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Case Report
 
Methicillin resistant Staphylococcus aureus necrotizing pneumonia and ceftaroline fosamil: An alternative regimen
 
Fermin López-Rivera1, Hernán González Monroig2, James Eggert3, Hector Cintrón Colón4, Jessica Castellanos Díaz1, Omar Méndez Meléndez2, Fernando Abreu5
 
1MD, PGY-II, Internal Medicine, San Juan City Hospital, San Juan, PR
2MD, PGY-III, Internal Medicine, San Juan City Hospital, San Juan, PR
3MS-III, Internal Medicine, San Juan City Hospital, San Juan, PR
4MD, Research Fellow, Internal Medicine, San Juan City Hospital, San Juan, PR
5MD, Attending, PI, Internal Medicine, San Juan City Hospital, San Juan, PR

Article ID: 100042CRINTFL2017
doi:10.5348/crint-2017-42-CR-10

Address correspondence to:
Fermín López-Rivera
550 Calle Jazmin Coto Laurel, Puerto Rico
00780. Telephone 1-787-718-1870. Fermín López-Rivera
550 Calle Jazmín Coto Laurel, Puerto Rico
Ponce, Puerto Rico
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How to cite this article
López-Rivera F, González H, Eggert J, Cintrón H, Castellanos J, Méndez O, Abreu F. Methicillin resistant Staphylococcus aureus necrotizing pneumonia and ceftaroline fosamil: An alternative regimen. Case Rep Int 2017;6:43–48.


ABSTRACT
Introduction: Pneumonia is defined as an infection of the parenchyma of the lung and is one of the most common causes of death from infectious diseases in the United States (US). Pneumonia is classified into two groups; community acquired pneumonia (CAP) and hospital acquired pneumonia (HAP). Most CAPs are secondary to bacterial pathogens. Methicillin resistant Staphylococcus aureus (MRSA) is identified as a potential pathogen in 8.9% of CAP cases. Community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) produces a cytotoxin called Panton–Valentine leukocidin (PVL), which causes white blood cell destruction and necrosis, resulting in necrotizing pneumonia when it reaches the lungs. Vancomycin and linezolid are most common recommended antibiotics when treating MRSA necrotizing pneumonia. Ceftaroline fosamil, a fifth-generation cephalosporin, is approved for the treatment of skin and soft tissue infection caused by MRSA and pneumonia, but it has not been approved for MRSA pneumonia.
Case Report: A 72-year-old Hispanic male presented with a medical history of hypertension, diabetes mellitus type 2, chronic kidney disease stage 3B, unspecified chronic thrombocytopenia and asthma developed an upper respiratory tract infection that manifested with fever and rhinorrhea and resolved without treatment. Ten days later, the patient arrived at the emergency room due to productive cough of rust colored sputum that started three days before admission. Associated symptoms included malaise, fever, chills and shortness of breath. The patient was admitted to medicine ward with diagnosis of CAP and was initially managed with azithromycin/ceftriaxone. However, persistent fever and tachypnea resulted in the need for reassessment. Sputum culture revealed MRSA and the patient was switched to ceftaroline fosamil for a 21-day course of treatment. Patient was discharged home and has been followed at the outpatient clinic with none of the aforementioned symptoms.
Conclusion: Methicillin resistant Staphylococcus aureus necrotizing pneumonia is an uncommon cause of CAP, but its incidence has increased during the recent years. This type of CAP has gained notoriety due to the PVL cytotoxin, with its dire results. Vancomycin and linezolid are the most recommended antibiotics; vancomycin is recommended if the bacteria show a minimum inhibitory concentration (MIC) < 2. In this case, the S. aureus recovered at sputum culture showed a MIC >2 and since the patient presented with several additional comorbidities management was started with ceftaroline fosamil, a fifth-generation cephalosporin that has no hepatic adjustment and has no problem in thrombocytopenic patients. The ceftaroline fosamil was administered at 400 mg intravenously every 12 hours for 21 days. The patient improved clinically and was discharged home and followed the next week then monthly for two months.

Keywords: Ceftaroline fosamil, Methicillin resistant Staphylococcus aureus (MRSA), Panton–Valentine leukocidin, Pneumonia



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Acknowledgements
We wish to acknowledge the guidance and assistance of Emily Pagán Colón, RN; in the preparation of this article.

Author Contributions
Fermin López-Rivera – Substantial contributions to conception and design, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Hernán González Monroig – Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
James Eggert – Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Hector Cintrón Colón – Substantial contributions to conception and design, Acquisition of data, Drafting the article, Final approval of the version to be published
Jessica Castellanos Díaz – Substantial contributions to conception and design, Acquisition of data, Drafting the article, Final approval of the version to be published
Omar Méndez Meléndez – Substantial contributions to conception and design, Acquisition of data, Drafting the article, Final approval of the version to be published
Fernando Abreu – Substantial contributions to conception and design, Acquisition of data, Drafting the article, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2017 Fermin López-Rivera et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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