MINNEAPOLIS (FRONTLINE MEDICAL NEWS) – A large single-site case review found that most pediatric patients with staphylococcal scalded skin syndrome (SSSS) had a classic presentation, often preceded by an upper respiratory tract infection.

In the review, surgical debridement increased hospital length of stay, and the use of clindamycin gave none of the benefit that might be expected from an antitoxin-specific antibiotic, according to Carmen Liy-Wong , MD, a pediatric medicine fellow at the Hospital for Sick Children in Toronto.

All children in the 84-patient study had a skin rash, which was also the first symptom noticed for 94% of the patients (n = 79). All children also had the classic SSSS clinical signs of skin erythema and exfoliation or desquamation; most (88%, n = 74) had skin tenderness. In more than half of the children in the study, erythema, exfoliation, and bullae formation first presented on the head or neck.

Dr. Liy-Wong presented her findings at the annual meeting of the Society for Pediatric Dermatology. She and her collaborators used a retrospective chart review to develop the largest case series to date of SSSS in pediatric hospitalized children to describe both the clinical presentation of SSSS and antimicrobial use and susceptibilities. Study objectives, she said, included identifying the clinical characteristics of children with SSSS, as well as identifying management practices and associated outcomes for hospitalized children with SSSS.

Of the 84 patients who met inclusion criteria, 49 (58%) were male, and the mean age at SSSS diagnosis was 3.1 (plus or minus 2.4) years. Children, aged 0-18 years, were included if they had a clinical diagnosis of SSSS. Children with localized exfoliative staphylococcal infections, such as bullous impetigo, were excluded from the study.

In addition to erythema, exfoliation, and bullae formation, most children also had a history of skin tenderness (68%, n = 79); a little over a third had a history of fever or pruritus (38%, n = 32 for both). Thirty-five of the children (42%) had an upper respiratory tract infection in the 2 weeks preceding the SSSS diagnosis.

Facial edema, perioral or periocular crusting, and vesicles or bullae were seen in more than half of children. A few patients had conjunctivitis (11%, n = 9), mucous membrane involvement (5%, n = 4), or a sandpaper-like scarlatiniform rash (11%, n = 9).

No patients in the study died. Complications were rare: shock syndrome in one patient, and generalized bacteremia in three patients (4%).

Pain management was a mainstay of inpatient care for children with SSSS; 75 children (89%) required pain medication, and opioids were used in more than half. One in five children received morphine by continuous intravenous infusion.

Patients who underwent surgical debridement stayed a mean 5.8 (plus or minus 4.1) days, compared with a mean 3.6 (plus or minus 2.1) days for those children not receiving debridement (P = 0.03).

The study also aimed to identify antibiotic resistance patterns for SSSS in the single-site study population. Blood cultures were obtained from all but five patients and were positive in three patients. Bullae were cultured in 28 patients (33%), and periorificial lesions were cultured in 57 patients (68%). Throat cultures were obtained in 31 patients, but culture results were not reported.

“Periorificial cultures were more useful than other sites in identification of the causative organism,” Dr. Liy-Wong noted, since 74% (42 of 57) of periorificial cultures were positive. In all, 50 of 195 cultures (26%) were positive for Staphylococcus aureus. Almost all of the 50 isolates (98%, n = 49) were sensitive to oxacillin. Just under half of isolates were sensitive to clindamycin (48%, n = 24,) and erythromycin (46%, n = 23).

The use of clindamycin, an antibiotic known to be effective in inhibiting exotoxin production by staphylococcus species, was not associated with reduced hospital length of stay (P = .63 for comparison with nonantitoxin antibiotics). Dr. Liy-Wong and her collaborators noted that “no statistically significant difference in outcomes was found in patients treated with specific antitoxin medication (clindamycin),” a practice that requires further study.

SSSS was diagnosed by dermatologists in 35 of the 84 cases, followed by emergency department physicians in 29 cases (34%), pediatricians in 16 cases (19%), and family physicians in 4 cases (5%).

Dr. Liy-Wong and her colleagues reported no external sources of funding, and no conflicts of interest.

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