Clinical Presentation and Management of Methicillin-Resistant Staphylococcus aureus Pericarditis—Systematic Review

Abstract

In the expanding era of antibiotic resistance, new strains of Staphylococcus aureus have emerged which possess resistance to traditionally used antibiotics (MRSA). Our review aimed to systematically synthesize information on previously described MRSA pericarditis cases. The only criterion for inclusion was the isolation of MRSA from the pericardial space. Our review included 30 adult and 9 pediatric patients (aged: 7 months to 78 years). Comorbid conditions were seen in most adult patients, whereas no comorbidities were noted amongst the pediatric patients. Pericardial effusion was found in 94.9% of cases, with evidence of tamponade in 83.8%. All cases isolated MRSA from pericardial fluid and 25 cases (64.1%) had positive blood cultures for MRSA. Pericardiocentesis and antibiotics were used in all patients. The mortality rate amongst adults was 20.5%, with a mean survival of 21.8 days, and attributed to multi-organ failure associated with septic shock. No mortality was observed in the pediatric population. In adult patients, there was no statistical difference in symptom duration, antibiotic duration, presence of tamponade, age, and sex in relation to survival. Conclusion: MRSA pericarditis often presents with sepsis and is associated with significant mortality. As such, a high clinical suspicion is needed to proceed with proper tests such as echocardiography and pericardiocentesis. In more than one third of the cases, MRSA pericarditis occurs even in the absence of documented bacteremia.

Influenza Myopericarditis and Pericarditis: A Literature Review

“…Influenza infections also predispose patients to a secondary bacterial infection, most commonly pneumonia. The pericardium may also be affected, with rare case reports of Methicillin-resistant Staphylococcus Aureus (MRSA), Group A Streptococcus , and Streptococcus pneumoniae pericarditis [ 103 , 104 , 105 , 106 ]. This occurs due to multiple immunological mechanisms, including damage of the tracheobronchial epithelial layer and local immunologic response suppression (i.e., bacterial clearance), causing easier bacterial adherence and translocation [ 107 ].…”

Potential Failure of Vancomycin Dosing Using AUC/MIC in a Patient With Purulent Methicillin-Resistant Staphylococcus aureus Pericarditis

“…A recent systematic review of MRSA pericarditis case reports found vancomycin alone or in-combination with other anti-staphylococcal agents was effective in approximately 60% of patients. 3 We report the first case describing the use of AUC/MIC vancomycin dosing and subsequent use of combination salvage therapy in an adult patient with MRSA purulent pericarditis.…”

A Rare Case of MRSA Pericarditis with Expanding, Purulent Pericardial Effusion Leading to Uremic Kidney Failure from a Right, Necrotic Toe

“…However, early diagnosis and treatment of purulent pericarditis from MRSA with sufficient source control are critical because of the downstream complications of pericardial tamponade, septic shock, pericardial abscess formation, and constrictive pericarditis [ 10 ]. With greater than one-third of patients with purulent pericarditis secondary to MRSA initially presenting with a lack of bacteremia and a high risk of pericardial injury in the setting of uremia, identification of the etiology can be difficult, but pericardial drainage and source control is critical to avoid the aforementioned complications due to delay in intervention [ 14 ].…”

“…However, for cases of purulent pericarditis from MRSA, hematogenous spread has been the most commonly cited means of seeding the pericardium with only a few cases reporting osteomyelitis as a documented source [ 17 , 18 ]. An expedited TTE with pericardiocentesis should be done for any clinical suspicion for an enlarging pericardial effusion because of the high prevalence of cardiac tamponade (84%) noted in a recent systematic review [ 14 ]. Cultures from the pericardial fluid should be sent for bacterial, fungal, and tuberculosis studies to confirm the diagnosis [ 10 ].…”

“…Therefore, prompt initiation of antibiotics that target MRSA along with placement of either a pericardial drain (such as our patient), pericardial window, pericardiotomy, or even surgical pericardiectomy is recommended since the recurrence of effusion is common and had been noted to be 30% in reported cases [ 1 , 10 ]. Even with attempted source control with the use of antibiotics and drainage of pus in the pericardial space, the feared complications of septic shock, reaccumulation of pus with potential abscess formation, and constrictive pericarditis can occur and have been reported in 15.4%, 30.8%, and 3.5% of reported cases, respectively [ 14 , 19 ].…”