Article Type : Case Report
Authors : Galvis AE and Regas NJ
Keywords : Bacteraemia; Paediatrics; Tetracycline’s
Methicillin-resistant
Staphylococcus aureus (MRSA) is a worldwide problem with high rates of
prevalence in the United States. The epidemiology of MRSA has shifted since the
late 1990s and is affecting more healthy individuals without
healthcare-associated MRSA risk factors. Ninety-five percent of
community-acquired MRSA (CA-MRSA) is isolated from skin and soft-tissue
infections, however, in rare circumstances it may result in severe infection
and even death. CA-MRSA is easily transmitted between close contacts in
households, day-care centres, competitive sports teams, and military
installations. We present the case of CA-MRSA bacteraemia in a 6-year-old
female without MRSA risk factors who received treatment at Children’s Hospital
of Nevada at UMC.
The traditional teaching that MRSA is a hospital pathogen has changed
due to the increasing number of reports of community-acquired MRSA infections
in healthy individuals. CA-MRSA is a pressing public health issue due to high
rates of transmission by asymptomatic MRSA carriers and the introduction of the
pathogen into hospitals. Clinicians must be aware of the threat posed by
CA-MRSA infections in paediatric populations and judiciously select antibiotic
coverage based on local resistance rates for MRSA isolates [1,2].
A 6-year-old female without established MRSA risk factors presented to the emergency department at Children’s Hospital of Nevada at UMC with a 6-day history of limping and a dull, aching pain overlying the left medial malleolus. Low-grade fever was also reported prior to admission. The left leg pain was described as sudden in onset, non-radiating and 4/10 in intensity. Ambulation and palpation of the affected area exacerbated the pain, while rest and Motrin were remitting factors. One day prior to admission, the patient’s pain intensified, and she was unable to bear weight on her left leg [3-5]. There was no history suggestive of trauma, and there was no history of redness, swelling, or warmth overlying the left leg. On physical examination, the patient was an ill-appearing female. Vital signs were as follows: temperature of 39 degrees Celsius, pulse of 146, respiratory rate of 28, and oxygen saturation of 97% on room air. There was an area of tenderness, erythema, and swelling overlying the left distal tibia, approximately 21.5 cm in diameter. The patient was unable to bear weight on her left leg and range of motion was difficult to assess due to pain. The rest of the physical examination on presentation was unremarkable. Of note, on day 3 of hospitalization, the leg swelling progressed to involve both the distal and proximal tibia and red streaking developed. Subsequently, the patient clinically worsened and became toxic-appearing with high fevers and tachypnea. A radiograph and ultrasound of the left ankle demonstrated mild soft tissue swelling. An MRI of the left lower leg showed marrow edema and enhancement in the distal tibial metaphysis and epiphysis compatible with osteomyelitis. Repeat MRI on day 3 of hospitalization showed progression of osteomyelitis to the mid and proximal tibia along with progressive cellulitis and myositis in the anterior and medial subcutaneous tissues [6-10] (Figures 1 and 2).
Figure 1: 6-year-old female diagnosed with CA-MRSA osteomyelitis and bacteremia: Radiograph of left lower extremity
Figure 2: 6-year-old female diagnosed with CA-MRSA osteomyelitis and bacteremia: Physical examination finding of LLES.
Laboratory results include a CBC which showed a WBC
count of 12,400 wbc/mcL with 78% neutrophils; Hgb of 13.7 g/dL, haematocrit of
38.3%, and platelets of 299 platelets/mcL. CRP was initially elevated at 93
mg/L and peaked at 184 on day 3 of hospitalization. ESR was elevated at 70
mm/hr. On day 2 of hospitalization, gram stain demonstrated gram-positive cocci
in clusters, and blood culture resulted positive for methicillin-resistant
Staphylococcus aureus on day 4 of hospitalization. The patient was initially
treated with IV Clindamycin without clinical improvement. The treatment was
transitioned on day 3 of hospitalization to Vancomycin to treat the MRSA
bacteraemia and osteomyelitis. The patient was also given fluid resuscitation
for early compensated shock and features of systemic inflammatory response
syndrome (SIRS). The repeat blood culture drawn on day 4 of hospitalization
demonstrated no growth. On day 5 of hospitalization, the patient demonstrated
clinical improvement with stabilization of vital signs and improvement of her
pain. The patient was ultimately discharged in stable condition on a course of
oral Linezolid [11-15].
There is a significant degree of alarm regarding
CA-MRSA and its predilection for targeting healthy hosts, namely children.
Prior to the mid-1990s, it was rare for MRSA strains to cause disease in
otherwise healthy people. Now, outbreaks of CA-MRSA infections affect healthy
hosts and hit hardest in ‘closed populations’ such as children who attend
daycare, competitive athletes, inmates, and personnel in military installations
[16-25]. Evidence also suggests that children from socially disadvantaged
minority groups are at greater risk of acquiring CA-MRSA infections.
Approximately thirty percent of the general population and up to fifty percent
of people with chronic medical conditions may be colonized with S. aureus [26].
The bacteria colonize the nares, axillae, groin, perineum, and gastrointestinal
tract of carriers. Many patients are colonized without demonstrating signs of
disease and may later suffer an infection from the strain. The clinical
presentation, severity of disease, and outcome vary significantly. Skin and
soft-tissue infections account for the majority of CA-MRSA infections in young
patients, however, five percent of all infections cause invasive diseases such
as pneumonia, osteomyelitis, bacteraemia, endocarditis, and necrotizing
fasciitis. MRSA strains express a penicillin-binding protein (PBP2a) that
creates high-level resistance to beta-lactam antibiotics. Furthermore, the
epidemiology of MRSA has shifted, and community-acquired infections are
increasingly common in the general population. The virulence of CA-MRSA
infections is attributed to the presence of Panton-Valentine leucocidin genes
which code for cytotoxins that lead to tissue necrosis and leukocyte
destruction [27]. These factors contribute to the versatility of CA-MRSA and
make it a challenging pathogen to treat.
According to the CDC,
incision and drainage is the recommended primary treatment for patients who
present with a cutaneous abscess, or other skin and soft-tissue infections
[28]. For smaller lesions not amenable to incision and drainage, hot compress
may be applied to promote drainage. For patients with purulent skin lesions,
empiric antibiotic treatment may be administered in combination with incision
and drainage. Factors that support supplementation with antimicrobial therapy
include the presence of cellulitis, severe and spreading SSTI, signs and
symptoms of systemic illness, lack of response to incision and drainage alone,
associated co-morbidities, or immune suppression. The choice of empiric
antibiotic therapy for CA-MRSA skin and soft-tissue infection requires that
clinicians differentiate between uncomplicated versus complicated SSTI’s. For
empiric coverage of CA-MRSA in paediatric outpatients with uncomplicated skin
and soft-tissue infections, oral antimicrobial options include the following:
clindamycin, trimethoprim-sulfamethoxazole, and linezolid. Tetracyclines are
not a viable option in children less than 8 years of age. In hospitalized
children with complicated SSTI’s, vancomycin is the treatment of choice. However,
if the paediatric patient is stable and has no signs or symptoms of
bacteraemia, clinicians may use empiric clindamycin therapy if the local
resistance rate is less than ten percent [29,30].
No conflict of interest to declare.