Mortality Aeromonas Infection

8/2/2019 Mortality Aeromonas Infection

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Morbidity & Mortality Aeromonas hydrophila Infection



Ch ief C omplain

A 45 y/o male came to t h e ER wit h eryt h ematous swelling of t h e rig h t leg andmultiple large h emorr h agic bullae.



Past &

Personal History

No job, smoking, drinking everydayHypertension

Type 2 diabetes mellitusLiver cirr h osis wit h ascitesAtrial fibrillationAdmission to GI due to fever, c h illness & diarr h eaon 100.8.19~8.21Bladder cancer - TUR-BT on 85.5.25Anal fistulectomy on 92.9.8 and anal fistectomy on92.11.24



Present Illness

Righ t leg eryt h ematous swelling and multiple bullae since one day ago.Fever, ch illness and pain over rig h t leg, so h ecame to our ER on 100.10.24.No known h istory of any sea food contact,

trauma, or insect bites.Under th e impression of rig h t leg necrotizingfasciitis, h e was admitted to our ward.



C ourse & Treatment

1 0 / 2 4E3M5V2-3

K+ 2.6meq/L,P otassiumreplacementP LT 39000Rocep h in 1gmq12 h

C onsultinfection Dr.Leg wound carewit h uburncream

1 0 / 2 5BP down, coma

Transfer to I C U,On Endo &ventilator Dopamin &levop h ed

NH3 88 - >Lactuloseenema tidRocep h in 2gmq12 h +

Doxycycline100mg bidDigoxin 1# qdfor Af (consultC V)Albumin x3

days

1 0 / 2 6GI bleeding

(C onsult GI) NP OLosec 1 ampq12 h

FFP 2u, P LT12uLactuloseenema tidRocep h in 2gmq12 h + Minocin100mg q12 h

S igned DNR

1 0 / 2 7Wound & blood

culutre: Aermonashydrophil aLosec 1 amp

q12 hFFP 2u, P LT12uLactuloseenema tidRocep h in 2gm

q12 h + Minocin100mg q12 h



10/24 10/25



Course & Treatment

1 0 / 2 8S top inotropes

& antibioticsas requested byfamilyS upportivetreatment only

1 0 / 2 9E3M4VE

NG: dark green

BP : 121-150/70-90mmHg

1 0 / 3 1C onsciousness

improvingE3-4M5-6VE

Familyaccepted AK amputationRocep h in 2gmq12 h +Minocin

100mg q12h

1 1 / 1E3M5VE

BP more stableS tart NGfeeding



10/26 10/28



Course & Treatment

1 1 / 3Under GA, AK

amputationKeep

antibiotics

1 1 / 6E3M3VE

C onsciousnessdown h ill

BP : 90/56mmHgAf

NH3: 37 (11/4)

1 1 / 7E1M1VE

BP : 90/50mmHg

S igned DNR

1 1 / 8BP dropped

Expired



11/0111/07



Laboratory Datadata

dateWBC Hb Platelet Neutrophil Lymphocyte Bun Cr Na K CRP NH3 Alb GOT GPT Bil(T/D) Osm Digoxin

10/24 4500 14.5 39000 88.2 10.8 18 2.3 139 2.6 29.5 101 50

10/25 5900 11.5 11000 83.8 7.4 99.4 88 1.8

10/26 8200 11.9 29000 91.4 4.8 45 2.8 139 3.4 83

10/27 8200 10.6 33000 91.3 7.3 67

10/28 8500 9.6 38000 86.9 9.3 43 2.3

10/31 9600 12.1 13000 81.8 15.2 55 1.9 162 3.4 24 2.2 123 85

11/01 10200 11.2 43000 165 3.6

11/02 10400 11.0 25000 162 25.13/18 373

11/04 8400 9.1 59000 41 1.8 162 3.3 37 2.1 0.61

11/07 6200 7.2 25000 73.4 23.0 156 3.6 57.5 2.0 94



BacterialC

ultureWound culture: Aeromonas hydrophilaBlood culture: Aeromonas hydrophila/ caviae



Aeromonas hydrophilaFound in all fres h water environments as well as brackis h ,ch lorinated, and unc h lorinated water.Both a gram-negative rod and a facultative anaerobe.

C an grow in temperatures as low as 4 oC . T h ese bacteria are motile by a polar flagella.Very toxic to many organisms. W h en it enters t h e body of its victim,it travels t h roug h th e bloodstream to t h e first available organ.P roduces Aerolysin C ytotoxic Enterotoxin (A C T), a toxin t h at cancause tissue damage.C

onsidered to be opportunistic path

ogens, meaning th

ey rarelyinfect h ealt h y individuals.C onsidered a major fis h and amp h ibian pat h ogen, and its

pat h ogenicity in h umans h as been recognized for decades.



Fish

and Amph

ibiansAssociated wit h diseases mainly found in fis h and amp h ibians, because t h ese organisms live in

aquatic environments.It is linked to a disease found in frogs called red leg,wh ich causes internal, sometimes fatal h emorr h age.Wh en infected, fis h develop ulcers, tail rot, fin rot,and h emorr h agic septicemia.Hemorr h agic septicemia causes lesions t h at lead toscale s h edding, h emorr h ages in t h e gills and analarea, ulcers, exop h th almia, and abdominal swelling.



Fish

and Amph

ibians



Sites of infection in

humans

GI : gastroenteritis/dysentery (c h ildren may be severe, adults less so or ch ronic), peritonitis (rare).Skin/soft tissue infection : ± C ellulitis (may be fulminant wit h necrotizing features). ± Necrotizing fascitiis and mynoecrosis also may occur.

Sepsis : bacteremia often associated wit h malignancy, h epatobiliarydisease suc h as cirr h osis, less commonly wit h diabetes.Bone : osteomyelitis, septic art h ritis

CNS : meningitis (rare)Cardiac : endocarditis (rare)



Gastroenteritis

Th roug h oral contact wit h contaminated water,food, soil, feces, and/or ingestion of

contaminated fis h or reptiles.Two types of gastroenteritis.1. S imilar to c h olera, w h ich causes rice-water diarr h ea.

2. Dysenteric gastroenteritis, wh

ich

causes loose stools filledwit h blood and mucus. Dysenteric gastroenteritis is t h emost severe out of t h e two types, and can last for multipleweeks.



Soft tissue infection

C ommonly acquired t h roug h an open wound t h at isexposed to contaminated water.C an cause severe skin/soft tissue infection and sepsis,often in t h e immunocompromised.Risk factors for severe infection: immunocompromise,diabetes, h epatobiliary disease (cirr h osis).C ellulitis can be severe and spread rapidly, often wit h inh ours following exposure.Infection into deeper tissues may cause necrotizingfasciitis or myonecrosis. Bullae and ecyt h magangrenosum may be observed.



Antibiotics treatmentResistant to penicillin, ampicillin,carbenicillin, and ticarcillin.S usceptible to broad-spectrumcep h alosporins, aminoglycosides,carbapenems, c h loramp h enicol, tetracycline,

trimet h oprim-sulfamet h oxazole, andquinolones.



Necrotizing Fasciitis (NF)An insidiously advancing soft tissue infection c h aracterized

by widespread fascial necrosis.Increased risk in diabetics, elderly, infants, t h ose wit h liver disease, or t h ose taking immunosuppressive drugs suc h as

ch

emoth

erapy for cancer.

± ± ±

C lassification ± Type I, or polymicrobial, after trauma or surgery.

A variant of NF type I is saltwater NF, a V ibrio species. ± Type II, or group A Streptococcal. ± Type III gas gangrene, or clostridial myonecrosis.



Fournier¶s Gangrene



V ibrio

Vulnific

u s



V ibrio Vu lnific u s



Streptococcal Necrotizing Fasciitis



Necrotizing Fasciitis wit h Mycotic Aneurysm

Infected wit h Salmonella



Treatment of NFAggressive resuscitation to maintain h emodynamicstability.

Broad-spectrum antibiotics to cover aerobic gram-positive& gram-negative organisms and anaerobes.S urgical debridement, early and aggressive, multiple andextensive.Following fluid resuscitation and nutritional support.Wound care, & wound reconstruction.Hyperbaric oxygen (HBO)



Conclusion

Aeromonas hydrophila infection is frequently t h ecause of necrotizing fasciitis in patients wit h

suppressed immune systems, diabetes, burns, andtrauma in an aquatic setting.Th ese patients require aggressive antimicrobialth erapy and debridement and t h e mortality rate ish igh .Individuals t h at fail to respond to t h ese treatmentmeasures may require amputation.

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Mortality Aeromonas Infection