post surgical complications and feelings (some may find images disturbing)

[katm]

Pellicle, So happy they found the source of infection. But what a pandoras box. Happy that you are knowledgable enough to know what questions to now ask. I'm still thinking, "goretex sheet?" You said it is normally put there, I had no idea. Keep us posted

Take care,
Kat

 

[pellicle]

Thanks Kat

Keep ya posted

 

[pellicle]

This is the new debridement wound, now placed higher above the old wound

I begin to wonder am I discussing a recovery or something else?

Just a feeling I get

 

[ramjet]

Infection "source control" ..thats the key. The goretex is now removed, if that was harbouring the bugs things should finally get better for you now. Who knows where the infection came from, could even have come from your skin or anywhere and it just flourised in a nice bed of goretex..which is now gone..Stay in touch, let us know how you go good mate.

 

[pellicle]

Infection "source control" ..thats the key. The goretex is now removed, if that was harbouring the bugs things should finally get better for you now.

Yes, you are right of course. I also discussed that yesterday with the doctors.

Just hard to not think of the what iffs and keep a positive outlook.

Thanks for the pat on the head mate

 

[gerrychuck]

Hey, Pellicle; just picked up this thread after being away from the forum for a while. Hopefully you have now eliminated the source of the infection and can start to finally and completely heal (physically at least). This problem even crops up in orthopaedic surgery, particularly knee replacements where there are voids in the new joint that can harbour infection and create problems. Again, hopefully you are now on the road to full recovery.

I think your comments on not taking OHS lightly are bang on. I am happy with the mechanical valve chosen for me by my surgeon, and have not found managing my anticoagulation to be particularly onerous. OHS has been refined to the point that the risks are very manageable, but they still are present, and recovery takes both time and effort even in the best circumstances.

Take care and good luck with your continued recovery, friend.

 

[ramjet]

Pat on the head....nah, I'd give you a man hug in a flash..... but I'll wait until your chest is all healed

 

[Eva]

I just caught up with your thread as I have not been around for a long time.

I am sorry for what you have to deal with emotionally and physically, especially with the loss of your wife.

I had the same swelling like yours in your photos one day after the plaster was removed off my incision. It was so big that it touched my chin. I was given antibiotics right away until it was gone. Until today, the wires at the top of my incision bother me. But I SHALL NOT GO BACK TO THE HOSPITAL to have them removed, as the surgeon suggested!! NOWAY, as long as there is no infection.

Keep us posted and hope you will heal soon.

 

[pellicle]

UPDATE:

its now over a week post (second) debridement. The VAC dressing change on Friday showed green ooze ponding in the wound, however the dressing change on Monday (it is now Wednesday morning) showed almost no ponding of muck in the wound.

I am taking this as a positive sign.

Next dressing change in an hour.

 

[socalhome]

I hope all goes smoothly in next days.

 

[pellicle]

Hi

have a little time to write. Things are difficult in my life at the moment, so I'm not always inclined to do things.

one week post debridement:

green ooze ponding in the wound. I was worried...

10 days post debridement:

green ooze no longer ponding and wound looking as if improving.

12 days post debridement:

now looking like a 'healthy' wound. (should you regard something as this as a state of health)


I am encouraged by the rapid progress from looking green and disgusting to looking like a wound. Yes, the white thing is my sternum bone (well actually the manubrium).

Wound management people tell me that as long as the wound does not become infected now (from an external source) that it will be about 6 weeks for it to regrow tissue.

 

[socalhome]

Your wound does look good! Much better than the first pictures. I can only imagine that the infection, antibiotics, hospitalization, treatments and now continual debridements have been a huge physical and mental set back to recovery. Hopefully the next few weeks will continue to look this good and you can gain some strength and sleep!

 

[pellicle]

Well it seems that the discharge has come back.

At first I didn't see it in the images

But then today it was hard to not notice

Reviewing the earlier shot with this in light makes me wonder if I can't indeed see evidence of a small amount in the wound and trickling down the bone, as well as around the edges of the dressing surface too.

Next installment when I know more

 

[pellicle]

Since the 18th I have done some research and so far don't find much favorable.

For instance this (not atypical) study seems to suggest a rough path:

The term dehisence is new to me, and I must say that the botanical implications are more attractive than the medical namespace use of the term.

# Dehiscence (botany) is the spontaneous opening at maturity of a plant structure, such as a fruit, anther, or sporangium, to release its contents.
# Wound dehiscence is a previously closed wound reopening.

The condition of the sub-wound infection (which is beneath the sternum) has more more or less reverted back to oozing at the same rate as after the first debridement operation months ago. This has not exactly put me "on top of the world".

The infection control specialist says things such as "well, we can't really count the first operation, because on the second operation we found and removed foreign material. So it would never have healed like that"

Well sadly its not as easy for me to just forget about the discomforts of that first operation.

My research also reveals that this sort of infection is becoming more commonly diagnosed and had previously avoided being diagnosed (and perhaps even associated with the surgery) because of the difficult nature of isolating and culturing the bacterium.

I must say that the most disturbing term I have recently discovered is "serial debridement".

Since I have little else to do (except ooze and wait paitently for the outcome) I have been exploring some "horizontal" research on the topic of how this infection comes about. My suspicion so far is most likely from inadequate skin preparation and perhaps something falling into the wound from one of the team.

The most promising article I have read is this one:

Prosthetic valve endocarditis caused by Propionibacterium species successfully treated with coadministered rifampin: report of two cases
BMJ Case Reports 2013; doi:10.1136/bcr-2012-007204
Summary

We describe two cases of prosthetic valve endocarditis caused by Propionibacterium spp. successfully treated with a combination of rifampin and intravenous penicillin. Rifampin was chosen due to its promising activity against planktonic and biofilm Propionibacterium, its favourable minimal inhibitory concentrations, its excellent oral bioavailability and tissue penetration.

that microbiologists are now recognising that this infection behaves in a biofilm manner rather than a planktonic manner represents a major step forward.

Rifampin is associated with renal failure however so it might be out of the frying pan and into the fire ... who knows.

I guess that noone else on this forum has ever had any experience like mine.

So its perhaps worthwhile to keep writing here so that folks can see that it did happen to some one real (and not just a stat)

Its fair to say that I may be expressing a little bleakness or negativity at the moment. I hope you never get to really understand why.

Stay well, and stay out of surgery if you can.

PS: some additional readings for anyone else researching this topic (the key words may be helpful for your google scholar searches)

Propionibacterium acnes as a Cause of Prosthetic Valve Aortic Root Abscess
Journal of Clinical Microbiolgy. 2007 January; 45(1): 259–261.
Published online 2006 October 25. doi: 10.1128/JCM.01598-06

.. The patient was well for the intervening 2 years before being admitted to a community hospital with a 1-month history

.. The presence of Propionibacterium acnes is a rare proven cause of endocarditis, although its actual prevalence is probably underestimated (12). This organism can be difficult to recover from blood cultures if optimal anaerobic culture procedures have not been employed (7). The average time taken for the organisms to grow is 6 to 7 days, and prolonged culture of blood/tissue for up to 3 weeks, both aerobically and anaerobically, may be required in order to detect the organism (11).

Role of Rifampin against Propionibacterium acnes Biofilm In Vitro and in an Experimental Foreign-Body Infection Model
Antimicrob Agents Chemother. 2012 April; 56(4): 1885–1891.

.. While all tested antimicrobials showed good activity against planktonic P. acnes, for eradication of biofilms, rifampin was needed. In combination with rifampin, daptomycin showed higher cure rates than with vancomycin in this foreign-body infection model.

.. The role of P. acnes in foreign-body infections is probably underestimated due to technical reasons. Detection of anaerobes requires rapid transport to the microbiology laboratory or special transport media and needs incubation for up to 14 days due to slow growth (7, 40). Late growth and/or growth in enrichment media only is often misinterpreted as contamination. Furthermore, although P. acnes is usually introduced during surgery, clinical symptoms of low-grade infections often manifest only months to years after implantation. Therefore, the association between implant surgery and infection is not always obvious (14).

I include this one as it has valuable input in the successful culturing of P.acnes

The diagnosis and management of infection following instrumented spinal fusion
Eur Spine J. 2008 March; 17(3): 445–450.

Management of infection is controversial, with some advocating serial wound debridement while others report that infection cannot be eradicated with retention of implants.
Propionibacteria are a common cause of infection and successful eradication of infection cannot be reliably achieved with antibiotics and wound debridement alone.
Propionibacteria are fastidious organisms that are facultative and in some cases, obligate anaerobes. In our hands, they typically require culture in cooked meat broth for 7 days for broths to become positive.
Seventeen per cent of CRP results, 45% of ESR and 95% of WBC results were within the normal range prior to the diagnosis of infection. These data reflect the unreliability of inflammatory markers as diagnostic markers of spinal implants infection when caused by low-grade pathogens.

 

[ramjet]

Dear Pellicle,

Sometimes you add 2 + 2 and come up with 22.

I'm not being critical, and in fact quite encouraging I hope.

1. Your infection is nasty, its not something any of us would like, but so far, rfom what you have said, you don't have endocarditis, and may never get endocarditis...I hope.
You have a bacterial infection of the wound, and I hope that it clears up and doesn't go elsewhere.

2. A small, single centre study which doesn't stratify patients based on a myriad of other risk factors and comorbidities does not, and should not, convince anyone that should they get endocarditis, then all pathways (virtually) lead to death. No one wants to get endcarditis, and thats why many diligent physicians still recommend antibiotics when we have dental work, but can I provide some level of encouragement.

Currently you don't have endocarditis, and otherwise you seem to be a fit and healthy relatively young educated person, and I have every confidence that you will recover quite nicely from this wound infection ...finally....take care, stay positive and please show us the picture of your wound when it all heals up...

 

[pellicle]

Hi Roger

Dear Pellicle,

Sometimes you add 2 + 2 and come up with 22.

or indeed other things ...

I'm not being critical, and in fact quite encouraging I hope.

1. Your infection is nasty, its not something any of us would like, but so far, rfom what you have said, you don't have endocarditis, and may never get endocarditis...I hope.

that is correct, and I am quite aware of that. I know that I do not have endocarditis, I did not suspect I had endocarditis. However there is no other research which I have found which goes into the details of what this bacteria is and enumerates a successful treatment of it.

I have very little information to go on with this bacteria and its treatments, and so I apologize if I have given the impression that I think I have endocarditis.

although I must confess that I missed the encouragement in your message.

You have a bacterial infection of the wound,

correct, and it has been diagnosed (from the first debridement operation) as being propionibacteria, which is why I am researching that and its treatments and reporting that here.

The letter I sent recently to the infection control specialist confirms that we are both on the same page with this and confirms that he was also considering rifampin as his next course of action.

Please note the other articles discussing the effects of this bacteria on surgical implants and prostheses and they too were not 'endocarditis' sufferers but also had long and difficult treatment strategies.

and I hope that it clears up and doesn't go elsewhere.

me to ... but as the discharge is accelerating one can only assume that it is not yet 'clearing up'

something which I have not reported is the pains which suddenly appear and disappear. They are felt as being deep behind the sternum and are quite like being punctured by a bad blood taker. The pains last 30 / 40 seconds and subside from initial stab of onset.

After the first debridement operaiton these went away, then returned as the pus discharge increased. The same pattern is emerging again.

2. A small, single centre study

if you care to research the literature you will find lots more than one small center study. I did not wish to quote all of it, only what I thought of quoting at the time.

for example, another article not about endocarditis but about propioni...

Role of Rifampin against Propionibacterium acnes Biofilm In Vitro and in an Experimental Foreign-Body Infection Model

Propionibacterium acnes is an important cause of orthopedic-implant-associated infections, for which the optimal treatment has not yet been determined. We investigated the activity of rifampin, alone and in combination, against planktonic and biofilm P. acnes in vitro and in a foreign-body infection model.

... Rifampin cured 63% of the infected cages in combination with daptomycin, 46% with vancomycin, and 25% with levofloxacin. While all tested antimicrobials showed good activity against planktonic P. acnes, for eradication of biofilms, rifampin was needed.

you will agree that the prosthetic valve implant surgery bears resemblance to this surgery.


There is evidence that this bacteria will cause ulceration of the tissue it exists in. It is after all an anerobe that produces propanoic acid as a part of its waste metabolism.

...finally....take care, stay positive and please show us the picture of your wound when it all heals up...

will do.


Perhaps in your haste you have not actually read what I have written and indeed perhaps I have not been clear in writing up what I have either.

Does this clear things up? Do you agree that I am not making 22 out of 2 + 2? (perhaps that I am visualising 6 instead of 4)

Also if I seem to be 'anxious' or perhaps even 'hypochondriac' in my view of things I would ask that you point that out clearly. But keep in mind that in the last year there has been a lot going on. Three deaths in my immediate family and 1 major and 2 minor surgeries for me.

so perhaps I am not seeing the 'rosy' view ... perhaps I have become dark ... but its not without being given some cause to

 

[ramjet]

No No, it was quite clear good buddy, no need to clear things up, but you are indeed still coming up with 22.......

I guess I just wanted to say again that no matter how hard you look at the "evidence" none of it will directly predict your situation, (and I know you realise this) and there are so many variables, (and I know you also realise this), but one of the most powerful determinants of outcomes, and its impossible to measure in randomised controlled studies, is the power of positive, optimistic states of mind....

Reading small case series reports can be interesting, but can also have the effect of getting us worried, and whilst we should be informed about the 'what ifs', it can get us distracted from the facts. I know thats easy for me to say given I don't have an infection, but I do have another operation to go through in the next decade or two...(if I don't get eaten by a shark or hit by a car, or die from cancer).

I actually got some detailed survival data about my heart valve, and when you analyse the data closes, huge proportions of the patients who had poor outcomes from valve surgery also had COPD, and lots of other medical conditions, which, fortunately, I don't have. The same with yoru situation. So whilst your infection could become much worse, the chances are that this very very common bacteria (that unforunately can cause nasty infections in small numbers of patients) will be cleared up with the excellent medical treatment that you are getting. No need to reply, I know what you meant, I guess I just wanted to put another lighyt on the topic ...just to brighten things up a little bit for readers. Stay focussed good mate.

 

[pellicle]

ramjet makes some good points in his reply, and I wish to make reference to them.

I would like to make it clear that I am not disagreeing with his points, or attempting to rebut them. But they do make good stepping off points for what I wished to say.

I guess I just wanted to say again that no matter how hard you look at the "evidence" none of it will directly predict your situation, (and I know you realise this) and there are so many variables

this is very true of almost all of medical science. Having for instance diabetes or being a smoker will immediately change your situation. Even something as simple as our individual responces to adhesive tapes used in dressings shows the variance which exists. The outcomes I have presented above represent some of the worse cases. The best cases would be "go home you're fine".

Some may only wish to know the positive side. I wished to explore what are the possibilities and to understand how this "simple bug" could still be pestering me months after surgery. Based on the descriptions I got at the start of this it should have been cleared by now.

but it has not.

one of the most powerful determinants of outcomes, and its impossible to measure in randomised controlled studies, is the power of positive, optimistic states of mind....

Most definitely. I agree with this. For some more than others this is easy. However even for me there comes a point where it is very hard to maintain a positive view when life just bitch slaps you from one day to the next.

I feel that all too often on this forum I see nothing but (struggles for a term) happy surgeries attitudes. People start off being shocked that they have learned of a medical condition, then become terrorfied by the surgery they face.

This seems to then transform to "well, it wasn't that bad". Some months or years afterwards, and the very real risks of surgery are pushed behind them into the mists of "that happens to other people" and they embrace the idea that surgery isn't that dangerous. Their initial fears have proven to be groundless and they begin to regard themselves as veterans.

I am writing here as much to provide a balance case example to sober that notion up. Sure, noone else here has undergone this, but then the stats of its happening would tend to support that view.

Granted the risks of modern surgery are low, but do not be beguiled by a success into thinking - pah, surgery is a walk in the park. Suffer for a few months and the be fine.

Complications do happen. I am not wishing to exaggerate how often, but they do happen.

Before this surgery I was fit and active, a non smoker and did not tick the box of any pre-surgery co-morbidity check list. I suspect that I was in the top percentiles of fitness of people who are members of this forum. The infection by this bacteria had nothing to do with my health or attendant comorbidities. It had everything to do with the stats of what happens.

Actually I feel that I was lucky. I feel that the raging torrent of grief and sadness that I underwent at my wifes death had a profound effect on this emerging when it has. Had I not been weakened (from the immuno-perspective) by that situation (and I assure you that grief does weaken you) then I may indeed have taken some years later to present symptoms.

For this bacteria does not go away when it has wires or prostheses to rest in. It just grows slowly. Perhaps then I may have been presenting with a worse situation in 2 more years (as some of those other cases did). Who knows ...

I feel that there are members of this community who disagree with my views, perhaps they'd prefer I just didn't write of the suffering. I am sure that makes it easier for everyone if we all only report lovely things and discuss the positive sides. Sadly this results in me feeling like an alien here; unwelcome and unsupported. Like a messenger who brings bad news.

... but I try to keep a good and positive attitude.

 

[Leah]

Pellicle,

I am so sorry you have had to go through so much. Very unfair. I hope things start looking up for you very soon. Take good care of yourself, you are in my thoughts .

Leah

 

[Lucky]

Hi Pellicle,

You really are having a rough time not only with your wound infection but other issues in your life.

It is really important to remember that not only does infection lower your general well-being but also life-events play an important part.

If you cannot come here and share your experiences, surgeries and information then I do not know where you should go., and lets face it, it is more by the grace of god that it is not one of us having to experience this mess!

So keep your pecker up as they say and know that there are many of us routing for your speedy recovery and more than happy to respond to your post.

Best wishes
Adrienne