Bacterial Infections Chapter 14 Infections Caused by Gram Positive Organisms. Michael Hohnadel, D.O. 10/7/03 1 •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 2 Embolic Phenomena With Endocarditis • Osler nodes Janeway lesion 3 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. 4 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. 5 Sycosis Vulgaris 6 Sycosis Lupoides • Staph infection that through extension results in central hairless scar surrounded by pustules. Pyogenic folliculitis and perifolliculitis with deep extension into hair follicles often with edema. • Thought to resemble lupus vulgaris in appearance. • Etiology: S. Aureus 7 Treatment of Folliculitis • Cleansing with soap and water. • Bactroban (Mupirocin) • Burrows solution for acute inflammation. • Antibiotics: cephalosporin, penicillinase resistant PCN. 8 Furunculosis • Presentation: 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. 9 Furuncle 10 Furuncle / Carbuncle 11 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. 12 Treatment of Chronic Furunculosis Avoid auto-inoculation, Eliminate carrier state. – Nares, axilla, groin and perianal sites of colonization. – 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) 13 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 cause acute abscess formation, Candida causes chronic swelling. • Treatment: • Avoid maceration / trauma • I&D of abscess • PCN, 1st Gen Cephalosporin, augmentin. • Chronic infection requires fungicide and a bactericide. 14 Pyogenic Paronychia • 15 Pyogenic Paronychia 16 Other predominately Staph Infections. • Botrymycosis – Presentation: Chronic, indolent d/o characterized by nodular, crusted, purulent lesions. • Sinus tracts discharge sulfur granules. Scaring. – Uncommon disorder. 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 and in children as well as AIDS pts. – Not associated with previous laceration. 17 Pyomyositis • 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 > S. Pyogenes. • Lesions located on exposed parts of body. • Group A Strep can cause AGN – Children <6 yrs old. – 2% to 5% – 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 24 Bullous Impetigo 25 Bullous Impetigo 26 Bullous Impetigo • 27 Staphylococcal Scalded Skin Syndrome. • Presentation: Febrile, rapidly evolving generalized desquamation of the skin seen primarily in 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 Nikolsky’s sign • Etiology: Exotoxin from S. Aureus infection located at a mucosal surface.. • Differentiate from TENS by location of blister plane high in epidermis. • Treatment as before. Prognosis is good. 28 Staphylococcal Scalded Skin Syndrome • 29 Staphylococcal Scalded Skin Syndrome 30 Toxic Shock Syndrome • Acute, febrile, multisystem disease. – One diagnostic criteria is widespread maculopapular eruption. • Causes: – S. Aureus : cervical mucosa historically in early 1980’s. Also: wounds, catheters, nasal packing. Mortality 12 %. – Group A Strep : necrotizing fasciitis. Mortality 30%. • Diagnosis: CDC – Temp >38.9C, 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. 31 Toxic Shock Syndrome • Treatment: – Systemic ABX, – Fluid therapy – Drainage of S. Aureus infected site. 32 Streptococcal Skin Infections 33 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. • Heal with scaring • Gangrene in predisposed individuals. • Treatment: Clean, topical and systemic ABX. 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. • Pastia’s 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 39 Scarlet Fever 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 , HA and leukocytosis >20,000. – 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: Systemic PCN for 10 days. 41 Erysipelas 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. • Group A strep and S. Aureus are usually causative. • Gangrene and sepsis possible particularly in compromised pt. • Treatment: PCNase – resistant PCN, 1st Gen Ceph. 45 Cellulitis 46 Cellulitis 47 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. • Treatment: Early debridement. ABX. • 20% mortality in best cases • Poor prognostic factors: Age >50, DM, Atherosclerosis, involvement of trunk, delay of surgery >7 days. 48 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 a 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. 49 Perianal Dermatitis 50 Other Gram Positive Infections. 51 Erysipeloid of Rosenbach. • Presentation: Purple, often polygonal, sharply marginated patches occurring on the hands. The central portion of the lesion may fade