Prevalence of methicillin resistance in Staphylococcus pseudintermedius isolates from dogs with skin and ear infections in South Africa

Staphylococcus pseudintermedius (SP) is an important opportunistic pathogen, frequently associated with pyoderma and otitis in dogs. The emergence and rapid expansion of methicillin-resistant Staphylococcus pseudintermedius (MRSP) is problematic due to multidrug resistance and reduced treatment options. The aim of this study was to determine i) the prevalence of MRSP in dogs with pyoderma or otitis externa, ii) the antimicrobial resistance patterns of MRSP from South African isolates, and iii) the risk factors for MRSP-associated pyoderma or otitis externa in dogs in South Africa (RSA). Sixty-eight presumptive clinical SP isolates (collected from 65 dogs) from five geographically dispersed laboratories in RSA were collected over 2 years. Possible MRSP isolates were flagged when resistance to oxacillin was observed. Thereafter, all isolates were confirmed as SP by polymerase chain reaction (PCR) and further genotyped for the mecA gene. Fifty-seven of 68 isolates were confirmed to be SP (83.8%), while 49/57 (85.9%) carried mecA. Our findings showed that preliminary phenotypic methods supplemented by genotypic methods increased the accuracy of correctly identifying SP. All isolates were resistant to at least one antimicrobial drug. There was a high incidence of amoxicillin (70.1%) and enrofloxacin (65%) resistance. Important risk factors for mecA positive carriage were previous hospital admission, pruritus, and previous antibacterial failure. This study demonstrates a high prevalence of mecA positive carriage (85.9% of samples) in MRSP pyoderma and otitis in dogs in RSA. There is an urgent need for better laboratory diagnosis of MRSP and surveillance of dogs presenting with pyoderma and otitis in South Africa.

The prevalence of scabies, pyoderma and other communicable dermatoses in the Bijagos Archipelago, Guinea-Bissau

INTRODUCTION

Skin diseases represent a significant public health problem in most low and middle income settings. Nevertheless, there is a relative paucity of high-quality epidemiological data on the prevalence of these conditions.

MATERIALS/METHODS

We conducted two cross-sectional population-based skin-surveys of children (6 months to 9 years old) in the Bijagós Archipelago of Guinea-Bissau during the dry season (February-March 2018) and the wet season (June-July 2018). Following a period of training, a nurse performed a standardised examination for communicable dermatoses for each participant. We calculated the prevalence of each skin condition and investigated demographic associations.

RESULTS

1062 children were enrolled in the dry season survey of whom 318 (29.9%) had at least one skin diseases. The most common diagnosis was tinea capitis (154/1062, 14.5% - 95% CI 12.5-16.8%) followed by tinea corporis (84/1062, 7.9% - 95% CI 6.4-9.7%), pyoderma (82/1062, 7.7% - 95% CI 6.2-9.5%) and scabies (56/1062. 5.2% - 95%CI 4.0-6.8%). 320 children were enrolled in the wet season survey of whom 121 (37.8%) had at least one skin problem. Tinea capitis remained the most common diagnosis (79/320, 24.7% - 95% CI 20.1-29.9%), followed by pyoderma (38/320, 11.9% - 95% CI 8.6-16.1%), tinea corporis (23/320, 7.2% - 95% 4.7-10.7%) and scabies (6/320, 1.9% - 95% CI 0.8-4.2%).

CONCLUSIONS

Our study, which utilised robust population-based cluster random sampling methodology, demonstrates the substantial disease burden caused by common communicable dermatoses in this setting. Given these findings, there is a need to consider common dermatoses as part of Universal Health Coverage to deliver 'skin-health for all'.

High burden and seasonal variation of paediatric scabies and pyoderma prevalence in The Gambia: A cross-sectional study

BACKGROUND

Scabies is a WHO neglected tropical disease common in children in low- and middle-income countries. Excoriation of scabies lesions can lead to secondary pyoderma infection, most commonly by Staphyloccocus aureus and Streptococcus pyogenes (group A streptococcus, GAS), with the latter linked to acute post-streptococcal glomerulonephritis (APSGN) and potentially rheumatic heart disease (RHD). There is a paucity of data on the prevalence of these skin infections and their bacterial aetiology from Africa.

METHODOLOGY/PRINCIPAL FINDINGS

A cross-sectional study, conducted over a four-month period that included the dry and rainy season, was conducted to determine the prevalence of common skin infections in Sukuta, a peri-urban settlement in western Gambia, in children <5 years. Swabs from pyoderma lesions were cultured for S. aureus and GAS. Of 1441 children examined, 15.9% had scabies (95% CI 12.2-20.4), 17.4% had pyoderma (95% CI 10.4-27.7) and 9.7% had fungal infections (95% CI 6.6-14.0). Scabies was significantly associated with pyoderma (aOR 2.74, 95% CI 1.61-4.67). Of 250 pyoderma swabs, 80.8% were culture-positive for S. aureus, and 50.8% for GAS. Participants examined after the first rains were significantly more likely to have pyoderma than those examined before (aRR 2.42, 95% CI 1.38-4.23), whereas no difference in scabies prevalence was seen (aRR 1.08, 95% CI 0.70-1.67). Swab positivity was not affected by the season.

CONCLUSIONS/SIGNIFICANCE

High prevalence of scabies and pyoderma were observed. Pyoderma increased significantly during the rainy season. Given the high prevalence of GAS pyoderma among children, further research on the association with RHD in West Africa is warranted.

Prevalence of Community-Acquired Pyoderma in Dermatological Outpatient Department of A Tertiary Care Hospital

Introduction

Pyoderma is defined as any purulent skin disease and represents infections in epidermis and dermis or hair follicles. This study aims to find out the prevalence of community-acquired pyoderma in dermatological outpatient department of a tertiary care hospital.

Methods

A descriptive cross-sectional study was carried out among patients who presented at dermatology outpatient department of Kathmandu Medical College Teaching Hospital between December 2018 and March 2019 after ethical clearance from institutional review committee. Convenience sampling method was done. Data was collected and analysis was done using SPSS software, point estimate at 95% CI was calculated along with frequency and proportion for binary data.

Results

Out of 385 cases, 72 (18%) cases were of community-acquired pyoderma. Prevalence of community-acquired pyoderma is 72 (18%). Primary pyoderma was seen in 49 (12.72%) mainly folliculitis 17 (4.41%), furunculosis 16 (4.15%), impetigo 6 (1.55%), abscess 6 (1.55%) and bacterial paronychia 4 (1.03%). Staphylococcus aureus was the most common organism isolated in 42 (58.3%) cases and Staphylococcus epidermidis was isolated in 3 (4.17%) cases. Staphylococcus aureus was most sensitive to Vancomycin 42 (100%) followed by Gentamycin 40 (95.2%), Ciprofloxacin 40 (95.2%) and Ceftriaxone 40 (95.2%). Highest resistance was seen to Azithromycin in 13 (30.95%), followed by Cloxacilllin in 11 (26.19%). Males were affected predominantly in 49 (68.06%) as compared to females in 23 (31.94%).

Conclusions

Prevalence of community-acquired pyoderma is high among patients visiting dermatological outpatient departments of a tertiary care hospital compared to other studies. Antibiotic resistance of commonly used antibiotics are increasing and thus proper culture and sensitivity reports may be required to guide our treatment.

Disorders of Bulldogs under primary veterinary care in the UK in 2013

The Bulldog is a popular companion breed in the UK despite widely reported disease predispositions. This study aimed to characterise the demography, mortality and common disorders of Bulldogs under veterinary care in the UK during 2013. VetCompass collates anonymised clinical data from UK primary-care veterinary practices for epidemiological research. The clinical records of all Bulldogs available in the VetCompass study dataset were reviewed manually in detail to extract the most definitive diagnoses recorded for all disorders that existed during 2013 and for all deaths. Bulldogs comprised 1621 (0.36%) of 445,557 study dogs. Bulldogs increased from 0.35% of the 2009 birth cohort to 0.60% in 2013. Median longevity was 7.2 years, which was lower in males (6.7 years) than females (7.9 years) (P = 0.021). The most prevalent fine-level precision disorders recorded were otitis externa (n = 206, prevalence 12.7%, 95% CI: 11.1–14.4), pyoderma (142, 8.8%, 95% CI: 7.4–10.2) and overweight/obesity (141, 8.7%, 95% CI: 7.4–10.2). The most prevalent disorder groups were cutaneous (n = 463, prevalence: 28.6%, 95% CI: 26.4–30.8), ophthalmological (292, 18.0%, 95% CI: 16.2–20.0), aural (211, 13.0%, 95% CI: 11.4–14.8), enteropathy (188, 11.6%, 95% CI: 10.1–13.3) and upper respiratory tract (171, 10.5%, 95% CI: 9.1–12.1). Provision of an evidence base on the most common disorders and causes of mortality within breeds can support owners, breeders and the veterinary profession to improve health and welfare within these breed.

Pyoderma outbreak among kindergarten families: Association with a Panton-Valentine leukocidin (PVL)-producing S. aureus strain

Objectives

We report on an outbreak of skin and soft tissue infections (SSTI) among kindergarten families. We analyzed the transmission route and aimed to control the outbreak.

Methods

The transmission route was investigated by nasal screening for Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus (PVL-SA), subsequent microbiological investigation including whole genome sequencing and a questionnaire-based analysis of epidemiological information. The control measures included distribution of outbreak information to all individuals at risk and implementation of a Staphylococcus aureus decontamination protocol.

Results

Individuals from 7 of 19 families were either colonized or showed signs of SSTI such as massive abscesses or eye lid infections. We found 10 PVL-SA isolates in 9 individuals. In the WGS-analysis all isolates were found identical with a maximum of 17 allele difference. The clones were methicillin-susceptible but cotrimoxazole resistant. In comparison to PVL-SAs from an international strain collection, the outbreak clone showed close genetical relatedness to PVL-SAs from a non-European country. The questionnaire results showed frequent travels of one family to this area. The results also demonstrated likely transmission via direct contact between families. After initiation of Staphylococcus aureus decontamination no further case was detected.

Conclusions

Our outbreak investigation showed the introduction of a PVL-SA strain into a kindergarten likely as a result of international travel and further transmission by direct contact. The implementation of a Staphylococcus aureus decontamination protocol was able to control the outbreak.

The Global Epidemiology of Impetigo: A Systematic Review of the Population Prevalence of Impetigo and Pyoderma

Objective

We conducted a comprehensive, systematic review of the global childhood population prevalence of impetigo and the broader condition pyoderma.

Methods

PubMed was systematically searched for impetigo or pyoderma studies published between January 1 1970 and September 30 2014. Two independent reviewers extracted data from each relevant article on the prevalence of impetigo.

Findings

Sixty-six articles relating to 89 studies met our inclusion criteria. Based on population surveillance, 82 studies included data on 145,028 children assessed for pyoderma or impetigo. Median childhood prevalence was 12·3% (IQR 4·2–19·4%). Fifty-eight (65%) studies were from low or low-middle income countries, where median childhood prevalences were 8·4% (IQR 4·2–16·1%) and 14·5% (IQR 8·3–20·9%), respectively. However, the highest burden was seen in underprivileged children from marginalised communities of high-income countries; median prevalence 19·4%, (IQR 3·9–43·3%).

Conclusion

Based on data from studies published since 2000 from low and low-middle income countries, we estimate the global population of children suffering from impetigo at any one time to be in excess of 162 million, predominantly in tropical, resource-poor contexts. Impetigo is an under-recognised disease and in conjunction with scabies, comprises a major childhood dermatological condition with potential lifelong consequences if untreated.

GAPO syndrome associated with pyoderma vegetans: an unreported co-existence

GAPO syndrome is a rare autosomal recessive disease and an acronym composed of growth retardation, alopecia, pseudoanodontia, optic atrophy. Approximately 38 cases have been reported in literature until now. Pyoderma vegetans is a chronic inflammatory disease characterized with vesicopustular, exudative and vegetative lesions usually localized on face, scalp, axilla and genitalia. Pyoderma vegetans is attributed to a bacterial infection frequently occurring in individuals with an underlying immunosuppressive condition. A 30-year-old female patient was admitted to our clinic with complaint of a hemorrhagic, crusted, exudative vegetative two plaques on the scalp. On her physical examination, she had a prematurely aged face, predominant lower lips, total tooth loss, frontal bossing, enlarged anterior fontanelle, marked scalp veins, micrognatia, depressed nasal bridge, short stature, growth retardation. She was diagnosed as GAPO syndrome as the result of her physical examination. Result of the biopsy taken from scalp was evaluated as pyoderma vegetans. And the diagnosis of pyoderma vegetans was established based on the correlate of both clinical and histopathologic findings. Pyoderma vegetans coexisting with GAPO syndrome has not been reported previously. Thus we wished to report it.

[About non-specific prophylaxis of infections typical for organized groups]

Respiratory tract infections and pyodermia are typical for personnel doing military service under conscription. Risk of progression of these infections is connected with activation of carry-over of causative agents among military personnel during replacement and decrease in immunity of conscripts. Usage of medication "Karmolis Kapli" for the purpose of prophylaxis allows to reduce cases of respiratory tract infections among the military personnel. Among the military servicemen who had take "Karmolis Kapli" was noted reduction of community-acquired pneumonia, tonsillitis and pyodermia morbidity. Non-specific protective effect of medication "Karmolis Kapli" is conditioned by increase of the common resistance of the body. For the purpose of prophylaxis it is necessary to use this medication during the personnel formation before the beginning of seasonal morbidity.

[Effect of imunofan on several indexes of immunity and pyoderma incidence among cadets of educational institutes]

It was discovered that during the first several months military service men have suppression of several indexes of immunity and a high level of morbidity by pyoderma. Was shown a high effectiveness of immunomodulatory agent Imunofan on correction of immunity status of servicemen and decrease of morbidity by pyoderma (more than on threefold): the effectiveness index is 3,25, the defense index is 69,2%. In addition, it was marked hepatitis- and stress-protect effect of the agent. It was made a conclusion about necessity of further examination of questions of correction of immunity status of military servicemen for the purpose of decrease of morbidity by infections, actual for studying units of the Armed Forces of RF.

Apparent Contrasting Rates of Pharyngitis and Pyoderma in Regions where Rheumatic Heart Disease is Highly Prevalent

BACKGROUND

The aim of the study was to describe the epidemiology of pharyngitis and pyoderma in a Central Australian Aboriginal community with a high prevalence of rheumatic heart disease (RHD) and compare it to communities in the Top End of the Northern Territory.

METHODS

Following ethics approval and community consultation, selected households were enrolled and visited over a 13-month period. People were asked if they had a sore throat and/or skin sores and asked about current or recent use of antibiotics; all throats and any pyoderma lesions were swabbed for bacterial culture. Beta-haemolytic streptococci (BHS), including group A streptococcus (GAS), were identified in the central laboratory using standard methods. Household crowding was also assessed. Results were then compared to those from the Top End study.

RESULTS

Sore throat was relatively common (480 episodes per 100 person years), although there was only one case of GAS pharyngitis in 326 consultations. Only 5.5% of children <15 years had pyoderma during the course of the study. This is the opposite picture to that reported in the Top End where symptomatic pharyngitis is rare and pyoderma is common.

CONCLUSIONS

Although the data are limited, the epidemiology of pharyngitis and pyoderma in this Central Australian Aboriginal community appears to be more akin to that seen in temperate climates rather than tropical Top End communities. In this community, RHD preventative measure should continue to include aggressive treatment of pharyngitis according to recommendations.

Group A streptococcal infections in children

The group A streptococcus causes the widest range of disease in humans of all bacterial pathogens. Group A streptococcal diseases are more common in children than adults with diseases ranging from pharyngitis and impetigo to invasive infections and the post-streptococcal sequelae--acute rheumatic fever and acute post-streptococcal glomerulonephritis. The global burden of severe group A streptococcal disease is concentrated largely in developing countries and Indigenous populations such as Aboriginal Australians. Control of group A streptococcal disease is poor in these settings and the need for a vaccine has been argued. With an ever-increasing understanding of the group A streptococcus at a molecular level, new and sophisticated vaccines are currently in human trials and the next decade holds exciting prospects for curbing group A streptococcal diseases.

Molecular typing of Streptococcus pyogenes from remote Aboriginal communities where rheumatic fever is common and pyoderma is the predominant streptococcal infection

Aboriginal Australians in remote communities have high rates of rheumatic heart disease (RHD); yet pharyngitis is reportedly rare whilst pyoderma is common. Some strains of group A streptococci (GAS) have preference for the throat and others for the skin depending on M protein type. A study in three remote communities provided 350 GAS isolates for emm sequence typing, 244 were also emm pattern typed. There was 100% correlation between emm sequence and pattern type. Patterns D and E (non-throat tropic) made up 71% of throat and 87% of skin isolates although patterns A-C (throat tropic) were more common in the throat than the skin (RR 2.3, 95% CI 1.4-3.8) whilst the opposite was found for pattern D (RR 2.2, 95% CI 1.7-3.0). Pattern E favoured the throat (RR 1.4, 95% CI 1.1-1.8). Where environmental factors predispose to skin infection, emm pattern types D and E prevail, whatever the recovery site.

Blastomycosis-like pyoderma

A 9-year-old female, presented with recurrent bilaterally symmetrically distributed flesh colored vegetative plaques, papules and nodules on trunk and upper and lower extremities since 15 days. Investigations revealed anemia, hypoproteinemia, decreased albumin and positive D-xylose test. Pus swab and biopsy for culture sensitivity showed Enterococci species. Biopsy showed spongiotic psoriasiform dermatitis with subcorneal pustule. She fulfilled criteria for the diagnosis of blastomycosis-like pyoderma viz. presentation of large verrucous plaques with pustules and elevated border, pseudoepitheliomatous hyperplasia with abscess histologically and growth of one pathogenic bacterium on culture or tissue biopsy. She responded to long-term amoxicillin-clavulanic acid therapy.

Pyoderma caused by Pseudomonas aeruginosa infection in dogs: 20 cases

In this report we describe the historical, clinical, histopathological and microbiological features, as well as treatments and clinical outcome, of pyoderma where Pseudomonas aeruginosa alone was isolated on bacterial culture from lesional skin. Twenty dogs were included in this retrospective study. Seven dogs without prior history of systemic or skin disease presented with acute deep pseudomonal pyoderma characterized by a sudden onset of dorsal truncal pain. Skin lesions in these dogs consisted of erythematous papules, haemorrhagic bullae, ulcers and haemorrhagic crusts confined to the dorsum. An excellent clinical response was achieved with 3-4 weeks of treatment with oral fluoroquinolones. Thirteen dogs with a more gradual onset of skin lesions associated with pseudomonal pyoderma had a history of prior skin, ear or systemic disease and had previously been treated with antibiotics and/or immunomodulatory drugs. Skin lesions in these dogs were variable and similar to those described for superficial and deep staphylococcal pyoderma. In this group, one dog was euthanized prior to commencement of treatment, two dogs were lost to follow up, and 9 had resolution of lesions following treatment with topical silver sulfadiazine (one dog), fluoroquinolones (six dogs) or cephalexin (two dogs) administered orally for 3 to 12 weeks. Rod-shaped bacteria were not always detected on cytology. Histopathology of dogs with deep pseudomonal pyoderma was characterized by severe perforating suppurative folliculitis and furunculosis.

Use of a single-nucleotide polymorphism genotyping system to demonstrate the unique epidemiology of methicillin-resistant Staphylococcus aureus in remote aboriginal communities

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a major public health problem in Australia, as in many other parts of the world. High rates of CA-MRSA skin and soft tissue infection have been reported from Aboriginal communities. We used a single-nucleotide polymorphism (SNP) genotyping typing system based on the multilocus sequence type (MLST) database to investigate the epidemiology of CA-MRSA and methicillin-sensitive S. aureus (MSSA) over a 12-month period in three remote Aboriginal communities of Northern Australia. This was supplemented by real-time PCR for Panton-Valentine leukocidin (PVL) genes, staphylococcal cassette chromosome mec (SCCmec) typing, and antimicrobial susceptibility testing. S. aureus was recovered from pyoderma lesions on 221 occasions and throat swabs on 44 occasions. The median monthly recovery rate of S. aureus from skin sores was 58% (interquartile range, 62 to 78%), and there was no seasonal variation. Twenty-three percent of isolates were CA-MRSA; the proportion was similar across the communities and did not vary over the study period. Erythromycin resistance was found in 47% of CA-MRSA and 21% of MSSA. SNP-based typing identified 14 different clonal complexes (cc); however, cc75 was predominant, accounting for 71% of CA-MRSA isolates. These were confirmed as ST75-like by using an additional SNP and MLST of selected isolates. All but one of the cc75 isolates had SSCmec type IV (one had type V), and all were PVL negative. Monthly tracking of SNP-based cc types showed a highly dynamic process. ST75-MRSA-IV appears to be unique to the region and probably evolved de novo in remote Aboriginal communities.

Etiology and incidence of chronic ulcers in Blantyre, Malawi

BACKGROUND

Little information is available on the incidence and etiology of chronic ulcers in the tropics. Therefore, the incidence and etiology of chronic skin ulcers were assessed in out-patients at the Department of Dermatology and in in-patients at the Departments of Dermatology, Surgery, Medicine, and Pediatrics, Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi.

METHOD

In a 10-week study period, 44 patients (31 males, 70%) with chronic skin ulcers were diagnosed from 6292 patients seen by the departments involved.

RESULTS

The mean age of patients with ulcers was 38 years (range, 9 months to 82 years). The most frequent cause of ulcers was bacterial infection (n=22), followed by malignancy (n=11) and trauma (n=7).

CONCLUSION

In contrast with developed countries, venous and diabetic ulcers were uncommon. In addition to bacterial infections, a surprisingly large number of malignancies were found in this study. We speculate that human immunodeficiency virus (HIV) infection, which is seen with a high prevalence at QECH, is a contributing factor. Because of the large number of malignancies, we recommend early histopathologic investigation of chronic ulcers in this part of Africa.

Investigation of a pyoderma outbreak caused by methicillin-susceptible Staphylococcus aureus in a nursery for newborns

An outbreak of pyoderma caused by methicillin-susceptible Staphylococcus aureus occurred in a nursery for newborns over 26 days. During this period, six neonates were involved. The mother of the first case had trunk pyoderma before delivery, which was regarded as the source of the outbreak. Contamination of the environment and equipment were implicated as the reservoirs of further pathogen spread, as supported by pulsed-field gel electrophoresis (PFGE) results, which showed that some screening isolates were indistinguishable from the epidemic strain. Termination of the outbreak was achieved by the reinforcement of infection control practices and disinfection of environmental surfaces.

The global burden of group A streptococcal diseases

The global burden of disease caused by group A streptococcus (GAS) is not known. We review recent population-based data to estimate the burden of GAS diseases and highlight deficiencies in the available data. We estimate that there are at least 517,000 deaths each year due to severe GAS diseases (eg, acute rheumatic fever, rheumatic heart disease, post-streptococcal glomerulonephritis, and invasive infections). The prevalence of severe GAS disease is at least 18.1 million cases, with 1.78 million new cases each year. The greatest burden is due to rheumatic heart disease, with a prevalence of at least 15.6 million cases, with 282,000 new cases and 233,000 deaths each year. The burden of invasive GAS diseases is unexpectedly high, with at least 663,000 new cases and 163,000 deaths each year. In addition, there are more than 111 million prevalent cases of GAS pyoderma, and over 616 million incident cases per year of GAS pharyngitis. Epidemiological data from developing countries for most diseases is poor. On a global scale, GAS is an important cause of morbidity and mortality. These data emphasise the need to reinforce current control strategies, develop new primary prevention strategies, and collect better data from developing countries.

[Pustular diseases of the newborn]

In the newborn, there exists a wide spectrum of pustular skin diseases. These range from transitory, benign adaptation disorders up to systemic, life threatening illnesses. In 30-60% of newborns pustules are observed in association with the relatively harmless Erythema toxicum, the origin of which is still unknown today. It is necessary to differentiate this from the pustular diseases which may be of infectious or non-infectious nature and which require therapy. Typical pathogens include Malassezia furfur, Staphylococci, Streptococci, Candida spp. and the herpes virus group.

Invasive group A streptococcal infection in high school football players, New York City, 2003

After being notified that 2 high school football teammates were hospitalized with confirmed or suspected invasive group A streptococcal infections, we conducted an investigation of possible spread among other team members. This investigation highlights a need for guidelines on management of streptococcal and other infectious disease outbreaks in team sport settings.

Definition of an algorithm for the management of common skin diseases at primary health care level in sub-Saharan Africa

In order to help primary health care (PHC) workers in developing countries in the care of common skin diseases, an algorithm for the management of pyoderma, scabies, superficial mycoses, contact dermatitis and referral of early leprosy cases (based on the identification of diseases through the presence of objective key signs, and on treatments by generic drugs) was elaborated. One thousand patients were seen by trained dermatologists, who established diagnoses and treatments; in addition, there was systematic recording of each key sign, according to the successive algorithm steps. We compared the diagnostics and treatments obtained for several combinations of diagnostic signs, with those of the dermatologists. Sensitivity, specificity, positive predictive value and negative predictive value of defined combinations were high for pyoderma, scabies and superficial mycoses. Values were less exact for dermatitis and leprosy, but were considered sufficient for the level of health care targeted. The apportionment of treatments between the algorithm and the dermatological approaches was considered appropriate in more than 80% of cases; mismanagement was possible in 7% of cases, with few predictable harmful consequences. The algorithm was found satisfactory for the management of the dermatological priorities according to the standards required at the PHC level.

Methicillin-resistant Staphylococcus aureus in community-acquired pyoderma

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is an important nosocomial pathogen. It can also cause community-acquired infections. Indian reports about MRSA in community-acquired infections are rare.

AIM

To evaluate the rate of MRSA in community-acquired pyoderma and the nasal colonisation with S. aureus in such patients.

METHODS

Two hundred and fifty patients with community-acquired pyoderma, who attended outreach camps around Mangalore, south India between January 2000 and July 2001, were studied. Swabs collected from the skin lesions and anterior nares were inoculated onto blood agar and MacConkey's agar. Antimicrobial sensitivity testing was performed using Kirby-Bauer disk diffusion, agar dilution, and agar screen.

RESULTS

Of 250 pyoderma cases, S. aureus was isolated from 202 (80.8%) patients. Twenty-two (10.9%) S. aureus isolates were methicillin resistant, 179 (88.6%) were resistant to penicillin, and 114 (56.4%) were resistant to erythromycin. S. aureus colonization in the anterior nares was observed in 136 (54.4%) cases, 11.8% of which were MRSA. Antibiograms of clinical isolates of S. aureus matched with nasal isolates in 99 (49%) cases.

CONCLUSION

The emergence of MRSA in the community is a warning. A high nasal carriage rate may contribute to recurrent pyoderma. A correct antimicrobial policy and the avoidance of inappropriate antimicrobial usage are mandatory to reduce the spread of MRSA in the community.

Pattern of pediatric dermatoses in a referral center in South India

This study was undertaken to determine the pattern of dermatoses in children in south India. All children <14 years presenting to us between May 2001 and June 2002 were recruited. A total of 2100 children (males -995; females- 1105) with 2144 dermatoses were recorded. Infections and infestations were the most common dermatoses (54.5%) followed by dermatitis and eczema (8.6%), pigmentary disorders (5.7%), insect bite reaction (5.27%), hair and nail disorders (5.2%), miliaria (4.1%), nutritional deficiency disorders (2.8%), urticaria (2.5%), genetic disorders (2.1%), psoriasis (1.4%), collagen vascular disorders (0.5%), hemangiomas (0.5%), drug eruptions (0.3%), pityriasis rosea (0.2%) and others (5.8%). Pyodermas were the most common dermatoses (47.13%) followed by scabies (30.6%) amongst infections and infestations. Atopic dermatitis was noticed only in 3 patients. Insect bite reactions (papular urticaria) (5.27%) and miliaria (4.1%) were attributed to the tropical weather conditions in this coastal area. Genetic disorders including ichthyosis and palmoplantar keratoderma contributed to 2.1% of cases and could be due to the high incidence of consanguinous marriages in this society.

Antimicrobial resistance in staphylococci from canine pyoderma: a prospective study of first-time and recurrent cases in Sweden

In a prospective study involving eight veterinary clinics during 1995 and 1996, samples from first-time and recurrent cases of canine pyoderma were collected by a needle technique. Three hundred and ninety-four staphylococci were isolated and their susceptibility to various antimicrobial drugs was assessed by a microdilution technique. Resistance to macrolides, lincosamides, fusidic add, tetracycline and streptomycin was significantly more common in isolates from the recurrent cases than from the first-time cases; 20 per cent of the isolates from the first-time cases were resistant to three or more of the antimicrobials tested, compared with 45 per cent of those from the recurrent cases. Coresistance between macrolide-lincosamides, tetracyclines and streptomycin was common. No resistance to penicillinase-stable beta-lactams was observed. A comparison with earlier studies indicated that there had been a marked increase in resistance during the previous five years.

Pyoderma among Hajj Pilgrims in Makkah

OBJECTIVE

Bacterial skin infections have been considered as a possible health problem of the Hajj pilgrims. Significant increase in the rate of resistance to commonly used antibiotics against gram positive organisms has been observed. The present study was planned to obtain the microbiological profile of bacterial skin infections and their susceptibility to antimicrobials.

METHODS

Pyodermas were investigated clinically and bacteriologically by a prospective study conducted on patients attending the dermatology clinic at the King Faisal Hospital, Makkah, Kingdom of Saudi Arabia during 2 Hajj periods (2000 - 2001).

RESULTS

Of a total of 80 pyoderma patients, 52.5% were primary and 47.5% secondary. The leading cause of primary pyoderma was found to be impetigo in 28.8% cases, and of secondary pyoderma was infected eczema in 18.8% cases. Positive cultures were found in 87.5% cases. The organisms responsible for primary pyoderma were: Staphylococcus aureus (65.6%), Streptococcus pyogenes (28.1%) or both (6.4%) while in secondary pydermas were: Staphylococcus aureus (44.7%), Streptococcus pyogenes (15.8%), or both (18.4%), and gram negative bacilli (21.1%). The resistant pattern of antimicrobials against Staphylococcus aureus was as follows: penicillin 80.85%, tetracycline 10.6%, gentamicin 6.4%, erythromycin 4.3% and cotrimoxazole [corrected] 4.3%. Oxacillin and cephalothin were found least resistant (2.1%).

CONCLUSION

Pyoderma appeared as one of the common health hazard of our Hajj pilgrims. Penicillin and tetracycline are found ineffective in treating skin infections caused by Staphylococcus aureus while oxacillin is recommended as first line of treatment.

A nursery outbreak of Staphylococcus aureus pyoderma originating from a nurse with paronychia

An outbreak of methicillin-susceptible Staphylococcus aureus pyoderma occurred in the nursery of a tertiary-care referral center. All strains retrieved from the outbreak, including one from a nurse's infected finger, were typed by arbitrarily primed polymerase chain reaction and automated ribotyping. The results indicated that the spread of the outbreak was probably facilitated by contamination of the nurse with paronychia.

Bacterial skin infections in a tropical environment

The subject of bacterial skin infection in the tropics has shown some significant advances in the past few years, although it is still relatively understudied. Of special interest is the emerging concern about the public health aspects of pyoderma, either primary or secondary to scabies, in developing countries. In addition, certain more unusual agents, such as Bacillus anthracis and Corynebacterium diphtheriae, continue to cause significant problems in some areas, while incidence of other tropical diseases, such as endemic treponematoses, has largely dropped.

Contrasting molecular epidemiology of group A streptococci causing tropical and nontropical infections of the skin and throat

Disease caused by group A streptococci (GAS) in tropical regions often takes the form of impetigo, whereas pharyngitis tends to predominate in temperate zones. GAS derived from asymptomatic throat infections and pyoderma lesions of rural Aboriginal Australians were evaluated for phylogenetic distant emm genes, which represent ecological markers for tissue site preference. On the basis of the percentage of total isolates from a given tissue, emm pattern A-C organisms exhibited a stronger predilection for the throat, whereas pattern D organisms preferred the skin. Only 16% of isolates collected by active surveillance displayed pattern A-C, which reflects the low incidence of oropharyngeal infection. Importantly, most (70%) pattern A-C organisms were isolated from skin sores, despite their innate tendency to infect the throat. Combined with findings from nontropical populations, analysis of the data supports the hypothesis that GAS tissue preferences are genetically predetermined and that host risk factors for infection strongly influence the differential reproduction of individual clones.

Skin infections and infestations in Aboriginal communities in northern Australia

The most important skin infections in Aboriginal communities in central and northern Australia are scabies and streptococcal pyoderma. Scabies is endemic in many remote Aboriginal communities, with prevalences in children up to 50%. The cycles of scabies transmission underlie much of the pyoderma. Up to 70% of children have skin sores, with group A streptococcus (GAS) the major pathogen. Group A streptococcus is responsible for the continuing outbreaks of post-streptococcal glomerulonephritis and acute rheumatic fever (ARF). The cycles of scabies transmission in dogs and humans do not appear to significantly overlap. Guidelines have been developed for community control of scabies and skin sores and successful community initiated coordinated programmes have occurred. The anthropophilic dermatophyte Trichophyton rubrum is ubiquitous in many communities, again reflecting living conditions. Other skin infections related to the tropical environment include melioidosis, nocardiosis, Chromobacterium violaceum and chromoblastomycosis. Sustainable and long-term improvements in scabies, skin sores and GAS-related disease and tinea require fundamental changes that address social and economic inequities and, in particular, living conditions and overcrowding.

Bacterial skin infections at a tertiary dermatological centre

BACKGROUND

Bacterial skin infections are common clinical problems encountered in most fields of clinical medicine. Staphylococcus aureus and group A streptococci are common invaders of eczematous, traumatised or immunocompromised skin. Advances in pharmacology have introduced a wide array of new antibiotics into the physician's armamentarium, but the rising incidence of bacterial resistance continues to be a problem. A retrospective study was carried out on 331 patients at the National Skin Centre, Singapore, to establish the causes of common primary and secondary pyodermas, as well as to determine the antibiotic sensitivities of the microorganisms responsible.

METHODS

A retrospective study of the medical records of 331 patients seen at the Centre for skin infections between October 1995 and May 1996 was done. Skin cultures and antibiotic sensitivity testing was carried out and the data analysed. Both primary pyodermas (impetigo, folliculitis, furuncles/carbuncles and cellulitis) and secondary pyodermas (infected ulcers and infected eczemas) were included. The results of bacterial isolation cultures and sensitivity of the organisms isolated to the commonly used antibiotics such as cloxacillin, penicillin, erythromycin and the tetracyclines were analysed.

RESULTS

Staphylococcus aureus was the commonest organism isolated from both primary and secondary pyodermas, accounting for 67% and 46.7% of the organisms isolated, respectively. There was no significant difference in the racial representation in each of the various skin infections, but there was a significantly greater female representation in the infected ulcers. The secondary pyodermas had a significantly higher incidence of gram negative organisms causing infections, as well as culture results showing multiple bacterial pathogens. The methicillin resistant strains of S. aureus were commoner in the secondary pyodermas, and accounted for 4.2% of the total organisms isolated and 7% of the total strains of S. aureus. The S. aureus had a high rate of resistance (89.5%) to penicillin and ampicillin, but was very sensitive (93%) to cloxacillin, cephalexin and cotrimoxazole. The incidence of erythromycin resistance was 18.7%.

CONCLUSIONS

In patients with primary pyodermas, cloxacillin should be the first line antibiotic used, with erythromycin as a useful but less preferred alternative. The favoured combination of ampicillin and cloxacillin has little place in routine treatment of skin infections, except for cellulitis and infected eczemas. A cephalosporin can also be used in these conditions if single drug therapy is desired. The secondarily infected ulcers are difficult to treat and would probably require the use of combination therapy in view of frequent mixed infections.

Phylogenetic analyses of Staphylococcus based on the 16S rDNA sequence and assignment of clinical isolates from animals

The nucleotide sequences of the 16S rDNA in 17 strains of 16 taxa of the genus Staphylococcus were determined. The sequences were compared phylogenetically together with the gene sequences of 10 (including 7 other species) Staphylococcus species retrieved from the DNA Data Bank of Japan. Although the primary and secondary structures of most of Staphylococcus species were very similar (homology values 96.4% or more) except for S. caseolyticus MAFF 911387T (homology values 95.4% or less), the 23 staphylococcal species were divided into 10 groups based on similarity, evolutionary distance and phylogenetic tree analysis. Nucleotide stretches in several variable domains in the 16S rDNA sequences appeared to be specific for the bacterial groups or the species. By comparing such characteristics in the sequence and phylogenies of 5 staphylococcal clinical isolates from bovine mastitis, canine and feline pyoderma, and feline urogenital syndrome with the information obtained in this study, the species level of each organism was identified.

Skin diseases of children in Mali: a public health problem

In order to estimate the importance as a public health problem of skin diseases, we investigated the prevalence and severity of skin diseases in a representative sample of children in Mali. 1817 children were randomly selected in 30 clusters by probability-proportional-to-size sampling in Koulikoro region. The mean prevalence (+/- 2 SD) of skin diseases was 34 +/- 4%. The most frequent dermatoses were pyoderma (12.3 +/- 1.6%), tinea capitis (9.5 +/- 2.5%), pediculosis capitis (4.7 +/- 1.4%), scabies (4.3 +/- 1.5%), and molluscum contagiosum (3.6 +/- 1%). The most troublesome dermatoses were scabies and severe pyoderma. Pyoderma was the only dermatosis associated with poor individual or household hygiene. Public health services were little used by the population for skin diseases, probably because of the lack of an adequate response by the services and the high cost of treatment. The high prevalence and the severity of many of the lesions, and the discomfort caused, make pyoderma and scabies a significant public health problem in Mali.

Multiple strains of Streptococcus pyogenes in skin sores of aboriginal Australians

A molecular technique (random amplification of polymorphic DNA) was used to characterize group A streptococcal (GAS) strains among 194 isolates from 55 swabs from 12 Australian Aboriginal children and adults with multiple pyoderma lesions. Ninety-three percent of the lesions contained only one strain of GAS, but 8 of 12 individuals were infected with more than one strain. We conclude that accurate epidemiologic surveys require that more than one swab specimen be obtained from each person, whereas typing of more than one colony per swab is less informative. Characterization of GAS strains by random amplification of polymorphic DNA analysis should help to provide important insights into the epidemiology of GAS, particularly in tropical populations where many isolates are M nontypeable, and into the mechanisms of genetic variation of GAS in such populations.

Group A streptococcal infection in an aboriginal community

OBJECTIVE

To determine whether group A streptococcal infection and poststreptococcal sequelae are still a significant health issue for Aboriginal communities.

DESIGN

A cross-sectional survey of streptococcal carriage, infection and antibody levels.

SETTING

A north Queensland Aboriginal community.

PARTICIPANTS

One hundred and twenty preschool and school-aged children (2 to 12 years of age) living in the Lockhart River Community on Cape York Peninsula.

RESULTS

Pyoderma was present in 43% of the children and in 76% of these culture of skin lesions grew group A streptococci. Group A streptococci also grew from 13% of throat swabs, making a total of 36% of children culture positive. Anti-streptolysin O and anti-DNAase B levels were remarkably high and increased with age.

CONCLUSIONS

The evidence presented confirms a high level of group A streptococcal carriage and infection in children of the Lockhart River Community. Further investigation of this problem is warranted in other Aboriginal communities with a view to instituting appropriate control programs.

Scabies and Pyoderma in Lilongwe, Malawi. Prevalence and seasonal fluctuation

From January 1988 to June 1989, data were collected daily on the patients who were seen at the Dermatology Clinic attached to the Kamuzu Central Hospital, Lilongwe, Malawi. Cases were diagnosed and patients were treated under the supervision of a dermatologist. A total of 34,002 patients were seen during the study period. Of these patients, 15,526 (45.7%) were children and 18,476 (54.3%) were adults. The prevalence of scabies was 40.4% in children and 31.6% in adults, whereas the prevalence of impetigo/bacterial skin infections was 26% in children and 10.4% in adults. Based on data accumulated for periods of 1 month, the incidence rate of scabies was highest during the cold, dry season (May-November) and the incidence rate of skin infection was highest during the hot, rainy season (December-April). Since the patients who were studied lived predominantly in rural settings, an explanation for the higher incidence rate of scabies during the cold season could be close body contact resulting from the overcrowding within the houses. The reason for the increase in the incidence rate of pyoderma during the rainy season might be linked to deficiencies in hygienic precautions. A community-based intervention strategy with children as its target population is proposed to combat these diseases.

The epidemiology of pyoderma in Jamaican children

Preschool and school-aged children from a small area of rural Jamaica were examined in an attempt to assess the epidemiologic factors predisposing certain persons to pyoderma. Twenty-three children were included in the affected group; their disease consisted of secondarily infected insect bites or infestations as well as primary pyoderma. The control group was composed of twenty-three children who had no evidence of infected skin disease. Comparison of the two groups revealed a significant difference in the socioeconomic status of the control and study groups. There was no statistically significant difference in nutritional status, size of family, bathing frequency, or water supply.

Scrum kidney: epidemic pyoderma caused by a nephritogenic Streptococcus pyogenes in a rugby team

In December, 1984, an outbreak of pyoderma affected five scrum players in the St Thomas' Hospital rugby team. The causative organism, Streptococcus pyogenes, was acquired during a match against a team experiencing an outbreak of impetigo, and was transmitted to two front row players of another team a week later, and to two girlfriends of affected St Thomas' players a month later. The strain was M-type 49, tetracycline-resistant, and virulent. It caused salpingitis in a girlfriend and acute glomerulonephritis in one rugby player. No case of subclinical glomerulonephritis was detected in eight patients with pyoderma. Screening of the St Thomas' Hospital team revealed four further cases of non-streptococcal skin infection, with evidence for contemporaneous spread of Staphylococcus aureus. Teams should not field players with sepsis, and it may be advisable to apply a skin antiseptic to traumatised skin after the match.

Resurgent yaws and other skin diseases in the Western Province of the Solomon Islands

A clinical study of the extent and nature of skin disease was undertaken among 10,224 Melanesians in the Western Province of the Solomon Islands. It was performed concurrently with a survey and selective mass treatment campaign for yaws which has reappeared in the area for the first time in 20 years. For children under 15 years old, prevalence rates for pyoderma and infectious yaws were 52% and 8.5%, respectively. Tinea versicolor was the commonest superficial dermatomycosis affecting nearly half of all adults seen. Glabrous skin (16% of all cases) and nails (25% of all cases) were the principle sites infected by the dermatophytes. Tinea imbricata, whilst uncommon, was restricted to small endemic foci. Pediculosis capitis was universal but scabies was present in only 4% of young children. Unfavourable environmental conditions and misconceptions about personal hygiene are important aetiological determinants. Education and motivation at a village level will be the mainstay of future control with specific therapy generally reserved for treponematoses, extensive dermatophytoses and scabies.

Epidemiologic approach to community dermatology

A survey on communicable dermatoses in economically weak villages in India showed wide variations in prevalence rates in similar ecologic setup. A skin diseases, on-spot-treatment, 1-day-camp was organized to treat 1787 subjects in five villages. Two applications of 1% lindane 1 week apart was the only treatment used without attending to hygiene for scabies and pediculosis. Application of 1% gentian violet with four daily doses of sulfamethoxy-pysidazine was administered for pyoderma. The cure rate for scabies and pediculosis was 86%. Epidemiologic determinants of communicable dermatoses are the most important factors in the practice of community dermatology.

Pediatric skin disease in Pakistan. A study of three Punjab villages

The population of children younger than 5 years old in three widely distributed villages in Punjab, Pakistan, was examined for skin disease in November 1980. Approximately 29% of the children had infectious skin disease, with pyoderma the predominant diagnostic category. There were significant differences in pyoderma prevalence rates between villages, with the suppressive effect of malathion spraying for malaria control on the insect population representing the most likely explanation for the observed differences. These data again emphasize the amount of skin disease, particularly in children, in rural areas of the lesser developed countries, and the desirability of focusing attention on the dermatologic needs of this vast sector of the world's population.

Epidemiology and control of staphylococcal pyoderma among newborn infants: evaluation of a method for routine cord care with 4 per cent chlorhexidine-detergent solution

The incidence and types of staphylococcal purulent lesions were prospectively studied among 3602 newborn infants. During an epidemic of post-discharge pyoderma, 87 per cent of all Staphylococcus aureus isolates from lesions could be traced to the nursery. The risk of post-discharge disease was related to the degree of staphylococcal skin colonization in the nursery. A method for routine cord care in the nursery with 4 per cent chlorhexidine-detergent solution was evaluated and proved to be effective in reducing staphylococcal colonization in the nursery as well as purulent skin disease at home. The clinical effectiveness of the regimen was followed up for 19 months and a persistent low infection rate was obtained among infants in the post-discharge period.

A three-year streptococcal survey among Singapore school children: Part II. Streptococcal infections

The cumulative streptococcal pyoderma and pharyngitis rates of 491 children followed over a period of three years were 19.8 and 15.7% respectively. Streptococcal infections occurred more commonly in Malays, in children from families with monthly household incomes of less than $500/- and in those living in attap/zinc-roofed houses. During the three years, streptococcal pyoderma and pharyngitis rates varied from 1.6-5.3 and 0.4-4.3% respectively. Skin sores occurred most frequently on lower limbs. About one in six acquisitions of streptococci in throats was accompanied by clinical manifestations of respiratory infections. 90.9% of pyoderma cases responded to penicillin therapy. Penicillin was effective in eradicating group A streptococci from the throats of 84.6% of 136 children with previous positive cultures. The treatment schedule implemented for School C did not seem to reduce the streptococcal infection and carrier rates in that school to a great extent.