Yoğun Bakımda Anaerobik Yumuşak Doku Enfeksiyonu Gelişen Olgunun Yönetimi
Özet
Bu olguda, yoğun bakım tedavisi sırasında sakral bölgede anaerob bakteriyel enfeksiyon ile komplike dekubit ülseri gelişen hastadaki tanı ve tedavi süreci sunulmaktadır. Vücut kitle indeksi (BMI): 18,5 kg/m2 olan, uzun süreli entübasyon nedeniyle trakeostomi açılan ve Glaskow Koma Skoru (GKS): 7 olarak takip edilen hastada, yatışının 78. gününde sakrum bölgesinde evre 3 bası yarası tesbit edildi. Enfeksiyon bulguları nedeniyle gönderilen kültürlerde K. pneumoniae ve P. aeruginosa izole edildi. Yara kültüründen yapılan gram boyama sonucunda gram-negatif basil ve birkaç sahada gram-pozitif kok görüldü ancak gram-pozitif kok’un kültürde tespit edilememesi nedeniyle kontaminasyon olarak değerlendirildi. Meropenem, amikasin ve linezolid tedavisi sonrası kötü kokulu akıntının devam etmesi nedeni ile tekrar doku kültürü gönderildi fakat üreme tespit edilemedi. Antibiyotik kullanımını takip eden 12. günde, pürülan materyalin gram boyama sonucunda gram-pozitif kok görülürken üreme tesbit edilemedi. Doku biyopsisi örneğine yapılan DNA izolasyonu ve klasik polimeraz zincir reaksiyonu (PCR) işlemi sonucu anaerob Peptostreptococcus spp. pozitif olarak belirlenmesi üzerine tedaviye metronidazol eklendi ve yara bölgesi günde iki defa metronidazol ile pansuman yapılarak oksijenizasyonun sağlanması için bölge açık bırakıldı. Anaerob tedaviyi takip eden 5. günde pürülan akıntı kesildi akut faz reaktanları geriledi. Sonuç olarak, anaerob mikroorganizmaların izolasyon ve identifikasyon sürecindeki zorluklar nedeniyle moleküler tanı yöntemlerinin kullanılması hızlı tanı açısından önemlidir.
This case report presents the diagnosis and treatment process of a patient who developed a decubitus ulcer complicated by an anaerobic bacterial infection in the sacral region during intensive care treatment. A patient with a body mass index (BMI) of 18.5 kg/m2, who underwent tracheostomy due to prolonged intubation and was monitored with a Glasgow Coma Score (GCS) of 7, was diagnosed with a grade 3 pressure ulcer in the sacrum region on the 78th day of hospitalization. Cultures sent due to signs of infection revealed the isolation of K. pneumoniae and P. aeruginosa. Gram staining of wound cultures revealed gram-negative bacilli and gram-positive cocci in a few areas; however, the inability to detect gram-positive cocci in the culture led to the assessment of contamination. Due to the persistence of foul-smelling discharge after treatment with meropenem, amikacin, and linezolid, a repeat tissue culture was sent, but no growth was detected. On the 12th day following antibiotic administration, gram-positive cocci were observed in the purulent material after Gram staining, but no bacterial growth was detected. DNA isolation and conventional polymerase chain reaction (PCR) of the tissue biopsy sample revealed a positive result for anaerobic Peptostreptococcus spp., whereupon metronidazole was added to the treatment, and the wound area was dressed with metronidazole twice daily and left open to ensure oxygenation. On the 5th day following anaerobic treatment, purulent discharge ceased and acute phase reactants subsided. In conclusion, due to the difficulties in the isolation and identification process of anaerobic microorganisms, the use of molecular diagnostic methods is important for rapid diagnosis.
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