Late-onset posttraumatic skin and soft-tissue infections caused by rapid-growing mycobacteria in tsunami survivors.

BACKGROUND: In the tsunami catastrophe in Thailand in 2004, several thousand Swedish tourists were injured, with contaminated crush trauma of the legs being the main cause of injury among the survivors. METHODS: Patient and laboratory data for those who received hospital care in Stockholm and Gothenburg and contracted late-onset infections due to rapid-growing mycobacteria were reviewed retrospectively. Also, concomitant infections were recorded. RESULTS: Fifteen patients with late-onset skin and soft-tissue infections due to rapid-growing mycobacteria are described here. Mycobacterium abscessus was isolated in 7 cases, Mycobacterium fortuitum was isolated in 6 cases, and Mycobacterium peregrinum and Mycobacterium mageritense were isolated in 1 case each. The infections appeared after a delay of 20-105 days (median, 60 days) after the trauma, targeting undamaged skin located near primary sutured wounds or skin grafts. Antimycobacterial drugs were given to 9 (60%) of the patients. The course of infection was protracted, but all infections due to rapid-growing mycobacteria healed within 12 months. Concomitant subcutaneous infections due to other microorganisms, such as Burkholderia pseudomallei or Cladophialophora bantiana, appeared early or late after the trauma. CONCLUSIONS: Repeated cultures of abscess and wound specimens for Mycobacterium species may be needed to find the etiologic agents causing contaminated skin and soft-tissue infections, such as those that developed after traumas that occurred during the tsunami. These cultures are especially necessary when symptoms appear late and when conventional bacterial culture results are negative. A biopsy is recommended for the best yield and for complementary histopathological examination.

Concomitant late soft tissue infections by Cladophialophora bantiana and Mycobacterium abscessus following tsunami injuries.

A Swedish man and woman sustained severe soft tissue injuries during the tsunami catastrophe in Thailand in December 2004, and subsequently received partial thickness skin grafts after multiple surgical revisions. Four to six weeks post trauma they displayed signs of purulent infections in the non-traumatized, virtually intact skin outside the resection margins. Skin biopsies revealed granulomatous reactions and pigmented fungal hyphae were observed in specimens from the male patient. Cladophialophora bantiana and Mycobacterium abscessus were recovered concomitantly from samples obtained from both patients. Antifungal treatment was given with voriconazole for one month, after which no fungal growth was detected on biopsies. Antimycobacterial treatment was given with clarithromycin and amikacin. The symptoms gradually subsided in the male patient, but recurrent abscesses were noted with the female patient, from which M. abscessus was recovered despite prolonged antibiotic therapy.

A prospective study of infections in burn patients.

In a 3-year prospective study, all infections presenting in the burns unit of a university hospital were registered in a specially designed database. Two-hundred and thirty adult patients were included. Eighty-three patients had in all 176 infections, giving an infection rate of 48 per 1000 patient days including both nosocomial and community-acquired infections. Thirty-five blood-stream infections (BSI) occurred in 22 patients; most common micro-organisms were coagulase-negative staphylococci and methicillin-sensitive Staphylococcus aureus. The device-specific BSI rate was 6 per 1000 central venous catheter days, which is low compared to other burn units. The pneumonia rate was 41 per 1000 ventilator days. Seventy-two patients had 107 burn wound infections. Antibiotics were given to only 50% of the burn patients, including 96% of the patients with infection and 26% of those without infection. Most frequently used antimicrobials were cloxacillin, penicillin and gentamicin. The antibiotic resistance rates were low, and multi-resistant bacteria or fungi were rare. The database can be used to evaluate the effects of changes in burn treatment, staffing and design of burn units, and antimicrobial resistance development in relation to antibiotic usage.