MRSA Necrotizing Fasciitis MRSA Necrotizing Fasciitis in a Neonatein a Neonate

Mei-Lin T. Pang MD, Carla T. Lee MD, Mei-Lin T. Pang MD, Carla T. Lee MD,

Brandie J. Metz MD, Sheila F. Friedlander MD, Brandie J. Metz MD, Sheila F. Friedlander MD,

Victoria R. Barrio MD, Lawrence F. Eichenfield MDVictoria R. Barrio MD, Lawrence F. Eichenfield MD

Children’s Hospital San DiegoChildren’s Hospital San Diego

July 8, 2006July 8, 2006

History of Present IllnessHistory of Present Illness

5 d.o. male -- T 1015 d.o. male -- T 101ºº F & “fussiness” F & “fussiness” FT NSVD; abdominal pustule --DOL3, FT NSVD; abdominal pustule --DOL3,

spontaneously resolvedspontaneously resolved ER evaluation: Irritable, no focal findingsER evaluation: Irritable, no focal findings

Sepsis w/u: unsuccessful LPSepsis w/u: unsuccessful LP Noted on admission: Noted on admission:

2 cm poorly defined subtle induration and erythema 2 cm poorly defined subtle induration and erythema noted at site of lumbar puncturenoted at site of lumbar puncture

History of Present IllnessHistory of Present Illness

Hospital course: hypoxia, hypotensionHospital course: hypoxia, hypotension intubation, pressors, PICUintubation, pressors, PICU

Pediatric dermatology consult re: Pediatric dermatology consult re: progressive induration and erythema of the progressive induration and erythema of the lumbar puncture sitelumbar puncture site

Necrotizing fasciitis (NF)Necrotizing fasciitis (NF)

Potentially fatal bacterial infection of soft Potentially fatal bacterial infection of soft tissuetissue--rapidly progressive tissue edema, --rapidly progressive tissue edema,

inflammation, and sytemic toxicityinflammation, and sytemic toxicity Prompt surgical debridement mandatoryPrompt surgical debridement mandatory

Neonatal Necrotizing Fasciitis:Neonatal Necrotizing Fasciitis:

Less than 70 cases in the literatureLess than 70 cases in the literature 2 series: Taiwan and Pakistan (12 patients)2 series: Taiwan and Pakistan (12 patients) Commonly truncal; abdominal wall most commonCommonly truncal; abdominal wall most common Mortality close to 50%Mortality close to 50% Associations: Associations:

--omphalitis --omphalitis --balanitis--balanitis --mastitis--mastitis --postoperative complications--postoperative complications --fetal monitoring--fetal monitoring

Hsieh W et al, Pediatrics (1999)Nazir Z, Pediatr Surg Int (2005)

Neonatal NFNeonatal NF

Usually polymicrobialUsually polymicrobial staph predominant organismstaph predominant organism Rare cases of MRSARare cases of MRSA

60%60% increase in MRSA - U.S. Hospitals increase in MRSA - U.S. Hospitals Rx: Vancomycin for all cases of Rx: Vancomycin for all cases of

necrotizing fasciitis in communities with necrotizing fasciitis in communities with high rates of MRSAhigh rates of MRSA

Purcell K et al. Arch Pediatr Adolesc Med. (2005)

ReferencesReferences

1.1. Hsieh W, Yang P, Chao H, et al. Neonatal necrotizing fasciitis: A report Hsieh W, Yang P, Chao H, et al. Neonatal necrotizing fasciitis: A report of three cases and review of the literature. of three cases and review of the literature. PediatricsPediatrics. [serial online]. April . [serial online]. April 1999;103:e53. Available at: 1999;103:e53. Available at: http://www.pediatrics.org/cgi/content/103/4/e53http://www.pediatrics.org/cgi/content/103/4/e53. .

2.2. Nazir Z. Necrotizing fasciitis in neonates. Nazir Z. Necrotizing fasciitis in neonates. Pediatr Surg Int.Pediatr Surg Int. 2005;21:641- 2005;21:641-644.644.

3.3. Purcell K, Fergie J. Epidemic of community-acquired methicillin resistant Purcell K, Fergie J. Epidemic of community-acquired methicillin resistant Staphylococcus aureusStaphylococcus aureus infections. infections. Arch Pediatr Adolesc Med. Arch Pediatr Adolesc Med. 2005;159:980-985. 2005;159:980-985.