Case Study: Tetanus Booster, Wound Observations, and Antibiotic Use

This case study analyzes a patient, Mary, who sustained a deep wound while gardening, raising concerns about potential tetanus infection. The case study explores the rationale for administering a tetanus booster based on age and potential exposure to Clostridium tetani. It delves into the physiological basis of wound observations, including redness, heat, swelling, and purulent discharge, linking them to the inflammatory response. The study further examines the development and benefits of fever, discussing how it helps combat infection. It also identifies possible endogenous and exogenous sources of wound contamination, particularly focusing on Staphylococcus aureus. The appropriateness of Augmentin as the prescribed antibacterial agent is discussed, highlighting its benefits and the role of its ingredients in combating antibiotic-resistant strains. Finally, the case study adheres to APA 6th Ed. referencing style and correct presentation, supported by relevant literature.

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(Please type your answers within the box underneath each question)
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1. Rationale for giving Mary a tetanus booster (Total: 5 marks)
1.1 What is the organism that causes tetanus and why is it of concern in this
situation?
The causative organism for tetanus is Clostridium tetani and can be found in manure
containing garden soil. On infecting a wound it can live anaerobically, is a Gram-
positive, endospore-forming, non-capsule forming pathogenic bacterium. The fact that
it is found in soil and can infect a wound is a matter of concern in Mary's case.
Because she suffered a 4cm deep cut on her leg while working in the garden, she
may have exposed herself to C. tetani endospores. It is also not clear whether she
has received a tetanus vaccine recently (Immunise.health.gov.au, 2017).
1.2 According to the guidelines in the “The Australian Immunisation Handbook” (Dept.
of health, 2017) on administering a tetanus booster, discuss the rationale for
giving Mary the tetanus booster
The rationale for giving Mary a tetanus booster is that she is 50 years of age and all
Australians above this age are recommended for a tetanus toxoid booster, particularly
if they have not received one during the previous 10 years. Besides, there have been
cases where a booster has not protected people with minor wounds from getting
tetanus, so a booster soon after the injury is usually given. Also, her exposure to
garden soil puts Mary at a risk of Clostridium tetani infection.
2. Physiological basis of the three wound observations (Total: 10 marks)
2.1 For each of the three wound observations indicate, and provide a rationale, as to
whether it is a sign or a symptom.
As soon as injury occurs, an acute inflammatory response sets in. The process of
homeostasis begins in order to prepare for repair of the injured tissue.
2.2 Discuss the physiological basis of the first observation.
The wound edges are hot to touch and red. There is an instant release of chemicals
that cause inflammation. These include histamines, complement components,
prostaglandins and kinins among others. Under the impact of these the arterioles
dilate and the permeability of their walls increases. This increases blood flow to the
area so it appears red. Chemotactic movement of lymphocytes, monocytes and

neutrophils to the area increases. An increase in the local temperature increases the
metabolic rate of cells in the vicinity of the injury, so the area is hot to touch. Cells with
phagocytic action, such as macrophages identify and kill the pathogens at the site of
the injury (Marieb & Hoehn, 2014).`
2.3 Discuss the physiological basis of the second observation.
The surrounding tissue is swollen because of the leakage of fluid from the capillaries.
This leads to the formation of exudate. The spaces between tissues are filled with the
protein-rich fluid and this causes swelling of the tissue. It is also referred to as edema.
Often the swollen tissue is painful and restricts activity in the affected area, thus
forcing the patient to rest. This allows the process of repair to occur faster (Marieb &
Hoehn, 2014).
2.4 Discuss the physiological basis of the third observation.
A purulent and odorous discharge is a sign that the wound is infected. Mary has also
complained of fever and may have to take systemic antibiotics in order to treat the
infection. In Mary's case the exposure of the wound to garden soil could be the
reason why her wound became infected with microorganisms. The warm, moist and
nutrition rich environment of the subcutaneous tissue promotes the growth of
pathogenic organisms. The immune system responds by increasing exudate
formation, inflammation and swelling and pain (Bowler, Duerden, & Armstrong, 2001).
The wound can be sampled for a culture test to determine the pathogen and a
sensitivity test can help to find the antibiotic that the infectious pathogen/s is sensitive
to (Bowler, Duerden, & Armstrong, 2001). Once the antibiotic is administered it can kill
the pathogen and help in the recovery from the injury.
3. Development and benefits of fever (Total: 5 marks).
3.1 How did Mary’s fever develop?
Mary developed fever as a consequence of the inflammatory response to
the infection of her wound. Release of exogenous pyrogens in the form of
endotoxins released by the pathogenic organism can stimulate the release
of endogenous pyrogens or cytokines, such as tumor necrosis factor-α,
interleukin-1, interleukin-6 and interferons. Prostaglandin E2 and
endothelin I along with corticotrophin-releasing factor are released in
response to the pyrogens. These act upon the preoptic area, a region of
the anterior hypothalamus and trigger a febrile response. The temperature
balance point is then raised to a higher level than it normally is. Heat
production in the body follows accompanied by conservation of the heat
and the body temperature begins to rise, resulting in fever (Craft, 2015).
3.2 Discuss two ways in which fever is beneficial.
Fever is beneficial in reducing infection because it can kill pathogens

because they cannot multiply at higher body temperature. It reduces
serum concentrations of copper, iron and zinc, these minerals are vital for
replication of bacteria. Fever helps in faster diffrentiation of lymphocytes
into B cells and T cells so the immune response becomes stronger and in
response to fever the phagocytosis gets enhanced for faster killing of
pathogens (Marieb & Hoehn, 2014; Craft, 2015).
4. Possible sources of contamination and modes of transmission (Total: 10 marks)
4.1 Name one endogenous source of contamination and discuss the mode of
transmission from the source to the new host.
Endogenous sources of contamination with Staphylococcus aureus is the skin and the
mucosal surfaces. The organism is a commensal and lives on these surfaces without
causing any harm to the human body. But in the inner reaches of a wound, the
environment is favourable for it to multiply and offers more moisture, an optimal
temperature and ample nutrition. But once it enters the wound, it becomes pathogenic
and delays the tissue repair and causes fever. The Stapylococci can be transferred to
the wound site through the patient's hand that may have been contaminated due to
nasal mucosa or the oropharyngeal mucosa (Lee, 2016). In a study on patients with
leg ulcers it was found that some patients who harboured Staphyloccoccal strains as
nasal carriage had the same strains in the leg ulcers. This points to the risk of
endogenous transmission of bacteria in patients (Gjødsbøl, Skindersoe, Skov, &
Krogfelt, 2013). Removal of infection is difficult when a reservoir is present in the
patient's body.
4.2 Name one exogenous source of contamination and discuss the mode of
transmission from the source to the new host.
When transfer of an organism to the patient occurs through contact with other
surfaces or persons, the source is said to be exogenous. An exogenous source of
the Staphylococus aureus could be contamination of hands of healthcare staff. Since
S. aureus contamination from soil is quite unlikely, exogenous contact through
hands of people around Mary could be a likely source. Contamination through
objects that been touched by other people is another possibility. In a study on
healthcare workers, it was found that they contaminated non-sterile disposable
gloves with pathogens and skin commensals (Hughes, Cornwall, Theis, & Brooks,
2013). Since the strains isolated from the gloves were virulent, it is alarming that
hand washing regimen is not being followed by healthcare workers when retrieving
gloves from a box. Gloves could therefore act as transmission vehicles and cause
nosocomial infections in hospital settings. Another study focussed on spread of
infectious organisms through the surfaces of stethescopes, keyboards and
handsets. The difference in microbial counts before and after disinfection was
compared. Disinfection was recommended in particular for the first aid units where
contamination of surfaces was found to be rather high (Messina, et al., 2013).

5. Appropriateness of Augmentin as the antibacterial agent prescribed to Mary
(Total: 5 marks)
5.1 Given the colonizing organism was Staphylococcus aureus, discuss why
Augmentin is an appropriate prescription?
Staphylococcus aureus causes wound infections but most of the infections are
caused by the antibiotic resistant strains. In Mary's case, her wound was infected
and the only way to cure the infection was to administer a systemic antibiotic which
would be effective against the causative organism. The wound swab that was taken
for a culture sensitivity test confirmed that it was an S aureus infection that was
sensitive to Amoxycillin and Augmentin also contains Amoxycillin, so it was an
appropriate choice of antibiotic for treating her infection (Bullock & Manias, 2017).
5.2 Describe the added benefits that Augmentin provides, with reference to the role of
the major ingredients in Augmentin.
Staphylococcus aureus is often resistant to the antibiotic Amoxycillin which is a
penicillin derivative. Amoxycillin can inhibit bacterial growth because the beta lactam
ring in its structure inhibits the formation of the peptidoglycan cell wall in bacteria.
But the inappropriate use of antibiotics has led to the development of antibiotic
resistance in bacteria. S. aureus can produce the enzyme beta lactamase which
renders the beta lactam antibiotics incapable of blocking cell wall formation.
Augmentin is a combination of amoxycillin and clavulenic acid. Clavulenic acid is a
beta lactamase inhibitor and therefore in its presence amoxycillin can continue to
inhibit the multiplication of S. aureus and cure the infection (Bullock & Manias,
2017).
6. Presentation (Total: 5 marks)
6.1 Referencing in-text and in reference list conforms to APA 6th Ed. referencing
style.
6.2 Critique supported by relevant literature as prescribed.
6.3 Correct sentence structure, paragraph, grammatical construction, spelling,
punctuation and presentation.

References
Bowler, P. G., Duerden, B. I., & Armstrong, D. G. (2001). Wound Microbiology and Associated Approaches to
Wound Management . Clinical Microbiology Reviews, 14(2), 244–269.
http://doi.org/10.1128/CMR.14.2.244-269.2001.
Bullock, S., & Manias, E. (2017). Fundamentals of pharmacology (8th ed.). Frenchs Forest, Australia: Pearson
Australia.
Craft, J. &. (2015). Understanding pathophysiology (2nd Australian and New Zealand ed.). . Chatswood,
Australia: Elsevier.
Gjødsbøl, K., Skindersoe, M. E., Skov, R. L., & Krogfelt, K. A. (2013). Cross-contamination: Comparison of
Nasal and Chronic Leg Ulcer Staphylococcus aureus Strains Isolated from the Same Patient. . The
Open Microbiology Journal, 7, 6–8.
Hughes, K. A., Cornwall, J., Theis, J.-C., & Brooks, H. J. (2013). Bacterial contamination of unused,
disposable non-sterile gloves on a hospital orthopaedic ward. The Australasian Medical Journal, 6(6),
331–338. http://doi.org/10.4066/AMJ.2013.1675.
Immunise.health.gov.au. (2017, August 1). /Aus-Imm-Handbook.pdf. Retrieved from
http://immunise.health.gov.au:
http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/
7B28E87511E08905CA257D4D001DB1F8/$File/Aus-Imm-Handbook.pdf
Lee, G. &. (2016). Microbiology and infection control for health professionals (6th ed.). . Melbourne, Victoria :
Pearson Australia.
Marieb, E., & Hoehn, K. (2014). Human Anatomy & Physiology, Global Edition. Pearson Education Limited.
Messina, G., Ceriale, E., Lenzi, D., Burgassi, S., Azzolini, E., & Manzi, P. (2013). Environmental Contaminants
in Hospital Settings and Progress in Disinfecting Techniques. BioMed Research International,
429780. http://doi.org/10.1155/2013/429780.