Citation:Rudnov V.A. Modern algorithms Antibacterial therapy of sepsis // RMG. 2004. №24. P. 1354.

The need for more distinct regulation of antibacterial therapy (ABT) of sepsis is associated with several circumstances: - high risk of adverse outcome for the inadequate choice of the drug; - making a decision in the conditions of time deficit; - a system-widespread system of duty and various levels of training doctors in the field of infections therapy; - the presence of evidence from pharmacoepidemiological studies, indicating errors and the irrational imposition of antibiotics. In recent years, a number of international and domestic recommendations and guidelines have appeared in order to overcome the discharges and improvement of approaches to therapy of this pathological process. Unlike other seventures of Sepsis pharmacotherapy, most of the provisions of ABT are not based on the evidence of a high level, but are recommendations of experts. This situation is not a lack of research organization, but reflects the complexity of sepsis, as a pathological process, and features of antibiotics, as pharmacological meansFor a variety of positions. In order to improve perception and accelerate implementation in clinical practice modern approaches According to Abt Sepsis, we considered it necessary to specify a number of key provisions in this publication. The start time of antibacterial therapy according to the existing consensus recommendations of SURVIVING SEPSIS Campaign, which united 11 international associations of various medical specialties, ABT with severe sepsis should be started during the first hour after the diagnosis and taking of material for bacteriological research. This Recommendation is based on prospective and retrospective studies that demonstrated significantly higher mortality in the case of inadequate selection of the initial ABT scheme or during the initiation of therapy in patients with sepsis and bacteremia, as well as hospital and complete Pneumonia heavy Current . Fast interpretation of the gravity of the infectious process can be performed using the use of the ACCP / SCCM sepsis diagnostic criteria, the criteria of organ dysfunction (Sofa, MODS, BAUE et al.) And / or express test for the procingtonin content, the level of which is higher than 2 ng / ml, , corresponds to sepsis with organ dysfunction (Table 1). Algorithms for choosing antibiotic therapy for the choice of the optimal scheme of empirical ABT should take into account the localization of the primary hearth, the place of occurrence of sepsis (extra-received, hospital, hospital in the ort), the level of sustainability of the causative agents of hospital infections (GI) to antibiotics in a particular branch, the presence / absence of bacteremia. To date, in most large polyvalent medical centers, the frequency of gram-positive (GR +) and gram-negative (GR-) sepsis was approximately equal. This happened as a result of an increase in role in pathology of bacteria such as Streptococcus SPP., Staphylococcus and Enterococcus SPP. The invasiveness of the treatment and the increase in the number of persons with reduced anti-infectious protection increased the share of infections caused by conditionally pathogenic microorganisms, especially S. Epidermidis. Among the population different species Staphylococcus-causative agents of sepsis is observed a steady increase in metaticillin (oxacillin) -re-resistant strains. The disappearance of the dominant role of gram-negative microorganisms is accompanied by changes in the etiological structure within this group. The frequency of sepsis caused by non-enzyme gram-negative bacteria (Pseudomonas Aeruginosa and Acinetobacter SPP is grew.), As well as Klebsiella Pneumonia producers? -Laktamaz expanded spectrum (BLRS), and in some medical institutions - Enterobacter Cloacae. As a rule, these microorganisms act as hospitals of hospital sepsis in patients of Orit. The increase in their significance in the development of severe infections is associated with an increase in the proportion of patients on a long-term IVL and is unnecessarily used in the clinical practice of the cephalosporins of the 3rd generation and aminoglycosides. The increase in the life expectancy of persons who have undergone critical states, the popularity of combined antibiotic treatment circuits and new drugs of the ultrashirex spectrum of action led to the appearance of first extremely rarely found in the pathology of microbes, such as Enterococcus Faecium, Stenothrophomonas Maltophilia, with Hryseobacterium SPP. et al. In general, the etiological structure of pathogens GI and the level of their resistance to ABP in various hospitals and branches (especially in the Orit) has its own "face". Therefore, the construction of an ABT algorithm taking into account the etiology and features of resistance to antibacterial agents is the most optimal approach. However, unfortunately, the existence of real databases in LPU based on well-organized microbiological studies is still rather an exception than the system. The situation remains recommended to focus on the results of multicenter national research. The relationship between the localization of the focus of infection and the character of the microflora, which runs the infectious inflammatory process, and its development site is displayed in Table 2. The mandatory view of the patient's condition estimation is the presence / lack of death risk factors in a patient with sepsis. Under the risk factor, there is any clinical laboratory characteristic (feature of the patient's condition), which is an independent statistically significant factor increasing the risk of adverse outcome. In this regard, the localization of the infectious focus, shock and severity of Pon, the place of occurrence of sepsis (hospital, extra-received), features of bacteremia (primary, secondary, genus or type of pathogen). These data were obtained both in the consideration of cohort studies and as a result of the implementation of the POST HOC analysis of a significant amount of controlled tests for evaluating the effectiveness of individual medicines during sepsis. In particular, it was proved that the localization of the infectious focus in the abdominal cavity and the lungs is accompanied by a higher mortality rate than when it was in urinary trait or skin I. soft tissues With identical values \u200b\u200bof indexes of the patient's condition. Mortality in secondary bacteremia exceeds such with primary and catheter-associated sepsis. And survival rate with gram-negative sepsis bacteremia is lower than with a gramist. In addition, the chances of survival are reduced by the elderly and elderly patients, as well as in individuals with decompensated chronic concomitant pathology (CPN, HSN, COPD, diabetes mellitus). In general, the algorithms for choosing an ABT scheme during sepsis from the designated positions are presented in tables 3-4. ABT division, depending on the risk of unfavorable outcome, under community-wide sepsis is due to the desire to maximize the likelihood of an error in the choice of the drug and a faster eradication of the pathogen in patients in a critical condition. In addition, in relation to the designated selection schemes currently there is an extensive clinical practice, separate cohort and controlled studies, indicating their high efficiency during sepsis. At the same time, given a distinct tendency to the growth of the stability of the sysegnaya stick to the carbapenes, it should be limited to their use for the therapy of the community-friendly sepsis in offices with a high level of prevalence of GI and resistance to these microorganism. Analysis of the application of domestic respiratory fluoroquinolones (levofloxacin, moxifloxacin) has demonstrated their advantage in terms of reducing the relative risk of death compared with cephalosporins of the 2-3rd generation in combination with macrolides. Due to the lack of clinical advantages and a significant increase in the risk of nephrotoxic effects, it is necessary to abandon the routine addition of aminoglycosides to? -Lactual ABP both with empirical and targeted therapy in patients with sepsis (Table 4). In the general group of patients, differences in the frequency of development of resistance to ABAP, as well as bacterial or fungal colonization and superinfection are identified. While nephrotoxicity with the combined ABT turned out to be statistically significantly higher - the relative risk indicator is RR \u003d 0.36 (0.28-0.47). What could be due to the difference between the results obtained in the experiment and in real clinical practice? For AMG, the characteristic volume of distribution in the body, which causes a low concentration in tissues, in particular, in the lungs. Apparently, in these conditions, their content in the tissues does not reach those values \u200b\u200bof minimally overwhelming concentrations (IPCs), which are necessary for the eradication of bacteria. With this circumstance, it is probably due to the lack of evidence of braking the development of sustainability of pathogens to ABP when adding AMG into the therapy scheme. Moreover, unreasonably widespread use of AMG led to an increase in sustainability of key pathogens of hospital infections in the Orit. The orientation logic to the risk factors when choosing an ABT scheme cannot be fully distributed to the hospital sepsis due to the greater priority significance of the situation with the local level of sensitivity of key pathogens to ABP. It is he who must determine the choice between drugs of different groups or inside one of them. Due to the very significant growth of the resistance of pathogens, potentially effective drugs in recent years has noticeably narrowed. Taking into account the results of multicenter studies in Russia, it can be concluded that the most reliable empirical therapy of the hospital sepsis may be associated with a fairly narrow circle of drugs - carbapenes and cefepim. The appointment of ciprofloxacin without knowledge of the peculiarities in a particular branch is associated with the risk of failure. Adding a vancomycin or linesolide will be justified with angiogenic sepsis (AC) or fan-associated pneumonia (WAP) in compartments with a high level of MRSA distribution or in patients with neutropenia. Several factors affect the etiological structure of the speakers: the duration of catheterization, the place of standing catheter (upper hollow or femoral vein), conducted by ABT, the prevalence of MRSA or MRSE in a particular orort. With catheterization more than 10 days and / or finding a catheter in the femoral vein, the risk of AS associated with P. Aeruginosa, Enterococcus SPP increases. and MRSA. If these factors are associated with a severe condition of the patient (shock, PON), it seems reasonable empirical therapy in the version of the image (TIENAM) + vancomycin or linoxolid. We emphasize that as a result of subpopulation analysis, identical clinical efficacy of monotherapy is established? -Laktami and their combinations with aminoglycosides, including in sepsis associated with P. Aeruginosa (Table 5). The possibilities of the declaration regime of antibacterial therapy during sepsis and septic shock Stabilization of hemodynamics, regression of CVR and organ dysfunction, subject to reliable identification of the pathogen and the nature of its sensitivity to the ABP, are the necessary preconditions for consideration of the possibility after 3-4 days of transition to an ABP of a narrower spectrum at the initial start with carbapenes or with a combination of antibiotics, overlapping the spectrum of possible pathogens. The transition to an antibiotic with a narrower spectrum of action on the results of bacteriological research is justified from the standpoint of control of resistance transmissible pathogens and saving material resources. The effectiveness and security of such a strategy was recently confirmed in prospective controlled studies, which concerned patients with hospital sepsis, complicated by pneumonia. The following characteristics are indicated about the initial gravity of sepsis: 44% of patients were in a state of shock, and 83.5% - IVL was required. As a starting mode, in this case, the impenet was used. In indispensable conditions for a declaration strategy for the use of ABP are the reliability of laboratory data and the absence of bacteremia associated with k. Pneumonia, Acinetobacter SPP., Enterobacter SPP. The fact is that with regard to severe infections of various localization with bacteremia caused by these microorganisms, there are studies, the results of which demonstrate significantly higher survival in therapy with the impediment than the cephalosporins of the 3-4th generation during the sensitivity to them in vitro. Therefore, it is impossible to carry out de essay when starting with carbapenes in these clinical situations. Moreover, the transition to this class ABP is justified in the absence of a clinical effect and initial therapy with cephalosporins. The path of introducing antibacterial drugs suction medicinal substances In septic patients with intramuscular injections, it is significantly reduced due to disorders of peripheral blood circulation, metabolic acidosis, limited mobility, reduced muscle tone. Moreover, an increase in the volume of distribution of drugs in hypershydration and conducting long, active infusion therapy is observed. As a result of the actions of the listed factors, the concentration of antibiotics in the focus of infectious inflammation is reduced. In this regard, during sepsis, an exclusively intravenous route of administration of the ABP should be used. Dosing mode The development of heavy sepsis is usually combined with kidney dysfunction (often and liver) and requires a more scrupulous attitude to the Dosage regime of the ABP. In the conditions of a rapidly changing situation, dynamic control of the level of clearance-specificine is useful, which will make it possible to make the right calculation of the ABP dosages at a particular point in time. Applications of the maximum possible doses requires a sepsis caused by a blue chopstick. Bactericidity? -laction antibiotics depends on the time of exceeding the concentration of the drug in blood / tissues over the IPC (minimum overwhelming concentrations) against sepsis causative agents. With these positions, a certain advantage is shown in their administration in the form of a constant intravenous infusion after the first loading dose as a bolus. This approach is justified primarily with hospital sepsis associated with problem microorganisms, which are characterized by a higher level of IPC (K. Pneumonia, Acinetobacter SPP., P. Aeruginosa). Applications of the maximum possible doses of antibiotics requires a sepsis caused by a blue rod. The duration of antibacterial therapy is currently in the light of consideration of sepsis as a systemic inflammatory reaction (CVR) of infectious genesis and accumulating clinical data, the duration of ABT for many of it clinical shapes Must be revised towards abbreviation. It should be recognized as obsolete recommendations for the implementation of ABT to the complete normalization of body temperature or the number of leukocytes in the blood or offering the minimum period - 10-14 days. It seems that the duration of ABT in many cases could be limited to 7-10 days. First of all, it concerns patients with surgical sepsis, which have a radical sanitation of the focus of an infect. The basis of individual decision-making should be clinical and instrumental data, testifying to the regression of signs of inflammation in the primary focus, the relief of systemic inflammation syndrome, the absence of signs of accession of superinfection. With hospital pneumonia, a dynamic quantitative assessment of the pathogen in the lower respiratory tract. The lack of effect from the optimally chosen scheme under the community-wide sepsis is primarily the basis for revising the surgical tactics and the search for non-sanited foci of an infection or consideration alternative sources Maintaining CVR. In the case of hospital sepsis, in addition to the noted, special attention should be paid to the re-analyzing of microbiological diagnosis in the aspect of "colonization - infection" and the conclusion on the nature of the sensitivity to ABP.

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Justification of the modes of empirical antimicrobial therapy of sepsis

The empirical selection of antibacterial drugs dictates the need to use already at the first stage of treatment of antibiotics with a fairly wide range of activity, sometimes in combination, taking into account the extensive list of potential pathogens with different sensitivity. When localizing the primary focus in the abdominal cavity and the rotoglot, it is also implied to participate in the infectious process of anaerobic microorganisms. A more definite judgment on the etiology of sepsis is possible in cases of bacteremia after splenectomy and catheter-associated bacteriamia.

Another important parameter that determines the program of start-up empirical therapy of sepsis is the severity of the disease. Heavy sepsis characterized by the presence of polyorgan deficiency (PON) has a higher percentage of mortality and more often leads to the development of terminal septic shock. The results of the antibacterial severe sepsis therapy with Pon are significantly worse compared to sepsis without Mon, therefore, the use of the maximum antibacterial therapy regime in patients with severe sepsis should be carried out at the earliest stage of treatment (the category of evidence C).

Since the greatest use of adequate antibacterial therapy reduces the risk of death, therefore, the effectiveness factor must dominate the cost factor.

§ Spectrum of the proposed pathogens depending on the localization of the primary focus (see Table 7 on p. 50);

§ the level of resistance of nosocomial pathogens according to microbiological monitoring1;

§ Conditions for the occurrence of sepsis - over-round or nosocomial;

§ The severity of infection, estimated by the presence of polyorgan deficiency or a scale of Apache II.

In the course of therapy program, antibacterial drugs are ranked on two levels - the means of the 1st row (optimal) and alternative means.

Funds 1 -to row - modes of antibacterial therapy, the use of which, from the standpoint of evidence-based medicine, and according to experts, makes it possible to achieve a clinical effect with the highest probability. At the same time, the principle of reasonable sufficiency was also taken into account, i.e. If possible, antibiotics with a narrower spectrum of antimicrobial activity were recommended as a means of choice.

Alternatively attributed antibacterial agents, the effectiveness of which under this pathology is also established, but they are recommended to secondly for various reasons (cost, portability, level of stability) and are appointed with the unavailability or intolerance to the 1st row funds.

Sepsis with an unspecified focus of infection

The rational choice of the antibacterial sepsis therapy regime is determined not only by localization of the source (focal) of infection, but also the conditions for the occurrence of infection (community-acquired or nosocomial). If there is reason to assume the extra-accessed nature of infection, then the drugs of the selection can be cephalosporins III (cefotaxim, ceftriaxone) or fluoroquinolones. Among the latest advantage have preparations of a new generation (levofloxacin, moxifloxacin), which have a higher activity against gram-positive bacteria. It is also permissible to use cephalosporins II of generation or protected aminopenicillins (ampicillin / closer, ampicillin / sulbactam) in combination with aminogly kosidami (gentamicin, neutylmicin). Given the high probability of abdominal sources of infection, cephalosporins and levofloxacin it is advisable to combine with metronidazole. With a severe community sepsis with the patent and critical state of the patient (Apache II of more than 15 points), the treatment of therapy with a maximum wide spectrum will be the most effective: carbapenem (impenet, Meropenem, Ertapenem), or Cephalosporin IV generation Cef-Pim in combination with metronidazole, or fluoroquinolone last generation (Levofloxacin + metronidazole or Moxifloxacin).

When choosing an adequate mode of therapy of nosocomial sepsis, not only coverage of all potential causative agents should be planned, but also the possibility of participating in the infectious process of poly-systemic hospital strains of microorganisms. It is necessary to take into account widespread in medical institutions Our country (especially in multidisciplose-in hospitals, orit) of metieticillinorestant staphylococci, some Enterobacteria (Klebsiella SPP., E. colt) - producers of R-lactamaz expanded spectrum (which is accompanied by a decrease in the effectiveness of cephalosporins and often aminogli-goat and fluoroquinolones), a cinema stick, resistant to gentamicin, ciprofloxacin, inhibitor-protected penicillins. Currently, we must recognize that the optimal regime of empirical therapy of heavy nosocomial sepsis with Pon are carbapenes (imipenem, meropenem) as drugs with the widest spectrum of activity, to which the smallest level of resistance among intrabiquier strains of gram-negative bacteria. In some situations, a decent alternative carbapenes are cefepim protected by antipsevdomonady | 3 lactams (Tse-Fopeoperance / Sulbactam, Piperillalin / Tazobaktam) and CIPRO-Floxacin in adequate doses. In the event of the ineffectiveness of these therapy modes, it is necessary to estimate the expediency of additional purpose of Vancomycin or Line-Solid, as well as systemic antimicotics (fluconazole, AM-Photoericin B).

1 With a severe sepsis with a pon or critical condition of the patient, the largest clinical effect is expected when the carbapenem is prescribed (imipenem, meropenem, ertapenem), or cefepim with metronidazole, or new fluoroquinolones (levofloxacin, moxifloxacin).

2 At high risk, MRSA should discuss the expediency of joining a vancomycin or a linesolid to any mode of therapy.

Sepsis with an established primary focus of infection

sepsis antibiotic therapy cephalosporin

Programs of the empirical antibacterial therapy of sepsis are not significantly different from the approaches of the therapy of the infections of the localization, which determines the primary focus of the generalized infection (Table 2). At the same time, with a severe sepsis with Pon under adequate antibacterial therapy, we understand the use of the maximum effective antibiotic Already at the first stage of empirical therapy, given the extremely unfavorable forecast and the possibility of rapid prisrscination of the process to septic shock.

In the case of angiogenic (catheter) sepsis, in the etiology of which staphylococci predominates, the most reliable regime of therapy is vancomycin and linoxolid.

Table 4.

Doses of intravenous antibiotics for empirical therapy of sepsis

Penicillins

Benzylpenicillin 1-2 million food 6 times a day

(streptococcal infections) ampicillin 4 million food 6-8 times a day

(gas gangrene, meningitis)

Oxacillin 2 g 4-6 times a day

Cephalosporins I-III generation without antsyneganic activity

Cephazolin 2 g 2-3 times a day

Cefotaxim 2 g 3-4 times a day1

Ceftriaxone 2 g 1 time per day1

Cefuroxime 1.5 g 3 times a day

Cephalosporins III-IV generations with antsingenic activity

Cefepim 2 g 2 times a day

Ceftazidim 2 g 3 times a day

Cefoperazone 2-3 g 3 times a day

Carbapenes
Imipen 0.5 g 4 times a day or 1 g 3 times a day

Meropenem 0.5 g 4 times a day or 1 g 3 times a day

Ertapenem 1 g 1 time per day

Combinations of r-lactam with inhibitorsb.- lactamaz

Amoxicillin / clavulanate 1.2 g 3-4 times a day

Ampicillin / soulbactam 1.5 g 3-4 times a day

TIKARCILLIN / CLAVULANAT 3.2 g 3-4 times a day

Cefoperazone / Sulbaktam 4 g 2 times a day

Aminoglycosides

Amikacin 15 mg / kg per day 2

Gentamicin 5 mg / kg per day 2

Nepylmicin 4-6 mg / kg per day 2

Fluoroquinolones

Levofloxacin 500-1000 mg 1 time per day

Moxifloxacin 400 mg 1 time per day

Offloxacin 400 mg 2 times a day

PERFLOXACIN 400 mg 2 times a day

Ciprofloxacin 400-600 mg 2 times a day

Preparations with antistaphococcal activity

Vancomycin 1 g 2 times a day

Linezolid 600 mg 2 times a day

Rifampicin 300-450 mg 2 times a day

Fusidium acid 500 mg 4 times a day

Anti-Anaerobic Activity Preparations

Clindamycin 600-900 mg 3 times a day

Lincomycin 600 mg 3 times a day

Metronidazole 500 mg 3-4 times a day

Antifungal Activity Preparations

Fluconazole 6-12 mg / kg / day - intravenous infusion at no more than 10 ml / min

Amphotericin at 0.6-1.0 mg / kg / day - intravenous infusion in 400 ml of 5% glucose solution at a rate of 0.2-0.4 mg / kg / h

Amphotericin in liposomal 3 mg / kg 1 time per day

Caspofungin first day - 70 mg 1 time per day, then - 50 mg 1 time per day

1 In the CNS infections, the daily dose should be increased twice

2 daily dose can be entered into one or 2-3 administration

The path of introducing antimicrobial means

During sepsis preferable is intravenous administration Antibacterial agents. There is no convincing data in favor of intraarterial or endolympatic administration of antibiotics.

Combined use of antibacterial drugs

The convincing data in favor of the routine purpose of the combinations of antibacterial drugs is not received. In the latest published metaanalysis, it provides data that during sepsis combination (3-lactams with aminoglycoside-mi no advantages compared to monotherapy (5 lactams in terms of both clinical efficacy and resistance development. The same clinical efficacy of monotherapy and combination therapy is shown for Sepsis caused by Enterobacteriaceae and P. Aeruginosa.

Duration of antibacterial therapy

Antibacterial therapy of sepsis is carried out until the persistent positive dynamics of the patient's condition and the disappearance of the main symptoms of infection. Due to the lack of pathognomonic signs of bacterial infection, the absolute criteria for the cessation of antibacterial therapy are difficult to establish. Usually, the question of the cessation of antibiotic therapy is solved individually on the basis of a comprehensive assessment of the patient's condition dynamics. IN general Criteria for the adequacy of antibacterial sepsis therapy can be represented as follows:

§ positive dynamics of major infection symptoms;

§ Lack of signs of a systemic inflammatory response;

§ Normalization function gastrointestinal tract;

§ normalization of the number of leukocytes Kommersant and leukocyte formula;

§ Negative hemoculture.

The preservation of only one sign of bacterial infection (fever or leukocytosis) is not an absolute indication to continue antibacterial therapy. Isolated subfebrile fever (the maximum daily body temperature within 37.9 ° C) without chills and changes in peripheral blood can be a manifestation of post-infectious asthenia or non-bacterial inflammation after surgery and does not require continuation of antibacterial therapy, as well as the preservation of moderate leukocytosis (9 - 12x10 ^ / l) in the absence of shift to the left and other signs of bacterial infection.

The usual timing of antibacterial therapy of surgical infections of various location (skin and soft tissues, peritonitis, NPIVL) range from 5 to 10 days. Longer antibiotic therapy is not desirable due to development possible complications treatment, risk of selection of resistant strains and the development of superinfection. In the recently published results of the controlled double-blind study, the same clinical and bacteriological efficiency of 8- and 15-day NPIVL therapy is shown, while the risk of selection of resistant strains was higher at a longer course of treatment.

In the absence of a persistent clinical and laboratory response to adequate antibacterial therapy for 5-7 days, an additional examination is required (ultrasound, computer tomography, etc.) to identify complications or focus of other localization infection.

In certain clinical situations, longer modes of antibacterial therapy are required. This is usually recommended for infections localizing in organs and tissues in which therapeutic concentrations of antibiotics are difficult to achieve, therefore, there is a higher risk of persistence of pathogens and relapses of infection. This applies primarily to osteomyelitis, infectious endocarditis, secondary purulent meningitis. In addition, with infections caused by S. Aureus, it is usually recommended to also recommend longer antibacterial therapy courses - 2--3 weeks. The developed recommendations for antibacterial therapy of sepsis are the most characteristic and frequently occurring surgical practice of community and nosocomial bacterial infections. At the same time, some complex clinical situations are not considered in these Recommendations, as it is difficult to standardize. In this case, the question of treatment tactics should be solved in conjunction with an antimicrobial chemotherapy specialist.

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Equally large number of literature as the very problem associated with the classification and the definition of sepsis is devoted to the issues of antibacterial therapy of sepsis. Most of the newly developed antibiotics are necessarily recommended for use in the treatment of sepsis. Recommendations are given, as a rule, the most common (indication - septicemia !?), which makes an additional confusion in the scheme of antibacterial therapy. The situation is further exacerbated by the lack of a single generally accepted classification of sepsis, and respectively, comparable treatment results.

The situation has changed in a largest way over the past 10 years due to the introduction into the clinical practice of concluding documents of the conciliation conference, which has received widespread practical distribution. The use of such terms as a systemic inflammatory response (CVR), sepsis, severe sepsis and septic shock made it possible to outline certain groups of states (enough, of course, conditional, but nevertheless defined!) That require various approaches for their treatment, including number and differentiated use of antibacterial therapy schemes. Researchers have the opportunity to develop more or less general principles of antibacterial therapy of generalized inflammatory reactions, in relation to its forms / phases (CVR, sepsis, severe sepsis, septic shock), compare the effectiveness of the therapy using various antibiotic schemes, evaluate the results of treatment.

The development of the principles of evidence-based medicine and the broad introduction of them in everyday clinical practice led to the need to evaluate the various methods used to treat generalized inflammatory processes. The studies carried out suggest that the use of antibiotics in the treatment of sepsis is substantiated on the evidence I (significantly) level. This allows us to consider the use of antibiotics in the treatment of sepsis, severe sepsis and septic shock with a necessary component, the effectiveness of which is not questioned.

Based on the definitions of sepsis adopted at the conciliation conference, it can be said that the appearance of two and more symptoms of the syndrome of the systemic inflammatory response (CVR) should serve as a good basis for setting the question of the qualitative nature of the SSR, and, consequently, about the possible beginning of antibiotic therapy, if there is an infectious process . First of all, it is necessary to prove (or exclude) the infectious nature of the systemic inflammatory response. Often it represents a far from a simple task. Approximate, far from complete, a list of basic states that can lead to the development of clinical signs of a systemic inflammatory response, is shown below.

• Acute pancreatitis
• Spinal injury
• Bleeding
• Emumbia Lungs
• Diabetic ketoacidosis
• Myocardial infarction
• System Vasculitis
• Systemic Red Volchanka
• Massive aspiration

The conducting of differential diagnosis in order to verify the qualitative nature of the SCLR becomes a question not at all academic sense, since the appointment of antibiotics does not indicate a significant, sometimes irreparable, damage. In order to finalize the reason for the development of a systemic inflammatory response syndrome, it is necessary to take all available diagnostic events, comprising a dynamic assessment of blood test (leukocytosis raising, an increase in the "shift of the formula to the left"), the use of instrumental diagnostic methods (X-ray and ultrasound research, etc.). In some cases, radionuclide studies are effective, as well as a new method that has not yet received a wide clinical propagation in domestic medicine, determining the concentration of procingtonin in serum.

The verification of the infectious nature of the system inflammatory response in accordance with the decisions of the conciliation conference makes it possible to formulate the diagnosis of "sepsis", which respectively requires the appointment of antibacterial therapy.

What principles when choosing antibacterial therapy schemes should the doctor be guided by the doctor?

Diagnosis "Sepsis" (in the interpretation of the 1991 conversation conference), indicating about the emergence of system signs of the infectious processallows you to consider sufficient various drugs The "first" row both in the case of empirical therapy and with an verified pathogel. Detection of signs of organ failure (2 or more points on the SOF scale), which indicates a "heavy sepsis", should force a doctor to recall the antibiotics of the so-called "reserve", the modern principles of "deseclative therapy".

The development of polyorgan insufficiency testifies to the extremely serious violation of the organ functions and the factors of the protection of the body, which must be considered when choosing the appropriate antibacterial drug. In addition to direct direct toxic effect on certain organs (aminoglycosides - kidneys, rifamycin - liver, etc.), this is directly related to the release of mediatosis inductors, which are structural elements of the wall of bacteria, released during the decay of the bacterial cell. These include lipopolysaccharide (endotoxin) gram-negative and taicheological acid - gram-positive microorganisms. Their release during decay or lysis of microorganisms can largely increase organ dysfunction (first of all, affecting the cardiovascular system), which must be necessarily taken into account.

Of course, this remark refers to drugs with bactericidal action. Nature also keep in mind that various antibacterial drugs affect the release of lipopolysaccharide in different ways. This should also be taken into account when choosing a drug (Table 1).

Table 1

Properties of antibiotics to enhance or loosen the release of endotoxin

Referring to the choice of the drug (preparations) in the treatment of septic shock, it is necessary to keep in mind all that has already been said about the "heavy sepsis". It should only take into account the need to start immediately from "de eager therapy", as well as select drugs with minimal release of endotoxin. Currently, we can assume that only carbapenes (impedite, meropenem) can be considered the only group of drugs that meet this requirement.

Thus, it can be said that one of the main and most important principles of antibacterial therapy of sepsis is as follows: the harder and more generalized inflammatory response (CVR, sepsis, severe sepsis, septic shock) is expressed, the more effective and safe antibiotic should be used. .

Antibacterial sepsis therapy in the overwhelming majority is empirical, especially at the beginning of treatment. It is necessary to immediately emphasize that the fence of the material for the microbiological research (the coloring of smears in terms of gram, various biological fluids and separated from drainage, etc.) should be made before the start of antibacterial therapy. Unfortunately, this is not always possible, especially when patients are translated from one hospital to another. However, regardless of the previous therapy and the state of the patient, a new stage of treatment should begin with an assessment of microbiological status.

The choice of the drug for empirical therapy is based on an organ approach (in which organ or system is localized infectious process), the most likely pathogel according to the clinical examination, as well as on a conventional resident flora present in the affected body. Based on the first principle, the drug is selected, which has the highest path in the tissues involved in the infectious process - osteotropic drugs during osteomyelitis, penetrating through the hematorecephalic barrier in infectious processes in the CNC, etc. Choosing an antibacterial drug, it must be remembered that it is particular The causative agent that caused the infectious process complicated by generalization is the leading defining factor. By defining a group of drugs acting on a specific pathogen, the subsequent selection of drugs is carried out depending on the severity of the generalized inflammatory response.

Determining the antibacterial therapy and producing the choice of the appropriate antibiotic, we always stand in front of the dilemma that choose, a variant of monotherapy with a wide range of action (cheaper, less toxic, etc.) or combined therapy (already spectrum, fewer resistant strains, etc. d.)? On this occasion, the following should be noted. To date, there is no reliable evidential base on the advantages of this or that method of therapy. Therefore, it is likely that the choice of a particular chart of therapy (mono or combined) should remain a lot of experience and taste of the doctor.

Thus, the drug is selected for therapy. It can be said that the choice of the drug is the most responsible moment after the testimony for antibacterial therapy is formulated. To this stage, you need to treat extraordinary attention. Only the accounting of all factors affecting the course and effectiveness of antibacterial therapy will minimize it side effects and reduce the risk of failure.

Developing signs of progression of the infectious process (continuing temperature, leukocyte shift, etc.) must first of all send the diagnostic process towards the search for the answer to the question: where, at what stage the infectious process began to develop not in the direction that was predicted, and Why was it possible? It should be noted that instead of setting a question in such a plane in the overwhelming majority of cases, another task is set - replacing one antibiotic to another due to the ineffectiveness of the first. And such replacements occur sometimes even several times a day.

Once again, I would like to remind you that the development (progression) of the infectious process against the background of the factors of antibiotic therapy in the overwhelming majority in the overwhelming majority of the factors of antibacterial therapy in the overwhelming majority indicates an inadequate surgery or development of an undiagnosed complication, and not about the ineffectiveness of the antibiotic. On the contrary, if the change of antibacterial therapy leads to a positive result, this testifies primarily that an error was initially applied. These are important general principles that each physician conducting antibacterial therapy should keep in mind.

Introduction:Inadequate initial antibacterial therapydefined as the absence of in vitro effect from the antimicrobial drug against the dedicated pathogen responsible for the development infectious diseaseis related to increasing morbidity and mortality of patients with neutropenic fever or severe sepsis. To reduce the likelihood of the appointment of inadequate antibacterial therapy in the latest international manuals for the treatment of sepsis, empirical therapy was proposed, focused on gram-negative bacteria, especially if suspected pseudomonadeinfection. Nevertheless, the authors of this recommendation are aware that "there is no research or meta-analysis that would have convincingly showed an excellent clinical result of the combination of drugs in a certain group of patients with individual pathogens."

Theoretical base for the purpose of combination therapy:

• an increase in the likelihood that at least one drug will be active in relation to the pathogen;
• preventing sustainable superinfection;
• immunomodulating nonantbacterial effect of the secondary agent;
• strengthening antimicrobial action in the calculation of synergistic activity.

In contrast to patients with febrile neutropenia, repeatedly and well-studied, no randomized studies of severe septic patients with syndrome of increased capillary permeability and polyorgan deficiency, in which the mechanisms of distribution and metabolism of antibiotics can be violated.

The main objective of this study was to compare the effectiveness of combined therapy with two antibiotics of a wide range of Moxifloxacin and Meropenem with a monotherapy with a meropenem with a polyorgan deficiency caused by sepsis.

Methods:A randomized open study was conducted in parallel groups. 600 patients with severe sepsis or septic shock participated.

Monotherapy received 298 people - the first group, and the combined therapy 302 is the second group. The study was conducted from October 16, 2007 to March 23, 2010 in 44 branches of intensive therapy of Germany. The number of estimated patients in the monotherapy group was 273 and 278 - in the group of combination therapy.

In the first group, patients were prescribed intravenous administration of Meropenema 1 g every 8 hours, in the second to Meropenemus added Moxifloxacin 400 mg every 24 hours. The duration of treatment was 7 - 14 days from the inclusion in the study or before discharge from the separation of intensive therapy or death, depending on what happened in the first place.

The main evaluation criterion was the degree of polyorgan deficiency on the Sofa scale (SEPSIS-Related Organ Failure), which is a baller scale in patients with septic syndrome on intensive therapy. The scale is more designed to quickly count the points and descriptions of a number of complications than for the forecast of the disease. State assessment: from 0 to 24 points, higher values \u200b\u200bindicate a more pronounced polyorgan deficiency. Also, the evaluation criterion was mortality from all reasons for 28 and 90 days. The survivors were supervised for 90 days.

RESULTS: Among the 551, the estimated patients did not have a statistically significant difference in the middle Sofa baller between the groups obtained by Meropenem and Moxifloxacin (8.3 points at 95% di, 7.8-8.8 points) and only Meropenem (7.9 points; 95% di 7.5 - 8.4 points) ( R = 0,36).

Also was not detected by a statistically significant difference in mortality at the age and 90th day.

By 28 days, 66 deaths occurred (23.9%, 95% disc 19.0% -29.4%) in the group of combination therapy compared with 59 patients (21.9%, 95% di 17.1% -27 , 4%) in the monotherapy group ( P. = 0,58).

96 deaths were recorded by 90% (35.3%, 95% di 29.6% -41.3%) in the group of combination therapy compared with 84 (32.1%, 95% di 26.5% -38, 1%) in the monotherapy group ( P. = 0,43).

CONCLUSIONS: In adult patients with severe sepsis, the combined treatment with Meropenem with Moxifloxacin compared with monotherapy Meropenemia does not lead to a decrease in the severity of polyorgan deficiency and does not affect the outcome.

Material prepared Ilyich E.A.

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The treatment of sepsis is carried out in the separation of intensive therapy. It includes surgical treatment, antibacterial therapy, detoxification therapy and immunotherapy, elimination of water and electrolyte and protein disorders, restoring disturbed functions of organs and systems, balanced high calorie nutrition, symptomatic treatment.

An integrated approach to the treatment of sepsis implies not only a combination of means and methods, but also parallel, simultaneous use. Multifactor changes in the body during sepsis, features of the primary focus of infection, the initial state of the body, concomitant diseases determine the individual approach to the treatment of a patient with sepsis.

Surgery

Pathogenetic and ethiotropic sepsis therapy provides for the elimination of an infection source and the use of antibacterial drugs.

Surgical intervention is performed in an emergency or urgent order. After stabilization of the basic functions of the body, primarily hemodynamics. Intensive therapy in these cases should be short-term and efficient, and the operation is performed whenever possible with adequate anesthesia.

Operational intervention can be primary when it is performed in the threat of generating infection or under sepsis, complicated by the flow of purulent diseases. Repeated operational interventions are performed when sepsis develops in the postoperative period or the primary operation did not lead to an improvement in the state of the patient with sepsis.

In operational intervention, the source of the infection is removed, if the state of the focus is allowed with a limited purulent process (the abscess of the breast, post-adjusting abscess), or an organ with an abscess (pyosalpinx, purulent endometritis, spleen abscess, kidney carbuncoon). More often operational treatment It is to open the abscess, phlegmon, the removal of non-viable tissues, the opening of purulent chambers, pockets, drainage.

With purulent peritonitis task surgical treatment - elimination of the cause, adequate abdominal rehabilitation (according to re-sanations); With osteomyelitis - opening of intraosseous uluses and drainage.

Repeated operational interventions are performed not only in the development of complications in the postoperative period, the appearance of purulent metastases, the suppuration of the Russian Academy of Sciences. Operations include opening and drainage of purulent chambers, pockets, shift drainage, transformation of purulent foci, cavity, repeated necrectomy, secondary surgical treatment of jointed wounds, opening and drainage of metastatic purulent foci.

The rehabilitation of purulent foci by closed methods (puncture, drainage) is performed with the formed glands. These are intra-abdominal and intrahepatic abscesses, ventilated pancreatic cysts, unfavorable lung abscesses, empty pleura, purulent arthritis.

Infected implants, foreign bodies that led to the generation of infection are to be removed (metal structures during osteosynthesis, vascular and articular dentures, heart valves, mesh implants with a plastic of abdominal, chest wall defects). Infected venous catheters You must also delete.

Antibacterial therapy

The importance of ethiotropic therapy of sepsis is undoubted, it is starting as early as possible. The fight against microflora is carried out as a focus of infection - local antibacterial therapy - adequate drainage, ethane necrectomy, flow-washing drainage, the use of antiseptics: sodium hypochlorite, chlorhexidine, dioxidine, ultrasound cavitation, etc.

The basis of general antibacterial therapy is antibiotics. Antibiotic therapy can be in two versions - primary selection of drugs or change of antibiotic treatment regimen. Most often, during sepsis, antibacterial therapy is empirical: drugs are chosen taking into account the intended pathogen and, depending on the primary source. For example, the wound septice most often has a staphylococcal nature, abdominal - mixed, mostly gram-negative, including anaerobic.

The high risk of severe complications and fatal outcome when items with effective antibacterial therapy even for a day is fraught with unpredictable consequences, forces treatment with combination therapy, and with severe sepsis - with reserve antibiotics.

Cefalosporins of the third-fourth generation are used to choose from the third-fourth-fourth generation, fluoroquinolones in combination with clindomycin or dioxide or method liphog, for monotherapy - carbopenmes.

In modern conditions, the role of nosocomial infection in the once-pitting sepsis is extremely high, and with the development of polyorgan deficiency (PON), the choice of an antibiotic for empirical therapy is important, if not defining. In such conditions, carbopenmes (impediment, meropenem) play a primary role.

The advantage of these drugs is wide spectrum Actions on aerobic and anaerobic flora (the drug is used in a monovariant). Microflora is highly sensitive to antibiotics of this group. Preparations are characteristic of high tropiness to different tissues, and tropiness to the peritoneum is higher than all other antibiotics.

In the choice of an antibiotic for empirical therapy, it is important to establish not only the estimated pathogen of infection, but also the primary source (leather and subcutaneous fiber, bone and joints, pancreas, peritonitis during colon perforations or under appendicitis). Selection of antibiotics, taking into account their organotroposis, is one of the most important components of rational antibacterial therapy. The organotoxicity of drugs is also taken into account, especially in the conditions of Pon.

When conducting antibiotic therapy, it is necessary to take into account the possibility of massive release of bacterial endotoxins in the bactericidal effects of drugs. When the shell of gram-negative bacteria is destroyed, polysaccharide (endotoxin), gram-positive bacteria - Teichoic acid with the development of Yaryshe-Hersheimer's syndrome. Especially pronounced toxic action These substances on the cardiovascular system.

After the selection of the pathogen from the hearth and blood is corrected by antibiotic therapy.

With staphylococcal sepsis caused by methicyl lifeline staphylococcus, oxacillin is used, with intraosseous foci of infection - in combination with gentamicin.

If sepsis is caused by methicillin-resistant stamps of staphylococcus, vancomycin or rifampicin is shown. The latter is quickly developed by the stability of microflora, which determines the need to combine it with ciprofloxacin.

With streptococcal sepsis antibiotics of choice, taking into account the sensitivity of the microbial flora are ampicillin, cefotoxin, vancomycin, imipenem, meropenem.

Pneumococcal sepsis determines the use of cephalosporins of the third-fourth generation, carbopenmes, vancomycin.

Among the gram-negative flora are dominated by enterubacteria, poly-resistant to antibiotics: E. coli, P. Mirabien, P. vulgaris, Klebs.spp., CitrobacterFreundis. The main antibiotics in the treatment of diseases caused by these microorganisms are carbopenmes. When you select Pseudomonas SPP., Acinetobacter SPP., Different, as a rule, multiple drug resistance, selection antibiotics are carboopenmes or ceftazidine in combination with amikacin.

Abdominal sepsis caused by anaerobic pathogens (bacteroids) or wound clodridial sepsis determine the need for combined therapy (cephalosporins, fluoroquinolones in combination with clindamycin, dioxide, metronidazole), and with abdominal sepsis - carbopenmes.

With fungal (candidal) sepsis, antibacterial therapy includes caspophungin, amphotericin B, fluconazole.

The basic principles of sepsis antibiotic therapy are as follows.

Empirical therapy begins with the use of the maximum therapeutic doses of cephalosporins of the third-fourth generation, semi-synthetic aminoglycosides, with ineffectiveness quickly go to fluoroquinolones or carbopenmes. The correction of antibiotic therapy is carried out according to the results of bacteriological studies of the contents of purulent focus, blood. If the drugs are effective, treatment is continuing.

If necessary, use a combination of two antibiotics with different spectrum of action or antibiotic with one of the chemical antiseptics (nitrofurans, dioxidine, metronidazole).

Antibacterial drugs are injected with different ways. Antiseptics are used locally (intracable, endotragically, intraosnially into the hollow of the joint, etc. depending on the localization of the focus), and the antibiotics are injected intramuscularly, intravenously, intraarterially.

The duration of the antibiotic treatment course is individual and depends on the state of the patient (the treatment continues to eliminate the signs of the SCRD: normalization of body temperature or decrease to subfebrile numbers, normalizing the number of leukocytes or moderate leukocytosis with a normal blood formula).

With osteomyelitis, the remaining cavity in the liver, lightly after the balance of the abscess, residual pleural cavity In emphasis, during sepsis caused by S. aureus, antibiotic therapy continues for 1-2 weeks after clinical recovery and two negative blood crops.

The answer to adequate antibacterial therapy is manifested in 4-6 days. The lack of effect determines the search for complications - the formation of metastatic foci, purulent chambers, the appearance of necroca foci.

Hypovolemia with shock, especially infectious toxic, is always available and it is determined not only by losing fluid, but also by the redistribution of it in the body (intravascular, interstitial, intracellular). Violations of the BCC are due to both developed sepsis and the initial levels of changes in the water-electrolytic balance associated with the main disease (abscess, phlegmon, emphasis, ventilated wound, burns, peritonitis, osteomyelitis, etc.).

The desire for the restoration of the BCC to normophemia is due to the need to stabilize hemodynamics, microcirculation, oncotic and osmotic blood pressure, the normalization of all three water basins.

Restoration of the water and electrolyte balance is the question of paramount importance, and is provided by colloid and crystalloid solutions. From colloidal solutions, preference is given to dextranum and hydroxyethylined starch. To restore the oncotic properties of blood, the correction of hypoalbumine (hypoproteinemia) in the acute situation, albumin remains ideal means in concentrated solutions, native, freshly frozen donor plasma.

To correct the disorders of the acid-alkaline state, 1% solution of potassium chloride during alkalosis or 5% sodium bicarbonate solution with acidosis is used. Amino acid mixtures (aminon, amino acid, alvezin), protein, albumin, dry and native plasma of donor blood are introduced to restore the protein balance. To combat anemia, regular transfusions of freshly consisted blood, erythrocytic mass are shown. The minimum hemoglobin concentration under sepsis 80-90 g / l.

Disinfecting therapy

Disinfection therapy is carried out by general principlesIt includes the use of infusion media, salt solutions, as well as forced diuresis. The amount of fluid injected (polyionic solutions, 5% solution of glucose, polyglyukin) is 50-60 ml (kg / day) with adding 400 ml of hemodesa. About 3 liters of urine should be allocated per day. Lazix, mannitol, mannitol use to strengthen the urinations. With polyorgan deficiency with predominance renal failure Extracorporal detoxification methods are used: plasmapheresis, hemofiltration, hemosorption.

In acute and chronic renal failure, hemodialysis is used, which allows removed only excess fluid and toxic substances with a small molecular weight. Gemofiltration expands the spectrum of removed toxic substances - products of impaired metabolism, inflammation, decay of tissues, bacterial toxins. Plasmapheresis is effective for removing toxic substances dissolved in plasma, microorganisms, toxins. Remote plasma is replenished with donor freshly frozen plasma, albumin in combination with colloid and crystalloid solutions.

With severe sepsis, the level of IGY, IgM, IgA is particularly reduced, a pronounced decrease in T- and B lymphocytes reflects the progressive insufficiency of immunity when the infectious process is not allowed. The indicators of the violation (perversion) of the body's immune response are manifested in the blood level of the CEC. The high level of the CEC also testifies to the violation of phagocytosis.

Of the means of specific impact, the use of antistaphococcal and anticolibacilla plasma, antistaphococcal gamma globulin, polyglobulin, Gabriglobin, Sandobulin, Pentaglobin is shown. In the oppression of cellular immunity (decrease in the absolute content of T-lymphocytes), the violation of the phagocytic reaction shows the transfusion of leukocytic mass, including from immunized donors, freshly prepared blood, the purpose of the drugs of the fork gland - thimaline, and the storage factories.

Passive immunization (substitution therapy) is carried out during the period of development, at the height of the disease, during the period of recovery, the means of active immunization - anatoxins, outovaccines are shown. Nonspecific immunotherapy includes lysozyme, Prodigiosan, Timalin. Taking into account the role of cytokines in the development of sepsis, interleukin-2 is used (Roncolekin) with a sharp decrease in the level of T-lymphocytes.

Corticosteroids are shown as substitution therapy after determining the hormonal background. Only with the complication of sepsis by bacterial-toxic shock are prescribed prednigasal (in 1 day to 500-800 mg, then 150-250 mg / day) for a short period (2-3 days). Corticosteroids in conventional therapeutic doses (100-200 mg / day) are used in allergic reactions.

Due to the high level of kininogenov, during sepsis and the role of kinines in a microcirculation violation into complex therapy of sepsis include proteolysis inhibitors (Galds of 200,000 - 300,000 units / day or contrikal of 40,000 - 60,000 units / day).

Symptomatic treatment provides for the use of cardiac, vascular tools, analgesics, anticoagulants, means that reduce vascular permeability, etc.

Intensive sepsis therapy is carried out for a long time, to a persistent improvement in the condition of the patient and restoring homeostasis.

The nutrition of the patients with sepsis should be diverse and balanced, high-calorie, with sufficient protein content and vitamins. Necessarily inclusion in the daily diet fresh vegetables and fruit. With the normal activity of the gastrointestinal tract, preference should be given to enteral nutrition, otherwise it is necessary to complete or additional parenteral nutrition.

The high degree of catabolic processes under sepsis is determined by the PON and is accompanied by the flow rate of tissue as a result of the destruction of its own cellular structures.

Specific energy value The daily diet should be 30-40 kcal / kg, the consumption of protein 1.3-2.0-1 kg or 0.25-0.35 g of nitrogen / kg, fat - 0.5-1 g / kg. Vitamins, trace elements and electrolytes - in the amount of daily needs.

Balanced nutrition begins as early as possible, without waiting for catabolic changes in the body.

With enteral nutrition, conventional foods are used, with probe diet, they give a balanced nutrient mixtures with the addition of certain ingredients. Parenteral nutrition provide solutions of glucose, amino acids, fat emulsions, electrolyte solutions. You can combine probe and parenteral nutrition, enteral and parenteral nutrition.

Specific species of sepsis

Sepsis can develop in the blood of some specific pathogens, for example, with actinomycosis, tuberculosis, etc.

Aktinomicotic sepsis complicates visceral actinomycosis. Distribution during the actinomyosis can lead to an isolated damage to metastasis of one of the organ or to the development of metastases simultaneously in several organs.

Clinically actinomicotic peymal is accompanied by a significant exacerbation of the actinomycotic process, an increase in temperature to 38-39 ° C, the formation of new actinomycotic infiltrates, purulent foci in various areas of the body and organs, strong pains, exhaustion and heavy bodies common state patient.

For the treatment of actinomycotic sepsis, in addition to means and methods used in bacterial sepsis, have a special large dose of antibiotics, actinolizats and blood transfusion.
Anaerobic sepsis can develop with anaerobic gangrene caused by clostridia. Sepsis can also be caused by other anaerobic microorganisms, although it happens much less often.

Anaerobic sepsis usually develops with severe injuries, in weakened, telescreen wounded. There is a rapid development of anaerobic gangrene with a high body temperature (40-40.5 ° C), frequent and small pulse, extremely difficult state, confusion or loss of consciousness (sometimes it is preserved, but excitement, euphoria). In peaceful time, anaerobic sepsis is almost never found.

To the above method of treating sepsis during anaerobic form, add intramuscular and intravenous drip administration of large doses of antichangrenous serum (10-20 prophylactic doses per day), intravenous drip and intramuscular administration of the mixture of antigangreas phages.

The sepsis of the newborns is more often associated with the introduction of infection (mainly staphylococcus) through the umbilical wound, abrasion, etc. The gouring temperature, lethargy, skin rash, jaundice, diarrhea and vomiting, hemorrhage into the skin and mucous membranes constitute a clinical picture of sepsis in children. Chills rarely, the spleen increases early.

Pneumonic foci, purulent pleurisy, lung abscesses and pericarditis, which are found during sepsis and are accepted for the main disease, are brought to the diagnostic errors. Sometimes sepsis occurs under the guise of food intoxication.

VC. Hotels