Possible Role of Staphylococcus aureus in Severe Oral Mucositis among Elderly Dehydrated Patients

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Abstract
Although sometimes isolated from the mouth, Staphvlococcus aureus is not part of the normal oral microbiota. This paper describes five elderly patients (aged 68-87 yrs), all of whom were dehydrated and receiving intravenous fluids, who presented with severe oral mucositis. S. aureus was isolated from the mouths of all five patients. Phage typing showed these strains to be heterogeneous. Three of the strains produced toxic shock syndrome toxin (TSST-1); one produced staphylococcal enterotoxin C; and one isolate produced enterotoxin A. Two of the three patients infected with TSST-1-producing strains were negative for antibody to TSST-1. Treatment of two of the patients with fiucloxacillin resulted in a dramatic improvement in their oral mucositis. Those for whom flucloxacillin was withheld deteriorated. Culture of oral swabs from 27 elderly control patients (aged 63-96 yrs) without mucositis revealed S. aureus in 11 (40 per cent). Three of these control isolates produced TSST-1 and one isolate produced staphylococcal enterotoxin D. Thus, in the elderly, the mouth is a potential source of S. aureus, some strains of which produce TSST-1 and staphylococcal enterotoxins. These oral isolates may play a local role in causing oral mucosal disease, but should also be considered a potential source of the organism in patients with systemic signs and symptoms of Toxic Shock Syndrome.