Importance of exfoliatin toxin A production by Staphylococcus aureus strains isolated from clustered epidemics of neonatal pustulosis.

Clustered epidemics of pustulosis due to Staphylococcus aureus occurred in two geographically distant newborn nurseries. In nurseries A and B an attack rate of pustulosis of 0.8 and 2.0 cases per 100 live births occurred, respectively. Experimental phage type 1046/1116 belonging to phage group II dominated clustered epidemics in nursery A, while group II phage type 3A/3C/55/71 and 3A/3C/55 occurred in nursery B. Other group II strains also occasionally produced clustered epidemics. These epidemic strains were found to be making heat-stable dermal exfoliatin toxin A (ETA) which had a pI of 6.8 and a molecular weight of 32,000 and 33,000. ETA-bearing strains did not make bacteriocin. Children infected with ETA-producing strains developed extensive bullous pustulosis. Surveillance cultures of personnel revealed an ETA-bearing strain in only one person. This strain was not the same phage type as the epidemic cluster. In contrast, ETA-bearing epidemic strains were found in the inanimate environment of both nurseries. ETA protein acts as an important virulence factor in the production of neonatal pustulosis infection and appears to be linked with the ability of S. aureus organisms to stick to the inanimate environment.