The Microbiology of Impetigo in Indigenous Children: Associations Between Streptococcus Pyogenes, Staphylococcus Aureus, Scabies
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Bowen et al. BMC Infectious Diseases DOI 10.1186/s12879-014-0727-5 RESEARCH ARTICLE Open Access The microbiology of impetigo in Indigenous children: associations between Streptococcus pyogenes, Staphylococcus aureus, scabies, and nasal carriage Asha C Bowen1,2,3*, Steven YC Tong1,4, Mark D Chatfield3 and Jonathan R Carapetis2,3 Abstract Background: Impetigo is caused by both Streptococcus pyogenes and Staphylococcus aureus; the relative contributions of each have been reported to fluctuate with time and region. While S. aureus is reportedly on the increase in most industrialised settings, S. pyogenes is still thought to drive impetigo in endemic, tropical regions. However, few studies have utilised high quality microbiological culture methods to confirm this assumption. We report the prevalence and antimicrobial resistance of impetigo pathogens recovered in a randomised, controlled trial of impetigo treatment conducted in remote Indigenous communities of northern Australia. Methods: Each child had one or two sores, and the anterior nares, swabbed. All swabs were transported in skim milk tryptone glucose glycogen broth and frozen at –70°C, until plated on horse blood agar. S. aureus and S. pyogenes were confirmed with latex agglutination. Results: From 508 children, we collected 872 swabs of sores and 504 swabs from the anterior nares prior to commencement of antibiotic therapy. S. pyogenes and S. aureus were identified together in 503/872 (58%) of sores; with an additional 207/872 (24%) sores having S. pyogenes and 81/872 (9%) S. aureus, in isolation. Skin sore swabs taken during episodes with a concurrent diagnosis of scabies were more likely to culture S. pyogenes (OR 2.2, 95% CI 1.1 – 4.4, p = 0.03). Eighteen percent of children had nasal carriage of skin pathogens. There was no association between the presence of S. aureus in the nose and skin. Methicillin-resistance was detected in 15% of children who cultured S. aureus from either a sore or their nose. There was no association found between the severity of impetigo and the detection of askinpathogen. Conclusions: S. pyogenes remains the principal pathogen in tropical impetigo; the relatively high contribution of S. aureus as a co-pathogen has also been confirmed. Children with scabies were more likely to have S. pyogenes detected. While clearance of S. pyogenes is the key determinant of treatment efficacy, co-infection with S. aureus warrants consideration of treatment options that are effective against both pathogens where impetigo is severe and prevalent. Trial registration: This trial is registered; ACTRN12609000858291. Keywords: Impetigo, Tropical, Endemic, Staphylococcus aureus, Streptococcus pyogenes, Scabies * Correspondence: [email protected] 1Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia 2Princess Margaret Hospital for Children, Perth, Western Australia, Australia Full list of author information is available at the end of the article © 2014 Bowen et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bowen et al. BMC Infectious Diseases Page 2 of 6 Background anterior nares was obtained to determine carriage of im- Impetigo is an epidermal infection caused by Staphylococ- petigo pathogens in the context of infection. Swabs were cus aureus and Streptococcus pyogenes. It is common in collected between 26 November 2009 and 20 November Indigenous children of northern Australia, with preva- 2012. Rayon tipped cotton swabs (Copan, Italy) were lence as high as 70% [1]. The reported relative abundance transported at 4°C in 1 mL of skim milk tryptone glu- of S. aureus and S. pyogenes has varied over time [2]. In re- cose glycogen broth (STGGB) and frozen at −70°C cent decades, S. aureus and increasingly methicillin- within 5 days of collection. Swabs were defrosted, vor- resistant S. aureus (MRSA) has been the dominant re- texed and an aliquot plated on horse blood agar and in- ported pathogen in impetigo studies worldwide, most of cubated for 48 hours at 37°C [10]. S. aureus and S. which have taken place in temperate-climate regions, usu- pyogenes were identified morphologically and confirmed ally in affluent countries [3] where there is a low burden with latex agglutination. All S. aureus isolates were sta- of disease. By contrast, in tropical regions, impetigo is far phytect (Oxoid, UK) and deoxyribonuclease (DNase, BD more common, and carries the greatest burden of se- Diagnostics, USA) positive. S. pyogenes agglutinated with quelae [4]. S. pyogenes is assumed to have remained the group A Lancefield antisera (Oxoid). dominant pathogen [5] but some reports are emerging on skin and soft tissue infections caused by S. aureus [6,7]. There is limited microbiological surveillance of Antimicrobial susceptibility testing causative impetigo pathogens from high burden con- Antimicrobial susceptibility testing for S. aureus was texts and rates of antimicrobial resistance are often un- determined on the Vitek2 platform using 22359 VITEK known [5]. Impetigo is strongly associated with scabies AST-P612 cards (bioMerieux, France) with Clinical and infestation in tropical environments [8], but the influence Laboratory and Standards Institute (CLSI, 2011) break- of scabies on the microbiology of impetigo has not previ- points utilised [11]. MRSA was defined as any S. aureus ously been described. We report here on the microbiology with a positive cefoxitin screen. Non-multidrug resist- of impetigo in a high burden setting, and explore the asso- antMRSA(nmMRSA)wasdefinedasMRSAresistant ciations of this microbiology with age, sex, region, severity, to <3 additional non beta-lactam antibiotics [12]. presence of scabies and nasal carriage of skin pathogens. Multidrug-resistant MRSA (mMRSA) was defined as Our dataset derives from a large, non-inferiority rando- MRSA that was resistant to ≥3 non beta-lactam antibi- mised controlled trial (RCT) comparing trimethoprim- otics [12]. sulphamethoxazole (SXT) with benzathine penicillin G We performed susceptibility testing for S. pyogenes (BPG) for the treatment of impetigo in Indigenous chil- with penicillin, erythromycin and clindamycin discs dren [9]. using CLSI disc diffusion standards. SXT susceptibility for S. pyogenes was determined with an E test® (bioMerieux) Methods according to the European committee on antimicrobial sus- Study design ceptibility testing (EUCAST) standards (www.eucast.org, Indigenous children aged 3 months to 13 years were last accessed 15 November 2014). SXT susceptible participants in the RCT. Children were eligible to par- strains had a MIC ≤1 mg/L and resistant isolates had a ticipate on more than one occasion if at least 90 days MIC >2 mg/L. had elapsed since their last involvement. As such, 508 children from 12 remote communities of the Northern Ethics statement Territory were enrolled for 663 episodes of impetigo; This study was approved by the Northern Territory all analysis presented here has been restricted to a Department of Health and Menzies School of Health child’s first episode only. Six communities (comprising Research Human Research Ethics Committee (09/08). 463/508 children) were located in the tropical climatic Written informed consent was obtained from a child’s region, commonly referred to as the “Top End”.The parent or guardian for all study procedures. remaining communities were in Central Australia where a desert climate prevails. Children were stratified by im- petigo severity. The severe stratum included children Statistical analysis with ≥2purulentorcrustedsoresand≥5 overall body Mixed-effects logistic regression (random effects ac- sores. counting for correlated data due to multiple sores for the children in the severe impetigo strata) using Stata 13 Swabbing, transportation and culture methods (Statacorp, Texas, USA) was performed to assess associ- Each child had swabs taken from one or two sores (ac- ations between the growth of skin pathogens and the cording to whether the episode was classified as mild or presence of scabies, severe impetigo, age, sex, region and severe) prior to commencing antibiotics. A swab of the nasal carriage. Bowen et al. BMC Infectious Diseases Page 3 of 6 Results Antibiotic susceptibility Baseline microbiology results One isolate each of S. pyogenes and S. aureus were se- Sores lected per child for reporting of the antibiotic suscepti- We obtained 872 swabs of sores from 508 children with bility profile. Where possible, isolates cultured from skin untreated impetigo (median age 7 years, interquartile sores were selected, with the remainder coming from range [IQR] 5 – 9 years) at baseline. Seventy-two per- swabs of the anterior nares. cent of children were in the severe impetigo stratum, all of whom had two sores swabbed. An impetigo pathogen S. pyogenes was identified in 488/508 (96%) of children. From the There were 455 children with at least one S. pyogenes 872 sores swabbed, S. aureus and S. pyogenes were iden- isolate available for antibiotic susceptibility assessment. tified together in 503/872 (58%), S. pyogenes alone in All S. pyogenes isolates were susceptible