Bacterial, fungal & parasitic Skin Infections Flashcards
What is the gram stain and shape of staphylococcus
Gram +ve (purple) cocci in clusters
Can staphylococcus grow in both aerobic and anaerobic conditions ?
Yes - grows best in aerobic conditions
So can streptococcus (grows in anaerobic conditions if it has too)
What are the 2 most important classifications of staphloccocus and how are the differentiated?
- Staph.arueus (coagulase positive)
- Coagulase negative Staph - (Staph. epidermidis, Staph. saprophyticus etc.)
What is the coagulase appearance of staph.aureus and coagulase negative staph (e.g. staph.epidermis)?
Staph.aurues is coagulase positive which shows up as golden
Coagulase negative shows up as white
Name and describe another test which can be down to distinguish staph.aureus from all the other strains of staph ?
Latex agglutination - Staph.aureus tests positive all other staph are negative
Note:
Latex agglutination test is a clinical method to detect certain antigens or antibodies in a variety of bodily fluids such as blood, saliva, urine or cerebrospinal fluid. The sample to be tested is sent to the lab and where it mixed with latex beads coated with a specific antigen or antibody.
What strain of staph is the only one which is Novobiocin resistant ?
Staph. saprophyticus
Describe some of the main features of staph.aureus including - some of the common infections it causes and some of the toxins/enzymes it produces
Causes wound, skin, bone & joint infections
Some strains produce toxins:
- Enterotoxin – food poisoning
- SSSST – staph. scalded skin syndrome toxin
- PVL – Panton Valentine Leukocidin
Produces enzymes, including coagulase, an enzyme that clots plasma hence coagulase positive
What is the first line antibiotic used to treat Staph.aureus?
If penicillin allergic then what would you give ?
Flucloxacillin
If penicillin allergic then give doxycycline
Are coagulase negative staph usually pathogenic ?
No usually just skin commensals but can cause infections
Note (staph.aureus is a common human pathogen)
What are the sort of infections that staph.epidermis is associated with ?
May cause infection in association with implanted artificial material, such as artificial joints, artificial heart valves, IV catheters
What infection is staph. saprophyticus associated with ?
Causes UTI in women of child bearing age
Describe the gram stain appearance of Streptococci
Gram +ve cocci in chains
How are the different types of streptoccoci classified ?
By haemolysis:
- β(beta)-haemolytic (complete haemolysis)
- α(alpha)-haemolytic (partial haemolyis)
- γ(gamma) or non-haemolytic (no haemolysis)
Describe some of the features of beta-haemolytic strep - including
They are pathogenic organisms
Produce enzymes (toxins) - e.g. haemolysin (hence complete haemolysis) that damage tissues
How are beta-haemolytic strep further classified and what type of infections are the 2 main classifications associated with ?
Further classified by antigenic structure on surface (serological grouping)
- Group A (throat, severe skin infections)
- Group B (meningitis in neonates)
What are the two most important types of alpha-haemolytic strep ?
Strep. pneumoniae and Strep.viridans
What infections are strep.pneumoniae and strep.viridans associated with ?
Strep.penuomiae - commonest cause of pneumonia
Strep.viridans - commensals of mouth, throat, vagina - rarely cause infection
Give some examples of non-haemolytic strep (gamma) and the type of infection they are mainly associated with
Enterococcus species (E. faecalis, E. faecium)
- Commensals of bowel
- Common cause of UTI
What are some of the defence features of the skin against infection ?
- Barrier
- Sebum - fatty acids - inhibit bacterial growth
- Competitive bacterial flora
Give a couple examples of the micro-organisms involved in the competitive bacterial flora of the skin
- Staphylococcus epidermidis
- Corynebacterium sp. (“diphtheroids”)
- Proprionobacterium sp.
List some of the skin infections which staph.aureus can cause
- Boils and Carbuncles
- Other minor skin sepsis (infected cuts etc.)
- Cellulitis
- Infected eczema
- Impetigo
- Wound infection
- Staphylococcal scalded skin syndrome
What bacterial complications can develop as a result of atopic dermatitis ?
- People with atopic dermatitis also seem to have a reduced ability to fight against these common bacteria on the skin.
- As a result, they frequently suffer from bacterial skin infections such as boils, folliculitis and impetigo.
What is impetigo?
- A common acute superficial bacterial skin infection. Characterised by pustules and honey-coloured crusted erosions (‘school sores’).
- It can be a primary infection or a complication of an existing skin condition such as eczema (in this case), scabies or insect bites
What is the main causative organisms of impetigo?
- Staph. Aureus
- Or sometimes Streptococcus pyogenes
In what age group is impetigo most common in ?
Children
Is impetigo contagious and if so how is it spread?
Yes very contagious:
- Spread is by direct contact with discharges from the scabs of an infected person. The bacteria invade skin through minor abrasions and then spread to other sites by scratching. Infection is spread mainly by the hands, but indirect spread via toys, clothing, equipment and the environment may occur.
Where on the body does impetigo most commonly develop?
- Face (in particular the peri-oral and peri-nasal areas), limbs esp hands and flexures (such as the axillae)
- Can occur anywhere though
What are the 2 main types of impetigo?
- Non-bullous - most common
- Bullous
What are the clinical features of non-bullous impetigo ?
- Vesciles or pustules initially develop & quickly rupture (so seldom seen clinically) releasing exudate which forms characteristic golden/brown crust
- Usually asymptomatic but may have mild itch
- Heals without scarring
What are the clinical features of bullous impetigo?
- Lesions initially appear as flacid fluid filled vesicles & blisters (bullae) for 2-3days
- Blisters then rupture leaving yellow (golden)/ brown crust
- Heals without scarring
How is impetigo diagnosed ?
- Clinically
- Swabs for culutures & sensitivity considered in cases which are persistent despite treatment, recurrent, or widespread.
What is the treatment of localised lesions of imetigo?
1st line = topical fusidic acid
What is the treatment of extensive or severe impetigo?
- 1st line = flucloxacillin
- 2nd line = clarithromycin
What skin infection is shown here and what could be the causative organism ?
Infected eczema - could be caused by:
staph.aureus, Strep pyogenes (Group A strep)
List some of the bacterial skin infections which Strep pyogenes (Group A strep) is associated with ?
- Infected eczema
- Impetigo
- Cellulitis
- Erysipelas
- Necrotising fasciitis – (N.B. may also be caused by mixed bacterial infection).
What is staphylococcal scalded skin syndrome (SSSS) & what is it caused by ?
- It is an illness characterised by red blistering skin that looks like a burn or scald
- SSSS is caused by the release of two exotoxins (epidermolytic toxins A and B) from toxigenic strains of the bacteria Staphylococcus aureus. These exotoxins causes splitting between desmosomes in granular layer
Who is most frequently affected by SSSS?
Children < 5 esp neonates
What are the clinical features of SSSS?
- SSSS starts from a localised staphylococcal infection:
- Initially - fever, irritability & widespread redness of the skin
- Exstremly tender fluid-fluid blisters (bullae) then form. These blisters easily rupture leaving an area of skin that looks like a burn (rash)
- Bullae are Nikolsky positive
- Characteristics of the rash include; tissue paper like wrinkling of the skin, rash spreads to other part of the body, top layer of skin peeling off in sheets leaving an exposed moist red & tender area
- Additional features - weakness & dehydration
How is SSSS diagnosed?
Usually clinically but swabs for C&S sent off & skin biopsy can be used to confirm it
What is the treatment of SSSS?
- Hospital admission for - Topical fuisidic acid + IV flucloaxcillin
- Also analgesia + Moist, bare areas should be lubricated with a bland emollient
What is cellulitis ?
It is an acute bacterial infection of the (lower) dermis and subcutaneous tissue.
What are the main causative organisms of cellulitis ?
Streptococcus pyogenes (two-thirds of cases) and Staphylococcus aureus (one third).
What are the risk factors for developing cellulitis ?
- Previous episode(s) of cellulitis
- Fissuring of toes or heels, eg due to athlete’s foot, tinea pedis or cracked heels
- Venous disease,eg gravitational eczema, leg ulceration, and/or lymphoedema
- Current or prior injury, eg trauma, surgical wounds, radiotherapy
- Immunodeficiency, eg human immunodeficiency virus infection (HIV)
- Immune suppressive medications
- Diabetes
- Chronic kidney disease
- Chronic liver disease
- Obesity
- Pregnancy
- Alcoholism
Where on the body is cellulitis most commonly seen?
More commonly seen in the lower limbs and usually affects one limb (bilateral leg cellulitis is very rare)
What are the clinical features of cellulitis ?
- An acute onset of erythema, painful, hot, swollen, and tender skin, that spreads rapidly.
- Usually an obvious skin break where the infecting organism may have entered e.g. a wound, macerated skin, fungal skin infection, an ulcer, or a concomitant skin disorder (such as atopic eczema).
- Erythema may be diffuse or well-demarcated allowing it ot be marked with a pen in order to monitor progress.
- Associated symptoms - may have Fever, malaise, nausea, shivering, and rigors
What is erysipelas ?
A superficial form of cellulitis it affects the upper dermis and extends into the superficial cutaneous lymphatics. It is also known as St Anthony’s fire due to the intense rash associated with it
What are the risk factors for developing erysipelas ?
Same as those for cellulitis
What is the main causative organism of erysipelas ?
Group A beta haemolytic streptococci (Streptococcus pyogenes)
What are the clinical features of erysipelas ?
- Usually affects the lower limbs but may affect the face witha butterfly distribution
- Rash occurs aburptly and is associated with fever
- The affected skin has a very sharp, raised border.
- It is bright red, firm and swollen. It may be finely dimpled (like an orange skin).
- Cellulitis does not usually exhibit such marked swelling but shares other features with erysipelas, such as pain and increased warmth of affected skin.
What skin infection is shown here and what could of caused it ?
Erysipelas
How is cellulitis & erysipelas diagnosed?
Clinically some investigations may be done however to rule out other causes or confirm:
- Inflam markers - ESR, CRP, WCC
- Doppler U/S to help exlude DVT
- Swab for culture if there is an open wound
What is the treatment of cellulitis & erysipelas ?
- 1st line = Flucloxacillin
- 2nd line = doxycyline if history or risk of MRSA
What is the treatment of facial cellulitis ?
- Treat as per cellulitis guidance
- HOWEVER if sinus/dental/mandibular source 1st line = co-amoxiclav or clindamycin
How are bacterial skin infections diagnosed ?
Swab of lesion if surface broken or swab Pus or tissue if deeper lesion. Take +/- blood cultures, if appropriate
What is the antibiotic treatment of choice for strep.pyogenes (Group A strep)?
Penicillin (flucloxacillin)
Define what Necrotising faciitis is
It is a very serious bacterial infection of the soft tissue and fascia. The bacteria multiply and release toxins and enzymes that result in thrombosis (clotting) in the blood vessels. The result is destruction of the soft tissues and fascia.