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LayoutMRSA Peritonitis Secondary to Perforation ofSigmoid Diverticulitis B y S h a w n M . V u o n g , M S I V; J a m e s E . A p p e l w i c k , M D Abstract:
The occurrence of methicillin-resistant Staphylococcus aureus (MRSA) is well documented, but the pathology is
usually associated with post surgical infections or long-term peritoneal dialysis. We report the case of a 50-year-old Caucasian man who presented with a one week history of left lower quadrant abdominal pain, poor appetite and nausea due to MRSA peritonitis secondary to perforated sigmoid diverticulitis. Despite a thorough search of the medical literature, we could not find that this problem has been previously described. We report this case to demonstrate the robust nature of MRSA, which has generally not been considered to be a normal colonizing Introduction
infections occurred in persons without obvious exposures to health care and the remaining 1 percent could not be Methicillin-resistant Staphylococcus aureus (MRSA) was classified.7 MRSA infections are associated with higher first identified more than four decades ago. Penicillinase- mortality, increased length of stay and increased costs.7-8 producing strains of Staphylococcus aureus were universally One study found that patients with surgical site infections present in hospitals as early as the 1950s, however, at that colonized with MRSA had a hospital stay five days longer time, S. aureus in the community was considered to be on average than patients colonized with methicillin- largely penicillin-susceptible.1 MRSA was identified in susceptible S. aureus. The study also found that patients hospital patients in the United Kingdom within one year of with MRSA had a 1.19-fold increase in hospital costs.8 the introduction of semisynthetic penicillin in 1961.2 The prevalence of MRSA has progressively increased since the As MRSA continues to be a health care burden worldwide, early 1980s, and by 2002, MRSA accounted for nearly 60 the species continues to evolve, becoming a dominant percent of S. aureus infections acquired in intensive-care pathogen and resistant to even more antibiotics.2 MRSA isolates have a high resistance to many antibiotics. A recent study found high resistance to cefixime, doxicycline, It is estimated that 25 percent to 30 percent of the popula- oxacillin, gentamicin, trimethoprim/sulfamethoxazole, tion is colonized in the nose with S. aureus, and less than 2 chloramphenicol, tobramicin, ofloxacin and ciprofloxacin.
percent are colonized with MRSA.4 A MRSA colonization One isolate of the study was found to be vancomycin- is a strong risk factor for subsequent infection, although most colonized individuals do not develop any clinical disease.5 In 2005, there were an estimated 478,000 hospital- izations with a diagnosis of S. aureus infection in U.S. MRSA infections are an important cause of skin infections, hospitals, and 278,000 of these hospitalizations were endocarditis, pneumonia and osteomyelitis.10 Although related to MRSA.6 It has been estimated that the number of peritonitis is not a common presentation for MRSA, it has people who developed an invasive MRSA infection in 2005 been well-documented in the literature. MRSA peritonitis was 94,360. Approximately 18,650 persons died during a is usually associated with post-surgical infections or long- hospital stay related to serious MRSA infections that same term peritoneal dialysis.11-17 However, to the best of the year. Eighty-five percent of the infections were associated authors’ knowledge, MRSA peritonitis has never been with exposures to health care delivery, 14 percent of all the described in a patient with perforated sigmoid diverticulitis November 2011
and no prior abdominal surgery. Thorough bibliographic liquid diet until pain subsided and to avoid drinking database searches were completed in the following: PubMed alcohol. The patient was also advised to return promptly if (MEDLINE), ScienceDirect, BIOSIS Previews, ISI Web of symptoms worsened, fever recurred, pain increased, if he Knowledge, Scitation, Springerlink, Access Medicine, noticed blood in the stool or he was unable to defecate. A Wiley Online Library, EBSCOhost and Ingenta. The search follow-up appointment was scheduled 10 days later with his strategy included the following MeSH headings and text words with truncation: periton*, perforation, perforated, Three days later the patient presented to the clinic complaining of continuing fever and abdominal pain. At Methicillin Resistant Staphylococcus Aureus, Staphylococc,* about 2 a.m., he had sudden onset of severe stabbing enteric, colon,* colorectal, sigmoid, bowel.* We are report- abdominal pain with fever and chills. The pain had ing this case to demonstrate the robust nature of MRSA, worsened. Tympanic temperature was 104°F, pulse 120 which has generally not been considered a normal beats per minute, and blood pressure 144 mmHg systolic colonizing bacterium of the sigmoid colon.
over 88 mmHg diastolic. His white blood cell count was Case Presentation
18,700. The patient had a distended abdomen with A 50-year-old Caucasian man presented to the clinic with tenderness to palpation and percussion across both lower a one-week history of left lower quadrant abdominal pain.
quadrants greater on the right than left. Intravenous fluids The patient stated that he had been having an increasingly and 2 mg of morphine sulfate were acutely given, and the poor appetite and nausea. He had some relief with bowel patient was admitted to the hospital. The patient was movement and flatus; however, his last normal bowel started on IV Levaquin 500 mg daily and IV Flagyl 500 mg movement was six days prior. He also stated he had fever up to 100°F. He also complained of pain in his right great toe The general surgeon was consulted due to suspected to the point that it was difficult to bear weight. The latter perforated diverticulitis. The patient was immediately taken to the operating room and found to have a generalized The patient had a history of asthma, chronic left hemidi- peritonitis secondary to a perforated mesosigmoid abscess as aphragm paresis, gout and hyperlipidemia. He stated that he a result of diverticulitis. The anesthesiologist placed a tho- smoked a half pack of cigarettes per day and had for a racic epidural block at the T9-T10 level for pain control.
number of years and admitted to drinking up to four alco- The surgeon performed a Hartmann procedure, which is an holic beverages per day. His list of medications included excision of the perforated bowel with end sigmoid colosto- oxycodone, Flexeril, Pulmicort and Albuterol nebulizers, my and closure of the distal sigmoid end or rectum. Cultures Foradil, Singulair, multivitamin, Indocin, Allopurinol, from the peritoneum were obtained, and subsequently were Crestor, Fenofibrate, Flonase, and omeprazole.
reported positive for Methicillin-resistant Staphylococcus aureus. After surgery, IV Levaquin was increased to 750 mg The patient was 72 inches tall, weighed 106 kg, and had a daily. The following day, Levaquin was discontinued and IV body mass index of 30.9 kg/m2. Tympanic temperature was 98.7°F, pulse 120 beats per minute, and his blood pressure was 134 mmHg systolic over 84 mmHg diastolic. Positive While the patient seemed to improve initially, over the findings on physical examination included: scattered course of the next three days he became increasingly rhonchi, scattered course crackles that cleared with cough confused, diaphoretic, tachycardic and tachpneic. He and an abdomen soft to palpation with voluntary guarding developed pneumonia in the right middle and left lower lobes [Figure 1]. At this point IV Flagyl was discontinued and IV Zosyn 4.5 mg every six hours and IV Cefepine 1 gm Computed tomography (CT) of the abdomen and pelvis every 12 hours were ordered. Because the patient also showed a short segment of sigmoid diverticulitis and fatty suffered from alcohol withdrawal, he was placed on the liver with no abscesses or obstructions. The CT also showed Clinical Institute Withdrawal Assessment (CIWA) protocol.
elevation of the left hemidiaphragm with some atelectasis.
On postoperative day three, there was significant drainage Pertinent laboratory findings included: a white blood cell from the wound, which also looked erythematous. The count of 11,000, normal serum amylase and normal liver patient developed wound dehiscence and he was immedi- ately taken to the operating room for a laparotomy. There The patient began a ten-day regimen of oral Levaquin 500 was marked intra-abdominal and abdominal wall edema mg daily and metronidazole 500 mg twice daily. He also along with free fluid. A culture from the peritoneal fluid began Miralax 17 grams with 8 ounces of fluid up to four grew MRSA. An initial abdominal wound vacuum device times per day. The patient was advised to go on a clear- was placed, and the patient was re-admitted to the intensive November 2011
This decision was based on the World Society of Figure 1. Chest X-ray showing bilateral pneumonia.
Abdominal Compartment Syndrome’s non-operative treatment algorithm.18 On postoperative day 10, the patient was sputum culture positive for 1+ growth of Candida albicans. The patient did not receive any anti-fungal medications. On day 15, the patient was transferred out of the intensive care unit to the surgical floor. Four days later, the patient was discharged from the hospital in good condition following a 19 day hospitalization. On discharge, the patient was instructed to continue outpatient IV antibiotic therapy as managed through infectious disease, and was to follow up with the surgeon in the clinic. The patient is asymptomatic and hopes to have the colostomy Conclusion
In summary, we treated a patient with MRSA peritonitis secondary to perforation of sigmoid diverticulitis using a Hartmann procedure. The patient had a complicated care unit. The patient was then started on IV vancomycin hospital course including development of bilateral pneumo- at 1 g every eight hours and IV Levaquin 750 mg daily.
nia, alcohol withdrawal, and wound dehiscence. We believe that use of the AbThera device facilitated a dramatic The following day the patient was again taken to the decrease in intra-abdominal and abdominal wall edema and operating room for removal of the initial wound vacuum resolution of peritoneal cavity free fluid, allowing for device and placement of the AbThera Open Abdomen reapproximation of the musculofascial layers of the Negative Pressure Therapy system. Marked intra-abdomi- abdomen. Although much is known about community- nal and abdominal wall edema as well as free fluid in the acquired MRSA infections, our literature search did not abdominal cavity were again noted. Another culture was identify any previous case reports of MRSA peritonitis obtained and again grew MRSA. After placement of the secondary to perforated sigmoid diverticulitis. We hope AbThera device, the patient was returned to the intensive we have provided some clinical insight into the highly care unit. Postoperatively, the patient continued to endure adaptable nature of MRSA to colonize areas of the body symptoms from bilateral pneumonia and alcohol withdraw- al. A cortisol level was 16.06 μg/dL (2.3-11.9 μg/dL).
Infectious disease was consulted at this time. The infectious REFERENCES
disease physician recommended continuing vancomycin at 1. Chambers HF. The changing epidemiology of Staphylococcus aureus? Emerg Infect 1 g IV every eight hours, starting Flagyl 500mg IV twice 2. Deresinski S. Methicillin-resistant Staphylococcus aureus: an evolutionary, daily and Rocephin 2g IV daily, and discontinuing Zosyn epidemiologic, and therapeutic odyssey. Clin Infect Dis. 2005;40(4):562-73. 3. National Nosocomial Infections Surveillance System. National Nosocomial Two days later, the patient was returned to the operating Infections Surveillance (NNIS) System Report, data summary from January 1992through June 2004, issued October 2004. Am J Infect Control 2004; 32: 470–85.
room for removal of the AbThera device. The intra-abdom- 4. Gorwitz RJ et al. Changes in the prevalence of nasal colonization with inal and abdominal wall edema had significantly decreased Staphylococcus aureus in the United States, 2001-2004. Journal of InfectiousDiseases. 2008:197:1226-34.
and there was no free fluid. Repeat peritoneal cultures were 5. von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source negative for MRSA. During this procedure, a small abscess of Staphylococcus aureus bacteremia. Study Group. N Engl J Med 2001; 344:11–6 in a remnant of the mesosigmoid was discovered and Please note: Due to limited space, we are unable to list all references. You may drained. Cultures of the abscess were positive for MRSA contact South Dakota Medicine at 605.336.1965 for a complete listing. colonization. Due to the significantly decreased edema and About the Authors:
absence of free fluid in the peritoneal cavity, a primary Shawn M. Vuong, MSIV, is a fourth-year medical student at the Sanford School ofMedicine of The University of South Dakota.
closure of the abdominal wall was performed.
James E. Appelwick, MD, is Clinical Assistant Professor, Department of Surgery, at theSanford School of Medicine of The University of South Dakota.
The patient was on neuromuscular blockade therapy and a Acknowledgement: We would like to acknowledge the administrative assistance of
ventilator in the intensive care unit for five days Barbara Papik, MLS, Medical Librarian Avera Sacred Heart Hospital Medical Library, postoperatively with the goals of keeping tension off the Yankton, S.D., and Anna Gieschen, MLS, Reference Services Librarian, Wegner HealthScience Information Center, Sioux Falls, S.D., for bibliographic database searching for surgical incision site and to reduce abdominal wall stress.
State Board of Medical Examiners Medical Licensure Commission www.albme.org January – March 2012 Volume 27, Number 1 Treating androgen defi ciency in the Inside: aging male: a urologist perspective Board of Medical Examiners Matthew R. Thom, MD, Tuscaloosa urologist Introduction Normal aging in men is accompanied by a decline in testosterone (T) production