A patient’s incision would not heal, despite antibiotic therapy and debridement; finally the cause was identified after much testing and consultation with 2 teams. The odyssey began when an obese 73-year-old woman was admitted to the surgical service for ventral hernia repair and panniculectomy. Surgery was uneventful, but her postoperative course was complicated by wound breakdown and painful necrotic-appearing skin at the surgical site. Cultures from the wound were sent, and she was placed on broad-spectrum antibiotics.Despite 2 weeks of antibiotic therapy, the patient had no clinical response and was taken back to the operating room for debridement of the wound. (By this time, the first set of cultures proved negative.) Non-vital tissue was removed, and intraoperative cultures were sent. She returned to the floor with an open horizontal wound, which extended down to the level of the fascia and across her entire abdomen. The defect was loosely packed with gauze with the ultimate goal of healing via secondary intention or with a future surgical procedure.
Within days of debridement, the tissue at the wound edges began to look necrotic again, with devitalized areas giving way to shallow ulceration continuous with the wound bed. The patient had intermittent low-grade fevers, and blood cultures were drawn. She continued on intravenous ampicillin/sulbactam, 1.5 g every 6 hours, with a recommendation from the infectious diseases consultant to complete a 14-day course. At that time, the dermatology consult service was contacted.
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— — Robert Micheletti, MD, Nicole Fett, MD
This article originally appeared in October 2011 issue of The American Journal of Medicine.
