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Ciprofloxacin-resistant Aeromonas hydrophila infection following leech therapy: A case report and review of the literature
Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, e20ee22
CASE REPORT
Ciprofloxacin-resistant Aeromonas hydrophila infection following leech therapy: A case report and review of the literature Ketan M. Patel*, Michael Svestka, Jeremy Sinkin, Paul Ruff IV Department of Plastic Surgery, Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC 20007, United States Received 10 September 2012; accepted 1 October 2012
KEYWORDS Leeches; Aeromonas hydrophila; Infection; Autologous flap
Summary Compromised flap perfusion can lead to the use of leech therapy to aid in flap salvage. Aeromonas hydrophila, a symbiont of the leech, is a well-known bacterial pathogen that has the potential to cause infection in patients receiving leech therapy. Ciprofloxacin is commonly regarded as the antibiotic of choice for prophylaxis against this pathogen. We present patient who underwent leech therapy during salvage attempts for a venous congested flap. A resultant infection developed despite being on appropriate antibiotics. Culture sensitivities indicated that A. hydrophila was resistant to ciprofloxacin. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Therapy with medicinal leeches, namely Hirudo medicinalis, has been a valuable adjunct to reconstructive surgeons in settings of venous insufficiency in free and pedicled flaps. While an individual leech can drain an initial 5e15 ml of blood, a substantial secondary benefit is conferred by anti-hemostatic factors, notably hirudin, in * Corresponding author. Tel.: þ1 202 444 7243; fax: þ1 202 444 7180. E-mail addresses: [email protected], khoppa@ gmail.com (K.M. Patel).
saliva of the leech. A well-recognized complication of H. medicinalis therapy is infection secondary to a symbiont bacteria, Aeromonas hydrophila, which populates the gut of leeches. These gram-negative rods may result in clinically significant infections with rates ranging from 2 to 36%.1 Reported infections by numerous studies2e4 have prompted the use of prophylactic antibiotics when leech therapy is initiated. Prophylaxis against Aeromonas during leech therapy is consistently endorsed in the literature, however specifics regarding antibiotic choice remain variable. Recommendations by Green and Shafritz suggest the use of oral ciprofloxacin for empiric prophylaxis,1 and this suggestion is supported by numerous other investigators.5,6
1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.10.002
Ciprofloxacin-resistant A. hydrophila infection following leech therapy Similar findings by Parker and Shaw demonstrate that ciprofloxacin and cefotaxime may be used successfully.7 We present a case report of a patient who underwent H. medicinalis leech therapy for a compromised microvascular flap for breast reconstruction. Despite being on antibiotics, infection developed. Bacterial cultures taken indicate A. Hydrophila infection that was resistant to Ciprofloxacin.
Case description A 60 year-old female elected for immediate unilateral breast reconstruction following mastectomy with a deep inferior epigastric perforator (DIEP) flap. Postoperatively, the patient was admitted in the intensive care for flap monitoring. Venous congestion resulted in the post-operative course prompting medicinal leech therapy. Intravenous ciprofloxacin was initiated for prophylaxis against A. hydrophila. Intravenous vancomycin was also included as a prophylactic antibiotic in the perioperative period. Leech therapy was continued for 3 days. Upon surgical reexploration, intra-flap thrombosis was found and the flap was removed. The breast cavity was irrigated and a silicone gel implant was placed in the partial submuscular plane. Antibiotics were continued following implant placement. Subsequently, the reconstructed breast became erythematous with turbid output from the drains. She then was taken back to the operating room for re-exploration. The implant was found to be infected and was removed. Cultures of the purulent breast fluid were consistent for multidrug resistant A. hydrophila. Resistance to Ciprofloxacin was identified on qualitative cultures. As a result, aztreonam was initiated. Leukocytosis and erythema later resolved.
e21
mediated quinolone resistance in environmental Aeromonas was reported by Cattoir et. al.,14 while chromosomal mutations conferring quinolone resistance were recently described in fish and water isolates by Han and colleagues.15 Clinically, a single case report has described an infection by fluoroquinolone-resistant A. hydrophila following medicinal leech therapy.16 Similarly, fluoroquinolone resistance was isolated following A. hydrophila in the patient described above. Sensitivities to aztreonam, piperacillin/tazobactam, ceftriaxone, and trimethoprim/ sulfamethoxazole were appreciated in the presented patient. In the era of increasing antibiotic resistance, considerations for additional antibiotic coverage may be warranted when medicinal leeches are used in reconstructive surgery. As susceptibility patterns develop and leech care becomes standardized, we anticipate future studies and guidelines will inform prophylaxis. A. hydrophila is not uniformly susceptible to a specific antibiotic class and thus changes in prophylactic therapy may be required as resistances become evident. When considering alternative therapies, it is important to note that A. hydrophila is known to produce beta-lactamase. In addition, awareness of cases of A. hydrophila antibiotic resistance with medicinal leech therapy may translate into avoiding complications related to infection following reconstruction.
Funding No funding was utilized for the preparation of this manuscript.
Discussion
Conflicts of interests
Infections following medicinal leech therapy have been previously reported in the literature. Schnabl et al. reported 100% of five patients developing infection without prophylactic antibiotics.8 Alternatively, Nguyen et al. encountered no infections following appropriate prophylaxis in a series of 39 patients.9 If a flap becomes infected, Aeromonas should be strongly considered the primary pathogen. A recent systematic review of 227 patients found an infection rate of 14.4% with A. hydrophila accounting for 87.9% of infections.10 In addition, Whitaker et al. evaluated a subset of patients who developed A. hydrophila infection following medicinal leech therapy with all infections being sensitive to ciprofloxacin.11 Antibiotic prophylaxis is well-accepted in the setting of medicinal leech therapy. The type of antibiotic used continues to evolve. Publications have supported monotherapy1,2,5,10 while few studies support other treatment modalities. Three out of eight patients in a series by Chepeha et al. received double therapy with ciprofloxacin and trimethoprim-sulfamethoxazole versus monotherapy with no infections reported.12 Similarly, Soucacos et al. reported the use of double-coverage antibiotics with aminoglycosides and a 3rd generation cephalosporin.13 While sensitivity to ciprofloxacin is generally appreciated, rare quinolone-resistant Aeromonas, may pose an emerging threat to medicinal leech therapy. Plasmid-
None declared.
References 1. Green PA, Shafritz AB. Medicinal leech use in microsurgery. J Hand Surg Am 2010;35(6):1019e21. 2. Bauters TG, Buyle FM, Verschraegen G, et al. Infection risk related to the use of medicinal leeches. Pharm World Sci 2007; 29(3):122e5. 3. Snower DP, Ruef C, Kuritza AP, Edberg SC. Aeromonas hydrophila infection associated with the use of medicinal leeches. J Clin Microbiol 1989;27(6):1421e2. 4. Ardehali B, Hand K, Nduka C, Holmes A, Wood S. Delayed leech-borne infection with Aeromonas hydrophila in escharotic flap wound. J Plast Reconstr Aesthet Surg 2006;59(1):94e5. 5. Whitaker IS, Kamya C, Azzopardi EA, Graf J, Kon M, Lineaweaver WC. Preventing infective complications following leech therapy: is practice keeping pace with current research? Microsurgery 2009;29(8):619e25. 6. Ko WC, Chaing SR, Lee HC, Tang HJ, Wang YY, Chuang YC. In vitro and in vivo activities of fluoroquinolones against Aeromonas hydrophila. Antimicrob Agents Chemother 2003; 47(7):2217e22. 7. Parker JL, Shaw JG. Aeromonas spp. clinical microbiology and disease. J Infect 2011;62(2):109e18. 8. Schnabl SM, Kunz C, Unglaub F, Polykandriotis E, Horch RE, Dragu A. Acute postoperative infection with Aeromonas
e22
9.
10.
11.
12.
K.M. Patel et al. hydrophila after using medical leeches for treatment of venous congestion. Arch Orthop Trauma Surg 2010;130(10):1323e8. Nguyen MQ, Crosby MA, Skoracki RJ, Hanasono MM. Outcomes of flap salvage with medicinal leech therapy. Microsurgery 2012;32(5):351e7. Whitaker IS, Oboumarzouk O, Rozen WM, et al. The efficacy of medicinal leeches in plastic and reconstructive surgery: a systematic review of 277 reported clinical cases. Microsurgery 2012;32(3):240e50. Whitaker IS, Josty IC, Hawkins S, et al. Medicinal leeches and the microsurgeon: a four-year study, clinical series and risk benefit review. Microsurgery 2011;31(4):281e7. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN. Leech therapy for patients with surgically unsalvageable venous obstruction after revascularized free tissue transfer. Arch Otolaryngol Head Neck Surg 2002;128(8):960e5.
13. Soucacos PN, Beris AE, Malizos KN, Xenakis TA, Georgoulis A. Successful treatment of venous congestion in free skin flaps using medical leeches. Microsurgery 1994;15(7): 496e501. 14. Cattoir V, Poirel L, Aubert C, Soussy CJ, Nordmann P. Unexpected occurrence of plasmid-mediated quinolone resistance determinants in environmental Aeromonas spp. Emerg Infect Dis 2008;14(2):231e7. 15. Han JE, Kim JH, Cheresca Jr CH, et al. First description of the qnrS-like (qnrS5)gene and analysis of quinolone resistancedetermining regions in motile Aeromonas spp. from diseased fish and water. Res Microbiol 2012;163(1):73e9. 16. Wang EW, Warren DK, Ferris VM, Casabar E, Nussenbaum B. Leech-transmitted ciprofloxacin-resistant Aeromonas hydrophila. Arch Otolaryngol Head Neck Surg 2011;137(2): 190e3.
CASE REPORT
Ciprofloxacin-resistant Aeromonas hydrophila infection following leech therapy: A case report and review of the literature Ketan M. Patel*, Michael Svestka, Jeremy Sinkin, Paul Ruff IV Department of Plastic Surgery, Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC 20007, United States Received 10 September 2012; accepted 1 October 2012
KEYWORDS Leeches; Aeromonas hydrophila; Infection; Autologous flap
Summary Compromised flap perfusion can lead to the use of leech therapy to aid in flap salvage. Aeromonas hydrophila, a symbiont of the leech, is a well-known bacterial pathogen that has the potential to cause infection in patients receiving leech therapy. Ciprofloxacin is commonly regarded as the antibiotic of choice for prophylaxis against this pathogen. We present patient who underwent leech therapy during salvage attempts for a venous congested flap. A resultant infection developed despite being on appropriate antibiotics. Culture sensitivities indicated that A. hydrophila was resistant to ciprofloxacin. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Therapy with medicinal leeches, namely Hirudo medicinalis, has been a valuable adjunct to reconstructive surgeons in settings of venous insufficiency in free and pedicled flaps. While an individual leech can drain an initial 5e15 ml of blood, a substantial secondary benefit is conferred by anti-hemostatic factors, notably hirudin, in * Corresponding author. Tel.: þ1 202 444 7243; fax: þ1 202 444 7180. E-mail addresses: [email protected], khoppa@ gmail.com (K.M. Patel).
saliva of the leech. A well-recognized complication of H. medicinalis therapy is infection secondary to a symbiont bacteria, Aeromonas hydrophila, which populates the gut of leeches. These gram-negative rods may result in clinically significant infections with rates ranging from 2 to 36%.1 Reported infections by numerous studies2e4 have prompted the use of prophylactic antibiotics when leech therapy is initiated. Prophylaxis against Aeromonas during leech therapy is consistently endorsed in the literature, however specifics regarding antibiotic choice remain variable. Recommendations by Green and Shafritz suggest the use of oral ciprofloxacin for empiric prophylaxis,1 and this suggestion is supported by numerous other investigators.5,6
1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.10.002
Ciprofloxacin-resistant A. hydrophila infection following leech therapy Similar findings by Parker and Shaw demonstrate that ciprofloxacin and cefotaxime may be used successfully.7 We present a case report of a patient who underwent H. medicinalis leech therapy for a compromised microvascular flap for breast reconstruction. Despite being on antibiotics, infection developed. Bacterial cultures taken indicate A. Hydrophila infection that was resistant to Ciprofloxacin.
Case description A 60 year-old female elected for immediate unilateral breast reconstruction following mastectomy with a deep inferior epigastric perforator (DIEP) flap. Postoperatively, the patient was admitted in the intensive care for flap monitoring. Venous congestion resulted in the post-operative course prompting medicinal leech therapy. Intravenous ciprofloxacin was initiated for prophylaxis against A. hydrophila. Intravenous vancomycin was also included as a prophylactic antibiotic in the perioperative period. Leech therapy was continued for 3 days. Upon surgical reexploration, intra-flap thrombosis was found and the flap was removed. The breast cavity was irrigated and a silicone gel implant was placed in the partial submuscular plane. Antibiotics were continued following implant placement. Subsequently, the reconstructed breast became erythematous with turbid output from the drains. She then was taken back to the operating room for re-exploration. The implant was found to be infected and was removed. Cultures of the purulent breast fluid were consistent for multidrug resistant A. hydrophila. Resistance to Ciprofloxacin was identified on qualitative cultures. As a result, aztreonam was initiated. Leukocytosis and erythema later resolved.
e21
mediated quinolone resistance in environmental Aeromonas was reported by Cattoir et. al.,14 while chromosomal mutations conferring quinolone resistance were recently described in fish and water isolates by Han and colleagues.15 Clinically, a single case report has described an infection by fluoroquinolone-resistant A. hydrophila following medicinal leech therapy.16 Similarly, fluoroquinolone resistance was isolated following A. hydrophila in the patient described above. Sensitivities to aztreonam, piperacillin/tazobactam, ceftriaxone, and trimethoprim/ sulfamethoxazole were appreciated in the presented patient. In the era of increasing antibiotic resistance, considerations for additional antibiotic coverage may be warranted when medicinal leeches are used in reconstructive surgery. As susceptibility patterns develop and leech care becomes standardized, we anticipate future studies and guidelines will inform prophylaxis. A. hydrophila is not uniformly susceptible to a specific antibiotic class and thus changes in prophylactic therapy may be required as resistances become evident. When considering alternative therapies, it is important to note that A. hydrophila is known to produce beta-lactamase. In addition, awareness of cases of A. hydrophila antibiotic resistance with medicinal leech therapy may translate into avoiding complications related to infection following reconstruction.
Funding No funding was utilized for the preparation of this manuscript.
Discussion
Conflicts of interests
Infections following medicinal leech therapy have been previously reported in the literature. Schnabl et al. reported 100% of five patients developing infection without prophylactic antibiotics.8 Alternatively, Nguyen et al. encountered no infections following appropriate prophylaxis in a series of 39 patients.9 If a flap becomes infected, Aeromonas should be strongly considered the primary pathogen. A recent systematic review of 227 patients found an infection rate of 14.4% with A. hydrophila accounting for 87.9% of infections.10 In addition, Whitaker et al. evaluated a subset of patients who developed A. hydrophila infection following medicinal leech therapy with all infections being sensitive to ciprofloxacin.11 Antibiotic prophylaxis is well-accepted in the setting of medicinal leech therapy. The type of antibiotic used continues to evolve. Publications have supported monotherapy1,2,5,10 while few studies support other treatment modalities. Three out of eight patients in a series by Chepeha et al. received double therapy with ciprofloxacin and trimethoprim-sulfamethoxazole versus monotherapy with no infections reported.12 Similarly, Soucacos et al. reported the use of double-coverage antibiotics with aminoglycosides and a 3rd generation cephalosporin.13 While sensitivity to ciprofloxacin is generally appreciated, rare quinolone-resistant Aeromonas, may pose an emerging threat to medicinal leech therapy. Plasmid-
None declared.
References 1. Green PA, Shafritz AB. Medicinal leech use in microsurgery. J Hand Surg Am 2010;35(6):1019e21. 2. Bauters TG, Buyle FM, Verschraegen G, et al. Infection risk related to the use of medicinal leeches. Pharm World Sci 2007; 29(3):122e5. 3. Snower DP, Ruef C, Kuritza AP, Edberg SC. Aeromonas hydrophila infection associated with the use of medicinal leeches. J Clin Microbiol 1989;27(6):1421e2. 4. Ardehali B, Hand K, Nduka C, Holmes A, Wood S. Delayed leech-borne infection with Aeromonas hydrophila in escharotic flap wound. J Plast Reconstr Aesthet Surg 2006;59(1):94e5. 5. Whitaker IS, Kamya C, Azzopardi EA, Graf J, Kon M, Lineaweaver WC. Preventing infective complications following leech therapy: is practice keeping pace with current research? Microsurgery 2009;29(8):619e25. 6. Ko WC, Chaing SR, Lee HC, Tang HJ, Wang YY, Chuang YC. In vitro and in vivo activities of fluoroquinolones against Aeromonas hydrophila. Antimicrob Agents Chemother 2003; 47(7):2217e22. 7. Parker JL, Shaw JG. Aeromonas spp. clinical microbiology and disease. J Infect 2011;62(2):109e18. 8. Schnabl SM, Kunz C, Unglaub F, Polykandriotis E, Horch RE, Dragu A. Acute postoperative infection with Aeromonas
e22
9.
10.
11.
12.
K.M. Patel et al. hydrophila after using medical leeches for treatment of venous congestion. Arch Orthop Trauma Surg 2010;130(10):1323e8. Nguyen MQ, Crosby MA, Skoracki RJ, Hanasono MM. Outcomes of flap salvage with medicinal leech therapy. Microsurgery 2012;32(5):351e7. Whitaker IS, Oboumarzouk O, Rozen WM, et al. The efficacy of medicinal leeches in plastic and reconstructive surgery: a systematic review of 277 reported clinical cases. Microsurgery 2012;32(3):240e50. Whitaker IS, Josty IC, Hawkins S, et al. Medicinal leeches and the microsurgeon: a four-year study, clinical series and risk benefit review. Microsurgery 2011;31(4):281e7. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN. Leech therapy for patients with surgically unsalvageable venous obstruction after revascularized free tissue transfer. Arch Otolaryngol Head Neck Surg 2002;128(8):960e5.
13. Soucacos PN, Beris AE, Malizos KN, Xenakis TA, Georgoulis A. Successful treatment of venous congestion in free skin flaps using medical leeches. Microsurgery 1994;15(7): 496e501. 14. Cattoir V, Poirel L, Aubert C, Soussy CJ, Nordmann P. Unexpected occurrence of plasmid-mediated quinolone resistance determinants in environmental Aeromonas spp. Emerg Infect Dis 2008;14(2):231e7. 15. Han JE, Kim JH, Cheresca Jr CH, et al. First description of the qnrS-like (qnrS5)gene and analysis of quinolone resistancedetermining regions in motile Aeromonas spp. from diseased fish and water. Res Microbiol 2012;163(1):73e9. 16. Wang EW, Warren DK, Ferris VM, Casabar E, Nussenbaum B. Leech-transmitted ciprofloxacin-resistant Aeromonas hydrophila. Arch Otolaryngol Head Neck Surg 2011;137(2): 190e3.