Toads-in-the-Hole

As far as flesh-eating bacteria goes, I exaggerated somewhat in my previous entry (before our unfortunate case of blog-jacking [no, Mom, we’re not going back to France this year, damn the luck]). It wasn’t the flesh-eating bacteria of the tabloid headlines. In fact, it was as innocuous a wound as you can imagine. The patient presented in our clinic with a small scrape on the knee with a wide ring of reddened skin around the abrasion, extending down to the mid-shin. My attending looked at me expectantly. “Looks like it’s infected,” I stated the obvious cautiously. The doctor nodded slowly and smiled encouragingly as you would to a toddler telling a story. Emboldened, I added, “Probably that ‘scalded-skin syndrome’ caused by Staph. aureus.” The patient had a fever and so the doctor admitted them to the hospital. I was surprised. It was, after all, just a little knee scrape, the kind of thing you might get playing soccer or falling off a bike.

My attending’s caution was well-founded, for by the time we visited the patient that evening the hot and red area had crept far past the border we had marked with a permanent marker down to the patient’s ankle, and the calf was visibly swollen. “We’ve started you on intravenous vancomycin,” my doctor told the patient, “which is an antibiotic that almost always works against the infection we think you have. Unfortunately you can only take it through an I.V., so we have to keep you here until we know what the bug is and what other medicine can deal with it.”

The patient seemed depressed by this news. It was just the beginning of summer, the weather had become reliably fine, and they had a long list of things they were looking forward to doing. Their hospital room quickly filled with family and friends, however, and something close to a continuous (and mostly sober) party reigned in the room for the next two days while we waited for the patient’s culture to grow. The vancomycin quickly reigned in the infection, and before the culture results came back the bright red leg dwindled to a bright red knee. Throughout, the patient reported only very mild pain. “It makes me limp a little, is all. Do I really have to stay here?”

We explained, while erring on the side of smiling reassurance, that if the infection spread it could quickly short-circuit the immune system and drive them into shock, or form a chronic and intractable infection in the bone. The lab finally reported that the cultures of the patient’s wounds’ ooze had grown out Staph. aureus, along with a list of the various antibiotics that had been thrown at the bacterial colony and their efficacy. The litany was chilling. The bug was resistant to all of the newer penicillins and cephalosporins, the usual antibiotics patients are sent home with, as well as most of the alternatives: the quinolones. One drug (other than vancomycin) had worked well: levofloxacin (a newer cousin to the well-known Cipro), which can be taken orally, allowing us to finally send the patient home. “Three days in the hospital because of a scraped-up knee,” the patient teased us as we helped organize the great mound of gifts, toys, and food their friends had brought in. “Remind me not to really cut myself on your watch.”

We said goodbye and hurried back to the clinic to continue our day, discussing the result all the while. I said, “So our antibiotics are weakening. Our vaccines sometimes fail (we were having outbreaks of measles and whooping cough among our well-vaccinated population])….”
“And we have to hospitalize people when they scrape their knees,” my attending finished. “This is what your generation gets to deal with.”
“It doesn’t seem fair,” I tried for a joking tone. “What did your generation have to face that was so tough?”
“Managed care plans and insurance companies,” my attending growled back. “Which I guess you’ll get, too.”