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Eurosurveillance, Volume 12, Issue 24, 14 June 2007
Articles

Citation style for this article: O’Connell N, Mannix M, Philip RK, Slevin B, Monahan R, Boyle L, Whyte D, Kearns A. Infant Staphylococcal Scalded Skin Syndrome, Ireland, 2007 – preliminary outbreak report. Euro Surveill. 2007;12(24):pii=3220. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3220

Infant Staphylococcal Scalded Skin Syndrome, Ireland, 2007 – preliminary outbreak report

NH O’Connell1, M Mannix2, RK Philip3, C MacDonagh-White4, B Slevin5, R Monahan1, L Boyle5, D Whyte (Dominic.Whyte@mailh.hse.ie)2, A Kearns6

1 Department of Medical Microbiology, Mid-Western Regional Hospital, Limerick, Ireland
2 Department of Public Health, HSE West, Limerick, Ireland
3 Department of Paediatrics, Mid-Western Regional Hospital, Limerick, Ireland
4 Occupational Health Department, Mid-Western Regional Hospital, Limerick, Ireland
5 Infection Control, Mid-Western Regional Hospital, Limerick, Ireland
6 Staphylococcal Reference Laboratory, Centre for Infections, Health Protection Agency, London, England

Between February and May 2007, five confirmed cases of Staphylococcal Scalded Skin Syndrome (SSSS) were identified in full-term healthy infants born at a maternity unit in Ireland (hospital A). This hospital serves a population of 340,000 people, with over 4,500 babies born annually. Up to May 2007, no disinfection was used in cord care at the hospital.

The five microbiologically confirmed cases of SSSS had all been born in hospital A and discharged. Three were male and two were female, lived in different areas, and had no history of admission to the neonatal unit. Within three to nine days of discharge from hospital A, they presented to paediatric services in a regional hospital (hospital B). A clinical diagnosis of SSSS was made. Samples taken from the infants upon admission to the paediatric services included skin and nasal swabs. The causative agent was confirmed as methicillin-sensitive Staphylococcus aureus. Further microbiological analyses conducted in conjunction with the Health Protection Agency (London, England) showed the following: all five isolates encoded exfoliative toxin A (but not B) in addition to enterotoxins G and I; four of the isolates were resistant to fusidic acid and proved indistinguishable by Pulsed Field Gel Electrophoresis (PFGE); the fifth isolate was susceptible to fusidic acid and gave an unrelated PFGE profile.

SSSS is a manifestation of a staphylococcal infection, associated with exfoliative toxin production, and is characterised by peeling skin. It is primarily a disease of neonates and children. The disease usually begins with a fever and redness of the skin. Then, a fluid-filled blister may form. This blister ruptures very easily, leaving an area of moist skin. Other symptoms may include the following: a crusted infection site, often around the nose or ears; red, painful areas around the site of infection; blistering; fever; weakness; fluid loss; and the top layer of the skin beginning to peel off in sheets. In newborns, lesions are often found in the nappy area or the umbilical cord. Older children more commonly have lesions on their arms, legs, and trunk.

Prevention and control
An Outbreak Control Team was convened on 30 April, and infection control policies were reviewed and updated. An effort was made to establish if the cases shared any common links such as labour wards, post-natal wards, clinical staff involved in their care, consumables etc. There were no obvious links. Environmental screening of the wards was conducted but yielded negative results. Strict adherence to infection control measures was emphasised, particularly hand hygiene and barrier precautions. Barrier precautions in hospital A included personal protective equipment, including the use of face masks, gloves and gowns for delivery, close contacts and interventional procedures, as well as isolation of suspected clinically diagnosed cases of SSSS in hospital B. As part of the investigation to determine the source of the infections, clinical staff in hospital A as well as the families of the affected children are being screened for S. aureus. These investigations are ongoing. All family doctors and public health nurses in the community were alerted to the outbreak. Information sheets were developed for hospital staff and parents. Public bulletins were issued in an effort to ascertain further cases that were diagnosed clinically in the community but who did not require hospitalisation. SSSS is a readily treatable infection. All five affected infants were treated with intravenous antibiotics, and pain and fluid management was provided as appropriate. All made a good recovery. The source of the infection has not yet been determined. Anti-staphylococcal prophylactic measures were introduced to optimise neonatal umbilical cord care and bathing.

SSSS is not a notifiable disease in Ireland. This is the first recorded outbreak of SSSS in Ireland, and only a small number of outbreaks have been reported internationally in the medical literature [1,2,3]. However, staphylococcal infections are increasing, and the incidence of S. aureus infection (both methicillin-sensitive and -resistant) is cause for concern in maternity and neonatal settings.

References:
  1. El Halali N, Carbonne A, Naas T, Kerneis S, Fresco O, Giovangrandi Y, et al. Nosocomial outbreak of staphylococcal scalded skin syndrome in neonates: epidemiological investigation and control. J Hosp Infect 2005;61(2):130-8.
  2. Curran JP and Al-Salihi FL. Neonatal staphylococcal scalded skin syndrome: massive outbreak due to an unsusual phage type. Pediatrics 1980;66(2):285-90.
  3. Dancer SJ, Simmons NA, Poston SM, Noble WC. Outbreak of staphylococcal scalded skin syndrome among neonates. J Infect 1988;16(1):87-103.

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