Uncomplicated skin and skin structure infections in children: diagnosis and current treatment options in the United States

Treatment of MRSA Infection: Where are We?

Staphylococcus aureus is a leading cause of septicemia, endocarditis, pneumonia, skin and soft tissue infections, bone and joint infections, and hospital-acquired infections. In particular, methicillin-resistant Staphylococcus aureus (MRSA) is associated with high morbidity and mortality, and continues to be a major public health problem. The emergence of multidrug-resistant MRSA strains along with the wide consumption of antibiotics has made anti-MRSA treatment a huge challenge. Novel treatment strategies (e.g., novel antimicrobials and new administrations) against MRSA are urgently needed. In the past decade, pharmaceutical companies have invested more in the research and development (R&D) of new antimicrobials and strategies, spurred by favorable policies. All research articles were collected from authentic online databases, including Google Scholar, PubMed, Scopus, and Web of Science, by using different combinations of keywords, including 'anti-MRSA', 'antibiotic', 'antimicrobial', 'clinical trial', 'clinical phase', clinical studies', and 'pipeline'. The information extracted from articles was compared to information provided on the drug manufacturer's website and Clinical Trials.gov (https://clinicaltrials.gov/) to confirm the latest development phase of anti-MRSA agents. The present review focuses on the current development status of new anti-MRSA strategies concerning chemistry, pharmacological target(s), indications, route of administration, efficacy and safety, pharmacokinetics, and pharmacodynamics, and aims to discuss the challenges and opportunities in developing drugs for anti-MRSA infections.

Efficacy of Dalbavancin and Telavancin in the Treatment of Acute Bacterial Skin and Skin Structure Infections

Objectives

Two glycopeptide analogues, such as dalbavancin and telavancin, with improved pharmacokinetic/pharmacodynamic parameters have been developed. These two glycopeptide analogues are approved by Food and Drug Administration (FDA) for treatment of various Gram-positive bacterial skin infections.

Materials and methods

We have conducted an open labelled prospective randomized study to compare the efficacy of these two drugs. A total of 200 patients diagnosed with acute bacterial skin and skin structure infections (ABSSSI) were recruited for the study. They were randomized to receive either a single dose of dalbavancin 1500 mg i.v (Group I) or telavancin 10 mg/kg intravenously (i.v.) every 24 hours for six days (Group II). The skin infection rating score (SIRS) was calculated on Day 0 for all patients at the time of diagnosis. Signs and symptoms of the lesions were assessed based on the following factors: blistering, exudate/pus, erythema/inflammation and itching/pain. Each factor was classified as one of the following: absent - 0, minimal - 1, moderate - 2 and severe - 3.

Results

Clinically successful treatment was defined as complete resolution of clinically meaningful signs and symptoms of infection, including SIRS score of 0. The outcome measure was the percentage of patients with SIRS score of 0 on day 7 (clinical success). The third most common diagnosis at baseline was impetigo (13% in both groups). Patients who received dalbavancin had a higher clinical success rate than those receiving telavancin.

Conclusion

Findings of the present study show that single i.v dose of dalbavancin is better than telavancin repeated doses in treatment of ABSSSI.

An Open Label, Multi-Center, Non-Interventional Post-Marketing Surveillance to Monitor the Safety and Efficacy of ALTARGO® (Retapamulin) Administered in Korean Patients According to the Prescribing Information

Background

With the approval of topical retapamulin ointment in 2011, it was officially required to conduct a post-marketing surveillance (PMS) study to obtain further data of its safety profile and effectiveness, in accordance with the requirement of the Korean Ministry of Food and Drug Safety (MFDS).

Objective

This study had prospectively designed to monitor safety and tolerability with the effectiveness of topical retapamulin in clinical practices.

Methods

Open label, multi-center, non-interventional observational study was done from May 2011 to October 2015. All subjects had bacterial skin infections of locally approved prescribing information accordingly. The study mainly focused on safety issues in the local target population (3,612 eligible subjects). And, drug effectiveness was also evaluated by physicians.

Results

The incidence of adverse events (AEs) and adverse drug reactions (ADRs) were 2.53% and 0.97%, respectively. In terms of the incidence of unexpected AEs and ADRs, 1.45% and 0.33%, and for the incidence of serious AEs, 0.28%, whereas no serious ADRs reported. And, the effectiveness of topical retapamulin rate was 96.1% (1,697 of total 1,765 subjects).

Conclusion

Topical retapamulin is to be well-tolerated and effective in patients with bacterial skin infections of locally approved prescribing information.

Perianal Lesions in Children: An Updated Review

Perianal lesions in children are common reasons for dermatology clinic visits and a well-defined approach to diagnosis and management is helpful to the practicing clinician. In this article, we review and update various etiologies of perianal lesions in the pediatric population, including infectious, papulosquamous, vascular, and neoplastic. We provide a standard initial approach to diagnosis and updates on current management. Infectious etiologies of perianal lesions discussed in this article include fungal, bacterial, parasitic, and viral. Perianal papulosquamous lesions often encountered in children, and discussed in this article, include acrodermatitis enteropathica, psoriasis, contact dermatitis, and many others. We also discuss the diagnosis and management of other entities including infantile hemangiomas, Langerhans cell histiocytosis, and fibrous hamartoma of infancy.

A randomized, double-blind, comparative study to assess the safety and efficacy of topical retapamulin ointment 1% versus oral linezolid in the treatment of secondarily infected traumatic lesions and impetigo due to methicillin-resistant Staphylococcus aureus

OBJECTIVE

To evaluate the clinical and bacteriological efficacy of topical retapamulin ointment 1% versus oral linezolid in the treatment of patients with secondarily infected traumatic lesions (SITLs; excluding abscesses) or impetigo due to methicillin-resistant Staphylococcus aureus (MRSA).

DESIGN

A randomized, double-blind, double-dummy, multicenter, comparative study (NCT00852540).

SETTING

Patients recruited from 36 study centers in the United States.

PATIENTS

Patients 2 months or older with SITL (including secondarily infected lacerations or sutured wounds) or impetigo (bullous and nonbullous) suitable for treatment with a topical antibiotic, with a total Skin Infection Rating Scale score of 8 or greater, including a pus/exudate score of 3 or greater.

INTERVENTIONS

Patients received retapamulin ointment 1% (plus oral placebo), twice daily for 5 days or oral linezolid (plus placebo ointment) 2 or 3 times daily for 10 days.

MAIN OUTCOME MEASURE

Primary end point: clinical response (success/failure) at follow-up in patients with MRSA at baseline (per-protocol population). Secondary efficacy end points: clinical and microbiologic response and outcome at follow-up and end of therapy; therapeutic response at follow-up.

MAIN RESULTS

The majority of patients had SITL (70.4% [188/267] and 66.4% [91/137] in the retapamulin and linezolid groups, respectively; intent-to-treat clinical population). Clinical success rate at follow-up was significantly lower in the retapamulin versus the linezolid group (63.9% [39/61] vs 90.6% [29/32], respectively; difference in success rate -26.7%; 95% CI, -45.7 to -7.7).

CONCLUSIONS

Clinical success rate at follow-up in the per-protocol MRSA population was significantly lower in the retapamulin versus the linezolid group. It could not be determined whether this was related to study design, bacterial virulence, or retapamulin activity.

Clinical and bacteriological efficacy of twice daily topical retapamulin ointment 1% in the management of impetigo and other uncomplicated superficial skin infections

BACKGROUND

Cutaneous bacterial infections are common in children and adults and frequently are caused by Staphylococcus aureus (S. aureus). Treatment failures with topical agents are not uncommon and have been shown to be secondary to bacterial resistance.

OBJECTIVE

To determine clinical and bacteriological efficacy of retapamulin ointment 1% in treatment of patients with cutaneous bacterial infections caused by methicillin-resistant S. aureus (MRSA) and other bacteria.

METHODS

Prospective, nonrandomized, uncontrolled, open label, single center trial conducted between April 2008 and November 2012 that evaluated efficacy of retapamulin ointment 1% in the treatment of impetigo, folliculitis, and other minor soft tissue infections in children and adults. Fifty patients, who presented to a dermatology outpatient clinic and were clinically diagnosed with impetigo, folliculitis, or minor soft tissue infection suitable for treatment with a topical antibiotic, were screened. Thirty-eight patients were enrolled and received treatment: topical retapamulin ointment 1% twice daily for 5 days. Seven patients were MRSA positive and qualified for the primary efficacy population. One patient withdrew due to an adverse event. Clinical and microbiological exams were performed at baseline and follow-up 5 to 7 days later to assess clinical, microbiological, and therapeutic responses. Primary outcome was clinical response at follow-up in primary efficacy population with MRSA isolated as the baseline pathogen. Secondary outcomes included clinical, microbiologic, and therapeutic responses in patients who were culture positive for any species of bacteria.

RESULTS

Clinical response at follow-up in the primary efficacy population (MRSA-positive patients) was not sufficiently powered to demonstrate significance; however, outcomes were excellent, with 7 of 7 patients demonstrating clinical success (5 of 7) or clinical improvement (2 of 7) at follow-up. Barring lack of significance due to small total sample size for patients who were culture positive for any species of bacteria (n = 35), overall success rates were favorable for clinical, microbiologic, and therapeutic responses with values of 66%, 97%, and 69%, respectively. Adverse events (AEs) were mild or moderate in severity. No serious AEs were reported.

CONCLUSION

Safety profile appears favorable given the low number of AEs. Study design limits conclusions that can be drawn. Nevertheless, this study supports use of topical retapamulin 1% ointment in treatment of cutaneous bacterial infections, particularly those caused by S. aureus, including MRSA.

Is there a relationship between hygiene practices and skin and soft tissue infections in diapered children?

OBJECTIVES

The perineal and gluteal regions are the most frequent areas of skin and soft tissue infection (SSTI) in diapered children. No studies have investigated the relationship between perineal and general hygiene practices and SSTIs in this population. This study was conducted to evaluate this relationship.

METHODS

A cross-sectional observational study was conducted in an urban pediatric emergency department. Subjects were recruited into 3 study groups as follows: gluteal/perineal SSTIs (SSTI), diaper dermatitis (DD), or healthy normal skin (NS). Survey responses were analyzed for significance followed by a clinically oriented staged regression to model predictors of SSTI compared with the NS and DD groups.

RESULTS

There were 100 subjects in the SSTI, 206 in the NS, and 151 in the DD groups. Race was the only demographic characteristic that differed between the groups. After adjustment for race, no day care attendance, history of SSTI, household contact with SSTI history, and higher propensity for diaper rash were associated with SSTI compared with NS. Regression results comparing SSTI to DD revealed no day care attendance, history of SSTI, household contact with SSTI history, less sensitive skin, and less diaper cream use to be predictors of SSTI.

CONCLUSIONS

Perineal and general hygiene practices were not significantly different between children with SSTI compared with children with NS or DD. Based on the results of this study, further prospective studies should evaluate diaper hygiene practices that prevent DD and subsequent SSTIs, the preventative role of day care attendance, and effective interventions that minimize the risk of recurrent SSTIs.

Bacterial resistance and impetigo treatment trends: a review

Impetigo is a common cutaneous infection that is especially prevalent in children. The prevalence of colonization and infection with resistant strains is continually increasing, forcing clinicians to reevaluate treatment strategies. Newer topical agents are effective in treating infections with resistant strains and may help minimize resistance and adverse effects from systemic agents. Use of topical disinfectants to decrease colonization is an important adjunctive measure. Physicians should be aware of local resistance patterns in impetigo to help guide therapy.

Recent microbiological shifts in perianal bacterial dermatitis: Staphylococcus aureus predominance

Traditionally, bacterial infections of the anal skin have been found to be caused by Streptococcus. The aim of this study was to determine the breakdown of bacterial isolates and the current presentation of bacterial diseases involving the perineum. From the chart review of children who had bacterial cultures of the anus from 2005 to 2008 in a pediatric dermatology practice population in New York City, 26 pediatric patients (ages 5 months to 12 yrs) who had the indications of anal erythema or recurrent buttocks dermatitis were identified. Bacterial cultures of 17 patients grew pathogens, that of 14 (82% of identifiably infected patients) grew Staphylococcus aureus, in 11 as a solo pathogen (6 MSSA and 5 MRSA in 2 family clusters). Streptococcus was identified in three patients, two on culture and one on latex agglutination test; and two patients were identified as having both group A beta hemolytic Streptococcus and Staphylococcus aureus (2 MSSA and 1 MRSA). In patients with S. aureus perianally, concurrent small papules and pustules of the buttocks or extension of the erythema to adjacent buttock skin was the primary clinical feature distinguishing this condition from isolated streptococcal disease. Whereas Streptococcal infections of the anus and buttocks occur commonly, Staphylococcus aureus has become the leading cause of anal bacterial infection in the setting of skin involvement; therefore, antibacterial therapy for anal and buttock bacterial infections should be tailored accordingly.