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Pyoderma Pyoderma = bacterial skin infection Canine pyoderma: my clinical impression with Convenia® Hill PB and al. Vet . Rec. 2006 Survey of the prevalence, diagnosis and treatment of dermatological conditions in small animals in general practice. 3707 consultations - 21,4% skin disease Pyoderma = one of the most frequent diagnosis Systemic antibiotics prescribed in 25% of the cases Luc BECO, DMV, Dip. ECVD Avenue Reine Astrid, 104 4900 Spa - Belgique www.monvt.eu Diagnostic procedure History Differential Diagnosis Other tests or Treatments First differential Diagnosis Examen clinique Classification: 3 groups Problem list Special procedure or Therapeutic trial Revised differential diagnosis Surface pyoderma Superficial pyoderma Deep pyoderma Diagnosis not confirmed Final diagnosis Treatment Surface pyoderma Surface pyoderma Acute moist dermatitis = pyotraumatic dermatitis = hot spot Skin fold pyoderma (intertrigo) Mucocutaneous pyoderma Damage and bacterial proliferation of the outermost layer of the skin « Acute moist dermatitis » Pyotraumatic pyoderma 1 Surface pyoderma Surface pyoderma Facial fold pyoderma Mucocutaneous pyoderma Vulvar fold pyoderma Superficial pyoderma Superficial Pyoderma: Impetigo Impetigo Bacterial folliculitis Superficial spreading pyoderma The bacterial infection involves the epidermis and follicular epithelium Papules, pustules, epidermal collarettes, crusts and circular patches of alopecia Impetigo Superficial Pyoderma: folliculitis Superficial Pyoderma: folliculitis 2 Superficial Pyoderma: folliculitis Superficial Pyoderma Superficial Pyoderma Superficial Pyoderma: folliculitis Superficial Spreading Pyoderma Deep pyoderma © M. Heimann Pyotraumatic folliculitis Pyotraumatic folliculitis and furonculosis Muzzle folliculitis and furonculosis Localized deep pyoderma Generalized deep folliculitis and furonculosis German shepherd dog pyoderma The bacterial infection involves the tissue deeper than the hair follicle Papules, pustules, furoncles, nodules, crusts, ulcerations 3 Deep pyoderma Muzzle folliculitis and furonculosis (« Chin acne ») Localized deep pyoderma Pedal furonculosis Deep pyoderma Bacterial Bacterial Cellulitis Deep pyoderma Day 0 7 months later Localized deep pyoderma Pedal furonculosis Deep pyoderma German Shepherd Dog Pyoderma 4 GSD Pyoderma Deep Pyoderma: furonculosis © M. Heimann Methicillin Resistant Staphylococcus (MRS) Staphylococcus Intermedius Major agent Carriage sites and bacterial folliculitis Higher population at mucosal sites/normal dogs Anal and nasal carriage > Same strains in pustules and at carriage site (94,4%) MRS: mecA gene encodes a special Penicillin-Binding Protein (PBP2a) with low activity for βlactam AB Survival of the bacteria MRSI in dogs 17% of 336 isolates in USA Disk diffusion test (Oxacillin/Cefoxitin) / Vitec PCR assay for nuc genes and for mecA genes Molecular typing Other Staphylococci Staphylococcus aureus in dogs and cats From humans (prefer human keratinocytes !) Wounds, hospitalisation, immunosuppressive therapy MRSA in US Vet University +/- 30% Staphylococcus schleiferi subsp. coagulans Staphylococus pseudintermedius Dogs with otitis and dogs with recurrent pyoderma Many are MRSS Pathogenic potential? MRSP in Japan and Canada Coagulase negative staphylococci S. Epidermidis, S. Hominis, S. Hemolyticus, S. Xylosus Opportunistic pathogens ? Other bacteria Secondary invaders Proteus sp Pseudomonas sp. (Hillier et al. Veterinary Dermatology 17, 2006) E. Coli Beta-hemolytic streptococci In cats Bacterial diseases are most commonly secondary to bite wounds Pasteurella multocida and anaerobes Porphyromonas spp., Fusobacterium spp., Bacteroides spp., Peptostreptococcus spp., Clostridium spp 5 Multicentric efficacy trial Clinical skin of soft tissue infection Clinical lesions: papules (dog), pustules (dog) , nodules, furoncles, erythematous macules (dog), erythema, epidermal collarettes (dog), purulent discharge, erosions/ulcerations (dog), swelling (cat only) Severity index: absent, mild, moderate, severe Cytology Bacterial culture Owner consent form Inclusion / exclusion criteria Convenia® injection / 2 weeks Multicentric efficacy trial Control of clinical signs every 2 weeks Convenia® injection if lesions are still observed Control 2 weeks after the last injection Control for recurrence 4 weeks after the last injection Multicentric efficacy trial Bacterial folliculitis 13 dogs Superficial Pyoderma « mothmoth-eaten » folliculitis Bordeaux dogues (3), Giant Schnauzer (2) American Staffordshire Terrier (2), Dachshund, Great Dane, Golden retriever, Flanders bouvier Scottish terrier, Weimaraner Type of visit First opinion vet.: 5 Second / third vet. consulted : 3 Referral cases: 5 Bordeaux Dogue Bacterial folliculitis Bordeaux Dogue 3/13 dogs 2 referral cases 1 second opinion Usually more difficult to treat ? Poor immunity ? Associated demodicosis and/or malassezia dermatitis Compliance: cost – duration of treatment ? Multicentric efficacy trial Bacterial Bull Terrier: referral case Berger de Beauce: second vet Feline furonculosis 2 dogs: abscess 1 cat: DSH First opinion case 6 Deep pyoderma Convenia ®: Day 0 Deep pyoderma Convenia ®: Day 14 Deep pyoderma Deep pyoderma Convenia ®: Day 28 Convenia ®: Day 42 Deep pyoderma Deep pyoderma Convenia ®: Day 56 Convenia ®: Day 73 (21days post treatment) treatment) 7 Multicentric efficacy trial Bacterial folliculitis Bacterial folliculitis Staphylococcus intermedius (single): 2 Feline Abscess (1 case !) Actinomyces viscosus, Fusobacterium nucleatum, Prevotella oralis 1 2 3 4 injection: (day 0): 2 dogs injections (day 0-15): 7 dogs injections: (day 0-15-30): 3 dogs injections: (day 0-15-30-45): 1 dog (Bordeaux D.) Bacterial furonculosis Bacterial furonculosis Staphylococcus intermedius (single): 10 Staph. intermedius (S), Strepto. β hem. (S), Proteus mirabilis (I): D09 Staph intermedius, Staph aureus: D03 Staph intermedius, Pseudomonas stutzeri: D12 Convenia®: treatment 5 injections: (day 0-15-30-45-60): Bull Terrier with bacterial furonculosis 2 injections with good improvement. Withdrawal because of pulmonary tromboembolism secondary to surgery/anesthesia Feline Abscess (1 case !) 1 injection Oral: treatment Convenia®: 30 days post-injection Bacterial Bacterial folliculitis Oral treatment: q 8h / q 12h / q 24h Duration ≥ 3 weeks Bacterial furonculosis Oral treatment: q 8h / q 12h / q 24h Duration ≥ 6 weeks Feline Abscess Oral treatment: q 8h / q 12h / q 24h Duration ≥ 7 days Compliance Oral folliculitis 12 cured 1 minor recurrence: Great dane Referal case Some papules/pustules St. Intermedius Bacterial Feline furonculosis 2 cured without recurrence abscess (1 case !) No recurrence Antibiotics: how to choose ? antibiotics Owner Tablets / Capsules / Solution / Gel Compliance ??? Compliance Convenia® Patient SC injection: one / 14 days 15 cases : 100% compliance Antibiotic Antibiotic Bacteria Bacteria 8 Side effects Oral antibiotics Side effects Convenia® GI tract dysfunction GI tract dysfunction 1 dog with soft stools (Great Dane) Vomiting, diarrhea, anorexia…… No local reaction Easy to administer No other signs Chondrocytes (growing dogs - quinolones) Retinal toxicity in cats (enrofloxacin) Idiosyncrasic reactions, KCS, hypothyroidism, bone marrow aplasia, cutaneous drug reactions (sulfonamides) … Failure of the antibiotherapy Wrong diagnosis Inappropriate antibiotic Dosage, duration, frequency of administration Antibiotic resistance Poor compliance Deficient patient immunity Failure to recognize underlying cause Pharmacokinetic / drug interactions Cefovecin clinical studies M.R. Stegemann et al. Clinical efficacy and safety of cefovecin in the treat ment of canine pyoderma and wound infections. Journal of Small Animal Practive (2007) 48, 378-386. MATERIAL AND METHODS 354 dogs included in 3 different studies Randomized, blinded study (versus placebo in 1 study) Cefovecin SC / 14d up to four courses (Convenia) Oral amoxicillin/clavulanic acid bid (Synulox) Efficacy 28d after initiation of the final course of AB Efficacy assessed by scoring the clinical signs Topical antibacterial treatment not permitted Cefovecin clinical studies M.R. Stegemann et al. Clinical efficacy and safety of cefovecin in the treat ment of canine pyoderma and wound infections. Journal of Small Animal Practive (2007) 48, 378386. RESULTS Efficacy: Cefovecin 96,9%, amoxicillin/clav 92,5% Superficial pyoderma: 87% cured with 1 or 2 courses of treatment No dog with more than 3 courses of treatment Deep pyoderma Cefovecin 68% < 4 courses of treatment Amoxi/Clav 72% < 4 courses of treatment Conclusion Convenia® is easy to administer Owners love this way to treat (useful and very easy for reluctant cats) In my hands, until now, Convenia® is as efficient to treat canine pyoderma than the other « good » antibiotics However, a good diagnosis is always needed before using antibiotics 9 ESVD – ECVD 23rd Annual Congress Bled, Slovenia September 2009 Q u e s t i o n s ? 10