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 25th November, 2011 25th November, 2011

2. Classical venereal infections – revision Gonorrhoea (rudely: the clap)Gonorrhoea (rudely: the clap) Neisseria gonorrhoeae Syphilis (in Central Europe also: lues)Syphilis (in Central Europe also: lues) Treponema pallidum Chancroid (soft chancre, ulcus molle)Chancroid (soft chancre, ulcus molle) Haemophilus ducreyi Lymphogranuloma venereumLymphogranuloma venereum Chlamydia trachomatis serotypes L 1, L 2, L 2a, L 3

3. GO: infections of the lower UGT – revision ♂urethritis♀cervicitisurethritisbartholinitis inflammation of Skene´s glands

4. GO: infections of the upper UGT – revision ♂ epididymitis (mind the orthography: i-i– y –i-i) i-i– y –i-i)♀endometritis from salpingitis up to adnexitis (PID = pelvic inflammatory disease) → sterility!

5. GO: other localized infections – revision ♂ i ♀ proctitispharyngitis blenorrhoea neonatorum ♀ peritonitis (Fitz-Hugh syndrome) perihepatitis (Curtis syndrome)

6. GO: disseminated infections – revision ♂ & ♀ affliction of skin (pustulae), joints (purulent arthritis of wrist, knee or ankle) and sinews (tendosynovitis)affliction of skin (pustulae), joints (purulent arthritis of wrist, knee or ankle) and sinews (tendosynovitis) monoarticular septic arthritismonoarticular septic arthritis endocarditis (rarely)endocarditis (rarely) meningitis (very rarely)meningitis (very rarely)

7. GO: complications – revision ♂prostatitis periurethral abscesses ♀ cervicitis chronica tuboovarial abscess adnexitis chronica → sterility graviditas extrauterina graviditas extrauterina

8. GO: laboratory diagnostics – revision I Direct detection only: microscopy culture molecular biology tests Sampling places: ♂ urethra ♀ cervix, urethra, rectum, pharynx (if necessary)

9. GO: laboratory diagnostics – revision II Way of sampling: always 2 swabs The 1st swab: inoculate it directly on culture media (warmed, not from the fridge) or put it into a transport medium and transport it at an ambient temperature From the 2nd swab make a film on the slide Microscopy (Gram): important in acute gonorrhoea in males symptomatic gonorrhoea in females

10. GO: laboratory diagnostics – revision III Media for gonococci: always combine a non-selective chocolate agar with a selective medium with antibiotics Always fresh (moist) & warm, culture it with added CO 2 (candle jar), read after 24 and 48 hrs Identification: biochemistry (oxidase +, glucose +, maltose – ) serology (slide agglutination) molecular biologic confirmation tests

11. GO: therapy – revision Nowadays, many strains of N. gonorrhoeae are resistant to penicillin & tetracyclines Therefore: ceftriaxone or ciprofloxacin usually in a single dose because of potential concurrent Chlamydia trachomatis infection: in a combination with doxycycline or azithromycine

12. Syphilis: course – revision From the very beginning: syphilis = always a systemic disease! Early syphilis: primary (ulcus durum) secondary (mostly rash) secondary (mostly rash) early latent early latent Late syphilis: latent terciary (gummas, aortitis, terciary (gummas, aortitis, paralysis progressiva, paralysis progressiva, tabes dorsalis) tabes dorsalis) Congenital syphilis: early and late

13. Syphilis: therapy – revision „One night with Venus, the rest of life with Mercury“ Ehrlich and Hata: preparation No 606 – salvarsan von Jauregg: malaria (because of high fever) Nowadays, the drug of choice is penicillin (in a high dose) Primary syphilis: benzathin penicillin (2,4 MIU) 1 dose Secondary and late syphilis: benzathin penicillin (2,4 MIU) 3 times after 7 days

14. Syphilis: laboratory dg – revision I Direct detection From exudative lesions only (mostly from ulcus durum) darkfield examination PCR immunofluorescence Indirect detection (serology) = mainstay of laboratory diagnostics of syphilis Two types of serologic tests: with nonspecific antigen (cardiolipin) with specific antigen (Treponema pallidum)

15. Syphilis: laboratory dg – revision II Nontreponemal tests (with cardiolipin): RRR, VDRL, RPR fast, cheap, positive early, reflect the activity, but sometimes falsely positive fast, cheap, positive early, reflect the activity, but sometimes falsely positive Treponemal tests (with T. pallidum): TPHA, ELISA, WB, FTA-ABS, TPIT sensitive, more expensive, more specific, but positive later, remaining positive for life

16. Soft chancre (chancroid) – revision Agent of ulcus molle: Haemophilus ducreyi Occurrence: the tropics Course: genital ulcerations (easier transmission of HIV) & purulent lymphadenitis Dg: only culture on enriched media (chocolate agar with supplements), 3 days at 33 °C in 10% CO 2

17. Lymphogranuloma venereum – revision Agent of lymphogranuloma venereum (LGV): Chlamydia trachomatis serotypes L 1, L 2, L 2a, L 3 Occurrence: the tropics and subtropics Course: purulent lymphadenitis (tropical bubo) & lymphangoitis with fistulae & scars devastating the pelvic region in females Dg: mostly serology – CFT with the common antigen of chlamydiae …

18. The most frequent agents of STD – revision The three most common agents of STD: 1.Papillomaviruses 2.Chlamydiae 3.Yeasts Other common agents of STD: Bacteriae: Mycoplasma & Ureaplasma Gardnerella vaginalis Gardnerella vaginalis Klebsiella granulomatis Klebsiella granulomatis Viruses: HSV 2 HBV HBV HCV? HCV? HIV HIV Parasites: Trichomonas vaginalis Sarcoptes scabiei Sarcoptes scabiei Phthirus pubis Phthirus pubis

19. Papillomaviruses – revision The most frequent agent of genital infections Papillomaviruses genotypes 6, 11 and many other: both ♂ & ♀ : anogenital warts (condylomata accuminata) 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

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

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

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

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

24. 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)

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

26. Viral agents of STD: HBV – revision Hepatitis B virus ♂ & ♀ : viral hepatitis B, acute and chronic A recombinant vaccine is available (containing HBsAg) Therapy: acute VHB: no medication, rest & diet chronic VHB: interferon chronic VHB: interferon Lab. dg: detection of laboratory markers in 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)

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

28. Viral agents of STD: HIV – revision Human immunodeficiency virus (HIV-1 and HIV-2) ♂ & ♀ : AIDS (acquired immunodeficiency syndrome) Therapy: combination of antiretrovirotics (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 special tests: detection of antigens determination of viral load determination of viral load

29. Parasitic agents of STD – revision I Trichomonas vaginalis (a flagellate) ♂ : no symptoms (rarely urethritis, males are usually asymptomatic 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

30. 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

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

32. Common superficial injuries Staphylococcus aureusStaphylococcus aureus Streptococcus pyogenesStreptococcus pyogenes beta-hemolytic streptococci of other groups (above all G, F, C)beta-hemolytic streptococci of other groups (above all G, F, C) ! Attention in case of a foreign body in the wound (splinter, thorn) and in case of deeper stab wounds (fork soiled by horse manure): Clostridium tetani

33. Severe contused wounds Agents of clostridial myonecrosis (mostly Clostridium perfringens, C. septicum, C. novyi, C. histolyticum)Agents of clostridial myonecrosis (mostly Clostridium perfringens, C. septicum, C. novyi, C. histolyticum) clostridial myonecrosis = anaerobic traumatosis = gas gangrene or malignant edema Clostridium tetaniClostridium tetani Staph. aureus, Strept. pyogenes & other pyogenic bacteriaStaph. aureus, Strept. pyogenes & other pyogenic bacteria

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

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

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

37. Burns Almost everything, but predominantly: Pseudomonas aeruginosaPseudomonas aeruginosa Staphylococcus aureusStaphylococcus aureus Streptococcus pyogenesStreptococcus pyogenes other streptococciother streptococci enterococcienterococci candidae and aspergillicandidae and aspergilli

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

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

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

41. Homework 7 – solution Edvard Munch (1863-1944): Death in a Sickroom (1893)

42. Homework 7 Successful homework 7 solvers: Mavis Araba Koufie Bárbara Raimundo Veronika Sykorova Congratulations!

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

44. Homework 8 Successful homework 8 solver: Mavis Araba Koufie Congratulations!

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

46. 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