Microbiological
Studies of Decubitus
Ulcers in Children
By ltzhak Brook
Bethesda, Maryland 0 Specimens from 58 children with decubitus ulcers were cultured for aerobic and anaerobic bacteria. Aerobic bacteria only were present in 29 (50%) ulcers, anaerobic bacteria only were recovered in 5 (9%). and mixed aerobic and anaerobic flora were present in 24 (41%). A total of 132 isolates (79 asrobes. 53 anaerobes) were recovered, an average of 2.3 isolates per specimen (1.4 aerobes, 0.9 anaerobes). The smallest number of isolates was recovered in ulcers of the skull (1.7 per site), and the highest number of isolates was found in ulcers of the buttocks (4.1 per site). The predominant isolates were Sfaphy/ococcus aureus (25 isolates), Peptostreptococcus species (22). Bacteroides fragilis group (IO), and Pseudomonas aeruginosa (7). Forty-two of the organisms isolated from 38 (58%) patients produced the enzyme p-lactamase. Most of the S aureus isolates were recovered from ulcers of the hand and the leg. Organisms that resided in the mucous membranes close to the ulcer predominated in the wounds next to these areas. Enteric gram-negative rods, group D streptococci, and B fragilis group predominated in ulcers of the buttocks. Group A streptococci, Haemophilus influenzae, Bacteroides melaninogenicus group, and Fusobacterium species were most frequently recovered in ulcers of the skull. The polymicrobial etiology of decubitus ulcers in hospitalized children and the association of bacterial flora with the anatomical site of the ulcer are demonstrated. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
D
Decubitus ulcers, pediatric;
bacterial flora.
ULCERS may occur in children who are bedridden for prolonged periods of time. These ulcers often harbor multiple aerobic and anaerobic organisms.1-3 The predominant organisms recovered from these ulcers are gram-negative enteric bacteria, Staphylococcus aureus, Streptococcus faecalis, anaerobic gram-positive cocci, and Bacteroides species. Previous studies of decubitus uIcers in adults”’ and children’ described the microbiology of these infections, but did not correlate the microbial flora with the anatomical location of the decubitus ulcers. This retrospective study was designed to investigate the aerobic and anaerobic bacteriology of decubitus ulcers in children, and correlate these findings with the sites of these ulcers. ECUBITUS
MATERIALS
AND METHODS
Patients Fifty-eight pediatric patients with decubitus ulcers were included in the study. Of these, 31 were boys and 27 were girls. Their ages ranged from 5 months to 16 years (mean age, 6 years 5 months). They were hospitalized between June 1976 and September 1981 at Fairview State Hospital (Costa Mesa, CA) and JournalofPediafric Surgery,
Vol26, No 2 (February), 1991: pp 207-209
Children’s Hospital (Washington, DC). These children suffered from mental retardation (31), congenital hydrocephalus (12) brain damage (ll), and hospitalization for prolonged periods of time because of surgical conditions (4). Eighteen of the ulcers were in the scalp (including all patients with hydrocephalus), 15 in the hands, 13 in the legs, 9 in the buttocks, and 3 at other sites. Antimicrobial agents were administered to 21 of the patients before sample collection. f3-Lactam-resistant penicillins were given to nine patients, ampicillin to six, cephalosporins to five, clindamytin to four, penicillin to three, and gentamicin to two.
Microbiological Methods Cultures were obtained by the following technique. The surface of the wound was prepared by vigorous scrubbing with povidoneiodine, rinsing with saline, and debridement. Specimens were obtained by scraping the base of the ulcer or deep portion of the wound with a sterile curette. Whenever possible, an aspirate of the material was obtained from the moist wound using a 16-gauge needle and syringe. Direct Gram stain was done to all aspirates. The air was evacuated from each syringe, and the syringe was sealed with a rubber stopper. Then the syringe specimens were transported to the laboratory. The swab specimens were transported in an anaerobic transport tube (Port-A Cul, Becton Dickson Company, Cockeysville, MD). The time between the collection of material and the inoculation of specimen was never more than 30 minutes. Specimens were inoculated onto 5% sheep blood, chocolate, and MacConkey’s agar plates for aerobic and facultative organisms. The plates were incubated at 37°C aerobically (MacConkey’s) or under 5% CO2 (5% sheep blood and chocolate), and examined at 24 and 48 hours. For anaerobes, the material was plated onto prereduced vitamin K,-enriched brucella blood agar, an anaerobic blood agar plate containing kanamycin and vancomycin, an anaerobic blood plate containing phenylethyl alcohol, and an enriched thioglycolate broth (containing bemin and vitamin K,).” The anaerobic plates and thioglycolate broth were incubated in GasPak jars (BBL, Cockeysville, MD), and examined at 48 and 96 hours. Venous blood for blood cultures was obtained from 24 patients after cleaning the skin with povidone-iodine and isopropyl alcohol. Blood (2 mL) was inoculated into 20 mL of broth in both a Lederle Blood Culture Bottle-SPS (Lederle Diagnostics, Pearl River, NY) for anaerobes, and a Liquid Blood Culture Bottle (Roche Diagnostic, Nutley, NJ) for aerobes. Routine Gram stain and subculture were performed after a 24-hour incubation period. After 7 days of incubation, the blood culture bottles were observed daily for up to 14 days, and Gram stain and subculture were performed whenever bacterial growth was suspected.
From the Department of Pediatrics, Naval Hospital, Bethesda, MD. Date accepted: February 5, 1990. The opinions and assertions contained herein are theprivate ones of the author and are not to be construed as official or reflecting the vtews of the Navy Depattment or the naval service at large. Address reprint requests to Itzhak Brook MD, MSc, Armed Forces Radiobiology Research Institute, Bethesda, MD 20814-5145. Copyright o 1991 by U! B. Saunders Company 0022-346819112602-0023$03.00/O
207
208
ITZHAK BROOK
Table 1. Characterization Scalp
Hand
of 58 Decubitus Ulcers Leg
Buttocks
Others
All Sites
No. of ulcers
18
15
13
9
3
58
Percentage of total cultures Type of bacterial growth
31
26
22
16
5
100
Aerobes only
6
11
10
0
2
29
Anaerobes only
4
0
0
1
0
5
8
4
3
8
1
24
Aerobes and anaerobes Bacterial isolates/ulcer Aerobes
0.8
1.4
1.5
2.4
1
1.4
Anaerobes
0.9
0.9
0.5
1.7
0.3
0.9
Total
1.7
2.3
2.0
4.1
1.3
2.3
Anaerobes were identified by techniques previously described.4 Aerobic bacteria were identified using conventional methods.5 P-Lactamase activity was determined on all organisms, using the chromogenic cephalosporin analog 87/312 methodology.6 RESULTS
Microorganisms were recovered from all specimens (Table 1). Aerobic bacteria only were present in 29 specimens (50%), anaerobic bacteria only were recovered in 5 (9%), and mixed aerobic and anaerobic flora were present in 24 (41%). A total of 132 isolates (79 aerobes, 53 anaerobes) were recovered, an average of 2.3 isolates per specimen (1.4 aerobes, 0.9 anaerobes) (Table 2). The average number of isolates per ulcer site is reported by anatomical area in Table 1. The smallest number of isolates per site was in ulcers of the scalp (1.7 per site), and the largest number was in ulcers of the buttocks (4.1 per site).
This was due to a higher number of both aerobes and anaerobes in the site. Mixed aerobic-anaerobic infections were found most often in the buttocks (8/9 instances). Eighteen (31%) of the ulcer cultures yielded only one organism. S aureu~ accounted for 13 (72%) of these instances. Three ulcers yielded pure cultures of a single anaerobe. The isolates recovered in these cases were one isolate each of Bacteroides fragilis, Bucteroides melaninogenicus, and Peptostreptococcus species. Table 2 shows the types of bacteria found in the ulcers. S aureus was present in 25 (43%) ulcers, and it was the only organism recovered in 13 (22%). Although S aureus was isolated from all areas, it predominated in the hand and the leg. S aureus mixed with anaerobic bacteria was recovered in five instances, and four of these were with Peptostreptococ-
Table 2. Isolation of Organisms From 58 Decubitus Ulcers at Different Anatomical Locations Total No. Hand
L-3
18
15
13
9
3
4
10
8
1
2
25
3
2 2
1
8
SXlp
No. of specimens
Buttocks
Others
of Isolates
Aerobic bacteria S aureus S epidermidis a and nonhem Streptococcus
2
1
2
Group A Streptococcus
3
4
2
Group D Streptococcus H influenzae
1
9 3
4
4
4
E coli Enferobacter
5
1
1
5
6
2
3
6
3
3
5
7
Proteus P aeruginosa
1
1
Kpneumoniae
1
1
21
19
22
79
8
1
5
22
3
2 1
2
8
10
1
5
Total no. of eerobes
14
2
Anaerobic bacteria Peptostreptococcus
7
P acnes Clostridium Eubacterium
1 1
2
B fragilis
5 4
1
2
E melaninogenicus
4
Fusobacterium
4
1
16
14
7
15
1
53
30
35
26
37
4
132
Total no. of anaerobes Total no. of isolates
5
MICROBIOLOGY
209
OF DECUBITUS ULCERS
cus species. Group A streptococci was never recovered from the buttocks, whereas three of the four isolates of group D streptococci were isolated from that site. All four isolates of Huemophilus influenzue were found in ulcers of the scalp. The most frequently isolated gram-negative enteric aerobes were Pseudomonas aeruginosa, Enterobacter species, and Escherichia coli. Most of these organisms were recovered from the buttocks and the leg. The predominant anaerobes were Peptostreptococcus species and Bacteroides species. Peptostreptococcus was isolated from all sites, whereas the Bfiagilis group was recovered from ulcers of only the buttocks and the leg. Most of the B melaninogenicus group and Fusobacterium species were recovered from the scalp. P-Lactamase activity was detected in 42 isolates recovered from 38 (66%) patients. These were all isolates of S aureus and the Bfragiri group, three of seven P aeruginosa, hvo of six E coli, and two of five of the B melaninogenicus group. Bacteremia occurred in five cases. The organisms isolated in the blood were similar to those found in the ulcers of these patients. These were S aureus and B ffagilis in two instances each, and E coli in one instance. The culture confirmed the interpretation of morphotypes in the corresponding Gram-stained smears in 40 of 58 (69%) of the ulcer specimens. DISCUSSION
This study supports previous observations’” documenting the polymicrobial nature of decubitus ulcers. Although the flora recovered in children is similar to the one recovered in adults, the recovery of H influenzae (a known pathogen in the pediatric age group) is unique to this age group.
S aureus, the most prevalent aerobe, was recovered in all areas but predominated in ulcers of the extremities. In contrast, organisms that resided in the mucous membranes close to the ulcer predominated in ulcers next to these sites. In this fashion, enteric gram-negative rods, group D streptococci, and the B fragilis group were found most often in ulcers of the buttocks. The most probable sources of these organisms are the rectal and vaginal orifices, where they normally reside.’ Group A streptococci, H influenzae, B melaninogenicus group, and Fusobacterium species were most commonly found in ulcers of the scalp that were close to the mouth, where they are part of the normal flora.* Similar distribution of bacterial flora was observed in cutaneous abscesses of adults and children’-” and in burns in children.” Because anaerobic bacteria are frequently associated with decubitus ulcers in pediatric patients, especially in areas adjacent to mucosal surfaces, physicians should anticipate their presence if antimicrobial therapy is used. Gram staining of the exudate and also appropriate aerobic and anaerobic techniques in cultivating specimens can help the physician in selecting the proper therapy. Because some of the anaerobes are resistant to penicillin, therapy in the more serious clinical situations should include coverage for these organisms. This could be important in the event of poor response to therapy, secondary spread of infection, or bacteremia. Surgical management is still the therapy of choice.
ACKNOWLEDGMENT The author gratefully acknowledges the laboratory support of L. Calhoun, P. Yocum, and J. Perry, and the secretarial assistance of Hayati Atan.
REFERENCES 1. Galpin JE, Chow AW, Bayers AS, et al: Sepsis associated with decubitus ulcers. Am J Med 61:346-350,1976 2. Lottie TJ, Bartlett JG, Tally FP, et al: Aerobic and anaerobic bacteria in diabetic foot ulcers. Ann Intern Med 85:461-463, 1976 3. Brook I: Anaerobic and aerobic bacteriology of decubitus ulcers in children. Am Surg 6:624-626,198O 4. Sutter VL, Citron DM, Finegold SM: Wadsworth Anaerobic Bacteriology Manual (ed 3). St Louis, MO, Mosby, 1980 5. Lennette EH, Balows A, Hausler W, et al: Manual of Clinical Microbiology (ed 3). Washington, DC, American Society for Microbiology, 1980 6. O’Callaghan CH, Morris A, Kirby SM, et al: Novel method for detection of p-lactamase by using a chromogenic cephalosporin substrate. Antimicrob Agents Chemother 1:282-288,1973
7. Gorbach SL: Intestinal microflora. Gastroenterology 60: 11lo1116.1971 8. Socransky SS, Manganiello SD: The oral microbiota of man from birth to senility. J Periodontol42:485-496, 1971 9. Brook I, Finegold SM: Aerobic and anaerobic bacteriology of cutaneous abscesses in children. Pediatrics 67:891-8951981 10. Brook I: Bacteriology of paronychia in children. Am J Surg 141:703-705, 1981 11. Meislin HW, Lerner SA, Graves MH, et al: Cutaneous abscesses: Anaerobic and aerobic bacteriology and outpatient management. Ann Intern Med 97:145-151,1977 12. Brook I, Randolph J: Aerobic and anaerobic flora of burns in children. J Trauma 21:313-318, 1981
Studies of Decubitus
Ulcers in Children
By ltzhak Brook
Bethesda, Maryland 0 Specimens from 58 children with decubitus ulcers were cultured for aerobic and anaerobic bacteria. Aerobic bacteria only were present in 29 (50%) ulcers, anaerobic bacteria only were recovered in 5 (9%). and mixed aerobic and anaerobic flora were present in 24 (41%). A total of 132 isolates (79 asrobes. 53 anaerobes) were recovered, an average of 2.3 isolates per specimen (1.4 aerobes, 0.9 anaerobes). The smallest number of isolates was recovered in ulcers of the skull (1.7 per site), and the highest number of isolates was found in ulcers of the buttocks (4.1 per site). The predominant isolates were Sfaphy/ococcus aureus (25 isolates), Peptostreptococcus species (22). Bacteroides fragilis group (IO), and Pseudomonas aeruginosa (7). Forty-two of the organisms isolated from 38 (58%) patients produced the enzyme p-lactamase. Most of the S aureus isolates were recovered from ulcers of the hand and the leg. Organisms that resided in the mucous membranes close to the ulcer predominated in the wounds next to these areas. Enteric gram-negative rods, group D streptococci, and B fragilis group predominated in ulcers of the buttocks. Group A streptococci, Haemophilus influenzae, Bacteroides melaninogenicus group, and Fusobacterium species were most frequently recovered in ulcers of the skull. The polymicrobial etiology of decubitus ulcers in hospitalized children and the association of bacterial flora with the anatomical site of the ulcer are demonstrated. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
D
Decubitus ulcers, pediatric;
bacterial flora.
ULCERS may occur in children who are bedridden for prolonged periods of time. These ulcers often harbor multiple aerobic and anaerobic organisms.1-3 The predominant organisms recovered from these ulcers are gram-negative enteric bacteria, Staphylococcus aureus, Streptococcus faecalis, anaerobic gram-positive cocci, and Bacteroides species. Previous studies of decubitus uIcers in adults”’ and children’ described the microbiology of these infections, but did not correlate the microbial flora with the anatomical location of the decubitus ulcers. This retrospective study was designed to investigate the aerobic and anaerobic bacteriology of decubitus ulcers in children, and correlate these findings with the sites of these ulcers. ECUBITUS
MATERIALS
AND METHODS
Patients Fifty-eight pediatric patients with decubitus ulcers were included in the study. Of these, 31 were boys and 27 were girls. Their ages ranged from 5 months to 16 years (mean age, 6 years 5 months). They were hospitalized between June 1976 and September 1981 at Fairview State Hospital (Costa Mesa, CA) and JournalofPediafric Surgery,
Vol26, No 2 (February), 1991: pp 207-209
Children’s Hospital (Washington, DC). These children suffered from mental retardation (31), congenital hydrocephalus (12) brain damage (ll), and hospitalization for prolonged periods of time because of surgical conditions (4). Eighteen of the ulcers were in the scalp (including all patients with hydrocephalus), 15 in the hands, 13 in the legs, 9 in the buttocks, and 3 at other sites. Antimicrobial agents were administered to 21 of the patients before sample collection. f3-Lactam-resistant penicillins were given to nine patients, ampicillin to six, cephalosporins to five, clindamytin to four, penicillin to three, and gentamicin to two.
Microbiological Methods Cultures were obtained by the following technique. The surface of the wound was prepared by vigorous scrubbing with povidoneiodine, rinsing with saline, and debridement. Specimens were obtained by scraping the base of the ulcer or deep portion of the wound with a sterile curette. Whenever possible, an aspirate of the material was obtained from the moist wound using a 16-gauge needle and syringe. Direct Gram stain was done to all aspirates. The air was evacuated from each syringe, and the syringe was sealed with a rubber stopper. Then the syringe specimens were transported to the laboratory. The swab specimens were transported in an anaerobic transport tube (Port-A Cul, Becton Dickson Company, Cockeysville, MD). The time between the collection of material and the inoculation of specimen was never more than 30 minutes. Specimens were inoculated onto 5% sheep blood, chocolate, and MacConkey’s agar plates for aerobic and facultative organisms. The plates were incubated at 37°C aerobically (MacConkey’s) or under 5% CO2 (5% sheep blood and chocolate), and examined at 24 and 48 hours. For anaerobes, the material was plated onto prereduced vitamin K,-enriched brucella blood agar, an anaerobic blood agar plate containing kanamycin and vancomycin, an anaerobic blood plate containing phenylethyl alcohol, and an enriched thioglycolate broth (containing bemin and vitamin K,).” The anaerobic plates and thioglycolate broth were incubated in GasPak jars (BBL, Cockeysville, MD), and examined at 48 and 96 hours. Venous blood for blood cultures was obtained from 24 patients after cleaning the skin with povidone-iodine and isopropyl alcohol. Blood (2 mL) was inoculated into 20 mL of broth in both a Lederle Blood Culture Bottle-SPS (Lederle Diagnostics, Pearl River, NY) for anaerobes, and a Liquid Blood Culture Bottle (Roche Diagnostic, Nutley, NJ) for aerobes. Routine Gram stain and subculture were performed after a 24-hour incubation period. After 7 days of incubation, the blood culture bottles were observed daily for up to 14 days, and Gram stain and subculture were performed whenever bacterial growth was suspected.
From the Department of Pediatrics, Naval Hospital, Bethesda, MD. Date accepted: February 5, 1990. The opinions and assertions contained herein are theprivate ones of the author and are not to be construed as official or reflecting the vtews of the Navy Depattment or the naval service at large. Address reprint requests to Itzhak Brook MD, MSc, Armed Forces Radiobiology Research Institute, Bethesda, MD 20814-5145. Copyright o 1991 by U! B. Saunders Company 0022-346819112602-0023$03.00/O
207
208
ITZHAK BROOK
Table 1. Characterization Scalp
Hand
of 58 Decubitus Ulcers Leg
Buttocks
Others
All Sites
No. of ulcers
18
15
13
9
3
58
Percentage of total cultures Type of bacterial growth
31
26
22
16
5
100
Aerobes only
6
11
10
0
2
29
Anaerobes only
4
0
0
1
0
5
8
4
3
8
1
24
Aerobes and anaerobes Bacterial isolates/ulcer Aerobes
0.8
1.4
1.5
2.4
1
1.4
Anaerobes
0.9
0.9
0.5
1.7
0.3
0.9
Total
1.7
2.3
2.0
4.1
1.3
2.3
Anaerobes were identified by techniques previously described.4 Aerobic bacteria were identified using conventional methods.5 P-Lactamase activity was determined on all organisms, using the chromogenic cephalosporin analog 87/312 methodology.6 RESULTS
Microorganisms were recovered from all specimens (Table 1). Aerobic bacteria only were present in 29 specimens (50%), anaerobic bacteria only were recovered in 5 (9%), and mixed aerobic and anaerobic flora were present in 24 (41%). A total of 132 isolates (79 aerobes, 53 anaerobes) were recovered, an average of 2.3 isolates per specimen (1.4 aerobes, 0.9 anaerobes) (Table 2). The average number of isolates per ulcer site is reported by anatomical area in Table 1. The smallest number of isolates per site was in ulcers of the scalp (1.7 per site), and the largest number was in ulcers of the buttocks (4.1 per site).
This was due to a higher number of both aerobes and anaerobes in the site. Mixed aerobic-anaerobic infections were found most often in the buttocks (8/9 instances). Eighteen (31%) of the ulcer cultures yielded only one organism. S aureu~ accounted for 13 (72%) of these instances. Three ulcers yielded pure cultures of a single anaerobe. The isolates recovered in these cases were one isolate each of Bacteroides fragilis, Bucteroides melaninogenicus, and Peptostreptococcus species. Table 2 shows the types of bacteria found in the ulcers. S aureus was present in 25 (43%) ulcers, and it was the only organism recovered in 13 (22%). Although S aureus was isolated from all areas, it predominated in the hand and the leg. S aureus mixed with anaerobic bacteria was recovered in five instances, and four of these were with Peptostreptococ-
Table 2. Isolation of Organisms From 58 Decubitus Ulcers at Different Anatomical Locations Total No. Hand
L-3
18
15
13
9
3
4
10
8
1
2
25
3
2 2
1
8
SXlp
No. of specimens
Buttocks
Others
of Isolates
Aerobic bacteria S aureus S epidermidis a and nonhem Streptococcus
2
1
2
Group A Streptococcus
3
4
2
Group D Streptococcus H influenzae
1
9 3
4
4
4
E coli Enferobacter
5
1
1
5
6
2
3
6
3
3
5
7
Proteus P aeruginosa
1
1
Kpneumoniae
1
1
21
19
22
79
8
1
5
22
3
2 1
2
8
10
1
5
Total no. of eerobes
14
2
Anaerobic bacteria Peptostreptococcus
7
P acnes Clostridium Eubacterium
1 1
2
B fragilis
5 4
1
2
E melaninogenicus
4
Fusobacterium
4
1
16
14
7
15
1
53
30
35
26
37
4
132
Total no. of anaerobes Total no. of isolates
5
MICROBIOLOGY
209
OF DECUBITUS ULCERS
cus species. Group A streptococci was never recovered from the buttocks, whereas three of the four isolates of group D streptococci were isolated from that site. All four isolates of Huemophilus influenzue were found in ulcers of the scalp. The most frequently isolated gram-negative enteric aerobes were Pseudomonas aeruginosa, Enterobacter species, and Escherichia coli. Most of these organisms were recovered from the buttocks and the leg. The predominant anaerobes were Peptostreptococcus species and Bacteroides species. Peptostreptococcus was isolated from all sites, whereas the Bfiagilis group was recovered from ulcers of only the buttocks and the leg. Most of the B melaninogenicus group and Fusobacterium species were recovered from the scalp. P-Lactamase activity was detected in 42 isolates recovered from 38 (66%) patients. These were all isolates of S aureus and the Bfragiri group, three of seven P aeruginosa, hvo of six E coli, and two of five of the B melaninogenicus group. Bacteremia occurred in five cases. The organisms isolated in the blood were similar to those found in the ulcers of these patients. These were S aureus and B ffagilis in two instances each, and E coli in one instance. The culture confirmed the interpretation of morphotypes in the corresponding Gram-stained smears in 40 of 58 (69%) of the ulcer specimens. DISCUSSION
This study supports previous observations’” documenting the polymicrobial nature of decubitus ulcers. Although the flora recovered in children is similar to the one recovered in adults, the recovery of H influenzae (a known pathogen in the pediatric age group) is unique to this age group.
S aureus, the most prevalent aerobe, was recovered in all areas but predominated in ulcers of the extremities. In contrast, organisms that resided in the mucous membranes close to the ulcer predominated in ulcers next to these sites. In this fashion, enteric gram-negative rods, group D streptococci, and the B fragilis group were found most often in ulcers of the buttocks. The most probable sources of these organisms are the rectal and vaginal orifices, where they normally reside.’ Group A streptococci, H influenzae, B melaninogenicus group, and Fusobacterium species were most commonly found in ulcers of the scalp that were close to the mouth, where they are part of the normal flora.* Similar distribution of bacterial flora was observed in cutaneous abscesses of adults and children’-” and in burns in children.” Because anaerobic bacteria are frequently associated with decubitus ulcers in pediatric patients, especially in areas adjacent to mucosal surfaces, physicians should anticipate their presence if antimicrobial therapy is used. Gram staining of the exudate and also appropriate aerobic and anaerobic techniques in cultivating specimens can help the physician in selecting the proper therapy. Because some of the anaerobes are resistant to penicillin, therapy in the more serious clinical situations should include coverage for these organisms. This could be important in the event of poor response to therapy, secondary spread of infection, or bacteremia. Surgical management is still the therapy of choice.
ACKNOWLEDGMENT The author gratefully acknowledges the laboratory support of L. Calhoun, P. Yocum, and J. Perry, and the secretarial assistance of Hayati Atan.
REFERENCES 1. Galpin JE, Chow AW, Bayers AS, et al: Sepsis associated with decubitus ulcers. Am J Med 61:346-350,1976 2. Lottie TJ, Bartlett JG, Tally FP, et al: Aerobic and anaerobic bacteria in diabetic foot ulcers. Ann Intern Med 85:461-463, 1976 3. Brook I: Anaerobic and aerobic bacteriology of decubitus ulcers in children. Am Surg 6:624-626,198O 4. Sutter VL, Citron DM, Finegold SM: Wadsworth Anaerobic Bacteriology Manual (ed 3). St Louis, MO, Mosby, 1980 5. Lennette EH, Balows A, Hausler W, et al: Manual of Clinical Microbiology (ed 3). Washington, DC, American Society for Microbiology, 1980 6. O’Callaghan CH, Morris A, Kirby SM, et al: Novel method for detection of p-lactamase by using a chromogenic cephalosporin substrate. Antimicrob Agents Chemother 1:282-288,1973
7. Gorbach SL: Intestinal microflora. Gastroenterology 60: 11lo1116.1971 8. Socransky SS, Manganiello SD: The oral microbiota of man from birth to senility. J Periodontol42:485-496, 1971 9. Brook I, Finegold SM: Aerobic and anaerobic bacteriology of cutaneous abscesses in children. Pediatrics 67:891-8951981 10. Brook I: Bacteriology of paronychia in children. Am J Surg 141:703-705, 1981 11. Meislin HW, Lerner SA, Graves MH, et al: Cutaneous abscesses: Anaerobic and aerobic bacteriology and outpatient management. Ann Intern Med 97:145-151,1977 12. Brook I, Randolph J: Aerobic and anaerobic flora of burns in children. J Trauma 21:313-318, 1981
