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CASE REPORT
Year : 2004  |  Volume : 22  |  Issue : 4  |  Page : 260-262
 

Postoperative infection of an abdominal mesh due to methicillin resistant Staphylococcus Aureus - A case report


Departments of Surgical Gastroenterology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad - 500 082, India

Date of Submission16-Apr-2004
Date of Acceptance19-May-2004

Correspondence Address:
Departments of Microbiology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad - 500 082, India

 ~ Abstract 

Methicillin resistant Stephylococcus aureus (MRSA) infection has now become a major problem in hospitals. We present a case of postoperative infection MRSA where the primary source of the infection was found to be an abdominal mesh that was used to reinforce the abdominal wall. After one year of surgery, the patient developed wound dehiscence and discharge. MRSA was isolated from the wound, mesh, external nares, throat and axilla. Initially she was started on clindamycin and discharged from the hospital. After 5 months, patient came back to the hospital with infection at the same site. The patient was then treated with vancomycin and MRSA clearance. She responded to the treatment with complete healing of the wound and clearance of MRSA.

How to cite this article:
Ashok R, Anuradha K, Babu S S, Bheerappa N, Sastry R A, Lakshmi V. Postoperative infection of an abdominal mesh due to methicillin resistant Staphylococcus aureus - A case report. Indian J Med Microbiol 2004;22:260-2


How to cite this URL:
Ashok R, Anuradha K, Babu S S, Bheerappa N, Sastry R A, Lakshmi V. Postoperative infection of an abdominal mesh due to methicillin resistant Staphylococcus aureus - A case report. Indian J Med Microbiol [serial online] 2004 [cited 2019 Aug 23];22:260-2. Available from: http://www.ijmm.org/text.asp?2004/22/4/260/12821


Infection with methicillin resistant Staphylococcus aureus   (MRSA) has now become a major problem in hospitals. MRSA first appeared in 1961 in Europe immediately after methicillin was introduced as an antibacterial agent.[1],[2] Since then, there have been many reports of MRSA causing various infections throughout the world. There is now an increasing awareness of this organism as a potentially dangerous pathogen not only in the hospitals,[3] but also in the community. Currently, almost half of nosocomial S.aureus infections are resistant to methicillin. MRSA is neither more infectious nor more virulent than methicillin susceptible S.aureus. However, it is difficult to eradicate and control because of its resistance to commonly used antibiotics.
We hereby report a case of an elderly female operated for para umbilical hernia, who presented one year later with MRSA infection of the mesh that was implanted for reinforcement of the abdominal wall.

 ~ Case Report Top

An obese lady aged 51 years was admitted in our hospital with complaints of pain and swelling of abdominal wall, vomiting since three days and fever since 10 days. She was an old case of our Institute, who had undergone a repair for para umbilical hernia with a mesh implantation, one-year back. Clinical examination indicated that she had infection at the operated site. The laboratory parameters were consistent with an ongoing sepsis. A CT image showed fluid collection at the site of previous mesh repair in the abdominal wall. With a diagnosis of an infection at the site of the abdominal mesh, incision and drainage of the fluid was performed. The abscess was drained and the infected mesh was removed. Both (abscess pus and the infected mesh) were sent for microbiology work up.
Direct Gram smear of the pus and the infected mesh showed plenty of pus cells and gram positive cocci in clusters. Both the specimens yielded pure growth of S.aureus. The isolate was identified as MRSA by the oxacillin screen agar medium[1],[4] and by mannitol salt agar with 6 g/mL[1],[5] oxacillin [Figure - 1], [Figure - 2]. The isolate was sensitive to erythromycin, clindamycin, vancomycin, teicoplanin, and minocycline. A high level resistance was observed against all cephalosporins, aminoglycosides and quinolones. The patient was treated with clindamycin orally (300 mg. 8 hourly) for 15 days. At the time of discharge the wound was clear and dry and she had no further complaints.
Five months later, the patient returned with fever and diarrhoea. The operated site was again found to be infected with MRSA, though not as severe as in the earlier admission. The antibiogram of this isolate was similar to the earlier one. With a possibility of an endogenous source of the MRSA, swabs were collected from the anterior nares[6], throat, axilla and groin of the patient.[2] MRSA was isolated from all the sites sampled. The antibiograms of all these isolates were also identical to that of the isolate from the previous admission. All the personnel who attended to the patient were also screened for MRSA to rule out any nasal carrier or exogenous source. All these were negative for MRSA.
This time the patient was treated with vancomycin (500 mg. 6hourly I/V) for 15 days and managed conservatively. The patient improved with the treatment and the abdominal wound healed. The CDC recommended protocol (Box) for MRSA clearance was followed strictly, i.e., application of 2% mupirocin (bactroban) to the anterior part of the inside of each nostril three times a day for seven days and a scrub bath with 4% chlorhexidine gluconate skin cleanser- Microshield 2 (Johnson & Johnson) to the areas around the nose, axilla, umbilicus, groin and perineum for two weeks.[1],[2] Repeat swabs from the infected site, nose and other sites were taken after stopping MRSA treatment protocol for five days. Three sets of screening swabs at weekly intervals were collected before the patient was considered to be "clear" of the MRSA. She was discharged from hospital and is under regular follow up. There was no recurrence of the infection at the time of this report.

 ~ Box: CDC recommended procedures for MRSA clearance from nares and body Top

Nares
Apply 2% mupirocin (bactroban) three times a day for seven days.A small amount of ointment should be placed on a cotton bud or on the little finger and applied to the anterior part of the inside of the each nostril. The nostrils are closed by pressing the sides of the nose together. This will spread the ointment through out the nares. A cotton bud should be used instead of little finger for application especially to infants and patients who are very ill.
Body bath
Chlorhexidine gluconate skin cleanser-Microshield 2(626) can be used. Apply antiseptic solution beginning with the face and working downwards, paying particular attention to the areas around the nose, axilla, umbilicus, groin and perineum. Avoid contact with eyes. The body is then rinsed and washed repeatedly (atleast twice), including hair. Finally, after the entire body is washed thoroughly it is dried with a clean towel. Patients confined to bed should be treated with an antiseptic solution using the standard bed bath technique.

 ~ Discussion Top

Of all the illnesses that can be picked up in the hospital, a Staphylococcus infection is surely fearsome. The stealthy bacterium snakes along intravenous lines or seeps into surgical wounds, destroying skin and bones, poisoning blood, and threatening death. Numerous studies have shown that in majority of surgical patients infected with MRSA, the organism is derived from the endogenous microflora colonizing the anterior nares or the moist areas of the body. The proportion of colonized patients who become infected varies between 5 and 60% depending on the population studied.[1] Carriers of S.aureus in the nose appear to play a key role in epidemiology and pathogenesis of postoperative infection.[7]
In order to achieve the most effective use of limited hospital resources and to minimize morbidity due to this organism it is essential to have a policy of planned preoperative screening to guide control measure to protect patients from MRSA colonization and infection. 

 ~ References Top

1.http://www.hpa.org.uk/srmd/div_esl_su/sops docs/bsops/bsop29i4.1.pdf., Issue no. 4.1: Issued by: Standard units, evaluations and standards laboratory, in standard operative procedure for the investigation of specimens for screening MRSA. 2003. p. 1-17.  Back to cited text no. 1    
2.Duckworth GJ. Diagnosis and management of methicillin resistant Staphylococcus aureus. BJM 1993;307(23):1049-1053.  Back to cited text no. 2    
3.Chaudhary UA. Prevalence of MRSA. Indian J Med Microbiol 1999;17(3):154-155.  Back to cited text no. 3    
4.Hindler J. ed. Antimicrobial Susceptibility Testing. C.M.P.H. Vol. Section 5, ASM 5.5.1-5.5.6.  Back to cited text no. 4    
5.Collee F. ed. Mackie and Mc Cartney Pratical Medical Microbiology. 14 ed.. 1996, (Churchhill Livingstone, London) 245-261.  Back to cited text no. 5    
6.Safdar N, Narans L, Gordon B, Maki DG. Comparison of culture screening methods for detection of nasal carriage of methicillin-resistant Staphylococcus aureus: a prospective study comparing 32 methods. J Clin Microbiol 2003;41(7): 3163-3166.  Back to cited text no. 6    
7.Jan Kluytmans AVB, verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Reviews 1997;10(3):505-520.  Back to cited text no. 7    
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2004 - Indian Journal of Medical Microbiology
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