[Genetically confirmed nosocomial transmission of staphylococcal scalded skin syndrome between two infants in the neonatal intensive care unit]

We report two consecutive cases of staphylococcal scalded skin syndrome (SSSS) in our neonatal intensive care unit (NICU). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from skin swabs. An epidemiological survey conducted on the NICU staff, isolated MRSA from nasal swabs of three personnel. Gene analysis of these five isolates using pulsed-field gel electrophoresis (PFGE) of the bacterial genome and polymerase chain reaction (PCR) for a panel of toxin genes encoded two patient-derived isolates of exfoliative toxin B (ETB) considered to be identical based on the spectrum of toxin genes encoded and PFGE patterns. Three staff-derived isolates did not, however, encode ETB and showed different repertoires of toxin genes and PFGE patterns from those of the two patient-derived isolates. Nasal application of mupirocin to all carriers successfully eradicated MRSA. Horizontal transmission of ETB-producing MRSA between the two patients in the NICU was confirmed, but no NICU personnel carried the same isolate. We therefore wish to emphasize the importance of strict standard and contact precautionary measures and the monitoring of MRSA in the NICU, together with the usefulness of gene analysis using PFGE and PCR as epidemiological tools.

[Neonatal staphylococcal epidermolysis due to maternal-fetal transmission]

INTRODUCTION

The staphylococcal scalded skin syndrome (SSSS) is due to exfoliative toxins A or B excreted by some strains of Staphylococcus aureus. This syndrome is exceptional in the first hours of life. We report a case of SSSS due to materno-fetal infection.

CASE REPORT

At 31 weeks of pregnancy a 40-year-old mother was febrile (39 degrees C) and a premature rupture of the amniotic sac occurred the following day. SSSS was diagnosed at 6 hours of life in the newborn, a 1760 g female. Staphylococcus aureus grew on the blood and vaginal bacterial cultures of the mother, as well as, from cultures of skin, nose, throat, and umbilical catheter in the newborn. The strains of Staphylococcus aureus isolated in the mother and the child had identical characteristic antibiotype and genotype by Random-PCR. The genes for both exfoliations A and B were present. Epidermization was rapidly obtained and no septicemia or septic complication was noted.

DISCUSSION

Staphylococcus aureus is usually responsible for nosocomial infections which occur in the early newborn period. In most cases, the infection is transmitted by a carrier who manipulates the child (family, visitors, nurse or medical staff). In our case, onset of SSSS early after birth suggested a perinatal transmission, due to lower genital tract infection in the mother. The presence of SSSS in the child and not in the mother may be explained by a massive perinatal infection and low elimination of the toxin in the newborn resulting in higher concentrations of exfoliative toxins in the blood.

Molecular epidemiology of staphylococcal scalded skin syndrome in premature infants

BACKGROUND

Outbreaks of nosocomial staphylococcal scalded skin syndrome (SSSS) in infants have been well-described associated with the well baby nursery or delivery room. We describe two cases of SSSS in very low birth weight infants in a neonatal intensive care unit (NICU) and the success of infection control strategies used to prevent an outbreak.

METHODS

Staphylococcal scalded skin syndrome was diagnosed in two infants in the NICU: Case I (a 47-day-old, formerly 530-g female); and Case II diagnosed 48 h later (a 41-day old, formerly 706-g female). Multiple infection control measures were implemented: (1) isolation and intravenous antibiotic treatment of cases; (2) placement of exposed infants into a cohort; (3) prophylactic mupirocin treatment of the anterior nares of all infants in the NICU and staff colonized with Staphylococcus aureus; and (4) personnel hand washing with hexachlorophene. Detection of exfoliative toxin A and studies to determine the genetic relatedness of S. aureus strains isolated from patients and staff were performed.

RESULTS

In addition to the two SSSS cases, S. aureus was isolated from 2 of 12 (17%) exposed asymptomatic infants, 2 of 20 (10%) ancillary staff, 8 of 30 (27%) nurses and 6 of 24 (25%) physicians. Exfoliative toxin A-producing strains were isolated from both cases and one asymptomatic infant. No toxin was expressed by strains isolated from staff. Pulse field gel electrophoresis demonstrated genetically identical strains of S. aureus from the two SSSS cases and the asymptomatic infant, whereas three staff members harbored strains genetically related to the case strain. Unexpectedly two additional unique clusters of genetically related S. aureus strains were identified from the surveillance cultures.

CONCLUSIONS

This report documents the rare occurrence of nosocomial SSSS attributed to transmission in the NICU among extremely low birth weight infants. Multiple infection control strategies were effective in limiting the outbreak. Molecular epidemiology investigation supported a unique S. aureus strain responsible for this event and the presence of bidirectional spread between staff and patients of non-toxin-producing strains.

Staphylococcal scalded skin syndrome in a neonate

A case of staphylococcal scalded skin syndrome in a neonate caused by mother-to-child transmission through breast-feeding is reported. Staphylococcus aureus isolates from mother and child were identified using random-amplified polymorphic DNA analysis, which is a simple and rapid method for comparing strains. This study confirms the need to avoid breast-feeding in cases of breast abscess.