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• W3006859260 abstract "Patients with AD are susceptible to S. aureus colonization and suffer from recurrent S. aureus infections, which most often manifest as circumscribed superinfection of lesional atopic skin (Leung, 2008Leung D.Y.M. Chapter 3. The role of Staphylococcus aureus in atopic eczema.Acta Dermato Venereol. 2008; 88: 21-27Crossref Scopus (11) Google Scholar). In contrast, SAB is a particularly severe disease with a high risk of complications, such as deep-seated metastatic foci, endocarditis, septic shock, or recurrences, and an in-hospital mortality rate of 20–30% (van Hal et al., 2012van Hal S.J. Jensen S.O. Vaska V.L. Espedido B.A. Paterson D.L. Gosbell I.B. Predictors of mortality in Staphylococcus aureus bacteremia.Clin Microbiol Rev. 2012; 25: 362-386Crossref PubMed Scopus (443) Google Scholar). Identified risk factors are, among others, healthcare contact with invasive procedures and interventions, diabetes mellitus, HIV infection, and other primary or secondary T-cell deficiencies. Moreover, the risk to develop invasive S. aureus infections is 4–5 times higher in S. aureus carriers than noncarriers (Wertheim et al., 2005Wertheim H.F. Melles D.C. Vos M.C. van Leeuwen W. van Belkum A. Verbrugh H.A. et al.The role of nasal carriage in Staphylococcus aureus infections.Lancet Infect Dis. 2005; 5: 751-762Abstract Full Text Full Text PDF PubMed Scopus (1598) Google Scholar). Compared with the overall rate of ∼20% permanent carriage in the general population, 70–90% of patients with AD are permanently colonized with S. aureus in high bacterial density, particularly in lesional atopic skin. (Leung, 2008Leung D.Y.M. Chapter 3. The role of Staphylococcus aureus in atopic eczema.Acta Dermato Venereol. 2008; 88: 21-27Crossref Scopus (11) Google Scholar, Totté et al., 2016Totté J.E.E. van der Feltz W.T. Hennekam M. van Belkum A. van Zuuren E.J. Pasmans S.G.M.A. Prevalence and odds of Staphylococcus aureus carriage in atopic dermatitis: a systematic review and meta-analysis.Br J Dermatol. 2016; 175: 687-695Crossref PubMed Scopus (153) Google Scholar, Wróbel et al., 2018Wróbel J. Tomczak H. Jenerowicz D. Czarnecka-Operacz M. Skin and nasal vestibule colonisation by Staphylococcus aureus and its susceptibility to drugs in atopic dermatitis patients.Ann Agric Environ Med. 2018; 25: 334-337Crossref PubMed Scopus (6) Google Scholar). Underlying mechanisms are a combination of reduced expression of innate defense antimicrobial peptides, dysbiosis, and increased adhesion of S. aureus on or within inflammatory lesions (Kim and Leung, 2018Kim B.E. Leung D.Y.M. Significance of skin barrier dysfunction in atopic dermatitis.Allergy Asthma Immunol Res. 2018; 10: 207-215Crossref PubMed Scopus (97) Google Scholar, Leung, 2008Leung D.Y.M. Chapter 3. The role of Staphylococcus aureus in atopic eczema.Acta Dermato Venereol. 2008; 88: 21-27Crossref Scopus (11) Google Scholar, Rieg et al., 2006Rieg S. Seeber S. Steffen H. Humeny A. Kalbacher H. Stevanovic S. et al.Generation of multiple stable dermcidin-derived antimicrobial peptides in sweat of different body sites.J Invest Dermatol. 2006; 126: 354-365Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar, Williams and Gallo, 2017Williams M.R. Gallo R.L. Evidence that human skin microbiome dysbiosis promotes atopic dermatitis.J Invest Dermatol. 2017; 137: 2460-2461Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar). Dense colonization with S. aureus may render patients with AD at risk for developing SAB and perhaps for suffering severe complications owing to a high pathogen inoculum. However, systematic studies of the association of SAB and AD are rare. In two epidemiologic reviews, a higher risk for bacteremia in patients with AD could be identified but without specification of pathogens and clinical manifestations (Narla and Silverberg, 2018Narla S. Silverberg J.I. Association between atopic dermatitis and serious cutaneous, multiorgan and systemic infections in US adults.Ann Allergy Asthma Immunol. 2018; 120: 66-72.e11Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, Oestergaard et al., 2018Oestergaard L.B. Schmiegelow M.D.S. Bruun N.E. Skov R. Andersen P.S. Larsen A.R. et al.Staphylococcus aureus bacteremia in children aged 5–18 years-risk factors in the new millennium.J Pediatr. 2018; 203: 108-115.e3Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). Triggered by the clinical observation of SAB in otherwise healthy young patients with AD, we sought to characterize the clinical manifestations and outcome of SAB in this specific patient subgroup using data of a prospectively evaluated cohort. This study is a post hoc analysis of data collected at the University Medical Center Freiburg. Since 2006, blood cultures growing S. aureus are reported daily by the microbiology laboratory with the intention that all patients with SAB are prospectively evaluated by infectious disease physicians on the ward. Definitions and collected data of the resulting prospective SAB cohort have been described in detail previously (Rieg et al., 2017Rieg S. Joost I. Weiß V. Peyerl-Hoffmann G. Schneider C. Hellmich M. et al.Combination antimicrobial therapy in patients with Staphylococcus aureus bacteraemia-a post hoc analysis in 964 prospectively evaluated patients.Clin Microbiol Infect. 2017; 23: 406.e1-406.e8Abstract Full Text Full Text PDF Scopus (31) Google Scholar). In three consecutive years (2014–2016), 419 patients with SAB were prospectively evaluated for the presence of AD. If AD or atopic eczema was reported in the past medical history and/or if clinical findings were consistent with AD or dermatitis as judged by infectious diseases physicians, patients were reviewed and evaluated by a dermatological consultant (SR), who either approved or discarded the diagnosis of AD on the basis of the diagnostic criteria of Hanifin and Rayka, 1980Hanifin J.M. Rayka G. Diagnostic features of atopic dermatitis.Acta Dermato Venereol (Suppl). 1980; 92: 44-47Google Scholar. The institutional review board of the University Medical Center Freiburg considered the investigation as evaluation of service within a quality assurance program and waived the need for written informed consent. The study is registered in the German Clinical Trials registry (DRKS00005045). Statistical analysis was performed using R Studio (R Core Team, Vienna, Austria). P-values < 0.05 were considered to be statistically significant. Of the 419 included patients with SAB, 14 patients (3.3%) were diagnosed with mild or moderate AD. A comparison of epidemiologic and clinical characteristics is outlined in Table 1. Patients with SAB with AD were younger, with a median age of 56 years (vs. 64 years in patients without AD), and had significantly fewer comorbidities (Charlson comorbidity index 2.7 vs. 5.9, P = 0.001). SAB in patients with AD was more often hospital-acquired (defined as onset of SAB > 48 hours after hospital admission, 57% vs. 39%, P = 0.23). The portal of entry was an intravascular catheter in seven patients (50%) or the skin in five patients (36%). Accordingly, in patients with AD, the identified main foci of infection (i.e., the most severe manifestation in a patient, thereby defining management and treatment duration) were either skin and soft tissue infections or intravascular catheter–related infections in 71% of patients (3 and 7 patients, respectively), differing significantly from patients without AD, in which infective endocarditis (10%), osteoarticular infections or a deep-seated abscess (20%), pneumonia (15%), or unknown foci accounted for most main foci. Overall, the clinical course of SAB was less severe in patients with AD, with only 14% of patients developing severe sepsis and no cases of septic shock (vs. 31% in patients without AD). No case of infective endocarditis was observed. One patient in the AD group died during hospitalization owing to his underlying conditions (all-cause in-hospital mortality 7% vs. 20% in non-AD group). There was no SAB-related death in the AD group, whereas 52 patients (13%) died as a consequence of SAB during hospitalization in the non-AD group (Table 1).Table 1Comparison of Epidemiological and Clinical Characteristics in Patients with SAB with and without ADCharacteristicAlln = 419AD+n = 14AD−n = 405P-ValueAge, median (Q1-Q3)64 (53–77)56 (44–67)64 (54–77)0.091Mann-Whitney U Test was used.Female142 (34%)6 (43%)136 (34%)0.57Charlson comorbidity index, mean (Q1-Q3)5.8 (3–8)2.7 (1.3–4)5.9 (3–9)0.0011Mann-Whitney U Test was used.Mode of acquisition0.232Chi-square test was used; all others used Fisher’s exact test. Community-acquired106 (25%)4 (29%)102 (n = 403; 25%) Community-acquired healthcare-associated146 (35%)2 (14%)144 (n = 403; 36%) Hospital-acquired165 (39%)8 (57%)157 (n = 403; 39%) MRSA as causative pathogen26 (6%)1 (7%)25 (6%)0.60Portal of entry0.032Chi-square test was used; all others used Fisher’s exact test. Skin lesion incl. surgical wound infection67 (16%)5 (36%)62 (15%) Intravascular catheter-related154 (37%)7 (50%)147 (36%) Intravascular drug abuse18 (4%)018 (4%) Other (including urogenital tract)46 (11%)046 (11%) Unknown133 (32%)2 (14%)131 (32%)Main focus0.022Chi-square test was used; all others used Fisher’s exact test. SSTI41 (10%)3 (21%)38 (9%) Intravascular catheter-related133 (33%)7 (50%)126 (31%) Infective endocarditis39 (9%)039 (10%) Pneumonia and other foci59 (14%)059 (15%) Osteoarticular infections, deep tissue/visceral abscesses84 (20%)4 (29%)80 (20%) Unknown62 (15%)062 (15%)Clinical characteristics Severe sepsis or septic shock128 (31%)2 (14%)126 (31%)0.24 Secondary foci of hematogenous dissemination37 (9%)1 (7%)36 (9%)0.79Mortality and follow-up All-cause in-hospital mortality82 (20%)1 (7%)81 (20%)0.32 SAB-related in-hospital mortality52 (13%)052 (13%)0.24 Mortality at day 90 post-onset100 (n = 324; 31%)1 (n = 10; 10%)99 (n = 314; 32%)0.18Abbreviations: AD, atopic dermatitis; MRSA, methicillin-resistant Staphylococcus aureus; Q, quartile; SAB, Staphylococcus aureus bloodstream infection SSTI, skin and soft tissue infection.1 Mann-Whitney U Test was used.2 Chi-square test was used; all others used Fisher’s exact test. Open table in a new tab Abbreviations: AD, atopic dermatitis; MRSA, methicillin-resistant Staphylococcus aureus; Q, quartile; SAB, Staphylococcus aureus bloodstream infection SSTI, skin and soft tissue infection. We found SAB in patients with AD to be hospital-acquired in about 60% of cases. The portals of entry and main foci were almost exclusively intravascular catheters and skin or soft tissue infections. Mortality was lower and complications less frequent compared with SAB in patients without AD. The observed AD rate of 3.3% in our SAB cohort is in the range of the reported AD prevalence of 1–3% at the age of ∼60 years (Bozek et al., 2012Bozek A. Fisher A. Filipowska B. Mazur B. Jarzab J. Clinical features and immunological markers of atopic dermatitis in elderly patients.Int Arch Allergy Immunol. 2012; 157: 372-378Crossref PubMed Scopus (25) Google Scholar, Tanei and Hasegawa, 2016Tanei R. Hasegawa Y. Atopic dermatitis in older adults: a viewpoint from geriatric dermatology.Geriatr Gerontol Int. 2016; 16: 75-86Crossref PubMed Scopus (41) Google Scholar). However, as we did not systematically investigate all patients with SAB with regard to the presence of minor AD manifestations (or having suffered from AD in childhood) and because hospitalization in AD is often a consequence of S. aureus superinfection, which may introduce selection bias, our study does not allow for firm conclusions if and to what extent AD may represent a risk factor for developing SAB. Only a population-based study could clearly delineate the prevalence of SAB in AD. Because of the observed differential pattern of portal of entry and main focus, our study indicates that atopic skin, either directly via superinfection of lesional AD skin, or indirectly via intravascular catheters, plays a major role in the development of SAB in patients with AD. As S. aureus carriage is a known risk factor for invasive infections and SAB, and ∼90% of SAB isolates are of endogenous origin, the high-level S. aureus colonization in AD may be even more so. Treatment outcome was better in patients with AD, which is most likely because of the fact that patients with AD were younger and suffered from fewer comorbidities and, as outlined above, portals of entry and main foci were predominantly superficial (i.e., uncomplicated). Nevertheless, prompt and adequate diagnostic and therapeutic management (basic principles are outlined in Table 2) are indispensable, as severe sequelae of uncomplicated SAB undoubtedly may arise if rigorous diagnostic work-up and antibiotic treatment are not secured (Park et al., 2019Park B.W. Shin Y.S. Cho E.B. Park E.J. Kim K.H. Kim K.J. Two cases of infective endocarditis in patients with atopic dermatitis.Ann Dermatol. 2019; 31: 70-74Crossref Scopus (1) Google Scholar).Table 2Management Standards of SAB in Patients with ADPrevention and Early Detection of SABAdequate treatment of AD to reduce adherence and high-level colonization of S. aureus on lesional skinMeticulous care of intravascular (peripheral or central) catheters with daily exchange of dressingNo placement of intravenous catheters in areas of lesional atopic skinDaily critical review concerning indication of intravascular catheterEarly removal of intravascular catheters with direct or indirect signs of infection (loss of function, erythema, warmth, tenderness, and secretion)Sampling of blood cultures before initiation of antibiotic treatmentDiagnostic Quality-of-Care Standards in SABBlood culture sampling every 24–48 hours to demonstrate bloodstream sterilizationThorough clinical examination to evaluate the portal of entry, main focus and (depending on clinical signs and symptoms) sites of metastatic seeding (psoas abscess, joint empyema, vertebral osteomyelitis, endocarditis, intravascular [e.g., pacemaker], or orthopedic devices)If suspicion of deep-seated focus or metastatic seeding, complementary imaging (abdominal ultrasound scan, CT, or MRI)Transthoracic and/or transesophageal echocardiography to rule out infective endocarditisTherapeutic Quality-of-Care Standards in SABIntravenous antibiotic treatment with agents of choice being flucloxacillin or cefazolin in MSSA and vancomycin or daptomycin in MRSA bloodstream infectionAdequate treatment duration (2 weeks in uncomplicated SAB [main focus (removable) intravascular catheter or skin and/or soft tissue infection], 4–6 weeks in complicated SAB [with any deep-seated foci, endocarditis, or osteoarticular infection])Early source and focus control, that is, removal of intravascular catheters, infected foreign devices, or debridement and drainage of abscessesAbbreviations: AD, atopic dermatitis; CT, computer tomography; MRI, magnetic resonance imaging; MSSA, methicillin-sensitive Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; SAB, Staphylococcus aureus bloodstream infection. Open table in a new tab Abbreviations: AD, atopic dermatitis; CT, computer tomography; MRI, magnetic resonance imaging; MSSA, methicillin-sensitive Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; SAB, Staphylococcus aureus bloodstream infection. Besides adequate management, prevention is pivotal (Table 2). Therefore, intravascular catheters (short- or long-term) should be used only when clearly indicated, as high-density S. aureus colonization may lead to catheter infection even within 24–48 hours, that is, in peripheral (very) short-term intravascular catheters. If catheters are placed, meticulous care and screening for complications is warranted. Development of fever in patients with AD and indwelling intravascular catheters should trigger prompt sampling of blood cultures. If no other plausible focus of infections can be detected, early catheter removal is mandatory, particularly upon loss of function of the catheter or development of any signs of inflammation or infection at the catheter site. Larger prospective studies are needed to substantiate the findings of this monocenter cohort study. However, SAB is yet another reason to tackle the vicious circle of S. aureus and AD in our patients. Original data is available on request. Philipp J. G. Mathé: http://orcid.org/0000-0002-0448-5338 Insa Joost: http://orcid.org/0000-0003-3162-920X Gabriele Peyerl-Hoffmann: http://orcid.org/0000-0002-0670-4848 Christian Schneider: http://orcid.org/0000-0002-8510-9472 Winfried Kern: http://orcid.org/0000-0003-2550-358X Siegbert Rieg: http://orcid.org/0000-0001-7493-7080 The authors state no conflicts of interest. Conceptualization: SR, WK; Data Curation: GPH, IJ, SR; Formal Analysis: PJGM, SR, WK; Investigation: CS, IJ, SR; Methodology: SR; Project Administration: SR; Resources: CS; Supervision: SR, WK; Validation: SR, WK; Visualization: PJGM, SR; Writing - Original Draft Preparation: PJGM, SR; Writing - Review and Editing: IJ, PJGM, SR, WK" @default.
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• W3006859260 title "Staphylococcus aureus Bloodstream Infection in Patients with Atopic Dermatitis, or: Think Twice Before Placing a Venous Catheter into Lesional Atopic Skin" @default.
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