Comprehensive management of multidrug-resistant bacterial infections and fungal infections after penetrating chest injury: a case of complex infection in a patient treated for a postinjury wound

Abstract

This case report describes the diagnosis and treatment process of a middle-aged male patient who developed multidrug-resistant bacterial infection and fungal infection after a fall injury. The patient sustained a penetrating injury to the right chest with pain and bleeding at multiple sites following the fall. After receiving emergency surgery, thoracic drainage, and comprehensive anti-infection treatment at the original hospital, he developed right empyema and wound infection on the 15th postoperative day, which were accompanied by a high fever and multiple organ dysfunction. The patient was subsequently transferred to our department. Upon admission, the patient was already in infectious shock, with significant fungal growth observed on the right chest wall. Through multidisciplinary joint diagnosis and treatment, we actively debrided the patient’s wound, applied VSD negative pressure drainage technology multiple times, and developed a comprehensive treatment plan targeting multidrug-resistant bacterial infection and fungal infection. After 30 days of active treatment, the patient’s condition improved, and he was discharged smoothly without any complications. This case emphasizes the importance of effective management and multidisciplinary joint diagnosis and treatment in addressing complex infections that may arise in the late stages of severe trauma, providing valuable insights for clinicians handling similar cases.

Clinical trial number

This report does not belong to clinical trials, and the clinical trial number is not applicable.

Background

Falls from heights can cause injuries in individuals falling from elevated positions and commonly occur at construction sites and in homes. These injuries often lead to severe trauma, potentially resulting in multiple organ damage, bleeding, and infections, among other complications [1]. Studies have shown that among patients with chest trauma due to falls from heights, approximately 20–30% experience varying degrees of infection, especially in cases of multiple injuries [2]. Furthermore, the mortality rate from posttraumatic infections is significantly higher than that of uninfected patients [3]. After chest trauma, the most common bacterial infections are caused by pathogens such as Staphylococcus aureus, Escherichia coli, and Klebsiella, and emergence of multidrug-resistant pathogens, particularly carbapenem-resistant Acinetobacter baumannii (CRAB), poses significant challenges for infection management following chest trauma. The presence of resistant strains diminishes the effectiveness of conventional antibiotic treatments, increasing the complexity of infections and the difficulty of treatment [4]. Moreover, the incidence of invasive fungal infections, such as aspergillosis, is on the rise, particularly among immunocompromised patients [4], further exacerbating the complexity and challenges of clinical management. The successful treatment of this case confirms that timely and effective infection control measures and multidisciplinary collaborative diagnosis and treatment are crucial for the prognosis of patients managed for complex infections following injuries [3].

Case presentation

The patient was a middle-aged male with a good health history who denied any underlying diseases, such as hypertension, diabetes, or coronary artery disease. He also denied any immunosuppression, chronic liver or kidney disease, or long-term medication history. Fifteen days prior to admission, the patient fell from the sixth floor (the specific mechanism of injury was unclear), and a steel pipe approximately the size of an adult’s wrist (approximately 6 cm in diameter) penetrated his right chest, causing massive bleeding, which was accompanied by chest pain, chest tightness, and shortness of breath, as well as pain and bleeding in multiple areas, including the right shoulder, back, and abdomen. After the injury, the firefighters cut the external steel pipe and transported the patient to a local county hospital. Considering the penetrating chest injury, an emergency surgery was performed to remove the steel pipe from his body. During the operation, severe chest wall damage and contamination of the wound were observed. Postoperatively, he was given ventilatory support, anti-infection treatment, and emergency measures against shock. Approximately ten days after the surgery, the patient developed a high fever, with a maximum body temperature of 39.5 °C. A reexamination of the chest CT showed multiple pulmonary contusions in both lungs, with partial atelectasis and consolidation in the right lung, along with a noticeable gap in the right chest wall. (Fig. 1). On the twelfth day postsurgery, he experienced severe shock and needed high doses of vasoactive drugs (0.8–1.0 µg/kg/min) to maintain blood pressure; he also experienced respiratory failure (oxygenation index < 150 mmHg), liver and kidney dysfunction and coagulation disorders. The external hospital adjusted the antibiotic regimen to imipenem/cilastatin 1.0 g q8h and actively managed the infected wound, but the condition continued to worsen, leading to his transfer to our hospital on the fifteenth day postinjury.

Fig. 1.

A reexamination of the chest CT showed multiple pulmonary contusions in both lungs, with partial atelectasis and consolidation in the right lung (As shown by the green arrow in panel a and b), along with a noticeable gap in the right chest wall (The white arrow in panel c shows the cross-section, the yellow arrow in panel d shows the sagittal section, and the blue arrow in panel e shows the coronal section of the wound CT)

Upon admission, the patient was in a continuous state of pain relief and sedation, with a body temperature of 39.3 °C, blood pressure of 98/42 mmHg (norepinephrine infused at 1.2 µg/kg/min), heart rate of 124 beats per minute, and ongoing ventilatory support (SIMV mode, PEEP 10 cmH2O, PS 12 cmH2O, FIO2 = 60%). Peripheral blood oxygen saturation fluctuated around 94%. The surgical area showed an elliptical wound approximately 5 × 10 × 3 cm in size, with the surrounding tissue red and swollen and extending deep into the muscle layer. The vitality of the edge and base of the wound was poor, with exudation, and some muscle and fascial tissue was devitalized, with a disorganized structure. The local tissue at the wound base was blackened and necrotic, extending approximately 10 cm along the right axilla (the condition of the postinjury chest wall infection is shown in Fig. 2: a, b, c, and d. After admission, considering the patient’s severe shock from the steel bar penetrating injury, significant infection in the surgical area, and the suspected fungal growth in the wound, empirical treatment was initiated with meropenem (1 g q8h) + linezolid (600 mg q12h) + a voriconazole loading dosage of 600 mg q12h, followed by a maintenance dosage of 400 mg q12h for anti-infection, with monitoring of the voriconazole blood concentration.

Fig. 2.

Illustrates the patient’s chest wall infection following an injury, highlighting the notable presence of fungal growth within the wound. The photo was taken on the day of admission (15th day after injury)

On the second day after admission, the patient underwent debridement of the right chest wall under general anaesthesia. During the operation, severe infection of the right chest wall was observed, with communication between the right chest wall and the thoracic cavity. It was decided to primarily perform debridement and drainage, implementing right chest wall abscess debridement + necrotic rib and muscle removal + wound drainage. The necrotic tissue was thoroughly removed, and VSD negative pressure drainage was performed for adequate drainage.

Postoperatively, the patient still had fever, with no decrease in the peak temperature. Although the circulation was relatively stable compared with that at admission, a negative balance was initiated under the guidance of the PiCCO monitor, but the patient had excessive sputum and poor oxygenation. On the third day after admission, cultures from the thoracic cavity and VSD drainage fluid indicated the growth of Aspergillus, and a sputum culture revealed multidrug-resistant Acinetobacter baumannii (CRAB; sensitive to tigecycline, Specimens were taken on the day of admission and cultured for 3 days). The patient experienced severe trauma complicated by mixed, extremely severe infections, a large amount of necrotic tissue, and fungal growth. The immediate treatment goals were to remove the lesions as much as possible and provide targeted anti-infection therapy. After multidisciplinary consultation, the following decisions were made: (1) For the wound, multiple debridements and VSD negative pressure drainage are needed to remove inactive necrotic tissue and ensure adequate drainage. (2) In accordance with the “IDSA 2024 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections,” for CRAB, a combination anti-infection plan based on high-dose sulbactam is recommended; thus, cefoperazone and sulbactam (3 g q8h) + sulbactam (2 g q8h) + tigecycline (200 mg) for the first dose, followed by 100 mg q12h for anti-infection treatment, were administered.

For wound management, right chest wall debridement and VSD negative pressure drainage were performed on Days 2, 5, 9, and 13 after admission (Fig. 3a-d). With active treatment, the patient’s overall condition improved, the amount of purulent drainage gradually decreased, the amount of granulation tissue in the wound increased well, and the amounts of necrotic tissue and pus significantly decreased. On the 16th day, the endotracheal tube was removed, and the patient was transferred to the general ward (Fig. 3e). On the 20th day, layered suturing was performed to close the wound (Fig. 3f). With active treatment, the patient’s respiratory and circulatory functions gradually stabilized, wound healing was satisfactory, and organ functions improved gradually (the specific test indicators are detailed in Table 1). The endotracheal tube was removed on the 16th day, and the patient was transferred to the general ward and discharged on the 30th day after recovery.The important time nodes or flowchart for treatment are shown in Fig. 4.

Fig. 3.

Illustrates the progression of the patient’s wound healing over time. Panel a depicts the wound condition on June 20 (On the 2nd day after admission), followed by panel b, which shows the status on June 24 (On the 5th day after admission). Panel c captures the condition on June 28 (On the 9th day after admission), while panel d presents the wound’s appearance on July 3 (On the 13th day after admission). Panel e reflects the state of the wound on July 8 (On the 20th day after admission), and finally, panel f displays the wound healing condition at the time of discharge (The 30th day after admission)

Table 1.

Partial test results and organ function assessment of the patient during hospitalization

		Admission Day	2nd days	5th days	9th days	13th days	Transfer Day	Discharge Day
Liver	ALT (U/L)	77	60	39	47	57	15	44
	AST (U/L)	67	55	32	35	84	28	25
	Total Bilirubin (µmol/L)	125.3	116.1	50	48	17.4	23.8	10.2
Kidney	Creatinine (µmol/L)	571	382	149	95	177	132	111
	24-Hour Urine Volume (ml)		1680	2500	2220	3710	4830	3672
Heart	BNP (pg/ml)	217	141	178	31	113	42	56
Blood	PT (sec)	12.9	13.7	13.0	12.2	14.3	14.5	13.8
	INR	1.33	1.20	1.25	1.07	1.25	1.27	1.18
	PLT (×109/l)	207	171	178	159	254	131	266
Respiration	Oxygenation Index	172	256	320	300	362	418	432
Circulation	Norepinephrine (µg/kg/min)	1.2	1.2	0.8	0.8	0	0	0
Neurology	Rass Score	-4	-1	-1	0	-1
	GCS Score						15	15

(the examination times were at the time of admission to our hospital; on the 2nd, 5th, 9th, and 13th days of hospitalization; on the day of transfer from the intensive care unit; and at discharge)

Fig. 4.

Patient treatment flowchart

Discussion and conclusions

This case presents a complex penetrating chest injury caused by a fall from height. The patient experienced multiple complications during treatment, particularly challenges in infection control. Such cases have significant warning implications in clinical practice, as they reflect the risks of severe infections and multiple organ dysfunction that may arise after high-risk injuries.

The occurrence of infections after severe trauma is closely related to patient mortality. Studies have shown that infectious complications significantly increase the mortality risk for hospitalized patients. For example, a retrospective cohort study analysing 150,948 trauma patients revealed that the inpatient mortality rate for infected patients was 10.5%, while that for uninfected patients was only 2.1% [5]. Furthermore, the impact of infections on mortality rates varies among patients with different severities of trauma. In patients with mild trauma, the mortality rate for infected patients was 17.1%, whereas it was only 2.9% for uninfected patients [5]. These results indicate that infections not only affect patient survival rates but may also exacerbate the severity of trauma, thereby influencing prognosis. Therefore, timely identification and management of posttraumatic infections are crucial for improving patient survival rates.

The relevant literature and epidemiological data suggest that common pathogens associated with severe posttraumatic infections include Staphylococcus aureus, Streptococcus pneumoniae, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Staphylococcus aureus, particularly methicillin-resistant Staphylococcus aureus (MRSA), is commonly found in hospital environments and is associated with severe infections and increased mortality [6]. Streptococcus pneumoniae is among the main pathogens that cause pneumonia and thoracic infections and is especially common in immunocompromised patients [2]. Klebsiella pneumoniae and Pseudomonas aeruginosa are often detected in hospital-acquired infections and are frequently coinfected with other pathogens, leading to complex clinical presentations and treatment challenges [7]. Although fungal infections are relatively rare, they should not be overlooked, especially in immunocompromised patients, as they can lead to severe complications. Studies have shown that the incidence of fungal infections significantly increases in critically ill patients after chest trauma, particularly in those receiving long-term antibiotic or immunosuppressive therapy [8]. Therefore, in the treatment of penetrating chest injuries, it is necessary to consider the combined effects of various pathogens to develop a reasonable anti-infection treatment plan.

In this case, the sputum culture indicated the presence of carbapenem-resistant Acinetobacter baumannii. After multidisciplinary joint diagnosis and treatment, we referred to the “IDSA 2024 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections”, the use of high-dose sulbactam can enhance antifungal activity against certain resistant fungi, especially when combined with other antifungal drugs, which can produce a synergistic effect. Therefore, a treatment regimen combining cefoperazone and sulbactam with tigecycline was adopted for anti-infection therapy while also increasing the dose of sulbactam alone to achieve an effective drug concentration. Some studies suggest that after the initial effective treatment of Acinetobacter baumannii infections, it is advisable to gradually reduce the dosages and types of antibiotics and switch to safer and better-tolerated oral antibiotics, such as fluoroquinolones [9]. Therefore, on the 14th day postinjury, we reduced the antibiotic dosage to 600 mg qd of levofloxacin. For multisite Aspergillus infections, voriconazole can be considered the first-line drug, but its pharmacokinetic characteristics show significant individual differences, especially among different patient populations, such as those with liver dysfunction or those undergoing chemotherapy, in whom its bioavailability may be affected [10]. Therefore, in clinical applications, appropriate dosage adjustments need to be made on the basis of the specific conditions of the patient to ensure an effective blood concentration. Studies have shown that the recommended blood concentration range for voriconazole is typically 1–6 mg/L, and maintaining this range can effectively improve treatment success rates while reducing the incidence of adverse reactions [11]. Therefore, in this case, we continued using voriconazole for antifungal treatment and monitored its blood concentration to titrate the dosage. For the maintenance treatment of Aspergillus infections, the use of antifungal drugs for 6 to 12 weeks after the initial treatment is generally recommended [12]. On the basis of the “2018 CPS Practice Guidelines: Individualized Use of Voriconazole” and the good oral bioavailability of voriconazole, we changed the antifungal regimen to oral voriconazole (200 mg q12h) on the 15th day after surgery.

In this case, for infection management, the patient received empirical anti-infection treatment involving the combined use of multiple antibiotics. Particularly for multidrug-resistant Acinetobacter baumannii infections and Aspergillus infections, timely adjustment of the treatment plan is crucial. Studies have shown that early implementation of targeted antifungal therapy has a positive effect on patient prognosis [13]. In this case, the use of voriconazole for antifungal treatment and its blood concentration monitoring reflect the importance of individualized treatment.

The selection of a reasonable surgical plan is undoubtedly key for improving the prognosis and quality of life of patients with severe trauma. For complex wound infections, the repeated use of negative pressure drainage (VSD) surgical methods has been proven to be an effective treatment strategy. Studies have shown that VSD can effectively remove necrotic tissue and promote the formation of new granulation tissue when complex wound infections occur [14]. The successful rescue of this patient also confirms the good application prospects of the VSD surgical method, which is worth promoting and applying in clinical practice for managing complex infections after penetrating chest trauma.

Moreover, the implementation of evidence-based strategies for infection prevention after major trauma is crucial. For high-risk patients, reasonable antibiotic management is key to preventing infections. Studies have shown that early source control is also an important strategy for preventing infections, as timely removal of the infection source can effectively reduce the risk of infection [15]. For high-risk patients, developing personalized prevention plans, including regular monitoring and early intervention, can significantly improve patient prognosis. Additionally, the implementation of prevention strategies against fungal infections should be considered, especially in patients receiving immunosuppressive therapy, in whom early identification of and intervention for fungal infections are crucial. Patients with severe trauma often require meticulous multidisciplinary management, and for handling infections after high-risk injuries, clinical doctors should emphasize the early identification of and intervention for infections, especially against the backdrop of increasing numbers of multidrug-resistant pathogens, which is vital for improving patient prognosis [16]. However, despite the encouraging results of this case, its limitations should not be overlooked. First, the uniqueness of the case may limit its generalizability, as some clinical characteristics, such as the nature of the trauma and the manifestations of infectious pathogens, may not apply to other patients. Therefore, future research should focus on larger sample sizes for clinical and evidence-based studies. In summary, this case provides a new perspective on the clinical management of complex infections after severe trauma, highlighting the importance of early identification, comprehensive treatment, and multidisciplinary joint diagnosis and treatment while also guiding future related research and clinical treatment.

Abbreviations

CRAB

Carbapenem-resistant Acinetobacter baumannii

MRSA

Methicillin-resistant Staphylococcus aureus

SIMV

Synchronized Intermittent Mandatory Ventilation

PEEP

Positive End-Expiratory Pressure

Author contributions

Gong Mingwei: Case writing and clinical data analysis Yang Zeping: Collection of clinical data and image materials Han Juan: Design and evaluation of the case report, modification of important knowledge content in the case.

Funding

This report was supported by the Key Specialty Fund of the Critical Care Medicine Department of the Third Affiliated Hospital of Chongqing Medical University, Fund Code: SLCZDZK202401. This funding was crucial for collecting data, analyzing it, interpreting the results, and writing the manuscript.

Data availability

The data and images involved in the report are authentic and available.

Declarations

Ethics approval and consent to participate

This case report has been approved by the Ethics Committee of the Third Affiliated Hospital of Chongqing Medical University (Fangda Hospital).All research participants and patients agreed to publication. Participants and patients in the study provided written informed consent for their personal or clinical details and any identifiable images published in this study.

Consent for publication

The publication has obtained the consent of patients and all researchers. We confirm that we have informed the participants and patients of this study in writing and successfully obtained consent for the personal information or clinical information in this study, as well as for any identifiable images that will be published in this study.

Competing interests

The authors declare no competing interests.