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 16 th November, 2012 16 th November, 2012

2. 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

3. 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

4. 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

5. 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)

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 ♀: 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

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 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)

10. 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)

11. 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)

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 special tests: detection of antigens determination of viral load determination of viral load

13. 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

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 salmonellaeshigellae 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 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 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

18. 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

19. 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)

20. 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)

21. 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)

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

23. 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

24. 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

25. 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)…

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 Part I – Bacterial infections Lecture for 3rd-year students 16 th December, 2012

27. Infections with skin symptoms 1.primary skin infections 2.secondary infections of already diseased skin 3.skin symptoms of systemic infections Etiology: bacterial viral viral fungal fungal parasitic parasitic

28. Primary acute bacterial skin infections – I acne vulgaris – Propionibacterium acnes carbunculus nuchae – Staph. aureus ecthyma gangraenosum – 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 hidradenitis suppurativa – Staph. aureus hordeolum (stye) – Staph. aureus impetigo – Staph. aureus, Str. pyogenes lymphangoitis – Streptococcus pyogenes panaritium – Staphylococcus aureus paronychium – Staphylococcus aureus sycosis barbae – Staphylococcus aureus

30. Primary chronic bacterial skin infections actinomycosis – e.g. Actinomyces israelii chronic subcutaneous abscesses – Actin. israelii, Nocardia asteroides, Rhodococcus equi skin granulomas – Mycobacterium marinum, M. haemophilum, M. chelonae leprosy – Mycobacterium leprae lupus vulgaris – 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 erythema migrans – Borrelia burgdorferi infective endocarditis – 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 8 Albert 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. I forgot to put the lecture on the university web.

35. Homework 9 Please 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