Hurdles to managing a case of methicillin-susceptible Staphylococcus aureus: A clinical nightmare

Staphylococcus aureus (SA), the most virulent of the many staphylococcal species, has been rightly described to be a cause of aggressive infections. Its versatility in evading host immune mechanisms and its ability to invade any human tissue make it a major cause for morbidity and mortality worldwide. With the current focus being on methicillin-resistant SA, the hurdles to the management of methicillin-susceptible SA (MSSA) are often underestimated. Here, we present a case of MSSA that was a skin colonizer, which gained entry inside the host following a fall. Although timely and adequate treatment for bacteremia was given, he progressed to sepsis with multiorgan dysfunction syndrome (MODS) and succumbed to the infection. A 79-year-old male, with a history of a recent fall which was treated, presented 2 weeks later, with complaints of fever and altered sensorium. The initial culture from the knee was negative. He was currently admitted for altered sensorium, which turned out to be MSSA bacteremia. He progressed to sepsis with MODS-septic arthritis, lobar pneumonia, and possible infective endocarditis (IE). He was on daptomycin and cefazolin. However, the patient did not respond to the treatment, progressed to septic shock, and unfortunately succumbed to infection. In our scenario, heavy skin colonization, followed by the breach in the skin following fall, possibly was the cause for septic arthritis weeks later. The lack of clinical response to daptomycin and the rapid clinical decline raised the suspicion of another source of SA invasion. Keeping in mind the aggressiveness of SA, a diagnosis of possible IE was also considered, and treatment was initiated. The management guidelines for treating MSSA are clearly defined by the Infectious Diseases Society of America and the National Health Service. We report this case to reflect on possible causes for nonresponse to treatment and to remind physicians of the devastating infectiveness of MSSA. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement.