Question

A 52-year-old man with chronic eczema was admitted to the Prince of Wales Hospital, Hong Kong, with fever and chills. Before admission, he had been treated for infected eczematous lesions for several weeks with oral ampicillin, cloxacillin, and cefazolin. He had no history of hospitalization in the past 10 years, and none of his family members were healthcare workers.

Examination showed an oral temperature of 40°C, blood pressure 95/55 mm Hg, and no audible murmur. Cellulitis in the left leg complicated his eczematous skin lesions. Chest radiograph showed right-middle-zone pneumonia. Neutrophilia (leukocytes 15.5 × 109/L, neutrophils 86%), thrombocytopenia (platelets 55 × 109/L), prolonged activated partial thromboplastin time (43.6 s), and elevated bilirubin level (31 μmol/L) were observed.

Two initial blood cultures grew gram-positive cocci in clusters, identified as S. aureus by positive results for catalase and slide/tube coagulase and a negative result for ornithine decarboxylase. Intravenous cloxacillin (2 g every 6 h) was given on days 2–5.

However, the patient's condition progressively deteriorated from day 2 to day 10 with persistent fever, chills, hypotension, and hemoptysis. A repeated chest radiograph showed small lung cavities with fluid, and a thoracic computed tomographic scan confirmed multiple lung abscesses. Results of an initial transthoracic echocardiograph were normal, but a subsequent transesophageal echocardiograph demonstrated tricuspid valve vegetation.

Questions

1.How do you find out if the strain that infected the patient is is MRSA?

2.What antibiotic/s can be substituted?

3.What are the precautions to be taken if this patient was to be hospitalized and why?

4.What would you recommend to do if this patient developed bed sores in the hospital

Answer 1

1.A simple swab test from nares,axillar and groin can easily identify the growth of the organism. Blood investigations can be used to identify the genetic strains of these organism.

2.The cloxacillin is the third line of drug therapy for MRSA.If this is not working, the fourth line drug Linezolid should be administered. The usual substitute for cloxacillin are dicloxacillin,Oxacillin,flucloxacillin. The flucloxacillin and dicloxacillin can be the most effective substitute drug.

3.The precautions which has to be taken if this patient to be hospitalized are

• Contact precautions
• Strict use of gloves, mask, gowns ,goggles
• Infection control practices
• Meticulous and struct hand hygiene before and after touching patient, before and after procedure, after touching the patient surrounding
• Isolate the patient
• Restrict the number of visitors
• Disinfection practice if the equipments used

4.If this patient develops bed sore

• Initiate antibiotic therapy as per order
• Daily aseptic dressing of the wound ,dry dressing is best for healing
• Changing positions every second hourly