Endogenous MRSA Endophthalmitis: Increasing Prevalence and Diagnosing Challenges

1. EBM Case Discussion 2011/08/31 R3王玨/VS趙安年

2. Discussion Endogenous MRSA endophthalmitis

3. Endogenous endophthalmitis • 5-10% endophthalmitis: result from endogenous seeding through the blood-eye barrier • DM • Indwelling catheters • IV drug abuse • Renal insufficiency/ failure • Malignancies • AIDS • Recent severe nonocular procedures, infection, trauma

4. Endogenous MRSA endophthalmitis • 25% endogenous bacterial endophthalmitis: cause by Staphylococcus aureus species • The prevalence of MRSA infection in immunocompetent individuals is increasing

5. Ranged form 1 day to 3 months, mean: 17 days Immunocompromise or chronic medicl disease

6. High rate of RD: 75% In other report: 6-29% Initial VA: CF or worse

7. CA-MRSA: community associated MRSA • MRSA strains were once largely confined to hospitals or other health care facilities • The incidence of CA-MRSA strains was increasing in the last decade • Lacking risk factors, no exposure to the health care system

8. CA-MRSA: community associated MRSA • S.aureus: Most often colonize asymptomatically on the mucous membranes or the skin • 20% of the population carry S. aureus persistently • 60% intermittent carriers • 20% noncarriers, rarely harbor the species • Colonization is associated with a higher risk of infection

9. CA-MRSA: community associated MRSA • MRSA: resistant to methicillin and other β-lactam antibiotics • CA-MRSA: often sensitive to trimethoprim–sulfamethoxazole, tetracycline, rifampin, clindamycin • Hospital strain: often resistant to all antibiotics except vancomycin and linezolid

10. CA-MRSA: community associated MRSA • Panton–Valentine leukocidin (PVL) • A cytotoxin that destroys polymorphonuclear leukocytes and macrophages in vitro • PVL-positive CAMRSA in USA: USA 300 • Most common: skin and soft tissue infection • Necrotizing pneumonia, necrotizing fasciitis, sepsis

11. All patients: except patient 8no hix of hospitalization, health care employment, or household contact with health care employees during the 2 years before presentation. Patient 8: ESRD under HD All had onset of infection in the community endocarditis and signs of systemic embolization

12. R S S Clindamycin: R Erythromycin: R

13. Community acquired MRSA • The community strains increase in prevalence and migrate into hospitals  Community associated rather then community acquired • The number of community acquired MRSAs, even in other healthy person, is increasing

14. Community acquired MRSA in children with no indentified predisposing risk • Reviewed the medical records for hospitalized children with 1 or more S aureus isolates from any site in the designated interval in UCCH • Community-acquired: MRSA isolated from a specimen obtained within 72 hours of admission • Nosocomial acquired: MRSA isolated from a specimen obtained beyond that time

15. Community acquired MRSA in children with no indentified predisposing risk No indentified predisposing risk • No previous hospitalization or antimicrobial therapy within 6 months of the date of MRSA isolation • No history of endotracheal intubation • No underlying chronic disorder • No use of indwelling venous or urinary catheter • No history of any surgical procedure • No notation in the medical record of a household contact with an identified risk factor

16. Community acquired MRSA in children with no indentified predisposing risk

17. Community acquired MRSA in children with no indentified predisposing risk

18. Conclusion • Back to our case: • Endogenous MRSA endophthalmitis • Community associated • Without identified risk factors • Difficulty in initially diagnosis • MRSA is becoming more prevalent, and the number of community acquired MRSAs is increasing • Endophthalmitis caused by MRSA may pose a more serious problem in the future

19. 35 y/o female, no DM,HTN 12 y/o female, heart DX WPW SP

21. Reference • Rutar T, Chambers HF, Crawford JB, et al. Ophthalmic manifestations of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology 2006;113:1455–1462. • Ness T, Schneider C. Endogenous endophthalmitis caused by methicillin-resistant Staphylococcus aureus (MRSA). Retina 2009;29:831–834. • Ho V, Ho LY, Ranchod TM, Drenser KA, Williams GA, Garretson BR. Endogenous methicillin-resistant Staphylococcus aureus endophthalmitis. Retina. 2011 Mar;31(3):596-601. • Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA. 1998 Feb 25;279(8):593-8.

22. Thank you