THE STUDY OF STAPHYLOCOCCUS AUREUS’S SUPERANTIGENS AND TREATMENT FOR PATIENT WITH ATOPIC DERMATITIS BY CEFUROXIM

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY CHAU VAN TRO THE STUDY OF STAPHYLOCOCCUS AUREUS’S SUPERANTIGENS AND TREATMENT FOR PATIENT WITH ATOPIC DERMATITIS BY CEFUROXIM Specialist: Dermatology Code: 62 72 01 52 SUMMARY OF THESIS HANOI - 2013 This thesis was completed at: HANOI MEDICAL UNIVERSITY Academic Advisor: Ass.Prof TRAN LAN ANH, PhD Ass.Prof NGUYEN TAT THANG, PhD Opponent 1:……………………………………………………… …………………………………………………………………… Opponent 2: …… ………………………… …………………… …………………………………………………………………… Opponent 3: …… ………………………… …………………… …………………………………………………………………… The thesis was presented to Dissertation Committee of HaNoi medical university Place: …………………………………………………………… Time: ………………………………………………………… May find the thesis in library: STUDIES RELATING TO THESIS WERE PUBLISHED 1. Chau Van Tro, Nguyen Tat Thang, Tran Lan Anh (2011) "Study of Staphylococcus aureus’s superantigens in adult patient with atopic dermatitis", Journal of practical medicine, 4 (760), pp. 122-126. 2. Chau Van Tro, Nguyen Tat Thang, Tran Lan Anh (2012), "Evaluation of treatment adult patient with subacute atopic dermatitis by cefuroxim combined with topical corticosteroids ", Journal of practical medicine, 5 (821), pp. 108 - 112. INTRODUCTION Atopic Dermatitis (AD) or atopic eczema (AE) is a common chronic inflammatory skin disease. The prevalence is from 10 to 20% of the children population. So far the causes and mechanisms of pathogenesis of AD still has not completely understood. The treatment of AD has a lot of difficulties. The disease is recurrences, so the prevalence diseases tend to be on the increase. In the late 20th century, Michael J. Cork, Abeck. D et al, Shuichi Higaki has found that Staphylococcus aureus played a very important role in the mechanism of pathogenesis of the disease. The studies of Adachi. Y et al, Strange. P et al, Yudate. T et al have shown that Staphylococcus aureus secretes the enterotoxines serves as an superantigen in the mechanism of pathogenesis of AD. According to Gong. J. Q et al, Breuer. K et al, superantigens of Staphylococcus aureus may penetrate the skin barrier and contribute to the persistence and exacerbation of allergic skin inflamation in AD through the stimulation of massive T cells. Until now, the treatment of AD is primarily used anti- histamine, topical corticosteroids, topical tacrolimus, pimecrolimus and skincare with moistures. The use of antibiotics when there are bacterial superinfections so that effect of treatment is not good. Study of Gong. J. Q et al also shows a new strategy in the treatment of AD is the use of antibiotics as important component of the overall management of AD. RESEARCH OBJECTIVES 1. Survey clinical characteristics and related factors to adult AD in hospital of Dermato-Venereology of Ho Chi Minh City from 08/2010 to 08/2012. 2. Determinate Staphylococcus aureus infection and Staphylococcus aureus 's superantigens genes on the atopic dermatitis adult patients. 3. Evaluate the effectiveness of treatment of subacute phase adult atopic dermatitis by cefuroxim combine with topical betamethasone dipropionate 0.05%. NEW CONTRIBUTIONS OF DISSERTATION The dissertation proved Staphylococcus aureus has very important role in the mechanism of pathogenesis of atopic dermatitis, making the onset or affect the degree of severity of the disease. The dissertation also proved the effectiveness of the use of oral antibiotics anti – Staphylococcus aureus as a measure of the combined in the treatment of atopic dermatitis. STRUCTURE OF DISSERTATION Dissertation consists of 111 pages, excluding appendices and reference , including 4 chapters , 32 tables, 2 charts, 5 pictures, 6 diagrams, 157 references (17 Vietnamese references, 140 English references) and addendum. The layout of the thesis consists of introduction (2 pages), overview (33 pages), subjects and methods (17 pages), results (29 pages), discussion (27 pages), conclusion (2 pages) and recommendation (1 page), and there are 2 articles related to the thesis has been published. CHAPTER 1: OVERVIEW 1.1 Atopic dermatitis Atopic dermatitis is a very common disease in dermatology. The prevalence is increasing especially in the industrialized countries. The prevalence is from 10 to 20% of the children population. Causes and mechanisms of pathogenesis remains unclear, related to multi factors such as: genes, allergens, nerve, endocrine, immune changes, climate, infection Clinical symptoms are plentiful such as: itching, insomnia, erythema, papules, oozing, crusts, lichenfication… There are three phases of atopic dermatitis: acute phase, subacute phase, and chronic phase. Currently there are many measures for treatment the AD but the effectiveness of the treatment is not high. The disease often relapse and influence on the quality of life of the patient. AD becomes the burden on the family and society. 1.2 The role of Staphylococcus aureus in AD On the skin of healthy people, the ratio of Staphylococcus aureus is about 5%. On the AD patients, the ratio of Staphylococcus aureus from 55-75% on the non - lesion skin, 85-90% on the chronic lesions, 80-100% of the acute lesions. It also found that the density of the Staphylococcus aureus on acute inflammatory lesions 1,000 times higher than on the non – lesion skin in AD patients. So the skin of the AD patients is a favorable environment for development of Staphylococcus aureus. The exact mechanism of the increase the ratio and the number of Staphylococcus aureus on skin of AD patients still is unknown. It may be a combination of the following mechanisms: Skin barrier dysfunction, reducing the production of antibacterial peptids in the skin (such as beta defensins and LL-37), reducing the antimicrobial immune response of the skin, change the skin pH That increase the adhesive of the Staphylococcus aureus on skin of AD patients. When Staphylococcus aureus adhesive on the skin they will produce enterotoxins that act as a superantigen enabled to differentiate a large number of T cells into Th1 and Th2. The differentiation that will produce cytokins such as IL4, IL5, IL10, TNF-γ, Cytokins activate the inflammatory response to cause the onset of AD. 1.3 Treatment of Staphylococcus aureus in patients with AD So far, the scientists studied a lot of measures treatment of Staphylococcus aureus in patients with AD. Methods do not take antibiotics such as repair skin barrier by moisturizing, use topical anti-inflammatory substances (corticosteroids, calcineurin inhibitors ) to reduce adhesive of Staphylococcus aureus on skin of AD patients. The antiseptics: Bactericidal soap, KMnO4, povidone-iodine 10% … reduce the number of Staphylococcus aureus on the skin of patients with AD, improve the clinical symptoms. However, these substances may to irritate the skin. Topical antibiotics: Topical antibiotics alone or in combination with corticosteroids have effective in the treatment of AD. However, using topical antibiotics have some disadvantages such as have only effective at the location of the treatment, cause allergic contact dermatitis, increase bacterial resistant. Therefore, the new trend is the combination of oral antibiotics in the treatment of AD. However, so far there is very little research on this issue. CHAPTER 2: SUBJECTS AND METHODS 2.1 Subjects 128 AD patients, > 12 years old, visit to hospital of Dermato-Venereology of Ho Chi Minh City from 08/2010 to 08/2012 and 40 healthy subjects, > 12 years old, does not have AD or other skin diseases. 2.1.1 Diagnosis of AD: AD was diagnosed following the criteria of Hanifin and Rajka. 2.1.2 Criteria of patient selection Criteria of patient selection for clinical research, the ratio of Staphylococcus aureus and genes encoding superantigens: AD patients > 12 years old, no infected lesions, agreemen participant. Criteria of patient selection for evaluating the effectiveness of treatment AD by taking topical betamethasone dipropionate 5% plus oral cefuroxim: sub – acute AD patients, ages from 12 to 60, positive Staphylococcus aureus on lesions, agreemen participant. 2.1.3 Criteria of patient exclution: Patients used topical antibiotics within 2 weeks and oral antibiotics within 1 month. Patients has signs of heart, liver or lung severe diseases. Patients with immunodeficiency (HIV/AIDS, diabetes, immune suppressant medication ). Patients who are pregnant or are breastfeeding. Patients suffering the side effects of corticosteroids such as skin atrophy, vasodilation, hirsutisum Patients allergic to either medication use (betamethasone dipropionate 0.05%) or cefuroxim. 2.2 Materials Beprosone®: Betamethasone dipropionate 0.05% is average topical corticosteroids, produced by HOE Pharmaceuticals Sdn Bhd, Malaysia. Licensed in VietNam by decision No VN-0421-6, 17/QD- QLD of Ministry of health. Zinnat®: Cefuroxim is bactericidal antibiotic belong to two generation Cefalosporin, tablets 500mg, produced by Glaxo Operations UK Ltd, licensed in Viet Nam VN-8475-04 by decision No. 85/QD-QLD of Ministry of health. 2.3 Methods 2.3.1 Study design: Cross-section, case - control and clinical trial. 2.3.2 Sample size - Cross - sectional study (for object 1): Convenient sampling, select all of the patients eligible for the study from August, 2010 to August, 2012. - Case – control study (for object 2): sample size is estimated according to the following sample size calculator: [ ] 2 21 2 22111222/1 )( )1()1()1(2 PP PPPPZPPZ N − −+−+− = −− βα P1: Ratio of the positive Staphylococcus aureus in AD patients (80- 95%, depending on the study). P2: Ratio of the positive Staphylococcus aureus in healthy subjects (35-45%, depending on the study). α: Probability of type 1 error (α = 0.05) → Z 1-α/2 = 1.96. β: Probability of type 2 error → Z 1-β = 1.28. We select P1 = 80%, P2 = 45% instead of the sample size calculator  N = 40  The minimum sample size of each group is 40. - Clinical trial (for object 3): Convenient sampling, select all of the sub – acute AD patients during the period from 08/2010 to 08/2012, eligible for the clinical trial stage and each group must be > 30 patients. 2.3.3 Steps to study - Clinical examination to identify AD. - Data collection - Assess the severity of the disease by SCORAD: Mild: SCORAD < 25 Moderate: SCORAD from 25 to 50 Severe: SCORAD > 50 - Assess the stage of the disease: acute, sub-acute and chronic - Culture to identify Staphylococcus aureus: In AD patients, we Culture and determine the Staphylococcus aureus on new lesions. In healthy subjects, we culture and determines the Staphylococcus aureus in the skin around the nostrils. - Identify of the genes encoding superantigens: By multiplex PCR (Polymerase Chain Reaction). - Clinical trials: We Split AD patients randomly into two groups: + Group 1: Will be treated with a regimen including shower by KMnO4 1/10,000, fexofenadin 60 mg (1 tablet /morning and 1 tablet / evening), cefuroxim 500 mg (1 tablet / morning and 1 tablet / evening), beprosone ® apply twice /day. + Group 2: Will be treated with a regimen including shower by KMnO4 1/10,000, fexofenadin 60 mg (1 tablet /morning and 1 tablet / evening), beprosone ® apply twice /day. + Duration of treatment: 2 weeks + Assess the result: Assess the clinical symptoms and SCORAD score after a week of treatment, culture Staphylococcus aureus at the end of week two. 2.4 Data processing: The data are processed and analysed by using EpiInfo software in 2002. - Descriptive statistics: Frequency, percentage is presented in the form of table and diagram. - Statistical analysis: Use χ ² and RR at 5% significance, confidence intervals (CI) 95% to measure differences in the relationship of results. - Use One-Way-ANOVA to compare average scores of clinical symptoms, SCORAD score of two groups before treatment, after 1 week of treatment, after 2 weeks of treatment. 2.5 Place and time of study: Place of study in hospital of Dermato- Venereology of Ho Chi Minh City and NamKhoa Biotek company (ISO 9001: 2000 and GMP/GLP of the WHO). Duration of study from 08/2010 to 08/2012 2.6 Research ethics: Proposal of the research was through by the Council of PhD proposal of Hanoi Medical University. The objects of the study was announced, explained and agreed to voluntarily participate in the study. All object information are kept secret through the computerized. All Patients are paid for tests. 2.7 Limits of the study: Superantigens are a relatively new concept. Their mechanism are very complicated. Therefore, we accept the mechanism of pathogenesis of superantigens in AD is explained on the dermatologist journals of the World Health Organization website. (http://www.who.int/hinari/en/). AD is a very complicated disease. The treatment is depending on the stage of the disease. We conducted clinical trial research on sub-acute phase. Because this stage occupy the majority of AD. CHAPTER 3: RESULTS From 8/2010 to 08/2012, we studied 128 AD patients and 40 healthy subjects. 3.1 Clinical characteristics and related factors of AD 3.1.1 Clinical characteristics [...]... skin lessen first and the extent of lesion lessens more slowly 4.3.3 S.aureus detection results on the 14th day of treatment of the two groups Before the treatment, the patients of the 2 groups tested positive for S.aureus After 14 days of treatment, 91.7% of group 1 and 21.88% of group 2 tested negative for it, and the difference between the two figures had a statistical significance with p < 0.001,... antibiotics based on the clinical symptoms of AD, therefore we cannot compare our findings with other authors A = extent of the lesion: Before the treatment, the average A of group 1 and group 2 were 13.50 ± 5.22 and 11.72 ± 3.72 respectively, and the difference had no statistical significance with p = 0.11 After 7 days of treatment, the figures were 13.19 ± 5.05 and 11.25 ± 3.29 respectively, and the difference... symptoms of pruritus and insomnia of the 2 groups on the 7 th and the 14th day of treatment, we saw that the score of group 1 fell by a greater degree, which has a statistical significance with p = 0.016 (at the time of the 7th day) and p = 0.002 (at the time of the 14 th day) This indicates that applying topical corticosteroid in combination with oral antibiotics can reduce the symptoms of pruritus and. .. and the ratio of the genes encoding superantigens of Staphylococcus aureus on the lesions at the stage acute, sub-acute and chronic difference not statistically significant with p > 0.05 3.3 Effective treatment adult AD patients by topical betamethasone dipropionate 0.05% plus oral cefuroxim During the study period, 74 AD patients were eligible for the clinical trial We divided all the patients randomly... Therefore, we made a comparison between the 2 regimens in terms of effectiveness of treatment, based on the everage score of the above clinical symptoms C = pruritus + insomnia: Before the treatment, this score of group 1 was 8.11 ± 3.23, while that of group 2 was 8.81 ± 3.35, and the difference between the two figures had no statistical significance with p = 0.38 After 7 days of treatment, the scores of. .. 22.39% 2 Compare the ratio of S.aureus and superantigen-encoding genes of S.aureus in adult patients with AD and healthy subjects Among the group of AD patients, the proportion detection of S.aureus was 81.25%, higher than the healthy group (37.5%), which had a statistical significance The fact that the incidence of S.aureus in the group of severe was higher than that in group of moderate and higher than... groups Each group has 37 patients However, during follow-up treatment (2 weeks), group 1 has 1 (2.7%) patient and group 2 has 5 (13.5%) patients did not finish the study Therefore, We analysis only 68 patients (group 1: 36 patients and group 2: 32 patients) 3.3.1 Comparison of therapeutic effect between two groups Table 3.2 Comparison of therapeutic effect based on the mean of SCORAD SCORAD Group 1... any adverse effects of the medicine in both groups Chapter 4: DISCUSSION 4.1 Clinical features and related factors of Atopic Dermatitis 4.1.1 Clinical features Pruritus: Pruritus is the main symptom and one of the main criteria for diagnosing Atopic Dermatitis (AD) According to medical books, 80-100% of patients with AD experience symptoms of pruritus In our research, 100% of our patients had pruritus... 2.99, and the difference between the 2 figures had no statistical significance with p = 0.25 After 7 days of treatment, the figure of group 1 fell to 6.36 ± 2.93 while that of group 2 fell to 7.15 ± 2.31, which meant the average B score of group 1 fell by a greater degree than that of group 2 but the difference had no statistical significance with p = 0.22 After 14 days of treatment, the average B of. .. that of group 2 decreased to 5.22 ± 1.91, which meant the average B of group 1 fell by a greater degree than that of group 2 with a statistical significance of p = 0.002 So the combination with oral antibiotics started to take effect of reducing the clinical symptoms of AD from the 7 th day of treatment to the 14th day We have not been able to consult any documents assessing the effectiveness of using . MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY CHAU VAN TRO THE STUDY OF STAPHYLOCOCCUS AUREUS’S SUPERANTIGENS AND TREATMENT FOR PATIENT WITH ATOPIC DERMATITIS BY CEFUROXIM. treatment the AD but the effectiveness of the treatment is not high. The disease often relapse and influence on the quality of life of the patient. AD becomes the burden on the family and society. 1.2. the non – lesion skin in AD patients. So the skin of the AD patients is a favorable environment for development of Staphylococcus aureus. The exact mechanism of the increase the ratio and the