Commentary

Cutaneous bacterial infections: Changing trends in bacterial resistance

Gita Nataraj, Sujata Baveja

Depar tment of Microbiology, Se th G. S. Medical College & K. E. M. Hospital, Mumbai, India.

Address for correspondence: Dr. Gita Nataraj, Department of Microbiology, Seth G. S. Medical College & K. E. M. Hospital, Parel, Mumbai -
400012, India. E-mail: [email protected]

Normal skin is colonized with resident bacterial flora, enterococci (VRE) and the extended spectrum beta-
usually Staphylococcus epidermidis, other coagulase- lactamase (ESBL) producing Gram-negative bacilli both
negative Staphylococci, Corynebacteria and Propionibac- in hospitalized patients and, to a lesser extent, in the
terium acnes. These bacteria form a protective layer and community are a serious cause for concern. This trend
prevent the adhesion and multiplication of potential in antibiotic resistant strains is true for infection at
pathogens. any site of the body.

Cutaneous infections arise whenever there is a break In order of frequency, Staphylococcus aureus accounts
in the continuity of the skin or as a part of systemic for 30-50% of skin and soft tissue infections, followed
infection. The spectrum of bacteria associated with by the Enterobacteriaeceae, non-fermenters, Streptococci
primary cutaneous infections has remained the same (beta-hemolytic Group A and others) and anaerobes.6,7
over the years though the frequency of their associa- On an average more than 90% of Staphylococcus aureus
tion has changed. Staphylococcus aureus, Streptococci, elaborate penicillinases or beta-lactamases (a trend
Corynebacterium spp, Erysipelothrix, Enterobacteriaeceae, seen even in community acquired strains) and 20-30%
Pseudomonas and anaerobes have been implicated in a of Staphylococcus aureus are methicillin resistant.8 The
variety of cutaneous infections with polymicrobial in- prevalence of MRSA in India is also on the rise and there
fections also being reported. The aerobic Gram-posi- are reports of detecting MRSA in community-acquired
tive cocci accounted for more than 60% of cutaneous infections though the prevalence is much lesser.9,10
infections in the 70’s. Though Staphylococcus aureus MRSA strains also demonstrate a high degree of
continues to be the predominant pathogen, Enterobac- resistance to other antibiotics especially beta-lactams,
teriaeceae, Pseudomonas and Enterococci are being in- erythromycin and aminoglycosides. This changing trend
creasingly reported.1,2 This spectrum is seen even in HIV- calls for changes in empirical therapy based on current
infected patients and intravenous drug users.3-5 susceptibility patterns. Beta-lactams or erythromycin
cannot be considered as the standard treatment options
Infections caused by antibiotic resistant strains have today, especially in hospitalized patients. A
become a global problem. The increasing prevalence combination of beta-lactam/beta-lactamase inhibitor
of multi-drug resistant organisms with few or no (amoxycillin/clavulanic acid, ampicillin/sulbactum) will
treatment options such as methicillin resistant elicit a better response. Vancomycin is considered as
Staphylococcus aureus (MRSA), vancomycin resistant the drug of choice for the treatment of infection due

How to cite this article: Nataraj G, Baveja S. Cutaneous bacterial infections: Changing trends in bacterial resistance. Indian J Dermat ol
Venereol Leprol 2003;69:375-6.
Paper Received: November, 2003. Paper Accepted: December, 2003. Sour ce of Support: Nil.

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CMYK375
Nataraj G, et al: Cutaneous bacterial infections

to MRSA but not for carriage or colonization.8 Favorable infective agent, the antibacterial profile of the
outcomes have also been reported with the use of antimicrobial agent and its pharmacokinetic properties.
teichoplanin and linezolid (an oxyzolidinone). Local A combination of beta-lactam/beta-lactamase inhibitor
eradication is usually achieved with mupirocin, may be a better option in community acquired
bacitracin or chlorhexidine. infections, whereas in hospitalized patients culture
sensitivity reports will be essential to decide on therapy.
Though there are no reports of penicillin resistant
Streptococcus pyogenes, these organisms are REFERENCES
demonstrating increasing tolerance to this antibiotic.
ESBLs are beta-lactamases that hydrolyze extended- 1. Rennie RP, Jones RN, Mutrick AH. Occurrence and antimicrobial
susceptibility patterns of pathogens isolated from skin and
spectrum cephalosporins with an oxyimino side chain.
soft tissue. Diagn Microbiol Infect Dis 2003;45:287-93.
These cephalosporins include cefotaxime, ceftriaxone, 2. Mohanty S, Kapil A, Dhawan B, Das BK. Bacteriological and
and ceftazidime, as well as the oxyimino-monobactam antimicrobial susceptibility profile of soft tissue infections
aztreonam. 11 Between 10% and 60% of from Northern India. Indian J Med Sci 2004;58:10-5.
enterobacteriaeceae associated with skin and soft 3. Manfredi R, Calza L, Chiodo F. Epidemiology and microbiology
of cellulitis and bacterial soft tissue infection during HIV
tissue infections have been reported as ESBL disease: A 10-year survey. J Cutan Pathol 2002;29:168-72.
producers.1,2,6,7 Beta-lactamase inhibitors such as 4. Bar A, Hantschke D, Mirmohammadsadegh A, Hengge UR.
clavulanate, sulbactam or tazobactam in vitro inhibit Spectrum of bacterial isolates in HIV-positive patients with
most ESBLs, but the clinical effectiveness of beta- skin and sof t tissue infections: emergence of methicillin-
resistant staphylococci. AIDS 2003;17:1253-6.
lactam/beta-lactamase inhibitor combinations cannot 5. Summanen PH, Talan DA, Strong C, McTeague M, Bennion R,
be relied on consistently for therapy. In fact, the Thompson JE Jr, et al. Bacteriology of skin and soft-tissue
therapy of choice for infections caused by ESBL- infections: Comparison of infections in intravenous drug users
producing members of the Enterobacteriaceae is a and individuals with no histor y of intravenous drug use. Clin
Infect Dis 1995;20:S279-82.
carbapenem.11 6. Gales AC, Jones RN, Pfaller MA, Gordon KA, Sader HS. Two
year assessment of pathogen frequency and antimicrobial
The presence of open skin lesions in hospitalized resistance pattern among organisms isolated from skin and
dermatology patients predisposes them to colonization soft tissue infections in L atin American hospitals: results from
the sentry antimicr obial surveillance programme, 1997-98,
with resistant organisms, which, if not adequately cared SENTRY study group. Int J Infect Dis 2000;4:75-84.
for, may lead to infection. The time is therefore apt 7. Doern GV, Jones RN, Pfaller MA, Kugler KC, Beach ML. Bacterial
not only to treat the infection and eradicate the pathogens isolated from patients with skin and sof t tissue
colonization or carriage but also to educate the patient infections: frequency of occurrence and antimicr obial
susceptibility pattern from the SENTRY antimicr obial
at the time of discharge about the appropriate use of
sur veillance programme, (US and Canada 1997), SENTRY study
antibiotics and proper wound care. This will reduce group (North America). Diagn Microbiol Infect Dis 1999;34:
the chances of dissemination of resistant pathogens in 65-72.
the community. 8. Simor AE. Containing methicillin-r esistant S. aureus.
Surveillance, control, and treatment methods. Postgrad Med
2001;110:43-8.
It is widely acknowledged that the rapidity of 9. Pulimood TB, Lalitha MK, Jesudason MV, Pandian R, Selwyn J,
development of resistance to an agent increases with Jacob T. The spectrum of antimicrobial resistance among
the magnitude of its use. Therefore newer agents methicillin resistant Staphylococcus aureus in a tertiar y care
should be used judiciously only on isolation of a center in India. Indian J Med Res 1996;103:212-5.
10. Saxena S, Singh K, Talwar V. Methicillin-resistant Staphylococcus
resistant pathogen from definite infection and not for aureus prevalence in community in the east Delhi area. Jpn J
treatment of colonization or contamination. Infect Dis 2003;56:54-6.
11. Paterson DL, Ko WC, von Gottberg A, Casellas JM, Mulazimoglu
Thus the antimicrobial options for treatment of L, Klugman KP, et al. Outcome of cephalosporin treatment for
serious infections due to apparently susceptible organisms
cutaneous infections have undergone a sea change. In
producing extended-spectrum beta-lactamases: implications
choosing the appropriate antimicrobial therapy, one for the clinical microbiology laboratory. J Clin Microbiol
must take into account the resistance profile of the 2001;39:2206-12.

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