Keratitis following leech therapy for periocular eczematous dermatitis: a case report.

BACKGROUND: The medicinal leech therapy (MLT) is a kind of complementary treatment method used for various diseases. The leeches (Hirudo medicinalis) have been used for more than 2500 years by surgeons. The substances presenting in the saliva of leeches have anti-inflammatory, anticoagulant, platelet inhibitory, thrombin regulatory, analgesic, extracellular matrix degradative and antimicrobial effects. The method is cheap, easy to apply, effective and its mechanisms of action have been clarified for specific diseases. Infection particularly Aeromonas infection is the most common complication of MLT. CASE PRESENTATION: In this case report, a keratitis case developing after leech therapy applied for the periocular and facial eczematous dermatitis lesions will be presented. The patient referred to our hospital with decreased vision, ocular pain, stinging, redness and lacrimation complaints. A large corneal epithelial defect with irregular margins, dying by fluorescein, involving more than inferior half of cornea and conjunctival hyperemia were seen in the right eye. No agent was determined in microbiological investigation, as the patient had used topical moxifloxacin eye drop which was commenced in another clinic before applying to us. The patient was treated with fortified vancomycin and ceftazidime, before using besifloxacin with the diagnosis of bacterial keratitis. Three weeks later epithelial defect improved completely leaving an opacity and neovascularization. CONCLUSIONS: MLT should be performed by certified physicians with sterile medicinal leeches and precautious antibiotics should be used before MLT for prevention against potential infections.

Improvement of patient care through hirudotherapy and the management of leeches from their reception to their disposal in France.

OBJECTIVE: Medicinal leech therapy - known as hirudotherapy (HT) - is an empirical medical technique that has become popular again in reconstructive surgery. However, at each step of leech management there are risks for blood contamination of the caregivers and severe infections for patients. This reduces the success of the treatment. The aim of this study was to improve the management of leeches from ordering to disposal to improve patient care. METHODS: First, a review of the literature was performed. Second, we conducted a retrospective study of patients' antibiotic prophylaxis from January 2018 to December 2019. The data we collected were patient characteristics, the specific care unit at the hospital, indication, contra-indication, posology, duration of HT, number of leeches delivered, antibiotic prophylaxis prescribed and microbial organism, if identified. Third, an interdisciplinary meeting was organised to review the entire leech circuit: ordering, maintenance, prescription, dispensing, application and disposal. RESULTS: At the end of the literature review, six articles based on practices implemented in France were selected for inclusion. These articles discussed antibiotic prophylaxis, iron supplementation, and leech storage, application and disposal. On the retrospective study performed, antibiotic prophylaxis for HT was performed for 60% (30/50) of patients, 77% (23/30) of the prescriptions followed the recommendations for antibiotic prophylaxis, and 20 patients did not receive antibiotic prophylaxis. The interdisciplinary meeting made it possible to define a collegially validated protocol, containing a computerised antibiotic prophylaxis prescription, including per os ciprofloxacin antibiotic prophylaxis, intravenous iron supplementation and biological monitoring. A leech application protocol was created, and the method of leech disposal was revised. CONCLUSION: Despite the absence of clear guidelines and heterogeneous practices, this study reveals the importance of a standard procedure including leech management practices before use, antibiotic prophylaxis and application and disposal guides. The interdisciplinary protocol allows improved patient care management and makes leech management safer for caregivers.

Intraoral Hirudotherapy for Venous Congestion following Free Flap Head and Neck Reconstruction: Novel Intraoral Technique.

Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report pre-sents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.

Implementation of a Leeches + Antimicrobial Prophylaxis Order Panel to Optimize Medicinal Leech Use at a Tertiary Care Academic Medical Center.

Medicinal leech therapy promotes vascular flow and can be used to salvage grafts. Medicinal leeches have a symbiotic relationship with Aeromonas species and can therefore present a risk of bacterial transmission to patients. Antimicrobial prophylaxis is warranted for the duration of leech therapy, however, an institutional evaluation of 40 patients receiving medicinal leech therapy demonstrated poor adherence with recommendations. An electronic medical record order panel for antimicrobial prophylaxis with medicinal leech therapy was implemented, leading to a subsequent improvement in adherence to prophylaxis use, including significant increases in the ordering of antibiotics and the appropriate timing of initiation in the subsequent 10 patients receiving medicinal leech therapy after panel implementation. Aeromonas infections were rare before and after panel implementation, and developed only in the patient subset with non-optimized prophylaxis.

Lichen Planus Due to Hirudotherapy

Lichen planus is a traumatic (koebner positive), chronic, inflammatory and autoimmune disease affecting the oral and genital mucosa, scalp and nails. The Food and Drug Administration approved the use of medical leeches for therapeutic purposes (hirudotherapy) in 2004 to ensure flap nutrition in plastic surgery. A 34-year-old male patient was admitted to our dermatology outpatient clinic with a swollen, itchy and purple-coloured rash on legs and back for a month, and white and reticulated plaques in the mouth. It was learned that a week earlier, eight leeches was applied to both knees and ankles to alleviate knee and leg pain. The patient had no history of drug use. A punch biopsy was taken from the patient with a preliminary diagnosis of lichen planus and lichenoid drug reaction. The histopathological examination showed hyperkeratosis, irregular acanthosis and hypergranulosis. Systemic methylprednisolone, levocetrizine and topical methylprednisolone aceponate were planned for the therapy. To the best of our knowledge, the appearance of lichen planus after hirudotherapy was never reported in literature. Hence, physicians should keep in mind that lichen planus and similar dermatoses could be triggered due to hirudotherapy. The fact that lichen planus appeared a week after hirudotherapy does not necessarily mean that leeches were the cause of this phenomenon. Accordingly, it could be deduced that lichen planus was probably developed as a result of leech therapy.

Periorbital ecchymosis and subconjunctival hemorrhage due to leech therapy for headache / Equimose periorbital e hemorragia subconjuntival devido à terapia com sanguessugas para dor de cabeça

ABSTRACT A 62-year-old woman was admitted to our clinic with the complaints of periorbital ecchymosis and subconjunctival hemorrhage that are visible, especially on the right eye. We noted that her complaints began the day after she underwent leech therapy on the glabella area for headache. On the glabella, 2 leech bites were observed close to the right side. Examination revealed ecchymosis on the bilateral eyelids and subconjunctival hemorrhage on the inferolateral and medial limbus on the right eye. No treatment was initiated, rather control measures were recommended. The follow-up after 1 month revealed that the patient's complaints had disappeared.(AU)

RESUMO Uma paciente de 62 anos procurou nosso ambulatório com queixas de equimose periorbital e hemorragia subconjuntival, visíveis principalmente no olho direito. Descobrimos que suas queixas começaram no dia seguinte a um tratamento para dor de cabeça com sanguessugas na área da glabela. Na glabela, 2 mordidas de sanguessuga foram encontradas próximas ao lado direito. Durante os exames da paciente, foram detectadas equimoses nas pálpebras bilaterais e hemorragia subconjuntival no limbo ínfero lateral e medial do olho direito. Nenhum tratamento foi iniciado, sendo recomendado apenas controle. No acompanhamento, observou-se que as queixas da paciente desapareceram em cerca de um mês.(AU)

Periorbital ecchymosis and subconjunctival hemorrhage due to leech therapy for headache.

A 62-year-old woman was admitted to our clinic with the complaints of periorbital ecchymosis and subconjunctival hemorrhage that are visible, especially on the right eye. We noted that her complaints began the day after she underwent leech therapy on the glabella area for headache. On the glabella, 2 leech bites were observed close to the right side. Examination revealed ecchymosis on the bilateral eyelids and subconjunctival hemorrhage on the inferolateral and medial limbus on the right eye. No treatment was initiated, rather control measures were recommended. The follow-up after 1 month revealed that the patient's complaints had disappeared.

Hirudo (Leech) for proliferative vitreous retinopathy: A protocol for systemic review and meta-analysis.

INTRODUCTION: Proliferative vitreous retinopathy (PVR) is characterized by proliferation of cells and contraction of membranes on either the retinal surface or in the vitreous cavity, which leads to retinal detachment and visual impairment. PVR is commonly seen in patients with rhegmatogenous retinal detachment and diabetic retinopathy, which seriously affects the patient's work and life. Previous studies indicated that Hirudo (Leech) or compound prescription containing Hirudo (Leech) for treatment of PVR would be effective. However, due to the lack of evidence, there are no specific methods or suggestions, so it is necessary to carry out systematic evaluations on Hirudo (Leech) for PVR and provide effective evidence for further research. METHODS AND ANALYSIS: The following 8 databases will be searched: Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Database, and Wanfang Database. All randomized controlled trials in English or Chinese related to Hirudo (Leech) for PVR will be included. Outcomes will include change in Vitreous opacity, Vision changes, production of the anterior macular membrane, and retinal detachment again. The incidence of adverse events will be assessed for safety evaluation. Study inclusion, data extraction and quality assessment will be performed independently by 2 reviewers. Assessment of risk of bias and data synthesis will be performed using Review Manager V.5.3. RESULTS: In this systematic review and meta-analysis, we will synthesize the studies to assess the safety and efficacy of Hirudo (Leech) for PVR. CONCLUSION: The summary of our study will clarify whether Hirudo (Leech) therapy could be an efficient and safe method for PVR, which can further guide the promotion and application of it. OPEN SCIENCE FRAMEWORK OSF REGISTRATION NUMBER: 10.17605/OSF.IO/FP7VG (https://osf.io/fp7vg).

Multidrug resistant Aeromonas infection following medical leech therapy: A case report and development of a joint antimicrobial stewardship and infection prevention protocol.

OBJECTIVE: Aeromonas sp. infections are a recognized complication of medical leech therapy (MLT). In patients requiring MLT, ciprofloxacin or trimethoprim-sulphamethoxazole are commonly used to prevent such nosocomial infections. After a patient at our institution developed a MLT-associated multi-drug resistant (MDR) Aeromonas infection, we developed and evaluated a joint antimicrobial stewardship and infection prevention protocol for MLT at our institution. METHODS: We describe a case of a surgical site infection with MDR Aeromonas following MLT that was resistant to typically prescribed prophylactic antimicrobials, and development of a new leech culture protocol to proactively monitor for antimicrobial resistance among our institution's leech supply. We also report the rates of MLT-associated infections prior to and following implementation of this protocol and the antimicrobial susceptibility profiles detected in leech culture at our institution. RESULTS: Between October 2014 and February 2018, 46 patients received MLT at our institution. Other than the case described in this report, no other instances of MLT-related infections were noted during this time period. Culture results from 22 leeches in six batches since February 2018 showed that all were susceptible to ciprofloxacin, TMP-SMX, and ceftriaxone. Since initiation of a leech culture protocol, no further cases of MLT-associated infections have been reported at our institution. CONCLUSIONS: In light of increasing antimicrobial resistance and the potentially devastating consequences of MLT-associated infections, institutions offering MLT should be aware of these risks and ensure that protocols are in place to minimize infection risks for patients.

Evolving Antibiotic Resistance of Aeromonas Species in Finger Replantation.

Background: Infections with Aeromonas spp. are a recognized complication of leech therapy for circulatory complications in replanted digits. Ciprofloxacin is commonly used empirically for Aeromonas coverage in such cases. Evolving resistance patterns of Aeromonas should be considered in designing an antibiotic strategy. Methods: Three consecutive patients with complicated replantations had site cultures yielding Aeromonas isolates resistant to ciprofloxacin. These cultures were analyzed to identify effective antibiotic agents. Results: Each Aeromonas isolate, and each additional site organism, was sensitive to cefepime. Conclusion: Our routine antibiotic coverage for leech application has been changed to cefepime. Aeromonas sensitivities and resistances should be monitored to adapt to future changes in appropriate antibiotics.

Cutaneous lymphoid hyperplasia induced by Hirudo medicinalis (leeches).

For centuries, Hirudo medicinalis (medicinal leech) has been used as a remedy to treat many discomforts, such as muscle and joint pain. Nowadays, using leech in reconstructive surgery, microsurgery, wound and flap healing, venous insufficiency, varicosities and many other disorders has increased. In this study, we report a 45 year old female patient with six pruritic papules on her legs since10 months ago that appeared about 4 weeks after one session of leech application. Skin biopsy was performed on one of the papules, and in histopathology, superficial ulceration with a dense superficial and deep inflammatory infiltrate within the dermis composed of lymphocytes and eosinophils detected that considering history of leech application at this site, these constellation of data was compatible with the diagnosis of cutaneous lymphoid hyperplasia induced by leeches and the patient was cured by a topical steroid and cryotherapy.

Cutaneous Pseudolymphoma Due to Hirudotherapy

Pseudolymphoma, also known as Jessner's lymphocytic infiltration, is a benign but usually chronic, T-cell infiltrating disease with erythematous papules and plaques usually seen on the skin of the face, neck, and back. The use of leech therapy also known as hirudotherapy has increased in recent years. Here, we report a 52-year-old male patient who had undergone hirudotherapy in his neck and developed infiltrating plaques after four months. A skin biopsy confirmed the diagnosis of Jessner's lymphocytic infiltration. In parallel with the increasing use of hirudotherapy in recent years, the side-effect reports will likely to increase. Indications and contraindications of hirudotherapy, which is being used officially in hospitals, should be taken into consideration.

Low-Level Antimicrobials in the Medicinal Leech Select for Resistant Pathogens That Spread to Patients.

Fluoroquinolones (FQs) and ciprofloxacin (Cp) are important antimicrobials that pollute the environment in trace amounts. Although Cp has been recommended as prophylaxis for patients undergoing leech therapy to prevent infections by the leech gut symbiont Aeromonas, a puzzling rise in Cp-resistant (Cpr) Aeromonas infections has been reported. We report on the effects of subtherapeutic FQ concentrations on bacteria in an environmental reservoir, the medicinal leech, and describe the presence of multiple antibiotic resistance mutations and a gain-of-function resistance gene. We link the rise of CprAeromonas isolates to exposure of the leech microbiota to very low levels of Cp (0.01 to 0.04 µg/ml), <1/100 of the clinical resistance breakpoint for Aeromonas Using competition experiments and comparative genomics of 37 strains, we determined the mechanisms of resistance in clinical and leech-derived Aeromonas isolates, traced their origin, and determined that the presence of merely 0.01 µg/ml Cp provides a strong competitive advantage for Cpr strains. Deep-sequencing the Cpr-conferring region of gyrA enabled tracing of the mutation-harboring Aeromonas population in archived gut samples, and an increase in the frequency of the Cpr-conferring mutation in 2011 coincides with the initial reports of CprAeromonas infections in patients receiving leech therapy.IMPORTANCE The role of subtherapeutic antimicrobial contamination in selecting for resistant strains has received increasing attention and is an important clinical matter. This study describes the relationship of resistant bacteria from the medicinal leech, Hirudo verbana, with patient infections following leech therapy. While our results highlight the need for alternative antibiotic therapies, the rise of Cpr bacteria demonstrates the importance of restricting the exposure of animals to antibiotics approved for veterinary use. The shift to a more resistant community and the dispersion of Cpr-conferring mechanisms via mobile elements occurred in a natural setting due to the presence of very low levels of fluoroquinolones, revealing the challenges of controlling the spread of antibiotic-resistant bacteria and highlighting the importance of a holistic approach in the management of antibiotic use.

Ceftriaxone-Resistant Aeromonas hydrophila Infection Following Leech Therapy: A New Resistant Strain.

We report a case of ceftriaxone-resistant Aeromonas hydrophila infection in a 32-year-old man after medicinal leech therapy. The patient underwent a free gracilis muscle flap for dorsal foot soft tissue reconstruction. Because of persistent congestion after venous revision, medicinal leech therapy was initiated to aid in flap salvage. Intravenous ceftriaxone was administered prior to application of leeches for prophylaxis against A. hydrophila. Leech therapy was discontinued after 1 week, and ceftriaxone was discontinued 24 hours thereafter. An infection developed despite being on appropriate antibiotics. Culture sensitivities indicated that A. hydrophila was resistant to ceftriaxone.

Leech management before application on patient: a nationwide survey of practices in French university hospitals.

Background: Leech therapy in plastic/reconstructive microsurgery significantly improves a successful outcome of flap salvage but the drawback is a risk of severe infection that results in a drop of the salvage rates from 70-80% to below 30%. We report the results of a national survey conducted in all the French university hospitals to assess the current extent of use of leech for medical practices in the hospital and to investigate maintenance, delivery practices and prevention of the risk of infection. Methods: Data concerning conditions of storage, leech external decontamination, microbiological controls, mode of delivery and antibiotic prophylaxis were collected from all the French university hospitals in practicing leech therapy, on the basis of a standardized questionnaire. Results: Twenty-eight of the 32 centers contacted filled the questionnaire, among which 23 practiced leech therapy, mostly with a centralized storage in the pharmacy; 39.1% of the centers declared to perform leech external decontamination and only 2 centers recurrent microbiological controls of the water storage. Leech delivery was mostly nominally performed (56.5%), but traceability of the leech batch number was achieved in only 39.1% of the cases. Only 5 centers declared that a protocol of antibiotic prophylaxis was systematically administered during leech therapy: either quinolone (2), sulfamethoxazole/trimethoprim (2) or amoxicillin/clavulanic acid (1). Conclusions: Measures to prevent infectious complications before application to patient have to be better applied and guidelines of good practices are necessary.