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Wound infection due to fresh water contamination by Aeromonas hydrophila
The Journal of Emergency
Medicine.
Vol. 8, pp. 701-703,
Printed in the USA. Copyright
1990
C 1990 Pergamon Press plc
WOUND INFECTION DUE TO FRESH WATER CONTAMINATION BY AEROMONAS HYOROPHILA John J. Skiendzielewski, Reprint address:
Department Kelly P. O’Keefe,
of Emergency Department
MD,
MD, FACEP,
MD
Medicine, Geisinger Medical Center, Danville, Pennsylvania of Emergency Medicine, Wilford Hall, USAF Medical Center, San Antonio, TX 78236
IJ Abstract - We report the case of a 24-year-old man who sustaine& a scalp laceration in a diving accident. His wound became infected, and he was treated with an oral cephalosporin, with subsequent progression of the infection. Cultures subsequently grew Aeromonas hydrophila. Many strains of Aeromonas are not sensitive to the antibiotics commonly used for wound infections. Aeromonas must be suspected as a pathogen in all wounds occurring in fresh water if proper treatment is to be initiated.
infected scalp laceration. Thirty-six hours prior to admission, he had dived head first into a rocky creek bed sustaining a large laceration over the crown of his head. He was seen at another institution where the wound was irrigated and sutured, but returned there 24 hours later with drainage from the wound and pain. He was placed on cephalexin 250 mg 4 times per day orally and was again discharged. He returned 10 hours later with increased pain and swelling in the forehead and around the eye. At that point he was transferred. On admission to the emergency department, he was in moderate distress. His temperature was 36.9”C. orally, pulse 80 per minute, respirations 20 per minute, and his blood pressure was 120/80 mmHg. He had a large laceration over the crown of his head that was draining a pink serous fluid. There was marked swelling of the soft tissue of his head and face (see Figure 1). The remainder of his examination was unremarkable. His white blood cell count was 18,800/mm3 with 58% segmented neutrophils and 27% band neutrophils. The wound was opened and irrigated, and then packed with wet to dry saline dressings. A Gram’s stain of the purulent material revealed gram-positive rods and gram-negative rods. Because of the possibility of bacteremia, the patient was admitted to the hospital and treated with intravenous imipenem, 1 g every 6 hrs. Culture of the wound subsequently revealed four separate organisms: Aeromonas hydrophila, Plesiomonas shigelloides, Escherichia coli, and nonhemolytic Streptococcus. The aeromonas isolate was resistant to ampicillin, with intermediate sensitivity to cephalexin. Both the Plesiomonas and E. coli isolates were sensitive to cephalexin. All three organisms were sensitive to tetra-
0 Keywords - Wound infection; fresh water, Aeromonas hydrophila
INTRODUCTION Infection with Aeromonas hydrophila is common following fresh water contamination of injuries. Emergency physicians must be familiar with this organism and its correct treatment, as they most frequently will provide the definitive care of minor wounds and subsequent infection (should it occur) for victims of trauma suffered in the fresh water environment. We recently cared for a young man with a scalp laceration sustained in a creek, which subsequently became infected secondary to Aeromonas hydrophila contamination.
CASE REPORT A 24-year-old white male was transferred to the emergency department from another institution because of an
=zzzz=z
and Kelly P. O’Keefe,
Clinical Communications, focusing primarily on adult emergencies, is coordinated by Ron Walls, MD, of Vancouver General Hospital, Vancouver, BC, Canada.
RECEIVED:8 May 1989; FINAL SUBMISSION RECEIVED:30 August ACCEPTED:5 October 1989 701
1989;
0736-4679/90
$3.00 + .OO
702
John J. Skiendzielewski and Kelly P. O’Keefe
Figure 1. Photograph of patlent, showlng scalp laceratlon and serous pink dralnage, with head and facial swelling to Include perlorbltal edema.
cycline and sulfamethoxazole/trimethoprim. Blood cultures at our institution were negative. He had an uneventful hospital course and was discharged to home care in 7 days.
DISCUSSION Aeromonas hydrophila, a facultative anaerobic gramnegative rod, is a very common contaminant of fresh water lakes and streams (1). It is a member of the bacterial family Pseudomonadaceae, and is described as being asporogenous, polarly flagellated, a fermenter of acid and gas, and oxidase positive (2). In the past the organism had been considered opportunistic and of low virulence, but numerous reports of sepsis, meningitis, pneumonia, osteomyelitis, endocarditis, and other infections have occurred, primarily in the immunocompromised, but occasionally in previously healthy patients (2-10). Most frequently, Aeromonas infections in the healthy host are localized and occur following penetrating trauma in fresh water. Hanson reported an extensive facial cellulitis caused by Aeromonas hydrophila occurring after repair of a scalp laceration sustained while diving in shallow lake water, and showed through bacteriologic studies of the lake’s water that considerable contamination could occur with relatively low lake water bacterial concentration and acceptable fecal coliform counts (11). Other case reports have included Aeromonas infections following an alligator bite, water skiing accident, open fracture suffered in water, and
puncture to the foot under water (5,10,12,13,14). Infections have occurred in injuries sustained in swimming pools as well (2,10,15). Aeromonas species are also listed as marine pathogens (16), and have been reported to cause cornea1 ulcers following foreign body injury in an ocean environment (17). Infection from Aeromonus is usually evident within 48 hours post injury, and often presents much sooner. Leukocytosis and a variable degree of temperature elevation are present. The picture of cellulitis may be indistinguishable from that caused by a streptococcal infection (1,2,13). Bullae may be present (1,7,18). Aeromonas is also capable of gas formation in soft tissue infection (4). In Auerbach’s study, Aeromonas species were the most commonly isolated organisms, with every specimen from all fresh water sources studied growing at least one Aeromonas species isolate (1). Contamination with several species is not uncommon, and isolation of all organisms involved may not be possible without special techniques and media. More than 90% of all gram-negative fresh water isolates were shown to be susceptible to ciprofloxacin, imipenem, ceftazadime, gentamicin, and trimethoprim-sulfamethoxazole; 83.3% of isolates were susceptible to tetracycline. Ciprofloxatin was effective against 100% of isolates (1). Treatment involves surgical drainage with or without antibiotic therapy. Although antibiotics are usually given, it has been reported that surgical drainage and debridement without antibiotics are adequate in some infections (10). Standard antibiotics for wound infections (ie, cephalexin, erythromycin, or dicloxacillin) are likely to be ineffective. Sanford recommends as a first choice ciprofloxacin or norfloxacin, with trimethoprim/sulfamethoxazole as a second-choice drug, and the antiPseudomonal aminoglycosides , imipenem, and thirdgeneration parenteral cephalosporins as also being effective (19). Auerbach recommends the oral use of trimethoprirn/sulfamethoxazole or tetracycline for even minor abrasions or lacerations as prophylaxis in the immunocompromised host, who is more susceptible to the development of a serious infection or sepsis (1). In addition, antibiotic prophylaxis should be considered in wounds prone to infection, such as those requiring extensive debridement, puncture wounds, wounds with retained foreign bodies, and any other situation where adequacy of irrigation is in question. Any wound with fresh water contamination should be cultured if infected, and Aeromonas must be suspected as a pathogen. SUMMARY We report a case of Aeromonas hydrophila wound infection acquired after a fresh water injury, which did
Aeromonas
Wound infection
703
not respond to initial antibiotic treatment. Correct antibiotic use includes trimethoprimkulfamethoxazole, tetracycline, or a quinolone as initial treatment. Emer-
gency physicians must be aware of the frequency of aeromonas hydrophila contamination of fresh water injuries.
REFERENCES 1. Auerbach PS, Yajko DN, Nassos PS, Kizer KW, Morris JA, Hadley WK. Bacteriology of the fresh water environment: implications for clinical therapy. Ann Emerg Med. 1987;16:1016-22. 2. Von Graevenitz A, Mensch AH. The genus Aeromonas in human bacteriology. N Engl J Med. 1968;278:245-9. 3. Davis WA II, Kane KG, Garagusi VF. Human aeromonas infections: a review of the literature and a case report of endocarditis. Medicine. 1978;57:267-77. 4. Levin ML. Gas forming aeromonas hydrophila infection in a diabetic. Postgrad Med. 1973;54: 127-9. 5. Karem GH, Ackley AM, Dismukes WE. Posttraumatic aeromonas hydrophila osteomyelitis. Arch Intern Med. 1983;143:20734. 6. Reines HD, Cook FV. Pneumonia and bacteremia due to Aeromonas hydrophila. Chest. 1981;80:264-7. 7. Ramsay AN, Rosenbaum BJ, Yarbrough CL, Hotz JA. Aeromonas hydrophila sepsis in a patient undergoing hemodialysis therapy. JAMA. 1978;239:128-9. 8. Scott EG, Russel CM, Noel1 KT, Sproul AE. Aeromonas hydrophila sepsis in a previously healthy man. JAMA. 1978;239:1742. 9. Washington JA. Aeromonas hydrophila in clinical bacteriologic specimens. Ann Intern Med. 1972;76:61 l&4.
10. McCracken AW, Barkley R. Isolation of Aeromonas species from clinical sources. J Clin Pathol. 1972;25:97C-5. 11. Hanson PG. Standridge J, Jarrett F, Maki DG. Fresh water wound infection due to Aeromonas hydrophila. JAMA. 1977;238:10534. 12. Rosenthal SG, Bernhardt HE, Phillips JA. Aeromonas hydrophila wound infection. Plast Reconst Surg. 1974;53:77-9. 13. Katz D, Smith H. Aeromonas hydrophila infection of a puncture wound. Ann Emerg Med. 1980;9:529-31. 14. Phillips JA, Bemhardt HE, Rosenthal SG. Aeromonas hydrophila infections. Pediatrics. 1979;53:110-12. 15. Fraire AE. Aeromonas hydrophila infection. JAMA. 1978;239: 192. 16. Auerbach PS, Yajko DN, Nassos PS, et al. Bacteriology of the marine environment: implications for clinical therapy. Ann Emerg Med. 1987;16:643-9. 17. Feaster Fl’, Nisbet RM, Barber JC. Aeromonas hydrophila corneal ulcer. Am J Ophthalmol. 1978;85:114-7. 18. Fulghum DD, Linton WR, Taplin D. Fatal aeromonas infection of the skin. South Med J. 1978;71:73941. Therapy 1988. Bethesda: 19. Sanford JP. Guide to Antimicrobial Antimicrobial Therapy, Inc.; 1988:36.
Medicine.
Vol. 8, pp. 701-703,
Printed in the USA. Copyright
1990
C 1990 Pergamon Press plc
WOUND INFECTION DUE TO FRESH WATER CONTAMINATION BY AEROMONAS HYOROPHILA John J. Skiendzielewski, Reprint address:
Department Kelly P. O’Keefe,
of Emergency Department
MD,
MD, FACEP,
MD
Medicine, Geisinger Medical Center, Danville, Pennsylvania of Emergency Medicine, Wilford Hall, USAF Medical Center, San Antonio, TX 78236
IJ Abstract - We report the case of a 24-year-old man who sustaine& a scalp laceration in a diving accident. His wound became infected, and he was treated with an oral cephalosporin, with subsequent progression of the infection. Cultures subsequently grew Aeromonas hydrophila. Many strains of Aeromonas are not sensitive to the antibiotics commonly used for wound infections. Aeromonas must be suspected as a pathogen in all wounds occurring in fresh water if proper treatment is to be initiated.
infected scalp laceration. Thirty-six hours prior to admission, he had dived head first into a rocky creek bed sustaining a large laceration over the crown of his head. He was seen at another institution where the wound was irrigated and sutured, but returned there 24 hours later with drainage from the wound and pain. He was placed on cephalexin 250 mg 4 times per day orally and was again discharged. He returned 10 hours later with increased pain and swelling in the forehead and around the eye. At that point he was transferred. On admission to the emergency department, he was in moderate distress. His temperature was 36.9”C. orally, pulse 80 per minute, respirations 20 per minute, and his blood pressure was 120/80 mmHg. He had a large laceration over the crown of his head that was draining a pink serous fluid. There was marked swelling of the soft tissue of his head and face (see Figure 1). The remainder of his examination was unremarkable. His white blood cell count was 18,800/mm3 with 58% segmented neutrophils and 27% band neutrophils. The wound was opened and irrigated, and then packed with wet to dry saline dressings. A Gram’s stain of the purulent material revealed gram-positive rods and gram-negative rods. Because of the possibility of bacteremia, the patient was admitted to the hospital and treated with intravenous imipenem, 1 g every 6 hrs. Culture of the wound subsequently revealed four separate organisms: Aeromonas hydrophila, Plesiomonas shigelloides, Escherichia coli, and nonhemolytic Streptococcus. The aeromonas isolate was resistant to ampicillin, with intermediate sensitivity to cephalexin. Both the Plesiomonas and E. coli isolates were sensitive to cephalexin. All three organisms were sensitive to tetra-
0 Keywords - Wound infection; fresh water, Aeromonas hydrophila
INTRODUCTION Infection with Aeromonas hydrophila is common following fresh water contamination of injuries. Emergency physicians must be familiar with this organism and its correct treatment, as they most frequently will provide the definitive care of minor wounds and subsequent infection (should it occur) for victims of trauma suffered in the fresh water environment. We recently cared for a young man with a scalp laceration sustained in a creek, which subsequently became infected secondary to Aeromonas hydrophila contamination.
CASE REPORT A 24-year-old white male was transferred to the emergency department from another institution because of an
=zzzz=z
and Kelly P. O’Keefe,
Clinical Communications, focusing primarily on adult emergencies, is coordinated by Ron Walls, MD, of Vancouver General Hospital, Vancouver, BC, Canada.
RECEIVED:8 May 1989; FINAL SUBMISSION RECEIVED:30 August ACCEPTED:5 October 1989 701
1989;
0736-4679/90
$3.00 + .OO
702
John J. Skiendzielewski and Kelly P. O’Keefe
Figure 1. Photograph of patlent, showlng scalp laceratlon and serous pink dralnage, with head and facial swelling to Include perlorbltal edema.
cycline and sulfamethoxazole/trimethoprim. Blood cultures at our institution were negative. He had an uneventful hospital course and was discharged to home care in 7 days.
DISCUSSION Aeromonas hydrophila, a facultative anaerobic gramnegative rod, is a very common contaminant of fresh water lakes and streams (1). It is a member of the bacterial family Pseudomonadaceae, and is described as being asporogenous, polarly flagellated, a fermenter of acid and gas, and oxidase positive (2). In the past the organism had been considered opportunistic and of low virulence, but numerous reports of sepsis, meningitis, pneumonia, osteomyelitis, endocarditis, and other infections have occurred, primarily in the immunocompromised, but occasionally in previously healthy patients (2-10). Most frequently, Aeromonas infections in the healthy host are localized and occur following penetrating trauma in fresh water. Hanson reported an extensive facial cellulitis caused by Aeromonas hydrophila occurring after repair of a scalp laceration sustained while diving in shallow lake water, and showed through bacteriologic studies of the lake’s water that considerable contamination could occur with relatively low lake water bacterial concentration and acceptable fecal coliform counts (11). Other case reports have included Aeromonas infections following an alligator bite, water skiing accident, open fracture suffered in water, and
puncture to the foot under water (5,10,12,13,14). Infections have occurred in injuries sustained in swimming pools as well (2,10,15). Aeromonas species are also listed as marine pathogens (16), and have been reported to cause cornea1 ulcers following foreign body injury in an ocean environment (17). Infection from Aeromonus is usually evident within 48 hours post injury, and often presents much sooner. Leukocytosis and a variable degree of temperature elevation are present. The picture of cellulitis may be indistinguishable from that caused by a streptococcal infection (1,2,13). Bullae may be present (1,7,18). Aeromonas is also capable of gas formation in soft tissue infection (4). In Auerbach’s study, Aeromonas species were the most commonly isolated organisms, with every specimen from all fresh water sources studied growing at least one Aeromonas species isolate (1). Contamination with several species is not uncommon, and isolation of all organisms involved may not be possible without special techniques and media. More than 90% of all gram-negative fresh water isolates were shown to be susceptible to ciprofloxacin, imipenem, ceftazadime, gentamicin, and trimethoprim-sulfamethoxazole; 83.3% of isolates were susceptible to tetracycline. Ciprofloxatin was effective against 100% of isolates (1). Treatment involves surgical drainage with or without antibiotic therapy. Although antibiotics are usually given, it has been reported that surgical drainage and debridement without antibiotics are adequate in some infections (10). Standard antibiotics for wound infections (ie, cephalexin, erythromycin, or dicloxacillin) are likely to be ineffective. Sanford recommends as a first choice ciprofloxacin or norfloxacin, with trimethoprim/sulfamethoxazole as a second-choice drug, and the antiPseudomonal aminoglycosides , imipenem, and thirdgeneration parenteral cephalosporins as also being effective (19). Auerbach recommends the oral use of trimethoprirn/sulfamethoxazole or tetracycline for even minor abrasions or lacerations as prophylaxis in the immunocompromised host, who is more susceptible to the development of a serious infection or sepsis (1). In addition, antibiotic prophylaxis should be considered in wounds prone to infection, such as those requiring extensive debridement, puncture wounds, wounds with retained foreign bodies, and any other situation where adequacy of irrigation is in question. Any wound with fresh water contamination should be cultured if infected, and Aeromonas must be suspected as a pathogen. SUMMARY We report a case of Aeromonas hydrophila wound infection acquired after a fresh water injury, which did
Aeromonas
Wound infection
703
not respond to initial antibiotic treatment. Correct antibiotic use includes trimethoprimkulfamethoxazole, tetracycline, or a quinolone as initial treatment. Emer-
gency physicians must be aware of the frequency of aeromonas hydrophila contamination of fresh water injuries.
REFERENCES 1. Auerbach PS, Yajko DN, Nassos PS, Kizer KW, Morris JA, Hadley WK. Bacteriology of the fresh water environment: implications for clinical therapy. Ann Emerg Med. 1987;16:1016-22. 2. Von Graevenitz A, Mensch AH. The genus Aeromonas in human bacteriology. N Engl J Med. 1968;278:245-9. 3. Davis WA II, Kane KG, Garagusi VF. Human aeromonas infections: a review of the literature and a case report of endocarditis. Medicine. 1978;57:267-77. 4. Levin ML. Gas forming aeromonas hydrophila infection in a diabetic. Postgrad Med. 1973;54: 127-9. 5. Karem GH, Ackley AM, Dismukes WE. Posttraumatic aeromonas hydrophila osteomyelitis. Arch Intern Med. 1983;143:20734. 6. Reines HD, Cook FV. Pneumonia and bacteremia due to Aeromonas hydrophila. Chest. 1981;80:264-7. 7. Ramsay AN, Rosenbaum BJ, Yarbrough CL, Hotz JA. Aeromonas hydrophila sepsis in a patient undergoing hemodialysis therapy. JAMA. 1978;239:128-9. 8. Scott EG, Russel CM, Noel1 KT, Sproul AE. Aeromonas hydrophila sepsis in a previously healthy man. JAMA. 1978;239:1742. 9. Washington JA. Aeromonas hydrophila in clinical bacteriologic specimens. Ann Intern Med. 1972;76:61 l&4.
10. McCracken AW, Barkley R. Isolation of Aeromonas species from clinical sources. J Clin Pathol. 1972;25:97C-5. 11. Hanson PG. Standridge J, Jarrett F, Maki DG. Fresh water wound infection due to Aeromonas hydrophila. JAMA. 1977;238:10534. 12. Rosenthal SG, Bernhardt HE, Phillips JA. Aeromonas hydrophila wound infection. Plast Reconst Surg. 1974;53:77-9. 13. Katz D, Smith H. Aeromonas hydrophila infection of a puncture wound. Ann Emerg Med. 1980;9:529-31. 14. Phillips JA, Bemhardt HE, Rosenthal SG. Aeromonas hydrophila infections. Pediatrics. 1979;53:110-12. 15. Fraire AE. Aeromonas hydrophila infection. JAMA. 1978;239: 192. 16. Auerbach PS, Yajko DN, Nassos PS, et al. Bacteriology of the marine environment: implications for clinical therapy. Ann Emerg Med. 1987;16:643-9. 17. Feaster Fl’, Nisbet RM, Barber JC. Aeromonas hydrophila corneal ulcer. Am J Ophthalmol. 1978;85:114-7. 18. Fulghum DD, Linton WR, Taplin D. Fatal aeromonas infection of the skin. South Med J. 1978;71:73941. Therapy 1988. Bethesda: 19. Sanford JP. Guide to Antimicrobial Antimicrobial Therapy, Inc.; 1988:36.