Successful use of extracorporeal membrane oxygenation in severe necrotizing pneumonia caused by Staphylococcus aureus

Entzündliche und infektiöse Erkrankungen der Lunge und Pleura bei Kindern und Jugendlichen

Entzündliche Erkrankungen der Lunge und Pleura bei Kindern und Jugendlichen umfassen ein weites Spektrum von der komplizierten Pneumonie, der Tuberkulose, Mykosen bis hin zur Echinokokkose. Die Häufigkeit hängt stark von der geografischen Herkunft ab. Diese Übersichtsarbeit gibt einen Überblick von der Diagnostik bis hin zur chirurgischen Therapie dieser Erkrankungen beim pädiatrischen Kollektiv.

Severe Staphylococcus aureus infections in children: Case reports and management of positive Panton-Valentine leucocidin cases

BACKGROUND

Staphylococcus aureus is a well-known bacterium associated with carriage and responsible for different types of infections. The Panton-Valentine leucocidin (PVL) is a key virulence factor causing tissue necrosis. PVL can, however, be present in both benign and life-threatening infections.

CASE REPORTS AND MANAGEMENT

We present three pediatric severe infections occurring over a period of only three weeks, in February 2021, and caused by genetically unrelated methicillin-sensitive Staphylococcus aureus producing PVL in a tertiary children's hospital in Belgium. The first one presented with necrotizing pneumonia, the second one with a neck abscess extended to the mediastinum, and the last one had sacral osteomyelitis complicated by endocarditis. The management of these infections is mostly based on expert opinions. The most appropriate treatment seems to be the combination of early surgical drainage of infected collections with an antibiotic regimen associating two antibiotics; beta-lactams and either clindamycin or linezolid. Human immunoglobulins also appear to be useful as adjunctive therapy.

CONCLUSION

PVL-producing Staphylococcus aureus is associated with life-threatening infections in children. Prompt management is needed including surgery and appropriate antibiotic regimens.

Risk factors for complicated community-acquired pneumonia in children

BACKGROUND

Community-acquired pneumonia (CAP) in children continues to be one of the prominent causes of pediatric morbidity and mortality worldwide. By determining the risk factors associated with the development of complicated CAP (CCAP), new approaches for early diagnosis and effective treatment can be identified.

METHODS

This retrospective cohort study enrolled patients with CAP and CCAP who visited the pediatric ward of the study hospital between January 1, 2017 and December 31, 2017. For patients with CCAP, data regarding medical procedures performed, surgical intervention, and hospitalization duration were collected.

RESULTS

A total of 111 patients, 93 (83.7%) with CAP and 18 (16.3%) with CCAP, aged between 3 months and 18 years were hospitalized because of severe pneumonia. The mean age of the patients was 3.6 ± 1.2 years and 60 (54%) of them were female. The mean age of patients with CCAP was higher than that of patients with CAP (4.2 ± 3.3 vs. 2.8 ± 2.1 years respectively); however, the difference was not significant (p = 0.012). Patients with CCAP exhibited a significantly higher C-reactive protein level than those with CAP (10.06 ± 7.55 vs. 4.43 ± 3.37 g/L respectively; p = 0.007). Hypoxia upon admission was noted more commonly in the CCAP group than in the CAP group (p < 0.001).

CONCLUSION

Findings related to hypoxia, respiratory distress, and pleural effusion on imaging are important distinguishing factors associated with the development of complications in patients hospitalized with CAP. Therefore, CCAP etiology, diagnosis, and treatment approaches should be established and protective measures adopted.

Complicated pneumonia in children

Complicated community-acquired pneumonia in a previously well child is a severe illness characterised by combinations of local complications (eg, parapneumonic effusion, empyema, necrotising pneumonia, and lung abscess) and systemic complications (eg, bacteraemia, metastatic infection, multiorgan failure, acute respiratory distress syndrome, disseminated intravascular coagulation, and, rarely, death). Complicated community-acquired pneumonia should be suspected in any child with pneumonia not responding to appropriate antibiotic treatment within 48-72 h. Common causative organisms are Streptococcus pneumoniae and Staphylococcus aureus. Patients have initial imaging with chest radiography and ultrasound, which can also be used to assess the lung parenchyma, to identify pleural fluid; CT scanning is not usually indicated. Complicated pneumonia is treated with a prolonged course of intravenous antibiotics, and then oral antibiotics. The initial choice of antibiotic is guided by local microbiological knowledge and by subsequent positive cultures and molecular testing, including on pleural fluid if a drainage procedure is done. Information from pleural space imaging and drainage should guide the decision on whether to administer intrapleural fibrinolytics. Most patients are treated by drainage and more extensive surgery is rarely needed; in any event, in low-income and middle-income countries, resources for extensive surgeries are scarce. The clinical course of complicated community-acquired pneumonia can be prolonged, especially when patients have necrotising pneumonia, but complete recovery is the usual outcome.

Pneumonectomy in a Child with Multilobar Pneumatocele Secondary to Necrotizing Pneumonia: Case Report and Review of the Literature

Background

Community-acquired pneumonia (CAP) is common within pediatrics and contributes disproportionately to morbidity and mortality. Necrotizing pneumonia is a well-documented complication of CAP. It is thought to be caused by necrosis and liquefaction of consolidated lung and can result in damage to lung parenchyma, including pneumatocele development. Management of necrotizing pneumonia with pneumatocele may include hospitalization, intensive care unit admission, and lengthy antibiotic courses. Severe cases may need invasive procedures.

Case Presentation

We present a case of severe necrotizing pneumonia requiring prolonged venovenous extracorporeal membrane oxygenation (V-V ECMO) with development of persistent pneumatoceles, requiring pneumonectomy while on ECMO support to allow for decannulation and extubation.

Conclusions

In critically ill patients with extensive unilateral necrotizing pneumonia with pneumatocele development, surgical intervention can be considered when attempts to wean ventilation have been unsuccessful. This case provides evidence that V-V ECMO and pneumonectomy is a viable salvage therapy in the most critically unwell children.

Lobectomy on ECMO as a Life-Saving Procedure following Necrotizing Pneumonia in a Toddler: A Case Study

Necrotizing pneumonia is a severe form of pneumonia that is mainly treated with conservative treatment, including antibiotics. We report a unique case of necrotizing pneumonia due to group A streptococcus infection in an 18-month-old boy who required extracorporeal membrane oxygenation (ECMO) support. Following surgical lobectomy, the child was weaned off ECMO and recovered uneventfully.

Necrotizing pneumonia: an emerging problem in children?

BACKGROUND

In children, necrotizing pneumonia (NP) is an uncommon, severe complication of pneumonia. It is characterized by destruction of the underlying lung parenchyma resulting in multiple small, thin-walled cavities and is often accompanied by empyema and bronchopleural fistulae.

REVIEW

NP in children was first reported in children in 1994, and since then there has been a gradual increase in cases, which is partially explained by greater physician awareness and use of contrast computed tomography (CT) scans, and by temporal changes in circulating respiratory pathogens and antibiotic prescribing. The most common pathogens detected in children with NP are pneumococci and Staphylococcus aureus. The underlying disease mechanisms are poorly understood, but likely relate to multiple host susceptibility and bacterial virulence factors, with viral-bacterial interactions also possibly having a role. Most cases are in previously healthy young children who, despite adequate antibiotic therapy for bacterial pneumonia, remain febrile and unwell. Many also have evidence of pleural effusion, empyema, or pyopneumothorax, which has undergone drainage or surgical intervention without clinical improvement. The diagnosis is generally made by chest imaging, with CT scans being the most sensitive, showing loss of normal pulmonary architecture, decreased parenchymal enhancement and multiple thin-walled cavities. Blood culture and culture and molecular testing of pleural fluid provide a microbiologic diagnosis in as many as 50% of cases. Prolonged antibiotics, draining pleural fluid and gas that causes mass effects, and maintaining ventilation, circulation, nutrition, fluid, and electrolyte balance are critical components of therapy. Despite its serious nature, death is uncommon, with good clinical, radiographic and functional recovery achieved in the 5-6 months following diagnosis. Increased knowledge of NP's pathogenesis will assist more rapid diagnosis and improve treatment and, ultimately, prevention.

CONCLUSION

It is important to consider that our understanding of NP is limited to individual case reports or small case series, and treatment data from randomized-controlled trials are lacking. Furthermore, case series are retrospective and usually confined to single centers. Consequently, these studies may not be representative of patients in other locations, especially when allowing for temporal changes in pathogen behaviour and differences in immunization schedules and antibiotic prescribing practices.

Successful rescue combination of extracorporeal membrane oxygenation, high-frequency oscillatory ventilation and prone positioning for the management of severe methicillin-resistant Staphylococcus aureus pneumonia complicated by pneumothorax: a case report and literature review

BACKGROUND

To describe the experience of combination therapy with extracorporeal membrane oxygenation(ECMO), high-frequency oscillatory ventilation(HFOV) and prone positioning in treating severe respiratory failure caused by community acquired methicillin resistant Staphylococcus aureus(CA-MRSA).

CASE PRESENTATION

A 30-year-old female presented with fever and dyspnea for 3 days. She was diagnosed CA-MRSA pneumonia complicated by severe respiratory failure, pneumothorax and neutropenia. Venovenous ECMO was applied within 8 h of the pneumothorax diagnosis. For amelioration of ventilator-induced lung injury, HFOV and prone positioning were combined with ECMO. The patient's condition improved considerably. ECMO was weaned on day 19, and she was discharged on day 48 with good lung recovery.

CONCLUSIONS

To the best of our knowledge, this was the first case in which ECMO was combined with HFOV and prone positioning to treat severe necrotic CA-MRSA pneumonia complicated with pneumothorax. This combination therapy may provide safe respiratory support, may minimize the risk of barotrauma, and provide better drainage of secretions in patients with necrotizing pneumonia.

Ventilator Management of Bronchopleural Fistula Secondary to Methicillin-Resistant Staphylococcus aureus Necrotizing Pneumonia in a Pregnant Patient with Systemic Lupus Erythematosus

Managing mechanical ventilation in patient with bronchopleural fistula with coexisting acute respiratory distress syndrome is a challenging situation for the intensivist. We are reporting a case of a pregnant patient with systemic lupus erythematosus on immunosuppressive medications who developed methicillin-resistant Staphylococcus aureus necrotizing pneumonia complicated by bronchopleural fistula and acute respiratory distress syndrome.

Extracorporeal membrane oxygenation and toilet bronchoscopy as a bridge to pneumonectomy in severe community-acquired methicillin-resistant Staphylococcus aureus pneumonia

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia is associated with very high mortality. Though surgical evacuation of necrotic tissue is desirable in patients unresponsive to antimicrobial therapy, most patients are acutely ill precluding surgical intervention. We utilized a combination of extracorporeal membrane oxygenation (ECMO) with frequent toilet bronchoscopies to salvage an unaffected right lung from spillage of necrotic pus from left lung cavitary CA-MRSA pneumonia in a 22-year-old patient. Our patient while on ECMO and after decannulation was positioned with the right lung up at all times with 1-2 toilet bronchoscopies every day for almost 30 days. This time was utilized for ventilator weaning and optimizing the nutritional status prior to extrapleural left pneumonectomy. Prevention of soilage of the unaffected right lung and mitigating volutrauma with ECMO support combined with the subsequent surgical evacuation of necrotic left lung tissue led to a favorable outcome in this case. This strategy could be of value in similar presentations of unilateral suppurative pneumonia, where the progressive disease occurs despite optimal medical therapy.

Pathogenesis of Staphylococcus aureus necrotizing pneumonia: the role of PVL and an influenza coinfection

Only recently necrotizing pneumonia was defined as a specific disease entity that is caused by a Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus strain and is frequently preceded by an influenza infection. Necrotizing pneumonia is characterized by a sudden onset and rapid worsening of symptoms, leukopenia, airway hemorrhages, severe respiratory failure and a high mortality rate. Despite clear epidemiological data, the function of PVL in necrotizing pneumonia has been controversially discussed due to conflicting results from different disease models. Furthermore, there are many proposed mechanisms how a viral infection could facilitate and interact with a bacterial superinfection. In this review, we summarize current data from 43 clinical cases and results from various infection models on necrotizing pneumonia. We discuss the contribution of S. aureus PVL and a preceding influenza infection and present a concept of the pathogenesis of necrotizing pneumonia.

Panton-Valentine leukocidin-associated Staphylococcus aureus necrotizing pneumonia in infants: a report of four cases and review of the literature

Four children under 16 months of age presented within an 18-month period with severe, rapidly progressive Panton-Valentine leukocidin-associated ST93 Staphylococcus aureus necrotizing pneumonia. Two of the cases that required extracorporeal membranous oxygenation and proved fatal had poor prognostic features of leukopenia, rash and pulmonary haemorrhage. All four cases had recent contact with S. aureus infection in a family member. Reported cases of S. aureus necrotizing pneumonia in infants are reviewed, and approach to management is discussed.