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A case of life-threatening infections due to preservative absence in a topical cream and audit demonstrating magnitude of the problem.

This case report and product analysis initially discusses the case of a 2-year-old patient with atopic dermatitis (AD) who had multiple abscesses, impetigenized eczematous lesions, and staphylococcal septicemia that did not respond to intravenous antibiotics. At the time of his last hospital admission, a jar of an emollient cream that the parents had obtained over the counter and used without the knowledge of the clinical team was noticed next to the child's bed. The cream smelled unpleasant and was discolored. It was, therefore, sent for bacterial culture, which demonstrated high concentrations of Staphylococcus aureus ([10.sup.7] colony-forming units per mL). When the contaminated cream was discontinued, the patient's lesions rapidly disappeared. Further investigation revealed that the cream contained no preservatives.

The case prompted investigators to ask other parents to bring in emollients that they were currently using on their children. Their microbiological analysis of 125 samples revealed that nearly half (49.6%) were contaminated with bacteria (Table). About one of four samples contained S aureus, nearly 1% contained methicillin-resistant S aureus, 2.4% had group A Streptococcus, and 6.4% had other bacteria, including Enterococcus and nongroup A Streptococcus. (The remaining 16% of these samples contained normal skin flora.) The investigators believe that some of these products were the probable cause of recurrent exacerbations of their patients' AD.

This investigation of patients' emollient creams also linked several preservative-free products that were found to be contaminated with S aureas with serious skin infections, and their follow-up audit of the 125 samples also found that even some creams with approved preservatives were contaminated. With these results in mind, the investigators recommend several precautions for their patients with AD:

* Always wash one's hands before using creams

* Use only products with approved (by regulatory author ities) preservatives

* If the cream is dispensed in a pump or tube, avoid con tact with the nozzle and wipe it after each use

* Refrigerate open containers of unpreserved products such as ointments

Commentary From Ms Vernon

Professor Cork's study raises some important issues for pediatric practitioners. In our practice in Denver, Colorado, we encounter many parents who use preservative-free creams. In fact, because we see so many patients with contact dermatitis, we have been encouraging parents to use paraben-free products, avoid organic products, and use products with fewer preservatives to reduce the risk of allergic reactions to these additives. But this new research makes it clear that preservatives serve an important purpose by preventing the buildup of pathologic microbes. In fact, the study suggests that such preservatives offer more advantages than disadvantages.

This investigation should also encourage clinicians who are caring for a patient who is not responding to a standard treatment regimen to explore the possibility that the patient is having an adverse reaction to an inadequately preserved cream. In such a situation, the best course of action would be to recommend to parents that they discontinue applying the potentially offending product and buy a new cream containing an approved preservative.

The study should also change the way we practice in general. It gives us good reason to routinely ask patients about the kinds of over-the-counter creams that they are using during our initial assessment.

Reference: Sultan A, Carr J, Danby S, et al. A case of life-threatening infections clue to preservative absence in a topical cream and audit demonstrating magnitude of the problem. Poster presented at: 26th International Pediatric Association Congress of Pediatrics 2010; August 4-9, 2010; Johannesburg, South Africa.


A. Sultan, J. Carr, Sheffield Children's Hospital NHS Trust, Sheffield, UK; S. Danby, The University of Sheffield, Sheffield, UK; M. Akram, A. Messenger, P. Fenton, M. Moustafa, The University of Sheffield; Sheffield Children's Hospital NHS Trust; M Cork, Sheffield Children's Hospital NHS Trust; The Royal Hallamshire Hospital, Sheffield, UK.
Table. Summary of Bacterial Growth From Cultures Taken
From Emollient Samples (N=125). Data Are Presented as
Percentage of the Number of Tested

No growth                50.4%
S. aureas                24.0%
MRSA                     0.8%
Group A streptococcus    2.4%
Other bacteria           6.4%
Skin flora              16.0%
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Author:Sultan, A.; Carr, J.; Danby, S.; Akram, M.; Messenger, A.; Fenton, P.; Moustafa, M.; Cork, M.
Publication:Pediatric News
Date:Sep 1, 2010
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