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INTRODUCTION

Problem urgency

Acute respiratory infections (SHOUT) remain one of the important problems of public health services, especially with children, because of high risk of development of complications in any terms from the illness beginning that puts forward these infections in number of the most actual in practice of the pediatrist.

Feature SHOUT a virus aetiology at children's age high degree of probability by 3-5 days of illness is to become complicated a bacteriemic infection. Special group of risk are often and it is long ill children, more all inclined to the bacteriemic complications, caused by bacteria, vegetans in respiratory tracts. ORZ, irrespective of an aetiology, is inflammatory process in the respiratory tracts, developing in
Result of that virus, bacteriemic patogeny or their toxic substances, at imperfection of factors local mukotsiliarnoj (not immune) and immune protection, adgezirujutsja on a mucosa with primary alteration of a respiratory epithelium. It induces development of inflammatory reaction. To risk groups on development of acute obstructive diseases of a respiratory tract - a stenosing laryngotracheitis or a laryngotracheobronchitis, carry children with allergic diseases: atopicheskoj anomaly of the constitution, an alimentary and postvaccinal allergy, it is frequent and it is long ill, sensibilizirovannyh previous infections and medicinal therapy. [164, 147, 38]

Till 70-80 years of 20 centuries many authors considered, that acute stenosing laryngotracheitis OSLT (croup) arises in the acute period of a respiratory mono-virus infection and is one of disease symptoms [52, 144, 145, 182, 184].

Last decades in the literature data that detection of respiratory viruses in the top respiratory tracts at children with clinical implications of respiratory disease, and in the absence of those at practically healthy children, is natural [128, 7, 14, 27, 139] According to a number of authors [198, 214] respiratornoyosintsitialnaja an infection (RS) have collected, the parainfluenza of 3rd and 1st types, a flu And and In, an adenovirus, besides the independent importance in disease development, especially at children of early age are a prelude of a bacteriemic inflammation, and all serious forms of an infection are bound to bacteriemic flora (quite often with a hemophilic rod of type b). Associations of originators have paramount value at OSLT at children who are in units of resuscitation and an intensive care (ORIT), and cause development of serious forms of disease and lethal outcomes. In the literature there is a description of the casuistic observation OSLT caused Pasterella
haemolitica (Gram-negative aerobes) which has been allocated from a trachea at 9й the monthly girl [210, 118].

Any is conditional-pathogenic flora, besides the independent importance in aetiology OSLT, at long persistentsii causes not only disbioticheskie processes in an organism, but also promotes development of a bacteriemic sensibilization and formation of a respiratory allergosis. Frequency of revealing of a sensibilization to bacteriemic allergens at children with diseases of a respiratory tract fluctuates from 20 % to 40 %. Also through the changed mucosas of the top respiratory tracts and an intestine there is an absorption of bacteriemic endotoxins in blood that conducts to suppression of immunologic resistance and an allergization [6, 15, 19, 24, 107, 171, 156].

Acknowledgement to that is the fact of high level of a carriage of an is conditional-pathogenic bacteriemic microflora, especially among the preschool children visiting kindergartens and a day nursery, leading during an acute respiratory infection to complications. Therefore patients of this age category often have an admixed aetiology zabolevanja. In the Russian Federation according to the official statistics on their share it is necessary about 77 % of injury from all infectious diseases [106].

In modern understanding disbioz is not illness, and represents disturbance of balance of the microflora, capable to cause a number of diseases.

On a boundary XX - the XXI-st centuries representation about ekosisteme a human body as about one more "organ", covering in the form of Membranula mucosas and a skin of the person was generated. Remaining invisible, this "organ" which size 3-5 kg has the mass,
Totals an order of 1014 cells of microorganisms, that ten times there is more than number of cells of a human body [177].

However, studying of a spectrum of the microorganisms living at the person, on present time is carried out routine by crops of contents of various organs and cavities on nutrient mediums that does not reflect a true picture of a microbiocenosis as microbic communities live attached to a surface mucous, forming Biomembranulas balanced on specific structure and functional distribution.

According to prof. A.N.Majanskogo the cavitary microflora (svobodnozhivushchaja, or planktonic) mismatches pristenochnoj to Biomembranula which is stabler and is physiologic. Quoting A.N.Majanskogo regarding definition of a dysbacteriosis of an intestine on excrements it is impossible to disagree that Actually this expensive (demanding testing in dynamics), labour-consuming research with low (if not with zero) return.

Therefore kulturalnyj diagnostics method for today of has got rid! Why? Yes because there is no screening, the doctor should define - what group of microbes to define and what method: crops on mushrooms, on aerobes, anaeroby, on metabolites. And if it is necessary to investigate a material on presence of chlamydias, viruses, tuberculosis micobacteria it is necessary to address in specialised laboratory. Thus the probability of revealing real patogena is small for the reason, that it try to tap in sterile medium - urine, blood, liquor, pus, an exsudate - liquids which have the developed antigenic system, and hypothetically in them there should not be teleorgnic microorganisms. At testing of resistance of the clinical strain in vitroвозникает a number of difficulties: the allocated strain seldom is the true or unique agent of an inflammation, sensitivity to antibiotics in vivo, as is known, is far from sensitivity in cup Petri. More precisely - microbic community in
Biomembranula condition at quorum-sensingignoriruet any strongest antibiotics. [189].

According to data akad. A.A.Vorobeva (2010г.), the infection patholologically (clinically significant is considered in case of an organ becoming infected, in which there is Biomembranula of microbic cells (WHICH> 103) for occurrence quorum sensing - generalisation of genetic, trophic, power, toxic, pathogenetic activity of microbic community. Thus, the absolute proof of an etiological role of a microorganism in disease is its detection in tissues, a secret, bloods of the patient. [50].

Unfortunately, in daily practice of the doctor the above-stated ways of verification of the originator of disease are not accessible. Nevertheless, in a century of demonstrative medicine and modern representation about ekosisteme an organism has ripened necessity for wider application of hi-tech methods of diagnostics.

Our attention was involved with a method of molecular diagnostics which has appeared in Russia in the early nineties of the XX-th century. The given method of diagnostics is based on revealing of a spectrum of microorganisms in various objects on chemical substances specific to them - to markers from among fat acids, aldehydes and the sterols which are a part of their cellular wall. The method of detecting of microorganisms on fat acids or a method of a gas chromatography in a combination to mass spectrometry is similar genetic (PTSR, definition of sequence of nucleotides 1€? sl3I ІК and so forth) as the structure of fat acids is determined in DNA and is reproduced by replikatsii a site genoma transport РІК and subsequent synthesis ZHK in mitochondrions on matrix РІК. [87, 102].

In it basic difference of method GH-MS of the microbic markers, qualitatively new property giving to it - possibility of decomposing of superposition of all pool of microbic markers that allows to estimate the contribution from each of hundreds species of microorganisms which live, for example, in an intestine. The method is high-strung, fast (2,5 ch on polyonyj the research cycle), universal, economic and has a wide diagnostic spectrum. Introduction GH-MS gives the chance to reduce time and research cost, passing stages of repeated resowings of primary colonies and test fermentations which are especially difficult, labour-consuming and long for anaerobov. The method allows not only to define markernye substances (fat acids, aldehydes, alcohols and sterols) in pure cultures of the microorganisms allocated from klinicheyoskogo of a material on known technology, but also quantitatively to establish structure of microbic community which is covered behind a set of markers of concrete assay [95, 103, 196, 179, 135, 161, 95].

Considering small informativnost results of routine bacteriological methods of etiological decoding

Bacteriemic complications at children with the respiratory infections, top respiratory tracts proceeding with obstruction (a larynx stenosis), now has ripened necessity of use of modern hi-tech methods of diagnostics allowing with larger reliability to judge an aetiology of acute respiratory diseases, proceeding with OSLT in variants of a fixing current and relapses of obstruction of a larynx. All it defines an urgency of the present research.

The purpose and research problems

Research objective: studying of aetiology OSL (groats) by means of modern methods of diagnostics, allowing to estimate an organism condition as uniform ekosistemu, for a representation excavation about a role of a bacteriemic infection and factors of its pathogenicity on a current of disease and a substantiation of timely appointment of a causal treatment.

Research problems:

1. To study a new direction in molecular microbic diagnostics for

Mikst-infection revealings, disbiozov and inflammatory processes on specific markers (to fat acids, aldehydes and sterolam) by means of hromato-mass spectrometry in blood, a saliva at children with OSL (croup).

2. To study frequency of occurrence of virusno-bacteriemic associations at

OSL (groats) at children.

3. To define character of a microflora of the top respiratory tracts taking into account factors of pathogenicity of bacteriemic flora.

4. To develop diagnostic algorithm OSL (groats) of a virus and bacteriemic aetiology of disease to leading clinical signs from positions of demonstrative medicine and to solve a question on timely appointment of a causal treatment.

5. To estimate efficiency of system antibacterial therapy and the preparations strengthening a causal treatment at children with OSL (croup).

Scientific novelty:

1. For the first time at children with OSL (croup) the aetiology of disease by results of allocation of microorganisms from a saliva and blood by means of a method of a gas chromatography - mass spectrometry is studied.

2. For the first time it is shown, that the organism of the child represents uniform ekosistemu. For revealing of the etiological factor it is possible
To be guided by indicators of any one medium, avoiding invasive methods of diagnostics.

3. For the first time it is shown, that in aetiology OSL (groats) children always have a mikst-infection. The bacteriemic flora is presented basically by colonisation aktinomitsetov and anaerobov. Respiratory viruses are allocated at all children in the acute period of disease with method PTSR.

4. For the first time at children with OSL (croup) the estimation of the form of gravity of disease by means of LII and JAII is spent.

5. For the first time treatment of children with OSL (croup) with bacteriemic complications not only antibiotics, but also the preparations strengthening a causal treatment is offered.

The practical importance. Results of the present research have shown, that at children with OSL (croup) in a disease aetiology the mikst-infection often takes place. For today, at presence at children with OSL (croup) of signs of a probable virusno-bacteriemic infection, it is possible to tell with confidence, that at them the bacteriemic aetiology of disease prevails. And even if the doctor doubts necessity of appointment of an antibacterial preparation it is better to prescribe it before reception of objective data of a bacteriemic infection. Further in the absence of clinic and laboratory signs of a bacteriemic infection the antibiotic can be cancelled (not to spend so-called "course" for 7 and more days), that reduces fastness of microorganisms. For the purpose of the prevention of bacteriemic complications it is necessary for doctors of an out-patient network to strengthen volume of laboratory inspection, to carry out the treatment report at ORVI and a flu, especially at children of early age. At children with OSL (croup) with bacteriemic complications in the absence of positive dynamics during disease the empirical choice of antibiotics should be from group linkozamidov, ingibitorzashchishchennyh
Penicillinums, cephalosporins III-IV of generations, glikopeptidov as the basic representatives of bacteriemic flora are aerobic aktinomitsety and anaeroby. In work efficiency of the etiotropic antibacterial preparation roksigeksal influencing cupping of the basic symptoms of disease is shown. Criteria of treatment was presence eradikatsii patogenov. Use in therapy of the preparations intensifying a causal treatment, influencing an organism homeostasis, in particular preparation Vobenzim is proved.

The substantive provisions which are taken out on protection:

1. At children with OSL (croup) the disease aetiology is presented now by a mikst-infection. The bacteriemic flora is presented by colonisation anaerobov to 50 % of cases of observation, aktinomitsetov in 20 %, other aerobes have made 30 %, of them the originators taped in bacteriological laboratories, have made 15,6 %. Primary colonisation possess Streptococcus, Nocardia, Streptomyces and other is conditional-pathogenic flora.

2. In revealing of genesis OSL (croup) it is possible to be guided by indicators of any one medium, avoiding invasive methods of diagnostics as the organism of the child represents uniform ekosistemu.

3. Children with OSL (croup) always have a mikst-infection. The bacteriemic flora is presented basically by colonisation aktinomitsetov and anaerobov. Respiratory viruses are allocated at all children in the acute period of disease with method PTSR.

4. The given fact pathogenetically proves causal treatment appointment, and also the preparations strengthening their action at children with OSL (croup) for normalisation of a microflora and restoration mukozalnoj of protection.

Introduction in practice Results of research are introduced in practice of work of the Morozovsky children's city hospital, recommended for wide use in practical public health services. Work substantive provisions are used in practice of a lecture course and seminar employment on chair of infectious diseases at children №1 pediatric faculties GBOU VPO RNIMU of N.I.Pirogova of Ministry of Health of Russia.

Dissertation approbation. Materials of dissertational work are reported and discussed at joint session of scientifically-practical conference of employees of chair of infectious diseases at children №1 pediatric faculties GBOU VPO RNIMU of N.I.Pirogova of Ministry of Health of Russia and employees of units GBUZ Morozovsky DGKB DZM.

The basic results of work are reported at session of infectious section of the Moscow unit of the Union of pediatrists of Russia (Moscow, 2010,2011гг.) and on IX-X the congresses of nurseries infektsionistov Russia (Moscow, 2010-2011гг).

Publications. On a dissertation theme 27 printing works, including articles in leading reviewed scientific magazines recommended VAK to the edition are published.

Structure and dissertation volume

The dissertation is stated on _______________ pages of the typewritten text,

Contains 3 extracts from case histories, ___ tables, ___ drawings. The dissertation consists of introduction, the review of the literature, the description of materials and research methods, 4 heads of own researches, the conclusion, conclusions, practical references and the index of the literature including 172 domestic and 54 foreign sources.

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Scientific source FELDFIKS LARISSA IZEVNA. ROLE of the BACTERIEMIC INFECTION AT the ACUTE STENOSING LARYNGITIS (CROUP) At CHILDREN. The dissertation on competition of a scientific degree of the candidate of medical sciences. Moscow - 2014. 2014

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