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PubMed1976

The dynamics of streptococcal infections in a defined population of children: serotypes associated with skin and respiratory infections.

Serial observations including cultures of the upper respiratory tract and of infected skin lesions and streptococcal antibody determinations were made over a two-year period in a semi-closed population of children between 10 months and 15 years of age. There was a high prevalence of group A streptococci in nose and throat cultures and of skin lesions containing these organisms. Almost 90% of the study population developed streptococcal impetigo during the study period. A slightly higher proportion of males than females developed skin infection but there was no relationship to age. Impetigo was observed throughout the calendar year, exceeding 12% of child-visits in one winter month, but was generally more common in the summer and fall. Conversely, group A streptococci were more often isolated from nose and throat cultures in the winter months. The increase in recovery of streptococci from nose and throat cultures lagged behind the increase in streptococcal impetigo and continued into the winter months, when the prevalence of impetigo had declined. Calculation of ratios for individual streptococcal serotypes isolated from different body sites revealed a clear cut distinction between "respiratory" and "impetigo" serotypes, with respect to both prevalence and acquisition rates. Respiratory serotypes were more commonly isolated in the winter and impetigo serotypes in the summer and fall. Significant antibody responses to extracellular antigens of the streptococcus were documented for pharyngeal acquisitions of both impetigo and respiratory serotypes and for skin lesions associated with impetigo serotypes. Group A streptococcal serotypes may be divided into three categories on the basis of their human pathogenicity for body sites: some with the potential for respiratory infection, others with the potential for skin infection and a few unusual serotypes with the potential for infecting both sites.

Age Factors↗
PubMed1997

Producibility of exfoliative toxin and staphylococcal coagulase types of Staphylococcus aureus strains isolated from skin infections and atopic dermatitis.

BACKGROUND: Strains of Staphylococcus aureus which cause staphylococcal scalded skin syndrome (SSSS) and bullous impetigo secrete exfoliative toxin (ET). Two antigenically distinct serotypes of ET, ETA and ETB, have been reported. MATERIALS AND METHODS: Two hundred eighty-three strains of S. aureus isolated from impetigo, SSSS, furuncles (including furunculosis) and atopic dermatitis were examined in terms of the producibility of ET, ET serotypes and coagulase types. We examined ET production and ET serotypes using the polymerase chain reaction with the oligonucleotide primers for eta and etb. RESULTS: The incidence of ET producers was 69.4% (100/144) in impetigo, 100% (6/6) in SSSS, 2.8% (3/112) in atopic dermatitis and 0% (0/21) in furuncles. ETA alone was produced by 57 strains from impetigo and by 3 strains from atopic dermatitis. ETB alone was produced by 36 strains from impetigo and by all 6 strains from SSSS. Seven strains from impetigo produced both ETA and ETB. Most ETA producers belonged to coagulase type V and most ETB producers to coagulase type I. Impetigo strains mostly belonged to type I or V. All strains from SSSS were classified as type I. Type IV was most frequent among S. aureus isolates from furuncles. CONCLUSION: These results add to the epidemiological information as to ET producibility and ET serotypes of S. aureus strains isolated from impetigo, SSSS, furunculosis and atopic dermatitis. We have found that there is a relationship between the ET serotypes and the coagulase types of ET-producing strains.

Coagulase↗
PubMed2005

Bacterial diseases of the skin.

When considering common bacterial diseases of the skin, rather distinct clinical responses to a variety of bacterial infections have been identified. In these cases, it is the specific site of infection and the attendant inflammatory responses that provide the characteristic clinical picture. When the pyoderma extends just below the stratum corneum, it is called impetigo. Nonbullous impetigo is the most common pediatric skin infection. It usually starts in a traumatized area. The typical lesion begins as an erythematous papule, after which it becomes a unilocular vesicle. When the subcorneal vesicle becomes pustular, it ruptures and eventually becomes a yellow, golden crust that is a hallmark of the disease process. Bullous impetigo is a less common form of impetigo, accounting for fewer than 30% of all impetigo cases. It occurs in infants and is characterized by rapid progression of vesicles to the formation of bullae measuring larger than 5 mm in diameter in previously untraumatized skin. Treatment of nonbullous impetigo must include intervention against the pathogen as well as improvements in the hygiene and living conditions of the patient. A fundamental tenet is to debride the crust (scab) from the wound surface using poloxamer 188. If the lesions are not widespread, topical mupirocin is the treatment of choice. Treatment of bullous impetigo is similar, except that the local cleansing and topical antibiotic must be complemented by systemic antibiotics if there is evidence of disseminating infections. Ecthyma is usually a consequence of failure to treat effectively impetigo. The untreated infection extends deep into the tissue in shallow ulcerations that often heal without scar. Treatment for ecthyma usually requires systemic antibiotics against either staphylococcus or streptococcus. Folliculitis is a pyoderma located within a hair follicle, secondary to follicular occlusion by keratin, overhydration, or either bacterial or fungal infection. Folliculitis may be divided into either a deep or a superficial type. In the superficial type, the pustule is located at the opening of the hair follicle. In the deep form, the infection may extend beyond the confines of the hair follicle, becoming a furuncle or boil. Carbuncles are aggregates of interconnected furuncles that drain through multiple openings of the skin. Treatment of folliculitis must include searching for and avoiding any factors predisposing to infection. If topical antibiotic therapy is ineffective in controlling the infection, surgical drainage of the infected skin abscess will be necessary. Paronychia is the most common bacterial infection of the hand, which often requires surgical incisional drainage. Similarly, a felon that is an infection of the distal pulp of a finger usually requires surgical drainage. Finally, cellulitis is an acute inflammatory reaction involving the skin and underlying subcutaneous tissue. It usually starts as erysipelas and may advance to lymphangitis, lymphadenitis, or gangrene,which will respond to life-saving interventions in the hospital that usually include systemic antibiotic treatment as well as surgical intervention.

Anti-Bacterial Agents↗
PubMed1983

The staphylococcal scalded skin syndrome in historical perspective: emergence of dermopathic strains of Staphylococcus aureus and discovery of the epidermolytic toxin. A review of events up to 1970.

The gradual recognition of dermopathic strains of Staphyloccus aureus, which cause staphylococcal impetigo, pemphigus neonatorum, Ritter's disease, and what was originally called staphylococcal toxic epidermal necrolysis, is described. Obstacles delaying their recognition included an entrenched belief that staphylococci should produce pus, the striking dissimilarity of their main clinical effects (impetigo and scalding), the strongly held opinions of von Rittershain, and controversy over the cause of impetigo. Phage typing and histopathology confirmed the common etiology of these diseases and established the existence of dermopathic strains securely. The important contributions made by Melish and Glasgow were to provide an experimental model for these strains and to discover the epidermolytic toxin, whose action of splitting the epidermis underlies the pathogenesis of all these diseases (which have become known collectively as the staphylococcal scalded skin syndrome). Clinically, however, the impetigo effects and the scalding effects differ markedly, so it is proposed that staphylococcal impetigo should be retained as a separate clinical entity, and that staphylococcal impetigo and the modified staphylococcal scalded skin syndrome should be known collectively as the staphylococcal epidermolytic toxin syndrome.

Bacterial Toxins↗
PubMed1992

Streptococcal infection and renal disease markers in Australian aboriginal children.

OBJECTIVE: To demonstrate an association between markers of streptococcal infection and markers of glomerulonephritis in Aboriginal children. DESIGN: A cross-sectional study of Aboriginal children of school age. SETTING: Three Aboriginal communities in the Northern Territory--two, coastal and one, desert. PARTICIPANTS: Sixty children, randomly selected from the school roll, were studied in each community; thus there were 180 children in total, aged 5-17 years. Midstream urine and venous blood was collected and swabs were taken from the pharynx and from impetiginous skin lesions or axillary skin in the absence of impetigo. Clinical records were examined for evidence of past glomerulonephritis. MAIN OUTCOME MEASURES: Swabs were cultured for beta-haemolytic streptococci and isolates were grouped; serum was tested for titres of antistreptolysin O (ASO) and antideoxyribonuclease B (anti-DNaseB). Protein and creatinine levels were measured in urine, and a ratio of protein to creatinine (UPC) of more than 50 mg protein per mmol creatinine was taken as a measure of significant proteinuria. Urine was examined microscopically for glomerular haematuria (greater than 10 red blood cells per microL with at least 20% dysmorphic red cells). RESULTS: Group A beta-haemolytic streptococci were isolated from the throat swabs of two children and from skin swabs of 25 (13.9%) children; 20 of these were from impetiginous lesions and five from normal axillary skin. beta-Haemolytic streptococci of group C or G were grown from the throat swabs of 13 (8.1%) children. The median titre of ASO (256 IU) was raised compared with a reference level, and the median titre of anti-DNaseB (3172 IU) was particularly high; ASO titres were significantly higher in 31 children with impetigo than in 149 children without impetigo. Significant proteinuria was present in 7 (3.9%) children and glomerular haematuria in 16 (8.9%). Glomerular haematuria was present in 2/7 (28%) children with proteinuria, 4/21 (19%) children with a past history of post-streptococcal glomerulonephritis, in 5/31 (16%) of those with impetigo and in 4/25 (16%) of those with positive skin cultures. However, none of these prevalences was significantly greater than the prevalence of glomerular haematuria among the other children. The prevalence of proteinuria differed significantly between communities and increased significantly with age. Furthermore, the differences in childhood proteinuria observed between communities in this study were parallel with community differences in the prevalence of proteinuria in a related study of adults. CONCLUSIONS: Group A streptococci are important causes of impetigo in Aboriginal children. Streptococcal skin infection may contribute to glomerular haematuria, proteinuria and persistent glomerulonephritis in Aboriginal children, and possibly to chronic glomerulonephritis in adult life. Public health programs are needed to reduce the prevalence of impetigo and group A streptococcal infections in Aboriginal communities; longitudinal studies are needed to test the relationship between streptococcal skin infection in Aboriginal children and chronic renal disease in later life.

Adolescent↗
PubMedDate not supplied

Effect of handwashing on child health: a randomised controlled trial.

BACKGROUND: More than 3.5 million children aged less than 5 years die from diarrhoea and acute lower respiratory-tract infection every year. We undertook a randomised controlled trial to assess the effect of handwashing promotion with soap on the incidence of acute respiratory infection, impetigo, and diarrhoea. METHODS: In adjoining squatter settlements in Karachi, Pakistan, we randomly assigned 25 neighbourhoods to handwashing promotion; 11 neighbourhoods (306 households) were randomised as controls. In neighbourhoods with handwashing promotion, 300 households each were assigned to antibacterial soap containing 1.2% triclocarban and to plain soap. Fieldworkers visited households weekly for 1 year to encourage handwashing by residents in soap households and to record symptoms in all households. Primary study outcomes were diarrhoea, impetigo, and acute respiratory-tract infections (ie, the number of new episodes of illness per person-weeks at risk). Pneumonia was defined according to the WHO clinical case definition. Analysis was by intention to treat. FINDINGS: Children younger than 5 years in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than controls (95% CI (-65% to -34%). Also compared with controls, children younger than 15 years in households with plain soap had a 53% lower incidence of diarrhoea (-65% to -41%) and a 34% lower incidence of impetigo (-52% to -16%). Incidence of disease did not differ significantly between households given plain soap compared with those given antibacterial soap. INTERPRETATION: Handwashing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally-namely, diarrhoea and acute lower respiratory infections. Handwashing with daily bathing also prevents impetigo.

Acute Disease↗
PubMed1983

Treatment of staphylococcal skin infections: a comparison of cephalexin and dicloxacillin.

Cephalexin, given twice daily, and dicloxacillin, given four times daily, were compared in a randomly controlled study for the treatment of staphylococcal skin and skin structure infections. Among 70 evaluable patients, 57 had staphylococcal bullous impetigo. The remaining 13 patients had bullous impetigo with streptococcal or mixed streptococcal-staphylococcal cultures (6 patients), abscess (4 patients), or cellulitis with pyoderma (3 patients). Staphylococci were recovered from lesions of 64 of the 70 evaluable patients; all strains were sensitive to both cephalexin and dicloxacillin, but only 2 of the 64 strains were susceptible to penicillin G. Cephalexin and dicloxacillin proved equally effective. Treatment failures were uncommon (1 patient in each group), and recurrences (3 patients in each group) were limited to patients with bullous impetigo. In general, patients with staphylococcal bullous impetigo responded promptly, with clearing of lesions evident within the first week, but delayed healing with persistence of staphylococci in lesions was more common in the group receiving dicloxacillin. Twice-daily dosing with oral antibiotics is obviously convenient and may enhance compliance. Twice-daily therapy with cephalexin for staphylococcal skin and skin structure infections can be recommended with confidence.

Abscess↗
PubMed2005

Clinical manifestations of staphylococcal scalded-skin syndrome depend on serotypes of exfoliative toxins.

We sought a possible correlation between the clinical manifestations of staphylococcal scalded-skin syndrome (SSSS) and the serotype of exfoliative toxins (ET) by PCR screening of the eta and etb genes in Staphylococcus aureus strains isolated from 103 patients with generalized SSSS and 95 patients with bullous impetigo. The eta gene and the etb gene were detected in, respectively, 31 (30%) and 20 (19%) episodes of generalized SSSS and 57 (60%) and 5 (5%) episodes of bullous impetigo. Both genes were detected in 52 (50%) episodes of generalized SSS and 33 (35%) episodes of bullous impetigo. To explain this link between etb and generalized SSSS, we examined the distribution of ETA- and ETB-specific antibodies in the healthy population (n = 175) and found that the anti-ETB antibody titer was lower than the anti-ETA titer. Thus, ETA is associated with bullous impetigo and ETB is associated with generalized SSSS, possibly owing to a lower titer of anti-ETB neutralizing antibodies in the general population.

Adolescent↗
PubMed1970

Complement in overt and asymptomatic nephritis after skin infection.

In an ongoing study of streptococcal skin infection and acute glomerulonephritis (AGN) begun in 1964, C'3 determinations were done in 784 patients. There were 126 patients with acute poststreptococcal nephritis, 172 of their siblings, and 486 patients with uncomplicated impetigo from families without an index case of nephritis.90% of the patients with nephritis were infected with one of the four prevalent streptococcal serotypes associated with nephritis in this population; only 12% of patients with uncomplicated impetigo were infected with similar serotypes.93% of the patients with overt nephritis had diminished complement levels. Low complement was more often observed (8%) in AGN siblings than was transient hypertension and/or hematuria (5%). Considering the relationship of low C'3 alone and low C'3 preceded hematuria in four others. Two (0.4%) of the patients with uncomplicated impetigo had low complement values, both of whom were infected with nephritogenic strains. Transient hematuria and/or hypertension was less frequently observed (2.7%) among patients with uncomplicated impetigo. Serial determinations in patients with low complement revealed a return to normal in a linear fashion within 2-12 wk. The validity of the hypothesis that the asymptomatic patients with low complement levels, with or without hematuria, likely had subclinical nephritis is strengthened by the accompanying epidemiologic data. The finding of low complement before the onset of, or in the absence of, hematuria or other evidence of nephritis supports the concept that an immunologic mechanism may precipitate the renal injury of acute streptococcal nephritis.

Adolescent↗
PubMed1981

[Clinical trials of cefroxadine on skin and soft tissue infections in the field of pediatrics (author's transl)].

CXD was administered orally at an average dose of 28.6 mg/kg (18.3 approximately 42.3 mg/kg) for an average 6 days (3 approximately 12 days) to a total of 99 pediatric cases with skin and soft tissue infections (impetigo 89, abscess 7 and furuncle 3) ranging from 3 months to 9 years old. The drug was given twice to 4 times per day after meals. The clinical and bacteriological effects and adverse reactions of CXD as well as the susceptibility of the causative organisms against CXD and CEX were studied, and the results obtained are as described below: 1. According to judgement of the attending doctors, CXD had a high global efficacy rate of 90.9%. 2. Analysis of the attending physicians' evaluations of the clinical effects on impetigo revealed that a dose of CXD 20.5 approximately 30.4 mg/kg t.i.d. can produce satisfactory responses. 3. According to the assessments by Evaluation Committee, the global clinical effects after 3, 5 and 7 days were 81.4, 91.2 and 94.6%, respectively. This indicates that clinical responses increased with prolongation of the treatment period, viz. better responses obtained after 5 and 7 days. This suggests that a minimum of 5 days administration is required for treating these infections. 4. As for impetigo having the largest number of patients in this study, a dose of CXD 20.5 approximately 30.4 mg/kg per day seemed to produce satisfactory clinical effects. 5. As for dose per day, the t.i.d. regimen of CXD 20.5 approximately 30.4 mg/kg seemed to exhibit satisfactory clinical responses, as already mentioned. Because of quite a small number of patients on the q.i.d. regimen of higher doses, however, the question of whether the t.i.d. treatment with 20.5 approximately 30.4 mg is adequate or not should be determined by a comparative study between the q.i.d. and t.i.d. treatments. 6. As for bacteriological responses, a high global effect of 87.1% was obtained with CXD against S. aureus and S. pyogenes isolated from 74 and 1 cases, respectively. 7. As for impetigo with predominant number of cases, CXD was highly effective bacteriologically at a daily dose of 20.5 approximately 30.4 mg/kg t.i.d. As an appropriate comparative evidence with the q.i.d. treatment was lacking, however, therapeutic validity of the t.i.d. treatment could not be determined definitely. 8. Utility was evaluated by the attending physicians on the total 99 cases, and CXD showed as high as 88.9%. 9. There were neither non-compliances nor adverse reactions to this treatment. 10. CXD showed a distribution of antimicrobial activity similar to that of CEX, against 74 isolates of S. aureus with the MICs of CXD ranging from 1.56 to 25 mcg/ml and those of CEX ranging from 0.78 to 25 mcg/ml, with peak MIC being 3.13 mcg/ml for both drugs. As for S. pyogenes, only one isolate from the same species, CXD was antimicrobial activity at 0.2 mcg/ml and CEX was antimicrobial at 0.39 mcg/ml. The above findings suggest that CXD is highly effective against acute skin and soft tissue infections in pediatrics.

Abscess↗
PubMed1999

Streptococci isolated from various skin lesions: the interaction with Staphylococcus aureus strains.

We isolated 73 streptococcus strains (41 from infections, and 32 from colonization) from various skin diseases between March, 1994, and June, 1998. In 29 out of 41 cases of infective origin, Staphylococcus aureus strains were simultaneously isolated. Twenty-four out of 28 patients with impetigo were suffering from atopic dermatitis. We confirmed that impetigo lesions where Streptococcus pyogenes was dominant in number always showed thick-walled pustules on an erythematous base; these skin lesions were considered to be an early manifestation of streptococcal impetigo. We further confirmed that thick-crusted lesions in streptococcal impetigo, where S. aureus exceeded S. pyogenes in number, were a late manifestation. Antimicrobial agents such as minocycline, fusidic acid, ofloxacin and tosufloxacin, were more effective against S. aureus strains than against beta-hemolytic streptococcal strains. In contrast, ampicillin, cefdinir, imipenem, erythromycin and vancomycin were more effective against beta-hemolytic streptococcal strains.

Ampicillin↗