PEDIATRIC CUTANEOUS BACTERIAL INFECTIONS DR. PEARL C. KWONG MD PHD BOARD CERTIFIED PEDIATRIC DERMATOLOGIST JACKSONVILLE, FLORIDA DISCLOSURE • No relevant relationships PRETEST QUESTIONS • In Staph scalded skin syndrome: • A. The staph bacteria can be isolated from the nares , conjunctiva or the perianal area • B. The patients always have associated multiple system involvement including GI hepatic MSK renal and CNS • C. common in adults and adolescents • D. can also be caused by Pseudomonas aeruginosa • E. None of the above PRETEST QUESTIONS • Scarlet fever • A. should be treated with penicillins • B. should be treated with sulfa drugs • C. can lead to toxic shock syndrome • D. can be associated with pharyngitis or circumoral pallor • E. Both A and D are correct PRETEST QUESTIONS • Strep can be treated with the following antibiotics • A. Penicillin • B. First generation cephalosporin • C. clindamycin • D. Septra • E. A B or C • F. A and D only PRETEST QUESTIONS • MRSA • A. is only acquired via hospital • B. can be acquired in the community • C. is more aggressive than OSSA • D. needs treatment with first generation cephalosporin • E. A and C • F. B and C CUTANEOUS BACTERIAL PATHOGENS • Staphylococcus aureus: OSSA and MRSA • Gp A Streptococcus GABHS • Pseudomonas aeruginosa CUTANEOUS BACTERIAL INFECTIONS • Folliculitis • Non bullous Impetigo/Bullous Impetigo • Furuncle/Carbuncle/Abscess • Cellulitis • Acute Paronychia • Dactylitis • Erysipelas • Impetiginization of dermatoses BACTERIAL INFECTION • Important to diagnose early • Almost always curable • Serious complications if delayed Rx or if Rx is inadequate • Septicemia, nephritis, carditis, arthritis PTS PRONE TO BACTERIAL INFECTIONS • Immunocompromised pts • Babies /Children • Pts with chronic skin conditions BACTERIAL INFECTION • Localized • Spreading • Superficial • Deep • Rash is secondary to the infection SKIN REACTION TO BACTERIAL INFECTION • Guttate psoriasis • SSSS • TSS • Scarlet fever/scarlatina • Beaus lines and onychomadesis FOLLICULITIS • Infection of the hair follicles • Superficial or deep • Staph most common pathogen but Strep Gram negative and even dermatophytes • Folliculitis barbae (sycosis barbae) • Pseudomonas Folliculitis (hot tub folliculitis) FOLLICULITIS FOLLICULITIS IMPETIGO • Superficial infection • Bullous or nonbullous • Erythematous papules with honey yellow colored crusting; peripheral collarettes • Multiple lesions due to autoinoculation • S Aureus , GABHS or both • Topical antibiotics if localized , oral if spreading IMPETIGO IMPETIGO IMPETIGO IMPETIGO BULLOUS IMPETIGO FURUNCLE CARBUNCLE • Boils • Painful deep perifollicular abscesses with central necrosis suppuration; fluctuant • S aureus • Carbuncles larger deeper seated abscess aggregates • I and D and oral antibiotics. FURUNCLE/CARBUNCLE FURUNCLE/CARBUNCLE CELLULITIS • Acute infection of the skin sub q • Erythema swelling tenderness • Borders not elevated or sharply defined • Follows skin trauma • Can have constitutional sx • S aureus and GABHS and under 2 H influenza type b,strep pneumoniae PERIORBITAL CELLULITIS • Erythema and periorbital swelling • Can spread thru orbital septum • Orbital cellulitis: proptosis ophthalmoplegia decreased visual acuity • Need CT and consult to ophthalmology. Need to rule out meningitis • Complication: abscess formation and cavernous sinus thrombosis • Used to be due to Hib now more Staph and strep CELLULITIS ERYSIPELAS • Superficial cellulitis with marked lymphatic involvement • GABHS • Direct inoculation thru break in skin • Warm shiny bright red infiltrated plaque distinct border ERYSIPELAS PERIANAL STREPTOCOCCAL DERMATITIS PSD • Frequently overlooked • Sharply circumscribed perianal erythema • Fissuring and purulent discharge and or functional disturbances • Strep /staph. PERIANAL STREP INFECTION BLISTERING DACTYLITIS • Bullous manifestation of strep or staph infection • Painful tense one finger or several • DDx herpetic whitlow DACTYLITIS/ACUTE PARONYCHIA SKIN REACTIONS TO BACTERIAL INFECTION • SSSS • TSS • Scarlet fever/scarlatina • Guttate psoriasis • Beaus lines and onychomadesis STAPH SCALDED SKIN SYNDROME • Blistering skin disease caused by epidermolytic toxin producing S aureus • Exfoliative toxin ETA ETB • Generally starts with infection of the conjunctiva or the nares perioral region perineum or umbilicus/ • Initial nidus can be from pneumonia septic arthritis endocarditis or pyomyositis • Fever malaise lethargy irritability poor feeding • Erythema crusting denudation and tender skin. • Nikolsky sign is positive SSSS SSSS SSSS STAPH SCALDED SKIN SYNDROME SSSS SSSS SSSS NEWBORN SSSS NEWBORN TOXIC SHOCK SYNDROME • Acute febrile illness • Fever rash hypotension multisystem organ involvement • Classic history : use of superabsorbent tampons. • Non menstrual cases : nasal packing postpartum state and a variety of staph infections TSS Temp >38.9 Diffuse macular erythroderma Desquamation and 1-2 weeks after onset , esp palms and soles Hypotension Multisystem involvement of 3 or more:GI , MSK, renal , hepatic , hematologic, CNS Negative tests on blood throat or CSF cultures, or serologic tests for RMSF leptospirosis or measles. TSS DESQUAMATION TSS DESQUAMATION SCARLET FEVER/SCARLATINA • Caused by GABHS • Fever chills sore throat headaches • Tonsillopharyngeal erythema exudate or petechial macules of the palate • Tongue with white strawberry appearance then red strawberry tongue • Circumoral pallor • Asstd cervical lymphadenopathy • Sandpapery • Pastia’s lines: petechial component in the flexural areas • Desquamation SCARLET FEVER /SCARLATINA SCARLET FEVER SCARLET FEVER DESQUAMATION POST SCARLET FEVER ONYCHOMADESIS SECONDARY TO STREP INFECTION GUTTATE PSORIASIS IMPETIGINIZATION OF DERMATOSES • Atopic dermatitis • Tinea capitis • Psoriasis IMPETIGINIZED ECZEMA IMPETIGINIZED ECZEMA IMPETIGINIZED ECZEMA IMPETIGINIZED ATOPIC DERMATITIS IMPETIGINIZED TINEA CAPITIS APPROACH TO TREATMENT • Empirical treatment • Cultures to determine sensitivity • Topical antibiotics • Systemic antibiotics • Pediatric considerations • I and D • Prevention TOPICAL ANTIBIOTICS OTC options: neosporic polysporin bacitracin Mupirocin Fusidic acid Silvadene Clindamycin Gentamicin SYSTEMIC ORAL ANTIBIOTICS • Cloxacillin • Augmentin • Cephalexin. First generation , second generation • Clindamycin • Sulfa • Ciprofloxacin • Doxycycline SPECIAL PEDIATRIC CONSIDERATIONS • Allergies • Safety in children: Doxy, cipro • Palatability • Dosing • Cost • Drug Interactions SURGICAL TREATMENT • I and D abscess TREATMENT OF SKIN BACTERIAL INFECTIONS • Cultures important. • Important to know WHERE to culture. • Good complete physical exam • Recognize yellow crusting, wet lesions. • Don’t forget to look in the groin perianal area eyelids external ear canals, folds • Don’t forget to treat contacts. Contacts may include FIDO the family dog PREVENTION • Disinfectants: Bleach baths, hibiclens wash, mupirocin to nostrils and to body folds • Disinfect surfaces. • No toys in bathtubs, no loofahs etc • Change blades from shavers • WARN PTS INFECTION CAN BE RECURRENT! • Treat family pets too! CA-MRSA • Usually presents as deeper furuncle/carbuncle • More aggressive • Common in community not just hospital setting CA MRSA ERADICATION SUGGESTIONS: • Treat affected areas with topical antibiotics Mupirocin • Prone areas : nares folds • Bleach baths • Hibiclens • Treat contacts including Fido • Mouthwash to treat pharynx and soak toothbrushes combs in mouthwash • Clorox wipes vs Saniwipes • Change linens daily • Change razors PRETEST QUESTIONS • In Staph scalded skin syndrome: • A. The staph bacteria can be isolated from the nares , conjunctiva or the perianal area • B. The patients always have associated multiple system involvement including GI hepatic MSK renal and CNS • C. common in adults and adolescents • D. can also be caused by Pseudomonas aeruginosa • E. None of the above PRETEST QUESTIONS • Scarlet fever • A. should be treated with penicillins • B. should be treated with sulfa drugs • C. can lead to toxic shock syndrome • D. can be associated with pharyngitis or circumoral pallor • E. Both A and D are correct PRETEST QUESTIONS • Strep can be treated with the following antibiotics • A. Penicillin • B. First generation cephalosporin • C. clindamycin • D. Septra • E. A B or C • F. A and D only PRETEST QUESTIONS • MRSA • A. is only acquired via hospital • B. can be acquired in the community • C. is more aggressive than OSSA • D. needs treatment with first generation cephalosporin • E. A and C • F. B and C .