Compartment syndrome as a novel complication of extended spectrum beta lactamase Escherichia coli necrotising soft tissue infection – A case report

Introduction and importance

Necrotising soft tissue infections (NSTI) encompass a group of destructive soft tissue disease processes which can involve skin, subcutaneous tissue, fascia and or muscle, associated with rapid spread along tissue planes and mortality. Clinical presentations include progressive pain, suppuration/necrosis and systemic toxicity with haemodynamic instability. While diagnosis is based on clinical findings it can be augmented with imaging. Treatment is typically in the form of resuscitation, immediate administration of broad spectrum intravenous antibiotics and urgent source control through radical surgical debridement.

Case presentation

An 82-year-old man presented with left forearm/hand pain and fevers in the context of immunocompromise. Examination found tense swelling of the left volar and dorsal forearm and hand, absent distal pulses with pain and paraesthesia over both surfaces. He underwent surgical debridement with fasciotomy and remained in intensive care with blood cultures revealing ESBL E. coli.

Clinical discussion

Compartment syndrome is a rare complication of NSTI and its clinical presentation can obscure early diagnosis. ESBL E. coli is an uncommon pathogen to cause monomicrobial infection and must be accounted for when considering broad spectrum empirical antibiotic cover.

Conclusion

Review of this case and the literature show a rare presentation of NSTI and highlights the importance of early diagnosis based on even a small index of suspicion. It also shows the key significance rationalisation of antibiotics as soon as practicable, given that even broad spectrum empirical cover can be inappropriate in the context of novel microorganisms, particularly in high risk patients.

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First recorded case of monomicrobial ESBL E. coli compartment syndrome

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ESBL E. coli NSTI is rare and not covered by many empirical antimicrobial guidelines.

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Compartment syndrome secondary to NSTI is uncommon and associated with streptococci.

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Early recognition and prompt management are essential to prognosis.

A systematic review of quantitative burn wound microbiology in the management of burns patients

BACKGROUND

The early diagnosis of infection or sepsis in burns are important for patient care. Globally, a large number of burn centres advocate quantitative cultures of wound biopsies for patient management, since there is assumed to be a direct link between the bioburden of a burn wound and the risk of microbial invasion. Given the conflicting study findings in this area, a systematic review was warranted.

METHODS

Bibliographic databases were searched with no language restrictions to August 2015. Study selection, data extraction and risk of bias assessment were performed in duplicate using pre-defined criteria. Substantial heterogeneity precluded quantitative synthesis, and findings were described narratively, sub-grouped by clinical question.

RESULTS

Twenty six laboratory and/or clinical studies were included. Substantial heterogeneity hampered comparisons across studies and interpretation of findings. Limited evidence suggests that (i) more than one quantitative microbiology sample is required to obtain reliable estimates of bacterial load; (ii) biopsies are more sensitive than swabs in diagnosing or predicting sepsis; (iii) high bacterial loads may predict worse clinical outcomes, and (iv) both quantitative and semi-quantitative culture reports need to be interpreted with caution and in the context of other clinical risk factors.

CONCLUSION

The evidence base for the utility and reliability of quantitative microbiology for diagnosing or predicting clinical outcomes in burns patients is limited and often poorly reported. Consequently future research is warranted.

Protocol for a systematic review of quantitative burn wound microbiology in the management of burns patients

BACKGROUND

Sepsis from burn injuries can result from colonisation of burn wounds, especially in large surface area burns. Reducing bacterial infection will reduce morbidity and mortality, and mortality for severe burns can be as high as 15 %. There are various quantitative and semi-quantitative techniques to monitor bacterial load on wounds. In the UK, burn wounds are typically monitored for the presence or absence of bacteria through the collection and culture of swabs, but no absolute count is obtained. Quantitative burn wound culture provides a measure of bacterial count and is gaining increased popularity in some countries. It is however more resource intensive, and evidence for its utility appears to be inconsistent. This systematic review therefore aims to assess the evidence on the utility and reliability of different quantitative microbiology techniques in terms of diagnosing or predicting clinical outcomes.

METHODS/DESIGN

Standard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. Bibliographic databases and ongoing trial registers will be searched and conference abstracts screened. Studies will be eligible if they are prospective studies or systematic reviews of burn patients (any age) for whom quantitative microbiology has been performed, whether it is compared to another method. Quality assessment will be based on quality assessment tools for diagnostic and prognostic studies and tailored to the review as necessary. Synthesis is likely to be primarily narrative, but meta-analysis may be considered where clinical and methodological homogeneity exists.

DISCUSSION

Given the increasing use of quantitative methods, this is a timely systematic review, which will attempt to clarify the evidence base. As far as the authors are aware, it will be the first to address this topic.

TRIAL REGISTRATION

PROSPERO, CRD42015023903.

A model of pressure distribution under peripherally secured foam dressings on a convex surface: does this contribute to skin graft loss?

BACKGROUND

Successful skin grafting requires multiple factors for success. An even distribution of constant pressure exerted upon the graft is necessary for successful graft take. It is well known that excessive pressure on a graft causes ischemia and may result in the failure of graft take. The aim of this study was to demonstrate the variation in skin pressure (tension) on curved surfaces, particularly relating to apical pressure on such surfaces at standard atmospheric pressure.

METHODS

A synthetic Sawbone skull model was used to determine skin tension over a curved surface. A 10-cm diameter circle was centered on the parietal eminence, the area of maximum curvature. Peripheral screws gave fixed reproducible points to secure the foam dressing. Open-cell VAC dressing foam was used and calibrated Tekscan sensors were used to determine pressure variation under the foam dressing.

RESULTS

Five hundred pressure readings were obtained for the unscored foam, and an additional 500 for the cross-scored foam. In the unscored foam, the pressure under the dressing was significantly higher at the apex. Cross-scoring the foam reduced the pressure, with the greatest reduction being at the apex. The pressure under the foam dressing was maximal at the apical point (95% confidence interval).

CONCLUSION

Higher contact force at the apex of a curved graft bed may explain skin graft loss. Unequal pressure distribution can be reduced and equalized by scoring the foam.