{"id":1138,"date":"2014-05-01T16:44:56","date_gmt":"2014-05-01T16:44:56","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1138"},"modified":"2022-02-16T16:01:19","modified_gmt":"2022-02-16T16:01:19","slug":"treating-resistant-skin-infections-in-dogs","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/dermatology\/treating-resistant-skin-infections-in-dogs\/","title":{"rendered":"Treating Resistant Skin Infections in Dogs"},"content":{"rendered":"<p>Pyoderma is a common skin disorder in small animal practice. Now that the major canine pathogen, <em><span class=\"garamon-italics\">Staphylococcus pseudintermedius<\/span><\/em><span class=\"garamond-9-5\">, has acquired methicillin resistance, treatment has become more challenging and more expensive. Keys to success in treatment and prevention require:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Prompt identification and treatment of the underlying cause<\/span><\/li>\n<li><span class=\"garamond-9-5\">Use of culture and sensitivity to guide antibiotic use<\/span><\/li>\n<li><span class=\"garamond-9-5\">Increased reliance on topical therapy.<\/span><\/li>\n<\/ul>\n<hr \/>\n<p><span class=\"bluboldheader\"><strong>Editor\u2019s Note:<\/strong> This article was originally published in May\/June 2015. Please use this content for reference or educational purposes, but note that it is not being actively vetted after publication. For the most recent peer-reviewed content, see our <a href=\"https:\/\/todaysveterinarypractice.com\/issue-archives\/\">issue archive<\/a>.<\/span><\/p>\n<hr \/>\n<h2><span class=\"bluboldheader\">WHY ARE DOGS SUSCEPTIBLE TO SKIN INFECTIONS?<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Of all the species with which we work, dogs seem uniquely predisposed to bacterial skin infections.<sup>1-5<\/sup>\u00a0Dogs are more susceptible to skin infections due to basic structural features, such as:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Lack of a follicular lipid plug, which acts like a drain stopper<\/span><\/li>\n<li><span class=\"garamond-9-5\">Fragile skin barrier<\/span><\/li>\n<li><span class=\"garamond-9-5\">Alkaline pH.\u00a0<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><strong><span class=\"garamond-bold\">Table 1\u00a0<\/span><\/strong><span class=\"garamond-9-5\">lists underlying skin disorders that predispose dogs to staphylococcal skin infections.<sup>6<\/sup>\u00a0Dogs with atopic dermatitis are especially susceptible due to:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">A defective skin barrier, which is represented by the stratum corneum and one of the first physical and chemical defenses against microbial infection<sup>7-9<\/sup><\/span><\/li>\n<li><span class=\"garamond-9-5\">Potentially decreased levels of defensins\u2014cationic antimicrobial proteins that defend against bacterial infections as part of the innate immune system.<sup>10<\/sup><\/span><\/li>\n<\/ul>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.45.19-AM.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"size-full wp-image-4714 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.45.19-AM.png\" alt=\"Screen Shot 2015-06-18 at 10.45.19 AM\" width=\"288\" height=\"185\" \/><\/a><\/p>\n<h2 class=\"left-justified\"><span class=\"bluboldheader\">WHICH BACTERIA CAUSE PYODERMA IN DOGS?<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">The major canine skin pathogen is\u00a0<\/span><em><span class=\"garamon-italics\">S pseudintermedius<\/span><\/em><span class=\"garamond-9-5\">;<sup>11<\/sup>\u00a0however,\u00a0<\/span><em><span class=\"garamon-italics\">Staphylococcus schleiferi<\/span><\/em><span class=\"garamond-9-5\">,\u00a0<\/span><em><span class=\"garamon-italics\">Staphylococcus aureus<\/span><\/em><span class=\"garamond-9-5\">, and\u00a0<\/span><em><span class=\"garamon-italics\">Pseudomonas aeruginosa<\/span><\/em><span class=\"garamond-9-5\"><em> \u00a0<\/em>have also been identified in canine pyoderma.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\"><em class=\"bolditalic\">S aureus<\/em>\u2014a human pathogen\u2014has been identified in a low percentage of dogs. However, this bacterium has received a great deal of attention due to its methicillin resistance in humans and potential role as a zoonotic agent\u2014dogs infected with methicillin-resistant\u00a0<\/span><em><span class=\"garamon-italics\">S aureus<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>(MRSA) most likely acquired the infection from a human.<\/span><\/p>\n<p class=\"indent-125\"><em><span class=\"bolditalic\">S pseudintermedius<\/span><\/em><span class=\"garamond-9-5\">, while not as virulent, shares many characteristics with\u00a0<\/span><span class=\"garamon-italics\">S aureus<\/span><span class=\"garamond-9-5\">, including:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Enzyme and toxin production<\/span><\/li>\n<li><span class=\"garamond-9-5\">Ability to adhere to matrix adhesive proteins<\/span><\/li>\n<li><span class=\"garamond-9-5\">Ability to form biofilms.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Methicillin-resistant\u00a0<\/span><em><span class=\"garamon-italics\">S pseudintermedius<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>(MRSP) is unlikely to cause human infection, unless a person is very young, very old, or immunocompromised.<\/span><\/p>\n<p class=\"indent-125\"><em><span class=\"bolditalic\">S schleiferi<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>was first identified from human clinical specimens in 1988, and has now been identified as a cause of pyoderma and otitis externa in dogs.<sup>12-14<\/sup><\/span><\/p>\n<p class=\"indent-125\"><em><span class=\"bolditalic\">P aeruginosa<\/span><\/em><span class=\"garamond-9-5\">\u2014while not common\u2014has been identified on the skin of dogs, particularly in lip fold pyodermas and postgrooming folliculitis.<sup>15-16<\/sup><\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Identifying the particular\u00a0<\/span><em><span class=\"garamon-italics\">Staphylococcus<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>species involved in skin infections, and its antimicrobial sensitivity, is important with regard to determining whether the dog is infected with a methicillin-resistant strain.\u00a0<\/span><\/p>\n<h2 class=\"left-justified\"><span class=\"bluboldheader\">WHAT ARE THE CLINICAL MANIFESTATIONS OF PYODERMA?<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Pyoderma can be classified many ways, but categorizing it by depth of skin affected is particularly useful because it can help determine type and duration of therapy.<\/span><\/p>\n<p class=\"indent-125\"><strong><span class=\"garamond-bold\">Surface pyodermas<\/span><\/strong><span class=\"garamond-9-5\"><strong>\u00a0<\/strong>are bacterial infections confined to the surface of the skin. These bacteria produce toxins, resulting in inflammation. The best examples include fold pyodermas of the face, lips, tail, and axilla.<\/span><\/p>\n<p class=\"indent-125\"><strong><span class=\"garamond-bold\">Superficial pyodermas<\/span><\/strong><span class=\"garamond-9-5\"><strong>\u00a0<\/strong>are bacterial infections that present beneath the stratum corneum layer of the epidermis, and include impetigo, folliculitis, and bacterial overgrowth syndrome.<\/span><\/p>\n<ul>\n<li><span class=\"garamond-bold\"><strong>Impetigo<\/strong><\/span><span class=\"garamond-9-5\">\u00a0is a subcorneal pustular disease seen frequently on the abdomen of puppies; it may, or may not, be pruritic, but is often self-limiting.<\/span><\/li>\n<li><span class=\"garamond-bold\"><strong>Bacterial folliculitis<\/strong><\/span><span class=\"garamond-9-5\">\u2014infection and inflammation of the hair follicles\u2014is the most common pyoderma seen in dogs. It has many clinical forms, the features of which may be unique to the individual dog breed. The earliest form is a follicular papule\u2014the lesion progresses as bacteria spread into surrounding hair follicles. The classic lesion is the epidermal collarette, characterized by a circular area of hair loss with variable redness, crusting, and hyperpigmentation. These lesions may, or may not, be pruritic; however, pruritus is usually quite profound in atopic dogs and pyoderma is a factor that escalates itch.\u00a0<\/span><\/li>\n<li><span class=\"garamond-bold\"><strong>Bacterial overgrowth syndrome<\/strong><\/span><span class=\"garamond-9-5\">\u00a0is a superficial cutaneous disorder, associated with an overgrowth of\u00a0<\/span><span class=\"garamon-italics\">S pseudintermedius<\/span><span class=\"garamond-9-5\">\u00a0and characterized by large numbers of bacteria, erythema, pruritus, and malodor.<sup>17<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Deep pyodermas<\/strong><\/span><span class=\"garamond-9-5\">\u00a0are less common, and occur as either focal, or localized, furunculosis or generalized furunculosis and\/or cellulitis. Furunculosis is caused by bacterial infection that affects the hair follicles and causes small abscesses under the skin.<\/span><\/p>\n<ul>\n<li><span class=\"garamond-bold\"><strong>Localized forms of furunculosis<\/strong><\/span><span class=\"garamond-9-5\">\u00a0occur on chins of short-coated dogs (eg, English and French bulldogs, boxers, pugs, Boston terriers, Doberman pinschers, Great Danes, pitbulls and related breeds\/crosses), on lateral stifles and other pressure points, and between the digits (interdigital pyoderma or interdigital cyst). Golden retrievers develop furunculosis that has many features of acute pyotraumatic dermatitis; however, it is an acute and deep bacterial skin infection. These dogs will often have fever, loss of appetite, and malaise prior to the eruption of the lesions.<sup>6<\/sup>\u00a0Likely these infections represent an individual host\u2013pathogen interaction.<\/span><\/li>\n<li><span class=\"garamond-bold\"><strong>Generalized furunculosis and cellulitis<\/strong><\/span><span class=\"garamond-9-5\">\u00a0are not common, but often accompany demodicosis. Inflammation is quite severe, and dogs are often systemically ill when infection is deep. German shepherd dogs develop a severe ulcerative pyoderma that is generalized and painful. Hemorrhagic bullae and ulcers often result in the mistaken notion that affected dogs have an autoimmune disease.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Any of the bacteria listed previously can cause surface, superficial, or deep pyoderma.<\/span><\/p>\n<h2 class=\"left-justified\"><span class=\"bluboldheader\">HOW DO WE DIAGNOSE PYODERMA?<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Pyoderma is diagnosed by history and clinical examination, and supported by cytologic findings.\u00a0<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Cytology<\/strong><\/span><span class=\"garamond-9-5\">\u00a0is important for several reasons; it:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Identifies coexistent staphylococcal and\u00a0<\/span><em><span class=\"garamon-italics\">Malassezia<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>infections; in order to resolve the infections, both need to be treated\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Confirms the presence of bacteria and white blood cells\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Helps to differentiate pyoderma from other cutaneous diseases that mimic, or may coexist with, pyodermas, such as pemphigus foliaceus.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Samples can be obtained for cytology in several ways.\u00a0<\/span><\/p>\n<ul>\n<li><strong><span class=\"garamond-bold\">Clear tape<\/span><\/strong><span class=\"garamond-9-5\"><strong>\u00a0<\/strong>is an excellent way to collect materials from feet and skin folds, as well as from collarettes. See\u00a0<\/span><strong><span class=\"garamond-bold\">Step by Step: Using Clear Tape for Cytologic Evaluation of Pyoderma<\/span><\/strong><span class=\"garamond-9-5\">.<\/span><\/li>\n<li><span class=\"garamond-9-5\">\u00a0<\/span><strong><span class=\"garamond-bold\">Direct impression smears<\/span><\/strong><span class=\"garamond-9-5\"><strong>\u00a0<\/strong>can be obtained from moist lesions and pustule exudate, allowed to dry, and then stained.\u00a0<\/span><\/li>\n<li><strong><span class=\"garamond-bold\">A dry #10 blade<\/span><\/strong><span class=\"garamond-9-5\"><strong>\u00a0<\/strong>can collect crusts from very dry lesions, which are then placed on a slide and minced into sterile saline. Once dried, the slide can be stained and examined.\u00a0<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Culture and sensitivity<\/strong><\/span><span class=\"garamond-9-5\">\u00a0is recommended for all generalized deep pyodermas and if treatment with 2 different classes of oral antibiotic, repeated courses of a previously effective antibiotic, or one injection of cefovecin<sup>18<\/sup>\u00a0fail to resolve any superficial or deep infections (<\/span><strong><span class=\"garamond-bold\">Figure 1<\/span><\/strong><span class=\"garamond-9-5\">).\u00a0<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Methicillin resistance is increasing in canine skin infections, and sensitivity results are required to select the correct antibiotic.<\/span><\/li>\n<li><span class=\"garamond-9-5\">Currently, we do not have validated methods for empirically selecting antibiotics for methicillin-resistant staphylococcal infections in dogs.<\/span><\/li>\n<\/ul>\n<div class=\"orange-box\">\n<h3 align=\"LEFT\">Step by Step: Using Clear Tape for Cytologic Evaluation of Pyoderma<\/h3>\n<ol>\n<li>Press the tape\u2014sticky side down\u2014onto the lesion, then stain with a modified Wright\u2019s Giemsa stain, such as Diff-Quick. Do not fix the tape with methanol as it will cloud the tape.<\/li>\n<li>After staining, rinse with water and lay\u2014sticky side down\u2014onto a glass slide.<\/li>\n<li>Press out excess water with a paper towel; then examine the slide.<\/li>\n<li>While the slide can be scanned at lower powers, the oil immersion lens is recommended for examination of bacteria and yeast.<\/li>\n<\/ol>\n<\/div>\n<p>&nbsp;<\/p>\n<h2 class=\"left-justified\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.45.30-AM.png\"><img decoding=\"async\" class=\"wp-image-4715 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.45.30-AM.png\" alt=\"Screen Shot 2015-06-18 at 10.45.30 AM\" width=\"494\" height=\"419\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.45.30-AM.png 543w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.45.30-AM-300x255.png 300w\" sizes=\"(max-width: 494px) 100vw, 494px\" \/><\/a><\/h2>\n<h2 class=\"left-justified\"><span class=\"bluboldheader\">HOW DO WE TREAT PYODERMA IN DOGS?\u00a0<\/span><\/h2>\n<h3 class=\"left-justified\"><span class=\"Orange\">Specific to Type of Pyoderma<\/span><\/h3>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Surface infections<\/strong><\/span><span class=\"garamond-9-5\">\u00a0are often best treated topically. They are not considered curable because the moisture and occlusive nature of folds predisposes toward recurrence. Surgical excision may be curative in some cases of vulvar fold pyoderma and tail fold pyoderma in English bulldogs.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Superficial pyodermas<\/strong><\/span><span class=\"garamond-9-5\">\u00a0can often be treated exclusively with topical therapy (which is preferred to systemic antibiotic administration in my opinion), but frequent bathing is required (daily or every other day). Bathing frequency can be reduced by the use of chlorhexidine leave-on conditioners, sprays, wipes, and mousses in between. The use of topical therapy seems to speed the rate of recovery, and we suspect topical therapy reduces the length of time a dog requires systemic antibiotics.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Deep pyodermas<\/strong><\/span><span class=\"garamond-9-5\">\u00a0usually require prolonged (several weeks) courses of antibiotic therapy. While topical therapy alone is unlikely to resolve a deep pyoderma, it is an invaluable tool in the dog\u2019s recovery. Bathing helps to remove adherent crusts and sticky exudates, promoting drainage and drying.<\/span><\/p>\n<h3 class=\"left-justified\"><span class=\"Orange\">Topical Treatment<\/span><\/h3>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Most of the veterinary dermatologic literature supports the use of 2% to 4% chlorhexidine as the most effective topical antiseptic agent against\u00a0<\/span><span class=\"garamon-italics\"><em>S pseudintermedius<\/em>, <em>P aeruginosa<\/em><\/span><span class=\"garamond-9-5\">, and\u00a0<\/span><em><span class=\"garamon-italics\">Malassezia<\/span><\/em><span class=\"garamond-9-5\"><em>species<\/em>.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">One of the most critical aspects of pyoderma treatment is bathing (see\u00a0<\/span><strong><span class=\"garamond-bold\">Step by Step: Bathing as Topical Therapy for Pyoderma<\/span><\/strong><span class=\"garamond-9-5\">), which is beneficial because it:<\/span><\/p>\n<ol>\n<li><span class=\"garamond-9-5\">Helps clean the skin, removing scaling and crusts that contain bacteria<\/span><\/li>\n<li><span class=\"garamond-9-5\">Makes the dog look, feel, and smell better\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Frequently helps compress the course of antibiotics, reducing the time for selection of resistant strains.<\/span><\/li>\n<\/ol>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">If bathing is combined with systemic antibiotics, minimal bathing frequency should be once weekly. However, if owners are willing and able to bathe more frequently, they should be encouraged to do so. They can augment their bathing with the use of rinses, sprays, leave-on conditioners, mousses, and wipes in between baths.<\/span><\/p>\n<div class=\"orange-box\">\n<h3 align=\"LEFT\">Step by Step: Bathing as Topical Therapy for Pyoderma<\/h3>\n<p align=\"LEFT\">Advise owners to:<\/p>\n<ol>\n<li>Bathe using tepid water.<\/li>\n<li>Massage the shampoo gently in by hand, first onto the areas most affected (rather than pouring it down the back).<\/li>\n<li>Wash the rest of the dog and leave the shampoo on the skin for 10 minutes before rinsing.<\/li>\n<li>Soak crusts that are tightly adherent, which helps loosen them gently.<\/li>\n<\/ol>\n<\/div>\n<h3 class=\"left-justified\"><span class=\"Orange\">Systemic Antibiotics<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Modern recommendations for antibiotic selection suggest that we:\u00a0<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Consider efficacy, safety, and compliance<\/span><\/li>\n<li><span class=\"garamond-9-5\">Use those that are best in class.\u00a0<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Traditionally, we have been taught to select older generation, less active antibiotics based on the belief that if the antibiotic fails, we can then use newer, more active compounds. However, this principle can no longer be applied in the age of staphylococcal methicillin resistance\u2014once the less active, beta-lactam antibiotics become ineffective, the entire class is useless for systemic therapy.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Most dermatologists believe that the most appropriate first-choice antibiotic for canine pyoderma is a cephalosporin and, in most patients, treatment with cephalosporins may be empirical. If a pyoderma fails to resolve with a cephalosporin, it is important to step back and re-evaluate the diagnosis and treatment plan.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">If cytology from lesions of pyoderma identifies rods, suspicion is raised for a\u00a0<\/span><em><span class=\"garamon-italics\">Pseudomonas<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>or other gram negative pyoderma. The empirical choice of antibiotic in these patients is a fluoroquinolone. However, infections with rod-shaped bacteria should be cultured to verify:\u00a0<\/span><\/p>\n<ol>\n<li><span class=\"garamond-9-5\">What bacteria are present\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Which antibiotic (if any) is indicated.\u00a0<\/span><\/li>\n<\/ol>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Table 2<\/strong>\u00a0<\/span><span class=\"garamond-9-5\">contains a list of antibiotics and doses used to treat canine pyoderma.\u00a0<\/span><\/p>\n<p class=\"indent-125\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.46.38-AM.png\"><img decoding=\"async\" class=\"size-full wp-image-4716 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.46.38-AM.png\" alt=\"Screen Shot 2015-06-18 at 10.46.38 AM\" width=\"316\" height=\"901\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.46.38-AM.png 316w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.46.38-AM-105x300.png 105w\" sizes=\"(max-width: 316px) 100vw, 316px\" \/><\/a><\/p>\n<p class=\"indent-125\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/DD-Challenges.png\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-8604 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/DD-Challenges-300x149.png\" alt=\"DD Challenges\" width=\"300\" height=\"149\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/DD-Challenges-300x149.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/DD-Challenges.png 500w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<h2 class=\"left-justified\"><span class=\"bluboldheader\">WHAT IS METHICILLIN RESISTANCE, AND HOW DO WE RECOGNIZE IT?\u00a0<\/span><\/h2>\n<h3 class=\"left-justified\"><span class=\"Orange\">Genetic Development<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Methicillin resistance in\u00a0<\/span><em><span class=\"garamon-italics\">Staphylococci<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>is associated with acquisition of a gene, mecA, that is incorporated into the bacterial genome and subsequently passed on to all daughter cells.<sup>22-24<\/sup><\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">MecA encodes for a mutated form of penicillin-binding protein on the bacteria\u2019s surface.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">This mutant protein cannot bind any beta-lactam antibiotic; therefore, all penicillins and cephalosporins are ineffective.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">The genetic element on which the mecA gene resides can also carry other antibiotic-resistant genes, and some\u00a0<\/span><em><span class=\"garamon-italics\">S pseudintermedius<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>will be resistant to all antibiotics tested.<\/span><\/li>\n<li><span class=\"garamond-9-5\">This genetic element is retained within the\u00a0<\/span><em><span class=\"garamon-italics\">Staphylococcus<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>as long as antibiotic pressure is present. If antibiotic pressure is removed, the bacteria have the potential to excise the incorporated genetic element and become sensitive again.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">For this reason, it may work best to avoid systemic antibiotic therapy for dogs with surface or superficial pyoderma caused by methicillin-resistant staphylococci (MRS) and, instead, focus on aggressive topical therapy.<\/span><\/li>\n<\/ul>\n<h3 class=\"left-justified\"><span class=\"Orange\">Diagnosis<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">To diagnose methicillin resistance, culture and sensitivity testing is needed. It is no longer acceptable for a laboratory to report coagulase-positive\u00a0<\/span><em><span class=\"garamon-italics\">Staphylococcus<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>species as the final diagnosis\u2014the\u00a0<\/span><em><span class=\"garamon-italics\">Staphylococcus<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>species should be determined to allow clinicians to appropriately counsel clients as to risk of contagion.\u00a0<\/span><\/p>\n<p class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">It is very important to provide precise terminology:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">MRSA refers specifically to methicillin-resistant\u00a0<\/span><em><span class=\"garamon-italics\">S aureus<\/span><\/em><span class=\"garamond-9-5\">, the human pathogen.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">MRSP is not more contagious or virulent than methicillin-susceptible\u00a0<\/span><em><span class=\"garamon-italics\">S pseudintermedius<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>(MSSP); just simply harder to treat.<\/span><\/li>\n<\/ul>\n<h2 class=\"left-justified\"><span class=\"bluboldheader\">HOW DO WE TREAT METHICILLIN-RESISTANT PYODERMA IN DOGS?\u00a0<\/span><\/h2>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Systemic antibiotic therapy for dogs with MRS should not be selected empirically\u2014culture and sensitivity is required to identify the antibiotic most likely to be effective. Given that systemic antibiotic therapy drives retention of resistance factors, clinicians should consider topical antiseptic therapy for superficial pyoderma.<\/span><\/p>\n<h3 class=\"left-justified\"><span class=\"Orange\">Topical Therapy<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">It has been hypothesized that topical therapy may give bacteria time and opportunity to eject the resistance genes and become susceptible again (see\u00a0<\/span><strong><span class=\"garamond-bold\">Topical Therapy: A Stand-Alone Treatment?<\/span><\/strong><span class=\"garamond-9-5\">).<\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-bold\"><strong>Shampoos containing 2% to 4% chlorhexidine<\/strong><\/span><span class=\"garamond-9-5\">\u00a0are best,<sup>22-28<\/sup>\u00a0and use of only shampoos produced by quality veterinary pharmaceutical companies is recommended, as careful formulation is critical to maintain the activity of chlorhexidine.\u00a0<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Shampoos improve skin and coat quality as infection is resolved, and are considered superior to other topical therapies because many shampoos contain:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Lipids, such as ceramide complex or phytosphingosine, that help repair the skin barrier when used over time<\/span><\/li>\n<li><span class=\"garamond-9-5\">Emollients that help prevent drying of the skin, which can happen with other products, such as scrubs.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Topical antibiotics<\/strong><\/span><span class=\"garamond-9-5\">\u00a0can be used in some cases to help resolve MRS-associated pyodermas.\u00a0<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Mupirocin topical ointment is effective against most strains of MRSP and can be used to resolve focal lesions.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Topical amikacin spray can be used twice daily in some patients; it can be made by mixing amikacin (5 mg\/mL) in Tris-EDTA. This spray is preferable to commercial products containing gentamicin and betamethasone.\u00a0<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><em><strong><span class=\"garamond-bolditalaic\">Note:\u00a0<\/span><\/strong><\/em><span class=\"garamond-9-5\">Betamethasone is a potent steroid that can induce severe cutaneous atrophy if overused; its use should be restricted to less than 14 days, particularly on thin skin such as that on the abdomen.<\/span><\/p>\n<div class=\"orange-box\">\n<h3 align=\"LEFT\">Topical Therapy: A Stand-Alone Treatment?<\/h3>\n<p align=\"LEFT\">In 2010, a randomized, double-blinded, controlled study tested the hypothesis that <strong>topical therapy alone could treat dogs with methicillin-resistant <\/strong><strong>superficial pyodermas<\/strong>.<sup>28<\/sup><\/p>\n<ul>\n<li>Ten dogs with MRS P were bathed daily with a surgical scrub containing 2% chlorhexidine.<\/li>\n<li>A scoring system graded the following components\u2014based on severity\u2014on a scale of 0 to 3: pruritus, erythema, crusting, and hair loss.<\/li>\n<li>At 2 weeks, all dogs demonstrated 50% or greater improvement, with 3 dogs experiencing complete resolution.<\/li>\n<li>At 4 weeks, pyoderma lesions had resolved in all dogs but one, whose pruritus was due to uncontrolled atopic dermatitis.<\/li>\n<li>All dogs were cleared of clinically observable infection within 30 days (<strong>Figure 2<\/strong>).<\/li>\n<\/ul>\n<\/div>\n<h3 class=\"left-justified\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.48.31-AM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4717 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.48.31-AM.png\" alt=\"Screen Shot 2015-06-18 at 10.48.31 AM\" width=\"485\" height=\"330\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.48.31-AM.png 682w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.48.31-AM-300x204.png 300w\" sizes=\"(max-width: 485px) 100vw, 485px\" \/><\/a><\/h3>\n<h3 class=\"left-justified\"><span class=\"Orange\">Systemic Therapy<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Not all dogs with MRS will respond to topical therapy, particularly if the infection is severe, generalized, or a deep pyoderma. For these dogs, systemic antibiotic therapy is required, and culture and sensitivity mandatory.\u00a0<\/span><span class=\"garamond-bold\"><strong>Table 2<\/strong>\u00a0<\/span><span class=\"garamond-9-5\">contains a list of antibiotics, with doses to be considered.\u00a0<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Sulfonamides<\/strong>:\u00a0<\/span><span class=\"garamond-9-5\">If the organism is sensitive, potentiated sulfonamides can be used. While side effects are possible, most dogs tolerate these drugs quite well. Sulfamethoxine\/ormetoprim is useful, as it can be administered once daily.\u00a0<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Lincosamides<\/strong>:<\/span><span class=\"garamond-9-5\">\u00a0If reported as sensitive, clindamycin can also be used, but only if the bacteria are sensitive to all macrolides.<sup>29<\/sup>\u00a0A resistance factor, termed the\u00a0<\/span><em><span class=\"garamon-italics\">clindamycin-inducible resistance factor<\/span><\/em><span class=\"garamond-9-5\">, can be found in\u00a0<\/span><em><span class=\"garamon-italics\">Staphylococcus<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>species. One indicator that this gene may be present is reported resistance to erythromycin, but sensitivity to clindamycin. Treatment with clindamycin will rapidly induce the resistance factor, and antibiotic therapy will fail.\u00a0<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Tetracyclines<\/strong>:\u00a0<\/span><span class=\"garamond-9-5\">Although use of tetracyclines is not advocated for most\u00a0<\/span><em><span class=\"garamon-italics\">S pseudintermedius<\/span><\/em><span class=\"garamond-9-5\"><em>\u00a0<\/em>infections\u2014because most isolates are resistant to tetracyclines and penicillins\u2014MRSP may revert to tetracycline sensitive. However, considering that tetracycline is no longer available, doxycycline or minocycline may be used instead. However, the breakpoints for determining sensitivity to doxycycline are changing: if the minimum inhibitory concentration is greater than 0.5 to 1 mcg\/mL, then failure of therapy is more likely even if a culture indicates sensitivity.<sup>30<\/sup><\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">The majority of MRSP are sensitive to chloramphenicol, rifampin, and amikacin:<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Amphenicols<\/strong>:<\/span><span class=\"garamond-9-5\">\u00a0Chloramphenicol must be given at 30 to 50 mg\/kg Q 8 H, which can result in poor compliance.\u00a0<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">After 30 days of treatment, most dogs become nauseated or develop vomiting and diarrhea, and some dogs develop a poorly understood hindlimb paresis that resolves upon cessation of antibiotic use.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Chloramphenicol is a health risk for humans, with the potential to induce aplastic anemia. If dispensed to clients, advise clients to handle the medication carefully.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Aminoglycosides<\/strong>:\u00a0<\/span><span class=\"garamond-9-5\">Amikacin is well tolerated by most dogs but must be given by subcutaneous injection (15 mg\/kg once daily) and does present the risk for renal toxicity.\u00a0<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Frequent monitoring of urine for casts and repeated blood analysis of blood urea nitrogen (BUN) and creatinine can make this an expensive option.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">For a healthy dog, weekly urinalysis can evaluate cast formation, proteinuria, and a drop in specific gravity.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Urinalysis is more sensitive than BUN or creatinine to amikacin-induced renal toxicosis.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-bold\"><strong>Rifamycins<\/strong>:<\/span><span class=\"garamond-9-5\">\u00a0Rifampin can be used as monotherapy for staphylococcal infections, but can be hepatotoxic; therefore, monitoring liver enzymes is important. Side effects can be minimized if the daily dosage is kept at 10 mg\/kg\/day or less.<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">In an otherwise healthy dog, blood analysis should occur before administration, then 10 to 14 days into therapy.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Owners should be warned to stop administration if dogs have any loss of appetite or vomiting.\u00a0<\/span><\/li>\n<li><span class=\"garamond-9-5\">Urine may look red or orange due to the drug\u2019s color, but is not a reason to stop therapy.<\/span><\/li>\n<\/ul>\n<blockquote>\n<p align=\"LEFT\">Many methicillin-resistent staphylococcal infections are also multi-drug resistant\u2014in these types of infections, the bacteria have acquired resistance factors to antibiotics other than beta-lactams, complicating treatment and limiting therapeutic options.<\/p>\n<\/blockquote>\n<h2 class=\"left-justified\"><span class=\"bluboldheader\">IN SUMMARY<\/span><\/h2>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Pyoderma management in the age of methicillin resistance is an ongoing challenge in veterinary medicine. My manifesto for pyoderma is to:<\/span><\/p>\n<ol>\n<li><span class=\"tabs-and-bullets\">Utilize frequent bathing<\/span><span class=\"garamond-9-5\">\u00a0with chlorhexidine shampoos and\/or other topicals instead of systemic antibiotics whenever possible.<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Be aggressive when systemic antibiotics<\/span><span class=\"garamond-9-5\">\u00a0are required, treating with the appropriate dose until the pyoderma is completely resolved. Always combine systemic antibiotics with topical therapy.<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Avoid empirical use of fluoroquinolones<\/span><span class=\"garamond-9-5\">\u00a0for staphylococcal pyodermas. Fluoroquinolones, particularly the early generations, are more effective against gram negative bacteria than gram positive bacteria.\u00a0<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Utilize topical therapy<\/span><span class=\"garamond-9-5\">\u00a0to prevent recurrence.<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Diagnose and treat<\/span><span class=\"garamond-9-5\">\u00a0the underlying cause.<\/span><\/li>\n<\/ol>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">A very useful resource for current information about MRS, particularly zoonotic potential, is the Worms and Germs blog, coordinated by Dr. Scott Weese and Dr. Maureen Anderson (<\/span><a href=\"http:\/\/wormsandgermsblog.com\/promo\/services\"><span class=\"garamond-bold\">wormsandgermsblog.com\/promo\/services<\/span><\/a><span class=\"garamond-9-5\">). At this site, you can download PDF files for your clients that explain these infections and how to handle them.<\/span><\/p>\n<p class=\"no-indent-\"><span class=\"helvetica-9-pt\">BOG = bacterial overgrowth syndrome; BUN = blood urea nitrogen; MRS = methicillin-resistant <em>Staphylococci<\/em>; MRSA = methicillin-resistant<em> S aureus<\/em>; MRSP = methicillin-resistant <em>S pseudintermedius<\/em>; MSSP = methicillin-susceptible <em>S pseudintermedius<\/em><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Pyoderma is a common skin disorder in small animal practice.<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":17712,"footnotes":""},"categories":[366],"tags":[13],"class_list":["post-1138","post","type-post","status-publish","format-standard","hentry","category-may-june-2014","tag-peer-reviewed","clinical_topics-dermatology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Treating Resistant Skin Infections in Dogs | Today&#039;s Veterinary Practice<\/title>\n<meta name=\"description\" content=\"Due to methicillin resistance, treating canine pyoderma is challenging. 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