Chronic venous leg ulcer with multidrug resistant sepsis
The present case has been published in the Journal of the Scientific Society.

A 52-year-old obese, diabetic male patient presented with a non-healing ulcer on gaiter area of right leg and high-grade fever. The ulcer was present on and off for some 5 years with much increase in size and discharge for last 1 month. There was yellowish necrotic debris and granulation tissue over the base of the ulcer with large amount of odoros discharge. Plain X-ray of ulcer area revealed no bony involvement.

Venous duplex sonography revealed incompetent sapheno femoral valve and lower perforating veins. Ankle-brachial pressure index value was 1.1, thereby excluding any arterial disease.

A consultation was made on fourth hospitalization day for wound debridement and obtaining of wound specimens for bacterial cultures and anti-biogram. The wound was thoroughly cleaned and irrigatedGE and debridement of necrotic tissue enclosing the ulcer area was carried out. After repeat irrigation, the specimen was collected with a sterile culture swab and immediately sent to Microbiology department for further processing.

Susceptibility to cefoxitin, cefepime, ceftriaxone, chloramphenicol, ciprofloxacin, clindamycin, erythromycin, oxacillin, vancomycin, gentamicin, imipenem, colistin, rifampicin, tazobactam-piperacillin, tetracycline, and trimethoprim/sulfamethoxazole was determined using the disc diffusion test.

Final microbiological analysis revealed a polymicrobial infection with MRSA and MBL producing strains of Acinetobacter baumanii and Acinetobacter lowffii. MRSA strain showed intermediate susceptibility only against vancomycin. A. baumanii was resistant to all drugs tested and A. lowffii was only susceptibile to colistin.

Based on this IV vancomycin and colistin was started from eighth hospitalization day. After the initial improvement on the 12 th day , there was a progression of the infection with the patient having systemic symptoms including increased body temperature and diaphoresis . Due to these results on the 20 th hospitalization day below ankle amputation of affected limb was done.

Key takeaways:-
- Bacterial resistance is an issue that is increasingly common in CVLU infection. Various risk factors like previous antibiotic therapy and its duration, frequency and length of hospitalization for the same wound are related to antibiotic resistance.

- In this case, the patient reported of not having used antibiotic for exacerbation of CVLU as well as not having been hospitalized in the previous 5 months. However, at the time of hospitalization, he received empirical broad-spectrum antibiotic therapy.

- Therefore, it could be suggested that natural selection imposed by antibiotics led to the elimination of susceptible bacterial species, leaving only the resistant strains in the damaged tissue.

-The existence of bio-flim on chronic difficult to heal wound complicates the clinical use of antimicrobial, favoring the emergence of resistant bacteria and hence, the treatment strategy should be based on isolating the causative agent and on determining the sensitivity profile in regards to antimicrobial agents.

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