Bacterial & Fungal skin, Soft Bacterial & Fungal skin, Soft Tissue & Muscle infectionsTissue & Muscle infections

For Second Year Medical For Second Year Medical StudentsStudents

Prof. Dr Asem ShehabiProf. Dr Asem Shehabi

Infections of Skin & Soft TissuesInfections of Skin & Soft Tissues

Infections depends upon the Layers of Infections depends upon the Layers of Skin & Soft Skin & Soft TissuesTissues involved ( epidermis, dermis, subcutis, involved ( epidermis, dermis, subcutis, muscle).. Infections may involve several layers.muscle).. Infections may involve several layers.

Skin InfectionsSkin Infections are associated with: are associated with: swelling ,tenderness, warm skin, blisters, ulceration, swelling ,tenderness, warm skin, blisters, ulceration, fever headache.. Rare Systemic disease.fever headache.. Rare Systemic disease.

Few Normal Few Normal Bacteria & YeastBacteria & Yeast live in hair follicles.. live in hair follicles.. SkinSkin .. .. maymay cause inflammation of Hair cause inflammation of Hair follicles ..folliculitis, Abscess formation ( Boils).. follicles ..folliculitis, Abscess formation ( Boils)..

Skin InfectionsSkin Infections

Type of Skin InfectionType of Skin Infection

Skin infectionSkin infection increased .. production Androgenic increased .. production Androgenic Hormones.. Puberty… Increase activities Sebaceous Hormones.. Puberty… Increase activities Sebaceous ducts..ducts..IncreaseIncrease Sebum Sebum (Fatty Acid+ Peptides)… (Fatty Acid+ Peptides)… Increase keratin & presence of desquamation … Increase keratin & presence of desquamation …

AnaerobicAnaerobic Propionibacteria acnes Propionibacteria acnes ( gram+ve small ( gram+ve small bacilli) & Staph spp. excrete Enzymes.. Splittingbacilli) & Staph spp. excrete Enzymes.. Splitting Sebum ..cause inflammation ..develop Sebum ..cause inflammation ..develop Acne vulgarisAcne vulgaris

Certain Systemic InfectionCertain Systemic Infection may cause skin may cause skin infectioninfection .. ..N. meningitidis (Haemorrhagic Lesions) N. meningitidis (Haemorrhagic Lesions) Salmonella typhi ( skin Rash, Rose spots), Treponem Salmonella typhi ( skin Rash, Rose spots), Treponem pallidumpallidum ..Syphilis.. ..Syphilis.. Pseudomonas aeruginosa.. RashPseudomonas aeruginosa.. Rash

AcneAcne

Common Normal Skin Flora & Common Normal Skin Flora & PathogensPathogens

Staphylococci, hemolytic Streptococci (Staphylococci, hemolytic Streptococci (Group AGroup A) ) Micrococci, Propionibacteria , Acinetobacter , Micrococci, Propionibacteria , Acinetobacter , PityrosporumPityrosporum (Yeasts) (Yeasts)

S. aureusS. aureus (coagulase+ve) is the most common & important (coagulase+ve) is the most common & important cause of human Skin diseases.. Various Enterotoxins & cause of human Skin diseases.. Various Enterotoxins & Enzymes..Coagulase, DNAse, Hemolysins , Hayluronidase .Enzymes..Coagulase, DNAse, Hemolysins , Hayluronidase .

About 15-40 per cent of healthy humans are healthy carriers of About 15-40 per cent of healthy humans are healthy carriers of S. aureus S. aureus inin their nose their nose or skin.. Infants carry or skin.. Infants carry S. aureus in S. aureus in fecesfeces

Common Clinical skin features Common Clinical skin features S.aureusS.aureus

Folliculitis / FurunclesFolliculitis / Furuncles .. Hair follicular-based papules and pustules.. Erythematous lesions.. affect All ages.

-- Impetigo:Impetigo: Epidermis, Crusted lesions.. SkinSkin sores.. face and extremities.. Common Young childrenYoung children

--Toxic Schlock SyndromeToxic Schlock Syndrome:: Systemic InfectionSystemic Infection....high high fever,fever, Rash & Skin Desquamation due to Release Rash & Skin Desquamation due to Release Toxic Shock Syndrome Toxin-1 (TSST-1 ).. Super- Toxic Shock Syndrome Toxin-1 (TSST-1 ).. Super- antigens toxin.. Activate T-lymphocytes.. Release antigens toxin.. Activate T-lymphocytes.. Release Cytokines.. General massive inflammatory response, Cytokines.. General massive inflammatory response, hypotension, hypotension, Shock, Comma.. Vomiting, diarrhea Vomiting, diarrhea multiple organ failure.. Hepatic inflammation, kidney multiple organ failure.. Hepatic inflammation, kidney failure, failure, Death.. Common Common children > five years old, children > five years old, menstruated Women.menstruated Women.

- - Scalded Skin SyndromeScalded Skin Syndrome:: Exfoliative A,B Toxins.. Exfoliative A,B Toxins.. Minor Skin Lesion.. Destruction Skin Intercellular Minor Skin Lesion.. Destruction Skin Intercellular Connection .. Large Blisters Containing Fluid .. Skin Connection .. Large Blisters Containing Fluid .. Skin Scaling.. Painful.. Common Babies Scaling.. Painful.. Common Babies

- Methicillin Resistant - Methicillin Resistant S. aureusS. aureus

S. epidermidisS. epidermidis.. normal inhabitants of the skin .. normal inhabitants of the skin surface.. but Less Pathogenic. Most its infections surface.. but Less Pathogenic. Most its infections occur in normal individuals.. Dry Skin.. Injury.. but occur in normal individuals.. Dry Skin.. Injury.. but underlying illness increase the risk of infection.. underlying illness increase the risk of infection.. Infants.. compromised patients Infants.. compromised patients

StaphylococciStaphylococci are becoming increasingly resistant to are becoming increasingly resistant to many commonly used antibiotics including:many commonly used antibiotics including:

Penicillins-Cephalospoins.. Methicillin & flucloxacillin , Penicillins-Cephalospoins.. Methicillin & flucloxacillin , Augmentin (amoxycillin + clavulonic acid) .. B-Augmentin (amoxycillin + clavulonic acid) .. B-lactamase-resistant penicillins.. Other antibioticslactamase-resistant penicillins.. Other antibiotics

Worldwide Spread Methicillin resistance (Worldwide Spread Methicillin resistance (MRSA)..MRSA).. 20- 20-90% ..in Jordan about 60% clinical isolates (2004)90% ..in Jordan about 60% clinical isolates (2004)

Diagnosis &Treatment of staphylococcal Diagnosis &Treatment of staphylococcal infectionsinfections

Lab DiagnosisLab Diagnosis of staphylococcal infectionsof staphylococcal infections should should be confirmed by: culture, gram-stain positive cocci, be confirmed by: culture, gram-stain positive cocci, +ve catalase , coagulase test .+ve catalase , coagulase test .

Effective treatment ForEffective treatment For MRSAMRSA .. Vancomycin, .. Vancomycin, Teicoplanin, Imipenem, Fusidic acidTeicoplanin, Imipenem, Fusidic acid

DrainageDrainage of pus collections before treatment of pus collections before treatment Surgical removal Surgical removal (debridement(debridement)) of dead tissue of dead tissue

(necrosis) (necrosis) Removal of Removal of foreign bodiesforeign bodies (stitches) that may be a (stitches) that may be a

focus of persisting infection focus of persisting infection Treating the Treating the underlying skin diseaseunderlying skin disease

Streptococcal Skin Infections-1Streptococcal Skin Infections-1

Streptococcus pypgenes Streptococcus pypgenes / B-H-Group A) / B-H-Group A) ....Major Major

virulence factors: virulence factors: M-Protein .. Hemolysin O & S, Pyrogenic M-Protein .. Hemolysin O & S, Pyrogenic exotoxins -Erythrogenic toxin .. Causing Scarlet fever + Toxic exotoxins -Erythrogenic toxin .. Causing Scarlet fever + Toxic Shock Syndrome, Hayluronidase , Streptokinase (Fibrinolysin- Shock Syndrome, Hayluronidase , Streptokinase (Fibrinolysin- digest Fibrin & Proteins in Plasma), Streptodornase (DNA)digest Fibrin & Proteins in Plasma), Streptodornase (DNA)– CellulitesCellulites : Acute Rapidly Spreading Infection in Skin & : Acute Rapidly Spreading Infection in Skin &

Subcutaneous Tissues.. Following.. Wounds, Burns.. Highly Subcutaneous Tissues.. Following.. Wounds, Burns.. Highly CommunicableCommunicable

– ErysipelasErysipelas : Massive Brawny Edema.. Dermis.. Children : Massive Brawny Edema.. Dermis.. Children– ImpetigImpetigoo: Pyoderma Superficial Layers Skin.. Epidermis, : Pyoderma Superficial Layers Skin.. Epidermis,

Blisters, Children.. Highly Communicable.. Following Blisters, Children.. Highly Communicable.. Following Streptococcus Sore ThroatStreptococcus Sore Throat

B-H-StreptococciB-H-Streptococci

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- - Necrotizing fasciitis Necrotizing fasciitis : Following wound infection.. : Following wound infection.. Subcutaneous Tissues & Fascia, Rapid Spread Subcutaneous Tissues & Fascia, Rapid Spread Necrosis.. Tissue Liquidation.. Fatal without Rapid Necrosis.. Tissue Liquidation.. Fatal without Rapid Antibiotic Treatment Antibiotic Treatment

-- Scarlet fever: Scarlet fever: Following Group A Strept. Infection..Following Group A Strept. Infection.. Erythematous Rash due toErythematous Rash due to Erythrogenic Toxin.. Erythrogenic Toxin.. ChildrenChildren

- - Streptococcal Toxic Shock SyndromeStreptococcal Toxic Shock Syndrome:: Pyrogenic Pyrogenic Exotoxin A.. Invasive Group A, Infected Trauma .. Exotoxin A.. Invasive Group A, Infected Trauma .. Bacteremia, Respiratory & Multi Organ Failure, 30% Bacteremia, Respiratory & Multi Organ Failure, 30% DeathDeath

– Allergic hypersensitivity ..Allergic hypersensitivity ..Erythema NodosumErythema Nodosum.. .. VasculitisVasculitis

Skin rash - Scarlet FeverSkin rash - Scarlet Fever

Diagnosis & TreatmentDiagnosis & Treatment

Culture on blood, Culture on blood, B-Hemolytic reactionB-Hemolytic reaction, Gram-+ve , Gram-+ve cocci in chain, catalase-ve, Bacitracin-Susceptiblecocci in chain, catalase-ve, Bacitracin-Susceptible

SerotypingSerotyping should used to confirm group of should used to confirm group of streptococcal infection.. A, B, C etc. using antisera streptococcal infection.. A, B, C etc. using antisera against group-specific cell wall carbohydrate –against group-specific cell wall carbohydrate –Antigens (Lancefield classification)Antigens (Lancefield classification)

PenicillinPenicillin is the drug of choice.. All Group A is the drug of choice.. All Group A streptococci are very sensitive to penicillin. streptococci are very sensitive to penicillin.

Patients with penicillin allergy may be given Patients with penicillin allergy may be given Erythromycin.. Azithromycin..Erythromycin.. Azithromycin..

Less Common Bacterial associated with Less Common Bacterial associated with Skin InfectionsSkin Infections

GonorrheaGonorrhea : : Neisseria gonorrhoeaNeisseria gonorrhoea.. Skin rash.. Skin rash Soft chancre /chancroid Soft chancre /chancroid : : Haemophilus ducreyiHaemophilus ducreyi.. ..

STD.. Painful Skin Ulcer, Extra Genitalia, Tropical STD.. Painful Skin Ulcer, Extra Genitalia, Tropical countriescountries

SyphilisSyphilis: : Treponema pallidumTreponema pallidum.. Genital ulcers.... Genital ulcers.. MeningococemiaMeningococemia : : N. meningitidis N. meningitidis.. Skin rash & .. Skin rash &

hemorrhage .. Thrombosishemorrhage .. Thrombosis Rickettsia diseasesRickettsia diseases: human lices.. Transmit R. : human lices.. Transmit R.

prowazeki (Typhus), R. rickettsii (Spotted fever)..prowazeki (Typhus), R. rickettsii (Spotted fever).. Pseudomonas aeruginosa Pseudomonas aeruginosa : Wound infections, Burns : Wound infections, Burns

skin follicultisskin follicultis