Cellulitis & Hardware ... Advice Needed

[smileplur]

Hi All,

I have posted here before with good results. So, I am going to try again. I will thank you in advance for any advice you can give me in my situation.

2 years ago, I had a spiral fracture in the lower part of my right leg. This was due to a motorbike accident. As a result, I had an operation to install "hardware" in my lower leg. I had 1 rod, 2 plates, and 14 screws installed at Samitivej Sukhumvit Hospital. Since that time, my bone has healed 100% completely. However, I have experienced a great deal of pain. I have been on codeine for the duration of the two years. I have taken breaks from the pain medication for a few weeks here and there when my work load was light. I haven't been on the pain meds for about a month and a half. I haven't had any problems regarding that.

3 weeks ago, I had serious pain in my leg. Actually, it was near one of the scars from the surgery at the top of my right ankle. It became inflamed and red. I didn't think too much of it, but the pain became worse. One day, puss and a small amount of blood came out. Immediately, I made an appointment with my doctor at Samitivej who was responsible for my post-op care (and surgery).

Last Monday, I went to visit him. I have no complications from the hardware, and the bone has healed completely. I was sent to an infection specialist. He said that I had a bacterial infection. He said he wasn't sure if he could eliminate it. He wanted to admit me immediately for extraction of the titanium. I thought this was a bit extreme. I thought the best course of action would be to try antibiotics to remove the infection before surgery.

He put me on Cravit for a week (500 mg a day) and gave me codeine. He sent me on my way. Since I began my course of antibiotics, I haven't had any discharge at all. The redness has reduced by 85%. What is still red, is now a light pink. The pain has lessened significantly. The swelling is gone.

I had to postpone my follow up appointment with him and the surgeon. He will again push for extraction of the hardware.

I am aware that bacteria can live in the biofilm that develops on such hardware. I'm also aware that antibiotics cannot reach the biofilm. I also understand that they have no way of knowing if the bacteria is living in the biofilm or not; however, removing it means the infection can fully be resolved if it lives in the biofilm. While I might be able to kill off the symptoms now, the infection can return if it is alive in the biofilm.

I don't have a lot of time at the moment. I have a family to support. I have work to do. My family (wife and 1 year old child) are scheduled to fly to the US on the 25th of April.

I thought about going to Bumrungrad for a second opinion until it dawned on me that they are just as business oriented as Samitivej. I am now leaning towards taking myself to Sukhumvit Hospital to see what their opinion is.

What do you think about this situation?

Thanks again for your help!

[thepool]

As soon as the infection settles plan for the hardware to be removed.

The chances of repeat episodes of "cellulitis " are high and can lead to serious complications.

This is a recognised problem associated with internal fixation of lower leg fractures.

You have received good advise which is not based on "business" but good clinical practice.

Edit

spelling

Edited March 30, 2014 by thepool

[smileplur]

As soon as the infection settles plan for the hardware to be removed.

The chances of repeat episodes of "cellulitis " are high and can lead to serious complications.

This is a recognised problem associated with internal fixation of lower leg fractures.

You have received good advise which is not based on "business" but good clinical practice.

Edit

spelling

Thank you for taking the time to reply. I certainly appreciate it.

I am no doctor, but I have done a bit of research myself about the issue. The doctors weren't able to articulate it to me very well in English at Samitvej which is quite shocking considering the sums of money they charge and their 'branding' as an international hospital with translators present for many different languages.

I spelled it out in the OP very quickly, as it is my hope that people responding will understand terms like 'biofilm'. I also hope they will understand that antibiotics work by cellular diffusion. If there are no cells in the biofilm, my understanding is that antibiotics are absolutely useless. Changing the route of administration of antibiotics will also be futile for the same reason. Therefore, my understanding is that IV Antibiotics will be just as useless as orally administered antibiotics.

It would seem more logical to me (and most of the medical information I have reviewed) to first attempt to clear the cellulitis using the 'normal' method. Because we haven't got the technology to determine if it is living in the biofilm, it is a guessing game. Invasive surgery should be the last step. If the cellulitis were to return, it would be time to explore having surgery. However, there is a very good chance that the infection is concentrated in the cells at the epidermis level. It would be foolish to blindly believe that bacteria has penetrated deep beneath the surface of the skin and infiltrated the biofilm. My understanding is that this does occur sometimes, but it isn't too frequent. Cellulitis is frequent in this part of the world. Even more frightening is the fact that many of the bacteria that cause the problem are resistant to antibiotics for reasons we all know.

Looking at the choice of antibiotics given to me vs. those recommended on many websites I have read, I also question if Cravit (Levofloxacin) is a good choice. The doctor told me that he was just making a guess, as he couldn't accurately prescribe me the correct antibiotic without a sample of the puss. Fortunate or not, no puss has come out since Monday.

Nearly a week later, the pain associated with the cellulitis has almost diminished. I still have the regular pain I have experienced since the operation, but the very localized, different pain that came with the infection is almost gone entirely. The redness has turned pink in the area where discoloration still persists. That discoloration is an area of 20% or less of the original bright red. The swelling is gone.

As I said, I am scheduled to depart for America with my wife and 1 year old son on 25 April. In addition to that, I have work that must be completed before I leave. It is impossible for me to do my job remotely.

Complicating matters more, my insurance is pretty useless. While I always thought I was well covered, I know that I am not now. My understanding of the policy provided by my employer came directly from their verbal translation of the policy. It wasn't until this accident that I realized the gravity of the situation. My initial surgery was around 300,000 Baht. My insurance (AIA) covered about 30,000 Baht of the total. After months of disputing it, I was sent a stack paperwork several inches high and a presented with a check for 150 Baht. I've never bothered to take that check to the bank. I laugh when it shows up from time to time when I am cleaning my house. So, financially, I am not in a very good position to pay for this out of pocket when it seems there are other avenues to explore first. If it is determined that I MUST remove the hardware, I am prepared to pay for the operation. However, I would prefer to be a bit more cautious about having such surgery.

Again, any advice given is most certainly appreciated.

[thepool]

You must follow your instincts and do what you believe to be right.

Take advise when you get back to the States but do not be surprised if advised to have the "hardware" removed!

Make sure you take all the clinical records/ x-rays back to the States.

BTW I do understand "biofilm" and I can also assure you that most (if not all) surgeons would wish to treat a cellulitis with IV antibiotics prior to undertaking a surgical procedure involving orthopaedic implants.

All the best whatever you decide

[Sheryl]

Unless there was a bite or other break in the skin which you have not mentioned that could account for the cellulitis, it probably did originate from the internal hardware. If there was such a lesion on the skin then yes, it is possible the cellulitis was incidental to the hardware and could wait and see. but if not, odds are good you will have to have it removed.

Bear in mind the risk of osteomyelitis (infection entering the bone) -- that is extremely serious and can take months, even years, to clear.

But by all means get other opinions. The issue is not the hospital as the doctor. "Hospitals" do not give advice, individuals doctors working in them do, and they are each different. Certainly you should see a doctor with fluent English able to discuss the pros and cons of various approaches to you clearly. There are such doctors at Samitivej, but apparently not the one you consulted.

As to the choice of antibiotic, clearly it was correct given the good clinical response.

Some well qualified infectious disease specialists:

Samitivej:

http://www.samitivejhospitals.com/DoctorProfile/INTERNAL_MEDICINE_11931553/en

Bumrungrad:

http://www.bumrungrad.com/doctors/Ekachai-Singhatiraj

However if I were you, I would first go back to the doc who saw you previously at Samitivej (and thus has the advantage of knowing how the leg looked prior to starting the antibiotic) and see what he now thinks. You say "He will again push for extraction of the hardware." but you do not in fact know this to be the case. From what you say, there has been a dramatic clinical response to oral antibiotics, better than had been anticipated.

I am not sure how waiting until you are in the US will help the situation in terms of finances/insurance? Surgery will cost all the more back there.

[smileplur]

Indeed, I am absolutely certain that I would be on a course of IV Antibiotics before sugery takes place. Even if the antibiotics cannot kill the bacteria that may or may not be alive in the biofilm, they need to be certain that they have made every attempt to eliminate as much of the infection in the cells around the area prior to operating. If they didn't, it would be a recipe for a disaster.

I am new to all of this. I have never had cellulitis before. Having had two family members pass away from sepsis, the thought of that possibility frightens me enormously. When mentioning that outcome, the doctor had a laugh. Apparently, I am nowhere near that stage or level of concern. Nonetheless, I am terrified of what the ramifications of this could be.

I am not planning to get treatment in the states, as I will only be there for 16 days. Rather, I was hoping to clear up the infection, return to the states to see my family (it's been a few years and they all want to meet my son), and return to Thailand. Upon return, I plan to continue to closely monitor the area of infection. If signs indicate the problem will recur, I would then strongly consider removing the hardware. I am not convinced that it will return. The doctor cannot say definitively that it will return. Rather, he immediately decided that surgery was the way forward. He wanted to admit me on the spot! My gut feeling was suspicious. I am still rather suspicious. It seemed like a hasty decision on his part.

Surgery is not something that should be taken lightly in my opinion. I do believe it should be a very well thought out decision that is made after other attempts to rectify the problem at hand have not been successful. I don't think a doctor in the states would be so quick to put you on the operating table. Lawsuits are far too common there to come to such a conclusion within the timeframe of 10 minutes at an initial consultation which is exactly what happened at Samitvej. Forgive me, but don't you think 10 minutes is a bit short to come to such a conclusion? This is especially true considering he hadn't spoken with the doctors and surgeon who were involved with my original operation despite the fact that they were a few minutes away.

[Sheryl]

As you are clearly unhappy with the doctor I again suggest you get another opinion (see my post above).

Though you might also first go back to him and see what he says in light of the good clinical response. It sounds to me like he was extremely worried about the risk of osteomyelitis when he first saw you hence the receommendation to proceed to surgery. He may feel more comfortable waiting a bit now.

[moe666]

I have had cellulitis since 1995 and it comes and goes, it can hide out in the bowel and when you are stressed it can reappear. My first episode was a full blown case red swollen leg very painful and as the Dr. said as she examined me where is the bite mark or wound, I had none. After a week in the hospital on IV antibiotics I was sent home. I have attacks over the years but only one other hospitalization and that was at Ram Hospital in Chiang Mai, the other outbreaks have been handled with oral antibiotics. I am in need of a knee replacement and I am a bit worried about infection because of my history.