More on Bullous Impetigo
In response to DesPain A. What is causing this newborn’s rash? Consultant for Pediatricians. 2016;15(6):251-253.
TO THE EDITOR:
It appears that the case of bullous impetigo was a nosoco- mial infection. The author did not comment on whether this case was reported to the hospital epidemiologist or not. The hospital epidemiologist is usually a member of the Infection Control Committee of the hospital. The pediatrician clearly should have reported this case when the diagnosis was made.
Regarding treatment, in mild cases such as this, mupirocin is effective in treating the infection. However, when an oral antimicrobial agent is required, treatment becomes more com- plicated. If methicillin-resistant Staphylococcus aureus (MRSA) is the cause, as in this case, cephalexin and dicloxacillin are not effective because MRSA is resistant to these agents.
In addition, doxycycline or any other tetracycline-like drug is contraindicated and should not be used in children under 9 years of age because of its potential deleterious ef-
fects on the teeth. Trimethoprim-sulfamethoxazole (TMP- SMX) is also not recommended in children this age. It can block the binding of bilirubin to the serum albumin and may cause an increase in the indirect component of biliru- bin, causing hyperbilrubinemia.
Clindamycin can be used, but one must be aware of certain drawbacks when using this antibiotic. For example, MRSA can rapidly develop resistance to clindamycin during the course of therapy. When the culture and sensitivities are obtained, most hospital laboratories can test for clindamycin resistance by using the simple D test on a routine basis. Furthermore, it is recommended that clindamycin be used 4 times a day, and the taste is terrible. These factors make adherence much more difficult. For serious MRSA infections treated in the hospital, vancomycin is usually the drug of choice.
Michael W. Cater, MD Pediatric and Adult Medicine in Tustin, California
In response to DesPain A. What is causing this newborn’s rash? Consultant for Pediatricians. 2016;15(6):251-253.
The case of bullous impetigo is described as secondary to circumcision. As a pediatrician who has done over 2000 cir- cumcisions over the past several decades, I very much doubt that the circumcision and the impetigo are at all connected. In the hands of a skilled clinician, using aseptic technique, there should never be any infection after this procedure.
Theodore Tapper, MD Associate Clinical Professor of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
THE AUTHOR RESPONDS:
I appreciate the feedback and the interest this article has received. In regards to Dr Tapper’s comments, circumcision remains one of the most common surgical procedures in the United States, and it is true that bullous impetigo is not a common complication of circumcisions. However, despite sterile technique, infection is always a possible complication with any procedure. Thus, it is not out of the question for bullous impe- tigo to occur postcircumcision.
A 2007 article in Clinical Pediatrics provides more informa- tion on this complication.1 According to the article, circum- cised boys are at an increased risk for staphylococcal coloniza- tion and infection. This is likely due to skin surface promptly being colonized with hospital flora after birth, which is rich with MRSA. At the time of circumcision, MRSA can gain ac- cess via disrupted epithelial barriers. Despite sterile technique employed during the procedure, infant boys’ groin areas are still subject to the nonsterile environment of the hospital and handling by families, physicians, and nurses while the surgical site is still fresh.
In addition, a chapter of Remington and Klein’s Infectious Dis- eases of the Fetus and Newborn delineates postcircumcision cases of bacteremia, staphylococcal scalded skin syndrome, necrotiz- ing fasciitis, and bullous impetigo.2
Moreover, an article in Pediatric Infectious Disease demon- strated multiple cases of impetigo following circumcision using the plastic bell clamp technique, even though every case was performed under sterile technique.3
I also appreciated Dr Cater’s response to the article. Bullous impetigo is treated differently for various age groups. I very much agree that mupirocin was effective in this case of bullous impetigo because the infection was limited to the groin area and was not systemic.
In the treatment section, I merely discussed general treat- ment options for bullous impetigo. I should have been more specific in listing antibiotic regimens based on age group. TMP-SMX is indeed contraindicated in children less than 2 months of age. This is due to the drug mechanism of caus- ing bilirubin displacement from albumin, leading to possible kernicterus. Additionally, tetracyclines are not prescribed to children under the age of 9 due to staining of teeth.
For bullous impetigo caused by MRSA in a neonate requir- ing oral antibiotics, I would agree with his choice of using clindamycin. Liquid clindamycin is terrible tasting and dosed 3 times a day or even 4 times a day, making it a difficult sell to any pediatric patient. However, pharmacies often flavor medi- cations for a relatively low cost to make them more palatable. And for serious resistant MRSA cases, vancomycin remains the drug of choice.
Angelica Wong DesPain, MD Children’s National Medical Center, Washington, DC
REFERENCES
1. Van Howe RS, Robson WLM. The possible role of circumcision in newborn outbreaks of community-associated methicillin-resistant Staphylococcal aureus. Clin Pediatr (Phila). 2007;46(4):356-358.
2. Overturf GD, Muller M, Nizet V. Focal bacterial infections. In: Wilson CB, Nizet V, Maldonado Y, Remington JS, Klein JO, eds. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant. 8th ed. Philadelphia, PA: Elsevier Saunders; 2016:Chap 10.
3. Stranko J, Ryan ME, Bowman AN. Impetigo in newborn male infants associated with a plastic bell circumcision. Pediatr Infect Dis. 1986;5(5):597-599.