peudomonas putida , a rod - shaped non fermenting gram - negative organism frequently found in the environment were previously thought to be of low pathogenicity . a study in taiwan in 1996 found that p. putida - related infections were only 5% ( 3/55 ) of microbiological isolates from ssti in a 5-year period . a study in japan in 2011 and korea in 2012 found 5 and 18 cases of p. putida bacteremia respectively . in the last three decades it had been reported as cause of nosocomial infection in immunocompromised patients and in patients possessing medical devices or catheters . clinical data on p. putida infections are lacking due to the rarity , relatively low virulence , and high antimicrobial susceptibility . however , the emergence of multi - drug - resistant ( mdr ) and carbapenem - resistant p. putida has become a concern . here , we report a multi drug resistant p. putida case in diabetic foot gangrene . a female green grocer , 51 year - old came to internal medicine out - patient clinic with wound in right toe since 1 month prior . she did not realize how the wound originated . at the beginning it was only a small blister ( diameter of 3 centimeters ) . the patient suffered diabetes and hypertension since a year ago , but she seldom took medicines . she also had a history of same kind of wound in her left sole ( diameter of 2 centimeters ) 5 month prior , which resolved after a week of antibiotic ointment . on physical examination , she was moderately ill , compos mentis , within tachycardia and fever . , she got gangrene on her 1 , 2 and 3 digit and wound sized 15 by 4 centimeter on the palm of the sole . laboratory examination showed leucocyte count 33,120/l with 85% neutrophil , random blood glucose 252 mg / dl , and ( + + ) proteinuria . other laboratory examination , procalcitonin level , chest radiology and electrocardiography were within normal range . her foot radiology showed porous structure , litic lesion on distal proximal phalangs of 1 digit and sub cuticular emphysema . the patient was treated with sub cutaneous ultra fast insulin and empiric antibiotics of ceftriaxone 2 grams b.i.d and metronidazole 500 mg t.i.d . she undergone amputation of the 1 digit and wound debridement on 5 day of admission , then amputation of the 2 and 3 digit on the 10 day of admission . the leucocyte count was 13,700/l with 83% neutrophil on the 10 day and the leucocyte was 9,500/l on the 14 day . the microorganism 's culture obtained from pus of the wound of 1 amputation revealed multi drug resistant pseudomonas putida came out on the 10 day [ table 1 ] . ceftriaxone were substituted with amikacin 250 mg b.i.d on the 10 day , according to the culture result . the patient was discharged on the 15 day of admission with good condition . the microorganism culture obtained from pus of the wound of the patient pseudomonas putida is a rod - shaped , non fermenting gram - negative organism frequently found in the environment that utilizes aerobic metabolism . it is able to tolerate environmental stresses due to its diverse control of proteins including protein and peptide secretion and trafficking , protein modification and repair , protein folding and stabilization , and degradation of proteins , peptides , and glycopeptides . some important proteins include the global regulatory proteins which link the pathway genes to the cell status . an important protein of p. putida is the crc protein which is part of the signal transduction pathway moderating the carbon metabolism . a study revealed that the prognosis of p. putida bacteremia has been shown to be good , with 93% of cases being cured . in contrast to previous reports , another study found that the mortality rate in p. putida bacteremia was high , where mortality rate in patients with p. putida pneumonia was 40% compared to 13% in previous studies . in this case illustration , we report a case of p. putida skin and soft tissue infections in a 51 year - old female with diabetic foot gangrene . the patient had symptoms and signs of sepsis , such as tachycardia , fever , and leucocytosis ; but the procalcitonin level was not elevated . the underlying diseases of p. putida infection were solid tumor followed by traumatic intracranial hemorrhage , history of operation within the previous 3 months , and neutropenia . the most common primary site of p. putida infection was the central venous catheter followed by ventilator - associated pneumonia and the biliary tract . seventy seven percent were device - related infections ( central venous catheter , endotracheal tube , biliary stent , and indwelling urinary catheter ) . pseudomonas putida is not commonly isolated from skin and soft tissue infections ( sstis ) . a study about p. putida infections over a 5-year period showed that sstis represented only 5% of cases . of the 5 cases of sstis , 80% were associated with trauma , and the other case may have had an inoculating event given that they contracted the illness from wading through flood water . bacteremia was present in only 1 of the 5 cases and appropriate antimicrobial therapy resulted in a good clinical outcome in all patients . infection control also plays an important role in the treatment of p. putida sstis . a case report on p. putida bacteremia due to skin and soft tissue infections that was lethal , which had malnutrition , immobility , and peripheral vascular disease as risk factors . it can be concluded that p. putida infection and bacteremia is associated with an indwelling device or immunocompromised state . in this case , the patient had uncontrolled diabetes mellitus with its micro and macro vascular complications , such as nephropathy and peripheral arterial disease as risk factors for p. putida infection . the patient works as green grocer at traditional market , owing to the possibility of her contact with p. putida in the plant roots . a study found 100% susceptibility of to ciprofloxacin and tobramycin and 87% to imipenem and piperacillin / tazobactam . studies recently have reported the emergence of multi drug resistant ( mdr ) and carbapenem - resistant p. putida isolates from the urinary tract , tracheal aspiration , and areas other than blood . this carbapenem - resistance mechanism was known to be related with metallo--lactamase ( mbl ) production . the carbapenem - resistance rates did not differ significantly from those of p. aeruginosa blood isolates ( p = 0.771 ) . the microorganism culture specimen obtained from this patient recovered multi drug resistant p. putida , only sensitive to amikacin . the patient had been treated with ceftriaxone and metronidazole for 10 days , and ceftriaxone was substituted with amikacin after culture result came out . even that the result was good , as the patient 's foot gangrene resolved and she was discharged with good condition . the first explanation was the difference of microorganism 's susceptibility to antibiotics at in vitro and in vivo settings . the second explanation was the p. putida infection was not become a bacteremia , as the procalcitonin level was normal , so the wound debridement and amputation able to remove the source of infection before p. putida spread . we have reported a case of multi drug resistant p. putida infection in diabetic foot gangrene . the infection was able to be taken care of and result was good , but we must be aware of the multi drug resistant p. putida in skin and soft tissue infection .
pseudomonas putida is a rod - shaped , non fermenting gram - negative organism frequently found in the environment that utilizes aerobic metabolism , previously thought to be of low pathogenicity . 
 it had been reported as cause of skin and soft tissue infection , especially in immunocompromised patients . a female green grocer , 
 51 year - old came to internal medicine out - patient clinic with gangrene and osteomyelitis on her 1st , 2nd and 3rd digit and wound on the sole of the right foot since 1 month prior . 
 the patient had history of uncontrolled diabetes since a year ago . 
 she was given ceftriaxone 2 grams b.i.d , metronidazole 500 mg t.i.d empirically and then amikacin 250 mg b.i.d , followed by amputation of the digits and wound debridement . 
 the microorganism 's culture from pus revealed multi drug resistant pseudomonas putida . 
 she recovered well after antibiotics and surgery .