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Prevalence, Clinical Features and Antibiotic Susceptibility of Group A Streptococcal Skin Infections in School Children in Urban Western and Northern Uganda

Chang, Aileen Y. MD*; Scheel, Amy MPH; Dewyer, Alyssa BS; Hovis, Ian W. MD; Sarnacki, Rachel BA; Aliku, Twalib MBChB, MMed, MBA§; Okello, Emmy MBChB, MMed, PhD§; Bwanga, Freddie MBChB, MMed, PhD; Sable, Craig MD; Maurer, Toby A. MD; Beaton, Andrea Z. MD**,††

The Pediatric Infectious Disease Journal: December 2019 - Volume 38 - Issue 12 - p 1183–1188
doi: 10.1097/INF.0000000000002467
Original Studies
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Background: Group A Streptococcus (GAS) skin infections can lead to invasive sepsis, poststreptococcal glomerulonephritis, and potentially rheumatic heart disease (RHD). Within a study to identify predisposing factors of RHD in Ugandan schoolchildren, we determined the prevalence of skin infections and assessed the clinical features and antibiotic susceptibility of GAS skin infection.

Methods: Cross-sectional study conducted at 3 urban primary schools in Western and Northern Uganda in March 2017. A dermatologist rendered clinical diagnoses and obtained a skin swab specimen from lesions with signs of bacterial infection. Beta-hemolytic colonies underwent Lancefield grouping, species identification by polymerase chain reaction and antimicrobial susceptibility testing.

Results: From 3265 schoolchildren, we observed 32% with ≥1 fungal, 1.8% with ≥1 bacterial, 0.9% with ≥1 viral, and 0.2% with ≥1 ectoparasitic infection. Of 79, 25 (32%) specimens were GAS-positive, of which one-third demonstrated tetracycline resistance. Of 17 impetigo cases, 13 (76%) were located on the leg/foot and 3 (18%) on the head/neck. Prevalence of GAS skin infection was 0.8% (25 of 3265). In Northern Uganda, where subclinical definite RHD prevalence is 1.1%, GAS skin infection prevalence was 1.2% (4 of 343) and 0.9% (3 of 352).

Conclusion: This study identifies tetracycline-resistant GAS in Ugandan communities, suggests modified skin examination of exposed anatomic locations may be appropriate for population-based GAS skin infection studies, and underscores need for clear case definitions of GAS skin infection. Future studies are needed to evaluate the role of GAS skin infection in development of RHD in Ugandan communities.

*Department of Dermatology, University of California San Francisco, San Francisco, California

School of Medicine, Emory University, Atlanta, Georgia

Division of Cardiology, Children’s National Health System, Washington, D.C.

§Uganda Heart Institute, Mulago National Referral Hospital

Department of Medical Microbiology, Makerere University College of Health Sciences, Kampala, Uganda

Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana

**Heart Institute, Cincinnati Children’s Hospital Medical Center

††Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.

Accepted for publication August 14, 2019.

Supported by philanthropic support from Karp Family Foundation and Gift of Life International to the Children’s National Health System, Washington, D.C.; NIH Research Training Grant # R25 TW009343 funded by the Fogarty International Center (A.Y.C.); the National Institute of Mental Health; the National Health, Lung and Blood Institute; and the Office of Research on Women’s Health, as well as the University of California Global Health Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the University of California Global Health Institute. E.O. is a DELTAS/THRiVE fellow under grant DEL-15-001/07742/Z/15/Z. The authors have no conflicts of interest to disclose.

Address for correspondence: Aileen Y. Chang, MD, Department of Dermatology, University of California San Francisco, San Francisco General Hospital, 1001 Potrero, Building 90, Ward 92San Francisco, CA 94110. E-mail: aileen.chang@ucsf.edu.

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