8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 14

Hindawi Publishing CorporationCase Reports in PediatricsVolume 983090983088983089983091 Article ID 983089983093983091983090983091983097 983091 pageshttpdxdoiorg983089983088983089983089983093983093983090983088983089983091983089983093983091983090983091983097

Case Report Acute MRSA Sinusitis with Intracranial Extension andMarginal Vancomycin Susceptibility

Parvathi S Kumar and Kenji M Cunnion

Department of Pediatrics Division of Infectious Diseases Childrenrsquos Hospital of the Kingrsquos Daughters and EVMSNorfolk VA 983090983091983093983088983095 USA

Correspondence should be addressed to Parvathi S Kumar doctorkumar983089gmailcom

Received 983089983088 July 983090983088983089983091 Accepted 983089983091 August 983090983088983089983091

Academic Editors N-C Chiu and K-H Lue

Copyright copy 983090983088983089983091 P S Kumar and K M Cunnion Tis is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

Methicillin resistant Staphylococcus aureus (MRSA) is increasingly being described as a cause o acute sinusitis We presenta patient with acute MRSA sinusitis complicated by rapid intracranial extension marginal vancomycin susceptibility (MIC =983090 mgL) delayed drainage o intracranial abscess and subsequent development o riampin resistance Given the relatively highrisk o intracranial extension o severe acute bacterial sinusitis and high mortality associated with invasive MRSA inections wesuggest early surgical drainage o intracranial abscesses in these circumstances We believe this is important given the limitedintracranial penetration o currently available treatment options or MRSA especially those with a vancomycin minimal inhibitory

concentration (MIC) o ge983090 mgL

1 Introduction

Our patient a previously healthy 983089983090-year-old male presentedwith acute MRSA sinusitis and rapid intracranial extensionTe clinical case was complicated by a marginal vancomycinsusceptibility (MIC = 2 mgL) delayed drainage o intracra-nial abscess and development o riampin resistance Tiscase is illustrative o community-associated MRSA as a pote-ntial cause o acute sinusitis leading to intracranial exten-sion the challenges o antibiotic management o intracranial

MRSA abscess and the hazards o delayed drainage o intracranial MRSA abscess

2 Case Presentation

A previously healthy 983089983090-year-old male with a history o inter-mittent migraines was admitted with acute onset o alteredmental status and acial swelling Te patient had symptomso headache ldquoupset stomachrdquo increasing atigue and tactileever ortwo days prior to admission On theday o admissionhe was ound to be minimally responsive with signi1047297cantswelling to the lef aspect o the ace yellowish dischargerom the lef eye and a protuberance rom the orehead A

noncontrast head C scan done at an outside health careacility demonstrated bilateral orbital cellulitis pansinusitisand possible venous sinus thrombosis prompting transer toa pediatric hospital

On admission the complete blood count (CBC) revealeda white blood cell count o 983096983092983088983088 cellsL with a manual di-erential o 983096 bands 983091 metamyelocytes 983095983092 neutrophilsand 983097 lymphocytes hemoglobin (gmdL)hematocrit ()

o 983096983090983090983092983091 and platelet count o 101 times 103L Additionally

a coagulation panel revealed a prolonged prothrombin time

(P) and activated partial thromboplastin time (aP) o 983089983097seconds and 983092983090983091 seconds respectively as well elevated D-dimer levels o 983089983089983089983089 mgL suggestive o disseminatedintravas-cular coagulation in this patient A brain MRI showed asuperior midline epidural 1047298uid collection measuring 983096983094cmanteroposterior times 983091983089 cm transverse times 983089983088 cm craniocaudalollowing the dorsal aspect o the superior sagittal sinus(Figures 983089(a) and 983089(b)) Te 1047298uid collection demonstrated athin enhancing wall and diffuse smooth dural enhancementwas noted bilaterally Additionally a tiny ocus o intracranialair was present posterior and superior to the opaci1047297ed rontalsinuses Pansinusitis with bilateral orbital cellulitis was alsoreported An MRAMRV o the head noted mild narrowing

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 24

983090 Case Reports in Pediatrics

(a) (b)

F983145983143983157983154983141 983089 (a) MRI o the brain showing sagittal 983089-weighted image afer administration o contrast Te 1047298uid collection reported to have athin enhancing wall ran along the dorsal aspect o the superior sagittal sinus (b) MRI o the brain showing coronal 983089-weighted image aferadministration o contrast Diffuse smooth dural enhancement is noted bilaterally

o the anterior sagittal sinus by the adjacent epidural abscessbut no occlusion o the sinus and no evidence o thrombosisHe was intubated and sedated due to severely depressed men-tation Physical examination was notable or a temperatureo 983091983097983088∘C with diffuse acial swelling protuberant eyelidsyellow discharge rom both nares and a mildly protuberantsof mass in the lower midline orehead consistent withPottrsquos puffy tumor Antibiotics were initiated with ceotaxime

vancomycin and metronidazoleNeurosurgical consultation was requested or surgical

drainage o the intracranial abscess but operative interven-tion was reused citing that the collection was epidural andnot contributing to a mass effect Neurosurgical consultants

questioned whether the collection was an abscess despitethe patientrsquos history symptomatology and imaging strongly suggesting that this was a case o acute bacterial sinusitis withrapid extension intracranially orbitally and subcutaneously

Initial peripheral blood culture was positive at 983089983092 hours o incubation and identi1047297ed as MRSA Signi1047297cant concern wasraisedabout theMRSA having anMIC o983090 mgL which istheupper limit o susceptiblegiven the challenges o vancomycinpenetration into an intracranial abscess Because the epiduralMRSA abscess was not drained initially riampin was addedIt took 983092 days to achieve a target vancomycin trough level o 983089983095 gmL

Te patient remained ebrile clinically unstable and intu-

bated during the 1047297rst three days o hospitalization A repeatMRI on day three o hospitalization was interpreted by theradiologist as a mild increase in size o the epidural abscessin the superior midline but surgical intervention was againdeerred by neurosurgical consultants Te patientrsquos clinicalstatus did not improve on antibiotics and a head MRI on thesixth day o hospitalization showed an increased size o theepidural hematoma with a new abscess along the outer tableo the lef rontal bone and a small subdural 1047298uid collectionalong the anterior lef rontal lobe A craniotomy procedurewith abscess drainage was then perormed recovering puru-lent 1047298uid all cultures o which grew MRSA demonstratingthe persistence o the organism in the intracranial abscess

On hospital day ten otolaryngology surgeons perormedbilateral maxillary antrostomies bilateral ethmoidectomiesbilateral rontal sinus drainage and lef orbital subperiostealabscess drainage MRSA recovered rom the rontal sinusdemonstrated new resistance to riampin which was thendiscontinued On hospital day thirteen a right-sided thora-cotomy was perormed to drain an empyema which grew MRSA Afer our weeks o hospitalization the patient wasdischarged home on antibiotics and has subsequently madea complete recovery Although a ormal evaluation o thepatientrsquos immune system was not perormed he had anormal globulin raction o 983091 gmdL suggesting that a majorde1047297ciency o antibody production was unlikely

3 Discussion

Community-associated MRSA has been the predominantcause o skin and sof tissue inections in North Americaor the past decade [983089 983090] Staphylococcus aureus has longbeen appreciated as a causative agent o chronic bacterialsinusitis [983091] but MRSA as a cause o acute maxillary andsphenoid sinusitis has been only recently appreciated [983092 983093]o our knowledge this is the 1047297rst report o an immuno-competent child with acute MRSA sinusitis complicated by rapid intracranial extension It is reasonable to expect thatthis scenario will occur more requently in the uture given

that the reported risk o intracranial extension in patientshospitalized with a diagnosis o sinusitis ranges rom 983091983095 to983089983089 [983094 983095] Recognition o the possibility o acute MRSAsinusitis leading to intracranial inection is vital due tothe high risk o morbidity and mortality associated witheither intracranial complications o acute sinusitis o 983093ndash983089983088[983096] or invasive MRSA inections o 983089983095ndash983091983090 [983097ndash983089983089] Giventhat antibiotic treatment o acute sinusitis with intracranialextension is unlikely to be initially directed against MRSAthe risk o mortality may be even higher or MRSA sinusitiswith intracranial extensionTis scenario also emphasizes theimportance o achieving a microbiological diagnosis or risk delaying appropriate antibiotic management

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 34

Case Reports in Pediatrics 983091

Tis case additionally illustrates the importance o timely drainage o an intracranial MRSA abscess MRSA subpe-riosteal abscesses in orbital inections have been noted tobe increasing in incidence and are associate with a moreaggressive disease course than or other organisms leading torecommendations or empiric antibiotic coverage with a

very low threshold or surgical intervention [983089983090ndash983089983093] It isreasonable that similar recommendations or timely surgicalmanagement be applied in the setting o MRSA sinusitis withintracranial extensions given limited CNS penetration or

vancomycin o 983095ndash983089983092 o serum concentration [983089983094] Limited vancomycin penetration into abscesses [983089983095] additionally com-promises antimicrobial effectiveness Tese challenges areespecially daunting in the ace o MRSA with a marginal

vancomycin MIC o 983090 mgL which has been requently associated with antibiotic ailure in a variety o clinicalsettings [983089983096 983089983097] For our patient six days o vancomycintherapy did not sterilize or prevent extension o the abscessemphasizing the importance o timely surgical debridementGallagher et al concluded that optimal treatment o suppu-rative intracranial complications o sinusitis is debridemento the paranasal sinuses in combination with neurosurgicaldrainage o the intracranial ocus and intravenous antibiotics[983090983088]

Delayed surgical intervention has also been associatedwith increasing MIC values or vancomycin leading tothe development o resistance (VISA) and heteroresistance(hVISA) [983090983089] Although increasing vancomycin MIC did notoccur or this patient his MRSA did develop riampin resis-tance while on vancomycin and riampin Tis likely rep-resented inadequate vancomycin antimicrobial activity inpurulent 1047298uid collections consistent with delayed surgicaldebridement and the marginal vancomycin MIC or thisMRSA

References

[983089] J S Gerber S E Coffin S A Smathers and E Zaoutisldquorends in the incidence o methicillin-resistant Staphylococcusaureus inection in childrenrsquos hospitals in the United StatesrdquoClinical Infectious Diseases vol 983092983097 no 983089 pp 983094983093ndash983095983089 983090983088983088983097

[983090] J Edelsberg C aneja M Zervos et al ldquorends in US hospitaladmissions or skin and sof tissue inectionsrdquo Emerging Infec-tious Diseases vol 983089983093 no 983097 pp 983089983093983089983094ndash983089983093983089983096 983090983088983088983097

[983091] Kingdom and R E Swain Jr ldquoTe microbiology and anti-microbial resistance patterns in chronic rhinosinusitisrdquo Ameri-

can Journal of Otolaryngology vol 983090983093 no 983093 pp 983091983090983091ndash983091983090983096 983090983088983088983092[983092] W-H Huang and P-K Hung ldquoMethicillin-resistant Staphylo-

coccus aureus inections in acute rhinosinusitisrdquo Laryngoscope vol 983089983089983094 no 983090 pp 983090983096983096ndash983090983097983089 983090983088983088983094

[983093] I Brook P A Foote and J N Hauseld ldquoIncrease in therequency o recovery o meticillin-resistant Staphylococcusaureus in acute and chronic maxillary sinusitisrdquo Journal of Medical Microbiology vol 983093983095 no 983096 pp 983089983088983089983093ndash983089983088983089983095 983090983088983088983096

[983094] G L Clayman G L Adams D R Paugh and C F Koop-mann Jr ldquoIntracranial complications o paranasal sinusitis acombined institutional reviewrdquo Laryngoscope vol983089983088983089 no 983091pp983090983091983092ndash983090983091983097 983089983097983097983089

[983095] R W Dolan and K Chowdhury ldquoDiagnosis and treatmento intracranial complications o paranasal sinus inectionsrdquo

Journal of Oral and Maxillofacial Surgery vol983093983091no983097pp983089983088983096983088ndash983089983088983096983095 983089983097983097983093

[983096] EE LangA J CurranN PatilR MWalshD Rawluk and MA Walsh ldquoIntracranial complications o acute rontal sinusitisrdquoClinical Otolaryngology and Allied Sciences vol 983090983094 no 983094 pp983092983093983090ndash983092983093983095 983090983088983088983089

[983097] M Pastagia L C Kleinman E G Lacerda de la Cruz and SG Jenkins ldquoPredicting risk or death rom MRSA bacteremiardquoEmerging Infectious Diseases vol 983089983096 no 983095 pp 983089983088983095983090ndash983089983088983096983088 983090983088983089983090

[983089983088] E D McCoul D N Jourdy M R Schaberg and V KAnand ldquoMethicillin-resistant Staphylococcus aureus sinusitis innonhospitalized patients a systematic review o prevalence andtreatment outcomesrdquo Laryngoscope vol 983089983090983090 no 983089983088 pp 983090983089983090983093ndash983090983089983091983089 983090983088983089983090

[983089983089] Active Bacterial Core Surveillance Report ldquoEmerging Inec-tions Program Network Methicillin-Resistant Staphylococcusaureusrdquo 983090983088983088983096 httpwwwcdcgovabcsreports-1047297ndingssurv-reportsmrsa983088983096html

[983089983090] S Liao M L Durand and M J Cunningham ldquoSinogenicorbital and subperiosteal abscesses microbiology and methici-

llin-resistant Staphylococcus aureus incidencerdquo Otolaryngology vol 983089983092983091 no 983091 pp 983091983097983090ndash983091983097983094 983090983088983089983088

[983089983091] V E Soon ldquoPediatric subperiosteal orbital abscess secondary to acute sinusitis a 983093-year reviewrdquo American Journal of Oto-laryngology vol 983091983090 no 983089 pp 983094983090ndash983094983096 983090983088983089983089

[983089983092] G J Harris ldquoSubperiosteal abscess o the orbit older childrenand adults require aggressive treatmentrdquo Ophthalmic Plastic and Reconstructive Surgery vol 983089983095 no 983094 pp 983091983097983093ndash983091983097983095 983090983088983088983089

[983089983093] S Coenraad and J Buwalda ldquoSurgical or medical managemento subperiosteal orbital abscess in children a critical appraisalo the literaturerdquo Rhinology vol 983092983095 no 983089 pp 983089983096ndash983090983091 983090983088983088983097

[983089983094] I Lutsar G H McCracken Jr and I R Friedland ldquoAntibioticpharmacodynamics in cerebrospinal 1047298uidrdquo Clinical InfectiousDiseases vol 983090983095 no 983093 pp 983089983089983089983095ndash983089983089983090983097 983089983097983097983096

[983089983095] E Brauner S Gorbach and P Davey ldquoComparative study o clindamycin imipenem oxacillin and vancomycin in theinected granuloma pouch modelrdquo Journal of Antimicrobial Chemotherapy vol 983090983091 no 983094 pp 983096983097983089ndash983096983097983096 983089983097983096983097

[983089983096] J-L Wang J- Wang W-H Sheng Y-C Chen and S-C Chang ldquoNosocomial methicillin-resistant Staphylococcusaureus (MRSA) bacteremia in aiwan mortality analyses andthe impact o vancomycin MIC = 983090 mgL by the brothmicrodilution methodrdquo BMC Infectious Diseases vol 983089983088 article983089983093983097 983090983088983089983088

[983089983097] A Soriano F Marco J A Martınez et al ldquoIn1047298uence o van-comycin minimum inhibitory concentration on the treatmento methicillin-resistantStaphylococcus aureus bacteremiardquo Clin-ical Infectious Diseases vol 983092983094 no 983090 pp 983089983097983091ndash983090983088983088 983090983088983088983096

[983090983088] R M Gallagher C W Gross and C D Phillips ldquoSuppurativeintracranial complications o sinusitisrdquo Laryngoscope vol 983089983088983096no 983089983089 pp 983089983094983091983093ndash983089983094983092983090 983089983097983097983096

[983090983089] B P Howden P D R Johnson P B Ward P Stinear andJ K Davies ldquoIsolates with low-level vancomycin resistanceassociated with persistent methicillin-resistant Staphylococcusaureus bacteremiardquo Antimicrobial Agents and Chemotherapy vol 983093983088 no 983097 pp 983091983088983091983097ndash983091983088983092983095 983090983088983088983094

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 44

Submit your manuscripts at

httpwwwhindawicom

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 24

983090 Case Reports in Pediatrics

(a) (b)

F983145983143983157983154983141 983089 (a) MRI o the brain showing sagittal 983089-weighted image afer administration o contrast Te 1047298uid collection reported to have athin enhancing wall ran along the dorsal aspect o the superior sagittal sinus (b) MRI o the brain showing coronal 983089-weighted image aferadministration o contrast Diffuse smooth dural enhancement is noted bilaterally

o the anterior sagittal sinus by the adjacent epidural abscessbut no occlusion o the sinus and no evidence o thrombosisHe was intubated and sedated due to severely depressed men-tation Physical examination was notable or a temperatureo 983091983097983088∘C with diffuse acial swelling protuberant eyelidsyellow discharge rom both nares and a mildly protuberantsof mass in the lower midline orehead consistent withPottrsquos puffy tumor Antibiotics were initiated with ceotaxime

vancomycin and metronidazoleNeurosurgical consultation was requested or surgical

drainage o the intracranial abscess but operative interven-tion was reused citing that the collection was epidural andnot contributing to a mass effect Neurosurgical consultants

questioned whether the collection was an abscess despitethe patientrsquos history symptomatology and imaging strongly suggesting that this was a case o acute bacterial sinusitis withrapid extension intracranially orbitally and subcutaneously

Initial peripheral blood culture was positive at 983089983092 hours o incubation and identi1047297ed as MRSA Signi1047297cant concern wasraisedabout theMRSA having anMIC o983090 mgL which istheupper limit o susceptiblegiven the challenges o vancomycinpenetration into an intracranial abscess Because the epiduralMRSA abscess was not drained initially riampin was addedIt took 983092 days to achieve a target vancomycin trough level o 983089983095 gmL

Te patient remained ebrile clinically unstable and intu-

bated during the 1047297rst three days o hospitalization A repeatMRI on day three o hospitalization was interpreted by theradiologist as a mild increase in size o the epidural abscessin the superior midline but surgical intervention was againdeerred by neurosurgical consultants Te patientrsquos clinicalstatus did not improve on antibiotics and a head MRI on thesixth day o hospitalization showed an increased size o theepidural hematoma with a new abscess along the outer tableo the lef rontal bone and a small subdural 1047298uid collectionalong the anterior lef rontal lobe A craniotomy procedurewith abscess drainage was then perormed recovering puru-lent 1047298uid all cultures o which grew MRSA demonstratingthe persistence o the organism in the intracranial abscess

On hospital day ten otolaryngology surgeons perormedbilateral maxillary antrostomies bilateral ethmoidectomiesbilateral rontal sinus drainage and lef orbital subperiostealabscess drainage MRSA recovered rom the rontal sinusdemonstrated new resistance to riampin which was thendiscontinued On hospital day thirteen a right-sided thora-cotomy was perormed to drain an empyema which grew MRSA Afer our weeks o hospitalization the patient wasdischarged home on antibiotics and has subsequently madea complete recovery Although a ormal evaluation o thepatientrsquos immune system was not perormed he had anormal globulin raction o 983091 gmdL suggesting that a majorde1047297ciency o antibody production was unlikely

3 Discussion

Community-associated MRSA has been the predominantcause o skin and sof tissue inections in North Americaor the past decade [983089 983090] Staphylococcus aureus has longbeen appreciated as a causative agent o chronic bacterialsinusitis [983091] but MRSA as a cause o acute maxillary andsphenoid sinusitis has been only recently appreciated [983092 983093]o our knowledge this is the 1047297rst report o an immuno-competent child with acute MRSA sinusitis complicated by rapid intracranial extension It is reasonable to expect thatthis scenario will occur more requently in the uture given

that the reported risk o intracranial extension in patientshospitalized with a diagnosis o sinusitis ranges rom 983091983095 to983089983089 [983094 983095] Recognition o the possibility o acute MRSAsinusitis leading to intracranial inection is vital due tothe high risk o morbidity and mortality associated witheither intracranial complications o acute sinusitis o 983093ndash983089983088[983096] or invasive MRSA inections o 983089983095ndash983091983090 [983097ndash983089983089] Giventhat antibiotic treatment o acute sinusitis with intracranialextension is unlikely to be initially directed against MRSAthe risk o mortality may be even higher or MRSA sinusitiswith intracranial extensionTis scenario also emphasizes theimportance o achieving a microbiological diagnosis or risk delaying appropriate antibiotic management

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 34

Case Reports in Pediatrics 983091

Tis case additionally illustrates the importance o timely drainage o an intracranial MRSA abscess MRSA subpe-riosteal abscesses in orbital inections have been noted tobe increasing in incidence and are associate with a moreaggressive disease course than or other organisms leading torecommendations or empiric antibiotic coverage with a

very low threshold or surgical intervention [983089983090ndash983089983093] It isreasonable that similar recommendations or timely surgicalmanagement be applied in the setting o MRSA sinusitis withintracranial extensions given limited CNS penetration or

vancomycin o 983095ndash983089983092 o serum concentration [983089983094] Limited vancomycin penetration into abscesses [983089983095] additionally com-promises antimicrobial effectiveness Tese challenges areespecially daunting in the ace o MRSA with a marginal

vancomycin MIC o 983090 mgL which has been requently associated with antibiotic ailure in a variety o clinicalsettings [983089983096 983089983097] For our patient six days o vancomycintherapy did not sterilize or prevent extension o the abscessemphasizing the importance o timely surgical debridementGallagher et al concluded that optimal treatment o suppu-rative intracranial complications o sinusitis is debridemento the paranasal sinuses in combination with neurosurgicaldrainage o the intracranial ocus and intravenous antibiotics[983090983088]

Delayed surgical intervention has also been associatedwith increasing MIC values or vancomycin leading tothe development o resistance (VISA) and heteroresistance(hVISA) [983090983089] Although increasing vancomycin MIC did notoccur or this patient his MRSA did develop riampin resis-tance while on vancomycin and riampin Tis likely rep-resented inadequate vancomycin antimicrobial activity inpurulent 1047298uid collections consistent with delayed surgicaldebridement and the marginal vancomycin MIC or thisMRSA

References

[983089] J S Gerber S E Coffin S A Smathers and E Zaoutisldquorends in the incidence o methicillin-resistant Staphylococcusaureus inection in childrenrsquos hospitals in the United StatesrdquoClinical Infectious Diseases vol 983092983097 no 983089 pp 983094983093ndash983095983089 983090983088983088983097

[983090] J Edelsberg C aneja M Zervos et al ldquorends in US hospitaladmissions or skin and sof tissue inectionsrdquo Emerging Infec-tious Diseases vol 983089983093 no 983097 pp 983089983093983089983094ndash983089983093983089983096 983090983088983088983097

[983091] Kingdom and R E Swain Jr ldquoTe microbiology and anti-microbial resistance patterns in chronic rhinosinusitisrdquo Ameri-

can Journal of Otolaryngology vol 983090983093 no 983093 pp 983091983090983091ndash983091983090983096 983090983088983088983092[983092] W-H Huang and P-K Hung ldquoMethicillin-resistant Staphylo-

coccus aureus inections in acute rhinosinusitisrdquo Laryngoscope vol 983089983089983094 no 983090 pp 983090983096983096ndash983090983097983089 983090983088983088983094

[983093] I Brook P A Foote and J N Hauseld ldquoIncrease in therequency o recovery o meticillin-resistant Staphylococcusaureus in acute and chronic maxillary sinusitisrdquo Journal of Medical Microbiology vol 983093983095 no 983096 pp 983089983088983089983093ndash983089983088983089983095 983090983088983088983096

[983094] G L Clayman G L Adams D R Paugh and C F Koop-mann Jr ldquoIntracranial complications o paranasal sinusitis acombined institutional reviewrdquo Laryngoscope vol983089983088983089 no 983091pp983090983091983092ndash983090983091983097 983089983097983097983089

[983095] R W Dolan and K Chowdhury ldquoDiagnosis and treatmento intracranial complications o paranasal sinus inectionsrdquo

Journal of Oral and Maxillofacial Surgery vol983093983091no983097pp983089983088983096983088ndash983089983088983096983095 983089983097983097983093

[983096] EE LangA J CurranN PatilR MWalshD Rawluk and MA Walsh ldquoIntracranial complications o acute rontal sinusitisrdquoClinical Otolaryngology and Allied Sciences vol 983090983094 no 983094 pp983092983093983090ndash983092983093983095 983090983088983088983089

[983097] M Pastagia L C Kleinman E G Lacerda de la Cruz and SG Jenkins ldquoPredicting risk or death rom MRSA bacteremiardquoEmerging Infectious Diseases vol 983089983096 no 983095 pp 983089983088983095983090ndash983089983088983096983088 983090983088983089983090

[983089983088] E D McCoul D N Jourdy M R Schaberg and V KAnand ldquoMethicillin-resistant Staphylococcus aureus sinusitis innonhospitalized patients a systematic review o prevalence andtreatment outcomesrdquo Laryngoscope vol 983089983090983090 no 983089983088 pp 983090983089983090983093ndash983090983089983091983089 983090983088983089983090

[983089983089] Active Bacterial Core Surveillance Report ldquoEmerging Inec-tions Program Network Methicillin-Resistant Staphylococcusaureusrdquo 983090983088983088983096 httpwwwcdcgovabcsreports-1047297ndingssurv-reportsmrsa983088983096html

[983089983090] S Liao M L Durand and M J Cunningham ldquoSinogenicorbital and subperiosteal abscesses microbiology and methici-

llin-resistant Staphylococcus aureus incidencerdquo Otolaryngology vol 983089983092983091 no 983091 pp 983091983097983090ndash983091983097983094 983090983088983089983088

[983089983091] V E Soon ldquoPediatric subperiosteal orbital abscess secondary to acute sinusitis a 983093-year reviewrdquo American Journal of Oto-laryngology vol 983091983090 no 983089 pp 983094983090ndash983094983096 983090983088983089983089

[983089983092] G J Harris ldquoSubperiosteal abscess o the orbit older childrenand adults require aggressive treatmentrdquo Ophthalmic Plastic and Reconstructive Surgery vol 983089983095 no 983094 pp 983091983097983093ndash983091983097983095 983090983088983088983089

[983089983093] S Coenraad and J Buwalda ldquoSurgical or medical managemento subperiosteal orbital abscess in children a critical appraisalo the literaturerdquo Rhinology vol 983092983095 no 983089 pp 983089983096ndash983090983091 983090983088983088983097

[983089983094] I Lutsar G H McCracken Jr and I R Friedland ldquoAntibioticpharmacodynamics in cerebrospinal 1047298uidrdquo Clinical InfectiousDiseases vol 983090983095 no 983093 pp 983089983089983089983095ndash983089983089983090983097 983089983097983097983096

[983089983095] E Brauner S Gorbach and P Davey ldquoComparative study o clindamycin imipenem oxacillin and vancomycin in theinected granuloma pouch modelrdquo Journal of Antimicrobial Chemotherapy vol 983090983091 no 983094 pp 983096983097983089ndash983096983097983096 983089983097983096983097

[983089983096] J-L Wang J- Wang W-H Sheng Y-C Chen and S-C Chang ldquoNosocomial methicillin-resistant Staphylococcusaureus (MRSA) bacteremia in aiwan mortality analyses andthe impact o vancomycin MIC = 983090 mgL by the brothmicrodilution methodrdquo BMC Infectious Diseases vol 983089983088 article983089983093983097 983090983088983089983088

[983089983097] A Soriano F Marco J A Martınez et al ldquoIn1047298uence o van-comycin minimum inhibitory concentration on the treatmento methicillin-resistantStaphylococcus aureus bacteremiardquo Clin-ical Infectious Diseases vol 983092983094 no 983090 pp 983089983097983091ndash983090983088983088 983090983088983088983096

[983090983088] R M Gallagher C W Gross and C D Phillips ldquoSuppurativeintracranial complications o sinusitisrdquo Laryngoscope vol 983089983088983096no 983089983089 pp 983089983094983091983093ndash983089983094983092983090 983089983097983097983096

[983090983089] B P Howden P D R Johnson P B Ward P Stinear andJ K Davies ldquoIsolates with low-level vancomycin resistanceassociated with persistent methicillin-resistant Staphylococcusaureus bacteremiardquo Antimicrobial Agents and Chemotherapy vol 983093983088 no 983097 pp 983091983088983091983097ndash983091983088983092983095 983090983088983088983094

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 44

Submit your manuscripts at

httpwwwhindawicom

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 34

Case Reports in Pediatrics 983091

Tis case additionally illustrates the importance o timely drainage o an intracranial MRSA abscess MRSA subpe-riosteal abscesses in orbital inections have been noted tobe increasing in incidence and are associate with a moreaggressive disease course than or other organisms leading torecommendations or empiric antibiotic coverage with a

very low threshold or surgical intervention [983089983090ndash983089983093] It isreasonable that similar recommendations or timely surgicalmanagement be applied in the setting o MRSA sinusitis withintracranial extensions given limited CNS penetration or

vancomycin o 983095ndash983089983092 o serum concentration [983089983094] Limited vancomycin penetration into abscesses [983089983095] additionally com-promises antimicrobial effectiveness Tese challenges areespecially daunting in the ace o MRSA with a marginal

vancomycin MIC o 983090 mgL which has been requently associated with antibiotic ailure in a variety o clinicalsettings [983089983096 983089983097] For our patient six days o vancomycintherapy did not sterilize or prevent extension o the abscessemphasizing the importance o timely surgical debridementGallagher et al concluded that optimal treatment o suppu-rative intracranial complications o sinusitis is debridemento the paranasal sinuses in combination with neurosurgicaldrainage o the intracranial ocus and intravenous antibiotics[983090983088]

Delayed surgical intervention has also been associatedwith increasing MIC values or vancomycin leading tothe development o resistance (VISA) and heteroresistance(hVISA) [983090983089] Although increasing vancomycin MIC did notoccur or this patient his MRSA did develop riampin resis-tance while on vancomycin and riampin Tis likely rep-resented inadequate vancomycin antimicrobial activity inpurulent 1047298uid collections consistent with delayed surgicaldebridement and the marginal vancomycin MIC or thisMRSA

References

[983089] J S Gerber S E Coffin S A Smathers and E Zaoutisldquorends in the incidence o methicillin-resistant Staphylococcusaureus inection in childrenrsquos hospitals in the United StatesrdquoClinical Infectious Diseases vol 983092983097 no 983089 pp 983094983093ndash983095983089 983090983088983088983097

[983090] J Edelsberg C aneja M Zervos et al ldquorends in US hospitaladmissions or skin and sof tissue inectionsrdquo Emerging Infec-tious Diseases vol 983089983093 no 983097 pp 983089983093983089983094ndash983089983093983089983096 983090983088983088983097

[983091] Kingdom and R E Swain Jr ldquoTe microbiology and anti-microbial resistance patterns in chronic rhinosinusitisrdquo Ameri-

can Journal of Otolaryngology vol 983090983093 no 983093 pp 983091983090983091ndash983091983090983096 983090983088983088983092[983092] W-H Huang and P-K Hung ldquoMethicillin-resistant Staphylo-

coccus aureus inections in acute rhinosinusitisrdquo Laryngoscope vol 983089983089983094 no 983090 pp 983090983096983096ndash983090983097983089 983090983088983088983094

[983093] I Brook P A Foote and J N Hauseld ldquoIncrease in therequency o recovery o meticillin-resistant Staphylococcusaureus in acute and chronic maxillary sinusitisrdquo Journal of Medical Microbiology vol 983093983095 no 983096 pp 983089983088983089983093ndash983089983088983089983095 983090983088983088983096

[983094] G L Clayman G L Adams D R Paugh and C F Koop-mann Jr ldquoIntracranial complications o paranasal sinusitis acombined institutional reviewrdquo Laryngoscope vol983089983088983089 no 983091pp983090983091983092ndash983090983091983097 983089983097983097983089

[983095] R W Dolan and K Chowdhury ldquoDiagnosis and treatmento intracranial complications o paranasal sinus inectionsrdquo

Journal of Oral and Maxillofacial Surgery vol983093983091no983097pp983089983088983096983088ndash983089983088983096983095 983089983097983097983093

[983096] EE LangA J CurranN PatilR MWalshD Rawluk and MA Walsh ldquoIntracranial complications o acute rontal sinusitisrdquoClinical Otolaryngology and Allied Sciences vol 983090983094 no 983094 pp983092983093983090ndash983092983093983095 983090983088983088983089

[983097] M Pastagia L C Kleinman E G Lacerda de la Cruz and SG Jenkins ldquoPredicting risk or death rom MRSA bacteremiardquoEmerging Infectious Diseases vol 983089983096 no 983095 pp 983089983088983095983090ndash983089983088983096983088 983090983088983089983090

[983089983088] E D McCoul D N Jourdy M R Schaberg and V KAnand ldquoMethicillin-resistant Staphylococcus aureus sinusitis innonhospitalized patients a systematic review o prevalence andtreatment outcomesrdquo Laryngoscope vol 983089983090983090 no 983089983088 pp 983090983089983090983093ndash983090983089983091983089 983090983088983089983090

[983089983089] Active Bacterial Core Surveillance Report ldquoEmerging Inec-tions Program Network Methicillin-Resistant Staphylococcusaureusrdquo 983090983088983088983096 httpwwwcdcgovabcsreports-1047297ndingssurv-reportsmrsa983088983096html

[983089983090] S Liao M L Durand and M J Cunningham ldquoSinogenicorbital and subperiosteal abscesses microbiology and methici-

llin-resistant Staphylococcus aureus incidencerdquo Otolaryngology vol 983089983092983091 no 983091 pp 983091983097983090ndash983091983097983094 983090983088983089983088

[983089983091] V E Soon ldquoPediatric subperiosteal orbital abscess secondary to acute sinusitis a 983093-year reviewrdquo American Journal of Oto-laryngology vol 983091983090 no 983089 pp 983094983090ndash983094983096 983090983088983089983089

[983089983092] G J Harris ldquoSubperiosteal abscess o the orbit older childrenand adults require aggressive treatmentrdquo Ophthalmic Plastic and Reconstructive Surgery vol 983089983095 no 983094 pp 983091983097983093ndash983091983097983095 983090983088983088983089

[983089983093] S Coenraad and J Buwalda ldquoSurgical or medical managemento subperiosteal orbital abscess in children a critical appraisalo the literaturerdquo Rhinology vol 983092983095 no 983089 pp 983089983096ndash983090983091 983090983088983088983097

[983089983094] I Lutsar G H McCracken Jr and I R Friedland ldquoAntibioticpharmacodynamics in cerebrospinal 1047298uidrdquo Clinical InfectiousDiseases vol 983090983095 no 983093 pp 983089983089983089983095ndash983089983089983090983097 983089983097983097983096

[983089983095] E Brauner S Gorbach and P Davey ldquoComparative study o clindamycin imipenem oxacillin and vancomycin in theinected granuloma pouch modelrdquo Journal of Antimicrobial Chemotherapy vol 983090983091 no 983094 pp 983096983097983089ndash983096983097983096 983089983097983096983097

[983089983096] J-L Wang J- Wang W-H Sheng Y-C Chen and S-C Chang ldquoNosocomial methicillin-resistant Staphylococcusaureus (MRSA) bacteremia in aiwan mortality analyses andthe impact o vancomycin MIC = 983090 mgL by the brothmicrodilution methodrdquo BMC Infectious Diseases vol 983089983088 article983089983093983097 983090983088983089983088

[983089983097] A Soriano F Marco J A Martınez et al ldquoIn1047298uence o van-comycin minimum inhibitory concentration on the treatmento methicillin-resistantStaphylococcus aureus bacteremiardquo Clin-ical Infectious Diseases vol 983092983094 no 983090 pp 983089983097983091ndash983090983088983088 983090983088983088983096

[983090983088] R M Gallagher C W Gross and C D Phillips ldquoSuppurativeintracranial complications o sinusitisrdquo Laryngoscope vol 983089983088983096no 983089983089 pp 983089983094983091983093ndash983089983094983092983090 983089983097983097983096

[983090983089] B P Howden P D R Johnson P B Ward P Stinear andJ K Davies ldquoIsolates with low-level vancomycin resistanceassociated with persistent methicillin-resistant Staphylococcusaureus bacteremiardquo Antimicrobial Agents and Chemotherapy vol 983093983088 no 983097 pp 983091983088983091983097ndash983091983088983092983095 983090983088983088983094

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 44

Submit your manuscripts at

httpwwwhindawicom

8192019 153239pdf

httpslidepdfcomreaderfull153239pdf 44

Submit your manuscripts at

httpwwwhindawicom