Bullous erysipelas: clinical presentation, staphylococcal involvement and methicillin resistance

Konstantin Krasagakis, George Samonis, Panagiotis Maniatakis, Sophia Georgala, Androniki Tosca
Dermatology: International Journal for Clinical and Investigative Dermatology 2006, 212 (1): 31-5

BACKGROUND: Erysipelas is a bacterial infection of the dermis and hypodermis, mostly of streptococcal origin. Bullous erysipelas represents a severe form of the disease.

OBJECTIVE: To evaluate the clinical and microbiological characteristics and treatment of bullous erysipelas.

METHODS: Patients with a diagnosis of bullous erysipelas who were treated at the Department of Dermatology, University Hospital of Heraklion, Crete, Greece, between the years 1996 and 2001 were retrospectively studied.

RESULTS: Fourteen patients (11 women, 3 men) with bullous erysipelas were evaluated. The lesions were located on the legs and face in 9 and 4 patients, respectively. The median duration of disease before hospital admission was 4 days. Eight patients had fever at presentation. Local trauma and various lesions were common causes for pathogen entry. The initial empirical antibiotic treatment included intravenous beta-lactams and was modified according to the sensitivities of the isolated strains. Staphylococcus aureus was isolated from 7 (50%), while S. warneri, Streptococcus pyogenes and Escherichia coli grew from the lesions of 3 other patients. Six out of 7 S. aureus strains were methicillin resistant (MRSA) but susceptible to several other non-beta-lactam antibiotics such as quinolones, vancomycin, rifampicin and trimethoprim/sulfamethoxazole.

CONCLUSION: Our findings suggest that S. aureus is frequently involved in and probably contributes in synergy with beta-hemolytic streptococci to the complicated course of bullous erysipelas. The frequency of MRSA isolation suggests that beta-lactam antibiotics may not be sufficient for the treatment of bullous erysipelas anymore, at least in areas with a high incidence of MRSA strains. The role of other classes of antibiotics providing adequate coverage for MRSA has to be evaluated in prospective clinical trials.

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