MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTHHANOI MEDICAL UNIVERSITY CHAU VAN TRO THE STUDY OF STAPHYLOCOCCUS AUREUS’S SUPERANTIGENS AND TREATMENT FOR PATIENT WITH ATOPIC DERMAT
Trang 1MINISTRY 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: DermatologyCode: 62 72 01 52
SUMMARY OF THESIS
HANOI - 2013
Trang 2This thesis was completed at: HANOI MEDICAL UNIVERSITY
Academic Advisor:
Ass.Prof TRAN LAN ANH, PhD
Ass.Prof NGUYEN TAT THANG, PhD
Opponent 1:………
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Opponent 2: …… ……… ………
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Opponent 3: …… ……… ………
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The thesis was presented to Dissertation Committee of HaNoi medical university Place: ………
Time: ………
May find the thesis in library:
Trang 3STUDIES 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 atopicdermatitis by cefuroxim combined with topical
corticosteroids ", Journal of practical medicine, 5 (821), pp.
108 - 112
Trang 4Atopic Dermatitis (AD) or atopic eczema (AE) is a commonchronic inflammatory skin disease The prevalence is from 10 to20% of the children population So far the causes and mechanisms
of pathogenesis of AD still has not completely understood Thetreatment 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 histamine, topical corticosteroids, topical tacrolimus, pimecrolimusand skincare with moistures The use of antibiotics when there arebacterial superinfections so that effect of treatment is not good.Study of Gong J Q et al also shows a new strategy in the treatment
anti-of AD is the use anti-of antibiotics as important component anti-of the overallmanagement of AD
RESEARCH OBJECTIVES
1 Survey clinical characteristics and related factors to adult
AD in hospital of Dermato-Venereology of Ho Chi MinhCity from 08/2010 to 08/2012
2 Determinate Staphylococcus aureus infection and
Staphylococcus aureus 's superantigens genes on the atopic
dermatitis adult patients
Trang 53 Evaluate the effectiveness of treatment of subacute phaseadult atopic dermatitis by cefuroxim combine with topicalbetamethasone 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 andreference , including 4 chapters , 32 tables, 2 charts, 5 pictures, 6diagrams, 157 references (17 Vietnamese references, 140 Englishreferences) and addendum The layout of the thesis consists ofintroduction (2 pages), overview (33 pages), subjects and methods(17 pages), results (29 pages), discussion (27 pages), conclusion (2pages) 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 industrializedcountries The prevalence is from 10 to 20% of the childrenpopulation Causes and mechanisms of pathogenesis remainsunclear, related to multi factors such as: genes, allergens, nerve,endocrine, immune changes, climate, infection Clinical symptomsare 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 aremany measures for treatment the AD but the effectiveness of thetreatment is not high The disease often relapse and influence on the
Trang 6quality of life of the patient AD becomes the burden on the familyand 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 theskin 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 antibacterialpeptids in the skin (such as beta defensins and LL-37), reducing theantimicrobial 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 todifferentiate a large number of T cells into Th1 and Th2 Thedifferentiation that will produce cytokins such as IL4, IL5, IL10,TNF-γ, Cytokins activate the inflammatory response to cause theonset 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
Trang 7patients with AD, improve the clinical symptoms However, thesesubstances may to irritate the skin.
Topical antibiotics: Topical antibiotics alone or incombination with corticosteroids have effective in the treatment of
AD However, using topical antibiotics have some disadvantagessuch as have only effective at the location of the treatment, causeallergic contact dermatitis, increase bacterial resistant Therefore, thenew 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 ofDermato-Venereology of Ho Chi Minh City from 08/2010 to08/2012 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 hassigns of heart, liver or lung severe diseases Patients withimmunodeficiency (HIV/AIDS, diabetes, immune suppressantmedication ) Patients who are pregnant or are breastfeeding.Patients suffering the side effects of corticosteroids such as skin
Trang 8atrophy, vasodilation, hirsutisum Patients allergic to eithermedication use (betamethasone dipropionate 0.05%) or cefuroxim.
2.2 Materials
Beprosone®: Betamethasone dipropionate 0.05% is averagetopical 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 twogeneration Cefalosporin, tablets 500mg, produced by GlaxoOperations UK Ltd, licensed in Viet Nam VN-8475-04 by decision
No 85/QD-QLD of Ministry of health
- Case – control study (for object 2): sample size is estimatedaccording to the following sample size calculator:
2 2 1
2 2 2
1 1
1 2
2 2
/
1
) (
) 1 ( ) 1 ( )
1 ( 2
P P
P P
P P
Z P P
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
Trang 9- Clinical trial (for object 3): Convenient sampling, select all of thesub – acute AD patients during the period from 08/2010 to 08/2012,eligible for the clinical trial stage and each group must be > 30patients.
- 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 1tablet / 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 1tablet / 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
Trang 10- Descriptive statistics: Frequency, percentage is presented in theform of table and diagram.
- Statistical analysis: Use χ ² and RR at 5% significance, confidenceintervals (CI) 95% to measure differences in the relationship ofresults
- Use One-Way-ANOVA to compare average scores of clinicalsymptoms, SCORAD score of two groups before treatment, after 1week 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 studyfrom 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 voluntarilyparticipate in the study All object information are kept secretthrough the computerized All Patients are paid for tests
2.7 Limits of the study:
Superantigens are a relatively new concept Theirmechanism are very complicated Therefore, we accept themechanism of pathogenesis of superantigens in AD is explained onthe dermatologist journals of the World Health Organization website.(http://www.who.int/hinari/en/)
AD is a very complicated disease The treatment isdepending on the stage of the disease We conducted clinical trialresearch on sub-acute phase Because this stage occupy the majority
Trang 11Ratio of clinical symptoms: Itching 100%, dry skin 78.91%,insomnia 75% , non – pecific hand dermatitis 57.81%, cheilitis47.56%, anterior neck folds 42.18%, white dermographism 40.62%,orbital darkening 26.56%, Dennie Morgan infraorbital folds 21.09%,pityriasis alba 18.75%, keratosis pilaris 18.75%, ichthyosis vulgaris7.81%, nipple eczema 3.9%.
The stage and the severity: Sub-acute phase 71.87%,chronic phase 17.97%, and acute phase 10.16% Average SCORADscore is 12.35 ± 40.55 Moderate 44 53%, severe 28.12%, and mild27.34%
3.1.2 Related factors of AD
Patient and family history has atopic diseases
Table 3.1: Ratio of patient and family history has atopic diseases
Onset factors of AD
Trang 12Chart 3.1: The majority of adult AD patients (55.47%) was
exacerbated by contact allergens
The age of onset
Chart 3.2: The majority of AD patients (51.56%) has the age of
onset < 2 years old
Relation between severity of AD with related factors
Trang 13We used 2 x 2 table statistic analysis found that gender, age,history of AD, asthma, allergic rhinitis does not affect the severity ofthe disease However, contact allergens and early age onset affectsseverity of the disease
3.2 Staphylococcus aureus and genes encoding superantigens of Staphylococcus aureus on AD patients skin.
3.2.1 Ratio of Staphylococcus aureus positive in AD patients and
Chart 3.3: Ratio of the Staphylococcus aureus positive on the lesions
of AD patients is higher than that on peri – notrils of healthy subjectsstatistical significance p < 0.001; RR = 2.17; 95% CI (1.44 - 3.26)
We used 2 x 2 table statistic analysis found that the ratio of
Staphylococcus aureus positive in severe patient groups is higher
than that in the mild patient group statistical significance p = 0.001,
RR = 7.12; 95% CI (1.08-47.04)
The ratio of Staphylococcus aureus positive in acute and sub-acute
stage is higher than that in chronic stage statistical significance p =0.015, RR = 1.38; 95% CI (1.006-1.90)
3.2.2 The genes encoding superantigens of Staphylococcus aureus
on AD patients skin and on healthy subjects
p < 0.001; RR = 2.17; 95% CI (1.44 – 3.26)
%