Bacterial superinfection of chicken pox: Best antibiotic to use? Joshua Burns & Megan Collins

Paediatric varicella hospitalisations in France: a nationwide survey1 1575 patients hospitilised between March 2003 and July 2005 From 200 paediatric wards across France Median age was 2 years, 87.5% were <5 years, and 2.7% were neonates Based on national surveillance network data Results Skin/soft tissue infection was most common complication (36.5%) Other common complications: Neurologic (8.1%), febrile seizures (6.4%), bacterial pneumonia (3.1%), ENT (2.9%), varicella pneumonia (2.4) In order to better estimate the burden of paediatric hospitalisations caused by varicella in France, a national surveillance network was established. The present report presents a descriptive analysis of the results of surveillance for the first 2 years. Each patient admitted for ongoing varicella and/or complications or events attributed to varicella was recorded. Hospitalisations unrelated to varicella, and conditions with an onset of varicella >5 days after admission, were excluded. Skin/soft tissue included cellulitis, abscess, necrotizing skin lesion, scalded skin syndrome and necrotizing fasciitis Most common neuro complications were cerebellitis and encephalitis

Results (continued) A pathogen was identified in 268 cases of skin/soft tissue superinfection 158 were Staphylococcus Aureus (59%) 88 were Group A Beta-haemolytic streptococci (33%) 14 were Staph. Aureus + Group A strep (5%) 97% cases were Staph. Aureus or Group A Strep. Strengths Weaknesses Correct demographics (age-range, hospitilised) Retrospective study Sufficient sample size Methods for how organism was determined are unclear in paper Recorded all complications Remaining 3% including Staphylococcus epidermidis, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis

Disease manifestations and pathogenic mechanisms of Group A Streptococcus2 Narrative review American Society for Microbiology – Clinical Microbiology Reviews ‘Group A Strep remains exquisitely and universally sensitive to penicillin’ Suggests use of beta-lactam antibiotics for group A strep Clindamycin, macrolides and cephalosporins all also appropriate Slection bias?

Skin infections that have progressed to bacteraemia Antimicrobial Activities of Ceftaroline and Comparator Agents against Bacterial Organisms Causing Bacteremia in Patients with Skin and Skin Structure Infections in U.S. Medical Centers, 2008 to 20143 Bacteria collected as part of Assessing Worldwide Antimicrobial Resistance Evaluation (AWARE) Skin infections that have progressed to bacteraemia In adult population Included 670 Staph. Aureus and 138 Beta-haemolytic Streptococci Not accounting for local resistance profiles

Staphylococcus Aureus (670) Beta-haemolytic streptococci (138) Antibiotic % Susceptibility Ceftaroline 97.9 Ceftriaxone 49.4 Oxacillin Clindamycin 82.4 Daptomycin 99.7 Erythromycin 39.0 Levofloxacin 59.0 Linezolid 99.9 Tetracycline 95.8 Tigecycline 100 Vancomycin Beta-haemolytic streptococci (138) Antibiotic % Susceptibility Ceftaroline 100 Ceftriaxone Penicillin Clindamycin 84.8 Daptomycin Erythromycin 71.0 Levofloxacin 99.3 Linezolid Tetracycline 44.9 Tigecycline Vancomycin Oxacillin, most similar to flucloxacillin – resistant to penicillinase commonly produced by staph aureus

Staphylococcus Aureus (584) Skin and soft tissue infections in Latin American medical centers: four-year assessment of the pathogen frequency and antimicrobial susceptibility patterns4 Antimicrobial susceptibility of isolates collected from skin and soft tissue infections during the first 4 years (1997-2000) of the SENTRY Antimicrobial Surveillance Program Staphylococcus Aureus in 32.8% Staphylococcus Aureus (584) Antibiotic % Susceptibility Penicillin 5.3 Co-amoxiclav 71.6 Tetracycline 71.2 Linezolid, daptomycin and vancomycin again showed 100% efficacy against staph aureus. Not first line though

Chickenpox in adults - Clinical management5 “Secondary bacterial infection with Staphylococcus aureus or Group A Streptococci is a common complication of chickenpox … treatment with appropriate antibiotics, such as flucloxacillin, co-amoxiclav or a macrolide should be considered.’’ anecdotal

Conclusions Superinfected chicken pox lesions most likely to be Group A Streptococcus or Staphylococcus Aureus Literature consensus is that Group A strep. is susceptible to penicillin antibiotics, including co-amoxiclav Co-amoxiclav seems to be good choice for most but not all of Staph. Aureus strains Could argue that clindamycin could be added in for their additional cover and as they are protein synthesis inhibitors, they reduce the effect of the toxins produced by the organisms, lowering risk of toxic shock or scalded skin

References 1 Grimprel E, Levy C, de La Rocque F, Cohen R, Soubeyrand B, Caulin E, Derrough T, Lecuyer A, d'Athis P, Gaudelus J. Paediatric varicella hospitalisations in France: a nationwide survey. Clinical microbiology and infection. 2007 May 1;13(5):546-9. 2 Walker MJ, Barnett TC, McArthur JD, Cole JN, Gillen CM, Henningham A, Sriprakash KS, Sanderson-Smith ML, Nizet V. Disease manifestations and pathogenic mechanisms of group A Streptococcus. Clinical microbiology reviews. 2014 Apr 1;27(2):264-301. 3 Sader HS, Flamm RK, Mendes RE, Farrell DJ, Jones RN. Antimicrobial activity of ceftaroline and comparator agents tested against bacterial organisms causing bacteremia in patients with skin and skin structure infections in United States medical centers (2008-2014). Antimicrobial agents and chemotherapy. 2016 Feb 8:AAC-02794. 4 Sader HS, Jones RN, Silva JB, SENTRY Participants Group. Skin and soft tissue infections in Latin American medical centers: four-year assessment of the pathogen frequency and antimicrobial susceptibility patterns. Diagnostic microbiology and infectious disease. 2002 Nov 30;44(3):281-8. 5 Tunbridge AJ, Breuer J, Jeffery KJ. Chickenpox in adults–Clinical management. Journal of Infection. 2008 Aug 31;57(2):95-102.