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P04.02 A case of Mycobacterium fortuitum causing surgical site wound infection
Abstracts, 7th International Conference of the Hospital Infection Society, 10–13 October 2010, Liverpool, UK / Journal of Hospital Infection 76S1 (2010) S1–S90
S15
Methods: 350 peripheral IV cannula insertions were studied in three NHS organisations. Equipment problems during cannulation were recorded and staff interviewed to identify causes. Results: Out of the 350 cannulation procedures, 47 incidents of equipment problems (Table 1) were recorded during 46 cannulation procedures. This equates to a reliability of 87% across the three organisations. Interviews revealed a variety of causes including problems with supply of the right size of cannula, lack of tourniquets and a lack of sharps bins to dispose of the needles. Often staff found work-arounds to deal with these problems.
ward. The patient successfully battled against the odds of multiple medical setbacks, surgical & infective complications with MDR bacteria. After multiple cycles of infection & targeted treatment through multidisciplinary input the patient was successfully treated.
Table 1: Summary of non-availability of equipment across the whole study
Introduction: Mycobacteria which grow rapidly are considered uncommon human pathogens. Two members of this group, Mycobacterium fortuitum and Mycobacterium chelonae have been identified as opportunistic pathogens. We report a case of culture positive surgical site wound infection caused by Mycobacterium fortuitum. Case report: A 45 years old post renal transplant patient, presented to the out patient department with the complaints of multiple non tender nodules on the surgical wound site on the anterior abdominal wall for last 4 months. The first lesions appeared as a small nodule which gradually increased and developed suppuration and purulent discharge. Examination of anterior abdominal wall showed three oval nodular lesions along the line of incision, each measuring 2–3 cms. Pus swabs were taken with aseptic precautions. Gram stained smear showed numerous pus cells and Gram positive beeded rods and staining with ZiehlNeelsen method using 20% H2SO4 as decolorizer showed acid fast bacilli. Swabs were inoculated on Blood, MacConkey’s and Lowenstein Jensens (LJ) medium and incubated at 37°c. After 3 days incubation, a number of small creamy white colonies appeared on Blood agar, lactose fermenting colonies on MacConkey’s agar and rough buff colonies on LJ medium. The isolate was identified as M. fortuitum by standard microbiological techniques. Antimicrobial sensitivity was done on Mueller Hinton agar using Kirby Bauer disc diffusion technique which showed the organism sensitive to ciprofloxacin and azithromycin but resistant to polymixin B, further confirming our identification. The patient was treated according to antimicrobial sensitivity report and he started to improve. Conclusion: In all purulent samples from immunocompromised patients, a high index of suspicion and diligent search for acid fast organism, and inclusion of appropriate media with sufficiently long incubation period are likely to prove beneficial.
Item
Hand hygiene facilities Personal protection e.g. gloves Skin preparation e.g. 2% chlorhexidine Clean tourniquet Intravenous cannula Specific intravenous cannula dressing Sharps disposal bin Total failures Reliability
Failures (%) Organisation A
Organisation D
Organisation F
All incidents across organisations
0 0 0 8/76 (11%) 2/76 (3%) 0 5/76 (7%) 15/76 (19.7%) 80.3%
0 0 2/62 (3.2%) 0 0 5/62 8.0% 0 7/62 (11.3%) 88.7%
0 0 1/212 (0.5%) 0 2/212 (1.0%) 2/212 (1.0%) 20/212 (9.4%) 25/212 (11.8%) 88.2%
0 0 3/47 (6.4%) 8/47 (17%) 4/47 (8.5%) 7/47 (14.9%) 25/47 (53.2%) 47/350 (13.4%) 86.9%
Conclusion: This study is part of a broader project to assess the reliability of healthcare systems. Given the importance of having the right equipment available for inserting IV cannulae in preventing infections the findings here indicate that all hospitals should measure the reliability of their systems to ensure that staff are able to practice safely for them and their patients. Poster Session 4 – Clinical Cases P04.01 ‘The 6 Million Dollar Man’: An unusual case of adaptative commensalism with multidrug resistant bacteria in a surgical patient treated for 18 months M. Przybylo, S. Summers, A. Guleri, M. Qulaghassi. Blackpool Victoria Hospital, United Kingdom Background: The Six Million Dollar Man’, a 1970’s American television series about a fictional severely injured man, rebuilt with bionics at a cost of $6 million. We present a parallel – an unusual case of stabbing injury who miraculously survived – multiple surgical, medical and infective complications during next 18 months care in ITU & ward. He demonstrated an interesting phenomenon of adaptative commensalism with MDR bacteria after multiple cycles of sepsis & treatment. Case study: A 51-yr-old male was admitted with right sided stab injuries to base of neck, damaged subclavian artery (SbA) & haemothorax. His subsequent course in critical care included MI, four episodes cardiac arrest, failed SbA repair, further episodes of haemothorax, diagnosis of pseudo-aneurysm SbA & right SbAInt jugular fistula. Surgical interventions included emergency thoracotomies & re-opening, sternotomy, arteriovenous fistula repair, repair & then ligation of SbA, rib resection and partial resection of his exposed right scapula. He had multiple cycles of empiric and targeted antimicrobial treatment for multiple episodes of sepsis, pneumonia (VAP/HAP), thoracotomy wound infections, empyema, etc. Cumulative antimicrobial use (over 18-months) included meropenem (63 d), pip-tazobactam (87 d), flucloxacillin (24 d), ciprofloxacin (31 d), nebulised colistin (345 d), caspofungin (14 d) and fluconazole (26 d). Culture results included MDR P. aeruginosa, S. aureus, K. oxytoca, C. freundii, S. maltophilia, Pantoea, B. fragilis & Candida albicans. Twice daily fibreoptic bronchoscopy was required to clear resp plugs. Discussion: This was an unusual case in several ways. The patient had unusually extended stay between intensive (166 d), high care &
P04.02 A case of Mycobacterium fortuitum causing surgical site wound infection F. Kaleem, J. Usman, K. Roz Uddin, M. Omair, A. Khalid, A. Hassan. National University of Sciences and Technology, AMC, Pakistan
P04.03 A case of isolation of an unusual pathogen from ascitic fluid F. Kaleem1 , S. Abbasi2 , J. Usman1 , A. Hassan1 . 1 National University of Sciences and Technology, AMC., Pakistan; 2 AFIP, Pakistan Introduction: Spontaneous bacterial peritonitis (SBP) is defined as an ascitic fluid infection with a positive bacterial culture and polymorphonuclear cell count of >250/mm3 with no source of abdominal infection. SBP caused by Salmonella is uncommon and rarely reported. A 46 years old lady, diagnosed with an end stage renal disease, on maintenance hemodialysis for last ten years and chronic liver disease from last 4 years was brought to the emergency department with the complaints of progressive abdominal distension, vomiting and fever for last ten days. On examination she was found to be jaundiced, emaciated, febrile (102°F) and in hepatic encephalopathy. Liver function tests revealed a serum total bilirubin 26 umol/L, serum ALT 21 U/L, serum alkaline phosphatase 265 U/L. Ultra sound abdomen showed liver cirrhosis and grade 3 bilateral renal parenchymal disease. Diagnostic as well as therapeutic ascitic tap done and fluid revealed specific gravity of 1030 with a protein content of 4.0 g/dL, Rivaltas test was positive, cell count was 9000/cmm. Leishman’s stain showed mostly neutrophils
S15
Methods: 350 peripheral IV cannula insertions were studied in three NHS organisations. Equipment problems during cannulation were recorded and staff interviewed to identify causes. Results: Out of the 350 cannulation procedures, 47 incidents of equipment problems (Table 1) were recorded during 46 cannulation procedures. This equates to a reliability of 87% across the three organisations. Interviews revealed a variety of causes including problems with supply of the right size of cannula, lack of tourniquets and a lack of sharps bins to dispose of the needles. Often staff found work-arounds to deal with these problems.
ward. The patient successfully battled against the odds of multiple medical setbacks, surgical & infective complications with MDR bacteria. After multiple cycles of infection & targeted treatment through multidisciplinary input the patient was successfully treated.
Table 1: Summary of non-availability of equipment across the whole study
Introduction: Mycobacteria which grow rapidly are considered uncommon human pathogens. Two members of this group, Mycobacterium fortuitum and Mycobacterium chelonae have been identified as opportunistic pathogens. We report a case of culture positive surgical site wound infection caused by Mycobacterium fortuitum. Case report: A 45 years old post renal transplant patient, presented to the out patient department with the complaints of multiple non tender nodules on the surgical wound site on the anterior abdominal wall for last 4 months. The first lesions appeared as a small nodule which gradually increased and developed suppuration and purulent discharge. Examination of anterior abdominal wall showed three oval nodular lesions along the line of incision, each measuring 2–3 cms. Pus swabs were taken with aseptic precautions. Gram stained smear showed numerous pus cells and Gram positive beeded rods and staining with ZiehlNeelsen method using 20% H2SO4 as decolorizer showed acid fast bacilli. Swabs were inoculated on Blood, MacConkey’s and Lowenstein Jensens (LJ) medium and incubated at 37°c. After 3 days incubation, a number of small creamy white colonies appeared on Blood agar, lactose fermenting colonies on MacConkey’s agar and rough buff colonies on LJ medium. The isolate was identified as M. fortuitum by standard microbiological techniques. Antimicrobial sensitivity was done on Mueller Hinton agar using Kirby Bauer disc diffusion technique which showed the organism sensitive to ciprofloxacin and azithromycin but resistant to polymixin B, further confirming our identification. The patient was treated according to antimicrobial sensitivity report and he started to improve. Conclusion: In all purulent samples from immunocompromised patients, a high index of suspicion and diligent search for acid fast organism, and inclusion of appropriate media with sufficiently long incubation period are likely to prove beneficial.
Item
Hand hygiene facilities Personal protection e.g. gloves Skin preparation e.g. 2% chlorhexidine Clean tourniquet Intravenous cannula Specific intravenous cannula dressing Sharps disposal bin Total failures Reliability
Failures (%) Organisation A
Organisation D
Organisation F
All incidents across organisations
0 0 0 8/76 (11%) 2/76 (3%) 0 5/76 (7%) 15/76 (19.7%) 80.3%
0 0 2/62 (3.2%) 0 0 5/62 8.0% 0 7/62 (11.3%) 88.7%
0 0 1/212 (0.5%) 0 2/212 (1.0%) 2/212 (1.0%) 20/212 (9.4%) 25/212 (11.8%) 88.2%
0 0 3/47 (6.4%) 8/47 (17%) 4/47 (8.5%) 7/47 (14.9%) 25/47 (53.2%) 47/350 (13.4%) 86.9%
Conclusion: This study is part of a broader project to assess the reliability of healthcare systems. Given the importance of having the right equipment available for inserting IV cannulae in preventing infections the findings here indicate that all hospitals should measure the reliability of their systems to ensure that staff are able to practice safely for them and their patients. Poster Session 4 – Clinical Cases P04.01 ‘The 6 Million Dollar Man’: An unusual case of adaptative commensalism with multidrug resistant bacteria in a surgical patient treated for 18 months M. Przybylo, S. Summers, A. Guleri, M. Qulaghassi. Blackpool Victoria Hospital, United Kingdom Background: The Six Million Dollar Man’, a 1970’s American television series about a fictional severely injured man, rebuilt with bionics at a cost of $6 million. We present a parallel – an unusual case of stabbing injury who miraculously survived – multiple surgical, medical and infective complications during next 18 months care in ITU & ward. He demonstrated an interesting phenomenon of adaptative commensalism with MDR bacteria after multiple cycles of sepsis & treatment. Case study: A 51-yr-old male was admitted with right sided stab injuries to base of neck, damaged subclavian artery (SbA) & haemothorax. His subsequent course in critical care included MI, four episodes cardiac arrest, failed SbA repair, further episodes of haemothorax, diagnosis of pseudo-aneurysm SbA & right SbAInt jugular fistula. Surgical interventions included emergency thoracotomies & re-opening, sternotomy, arteriovenous fistula repair, repair & then ligation of SbA, rib resection and partial resection of his exposed right scapula. He had multiple cycles of empiric and targeted antimicrobial treatment for multiple episodes of sepsis, pneumonia (VAP/HAP), thoracotomy wound infections, empyema, etc. Cumulative antimicrobial use (over 18-months) included meropenem (63 d), pip-tazobactam (87 d), flucloxacillin (24 d), ciprofloxacin (31 d), nebulised colistin (345 d), caspofungin (14 d) and fluconazole (26 d). Culture results included MDR P. aeruginosa, S. aureus, K. oxytoca, C. freundii, S. maltophilia, Pantoea, B. fragilis & Candida albicans. Twice daily fibreoptic bronchoscopy was required to clear resp plugs. Discussion: This was an unusual case in several ways. The patient had unusually extended stay between intensive (166 d), high care &
P04.02 A case of Mycobacterium fortuitum causing surgical site wound infection F. Kaleem, J. Usman, K. Roz Uddin, M. Omair, A. Khalid, A. Hassan. National University of Sciences and Technology, AMC, Pakistan
P04.03 A case of isolation of an unusual pathogen from ascitic fluid F. Kaleem1 , S. Abbasi2 , J. Usman1 , A. Hassan1 . 1 National University of Sciences and Technology, AMC., Pakistan; 2 AFIP, Pakistan Introduction: Spontaneous bacterial peritonitis (SBP) is defined as an ascitic fluid infection with a positive bacterial culture and polymorphonuclear cell count of >250/mm3 with no source of abdominal infection. SBP caused by Salmonella is uncommon and rarely reported. A 46 years old lady, diagnosed with an end stage renal disease, on maintenance hemodialysis for last ten years and chronic liver disease from last 4 years was brought to the emergency department with the complaints of progressive abdominal distension, vomiting and fever for last ten days. On examination she was found to be jaundiced, emaciated, febrile (102°F) and in hepatic encephalopathy. Liver function tests revealed a serum total bilirubin 26 umol/L, serum ALT 21 U/L, serum alkaline phosphatase 265 U/L. Ultra sound abdomen showed liver cirrhosis and grade 3 bilateral renal parenchymal disease. Diagnostic as well as therapeutic ascitic tap done and fluid revealed specific gravity of 1030 with a protein content of 4.0 g/dL, Rivaltas test was positive, cell count was 9000/cmm. Leishman’s stain showed mostly neutrophils