‘The Violet Killer’—Successful Treatment of an Infant with Chromobacterium violaceum Sepsis

Abstract Chromobacterium violaceum, a facultative anaerobic proteobacterium, is isolated from water and soil in tropical areas and has been implicated in infections like septicemia, visceral abscesses, skin and soft tissue infections, meningitis and diarrhea. Chromobacterium violaceum sepsis, a rarely reported phenomenon has a very high mortality rate. Here, we report a unique case of Chromobacterium sepsis in an infant. A 48-day-old baby boy was referred to our institution with h/o fever, loose stools and reduced activity. He was intubated and referred to us in septic shock. Radiological investigations revealed multiple abscesses in the liver, spleen and kidneys. The infant was successfully treated with trimethoprim-sulfamethoxazole and ciprofloxacin.

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Necrotizing Soft Tissue Infections in Intensive Care

Journal of Intensive Care Medicine ◽

10.1177/08850666211010127 ◽

2021 ◽

pp. 088506662110101

Author(s):

Alexandru Ogica ◽

Christoph Burdelski ◽

Holger Rohde ◽

Stefan Kluge ◽

Geraldine de Heer

Keyword(s):

Septic Shock ◽

Intensive Care ◽

Soft Tissue ◽

Sofa Score ◽

Laboratory Data ◽

Serum Lactate ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections ◽

The Mean ◽

Organ Dysfunctions

Background: Necrotizing soft tissue infections (NSTIs) are typically characterized by extensive soft tissue destruction with systemic signs of toxicity, ranging from sepsis to septic shock. Our aim was to analyze the clinical characteristics, microbiological results, laboratory data, therapies, and outcome of patients with NSTIs admitted to an intensive care unit (ICU). Methods: A monocentric observational study of patients admitted to the ICU of a university hospital between January 2009 and December 2017. The demographic characteristics, comorbidities, clinical features, microbiology and laboratory results, organ dysfunctions, therapies, and outcome were retrospectively analyzed. Results: There were 59 patients and 70% males. The mean age (± SD) was 55 ± 18; type II (monomicrobial) NSTI was present in 36 patients (61%); the most common isolated pathogen was Streptococcus pyogenes in 28 patients (48%). Septic shock was diagnosed in 41 patients (70%). The most common organ dysfunctions were circulatory and renal in 42 (71%) and 38 patients (64%). The mean value (± SD) of serum lactate at admission to the ICU was 4.22 ± 5.42 mmol/l, the median SOFA score and SAPS II were 7 (IQR 4 - 10) and 46 (IQR 30.5 - 53). ICU mortality rate was 25%. Both SOFA score and serum lactate demonstrated a good prognostic value regarding ICU outcome (OR 1.29, 95%CI 1.07-1.57, P < 0.007 and OR 1.53, 95%CI 1.19-1.98, P < 0.001). A cut-off value for serum lactate of 6.55 mmol/L positively predicted mortality with 67% sensitivity and 97% specificity. Conclusion: NSTIs carry a high risk of septic shock and multiple organ dysfunction syndrome and thus are still associated with high mortality. In our study, the value of serum lactate at admission to the ICU correlated well with mortality. This easy-to-measure parameter could play a role in the decision-making process regarding prognosis and continuation of care.

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Factors Associated with Mortality and Amputation Caused by Necrotizing Soft Tissue Infections of the Upper Extremity: A Retrospective Cohort Study

World Journal of Surgery ◽

10.1007/s00268-019-05256-9 ◽

2019 ◽

Vol 44 (3) ◽

pp. 730-740 ◽

Cited By ~ 1

Author(s):

Femke Nawijn ◽

Svenna H.W.L. Verhiel ◽

Kiera N. Lunn ◽

Kyle R. Eberlin ◽

Falco Hietbrink ◽

...

Keyword(s):

Risk Factor ◽

Soft Tissue ◽

Mortality Rate ◽

Upper Extremity ◽

Base Deficit ◽

Amputation Rate ◽

Soft Tissue Infections ◽

Factors Associated ◽

Asa Classification ◽

Necrotizing Soft Tissue Infections

Abstract Background It is unclear what the exact short-term outcomes of necrotizing soft tissue infections (NSTIs), also known and necrotizing fasciitis of the upper extremity, are and whether these are comparable to other anatomical regions. Therefore, the aim of this study is to assess factors associated with mortality within 30-days and amputation in patients with upper extremity NSTIs. Methods A retrospective study over a 20-year time period of all patients treated for NSTIs of the upper extremity was carried out. The primary outcomes were the 30-day mortality rate and the amputation rate in patients admitted to the hospital for upper extremity NSTIs. Results Within 20 years, 122 patients with NSTIs of the upper extremity were identified. Thirteen patients (11%) died and 17 patients (14%) underwent amputation. Independent risk factors for mortality were an American Society of Anesthesiologists (ASA) classification of 3 or higher (OR 9.26, 95% CI 1.64–52.31) and a base deficit of 3 meq/L or greater (OR 10.53, 95% CI 1.14–96.98). The independent risk factor for amputation was a NSTI of the non-dominant arm (OR 3.78, 95% CI 1.07–13.35). Length of hospital stay was 15 (IQR 9–21) days. Conclusion Upper extremity NSTIs have a relatively low mortality rate, but a relatively high amputation rate compared to studies assessing NSTIs of all anatomical regions. ASA classification and base deficit at admission predict the prognosis of patients with upper extremity NSTIs, while a NSTI of the non-dominant side is a risk factor for limb loss.

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Hospital admissions for skin and soft tissue infections in a population with endemic scabies: A prospective study in Fiji, 2018–2019

PLoS Neglected Tropical Diseases ◽

10.1371/journal.pntd.0008887 ◽

2020 ◽

Vol 14 (12) ◽

pp. e0008887

Author(s):

Li Jun Thean ◽

Adam Jenney ◽

Daniel Engelman ◽

Lucia Romani ◽

Handan Wand ◽

...

Keyword(s):

Soft Tissue ◽

Prospective Study ◽

Indigenous Population ◽

Hospital Admissions ◽

Case Fatality ◽

Soft Tissue Infections ◽

Predisposing Factor ◽

A Prospective Study ◽

Crusted Scabies ◽

Very High

Scabies is an important predisposing factor for impetigo but its role in more serious skin and soft tissue infections (SSTIs) is not well understood. Information is limited on incidence of SSTIs in the presence of endemic scabies. We conducted a prospective study of hospital admissions for SSTIs in the Northern Division of Fiji (population: 131,914). Prospective surveillance for admissions with impetigo, abscess, cellulitis, wound infection, pyomyositis, necrotizing fasciitis, infected scabies, and crusted scabies was conducted at the Division’s referral hospital between 2018 to 2019. Information was collected on demographic characteristics, clinical features, microbiology, treatment and outcomes. Over the study period, 788 SSTI admissions were recorded corresponding to a population incidence 647 per 100,000 person-years (95%CI 571–660). Incidence was highest at the extremes of age with peak incidence in children aged <5 years (908 per 100,000) and those aged ≥65 years (1127 per 100,000). Incidence was 1.7 times higher among the Indigenous Fijian population (753 per 100,000) compared to other ethnicities (442 per 100,000). Overall case fatality rate was 3.3%, and 10.8% for those aged ≥65 years. Scabies was diagnosed concurrently in 7.6% of all patients and in 24.6% of admitted children <5 years. There is a very high burden of hospital admissions for SSTIs in Fiji compared to high-income settings especially among the youngest, oldest and indigenous population which is concordant with scabies and impetigo distribution in this population. Our findings highlight the need for strategies to reduce the burden of SSTIs in Fiji and similar settings.

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Risk Factors and Predictors of Mortality in Streptococcal Necrotizing Soft-tissue Infections: A Multicenter Prospective Study

Clinical Infectious Diseases ◽

10.1093/cid/ciaa027 ◽

2020 ◽

Cited By ~ 11

Author(s):

Trond Bruun ◽

Eivind Rath ◽

Martin Bruun Madsen ◽

Oddvar Oppegaard ◽

Michael Nekludov ◽

...

Keyword(s):

Risk Factors ◽

Septic Shock ◽

Soft Tissue ◽

Blunt Trauma ◽

Gene Profiling ◽

Soft Tissue Infections ◽

Lasso Regression ◽

Factors Associated ◽

Necrotizing Soft Tissue Infections ◽

The Impact

Abstract Background Necrotizing soft-tissue infections (NSTI) are life-threatening conditions often caused by β-hemolytic streptococci, group A Streptococcus (GAS) in particular. Optimal treatment is contentious. The INFECT cohort includes the largest set of prospectively enrolled streptococcal NSTI cases to date. Methods From the INFECT cohort of 409 adults admitted with NSTI to 5 clinical centers in Scandinavia, patients culture-positive for GAS or Streptococcus dysgalactiae (SD) were selected. Risk factors were identified by comparison with a cohort of nonnecrotizing streptococcal cellulitis. The impact of baseline factors and treatment on 90-day mortality was explored using Lasso regression. Whole-genome sequencing of bacterial isolates was used for emm typing and virulence gene profiling. Results The 126 GAS NSTI cases and 27 cases caused by SD constituted 31% and 7% of the whole NSTI cohort, respectively. When comparing to nonnecrotizing streptococcal cellulitis, streptococcal NSTI was associated to blunt trauma, absence of preexisting skin lesions, and a lower body mass index. Septic shock was significantly more frequent in GAS (65%) compared to SD (41%) and polymicrobial, nonstreptococcal NSTI (46%). Age, male sex, septic shock, and no administration of intravenous immunoglobulin (IVIG) were among factors associated with 90-day mortality. Predominant emm types were emm1, emm3, and emm28 in GAS and stG62647 in SD. Conclusions Streptococcal NSTI was associated with several risk factors, including blunt trauma. Septic shock was more frequent in NSTI caused by GAS than in cases due to SD. Factors associated with mortality in GAS NSTI included age, septic shock, and no administration of IVIG.

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Chromobacterium violaceum Periareolar Infection, First Non-Lethal Case in Colombia: Case Report and Literature Review

Infectious Disease Reports ◽

10.3390/idr13020053 ◽

2021 ◽

Vol 13 (2) ◽

pp. 571-581

Author(s):

Diego Alejandro Cubides Diaz ◽

Daniel Arsanios Martin ◽

Nicolas Bernal Ortiz ◽

Ana Lucia Ovalle Monroy ◽

Valentina Hernandez Angarita ◽

...

Keyword(s):

Case Report ◽

Soft Tissue ◽

Kidney Disease ◽

Clinical Manifestations ◽

Chromobacterium Violaceum ◽

Polycystic Kidney ◽

Gram Negative ◽

Lethal Infection ◽

Facultative Anaerobic ◽

Human Infections

Chromobacterium violaceum is a facultative anaerobic, Gram-negative rod found in different ecosystems, especially tropical and subtropical areas. Human infections are rare, and just a few cases have been reported in literature. In this paper, we present the first non-lethal infection due to Chromobacterium violaceum, in an adult male with polycystic kidney disease in Colombia. Periareolar soft tissue infection was documented with isolation of Chromobacterium violaceum. Clinical manifestations, treatment, and outcome are shown.

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Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

World Journal of Emergency Surgery ◽

10.1186/s13017-019-0286-6 ◽

2020 ◽

Vol 15 (1) ◽

Cited By ~ 6

Author(s):

Femke Nawijn ◽

Diederik P. J. Smeeing ◽

Roderick M. Houwert ◽

Luke P. H. Leenen ◽

Falco Hietbrink

Keyword(s):

Surgical Treatment ◽

Soft Tissue ◽

Mortality Rate ◽

Meta Analysis ◽

Operating Time ◽

Mortality Rates ◽

Soft Tissue Infections ◽

Included Patient ◽

Necrotizing Soft Tissue Infections ◽

Analysis Models

Abstract Background Although the phrase “time is fascia” is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models. Result A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26–0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27–0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively. Conclusion Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.

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Chromobacterium violaceumIsolated from a Wound Sepsis: A Case Study from Nepal

Case Reports in Infectious Diseases ◽

10.1155/2015/181946 ◽

2015 ◽

Vol 2015 ◽

pp. 1-4 ◽

Cited By ~ 4

Author(s):

Shamshul Ansari ◽

Pramod Paudel ◽

Kishor Gautam ◽

Sony Shrestha ◽

Sangita Thapa ◽

...

Keyword(s):

Septic Shock ◽

Mortality Rate ◽

Multiorgan Failure ◽

Middle Finger ◽

Chromobacterium Violaceum ◽

Causative Organism ◽

Wound Sepsis ◽

First Case ◽

Systemic Infections

Chromobacterium violaceumis a facultative anaerobic, Gram-negative rod, prevalent in tropical and subtropical regions. It enters through the skin injury and is capable of causing severe systemic infections leading to septic shock and multiorgan failure. It has been reported by few authors across the world but this is probably the first case ofChromobacterium violaceumisolated from wound sepsis from Nepal. In this study, a pus sample from the infection of a prick injury in the left middle finger was collected from the patient admitted to the intensive care unit. Bacteriological investigations of the pus sample revealed the causative organism to beChromobacterium violaceum. This case study indicates thatChromobacterium violaceumcan act as a potential cause of wound sepsis that may lead to the septic shock and if not treated timely, the mortality rate can be high as was in this study. Although this organism is very rare, the infection caused requires prompt treatment to minimize the mortality rate. Therefore, we recommend the timely diagnosis and antimicrobial therapy of this infection to combat the consequences led.

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Melioidosis in the Philippines

Tropical Medicine and Infectious Disease ◽

10.3390/tropicalmed3030099 ◽

2018 ◽

Vol 3 (3) ◽

pp. 99

Author(s):

Peter San Martin ◽

Joseph Chua ◽

Ralph Bautista ◽

Jennifer Nailes ◽

Mario Panaligan ◽

...

Keyword(s):

Diabetes Mellitus ◽

Soft Tissue ◽

Mortality Rate ◽

Surveillance System ◽

Case Series ◽

The Philippines ◽

Soft Tissue Infections ◽

Intensive Phase ◽

Co Morbidity ◽

Tertiary Hospitals

The first documented case of melioidosis in the Philippines occurred in 1948. Since then, there have been sporadic reports in the literature about travelers diagnosed with melioidosis after returning from the Philippines. Indigenous cases, however, have been documented rarely, and under-reporting is highly likely. This review collated all Philippine cases of melioidosis published internationally and locally, as well as unpublished case series and reports from different tertiary hospitals in the Philippines. In total, 25 papers and 41 cases were identified. Among these, 23 were indigenous cases (of which 20 have not been previously reported in the literature). The most common co-morbidity present was diabetes mellitus, and the most common presentations were pulmonary and soft tissue infections. Most of the cases received ceftazidime during the intensive phase, while trimethoprim-sulfamethoxazole was given during the eradication phase. The known mortality rate was 14.6%, while 4.9% of all cases were reported to have had recurrence. The true burden of melioidosis in the country is not well defined. A lack of awareness among clinicians, a dearth of adequate laboratories, and the absence of a surveillance system for the disease are major challenges in determining the magnitude of the problem.

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Mandatory Operative Re-Exploration after Initial Debridement of Necrotizing Soft Tissue Infections: Is it Mandatory?

The American Surgeon ◽

10.1177/000313481708301021 ◽

2017 ◽

Vol 83 (10) ◽

pp. 1117-1121

Author(s):

Lara H. Spence ◽

Huan Yan ◽

Ashkan Moazzez ◽

Alexander Schwed ◽

Jessica Keeley ◽

...

Keyword(s):

Septic Shock ◽

Soft Tissue ◽

Clinical Examination ◽

Source Control ◽

Soft Tissue Infections ◽

Duration Of Symptoms ◽

Safe Strategy ◽

Necrotizing Soft Tissue Infections ◽

Operative Debridement ◽

Prompt Diagnosis

Necrotizing soft tissue infections (NSTIs) are aggressive infections requiring prompt diagnosis and extensive surgical debridement. Traditionally, patients undergo mandatory re-exploration to ensure adequacy of source control. The purpose of this study is to determine if re-exploration in the operating room is mandatory for all patients with NSTIs. An eight-year retrospective analysis of adult patients with NSTIs was performed comparing two groups: mandatory operative re-exploration versus operative re-exploration based on clinical examination findings. Outcomes measured included mortality, number of debridements, and length of stay (LOS). Twenty-two per cent of patients underwent a mandatory re-exploration. These patients were older, had a higher incidence of diabetes, and a longer duration of symptoms. There were no significant differences between groups with regard to the physical examination, severity of sepsis, time to repeat debridements, or in-hospital mortality, whereas LOS and the total number of debridements were increased in mandatory re-exploration. Bacteremia and septic shock were predictive of the need for further debridement in patients in the operative re-exploration based on clinical examination findings group. Mandatory re-exploration after initial debridement may not be necessary in all patients with NSTIs. Instead, bedside wound checks may be a safe strategy to determine the need for further operative debridement.

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