RU2705415C1 - Diagnostic technique of staphylococcal abdominal surgical infection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for diagnosing staphylococcal abdominal surgical infection. Biological liquids are analyzed. Concentration of immunoglobulin G and fibrinogen degradation products is determined in surgical patients with postoperative peritonitis in blood serum and peritoneal fluid simultaneously. A DC diagnostic coefficient is calculated by formula: DC=(IGG_BS/IGG_PF)x(FDP_PF/FDP_BS), where: DC – diagnostic coefficient of presence of staphylococcal abdominal surgical infection; IGG_BS is concentration of blood serum immunoglobulin G (g/l); IGG_PF is concentration of immunoglobulin G in peritoneal fluid (g/l); FDP_PF – concentration of fibrinogen degradation products in peritoneal fluid (mg/l); FDP_BS is concentration of fibrinogen degradation products in blood serum (mg/l). If the DC coefficient is equal to or greater than 2.4, the presence of staphylococcal abdominal infection is diagnosed.

EFFECT: method provides more effective diagnosis of staphylococcal abdominal surgical infection ensured by simultaneous quantitative determination of blood serum and peritoneal fluid of two proteins – immunoglobulin G and fibrinogen degradation products.

1 cl, 1 dwg, 2 tbl, 4 ex

Description

The invention relates to medicine, namely to surgery and can be used for preliminary diagnosis of staphylococcal abdominal surgical infection.

An analysis of the mortality structure in patients with abdominal surgical pathology shows that the main cause of death in these patients was and remains peritonitis (Abdominal surgical infection: clinic, diagnosis, antimicrobial therapy. Practical guide / Edited by BC Savelyev, B. R. Gelfand. - M .: Litterra, 2006. - 168 s), and mortality in peritonitis ranges from 18-20%, and with a common form, it rises to 60%. Such a large percentage of mortality in this category of patients is associated with a clinically important feature of intra-abdominal infections, which largely determines the poor prognosis, consisting in the rapid development of a generalized response of the macroorganism in response to the infectious process, due to the action of bacterial endo- and exotoxins and various inflammatory mediators.

Studies in Russian clinics confirm the polymicrobial nature of intra-abdominal infections involving a wide range of aerobic and anaerobic gram-negative and gram-positive bacteria (Gelfand B.R., Gologorsky V.A., Burnevich S.Z. Antibacterial therapy for certain forms of abdominal surgical infection. // Consilium medicum. - 2000. - No. 4. P. 21-26; Savelyev BC, Gelfand BR, Abdominal surgical infection: clinic, diagnostics. Antimicrobial therapy: practical guide 2006. - 168 s; Chernov V.N. Emergency surgeon I: diagnosis and treatment of acute surgical pathology M., 2007. - 350 c)..

However, in 43.62% of cases with abdominal surgical infection, monocultures of pathogenic bacteria are sown from peritoneal exudate (Volkov A.G., Zarivchatsky M.F. Microbial landscape of abdominal surgical infections in patients of a multidisciplinary hospital // Perm Medical Journal. - 2014. - Volume XXXI, No. 1. - S. 53-57).

According to many researchers, in the etiology of peritonitis, the dominant role belongs to the group of Escherichia coli. The share in the structure of Escherichia coli abdominal microorganisms is not less than 40% (Abdominal surgical infection. Russian national recommendations. / Edited by B.C. Saveliev, B.R. Gelfand. - M.: BORGES Company, 2011. - 99 p.).

However, microorganisms of the genera Staphylococcus (from 8.33 to 42.86%) (Volkov A.G., Zarivchatsky M.F. Microbial landscape of abdominal surgical infections in patients of a multidisciplinary hospital) are also significant in the etiological plan // Perm Medical Journal. - 2014. - Volume XXXI, No. 1. - S. 53-57.).

The operating surgeon can sometimes indicate a number of clinical signs on the participation of certain bacteria in the development of intra-abdominal infectious processes: tissue necrosis in inflammatory foci; staining exudate in black; fetid odor of exudate, contents of an abscess or wound, associated with the formation of acidic metabolic products with the participation of anaerobes. Gas formation is most pronounced in the presence of Clostridium spp., Or may be the result of the influence of some optional aerobes; concomitant septic thrombophlebitis and septic embolism of the blood vessels of the liver are characteristic for participation in the pathological process of bacteroids.

However, such quickly received information is biased and directly related to the experience and other subjective qualities of the surgeon (Abdominal surgical infection. Russian national recommendations. / Under the editorship of BC Savelyev, BR Gelfand. - M.: BORGES company, 2011. - 99 from).

Therefore, the only objective and reliable method for the diagnosis of staphylococcal abdominal surgical infection is a bacteriological study, regulated at all stages by official instructions. Data from microbiological studies play a decisive role for the rational antibiotic therapy of abdominal infection in surgery. The final identification of pathogens and determination of their sensitivity to antibacterial drugs is carried out after obtaining a pure culture. The results of native bacterioscopy help in the appointment of primary empirical antibiotic therapy (Yuryukhin I.A., Khrupky V.A., Badikov V.M. http://medbe.ru/materials/infektsii-v-khirurgii/bakteriologicheskava-mikrobiologicheskaya-diagnostika- ranevoy-infektsii).

However, specific bacteriological diagnosis of infection is time-consuming, time-consuming and accessible to few medical institutions: 24-48 hours after sowing, the cultural and morphological properties of grown colonies are evaluated visually and, as a rule, individual colonies are reseeded to specialized media. Then, strains are identified based on the biochemical detection of specific enzyme markers or typical metabolites.

In large treatment centers, accelerated methods of microvolume biochemical identification of bacteria can be used with the help of automatic bacteriological analyzers from Bio Merieux (France) or Dade AG (USA), which can reduce the time of bacteriological studies to 4-6 hours. These devices and consumables they have a high cost, which limits their application (Sivolodsky EP Systematics and identification of enterobacteria. // Pasteur Institute of Epidemiology and Microbiology. Department of New Technologies / Edition third, revised and supplemented. St. Petersburg, 2011. - 21 p.),

Clinical efficacy studies are currently underway on high-tech diagnostic methods for pathogens that dominate the microbial association, regardless of their quantitative content. Such methods include, for example, gas chromatography, which allows one to recognize the characteristic metabolites of individual microbiota, which, by their microbiological properties, can act as dominant pathogens (RF Patent No. 2235325 of 08/26/2002 “Method for determining infected abdominal effusion and a method for treating diseases, accompanied by effusion into the abdominal cavity ").

This should also include modern methods of genetic analysis using artificial polymerase chain reaction (PCR) (RF Patent No. 2509804 of 03.20.2014, “A set of differentiating and specific oligonucleotides for identifying DNA of pathogens of acute intestinal infections, a method for identifying OCI, a microchip and a diagnostic system for way ”).

The disadvantages of all these specific bacteriological methods for identifying the causative agent of surgical abdominal infection are:

- inaccessibility in the foreseeable future for most surgical departments due to the high cost of equipment, reagents and qualified personnel to service the relevant equipment.

- the duration and complexity of the study;

- the need for preliminary production of sufficient biomaterial for research;

- Clinicians question the feasibility of comprehensive microbiological monitoring in the management of patients with abdominal infections.

There are methods for serodiagnosis of the pathogen, based on the detection in the blood of patients of specific antibodies to various bacterial antigens by direct reactions (RPHA) and indirect hemagglutination (RNGA), complement fixation (CSC) and their numerous modifications (Kathanov AM, Klimova LI, Boyko N.A., Tlish M.M. Method for the diagnosis of staphylococcal infection // RF Patent No. 2144190 dated 01/13/1998; Kuznetsov A.A., Kuznetsov O.A., Biletsky S.F., Biletskaya N.I. and identification of bacterial cells // RF Patent No. 2330292 of 07.27.2008).

The main disadvantages of these methods are:

- the inefficiency of serodiagnosis in relation to rapidly developing abdominal infection, since the titer of specific antibodies in the blood increases in response to an infection that has already been transmitted;

- the impossibility of applying serodiagnostic methods in an urgent laboratory service;

- serodiagnosis is unreliable, since the level of specific antibodies to the pathogen varies widely depending on the state of the patient’s immune system and the history of infections.

Among the methods for non-bacteriological diagnosis of infection, there are methods for the biochemical diagnosis of bacterial infection or sepsis, which include blood tests and determination of high levels of marker proteins in the blood serum of patients (Belkov V.V. Complex laboratory diagnosis of systemic infections and sepsis: C-reactive protein, procalcitonin, presepsin 2015. - 117 p .; Chernov V.N., Taranov I.I., Babiev V.F. Method for the diagnosis of anaerobic surgical infection of soft tissues // RF Patent No. 2073245 of 02/10/1997).

The disadvantages of these methods are:

- inefficiency in relation to the diagnosis of the microbiological structure of abdominal surgical infection;

- diagnosis is based on the determination of a certain threshold value of a biochemical analyte in the blood and is not free from various kinds of measurement errors (including those related to hemodilution).

- to establish a diagnosis, a repeated blood test is necessary in the same patient due to the extremely wide range of individual values of biochemical marker proteins.

Closest to our proposed method is a method for diagnosing a bacterial infection in a patient with non-specific complaints, comprising the following steps: (i) providing a sample from the patient’s body, received with non-specific complaints; (ii) determining the level of procalcitonin (PCT) or a fragment thereof of at least 12 amino acids in the aforementioned sample; and (iii) determining the presence or absence of a bacterial infection in the aforementioned patient by comparing the aforementioned determined level of PCT with a predetermined threshold level (Struck J., Nickel K ., Bingisser R., Girsdorf S., Hartmann O. Procalcitonin for the diagnosis of bacterial infections and antibiotic treatment control for patients with non-specific complaints // RF Patent No. 2580278 of 04/10/2016).

The disadvantages of the prototype are:

- the ineffectiveness of the method for the differential diagnosis of gram-positive and gram-negative abdominal surgical infections, each requiring their own antibiotic therapy;

- the limitations of the method - the use of a single parameter (procalcitonin level) gives a minimum of diagnostic information (allows you to distinguish only viral and bacterial infections);

- high cost of equipment and reagents - determination of the concentration of procalcitonin on a chemiluminometer in the format of a PCT test (BRAHMS PCT LIA sensitive) with a sensitivity of 0.007 ng / ml is not available for most clinical laboratories;

- the complexity of the method - the diagnosis is based on complex preliminary calculations of threshold levels of procalcitonin for each variant of immunoassay;

- inefficiency of the method for substantiating etiotropic antibacterial chemotherapy.

The invention is aimed at improving the efficiency of diagnosis of staphylococcal abdominal surgical infection.

The specified technical result is achieved by the fact that in surgical patients with postoperative peritonitis, the concentrations of immunoglobulin G and fibrinogen degradation products are simultaneously determined in blood serum and peritoneal fluid and the diagnostic DC coefficient is calculated by the formula:

Where:

DK - diagnostic coefficient of the presence of staphylococcal abdominal surgical infection;

IGG _SK - the concentration of immunoglobulin G in blood serum (g / l);

IGG _pancreas - the concentration of immunoglobulin G in the peritoneal fluid (g / l);

ПДФ _ПЖ - concentration of fibrinogen degradation products in peritoneal fluid (mg / l);

PDF _SC - concentration of fibrinogen degradation products in blood serum (mg / l);

and when the DC coefficient is equal to or higher than 2.4, the presence of staphylococcal abdominal infection is diagnosed.

In the proposed method for the preliminary diagnosis of staphylococcal abdominal surgical infection, which is able to predict a developing infection in patients with postoperative peritonitis, two proteins are simultaneously quantified in the blood serum and peritoneal fluid - immunoglobulin G (IGG) and fibrinogen degradation products (PDF).

The invention is based on the technical result that we have identified, namely, that when infected with peritoneal fluid (RV), higher concentrations of PDP are found in it than in serum (SC), and vice versa, higher concentrations of IGG in blood than in peritoneal fluid .

Obtaining peritoneal fluid through lavage with physiological saline leads to its dilution and a decrease in the true concentrations of IGG and PDF, as well as the total protein in it. That is, in the clinical practice of an abdominal surgeon, for the biochemical analysis of peritoneal fluid, a diluted fluid is taken, flowing through the drains, distorting the results of the study.

The method does not depend on the degree of dilution of peritoneal fluid.

Parallel measurement of the concentration of IGG and PDF simultaneously in two biological fluids - blood serum and peritoneal fluid allows us to calculate not only the ratio, but also to calculate their product, which we called the diagnostic coefficient of DC. The choice of specific two proteins (IGG and PDF) for the diagnosis of staphylococcal abdominal surgical infection in patients with peritonitis is explained not so much by the fact that both proteins have affinity for staphylococcus, but by the results obtained in animal experiments and in the conditions of a surgical clinic (Tables 1 and 2 )

Previously, in experiments on modeling bacterial peritonitis in laboratory rats by intraperitoneal injection of a monoculture of pathogenic bacteria, we found that, depending on the type of pathogen of abdominal surgical infection, the ratio of a specific protein in the pancreas and SC does not concern all the studied proteins, but only a strictly defined group of proteins ( Table 1).

Experiments in rats to simulate an intraperitoneal infection with a monoculture of pathogenic bacteria, blood serum and peritoneal exudate samples of which were tested in dynamics for levels of C-reactive protein (CRP), lactoferrin (LF), fibrinogen degradation products (PDF), and three classes of immunoglobulins (IgG, IgM, IgA) and lysozyme (LZC), and their multivariate analysis showed that the minimum and sufficient for differential diagnosis of staphylococcal abdominal infection from gram-negative and streptococcal is DC for only two proteins: IGG and PDF (table 1).

That is, rat peritonitis caused by staphylococcal bacteria at doses equal to 0.5 LD ₅₀ led to a significant increase in ratios only for IGG _SC / IGG _RV to 1.66 and PDF _RV / PDF _SC to 1.96 (Table 1).

An even more indicative and sensitive indicator for the diagnosis of staphylococcal abdominal infection (Table 1) is the product of the relations IGG _SC / IGG _RV and PDF _RV / PDF _SC , which we called the diagnostic coefficient DK (DK = IGG _RV / IGG _SC × PDF _RV / PDF _SK ) .

According to the ROC analysis, the threshold value of DC that cut-off cuts off the presence of peritonitis caused by gram-negative abdominal infection from peritonitis with gram-positive abdominal infection by calculating the ratios IGG _SC / IGG _RV and PDF _RV / PDF _SK is a DC value equal to or above 2.4 (Fig. 1).

The ROC curve explaining the choice of a cut-off threshold value for the diagnostic coefficient of DC, providing the maximum diagnostic sensitivity, diagnostic specificity and diagnostic efficiency of the method for diagnosing staphylococcal abdominal surgical infection, is presented in FIG. one.

Similar results were obtained in cases of diagnosis of staphylococcal infection in patients with widespread purulent peritonitis due to pancreatic necrosis, phlegmonous appendicitis or its proved absence in patients with acute destructive pancreatitis complicated by diffuse enzymatic peritonitis without infection of peritoneal effusion.

The essence of the invention is illustrated in tables 1 and 2 and figure 1.

The proposed method has been successfully tested in the surgical departments of the NIH "Department Hospital at the station. Astrakhan-1 "JSC Russian Railways, GBUZ JSC" Alexander-Mariinsky Regional Clinical Hospital ", GBUZ JSC" City Clinical Hospital No. 3 named after CM. Kirov ", at the departments of pathological physiology, and surgical diseases of the pediatric faculty of Astrakhan State Medical University during 2016-2018.

The following are test results:

Example 1

We studied the ratio of protein levels and their ratio of pancreas and SC for a group of diagnostically significant proteins in experiments on white laboratory rats. The animals were divided into 5 groups of 12 rats to which five different cultures of conditionally pathogenic bacteria were injected once intraperitoneally. In the 6th comparison group, out of 30 animals, aseptic peritonitis was reproduced by a single intraperitoneal injection of carrageenan in 1 ml of physiological saline, which was prepared by dissolving carrageenan (Tinox-Him LLC, Moscow) in a sterile isotonic sodium chloride solution at the rate of 50 mg of dry powder per ampoule ( 10 ml).

For infection of animals, daily agar cultures of aerobic gram-positive bacteria: Staphylococcus aureus, Streptococcus pyogenes (Serovar A) and aerobic gram-negative bacteria: Proteus vulgaris, Pseudomonas aeruginosa, Klebsiella oxytoca, prepared in 0.9% sodium chloride solution were used. Intraperitoneal infection of the animal was carried out by injection of pre-titrated doses containing 0.5 ml of 1 × 10 ⁸ microbial bodies of staphylococcus and streptococcus and 1 × 10 ⁷ microbial bodies of Proteus, Klebsiella and Pseudomonas aeruginosa. The choice of these 5 bacterial strains is explained by the most frequent detection of precisely them in peritoneal exudate with diffuse purulent peritonitis. The dose selection of each bacterial culture provided 0.5 LD ₅₀ and ensured the survival of all laboratory animals for more than 3 days. In order to slow down the resorption of bacteria into the blood and prevent lethal sepsis, a solution of carrageenan was administered intraperitoneally simultaneously with infection to all animals according to the scheme and in doses of animals of the 6th comparison group. 48 hours after intraperitoneal injection under ether anesthesia, animals were euthanized by decapitation followed by sampling.

The material for the study was the blood serum of laboratory animals obtained from the jugular vein, and the whole peritoneal exudate obtained by aspiration of the abdominal cavity with a Pasteur pipette.

The quantification of fibrinogen degradation products (PDF) was carried out by the method of immunodiffusion analysis (IDA) in agar according to O. Ouchterlony modified by N.I. Khramkova and G.I. Abeleva using immunochemical test systems developed at the Department of Biological Chemistry, FSBEI HE "Astrakhan State Medical University" of the Ministry of Health of Russia, the sensitivity of the method is 3.5 mg / l. The concentration of IgG, IgM and IgA immunoglobulins was determined by radial immunodiffusion (RID) in agar according to the Mancini method according to the instructions of the manufacturers. The total protein content in rat peritoneal fluid samples and blood serum was determined spectrophotometrically at 280 and 260 nm according to Warburg.

Since the concentration of total protein in rat peritoneal fluid corresponded to its concentration in blood serum, the factor F = 1.

The average concentrations of IGG and PDF in the peritoneal fluid (RV) and blood serum (SC), their ratio (RV / SC) and the diagnostic DC coefficient after modeling peritonitis rats with various strains of gram-positive and gram-negative bacteria are shown in Table 1.

A feature of immunoglobulin G (IgG), in contrast to other studied proteins, is that its concentration in peritonitis in the peritoneal fluid is always lower than in blood serum, regardless of the cause of peritonitis. After intraperitoneal injection of all three strains of gram-negative bacteria: Proteus vulgaris, Pseudomonas aeruginosa, Klebsiella oxytoca, gram-positive Streptococcus pyogenes and with aseptic peritonitis caused by intraperitoneal injection of carrageenan, the concentration of IgG in rat peritoneal fluid U (0) was significantly (0) 15-35% lower than the concentration of IgG in the blood serum of the same rats. And only with peritonitis caused by intraperitoneal injection of Staphylococcus aureus, the concentration of IgG in rat peritoneal fluid was statistically significantly reduced by more than 1.5 times the concentration of IgG in the blood (IgG _SC / IgG _RV = 1.66) (Table 1).

The average concentration of PDP in rat peritoneal fluid was significantly (P (U) <0.01) higher than the level of PDP in the blood serum of the same rats only after intraperitoneal injection of gram-positive bacteria Staphylococcus aureus and Streptococcus pyogenes and did not significantly differ from the level of PDP in the blood at aseptic peritonitis and peritonitis caused by intraperitoneal injection of strains of gram-negative bacteria: Proteus vulgaris, Pseudomonas aeruginosa, Klebsiella oxytoca (Table 1).

The diagnostic coefficient of DC in rats with peritonitis after intraperitoneal infection with staphylococcal abdominal infection was:

and with intraperitoneal infection with streptococcus, DC = 2.9 (Table 1).

Similar DC values after intraperitoneal infection of rats with gram-negative bacteria: for Proteus vulgaris and for Klebsiella oxytoca, DC = 1.6, for Pseudomonas aeruginosa, DC = 1.5 (Table 1).

Thus, with DC equal to or higher than 2.4, the presence of staphylococcal abdominal infection is diagnosed with a high degree of certainty.

Example 2

Patient I., 69 years old, was admitted to the emergency surgery department of the City Clinical Hospital No. 3 09/27/2016, with a diagnosis of acute pancreatitis. According to the results of a physical examination, the patient was placed in the intensive care unit. Conservative treatment has been prescribed. During the day, the patient's condition did not improve, despite the treatment, heart rate - 114 per min, NPV - 35 per min, increased leukocytosis, body temperature rose to 38 ° C, amylase activity increased. General blood test: red blood cells 4.05 × 10 ¹² / l; Hb - 113 g / l; Le - 11.2 × 10 ⁹ / L, LII = 8.1, ESR - 10 mm / h, blood chemistry: total protein - 41 g / L, creatinine - 178 mmol / L, urea - 21.5 mmol / l, blood glucose - 5.7 mmol / l, α-amylase - 49 g / l * h, lipase - 505 g / l * h, urine diastase - 658 g / l * h. The serum level of immunoglobulin G (IGG) is 6.5 g / l, and fibrinogen degradation products (PDF) are 2.3 mg / l.

Ultrasound conclusion: “Echographic signs of an increase in pancreatogenic infiltrate, heterogeneity of the structure of the infiltrate with many small anechogenic formations of regular round shape up to 0.5-1 mm in diameter (gas bubbles), along the formation contour, a liquid with a small the amount of hyperechoic suspension. Hepatomegaly. Echographic signs of diffuse changes in the liver, calculi in the gall bladder. " MSCT conclusion: "An increase in the size of the pancreas, heterogeneity of the image of the parenchyma, limited fluid formations in the retroperitoneal tissue are determined." In the evening of the same day, the patient underwent diagnostic video laparoscopy with drainage and sanitation of the abdominal cavity. Under the control of ultrasound, an exudate (1.5 ml) was taken from the abdominal cavity. Diagnosed with severe intestinal paresis.

In the peritoneal exudate, the concentrations of immunoglobulin G (IGG) were determined at 4.2 g / l and fibrinogen degradation products (PDF) at 5.1 mg / l, which are necessary for the diagnostic method.

According to the diagnostic method, the determination of DC by the formula:

which indicated that the patient had staphylococcal abdominal infection and a high risk of the transition of sterile pancreatic necrosis to pancreatic necrosis infected with staphillococcus. The patient was prescribed powerful antibacterial, immunomodulating and detoxification therapy.

Over the next day, the patient's condition continued to deteriorate. September 28, 2016, the patient underwent a laparotomy. Opening, rehabilitation and drainage of the stuffing box, abdominal cavity, retroperitoneal space. Cholecystectomy Drainage of the common bile duct by Pikkovsky.

The results of bacteriological culture of the peritoneal effusion of the abdominal cavity revealed the growth of colonies of Staphylococcus aureus and confirmed the diagnostic result by our proposed method.

After surgical treatment and correction of drug therapy, a slow improvement in laboratory and biochemical parameters was noted. Clinically, the patient in the postoperative period for a long time remained hyperthermia. Gradually, the signs of endogenous intoxication were stopped, and laboratory indicators returned to normal. On the control ultrasound and MSCT there was a positive diamics. The patient was discharged on the 24th day in a satisfactory condition.

When viewed after 1 month - no complaints.

The main diagnosis: Acute necrotizing pancreatitis.

Complication of the main diagnosis: Omentobursitis. Abscesses of the stuffing bag. Phlegmon retroperitoneal space. Spilled purulent peritonitis.

The concentrations of IGG and PDF in the peritoneal fluid (RV) and serum (SC), their ratio (RV / SC) and diagnostic DC coefficients in patients with peritonitis from examples 2, 3 and 4 are presented in table 2.

Example 3

Patient K., 57 years old. Received on December 11, 2017 at the intensive care unit and intensive care unit of City Clinical Hospital No. 3 with a direct diagnosis: acute destructive pancreatitis. Ultrasound conclusion: “Echostructural signs of diffuse enlargement of the pancreas, acute pancreatitis, omenobursitis, retroperitoneal tissue infiltration. Hepatomegaly, diffuse changes in the liver. " Operation - laparoscopic drainage of the abdominal cavity, omental bursa. Duration of the disease - three days, temperature - 38 ° C, heart rate - 88 per minute, NPV - 18 per minute. General blood test: red blood cells 4.37 × 10 ¹² / l; Hb - 121 g / l; Le - 9.8 × 10 ⁹ / l, LII = 7, ESR - 12 mm / h, blood chemistry: total protein - 56 g / l, creatinine - 256 mmol / l, urea - 9.3 mmol / l, blood glucose - 5.8 mmol / l, α-amylase - 43 g / l * h, lipase - 402 g / l * h, urine diastase - 256 g / l * h. Serum level of immunoglobulin G (IGG) - 7.4 g / l, fibrinogen degradation products (PDF) - 3.6 mg / l

According to the diagnostic method in the peritoneal fluid, the concentration of immunoglobulin G (IGG) was determined at 6.2 g / l, the products of fibrinogen degradation (PDF) at 4.7 mg / l.

Determination of DC by the formula according to the diagnostic method:

indicates the absence of staphylococcal abdominal infection.

For this patient, the possibility of conservative treatment was determined; on the third day, the patient's body temperature gradually returned to normal, signs of endogenous intoxication stopped, laboratory parameters, ultrasound data returned to normal. On day 12, drainage was removed from the stuffing bag. The patient was discharged for outpatient aftercare in satisfactory condition for 18 days.

The main diagnosis: Acute necrotizing pancreatitis. Complication of the main diagnosis: Omentobursitis. Spilled enzymatic peritonitis.

Thus, DC confirmed the absence of pancreatic necrosis infected with staphylococcal microflora. Spilled enzymatic peritonitis did not become infected, which in the early stages of treatment was predicted by the diagnosis result by our proposed method.

Example 4

Patient S. fell ill on 01/07/16, did not seek medical help. The patient was delivered by ambulance on 10.01.16, in serious condition, conscious, lethargic, skin temperature of 39.4 ° C. The skin of a pale color is dry to the touch, a spasm of peripheral vessels is expressed. Heart rate 108 beats. in 1 minute, NPV 24 in 1 minute. The abdomen is swollen, painful on palpation. The symptom of Shchetkin-Blumberg is positive. Peristalsis sluggish single waves. General blood test: red blood cells 3.37 × 10 ¹² / l; Hb - 118 g / l; Le - 15.4 × 10 ⁹ / L. ESR - 8 mm / hour. Dz: Peritonitis. On the operation: acute gangrenous-perforated appendicitis. Spilled purulent peritonitis.

For treatment in the postoperative period, the patient was transferred to the intensive care unit. The patient's condition continued to be severe. The temperature of the skin kept on fibril figures: 38.0-38.9 ° C. Heart rate 100-108 bpm; NPV 28-30 breaths in 1 minute. The abdomen is swollen, peristalsis is sluggish, uneven throughout the abdomen. General blood test: red blood cells 3.37 × 10 / l; Hb - 99 g / l; Le - 10.6 × 10 ⁹ / L. ESR - 11 mm / h, blood biochemical analysis: total protein - 48 g / l, creatinine - 154 mmol / l, urea - 12.6 mmol / l, glucose - 6.4 mmol / l, LII - 5.7 ie, immunoglobulin G (IGG) - 6.1 g / l, fibrinogen degradation products (PDF) - 2.4 mg / l. Biochemical analysis of peritoneal fluid: total protein: 39 g / l, immunoglobulin G (IGG) - 5.6 g / l, fibrinogen degradation products (PDF) - 5.3 mg / l.

According to the diagnostic method, the determination of DC by the formula

which indicated the presence of staphylococcal abdominal infection in the patient.

The results of a bacteriological study of peritoneal exudate, obtained three days after the operation, revealed both gram-negative strains of Proteus vulgaris, Pseudomonas aeruginosa, and the presence of gram-positive coccal microflora (Staphylococcus aureus, Streptococcus pyogenes) in the exudate, which corresponded to the diagnostic results of the proposed method.

The patient was given infusion therapy, which included crystalloid solutions, colloids, 10% glucose solution, antibacterial treatment, cardiac drugs and vitamins.

On January 13 and 14, 2016, the patient's condition remained stably moderate. The temperature of the skin was kept at subfebrile and low febrile numbers: 37.2-38.0 ° C. Heart rate of 90-92 bpm / min, respiratory rate of 24-26 breaths per 1 minute.

January 19, 2016 the patient was taken to the operating room and operated on. On the operation found interloop abscesses. Abscesses are opened, the abdominal cavity is washed and sutured tightly. In the first postoperative day, the patient continued to have severe intoxication. In the subsequent postoperative period, it went smoothly and the studied parameters gradually returned to normal. February 9, 2016 the patient was discharged from the hospital.

This example shows that the diagnostic method allows in advance to predict the possible development of staphylococcal abdominal infection in the early stages of peritonitis.

The proposed method improves the diagnosis of staphylococcal abdominal infection in surgical patients with suspected postoperative peritonitis, namely:

- increase in diagnostic specificity to 83% and diagnostic sensitivity to 71% (for the threshold value of DC = 2.4). The area under the curve (AUC), reflecting the diagnostic effectiveness of the method, was 0.844 (in the prototype - 0.721).

- high speed enzyme-linked immunosorbent assay of proteins included in this method provides a quick result of the study;

- evidence-based administration of antibacterial agents;

- early onset of targeted antibacterial chemotherapy;

- technical simplicity, insignificant labor costs (for the practical execution of the method, only 1 laboratory assistant is enough);

- the availability of the method for the surgical department of any health care unit;

- cost-effectiveness (the method does not require exclusive and expensive equipment and reagents, auxiliary equipment and highly qualified medical staff), the analyzes performed are of low cost;

The proposed method makes it possible to predict the development of postoperative infectious complications in the abdominal cavity.

The proposed method can be implemented in any surgical department for rapid diagnosis of the presence of staphylococcal abdominal surgical infection, ahead of the results of bacteriological studies, and the timely initiation of etiotropic antibacterial therapy.

Claims (9)

A method for the diagnosis of staphylococcal abdominal surgical infection, which consists in the study of biological fluids, characterized in that in surgical patients with postoperative peritonitis in the blood serum and peritoneal fluid, the concentrations of immunoglobulin G and fibrinogen degradation products are determined and the diagnostic coefficient of DC is calculated by the formula:

Where: DK - diagnostic coefficient of the presence of staphylococcal abdominal surgical infection; IGG _SK - the concentration of immunoglobulin G in blood serum (g / l); IGG _pancreas - the concentration of immunoglobulin G in the peritoneal fluid (g / l); ПДФ _ПЖ - concentration of fibrinogen degradation products in peritoneal fluid (mg / l); PDF _SC - concentration of fibrinogen degradation products in blood serum (mg / l); and when the DC coefficient is equal to or higher than 2.4, the presence of staphylococcal abdominal infection is diagnosed.

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