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Case Study

Mary, 21 years old, presented to the hospital emergency department with an infected laceration on her left foot. Mary was at a beach resort four days ago, when she trod on a broken glass bottle and sustained a deep 2 cm long jagged laceration over the lateral aspect of her left foot. She used her handkerchief to bandage the wound. This morning the wound was extremely painful, swollen and had a purulent discharge.

On inspection of the wound the following wound observations were made:

  • Painful and swollen,
  • – Red and warm when touched,
  • – Purulent discharge.

A wound swab was taken for culture and sensitivity. A stat dose of ceftriaxone 1g was administered IVI immediately (she did not require a booster tetanus injection as she had already received one three months ago).

She was then commenced on oral cephalexin 500mg to be taken every 6 hours before being sent home.

Answer the following questions:

1.Describe the physiological basis for the appearance of Mary’s wound.

2.Explain TWO (one endogenous and one exogenous) likely sources for the contamination of the wound and the mode of transmission of the microorganism from each source.

Culture and sensitivity test confirmed the microorganism infecting the wound to be Staphylococcus aureus. The drug cephalexin was discontinued and replaced with oral dicloxacillin 500 mg every 6 hours.

3.Explain the rationale for the initial choice of antibiotics, and the subsequent change in antibiotic therapy to dicloxacillin.Discuss the mode of action of this antibiotic, and state any TWO of its common adverse reactions 

4.Describe the process by which Mary’s wound will heal.

Patient Profile: Mary, 21 years old

The case study represents the case of Mary who is a 21 year old patient who appeared to the emergency department with an infected laceration wound on her left foot. The patient attained the wound via a broken glass bottle which led to her having a 2 cm long jagged laceration over the lateral aspect of her left foot. She had used her handkerchief to bandage the wound but the wound turned swollen, painful, and started having a purulent discharge in the next morning. Considering the physiology of a laceration wound, it has to be mentioned that a laceration is a wound that is torn or jagged in appearance (Hundenborn et al., 2013). The skin torn and jagged by a sharp object tends to form laceration wounds, however, this irregular wound can also be caused due to the injury from a blunt object or force as well. Considering the physiology of the infection in the laceration wound, it has to be mentioned that infections in the laceration wounds are uncommon. Although, in this case, the patient had a serious injury that was severe and she had not received a proper aseptic dressing and wound cleaning for the wound, the wound was infected and she experienced swelling, pain and purulent discharge. Another very important aspect for the infection of her laceration wound is the fact that the wound could also be contaminated with the pathogen or debris of the object that caused the wound or can be from the handkerchief she used to bandage her wound (Lo et al., 2012).

It has to be mentioned that the wound that the patient presented with included a purulent discharge and swelling, the exudates or laceration drainage is generally caused due to the dilation of the blood vessels during the early inflammatory of the laceration. As the patient had infected her wound through not proper dressing and contamination through the sharp object causing the laceration, the chances of her bacterial contamination is extremely high. The purulent discharge of usually yellow colour is created by the body due to making an optimal moist wound environment that assists in healing in this condition the patient requires immediate and periodical aseptic wound dressing and management along with antibiotics and analgesia to assist with the healing process (Sharkey et al., 2012).

Name one endogenous source of contamination and discuss the mode of transmission from the source to the new host. 

Symptoms and Wound Observations

Endogenous infection is generally caused by the pathogen that is already present in the body, these are generally opportunistic pathogens that remain passive or dormant in the body of the host. Staphylococcus aureus is one common source of endogenous pathogen that can cause infection to the laceration wound that the patient had (Batabyal, Kundu & Biswas, 2012). It has to be mentioned that the patient has been exhibiting signs of swelling, redness, tenderness around the wound tissue which had purulent discharge from the wound and had been warm to touch. According to authors, these are the most common symptoms of a wound that has been infected by Staphylococcus aureus, it can be considered as the most likely source of contamination of the wound (Proctor, 2012).


The most common mode of transmission to a new host is direct contact with the wound. It has to be mentioned that Staphylococcus aureus infection is a highly contagious infection and anyone coming in direct contact with the wound, the exudates, or the material used to clean the wound is at high risk of contamination in case infection control measures are not taken (Batabyal, Kundu & Biswas, 2014).

Name one exogenous source of contamination and discuss the mode of transmission from the source to the new host

A common exogenous source of pathogen that can cause infection of the laceration wound that the patient presented in the facility with is the Pseudomonas aeruginosa. It is a very common aerobic bacteria that can easily infect the skin of the host through torn or jagged soft tissue. As the patient presented with a jagged laceration wound, it is very likely for an exogenous bacteria like Pseudomonas aeruginosa to infect her wound (Serra et al., 2015).

This particular pathogenic Bacteria is airborne and can be easily transmitted through direct contact via hands of the healthcare worker and can easily contaminate other patients with the pathogen if they do not follow a thorough hand hygiene protocol causing direct transmission to a new host. Along with that, this pathogen can also be transmitted through anyone coming into contact with the supplies or equipment that have been used to clean or dress the laceration wound of the patient. Anyone coming into direct contact with the patient or her laceration wound directly can also become a new host to the pathogen why are contact transmission (Serra et al., 2015).

Rationale for the stat dose of ceftriaxone administered IVI immediately. 

Ceftriaxone is a third generation cephalosporin antibiotic which is derived from Cephalosporium acrimonium. It has a beta lactam ring and hence it is considered to be a highly active broad spectrum antibiotic which is effective against a varied range of gram negative bacteria that are usually responsible for skin infections. Along with that it has been reported to be extremely effective in intramuscular IV dose and it is very quickly distributed throughout the body and having a long plasma half-life of about 8 hours; hence, it is one of the primary choices of broad spectrum antibiotics given in case of infections. Hence in this case is well this antibiotic was prescribed in an IV stat dose (Dancer et al., 2013).

Treatment and Management

Rationale for the oral cephalexin.

Cephalexin is another form of cephalosporin antibiotic which is given in case of mild infections including ear infection skin infection and urinary tract infections. It is a very common systemic antibiotic that is administered orally for care or stopping wound infections. The mode of action of this systemic antibiotics MI mix that of penicillin such as it stops the growth of the pathogen inside the body by preventing the bacteria from producing cell walls that surround is cell and hence inhibiting the bacteria to multiply any further and exerting a bacteriostatic effect on the infection (Pallin et al., 2013). Hence, this medication was administered to the patient in this case as well

Rationale for the change to oral dicloxacillin.

Cephalexin is one of the most commonly administered antibiotic to treat mild skin infections or wound infections, although the systemic antibiotic is not very functional for Staphylococcus aureus infection. Many of the Staphylococcus aureus strains such as MRSA resistance to the common systemic antibiotic such as cephalexin. As the patient in the case study was diagnosed with a Staphylococcus aureus infection, the cephalexin antibiotic was discontinued and oral dicloxacillin was administered which is a gold standard antibiotic, is prescribed for Staphylococcus aureus strains that are resistant to cephalexin (Nissen et al., 2013).State two adverse reactions to dicloxacillin Two most common adverse reactions to dicloxacillin are nausea and diarrhoea.

Wound healing takes place by a systematic and progressive process involving inflammatory phase, proliferative phase, and maturation phase. The information stage will start with damaged and death cells been cleared out followed by the means of collagen deposition and granulation tissue formation followed by epithelialization which will lead to wound contraction. In the last how much your recent face remodelling of the deposited collage and takes place and the collision is aligned along the tension lines which leads to completing the healing process (Darby et al., 2014). A wound infection caused by Staphylococcus aureus usually takes 10 days to heal depending on the security of the wound and the efficiency of the wound care management procedure followed. It has to be mentioned in this context that Staphylococcus aureus is a pathogen that is very difficult to heal as it is resistance to many of the antibiotics. However as dicloxacillin is included in the gold standard of antibiotic management recommended for Staphylococcus aureus infection the wound healing will be accelerated with the bacteriostatic activity of the antibiotic administered on the pathogen.

References

Batabyal, B., Kundu, G. K., & Biswas, S. (2012). Methicillin-resistant Staphylococcus aureus: a brief review. International Research Journal of Biological Sciences, 1(17), 65-71.

Dancer, S. J., Kirkpatrick, P., Corcoran, D. S., Christison, F., Farmer, D., & Robertson, C. (2013). Approaching zero: temporal effects of a restrictive antibiotic policy on hospital-acquired Clostridium difficile, extended-spectrum β-lactamase-producing coliforms and meticillin-resistant Staphylococcus aureus. International journal of antimicrobial agents, 41(2), 137-142.

Darby, I. A., Laverdet, B., Bonté, F., & Desmoulière, A. (2014). Fibroblasts and myofibroblasts in wound healing. Clinical, cosmetic and investigational dermatology, 7, 301.

Hundenborn, J., Thurig, S., Kommerell, M., Haag, H., & Nolte, O. (2013). Severe wound infection with Photobacterium damselae ssp. damselae and Vibrio harveyi, following a laceration injury in marine environment: a case report and review of the literature. Case reports in medicine, 2013.

Lo, S., Hallam, M. J., Smith, S., & Cubison, T. (2012). The tertiary management of pretibial lacerations. Journal of Plastic, Reconstructive & Aesthetic Surgery, 65(9), 1143-1150.

Nissen, J. L., Skov, R., Knudsen, J. D., Østergaard, C., Schønheyder, H. C., Frimodt-Møller, N., & Benfield, T. (2013). Effectiveness of penicillin, dicloxacillin and cefuroxime for penicillin-susceptible Staphylococcus aureus bacteraemia: a retrospective, propensity-score-adjusted case–control and cohort analysis. Journal of Antimicrobial Chemotherapy, 68(8), 1894-1900.

Pallin, D. J., Binder, W. D., Allen, M. B., Lederman, M., Parmar, S., Filbin, M. R., ... & Camargo Jr, C. A. (2013). Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases, 56(12), 1754-1762.

Proctor, R. A. (2012). Is there a future for a Staphylococcus aureus vaccine?. Vaccine, 30(19), 2921-2927.

Sampedro, G. R., DeDent, A. C., Becker, R. E., Berube, B. J., Gebhardt, M. J., Cao, H., & Bubeck Wardenburg, J. (2014). Targeting Staphylococcus aureus α-toxin as a novel approach to reduce severity of recurrent skin and soft-tissue infections. The Journal of infectious diseases, 210(7), 1012-1018.

Serra, R., Grande, R., Butrico, L., Rossi, A., Settimio, U. F., Caroleo, B., ... & de Franciscis, S. (2015). Chronic wound infections: the role of Pseudomonas aeruginosa and Staphylococcus aureus. Expert review of anti-infective therapy, 13(5), 605-613.

Sharkey, E. J., Cassidy, M., Brady, J., Gilchrist, M. D., & NicDaeid, N. (2012). Investigation of the force associated with the formation of lacerations and skull fractures. International journal of legal medicine, 126(6), 835-844.

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