Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 40  |  Issue : 2  |  Page : 116-118

Chronic venous leg ulcer with multidrug resistant bacterial infection in a tertiary care hospital of Eastern India


1 Department of Microbiology, IPGMER and SSKM Hospital, Kolkata, India
2 Department of Dermatology, IPGMER and SSKM Hospital, Kolkata, India

Date of Web Publication23-Jul-2013

Correspondence Address:
Kalidas Rit
70 B T C Mukherjee Street, P.O. Rishra, District Hooghly - 712 248, West Bengal, Kolkata
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.115489

Rights and Permissions
  Abstract 

Chronic venous leg ulcer represents a major issue for both patients and health-care provider being associated with impaired quality of life. We here report a case of non-healing venous ulcer over gaiter area of right leg. The ulcer presented with unique features of polymicrobial infection of multi-drug resistant species including, methicillin-resistant Staphylococcus aureus, metallo-β lactamase producing Acinetobacter baumanii and Acinetobacter lowffii.

Keywords: Acinetobacter , metallo-β lactamase, methicillin-resistant Staphylococcus aureus, multi-drug resistance, venous leg ulcer


How to cite this article:
Rit K, Nag F, Sarkar A, Maiti PK. Chronic venous leg ulcer with multidrug resistant bacterial infection in a tertiary care hospital of Eastern India. J Sci Soc 2013;40:116-8

How to cite this URL:
Rit K, Nag F, Sarkar A, Maiti PK. Chronic venous leg ulcer with multidrug resistant bacterial infection in a tertiary care hospital of Eastern India. J Sci Soc [serial online] 2013 [cited 2019 Jul 19];40:116-8. Available from: http://www.jscisociety.com/text.asp?2013/40/2/116/115489


  Introduction Top


Venous ulcers are most debilitating sequel of chronic venous insufficiency and venous hypertension. They account for nearly 80% of lower extremity ulcers with overall prevalence of 1-2%. [1] The bacterial population present within chronic venous leg ulcer (CVLU) with severe infection includes, multi-drug resistant (MDR) strains of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin resistant Enterococcus species, gram-negative bacteria including, Pseudomonas species, Acinetobacter species, Klebsiella pneumoniae and other organisms. [2] Given this resistances panorama it is necessary to determine the bacteriological profile of hospitalized patients in order to reduce morbidity and improve the quality of life.


  Case Report Top


A 52-year-old obese, diabetic male patient presented to the dermatology OPD of our hospital, with a non-healing ulcer [Figure 1] on gaiter area of right leg and high-grade fever. The ulcer was present on and off for some 5 years with much increase in size and discharge for last 1 month. There was yellowish necrotic debris and granulation tissue over the base of the ulcer with large amount of odoros discharge. Plain X-ray of ulcer area revealed no bony involvement. Venous duplex sonography revealed incompetent sapheno femoral valve and lower perforating veins. Ankle-brachial pressure index value was 1.1, thereby excluding any arterial disease. Laboratory investigation revealed hemoglobin 9 mg/dL, white cell count 22.5 × 10 3 /mm 3 , granulocyte percentage 86% (reference value: 43-76%). The differential count showed a segmented neutrophil percentage of 80% (reference value: 54-62%/2,700-6,200/mm 3 ). The fasting plasma glucose level corresponded to 95 mg/dL.
Figure 1: Infected venous leg ulcer

Click here to view


After the admission, patient was treated empirically with intravenous ciprofloxacin and IV gentamicin to prevent any clinical and systemic sign of sepsis. A consultation was made on fourth hospitalization day for wound debridement and obtaining of wound specimens for bacterial cultures and anti-biogram. The wound was thoroughly cleaned and irrigated by using 0.85% sterile sodium chloride (Nacl) solution and debridement of necrotic tissue enclosing the ulcer area was carried out. After repeat irrigation, the specimen was collected with a sterile culture swab and immediately sent to Microbiology department for further processing. The specimen was seeded in selective MacConkey agar [Figure 2], blood agar, and brain heart infusion broth (Hi-Media, Mumbai), followed by incubation in conventional atmosphere at 37°C for 24 h. Biochemical tests were performed to identify bacteria at species level.

Susceptibility to cefoxitin, cefepime, ceftriaxone, chloramphenicol, ciprofloxacin, clindamycin, erythromycin, oxacillin, vancomycin, gentamicin, imipenem, colistin, rifampicin, tazobactam-piperacillin, tetracycline, and trimethoprim/sulfamethoxazole was determined using the disc diffusion test. All assays were performed in accordance with clinical and laboratory standard institute guidelines. [3] S. aureus (ATCC 25923) was included as control strains. Susceptibility of S. aureus to oxacillin was determined using oxacilli-salt-screen-agar containing 6 ug/ml oxacillin and 4% Nacl, followed by the use of cefoxitin (30 ug) agar disc diffusion. metallo-β lactamase (MBL) production was detected [Figure 3] by imipenem-EDTA Combined Disc Diffusion test. [4]
Figure 2: Colony of Acinetobacter baumannii in MacConkey agar media

Click here to view
Figure 3: Imipenem-EDTA combined disc diffusion test with metallo-β lactamase production

Click here to view


Final microbiological analysis revealed a polymicrobial infection with MRSA and MBL producing strains of Acinetobacter baumanii and Acinetobacter lowffii. MRSA strain showed intermediate susceptibility only against vancomycin. A. baumanii was resistant to all drugs tested and A. lowffii was only susceptibile to colistin. Based on this IV vancomycin and colistin was started from eighth hospitalization day. After the initial improvement on the 12 th day , there was a progression of the infection with the patient having systemic symptoms including increased body temperature and diaphoresis . Due to these results on the 20 th hospitalization day below ankle amputation of affected limb was done.


  Discussion Top


CVLUs often have a polymicrobial infection including aerobic and anerobic flora. In this study, we used sterile culture swab for collection of specimen. Wound swab offer ease to use, low-cost procedure and recent studies indicate they give similar results to tissue biopsies. The bacterial species isolated in this study were methicillin-resistant S. aureus, A. baumanii and A. lowffii, all with MDR phenotype. Methicillin resistant S. aureus strains represent a chronic problem in hospital environment with prevalence of 40-55% in India. [5] Since the 1980, several cases of community acquired MRSA infection were reported . An important fact about our case report is that the collection of the specimen for culture was performed on the 4 th day of hospitalization and although, the patient had reported not having been admitted in the previous 5 months, the colonization could have occurred after hospitalization.

This case report also identified two species of Acinetobacter, s genus (A. baumanii and A. lowffii), both showing the phenotypic pattern of resistance to all classes tested according to the recommendation of the CLSI (except A. lowffii showed susceptibility to colistin) and both were potential MBL producer. The A. lowffii is present as skin commensal in approximately 25% of healthy individuals. [6] However, A. baumanii is mostly associated with nosocomial infection and rarely found in human skin microbiota. The pathogenic potential of these bacterial species is due to its various virulence factors that allow their survival in hospital environment as well as the ability to cause disease, particularly in debilitated patients.

Bacterial resistance is an issue that is increasingly common in CVLU infection. Various risk factors like previous antibiotic therapy and its duration, frequency and length of hospitalization for the same wound are related to antibiotic resistance. [7] In our case, the patient reported of not having used antibiotic for exacerbation of CVLU as well as not having been hospitalized in the previous 5 months. However, at the time of hospitalization, he received empirical broad-spectrum antibiotic therapy. Therefore, it could be suggested that natural selection imposed by antibiotics led to the elimination of susceptible bacterial species, leaving only the resistant strains in the damaged tissue. The existence of bio-flim on chronic difficult to heal wound complicates the clinical use of antimicrobial, favoring the emergence of resistant bacteria and hence, the treatment strategy should be based on isolating the causative agent and on determining the sensitivity profile in regards to antimicrobial agents.

 
  References Top

1.Baker SR, Stacey MC, Singh G, Hoskin SE, Thompson PJ. Aetiology of chronic leg ulcers. Eur J Vasc Surg 1992;6:245-51.  Back to cited text no. 1
[PUBMED]    
2.Lookingbill DP, Miller SH, Knowles RC. Bacteriology of chronic leg ulcers. Arch Dermatol 1978;114:1765-8.  Back to cited text no. 2
[PUBMED]    
3.Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. Approved Standard M100-S19. 9 th ed. Wayne PA: CLSI; 2009. p. M2-A9.  Back to cited text no. 3
    
4.Yong D, Lee K, Yum JH, Shin HB, Rossolini GM, Chong Y. Imipenem-EDTA disk method for differentiation of metallo-beta-lactamase-producing clinical isolates of Pseudomonas spp. and Acinetobacter spp. J Clin Microbiol 2002;40:3798-801.  Back to cited text no. 4
[PUBMED]    
5.Davies CE, Hill KE, Newcombe RG, Stephens P, Wilson MJ, Harding KG, et al. A prospective study of the microbiology of chronic venous leg ulcers to reevaluate the clinical predictive value of tissue biopsies and swabs. Wound Repair Regen 2007;15:17-22.  Back to cited text no. 5
[PUBMED]    
6.Rajaduraipandi K, Mani KR, Panneerselvam K, Mani M, Bhaskar M, Manikandan P. Prevalence and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus: A multicentre study. Indian J Med Microbiol 2006;24:34-8.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Dijkshoorn L, Nemec A, Seifert H. An increasing threat in hospitals: Multidrug-resistant Acinetobacter baumannii. Nat Rev Microbiol 2007;5:939-51.  Back to cited text no. 7
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed3680    
    Printed53    
    Emailed0    
    PDF Downloaded240    
    Comments [Add]    

Recommend this journal