Epidemiological data of staphylococcal scalded skin syndrome in France from 1997 to 2007 and microbiological characteristics of Staphylococcus aureus associated strains

Abstract

Epidemiological data on staphylococcal scalded skin syndromes (SSSS), including bullous impetigo (BI) and generalized exfoliative syndrome (GES), are scarce. To better characterize SSSS and associated Staphylococcus aureus strains, we conducted a retrospective study of 349 cases collected in France between 1997 and 2007 by the National Reference Centre of Staphylococci. Our results showed a stationary evolution of SSSS cases, with a heterogeneous distribution of cases in France. Although notification was not exhaustive, we estimated an incidence of 0.56 cases/year/million inhabitants, in accordance with previous studies conducted in France and Europe, with a median age of 2 years old and sex ratios of 1. A seasonal effect was observed, with a higher GES/BI ratio in autumn compared with other seasons, which could be explained by the impact of viral co-infection. Genetic analysis of S. aureus strains showed that accessory gene regulator (agr) 4, exfoliative toxin A (eta) and B (etb) genes, staphylococcal and enterotoxin-like O (selo) gene and agr4 etb selo profiles were predominantly associated with GES, whereas agr2 eta and agr4 eta selo were more frequently observed with BI. Only one methicillin-resistant strain was found. Protein A (spa) typing identified two main genotypes: spa clonal complex (CC) 159/sequence-type (ST) 121 (75%) and spaCC346/ST15 (18%). spaCC159 was mainly associated with agr4 eta etb selo, agr4 eta selo and agr4 etb selo, and spaCC346 was mainly associated with agr2 eta, suggesting that French SSSS cases are caused by these two main lineages. However, in a multivariate analysis, only etb was independently associated with GES.

Staphylococcal scalded skin syndrome

“…It usually has a favourable course, with reported death rate of 4%,5 8 which occurs related to complications like dehydration or bacterial superinfection.

Learning points

Staphylococcal scalded skin syndrome constitutes a rare cause of skin infection mostly encountered in neonates and early childhood.

Diagnosis is usually based on clinical evaluation alone, which discloses an erythematous extensive skin rash respecting mucosa.

An appropriate antimicrobial therapy based on antistaphylococcal penicillins generally allows a favourable outcome, but a clinician must be aware of the risk of dehydration and bacterial superinfection.

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Rapid containment of nosocomial transmission of a rare community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) clone, responsible for the Staphylococcal Scalded Skin Syndrome (SSSS)

“…In newborns, lesions are often found in the diaper area, axillary folds and around the navel; the top layer of skin begins peeling off in sheets, leaving a moist, red and tender area exposed. Other symptoms may include weakness and dehydration [2–4]. …”

“…These toxins induce epidermal blistering through the cleavage of the cell-cell adhesion molecule desmoglein-1, which is only expressed by keratinocytes in the granular cell layer, leading to a spectrum of illnesses ranging from mild localized blistering to extensive generalized lesions [2, 5]. ETs producing S. aureus strains have been associated with specific genetic backgrounds, on the basis of their phage types, accessory gene regulator ( agr ) groups and macrorestriction profiles [3–10].…”

“…SSSS in newborns has been mainly reported in clonal complexes (CC) 121 and 15, carrying eta and/or etb genes [2], but also in other less common genotypes, such as ET B -positive ST91 MRSA and ET A -positive ST2993-t211 (CC8) with and without SCC mec V [11, 12]. …”

“…Approximately 5% of S. aureus strains produce exfoliative toxins, with a variable prevalence index in different countries. In Europe, the incidence of SSSS varies from 0.56 cases/million/year in France, to 2.53 cases/million/year in the Czech Republic [2, 3]. …”