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Microbiological Evaluation of Infected Wounds Of 32 32tAccid Emerg Med 1999;16:32-34 Microbiological evaluation of infected wounds of the extremities in 214 adults J Accid Emerg Med: first published as 10.1136/emj.16.1.32 on 1 January 1999. Downloaded from Laurent Holzapfel, Thierry Jacquet-Francillon, Jamil Rahmani, Pascal Achard, Eric Marcellin, Thierry Joffre, P Y Lallement, A Bousquet, Sabine Devaux, A Coupry Abstract studies with a small number of patients.1`3 Objective-The aim of this multicentre Streptococcus pyogenes and Staphylococcus aureus prospective study was to analyse micro- were the most frequent micro-organisms bial pathogens cultured from an infected found, but Gram negative bacilli were also iso- wound. lated. Methods-The study was performed in the The aim of this multicentre prospective emergency rooms of 10 public hospitals. study was to analyse microbial pathogens All adult patients with a clinical diagnosis cultured from an infected wound to better of celiulitis after a wound in the upper or define microbiological sensitivities and the lower extremities were included. Cultures treatment that should be prescribed. were obtained with swabs from infected lesions. Micro-organisms cultured were Patients and methods identified by the usual methods and STUDY POPULATION susceptibility testing was performed. The study was performed from October 1994 Results-The study population consisted to June 1996 in the emergency rooms of 10 of 214 patients, 153 men and 61 women, public non-teaching hospitals. All patients of with a mean (SD) age of 40 (10) years. 18 years old or more who came to the Wound cultures remained sterile in 28 emergency room of the hospital with a clinical cases and infected with micro-organisms diagnosis of open cellulitis complicating a trau- in 186 cases. Of the 186 positive cultures, matic wound of the upper or lower extremities three were not identified. Of the 183 were included in the study. Open cutaneous remaining cultures, one micro-organism cellulitis was defined as a localised process was present in 132 patients (62%) and sev- characterised by at least two of the following Centre Hospitalier de eral micro-organisms in 51 patients items: erythema, increased warmth, swelling, Bourge-en-Bresse, (24%). A total of 248 micro-organisms pain, and presence of purulent material. 01012 Bourg en Bresse, were isolated in 183 patients. Staphylococ- France Patients were excluded for the following L Holzapfel cus and streptococcus were the most reasons: cellulitis of the head and neck, thorax T Jacquet-Francillon frequently isolated micro-organisms (56% and abdomen, history of antibiotic use in the A Coupry and 21% respectively) followed by Gram preceding four days, surgical wound infection, negative bacilli (18%). Determination of illicit injection, likelihood of another diagnosis http://emj.bmj.com/ Centre Hospitalier, the susceptibility to the antibiotics com- (for example, ulcers, impetigo, folliculitis, Levallois-Perret wound J Rahmani monly used to treat infections carbuncles, abscess, or other deep seated soft showed resistance in some cases. tissue infection, bites, erysipelas) or gangre- Centre Hospitalier, Conclusion-These results support the nous cellulitis (cellulitis that has rapidly Annecy need always to take culture specimens progressed with extensive necrosis of sub- P Achard from infected wounds for microbiological cutaneous tissues and overlying skin). A stand- evaluation and antibiotic susceptibility ardised data collection form was used to collect on October 1, 2021 by guest. Protected copyright. Hopital General, Orleans determination, so that adapted chemo- the historical data. Informed consent was not E Marcellin therapy can be prescribed. required by the ethics committee of Lyon Uni- (7Accid Emerg Med 1999;16:32-34) versity. Centre Hospitalier, Vienne Keywords: infected wounds; micro-organisms; cellulitis; antibiotics MICROBIOLOGICAL PROCEDURES T Joffre Cultures were obtained with swabs from puru- Centre Hospitalier, lent material of cellulitis lesions without Soissons Traumatic wound of the extremities is a preparatory cleansing. Samples were placed in P Y Lallement common clinical problem and its treatment is transport media and sent to the clinical labora- well codified. Wound infection can be observed tory, where they were plated onto blood, Centre Hospitalier, chocolate, and MacConkey agar. The agar Saintes during the healing process. Serious infections A Bousquet such as anaerobic gangrenous cellulitis are plates were incubated for 48 hours at 35°C in infrequent and most cellulitis is caused by 5% carbon dioxide. Micro-organisms cultured Centre Hospitalier, aerobic micro-organisms. The presentation is were identified by the usual methods and Argenteuil generally a localised infection, but serious sep- susceptibility testing was performed by the S Devaux sis can be seen. The consequences of cellulitis Bauer-Kirby disk method. Correspondence and reprint are to slow down scar formation and to cause requests to: Dr Holzapfel aesthetic and functional sequelae. Results (e-mail: [email protected]). Treatment of cellulitis consists of local care STUDY POPULATION and intravenous or oral antibiotics. Microbial The study population consisted of 214 pa- Accepted 7 August 1998 pathogens have been analysed in only a few tients, 153 men and 61 women, aged 18 to 92 Microbiological evaluation ofinfected wounds 33 Table 1 Microbiologicalfindings in 214 patients with previous history of methicilin resistant S aureus positive cultures sensitivity or was known to have HIV. Gram positive cocci 196 (79%) J Accid Emerg Med: first published as 10.1136/emj.16.1.32 on 1 January 1999. Downloaded from Staphylococcus 139 (56%) MICROBIOLOGICAL FINDINGS S aureus 111 S epidermidis 8 Of the 214 total wound cultures performed, 28 Other staphylococcus coagulase 20 remained sterile and 186 grew micro- negative organisms. Of the 186 positive cultures, three Streptococcus 51 (21%) were not Group A 30 identified. Of the 183 remaining cul- Group B 5 tures, one micro-organism grew in 132 patients Other 16 (62%) and several micro-organisms in 51 Enterococcus 6 (2%) patients (24%). A total of 248 Gram negative bacilli 45 (18%) micro- Acinetobacter 4 organisms were isolated in 183 patients. The Enterobacter 11 micro-organisms are shown in table 1; table 2 Escherichia coli 7 Citrobacter 2 shows their susceptibility to the antibiotics Klebsiella 2 commonly used to treat cellulitis. Proteus 5 Providencia Morganella 1 Aeromonas 4 Discussion Haemophilus 1 Our results confirm the frequent occurrence of Pseudomonas aeruginosa 5 S aureus and streptococcus in wound infections Pseudomonas sp 2 Anaerobic bacteria 2 (1%) and the presence of Gram negative bacilli. Peptostreptococcus Determination of the susceptibility to antibiot- Propionibacterium 1 ics showed frequent resistance to the antibiot- Others 5 (2%) ics that are commonly used to treat wound infections. Table 2 Susceptibility to antibiotics of isolated micro-organisms (o%) This prospective study included an homog- enous group of 214 adult patients with an Gram infected wound of the extremities. Prior studies negative have included only a small number of patients Staphylococcus Streptococcus bacilli with cellulitis of various body areas that were Penicillin G 18 94 caused by different kinds of lesion (fungal Amoxycillin (AMX) 37 100 31 AMX-clavulanate 99 100 51 infection, cutaneous ulceration, bites, illicit Oxacillin or injections, erysipelas).' 2 4 cloxacillin 98 90 In our study, cultures were obtained with Gentamicin 100 - 93 Cefotaxime 97 100 85 swabs from purulent material of cellulitis Ticarcillin-clavulanate- - 96 lesions. In 1995 Uman and Kunin described the use of needle aspiration for diagnosis in patients with soft tissue infections.9 In different studies, the number of patients with positive years (mean (SD) 40 (10) years). Of the 214 cultures from needle aspiration were as follows: patients, 133 had significant underlying condi- (10%),6 3/30 7/25 (28%),5 30/94 (32%),' http://emj.bmj.com/ or an adverse = tions lifestyle: smoking (n 96), 20/42 (48%),7 and 21/31 (68%).' In most of venous insufficiency (n = 40), alcoholism these studies the authors concluded that = = (n 25), diabetes mellitus (n 10), drug needle aspiration may not be justified as a rou- addiction (n = 4), and immunosuppressive tine procedure for patients with cellulitis. treatment (n = 3). A hospital stay within the Other microbiological sampling techniques six preceding months was noted in 20 patients. have been used. In a study on 16 patients, inci- Localisation of the infected wound was the sion and drainage yielded pus and cultures upper extremities in 129 patients (60%), lower were positive in 10 cases.2 In another study on on October 1, 2021 by guest. Protected copyright. extremities in 83 patients (39%), and both in 15 patients punch biopsy cultures were positive two patients. Length of the wound was 2.72 cm in 10 patients, aspirate and blood cultures were (range 0.3-15). The wound was caused by a positive in five and two respectively, and sharp object in 79 patients (37%) and by a cultures obtained with swabs from primary non-sharp object in 135 patients (63%). Delay lesions in 10 patients showed the same before infection was four days or less in 81 organisms cultured by more invasive methods.4 patients (39%) and more than four days in 126 Table 3 summarises microbiological data patients (61%). Initial local wound care was obtained in these studies. Comparison with our performed in 111 patients and 43 of them were results
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