Antibiotics (Properties, Application, Interactions) - M.P. Cherenko 1999

Putrefactive infection

Non-specific surgical infection, apart from purulent and pyogenic forms, may also present as putrefactive (mixed — purulent-putrefactive, or pure, caused by a monoculture of a pathogenic microbe). Over the past two decades, putrefactive infections have become increasingly common. This trend is driven by a rising incidence of severe trauma and Polytrauma, malignant tumors of the colon and Lungs, a progressive increase in the number of elderly and senile patients as well as those with Diabetes Mellitus among surgical patients, the widespread and often irrational use of Antibiotics—particularly broad-spectrum agents (which promote the proliferation of opportunistic Gram-negative microflora as the primary causative agents of putrefactive infections)—a decline in hospital asepsis and patient care standards, and the proliferation of invasive diagnostic Methods, among other factors.

Putrefactive infections are predominantly caused by Gram-negative, and less frequently Gram-positive, microorganisms inhabiting the intestinal tract (especially the oropharynx and colon) and the Skin. These are primarily facultative and obligate anaerobes belonging to the Enterobacteriaceae and Bacteroides families (Escherichia coli, Pr. vulgaris, Fusobacterium nucleatum and necrophorum, Bac. melaninogenicus, Bac. fragilis), occasionally including members of the genera Klebsiella and Salmonella, as well as Gram-positive microorganisms of the family Lactobacillaceae (Peptostreptococcus and Streptococcus faecalis), alongside the Gram-negative aerobe Pseudomonas aeruginosa.

Pathogens of putrefactive infection enter Tissues through accidental injuries to the skin and mucous membranes, endoscopic Procedures, surgical interventions on the digestive tract, as well as via hematogenous, lymphogenous, and bronchopulmonary pathways. Putrefactive infection most commonly manifests as Phlegmon, abscesses, and other inflammatory processes localized near mucosal-lined tracts and cavities (phlegmon of the floor of the Mouth and neck, mediastinitis, lung abscesses, paraproctitis, Peritonitis, urological and gynecological conditions), as well as wound complications (crush injuries, gunshot wounds), deep Burns, grade III–IV frostbite, and Circulatory Disorders.

Both local and systemic factors contribute to The Development of putrefactive infections. Local factors include soft tissue and bone trauma, localization of pathological processes and injuries in the anal and vaginal regions, poor dental and oral hygiene, local circulatory disorders (pressure ulcers, inadequate wound management), and breaches of endoscopic Procedure protocols. Systemic factors include severe underlying conditions and disorders such as malignant tumors, diabetes mellitus, circulatory failure, atherosclerosis, various Digestive System disorders, advanced age and obesity, anemia and hypoproteinemia, hypovitaminosis, intensive antibiotic therapy, and congenital or acquired immunodeficiencies. In some of these severe conditions, putrefactive pathogens—particularly intestinal Gram-negative microflora—penetrate the intestinal wall and migrate into the Abdominal cavity AND Circulatory system, causing both local and systemic forms of putrefactive infection, namely Sepsis.

The defining features of putrefactive infection include tissue necrosis without a distinct zone of reactive inflammation in adjacent tissues, accompanied by a foul colibacillary odor produced by the infection source's microflora. Tissues affected by putrefactive infection appear dark gray, dull, or brownish-black; they are edematous and gelatinous, with a typically scanty seropurulent or serohemorrhagic exudate that carries a foul odor and often contains fat droplets. The overlying skin often shows minimal changes, and the borders between necrotic and healthy tissues are difficult to palpate. Reactive Changes in the surrounding tissues are likewise absent. Thrombosis and thrombophlebitis frequently develop within them, and erosive hemorrhages are not uncommon. In cases of putrefactive infection caused by Pseudomonas aeruginosa, the exudate stains dressings blue-green and emits a sickly-sweet odor. This bacterium is capable of deep tissue penetration within wounds, which can occasionally lead to sepsis. In anaerobic putrefactive cellulitis, the infection tends to spread extensively through tissues with minimal skin involvement, whereas in necrotizing fasciitis, the skin remains virtually unchanged while the fascia and underlying adipose tissue undergo necrosis and liquefaction over a large area.

Putrefactive infections, especially mixed variants, follow a severe clinical course. Alongside local necrotic-purulent tissue changes, they are accompanied by pronounced systemic manifestations: high fever, chills, weakness, depressed psycho-emotional status, tachycardia, decreased Blood pressure, headache, dyspeptic and intestinal disorders, alterations in protein, Water-electrolyte, and acid-base balance, progressive anemia, and hemogram abnormalities (leukocytosis, elevated ESR). In recent years, putrefactive infections have increasingly been complicated by Gram-negative sepsis. Gram-negative sepsis is frequently complicated by septic Shock, which carries a high mortality rate (up to 50% or higher).

Treatment of putrefactive infection relies primarily on prompt and adequate surgical intervention at the source of the infection. This involves wide incision of the infectious focus as well as debridement (excavation) of non-viable (nerotic) tissues. Mechanical intervention is supplemented by wound cavity irrigation using antiseptics—predominantly oxidizing agents—and other antimicrobial solutions, followed by continuous or fractionated irrigation with antiseptics. Hyperbaric Oxygenation and aerotherapeutic chamber (ATC) treatments have also proven effective. Systemic antibiotic therapy is mandatory. Prescribed medications include semi-synthetic Penicillins (ampicillin, amoxicillin, etc.), Aminoglycosides (gentamicin, kanamycin), chloramphenicol, clindamycin, metronidazole, tienam, mefoxin, polymyxin, ciprofloxacin, and its derivatives.

Intensive detoxification therapy (administration of sodium lactate, polyvinylpyrrolidone, etc.) and energy-supportive therapy (10% glucose solution, lipid emulsions) are administered alongside symptomatic treatments and replacement therapy.

Patients, particularly the elderly, are administered cardiac Glycosides, B-group Vitamins, and ascorbic acid, alongside lung oxygenation and breathing exercises. In rare cases of severe putrefactive infection complicated by gangrene, amputation of the affected limb is performed.

In recent years, The Role of bacteroides in the development of putrefactive infections has been uncovered. Bacteroidal (non-spore-forming anaerobic) infection is considered separately.