细菌性皮肤病原发感染 : 病原菌直接侵入皮肤, 在局部造成炎症如葡萄球菌引起毛囊炎疖痈等 ; 链球菌引起丹毒及蜂窝织炎等继发感染 : 在原有皮肤创伤或皮肤病基础上发生感染

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1 细菌性皮肤病 Dermatoses caused by bacteria 浙医一院方红 Dermatology Department, The 1st Affiliated Hospital, College of Medicine, Zhejiang University

2 细菌性皮肤病原发感染 : 病原菌直接侵入皮肤, 在局部造成炎症如葡萄球菌引起毛囊炎疖痈等 ; 链球菌引起丹毒及蜂窝织炎等继发感染 : 在原有皮肤创伤或皮肤病基础上发生感染

3 皮肤及软组织感染 (SSTI) 皮肤及软组织感染 (skin and soft tissue infection, SSTI) 是由化脓性致病菌侵犯表皮真皮和皮下组织引起的炎症性疾病皮科脓疱疮毛囊炎外科深在性脓疱疮 ( 臁疮 ) 疖 / 痈其他科室原发感染疖痈丹毒甲沟炎丹毒蜂窝织炎皮炎湿疹继发感染疱疹继发感染外伤感染动物或人咬伤后的感染会阴侧切脐炎继发感染物理治疗术后感染 ( 激光电疗 ) 葡萄球菌性烫伤样综合征痤疮继发感染药疹继发感染褥疮继发感染烧烫伤继发感染糖尿病足继发感染肠造瘘口和手术感染

4 SSTI 病原菌流行病学趋势皮肤软组织感染主要病原菌变化趋势 : 由链球菌向金萄菌转变 1.2 注 :CNS 表示凝固酶阴性的葡萄球菌 1 Schachner L,Taplin D, Scott GB, et al. Pediatr Clin North Am. 1983,30: Moran GJ,Krishnadasan A,Gorwitz RJ, et al. NEJM, 2006, 355(7):

5 P1 下皮肤源性 MRSA 检出率逐年升高 1 1 Moran GJ, Amii RN, Abrahamian FM, et al. Emerg Infect Dis, 2005, 11(6):

6 继发 SSTI 的病原菌同样以 G + 球菌为常见疾病常见病原菌疾病常见病原菌湿疹继发性感染金葡菌外伤继发感染金黄色葡萄菌链球菌皮炎继发性感染金葡菌动物或人咬伤后的感染葡萄菌属链球菌属肠道杆菌属单纯性疱疹继发性感染金葡菌褥疮继发感染金黄色葡萄球菌绿脓杆菌大肠埃希氏杆菌大疱性表皮坏死松懈症型药疹继发性感染金葡菌表皮葡萄球菌烧烫伤继发感染金黄色葡萄球菌 (MRSA 占 SA 的 82.5% ) 脓疱型痤疮继发性感染表皮葡萄球菌糖尿病足继发感染金葡菌链球菌革兰阴性杆菌

7 原发 SSTI 的病原菌以 G + 球菌为常见疾病常见病原菌疾病常见病原菌毛囊炎金葡菌蜂窝织炎 β 溶血链球金葡菌疖金葡菌丹毒化脓链球菌痈金葡菌臁疮金葡菌 β 溶血链球脓疱疮化脓链球菌金葡菌甲沟炎金葡菌

8 细菌性皮肤病细菌的致病性侵袭力毒力超抗原细菌引起的皮肤病表现为原发性感染继发性感染

9 脓疱疮 (Impetigo) 俗称黄水疮, 是儿童常见的化脓性皮肤病主要由凝固酶阳性的金黄色葡萄球菌, 其次为乙型溶血性链球菌引起, 亦可两者混合感染 S. aureus and GAS (S. pyogenes) cause superficial infections of the epidermis (impetigo), which may extend into the dermis (ecthyma), characterized by crusted erosions or ulcers. 临床主要表现为浅表脓疱和脓痂

10 脓疱疮 (impetigo) S. aureus and GAS (S. pyogenes) cause superficial infections of the epidermis (impetigo), which may extend into the dermis (ecthyma), characterized by crusted erosions or ulcers. They may arise as primary infections in minor superficial breaks in the skin or as secondary infections of preexisting dermatoses (impetiginization, or secondary infection).

11 Etiolog S. aureus most commonly; also, GAS or mixed S. aureus and GAS. Bullous impetigo: 80% caused by S. aureus phage group 2 (types 71 and 55), which produce exfoliative toxins and also cause staphylococcal scalded-skin syndrome.

12 Predisposing Factors 1.Primary Impetigo :Arises at minor breaks in the skin. 2. Secondary Impetigo (Impetiginization): Arises in a variety of underlying dermatoses and traumatic breaks in the integrity of the epidermis. Inflammatory Dermatoses:Atopic dermatitis, stasis dermatitis, psoriasis vulgaris, chronic cutaneous lupus erythematosus, pyoderma gangrenosum.

13 寻常型脓疱疮 Impetigo vulgaris 多见于夏秋季, 好发于儿童金葡菌和链球菌单独或合并感染好发于颜面口周鼻孔周围及四肢, 有的可继发于痱子湿疹等皮损为成群分布的薄壁脓疱, 周围红晕, 易破溃, 破后露出红色糜烂面, 脓液干燥后形成蜜黄色结痂, 可互相融合, 并可自身接种

14 Impetigo vulgaris Nonbullous Impetigo :Transient superficial small vesicles or pustules rupture, resulting in erosions, which in turn become surmounted by a crust. Golden-yellow crusts are often seen in impetigo but are not pathognomonic. 1- to 3-cm lesions; central healing often apparent if lesions present for several weeks. Arrangement: scattered, discrete lesions; without therapy, lesions may become confluent; satellite lesions occur by autoinoculation.

16 大疱型脓疱疮 impetigo bullosa 儿童好发, 多见于夏秋季由凝固酶阳性噬菌体 II 组 71 型或 55 型的金黄色葡萄球菌引起好发于颜面躯干及四肢皮损为成群分布的大脓疱, 可见脓液下垂呈半月状, 疱壁薄, 易破溃, 破后露出红色糜烂面, 起病急, 传染性强, 可自身接种

17 Bullous Impetigo Vesicles and bullae containing clear yellow or slightly turbid fluid without surrounding erythema, arising on normalappearing skin. With rupture, bullous lesions decompress. If roof of bulla is removed, shallow moist erosion forms.

19 深脓疱疮 ( 臁疮 )ecthyma 主要发生于营养不良儿童或老年人由溶血性链球菌引起的溃疡性脓疱疮好发于小腿及臀部皮损早期为脓疱, 向深部发展, 表面坏死黑色厚痂, 周围红晕

20 Ecthyma Ulceration with a thick adherent crust. Lesions may be tender, indurated. Distribution: more common on distal extremities.

21 Ecthyma: S. aureus A large, circumscribed chronic ulcer with surrounding erythema in the pretibial region.

22 毛囊性脓疱疮表浅性脓疱性毛囊炎金葡菌感染好发于四肢头皮面部和口周薄壁半球状易破的黄白色小脓疱疱疹红晕

23 新生儿脓疱疮 impetigo neonatorum 发生于新生儿的大疱性脓疱疮起病急, 传染性强, 可伴高热及中毒症状皮损为大疱性脓疱疮, 疱周红晕, 破后露出红色糜烂面, 可自身接种

25 葡萄球菌烫伤样皮肤综合征 staphylococcal scalded skin syndrome 发生于出生后 3 个月的婴儿由凝固酶阳性噬菌体 II 组 71 型或 55 型的金黄色葡萄球菌产生的表皮剥脱毒素引起颜面口周开始, 迅速波及躯干及四肢皮损为大片红斑基础上出现松弛性水疱, 尼氏征阳性, 皮肤大面积剥脱后露出红色糜烂面, 似烫伤样外观, 起病急, 可危及生命

27 葡萄球菌烫伤样皮肤综合征重症者可伴邻近淋巴结肿大, 可有发热, 畏寒等全身症状个别病例可引起败血症或肾炎实验室检查白细胞总数及中性粒细胞可增高脓液细菌培养为金黄色葡萄球菌或溶血性链球菌

28 Diagnosis Clinical findings confirmed by Gram's stain or culture.

29 治疗患儿隔离, 环境衣物消毒 ; 局部用药前, 可用 0.05% 黄连素液或 0.02% 高锰酸钾液清洗患部或湿敷 ; 外用百多邦软膏以及红霉素氯霉素软膏等还可用龙胆紫液 ; 皮损泛发, 全身症状明显者, 可系统应用抗生素 ( 对金葡菌敏感的 ) 治疗及对症处理, 如阿莫西林甲氧苯青霉素大环内酯类或头孢菌素等

30 Topical Treatment Mupirocin (pseudomonic acid) ointment is highly effective in eliminating both GAS and S. aureus, including MRSA, from the nares and cutaneous lesions. Apply three times daily to involved skin and to nares for 7 to 10 days.

31 Systemic Antimicrobial Treatment For MRSA, sensitivities of the isolated organism and personal history of antibiotic allergies determine drug of choice and alternatives. Non-penicillinase producing :Penicillin G or V ;A cephalosporin; clindamycin; vancomycin; imipenem; a fluoroquinolone. Penicillinase-producing,A penicillinase-resistant penicillin. PO: dicloxacillin, cloxacillin. IV for severe infections; nafcillin, oxacillin, A cephalosporin; vancomycin; amoxicillin/clavulanicacid; ticarcillin/clavulanic acid; piperacillin/tazobactam; ampicillin/sulbactam; imipenem; clindamycin; a fluoroquinolone.

32 Prevention Daily bath. Benzoyl peroxide wash (bar). Check family members for signs of impetigo. Ethanol or isopropyl gel for hands and/or involved sites.

33 毛囊炎 (folliculitis) 系由凝固酶阳性金黄色葡萄球菌等感染毛囊引起的化脓性炎症 Folliculitis is a localized bacterial infection occurring within a single hair follicle that manifests as small pustules surrounded by mild erythema.

34 临床特点好发于头面四肢及外阴部等处初起为粟粒大红色毛囊性丘疹, 顶端化脓形成小脓疱, 大多分批出现, 互不融合, 脓疱破裂后可排出少量脓血, 但无脓栓自觉痒痛易复发

36 发生在胡须部的称须疮

37 发生头皮愈后留有脱发和瘢痕形成 --- 瘢痕疙瘩性毛囊炎

38 疖和痈 furuncle carbuncle 疖为毛囊和毛囊深部及周围组织的急性化脓性感染, 多个损害称为疖病痈多个相邻毛囊深部感染或数个疖肿相互融合凝固酶阳性金黄色葡萄球菌白色葡萄球菌链球菌等

39 Furuncle Carbuncle A furuncle is an acute, deep-seated, red, hot, tender nodule or abscess that evolves from a staphylococcal folliculitis. A carbuncle is a deeper infection composed of interconnecting abscesses usually arising in several contiguous hair follicles.

40 Furuncle: S. aureus Soft-tissue swelling of the forehead with central abscess formation, nearing rupture.

41 Furuncles: S. aureus Multiple areas of folliculitis in the moustache area, extending to become furuncles.

42 Multiple furuncles: MRSA Multiple, painful ulcerated nodules on the buttocks of a 20-year-old male, occurring during hospitalization for ulcerative colitis.

43 Carbuncle: S. aureus A very large, inflammatory plaque studded with pustules, draining pus, on the nape of the neck. Infection extends down to the fascia and has formed from a confluence of many furuncles.

45 Laboratory Examinations Gram's Stain Gram-positive cocci within PMN leukocytes. Bacterial Culture Culture of pus isolates S. aureus. Sensitivities to antimicrobial agents may determine management. Antibiotic Sensitivities

46 治疗外用杀菌止痒和保护的药物如 2.5% 碘酊洁霉素液等根据病情选用适当的抗生素内用早期可用紫外线超短波等物理治疗慢性反复发作者应寻找有无糖尿病贫血等全身疾病, 可应用免疫调节剂

47 丹毒和蜂窝织炎 Erysipelas Cellulitis Erysipelas and cellulitis are acute, spreading infections of dermal and subcutaneous tissues, characterized by a red, hot, tender area of skin, often originating at the site of bacterial entry, caused most frequently by GAS (erysipelas) or S. aureus.*

48 丹毒 (erysipelas) 丹毒系 A 群乙型溶血性链球菌所致的急性皮肤及皮肤浅层淋巴组织急性炎症病原菌大多经过皮肤黏膜的微细损伤侵入引起组织感染故鼻部炎症抠鼻掏耳足癣等因素常成为丹毒的侵入门户, 病原菌可潜伏于淋巴管内, 引起复发

49 Etiology Adults: S. aureus, GAS. Children: H.influenzae type b (Hib), GAS, S. aureus.

50 Risk Factors Drug and alcohol abuse, cancer and cancer chemotherapy, chronic lymphe de ma, cirrhosis, diabetes mellitus, nephritic syndrome, iatrogenic immunosuppression, neutropenia, immunodeficiency syndromes, malnutrition, renal failure, systemic atherosclerosis.

51 临床特点皮损好发于小腿颜面部发病前常有畏寒全身不适等先驱症状, 继之发生高热,39~40 皮损为略高出皮面的鲜红色水肿性斑, 表面紧张发亮, 边界较清楚, 严重者可发生水疱, 压痛明显, 局部皮温高局部淋巴结肿大复发性丹毒引起慢性淋巴水肿, 在乳癌病人腋部淋巴结清除术后由于淋巴淤滞, 也易反复罹患丹毒, 下肢反复发作可导致橡皮肿白细胞总数增高, 其中以嗜中性白细胞为主

52 Erysipelas of face: group A streptococcus Painful, well-defined, shiny, erythematous, edematous plaques involving eyelids, cheeks, and the nose of an elderly febrile male. On palpation the skin is hot and tender. Portal of entry was conjunctivitis.

53 Erysipelas of leg: S. aureus The lower leg is red, hot, tender, and edematous. Erythematous plaque is well defined. The infection is recurrent with interdigital tinea pedis as the portal of entry.

55 蜂窝织炎 (cellulitis) 蜂窝织炎系乙型溶血性链球菌和金黄色葡萄球菌感染引起的广泛的皮肤深部结缔组织的急性弥漫性化脓性炎症继发于外伤溃疡局限性化脓性炎, 细菌由皮肤微小创伤侵入

56 临床特点皮损好发于四肢面部外阴肛周急性期疼痛高热,39~40 皮损为弥漫性水肿性浸润性红斑, 边界不清楚, 压痛明显, 局部皮温高, 严重者形成深部化脓组织坏死局部淋巴结肿大淋巴结可发生败血症白细胞总数增高, 其中以嗜中性白细胞为主

57 Cellulitis of cheek: H. influenzae Erythema and edema of the cheek of a young child, associated with fever and malaise. H. influenzae was isolated on culture of the nasopharynx.

58 Laboratory Examinations Smears and Cultures: Gram's stain of exudate, pus, bulla fluid, aspirate, or touch preparation may show bacteria. GAS: chains of gram-positive cocci. S. aureus: clusters of gram-positive cocci. Clostridia: gram-negative rods, few neutrophils.

59 Treatment 治疗原则为积极抗感染早期足量有效抗生素治疗首选青霉素,480~800 万单位 / 日, 静滴, 过敏者可用红霉素 1~1.5g/ 日静点, 或选用喹诺酮类, 也可选用头孢菌素静滴一般疗程为 10~14 天局部治疗 : 有水疱破溃者可用 0.05% 黄连素或呋喃西林液湿敷, 可外用抗生素类软膏如百多邦软膏诺氟沙星乳膏等, 有化脓者切开排脓物理疗法, 采用紫外线照射音频电疗超短波红外线等, 均有一定疗效积极治疗局部病灶, 如足癣鼻炎等, 下肢损害应抬高患肢

60 思考题 Describe the clinical type of impetigo and main manifestation respectively. Describe the definition and main manifestation of furuncle. Describe the diagnosis and the differential diagnosis of erysipelas.

61 Thanks!

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ºî½×2-p174-184 174 美國感染症醫學會 Methicillin 抗藥性金黃色葡萄球菌治療指引李倩瑜 1 鄭舒倖 2 行政院衛生署桃園醫院 1 小兒科 2 感染科 (IDSA) 2011 methicillin (methicillin-resistant Staphylococcus aureus; MRSA) (practice guidelines)[1]

细菌性皮肤病 原发感染 : 病原菌直接侵入皮肤, 在局部造成炎症 如葡萄球菌引起毛囊炎 疖 痈等 ; 链球菌引起丹毒及蜂窝织炎等 继发感染 : 在原有皮肤创伤或皮肤病基础上发生感染

细菌性皮肤病原发感染 : 病原菌直接侵入皮肤, 在局部造成炎症如葡萄球菌引起毛囊炎疖痈等 ; 链球菌引起丹毒及蜂窝织炎等继发感染 : 在原有皮肤创伤或皮肤病基础上发生感染