Epidermolytic ichthyosis complicated by staphylococcal scalded skin syndrome in the newborn.

Epidermolytic ichthyosis is characterized by erythema and blistering at birth. We present a neonate with epidermolytic ichthyosis who had a subtle change in clinical findings while hospitalized, including increased fussiness, erythema, and a change in her skin odor, which represented superimposed staphylococcal scalded skin syndrome. This case highlights the unique challenge of recognizing cutaneous infections in neonates with blistering skin disorders and emphasizes the importance of having a high suspicion for superinfection in this population.

Staphylococcal scalded skin syndrome: An epidemiological and clinical review of 84 cases.

BACKGROUND: Staphylococcal scalded skin syndrome (SSSS) is a toxin-mediated, blistering skin disorder that mainly affects infants and children. There is limited literature regarding pediatric SSSS. The purpose of this study was to describe the epidemiology, clinical features, and management of pediatric SSSS. METHODS: Retrospective cohort study of pediatric patients with a clinical diagnosis of SSSS seen at the Hospital for Sick Children in Toronto, Ontario, Canada, from January 1994 to March 2016. RESULTS: We included 84 patients with a clinical diagnosis of SSSS; 49/84 (58%) were male. Mean age of diagnosis was 3.1 ± 2.4 years. All patients presented with erythema and exfoliation, while 64/84 (76%) presented with vesicles/ bullae. Skin tenderness was the most common symptom, present in 68/84 (81%) subjects. Staphylococcus aureus was more commonly isolated from periorificial cultures than from bullae. Mean hospitalization was 4.7 ± 2.3 days. No difference was found in admission duration between children receiving clindamycin and those that did not (3.6 ± 2.2 vs 3.9 ± 2.34 days, P = .63). Skin debridement was the only risk factor leading to more complications and prolonged hospitalization (P = .03). Severe complications were seen in 4 (5%) cases, and no fatalities were observed. CONCLUSIONS: Healthcare providers should be aware of SSSS and consider it in the differential diagnosis of infants and children with new onset erythema, exfoliation, and/or vesiculation. Suspected culprit pathogens were more often obtained from periorificial swabs; however, these isolates were not tested for exfoliative toxin to confirm causality. Antibiotic treatment should be guided by sensitivity testing. Addition of clindamycin as an anti-toxin agent had no effect on the duration of hospitalization, and this should be further investigated. Surgical debridement of the skin in patients with SSSS should be discouraged.

Increasing Numbers of Staphylococcal Scalded Skin Syndrome Cases Caused by ST121 in Houston, Texas.

BACKGROUND: The molecular epidemiology of Staphylococcus aureus strains causing staphylococcal scalded skin syndrome (SSSS) in the United States has not been described. We analyzed patient and S. aureus isolate characteristics associated with SSSS in children at Texas Children's Hospital. METHODS: Patients with SSSS were identified by ICD9/10 codes and available S. aureus isolates were identified from an ongoing S. aureus surveillance study. Medical records were reviewed for 58 patients with available S. aureus isolates. Isolate analyses included PCR for agr group, pvl (lukSF-PV), tst, eta and etb, pulsed-field gel electrophoresis, multi-locus sequence typing and antimicrobial susceptibilities. RESULTS: Cases of SSSS increased from 2.3/10,000 admissions in 2008 to 52.6/10,000 admissions in 2017 (P < 0.0001). The 58 study cases (57 methicillin-susceptible S. aureus, 1 MRSA) with isolates were from 2013 to 2017. The majority (88%) of isolates was of clonal cluster (CC) 121, agr group IV, pvl, tst and carried eta and/or etb and 26% were clindamycin resistant. Twelve ST121 isolates had high level resistance to mupirocin. Patients were treated with standard supportive care plus systemic antibiotics [clindamycin alone or in combination with another antibiotic (n = 44)]. One patient had a recurrent SSSS and one patient was transferred to a burn unit on day 3. CONCLUSIONS: Cases of SSSS are increasing at our hospital. Most S. aureus strains isolated were of one CC, CC121 and carried eta and etb. Supportive care plus clindamycin was effective treatment. We speculate that CC121 was recently introduced to our region and is responsible for the increasing numbers of SSSS cases observed at Texas Children's Hospital.

Staphylococcal-scalded skin syndrome: evaluation, diagnosis, and management.

BACKGROUND: Staphylococcal-scalded skin syndrome (SSSS), also known as Ritter disease, is a potentially life-threatening disorder and a pediatric emergency. Early diagnosis and treatment is imperative to reduce the morbidity and mortality of this condition. The purpose of this article is to familiarize physicians with the evaluation, diagnosis, and treatment of SSSS. DATA SOURCES: A PubMed search was completed in Clinical Queries using the key terms "Staphylococcal scalded skin syndrome" and "Ritter disease". RESULTS: SSSS is caused by toxigenic strains of Staphylococcus aureus. Hydrolysis of the amino-terminal extracellular domain of desmoglein 1 by staphylococcal exfoliative toxins results in disruption of keratinocytes adhesion and cleavage within the stratum granulosum which leads to bulla formation. The diagnosis is mainly clinical, based on the findings of tender erythroderma, bullae, and desquamation with a scalded appearance especially in friction zones, periorificial scabs/crusting, positive Nikolsky sign, and absence of mucosal involvement. Prompt empiric treatment with intravenous anti-staphylococcal antibiotic such as nafcillin, oxacillin, or flucloxacillin is essential until cultures are available to guide therapy. Clarithromycin or cefuroxime may be used should the patient have penicillin allergy. If the patient is not improving, critically ill, or in communities where the prevalence of methicillin-resistant S. aureus is high, vancomycin should be used. CONCLUSION: A high index of suspicion is essential for an accurate diagnosis to be made and treatment promptly initiated.

Rapid containment of nosocomial transmission of a rare community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) clone, responsible for the Staphylococcal Scalded Skin Syndrome (SSSS).

BACKGROUND: The aims of this study were to identify the source and the transmission pathway for a Staphylococcal Scalded Skin Syndrome (SSSS) outbreak in a maternity setting in Italy over 2 months, during 2014; to implement appropriate control measures in order to prevent the epidemic spread within the maternity ward; and to identify the Methicillin-Resistant Staphylococcus aureus (MRSA) epidemic clone. METHODS: Epidemiological and microbiological investigations, based on phenotyping and genotyping methods, were performed. All neonates involved in the outbreak underwent clinical and microbiological investigations to detect the cause of illness. Parents and healthcare workers were screened for Staphylococcus aureus to identify asymptomatic carriers. RESULTS: The SSSS outbreak was due to the cross-transmission of a rare clone of ST5-CA-MRSA-SCCmecV-spa type t311, exfoliative toxin A-producer, isolated from three neonates, one mother (from her nose and from dermatological lesions due to pre-existing hand eczema) and from a nurse (colonized in her nose by this microorganism). The epidemiological and microbiological investigation confirmed these as two potential carriers. CONCLUSIONS: A rapid containment of these infections was obtained only after implementation of robust swabbing of mothers and healthcare workers. The use of molecular methodologies for typing was able to identify all carriers and to trace the transmission.

Nosocomial outbreak of staphyloccocal scalded skin syndrome in neonates in England, December 2012 to March 2013.

Staphylococcal scalded skin syndrome (SSSS) is a blistering skin condition caused by exfoliative toxin-producing strains of Staphylococcus aureus. Outbreaks of SSSS in maternity settings are rarely reported. We describe an outbreak of SSSS that occurred among neonates born at a maternity unit in England during December 2012 to March 2013. Detailed epidemiological and microbiological investigations were undertaken. Eight neonates were found to be infected with the outbreak strain of S. aureus, of spa type t346, representing a single pulsotype. All eight isolates contained genes encoding exfoliative toxin A (eta) and six of them contained genes encoding toxin B (etb). Nasal swabs taken during targeted staff screening yielded a staphylococcal carriage rate of 21% (17/80), but none contained the outbreak strain. Mass screening involving multi-site swabbing and pooled, enrichment culture identified a healthcare worker (HCW) with the outbreak strain. This HCW was known to have a chronic skin condition and their initial nasal screen was negative. The outbreak ended when they were excluded from work. This outbreak highlights the need for implementing robust swabbing and culture methodswhen conventional techniques are unsuccessful in identifying staff carrier(s). This study adds to the growing body of evidence on the role of HCWs in nosocomial transmission of S. aureus.

Staphylococcal scalded skin syndrome in neonates: an 8-year retrospective study in a single institution.

Staphylococcal scalded skin syndrome (SSSS) is a rare disorder in children. Complications may occur without timely treatment. Mortality in children with SSSS is approximately 4%. Other than a limited number of case reports, data on SSSS in neonates are limited. The objective of the current study was to investigate SSSS in neonates. A retrospective review of neonates with a diagnosis of SSSS from January 2004 to January 2012 was performed. Population distribution, historical features, physical examination findings including laboratory tests, antibiotic therapies, and outcomes were evaluated. Thirty-nine cases were included, 31 (79.5%) in the last 4 years. The mean patient age was 17.4 ± 7.7 days. Boys (25 cases) were more commonly affected, and occurrence during summer and autumn months was more frequent. The face was the most common body part affected and the area most commonly initially affected. Fever, high white blood cell count, and high C-reactive protein levels were uncommon. Pneumonia was the most frequent complication (74.4%). The positive rate of Staphylococcus aureus isolation was low (23.5%). Drug susceptibility tests showed that amoxicillin with clavulanic acid and cephalosporins were effective in practice. The median length of hospitalization was 9.0 days. All of the 39 neonates were cured without scarring. This study established basic epidemiologic characteristics of a group of neonates diagnosed with SSSS. In the presence of a clinical suspicion of SSSS, even with apparently normal laboratory tests, immediate treatment with cephalosporins, ß-lactamase-resistant semisynthetic penicillin, or both is advocated.

Epidemiological data of staphylococcal scalded skin syndrome in France from 1997 to 2007 and microbiological characteristics of Staphylococcus aureus associated strains.

Epidemiological data on staphylococcal scalded skin syndromes (SSSS), including bullous impetigo (BI) and generalized exfoliative syndrome (GES), are scarce. To better characterize SSSS and associated Staphylococcus aureus strains, we conducted a retrospective study of 349 cases collected in France between 1997 and 2007 by the National Reference Centre of Staphylococci. Our results showed a stationary evolution of SSSS cases, with a heterogeneous distribution of cases in France. Although notification was not exhaustive, we estimated an incidence of 0.56 cases/year/million inhabitants, in accordance with previous studies conducted in France and Europe, with a median age of 2 years old and sex ratios of 1. A seasonal effect was observed, with a higher GES/BI ratio in autumn compared with other seasons, which could be explained by the impact of viral co-infection. Genetic analysis of S. aureus strains showed that accessory gene regulator (agr) 4, exfoliative toxin A (eta) and B (etb) genes, staphylococcal and enterotoxin-like O (selo) gene and agr4 etb selo profiles were predominantly associated with GES, whereas agr2 eta and agr4 eta selo were more frequently observed with BI. Only one methicillin-resistant strain was found. Protein A (spa) typing identified two main genotypes: spa clonal complex (CC) 159/sequence-type (ST) 121 (75%) and spaCC346/ST15 (18%). spaCC159 was mainly associated with agr4 eta etb selo, agr4 eta selo and agr4 etb selo, and spaCC346 was mainly associated with agr2 eta, suggesting that French SSSS cases are caused by these two main lineages. However, in a multivariate analysis, only etb was independently associated with GES.

Staphylococcal scalded skin syndrome in the Czech Republic: an epidemiological study.

OBJECTIVE: To identify the basic epidemiological characteristics of children hospitalized with diagnosis of Staphylococcal scalded skin syndrome in the Czech Republic in the years 1994-2009. INTRODUCTION: Staphylococcal scalded skin syndrome (SSSS) is a relatively rare disease in childhood. This syndrome was first defined in 1878 by Baron Gottfried Ritter von Rittershainem and belongs to the group of diseases called Burn-like syndromes. It is a bullous skin disease caused by exfoliative toxins which are produced by certain types of Staphyloccocus aureus. Typical structures affected by these toxins are desmosome proteins called Desmoglein-1 located in the stratum granulosum of epidermis. Unlike in Lyell's syndrome or Stevens-Johnson's syndrome, the exfoliation is caused by loss of adhesivity particularly in the stratum granulosum and not by induction of apoptosis in the dermo-epidermal junction. MATERIAL AND METHODS: This retrospective study was conducted on patients hospitalized in the Czech Republic in the period from 1.1.1994 to 31.12.2009. The basic condition for the inclusion in the retrospective study was age under 1 year and hospitalization due to SSSS. A total of 399 children (177 girls) fulfilled the criteria for inclusion into the study. Information was obtained from a central data depository, the Department of Health Information and Statistics, Czech Republic. RESULTS: A total of 399 children under 1 year were hospitalized for the diagnosis of SSSS in the study period. The group included 177 girls and 222 boys. M:F ratio was 1.25:1. The average incidence of SSSS in the Czech Republic was 25.11 cases per 100,000 children under 1 year of age. The highest recorded incidence in the followed period was in 1994, when a total of 57 cases of SSSS was reported, namely 53.47 per 100,000 children. By contrast, in 2003, there were reported only 12 cases and the incidence of 12.81 per 100,000 children. The average length of hospitalization was 6.39 days. In 1995, the highest average length of hospitalization was reported, which was 8.1 days, and then in 2007, the lowest average length of hospitalization, 4.4 days. There was no significant difference in the length of hospitalization in boys and girls. None of the 399 children in the population died. CONCLUSION: In our retrospective study, we established basic epidemiological characteristics of a group of children aged under 1 year with diagnosis of SSSS. As epidemiological data show, the occurrence of this syndrome is not sporadic, but steady.

Síndrome estafilocócico de la piel escaldada. Nuestra experiencia en 10 años / Staphylococcal scalded skin syndrome (SSSS). Our 10-year experience

El síndrome estafilocócico de la piel escaldada (SEPE) es una enfermedad cutánea aguda infrecuente, causada por toxinas exfoliativas del Staphylococcus aureus. El objetivo de este estudio es describir las características epidemiológicas, clínicas y terapéuticas de los pacientes con diagnóstico de SEPE en nuestro medio.Material y métodos.Se realizó un estudio retrospectivo, descriptivo y observacional, en el que se revisaron las historias clínicas de los pacientes con diagnóstico de SEPE vistos entre mayo de 2000 y mayo de 2010, atendidos en la Sección de Dermatología Pediátrica del Hospital Ramos Mejía, y entre mayo de 2005 y mayo de 2010 en el Servicio de Dermatología del Hospital Alemán.Resultados.Se incluyó un total de 62 pacientes, cuya edad media al momento del diagnóstico fue de 22 meses. No se observó predilección por sexo ni estación del año. El 13% de los pacientes recibió corticoides sistémicos previo al diagnóstico de SEPE. Todos los pacientes excepto uno, realizaron tratamiento antibiótico luego del diagnóstico de esta entidad. El 92% recibió cefalosporinas de primera generación. El 23% de los pacientes requirió internación y el 100% evolucionó satisfactoriamente.Conclusiones.El SEPE es una entidad poco frecuente. Si bien en nuestro medio no hallamos datos epidemiológicos sobre esta entidad, los datos demográficos encontrados en este estudio difieren de los publicados en la literatura mundial. Debe sospecharse en recién nacidos y niños pequeños con eritrodermia aguda y afectación peribucal o conjuntival.

Staphylococcal scalded skin syndrome (SSSS) is a rare cutaneous disease caused by exfoliativetoxins of Staphylococcus aureus. The aim of this study is to describe the epidemiology, clinicalmanifestations and treatment of patients with the diagnosis of SSSS in our community.Methods. We conducted a retrospective, descriptive and observational study, reviewing the clinicalrecords of patients with a diagnosis of SSSS, as seen between May 2000 and May 2010 atthe Pediatric Dermatology Section of the Hospital Ramos Mejía, and between May 2005 and May2010 at the Dermatology Unit of the Hospital Alemán.Results. A total of 62 patients were included, whose average age at the time of diagnosis was22 months. No predilection for sex or season of the year was observed. Thirteen percent of thepatients received systemic steroids prior to SSSS diagnosis. All but one of the patients received antibiotictreatment after the diagnosis of this entity. First generation cephaloporins were given to92% of patients; 23% of them required hospitalization and all of them had a satisfactory outcome.Discussion. SSSS is an infrequent entity. Even though there are no epidemiological studies inour country concerning SSSS, the data we gathered differs with world-wide published literature.SSSS must be suspected in new-borns and in young children with an acute onset of erythroderma,perioral affectation and conjunctivitis.

Neonatal staphylococcal scalded skin syndrome: clinical and outbreak containment review.

Staphylococcal scalded skin syndrome (SSSS) is a toxin-mediated exfoliating skin condition predominated by desquamation and blistering. Neonatal outbreaks have already been reported; however, our outbreak highlights the potential for SSSS following neonatal health promotion measures such as intra-muscular vitamin K administration and metabolic screening (heel prick) as well as effective case containment measures and the value of staff screening. Between February and June 2007, five confirmed cases of neonatal SSSS were identified in full-term neonates born in an Irish regional maternity hospital. All infants were treated successfully. Analysis of contact and environmental screening was undertaken, including family members and healthcare workers. Molecular typing on isolates was carried out. An outbreak control team (OCT) was assembled and took successful prospective steps to prevent further cases. All five Staphylococcus aureus isolates tested positive for exfoliative toxin A, of which two distinct strains were identified on pulsed-field gel electrophoresis analysis. Two cases followed staphylococcal inoculation during preventive measures such as intra-muscular vitamin K administration and metabolic screening (heel prick). None of the neonatal isolates were methicillin resistant. Of 259 hospital staff (70% of staff) screened, 30% were colonised with S. aureus, and 6% were positive for MRSA carriage. This is the first reported outbreak of neonatal SSSS in Ireland. Effective case containment measures and clinical value of OCT is demonstrated. Results of staff screening underlines the need for vigilance and compliance in hand disinfection strategies in maternity hospitals especially during neonatal screening and preventive procedures.

Síndrome de escaldadura estafilocócica / Staphylococcal scalded skin syndrome

Introducción: El síndrome de escaldadura estafilocócica es una enfermedad causada por Staphylococcus aureus productor de toxinas exfoliativas. Es poco frecuente y apenas hay datos de su epidemiología en nuestro país. Pacientes y métodos: Se llevó a cabo un estudio observacional de cohortes en el que se revisaron los casos de escaldadura estafilocócica controlados en el Hospital Materno-Infantil La Paz en los últimos 10 años (enero 1997-diciembre 2006). Resultados: Se obtuvo un total de 26 pacientes, 7 en los primeros 5 años y 19 en los siguientes, con una media de edad en el momento del diagnóstico de 29 meses; 4 casos (15 %) fueron de diagnóstico neonatal. El 67 % de los casos ocurrieron en primavera y verano. Las manifestaciones clínicas más frecuentes fueron: eritrodermia con aparición de ampollas y descamación posterior (100 %), fisuración y costras periorales (54 %), fiebre (46 %), conjuntivitis (42 %) y edema palpebral (31 %). En la analítica no se detectó un aumento significativo de leucocitos (media: 11.341/μl) ni de proteína C reactiva (media: 9 mg/l). El diagnóstico fue principalmente clínico, con aislamiento de S. aureus en frotis nasal o conjuntival en el 59 % de los casos. Todas las cepas fueron sensibles a cloxacilina, clindamicina y vancomicina. El tratamiento se realizó con cloxacilina intravenosa con evolución favorable. Conclusiones: El síndrome de escaldadura estafilocócica parece ser más frecuente en los últimos años y debe sospecharse en un niño con eritrodermia aguda y afectación conjuntival o peribucal. El tratamiento con cloxacilina consigue la curación sin secuelas (AU)

Introduction: Staphylococcal scalded skin syndrome is a rare disease caused by Staphylococcus aureus that produces exfoliative toxins. There are few epidemiological data in our environment. Patients and methods: We present an observational cohort study. We review the cases of staphylococcal scalded skin syndrome monitored at La Paz Children Hospital during the last ten years (January 1997 to December 2006). Results: We obtained 26 patients, 7 in the first 5 years and 19 more in the following years. The mean age at diagnosis was 19 months. Four cases (15 %) occurred during the neonatal period. Sixty-seven percent of the cases were diagnosed during spring and summer. Main clinical signs were: erythroderma with blisters and posterior desquamation (100 %), perioral fissures (54 %), fever (46 %), conjunctivitis (42 %) and palpebral edema (31 %). No significant increases in leukocytes (mean: 11,341/μl) or C-reactive proein (mean: 9 mg/l) were found on blood analysis. Diagnosis was made by clinical findings. S. aureus was isolated in nasal or conjunctival samples on 59 % of cases. All strains were sensitive to cloxacillin, clindamycin and vancomycin. The patients were treated with cloxacillin with good progress. Conclusions: Staphylococcal scalded skin syndrome seems to be more common in the last few years. It must be suspected in children with acute erythroderma and perioral or conjunctival lesions. Treatment with cloxacillin leads to healing without sequelae (AU)

Síndrome de escaldadura estafilocócica de presentación neonatal / Neonatal staphylococcal scalded skin syndrome

Introducción: La incidencia del síndrome de escaldadura estafilocócica en neonatos parece haber aumentado en los últimos años. Métodos: Revisamos los casos de síndrome de escaldadura estafilocócica de presentación neonatal, controlados en nuestro servicio en los últimos 10 años (1997-2006). Resultados: Durante este periodo, se diagnosticaron 26 casos de síndrome de escaldadura estafilocócica, 4 de ellos (15%) en el primer mes de vida. Todos presentaron eritrodermia, ampollas, costras perinasales, fisuración perioral y conjuntivitis purulenta. En ningún caso apareció fiebre ni elevación de reactantes de fase aguda. En todos los pacientes se aisló Staphylococcus aureus sensible a meticilina en el frotis nasal y conjuntival. Se realizó un tratamiento con cloxacilina intravenosa durante una media de 7 días, y los pacientes presentaron descamación en láminas sin lesiones residuales. Conclusiones: El síndrome de escaldadura estafilocócica se presenta en el periodo neonatal hasta en el 15% de los casos. El tratamiento temprano con cloxacilina intravenosa permite una evolución favorable, e iguala el buen pronóstico característico del resto de edades

Introduction: The incidence of staphylococcal scalded skin syndrome among newborn infants seems to be increasing in recent years. Methods: We review the cases of neonatal staphylococcal scalded skin syndrome followed at our hospital over the last 10 years (1997-2006). Results: Twenty-six cases of this syndrome were diagnosed, four of them (15%) during the first month of life. All of them presented erythroderma, bullae, perioral and nasal fissures and purulent conjunctivitis. None had fever, leukocytosis or an increase in C-reactive protein. Methicillin-sensitive Staphylococcus aureus was isolated in nasal or conjunctival samples. The patients were treated with intravenous cloxacillin for a mean period of 7 days and they presented desquamation without scarring. Conclusions: Staphylococcal scalded skin syndrome appears during the neonatal period in up to 15% of cases. Early treatment with intravenous cloxacillin results in a favorable outcome

Antimicrobial agent of susceptibilities and antiseptic resistance gene distribution among methicillin-resistant Staphylococcus aureus isolates from patients with impetigo and staphylococcal scalded skin syndrome.

The susceptibilities to antimicrobial agents of and distributions of antiseptic resistance genes in methicillin-resistant Staphylococcus aureus (MRSA) strains isolated between 1999 and 2004 in Japan were examined. The data of MRSA strains that are causative agents of impetigo and staphylococcal scalded skin syndrome (SSSS) were compared with those of MRSA strains isolated from patients with other diseases. The susceptibilities to antiseptic agents in MRSA isolates from patients with impetigo and SSSS were higher than those in MRSA isolates from patients with other diseases. The distribution of the qacA/B genes in MRSA strains isolated from patients with impetigo and SSSS (1.3%, 1/76) was remarkably lower than that in MRSA strains isolated from patients with other diseases (45.9%, 95/207). Epidemiologic typings of staphylococcal cassette chromosome mec (SCCmec) and pulsed-field gel electrophoresis (PFGE) showed that MRSA strains isolated from patients with impetigo and SSSS had type IV SCCmec (75/76), except for one strain, and 64.5% (49/76) of the strains had different PFGE types. In addition, the patterns of restriction digestion of all tested qacA/B plasmid in MRSA isolates having different PFGE types were identical. The results showed that a specific MRSA clone carrying qacA/B was not prevalent, but qacA/B was spread among health care-associated MRSA strains. Therefore, it was concluded that the lower distribution rate of qacA/B resulted in higher susceptibilities to cationic antiseptic agents in MRSA isolated from patients with impetigo and SSSS.

Nosocomial outbreak of staphylococcal scalded skin syndrome in neonates: epidemiological investigation and control.

Over a three-month period, 13 neonates developed staphylococcal scalded skin syndrome (SSSS) in a maternity unit, between four and 18 days after their birth. An epidemiological and descriptive study followed by a case-control study was performed. A case was defined as a neonate with blistering or peeling skin, and exfoliative toxin A Staphylococcus aureus positive cultures. Controls were selected at random from the asymptomatic, non-colonized neonates born on the same day as the cases. All staff members and all neonates born during the outbreak period were screened for carriage by nasal swabs and umbilical swabs, respectively. S. aureus isolates were polymerase chain reaction (PCR) screened for etA gene and genotyped by pulsed-field gel electrophoresis (PFGE). Two clusters of eight and five cases were identified. Receiving more than one early umbilical care procedure by the same ancillary nurse was the only risk factor identified in the case-control study (odds ratio=15, 95% confidence intervals 2-328). The ancillary nurse suffered from chronic dermatitis on her hands that favoured S. aureus carriage. Exfoliative-toxin-A-producing strains, as evidenced by PCR and indistinguishable by PFGE, were isolated from all but one of the SSSS cases, from four asymptomatic neonates, from two staff members and from the ancillary nurse's hands. Removal of the ancillary nurse from duty, infection control measures (isolation precautions, chlorhexidine handwashing and barrier protections), and treatment of the carriers (nasal mupirocin and chlorhexidine showers) led to control of the epidemic. In conclusion, this study emphasizes the need for tight surveillance of chronic dermatitis in healthcare workers.

Clinical manifestations of staphylococcal scalded-skin syndrome depend on serotypes of exfoliative toxins.

We sought a possible correlation between the clinical manifestations of staphylococcal scalded-skin syndrome (SSSS) and the serotype of exfoliative toxins (ET) by PCR screening of the eta and etb genes in Staphylococcus aureus strains isolated from 103 patients with generalized SSSS and 95 patients with bullous impetigo. The eta gene and the etb gene were detected in, respectively, 31 (30%) and 20 (19%) episodes of generalized SSSS and 57 (60%) and 5 (5%) episodes of bullous impetigo. Both genes were detected in 52 (50%) episodes of generalized SSS and 33 (35%) episodes of bullous impetigo. To explain this link between etb and generalized SSSS, we examined the distribution of ETA- and ETB-specific antibodies in the healthy population (n = 175) and found that the anti-ETB antibody titer was lower than the anti-ETA titer. Thus, ETA is associated with bullous impetigo and ETB is associated with generalized SSSS, possibly owing to a lower titer of anti-ETB neutralizing antibodies in the general population.