होम Australasian Journal of Dermatology Systematic literature review to identify methods for treating and preventing bacterial skin...

Systematic literature review to identify methods for treating and preventing bacterial skin infections in Indigenous children

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भाषा:
english
पत्रिका:
Australasian Journal of Dermatology
DOI:
10.1111/ajd.12680
Date:
July, 2017
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PDF, 112 KB
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आप पुस्तक समीक्षा लिख सकते हैं और अपना अनुभव साझा कर सकते हैं. पढ़ूी हुई पुस्तकों के बारे में आपकी राय जानने में अन्य पाठकों को दिलचस्पी होगी. भले ही आपको किताब पसंद हो या न हो, अगर आप इसके बारे में ईमानदारी से और विस्तार से बताएँगे, तो लोग अपने लिए नई रुचिकर पुस्तकें खोज पाएँगे.
Australasian Journal of Dermatology (2017) , –

doi: 10.1111/ajd.12680

ORIGINAL RESEARCH

Systematic literature review to identify methods for
treating and preventing bacterial skin infections in
Indigenous children
Smriti Nepal,1 Susan L Thomas,2

Richard C Franklin,1

Kylie A Taylor3 and Peter D Massey4,5

1

Discipline of Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences,
James Cook University, Townsville, Queensland, 2Hunter Medical Research Institute, University of Newcastle,
Newcastle, 3School of Health, University of New England, Armidale, 4Hunter New England Population Health,
Tamworth, New South Wales, and 5College of Medicine and Dentistry, James Cook University, Townsville,
Queensland, Australia

ABSTRACT
Background/Objectives: Bacterial skin infections
in Indigenous children in Australia frequently lead
them to access primary health care. This systematic
review aims to identify and analyse available studies
describing the treatment and prevention of bacterial
skin infections in Indigenous children.
Methods: Electronic databases including Scopus,
MEDLINE, CINAHL, ProQuest, Informit and Google
Scholar were searched. Studies in English published
between August 1994 and September 2016, with the
subject of bacterial skin infections involving Indigenous children and conducted in Australia, New Zealand, the USA or Canada were selected.
Results: Initially 1474 articles were identified. After
the application of inclusion and exclusion criteria,
10 articles remained. Strategies for the treatment
and prevention of bacterial skin infections included
the management of active infections and lesions,
improving environmental and personal hygiene, the
installation of swimming pools and screening and
treatment.
Conclusion: There is a need for more, rigorous,
large-scale studies to develop evidence for appropriate, culturally acceptable methods to prevent and
manage bacterial skin infections in Indigenous children in Australia. The problem is complex with

Corresp; ondence: Dr Susan L Thomas, Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia.
Email: susan.thomas3@hnehealth.nsw.gov.au
Smriti Nepal, MPH. Susan L Thomas, PhD. Richard C Franklin,
FPHAA. Kylie A Taylor, DipPH. Peter D Massey, DrPH.
Conflict of interest: none.
Submitted 25 July 2016; accepted 4 May 2017.
© 2017 The Australasian College of Dermatologists

multiple determinants. Until underlying socioeconomic conditions are addressed skin infections will
continue to be a burden to communities.
Key words: Aboriginal and Torres Strait Islander,
CA-MRSA, children, pyoderma, Staphylococcus
aureus, Streptococcus pyogenes.

INTRODUCTION
In Australia there is a disparity in health outcomes
between Aboriginal and Torres Strait Islander (hereafter
Indigenous) children and other Australian children.
Factors contributing to this include socioeconomic and
environmental determinants and access to culturally
appropriate primary health care.1–3 Bacterial skin infections are one example of poorer health outcomes and a
common reason for Indigenous children to access primary
health care services.4 Such infections are common in
Indigenous communities and pose a burden on families as
they are difficult to eradicate, often recur and impact
health, school attendance and quality of life.4,5
The most common organisms causing bacterial skin
infections are group A beta haemolytic streptococci and
Staphylococcus aureus.6–8 While group A streptococcus
(GAS) has been reported as the predominant bacteria
causing skin infections in Indigenous children in Australia,5,9 studies show evidence that the rising rates of
S. aureus are the causative agent for skin and soft tissue
Abbreviations:
CA
GAS
MRSA

community-associated
group A streptococcus
methicillin-resistant S. aureus

2

S Nepal et al.

infections7,10,11 and that co-infection with both GAS and
S. aureus is common.9 The infections are communicable,
with transmission occurring mainly through direct skin-toskin contact, fomite contact or by close contact with nasal
carriers.12 When they are diagnosed early and appropriate
treatment is instituted these skin infections are generally
curable and heal without scarring.13 Delayed or inadequate treatment can lead to nephritis, carditis, arthritis,
septicaemia and antibiotic resistance.13
Colonisation and invasion of the skin by bacteria occurs
when the normal flora of the skin is transformed by
changes in ambient temperature and humidity and by low
levels of personal and environmental hygiene.13 Other factors associated with bacterial skin infections include living
in crowded dwellings, skin injuries, scabies co-infection
and previous antimicrobial drug treatment.6,13 Signs and
symptoms include erythema, warmth, pain or tenderness,
swelling, crusting and drainage from skin lesions.12 Skin
infections with Streptococcus pyogenes are linked to acute
rheumatic fever or rheumatic heart disease and acute
post-streptococcal glomerulonephritis, often leading to significant morbidity. Between 1989 and 1993 the average
annual rate of rheumatic heart disease was 0.014% in the
general Australian population, compared with 3% in
remote Indigenous communities.14 While available evidence supports the hypothesis that GAS plays a role in the
pathogenesis of rheumatic heart disease, this link is yet to
be fully understood.15 Experiencing acute post-streptococcal glomerulonephritis during childhood is associated with
a sixfold increase in the risk of acquiring renal disease in
adulthood.10 In Indigenous peoples these complications
are a result of pyoderma rather than the more common
route via throat infections. Acquiring pyoderma at an early
age, together with recurrent infections, increases the risk
of developing more serious cardiac and renal disease,
making this an important public health problem.16
In 2005 the World Health Organization estimated that in
less developed countries more than 111 million children
under the age of 15 had pyoderma at any one time.14
Infection with pyoderma often occurs in the first year of
life with presentations to health services peaking at
2 months of age.11 Developed countries, including Australia, USA, New Zealand and Canada report a higher
prevalence of pyoderma among Indigenous populations
(particularly those living in the most disadvantaged settings), compared with the non-Indigenous population,
where the prevalence of skin infection is generally low.11
Data on the incidence of pyoderma in Australia is not routinely collected. In remote Indigenous communities of the
Northern Territory, skin infections and infestations are one
of the most common reasons for children to access primary health care.4 In 2000 the prevalence rates of pyoderma in Northern Territory children in remote
communities were reported to be between 10 and 70%.5
This may reflect differences in living conditions, tropical
versus arid environments and limitations in data quality
and availability. In August 2004 in East Arnhem Land (in
the Northern Territory’s tropical north) the average
monthly prevalence of pyoderma in children was 36%.17 In
© 2017 The Australasian College of Dermatologists

non-tropical Perth, Western Australia, 16% of general
practice consultations for Indigenous children were for
skin disorders.18
Common modes of S. aureus transmission are through
close contact with an infected person and contact with
open lesions.23 It is recommended that children with pyoderma be isolated until lesions have dried up or antimicrobial treatment has commenced.23 This may be difficult in
settings where the disease is common. In cases of recurrent infections, isolation will cause frequent absence from
school, adding to poorer educational outcomes for the
patients, which are underlying determinants of higher
rates of pyoderma.5 Adult carers may have to take time off
work in order to care for sick children,23 which can exacerbate financial hardship.11,24
This systematic review aims to identify and critically analyse the available literature describing the treatment and prevention of bacterial skin infections in Indigenous children
aged 0–19 years in both community and hospital settings.

MATERIAL AND METHODS
The design and reporting of the review was based on the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses statement and checklist.25 Literature in
electronic databases from August 1994 to September 2016
was included. The electronic databases included MEDLINE, CINAHL, Scopus, ProQuest Health and Medical
Complete, Informit and Google Scholar. In Informit the
search was conducted on multiple databases including the
Australasian Medical Index, Health and Society, Aboriginal
and Torres Strait Islander Health and RURAL. Keywords
included ‘skin infections,’ ‘bacterial,’ ‘children,’ ‘MRSA,’
‘CA-MRSA,’ ‘Staphylococcus aureus,’ ‘Streptococcus pyogenes,’ ‘pyoderma,’ ‘Indigenous,’ ‘prevention,’ ‘hygiene’ and
‘decolonization’ (Table S1).
Inclusion criteria were studies involving only Indigenous
children 0–19 years that had been conducted in Australia,
New Zealand, the USA or Canada; studies describing the
treatment or prevention of bacterial skin infections and the
related outcome. These countries were chosen as they
share a similar history of invasion and the subsequent displacement of Indigenous peoples. Exclusion criteria were
studies involving only adults aged 20 years and over, studies undertaken on animals, studies describing treatment
only for fungal, viral and parasitic skin infections and
those which described skin infections due to systemic illnesses and involving immunocompromised patients. A
total of 1474 studies were identified from the initial search
of the databases. Ten articles fulfilled the inclusion and
exclusion criteria (Fig. S1), all Australian. They included
one randomised control trial, a post hoc analysis, a pilot
study, a prospective cohort study, two ecological studies,
an intervention study and three observational studies.

RESULTS
The results are described under the themes of the management of active infections and lesions, environmental

Skin infections in Indigenous children
and personal hygiene measures, the installation of swimming pools and screening and treatment. Table 1 details
the trial design, results and limitations of each study.

Management of active infections and lesions
Two articles focused on the management of active infection
and lesions.26,27 An open label, randomised, controlled, noninferiority trial (Bowen 2014) compared short-course oral
co-trimoxazole with i.m. benzathine benzylpenicillin as systemic agents for impetigo.26 Short-course oral co-trimoxazole was found to be as effective as one i.m. injection of
benzathine benzylpenicillin (ideally used in S. pyogenes-prevalent areas) (Table 1). The trial assigned 508 Indigenous
children in the Northern Territory to receive either one benzathine benzylpenicillin injection, short-course oral co-trimoxazole twice daily for 3 days or once daily for 5 days. On
day 7 the outcome of treatment success (healed or improved)
showed equal efficacy between the pooled short-course oral
co-trimoxazole groups and the i.m. benzathine benzylpenicillin. All groups resulted in an 85% success rate. The recovery rate for MRSA (from swabs taken before treatment and at
day 7) fell from 19 to 11% in the benzylpenicillin group and
from 13 to 2% in the pooled short-course oral co-trimoxazole. Short-course oral co-trimoxazole is practical, available
and carries fewer risks. The authors concluded that it is low
cost and generally pain free, making it the preferred option
(unless oral medications are contra-indicated).
A post-hoc analysis (Tasani (2016) of the study described
above examined the importance of scabies co-infection in
treatment considerations for impetigo.27 The study found a
high burden of scabies in children in the trial (84/508,
17%) and that children with scabies co-infection had more
severe impetigo than those without scabies infection and
were less likely to respond to antibiotics. Treatment success for impetigo with and without scabies co-infection
was 76 and 87%, respectively; an absolute difference of
11% (95% CI 1–21%). Treatment success with co-infection
was more likely with short-course oral co-trimoxazole
than with i.m. benzathine benzylpenicillin.

Environmental and personal hygiene measures
Three articles focused on environmental and personal
hygiene measures.5,28,29 In a pilot study (Bailie 2005), the
health records of 138 children in three remote communities in the Northern Territory found rates of skin infections
to be higher in houses that lacked functioning facilities for
removing faeces or that had concrete floors (the latter was
exacerbated by crowding). Younger children in older
houses were more at risk. Socio-demographic variables
appear to be directly associated with high rates of skin
infections.
The cross-sectional nature of the data limited its capacity
to infer causation. Other limitations included the small
sample size and poor quality of health records in one community.5
A second prospective cohort study (Bailie 2012) of 418
children aged 7–10 years, living in 185 houses in 10

3

Indigenous communities used inspection of houses and
interviews with carers following a housing improvement
programme in 2004–2005. There was no consistent reduction in parents reporting common childhood infections
including skin infections related to building and infrastructure improvements but these were strongly associated with
improvements in the hygienic conditions of the house.
Building programmes alone cannot reduce infections and
need to be supported by a range of appropriate community
initiatives for them to appreciate the potential health gains
for children. This highlights the need for further, contextual research on socioeconomic and socio-demographic
factors. The limitations of the study included recall bias,
the potential for chance associations in analyses and loss
to follow up.28
An ecological study in remote Aboriginal communities
(McDonald 2010) used mixed methods to identify the
social, economic, cultural and environmental factors that
contributed to inadequate hygiene and to determine
approaches that would improve hygiene and reduce infection in children.29 A housing survey (86 houses), focus
groups (nine participants), case studies (five) and individual interviews (nine) were conducted. The study found
that crowding, non-functioning health hardware and poor
hygiene underlay the high burden of infection in children.
Improving the environmental conditions that contribute to
skin infections was seen as a complex problem requiring a
strategic approach that recognised and incorporated cultural practices and beliefs, was multifaceted, built capacity
and empowered individuals and communities. The limitations of the study were that only one community was
involved. Limited resources meant researchers could not
investigate other contributing factors.29

Installation of swimming pools
Four articles examined the potential benefits of swimming
pools on skin health.30–33 Two articles explored the benefits of new swimming pools30,31 opened in September 2000
in two remote Indigenous communities (A and B) in Western Australia, located more than 1200 km north of Perth.
An interventional study in 2003 measured the prevalence
and severity of pyoderma in 162 children at 6-monthly
intervals for 18 months after the pools were opened.30 The
rate of pyoderma declined from 62 to 18% in community A
and from 70 to 20% in community B. Over the same period
the rate of severe pyoderma fell from 30 to 15% in community A and from 48 to 0% in community B. The chlorinated or salt water was found to be useful not just to
cleanse the skin but also by providing a nasal and ear
washout. The study limitations included loss to follow up
of children due to population mobility and the lack of a
control community.30 In an observational study in Jigalong
(131 children) and Mugarinya (128 children), Western
Australia, the local clinic records were examined from
1998 to 2005 to determine the effects of the pools on
antibiotic use and clinical attendance for infections.31 The
study found a 68% decline in skin infections in Jigalong
and a rate of decline between 53 and 77% annually in
© 2017 The Australasian College of Dermatologists

S Nepal et al.

4

Table 1 Summary of 10 Australian studies identifying methods for the treatment and prevention of skin infections in Indigenous children,
1994–2016
Author, year,
reference number

Description

Management of active infections and lesions
Bowen et al.
Open-label, randomised, controlled, non-inferiority trial
(2014)26
Evidence level: II
Benzathine benzylpenicillin i.m. vs twice-daily co-trimoxazole for 3 days vs once-daily co-trimoxazole for 5 days
Participants: 508 Aboriginal children aged 3 months to 13 years
Primary outcome measure: treatment success at day 7 and at day 2, detection of S. aureus and S. pyogenes on days 0, 2,
and 7 and comparison of individual co-trimoxazole groups with IM benzathine benzylpenicillin
Result: primary outcome: non-inferiority of co-trimoxazole to benzathine benzylpenicillin in a 10% margin (absolute
difference 1%, 95% CI: 6.2–7.3). S. pyogenes reduced from 85% at day 0 to <7% at day 7 while S. aureus fell from 83%
at day 0 to 20% at day 7 with co-trimoxazole, and from 81 to 52% with benzathine benzylpenicillin (P < 0.0001 for a
comparison of recovery rates at day 7)
Limitations: absence of placebo or control group. The open-label design meant the researchers were aware of which
treatment was given to each patient, which may have influenced their assessments
Tasani et al.
Post hoc analysis of the Bowen et al. skin sore trial
(2016)27
Of the 508 children treated for impetigo 84 (17%) had scabies
Key findings: high burden of scabies in children in the trial. Children with scabies co-infection had more severe
impetigo and were less likely to respond to treatment with antibiotics
Treatment success for impetigo with and without scabies co-infection independent of treatment group was 76 and 87%,
respectively; absolute difference 11% (95% CI 1–21%)
Treatment success with scabies co-infection may be more likely to be achieved with oral short course co-trimoxazole
than i.m. benzathine benzylpenicillin
Limitations: clinical diagnosis for scabies rather than scrapings or microscopy; scabies treatment not observed;
randomisation was not stratified by the presence of scabies
Environmental and personal hygiene measures
Bailie et al.
Pilot study using survey, interviews and health record audit
(2005)5
Evidence level: IV
Objective: test approaches of data collection, analysis and feedback for a follow-up study of the impact of housing
conditions on child health
Three remote communities in the Northern Territory were invited to participate
Methods: survey of dwelling conditions, interviews with the main householder and carer of each child <7 years of age
and an audit of health centre records
Results: data were available for 161 children. Almost 40% of children had not presented for skin infections at a health
centre, about 34% had two or more presentations and 10% had five or more. Factors associated with high levels of
skin infections included lack of facilities for removing human faeces, concrete floors and crowding, younger children
living in older houses and a number of socio-economic and demographic variables including age of carer, family
income and high child mobility
Limitations: cross sectional nature of data limits ability to infer causation, small sample size, inadequacies of heath data
Bailie et al.
Prospective cohort study
(2012)8
Evidence level: lll
Objective: to determine whether improvement in poor housing infrastructure in Australian Indigenous communities
results in a reduction in common childhood illness and to identify important mediating factors in this relationship
Method: 418 children aged <7 years in 10 Indigenous communities that had benefited from government-funded housing
programmes from 2004–2005 were selected
Data describing the state of housing, reports of common illnesses and on socioeconomic conditions were collected
through inspections of households and interviews with carers
Result: after adjusting for confounders there was no consistent reduction in the reporting of common childhood illnesses,
including skin infections, associated with improvements in housing infrastructure
Limitations: difficulty defining and measuring indicators for a range of complex constructs, potential recall bias,
potential of chance associations in analyses, loss to follow up
McDonald et al. Ecological study
29
(2010)
Evidence level: IV
Aim: to identify social, economic, cultural and environmental factors that contribute to poor hygiene in remote
Aboriginal communities in the Northern Territory and identify approaches to reduce the burden of infection among
children
Methods: narrative and systematic literature review, quantitative and qualitative community-based studies
Result: complex historical and contemporary interrelated factors are responsible for poor living conditions and the
continued high rates of childhood infections in Aboriginal communities. A strategic, intersectoral approach needed to
address the underlying issues
Limitations: only one community involved. Limited time and resources
Installation of swimming pools
Lehmann et al.
Interventional study
(2003)30
Evidence level: III-2

© 2017 The Australasian College of Dermatologists

Skin infections in Indigenous children
Table 1

5

Continued

Author, year,
reference number

Description

Installation of swimming pools in two remote Aboriginal communities in Western Australia
Participants: 162 children aged <17 years
Outcome measures: prevalence of and severity of pyoderma
Results: community A: initial pyoderma prevalence: 62%; 30% severe pyoderma. The prevalence of any skin infection at
four consecutive surveys was 64, 51, 43 and 18%, respectively
Community B: initially 70% pyoderma and 48% was severe. At four consecutive surveys the rates were 78, 43, 69 and
20%, respectively. The prevalence of severe pyoderma fell to 31% 1 year later
Limitations: poor follow up of children and lack of a control community
Silva et al.
Observational study
(2008)31
Evidence level: III-2
Effect of installation of swimming pools in 2000 on antibiotic use and clinical attendance for infections in two remote
Aboriginal communities in Western Australia
Participants: children aged <17 years of age; 131 children in Jigalong and 128 in Mugarinya
Outcome measures: clinical attendance rates for skin, middle-ear and respiratory tract infections and trauma;
prescription rates for antibiotics
Decline in skin infections in Jigalong: clinic-based selection method showed a 68% decline and Mugarinya: between 53
and 77% decline annually until 2003–2004
Limitations: high population mobility can affect the interpretation of results, attendance at clinics may have been
reduced for other reasons, selection bias, as healthy children may not have been attending the clinic, leading to an
overestimate of morbidity rates
Australian
Observational study
Government
Evidence level: III-2
Department
Participants: 262 Aboriginal children aged 0–19 years in three communities in South Australia’s Anangu Pitjantjatjara
of Health
Yankunytjatjara Lands
(2009)32
Aim: to assess the skin health and social benefits of the swimming pools in three communities
Outcome measures: presence and severity of pyoderma at four 6-monthly visits with 0 meaning no pyoderma, 1–4
lesions were classed as non-severe and 5 or more were severe
Result: In two communities where pre-swimming pool data was available, 1 year after opening a swimming pool, the
proportion of children with no sores increased from 32 to 78% (z = 3.362, P < 0.001). In the same period, there was a
reduction in the proportion of those presenting with severe pyoderma, from 25 to 6% (z = 3.103, P = 0.001)
Limitations: small sample sizes, high population mobility, pools were not always open during the evaluation period and
a high burden of other infections and illnesses that may have limited the positive impact of the swimming pools on
skin health
Carapetis et al.
Observational study
(1995)33
Evidence level:111–2
Participants: schoolchildren in the tropical Northern Territory
Aim: to determine whether regular swimming in a chlorinated pool may help reduce the prevalence of pyoderma
Outcome measure: mild pyoderma if less than 5 lesions and moderate if 5–20 lesions
Results: in September 1994, 81 children were surveyed and 39 (48%) had pyoderma with 90% being mild and 10%
moderate. In December, after the opening of the pool in October that year, 54 children were surveyed and 22 (41%)
had pyoderma, all of which were considered mild (v2 = 0.72, P = 0.40). Children who swam more than once a week
had fewer skin sores than those who swam once a week or less (30 vs 57%). This was more pronounced in children
aged less than 9 years where nine of 16 children (56%) who swam once or less had pyoderma compared with four out
of 18 (22%) who swam more than once a week
Limitations included a small sample size, populations surveyed before and after were not identical groups
Screening and treatment
Andrews et al.
Ecological study
(2009)11
Evidence level: IV
Active surveillance for skin infections (scabies and pyoderma) was conducted in 5 East Arnhem communities in the
Northern Territory over a 3-year period from 2004
Two pictorial flipcharts developed; one to explain the ‘healthy skin story’ in lay terms to study participants; the other to
assist in diagnosis, focusing primarily on recognition and treatment of pyoderma, scabies and tinea
Participants: 2329 children <15 years of age; screened at either the local health centre, home, community or at school
using a standard data collection form
Primary outcome measure: for pyoderma, reduction of prevalence from 50% (expected pre-programme) to <25%.
Secondary objective: to reduce the severity of pyoderma in the target group; moderate/severe from 40% (preprogramme) to <15%
Result: the pyoderma prevalence at baseline was approximately 47%; dropping to a median of 32% (IQR 29–41%) during
the follow up. The absolute reduction was 14.7% (IQR 5–17%). Over the previous 18 months: an absolute reduction in
pyoderma prevalence of 18 cases per 100 children. Treatment uptake increased over the same period
Limitation: population movement between communities over time; potential bias in care-seeking/screening-seeking
behaviour and lack of control for potential confounding factors

IQR, interquartile range; NT, Northern Territory.

© 2017 The Australasian College of Dermatologists

6

S Nepal et al.

Mugarinya. In Jigalong the antibiotic prescription rate
decreased by 45% between 1999 and 2000 and 2004–2005,
while the decline was minimal in Mugarinya.31
In South Australia the Department of Health and Ageing
undertook a 2-year evaluation of the health benefits of
swimming pools in four communities on the Anangu Pitjantjatjara Yankunytjatjara Lands.32 Between September
2007 and April 2009 four 6-monthly visits were undertaken
by researchers, at which time a medical doctor assessed
children for pyoderma and classified them as non-severe if
they had 1–4 lesions and severe if they had five or more.
In total, 262 children aged 0–19 years were assessed. Due
to high population mobility only 10 (4%) children were
seen all four times and 145 (55%) were seen at least once.
In the two communities where pre-swimming pool data
was available, 1 year after opening the swimming pool the
proportion of children with no sores increased from 32 to
78% (z = 3.362, P < 0.001). In the same period there was a
reduction in the proportion of those presenting with severe
pyoderma from 25 to 6% (z = 3.103, P = 0.001). 32
A comparison study (Carapetis 1995) in the Northern Territory used two surveys of pyoderma rates in children before
and after the opening of a community swimming pool.33 The
skin lesions were graded by Aboriginal health workers and
the district medical officer as mild, if less than 5 and moderate if 5–20. In September 1994, 81 children were surveyed
and 39 (48%) had pyoderma, with 90% being mild and 10%
moderate. In December, after the opening of the pool in
October that year, 54 children were surveyed and 22 (41%)
had pyoderma, all of which were considered mild (v2 = 0.72,
P = 0.40). Children who swam more than once a week had
fewer skin sores than those who swam once a week or less
(30 vs 57%). This was more pronounced in children aged less
than 9 years. Nine of 16 children (56%) who swam once or
less had pyoderma compared with four of 18 (22%) who
swam more than once a week.33
With high rates of infections and chronic disease and the
broad health and social gains associated with swimming
pools, their use has been recommended.34 A number of
limitations in these studies have been identified (Table 1)
and caution is recommended in interpreting outcomes and
in generalising results. It was unclear how often children
should use the pool and for how long in order to achieve
positive results. The installation, and maintenance of
swimming pools and supervising children when they are
swimming may not always be feasible, as resources are
limited.23 However, if swimming pools reduce pyoderma
and therefore reduce the rate of GAS-related chronic illness and associated costs of renal dialysis and heart valve
replacement, they may be cost-effective.31

Screening and treatment
One article focused on screening and treatment.17 This 3year ecological study in five remote communities in the
Northern Territory used active surveillance for skin infections (pyoderma and scabies) among children aged less
than 15 years. There were 6038 skin assessments conducted on 2329 children in health centres, homes, schools
© 2017 The Australasian College of Dermatologists

and other community settings. The diagnosis of pyoderma
was based on the appearance, site and number of lesions.
All children diagnosed with pyoderma were referred to a
clinic for treatment according to clinical guidelines. The
prevalence of pyoderma fell from 47% at commencement
to a median of 32% (OR 29–41%) during the follow-up period. An increase in treatment uptake was also identified
over the same period. The authors noted that pyoderma has
become normalised in Indigenous communities and that
the main driver for decreasing its prevalence was an
increased uptake of treatment through basic primary health
care, with surveillance playing an important role. Study
limitations included population mobility, lack of control of
confounders and potential bias in care-seeking behaviour.17

DISCUSSION
This systematic review aimed to identify and critically analyse the available literature describing the treatment and prevention of bacterial skin infections in Indigenous children
aged 0–19 years in both community and hospital settings.
There were few studies that both met our selection criteria
and provided a high level of evidence. While a number of
studies have explored the epidemiology and clinical features
of staphylococcal skin infections, there are few evidencebased studies on effective prevention and treatment, particularly for recurrent skin infections.35 Some studies may be
been missed where Indigenous children were included in
the sample without being identified as such.
Some studies were limited by a lack of quality data, loss to
follow up and reliance on self-reporting. There was an
absence of exact recommendations on the use of swimming
pools. Population mobility is common among Indigenous
peoples in Australia and this may have affected the interpretation of the results in all studies. It was not clear whether
other interventions were being undertaken at the same
time. There were no studies that explored prevention and
treatment strategies from an Indigenous perspective, or
studies that provided practical solutions to the underlying
determinants influencing disease occurrence, such as
crowding and poor housing infrastructure. It was not possible to compare the articles described due to variations in
context (differing geography, climate and cultures).
The results from the articles reviewed point to possible
treatment and prevention strategies for bacterial skin infections in Indigenous children. However, the problem is complex and has multiple determinants. Until the underlying
socioeconomic and environmental conditions that contribute to the persistence of skin infections are addressed
they will continue to be a significant problem affecting
Indigenous children.36 This review revealed a need for rigorous and large-scale studies to develop the evidence required
for methods to prevent and manage skin infections in Indigenous children. More research needs to be done in other
states in Australia where the context differs from the remote
communities in Western Australia, the Northern Territory
and South Australia and in other countries such as New Zealand, the USA and Canada, where the colonial experiences of
Indigenous peoples have been similar.

Skin infections in Indigenous children

ACKNOWLEDGEMENTS
All funds for this systematic review were internal and
formed part of employees’ salaries. The work is not part of
a grant.

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Supporting Information
Additional Supporting Information may be found online in
Supporting Information:
Table S1. Keywords used in searches of databases.
Figure S1. PRISMA flowchart.

© 2017 The Australasian College of Dermatologists