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Infection/Inflammation

Retroperitoneal Infections by Community


Acquired Methicillin Resistant Staphylococcus Aureus
Diego A. Abreu,* Fernando Osorio, Luís G. Guido, Gustavo F. Carvalhal†
and Laura Mouro
From the Departments of Urology, Hospital de Clínicas (DAA, FO, LGG, LM), Montevideo, Uruguay, and Pontifícia Universidade Católica
(GFC), Porto Alegre, Brazil

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

I the incidence and virulence of reported infections due to


methicillin resistant Staphylococcus aureus.1 Since
these cases were community acquired, affecting healthy chil-
to serious septic complications and even death.1,2,10
CA-MRSA infection is an emerging disease with world-
wide distribution that is considered one of the major prob-
dren and young adults who did not have predisposing risk lems in health care today.1 The first cases were reported in
factors for hospital acquired infections, they were named 1990 among Australian native aborigines but subsequently
CA-MRSA.1,2 there were reports of infection in New Zealand, Europe,
Multiple factors favor the spread of CA-MRSA infections, Canada and the United States.11–13
such as confinement, poor hygiene, close contact, and shar- In Uruguay CA-MRSA infection was initially reported in
ing of clothes and other objects of personal use.3– 6 Sexual 2001 and it became a massive outbreak in 2004. In accor-
contact is also associated with these infections, especially dance with the literature most Uruguayan infections were
among male homosexuals.7,8 mild with involvement of the skin, while a minority of pa-
Recent investigations aimed at characterizing the strains tients showed severe, invasive disease requiring admission
of CA-MRSA revealed striking differences in epidemiology, to the intensive care unit.14,15 Having evaluated a series of
genetic signature, clinical presentation, virulence and anti- patients with retroperitoneal infection due to CA-MRSA to
biotic sensitivity compared to those of the hospital acquired our knowledge we describe for the first time aspects of the
variety.9,10 Most cases of CA-MRSA are mild, affecting pre- epidemiology, clinical findings and response to specific treat-
dominantly skin and soft tissues. However, there are inva- ments of this disease.
sive forms, including pneumonia, septic pulmonary embo-

MATERIALS AND METHODS


Submitted for publication April 24, 2007. We performed a multicenter, retrospective study from May
* Correspondence: Catedra de Urologia, Oscar Gestide 2786, Apt. 2004 through June 2005. Included were 13 patients with a
5, Montevideo, Uruguay 12600.
† Financial interest and/or other relationship with Novartis and positive culture for CA-MRSA in retroperitoneal infections
AstraZeneca. who were treated at 3 hospitals, that is Hospital de Clínicas

0022-5347/08/1791-0172/0 172 Vol. 179, 172-176, January 2008


THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2007.08.134
RETROPERITONEAL INFECTIONS BY STAPHYLOCOCCUS AUREUS 173

TABLE 1. Patient characteristics


Delay (days)
Pt
No.—Age—Sex Comorbidity Lesion–Clinic Visit Visit–Diagnosis Diagnosis–Treatment

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

Of the 13 patients 11 were male (84.6%). Mean patient age


was 32 years (range 17 to 65). Except for 1 patient with
diabetes there were no associated comorbidities in the pa-
tients studied (table 1). All patients presented with a history
of a suppurated skin lesion, of which 2 were confirmed
CA-MRSA infections. All patients presented with fever and
lumbar pain, 2 (15.4%) showed symptoms of psoas inflam-
mation and 1 (7.7%) presented with respiratory symptoms.
Mean time between the finding of the skin lesion and lumbar
pain was 48 days (range 10 to 90). Mean time between the
first office or emergency room medical visit and the diagno-
sis of retroperitoneal infection was 11 days. In all 6 patients
in whom ultrasound was used for diagnosis retroperitoneal
involvement was confirmed. Abdominal CT, which was per-
formed in all cases, also identified retroperitoneal involve-
FIG. 1. CT of 31-year-old man reveals CA-MRSA abscess in upper
ment in all (figs. 1 and 2). When analyzing CT findings, we pole of right kidney. Surgical drainage was performed and nephrec-
found that in 85% of cases there was compromise of more tomy was unnecessary.
174 RETROPERITONEAL INFECTIONS BY STAPHYLOCOCCUS AUREUS

tals of entry identified in our patients were skin lesions,


which were easily remembered due to their severity. Many
lesions were multiple, had severe inflammatory signs and
had been drained digitally. All required a long time to im-
prove. Additionally, all patients presented with a history of
personal contact with other individuals with skin infections,
of which most were due to CA-MRSA, during a major CA-
MRSA outbreak in Uruguay. Although the precise etiology
of the skin lesions was not confirmed in most patients and
the mean time between the skin lesions and the onset of
symptoms was prolonged, we must consider the skin as the
possible entry site. This was further corroborated by the
absence of other foci of infection and by the fact that the
patients were young, healthy and had a normal urinary
tract. Thus, it is important to investigate previous skin
infections, which may not be routinely evaluated during
anamnesis and physical examination.
The delay in diagnosis was more likely associated with a
lack of clinical suspicion than with the nonspecific clinical
FIG. 2. CT of 37-year-old man shows left perinephric and psoas symptoms. We observed that it was considerably decreased
CA-MRSA abscess. Percutaneous drainage of collections was per- in the last cases due to the previous knowledge about the
formed with 12Fr pigtail catheters and open surgery was unneces-
sary. possibility of retroperitoneal abscesses related to CA-MRSA.
The frequent finding of multiple sites of involvement, eg
the perinephric space and psoas muscle, reveals the ability
drainage of the retroperitoneal abscesses, which had a mean to disseminate and the impressive virulence of CA-MRSA. In
size of 7.8 cm. All abscesses were drained by open surgery most cases this caused large, suppurated collections, of
except 1, which was treated percutaneously. Three patients which many were multiloculated and required invasive ther-
initially underwent percutaneous drainage under CT guid- apies. Another characteristic finding that differentiates
ance but they required additional open surgical drainage. In these infections from classic Staphylococcus infections is the
1 patient nephrectomy was required. None of the patients fact that CA-MRSA forms collections in the perinephric
died. Mean hospitalization was 20 days and all patients space instead of in the renal cortex.
recovered after hospital discharge. Regarding imaging, CT had 100% diagnostic sensitivity.
Therefore, we consider that CT should be the imaging study
DISCUSSION of choice when there is clinical suspicion for a retroperito-
neal CA-MRSA infection.
Retroperitoneal (kidney/perinephric) abscesses are infre- Anemia and hypoprothrombinemia are not specific to CA-
quent nowadays, mainly due to the widespread and prompt MRSA infections. Nevertheless, we believe that these hema-
use of broad-spectrum antibiotics to manage urinary and tological findings may serve as aids in the diagnostic process
skin infections.16 Of retroperitoneal abscesses perinephric since their presence was constant in our patients. Addition-
ones are more prevalent since they are generally secondary ally, these hematological abnormalities are not consistently
to renal primary infection.17,18 In the pre-antibiotic era most described in the literature about renal and perinephric ab-
retroperitoneal abscesses were secondary to the hematoge- scesses.17–19 Based in the findings of our series, we suggest
nous spread of Staphylococcus infections. In recent decades that a diagnostic algorithm should be used in the clinical
the incidence of retroperitoneal abscesses due to gram-pos- suspicion of CA-MRSA retroperitoneal infections (fig. 3).
itive organisms decreased and gram-negative organisms, Regarding medical therapy, we acknowledge that our
especially Escherichia coli, became the predominant cause, criteria for establishing the treatment duration was entirely
whether or not associated with urinary lithiasis.18,19 empirical, although we considered parameters such as clin-
In our series of 13 cases of retroperitoneal abscesses due ical progress and laboratory markers of infectious activity.
to CA-MRSA demographic characteristics were similar to An extensive range of antibiotics has been suggested for
those in previous studies performed in our country and
abroad concerning CA-MRSA infections.1,2 The possible por-

TABLE 3. CA-MRSA retroperitoneal infection antibiotic


sensitivity profile in 13 patients
TABLE 2. Retroperitoneal structures affected by No. No.
CA-MRSA abscesses No. Sensitivity Resistance
Antibiotic Pts (%) (%)
Abscess Focus No. Pts (%)

Isolated renal 1 (7.7) Oxacillin 13 0 13 (100)


Isolated perinephric 1 (7.7) Erythromycin 9 5 (55) 4 (45)
Isolated psoas muscle 0 Clindamycin 10 6 (60) 4 (40)
Renal ⫹ perinephric 1 (7.7) Trimethoprim-sulfamethoxazole 13 13 (100) 0
Renal ⫹ perinephric ⫹ psoas 4 (31) Vancomycin 5 5 (100) 0
Perinephric ⫹ psoas 6 (46) Ciprofloxacin 10 10 (100) 0
Gentamicin 10 10 (100) 0
13 Rifampin 1 1 (100) 0
RETROPERITONEAL INFECTIONS BY STAPHYLOCOCCUS AUREUS 175

FIG. 3. Suggested diagnostic algorithm of retroperitoneal infections by CA-MRSA

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
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