Ciprofloxacin-resistant Aeromonas hydrophila infection following leech therapy: A case report and review of the literature

Effects of ciprofloxacin and levofloxacin on initial colonization of intestinal microbiota in Bufo gargarizans at embryonic stages

Ciprofloxacin (CIP) and levofloxacin (LEV) are broad-spectrum antibiotics with potent antibacterial activity. Although many studies have shown that antibiotics can lead to gut microbiota disruption, the effects of CIP and LEV on gut microbial colonization at the embryonic stage remain poorly characterized. Here, we evaluated the response of Bufo gargarizans embryos in terms of gut microbiota colonization, growth and developmental stages to CIP and LEV exposure. Embryos treated with 100 μg/L CIP and LEV exhibited significantly reduced diversity and richness of the gut microbiota, as well as altered community structure. Both CIP and LEV treatments resulted in an increase in the pathogenic bacteria Bosea and Aeromonas, and they appeared to be more resistant to CIP than LEV. Additionally, CIP exposure caused reduced total length and delayed the development in B. gargarizans embryos, while LEV increased the total length and promoted embryonic development. The present study revealed the adverse effects of CIP and LEV exposure on host gut microbiota, growth and development during the embryonic stage, and contributed new perspectives to the evaluation of early aquatic ecological risk under CIP and LEV exposure.

Epidemiology of secondary infection after snakebites in center-west Brazil

BACKGROUND

Snakebites represent a significant health problem in tropical countries, with an annual incidence of 2.7 million cases worldwide. The incidence of secondary infections after snake bites is also high and is usually caused by bacteria from the oral cavity of snakes. Morganella morganii has been identified as an important cause of infections and has been guiding antibiotic therapy in several regions of Brazil and the world.

METHODOLOGY/PRINCIPAL FINDINGS

We performed a retrospective cross-sectional evaluation of snakebites in hospitalized patients between January 2018 and November 2019 and selected those with secondary infection in their medical records. During the period, 326 cases of snakebites were treated, and 155 (47.5%) of them eventually had secondary infections. However, only seven patients underwent culture of soft tissue fragments, in which three cases were negative culture results, while Aeromonas hydrophila was identified in four cases. Of these, 75% were resistant to ampicillin/sulbactam, 50% had intermediate sensitivity to imipenem, and 25% had intermediate sensitivity to piperacillin/tazobactam. Trimethoprim/sulfamethoxazole (TMP-SMX) was not tested on any strain. Of the 155 cases that progressed to secondary infections, 48.4% (75) were empirically treated with amoxicillin/clavulanate, 41.9% (65) with TMP-SMX, and 32 (22%) of these 144 cases required a change to a second regimen, and 10 of these 32 patients required a third therapeutic regimen.

CONCLUSION

Wild animals act as reservoirs of resistant bacteria because their oral cavity favors biofilm formation, which explains the finding of A. hydrophila with a reduced sensitivity profile in this study. This fact is essential for the appropriate choice of empirical antibiotic therapy.

A Systematic Review of Culture-Based Methods for Monitoring Antibiotic-Resistant Acinetobacter, Aeromonas, and Pseudomonas as Environmentally Relevant Pathogens in Wastewater and Surface Water

PURPOSE OF REVIEW

Mounting evidence indicates that habitats such as wastewater and environmental waters are pathways for the spread of antibiotic-resistant bacteria (ARB) and mobile antibiotic resistance genes (ARGs). We identified antibiotic-resistant members of the genera Acinetobacter, Aeromonas, and Pseudomonas as key opportunistic pathogens that grow or persist in built (e.g., wastewater) or natural aquatic environments. Effective methods for monitoring these ARB in the environment are needed to understand their influence on dissemination of ARB and ARGs, but standard methods have not been developed. This systematic review considers peer-reviewed papers where the ARB above were cultured from wastewater or surface water, focusing on the accuracy of current methodologies.

RECENT FINDINGS

Recent studies suggest that many clinically important ARGs were originally acquired from environmental microorganisms. Acinetobacter, Aeromonas, and Pseudomonas species are of interest because their ability to persist and grow in the environment provides opportunities to engage in horizontal gene transfer with other environmental bacteria. Pathogenic strains of these organisms resistant to multiple, clinically relevant drug classes have been identified as an urgent threat. However, culture methods for these bacteria were generally developed for clinical samples and are not well-vetted for environmental samples. The search criteria yielded 60 peer-reviewed articles over the past 20 years, which reported a wide variety of methods for isolation, confirmation, and antibiotic resistance assays. Based on a systematic comparison of the reported methods, we suggest a path forward for standardizing methodologies for monitoring antibiotic resistant strains of these bacteria in water environments.

Case Reports and Experts Opinions about Current Use of Leech Therapy in Dermatology and Cosmetology

This article aimed to determine the experts’ opinion on the use of hirudotherapy in cosmetology, to supplement knowledge, and to identify factors that, in the opinion of experts, affect the effectiveness and frequency of use of this method in eliminating skin problems. The study was conducted using the expert interview method. The research tool was a categorized expert interview questionnaire using the CAWI (Computer Assisted Web Interview) technique. Hirudotherapy is one of the oldest healing methods. The mechanism of action is based on the therapeutic properties of bioactive substances isolated from leech saliva. It has been shown to have a wide range of applications in the treatment of numerous diseases in various fields of medicine, including dermatology and cosmetology. Despite its therapeutic properties and effectiveness, hirudotherapy is a rarely used tool in cosmetology. It has been found effective in the treatment of many dermatoses. The most spectacular effects have been observed in the treatment of rosacea, local inflammations, lipomas, skin scars, hard to heal wounds and contusions.

A Novel Aeromonas popoffii Phage AerP_220 Proposed to Be a Member of a New Tolavirus Genus in the Autographiviridae Family

Aeromonas popoffii is one of the environmental Aeromonas species. A number of factors of virulence have been described for this species and it has been reported as a causative agent of urinary tract infection. The first A. popoffii bacteriophage AerP_220 along with its host strain A. popoffii CEMTC 4062 were isolated from river water. The phage has a podovirus morphotype, shows a narrow host range and is lytic against the host strain. The AerP_220 genome comprises 45,207 bp and does not contain genes responsible for antibiotic resistance and toxin production. Fifty-nine co-directional putative ORFs were found in the AerP_220 genome. Thirty-three ORFs encoded proteins with predicted functions; the products of 26 ORFs were hypothetical proteins. AerP_220 genome analysis revealed that this phage can be considered a novel species within the Autographiviridae family. Comparative genomic and proteomic analysis revealed that AerP_220 along with the Aeromonas phage vB_AspA_Tola (OM913599) are members of a new putative Tolavirus genus in the family Autographiviridae. The Gajwadongvirus and proposed Tolavirus genera along with Pantoea phage Nufs112 and phage Reminis could form a new Tolavirinae subfamily within the Autographiviridae family.

Antibiotic Prophylaxis in Plastic Surgery: From Systematic Review to Operative Algorithm

BACKGROUND

We aimed to provide a single, viable and user-friendly operative protocol for preoperative antibiotic prophylaxis that meets the needs of all plastic surgery practitioners.

METHODS

The research was conducted through the abstract and citation databases of peer-reviewed literature Pubmed® (National Center for Biotechnology Information), Medscape® (General Surgery) and Scopus® (Elsevier), comparing existing data from 2010 to 2020. A separated and dedicated research was accomplished for each of 8 macroareas such as: skin and soft tissue, hand, breast, aesthetics, head and neck, trauma, burns and miscellaneous.

RESULTS

The findings for each macroareas included the choice of the antibiotic, the route and timing of administration and the clinical applications. Finally, the review has been condensed in an operative algorithm for antibiotic use to apply in each field of plastic surgery.

CONCLUSION

We could provide plastic surgeon an effective, easy-to-use operative protocol for antibiotic prophylaxis in daily activity.

Combination therapy with levofloxacin and cefepime to treat severe respiratory infection due to Aeromonas caviae after a near-drowning accident in river water

Background

Aeromonas spp. are gram-negative anaerobic rods that are mainly found in water. Respiratory infections due to Aeromonas sp. are rare but have a high mortality rate.

Case presentation

A 43-year-old man fell into a river following an automobile accident and almost drowned. He developed a severe respiratory infection and acute respiratory distress syndrome. Ampicillin/sulbactam was given; however, Aeromonas caviae was detected in his blood culture. Despite treatment with levofloxacin, to which A. caviae was susceptible, his condition failed to improve. However, with additional treatment with cefepime, his blood culture results were negative, and his condition improved.

Conclusion

When a patient develops a respiratory infection after aspiration of river water, empiric antimicrobial therapy should be given as soon as possible to manage the risk of Aeromonas sp. infection.

Aeromonas: the multifaceted middleman in the One Health world

Aeromonas is at the interface of all the One Health components and represents an amazingly sound test case in the One Health approach, from economic loss in aquaculture tochallenges related to antibiotic-resistant bacteria selected from the environment. In human health, infections following leech therapy is an outstanding example of such One Health challenges. Aeromonads are not only ubiquitous environmental bacteria, able to rapidly colonize and cause opportunistic infections in humans and animals, they are also capable of promoting interactions and gene exchanges between the One Health components. This makes this genus a key amplifier of genetic transfer, especially of antibiotic resistance genes.

Clinical and microbiological characteristics of Aeromonas bacteremia in Turkey

We investigated the cases with Aeromonas bacteremia in terms of clinical and microbiological characteristics, underlying disease and mortality rates. Patients with positive blood cultures were included in this research. Aeromonas bacteremia was diagnosed as at least one positive blood culture for Aeromonas species. The bacteremia was defined as community origin if the onset was in the community or within 72 hours of hospital admission. The others were considered as nosocomial. All bacteria were defined as Aeromonas with conventional method. Species identification was verified by VITEK system. Antibiotic susceptibility tests were analyzed with the disc diffusion, E-test method or VITEK system. Thirty-three patients were diagnosed with bacteremia due to Aeromonas spp. Hematologic and solid tumors were the leading underlying conditions, followed by cirrhosis. Two patients (6%) had community-acquired infections. Aeromonas hydrophila was the most common isolated bacterium. The crude mortality rate was 36%. 12 patients died and 6 deaths and 4 deaths were detected in patients with bacteremia caused by A. hydrophila and Aeromonas sobria respectively. All strains were resistant to ampicillin and more than 90% of the strains were susceptible to trimethoprim-sulfamethoxazole, fluoroquinolone, third generation cephalosporins, and carbapenems. Aeromonas sp. is not a frequent cause of bacteremia however, it may lead to high mortality rates, especially in the immunocompromised hosts and patients with liver cirrhosis. Nosocomial Aeromonas bacteremia is not uncommon in these populations. Broad-spectrum cephalosporins, piperacillin-tazobactam, fluoroquinolones, and carbapenems remain as effective antimicrobial agents for therapy of Aeromonas bacteremia.

Implementation of a Leeches + Antimicrobial Prophylaxis Order Panel to Optimize Medicinal Leech Use at a Tertiary Care Academic Medical Center

Medicinal leech therapy promotes vascular flow and can be used to salvage grafts. Medicinal leeches have a symbiotic relationship with Aeromonas species and can therefore present a risk of bacterial transmission to patients. Antimicrobial prophylaxis is warranted for the duration of leech therapy, however, an institutional evaluation of 40 patients receiving medicinal leech therapy demonstrated poor adherence with recommendations. An electronic medical record order panel for antimicrobial prophylaxis with medicinal leech therapy was implemented, leading to a subsequent improvement in adherence to prophylaxis use, including significant increases in the ordering of antibiotics and the appropriate timing of initiation in the subsequent 10 patients receiving medicinal leech therapy after panel implementation. Aeromonas infections were rare before and after panel implementation, and developed only in the patient subset with non-optimized prophylaxis.

Multidrug resistant Aeromonas infection following medical leech therapy: A case report and development of a joint antimicrobial stewardship and infection prevention protocol

OBJECTIVE

Aeromonas sp. infections are a recognized complication of medical leech therapy (MLT). In patients requiring MLT, ciprofloxacin or trimethoprim-sulphamethoxazole are commonly used to prevent such nosocomial infections. After a patient at our institution developed a MLT-associated multi-drug resistant (MDR) Aeromonas infection, we developed and evaluated a joint antimicrobial stewardship and infection prevention protocol for MLT at our institution.

METHODS

We describe a case of a surgical site infection with MDR Aeromonas following MLT that was resistant to typically prescribed prophylactic antimicrobials, and development of a new leech culture protocol to proactively monitor for antimicrobial resistance among our institution's leech supply. We also report the rates of MLT-associated infections prior to and following implementation of this protocol and the antimicrobial susceptibility profiles detected in leech culture at our institution.

RESULTS

Between October 2014 and February 2018, 46 patients received MLT at our institution. Other than the case described in this report, no other instances of MLT-related infections were noted during this time period. Culture results from 22 leeches in six batches since February 2018 showed that all were susceptible to ciprofloxacin, TMP-SMX, and ceftriaxone. Since initiation of a leech culture protocol, no further cases of MLT-associated infections have been reported at our institution.

CONCLUSIONS

In light of increasing antimicrobial resistance and the potentially devastating consequences of MLT-associated infections, institutions offering MLT should be aware of these risks and ensure that protocols are in place to minimize infection risks for patients.

Outcomes of a Treatment Protocol for Compromised Nasal Skin in Primary and Revision Open Rhinoplasty

Importance: This is the first study to review the incidence of nasal skin compromise after open rhinoplasty surgery and outcomes of treatment. Objectives: To determine whether risk of skin compromise after open rhinoplasty surgery can be predicted and whether our treatment protocol led to acceptable outcomes. Design, Setting, and Participants: This is a retrospective chart review of the senior author's private patients. In total, 384 rhinoplasty cases were reviewed and all cases with signs of vascular compromise requiring treatment were analyzed. Main Outcomes and Measures: Descriptive statistics were used to evaluate characteristics of patients who developed intra- and postoperative skin compromise, and unpaired two-tailed t-test was used to compare the characteristics of patients with and without compromised nasal skin when possible. Overall satisfaction results and complications in the skin compromise group were reported. Results: A total of 384 open rhinoplasties were performed by the senior author between October 1, 2015, and December 31, 2018. Of them, 109 were primary rhinoplasties and 275 were revision rhinoplasties. Of the 384 rhinoplasties, 27 (7%) had skin compromise leading to unplanned postoperative treatment. Two of the patients in the skin compromise group underwent primary surgeries (7.4%) and 25 underwent revision procedures (92.6%). Advanced age (p < 0.0001), prior or current history of smoking (p = 0.027), and greater number of prior rhinoplasty surgeries (p = 0.0002) were significantly correlated with risk of skin compromise. The average time to last follow-up in the skin compromise group was 392 days (range 15-1057 days). At their last follow-up, 12 patients had complete resolution of all signs of nasal skin compromise with no further treatment required (44.4%). The revision rate for patients experiencing skin compromise was 22.2%. One patient underwent revision surgery directly related to a complication of skin compromise and one is considering revision directly related to skin breakdown. Conclusions and Relevance: The rate of skin compromise after open rhinoplasty is low. Older patients and patients with more prior rhinoplasty surgeries may be at increased risk. Prompt treatment of compromised nasal blood supply after rhinoplasty surgery can salvage skin in most patients.

Evolving Antibiotic Resistance of Aeromonas Species in Finger Replantation

Background: Infections with Aeromonas spp. are a recognized complication of leech therapy for circulatory complications in replanted digits. Ciprofloxacin is commonly used empirically for Aeromonas coverage in such cases. Evolving resistance patterns of Aeromonas should be considered in designing an antibiotic strategy. Methods: Three consecutive patients with complicated replantations had site cultures yielding Aeromonas isolates resistant to ciprofloxacin. These cultures were analyzed to identify effective antibiotic agents. Results: Each Aeromonas isolate, and each additional site organism, was sensitive to cefepime. Conclusion: Our routine antibiotic coverage for leech application has been changed to cefepime. Aeromonas sensitivities and resistances should be monitored to adapt to future changes in appropriate antibiotics.

Postoperative Management and Rehabilitation of the Replanted or Revascularized Digit

Postoperative care of amputated digits begins before replantation. Detailed informed consent should be obtained and completion amputation discussed if revascularization is not ultimately successful. Complications and failure of the replanted digit should also be addressed. Postoperative pharmacologic treatment should consist of aspirin, at minimum. Complications, such as venous congestion or occlusion, and arterial thrombosis, should be dealt with expediently. Digital motion rehabilitation should start after 5 to 7 days of digital viability and splinting of the affected digit. Early protective motion protocol is implemented to maintain digital motion with emphasis on tendon glide and joint motion.

Low-Level Antimicrobials in the Medicinal Leech Select for Resistant Pathogens That Spread to Patients

Fluoroquinolones (FQs) and ciprofloxacin (Cp) are important antimicrobials that pollute the environment in trace amounts. Although Cp has been recommended as prophylaxis for patients undergoing leech therapy to prevent infections by the leech gut symbiont Aeromonas, a puzzling rise in Cp-resistant (Cpr) Aeromonas infections has been reported. We report on the effects of subtherapeutic FQ concentrations on bacteria in an environmental reservoir, the medicinal leech, and describe the presence of multiple antibiotic resistance mutations and a gain-of-function resistance gene. We link the rise of CprAeromonas isolates to exposure of the leech microbiota to very low levels of Cp (0.01 to 0.04 µg/ml), <1/100 of the clinical resistance breakpoint for Aeromonas Using competition experiments and comparative genomics of 37 strains, we determined the mechanisms of resistance in clinical and leech-derived Aeromonas isolates, traced their origin, and determined that the presence of merely 0.01 µg/ml Cp provides a strong competitive advantage for Cpr strains. Deep-sequencing the Cpr-conferring region of gyrA enabled tracing of the mutation-harboring Aeromonas population in archived gut samples, and an increase in the frequency of the Cpr-conferring mutation in 2011 coincides with the initial reports of CprAeromonas infections in patients receiving leech therapy.IMPORTANCE The role of subtherapeutic antimicrobial contamination in selecting for resistant strains has received increasing attention and is an important clinical matter. This study describes the relationship of resistant bacteria from the medicinal leech, Hirudo verbana, with patient infections following leech therapy. While our results highlight the need for alternative antibiotic therapies, the rise of Cpr bacteria demonstrates the importance of restricting the exposure of animals to antibiotics approved for veterinary use. The shift to a more resistant community and the dispersion of Cpr-conferring mechanisms via mobile elements occurred in a natural setting due to the presence of very low levels of fluoroquinolones, revealing the challenges of controlling the spread of antibiotic-resistant bacteria and highlighting the importance of a holistic approach in the management of antibiotic use.

Leech management before application on patient: a nationwide survey of practices in French university hospitals

Background

Leech therapy in plastic/reconstructive microsurgery significantly improves a successful outcome of flap salvage but the drawback is a risk of severe infection that results in a drop of the salvage rates from 70-80% to below 30%. We report the results of a national survey conducted in all the French university hospitals to assess the current extent of use of leech for medical practices in the hospital and to investigate maintenance, delivery practices and prevention of the risk of infection.

Methods

Data concerning conditions of storage, leech external decontamination, microbiological controls, mode of delivery and antibiotic prophylaxis were collected from all the French university hospitals in practicing leech therapy, on the basis of a standardized questionnaire.

Results

Twenty-eight of the 32 centers contacted filled the questionnaire, among which 23 practiced leech therapy, mostly with a centralized storage in the pharmacy; 39.1% of the centers declared to perform leech external decontamination and only 2 centers recurrent microbiological controls of the water storage. Leech delivery was mostly nominally performed (56.5%), but traceability of the leech batch number was achieved in only 39.1% of the cases. Only 5 centers declared that a protocol of antibiotic prophylaxis was systematically administered during leech therapy: either quinolone (2), sulfamethoxazole/trimethoprim (2) or amoxicillin/clavulanic acid (1).

Conclusions

Measures to prevent infectious complications before application to patient have to be better applied and guidelines of good practices are necessary.

The use of medical leeches for venous congestion

The medicinal leech, Hirudo medicinalis, has been used for hundreds of years in human medicine for a variety of diseases, most recently including venous congestion following reconstructive surgeries (skin flaps and reimplantations), excessive lingual and periorbital swelling, and non-traditional treatments for osteoarthritis, compartment syndrome and sialoadenitis. The treatment of venous congestion in animals using leeches has been mentioned anecdotally, but the only published report pertains to the use of leeches in a cat suffering from polycythemia vera. We report the use of medical grade leeches in a one-year-old male castrated Domestic Shorthaired cat presenting with severe swelling of the paw after sustaining a constrictive injury from a bandage. The limb use had become compromised and the swelling was not responsive to compression bandages so leech therapy was instituted for four days and the swelling dramatically improved. The patient's limb use improved back to normal and the constrictive wound went on to heal without complication. The use of leeches in this case allowed for resolution of severe venous congestion and a full return to function in this patient with no continued skin loss. The mechanism of action of hirudotherapy for venous congestion is to allow for an alternative egress of pooled venous blood leading to a reduction in capillary pressure and increases in arterial reperfusion of capillary beds. The human and veterinary applications, method, and potential complications with hirudotherapy are discussed in this review.

Alive in the Airways: Live Endobronchial Foreign Bodies

Aspiration of a foreign body into the lower airways is a common occurrence and can cause significant morbidity and mortality in humans. Most foreign bodies of the tracheobronchial tree are inanimate. However, the medical literature includes reports of live foreign bodies in the airways. Fish, leeches, and roundworms are the most common live foreign bodies of the lower airways. Fishermen are more prone to experience a live fish aspiration, whereas substandard conditions may expose individuals to leech and roundworm infestations. The dangers of and the approaches to the management of these foreign bodies differ from those associated with aspirated inanimate objects. The focus of this review of the medical literature was on live foreign body aspiration and its management.

Host Matters: Medicinal Leech Digestive-Tract Symbionts and Their Pathogenic Potential

Digestive-tract microbiota exert tremendous influence over host health. Host-symbiont model systems are studied to investigate how symbioses are initiated and maintained, as well as to identify host processes affected by resident microbiota. The medicinal leech, Hirudo verbana, is an excellent model to address such questions owing to a microbiome that is consistently dominated by two species, Aeromonas veronii and Mucinivorans hirudinis, both of which are cultivable and have sequenced genomes. This review outlines current knowledge about the dynamics of the H. verbana microbiome. We discuss in depth the factors required for A. veronii colonization and proliferation in the leech crop and summarize the current understanding of interactions between A. veronii and its annelid host. Lastly, we discuss leech usage in modern medicine and highlight how leech-therapy associated infections, often attributable to Aeromonas spp., are of growing clinical concern due in part to an increased prevalence of fluoroquinolone resistant strains.

Leech therapy in flap salvage: Systematic review and practical recommendations

INTRODUCTION

Medicinal leeches have been part of the therapeutic armamenterium of plastic surgeons for more than 50 years. While their use in hand surgery is a matter of course, their use in salvage of flaps with venous congestion remains facultative depending on teams.

MATERIALS AND METHODS

We conducted a systematic review of leech therapy for flap salvage between 1960 and 2015, analyzing 121 articles and subsequently taking into consideration 41 studies. In parallel, we collected data from 43 patients for whom leach therapy had recently been applied in treatment of venous insufficiency in pedicled or free flaps after revision surgery had failed to improve flap vascularization, or in cases where flap revision was not appropriate. The data collected pertained to relevant indications, treatment procedure, efficacy, adjuvant therapies, side effects and complications.

RESULTS

For this indication, the success rate of leech therapy ranged from 65 to 85% (83.7% in our series) according to the situations encountered. Optimal frequency of application ranged from 2 to 8hours, while average overall duration ranged from 4 to 10 days. The number of leeches to be applied can be determined depending on volume of the flap. In 50% of the cases reported in the literature, the patients required transfusion. Antibiotic prophylaxis against Aeromonas is highly advisable. A ciprofloxacin and trimethoprim-sulfametoxazole combination currently appears as the most relevant prophylactic antibiotherapy.

CONCLUSION

Hirudotherapy is a reliable treatment in cases of patent venous insufficiency of pedicled or free flaps (or when revision surgery is not recommended). Even though the relevant literature is highly heterogeneous, we have attempted to put forward a specific protocol bringing together dosage, delivery route, frequency of administration and appropriate prophylactic antibiotherapy. An algorithm for treatment and management of venous congestion and a practical information sheet have been placed at the disposal of plastic surgery teams.

Ciprofloxacin-resistant Aeromonas infection following leech therapy for digit replantation: report of 2 cases

Medicinal leeches are commonly used after finger replantation to treat surgically unsalvageable venous congestion. Infection from Aeromonas hydrophila is a recognized complication of leech therapy that can be underestimated by the medical community. Ciprofloxacin and trimethoprim-sulfamethoxazole are the most commonly recommended prophylactic antibiotics used to prevent A. hydrophila infections during leech therapy. Here, we report 2 cases of ciprofloxacin-resistant Aeromonas infections, occurring within 4 months of each other. Both cases developed after leech therapy for unsuccessful digital replantation. These infections were successfully treated with ceftriaxone. Ciprofloxacin-resistant Aeromonas should be recognized when determining prophylactic antibiotic protocols for replant centers when leech therapy is used for finger replantation.

Ciprofloxacin-resistant Aeromonas hydrophila cellulitis following leech therapy

We report a case of surgical site infection with ciprofloxacin-resistant Aeromonas hydrophila following leech therapy. Antimicrobial and genetic analyses of leech and patient isolates demonstrated that the resistant isolates originated from the leech gut microbiota. These data suggest that ciprofloxacin monotherapy as a prophylaxis regimen prior to leech therapy may not be effective in preventing infection.