jslum.
com | Medicine
Soft Tissue Infections
Impetigo
Common in children
Skin/ epidermis of Face
Around Mouth & Nose
Non-bullous
Streptococcus pyogenes
(group A streptococci)
“honey-cru st” lesion
Bullous
Staphylococcus aureus
Rupture of bullae leaves a thin
“varnish-like” crust
Bullous
Non-bullous Impetigo
Honey-crust lesion
Folliculitis
Infection of hair follicles
Occur after exfoliating, shaving,
spontaneous
Whirlpool (hot tub/ spa)
folliculitis
Pseudomonas aeruginosa
Furuncle/ boil
Staphylococcus aureus
Staphylococcus epidermidis
(CONS)
Furuncle/ boil
Inflammation of hair follicles
Localized accu mulation of pus,
dead tissue
Carbuncles (cluster of boils )
Boils can develop to abscess
Furuncle
Cellulitis
Acute spreading inflammation
involving Epidermis, Dermis,
Subcutaneous fat
Staphylococcus aureus
β-haemolytic streptococci
(group A – S. pyogenes)
(group C & G)
Crepitant anaerobic cellulitis
Necrotic soft tissue infection
Abundant CT gas
Lack of mark systemic toxicity
Gradual onset
Less pain
Absence of mu scle involvement
Bacteroides species
Peptostreptococcu s species
Clostridium species
Enterobacteriaceae
Cellulitis
Necrotising fasciitis
Rare infection
High mortality (30-40%)
Surgical emergency
Radical debridement of
devitalised tissue
Type 1
Caused by multiple organisms
(often gut origin)
(synergistic gangrene)
Anaerobes
• Peptostreptococcu s
• Bacteroides
• Fusobacterium species
Aerobic
• Streptococcus group A
(Streptococcus pyogenes )
• Staphylococcus aureus
• E. coli
Type 2
Caused by group A streptococci
(GAS)
Flesh eating bacteria
Complications
Severe systemic toxicity
Hypotension
Respiratory distress
Multiorgan failure
Clinical
Severe pain in affected area
Skin changes modest (early)
Progressing to fascial & skin
necrosis & deep tissue
infarction (mus cle layers)
Thrombosis of s ubcutaneous
blood vessels – necrosis of skin
Initial local pain – replaced by
numbness, analgesia (involves
cutaenous nerves)
Most cases follow after
surgery, minor trauma
Highest incidence – small vessel
disease – diabetes mellitus
Necrotising fasciitis
Skin, deep structures of neck
Necrotising fasciitis
Large, dark, boil-like blisters
Flash-eating disease (GAS)
Clostridial Myonecrosis
= Gas gangrene
Clostridial infection primarily of
muscle tissue
Clostridium perfringens
C. novyi
C. septicum
C. histolyticum
C. fallax
C. bifermentans
Infection occurs in areas of
Major trauma
Surgery
Complication of thermal burns
Can occur spontane ously by
Activation of dormant
clostridial spores (old scar)
Bacteremic spread from GIT or
GUT site
Clinicals
Rapid onset of myone crosis
within 4-6 hours after injury
Muscle swelling
Severe pain
Gas production - crepitus
Sepsis
Exudate – sweet “mousy” odor
Pathophysiol ogy
• Clostridium – soil, GIT
• Traumatic & Surgical gas
gangrene – direct inoculation
of wound
• Compromise d blood sup ply –
wound has anaerobic
environment – ideal for
Clostridium perfringens
• Spontaneous gas gangrene –
caused by hematogeneous
spread of C. Septicum from
GIT with colon cancer
• C. Septicum enter blood (via
small break) in GIT mucosa
and seeds muscle tissue
• C. Septicum is aerotolerant
(unlike C. perfringens) – can
infect normal tissues
• When sufficienct devitalized
tissue present (support
anaerobic metabolism),
myonecrosis develop
Virulence factors
Extra-cellular toxins
Hydrolyze cell membranes
Abnormal coagulation
Microvascular thrombosis
Cardiodepressive effects
α-toxin (lecithinase) –
haemolytic, histotoxic,
necrotizing
Toxic factor produ ced
Treatment
Antiobiotics – penicillin
(interfere cell wall synthesis)
Surgery - debridement
Hyperbaric oxygen
 jslum.com | Medicine
Bone Infections
Acute Hematogenous OM
Osteomyelitis Mainly in infants, children
Bone infected throug h Adult ↑ frequency
Haematogenous Infants & Children
2° to contiguous focus of infection – relatively normal vascularity, generalized Metaphysis of long bones (tibia, femur)
vascular insufficiency (eg. Diabetic foot) Non anastomosing ca pillary ends of nutrient artery
Children Make sharp loops under growth plate
Long bones Enter a system of large venous sinusoids
Adults Blood flow becomes slow & turbulent
Feet Obstruction to capillary ends
Vertebrae bodies – lumbar, thoracic Avascular necrosis (AVN)
Pelvis Clinical
Diaphysis of long bones Localised bone pain
Risk factors ↓ movement of affected body part
Recent trauma Skin – red, hot, swollen, pus
Diabetes Spasms of mus cles
Hemodialysis Weight ↓
IV drug abuse Malaise (general)
Removal of spleen (↑ risk) ↑ Temperature
Pathophysiol ogy Sweat excessively
Infection produ ces local cellulitis Chills
(↑ bone pressure, ↓ pH, breakdown of leukocytes) Lymphadenopathy
Necrosis of bone Complications
Infection procee d laterally, through Haversian & Volkmann canal system, Chronic OM
perforate cortex, lift periosteum Bone abscess (pocket of pus )
Extend into intramedullary canal Bone necrosis (bone death)
Vascular compromise Spread of infection
Bone necrosis Inflammation of s oft tissue (cellulitis)
Capillaries penetrate growth plate (infants) Sepsis
Infection spread to epiphysis & joint space
Chronic Hematogenous OM
Children > 1 y/o Dead areas of bone (sequestrum)
Growth plate no longer penetrated by capillaries Fail to respond to treatment
Epiphysis & joint space – protected from infection Recur for a long time
Polymicrobial
Adults
Growth plate resorbed
Joint extension of metaphyseal infection can recur
Etiological agents
Staphylococcus aureus
Streptococcus pyogenes
Haemophilus influenzae (rare, Hib vaccine)
Pseudomonas aeruginosa (intravenous drug abusers – vertebral osteomyelitis)

Fungal osteomyelitis Chronic osteomyelitis (Right great toe) Chronic osteomyelitis

Coccidioides Persistent swelling Bony destruction
Blastomyces Closed fistulus tract (arrow)
Cryptococcus Management
Sporothrix species Hospitilization, IV antibiotics
Lesion appears as cold abscess overlying OM lesion Long term antibiotics (4-6 weeks or more) oral + IV
Joint space extension (occur in coccidioidomycosis & blastomycosis ) Pain-killing medication
Therapy Surgical debridement
Surgical debridement Skin grafts
Antifungal chemotherapy Amputation
Replace with prosthetics
Lifestyle – stop smoking to improve blood circulation
Treat underlying causes - diabetes

Diabetic foot infection

Factors
Micro-angiopathy (impaired blood supply)
Diabetic sensory neuropathy (impaired pain sensation)
Sporotrichosis Sporotrichosis ↑ sweet glucose (promotes bacteria growth)
15X higher rate for lower extremity amputation compared to non-diabetics
Diabetic lower extremity amputation
Gangrene
Infection
 jslum.com | Medicine

Streptococcus pyogenes Clostridium perfringens Staphylococcus aureus Haemophilus Influenzae Pseudomona s Escherichia coli
(GAS) aeruginosa

Incomplete hemolysis
zone
Complete hemolysis zone
Blood agar Blood agar Blood agar Chocolate bl ood agar Nutrient agar MacConkey agar
Small size Large Medium size Small Medium to Large size Smooth
Convex Smooth Convex Circular Low convex colonies Convex
Circular Low convex Circular Low convex Extracellular pigment Small to Medium size
Translucent colonies Circular White colour colonies Smooth (green) Pink colour
Beta hemolysis Translucent colonies Beta hemolysis Pale gray (lactose fermenting
Double zone of he molysis Transparent colonies)
(complete, incomplete)

Gram stain Gram stain Gram stain Gram stain Gram stain Gram stain
Gram +ve Gram +ve Gram +ve cocci Gram –ve Gram –ve Gram –ve
Cocci in chains Bacilli Grape like clusters Pleomorphic Bacilli Bacilli
Sub terminal spore Single & Paired Cocci