A 60-year-old woman with squamous cell carcinoma
of the glottis underwent laryngectomy, anterior neck dissection,
and pectoralis flap reconstruction of the anterior esophagus.
Postoperatively, she was started on clindamycin for surgical site
infection prophylaxis. On postoperative day three, increased
drainage from the surgical site was noted, which progressed and
required a return to the operating room for exploration on
postoperative day six. The site revealed purulent material with
involvement of the jugular sheath. Cultures of the wound were
taken, and the site was irrigated and re-closed.
Two days later, the wound cultures grew
Staphylococcus aureus. Per hospital protocol, the
microbiology laboratory called the nursing unit to report the
positive culture, and the patient's nurse informed the physician
team. Clindamycin was continued. Three days later, a final
sensitivity profile for the S. aureus isolate returned,
showing resistance to clindamycin. Hospital policy does not call
for notification to clinicians by the microbiology lab when a
"preliminary" culture result becomes "final" (when final
sensitivities become available). At this facility, physicians view
laboratory results in a scrolling text–based computer system,
which presents results in chronological order according to the time
of specimen collection. The final microbiology result and the
critical sensitivity results in this case remained in chronological
order (now 5 days prior). The physicians did not view the updated
culture results, and the patient remained on clindamycin.
The next day, the right internal jugular vein
ruptured, and the patient was taken emergently to the operating
room. A widespread infection of the surgical site with destruction
of the jugular sheath and erosion into the internal jugular vein
was noted. The internal jugular vein was ligated and sacrificed.
The patient died of sepsis and multiorgan system failure 3 days
later.
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