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4.1. Studying of a microbiocenosis of a stomatopharynx and an intestine in nasopharyngeal washouts and excrements

At carrying out of laboratory methods of inspection we used methods of diagnostics of children with OSL (croup) so that it was possible to establish the leading part of a virus and-or bacteriemic aetiology of disease from positions of demonstrative medicine, to estimate the form of gravity and necessity of timely appointment of a causal treatment.

For the purpose of revealing of an aetiology of disease bacteriological, virologic and mass spectrometer methods of research have been spent.

To define at each patient presence of a respiratory virus in stomatopharynx washout it is inexpedient, as it is already proved, as at healthy children it is possible by means of PTSR to allocate respiratory viruses from a stomatopharynx (a drawing 4)

Drawing 4. Results of research of nasopharyngeal washouts at CHBD c ORZ (n=55) - I and without ORZ (n=51) - II method PTSR (Zamahina E.V., 2009г.

And at carrying out of selective virologic researches at all children it was defined any, and it is frequent and 2 respiratory viruses. Prevalence of this or that respiratory virus in sample depended on a season when research (a drawing 5) was carried out.


Drawing 5. Aetiology ORVI at 60 children OSL (croup) (ІХ - XI 2008г)

As a result of numerous researches of a microbiocenosis of a stomatopharynx by a bacteriological method it has been taped, that the received results directly are bound to quality of work of microbiological laboratory. So, at studying of frequency of detection of microorganisms in crops of slime from a nose and a stomatopharynx at 2761 patients, being on treatment in MDGKB for 2007г. By a bacteriological method it has been taped, that in 62,4 % of cases of observation the negative result (a drawing 6) became perceptible.


Drawing 6. Frequency of detection of microorganisms in crops of slime from a nose and a stomatopharynx at 2761 patients, being on treatment in MDGKB for 2007г. A bacteriological method

The similar situation cannot be only because in the existing order 535 from 22.04.1985г. Research of a biocenosis of a stomatopharynx is spent not only qualitative way, but also the quantitative maintenance of microorganisms on mucous stomatopharynxes taking into account the existing norms calculated in WHICH/TAMPON is defined. According to the methodical references stated in the order №535 MZ Russian Federation from 1985г., following specifications have been accepted: Staph. aureus-101-102; Str. haemolyticus - 103-104; Enterococcus - 101-102; E. coli - 101-102; C. albicans - 101-102; Bacillus - 102; Klebsiella 101-102; Streptococcus 103-104; Staph. saprophyticus 101; Candida sp. - 101.


At selective carrying out of bacteriological inspection in laboratory of microbiology NIIEiM of N.F.Gamaleja for I - V 2007г. At each patient it was sowed on 3-4-5 originators, but their bacteriemic spectrum also corresponded to "the laboratory standard.

Drawing 7. Frequency of detection of microorganisms in crops of slime from a stomatopharynx at 60 sick OSL (croup) with bacteriemic complications (according to NIIEiM of N.F.Gamaleja for I - V 2007г)

At research of patients with OSL (croup) during 2006г. Also in laboratory of microbiology NIIEiM of N.F.Gamalei among the allocated microorganisms most often and with high degree obsemenennosti at children golden and saprophytic staphilococcuses (65 %), haemophilus spp were found out. (62,5 %), streptococcuses of various kinds (an alpha, beta and scale) (60 %), are much more rare mushrooms of sort Candida and others patogeny.


On the basis of microbiological shifts at 29 (72,5 %) patients it became perceptible disbioz oral cavities of III degree, at 11 (27,5 %) - disbioz IV degrees. However, the spectrum sowed patogenov remained former (a drawing 8).

Drawing 8. Frequency of detection of microorganisms in crops of slime from a stomatopharynx at patients OSL (croup) n=80

(By data laboratory of microbiology NIIEiM of N.F.Gamalei, 2006г).

At carrying out of microbiological research of a microflora of a stomatopharynx staphilococcuses among which golden made 45 % were found out in children with ORVI among the allocated microorganisms in 25,8 %; in 24,4 % - streptococcuses among which beta and alpha hemolitic made 24,4 %; in 14 % - nejsserii among which in 43 % of cases log a caption was> 6; in 14 % - haemophilus spp.; in 6 % - mushrooms of sort Candida; in 10,1 % others were allocated patogeny.


On the basis of microbiological shifts at 38 (76 %) we diagnosed patients it became perceptible disbioz oral cavities of III degree, at 12 (24 %) - disbioz IV degrees. (A drawing 9)

Drawing 9. A biocenosis of a stomatopharynx at patients ORVI (n=200) (according to NIIEiM of N.F.Gamaleja for 2006г)

Thus, the obtained data testify that at carrying out of a bacteriological method of research at each child the flora "traditional" for microbiological inspection is allocated, but with various level of colonisation.

At carrying out of microbiological research of a microflora of an intestine at children with OSL (croup) among the allocated microorganisms typical for a biocenosis of an intestine the flora also was allocated.

On set clinico-datas of laboratory at 21 (56,8 %) patients diagnosed disbioz an intestine of III degree, at 16 (43,2 %) - disbioz IV degrees (a drawing 10).


Drawing 10. A biocenosis of an intestine at patients OSL (croup) with

Bacteriemic complications (n=106) (according to microbiological laboratory "Инвитро" for 2008г)

In obligate flora of an intestine at patients OSL (croup) with bacteriemic complications became perceptible at 34 (91,8 %) children - deficiency laktobaktery, at 21 (56,8 %) - an intestinal rod, at 18 (48,6 %) - fecal streptococcuses, at 27 (73 %) - bifidobaktery, at 15 (40,5 %) the golden staphilococcus, at 9 (24,3 %) - laktozootritsatelnaja culture enterobaktery (fig. unok 11) is allocated.

Drawing 11. Obligate flora of an intestine at patients OSL (croup) with bacteriemic complications

Facultative flora of an intestine at patients OSL (croup) with

Bacteriemic complications it has been presented by the big colonisation both pathogenic, and is conditional-pathogenic flora (рисунок.12).

Drawing 12. Facultative flora of an intestine at patients

OSL (croup) with bacteriemic complications

Thus, at carrying out bakteriologichenskogo studying of a microbiocenosis of washouts from a stomatopharynx and intestine flora presence of the identical flora which are colonizing all mucosas GASTROINTESTINAL TRACT and being "traditional" for given method of inspection has been taped.

Clinical example 1

As example OSL (relapsing croup) with presence expressed disbioticheskih changes in a stomatopharynx it is resulted following observation.

Yaroslav V, suffers 10 years a relapsing croup with 2001г., at the moment of inspection croup relapse became perceptible 8 times, last - in 2009г. For the first time the croup has developed in 1,5 years, within the next years repeated on 2 times a year with constant hospitalisation in a hospital. Croup relapses have been bound with ORVI, at each disease received antibacterial therapy.

From the anamnesis it is known, that the child from 1 pregnancy proceeding with a toxicosis in 1st half of pregnancy. Labours in time, estestvenym by. The period novorozhdennosti proceeded without features. Was on the admixed feeding about 4 months, then has been translated on artificial feeding then allergic reactions in the form of spotty-papular enanthesises began to become perceptible. The polyvalent allergy further has developed. It is inoculated on age, after introduction of a meningococcal vaccine the next relapse of a croup has developed. From the transferred diseases: monthly ORVI till 7 years, 2 times a bronchitis, a chicken pox.

Heredity: at mother allergic reactions to medicines to edematization Kvinke, at the grandmother in the area of mother - dermatoyorespiratornyj a syndrome, at the cousin - relapsing croup (till 12 years it became perceptible to 30 times), at one cousin from the same family - frequent ORVI with the laryngitis phenomena become perceptible.

At survey shows complaints on frequent ORVI, pershenie in a stomatopharynx, chihanie, nervousness. At survey the general condition of moderate severity level, state of health is broken: dry tussis, nervousness, a rhinorrhea bound with frequent chihaniem periodically becomes perceptible.

At survey: integuments acyanotic, a periorbital cyanosis, expression of a vascular drawing on a head skin. The boy of a correct constitution. Appetite is lowered, is physically a little active. Plural cervical, submandibular, axillary, inguinal lymphonoduses in the size 1,0х1,5мм, elastic, painless, not soldered to surrounding fat are palpated.

Mucous stomatopharynxes with the phenomena of a congestive hyperemia, the back wall of a pharynx brightly giperemirovana, with set of lymphoid formations, flows down viscous slime. Palatine tonsils are hypertrophied, quaggy, with allocated lacunas Tongue is total is imposed by white-yellow dense scurf. Nasal breath is complicated, it becomes perceptible seroznognojnoe a discharge. At a percussion of lungs the sound with a bandbox shade is defined pulmonary. Breath in lungs rigid, is spent to all departments. Cardiac sounds sonorous, rhythmical, systolic hum in P-m mezhrebere at the left and on an apex, which is auscultated at an exercise stress not narostaet. The stomach soft, is accessible to a deep palpation, painful in epigastric area, the liver and a lien do not act from under edge of a costal arch. Diarrhoeia episodes periodically become perceptible. The child flaccid, at survey a little contact. At school progress good, but is engaged basically at home.

At inspection:

1. In the general analysis of blood: Hb-112 a g/l; erythrocytes - 4,9h1012/l; leucocytes - 8,5h109/l; (the leukocytic formula: has fallen. - 5 %, segm. - 34 %, lymphs. - 52 %, mon. - 1 %, eoz.-8 %); an ESR-14 mm/hour.

2. In the general analysis of urine of a pathology it is not taped.

3. At research of a biocenosis of a stomatopharynx: Staph. aureus-105; Str. haemolyticus-104; Enterococcus-103; E. coli - 104; C. albicans-105; Bacillus - 104; Klebsiella-105; Streptococcus-107; Staph. saprophyticus - 104; Candida sp. - 103, Branhamela catarrhalis-104. (At norm Staph. aureus-101-102; Str. haemolyticus - 103-104; Enterococcus - 101-102; E. coli - 101-102; C. albicans - 101-102; Bacillus - 102; Klebsiella 101-102; Streptococcus 103-104; Staph. saprophyticus 101; Candida sp. - 101) (research was spent in microbiological laboratory NiIeiM of N.F.Gamalei).

The analysis of results of research has shown presence disbioza stomatopharynxes of IV degree at the expense of a prevalence of colonisation of pathogenic and fungoid flora.

On the basis of data of the anamnesis, the objective survey, the given laboratory methods of inspection it is possible to think of the diagnosis: OSL (relapsing croup). An allergic rhinitis. A chronic hypertrophic pharyngitis. An adenoid disease, the compensated form. Chronic gastroduodenit. Disbioz stomatopharynxes of IV degree. The conclusion. In this case at the child with OSL (relapsing croup), having a chronic ENT-pathology of a stomatopharynx, takes place the expressed colonisation by microorganisms of a stomatopharynx at the expense of a prevalence of streptococcuses among aerobic microorganisms and detection Branchamella catarrhalis, not characteristic for normotsenoza which can promote kolonizatsionnoj to resistance of an organism.

4.2. Studying of factors of pathogenicity and other probable signs of a bacteriemic infection

Considering uniformity of allocation of bacteriemic markers at surveyed children and impossibility of definition of the core or the basic originators in an aetiology of disease for the purpose of verification of the possible

Changes of clinical semiology and the form of gravity of current infectious process we have resorted to definition of metabolites of a staphilococcus - staphylococcal enterotoxins (SE. Work it was spent to laboratories of microbiology NIIEiM of N.F.Gamalei, 2008г. D.b.n. Fluer F.S., zav.lab. D.b.n., the prof. Prokhorov V. JA.

At the moment of research there was a definition possibility only Enterotoxins And and In which were allocated in pure culture Staphylococcus.

From 10 surveyed children at 4 children has been allocated Staph. Aureus; at 2 - Staph. Epidermidis; at 2 - Staph.haemolyticus; at 1-Staph. Capitis; at 1-Staph.xylosus;. The majority (80 %) children were younger age.

In clinic of disease at these children we did not note any features.

As a result of the spent inspection in one case of observation we had no positive take. In definition of toxins on the research spent by us it is possible to explain the received negative results to that in all cases of observation at reception of antibacterial therapy sensitive strains to an antibiotic disappeared or changed the kulturalnye properties.

Definition of other enterotoxins most likely was inexpedient, as more often (by data d.b.n. Fluer F.S., zav.lab. d.b.n., the prof. Prokhorov V. JA) is allocated SE "And" and "In".

Acknowledgement to that is research spent by the employee of our chair Adeishvili P. S which surveyed 10 patients with an infectious mononucleosis at which applyings on tonsils became perceptible. At bacteriological research has been allocated Staph., all these children did not receive before inspection of antibacterial therapy.

As a result of the spent inspection at patients with an infectious mononucleosis in 90 % of cases toxin "And", in 80 %-токсин "In", in 40 % - toxin "D" was defined.

Таблица2 DEFINITION ENTEROTOKSIGENNOSTI STAPHYLOCOCCUS on production (SEA, SEB, SECI2, SED, SEE) and toxin of a toxic shock (TSST-1) laboratory of microbiology NIIEiM of N.F.Gamalei, 2008г. D.b.n. Fluer F.S., zav.lab. D.b.n., the prof. Prokhorov V. JA.

Besides for an estimation of the form of gravity and expression of inflammatory reaction we used nuclear and leukocytic indexes of an intoxication which counted by results of the general analysis of blood. By means of simple calculation it is objectively registered both srednetjazhelaja, and dekompensirovannaja the form of gravity of disease which develops because an appreciable part of toxic products of the albuminous nature and endotoxins is fixed on microclots and units and, being switched off from the general blood flow, reduces toxicity of blood.

As a result of the spent inspection at all children the disease form became perceptible sredneyotjazhelaja. However, the average form of gravity with moderate signs of an intoxication became perceptible only at 29,5 % of patients, in 70,5 % of cases of observation disease proceeded with the expressed signs of an intoxication (a drawing ___).


Drawing 13 Form of gravity of disease at patients OSL (croup) with bacteriemic complications on a nuclear index of an intoxication (JAII) (n=106)

S-jet fiber defined (SRB) at 32 patients, its average value have made - 0,012 yo 0,2 g/l (at norm> 70 mg/l = 0,007 g/l)

Thus, the obtained data about absence SE at children with OSL (croup) against treatment by antibacterial preparations testify to inexpediency of carrying out of a similar method of diagnostics for specification of an aetiology of disease. Besides allocation SE is long enough process, that also is an obstacle for the timely equipment of an aetiology of disease. Definition SRB and JAII are exact and fast methods for acknowledgement of a bacteriemic aetiology of disease, however in clinical practice "delay" of changes from laboratory methods of research quite often becomes perceptible. Therefore now constantly there is a search of more perfect methods of diagnostics allowing quickly and is high-grade to estimate a disease aetiology.


As an example of serious current OSL (croup) at which it did not become perceptible authentic signs of a bacteriemic infection (change of laboratory indicators have been delayed in comparison with disease clinic) it is resulted following observation.

Clinical example 2

Azamat b.nahodilsja in unit of resuscitation MDGKB with 03-05.04.2010г. In 18 i/o 05-27.04.2010г. Concerning the diagnosis: the Acute stenosing laryngitis (croup), a stenosis of a larynx of II degree against ORVI. An obstructive bronchitis, DN II degrees.

The child from mother of 38 years somaticheski healthy, from 6 pregnancies, proceeding with a toxicosis in 2 half of pregnancy (was on hospitalisation) from 3 overdue sorts on 42 week of pregnancy

At a birth body mass = 4620грамм Has cried at once, has been enclosed to a breast for 3 days (in connection with a grave condition of mother - plural ruptures).vypisan for 11 days. Dews also developed according to age. On the dispensary account at experts does not consist. Was on smeshennom feeding till 3,5 months, and then in connection with departure of mother has been translated on artificial feeding (an admixture agusha-1).v 4 months in connection with the phenomena disbioza and changes of character of a chair have been translated on admixture NAN-1. C 4х months has started to receive the first feeding up-boiled rice, since 4,5 months fruit juice (apple, peach).pervyj the tooth has appeared in 5 months. The transferred diseases: was ill for the first time, antibiotics did not receive. 7 day-vaccination against a tuberculosis is inoculated according to the accepted national calendar прививок:первые 12 hours of a life - the first bacterination against V.Na's virus hepatitis. В3 month - the first
Bacterination against a diphtheria, a whooping cough, a tetanus, the first bacterination against the poliomyelitis, the second bacterination against V.Otmechalas's virus hepatitis reaction to introduction of a vaccine against a diphtheria, a whooping cough, a tetanus and a poliomyelitis in the form of lifting of temperature to 38,0C within 2 days. In 5 months (16.03) second bacterination against a diphtheria, a whooping cough, a tetanus, the second bacterination against a poliomyelitis. Reaction to introduction of a vaccine in the form of temperature lifting do37,8 - 38,0C within 2 days also became perceptible. Presence of allergic diseases and reactions to medicines, household and alimentary allergens denies. At the allergist it is not observed. Presence at relatives of allergic diseases denies. Social conditions satisfactory. Lives in separate 2h-apartment on 4 floor, with 4 adults (mum, the daddy, sister of 17 years).

The epidemiological anamnesis: contacts to infectious patients denies.

01.04.10г. Mother has noted occurrence of a white fur, gums, mucous cheeks, a plentiful sialosis. Were treated independently (processed mucous a soda solution). 02.04 has processed mucous a mouth solution Ljugolja and has given to the child streptocide powder in the evening. The aggravation of symptoms 02.04 evening became perceptible: lifting of temperature to 39,5С independently tried to lower temperature (a nonsteroid antiinflammatory preparation-suspension nurofen 2,5 ml inside). There was a dyspnea, dry кашель.03.04 repeated lifting of temperature to 39,5С have repeatedly given to the child a nonsteroid antiinflammatory preparation (suspension nurofen 2,5 ml inside). Effect was not. The brigade of the first help has been caused. By a first aid brigade at a pre-hospital stage it has been spent: the combined broncholitic preparation: berodual 6 drops ingaljatsiono with the help nebulajzera; gljukokortikosteroid for local application: pulmikort 0,25 mg ingaljatsiono with the help nebulajzera; The synthetic hormonal
Preparation: a solution deksametozona 2 mg intramusculary; during transportation an oxygenotherapy.

The child has been delivered by a brigade of the first help in intensive care unit MDKB with the diagnosis: the Acute stenosing laryngotracheitis (croup), a stenosis of a larynx of III degree against ORVI. An obstructive bronchitis, DN 2-3 degrees.

At survey in intensive care unit MDGKB: the Condition serious. Uneasy. A voice osiplyj. The big fontanel of 1,5*1,5 sm does not pulse, not vybuhaet. Integuments pure, hot, acyanotic, a Crocq's disease, a periorbital cyanosis. Toxicosis symptoms are expressed. Mucous light pink, pure. Breath independent, rhythmical, the inspiratory dyspnea is expressed. Tussis rare, barking. At auscultation breath weakened to be spent over a surface of both lungs, symmetric. A tachycardia.

At inspection it is taped: Gas structure of blood

03апр 04апр 05апр
13:48 16:00 10:00 14:47 23:49 10:22
pH 7,294 7,234 7,405 7,421 7,41 7,431 7,437
pCO2 45,4 49,6 30,5 32,2 31,9 34,7 34,2
pO2 60,2 192 302 49,2 156 167 56,9
sO2 90,3 99,4 100,6 88,5 99,7 99,5 93,6
ABEc -4,6 -6,8 -4,7 -2,8 -3,6 -0,8 -0,8
SBEc -4,1 -6 -5,1 -3,2 -4 -1 -1
zaklju Dekompen Kompens Kompens Kompens Kompens No No

chenija sirovan irovan irovan irovan irovan patol patol
It is admixed It is admixed Metabolum Metabolum Metabolum ogii ogii
Acidosis Acidosis ich ich ich
atsmdoz atsmdoz atsmdoz

On the roentgenogram of organs of a thorax executed laying on an exhalation. The shade sredostenja is displaced to the right at the expense of turn. In visible departments of lungs the vascular drawing is enriched. The right contour of a vascular fascicle vybuhaet, possibly, for the account summatsii with a thymic gland. Heart is wide prilezhit to a diaphragm. A diaphragm accurate. Sine are differentiated. Distal department i.v. a catheter on the right at level of body C2. Виgна a shade of a thick catheter at level of a back piece of V rib at the left.

In the general analysis of blood from 03.04 (3rd day of illness): Hb-117 a g/l; erythrocytes - 4,5h1012/l; leucocytes - 12,6h109/l; (п-9 %, s-41 %, l-40 %, m-5 %, e-5 %); an ESR-20 mm/hour. In the general analysis of urine from 04.04. lithates in a significant amount, fiber-0,040; other indicators in norm.

In the biochemical analysis of blood: the general fiber - 64 (65-85 g/l); Triglycerides - 6,65 (0,45-1,7 mmol/l); V-lipoproteidy - 28 (35-55 Units);

Seromucoid - 0,27 (0,100-0,200 Units); LDG - 605 (To 480 Ed/l); SRB - 0,004 (to 0,001g/l). Other indicators in norm.

Treatment has been prescribed: punktsionnaja a catheterization of a subclavial vein on the right on Seldingeru, TSeftriakson 500мг*2 time i.v. strujno; Dexasonum of 6 mg i.v. strujno; infusional therapy; berodual 5 drops ingaljatsiono with the help nebulajzera; pulmikort 0,25 mg ingaljatsiono with the help nebulajzera. After the spent therapy in intensive care unit the condition has improved, the child is translated in 18 infectious unit.

For a moment entering in unit: a condition serious, the child is uneasy. A skin swarty, on a scrotum, in inguinal areas fine pjatnistoyopapuleznaja an eruption. Mucous stomatopharynxes giperemirovany, become perceptible belesovatye applyings on tonsils. A voice osiplyj, tussis dry
The barking. There is an inspiratory dyspnea at a load. At auscultation breath rigid, wire rhonchuses from both parties. A stomach soft, painless. Liver augmentation + 4. A chair was not. An emiction free.

The conclusion: on the basis of data of the anamnesis of disease, data of survey at the child the diagnosis takes place: the Acute stenosing laryngitis (croup), a stenosis of a larynx of II degree against acute respiratory disease. An obstructive bronchitis, DN II degrees. A fungoid dermatitis

Thus, the set clinical example objectively proves the leading part of a bacteriemic infection in disease development, thus authentic signs of a bacteriemic infection at the moment of inspection of the child were absent. The similar situation in practice of the doctor meets not seldom. Therefore in daily practice it is not obligatory to wait
Authentic signs of a bacteriemic infection for the purpose of defensible appointment of an etiotropic preparation.

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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

Other medical related information 4.1. Studying of a microbiocenosis of a stomatopharynx and an intestine in nasopharyngeal washouts and excrements:

  1. CHAPTER 4. DISCUSSION
  2. 1. Modern representations about an aetiology and a pathogenesis of functional disturbances of a motility of organs of digestion
  3. the Role korotkotsepochechnyh fat acids in an intestine of the person
  4. Chapter 4 Discussion of the received results
  5. the List of the used literature:
  6. INTRODUCTION
  7. the Maintenance
  8. modern representation about an aetiology and a pathogenesis of an acute stenosing laryngitis (croup) at children
  9. inspection methods
  10. CHAPTER 4. RESULTS OF STUDYING OF THE MICROFLORA OF THE STOMATOPHARYNX AND THE INTESTINE BY MEANS OF THE BACTERIOLOGICAL METHOD OF RESEARCH WITH DEFINITION OF FACTORS OF PATHOGENICITY OF STAPHILOCOCCUSES AND DEGREES OF THE ENDOGENOUS INTOXICATION
  11. 4.1. Studying of a microbiocenosis of a stomatopharynx and an intestine in nasopharyngeal washouts and excrements
  12. 6.2 Results of application of a preparation of system enzymotherapy (Vobenzim) as an agent strengthening action of a causal treatment at children with OSL (croup)
  13. THE CONCLUSION
  14. THE LITERATURE LIST
  15. ophthalmologic implications of a nephrological pathology
  16. THE LITERATURE LIST