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Methicillin-resistant Staphylococcus aureus pelvic abscesses in a female after gynecologic pelvic surgery
Case Report
www. AJOG.org
Methicillin-resistant Staphylococcus aureus pelvic abscesses in a female after gynecologic pelvic surgery Charles H. Feng, MD; Donald D. Stevenson, MD; Bruce Kahn, MD; Philip A. Higginbottom, MD
P
olypropylene mesh use during the surgical repair of pelvic organ prolapse and stress urinary incontinence is becoming increasingly popular. Mesh kits that replace the weakened suspensory ligaments in the pelvis have been developed and effectively act as support during straining maneuvers. Midurethral slings are now commonly used to stabilize the urethra in patients with stress urinary incontinence.1 A rare complication that can occur after sling placement is a pelvic abscess.2 Because of their heightened potential for hematagenous spread and direct infection to surrounding organs, pelvic abscesses require extra attention, especially if they are infected with a drug-resistant organism such as methicillin-resistant Staphyloccocus aureus (MRSA).
C ASE R EPORT A 62 year old female had a worsening pelvic organ prolapse. To have a bowel movement, the patient routinely used her fingers to reduce the prolapse (splinting). During this time, the patient, using the same fingers, was also changing the dressings of her husband’s MRSA-infected leg abscess without using sterile procedure. Because of the symptomatic prolapse, the patient underwent total vaginal hysterFrom the Department of Internal Medicine (Dr Feng), Division of Allergy and Immunology (Dr Stevenson), Department of Obstetrics and Gynecology (Dr Kahn), and Division of Infectious Diseases (Dr Higginbottom), Scripps Green Hospital, La Jolla, CA. Received Feb. 24, 2011; accepted May 5, 2011. P.A.H. is deceased. Reprints: Charles Feng, MD, 10666 Torrey Pines Rd. MS:403C, La Jolla, CA 92037. [email protected]. 0002-9378/free © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.05.023
e4
Pelvic abscesses occurring after gynecologic pelvic surgery are uncommon. We describe the case of a woman who, after undergoing such a procedure, was found to have pelvic abscesses infected with methicillin-resistant Staphyloccocus aureus. The purpose of this report is to raise awareness of a life-threatening complication of gynecologic pelvic surgery. Key words: methicillin-resistant Staphyloccocus aureus, pelvic abscess, pelvic organ prolapse
ectomy, bilateral salpingo-oophorectomy, anterior and posterior culporrhaphy with repair of enterocele, sacrospinous ligament fixation with the placement of a polypropylene mesh in the anterior vaginal compartment (Uphold; Boston Scientific, Natick, MA), and placement of a suburethral sling for the treatment of stress urinary incontinence (Prefyx; Boston Scientific). Her initial postoperative course was complicated by urinary retention. The patient was discharged home on postoperative day 1 with a Foley catheter in place, with the urinary retention resolving on postoperative day 3. However, on postoperative day 8, the day of admission, the patient presented with nausea, vomiting, abdominal pain, fever, and recurrent urinary retention. Her past medical history was notable for bipolar disorder, for which she took lithium. She was G2P2. She had no known drug allergies. Her physical examination was notable for tenderness in the left lower quadrant of the abdomen and a malodorous vaginal discharge. Urinalysis was normal and urine culture was negative. Computed tomography (CT) of the abdomen and pelvis showed multiple fluid collections consistent with pelvic abscesses. Piperacillin/tazobactam was started. On the second hospital day, the largest fluid collection was drained. Blood cultures grew out Staphyloccocus aureus in 1 of 4 bottles, and MRSA in 1 of the same 4 bottles. Urine culture and pelvic abscess culture also showed MRSA with a sensi-
American Journal of Obstetrics & Gynecology NOVEMBER 2011
tivity profile that matched what was found in the blood cultures. Piperacillin/tazobactam was discontinued, and intravenous vancomycin and rifampin were started. Subsequent blood cultures were negative. On the fifth hospital day, CT of the abdomen and pelvis showed a marked improvement in the primary abscess cavity as well as a decrease in size of the multiple satellite lesions. The next day the patient continued to be afebrile, with reduced abdominal pain. She was discharged home and completed a 4 week course of antibiotics. One year later she still continues to be in good health.
C OMMENT Published reports of MRSA-infected pelvic abscesses after vaginal surgery are rare.3 In a patient who is found to have pelvic abscesses, blood cultures should be drawn, and the pelvic abscess should be promptly drained and cultured. Broadspectrum antibiotics, including those directed against the MRSA, should be started while waiting for the cultures and sensitivities to return, at which time the antibiotic choice can be properly focused. Common complications of pelvic organ prolapse surgery using synthetic graft materials include urinary tract infections, pain, mesh erosion, fistula formation, voiding dysfunction, and new-onset urgency.4 Even though pelvic abscesses infected with MRSA have been reported, none have occurred after placement of a midurethral sling.5,6 Because of the sheer number of patients now infected with MRSA, a rise in the
Case Report
www.AJOG.org number of postoperative MRSA-infected pelvic abscesses should be expected in the future. Furthermore, physicians need to be vigilant in patients who have predisposing risk factors for MRSA infections, such as recent hospitalizations, or placement of invasive devices like central lines or urinary catheters. We hypothesize that the patient transferred MRSA from her husband’s leg abscess into her vaginal mucosa while she was reducing her uterine prolapse. Thus, special attention should also be given to patients who handle cutaneous infections.
In a patient with MRSA finger contamination, the preoperative evaluation should include MRSA screening. Indeed, even when MRSA colonization is recognized and prophylaxis is given, MRSA infection may not be prevented.4 f REFERENCES 1. Lee YS, Lee HN, Lee KS. The evolution of surgical treatment for female stress urinary incontinence: era of mid-urethral slings. Korean J Urol 2010;51:223-32. 2. Deval B, Haab F. Management of the complications of the synthetic slings. Curr Opin Urol 2006;1:240-3.
3. Marzolf SM. Methicillin-resistant Staphylococcus aureus sepsis after elective vaginal prolapse surgery. Int Urogynecol J Pelvic Floor Dysfunct 2010;21:117-9. 4. Margulies RU, Lewicky-Gaupp C, Fenner DE, et al. Complications requiring re-operation following vaginal mesh kit procedures for prolapse. Am J Obstet Gynecol 2008;199:678. 5. Lin TW, Liu CH. Pelvic abscess induced by a methicillin-resistant Staphylococcus aureus from haematogenous spread via the CVP line in a burn patient. Burns 1995;21:387-8. 6. Okubo T, Yabe S, Otsuka T, et al. Multifocal pelvic abscesses and osteomyelitis from community-acquired methicillin-resistant Staphylococcus aureus in a 17-year-old basketball player. Diagn Microbiol Infect Dis 2008;60: 313-8.
NOVEMBER 2011 American Journal of Obstetrics & Gynecology
e5
www. AJOG.org
Methicillin-resistant Staphylococcus aureus pelvic abscesses in a female after gynecologic pelvic surgery Charles H. Feng, MD; Donald D. Stevenson, MD; Bruce Kahn, MD; Philip A. Higginbottom, MD
P
olypropylene mesh use during the surgical repair of pelvic organ prolapse and stress urinary incontinence is becoming increasingly popular. Mesh kits that replace the weakened suspensory ligaments in the pelvis have been developed and effectively act as support during straining maneuvers. Midurethral slings are now commonly used to stabilize the urethra in patients with stress urinary incontinence.1 A rare complication that can occur after sling placement is a pelvic abscess.2 Because of their heightened potential for hematagenous spread and direct infection to surrounding organs, pelvic abscesses require extra attention, especially if they are infected with a drug-resistant organism such as methicillin-resistant Staphyloccocus aureus (MRSA).
C ASE R EPORT A 62 year old female had a worsening pelvic organ prolapse. To have a bowel movement, the patient routinely used her fingers to reduce the prolapse (splinting). During this time, the patient, using the same fingers, was also changing the dressings of her husband’s MRSA-infected leg abscess without using sterile procedure. Because of the symptomatic prolapse, the patient underwent total vaginal hysterFrom the Department of Internal Medicine (Dr Feng), Division of Allergy and Immunology (Dr Stevenson), Department of Obstetrics and Gynecology (Dr Kahn), and Division of Infectious Diseases (Dr Higginbottom), Scripps Green Hospital, La Jolla, CA. Received Feb. 24, 2011; accepted May 5, 2011. P.A.H. is deceased. Reprints: Charles Feng, MD, 10666 Torrey Pines Rd. MS:403C, La Jolla, CA 92037. [email protected]. 0002-9378/free © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.05.023
e4
Pelvic abscesses occurring after gynecologic pelvic surgery are uncommon. We describe the case of a woman who, after undergoing such a procedure, was found to have pelvic abscesses infected with methicillin-resistant Staphyloccocus aureus. The purpose of this report is to raise awareness of a life-threatening complication of gynecologic pelvic surgery. Key words: methicillin-resistant Staphyloccocus aureus, pelvic abscess, pelvic organ prolapse
ectomy, bilateral salpingo-oophorectomy, anterior and posterior culporrhaphy with repair of enterocele, sacrospinous ligament fixation with the placement of a polypropylene mesh in the anterior vaginal compartment (Uphold; Boston Scientific, Natick, MA), and placement of a suburethral sling for the treatment of stress urinary incontinence (Prefyx; Boston Scientific). Her initial postoperative course was complicated by urinary retention. The patient was discharged home on postoperative day 1 with a Foley catheter in place, with the urinary retention resolving on postoperative day 3. However, on postoperative day 8, the day of admission, the patient presented with nausea, vomiting, abdominal pain, fever, and recurrent urinary retention. Her past medical history was notable for bipolar disorder, for which she took lithium. She was G2P2. She had no known drug allergies. Her physical examination was notable for tenderness in the left lower quadrant of the abdomen and a malodorous vaginal discharge. Urinalysis was normal and urine culture was negative. Computed tomography (CT) of the abdomen and pelvis showed multiple fluid collections consistent with pelvic abscesses. Piperacillin/tazobactam was started. On the second hospital day, the largest fluid collection was drained. Blood cultures grew out Staphyloccocus aureus in 1 of 4 bottles, and MRSA in 1 of the same 4 bottles. Urine culture and pelvic abscess culture also showed MRSA with a sensi-
American Journal of Obstetrics & Gynecology NOVEMBER 2011
tivity profile that matched what was found in the blood cultures. Piperacillin/tazobactam was discontinued, and intravenous vancomycin and rifampin were started. Subsequent blood cultures were negative. On the fifth hospital day, CT of the abdomen and pelvis showed a marked improvement in the primary abscess cavity as well as a decrease in size of the multiple satellite lesions. The next day the patient continued to be afebrile, with reduced abdominal pain. She was discharged home and completed a 4 week course of antibiotics. One year later she still continues to be in good health.
C OMMENT Published reports of MRSA-infected pelvic abscesses after vaginal surgery are rare.3 In a patient who is found to have pelvic abscesses, blood cultures should be drawn, and the pelvic abscess should be promptly drained and cultured. Broadspectrum antibiotics, including those directed against the MRSA, should be started while waiting for the cultures and sensitivities to return, at which time the antibiotic choice can be properly focused. Common complications of pelvic organ prolapse surgery using synthetic graft materials include urinary tract infections, pain, mesh erosion, fistula formation, voiding dysfunction, and new-onset urgency.4 Even though pelvic abscesses infected with MRSA have been reported, none have occurred after placement of a midurethral sling.5,6 Because of the sheer number of patients now infected with MRSA, a rise in the
Case Report
www.AJOG.org number of postoperative MRSA-infected pelvic abscesses should be expected in the future. Furthermore, physicians need to be vigilant in patients who have predisposing risk factors for MRSA infections, such as recent hospitalizations, or placement of invasive devices like central lines or urinary catheters. We hypothesize that the patient transferred MRSA from her husband’s leg abscess into her vaginal mucosa while she was reducing her uterine prolapse. Thus, special attention should also be given to patients who handle cutaneous infections.
In a patient with MRSA finger contamination, the preoperative evaluation should include MRSA screening. Indeed, even when MRSA colonization is recognized and prophylaxis is given, MRSA infection may not be prevented.4 f REFERENCES 1. Lee YS, Lee HN, Lee KS. The evolution of surgical treatment for female stress urinary incontinence: era of mid-urethral slings. Korean J Urol 2010;51:223-32. 2. Deval B, Haab F. Management of the complications of the synthetic slings. Curr Opin Urol 2006;1:240-3.
3. Marzolf SM. Methicillin-resistant Staphylococcus aureus sepsis after elective vaginal prolapse surgery. Int Urogynecol J Pelvic Floor Dysfunct 2010;21:117-9. 4. Margulies RU, Lewicky-Gaupp C, Fenner DE, et al. Complications requiring re-operation following vaginal mesh kit procedures for prolapse. Am J Obstet Gynecol 2008;199:678. 5. Lin TW, Liu CH. Pelvic abscess induced by a methicillin-resistant Staphylococcus aureus from haematogenous spread via the CVP line in a burn patient. Burns 1995;21:387-8. 6. Okubo T, Yabe S, Otsuka T, et al. Multifocal pelvic abscesses and osteomyelitis from community-acquired methicillin-resistant Staphylococcus aureus in a 17-year-old basketball player. Diagn Microbiol Infect Dis 2008;60: 313-8.
NOVEMBER 2011 American Journal of Obstetrics & Gynecology
e5