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Purpose: We describe the clinical presentation and response to treatment of community acquired, methicillin resistant
Staphylococcus aureus retroperitoneal infections.
Materials and Methods: A total of 13 patients with unusual retroperitoneal infections who fulfilled Centers for Disease
Control criteria for community acquired, methicillin resistant S. aureus were included in this multicenter study, which was
done from May 2004 to June 2005. Distinctive features of these infections were noted and treatment alternatives are
proposed.
Results: Mean patient age was 32 years and 85% of the patients were male. All 13 patients presented with back pain and
fever. Infected skin lesions were the presumed portals of entry for bacteria in all cases. Mean time between skin infection and
lumbar pain was 48 days. After lumbar pain was established a retroperitoneal abscess was diagnosed at a mean delay of 11
days. An association of foci (kidney, perinephric tissue and psoas) occurred in 85% of cases. Perinephric tissue was the most
affected site. Of note, all patients presented with anemia and low serum prothrombin, and required drainage of the
retroperitoneal collection. Open drainage was performed in all except 1 patient, in whom percutaneous drainage and
antibiotic treatment were sufficient. In 1 patient nephrectomy was necessary. Specific antibiotics were administered as soon
as culture results were obtained. Sensitivity was 100% to vancomycin, trimethoprim-sulfamethoxazole, ciprofloxacin and
gentamicin. There were no deaths.
Conclusions: Three characteristics shared by our patients should be given special consideration, including an infected skin
lesion as the possible portal of entry, anemia plus hypoprothrombinemia and frequent involvement of the perinephric region.
Treatment with drainage and antibiotic therapy was effective in all cases.
Key Words: Staphylococcus aureus, community-acquired infections, retroperitoneal space, abscess, methicillin resistance
n recent years there has been a substantial increase in lism, osteomyelitis and visceral abscesses, that may evolve
1—17—M No 30 3 2
2—31—M No 45 7 1
3—38—M No 90 35 0
4—65—M Diabetes mellitus 90 30 1
5—23—M No 50 7 0
6—21—M No 20 3 2
7—30—M No 12 2 0
8—36—F No 90 30 0
9—21—M No 90 15 0
10—37—F No 10 0 0
11—25—M No 45 0 2
12—30—M No 30 14 0
13—32—M No 24 1 7
Mean 32 48 11 1
Of the 13 patients 11 (84.6%) were male and 1 (7.7%) had a comorbid condition.
and Hospital Pasteur in Montevideo, and Hospital de Pay- than 1 retroperitoneal structure (table 2). The perinephric
sandú (7, 5 and 1 patients, respectively). space was the most commonly affected site (12 of 13 patients
Inclusion criteria for CA-MRSA infection were those pro- or 92.3%). In 2 cases (15.4%) there was associated lung and
posed by the Centers for Disease Control and Prevention, pleural compromise, which required admission to the inten-
including ambulatory patients with cultures positive for sive care unit.
MRSA or hospitalized patients with positive cultures ob- Relevant laboratory findings included anemia and low
tained within the first 48 hours of admission and without a serum prothrombin time in all cases. Hemoglobin was 6.3 to
history of infection by MRSA or hospitalizations in the last 11.8 gm/dl (normal 12 to 16) and serum prothrombin was
12 months.7 Exclusion criteria were institutionalized pa- 52% to 68% (normal 70% to 100%).
tients, patients on chronic dialysis, those using permanent CA-MRSA was confirmed in all patients by culture of the
catheters or percutaneous devices and recently operated retroperitoneal foci. However, blood cultures were only pos-
patients. None of the patients met the exclusion criteria. itive in 23% of cases. Urine cultures were negative in all
In the study the variables were demographic data, the patients. The antibiotic sensitivity profile was 100% for van-
portal of entry for the CA-MRSA infection, clinical presen- comycin, trimethoprim-sulfamethoxazole, ciprofloxacin and
tation, mean time between the skin lesion and the onset of gentamicin (table 3). Specific antibiotic therapy was begun
specific symptoms, mean time between initial presentation by combining intravenous antibiotics for at least 15 days,
and diagnosis, and mean time between initial presentation followed by oral antibiotics for at least 4 more weeks.
and specific treatment. We also evaluated imaging findings, After image diagnosis was established the drainage pro-
such as the affected retroperitoneal structures and the as- cedure had an average delay of 1 day. All patients required
sociation of foci, when present. Multi-organ dysfunction, mi-
crobiological data, the sensitivity profile to antibiotics, the
treatment received and hospital stay were also studied. All
collected data were stored in a computerized Microsoft®
Excel® database and descriptive statistics were produced
using the same software.
RESULTS
invasive infections and to our knowledge the optimal ther- We believe that the clinical picture of a patient with fever
apy for this condition is unknown. However, our choice of and lumbar pain, and a history of skin infection, anemia and
antibiotics is accepted by most investigators. For example, hypoprothrombinemia, and a retroperitoneal collection in
the Centers for Disease Control and Prevention stated that the perinephric space shown on imaging should indicate
the first line antibiotic therapy for severe infections caused with a high level of suspicion the diagnosis of a retroperito-
by CA-MRSA is vancomycin alone or combined with tri- neal abscess caused by CA-MRSA. These infections seem to
methoprim-sulfamethoxazole, gentamicin or clindamycin.20 be associated with a favorable prognosis provided that anti-
Due to its rarity there are no definite guidelines for the biotic treatment and appropriate drainage procedures are
treatment of retroperitoneal infections caused by CA-MRSA. administered in timely fashion.
The fact that none of our patients died and only 1 required
nephrectomy before specific antibiotic therapy may indicate
that our treatment options were reasonable. Abbreviations and Acronyms
CA-MRSA ⫽ community acquired, methicillin
CONCLUSIONS resistant Staphylococcus aureus
A major challenge in the treatment of retroperitoneal infec- CT ⫽ computerized tomography
tions is the diagnosis since the clinical presentation is often
misleading, and considering that delays in the initiation of
treatment may be potentially dangerous. Some practical REFERENCES
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