The Susceptibility Pattern of Staphylococcus Aureus and

Streptococcus Pyogenes to Fusidic Acid and Mupirocin in Superficial

Pyoderma

Amalia Rizkha Malini

, M. Athuf Thaha

, Fitriani

Dermatovenereologist from Department of Dermatology and Venereology Faculty of Medicine Sriwijaya University/Dr.

Moh. Hoesin General Hospital Palembang, Jendral Sudirman Street Km 3.5, Palembang, South of Sumatera, Indonesia

Professor of

Department of Dermatology and Venereology Faculty of Medicine Sriwijaya University/Dr. Moh. Hoesin

General Hospital Palembang, Jendral Sudirman Street Km 3.5, Palembang, South of Sumatera, Indonesia

Staff of

Department of Dermatology and Venereology Faculty of Medicine Sriwijaya University/Dr. Moh. Hoesin General

Hospital Palembang, Jendral Sudirman Street Km 3.5, Palembang, South of Sumatera, Indonesia

Keywords: susceptibility pattern, fusidic acid, mupirocin, Staphylococcus aureus, Streptococcus pyogenes

Abstract: The most common causes of superficial pyoderma are Staphylococcus aureus (S. aureus) and Streptococcus

pyogenes (S. pyogenes). Currently, many regions have reported of S. aureus and S. pyogenes resistance to

fusidic acid and mupirocin, whereas there are regions that still susceptible. Antibiotic resistance is a health

issues in many countries, which increase the morbidity and mortality. The susceptibility test is one of methods

to determine the resistance problems. About 27 and 12 of S. aureus and S. pyogenes isolates, consecutively,

were collected from 44 specimen samples of superficial pyoderma patients. All isolates were subjected to

susceptibility test to fusidic acid and mupirocin using broth microdilution methods. This study showed

differences between S. aureus to fusidic acid versus mupirocin, whereas S. aureus 8 times more susceptible

to fusidic acid than mupirocin significantly (PR = 8.312; p = 0.001); S. pyogenes is more susceptible to fusidic

acid than mupirocin significantly (p = 0.000). This study has been show Staphylococcus aureus and S.

pyogenes are more susceptible to fusidic acid than mupirocin

1 INTRODUCTION

Superficial pyoderma is a bacterial skin infection that

affects the epidermis, beneath the stratum corneum

and hair follicles (Nirwati,2013). Approximately

30% of superficial pyoderma in developing countries

occurs at below 15 years old (Depari, 2016). The 14

meta analysis collected by World Health

Organization (WHO), reported that in tropical

countries superficial pyoderma primarily caused by

Staphylococcus aureus (S. aureus) and Streptococcus

pyogenes (S. pyogenes), whereas in developing

countries is S. aureus (Depari, 2016). Inadequate

superficial pyoderma therapy may lead to

complications either extending to the layer beneath

the epidermis or other organs, therefore requiring

immediate empirical therapy (Milet, 2012). Empirical

therapy can trigger antibiotic resistant of bacterial

strains and treatment failure, especially when used

irrationally. The widespread use of topical antibiotics

is one of the causes of antibiotic resistance

(Poovelikunnel, 2015) (Antonov,2015)

Currently various studies have reported resistance

of S. aureus and S. pyogenes both to fusidic acid and

mupirocin in various regions, but there are still

regions where S. aureus and S. pyogenes are

susceptible to both agent (Koning,2012) The

objective of this study is to determine the

susceptibility of S. aureus and S. pyogenes to fusidic

acid and mupirocin in Dermatology and Venereology

Policlinic of Dr. Mohammad Hoesin General

Hospital Palembang and analyzed the differences

between S. aureus and S. pyogenes susceptibility to

fusidic acid and mupirocin

2 METHODS

This is an observational analytical laboratory study

with cross sectional design conducted from July to

October 2017 at Dermatologic Infection Division,

DV Department, Clinical Pathology and

Microbiology Department of Dr. Mohammad Hoesin

Malini, A., Thaha, M. and Fitriani, .

The Susceptibility Pattern of Staphylococcus Aureus and Streptococcus Pyogenes to Fusidic Acid and Mupirocin in Superﬁcial Pyoderma.

DOI: 10.5220/0008154502270230

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 227-230

ISBN: 978-989-758-494-7

227

General Hospital Palembang, and Health laboratory

for Palembang. The 44 study samples that fullfiled the

inclusion criteria, then were subjected to culture

examination and identified. Each S. aureus and S.

pyogenes isolates that grow later were subjected to

susceptibility test using broth microdilution methods.

3 RESULTS

The study samples included in this study from < 1

to15 years old, majority of the subjects (59.1%) were

in the 1-5 years old group, with same ratio of male

and female (1:1). The majority of the subjects

(36.4%) of this study was in the middle

socioeconomic level and poor environmental

conditions (27.4%). The sample of this study mostly

normoweight (70.5%). A total of 30 subjects (68.2%)

using antibiotics where as 11 subjects using

appropriate antibiotics questioned by researchers i.e

amoxicillin, chloramphenicol, and gentamicin. Based

on clinical manifestation, the majority of diagnosis

found in the study sample was vesicobullous impetigo

(38.6%) (Table 1).

Table 1. Sosiodemografic characteristic of sample

Characteristic N %

Age (years old), mean ± SD 5,02±3,65

Age

 < 1 years old

 1 - 5 years old

 6 - 10 years old

 10

–

ears old

6,8

59,1

25,0

9,1

Sex, n (%)

 Male

 Female

Sosioeconomic Condition

 Low

 Middle

 High

 Very high

29,5

36,4

27,3

6,8

Environment

 Good

 Poo

61,4

38,6

Body Mass Index

 Underweight

 Normoweight

 Overweight

22,7

70,5

6,8

Among 44 specimens obtained from 44 subjects,

48 isolates were found in culture, 4 of which were

mixed. The most bacteria found were S. aureus, 27

isolates (61,3%) and S. pyogenes 12 isolates (27,2%).

The susceptibility test for fusidic acid, found that

77.8% of S. aureus isolates and all S. pyogenes

isolates (100%) were susceptible to fusidic acid

(Table 2). While, susceptibility test result for

mupirocin showed that 29.6% isolates of S. aureus

susceptible to mupirocin and only 8.3% of S.

pyogenes isolates were susceptible to mupirocin

(Table 2). There was a difference between S. aureus

susceptibility to fusidic acid and mupirocin, with S.

aureus 8 times more susceptible to fusidic acid than

mupirocin significantly (Table 3). In addition, S.

pyogenes are more susceptible to fusidic acid than

mupirocin significantly (Table 4).

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Table 2. Susceptibility of S. aureus dan S. pyogenes to fusidic acid and mupirocin

Antibiotic S. aureus S. pyogenes

Susceptible Resistant Susceptible Resistant

Fusidic acid 21 (77,8) 6 (22,2) 12 (100) 0 (0)

Mupirocin 8 (29,6) 19 (70,4) 1 (8,3) 11 (91,7)

Table 3. Comparasion of S. aureus susceptibility between fusidic acid to mupirocin

Characteristic Susceptibility of S. aureus

Total

PR*

(CI 95%)

p value*

Susceptible Resistant

Antibiotic

Fusidic acid

Mupirocin

8,312

(2,437-28,354)

0,001

Total 29 25 54

*chi-square test

Table 4. Comparasion of S. pyogenes susceptibility between fusidic acid to mupirocin

Chracteristic Susceptibility of S. pyogenes

Total

PR*

(CI 95%)

p value*

Susceptible Resistant

Antibiotic

Fusidic acid

Mupirocin

0,000

Total 13 11 24

* Fisher’s exact test

4 DISCUSSION

The incidence of superficial pyoderma is influenced

by host factors (immune status and skin barrier state),

environment and agent (Nirwati,2013) (Milet, 2012).

Predisposing factors are associated with superficial

pyoderma, including age, sex, socioeconomic status,

environmental condition, and nutritional status of the

patient (Depari,2016) (Karimkhani,2014)

The results of this study indicate that S. aureus

and S. pyogenes are still sensitive to fusidic acid and

have good in vitro effectiveness. Low susceptibility

of S. aureus and S. pyogenes to mupirocin in this

study, suggesting in vitro resistance of S. aureus and

S. pyogenes to mupirocin. Susceptibility patterns are

influenced by factors including geographic factors

(environmental contamination, population density,

and population migration), socioeconomic,

prevalence of MRSA or antibiotic resistant bacteria,

and antibiotic usage

7,12

. Antonov et al., Found a

strong association between mupirocin resistance and

some factors were: history of mupirocin use (19.2% -

26.5%, p <0.001), MRSA isolates (55.4%, p <0.001),

and history of other topical and systemic antibiotics

(OR 3.6, p <0.006) (Antonov, 2015)

Mupirocin resistance is caused by point mutations

in the ileS gene, as well as the transmission of MupA

or MupB genes via plasmid-mediated intergene

bacteria to form gene modification ileS. This

modification gene is the form of "eukaryotic-like"

genes RNA synthetase that has no affinity for

mupirocin

. MupA genes are also known to be present

in plasmids bacteria that are resistant to some other

antibiotics that may cause cross resistance with other

antibiotics via a plasmid conjugation mechanism.

(Poovelikunnel, 2015) (Cadilla, 2011)

High resistance of S. aureus and S. pyogenes

isolates to mupirocin versus fusidic acid in this study

may be due to antibiotic usage (Poovelikunnel,2015)

(Cadilla, 2011)The use of antibiotics with chemical

structures resembling mupirocin is known to cause

horizontal transfer between bacterial carriers of

resistant genes against the antibiotic. Candilla et al.,

found that the MupA gene was strongly associated

with MDR (p <0.0001), 23% among 837 antibiotic-

resistant samples of the β-lactam and non-β-lactam

groups were MupA carriers. In addition mupirocin-

The Susceptibility Pattern of Staphylococcus Aureus and Streptococcus Pyogenes to Fusidic Acid and Mupirocin in Superﬁcial Pyoderma

229

resistant bacteria had a 9-fold (OR 9.83%) risk for

resistance to at least 4 β-lactam and non-β-lactam

antibiotics (erythromycin, tetracycline,

chloramphenicol, gentamicin, ofloxacin, or

trimethoprim-sulfamethoxazole). (Cadilla, 2013)

Fusidic acid has a unique and very different

chemical structure. The carbon chains in the chemical

structure of fusidic acid are similar to steroids than

antibiotics so rarely cause cross-resistance

. The in

vitro efficacy of antibiotics is more significant if

proven to be in vivo. In vitro sensitivity is not entirely

predictable for in vivo effect. In addition, in vitro

resistance is common, but not necessarily related to

treatment failure

(McNeil,2014)

5 CONCLUSION

The results of this study showed that there has been

in vitro resistance of S. aureus and S. pyogenes to

mupirocin. In addition, S. aureus and S. pyogenes are

more susceptible to fusidic acid than mupirocin. In

vitro effectivity of fusidic acid was better than

mupirocin. The emergence of resistance in this study

is influenced by various factors, especially the use of

antibiotics that causes cross resistance between

bacterial carrier resistant genes.

ACKNOWLEDGEMENTS

The authors would like to thank Dr. dr. M.

Zulkarnain, ScPKK and dr. Lisa Dewi, M. KEs who

assist in the effort of this research. The authors also

would like to Department of Dermatology and

Venereology, and Faculty of Medicine of Sriwijaya

University.

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