What is the worst type of infection there is? While nearly any answer to this question is by default subjective, here are the 5 worst infections from the perspective of a clinical infectious diseases pharmacist with significant experience in the field…
Authored By: Timothy P. Gauthier, Pharm.D., BCPS-AQ ID
In my time as a hospital-based infectious diseases (ID) pharmacist I have encountered patients with infections of the skin, muscle, bone, lungs, kidneys, liver, blood, brain, eye, prostate and pretty much every other body part too. From parasites to bacteria to viruses, I am absolutely amazed by all of the tiny microorganisms that try so hard to do us harm.
As a pharmacist, I do not claim to have the on-hand experience you would find from an infectious diseases physician or other diagnostician, but I have seen many patients during rounds and have spent countless hours reviewing the medical records of infected patients to assess the appropriateness of the prescribed medication regimens. This includes review of medication lists, imaging (e.g., CT, MRI), surgical reports, progress notes, microbiology results and more.
Having worked and trained at one of the largest tertiary care medical centers in the United States, I have had the opportunity to witness and learn from some very unique patient cases. Cases that you may encounter once in five years at smaller hospitals, we may see many times in a single year.
So, when I get the question: What do you do for a living? As you may expect, it is fairly common that one of the next questions is: What is the worst infection you have ever seen?
To be honest, there is no answer to this second question. They are all bad in their own way. However, I do find attempting to respond to be a positive educational exercise, as it forces you to differentiate why you hold one disease process “worse” than another.
With the intention that this post will serve to inform others about key concepts in the management of infectious diseases and antimicrobial chemotherapy, I have compiled the following list. This is completely opinion-based. The following are what I would consider the worst 5 infections.
1. Fournier’s gangrene
Qualifications: severity, location
Do not search this term on google unless you are prepared to see graphic images. Fournier’s gangrene is a necrotizing infection often effecting men and originating from the perineum (space between the genitals and the anus).
For this infection it is common to require surgical intervention to remove the necrotic (dead) tissue. Thus, the resulting post-surgical images can be quite striking.
A take-home lesson here is that removal of dead tissue is a cornerstone in the management of necrotizing infections. In this case, the location of such infection is extremely unfortunate. You can find a recent review of this infection here [1].
2. Invasive mucormycosis
Qualifications: severity, required intervention
This is an uncommon life-threatening fungal infection that I associate with the term “ice-cream scoop.” The association here is because of how surgical intervention for this infection was first described to me: “they essentially go in with an ice-cream scoop to clean it out.”
You see, blood vessel thrombosis that occurs results in tissue necrosis, which means poor penetration of antifungal agents to the infection site. In turn, debridement (removal) of the dead tissue is essential – and the removal of tissue can be considerable.
This infection more commonly occurs in patients with diabetes mellitus, neutropenia, malignancy or those who have received organ or hematopoietic stem cell transplant. Fortunately, this infection is extremely rare. You can find more about this infection here [2].
3. Clostridium difficile diarrhea
Qualifications: incidence, symptoms
As one of the most problematic infections in healthcare today, people with Clostridium difficile infection may experience diarrhea to the tune of 20 or more times per day! Combine that with the fact that nearly 250,000 Americans require hospitalization for this infection each year and you can see why the U.S. Centers for Disease Control and Prevention labeled it as an urgent threat [3].
Virtually all antibiotic drugs have the potential to cause Clostridium difficile infection, which is one of the ecological consequences of antibiotic use. One thing we can do to prevent this infection is to avoid unnecessary exposure to antibiotics.
4. Infections due to carbapenem-resistant & colistin-resistant bacteria
Qualifications: lack of safe & effective treatments
No these organisms may not be impressive at bedside since they do not typically cause dramatic flesh-eating infections, but in the microbiology lab their discovery garners immediate attention and respect.
Imagine you receive the results from susceptibility testing performed on an organism that grew after your infected patient was cultured. You read the result and there are no drugs listed as susceptible. What now? This is exactly if not very close to what happens many times when an organism is found to be carbapenem and/or colistin-resistant.
As drug resistance to our antibiotics spreads, people are saying we are beginning to re-enter a pre-antibiotic era [4]. I hope with all of my heart we never truly get there, but things are not looking so great. It is becoming all too frequent that clinicians frankenstein together unconventional therapies in attempts to treat drug-resistant bacteria.
5. Diabetic foot infections
Qualifications: incidence, required intervention
This is by far the most common reason I have seen patients have their toe, foot or leg amputated. With the incidence of diabetes on the rise in the last two decades [5], the occurrence of this infection type is all too frequent today.
Diabetic patients commonly lose feeling in their lower extremities over time (peripheral neuropathy), which can lead to wounds going unnoticed. The wounds progress if not treated and this can mean surgical intervention (all too commonly with amputation) is necessary.
Diabetic foot infections are such a substantial problem that the Infectious Diseases Society of America has an entire guideline dedicated to their management, which you can find here [6].
…Other infections I considered but did not ultimately include: disseminated strongyloidiasis, multiple abdominal abscess, spinal abscess with hardware, Norwegian scabies, mediastinitis, cryptococcal meningitis, H1N1, pyomyositis and gas gangrene… but let’s face it, there is no real answer to this question, what we need to do is anything we can to PREVENT these things in the first place while PRESERVING the tools (i.e., antibiotics) we do have for when we need them.
REFERENCES
To see what others found to be the worst infection they had encountered, the above article was posted to Twitter. Comment was requested. Here is what was provided as people weighed in.
- @mmPharmD: cringe-factor wise? Old man used Gatorade bottle as makeshift urinal & got stuck. Necrosis. Pen-ectomy. Polymicrobial infxn. AND Txt wise? 2 yrs ago, three 20-something IVDUs present same week w fungal endocarditis. 2 died in OR. Ampho+5FC ..how to dose?
- @CMDoran: I’ll never forget the overwhelming candidemia I saw in a very premature baby. He died. In days of amphotericin b 1.0.
- @Blandman19: MRSA bacteremia for 3 weeks from PICC line in pre-ceftaroline era. Took 5 drugs to clear. Had diskitis on 2nd MRI.
- @BRxAD: Hard to pick 1, but would choose disseminated strongyloidiasis with meningitis – devastating neuro sequelae/mortality
- @Julie_Justo: XDR Acinetobacter baumannii meningitis/cerebral abscess 2/2 NSG/EVD. Wasn’t much we could do. Bug took residence in ICU
- @real_idpharmd: #Cdiff b/c WE cause it, lack of IC/poor ABX prescribing #StaphIsBad nuff said #influenza as >40K death/yr, preventable w jabs
- @EmilyLHeil: serious intra-abdominal infections without source control – antibiotics can only do so much! Bad bugs breeding ground.
- @Manfordou: lady with stray cat bite, and cat died on its own 2 days later hand looks bad, surgery x3, ended up being tularemia
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