Article
Treatment regimens and outcomes of cutaneous diphtheria in migrant children and adolescents in Germany, June 2022 – October 2023
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Authors
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Alicia Zink
- Sektion für Pädiatrische Infektiologie und Rheumatologie, Zentrum für Kinder- und Jugendheilkunde, Universitätsklinikum Freiburg, Germany
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Juliana Hofer
- Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum Freiburg, Germany
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Christian Schneider
- Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum Freiburg, Germany
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Franziska Kessler
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Hannes Klenze
- Zentrum für Kinder- und Jugendgesundheit, Hegau-Bodensee-Klinikum Singen, Gesundheitsverbund Landkreis Konstanz, Germany
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Dietrich Klauwer
- Zentrum für Kinder- und Jugendgesundheit, Hegau-Bodensee-Klinikum Singen, Gesundheitsverbund Landkreis Konstanz, Germany
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Klaudia Maleki
- Abteilung für Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, interdisziplinäre Flüchtlingsambulanz der Landeserstaufnahmeeinrichtung Patrick-Henry-Village, Germany
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Andreas Müller
- Erstaufnahmeeinrichtung des Landes Hessen, Regierungspräsidium Gießen, Gießen, Germany
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Sarah Goretzki
- Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Germany
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Shubei Wang
- Allgemeine und Spezielle Pädiatrie, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
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Robin Kobbe
- Institut für Infektionsforschung und Impfstoffentwicklung, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany; Abteilung Infektionsepidemiologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany
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Andrea Vanegas Ramirez
- Bundeswehrkrankenhaus Hamburg, Tropendermatologie am Bernhard-Nocht-Institut für Tropenmedizin, Hamburg, Germany
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Sebastian Bode
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Ulm, Germany
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Ales Janda
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Ulm, Germany
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Roland Fressle
- Kinder- und Jugendarztpraxis Dr. Roland Fressle, Freiburg, Germany
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Jonathan Remppis
- Abteilung für Neuropädiatrie, Allgemeinpädiatrie, Diabetologie, Endokrinologie, Sozialpädiatrie, Universitätskinderklinik Tübingen; Institut für Tropenmedizin, Reisemedizin und Humanparasitologie, Universitätsklinikum Tübingen, Germany
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Anja Berger
- Konsiliarlabor für Diphtherie, WHO Collaborating Centre for Diphtheria, Bayerisches Landesamt für Gesundheit und Lebensmittelsicherheit, Oberschleißheim, Germany
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Andreas Sing
- Konsiliarlabor für Diphtherie, WHO Collaborating Centre for Diphtheria, Bayerisches Landesamt für Gesundheit und Lebensmittelsicherheit, Oberschleißheim, Germany
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Markus Hufnagel
- Sektion für Pädiatrische Infektiologie und Rheumatologie, Zentrum für Kinder- und Jugendheilkunde, Universitätsklinikum Freiburg, Germany
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Benedikt D. Spielberger
- Sektion für Pädiatrische Infektiologie und Rheumatologie, Zentrum für Kinder- und Jugendheilkunde, Universitätsklinikum Freiburg, Germany
| Published: | November 4, 2024 |
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Outline
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Introduction: Diphtheria is a rare, potentially lethal upper respiratory tract infection that causes systemic illness associated with toxemia. In Western countries – where diphtheria is not endemic – unspecific wound infections due to toxigenic Corynebacterium diphtheriae strains are usually observed in travelers and patients with migration history. From September 2022 until 8th January 2024, a total of 442 cases of C. diphtheriae infection have been reported to ECDC and most cases were cutaneous infections. The clinical picture of cutaneous diphtheria was mostly reported as chronic, erosive skin infections and a polymicrobial infection with S. aureus or S. pyogenes as the most common additional pathogens. Roughly, 50% of S. aureus isolates were methicillin-resistant and a high rate of resistance against clindamycin and tetracyclines was detected in some cohorts. We therefore aimed to get more insight into treatment regimens chosen by practitioners and the outcome of affected individuals.
Methods: The survey was distributed through the German Pediatric Infectious Diseases society (DGPI) and professional contacts in Germany, Switzerland and Austria. We focused on children and adolescents presenting to pediatric hospitals. The collected information was derived from routine medical care and reported in an anonymous format. Anonymized data was then compared with results from the consultant laboratory.
Results: A total of 36 adolescents with cutaneous diphtheria were reported from 9 centers. The majority (n=28; 78%) was born in Afghanistan. Of those who were asked for their migration route (n=21; 57%), the majority (n=20; 95%) came via the Balkan route. Skin wounds mostly affected lower legs (27%), feet (25%) and hands (20%). Toxigenic C. diphtheriae was isolated from 29 (81%) individuals from skin wounds, while 3 (8%) had non-toxigenic C. diphtheriae and toxin status was not reported for 4 individuals (11%). Co-infection with S. aureus and S. pyogenes was common and 56% of S. aureus isolates were methicillin-resistant. C. diphtheriae was reportedly resistant to cotrimoxazole in 28% of isolates and to macrolides in 6% of cases. No resistances to tetracyclines or clindamycin were reported. Topical treatment was prescribed for 28 patients (78%), mostly with topical antiseptics (n=25; 89%). Systemic antibiotic treatment was prescribed for 31 patients (86%), mostly clindamycin (32%) or amoxicillin/clavulanic acid (26%), followed by macrolides and penicillin (Table 1 [Tab. 1]). Treatment duration varied between 5 to 17 days (Figure 1 [Fig. 1]). Clinical outcomes were most favourable with combination of local antiseptic and systemic antibiotic therapy.
Discussion: Our data highlight the need for awareness for cutaneous diphtheria in children and adolescents with recent migration history. Treatment duration for skin wounds was ranging from 5 to 17 days. Clindamycin, aminopenicillins with beta-lactamase inhibitors and macrolides were among the preferred treatments, alongside topical antiseptic treatment. Comparing our results with those from the consultant laboratory, an overall 5% resistance rate against clindamycin and the need for increased exposure to penicillin must be taken into account. From an antibiotic stewardship perspective, we advise, treating with clindamycin in combination with high doses of oral penicillin V for cutaneous mixed infections in a setting with a high rate of MRSA and C. diphtheriae in the ongoing European outbreak among refugees.
