What antibiotics are recommended for patients with Epidermolysis bullosa (EB)?

Antibiotic Management for Epidermolysis Bullosa Infections

For patients with Epidermolysis bullosa (EB), antibiotic selection should be based on wound culture results and clinical symptoms, with empiric therapy targeting Staphylococcus aureus and Pseudomonas aeruginosa as the most common pathogens while awaiting culture results. 1

Infection Assessment and Antibiotic Selection

When to Collect Cultures

• Obtain wound cultures when:
  • Clinical signs of infection are present (increased pain, erythema, exudate, odor)
  • Before starting systemic antibiotics
  • For monitoring of colonization in high-risk patients

Empiric Antibiotic Selection

For symptomatic wounds with no systemic symptoms:

• First-line: Oral antibiotics based on local resistance patterns 2
  • Tetracyclines (doxycycline 200 mg/day, minocycline 100 mg/day) for non-superinfected wounds
  • Oral quinolones for suspected Pseudomonas infection

For systemic infection/sepsis:

• Intravenous antibiotics covering both Staphylococcus aureus and Pseudomonas aeruginosa 2, 3
  • Consider local resistance patterns (high rates of MRSA and resistant Pseudomonas reported)
  • Adjust based on culture results when available

Special Considerations for Different EB Types

Neonatal EB

• Critical recommendation: Select antibiotics based on swab results and wound symptoms to reduce resistance risk 2
• Limit topical antibiotics and use in rotation to avoid development of microbial resistance
• Monitor closely for signs of sepsis, especially in severe subtypes (EBS generalized severe and junctional EB) 2

Recessive Dystrophic EB

• Higher risk for bloodstream infections, particularly with Pseudomonas aeruginosa and Staphylococcus aureus 3
• Consider broader coverage for empiric therapy due to high rates of antimicrobial resistance:
  • 42% of Pseudomonas isolates resistant to ceftazidime
  • 33% resistant to meropenem and quinolones
  • 36% of S. aureus isolates methicillin-resistant 3

Antimicrobial Management Strategies

Topical Antimicrobials

• Use antimicrobial soaks for non-symptomatic positive wound cultures 2
• Rotate antimicrobials if using long-term to prevent resistance
• Medical-grade honey can be used safely, even in neonates 2
• Caution: Diluted bleach or vinegar is not recommended for neonates 2
• Silver is not recommended as first-line treatment of infections in neonates 2

Systemic Antibiotics

• Reserve for:
  • Symptomatic wounds with spreading infection
  • Presence of systemic symptoms
  • Failed topical antimicrobial therapy

Viral Infections

• Consider viral cultures when faced with unclear source of fever, particularly for oral lesions
• Herpetic infections (HSV-1) can complicate EB and may present as gingivostomatitis 4

Pitfalls and Caveats

1. Antimicrobial resistance: High rates of resistance have been documented in EB patients, particularly to mupirocin, fluoroquinolones, and trimethoprim/sulfamethoxazole 1

2. Overtreatment risk: Antibiotics are not always required for asymptomatic wounds with positive bacterial swabs; consider antimicrobial soaks first 2

3. Diagnostic challenges: Distinguish between colonization and true infection to avoid unnecessary antibiotic use

4. Route of administration: Consider trauma risk from intravenous cannulation when deciding between enteral and parenteral antibiotics 2

5. Monitoring: Regular surveillance of antimicrobial resistance patterns is essential for guiding empiric therapy in this population 1

By following these evidence-based recommendations and maintaining vigilance for signs of infection, clinicians can effectively manage infections in patients with EB while practicing good antimicrobial stewardship.