|Year : 2013 | Volume
| Issue : 2 | Page : 116-118
Chronic venous leg ulcer with multidrug resistant bacterial infection in a tertiary care hospital of Eastern India
Kalidas Rit1, Falguni Nag2, Abhik Sarkar1, Prasanta Kumar Maiti1
1 Department of Microbiology, IPGMER and SSKM Hospital, Kolkata, India
2 Department of Dermatology, IPGMER and SSKM Hospital, Kolkata, India
|Date of Web Publication||23-Jul-2013|
70 B T C Mukherjee Street, P.O. Rishra, District Hooghly - 712 248, West Bengal, Kolkata
Source of Support: None, Conflict of Interest: None
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 Oct 13];40:116-8. Available from: http://www.jscisociety.com/text.asp?2013/40/2/116/115489
| Introduction|| |
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%.  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.  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|| |
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.
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.  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. 
|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|| |
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.  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.  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.  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|| |
|1.||Baker SR, Stacey MC, Singh G, Hoskin SE, Thompson PJ. Aetiology of chronic leg ulcers. Eur J Vasc Surg 1992;6:245-51. |
|2.||Lookingbill DP, Miller SH, Knowles RC. Bacteriology of chronic leg ulcers. Arch Dermatol 1978;114:1765-8. |
|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. |
|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. |
|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. |
|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. |
|7.||Dijkshoorn L, Nemec A, Seifert H. An increasing threat in hospitals: Multidrug-resistant Acinetobacter baumannii. Nat Rev Microbiol 2007;5:939-51. |
[Figure 1], [Figure 2], [Figure 3]