SKIN AND WOUND INFECTIONS

Dr. Lakmini Yapa,

Senior Registrar ( Medical Microbiology), T/H Kurunegala

3/27/2013

Be able to
1. Describe the risk factors for infections of the skin 2. Describe the principles of classifying post operative wound infections 3. Describe the methods of collection and transport of samples for microbiological diagnosis 4. Outline principles of treatment and prevention

Factors controlling skin microbial load

Dry skin
Few organisms Mainly staphylococci / diphtheroids

Moist skin
Many organisms Including staphylococci / Diphtheroids/ Gram negatives etc

papilloma

macule

pustule

ulcer

vesicle

Wound Depth can Result in Different Diseases

S. aureus infections

S. aureus infections

Folliculitis Carbuncle CA MRSA Near nares / upper lips -

S. aureus infections

Group A Streptococcal infections

cellulitis erysepalas

lymphadenitis
Necrotizing fasciitis

Rash of scarlet fever

Necrotizing fasciitis
Clinical features
Early pain, cellulitis, fever, swelling, induration, skin anaesthesia Late severe pain, blistering, skin discolouratin, dishwater discharge, crepitus, multiorgan failure

Diagnosis
Clinical and needs high index of suspicion

Microbiology Management

Necrotizing fasciitis
Microbiology
Group A streptococci 15% of cases
M types 1 & 3 Produce exotoxin A and streptolysin O which act as super-antigens

Often polymicrobial
Other Gram positive cocci Gram negative bacilli aeobic and anaerobic

Occasionally fungi and vibrio

Management
Early diagnosis and adequate surgical debridement Appropriate antibiotics

Cutaneous infections
Cutaneous anthrax

Erythrasma Corynebacterium minutissimum

Mycobacterial infections

Atypical mycobacterial infections

M.marinum

M ulcerans

Buruli ulcer

Viral infections of skin

fungal infections of the skin

Tinea versicolor

onychomycosis

Candida infection

Serious infections associated with skin manifestations

Post operative wound infections

Increases morbidity / mortality Increases cost Varying risk
Type of operation Elective / emergency Experience of surgeon Patient co-morbidities

Classification of operative wounds by level of bacterial contamination Clean wound

in which no inflammation was encountered a non traumatic wound no break in technique occurred respiratory/ GU and alimentary tracts not opened
I. II. Vascular surgery mastectomy

infection rate:

without prophylaxis with prophylaxis

5.1% 0.8%

Classification of operative wounds by level of bacterial contamination Clean-contaminated wound non traumatic

GI/GU/Respiratory tract entered without spillage

I. II. Appendectomy Abdominal and Vaginal Hysterectomy

Infection rate: without prophylaxis 10.1% with prophylaxis 1. 3%

Classification of operative wounds by level of bacterial contamination Contaminated wound

fresh traumatic wound from a relatively clean source operative wound with major breach in technique gross spillage from GI tract entry into biliary or urinary tract with infected bile or urine incisions encountering acute non purulent inflammation dirty wounds (dirty source/delayed) faecal contamination / foreign bodies / devitalized viscus pus from any source encountered
Infection rate: without prophylaxis 21.9% with prophylaxis 10.2%

Classification of operative wounds by level of bacterial contamination Dirty wound

Operative wound dirty Traumatic wound from dirty source Traumatic wound with delayed treatment Fecal contamination Foreign body Retained devitalized tissue Operative wound w/ acute bacterial inflammation or perforated viscus Operative wound where clean tissue is transected to gain access to a collection of pus

Major pathogens
Specific pathogen not reliably predictable Sensitivities also not reliably predictable

Differentiate between colonization and pathogen necessary

multiple pathogens common in many situations (gut)

antibiotic cover for major pathogen(s) adequate - both for prophylaxis and treatment)
Clean surgery - S aureus gut related surgery - mixed flora including anaerobes

Route of bacterial contamination of surgical wounds

Prevention of surgical infections

Surgical technique Asepsis Antibiotic prophylaxis
Microbial Injury to Foreign Resistance to concentration + wound + material + perioperative and virulence tissue antibiotics

=
General and host immunity + Peri-operative antibiotics

Risk of wound infections

Interventions of benefit in reducing risk of surgical wound infections

Reduce inoculation of virulent or antimicrobial resistant bacteria into wound

Interventions of benefit in reducing risk of surgical wound infections (cont.)

Reduce inoculation of virulent or antimicrobial resistant bacteria into wound Intra-operative and post-operative
careful preparation of skin with povidone-iodine or chlorhexidine containing solution rigorous adherence to aseptic technique high flow of filtered air* consider laminar flow environment* consider irrigation of wound with antibiotic containing solution isolate clean from contaminated surgical fields minimize drains (drains through separate stab wound) minimize catheters and IV lines post-operatively

Peri-operative antibiotic prophylaxis

Efficacy - unquestioned Selection of appropriate antibiotic(s)
based on clinical trials (usually under powered) likely pathogen(s) and ABST safety / cost

Timing and duration of prophylaxis

with induction (exception-colonic surgery) operations>4 hours - repeat dose intra-operatively every 4 hours duration -contentious issue (single vs multiple)

Peri-operative antibiotic prophylaxis (cont.)

Recommendation for prophylaxis
see current literature

Side effects of prophylaxis

antibiotic associated colitis vancomycin related hypotension selection of resistant hospital flora

Cost-benefit of prophylaxis
difficult

Aetiological diagnosis in skin infections

Specimens Macules / papules - usually no direct examination Vesicles / ulcers aspirate / scraping from base Pustules/boils / carbuncles pus (by aspiration or incision
and drainage)

Wound infections aspirate / tissues removed at surgery

(surface swabs often taken but often reflect colonizing flora)

Request from microbiology laboratory

Microscopy - Gram stain / Zeihl Neelsen / wet prep

Culture bacterial / fungal / viral

Particularly viral infections antigen detection / PCR

Interpretation of results
Culture of wounds : Surface of wounds colonized with many organisms Surface swab reflects this colonization
miss true pathogen lead to overuse of antibiotics

http://jdfc.org/spotlight/diabetic-foot-infections-current-diagnosis-and-treatment/

The Journal of Diabetic Foot Complications, 2012; Volume 4, Issue 2, No. 1, Pages 26-45