Noomprehensive management of multidrug-resistant bacterial and fungal infections after penetrating chest injury: Treatment of complex postinjury wound infection

Noomprehensive management of multidrug-resistant bacterial and fungal infections after penetrating chest injury: Treatment of complex postinjury wound infection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Noomprehensive management of multidrug-resistant bacterial and fungal infections after penetrating chest injury: Treatment of complex postinjury wound infection Mingwei Gong, zheping Yang, Juan Han This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7395382/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Dec, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 12 You are reading this latest preprint version Abstract This case report outlines the diagnosis and treatment of a middle-aged male patient who experienced high fall injuries complicated by multidrug-resistant bacterial and fungal infections. The patient sustained a penetrating injury to the right chest, which was accompanied by multiple areas of pain and bleeding. Following emergency surgery and chest drainage, he developed empyema, wound infection, high fever, and multiple organ dysfunction 15 days after the operation, necessitating his transfer from another hospital to our department. Upon admission, we implemented aggressive debridement and multiple vacuum-assisted drainage (VSD) procedures, alongside a comprehensive treatment plan aimed at addressing multidrug-resistant and fungal infections. After 30 days of intensive treatment, the patient experienced significant improvement and was discharged without complications. This case underscores the critical importance of effectively managing complex infections that can arise in the late stages of severe trauma, offering valuable insights for clinicians dealing with similar cases. chest penetrating injury Aspergillus Acinetobacter baumannii debridement VSD Figures Figure 1 Figure 2 Figure 3 Introduction High fall injuries, which occur when an individual falls from a height, are common in settings such as construction sites and homes. These injuries often result in severe trauma, leading to potential complications such as multiple organ damage, bleeding, and infections [ 1 ] . Research indicates that patients with fall injuries frequently present with symptoms such as chest pain, difficulty breathing, and bleeding. Owing to the intricate nature of injury mechanisms, clinical diagnosis and treatment can be particularly challenging [ 2 ] . Therefore, timely surgical intervention and effective infection control measures during emergency care are essential for enhancing patient outcomes [ 3 ] . Case Introduction The patient is a middle-aged male who sustained a severe injury after falling from the sixth floor 15 days before admission. The specifics of the fall are not entirely clear, but a steel pipe, roughly the diameter of an adult wrist (approximately 6 cm), penetrates his right chest, resulting in significant bleeding, chest pain, tightness, and shortness of breath. Additionally, the patient experienced pain and bleeding in various areas, including the right shoulder, back, and abdomen. After the firefighters removed the external steel pipe, he was transported to a local county hospital. Given the nature of his "penetrating chest injury," emergency surgery was performed to extract the pipe, and he received ventilatory support, anti-infection treatment, and management for shock. Approximately 10 days after the operation, the patient developed a high fever, peaking at 39.5℃. A follow-up chest CT scan revealed multiple pulmonary contusions in both lungs; partial atelectasis with consolidation in the right lung(Fig. 2); and extensive soft tissue emphysema affecting the neck, chest wall, perineum, and bilateral scrotal areas. On the 12th day postoperation, the patient suffered from severe shock, necessitating high doses of vasopressors to sustain his blood pressure (norepinephrine at 0.8–1.0 µg/kg/min), respiratory failure (with an oxygenation index below 150 mmHg), liver and kidney dysfunction, and coagulopathy. The external hospital modified his antibiotic treatment to imipenem‒cilastatin (1.0 g) every 8 hours and actively managed the infected wound; however, his condition continued to deteriorate, prompting his transfer to our hospital on the 15th day following the injury. Upon admission, the patient presented with continuous analgesia and sedation, with a temperature of 39.3°C, a blood pressure of 98/42 mmHg (with norepinephrine infused at 1.2 µg/kg/min), and a heart rate of 124 beats per minute. The patient required ongoing ventilatory support, utilizing SIMV mode with PEEP set at 10 cmH2O, pressure support at 12 cmH2O, and an FIO2 of 60%, while peripheral blood oxygen saturation fluctuated around 94%. The surgical site revealed an elliptical wound measuring approximately 5 cm × 10 cm × 3 cm, characterized by surrounding tissue that was swollen and red, extending deep into the muscle layer. The edges and base of the wound displayed poor vitality and exudation, with some muscle and fascia showing signs of necrosis and structural disarratably, the local wound base tissue was black and necrotic, extending approximately 10 cm along the right axilla(The situation of chest wall infection after injury is shown in the Fig. 1: ①②③④). Given the patient's severe shock resulting from a penetrating steel injury, significant infection in the surgical area, and suspicion of fungal growth within the wound, empirical treatment was promptly initiated. This included meropenem at a dosage of 1 g every 8 hours, linezolid at 600 mg every 12 hours, and a voriconazole loading dose of 600 mg every 12 hours, followed by a maintenance dose of 400 mg every 12 hours, all while closely monitoring voriconazole blood levels. On the second day after the patient's admission, right chest wall debridement was carried out under general anesthesia because severe infection was observed in the right chest wall, which was found to be communicating with the pleural cavity. The surgical team opted for a primary approach that included debridement and drainage, specifically performing "right chest wall abscess debridement, necrotic rib and muscle removal, and wound drainage." This procedure aims to eliminate necrotic tissue thoroughly while placing a vacuum-assisted drainage system (VSD) to ensure adequate drainage. Following surgery, the patient continued to experience persistent fever, with peak temperatures remaining unchanged. Although his circulatory status was relatively stable compared with that at the time of admission and a negative fluid balance was achieved through PiCCO monitoring, he produced copious sputum and exhibited poor oxygenation. By the third day postadmission, cultures taken from the pleural cavity and VSD drainage fluid revealed the presence of Aspergillus fumigatus , while sputum culture revealed multidrug-resistant Acinetobacter baumannii (Carbapenem-resistant Acinetobacter baumannii,CRAB), which is sensitive to tigecycline. The patient faced severe trauma complicated by mixed infections, characterized by extremely severe infections, significant necrotic tissue, and fungal growth. The primary treatment objective was to remove as much of the infected tissue as possible while providing targeted anti-infection therapy. After a multidisciplinary consultation, the following decisions were made: first, multiple debridements and VSD drainage would be necessary to effectively remove necrotic tissue and ensure proper drainage of the wound; second, the anti-infection regimen would be guided by the "IDSA 2024 Guidelines for the Treatment of Antimicrobial Resistant gram-negative Bacteria," which recommended high-dose sulbactam-based combination therapy for CRAB. Consequently, the treatment plan included administering piperacillin-tazobactam 3 g every 8 hours, sulbactam 2 g every 8 hours, and a loading dose of 200 mg of tigecycline followed by 100 mg every 12 hours to combat the infection. Voriconazole is the first-line treatment for multisite Aspergillus infections, but its pharmacokinetic characteristics can vary significantly among individuals, particularly in patient populations such as those with liver dysfunction or those undergoing chemotherapy, which can affect drug bioavailability [ 4 ] . Consequently, it is crucial for physicians to adjust dosages on the basis of each patient's unique circumstances to achieve effective blood drug concentrations. Research indicates that the recommended blood concentration range for voriconazole is typically between 1–6 mg/L; maintaining this range can increase treatment success rates while minimizing the risk of adverse reactions [ 5 ] . Therefore, we continued antifungal treatment with voriconazole and closely monitored the blood drug concentrations to fine-tune the dosages accordingly. Research indicates that after effective initial treatment for Acinetobacter baumannii infections, gradually reducing the dosage and types of antibiotics while transitioning to safer and better-tolerated oral options, such as fluoroquinolones, is advisable [ 6 ] . Consequently, on the 14th day postinjury, we adjusted the antibiotic regimen to levofloxacin 600 mg once daily. For the management of Aspergillus infections, the continuation of antifungal therapy for 6–12 weeks following initial treatment is generally recommended [ 7 ] . In line with the "2018 CPS Practice Guidelines: Individualized use of Voriconazole" and considering the favorable oral bioavailability of voriconazole, we switched the antifungal treatment to oral voriconazole 200 mg every 12 hours on the 15th day postoperation. With respect to wound management, right chest wall debridement and vacuum-assisted closure (VSD) drainage were performed on the 2nd, 5th, 9th, and 13th days after admission9(Fig. 3:ABCD). With proactive treatment, the patient's overall condition markedly improved; purulent drainage decreased, granulation tissue developed well, and both necrotic tissue and pus significantly diminished. On the 16th day, the endotracheal tube was removed, and the patient was transferred back to a general ward(Fig. 3:E). By the 20th day, layered suturing was conducted to close the wound(Fig. 3:F). Owing to ongoing treatment, the patient's respiratory and circulatory functions gradually stabilized, and the wound healed effectively, leading to his discharge on the 30th day. Discussion Infections following severe trauma are closely associated with increased mortality rates among patients. Research indicates that infectious complications significantly increase the risk of death for those hospitalized. For example, a retrospective cohort study involving 150,948 trauma patients revealed that the inpatient mortality rate for those with infections was 10.5%, in stark contrast to the 2.1% reported for those without infections [ 8 ] . Furthermore, the impact of infections on mortality varies depending on the severity of the trauma. In cases of mild trauma, the mortality rate for infected patients reached 17.1%, whereas it was only 2.9% for uninfected individuals [ 8 ] . These findings suggest that infections not only influence survival rates but also may worsen the severity of trauma, thereby affecting overall prognosis. Consequently, prompt identification and management of posttraumatic infections are essential for improving patient survival outcomes. A specific case illustrates a complex penetrating chest injury resulting from a high fall, where the patient faced numerous complications during treatment, particularly in managing infections. These cases have significant clinical implications, highlighting the risks of severe infections and multiple organ dysfunction that can occur after high-risk injuries. Severe infections, with common pathogens, including Staphylococcus aureus , Streptococcus pneumoniae , Klebsiella pneumoniae , and Pseudomonas aeruginosa , are critical contributors to mortality following penetrating chest injuries. Notably, Staphylococcus aureus , especially methicillin-resistant Staphylococcus aureus (MRSA), is frequently encountered in hospital environments and is linked to severe infections and high mortality rates [ 9 ] . Additionally, Streptococcus pneumoniae is a leading cause of pneumonia and pleural infections, particularly among immunocompromised patients [ 10 ] . Klebsiella and Pseudomonas aeruginosa are commonly found in hospital-acquired infections and are often associated with coinfections with other pathogens, leading to complex clinical manifestations and treatment challenges [ 11 ] . Fungal infections, although relatively rare, should not be overlooked. Fungal infections, particularly Candida and Aspergillus infections, can lead to severe complications in immunocompromised patients. Studies have shown that after chest trauma, the incidence of fungal infections significantly increases in critically ill patients, especially in those who have been receiving long-term antibiotic or immunosuppressive therapy [ 12 ] . Therefore, when treating penetrating chest injuries, it is essential to consider the combined effects of various pathogens to develop an effective anti-infection treatment plan [ 11 ] . The invasion of foreign objects, such as a steel pipe penetrating the chest wall, significantly increases the risk of mixed infections [ 13 ] . In this case, the patient underwent emergency surgery and chest drainage; however, the persistence of high fever and multiple positive bacterial and fungal cultures later indicated inadequate infection control. This observation aligns with findings in the literature regarding the incidence of infections following chest injuries, highlighting the critical need for timely and effective anti-infection treatment [ 14 ] . Aspergillus infections are particularly severe and commonly affect patients with a weakened immune system, such as those who are receiving chemotherapy or organ transplantation or who are living with HIV. These infections can present with a range of symptoms and may lead to pulmonary infections or systemic fungal infections, often progressing rapidly and potentially resulting in fatal outcomes in severe cases [ 15 ] . For these patients, prompt and effective treatment is essential. Voriconazole, a broad-spectrum antifungal medication, is frequently used to treat Aspergillus infections because of its high efficacy and relatively favorable safety profile [ 16 ] . However, its pharmacokinetics can complicate its clinical use, particularly with respect to dosage adjustments and personalized treatment plans [ 17 ][ 18 ] . Research indicates that the clearance rate of voriconazole is affected by several factors, including patient age, liver function, CYP2C19 gene polymorphisms, and other medications being taken concurrently [ 19 ][ 20 ] . Therefore, a thorough understanding of the pharmacokinetic properties of voriconazole and its application strategies in treating Aspergillus infections is vital for clinicians to optimize treatment regimens and minimize the risk of adverse reactions [ 21 ][ 22 ] . In this patient, the management of infection involved the administration of empirical anti-infection treatment with a combination of multiple antibiotics. This approach is particularly important for addressing multidrug-resistant infections caused by Acinetobacter baumannii and Aspergillus fumigatus , where timely adjustments to the treatment regimen are crucial. Research has shown that the early implementation of targeted antifungal therapy can significantly improve patient prognosis [ 23 ] . In this case, the use of voriconazole for antifungal treatment, along with monitoring blood drug concentrations, underscores the importance of individualized treatment strategies. Additionally, selecting an appropriate surgical plan is a key factor in improving the prognosis and quality of life of patients suffering from severe trauma. The development of multiple organ dysfunction during treatment, particularly renal dysfunction, further complicates the patient's condition. The literature suggests that the incidence of multiple organ dysfunction following trauma is closely linked to the severity of infection, delays in treatment, and the patient's baseline health status [ 24 ] . Therefore, enhancing infection monitoring and implementing early interventions are critical. Patients with severe trauma often require meticulous management from various specialties. To effectively address infections that arise after high-risk injuries, clinicians should prioritize the early recognition and intervention of infections, especially given the increasing prevalence of multidrug-resistant pathogens, as this is vital for improving patient prognostic outcomes [ 25 ] . This case report has been approved by the Ethics Committee of the Third Affiliated Hospital of Chongqing Medical University (Fangda Hospital).All research participants and patients agreed to publication. Participants and patients in the study provided written informed consent for their personal or clinical details and any identifiable images published in this study. Abbreviations VSD Vacuum-assisted drainage CRAB Carbapenem-resistant Acinetobacter baumannii SIMV Synchronized Intermittent Mandatory Ventilation PEEP Positive End-Expiratory Pressure MRSA Methicillin-resistant Staphylococcus aureus Declarations registration details : This report does not belong to clinical trials, and the clinical trial number is not applicable. Funding Declaration: This report has no funding support, and there are no ccompeting interests among all authors. Consent to Publish declaration: This case report has been approved by the Ethics Committee of the Third Affiliated Hospital of Chongqing Medical University (Fangda Hospital).All research participants and patients agreed to publication. Participants and patients in the study provided written informed consent for their personal or clinical details and any identifiable images published in this study. Consent for publication: The publication has obtained the consent of patients and all researchers. Availability of data and materials: The data and images involved in the report are authentic and available. Authors' contributions: Mingwei Gong: Case writing and clinical data analysis. Zeping Yang: Collection of clinical data and image materials. Juan Han: Design and evaluation of the case report, modification of important knowledge content in the case Acknowledgements: I would like to express my gratitude to Dr. Baigang Yan,Dr. Shiwei Xu,Professor Lei Zhan for Their invaluable guidance and support throughout the writing of this paper. Author details: Emergency and Critical Care Medicine Center,The Third Affiliated Hospital of Chongqing Medical University (Fangda Hospital),Chongqing,China References Bolton L. Preventing Fall Injury. Wounds. 2019;31(10):269-271. Phelan EA, Rillamas-Sun E, Johnson L, et al. Determinants, circumstances and consequences of injurious falls among older women living in the community. Inj Moreland BL, Burns ER, Haddad YK. Differences in fall-related emergency departments visits with and without an Injury, 2018. J Safety Res. 82:367-370. doi:10.1016/j.jsr.2022.07.002 Barda O, Sadhasivam S, Gong D, et al. Aneuploidy Formation in the Filamentous Fungus Aspergillus flavus in Response to Azole Stress. Microbiol Spectr. 2023;11(4):e0433922. doi:10.1128/spectrum.04339-22 Ferreira EDS, Cordeiro LV, Silva DF, et al. Evaluation of antifungal activity, mechanisms of action and toxicological profile of the synthetic amide 2-chloro-N-phenylacetamide. Drug Chem Toxicol. 2024;47(2):191-202. doi:10.1080/01480545.2022.2158849 Monforte A, Los-Arcos I, Martín-Gómez MT, et al. Safety and Effectiveness of Isavuconazole Treatment for Fungal Infections in Solid Organ Transplant Recipients (ISASOT Study). Microbiol Spectr. 2022;10(1):e0178421. doi:10.1128/spectrum.01784-21 Salzer HJF. [Anti-infective treatment of fungal infections by Candida and Aspergillus]. Med Klin Intensivmed Notfmed. 2023;118(6):470-476. doi:10.1007/s00063-023-01051-6 Komori A, Iriyama H, Kainoh T, Aoki M, Naito T, Abe T. The impact of infection complications after trauma differs according to trauma severity. Sci Rep. 2021;11(1):13803. Published 2021 Jul 5. doi:10.1038/s41598-021-93314-5 Zhang K, Wang L. Successful management of a combined cardiopulmonary penetrating injury: a case report. Ann Transl Med. 2022;10(17):940. doi:10.21037/atm-22-3866 Peter SD, Ozoilo KN, Isichei MW, et al. Severe Chest Injury Revisited - An Analysis of The Jos University Teaching Hospital Trauma Registry. Niger J Clin Pract. 2021;24(8):1247-1251. doi:10.4103/njcp.njcp_92_21 Khang TT. Management of cardiac trauma and penetrating cardiac injuries with severe hemorrhagic shock: a 5-year experience. J Trauma Inj. 2024;37(4):268-275. doi:10.20408/jti.2024.0063 Schreyer C, Eckermann C, Neudecker J, Becker L, Schulz-Drost S. [VATS in Thorax Trauma]. Zentralbl Chir. 2023;148(1):74-84. doi:10.1055/a-1957-5511 Castro IPR, Valença GT, Pinto EB, Cavalcanti HM, Oliveira-Filho J, Almeida LRS. Predictors of Falls with Injuries in People with Parkinson's Disease. Mov Disord Clin Pract. 2023;10(2):258-268. Published 2023 Feb. doi:10.1002/mdc3.13636 Chen TY, Rajan SI, Saito Y. Nutritional Status Predicts Injurious Falls Among Community-Dwelling Older Adults: Does Sex Matter? J Appl Gerontol. 2023;42(11):2207-2218. doi:10.1177/07334648231184950 Xu RM, Yuan XL, Ge QQ, He YY, Cao QM. Observational study on Aspergillus infections in critically ill patients with coronavirus disease 2019 at a single medical center using sputum samples. J Infect Dev Ctries. 2025;19(5):677-682. Published 2025 May 31. doi:10.3855/jidc.20072 Xue W, Li Y, Zhao Q, et al. Research Note: Study on the antibacterial activity of Chinese herbal medicine against Aspergillus flavus and Aspergillus fumigatus of duck origin in laying hens. Poult Sci. 2022;101(5):101756. doi:10.1016/j.psj.2022.101756 Tang D, Song BL, Yan M, et al. Identifying factors affecting the pharmacokinetics of voriconazole in patients with liver dysfunction: A population pharmacokinetic approach. Basic Clin Pharmacol Toxicol. 2019;125(1):34-43. doi:10.1111/bcpt.13208 Boglione-Kerrien C, Zerrouki S, Le Bot A, et al. Can we predict the influence of inflammation on voriconazole exposure? An overview. J Antimicrob Chemother. 2023;78(11):2630-2636. doi:10.1093/jac/dkad293 Liu S, Yao X, Tao J, et al. Impact of CYP2C19, CYP2C9, CYP3A4, and FMO3 Genetic Polymorphisms and Sex on the Pharmacokinetics of Voriconazole after Single and Multiple Doses in Healthy Chinese Subjects. J Clin Pharmacol. 2024;64(8):1030-1043. doi:10.1002/jcph.2440 Roig J, DeBolt CA, Cabrera M, et al. Use of Respiratory and Contact Precautions to Decrease the Spread of SARS-CoV-2 Infection Was Not Associated with a Decrease in Endometritis-Intra-Amniotic Infection. Am J Perinatol. 2024;41(15):2082-2090. doi:10.1055/s-0044-1786034 Pantet O, Laurent A, Abdel-Sayed P, et al. Effective Management Of Topical Nosocomial Aspergillus Spp. Infections In Three Severely Burned Patients. Ann Burns Fire Disasters. 2021;34(3):235-239. Liu S, Li Z, Zheng J, He N. Invasive Aspergillus outbreak in inhalation injury: a case presentation and literature review. BMC Infect Dis. 2022;22(1):386. Published 2022 Apr 18. doi:10.1186/s12879-022-07366-7 Marfella R, Sardu C, D'Onofrio N, et al. Glycemic control is associated with SARS-CoV-2 breakthrough infections in vaccinated patients with type 2 diabetes. Nat Commun. 2022;13(1):2318. 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Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 14 Oct, 2025 Reviews received at journal 28 Sep, 2025 Reviewers agreed at journal 26 Sep, 2025 Reviews received at journal 25 Sep, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviews received at journal 24 Sep, 2025 Reviewers agreed at journal 23 Sep, 2025 Reviewers invited by journal 23 Sep, 2025 Editor assigned by journal 23 Sep, 2025 Editor invited by journal 22 Sep, 2025 Submission checks completed at journal 22 Sep, 2025 First submitted to journal 22 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7395382","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":524257338,"identity":"6111eaea-b51d-4dce-beab-62dfde4aa1f7","order_by":0,"name":"Mingwei Gong","email":"","orcid":"","institution":"Emergency and Critical Care Medicine Center,The Third Affiliated Hospital of Chongqing Medical University (Fangda Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Mingwei","middleName":"","lastName":"Gong","suffix":""},{"id":524257339,"identity":"3f407559-f20c-4f13-afa6-f367bfce313e","order_by":1,"name":"zheping 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14:29:21","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":59408,"visible":true,"origin":"","legend":"","description":"","filename":"4c36ea986ac546f3a21ad58c5654e2c11structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7395382/v1/4fb6061c615acef4a561ea08.xml"},{"id":92875345,"identity":"4a5c9039-44f3-41d1-8f6b-023cb6911aba","added_by":"auto","created_at":"2025-10-06 14:37:21","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66407,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7395382/v1/480b3a579a54720c317a0839.html"},{"id":92874671,"identity":"a8e2361c-856a-4e3a-b35e-548fa4c49748","added_by":"auto","created_at":"2025-10-06 14:29:21","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":389623,"visible":true,"origin":"","legend":"\u003cp\u003eillustrates the patient's chest wall infection following an injury, highlighting the notable presence of fungal growth within the wound.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7395382/v1/e5fd909c7344116fca4b74ec.jpeg"},{"id":92873025,"identity":"75817675-d9e9-4006-8211-a32ebe9f3cbf","added_by":"auto","created_at":"2025-10-06 14:21:21","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":183147,"visible":true,"origin":"","legend":"\u003cp\u003epresents the patient's repeat chest CT scan conducted after the injury, providing further insights into the condition of the chest wall and any associated complications.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7395382/v1/ddeb6ad70c0ac25f77d689b7.jpeg"},{"id":92873020,"identity":"b06244f5-23b6-436a-bfc3-98279ce3bd7b","added_by":"auto","created_at":"2025-10-06 14:21:21","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":808526,"visible":true,"origin":"","legend":"\u003cp\u003eillustrates the progression of the patient's wound healing over time. Panel A depicts the wound condition on June 20, followed by panel B, which shows the status on June 24. Panel C captures the condition on June 28, while panel D presents the wound's appearance on July 3. Panel E reflects the state of the wound on July 8, and finally, panel F displays the wound healing condition at the time of discharge.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7395382/v1/0b113c952af77da2e3ffd46c.jpeg"},{"id":99172956,"identity":"a306d2ce-8241-4283-be94-18ad99e084f6","added_by":"auto","created_at":"2025-12-29 16:12:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1713079,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7395382/v1/722e2443-2845-4599-9362-6f19e89ab514.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Noomprehensive management of multidrug-resistant bacterial and fungal infections after penetrating chest injury: Treatment of complex postinjury wound infection","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHigh fall injuries, which occur when an individual falls from a height, are common in settings such as construction sites and homes. These injuries often result in severe trauma, leading to potential complications such as multiple organ damage, bleeding, and infections\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Research indicates that patients with fall injuries frequently present with symptoms such as chest pain, difficulty breathing, and bleeding. Owing to the intricate nature of injury mechanisms, clinical diagnosis and treatment can be particularly challenging\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Therefore, timely surgical intervention and effective infection control measures during emergency care are essential for enhancing patient outcomes\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Case Introduction","content":"\u003cp\u003eThe patient is a middle-aged male who sustained a severe injury after falling from the sixth floor 15 days before admission. The specifics of the fall are not entirely clear, but a steel pipe, roughly the diameter of an adult wrist (approximately 6 cm), penetrates his right chest, resulting in significant bleeding, chest pain, tightness, and shortness of breath. Additionally, the patient experienced pain and bleeding in various areas, including the right shoulder, back, and abdomen. After the firefighters removed the external steel pipe, he was transported to a local county hospital. Given the nature of his \"penetrating chest injury,\" emergency surgery was performed to extract the pipe, and he received ventilatory support, anti-infection treatment, and management for shock. Approximately 10 days after the operation, the patient developed a high fever, peaking at 39.5℃. A follow-up chest CT scan revealed multiple pulmonary contusions in both lungs; partial atelectasis with consolidation in the right lung(Fig.\u0026nbsp;2); and extensive soft tissue emphysema affecting the neck, chest wall, perineum, and bilateral scrotal areas. On the 12th day postoperation, the patient suffered from severe shock, necessitating high doses of vasopressors to sustain his blood pressure (norepinephrine at 0.8–1.0 µg/kg/min), respiratory failure (with an oxygenation index below 150 mmHg), liver and kidney dysfunction, and coagulopathy. The external hospital modified his antibiotic treatment to imipenem‒cilastatin (1.0 g) every 8 hours and actively managed the infected wound; however, his condition continued to deteriorate, prompting his transfer to our hospital on the 15th day following the injury.\u003c/p\u003e\u003cp\u003eUpon admission, the patient presented with continuous analgesia and sedation, with a temperature of 39.3°C, a blood pressure of 98/42 mmHg (with norepinephrine infused at 1.2 µg/kg/min), and a heart rate of 124 beats per minute. The patient required ongoing ventilatory support, utilizing SIMV mode with PEEP set at 10 cmH2O, pressure support at 12 cmH2O, and an FIO2 of 60%, while peripheral blood oxygen saturation fluctuated around 94%. The surgical site revealed an elliptical wound measuring approximately 5 cm × 10 cm × 3 cm, characterized by surrounding tissue that was swollen and red, extending deep into the muscle layer. The edges and base of the wound displayed poor vitality and exudation, with some muscle and fascia showing signs of necrosis and structural disarratably, the local wound base tissue was black and necrotic, extending approximately 10 cm along the right axilla(The situation of chest wall infection after injury is shown in the Fig.\u0026nbsp;1: ①②③④). Given the patient's severe shock resulting from a penetrating steel injury, significant infection in the surgical area, and suspicion of fungal growth within the wound, empirical treatment was promptly initiated. This included meropenem at a dosage of 1 g every 8 hours, linezolid at 600 mg every 12 hours, and a voriconazole loading dose of 600 mg every 12 hours, followed by a maintenance dose of 400 mg every 12 hours, all while closely monitoring voriconazole blood levels.\u003c/p\u003e\u003cp\u003eOn the second day after the patient's admission, right chest wall debridement was carried out under general anesthesia because severe infection was observed in the right chest wall, which was found to be communicating with the pleural cavity. The surgical team opted for a primary approach that included debridement and drainage, specifically performing \"right chest wall abscess debridement, necrotic rib and muscle removal, and wound drainage.\" This procedure aims to eliminate necrotic tissue thoroughly while placing a vacuum-assisted drainage system (VSD) to ensure adequate drainage.\u003c/p\u003e\u003cp\u003eFollowing surgery, the patient continued to experience persistent fever, with peak temperatures remaining unchanged. Although his circulatory status was relatively stable compared with that at the time of admission and a negative fluid balance was achieved through PiCCO monitoring, he produced copious sputum and exhibited poor oxygenation. By the third day postadmission, cultures taken from the pleural cavity and VSD drainage fluid revealed the presence of \u003cem\u003eAspergillus fumigatus\u003c/em\u003e, while sputum culture revealed multidrug-resistant \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e (Carbapenem-resistant Acinetobacter baumannii,CRAB), which is sensitive to tigecycline. The patient faced severe trauma complicated by mixed infections, characterized by extremely severe infections, significant necrotic tissue, and fungal growth. The primary treatment objective was to remove as much of the infected tissue as possible while providing targeted anti-infection therapy. After a multidisciplinary consultation, the following decisions were made: first, multiple debridements and VSD drainage would be necessary to effectively remove necrotic tissue and ensure proper drainage of the wound; second, the anti-infection regimen would be guided by the \"IDSA 2024 Guidelines for the Treatment of Antimicrobial Resistant gram-negative Bacteria,\" which recommended high-dose sulbactam-based combination therapy for CRAB. Consequently, the treatment plan included administering piperacillin-tazobactam 3 g every 8 hours, sulbactam 2 g every 8 hours, and a loading dose of 200 mg of tigecycline followed by 100 mg every 12 hours to combat the infection. Voriconazole is the first-line treatment for multisite Aspergillus infections, but its pharmacokinetic characteristics can vary significantly among individuals, particularly in patient populations such as those with liver dysfunction or those undergoing chemotherapy, which can affect drug bioavailability\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Consequently, it is crucial for physicians to adjust dosages on the basis of each patient's unique circumstances to achieve effective blood drug concentrations. Research indicates that the recommended blood concentration range for voriconazole is typically between 1–6 mg/L; maintaining this range can increase treatment success rates while minimizing the risk of adverse reactions\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Therefore, we continued antifungal treatment with voriconazole and closely monitored the blood drug concentrations to fine-tune the dosages accordingly.\u003c/p\u003e\u003cp\u003eResearch indicates that after effective initial treatment for \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e infections, gradually reducing the dosage and types of antibiotics while transitioning to safer and better-tolerated oral options, such as fluoroquinolones, is advisable\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Consequently, on the 14th day postinjury, we adjusted the antibiotic regimen to levofloxacin 600 mg once daily. For the management of Aspergillus infections, the continuation of antifungal therapy for 6–12 weeks following initial treatment is generally recommended\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. In line with the \"2018 CPS Practice Guidelines: Individualized use of Voriconazole\" and considering the favorable oral bioavailability of voriconazole, we switched the antifungal treatment to oral voriconazole 200 mg every 12 hours on the 15th day postoperation. With respect to wound management, right chest wall debridement and vacuum-assisted closure (VSD) drainage were performed on the 2nd, 5th, 9th, and 13th days after admission9(Fig.\u0026nbsp;3:ABCD). With proactive treatment, the patient's overall condition markedly improved; purulent drainage decreased, granulation tissue developed well, and both necrotic tissue and pus significantly diminished. On the 16th day, the endotracheal tube was removed, and the patient was transferred back to a general ward(Fig.\u0026nbsp;3:E). By the 20th day, layered suturing was conducted to close the wound(Fig.\u0026nbsp;3:F). Owing to ongoing treatment, the patient's respiratory and circulatory functions gradually stabilized, and the wound healed effectively, leading to his discharge on the 30th day.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eInfections following severe trauma are closely associated with increased mortality rates among patients. Research indicates that infectious complications significantly increase the risk of death for those hospitalized. For example, a retrospective cohort study involving 150,948 trauma patients revealed that the inpatient mortality rate for those with infections was 10.5%, in stark contrast to the 2.1% reported for those without infections\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Furthermore, the impact of infections on mortality varies depending on the severity of the trauma. In cases of mild trauma, the mortality rate for infected patients reached 17.1%, whereas it was only 2.9% for uninfected individuals\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. These findings suggest that infections not only influence survival rates but also may worsen the severity of trauma, thereby affecting overall prognosis. Consequently, prompt identification and management of posttraumatic infections are essential for improving patient survival outcomes.\u003c/p\u003e\u003cp\u003eA specific case illustrates a complex penetrating chest injury resulting from a high fall, where the patient faced numerous complications during treatment, particularly in managing infections. These cases have significant clinical implications, highlighting the risks of severe infections and multiple organ dysfunction that can occur after high-risk injuries.\u003c/p\u003e\u003cp\u003eSevere infections, with common pathogens, including \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e, \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e, and \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e, are critical contributors to mortality following penetrating chest injuries. Notably, \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, especially methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (MRSA), is frequently encountered in hospital environments and is linked to severe infections and high mortality rates\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Additionally, \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e is a leading cause of pneumonia and pleural infections, particularly among immunocompromised patients\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Klebsiella and \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e are commonly found in hospital-acquired infections and are often associated with coinfections with other pathogens, leading to complex clinical manifestations and treatment challenges \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Fungal infections, although relatively rare, should not be overlooked. Fungal infections, particularly Candida and Aspergillus infections, can lead to severe complications in immunocompromised patients. Studies have shown that after chest trauma, the incidence of fungal infections significantly increases in critically ill patients, especially in those who have been receiving long-term antibiotic or immunosuppressive therapy \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Therefore, when treating penetrating chest injuries, it is essential to consider the combined effects of various pathogens to develop an effective anti-infection treatment plan\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe invasion of foreign objects, such as a steel pipe penetrating the chest wall, significantly increases the risk of mixed infections\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. In this case, the patient underwent emergency surgery and chest drainage; however, the persistence of high fever and multiple positive bacterial and fungal cultures later indicated inadequate infection control. This observation aligns with findings in the literature regarding the incidence of infections following chest injuries, highlighting the critical need for timely and effective anti-infection treatment\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAspergillus infections are particularly severe and commonly affect patients with a weakened immune system, such as those who are receiving chemotherapy or organ transplantation or who are living with HIV. These infections can present with a range of symptoms and may lead to pulmonary infections or systemic fungal infections, often progressing rapidly and potentially resulting in fatal outcomes in severe cases\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. For these patients, prompt and effective treatment is essential. Voriconazole, a broad-spectrum antifungal medication, is frequently used to treat Aspergillus infections because of its high efficacy and relatively favorable safety profile\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. However, its pharmacokinetics can complicate its clinical use, particularly with respect to dosage adjustments and personalized treatment plans\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Research indicates that the clearance rate of voriconazole is affected by several factors, including patient age, liver function, CYP2C19 gene polymorphisms, and other medications being taken concurrently\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e][\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Therefore, a thorough understanding of the pharmacokinetic properties of voriconazole and its application strategies in treating Aspergillus infections is vital for clinicians to optimize treatment regimens and minimize the risk of adverse reactions\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this patient, the management of infection involved the administration of empirical anti-infection treatment with a combination of multiple antibiotics. This approach is particularly important for addressing multidrug-resistant infections caused by \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e and \u003cem\u003eAspergillus fumigatus\u003c/em\u003e, where timely adjustments to the treatment regimen are crucial. Research has shown that the early implementation of targeted antifungal therapy can significantly improve patient prognosis\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. In this case, the use of voriconazole for antifungal treatment, along with monitoring blood drug concentrations, underscores the importance of individualized treatment strategies.\u003c/p\u003e\u003cp\u003eAdditionally, selecting an appropriate surgical plan is a key factor in improving the prognosis and quality of life of patients suffering from severe trauma. The development of multiple organ dysfunction during treatment, particularly renal dysfunction, further complicates the patient's condition. The literature suggests that the incidence of multiple organ dysfunction following trauma is closely linked to the severity of infection, delays in treatment, and the patient's baseline health status\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Therefore, enhancing infection monitoring and implementing early interventions are critical.\u003c/p\u003e\u003cp\u003ePatients with severe trauma often require meticulous management from various specialties. To effectively address infections that arise after high-risk injuries, clinicians should prioritize the early recognition and intervention of infections, especially given the increasing prevalence of multidrug-resistant pathogens, as this is vital for improving patient prognostic outcomes\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis case report has been approved by the Ethics Committee of the Third Affiliated Hospital of Chongqing Medical University (Fangda Hospital).All research participants and patients agreed to publication. Participants and patients in the study provided written informed consent for their personal or clinical details and any identifiable images published in this study.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVSD \u0026nbsp; \u0026nbsp; \u0026nbsp;Vacuum-assisted drainage\u003c/p\u003e\n\u003cp\u003eCRAB \u0026nbsp; \u0026nbsp; Carbapenem-resistant Acinetobacter baumannii\u003c/p\u003e\n\u003cp\u003eSIMV \u0026nbsp; \u0026nbsp; Synchronized Intermittent Mandatory Ventilation\u003c/p\u003e\n\u003cp\u003ePEEP \u0026nbsp; \u0026nbsp;Positive End-Expiratory Pressure\u003c/p\u003e\n\u003cp\u003eMRSA \u0026nbsp; \u0026nbsp;Methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eregistration details :\u003c/p\u003e\n\u003cp\u003eThis report does not belong to clinical trials, and the clinical trial number is not applicable.\u003c/p\u003e\n\u003cp\u003eFunding Declaration:\u003c/p\u003e\n\u003cp\u003eThis report has no funding support, and there are no ccompeting interests among all authors.\u003c/p\u003e\n\u003cp\u003eConsent to Publish declaration:\u003c/p\u003e\n\u003cp\u003eThis case report has been approved by the Ethics Committee of the Third Affiliated Hospital of Chongqing Medical University (Fangda Hospital).All research participants and patients agreed to publication.\u0026nbsp;Participants and patients in the study provided written informed consent for their personal or clinical details and any identifiable images published in this study.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003c/p\u003e\n\u003cp\u003eThe publication has obtained the consent of patients and all researchers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data and images involved in the report are authentic and available. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMingwei Gong: Case writing and clinical data analysis. Zeping Yang: Collection of clinical data and image materials. Juan Han: Design and evaluation of the case report, modification of important knowledge content in the case \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI would like to express my gratitude to Dr. Baigang Yan,Dr. Shiwei Xu,Professor Lei Zhan for Their invaluable guidance and support throughout the writing of this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor details:\u003c/p\u003e\n\u003cp\u003eEmergency and Critical Care Medicine Center,The Third Affiliated Hospital of Chongqing Medical University (Fangda Hospital),Chongqing,China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBolton L. Preventing Fall Injury. Wounds. 2019;31(10):269-271.\u003c/li\u003e\n\u003cli\u003ePhelan EA, Rillamas-Sun E, Johnson L, et al. Determinants, circumstances and consequences of injurious falls among older women living in the community. Inj\u003c/li\u003e\n\u003cli\u003eMoreland BL, Burns ER, Haddad YK. Differences in fall-related emergency departments visits with and without an Injury, 2018. J Safety Res. 82:367-370. doi:10.1016/j.jsr.2022.07.002\u003c/li\u003e\n\u003cli\u003eBarda O, Sadhasivam S, Gong D, et al. Aneuploidy Formation in the Filamentous Fungus \u003cem\u003eAspergillus flavus\u003c/em\u003e in Response to Azole Stress. Microbiol Spectr. 2023;11(4):e0433922. doi:10.1128/spectrum.04339-22\u003c/li\u003e\n\u003cli\u003eFerreira EDS, Cordeiro LV, Silva DF, et al. Evaluation of antifungal activity, mechanisms of action and toxicological profile of the synthetic amide 2-chloro-\u0026lt;i\u0026gt;N\u0026lt;/i\u0026gt;-phenylacetamide. Drug Chem Toxicol. 2024;47(2):191-202. doi:10.1080/01480545.2022.2158849\u003c/li\u003e\n\u003cli\u003eMonforte A, Los-Arcos I, Mart\u0026iacute;n-G\u0026oacute;mez MT, et al. Safety and Effectiveness of Isavuconazole Treatment for Fungal Infections in Solid Organ Transplant Recipients (ISASOT Study). Microbiol Spectr. 2022;10(1):e0178421. doi:10.1128/spectrum.01784-21\u003c/li\u003e\n\u003cli\u003eSalzer HJF. [Anti-infective treatment of fungal infections by Candida and Aspergillus]. Med Klin Intensivmed Notfmed. 2023;118(6):470-476. doi:10.1007/s00063-023-01051-6\u003c/li\u003e\n\u003cli\u003eKomori A, Iriyama H, Kainoh T, Aoki M, Naito T, Abe T. The impact of infection complications after trauma differs according to trauma severity. Sci Rep. 2021;11(1):13803. Published 2021 Jul 5. doi:10.1038/s41598-021-93314-5\u003c/li\u003e\n\u003cli\u003eZhang K, Wang L. Successful management of a combined cardiopulmonary penetrating injury: a case report. Ann Transl Med. 2022;10(17):940. doi:10.21037/atm-22-3866\u003c/li\u003e\n\u003cli\u003ePeter SD, Ozoilo KN, Isichei MW, et al. Severe Chest Injury Revisited - An Analysis of The Jos University Teaching Hospital Trauma Registry. Niger J Clin Pract. 2021;24(8):1247-1251. doi:10.4103/njcp.njcp_92_21\u003c/li\u003e\n\u003cli\u003eKhang TT. Management of cardiac trauma and penetrating cardiac injuries with severe hemorrhagic shock: a 5-year experience. J Trauma Inj. 2024;37(4):268-275. doi:10.20408/jti.2024.0063\u003c/li\u003e\n\u003cli\u003eSchreyer C, Eckermann C, Neudecker J, Becker L, Schulz-Drost S. [VATS in Thorax Trauma]. Zentralbl Chir. 2023;148(1):74-84. doi:10.1055/a-1957-5511\u003c/li\u003e\n\u003cli\u003eCastro IPR, Valen\u0026ccedil;a GT, Pinto EB, Cavalcanti HM, Oliveira-Filho J, Almeida LRS. Predictors of Falls with Injuries in People with Parkinson\u0026apos;s Disease. Mov Disord Clin Pract. 2023;10(2):258-268. Published 2023 Feb. doi:10.1002/mdc3.13636\u003c/li\u003e\n\u003cli\u003eChen TY, Rajan SI, Saito Y. 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Identifying factors affecting the pharmacokinetics of voriconazole in patients with liver dysfunction: A population pharmacokinetic approach. Basic Clin Pharmacol Toxicol. 2019;125(1):34-43. doi:10.1111/bcpt.13208\u003c/li\u003e\n\u003cli\u003eBoglione-Kerrien C, Zerrouki S, Le Bot A, et al. Can we predict the influence of inflammation on voriconazole exposure? An overview. J Antimicrob Chemother. 2023;78(11):2630-2636. doi:10.1093/jac/dkad293\u003c/li\u003e\n\u003cli\u003eLiu S, Yao X, Tao J, et al. Impact of CYP2C19, CYP2C9, CYP3A4, and FMO3 Genetic Polymorphisms and Sex on the Pharmacokinetics of Voriconazole after Single and Multiple Doses in Healthy Chinese Subjects. J Clin Pharmacol. 2024;64(8):1030-1043. doi:10.1002/jcph.2440\u003c/li\u003e\n\u003cli\u003eRoig J, DeBolt CA, Cabrera M, et al. Use of Respiratory and Contact Precautions to Decrease the Spread of SARS-CoV-2 Infection Was Not Associated with a Decrease in Endometritis-Intra-Amniotic Infection. Am J Perinatol. 2024;41(15):2082-2090. doi:10.1055/s-0044-1786034\u003c/li\u003e\n\u003cli\u003ePantet O, Laurent A, Abdel-Sayed P, et al. Effective Management Of Topical Nosocomial Aspergillus Spp. Infections In Three Severely Burned Patients. Ann Burns Fire Disasters. 2021;34(3):235-239.\u003c/li\u003e\n\u003cli\u003eLiu S, Li Z, Zheng J, He N. Invasive Aspergillus outbreak in inhalation injury: a case presentation and literature review. BMC Infect Dis. 2022;22(1):386. Published 2022 Apr 18. doi:10.1186/s12879-022-07366-7\u003c/li\u003e\n\u003cli\u003eMarfella R, Sardu C, D\u0026apos;Onofrio N, et al. Glycemic control is associated with SARS-CoV-2 breakthrough infections in vaccinated patients with type 2 diabetes. Nat Commun. 2022;13(1):2318. Published 2022 Apr 28. doi:10.1038/s41467-022-30068-2\u003c/li\u003e\n\u003cli\u003eKim SH, Kim S, Cho GC, Lee JH, Park EJ, Lee DH. Characteristics of fall-related head injury versus nonhead injury in the older adults. BMC Geriatr. 2021;21(1):196. Published 2021 Mar 20. doi:10.1186/s12877-021-02139-4\u003c/li\u003e\n\u003cli\u003eInoue Y, Nakata A, Tateishi S, et al. Insufficient Workplace Infection Control and Unhealthy Lifestyle Behaviors Are Related to Poor Self-Rated Health During the COVID-19 Pandemic. 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The patient sustained a penetrating injury to the right chest, which was accompanied by multiple areas of pain and bleeding. Following emergency surgery and chest drainage, he developed empyema, wound infection, high fever, and multiple organ dysfunction 15 days after the operation, necessitating his transfer from another hospital to our department. Upon admission, we implemented aggressive debridement and multiple vacuum-assisted drainage (VSD) procedures, alongside a comprehensive treatment plan aimed at addressing multidrug-resistant and fungal infections. After 30 days of intensive treatment, the patient experienced significant improvement and was discharged without complications. This case underscores the critical importance of effectively managing complex infections that can arise in the late stages of severe trauma, offering valuable insights for clinicians dealing with similar cases.\u003c/p\u003e","manuscriptTitle":"Noomprehensive management of multidrug-resistant bacterial and fungal infections after penetrating chest injury: Treatment of complex postinjury wound infection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-06 14:21:17","doi":"10.21203/rs.3.rs-7395382/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-14T16:55:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T04:29:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282396088560273409800656749422200863762","date":"2025-09-27T02:00:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-25T19:28:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173293300378065991163739799412018710012","date":"2025-09-25T17:24:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-25T02:51:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139199700289397626183952558740085751335","date":"2025-09-23T17:42:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-23T17:12:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-23T17:07:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-22T11:15:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-22T08:13:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-09-22T08:06:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"423bb4d4-d4bf-4d4e-af69-0e778f5f07af","owner":[],"postedDate":"October 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:10:45+00:00","versionOfRecord":{"articleIdentity":"rs-7395382","link":"https://doi.org/10.1186/s12879-025-12383-3","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-12-26 15:58:31","publishedOnDateReadable":"December 26th, 2025"},"versionCreatedAt":"2025-10-06 14:21:17","video":"","vorDoi":"10.1186/s12879-025-12383-3","vorDoiUrl":"https://doi.org/10.1186/s12879-025-12383-3","workflowStages":[]},"version":"v1","identity":"rs-7395382","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7395382","identity":"rs-7395382","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}