Case Study: Enterobacter cloacae contamination on a post-operative wound

Following surgical excision of a pustulent abcess, a 48-year-old obese woman presented with intermittent sutures on her right tibia. On this first day, the patient had a slight fever and the periwound showed signs of infection and inflammation. At this stage, the wound was 9.6 cm in diameter, extremely malodorous, revealing necrotic subcutaneous tissue and exuding heavily.

The dorsal aspect of the leg surrounding the popliteal fossa was edematous and a culture swab taken from the wound determined contamination with Enterobacter cloacae. The patient received systemic antibiotic treatment to clear the infection and the wound was initially treated with povidone iodine solution, povidone iodine paste and paraffin gauze. However, there was no improvement.

Enterobacter is a gram-negative bacillus and belongs to the most common bacterial isolates recovered from clinical specimens. Enterobacter wound infections have been reported in literature, most of these on burns and different types of injuries involving trauma to multiple sites.

Some authors have noted a trend of traditional wound bacteria (e.g. Staphylococcus aureus) being replaced by Enterobacter species and other nosocomial pathogens. The prevalence of Enterobacter resistance to beta-lactam antibiotics, aminoglycosides, trimethoprim-sulfamethoxazole, and quinolones seems to be higher in certain European countries than in the United States and Canada. E. cloacae infection is associated with the highest mortality rate of all Enterobacter infections.

From here, the surgeon decided to try a honey-based ointment and mesh. Honey is known for being an effective agent against gram negative bacteria. In comparison to silver dressing treated patients and control groups, honey was shown to stimulate the growth of new cells to a significantly greater extent than other treatments. 

The wound was cleaned daily with saline before the honey-mesh was applied on the wound, which was then covered with a layer of the honey ointment. This was covered and fixated with gauze to function as light compression therapy. The applications with L-Mesitran Ointment were easy and did not irritate the surrounding area. Dressing regime was subject to bandage changes every 24 hours during the 5 day in-patient hospital stay. On the 3rd day of medical grade honey treatment, the wound physiology changed.

On the 5th day, the malodour, debris, swelling and wound exudate improved dramatically. The patient was discharged and treated every 2 days on an outpatient basis. The discharge from the clinic and the apparent improvement of trauma had a positive impact on the patient’s psychology as there had been a possibility of losing her leg. Treatment was continued without any adverse effects and the trauma epithelialized completely within two months.

This case demonstrated what has been described in literature; Medical grade honey can offer a valuable addition (or replacement) in healing post-operative surgical wounds quickly and effectively, and it can prevent antibiotic use.