Global Antimicrobial Susceptibility Patterns of Staphylococcus aureus in Atopic Dermatitis: A Systematic Review and Meta-Analysis

Importance

Individuals with atopic dermatitis are frequently colonized and infected with Staphylococcus aureus. Empirical antibiotic therapy for individuals with atopic dermatitis is common, but data about the antimicrobial susceptibility profiles of S aureus strains isolated from these individuals are scarce for those living in particular geographic areas.

Objective

To determine the antimicrobial susceptibility of S aureus from individuals with atopic dermatitis and analyze differences according to the income level of the country of origin and the data collection period.

Data Sources

A meta-analysis of the literature was performed from the inception of the included databases (MEDLINE, Embase, Web of Science, Scopus, and Cochrane) to June 20, 2023, using predetermined Medical Subject Headings.

Study Selection

Studies were included if they reported antibiotic susceptibility profiles of 1 or more S aureus cutaneous isolates from individuals with atopic dermatitis. Articles written in English, Spanish, French, or German were included.

Data Extraction and Synthesis

Working in pairs, 6 of the authors conducted the data extraction. The guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed.

Main Outcomes and Measures

The outcome of interest was antimicrobial susceptibility.

Results

A total of 61 studies reported 4091 S aureus isolates from individuals with atopic dermatitis. For 4 of the 11 commonly used antibiotics (36.4%), antimicrobial susceptibility was 85% or less, including for methicillin (binomial proportion, 0.85 [95% CI, 0.76-0.91]), erythromycin (binomial proportion, 0.73 [95% CI, 0.61-0.83]), fusidic acid (binomial proportion, 0.80 [95% CI, 0.62-0.91]), and clindamycin (binomial proportion, 0.79 [95% CI, 0.65-0.89]). Most studies (46; 75.4%) were conducted in high-income countries. Antimicrobial susceptibility to erythromycin, methicillin, and trimethoprim and sulfamethoxazole was significantly lower in lower middle-income countries and upper middle-income countries. Regarding the temporal trends, 33 studies (54.1%) reported data collected from 1998 to 2010. Antimicrobial susceptibility patterns have not changed over time.

Conclusions and Relevance

In this systematic review and meta-analysis, antimicrobial susceptibility of S aureus to β-lactams, erythromycin, clindamycin, and fusidic acid may be suboptimal for empirical use in individuals with atopic dermatitis. Significant differences in antimicrobial susceptibility patterns were found in high-income countries and in lower middle-income countries and upper middle-income countries for some antibiotics.

Isolation of the novel phage SAP71 and its potential use against Staphylococcus aureus in an atopic dermatitis mouse model

Atopic dermatitis (AD) is accompanied by changes in skin microbiota, in which abnormal colonization of Staphylococcus aureus is particularly common. The antibiotic treatment is prone to destroy the commensal bacterial community, further exacerbating the microbiome dysbiosis. Elimination of S. aureus through phage-targeted therapies presents a promising method in the treatment strategy of AD. In this study, we isolated a novel phage SAP71, which specifically lysed S. aureus. Genome sequencing showed that SAP71 contained no virulence, lysogenic, or antimicrobial resistance genes, making this lytic phage a potential agent for phage therapy. Moreover, we demonstrated that phage SAP71 was able to significantly improve the skin lesions, reduce the bacterial loads in the skin, and prevent the development of AD-like skin pathological changes in an AD model. In short, phage SAP71 was demonstrated to effectively treat S. aureus infection in AD, which provided a theoretical basis for the clinical phage therapy of AD.

Gentamycin irrigation significantly reduces 28-day surgical site infection after emergency neurosurgery

OBJECTIVE

This study aims to evaluate the effectiveness of gentamycin irrigation in preventing postoperative surgical site infection (SSI) in emergency neurosurgical procedures.

METHODS

A total of 518 consecutive emergency neurosurgeries, including craniotomies, endoscopic and burr hole procedures were reviewed retrospectively. Patients received either only normal saline (NS) irrigation or NS irrigation with gentamycin added (80 mg/L) during the whole process of surgery. SSIs including wound infection and intracranial infection were the primary outcome. SSI was considered while purulence was observed during wound dressing and confirmed with bacterial culture of wound exudation. In addition, positive result of bacterial growth culture of cerebrospinal fluid was also considered as infection. Infection rates were calculated 28 days after surgery. Statistical analysis was performed using t test or Chi-squared test where appropriate.

RESULTS

This study included 444 patients. Gentamycin was used in 179 (40.3%) patients. Only 2 (1.1%) of 179 patients receiving gentamycin irrigation had an infection. However, among the other 265 patients receiving only NS irrigation, the infection rate was 8.3%. With the addition of gentamycin, the infection rate was decreased by 86.7% (P = 0.001). The two infected patients in gentamycin group were compromised postoperatively: one patient had removed his own extraventricular drainage tube accidentally due to restlessness, and the other had severely contaminated his wound with vomitus during the intracranial drainage tube removal process. If these two patients were excluded from analysis, the effective infection rate using gentamycin irrigation is 0%.

CONCLUSION

The gentamycin plus NS irrigation during emergency neurosurgical procedures can lead to a significantly lower rate of postoperative infection than when NS is used alone.

Staphylococcus aureus from Atopic Dermatitis Patients: Its Genetic Structure and Susceptibility to Phototreatment

We characterized the population of Staphylococcus aureus from patients with atopic dermatitis (AD) in terms of (i) genetic diversity, (ii) presence and functionality of genes encoding important virulence factors: staphylococcal enterotoxins (sea, seb, sec, sed), toxic shock syndrome 1 toxin (tsst-1), and Panton-Valentine leukocidin (lukS/lukF-PV) by spa typing, PCR, drug resistance profile determination, and Western blot. We then subjected the studied population of S. aureus to photoinactivation based on a light-activated compound called rose bengal (RB) to verify photoinactivation as an approach to effectively kill toxin-producing S. aureus. We have obtained 43 different spa types that can be grouped into 12 clusters, indicating for the first-time clonal complex (CC) 7 as the most widespread. A total of 65% of the tested isolates had at least one gene encoding the tested virulence factor, but their distribution differed between the group of children and adults, and between patients with AD and the control group without atopy. We detected a 3.5% frequency of methicillin-resistant strains (MRSA) and no other multidrug resistance. Despite genetic diversity and production of various toxins, all isolates tested were effectively photoinactivated (bacterial cell viability reduction ≥ 3 log10 units) under safe conditions for the human keratinocyte cell line, which indicates that photoinactivation can be a good option in skin decolonization. IMPORTANCE Staphylococcus aureus massively colonizes the skin of patients with atopic dermatitis (AD). It is worth noting that the frequency of detection of multidrug-resistant S. aureus (MRSA) in AD patients is higher than the healthy population, which makes treatment much more difficult. Information about the specific genetic background of S. aureus accompanying and/or causing exacerbations of AD is of great importance from the point of view of epidemiological investigations and the development of possible treatment options.

Integrative transcriptome-wide analysis of atopic dermatitis for drug repositioning

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases, which significantly impact the quality of life. Transcriptome-wide association study (TWAS) was conducted to estimate both transcriptomic and genomic features of AD and detected significant associations between 31 expression quantitative loci and 25 genes. Our results replicated well-known genetic markers for AD, as well as 4 novel associated genes. Next, transcriptome meta-analysis was conducted with 5 studies retrieved from public databases and identified 5 additional novel susceptibility genes for AD. Applying the connectivity map to the results from TWAS and meta-analysis, robustly enriched perturbations were identified and their chemical or functional properties were analyzed. Here, we report the first research on integrative approaches for an AD, combining TWAS and transcriptome meta-analysis. Together, our findings could provide a comprehensive understanding of the pathophysiologic mechanisms of AD and suggest potential drug candidates as alternative treatment options.

Integrative genomic and transcriptomic analyses on publicly available data-sets together with in silico drug repositioning identifies alternative therapeutic options to treat atopic dermatitis.

Linker-Improved Chimeric Endolysin Selectively Kills Staphylococcus aureus In Vitro, on Reconstituted Human Epidermis, and in a Murine Model of Skin Infection

Staphylococcus aureus causes a broad spectrum of diseases in humans and animals. It is frequently associated with inflammatory skin disorders such as atopic dermatitis, where it aggravates symptoms. Treatment of S. aureus-associated skin infections with antibiotics is discouraged due to their broad-range deleterious effect on healthy skin microbiota and their ability to promote the development of resistance. Thus, novel S. aureus-specific antibacterial agents are desirable. We constructed two chimeric cell wall-lytic enzymes, Staphefekt SA.100 and XZ.700, which are composed of functional domains from the bacteriophage endolysin Ply2638 and the bacteriocin lysostaphin. Both enzymes specifically killed S. aureus and were inactive against commensal skin bacteria such as Staphylococcus epidermidis, with XZ.700 proving more active than SA.100 in multiple in vitro activity assays. When surface-attached mixed staphylococcal cultures were exposed to XZ.700 in a simplified microbiome model, the enzyme selectively removed S. aureus and retained S. epidermidis. Furthermore, XZ.700 did not induce resistance in S. aureus during repeated rounds of exposure to sublethal concentrations. Finally, we demonstrated that XZ.700 formulated as a cream is effective at killing S. aureus on reconstituted human epidermis and that an XZ.700-containing gel significantly reduces bacterial numbers compared to an untreated control in a mouse model of S. aureus-induced skin infection.

Microbiologic characterisation of bacterial infections in children with atopic dermatitis

Background: Patients with atopic dermatitis (AD), the commonest chronic inflammatory skin disease are often colonised and infected by Staphylococcus aureus. In this study, we aimed to determine the type and antibacterial sensitivities of the bacteria infecting eczematous lesions in children with AD and to recommend first-line antibiotic therapy.Methods: A prospective study was conducted from June 2020 to June 2021 in children with AD presenting with a cutaneous infection at the King Edward hospital VIII outpatient dermatology clinic. Swabs were collected for microbial culture, confirming infections and assessing antibiotic sensitivity for infected sites.Results: Ninety six children were recruited during the study period with a mean age of 4.3 ± 3.4 years. The commonest cause of bacterial infection was Staphylococcus aureus seen in 74 (77.1%) cases, followed by Staphylococcus aureus and Group A β-haemolytic streptococcus (GAS) co-infection in 22 (22.9%) cases. The majority of these infections were observed on the lower limbs in 50 (52.08%) cases and in moderate 37 (38.5%) cases and severe eczema cases of 38 (39.6%) in AD. There was no gender predilection. Staphylococcus aureus was sensitive to amoxicillin-clavulanic acid in 57 (77.0%) cases, cloxacillin in 53 (71.6%) cases and clindamycin in 24 (32.4%) cases, whereas GAS was mostly sensitive to ampicillin in 10 (45.5%) cases. No swabs retained a resistant strain.Conclusion: Staphylococcus aureus is the commonest bacterial cause of cutaneous infection in children with AD in our setting. Amoxicillin-clavulanic acid and cloxacillin remain the most sensitive therapeutic options for this infection, however, a larger study is required to explore resistance strains, if any, in our setting.

Determination of nasal carriage and skin colonization, antimicrobial susceptibility and genetic relatedness of Staphylococcus aureus isolated from patients with atopic dermatitis in Szczecin, Poland

BACKGROUND

Atopic dermatitis (AD) is one of the most frequent chronic and inflammatory skin condition. AD is characterized by damaged epidermal barrier, xerosis and pruritus of eczematous skin lesions which tend to flare. The duration and frequency of exacerbation of AD symptoms markedly affects the quality of patient life. AD results from the interplay between host genetics, immunity, and environmental factors, however the detailed pathogenesis of this disease is still not entirely cleared. Furthermore, disturbances of the skin microbiota and skin functional impairment predispose to secondary skin infections. Staphylococcus aureus colonizes skin and mucous membranes of 20 to 80% of healthy individuals and of 90% of patients with AD in whom this bacterium is accounted as an important AD exacerbating factor. It is also proven, that S. aureus nasal carriage significantly increases the risk for self-transmission and endogenous infection. In the current study the presence of S. aureus either in nasal vestibule and on lesioned skin of 64 patients with AD enrolled in 10-year autovaccination program was determined. The genetic relatedness of 86 S. aureus isolated from patients nose and skin using Pulsed Field Gel Electrophoresis (PFGE) and antimicrobial susceptibility of all strains to methicillin, erythromycin, clindamycin, mupirocin, gentamicin, amikacin, tetracycline, chloramphenicol and cotrimoxazole was also evaluated.

RESULTS

In total 23 PFGE genotypes and 24 unique patterns were distinguished. 34 patients were S. aureus nasal carriers. Simultaneous presence of S. aureus in nose and on affected skin was found in 16 carriers colonized by indistinguishable or potentially related S. aureus vs 2 carriers colonized with non-related S. aureus in nasal vestibule and on skin. 4 isolates were methicillin resistant (MRSA) among which 3 showed constitutive MLSB resistance phenotype and remaining one was resistant to tetracycline and chloramphenicol. In 4 isolates inducible MLSB resistance phenotype was found, one of them was additionally resistant to tetracycline. 7 S. aureus were mupirocin resistant among them 3 - isolated from one patient, were resistant simultaneously to tetracyclines and chloramphenicol. 7 strains demonstrated resistance to chloramphenicol and susceptibility to all tested antimicrobial agents. The susceptibility to gentamicin, amikacin and cotrimoxazole among all examined S. aureus was confirmed.

CONCLUSION

The obtained results indicated non-clonal structure of S. aureus circulating in AD patients. PFGE results showed the clonal-structure of vast majority of S. aureus isolated from nose and skin from nasal carriers what may prove the autoinfection in these patients. All examined patients the moderate or strong severity of AD was reported. Susceptibility to most antibiotics among isolated strains was also observed.

The global prevalence of fusidic acid resistance in clinical isolates of Staphylococcus aureus: a systematic review and meta-analysis

BACKGROUND AND AIM

Staphylococcus aureus (S. aureus) is one of the most common pathogens causing nosocomial and community-acquired infections with high morbidity and mortality rates. Fusidic acid has been increasingly used for the treatment of infections due to methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA). The present study aimed to determine the precise prevalence of fusidic acid resistant MRSA (FRMRSA), fusidic acid resistant MSSA (FRMSSA), and total fusidic acid resistant S. aureus (FRSA) on a global scale.

METHODS

Several international databases including Medline, Embase, and the Web of Sciences were searched (2000-2020) to discern studies addressing the prevalence of FRSA, FRMRSA, and FRMSSA. STATA (version14) software was used to interpret the data.

RESULTS

Of the 1446 records identified from the databases, 215 studies fulfilled the eligibility criteria for the detection of FRSA (208 studies), FRMRSA (143 studies), and FRMSSA (71 studies). The analyses manifested that the global prevalence of FRSA, FRMRSA, and FRMSSA was 0.5%, 2.6% and 6.7%, respectively.

CONCLUSION

This meta-analysis describes an increasing incidence of FRSA, FRMSSA, and FRMRSA. These results indicate the need for prudent prescription of fusidic acid to stop or diminish the incidence of fusidic acid resistance as well as the development of strategies for monitoring the efficacy of fusidic acid use.

Economic burden of peanut allergy in pediatric patients with evidence of reactions to peanuts in the United States

BACKGROUND: The economic burden of food allergy is large; however, costs specific to individuals with peanut allergy experiencing reactions to peanuts remain to be evaluated. As the prevalence of peanut allergy continues to increase in children, a better understanding of the cost of care is warranted. OBJECTIVE: To assess the cost of care of peanut allergy among privately insured and Medicaid-insured pediatric patients in the United States. METHODS: This retrospective matched-cohort study included patients aged 4-17 years from the Optum Health Care Solutions and Medicaid Claims databases (January 1, 2007-March 31, 2017). Patients were classified into 2 cohorts: peanut allergy (with peanut allergy diagnosis codes and reactions triggering health care resource utilization [HRU]) and peanut allergy-free (no peanut allergy diagnosis codes in claims). Peanut allergy patients were matched 1:10 to peanut allergy-free patients based on baseline covariates. Comorbidities including anxiety and depression, HRU, and direct health care costs were compared between cohorts and reported for both perspectives separately. RESULTS: Compared with peanut allergy-free patients (n = 30,840 privately insured; n = 12,450 Medicaid), peanut allergy patients (n = 3,084 privately insured; n = 1,245 Medicaid) had higher prevalence of asthma, atopic dermatitis/eczema, other food allergies, allergic rhinitis, depression, and anxiety (all P < 0.01). Peanut allergy patients had higher HRU per patient per year (PPPY), including 90% more emergency department visits among both privately insured and Medicaid patients (P < 0.01) and higher direct health care costs PPPY, with incremental costs of $2,247 total or $1,712 excluding asthma-related costs for privately insured patients and $2,845 total or $1,844 excluding asthma-related costs for Medicaid patients (all P < 0.01). CONCLUSIONS: Pediatric patients in the United States with peanut allergy and reactions triggering HRU had significantly higher comorbidity burdens, HRU, and direct health care costs, regardless of asthma-related costs, versus those without peanut allergy. DISCLOSURES: This study was funded by Aimmune Therapeutics, a Nestlé Health Science company. The study sponsor was involved in several aspects of the research including the study design, the interpretation of data, the writing of the manuscript, and the decision to submit the manuscript for publication. Yu and Tilles are employees of Aimmune Therapeutics, a Nestlé Health Science company. Robison and Norrett were employees of Aimmune Therapeutics at the time this study was conducted. Blaiss, Meadows, and Hass provided paid consulting services to Aimmune Therapeutics. Guerin and Latremouille-Viau are employees of Analysis Group, a consulting company that provided paid consulting services to Aimmune Therapeutics. Parts of the results were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting held March 25-28, 2019, in San Diego, CA, and at the ISPOR Annual Meeting held May 18-22, 2019, in New Orleans, LA.

Genomic analysis reveals different mechanisms of fusidic acid resistance in Staphylococcus aureus from Danish atopic dermatitis patients

Background

Staphylococcus aureus skin colonization is common in patients with atopic dermatitis (AD) and is associated with risk of skin infections. AD patients therefore often receive antibiotic treatments, including topical treatment with fusidic acid, which have been associated with resistance development.

Objectives

To examine the prevalence of antibiotic resistance in S. aureus isolated from Danish AD patients, with a primary focus on fusidic acid resistance and the genetic mechanisms that underlie it.

Methods

One hundred and thirty-eight S. aureus isolates collected from lesional skin (n = 54), non-lesional skin (n = 27) and anterior nares (n = 57) from 71 adult AD patients were included in the study. Isolates were tested for susceptibility to 17 selected antibiotics. S. aureus whole-genome sequences were used to examine the genetic determinants of fusidic acid resistance (fusA or fusE mutations or carriage of fusB or fusC genes).

Results

One hundred and nine isolates (79%) were resistant to at least one of the tested antibiotics, with the most prevalent resistances being to penicillin (55%), fusidic acid (41%) and erythromycin (11%). The primary genetic mechanisms of fusidic acid resistance were carriage of fusC (57%) or mutations in fusA (38%). The most prevalent S. aureus lineage was ST1 (23%). All ST1 isolates carried fusC.

Conclusions

S. aureus fusidic acid resistance, caused by either fusA mutations or fusC gene carriage, is a major concern among AD patients. Resistant S. aureus might spread from the patients to the community, indicating the need to reduce the use of fusidic acid in the treatment of AD.

The atopic dermatitis-like lesion and the associated MRSA infection and barrier dysfunction can be alleviated by 2,4-dimethoxy-6-methylbenzene-1,3-diol from Antrodia camphorata

BACKGROUND

Atopic dermatitis (AD) is an inflammatory skin disease with an associated barrier dysfunction and Staphylococcus aureus infection. The mainstay steroid and calcineurin inhibitor therapy shows some adverse effects. 2,4-Dimethoxy-6-methylbenzene-1,3-diol (DMD) is a benzenoid isolated from Antrodia camphorata.

OBJECTIVE

We investigated the inhibitory effect of DMD on methicillin-resistant S. aureus (MRSA), the chemokine production in stimulated keratinocytes, and the AD-like lesion found in ovalbumin (OVA)-sensitized mice.

METHODS

The antimicrobial effect and cutaneous barrier function were evaluated using an in vitro culture model and an in vivo mouse model of AD-like skin.

RESULTS

DMD exhibited a comparative minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) against MRSA with nalidixic acid, a conventional antibiotic. The MIC and MBC for DMD was 78.1 and 156.3 μg/ml, respectively. DMD also showed the ability to eliminate the clinical bacteria isolates with resistance to methicillin and vancomycin. The DNA polymerase and gyrase inhibition evoked by DMD for bacterial lethality was proposed. In the activated keratinocytes, DMD stopped the upregulation of chemokines (CCL5 and CCL17) and increased the expression of differentiation proteins (filaggrin, involucrin, and integrin β-1). Topical application of DMD facilely penetrated into the skin, with AD-like skin displaying 2.5-fold greater permeation than healthy skin. The in vivo assessment using the mouse model with OVA sensitization and MRSA inoculation revealed a reduction of transepidermal water loss (TEWL) and bacterial burden by DMD by about 2- and 100-fold, respectively. Differentiation proteins were also restored after topical DMD delivery.

CONCLUSION

Our data demonstrated an advanced concept of AD treatment by combined barrier repair and bacterial eradication with a sole agent for ameliorating the overall complications.

Use of antibiotics by adults: a population-based cross-sectional study

BACKGROUND

The consumption of antibiotics has been widely discussed, mainly because of antibacterial resistance, which has become a worldwide concern. In Brazil, sale of antibiotics is currently ruled by Agência Nacional de Vigilância Sanitária (ANVISA) regulation RDC 20/2011, which restricts sales to those made under medical prescription. The aims of this study were to evaluate antibiotic use and associated factors among adults in the Metropolitan Region of Manaus, Amazonas, Brazil, and to assess the proportion of self-medication from this use.

DESIGN AND SETTING

Population-based cross-sectional study conducted in the Metropolitan Region of Manaus between May and August 2015.

METHODS

Adults aged ≥ 18 years were selected through probabilistic sampling in three stages. Trained interviewers collected data from the participants in their homes. Antibiotic consumption over the last 15 days was reported. Bivariate analysis was used to calculate the prevalence ratio (PR) of antibiotic usage, with 95% confidence interval (95% CI). A multivariate model adjusted according to significant variables at P ≤ 0.20 using Poisson regression with robust variance was constructed.

RESULTS

The prevalence of antibiotic use was 3.4% (95% CI 2.8-4.0%). Adjusted analysis showed that consumption was higher among women than among men (PR 1.58; 95% CI 1.11-2.24) and among people with fair health status than among those with good health (PR 1.52; 95% CI 1.08-2.15). The prevalence of self-medication was 19.0%; amoxicillin was the most self-medicated antibiotic (10/26).

CONCLUSION

Antibiotic use was associated with women and individuals with fair health status. One fifth of the antibiotics were consumed through self-medication, contrary to the current Brazilian legislation.

Inflammatory cytokines and biofilm production sustain Staphylococcus aureus outgrowth and persistence: a pivotal interplay in the pathogenesis of Atopic Dermatitis

Individuals with Atopic dermatitis (AD) are highly susceptible to Staphylococcus aureus colonization. However, the mechanisms driving this process as well as the impact of S. aureus in AD pathogenesis are still incompletely understood. In this study, we analysed the role of biofilm in sustaining S. aureus chronic persistence and its impact on AD severity. Further we explored whether key inflammatory cytokines overexpressed in AD might provide a selective advantage to S. aureus. Results show that the strength of biofilm production by S. aureus correlated with the severity of the skin lesion, being significantly higher (P < 0.01) in patients with a more severe form of the disease as compared to those individuals with mild AD. Additionally, interleukin (IL)-β and interferon γ (IFN-γ), but not interleukin (IL)-6, induced a concentration-dependent increase of S. aureus growth. This effect was not observed with coagulase-negative staphylococci isolated from the skin of AD patients. These findings indicate that inflammatory cytokines such as IL1-β and IFN-γ, can selectively promote S. aureus outgrowth, thus subverting the composition of the healthy skin microbiome. Moreover, biofilm production by S. aureus plays a relevant role in further supporting chronic colonization and disease severity, while providing an increased tolerance to antimicrobials.

Oral Aspects Identified in Atopic Dermatitis Patients: A Literature Review

Introduction:

Atopic dermatitis is a chronic inflammatory skin condition that is more prevalent in children (10-20% of the world's population) than in adults. As its etiology is multifactorial, it is important to know the most frequent oral manifestations in atopic dermatitis patients.

Methodology:

In the last decades, the correlation between atopic dermatitis and conditions and/or changes in the oral cavity has been demonstrated by several studies. The objective of this paper was to describe, through a review of the literature, the oral health conditions and/or oral aspects identified in patients with atopic dermatitis.

Search Strategy:

A descriptive literature review was carried out through a bibliographical survey based on the last 10 years, in order to answer the study questions.

Results:

As a result, we found six studies with different sample sizes, ranging from 43 to 468 patients, and the majority of them were of cross-sectional study design.

Discussion:

Two studies performed their analysis through dental exams and reported that patients with atopic dermatitis tend to have a greater frequency of carious lesions, and two studies correlated Candida with atopic dermatitis through mycological analyzes.

Conclusion:

There are a few studies in the literature that identify the oral aspects of atopic dermatitis. More investigations are needed in order to contribute to the knowledge of such oral aspects and the approach to treat these patients regarding oral health.

Decolonization of Staphylococcus aureus in patients with atopic dermatitis: a reason for increasing resistance to antibiotics?

INTRODUCTION

Exacerbation of atopic dermatitis can be associated with bacterial infection. The skin of patients is colonized with Staphylococcus aureus in 90% of cases. An attempt has been made to demonstrate that eradication significantly reduces the severity of the disease. Studies indicate the efficacy of topical antibiotics, topical corticosteroids and calcineurin inhibitors. Due to increasing resistance to drugs and the defective antimicrobial peptide profile, decolonization is virtually impossible.

AIM

To determine the prevalence of S. aureus colonization among patients with atopic dermatitis and to assess antimicrobial susceptibility of isolated strains to antibiotics, especially fusidic acid and mupirocin.

MATERIAL AND METHODS

One hundred patients with atopic dermatitis and 50 healthy subjects were microbiologically assessed for the carriage of S. aureus. Antimicrobial susceptibility tests were performed using the broth-microdilution method for antibiotics: ampicillin, ciprofloxacin, daptomycin, erythromycin, fusidic acid, linezolid, lincomycin, mupirocin, tetracycline and vancomycin.

RESULTS

Staphylococcus aureus strains were isolated from the majority of our patients, either from the skin (71%) or the anterior nares (67%). In the present study, 10% of isolations represented methicillin-resistant S. aureus (MRSA). Antibiotics exhibited diverse activities against clinical isolates of S. aureus. Among those tested, the highest rates of resistance were shown for ampicillin - 58.5%, lincomycin - 37.5% and erythromycin - 31.0%. Enhanced resistance levels were expressed to mupirocin (17.5%) and fusidic acid (15.5%).

CONCLUSIONS

According to the increasing rate of resistance and quick recolonization after discontinuation of the treatment, chronic use of topical antibiotics is not recommended and should be limited to exacerbation of atopic dermatitis with clinical signs of bacterial infection.

Staphylococcus aureus resistance to topical antimicrobials in atopic dermatitis

Background

Topical antimicrobial drugs are indicated for limited superficial pyodermitis treatment, although they are largely used as self-prescribed medication for a variety of inflammatory dermatoses, including atopic dermatitis. Monitoring bacterial susceptibility to these drugs is difficult, given the paucity of laboratory standardization.

Objective

To evaluate the prevalence of Staphylococcus aureus topical antimicrobial drug resistance in atopic dermatitis patients.

Methods

We conducted a cross-sectional study of children and adults diagnosed with atopic dermatitis and S. aureus colonization. We used miscellaneous literature reported breakpoints to define S. aureus resistance to mupirocin, fusidic acid, gentamicin, neomycin and bacitracin.

Results

A total of 91 patients were included and 100 S. aureus isolates were analyzed. All strains were methicillin-susceptible S. aureus. We found a low prevalence of mupirocin and fusidic acid resistance (1.1% and 5.9%, respectively), but high levels of neomycin and bacitracin resistance (42.6% and 100%, respectively). Fusidic acid resistance was associated with more severe atopic dermatitis, demonstrated by higher EASI scores (median 17.8 vs 5.7, p=.009). Our results also corroborate the literature on the absence of cross-resistance between the aminoglycosides neomycin and gentamicin.

Conclusions

Our data, in a southern Brazilian sample of AD patients, revealed a low prevalence of mupirocin and fusidic acid resistance of S. aureus atopic eczema colonizer strains. However, for neomycin and bacitracin, which are commonly used topical antimicrobial drugs in Brazil, high levels of resistance were identified. Further restrictions on the use of these antimicrobials seem necessary to keep resistance as low as possible.

New insights on the antibacterial efficacy of miconazole in vitro

Miconazole is a broad-spectrum antifungal used in topical preparations. In the present investigation the minimal inhibitory concentration (MIC) of miconazole for eighty wild type strains of gram-positive and gram-negative bacteria isolated from infected skin lesions was assessed using a modified agar dilution test (adapted to CLSI, Clinical Laboratory Standards Institute). 14 ATCC reference strains served as controls. Miconazole was found efficacious against gram-positive aerobic bacteria (n=62 species), the MICs against Staphylococcus (S.) aureus, S. spp., Streptococcus spp. und Enterococcus spp. ranged between 0.78 and 6.25 μg/mL. Interestingly, there were no differences in susceptibility between methicillin-susceptible (MSSA, 3) methicillin-resistant (MRSA, 6) and fusidic acid-resistant (FRSA, 2) S. aureus isolates. Strains of Streptococcus pyogenes (A-streptococci) (8) were found to be slightly more sensitive (0.78-1.563 μg/mL), while for gram-negative bacteria, no efficacy was found within the concentrations tested (MIC >200 μg/mL). In conclusion, for the gram-positive aerobic bacteria the MICs of miconazole were found within a range which is much lower than the concentration of miconazole used in topical preparations (2%). Thus topically applied miconazole might be a therapeutic option in skin infections especially caused by gram-positive bacteria even by those strains which are resistant to antibiotics.

Change in Antimicrobial Susceptibility of Skin-Colonizing Staphylococcus aureus in Korean Patients with Atopic Dermatitis during Ten-Year Period

BACKGROUND

A small subset of adolescents atopic dermatitis (AD) tends to persist. This also leads to get more antibiotics exposure with advancing years. Antibiotic resistance has been regarded as a serious problem during Staphylococcus aureus treatment, especially methicillin-resistant S. aureus (MRSA).

OBJECTIVE

It was investigated the S. aureus colonization frequency in the skin lesions and anterior nares of adolescent AD patients and evaluated the changes in S. aureus antimicrobial susceptibility for years.

METHODS

Patients who visited our clinic from September 2003 to August 2005 were classified into group A, and patients who visited from August 2010 to March 2012 were classified into group B. To investigate the differences with regard to patients' age and disease duration, the patients were subdivided into groups according to age. Lesional and nasal specimens were examined.

RESULTS

Among the 295 AD patients, the total S. aureus colonization rate in skin lesions was 66.9% (95/142) for group A and 78.4% (120/153) for group B. No significant changes in the systemic antimicrobial susceptibilities of S. aureus strains isolated from adolescent AD patients were observed during about 10-year period. The increased trend of MRSA isolation in recent adolescent AD outpatients suggest that the community including school could be the source of S. aureus antibiotic resistance and higher fusidic acid resistance rates provides evidence of imprudent topical use.

CONCLUSION

Relatively high MRSA isolation and fusidic acid resistance rates in recent AD patients suggest that the community harbors antibiotic-resistant S. aureus.

A Comprehensive Review of the Treatment of Atopic Eczema

Atopic eczema (AE) is a chronic, inflammatory skin disorder which usually develops in early childhood. In spite of intensive investigations, the causes of AE remain unclear, but are likely to be multifactorial in nature. Environmental factors or genetic-environmental interactions seem to play a key role in disease progression. Among various measures of AE managment, cutaneous hydration, which improves barrier function and relieve itchiness, may be helpful to reduce the need for topical steroid use and therefore should be used as a basic treatment. Avoiding aggravating factors is also a basic treatment of AE. Standard medical treatment with a pharmacologic approach may be necessary if basic treatment fails to control symptoms satisfactorily. Recently, more attention is given to a proactive therapeutic by regular intermittent application of low potency steroids or topical calcineurin inhibitors to prevent new flares. Furthermore, various targeted biologics are being introduced for AE control and are proposed as promising therapies. This paper provides a summary of the recent literature on the manangement of AE and a treatment guideline.

Antibiotic Susceptibility of Staphylococcus aureus in Atopic Dermatitis: Current Prevalence of Methicillin-Resistant Staphylococcus aureus in Korea and Treatment Strategies

BACKGROUND

Staphylococcus aureus is a well-known microbe that colonizes or infects the skin in atopic dermatitis (AD). The prevalence of methicillin-resistant S. aureus (MRSA) in AD has recently been increasing.

OBJECTIVE

This study aimed to determine the antimicrobial susceptibility patterns in AD skin lesions and evaluate the prevalence of MRSA in Korea. We also recommend proper first-line topical antibiotics for Korean patients with AD.

METHODS

We studied S. aureus-positive skin swabs (n=583) from the lesional skin of infants, children, and adults who presented to our outpatient clinic with AD from July 2009 to April 2012.

RESULTS

S. aureus exhibited high susceptibility against most antimicrobial agents. However, it exhibited less susceptibility to benzylpenicillin, erythromycin, clindamycin, and fusidic acid. The prevalence of MRSA was 12.9% among 583 S. aureus isolates, and the susceptibility to oxacillin was significantly lower in infants in both acute and chronic AD lesions.

CONCLUSION

S. aureus from AD has a high prevalence of MRSA and multidrug resistance, especially in infants. In addition, the rate of fusidic acid resistance is high among all age groups, and mupirocin resistance increases with age group regardless of lesional status. This is the first study comparing the antimicrobial susceptibility rates of S. aureus isolates from AD cases with respect to age and lesion status in Korea.

Advances in the diagnosis and therapeutic management of atopic dermatitis

Atopic dermatitis is a very prevalent disease that affects children as well as adults. The disease has a severe impact on quality of life for the patients and their families. The skin in atopic dermatitis patients is a site of both a severe inflammatory reaction dominated by lymphocytes and decreased skin barrier function. The treatment of the disease is mainly aimed at reducing the inflammation in the skin and/or restoring the skin barrier function. However, most of the treatments used today singularly aim at reducing the inflammation in the skin. Depending on the severity of the disease, the anti-inflammatory treatment may be topical or systemic, but basic treatment, no matter the severity, should always be emollients. In addition, new studies have shown good effects of psychosocial interventions, such as eczema schools, for patients and their families. This review covers the latest trends in the treatment of atopic dermatitis.

Interleukin-12 preserves the cutaneous physical and immunological barrier after radiation exposure

The United States continues to be a prime target for attack by terrorist organizations in which nuclear detonation and dispersal of radiological material are legitimate threats. Such attacks could have devastating consequences to large populations, in the form of radiation injury to various human organ systems. One of these at risk organs is the cutaneous system, which forms both a physical and immunological barrier to the surrounding environment and is particularly sensitive to ionizing radiation. Therefore, increased efforts to develop medical countermeasures for treatment of the deleterious effects of cutaneous radiation exposure are essential. Interleukin-12 (IL-12) was shown to elicit protective effects against radiation injury on radiosensitive systems such as the bone marrow and gastrointestinal tract. In this article, we examined if IL-12 could protect the cutaneous system from a combined radiation injury in the form of sublethal total body irradiation and beta-radiation burn (β-burn) directly to the skin. Combined radiation injury resulted in a breakdown in skin integrity as measured by transepidermal water loss, size of β-burn lesion and an exacerbated loss of surveillant cutaneous dendritic cells. Interestingly, intradermal administration of IL-12 48 h postirradiation reduced transepidermal water loss and burn size, as well as retention of cutaneous dendritic cells. Our data identify IL-12 as a potential mitigator of radiation-induced skin injury and argue for the further development of this cytokine as a radiation countermeasure.

[Adaptive immune response and associated trigger factors in atopic dermatitis]

Due to a broad variety of extrinsic trigger factors, patients with atopic dermatitis (AD) are characterized by complex response mechanisms of the adaptive immune system. Notably, skin colonization with Staphylococcus aureus seems to be of particular interest since not only exotoxins, but also other proteins of S. aureus can induce specific humoral and cellular immune responses which partially also correlate with the severity of AD. In a subgroup of AD patients Malassezia species induce specific IgE- and T cell-responses which has been demonstrated by atopy patch tests. Moreover, Mala s 13 is characterized by high cross-reactivity to the human corresponding protein (thioredoxin). Induction of a potential autoallergy due to molecular mimicry seems therefore to be relevant for Malassezia-sensitized AD patients. In addition, sensitization mechanisms to autoallergens aside from cross-reactivity are under current investigation. Regarding inhalant allergens, research projects are in progress with the aim to elucidate allergen-specific immune response mechanisms in more depth. For grass-pollen allergens a flare-up of AD following controlled exposure has been observed while for house dust mite-allergens a polarization towards Th2 and Th2/Th17 T cell phenotypes can be observed. These and further findings might finally contribute to the development of specific and effective treatments for aeroallergen-sensitized AD patients.

The effect of gentamicin in irrigating solutions on articular infection prophylaxis during arthroscopic ACL reconstruction

PURPOSE

The purpose of this study was to investigate whether gentamicin irrigation solutions provide a potential new tool to prevent joint infection after arthroscopic ACL reconstruction.

METHODS

In this prospective randomized study, 360 consecutive ACL recondition patients were randomized in two groups alternately from Feb 2008 to March 2012. In the first group, 180 patients underwent ACL reconstruction with a hamstring autograft, preoperative IV antibiotics, and normal saline (0.9% sodium chloride) solution. In the second group 180 patients underwent ACL reconstruction with a hamstring autograft, preoperative IV antibiotics, and normal saline (0.9% sodium chloride solution) with added gentamicin (80 mg/L) (group 2). Three patients from group 1 and six patients from group 2 were excluded from the study due to loss of follow-up. The patients were followed for 6 months and assessed for signs of deep infection.

RESULTS

In group 1, a total of 4 (2.2%) postoperative septic arthritis cases were documented. In group 2, just one postoperative deep infection (septic arthritis) was documented (0.57%). Although the rate of septic arthritis in group 1 was higher than in group 2, statistical analysis showed that the difference between using the gentamicin irrigation solution (80 mg/L) and the saline solution alone was not significant.

CONCLUSIONS

Using gentamicin in irrigating solutions during arthroscopic ACL reconstruction surgery does not statistically decrease post operation septic arthritis.

LEVEL OF EVIDENCE

Therapeutic Level II.

Difficult to control atopic dermatitis

Difficult to control atopic dermatitis (AD) presents a therapeutic challenge and often requires combinations of topical and systemic treatment. Anti-inflammatory treatment of severe AD most commonly includes topical glucocorticosteroids and topical calcineurin antagonists used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, the topical calcineurin inhibitors tacrolimus and pimecrolimus are preferred in certain locations. Systemic anti-inflammatory treatment is an option for severe refractory cases. Microbial colonization and superinfection contribute to disease exacerbation and thus justify additional antimicrobial / antiseptic treatment. Systemic antihistamines (H1) may relieve pruritus but do not have sufficient effect on eczema. Adjuvant therapy includes UV irradiation preferably of UVA1 wavelength. “Eczema school” educational programs have been proven to be helpful.

Guidelines for treatment of atopic eczema (atopic dermatitis) part I

The existing evidence for treatment of atopic eczema (atopic dermatitis, AE) is evaluated using the national standard Appraisal of Guidelines Research and Evaluation. The consensus process consisted of a nominal group process and a DELPHI procedure. Management of AE must consider the individual symptomatic variability of the disease. Basic therapy is focused on hydrating topical treatment, and avoidance of specific and unspecific provocation factors. Anti-inflammatory treatment based on topical glucocorticosteroids and topical calcineurin inhibitors (TCI) is used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, but the TCI tacrolimus and pimecrolimus are preferred in certain locations. Systemic immune-suppressive treatment is an option for severe refractory cases. Microbial colonization and superinfection may induce disease exacerbation and can justify additional antimicrobial treatment. Adjuvant therapy includes UV irradiation preferably with UVA1 wavelength or UVB 311 nm. Dietary recommendations should be specific and given only in diagnosed individual food allergy. Allergen-specific immunotherapy to aeroallergens may be useful in selected cases. Stress-induced exacerbations may make psychosomatic counselling recommendable. 'Eczema school' educational programs have been proven to be helpful. Pruritus is targeted with the majority of the recommended therapies, but some patients need additional antipruritic therapies.

Ionizing radiation: the good, the bad, and the ugly

Skin changes caused by ionizing radiation have been scientifically documented since 1902. Ionizing radiation is a widely accepted form of treatment for various types of cancer. Despite the technological advances, radiation skin injury remains a significant problem. This injury, often referred to as radiation dermatitis, occurs in about 95% of patients receiving radiation therapy for cancer, and ranges in severity from mild erythema to moist desquamation and ulceration. Ionizing radiation is not only a concern for cancer patients, but also a public health concern because of the potential for and reality of a nuclear and/or radiological event. Recently, the United States has increased efforts to develop medical countermeasures to protect against radiation toxicities from acts of bioterrorism, as well as cancer treatment. Management of radiation dermatitis would improve the therapeutic benefit of radiation therapy for cancer and potentially the mortality expected in any "dirty bomb" attack. Currently, there is no effective treatment to prevent or mitigate radiation skin injury. This review summarizes "the good, the bad, and the ugly" of current and evolving knowledge regarding mechanisms of and treatments for radiation skin injury.

Children with atopic dermatitis appear less likely to be infected with community acquired methicillin-resistant Staphylococcus aureus: the San Diego experience

Given the increasing rate of community-acquired methicillin resistant Staphylococcus aureus skin infections in the population, such infections might be concurrently increasing in patients with atopic dermatitis. This study assessed current and prior rates of community-acquired methicillin resistant Staphylococcus aureus and methicillin-susceptible Staphylococcus aureus skin and soft tissue infections in children with atopic dermatitis compared to the general pediatric population. Other antibiotic sensitivity and resistance patterns, including clindamycin-inducible resistance, were also identified. Retrospective study of all skin and soft tissue isolates were positive for Staphylococcus aureus during two distinct 1-year periods, obtained by the outpatient services and the emergency department at Rady Children's Hospital, the major regional pediatric health center in San Diego, California. Of the Staphylococcus aureus isolates obtained from January to December 2000, none from atopic dermatitis patients were methicillin resistant Staphylococcus aureus, while 4.2% of those obtained from the general outpatient pediatric population showed methicillin resistance. In the period from June 2007 to May 2008, 11 of 78 isolates (14.1%) from children with atopic dermatitis were methicillin resistant Staphylococcus aureus. This was significantly lower than the rate of increase noted in the general pediatric population (658 of 1482, or 44.4%, in 2007/2008, p < 0.05). Clindamycin-inducible resistance was noted in 1.9% of the isolates in the general population; all six tested isolates from atopic patients lacked clindamycin-inducible resistance. In this study, children with atopic dermatitis had a much lower rate of community-acquired methicillin resistant Staphylococcus aureus infection compared to the general outpatient pediatric population. Clindamycin-inducible resistance was very low in both groups.

Immunoglobulin E antibody reactivity to bacterial antigens in atopic dermatitis patients

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting up to 20% children and 9% adults world-wide. AD patients are often sensitized against a broad variety of allergens and more than 90% of them suffer from skin superinfections with Staphylococcus aureus.

OBJECTIVE

In this study, we searched for the presence of specific IgE antibodies against S. aureus and Escherichia coli antigens in AD patients.

METHODS

Sera from AD patients (n=79), patients suffering only from allergic rhinoconjunctivitis (n=41) or allergic asthma (n=37) were tested for IgE reactivity to nitrocellulose-blotted S. aureus, E. coli and gut bacterial antigens. IgE-reactive bacterial antigens were affinity purified and identified by mass spectrometry.

RESULTS

More than 30% of AD patients but not patients suffering only from allergic rhinoconjunctivitis and asthma or non-allergic persons exhibited IgE binding to several protein antigens among them DNA-binding and ribosomal proteins and flagellin. Patients with severe skin manifestations showed more frequently IgE reactivity to S. aureus compared with AD patients with mild symptoms. Positive immediate and late skin test reactions could be induced in sensitized AD patients with S. aureus extract.

CONCLUSION AND CLINICAL RELEVANCE

Specific IgE reactivities against a variety of bacterial antigens were observed in a subgroup comprising a third of AD patients and may contribute to allergic inflammation.