Community associated MRSA: an alert to paediatricians

Abstract

Community associated methicillin resistant Staphylococcus aureus (CA-MRSA) is an emerging pathogen typically associated with skin and soft tissue infection, with occasional reports of fatality in previously healthy children and young adults. We report a case of invasive CA-MRSA and highlight the potential impact of such infections on empirical treatment of staphylococcal infections.A n 11 year old boy of African origin was admitted to his local hospital with left hip pain, fever, and an inability to weight bear (day 1). The day before, he had fallen on to his left hip while playing football; his symptoms started soon afterwards. He had no significant past medical history; four months previously he had moved to the UK. At presentation he was unwell and febrile (40.1˚C) with a high C-reactive protein (CRP) of 104 mg/l. An ultrasound scan of his left hip was inconclusive. The pain extended to his left inguinal region and testis; he was treated with intravenous flucloxacillin and cefotaxime for epididymo-orchitis, and ibuprofen for pain relief. He remained febrile over the next four days and the pain spread to his left thigh and loin. MRSA was isolated from the single blood culture bottle taken at presentation. He developed acute renal failure on day 5 (urea 20.3 mmol/l, creatinine 396 mmol/l), which was treated with intravenous fluids without improvement; he was transferred to our renal unit. MRSA was identified again, from a blood culture drawn on day 2, and vancomycin was added to his therapy. He had no skin lesions. He now described right sided pleuritic chest pain. Examination revealed a right sided pleural rub and coarse crackles. A chest radiograph showed right basal consolidation with a pleural effusion. An MRI scan identified osteomyelitis of the left pubic ramus with a subperiostial collection, which was drained and irrigated surgically. MRSA was cultured from the intra-operative periosteum and pus specimens and histology confirmed acute osteomyelitis. His antibiotics were rationalised to vancomycin and oral rifampicin (600 mg once daily). Unusually, the MRSA isolates were susceptible in vitro to erythromycin and ciprofloxacin. He remained febrile (temperatures >38˚C) over the next six days, his CRP remained raised, and he developed a soft systolic murmur. Transthoracic echocardiography did not show vegetations and the murmur resolved. Pleural fluid aspirated on day 12 was purulent but sterile. His renal failure, which improved, was attributed to interstitial nephritis, secondary to b-lactams and/or ibuprofen. On day 16 his fever and CRP (35 mg/l) were settling. He was discharged to his local hospital on vancomycin and rifampicin.The MRSA susceptibility pattern and the epidemiology suggested that this might be a community associated strain. Genotypic analyses (including pulsed field gel electrophoresis, detection of the Panton-Valentine Leukocidin (PVL) genes, exfoliative toxin D gene, and SCCmec type IVc) confirmed this isolate to be representative of the sequence type 80 clonal lineage, the so called Eur...

Life-threatening infection due to community-acquired methicillin-resistant Staphylococcus aureus: case report and review

“…Review of the literature revealed that invasive CA-MRSA infections have (Table 2). This report supports the suggestion that aggressive antistaphylococcal therapy should be initiated in critically ill patients with suspected MRSA infection and shifted to less aggressive therapy as soon as culture results are obtained and MRSA is excluded [16]. CA-MRSA is usually associated with soft tissue superficial infections [14]; however, it may cause invasive and severe infections and even deaths in previously healthy children [5,12].…”

“…Βesides, it seems that PVL is involved in invasive CA-MRSA infections [17]. Questions for the most appropriate empirical therapy are emerging, as initial therapy in critically ill patients appears to be of paramount importance for outcome of patients [16].…”

Diagnosis and treatment of Panton–Valentine leukocidin (PVL)-associated staphylococcal pneumonia

“…The largest series was in the seminal paper by Gillet et al [4] who reported 12 deaths. Forty-three survivors have been reported in total [4,17,29,[35][36][37][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58], resulting in an overall fatality rate of 62% in these reported cases.…”

Pediatric Aspects of Inpatient Health Information Technology Systems

“…49 The extension and linkage of such systems beyond hospitals to public health information systems may have value as resistant organisms previously confined to inpatient settings migrate to the community. 50,51 …”