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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 5  |  Issue : 5  |  Page : 554-555
Community-acquired Acinetobacter skull base osteomyelitis in an immunocompetent adult


1 Department of Neurosurgery, MM Institute of Medical Sciences and Research, Mullana, Ambala, India
2 Department of Microbiology, MM Institute of Medical Sciences and Research, Mullana, Ambala, India
3 Department of Surgery, MM Institute of Medical Sciences and Research, Mullana, Ambala, India
4 Department of Radiology, MM Institute of Medical Sciences and Research, Mullana, Ambala, India
5 Department of Emergency, MM Institute of Medical Sciences and Research, Mullana, Ambala, India

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Date of Web Publication27-Dec-2012
 

How to cite this article:
Agrawal A, Singh VA, Goyal S, Mittal A, Sampley S, Goel VK. Community-acquired Acinetobacter skull base osteomyelitis in an immunocompetent adult. Ann Trop Med Public Health 2012;5:554-5

How to cite this URL:
Agrawal A, Singh VA, Goyal S, Mittal A, Sampley S, Goel VK. Community-acquired Acinetobacter skull base osteomyelitis in an immunocompetent adult. Ann Trop Med Public Health [serial online] 2012 [cited 2018 Nov 17];5:554-5. Available from: http://www.atmph.org/text.asp?2012/5/5/554/105165
Dear Sir,

Acinetobacter baumannii-calcoaceticus complex (ABC), an aerobic gram-negative coccobacillary rod, is also a well known cause of healthcare associated outbreaks, particularly in intensive care units and among immunocompromised patients [1],[2] and has been recognized as an important cause of traumatic wound infections in U.S. Marines with extremity wounds during the Vietnam War. [3] and also in U.S. Army soldiers injured in Iraq. [4] Acinetobacter species are rarely responsible for community-acquired infections in nonconflict environments. [5] A 20-year-male patient presented with pus discharging sinus over the forehead of 1 month duration. He sustained head injury because of machine shaft (iron rod) 2 months back. Following that he was apparently alright, there was no history of fever, headache, or meningitis. There were no focal neurological deficits. Local examination revealed pus-discharging sinus over the right side of the forehead with granulation tissue [Figure 1]. Routine blood investigations were normal. Pus culture from the wound (by a modified Stoke's disk diffusion method) showed growth of  Acinetobacter baumannii Scientific Name Search es sensitive to Amikacin, Gentamicin, Piperacillin-Tazobactem, Azithromycin, Meropenem, and resistant to Ampicillin, Ciprfloxacin, Co-trimoxazole, and ceftriaxone. CT scan tissue and bone window showed the frontal bone fracture more to the right side, extensive bone defect involving the anterior cranial fossa with features of osteomyelitis [Figure 1]. The patient underwent bifrontal craniotomy and extensive exposure of the anterior cranial base. There was presence of pus, unhealthy granulation tissue, and loose bone fragments. There was also a defect in the basal dura with herniation in the brain tissue into the bone defect. All unhealthy granulation tissue, loose bone fragments, and unhealthy looking bone were removed. Anterior cranial fossa was separated by extradural pericranial graft. In addition the patient received injection Amikacin and oral azithromycin. Injection Amikacin was stopped on fifth day postsurgery; however oral azithromycin (500 mg/once a day) was continued for 6 weeks. The patient is doing well at follow-up.
Figure 1: CT scan of brain plain tissue and bone window showing extensive bone destruction of the anterior cranial fossa on the right side (E, inset clinical image showing pus discharging sinus)

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Many studies have reported osteomyelitis caused by Acinetobacter species [5],[6],[7],[8],[9],[10] and osteomyelitis from multidrug-resistant (MDR) Acinetobacter has been reported in >30% of combat-related injuries in Iraq and Afghanistan. [8] It has to be recognized that many of the MDR-ABC infections are wound infections with underlying bone fracture [5],[11],[12] that can be associated with poor bone healing and delayed union [12] and osteomyelitis (adding the burden of prolonged courses of antimicrobials). [10] Clini­cal management of A. baumannii bone infections in humans has not been well established [9] and further complicated by an increase in antimicrobial resistance, especially multidrug resistance, with some strains now resistant to all or almost all commonly used antimicrobial agents. [4],[13],[14],[15] To overcome the problem of drug resistance, extended dual antimicrobial drug therapy based on susceptibility patterns of the recovered organisms has been shown to decrease the risk for development of more highly resistant organisms, which has been reported when single agents are used alone. [16] In the present case we used oral azithromycin as in in vitro studies with azithromycin has been shown it to be rapidly bactericidal [17] and in another study it is concluded that azithromycin has moderate bactericidal activity against the strains of A. baumannii; [18] it was also more effective for long-term treatment to the patient. We did not continue amikacin as the activities of the combination of azithromycin and with amikacin are indifferent. [18] Further it has been demonstrated that highly resistant Acinetobacter infection, including osteomyelitis, can be successfully treated with appropriate surgical debridement, directed antimicrobial drug therapy, and careful follow-up [5] and as in the present case a successful outcome can be expected in young patients with gener­al good health. [5]

In summary, in the present case the Acinetobacter baumannii skull base osteomyelitis responded well to surgical debridement supplemented with a short course of injectable Amikacin and a single oral dose of Azithromycin (500 mg as it produces tissue levels above MIC) for extended duration. There are few words of cautions, i.e., due to lack of facilities we performed sensitivity by a modified Stoke's disk diffusion method and the MIC value was not calculated; we used clinical response as the guiding point as further calculation of blood levels or tissue levels were no possible. Before Azithromycin can be considered as a drug to treat such infections we need more evidence to support its use.

 
   References Top

1.Villegas MV, Hartstein AI. Acinetobacter outbreaks, 1977-2000. Infect Control Hosp Epidemiol 2003;24:284-95.  Back to cited text no. 1
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2.Bergogne-Berezin E, Towner KJ. Acinetobacter spp. as nosocomial pathogens: Microbiological, clinical, and epidemiological features. Clin Microbiol Rev 1996;9:148-65.  Back to cited text no. 2
    
3.Tong MJ. Septic complications of war wounds. JAMA 1972;219:1044-7.  Back to cited text no. 3
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4.Griffith ME, Yun HC, Horvath LL, Murray CK. Minocycline therapy for traumatic wound infections caused by the multidrug-resistant acinetobacter baumannii-acinetobacter calcoaceticus complex. Infect Dis Clin Pract 2008;16:16-9.  Back to cited text no. 4
    
5.Davis KA, Moran KA, McAllister CK, Gray PJ. Multidrug-resistant Acinetobacter extremity infections in soldiers. Emerg Infect Dis 2005;11:1218-24.  Back to cited text no. 5
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6.Martin RW, Martin DL, Levy CS. Acinetobacter osteomyelitis from a hamster bite. Pediatr Infect Dis J 1988;7:364-5.  Back to cited text no. 6
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7.Volpin G, Krivoy N, Stein H. Acinetobacter sp. osteomyelitis of the femur: A late sequel of unrecognized foreign body implantation. Injury 1993;24:345-6.  Back to cited text no. 7
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8.Crane DP, Gromov K, Li D, Søballe K, Wahnes C, Büchner H, et al. Efficacy of colistin-impregnated beads to prevent multidrug-resistant A. baumannii implant-associated osteomyelitis. J Orthop Res 2009;27:1008-15.  Back to cited text no. 8
    
9.Schafer JJ, Mangino JE. Multidrug-resistant Acinetobacter baumannii osteomyelitis from Iraq. Emerg Infect Dis 2008;14:512-4.  Back to cited text no. 9
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10.Lazzarini L, Mader JT, Calhoun JH. Osteomyelitis in long bones. J Bone Joint Surg Am 2004;86-A:2305-18.  Back to cited text no. 10
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11.Murray CK, Hospenthal DR. Treatment of multidrug resistant Acinetobacter. Curr Opin Infect Dis 2005;18:502-6.  Back to cited text no. 11
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12.Johnson EN, Burns TC, Hayda RA, Hospenthal DR, Murray CK. Infectious complications of open type III tibial fractures among combat casualties. Clin Infect Dis 2007;45:409-15.  Back to cited text no. 12
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13.Blossom DB, Srinivasan A. Drug-Resistant Acinetobacter baumannii-calcoaceticus Complex: An Emerging Nosocomial Pathogen With Few Treatment Options. Infect Dis Clin Pract 2008;16:1-3.  Back to cited text no. 13
    
14.Centers for Disease C, Prevention. Acinetobacter baumannii infections among patients at military medical facilities treating injured U.S. service members, 2002-2004. MMWR Morb Mortal Wkly Rep 2004;53:1063-6.  Back to cited text no. 14
    
15.Hujer KM, Hujer AM, Hulten EA, Bajaksouzian S, Adams JM, Donskey CJ, et al. Analysis of antibiotic resistance genes in multidrug-resistant acinetobacter sp. isolates from military and civilian patients treated at the walter reed army medical center. Antimicrob Agents Chemother 2006;50:4114-23.  Back to cited text no. 15
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16.Rahal JJ, Urban C, Segal-Maurer S. Nosocomial antibiotic resistance in multiple gram-negative species: Experience at one hospital with squeezing the resistance balloon at multiple sites. Clin Infect Dis 2002;34:499-503.  Back to cited text no. 16
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17.Appleman MD, Belzberg H, Citron DM, Heseltine PN, Yellin AE, Murray J, et al. In vitro activities of nontraditional antimicrobials against multiresistant Acinetobacter baumannii strains isolated in an intensive care unit outbreak. Antimicrob Agents Chemother 2000;44:1035-40.  Back to cited text no. 17
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18.Fernandez Cuenca F, Pascual A, Martinez Martinez L, Perea EJ. [In vitro activity of azithromycin against clinical isolates of Acinetobacter baumannii]. Rev Esp Quimioter 2003;16:204-8.  Back to cited text no. 18
    

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Correspondence Address:
Amit Agrawal
Department of Neurosurgery, MM Institute of Medical Sciences and Research Maharishi Markandeshwar University, Mullana - Ambala - 133203, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.105165

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