We searched PubMed for English or Spanish language references published as of July, 2007, using combinations of the following terms: “Staphylococcus aureus”, “methicillin resistance”, “CA-MRSA”, “HA‐MRSA”, “community acquired”, “hospital acquired”, “healthcare associated”, “Panton Valentine leukocidin”, “PVL”, “community acquired pneumonia”, “pneumonia”, “necrotizing pneumonia”, “epidemiology”, “influenza”, “pathogenesis”, “virulence”, and “treatment”. The bibliographies of the articles
Grand RoundEmergence of community-acquired meticillin-resistant Staphylococcus aureus strain USA300 as a cause of necrotising community-onset pneumonia
Introduction
Staphylococcus aureus has long been recognised as a cause, albeit an infrequent one, of community-acquired pneumonia.1 Estimated to represent 1–10% of community-acquired pneumonia and 20–50% of nosocomial pneumonia,2, 3, 4, 5 it had been uncommon in healthy children and adults from high-income countries except when seen in the post-influenza setting.1, 6, 7, 8 Historically, pneumonia due to meticillin-resistant S aureus (MRSA) has been confined to health-care settings, representing 10–20% of pathogens that cause hospital and ventilator-associated pneumonia.5 In 1999, four paediatric deaths were reported due to community-acquired MRSA (CA-MRSA) necrotising pneumonia; these infections were caused by strains that differed from typical nosocomial strains in their antibiotic susceptibility patterns and pulsed field gel electrophoresis (PFGE) characteristics.9 3 years later, an association was found between the presence of Panton-Valentine leucocidin (PVL)—a staphylococcal toxin known to be associated with tissue necrosis—and this previously described syndrome of acute haemorrhagic necrotising pneumonia among otherwise healthy patients presenting with staphylococcal pneumonia from the community.10 Since then, many case reports and series have been described.9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 However, the overall incidence of CA-MRSA pneumonia remains unknown.
We describe two related cases of CA-MRSA necrotising pneumonia, and review the origins, pathophysiology, clinical features, outcomes, and treatment options for this emerging entity.
Section snippets
Case 1
A 45-year-old white woman presented to the hospital during the height of the influenza season with complaints of shortness of breath, fever, chills, and a cough that produced brown sputum of 1 week's duration. She denied haemoptysis, but gave a history of recurrent folliculitis for the past several months. She reported a preceding influenza-like illness (fever, myalgias, headache, and upper respiratory symptoms) 5 days before the onset of her current symptoms. Her medical history was notable
CA-MRSA
Meticillin resistance in S aureus emerged roughly 45 years ago, but MRSA infections were primarily confined to the health care setting until recently.9, 20, 34, 35, 36 The first report of community-onset infections with MRSA came from Australia in 1993.37 In the USA, reports of CA-MRSA necrotising pneumonia in healthy children appeared in the late 1990s,9 and were followed by reports of outbreaks of CA-MRSA skin and soft-tissue infections among prison inmates, homosexual men, native Americans,
Conclusion
CA-MRSA pneumonia has emerged as a cause of community-acquired pneumonia, generally after influenza or influenza-like illness and most often among previously healthy patients. The pathophysiology is incompletely understood, although some data suggest that PVL or other toxins, or both, might play an important part in the pathogenesis of the disease. CA-MRSA pneumonia manifests as a severe, necrotising pneumonia, associated with substantial morbidity and mortality. This entity should be suspected
Search strategy and selection criteria
References (112)
Hospital-acquired pneumonia: risk factors, microbiology, and treatment
Chest
(2001)- et al.
Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia
Chest
(2005) - et al.
The clinical spectrum of Staphylococcus aureus pulmonary infection
Chest
(1990) - et al.
Association between Staphyloccocus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients
Lancet
(2002) - et al.
Pleuropulmonary complications of Panton-Valentine leukocidin-positive community-acquired methicillin-resistant Staphylococcus aureus: importance of treatment with antimicrobials inhibiting exotoxin production
Chest
(2005) - et al.
Fatal community-associated methicillin-resistant Staphylococcus aureus pneumonia in an immunocompetent young adult
Ann Emerg Med
(2005) - et al.
Genetic analysis of community isolates of methicillin-resistant Staphylococcus aureus in Western Australia
J Hosp Infect
(1993) - et al.
Emergence of community-associated methicillin-resistant Staphylococcus aureus USA 300 clone as a cause of health care-associated infections among patients with prosthetic joint infections
Am J Infect Control
(2005) - et al.
Community-associated methicillin-resistant Staphylococcus aureus
Emerg Med Clin North Am
(2008) - et al.
The evolution of Staphylococcus aureus
Infect Genet Evol
(2008)
Community-associated methicillin-resistant Staphylococcus aureus (MRSA) in Australia
Int J Antimicrob Agents
Pore formation by a two-component leukocidin from Staphylococcus aureus within the membrane of human polymorphonuclear leukocytes
Biochim Biophys Acta
Protein A is a virulence factor in Staphylococcus aureus arthritis and septic death
Microb Pathog
Dissemination in Japanese hospitals of strains of Staphylococcus aureus heterogeneously resistant to vancomycin
Lancet
Continuation of a randomized, double-blind, multicenter study of linezolid versus vancomycin in the treatment of patients with nosocomial pneumonia
Clin Ther
Community-acquired methicillin-resistant Staphylococcus aureus (MRSA): new issues for infection control
Int J Antimicrob Agents
Staphylococcus aureus pneumonia
J Am Med Assoc
Staphylococcus aureus pneumonia: emergence of MRSA in the community
Semin Respir Crit Care Med
Population-based study of the epidemiology of and the risk factors for invasive Staphylococcus aureus infections
J Infect Dis
Asian influenza A in Boston, 1957–1958. II. Severe staphylococcal pneumonia complicating influenza
Arch Intern Med
Bacterial pneumonia during the Hong Kong influenza epidemic of 1968–1969
Arch Intern Med
Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus, Minnesota and North Dakota, 1997–1999
MMWR Morb Mortal Wkly Rep
Epidemiology and clonality of community-acquired methicillin-resistant Staphylococcus aureus in Minnesota, 1996–1998
Clin Infect Dis
Community-acquired methicillin-resistant Staphylococcus aureus infections in France: emergence of a single clone that produces Panton-Valentine leukocidin
Clin Infect Dis
Severe Staphylococcus aureus infections caused by clonally related community-acquired methicillin-susceptible and methicillin-resistant isolates
Clin Infect Dis
Life-threatening hemoptysis in adults with community-acquired pneumonia due to Panton-Valentine leukocidin-secreting Staphylococcus aureus
Intensive Care Med
Severe community-onset pneumonia in healthy adults caused by methicillin-resistant Staphylococcus aureus carrying the Panton-Valentine leukocidin genes
Clin Infect Dis
Pulmonary manifestations in children with invasive community-acquired Staphylococcus aureus infection
Clin Infect Dis
Severe community-acquired pneumonia due to Staphylococcus aureus, 2003–04 influenza season
Emerg Infect Dis
Factors predicting mortality in necrotizing community-acquired pneumonia caused by Staphylococcus aureus containing Panton-Valentine leukocidin
Clin Infect Dis
Severe methicillin-resistant Staphylococcus aureus community-acquired pneumonia associated with influenza; Louisiana and Georgia, December 2006–January 2007
MMWR Morb Mortal Wkly Rep
Fatal bacteraemic pneumonia due to community-acquired methicillin-resistant Staphylococcus aureus
Singapore Med J
Pneumonia and new methicillin-resistant Staphylococcus aureus clone
Emerg Infect Dis
Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: a lethal cause of pneumonia in an adult immunocompetent patient
Scand J Infect Dis
Methicillin-resistant Staphylococcus aureus necrotizing pneumonia
Emerg Infect Dis
Fatal pneumonia caused by Panton-Valentine leucocidine-positive methicillin-resistant Staphylococcus aureus (PVL-MRSA) transmitted from a healthy donor in living-donor liver transplantation
Transplantation
Fatal necrotising pneumonia due to community-acquired methicillin-resistant Staphylococcus aureus (MRSA)
Med J Aust
Severe community acquired pneumonia due to Staphylococcus aureus
Intensive Care Med
Fatal sepsis and necrotizing pneumonia in a child due to community-acquired methicillin-resistant Staphylococcus aureus: case report and literature review
Scand J Infect Dis
Necrotizing pneumonia and septic shock: suspecting CA-MRSA in patients presenting to Canadian emergency departments
CJEM
Pulsed-field gel electrophoresis typing of oxacillin-resistant Staphylococcus aureus isolates from the United States: establishing a national database
J Clin Microbiol
Involvement of Panton-Valentine leukocidin-producing Staphylococcus aureus in primary skin infections and pneumonia
Clin Infect Dis
Multiplex PCR strategy for rapid identification of structural types and variants of the mec element in methicillin-resistant Staphylococcus aureus
Antimicrob Agents Chemother
Methicillin-resistant Staphylococcus aureus skin or soft tissue infections in a state prison, Mississippi, 2000
MMWR Morb Mortal Wkly Rep
Methicillin-resistant Staphylococcus aureus infections among competitive sports participants: Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000–2003
MMWR Morb Mortal Wkly Rep
Methicillin-resistant Staphylococcus aureus infections in correctional facilities: Georgia, California, and Texas, 2001–2003
MMWR Morb Mortal Wkly Rep
A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns
Clin Infect Dis
Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk
JAMA
Methicillin-resistant Staphyloccus aureus in a high school wrestling team and the surrounding community
Arch Intern Med
An outbreak of methicillin resistant Staphylococcus aureus infection in a rugby football team
Br J Sports Med
Cited by (152)
Protection of DNase in the shell of a pH-responsive, antibiotic-loaded micelle for biofilm targeting, dispersal and eradication
2023, Chemical Engineering JournalNovel bacterial topoisomerase inhibitors derived from isomannide
2020, European Journal of Medicinal ChemistryThe role of new antibiotics in the treatment of acute adult community acquired pneumonia
2019, Revue des Maladies RespiratoiresSynthesis and anti-staphylococcal activity of novel bacterial topoisomerase inhibitors with a 5-amino-1,3-dioxane linker moiety
2018, Bioorganic and Medicinal Chemistry LettersAnti-staphylococcal properties of four plant extracts against sensitive and multi-resistant bacterial strains isolated from cattle and rabbits
2017, Microbial PathogenesisCitation Excerpt :Staphylococcus aureus is one of the most challenging of all bacterial pathogens owing largely to the dogged occurrence of antibiotic-resistant strains. This is obvious in the recent emergence of oxacillin sensitive S. aureus (SOSA1 and SOSA2), and methicillin-resistant S. aureus (MRSA1 and MRSA2), which was isolated in Denmark and United Kingdom [1,2]. The recalcitrance of many S. aureus infections to antimicrobials is yet another evidence.