Three Cases of Non-Tuberculosis Mycobacterium Skin Infection Outbreak in Beauty Institutions.

BACKGROUND: From June 2021 to July 2021, our hospital confirmed 3 cases of Mycobacterium infection in skin abscesses. All 3 patients underwent thread embedding and weight loss surgery at the same informal beauty institution, with a history of silk protein injection. None of the patients had any other underlying diseases or surgical history. Symptoms and signs show that the disease is acute and the course of the disease is short. All patients have found subcutaneous masses in different parts of the body. In most cases, the masses show redness and swelling, and some of the masses are accompanied by tenderness, wave sensation, and rupture. After some of the masses rupture, purulent secretions can be seen. METHODS: The pus secreted by the skin lesions of the three patients were cultured to a single bacterium, which was identified by MALDI-TOF MS. Multiple locus sequence typing (MLST) was performed using three specific genes (hsp65, rpoB, and secA1) and seven housekeeping genes (argH, cya, glpK, gnd, murC, pta, and purH). The results were queried through the MLST database of Mycobacterium abscess. RESULTS: All three strains of bacteria were Mycobacterium abscess type ST279 massiliense subtype. Three antibacterial drugs including cefmetazole, amikacin, and clarithromycin were administered in combination with 5-aminolevulinic acid photodynamic therapy (ALA-PDT). After 3 - 6 months, there was no obvious redness or swelling in the surrounding tissues of the wound, and no obvious purulent secretions were observed. All patients were cured and discharged from the hospital. After a follow-up of six months, there was no recurrence of the lesions. CONCLUSIONS: Medical institutions must strictly follow infection control guidelines and take preventive measures to prevent such incidents from happening again. ALA-PDT as a combination therapy for nontuberculous Mycobacterium (NTM) skin infections can improve treatment efficacy and shorten antibiotic usage time.

Investigation on an outbreak of cutaneous anthrax in a county of Shandong Province, China, 2021.

BACKGROUND: In order to verify the existence of an anthrax outbreak, determine its scope, grasp the epidemiological characteristics and find out the cause of the outbreak and recommend preventive and control measures. METHODS: Etiological hypothesis was developed through descriptive epidemiological methods. Hypotheses were tested by analyzing epidemiological methods by comparing the differences in the incidence of different exposure types. Nucleic acid detection and bacterial isolation and culture in the BSL-2 laboratories. SPSS 21 was used to conduct statistical analysis. RESULTS: A total of 126 family, workshop, shop environment samples and meat samples were collected, and 6 samples were collected from skin lesions of suspected cutaneous anthrax cases. 41 samples were positive by rPCR and 8 strains of Bacillus anthracis were cultivated. Participated in slaughtering, cutting beef of sick cattles was significantly associated with cutaneous anthrax (RR 3.75, 95% CI 1.08-13.07), this behavior is extremely dangerous. CONCLUSIONS: Comprehensive analysis of laboratory results and epidemiological survey results and environmental assessments, we judge this epidemic to be an outbreak of cutaneous anthrax, associated with slaughtering and other processes from infected cattle imported from other province.

Mycobacterium porcinum Skin and Soft Tissue Infections After Vaccinations - Indiana, Kentucky, and Ohio, September 2018-February 2019.

During December 2018-February 2019, a multistate investigation identified 101 patients with vaccination-associated adverse events among an estimated 940 persons in Kentucky, Indiana, and Ohio who had received influenza; hepatitis A; pneumococcal; or tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines at the workplace during September 11-November 28, 2018. These vaccines had been administered by staff members of a third-party health care company contracted by 24 businesses. Company A provided multiple vaccine types during workplace vaccination events across 54 locations in these adjoining states. Injection-site wound isolates from patients yielded Mycobacterium porcinum, a nontuberculous mycobacteria (NTM) species in the Mycobacterium fortuitum group; subtyping using pulsed-field gel electrophoresis of all 28 available isolates identified two closely related clusters. Site visits to company A and interviews with staff members identified inadequate hand hygiene, improper vaccine storage and handling, lack of appropriate medical record documentation, and lack of reporting to the Vaccine Adverse Event Reporting System (VAERS). Vaccination-associated adverse events can be prevented by training health care workers responsible for handling or administering vaccines in safe vaccine handling, administration, and storage practices, timely reporting of any suspected vaccination-associated adverse events to VAERS, and notifying public health authorities of any adverse event clusters.

Investigation of an anthrax outbreak in Makoni District, Zimbabwe.

BACKGROUND: Anthrax continues to be a disease of public health importance in Zimbabwe, with sporadic outbreaks reported annually in many parts of the country. A human anthrax outbreak occurred in wards 22 and 23 of Makoni District from mid-June 2013 to end of January 2014, following cattle deaths in the wards. Laboratory tests confirmed anthrax as the cause for the cattle deaths. This study investigated the clinical characteristics, distribution of cases (places, person and time) and risk factors for contracting the anthrax disease. We also assessed the environment, district preparedness and response, and outbreak prevention and control measures. METHODS: We conducted an outbreak investigation using a mixed-methods design. A 1:1 case-control study was used to assess risk factors for contracting anthrax. The controls were frequency matched to cases by sex. Data were collected using a structured interviewer-administered questionnaire. Environmental assessment, district preparedness and response, and outbreak prevention and control measures were assessed using a checklist, observations, and key informant interviews. Multivariable unconditional logic regression analysis was performed to identify independent risk factors associated with contracting anthrax. RESULTS: We interviewed 37 of the 64 cases, along with 37 controls. All the cases had cutaneous anthrax, with the hand being the most common site of the eschar (43%). Most of the cases (89%) were managed according to the national guidelines. Multivariable analysis demonstrated that meat sourced from other villages [vs butchery, OR = 15.21, 95% CI (2.32-99.81)], skinning [OR = 4.32, 95% CI (1.25-14.94)], and belonging to religions that permit eating meat from cattle killed due to unknown causes or butchered after unobserved death [OR = 6.12, 95% CI (1.28-29.37)] were associated with contracting anthrax. The poor availability of resources in the district caused a delayed response to the outbreak. CONCLUSION: The described anthrax outbreak was caused due to contact with infected cattle meat. Although the outbreak was eventually controlled through cattle vaccination and health education and awareness campaigns, the response of the district office was initially delayed and insufficient. The district should strengthen its emergency preparedness and response capacity, revive zoonotic committees, conduct awareness campaigns and improve surveillance, especially during outbreak seasons.

Sanitation, Obesity, and Low Body Mass Index as Risk Factors for Bacterial Skin Infections.

BACKGROUND: Bacterial skin infections can cause significant disability and can lead to mortality with inadequate treatment. OBJECTIVE: To determine whether sanitation and body mass index (BMI) are statistically significant risk factors for the incidence and prognosis of bacterial skin infections. METHODS: Country-level data regarding the age-standardized rates of incidence, prevalence, and years lived with disability (YLD) from bacterial skin infection per 100 000 persons from the Global Burden of disease dataset, and country-level data on age-standardized prevalence of obesity (BMI ≥30) and low BMI (BMI <18.5) from World Health Organization Global Health Observatory data repository were analyzed. Regression models were created to examine the effects of sanitation, obesity, and low BMI on the burden of bacterial skin infections. RESULTS: The percentage of population using basic sanitation services was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05). After controlling for sanitation, in countries with more than 50% of the population using basic sanitation services, obesity was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05). In countries with less than or equal to 50% of the population using basic sanitation services, low BMI was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05). CONCLUSIONS: Improving sanitation access in all countries, reducing the percentage of obese population in countries with good sanitation/hygiene techniques, and addressing malnutrition in countries with poor sanitation/hygiene techniques may help to reduce the burden of bacterial skin infections.

Bacterial Skin Infections in Hospitalized Patients with Bullous Pemphigoid.

OBJECTIVE: To explore the features and risk factors of bacterial skin infections (BSIs) in hospitalized patients with bullous pemphigoid (BP). METHODS: Records were retrospectively reviewed for 110 hospitalized patients with BP admitted to Peking University First Hospital between 2013 and 2019. Bacterial species and drug resistance were assessed, and then the underlying risk factors for BSIs were evaluated. RESULTS: Infections were present in 40% (44/110) of the patients. Staphylococcus aureus (72.7%, 32/44) was the most common bacterium, and it was highly resistant to penicillin (81.3%, 26/32), erythromycin (62.5%, 20/32), and clindamycin (56.3%, 18/32), but 100.0% sensitive to vancomycin and tigecycline. Coronary heart disease (P = .02; odds ratio [OR], 12.68), multisystem comorbidities (P = .02; OR, 3.67), hypoalbuminemia (P = .04; OR, 3.70), high levels of anti-BP180 antibodies (>112.4 U/mL; P = .003; OR, 6.43), and season (spring: reference; summer: P = .002; OR, 23.58; autumn: P = .02; OR, 12.19; winter: P = .02; OR, 13.19) were significantly associated with BSIs. CONCLUSIONS: Hospitalized patients with BP had a high incidence of BSIs, and those patients with underlying risk factors require careful management to prevent and control BSIs.

Longitudinal Analysis of Group A Streptococcus emm Types and emm Clusters in a High-Prevalence Setting: Relationship between Past and Future Infections.

Group A Streptococcus is a pathogen of global importance, but despite the ubiquity of group A Streptococcus infections, the relationship between infection, colonization, and immunity is still not completely understood. The M protein, encoded by the emm gene, is a major virulence factor and vaccine candidate and forms the basis of a number of classification systems. Longitudinal patterns of emm types collected from 457 Fijian schoolchildren over a 10-month period were analyzed. No evidence of tissue tropism was observed, and there was no apparent selective pressure or constraint of emm types. Patterns of emm type acquisition suggest limited, if any, modification of future infection based on infection history. Where impetigo is the dominant mode of transmission, circulating emm types either may not be constrained by ecological niches or population immunity to the M protein, or they may require several infections over a longer period of time to induce such immunity.

Control and Prevention of Anthrax, Texas, USA, 2019.

The zoonotic disease anthrax is endemic to most continents. It is a disease of herbivores that incidentally infects humans through contact with animals that are ill or have died from anthrax or through contact with Bacillus anthracis-contaminated byproducts. In the United States, human risk is primarily associated with handling carcasses of hoofstock that have died of anthrax; the primary risk for herbivores is ingestion of B. anthracis spores, which can persist in suitable alkaline soils in a corridor from Texas through Montana. The last known naturally occurring human case of cutaneous anthrax associated with livestock exposure in the United States was reported from South Dakota in 2002. Texas experienced an increase of animal cases in 2019 and consequently higher than usual human risk. We describe the animal outbreak that occurred in southwest Texas beginning in June 2019 and an associated human case. Primary prevention in humans is achieved through control of animal anthrax.

Drug susceptibility patterns of rapidly growing mycobacteria isolated from skin and soft tissue infections in Venezuela.

To our knowledge, this is the first work on drug susceptibility patterns of rapid growing mycobacteria from Latin America. The susceptibility patterns for 14 antimicrobial agents of the three most important species that cause skin infections in Venezuela were determined as follows: 63 strains belonging to Mycobacterium abscessus group, 66 strains of the Mycobacterium fortuitum group, and 13 Mycobacterium chelonae strains. The M. abscessus group strains were resistant to most antibiotics tested while M. fortuitum strains were relatively susceptible to a large number of antibiotics. We demonstrate the presence of an inducible and truncated erm(41) gene in M. abscessus group, namely M. abscessus subsp. massiliense. We show the variations in susceptibility to antimicrobial agents within and between the mycobacterial species and compare our susceptibility patterns with those reported from other countries. We conclude that the identification of mycobacteria to the species level can guide the antibiotic treatment, but that it is always important to consider drug susceptibility testing when rapidly mycobacteria are isolated.

Dermatoses in international travellers seen at Bordeaux teaching hospital travel clinic, 2015-2018: a GeoSentinel-based study.

Skin disorders are frequent in travellers, but data vary between different studies. The objectives of the current study were to describe imported dermatoses in the Bordeaux GeoSentinel prospective database between August 2015 and March 2018. During the study period, 1025 travellers were seen in the clinic, 201 of them with dermatoses. Patients with skin disorders were more likely to be aged > 60 years (OR = 1.88, 95% CI 1.22-2.89), to be tourists (OR 3.04, 95% CI 2.03-4.55) and to have travelled to South America (OR = 2.18, 95% CI 1.29-3.67), and less likely to have sought pretravel advice (OR = 0.53, 95% CI 0.31-0.91). Skin bacterial infections (19.4%) and Zika virus infections (18.4%) were the most common dermatoses. Dengue fever and bacterial skin infections were the leading causes of hospitalization. The contribution of tropical diseases to imported dermatoses remains important. Lack of pretravel advice puts tourists at risk of significant diseases such as dengue fever, Zika virus and bacterial infections.

Impact of co-infection with Lepeophtheirus salmonis and Moritella viscosa on inflammatory and immune responses of Atlantic salmon (Salmo salar).

This study was conducted to determine the effects of a co-infection with Moritella viscosa at different exposure levels of sea lice Lepeophtheirus salmonis in Atlantic salmon (Salmo salar). M. viscosa (1.14 × 106  cfu/ml) was introduced to all experimental tanks at 10 days post-lice infection (dpLs). Mean lice counts decreased over time in both the medium lice co-infection (31.5 ± 19.0 at 7 dpLs; 16.9 ± 9.3 at 46 dpLs) and high lice co-infection (62.0 ± 10.8 at 7 dpLs; 37.6 ± 11.3 at 46 dpLs). There were significantly higher mortalities and more severe skin lesions in the high lice co-infected group compared to medium lice co-infected group or M. viscosa-only infection. Quantitative gene expression analysis detected a significant upregulation of genes in skin from the high lice co-infection group consistent with severe inflammation (il-8, mmp-9, hep, saa). Skin lesions retrieved throughout the study were positive for M. viscosa growth, but these were rarely located in regions associated with lice. These results suggest that while M. viscosa infection itself may induce skin lesion development in salmon, co-infection with high numbers of lice can enhance this impact and significantly reduce the ability of these lesions to resolve, resulting in increased mortality.

Management of bacterial skin and soft tissue infections.

Skin and soft tissue infections (SSTIs) are a group of diseases usually caused by bacteria, and connected with different clinical picture, course, and prognosis. The increasing incidence of SSTIs is associated mainly with aging of the population, the increasing number of metabolic diseases, especially diabetes mellitus, as well as cardiovascular diseases. Although SSTIs are often benign and usually does not require medical consultations, some of them may cause a systemic infection. In this situation, knowledge of the principles of diagnostic work-up and therapy is essential. The principles of recognition and treatment of skin and soft tissue infections, including new biocidal drugs, are presented.

Decreasing Incidence of Skin and Soft-tissue Infections in 86 US Emergency Departments, 2009-2014.

Background: The incidence of skin and soft-tissue infections (SSTIs), for which human immunodeficiency virus (HIV) is a significant risk factor, in United States emergency departments (EDs) increased dramatically after 2000 with the emergence of community-associated methicillin-resistant Staphylococcus aureus. Few studies have examined SSTI incidence among HIV-infected and non-HIV-infected patients in the United States after 2010. Methods: Data were obtained for patient encounters at all academic medical center EDs affiliated with the Vizient clinical data warehouse assigned an SSTI-associated code based on the International Classification of Diseases, Ninth Revision, between 1 January 2009 and 31 December 2014. The rate was calculated per 1000 ED encounters by year and stratified by SSTI, HIV infection, or both, and by age group, race, payer type, and region of care. Poisson regression was used to assess temporal change over the study period. Results: In 2009-2014, a total of 47317 HIV-associated and 820440 SSTI-associated encounters were recorded among 25239781 ED patient encounters. The rate of SSTIs decreased by 8% among all patients and by 14.6%, among those with HIV infection. The SSTI incidence overall decreased from 32.0 to 29.7 per 1000 ED encounters between 2009 and 2014. HIV-infected patients had a significantly higher rate of SSTIs than HIV-uninfected patients (adjusted rate ratio, 1.91; 95% confidence interval, 1.84-1.99). Conclusions: The decline in SSTI incidence in US EDs between 2009 and 2014 is a remarkable epidemiologic shift from the increase in SSTIs after 2000, and further research is necessary to assess reasons for this decrease.

Etiological Characterization of the Cutaneous Ulcer Syndrome in Papua New Guinea Using Shotgun Metagenomics.

Background: Treponema pallidum subsp pertenue and Haemophilus ducreyi are causative agents of cutaneous ulcer (CU) in yaws-endemic regions in the tropics. However, a significant proportion of CU patients remain polymerase chain reaction (PCR) negative for both bacterial agents. We aimed to identify potential additional etiological agents of CU in a yaws-endemic region. Methods: This population-based cohort study included children in Lihir Island (Papua New Guinea) examined during a yaws eradication campaign in October 2013-October 2014. All consenting patients with atraumatic exudative ulcers of >1 cm diameter were enrolled. Lesional swabs were collected for real-time PCR testing for T. pallidum subsp pertenue and H. ducreyi. We then performed shotgun whole DNA metagenomics sequencing on extracted DNA and taxonomically assigned shotgun sequences using a human microbiome reference. Results: Sequence data were available for 122 samples. Shotgun sequencing showed high classification agreement relative to PCR testing (area under the curve for T. pallidum/H. ducreyi was 0.92/0.85, respectively). Clustering analysis of shotgun data revealed compositional clusters where the dominant species (median relative abundance ranged from 32% to 66%) was H. ducreyi (23% of specimens), T. pallidum subsp pertenue (16%), Streptococcus dysgalactiae (12%), Arcanobacterium haemolyticum (8%), and Corynebacterium diphtheriae (8%). Sample clustering derived from ulcer microbial composition did not show geographical patterns. Conclusions: These data suggest a diverse etiology of skin ulcers in yaws-endemic areas, which may help design more accurate diagnostic tools and more effective antimicrobial treatment approaches to the cutaneous ulcer syndrome.

Current Epidemiology, Etiology, and Burden of Acute Skin Infections in the United States.

The US burden of acute skin infections is substantial. While Staphylococcus aureus and Streptococcus spp. are the most common causes, gram-negative bacteria and mixed infections can occur in some settings. These mixed infections are more likely to result in inappropriate empiric antibiotic therapy. Important challenges remain in diagnosing and treating acute skin infections.

Analysis of Pooled Phase 3 Safety Data for Delafloxacin in Acute Bacterial Skin and Skin Structure Infections.

BACKGROUND: Through improved understanding of the structure-activity relationship attributes of fluoroquinolones, molecule development has improved efficacy, safety, and tolerability of the class. Adverse events (AEs) associated with the fluoroquinolones are well defined and a prospective part of the development process. However, not all fluoroquinolones have the same AE profile with different substitutions on the core molecule resulting in differences in side effects and spectrum of activity. Unique structural attributes of delafloxacin (DLX) may differentiate its AE profile compared to other fluoroquinolones. This analysis compared the incidence of AEs between DLX and vancomycin/aztreonam across two phase 3 ABSSSI studies in order to provide a broader overview of DLX safety. METHODS: Safety events occurring in all subjects in the pivotal phase 3 trials were pooled to provide a broad overview of DLX safety. RESULTS: DLX was safe and well-tolerated in the pooled phase 3 ABSSSI trial population of 741 subjects. Treatment-emergent AEs (TEAEs) were seen in the DLX group versus the comparator group at 45.1% and 47.7%, respectively. Most were mild or moderate in severity. Treatment-related TEAEs were reported in the DLX group versus the comparator group at rates of 22.1% and 26.1%, respectively. CONCLUSIONS: Available data show DLX is well tolerated in both intravenous and oral formulation for the treatment of ABSSSI and does not appear to be associated with increased risk of AEs associated with other fluoroquinolones. It remains important to monitor for potential AEs that have been observed with other fluoroquinolones.

Outbreak of Tattoo-associated Nontuberculous Mycobacterial Skin Infections.

BACKGROUND: On 29 April 2015, the Florida Department of Health in Miami-Dade County (DOH Miami-Dade) was notified by a local dermatologist of 3 patients with suspected nontuberculous mycobacterial (NTM) infection after receiving tattoos at a local tattoo studio. METHODS: DOH Miami-Dade conducted interviews and offered testing, described below, to tattoo studio clients reporting rashes. Culture of clinical isolates and identification were performed at the Florida Bureau of Public Health Laboratories. Characterization of NTM was performed by the Centers for Disease Control and Prevention and the US Food and Drug Administration (FDA), respectively. Whole-genome sequencing (WGS) and single-nucleotide polymorphism (SNP) analyses were used to construct a phylogeny among 21 Mycobacterium isolates at the FDA. RESULTS: Thirty-eight of 226 interviewed clients were identified as outbreak-associated cases. Multivariate logistic regression revealed that individuals who reported gray tattoo ink in their tattoos were 8.2 times as likely to report a rash (95% confidence interval, 3.1-22.1). Multiple NTM species were identified in clinical and environmental specimens. Phylogenetic results from environmental samples and skin biopsies indicated that 2 Mycobacterium fortuitum isolates (graywash ink and a skin biopsy) and 11 Mycobacterium abscessus isolates (5 from the implicated bottle of graywash tattoo ink, 2 from tap water, and 4 from skin biopsies) were indistinguishable. In addition, Mycobacterium chelonae was isolated from 5 unopened bottles of graywash ink provided by 2 other tattoo studios in Miami-Dade County. CONCLUSIONS: WGS and SNP analyses identified the tap water and the bottle of graywash tattoo ink as the sources of the NTM infections.

Mycobacterium marseillense Infection in Human Skin, China, 2018.

We describe a case of facial skin infection and sinusitis caused by Mycobacterium marseillense in an immunocompetent woman in China in 2018. The infection was cleared with clarithromycin, moxifloxacin, and amikacin. Antimicrobial drug treatments could not be predicted by genetic analyses; further genetic characterization would be required to do so.

Bacillus cereus-Attributable Primary Cutaneous Anthrax-Like Infection in Newborn Infants, India.

During March 13-June 23, 2018, anthrax-like cutaneous lesions attributed to the Bacillus cereus group of organisms developed in 12 newborns in India. We traced the source of infection to the healthcare kits used for newborn care. We used multilocus sequence typing to characterize the 19 selected strains from various sources in hospital settings, including the healthcare kits. This analysis revealed the existence of a genetically diverse population comprising mostly new sequence types. Phylogenetic analysis clustered most strains into the previously defined clade I, composed primarily of pathogenic bacilli. We suggest that the synergistic interaction of nonhemolytic enterotoxin and sphingomyelinase might have a role in the development of cutaneous lesions. The infection was controlled by removing the healthcare kits and by implementing an ideal housekeeping program. All the newborns recovered after treatment with ciprofloxacin and amikacin.

What's new in the epidemiology of skin and soft tissue infections in 2018?

PURPOSE OF REVIEW: Skin and soft tissue infections (SSTIs) are among the most common infections in outpatients and the most frequent infectious cause of referrals to emergency departments in developed world, contributing to significant morbidity and healthcare expenditures. We sought to review recent literature covering epidemiology of SSTIs. RECENT FINDINGS: Staphylococcus aureus and streptococci predominate and methicillin-resistant S. aureus (MRSA) poses additional challenges; community-acquired-MRSA in some areas is superseding methicillin-susceptible S. aureus and multidrug resistance is evolving. Incidence data of SSTIs from United States show a decreasing trend, whereas trends of hospitalization rates were increasing. Despite low mortality associated with SSTIs, high rates of treatment failure and relapses are of concern. Diagnosis and management decisions in the emergency department (ED) lack validated tools for prediction of clinical response particularly among elderly, immunocompromised, obese, and patients with comorbidities. A variety of modifiable and nonmodifiable risk factors of the host and data from local epidemiology should be considered to prevent recurrence and treatment failure. SUMMARY: An evolving epidemiology of SSTIs make microbiologic documentation and surveillance of local data imperative. New assessment algorithms with potential use in the ED are a priority. The universal applicability of international guidelines is questioned in this setting.