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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 38-41

A clinico – epidemiological and bacteriological study of secondary pyoderma from a tertiary care hospital in South India


1 Consultant Dermatologist, Hyderabad, India
2 Department of Dermatology, M. S. Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
3 Department of Microbiology, M. S. Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India

Date of Submission11-Feb-2021
Date of Decision23-Sep-2021
Date of Acceptance04-Oct-2021
Date of Web Publication25-Feb-2022

Correspondence Address:
Arakali Lakshminarayana Shyam Prasad
Department of Dermatology, M. S. Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_10_21

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  Abstract 


Background: Pyodermas, one of the most common clinical conditions encountered in dermatological practice in all age groups, are further classified into primary (including superficial and deep) and secondary. Bacterial infections occurring in preexisting dermatoses constitute secondary pyodermas and comprise infected eczemas/scabies/foot ulcers, surgical site infections and others. Objectives: This study was carried out to evaluate the clinical, epidemiological, and bacteriological features of secondary pyodermas in a tertiary hospital and document the various patterns of antibiotic resistance. Materials and Methods: This observational study was conducted on 101 consecutive cases of secondary pyodermas, both outpatients and inpatients, of a tertiary care hospital, over a period of 12 months. Clinicoepidemiological data was recorded, and pus samples were collected using sterile swabs for microbiological testing. Results: Diabetes mellitus was the most common comorbidity (n = 50). Of the total cases of secondary pyodermas, thirty (29.7%) were diabetic foot ulcers, and most lesions were of 2–5 cm size (n = 47), present for a duration of <1 week (n = 39), followed by 1–6 weeks (n = 35). Methicillin Susceptible Staphylococcus aureus (n = 38) among Gram-positive bacteria and Pseudomonas aeruginosa (n = 17) among Gram-negative bacteria were the most common organisms isolated. A high percentage of isolates exhibited antibiotic resistance, with Gram-positive bacteria showing resistance to Ciprofloxacin, Amoxycillin with Clavulanic acid, and Clindamycin but susceptibility to Linezolid, Cloxacillin, and Doxycycline. Among the Gram-negative isolates, there was antibiotic resistance toward most groups. Conclusion: As multi-drug resistance is an emerging concern, knowledge of associated comorbid conditions and documenting bacterial isolates and their sensitivity patterns becomes increasingly important.

Keywords: Antibiotic resistance, cutaneous bacterial infections, MRSA, MSSA, Pseudomonas, pyoderma


How to cite this article:
Atmakuri D, Shyam Prasad AL, Gayathri Devi D R. A clinico – epidemiological and bacteriological study of secondary pyoderma from a tertiary care hospital in South India. Clin Dermatol Rev 2022;6:38-41

How to cite this URL:
Atmakuri D, Shyam Prasad AL, Gayathri Devi D R. A clinico – epidemiological and bacteriological study of secondary pyoderma from a tertiary care hospital in South India. Clin Dermatol Rev [serial online] 2022 [cited 2022 May 17];6:38-41. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/1/38/338573




  Introduction Top


Cutaneous bacterial infections are among the most common diseases encountered in any dermatology outpatient setting. They are also extremely common in the Indian community, especially in children and in people of lower socioeconomic status.[1],[2] They are frequently seen in patients with comorbidities such as diabetes mellitus and immunosuppression.[1] The human skin is colonized by many bacteria which lie harmlessly as commensals on the surface and within the hair follicle.[1] The collective name given for cutaneous bacterial infections, which tend to produce pus, is pyoderma. Compromised integrity of the skin can lead to infections which could occur on previously normal skin (primary pyodermas) or on already damaged skin (secondary pyodermas).

Bacterial infections are most often caused by Gram-positive organisms, especially Staphylococcus and Streptococcus species, although other bacteria may occasionally be involved in causation of these diseases. Secondary infection can complicate many preexisting dermatoses, especially scabies, eczemas, fungal or viral infections, chronic ulcers, and following surgery or injury.[2] Certain diseases such as hidradenitis suppurativa, acne keloidalis nuchae, and acne conglobata are also considered to be secondary pyodermas.[3]

There is a paucity of data from Indian studies regarding secondary pyodermas. Documentation is of public health importance due to the increasing incidence of antimicrobial resistance, a consequence of indiscriminate antibiotic use in the general population.[4],[5] Emergence of drug resistance poses a potent problem to clinicians as most bacterial strains are now found to be resistant to one or more antibiotics.[6],[7]

This study helps to document the organisms isolated and their susceptibility patterns in secondary pyodermas, in correlation with clinical and etiological data in a tertiary care hospital. Having appropriate information on the causative organisms of secondary pyodermas and knowledge about their susceptibility pattern helps provide cost effective antibiotic therapy and achieving better treatment outcomes, thereby preventing drug resistance and improving patient compliance to treatment.[8]


  Materials and Methods Top


This was an observational study in a tertiary care hospital in Bangalore, South India, for a period of 12 months from January 2016 to December 2016, on 101 consecutive cases of secondary pyodermas. Based on the study of Malhotra et al.[5] and expecting similar findings, with a precision rate of 20% and a confidence interval of 95%, a sample size of 96 was estimated. On obtaining ethical approval (Ref. No: MSRMC/EC/2016), the cases were selected from outpatient and inpatient setting of the hospital during the study period and their clinicoepidemiological data were collected and recorded. A sample of pus was collected after rupture of intact pustules or removal of crusts or from deeper areas of the lesions, by means of sterile swabs for microbiological testing. The samples were inoculated on blood agar, MacConkey agar, and thioglycollate broth and incubated at 37°C for 24–48 h. Colonies grown on the plate were identified by Gram staining and morphology. Antimicrobial susceptibility tests were performed by diffusion method and the organisms were identified as resistant or susceptible. All patients with clinical diagnosis of secondary pyoderma were included and cases of pyoderma without a preexisting history of causality were excluded from the study. Descriptive statistics of isolates of bacteria from secondary pyoderma and its sensitivity to antibiotics were analyzed and presented in terms of percentage.


  Results Top


We conducted the present study on 101 consecutive cases of pyoderma at a tertiary care hospital. The male-to-female ratio was found to be 1.5:1 with 61 (60.4%) males and 40 (39.6%) females. Most cases of secondary pyodermas were found in the age group of >50 years. Out of the total cases of secondary pyodermas, the majority were present for a duration of <1 week (39 cases), followed by 1–6 weeks (35 cases).

Various etiological factors of secondary pyodermas seen in this study are shown in [Table 1]. Of all the factors, maximum number of cases were due to nonhealing ulcers secondary to diabetes (30 cases), followed by varicose ulcers (19 cases) and infected eczemas (18 cases).
Table 1: Etiological factors of secondary pyodermas

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[Table 2] shows the various bacterial isolates in secondary pyodermas. Of the 101 cases, 51 were caused by Gram-positive bacteria and 50 cases were caused by Gram-negative bacteria. MSSA (n = 38) was the most common Gram-positive bacteria and Pseudomonas aeruginosa (n = 17) was the most common Gram-negative one. There was only one case of MRSA.
Table 2: Classification of bacteria causing the secondary pyodermas

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Antibiotic susceptibility testing was performed on all isolates. The significant findings are highlighted in [Table 3] and [Table 4]. There was a high resistance to Ciprofloxacin among the Gram-positive isolates, and a significant resistance to Erythromycin, Amoxycillin with Clavulanic acid and Clindamycin. Most of these bacteria were susceptible to Linezolid, Cloxacillin, and Doxycycline. The solitary isolate of MRSA was susceptible to Amoxycillin with Clavulanic acid and Clindamycin, but resistant to Ciprofloxacin and Erythromycin. On the other hand, Gram-negative bacteria showed high levels of resistance to most of the antibiotics tested. Surprisingly, Pseudomonas aeruginosa isolates showed a higher susceptibility to Ciprofloxacin and Ampicillin, as compared to Klebsiella pneumonia and Escherichia coli.
Table 3: Highest resistant patterns for Gram-positive organisms

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Table 4: Highest resistance patterns for Gram-negative organisms

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  Discussion Top


The present study was undertaken primarily to determine the antibacterial resistance in cases of secondary pyoderma. On account of high prevalence of pyoderma cases in any dermatological setting, the need to administer antibiotics is significant, but understanding the etiological agents and predisposing factors and effective methods to control them is just as important as having information about the susceptibility patterns, especially in cases of secondary pyoderma.

The male-to-female ratio in this study was found to be 1.5:1 with 61 (60.4%) males and 40 (39.6%) females, similar to studies conducted by Janardhan et al.[8] and Singh et al.[2] where males were slightly more affected than females. The commonly affected age group in the present study was >50 years, but maximum cases of pyoderma were found to be in the pediatric age (0–10 years) in most other studies,[9],[10],[11] with higher incidence in the age group of <0 years. The reason for this discrepancy could be that all the above-mentioned studies were done on both primary and secondary pyodermas, whereas the current study included only cases of secondary pyodermas, where comorbidities play a significant role.

In this study, diabetes mellitus (n = 50) was the most common co-morbid condition observed, whereas gastrointestinal diseases such as ulcerative colitis, gastric disorders, and chronic active hepatitis were the commonly seen comorbidities in the study conducted by Ghazal et al.[12]

Out of total 101 cases of secondary pyodermas, diabetic foot ulcers were the maximum cases, seen in 30 cases (29.7%), followed by secondarily infected varicose ulcers in 19 cases (18.8%) and infected eczemas in 18 cases (17.8%). In the study conducted by Badabagni et al.[13] and Ramesh,[14] infected scabies and infected eczema were the commonly found secondary pyodermas. Since the setting of our study was a tertiary care private hospital, it is likely that scabies, which is prevalent among the lower socioeconomic group, would not be commonly encountered.

MSSA (n = 38) among Gram-positive bacteria and Pseudomonas aeruginosa (n = 17) among Gram-negative bacteria were the most common organisms isolated from the skin lesions of secondary pyoderma. Staphylococcus aureus was the most common causative organism seen in the study conducted by Gandhi et al.[15] and Singh et al.,[2] whereas Escherichia coli was the most common causative organism isolated from secondary pyodermas, followed by Citrobacter and Pseudomonas aeruginosa in the study conducted by Singh et al.[2]

The high incidence of Pseudomonas aeruginosa in our study probably reflects nosocomial infections, as there were many inpatients in the study group. Among Gram-positive bacteria, as expected, MSSA was the largest group. Surprisingly, in the present climate of MRSA, we could find only one such infection.

The interesting findings related to the antibiotic susceptibility patterns. We found that a high percentage of MSSA were resistant to Ciprofloxacin (35/38) and to a lesser extent to the common antibiotics used as first line for Gram-positive infections, namely Erythromycin, Amoxicillin with Clavulanic acid, and Clindamycin. MSCN Staphylococci also showed a similar resistance pattern, but to a lesser extent. However, most of these isolates were found susceptible to Linezolid, Cloxacillin, and Doxycycline.

Gram-negative bacterial infections, namely Pseudomonas aeruginosa, Klebsiella pneumonia, and Escherichia coli were found to demonstrate disturbingly high levels of resistance to almost all classes of antibiotics. Consequently, it becomes difficult to recommend any particular class of antibiotics which could be used as first-line therapy.


  Conclusion Top


Our study mainly focuses on secondary pyodermas, their clinical and bacteriological profile along with their antimicrobial susceptibility. Documentation of etiology and antibiotic resistance patterns in urban and rural areas, in primary, secondary, and tertiary health-care settings, as well as the community, is essential for optimal antibiotic usage and combating the increasing levels of drug resistance. MSSA among Gram-positive bacteria and Pseudomonas aeruginosa among Gram-negative bacteria were the most common organisms isolated from secondary pyoderma skin lesions. As multi-drug resistance is an emerging concern, knowledge of associated comorbid conditions and accurate antibiotic therapy that alleviate secondary pyodermas is essential to avoid ineffective drug therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hay RJ, Adriaans BM. Bacterial infections. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 8th ed. U.K: Wiley-Blackwell; 2010. p. 30.1-30.3.  Back to cited text no. 1
    
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Singh A, Gupta LK, Khare A, Mittal A, Kuldeep CM, Balai M. A clinico-bacteriological study of pyodermas at a tertiary health center in southwest Rajasthan. Indian J Dermatol 2015;60:479-84.  Back to cited text no. 2
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Bhat R. Bacterial infections. In: Sacchidanand S, editor. IADVL Textbook of Dermatology. 4th ed. Mumbai: Bhalani Publishing House; 2015. p. 437-8.  Back to cited text no. 3
    
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Furtado S, Bhat RM, Rekha B, Sukumar D, Kamath GH, Martis J, et al. The clinical spectrum and antibiotic sensitivity patterns of staphylococcal pyodermas in the community and hospital. Indian J Dermatol 2014;59:143-50.  Back to cited text no. 4
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Malhotra SK, Malhotra S, Dhalimal G, Thakur A. Bacteriological study of pyodermas in a tertiary care dermatological center. Ind J Dermatol 2012;57:358-36.  Back to cited text no. 5
    
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Ramani TV, Jaykar PA. Bacteriological study of 100 cases of pyodermas with special reference to stapylococci, their antibiotic sensitivity and phage pattern. Indian J Dermatol Venereol Leprol 1980;46:282-6.  Back to cited text no. 6
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Bhaskaran CS, Rao PS, Krishnamurty T, Tarachand P. Bacteriological study of pyoderma. Indian J Dermatol Venereol Leprol 1979;45:162-9.  Back to cited text no. 7
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Janardhan B, Prasad GK, Nandeshwar AJ, Vidyavathi N. Clinico-microbiological study of pyodermas. IJRSR 2015;6:3820-4.  Back to cited text no. 8
    
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Chopra A, Purl R, Mittal RR. Correlation of isolates from pyoderma and carrier sites. Indian J Dermatol Venereol Leprol 1995;61:273-5.  Back to cited text no. 9
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Baslas RG, Arora SK, Mukhija RD, Mohan L, Singh UK. Organisms causing pyoderma and their susceptibility patterns. Indian J Dermaol Venereol Leprol 1990;56:127-9.  Back to cited text no. 10
    
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Chopra A, Puri R, Mittal RR, Kanta S. A clinical and bacteriological study of pyodermas. Indian J Dermatol Venereol Leprol 1994;60:200-2.  Back to cited text no. 11
    
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Al Ghazal P, Herberger K, Schaller J, Strölin A, Hoff NP, Goerge T, et al. Associated factors and comorbidities in patients with pyoderma gangrenosum in Germany: A retrospective multicentric analysis in 259 patients. Orphanet J Rare Dis 2013;8:136.  Back to cited text no. 12
    
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Badabagni P, Malkud S. Clinico-etiological study of pyodermas in a tertiary care hospital. Indian J Clin Exp Dermatol 2016;2:53-7.  Back to cited text no. 13
    
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Bhat RM. Recurrent pyoderma in children. Indian J Paediatr Dermatol 2012;13:53-4.  Back to cited text no. 14
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Gandhi S, Ojha AK, Ranjan KP, Neelima. Clinical and bacteriological aspects of pyoderma. N Am J Med Sci 2012;4:492-5.  Back to cited text no. 15
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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