This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrowReprints and Permissions
Right arrow Copyright Information
Right arrow Books from ASM Press
Right arrow MicrobeWorld
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dhawan, B.
Right arrow Articles by Kapil, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dhawan, B.
Right arrow Articles by Kapil, A.

 Previous Article  |  Next Article 

Journal of Clinical Microbiology, May 2003, p. 2233-2234, Vol. 41, No. 5
0095-1137/03/$08.00+0     DOI: 10.1128/JCM.41.5.2233-2234.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.

CASE REPORT

Infection with an Extended-Spectrum ß-Lactamase-Producing Strain of Serratia marcescens following Tongue Reconstruction

Benu Dhawan,1 Richard Bonnet,2 N. K. Shukla,3 Purva Mathur,1 Bimal K. Das,1 and Arti Kapil1*

Department of Microbiology,1 Department of Surgical Oncology, Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi-29, India,3 Faculté de Médecine, Service de Bactériologie-Virologie, 63001 Clermont-Ferrand Cedex, France2

Received 5 August 2002/ Returned for modification 3 November 2002/ Accepted 2 January 2003


arrow
ABSTRACT
 
We report a case of postsurgical wound infection of polymicrobial etiology caused by Serratia marcescens and Pseudomonas aeruginosa following the use of a radial forearm free flap for oncological tongue reconstruction. S. marcescens was a producer of SHV-12 extended-spectrum ß-lactamase (ESBL). This is the first report from India of this ESBL. S. marcescens and P. aeruginosa were resistant to the empirical perioperative antibiotics administered. Delay in the recognition of the type of infection and in the institution of appropriate therapy resulted in total loss of the free flap.


arrow
CASE REPORT
 
A 39-year-old man was admitted to the surgical oncology ward of the All India Institute of Medical Sciences (New Delhi, India) with a history of a nonhealing ulcer of 1-year duration on the left side of the tongue. An initial examination revealed a 0.5- by 1-cm indurate area on the left ventrolateral surface of the tongue. A biopsy was performed which showed a well-differentiated squamous cell carcinoma of the left lateral border of the tongue. The tumor was classified as stages T1, N1, and M0.

The patient underwent operative treatment consisting of left hemiglossectomy and unilateral supraomohyoid neck dissection. This was followed by reconstruction of the tongue with a radial forearm free flap. An initial regimen of metronidazole, amoxicillin, and clavulanic acid was started postoperatively.

Ten days later, there were signs of collection of pus at the postoperative wound site. The pus was drained and sent for bacterial culture. Consecutive cultures obtained from the wound yielded growth of Serratia marcescens and Pseudomonas aeruginosa. S. marcescens is an opportunistic gram-negative bacterium that is associated with sporadic urinary tract infections and pneumonia in patients in intensive care units, although outbreaks can occur (1).

Antibiotic susceptibility profiles were done by using a standard disk diffusion method recommended by the NCCLS (7). P. aeruginosa was susceptible to ciprofloxacin, ceftazidime, cefpirome, piperacillin-tazobactam, and cefoperazone-sulbactam. It was resistant to amoxicillin-clavulanic acid, piperacillin, cefotaxime, and amikacin. S. marcescens exhibited resistance to piperacillin, cefotaxime, ceftazidime, ceftriaxone, cefoperazone, cefpirome, amikacin, netilmicin, ciprofloxacin, and amoxicillin-clavulanic acid. It was sensitive to piperacillin-tazobactam and cefoperazone-sulbactam. The strain tested positive, by the method described by the NCCLS (7), for the production of extended-spectrum ß-lactamase (ESBL).

Isoelectric focusing and gene sequencing characterized the ESBL. Isoelectric focusing was performed with polyacrylamide gels containing Ampholine with a pH range of 3.5 to 10 as previously described (2). ß-lactamases of known isoelectric points (pIs), TEM-1 (pI 5.4), TEM-2 (pI 5.6), TEM-24 (pI 6.5), SHV-5 (pI 8.2), and CTX-M-1 (pI 8.4), were used as standards. Isoelectric focusing showed that the ESBL focused at a pI of 8.4, suggesting that the ESBL of the S. marcescens strain was an SHV-type ß-lactamase. Positive amplification was obtained with primers SHVA (5'-3') and SHVB (5'-3'), which amplify the complete sequence of the SHV-type genes. Direct DNA sequencing of PCR products (2) showed that the SHV-type gene encoded the ESBL SHV-12, which was first described in 1997 in an Escherichia coli strain isolated in Switzerland (8).

The antibiotic treatment was changed to a parenteral combination of cefoperazone and sulbactam in an attempt to control the infection of the free flap. Samples from the patient's environment, including swabs from the dressing trolley, bed railing, mattress, in-use antiseptic solutions, intravenous fluids, and intravenous infusion sets used in the patient, were collected. The hospital water supply was also tested. Swabs from the hands of personnel attending the patient were collected to determine the source of infection. All the samples were found by culture to be negative.

Despite the change to the appropriate antimicrobial therapy, the radial forearm free flap could not be salvaged and total loss of the flap occurred as a result of infection.

Patients with cancer of the upper aerodigestive tract who undergo surgical resection of the neoplasm and reconstruction of the defect with a tissue flap have a high incidence of wound infection. Despite perioperative treatment with systemic antibiotics, reported wound infection rates in this group range from 20 to 25%, compared with wound infection rates of 5 to 10% in patients undergoing contaminated head and neck surgery without flap reconstruction (3, 11).

Our patient developed postoperative flap infection, which was polymicrobial in etiology. Both the organisms isolated were gram-negative aerobes. Among patients hospitalized for prolonged periods, those who are debilitated, or those who have head and neck cancers, the microflora may be altered by the emergence of gram-negative aerobic organisms (4).

Prophylactic perioperative antibiotics have been proven to be mandatory with contaminated head and neck surgery. Although the amoxicillin-clavulanic acid combination used for our patient provides coverage for both gram-positive and gram-negative organisms in addition to anaerobic organisms, it was ineffective against both S. marcescens and P. aeruginosa, which were cultured from the wound and were multidrug resistant. The delay in the submission of cultures for the detection of these resistant organisms resulted in the delay in the initiation of appropriate therapy, contributing to the flap failure.

The S. marcescens strain isolated from our patient was an ESBL producer. ESBL producers have most commonly been documented among Klebsiella pneumoniae and E. coli strains and less commonly among other members of the family Enterobacteriaceae, such as Serratia species (9). Putative ESBL-producing bacteria have been detected in India (6), but only ESBLs CTX-M-15 and SHV-5 have been characterized (5, 10). This is therefore the first report of an SHV-12-producing S. marcescens strain isolated in India.

In conclusion, perioperative vigilance and the timely submission of properly obtained cultures should make it possible to recognize infection with resistant bacteria and treat with appropriate antibiotics, thereby reducing the incidence of postoperative wound infections.


arrow
FOOTNOTES
 
* Corresponding author. Mailing address: Dept. of Microbiology, All India Institute of Medical Sciences, New Delhi-29, India. Phone: 686 4851, ext. 4237. Fax: 91-11-6862663. E-mail: artikapil{at}yahoo.com. Back


arrow
REFERENCES
 
    1
  1. Acar, J. F. 1986. Serratia marcescens infections. Infect. Control 7:273-278.[Medline]
    2. 2
  2. Bonnet, R., C. Dutour, J. L. M. Sampaio, C. Chanal, D. Sirot, R. Labia, C. De Champs, and J. Sirot. 2001. Novel cefotaximase (CTX-M-16) with increased catalytic efficiency due to substitution Asp-240->Gly. Antimicrob. Agents Chemother. 45:2269-2275.[Abstract/Free Full Text]
    3. 3
  3. Johnson, J. T., R. L. Wagner, D. E. Schuller, J. Gluckman, J. Y. Suen, and N. L. Snyderman. 1992. Prophylactic antibiotics for head and neck surgery with flap reconstruction. Arch. Otolaryngol. Head Neck Surg. 118:488-490.
    4. 4
  4. Johnson, J. T., V. L. Yu, E. N. Myers, and R. L. Wagner. 1987. An assessment of the need for gram-negative bacterial coverage in antibiotic prophylaxis for oncologic head and neck surgery. J. Infect. Dis. 155:331-333.[Medline]
    5. 5
  5. Karim, A., L. Poirel, S. Nagarajan, and P. Nordmann. 2001. Plasmid-mediated extended-spectrum beta-lactamase (CTX-M-3 like) from India and gene association with insertion sequence ISEcp1. FEMS Microbiol. Lett. 201:237-241.[Medline]
    6. 6
  6. Mathur, P., A. Kapil, B. Das, and B. Dhawan. 2002. Prevalence of extended spectrum beta lactamase producing gram negative bacteria in a tertiary care hospital. Indian J. Med. Res. 115:153-157.[Medline]
    7. 7
  7. National Committee for Clinical Laboratory Standards. 2000. Performance standards for antimicrobial disk susceptibility test, 7th ed. NCCLS document M2-A7. National Committee for Clinical Laboratory Standards, Villanova, Pa.
    8. 8
  8. Nuesch-Inderbinen, M. T., F. H. Kayser, and H. Hachler. 1997. Survey and molecular genetics of SHV beta-lactamases in Enterobacteriaceae in Switzerland: two novel enzymes, SHV-11 and SHV-12. Antimicrob. Agents Chemother. 41:943-949.[Abstract]
    9. 9
  9. Pitout, J. D., C. C. Sanders, and W. E. Sanders. 1997. Antimicrobial resistance with focus on beta-lactam resistance in gram-negative bacilli. Am. J. Med. 103:51-59.[CrossRef][Medline]
    10. 10
  10. Revathi, G., K. P. Shannon, P. D. Stapleton, B. K. Jain, and G. L. French. 1998. An outbreak of extended-spectrum, beta-lactamase-producing Salmonella senftenberg in a burns ward. J. Hosp. Infect. 40:295-302.[CrossRef][Medline]
    11. 11
  11. Urken, M. L., H. Weinberg, D. Buchbinder, J. F. Moscoso, W. Lawson, P. J. Catalano, and H. F. Biller. 1994. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications. Arch. Otolaryngol. Head Neck Surg. 120:633-640.

Journal of Clinical Microbiology, May 2003, p. 2233-2234, Vol. 41, No. 5
0095-1137/03/$08.00+0     DOI: 10.1128/JCM.41.5.2233-2234.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.



This article has been cited by other articles:

  • Delmas, J., Robin, F., Carvalho, F., Mongaret, C., Bonnet, R. (2006). Prediction of the Evolution of Ceftazidime Resistance in Extended-Spectrum {beta}-Lactamase CTX-M-9. Antimicrob. Agents Chemother. 50: 731-738 [Abstract] [Full Text]  

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrowReprints and Permissions
Right arrow Copyright Information
Right arrow Books from ASM Press
Right arrow MicrobeWorld
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dhawan, B.
Right arrow Articles by Kapil, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dhawan, B.
Right arrow Articles by Kapil, A.

Copyright © 2009 by the American Society for Microbiology.   For an alternate route to Journals.ASM.org, visit: http://intl-journals.asm.org | More Info»