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Coccus Gram

positive
Leli
Saptawati,dr.,Sp.MK

Berbagai Infeksi di Kulit dan lokasi Infeksinya

Staphylococcus

topik

Fisiologi dan struktur


Patogenesis dan immunitas
Epidemiologi
Clinical disesase

Pokok bahasan

Fisiologi dan struktur


Patogenesis dan immunitas
Epidemiologi
Clinical disesase

Gb. Struktur dinding sel Staphylococcus

1. Capsule or slime layer

A. Capsule :

Melindungi bakteri dari proses fagositosis

B. Slime layer :

Membantu bakteri untuk menempel pada jaringan


dan benda asing (misal kateter, grafts, prosthetic
valves and joint, and shunts)

2. Peptidoglycan

Has endotoxin like activity


Stimulating the production of endogenous pyrogen
Activation of complement
Production of interleukin-1 from monocytes
Aggregation of PMN

3. Polysaccharide A
(Theicoic acid)
Mediate the attachment of Staphylococci to

mucosal surfaces through their specific binding to


fibronectin

4. Protein A

The surface of S. aureus strains (but not the

coagulase negative staphylococci) is coated with


Protein A
It has a unique affinity for binding to the Fc

receptors of immunoglobin (Ig)G1, IgG2, and IgG4


so can effectively prevent antibody-mediated
immune clearance of the organism

Coagulase

The outer surface of most strains of S. aureus

contains clumping factor (also called bound


coagulase)
This protein is an important virulence factor in S.

aureus.
It binds fibrinogen and converts it to insoluble

fibrin, causing the Staphylococci to clump or


aggregate
Primary test for identifying S. aureus

Cytoplascmic membrane

It serves as an osmotic barrier for the cell and

provides an anchorage for the cellular bio


synthetic and respiratory enzymes

Pokok bahasan

Fisiologi dan struktur


Patogenesis dan immunitas
Epidemiologi
Clinical disesase

Pathogenesis & immunity

Staphylococcal toxins

Staphylococcal enzyme

Alpha toxin

Coagulase

Beta toxin

Catalase

Delta toxin

Hyaluronidase

Gamma toxin and


Panton-Valentine
Leukocidin

Fibrinolysin

Lipase

Nuclease

Penicilinase

Exfoliative toxins

Enterotoxins Toxic Shock


syndrome Toxin-1

Pokok bahasan

Fisiologi dan struktur


Patogenesis dan immunitas
Epidemiologi
Clinical disesase

Human normal flora

Pokok bahasan

Fisiologi dan struktur


Patogenesis dan immunitas
Epidemiologi
Clinical disesase :
Laboratory diagnosis

S. aurus

S. epidermidis and other coalgulase negative staphylococci

Tratment, prevention and control

Clinical disease :

Toxin-mediated disesase :

Staphylococcal Scaldedskin syndrome

Food poisoining

Toxic shock

Suppurative infection

Impetigo

Folliculitis

Furuncles

Carbuncles

Bacteremia and
endocarditis

Pneumonia and
empyema

Osteomyelitis

Septic arthritis

Staphylococcal disease

Clinical disease of S.
aureus

Cutaneous infection
Impetigo :

Localized cutaneous infection characterized by pus-filled vesicle


on an erythematous base

Folliculitis :

Impetigo involving hair follicles

Furuncle or boils :

Large, pain full, pus-filled cutaneous nodules

Carbuncles :

Coalesce of furuncles with extensions into the subcutaneous


tissue and evidence of systemic disease (chills, fever, bacteremia)

Impetigo

Folliculitis

Furuncle

Carbuncle

Patogenesis hair follicle infection


karena Staphylococcus aureus
S. auerus

Melekat pada
aureus
selVirulent
follicle S.
rambut

Jika tidak diterapi


akan terbentuk
karbunkel

Melakukan
multiplikasi

Terbentuk abces
yang lebih besar
di subcutan

Menyebar ke bawah
follicle dan
Glandula sebacea

Infeksi menyebar
ke jaringan lebih
dalam (subkutan)

Merangsang respon
inflamasi

Infeksi berlanjut,
membentuk abces
kecil

Dapat timbul
bakteriemia

Menginfeksi jantung,
tulang dan otak

Staphylococcal scalded skin


syndrome / Ritterss disease

Patogenesis Staphylococcal scalded


skin syndrome (SSSS)
S. aureus
mengeluarkan exfoliatin
di tempat infeksi

Risiko kematian
mencapai 40%Tergantung
ketepatan diagnosa & terapi,
usia, dan kondisi umum

Diabsorbsi dan dibawa


oleh aliran darah
ke kulit (area luas)

Risiko kehilangan cairan


dan terjadinya infeksi
sekunder oleh kuman
Gram(-) atau C. albican

Terpisahnya lapisan sel


dari epidermis tepat
di bawah
lapisan luar keratin yang
mati

Kulit kehilangan
lapisan luarnya (seperti
pada luka bakar berat)

SSSS..lanjutan

Toxin mediated disesase


Disseminated desquamation of

epithelium in infants
Blisters with no organisms or

leucocytes

Bullous impetigo

Toxic shock syndrome

Toxic shock
syndrome.lanjutan
Multisystem intoxication characterized

initially by fever, hypotension, and a


diffuse, macular erythematous rash
High mortality without prompt antibiotic

therapy and elimination of the focus of


infection

Bacteremia and endocarditis

Spread of bacteria into the blood from a

focus of infection
Endocarditis characterized by damage

to the endothelial lining of the heart

Clinical disease of S. epidermidis and other


coagulase-negative staphylococcal

Endocarditis
Catheter and shunt infection
Prosthetic joint infection
UTI

Pokok bahasan

Fisiologi dan struktur


Patogenesis dan immunitas
Epidemiologi
Clinical disesase :

S. aurus

S. epidermidis and other coalgulase negative staphylococci

Laboratory diagnosis
Tratment, prevention and control

Laboratory diagnosis

Microscopic
Culture
Serology
Identification

Microscopy useful for pyogenic infection but

not blood infection or toxic-mediated infection


Staphylococcus growth rapidly when cultured

on non selective media


Detection of Staphylococcal antibodies

generally of little value

Pokok bahasan

Fisiologi dan struktur


Patogenesis dan immunitas
Epidemiologi
Clinical disesase :

S. aurus

S. epidermidis and other coalgulase negative staphylococci

Laboratory diagnosis
Tratment, prevention and control

Antibiotics of choice

The focus of infection (e.g abcess) must be identified and


dried

Treatment is symptomatic for patient with food poisoning


(although the source of infection should be identified so that
appropriate preventive procedures can be enacted)

Proper cleansing of wounds and use of disinfectant help


prevent infection

Thorough hand washing and covering of exposed skin helps


medical personel prevent infection or spread to other patients

Streptococcus
S

Topics

S. pyogenes
S. agalactiae
Other beta haemolytic Streptococci
Viridans streptococci
S. pneumoniae

STREPTOCOCCUS
pyogenes

Physiology & structure


Gram positive cocci arranged in pairs and long chains
Beta hemolytic, more virulent strain with capsule
Facultative anaerob
Catalase negative, PYR positive, bacitracin sensitive
Group specific carbohydrate (A antigen) and type-

specific antigens (M and T proteins) in cell wall


Produce streptolysin O and DNase B (antibodies

against these Ag (ASO, anti-DNase B) are clinically


important)

Virulence factor

Epidemiology

Asymptomatic colonization in upper

respiratory tract and transient colonization of


skin
Person to person spread by respiratory droplet

or by through breaks in skin after direct


contact with infected person, fomite or
anthropod vector

disease

Suppurative infections :

Pharyngitis

Scarlet fever

Pyoderma

Erysipelas

Cellulitis

Necrotizing fasciitis

Streptococcla toxic shock syndrome

Other suppurative disesae

Nonsuppurative infections

Rheumatic fever

Acute glomerulonephritis

Suppurative infection

Pharyngitis :

Scarlet fever

Reddened pharynx with exudates generally present, cervical


lymphadenopathy can be prominent

Diffuse erythematous rash beginning on chest and spreading


to the extremities, complication of streptococcal pharyngitis

Pyoderma :

Localized skin infection with vesicles progressing to pustules,


no evidence of systemic disease

Erysipelas :

Localized skin infection with pain, inflammation, lymph node enlargement


and systemic symptoms

Cellulitis :

Infection of the skin that involves the subcutaneous tissues

Necrotizing fasciitis :

Deep infection of skin that involves destruction of muscle and fat layers

Streptococcal toxic shock syndrome

Multiorgan systemic infection resembling staphylococcal toxic shock


syndrome, however most patients bacteremic and with evidence of fasciitis

Other suppurative disease

Variety of other infections recognized including puerperal sepsis,


pymphangitis, pneumonia

Erysipelas (kiri) & necrotizing fasciitis (kanan)

Patogenesis group A Streptococcal


flesh eaters
Bakteri melakukan
kolonisasi menggunakan
Fibronectin-binding
protein

Kadang melakukan
penetrasi ke fascia di
sekitar otot dan juga
merusak jaringan otot

Organisme terus
bermultiplikasi dan
menghasilkan produk
toxic dalam
jaringan yang mati

Menyebabkan shock
karena lepasnya cytokine
dan mekanisme lain
Terjadi pembengkakan
karena peningkatan
tek osmotik dari
rusaknya jaringan

Kadang organisme dan


Produk toxic masuk
Ke aliran darah

Nonsuppurative
infection
Rheumatic fever :

Characterized by inflammatory changes of the heart


(pericarditis), joints (artharalgias to arthritis), blood
vessels, and subcutaneous tissues

Acute glomerulonephritis :

Acute inflammation of the renal glomeruli with


edema, hypertension, hematuria, and proteinuria

diagnosis
Microscopy is useful in skin anf soft tissue infecions
Direct antigen test are useful for the diagnosis of

streptococcal pharyngitis, but negaitve results must be


confirmed by culture
Culture is highly sensitive
Isolates identified by catalase (negative), positive PYR

reaction, susceptible to bacitracin, and presence of


group-specific antigen (group A antigen)
ASO test is useful for confirming rheumatic fever and

acute glomerulonephritis; anti-DNAse B test should also


be performed in acute glomerulonephritis is suspected

Treatment, control and prevention

Penicillin is drug of choice,

Erythromycin or oral cephalosporin is used


for patient allergic to penicillin,

Antistaphylococcal antibiotics are given for

mixed infection

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