Staphylococcal scalded skin syndrome: Clinical features, ancillary testing, and patient management

Abstract

Background/Objectives: The utility of ancillary testing in improving diagnostic precision or improving patient outcomes in staphylococcal scalded skin syndrome (SSSS) is unclear. Similarly, an optimal antibiotic regimen has yet to be established. Our goal was to describe clinical characteristics and ancillary work-up of SSSS, report bacterial resistance patterns, and examine patient outcomes under varying therapeutic strategies with the aim of developing an evidence-based management algorithm.Methods: We performed a retrospective review of pediatric patients diagnosed with SSSS at Intermountain Healthcare facilities between 2010 and 2021. A Kruskal-Wallis rank sum test was used to assess median length of stay between different antibiotic regimens.Results: Eighty-five cases were identified. The most common ancillary tests obtained were a complete blood count (88%), followed by chemistry analysis (80%). Blood cultures were collected in more patients (79%) compared to aerobic cultures (60%). No blood culture was positive for Staphylococcus aureus. All S. aureus isolates were methicillin-sensitive. Of those found resistant to clindamycin (36%), all demonstrated macrolide-induced clindamycin resistance. None were constitutively resistant to clindamycin. There was no statistical difference between antibiotic regimen and length of stay (p = .691). Receiving opiate medications was the only risk factor associated with prolonged hospitalization (p = .001). Conclusions: Ancillary testing does not improve diagnostic precision and can be reduced. Clindamycin does not improve patient outcomes, suggesting beta-lactams should be considered first line. Susceptibility patterns in our cohort demonstrate inducible clindamycin resistance as opposed to constitutive. K E Y W O R D S antibiotics, clindamycin, length of stay, staphylococcal scalded skin syndrome, treatment 1 | BACKGROUND Staphylococcal scalded skin syndrome (SSSS) is a rare, toxin-mediated desquamating skin disease caused by the bacterium Staphylococcus aureus. The disease is caused by exfoliative toxins A and B (ETA and ETB) on phage type 2 staphylococci, strains 71 and 55. Clinical manifestations include fragile bullae, desquamation, a positive Nikolsky sign and crusting around the nose, eyes, and mouth. 1,2 SSSS is considered a clinical diagnosis that can made by patient history and physical exam. Nonetheless, multiple ancillary tests are frequently sought during work-up. Retrospective cohort reviews indicate such testing does not improve patient outcomes. In a study by

Evolving trends in inpatient paediatric dermatology

“…However, blood cultures were the dominant culture obtained in their cohort (78.8%), which yielded no true pathogens. Similar to previous studies, cultures from facial mucocutaneous regions and the umbilical/genitourinary skin were of higher yield, with 64.7% positive for S. aureus [6 ▪ ]. Recent literature has shown that an overall reduction in ancillary testing in paediatric patients with SSSS has not led to increased length of stay or worse clinical outcomes [4,6 ▪ ].…”

“…However, several recent studies have shown that patients with resistant isolates treated with clindamycin monotherapy do not differ from those who receive adequate antibiotic coverage [8]. Gray et al [6 ▪ ] showed that all clindamycin resistance in their cohort was macrolide-induced (positive D-test). Therefore, it may be hypothesized that clindamycin monotherapy in clindamycin-resistant strains of SSSS remains efficacious due to inducible resistance rather than constitutive resistance.…”

“…Typically, patients are treated with methicillin-sensitive S. aureus (MSSA) coverage such as first-generation cephalosporins, penicillinase-resistant penicillins or vancomycin; however, antibiotics should be adjusted based on culture susceptibilities. Preference is given to cephalosporins given the readily available intravenous and oral formulations, tolerability, as well as the risk of phlebitis and infusion pain associated with penicillinase resistant penicillins [6 ▪ ]. Clindamycin is often used due to the theoretical ability to suppress the synthesis of bacterial toxins.…”

“…Recent findings in the last year advocate for reduced ancillary testing in suspected SSSS, and to consider cephalosporins as first-line therapy for MSSA coverage [6 ▪ ,8].…”

“…Patients with SSSS commonly receive ancillary testing in the inpatient setting [4]. In a recent retrospective cohort of 85 paediatric cases with SSSS, Gray et al [6 ▪ ] demonstrated that laboratory studies, such as complete blood counts, chemistry analysis and inflammatory markers were often within normal limits and nonspecific. In contrast to adult patients, bacteraemia in children with SSSS is rare [5].…”