops only in cases where the gastrointestinal tract simultaneously falls with food bacteria and their toxins.

Salmonellet pathogens are localized in the mucous membrane and the intestinal, causing hypersecration and reinforced intestinal peristalsis. Part of the pathogens through the lymphatic apparatus of the intestine falls into the blood flow and causes bacteremia. Endotoxin standing in the death of Salmonella has an impact on various organs and organism systems. First of all, the vascular-nervous apparatus is affected, which is manifested in increasing the permeability and decrease in the tone of the vessels, in violating thermoregulation.

The development of salmonellosis is associated with two main factors of the pathogen: infectious and toxic. The dominant factor determines the clinical picture of the disease.

With a massive dose of infection in the upper gastrointestinal tract departments, the mass death of salmonell, accompanied by autolysis, occurs bacterial cells With the yield of endotoxin and other toxic products. The toxic factor is the leading launcher of the disease, causing a rapidly developing picture of toxicoinfection.

With a small dose of infection, the phenomenon of intoxication appears only in the acute period of the disease. The starting mechanism is the colonization and reproduction of Salmonelle at first in the small intestine, then in other organs, therefore the infectious process is cyclic, as a result of which generalized or septic forms may develop. The variety of clinical forms of salmonellosis depends on the following factors:

The degree of pathogenicity of the pathogen, the types of toxins produced by them and their quantity; . infecting dose; . Protective Host Adaptation Features (Local Condition immune protection, level of specific and nonspecific humoral and cellular immunity, microbiocenosis of the gastrointestinal tract and other factors for the protection of the host).

The general development scheme of the pathological process includes the following stages:

1. Implementation of the pathogen. Salmonella penetrate into the mucous membrane of the small intestine, overcoming the epithelial barrier first, then embedded in the own plate of the mucous membrane. The introduction of enterocytes is provided through the system of biological recognition of the Leganda receptor. The ability of Salmonelle to implementation is also determined by their ability to adhesion and colonization. 2. The death of Salmonell. Endotoxinemia. Salmonella, which remain in the lumen of the intestines, die. In its own layer of the mucous small intestine, the death of salmonella and their destruction with the release of endotoxin occurs. Endotoxiny develops. Endotoxin action is a leading pathogenetic factor. As a result of the absorption of endotoxin, disorders of water-salt equilibrium and hemodynamics, violation of the activity of the cardiovascular system, secretory hormone disorders produced by the specialized cells of the small intestine are occurring. 3. Replication in the subtle intestinal department (enteral phase). The place of primary breeding Salmonella in the body is the delicate intestine. An increase in their population depends on two factors: the adhesive-colonatory ability of salmonell and the state of resistance to phagocytosis. 4. Bacteremia. Salmonella's blood fall into two ways: through the mucous membrane of the small intestine, thanks to invasive properties, and through macrophages, due to the resistance to phagocytosis. Bacteremia leads to the generalization of the process. Salmonella hematogenic means fall into various organs, multiply in them, causing allergic reactions. This process can be cyclical, in which immunological shifts are formed, or in the presence of an immunodeficiency state - septic and tyifoid forms. 5. Bacteridation. The infectious process may flow at a subclinical level (bacteriasis), in which there are no symptoms of toxicosis and toxinyology, and the leading tissue response to the invasion of the pathogen is missing.

Subsequently, the elimination of the pathogen with the reverse development of pathological processes is possible, but long-term bacteria is possible.

Immunity. The immune response to the salinelosis aggression depends on the severity of the disease, the age of children, the sorolot of the pathogen, the development of a mixture infection. The most pronounced and prolonged immune disorders occur during severe forms, in children of the breast, with diseases caused by S.Typhimurium and with layering respiratory infection.

When the adaptation mechanisms are depleted, the type of immune response is developing, which is characterized by a sharp decrease in the amount of T-lymphocytes and their subpopulations, inhibition of phagocytosis, the lack of switching the synthesis of antibodies with IgM on IgG, activation of the combination activity of the blood serum, a significant accumulation of CEC in the blood.

"Strong" type of response is expressed by a moderate decrease in the content of T-lymphocytes and their subpopulations, activation of the in-link of the immune system, the intensification of phagocytosis processes, the safety of the adaptation reserves of neutrophils, ascending the complementary activity of the blood and the CEC level, the absence of the IGM synthesis switch to IgG (A. Azizurrachman , 1995).

These immune shifts underlie the formation of inflammatory reactions. With moderate forms, these changes are protected-adaptive, aimed at restoring homeostasis. With severe forms, they reflect the "floor" in the body.

Patomorphology. With Salmonellosis, the main changes are developing in the intestine: in thin intestine Catarial inflammation occurs, in thick - catarrhal-hemorrhagic, follicular-hemorrhagic, fibrinous, ulcerative and ulcerative-diphiteritic. The nature of inflammation depends on the severity of the infectious process and largely determines the local clinical manifestations of salmonellosis.

Simultaneously with the intestine, changes are developing in the stomach, mesenteric lymphatic nodes, internal organs. In particular, dystrophy and lunching of the epithelium, swelling, hyperemia occur in the stomach mucosa, the cell infiltration of its own layer is enhanced.

Degenerative changes are observed in the liver, the muscle of the heart, the spleen.

With the septic form of salmonellosis in various organs (brain and its shell, lungs, kidneys, liver, etc.) metastatic foci is detected.

In cases of lethal exodes at salmonellosis, deep dystrophic changes parenchymal organs, hemorrhage. Elevation of the lungs and brain often serves as a direct cause of death.

Features of noselnichny salmonellosis. The emergence and circulation of salmonell in somatic departments followed by the formation of the "Non-community salmonellosis" the following factors contribute:

1. Epidemic:

1. Late diagnosis intestinal infections, in particular, Salmonelleza, in somatic patients. 2. Violation of the sanitary and hygienic regime in the departments (late detection and insulation of patients with salmonellosis, untimely bacteriological surveys of personnel and patients, improper storage of dirty and clean linen, lack of linen, etc.). 3. Overcompassing chambers. 4. The lack of boxes and pharmacarial chambers for insulation of patients with intestinal dysfunction in somatic compartments. 5. Failure to comply with personal hygiene rules. 6. Interruptions in the work of the water pipeline. 7. Sewer crashes.

II. Clinical:

1. Early age patients. 2. Haldified Premorbide Background. 3. The presence of concomitant pathology (infectious, somatic, surgical diseases), on which children are in the hospital. 4. The presence of atypical forms of salmonellosis (erased, subclinical, carriage) in medical personnel, caring for patients with children of the children themselves. 5. Development of salmonellosis complications (infectious-toxic shock, brain edema, hemolytic-uremic syndrome, etc.), which require the patient's stay in the intensive care unit. 6. The presence of a respiratory shape of salmonellosis.

III. Microbiological:

Formation of sustainability to most drugs in S.Typhimurium Serovar R ".

Criteria of "Intra-community" Salmonellosis:

1. The emergence of typical clinical symptoms of salmonellosis after 5-7 days or more than the hospitalization of patients in the hospital. 2. Allocation of Salmonelle 5-7 days and more from the moment of hospitalization, if this was preceded by the negative results of bacteriological research on the entire intestinal group or was the sows of other pathogens in patients with intestinal infections. 3. The increase in the titer of anticoal monoxide antibodies, which coincides with time with clinical flow Estimated salinelosis infection.

Diagnostics

Diagnostics is based on clinical data, carefully collected epidemiological history and laboratory studies.

The masses (50 ml), the washing water of the stomach (100-200 ml), flowing and urine (10-20 ml) in sterile or boiled banks, as well as blood (5-10 ml) on the hemoculture (5-10 ml), are directed to the laboratory.

A week later, the reaction of agglutination can be reacted, for which 1-2 ml of blood of the finger or from vein is directed to the laboratory.

The diagnosis of salinelosis infection in children is carried out on the basis of the following criteria:

1) epidemic; 2) clinical; 3) laboratory.

Epidemiological data allow you to establish contact with such infectious patients; consumption of a poor-quality food product; Stay in the hospital in the next 7 days.

Clinical diagnostics It is carried out on the basis of the allocation of the main syndromes:

Intoxication, or infectious toxicosis; . Excicosis; . Invasive diarrhea by type of gastroenteritis, enteritis, enterocolitis, gastroenterocolitis. . hepatosplegaly (in breast children and under generalized forms); . development of generalized forms (septic, typhoid, meningoencephalitic).

Also spending general analysis Blood, you can reveal leukocytosis from moderate to pronounced, neutropyl with a shift to the left, promotion of POPs. With a long-term course of the disease, anemia is possible.

The final diagnosis of salmonellosis is established on the basis of data of laboratory studies, fundamental bacteriological and immunological methods.

Bacteriological methods are aimed at the selection of the pathogen from feces, blood, urine and affected organs.

Treatment. Light forms of salmonellosis do not require treatment and patients do not more often resort to medical care. With more severe forms of the disease, it is necessary to wash the stomach with warm water or 0.5-1% solution of drinking soda. The washing is carried out with the help of a gastric probe or give a patient to drink several times 4-5 glasses of warm water or a solution of drinking soda, after which they cause vomiting. After washing, the laxative is prescribed (25 g of magnesium sulfate). With pronounced intoxication prescribed subcutaneous or intravenous administration 1000-1500 ml of saline in half with 5% glucose solution. In cases where the patient of vomiting does not stop, the hypertensive solution of sodium chloride (10-20 ml of 10% solution) is intravenously poured. According to the testimony, cardiovascular means are prescribed: caffeine, Cordiamine, Ephedrine. When the collapse state is intravenously introduced anti-flux liquid (2.5 g of sodium chloride, 0.5 g of sodium thiosulfate, 1.5 g of calcium chloride, 500 ml of distilled water) 300-500 ml for 15-20 minutes. In the case of a heavy collapse, an intravenous 500-1000 ml of polyglyukine is administered under the control of blood pressure (children - at the rate of 10-15 ml per 1 kg of weight).

In case of heavy forms of salmonellosis to remove intoxication, it is recommended to introduce intravenously, drip (50-60 drops in (minute) hemodez. A single dose is 300-400 ml for an adult and 5-15 ml per 1 kg of the child's weight. Infusion is repeated after 12 hours and more . When cramps and chills are shown the heights to the legs, warm baths.

After the cessation of vomiting in typhoid and septic forms, antibiotic treatment is prescribed. Depending on the testimony, levomycenetin is given in 0.5 g 4-5 times a day.

Prevention. Measures to prevent salmonellosis include sanitary and veterinary surveillance of livestock, careful sanitary supervision on slaughterhouses, proper storage and transportation of meat in order to prevent its pollution; Destruction of rodents; storage of foods at low temperatures, their reliable heat treatment, preventing joint processing of raw and boiled products; Timely detection and insulation of patients and carriers of Salmonella, compliance with personal hygiene rules.

Of great importance is the prevention of a disease of the sore cattle together with healthy, as well as inspection and excerpt of healthy cattle before the caution after transportation, distillation, etc. Meat from forced cattle must be used in a centralized manner, where it is subjected to long heat treatment. Specific prophylaxis is absent.

Events in the hearth. Patients are subject to hospitalization. Before hospitalizing the patient or before recovery, if it is isolated at home, the focus produces current disinfection, and after hospitalization or recovery of the diseased - final disinfection.

Behind people in contact with the patients establish medical observation over the next 6--7 days with the aim of early detection of possible diseases and conduct a single inspection for carriage (measurement and urine).

The extract of patients from the hospital is made after complete clinical recovery and two-time bacteriological research of feces and urine with a negative result.

The admission of children by salmonelles, in children's institutions, as well as equipment workers and individuals, to their equivals, is permitted to work after additional clinical observation within 15 days and a three-time study on Salmonella's carriage.

After discharge from the hospital of the surveys examining a three-year (with an interval of 3-5 days) on the carriage during a monthly clinical observation.

Events held in the team. In group diseases, patients have medical care And the epidemiological examination is carried out to identify the food product that caused poisoning, and circumstances that contributed to infection.

The identified food products are made of circulation and take measures to prevent new cases of the disease. Events for the prevention of salmonellosis are carried out jointly by epidemiologists and sanitary doctors.

Gonorrhea - infectious disease. The causative agent (Gonokokk) was opened in 1879 by Albert Neussser, who found him

pages: 17-20.

V.P. Small, Ph.D., Professor, Head. Department of Infectious Diseases Kharkiv Medical Academy of Postgraduate Education, V.A. Zaitseva Kharkov National University named after V.N. Karazin, medical faculty

Intra-community salineles represent a serious problem for hospitals of various profiles. In the structure of nosocomial intestinal infections, their share can reach half, and they are more often of other infections of this group form-agenic outbreaks.

Epidemiology

According to some specialists (Yafaev R.Kh., Zuev L.P., 1989; Akimkin V.G., 1998), Salmonellosis is the only nosological form (not counting some purulent-septic infections), for which great importance in the preservation of the pathogen As a biological species has its circulation in therapeutic institutions. The epidemic characteristic of intra-hospital salmonellosis is largely different from the epidemiology of classical salmonellosis. More often, salmonellosis in hospitals occurs and applies due to circulation hospital strains The pathogen having peculiar parameters (although in the hospital there are outbreaks associated with violation of the technology of cooking animal meat).

The joining of salmonellosis to the already existing pathology in patients aggravates the severity of the current disease. Up to 6% of noselvantic salmonellosis ends with a fatal outcome (Kovaleva E.P., Semin N.A., 1993; Bukharin O.V. et al., 2000; Akimkina V.G., Pokrovsky V.I., 2002).

E.A. Trunilina (2004) notes that mortality at salmonelles is more than 7%, but in 96.7% these cases are caused by infection Salmonella typhimurium. The fatal outcome occurs due to sepsis, intestinal perforations after a long-term operation with the development of peritonitis, pneumonia, polyorgan deficiency as a result of intoxication syndrome and for other reasons.

The ability to propagate the various Salmonella Serovas, but a leading role belongs to S. Typhimurium., on the example of which the epidemic process of noselnical salmonellosis was studied and the principles were developed epidemiological supervision (Masalin Yu.M., Peredkin VS, 1995; Demin I.A., Brusina E.B., 2006).

In many territories, second place in the structure of salmonellosis resistant holds Salmonella Enteritidisand the third - Salmonella infantis (Demin I.A., Brusina E.B., 2006). Under certain conditions, each of these two serovarov can become leading and induced by a non-hospital outbreak.

Significant differences in epidemiology, etiology, the clinic of classical (zoono) and nosocomial salmonellase allow the latter to a special group of infections, giving it the status of independent nosoform of the human infectious pathology.

Epidemiological patterns of hospital salmonellosis differ significantly from extractive, observed with the traditional food path of their distribution.

Salmonelle's hospital strains are a special biological species that has a number of properties that allow them to differentiate them from ordinary serovars, and have the ability to form foci of infection, characterized by a significant number of fundamental features of the epidemic process of the epidemic process, in contrast to the classic salineliness infection.

In contrast to the traditional food zoonous salmonellosis, hospital salmonellosis is inherent in the peculiarity of all units of the epidemic process: the source of infection, pathogen transmission paths and susceptible to infection of the body.

A fundamentally important feature of Salmonellosis as hospital infection It is that the source of the pathogen and the main reservoir of infection under these conditions is a person - children and adults (patients or bacteria carriers) entering the hospital or in it, as well as medical personnel. The diseases may be on treatment in various branches (surgical, resuscitation, children's, infectious, therapeutic, etc.). Resistant foci of infection in hospitals are maintained due to the epidemic process of medical personnel, in some cases up to 5-9% of all detected diseases (carriers; Akimkin V.G., Pokrovsky V.I., 2002; Demin I.A. , Brusina E.B., 2006). The translation of patients with salmonellosis from some departments to others leads to cases of infection and contributes to the formation of persistent foci of nosocomial salmonellosis.

The epidemic process is involved in newborns, the children of the first year of life, the face of the elderly and senile age (Akimkin V.G. et al., 2000; Trunilina R.A., 2004), patients with severe public human pathology. Analysis of outbreaks of intrabiquier salmonellosis of contact-domestic nature (Akimkin VG, 1998, 2000; Demin M.A., Other E. B., 2006; Trukhina G.M., Nalolova I.V., 2008) Shows that the originality of the epidemic process is due to the set risk factors:

Conditions of a closed collective;
concentration of contingenty risk of disease development (acute surgical pathology of the digestive tract and urinary tract, extensive thermal lesions of the skin, oncological diseases, traumatic damage, etc.);
conditions for the reservation of hospital Salmonella strains;
features of the content and care of patients;
displacements by hospitals (branches);
dysbacteriosis;
severe immunosuppression, etc.

Outbreaks of noselvantic salmonellosis and sporadic cases lead to contamination of air pathogens, chambers, patient care objects, bed linen, medical diagnostic equipment, furniture, etc. with significant resistance to antibacterial drugs and disinfectant solutions in conventional concentrations (Salmonella die only When processing disinfecting solutions in high concentrations or when exposed to disinfectants and new generation antiseptics). In connection with this nosocomial salmonellosis, in contrast to the classical, having a fecal-oral transmission mechanism of infection with mainly food, to the greatest extent inherent domestic contact . Infeitation in this case, most often occurs through general items (tools, medical equipment, nipples, toys and other items, furnishings and care in the ward sections), dirty hands of staff, dishes, medicinal products (saline solution, solution of glucose), contaminated by salmonella. The specified transmission mechanism in a large number of cases is confirmed by bacteriologically.

Another transmission mechanism - air-dusty Although it is a discountable. Currently, the accumulated practical experience of epidemiological surveys of foci of nosocomial salmonellet allows not only to convincingly talk about its presence, but in some cases, such a transmission mechanism (that is, the most active; Belyakov V.D., Akimkin V.G., 1997; Akimkin V.G. et al., 2000). The air-dust transmission path can be realized in two ways (RoTeva T. et al., 1969): with the direct penetration of the pathogen with inhaled air containing dust particles (aerosol), and through food products as a result of falling dust particles carrying salmonella.

Cases are described selection of salmonell from the wound In the hospital's conditions. With the formed chronic focus of the National Emirates Salmonellosis in a large multidisciplinary hospital caused by a serovar S. infantisFor more than 10 years, a large number of patients who were in a difficult or terminal state were revealed, which from RAS stood out this Serovar (Demin I.A., 2003). Moreover, most strains were sown with typical pathogens of wound infections (from 1 to 4 pathogenic bacteria - staphylococci, streptococci, protea, intestinal wand, Klebsiella, etc.). According to observations, the invalidation of the wound S. infantis happened in some cases endogenous way In generalizing the salmonellosis infection, in others - exogenous (with a contact-domestic path of infection) and did not depend on the intestinal nonsense, that is, it was an independent process.

An important feature of hospital salmonellosis is also the possibility of infecting patients in hospitals small infamary dose salmonelle - 10 3 microbial bodies (Blaser M.I., NEWMAN I.S., 1982). This is due to the polyzerism of nosocomial strains, the combination of stability to the effects of the environmental factors caused by a long-term (up to 180-250 days) survival (Akimkin V.G., 1998), and a high degree of contagiousness (Belyakov V.D., Akimkin V. , 1997) in relation to certain categories of patients and hospital personnel. An infectious dose for an immunocompetent person is a dose of 107 bacteria. Remain transmission The causative agent of infection is the characteristic feature of the epidemiology of intra-sepital salmonellosis.

The biological properties of the pathogen, the specificity of the affected groups of stationary patients, the features of the leading drive mechanisms of the pathogen determine the dynamics of the course of the epidemic process of nosocomial salmonellosis, which is characterized by the gradual start, wave-imagination and trampidity of the course, involvement in the epidemic process predominantly immunocomplete individuals and children of the first year of life. The most susceptible to this person infection with immunodeficiency, as well as with hypo-and ahlorohydria. The course acquires, as a rule, the nature of the chronic epidemic, which is ongoing several months, and sometimes years, is accompanied by periodic rates and decals of morbidity.

Clinical picture

The incubation period is 3-8 days. More than 90% of the diseased nosocomial salmonellosis diarrhea appears on the 3rd day. The disease develops gradually, diarrhea may be insignificant (Masalin Yu.M., Perepelkin VS, 1995), in many cases enterocolitis is observed. In the same time clinical picture Nosocomial salmonellosis can be characterized by a rapid beginning with high and long fever, dyspeptic phenomena against the background of pronounced intoxication (Akimkin V.G., 1998).

The intestinal damage is common and more than 50% of cases is accompanied by gastroenteritically syndrome. A liquid watery stool with an admixture of mucus is recorded, sometimes blood. Often the process involves the hepatobiliary system. Most patients have a renal hemodynamics. Almost all patients have pronounced changes in the intestinal microflora.

In the structure of manifestations of nosocomial salmonellosis, manifest form with the typical course of the disease is dominated. However, there is a significant number of cases (1/4) with atypical manifestations of the infectious process, including sometimes the symptoms of salmonellosis as a purulent-septic infection appears to the fore. In a separate group of patients (operated oncobolen), hospital salmonellosis in 80-97% of cases occurs, it is heavily with the same frequency of development of localized and generalized forms (Belyakov V.D., Akimkin V.G., 1997; Akimkin VG, 1998) .

The fact that in the first 7 months of outbreaks in the clinic, heavier forms are dominated in the clinic (74.7%), and they are practically absent in recent months of registration of the disease (Belyakov V.D., Akimkin V.G., 1997). Infectness of patients mainly (65%) occurs in the postoperative period.

The pathogens of nosocomial salmonellosis are distinguished by significant polyesistance to antibiotics, which develops not only as a result of their intensive use. V.D. Belyakov, V.G. Akimkin in 1997 noted that the allocated strains from patients in medical and prophylactic institutions in 81.7% of cases were absolutely insensitive to 38 well-known antibiotics of a wide range of action. Back in the second half of the twentieth century. After the course of antibacterial therapy, up to 30-50% of patients were isolated Salmonella again (Buchwald D.S., Blaser M.I., 1984; Kovaleva E.P., Semin N.A., 1993). Therefore, the choice of etiotropic therapy and prevention of the disease, as well as the treatment of drugs should be scientifically justified.

Along with antibiotic-resistant, there is a significant stability of the isolated strains to the disinfectants in conventional concentrations.

In this way, Nosocomial salinelese infection is characterized by:

The formation of persistent foci with the formed hospital strains of the pathogen;
the existence of a totality of the risk factors of the hospital morbidity;
Long incubation period;
acute or gradual principle;
gastrointestinal syndrome, less often - in the form of a purulent-septic infection;
involvement in the process of the hepatobiliary system;
the predominance of heavier infection forms;
aggravation of the severity of the main disease;
Often repeated excretion of Salmonelle;
polyantibiotic resistance of the causative agent of infection.

Prevention

Preventive and anti-epidemic events are quite laborious and complex.

The effectiveness of eliminating salmonellaz foci in medical preventive institutions depends on timeliness, the quality of the complex of anti-epidemic events oriented to all links of the epidemic process: timely insulation of the patient, adequate therapy, monitoring contact persons, wet cleaning of the chambers at least 2 times a day, current and Final disinfection in the focus, processing and disinfection of tools and equipment, disinfection of bedding and mattresses, control of the food rubber. All susceptible in charge of the high risk of infection (branch of resuscitation, crediting surgery) in epidemiological an unfavorable period, prophylactically appropriate for the prescription of the salmonella bacteriophage. Significant reduction in the level of morbidity and pronounced therapeutic effect Obtained only when using salinelose bacteriophage adapted to Salmonella strains isolated from the hearth (Belyakov V.D., Akimkin V.G., 1997). It is necessary to conduct a rehabilitation and prevention of infection among medical personnel, bacteriological examination of all patients, primarily entering the separation of the surgical profile.

System preventive events It is based on the monitoring of diarrheal syndrome, the identification of precursors of epidemic disadvantage, reducing the patient's stay in the hospital, ensuring a high degree of anti-infectious protection of medical technologies, reducing the number of patients in the chamber, systematic training personnel.