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Emergency Medicine > INFECTIOUS DISEASES
Staphylococcal Scalded Skin Syndrome
Article Last Updated: Jul 13, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Randall W King, MD, Assistant Clinical Professor of Emergency Medicine, Medical College of Ohio; Program Director, Associate Chair, Department of Emergency Medicine, St Vincent Mercy Medical Center
Randall King is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, Ohio State Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society
Coauthor(s):
Paul de Saint Victor, MD, Chair, Assistant Clinical Professor, Departments of Surgery, Pediatrics and Emergency Medicine, Medical College of Ohio, Saint Vincent Mercy Medical Center
Editors: Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Associate Professor, Department of Emergency Medicine, University of Texas-Houston; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jeter (Jay) Pritchard Taylor III, MD, Compliance Officer, Attending Physician Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, University of South Carolina; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Charles V Pollack, Jr, MD, MA, FACEP, Professor, Department of Emergency Medicine, University of Pennsylvania College of Medicine; Chairman, Department of Emergency Medicine, Pennsylvania Hospital
Author and Editor Disclosure
Synonyms and related keywords:
SSSS, Ritter von Ritterschein disease, Ritter disease, Lyell disease, staphylococcal epidermal necrolysis, staphylococcal scalded skin syndrome, acute exfoliation of the skin, staphylococcal infection, erythematous cellulitis, phage group 2 Staphylococcus aureus, S aureus, epidermolytic toxins
Background
Staphylococcal scalded skin syndrome (SSSS) is a syndrome of acute exfoliation of the skin following an erythematous cellulitis. SSSS is caused by an exotoxin from a staphylococcal infection. SSSS also is known as Ritter von Ritterschein disease in newborns, Ritter disease, Lyell disease, and staphylococcal epidermal necrolysis.
Pathophysiology
A toxin produced by phage group 2 Staphylococcus aureus causes SSSS. An infection commonly occurs at a site such as the oral or nasal cavities, throat, or umbilicus. Two epidermolytic toxins (A and B) are then produced and act at a remote site leading to a red rash and separation of the epidermis beneath the granular cell layer. This is due to binding of the toxins to desmoglein 1 in desmosomes, causing it to break down. Bullae form, and diffuse sheetlike desquamation occurs. Involvement may occasionally be localized or patchy rather than diffuse. Children are more at risk because of lack of immunity and immature renal clearance capability.
Healing typically occurs within 1-2 weeks.
Frequency
United States
SSSS is most common in children and neonates. It is rare in adults.
International
Overall incidence is higher in developing countries.
Mortality/Morbidity
Mortality rate from SSSS in children is very low (1-5%), unless associated sepsis or an underlying serious medical condition exists. Mortality rate in adults is higher (as high as 20-30%). Significant morbidity can result from hematologic or local spread of infection.
Sex
No gender predilection is documented in children. In adults, the male-to-female ratio is approximately 2:1.
Age
SSSS primarily is a disease of children.
- The disease can occur individually or as outbreaks in nurseries.
- Most children (62%) are younger than 2 years, and almost all (98%) are younger than 6 years.
- SSSS is very rare in adults, with fewer than 50 cases formally reported in the literature. Adults with SSSS are most often immunocompromised or have renal failure.
History
- Staphylococcal scalded skin syndrome (SSSS) presents as a red rash followed by diffuse epidermal exfoliation.
- A prodromal localized S aureus infection of the skin, throat, nose, mouth, umbilicus, or GI tract occurs. Such an infection often is not apparent before the SSSS rash appears.
- General malaise
- Fever
- Irritability
- Skin tenderness
Physical
- Fever, although patients may be afebrile
- Tenderness to palpation
- Warmth to palpation
- Diffuse erythematous rash (see Image 1)
- Sandpaperlike
- Accentuated in flexor creases (see Image 2)
- Bullae (see Image 3)
- Nikolsky sign (gentle stroking of the skin causes the skin to separate at the epidermis)
- Exfoliation of skin, which may be patchy or sheetlike in nature (see Images 4-6)
- Facial edema
- Perioral crusting
- Most patients do not appear severely ill.
- Dehydration may be present and significant.
Causes
- Infection by group 2 phage S aureus (several types) leads to release of exotoxin.
- Exotoxin is a protein and is classified as either type A or B. Most are type A.
- Exotoxin causes separation of the epidermis beneath the granular cell layer.
- Cases of SSSS have been reported among infants who have breastfed from mothers with S aureus breast abscess.
- A case has been reported of neonatal SSSS secondary to maternal-fetal transmission at birth.
- Outbreaks have been reported in neonatal and newborn nurseries.
- Reports are increasing implicating community-acquired methicillin Staphylococcus aureus (CA-MRSA) as a cause of SSSS.
Abdominal Pain in Elderly Persons
Burns, Chemical
Burns, Thermal
Cellulitis
Dermatitis, Contact
Dermatitis, Exfoliative
Erysipelas
Erythema Multiforme
Gas Gangrene
Hydrofluoric Acid Burns
Impetigo
Necrotizing Fasciitis
Pediatrics, Scarlet Fever
Scarlet Fever
Stevens-Johnson Syndrome
Toxic Epidermal Necrolysis
Lab Studies
- White blood count (WBC) may be elevated; however, often WBC is normal.
- Erythrocyte sedimentation rate (ESR) frequently is elevated.
- A polymerase chain reaction (PCR) serum test for the toxin is available.
- Cultures of bullae are negative.
- Blood culture
- Usually negative in children
- Usually positive in adults
- A Gram stain and/or culture from the remote infection site may confirm staphylococcal infection.
Procedures
- Frozen section of the peeled skin confirms the site of cleavage as superficial. Toxic epidermal necrolysis (TEN) shows deeper cleavage below the epidermis.
Emergency Department Care
- The major focus of ED care should be to identify staphylococcal scalded skin syndrome (SSSS) and to stabilize the patient's condition.
- Patients need fluid rehydration, topical wound care similar to the care for thermal burns, and parenteral antibiotics to cover S aureus.
- Consideration must be given for the sharply increasing rates of community-acquired S aureus infection (CA-MRSA).
- Fluid rehydration is initiated with Lactated Ringer solution at 20 cc/kg initial bolus. Repeat the initial bolus as clinically indicated followed by maintenance therapy with consideration for fluid losses from exfoliation of skin being similar to a burn patient.
- Topical wound care should begin with saline, followed by topical antibiotic ointment.
- Cultures from the exfoliated sites as well as nose, throat, and other potential sites of the original focus of infection should be performed.
- A chest radiograph should be considered to rule out pneumonia as the original focus of infection.
- Steroids are not indicated at this time.
Consultations
- Pediatrics
- Possibly, infectious disease and burn specialists (eg, plastic surgery)
Drug therapy consists of parenteral antibiotics to cover S aureus, which is considered the primary source of the toxin-mediated syndrome.
Drug Category: Antibiotics
When the susceptibility of the organism is not yet known, the DOC is a penicillinase-resistant synthetic penicillin (eg, nafcillin). However, should the organism show susceptibility to penicillin G, then that drug should be chosen as the main course of therapy. A first-generation cephalosporin can be used as an alternative. In penicillin-allergic patients, macrolides or aminoglycosides may be substituted. Increasing rates of CA-MRSA associated infections warrants consideration for vancomycin therapy in patients who initially appear toxic or who fail to respond to nafcillin.
| Drug Name | Nafcillin (Nafcil, Unipen) |
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| Description | Treats infections caused by penicillinase-producing staphylococci, and thus is DOC for penicillin G-resistant staphylococcal infections. Do not use for treatment of penicillin G-susceptible staphylococci. Use parenteral therapy initially in severe infections, using very high doses for very severe infections. |
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| Adult Dose | Parenteral: 500 mg IV/IM q4-6h
Severe infections: 1 g IV/IM q4h
Oral: 250-500 mg PO q4-6h
Severe infections: 1 g PO q4-6h |
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| Pediatric Dose | 0-4 kg (neonates): 10 mg/kg IM or 10 mg/kg PO tid/qid; if inadequate, change to parenteral nafcillin sodium
4-40 kg: 25 mg/kg IM bid; alternatively, 100-200 mg/kg/d IV/IM in 4-6 divided doses
Oral: 50 mg/kg/d PO divided qid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Associated with warfarin resistance; bacteriostatic action of tetracycline derivatives may decrease effects |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | To optimize therapy, determine causative organisms and susceptibility; treat for >10 d to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); take cultures after treatment to confirm that infection is eradicated |
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| Drug Name | Penicillin G procaine (Crysticillin, Wycillin) |
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| Description | Long-acting parenteral penicillin (IM only) indicated in treatment of moderately severe infections caused by penicillin G-sensitive microorganisms. Useful in treatment of moderately severe infections of skin and skin structures. In adults, administer by deep IM injection only into upper, outer quadrant of buttock. In infants and small children, midlateral aspect of thigh may be better site for administration. |
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| Adult Dose | 600,000-1 million U/d IM |
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| Pediatric Dose | <30 kg: 300,000 U/d IM
>30 kg: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Warfarin increases risk of bleeding; ethacrynic acid, aspirin, indomethacin, and furosemide may compete with penicillin G for renal tubular secretion, increasing penicillin serum concentrations |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Never use IV route to administer penicillin G procaine; administer >10 d to eliminate organism and prevent complications such as endocarditis and rheumatic fever; perform cultures after treatment to confirm pathogen eradication |
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| Drug Name | Amoxicillin and clavulanate (Clavulin, Augmentin) |
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| Description | Drug combination that extends antibiotic spectrum of this penicillin to include bacteria normally resistant to beta-lactam antibiotics. Indicated for skin and skin-structure infections caused by beta-lactamase-producing strains of S aureus. In children > 3 mo, base dose on amoxicillin content. Due to different amoxicillin-to-clavulanic acid ratios in 250 mg tablets (250/125) vs 250 mg chewable tablets (250/62.5), do not use 250 mg tablet until child weighs >40 kg. |
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| Adult Dose | 500 mg PO q12h or 250 mg PO q8h |
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| Pediatric Dose | <3 months: 125 mg/5 mL PO susp based on amoxicillin; 30 mg/kg/d divided bid
>3 months: if using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO q12h; if using 125 mg/5 mL or 250 mg/5 mL susp, 40 mg/kg/d PO q8h
>40 kg: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Warfarin or heparin increases risk of bleeding |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Give for minimum of 10 d to eliminate organism and prevent sequelae (endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of pathogen |
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| Drug Name | Cefazolin (Ancef, Kefzol, and Zolicef) |
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| Description | First-generation semisynthetic cephalosporin, which, by binding to one or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth. Primarily active against skin flora, including S aureus. Typically used alone for skin and skin-structure coverage. Total daily dosages are same for IV/IM routes. |
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| Adult Dose | 250 mg to 2 g IV/IM q6-12h depending on severity of infection; not to exceed 12 g/d |
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| Pediatric Dose | 25-100 mg/kg/d IV/IM divided q6-8h depending on severity of infection; not to exceed 6 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid prolongs effect; aminoglycosides may increase renal toxicity; may yield false-positive urine dip test for glucose |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy |
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| Drug Name | Cephalexin (Keflex, Biocef) |
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| Description | First-generation cephalosporin that inhibits bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls. Primarily active against skin flora. Typically used for skin-structure coverage and as prophylaxis in minor procedures. |
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| Adult Dose | 250-1000 mg PO q6h; not to exceed 4 g/d |
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| Pediatric Dose | 25-50 mg/kg/d PO q6h; not to exceed 3 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Aminoglycosides increase nephrotoxic potential |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Adjust dose in renal impairment |
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| Drug Name | Clindamycin (Cleocin) |
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| Description | Lincosamide useful as treatment against serious skin and soft-tissue infections caused by most staphylococci strains. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome, where it binds preferentially to 50S ribosomal subunit, inhibiting bacterial growth. |
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| Adult Dose | 600-1200 mg/d IV divided q6-8h, depending on degree of infection |
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| Pediatric Dose | 8-16 mg/kg/d IV divided tid/qid
Severe infections: May increase dose to 16-20 mg/kg/d IV divided tid/qid |
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| Contraindications | Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis |
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| Interactions | Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis |
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| Drug Name | Gentamicin (Garamycin, Gentacidin) |
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| Description | Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both agent against gram-positive organisms and one that covers anaerobes.
Not antibiotic of first choice. Consider using only if penicillins or other less toxic drugs are contraindicated, when bacterial susceptibility tests and clinical judgment indicate its use, and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms.
Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least trough level drawn on third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion. |
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| Adult Dose | Serious infections and normal renal function: 3 mg/kg/d IV q8h
Extended dosing regimen for life-threatening infections: 5 mg/kg/24 h IV q6-8h
Loading dose: 1-2.5 mg/kg IV q8h
Maintenance dose: 1-1.5 mg/kg IV q8h |
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| Pediatric Dose | <5 years with normal renal function: 2.5 mg/kg/dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg/dose IV q8h or 6-7.5 mg/kg/d IV divided q8h; not to exceed 300 mg/24 h |
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| Contraindications | Documented hypersensitivity; non-dialysis–dependent renal insufficiency |
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| Interactions | Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; loop diuretics may increase auditory toxicity—possible irreversible hearing loss of varying degrees may occur (monitor regularly) |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment |
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| Drug Name | Tobramycin (Nebcin) |
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| Description | Used in skin, bone, and skin-structure infections caused by S aureus, Pseudomonas aeruginosa, Proteus species, Escherichia coli, Klebsiella species, and Enterobacter species. Indicated in serious staphylococcal infections when penicillin or other potentially less toxic drugs contraindicated and when bacterial susceptibility testing and clinical judgment indicate use. To prevent increased toxicity caused by excessive blood levels do not exceed 5 mg/kg/d, unless serum levels monitored. |
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| Adult Dose | Serious infection: 3 mg/kg/d IV/IM divided tid
Life-threatening infection: Up to 5 mg/kg/d IV/IM divided tid/qid; reduce to 3 mg/kg/d as soon as clinically indicated |
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| Pediatric Dose | 6-7.5 mg/kg/d IV/IM divided tid/qid (2-2.5 mg/kg q8h or 1.5-1.9 mg/kg q6h) |
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| Contraindications | Documented hypersensitivity; renal impairment; preexisting auditory or vestibular impairment; neuromuscular disorders |
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| Interactions | Increases effects of neuromuscular blockers and potentiates effect of extended-spectrum penicillins; amphotericin B, cephalosporins, and loop diuretics increase risk of nephrotoxicity |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Avoid in renal impairment, preexisting auditory or vestibular impairment, and neuromuscular disorders; associated with nephrotoxicity and ototoxicity |
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| Drug Name | Erythromycin (E-mycin, Ery-Tab, Erythrocin) |
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| Description | Indicated for treatment of infections caused by susceptible strains including S aureus. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl t-RNA from ribosomes. This inhibits bacterial growth.
Age, weight, and severity of infection determine proper dosage. When bid dosing desired, half of total daily dose may be taken q12h. For more severe infections, double dose. |
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| Adult Dose | 250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h 1 h ac, or 500 mg PO q12h; alternatively, 333 mg PO q8h; increase up to 4 g/d |
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| Pediatric Dose | 30-50 mg/kg/d (15-25 mg/lb/d) PO in divided doses |
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| Contraindications | Documented hypersensitivity; hepatic impairment |
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| Interactions | May increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; lovastatin and simvastatin increase risk of rhabdomyolysis |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur |
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| Drug Name | Vancomycin (Vancocin) |
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| Description | Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures. |
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| Adult Dose | 1 g or 15 mg/kg IV q12h |
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| Pediatric Dose | 30-40 mg/kg/d IV in 2 doses |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction |
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Further Inpatient Care
- Further inpatient care involves fluid rehydration, local burn/wound care, and eradication of the underlying infection.
Transfer
- Patients with severe disease may require ICU or burn unit care.
Deterrence/Prevention
- Avoidance of the primary staphylococcal infection that may lead to the toxic syndrome
- Timely treatment of established staphylococcal infections
Complications
- Dehydration
- Shock
- Generalized bacteremia and/or sepsis
- Local or remote spread of infection
- Scarring, disability, and death
Prognosis
- Prognosis in children is excellent.
- Prognosis in adults depends on the host's immune status, the speed in initiating proper treatment, the course of the infection, and the occurrence of complications. SSSS in adults carries significant rates of morbidity and mortality.
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Staphylococcal scalded skin syndrome. Photograph by David Effron MD, FACEP. |
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Staphylococcal scalded skin syndrome. Photograph by David Effron MD, FACEP. |
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Staphylococcal scalded skin syndrome. Photograph by David Effron MD, FACEP. |
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Staphylococcal scalded skin syndrome. Photograph by David Effron MD, FACEP. |
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Staphylococcal scalded skin syndrome. Photograph by David Effron MD, FACEP. |
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- Acland KM, Darvay A, Griffin C, et al. Staphylococcal scalded skin syndrome in an adult associated with methicillin-resistant Staphylococcus aureus. Br J Dermatol. Mar 1999;140(3):518-20. [Medline].
- Adhisivam B, Mahadevan S. Abscess of the nasal septum with staphylococcal scalded skin syndrome. Indian Pediatr. Apr 2006;43(4):372-3. [Medline].
- Amagai M, Yamaguchi T, Hanakawa Y. Staphylococcal exfoliative toxin B specifically cleaves desmoglein 1. J Invest Dermatol. May 2002;118(5):845-50. [Medline].
- Baartmans MG, Maas MH, Dokter J. Neonate with staphylococcal scalded skin syndrome. Arch Dis Child Fetal Neonatal Ed. Jan 2006;91(1):F25. [Medline].
- Chi CY, Wang SM, Lin HC. A clinical and microbiological comparison of Staphylococcus aureus toxic shock and scalded skin syndromes in children. Clin Infect Dis. Jan 15 2006;42(2):181-5. [Medline].
- Cribier B, Piemont Y, Grosshans E. Staphylococcal scalded skin syndrome in adults. A clinical review illustrated with a new case. J Am Acad Dermatol. Feb 1994;30(2 Pt 2):319-24. [Medline].
- El Helali N, Carbonne A, Naas T. Nosocomial outbreak of staphylococcal scalded skin syndrome in neonates: epidemiological investigation and control. J Hosp Infect. Oct 2005;61(2):130-8. [Medline].
- Ginsburg CM. Staphylococcal toxin syndromes. Pediatr Infect Dis J. Apr 1991;10(4):319-21. [Medline].
- Greenwood JE, Dunn KW, Davenport PJ. Experience with severe extensive blistering skin disease in a paediatric burns unit. Burns. Feb 2000;26(1):82-7. [Medline].
- Hedrick J. Acute bacterial skin infections in pediatric medicine: current issues in presentation and treatment. Paediatr Drugs. 2003;5 Suppl 1:35-46. [Medline].
- Hochman MA, Mayers M. Stevens-Johnson Syndrome, epidermolysis bullosa, staphylococcal scalded skin syndrome and dermatitis herpetiformis. Int Ophthalmol Clin. 1997;37(2):77-92. [Medline].
- Ito Y, Funabashi Yoh M, Toda K. Staphylococcal scalded-skin syndrome in an adult due to methicillin-resistant Staphylococcus aureus. J Infect Chemother. Sep 2002;8(3):256-61. [Medline].
- Ladhani S, Evans RW. Staphylococcal scalded skin syndrome. Arch Dis Child. Jan 1998;78(1):85-8. [Medline].
- Ladhani S, Joannou CL, Lochrie DP, et al. Clinical, microbial, and biochemical aspects of the exfoliative toxins causing staphylococcal scalded-skin syndrome. Clin Microbiol Rev. Apr 1999;12(2):224-42. [Medline].
- Ladhani S. Understanding the mechanism of action of the exfoliative toxins of Staphylococcus aureus. FEMS Immunol Med Microbiol. Nov 28 2003;39(2):181-9. [Medline].
- Lina G, Gillet Y, Vandenesch F, et al. Toxin involvement in staphylococcal scalded skin syndrome. Clin Infect Dis. Dec 1997;25(6):1369-73. [Medline].
- Moss C, Gupta E. The Nikolsky sign in staphylococcal scalded skin syndrome. Arch Dis Child. Sep 1998;79(3):290. [Medline].
- Noguchi N, Nakaminami H, Nishijima S. Antimicrobial Agent of Susceptibilities and Antiseptic Resistance Gene Distribution among Methicillin-Resistant Staphylococcus aureus Isolates from Patients with Impetigo and Staphylococcal Scalded Skin Syndrome. J Clin Microbiol. Jun 2006;44(6):2119-25. [Medline].
- Oono T, Kanzaki H, Yoshioka T, Arata J. Staphylococcal scalded skin syndrome in an adult. Identification of exfoliative toxin A and B genes by polymerase chain reaction. Dermatology. 1997;195(3):268-70. [Medline].
- Payne AS, Hanakawa Y, Amagai M, Stanley JR. Desmosomes and disease: pemphigus and bullous impetigo. Curr Opin Cell Biol. Oct 2004;16(5):536-43. [Medline].
- Prevost G, Couppie P, Monteil H. Staphylococcal epidermolysins. Curr Opin Infect Dis. Apr 2003;16(2):71-6. [Medline].
- Resnick SD. Staphylococcal toxin-mediated syndromes in childhood. Semin Dermatol. Mar 1992;11(1):11-8. [Medline].
- Rodriguez Prieto MA, Manchado Lopez P, Ruiz Gonzalez I. Toxic epidermal necrolysis associated with scalded skin syndrome in an adult. Int J Dermatol. Nov 1997;36(11):875-6. [Medline].
- Shelley ED, Shelley WB, Talanin NY. Chronic staphylococcal scalded skin syndrome. Br J Dermatol. Aug 1998;139(2):319-24. [Medline].
- Shirin S, Gottlieb AB, Stahl EB. Staphylococcal scalded skin syndrome in an immunocompetent adult: possible implication of low-dosage prednisone. Cutis. Nov 1998;62(5):223-4. [Medline].
- Uzun S, Durdu M. The specificity and sensitivity of Nikolskiy sign in the diagnosis of pemphigus. J Am Acad Dermatol. Mar 2006;54(3):411-5. [Medline].
- Veien NK. The clinician''s choice of antibiotics in the treatment of bacterial skin infection. Br J Dermatol. Dec 1998;139 Suppl 53:30-6. [Medline].
- Whittock NV, Bower C. Targetting of desmoglein 1 in inherited and acquired skin diseases. Clin Exp Dermatol. Jul 2003;28(4):410-5. [Medline].
- Williams RE, MacKie RM. The staphylococci. Importance of their control in the management of skin disease. Dermatol Clin. Jan 1993;11(1):201-6. [Medline].
- Wong GW, Oppenheimer SJ, Evans RM, et al. Pyomyositis and staphylococcal scalded skin syndrome. Acta Paediatr. Jan 1993;82(1):113-5. [Medline].
- Wooldridge WE. Managing skin infections in children. Postgrad Med. Mar 1991;89(4):109-12. [Medline].
- Yamasaki O, Yamaguchi T, Sugai M. Clinical manifestations of staphylococcal scalded-skin syndrome depend on serotypes of exfoliative toxins. J Clin Microbiol. Apr 2005;43(4):1890-3. [Medline].
Staphylococcal Scalded Skin Syndrome excerpt Article Last Updated: Jul 13, 2006
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