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Emergence of community-acquired meticillin-resistant Staphylococcus aureus strain USA300 as a cause of necrotising community-onset pneumonia

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Summary

Meticillin-resistant Staphylococcus aureus (MRSA), usually known as a nosocomial pathogen, has emerged as the predominant cause of skin and soft-tissue infections in many communities. Concurrent with the emergence of community-acquired MRSA (CA-MRSA), there have been increasing numbers of reports of community-acquired necrotising pneumonia in young patients and others without the classic health-care-associated risk factors. Community-onset necrotising pneumonia due to CA-MRSA is now recognised as an emerging clinical entity with distinctive clinical features and substantial morbidity and mortality. A viral prodrome (eg, influenza or influenza-like illness) followed by acute onset of shortness of breath, sepsis, and haemoptysis is the most frequent clinical presentation. The best treatment of this partly toxin-mediated disease has not been clearly defined. Whereas cases of CA-MRSA pneumonia have now been reported from almost every continent, the overall burden of disease of this emerging syndrome remains incompletely described. We report two related cases of community-onset pneumonia due to the MRSA USA300 genotype and review the literature regarding the emergence of CA-MRSA 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

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

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