The Rising Tide of Infectious Diseases One expert sheds light on the current state of infectious diseases in dermatology and shares insights on new data and therapies.

By Ted Pigeon, Senior Associate Editor

ational trends show that skin and soft tissue infections are on the rise in the US. Data show that there was an increase in visits for Nabscesses and cellulitis between 2001 and 2004. In general, patients 18 and younger, black patients, and patients of lower socioeconomic status were particularly likely for infection. Sixty-five per- cent of patients with infections, were treated with prescription antibiotics, and only seven to 28 percent for MRSA. Importantly, while skin and soft tissue infections appear to be increasing, the number of hospital admissions for these conditions remained unchanged. were 126,000 hospitalizations in the US for MRSA. Although infectious diseases are addressed and Of these, 94,000 cases were deemed life-threaten- treated in other specialties, practicing dermatolo- ing, resulting 19,000 deaths.1 According to Dr. gists consistently encounter a variety of infectious Tomecki, community-acquired MRSA (CAMRSA) is diseases. Therefore, it is important to follow prominent in younger patients; populations most research and media reports about local and nation- at-risk are athletes, inmates, kids in daycare, and al trends, as well as pay attention to potential new category IV drug users. therapies. At the 2009 Fall Clinical Dermatology Conference in Las Vegas, Kenneth J. Tomecki, MD, Take-Home Tips. Vice Chairman of the Department of Dermatology • Infections rates are rising in the US. at the Cleveland Clinic, shared insights on infec- • New and established therapies, especially antibiotics, can be used tious diseases and dermatology. He discussed a to treat infectious diseases successfully. range of infections and useful treatments that cli- nicians should be aware of. • New treatments include the topical antibiotic Altabax 1% and Benzyl Alchohol Lotion 5%. Skin and Soft Tissue Infections • Recent data show that corticosteroids can be safe and effective, as MRSA. One of the more hot-topic issues in media they have an ant-inflammatory effect. ● reports and in practice is MRSA. In 2005, there

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The morphology of CAMRSA infections is approximately 70 percent abscess, 15 percent furunculosis/folliculitis, and five percent cellulitis.2 The mainstay of treatment is incision and drainage.3 Antibiotics are usually not necessary, noted Dr. Tomecki, unless the patient has a large lesion (particularly in the central face), cellulitis, comorbidity, extremes of age, or previous treatment failures.4 Preferred antibiotics for MRSA infections are trimethoprim/suffamethoxyzole (TMP/SMZ), tetracyclines, especially doxycycline, vancomycin, lincosamides (clindamycin), linezolid, daptomycin, and quinopristin/Dalfopristin. Syphilis. Syphilis has been on the rise in the US Methicillin-resistant Staphylococcus aureus infection. in the last decade, despite a major decrease in the preceding two decades. Since 2001, incidence has avoidance of vaccination on religious or moral increased 57 percent, primarily in the setting of men grounds. Recent controversy over the purported having sex with men, explained Dr. Tomecki. In link between vaccines and autism, some reports developed countries, syphilis is typically transmitted have suggested, may have also contributed to these by sexual contact in individuals with multiple sexual decreasing vaccination rates. partners. Unlike HIV, oral sex is the usual route of transmission, though it also can be transmitted via New Research and Therapies recreational drug use. Penicillin is still the drug of Regarding new therapies, a new topical antibiotic is choice for primary, secondary, and latent syphilis. now available — retapamulin ointment 1% For patients allergic to penicillin, doxycycline 100 (Altabax, GlaxoSmithKline), a pleuromutilin (pteu- mgm two times per day for 14 days if the therapy of rotus mutilus) approved for the treatment of choice, Dr. Tomecki suggested. impetigo. It is indicated for individuals as young as Rocky Mountain Spotted Fever. Transmitted by nine months, and treatment is twice daily for five American dog ticks or Rocky Mountain wood ticks, days. Rocky Mountain Spotted Fever (RMSF) occurs pri- marily in the Western Hemisphere, particularly in Bacterial Infections in Biologic Therapy the US Carolinas and the Southern Central US. There have also been cases reported in Asia, Biologic agents have been scrutinized more heavily recently Europe, Africa, and Australia. The number of cases regarding safety. Among the areas of concern are bacterial infec- of RMSF has increased four-fold within the last five tions, which have long been known as potential adverse events years, its third phasic increase in the last 80 years. resulting from biologic therapy. One recent study presented Treatment is straightforward: doxycycline, or chlo- results from a nationwide survey of infectious disease consult- ramphenicol for children and pregnant women. Chloramphenicol is most effective when used with- ants to identify mycobacterial and other serious infections in in five days of having the disease. patients receiving anti-tumor necrosis factor compounds and The Measles. Surprisingly, measles is on the rise other novel targeted therapies. Researchers found that nontuber- in the US and Europe. There have also been docu- culous mycobacterial infections, histoplasmosis, and invasive mented increases in Israel and Europe. Its resur- Staphylococcus aureus infection were all reported more fre- gence is possibly related to decreasing vaccination quently than tuberculosis. rates in home-schooled children and some parents’

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At the Winter Clinical Dermatology Meeting in Hawaii in January, Ted Rosen, MD gave Table 2. % MRSA Susceptible: USA an antimicrobial update on MRSA. Among his observations, Dr. Rosen presented a list of newer MRSA drugs worth noting (Table 1). He also referenced data concerning Antibiotic CA-MRSA HA-MRSA percentages of MRSA susceptibility among various antibiotics (Table 2).5 Erythromycin 8% 4%

Table 1. Newer MRSA Drugs Levofloxacin 5-90% 12% Clindamycin 30-92% 38% Drug Class MOA Route AEs Doxycycline 86% 89% Linezolid Oxazolidinone Ribosome formation PO, IV ▲ BP Myelosuppression TMP-SMX 98% 92% Daptomycin Lipopeptide Membrane depolarizer IV Neuropathy Myopathy Linezolid 99-100% 99-100% Tigecycline Glycylcycline Binds 30S ribosome IV GI intolerance pancreaitis Vancomycin 90-99% 90-100% Quinupristin Streptogramin ▼ AA-tRNA IV Phlebitis Arthralgia New IV Drugs* -100% -100% Dalfopristin peptide bond *Daptomycin, Tigecycline, Linezolid = Zyvox® Quinupristin-Dalfoprisitin = Synercid® Quinupristin-Dalfopristin Daptomycin = Cubicin® Tigecycline = Tygacil®

Benzyl Alcohol Lotion 5% (Sciele Pharma) was ally improved survival rates for many infections, also recently approved as an alternative treatment such as bacterial meningitis, TB meningitis and of head lice in adults and children aged six months pericarditis, typhoid fever, tetanus, and PCP. and older. Benzyl alcohol coats the lice on the scalp Corticosteroids were beneficial and reduced long- and scalp hair. Application is 10 minutes, twice term disability or some, e.g. those with bacterial weekly, with a second treatment one week later. arthritis, and relieved symptoms including HIV, Studies have shown that Benzyl alcohol is safe and zoster, and cellulitis for many others. efficacious, with a 75 percent success rate. Side Corticosteroid treatment should last no longer than effects include irritation and possible numbness at three weeks. the site of application. Given the data, Dr. Tomecki concluded that sys- Corticosteroids tend to be avoided for infectious temic corticosteroids can be beneficial and safe for diseases, according to Dr. Tomecki. But a 2008 a wide variety of infectious diseases. Benefits typi- publication examining over 190 studies involving cally depend on type, amount, and duration of corticosteroids vs. placebo in the setting of antimi- treatment, but their main benefit is their anti- crobial therapy revealed that corticosteroids gener- inflammatory effect. ■

1. Moran GJ, et al. Methicillin-resistant S. aureus infections among patients in emer- Insect Info gency department. New Engl J Med. 2006; 355: 666-674. 2. Del Giudice P, et al. Emergence of two populations of methicillin-resistant It might be beneficial to explain to patients that certain bugs and Staphylococcus aureus with distinct epidemiological, clinical and biological features, isolated from patients with community-acquired skin infections. Br J Dermatol. 2006 insects carry toxins that may result in skin and infectious dis- Jan;154(1):118-24. eases. For example, imported fire ants can be either black 3. Iyer S, Jones DH. Community-acquired methicillin-resistant Staphylococcus aureus skin infection: a retrospective analysis of clinical presentation and treatment of a (solenopsis richteri) or red (solenpsis invicta) and their venom local outbreak. J Am Acad Dermatol. 2004 Jun;50(6):854-8. contain heme factors and amines. One potential treatments for 4. Paydar KZ, et al. Inappropriate antibiotic use in soft tissue infections. Arch Surg. 2006 Sep;141(9):850-4. this venom, according to Dr. Tomecki, is ammonia. 5. Diagn Microbol Inf Dis 2007; 58: 41.

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