Outbreak of staphylococcal bullous impetigo in a maternity ward linked to an asymptomatic healthcare worker

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Summary

An outbreak of staphylococcal bullous impetigo occurred over a period of five months in a maternity ward involving seven infected and two colonised neonates. The skin lesions were due to epidermolytic toxin A-producing Staphylococcus aureus. Infection control measures were implemented and a retrospective case–control study performed. Contact with an auxiliary nurse was the only risk factor for cases of bullous impetigo (P < 0.01). The nurse cared for all seven cases and was an asymptomatic nasal carrier of the epidemic strain. Repeated courses of decontamination treatment failed to eradicate carriage. Nine months after the last case, another neonate developed a more severe form of bullous impetigo and the auxiliary nurse was reassigned to an adult ward.

Introduction

Staphylococcal skin infections are among the commonest skin diseases in children.1 Bullous impetigo, also known as pemphigus neonatorum, and the staphylococcal scalded-skin syndrome (SSSS) represent a collection of blistering skin diseases induced by epidermolytic toxins A (ETA) and B (ETB).1, 2 Whereas in bullous impetigo the toxin produces blisters locally at the site of infection, in SSSS it produces blisters at distant sites.1 SSSS remains a potentially fatal condition particularly in its generalised form, with a mortality rate <5% among children.1, 2 Many outbreaks of bullous impetigo and SSSS have been reported among neonates.3, 4, 5, 6, 7, 8, 9, 10 Risk factors for staphylococcal outbreaks include carriers in close contact with infants, improper cord hygiene, overcrowding, understaffing and inadequate infection control practices.2, 3, 4, 5, 6, 9, 10, 11, 12

We describe here an outbreak of seven cases of staphylococcal bullous impetigo in a maternity ward.

Section snippets

Hospital setting

The hospital of Perigueux is a 1325-bed public hospital in South-Western France. The maternity unit has 44 beds with an obstetric unit performing about 1000 deliveries per year. It employs 64 healthcare workers (HCWs).

Recognition of an outbreak

In May 2005, the laboratory microbiologist noticed Staphylococcus aureus from swabs of skin lesions from two neonates. As the occurrence of two similar cases appeared unusual, he alerted the infection control team and a follow-up of new cases began. A third case appeared in June

Results

The outbreak took place over five months. Two potential cases and two outbreak cases appeared between 14 May and 6 July 2005. One outbreak case appeared in August. They were all infected by an erythromycin–kanamycin-resistant S. aureus strain. In September, 86 neonates were screened. Eighteen (20.9%) were nasal carriers of S. aureus, of whom four carried the epidemic strain. Two of the latter developed bullous impetigo in September making a total of seven cases. All cases were apyrexial. The

Discussion

Over 13 months, eight cases and two colonised neonates were affected by the same strain of S. aureus. The investigation and case-control study identified an asymptomatic HCW carrying and transmitting the epidemic strain to neonates.

It is known that HCWs have a higher prevalence of S. aureus carriage than the general population in which carriage rate is already around 30%.2, 7 Outbreaks of ET-producing S. aureus due to HCWs have been reported in maternity wards. They originated from infected

Acknowledgements

We thank the healthcare workers involved in this outbreak for their active co-operation.

Conflict of interest statement

None declared.

Funding sources

None.

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