Persistent Wound Infections Research Articles

The interplay of Pseudomonas aeruginosa and Staphylococcus aureus in dual-species biofilms impacts development, antibiotic resistance and virulence of biofilms in in vitro wound infection models.

Due to high tolerance to antibiotics and pronounced virulence, bacterial biofilms are considered a key factor and major clinical challenge in persistent wound infections. They are typically composed of multiple species, whose interactions determine the biofilm's structural development, functional properties and thus the progression of wound infections. However, most attempts to study bacterial biofilms in vitro solely rely on mono-species populations, since cultivating multi-species biofilms, especially for prolonged periods of time, poses significant challenges. To address this, the present study examined the influence of bacterial composition on structural biofilm development, morphology and spatial organization, as well as antibiotic tolerance and virulence on human skin cells in the context of persistent wound infections. By creating a wound-mimetic microenvironment, the successful cultivation of dual-species biofilms of two of the most prevalent wound pathogens, Pseudomonas aeruginosa and Staphylococcus aureus, was realized over a period of 72 h. Combining quantitative analysis with electron microscopy and label-free imaging enabled a comprehensive evaluation of the dynamics of biofilm formation and matrix secretion, revealing a twofold increased maturation of dual-species biofilms. Antibiotic tolerance was comparable for both mono-species cultures, however, dual-species communities showed a 50% increase in tolerance, mediated by a significantly reduced penetration of the applied antibiotic into the biofilm matrix. Further synergistic effects were observed, where dual-species biofilms exacerbated wound healing beyond the effects observed from either Pseudomonas or Staphylococcus. Consequently, predicting biofilm development, antimicrobial tolerance and virulence for multi-species biofilms based solely on the results from mono-species biofilms is unreliable. This study underscores the substantial impact of a multi-species composition on biofilm functional properties and emphasizes the need to tailor future studies reflecting the bacterial composition of the respective in vivo situation, leading to a more comprehensive understanding of microbial communities in the context of basic microbiology and the development of effective treatments.

Low-level photodynamic therapy in chronic wounds

BackgroundChronic wounds refer to those that can't reconstruct anatomical and physical functional integrity, and are usually associated with signs of microbial infection. Current therapies include debridement and dressing change, local or systemic application of antibiotics, and medical dressing care, which are not ideal for the healing of chronic wounds. ObjectiveTo explore the efficacy and safety of photodynamic therapy (ALA-PDT) for the treatment of chronic infectious wounds. Materials and methodsALA-PDT was used in ten patients with persistent wound infections and systemic complications who did not respond to conventional treatment. 5 % ALA solution was applied to the wound surface after debridement, incubated for 3 h with light protection, and then irradiated with red light for 20 min. This procedure was repeated every two weeks, and any adverse reactions were recorded. After the end of three treatments, the patients were followed up for 3 months. ResultsPatients who exhibit resistance to traditional therapies demonstrate a favorable therapeutic outcome with ALA-PDT, although complications may impede wound healing. All participants successfully underwent ALA-PDT treatment and subsequent monitoring, with 90 % achieving complete healing. Common adverse reactions to ALA-PDT encompass treatment-related pain, temporary erythema, and swelling, all of which are well-tolerated by patients without enduring severe consequences. ConclusionsALA-PDT proves to be an efficacious intervention for managing chronic wounds, irrespective of the presence of localized infections or systemic complications.

Unravelling host-pathogen interactions by biofilm infected human wound models

Approximately 80 % of persistent wound infections are affected by the presence of bacterial biofilms, resulting in a severe clinical challenge associated with prolonged healing periods, increased morbidity, and high healthcare costs. Unfortunately, in vitro models for wound infection research almost exclusively focus on early infection stages with planktonic bacteria. In this study, we present a new approach to emulate biofilm-infected human wounds by three-dimensional human in vitro systems. For this purpose, a matured biofilm consisting of the clinical key wound pathogen Pseudomonas aeruginosa was pre-cultivated on electrospun scaffolds allowing for non-destructive transfer of the matured biofilm to human in vitro wound models. We infected tissue-engineered human in vitro skin models as well as ex vivo human skin explants with the biofilm and analyzed structural tissue characteristics, biofilm growth behavior, and biofilm-tissue interactions. The structural development of biofilms in close proximity to the tissue, resulting in high bacterial burden and in vivo-like morphology, confirmed a manifest wound infection on all tested wound models, validating their applicability for general investigations of biofilm growth and structure. The extent of bacterial colonization of the wound bed, as well as the subsequent changes in molecular composition of skin tissue, were inherently linked to the characteristics of the underlying wound models including their viability and origin. Notably, the immune response observed in viable ex vivo and in vitro models was consistent with previous in vivo reports. While ex vivo models offered greater complexity and closer similarity to the in vivo conditions, in vitro models consistently demonstrated higher reproducibility. As a consequence, when focusing on direct biofilm-skin interactions, the viability of the wound models as well as their advantages and limitations should be aligned to the particular research question of future studies. Altogether, the novel model allows for a systematic investigation of host-pathogen interactions of bacterial biofilms and human wound tissue, also paving the way for development and predictive testing of novel therapeutics to combat biofilm-infected wounds.

Recent Trends in Electrospun Antibacterial Nanofibers for Chronic Wound Management

Abstract: Chronic wounds and lesions have a severe impact on the socioeconomic status and compliance of patients all over the world. Diabetes-related chronic, non-healing lesions may necessitate amputation of the damaged limb or organ. These skin lesions are susceptible to microorganisms that cause infections that impede the healing process. Despite the advances in medication development and sophisticated formulations, treating persistent wound infections remains difficult. Electrospun antimicrobial wound dressings offer considerable potential for lowering the risk of infection and accelerating the healing of chronic wounds. Electrospinning is a cost-effective, reproducible, simple, and multifaceted technique for encapsulating hydrophobic and hydrophilic therapeutic molecules within polymeric carriers with wide-ranging applications. In this review, we have discussed extensively the recent advances in electrospun nanofiber formulation techniques for use as wound dressings, as well as the entrapment of various antibacterial biomolecules, such as synthetic antibiotics, phytoconstituents, and metal nanoparticles, which have been embedded into the electrospun nano-fibers, highlighting bioactive antibacterial agents capable of enhancing wound healing. In addition, we focus on the challenges currently being faced in the area of biomedicine as well as the opportunities for electrospinning-based nanomaterials.

Multidrug-Resistant and Virulent Organisms Trauma Infections: Trauma Infectious Disease Outcomes Study Initiative.

During the wars in Iraq and Afghanistan, increased incidence of multidrug-resistant (MDR) organisms, as well as polymicrobial wounds and infections, complicated the management of combat trauma-related infections. Multidrug resistance and wound microbiology are a research focus of the Trauma Infectious Disease Outcomes Study (TIDOS), an Infectious Disease Clinical Research Program, Uniformed Services University, research protocol. To conduct comprehensive microbiological research with the goal of improving the understanding of the complicated etiology of wound infections, the TIDOS MDR and Virulent Organisms Trauma Infections Initiative (MDR/VO Initiative) was established as a collaborative effort with the Brooke Army Medical Center, Naval Medical Research Center, U.S. Army Institute of Surgical Research, and Walter Reed Army Institute of Research. We provide a review of the TIDOS MDR/VO Initiative and summarize published findings. Antagonism and biofilm formation of commonly isolated wound bacteria (e.g., ESKAPE pathogens-Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.), antimicrobial susceptibility patterns, and clinical outcomes are being examined. Isolates collected from admission surveillance swabs, as part of infection control policy, and clinical infection workups were retained in the TIDOS Microbiological Repository and associated clinical data in the TIDOS database. Over the TIDOS study period (June 2009 to December 2014), more than 8,300 colonizing and infecting isolates were collected from military personnel injured with nearly one-third of isolates classified as MDR. At admission to participating U.S. military hospitals, 12% of wounded warriors were colonized with MDR Gram-negative bacilli. Furthermore, 27% of 913 combat casualties with ≥1 infection during their trauma hospitalization had MDR Gram-negative bacterial infections. Among 335 confirmed combat-related extremity wound infections (2009-2012), 61% were polymicrobial and comprised various combinations of Gram-negative and Gram-positive bacteria, yeast, fungi, and anaerobes. Escherichia coli was the most common Gram-negative bacilli isolated from clinical workups, as well as the most common colonizing MDR secondary to extended-spectrum β-lactamase resistance. Assessment of 479 E. coli isolates collected from wounded warriors found 188 pulsed-field types (PFTs) from colonizing isolates and 54 PFTs from infecting isolates without significant overlap across combat theaters, military hospitals, and study years. A minority of patients with colonizing E. coli isolates developed subsequent infections with the same E. coli strain. Enterococcus spp. were most commonly isolated from polymicrobial wound infections (53% of 204 polymicrobial cultures). Patients with Enterococcus infections were severely injured with a high proportion of lower extremity amputations and genitourinary injuries. Approximately 65% of polymicrobial Enterococcus infections had other ESKAPE organisms isolated. As biofilms have been suggested as a cause of delayed wound healing, wound infections with persistent recovery of bacteria (isolates of same organism collected ≥14 days apart) and nonrecurrent bacterial isolates were assessed. Biofilm production was significantly associated with recurrent bacteria isolation (97% vs. 59% with nonrecurrent isolates; P < 0.001); however, further analysis is needed to confirm biofilm formation as a predictor of persistent wound infections. The TIDOS MDR/VO Initiative provides comprehensive and detailed data of major microbial threats associated with combat-related wound infections to further the understanding of wound etiology and potentially identify infectious disease countermeasures, which may lead to improvements in combat casualty care.

PH-Responsive "Smart" Hydrogel for Controlled Delivery of Silver Nanoparticles to Infected Wounds.

Persistent wound infections have been a therapeutic challenge for a long time. Current treatment approaches are mostly based on the delivery of antibiotics, but these are not effective for all infections. Here, we report the development of a sensitive pH-responsive hydrogel that can provide controlled, pH-triggered release of silver nanoparticles (AgNPs). This delivery system was designed to sense the environmental pH and trigger the release of AgNPs when the pH changes from acidic to alkaline, as occurs due to the presence of pathogenic bacteria in the wound. Our results show that the prepared hydrogel restricts the release of AgNPs at acidic pH (pH = 4) but substantially amplifies it at alkaline pH (pH = 7.4 and pH = 10). This indicates the potential use of the hydrogel for the on-demand release of Ag+ depending on the environmental pH. In vitro antibacterial studies demonstrated effective elimination of both Gram-negative and positive bacteria. Additionally, the effective antibacterial dose of Ag+ showed no toxicity towards mammalian skin cells. Collectively, this pH-responsive hydrogel presents potential as a promising new material for the treatment of infected wounds.

Effects of Rationally Designed Physico-Chemical Variants of the Peptide PuroA on Biocidal Activity towards Bacterial and Mammalian Cells.

Antimicrobial peptides (AMPs) often exhibit wide-spectrum activities and are considered ideal candidates for effectively controlling persistent and multidrug-resistant wound infections. PuroA, a synthetic peptide based on the tryptophan (Trp)-rich domain of the wheat protein puroindoline A, displays strong antimicrobial activities. In this work, a number of peptides were designed based on PuroA, varying in physico-chemical parameters of length, number of Trp residues, net charge, hydrophobicity or amphipathicity, D-versus L-isomers of amino acids, cyclization or dimerization, and were tested for antimicrobial potency and salt and protease tolerance. Selected peptides were assessed for effects on biofilms of methicillin-resistant Staphylococcus aureus (MRSA) and selected mammalian cells. Peptide P1, with the highest amphipathicity, six Trp and a net charge of +7, showed strong antimicrobial activity and salt stability. Peptides W7, W8 and WW (seven to eight residues) were generally more active than PuroA and all diastereomers were protease-resistant. PuroA and certain variants significantly inhibited initial biomass attachment and eradicated preformed biofilms of MRSA. Further, P1 and dimeric PuroA were cytotoxic to HeLa cells. The work has led to peptides with biocidal effects on common human pathogens and/or anticancer potential, also offering great insights into the relationship between physico-chemical parameters and bioactivities, accelerating progress towards rational design of AMPs for therapeutics.

Biodistribution and intracellular localization of hyaluronan and its nanogels. A strategy to target intracellular S. aureus in persistent skin infections

Intracellular pathogens are a critical challenge for antimicrobial therapies. Staphylococcus aureus (S. aureus) causes approximately 85% of all skin and soft tissue infections in humans worldwide and more than 30% of patients develop chronic or recurrent infections within three months, even after appropriate antibacterial therapies. S. aureus is also one of the most common bacteria found in chronic wounds. Recent evidences suggest that S. aureus is able to persist within phagolysosomes of skin cells (i.e. keratinocytes, phagocytic cells), being protected from both the immune system and a number of antimicrobials. To overcome these limits, nano-formulations that enable targeted therapies against intracellular S. aureus might be developed. Herein, the biodistribution and intracellular localisation of hyaluronan (HA) and HA-based nanoparticles (nanogels, NHs) are investigated, both after intravenous (i.v.) injections (in mice) and topical administrations (in ex vivo human skin). Results indicate HA and NHs accumulate especially in skin and liver of mice after i.v. injection. After topical application on human skin explants, no penetration of both HA and NHs was detected in skin with intact stratum corneum. By contrast, in barrier-disrupted human skin (with partial removal and loosening of stratum corneum), HA and NHs penetrate to the viable epidermis and are taken up by keratinocytes. In mechanically produced wounds (skin without epidermis) they accumulate in wound tissue and are taken up by dermis cells, e.g. fibroblasts and phagocytic cells. Interestingly, in all cases, the cellular uptake is CD44-mediated. In vitro studies confirmed that after CD44-mediated uptake, both HA and NHs accumulate in lysosomes of dermal fibroblasts and macrophages, as previously reported for keratinocytes. Finally, the colocalisation between intracellular S. aureus and HA or NHs is demonstrated, in macrophages. Altogether, for the first time, these results strongly suggest that HA and HA-based NHs can provide a targeted therapy to intracellular S. aureus, in persistent skin or wound infections.

Staphylococcus epidermidis facilitates intracellular pathogen clearance through upregulation of antimicrobial protein perforin-2 (P-2) in the human skin gamma delta T cells

Abstract Staphylococcus epidermidis (SE), nonvirulent Gram-positive (G+) bacterium, is a member of the normal human skin microbiota with beneficial relationship with the host. Gamma delta (GD) T cells as the major T cell population in epithelial tissues have been implicated in maintaining tissue integrity, regulating inflammation and defending against pathogens. Perforin-2 (P-2) is a recently described antimicrobial protein responsible for clearance of intracellular G+ and G− bacteria. We examine the relationship between SE and P-2 expression in the human skin. Healthy human skin tissue was used for flow cytometric and bacterial infection analyses. We analyzed P-2 expression at a single cell resolution using an amplified fluorescence in situ hybridization (FISH) technique for detection of P-2 mRNA in combination with immune-phenotyping. Methicillin resistant Staphylococcus aureus (MRSA) intracellular killing assay was performed on the skin cells that were pretreated with S. epidermidis for 24 h. We found increase in the frequency of skin GDT cells and induction of P-2 transcripts in GDT cells after S. epidermidis infection. Incubating skin cells with S. epidermidis for 24h prior infection with MRSA resulted in rapid intracellular clearance of MRSA. Our findings reveal a novel P-2 mediated mechanism by which skin commensal bacteria may exert their beneficial role in modulating host innate immune response. In contrast, establishment of S. aureus biofilm resulted in suppression of P-2 expression, revealing a mechanism by which S. aureus escapes cutaneous immunity to cause persistent biofilm wound infections.

Single cell analyses reveal specific distribution of anti-bacterial molecule Perforin-2 in human skin and its modulation by wounding and Staphylococcus aureus infection.

Perforin-2 (P-2) is a recently described antimicrobial protein with unique properties to kill intracellular bacteria. We investigated P-2 expression pattern and cellular distribution in human skin and its importance in restoration of barrier function during wound healing process and infection with the common wound pathogen Staphylococcus aureus. We describe a novel approach for the measurement of P-2 mRNA within individual skin cells using an amplified fluorescence in situ hybridization (FISH) technique. The unique aspect of this approach is simultaneous detection of P-2 mRNA in combination with immune-phenotyping for cell surface proteins using fluorochrome-conjugated antibodies. We detected P-2 transcript in both hematopoietic (CD45+ ) and non-hematopoietic (CD45- ) cutaneous cell populations, confirming the P-2 expression in both professional and non-professional phagocytes. Furthermore, we found an induction of P-2 during wound healing. P-2 overexpression resulted in a reduction of intracellular S.aureus, while infection of human wounds by this pathogen resulted in P-2 suppression, revealing a novel mechanism by which S.aureus may escape cutaneous immunity to cause persistent wound infections.

Skin and Soft Tissue Models for Acinetobacter baumannii Infection.

Multidrug-resistant A. baumannii are important Gram-negative pathogens causing persistent wound infections in both wounded and burned victims, which often result in secondary complications such as delayed wound healing, skin graft failure, and sometimes more serious outcomes such as sepsis and amputation. The choice of antibiotics to remediate these A. baumannii infections is becoming limited; and therefore, there has been a renewed interest in the research and development of new antibacterials targeting this pathogen. However, the evaluation of safety and efficacy is made more difficult by the lack of well-established in vivo models. This chapter describes established rodent and large animal models that have been used to investigate and develop treatments for A. baumannii skin and soft tissue infections.

Biofilm detection by wound blotting can predict slough development in pressure ulcers: A prospective observational study.

Bacteria have been found to form multicellular aggregates which have collectively been termed "biofilms." It is hypothesized that biofilm formation is a means to protect bacterial cells including protection form the immune response of humans. This protective mechanism is believed to explain persistent chronic wound infections. At times, the biofilms are abundant enough to see, and remove by simple wiping. However, recent evidence has shown that the removal of these visible portions are not sufficient, and that biofilms can continue to form even with daily wiping. In this work, we tested an approach to detect the biofilms which are present after clinically wiping or sharp wound debridement. Our method is based on a variation of impression cytology in which a nitrocellulose membrane was used to collect surface biofilm components, which were then differentially stained. In this prospective study, members of an interdisciplinary pressure ulcer team at a university hospital tested our method's ability to predict the generation of wound slough in the week that followed each blotting. A total of 70 blots collected from 23 pressure ulcers produced 27 wounds negative for staining and 43 positive. In the negative blots 55.6% were found to have decreased wound slough, while 81.4% with positive staining had either increase or unchanged wound slough generation. These results lead to an odds ratio of positive blotting cases of 9.37 (95% confidence intervals: 2.47-35.5, p = 0.001) for slough formation; suggesting that the changes in wound slough formation can be predicted clinically using a non-invasive wound blotting method.

Activity of Norspermidine on Bacterial Biofilms of Multidrug-Resistant Clinical Isolates Associated with Persistent Extremity Wound Infections.

Biofilm formation is a major virulence factor for numerous pathogenic bacteria and is cited as a central event in the pathogenesis of chronic human infections, which is in large part due to excessive extracellular matrix secretion and metabolic changes that occur within the biofilm rendering them highly tolerant to antimicrobial treatments. Polyamines, including norspermidine, play central roles in bacterial biofilm development, but have also recently been shown to inhibit biofilm formation in select strains of various pathogenic bacteria. The aim of this study was to evaluate in vitro the biofilm dispersive and inhibitory activities of norspermidine against multidrug-resistant clinical isolates of Acinetobacter baumannii(n = 4), Klebsiella pneumoniae (n = 3), Pseudomonas aeruginosa (n = 5) and Staphylococcus aureus (n = 4) associated with chronic extremity wound infections using the semi-quantitative 96-well plate method and confocal laser microscopy. In addition to the antibiofilm activity, biocompatibility of norspermidine was also evaluated by measuring toxicity in vitro to human cell lines and whole porcine tissue explants using MTT viability assay and histological analysis. Norspermidine (5-20 mM) had variable dispersive and inhibitory activity on biofilms which was dependent on both the strain and species. Of the clinical bacterial species evaluated herein, A. baumannii isolates were the most sensitive to the effect of norspermidine, which was in part due to the inhibitory effects of norspermidine on bacterial motility and expression of genes involved in the production of homoserine lactones and quorum sensing molecules both essential for biofilm formation. Importantly, exposure of cell lines and whole tissues to norspermidine for prolonged periods of time (≥24 h) was observed to reduce viability and alter tissue histology in a time and concentration dependent manner, with 20 mM exposure having the greatest negative effects on both tissues and individual cell lines. Collectively our findings demonstrate that, similar to other polyamines, norspermidine displays both inhibitory and dispersive activities on biofilms of clinical multidrug-resistant bacterial isolates, in particular for strains of A. baumannii. Additionally our findings suggest that direct application may be considered on tissues, albeit for limited exposure times.

Biofilms and persistent wound infections in United States military trauma patients: a case–control analysis

BackgroundComplex traumatic injuries sustained by military personnel, particularly when involving extremities, often result in infectious complications and substantial morbidity. One factor that may further impair patient recovery is the persistence of infections. Surface-attached microbial communities, known as biofilms, may play a role in hindering the management of infections; however, clinical data associating biofilm formation with persistent or chronic infections are lacking. Therefore, we evaluated the production of bacterial biofilms as a potential risk factor for persistent infections among wounded military personnel.MethodsBacterial isolates and clinical data from military personnel with deployment-related injuries were collected through the Trauma Infectious Disease Outcomes Study. The study population consisted of patients with diagnosed skin and soft-tissue infections. Cases (wounds with bacterial isolates of the same organism collected 14 days apart) were compared to controls (wounds with non-recurrent bacterial isolates), which were matched by organism and infectious disease syndrome. Potential risk factors for persistent infections, including biofilm formation, were examined in a univariate analysis. Data are expressed as odds ratios (OR; 95% confidence interval [CI]).ResultsOn a per infected wound basis, 35 cases (representing 25 patients) and 69 controls (representing 60 patients) were identified. Eight patients with multiple wounds were utilized as both cases and controls. Overall, 235 bacterial isolates were tested for biofilm formation in the case–control analysis. Biofilm formation was significantly associated with infection persistence (OR: 29.49; CI: 6.24-infinity) in a univariate analysis. Multidrug resistance (OR: 5.62; CI: 1.02-56.92), packed red blood cell transfusion requirements within the first 24 hours (OR: 1.02; CI: 1.01-1.04), operating room visits prior to and on the date of infection diagnosis (OR: 2.05; CI: 1.09-4.28), anatomical location of infected wound (OR: 5.47; CI: 1.65-23.39), and occurrence of polymicrobial infections (OR: 69.71; CI: 15.39-infinity) were also significant risk factors for persistent infections.ConclusionsWe found that biofilm production by clinical strains is significantly associated with the persistence of wound infections. However, the statistical power of the analysis was limited due to the small sample size, precluding a multivariate analysis. Further data are needed to confirm biofilm formation as a risk factor for persistent wound infections.

Microbial profile of canine persistent wound infections

Microbial profile of canine persistent wound infections

Manuka honey inhibits siderophore production in Pseudomonas aeruginosa

The aim of this study was to determine whether manuka honey affected siderophore production by three strains of Pseudomonas aeruginosa. The minimum inhibitory concentration (MIC) of manuka honey against each of the test bacteria was determined. The effect of manuka honey on siderophore production by three strains of Ps.aeruginosa was investigated using the Chrome azurol S assay (CAS) and CAS-agar plates. Manuka honey at ½ and ¼ of the MIC for each strain led to reduced production of siderophores (1·3-2·2-fold less) which was found to be statistically significant when compared to the untreated control. Manuka honey effectively inhibited siderophore production by all three strains of Ps.aeruginosa used in this study. This suggests that manuka honey may impact on bacterial iron homoeostasis and identified a new target for manuka honey in Ps.aeruginosa. Pseudomonas aeruginosa is an opportunistic human pathogen that can cause acute, life-threatening or persistent wound infections. Part of the virulence repertoire of this micro-organism includes the ability to sequester iron from the host during infection by the synthesis and secretion of siderophores. Manuka honey may limit wound infection by Ps.aeruginosa by limiting its ability to capture iron. This is the first time this mechanism has been investigated.

Synergistic interaction of Helichrysum pedunculatum leaf extracts with antibiotics against wound infection associated bacteria.

The effect of combinations of the crude methanolic extract of the leaves of Helichrysum pedunculatum and eight first-line antibiotics were investigated by time kill assays against a panel of bacterial strains that have been implicated in wound infections. The plant extract showed appreciable antibacterial activities against the test bacteria with zones of inhibition ranging between 18 and 27 mm, and minimum inhibitory concentrations (MICs) varying between 0.1 and 5.0 mg/ml. The MICs of the test antibiotics range between 0.001 and 0.412 mg/ml, and combination of the plant extract and the antibiotics resulted in reduction of bacterial counts by between 0 and 6.63 Log10 cfu/ml. At V2 MIC, 56.81% synergy; 43.19% indifference and no antagonism were observed, and at MIC levels, 55.68% synergy; 44.32% indifference and no antagonism were observed when the extracts were combined with eight different antibiotics. In all, 60% of the interactions were synergistic. All combination regimes on Staphylococcus aureus ATCC 6538 yielded no synergy, neither was antagonism detected in any of the assays. We propose that extracts of the leaves of Helichrysum pedunculatum could be of relevance in combination therapy and as a source of resistance modifying principies that could be useful as treatment options for persistent wound infections.

Synergistic interaction of Helichrysum pedunculatum leaf extracts with antibiotics against wound infection associated bacteria

The effect of combinations of the crude methanolic extract of the leaves of Helichrysum pedunculatum and eight first-line antibiotics were investigated by time kill assays against a panel of bacterial strains that have been implicated in wound infections. The plant extract showed appreciable antibacterial activities against the test bacteria with zones of inhibition ranging between 18 and 27 mm, and minimum inhibitory concentrations (MICs) varying between 0.1 and 5.0 mg/ml. The MICs of the test antibiotics range between 0.001 and 0.412 mg/ml, and combination of the plant extract and the antibiotics resulted in reduction of bacterial counts by between 0 and 6.63 Log10 cfu/ml. At V2 MIC, 56.81% synergy; 43.19% indifference and no antagonism were observed, and at MIC levels, 55.68% synergy; 44.32% indifference and no antagonism were observed when the extracts were combined with eight different antibiotics. In all, 60% of the interactions were synergistic. All combination regimes on Staphylococcus aureus ATCC 6538 yielded no synergy, neither was antagonism detected in any of the assays. We propose that extracts of the leaves of Helichrysum pedunculatum could be of relevance in combination therapy and as a source of resistance modifying principies that could be useful as treatment options for persistent wound infections.

Necrotizing mastitis caused by calciphylaxis

A 53-year-old Moroccan woman presented at our outpatient clinic with tenderness and redness of the right breast. For 3 years she had been peritoneal dialysis-dependent, due to a left nephrectomy because of nephrolithiasis and diabetic nephropathy. The peritoneal dialysis treatment had been unremarkable. The patient’s medical history revealed a 9-year history of type 2 diabetes mellitus with multiple comorbidities including angina pectoris and epilepsy due to an ischaemic cerebrovascular accident. She had been treated with insulin for the previous 4 years. Because the redness of the right breast progressed to ulceration, the dermatologist did a skin biopsy of the breast, which revealed an unspecified ulcer. A mammogram demonstrated the presence of vascular calcifications in both breasts. Mastitis carcinomatosis, tuberculous mastitis and vasculitis were excluded. Coumarin-induced skin necrosis was unlikely, because she did not use coumarin derivates. In the following month, an ulcer also developed in the left breast. She was admitted to the hospital because of intolerable breast pains. Physical examination revealed an obese female (body mass index of 35 kgm). The left and right breasts had necrotic ulcerations (Figure 1). Furthermore, her left middle fingertip was painful and the fingertip was necrotizing, probably resulting from punctures for blood glucose checking. Laboratory investigations showed an increased white blood cell count (13 10/l) and elevated serum levels of C-reactive protein (171mg/dl). Markedly elevated levels of calcium (2.7mmol/l), phosphorus (2.0mmol/l) and PTH (145 pmol/l) were found. We concluded that the most likely diagnosis was necrotic breast lesions due to calciphylaxis. In order to improve the management of the calcium phosphorus homoeostasis and to reduce the secondary hyperparathyroidism, a three and a half gland parathyroidectomy was performed. As the breast lesions became secondarily infected a simple bilateral mastectomy was performed. Microscopic examination showed necrotizing inflammation in both breasts. In one slide, calcium deposits were observed around small blood vessels (Figure 2). Despite these procedures, the patient’s clinical condition deteriorated because of persistent wound infections. In addition she developed a stroke which was complicated by epileptic seizures and an aspiration pneumonia. Although we managed to keep the serum phosphorus and calcium levels in the normal range, she developed more necrotizing ulcerations on her hips and legs. Intravenous sodium thiosulfate administration has been used successfully in the treatment of calciphylaxis [1]. Therefore, we decided to treat our patient with sodium thiosulfate three times per week intravenously. Unfortunately, this treatment did not result in a reduction of the skin ulcerations. Subsequently, our patient died of sepsis due to wound infections. Fig. 1. Necrotic ulceration of the left breast.

An outbreak of post-acupuncture cutaneous infection due to Mycobacterium abscessus

BackgroundDespite the increasing popularity of acupuncture, the importance of infection control is not adequately emphasized in Oriental medicine. In December 2001, an Oriental medical doctor in Seoul, South Korea, encountered several patients with persistent, culture-negative skin lesions on the trunk and extremities at the sites of prior acupuncture treatment. We identified and investigated an outbreak of Mycobacterium abscessus cutaneous infection among the patients who attended this Oriental medicine clinic.MethodsPatients were defined as clinic patients with persistent cutaneous infections at the acupuncture sites. Medical records for the previous 7 months were reviewed. Clinical specimens were obtained from the patients and an environmental investigation was performed. M. abscessus isolates, cultured from patients, were compared by pulsed-field gel electrophoresis (PFGE).ResultsForty patients who attended the Oriental medicine clinic and experienced persistent cutaneous wound infections were identified. Cultures from five of these patients proved positive, and all other diagnoses were based on clinical and histopathologic examinations. All environmental objects tested were negative for M. abscessus, however, most were contaminated by various nosocomial pathogens. Molecular analysis using PFGE found all wound isolates to be identical.ConclusionWe have identified a large outbreak of rapidly growing mycobacterial infection among patients who received acupuncture at a single Oriental medicine clinic. Physicians should suspect mycobacterial infections in patients with persistent cutaneous infections following acupuncture, and infection control education including hygienic practice, should be emphasized for Oriental medical doctors practicing acupuncture.