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Bacterial Infections Chapter 14

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Lesions are usually pustules, furuncles or erosions with honey colored crust. ... Superficial folliculitis with thin wall, fragile ... TX with ABX. ... – PowerPoint PPT presentation

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Title: Bacterial Infections Chapter 14


1
Bacterial Infections Chapter 14
  • Infections Caused by Gram Positive Organisms.
  • Michael Hohnadel, D.O.
  • 02/07/2006

2
Staphylococcal Infections
  • General
  • 20 of adults are nasal carriers.
  • HIV infected are more frequent carriers.
  • Lesions are usually pustules, furuncles or
    erosions with honey colored crust.
  • Bullae, erythema, widespread desquamation
    possible.
  • Embolic phenomena with endocarditis
  • Olser nodes
  • Janeway Lesions

3
Embolic Phenomena With Endocarditis

Osler nodes
Janeway lesion
4
Superficial Pustular Folliculitis
  • Also known as Impetigo of Bockhart
  • Presentation Superficial folliculitis with thin
    wall, fragile pustules at follicular orifices.
  • Develops in crops and heal in a few days.
  • Favored locations
  • Extremities and scalp
  • Face (esp periorally)
  • Etiology S. Aureus.

5
Sycosis Vulgaris (Sycosis Barbae)
  • Perifollicular, Chronic , pustular staph
    infection of the bearded region.
  • Presentation Itch/burn followed by small,
    perifollicular pustules which rupture. New crops
    of pustules frequently appear esp after shaving.
  • Slow spread.
  • Distinguishing feature is upper lip location and
    persistence.
  • Tinea is lower.
  • Herpes short lived
  • Pseudofolliculitis Barbea ingrown hair and
    papules.

6
Sycosis Vulgaris
7
Sycosis Lupoides
  • Etiology Staph. Aureus infection that, through
    extension, results in a central hairless scar
    surrounded by pustules.
  • Histopathology Pyogenic folliculitis and
    perifolliculitis with deep extension into hair
    follicles often with edema.
  • Thought to resemble lupus vulgaris in appearance.

8
Treatment of Folliculitis
  • Cleansing with soap and water.
  • Bactroban (Mupirocin)
  • Burrows solution for acute inflammation.
  • Antibiotics cephalosporin, penicillinase
    resistant PCN.

9
Furunculosis
  • Presentation A perifollicular, round, tender
    abscess that ends in central suppuration.
  • Etiology S. Aureus
  • Breaks in skin integrity is important.
  • Various systemic disorders may predispose.
  • Hospital epidemics of abx resistant staph. may
    occur
  • Meticulous hand washing is essential.

10
Furuncle
11
Furuncle / Carbuncle

12
Furunculosis
  • Treatment of acute lesions
  • ABX may arrest early furuncles.
  • Incision and drainage AFTER furuncle is localized
    with definite fluctuation.
  • No incision of EAC or nasal furuncles. TX with
    ABX.
  • Upper lip and nose, danger triangle, requires
    prompt treatment with ABX to avoid possible
    venous sinus thrombosis, septicemia, meningitis.

13
Treatment of Chronic Furunculosis
  • (Avoid auto-inoculation, Eliminate carrier
    state.)
  • Sites of colonization Nares, axilla, groin and
    perianal.
  • Use Anti-staph cleansers soap, chlorhexidine.
  • Frequent laundering.
  • Bactroban to nares of pt and family members
  • BID to nares for one week (q 4th week.).
  • Rifampin 600mg QD for 10 days with cloxacillin
    500 mg QID (or Clindamycin 150mg qd for 3 mo)

14
Pyogenic Paronychia
  • Presentation Tender painful swelling involving
    the skin surrounding the fingernail.
  • Etiology Moisture induced separation of
    eponychium from nail plate by trauma or moisture
    leading to secondary infection.
  • Often work related
  • Bacteria acute abscess formation.
    Candida chronic swelling.
  • Treatment
  • Avoid maceration / trauma
  • ID of abscess
  • PCN, 1st Gen Cephalosporin, augmentin.
  • Chronic infection requires fungicide and a
    bactericide.

15
Pyogenic Paronychia

16
Pyogenic Paronychia

17
Other predominately Staph Infections.
  • Botryomycosis
  • Presentation Chronic, indolent d/o characterized
    by nodular, crusted, purulent lesions.
  • Sinus tracts discharge sulfur granules. Scaring.
  • Uncommon. Assoc with altered immune
    function.
  • S. Aureus most common. (Pseudo, E-coli, Proteus,
    Bacteroides, Strep.)
  • Pyomyositis
  • S. aureus abcess in deep, large striated muscle.
  • Most frequent location is thigh
  • Occurs in tropics. More frequent in children and
    AIDS pts.
  • May not be associated with previous laceration.

18
Impetigo Contagiosa
  • Presentation 2mm erythematous papule develops
    into vesicles and bullae. Upon rupture a straw
    colored seropurulent discharge dries to form
    yellow, friable crust.
  • Etiology S. Aureus gt S. Pyogenes.
  • Lesions located on exposed parts of body.
  • Group A Strep can cause AGN
  • Children lt6 yrs old.
  • 2 to 5 of infections
  • Serotytpes 49, 55, 57, 60 strain M2 most
    associated
  • Good prognosis in children.

19
Impetigo Contagiosa
  • Treatment
  • PCN, 1st Gen. Cephalosporin.
  • Topical bacitracin or mupirocin after soaking
    off crust.
  • Topical ABX prophylaxis of traumatic injury.
  • Reduced infection 47
  • Treatment of nares for carriers.

20
Impetigo Contagiosa

21
Impetigo Contagiosa
22
Impetigo Contagiosa
23
Bullous Impetigo
  • Presentation Large, fragile bullae, suggestive
    of pemphigus. Rupture leaves a circinate, weepy
    crusted lesion (impetigo circinata). Collarette
    of scale present.
  • Affects newborns at the 4-10th days of life.
    Adults in warm climates.
  • Organism present in the lesions.

24
Bullous Impetigo
25
Bullous Impetigo
26
Staphylococcal Scalded Skin Syndrome.
  • Presentation Febrile, rapidly evolving
    generalized desquamation of the skin.
  • Primarily affects neonates and children.
    Begins with skin tenderness and erythema of neck
    groin, axillae with sparing of palm and soles
  • Blistering occurs just beneath granular layer.
  • Positive Nikolskys sign
  • Etiology Exotoxin from S. Aureus infection
    located at a mucosal surface (not in lesions).
  • Differentiate from TENS
  • Treatment as before. Prognosis is good.

27
Staphylococcal Scalded Skin Syndrome

Blister plane in granular layer
28
Staphylococcal Scalded Skin Syndrome
29
Toxic Shock Syndrome
  • Presentation
  • Acute, febrile, multi-system disease.
  • One diagnostic criteria is widespread
    maculopapular eruption.
  • Causes
  • S. Aureus
  • Cervical mucosa historically in early 1980s.
  • Also seen with wounds, catheters, nasal packing.
    Mortality 12 .
  • Group A Strep
  • necrotizing fasciitis. Mortality 30.

30
Toxic Shock Syndrome
  • Diagnosis CDC
  • Temp gt38.9C, erythematous eruption with
    desquamation of palms and soles 1-2 wks after
    onset. Hypotension
  • AND involvement of three of more other systems
  • GI, muscular, renal, CNS.
  • AND Test for RMSF, Leptospirosis and rubeola as
    well as blood urine and CSF should be negative.
  • Treatment
  • Systemic ABX,
  • Fluid therapy
  • Drainage of S. Aureus infected site.

31
  • Streptococcal Skin Infections

32
Ecthyma
  • Presentation Vesicle/pustule which enlarges
    over several days and becomes thickly crusted.
    When crust is removed a superficial saucer shaped
    ulcer remains with elevated edges.
  • Nearly always on shins or dorsal feet.
  • Heals in a few weeks with scarring.
  • Agent Staph or Strep.
  • Heals with scaring
  • Gangrene in predisposed individuals.
  • Treatment Clean, topical and systemic ABX.

33
Ecthyma
34
Ecthyma

35
Scarlet Fever
  • Presentation 24 48 hrs after Strep. Pharyngitis
    onset.
  • Cutaneous
  • Widespread erythema with 1-2 mm papules. Begins
    on neck and spreads to trunk then extremities.
  • Pastias lines accentuation over skin folds
    with petechia.
  • Circumoral pallor
  • Desquamation of palms and soles at appox two wks.
  • May be only evidence of disease.
  • Other strawberry tongue
  • Causes erythrogenic exotoxin of group A Strep.
  • Culture to recover organism or use streptolysin O
    titer if testing is late.
  • TX PCN, E-mycin, Cloxacillin.

36
Scarlet Fever
37
Scarlet Fever
38
Scarlet Fever
Rash with circumoral pallor
39
Scarlet Fever
Sandpaper Rash
40
Erysipelas
  • Presentation erythematous patch with a
    distinctive raised, indurated, advancing border.
    Affected skin is very painful and is warm to
    touch. Freq. associated with fever , Headache
    and leukocytosis gt20,000.
  • Face and Legs are most common sites.
  • Involves superficial dermal lymphatics
  • Cause Group A strep., (Group B in newborns)
  • Differential
  • Contact derm more itching little pain.
  • Scarlet fever widespread punctate erythema
  • Malar rash of Lupus and Acute tuberculoid
    Leprosy Absence of fever pain and
    leukocytosis.
  • Treatment Oral or Systemic abx depending on
    severity.

41
Erysipelas
Sharp, raised border.
42
Erysipelas

43
Erysipelas
44
Cellulitis
  • Presentation Local erythema and tenderness which
    intensifies and spreads. Often associated with a
    discernable wound. Lymphangitis, fever and
    streaking may accompany the infection.
  • Less defined border than erythrasma
  • Etiology Group A strep and S. Aureus
  • Gangrene and sepsis possible particularly in
    compromised pt.
  • Treatment Culture. PCNase resistant PCN, 1st
    Gen Ceph.

45
Cellulitis
46
Cellulitis
47
Cellulitis
48
Necrotizing Fasciitis
  • Presentation Following surgery or trauma (24 to
    48 hours) - erythema, pain and edema which
    quickly progress to central patches of dusky blue
    discoloration.
  • Anesthesia of the involved skin is very
    characteristic.
  • By day 4-5 the involved area becomes gangrenous.
  • Infection of the fascia.
  • Many causative agents. Aerobic and anaerobic
    cultures should be taken.

49
Necrotizing Fasciitis
  • Treatment Early debridement. ABX.
  • 20 mortality in best cases.
  • Poor prognostic factors
  • Age gt50,
  • DM,
  • Atherosclerosis,
  • Involvement of trunk,
  • Delay of surgery gt7 days.

50
Necrotizing Fasciitis
Necrosis of the subcutaneous fat and fascia of
the inner aspect of the upper arm in an elderly
patient with diabetes mellitus.
51
More Staph and Strep Infections
  • Blistering Distal dactylitis
  • Superficial blisters on volar fat pads
  • Typical pt is 2-16 yrs old
  • Perianal Dermatitis
  • Superficial, perianal, well demarcated rim of
    erythema which is often confused with irritant
    dermatitis.
  • Typical pt is 1-8 yrs old.
  • Group B infection
  • Consider in any neonates. Also seen in adults
    with DM and peripheral vascular disease.
  • Staph Iniae
  • 1997 first reported
  • Cellulitis of hands assoc with preparation of
    tilapia fish.

52
Perianal Dermatitis
53
  • Other Gram Positive Infections.

54
Erysipeloid of Rosenbach.
  • Presentation Purple, often polygonal, sharply
    marginated patches occurring on the hands. The
    central portion of the lesion may fade as the
    border advances. New purplish patches appear at
    nearby sites ( or possibly distant sites).
    Painful.
  • Causative agent Erysipelothrix Rhusopathiae.
    Rod shaped grm () that forms long branching
    filaments. Culture on media fortified with serum
    at room temp.
  • Organism found on dead animal matter and the
    affliction is seen most commonly among fishermen
    (crabs, shrimp), veterinarians, and in the meat
    packing industry (esp pork)
  • Treatment PCN 1.0 gm/day 5-10 days.

55
Erysipeloid
56
Anthrax
  • Three forms
  • Cutaneous 95 of cases.
  • Inhalation
  • GI
  • Cutaneous presentation Inflammatory papule
    rapidly becomes a bulla surrounded by intense
    erythema which spontaneously ruptures purulent or
    sanguineous contents. A dark brown eschar
    surrounded by vesicles then develops with
    induration. Regional lymph glands then enlarge
    and frequently suppurate. The lesion is not
    tender or painful.
  • Mild cases - gangrenous skin sloughs and eschar
    heals.
  • In severe cases erythema and extensive edema
    develops. Lesions appear at other sites. Fever,
    prostration and death (20 of untreated cases.)

57
Anthrax
  • Human infection generally from infected animals.
    Human to human transmission is possible.
  • Diagnosis smear with gram stain. Cultures of
    wound.
  • Gamma bacteriophage to identify
  • Mice serum titer.
  • Electrophoretic immunoblots.
  • Treatment PCN G 2 million units IV q 6 hours for
    4-6 days followed by oral PCN for 7-10 days.

58
Anthrax
59
Anthrax
60
Anthrax
61
Anthrax
62
Listeriosis
  • Listeria Monocytogenes
  • Ubiquitous organism which usually causes
    meningitis of encephalitis.
  • Rare cutaneous affliction causing erythematous,
    tender papules and pustules with lymphadenopathy,
    fever and malaise.
  • Risk to immunosuppressed
  • Neonates Granulomatosis infanta peptica.
  • May be missed on bacteriologic exam. Serologic
    test useful.
  • Treatment sensitive to most ABX.

63
Cutaneous Diphtheria
  • Corynebacterium Diphtheriae infection in
    unimmunized individual
  • Presentation
  • Ulcer with a hard rolled border with a pale blue
    tinge. A leathery gray membrane often coves the
    lesion.
  • Eczematous, impetinginous, vesicular or pustular
    scratches.
  • Paralysis and cardiac complications from
    diphtheria toxin are possible.
  • Common in tropical areas with most U.S. cases
    from non-immunized migrant workers.
  • Treatment Diphtheria antitoxin, E-mycin is DOC.
    Also rifampin and PCN.

64
Desert Sore
  • Ulcerative disease endemic amongst bushmen and
    soldiers in Australia.
  • Presentaion Grouped vesicles on extremities
    which rupture to form superficial, indolent
    ulcers that may be 2.0 cm in diameter.
  • Cause Staph, Strep and Corynebacterium
    Diphtheria.
  • Treatment Diphtheria antitoxin if organism
    present and topical ABX with oral PCN or E-mycin.

65
Tropical Ulcer
  • Presentation
  • Inflammatory papule with vesiculation and ulcer
    formation frequently with undermined edges.
  • Pseudomembrane may be present or simply crusting.
  • Minimal distress other then mild itching.
  • Usually single lesion on one extremity.
  • Auto inoculation spreads infection.
  • Most common in native laborers or school children
    during the rainy season.
  • Usually occur at sites of cutaneous injury.
  • Etiology Many organisms found under description
    of topical ulcer
  • Bacteriodes Fusiformis, spirochetes, anaerobes.

66
Tropical Ulcer
  • Differential
  • Vascular ulcers
  • Arteriosclerotic ulcer deep to expose fascia
    and tendons.
  • HTN ischemic ulcer shallow, painful mid to
    lower legs.
  • Venous ulcers shallow, varicosities. Above
    medial malleolus.
  • Other
  • Desert ulcer C diptheriae
  • Gummatous ulcer punched out, other syphilis
    signs.
  • Tuberculous ulcer not usually on leg.
  • Mycotic ulcer nodular with fungi on inspection.
  • Buruli ulcer Mycobacterium ulcerans.
  • Leshmania ulcer contans Leishmania tropicans,
    not on leg.
  • Ulcer of blood abnormalities.

67
Tropical Ulcer
68
Tropical Ulcer
69
Erythrasma
  • Presentation sharply delineated, dry, brown,
    slightly scaling patches located in intertrignous
    areas. (axillae, genitocrural crease and webs of
    4-5 toes). Rarely, widespread lesions will occur
    with lamellated plaques.
  • Lesion are generally asymtomatic except for the
    groin where minor itching may be reported.
  • Extensive involvement is assoc. with DM
  • Etiology Corynebacterium Minutissimum.
  • Diagnosis Woods lamp coral red.
  • Treatment e-mycin 250 qid x 7 days. Tolnaftate,
    miconazole, e-mycin, clindamycin topicals also
    effective.

70
Erythrasma
71
Intertrigo
  • Presentation Superficial inflammatory dermatitis
    where two skin surfaces are in apposition.
  • Etiology Friction and moisture allows infection
    by bacteria (Staph, Strep, Pseudo.) or fungi or
    both.

72
Intertrigo
73
Intertrigo
74
Intertrigo
75
Pitted Keratolysis
  • Presentation Thick, weight bearing portions of
    the soles gradually covered by asymptomatic round
    pits 1-3 mm in diameter. Pits may become
    confluent forming furrows. Rarely, palms may be
    affected.
  • Etiology unknown. Micrococcus sedentarius in
    synergy with corynebacteria is suspected
  • Men with sweaty feet are most susceptible.
  • Treatment Topical E-mycin, clindamycin.
    Miconazole, benzoyl perioxide gel, AlCl solution.

76
Pitted Keratolysis
77
Pitted Keratolysis
78
Gas Gangrene
  • Presentation Several hours after a patient
    receives a deep laceration, severe pain and wound
    site crepitance develop as well as fever, chills
    and prostration. A mousy odor is characteristic.
  • Etiology (2 types)
  • Clostridium types perfringens, oedematiens,
    septicum and haemolyticum. Acute onset !
  • Peptostreptococcus. Delayed onset up to several
    days.
  • Treatment
  • Clostridium Wide debridement and PCN G,
    hyperbaric
  • Peptostreptococcus Surgical debridement limited
    to glossy necrotic muscle.

79
Gas Gangrene
80
Chronic Undermining Burrowing Ulcers ( Meleneys
Gangrene)
  • Presentation Pt who recently (1-2 wks)
    underwent surgical drainage of a peritoneal or
    lung abscess develops carbunculoid appearance at
    the sutures or wound site. Pain is excruciating.
  • The lesion then differentiates into three zones
  • outer zone - bright red,
  • middle zone - dusky purple,
  • inner zone - gangrenous with central areas of
    granulation tissue.

81
Chronic Undermining Burrowing Ulcers
  • Etiology Peptostreptococcus in periphery. S.
    Aureus or Enterobacteriaceae in zone of gangrene.
  • Bacterial synergetic gangrene
  • Treatment Wide excision with ABX (PCN and
    aminoglycoside).

82
Fourniers Gangrene of the Penis and Scrotum
  • Presentation Gangrenous infection of penis,
    scrotum or perineum which spreads along fascial
    planes.
  • Etiology Group A Strep or mixed organism.
  • Ages 20-50
  • Culture for aerobic and anaerobic organisms.
  • Treatment ABX as indicated.
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