{"id":9211,"date":"2020-04-23T03:31:28","date_gmt":"2020-04-23T00:31:28","guid":{"rendered":"https:\/\/www.synevo.ro\/product\/cultura-exsudat-faringian-cu-antibiograma-dupa-caz\/"},"modified":"2026-02-18T23:17:19","modified_gmt":"2026-02-18T21:17:19","slug":"cultura-exsudat-faringian-cu-antibiograma-dupa-caz","status":"publish","type":"product","link":"https:\/\/old.synevo.md\/ru\/shop\/cultura-exsudat-faringian-cu-antibiograma-dupa-caz\/","title":{"rendered":"\u041f\u043e\u0441\u0435\u0432 \u0433\u043b\u043e\u0442\u043e\u0447\u043d\u043e\u0433\u043e \u044d\u043a\u0441\u0441\u0443\u0434\u0430\u0442\u0430 (\u0410\u043d\u0442\u0438\u0431\u0438\u043e\u0442\u0438\u043a\u043e\u0433\u0440\u0430\u043c\u043c\u0430 \u043f\u043e \u043d\u0435\u043e\u0431\u0445\u043e\u0434\u0438\u043c\u043e\u0441\u0442\u0438)"},"content":{"rendered":"<p><strong><em>\u041e\u0431\u0449\u0430\u044f \u0438\u043d\u0444\u043e\u0440\u043c\u0430\u0446\u0438\u044f<\/em><\/strong><\/p>\n<p style=\"text-align: justify;\">Tractul respirator superior cuprinde fosele nazale, nazofaringele (cu cavit\u0103\u0163ile conecte: sinusurile paranazale \u015fi urechea medie), orofaringele \u015fi laringofaringele. Datorit\u0103 lipsei barierelor anatomice distincte \u00eentre segmentele c\u0103ilor respiratorii superioare, infec\u0163ia se poate propaga prin continuitate, cu frecvente complica\u0163ii prin afectarea urechii medii, a laringelui \u015fi chiar a c\u0103ilor respiratorii inferioare<sup>1;2;6<\/sup>.<\/p>\n<p style=\"text-align: justify;\">Faringitele \u015fi tonsilitele sunt cele mai frecvente afec\u0163iuni ale tractului respirator superior pentru care pacientul se adreseaz\u0103 medicului \u015fi, implicit, laboratorului.<\/p>\n<p style=\"text-align: justify;\">\u00cen diagnosticul microbiologic, laboratorul trebuie s\u0103 aib\u0103 \u00een vedere flora bacterian\u0103 care exist\u0103 \u00een mod normal \u00een anumite situsuri anatomice. Aceast\u0103\u00a0<em>flor\u0103 normal\u0103<\/em>, care se afl\u0103 \u00eentr-o rela\u0163ie de simbioz\u0103 cu gazda, joac\u0103 un rol important \u00een protec\u0163ia acesteia fa\u0163\u0103 de microorganismele patogene, put\u00e2nd preveni proliferarea \u015fi invazia acestora prin diferite mecanisme<sup>1<\/sup>. Etajul supraglotic al tractului respirator g\u0103zduie\u015fte o flor\u0103 bacterian\u0103 ce cuprinde peste 200 specii repartizate la nivelul crevaselor gingivale, pl\u0103cii dentare, mucoasei jugale \u015fi linguale, oro-faringelui, criptelor amigdaliene \u015fi nazofaringelui, bacteriile anaerobe domin\u00e2ndu-le pe cele aerobe \u00een propor\u0163ie de 5-10:1<sup>2<\/sup>.<\/p>\n<p style=\"text-align: justify;\"><strong><em>Etiologia faringitelor<\/em><\/strong><\/p>\n<p style=\"text-align: justify;\"><u>Infec\u0163iile virale<strong>\u00a0<\/strong><\/u><\/p>\n<ul style=\"text-align: justify;\">\n<li>Aproximativ 70% din faringite sunt de etiologie viral\u0103: rhinovirusuri, adenovirusuri, virusuri gripale, paragripale, Coxsackie A, virusul Epstein-Barr care determin\u0103 mononucleoza infec\u0163ioas\u0103 caracterizat\u0103 prin angin\u0103 severa, frecvent ulcerat\u0103, adenita cervical\u0103 \u015fi semne de afectare sistemic\u0103<sup>1;2;6<\/sup>.<\/li>\n<li>Au evolu\u0163ie auto-limitant\u0103 dar, prin lezarea epiteliului respirator \u015fi obturarea congestiv\u0103 a orificiilor sinuzale sau a trompei lui Eustachio, favorizeaz\u0103 suprainfec\u0163ia cu bacterii din microbiota indigen\u0103<strong>.<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><u>Infec\u0163iile bacteriene<\/u><\/p>\n<ul style=\"text-align: justify;\">\n<li>Cel mai frecvent implicat este\u00a0<em>Streptococcus pyogenes <\/em>(Streptococ \u03b2 hemolitic grup A, PYR pozitiv).\u00a0<em>Streptococcus pyogenes<\/em> este unul dintre patogenii umani importan\u0163i, singurul rezervor cunoscut \u00een natur\u0103 fiind reprezentat de pielea \u015fi mucoasele umane; imprim\u0103 gravitate faringitelor prin complica\u0163iile\u00a0<em>infec\u0163ioase <\/em>(sinuzite, otite medii, mastoidite, adenite cervicale supurate, abces amigdalian, flegmon amigdalian, celulita difuz\u0103 a planseului bucal \u2013 angina Ludwig) \u015fi\u00a0<em>post<\/em>\u00a0<em>infec\u0163ioase<\/em>\u00a0(reumatism articular acut, glomerulonefrita acut\u0103, cardita reumatismal\u0103). Prezen\u0163a antigenelor Lancefield de grup A nu este specific\u0103 pentru\u00a0<em>Streptococcus pyogenes<\/em>, acestea put\u00e2nd fi prezente \u015fi \u00een cadrul grupului anginosus, din care fac parte\u00a0<em>Streptococcus anginosus<\/em>,\u00a0<em>Streptococcus constellatus<\/em>\u00a0\u0438\u00a0<em>Streptococcus intermedius<\/em>. Testul PYR diferen\u0163iaz\u0103\u00a0<em>Streptococcus pyogenes<\/em>\u00a0care este responsabil de majoritatea faringitelor bacteriene de grupul anginosus care face parte din microbiota faringian\u0103 normal\u0103<sup>1;4;5<\/sup>.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Faringitele cu tulpini eritrotoxigene de Streptococcus pyogenes se \u00eenso\u0163esc de scarlatin\u0103<sup>1;2<\/sup>.<\/p>\n<ul style=\"text-align: justify;\">\n<li>Abcesul periamigdalian apare mai frecvent la copiii peste 5 ani \u015fi adul\u0163ii tineri, put\u00e2nd deveni o infec\u0163ie grav\u0103 prin afectarea \u0163esuturilor adiacente, ca \u015fi prin erodarea arterei carotide. Organismele implicate sunt \u00een principal:\u00a0<em>Streptococcus pyogenes<\/em>,\u00a0<em>Arcanobacterium haemolyticum<\/em>,\u00a0<em>Staphylococcus aureus<\/em>, anaerobii (e.g. Fusobacterium spp. \u015fi Bacteroides)<sup>1;2<\/sup>.<\/li>\n<li><em>Streptococii \u03b2 hemolitici grup C \u015fi G <\/em>pot determina faringite a c\u0103ror evolu\u0163ie poate fi grav\u0103.<\/li>\n<li><em>Arcanobacterium haemolyticum<\/em>\u2013 poate cauza, mai frecvent la adul\u0163ii tineri, faringit\u0103 \u015fi abces periamigdalian. Faringitele, asem\u0103n\u0103toare celor streptococice, se \u00eenso\u0163esc de erup\u0163ie scarlatiniform\u0103 \u015fi\/sau adenit\u0103 cervical\u0103 la circa 50% dintre pacien\u0163i. \u00centruc\u00e2t face parte din flora comensal\u0103, doar cre\u015fterea predominant\u0103 \u00een placa de izolare are semnifica\u0163ie clinic\u0103<sup>2;5<\/sup>.<\/li>\n<li><em>Chlamydia pneumoniae <\/em>\u2013 cauz\u0103 frecvent\u0103 a faringitelor<sup>2<\/sup>.<\/li>\n<li><em>Mycoplasma pneumoniae <\/em>\u2013 determin\u0103 p\u00e2n\u0103 la 10% din faringitele \u015fcolarilor<sup>2<\/sup>.<\/li>\n<li><em>Neisseria gonorrhoeae <\/em>\u2013 faringita gonococica apare dup\u0103 raporturi sexuale aberante \u015fi evolueaz\u0103 benign. Investiga\u0163ia de laborator se face doar la cerere expres\u0103. Microscopia nu are valoare din cauza numeroaselor neisserii nepreten\u0163ioase din microbiota orofaringian\u0103<sup>2<\/sup>.<\/li>\n<li><em>Corynebacterium diphteriae <\/em>\u2013 determin\u0103 faringita sau angina pseudomembranoa\u0103 grav\u0103, <u>\u00ee<\/u>nso\u0163it\u0103 de toxemie. Complica\u0163iile cele mai de temut sunt cele ce implic\u0103 sistemul nervos central (orbire, com\u0103).<\/li>\n<li><em>Asocierea fuso-spirochetozica <\/em>\u2013 infec\u0163ie mixt\u0103 cu bacterii anaerobe (Fusobacterium spp) \u015fi spirochete, determin\u0103 stomatita \u015fi angina Vincent. Infec\u0163ia, relativ rar\u0103 ast\u0103zi, se caracterizeaz\u0103 prin leziuni ulcero-necrotice care pot fi acoperite de false membrane. Afecteaz\u0103 mai frecvent adul\u0163ii dec\u00e2t copiii, \u00een special pe cei cu igiena oral\u0103 deficitar\u0103 \u015fi deficite locale sau sistemice ale apararii antiinfec\u0163ioase<sup>1;2<\/sup>.<\/li>\n<li><em>Haemophilus influenzae <\/em>(doar serotipul b are implica\u0163ii \u00een patologie),\u00a0<em>Streptococcus pneumoniae<\/em>\u0438\u00a0<em>Staphylococcus aureus<\/em> sunt microorganisme care, de\u015fi frecvent izolate din exsudatul faringian \u015fi secre\u0163ia nazal\u0103, nu au fost confirmate ca fiind implicate \u00een etiologia faringitelor. Statusul de purt\u0103tor pentru unul dintre aceste microorganisme, ca \u015fi pentru Neisseria meningitidis, poate avea semnifica\u0163ie clinic\u0103 pentru anumi\u0163i pacien\u0163i sau contac\u0163ii lor<sup>1;2<\/sup>. Investiga\u0163ia de laborator se face doar la cerere expres\u0103 a medicului curant, cu bilet de trimitere parafat \u00een care se men\u021bioneaz\u0103 suspiciunea clinic\u0103 \u0219i microorganismele care se doresc a fi c\u0103utate suplimentar.<\/li>\n<li>Cre\u015fterea predominant\u0103 \u015fi \u00een cantitate mare \u00een cultura bacililor Gram negativ, a pseudomonadelor \u015fi a levurilor (<em>Candida albicans <\/em>\u2013 levura din microbiota orofaringian\u0103) poate avea semnifica\u0163ie clinic\u0103 la nou n\u0103scu\u0163i, \u00een cazul prematurilor, a pacien\u0163ilor spitaliza\u0163i pentru boli grave, imunodeprima\u0163i sau a celor ce au urmat tratament antimicrobian care a indus disbioze importante<sup>2<\/sup>. De aici importan\u0163a stabilirii unei bune comunic\u0103ri \u00eentre medicul clinician \u015fi medicul de laborator \u00een vederea cunoa\u015fterii contextului clinic al pacientului.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Un caz particular de infec\u0163ie faringian\u0103 apare la copiii cu\u00a0<em>fibroz\u0103 chistic\u0103<\/em>, afec\u0163iune ce trebuie men\u0163ionat\u0103 \u00een cererea trimis\u0103 laboratorului de c\u0103tre medicul clinician. Unul din produsele patologice acceptate \u00een acest caz este exsudatul faringian profund, laboratorul comunic\u00e2nd prezen\u0163a \u00een orice cantitate a urm\u0103torilor germeni: Staphylococcus aureus, Pseudomonas aeruginosa \u015fi Burkholderia cepacia<sup>4<\/sup>.<\/p>\n<p style=\"text-align: justify;\"><strong><em>Recoltarea \u015fi transportul probelor<\/em><\/strong><\/p>\n<p style=\"text-align: justify;\">Exsudatul faringian se prelev\u0103 \u00eenainte sau dup\u0103 4 ore de la toaleta cavit\u0103\u0163ii bucale sau ingestia de alimente sau lichide.<\/p>\n<p style=\"text-align: justify;\"><u>Tehnica de recoltare<\/u><\/p>\n<p style=\"text-align: justify;\">\u2013 Se a\u015faz\u0103 pacientul pe scaun cu fa\u0163a spre sursa de lumin\u0103, g\u00e2tul \u00een u\u015foar\u0103 extensie \u015fi ceafa sprijinit\u0103 de sp\u0103tar sau perete.<\/p>\n<p style=\"text-align: justify;\">\u2013 Se deprim\u0103 baza limbii cu ap\u0103s\u0103torul \u015fi, \u00een timp ce pacientul pronun\u0163\u0103 vocala \u201ca\u201d, se \u015fterg ferm cu tamponul amigdalele \u015fi peretele posterior al faringelui, insist\u00e2nd asupra zonelor inflamate, ulcerate sau cu depozite purulente; dac\u0103 exist\u0103 false membrane, acestea se desprind u\u015for, tampon\u00e2ndu-se mucoasa subiacent\u0103; at\u00e2t la introducerea, c\u00e2t \u015fi la scoaterea tamponului, se evit\u0103 atingerea bazei limbii \u015fi a palatului moale.<\/p>\n<p style=\"text-align: justify;\">\u2013 Se introduce tamponul \u00een tubul protector simplu sau prevazut cu mediu de transport (Amies sau Stuart), care se eticheteaz\u0103 corespunz\u0103tor.<\/p>\n<p style=\"text-align: justify;\">\u2013 Se prelev\u0103:<\/p>\n<ul style=\"text-align: justify;\">\n<li>un tampon cu mediu de transport Amies lichid, din care se vor efectua testele solicitate (se pot efectua din acela\u0219i recipient examen microscopic fusospirili, cultur\u0103 exsudat faringian \u0219i cultur\u0103 fungi din exsudat faringian)<\/li>\n<li>\u00een cazul solicit\u0103rii testului rapid (imunoenzimatic) pentru detectarea doar a antigenului streptococic de grup A, se va recolta urm\u00e2nd aceia\u0219i tehnica un tampon steril, f\u0103r\u0103 mediu de transport.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Transportul probelor c\u0103tre laborator se face \u00een maximum\u00a0<em>24 h ore<\/em>\u00a0de la prelevare.<\/p>\n<p style=\"text-align: justify;\"><strong><em>Metoda de lucru: <\/em><\/strong>examinare microscopic\u0103, cultur\u0103 bacterian\u0103 sau cultur\u0103 levuri (\u00een func\u021bie de solicitare)<\/p>\n<p style=\"text-align: justify;\"><strong><em>Criterii pentru efectuarea antibiogramei \u00een cazul culturilor bacteriene<\/em><\/strong><\/p>\n<p style=\"text-align: justify;\">\u00centruc\u00e2t Streptococii \u03b2 hemolitici \u015fi-au p\u0103strat sensibilitatea natural\u0103 la Penicilin\u0103, antibiogram\u0103 se efectueaz\u0103 doar la cererea medicului sau \u00een cazul\u00a0 alergiei la Penicilin\u0103.<\/p>\n<p style=\"text-align: justify;\">Dac\u0103 \u00een cultura Streptococul \u03b2 hemolitic se asociaz\u0103 cu Staphylococcus aureus, se va men\u0163iona \u00een buletinul de rezultate aceast\u0103 asociere, iar tratamentul pentru Streptococ\u00a0<strong>nu<\/strong>\u00a0se va efectua cu Penicilin\u0103, deoarece majoritatea tulpinilor de Stafilococ sunt secretoare de penicilinaz\u0103<sup>3<\/sup>.<\/p>\n<p style=\"text-align: justify;\"><strong><em>Interpretarea rezultatelor<\/em><\/strong><\/p>\n<p style=\"text-align: justify;\">Uzual, \u00een laboratoarele Synevo se comunic\u0103:<\/p>\n<ul style=\"text-align: justify;\">\n<li>Streptococii \u03b2 hemolitici: Str. pyogenes, streptococ grup C \u0219i streptococ grup G<\/li>\n<li>Staphylococcus aureus doar \u00een asociere cu un Streptococ \u03b2 hemolitic.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">\u00cen cadrul laboratorului Synevo nu se efectueaz\u0103 culturi pentru <em>Chlamydia pneumoniae, Mycoplasma pneumoniae<\/em> \u0438<em> Corynebacterium diphteriae, <\/em>Arcanobacterium haemolyticum, Neisseria gonorrhoeae.<\/p>\n<p style=\"text-align: justify;\"><em>\u00a0<\/em><\/p>\n<p style=\"text-align: justify;\">\u0411\u0438\u0431\u043b\u0438\u043e\u0433\u0440\u0430\u0444\u0438\u044f<\/p>\n<ol>\n<li style=\"text-align: justify;\">Betty A. Forbes, Daniel S. Sahm, Alice S. Weissfeld. Upper respiratory tract infections and other infections of the oral cavity and neck. In Diagnostic Microbiology, Twelfth Edition, 2007, 54: 814\u2013821.<\/li>\n<li style=\"text-align: justify;\">Dumitru Buiuc, Marian Negut. Diagnosticul de laborator al infec\u0163iilor tractusului respirator superior \u015fi cavit\u0103\u0163ilor conecte. \u00cen Tratat de Microbiologie Clinica, Edit. Medical\u0103 2008, 12: 208\u2013224.<\/li>\n<li style=\"text-align: justify;\">Laborator Synevo. Referin\u0163ele specifice tehnologiei de lucru utilizate 2019. Ref Type: Catalog.<\/li>\n<li style=\"text-align: justify;\">Amy L. Leber. Guidelines for Performance of Respiratory Tract Cultures. In Clinical Microbiology Procedures Handbook, American Society for Microbiology, 2016; 3.11.1.<\/li>\n<li style=\"text-align: justify;\">Olga Mihaela Dorobat. Bacteriologie Medical\u0103, 2006, 12: 189, 19: 300- 303.<\/li>\n<li style=\"text-align: justify;\">Erin McElvania, Kamaljit Singh. Specimen collection, transport and processing: Bacteriology. In Manual of Clinical Microbiology, 12th ed. 2019, 19: 302-330.<\/li>\n<\/ol>","protected":false},"excerpt":{"rendered":"<p>\u041d\u0430\u0434\u0433\u043b\u043e\u0442\u043e\u0447\u043d\u044b\u0439 \u0443\u0440\u043e\u0432\u0435\u043d\u044c \u0434\u044b\u0445\u0430\u0442\u0435\u043b\u044c\u043d\u044b\u0445 \u043f\u0443\u0442\u0435\u0439 \u0437\u0430\u0441\u0435\u043b\u0435\u043d \u0431\u0430\u043a\u0442\u0435\u0440\u0438\u0430\u043b\u044c\u043d\u043e\u0439 \u0444\u043b\u043e\u0440\u043e\u0439, \u043a\u043e\u0442\u043e\u0440\u0430\u044f \u0432\u043a\u043b\u044e\u0447\u0430\u0435\u0442 \u0431\u043e\u043b\u0435\u0435 200 \u0432\u0438\u0434\u043e\u0432 \u0431\u0430\u043a\u0442\u0435\u0440\u0438\u0439, \u0440\u0430\u0441\u0441\u0435\u043b\u0435\u043d\u043d\u044b\u0445 \u0432\u00a0\u0440\u0430\u0441\u0449\u0435\u043b\u0438\u043d\u0430\u0445 \u0434\u0435\u0441\u0435\u043d, \u0437\u0443\u0431\u043d\u043e\u043c \u043d\u0430\u043b\u0435\u0442\u0435, \u0441\u043b\u0438\u0437\u0438\u0441\u0442\u043e\u0439 \u043e\u0431\u043e\u043b\u043e\u0447\u043a\u0435 \u044f\u0437\u044b\u043a\u0430 \u0438\u00a0\u0449\u0435\u043a, \u0440\u043e\u0442\u043e\u0433\u043b\u043e\u0442\u043a\u0438, \u043a\u0440\u0438\u043f\u0442\u0430\u0445 \u043c\u0438\u043d\u0434\u0430\u043b\u0438\u043d \u0438\u00a0\u043d\u043e\u0441\u043e\u0433\u043b\u043e\u0442\u043a\u0435, \u0433\u0434\u0435 \u0430\u043d\u0430\u044d\u0440\u043e\u0431\u043d\u044b\u0435 \u0431\u0430\u043a\u0442\u0435\u0440\u0438\u0438 \u0434\u043e\u043c\u0438\u043d\u0438\u0440\u0443\u044e\u0442 \u043d\u0430\u0434 \u0430\u044d\u0440\u043e\u0431\u043d\u044b\u043c\u0438.<\/p>\n<p>\u041a\u00a0\u0440\u0435\u0437\u0438\u0434\u0435\u043d\u0442\u043d\u043e\u0439 \u043c\u0438\u043a\u0440\u043e\u0444\u043b\u043e\u0440\u0435 \u0441\u043b\u0438\u0437\u0438\u0441\u0442\u043e\u0439 \u043e\u0431\u043e\u043b\u043e\u0447\u043a\u0438 \u0437\u0435\u0432\u0430 \u043e\u0442\u043d\u043e\u0441\u044f\u0442\u0441\u044f: \u043d\u0435\u0439\u0441\u0441\u0435\u0440\u0438\u0438, \u0434\u0438\u0444\u0442\u0435\u0440\u043e\u0438\u0434\u044b,\u00a0\u0430\u043b\u044c\u0444\u0430-\u0433\u0435\u043c\u043e\u043b\u0438\u0442\u0438\u0447\u0435\u0441\u043a\u0438\u0435,\u00a0\u0433\u0430\u043c\u043c\u0430-\u0433\u0435\u043c\u043e\u043b\u0438\u0442\u0438\u0447\u0435\u0441\u043a\u0438\u0435\u00a0\u0441\u0442\u0440\u0435\u043f\u0442\u043e\u043a\u043e\u043a\u043a\u0438, \u044d\u043d\u0442\u0435\u0440\u043e\u043a\u043e\u043a\u043a\u0438, \u043c\u0438\u043a\u043e\u043f\u043b\u0430\u0437\u043c\u044b,\u00a0\u043a\u043e\u0430\u0433\u0443\u043b\u0430\u0437\u043e-\u043e\u0442\u0440\u0438\u0446\u0430\u0442\u0435\u043b\u044c\u043d\u044b\u0435\u00a0\u0441\u0442\u0430\u0444\u0438\u043b\u043e\u043a\u043e\u043a\u043a\u0438, \u043c\u043e\u0440\u0430\u043a\u0441\u0435\u043b\u043b\u044b, \u0431\u0430\u043a\u0442\u0435\u0440\u043e\u0438\u0434\u044b, \u0431\u043e\u0440\u0440\u0435\u043b\u0438\u0438, \u0442\u0440\u0435\u043f\u043e\u043d\u0435\u043c\u044b, \u0430\u043a\u0442\u0438\u043d\u043e\u043c\u0438\u0446\u0435\u0442\u044b\u00a0\u0438 \u0442. \u0434.\u00a0\u041e\u043a\u043e\u043b\u043e 70% \u0444\u0430\u0440\u0438\u043d\u0433\u0438\u0442\u043e\u0432 \u044f\u0432\u043b\u044f\u044e\u0442\u0441\u044f \u0437\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f\u043c\u0438 \u0432\u0438\u0440\u0443\u0441\u043d\u043e\u0439 \u044d\u0442\u0438\u043e\u043b\u043e\u0433\u0438\u0438. \u041f\u0440\u043e\u0446\u0435\u0441\u0441 \u0445\u0430\u0440\u0430\u043a\u0442\u0435\u0440\u0438\u0437\u0443\u0435\u0442\u0441\u044f \u043f\u043e\u0440\u0430\u0436\u0435\u043d\u0438\u0435\u043c \u044d\u043f\u0438\u0442\u0435\u043b\u0438\u044f \u0434\u044b\u0445\u0430\u0442\u0435\u043b\u044c\u043d\u044b\u0445 \u043f\u0443\u0442\u0435\u0439 \u0438\u00a0\u0437\u0430\u0441\u0442\u043e\u0439\u043d\u043e\u0439 \u043e\u0431\u0441\u0442\u0440\u0443\u043a\u0446\u0438\u0435\u0439 \u0441\u0438\u043d\u0443\u0441\u043e\u0432\u044b\u0445 \u043e\u0442\u0432\u0435\u0440\u0441\u0442\u0438\u0439 \u0438\u043b\u0438 \u0435\u0432\u0441\u0442\u0430\u0445\u0438\u0435\u0432\u043e\u0439 \u0442\u0440\u0443\u0431\u044b, \u0441\u043f\u043e\u0441\u043e\u0431\u0441\u0442\u0432\u0443\u044f \u0438\u0437\u0431\u044b\u0442\u043e\u0447\u043d\u043e\u043c\u0443 \u0431\u0430\u043a\u0442\u0435\u0440\u0438\u0430\u043b\u044c\u043d\u043e\u043c\u0443 \u0438\u043d\u0444\u0438\u0446\u0438\u0440\u043e\u0432\u0430\u043d\u0438\u044e \u043c\u0435\u0441\u0442\u043d\u044b\u043c\u0438 \u043c\u0438\u043a\u0440\u043e\u0431\u0438\u043e\u0442\u0430\u043c\u0438. \u041d\u0430\u0438\u0431\u043e\u043b\u0435\u0435 \u0447\u0430\u0441\u0442\u043e \u0432\u00a0\u043a\u0430\u0447\u0435\u0441\u0442\u0432\u0435 \u0431\u0430\u043a\u0442\u0435\u0440\u0438\u0430\u043b\u044c\u043d\u043e\u0433\u043e \u0430\u0433\u0435\u043d\u0442\u0430 \u0432\u044b\u0441\u0442\u0443\u043f\u0430\u0435\u0442\u00a0<em>Streptococcus pyogenes<\/em>\u00a0(\u0431\u0435\u0442\u0430-\u0433\u0435\u043c\u043e\u043b\u0438\u0442\u0438\u0447\u0435\u0441\u043a\u0438\u0439\u00a0\u0441\u0442\u0440\u0435\u043f\u0442\u043e\u043a\u043e\u043a\u043a \u0433\u0440\u0443\u043f\u043f\u044b, \u0410), \u043e\u0431\u0443\u0441\u043b\u0430\u0432\u043b\u0438\u0432\u0430\u044e\u0449\u0438\u0439 \u0442\u044f\u0436\u0435\u043b\u043e\u0435 \u0442\u0435\u0447\u0435\u043d\u0438\u0435 \u0444\u0430\u0440\u0438\u043d\u0433\u0438\u0442\u043e\u0432 \u0441\u00a0\u0438\u043d\u0444\u0435\u043a\u0446\u0438\u043e\u043d\u043d\u044b\u043c\u0438 \u043e\u0441\u043b\u043e\u0436\u043d\u0435\u043d\u0438\u044f\u043c\u0438 (\u0441\u0438\u043d\u0443\u0441\u0438\u0442\u044b, \u043e\u0442\u0438\u0442\u044b \u0441\u0440\u0435\u0434\u043d\u0435\u0433\u043e \u0443\u0445\u0430, \u043c\u0430\u0441\u0442\u043e\u0438\u0434\u0438\u0442\u044b, \u0430\u0431\u0441\u0446\u0435\u0441\u0441\u044b, \u0444\u043b\u0435\u0433\u043c\u043e\u043d\u044b \u043c\u0438\u043d\u0434\u0430\u043b\u0438\u043d\u00a0\u0438 \u0442. \u0434.).<\/p>\n<p>\u041f\u0430\u0440\u0430\u0442\u043e\u043d\u0437\u0438\u043b\u043b\u044f\u0440\u043d\u044b\u0439 \u0430\u0431\u0441\u0446\u0435\u0441\u0441 \u0432\u0441\u0442\u0440\u0435\u0447\u0430\u0435\u0442\u0441\u044f \u0447\u0430\u0449\u0435 \u0443\u00a0\u0434\u0435\u0442\u0435\u0439 \u0441\u0442\u0430\u0440\u0448\u0435 5 \u043b\u0435\u0442 \u0438\u00a0\u043c\u043e\u043b\u043e\u0434\u044b\u0445 \u043b\u044e\u0434\u0435\u0439, \u043d\u0430\u0438\u0431\u043e\u043b\u0435\u0435 \u0447\u0430\u0441\u0442\u043e \u0432\u044b\u0437\u044b\u0432\u0430\u0435\u0442\u0441\u044f \u0442\u0430\u043a\u0438\u043c\u0438 \u043c\u0438\u043a\u0440\u043e\u043e\u0440\u0433\u0430\u043d\u0438\u0437\u043c\u0430\u043c\u0438 \u043a\u0430\u043a\u00a0<em>Streptococcus pyogenes, Arcanobacterium haemolyticum, Staphylococcus aureus<\/em>, \u0430\u043d\u0430\u044d\u0440\u043e\u0431\u044b (\u043d\u0430\u043f\u0440\u0438\u043c\u0435\u0440,\u00a0<em>Fusobacterium spp.<\/em>\u00a0\u0438\u00a0<em>Bacteroides<\/em>). \u03b2-\u0433\u0435\u043c\u043e\u043b\u0438\u0442\u0438\u0447\u0435\u0441\u043a\u0438\u0435 \u0441\u0442\u0440\u0435\u043f\u0442\u043e\u043a\u043e\u043a\u043a\u0438 \u0433\u0440\u0443\u043f\u043f\u044b \u0421\u00a0\u0438\u00a0G\u00a0\u043c\u043e\u0433\u0443\u0442 \u0432\u044b\u0437\u044b\u0432\u0430\u0442\u044c \u0444\u0430\u0440\u0438\u043d\u0433\u0438\u0442\u044b, \u0440\u0430\u0437\u0432\u0438\u0442\u0438\u0435 \u043a\u043e\u0442\u043e\u0440\u044b\u0445 \u043c\u043e\u0436\u0435\u0442 \u0441\u043e\u043f\u0440\u043e\u0432\u043e\u0436\u0434\u0430\u0442\u044c\u0441\u044f \u0442\u044f\u0436\u0435\u043b\u044b\u043c\u0438 \u043e\u0441\u043b\u043e\u0436\u043d\u0435\u043d\u0438\u044f\u043c\u0438.\u00a0<em>Haemophilus influenzae<\/em>\u00a0(\u0432\u00a0\u043a\u0430\u0447\u0435\u0441\u0442\u0432\u0435 \u043f\u0440\u0438\u0447\u0438\u043d\u044b \u0440\u0430\u0437\u0432\u0438\u0442\u0438\u044f \u0444\u0430\u0440\u0438\u043d\u0433\u0438\u0442\u0430 \u0432\u044b\u0441\u0442\u0443\u043f\u0430\u0435\u0442 \u0442\u043e\u043b\u044c\u043a\u043e \u0441\u0435\u0440\u043e\u0442\u0438\u043f \u0412),\u00a0<em>Streptococcus pneumoniae<\/em>\u00a0\u0438\u00a0<em>Staphylococcus aureus<\/em>, \u0445\u043e\u0442\u044f \u0438\u00a0\u0447\u0430\u0441\u0442\u043e \u0432\u044b\u0434\u0435\u043b\u044f\u044e\u0442\u0441\u044f \u0438\u0437\u00a0\u0433\u043b\u043e\u0442\u043e\u0447\u043d\u043e\u0433\u043e \u044d\u043a\u0441\u0441\u0443\u0434\u0430\u0442\u0430 \u0438\u00a0\u043d\u043e\u0441\u043e\u0432\u043e\u0433\u043e \u0441\u0435\u043a\u0440\u0435\u0442\u0430, \u043e\u0434\u043d\u0430\u043a\u043e \u0438\u0445\u00a0\u0443\u0447\u0430\u0441\u0442\u0438\u0435 \u0432\u00a0\u0440\u0430\u0437\u0432\u0438\u0442\u0438\u0438 \u0444\u0430\u0440\u0438\u043d\u0433\u0438\u0442\u0430 \u0434\u043e\u00a0\u0441\u0438\u0445 \u043f\u043e\u0440 \u043d\u0435\u00a0\u043f\u043e\u0434\u0442\u0432\u0435\u0440\u0436\u0434\u0435\u043d\u043e. \u0421\u0442\u0430\u0442\u0443\u0441 \u043d\u043e\u0441\u0438\u0442\u0435\u043b\u044f \u043e\u0434\u043d\u043e\u0433\u043e \u0438\u0437\u00a0\u044d\u0442\u0438\u0445 \u043c\u0438\u043a\u0440\u043e\u043e\u0440\u0433\u0430\u043d\u0438\u0437\u043c\u043e\u0432, \u043a\u0430\u043a \u0438\u00a0\u0434\u043b\u044f\u00a0<em>Neisseria meningitidis, S.aureus<\/em>\u00a0(10<sup>3<\/sup>\u00a0\u041a\u041e\u0415\/\u043c\u043b), \u043c\u043e\u0436\u0435\u0442 \u0438\u043c\u0435\u0442\u044c \u043a\u043b\u0438\u043d\u0438\u0447\u0435\u0441\u043a\u043e\u0435 \u0437\u043d\u0430\u0447\u0435\u043d\u0438\u0435 \u043b\u0438\u0448\u044c \u0434\u043b\u044f \u043e\u043f\u0440\u0435\u0434\u0435\u043b\u0435\u043d\u043d\u044b\u0445 \u043f\u0430\u0446\u0438\u0435\u043d\u0442\u043e\u0432 \u0438\u043b\u0438 \u043a\u043e\u043d\u0442\u0430\u043a\u0442\u0438\u0440\u0443\u044e\u0449\u0438\u0445 \u0441\u00a0\u043d\u0438\u043c\u0438 \u043b\u0438\u0446.<\/p>\n<p>\u0414\u043e\u043c\u0438\u043d\u0438\u0440\u0443\u044e\u0449\u0435\u0435 \u0443\u0432\u0435\u043b\u0438\u0447\u0435\u043d\u0438\u0435, \u043f\u0440\u0438\u0447\u0435\u043c \u0432\u00a0\u0431\u043e\u043b\u044c\u0448\u0438\u0445 \u043a\u043e\u043b\u0438\u0447\u0435\u0441\u0442\u0432\u0430\u0445, \u043f\u0440\u0438 \u043f\u043e\u0441\u0435\u0432\u0435 \u043a\u0443\u043b\u044c\u0442\u0443\u0440 \u0433\u0440\u0430\u043c\u043e\u0442\u0440\u0438\u0446\u0430\u0442\u0435\u043b\u044c\u043d\u044b\u0445 \u0431\u0430\u043a\u0442\u0435\u0440\u0438\u0439,\u00a0<em>Pseudomonas<\/em>\u00a0\u0438\u00a0\u0434\u0440\u043e\u0436\u0436\u0435\u043f\u043e\u0434\u043e\u0431\u043d\u044b\u0445 \u0433\u0440\u0438\u0431\u043e\u0432 (\u0440\u043e\u0434\u0430\u00a0<em>Candida albicans<\/em>, \u043a\u043e\u043c\u043f\u043e\u043d\u0435\u043d\u0442 \u043c\u0438\u043a\u0440\u043e\u0444\u043b\u043e\u0440\u044b \u0440\u043e\u0442\u043e\u0433\u043b\u043e\u0442\u043a\u0438) \u043c\u043e\u0436\u0435\u0442 \u0438\u043c\u0435\u0442\u044c \u043a\u043b\u0438\u043d\u0438\u0447\u0435\u0441\u043a\u043e\u0435 \u0437\u043d\u0430\u0447\u0435\u043d\u0438\u0435 \u0443\u00a0\u043d\u043e\u0432\u043e\u0440\u043e\u0436\u0434\u0435\u043d\u043d\u044b\u0445, \u043d\u0435\u0434\u043e\u043d\u043e\u0448\u0435\u043d\u043d\u044b\u0445, \u0433\u043e\u0441\u043f\u0438\u0442\u0430\u043b\u0438\u0437\u0438\u0440\u043e\u0432\u0430\u043d\u043d\u044b\u0445 \u0431\u043e\u043b\u044c\u043d\u044b\u0445 \u0441\u00a0\u0442\u044f\u0436\u0435\u043b\u044b\u043c\u0438 \u0437\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f\u043c\u0438, \u043b\u0438\u0446 \u0441\u00a0\u043e\u0441\u043b\u0430\u0431\u043b\u0435\u043d\u043d\u044b\u043c \u0438\u043c\u043c\u0443\u043d\u0438\u0442\u0435\u0442\u043e\u043c \u0438\u043b\u0438 \u043f\u0435\u0440\u0435\u043d\u0435\u0441\u0448\u0438\u0445 \u0430\u043d\u0442\u0438\u0431\u0430\u043a\u0442\u0435\u0440\u0438\u0430\u043b\u044c\u043d\u0443\u044e, 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