On July 18, 2015, a 73-year-old obese woman (body mass index 30.5) with hypertonia and diabetes mellitus presented herself to the emergency room of hospital A in Vienna, one day after swimming in pond A in the province of Lower Austria. She complained of severe pain in the left lower leg, livid-blue discoloration, local hyperthermia and of fever up to 38 °C. She recalled a minor excoriation on her left leg. Laboratory examinations demonstrated elevated C-reactive protein (26.0 mg/l, normal < 5 mg/l), a white blood cell count of 19.0 G/l (normal 4–9 G/l) and elevated serum-lactate (3.4 mmol/l, normal 0.5–1.6 mmol/l). A duplex sonography of the leg veins indicated a compartment syndrome. Initial surgical treatment consisted of bilateral fasciotomy (medial + lateral). Necrotizing fasciitis was diagnosed and swabs gained intraoperatively yielded non-O1/non-O139
V. cholerae (bacteriological results reported on day 7). Blood cultures remained sterile. Empiric antibiotic therapy initiated on day 1 consisted of ampicillin/sulbactam (3 g, tid, IV). On day 2 of hospitalization, C-reactive protein increased to 393.6 mg/l and white blood cell count to 26.4 G/l; serum procalcitonin was 33.48 ng/ml (normal < 0.5 ng/ml), antithrombin III activity was 66 % (normal 83–128 %) and the patient required intensive care. Antibiotic treatment was switched to a combination of piperacillin/tazobactam (4.5 g, tid, IV) and fosfomycin (8 g, tid, IV); the first of four soft tissue debridements was performed that day. On day 3, clindamycin (900 mg, tid, IV) was added; antithrombin III activity was 34 % and C-reactive protein 463.2 mg/l. On day 5, the patient became afebrile. On day 7, with arrival of bacteriological results showing
V. cholerae susceptible to piperacillin/tazobactam, antibiotic therapy was deescalated to the latter antimicrobial for another 2 weeks. The isolates were also susceptible to ampicillin, trimethoprim-sulfamethoxazole, ciprofloxacin and tigecycline, tested according to the European committee on antimicrobial susceptibility testing (EUCAST) recommendations for enterobacteriaceae [
7]. Wound swabs taken on day 3, 4, and 6 again yielded
V. cholerae. The first culture-negative wound swab was on day 9. A stool sample on day 7 was negative for
V. cholerae. On day 9, negative pressure wound therapy system (VAC, vacuum-assisted closure; KCI Corp, Vienna, Austria) was applied. On day 14, the patient was transferred to a surgical ward. Figure
1 depicts the wound status at that point in time. On day 22, a split skin-graft transplantation was done. The patient was transferred to the plasticsurgery ward on day 27, where she stayed till discharge on September 30, after 73 days of hospitalization. Figure
2 depicts the clinical status as of day 68.