P012 Metastatic <i>Staphylococcus aureus</i> bacteraemia in atopic dermatitis: a case series

Abstract Atopic dermatitis (AD) is the most common inflammatory skin disorder. The role of Staphylococcus aureus as a pathogen of significance in AD is well established, with expression of clumping factor B by the bacterium facilitating bacterial adhesion, and disruption of the epidermal barrier being mediated by endotoxin production. The clinical consequences of such host–pathogen interactions may include impetiginized AD flares, or, in select cases, S. aureus bacteraemia (SAB). We describe our single-centre experience with five cases of metastatic SAB in patients with severe AD. The disease severity and treatment of these patients are summarized in Table 1. All patients had blood cultures that were positive for S. aureus. Three had methicillin-sensitive S. aureus, while two patients had methicillin-resistant S. aureus. Four patients (80%) developed infective endocarditis (IE), and one patient developed septic arthritis as a complication of SAB. Of those who developed IE, the mean time from admission to diagnosis was 3.6 days (range 0–8). Salient clinical features and associated therapies of SAB are outlined in Table 2. This case series highlights potential complications associated with severe AD, most notably in the form of metastatic SAB. Few reports in the literature describe the relationship between AD severity and complicated SAB. We advocate for prompt consideration and recognition of complicated SAB in unwell patients with a background of AD.Table 1Disease severity and treatmentPatientSexAge (years)Disease severityAD targeted therapies on admission for SAB1Male59IGA 4Betamethasone valerate 0.1%, emollients, prednisolone, methotrexate2Male17IGA 4Narrowband ultraviolet B phototherapy, betamethasone valerate 0.025%, emollients 3Female61‘Suboptimal control’Betamethasone valerate 0.1%, emollients4Male29IGA 4Betamethasone valerate 0.1%, clobetasone butyrate 0.05%, emollients 5Male48IGA 4Betamethasone valerate 0.1%, emollientsAD, atopic dermatitis; IGA, Investigator’s Global Assessment; SAB, Staphylococcus aureus bacteraemia. Table 2Clinical features and therapies. IV, intravenousPatientClinical manifestationsComplications of SABTreatment of metastatic SABOutcome1Diaphoresis, rigors, nausea, fatigueMitral/aortic valve IE8 weeks IV flucloxacillinRecommenced on methotrexate; good control of AD2ErythrodermaMitral valve IE6 weeks IV flucloxacillinCommenced on dupilumab; excellent control of AD3Pyrexia and rigors following abscess development at footMitral/aortic valve IE6 weeks IV cefazolinMitral valve repair for mitral regurgitation. Recent commencement of dupilumab; AD improving4Erythroderma, subjective fevers, fatigueMRSA bacteraemia with mitral valve IETotal duration 6 weeks 6 days: IV vancomycin → IV daptomycin → IV ceftaroline + vancomycin → oral linezolidRecent recommencement of tralokinumab; AD improving5Right shoulder painSeptic arthritis of right shoulderIV flucloxacillin + vancomycin → 8 weeks daptomycin + rifampicin → 6 weeks doxycyclineCommenced on dupilumab; excellent control of ADAD, atopic dermatitis; IE, infective endocarditis; IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus; SAB, Staphylococcus aureus bacteraemia.