Agents of Wound Infections: Lecture for 3rd-year Students

1. Institute for Microbiology, Medical Faculty of Masaryk University and St. Anna Faculty Hospital in Brno Miroslav Votava Agents of wound infections Lecture for 3rd-year students 16th November, 2012

2. The most frequent agents of STD– revision The three most common agents of STD: Papillomaviruses Chlamydiae Yeasts Other common agents of STD: Bacteriae: Mycoplasma & Ureaplasma Gardnerella vaginalis Klebsiella granulomatis Viruses: HSV 2 HBV HCV? HIV Parasites: Trichomonas vaginalis Sarcoptes scabiei Phthirus pubis

3. Papillomaviruses – revision The most frequent agent of genital infections Papillomavirusesgenotypes 6, 11 and many other: both ♂ &♀:anogenital warts (condylomata accuminata) Genotypes 16, 18 and some other♀:infection of cervix→ Ca A vaccine exists against carcinogenic types Cultivation impossible – diagnostics is performed via molecular methods

4. Chlamydiae – revision The secondmost frequent agent of genital infections Chlamydia trachomatisserotypesD to K♂: nongonococcal & postgonococcal urethritis ♀:cervicitis → blenorrhoea neonatorum Therapy: macrolides and tetracyclines Lab. dg: direct: detection of antigen detection of DNA culture (special cell culture) indirect(serology): not very useful

5. Yeasts – revision The thirdmost frequent agent of genital infections Candida albicans(rarely other candidae)♂: balanoposthitis ♀:vaginal mycosis (candidosis, vulvovaginitis) Therapy: topical imidazoles (clotrimazole) systemic triazoles (fluconazole) Lab. dg: microscopy cultivation(Sabouraud agar)

6. Mycoplasmas – revision Mycoplasma hominis Ureaplasma urealyticum ♂&♀: urethritis ♀: postpartum fever, PID? Therapy: macrolides and tetracyclines Lab. dg: direct only – culture on special media

7. Gardnerellae – revision Gardnerella vaginalis ♂: 0 ♀: bacterialvaginosis(no leukocytes) Therapy: metronidazole Lab. dg: direct only – fish odour test microscopy (clue cells = epitheliae with adhering G± cocobacilli – „pepper & salt“) culture on special agar

8. Agent of donovanosis – revison Klebsiella granulomatis(formerly Donovania granulomatis, afterwards Calymmatobacterium granulomatis) ♂&♀: granuloma inguinale, donovanosis (genital ulcers in tropics) Therapy: tetracyclines, macrolides Lab. dg: microscopy only (Donovan bodies)

9. Viral agents of STD: HSV 2 – revision Herpes simplex virus type 2 ♂&♀: herpes genitalis, primary recurrent Therapy: acyclovir Lab. dg: isolation on a cell culture detection of DNA by PCR serology (useful in primary infection only)

10. Viral agents of STD: HBV – revision Hepatitis B virus ♂&♀: viralhepatitis B, acute and chronic A recombinant vaccine is available (containing HBsAg) Therapy: acute VHB: no medication, rest & diet chronic VHB: interferon Lab. dg: detection of laboratory markersin blood serum: HBsAg (in acute & chronic infection, in chronic carriers) HBeAg (usually in an acute infection only) anti-HBs (after full recovery, after vaccination) anti-HBe (after full recovery & in chronic carriers) anti-HBc (IgG: dtto, IgM: in acute infection) HBV DNA (in acute & chronic infection)

11. Viral agents of STD: HCV – revision Hepatitis C virus(sexual transmission very probable) ♂&♀: viralhepatitis C, acute and chronic Therapy: pegylated interferon + ribavirin Lab. dg: detection of viral RNA detection of antibodies (anti-HCV)

12. Viral agents of STD: HIV – revision Human immunodeficiency virus(HIV-1 and HIV-2) ♂&♀: AIDS (acquired immunodeficiency syndrome) Therapy: combination of antiretrovirotics (zidovudin, lamivudin, nevirapin, saquinavir etc.) even HAART = highly active antiretroviral treatment doesn´t cure the patient completely but prolongs life for many years Lab. dg: detection of antibodies (& confirmation of positive findings) special tests: detection of antigens determination of viral load

13. Parasitic agents of STD – revision I Trichomonas vaginalis(a flagellate) ♂: no symptoms (rarely urethritis,males are usuallyasymptomatic carriers) ♀: vaginitis, cervicitis, urethritis Therapy: metronidazole (both partners must be treated) Lab. dg: direct only – microscopy (wet mount, Giemsa stained film) &culture on special media

14. Parasitic agents of STD – revision II Sarcoptes scabiei(itch mite) ♂&♀: scabies (mange) Therapy: antiscabiotics (permethrine, lindane) Lab. dg: microscopy from skin Phthirus pubis(pubic louse, crab louse) ♂&♀: pediculosis pubis (phthiriasis) Therapy: lindane Lab. dg: demonstration of lice or eggs

15. Opportunistic agents of STD– revision salmonellae shigellae campylobacters etc. HAV intestinal parasites →opportunistic STD after oral-anal contacts (serious course usually because of a very high infectious dose) …

16. Agents of wound infections

17. Common superficial injuries • Staphylococcusaureus • Streptococcuspyogenes • beta-hemolytic streptococci of other groups (above all G, F, C) Attention!In case of aforeign body in the wound (splinter, thorn) and in case of deeper stab wounds (fork soiled by horse manure): Clostridiumtetani

18. Severe contused wounds • Agents of clostridial myonecrosis (mostly Clostridium perfringens, C. septicum, C. novyi, C. histolyticum) clostridial myonecrosis = anaerobic traumatosis = gas gangreneor malignant edema • Clostridiumtetani • Staph. aureus, Strept. pyogenes & other pyogenic bacteria

19. Wounds sustained in water • In fresh water: - Pseudomonas aeruginosa - Aeromonas hydrophila -otherpseudomonads and aeromonads • In salt water: - Vibrio parahaemolyticus, V. vulnificus - Mycobacterium marinum (also in fresh-water swimming pools, tanks and aquaria)

20. Injuries sustained in the tropics Mainly on feet • soil nocardiae (Dermatophilus congolensis, Rhodococcus equi) • atypical mycobacteria (Mycobacterium ulcerans, Mycobacterium haemophilum) • micromycetes (Sporothrix schenckii, Paracoccidioides brasiliensis)

21. Surgical wounds • Staphylococcus aureus • coagulase-negative staphylococci (mainly Staphylococcus epidermidis) • Enterobacteriaceae (Escherichia coli, Proteus mirabilis) • Streptococcus pyogenes • anaerobes (Peptostreptococcus micros, Peptostreptococcus anaerobius, Bacteroides fragilis)

22. Burns Almost everything, but predominantly: • Pseudomonas aeruginosa • Staphylococcus aureus • Streptococcus pyogenes • other streptococci • enterococci • candidae and aspergilli

23. Man- inflicted bites • members of oral microflora - “oral streptococci” (Streptococcus sanguinis, S. oralis, S. anginosus) - anaerobes (Fusobacterium nucleatum ssp. nucleatum, Porphyromonas gingivalis) • Staphylococcus aureus

24. Animal bites Most often: • Pasteurella multocida (cats, dogs) Less often: • Staphylococcus aureus(any animal) • Capnocytophaga canimorsus (dogs) • Streptobacillus moniliformis (rats) • Spirillum minus (mice, rats, cats, dogs) • Francisella tularensis (cats) • & many others

25. Other injuries by animals • Francisella tularensis (rodents, hares – tularemia) • Bartonella henselae (cat scratch disease) • Erysipelothrix rhusiopathiae (pigs, carps – erysipeloid) • Bacillus anthracis (herbivores – skin anthrax, pustula maligna) • Burkholderia mallei (horses, donkeys – glanders, malleus) …

26. Institute for Microbiology, Medical Faculty of Masaryk University and St. Anna Faculty Hospital in Brno Miroslav Votava Agents of skin-manifested infections Part I – Bacterial infections Lecture for 3rd-year students 16thDecember, 2012

27. Infections with skin symptoms • primary skin infections • secondary infections of already diseased skin • skin symptoms of systemic infections Etiology: bacterial viral fungal parasitic

28. Primary acute bacterial skin infections – I acne vulgaris –Propionibacterium acnes carbunculusnuchae – Staph. aureus ecthymagangraenosum – Ps. aeruginosa erysipelas – Streptococcus pyogenes erysipeloid – Erysipelothrix rhusiopathiae erythrasma – Corynebact. minutissimum folliculitis – Staph. aureus, P. aeruginosa furunculosis (boil) – Staph. aureus

29. Primary acute bacterial skin infections – II hidradenitissuppurativa – Staph. aureus hordeolum (stye) – Staph. aureus impetigo – Staph. aureus, Str. pyogenes lymphangoitis – Streptococcus pyogenes panaritium – Staphylococcus aureus paronychium – Staphylococcus aureus sycosisbarbae – Staphylococcus aureus

30. Primary chronic bacterial skin infections actinomycosis – e.g. Actinomyces israelii chronicsubcutaneous abscesses – Actin. israelii, Nocardia asteroides, Rhodococcus equi skingranulomas – Mycobacterium marinum, M. haemophilum, M. chelonae leprosy – Mycobacterium leprae lupusvulgaris – Mycob. tuberculosis scrophuloderma – M. tuberculosis, M. bovis

31. Secondary infections of skin lesions decubitus (bedsore), trophic ulcer – neighbouring and endogenous flora (staphylococci, streptococci, enterococci, enteric bacteria, pseudomonads and other Gram-negative non-fermenting rods, anaerobes, yeasts) infected atheroma – S. aureus, Propionib. acnes infected intertrigo (raw) – S. aureus, P. acnes sec. infected dermatomycoses – S. pyogenes infected wounds – discussed in previous lecture

32. Skin symptoms of systemic bacterial infections roseola (rash in typhoid fever)– Salmonella Typhi disseminated gonorrhoea – Neisseria gonorrhoeae erythemamigrans – Borrelia burgdorferi infectiveendocarditis – will be dealt with by sepsis meningococcemia – Neisseria meningitidis scarlatina (scarlet fever) – Streptococcus pyogenes SSSS (staphylococcal scalded skin syndrome) – Staphylococcus aureus toxic shock syndrome – S. aureus, S. pyogenes syphilis – Treponema pallidum …

33. Homework 8Albert Anker (1831-1910):The Quack Doctor (1879)

34. Homework 8 Successful homework 8 solver: I am sorry, I forgot to put the lecture on the university web.

35. Homework 9Please give the name of the author and of the painting

36. Answer and questions The solution of the homework and possible questions please mail to the address mvotava@med.muni.cz Thank you for your attention