Bacterial Infections of the Skin Bacterial Organisms Staphylococcus Streptococcus Gram (+) cocci -- Catalase test: (+) Staphylococcus

us (-) Streptococcus Staphylococci staphyle: bunch of grapes Non-motile, non spore former Relatively resistant to heat & drying Can persist for long periods in fomites Facultative anaerobes Fermenting carbohydrates Inhibited by certain chemicals (hexachlorophene) Suppuration, abscess formation, a variety of pyogenic infections, & even fatal septicemia Pathogenic staphylococci: hemolyze blood, coagulate plasma & produce a variety of extracellular enzymes & toxin Heat-stable staphylococcal enterotoxin Develop resistance Staphylococcus Coagulase test: (+) S. aurues (-) S. epidermis, S. saprophyticus Staphylococci 40 species 1. Staphylococcus aureus Major pathogen for humans 2. Staphylococcus epidermidis 90% of normal flora Potentially pathogenic 3. Staphylococcus saprophyticus Immunocompromised patients Common cause of UTI in young women Staphylococci Cell Wall Major Components: antigenic structures

Peptidoglycan rigid exoskeleton of the cell wall N acetyl muramic acid with tetrapeptide chains cross-linked by pentaglycine bridges Tight structure; survival in environment of host tissue Destroyed by strong acid or exposure to lysozyme Important in the pathogenesis of infection Elicits production of interleukin-1 (endogenous pyrogen) and opsonic antibodies by monocytes Chemoattractant for polymorphonuclear leukocytes Endotoxin-like activity Activate complement Teichoic acids Polymers of glycerol or ribitol phosphate Linked to the peptidoglycan Component of phage receptor Antiteichoic acid antibodies detectable in patients with active endocarditis Controls activity of autolytic enzymes(growth of cell wall & separation of daughter cells) Protein A Surface protein; specific for S.aureus adhesins (MSCRAMMS) microbial surface component recognizing matrix molecules): virulence factor covalently linked with peptidoglycan binds to the Fc portion of IgG molecules except IgG3 important reagent in immunology and diagnostic laboratory technology coagglutination Anticomplimentary: antiphagocytic; elicits HPS reaction; platelet injury Capsules inhibit phagocytosis by PMNs Coagulase, or clumping factor binds nonenzymatically to fibrinogen, yielding aggregation of the bacteria 1

Staphylococci Grouping of stains: susceptibility of S. aureus to temperate bacteriophage group I group II: skin infections (impetigo; pemphigus of NB) group III: methicillin resistant; enterotoxin group IV: enterotoxin Determinants of pathogenecity: surface antigens: antiphagocytic extracellular enzymes: ability to multiply and spread widely in tissues coagulases: clots plasma lipases: active on plasma, fats & oils; intense colonization in sebaceous areas; invasion of healthy skin; correlation with boils 1. Catalase - Converts hydrogen peroxide into water and oxygen 2. Coagulase and Clumping Factor - Clots plasma - Binds to prothrombin enzymatically active and initiate fibrin polymerization - Protects organism from phagocytosis and isolate from defenses - Invasive pathogenic potential Clumping factor: adherence of the organisms to fibrinogen & fibrin 3. Other enzymes Hyaluronidase - hydrolyzes hyaluronic acid in intracellular ground substance (spreading factor) Staphylokinase - fibrinolytic; activation of plasma plasminogen to fibrinolytic enzyme plasmin Nucleases cleaves DNA or RNA Proteinases; lipases and lactamase 4. Exotoxins Alpha toxins hemolysis; lethal & dermonecrotic Disrupts lysosomes; cytotoxic to tissues

Injury to circulatory system, muscle tissues, renal cortex Beta toxins degardes sphingomyelin, RBCs Delta toxins Gamma toxins diarrheal diseases Lysing WBCs by causing pore formation Release IL8, leukotriene, histamine 5. Panton-Valentine Leukocidin Fast & slow components Kill white blood cells of humans & rabbits Synergistically on the white blood cell membrane to form pores and increase cation permeability Associated with MRSA 6. Exfoliative toxins (epidermolytic toxins) Generalized exfoliation (Ritters syndrome) Toxic epidermal necrolysis (adult) Staphylococcal Scalded Skin syndrome (SSS) or Generalized scarlatiniform eruptions: children Epidermolytic toxin A - Chromosomal gene product; heat stable (resists boiling for 20 minutes) Epidermolytic B - Plasmid-mediated and heat-labile Superantigens EXOTOXIN & EXFOLIATIVE TOXINS: Clinical Manifestations Histologically: intraepidermal cleavage plane at stratum granulosum (S. Aureus group II) 7. Toxic Shock Syndrome Toxin (TSST) Superantigen Binds to MHC Class II molecules T cell stimulation Protean manifestations of the toxic shock syndrome-1 (TSST-1) - Fever, shock & multisystem involvement, including a desquamative skin rash Gene for TSST-1: 20% of S. aureus isolates 2

Pathogenesis Nasal carriage of S aureus: 20-50% of humans Found in clothing, bed linens & other fomites in human environments Combined effect of extracellular factors and toxins together with the invasive properties of the strain Pathology: Penetrate sebaceous gland or hair shaft Proteases: chemotaxis Tissue necrosis (dermonecrotic factor) Coagulase: coagulates fibrin around the lesion & within the lymphatics (formation of a wall) Accumulation of inflammatory cells Fibrous tissue (avascular fibroblastic wall) Liquefaction of the necrotic tissue Abscess points in the direction of least resistance Granulation tissue and eventual healing Folliculitis Furunculosis Carbuncle Abscess

Diagnostic Laboratory Tests Specimens Surface swab, pus, blood, tracheal aspirate, or spinal fluid for culture Smears Not possible to distinguish saprophytic from pathogenic Culture Blood agar plates Catalase Test A drop of hydrogen peroxide solution plus a small amount of the bacterial growth Positive test: formation of bubbles (the release of oxygen) Coagulase Test Citrated rabbit (or human) plasma mixed with growth colonies on agar and incubated at 37C Positive: clots form in 1-4 hours Coagulase (+): pathogenic Susceptibility Testing Broth microdilution or disk diffusion susceptibility testing Gene detection by polymerase chain reaction Serologic and Typing Tests Little value Molecular typing techniques Resistance Classes - Plasmid mediated; genetic 1. Beta-Lactamse producing: - Resistant to many penicillins (penicillin G, ampicillin, ticarcillin, piperacillin & similar drugs) 2. Resistance to nafcillin (and to methicillin and oxacillin): - Staphylococcal cassette chromosome SCCmecA gene - SCCmec typeIV: community acquired MRSA

Staphylococci Clinical Findings Wall prevent spread of the organisms Direct contamination of a wound - Spread via the lymphatics & bloodstream - Associated with thrombosis - Bacteremia; endocarditis, acute hematogenous osteomyelitis, meningitis, or pulmonary infection Toxic shock syndrome - Abrupt onset of high fever, vomiting, diarrhea, myalgias, a scarlatiniform rash, and hypotension with cardiac & renal failure - Associated with the use of tampons - In wounds or other localized infections, or in the throat but virtually never in the blood stream

Lack or inaccessibility or penicillin-binding proteins (PBPs) in the organisms

3. Vancomycin-Intermediate S Aureus or VISA - Patients with complex infections on prolonged vancomycin therapy - Associated with increased cell wall synthesis and alterations in the cell wall 4. Vancomycin-resistant S aureus (VRSA) strains gene vanA from enterococci - Nafcillin resistance gene mecA - Major concern worldwide 5. Plasmid-mediated resistance to tetracyclines, erythromycins, aminoglycosides 6. Tolerance: inhibited but not killed by the drug - Difference between minimal inhibitory and minimal lethal concentrations of an antimicrobial drug - Attributed to lack of activation of autolytic enzymes in the cell wall Streptococci Gram-positive cocci in pairs or chains 20 species Pasteur: in puerperal sepsis Kochs: wound infection 1883: pure culture 1930: Lancefield classification Classification based on: 1. Colony growth characteristics 2. Cell wall group-specific cell substance and capsular antigens 3. Biochemical reactions 4. Ecologic features Catalase negative Hemolysis: Beta Hemolysis: complete disruption of erythrocytes, clearing of blood around growth culture

Alpha hemolysis: incomplete lysis (S.pneumoniae) Viridans Group (S.mutans, S. sanguis, S.milleri, S. mitior) Group-Specific Cell Wall Antigen Lancefield groups A-H, K-U: Carbohydrate-cell wall; basis of serologic grouping Specificity of the group-specific carbohydrate: determined by an amino sugar Group A streptococci (GAS): rhamnose-Nacetylglucosamine Group A, B, and C strains: produce capsules of hyaluronic acid-impede phagocytosis A- S.pyogenes: Human pathogen Local or systemic Poststreptococcal disorders B- S. agalactiae C- S.equi D- enterococci Streptococcus Pyogenes Group A b --- hemolytic streptococcus Rigid cell wall Capsule: hyaluronic acid identical to that of humans: binds to hyaluronic acid binding protein CD44 in human epithelial cells Produces hyaluronidase Fuzzy surface: type specific M protein Energy: principally from the utilization of sugars (lactic acid as end product) Facultative anaerobes Oxidase (-) Variants of the same streptococcus strain may show different colony forms - Matt colonies: M proteins-rich; heavy encapsulation; virulent and insusceptible to phagocytosis by human leukocytes - Glossy colonies: often nonvirulent Streptotcoccus Pyogenes Cell wall: Proteins (M, T, R antigens) Carbohydrates (group-specific) Peptidoglycans Hair-like pili project through the capsule 4

 Pili M protein and covered with lipoteichoic acid (attachment of streptococci to epithelial cells) Streptococcus Pyogenes: Antigenic Structure M Protein Major virulence factor Hair-like projections in the cell wall Able to resist phagocytosis by PMNs Prevents activation of complement 150 types Presence of type-specific antibodies to M protein: immunity Two major structural classes of M protein: Classes ! & II Important role in the pathogenesis of rheumatic fever Class I M protein - induces antibodies that cross react with human cardiac muscle tissue (virulence determinant for rheumatic fever) T Substance No relationship to virulence Determined by agglutination with specific antisera R protein Destroyed by pepsin not trypsin Nucleoproteins P substances: streptococcal cell body No serologic activity Capsular antigens: Hyaluronic acid; little antigenic significance Enhances virulence Toxins & Enzymes 1. Streptokinase (Fibrinolysin): - Active proteolytic enzyme that digests fibrin and other proteins (dissolves clots) - Transforms that plaminogen of human plasma into plasmin - Antistreptokinase: specific antibody Given for the treatment of pulmonary emboli and coronary artery and venous thromboses

2.

Streptodornase: Streptotococcal deoxyribonuclease Depolymerizes DNA Purulent exudates: deoxyribonucleoprotein Antibody vs. DNAse: develops after skin infection; serodiagnosis Streptodornase and streptokinase: in enzymatic debridement

3. Hyaluronidase Spreading infecting microorganisms (spreading factor) Splits hyaluronic acid: ground substance of connective tissue Antigenic and specific Serodiagnosis 4. Pyrogenic Exotoxins (Erythrogenic Toxin) - Rash in scarlet fever, pyrogenicity; dermal reactivity; secondary hypersensitivity Exotoxin A - Streptococcal toxic shock syndrome - Scarlet fever Exotoxin C - Increases permeability of BBB to endotoxin; pyretic effect on hypothalamus Exotoxin B: unclear 5. Diphosphopyridine Nucleotidase Elaborated into the environemtn by some streptococci Ability to kill leukocytes Serodiagnosis of pharyngeal and skin infections Proteinases and amylase 6. Hemolysins: a. Streptolysin O (SLO): potent antigen Inactivated by oxygen; inactivated by cholesterol Toxic for RBCs, WBCs, myocardial cells Immunogenic Antistreptolysin O (ASO) antibody vs. SLO - Quantitative test for the antibody 5

Serum titer: >160-200 units: recent infection with streptococci or earlier exposure in a hypersensitive person b. Streptolysin S: Oxygen stable, non antigenic Responsible for the hemolytic zones around colonies growing in blood agar plates Elaborated in the presence of serum Hemolysis by direct cell to cell contact (RBCs and WBCs) Independent of past infection

Rash trunk to extremities Streptococcal Toxic Shock Syndrome Bacteremia, respiratory and multiorgan failure following soft tissue infection M types 1 or 3; 12 and 28 producing exotoxin A or B Poststreptococcal Acute Glomerulonephritis (PSGN) 1-4 weeks after skin infection M types 2, 42,49,56,57,60 Antigen-antibody complexes on the glomerular membrane Hematuria, proteinuria, edema, hypertension Chronic GN, renal failure Diagnosis: Smears Culture: blood agar Antigen detection Serologic tests: ASO; antiDNAse; antihyaluronidase; antistreptokinase, antiM Treatment: Penicillin G Erythromycin Vary in their susceptibility Aminoglycosides often enhance the rate of bactericidal action of penicillin Propionibacterium Normal flora of the skin; gm (+) anaerobe Highly pleomorphic, showing curved, clubbed, or pointed ends, long forms with beaded uneven staining and occasionally coccoid or spherical forms Contaminates blood or cerebrospinal fluid cultures Metabolic products include propionic acid Acne: produces lipases split fatty acids tissue inflammation Post surgical infections

Streptococcus Pyogenes Diseases: Invasion by S. pyogenes Portal of entry: determines the principal clinical picture Diffuse and rapidly spreading infection Minimal local suppuration Infection can extend to the bloodstream Streptococcal Pyoderma: Impetigo Superficial layer of the skin Highly communicable Hot & humid climates M types 49, 57, 59-61 May lead to glomerulonephritis Streptococcus Pyogenes: Erysipelas Skin & subcutaneous tissues Face Cellulitis: Lymphangitis, lymphadenopathy Streptococcus Pyogenes Necrotizing Fascitis Streptococcal gangrene Soft tissue; muscles; fascia flesh eating bacteria Associated with diabetes, PVD Usually mixed infections Exotoxin A Scarlet Fever Strep producing exotoxin A-C; following pharyngitis or skin or soft tissue infection

Pseudomonas Aeruginosa Widely distributed I n nature, soil, water Normal stools, skin Commonly present in moist environments in hospitals Saprophyte Opportunistic pathogen Primarily a nosocomial pathogen Motile and rod-shaped, gram-negative Resistant to chemical disinfection Gram negative obligate aerobe In culture sweet or grape-like or corn tacolike odor Forms smooth round colonies with a fluorescent greenish color Pyocyanin Pyoverdin Pyorubin Pyomelanin Can produce multiple colony types Different biochemical and enzymatic activities and different antimicrobial susceptibility patterns Oxidase-positive Oxidize glucose Pseudomonas Aeruginosa Antigen Structure & Toxins Somatic or O antigen: grouping of strains Pili (fimbriae): attachment to host epithelial cells Exopolysaccharide: for the mucoid colonies Lipopolysaccharide: endotoxic properties Pathogenesis Burns, malignancy, metabolic diseases, instrumentation/manipulation (intravenous or urinary catheters) Attaches to and colonizes the mucous membranes or skin, invades locally and produces systemic disease Clinical Findings: Pseudomonas dermatitis Otitis externa: swimmers ear Infection of wounds and burns: blue-green pus; Verdoglobin

Ecthyma gangrenosum Meningitis, urinary tract infection necrotizing pneumonia Fatal sepsis Diagnostic Laboratory Tests Specimens: from site of infection Smears Gram-negative rods No specific morphologic characteristics Culture Blood agar Does not ferment lactose Specific test Treatment Should not be treated with single-drug therapy Ticarcillin or piperacillin plus aminoglycoside Aztreonam, imipenem Quinolones (ciprofloxacin) Ceftazidime and cefoperazone Susceptibility tests Mycobacterium Leprae Leprosy; 1400 BC Hebrew writings Old testament stories Hansen in 1873 Mycobacterium Leprae Obligate intracellular organism Acid-fast, long, slender, non-motile bacilli Resistant to drying but not to heat or ultraviolet irradiation Cell walls: contain long chain bhydroxylated fatty acids (mycolic acids) complexed with carbohydrates and proteins creating a waxy hydrophobic surface Multiplies slowly; generation time 12 days Preferred sites: temp 30C (nose;feet) Strong predilection for nerves Found within the endothelial cells of blood vessels or in mononuclear cells (histiocytes of the skin; Schwann cells of nerves) lepra cells packet of cigars 7

 Man is the only host Armadillos: naturally infected O-diphenoloxidase: to differentiate from other mycobacterium and nocardia Lepromin test a. Early reaction (Fernandez reaction): 24-48 hours b. Delaye d HPS reaction (Mitsuda reaction): 3-4 weeks Pathogenesis Transmitted from human to human: exudates of skin lesions, abrasions Low infectivity, protracted incubation period (years) Chronic granulomatous condition of peripheral nerves and mucocutaneous tissue Clinical findings: Insidious onset (3 months to 40 years) Hypopigmented macules trunk and distal extremities Skin, superficial nerves, nose, pharynx, larynx, eyes and testicles Anesthetic macular lesions Diffuse or discrete erythematous, infiltrated nodules Diffuse skin infiltration Anesthesia, neuritis, paresthesia, trophic ulcers, and bone resorption and shortening of digits Lepromatous Leprosy: Progressive and malignant Nodular skin lesions/erythema nodosum; multiple skin lesions Symmetric nerve involvement Leonine facie Abundant acid-fast bacilli in the skin lesions Continuous bacteremia Negative lepromin (extract of lepromatous tissue) skin test Cell-mediated immunity: deficient Suppressor T cells in the lesions 2. Tuberculoid: Benign and nonprogressive

Large maculae in cooler body parts (nose, ear lobes, testicles), neuritis (anesthesia) Macular skin lesions Asymmetric nerve involvement Few bacilli present in the lesions Positive lepromin skin test Cell-mediated immunity: intact Helper T cells in the lesions Anemia; lymphadenopahty; eye involvement Amyloidosis 3. Intermediate stages Diagnosis Scrapings: skin or mucous membranes (nasal septum) in lepromatous leprosy Biopsy of earlobe skin Ziehl-Neelsen technique Histopath No serologic tests Nontreponemal serologic tests for syphilis: false-positive results in leprosy Laboratory Identification Cannot be grown in artificial medium Animal inoculation o Footpads of mice o Armadillo PCR Treatment Sulfones such as dapsone: first-line therapy Rifampin Clofazimine Minocycline Clarithromycin Fluoroquinolones Several years of therapy Epidemiology Prolonged periods of exposure to heavy shedders Incubation period: 2-10 years Prevention & Control Identification & treatment of patients Chemophrophylaxis 8

 Experimental BCG vaccination and an M leprae vaccine Erysipelothrix rhusiopathiae - Erysipeloid: seal fingers or whale fingers - Gram (+) bacillus; singly or pairs; :hemolytic - Land and sea animals - Causes erysipelas in swines, human accidental exposure - Non suppurative painless swelling violaceous lesions at the site of inoculation - Penicillin, erythromycin Actinomycetoma (Mycetoma/Madura Foot) Nocardia asteroids N. brasiliensis Streptomyces somaliensis Actinomadura madurae Saprophytes Gram-positive anaerobic bacilli; bacillary chains or filaments; acid fast Chronic suppurative & granulomatous infection Pyogenic lesions with interconnecting sinus tracts that contain granules actinomycetoma granule Streptomycin, trimethoprim-sulfamethoxazole, and dapsone

Clostridium perfringens Gas gangrene Produce the alpha toxin: necrotizing, hemolytic exotoxin lecithinase Present throughout the environment Wound contamination (trauma;abortion); fatal bacteremia CO2 and H2 detectable as gas Surgical removal of the infection Penicillin G