Tropic Infection-1 Case Discussion

SEPSIS E.C MRSS INFECTION IN

PATIENT WITH CVA

Iswanto Korompot

Moderator :

1
Data Base
Female, 45 y.o, Admission date 12-06-2018
 Chief complaint: fever
 Patients complain of fever since 5 days ago.
 Also complain of nausea, vomit and decreased appetite
 Also complain of dizziness
 the patient does not cough, there is no abdominal pain, and
there is no diarrhea
 History of hipertensi (+)
 History of DM denied

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Past medical history :
 Uncontrolled hypertension (+), DM (-)

Family History :
 No family member has the same complaint as the
patient, hypertension (-), DM (-)

Social History :

3
Physical Examination
 General condition: moderately ill, GCS: 456, BW: 55 kgs,
 Vital sign
 BP: 210/108 mmHg HR: 120 bpm RR: 22 x/mnt Tax:
38°C SpO2 92% CRT <2”
 H/N: anemic conj -/-, icteric sclera -/-, epistaxis (-), JVP: R+2
cmH2O, lymph nodes enlargement (-)
 Thorax
 P: symetrical chest movement
SF D=S, sonor, vesicular, rh-/-, wh -/-

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Laboratory Examination (hematology)
Parameter 12/ 14/6 Reference
6 Range
Hb (g/dL) 16,63 14,67 13.0-18.0
Erythrocyte 5,878 5,323 4.0-5.5
(106/μL)
Hematocrite (%) 46,27 42,88 40-54
MCV (fL) 78,72 80,55 80-93
MCH (pg) 28,29 27,56 27-31
RDW (%) 9,90 10,21 11.5-14.5
Leukocyte (/μL) 28,27 20,29 4.000-10.000
Trombocyte (/μL) 351 381 150.000-400.000
Diff. count -/-/79/12 -/-/82/12/6 0-1/0-4/51-67/
/9 25-33/2-5
Reticulocyte (%) 0.5-2.5
LED (mm/h) 0-15
Blood type
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 Blood 12/6 Reference
Chemistry Prev
Lab
Ureum 27 16,6 – 48,5 mg/dL
Creatinine 1,192 < 1,2 mg/dL
Glucosa 533
sewaktu

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Immunoserology 12/6 Reference
widal
S. Typhi O negatif negatif
S. Typhi H negatif
S. Paratyphi PA negatif
S. Paratyphi PB negatif

Electrolyte 12/6 Reference

Prev Lab
Na 131 136-145 mmol/L
K 2,89 3,5-5,0 mmol/L
Cl 88,26 98-106 mmol/L

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8
9
Perjalanan Penyakit Pasien
12-06-2018 13 -06-2018 14-06-2018 15-06-2018 17-06-2018
(1 hari
paska MRS)
MRS Terdiagnosa Pasien Hasil kultur
stroke meninggal
iskemi

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 Data Interpretations

 From laboratory test results showed

leucocytosis with absolute neutrophilia,
hyperuricemia, hyponatremia, hypocalemia,
culture : MRSS
 Data Interpretations

 Based on medical history, physical examination,

laboratory data and other examinations showed
Ischemic stroke attack due to uncontrolled
hypertension, septic condition dt MRSS,
electrolyte imbalance due to Gastrointestinal loss
 Suggestion:
 Urinalysis, BGA
 Monitoring CBC
DISCUSSION

Establishment the Diagnosis

Methicillin Resistant
Staphylococcus Spesies (MRSS)
CVA

 CVA : sudden death of some brain cells due to

lack of oxygen when the blood flow to the brain
is impaired by blockage or rupture of an artery to
the brain
 Types :
 Ischemic strokes : caused by a blockage (clog) in one of
the blood vessels that supply oxygen and other
important nutrients to the brain. Types : thrombotic,
embolic
 Hemorrhagic strokes occur when blood vessels in the
brain leak or rupture (break), causing bleeding in or
around the brain. Types : ICH, SAH
14
Wilkinson and Lennox.2005. Essential Neurology
Ischemic Stroke

 Thrombotic stroke — A thrombotic stroke results from a

problem within an artery (blood vessel) that supplies blood to
the brain. This is most likely to occur in arteries that are
clogged with fatty deposits, called plaques. Plaques partially
block the artery, and can rupture and bleed, forming a blood
clot. This blood clot ("thrombus") can further clog or
completely block the artery, which then slows or prevents
blood flow to the area of brain fed by that artery. Blood
clotting disorders can also cause clots to form within arteries
in some people.

Wilkinson and Lennox.2005. Essential Neurology

Ischemic Stroke

 Embolic stroke — An embolic stroke occurs when a blood clot

or other particle travels from another part of the body (often
the heart) through the bloodstream to the brain where it
lodges in a smaller blood vessel. The blood clot or particle,
called an "embolus," then blocks blood flow to that area of
the brain, reducing the amount of oxygen and nutrients that
reach that area. One of the most common causes of embolic
strokes is an irregular heart rhythm called "atrial fibrillation."
Emboli can also originate in the aorta and in the arteries
within the neck and head and travel further along within
arteries within the brain.

Wilkinson and Lennox.2005. Essential Neurology

 This Patient
 Female, 45 y.o, on follow up DOC 13/6/2018 (2-2-4),
dysarthria, hemiparesis dextra, severe headache
 HT uncontrolled
 BP : 210/108
 Babinsky +/-, decrease motoric & sensory dextra

Ischemic Stroke

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Sepsis

 Sepsis is life-threatening organ dysfunction

caused by a dysregulated host response to
infection
 Organ dysfunction can be identified as an acute
increase of ≥2 SOFA points consequent to the
infection
 The baseline SOFA score can be assumed to be
zero in patients not known to have preexixting
organ dysfunction
 Severe sepsis : sepsis with at least one acute
organ dysfunction

JAMA. 2016;315(8):801-810. 18
 JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

TOTAL = 3
Date of download: 3/15/2016 19
Copyright © 2016 American Medical Association. All rights reserved.
This Patient
 GCS ↓ (on follow up), fever 5 days
 Tachycardia, tachypnea (follow up)
 Leukocytosis with absolute neutrophilia
 SOFA score : 3

SIRS + SOURCE OF INFECTION

SEPSIS dt MRSS
urinalysis, BGA , Monitoring : CBC,,

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 This Patient
 Female, 45 y.o, suddenly DOC (2-2-4 in follow up)
 HT uncontrolled
 Hyponatremia
 Hypocalemia

Electrolyte imbalance

 Monitoring Serum Electrolyte

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 Methicillin-resistant Staphylococcus spesies
(MRSS)
 . Staphylococcus is a genus of Gram-positive bacteria
in the family Staphylococcacus. Under the microscope,
they appear spherical (cocci), and form in grape-like
clusters.

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 Methicillin-resistant Staphylococcus spesies
(MRSS)
 staphylococcus is divided into two: coagulase positive
and coagulate negative

 positive coagulation consists of s. aureus and s

intermedius
 negative coagulation is other than the two species

above called also staphylococcus species

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 Methicillin-resistant Staphylococcus spesies
(MRSS)
 Methicillin-resistant Staphylococcus species (MRSS) are
Staphylococcus spesies that are resistant to methycillin
class antibiotics (oxacillin & cefoxitin)

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 Methicillin-resistant Staphylococcus spesies
(MRSS)
 what's different with MRSA?

 In principle it is the same, in handling clinical cases.

 Kebersihan tangan → gunakan alcohol hand rub atau sabun
dan air.
 Isolasi pasien di kamar tersendiri, pintu harus selalu tertutup
setiap saat
 Jika ruangan tidak ada yang sendirian, pasien bisa dirawat di
satu ruangan bersama-sama dengan kasus yang sama
 Kenakan sarung tangan dan aprons
 Keluarkan sarung tangan dan aprons, cuci tangan sebelum
meninggalkan ruangan
 Pengobatan infeksi klinis
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 ...Methicillin-resistant Staphylococcus spesies (MRSS)

 the difference between groups staphylococcus aureus

is more virulent than staphylococcus species because
staphylococcus aureus expresses various potential
virulence factors than Staphylococcus spesies

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 ... Methicillin-resistant Staphylococcus spesies (MRSS)

 S aureus expresses many potential virulence factors.

 (1) Surface proteins that promote colonization of host

tissues.

 (2) Factors that probably inhibit phagocytosis (capsule,

immunoglobulin binding protein A).

 (3) Toxins that damage host tissues and cause disease

symptoms.

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Table 1. Differences between HA-MRSA and CA-MRSA

, 2008

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Table 1. Differences between HA-MRSA and CA-MRSA

, 2008

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TEORI CA-MRSS PASIEN

 Daerah luka operasi

 Di tempat pemasangan eksternal
fiksasi

 Riwayat MRS < 12 bln ( 1.5 bulan )

 Riwayat operasi pemasangan fiksasi
eksternal

Kemungkinan :
 Kontak kulit dengan penderita yang
terinfeksi MRSA
 Kontak dengan permukaan yang
mengandung MRSA
 Terkontaminasi oleh alat
kesehatan/alat medis
 Hand hygiene jelek

PASIEN = HA-MRSA
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selection of antibiotics in these
patients
antibiotic susceptability class
Trimetoprim S A
Sulfametoxazol
Vancomicin S B
Linezolid S B
Tetraciclin S B
Minociclin S B
Rifampicin S B

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...selection of antibiotics in these patients

Moxifloxacin S C
Ciprofloxacin S C
Gentamycin S C
Gatifloxacin S O
Norfloxacin S O

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selection of antibiotics in these
patients
 In this case the recommended antibiotics
areTrimethoprim sulfamethoxazol
 Linezolid
 Vancomycin  but be careful not to use it
freely because it can cause vancomycin
intermediate staphylococcus aureus (VISA) or
vancomycin Resistance staphylococcus aureus
(VRSA)

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 Resistance to methicillin is determined by the mecA
gene, which encodes the low-affinity penicillin-
binding protein PBP 2A. Lately, new methicillin
resistance gene, mecC has been discovered from
humans, animals and food products.

 MRSA infection was first considered hospital

associated (HA-MRSS) and community-associated
MRSA (CA-MRSS) infections. However, another group
emerged known as livestock-associated MRSS
(LA-MRSS).
Hafsat et al. Methicillin Resistant Staphylococcus aureus (MRSA): A Review. 2015 34
Detection of
Methicillin-resistant Staphylococcus spesis
(MRSS)
 Various methods are applied for the detection of
MRSS through phenotypic and genotypic
characterization of samples from infected sites such
as skin lesions, abscesses or blood.

 Phenotypic methods involves standard

microbiological technique of S. spesies detection
which include Gram staining, colonial morphorlogy,
catalase and coagulase tests, pigment production and
anaerobic growth. 35
Detection of
Methicillin-resistant Staphylococcus spesis
(MRSS)
 Additional methods include Minimum Inhibitory
Concentrations, methods that detect mecA gene or
PBP20 protein and media containing oxacillin.

 In addition to culture media, antimicrobial

susceptibility tests (AST) such as agar disc diffusion
technique or minimum inhibitory concentration are
used in diagnostic laboratories to isolate MRSS

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 Resistance of S. simulans to oxacillin and/or
cefoxitin provides a clue for MRSS suspicion.
Oxacillin and cefoxitin test are the preferred method for
testing mecA resistant gene of S. simulans.

 In order to report isolates as resistant or susceptible

should be based on the result obtained on the cefoxitin
test. Cefoxitin disc diffusion is the most sensitive
methods for detecting MRSS isolates showing negative
and positive predictive values of 100% and 98%,
respectively
Hafsat et al. Methicillin Resistant Staphylococcus aureus (MRSA): A Review. 2015 37
 Test Oxicillin MecA-mediated Oxacillin
Resistance Resistant Using Cefoxitin
Organism S.aureus S.Aureus and S.Aureus and
group S. S.
Lugdunensis Lugdunensis
CoNS
Test method Agar dilution Disk diffusion Broth
microdilution
Medium MHA with 4% MHA CAMHB
NaCl
Antimicrobial 6ug/mL 30 ug cefoxitin 4 ug/mL
Concentration disk cefoxitin
Inoculum Direct colony Standard disk Standard disk
suspension to diffusion diffusion
obtain o.5 procedure procedure
McFarland
turbidty
 Test Oxicillin MecA-mediated Oxacillin Resistant
Resistance Using Cefoxitin

Incubation 33-35oC, 33-35oC, ambient air 33-35oC,

condition ambient air ambient air
Incubation 24 h 16-18 h 24 h 16-20 h
length
Results Examine ≤ 21 mm= ≤ 24 mm= > 4µg/mL=
carefuly with mec A mec A mec A
transmitted positive positive positive
light for > 1 ≥ 22 mm = ≥ 25 mm = ≤ 4µg/mL =
colony or mec A mec A mec A
light film of negative negative negative
growth
.1 colony=
oxacilin
resistant
 Test Oxicillin MecA-mediated Oxacillin
Resistance Resistant Using Cefoxitin

Additional Oxacillin Cefoxitin is Cefoxitin is used as a

testing resistant used as a surrogate for mecA-
and staphylococci surrogate mediated oxacillin
reporting are resistant for mecA- resistant
to all β mediated Because of the rare
lactam oxacillin occurrence of oxacillin
agents resistant resistance mechanism
other than mecA,
isolates that test as
mec A negative, but for
which the oxacillin MIC
are resistant, should
be reported as oxacillin
resistant
41
 Minimum inhibitory concentrations (MICs) are
defined as the lowest concentration of
antimicrobial that will inhibit the visible growth
of a micro-organism after overnight incubation,
and minimum bactericidal concentrations (MBCs)
the lowest concentration of antimicrobial that
will prevent the growth of an organism after sub-
culture on to antibiotic free media.
 MICs are used by diagnostic laboratories, mainly
to confirm resistance, but most often as a
research tool to determine the in-vitro activity of
new antimicrobials.

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Conclution

 It has been discussed patient with ischemic

stroke dt uncontrolled hypertension, septic
condition dt Methicillin Resistant
Staphylococcus spesies
 Medical practitioners should be encouraged
to choose antibiotic based on susceptibility
test and to wear protective equipment during
surgery and handling of patients to reduce
contamination and spread of MRSS

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 PCCL Problem List Initial Diagnosis PDx
1. female/ 45 y.o 1. Electrolyte Electrolyte • Monitorin
imbalance imbalance d.t. GI g SE
• Hiponatremia(131) loss
• Hipokalemia
• Hipoklorida )
• History of vomit and
low intake

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 PCCL Problem List Initial Diagnosis PDx
2. female/ 45 y.o 2. SIRS Sepsis d.t. MRSS • Monitorin
g CBC
• leukositosis
• Neutrofilia
• Hiperglikemia
• Hiponatremia(131)
• Hipokalemia
• Hipoklorida )

• History of fever
• Respiratory rate 22
follow up 37 x/m
• Heart rate 122 bpm
• Blood culture (+)

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 PCCL Problem List Initial Diagnosis PDx
1. female/ 45 y.o 3. Suspek HHS d.t. • HbA1C
Hiperglikemi DM type 2 with • FH
• leukositosis a complication CVA
• Neutrofilia
• Hiperglikemia

• Follow up 13/06-18
• Badan lemah kanan
• Hemiplegi, bicara
pelo, tic fasialis

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 Pemilihan AB pada pasien ini pada kasus ini
 Hasil TKA sensitif pada

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