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In our intensive care unit we treated a 42-year-old man with a history of intravenous drug use for community-acquired pneumonia. He was intubated, ventilated, and commenced on amoxicillin–clavulanic acid and clarithromycin in accordance with local guidelines. Within 3 days the patient developed a small erythematous lesion on the palmar aspect of his left distal forearm. The lesion began to develop a necrotic centre with irregular erythematous edges (Figure 1). Injectional anthrax was considered in the differential diagnosis given the history of prior drug use, however no change in therapy was advised because amoxicillin–clavulanic acid is active against Bacillus anthracis. A swab culture of the lesion revealed heavy growth of Pseudomonas aeruginosa. Initial sputum cultures also grew P. aeruginosa and therefore it was suspected that the lesion may represent ecthyma gangrenosum, a rare cutaneous complication of pseudomonal sepsis in patients who are critically ill or immunocompromised.
Identification of this infection allowed us to promptly switch therapy to intravenous meropenem to cover for P. aeruginosa. This was crucial as amoxicillin–clavulanic acid provides no cover for this organism.
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