Community-acquired pneumonia due to pandemic A(H1N1)2009 influenzavirus and methicillin resistant Staphylococcus aureus co-infection

Abstract

Background: Bacterial pneumonia is a well described complication of influenza. In recent years, community-onset methicillin-resistant Staphylococcus aureus (cMRSA) infection has emerged as a contributor to morbidity and mortality in patients with influenza. Since the emergence and rapid dissemination of pandemic A(H1N1)2009 influenzavirus in April 2009, initial descriptions of the clinical features of patients hospitalized with pneumonia have contained few details of patients with bacterial co-infection.

Methodology/principal findings: Patients with community-acquired pneumonia (CAP) caused by co-infection with pandemic A(H1N1)2009 influenzavirus and cMRSA were prospectively identified at two tertiary hospitals in one Australian city during July to September 2009, the period of intense influenza activity in our region. Detailed characterization of the cMRSA isolates was performed. 252 patients with pandemic A(H1N1)2009 influenzavirus infection were admitted at the two sites during the period of study. Three cases of CAP due to pandemic A(H1N1)2009/cMRSA co-infection were identified. The clinical features of these patients were typical of those with S. aureus co-infection or sequential infection following influenza. The 3 patients received appropriate empiric therapy for influenza, but inappropriate empiric therapy for cMRSA infection; all 3 survived. In addition, 2 fatal cases of CAP caused by pandemic A(H1N1)2009/cMRSA co-infection were identified on post-mortem examination. The cMRSA infections were caused by three different cMRSA clones, only one of which contained genes for Panton-Valentine Leukocidin (PVL).

Conclusions/significance: Clinicians managing patients with pandemic A(H1N1)2009 influenzavirus infection should be alert to the possibility of co-infection or sequential infection with virulent, antimicrobial-resistant bacterial pathogens such as cMRSA. PVL toxin is not necessary for the development of cMRSA pneumonia in the setting of pandemic A( H1N1) 2009 influenzavirus co-infection.

Figure 1. Chest radiography in pandemic A(H1N1)2009/cMRSA co-infection.

(a) patient 1, (b) patient 3.

Figure 2. Chest computerized tomography scan in pandemic A(H1N1)2009/cMRSA co-infection.

Patient 1, (a) 8 days and (b) 27 days following admission.

Figure 3. Histopathology of pandemic A(H1N1)/cMRSA co-infection.

Patient 5, right lower lobe lung, demonstrating areas of necrotizing pneumonia (haematoxylin and eosin, ×40).

Figure 4. Histopathology of pandemic A(H1N1)/cMRSA co-infection.

Patient 4, right lower lobe lung, demonstrating acute pneumonia (haematoxylin and eosin, ×200).

Figure 5. Pulsed-field gel electrophoresis of MRSA isolates (Sma1 macrorestriction).