IN THE NAME OF THE MOST HIGH

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IN THE NAME OF THE MOST HIGH
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SKIN AND SOFT TISSUE INFECTIONS
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PHYSICAL CHARACTERISTICS OF THE SKIN

• Mechanical barrier of stratum corneum
• Relatively low PH(5.5)
• Natural antibacterial substances in the
  secretions of sebaceous glands
• Relative dryness of normal skin
• Bacterial interference

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PREDISPOSING FACTORS

• Disruption of stratum corneum
• Burn and bites
• abrasion
• Surgery
• Vascular/pressure ulcer
• Underlying condition (dermatitis ,HSV,
  varicella)
• injections
• Foreign body ( IV cath. Suture )
• Hair follicle normal flora
• extrinsic bacteria

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PREDISPOSING FACTORS

• Reduced vascular supply
• Disruption of lymphatic or venous drainage
• Compromised immune system

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IMPETIGO
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Etiology

• gAS
• Staphylococcus aureus (MRSA has been reported)
• gCS rarely
• gGS
• Gbs (in newborn)

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Epidemiology

• gAS -hot,humid,summer weather (tropical,
  semitropical)
• -young children (2 5 y)
• -follows skin colonization by 10d
• -sporadic cases in cooler climates
  may
• be due to contagious spread from
• nasopharynx
• Highly communicable
• Related to PSGN but not ARF
• S.aereus -follow nasal colonization

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Predisposing factor

• Poor hygiene
• Crowding
• Minor trauma (scratch)
• Insect bite
• Preexisting skin disease(dermatitis)

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Clinical manifestation

• Red papule ? Small vesicle ?pustulate ?
• rupture ?
• Thick yellow stuck-on crusts
• Usual site face(around the nose and mouth)
• legs
• Painless
• Pruritic
• Mild regional adenopathy
• Minimal constitutional symptoms
• Recovery without scar

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Bullous impetigo

• S.aureus
• Newborn and younger children
• 10 of all cases of impetigo
• Epidermal split caused by exfoliative toxin
• More extensive lesions
• 1-2 cm bullae containing neutrophils and organism
• thin paper-like crusts

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TREATMENT

• Topical mupirocin
• PRP cloxacillin 250mg qid
• 1st g. ceph. cephalexin 250mg qid
• In the past penicillins (benzathin,oral P.V,
• 
  amoxicillin)
• in case of allergy erythromycin
• duration 10d

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FOLLICULITIS
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General considerations

• Etiology Staphylococcus.aureus
• Superficial infection within hair follicles
  apocrine region
• papule
• small(2-5mm)
• erythematous
• Occasionally pruritic
• Topped by a central pustule

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Treatment

• Local measures
• saline compress
• topical antibacterials
• Duration until resolution of infection
• (5-7 d)

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• Chronic folliculitis
• Uncommon except in acne vulgaris,
• Constituents of the normal flora (e.g.,
  Propionibacterium acnes) may play a role
• Diffuse folliculitis
• Hot-tub folliculitis
• Swimmers itch

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Hot-tub folliculitis

• Pseudomona.aeruginosa
• -contaminated swimming pools
• insufficiently chlorinated , 37-40c
• -IP48h
• -papulourticarial?pustule
• -healing within 5 days
• -bacteremia has been reported

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swimmers itch

• Exposure of skin to freshwater infested with
  avian schistosomes
• Warm water and alkaline PH
• suitable for mollusks(intermediate host)
• Schistosomal cercariae penetrate hair follicles
  but quickly dies
• Allergic reaction intense itching and erythema

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Other less common forms

• Enterbacteriaceae
• -complicate acne
• -during prolonged AB therapy
• Candida
• -surrounding areas of intertriginous
• -pruritic satellite lesion
• -prolonged AB or C.S

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FURUNCLECARBUNCLE
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Furuncle

• Deep seated (subcut.) necrotic infection
• Extend from a hair follicle to a true abscess
• Siteareas that are subject to friction and
  perspiration and contain hair follicles
  (buttock,face,neck)
• Painful , firm, red nodule
• Fever and constitutional symptoms
• Subside after spontaneous drainage

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Carbuncle

• Deep infection of a group of contiguous follicles
• Site back of the neck,shoulders,hip,thigh
• More severe,necrotic and painful
• External drainage along hair follicules
• Intense inflammation of surrounding and
  underlying connective tissue
• Fever ,malaise and leukocytosis

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Predisposing factors

• Diabetes mellitus
• Obesity
• Blood dyscrasia
• Corticosteroid therapy
• Defect in neutrophil function

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Complication

• Blood stream invasion
• Infective endocarditis
• Metastatic foci
• Osteomyelitis
• Upper lip,nose spread to cavernous sinus

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Treatment

• Systemic antibiotics esp. if cellulitis
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  fever
• 
  midface
• Severe infection nafcillin/cloxacillin
• 
  1-2g iv q4h
• cefazolin 1g iv
  q8h
• Mild infection cloxacillin/cephalexin
• 250-500mg po
  qid
• Duration 7-10d
• Surgery large and fluctuent

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Furuncle
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Furuncle
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Carbuncle
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ERYSIPELAS
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Etiology

• gAStrep
• Uncommonly gC gGStrep
• In newborns gBStrep

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Clinical manifestation

• Site formerly face was most common
• now distribution has changed
• 70-80 lower
  extremity
• 5-20 face
• Infants and elderly adults most affected

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Clinical manifestation

• Abrupt onset
• Rapid progression
• Translocation of strep. laterally via lymphatics
• Flaccid edema of the epidermis
• Engorgement or obstruction of lymphatics

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Clinical manifestation

• Bright,red swelling
• Warm , intense pain
• Raised,indurated,sharply demarcated margin
• Peau d orange texture
• involvement of superficial lymphatic
• Flaccid bullae during 2nd or 3rd day
• Desquamation 5-10 days in to the illness
• Fever , leukocytosis is a feature
• Extension to deeper soft tissue is rare
  

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Treatment

• Mild,early -procaine penicillin 1.2mu bid IM
• -penicillin.V
  oral
• -erythromycin in case of
  allergy
• Severe -penicillin.G 1-2mu q4h IV
• If cellulitis is a D.Dx -PRP(nafcillin,oxacilli
  n)
• -1st g.
  ceph.

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Treatment

• Swelling may progress despite appropriate
  treatment
• Fever
• Pain diminish
• Intense red color

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CELLULITIS
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Etiology

• S.aereus
• MRSA is rapidly replacing MSSA
• gA strep.
• gC strep sometimes
• gG strep sometimes
• Wide variety of exogenous bacteria

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Predisposing factor

• S.aureus central localized infection (e.g.
  abscess , folliculitis , infected foreign body ,
  surgical or traumatic wounds)
• Strep. minor or inapparent breaks
• disrupted lymphatic drainage
• surgical wound infection (1st 24 h )

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Clinical manifestation

• Pain and local tenderness
• Hot
• swollen
• Erythema
• Strep more rapidly spreading
• frequently associated with fever
• and lymphangitis

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Clinical manifestation

• Diffuse spreading infection
• Involves skin and subcutaneous tissue
• (deeper than erysipelas)
• Systemic signs (fever,malaise,chills)
• Regional lymphadenopathy
• Border not elevated ,not demarcated

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Diagnosis

• If drainage
• an open wound gram
  stain
• an obvious port of entry culture
• In the absence of these findings definite
  diagnosis of etiology is difficult
• Culture of needle aspiration and punch biopsy
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• Blood culture lt5

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Differential diagnosis

• Necrotizing fasciitis
• Insect bite
• Fixed drug eruption
• DVT
• FMF
• Pyoderma gangrenosa
• Sweets syndrome

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Treatment

• Indications for admission
• - rapid progression
• - systemic reaction (chills and fever)
• - underlying condition (immunedefficiency,
  asplenia, previous edema, cirrhosis, renal
  failure, heart failure)

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Treatment

• Hospitalized patients
• -Nafcillin or oxacillin 2g iv
  q4-6h
• -Cefazolin 1-2g iv
  q8h
• Mild infection
• -Cloxacillin 500mg po
  q6h
• -Cephalexin 500mg po
  q6h
• Other agents vancomycin, clindamycin,
  erythromycin, TMP/SMX, quinolones (CAMRSA)

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Treatment

• Duration 10-14 days
• Shift from IV to PO after systemic symptoms and
  erythema resolved

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Recurrent forms

• Saphenous venectomy for CABG
• Edema,erythema,tenderness
• Chills,high fever,toxicity
• Associated lymphangitis
• Spread along the course of venectomy
• EtiologygA non gAßHS (gC,gG)
• Port of entryassociated area of tinea pedis

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Recurrent forms

• Chronic lower extremity lymphedema
• Radiation therapy
• Neoplastic involvement of pelvic lymph node
• Lymph node dissection
• Chronic venous stasis (prior DVT)

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Recurrent forms

• Stapylococcus
• Job s syndrome (eosinophilia and, IgE)
• Nasal carriers of staph

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Other microorganisms

• S.agalactiae(gBS)
• Elderly, diabetes, neurologic impairment,
  Peripheral vascular disease, HIV
• Haemophilus.influenza
• Children
• Violaceous, facial cellulitis(periorbital,cheek)
• In association with sinusitis,otitis,epiglotitis

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Other microorganisms

• P.aeruginosa
• 3 types of soft tissue infections
• Ecthyma gangrenosum in neutropenic patients
• Hot tub folliculitis
• Cellulitis penetrating injuries (step on a
  nail)
• hospitalized
  immunocompromised host
• Treatment surgical drainage and
  inspection
• antimicrobial (AG , 3rd
  generation ceph.
• ,
  semisynthetic penicillin , quinolone)

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Other microorganisms

• Pasteurella multocida, Staphylococcus intermedius
  and Capnocytophaga canimorsus
• cat or dog bite
• Eikenella corrodens
• human bite
• Amoxicillin/clavulanate, ampicillin/sulbactam,
  and cefoxitin are good choices for the treatment
  of animal or human bite infections

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Other microorganisms

• Erysipelothrix.rhusiopathiae
• Fish and domestic swine butcher, fisherman,
  veterinarian
• Aeromonas hydrophilia
• Fresh water (lakes,rivers,streams)
• Vibrio vulnificus
• Seawater or seafoods
• M. marinum
• water in aquariums or swimming pools

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NECROTIZING SOFT TISSUE INFECTIONS
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Necrotizing fasciitis

• Destruction of subcutaneous tissue and fascia
• Physical findings ,particularly early in the
  illness, may not be striking when pain or
  unexplained fever is the only manifestation with
  no or minimal erythema

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• Infectious disease emergency
• In the initial phase distinguishing between
  cellulitis and fasciitis is difficult

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Necrotizing fasciitis

• Involvement of deeper tissue is suggested
• Failure to respond to therapy
• Hard , wooden feel of subcutaneous tissue
• Systemic toxicity
• Bullous lesion
• Skin necrosis and ecchymosis
• Rapid spread
• Gas in soft tissue
• Edema that extends beyond the margin of erythema
• Skin anesthesia

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Necrotizing fasciitis

• Clinical manifestation
• severe local pain?anesthesia
• cellulitis with progressive edema,erythema
• dark red induration of epidermis
• bullae filled with blue or purple fluid
• friable skin with bluish ,maroon or black color
• thrombose of blood vessels in dermal papilla
• crepitation
• fever , systemic toxicity ?shock and multiorgan
  failure

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Necrotizing fasciitis

• TYPE 1 polymicrobial (anaerobe,g ,g- )
• Predisposing - a breach in the integrity of
  mucous membrane (GI or GU) malignancy ,
  diverticulum , urethral tear
• - surgery
• - diabetes
• - peripheral
  vascular disease
• - injection drug use

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Necrotizing fasciitis

• TYPE 2 gAstrep (streptococcal gangrene)
• Predisposing
• - non penetrating minor trauma(a
  bruise, muscle strain) via transient bactremia
• - cutaneous infection , penetrating
  trauma
• Toxicity is severe
• 20-40 myositis occur concomitantly
• Markedly elevated CPK
• Gas is not usually present

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Fourniers gangrene

• A type of necrotizing fasciitis
• Leakage to the perineal area
• Mixed aerobe-anaerobe infection
• Massive swelling of scrotum and penis
• Extension to the prineum , abdominal wall and
  legs

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Necrotizing fasciitis

• Diagnosis
• Vigilant and serial clinical examination
• Soft tissue radiographs and CTscans
• Local abscess or gas
• only soft tissue swelling in some cases
• Aspiration of the leading edge or punch biopsy
• false negative in nearly 80
• Open surgical inspection with debridement

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Necrotizing fasciitis

• Rx surgical drainage and debridement
• 1) visualize the deep structure
• 2)remove necrotic tissue
• 3)reduce compartment pressure
• 4)obtain material for smear
  culture
• Hyperbaric oxygen

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Necrotizing fasciitis

• Rx type 1 Ampicillin or
  ampicillin/sulbactam
• Gentamicin
• metronidazole/clindam
  ycin
• ampicillin
• ciprofluxacin
• metronidazole/clindam
  ycin
• type 2 penicillin G
• clindamycin

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Clostridial gas gangrene(clostridial myonecrosis)
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Etiology

• Clostridial spp.
• C.perfringes? 80 of cases
• -trauma
• need not to be severe
• but must be
  deepnecrotic
• -surgery
• -intramuscular injection

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Etiology

• C.septicum?spontanous,nontraumatic
• GI abn (cancer,surgery,diverticulitis)
• leukemia,lymphoma
• neutropenia
• HIV infection

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Clinical manifestation

• Short IP almost alwayslt3d frequentlylt24h
• Sudden onset of exquisite increasing pain
• Local swelling and edema
• Thin hemorrhagic exudate
• Frothiness of wound exudate
• Tachycardia ,minor elevation in temperature
• Gas may be absent at early stages

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Clinical manifestation

• Skin is tense , white marbled with blue and
  cooler than normal
• Rapid progression of edema toxemia
• Profuse serosanginous discharge with sweetish
  smell
• Bullae ,patches of cutaneous gangrene, bronze
  discoloration
• Gas in affected tissue

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Clinical manifestation

• High LOC until just before death
• Hypotension ,renal failure
• At surgery -muscle may appear pale
• -does not contract
• -beefy red and nonviable
  when
• dissected

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Diagnosis Treatment

• Gram stain gram positive bacilli (box car)
• paucity of PMN
• Surgery muscles are pale ,nonviable
• frozen section
• Rx surgical removal of devitalized tissue
• antibiotic clindamycin penicillin
• metronidazole
• chloramphenicol
• hyperbaric oxygen

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DIABETIC FOOT ULCERS

• Chronic foot infections in patients with D.M are
  common and difficult problems
• Minor trauma in presence of peripheral
  neuropathy , neuropathic ulcers , vascular
  insufficiency
• Different forms cellulitis , tissue necrosis ,
  osteomyelitis

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Clinical manifestation

• Non limb threatening
• Superficial
• Lack of systemic toxicity
• Minimal cellulitis lt 2 cm from port of entry
• Ulceration (if present) not fully extending
  through the skin
• Lack of significant ischemia

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Clinical manifestation

• Limb threatening
• More extensive cellulitis
• Lymphangitis
• Ulcer penetrating through skin in to subcutaneous
  tissue
• Prominent ischemia

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Etiology

• Non limb threatening
• S.aureus is major pathogen
• Facultative streptococci in one third
• Facultative gram negative and anaerobe are
  uncommon
• Limb threatening
• Polymicrobial (S.aureus ,Gbstrep. ,facultative
  gram negative ,anaerobe)

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Medical Treatment

• Non limb threatening
• Mild oral cephalexin , cloxacillin ,
• clindamycin
• Complicated by cellulitis parentral cephazolin
• Limb threatening
• Broad spectrum eg clindamycin3rd g ceph.
• 
  clindamycinciprofluxacin
• 
  Ampicillin-sulbactam

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Surgical management

• Unroofing
• Probing
• Debridement and drainage promptly if
• -deep ulcers extending to subcutan.
• -deep tissue necrosis
• -suppuration
• Amputation

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Other measures

• Bed rest
• Elevation
• Control of diabetes

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Prevention

• Tight glycemic control
• Examination of the foot
• Avoid extreme bath water temperature
• Avoid foot soaks
• Dry the foot thoroughly after bath
• Trim the nails correctly
• Treat tinea pedis promptly
• Selection of appropriate footwear

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