Staphylococcus aureus infections in pediatric patients with diabetes mellitus☆
Introduction
Diabetes mellitus is increasing among children worldwide. It is estimated that about 65,000 children under 15 years of age develop type 1 diabetes mellitus each year1 and recent studies have shown an increase in the number of children with type 2 diabetes mellitus.2, 3 Type 2 diabetes accounted for 2–4% of new cases of diabetes in children and adolescents before 1992, but may now account for up to 45% of new-onset cases among adolescents.3 The increasing prevalence of type 2 diabetes in children and adolescents has paralleled increasing rates of overweight and obese children and adolescents.2
Among adults, diabetic patients are more susceptible to infections compared to healthy individuals.4, 5 Common sites of infection in diabetic patients include the respiratory tract, urinary tract, and skin and soft tissues.6 The increased prevalence of infection may involve impairment of phagocytic activity of polymorphonuclear leukocytes which is depressed in diabetic patients due to a high serum concentration of glucose.7, 8
In one study, a direct correlation was found between the overall prevalence of infection in adult patients with diabetes and their mean plasma glucose levels,5 and it has been suggested that a tight control of blood sugar levels in diabetic patients may prevent the risks and complications of infections. There are no data investigating the impact of glycemic control on infectious complications in the pediatric population.
Staphyloccocus aureus is known to cause pediatric infections ranging from skin and soft tissue infections to invasive infections such as osteomyelitis, septic arthritis, bacteremia and pneumonia. In the United States, community-acquired methicillin-resistant S. aureus (CA-MRSA) has emerged as a major cause of S. aureus infections in addition to methicillin susceptible S. aureus (MSSA).9 The increase in CA-MRSA infections among both children and adults has been mainly attributed to one particular clone, USA300, which causes the majority of CA-MRSA infections at Texas Children’s Hospital (TCH), Houston, TX, and in many other regions of the United States. USA300 has also been described among MSSA isolates,10, 11 and has been associated with skin and soft tissue infections (SSTI)12, 13 as well as severe invasive disease.14, 15, 16 Features associated with USA300 include the Panton–Valentine leukocidin, a poreforming toxin, a SCCmec cassette type IV conferring the oxacillin resistance, and an arginine catabolic mobile element (ACME).17, 18
While the role of MRSA in adult diabetic foot infections has been well described,19 general studies on S. aureus infections in patients with diabetes mellitus are lacking, especially in the pediatric population. Large studies on MRSA infections frequently identify diabetes as a risk factor, and a recent publication compiling results from three randomized controlled treatment trials for MRSA SSTIs found that patients with diabetes did not respond as well to treatment as did those without diabetes.20
No studies have described in detail the S. aureus infections seen in children and adolescents with diabetes mellitus. We hypothesized that S. aureus infections in children with diabetes mellitus would differ from those of normal children with respect to clinical course, e.g., the infections would be more difficult to treat and there would be more complications. Based on previous studies we expected these differences to be related to the level of glycemic control.
The first objective of this study was to identify the clinical characteristics of pediatric diabetes patients with S. aureus infections at our institution. We compared patients with type 1 vs. type 2 diabetes mellitus and patients grouped according to their level of glycemic control (hemoglobin A1c levels greater or less than 10%). We also characterized the corresponding S. aureus isolates.
Second, we compared the patient characteristics from the study population to a group of age-matched controls, which consisted of previously healthy children with a S. aureus SSTI who sought care at TCH within the study period.
Section snippets
Study design and patients
Patients with S. aureus infections have been prospectively identified and their isolates collected at TCH, Houston, TX, since August 1, 2001.21 The study was approved by the Baylor College of Medicine Institutional Review Board and was exempt from obtaining informed consent.
From the surveillance database, pediatric patients with diabetes, who presented with S. aureus infections to TCH between February 2002 and June 2010, were identified. Patients were excluded if they had cystic fibrosis
Cases
Forty-seven patients with diabetes who had a S. aureus infection from between February 2002 and June 2010 were identified. Nine patients had a total of 16 recurrent infections. Only the first incident of infection was included in the main analysis; recurrences were compared separately.
Thirty-nine (83.0%) patients were female. The mean age at time of infection was 14.2 years (SD = 3.7). The mean BMI percentile was 82.0% (SD = 17.7), 12 (25.5%) patients were classified as overweight and 15
Discussion
In recent years, CA-MRSA infections have become increasingly prevalent among pediatric patients and diabetes has been described as a risk factor for S. aureus infection among both adults and children.25, 26 While no recent studies have investigated S. aureus infections in children and adolescents with type 1 and type 2 diabetes, several studies describe S. aureus nasal colonization, which may predispose to infection.27 The studies differ widely in the percentage of adult and pediatric diabetes
Acknowledgment
The study was presented, in part, as a poster at the Pediatric Academic Society Annual Meeting, Denver, Colorado, April 30–May 3, 2011, Paper #535. This study was supported, in part, by an investigator initiated grant from Pfizer (Kaplan). The funding source had no role in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Dr. Kaplan is the local PI for a study initiated by
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Cited by (11)
Modification of physico-chemical surface properties and growth of Staphylococcus aureus under hyperglycemia and ketoacidosis conditions
2022, Colloids and Surfaces B: BiointerfacesCitation Excerpt :However, very little attention has been paid to the possible impact that diabetic alterations, such as hyperglycemia and ketoacidosis, exert on the pathogenic bacteria, directly responsible for the infections. Staphylococci is one of the most frequently isolated genera in infections in the context of diabetes [16–20], and in particular, the species Staphylococcus aureus. Casqueiro et al. review the pathogenesis of diabetic’s infections.
Antimicrobial photodynamic therapy (aPDT) with curcumin controls intradermal infection by Staphylococcus aureus in mice with type 1 diabetes mellitus: a pilot study
2021, Journal of Photochemistry and Photobiology B: BiologyCitation Excerpt :Due to increased susceptibility to infectious diseases, individuals with T1DM have an increased risk of skin and respiratory tract infections, endocarditis, bacteremia and diabetic foot. [10]. A major pathogen that causes the aforementioned conditions in diabetic individuals is the gram-positive bacterium Staphylococcus aureus (S. aureus) [11–13]. Nowadays, one of the biggest problems in the treatment of infections caused by this pathogen is antimicrobial resistance, where the strain Methicilin Resistant Staphylococcus aureus (MRSA) has been widely distributed worldwide, representing a serious public health issue [14].
Cutaneous manifestations in children with diabetes mellitus and obesity
2014, Actas Dermo-SifiliograficasTrends in ophthalmic manifestations of methicillin-resistant Staphylococcus aureus (MRSA) in a northern California pediatric population
2013, Journal of AAPOSCitation Excerpt :Other factors analyzed included other family members with MRSA (7.3%), previous trauma or surgery (5%), and immune compromised (6.6%, including asthma, eczema, premature birth). Diabetes was not found to be a significant risk factor, in contrast to a previous study, in which the authors reported poor glycemic control to be associated with MRSA cases.41 None of the patients in this series developed severe ocular infections, such as endophthalmitis, keratitis/corneal ulcer, blebitis, or permanent visual impairment.
Infectious diseases associated with pediatric type 1 diabetes mellitus: A narrative review
2022, Frontiers in Endocrinology
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This study was, in part funded by a grant from Pfizer.