Increasing Skin Infections and Staphylococcus aureus Complications in Children, England, 1997–2006

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Volume 16, Number 3–March 2010
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Increasing Skin Infections and Staphylococcus aureus Complications in Children, England, 1997–2006
Sonia Saxena, Paula Thompson, Ruthie Birger, Alex Bottle, Nikos Spyridis, Ian Wong, Alan P. Johnson, Ruth Gilbert, and Mike Sharland, on behalf of improving Children's Antibiotic Prescribing Group
Author affiliations: Imperial College London, London, UK (S. Saxena, R. Birger, A. Bottle); School of Pharmacy, London (P. Thompson, I. Wong); St. George's Hospital National Health Service Trust, London (N. Spyridis); Health Protection Agency, London (A.P. Johnson, M. Sharland); and University College London Institute of Child Health, London (R. Gilbert)

Suggested citation for this article

Abstract
During 1997–2006, general practitioner consultations for skin conditions for children <18 years of age in England increased 19%, from 128.5 to 152.9/1,000 child-years, and antistaphylococcal drug prescription rates increased 64%, from 17.8 to 29.1/1,000 child-years. During the same time period, hospital admissions for Staphylococcus aureus infections rose 49% from 53.4 to 79.3/100,000 child-years.

Staphylococcus aureus infection is a leading cause of staphylococcal bacteremia in adults (1) and children (2) in hospitals in the United Kingdom, and recent reports suggest invasive staphylococci are emerging from the community (3). Flucloxacillin is the antimicrobial drug recommended for treating S. aureus skin infection in UK primary care centers (4). Therefore, its use provides a proxy marker of S. aureus skin infection in children. Flucloxacillin prescribing in children has increased over the past 15 years (5), despite well-documented reductions in prescribing rates for other commonly prescribed antibacterial drugs during 1995–2000 (6), which suggests that S. aureus skin infections in the community may be increasing.

We examined the incidence of local complications of S. aureus disease in children over a 10-year period using nationally representative data from primary care clinicians in England. Ethics approval for this study was obtained from the Independent Scientific and Ethical Advisory Committee, application no. 2006/ISEAC/012.

The Study
The MediPlus UK database contains anonymized longitudinal data from >500 UK general practitioners who contribute clinical data on >1 million patients (7) that have been used widely for research (8). Consultations are coded by using the International Classification of Diseases, Tenth Revision (ICD-10), and antimicrobial drug prescriptions are coded by using the British National Formulary for children, Chapters 5.1.1–5.1.3 (9). Using Mediplus UK, we extracted data on all skin conditions (ICD-10 code) and atopic dermatitis (ICD-10 code L20) as an index condition in children <18 years of age who saw general practitioners in England from January 1, 1997, through December 31, 2006. We counted prescriptions for all oral and topical antibacterial drugs prescribed for skin infections, and used all oral preparations containing flucloxacillin prescribed for skin conditions as a proxy measure of unresolved S. aureus skin infection. We calculated age–sex adjusted annual consulting and prescribing rates by totaling the number of consultations or prescriptions and dividing by the number of person–years contributed by each child in the registered population for each calendar year. We then directly standardized these rates by using the age–sex distribution for the reference year 2000.

The Hospital Episode Statistics (HES) database has recorded all inpatient hospital activity in National Health Service hospitals across England since 1989 and is used widely to monitor disease trends in England (www.hesonline.nhs.uk) (10). The main reason for admission, i.e., primary diagnosis, is recorded by using ICD-10 codes. We used HES data to calculate age–sex adjusted admission rates per 100,000 resident population for children <18 years of age for each calendar year from January 1, 1997, through December 31, 2006, for conditions commonly caused by S. aureus, including septic arthritis (ICD-10 codes M00.0 for staphylococcal arthritis and M00.9 for pyogenic arthritis), osteomyelitis (M86), and locally invasive skin infections (L02, cutaneous abscesses and boils; L03, cellulitis). Rates were calculated as the total number of admissions per year divided by the mid-year estimate of the number of children residing in England (using the 2000 population in England as the reference population) (11). Confidence intervals (CIs) were generated with a Poisson approximation. We used linear regression to test for linear trends in age–sex adjusted admission rates across the period. We used Stata version 9 software (Stata Corp., College Park, TX, USA) for all statistical analysis.

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Acknowledgments
We thank International Marketing Systems Health for providing access to the Mediplus UK data and all the members of the improving Children's Antibiotic Prescribing group.

S.S. has a postdoctoral award from the National Institute for Health Research (NIHR). I.W.'s post was funded by a Department of Health Public Health Career Scientist Award. N.S.'s post is funded by the European Society for Pediatric Infectious Diseases. We are grateful for support from the NIHR Biomedical Research Centre funding scheme.

Dr Saxena is a National Health Service general practitioner in London and senior clinical lecturer in the Department of Primary Care and Social Medicine at Imperial College London. Her research interests are in the epidemiology and treatment of childhood illness in primary care.

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Figures
Figure 1. General practitioner consultation and prescribing rates for all skin conditions in children <18 years of age, England, 1997–2006.
Figure 2. Prescribing rates for antibacterial drugs for children <18 years of age, England, 1997–2006.

Tables
Table 1. Age- and sex-adjusted skin condition consultation and antibacterial drug prescribing rates for children <18 years of age, England, 1997–2006
Table 2. Age- and sex-adjusted hospital admission rates for skin, bone, and joint infections in children <18 years of age, England, 1997–2006

Suggested Citation for this Article
Saxena S, Thompson P, Birger R, Bottle A, Spyridis N, Wong I, et al. Increasing skin infections and Staphylococcus aureus complications in children, England, 1997–2006. Emerg Infect Dis [serial on the Internet]. 2010 March [date cited]. http://www.cdc.gov/EID/content/16/3/530.htm

DOI: 10.3201/eid1603.090809