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Aeromonas sepsis as a marker of devitalized tissue in traumatic injuries.

To the Editor: Monaghan et al. have recently reported managing Aeromonas hydrophila sepsis in a patient with an extensive, crushing, traumatic, soft tissue injury [1]. In addition to the specifics of the management of this case, this report illustrates the significance of Aeromonas sepsis in an otherwise healthy trauma patient. Aeromonas sepsis in such circumstances is a toxic indicator of devitalized, contaminated soft tissue requiring definitive debridement. In 1986, I first encountered post-traumatic Aeromonas sepsis in a patient who suffered a devascularizing foot wound in a boating accident. After emergency revascularization surgery, the patient became febrile and hypotensive. The patient underwent debridement of devitalized tissue from the margins of the wound. Cultures from this tissue grew Aeromonas hydrophila, consistent with the history of fresh-water contamination at the time of injury. With debridement and appropriate antibiotics, the infection resolved, and the residual wounds were covered with skin grafts [2]. I later managed a number of Aeromonas infections in complicated microsurgical replantation cases treated for venous insufficiency with medicinal leeches. Beginning in the 1980s, hand surgeons increasingly used leeches to provide temporary venous outflow in replanted fingers that had occluded or insufficient veins. Leeches were applied at intervals to such fingers for three to five days, at which time capillary venous return across the amputation site was re-established. Salvage of ‘‘artery only’’ replants with leech use proved to be as high as 70%, and this strategy has become standard care in many centers performing replantation surgery [3]. Aeromonas hydrophila is an enteric organism of medicinal leeches and inevitably contaminates any site on which a leech is placed [4]. With increased use of leeches on replanted fingers with zones of traumatized tissue, Aeromonas infections became a measurable complication, with rates as high as 30% of cases [5]. The infections ranged from cellulitis to abscess formation and sepsis, and replantation surgeons eventually recognized that the Aeromonas infection was based on devitalized tissue. Any evidence of Aeromonas infection became understood as an indication for prompt and thorough debridement, including the removal of the replanted part if necessary. With further experience, the occurrence of Aeromonas infection in replantation patients proved to be generally avoidable if leeches were restricted to replanted parts with clear evidence of arterial inflow and if the patient was given antibiotics effective against Aeromonas hydrophila before leech application [6]. These collective observations clarify the dynamics of Aeromonas infections in otherwise healthy patients with significant tissue trauma. Such Aeromonas infections indicate the presence of devitalized tissue requiring immediate debridement.