REPORT
MICROBIOLOGY OF SECONDARILY INFECTED DIAPER DERMATITIS ITZHAK BROOK, M.D., M,Sc.
Abstract Specimens obtained from 67 infants with secondarily infected diaper dermatitis were cultured for aerobic and anaerobic bacteria. Bacteria growth was obtained in 58, Aerobic facultative bacteria or Candida sp, only were present in 28 patients (48%), anaerobic bacteria only in 11 (19%), and mixed anaerobic with aerobic, facultative, or yeast flora was present in 19 (33%), Ninety-one bacterial or fungal isolates were recovered (1,6 per specimen), 54 (0,9 per specimen) aerobic or facultative bacteria, 8 (0,1 per specimen) Candida sp,, and 31 (0,6 per specimen) strict anaerobes. The predominant aerobic and facultative bacteria were Staphyiococcus aureus (23 isolates). Streptococcus sp, (16), and Escherichia coli (6), The predominant anaerobes included Bacteroides sp, (12, including 9 Bacteroides fragiiis group) and Peptostreptococcus sp, (11), Single bacterial isolates were recovered in 32 (55%) patients, 18 of which were S. aureus. Twenty-five beta-lactamase-producing bacteria were detected in 22 (51%) of the 43 tested patients. These included 16 S, aureus and 6 6, fragiiis group. These data highlight the importance of anaerobic bacteria in the polymicrobial nature of secondarily infected diaper dermatitis, Int J Dermatol 1992; 31:700-702 The role of microorganisms in diaper dermatitis has been evaluated in several studies. While some studies suggested the importance of Candida albicans^'^ and Staphylococcus aureus,^ other studies did not elucidate a role for these organisms,'*'^ or ammonia-producing microorganisms^; however, the importance of microorganisms in secondarily infected diaper dermatitis is clinically well recognized. The organisms commonly recognized as secondary invaders causing further inflammation are Staphylococcus sp.. Streptococcus sp., and C. albicans.^ Although anaerobic bacteria of enteric origin colonize the skin adjacent to the rectal area, their role as causing secondary inflammation in diaper dermatitis has not been evaluated.
From the Armed Forces Radiology Research Institute, Bethesda, Maryland. The opinions and assertions contained herein are the private ones of the writer, and are not to be construed as official or reflecting tbe views of the Department of Defense, the Navy Department, or the Naval Service at large. Address for correspondence: Itzhak Brook, M.D,, M,Sc., Armed Forces Radiobiology Research Institute, Bethesda, MD 20889-5603. 700
The purpose of this retrospective study was to define the aerobic and anaerobic bacteriology of secondarily infected diaper dermatitis in infants. Materials and Methods Specimens were obtained between September 1976 and June 1986, from infants presenting with diaper rash over the anal, pubic, or groin areas that showed signs of secondary infection as manifested by erythema, oozing, vesiculopustular lesions, and pus formation. During the study period, 67 specimens were submitted to the Microbiology Laboratories, Of these, bacterial growth was present in 58, and only these specimens were included in the final analysis. Of the 58 infants, 34 were boys. Patients' ages ranged from 2 weeks to 21 months (median age 5 months). The children included in the report were studied by the author in the following hospitals: University of California Medical Center in Los Angeles, Los Angeles County Medical Center, Children's Hospital National Medical Center, Washington, DC, and Southeast Medical Center, Washington, DC, The duration of diaper rash was noted in 51 patients and was between 6 days and 10 weeks (median 23 days), and the length of secondary infection was noted in 37 cases and was between 2 and 15 days (median 4,5 days). Forty-one of the patients had received prior local therapy with nonantibacterial or antifungal agents. None had received local or systemic antibacterial or antifungal agents. Fifty-four patients were seen at the outpatient clinic, and four were patients who developed the eruption while hospitalized for nondiarrheal diseases. Clinical data for the patients were noted and were correlated with microbiologic findings. Specimens were obtained by swabbing or aspirating the purulent material. All specimens were sent to the laboratory using Port-A-Cul swabs (BBL, Cockeysville, MD) or a corked syringe and needle. The time between specimen collection and inoculation never exceeded 30 minutes. Sheep blood, chocolate, and MacConkey's agar plates were inoculated for aerobic organisms. The plates were incubated at 37°C aerobically (MacConkey's) or undet 5% CO2, and examined at 24 and 48 hours. For anaerobic bacteria, the material was plated on to ptereduced vitamin Ki-enriched Brucella blood agar, and a selective blood agar plate containing kanamycin and vancomycin, anaerobic blood plate containing colistin and nalidixic acid, and inoculated into enriched thioglycolate broth (containing hemin, and vitamin Kl),' The plates were incubated in GasPak jars (BBL, Cockeysville, MD) and examined at 48 and 96 hours. The thioglycolate broth was incubated for 14 days. Anaerobes were identified by techniques previously described,' Aerobic bacteria were identified using conventional methods,^ Beta-lactamase activity was determined on organisms recovered from 43 specimens using the chromogenic
Diaper Dermatitis Brook
Table 1. Microorganisms Isolated in 58 Infants with Infected Diaper Dermatitis Anaerobic Anaerobic cocci Peptostreptococcus sp. Peptostreptococcus magnus Peptostreptococcus prevotii Peptostreptococcus asaccharolyticus Pep tost rep tococcus saccharolyticus Peptostreptococcus anaerobius
Aerobic and Facultative Gram-positive Gamma hemolytic Streptococcus Alpha hemolytic Streptococcus . Streptococcus pyogenes Group B beta hemolytic Streptococcus Group D Streptococcus Staphylococcus aureus Staphylococcus epidermidis
2 5 2 S 2 23 3
Gram-positive bacilli Propionibacterium acnes Clostridiuin sp. Clostridium perfringens Gram-negative bacilli Bacteroides fragiiis Bacteroides distasonis Bacteroides thetaiotaomicron Bacteroides ureolyticus Prevotella melaninogenica Porphyromonas asaccharolytica
Gram-negative bacilli Escherichia coli Proteus mirabilis Citrobacter sp, Yeast Candida albicans Candida tropicalis Total
6 3 1 .
7 1 60
Total
cephalosporin analog 87/312 methodology,^ Clinical and historical information was correlated with microbiologic data. Statistical analysis was done using the Student's t-test,
1
2 2
6 1 2 3 2 1
31
bacterial isolates and tbe patient's past medical history or duration of the rash or the infection. Beta-lactamase production was detected in 25 isolates recovered from 22 of the 43 (51%) patients whose isolates were tested for beta-lactamase production. These included all 16 tested S. aureus and all six tested B. fragiiis group, two of the four E. coli, and one of two Prevotella melaninogenica.
RESULTS
Aerobic, facultative bacteria or Candida sp. only were isolated in 28 patients (48%), anaerobic bacteria only in 11 (19%), and mixed anaerobic with aerobic, facultative, or yeast flora was present in 19 (33%). No correlation was noticed between the technique of specimen collection (i.e., swab or aspiration), the site of the type of lesion (i.e., vesicle, pustule, erosion, etc.), and the microbial isolates. Ninety-one bacterial or fungal isolates (Table 1) were recovered (1.6 per specimen), 60 (1.0 per specimen) aerobic or facultative bacteria or fungi, and 31 (0.5 per specimen) strict anaerobes. The predominant aerobic and facultative bacteria were S. aureus (23 isolates). Streptococcus sp. (16 isolates, including 5 Group B streptococci and 2 Streptococcus pyogenes), and Escherichia coli (6). The predominant anaerobes included Bacteroides sp. (12 isolates, including 9 Bacteroides fragiiis group) and Peptostreptococcus
2 4 2 1 1 1
DISCUSSION
The present report highlights the diversity of the microbiology of secondarily infected diaper dermatitis. The •recovery of multiple organisms from 26 of the 58 (45%) patients illustrates the polymicrobial nature of the infection and the potential for bacterial synergy between the different microbial isolates. Polymicrobic infections are known to be more pathogenic for experimental animals than are those involving single organisms.'" Several studies documented the synergistic effect of mixtures of aerobic and anaerobic bacteria in experimental infections.'""'Various bypotbeses have been proposed to explain such microbial synergy. When this phenomenon occurs in mixtures of aerobic and anaerobic flora, it may be due to protection from phagocytosis and intracellular killing,'^ production of essential growth factors,''' and lowering of oxidation-reduction potentials in host tissue." Our data demonstrate the presence of beta-lactamase-producing organisms in secondarily infected diaper dermatitis. Tbese organisms not only survive penicillin therapy but can also protect penicillin-susceptible bacteria from penicillin by releasing the free enzyme into the abscess cavity.""
sp. (11).
A single isolate was recovered in 32 (55%) patients. These included 18 S. aureus, three Peptostreptococcus sp., two each of group B. streptococci, B. fragiiis, and Candida albicans, and one each of E. coli, group D streptococcus, Clostridium perfringens, Clostridium sp., and Porphyromonas asaccharolytica. Two isolates were recovered in 21 instances (in 3 instances B. fragiiis group was mixed with S. aureus), three isolates were found in three cases, and four isolates in two cases. No consistent patterns of combination between the organisms was noted. No correlation was noted between the 701
International journal of Dermatology Vol, 31, No, 10, October 1992
Although S. aureus and Candida were the predominant isolates, organisms such as groups B and D streptococcus and Enterobacteriaceae, all known pathogens in the neonatal period have been isolated from our patients. Of great interest is the recovery of anaerobes in over 50% of our patients. Their isolation is not surprising since the infants' gastrointestinal flora harbors these organisms in quantities similar to these found in adults within a few days after delivery.'^ Anaerobic as well as aerobic and facultative bacteria of gastrointestinal origin have been recognized as important pathogens in other types of skin and soft tissue infections in the rectal area, such as wounds and abscesses,"* and decubitus ulcers.'' It is, therefore, plausible that these organisms can contribute to the secondarily infected diaper dermatitis. The involvement of microorganisms in diaper dermatitis has been previously investigated. Montes et al. evaluated the microbiology of the diaper area in 35 patients with diaper dermatitis and in 25 normal controls.' Candida albicans was isolated from 27 patients with diaper dermatitis but from skin of only tbree controls. £. coli and S. aureus were equally found in lesions of diaper dermatitis as well as in controls. In contrast, Brookes et al. did not find any difference between the buttocks' skin flora of 25 patients with dermatitis and 35 normal patients.'' Pittillo et al. compared the bacterial flora of the groins with that of the backs of 10 infants with diaper dermatitis.^ The number of bacteria found on backs was much smaller than that found on groins. E. coli was frequently recovered from the groin but was absent in the cultures obtained from backs. Leyden and Kligman recovered S. aureus from 50% of patients with diaper dermatitis;^ this was not isolated from normal infants. The density of bacteria per square centimeter skin surface in infants with diaper dermatitis is higher in the thigh and labial areas tban those infants without dermatitis. Bacterial overgrowth on the skin of infants with diaper dermatitis may represent a secondary event; however, the actual role of bacterial proliferation in the etiology of diaper dermatitis is not well settled. The exact pathogenic role of the organisms isolated from secondarily infected diaper dermatitis has not yet been determined. Altbough many of these organisms can also be recovered from tbe skin surfaces, their recovery in secondarily infected lesions may signify that they induce an infection at that stage of the inflammation. Further studies using quantitative microbiology and assessment of antimicrobials effective against anaerobes are warranted to explore their contribution to the inflammatory process. When cultures are obtained from secondarily infected diaper dermatitis, these should be adequate for the recovery of aerobic as well as anaerobic bacteria. Acknowledgment: L. Calhoun, P. Yocum, and J.E, Perry provided laboratory support.
REFERENCES
1.
Montes LF, Pittillo R, Hunt D, Narkates AJ, Dillon HG. Microbiology of infants skin comparison of types of microorganisms between normal skin and diaper dermatitis. Arch Dermatol 1972; 103:640-648.
2.
Leyden JJ, Katz S, Steward R, Kligman AM. Urinary ammonia and ammonia-producing microorganisms in infants with and without diaper dermatitis. Arch Dermatol 1977; 113:1678-1680,
3.
Leyden JJ, Kligman AM. The role of microorganisms in diaper dermatitis. Arch Dermatol 1978; 114:56-61,
4.
Brookes DB, Hubbert RM, Sarkamy J. Skin flora of infants with napkin rash. Br J Dermatol 1971; 85: 250-253.
5.
Pittillo RF, Moore WJ, Panzer JO, Montes LF, Bacterial flora of infants skin comparison between diaper-occluded and unoccluded areas, Int J Dermatol 1973; 12: 245-249,
6.
Rasmussen JF, Diaper dermatitis, Pediatr Rev 1984; 6: 77-82.
7,
Sutter VL, Citron DM, Edelstein MAC, Finegold SM, Wadsworth anaerobic bacteriology manual, 4th Ed, Belmont, CA: Star Publishing, 1985, 8, Lennette EH, Balows A, Hausler W, Shadomy HJ. Manual of clinical microbiology, 4th Ed, Washington, DC: American Society for Microbiology, 1985, 9, O'Callaghan DH, Morris A, Kirby SM, Shingler AH. Novel method for detection of beta-lactamase by using a chromogenic cephalosporin substrate. Antimicrob Agents Chemother 1972; 1:283-288. 10, Meleney FL, Bacterial synergy in disease processes, Ann Surg 1931; 22:961-981, 11, Altemeier WA, The pathogenicity of the bacteria of appendicitis. Surgery 1942; 11:374-378, 12, Brook 1, Hunter V, Walker RI. Synergistic effects of Bacteroides, Clostridia, Fusobacteria, anaerobic cocci, and aerobic bacteria on mortality and induction of subcutaneous abscess in mice, J Infect Dis 1984; 149:924-928, 13,
Ingham HR, Tharagonnet D, Sisson PR. Inhibition of phagocytosis in-vitro by obligate anaerobes. Lancet 1977; i:252-254,
14,
Lev M, Krudell KC, Milford AF, Succinate as a growth factor for Bacteroides melaninogenicus. J Bacteriol 1971; 108:175-178,
15,
Mergenhagen SE, Thonard JC, Scherp HW, Studies on synergistic infection: I, Experimental infection with anaerobic streptococci, J Infect Dis 1958; 103:33-44, Brook I, The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection. Rev Infect Dis 1984; 6:601-607.
16,
17,
Long SS, Swenson RM, Development of anaerobic fecal flora in healthy newborn infants, J Pediatr 1977; 91: 298-302,
18,
Brook I, Finegold SM. Aerobic and aerobic bacteriology of cutaneous abscesses in children. Pediatrics 1981; 67:891-895, Brook I. Anaerobic and aerobic bacteriology of decubitus ulcers in children. Am Surg 1980; 6:624-626.
19,
702
MICROBIOLOGY OF SECONDARILY INFECTED DIAPER DERMATITIS ITZHAK BROOK, M.D., M,Sc.
Abstract Specimens obtained from 67 infants with secondarily infected diaper dermatitis were cultured for aerobic and anaerobic bacteria. Bacteria growth was obtained in 58, Aerobic facultative bacteria or Candida sp, only were present in 28 patients (48%), anaerobic bacteria only in 11 (19%), and mixed anaerobic with aerobic, facultative, or yeast flora was present in 19 (33%), Ninety-one bacterial or fungal isolates were recovered (1,6 per specimen), 54 (0,9 per specimen) aerobic or facultative bacteria, 8 (0,1 per specimen) Candida sp,, and 31 (0,6 per specimen) strict anaerobes. The predominant aerobic and facultative bacteria were Staphyiococcus aureus (23 isolates). Streptococcus sp, (16), and Escherichia coli (6), The predominant anaerobes included Bacteroides sp, (12, including 9 Bacteroides fragiiis group) and Peptostreptococcus sp, (11), Single bacterial isolates were recovered in 32 (55%) patients, 18 of which were S. aureus. Twenty-five beta-lactamase-producing bacteria were detected in 22 (51%) of the 43 tested patients. These included 16 S, aureus and 6 6, fragiiis group. These data highlight the importance of anaerobic bacteria in the polymicrobial nature of secondarily infected diaper dermatitis, Int J Dermatol 1992; 31:700-702 The role of microorganisms in diaper dermatitis has been evaluated in several studies. While some studies suggested the importance of Candida albicans^'^ and Staphylococcus aureus,^ other studies did not elucidate a role for these organisms,'*'^ or ammonia-producing microorganisms^; however, the importance of microorganisms in secondarily infected diaper dermatitis is clinically well recognized. The organisms commonly recognized as secondary invaders causing further inflammation are Staphylococcus sp.. Streptococcus sp., and C. albicans.^ Although anaerobic bacteria of enteric origin colonize the skin adjacent to the rectal area, their role as causing secondary inflammation in diaper dermatitis has not been evaluated.
From the Armed Forces Radiology Research Institute, Bethesda, Maryland. The opinions and assertions contained herein are the private ones of the writer, and are not to be construed as official or reflecting tbe views of the Department of Defense, the Navy Department, or the Naval Service at large. Address for correspondence: Itzhak Brook, M.D,, M,Sc., Armed Forces Radiobiology Research Institute, Bethesda, MD 20889-5603. 700
The purpose of this retrospective study was to define the aerobic and anaerobic bacteriology of secondarily infected diaper dermatitis in infants. Materials and Methods Specimens were obtained between September 1976 and June 1986, from infants presenting with diaper rash over the anal, pubic, or groin areas that showed signs of secondary infection as manifested by erythema, oozing, vesiculopustular lesions, and pus formation. During the study period, 67 specimens were submitted to the Microbiology Laboratories, Of these, bacterial growth was present in 58, and only these specimens were included in the final analysis. Of the 58 infants, 34 were boys. Patients' ages ranged from 2 weeks to 21 months (median age 5 months). The children included in the report were studied by the author in the following hospitals: University of California Medical Center in Los Angeles, Los Angeles County Medical Center, Children's Hospital National Medical Center, Washington, DC, and Southeast Medical Center, Washington, DC, The duration of diaper rash was noted in 51 patients and was between 6 days and 10 weeks (median 23 days), and the length of secondary infection was noted in 37 cases and was between 2 and 15 days (median 4,5 days). Forty-one of the patients had received prior local therapy with nonantibacterial or antifungal agents. None had received local or systemic antibacterial or antifungal agents. Fifty-four patients were seen at the outpatient clinic, and four were patients who developed the eruption while hospitalized for nondiarrheal diseases. Clinical data for the patients were noted and were correlated with microbiologic findings. Specimens were obtained by swabbing or aspirating the purulent material. All specimens were sent to the laboratory using Port-A-Cul swabs (BBL, Cockeysville, MD) or a corked syringe and needle. The time between specimen collection and inoculation never exceeded 30 minutes. Sheep blood, chocolate, and MacConkey's agar plates were inoculated for aerobic organisms. The plates were incubated at 37°C aerobically (MacConkey's) or undet 5% CO2, and examined at 24 and 48 hours. For anaerobic bacteria, the material was plated on to ptereduced vitamin Ki-enriched Brucella blood agar, and a selective blood agar plate containing kanamycin and vancomycin, anaerobic blood plate containing colistin and nalidixic acid, and inoculated into enriched thioglycolate broth (containing hemin, and vitamin Kl),' The plates were incubated in GasPak jars (BBL, Cockeysville, MD) and examined at 48 and 96 hours. The thioglycolate broth was incubated for 14 days. Anaerobes were identified by techniques previously described,' Aerobic bacteria were identified using conventional methods,^ Beta-lactamase activity was determined on organisms recovered from 43 specimens using the chromogenic
Diaper Dermatitis Brook
Table 1. Microorganisms Isolated in 58 Infants with Infected Diaper Dermatitis Anaerobic Anaerobic cocci Peptostreptococcus sp. Peptostreptococcus magnus Peptostreptococcus prevotii Peptostreptococcus asaccharolyticus Pep tost rep tococcus saccharolyticus Peptostreptococcus anaerobius
Aerobic and Facultative Gram-positive Gamma hemolytic Streptococcus Alpha hemolytic Streptococcus . Streptococcus pyogenes Group B beta hemolytic Streptococcus Group D Streptococcus Staphylococcus aureus Staphylococcus epidermidis
2 5 2 S 2 23 3
Gram-positive bacilli Propionibacterium acnes Clostridiuin sp. Clostridium perfringens Gram-negative bacilli Bacteroides fragiiis Bacteroides distasonis Bacteroides thetaiotaomicron Bacteroides ureolyticus Prevotella melaninogenica Porphyromonas asaccharolytica
Gram-negative bacilli Escherichia coli Proteus mirabilis Citrobacter sp, Yeast Candida albicans Candida tropicalis Total
6 3 1 .
7 1 60
Total
cephalosporin analog 87/312 methodology,^ Clinical and historical information was correlated with microbiologic data. Statistical analysis was done using the Student's t-test,
1
2 2
6 1 2 3 2 1
31
bacterial isolates and tbe patient's past medical history or duration of the rash or the infection. Beta-lactamase production was detected in 25 isolates recovered from 22 of the 43 (51%) patients whose isolates were tested for beta-lactamase production. These included all 16 tested S. aureus and all six tested B. fragiiis group, two of the four E. coli, and one of two Prevotella melaninogenica.
RESULTS
Aerobic, facultative bacteria or Candida sp. only were isolated in 28 patients (48%), anaerobic bacteria only in 11 (19%), and mixed anaerobic with aerobic, facultative, or yeast flora was present in 19 (33%). No correlation was noticed between the technique of specimen collection (i.e., swab or aspiration), the site of the type of lesion (i.e., vesicle, pustule, erosion, etc.), and the microbial isolates. Ninety-one bacterial or fungal isolates (Table 1) were recovered (1.6 per specimen), 60 (1.0 per specimen) aerobic or facultative bacteria or fungi, and 31 (0.5 per specimen) strict anaerobes. The predominant aerobic and facultative bacteria were S. aureus (23 isolates). Streptococcus sp. (16 isolates, including 5 Group B streptococci and 2 Streptococcus pyogenes), and Escherichia coli (6). The predominant anaerobes included Bacteroides sp. (12 isolates, including 9 Bacteroides fragiiis group) and Peptostreptococcus
2 4 2 1 1 1
DISCUSSION
The present report highlights the diversity of the microbiology of secondarily infected diaper dermatitis. The •recovery of multiple organisms from 26 of the 58 (45%) patients illustrates the polymicrobial nature of the infection and the potential for bacterial synergy between the different microbial isolates. Polymicrobic infections are known to be more pathogenic for experimental animals than are those involving single organisms.'" Several studies documented the synergistic effect of mixtures of aerobic and anaerobic bacteria in experimental infections.'""'Various bypotbeses have been proposed to explain such microbial synergy. When this phenomenon occurs in mixtures of aerobic and anaerobic flora, it may be due to protection from phagocytosis and intracellular killing,'^ production of essential growth factors,''' and lowering of oxidation-reduction potentials in host tissue." Our data demonstrate the presence of beta-lactamase-producing organisms in secondarily infected diaper dermatitis. Tbese organisms not only survive penicillin therapy but can also protect penicillin-susceptible bacteria from penicillin by releasing the free enzyme into the abscess cavity.""
sp. (11).
A single isolate was recovered in 32 (55%) patients. These included 18 S. aureus, three Peptostreptococcus sp., two each of group B. streptococci, B. fragiiis, and Candida albicans, and one each of E. coli, group D streptococcus, Clostridium perfringens, Clostridium sp., and Porphyromonas asaccharolytica. Two isolates were recovered in 21 instances (in 3 instances B. fragiiis group was mixed with S. aureus), three isolates were found in three cases, and four isolates in two cases. No consistent patterns of combination between the organisms was noted. No correlation was noted between the 701
International journal of Dermatology Vol, 31, No, 10, October 1992
Although S. aureus and Candida were the predominant isolates, organisms such as groups B and D streptococcus and Enterobacteriaceae, all known pathogens in the neonatal period have been isolated from our patients. Of great interest is the recovery of anaerobes in over 50% of our patients. Their isolation is not surprising since the infants' gastrointestinal flora harbors these organisms in quantities similar to these found in adults within a few days after delivery.'^ Anaerobic as well as aerobic and facultative bacteria of gastrointestinal origin have been recognized as important pathogens in other types of skin and soft tissue infections in the rectal area, such as wounds and abscesses,"* and decubitus ulcers.'' It is, therefore, plausible that these organisms can contribute to the secondarily infected diaper dermatitis. The involvement of microorganisms in diaper dermatitis has been previously investigated. Montes et al. evaluated the microbiology of the diaper area in 35 patients with diaper dermatitis and in 25 normal controls.' Candida albicans was isolated from 27 patients with diaper dermatitis but from skin of only tbree controls. £. coli and S. aureus were equally found in lesions of diaper dermatitis as well as in controls. In contrast, Brookes et al. did not find any difference between the buttocks' skin flora of 25 patients with dermatitis and 35 normal patients.'' Pittillo et al. compared the bacterial flora of the groins with that of the backs of 10 infants with diaper dermatitis.^ The number of bacteria found on backs was much smaller than that found on groins. E. coli was frequently recovered from the groin but was absent in the cultures obtained from backs. Leyden and Kligman recovered S. aureus from 50% of patients with diaper dermatitis;^ this was not isolated from normal infants. The density of bacteria per square centimeter skin surface in infants with diaper dermatitis is higher in the thigh and labial areas tban those infants without dermatitis. Bacterial overgrowth on the skin of infants with diaper dermatitis may represent a secondary event; however, the actual role of bacterial proliferation in the etiology of diaper dermatitis is not well settled. The exact pathogenic role of the organisms isolated from secondarily infected diaper dermatitis has not yet been determined. Altbough many of these organisms can also be recovered from tbe skin surfaces, their recovery in secondarily infected lesions may signify that they induce an infection at that stage of the inflammation. Further studies using quantitative microbiology and assessment of antimicrobials effective against anaerobes are warranted to explore their contribution to the inflammatory process. When cultures are obtained from secondarily infected diaper dermatitis, these should be adequate for the recovery of aerobic as well as anaerobic bacteria. Acknowledgment: L. Calhoun, P. Yocum, and J.E, Perry provided laboratory support.
REFERENCES
1.
Montes LF, Pittillo R, Hunt D, Narkates AJ, Dillon HG. Microbiology of infants skin comparison of types of microorganisms between normal skin and diaper dermatitis. Arch Dermatol 1972; 103:640-648.
2.
Leyden JJ, Katz S, Steward R, Kligman AM. Urinary ammonia and ammonia-producing microorganisms in infants with and without diaper dermatitis. Arch Dermatol 1977; 113:1678-1680,
3.
Leyden JJ, Kligman AM. The role of microorganisms in diaper dermatitis. Arch Dermatol 1978; 114:56-61,
4.
Brookes DB, Hubbert RM, Sarkamy J. Skin flora of infants with napkin rash. Br J Dermatol 1971; 85: 250-253.
5.
Pittillo RF, Moore WJ, Panzer JO, Montes LF, Bacterial flora of infants skin comparison between diaper-occluded and unoccluded areas, Int J Dermatol 1973; 12: 245-249,
6.
Rasmussen JF, Diaper dermatitis, Pediatr Rev 1984; 6: 77-82.
7,
Sutter VL, Citron DM, Edelstein MAC, Finegold SM, Wadsworth anaerobic bacteriology manual, 4th Ed, Belmont, CA: Star Publishing, 1985, 8, Lennette EH, Balows A, Hausler W, Shadomy HJ. Manual of clinical microbiology, 4th Ed, Washington, DC: American Society for Microbiology, 1985, 9, O'Callaghan DH, Morris A, Kirby SM, Shingler AH. Novel method for detection of beta-lactamase by using a chromogenic cephalosporin substrate. Antimicrob Agents Chemother 1972; 1:283-288. 10, Meleney FL, Bacterial synergy in disease processes, Ann Surg 1931; 22:961-981, 11, Altemeier WA, The pathogenicity of the bacteria of appendicitis. Surgery 1942; 11:374-378, 12, Brook 1, Hunter V, Walker RI. Synergistic effects of Bacteroides, Clostridia, Fusobacteria, anaerobic cocci, and aerobic bacteria on mortality and induction of subcutaneous abscess in mice, J Infect Dis 1984; 149:924-928, 13,
Ingham HR, Tharagonnet D, Sisson PR. Inhibition of phagocytosis in-vitro by obligate anaerobes. Lancet 1977; i:252-254,
14,
Lev M, Krudell KC, Milford AF, Succinate as a growth factor for Bacteroides melaninogenicus. J Bacteriol 1971; 108:175-178,
15,
Mergenhagen SE, Thonard JC, Scherp HW, Studies on synergistic infection: I, Experimental infection with anaerobic streptococci, J Infect Dis 1958; 103:33-44, Brook I, The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection. Rev Infect Dis 1984; 6:601-607.
16,
17,
Long SS, Swenson RM, Development of anaerobic fecal flora in healthy newborn infants, J Pediatr 1977; 91: 298-302,
18,
Brook I, Finegold SM. Aerobic and aerobic bacteriology of cutaneous abscesses in children. Pediatrics 1981; 67:891-895, Brook I. Anaerobic and aerobic bacteriology of decubitus ulcers in children. Am Surg 1980; 6:624-626.
19,
702
![[Diaper dermatitis].](/assets/img/hold.png)
