Antibiotic Choice and Methicillin-Resistant Staphylococcus aureus Rate in Children Hospitalized for Atopic Dermatitis

Rory Nicolaides; Jeffrey Chambliss

doi:10.1542/peds.2019-2461EE

V Wang, M Keefer, PY Ong. Ann Allergy Asthma Immunol. 2019;122(3):314–317

Purpose of the Study:

To examine the prescribing patterns of systemic antibiotics for children hospitalized for atopic dermatitis (AD) exacerbation compared with infectious complications.

Study Population:

A total of 174 patients with AD who were admitted to Children’s Hospital Los Angeles from 2013 to 2018 were included (70 with AD exacerbation and 104 with infectious complications).

Methods:

Subjects were identified via retrospective chart review by International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision codes for AD. Secondary codes for contact dermatitis and other eczema, dermatitis unspecified, and unspecified contact dermatitis, unspecified cause were only included in patients with a physician diagnosis of AD. Infectious complications of AD included patients experiencing focal infections (cellulitis or abscess), invasive infections (bacteremia, osteomyelitis, septic arthritis, or endocarditis), or eczema herpeticum, whereas acute exacerbation of AD was confirmed in the history of present illness, physical examination, or diagnosis on physician discharge summary.

Results:

Systemic antibiotics were administered in 80% (56 out of 70) of patients with AD exacerbation and 94% (98 out of 104) of those with infectious complications. The most frequently prescribed antibiotics on admission offered empirical coverage against methicillin-resistant Staphylococcus aureus (MRSA), specifically clindamycin and vancomycin, at a total rate of 88% for both AD exacerbation and infectious complications. Rates of use were similar between both groups (75% and 74% for clindamycin and 13% and 14% for vancomycin, in AD versus infectious groups, respectively). Anti-MRSA agents were prescribed at discharge at similar rates between both groups; clindamycin was most commonly prescribed (54% of AD patients and 59% of patients with infectious complications). Sulfamethoxazole-trimethoprim was also prescribed a similar rates for both groups (4% AD, 5% infectious). MRSA was significantly less common in children with AD exacerbation (22%) versus infectious complications (39%) on wound culture results. Significant differences in patients with infections complications included longer length of stay (P < .0001) and higher C-reactive protein levels and erythrocyte sedimentation rates (P = .007 and P = .003, respectively). Patients with AD exacerbation had higher total serum immunoglobulin E levels, but the difference was not significant (P = .07).

Conclusions:

Although AD is a risk factor for S aureus infections, distinguishing clinical characteristics between AD exacerbation and infectious complications is challenging, and no standard definition for secondary infection or superinfection of AD exists. Antibiotic use for AD exacerbation varies, but empirical use of anti-MRSA agents may not be appropriate. C-reactive protein or erythrocyte sedimentation rate may have a role in distinguishing patients with infectious complications from those with exacerbation.

Reviewer Comments:

Overall, this study informs the practice of empirical systemic antibiotic use in pediatric patients admitted for AD exacerbation and infectious complications. Further studies are needed, but empirical antibiotic therapy used for infectious complications may not be appropriate for AD exacerbation, particularly while promoting antimicrobial stewardship.