Recently, I performed an incision and drainage on a patient with gas gangrene. I consulted an infectious disease specialist who said the patient had developed infective endocarditis. Prior to this, I knew very little about the condition. Here is what I have learned from the physician and my research. The patient was a 56-year-old male with diabetes who presented to the hospital with gas gangrene of his right foot. I took him to the OR for an aggressive incision and drainage. His cultures revealed methicillin resistant Staphylococcus aureus (MRSA) in both his foot wound and blood cultures. Bacteremia was a direct result of the foot infection. According to infectious disease specialist Andrew Catanzaro, MD, “If you have a patient who has repeat blood cultures that are positive for bacteremia and it is slow to clear from the blood stream for greater than 48 hours, then you should be suspicious of infective endocarditis.”1 The patient also had a prior history of receiving a peripherally inserted central catheter (PICC) line due to a previous foot infection. He was immunocompromised, which also increased the level of suspicion. Additionally, the patient had increased white blood cells, positive blood cultures and an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Therefore, the next step was to order an echocardiogram to help with confirming infective endocarditis. The patient had initial incision and drainage. Eventually, he had a transmetatarsal amputation after serial debridements. I monitored weekly ESR, CRP and vancomycin levels for this patient. He received six to eight weeks of IV antibiotics and will complete a repeat echocardiogram after his course of IV antibiotics. There was close follow-up with his primary care physician, podiatrist and infectious disease doctor. A Quick Primer On Infective Endocarditis Infective endocarditis is a type of endocarditis of the inner tissue of the heart caused by infectious agents. The incidence is two to 10 episodes per 100,000 people.2 It accounts for one in 1,000 hospital admissions. With this condition, the valves of the heart do not receive any dedicated blood supply. As a result, defensive immune mechanisms cannot directly reach the valves via the bloodstream. If an organism attaches to a valve surface and forms a vegetation, this blunts the host immune response. Many microorganisms can cause infective endocarditis. The damaged part of a heart valve creates a local blood clot. The platelet and fibrin deposits that form as part of the blood clotting process allow bacteria to take hold and develop vegetations. The body has no direct methods of combating valvular vegetations because the valves do not have a dedicated blood supply. This combination of damaged valves, bacterial growth and lack of a strong immune response results in infective endocarditis. Infective endocarditis...

At our wound care center, we recently had a patient who presented with maggots in her wound. At first glance I thought it was worrisome but then I remembered that maggot therapy is still common for wounds that need debridement. I wanted to revisit maggot therapy to see if I should be considering this treatment as an additional option to heal my patients. A maggot is the larva of a fly. Maggot debridement pertains in particular to the larvae of Dipteran flies, specifically Lucilia sericata. Maggots can efficiently consume dead tissue. They consume rotting flesh, leaving healthy tissue intact. In the 1940s, with the rise of penicillin, clinical maggots became less useful but their use returned in the 1990s when the rise of antibiotic-resistant bacteria necessitated alternative treatments. In 2004, the U.S. Food and Drug Administration approved maggot therapy as a prescription treatment indicated “for debriding non-healing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcerations, neuropathic foot ulcers, and non-healing traumatic post-surgical wounds.”1 Besides debridement as a benefit of maggot therapy, Gwendolyn Cazander, MD, PhD, of Leiden University Medical Center in the Netherlands states there are other benefits.2 The larvae and their secretions have antibacterial effects, reduce inflammation, promote neo-angiogenesis and improve wound healing. Maggots also remove non-viable tissue effectively, which helps combat infection by reducing bioburden and may facilitate the remodeling process. According to Dr. Cazander, maggot therapy occurs in her inpatient and outpatient settings twice weekly.3 John Steinberg, DPM, the Director of Podiatric Surgical Residency at MedStar Washington Hospital Center and MedStar Georgetown University Hospital said, “we do occasionally use maggot therapy for patients who are not candidates for surgical debridement. We probably use them twice per month on inpatients.” After reviewing maggot therapy, my perspective has changed. Maggot debridement will become a treatment I consider in specific patients, especially those who are not responding to conventional treatment. References 1. Gabrielsen P. How maggots heal wounds. Science. Available athttp://news.sciencemag.org/2012/12/how-maggots-heal-wounds . Published Dec. 6, 2012. Accessed Aug. 19, 2014. 2. Cazander G, Pritchard DI, Nigam Y, et al. Multiple actions of Lucilia sericata larvae in hard-to-heal wounds: larval secretions contain molecules that accelerate wound healing, reduce chronic inflammation and inhibit bacterial infection. Bioessays. 2013; 35(12):1083-92. 3. Cazander G, Gottrup F, Jukema GN. Maggot therapy for wound healing: clinical relevance, mechanisms of action and future prospects. J Wound Technology. 2009; 5. Original Posted on Podiatry...