Community-acquired Acinetobacter skull base osteomyelitis in an immunocompetent adult

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 2020 Nov 26];5:554-5. Available from:

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 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.



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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.105165


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