Surgical wound infections due to Propionibacterium acnes: a study of 10 cases

Journal of Hospital Infection (1995) 30, 229-232

Surgical

wound

Propionibacterium J. Esteban,

J-M.

Ramos,

infections due to acnes: a study of 10 cases

P. Jimenez-Castillo

and F. Soriano

Department of Medical Microbiology, Fundacidn Jimenex Diaz, Universidad Autonoma, Madrid, Spain Accepted for publication

29 March 1995

Summary: Ten cases of surgical wound infection in which Propionibacterium acnes was probably the aetiologic agent were reviewed; in five the organism was isolated in pure culture. Six patients underwent a neurosurgical procedure. The average time for development of infection was 17.5 days (range l-30 days). All patients were cured by surgical drainage and, in nine cases, with appropriate antimicrobial therapy. In conclusion, P. acnes must be considered as a cause of surgical wound infections especially after neurosurgery. Keywords: Proprionibacterium

acnes; surgical wound infections; neurosurgery.

Introduction The genus Propionibacterium includes several species of Gram-positive, branching, anaerobic bacilli that are common inhabitants of human skin.’ Among these species, P. acnes has been the most commonly implicated in human pathology, mainly as a cause of acne, but also as a pathogen in other infections including those of prosthetic grafts.* However, there are few reports of surgical wound infections caused by this organism. Here we review our experience of surgical wound infections caused by P. acnes. Methods A retrospective review of the records from the Department of Medical Microbiology of the Fundacibn Jimenez Diaz between 1988 and 1993 was performed. During the study period the surgical wound specimens were by Gram processed following current protocols.3 Isolates were identified Correspondence to: Jaime Esteban, Department Av. Reyes Catolicos 2, 28040 Madrid, Spain. 01954701/95/070229+04

of Medical

Microbiology,

Fundacidn

0 1995 The Hospital

$08.00/O

229

Jimenez Diaz,

Infection

Society

230

J. Esteban

et al.

staining, colony morphology, respiration, catalase production, and biochemical reactions (API system, BioMerieux, France). We reviewed the clinical charts of those patients with surgical wound samples from which a moderate or abundant culture of P. acne~ was obtained. The diagnosis of surgical wound infection was made in accordance with Centers for Disease Control (CDC) criteria.4

Results

During the study period, 38 samples from 28 patients (l-36 samples per patient) grew a moderate or heavy culture of P. acnes. Twenty-one sets of case notes were available for review. Ten patients had a diagnosis of surgical wound infection due to P. acnes; in another nine the isolate was regarded as a contaminant. Two patients had a surgical wound infection, in which the pathogenic role of P. acne~ was doubtful. All 10 samples from the patients with surgical wound infections contained pus. Details of the 10 infected patients are shown in Table I. All 10 were treated with surgical drainage or excision of the infected issues, and in one patient an indwelling traction ring was removed. All patients were cured.

Discussion

Although P. acnes is a common saprophyte of human skin, sited particularly within the sebaceous glands,3’5 it has been implicated only rarely in human pathology, mainly in infections related to foreign devices or previous surgical procedures.2 Surgical wound infection due to this species of bacteria is rarely reported in the literature6s7 and the isolation of P. acnes, together with coagulase-negative staphylococci, is usually interpreted as contamination of the specimen.8 However from this study we conclude that P. ucne.r can cause surgical wound infections for several reasons. Firstly, the patients had clinical signs of infection (tenderness, local increase of temperature, purulent exudation), which required antimicrobial therapy and surgical drainage. Secondly, samples from the infected tissues showed a great number of polymorphonuclear leucocytes, and P. ucnes was the predominant organism; being in five cases the only bacterial isolate. The clinical characteristics of these infections were otherwise indistinguishable from those caused by other microorganisms.7’8 However, it is notable that neurosurgical wound infections predominate in our series. This could relate to the high concentration of P. ucnes in the sebaceous glands of the scalp and forehead so making neurological sites a frequent target for expression of its pathogenic potential.’ This study suggests that P. ucnes should be considered as a possible cause of postoperative wound infection, and that cultures of this organism should not be disregarded as contaminants.

Internal

Cardiac surgery Digestive surgery Neurosurgery

80/M

62/M 30/M 31/F

2

Neurosurgery Neurosurgery

Neurosurgery

31/F 43/F

41/F

M, Male; F, Female; CNS, Coagulase-negative * Other than sutures. t Infection of biopsy wound.

Neurosurgery

44/F

7

Neurosurgery

63/F

6

medicine+

Traumatology

55/F

1

Unit ring

staphylococci.

No

No No

No

No

No No No

No

Traction

Foreign devices*

11

17

2;

25

30

1

Days since surgery

isolates

CNS

CNS None

None

None

Candida

perfringens None None CNS

CNS Clostridium

CNS

Other

Cloxacillin, Norfloxacin, Penicillin Cloxacillin, Penicillin Cloxacillin Cloxacillin, Amoxycillin Cloxacillin

Cloxacillin None Cloxacillin

Amoxycillin/ Clavulanic acid Ciprofloxacin

Treatment

and microbiological data from patients with surgical wound infection and isolation of Propionibacterium

Age/sex

I. Clinical

Case

Table

Cure

Cure Cure

Cure

Cure

Cure Cure Cure

Cure

Cure

Outcome

acnes

P 2

7 s k ti

a 4. c

f: 3 I

.*c

232

J. Esteban

et al.

References 1. Cummins CS, Johnson JL. Genus P~opionibacterz’um. In: Sneath PHA, Mair NS, Sharpe ME, Holt JG, Eds. Bergey’s Manual of Systematic Bacteriology. Baltimore: Williams & Wilkins 1986; 1346-1353. 2. Brook I, Frazier EM. Infections caused by Propionibacterium species. Rev Infect Dis 1991; 13: 819-822. 3. Allen SD, Siders JA, Marler LM. Isolation and examination of anaerobic bacteria. In: Lennette EH, Balows A, Mausler WJ Jr, Shadomy MJ, Eds. Manual of Clinical Microbiology, 4th edn. Washington DC: American Society for Microbiology 198.5; 413-433. 4. Moran TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site mfections, 1992: A modification of CDC definitions of surgical wound infections. Am J Infect Control 1992; 20: 271-274. 5. Ray LF, Kellum RE. Corynebacterium acnes from human skin. Arch Dermatol 1979; 101: 36-40. 6. Collignon PJ, Munro R, Sorrel1 TC. Propionibncterium acnes infection in neurosurgical patients: Experience with high-dose penicillin therapy. MedJ Aust 1986; 145: 408-410. 7. Maniatis A, Vassiliouthis J. Propionibacterium acnes infection complicatmg craniotomy. J Hosp Infect 1980; 1: 261-264. 8. Twum-Danso K, Grant C, Al-Suleiman SA et al. Microbiology of postoperative wound infection: A prospective study of 1770 wounds. J Hasp Infect 1992; 21: 29-37. 9. Ramos JM, Esteban J, Soriano F. Isolation of Pronionibacterium acnes from Central Nervous System infections. Anaerobe 1995; 1: 17-20