- Email: [email protected]
Aeromonas hydrophila in burn patients
Burns 24 (1998) 32iO-353
Aeromonas hydrophila in burn patients Paul J. Skoll*, Donald A. Hudson, John A. Simpson i3ur~~s Unit, IVew Somerset
Hospital,
Department
of Plasfic and Reconstructive Surger)i University Medical Research, Cape Town, SOL& Aftica
qf Cape
Town, and the South A.frica:7
hrstitute
for
Accepted 5 Januar:/ 19987
Abstract Burn
wound infection with Aeronlonas hydrophila appears to be very uncommon. This study reports on nine cases of A. in burn patients treated over a 21 month period at the New Somerset Hospital Burn Unit. Thle average age of the patients was 31 years (range 24-60 years) and the average TBSA was 33% (range 16-51%). All patients had positive wound cultures for A. hydrophila, obtained on admission or shortly thereafter. One patient also had a positive blood culture. Two patients with small partial thickness burns did not receive antibiotic therapy, and made an uneventful recovery with topical therapy alone. The other seven patients developed clinical signs of septicaemia and required parenteral antibiotics, in addition to topical therapy. One patient died of ARDS, but the other eight recovered and were discharged. No patient had evidence of myonecrosis. Small, superficial burns which culture A. hydrophilu can be treated by topical therapy alone. Large and/or deep burns, require antibiotic therapy and debridement of all necrotic tissue, particularly when myonecrosis is present. The antibiotics of choice are the aminoglycosides or the quinolones. 0 1998 Elsevier Science Ltd for ISBI. All rights reserved. hydrophila
1. Introduction
Aeromonadis are gram negative, motile, facultative anaerobic rods that are beta haemolytic on blood agar [l-7]. As their name suggests, these bacteria are usually found in fresh or brackish water, most often being pathogens of fish, aquatic reptiles and amphibians [1,3,6]. Isolates have also been recovered from fish tanks, swimming pools and tap water, including hospital water supplies [2,3,6]. Human infection with Aeromonas species is uncommon, and most often associated with trauma in an aquatic environment, immunosuppression, and chronic disease [2,4,6,8]. Infection in burn patients is particularly uncommon, and usually associated with large, deep burns [l,lO]. We report on nine cases of Aeromonas hydrophila isolated from burn patients treated at a major referral hospital over a 21 month period. 2. Methods
A retrospective analysis of all patients admitted to the Burns Unit with positive A. hydrophila cultures “Corresponding author. Ward F17, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa. Tel.: +27-21-404 3426; Fax: 27-21-4486461.
between March 1993 and September 1997 was undertaken. Clinical data included the age, sex and domicile of the patient. The total burn surface area (TBSA), as well as the area of the burn that was full thickness, was no’ted. The site of the burn was also recorded. The types of other organisms cultured, including antibiotic sensitivity, was documented. The length of hospital stay and outcome was noted. All patients are bathed daily and, then treated with povidone iodine or silver sulphadiazine dressings. Deep partial thickness and full thickness burns are treated by tangential excision and skin grafting. Wound swabs are taken routinely on the day of admission and then twice weekly unless otherwise indicated. Antibiotics are prescribed to patients who develop clinical signs of septicaemia (high fever, tachycardia etc.). The antibiotics used are empirical, and are adjusted once sensitivities become available. Prior to antibiotic administration, a blood culture is taken. Isolates of A. hydrophila were identified by colonial morphology with large zones of beta haemolysis on blood agar, and growth of the isolate on MacConkey agar. A positive oxidase and indole reaction and lack of the ornithine decarboxylase enzyme characterises this organism. The absence of the ornithine decarboxylase enzyme differentiates Aeromonas from Plesiomonas species, while the presence of arginine decarboxylase
0305-4179/98/$19.(JO 0 1998 Elsevier Science Ltd for ISBI. All rights reserved PII: SO305-4179(98)00024-2
l? J. Sk011 et aLlBurns
enzyme in .Aerorraorzas differentiates
it from
Vz’/l:bvio
cholerae. 3. Results
Between March 1993 and December 1995, 543 patients were admitted to the burns unit and during this period no Aerornonas species were cultured. Between Ja-nuary 1996 and September 1997, 322 patients were admitted to the burns unit of which nine cases of A. hydmphila were identified. These were from burn surface swabs in all patients, and a positive blood culture in one. Pat.ient data is reflected in Table 1. The average age of thfese patients was 31 yr, with a range from 24 to 60 yr. None had predisposing medical illness, and all denied exposure to water at the time of the burn. They were all shack dwellers. The average TBSA was 33% (16-51%) and the average area of fuull thickness burn was 14% (2-35%). No patient had evidence of myonecrosis. All patients sustained flame burns, but only two had evidence of intubation and inhalation injury, which required ventilation. All patients had positive wound surface cultures for A. hydrophila. The organism was cultured on or shortly after admission: two patients had positive burn surface cultures taken on the day of the burn, five patients had positive cultures on post burn day 1, and in two patients the organism was cultured from a swab sent on post burn day 2. Only one patient had a positive blood culture which occurred on the fourth day after sustaining the burn. Six of the nine burn surface swabs (66%) which grew A. hydrophila, showed polymicrobial cultures. All but two patients received antibiotic therapy which was adjusted according to bacteriologic sensitivities. The sensitivities of the A. hydrophila are listed in Table 2. There was uniform resistance to amoxicillin,
24 (1998)
350-353
351
with variable sensitivity to amoxicillin-clavulanic acid and co-trimoxazole. All were sensitive to aminoglycosides and quinolones. Two patients did not receive antibiotics. Patient 3 had 22% partial thickness burns to her torso, with 2% requiring skin grafting. Wound swabs showed moderate to abundant A. hydrophila on admission, which was treated with topical silver sulphadiazine only. She remained well, suffered no graft loss, and was discharged on day 24. Patient 7 had 16% partial thickness flame burns and was treated with daily silver sulphadiazine dressings only. Wound swabs showed scanty A. hydrophila on post burn clay 1, however, there was no systemic evidence of infection. She made an weventful recovery on conservative treatment, and did not require skin grafting. She was discharged on day 8 for daily dressings as an outpatient. Eight of the nine patients made an uneventful recovery. Patient 9 suffered 35% full thickness cutaneous burns and severe inhalational injury. He was transferred from a peripheral hospital on post burn day two, was septic on admission, and required ventilation for severe ARDS. Despite intensive therapy? he died 2 weeks later. Aeromonas hydrophila and Klebsiella pneumoniae were cultured from burn surface swabs on aIdmission to the unit.
4.. Discussion Aevomorm hydrophil~ is an uncommon human p;sthogen, and appears to be particularly uncommon in burn wound infection, with few reported cases. In the last 20 yr, only four studies have reported on this organism in burn patients in the English literature. In 1996 Barillo et al. [l] reported on eight cases of A,eromonas bacteraemia from 81.51 burn patients. In 1988 Purdue and Hunt [lo] reported three cases from 2400 inpatient burns, one of which died of
Table 1 Patient data Patient
Age
Sex
TBSA (%I
Full thickness
Post burn day positive swab
Other organisms also cultured
1 2 Day of burn Day of burn 1 1 1 1 2
+ + + + + -
Number of operations
Antibiotic given
Site”
Hospital stay (days)
Outcome
4 1
Yes Yes No Yes Yes Yes No Yes Yes
UL UL and T H and N UL and LL. UL LL LL LL UL
24 46 24 47 95 103 8 N/A 14
DCb DC DC DC DC DC DC DC Died
(%I
8 9
30 24 29 30 41 60 22 27 24
M M F F F F F F :cI
“Site: UL = upper “DC = discharged.
20 50 22 30 45 28 16 52 35 limb;
10 20 2 15 15 4 0 35 35 LL = lower
limb;
T = trunk;
+
H and N = head and neck.
fl3. Sk011 et aLlBums
352 Table 2 Antibiotic
sensitivity
of A. hydroplzila 1
-__ Cotrimoxazole Amoxicillin-clavulanic Amikacin Amoxicillin Gentamicin Ciprofloxacin Olloxacin Ceftriaxone Povidone iodine Silver sulphadiazine
acid
in nine patients 2
3
SSRSSSRRS RRRRRSSSR s s s RRRRRRRRR s s s s s s s s s s s s s s s s s s
4
5
6
7
8
9
s
s
s
s
s
s
s s s s s s
s s s s s s s s s s SRSSS
s s s s s
s s s s s
s s s s s
24 (1998)
350-353
setting, when cultured, measures need to be taken to eradicate this organism. These measures include appropriate antibiotics, and here aminoglycosides or the quinolones should be considered as ffirst line treatment. Aeromonas hydrophila is reported to be universally resistant to penicillin, ampicillin, carbenicillin and cefazolin [1,3]. The sensitivity to topical treatment should also be checked: in this study the organism was sensitive to both povidone iodine and silver sulphadiazine in all but one case (Table 2). ln addition, as A. hydrophila is particularly pathogenic to muscle, any nefcrotic muscle needs urgent surgical debridement P, 21.
R = resistant;
S = sensitive.
overwhelming sepsis. Two case reports have also appeared: asymptomatic colonisation of burn blister fluid following a hand scald was reported in 1980 [4], and a patient who sustained a 40% burn, who jumped into a pond to extinguish the flames, was reported in 2981 [9]. Most of the reported cases following trauma have been secondary to water exposure [l-4,6,8,9], however, the patients in this study denied exposure to water. Contact with soil [2,4,7] may also lead to contamination with this organism. All the patients in this study lived in shacks surrounded by soil, which is the likely source of the bacteria. The occurrence of this organism over such a limited period is difficult to explain, but may reflect the increasing number of patients with shack fire burns admitted to the burns unit [ll]. Another possible explanation is that some cases may have arisen due to cross contamination, although this is unlikely as the majority of patients in this series had positive swabs in the first 24 h post burn. Also, as noted in other series [&lo], the incubation period of A. hydrophila is 1-2 days or less, and therefore infection with this organism usually occurs shortly after sustaining an injury. The average size of the burns in this series was 33% of which only 14% was full thickness. This is a considerably smaller surface area than that reported by Barillo et al. [l]. In the patient who sustains a small partial thickness burn ( ~20% TBSA) and is not immunocompromised, the A. hydrophila appears to exist as a contaminant/colonizer of the wound, and bacteraemia in this setting appears to be uncommon [2,3,6]. These patients do not require antibiotics routinely and can be managed conservatively by topical dressings, however, sensitivities to topical agents must be ensured (Table 2). This form of treatment was successful in two patients in this study. In the patient with a large burn, who is likely to be immunocompromised as a result of the burn, or who sustains a deep full thickness burn involving muscle, infection from A. hydp-oyhilu can occur. In this clinical
This is the first study from Africa reporting on the presence of A. hydrophila in burn wounds. Exposure to soil in patients living in shacks appears to be the source of the organism. In the small and superficial burn wound, the organism appears to act as a coloniser rather than a pathogen and in the absence of clinical signs of invasion, can be dealt with by appropriate topical therapy. In these patients morbidity due to A. hydrophila should be low. However, in the large and, or deep burn, rapid infection can occur due to A. hydrophila. In these patients, topical therapy as well as appropriate antibiotics (aminoglycosides or quinolones) should be administered to eradicate the organism. Necrotic muscle should be debrided immediately to avoid a rampant myonecrosis which may require limb ablation as a life saving procedure.
Acknowledgements
The authors wish to thank Miss Janet Hitchcock of the South African Institute for Medical Research for her assistance in data retrieval.
Refferences [l]
[2]
[3]
[4] [5]
[6]
Barillo DJ, McManus AT, Cioffi WG, McManus WF, Kim SH, Pruitt BA Jr. Aeromonas bacteraemia in burn patients. Burns 1996;22:48-52. Davis WA, Kane JG, Garagusi VF. Human Aaronmzas infections; a review of the literature and a case report of endocarditis. Medicine 1978;57:267-277. Gold WL, Salit IE. Aeronzonas hydrophila infections of skin and soft tissue; a report of 11 cases and review. Clinical Infectious Diseases 1993;16:69-74. Smith JA. Aeromonas hydrophila: analysis of 11 cases. Canadian Medical Association Journal 1980;122:12;10-1272. Golik A, Leonov Y, Schlaeffer F et al. Aeromonas species bacteraemia in nonimmunocompromised hosts two cases reports and a review of the literature. Israel Journal of Medical Science 1990;26:87-90. Semel JD, Trenholme G. Aeromonas hydvophila water associated traumatic wound infections; a review. Journal of Trauma 1990;30:324-327.
P J. Skoll et al./Burns
[7] Deepe GS, Conrood Aeromonas
hydrophila.
JD. Fulminant wound infection with South African Medical Journal
1980;73:1%6-1547. [8] Rosenthal SG, Bernhardt HE, Phillips JA. Aerornonas philrr wound infection. Plastic Reconstruction 1974;53:77--79.
hyc!ro-
Surgery
24 (1998)
350-353
353
[9] Ampei N. Peter G. Aerornonas bacteraemia in a burn patient. Lancet 1981;31: 987 [lo] Purdue GF, Hunt JL. Aeromonns hydrophila infection in burn patients. Burns 1988;14:220-221. [ll] Godwin Y, Hudson DA, Bloch C. Shack fires: a consequence of urban migration. Burns 1997;23:151-153.
Aeromonas hydrophila in burn patients Paul J. Skoll*, Donald A. Hudson, John A. Simpson i3ur~~s Unit, IVew Somerset
Hospital,
Department
of Plasfic and Reconstructive Surger)i University Medical Research, Cape Town, SOL& Aftica
qf Cape
Town, and the South A.frica:7
hrstitute
for
Accepted 5 Januar:/ 19987
Abstract Burn
wound infection with Aeronlonas hydrophila appears to be very uncommon. This study reports on nine cases of A. in burn patients treated over a 21 month period at the New Somerset Hospital Burn Unit. Thle average age of the patients was 31 years (range 24-60 years) and the average TBSA was 33% (range 16-51%). All patients had positive wound cultures for A. hydrophila, obtained on admission or shortly thereafter. One patient also had a positive blood culture. Two patients with small partial thickness burns did not receive antibiotic therapy, and made an uneventful recovery with topical therapy alone. The other seven patients developed clinical signs of septicaemia and required parenteral antibiotics, in addition to topical therapy. One patient died of ARDS, but the other eight recovered and were discharged. No patient had evidence of myonecrosis. Small, superficial burns which culture A. hydrophilu can be treated by topical therapy alone. Large and/or deep burns, require antibiotic therapy and debridement of all necrotic tissue, particularly when myonecrosis is present. The antibiotics of choice are the aminoglycosides or the quinolones. 0 1998 Elsevier Science Ltd for ISBI. All rights reserved. hydrophila
1. Introduction
Aeromonadis are gram negative, motile, facultative anaerobic rods that are beta haemolytic on blood agar [l-7]. As their name suggests, these bacteria are usually found in fresh or brackish water, most often being pathogens of fish, aquatic reptiles and amphibians [1,3,6]. Isolates have also been recovered from fish tanks, swimming pools and tap water, including hospital water supplies [2,3,6]. Human infection with Aeromonas species is uncommon, and most often associated with trauma in an aquatic environment, immunosuppression, and chronic disease [2,4,6,8]. Infection in burn patients is particularly uncommon, and usually associated with large, deep burns [l,lO]. We report on nine cases of Aeromonas hydrophila isolated from burn patients treated at a major referral hospital over a 21 month period. 2. Methods
A retrospective analysis of all patients admitted to the Burns Unit with positive A. hydrophila cultures “Corresponding author. Ward F17, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa. Tel.: +27-21-404 3426; Fax: 27-21-4486461.
between March 1993 and September 1997 was undertaken. Clinical data included the age, sex and domicile of the patient. The total burn surface area (TBSA), as well as the area of the burn that was full thickness, was no’ted. The site of the burn was also recorded. The types of other organisms cultured, including antibiotic sensitivity, was documented. The length of hospital stay and outcome was noted. All patients are bathed daily and, then treated with povidone iodine or silver sulphadiazine dressings. Deep partial thickness and full thickness burns are treated by tangential excision and skin grafting. Wound swabs are taken routinely on the day of admission and then twice weekly unless otherwise indicated. Antibiotics are prescribed to patients who develop clinical signs of septicaemia (high fever, tachycardia etc.). The antibiotics used are empirical, and are adjusted once sensitivities become available. Prior to antibiotic administration, a blood culture is taken. Isolates of A. hydrophila were identified by colonial morphology with large zones of beta haemolysis on blood agar, and growth of the isolate on MacConkey agar. A positive oxidase and indole reaction and lack of the ornithine decarboxylase enzyme characterises this organism. The absence of the ornithine decarboxylase enzyme differentiates Aeromonas from Plesiomonas species, while the presence of arginine decarboxylase
0305-4179/98/$19.(JO 0 1998 Elsevier Science Ltd for ISBI. All rights reserved PII: SO305-4179(98)00024-2
l? J. Sk011 et aLlBurns
enzyme in .Aerorraorzas differentiates
it from
Vz’/l:bvio
cholerae. 3. Results
Between March 1993 and December 1995, 543 patients were admitted to the burns unit and during this period no Aerornonas species were cultured. Between Ja-nuary 1996 and September 1997, 322 patients were admitted to the burns unit of which nine cases of A. hydmphila were identified. These were from burn surface swabs in all patients, and a positive blood culture in one. Pat.ient data is reflected in Table 1. The average age of thfese patients was 31 yr, with a range from 24 to 60 yr. None had predisposing medical illness, and all denied exposure to water at the time of the burn. They were all shack dwellers. The average TBSA was 33% (16-51%) and the average area of fuull thickness burn was 14% (2-35%). No patient had evidence of myonecrosis. All patients sustained flame burns, but only two had evidence of intubation and inhalation injury, which required ventilation. All patients had positive wound surface cultures for A. hydrophila. The organism was cultured on or shortly after admission: two patients had positive burn surface cultures taken on the day of the burn, five patients had positive cultures on post burn day 1, and in two patients the organism was cultured from a swab sent on post burn day 2. Only one patient had a positive blood culture which occurred on the fourth day after sustaining the burn. Six of the nine burn surface swabs (66%) which grew A. hydrophila, showed polymicrobial cultures. All but two patients received antibiotic therapy which was adjusted according to bacteriologic sensitivities. The sensitivities of the A. hydrophila are listed in Table 2. There was uniform resistance to amoxicillin,
24 (1998)
350-353
351
with variable sensitivity to amoxicillin-clavulanic acid and co-trimoxazole. All were sensitive to aminoglycosides and quinolones. Two patients did not receive antibiotics. Patient 3 had 22% partial thickness burns to her torso, with 2% requiring skin grafting. Wound swabs showed moderate to abundant A. hydrophila on admission, which was treated with topical silver sulphadiazine only. She remained well, suffered no graft loss, and was discharged on day 24. Patient 7 had 16% partial thickness flame burns and was treated with daily silver sulphadiazine dressings only. Wound swabs showed scanty A. hydrophila on post burn clay 1, however, there was no systemic evidence of infection. She made an weventful recovery on conservative treatment, and did not require skin grafting. She was discharged on day 8 for daily dressings as an outpatient. Eight of the nine patients made an uneventful recovery. Patient 9 suffered 35% full thickness cutaneous burns and severe inhalational injury. He was transferred from a peripheral hospital on post burn day two, was septic on admission, and required ventilation for severe ARDS. Despite intensive therapy? he died 2 weeks later. Aeromonas hydrophila and Klebsiella pneumoniae were cultured from burn surface swabs on aIdmission to the unit.
4.. Discussion Aevomorm hydrophil~ is an uncommon human p;sthogen, and appears to be particularly uncommon in burn wound infection, with few reported cases. In the last 20 yr, only four studies have reported on this organism in burn patients in the English literature. In 1996 Barillo et al. [l] reported on eight cases of A,eromonas bacteraemia from 81.51 burn patients. In 1988 Purdue and Hunt [lo] reported three cases from 2400 inpatient burns, one of which died of
Table 1 Patient data Patient
Age
Sex
TBSA (%I
Full thickness
Post burn day positive swab
Other organisms also cultured
1 2 Day of burn Day of burn 1 1 1 1 2
+ + + + + -
Number of operations
Antibiotic given
Site”
Hospital stay (days)
Outcome
4 1
Yes Yes No Yes Yes Yes No Yes Yes
UL UL and T H and N UL and LL. UL LL LL LL UL
24 46 24 47 95 103 8 N/A 14
DCb DC DC DC DC DC DC DC Died
(%I
8 9
30 24 29 30 41 60 22 27 24
M M F F F F F F :cI
“Site: UL = upper “DC = discharged.
20 50 22 30 45 28 16 52 35 limb;
10 20 2 15 15 4 0 35 35 LL = lower
limb;
T = trunk;
+
H and N = head and neck.
fl3. Sk011 et aLlBums
352 Table 2 Antibiotic
sensitivity
of A. hydroplzila 1
-__ Cotrimoxazole Amoxicillin-clavulanic Amikacin Amoxicillin Gentamicin Ciprofloxacin Olloxacin Ceftriaxone Povidone iodine Silver sulphadiazine
acid
in nine patients 2
3
SSRSSSRRS RRRRRSSSR s s s RRRRRRRRR s s s s s s s s s s s s s s s s s s
4
5
6
7
8
9
s
s
s
s
s
s
s s s s s s
s s s s s s s s s s SRSSS
s s s s s
s s s s s
s s s s s
24 (1998)
350-353
setting, when cultured, measures need to be taken to eradicate this organism. These measures include appropriate antibiotics, and here aminoglycosides or the quinolones should be considered as ffirst line treatment. Aeromonas hydrophila is reported to be universally resistant to penicillin, ampicillin, carbenicillin and cefazolin [1,3]. The sensitivity to topical treatment should also be checked: in this study the organism was sensitive to both povidone iodine and silver sulphadiazine in all but one case (Table 2). ln addition, as A. hydrophila is particularly pathogenic to muscle, any nefcrotic muscle needs urgent surgical debridement P, 21.
R = resistant;
S = sensitive.
overwhelming sepsis. Two case reports have also appeared: asymptomatic colonisation of burn blister fluid following a hand scald was reported in 1980 [4], and a patient who sustained a 40% burn, who jumped into a pond to extinguish the flames, was reported in 2981 [9]. Most of the reported cases following trauma have been secondary to water exposure [l-4,6,8,9], however, the patients in this study denied exposure to water. Contact with soil [2,4,7] may also lead to contamination with this organism. All the patients in this study lived in shacks surrounded by soil, which is the likely source of the bacteria. The occurrence of this organism over such a limited period is difficult to explain, but may reflect the increasing number of patients with shack fire burns admitted to the burns unit [ll]. Another possible explanation is that some cases may have arisen due to cross contamination, although this is unlikely as the majority of patients in this series had positive swabs in the first 24 h post burn. Also, as noted in other series [&lo], the incubation period of A. hydrophila is 1-2 days or less, and therefore infection with this organism usually occurs shortly after sustaining an injury. The average size of the burns in this series was 33% of which only 14% was full thickness. This is a considerably smaller surface area than that reported by Barillo et al. [l]. In the patient who sustains a small partial thickness burn ( ~20% TBSA) and is not immunocompromised, the A. hydrophila appears to exist as a contaminant/colonizer of the wound, and bacteraemia in this setting appears to be uncommon [2,3,6]. These patients do not require antibiotics routinely and can be managed conservatively by topical dressings, however, sensitivities to topical agents must be ensured (Table 2). This form of treatment was successful in two patients in this study. In the patient with a large burn, who is likely to be immunocompromised as a result of the burn, or who sustains a deep full thickness burn involving muscle, infection from A. hydp-oyhilu can occur. In this clinical
This is the first study from Africa reporting on the presence of A. hydrophila in burn wounds. Exposure to soil in patients living in shacks appears to be the source of the organism. In the small and superficial burn wound, the organism appears to act as a coloniser rather than a pathogen and in the absence of clinical signs of invasion, can be dealt with by appropriate topical therapy. In these patients morbidity due to A. hydrophila should be low. However, in the large and, or deep burn, rapid infection can occur due to A. hydrophila. In these patients, topical therapy as well as appropriate antibiotics (aminoglycosides or quinolones) should be administered to eradicate the organism. Necrotic muscle should be debrided immediately to avoid a rampant myonecrosis which may require limb ablation as a life saving procedure.
Acknowledgements
The authors wish to thank Miss Janet Hitchcock of the South African Institute for Medical Research for her assistance in data retrieval.
Refferences [l]
[2]
[3]
[4] [5]
[6]
Barillo DJ, McManus AT, Cioffi WG, McManus WF, Kim SH, Pruitt BA Jr. Aeromonas bacteraemia in burn patients. Burns 1996;22:48-52. Davis WA, Kane JG, Garagusi VF. Human Aaronmzas infections; a review of the literature and a case report of endocarditis. Medicine 1978;57:267-277. Gold WL, Salit IE. Aeronzonas hydrophila infections of skin and soft tissue; a report of 11 cases and review. Clinical Infectious Diseases 1993;16:69-74. Smith JA. Aeromonas hydrophila: analysis of 11 cases. Canadian Medical Association Journal 1980;122:12;10-1272. Golik A, Leonov Y, Schlaeffer F et al. Aeromonas species bacteraemia in nonimmunocompromised hosts two cases reports and a review of the literature. Israel Journal of Medical Science 1990;26:87-90. Semel JD, Trenholme G. Aeromonas hydvophila water associated traumatic wound infections; a review. Journal of Trauma 1990;30:324-327.
P J. Skoll et al./Burns
[7] Deepe GS, Conrood Aeromonas
hydrophila.
JD. Fulminant wound infection with South African Medical Journal
1980;73:1%6-1547. [8] Rosenthal SG, Bernhardt HE, Phillips JA. Aerornonas philrr wound infection. Plastic Reconstruction 1974;53:77--79.
hyc!ro-
Surgery
24 (1998)
350-353
353
[9] Ampei N. Peter G. Aerornonas bacteraemia in a burn patient. Lancet 1981;31: 987 [lo] Purdue GF, Hunt JL. Aeromonns hydrophila infection in burn patients. Burns 1988;14:220-221. [ll] Godwin Y, Hudson DA, Bloch C. Shack fires: a consequence of urban migration. Burns 1997;23:151-153.