Piperacillin/tazobactam-induced sudden severe thrombocytopenia in a patient with a pressure ulcer: a case report.

The standard treatment for an infected pressure ulcer (PU) with osteomyelitis is debridement, wound coverage and antibiotic administration. However, systemic administration of antibiotics in patients with osteomyelitis is controversial, and the optimal treatment duration for chronic osteomyelitis has not been standardised. We report a case of sudden severe thrombocytopenia induced by piperacillin/tazobactam (PIPC/TAZ) in a patient with PU-related osteomyelitis. A 57-year-old male patient with paraplegia, using a wheelchair full-time, presented to our plastic surgery department with infection of a stage IV hard-to-heal ischial PU. We surgically debrided the necrotising tissue and raised an ipsilateral biceps femoris musculocutaneous propeller flap for wound coverage. Polymicrobial infections, including Pseudomonas aeruginosa, were detected in the bone biopsy sample; therefore, systemic PIPC/TAZ was administered for the osteomyelitis. Unexpectedly, during the next 12 days of antibiotic administration, the patient's platelet count acutely dropped to 1×103/µl over three days. Based on a series of examinations, PIPC/TAZ was suspected to be the most likely cause of the severe thrombocytopenia. After drug discontinuation, the thrombocytopenia gradually improved. PIPC/TAZ is one of the most widely used antibiotic combinations in the plastic surgery field; it is conventionally administered for hard-to-heal wounds such as PUs and diabetic foot. The present case suggests that surgeons must take special precautions for patients undergoing PIPC/TAZ treatment. In this report, PIPC/TAZ-induced thrombocytopenia and the efficacy of antibiotic treatment for PU-related osteomyelitis are discussed in light of the available literature.

Sacral defect reconstruction using a sensate superior gluteal artery perforator flap based on the superior cluneal nerves: A report of two cases.

The superior gluteal artery perforator (SGAP) flap is a widely used flap for sacral reconstruction. However, it is non-sensate flap and sensory loss is one of the most important risk factors for pressure ulcer development and recurrence; therefore, a sensate SGAP flap would be ideal for the reconstruction. Because the upper buttock is innervated by the superior cluneal nerves (SCNs) which originate from Th11 to L4, a sensate SGAP flap based on SCNs is anatomically possible. Herein, we present a novel sensate SGAP flap based on SCNs for reconstruction of sacral defects. Two patients with a sacral defect underwent reconstruction using a sensate SGAP flap (53 and 56 years old, both men). Diagnoses were sacral spindle cell sarcoma and sacral pressure ulcer. The defect sizes were 16 × 13 and 12 × 11 cm. The flap was designed based on the locations of SCNs which are commonly located at 6-8 cm lateral from the midline at the iliac crest. Flap sizes were 16 × 9 and 15 × 13 cm, respectively. The flaps survived completely in both cases. Flap sensation was observed immediately after surgery except in flap margins. However, sensory recovery occurred in these areas as well several months postoperatively. None of the patients developed postoperative pressure ulcers during the follow-up period of 37 and 13 months. This method may preserve flap sensation and therefore can contribute to reducing the risk of postoperative pressure ulcers and could be a useful option for sacral reconstruction.