Staphylococcus

aureus
Pneumonia Dr. Abdul Rohman, SpP
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 KEY POINT
About Staphylococcus aureus Pneumonia

1. These large gram-positive aerobic cocci form

tetrads and clusters.
2. The disease most commonly follows influenza,
and is seen in patients with AIDS and IV drug
abusers.
3. Destructive bronchopneumonia is complicated
by : a) lung abscesses
b) pneumothorax
c) empyema
 Epidemiology

A human commensal organism most commonly

(anterior nares, axilla, inguinal, and perineal)

• Asymptomatic carrier (20-40% adults)  50% of
adult : colonized during their life
• DM chronic, exfoliative skin conditions, chronic
hemodialysis (carriage 90%)
• Health case worker, IDU (greater risk for
colonization)
Nosocomial  2% of all patients that are admitted
 Twice the length of hospital stay  †
 resistant to penicillin (55-59%)
 resistant to meticillin

Risk factor – hospital acquired (MRSA)

• Prolonged hospitalization (> 14 days)
• Preceding antimicrobial Tx (esp. cephalosporine, or
fluoroquinolon)
• ICU or burn unit
• Hemodyalisis
• Having surgical site infection
• Proximity to a patient colonized or infected with MRSA
In the community  The most common cause of SSTIS (Skin
and Soft Tissue Infection Syndrome) and CA MRSA

Risk factors CA MRSA:

• African American race
• HIV infection
• Recent antibiotic with in the post 6 months
• Skin trauma
To spread in circumstances that involve close contact
between people and their sharing of equipment

CA MRSA outbreak :
- Inconcerated individuals - Football players
- Military personel - Family members
• Rarely causes pneumonia except after a preceding influenzal viral
illness.
• The infection starts in the bronchi, leading to patchy areas of
consolidation in one or more lobes, which breakdown to form
abscessess. These may appear as cysts on the chest X-ray.
• Pneumothorax, effusion and empiema are frequent.
Septicemia develops with metastatic abcessess in other organs.
Are very ill — IV antibiotics must be administered promptly, but are
not always effective.
Fulminating staphylococcal pneumonia can lead to death in hours
• Area of pneumonia (septic infarcts) are also seen in staph. Pn — in
IDU, and CVP for parenteral nutrition.
• The infected punture site is the source of the staphylococus.
• Pulmonary symptoms are often few but breathlessness and cough
occur and the chest X-ray reveals areas of consolidation. Abscess
formation is frequent.
CoNS
- normal flora of human skin and mucous membrane
- 50% positive blood culture (contaminant)

Misinterpretations of pus blood culture has important
implications

Risk factors:
• CVP catheter
• Prosthetic devices
• Immunocompromized hosts
• Hematologic malignancies
• Coagulase  inhibit neutrophile acces to
organism
• Capsule or slyme layer  limit phagocytosis
• Clumping factor and protein A  opsonization
• Catalase  interface with intracellular killing

• Toxins:
– TSS
– Enterotoxin
– Exfoliative
– Cytogen
– Pathogenicity islands  hospital >< CA-MRSA
PATHOPHYSIOLOGY
Staphylococcus aureus

Tissue invasion Toxic production CA-MRSA

Hand carriage Enterotoxin Enterotoxin Exfoliative toxin

Overtbreaks Breakdown B & C (non- TSST-1

in dermal in barrier menstrual (menstrual Foodborne Staphylococcus
surfaces function women) women) illness scalded skin
synd (Ritter dis)

vascular operative eczema shaving-

catheteri incision associated Cytokines
zation trauma
Toxic shock syndrome
Abscess
Pneumonia
Serious complication
Hematogenously Bone & joint infection
& fatal sepsis
Heart
 CLINICAL PRESENTATION
- Skin and soft tissue (impetigo)
- Scalded skin syndr (Ritter dis)
- Folliculitis, furuncle, and carbuncle
- Bone infection (osteomyelitis)
- Septic arthritis
- Endocarditis
- Toxic shock syndrome (TSS)
- Pneumonia
- Thrombophlebitis
- Deep tissue abscess and infection
 Pneumonia
Causes
• Primary form occurs without an
extrapulmonary focus  direct inoculation to
the lungs.
• Secondary form  hematogenous seeding of
the lungs during endocarditis or bacteriemia.
• Predisposing factors include infancy, chronic
illness, and viral respiratory disease such as
influenza
 Pneumonia
History
• Short prodome fever
• Rapid onset of respiratory distress
– Tachypnea
– Retractions
– Cyanosis
• GI tract symptoms
• After influenza infection  young adults
 PHYSICAL EXAMINATION
PNEUMONIA
- Fever is present

- Finding of respiratory distress include

tachypnea, cyanosis, grunting , and retractions
Vomiting and abdominal distension occur.

- Clinical deterioration is rapid.

 Pneumonia
Physical Examination
• Fever
• Tachypnea
• Cyanosis
• Grunting
• Retractions
• Vomiting
• Abdominal distension
• Rapid clinical deterioration
 Pneumonia

• purulent pneumonia
- Aspiration of nasopharyngeal contents colonized with staphylococcus
- Hematogenous spread (e.c. metastatic spread from bacteriemia, septic
emboly from right sided endocarditis

Tend to be fulminant & is often associated with infiltrative lesion 

cavitation, pleural empyema

• secondary bacterial pneumonia (common cause)  following infection

with influenza viral (SARS)

- Anti-staphylococcal antibiotic  effective

- Surgical drainage  pleural empyema
 Laboratory Studies
PNEUMONIA
- Blood cultur finding for S.aureus are more likely to be
positive in secondary disease than in primary disease
(90% vs 20%).
Because blood culture result are often negative, an
adequate respiratory tract specimen should be
obtained prior to initiating therapy; specimen may
include endotracheal sampling, pleural fluid, or lung
tap.
- Sputum is not considered adequate because the
organism is frequently present in the upper
respiratory secretion of healthy individuals.
 Imaging Studies
PNEUMONIA
- No radiologic features are highly specific, but the chest
radiograph may provide information, esp. in
demonstrating its progression.
- Radiographs of patients w/ primary staphylococcus
pneumonia may reveal unilateral consolidation, while
patients w/ secondary staphylococcual pneumonia are
more likely to demonstrate bilateral infiltrates on
radiographs.
- Early in the disease course, the chest radiograph may
reveal minimal infiltrates, but, within hours, they
rapidly progress.
- Pleural effusion, pneumatoceles, and pneumothorax
are also common.
 Management and Tx
1. Drainage of infected material and
2. Antibiotics

-lactamase Penicillin binding protein (PBPs)

 
-lactamase stable Methicillin resistant strain
- Nafcillin
- Oxacillin


Regional antibiotics susceptibility patterns
 Prevention
• Intranasal mupirocin
• Topical antiseptic washes (i.e. chlorhexidine gluconate)
during daily showers and weekly chlorine baths (about 1
tsp per gallon of bath water with a 10 minute soak)
• Personal hygiene measures:
– Keeping nails trimmed short and scrubbed daily with soap
– Single use only of bath towels and garments
– Washing clothes in hot water
• A single patient (recurrent MRSA outbreak)
– Oral antibiotics
– All members of household  general decolonization measures
• Eradication of MRSA colonization in hospitalized patients
for at least 3 months
• Intranasal mupirosin + chlorhexidine gluconate washes +
rifampicin + doxycycline (for 7 days)
Staphylococcal scalded skin syndrome
(Ritter disease)
Children < 5 years
• An exfoliative toxins  Nikolsky’s sign: skin
sloughs easily when touched
• Fever + irritability
• Mucopurulent eye discharge
• Large area  volume and electrolyte losses

• Tx antibiotic + electrolyte and volume loss
 Staphylococcal TSS
• Rash, fever, myalgia, diarrhea, and 
consciousness

24-48 hours

Renal failure, hepatitis, and shock

• Be severe  digital necrosis
• Is accompanied – disquamative rash (hands and
feet)
 Staphylococcal food poisoning
• 10-20%: outbreaks of food-borne disease (USA)
• Ingestion of any of the several heat-stable bacterial
exotoxins ( uncooked or partially cooked food )

2-6 hours

Acute onset
• Nausea and vomiting
• Watery diarrhea resolve in 12 hours
• Febrile (–) (self limited)
• Quite ill e.c. hypovolemic

Tx supportive, antibiotics not required

 Avoiding Tx Errors
• Most serious infections caused by staphylococcus are
not subtle (tak kentara)
• Pitfall  typically involved the failure to consider
staphylococcus as the infectious agents
• Lock of consideration for the drug-resistance potential
• Culture of material (e.g. wound drainage, sputum,
blood)  essential
• Isolation of staphylococcus in the urine  endocarditis
or endovascular infections  this organism commonly
enter the genitourinary system   hematogenously
 medication
Antistaphylococcal
• Telavancin • Clavulanate
• Dicloxacillin • Vancomycin
• Oxacillin • Clidamycin
• Nafcillin • Dactomycin
• Cephalexin • Linezolid
• Cefuroxine • Rifampin
• Cefazolin • Sulfamethoxazole
• Amoxicillin • Trimethoprim
• Impetigo  none
• Bullous impetigo
– Pemphigus
– Pemphigoid
– Burn
– Steven-Johnson Syndrome
– Dermatitis Herpetiformis
• Scalded skin syndrome (Ritter disease)
– Nonaccidental injury
– Scalding
– Abrasion Trauma
– Sunburn
– Erythema multiforme
– Toxic Epidermal Necrolysis
• Bone and joint infections
– Bone Infarction (in patients with
sickle cell disease)
– Toxic synovitis
– Leukemia
Differential Diagnosis
• Septic arthritis
– Trauma
– Deep Cellulitis
– Henoch-Schӧnlein Purpura
– Slipped Capital Femoral Epiphysis
– Legg-Calve-Perthes disease
– Leukemia
– Toxic Synovitis
– Metabolic disease affecting joints
(Ochronosis)
• Endocarditis  bacteriemia
• TSS
– Staphylococcal Scalded-Skin Syndrome
– Meningococcemia
– Rubeila
– Adenoviral Infections
– Dengue fever
– Severe Allergic Drug Reactions
 Differential Diagnosis
• Bacteriemia • Leptospirosis
• Burns, chemical • Osteomyelitis
• Endocarditis, bacterial • Parvovirus B19 Infection
• Enteroviral infections • Rheumatoid Fever
• Irritable bowel • Rocky Mountain
syndrome Spotted Fever
• Juvenile Rheumatoid • Serum Sickness
Arthritis • Streptococcal Infection,
• Kawasaki Disease Group A
 Differential Diagnosis
Pneumonia Staphylococcus

• Bronchopneumonia (pola CXR)

 Complications
• Pneumonia  empyema, cavitation
• Bone and joint infection
• Infection of the heart valves
• Immunocompromised hosts  20-30% develop
serious complications or fatal sepsis following
catheter-related S. aureus bacteriemia
• CA MRSA infection  more serious and
associated with thrombogenesis
• Multiple brain abscesses  in premature infants
 Complications
Pneumonia Staphylococcus

• Lung abscess
• Pneumothorax
• Empyema
 Prognosis
• Morbidity and mortality associated with
staphylococcal bacteriemia in children seem
to be less significant than observed in
bacteriemic adults
 Prognosis
Pneumonia Staphylococcus

• depends on severity of the infection and

likelyhood that’s it caused by methicillin-
resistant strain
 Prevention
Pneumonia Staphylococcus

Personal hygiene measures

• keeping nails trimmed short
• Scrubbed daily with soap
• Single use of bath towels and garments
• Washing clothes in hot water
• Showers:
– Daily: topical antiseptic washes
– Weekly: chlorine baths
 THANK YOU FOR YOUR ATTENTION
ABOUT “Pneumonia
Stafilokokus”

ANGAN ANTUUUUK
YAAAAAAA !!!
 Background
• Gram-positive cocci, individual, in pairs, and in
irregular, grapelike clusters a bunch of grapes
• Nonmotile, non-spore-forming, and catalase- positive
bacteria.
• The cell wall contains peptidoglican and teichoic acid’
• Resistant to temperatures as high as 50°C, to high salt
concentrations, and to drying.
• Colonies are usually large (6-8 mm in diameter),
smooth, and translucent . The colonies of most strains
are pigmented, ranging from cream-yellow to orange.