Aeromonas hydrophylia was isolated in pure culture on the four tissue samples and two pus swabs that were submitted. The local wound bed was indurated and clinically infected. The subsequent wound inspection performed in the Intensive Care Unit revealed a flap survival of only 80%, with tissue breakdown on the inferior suture line. The procalcitonin (PCT) levels were monitored post-operatively and this showed an initial reduction ( Figure 3). Multiple intraoperative tissue samples and swabs were again collected for microbiological analysis, as per protocol. The wound bed was deemed acceptable for a reconstructive procedure and a local soleus flap was performed. These changes were in keeping with the local trauma. Although there was some local induration and erythema around the wound, no frank pus was noted. The plastic surgeon was consulted to assist with soft tissue coverage of the exposed bone. The patient returned to theatre 48 hours post initial debridement for a second wound inspection. Triple intravenous antibiotic therapy (cephazolin, gentamycin and metronidazole) was commenced empirically, owing to the degree of contamination. Postoperatively the supportive care continued in the trauma ICU. The defect was managed with a gentamicin/Intrasite/Opsite pouch. These initial samples rendered negative cultures. Several tissue samples were taken during the procedure and submitted for microbiological analysis. A monolateral external fixator was used to hold the reduction ( Figure 2). The wound was rinsed out with copious amounts of a chlorhexidine water solution. The bone ends were delivered through the wound and thoroughly cleaned. The open fracture was surgically debrided by extending the wounds for better exposure and removal of all foreign material and devitalised tissue. An intracranial pressure monitor was inserted. Once stabilised, the patient underwent a craniotomy to evacuate the SAH. The time span from injury to initial irrigation was approximately 6 hours owing to delayed transport to the emergency unit. He received his first dose of antibiotics (cephazolin 2g stat IV) along with tetanus prophylaxis and analgesia. The management of the open fracture commenced in the resuscitation bay with a thorough rinsing of the wound with sterile water, followed by sterile dressings and splintage with an above-knee Plaster of Paris backslab. The neurosurgeon and orthopaedic surgeon were consulted to manage this patient further. The subsequent clinical and radiological examinations after stabilisation in casualties, revealed a traumatic subarachnoid haematoma (SAH) and a Gustilo-Anderson grade IIIB open tibia and fibula fracture ( Figure 1). He was intubated at the accident scene to secure his airway. The patient was found unconscious and lying in a pool of water. Local epidemiology and resistance patterns need to be taken into account when deciding on the initial empiric antibiotic regimen.Ī 26-year-old male was involved in a motor vehicle accident, in which the car hit a fire hydrant. Thus, different empiric antimicrobials were suggested according to the water sources used for irrigation. A recent article published by Ribeiro et al 3 focusing on the management of burns patients, noted that water exposure due to irrigation of the wounds as part of first aid management resulted in Gram-negative colonisation and infection. Wound infections secondary to exposure to water sources poses a unique challenge in that a different spectrum of microorganisms are expected and varies according to the type of water source. Staphylococci and Streptococci are the most common aetiological agents 2-3 for wound sepsis in the orthopaedic setting, and are typically covered by the first generation cephalosporins. 1 Empiric choice of antimicrobial(s) should target the most likely pathogens at the site of infection. Research has shown that the combination of early wound debridement, fracture stabilisation, soft tissue cover and empiric antibiotic use can reduce the incidence of infective complications. The treatment of contaminated open fractures of the tibia remains problematic. Consultant: Department Medical Microbiology, University of Pretoria National Health Laboratory Services TAD VMBChB(Medunsa) FC Path (Micro) DTM&H(Wits) PDIC(Stell). Senior Registrar: Department Orthopaedic Surgery, University of Pretoria Registrar: Department Medical Microbiology, University of Pretoria National Health Laboratory Services TAD Senior Registrar: Department Clinical Pathology, University of Pretoria National Health Laboratory Services TAD Consultant: Department Orthopaedic Surgery, University of Pretoria IMBChB(Pret) Dip(PEC)SA MMed(Ort)(Pret) FC(Ort)SA. Management of open tibia fracture following fresh water contaminationĬH Snyckers I A Visser II E Hoosien III T Monni IV NA Ismail V
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