Occlusive bandaging of wounds with decreased circulation promotes growth of anaerobic bacteria and necrosis: case report
© The Author(s) 2016
Received: 2 April 2016
Accepted: 4 August 2016
Published: 8 August 2016
Topical occlusive/semi-occlusive dressings that induce a damp and trapped environment are widely used in wound treatment. Subjecting the wound with impaired circulation to such trapped/air-free environment potentiates the growth of anaerobic bacteria and risk for serious infection.
We present a case of previously healthy Swedish male that had a muscle contusion after heavy trauma that induced impaired circulation. The application of an occlusive bandage to the post-traumatic wound on the patient resulted in a poly-microbial anaerobic infection and necrosis. These complications were treated successfully with antibiotics and open dressing of the wound.
The pathophysiology of difficult- to- treat ulcers should be reviewed by the physician and occlusive dressing should be avoided when treating wounds with impaired circulation.
Subjecting wounds to an occlusive trapped/air-free environment potentiates the growth of anaerobic bacteria, which can result in significant sepsis . In a report by Mousa , study of 127 cases of burn wound infection revealed that 55.1 % of ulcers were infected with anaerobic bacteria. Patients with openly dressed wounds recovered more quickly from anaerobic bacterial infections than patients with occlusive wound dressings (P < 0.01). Pressure ulcers are also susceptible to infection by biofilm-growing aerobic and anaerobic bacteria, the biofilm formation on the wound being the main reason for its delayed healing . Survey of bacterial diversity in chronic wounds using pyrosequencing  showed that 62 % of the bacterial populations in pressure ulcers were identified as obligate anaerobes.
The present case report describes a post-traumatic wound complicated with polymicrobial anaerobic infection and necrosis. We aim to emphasize the importance of the assessment of pathophysiology of wounds in order to gain a better understanding of the wound’s microbiota and recommendation of appropriate wound dressings by the physician before their routine application by medical assistants.
The local status motivated an ulcer revision and debridement of muscle tissue necrosis. However, there was no sign of acute inflammation in the ulcer area and with respect to the severe necrosis and significant growth of anaerobic bacteria together with gram-positive bacteria in a biofilm [5, 6], there was a risk of developing a larger ulcer area with impaired healing. The clinical status of patient was stable. Intravenous meropenem (3 × 1 g) was started immediately after cultures from blood and ulcer secretion were secured. A culture from the ulcer secretion revealed growth of Staphylococcus aureus, Streptococcus beta hemolytic group G, Clostridium innocuum, and Bacterioides thetaiotaomicron. The ulcer was treated conservatively with the local application of an antibiotic gel containing 250 mg vancomycin and hepatocyte growth factor (HGF in 100 IU antithrombin III Baxter)  plus sodium chloride for 2 days, followed by antithrombin III plus sodium chloride gel for 5 days. The wound dressing comprised sterile cotton compresses that were changed daily during the first week.
Anaerobic bacteria are a common cause of infections, some of which can be serious and life-threatening . Because of their fastidious nature, anaerobes are hard to isolate and are often not recovered from infected sites. The delayed or inappropriate therapy against these organisms may lead to failures in eradication of these infections . Clostridium innocuum is a relatively antimicrobial-resistant, frequently misidentified anaerobe that has been associated with bacteremia . Clostridial myonecrosis is a rapidly progressive disease characterized by muscle necrosis and systemic toxicity [11, 12]. In a 1997 report, Mousa found that Bacteroides species were isolated from 14 of 17 cases with burn wounds that developed septic shock, and were also recovered from four patients who had anaerobic infection alone .
The patient in the present case had a muscle contusion after heavy trauma that induced impaired circulation and was susceptible to a trapped, air-free environment under an occlusive dressing. The discolored subcutaneous tissue, odorous secretion, slightly increased acute phase proteins, and growth of S. aureus, Streptococcus beta hemolytic group G, C. innocuum, and B. thetaiotaomicron might indicate a serious infection and risk for deleterious consequences. However, because of the patient’s immune competence and appropriate antibiotic therapy, he survived this life-threatening situation.
Wounds with impaired circulation are highly vulnerable to infection. Anaerobic and gram-positive bacteria are over-presenting microorganisms in development of biofilms in such wounds. Occlusive dressing should be avoided when treating wounds with impaired circulation such as after heavy trauma, burn ulcers or pressure ulcers. The conventional open clean cotton dressings are recommended in such cases.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
The medical assistants at the Department of Infectious Diseases University Hospital in Linköping have performed the nursing for the patient. The report has been supported for language editing by PEAS Institut in Linköping.
The author declares that he has no competing interests.
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