MICROORGANISMS RELATED WITH SKIN INFECTION

Dr. Sadeli Masria, dr., SpMK., MS., DMM.

Microbial flora of the skin and mucous membranes :

1. Normal flora, usually commensally microorganisms

2. Pathogenic microorganisms
Role of resident flora of the skin and mucous membranes:

To prevent colonization by pathogens and possible disease through

bacterial interference.
The mechanisms of bacterial interference :
1. competition for receptors or binding site on host cells
2. competition for nutrients
3. mutual inhibition by metabolic or toxic products
4. mutual inhibition by antibiotic materials or bacteriocins

- Suppression of the normal flora creates a partial local void that tend to be
filled by microorganisms from the environment or from other part of the
body.
- Such organisms behaves as opportunists and may be become pathogen
Role of the resident flora

• Members of the normal flora may themselves produce disease

under certain circumstances
• These organisms are adapted to the noninvasive mode of life defined
by the limitations of the environment
• If forcefully remove the restrictions of that environment and
introduced into the blood stream or tissues, these organisms may
become pathogenic
• Large numbers of Streptococcus viridans (normal flora of the upper
respiratory tract ) introduced into the bloodstream (following tooth
extraction or tonsillectomy), they may settle on deformed heart
valve and produce infective endocarditis
Normal flora of the skin

• The skin is particularly apt to contain transient microorganisms, because of its

constant exposure to and contact with the environment
• There is a constant and well-defined resident flora, modified in different anatomic
area by secretions, proximity to mucous membranes (mouth, nose, perineal areas) ,
and habitual wearing of clothing
• The factors that may be important in eliminating nonresident microorganism from
the skin are the low pH, the fatty acid in sebaceous secretions, and the presence of
lysozyme
• Neither profuse sweating nor washing and bathing can eliminate or significantly
modify the normal resident flora
• The number of superficial microorganisms may be diminished by vigorous daily
scrubbing with soap, but the flora is rapidly replenished from sebaceous and sweat
glands even when contact with other skin area or with the environment is
completely excluded
• Placement of an occlusive dressing on the skin tends to result in a large increase in
the total microbial population and may also produce qualitative alterations in the
flora
Normal flora of the skin

• Anaerobic and aerobic bacteria often to join to form synergistic

infections ( gangrene, necrotizing fasciitis, cellulitis) of skin and soft
tissues
• The bacteria are frequently part of the normal microbial flora
• It is usually difficult to pinpoint one specific organisms as being
responsible for the progressive lesion, since mixtures of organisms are
usually involved
Normal flora of the skin

• Staphylococcus epidermidis
• Staphylococcus aureus ( in small numbers )
• Alpha-hemolytic and nonhemolytic Streptococcus
• Micrococcus species
• Peptostreptococcus species
• Neisseriae species ( nonpathogenic )
• Propionibacterium species
• Diphtheroids
• Candida species ( small numbers )
• Acinetobacter species ( small numbers )
 Genus Staphylococcus

. Cells spherical, 0,5 – 1,5 um in diameter, occurring singly, in pair and irregular
cluster
• Gram positive, nonmotile, nonsporing
• Facultative anaerobic, chemoorganotrophic,with both respiratory and fermentative
metabolism
• Colonies are usually opaque and may be white or cream and sometimes yellow to
orange
• Usually catalase positive, cytochromes present but usually oxidase negative
• Nitrate often reduce to nitrite, susceptible to lysis by lysostaphin but not by
lysozyme
• Usually grow with 10 % NaCl, the optimum temperature is 300-370C
• Mainly associated with the skin and mucous membranes of warm-blooded
vertebrates, but are often isolated from food products, dust and water
• Some species produce extracellular toxin
 Tabel 1. Laboratory test for differentiation of
Staphylococcal sp.

Test S. aureus S.epidermidis S.saprophyticus

MSA :
-Growth + + +
-Fermentation + - -
Coagulase + - -
DNase + - -
Hemolysis beta - -
Novobiocin S S R
test
Pigmentation Golden white white
yellow
 Genus Streptococcus

• Cells spherical or ovoid, 0,5 – 2,0 um in diameter, occurring in pairs

or chains when grown in liquid media; they sometimes elongated in
the axis to a lanceolate shape
• Gram positive, nonmotile, nonsporing, some sp are encapsulated
• Facultative anaerobic, chemoorganotrophs, requiring nutritionally
rich media for growth and sometime 5 % CO2
• Metabolism fermentative, producing mainly lactate but no gas
• Catalase negative, commonly attack red blood cells, with either
greenish discolorization ( alpha hemolysis ) or complete clearing
(beta hemolysis ), growth is usually restricted to a temperature of 250
– 450 C (optimum 370C )
• Mainly inhabiting the mouth and upper respiratory tract
 Genus Peptostreptococcus

• Cells spherical, 0,5 – 1,2 um in diameter, and sometimes ovoid;

arrangement is variable; in pair, tetrads, clumps, or chains.
• Gram positive, nonmotile, nonsporing
• Anaerobic, chemoorganotrophic and fermentative, requiring
nutritionally rich media, metabolize peptone to mainly acetic acid;
their attack on carbohydrates is usually weak or absent
• Usually catalase negative, but weak or pseudocatalase reactions may
occur; some members produce indole and reduce nitrate
• The optimum temperature is 370 C
• The genus is differentiated from Peptococcus mainly by its lower mol
% G+C content of the DNA ( 27 – 45 )
• Obligate parasites of the mouth, mucous membranes, and intestinal
tract of mammals, and may play a part in purulent infections
 Genus Neisseria

• Cocci are 0,6 1,0 um in diameter, occurring singly but more often in
pairs with adjacent sides flattened; one species (N. elongata) is an
exception and consists of short rods 0,5 um wide, often arranged as
diplobacilli or in short chains
• Division of the coccal species is in two planes at right angle to each
other, sometimes resulting in tetrads
• Capsules and fimbriae (pili) may be present; endospore are not
present
• Cells stain Gram negative, but there is tendency to resist
decolorization
• Swimming motility does not occur, and flagella are absent
• Aerobic; some species produce a greenish yellow carotenoid pigment
 Genus Neisseria

• Some species are nutritionally fastidious and hemolytic, optimum

temperature is 350 – 370 C
• Oxydase positive, catalase positive, except N. elongata; carbonic
anhydrase is produced by all species; all species reduce nitrite except
N. gonorrhoeae and N. canis.
• Chemoorganotrophic, some species are saccharolytic
• They are inhabitants of the mucous membranes of mammals
• Some species are primary pathogens for humans
 Genus Propionibacterium

• Pleomorphic rods, 0,5-0,8x1-5 um, are often club shaped with one
end rounded and the other tapered; some cells may be coccoid, bifid
or branched, but they are not filamentous; cells occur singly, in pairs
or short chains, in V or Y configurations, or in clumps with “chinese
character” arrangement
• Gram positive, non motile, nonsporing
• Facultative anaerobes but have variable aerotolerance; most grow
somewhat in air but better anaerobically, giving on blood agar
colonies that are usually convex, semi opaque, glistening, and often
pigmented in shades of cream to reddish
• Chemoorganotrophic with complex nutritional requirement, have a
metabolism fermentative, producing from glucose and some other
carbohydrates large amounts of propionic acid , acetic acid and often
small amounts of gas
 Genus Propionibacterium

• The optimum growth temperature is 300 – 370 C

• Usually catalase positive; they are found mainly in cheese and dairy
products and on human skin
• Readily confused with some species of Corynebacterium or
Clostridium
 Genus Corynebacterium

• Straight or slightly curved, slender rods have tapered or sometimes

clubbed ends and are 0,3-0,8 x 1,5-8,8 um
• Cells are usually arranged singly or in pairs, often in a V formation
or in palisade of several parallel cells
• Gram positive, though some cells stain unevenly, giving beaded
appearance; metachromatic granules of polymethaphosphate are
commonly formed within the cells
• Nonmotile, nonsporing,not acid-fast
• Facultative anaerobs, commonly requiring nutritionally rich media
such serum or blood media, on which colonies are usually convex and
semi opaque, with a mat surface
• Chemoorganotrophs with fermentative metabolism, most species
produce acid without gas from glucose and some other carbohydrates
 Genus Corynebacterium

• Catalase positive, often reduce nitrate and tellurite; rarely acidify

lactose or raffinose or liquefy gelatin
• Primarily obligate parasites of mucous membranes of skin of
mammals; but occasionally they are found in other sources; some
species are pathogenic for mammals
 Normal flora of the mucous membranes

, Conjunctiva
• Mouth and upper respiratory tract
• Intestinal tract
• Urethra
• Vagina
 Normal flora of the conjunctiva

The predominant organisms of the conjunctiva are :

• Diphtheroids
• Staphylococcus epidermidis
• Streptococcus (nonhemolyticus)
• Neisseriae
• Moraxella sp

The conjunctival flora is normally held in check by the flow of tears;

which contain antibacterial lyzozyme
 Normal flora of the mouth and upper respiratory tract

• The mucous membranes of the mouth and pharynx are often sterile at
birth but may be contaminated by passage through birth canal
• Within 4 – 12 hours after birth, viridans streptococci become
established as the most prominent members of the resident flora and
remain so for life. They probably originate in the respiratory tracts of
the mother and attendants.
• Early in life, aerobic and anaerobic staphylococci, gram negative
diplococci ( Neisseriae, Moraxella catarrhalis ), diphtheroids, and
occasional lactobacilli are added
 Normal flora of the mouth and upper respiratory tract

• When teeth begin to erupt, the anaerobic spirochetes, Prevotella sp

(especially P. melaninogenica ), Fusobacterium sp, Rothia sp, and
Capnocytophaga sp established themselves, along with some
anaerobic vibrios and lactobacilli
• Actinomyces sp are normally present in tonsillar tissue and on the
gingivae in adults, and various protozoa may also present. Yeast
(Candida sp) occur in the mouth
• In the pharynx and trachea, a similar flora established itself, whereas
few bacteria are found in normal bronchi. Small bronchi and alveoli
are normally sterile
 Normal flora of the mouth and upper respiratory tract

• Infections of the mouth and respiratory tract are usually caused by

mixed oronasal flora, including anaerobes
• Periodontal infections, perioral abscess, sinusitis and mastoiditis may
involved predominantly Prevotella melaninogenica, Fusobacteria and
Peptostreptococci
• Aspiration of saliva (containing up to 102 of these organisms and
aerobes) may results in necrotizing pneumonia, lung abscess and
empyema
 Normal flora of the mouth and upper respiratory tract

• The predominant organisms in the upper respiratory tract, particularly

in the pharynx :

• Nonhemolytic streptococcus
• Alpha hemolytic streptococcus
• Neisseriae
• Staphylococci
• Diphtheroid
• Haeomophili
• Pneumococci
• Mycoplasma
• Prevotella
 Normal flora of the mouth and upper respiratory tract

The flora of the nose consist of :

- Corynebacteria
- Staphylococcus epidermidis
- Staphylococcus aureus
- Streptococci
 Normal flora of the intestinal tract

• At birth the intestine is sterile, but organisms are soon introduced

with food. In breast-fed children, the intestine contain large numbers
of lactic acid streptococci and lactobacilli. These aerobic and
anaerobic, gram positive, nonmotile organisms (e.g. Bifidobacterium
species) produced acid from carbohydrates and tolerate pH 5.0
• In bottle-fed children, a more mixed flora exist in the bowel, and
lactobacilli are less prominent. As food habits develop toward the
adult pattern, the bowel flora changes
• Diet has a marked influence on the relative composition of the
intestinal fecal flora
• Bowels of newborns in intensive care nurseries tend to be colonized
by Enterobacteriaceae, e.g. Klebsiella, Citrobacter, Enterobacter
 Normal flora of the intestinal tract

• In normal adults, the esophagus contains microorganisms arriving

with saliva and food.
• The stomach’s acidity keep the number of microorganisms at
minimum (103 – 105 /gr content ) unless obstruction at the pylorus
favors the proliferation of gram positive cocci and bacilli. The
normal acid pH of the stomach markedly protects against infection
with some enteric pathogens, e.g. cholera
• Administration of cimetidine for peptic ulcer leads to great increase in
microbial flora of the stomach, including many organisms usually
prevalent in feces
 Normal flora of the intestinal tract

• As the pH of intestinal content become alkaline, the resident flora

gradually increases. In the adult duodenum, there are 103 -106 bacteria
per gram of content; in the jejunum and ileum, 105-108 bacteria/gr;
and in the cecum and transverse colon, 108-1010 bacteria/gr
• In the upper intestine, lactobacilli and enterococci predominate, but in
the lower ileum and cecum, the flora is fecal
• In the sigmoid colon and rectum, there are about 1011 bacteria/gr of
content, constituting 10 – 30% of the fecal mass
 Normal flora of the intestinal tract

• Anaerobes outnumber facultative organisms by 1000-fold. In

diarrhea the bacterial content may diminish greatly, whereas in
intestinal stasis the count rises
• In the normal adult colon, 96 – 99% of the resident bacterial flora
consists of anaerobes :
• Bacteroides sp, especially B. fragilis
• Fusobacterium sp
• Anaerobic lactobacilli, e.g. bifidobacteria
• Clostridia ( C.perfringens, 103 -105/gr)
• Anaerobic gram positive cocci (Peptostreptococcus sp)
 Normal flora of the intestinal tract

• Only 1 – 4% are facultative aerobes :

• Gram negative coliform bacteria
• Enterococci
• Small number of proteus, pseudomonads, lactobacilli, candidae
• More than 100 distinct types of organisms, which can be cultured
routinely in the laboratory, occur regularly in the normal fecal flora
• There probably are more than 500 sp of bacteria in the colon
including many that are likely unidentified. Minor trauma(e.g.
sigmoidoscopy, barium enema) may induce transient bacteremia in
about 10% of procedures
 Normal flora of the intestinal tract

Intestinal bacteria are important in :

• Synthesis of vitamin K
• Conversion of bile pigments and bile acids
• Absorption of nutrients and breakdown products
• Antagonism to microbial pathogens
• The intestinal flora produces ammonia and other breakdown products
that are absorbed and can contribute to hepatic coma
• Among aerobic coliform bacteria, only few serotypes persist in the
colon for prolonged periods, and most serotypes of Escherichia coli
are present only over period of a few days
 Normal flora of the intestinal tract

• Antimicrobial drugs taken orally can, in human, temporarily suppress

the drug susceptible component of the fecal flora
• This is commonly done by preoperative oral administration of
insoluble drug. For example, neomycin plus erythromycin can in 1 – 2
days suppress part of the bowel flora, especially aerobes
• Metronidazole accomplishes that for anaerob. If lower bowel surgery
is performed when the counts are at their lowest, some protection
against infection by accidental spill can be achieved
• However, soon thereafter the counts of fecal flora rise again to
normal or higher than normal levels, principally of organisms selected
out because to relative resistance to the drug employed
 Normal flora of the intestinal tract

• The drug susceptible microorganisms are replace by drug resistant

ones, particularly staphylococci, enterobacters, enterococci, protei,
pseudomonads, Clostridium difficile and yeast
• The feeding of large quantities of Lactobacillus acidophilus may
results in the temporary establishment of this organisms in the gut
and the concomitant partial suppression of other gut microflora
• The anaerobic flora of the colon, including B. fragilis, clostridia and
peptostreptococci , play a main role in abscess formation originating
in perforation of the bowel.
• Prevotella bivia, P. disiens are important in the abscesses of the pelvis
originating in the female genital organ
• These sp are penicillin-resistant
 Normal flora of the urethra

• The anterior urethra of both sexes contains small numbers of the same
types of organisms found on the skin and perineum
• This organism regularly appear in normal voided urine in numbers of
102 – 104/mL
 Normal flora of the vagina

• Soon after birth, aerobic lactobacilli appear in the vagina and

persist as long as the pH remains acids (several weeks)
• When pH become neutral (remaining so until puberty), a mixed flora
of cocci and bacilli is present
• At puberty, aerobic and anaerobic lactobacilli reappear in large
numbers and contribute to the maintenance of acid pH through the
production of acid from carbohydrates, particularly glycogen
• This appears to be an important mechanisms in preventing the
establishment of other, possibly harmful microorganism in the vagina
 Normal flora of the vagina

• If lactobacilli are suppressed by the administration of antimicrobial

drugs, yeast or various bacteria increase in numbers and cause
irritation and inflammation
• After menopause, lactobacilli again diminish in number and mixed
flora returns. The normal vaginal flora includes group B streptococci
in as many as 25% of women of childbearing age.
• During the birth process, a baby can acquire group B streptococci,
which subsequently may cause neonatal sepsis and meningitis
• The normal vaginal flora often includes also alpha hemolytic
streptococci, anaerobic streptococci( peptostreptococci), Prevotella sp
, clostridia, Gardnerella vaginalis, Ureaplasma urealyticum, and
sometimes listeria or Mobiluncus sp
 Normal flora of the vagina

• The cervical mucus has antibacterial activity and contain lysozyme. In

some women, the vaginal introitus contain a heavy flora resembling
that the perineum and perianal area
• This may be a predisposing factor in recurrent urinary tract infections
• Vaginal organisms present at time of delivery may infect the newborn
(e.g. group B streptococci )
PREDOMINANT NORMAL FLORA AT VARIOUS BODY SITES
Body sites Microbial flora

Skin S. epidermidis, Corynebacterium, Propionibacterium, micrococcus, yeast

Conjunctivae S. epidermidis
Nose and nasopharynx S. epidermidis, S. aureus, Streptococcus sp.
Mouth and oropharynx S. epidermidis, S.pneumoniae, S. mitis,
S. salivarius, Neisseria, Haemophillus, Veilonella, Bacteroides, Fusobacterium, Lactobacillus, yeast
Intestinal tract :
Small intestine Lactobacillus, Streptococcus spp., Enterococcus, Veillonella, Actinomycetes, yeast
Large intestine Bacteroides, Clostridium, Fusobacterium, Eubacterium, Bifidobacterium,
Lactobacillus, Peptostreptococcus, Enterococcus, Enterobacteriaceae
Genitourynary Tract Corynebacterium, alpha and nonhemolytic Streptococci, S. epidermidis,
Enterococcus, Lactobacillus,
Mycobacterium smegmatis, Enterobacteriaceae, Bacteroides, Fusobacterium
Blood and Cerebrospinal fluid Sterile
Tissues, Bladder, Uterus and Sterile
fallopian tubes, middle ear and paranasal sinuses
 Skin and soft tissue infections:

Staphylococcus aureus

• Attributes of pathogenicity of S. aureus :

• Coagulase enhance fibrin deposition and abscess formation. There is also clumping
factor that coats the cells with fibrin
• Cytolytic toxin (alpha, beta, gamma, delta and leukocidin ) are all hemolytic (except
leukosidin) and destroy cellular membranes
• TSST-1 formerly termed enterotoxin F, is a superantigen and toxin produced under
certain environmental conditions, most commonly associated with tampon use and
surgical packing.
• TSST-1 reduces liver clearance of endogenous endotoxin
• Exfoliatins produced by phage group II S. aureus cause surface layer of the skin to
separate (probably through disruption of intracellular junctions) leading to
desquamation
Attributes pathogenicity of S. aureus

• Protein A ( a surface protein ) is anti phagocytic (binding to the Fc

portion of antibody, making it unavailable to attach to phagocytes
• Teichoic acids aids in attachment and stimulate the inflamatory
response when complexed with peptidoglycan
Clinical disease

• Skin infections include impetigo (often bullous), folliculitis of the

bearded region, boils (furuncles), carbuncles (more extensive),
styes, and surgical wound, burn, or traumatic-lession infections
• Scalded skin syndrome, with its characteristic bullae and
desquamation of body surfaces, occur most commonly in children
younger than 5 years old, sometimes with fairly minor infections but
circulating exfoliatins
Streptococcus pyogenes

General characteristic of S. pyogenes :

• Occur as single,paired, or chained gram positive cocci, depending on
the environment, facultative anaerobe, attaches to epithelial surface
via lipoteichoic acid portion of fimbriae (pili)
• Classification :
• Classified as group A of the 21 Lancefield group of streptococci,
which are distinguished serologically by slight differences in specific
cell wall carbohydrates
• Contains group A- specific carbohydrate and several antigenic
protein (M,T and R antigen) in the cell wall
• Subdivided into more than 80 types base on antigenic differences in
the M protein
• Sensitive to bacitracin, catalase negative, rarely become resistant to
penicillin
Attributes of pathogenicity of S. pyogenes

• Possesses M protein, a potent virulence factor found on fimbriae that

interferes with phagocytosis
• Has a nonantigenic, antiphagocytic hyaluronic acid capsule that
promote invasiveness
• Produce two hemolysin : streptolysin S ( a leukocidal protein
reponsible for beta hemolysis on blood agar plate) and Streptolysin O
(an oxygen sensitive leukosidal protein )
• Possesses multiple other enzyme systems (e.g. hyaluronidase,
streptokinase, streptodornase, nicotinamide adenine dinucleotidase)
Classification

Classified into hemolytic group of the three types of enzymatic

hemolysis of red blood cells produced by streptococci on blood
agar plate :
• Alpha-hemolytic group; is characterized by incomplete lysis, with
green pigment surrounding the colony
• Beta-hemolytic group, is characterized by total lysis and release of
hemoglobin and clear area around the colony
• Gamma-hemolytic group, is characterized by absence of lysis
Clinical disease

Impetigo :
• An easily spread exudative infection of the epidermis occurring
primarily in children; may results in nephritis as complications
• Should be treated with penicillin and scratching should be prevented
Cellulitis and erysipelas :
• Initiated by infection through a small break in the skin
• The term cellulitis applies if the lesion is defined
• Erysipelas applies if the lesion spreads, primarily through the
lymphatic Fasciitis :
• A rapidly spreading infection of the fascia; tends to occur in diabetic
patients; needs surgical debridements of necrotic tissue and therapy
with antibiotics
Clostridium perfringens

General characteristic of Cl. perfringens :

• Anaerobic, spore-forming, large Gram positive rod
• Spore can be central or subterminal and relatively heat resistant
• Has soil as natural habitat; contamination can occur in home-canned
goods, smoked fish, and honey
• Has germination of spores and emergence of vegetative cells as being
necessary for toxin production
Attributes of pathogenicity of Cl. Perfringens

• Produced alpha toxin, a potent lecithinase that damage cellular

membranes
• Produce 11 other toxins or enzymes that damage eukaryotic cells
• Produces an enterotoxin associated with food poisoning
Clinical disease

Cl. perfringens cause two types of infections :

• Soft tissue wound infections following severe trauma; organisms
elaborate toxins and enzymes to produce gas, edema, and impaired of
circulation; vascular destruction and lactic acid accumulation lower
the redox potential, with two consequences :
1. anaerobic cellulitis, causing destruction of traumatized only
2. myonecrosis (gas gangrene) or destruction of traumatized tissue
and surrounding healthy tissue
Pseudomonas aeruginosa

General characteristic of P. aeruginosa :

• A small, polarly flagellated, Gram negative rod with pili
• A non fermentative, oxydase positive bacterium
• A ubiquitous environmental organism found in water and soil and
widely distributed on plants
• It can grow in both distilled water or tap water overnight to large
number
• Often produces pigments that may be clinically useful, such as
fluorescein ( pyoverdin ) , a greenish fluorescent pigment, and
pyocyanin, a blue-green pigment
• Blue-green pus is a classic sign of P. aeruginosa infection
Attributes pathogenicity of P. aeruginosa

Invasive factor includes :

• Pili, which adhere
• A polysaccharide slime layer, which increases adherence to tissue,
making them less susceptible to phagocytosis
Virulence factor includes :
• Exotoxin A, an ADP ribose transferase similar to diphtheria toxin,
which inactivates the tRNA elongation factor (EF 2), halt protein
synthesis, and causes liver necrosis
• Exoenzyme S , an ADP ribose transferase capable of inhibiting
eukaryotic protein synthesis
• Lipopolysaccharide
• Phospolipase C, which damages membranes causing tissue damage
• Elastase and other proteolytic enzyme
Clinical disease

Cellulitis :
• Occur in patient with burns, wound, or neutropenia; may be highly
necrotic; indicated by blue-green pus and grape-like sweet odor
Septicemia :
• Results from hematogenous spread of infection from local lesion or
gastrointestinal tract and causes gram negative shock
• May result in a distinctive lesion, ecthyma gangrenosum, when
dermal veins and tissue are invaded. These lesions become necrotic
Diagnosis

• Most commonly made by clinical suspicion (grape-like odor, blue-

green pus or ecthyma gangrenosum) and confirm by culture
• Shows beta hemolysis on blood agar, with pigment production
• Shows nonfermentation on macConkey agar, blue-green pigment,
grape like odor, and oxydase positivity
Alhamdulillah