ORIGINAL ARTICLE

EPIDEMIOLOGY

Epidemiological data of staphylococcal scalded skin syndrome in France

from 1997 to 2007 and microbiological characteristics of Staphylococcus
aureus associated strains
V. Lamand1, O. Dauwalder1,2,3, A. Tristan1,2,3,4, J. S. Casalegno5,6, H. Meugnier1,2,3, M. Bes1,2,3, O. Dumitrescu3,7, M. Croze1,2,
F. Vandenesch1,2,3,4, J. Etienne1,2,3,4 and G. Lina1,3,7
1) Hospices Civils de Lyon, Centre National de Reference des Staphylocoques, 2) Hospices Civils de Lyon, Laboratoire de Bacteriologie, Centre de Biologie et
de Pathologie Est, Bron, 3) INSERM U851, 4) Universite de Lyon, Faculte de Medecine Lyon Est, Domaine de la Buire, Lyon, 5) Hospices Civils de Lyon, Laboratoire de Virologie, Centre de Biologie et Pathologie Est, Bron, France, 6) Universite Lyon 1 Universite de Lyon, Virologie et Pathologie Humaine (VirPath),
EMR 4610, Faculte de Medecine Lyon Est, Domaine de la Buire, Lyon, France and 7) Hospices Civils de Lyon, Laboratoire de Bacteriologie, Centre de Biologie et de Pathologie Sud, Pierre Benite, France

Abstract
Epidemiological data on staphylococcal scalded skin syndromes (SSSS), including bullous impetigo (BI) and generalized exfoliative syndrome (GES), are scarce. To better characterize SSSS and associated Staphylococcus aureus strains, we conducted a retrospective study
of 349 cases collected in France between 1997 and 2007 by the National Reference Centre of Staphylococci. Our results showed a stationary evolution of SSSS cases, with a heterogeneous distribution of cases in France. Although notification was not exhaustive, we estimated an incidence of 0.56 cases/year/million inhabitants, in accordance with previous studies conducted in France and Europe, with a
median age of 2 years old and sex ratios of 1. A seasonal effect was observed, with a higher GES/BI ratio in autumn compared with
other seasons, which could be explained by the impact of viral co-infection. Genetic analysis of S. aureus strains showed that accessory
gene regulator (agr) 4, exfoliative toxin A (eta) and B (etb) genes, staphylococcal and enterotoxin-like O (selo) gene and agr4 etb selo
profiles were predominantly associated with GES, whereas agr2 eta and agr4 eta selo were more frequently observed with BI. Only one
methicillin-resistant strain was found. Protein A (spa) typing identified two main genotypes: spa clonal complex (CC) 159/sequence-type
(ST) 121 (75%) and spaCC346/ST15 (18%). spaCC159 was mainly associated with agr4 eta etb selo, agr4 eta selo and agr4 etb selo, and
spaCC346 was mainly associated with agr2 eta, suggesting that French SSSS cases are caused by these two main lineages. However, in a
multivariate analysis, only etb was independently associated with GES.
Keywords: Bullous impetigo, exfoliative toxin, France, generalized exfoliative syndrome, incidence, staphylococcal scalded skin syndrome, Staphylococcus aureus, typing
Original Submission: 7 June 2012; Revised Submission: 16 September 2012; Accepted: 17 September 2012
Editor: F. Allerberger
Article published online: 25 September 2012
Clin Microbiol Infect 2012; 18: E514E521
10.1111/1469-0691.12053
Corresponding author: G. Lina, Hospices Civils de Lyon, Centre
de Biologie et de Pathologie Sud, 165, chemin du grand Revoyet, F69495 Pierre Benite, France
E-mail: gerard.lina@univ-lyon1.fr

Introduction
Staphylococcal scalded skin syndrome (SSSS) is a generic
term referring to a group of rare blistering diseases ranging
from generalized diseases (generalized exfoliative syndrome

(GES), Ritters disease in newborns) to localized bullous

impetigo (BI) caused by Staphylococcus aureus producing exfoliative (or epidermolytic) toxin (ET). To date, four variants
of the toxin have been described: exfoliative toxins A, B, C
and D (ETAETD) [13]. ETA, ETB and ETD belong to the
serine protease family, whereas there are still doubts concerning ETC because the sequence published in GenBank
(BAA99412) corresponds to an adenylosuccinate lyase [2].
The ETs induce epidermal blistering through the cleavage of
the cellcell adhesion molecule desmoglein-1, which is only
expressed by keratinocytes in the granular cell layer [4]. ET

2012 The Authors

Clinical Microbiology and Infection 2012 European Society of Clinical Microbiology and Infectious Diseases

CMI

Lamand et al.

activity is host specific and among ETs only ETA and ETB
exhibit human specificity as the result of a strong cleavage
activity of human desmoglein-1, which explains why only
ETA-producing and ETB-producing strains are epidemiologically associated with SSSS, and not ETD [46].
Only 5% of S. aureus human isolates produce ETA or ETB,
with differences in their prevalence between countries [7].
Previous studies have suggested that ET-producing strains are
mainly associated with a few S. aureus genetic backgrounds, as
defined by phage type, accessory gene regulator (agr) groups
or amplified fragment length polymorphism analysis, but these
genetic backgrounds have not been extensively defined by
protein A (spa) typing or multilocus sequence typing [8,9].
From an epidemiological point of view, data on SSSS are
scarce in the absence of active survey of the diseases.
The aim of this work was to examine the epidemiology of
SSSS and the microbiological characteristics of ET-producing
strains isolated in France during the last 10 years.

Material and Methods

Cases

All cases of SSSS referred to the National Reference Centre of

staphylococci (CNR-Staph) between 1 January 1997 and 31
December 2007, from different hospitals in France were considered in the study. The included cases were identified primarily by review of the medical records. GES was diagnosed in
patients with erythroderma progressing within 12 days to
spontaneous exfoliation with a positive Nikolskys sign and
fever; BI was diagnosed in patients with localized bullous
lesions and exfoliation who were afebrile [7]. A total of 349
cases fulfilling the definition of SSSS were included in this
study, comprising 212 GES cases and 137 BI cases. Data including age, sex, date of SSSS diagnosis, geographic localization,
source of the clinical sample where the strain was isolated and
clinical associate diagnosis were collected for each case.
S. aureus isolates

Staphylococcus aureus was isolated from patients with GES by

swab culture of the skin surface or distant sites, such as the
throat, nose, eyes and ears, and blood culture. Isolates from
patients with BI were generally cultured from bullous lesions.
A single isolate was studied when multiple identical isolates
were recovered from the same patient. The S. aureus was
identified as previously described [8].

French epidemiology of scalded skin syndrome

E515

38, 33, 36, 50, 52 and 33 strains isolated in 1997, 1998 and
2000 to 2007, respectively. They comprised a subset of strains
isolated between 1997 and 1999 from Jarrauds collection (a
random selection of strain isolated between 1985 and 1999) [8]
and all SSSS strains received by the CNR-Staph between 2000
and 2007. Genomic DNA was extracted with a standard procedure. A PCR was used to detect sequences specific for agr and
the following toxin genes as previously described [8,10,11]:
tst, sea, seb, sec, sed, seh, selo, eta, etb, etd, pvl and mecA encoding toxic shock syndrome toxin-1, staphylococcal enterotoxins
AD and H, staphylococcal enterotoxin-like O, exfoliative toxins A, B and D, PantonValentine leukocidin and methicillin
resistance, respectively. Staphylococcal Cassette Chromosome
mec cassette type was determined by DNA microarray (StaphyType kit; Alere Technologies GmBH, Jena, Germany) as previously described [12]. Typing of spa was also performed as
previously described [13]; spa types were determined using
RIDOM STAPH TYPE software (Ridom GmbH, Munster, Germany, http://spaserver.ridom.de) [13], and spa types were clustered into clonal complexes (spaCCs) with the integrated
Based Upon Repeat Patterns (BURP) algorithm [14]. Userdefinable parameters were set as follows: cluster spa types into
spaCC if cost distances are 4 and exclude spa types shorter
than five repeats. Sequence type (ST) was inferred from certain
spa-types as suggested by RIDOM STAPH TYPE software [13].
Statistical analysis

Incidence per million inhabitants was calculated per year on the

average population of the cover area. The average yearly population corresponding to the period 19972007 was obtained
from the French Institut national de la statistique et des etudes
economiques (INSEE; http://www.insee.fr/fr/). The number of
observed cases per year was considered a sample over the time
to estimate 95% CI for the number of expected new cases per
year. Taking into account that the occurrence of SSSS is extremely rare, the 95% CI were calculated assuming a Poisson distribution as previously performed [15]. Chi-square tests were
used to compare proportions. Genetic determinants (toxin
gene, agr type, spaCC) with unequal distribution between GES
and BI were included in a binary multivariate logistic regression
analysis to determine the most influential explanatory variables
for the clinical presentation. All of the analyses were performed
using SPSS software (SPSS Inc., Chicago, IL, USA).

Results

Strain characterization

Number and distribution of SSSS cases in France

A total of 283 strains, corresponding to 167 GES and 116 BI

cases, were selected among 349 strains including 3, 1, 9, 28,

Between January 1997 and December 2007, we collected

349 cases, including 212 cases of GES and 137 cases of BI.

2012 The Authors

Clinical Microbiology and Infection 2012 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, E514E521

E516

Clinical Microbiology and Infection, Volume 18 Number 12, December 2012

The number of cases varied from 10 to 53 per year, with a

non-significant increase in the number of cases during these
10 years (Fig. 1). The mean incidence of SSSS in France was
estimated to be 0.56 cases/year/million inhabitants (95% CI
0.370.74; Table 1) with extreme values going to 0.17 (95%
CI 0.010.27) cases/year/million inhabitants in 1997 to 0.84
(95% CI 0.631.1) cases/year/million inhabitants in 2006.
However, high variation between administrative regions was
observed (1118 cases), suggesting a non-exhaustive sample
(Table 1). The highest notification was in the Rhone area
(75 cases in 10 years for 1 700 000 inhabitants, that is c.4.4
(95% CI 1.37.6) cases/year/million inhabitants), where
CNR-Staph is located. At the regional level, we observed a
homogeneous distribution of SSSS cases per year, except
for the Ile de France region from 2003 to 2005 and the
Aquitaine region in 2005 (see Supplementary material,
Fig. S1).

CMI

Effect of seasons on SSSS occurrence

We observed variations in the number of notified cases of

SSSS between seasons. The number of SSSS cases increased
during the summer for both GES and BI. However, the GES/
BI ratio was significantly higher in autumn compared with
other seasons (p 0.021; Fig. 2).
Isolation sites of SSSS strains

Of the 212 cases of GES, eta- and/or etb-positive strains

were isolated from skin lesions in 119 (56.1%) cases; the
throat, nose, eyes or ears in 75 (35.4%) cases; and the stool
in two (0.9%) cases. In 13 (6.1%) cases, toxigenic strains
were isolated from deep sites, such as blood cultures (eight
cases, 3.8%) and peritoneal fluid. The sampling site was not
indicated for three (1.4%) patients. In the 137 BI cases, etaand/or etb-positive strains were isolated from skin lesions in
113 (82.5%) cases and the throat, nose, eyes or ears in 23
(20.4%) cases. Only one (0.7%) sampling site was not known.

Characteristics of patients suffering from SSSS

The vast majority of the cases occurred in young patients,

with a median age of 1.8 years for GES (newborn to
81.3 years) and 2.3 years for BI (newborn to 72.3 years).
Only five (2.4%) cases of GES and ten (7.3%) cases of BI
were from patients older than 18 years. Sex ratios were
roughly similar: 0.81 for GES and 1.19 for BI. Of note, 19
(5.4%) cases of SSSS occurred after varicella: nine (4.2%)
GES and ten (7.3%) BI.

Toxin profiles of French SSSS strains

The toxin gene profile was determined in a subset of 283

strains. These strains were all positive for the production of
at least one exfoliative toxin: 36% of strains carried eta
alone, 10% carried etb alone and 54% carried both eta and
etb. No strain carried the etd gene (Table 2). Allelic determination of agr showed that 76% of strains were agr4, 22%
were agr2, 2% were agr3 and one strain was agr1. Among

FIG. 1. Distribution of the number of cases of staphylococcal scalded skin syndrome (SSSS), generalized exfoliative syndrome (GES) and localized bullous impetigo (BI) per year and per year estimated incidence of SSSS cases according to the French National Reference Centre of staphylococci notifications from 1997 to 2007. Annual estimated incidences of SSSS cases (dotted curve and secondary scale in grey) were calculated
with the French population data provided by the French Institut National des Statistiques et des Etudes Economiques and available from http://
www.insee.fr/fr/themes/tableau.asp?reg_id=0&ref_id=NATnon02145.
2012 The Authors
Clinical Microbiology and Infection 2012 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, E514E521

Lamand et al.

CMI

French epidemiology of scalded skin syndrome

E517

TABLE 1. Estimated incidence of staphylococcal scalded

TABLE 2. Distribution of toxin and spa clusters among

skin syndrome (SSSS) cases in France according to the

Staphylococcus aureus isolates from generalized exfoliative

French National Reference Centre of staphylococci notifica-

syndromes (GES) and bullous impetigo (BI)

tions from 1997 to 2007

Name of French region

Calculated
Number of SSSS
cases between
Number of incidence of
a
1997 and 2007
inhabitants SSSS cases

Alsace
6
Aquitaine
29
Auvergne
9
Brittany
7
Burgundy
17
Centre
3
Champagne-Ardennes
4
Corse
0
Franche-Comte
3
Ile de France
43
Languedoc-Roussillon
4
Limousin
10
Lorraine
12
Lower Normandy
6
Midi-Pyrenees
9
Nord Pas de Calais
21
Pays de Loire
6
Picardy
5
Poitou-Charentes
6
Provence Alpes Cote dAzur 20
Rhone-Alpes
118
Upper Normandy
6
Overseas regions
5
Total
349

1
3
1
3
1
2
1
1
11
2
2
1
2
4
3
1
1
4
6
1
2
64

837
177
341
149
638
531
338
302
163
659
581
740
346
467
838
024
510
906
752
882
117
825
013
148

087
625
863
701
588
588
004
966
931
260
718
743
361
425
228
490
170
601
708
913
229
667
445
311

0.33
0.91
0.67
0.22
1.04
0.12
0.30
0
0.26
0.37
0.15
1.35
0.51
0.41
0.32
0.52
0.17
0.26
0.34
0.41
1.93
0.33
0.25
0.54

Number of inhabitants in 2008, as provided by the French Institut National des

Statistiques et des Etudes Economiques, available from http://www.insee.fr/fr/
ppp/bases-de-donnees/recensement/populations-legales/france-regions.asp?annee=2008&title=Populations%20l%C3%A9gales%202008%20des%20r%C3%A9gions.

Genes/gene association

GES (n = 167)

BI (n = 116)

pa

Genes
etab
etbb
etdb
sead
sebd
sedd
seloe
pvlf
mecAg
agr1h
agr2h
agr3h
agr4h

142
127
0c
1
7
1
146
2
0
0
24
3
140

(14)
(1.8)
(83)

112
54
0c
0
4
0
82
0
1
1
38
2
75

(0.9)
(33)
(1.7)
(65)

0.001
<0.001
nd
nd
nd
nd
0.001
nd
nd
nd
<0.001
nd
<0.001

spaCCi
spaCC159
spaCC346
spa209/4812
spa186/692
spa2166/8692

141
16
3
3
1

(84.4)
(9.6)
(1.8)
(1.8)
(0.6)

71
34
6
2
1

(61.2)
(29.3)
(5.2)
(1.7)
(0.9)

<0.001
<0.001
nd
nd
nd

(85)
(76)
(0.6)
(4)
(0.6)
(87)
(1.1)

(97)
(47)

(3.4)
(71)

spa type using RIDOM STAPH TYPE software and spaCC were determined using
the integrated Based Upon Repeat Patterns (BURP) algorithm as described in
Material and methods. Sequences specific for agr14 and the toxin genes tst,
sea, seb, sec, sed, seh, selo, eta, etb, and lukS-PV-lukF-PV were detected by polymerase chain reaction. Percentages were calculated in comparison to total numbers of GES and BI respectively. Data given in parentheses are expressed as
percentage.
Nd, not determined.
a
Chi-square test.
b
eta, etb and etd: genes encoding exfoliative toxins A, B and D.
c
etd detection was performed on only 278 isolates.
d
sead, genes encoding staphylococcal enterotoxin AD.
e
selo, genes encoding staphylococcal enterotoxin-like O.
f
pvl, gene encoding PantonValentine leukocidin.
g
mecA, gene encoding resistance to methicillin.
h
agr, allele of accessory gene regulator.
j
spaCC, clonal complexes determined by spa typing.

Spa types of French SSSS strains and their sequence type

assignments

FIG. 2. Distribution of staphylococcal scalded skin syndrome pre-

Spa typing was successfully performed on 280 of the 283

S. aureus isolates and led to the classification of 277 strains
with 40 different spa types distributed in five main spaCC
clusters plus singletons (Tables 2 and 3). The number of isolates associated with each spaCC cluster ranged from 2 to
212 isolates. Among them, 75% belonged to spaCC159
(ST121), and 18% belonged to spaCC346 (ST15). For the
other spaCCs, no founder was identified. The distribution of
spaCCs remained stable during the 10 years of the survey.

sentations over the seasons. BI, localized bullous impetigo; GES, generalized exfoliative syndrome. p calculated using a chi-square test.

genes encoding superantigenic toxins, 80% of isolates were

positive for selo and 4% were positive for seb, whereas sea
and sed were detected only once, no strain contained tst or
sec, and pvl was detected in two isolates. The most frequent
gene associations were agr4 eta etb selo (50%), followed by
agr2 eta (17%), agr4 eta selo (12%) and agr4 etb selo (10%).

Methicillin resistance of French SSSS strains

Only one strain isolated from a post-varicella GES and characterized by a genetic profile of agr3 eta spa t186 (ST88) was
mecA positive, showing an IV-SSCmec cassette type (Table 2).
Analysis of potential associations between SSSS clinical presentation, toxin gene contents, and spa type

When we compared the distribution of genes between isolates from patients with GES and BI, the distribution of eta,

2012 The Authors

Clinical Microbiology and Infection 2012 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, E514E521

E518

Clinical Microbiology and Infection, Volume 18 Number 12, December 2012

CMI

TABLE 3. Spa type, agr type and toxin gene profile of Staphylococcus aureus isolates from staphylococcal scalded skin syndrome
Cluster (spaCCa)
1 (spaCC159)

spa type
159

agrb
4

162

171

269

272

2
4

284
408
605
645

4
4
2
4

659

1425
2019
2086
2155

2
4
4
4
2
4
4
4
4

3241
4151
4390
8194

4
4
4
4

8639
8688
8762
8822
84

4
4
4
4
4

940
1077
1260

2 (spaCC346)

2
97
254
346

3 (spaCC ND)

360
1875
1877
209

4 (spaCC ND)

4812
186

5 (spaCC ND)
NC

692
2166
8692
67
3623

2
2
4
2
1
2
2
2
4
2
2
4
3
3
4
4
1
3

Genes encoding toxins

c

eta , etb , seb , selo

eta, etb, selo
eta, selo
etb, seb, selo
etb, selo
eta, etb, selo
eta, etb
eta, selo
eta
eta, etb, selo
eta, selo
eta, etb, selo
eta, selo
etb, selo
eta, etb, selo
eta, selo
eta
eta, etb, selo
eta, seb, selo
eta, selo
eta, etb, selo
eta, etb, selo
eta
eta, etb, selo
eta, seb, selo
eta, selo
etb, selo
eta, etb, selo
eta, selo
eta
etb, selo, pvlf
etb, selo
eta, etb, selo
eta, selo
eta, etb, selo
eta, selo
eta, selo
eta, etb, seb, selo
eta, etb, selo
eta, selo
etb, selo
eta, etb, selo
eta, etb, selo
etb, selo
eta, etb, selo
etb, selo
eta, etb, selo
eta, etb, selo
eta, etb, selo
eta, selo
eta, selo
eta
eta
eta
eta
eta, selo
eta
eta, selo
eta
eta
eta
eta, selo
eta, selo
eta
eta, selo
eta, etb, selo
eta
eta
eta, etb, selo
eta, etb, selo
eta, selo
eta, sea, selo, pvl

etb, selo, agr2 and agr4 differed significantly (Table 2). Briefly,
etb, selo and agr4 were more frequent in isolates from GES
than BI; however, the opposite was found for eta and agr2.

Total

GES (n = 167)

BI (n = 116)

2
82
15
1
17
1
1
1
2
1
1
17
3
1
2
2
1
3
1
2
3
4
1
10
1
2
4
3
1
1
1
1
1
1
3
1
1
6
1
1
1
1
1
1
1
1
1
2
3
1
1
29
1
5
1
1
3
1
1
1
2
1
6
1
1
1
2
2
1
1
1
1

1
49
9
1
15
1
1
0
1
0
1
12
1
1
2
0
1
3
1
0
2
3
1
10
0
0
3
3
1
0
1
1
0
1
3
0
1
4
1
0
1
1
0
0
0
1
1
2
1
1
0
12
0
1
0
0
0
0
0
0
1
0
2
0
1
1
2
0
1
0
1
1

1
33
6
0
2
0
0
1
1
1
0
5
2
0
0
2
0
0
0
2
1
1
0
0
1
2
1
0
0
1
0
0
1
0
0
1
0
2
0
1
0
0
1
1
1
0
0
0
2
0
1
17
1
4
1
1
3
1
1
1
1
1
4
1
0
0
0
2
0
1
0
0

When we compared associations between gene profiles and

the type of diseases, we observed similar results: agr4 eta etb
selo and agr4 etb selo gene profiles were predominantly

2012 The Authors

Clinical Microbiology and Infection 2012 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, E514E521

Lamand et al.

CMI

French epidemiology of scalded skin syndrome

E519

TABLE 3. Continued.
Cluster (spaCCa)

spa type

agrb

Genes encoding toxins

Total

GES (n = 167)

NT
NT

4
4

eta, selo
etb, selo

2
1

0
1

2
0

BI (n = 116)

spa type and spaCC were determined using the integrated Based Upon Repeat Patterns (BURP) algorithm as described in Material and methods. Sequences specific for agr1
4 and the toxin genes tst, sea, seb, sec, sed, seh, selo, eta, etb, and lukS-PV-lukF-PV were detected by PCR.
GES, generalized exfoliative syndrome; BI, bullous impetigo; ND, not described; NC, not clustered; NT, not typeable.
a
spaCC, clonal complexes determined by spa typing.
b
agr, allele type of accessory gene regulator.
c
eta, etb, genes encoding exfoliative toxins A and B.
d
seb, gene encoding staphylococcal enterotoxin B.
e
selo, gene encoding staphylococcal enterotoxin-like O.
g
pvl, gene encoding PantonValentine leukocidin.

associated with GES, whereas for BI, the predominant gene

profiles were agr2 eta and agr4 eta selo. Clinical presentation
also depended of the spa type: spaCC159 was more frequent
in isolates from GES than BI, whereas it was the opposite
for spaCC349. Gene profiles of the strains were also linked
to the spa type. Genotypes agr4 eta etb selo, agr4 etb selo,
and agr4 eta selo were mainly associated with spaCC159,
whereas genotype agr2 eta was predominantly associated
with spaCC346. However, in binary logistic regression analysis including spaCC groups, agr alleles, eta, etb and selo, only
etb was independently associated with GES (p 0.01).

Discussion
We have retrospectively examined the epidemiology of 349
cases of SSSS, corresponding to 212 cases of GES and 137
cases of BI, that were reported to CNR-Staph from 1997 to
2007 by medical laboratories distributed throughout France.
The number of cases remained stable during these 10 years,
except for the Ile de France region from 2003 to 2005 and
the Aquitaine region in 2005, which corresponded to two
outbreaks in maternity wards, as previously reported
[16,17]. Although SSSS is not a notifiable disease in France,
our results allowed us to establish a mean incidence of SSSS
cases based on spontaneous reporting by French microbiological laboratories of 0.56 (95% CI 0.370.74) cases/year/
million, in accordance with previous estimates (0.30 and 0.35
during 19941997 and 19982000, respectively) and an estimation of 0.13 in Germany [15,18,19]. However, a large discrepancy in the notification between French regions is
observed, suggesting many under-declarations of cases to
CNR-Staph. Incidence estimation in the Rhone area, where
declarations are the highest, was 4.4 cases/year/million. This
value is closer to the incidence recently described in the
Czech Republic from a 15-year survey, with an average incidence of 25.11 cases/million/year in children under 1 year
old, which corresponds to 2.53 cases per million inhabitants

per year [20]. However, SSSS, notably GES, can be difficult

to diagnose on clinical signs with the lack of adapted microbiological samples and strain isolation. In accordance to similar SSSS surveys based on S. aureus strain isolations, our
study is not exhaustive suggesting a higher incidence of SSSS
cases in France than measured. Prospective surveys, including
mild SSSS forms and based on clinical and histological data,
should be performed. When we examined variations in the
GES/BI ratio between seasons, most of the SSSS cases were
observed during the summer. However, we observed a significantly higher ratio of GES/BI in autumn than other seasons (Fig. 2). Autumn shows a high incidence of viral upper
respiratory tract infections in France caused by rhinovirus,
parainfluenza virus, enterovirus, respiratory syncytial virus
and influenza virus [21]. Because GES is usually accompanied
by non-specific virus-like prodromal signs and symptoms in
the upper respiratory tract, such as coryza, viral infections
could contribute to the development of GES in young
patients colonized by S. aureus ET-producing strains. We
hypothesize that in ET-producing strain carriers, a virus
infecting the upper respiratory tract of a young patient alters
the epithelium and stimulates S. aureus proliferation, triggering ET production and diffusion in the body. Cooperation
between influenza and parainfluenza viruses, and S. aureus
has been previously described in pneumonia [2224]. Moreover, we previously conducted a retrospective survey on
S. aureus superinfections during varicella [25]. Exfoliative
toxin genes were the second major toxinic factor detected
in S. aureus isolates, suggesting that a specific survey should
be performed to confirm the involvement of a virus in the
pathophysiology of SSSS.
Regarding patient data linked to strains, the most cases
occurred in young children. Only five GES and ten BI cases
were observed in adult patients without renal dysfunction or
immunosuppression, two main factors classically reported to
be associated with SSSS in adults [26]. The vast majority of
GES cases occurred in patients with only nasal colonization
by S. aureus ET-producing strains and no focal infection; the

2012 The Authors

Clinical Microbiology and Infection 2012 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, E514E521

E520

Clinical Microbiology and Infection, Volume 18 Number 12, December 2012

exceptions were SSSS cases after superinfection of varicella,

peritoneal infection and endocarditis.
In contrast to Japan, Switzerland and Taiwan [2729], we
did not observe the emergence of methicillin-resistant S. aureus (MRSA) -associated exfoliative toxin genes, with only one
MRSA strain being agr3 spa t186 (ST88) with an IV-SSCmec
cassette type. Although epidemiological data on MRSA isolated from SSSS were scarce, ST88, ST89 and ST91 have
recently been linked to MRSA associated with BI in Japan
[29,30]. Our strain belongs to one of these main MRSA
clones and could be an imported Japan strain; however, no
clinical data sustain this hypothesis. For decades, the majority
of S. aureus strains responsible for SSSS in Europe have
belonged to phage group II, particularly types 71 and 55/71
[26], agr4 or agr2 and the specific amplified fragment length
polymorphism phylogenetic groups AF1 agr4 or AF2 agr2
[8,9]. Our results showed that 75% of S. aureus strains isolated from SSSS were agr4 spaCC159 (ST121), and 18%
were agr2 spaCC346 (ST15). These strains correspond to
AF1 agr4 and AF2 agr2, respectively. Because we did not
perform phage typing, we do not know to which phage type
they belonged. ST121 clones have previously been associated
with skin and soft tissue infections involving PantonValentine leukocidin-positive methicillin-susceptible S. aureus
(MSSA) strains in Europe and China [31]. Sporadic ST121
strains with exfoliative genes, MSSA and, more recently,
MRSA have been described in paediatric patients in Portugal
[32]. However, a recent multicentre Japanese study on
MRSA strains responsible for BI noted that ST121 seemed
to be the most common ST for exfoliative-positive MSSA
[30]. Moreover, data describing ST15 strains are scarce.
MRSA ST15 strains have been found in Italy, and ST15 MSSA
strains with spa type t084 from spaCC346 have been similarly observed in China and Africa, but no data regarding exfoliative toxins or associations with specific clinical signs are
available [33,34]. Only the previous Japanese study found
three isolates of ST15 MSSA in addition to an ST8 MRSA in
BI lesions [30]. Hence, our work is the first study that
clearly associates, on a large collection of strains, spaCC159
(ST121) and spaCC346 (ST15) with SSSS and, more precisely, spaCC159 (ST121) with GES and spaCC346 (ST15)
with BI. In fact, the genetic background of S. aureus is not
enough to explain the occurrence of SSSS because ETA and/
or ETB are necessary to induce SSSS. Because eta and etb
are carried by mobile genetic elements [26,35], it is possible
that the spaCC159 (ST121) and spaCC346 (ST15) backgrounds are favourable for their acquisition or expression.
Moreover, we previously showed that eta was associated
with BI, whereas etb was associated with GES [36]. The
strength of this association was confirmed in our multivariate

CMI

analysis, which demonstrated that only etb was independently

associated with GES. Finally, we confirmed the lack of association between SSSS and ETD, with no etd-positive strain, as
previously described in 2006 and confirmed by Japanese and
Czech studies [5,6,37]. However, the possibility of overlooking an SSSS-like disease caused by an etd-positive strain could
not be excluded because the clinical symptoms induced by
these isolates may be milder than those caused by eta-positive or etb-positive strains and not notified to CNR-Staph.
In conclusion, during the last 10 years, we observed the
stability of epidemiological parameters of SSSS and S. aureus
lineages involved in these diseases, including spaCC159
(ST121) and spaCC346 (ST15) carrying eta or etb. We confirmed that the generalized form of SSSS is linked to the
presence of etb, whereas the relative increase in GES in
autumn suggests that autumnal upper respiratory tract infections by a viral agent may trigger ET effects in S. aureus ETproducing carriers.

Acknowledgments
We thank our biologist colleagues and specialists in laboratory medicine who sent us French Staphylococcus aureus isolates. We are also grateful to Christine Courtier, Christine
Gardon, Celine Spinelli, Caroline Bouveyron, Virginie Dumoulin, Annie Martra and Martine Rougier for their technical
help.

Transparency Declaration
This study was supported by Institut Francais de Veille Sanitaire (InVS), Institut National de la Sante et de la Recherche
Medicale (INSERM) and Hospices Civils de Lyon. The
authors declare that they have no conflicting interests in
relation to this work.

Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Fig. S1. Distribution of the number of cases of staphylococcal scalded skin syndrome per year among French
administrative regions between 1997 and 2007.
Please note: Wiley-Blackwell is not responsible for the content or functionality of any supporting materials supplied by
the authors. Any queries (other than missing material) should
be directed to the corresponding author for the article.

2012 The Authors

Clinical Microbiology and Infection 2012 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, E514E521

CMI

Lamand et al.

References
1. Wiley BB, Rogolsky M. Molecular and serological differentiation of
staphylococcal exfoliative toxin synthesized under chromosomal and
plasmid control. Infect Immun 1977; 18: 487494.
2. Sato H, Matsumori Y, Tanabe T, Saito H, Shimizu A, Kawano J. A
new type of staphylococcal exfoliative toxin from a Staphylococcus
aureus strain isolated from a horse with phlegmon. Infect Immun
1994; 62: 37803785.
3. Yamaguchi T, Nishifuji K, Sasaki M et al. Identification of the Staphylococcus aureus etd pathogenicity island which encodes a novel exfoliative toxin, ETD, and EDIN-B. Infect Immun 2002; 70: 58355845.
4. Amagai M, Matsuyoshi N, Wang ZH, Andl C, Stanley JR. Toxin in bullous impetigo and staphylococcal scalded-skin syndrome targets desmoglein 1. Nat Med 2000; 6: 12751277.
5. Yamasaki O, Tristan A, Yamaguchi T et al. Distribution of the exfoliative toxin D gene in clinical Staphylococcus aureus isolates in France.
Clin Microbiol Infect 2006; 12: 585588.
6. Nakaminami H, Noguchi N, Ikeda M et al. Molecular epidemiology
and antimicrobial susceptibilities of 273 exfoliative toxin-encodinggene-positive Staphylococcus aureus isolates from patients with impetigo in Japan. J Med Microbiol 2008; 57: 12511258.
7. Ladhani S. Recent developments in staphylococcal scalded skin syndrome. Clin Microbiol Infect 2001; 7: 301307.
8. Jarraud S, Mougel C, Thioulouse J et al. Relationships between Staphylococcus aureus genetic background, virulence factors, agr groups
(alleles), and human disease. Infect Immun 2002; 70: 631641.
9. Jarraud S, Lyon GJ, Figueiredo AM et al. Exfoliatin-producing strains
define a fourth agr specificity group in Staphylococcus aureus. J Bacteriol 2000; 182: 65176522.
10. Tristan A, Ying L, Bes M, Etienne J, Vandenesch F, Lina G. Use of
multiplex PCR to identify Staphylococcus aureus adhesins involved in
human hematogenous infections. J Clin Microbiol 2003; 41: 44654467.
11. Murakami K, Minamide W, Wada K, Nakamura E, Teraoka H, Watanabe S. Identification of methicillin-resistant strains of staphylococci
by polymerase chain reaction. J Clin Microbiol 1991; 29: 22402244.
12. Monecke S, Jatzwauk L, Weber S, Slickers P, Ehricht R. DNA microarray-based genotyping of methicillin-resistant Staphylococcus aureus
strains from Eastern Saxony. Clin Microbiol Infect 2008; 14: 534545.
13. Harmsen D, Claus H, Witte W et al. Typing of methicillin-resistant
Staphylococcus aureus in a university hospital setting by using novel
software for spa repeat determination and database management. J
Clin Microbiol 2003; 41: 54425448.
14. Mellmann A, Weniger T, Berssenbrugge C et al. Characterization of
clonal relatedness among the natural population of Staphylococcus aureus strains by using spa sequence typing and the BURP (based upon
repeat patterns) algorithm. J Clin Microbiol 2008; 46: 28052808.
15. Mockenhaupt M, Idzko M, Grosber M, Schopf E, Norgauer J. Epidemiology of staphylococcal scalded skin syndrome in Germany. J Invest
Dermatol 2005; 124: 700703.
16. El Helali N, Carbonne A, Naas T et al. Nosocomial outbreak of
staphylococcal scalded skin syndrome in neonates: epidemiological
investigation and control. J Hosp Infect 2005; 61: 130138.
17. Occelli P, Blanie M, Sanchez R et al. Outbreak of staphylococcal bullous impetigo in a maternity ward linked to an asymptomatic healthcare worker. J Hosp Infect 2007; 67: 264270.
18. Lina G, Etienne J, Vandenesch F. Les syndromes toxiniques staphylococciques en France de 1994 a` 1997. BEH 1997; 17: 6970.
19. Lina G, Vandenesch F, Etienne J. Staphylococcal and streptococcal
pediatric toxic syndrome from 1998 to 2000. Data from the National
Center for Staphylococcal Toxemia. Arch Pediatr 2001; 8 (suppl 4):
769s775s.

French epidemiology of scalded skin syndrome

E521

20. Lipovy B, Brychta P, Chaloupkova Z, Suchanek I. Staphylococcal

scalded skin syndrome in the Czech Republic: an epidemiological
study. Burns 2011; 38: 296300.
21. Monto AS. The seasonality of rhinovirus infections and its implications for clinical recognition. Clin Ther 2002; 24: 19871997.
22. Gillet Y, Etienne J, Lina G, Vandenesch F. Association of necrotizing
pneumonia with PantonValentine leukocidin-producing Staphylococcus
aureus, regardless of methicillin resistance. Clin Infect Dis 2008; 47:
985986.
23. Lee MH, Arrecubieta C, Martin FJ, Prince A, Borczuk AC, Lowy FD.
A postinfluenza model of Staphylococcus aureus pneumonia. J Infect Dis
2010; 201: 508515.
24. Wenzel JJ, Hentschel J, Silvis W et al. Rapidly fatal necrotizing pneumonia in a 12-year-old boy caused by co-infection with parainfluenza
virus type 1 and PantonValentine leukocidin (PVL)-positive methicillin-sensitive Staphylococcus aureus. Infection 2009; 37: 7577.
25. Raulin O, Durand G, Gillet Y et al. Toxin profiling of Staphylococcus
aureus strains involved in varicella superinfection. J Clin Microbiol
2010; 48: 16961700.
26. Ladhani S, Joannou CL, Lochrie DP, Evans RW, Poston SM. Clinical,
microbial, and biochemical aspects of the exfoliative toxins causing
staphylococcal scalded-skin syndrome. Clin Microbiol Rev 1999; 12:
224242.
27. Chi CY, Wang SM, Lin HC, Liu CC. A clinical and microbiological
comparison of Staphylococcus aureus toxic shock and scalded skin syndromes in children. Clin Infect Dis 2006; 42: 181185.
28. Liassine N, Auckenthaler R, Descombes MC, Bes M, Vandenesch F,
Etienne J. Community-acquired methicillin-resistant Staphylococcus aureus isolated in Switzerland contains the PantonValentine leukocidin
or exfoliative toxin genes. J Clin Microbiol 2004; 42: 825828.
29. Hisata K, Ito T, Matsunaga N et al. Dissemination of multiple MRSA
clones among community-associated methicillin-resistant Staphylococcus aureus infections from Japanese children with impetigo. J Infect
Chemother 2011; 17: 609621.
30. Shi D, Higuchi W, Takano T et al. Bullous impetigo in children
infected with methicillin-resistant Staphylococcus aureus alone or in
combination with methicillin-susceptible S. aureus: analysis of genetic
characteristics, including assessment of exfoliative toxin gene carriage.
J Clin Microbiol 2011; 49: 19721974.
31. Rasigade JP, Laurent F, Lina G et al. Global distribution and evolution
of PantonValentine leukocidin-positive methicillin-susceptible Staphylococcus aureus, 19812007. J Infect Dis 2010; 201: 15891597.
32. Conceicao T, Aires-de-Sousa M, Pona N et al. High prevalence of
ST121 in community-associated methicillin-susceptible Staphylococcus
aureus lineages responsible for skin and soft tissue infections in Portuguese children. Eur J Clin Microbiol Infect Dis 2011; 30: 293297.
33. Campanile F, Bongiorno D, Borbone S, Stefani S. Hospital-associated
methicillin-resistant Staphylococcus aureus (HA-MRSA) in Italy. Ann Clin
Microbiol Antimicrob 2009; 8: 22.
34. Schaumburg F, Kock R, Friedrich AW et al. Population structure of
Staphylococcus aureus from remote African Babongo Pygmies. PLoS
Negl Trop Dis 2011; 5: e1150.
35. Yoshizawa Y, Sakurada J, Sakurai S, Machida K, Kondo I, Masuda S.
An exfoliative toxin A-converting phage isolated from Staphylococcus
aureus strain ZM. Microbiol Immunol 2000; 44: 189191.
36. Yamasaki O, Yamaguchi T, Sugai M et al. Clinical manifestations of
staphylococcal scalded-skin syndrome depend on serotypes of exfoliative toxins. J Clin Microbiol 2005; 43: 18901893.
37. Ruzickova V, Pantucek R, Petras P, Machova I, Kostylkova K, Doskar
J. Major clonal lineages in impetigo Staphylococcus aureus strains isolated in Czech and Slovak maternity hospitals. Int J Med Microbiol
2012; In press.

2012 The Authors

Clinical Microbiology and Infection 2012 European Society of Clinical Microbiology and Infectious Diseases, CMI, 18, E514E521