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First case report of vancomycin-intermediate sequence type 72 Staphylococcus aureus with nonsusceptibility to daptomycin.

Tsukimori A, Nakamura I, Okamura S, Sato A, Fukushima S, Mizuno Y, Yamaguchi T, Matsumoto T - BMC Infect. Dis. (2014)

Bottom Line: The infectious agent was definitively identified as vancomycin-intermediate, daptomycin-nonsusceptible, rifampicin-resistant ST72-MRSA-IV based on culture results and minimum inhibitory concentration testing.Such information will help to minimize the emergence and spread of antibiotic-resistant strains.This report concerns one particular bacterial strain; however, the basic concepts involved in this case translate to all infectious disease fields.

View Article: PubMed Central - PubMed

Affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan. task300@tokyo-med.ac.jp.

ABSTRACT

Background: Sequence type 72 methicillin-resistant Staphylococcus aureus (MRSA) SCCmec type IV (ST72-MRSA-IV) is the most common community-acquired MRSA clone in Korea. Resistance to daptomycin or vancomycin among community-acquired MRSA clones is not well described in the literature. We herein report the first case of vancomycin-intermediate, daptomycin-nonsusceptible ST72-MRSA-IV.

Case presentation: A 45-year-old Japanese man underwent aortic arch prosthesis implantation for treatment of a dissecting aortic aneurysm. Fourteen months later, he developed a prosthetic graft infection of the aortic arch and an anterior mediastinal abscess caused by ST72-MRSA-IV. First-line treatment with vancomycin and rifampicin failed, and daptomycin was thus administered. After several days, the treatment was changed to linezolid because of the re-emergence of fever. The patient's condition resolved and no recurrence or other problems were seen for 1 year post-treatment. The infectious agent was definitively identified as vancomycin-intermediate, daptomycin-nonsusceptible, rifampicin-resistant ST72-MRSA-IV based on culture results and minimum inhibitory concentration testing.

Conclusion: This case report illustrates the importance of fully understanding the changing epidemiology of infectious agents and the risk factors for the development of antibiotic resistance. Such information will help to minimize the emergence and spread of antibiotic-resistant strains. This report concerns one particular bacterial strain; however, the basic concepts involved in this case translate to all infectious disease fields.

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Related in: MedlinePlus

Time course of body temperature variation and antibiotic regimen of the patient. The patient’s blood culture became negative for MRSA once in the course of vancomycin therapy, but his fever persisted. With the initiation of daptomycin therapy, his temperature remained relatively low for several days and then increased when the blood culture became positive again for MRSA. 1: blood culture on the first hospital day; 1’: pus from the abscess on the first hospital day; 2: pus from the abscess on the 6th hospital day; 3: blood culture on the 40th hospital day; 4: pus from the abscess on the 55th hospital day. CEZ: cefazolin; VCM: vancomycin; RFP: rifampicin; DAP: daptomycin; LZD: linezolid; CLDM: clindamycin
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Fig1: Time course of body temperature variation and antibiotic regimen of the patient. The patient’s blood culture became negative for MRSA once in the course of vancomycin therapy, but his fever persisted. With the initiation of daptomycin therapy, his temperature remained relatively low for several days and then increased when the blood culture became positive again for MRSA. 1: blood culture on the first hospital day; 1’: pus from the abscess on the first hospital day; 2: pus from the abscess on the 6th hospital day; 3: blood culture on the 40th hospital day; 4: pus from the abscess on the 55th hospital day. CEZ: cefazolin; VCM: vancomycin; RFP: rifampicin; DAP: daptomycin; LZD: linezolid; CLDM: clindamycin

Mentions: The patient’s condition was diagnosed as an anterior mediastinal abscess and hemorrhagic cerebral infarction associated with a prosthetic graft infection of the aortic arch. Surgical intervention to remove the infected graft, which required anticoagulant therapy during cardiopulmonary bypass, was not possible because of intracerebral hemorrhage. Initial treatment for the prosthetic graft infection was started with vancomycin at 3 g/day (1 g IV TID) and cefazolin at 6 g/day (2 g IV TID). On the second hospital day, drainage and continuous irrigation were started for treatment of the anterior mediastinal abscess. Because the results of the blood culture performed 2 days before admission revealed an MRSA infection, the treatment was switched to vancomycin at 3 g/day (1 g IV TID) and rifampicin at 600 mg/day (300 mg PO BID); this treatment was continued for 9 days. The isolates from the blood and anterior mediastinal cultures performed on the day of admission also indicated MRSA infection. The vancomycin serum trough levels remained at 9.8–12.2 μg/ml during vancomycin treatment. The vancomycin minimum inhibitory concentration (MIC) of the MRSA strain isolated from the pus in the abscess was 2 μg/ml, and this strain was also susceptible to most non-β-lactam agents except gentamicin (Table 1). The blood culture became negative for MRSA during the course of vancomycin and rifampicin therapy. However, the patient became feverish again on the 10th hospital day, and the treatment was switched to IV daptomycin at 6 mg/kg/day and rifampicin. On the 40th day, after the patient had remained in a stable condition for several days with daptomycin and rifampicin treatment, his fever returned and the blood culture became positive again for MRSA. Therefore, we suspected nonsusceptibility to daptomycin. Daptomycin was discontinued and treatment with linezolid was initiated at 1200 mg/day (600 mg IV BID). Reconstruction of the acute aortic dissection was carried out on the 61st day because the chest computed tomography scan performed during therapy showed persistence of the anterior mediastinal abscess and gallium scintigraphy showed persistence of prosthetic graft-associated inflammation. The infected prosthetic graft was completely removed and replaced. After the surgery, antimicrobial treatment was switched to linezolid at 1200 mg/day (600 mg PO BID) and clindamycin at 1800 mg/day (600 mg PO TID). The patient’s condition subsequently improved, and recurrence was not observed for 12 months of follow-up. The time course of his body temperature variations and antibiotic treatment regimen are shown in Figure 1.Table 1


First case report of vancomycin-intermediate sequence type 72 Staphylococcus aureus with nonsusceptibility to daptomycin.

Tsukimori A, Nakamura I, Okamura S, Sato A, Fukushima S, Mizuno Y, Yamaguchi T, Matsumoto T - BMC Infect. Dis. (2014)

Time course of body temperature variation and antibiotic regimen of the patient. The patient’s blood culture became negative for MRSA once in the course of vancomycin therapy, but his fever persisted. With the initiation of daptomycin therapy, his temperature remained relatively low for several days and then increased when the blood culture became positive again for MRSA. 1: blood culture on the first hospital day; 1’: pus from the abscess on the first hospital day; 2: pus from the abscess on the 6th hospital day; 3: blood culture on the 40th hospital day; 4: pus from the abscess on the 55th hospital day. CEZ: cefazolin; VCM: vancomycin; RFP: rifampicin; DAP: daptomycin; LZD: linezolid; CLDM: clindamycin
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4150982&req=5

Fig1: Time course of body temperature variation and antibiotic regimen of the patient. The patient’s blood culture became negative for MRSA once in the course of vancomycin therapy, but his fever persisted. With the initiation of daptomycin therapy, his temperature remained relatively low for several days and then increased when the blood culture became positive again for MRSA. 1: blood culture on the first hospital day; 1’: pus from the abscess on the first hospital day; 2: pus from the abscess on the 6th hospital day; 3: blood culture on the 40th hospital day; 4: pus from the abscess on the 55th hospital day. CEZ: cefazolin; VCM: vancomycin; RFP: rifampicin; DAP: daptomycin; LZD: linezolid; CLDM: clindamycin
Mentions: The patient’s condition was diagnosed as an anterior mediastinal abscess and hemorrhagic cerebral infarction associated with a prosthetic graft infection of the aortic arch. Surgical intervention to remove the infected graft, which required anticoagulant therapy during cardiopulmonary bypass, was not possible because of intracerebral hemorrhage. Initial treatment for the prosthetic graft infection was started with vancomycin at 3 g/day (1 g IV TID) and cefazolin at 6 g/day (2 g IV TID). On the second hospital day, drainage and continuous irrigation were started for treatment of the anterior mediastinal abscess. Because the results of the blood culture performed 2 days before admission revealed an MRSA infection, the treatment was switched to vancomycin at 3 g/day (1 g IV TID) and rifampicin at 600 mg/day (300 mg PO BID); this treatment was continued for 9 days. The isolates from the blood and anterior mediastinal cultures performed on the day of admission also indicated MRSA infection. The vancomycin serum trough levels remained at 9.8–12.2 μg/ml during vancomycin treatment. The vancomycin minimum inhibitory concentration (MIC) of the MRSA strain isolated from the pus in the abscess was 2 μg/ml, and this strain was also susceptible to most non-β-lactam agents except gentamicin (Table 1). The blood culture became negative for MRSA during the course of vancomycin and rifampicin therapy. However, the patient became feverish again on the 10th hospital day, and the treatment was switched to IV daptomycin at 6 mg/kg/day and rifampicin. On the 40th day, after the patient had remained in a stable condition for several days with daptomycin and rifampicin treatment, his fever returned and the blood culture became positive again for MRSA. Therefore, we suspected nonsusceptibility to daptomycin. Daptomycin was discontinued and treatment with linezolid was initiated at 1200 mg/day (600 mg IV BID). Reconstruction of the acute aortic dissection was carried out on the 61st day because the chest computed tomography scan performed during therapy showed persistence of the anterior mediastinal abscess and gallium scintigraphy showed persistence of prosthetic graft-associated inflammation. The infected prosthetic graft was completely removed and replaced. After the surgery, antimicrobial treatment was switched to linezolid at 1200 mg/day (600 mg PO BID) and clindamycin at 1800 mg/day (600 mg PO TID). The patient’s condition subsequently improved, and recurrence was not observed for 12 months of follow-up. The time course of his body temperature variations and antibiotic treatment regimen are shown in Figure 1.Table 1

Bottom Line: The infectious agent was definitively identified as vancomycin-intermediate, daptomycin-nonsusceptible, rifampicin-resistant ST72-MRSA-IV based on culture results and minimum inhibitory concentration testing.Such information will help to minimize the emergence and spread of antibiotic-resistant strains.This report concerns one particular bacterial strain; however, the basic concepts involved in this case translate to all infectious disease fields.

View Article: PubMed Central - PubMed

Affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan. task300@tokyo-med.ac.jp.

ABSTRACT

Background: Sequence type 72 methicillin-resistant Staphylococcus aureus (MRSA) SCCmec type IV (ST72-MRSA-IV) is the most common community-acquired MRSA clone in Korea. Resistance to daptomycin or vancomycin among community-acquired MRSA clones is not well described in the literature. We herein report the first case of vancomycin-intermediate, daptomycin-nonsusceptible ST72-MRSA-IV.

Case presentation: A 45-year-old Japanese man underwent aortic arch prosthesis implantation for treatment of a dissecting aortic aneurysm. Fourteen months later, he developed a prosthetic graft infection of the aortic arch and an anterior mediastinal abscess caused by ST72-MRSA-IV. First-line treatment with vancomycin and rifampicin failed, and daptomycin was thus administered. After several days, the treatment was changed to linezolid because of the re-emergence of fever. The patient's condition resolved and no recurrence or other problems were seen for 1 year post-treatment. The infectious agent was definitively identified as vancomycin-intermediate, daptomycin-nonsusceptible, rifampicin-resistant ST72-MRSA-IV based on culture results and minimum inhibitory concentration testing.

Conclusion: This case report illustrates the importance of fully understanding the changing epidemiology of infectious agents and the risk factors for the development of antibiotic resistance. Such information will help to minimize the emergence and spread of antibiotic-resistant strains. This report concerns one particular bacterial strain; however, the basic concepts involved in this case translate to all infectious disease fields.

Show MeSH
Related in: MedlinePlus