[10-038 ] Sowing for aerobic and facultative anaerobic flora with determination of sensitivity to an extended list of antibiotics and selection of the minimum effective dosage of the drug

1590 RUB

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Microbiological research on the VITEK bioMerieux analyzer, which allows, with a higher sensitivity and specificity than conventional culture, to identify about 200 types of clinically significant bacteria and select antibiotic therapy with the calculation of the minimum effective dosage of the drug. The advantages of the study in comparison with conventional sowing: the lead time is shorter by 24 hours; sensitivity is determined to an extended list of antibiotics (up to 20 pcs.); the result is given both in the form of critical values \u200b\u200b(sensitive, moderately stable, stable), and in the form of values \u200b\u200bof the minimum inhibitory concentrations of the antibiotic (MIC). This, in turn, allows you to choose the most effective minimum dose of the antibiotic, reducing its negative effect on the human body. * Antibiotic sensitivity will be determined when pathogenic and / or opportunistic microorganisms are detected. When microorganisms that make up the normal microflora are detected, antibiotic sensitivity is not determined, because has no diagnostic value.

Synonyms Russian

Bacteriological study of clinical material with determination of sensitivity to antibiotics on the VITEK bioMerieux analyzer; sowing for microflora in aerobic conditions.

Research method

Microbiological method.

What biomaterial can be used for research?

Breast milk, pocket swab, pharyngeal swab, conjunctival swab, nasal swab, nasopharyngeal swab, urogenital swab (with prostate secretion), sputum, ear drainage, vomit, synovial fluid, bronchial flush, middle portion morning urine, ejaculate.

How to properly prepare for the study?

• It is recommended to consume a large volume of liquid (pure non-carbonated water) 8-12 hours before sputum collection.
• Do not eat, drink, brush your teeth, rinse your mouth / throat, chew gum, or smoke 3-4 hours before taking oropharyngeal (pharyngeal) swabs. For 3-4 hours before taking nasal swabs, do not instill drops / sprays or rinse the nose. Taking swabs is best done in the morning, right after a night's sleep.
• For women, the study (the procedure for taking a urogenital smear or collecting urine) is recommended to be performed before menstruation or 2-3 days after its end.
• For men, do not urinate for 3 hours before taking a urogenital swab or urine collection.

General information about the study

- these are microorganisms, for the vital activity and reproduction of which oxygen is not required, for many of them, on the contrary, it is destructive. Anaerobes inhabit the human body normally (in the digestive tract, respiratory organs, genitourinary system). With a decrease in immunity or injury, damage, activation of the infection with the development of the inflammatory process is possible. The human body can then become, in fact, a source of infection for itself (endogenous infection). Less commonly, anaerobes enter the body from the outside (deep puncture wound, infected abortion, wounds of the abdominal and chest cavity, insertion of wires and prostheses). Developing in the thickness of the skin, soft tissues and muscles, anaerobic organisms are capable of causing cellulites, abscesses, myositis. Symptoms that allow one to suspect an anaerobic infection of soft tissues: dense edema, gas formation (feeling that air bubbles burst under the skin when pressed), putrid inflammation, fetid odor.

The main treatment for anaerobic inflammation is surgery. In this case, it is necessary to eliminate the source of inflammation or open the wound, providing access to oxygen, which is destructive for anaerobes.

Life activity aerobic flora possible only in the presence of free oxygen. Unlike anaerobes, in them it participates in the process of generating the energy they need for reproduction. These bacteria do not have a distinct nucleus. They multiply by budding or fission, forming toxic products when oxidized. Cultivation of aerobic bacteria involves not only using a suitable nutrient medium for them, but also quantitatively controlling the oxygen atmosphere and maintaining optimal temperatures. For each microorganism of this group, there is a minimum and maximum oxygen concentration in the environment, which is necessary for its normal reproduction and development.

Optional anaerobes- organisms that exist and perform all energy and reproductive cycles in an anaerobic way, but at the same time are able to exist and develop in the presence of oxygen. Obligate and facultative anaerobes differ in the last characteristic, because obligate are not able to exist in conditions of oxygen and when it appears they die. All the energy necessary for their existence, development and reproduction is obtained by facultative anaerobes through the splitting of organic and inorganic compounds.

For the differential diagnosis of anaerobic and aerobic infection, biomaterial is sown on the flora, since the principles of treatment in one case or another will be different. According to the grown culture, the type of microorganisms that are involved in the formation of the inflammatory reaction is determined. Knowing the type of pathogen, you can choose an antibacterial drug that is able to successfully affect these microorganisms.

In the course of this study, the presence of aerobic and facultative anaerobic flora is determined.

Microbiological research on the analyzer VITEK bioMerieux allows, with a higher sensitivity and specificity than conventional culture, to identify about 200 types of clinically significant bacteria and select antibiotic therapy with the calculation of the minimum effective dosage of the drug. The analyzer system is designed to identify gram-negative bacilli, gram-positive cocci, anaerobic bacteria, neisseria, haemophilus bacillus, other whimsical bacteria, corinbacteria, lactobacilli, bacilli, fungi (more than 450 taxa). The analyzer system consists of a bacteriological analyzer and a personal computer. Automation of the process reduces the risk of material contamination and errors in research results.

After identifying the culture of bacteria, it is advisable to determine their sensitivity to various antibiotics. Knowing the type of pathogen, you can choose an antibacterial drug that is able to successfully affect these microorganisms. Due to the fact that the development of antibiotic resistance of microorganisms is increasingly observed, the selection of antibiotics according to their spectrum of action on bacteria can lead to ineffective or generally ineffective treatment. An advantage of the antibiotic susceptibility test is the precise determination of the antibacterial drug that is most effective in a particular case.

What is research used for?

• Differential diagnosis of anaerobic and aerobic infections, selection of adequate therapeutic treatment, taking into account the detected microflora.
• Diagnostics of latent, latent and chronic infections: detection of persistent, difficult to cultivate and / or uncultured forms of microorganisms.
• To select an antibiotic to successfully treat an infection.

When is the study scheduled?

• For various pathologies of inflammatory and infectious genesis - for timely, quick identification of a possible pathogen.
• With symptoms that suggest anaerobic infection (gas formation, putrid inflammation).

What do the results mean?

The reason for the detection of microorganisms is the presence of growth of colonies of this type of microorganisms on a nutrient medium (this microflora can be normal: Streptococcus mitis, Neisseria mucosa, Staphylococcus aureus, Streptococcus viridans group).

This study does not provide for the isolation of anaerobic microflora, viruses, chlamydia, as well as microorganisms that require special cultivation conditions, such as Neisseria meningitidis, Neisseria gonorrhoeae, Bordetella pertussis, Bordetella parapertussis, Corynebacterium diphtheriae, Mycopaplasma spp. In the absence of growth of diagnostically significant microflora during bacteriological inoculation and the presence of a clinical picture, additional studies are recommended.



Who assigns the study?

Infectionist, therapist, gynecologist, general practitioner, otorhinolaryngologist, pediatrician.

Literature

• Fermin A Carranza, Paulo M. Camargo. The Periodontal Pocket. / Carranza "s Clinical Periodontology 2012, 127-139.
• Mirela Kolakovic, Ulrike Held, Patrick R Schmidlin, Philipp Sahrmann. An estimate of pocket closure and avoided needs of surgery after scaling and root planing with systemic antibiotics: a systematic review. / BMC Oral Health. 2014; 14:159.

For those people who live in a country house and do not have the means and possibilities for arranging a centralized sewage system, a number of difficulties with water disposal will have to be solved. It is necessary to look for a place where human waste will be dumped.

Most people use the services of a sewer truck, which is not very cheap. However, a septic tank that works on the basis of microorganisms is considered an alternative to a cesspool. These are modern bioenzyme preparations. They accelerate the decay of organic waste. Wastewater is treated and discharged into the surrounding nature without harm.

The essence of the method of cleaning domestic wastewater

Any wastewater treatment system is based on a system of natural waste decay. Complex substances are decomposed by simple bacteria. It turns out water, carbon dioxide, nitrates and other elements. For septic tanks, biological bacteria are used. This is a "dry extract" from natural ingredients.

If active microorganisms are artificially introduced into a septic tank, then the process of decomposition of organic substances can be regulated. There is practically no smell left during chemical reactions.

There are many factors that significantly influence the behavior of microorganisms in the drainage system:

• The presence of organic compounds;
• Temperature range from 4 to 60 degrees;
• Oxygen supply;
• Waste acidity level;
• Lack of toxic substances.

Preparations based on natural bacteria perform a number of tasks:

• Removal of fat and plaque on the walls of the septic tank;
• Dissolving sediment that is deposited at the bottom of the tank;
• Removal of blockages;
• Removing odors;
• No harm to plants after draining the water;
• Do not pollute the soil.

Septic tanks are divided into aerobic and anaerobic. It all depends on the type of microorganisms used.

Aerobic bacteria

Aerobic bacteria are microorganisms that require free oxygen to function. Such bacteria are widely used in many manufacturing industries. They are used to produce enzymes, organic acids, and bio-based antibiotics.

The scheme of work of a septic tank on aerobic bacteria

For deep biological treatment systems, anaerobic bacteria are used. Air is supplied to the septic tank through the compressor, which reacts with the existing drains. There is oxygen in the air. Thanks to it, aerobic bacteria begin to multiply very quickly.

The result is an oxidative reaction, during which carbon dioxide and heat are released. Beneficial bacteria are not removed from the septic tank along with water.

They remain at the bottom of the tank and on its walls. There is a fleecy fabric called textile shields. Bacteria continue to live on them for further work.

Aerobic septic tanks have several advantages:

• The water is highly purified and does not require further processing.
• The sediment that remains at the bottom of the tank (sludge) can be used as fertilizer in the vegetable garden or garden.
• A small amount of sludge is formed.
• During the reaction, no methane is released, so there is no unpleasant odor.
• The septic tank is often cleaned so that a large amount of sludge does not collect.

Anaerobic bacteria are microorganisms whose vital activity is possible even in the absence of oxygen in the environment.

The scheme of the septic tank based on anaerobic bacteria

When wastewater enters the tank, it liquefies. Their volume is getting smaller. A certain amount of sediment falls to the bottom. This is where the interaction of anaerobic bacteria takes place.

In the process of exposure to anaerobic microorganisms, biochemical wastewater treatment occurs.

However, it is noted that this cleaning method has several disadvantages:

• The effluent is cleaned by 60 percent on average. This means that it is necessary to additionally purify the water in the filtration fields;
• Solid sediments may contain substances that are harmful to humans and the environment;
• The reaction produces methane, which creates an unpleasant odor;
• The septic tank must be cleaned frequently as a large amount of sludge is generated.

Combined cleaning method

For a greater degree of wastewater treatment, a combined method is used. This means that aerobic and anaerobic bacteria can be used simultaneously.

Primary cleaning is carried out by means of anaerobic bacteria. Aerobic bacteria complete the wastewater treatment process.

Features of the choice of biological products

In order to choose one or another type of biological product, you need to know what problem will be solved. Today on the market you can find a large number of biological products that are intended for the treatment of wastewater in septic tanks. It should be said right away that there is no need to buy drugs that have inscriptions: unique, special, the latest development, and the like. This is a lie.

All bacteria are living microorganisms, and no one has invented new ones yet, and nature has not generated new species. When a drug is purchased, preference should be given to those brands that have already been tested. This is the only way to get the maximum amount of effect when creating active bacteria in a septic tank. The most common drug is Dr. Robik.

Delivery types

The bacteria are sold in dry or liquid form. You can find both tablets and plastic jars with liquid from 250 milligrams in volume. You can buy a small package in the size of a tea bag.

The amount of biological additive depends on the volume of the septic tank. For example, for one cubic meter of a septic tank, 250 grams of the substance is enough. You can buy the domestic drug Septi Treat. It contains 12 types of microorganisms. The drug can destroy up to 80 percent of the waste in the tank. There is practically no smell. The number of pathogenic microbes decreases.

There is another septic tank cleaner called BIOFORCE Septic. For one cubic meter in a septic tank, 400 milligrams of funds are needed. To maintain the activity of the drug in the septic tank, it is necessary to add 100 grams of the drug every month.

The Septic Comfort biological septic tank cleaner is sold in 12 gram sachets. For the first 4 days, you need to download 1 package. This amount is enough for 4 cubic meters of a septic tank. If the septic tank has a larger volume, then it is necessary to increase the dose to 2 sachets. Thus, 12 or 24 bags of funds are used per month.

Bioactivator cost

The cost of the drug on the market depends on the purpose of the drug. The volume of the package and the degree of efficiency play an important role.

Name	Series	Weight (gram)	Price, rub)
Septic 250	Basic	250	450
Septic 500	Basic	500	650
Septic Comfort	Comfort	672 (12 bags x 56)	1750

The use of biological products in the winter

If it is necessary to preserve the septic tank for the winter, for example, after the end of the summer cottage, then it is worth using drugs that reduce their activity in the cold season and increase in the warm season. An ideal drug for such purposes would be “ UNIBAC-Winter" (Russia).

Mandatory requirements when using bacteria

Aggressive media like chlorine, washing powder, phenol, alkalis have a detrimental effect on aerobic and anaerobic agents.

In order for the septic tank to work effectively, as well as all microorganisms to perform their functions, it is necessary to regularly add biological products to the reservoir or directly to the sewage system at home.

Once every three years, it is necessary to clean the tank, in particular its walls, from blockages and silt. After cleaning, the reservoir must be filled with clean water.

For normal operation of filters, it is necessary to wash them once every six months with a solution of potassium permanganate. However, potassium permanganate can kill a large number of bacteria in the septic tank. After cleaning, it must be borne in mind that a large volume of water can immediately destroy the population of microorganisms. Do not overfill the septic tank.

Recommended rinse the drain pipes with pressurized water to avoid chemical damage to bacteria. It can be concluded that it is best to use biological additives based on natural ingredients. This creates an efficient environment for the processing of faeces in the sewer system.

Before using any type of biological supplement for a septic tank on the site, you should consult with specialists. It should be noted that a properly constructed septic tank can work with a high degree of efficiency and without additional additives.

Today there are a large number of preparations of biological additives that allow not only to speed up the processing of organic waste, but also capable of cleaning the structure as a whole.

It is necessarygive preference only to proven products that will not harm the environment when applied. It is important to follow all instructions for using a particular supplement. Otherwise, it will be impossible to achieve a positive effect when using the drug.

Today there are a large number of products on the market that differ in price and quality. It is best to buy only those that are based on natural ingredients.

In order to carry out the normal maintenance of the septic tank using anaerobic and aerobic bacteria, you need to contact a specialist who will help you choose the best means for your septic tank. Only professionals can advise on the best way to deal with organic waste recycling.

In order for the sewer system to function without failures, it is necessary to take care of its use. There is no need to drain various agents into the sewage system that can harm the microorganisms that process feces in the septic tank. Care must be taken to ensure that no foreign objects, such as rags and other debris, enter the drain.

Anaerobic infection

Etiology, pathogenesis, antibacterial therapy.

Foreword ................................................. ..................................... one

Introduction ................................................. ............................................ 2

1.1 Definition and characteristics .............................................. .... 2

1.2 The composition of the microflora of the main human biotopes ................. 5

2. Factors of pathogenicity of anaerobic microorganisms ......... 6

2.1. The role of anaerobic endogenous microflora in pathology

person ................................................. .................................. ………. 8

3. The main forms of anaerobic infection .................... ... ... ... ...... 10

3.1. Pleuropulmonary infection ................................................ ......….. ten

3.2. Diabetic foot infection .............................................. ... ... ten

3.3. Bacteremia and sepsis ............................................... ................. eleven

3.4. Tetanus................................................. .................................... eleven

3.5. Diarrhea................................................. ......................................... 12

3.6. Surgical infection of wounds and soft tissues ....................... 12

3.7. Gaseous soft tissue infection ............................. 12

3.8. Clostridial myonecrosis ................................................ ... 12

3.9. Slowly developing necrotizing wound infection ... 13

3.10. Intraperitoneal infection ............................... …………… .. 13

3.11. Characteristics of experimental anaerobic abscesses ..... 13

3.12. Pseudomembranous colitis ................................................ ..........14

3.13. Obstetric and gynecological infection ...................................... 14

3.14. Anaerobic infection in cancer patients …………… ..15

4. Laboratory diagnostics .............................................. ................15

4.1. Study material ................................................ .....................15

4.2. Stages of material research in the laboratory .............................. 16

4.3. Direct research of the material ............................................... .......16

4.4. Methods and systems for creating anaerobic conditions ................. 16

4.5. Culture media and cultivation ........................................... 17

5. Antibiotic therapy of anaerobic infection ................................. 21

5.1. Characteristics of the main antimicrobial drugs,

used in the treatment of anaerobic infection .......................... .... 21

5.2. A combination of beta-lactam drugs and inhibitors

beta-lactamase ............................................... .................................... 24

5.3. The clinical significance of determining the sensitivity of anaerobic

microorganisms to antimicrobial drugs ....... ………… ... 24

6. Correction of intestinal microflora ....................... ……………… .26

1. Conclusion ................................................. ......................................... 27
2. Authors …………………………………………………………… .27

Foreword

Recent years have been characterized by the accelerated development of many areas of general and clinical microbiology, which is probably due to both our more adequate understanding of the role of microorganisms in the development of diseases, and the need for doctors to constantly use information about the etiology of diseases, the properties of pathogens with the goal of successful patient management and obtaining satisfactory end results of chemotherapy or chemoprophylaxis. One of such rapidly developing areas of microbiology is clinical anaerobic bacteriology. In many countries of the world, considerable attention is paid to this section of microbiology. Sections dedicated to anaerobes and anaerobic infections are included in the training programs for doctors of various specialties. Unfortunately, in our country, insufficient attention was paid to this section of microbiology both in terms of training specialists and in the diagnostic aspect of the work of bacteriological laboratories. The methodological manual "Anaerobic infection" covers the main sections of this problem - the definition and classification, the characteristics of anaerobic microorganisms, the main biotopes of anaerobes in the body, the characteristics of the forms of anaerobic infection, directions and methods of laboratory diagnostics, as well as complex antibacterial -rapia (antimicrobial drugs, resistance / sensitivity of microorganisms, methods of its determination and overcoming). Naturally, the manual does not aim to provide detailed answers to all aspects of anaerobic infection. It is quite clear that microbiologists wishing to work in the field of anaerobic bacteriology need to go through a special training cycle, to more fully master the issues of microbiology, laboratory technology, methods of indication, cultivation and identification of anaerobes. In addition, good experience is gained by participating in special seminars and symposia dedicated to anaerobic infection, at the national and international levels. These guidelines are addressed to specialists in bacteriology, doctors of various specialties (surgeons, therapists, endocrinologists, obstetrician-gynecologists, pediatricians), students of medical and biological faculties, teachers of medical universities and medical schools.

Introduction

The first ideas about the role of anaerobic microorganisms in human pathology appeared many centuries ago. As early as the 4th century BC, Hippocrates described in detail the tetanus clinic, and in the 4th century AD Xenophon described cases of acute necrotizing ulcerative gingivitis in Greek soldiers. The clinical picture of actinomycosis was described by Langenbeck in 1845. However, at that time it was not clear what microorganisms cause these diseases, what their properties are, just as the concept of anaerobiosis was absent until 1861, when Louis Pasteur published the classic work on the study of Vibrio butyrigue and called organisms living in the absence of air, "anaero-bami" (17). Subsequently, Louis Pasteur (1877) isolated and cultivated Clostridium septicum , and Israel described actinomycetes in 1878. The causative agent of tetanus - Clostridium tetani - identified in 1883 by N.D. Monastirsky, and in 1884 by A. Nicolayer. The first studies of patients with clinical anaerobic infection were carried out by Levy in 1891. The role of anaerobes in the development of various medical pathologies was more fully described and argued for the first time by Veiloon and Zuber in 1893-1898. They described various types of severe infections caused by anaerobic microorganisms (gangrene of the lung, appendicitis, abscesses of the lung, brain, pelvis, meningitis, mastoiditis, chronic otitis media, bacteremia, parametritis, bartholinitis, purulent arthritis). In addition, they have developed many methodological approaches to the isolation and cultivation of anaerobes (14). Thus, by the beginning of the 20th century, many of the anaerobic microorganisms became known, an idea of \u200b\u200btheir clinical significance was formed, and an appropriate technique for the cultivation and isolation of anaerobic microorganisms was created. From the 60s to the present, the urgency of the problem of anaerobic infections continues to grow. This is due to both the etiological role of anaerobic microorganisms in the pathogenesis of diseases, and the development of resistance to widely used antibacterial drugs, as well as the severe course and high mortality of the diseases they cause.

1.1. Definition and characterization

In clinical microbiology, microorganisms are usually classified based on their relationship to atmospheric oxygen and carbon dioxide. This is easy to see when incubating microorganisms on blood agar under various conditions: a) in a normal air environment (21% oxygen); b) under the conditions of a CO 2 incubator (15% oxygen); c) under microaerophilic conditions (5% oxygen) d) anaerobic conditions (0% oxygen). Using this approach, bacteria can be divided into 6 groups: obligate aerobes, microaerophilic aerobes, facultative anaerobes, aerotolerant anaerobes, microaerotolerant anaerobes, obligate anaerobes. This information is useful for the initial identification of both aerobes and anaerobes.

Aerobes... For growth and reproduction, obligate aerobes need an atmosphere containing molecular oxygen in a concentration of 15-21% or CO; incubator. Mycobacteria, Vibrio cholerae and some fungi are examples of obligate aerobes. These microorganisms obtain most of their energy through the breathing process.

Microaerophiles (microaerophilic aerobes). They also need oxygen for reproduction, but in concentrations lower than it is present in the room atmosphere. Gonococci and Campylobacter are examples of microaerophilic bacteria and prefer an atmosphere of about 5% O2.

Microaerophilic anaerobes... Bacteria capable of growing under anaerobic and microaerophilic conditions, but unable to grow in a CO 2 incubator or air.

Anaerobes... Anaerobes are microorganisms that do not need oxygen for life and reproduction. Obligate anaerobes are bacteria that grow only under anaerobic conditions, i.e. in an oxygen-free atmosphere.

Aerotolerant microorganisms... They are able to grow in an atmosphere containing molecular oxygen (air, CO2 incubator), but they grow better under anaerobic conditions.

Optional anaerobes (optional aerobes). Able to survive in the presence or absence of oxygen. Many bacteria secreted from patients are facultative anaerobes (enterobacteria, streptococci, staphylococci).

Capnophils... A number of bacteria that grow better in the presence of increased concentrations of CO 2 are called capnophils, or capnophilic organisms. Bacteroids, fusobacteria, hemoglobinophilic bacteria belong to capnophils, since they grow better in an atmosphere containing 3-5% CO 2 (2,

19,21,26,27,32,36).

The main groups of anaerobic microorganisms are presented in Table 1. (42, 43,44).

TableI. The most significant anaerobic microorganisms

Genus	Views		a brief description of
Bacteroides	IN... fragilis IN... vulgatus IN... distansonis IN... eggerthii		Gram-negative, non-stick-forming spores
Prevotella	P. melaninogenicus P. bivia P. buccalis P. denticola P. intermedia
Porphyromonas	P. asaccharolyticum P. endodontalis P. gingivalis			Gram-negative, non-stick-forming spores
Ctostridium	C. perfringens C. ramosum C. septicum C. novyi C. sporogenes C. sordelii C. tetani C. botulinum C. difficile		Gram-positive, spore-forming rods, or bacilli
Actinomyces	AND... israelii A. bovis
Pseudoramibacter *	P. alactolyticum		Gram-positive, non-spore-forming rods
		E. lentum E. rectale E. limosum	Gram-positive, non-spore-forming rods
Bifidobacterium		B. eriksonii B. adolescentis B. breve	Gram-positive sticks
Propionobacterium		P. acnes P. avidum P. granulosum P. propionica **	Gram positive. non-spore sticks
Lactobacillus		L. catenaforme L. acidophylus	Gram-positive sticks
Peptococcus		P. magnus P. saccharolyticus P. asaccharolyticus
Peptostreptococcus		P. anaerobius P. intermedius P. micros P. productus	Gram-positive, non-spore-forming cocci
Veilonella		V. parvula	Gram-negative, non-spore-forming cocci
Fusobacterium		F. nucleatum F. necrophorum F. varium F. mortiferum	Fusiform sticks
Campilobacter		C. fetus C.jejuni	Gram-negative, thin, coiled, non-spore-forming rods

* Eubacterium alaclolyticum reclassified as Pseudoramibacter alactolyticum (43,44)

** earlier Arachnia propionica (44)

*** synonyms F. pseudonecrophorum, F. necrophorum biovar FROM(42,44)

1.2. The composition of the microflora of the main human biotopes

The etiology of infectious diseases has undergone significant changes in recent decades. As is well known, previously the main danger to human health was acutely infectious infections: typhoid fever, dysentery, salmonellosis, tuberculosis and many others, which were transmitted mainly by exogenous routes. Although these infections still remain socially important and now their medical importance is again increasing, in general, their role has decreased significantly. At the same time, there is an increase in the role of conditionally pathogenic microorganisms, representatives of the normal microflora of the human body. The normal human microflora includes more than 500 types of microorganisms. The normal microflora inhabiting the human body is largely represented by anaerobes (Table 2).

Anaerobic bacteria inhabiting human skin and mucous membranes, carrying out microbial transformation of substrates of exo- and endogenous origin, produce a wide range of various enzymes, toxins, hormones and other biologically active compounds that are absorbed and bind to complementary receptors and affect the function of cells and organs. Knowledge of the composition of specific normal microflora of certain anatomical areas is useful for understanding the etiology of infectious processes. The set of types of microorganisms that populate a specific anatomical region is called indigenous microflora. Moreover, the detection of specific microorganisms in significant numbers at a distance or in an unusual place for habitation only emphasizes their participation in the development of the infectious process (11, 17, 18, 38).

Respiratory tract... The microflora of the upper respiratory tract is very diverse and includes more than 200 species of microorganisms that are part of 21 genera. 90% of salivary bacteria are anaerobic (10, 23). Most of these microorganisms are not classified by modern taxonomic methods and are not essential for pathology. The airways of healthy people are most often colonized by the following microorganisms - Streptococcus pneumonie- 25-70%; H aemophilus influenzae- 25-85%; Streptococcus pyogenes- 5-10%; Neisseria meningitidis- 5-15%. Anaerobic microorganisms such as Fusobacterium, Bacteroides spiralis, Peptostreptococcus, Peptococcus, Veilonella and some types Actinomyces found in almost all healthy people. Coliform bacteria are found in the respiratory tract in 3-10% of healthy people. Increased colonization of the respiratory tract by these microorganisms was found in alcoholics, persons with a severe course of the disease, in patients receiving antibacterial therapy that suppresses the normal microflora, as well as in persons with impaired immune system functions.

Table 2. Quantitative content of microorganisms in biotopes

the human body is normal

Populations of microorganisms in the respiratory tract adapt to specific ecological niches (nose, pharynx, tongue, gingival crevices). The adaptation of microorganisms to these biotopes is determined by the affinity of bacteria to certain types of cells or surfaces, that is, it is determined by cellular or tissue tropism. For instance, Streptococcus salivarius attaches well to the cheek epithelium and dominates the buccal mucosa. Bacterial adhesion

rium can also explain the pathogenesis of some diseases. Streptococcus pyogenes adheres well to the epithelium of the pharynx and often causes pharyngitis, E. coli is affinity to the epithelium of the bladder and therefore causes cystitis.

Leather... The indigenous microflora of the skin is represented by bacteria of mainly the following genera: Staphylococcus, Micrococcus, Corynobacterium, Propionobacterium, Brevibacterium and Acinetobacter. Yeast of the genus is also often present Pityrosporium. Anaerobes are represented largely by gram-positive bacteria of the genus Propi- onobacterium (usually Propionobacterium acnes). Gram-positive cocci (Peptostreptococcus spp.) andgram-positive bacteria of the genus Eubacterium present in some individuals.

Urethra... Bacteria colonizing the distal urethra are staphylococci, non-hemolytic streptococcus, diphtheroids and, in a small number of cases, various representatives of the enterobacteriaceae family. Anaerobes are mostly represented by gram-negative bacteria - Bacteroides andFusobacterium spp..

Vagina.About 50% of the bacteria from the secretions of the cervix and vagina are anaerobic. Most of the anaerobes are lactobacilli and peptostreptococci. Prevotels are often found - P. bivia and P. disiens. In addition, there are gram-positive bacteria of the genus Mobiluncus and Clostridium.

Intestines... Of the 500 species that inhabit the human body, about 300 - 400 species live in the intestines. The largest number in the intestine are found the following anaerobic bacteria - Bacteroides, Bifidobacterium, Clostridium, Eubacterium, Lactobacillus andPeptostrepto- coccus. Bacteroids are the dominant microorganisms. It has been established that one E. coli cell accounts for one thousand bacteroid cells.

2. Factors of pathogenicity of anaerobic microorganisms

The pathogenicity of microorganisms means their potential to cause disease. The emergence of pathogenicity in microbes is associated with the acquisition by them of a number of properties that ensure the ability to attach, penetrate and spread in the host's body, resist its defense mechanisms, and cause damage to vital organs and systems. At the same time, it is known that the virulence of microorganisms is a polydeterminate property, which is fully realized only in the organism of a host sensitive to the pathogen.

Currently, there are several groups of pathogenic factors:

a) adhesins, or attachment factors;

b) factors of adaptation;

c) invasions, or factors of penetration

d) capsule;

e) cytotoxins;

f) endotoxins;

g) exotoxins;

h) enzymes toxins;

i) factors modulating the immune system;

j) superantigens;

k) heat shock proteins (2, 8, 15, 26, 30).

The stages and mechanisms, the spectrum of reactions, interactions and relationships at the molecular, cellular and organismal levels between microorganisms and the host organism are very complex and diverse. The knowledge of the pathogenicity factors of anaerobic microorganisms and their practical use for the prevention of diseases is still insufficient. Table 3 shows the main groups of pathogenicity factors of anaerobic bacteria.

Table 3. Factors of pathogenicity of anaerobic microorganisms

Interaction stage		Factor		Views
Adhesion		Fimbria Capsule Polysaccharides Hemagglutinins
Invasion		Phospholipase C Proteases
Damage fabrics	Exotoxins Hemolysins Proteases Collagenase Fibrinolysin Neuraminidase Heparinase Chondriitin sulfate glucuronidase N-acetyl-glucosaminidase Cytotoxins Enterotoxins Neurotoxins		P. melaninogenica P. melaninogenica
Factors that suppress the immune system	Metabolic products Lipopolysaccharides (O-antigen) Immunoglobulin proteases (G, A, M) С 3 and С 5 convertases Protease a 2 -microglobulin Metabolic products Fatty acids of anaerobes Sulfur compounds Oxidoreductase Beta-lactamase		Most anaerobes
Damage factor activators	Lipopolysaccharides (O-antigen) Surface structures

It has now been established that the pathogenicity factors of anaerobic microorganisms are genetically determined. Chromosomal and plasmid genes, as well as transposons encoding various factors of pathogenicity, have been identified. The study of the functions of these genes, mechanisms and patterns of expression, transmission and circulation in the population of microorganisms is a very important problem.

2.1. The role of anaerobic endogenous microflora in human pathology

Anaerobic microorganisms of normal microflora very often become pathogens of infectious processes localized in various anatomical parts of the body. Table 4 shows the frequency of anaerobic microflora in the development of pathology. (2, 7, 11, 12, 18, 24, 27).

A number of important generalizations regarding the etiology and pathogenesis of most types of anaerobic infection can be formulated: 1) the normal microflora of patients from their own gastrointestinal, respiratory or urogenital tract is the source of anaerobic microorganisms; 2) changes in tissue properties caused by trauma and / or hypoxia provide appropriate conditions for the development of secondary or opportunistic anaerobic infection; 3) anaerobic infections are usually polymicrobial and are often caused by a mixture of several types of anaerobic and aerobic microorganisms, synergistically damaging; 4) the infection is accompanied by the formation and release of a strong odor in about 50% of cases (non-spore-forming anaerobes synthesize volatile fatty acids that cause this odor); 5) the infection is characterized by the formation of gases, tissue necrosis, the development of abscesses and gangrene; 6) the infection develops against the background of treatment with aminoglycoside antibiotics (bacteroids are resistant to them); 7) there is a black staining of the exudate (porphyromonas and prevotella produce dark brown or black pigment); 8) the infection has a protracted, sluggish, often subclinical course; 9), there are extensive necrotic tissue changes, a discrepancy between the severity of clinical symptoms and the volume of destructive changes, bleeding on the cut.

Although anaerobic bacteria can cause serious and fatal infections, the initiation of infection generally depends on the state of the body's defense factors, i.e. functions of the immune system (2, 5, 11). Principles of treatment for such infections include the removal of dead tissue, drainage, restoration of adequate blood circulation, removal of foreign substances, and the use of active antimicrobial therapy appropriate to the pathogen, in an adequate dose and for the required duration.

Table 4. Etiological role of anaerobic microflora

in development diseases

Diseases	Number of examined	Anaerobic excretion rate
Head and neck Non-traumatic head abscesses Chronic sinusitis Perimandibular space infections
Rib cage Aspiration pneumonia Lung abscess
Abdominal cavity Abscesses or peritonitis Appendicitis Liver abscess
Female genital tract Mixed types Pelvic abscesses Inflammatory processes			33 (100%) 22 (88%)
Soft tissue Wound infection Skin abscesses Diabetic limb ulcers Non-clostridial cellulitis
Bacteremia All cultures Intra-abdominal sepsis Septic abortion

3. The main forms of anaerobic infection

3.1. Pleuropulmonary infection

Etiologically significant anaerobic microorganisms in this pathology are representatives of the normal microflora of the oral cavity and upper respiratory tract. They are the causative agents of various infections, including aspiration pneumonia, necrotizing pneumonia, actinomycosis, and pulmonary abscess. The main causative agents of pleuropulmonary diseases are presented in Table 5.

Table 5. Anaerobic bacteria causing

pleuropulmonary infection

Factors that contribute to the development of anaerobic pleuropulmonary infection in a patient include aspiration of normal micro-flora (as a result of loss of consciousness, dysphagia, the presence of mechanical objects, obstruction, poor oral hygiene, necrotic pulmonary tissue) and hematogenous spread of microorganisms. As can be seen from Table 5, aspiration pneumonia is most commonly caused by organisms previously designated as "oral bacteroid" species (currently Prevotella and Porphyromonas species), Fusobacterium and Peptostreptococcus. The spectrum of bacteria isolated from anaerobic empyema and pulmonary abscess is almost the same.

3.2. Diabetic foot infection

Fetid foot is the most common infectious cause of hospitalization among more than 14 million US diabetics. This type of infection is often ignored at the initial stage by the patient, and sometimes it is inadequately treated by doctors. In general, patients do not seek to carefully and regularly examine the lower extremities and do not follow the recommendations of doctors on care and walking regimen. The role of anaerobes in the development of foot infections in diabetics has been established many years ago. The main types of microorganisms that cause this type of infection are presented in table 6.

Table 6. Aerobic and anaerobic microorganisms causing

foot infection in diabetics

Aerobes	Anaerobes
Proteus mirabili	Bacteroides fragilis
Pseudomonas aeruginosa	other species of the B. fragilis group
Enterobacter aerogenes	Prevotella melaninogenica
Escherichia coli	other types of Prevotella \\ Porphyromonas
Klebsiella pneumonia	Fusobacterium nucleatum
	other fusobacteria
	Peptostreptococcus
Staphylococcus aureus	other types of clostridia

It has been established that 18-20% of diabetic patients have mixed aerobic / anaerobic infection. On average, one patient had 3.2 aerobic and 2.6 anaerobic species of microorganisms. Of the anaerobic bacteria, peptostreptococci were dominant. Bacteroids, prevotella, and clostridia were also frequently identified. The association of bacteria was isolated from deep wounds in 78% of cases. Gram-positive aerobic microflora (staphylococci and streptococci) was detected in 25% of patients, and in approximately 25% - gram-negative rod-shaped aerobic microflora. About 50% of anaerobic infections are mixed. These infections are more severe and most often require amputation of the affected limb.

3.3. Bacteremia and sepsis

The share of anaerobic microorganisms in the development of bacteremia ranges from 10 to 25%. Most studies show that IN.fragilis and other types of this group, as well as Bacteroides thetaiotaomicron are the more common cause of bacteremia. Clostridia (especially Clostridium perfringens) and peptostreptococci. They often stand out in pure culture or associations. In recent decades, in many countries of the world, there has been an increase in the frequency of anaerobic sepsis (from 0.67 to 1.25 cases per 1000 hospitalized). The mortality rate of patients with sepsis caused by anaerobic microorganisms is 38-50%.

3.4. Tetanus

Tetanus is a serious and often fatal infection, well known since the time of Hippocrates. For centuries, this disease has been an urgent problem associated with gunshot, burn and traumatic wounds. Controversy Clostridium tetani are detected in human and animal feces and are widespread in the environment. Ramon and colleagues in 1927 successfully proposed toxoid immunization for the prevention of tetanus. The risk of developing tetanus is higher in people over 60 years of age due to a decrease in the effectiveness / loss of protective post-vaccination antitoxic immunity. Therapy includes the administration of immunoglobulins, wound care, antimicrobial and antitoxic therapy, ongoing nursing care, the use of sedatives and analgesics. Special attention is currently being paid to neonatal tetanus.

3.5. Diarrhea

There are a number of anaerobic bacteria that cause diarrhea. Anaerobiospirillum succiniciproducens- motile spiral-shaped bacteria with bipolar flagella. The pathogen is excreted in the feces of dogs and cats in asymptomatic infections, as well as from people with diarrhea. Enterotoxigenic strains IN.fragilis. In 1984, Mayer showed the role of toxin-producing strains IN.fragilis in the pathogenesis of diarrhea. Toxigenic strains of this pathogen are secreted during diarrhea in humans and animals. They cannot be differentiated from common strains by biochemical and serological methods. Experimentally, they cause diarrhea and characteristic damage to the large intestine and distal small intestine with crypt hyperplasia. Enterotoxin has a molecular weight of 19.5 kD and is thermolabile. The pathogenesis, spectrum and incidence of morbidity, as well as the optimal therapy, have not yet been sufficiently developed.

3.6. Surgical anaerobic wound and soft tissue infection

The causative agents of infections isolated from surgical wounds largely depend on the type of surgical intervention. The cause of suppuration during clean surgical interventions that are not accompanied by opening the gastrointestinal, urogenital, or respiratory tract is usually St. aureus. With other types of wound suppuration (purely contaminated, contaminated and dirty), the mixed polymicrobial microflora of surgically resected organs is most often isolated. In recent years, there has been an increase in the role of conditionally pathogenic microflora in the development of such complications. Most superficial wounds are diagnosed at a later date between the eighth and ninth days after surgery. If the infection develops earlier - within the first 48 hours after the operation, then this is typical for gangrenous infection caused by certain species or Clostridium or beta-hemolytic streptococcus. In these casesthere is a dramatic increase in the severity of the disease, pronounced toxicosis, rapid local development of infection with the involvement of all layers of body tissues in the process.

3.7. Gas generating soft tissue infection

The presence of gas in infected tissues is an ominous clinical sign, and in the past, this infection was most often associated by doctors with the presence of pathogens of Clostridial gas gangren. It is now known that gassing infection in surgical patients is caused by a mixture of anaerobic microorganisms such as Clostridium, Peptostreptococcus or Bacteroides, or one of the aerobic coliform bacteria. The predisposing factors for the development of this form of infection are vascular diseases of the lower extremities, diabetes, trauma.

3.8. Clostridial myonecrosis

Gas gangrene is a destructive process of muscle tissue associated with local crepitus, pronounced systemic intoxication caused by anaerobic gas-forming Clostridia Clostridia are gram-positive obligate anaerobes that are widespread in soil contaminated with animal excreta. In humans, they are normally inhabitants of the gastrointestinal and female genital tract. Sometimes they can be found on the skin and in the mouth. The most significant of the 60 known species is Clostridium perfringens. This microorganism is more tolerant to atmospheric oxygen and is fast-growing. He is an alpha-toxin, phospholipase C (lecithinase), which breaks down lecithin into phosphorylcholine and diglycerides, as well as collagenase and proteases, which cause tissue destruction. Alpha-toxin production is associated with high mortality in gas gangrene. It has hemolytic properties, destroys platelets, causes intense damage to capillaries and secondary tissue destruction. In 80% of cases, myonecrosis is caused by FROM.perfringens. In addition, the etiology of this disease is involved FROM.novyi, FROM. septicum, FROM.bifer- mentas. Other types of clostridia C. histoliticum, FROM.sporogenes, FROM.fallax, FROM.tertium are of low etiological significance.

3.9. Slowly developing necrotizing wound infection

Aggressive life-threatening wound infection May appear 2 weeks after infection, especially in diabetic

sick. Usually these are either mixed or monomicrobial fascial infections. Monomicrobial infections are relatively rare. in about 10% of cases and is usually seen in children. The causative agents are group A streptococci, Staphylococcus aureus and anaerobic streptococci (peptostreptococci). Staphylococci and hemolytic streptococcus are secreted with the same frequency in about 30% of patients. Most of them become infected outside the hospital. Most adults have necrotizing fasciillitis of the extremities (in 2/3 of cases, the extremities are affected). In children, the trunk and groin are more commonly involved. Polymicrobial infection involves a number of processes caused by anaerobic microflora. On average, about 5 main types are distinguished from wounds. The mortality rate in such diseases remains high (about 50% among patients with severe forms). Older people generally have a poor prognosis. Mortality in persons over 50 is more than 50%, and in diabetic patients - more than 80%.

3.10. Intraperitoneal infection

Intra-abdominal infections are the most difficult for early diagnosis and effective treatment. A successful outcome primarily depends on early diagnosis, prompt and adequate surgical intervention, and the use of an effective antimicrobial regimen. The polymicrobial nature of the bacterial microflora involved in the development of peritonitis, as a result of perforation in acute appendicitis, was first shown in 1938. Altemeier. The number of aerobic and anaerobic microorganisms isolated from areas of intra-abdominal sepsis depends on the nature of microflora or injured organ. The generalized data indicate that the average number of bacterial species isolated from the focus of infection ranges from 2.5 to 5. For aerobic microorganisms, these data are 1.4-2.0 species and 2.4-3.0 species of anaerobic microorganisms. At least 1 type of anaerobes is detected in 65-94% of patients. Of aerobic microorganisms, Escherichia coli, Klebsiella, streptococci, Proteus, Enterobacter are most often detected, and of anaerobic microorganisms - bacteroids, peptostreptococci, and clostridia. Bacteroids account for from 30% to 60% of all isolated strains of anaerobic microorganisms. According to the results of numerous studies, 15% of infections are caused by anaerobic and 10% aerobic microflora, and, accordingly, 75% are caused by associations. The most significant of them are E.coli and IN.fragilis. According to Bogomolova N.S. and Bolshakov L.V. (1996), anaerobic infection

was the cause of the development of odontogenic diseases in 72.2% of cases, appendicular peritonitis - in 62.92% of cases, peritonitis due to hynecological diseases - in 45.45% of patients, cholangitis - in 70.2%. Anaerobic microflora was most often excreted in severe peritonitis in the toxic and terminal stages of the disease.

3.11. Characterization of experimental anaerobic abscesses

In experiment IN.fragilis initiates the development of a subcutaneous abscess. The initial events are the migration of polymorphonuclear leukocytes and the development of tissue edema. After 6 days, 3 zones are clearly identified: internal - consists of necrotic masses and degeneratively changed inflammatory cells and bacteria; middle - formed from a leukocyte shaft and the outer zone is represented by a layer of collagen and fibrous tissue. The concentration of bacteria ranges from 10 8 to 10 9 in 1 ml of pus. An abscess is characterized by a low redox potential. It is very difficult to treat it, since the destruction of antimicrobial drugs by bacteria, as well as evasion of the host's defense factors, is observed.

3.12. Pseudomembranous colitis

Pseudomembranous colitis (MVC) is a serious gastrointestinal disorder characterized by exudative plaques on the colon mucosa. This disease was first described in 1893, long before the advent of antimicrobial drugs and their use for medicinal purposes. It has now been established that the etiological factor of this disease is Clostridium difficile. Violation of intestinal microecology due to the use of antibiotics is the reason for the development of MVP and the wide spread of infections caused by FROM.difficile, the clinical spectrum of manifestations of which varies widely - from carriage and short-term, self-passing diarrhea to the development of MVP. The number of patients with colitis caused by S. difficile, among outpatients 1-3 per 100,000, and among hospitalized patients 1 per 100-1000.

Pathogenesis.Colonization of the human intestine with toxigenic strains FROM,difficile is an important factor in the development of MVP. However, asymptomatic carriage occurs in approximately 3-6% of adults and 14-15% of children. The normal intestinal microflora serves as a reliable barrier against colonization by pathogenic microorganisms. It is easily disturbed by antibiotics and very difficult to recover. The most pronounced effect on the anaerobic microflora is possessed by the third generation cephalosporins, clindamycin (lincomycin group) and ampicillin. As a rule, all patients with MVP suffer from diarrhea. In this case, the stool is liquid with admixtures of blood and mucus. There is hyperemia and swelling of the intestinal mucosa. Ulcerative colitis or proctitis is often noted, characterized by granulations, hemorrhagic mucosa. Most patients with this disease have fever, leukocytosis, and abdominal tension. Subsequently, serious complications may develop, including general and local intoxication, hypoalbuminemia. Symptoms of antibiotic-associated diarrhea begin on days 4-5 of antibiotic therapy. In the stool of such patients, C. difficile in 94% of cases, while in healthy adults this microorganism is excreted only in 0.3% of cases.

FROM.difficile produces two types of highly active exotoxins - A and B. Toxin A is an enterotoxin, causes hypersecretion and accumulation of fluid in the intestine, as well as an inflammatory reaction with hemorrhagic syndrome. Toxin B is a cytotoxin. It is neutralized by polyvalent antigangrenous serum. This cytotoxin was found in approximately 50% of patients with antibiotic-associated colitis without pseudomembrane formation and in 15% of patients with antibiotic-associated diarrhea with normal sigmoidoscopic findings. Its cytotoxic action is based on the depolymerization of microfilament actin and damage to the cytoskeleton of enterocytes. Recently, more and more data on FROM.difficile as an intra-hospital infectious agent. In this regard, it is advisable to isolate patients with a surgical profile, carriers of this microorganism, in order to avoid the spread of infection in the hospital. FROM.difficile most sensitive to vancomycin, metronidazole and bacitracin. Thus, these observations confirm that the toxin-producing strains FROM.difficile cause a wide range of diseases, including diarrhea, colitis, and MVP.

3.13. Obstetric and gynecological infections

Understanding the patterns of development of infections of female genital organs is possible on the basis of an in-depth study of the microbiocenosis of the vagina. The normal microflora of the vagina must be considered in terms of a protective barrier against the most common pathogens.

Dysbiotic processes contribute to the formation of bacterial vaginosis (BV). BV is associated with the development of such complications as anaerobic postoperative soft tissue infections, postpartum and post-abortion endometritis, premature termination of pregnancy, and intra-amniotic infection (10). Obstetric and gynecological infection is polymicrobial in nature. First of all, I would like to note the increasing role of anaerobes in the development of acute inflammatory processes of the pelvic organs - acute inflammation of the uterine appendages, postpartum endometritis, especially after surgical delivery, postoperative complications in gynecology (pericultitis, abscesses, wound infection) (5 ). The microorganisms most often isolated during infections of the female genital tract include Bactemides fragilis, as well as types Peptococcus and Peptostreptococcus. Group A streptococci are not often found in pelvic infections. Group B streptococci more often cause sepsis in obstetric patients, the entrance gate of which is the genital tract. In recent years, with obstetric and gynecological infections, FROM.trachomatis. The most common infectious processes in the urogenital tract include pelvioperitonitis, endometritis after cesarean section, vaginal cuff infections after hysterectomy, and pelvic infections after septic abortion. The effectiveness of clindamycin for these infections ranges from 87% to 100% (10).

3.14. Anaerobic infection in cancer patients

The risk of developing an infection in cancer patients is incomparably higher than in other surgical patients. This feature is explained by a number of factors - the severity of the underlying disease, immunodeficiency state, a large number of invasive diagnostic and therapeutic procedures, a large volume and traumatism of surgical interventions, the use of very aggressive methods of treatment - radio and chemotherapy. In patients operated on for tumors of the gastrointestinal tract, in the postoperative period, subphrenic, subhepatic and intraperitoneal abscesses of anaerobic etiology develop. Among pathogens dominated by Bacteroides fragi- lis, Prevotella spp.. Fusobacterium spp., gram-positive cocci. In recent years, there have been more and more reports on the important role of non-sporogenic anaerobes in the development of septic conditions and on their isolation from the blood during bacteremia (3).

4. Laboratory diagnostics

4.1. Study material

Laboratory diagnosis of anaerobic infection is a rather difficult task. The research time from the moment the pathological material is delivered from the clinic to the microbiological laboratory and until the full detailed answer is received is from 7 to 10 days, which cannot satisfy clinicians. Often, the result of bacteriological analysis becomes known by the time the patient is discharged. Initially, the question should be answered: are there anaerobes in the material? It is important to remember that anaerobes are the main constituent of the local microflora of the skin and mucous membranes, and moreover, that their isolation and identification must be carried out under appropriate conditions. The successful start of research in the clinical microbiology of anaerobic infection depends on the correct collection of appropriate clinical material.

In normal laboratory practice, the following materials are most often used: 1) infected lesions from the gastrointestinal tract or female genital tract; 2) material from the abdominal cavity with peritonitis and abscesses; 3) blood from septic patients; 4) discharge in chronic inflammatory diseases of the respiratory tract (sinusitis, otitis media, mastoiditis); 5) material from the lower parts of the respiratory tract with aspiration pneumonia; 6) cerebrospinal fluid with meningitis; 7) the contents of the brain abscess; 8) local material for dental diseases; 9) contents of superficial abscesses; 10) contents of superficial wounds; 11) material of infected wounds (surgical and traumatic); 12) biopsies (19, 21, 29, 31, 32, 36, 38).

4.2. Stages of material research in the laboratory

Successful diagnosis and treatment of anaerobic infection is possible only with the interested cooperation of microbiologists and clinicians of the relevant profile. Obtaining adequate sample samples for microbiological examination is critical. The methods of taking the material depend on the location and type of the pathological process. Laboratory research is based on the indication and subsequent species identification of anaerobic and aerobic microorganisms contained in the test material using traditional and express methods, as well as on the determination of the sensitivity of isolated microorganisms to antimicrobial chemotherapeutic drugs (2).

4.3. Direct material research

There are many quick direct tests that strongly indicate the presence of anaerobes in large quantities in the test material. Some of them are very simple and cheap and therefore have advantages over many expensive laboratory tests.

1.3 a p a x. Fetid materials always contain anaerobes, only a few of them are odorless.

2. Gas-liquid chromatography (GLC). Refers to the number of express diagnostic methods. GLC allows the determination of short-chain fatty acids (acetic, propionic, isovaleric, isocaproic, nylon) in the pus, which cause the smell. With the help of GLC according to the spectrum of volatile fatty acids, it is possible to carry out the species identification of the microorganisms present in it.

3. Fluorescence. Examination of materials (pus, tissue) in ultraviolet light at a wavelength of 365 nm reveals intense red fluorescence, which is explained by the presence of black-pigmented bacteria belonging to the Vasteroides and Porphyromonas groups, and which indicates the presence of anaerobes.

4. Bacterioscopy. In the study of many preparations stained by the Gram method, the presence of cells of the inflammatory focus, microorganisms, especially polymorphic gram-negative rods, small gram-positive cocci or gram-positive bacilli is revealed in the smear.

5. Immunofluorescence. Direct and indirect immunofluorescence are express methods and allow to identify anaerobic microorganisms in the test material.

6. Immunoassay method. Immunoassay analysis allows to determine the presence of structural antigens or exotoxins of anaerobic microorganisms.

7. Molecular biological methods. Polymerase chain reaction (PCR) has shown the greatest distribution, sensitivity and specificity in recent years. It is used both for detecting bacteria directly in the material and for identification.

4.4. Methods and systems for creating anaerobic conditions

Material collected from appropriate sources and in suitable containers or transport media must be delivered promptly to the laboratory. However, there is evidence that clinically significant anaerobes in large volumes of pus or in an anaerobic transport environment survive for 24 hours. It is important that the medium in which the inoculation was carried out was incubated under anaerobic conditions or was placed in a vessel filled with CO2 and kept until the moment of transfer to a special incubation system. There are three types of anaerobic systems commonly used in clinical laboratories. More widely used microanerostatic systems of the type (GasPark, BBL, Cockeysville), which have been used in laboratories for many years, especially in small laboratories, and provide satisfactory results. Petri dishes with inoculation of anaerobic bacteria are placed inside the vessel simultaneously with a special gas generating package and an indicator. Water is added to the bag, the vessel is hermetically sealed, CO2 and H2 are released from the bag in the presence of a catalyst (usually palladium). In the presence of a catalyst, H2 reacts with O2 to form water. CO2 is essential for the growth of anaerobes as they are capnophils. Methylene blue is added as an indicator of anaerobic conditions. If the gas generating system and catalyst work efficiently, the indicator will become discolored. For most anaerobes, cultivation is required for at least 48 hours. After that, the chamber is opened and the cups are examined for the first time, which seems to be not entirely convenient, since anaerobes are sensitive to oxygen and quickly lose their viability.

Recently, simpler anaerobic systems - anaerobic sacs - have come into practice. In a transparent, hermetically sealed polyethylene bag, place one or two inoculated dishes with a gas-generating bag and incubate under a thermostat. The transparency of the polyethylene bags makes it easy to periodically monitor the growth of microorganisms.

The third system for the cultivation of anaerobic microorganisms is an automatically sealed chamber with a glass front wall (anaerobic station) with rubber gloves and an automatic supply of an oxygen-free mixture of gases (N2, H2, CO2). Materials, cups, test tubes, plates for biochemical identification and antibiotic susceptibility testing will be placed in this room through a special hatch. All manipulations are performed by a bacteriologist wearing rubber gloves. Material and plates in this system can be viewed daily, and inoculations can be incubated for 7-10 days.

These three systems have their advantages and disadvantages, but they are effective for the isolation of anaerobes and should be in every bacteriological laboratory. They are often used simultaneously, although the most reliable method belongs to the cultivation method in an anaerobic station.

4.5. Culture media and cultivation

The study of anaerobic microorganisms is carried out in several stages. The general scheme for the isolation and identification of anaerobes is shown in Figure 1.

An important factor in the development of anaerobic bacteriology is the availability of a collection of typical bacterial strains, including reference strains from the ATCC, CDC, VPI collections. This is especially important for the control of nutrient media, for the biochemical identification of pure cultures and the assessment of the activity of antibacterial drugs. There is a wide variety of basic media that are used to prepare specific culture media for anaerobes.

Nutrient media for anaerobes must meet the following basic requirements: 1) satisfy nutritional requirements; 2) ensure the rapid growth of microorganisms; 3) be adequately reduced. Primary inoculation of the material is carried out on blood agar plates or elective media, shown in Table 7.

Increasingly, the isolation of obligate anaerobes from clinical material is carried out on media that include selective agents at a certain concentration, which make it possible to isolate certain groups of anaerobes (20, 23) (Table 8).

The duration of incubation and the frequency of examination of inoculated dishes depends on the test material and the composition of the microflora (table 9).

Study material Detachable wounds Content of abscesses, Tracheobronchonal aspirate, etc. Transport to the laboratory: in cypress, in a special transport environment (immediate placement of material on Wednesday) Material microscopy Gram stain

Cultivation and isolation pure culture Aerobic cups for 35 ± 2 ° C comparison with 18 - 28 hours anaerobes 5-10% C0 2 1. Blood agarMicroaerostat Gaz-Pak (H 2 + C0 2) 35 ± 2 ° C from 48 hours to 7 days 2. Schedler's Blood Agar 35 ± 2 ° C from 48 hours to 7 days 3. Selective medium for identification anaerobes from 48 hours to 2 weeks 4. Liquid medium (thioglycolic)

Identification. Pure cultures from isolated colonies 1.Staining according to Gram and Ozheshko to identify spores 2.Morphology of colonies 3 colony type association with oxygen 4.Preliminary differentiation by sensitivity to antimicrobial drugs 5 biochemical tests Determination of antibiotic susceptibility 1. Method of dilution in agar or broth 2.Paper disk method (diffusion)

Figure: 1. Isolation and identification of anaerobic microorganisms

anaerobic microorganisms

Wednesday	Appointment
Brucella Blood Agar (CDC Anaerobic Blood Agar, Schadler Blood Agar) (BRU agar)	Non-selective, for the isolation of anaerobes present in the material
Bacteroid Bile Esculin Agar (BBE agar)	Selective and differential; for the isolation of bacteria of the Bacteroides fragilis group
Kanamycin Vancomycin Blood Agar (KVLB)	Selective for most non-spore-forming gram-negative bacteria
Phenyl Ethyl Agar (PEA)	Inhibits the growth of Proteus and other enterobacteria; stimulates the growth of gram-positive and gram-negative anaerobes
Thioglycolic broth (THIO)	For special situations
Yolk agar (EYA)	To isolate clostridia
Cycloserine Cefoxitin Fructose Agar (CCFA) or Cycloserinemannite Agar (CMA) or Cycloserinemannite Blood Agar (CMBA)	Selective for C. difficile
Crystal Violet Erythromycin Agar (SVEV)	For the isolation of Fusobacterium nucleatum and Leptotrichia buccalis
Bacteroid gingivalis agar(BGA)	For the isolation of Porphyromonas gingivalis

Table 8. Selective agents for obligate anaerobes

Organisms	Selective agents
Obligate anaerobes from clinical material	neomycin (70mg / l) nalidixic acid (10 mg / l)
Actinomyces spp.	metronidazole (5 mg / l)
Bacteroides spp. Fusobacterium spp.	nalidixic acid (10 mg / l) + vancomycin (2.5 mg / l)
Bacteroides urealytica	nalidixic acid (10 mg / l) teicoplanin (20 mg / l)
Clostridium difficile	cycloserine (250 mg / l) cefoxitin (8 mg / l)
Fusobacterium	rifampicin (50 mg / l) neomycin (100 mg / l) vancomycin (5mg / l)

The results are taken into account by describing the cultural properties of grown microorganisms, colony pigmentation, fluorescence, hemolysis. Then a smear is prepared from the colonies, stained according to Gram and thus gram-negative and gram-positive bacteria are identified, microscopic and describe the morphological properties. Subsequently, microorganisms of each type of colonies are subcultured and cultivated in thioglycol broth with the addition of hemin and vitamin K. The morphology of the colonies, the presence of pigment, hemolytic properties and the characteristics of bacteria during Gram staining allow preliminary identification and differentiation of anaerobes. As a result, all anaerobic microorganisms can be divided into 4 groups: 1) Gr + cocci; 2) Gr + bacilli or coccobacilli: 3) Gr - cocci; 4) Gr - bacilli or coccobacilli (20, 22, 32).

Table 9. Duration of incubation and frequency of research

crops of anaerobic bacteria

Type of crops	Incubation time *	Research frequency
Blood		Daily until 7th and after 14th
Liquids		Daily
Abscesses, wounds		Daily
Airways Sputum Transtracheal aspirate Bronchial discharge		Daily Once Daily Daily
Urogenital tract Vagina, uterus Prostate		Daily Daily Daily Once
Feces		Daily
Anaerobes Brucella Actinomycetes		Daily 3 times a week Once a week

* until negative result

At the third stage of research, a longer identification is carried out. The final identification is based on the determination of biochemical properties, physiological and genetic characteristics, pathogenicity factors in the toxin neutralization test. Although the completeness of the identification of anaerobes can vary significantly, some simple tests with a high probability allow the identification of pure cultures of anaerobic bacteria - Gram stain, motility, determination of sensitivity to some antibiotics using paper discs and biochemical properties.

5. Antibacterial therapy of anaerobic infection

Antibiotic-resistant strains of microorganisms emerged and began to spread immediately after the widespread introduction of antibiotics into clinical practice. The mechanisms of the formation of resistance of microorganisms to antibiotics are complex and diverse. They are classified into primary and acquired. The acquired resistance is formed under the influence of drugs. The main ways of its formation are the following: a) inactivation and modification of the drug by the enzyme systems of bacteria and its conversion into an inactive form; b) a decrease in the permeability of the surface structures of the bacterial cell; c) violation of the mechanisms of transport into the cell; d) change in the functional significance of the target for the drug. The mechanisms of acquired resistance of microorganisms are associated with changes at the genetic level: 1) mutations; 2) genetic recombinations. Mechanisms of intra and interspecies transmission of extrachromosomal heredity factors - plasmids and transposons, which control the resistance of microorganisms to antibiotics and other chemotherapeutic drugs - play an extremely important role (13, 20, 23, 33, 39). Information on the antibiotic resistance of anaerobic microorganisms is obtained from both epidemiological and genetic / molecular studies. Epidemiological data indicate that since about 1977 there has been an increase in the resistance of anaerobic bacteria to several antibiotics: tetracycline, erythromycin, penicillin, ampicillin, amoxicillin, ticarcillin, imipenem, metronidazole, chloramphenicol, etc. Approximately 50% of bacteroids are resistant to penicillin. and tetracycline.

When prescribing antibacterial therapy for mixed aerobic-anaerobic infection, it is necessary to answer a number of questions: a) where is the infection localized ?; b) what microorganisms most often cause infections in this area ?; c) what is the severity of the disease?; d) what are the clinical indications for the use of antibiotics ?; e) what is the safety of this antibiotic ?; f) what is its cost ?; g) what is its antibacterial characteristic?; h) what is the average duration of drug use to achieve cure ?; i) does it penetrate the blood-brain barrier ?; j) how does it affect the normal microflora?; k) Do you need additional antimicrobial drugs to treat this process?

5.1. Characteristics of the main antimicrobial drugs used in the treatment of anaerobic infection

P e n and c l l n s... Historically, penicillin G has been widely used to treat mixed infections. However, anaerobes, especially bacteria of the Bacteroides fragilis group, have the ability to produce beta-lactamase and destroy penicillin, which reduces its therapeutic efficacy. It has low to moderate toxicity, little effect on normal microflora, but has little activity against beta-lactamase-producing anaerobes, in addition, it has limitations for aerobic microorganisms. Semisynthetic penicillins (naflacin, oxacillin, cloxacillin, and dicloxacillin) are less active and inadequate for the treatment of anaerobic infection. A comparative randomized study of the clinical efficacy of penicillin and clindamycin for the treatment of pulmonary abscesses showed that the use of clindamycin in patients reduced the period of fever and sputum production to 4.4 versus 7.6 days and to 4.2 versus 8 days, respectively. On average, 8 (53%) of 15 patients treated with penicillin were cured, while with clindamycin treatment, all 13 patients (100%) were cured. Clindamycin is more effective than penicillin in the treatment of patients with anaerobic pulmonary abscess. On average, the effectiveness of penicillin was about 50-55%, and clindamycin was 94-95%. At the same time, the presence of microorganisms resistant to penicillin in the material was noted, which caused a frequent reason for the ineffectiveness of penicillin and at the same time showed that clindamycin is the drug of choice for therapy at the beginning of treatment.

T e t r and c and l and s. Tetracyclines are also characterized by low

some toxicity and minimal effect on the normal micro-flora. Tetracyclines were previously also the drugs of choice, since almost all anaerobes were sensitive to them, but since 1955, there has been an increase in resistance to them. Doxycycline and monocycline are the more active of these, but a significant number of anaerobes are also resistant to them.

Chlo ramphenik about l. Chloramphenicol has a significant effect on normal microflora. This drug is extremely effective against bacteria of the B. fragilis group, it penetrates well into body fluids and tissues, has an average activity against other anaerobes. In this regard, it has been used as the drug of choice for the treatment of life-threatening diseases, especially those involving the central nervous system, as it easily penetrates the blood-brain barrier. Unfortunately, chloramphenicol has several disadvantages (dose-dependent inhibition of hematopoiesis). In addition, it can cause idiosencratic, dose-independent aplastic anemia. Some strains of C. perfringens and B. fragilis are capable of reducing the p-nitro group of chloramphenicol and selectively inactivating it. Some strains of B. fragilis are highly resistant to chloramphenicol, as they produce acetyltransferase. At present, the use of chloramphenicol for the treatment of anaerobic infection has significantly decreased due to both the fear of developing hematological side effects and the emergence of many new, effective drugs.

K l and d and m and c and n... Clindamycin is a 7 (S) -chloro-7-deoxy derivative of lincomycin. Chemical modification of the lincomycin molecule led to the emergence of several advantages: better absorption from the gastrointestinal tract, an eight-fold increase in activity against aerobic gram-positive cocci, broadening the spectrum of activity against many gram-positive and gram-negative anaerobic bacteria, as well as protozoa (toxoplasma and plasmodia). Therapeutic indications for the use of clindamycin are quite broad (Table 10).

Gram-positive bacteria. The growth of more than 90% of S. aureus strains is inhibited in the presence of clindamycin at a concentration of 0.1 μg / ml. At concentrations that can readily be achieved in serum, clindamycin is active against Str. pyogenes, Str. pneumonie, Str. viridans. Most strains of diphtheria bacillus are also sensitive to clindamycin. In relation to gram-negative aerobic bacteria Klebsiella, Escherichia coli, Proteus, Enterobacter, Shigella, Serrata, Pseudomonas, this antibiotic is inactive. Gram-positive anaerobic cocci, including all types of peptococci, peptostreptococci, as well as propionobacteria, bifidumbacteria and lactobacilli, are generally highly sensitive to clindamycin. Clinically significant clostridia - C. perfringens, C. tetani, as well as other clostridia often found in intraperitoneal and pelvic infections are sensitive to it.

Table 10. Indications for the use of clindamycin

Biotope	Disease
Upper respiratory tract	Tonsillitis, pharyngitis, sinusitis, otitis media of the middle ear, scarlet fever
Lower respiratory tract	Bronchitis, pneumonia, empyema, lung abscess
Skin and soft tissues	Pyoderma, boils, cellulitis, impetigo, abscesses, wounds
Bones and joints	Osteomyelitis, septic arthritis
Pelvic organs	Endometritis, cellulitis, vaginal cuff infections, tubo-ovarian abscesses
Oral cavity	Periodontal abscess, periodonitis
Septicemia, endocarditis

Gram-negative anaerobes - bacteroids, fusobacteria and veilonella - are highly sensitive to clindamycin. It is well distributed in many tissues and biological fluids, so that in most of them significant therapeutic concentrations are achieved, but it does not penetrate the blood-brain barrier. Of particular interest are the concentration of the drug in the tonsils, lung tissue, appendix, fallopian tubes, muscles, skin, bones, synovial fluid. Clindamycin is concentrated in neutrophils and macrophages. Alveolar macrophages concentrate clindamycin intracellularly (30 minutes after administration, the concentration exceeds the extracellular concentration by 50 times). It increases the phagocytic activity of neutrophils and macrophages, stimulates chemotaxis, and suppresses the production of certain bacterial toxins.

Metron and daz about l. This chemotherapeutic drug is characterized by a very low toxicity, is bactericidal against anaerobes, and is not inactivated by beta-lactamases of bacteroids. Bacteroids are highly sensitive to it, however, certain anaerobic cocci and anaerobic gram-positive bacilli can be resistant. Metronidazole is inactive in relation to aerobic microflora and in the treatment of intra-abdominal sepsis, it must be combined with gentamicin or some aminoglycosides. May cause transient neutropenia. The metronidazole-gentamicin and clindamycin-gentamicin combinations do not differ in their effectiveness in the treatment of serious intra-abdominal infections.

C e f o c s and t in. This antibiotic belongs to cephalosporins, has low and medium toxicity and, as a rule, is not inactivated by the beta-lactamase of bacteroids. Although there is information about cases of isolation of resistant strains of anaerobic bacteria, due to the presence of antibiotic-binding proteins that reduce the transport of the drug into the bacterial cell. The resistance of bacteria of the B. fragilis group to cefoxitin ranges from 2 to 13%. It is recommended for the treatment of moderate abdominal infections.

C e phot e t n... This drug is more active against gram-negative anaerobic microorganisms in comparison with cefoxitin. However, it has been found that approximately 8% to 25% of B. fragilis strains are resistant to it. It is effective in the treatment of gynecological and abdominal infections (abscesses, appendicitis).

C e f m e t z o l... It is similar in its spectrum of action to cefoxitin and cefotetan (more active than cefoxitin, but less active than cefotetan). Can be used to treat mild to moderate infections.

C e f a p e r z o n... It is characterized by low toxicity, higher activity in comparison with the three above-mentioned drugs, but from 15 to 28% of resistant strains of anaerobic bacteria have been identified. It is clearly not the drug of choice for the treatment of anaerobic infection.

C e f t i z o k s i m... It is a safe and effective drug in the treatment of leg infections in diabetic patients, traumatic peritonitis, appendicitis.

M ero p e m... Meropenem, a new carbapenem that is methylated at position 1, is characterized by resistance to the action of renal dehydrogenase 1, which destroys it. It is approximately 2-4 times more active than imipenem against aerobic gram-negative organisms, including representatives of enterobacteria, hemophilus, pseudomonas, neisseria, but has a slightly lower activity against staphylococci, some streptococci and enterococci. Its activity against gram-positive anaerobic bacteria is similar to that of imipenem.

5.2. Combinations of beta-lactam drugs and beta-lactamase inhibitors

The development of beta-lactamase inhibitors (clavulanate, sulbactam, tazobactam) is a promising area and allows the use of new beta-lactam agents protected from hydrolysis when administered simultaneously: a) amoxicillin - clavulanic acid - has a wider spectrum of antimicrobial activity than amoxicillin alone and in terms of effectiveness it is close to a combination of antibiotics - penicillin-cloxacillin; b) ticarcillin-clavulanic acid - expands the spectrum of antimicrobial activity of the antibiotic against beta-lacgamase-producing bacteria, such as staphylococci, hemophilus, Klebsiella and anaerobes, including bacteroids. The minimum inhibitory concentration of such a mixture was 16 times lower than that of ticarcillin; c) ampicillin-sulbactam - when combined in a 1: 2 ratio, their spectrum expands significantly and includes staphylococci, hemophilus, Klebsiella and most anaerobic bacteria. Only 1% of bacteroids are resistant to this combination; d) cefaperazone-sulbactam - in a 1: 2 ratio also significantly expands the spectrum of antibacterial activity; e) piperacillin-tazobactam. Tazobactam is a new beta-lactam inhibitor that acts on many beta-lactamases. It is more stable than clavulanic acid. This combination can be considered as a drug for empirical monotherapy for severe polymicrobial infections such as pneumonia, intra-abdominal sepsis, necrotic soft tissue infection, gynecological infections; f) imipenem-cilastatin - imipenem is a member of a new class of antibiotics known as carbapenems. It is used in combination with cilastatin in a 1: 1 ratio. Their efficacy is similar to clindamycin-aminoglycosides in the treatment of mixed anaerobic surgical infection.

5.3. The clinical significance of determining the sensitivity of anaerobic microorganisms to antimicrobial drugs

The growth of resistance of many anaerobic bacteria to antimicrobial agents raises the question of how and when the determination of sensitivity to antibiotics is justified. The cost of this testing and the time it takes to get the final result further increases the importance of this issue. It is clear that the initial therapy for anaerobic and mixed infection must be empirical. It is based on the specific nature of infections and a certain spectrum of bacterial microflora in this infection. The pathophysiological condition and previous use of antimicrobial agents that may have modified the normal microflora and microflora of the focus must be taken into account, as well as the results of Gram staining. The next step should be early identification of the dominant microflora. Information about the spectrum of species antibacterial sensitivity of the dominant microflora. Information about the spectrum of species antibacterial sensitivity of the dominant micro-flora will allow assessing the adequacy of the initially selected treatment regimen. In treatment, if the course of infection is unfavorable, it is necessary to use the determination of the sensitivity of a pure culture to antibiotics. In 1988, an ad hoc working group on anaerobes reviewed recommendations and indications for determining the antibiotic susceptibility of anaerobes.

Determination of the sensitivity of anaerobes is recommended in the following cases: a) the need to establish changes in the sensitivity of anaerobes to certain drugs; b) the need to determine the spectrum of activity of new drugs; c) in cases of providing bacteriological monitoring of an individual patient. In addition, certain clinical situations may also dictate the need for its implementation: 1) in the case of an unsuccessfully chosen initial antimicrobial regimen and persistence of infection; 2) when the choice of an effective antimicrobial drug plays a key role in the outcome of the disease; .3) when the choice of the drug in this particular case is difficult.

It should be borne in mind that from the clinical point of view, there are other points: a) increasing the resistance of anaerobic bacteria to antimicrobial drugs is a big clinical problem; b) there is disagreement among clinicians about the clinical efficacy of some drugs against anaerobic infection; c) there are discrepancies in the results of the sensitivity of microorganisms to drugs in vitro and their effectiveness in vivo; r) interpretations of results that are acceptable to aerobes may not always be applicable to anaerobes. Monitoring the sensitivity / resistance of 1200 strains of bacteria isolated from different biotopes showed that a significant part of them are highly resistant to the most widely used drugs (Table 11).

Table 11. Resistance of anaerobic bacteria to

widely used antibiotics

Bacteria	Antibiotics		Percentage of resistant forms
Peptostreptococcus	Penicillin Erythromycin Clindamycin
Clostridium perfringens	Penicillin Cefoxitin Metronidazole Erythromycin Clindamycin
Bacteroides fragilis	Cefoxitin Metronidazole Erythromycin Clindamycin
Veilonella	Penicillin Metronidazole Erythromycin

At the same time, numerous studies have established the minimum inhibitory concentrations of the most common drugs adequate for the treatment of anaerobic infections (table 12).

Table 12. Minimum inhibitory concentrations

antibiotics for anaerobic microorganisms

The minimum inhibitory concentration (MIC) is the lowest antibiotic concentration that completely inhibits the growth of microorganisms. A very important problem is the standardization and quality control of determining the sensitivity of microorganisms to antibiotics (tests used, their standardization, preparation of media, reagents, training of personnel performing this test, use of reference cultures: B. fragilis-ATCC 25285; B. thetaiotaomicron ATCC 29741; C. perfringens-ATCC 13124; E. lentum-ATCC 43055).

In obstetrics and gynecology, penicillin, some 3-4 generation cephalosporins, lincomycin, chloramphenicol are used for the treatment of anaerobic infection. However, the most effective anti-anaerobic drugs are representatives of the 5-nitroimidazole group - metronidazole, tinidazole, ornidazole, and clindamycin. The effectiveness of treatment with metronidazole alone is 76-87%, depending on the disease, and 78-91% with tinidazole. The combination of imidazoles with aminoglycosides, cephalosporins of the 1st and 2nd generation increases the rate of successful treatment to 90-95%. Clindamycin plays a significant role in the treatment of anaerobic infection. The combination of clindamycin with gentamicin is a reference method for the treatment of purulent-inflammatory diseases of the female genital organs, especially in cases of mixed infections.

6. Correction of intestinal microflora

During the last century, the normal human intestinal microflora has been the subject of active research. Numerous studies have established that the indigenous microflora of the gastrointestinal tract plays a significant role in ensuring the health of the host organism, playing an important role in the maturation and maintenance of the function of the immune system, as well as in providing a number of metabolic processes. The starting point for the development of dysbiotic manifestations in the intestine is the suppression of indigenous anaerobic microflora - bifidobacteria and lactobacilli, as well as stimulation of the reproduction of opportunistic microflora - enterobacteria, staphylococci, streptococci, clostridia, candida. I.I.Mechnikov formulated the main scientific theses regarding the role of indigenous intestinal microflora, its ecology and put forward the idea of \u200b\u200breplacing harmful microflora with useful in order to reduce intoxication of the body and prolong human life. The idea of \u200b\u200bI. I. Mechnikov was further developed in the development of a number of bacterial preparations used to correct or "normalize" the human microflora. They are called "eubiotics", or "probiotics", and contain live or

dried bacteria of the genera Bifidobacterium and Lactobacillus. The immunomodulatory activity of a number of eubiotics has been shown (stimulation of antibody production, the activity of peritoneal macrophages is noted). The fact of the presence of chromosomal resistance in strains of eubiotic bacteria to antibiotics is also important, and their joint administration increases the survival rate of animals. The most widespread are the fermented milk forms of lactobacterin and bifidumbacterin (4).

7. Conclusion

Anaerobic infection is one of the unsolved problems of modern medicine (especially surgery, gynecology, therapy, stomatology). Diagnostic difficulties, incorrect assessment of clinical data, errors in treatment, implementation of antibacterial therapy, etc. lead to high mortality in patients with anaerobic and mixed infections. All this indicates the need to quickly eliminate both the existing lack of knowledge in this area of \u200b\u200bbacteriology and significant shortcomings in diagnostics and therapy.

Anaerobic infection is a rapidly developing pathogenic process that affects various organs and tissues in the body and is often fatal. It affects all people, regardless of gender or age. Timely diagnosis and treatment can save a person's life.

What it is?

Anaerobic infection is an infectious disease that occurs as a complication of various injuries. Its pathogens are spore-forming or non-spore-forming microorganisms that thrive in an oxygen-free environment or with a small amount of oxygen.

Anaerobes are always present in normal microflora, mucous membranes of the body, in the gastrointestinal tract and genitourinary system. They are classified as conditionally pathogenic microorganisms, since they are natural inhabitants of biotopes of a living organism.

With a decrease in immunity or the influence of negative factors, bacteria begin to actively multiply uncontrollably, and microorganisms turn into pathogens and become sources of infection. Their waste products are hazardous, toxic and quite corrosive substances. They are capable of easily penetrating cells or other organs of the body and affecting them.

In the body, some enzymes (for example, hyaluronidase or heparinase) increase the pathogenicity of anaerobes, as a result, the latter begin to destroy the fibers of muscle and connective tissue, which leads to a violation of microcirculation. Vessels become fragile, erythrocytes are destroyed. All this provokes the development of immunopathological inflammation of blood vessels - arteries, veins, capillaries and microthrombosis.

The danger of the disease is associated with a large percentage of deaths, so it is extremely important to notice the onset of the infection in time and immediately begin to treat it.

Causes of infection

There are several main reasons for infection:

• Creation of suitable conditions for the vital activity of pathogenic bacteria. This can happen:
• when an active internal microflora enters the sterile tissue;
• when using antibiotics that have no effect on anaerobic gram-negative bacteria;
• in case of impaired blood circulation, for example, in the case of surgery, tumors, injuries, ingress of a foreign body, vascular diseases, with tissue necrosis.
• Infection of tissue with aerobic bacteria. They, in turn, create the necessary conditions for the vital activity of anaerobic microorganisms.
• Chronic diseases.
• Some tumors that are localized in the intestine and head are often accompanied by this disease.

Types of anaerobic infections

It differs depending on which agents are provoked and in which area:

Surgical infection or gas gangrene

Anaerobic surgical infection or gas gangrene is a complex complex reaction of the body to the effects of specific pathogens. It is one of the most difficult and often intractable wound complications. In this case, the patient is worried about the following symptoms:

• increasing pain with a feeling of fullness, since the process of gas formation occurs in the wound;
• fetid odor;
• exit from the wound of a purulent heterogeneous mass with gas bubbles or splashes of fat.

The swelling of the tissues progresses very quickly. Outwardly, the wound becomes gray-green in color.

Anaerobic surgical infection is rare, and its occurrence is directly related to the violation of antiseptic and sanitary standards during surgical operations.

Anaerobic Clostridial Infections

The causative agents of these infections are obligate bacteria that live and reproduce in an oxygen-free environment - spore-forming representatives of Clostridia (gram-positive bacteria). Another name for these infections is clostridiosis.

In this case, the pathogen enters the human body from the external environment. For example, these are the following pathogens:

• tetanus;
• botulism;
• gas gangrene;
• toxic infections associated with the consumption of low-quality contaminated food.

The toxin secreted, for example, by clostridia, contributes to the appearance of exudate - a fluid that appears in body cavities or tissue during inflammation. As a result, the muscles swell, become pale, a lot of gas appears in them, and they die off.

Anaerobic non-clostridial infections

Unlike obligate bacteria, representatives of a facultative species are able to survive in the presence of an oxygen environment. The causative agents are:

• (globular bacteria);
• shigella;
• escherichia;
• yersinia.

These pathogens cause anaerobic non-clostridial infections. These are more often purulent-inflammatory infections of the endogenous type - otitis media, sepsis, abscesses of internal organs and others.

In gynecology

The microflora of the female genital tract is rich in various microorganisms and anaerobes as well. They are part of a complex microecological system that contributes to the normal functioning of a woman's genitals. Anaerobic microflora is directly related to the occurrence of severe purulent-inflammatory gynecological diseases, for example, acute bartholinitis, acute salpingitis and pyosalpinx.

The penetration of anaerobic infection into the female body is facilitated by:

• trauma to the soft tissues of the vagina and perineum, for example, during childbirth, during abortion or instrumental examinations;
• various vaginitis, cervicitis, erosion of the cervix, tumors of the genital tract;
• remnants of membranes, placenta, blood clots after childbirth in the uterus.

An important role in the development of anaerobic infection in women is played by the presence, administration of corticosteroids, radiation and chemotherapy.

Qualification of anaerobic infections by localization of its focus

The following types of anaerobic infections are distinguished:

• Infection of soft tissues and skin... The disease is caused by anaerobic gram-negative bacteria. These are superficial diseases (cellulite, infected skin ulcers, consequences after major diseases - eczema, scabies and others), as well as subcutaneous infections or postoperative ones - subcutaneous abscesses, gas gangrene, bite wounds, burns, infected ulcers in diabetes, vascular diseases. With deep infection, soft tissue necrosis occurs, in which there is an accumulation of gas, gray pus with a foul odor.
• Bone infection... Septic arthritis is often a consequence of neglected Vincent, osteomyelitis, a purulent-necrotic disease that develops in the bone or bone marrow and surrounding tissues.
• Internal infections, including, women may experience bacterial vaginosis, septic abortion, abscesses in the genital apparatus, intrauterine and gynecological infections.
• Bloodstream infections - sepsis. It spreads through the bloodstream;
• Serous cavity infections - peritonitis, that is, inflammation of the peritoneum.
• Bacteremia- the presence of bacteria in the blood, which enter there exogenous or endogenous.

Aerobic Surgical Infection

Unlike anaerobic infections, aerobic pathogens cannot exist without oxygen. Cause infection:

• diplococci;
• sometimes;
• intestinal and typhoid bacilli.

The main types of aerobic surgical infection include:

• furuncle;
• furunculosis;
• carbuncle;
• hydradenitis;
• erysipelas.

Aerobic microbes enter the body through the affected skin and mucous membranes, as well as through the lymphatic and blood vessels. It is characterized by increased body temperature, localized redness, swelling, pain and redness.

Diagnostics

For a timely diagnosis, it is necessary to correctly assess the clinical picture and provide the necessary medical assistance as soon as possible. Depending on the localization of the focus of the infection, various specialists are engaged in diagnostics - surgeons of different directions, otolaryngologists, gynecologists, traumatologists.

Only microbiological studies can confirm for sure the participation of anaerobic bacteria in the pathological process. However, a negative answer about the presence of anaerobes in the body does not reject their possible participation in the pathological process. According to experts, about 50% of the anaerobic representatives of the microbiological world today are uncultivated.

High-precision methods for indicating anaerobic infection include gas-liquid chromatography and mass spectrometric analysis, which determines the amount of volatile liquid acids and metabolites - substances that form in the process of metabolism. No less promising methods are the determination of bacteria or their antibodies in the patient's blood using enzyme immunoassay.

They also use express diagnostics. The biomaterial is studied in ultraviolet light. Carry out:

• bacteriological sowing of the contents of the abscess or the separated part of the wound into the nutrient medium;
• sowing blood for the presence of bacteria, both anaerobic and aerobic;
• blood sampling for biochemical analysis.

The presence of an infection is indicated by an increase in the amount of substances in the blood - bilirubin, urea, creatinine, as well as a decrease in the content of peptides. Increased activity of enzymes - transaminase and alkaline phosphatase.

X-ray examination reveals the accumulation of gases in the damaged tissue or body cavity.

When diagnosing, it is necessary to exclude the presence of erysipelas in the patient's body - a skin infectious disease, deep vein thrombosis, purulent-necrotic tissue lesions by another infection, pneumothorax, exudative erythema, frostbite stage 2–4.

Treatment of anaerobic infection

When treating, you can not do such measures as:

Surgical intervention

The wound is dissected, the dead tissue is drastically dried out, and the wound is treated with a solution of potassium permanganate, chlorhexidine or hydrogen peroxide. The procedure is usually performed under general anesthesia. With extensive tissue necrosis, limb amputation may be required.

Drug therapy

It includes:

• taking anesthetic components, vitamins and anticoagulants - substances that prevent clogging of blood vessels by blood clots;
• antibiotic therapy - taking antibiotics, and the appointment of a particular drug occurs after an analysis has been made for the sensitivity of pathogens to antibiotics;
• administration of anti-gangrenous serum to the patient;
• transfusion of plasma or immunoglobulin;
• introduction of drugs that remove toxins from the body and eliminate their negative effects on the body, that is, they detoxify the body.

Physiotherapy

In physiotherapy, wounds are treated with ultrasound or laser. Ozone therapy or hyperbaric oxygenation is prescribed, that is, they act with oxygen under high pressure on the body for medicinal purposes.

Prevention

To reduce the risk of developing the disease, a high-quality primary wound treatment is carried out on time, a foreign body is removed from the soft tissues. When carrying out surgical operations, the rules of asepsis and antiseptics are strictly observed. For large areas of damage, antimicrobial prophylaxis and specific immunization - preventive vaccinations are carried out.

What will be the result of the treatment? This largely depends on the type of pathogen, the location of the focus of infection, timely diagnosis and properly selected treatment. Doctors usually give a cautious but favorable prognosis for such diseases. With advanced stages of the disease, with a high degree of probability, we can talk about the death of the patient.

Next article.

Aerobic bacteria are microorganisms that require free oxygen to function properly. Unlike all anaerobes, they also participate in the process of generating the energy they need for reproduction. These bacteria do not have a distinct nucleus. They multiply by budding or fission, and upon oxidation they form various toxic products of incomplete reduction.

Features of aerobes

Not many people know that aerobic bacteria (in simple words, aerobes) are such organisms that can live in soil, air, and water. They are actively involved in the circulation of substances and have several special enzymes that ensure their decomposition (for example, catalase, superoxide dismutase, and others). Respiration of these bacteria is carried out by direct oxidation of methane, hydrogen, nitrogen, hydrogen sulfide, iron. They are capable of existing in a wide range at a partial pressure of 0.1-20 atm.

The cultivation of aerobic gram-negative and gram-positive bacteria implies not only the use of a suitable nutrient medium for them, but also the quantitative control of the oxygen atmosphere and the maintenance of optimal temperatures. For each microorganism of this group, there is both a minimum and a maximum oxygen concentration in the environment that is necessary for its normal reproduction and development. Therefore, the cessation of the vital activity of such microbes leads to both a decrease and an increase in oxygen content beyond the "maximum". All aerobic bacteria die at an oxygen concentration of 40 to 50%.

Types of aerobic bacteria

According to the degree of dependence on free oxygen, all aerobic bacteria are divided into the following types:

1. Obligate aerobes - these are "unconditional" or "strict" aerobes, which are able to develop only when there is a high concentration of oxygen in the air, since they receive energy from oxidative reactions with its participation. These include:

2. Optional aerobes - microorganisms that develop even with very low oxygen levels. This group belongs to.