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Overwhelming postsplenectomy sepsis is a dreaded sequel of splenectomy. The rate of overwhelming sepsis in children after splenectomy for trauma is reported to be 10 to 30 times that of the general population. Episodes of pneumonia, septicemia, and meningitis in adults after a splenectomy are 166 times more common than in the general population. The care of a patient with burns and asplenia presents many unique management challenges to the burn physician. Awareness of the development of overwhelming postsplenectomy sepsis and its most common infecting organisms is crucial. The specific immunologic deficiencies of reduced immunoglobulin production and cell-mediated immunity that exist in patients after a splenectomy may be compounded by burn injury. Specific treatment recommendations for patients with burns and asplenia are lacking. We report a fatal case of overwhelming sepsis in a patient with asplenia and with an 8% total body surface area partial-thickness burn, and we review the pathogenesis of overwhelming postsplenectomy sepsis. We focus on treatment recommendations regarding the use of prophylactic antimicrobials, intravenous immunoglobulin replacement therapy, and pneumococcal polyvalent vaccine to standardize the care of the patient with burns and asplenia and reduce infectious morbidity and deaths.

Purpose: To determine risk factors for postoperative toxic shock syndrome (PTSS), a rare, rapidly progressive, and potentially fatal syndrome associated with postoperative wound infections. Components of PTSS include fever, rash, desquamation, hypotension, and multisystem organ dysfunction., Methods: We conducted a retrospective review of all cases of PTSS occurring in 2 community hospitals from 1981 to 1993, following 390,000 surgical procedures., Results: There were 12 cases of PTSS among the procedures reviewed (0.003%). Orthopedic procedures included excision of accessory navicular and patellar realignment. Wounds ranged from those with scant superficial exudates to those with gross purulence; all cultures yielded Staphylococcus aureus. All tested isolates were susceptible to methicillin or cephalothin. Mean time from surgery to onset of symptoms was 4 days. All patients had sudden onset of fever; mean maximal temperature was 40 degrees C. All patients displayed a rash, most in a truncal "sunburn" pattern. Eleven of 12 patients desquamated. All patients required vigorous fluid resuscitation. All patients survived. No correlation could be demonstrated between PTSS and patient age, sex, preoperative skin preparation or antibiotics, members of surgical team, or duration of procedure., Conclusions: Early recognition and treatment of PTSS are essential. No risk factors for PTSS have been identified. PTSS should be considered in the postoperative, acutely febrile, systemically ill patient, though surgical wounds may be deceptively benign in appearance.

We describe a pediatric patient with burns who experienced a septic hip joint from hematogenous seeding by sustained Staphylococcus aureus bacteremia. A search for a central vascular focus of the bacteremia included the use of an indium scan, which localized purulence within the left hip joint. The physical findings, radiographic findings, and subsequent aspiration of the hip joint were diagnostic for a septic arthritis. This case alerts the physician that the pediatric hip is a potential site for infection in the presence of bacteremia. Once infected, the joint may become a secondary source of an ongoing bacteremia. The diagnostic work-up and treatment for a septic hip have been discussed. This occult site of infection is easy to overlook because a painful hip joint in the pediatric patient with burns may be confused for painful burn wounds. The prerequisites to joint infections in this population were all present: bacteremia, intercurrent illness, unique vascular anatomy, and an impaired immune response.

Enterococcal endocarditis occurred in a young man with tetralogy of Fallot who had just completed therapy for staphylococcal endocarditis. The patient had a transient reversal of flow through the ventricular septal defect during staphylococcal endocarditis with lung abscesses and had persistently elevated teichoic acid antibody titers during the second episode caused by enterococcus. Our review of the literature on recurrent infective endocarditis indicates that our case represents one of the shortest intervals of recurrence with a second organism.

One hundred sixteen infants in an intensive care nursery acquired Staphylococcus aureus resistant to gentamicin and methicillin; 54 patients acquired S. aureus sensitive to gentamicin and methicillin. Topical application of gentamicin ointment was significantly associated with acquisition of GMRS. Of 78 infants who acquired GMRS, 38 had received GmO before GMRS was first cultured, whereas only one of 49 infants with GMSS had previously received GmO (P = 8.6 X 10(-8)). Infants with GMRS were also more likely than patients with GMSS to have had a lower mean birth weight, Apgar score, and gestational age; systemic antibiotic therapy and incubator care were significantly prolonged for patients with GMRS, but these factors did not explain susceptibility to GMRS infection. Multivariate logistic regression analysis showed that use of GmO was the single most important risk factor.