Antibacterial and deodorizing effects of cold atmospheric plasma-applied electronic deodorant

Axillary odor is a malodor produced by bacterial metabolism near the apocrine glands, which often causes discomfort in an individual's daily life and social interactions. A deodorant is a personal care product designed to alleviate or mask body odor. Currently, most deodorants contain antimicrobial chemicals and fragrances for odor management; however, direct application to the underarm skin can result in irritation or sensitivity. Therefore, there is a growing interest in technologies that enable disinfection and odor control without the antiperspirants or perfumes. The cold atmospheric plasma temporally generates reactive radicals that can eliminate bacteria and surrounding odors. In this study, cultured Staphylococcus hominis and Corynebacterium xerosis, the causative bacteria of axillary bromhidrosis, were killed after 90% plasma exposure for 3 min. Moreover, the electronic nose system indicated a significant reduction of approximately 51% in 3-hydroxy-3-methylhexanoic acid and approximately 34% in 3-methyl-3-sulfanylhexan-1-ol, the primary components of axillary odor, following a 5-min plasma exposure. These results support the dual function of our deodorant in eliminating bacteria and axillary odors without the chemical agents. Therefore, cold atmospheric plasma-applied deodorant devices have great potential for the treatment and management of axillary odors as a non-contact approach without chemical use in daily life.

Estimation of the contribution to intraoperative pathogen transmission from bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen

BACKGROUND

Earlier studies showed net cost saving from anesthesia practitioners' use of a bundle of infection prevention products, with feedback on monitored Staphylococcus aureus intraoperative transmission. ESKAPE pathogens also include Enterococcus and gram-negative pathogens: Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter. We evaluated whether bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen all contribute meaningfully to ESKAPE pathogen transmission within anesthesia work areas.

METHODS

The retrospective cohort study used bacterial count data from nine hospitals, 43 months, and 448 ESKAPE pathogen transmission events within anesthesia areas of 86 operating rooms. Transmission was measured within and between pairs of successive surgical cases performed in the same operating room on the same day.

RESULTS

There were 203 transmission events with S. aureus, 72 with Enterococcus, and 173 with gram negatives. ESKAPE pathogens in the nose contributed to transmission for 50% (99% confidence limit ≥45%) of case pairs, on the groin or axilla for 54% (≥49%), on the hands for 53% (≥47%), on the anesthesia machine for 21% (≥17%), and in the intravenous lumen for 24% (≥20%). ESKAPE pathogens in the nose started a transmission pathway for 27% (≥22%) of case pairs, on the groin or axilla for 24% (≥19%), on the hands for 38% (≥33%), on the anesthesia machine for 11% (≥7.6%), and in the intravenous lumen for 8.0% (≥5.3%). All P ≤ 0.0022 compared with 5%.

CONCLUSIONS

To prevent intraoperative ESKAPE pathogen transmission, anesthesia practitioners would need to address all five categories of infection control approaches: nasal antisepsis (e.g., povidone-iodine applied the morning of surgery), skin antisepsis (e.g., chlorhexidine wipes), hand antisepsis with dispensers next to the patient, decontamination of the anesthesia machine before and during anesthetics, and disinfecting caps for needleless connectors, disinfecting port protectors, and disinfecting caps for open female Luer type connectors.

Effect of a bioconverted product of Lotus corniculatus seed on the axillary microbiome and body odor

The skin microbiome, especially the axillary microbiome, consists of odor-causing bacteria that decompose odorless sweat into malodor compounds, which contributes to the formation of body odor. Plant-derived products are a cheap source of bioactive compounds that are common ingredients in cosmetics. Microbial bioconversion of natural products is an ecofriendly and economical method for production of new or improved biologically active compounds. Therefore, in this study, we tested the potential of a Lactobacillus acidophilus KNU-02-mediated bioconverted product (BLC) of Lotus corniculatus seed to reduce axillary malodor and its effect on the associated axillary microbiota. A chemical profile analysis revealed that benzoic acid was the most abundant chemical compound in BLC, which increased following bioconversion. Moreover, BLC treatment was found to reduce the intensity of axillary malodor. We tested the axillary microbiome of 18 study participants, divided equally into BLC and placebo groups, and revealed through 16S rRNA gene sequencing that Staphylococcus, Corynebacterium, and Anaerococcus were the dominant taxa, and some of these taxa were significantly associated with axillary malodor. After one week of BLC treatment, the abundance of Corynebacterium and Anaerococcus, which are associated with well-known odor-related genes that produce volatile fatty acids, had significantly reduced. Likewise, the identified odor-related genes decreased after the application of BLC. BLC treatment enhanced the richness and network density of the axillary microbial community. The placebo group, on the other hand, showed no difference in the microbial richness, odor associated taxa, and predicted functional genes after a week. The results demonstrated that BLC has the potential to reduce the axillary malodor and the associated odor-causing bacteria, which makes BLC a viable deodorant material in cosmetic products.

Understanding the microbial basis of body odor in pre-pubescent children and teenagers

BACKGROUND

Even though human sweat is odorless, bacterial growth and decomposition of specific odor precursors in it is believed to give rise to body odor in humans. While mechanisms of odor generation have been widely studied in adults, little is known for teenagers and pre-pubescent children who have distinct sweat composition from immature apocrine and sebaceous glands, but are arguably more susceptible to the social and psychological impact of malodor.

RESULTS

We integrated information from whole microbiome analysis of multiple skin sites (underarm, neck, and head) and multiple time points (1 h and 8 h after bath), analyzing 180 samples in total to perform the largest metagenome-wide association study to date on malodor. Significant positive correlations were observed between odor intensity and the relative abundance of Staphylococcus hominis, Staphylococcus epidermidis, and Cutibacterium avidum, as well as negative correlation with Acinetobacter schindleri and Cutibacterium species. Metabolic pathway analysis highlighted the association of isovaleric and acetic acid production (sour odor) from enriched S. epidermidis (teen underarm) and S. hominis (child neck) enzymes and sulfur production from Staphylococcus species (teen underarm) with odor intensity, in good agreement with observed odor characteristics in pre-pubescent children and teenagers. Experiments with cultures on human and artificial sweat confirmed the ability of S. hominis and S. epidermidis to independently produce malodor with distinct odor characteristics.

CONCLUSIONS

These results showcase the power of skin metagenomics to study host-microbial co-metabolic interactions, identifying distinct pathways for odor generation from sweat in pre-pubescent children and teenagers and highlighting key enzymatic targets for intervention.

Structural basis of malodour precursor transport in the human axilla

Mammals produce volatile odours that convey different types of societal information. In Homo sapiens, this is now recognised as body odour, a key chemical component of which is the sulphurous thioalcohol, 3-methyl-3-sulfanylhexan-1-ol (3M3SH). Volatile 3M3SH is produced in the underarm as a result of specific microbial activity, which act on the odourless dipeptide-containing malodour precursor molecule, S-Cys-Gly-3M3SH, secreted in the axilla (underarm) during colonisation. The mechanism by which these bacteria recognise S-Cys-Gly-3M3SH and produce body odour is still poorly understood. Here we report the structural and biochemical basis of bacterial transport of S-Cys-Gly-3M3SH by Staphylococcus hominis, which is converted to the sulphurous thioalcohol component 3M3SH in the bacterial cytoplasm, before being released into the environment. Knowledge of the molecular basis of precursor transport, essential for body odour formation, provides a novel opportunity to design specific inhibitors of malodour production in humans.

Microbial Ecology of the Human Skin

This review article on the skin microbiota was written in response to recent advances that transitioned from culture methods to PCR amplification and sequencing of bacterial and fungal genes as a result of the Human Microbiome Project. This transition enables the investigation of the full diversity of microorganisms inhabiting human skin. The skin provides a range of habitats with different microbiota associated with the three major regions of the skin, namely the moist axilla, perineum, and toe webs; oily or sebaceous head, neck, and trunk; and dry forearms and legs. These new culture-independent tools are revealing the diversity of the human skin microbiota in the different locations of the body and with skin depth. These tools should lead to a better understanding of the state of homeostasis between the microbiota and the host and the overall functionality of that microbiota.

Cutaneous Tuberculosis Occurring After a Skin Cut in a Child

BACKGROUND

Tuberculosis is a common problem in Turkey, and cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis. Herein, the authors describe a case of cutaneous tuberculosis (lupus vulgaris) occurring after contact with a sheep.

CASE

A 15-year-old boy was admitted to Marmara University School of Medicine Pendik Training and Research Hospital (Istanbul, Turkey) with delayed wound healing on the left index finger and left axillary lymphadenopathy. His medical history was unremarkable except for a wound incurred when he slaughtered a sheep 3 months before. One month after this injury, the patient developed enlargement of the left axillary lymph node on the side of the wounded extremity, and the wound turned a dark black color. The biopsy specimens obtained from the wounded skin and lymph nodes showed granulomatous reaction, but acid-fast bacilli (AFB) could not be shown with Ehrlich-Ziehl Neelsen staining. The patient tested positive in an interferon-gamma release assay. Computerized tomography scans of the thorax were normal, and early morning gastric lavage specimen was negative for AFB. The wound and axillary lymphadenopathy disappeared after institution of anti-tuberculosis therapy.

CONCLUSION

Tuberculosis infection must be considered in chronic skin lesions with granulomatous reaction occurring in countries with high prevalence of tuberculosis.

Risk factors for methicillin-resistant Staphylococcus aureus carriage among residents in 7 nursing homes in Shanghai, China

BACKGROUND

Nursing home residents are a population at risk for methicillin-resistant Staphylococcus aureus (MRSA) carriage, but few data about MRSA in this setting in Shanghai are available. The aim of this study is to determine the prevalence and risk factors for MRSA carriage in nursing home residents in Shanghai, China.

METHODS

Four hundred forty-three residents from 7 nursing homes in Shanghai, China, participated in this study; nasal and axillary swabs were obtained from these residents. Laboratory identification for S aureus and antimicrobial susceptibility testing were performed when isolated. Data, including individual resident characteristics and nursing home characteristics, were collected and analyzed.

RESULTS

Of the 443 participating residents, 99 (22.3%) and 45 (10.2%) residents were colonized by S aureus and MRSA, respectively. Previous hospitalization (odds ratio [OR], 2.564; 95% confidence interval [CI], 1.214-5.415; P = .014), presence of an invasive device (OR, 3.455; 95% CI, 1.678-7.113; P = .001), chloramphenicol therapy (OR, 7.672; 95% CI, 1.807-32.580; P = .006), and macrolides therapy (OR, 2.796; 95% CI, 1.056-7.403; P = .038) were independent risk factors for MRSA colonization. Low expenditure per month and less good sanitary condition also increased the risk for MRSA colonization.

CONCLUSIONS

Our study suggests that nursing homes are significant reservoirs for MRSA. Implementation of infection control strategies must be given high priority in nursing homes to fight the high prevalence of MRSA, and increased convenience and feasibility should also be realized with these control strategies for MRSA colonization.

Body Site Is a More Determinant Factor than Human Population Diversity in the Healthy Skin Microbiome

We studied skin microbiota present in three skin sites (forearm, axilla, scalp) in men from six ethnic groups living in New York City. Methods. Samples were obtained at baseline and after four days following use of neutral soap and stopping regular hygiene products, including shampoos and deodorants. DNA was extracted using the MoBio Power Lyzer kit and 16S rRNA gene sequences determined on the IIlumina MiSeq platform, using QIIME for analysis. Results. Our analysis confirmed skin swabbing as a useful method for sampling different areas of the skin because DNA concentrations and number of sequences obtained across subject libraries were similar. We confirmed that skin location was the main factor determining the composition of bacterial communities. Alpha diversity, expressed as number of species observed, was greater in arm than on scalp or axilla in all studied groups. We observed an unexpected increase in α-diversity on arm, with similar tendency on scalp, in the South Asian group after subjects stopped using their regular shampoos and deodorants. Significant differences at phylum and genus levels were observed between subjects of the different ethnic origins at all skin sites. Conclusions. We conclude that ethnicity and particular soap and shampoo practices are secondary factors compared to the ecological zone of the human body in determining cutaneous microbiota composition.

Identification of axillary Staphylococcus sp. involved in the production of the malodorous thioalcohol 3-methyl-3-sufanylhexan-1-ol

The production of malodour by humans is mediated by bacterial transformation of naturally secreted, non-odorous molecules. Specifically in the underarm (axilla), malodour arises due to biotransformation by the microbiota of dipeptide-conjugated thioalcohols, particularly S-[1-(2-hydroxyethyl)-1-methylbutyl]-(L)-cysteinylglycine (Cys-Gly-3M3SH). This molecule, secreted by the axilla, has a well-established role in malodour when metabolized to free thioalcohol by bacteria. We present Cys-Gly-3M3SH biotransformation data from a library of skin-isolated corynebacteria and staphylococci and report a significant variation in thioalcohol generation across individual bacterial species. Staphylococcus hominis, Staphylococcus haemolyticus and Staphylococcus lugdunensis were particularly efficient Cys-Gly-3M3SH transformers. In contrast, Staphylococcus epidermidis and Corynebacterium tuberculostearicum, both highly prevalent axillary commensals, are low producers of 3M3SH. We also identify significant differences between the ability of several isolates to biotransform Cys-Gly-3M3SH compared to S-benzyl-L-Cys-Gly, a dipeptide-linked version of a commonly used malodour precursor substrate. Finally, using traditional biochemical assays we subsequently establish that Cys-Gly-3M3SH is actively transported into S. hominis, rather than passively diffusing across the membrane. This work significantly enhances our knowledge of Cys-Gly-3M3SH biotransformation by physiologically important bacteria in the axillary microbiota.

The effect of axillary hair on surgical antisepsis around the shoulder

BACKGROUND

Infection after shoulder surgery can have devastating consequences. Recent literature has implicated Propionibacterium acnes as a causative agent for postoperative shoulder infections. Axillary hair removal has been suggested as a method for infection prevention, although data quantifying its effect on the bacterial load around the shoulder are lacking.

METHODS

We clipped one randomly selected axilla in 85 healthy male volunteers with commercially available surgical clippers. Aerobic and anaerobic culture specimens were taken from the clipped and unclipped axillae. Each shoulder was then prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. Repeated culture specimens were then taken from both axillae. Cultures were held for 14 days and recorded with a semiquantitative system (0-4 points). Results were compared by the Wilcoxon signed rank test.

RESULTS

There was no difference in the burden of P. acnes between the clipped and unclipped axillae before or after surgical preparation (P = .109, P = .344, respectively). There was a significantly greater bacterial burden in the clipped shoulder compared with the unclipped shoulder before preparation (P < .001) but not after preparation (P = .285). There was a significant reduction in total bacterial load and P. acnes load for both axillae after surgical preparation (P < .001 for all).

CONCLUSIONS

Removal of axillary hair has no effect on the burden of P. acnes in the axilla. Clipped axillae had a higher total bacterial burden. A 2% chlorhexidine gluconate surgical preparation is effective at removal of all bacteria and specifically P. acnes from the axilla.

[Quantitative and qualitative composition of axilla microbiota in practically healthy individuals]

AIM

Characteristics of quantitative and qualitative composition of cultured microorganisms isolated from axilla skin of practically healthy individuals.

MATERIALS AND METHODS

77 practically healthy individuals aged 18 to 40 years were examined. Species identification of microorganisms was carried out byculture-morphologic, tinctorial and biochemical properties using time-of-flight mass spectrometer and rpoB gene amplification with subsequent direct sequencing.

RESULTS

Quantitative evaluation of microbial composition of axilla skin microbiota in most of the practically healthy individuals varied in the 4-5 lg CFU/ml interval, whereas seeding of skin by this microbiota at the level of 8 lg CFU/ml was not detected. 158 strains of 24 microorganism species were identified in this biotope. Most of these strains (68.9%) belonged to Corynebacterium genus, 21.6% of strains--to Staphylococcus genus, 7.6% of strains--to Micrococcus genus and 1.9% of strains--Candida albicans. 16 species of corynebacteria were isolated with predomination of C. tuberculostearicum (40.3%), C. amycolatum (18.4%) and C. ureicelerivorans (14.8%) strains. The microbial landscape in most of the examined individuals (77.9%) was presented by microorganism association.

CONCLUSION

Quantitative and qualitative species composition of cultured microorganisms isolated from axilla skin biotope of practically healthy individuals was characterized for the first time.

Trichobacteriosis: contribution of dermoscopy

We report a case of axillary trichobacteriosis in a 34-year-old patient whose complaints were bromhidrosis and hyperhidrosis axillaris. The condition can be diagnosed clinically; dermoscopy may be useful and reveal typical signs.

Screening cultures for detection of methicillin-resistant Staphylococcus aureus in a population at high risk for MRSA colonisation: identification of optimal combinations of anatomical sites

This retrospective study analysed the diagnostic yield of single-site, two-site, and three-site anatomical surveillance cultures in a population of 4,769 patients at high risk for methicillin-resistant Staphylococcus aureus (MRSA) colonisation. Cultures of seven anatomical sites were used as the gold standard against which to measure the sensitivity of MRSA detection. Detection rates for the seven single-sites, 21 two-site, and 35 three-site combinations are presented. Single-site swabbing only detected 50.5% (nose) of total cases, while three-site surveillance achieved a 92% (groin + nose + throat) sensitivity of detection at best. It is recommended that at least three anatomical sites should be screened for MRSA colonisation in these high-risk patients.

Characterization of Staphylococcus and Corynebacterium clusters in the human axillary region

The skin microbial community is regarded as essential for human health and well-being, but likewise plays an important role in the formation of body odor in, for instance, the axillae. Few molecular-based research was done on the axillary microbiome. This study typified the axillary microbiome of a group of 53 healthy subjects. A profound view was obtained of the interpersonal, intrapersonal and temporal diversity of the human axillary microbiota. Denaturing gradient gel electrophoresis (DGGE) and next generation sequencing on 16S rRNA gene region were combined and used as extent to each other. Two important clusters were characterized, where Staphylococcus and Corynebacterium species were the abundant species. Females predominantly clustered within the Staphylococcus cluster (87%, n = 17), whereas males clustered more in the Corynebacterium cluster (39%, n = 36). The axillary microbiota was unique to each individual. Left-right asymmetry occurred in about half of the human population. For the first time, an elaborate study was performed on the dynamics of the axillary microbiome. A relatively stable axillary microbiome was noticed, although a few subjects evolved towards another stable community. The deodorant usage had a proportional linear influence on the species diversity of the axillary microbiome.

Do methicillin resistant staphylococcus (MRSA) carrier patients influence MRSA infection more than MRSA-carrier medical officers and MRSA-carrier family?

AIM

to determine the rate of MRSA-carrier among patients, family members and health care providers, and the association between MRSA-carrier family members and health care providers on MRSA infection patient after orthopaedic surgery.

METHODS

this is a cross-sectional analytical study. Samples were taken consecutively during December 2010 to December 2011, consisting of postoperative patients infected with MRSA, attending family members, and the medical officers with history of contact with the patient. Swab culture were taken from nasal and axilla of all subjects. The incidence of MRSA infection, and MRSA-carrier on the patient, family members and medical officers were presented descriptively, while their association with MRSA infection was statistically tested using Fischer exact test.

RESULTS

during the study period, there were 759 surgeries, with 4 (0.5%) patients were identified to have MRSA infection. Of these four cases, 48 subjects were enrolled. The rate of MRSA-carrier among patients, family and health care providers were 50%, 25% and 0% respectively. There were no significant association between MRSA and the rates of MRSA-carrier on the family member or health care providers.

CONCLUSION

the incidence of MRSA infection, MRSA-carrier patient, MRSA-carrier health care providers, and family member carrier were 0.5%, 50%, 0%, and 25% respectively. No significant association found between MRSA-carrier on the family member or health care providers and MRSA infection patient. There were no MRSA infection found on the health care provider.

Rapid detection of Methicillin-Resistant Staphylococcus aureus MRSA in nose, groin, and axilla swabs by the BD GeneOhm MRSA achromopeptidase assay and comparison with culture

OBJECTIVES

To compare the BD GeneOhm Methicillin Resistant Staphylococcus aureus (MRSA) Achromopeptidase (ACP) polymerase chain reaction (PCR) assay with the culture method for the detection of MRSA colonization.

METHODS

One hundred and two patients were admitted to the Intensive Care Unit in King Khalid Hospital, Najran, Kingdom of Saudi Arabia from July 2010 to February 2011. Separate swabs from the nose, axilla, and groin of each patient were processed by the culture method (sheep blood agar plate and mannitol salt agar plate) and BD GeneOhm MRSA ACP assay.

RESULTS

Of the 287 samples, 62 (21.6%) were MRSA positive by the PCR assay and 26 (9%) were MRSA positive by the culture method. The PCR method showed 88.4% sensitivity and 98.6% negative predictive value. The number of MRSA-PCR positive groin specimens was nearly the same as nasal specimens. The PCR method gave positive results in 22.5% of patients by nasal specimens, 27.5% of patients by nasal and groin specimens, and 30.4% of patients by nasal, groin, and axilla specimens. The PCR method detected 30.4% of patients as MRSA positive while the culture method detected 19.6% of patients as positive for MRSA.

CONCLUSION

The BD GeneOhm MRSA ACP assay has high sensitivity and NPV and hence is a useful screening method to exclude patients who are not colonized with MRSA.

Two at one blow: reemergence of tularemia in Upper Austria

After field dressing a rabbit in the state of Upper Austria, Austria two members of a family were infected with tularemia in November 2010. The patients were a man in his forties and his father-in-law in his sixties. Tularemia is a rare disease in Austria. In the last 10 years between 2 and 8 cases have been reported annually. Of the total of 40 cases none was reported in the state of Upper Austria. Thus, this case report documents the reemergence of tularemia in Upper Austria.

Green concretions on the left axillae

Case study A man, 47 years of age, with an unremarkable past medical history, attended our dermatology outpatient clinic having developed changes in the colour and texture of the hair of his left axillae 2 weeks earlier, causing him moderate itching. He did not remember any changes in his lifestyle or recall any changes in sweating patterns.

Incidence of and risk factors for community-associated methicillin-resistant Staphylococcus aureus acquired infection or colonization in intensive-care-unit patients

The incidence of and risk factors for acquiring community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among patients staying in intensive care units (ICUs) remain unclear. We enrolled patients staying in two ICUs at the Far Eastern Memorial Hospital during the period of 1 September 2008 to 30 September 2009 to clarify this issue. Surveillance cultures for MRSA were taken from nostril, sputum or throat, axillae, and the inguinal area in all enrolled patients upon admission to the ICU, every 3 days thereafter, and on the day of discharge from the ICU. For each MRSA isolate, we performed multilocus sequence typing, identified the type of staphylococcal cassette chromosome mec, detected the presence of the Panton-Valentine leukocidin gene, and conducted drug susceptibility tests. Among the 1,906 patients who were screened, 203 patients were carriers of MRSA before their admission to the ICU; 81 patients acquired MRSA during their stay in the ICU, including 31 who acquired CA-MRSA. The incidence rates of newly acquired MRSA and CA-MRSA during the ICU stay were 7.9 and 3.0 per 1,000 patient-days, respectively. Prior usage of antipseudomonal penicillins and antifungals and the presence of a nasogastric tube were found to be independent risk factors for acquiring CA-MRSA during the ICU stay when data for CA-MRSA carriers and patients without carriage of MRSA were compared (P=0.0035, 0.0330, and 0.0262, respectively). Prior usage of carbapenems was found to be a protective factor against acquiring CA-MRSA when data for patients with CA-MRSA and those with health care-associated MRSA acquired during ICU stay were compared (P=0.0240).

Co-existing tubercular axillary lymphadenitis with carcinoma breast can falsely over-stage the disease--case series

The synchronous occurrence of tuberculosis and carcinoma in breast is unusual. The simultaneous occurrence of both the diseases can complicate the neoplastic disease. The diagnosis and treatment of tuberculosis in a patient with cancer assumes importance as it can prevent high mortality in patients with co-existent disease and thereby create problems in treatment decision. Axillary lymph node enlargement in breast cancer patient is not always caused by metastatic tumour of the breast even in the ipsilateral axillary nodes. We present here six case reports as an example of tuberculous axillary lymphadenitis co-existing with invasive ductal carcinoma of the breast. Accurate diagnosis has helped in down-staging carcinoma of the breast and also in identifying curable disease.

Primary multi-drug resistant tubercular lymphadenitis in an HIV infected patient

Cervical lymphadenitis is a common extra-pulmonary manifestation of tuberculosis in HIV patient; nevertheless, it seems that the primary Multi Drug Resistant (MDR) involving extra-pulmonary site is uncommon. We report a case of tubercular lymphadenitis by multi-drug resistant strain of Mycobacterium tuberculosis in an HIV seropositive male, which has not been reported so far in literature.

Methicillin-resistant Staphylococcus aureus (MRSA) detection: comparison of two molecular methods (IDI-MRSA PCR assay and GenoType MRSA Direct PCR assay) with three selective MRSA agars (MRSA ID, MRSASelect, and CHROMagar MRSA) for use with infection-control swabs

Methicillin-resistant Staphylococcus aureus (MRSA) is an increasing problem. Rapid detection of MRSA-colonized patients has the potential to limit spread of the organism. We evaluated the sensitivities and specificities of MRSA detection by two molecular methods (IDI-MRSA PCR assay and GenoType MRSA Direct PCR assay) and three selective MRSA agars (MRSA ID, MRSASelect, and CHROMagar MRSA), using 205 (101 nasal, 52 groin, and 52 axillary samples) samples from consecutive known MRSA-infected and/or -colonized patients. All detection methods had higher MRSA detection rates for nasal swabs than for axillary and groin swabs. Detection of MRSA by IDI-MRSA was the most sensitive method, independent of the site (94% for nasal samples, 80% for nonnasal samples, and 90% overall). The sensitivities of the GenoType MRSA Direct assay and the MRSA ID, MRSASelect, and CHROMagar MRSA agars with nasal swabs were 70%, 72%, 68%, and 75%, respectively. All detection methods had high specificities (95 to 99%), independent of the swab site. Extended incubation for a further 24 h with selective MRSA agars increased the detection of MRSA, with a corresponding decline in specificity secondary to a significant increase in false-positive results. There was a noticeable difference in test performance of the GenoType MRSA Direct assay in detection of MRSA (28/38 samples [74%]) compared with detection of nonmultiresistant MRSA (17/31 samples [55%]) (susceptible to two or more non-beta-lactam antibiotics). This was not observed with selective MRSA agar plates or IDI-MRSA. Although it is more expensive, in addition to rapid turnaround times of 2 to 4 h, IDI-MRSA offers greater detection of MRSA colonization, independent of the swab site, than do conventional selective agars and GenoType MRSA Direct.

Multiple neonatal staphylococcal cold abscesses of the large folds

BACKGROUND

We describe three neonates who presented around the tenth day of life with multiple bilateral fluctuating cold abscesses situated in the lymph node areas, with secondary fistulation but without associated fever or general symptoms.

RESULTS

In all cases, Staphylococcus aureus was found in the abscesses and the umbilicus with similar antibiograms. The evolution was good and the children remained in good health afterwards.

CONCLUSION

Disseminated neonatal staphylococcal infections with a benign evolution are not commonly described in the medical literature. Clinically, cold inflammatory abscesses of the large folds associated with omphalitis may correspond to either transient bacteriemia well controlled in an immunocompetent host or more likely a local contamination process.

Carriage of multiple subtypes of methicillin-resistant Staphylococcus aureus by intensive care unit patients

OBJECTIVE

To determine how consistently patients are colonized with methicillin-resistant Staphylococcus aureus (MRSA) at various sites and how many subtypes can be carried simultaneously by a single patient.

SETTING

A 28-bed Intensive care unit in a tertiary-care referral hospital.

METHODS

A total of 1,181 patients were screened by culture of swab specimens obtained from the nose, throat, groin, and axilla on admission to the intensive care unit (ICU), twice weekly during their ICU stay, and at discharge.

RESULTS

MRSA was isolated at least once from 224 patients. Of these isolates, 359 were selected from 32 patients to be subtyped using pulsed-field gel electrophoresis. The rate of compliance with collection of swab specimens was 79.9%. The combination of sites colonized varied frequently over time for many patients. Of patients who had swab specimens obtained twice in 1 day, 8.7% had discordant results from the 2 swab sets. No patient had a clinical isolate that was not of an identical subtype to an isolate from an anatomical site that was sampled for screening. Half the patients carried multiple subtypes during their stay, with up to 4 subtypes per patient.

CONCLUSIONS

The findings of this study may indicate that these patients have been colonized with MRSA on more than one occasion, possibly because of multiple breaches in infection control procedure. In MRSA-colonized patients, anatomical sites were intermittently colonized and carriage of multiple subtypes was common. These findings indicate that MRSA carriage is not a fixed state but may vary over time.

Methicillin-resistant Staphylococcus aureus colonization and its association with infection among infants hospitalized in neonatal intensive care units

OBJECTIVES

We conducted this study to assess the rate of methicillin-resistant Staphylococcus aureus colonization and its association with infection among infants hospitalized in methicillin-resistant S aureus-endemic NICUs.

METHODS

Between March 2003 and February 2004, surveillance culture specimens from the nares, postauricular areas, axillae, and umbilicus of infants admitted to the NICUs at a children's hospital in Taiwan were obtained weekly for the detection of methicillin-resistant S aureus. All colonized and clinical isolates from each study infant with methicillin-resistant S aureus infection were genotyped with pulsed-field gel electrophoresis, with Sma1 digestion, and compared.

RESULTS

A total of 783 infants were included in this study. Methicillin-resistant S aureus colonization was detected for 323 infants during their NICU stays, with detection with the first 2 samples for 89%. Nares and umbilicus were the 2 most common sites of initial colonization. Methicillin-resistant S aureus colonization was associated significantly with premature birth (< or = 28 weeks) and low birth weight (< or = 1500 g), and infants with colonization had a significantly higher rate of methicillin-resistant S aureus infection, compared with those without colonization (26% vs 2%). Methicillin-resistant S aureus colonization was noted for 84 of 92 infants with methicillin-resistant S aureus infections. Of the 68 episodes with previous colonization and isolates available for genotyping analysis, colonized and clinical isolates were indistinguishable in 63 episodes, highly related in 2 episodes, and distinct in 3 episodes.

CONCLUSIONS

More than 40% of the hospitalized infants were colonized with methicillin-resistant S aureus during their stay in methicillin-resistant S aureus-endemic NICUs; this was associated significantly with methicillin-resistant S aureus infection. Most infants with methicillin-resistant S aureus infections had previous colonization with an indistinguishable strain.

Evaluation of separate vs pooled swab cultures, different media, broth enrichment and anatomical sites of screening for the detection of methicillin-resistant Staphylococcus aureus from clinical specimens

Early identification of methicillin-resistant Staphylococcus aureus (MRSA) carriers is a major component of an MRSA control programme. The cost and laboratory workload could be markedly reduced by processing multiple swabs from one person in one culture broth (specimen pooling). We evaluated the sensitivity for MRSA detection and the growth rate of pooled swabs compared with individual processing. In total, 1254 swabs from 423 subjects (two to five swabs per subject) were submitted for detection of MRSA. Swabs were suspended in 2-mL volumes of sterile Todd-Hewitt Broth and divided into two 1-mL aliquots. One aliquot of the suspension was processed as a single specimen, and the other aliquot was mixed (pooled) with other suspensions in which swabs from the same patient were suspended. Forty-four (10%) pooled samples were positive for MRSA. Specimens from seven additional patients that were negative when pooled were positive when processed separately. There was no case where the pooled specimen was positive but the separate specimens were negative. The diagnostic sensitivity of pooled surveillance cultures compared with single cultures, when only subjects colonized by MRSA were considered, was 86% and the false-negative rate was 14%. Eighty percent of the pooled positive cultures were detected by the third day and all were detected by the fourth day. Fifty-four percent of the specimens processed separately were detected by the second day and all were detected by the fourth day. Pooling of specimens decreases the sensitivity of MRSA detection compared with processing each swab separately, particularly in swabs with a low number of colony-forming units. In all subjects whose pooled samples were negative but whose swabs examined separately were positive, the swabs examined separately were negative on primary plates and positive only after culturing in enrichment broth.

Sparing of the upper axillary area in pityriasis versicolor

Increased temperature and sweating are considered factors predisposing to pityriasis versicolor. In this case report, sparing of the vaults of the axillae which are naturally occluded and sweaty areas, in a patient with widespread lesions of pityriasis versicolor is discussed. It is the second observation in this regard and further contributions are invited.

Staphylococcal infections in PD: monitoring, screening and prevention

Peritonitis and catheter infections remain a major complication of peritoneal dialysis, accounting for much of the morbidity associated with the technique. The most common source of infection is contamination with predominantly Gram positive skin flora, Staphylococcus (S) epidermidis and S. aureus. The aims of this study were, (a) to determine the incidence of S. aureus and S. epidermidis infections in the unit, (b) to examine whether treatment of S. aureus carriers may reduce the incidence of exit site infection and (c) to examine whether improving patient education may reduce S. epidermidis peritonitis rate.

Identification of the Precursor of (S)-3-Methyl-3-sulfanylhexan-1-ol, the Sulfury Malodour of Human Axilla Sweat

A careful study of human axillary microflora led us to the identification of a new strain of Staphylococcus haemolyticus. The role in axillary malodour formation of this microorganism was compared to those of Corynebacterium xerosis and Staphylococcus epidermidis, upon incubation on sterile human eccrine and apocrine axilla sweat. St. haemolyticus was responsible for the strongest sulfury malodour and the generation of the volatile sulfur compound (VSC) (S)-3-methyl-3-sulfanylhexan-1-ol (3). In this study, we investigated the nonvolatile precursors of VSCs. Human axillary sweat was collected, fractionated and analysed by HPLC/APCI-MS (High-Pressure Liquid Chromatography coupled to Atmospheric Pressure Chemical Ionisation Mass Spectrometry). The precursor of 3 was identified as [1-(2-hydroxyethyl)-1-methylbutyl]-L-cysteinylglycine (Cys-Gly-(S)-conjugate; 12). Because Cys-Gly-(S)-conjugates are key intermediates in the glutathione biodetoxification pathway, other derivatives of 12, specifically glutathione-(S)-conjugate 11 and Cys-(S)-conjugate 13, were prepared. Compounds 11 and 13 were not detected by HPLC/MS of sterile sweat. Synthetic homologues 11, 12, and 13 were incubated with C. xerosis, St. heamolyticus, and St. epidermidis. We observed efficient conversion of precursors 12 and 13 to form VSCs when incubated with St. haemolyticus, with a clear preference for 12. C. xerosis and St. epidermidis were less efficient in cleaving Cys-Gly-(S)-conjugate 12 to form the corresponding thiol 3. Incubation of glutathione-(S)-conjugate 11 never led to the formation of 3 under the experimental conditions employed.

Cutaneous Community-acquired Methicillin-resistant Staphylococcus aureus Infection in Participants of Athletic Activities

OBJECTIVES

Cutaneous community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) has been identified in otherwise healthy individuals either with or without methicillin-resistant S. aureus (MRSA)-associated risk factors who participate in athletic activities. The purpose of this study was to describe the clinical features of CAMRSA skin infection that occurred in university student athletes, evaluate the potential mechanisms for the transmission of MRSA infection of the skin in participants of athletic activities, and review the measures for preventing the spread of cutaneous CAMRSA infection in athletes.

METHODS

A retrospective chart review of the student athletes from the University of Houston whose skin lesions were evaluated at the Health Center and grew MRSA was performed. The clinical characteristics and the postulated mechanisms of cutaneous MRSA infection in the athletes were compared with those previously published in reports of CAMRSA skin infection outbreaks in other sports participants.

RESULTS

Cutaneous CAMRSA infection occurred in seven student athletes (four women and three men) who were either weight lifters (three students) or members of a varsity sports team: volleyball (two women), basketball (one woman), and football (one man). The MRSA skin infection presented as solitary or multiple, tender, erythematous, fluctuant abscesses with surrounding cellulitis. The lesions were most frequently located in the axillary region (three weight lifters), on the buttocks (two women), or on the thighs (two women). The drainage from all of the skin lesions grew MRSA, which was susceptible to clindamycin, gentamicin, rifampin, trimethoprim/sulfamethoxazole, and vancomycin; five of the isolates were also susceptible to ciprofloxacin and levofloxacin. All of the bacterial strains were resistant to erythromycin, oxacillin, and penicillin. The cutaneous MRSA infections persisted or worsened in the six athletes who were empirically treated for methicillin-sensitive S. aureus at their initial visit. Complete resolution of the skin infection occurred after the abscesses had been drained and the athlete had been treated with systemic antimicrobial therapy for which the bacterial strain was susceptible.

CONCLUSIONS

Cutaneous CAMRSA infection typically presents as an abscess, with or without surrounding cellulitis, in otherwise healthy participants of athletic activities who have or do not have MRSA-associated risk factors. Athletes who have MRSA skin infections include weight lifters and team members from competitive sports such as basketball, fencing, football, rugby, volleyball, and wrestling. Bacterial culture of suspected infectious skin lesions should be performed to establish the diagnosis of cutaneous MRSA infection and to determine the antibiotic susceptibility of the bacterial isolate. Treatment of cutaneous MRSA infection involves drainage of the abscess (either spontaneously or after incision) and appropriate systemic antimicrobial therapy. Direct skin-to-skin physical contact with infectious lesions or drainage, skin damage that facilitates the entry of bacteria, and sharing of infected equipment, clothing, or personal items may result in the acquisition and transmission of MRSA infection in participants of athletic activities. Earlier detection and topical treatment of the athlete's skin wounds by their coaches, avoidance of contact with other participants' cutaneous lesions and their drainage, and good personal hygiene are measures that can potentially prevent the spread of cutaneous MRSA infection in participants of athletic activities.

Identification of New Odoriferous Compounds in Human Axillary Sweat

3-Hydroxy-3-methylhexanoic acid (1) and the 3-sulfanylalkan-1-ols 2-5 were identified to contribute to the odor of human axillary sweat. Quantitative analyses of axillary sweat extracts from 50 healthy men showed an unambiguous correlation between the detected levels of 1 and the intensity of the axillary odor. Chiral-GC analyses revealed 1 to be a 72:28 mixture of the (S)/(R)-isomers. Optically pure (S)-1 (>97% ee) emanated a strong spicy note, which recalled typical axillary odors. 3-Methyl-3-sulfanylhexan-1-ol (2), the enantiomeric ratio of which equaled that of 1, was present in greater quantity than any of the other 3-sulfanylalkanols. Optically pure (S)-2 (>97% ee) had a strong meaty, fruity note, also reminiscent of axillary odor. The compounds identified, in particular (S)-1 and (S)-2, contribute significantly to the olfactory impression of human axillary odor.

3-Methyl-3-sulfanylhexan-1-ol as a Major Descriptor for the Human Axilla-Sweat Odour Profile

This study sets out to redress the lack of knowledge in the area of volatile sulfur compounds (VSCs) in axillary sweat malodour. Sterile odourless underarm sweat (500 ml) was collected from 30 male volunteers after excessive sweating. Five strains of bacteria, Corynebacterium tuberculostearicum, Corynebacterium minutissimum, Staphylococcus epidermidis, Staphylococcus haemolyticus, and Bacillus licheniformis, were isolated and characterised for their ability to generate an authentic axillary odour from the sweat material collected. As expected, all of the five bacterial strains produced strong sweat odours. Surprisingly, after extensive olfactive evaluation, the strain of Staphylococcus haemolyticus produced the most sulfury sweat character. This strain was then chosen as the change agent for the 500 ml of odourless underarm sweat collected. After bacterial incubation, the 500-ml sample was further processed for GC-olfactometry (GC-O), GC/MS analysis. GC-O of an extract free of organic acids provided three zones of interest. The first was chicken-sulfury, the second zone was onion-like, and the third zone was sweat, clary sage-like. From the third zone, a new impact molecule, (R)- or (S)-3-methyl-3-sulfanylhexan-1-ol, was isolated and identified by GC/MS, MD-GC, and GC AED (atomic emission detector). (S)-3-methyl-3-sulfanylhexan-1-ol was sniff-evaluated upon elution from a chiral GC column and was described as sweat and onion-like; its opposite enantiomer, (R)-3-methyl-3-sulfanylhexan-1-ol, was described as fruity and grapefruit-like. The (S)-form was found to be the major enantiomer (75%).

The effect of lipids on the adherence of axillary aerobic coryneform bacteria

AIMS

A wide range of lipids are present on the skin surface of human beings and bacterial lipases are known to modify them. The microflora of the underarm (axilla) is often dominated by aerobic coryneforms and whilst many require lipids for growth, they appear not to be utilized as carbon sources. The aim of this study was to investigate the adherence aerobic coryneforms to lipids present on the skin surface of the human axilla to determine whether they contribute to colonization of the skin.

METHODS

Aerobic coryneforms were grown in a defined synthetic medium in the presence of (14)C-glucose to produce radio-labelled cells. Adherence to lipids was tested using a thin layer chromatography plate-based assay.

SIGNIFICANCE AND IMPACT OF THE STUDY

The mechanism of bacterial adhesion to skin lipids is unknown. The results of this study show that a significant proportion of cutaneous aerobic coryneform isolates from the axilla interact with skin lipids resulting in increased adherence, which may contribute to skin colonization.

Production of malodorous steroids from androsta-5,16-dienes and androsta-4,16-dienes by Corynebacteria and other human axillary bacteria

The biotransformations of a number of steroids, chiefly 5,6,16,17-tetradehydro-androstanes, are reported. The strains investigated were Corynebacteria sp. G38, G40, G41, B, Brevis sp. CW5 and Micrococcus sp. M-DH2. Corynebacterium sp. G41 proved remarkably efficient in effecting oxidative isomerisation of 5-ene-3-sterols into the corresponding 4-en-3-ones. The main biochemical reactions involved were oxidation at C-3; no reduction processes were observed. Conversions of 3beta-sterols into the C-3 oxo-steroids were high, but were correspondingly low for the 3alpha-sterol epimers. Androsta-4,16-dien-3-one and 5beta-androsta-16-en-3-one are crucial to the formation of malodour. The rate of formation of these compounds was measured over 72 h incubation periods using three substrates: androsta-5,16-dien-3beta-ol, androsta-4,16-dien-3beta-ol and androsta-5,16-dien-3-one. Induction studies of the transformation of the androsta-5,16-dien-3beta-ol into the very odorous compound androsta-4,16-dien-3-one showed that cells incubated with a mixture of antibiotics displayed the same extent of biotransformation as normal cells if the concentration of antibiotic was low (1, 3, 5 and 7 microg/ml), although at concentrations higher than 10 microg/ml, biotransformation yields were reduced. Pre-incubation with a 3beta-fluoro-steroid inhibited the formation of the odorous androsta-4,16-dien-3-one.

Microbial pathways leading to steroidal malodour in the axilla

Odorous steroids, specifically the 16-androstenes, 5alpha-androstenol and 5alpha-androstenone, are widely accepted as being contributors to underarm odour, but the precursors and pathways to these odorous steroids were unclear. This study demonstrated that the axillary microflora could only generate odorous 16-androstenes from precursors that already contain the C16 double bond, such as 5,16-androstadien-3-ol and 4,16-androstadien-3-one. In incubations containing 5,16-androstadien-3-ol, mixed populations of Corynebacterium spp., isolated from the axilla, could generate many different 16-androstene metabolites, several of which were odorous. Isolation of individual Corynebacterium strains, followed by pure culture incubations with 5,16-androstadien-3-ol, revealed organisms capable of efficient, rapid reactions. However, no single isolate could carry out a full complement of the observed biotransformations. 16-Androstene metabolites were identified by gas chromatography-mass spectrometry (GC-MS), either by comparison with known standards, or by prediction from molecular ion and fragmentation patterns. Based on detection of these metabolites, a metabolic map for axillary corynebacterial 16-androstene biotransformations was proposed, detailing potential enzyme activities. In summary, the formerly implicated 4,16-androstadien-3-one, 5alpha-androstenone and 5alpha-androstenol were detected, along with previously unreported hydroxy- and keto-substituted 16-androstenes, 16-androstatrienones and 16-androstatrienols. Additionally, many other metabolites with steroidal fragmentation patterns were present, but have remained unidentified.A key observation was that very low prevalences of microorganisms capable of biotransforming 16-androstenes were present on skin. For example, from a panel of 21 individuals, only 4 of 18 mixed populations of corynebacteria, and only 4 of 45 Corynebacterium isolates, could biotransform 5,16-androstadien-3-ol. This study has increased understanding of the metabolic pathways involved in steroidal malodour formation, and has demonstrated that the biotransformations are more complex than previously anticipated. However, it is clear that further research is required, both to assess the level of contribution of 16-androstenes to underarm odour, and to further elucidate the pathways and odour molecules formed by corynebacteria.

A specific bacterial aminoacylase cleaves odorant precursors secreted in the human axilla

Human axillary odor is known to be formed upon the action of Corynebacteria sp. on odorless axilla secretions. The known axilla odor determinant 3-methyl-2-hexenoic acid was identified in hydrolyzed axilla secretions along with a chemically related compound, 3-hydroxy-3-methylhexanoic acid. The natural precursors of both these acids were purified from non-hydrolyzed axilla secretions. From liquid chromatography/mass spectrometry analysis, it appeared that the acids are covalently linked to a glutamine residue in fresh axilla secretions, and the corresponding conjugates were synthesized for confirmation. Bacterial isolates obtained from the human axilla and belonging to the Corynebacteria were found to release the acids from these odorless precursors in vitro. A Zn(2+)-dependent aminoacylase mediating this cleavage was purified from Corynebacterium striatum Ax20, and the corresponding gene agaA was cloned and heterologously expressed in Escherichia coli. The enzyme is highly specific for the glutamine residue but has a low specificity for the acyl part of the substrate. agaA is closely related to many genes coding for enzymes involved in the cleavage of N-terminal acyl and aryl substituents from amino acids. This is the first report of the structure elucidation of precursors for human body odorants and the isolation of the bacterial enzyme involved in their cleavage.

Comparison of two sampling techniques to assess quantity and distribution of Malassezia yeasts on the skin of Basset Hounds

Cytological examination using the tape-strip technique and fungal culture using contact plates with modified Dixon's medium were compared to evaluate the carriage of Malassezia yeasts on four cutaneous sites (left pinna, umbilical region, axilla and perianal area) in adult Basset Hounds. Twenty animals were included in the study. High numbers of Malassezia were isolated from at least one area in 100% of the animals. The frequencies of isolation and population sizes differed significantly according to anatomical location. They were greater on the pinna, followed by the umbilical area, axilla and perianal area. Fungal culture was more sensitive than cytology for the isolation of Malassezia yeasts. Frequencies of isolation were greater using this method, but population sizes were constantly smaller than with cytology.

Antibiotic resistance patterns of aerobic coryneforms and furazolidone-resistant Gram-positive cocci from the skin surface of the human axilla and fourth toe cleft

Samples of skin surface bacteria from 28 healthy subjects plated directly on to selective and non-selective media revealed that the proportion of aerobic coryneforms and furazolidone-resistant Gram-positive cocci (FURECs) resistant to erythromycin was significantly greater in the fourth toe cleft than in the axilla (P < 0.05). There were more erythromycin-resistant bacteria than tetracycline-resistant bacteria at both sites (P = 0.001 for the toe cleft; P < 0.01 for the axilla). In total, 160 distinct isolates were obtained, of which 42 were FURECs and 118 were aerobic coryneforms. Of these, 153 (96%) were resistant to erythromycin and 66 (41%) to tetracycline. All except seven of the tetracycline-resistant strains were also resistant to erythromycin. The resistant isolates belonged to a variety of species. CDC group ANF corynebacteria were most numerous and composed 31% of all isolates. The majority (76%) of FURECs were identified as Micrococcus luteus. MIC determinations on selected strains revealed that tetracycline-resistant FURECs were sensitive to doxycycline and minocycline, as were most tetracycline-resistant coryneforms. Nine coryneform isolates were cross-resistant to all three tetracyclines. Only a minority of erythromycin-resistant FURECs (21%) demonstrated a macrolide-lincosamide-streptogramin type B (MLS)-resistant phenotype with inducible or constitutive cross-resistance to clindamycin and the type B streptogramin, pristinamycin IA. Twenty-nine erythromycin-resistant FURECs had a novel phenotype distinct from MLS and macrolide-streptogramin type B resistance. In contrast, most coryneforms (79%) were MLS resistant. Among the remainder, two unusual erythromycin resistance phenotypes were apparent, both of which differed from the unusual phenotype in FURECs. This study has revealed that the non-staphylococcal aerobic flora of skin contains a considerable reservoir of tetracycline and erythromycin resistance determinants. The three unusual macrolide resistance phenotypes may be associated with novel resistance mechanisms.

[Trichophyton rubrum syndrome with axillary tinea infection]

Trichophyton rubrum infections occur worldwide. In the last few years Trichophyton rubrum has increasingly often been isolated from other parts of the body besides the soles of the feet, toenails and the groin. Our patient's infection spread from the feet, to the inguinal region, to the thighs, to the hips, to the abdominal wall, to the left forearm and even the axillae. Such skin lesions have recently been called chronic dermatophytosis syndrome. We describe this new entity for the first time in the German literature and discuss it in relation to commonly found Trichophyton rubrum infections.

Role of the preaxillary flora in pacemaker infections: a prospective study

BACKGROUND

Infection remains a severe complication after pacemaker implantation. The purpose of our prospective study was to evaluate the role of the local bacteriologic flora in its occurrence.

METHODS AND RESULTS

Specimens were collected at the site of implantation for culture from the skin and the pocket before and after insertion in a consecutive series of patients who underwent elective permanent pacemaker implantation. Microorganisms isolated both at the time of insertion and of any potentially infective complication were compared by using conventional speciation and ribotyping. There were 103 patients (67 men and 36 women) whose age ranged from 16 to 93 years (mean+/-SD, 67+/-15). At the time of pacemaker implantation, a total of 267 isolates were identified. The majority (85%) were staphylococci. During a mean follow-up of 16.5 months (range, 1 to 24), infection occurred in four patients (3.9%). In two of them, an isolate of Staphylococcus schleiferi was recognized by molecular method as identical to the one previously found in the pacemaker pocket. In one patient, Staphylococcus aureus, an organism that was absent at the time of pacemaker insertion, was isolated. In another patient, a Staphylococcus epidermidis was identified both at the time of pacemaker insertion and when erosion occurred; however, their antibiotic resistance profiles were different.

CONCLUSIONS

This study strongly supports the hypothesis that pacemaker-related infections are mainly due to local contamination during implantation. S schleiferi appears to play an underestimated role in infectious colonization of implanted biomaterials and should be regarded as an important opportunistic pathogen.