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CASE REPORT: A CASE OF STUBBORN STAPH SEPSIS.
Brian Cervoni, MD1; Sarah Cantrell, MLIS1; Kevin Douglas, MD, MPH, FACP2
1. Walter Reed National Military Medical Center, Bethesda, MD. 2. Uniformed Services University of the Health Sciences, Bethesda, MD.
Background
Persistent bacteremia more than 10 days after initiation of culture-directed therapy is considered treatment failure
(1). This rarely occurs and can be particularly problematic with Staphylococcus infections since up to 30% of the
cases result in metastatic infections, which may result in poor outcomes (2-4).
Case Presentation
A 64-year-old man with a history of chronic back pain presented to the emergency room with 2 days of worsening
low back pain and new buttock pain. Physical exam was remarkable for fever, right wrist tenderness, midline spine
tenderness at L2-L5 levels, and pain with active hip flexion. Evaluation with MRI revealed psoas, paraspinal, and
epidural abscesses, vertebral osteomyelitis, and possible discitis. The patient was admitted to the neurosurgery
service with infectious disease, orthopedic surgery, and interventional radiology consultations. Blood cultures drawn
on admission turned positive within 12 hours for Gram positive cocci at which time he was started on vancomycin.
Interventional radiology drained the psoas abscess and the patient was transferred to the internal medicine service.
Orthopedic surgery evaluated the patient’s right wrist, which was consistent with cellulitis. Brain MRI and
transthoracic echocardiogram (TTE) were unremarkable. On hospital day 3, admission blood cultures revealed
MSSA, and the patient’s antibiotic regimen was changed to nafcillin. Repeat blood cultures from day 2 showed
persistent bacteremia, and a transesophageal echocardiogram (TEE) was performed which was unremarkable. The
patient remained bacteremic after 6 days, and a WBC scan was consistent with prior MRI findings except for the
addition of a right calcaneal abscess, which was drained by orthopedic surgery. A repeat MRI on day 10 revealed
overall worsening of infection, but repeat TTE and TEE were negative for endocarditis. Neurosurgery deferred
surgical intervention of the spinal abscesses and continued monitoring the patient while on antibiotics. Finally, the
patient cleared his bacteremia on day 14. A repeat MRI showed stable disease. The patient remained afebrile for
more than 48 hours, and he was discharged to a rehabilitation facility to continue nafcillin for a total of 8 weeks with
outpatient follow up and repeat imaging.
Discussion
Persistent bacteremia caused by Staphylococcus aureus is dangerous, often resulting in metastatic infections as seen
here. Conversely, and also in this case, widely metastatic infection may result in persistent bacteremia, creating a
vicious cycle. Ultimately, what matters is eradicating the bacteremia, and multidisciplinary consultation is
imperative to improve outcomes (5,6).
References:
1. Lodise TP, Graves J, Evans A, et al. Relationship between vancomycin MIC and failure among patients with
methicillin-resistant Staphylococcus aureus bacteremia treated with vancomycin. Antimicrob Agents Chemother
2008; 52:3315.
2. Horino T, Sato F, Hosaka Y, et al. Predictive factors for metastatic infection in patients with bacteremia caused by
methicillin-sensitive Staphylococcus aureus. Am J Med Sci. 2015 Jan;349(1):24-8.
3. Ing MB, Baddour LM, Bayer AS. Bacteremia and infective endocarditis: Pathogenesis, diagnosis, and
complications. In: The Staphylococci in Human Disease, Crossley KB, Archer GL (Eds), Churchill Livingstone,
New York 1997. p.331.
4. Darouiche RO, Hamill RJ, Greenberg SB, et al. Bacterial spinal epidural abscess. Review of 43 cases and
literature survey. Medicine (Baltimore) 1992; 71:369.
5. Jenkins TC, Price CS, Sabel AL, et al. Impact of routine infectious diseases consultation on the evaluation,
management, and outcomes of Staphylococcus aureus bacteremia. Clin Infect Dis 2008; 46:1000.
6. Vogel M, Schmitz RP, Hagel S, et al. Infectious disease consultation for Staphylococcus aureus bacteremia – A
systemic review and meta-analysis. J Infect 2016; 72:19.