Abstract

This case report describes a 92-year-old man who developed a wound infection with the rare organism Shewanella putrefaciens following an open fracture of the calcaneum and ankle sustained during a boating accident. Despite prompt and appropriate management according to national guidelines, the patient developed this unusual infection. This case highlights the potential for even uncommon pathogens to cause significant infections and the importance of considering all factors when managing open wounds.

Introduction

Open fractures are a common presentation in emergency departments and require immediate intervention to prevent complications like infections. This case demonstrates that strict adherence to national guidelines may not always prevent infection, especially with unusual mechanisms of injury and specific patient characteristics.

Narrative

A 92-year-old male with type 2 diabetes mellitus presented after falling from his boat and catching his foot in the propeller. He sustained a laceration and fractures of the calcaneum and medial malleolus. Following national guidelines, he received immediate wound irrigation, broad-spectrum antibiotics, and surgical debridement with fracture fixation. Despite initial clean wound appearance, he developed a localized infection with Shewanella putrefaciens 14 days after discharge.

Investigations

Plain radiographs confirmed fractures of the calcaneum and medial malleolus. Wound swabs grew Shewanella putrefaciens, sensitive to ciprofloxacin.

Treatment

The patient initially received intravenous co-amoxiclav followed by oral co-amoxiclav. After diagnosis of Shewanella putrefaciens infection, he received an 8-week course of oral ciprofloxacin.

Outcome and Follow-up

The patient recovered well with complete wound healing and no further complications after completing the antibiotic course.

Discussion

Shewanella putrefaciens is an uncommon pathogen typically found in marine environments. It can cause various infections, including skin and soft tissue infections. Risk factors for infection include immunocompromise, warm climates, and chronic wounds. The boat propeller likely served as the source of the organism, and the patient's diabetic status may have contributed to his susceptibility.

This case highlights the potential limitations of national guidelines in managing all open fractures, particularly when considering unusual injury mechanisms and patient characteristics. Although the initial management followed best practices, a higher index of suspicion for infection might have been warranted given the circumstances. Early formal wound checks after discharge could have facilitated faster diagnosis and potentially prevented complications.

Conclusion

This case emphasizes the importance of close monitoring for wound infections, even in seemingly clean wounds, especially for patients with significant injuries and those at higher risk of infection. Additionally, healthcare professionals need to be aware of emerging pathogens like Shewanella putrefaciens, particularly when dealing with unique injury mechanisms and immunocompromised patients.