Central nervous system, skin and

soft tissue infections

Antal Gbor Kondsz Med.
Resident doctor of infectious diseases

Szeged 2016 october 18

Central nervous system infections
Stucture of central nervous sytem
 Localisation of infection
Meningitis
Encephalitis
Myelitis
Meningo-encephalo-myelitis
Intracerebral absces
Epiduralis empyema
 Meningitis
The inflammation of meninx involved the
liquorspace

No time to lose, dieases required urgent,

immediate diagnose and treatment

The delay causes the death of the patient or

causes serious residual symptoms
 The routes of the infection
Hematogenous (abcess)
Nose and paranasal sinuses
Airways (meningoencephalitis)
Skull fractures (abscess,
epidural empyema, meningitis)
Periferial nerv (rabies, HSV, VZV)
Epidemiology
 Predisposing
Elderly people (above 60 years)
Alcoholism, liver cirrhosis, malnutriction homo canaliculus
Chronic renal diseases
HIV and other immundeficiencies
Diabetes, malignancies
Head injuries (neurological surgery)
Brain ventricular drainage or shunts
Leak of the meningx
Community (dorms or army base in early 2000 Neisseria menigitis
epidemic in Hungary)
Otitis media, sinusitis, mastoiditis
Pneumonia (abcessus)
Special predisposing factors by
presumable agents
Clinical signs which sign meningitis
THESE ARE ALARM SIGNS, BUT MISSING ARE
NOT EXCLUDE MENINGITIS
 Signs of meningeal Maneuver
irritation
Kernig sign Place patient supine with
hip flexed at 90 degrees.
Attempt to extend the leg
at the knee.
Brudzinski sign Place patient in the supine
position and passively flex
the head toward the chest.
Jolt accentuation of Patient rotates his/her
headache head horizontally two to
three times per second.
Positive test
The test is positive when
there is resistance to
extension at the knee to
>135 degrees or pain in the
lower back or posterior
thigh.
The test is positive when
there is flexion of the
knees and hips of the
patient.
The test is positive if the
patient reports
exacerbation of his/her
headache with this
maneuver.
 CT scan
Every time needed:
Intracranial pressures
Differencial diagnosis:
Trauma
Vascular abnormalities
Neoplasms
 Lumbal puncture
Make in experenced hand its safety procedure
with a minimal pain
So called a neurologist or a neurosurgeon
Liquor diagnostic tests
Cytology
Chemical
Microbiologycal
 Cytology
Normal Purulent Serosus
Normal liquor
 Microbiologycal diagnostic
The liquor in physiologycal is steril.
For the microbiologycal testing need more than 2 ml sample, much better
if 5-10 ml.
Need a rapid transport to the labory, but if isnt possible:
Suspicion of bacterial infection in room temperature
Suspicion of viral infection store in the fridge till the transport
Liquor cytology have result within 30 minute
Rapid test for the most common bacterial agents have result within 2
hours
Definitive result, with antibiotic sensitivity :
Aerob bacterias within 3 days with antiotic sensitivity
Anaerob bacteria within 10 days
Virus or Mycobacterium sp. PCR if it possible in the laboratotory with in 6-12
hours
Mycobacterium sp. Cultur within 30 days
 Tipical bacterial agent of meningitis
Organism Site of entry Age range Predisposing conditions

Neisseria Nasopharynx All ages Usually none, rarely complement deficiency

meningitidis
Streptococcus Nasopharynx, direct extension across All ages All conditions that predispose to
pneumoniae skull fracture, or from contiguous or pneumococcal bacteremia, fracture of
distant foci of infection cribriform plate, cochlear
implants, cerebrospinal fluid otorrhea from
basilar skull fracture, defects of the ear ossicle
(Mondini defect)
Listeria Gastrointestinal tract, placenta Older adults Defects in cell-mediated immunity (eg,
monocytogenes and neonates glucocorticoids, transplantation [especially
renal transplantation]), pregnancy, liver
disease, alcoholism, malignancy
Coagulase-negative Foreign body All ages Surgery and foreign body, especially
staphylococci ventricular drains
Staphylococcus Bacteremia, foreign body, skin All ages Endocarditis, surgery and foreign body,
aureus especially ventricular drains; cellulitis,
decubitus ulcer
Gram-negative bacilli Various Older adults Advanced medical illness, neurosurgery,
and neonates ventricular drains, disseminated
strongyloidiasis
Haemophilus Nasopharynx, contiguous spread from Adults; Diminished humoral immunity
influenzae local infection infants and
children if not
vaccinated
Empirical therapy in CNS infections
Agaist cerebral oedema:
Mannitol
Dexamethason
Antibiotic therapy:
2x2 g Ceftriaxon intravenousos dosing
Antiviral thrapy:
Acyclovir 10 mg/ body mass kg intravenousos
dosin
 Empirical antibiotic therapy
Predisposing factor Common bacterial pathogens Antimicrobial therapy

Age

<1 month Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes Ampicillin plus cefotaxime; OR ampicillin plus an
aminoglycoside

1 to 23 months Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Vancomycin plus a third-generation cephalosporin
Haemophilus influenzae, E. coli

2 to 50 years N. meningitidis, S. pneumoniae Vancomycin plus a third-generation cephalosporin

>50 years S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram- Vancomycin plus ampicillin plus a third-generation
negative bacilli cephalosporin

Head trauma

Basilar skull fracture S. pneumoniae, H. influenzae, group A beta-hemolytic streptococci Vancomycin plus a third-generation cephalosporin

Penetrating trauma Staphylococcus aureus, coagulase-negative staphylococci Vancomycin plus cefepime; OR vancomycin plus
(especially Staphylococcus epidermidis), aerobic gram-negative ceftazidime; OR vancomycin plus meropenem
bacilli (including Pseudomonas aeruginosa)

Postneurosurgery Aerobic gram-negative bacilli (including P. aeruginosa), S. aureus, Vancomycin plus cefepime; OR vancomycin plus
coagulase-negative staphylococci (especially S. epidermidis) ceftazidime; OR vancomycin plus meropenem

Immunocompromised S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram- Vancomycin plus ampicillin plus cefepime; OR
state negative bacilli (including P. aeruginosa) vancomycin plus ampicillin plus meropenem
 Microorganism, susceptibility Standard therapy Alternative therapies
Streptococcus pneumoniae
Penicillin MIC
0.06 mcg/mL Penicillin G or ampicillin Third-generation cephalosporin,
chloramphenicol
Third-generation Third-generation cephalosporin Cefepime, meropenem
cephalosporin MIC <1
Third-generation cephalosporin Vancomycin plus a third-generation Fluoroquinolone
MIC 1 cephalosporin
Neisseria meningitidis
Penicillin MIC
<0.1 mcg/mL Penicillin G or ampicillin Third-generation cephalosporin,
chloramphenicol
0.1 to 1.0 mcg/mL Third-generation cephalosporin Fluoroquinolone, meropenem,
chlorampenicol
Listeria monocytogenes Ampicillin or penicillin G Trimethoprim-sulfamethoxazole
Streptococcus agalactiae (group B Ampicillin or penicillin G Third-generation cephalosporin
Streptococcus)
 Microorganism, susceptibility
Escherichia coli and other
Enterobacteriaceae
Pseudomonas aeruginosa
Acinetobacter baumannii
Haemophilus influenzae
Beta-lactamase negative
Beta-lactamase positive
Staphylococcus aureus
Methicillin susceptible
Methicillin resistant
Staphylococcus epidermidis
Enterococcus species
Ampicillin susceptible
Ampicillin resistant
Ampicillin and vancomycin resistant
Standard therapy
Third-generation cephalosporin
Cefepime or ceftazidime
Meropenem
Ampicillin
Third-generation cephalosporin
Nafcillin or oxacillin
Vancomycin
Vancomycin
Ampicillin plus gentamicin
Vancomycin plus gentamicin
Linezolid
Alternative therapies
Aztreonam, fluoroquinolone,
meropenem, trimethoprim-
sulfamethoxazole, ampicillin
Aztreonam, ciprofloxacin, meropenem
Colistin or polymyxin B
Third-generation cephalosporin,
cefepime, fluoroquinolone, aztreonam,
chloramphenicol
Cefepime, fluoroquinolone, aztreonam,
chloramphenicol
Vancomycin, meropenem, linezolid,
daptomycin
Trimethoprim-sulfamethoxazole,
linezolid, daptomycin
Linezolid
 Meningoencephalitis
Usualy viral infection of the etiologycal agents
But some bacterial infection make a same
symptoms
Empiric terapy same as like in meningitis
In diagnostic use PCR and serological testing
of the blood and liquor
 Suggested initial therapy for agents that cause
encephalitis
Agent Specific therapy Agent Specific therapy
Virus Bacteria
Cytomegalovirus Ganciclovir plus foscarnet Mycoplasma pneumonia Macrolide , doxycycline, or fluoroquinolone

Epstein-Barr No specific treatment Listeria monocytogenes Ampicillin plus gentamicin; trimethoprim-

sulfamethoxazole
Hepatitis B Valgancyclovir
Tropheryma whipplei Ceftiaxone, followed by either trimethoprim-
Herpes simplex Acyclovir sulfamethoxazole or cefixime
Human herpesvirus 6 Gancyclovir or foscarnet Anaplasma phagocytophilum
HIV Antiretroviral therapy Ehrlichia chafeensis Doxycyclin
St. Louis encephalitis Interferon-2-alpha Rickettsia rickettsii
Influenza Oseltamivir Borrelia burgdorferi Ceftriaxon cefotaxim
JC virus Reversal of Treponema pallidum Penicillin G
immunosuppression if possible
Mycobacterium tuberculosis 4-drug regimen; consider addition of corticosteroid
Measles Ribavirin
Nipah Ribavirin
Varicella-zoster Acyclovir
West Nile No specific treatment
 Mycobacterium tuberculosis meningitis
Tuberculous meningitis accounts for about 1 percent of all cases of
tuberculosis
5 percent of all extrapulmonary disease in immunocompetent individuals
the case-fatality ratio remains relatively high (15 to 40 percent) despite
effective treatment regimens
Early recognition of tuberculous meningitis is of paramount importance
because the clinical outcome depends greatly upon the stage at which
therapy is initiated.
Empiric antituberculous therapy should be started
Cerebrospinal fluid (CSF) findings of low glucose concentration, elevated
protein, and lymphocytic pleocytosis
Serial examination of the CSF by acid-fast stain and culture is the best
diagnostic approach.
Smears and cultures will yield positive results even days after treatment
has been initiated.
Nucleic acid amplification testing also may be helpful.
Skin and soft tissue infections
 Normal Skin Flora
Propionibacterium acnes
Corynebacterium sp.
Staphylococci
Staphylococcus epidermidis
Staphylococcus aureus
Streptococci sp.
Candida albicans (yeast)
Many others
 Classification
Simple uncomplicated (mostly Gram +)
Cellulitis
Impetigo
Erysipelas
Simple abscess
Furuncles (boils)
Complicated: (Gram & Gram + )
Decubitus ulcers
Necrotising fasciitis
Cellulitis
Gangrene
 Celulitis
Acute, spreading infectious process affecting
epidermis and dermis
Inflammation with little or no necrosis, edema
Lymphatic involvement
Fever, chills, leukocytosis Bacteremia up to
30% of cases
Complications:
Abscess and osteomyelitis
 Microbiology
Majority of infections:
Staphylococcus aureus
streptococci
Considerations:
Methicillin resistant S. aureus (MRSA)
Vancomycin resistant enterococci (VRE)
Gram negatives: pseudomonas, E. coli
Anaerobes:
Clostridium, Bacteroides, peptostreptococcus
 Treatment
Duration 7 to 10 days

Penicillins:
Penicillin (group A streptococcus only): orally/IM
Nafcillin (MSSA or streptococcus)
Dicloxacillin orally
Cephaloporins: (1st generation)
Cefazolin IV
Cephalexin/cefprozil orally
Macrolides:
Erythromycin/Azithromycin/Clarithromycin
Clindamycin
Vancomycin IV: PCN allergic
Linezolid IV/PO
 MRSA celulitis
Methicillin resistance: Penicillin binding protein (PBP-2A)
(Resistance to all beta-lactam and penicillin antibiotics)

Vancomycin
Linezolid
Clindamycin (confirm sensitivity) +/- Vancomycin
Daptomycin
Trimethoprin-sulfamethoxazole
Synercid
 Erysipelas
Superficial cellulitis with extensive lympathic
involvement
S. pyogenes (group A streptococci)
30% of pts. have had a streptococcal respiratory
infection.
Treatment:
Penicillin
1st gen. cephalosporin
macrolide
 Impetigo
Superficial cellulitis
Group A streptococci
S. aureus 10% of patients
Small, fluid-filled vesicles, pus-filled blisters
Lesions dry to form golden-yellow crusts
Treatment:
Penicillin (drug of choice)
Benzathine penicillin G IM x1
Penicillin VK PO
PCN-allergic: erythromycin PO x 7 to 10 days
Mupirocin: topical less effective than oral therapy
 Folliculus
Etiology
Infection of hair follicle that results in pustule formation
Generally the result of a staphy. infection
Signs and Symptoms
Pustule that becomes reddened and enlarged as well as hard
from internal pressure
Pain and tenderness increase with pressure
Most will mature and rupture
Management
Care involves protection from additional irritation
Referral to physician for antibiotics
Keep athlete from contact with other team members while boil
is draining
 Carbunculus
Etiology
Similar in terms of early stage development as furuncles
Signs and Symptoms
Larger and deeper than furuncle and has several openings
in the skin
May produce fever and elevation of WBC count
Starts hard and red and over a few days emerges into a
lesion that discharges yellowish pus
Management
Surgical drainage combined with the administration of
antibiotics
Warm compress is applied to promote circulation
 Foliculitis
Etiology
Inflammation of hair follicle
Caused by non-infectious or infectious agents
Moist warm environment and mechanical occlusion contribute to
condition
Psuedofolliculitis (PFB)
Signs and Symptoms
Redness around follicle that is followed by development of papule or
pustule at the hair follicle
Followed by development of crust that sloughs off with the hair
Deeper infection may cause scarring and alopecia in that area
Management
Management is much like impetigo
Moist heat is used to increase circulation
Antibiotics can also be used depending on the condition
 Hidradenitis Suppurativa
Etiology
Primary inflammation event of the hair follicle
resulting in secondary blockage of the apocrine gland
Signs and Symptoms
Begins as small papule that can develop into deep
dermal inflammation
Management
Avoid use of antiperspirants, deodorants and shaving
creams
Use medicated soaps and systemic antibiotics
 Acne vulgaris
Etiology
Inflammatory disease of the hair follicle and the sebaceous
glands
Sex hormones may contribute
Signs and Symptoms
Present with whiteheads, blackheads, flesh or red colored
papules, pustules or cysts
If chronic and deep = may scar
Psychological impact
Management
Topical and systemic agents used to treat acne
Mild soaps are recommended
 Paronychia and Onychia
Etiology
Caused by staph, strep and or fungal organisms that accompany
contamination of open wounds or hangnails
Damage to cuticle puts finger at risk
Paronychia inflamation / infection of the surrounding tissue
Onychia infection of the nail.
Signs and Symptoms
Rapid onset; painful with bright red swelling of proximal and lateral
fold of nail
Accumulation of purulent material w/in nail fold
Management
Soak finger or toe in hot solution of Epsom salt 3 times daily
Topical antibiotics, systemic antibiotics if severe
May require pus removal through skin incision
Skin ulcer
Polymicrobial:
3 to 5 organisms per infection in hospitalized
patients
Staphylococci most common, 2nd most common
Streptococcus
Gram negative bacilli and/or anaerobes occur in
approx. 50% of cases

Gram Negative Gram positive Anaerobes

Proteus spp. S. aureus Peptostreptococcus
E. coli S. epidermidis Clostridium spp.
Klebsiella pneumoniae Streptococci spp. Bacteroides spp.
Pseudomonas aeruginosa Entercoccus spp.
Enterobacter spp.
 Treatment
Empiric oral:
Amoxicillin/clavulanic acid Dicloxacillin
TMP/SMX Cephalexin
Clindamycin Levofloxacin
Clindamycin + Quinolone Gatifloxacin
Moxifloxacin
(if no clinical improvement in 48 to 72 hrs, IV abx)
Empiric intravenosus:
Ampicillin/sulbactam + aminoglycoside
Piperacillin/tazobactam + aminoglycoside
Imipenim/cilastatin (meropenem) + aminoglycoside
Ampicillin + clindamycin + aminoglycoside
Levofloxacin or Gatifloxacin + aminoglycoside (includes Pseudomonas
coverage)
Fascitis necrotisans
 Disease starts as localized infection
Pain in area, flu-like symptoms
Invasive and spreading
May lead to toxic shock (drop in blood
pressure)
Incidence 1-20/100,000
30-70% mortality
Surgical removal, antibiotics
 Gas gangrena
Signs and symptoms
Blackening of infected muscle and skin
Presence of gas bubbles
Pathogens and virulence factors
Caused by several Clostridium species
Bacterial endospores survive harsh conditions
Vegetative cells secrete 11 toxins
 Pathogenesis and epidemiology
Traumatic event must introduce endospores into
dead tissue
Mortality rate exceeds 40%
Diagnosis, treatment, and prevention
Appearance is usually diagnostic
Rapid treatment is crucial
Surgical removal of dead tissue
Administration of antitoxin and penicillin
Prevent with proper cleaning of wounds
 Bite wounds
4 million people bitten by dogs annually.
40% cat bites/scratches become infected
Pasteurella multocida (most common)
S. aureus, streptococcus
Anaerobes: Bacteroides and Fusobacterium
Treatment:
Penicillin
Augmentin Tetracycline
TMP/SMX
levofloxacin
Thank you for your patience!