| Abstract|| |
Background: The spectrum of pyoderma changes constantly, and so does the antibiotic susceptibility pattern. Aims: This study was done to assess the magnitude and clinical patterns of pyodermas, their causative micro-organisms, and the antibiotic susceptibility patterns. Materials and Methods: Five hundred consecutive, clinically diagnosed and untreated cases of pyoderma, attending the Dermatology OPD of RNT Medical College and MB Government Hospital, Udaipur, from October 2010 to September 2011 were the subjects of this study. A detailed clinical examination, and relevant investigations including bacterial culture and sensitivity, were carried out and recorded. Statistical Analysis: For statistical analysis of data, the software 'EPI-INFO Version 6' was used, and Chi-square (χ2) test was applied. Results: Of 19576 cases attending skin OPD during the study period, pyoderma was seen in 500 patients; the incidence being 2.55%. Males outnumbered females. The highest number of cases (109; 21.8%) was observed in 1st decade. Lower extremities were the commonest site of predilection. Primary pyodermas outnumbered secondary pyodermas. Furuncle (136; 27.2%) and infectious eczematoid dermatitis (62; 12.4%) were the commonest entities among primary and secondary pyoderma respectively. Staphylococcus aureus was the commonest causative agent in both primary and secondary pyoderma. It showed high susceptibility to amoxycillin + sulbactam, aminoglycosides and cefoperazone, moderate susceptibility to linezolid, while low susceptibility to fluoroquinolones and cephalexin. Conclusion: Such studies help to assess the changing trend of bacterial infections, their causative organisms and antibiotic susceptibility pattern.
Keywords: Antibiotic susceptibility, primary pyoderma, secondary pyoderma, Staphylococcus aureus
|How to cite this article:|
Singh A, Gupta LK, Khare AK, Mittal A, Kuldeep C M, Balai M. A clinico-bacteriological study of pyodermas at a tertiary health center in southwest Rajasthan. Indian J Dermatol 2015;60:479-84
|How to cite this URL:|
Singh A, Gupta LK, Khare AK, Mittal A, Kuldeep C M, Balai M. A clinico-bacteriological study of pyodermas at a tertiary health center in southwest Rajasthan. Indian J Dermatol [serial online] 2015 [cited 2021 Sep 20];60:479-84. Available from: https://www.e-ijd.org/text.asp?2015/60/5/479/164368
What was known?
The clinical pattern of pyoderma, the causative micro-organisms and antibiotic susceptibility pattern changes with time and need to be periodically assessed through such clinico-bacterial studies done at different centres. Primary pyoderma is more commoner than secondary. Staphylococcus aureus is most common microorganism causing pyoderma
| Introduction|| |
Pyoderma or pyogenic infection of the skin, defined as 'any purulent skin disease',  is one of the commonest conditions encountered in dermatological practice.  Studies indicate that up to 17% of the clinical visits may be for bacterial skin infections.  Various factors like poverty, malnutrition, overcrowding, illiteracy, customs, habits, and so on have been stated to be responsible for its high incidence.  Climatic conditions also play a role, with the hot and rainy seasons being the period of maximum occurrence.  Besides, patients on treatment with steroids or chemotherapeutic agents and those with pre-existing skin diseases, obesity, disorders of the immune system, and diabetes are found to have bacterial skin infections more commonly. 
Cutaneous bacterial infection is divided into primary and secondary types. The majority of the primary and secondary pyodermas are caused by either Staphylococcus aureus or group A Streptococcus. These bacteria cause a broad clinical spectrum of infections, ranging from superficial pyodermas to invasive soft tissue infections, depending on the organism, the anatomic location of infections, and host factors.  The spectrum of cutaneous bacterial disease is forever changing.  Increasing resistance to antibiotics seen in micro-organisms poses a big problem to the clinicians. Many cases do not respond to some antibiotics which were previously very effective for such cases, owing perhaps to the indiscriminate use of topical and systemic antibiotics. Therefore this study was carried out to assess the magnitude and clinical patterns of pyodermas, their causative micro-organisms, and the antibiotic susceptibility patterns.
| Materials and Methods|| |
This cross sectional study on pyodermas was conducted in the Department of Dermatology of the RNT Medical College and MB Government Hospital, Udaipur. A total of 500 consecutive, clinically diagnosed, and untreated cases of primary and secondary pyoderma were studied over a period starting from October 2010 to September 2011. Patients with a history of using topical or systemic antibiotic in the past 2 weeks were excluded.
A complete general, systemic, and dermatological examination was done. Relevant investigations, including complete blood count (CBC), urine examination, blood sugar [fasting and postprandial (F/PP)] in all cases and investigations like Human immunodeficiency virus (HIV) serology, peripheral blood film (PBF), liver function tests (LFTs), renal function tests (RFTs), and thyroid profile as and when indicated, were carried out. All these findings were recorded in a pro forma. Bacterial culture and sensitivity could be done in 230 patients.
The sample site was cleaned with 70% ethyl alcohol and then washed with saline. The material was taken on a sterile swab. Primary inoculation of the swab was done onto MacConkey agar plate, nutrient agar plate, and blood agar plate. Thereafter the samples were incubated aerobically at 37° C for 24-48 hours. Standard biochemical tests were performed for identification of the organisms.  Sensitivity of the organisms to antibiotics was tested on Muller-Hinton agar by Kirby-Bauer disc diffusion method. 
For statistical analysis of the data, the software Epi Info version 6 was used, and Chi-square (χ2) test was applied. The results were considered significant at P < 0.05.
| Results|| |
Of 19,576 cases seen in the outpatient department (OPD), the number of new pyoderma cases was 500, the incidence being 2.55%. The male-to-female ratio was 1.7:1, with 315 (63%) males and 185 (37%) females. The average age was 28.57 years. The highest number of cases was seen in patients up to 10 years of age (109; 21.8%), followed by an equal number of cases (90; 18%) in the second and third decades. Although males outnumbered females in all age groups, the difference was not significant (P > 0.05). Rural patients (269; 53.8%) slightly outnumbered urban patients (231; 46.2%). Good hygiene was maintained by 385 (77%) cases, whereas 115 (23%) patients had poor hygiene.
Primary pyodermas (305; 61%) were seen more frequently as compared to secondary pyodermas (195; 39%). Among primary pyodermas, furuncle (136; 27.2%) was the commonest entity, followed by folliculitis (66; 13.2%) and impetigo (47; 9.4%). Infectious eczematoid dermatitis (62; 12.4%), followed by infected scabies (34; 6.8%) were the two most common entities among secondary pyodermas. Impetigo and infected scabies showed a predilection for children up to 10 years of age. [Table 1] shows the pattern of various pyodermas.
Lower extremities were involved most frequently, followed by upper extremities, face, and trunk. The groin and genitalia were the least commonly involved, followed by the head and neck. Thirty-three (6.6%) patients had diabetes mellitus, in whom furuncle (12/33) was the most common entity, followed by folliculitis. Twenty (60.61%) of these diabetics gave a history of recurrence; the recurrence rate was 100 and 91.67% in folliculitis and furunculosis, respectively. Systemic comorbidities were found associated in 145 (29%) cases. Of these, anemia (70; 48.27%) was the commonest, followed by immunosuppression (31; 21.37%). Immunosuppression included patients on immunosuppressive therapy (18, 12.41%) and HIV-positive patients (13; 8.97%). Other systemic comorbidities were hypertension, protein energy malnutrition, hypothyroidism, tuberculosis, pelvic inflammatory disease, chronic obstructive pulmonary disease, chronic suppurative otitis media, and osteoarthritis.
A total of 230 samples (121: Primary pyoderma; 109: Secondary pyoderma) were subjected to bacterial culture and sensitivity. In 192 (83.48%) patients, Gram-positive organisms and in 26 (11.3%) patients, Gram-negative organisms were isolated. In 12 (5.22%) patients, no organism could be isolated. A single isolate was obtained from 217 patients, whereas two organisms were isolated from one patient. Staphylococcus aureus was isolated from 180 (78.26%) samples followed by Escherichia More Details coli (11; 4.79%), Streptococcus haemolyticus (5; 2.17%), Citrobacter (5; 2.17%), coagulase-negative Staphylococcus (4; 1.74%), and Pseudomonas aeruginosa (4; 1.74%). In both primary and secondary pyoderma groups, Gram-positive organisms (192/230), mainly S. aureus (180/230), were isolated. Gram-negative organisms were grown in six (4.96%) samples of primary pyoderma and 20 (18.35%) samples of secondary pyoderma [Table 2]. S. aureus was the main causative agent of all entities, except cellulitis which was mainly caused by S. haemolyticus.
Antimicrobial susceptibility testing was carried out on all isolates. The susceptibility pattern of the five most common organisms - S. aureus, S. haemolyticus, E. coli, Citrobacter, and P. aeruginosa - is depicted in [Table 3].
| Discussion|| |
On account of the high prevalence of pyoderma, changing pattern of causative micro-organisms, and the indiscriminate use of antibiotics leading to altered antibiotic susceptibility pattern, there is a constant need to obtain more information about etiological agents, predisposing factors, modes of transmission, and effective methods for control. Various studies have been carried out in India , and abroad , on epidemiology, clinical and bacteriological aspects of pyodermas, and antibiotic sensitivity patterns.
In our study an incidence of 2.55% was noted. Varied and higher incidence of pyoderma has been noted in different studies. ,, The relatively low incidence in our study as compared to quoted studies may perhaps be due to the fact that all these have been carried out in the pediatric population, which is more susceptible to develop pyodermas. Our study, however, included all age groups. The highest number of cases (109; 21.8%) was seen in the first decade of life, a finding observed in many studies. ,,,, Bhaskaran et al. and Khare et al., however, reported the maximum cases of pyoderma in the age group of 21-30 years. High incidence of pyoderma in the first three decades may be consequent to a more active life.
Like in most studies, ,,,,,, primary pyodermas (305; 61%) outnumbered the secondary pyodermas (195; 39%) in our study as well. However, some studies ,, have reported a higher occurrence of secondary pyoderma. In the index study, furuncle (136; 27.2%) was the commonest entity among primary pyodermas, followed by folliculitis (66; 13.2%) and impetigo (47; 9.4%). Furunculosis as the commonest primary pyoderma has been reported by others , also. In many studies, ,,,,, however, impetigo has been recorded as the most common primary pyoderma, whereas a few studies ,, have reported folliculitis as the most common primary pyoderma. Among secondary pyodermas, infectious eczematoid dermatitis (62; 12.4%) and infected scabies (34; 6.8%) were the two most common entities in our study. Infectious eczematoid dermatitis has been reported to be the commonest secondary pyoderma in some other studies ,,, also, where as several studies ,,, have reported infected scabies as the most common presentation.
In the index study, lower extremities were the most frequently involved sites, followed by upper extremities. A predilection for the lower limbs has been reported in other studies , also. Kakar et al. observed the face and legs to be the most commonly affected sites. A higher incidence of pyoderma on the lower extremities may possibly be due to higher chances of trauma at this site.
Thirty-three patients in our study had diabetes mellitus, in whom furunculosis (12/33) was the most frequent pyoderma, followed by folliculitis (6/33). A fairly high recurrence (20/33) of pyoderma, mainly furunculosis and folliculitis, was reported by diabetic patients. A significant recurrence was also recorded in patients on immunosuppressive therapy (14/18) and HIV- positive patients (11/13).
Of the 230 patients subjected to bacterial culture and sensitivity, Gram-positive organisms were cultured from 192 (83.48%), whereas from 26 (11.3%) patients, Gram-negative organisms were obtained. Most of the studies ,,,,,,,,,,,,,, have also documented Gram-positive organisms to be the commonest isolates from pyoderma. Like in our study, S. aureus has been the commonest isolate in other studies ,,,,,,,,,,, too. There has been an increasing trend in the isolation of S. aureus as an etiological agent in pyoderma over the years. Ghadage et al., in 1999, reported S. aureus comprising 37.44% of the total isolates, whereas Sugeng et al., in the same year, documented 55.34% of the yield as S. aureus. In 2002, Fatani et al. observed S. aureus in 59.49% of the total isolates. Recently, Abdallah et al. (2007) found 64.58% of the total strains being S. aureus. Our study, which recorded 82.19% (180/219) of the total strains as S. aureus, also supports the same trend. Gram-negative organisms, although less frequently grown (26/230) as compared to Gram-positive organisms in both the groups, were relatively more frequent in the secondary pyoderma group (20/26) compared to primary pyoderma (6/26). Another study  has also reported a similar observation. Among Gram-negative organisms, E. coli (11/26) was isolated most frequently.
The earlier view  that Streptococcus is the leading cause of impetigo no longer stands true. Several studies, ,,,,, including ours, show that S. aureus is the commonest etiological agent of impetigo.
S. aureus was highly susceptible (>80%) to amoxicillin plus sulbactam, amikacin, cefoperazone, tobramycin, and amoxicillin plus clavulanate, and moderately susceptible (70-77.2%) to gentamicin, ampicillin plus sulbactam, linezolid, cefotaxime, and ceftizoxime. Low susceptibility (8.3-14.6%) was noted to fluoroquinolones and cephalexin. Many other studies ,,,,, have reported S. aureus to be highly susceptible to aminoglycosides, particularly to gentamicin. In the index study, a decline was observed in the susceptibility to fluoroquinolones as opposed to several studies ,,, done in the past, wherein S. aureus showed around 90% susceptibility. Linezolid, considered as the drug of choice for S. aureus, also does not seem to have escaped resistance by this bacterium. S. haemolyticus was most susceptible (100%) to linezolid and amoxicillin plus sulbactam.
E. coli was highly susceptible (>80%) to amikacin, tobramycin, and ceftriaxone plus sulbactam. P. aeruginosa showed a high susceptibility (100%) to polymyxin, and moderate susceptibility (75%) to piperacillin, levofloxacin, and ciprofloxacin, though the size of the sample was small (n = 4).
This study yielded some useful epidemiological and clinico-bacteriological data about pyodermas in Southwest Rajasthan. These observations might assist clinicians to choose suitable antimicrobial (s) for pyodermas, especially in the absence of culture and sensitivity reports. Ideally, the choice of the antibacterial agent would depend on the culture and sensitivity pattern in a particular region, but pending a culture-sensitivity report, amoxicillin with sulbactam/clavulanate, linezolid or ampicillin with sulbactam may be preferred. The changing trend of causative agents of pyodermas and their susceptibility pattern needs constant monitoring through prospective studies in the future also.
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What is new?
- Furuncle was the most common primary pyoderma while infective eczema, the commonest secondary pyoderma. Lower limb was most common site affected.
- Although Staphylococcus aureus was the most common pathogen cultured, there was a decline in the susceptibility to fluoroquinolones and cephalexin group of antibiotics as well as to linezolid
[Table 1], [Table 2], [Table 3]