Management and outcome of cutaneous diphtheria in adolescent refugees in Germany, June 2022 - October 2023.
Balkan route
Cutaneous diphtheria
Diphtheria
Minor refugee
Throat diphtheria
Toxigenic C. diphtheriae
Journal
Infection
ISSN: 1439-0973
Titre abrégé: Infection
Pays: Germany
ID NLM: 0365307
Informations de publication
Date de publication:
27 Aug 2024
27 Aug 2024
Historique:
received:
27
06
2024
accepted:
11
08
2024
medline:
27
8
2024
pubmed:
27
8
2024
entrez:
27
8
2024
Statut:
aheadofprint
Résumé
From September 2022 an increase in Corynebacterium diphtheriae (C. diphtheriae) infections was reported in Europe. Our study focuses on 31 adolescent and young adult refugees with cutaneous C. diphtheriae infections detected in Germany. We examined treatment regimens and outcomes to provide targeted insights into the management of this infection. We distributed a standardized survey, focused on children and adolescents presenting to paediatric clinics through the German Paediatric Infectious Diseases Society (DGPI) and additional professional contacts in Germany. Data were extracted from routine medical documentation and reported anonymously. A total of 31 individuals with cutaneous C. diphtheriae infection were reported by 9 centres. Two of these showed diphtheria toxin (DT) related systemic symptoms and four exhibited systemic inflammation requiring complex management. The remaining 25 cases, with exclusively cutaneous manifestations, were afebrile. Treatment with topical antiseptics and systemic antibiotics, mainly aminopenicillin/beta-lactamase inhibitors (BLI) (35%) or clindamycin (25%), achieved eradication in all but two cases treated with aminopenicillin/BLI. Treatment duration varied between 5 and 17 days. In refugees presenting with chronic skin wounds, C. diphtheriae should be included into the differential diagnosis. Fever seems to be a valuable marker to differentiate severe cases with potentially DT-mediated sequelae from exclusively cutaneous diphtheria (CD). For afebrile CD, topical antiseptics and oral antibiotic therapy with clindamycin for 7 days, followed by clinical surveillance appears to be a safe treatment regimen. Patients with CD who present with fever or pharyngitis should be thoroughly investigated including blood and pharyngeal swab cultures.
Identifiants
pubmed: 39190269
doi: 10.1007/s15010-024-02374-y
pii: 10.1007/s15010-024-02374-y
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024. The Author(s).
Références
Sharma NC, Efstratiou A, Mokrousov I, Mutreja A, Das B, Ramamurthy T, Diphtheria. Nat Rev Dis Primer. 2019;5(1):1–18.
doi: 10.1038/s41572-019-0131-y
Truelove SA, Keegan LT, Moss WJ, Chaisson LH, Macher E, Azman AS, et al. Clinical and epidemiological aspects of Diphtheria: a systematic review and pooled analysis. Clin Infect Dis off Publ Infect Dis Soc Am. 2020;71(1):89–97.
doi: 10.1093/cid/ciz808
Hadfield TL, McEvoy P, Polotsky Y, Tzinserling VA, Yakovlev AA. The pathology of diphtheria. J Infect Dis. 2000;181(Suppl 1):S116–120.
doi: 10.1086/315551
pubmed: 10657202
Sing A, Heesemann J, Imported Cutaneous Diphtheria G. Emerg Infect Dis. 2005;11(2):1997–2003.
doi: 10.3201/eid1102.040560
Berger A, Dangel A, Schober T, Schmidbauer B, Konrad R, Marosevic D et al. Whole genome sequencing suggests transmission of Corynebacterium diphtheriae-caused cutaneous diphtheria in two siblings, Germany, 2018. Eurosurveillance [Internet]. 2019 Jan 10 [cited 2023 Jan 30];24(2). https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2019.24.2.1800683
Communicable disease threats report. 7 1 13 January 2024, week 2 [Internet]. [cited 2024 Jan 18]. https://www.ecdc.europa.eu/sites/default/files/documents/communicable-disease-threats-report-week-2-2024.pdf
Badenschier F, Berger A, Dangel A, Sprenger A, Hobmaier B, Sievers C et al. Outbreak of imported diphtheria with Corynebacterium diphtheriae among migrants arriving in Germany, 2022. Eurosurveillance [Internet]. 2022 Nov 17 [cited 2022 Nov 23];27(46). https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.46.2200849
Spielberger BD, Hansel A, Nazary A, Kleißle EM, Lehr CG, Utz M, et al. Imported Toxigenic Corynebacterium Diphtheriae in refugees with Polymicrobial skin infections, Germany, 2022. Emerg Infect Dis. 2023;29(10):2112–5.
doi: 10.3201/eid2910.230285
pubmed: 37690442
Kofler J, Ramette A, Iseli P, Stauber L, Fichtner J, Droz S et al. Ongoing toxin-positive diphtheria outbreaks in a federal asylum centre in Switzerland, analysis July to September 2022. Eurosurveillance [Internet]. 2022 Nov 3 [cited 2023 Jan 30];27(44). https://www.eurosurveillance.org/content/10.2807/1560-7917.ES .2022.27.44.2200811.
Increase of reported diphtheria cases. among migrants in Europe due to Corynebacterium diphtheriae, 2022 [Internet]. 2022 [cited 2023 Jul 10]. https://www.ecdc.europa.eu/en/publications-data/increase-reported-diphtheria-cases-among-migrants-europe-due-corynebacterium
Clinical management of diphtheria: guideline. 2 February 2024 [Internet]. [cited 2024 Apr 5]. https://www.who.int/publications-detail-redirect/WHO-DIPH-Clinical-2024.1
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of Observational studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet Lond Engl. 2007;370(9596):1453–7.
doi: 10.1016/S0140-6736(07)61602-X
Kortas AZ, Polenz J, von Hayek J, Rüdiger S, Rottbauer W, Storr U, et al. Screening for infectious diseases among asylum seekers newly arrived in Germany in 2015: a systematic single-centre analysis. Public Health. 2017;153:1–8.
doi: 10.1016/j.puhe.2017.07.011
pubmed: 28800522
Janda A, Eder K, Fressle R, Geweniger A, Diffloth N, Heeg M et al. P Spiegel editor 2020 Comprehensive infectious disease screening in a cohort of unaccompanied refugee minors in Germany from 2016 to 2017: a cross-sectional study. PLOS Med 17 3 e1003076.
doi: 10.1371/journal.pmed.1003076
pubmed: 32231358
pmcid: 7108686
Alberer M, Wendeborn M, Löscher T, Seilmaier M. [Spectrum of diseases occurring in refugees and asylum seekers: data from three different medical institutions in the Munich area from 2014 and 2015]. Dtsch Med Wochenschr 1946. 2016;141(1):e8–15.
Bischoff A, Schneider M, Denhaerynck K, Battegay E. Health and ill health of asylum seekers in Switzerland: an epidemiological study. Eur J Public Health. 2009;19(1):59–64.
doi: 10.1093/eurpub/ckn113
pubmed: 19158102
May MLA, McDougall RJ, Robson JM. Corynebacterium diphtheriae and the Returned Tropical traveler. J Travel Med. 2014;21(1):39–44.
doi: 10.1111/jtm.12074
pubmed: 24383653
World Health Organization null. Diphtheria vaccine: WHO position paper, August 2017 - recommendations. Vaccine. 2018;36(2):199–201.
doi: 10.1016/j.vaccine.2017.08.024
Organization WH. WHO laboratory manual for the diagnosis of diphtheria and other related infections [Internet]. World Health Organization; 2021 [cited 2024 Apr 2]. https://iris.who.int/handle/10665/352275
Maple PA, Efstratiou A, Tseneva G, Rikushin Y, Deshevoi S, Jahkola M, et al. The in-vitro susceptibilities of toxigenic strains of Corynebacterium diphtheriae isolated in northwestern Russia and surrounding areas to ten antibiotics. J Antimicrob Chemother. 1994;34(6):1037–40.
doi: 10.1093/jac/34.6.1037
pubmed: 7730218
Schmitz FJ, Sadurski R, Kray A, Boos M, Geisel R, Kohrer K, et al. Prevalence of macrolide-resistance genes in Staphylococcus aureus and Enterococcus faecium isolates from 24 European university hospitals. J Antimicrob Chemother. 2000;45(6):891–4.
doi: 10.1093/jac/45.6.891
pubmed: 10837446
Sing A, Badenschier F, Dangel A, Sprenger A, Hobmaier B, Külper-Schiek W, et al. Clustering of diphtheria cases in refugees that arrived in Germany in 2022. Dtsch Arzteblatt Int. 2023;120(33–34):557–8.
Hoefer A, Seth-Smith H, Palma F, Schindler S, Freschi L, Dangel A et al. Phenotypic and genomic analysis of a large-scale Corynebacterium diphtheriae outbreak among migrant populations in Europe [Internet]. medRxiv; 2023 [cited 2024 Apr 2]. p. 2023.11.10.23297228. https://www.medrxiv.org/content/ https://doi.org/10.1101/2023.11.10.23297228v1
Marosevic DV, Berger A, Kahlmeter G, Payer SK, Hörmansdorfer S, Sing A. Antimicrobial susceptibility of Corynebacterium diphtheriae and Corynebacterium ulcerans in Germany 2011-17. J Antimicrob Chemother. 2020;75(10):2885–93.
doi: 10.1093/jac/dkaa280
pubmed: 32747952
Yamamoto A, Hifumi T, Ato M, Iwaki M, Senoh M, Hatanaka A, et al. Clinical characteristics of Corynebacterium ulcerans infection, Japan. Emerg Infect Dis. 2023;29(8):1505–15.
doi: 10.3201/eid2908.220058
pubmed: 37486266
pmcid: 10370844
Elsinga J, van Meijeren D, Reubsaet F. Surveillance of diphtheria in the Netherlands between 2000–2021: cutaneous diphtheria supersedes the respiratory form. BMC Infect Dis. 2023;23(1):420.
doi: 10.1186/s12879-023-08388-5
pubmed: 37344769
pmcid: 10283224
RKI - RKI-Ratgeber. - Diphtherie [Internet]. [cited 2024 Apr 5]. https://www.rki.de/DE/Content/Infekt/EpidBull/Merkblaetter/Ratgeber_Diphtherie.html#doc2374528bodyText13
Meinel DM, Kuehl R, Zbinden R, Boskova V, Garzoni C, Fadini D, et al. Outbreak investigation for toxigenic Corynebacterium diphtheriae wound infections in refugees from Northeast Africa and Syria in Switzerland and Germany by whole genome sequencing. Clin Microbiol Infect off Publ Eur Soc Clin Microbiol Infect Dis. 2016;22(12):e10031–8.
WHO, U. WHO and UNICEF estimates of immunization coverage. 2021 revision [Internet]. 2022 [cited 2023 Feb 17]. https://www.who.int/teams/immunization-vaccines-and-biologicals/immunization-analysis-and-insights/global-monitoring/immunization-coverage/who-unicef-estimates-of-national-immunization-coverage
Epidemiologisches Bulletin 48. /2022 [Internet]. [cited 2024 Mar 13]. https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2022/Ausgaben/48_22.pdf?__blob=publicationFile
Koch-Institut R. Epidemiologisches Bulletin 4/2023. 2023; https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2023/Ausgaben/04_23.pdf?__blob=publicationFile