Ll;nc6HOTH'ICCKHe HJMeHeHHB HOpMaJihHOH MHKpo-t,Jiopi.1 KHWC'IHHKa

C cospeMeHHOH TO'-IKH 3peHml HOpMaJibHaH MHKpocprropa qeJJOBe­ Ka n B nepsy10 oqepe,D,b ero ToncToro KHUie'IHHKa npe,lJ,cTaBJIHeT co6ou CBOeo6pa3HbIH «3KCTpaKopnopanrnHI,IH opraH», COCTOHW:HH H3 orpoMHOH MaCCbl pa3JIH'IHblX MHKpoopraHH3MOB, C)l(H3He;:i;eaTeJJbHOCTblO KOTOpbIX TeCHO CBH3aHbl MHOfO'IHCJieHHble peaKI.(HH H q>H3HOJIOfHtJecKHe cpyHKUHH opraHH3Ma qeJIOBeKa. 06rra;:i;rui o6MeHHblMH, 3all(HTHbIMH" HMMYHOHH­

,lJ,YQHPYlOIII,HMH csoncTBaMH, HopMocpnopa yqacTByeT B no;:i;,lJ,ep)KaHHH 3y6u03a B opraHH3Me X03.Snrna. CoxpaHeHHe,lJ,HHaMH'ICCKOro paBHOBeCHH ocyw:ecTBJIHeTc.si: 6naro.l{apa cnoco6uocTu MHKpo6noQeHo3a KHllle'IHHKa K ayrocTa6MJIH3aQHH, CBOHCTBeHHOH BCeM 3BOJilOQHOHHO CJJO:>KHBIIIHMC.sl CH­

CTeMaM. 0.l{HaKO, IlO,lJ, BJJHHHHeM He6naronpHHTHbIX q>aKTopoB, MCXaHH3Mbl ayTOCTa6HJIH3aQHH MOryT 6bITh HapyIIIeHbl, 'ITO npHBO,lJ,HT K H3MeHeHHHM

B Ka'leCTBeHHOM " KOJIH'leCTBeHHOM COCTaBe MHKpocpnopbl " pa3BHTHIO

,l{HC6aKTepH03a (.D:HC6H03a).

 

l(uc6a1<mepuo1 (ouc6uo1) 1<ume11nu1<a-3mo l<llUHUK.O-lla6opamop­ HblU CUHOpOM, 603HUl<OIOUl,UU npu l,(eJIOM paoe 1a601le6anuu, l<llUHU'leC-

19

 

KllX cumyat(Uii II nm> 6.,1l1RHUe.M He6.ruuonpURmHblX t/JllKmOptJtl, KOmt,pbtii xapa1<mep1nyemcR u1ue11e11ue.M 1<a•1ecm11e1111ozo u 1<0.'1u•1ecm11e1111ozo cocma11a ttfl/J.•''°'/mopbt onpede.,r1en111u1, 6uonu1n11, a m111<.>1ce mpanc,101<(1- l{lleii ue1«>mopbtX ee 11peocma11ume.1ieii 6 11ect1oiic1tUJe111161e 6uomo11b1 c nocneoy10 u.llf11,uema60.riu'lecK1Luu u u.,,1.-ny11nbu11111apyme11mu111.

TTpH pa3BHTIHt)lHC6HOTHl.feCl<HX H'3MtHeHHH MHKpoqmopbl, KaKnpaBH­

JIU, 1rpu11l;'XUA•Hl:'A'H)Kt::HHt: KUJIU'HH:sa HUtfttOM pe3HCTeHTHOCTH, yrHeTeHHe

<PYHKUHH HMMYHHOH CHCTeMbl, nOBb!WaeTCSI BocnpHHM"IHBOCTb K HHq>eK­

UHOHHblM 1a60.rieBaH1-tSIM, B03MO)KH0 HapyweHHe o6MeHHblX npoueccos.

 

 

l1pu11uub1 pa36Unt.UR,>uc6aKmepuo3011:

,ni-tHTeJlbHaSI aHTH6HOTHKO-, XHMHO-, HJHt ro p MOHOTe p an H SI. 4ame scero.znrc6HOTH"leCKHe HapyweHHSI 803HHKalOT npH HCnOJlb'30BaHHH attn1oaKTepl:HlJlbHbIX npenapaTOB, OTHOCSII.UHXCSI K rpynne aMHHO­

llt:HHUHJtJlHHOB (aMnHUHJtJlHH, aMOKCHUHJJJlHH) H JIHHK03aMl-1HOB

(11HHKOMHUHH H KJlHHJlaMHUHH). B 3TOM CJIY'•fae HaH6onee TSJ.)KeJiblM

OCJIO)KHeHHeM SIBJtSieTCSI nceB)lOMeM6paH0'3HblH KOJJHT. accoU,HHpo­ BaHHhlH c Clostridium difficile.

80'3)leHCTBHe)KeCTKOro raMMa-H3JtYl.feHH.SI, HanpHMep np1-1 11yl.feBOH repanHH,o6nyt.teHHH.

'.:JaOOJteBaHl1SI)KeJlyJlOl.f.HO·KHWe'IHOro TpaKTa HH<peKU,HOHHOH H Ht:Htt(j.lt:KLU1UHHOfi:.:ffl1UJIOn1H,.u.pyn1t::.IJ.Jll1Tt::JlbHblt: '..iaUUJlt::BaHH», fl'MM)'1-1u,1.1.t:cl>Hu11rttoe cocTOSIHHe.

HeKal.fCCTBCHHOC mnattHe, aBHTaMHH03, tteonaronpHSITHaj[ 3KOJ1on1-

•1eCl<M OOCTaHOBKa (3arp.SI3HeHHe 80)),bl, nottBbl, 80 '3Jl)' Xa). CTpecCOBbJe H 3KCTpeMaJlbHble curyaum1.

JUITeJlbHOe npeOblBaHHe B CTaUHOHapax (HHcl>HUHpOBaHHe rocn11- HlllbtfblMH Ulli1MM'1l\U-i) H B YCJlOBHJIX 3aMKHyToro npocTpaHCTBa (KOCMH4eCKHe CTaHU 11H, no,nBO)],Hble JlO,LlKH).

Pa3BHTHIO.ll.HC6aKTepHo3a y neTeH paHHero so3pacrn TaJOKe cno­ l:oGc I IS)'tuL Ht:,l.lUHUWt:HHUl:l'b, IIUJ)UKl1 pa:.stsH nu1, t1ttqmut1put:SaHl1t: yc.llOBHO-narnr CHHOH <f>J1opoti (oco6eHHO CTac\)HJlOKOKKaMH) B po­

)lHJTbHOM,!lOMe, Ha.JTlMH'e.llHC6aKTep1103a y MaTepH, HCK)'CCTBeHHOe

BCKapMJlHBaHHe. HapyweHHe pe,KHMa n Kat1eCTBa mnaHIUI f,'4!6eHKa.

 

 

llpu 6aKmepu0.'10c'Ul/ec1-o.w UCC.17e00<3GHUU (KOilUl/ecm<JeHH0.",1) KU­ Ltte1woil,ltuKpo<Juopn1 npu duc6aKmepume Kuwe•mu,w perncTp11py10T l:HH)Kt::Hl1(: KUJll14(:l:TBa 11JIH '.JJIHMHHaUHtu 0.1.J.HOl'O HJll1 Ht:CKUJlbKHX ISH.1.J.06

20

 

HH.!l,Hre1mhlx Mln,poopra1-1J.13MOB, npe)l(,ue scero 6Hcjm.D,o6aKTepHH H JJaK­ To 6 au m m. O.[(HOBpeMeHHO npoHCX0,!lHT yBeJJH<leHHe J<0JJHqecTBa ycJJOBHO­ naToreJ-nlbrx I\H{KpoopraHH3MOB, KOTOpbie OTHOCsrTcsr K cpaeyJJbTanmHOH MHKpocjmope (UHTpaTaCCHMHJJHpy10m;ue 3HTepo6aKTepHH, npoTeH H.np.), npH 3TOM OHH MoryT pacnpocTpaH.srTbCR 3a npe)],eJJbl xapaKTepHblX.[(Jllf HID{ 6HOT0TTOB H Bl,I%1BaTb rra1'0JJ()fH1-Iec1<»e npoQeCCbl pa'.lJlHqf-lOH TSDl<eC'fJ(I3 3aBHCHMOCTH OT CTa.[(HH.[(HC6 a KTep H0 3a.

 

 

Pa3.,r1urw10m CJ1e<>y«1U(ue cma<>uu (cmene11u) ouc6at<mepuo1a:

1 cmmJUJI -. KO,HfU!HC1tpoeoHH(lfl. (pop.Ma ouc6aKnu!-pu03a.::ho na TeHTHa.st (cy6KJTHHH1IecKasr) CTa,UH.SI, npH KOTOpoH npoHCXO,llHT CHH)KeHHe

KOJmqecTBa 0,!J.H0ro H3 npe.!l,CTaBHTeJJeH HH)lJffeHHOH MHKpoqmopbl 6e3 H3MeHeHIHI.npyn1x C0CTaBJISllOll.lJ'IX MHKpo6HOQeHo3a. KJIHHH'LleCKH I -51

CTa,!lH.sr He nposrnJJsreTCSI H MO)l{e'r 6bITh.[(HarHOCTHpomrna TOJlbKO c no­ M0lllblO na6opaTOpHoro HCCJJe,Il0BaHlUI. flpH 3TOH q>opMe.[(HC6aKTepH03a peKoMeH.nyeTcsr paUH0HaJlbHaSI,[(HeTa C o6SI3aTeJlbHblM HCTT0Jib30BaHHeM cj)yHKUHOHaJibHbIX npo.nyKTOB ITHTamrn.

2 cmaou.R - cy6T<JlUHUl.{eCK{JJI_ rjJopMa. fJpoHCXO.[(HT CHIDKeHHe KOJIH'le­

CTBa HJlH 3JIHMHHaum, OT,U:eJJbHblX npe,IJ.cTaBHTeJJeH HH,UHreHHOH MHKpo­

qmopbI (Y:au\e Bcero 611cpH,no6aKTepnu ·n JJaKT06aKTep11n) H yaenWieHHe co,uep)l{aHHll q>aKyJJbT8THBHOH HIHJIH TpaH3HTOpHOH ycJJOBHo-naroreHHOH MHK.pocjmopb!. Jl:JJH cy6KoMneHCHpoBaHHOH qiopMbT xapaKTepHbl,llHC­

Q)YHKQHSI KHI.Ueqmu<a H l\leCTHble BOCITaJIHTeJibHble npoueCCbl - 3HTepHT, CTOM8THT H.n.p. Jl:n.st JTet:ieHHll peKOMett,uyeTCSI,llHeTa, <PYHKUffOHaJJbHOe UHTaHJ,fe H npHMeHeHHe K0pperwpyIOlUHX rrpenapaTOB - npo6HOTHKOB n

npe6HOTHKOB.

3 tmaOWl - OeKm-tneHCUp06GT-lHaJ1. <pop,wa. 0CHOBHble TeH,lleHUHH: H3- MeHeHHSI MUKpoqmop1,1 HapacTaIOT, ycJJOBHO-naroreHHbie MHKpoopraHH3Mbl

CTaH0BSITCSI,llOl\fHHHPYJOIUH.MH, OT,lleJlbHbie HX npe,UCTaBHTeJIH pacnpocTpa­ HSII-OTC.SI 1a npe,n:eJibl 6HOTona H IlOHBJlHIOTCSI 8 IT0JI0CTSIX, oprattax HTKaHSIX,

B KOT0pblX OHM o6bl'IHO He BCTp eq alOTC SI. HanpHMep, E.col i - B)KeJl'lHbIX

nyrnx, Candida - s M0'le u T.n. Pa3BHBaeTcH,ueKoMnettcnposattttasr <)>opMa

.LlHC6aKTepHo3a C Bbtpa)KeHHbIMH naTOJI0fff'ieCKHMH nposlBJJeHHlfMH, qame

l:! t:I U BUCWUHtTeJlhHuro xapaKrepa, 1:!IIJIU'fb,!.(0 'f.Sl)KeJlblX ellTH4eCKH:X cj)o p M.,!lJisi K0ppeKU:HH MHKpocpnopbl B 3T0H CTa,[(HH Hepe,UK0 HCITOJlb3YIOT

«ceneKTHBHYIO,lleKOHTaMHHaQHIO» nyTeM Ha3Hat:ieHHSI aHTH6aKTepHaJlb-

 

 

21

 

HblX npenapaT0B H3 rpynnbl q>TopXHHOJIOHOB, MOH06aKTaMOB, aMHH0- rm{K03H,A0B (nepopaJibHO). 3TH npenapaTbl 0611a.11:a10T H36HpaTeJihHOH aKTHBH0CThlO, npe)l(,Ae BCero, no 0THOllleHHI-0 K pa3HhIM npe,ncTaBHTeJISIM Enterobacteriaceae. KoppeKUHSI MHKpocp11op1,1 3asepmaeTc.s1 c noM0l..[(hIO

D.J IHTeJihHOro npHMeHeHHSI npenapaT0B npo6HOTHKOB, npe6HOTHKOB n

.D.HeTHqecKoro TIMTaHHSI.

 

 

MeT0,1-lbl Jia6opaTopHoii L{HarHOCTHKH

,nnc6aKTepuo1a Knme11uuKa

Ea1<.mepuonozu11ec1<.uii Memoo. Knacc11qecKHM MeTo,noM onpe,nene­ HH.sl KaqecTBeHH0ro H K0Jilf'{eCTBeHHoro C0CTaBa MHKpocpnophl KHIIIe'-IHHKa

.s1em1e-rcS1 6a1<.mepuonozu11ec1<.oe uccneootJaHue.,[(.rrSJ 3TOH Qerrn npo6y

6HOMaTepHaJia (HanpHMep: 1,0 r cpeKaJIHM) npe,nsapHTeJibH0 pa3B0,A.IIT H nony11eHHbte nocne,nosaTeJihHhie 10-KpaTHMe pa3Be,nemrn 3acesa10T Ha 'lalliKH TieTpH C pa3JIH'IHhlMH cerreKTHBHbIMH, o6ora[f.leHHhIMH H JJ:Hq>cpepeHQHaJibHO-JlHarHOCTH'leCKHMH cpenaMH, Ha K0T0phIX Bhl)leJUIIOT H H)leHTHq>HUHpyIOT 0K0JI0 20 BHJl0B - npe,ncTaBHTeJieH HOpMaJihHOH MHKpocpnopbI I<aK aHa3po6oB, TaK H a3po6os. KonH'-leCTBeHnoe conep)f(aHHe MHKpoopraHH3M0B B 1,0 r 6noMaTepmurn onpenerrSJIOT nyTeM noncqeTa BhlpOCllIHX Ha qarnKax KOJIOHHH (H3 pa3HhIX pa3Be)leHHH) H nonyqeHH0e qncno YMH0)l(aI-OT Ha C00TBeTCTByrol.[(ee p a3Be,nenne. Pe3yJihTaT Bb1p8)1(alOT

B KOE/r HJIH lg KOE/r, H cpaBHHBaJOT c 3TaJIOHHoii rn6nnu;eii, B KOTopoH

npe.ncTaBJieHE,I K0JIHtJeCTBeHHbte TI0Ka3aTeJIH cpeKaJibHOH MHKpocpnophl pa3J1lf'-1Hh!X B03paCTHblX rpynn (Ta6JI. 4).

,[(.rrSI Il0CTaH0BKU 0TihITa H3 1,0 r cpeKanHH)leJiaJOT nocne)l0BaTeJihHbie

I0-Kparn1,1e pa3senemrn B <pH3uorrorH'lecKoM pacTBope (1 0·¹, 10· ², 10· ³ H T..IJ..) "3aceBalOT no 0,1 MJl pa3Be)leHH.sl Ha qarnKU ITeTpH C 3Jle1'.-rHBHbIMH cpe.aaMH, npeJlHa3Ha'leHHhIMH i1:;rn pocTa onpeneneHHhIX npencTaBHTeneii MHKpocpnop1:,1. B1:.1.nerremre o6rrHraTHbIX ana3po6oe npoB0WIT B cTporo aHa3po6HhTX ycJI0BIUX. IToceBbl HHK)'6HpYJ-OT npH 37°C B Te'leHHe 2-3 cy­ T0K.)J;anee H3yl.faIOT noceBbT, Il0,[(C'IHThIBaIOT ql{CJl0 Bblpocurnx Ha qalIIKax TieTpH K0JIOHHH H onpe.neJISIIOT K0JIWieCTB0 MHKpo6oB e 1,0 r cpeKaJIHH.

 

3a}-lauue:

TipoBeCTH yl.feT noceB0B MHKpOq)JJOpbl T0JICT0ro KHIIIe'IHHKa (cpeKanHii):

 

22

 

•J Tio.npm:TaTh Komi:qecTBO KOJIOHHH, Bbipocun-1x Ha qallIKaX C 3JieK-

THBHhlMH H,ll,HcpcpepeHUHaJihHO-.lJJiarHOCTHqecKHMH cp e.n.aMH: E11¢0.n.06aKTepHH - cpe.n.a EnaypoKa;

JlaKrn6aUHJIJlhI - cpe.n.a MPC; EaKTepOH.ll.bI - Cpe.n:a KAE; KnocTpH.D.HH - KJIOCTpH.n.HaJihHhIM arap;

3HTepo6aKTepHH (3IIIepHXHH, KJie6cHeJIJihl H.n.pyrne) - cpe.n.a 3tt.n:o;

3HTepOKOKKH - 3HTepOKOKKOBbIH arap;

CTaq>HJTOKOKKH - CTaq>HJlOKOKKOBhIH arap;

fpH6hI KaH.D.H.D.a - cpe.n.a Ca6ypo.

2. onpe.n.eJIHTh KOJrnqecTBO MHKpoopraHH3MOB B 1,0 r cpeKaJIHM no cpopMYne

N = m:10-n X 10- 1 = m X 1o<n+l)

r.n:e N - o6mee KOJTWleCTBO MHKpo6os B I,Or cpeKanHH, m - KOJIH'ICCTBO I<OJIOHHM, Bhipocumx Ha qaIIIKe, n - senwnrna pa3se.n.emrn.

3. TionyqeHHhie pe3yJihTaThl no.n.cqern BHCCTH B Ta6mnzy 4 'cpaBHHTh

c HOpMo tt, c.n.enaTu 3aKmoqeHHe H onpe.n:enHTu crn.n.mo.D.Hc6aKTepHo3a(npH OTKJIOHCHHH OT HOpMbI).

4. lfayqwrh nepe'lHCJICHHhie HIDKe 6HonpenapaThI H.n.aTb peKOMeH,ll,a­

UHH,ll,JIR KOppeKUHH MHKpocpnophI npH.n.aHHOH CTa,ll,HH,ll,Hc6aKTepHo3a.

 

B HaCTORW:ee speMR pa3pa6oTaHhI H npHMeHRIOTCR pa31IHqHI,Ie 61m­

_XHMHqecKHe H Q)H3HKO-XHMH'·leCKHe 3KCnpecc-MeTO,ll,bI, Il03BOJIRIOU{He

nonyqan, pe3yJihTaT B,l],eHh HCCJIC,ll,OBaHHR. C IlOMOU{hlO 3THX MeTO,ll,OB BhIRBJIRIOT H3MeHeHHJI B COCTaBe MHKpocpnopbl KOCBeHHblM nyTCM - no H3MeHeHmo COCTaBa COOTBeTCTBYIOUlHX MeTa6oJIHTOB. HanpHMep, }'MCHb­ lIICHHe KOJIWICCTBa RHTapHOH KHCJIOTbI CB.Sl3aHo co CHH)l(CHHeM KOJIHqecTBa

6HcpH.n:o6aKTepHH, ysenwiem,e KOHUCHTpau1m npornmHOBOH KHCJIOThI - c H36brroqHl,IM pa3MHO)l(eHHeM 6aKTepOH,ll,OB.

HaH6onee H3BeCTHhIMH 3KCIIpecc-MeTo,UaMH RBJIRIOTCSI Za3060-JICU0-

1<.0CmHaa xpoMamozpatjJun., npHMeHsi:eMaR.n.nsi: onpe.n.eneHHR B q>eKaJIHSIX nezyqHx semecTB - nezyqHX)J(HpHhIX rrn:cnoT H apoMan1qecKHX coe.n:Htte­ HHH (cpeHOJihl, HH,lJ,OJihI) H JICUOl<.OCmHllll xpoMamozpatpU5J., TT03BOJIRIOU{aR onpeneJIRTh ttenezyque coe,z:urneHID1, TaKHe KaK npocTure H CJIO)l(HI,Ie aMHHhI,

<pemumponHOHOBYIO KHCJIOTY, Kap6oHOBhie KHCJIOThI n.ll.pyrne MeTa6o­ JIHTbJ. JTH MeTO,ll,hl He TT03BOJIRfOT H,l],eHnHpHUHpOBaTh co.n.ep)l(amHeCSI B HCCJie.n.yeMOM MaTepuane atta3p06bI.ll.0 BH,l],a.

23

 

3Kcnpecc-MeTO,L(bl DplffO,L(Hbl,[(JUI MaCCOBbfX o6cJie,L(OBaHHM (CKpmu-rn­ ra), wx npoao,wn Ha cneuHaJibHOM an n ap aiy p e. Mx pe3yJ1bTaTbI, 061,r•rno,

COTIOCTaBHMbl C)laHHbIMH, nony'-1:eHHbIMH 6aKTepHOJ10nflleCKHM MeTO,!lOM. Bo MHOrHX CTpaHax 3Kcnpecc-MeTO,!lbl urnpoKO npHMeHJIIOTCSI COBMeCTHO C 6aKTepwonorw-qecKHM MeTO.!lOM HJIH 3aMeHSISI era. B PoccMHCKOM <l>e.nepa­ UMH OCHOBHOM MeTO,L(HCCJle,L(oBamrn HOpManbHOM MHKpoq>JiopbI - 6aKTe­ pHOJIOrH1-leCKHM. 3cKnpecc-MeTO,L(bI npHMeIDIIOT B OCHOBHOM npH Hay<IHbIX

HCCJ1e)lOBamu1x H cpaBHHTeJibHO pe)lKO Ha npaKTHKe. B nocJie)lHee rO,!lbl BHe)lpS!eTCSI B npaKTHKY rrQP.

 

IlpHHUHDl,I KoppeKUHH napymenuii MHKpocl>J1opi.1 KHme'IHHKa npu,llHcoaKTepuo3e

KoppeKUHJO)lHC6HOTW-IeCKHX HapyrneHHM npOBO)lSIT KOMTIJieKCHO c y<leTOM OCHOBHOro 3a6oJieBaHIDI H npwnm, BbI3BaBllIHX H3MeHeHHe COCTaBa