infection of the skin, soft tissue,

8/17/2019 Infection of the Skin, Soft Tissue,

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Titiek Djannatun

Department of Microbiology, Faculty of Medicine

-YARSI ni!er"ity


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Infection of T#e Skin

T#e flora normal of t#e "kin play an

important role in defending t#e "urface from

$foreign in!ader"%

T#e "tructure of t#e "kin #elp" in

under"tanding t#e different "ort of infection

to ic# t#e "kin and it" underlying ti""ue"

are prone


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Three lines of Microbial Attack to The

Skin

Breach of intact skin, allowing infection

from the outside

Skin manifestations of systemic infection,

which may arise as a result of blood-bornespread from infected focus to the skin or by

direct extention

Toxin-mediated skin damage due toproduction of a microbial toxin at another

site in the body (e.g. Scarlet fever, TSS


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Skin manife"tation" of "y"temic infection cau"ed

by bacteria and fungi'

Organism Disease Skin manifestation

Salmonella tiphiSalmonella paratyphi B (S.scholtmuelleri)

)nteric fe!er *Ra"e "pot"+ containing bacteria

Neisseria meningitidis Septicemia, meningiti" etec#ial or maculapapular le"ion" containing bacteria

Pseudomonas aeruginosa Septicemia )ct#yma gangreno"um, "kin le"ion pat#ognomonic ifinfected by t#i" organi"m

Treponema pallidumTreponema pertenue

Syp#ili"Ya&"

Di""eminated infectiou" ra"# "een in "econdary "tage ofdi"ea"e, .-/ mont#" ot#er infection

Rickettsia prowazekii Rickettsia rickettsii Rickettsia coronii

Typ#u"Spotted fe!er Spotted fe!er"

Macular or #emorr#agic ra"#Macular or #emorr#agic ra"#Macular or #emorr#agic ra"#

Streptococcus pyogenes Scarlet fe!er )ryt#ematou" ra"# cau"ed by eryt#rogenic to0in

Staphylococcus aureus To0ic "#ock "yndrome Ra"# and de"cuamation due to to0in

Blastomyces dermatitidis bla"tomyco"i" apule or pu"tule de!elop" into granuloma le""ion"containing organi"m"

Cryptococcus neoformans 1rytococco"i" apule or pu"tule, u""ually on face or neck


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Direct )ntry Into Skin of 2acteria and Fungi

Structure involved Infection Common Cause

3eratini4ed epit#elium Ring&orm Dermatop#yte fungi (Trichophyton,epidermophyton and microsporum5

)pidermi" Impetigo Streptococcus pyogenes and6orStaphylococcus aureus

Dermi" )ry"ipela" Streptococcus pyogenes

7air follicle" Folliculiti"

2oil" (furuncle"5

1arbuncle"

Staphylococcus aureus

Subcutaneu" fat 1elluliti" Streptococcus pyogenes

Fa"cia 8ecroti4ing fa"citi" Anaerobe" and microaerop#ile", u"uallymi0ed infection"

Mu"cle Myonecro"i" gangrene Clostridium perfringens (and ot#er1lo"tridia5


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So what will you beSo what will you be

looking for?looking for? !hysical assessment"!hysical assessment"a inspectiona inspection

b palpationb palpation

c percussionc percussion

d auscultationd auscultation

#bserve#bserve si$e, shape, color of thesi$e, shape, color of thelesions, and %yes%check the odor lesions, and %yes%check the odor


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Bacterial Infections of Skin, Soft Tissue and

Muscle:

T#e cla""ification depend" upon t#e layer of "kin and "oft ti""ue

in!ol!ed'

Ab"ce"" formation 2oil" and carbuncle" re"ult of infection and

inflamation of t#e #air follicle" in t#e "kin (folliculiti"5

Spreading infection" ("ubcutan5

& Impetigo (epidermi"5 bullou", cru"ted or pu"tular eruption of t#e

"kin

& )ry"ipela" ()ryt#ematou" inflamation5 generally on face, leg" or

feet and often accompanied by pain and fe!er

8ecroti4ing infection"

& Fa"ciiti" T#e inflamatory re"pon"e to infection of t#e "oft ti""ue

bello& t#e dermi" cau"ing di"ruption of t#e blood "upply

gangrene or myonecro"i" a""ociated &it# i"c#emia of t#e mu"cle

layer (anaerobic organi"m" ga" gangrene5


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IT!OD"CTIO

Sta#h$loccocci % derived from &reek

'sta#$le( )bunch of gra#es*

&ram #ositive cocci arranged in clusters

+ard$ organisms surviving man$ non

#h$siologic conditions

Include a maor human #athogen and

skin commensals


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Mor#holog$

microsco#is

3oku", po"itif 9ram,ter"u"un "eperti bua# anggur


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&rou#ing for Clinical -ur#oses

1. Coagulase #ositive Sta#h$lococci


./ Coagulase negative Sta#h$lococci

Staphylococcus epidermidis

Staphylococcus saprophyticus


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A/ Staphylococcus aureus

Maor human #athogen

+abitat % #art of normal flora in somehumans and animals

Source of organism % can be infectedhuman host, carrier, fomite or

environment


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atural histor$ of disease

Man$ neonates, children, adults%intermittentl$ colonised b$ S. aureus

"sual sites % skin, naso#har$n0,#erineum

Breach in mucosal barriers % can enterunderl$ing tissue

Characteristic abscesses Disease due to to0in #roduction


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DIS1AS1S

Due to direct effect

of organism

2ocal lesions of

skinDee# abscesses

S$stemic

infections

To0in mediated

3ood #oisoning

to0ic shock

s$ndrome

Scalded skin

s$ndrome


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3actors #redis#osing to S. aureus

infections +ost factors

Breach in skin

Chemota0is defects

O#sonisation defectseutro#hil functional

defects

Diabetes mellitus

-resence of foreign

bodies

-athogen 3actors

Catalase )counteracts

host defences*

Coagulase+$aluronidase

2i#ases )Im#/ in

disseminating infection*

B lactasamase)ass/ 4ithantibiotic resistance*


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Virulency factors


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Di"ea"e" of "tap#ylococcu"


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S5I 21SIOS

Boils St$es

3uruncles )infection of hair follicle*

Carbancles )infection of several hair follicles*

4ound infections )#rogressive a##earance of

s6elling and #ain in a surgical 6ound after

about . da$s from the surger$*

Im#etigo )skin lesion 6ith blisters that break

and become covered 6ith crusting e0udate*


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S5I 21SIOS

)tiologi'

)ndogenou" may be ac:uired by *"elf-inoculation+ from a carrier

"ite (eg 8o"e5

)0ogenou" ac:uired by contact &it# anot#er per"on

at#ogen Stap#ylococcu" mo"t met#icylline and6or !ancomycine

re"i"tant

2oil" &it#in .-; day" of inoculation, a" "uperficial infection in

and arround a #air follicle (folliculiti"5 inten"e inflamatory

re"pon"e ab"ce""e", contain abundant yello& creamy pu"

Tretment in!ol!ed drainage and antimicroba (depend on t#e re"ult"

of "en"iti!ity te"t5 may be gi!en en t#e infection i" "e!ere and

t#e patient #e" fe!er


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Folliculiti"


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Impetigo i" a condition

limited to t#e epidermi",

&it# typically yello&,

cru"ted le"ion" It i"commonly cau"ed by

Streptococcus pyogenes

eit#er alone or toget#er &it#



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D11- ABSC1SSS1S

Can be single or multi#le

Breast abscess can occur in 7%89 of

nursing mothers in #uer#eriem

Can #roduce mild to severe disease

Other sites % kidne$, brain from se#tic

foci in blood


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S$stemic Infections

'. 4ith obvious focusOsteom$elitis, se#tic arthritis

./ o obvious focus

& heart )infective endocarditis*& Brain )brain abscesses*

8/ Ass/ 4ith #redis#osing factors

multi#le abscesses, se#ticaemia )I drugusers*

Staphylococcal pneumonia )-ost viral*


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B/ TO;I M1DIAT1D DIS1AS1S

1. Sta#h$lococcal food #oisoning

Due to #roduction of entero to0ins

heat stable entero to0in acts on gut#roduces severe vomiting follo6ing a

ver$ short incubation #eriod

!esolves on its o6n 6ithin about .<hours


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./ To0ic shock s$ndrome

+igh fever, diarrhoea, shock and

er$thematous skin rash 6hich des=uamate

Mediated via >to0ic shock s$ndrome to0in?

7@9 mortalit$ rate

Described in t6o grou#s of #atients

ass/ 4ith $oung 6omen using tam#ones

during menstruationDescribed in $oung children and men


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T


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8/ Scalded skin s$ndrome

Disease of $oung children

Mediated through minorSta#h$lococcal infection b$

>e#idermol$tic to0in? #roducing strains Mild er$thema and blistering of skin

follo6ed b$ shedding of sheets of

e#idermis Children are other6ise health$ and

most eventuall$ recover


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STA7Y?


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Antibiotic sensitivit$ #attern

er$ variable and not #redictable

er$ im#/ In -t/ Management

Mechanisms

7/B lactamase #roduction % #lasmid mediated

&+as made S. aureus resistant to #enicillin grou# ofantibiotics % @9 of S/ aureus ) A*

& B lactamase stable #enicillins )clo0acillin, o0acillin,methicillin* used

./ Alteration of #enicillin binding #roteins

& )Chromosomal mediated*

& +as made S/ aureus resistant to B lactamase stable#enicillins

& 7@%.@9 S/ aureus )B* &+ ColomboT+- resistant toall -enicillins and Ce#halas#orins*


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Te"ted in lab u"ing met#icillin

Referred to a" met#icillin re"i"tant S aureu"(MRSA5

)merging problem in t#e &orld

In Sri ?anka pre!alence !arie" from .C- ;C in#o"pital"

Drug of c#oice - !ancomycin

In Japan emergence of KIRSA(!ancomycin

intermediate re"i"tant S aureu"5

8o effecti!e antibiotic" di"co!ered -Ge mig#t #a!e

to di"co!er


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DIA&OSIS

7/ In all #us forming lesions

&ram stain and culture of #us

./ In all s$stemic infectionsBlood culture

8/ In infections of other tissues

Culture of relevant tissue or e0udate


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./ Sta#h$lococcus e#idermidis

Skin commensal

+as #redilection for #lastic material

Ass/ 4ith infection of I lines, #rosthetic

heart valves, shunts Causes urinar$ tract infection in

cathetarised #atients

+as variable ABS #attern Treatment should be aided 6ith ABST


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8/ Sta#$lococcus sa#ro#h$ticus

Skin commensal

Im#/ Cause of "TI in se0uall$

active $oung 6omen "suall$ sensitive to 6ide range of

antibiotics


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Streptococcal Skin Infection"(Streptococcus pyogenes5


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roperty of 2acterial

?ong c#ain cocci, gram po"iti!e

1oloniforn in 2lood Agar "moot# &it# ß #emoly"i" Sen"iti!e bacitracyn

7yaluronida"e #elp t#e organi"m to "pread in ti""ue,lymp#atic in!ol!ement, re"ulting lymp#adeniti" andlymp#angiti"

?y"ogenic "train" produce pyrogenic e0oto0in"(erytrogenic to0in"5 A" &it# TSST- in S.aureus, are

"uperantigen" &it# a potent influence on t#e immune"y"temyrogenic e0oto0in SpeA act on "kin blood!e""el" to cau"e t#e diffu"e eryt#ematou" ra"# of "carletfe!er, "treptococcal p#aryngiti", to0ic "#ock "yndrome


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roperty of 2acterial

Surface protein" antigen (M and T5 "ubdi!ided (type5

"treptococcu" a""ociated &it# "kin infection (differ from

t#e type" a""ociated &it# "ore t#roat"5

T rotein play no kno&n role in !irulence, and t#eir

function i" unkno&n

M protein !irulence factor" in#ibit op"onini4ation

and confer bacterium re"i"tant to p#agocyto"i"

Additional factor" to t#e !irulence organi"m lipoteic#oat

acid and F protein facilitate binding to epit#el cell"


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Im#etigo

mpetigo is a condition limited to the epidermis, with typically yellow,

crusted lesions. t is commonly caused by Streptococcus pyogenes

either alone or together with Staphylococcus aureus


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ImpetigoImpetigo


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ImpetigoImpetigo

Superficial skin infectionSuperficial skin infection

Bacterial%staphylococcusBacterial%staphylococcus

or streptococcusor streptococcus

Spread w) direct contactSpread w) direct contact

w) lesionsw) lesions

Thick, yellow crustThick, yellow crust

(commonly on the face(commonly on the face


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ImpetigoImpetigo

S)SS)S

- one or more pimple-like- one or more pimple-like

lesions surrounded bylesions surrounded by

reddened skinreddened skin- lesions fill w) pus and- lesions fill w) pus and

later form a thick crustlater form a thick crust

- itching- itching

TxTx

- Topical or oral *B+- Topical or oral *B+


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Erysipelas : infeksi oleh Streptococcus pyogenus melibatkan dermal lymphatic. Batas jelas dari

erythema dan indurasi. Bila infeksi pd mukamaka bentuk radang seperti kupu!kupu " butter-fy wing) R#eumatic fe!er "ebagai

kelanjutan dari infek"i

Streptococcus pyogenus

pd kulit jarang terjadi

R#eumatic fe!er

kebanyakan terjadi

"bg kelanjutan infek"i

Streptococcus

pyogenus pada

tenggorokan


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Acute 9lomerulonep#riti"

1auced by M type" (M;E5 Streptococcus pyogenes


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Acute 9lomerulonep#riti"

enicillin i" drug of c#oi"e, alt#oug#

eryt#romycin or an oral cep#alo"porin may be

u"ed for penicllin-allergic patient"

Se!ere infection may re:uire #o"pitali4ation Since A98 rarely recur" on "ub"e:uent

"treptococcal infection, longLterm pfofila0i"

&it# penicillin i" not indicated (in contra"t

follo&ing r#eumatic fe!er5


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1elluliti" and 9angrene


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Introduction

1elluliti" i" an acute "preading infection of t#e "kin t#at in!ol!e"

"ubcutaneu" ti""ue" )0tend deeper t#an ery"ipela"


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G#en t#e focu" of infection i" in "ubdermal fat, celluliti"-a "e!ere and

rapidly progre""i!e infection-i" t#e typical pre"entation ?arge bli"ter"

and "cab" may al"o be pre"ent on t#e "kin "urface

#$%$&I'S(() %I'&*BI*+*,I


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#$%$&I'S(() %I'&*BI*+*,I-$+++I/IS

2a#an pemerik"an'

a"pirat pada daera# pinggiran le"i pada bagian trauma (bila ada5

biop"i kulit

dara#

enyebaran penyakit "angat progre""if

keber#a"ilan i"ola"i patogen dari penderita .-/

penyebab utama adala# Streptococcus pyogenus dan

Staphylococcus aureus karena #al-#al ter"ebut diata" maka

diagno"e infek"i #anya dari gambaran klinik "akit

antimikroba pili#an, adala# antimikroba yang dapat

menanggulangi etiologi utama (S.pyogenus & S.aureus)


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Anaerobic 1elluliti"

Terjadi pad adaera# yang mengalami trauma, pada lukaopera"i

1endrung terjadi pada penderita diabete"

)tiologinya erat #ubungannya dengan loka"i infek"i'

ada bagian ba&a# tubu# kuman dari tinja danurin (pd &anita5

ada luka gigitan kuman bera"al dari mulut

2ila terjadi "ynergi"me antar etiologi (kuman aerob

Stapylococcu" dll dengan kuman anaerob Infek"i yg"angat de"truktif


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Anaerobic 1elluliti"

ciri-ciri k#a"nya' di"c#arge bau, pembengkakan di"ertai adanya ga" pada

bagian ba&a# jaringan

i b i l " hi i


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0iabetic ulcers "this one is0iabetic ulcers "this one is

necrotic tissue1necrotic tissue1


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0iabetic lcers0iabetic lcers

Sores on feet, especially onSores on feet, especially on

diabetic patientsdiabetic patients

hyhy

herehere- areas subected to weight- areas subected to weight

bearingbearing

- heel- heel

- tips of most prominent toes- tips of most prominent toes


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0iabetic lcers0iabetic lcers

S)SS)S

- painful, red sore on foot- painful, red sore on foot

- pus when infected- pus when infected

- foul-smelling discharge- foul-smelling discharge

TxTx

- sterile cleaning, dressings- sterile cleaning, dressings

- refer to diabetic- refer to diabeticspecialist)surgeon forspecialist)surgeon fordebridement or amputationdebridement or amputation


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8ecroti4ing Faciiti"

Merupakan infek"i yg akut dan fatal, etiologinya campurandari kuman anaerob dan kuman fakultatif anaerob

infek"i yg "angat tok"ik, menyebabkan nekro"i" berat yang

menyebar ke jaringan "ekitar dan ba&a#nya

)tiologi utamanya Streptococcus pyogenus (fle"# eating bacteria5 kematian tinggi

)k"i"i radical diperlukan untuk mengangkat jaringan

nekrotik

pembrian antibiotik lokal dan "i"temikFa"ciiti" pada dinding perut berakibat fatal


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8ecroti4ing Faciiti"


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Tok"in yang tela#

berikatan dengan

"yaraf tidak dapatdinetralkan ole#

antitok"in


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Traumatic or Surgical Gound" Infected

infek"i "ynergi"tik antara 7i"toto0ic 1lo"tridia dan kuman

fakultatif anaerob (flora normal tubu# lingkungan5

infek"i ber"ifat aggre""if dan de"trukti!e

tindakan amputa"i terpak"a dilakukan guna mencega# penyebaran

tok"in ke bagian tubu# lainnya

Yang tergolong dalam 7i"toto0ic 1lo"tridia' C.perfringens (yang

utama5, C.histolyticum' C.no%yi' C.solderli dll 5

Memproduk"i aneka ragam tok"in dan en4ym, memiliki

kemampuan memeca# karbo#idrat,gunanya untuk mempermuda#

in!a"i kuman dan pembentukan ga" pada antar aringan

aringanmati membengkak memberi bau khas

sbg isolat dpt ditemukan satu atau lebih kuman /lostridia, dan kuman

fakultatif anaerob lainnya


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er#atikan jaringan necro"i" dan akumula"i dari ga" pada jaringan

8ecro"e di"ebabkan ole# N tok"in memuda#kan infek"i kejaringan "e#at lainnya

(jarpengikat antar "el ru"ak5

3umula"i ga" "ebagai akibat fermenta"i (di"ertai pembentukan ga"5 pemeca#an

protein ole# Clostridium perfringens dan kuman aerob ikutan lainnya


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A 2

erbeni#an agar telur

A L H anti-tok"in

2 L tanpa anti-tok"in

ji netrali"a"i tok"in 8A9?)R untuk penentuan typeClostridium perfringens


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#ropionibacterium acnes and (cne

*cne teradi karena kera sama antara Propinibacteriun acnes denganperubahan horman pada masa puber

merupakan infeksi campuran, sebagai isolat selalu ditemukan" kuman

anaerob P.acnes (sebagai etiologi dan kuman aerob


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Mycobacterial Di"ea"e" of T#e Skin

0isebut uga sbg 1orbus 2ansen (2ansen3s disease atau 4epra

5tiologi Mycobacterium leprae

Bentuk batang (6 7ram" tahan asam

Belum dapat dibiak pd perbenihan sintetis

1asa inkubasinya lama (belum ada kesepakatan !enyebaran penyakit erat hubungannya dengan sosial ekonomi,

kepadatan penduduk, hygin dll

7ambaran klinik penyakit erat hubungannya dengan 8 /ell 1ediated

mmune (/19 response terhadap M.leprae”

Bentuk tuberculoid leprosy (TT lesi merah, mati rasa, padamuka, badan kaki dan tangan, dapat sembuh dengan sendirinya

Bentuk lepromateus leprosy (44, prognosisnya lebih buruk dari

pada (TT


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Mycobacterial Di"ea"e" of T#e Skin

infection of the skin, soft tissue,

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