Periodic synopsis
II
This report reflects the best data available at the time the report was prepared, but
caution should be exercised in interpreting the data; the results of future studies
may require alteration of the conclusions or recommendations set forth in this
report.
Bacterial infections of the skin
David S. Feingold, MD," Jan V. Hirschmann, MD, b and James J. Leyden, M D ~
Boston, Massachusetts, Seattle, Washington, and Philadelphia, Pennsylvania
S T A P H Y L O C O C C U S A UREUS INFECTIONS
I. Textbook reference
A. Noble WC. Microbiology of human skin. 2nd
ed. London: Lloyd-Luke, 1981.
This valuable reference discusses most aspects
of cutaneous infection covered in this Periodic
Synopsis. The chapter on S. aureus describes
the basic bacteriology of the organism, the wide
range of toxins it produces, and the factors
affecting the appearance of the lesions.
II. Journal references
A. Elias PM, Fritsch P, Epstein EH. Staphylococ-
cal scalded skin syndrome. Clinical features,
pathogenesis and recent microbiological and
biochemical developments. Arch Dermatol
1977;113:207-19.
An excellent review of all phases of staphylo-
coccal scalded skin syndrome; required read-
ing.
B. Leyden J, Marples RR, Kligman AM. Staphy-
lococcus aureus in the lesions of atopic derma-
titis. Br J Dermatol 1974;90:525-30.
Heavy colonization of eczematous skin com-
monly occurs; reduction in density of S. aureus
may modulate the degree of inflammation.
C. Dillon HC. Topical and systemic therapy for
pyoderma. Int J Dermatol 1980;19:443-51.
Topical antibiotic therapy may suffice for
superficial and localized infection. Deeper or
From the Departments of Dermatology, Tufts University School of
Medicine and the New England Medical Center," the Departments
of Medicine, University of Washington School of Medicine and the
Seattle Veterans Administration Medical Center,b and the Depart-
ment of Dermatology, University of Pennsylvania School of Medi-
cine.~
Reprint requests: David S, Feingold, MD, Department of Dermatolo-
gy, Tufts University School of Medicine, 750 Washington St.,
Boston, MA 02111.
I
widespread infection requires systemic thera-
PY.
III. Key points
A. Because the resident coagulase-negative staph-
ylococci organisms protect against growth of
other organisms, neonates, who have a minimal
cutaneous flora, are especially vulnerable to S.
aureus infection. In older children and adults S.
aureus is present in the anterior narcs in about
20% to 35% and in the perineal area in 10% to
20%. It is rarely present in other normal skin.
B. Important elements in the pathophysiology of
infection include virulence factors (toxins) pro-
duced by certain strains, disruption of the skin's
integrity by trauma or dermatitis, and spread
from reservoir sites, particularly the anterior
nares. Although recurrent or persistent infec-
tions can result from impaired host defenses
(e.g., diabetes mellitus), they more commonly
reflect difficulty eradicating S. aureus from the
nose. Approaches to the problem of recurrent
staphylococcal pyoderma include application of
topical antibiotie to the anterior nares twice
daily and protracted oral therapy with anti-
staphylococcal antibiotics (e.g., dicloxacillin) to
which a short course (e.g., 5 days) or oral
rifampin (adults, 600 mg daily) may be add-
ed.
C. Infection with S. aureus can vary from superfi-
cial suppuration to dermal abscesses, The com-
mon furuncle is an infection of the hair follicle
that forms an inflammatory nodule with a
pustular center. A carbuncle is an infection of
contiguous hair follicles that begins as a nodule
and then enlarges to create an inflammatory
mass that discharges pus from multiple follicu-
lar orifices. Treatment for small furuncles is
moist heat to promote spontaneous drainage.
Large furuncles or carbuncles may require
469

470 Feingold et aL
incision and drainage. Systemic antibiotics are
used for fever or extensive surrounding celluIi-
tis.
D. In bullous impetigo, superficial flaccid bullae
develop, rupture, and leave behind an area of
"scalded skin." A toxin, exfoliatin, produces the
subcorneal sprit in the epidermis. Bullous impe-
tigo, usually caused by group II phage type 71
strains of S, aureus, is highly contagious and
requires systemic antibiotics. In children lack-
hag antibodies or adults with immunooomprom-
ise or renal insufficiency,systemic absorption of
large quantifies of this toxin can cause the
staphylococcal scatded skin syndrome. In chil-
dren the responsible organisms often colonize a
mucocal surface whereas in adults a suppura-
tive focus is typically present. A generalized
tender cutaneous erythema occurs, followed by
widespread sloughing of the upper epidermis.
E. For unknown reasons, eczematous skin, espe-
cially atopic dermatitis, frequently becomes
colonized with S. aureus. The density of organ-
isms increases with worsening of the dermatitis
and diminishes with improvement. With heavy
growth, S. aureus may intensify the underlying
inflammation and, at times, frank infection
with pustules or ceUulitis may occur.
S T R E P T O C O C C U S P Y O G E N E S INFECTIONS
I. Journal references
A. Dillon HC. Impetigo contagiesa: suppurative
and nonsuppurative complications. Clinical,
bacteriologic, and epidemiologic characteristics.
Am J Dis Child 1968;115:530-41.
Classic description of bullous lesions caused by
S. aureus and crusted dermal lesions caused by
S. pyogenes, with full-page color photographs
of different clinical entities.
B. Ferrieri P, et al. Natural history of impetigo. I.
Site sequence of acquisitions and famih'al pat-
terns of spread of cutaneous streptococci. J Clin
Invest 1972;51:2851-62.
Dajani AS, Ferrieri P, Warmamaker LW.
Natural history of impetigo. II. Etiologic agents
and bacterial interactions. J Clin Invest 1972;
51:2863-71.
Classic studies demonstrating the difference in
migration patterns and site sequence for the
spread of staphylococcal and streptococcal dis-
ease. Generally both organisms are recovered
from normal skin before infection. Streptococci
spread from normal skin to lesions and then to
the respiratory tract. In contrast, staphylococci
first appear in the nose, then are recovered from
normal skin and finally from lesions.
Journal of the
American Academy of
Dermatology
C. Maddox JS, Ware JC, Dillon HC. The natural
history of streptococcal skin infection: preven-
tion with topical antibiotics. J AM ACADD~P,-
MATOL1985;13:207-12.
When applied to areas of mild skin trauma, a
topical antibiotic combination reduces the fre-
quency of streptococcal pyoderma in children
riving in a warm, moist climate.
D. Wannamaker LW. Medical progress: differ-
ences between stl'eptoooccal infection of the
throat and skin. N Engl J Med 1970;282:23-
31.
Poststreptoeoccal nephritis can be associated
with skin or pharyngeal infection. Strains asso-
ciated with pyoderma-induced nephritis differ
from pharyngeal strains associated with nephri-
tis. The latest period to develop nephritis is
longer after pyoderma than after pharyngitis.
Host antibody responses are quite different:
antistreptolysin O response is brisk with pha-
ryngeal strains and feeble with pyoderma
strains whereas anti-deoxyribonuclease B and
antihyaluronidase antibodies increase after
streptococcal infection of the skin. Rheumatic
fever has not been linked to cutaneous infec-
tion.
E. Hook EW III, et al. Microbiologic evaluation
of cutaneous cellulitis in adults. Arch Intern
Meal 1986;146:295-7.
ExceUent discussion of the difficulty in proving
the causative agent in cellulitis.
II. Key points
A. Except in children with infected siblings, S.
pyogenes (group A streptococci) is usually
absent from normal skin. The inability of this
organism to survive does not derive from any
inhibiting effects of the resident cutaneous flora
but from skin surface lipids, especially free fatty
acids, which inhibit its growth. Both coloniza-
tion and infection with S. pyogenes generally
require disruption of the integrity of the stra-
tum corneum. Important elements in promoting
streptococcal pyoderma include high environ-
mental temperature and humidity, poor
hygiene, and crowded living conditions.
B. Impetigo begins as a thin-walled vesiculopus-
tule on an erythematous base that ruptures to
form a crust. Ecthyma is a deeper lesion with
ulceration beneath the crust; unlike impetigo it
leaves a scar on healing. With these infections,
S. aureus is present in about 50% of cases.
When sparse and superficial, the lesions may
respond to topical antibiotics; widespread or
deep infections require systemic antimicrobial
therapy.
Volume 20
Number 3
March 1989
C. With impetigo or ecthyma, infection occasion-
ally may spread into dermal lymphatic vessels,
causing erysipelas, or into reticular dermis and
subcutaneous fat, producing cellulitis. More
frequently, erysipelas and cellulitis arise from
small, often inapparent, breaks in the skin. The
most common sites are the legs and the face.
Rapidly spreading areas of erythema and heat
form, often with high fever, lymphangitis, and
regional lymphadenitis. Vesicles and hemor-
rhage may develop in the inflamed skin. The
cause of these infections, which are clinically
similar, is usually group A streptococci organ-
isms, but other groups, especially B, C, and G,
sometimes may be responsible. Isolation of the
causative organism is difficult: cutaneous aspi-
ration and biopsy usually reveal negative find-
ings on culture. Treatment requires systemic
penicillin or another appropriate antibiotic for
those with penicillin allergy.
SKIN INFECTIONS FROM GRAM-POSITIVE
BACILLI
I. Journal references
A. Barnett JH, Estes SA, Wirman JA, Morris
RE, Staneck JL. Erysipeloid. J AM ACAO
Dr~RMATOL 1983;9:116-23.
A case report and review of this cutaneous
infection caused by Erysipelothrix rhusiopa-
thiae, a commensal of many wild and domestic
animals as well as birds and fish.
B. Zaias N. Pitted and ringed keratolysis. A
review and update. J AM AcAo DERMATOL
1982;7:787-91.
A review of the clinical features and treatment
of this entity, which the author considers an
infection with a Corynebacterium species.
C. Nordstrom KM, McGinley K J, Cappiello L,
Zechman JM, Leyden JJ. Pitted keratolysis.
The role of Micrococcus sedentarius. Arch
Dermatol 1987;123:1320-5.
The authors isolated M. sedentarius from eight
patients with pitted keratolysis and reproduced
the disorder in a volunteer by applying a paste
of this organism under occlusion for 6 weeks.
II. Key points
A. Erysipeloid, a cutaneous infection caused by E.
rhusiopathiae, occurs from handling dead ani-
mal products and is therefore an occupational
hazard of fishermen, butchers, veterinarians,
and farmers. One to seven days after inocula-
tion, burning pain develops at the site of the
injury, typically a finger or hand, a.ccompanied
or followed by sharply defined, tender purplish-
red plaques. Slow peripheral spread occurs,
Bacterial infections of the skin 471
often with central cleating. Lesions usually are
confined to one portion of the body, but some-
times multiple, diffuse areas are involved. Isola-
tion of the organism usually requires a full-
thickness skin biopsy, but such cultures are
often negative, perhaps because L-forms, which
require special media for growth, develop. Pen-
iciUin or erythromycin provides effective thera-
py. Systemic infection, including bacterial
endocarditis, occasionally occurs, often without
a primary skin lesion.
B. Pitted keratolysis consists of multiple pitted
erosions on the soles or, less commonly, collar-
ettes on the palms. These lesions, which usually
cause no symptoms, seem to occur from exces-
sive moisture because of increased sweating,
occlusive shoes, or frequent contact with water.
The feet may be malodorous. The responsible
microorganism appears to be a Corynebacteri-
um sp. in many cases and M. aedentarius in
others. The condition responds to several differ-
ent treatments, including topical mieonazole,
clotrimazole, erythromycin, and clindamycin,
as well as antiseptics such as glutaraldehyde
and formaldehyde. Systemic erythromyein also
is effective.
C. Erythrasma is a common and usually asymp-
tomatic superficial skin infection with C minu-
tissirnum, affecting intertriginous areas, espe-
ciaUy axillae, groins, and toewebs. In warm
climates, more extensive disease can occur
anywhere on the body. The commonest form of
erythrasma involves scaling, fissuring, and mac-
eration of the toewebs, particularly the fourth
interspace. Elsewhere, the lesions are scaly and
slightly brown or red. All lesions fluoresce red
to pink under Wood's ultraviolet light because
the organisms produce porphyrins. The disorder
responds to vigorous soap washing, Whitfield's
ointment, topical miconazole, oral erythromy-
cin, and various topical antibiotics, including
clindamycin.
D. Triehomycosis axillaris is the presence of yel-
low, red, or black nodules on the shafts of
axiUary hair. A similar process may affect
pubic or facial hair. The skin is not involved.
These nodules represent large colonies of Cory-
nebacterium organisms of several biochemical
types. Hyperhidrosis, poor personal hygiene,
and failure to use an axillary deodorant seem to
increase the incidence of this disorder. Shaving
the hair eliminates the disease, although topical
clindamycin or erythromycin also may be effec-
tive when treatment is desired for cosmetic
reasons or staining of the clothing.

472 Feingold et al.
SKIN INFECTIONS FROM GRAM-NEGATIVE
BACILLI
III. Key points
I. Textbook references
A. Weinberg AN, Swartz MN. Gram-negative
coccal and bacillary infections, and miscella-
neous bacterial infections with cutaneous mani-
festations. In: Fitzpatrick TB, Eisen AZ, Wolff
K, et al., eds. Dermatology in general medicine.
3rd ed. New York: McGraw-Hill; 1987:2121-
52.
A complete review of skin infections with these
organisms, which includes infections of the skin
resulting from systemic infection with gram-
negative bacilli.
II. Journal references
A. Tacket CO, Brenner F, Black PA. Clinical
features and an epidemiologic study of Vibrio
vulnificus infections. J Infect Dis 1984;149:
558-61.
A study of 30 cases reported to the Centers for
Disease Control showed that primary sepsis
with V. vulnificus occurred in patients who had
recently eaten raw oysters and in patients with
a history of liver disease. Wound infection with
the organism developed in patients with recent
exposure to salt water or shellfish.
B. Weber D J, Wolfson JS, Swartz M N , Hooper
DC. Pasteurella multocida infections, report of
34 cases and review of the literature. Medicine
1984;63:133-54.
The definitive study of the clinical aspects of
this infectious agent, showing the central role of
bites by cats and dogs.
C. Gustafson TL, Band JD, Hutcheson R_H Jr, et
al. Pseudomonas folliculitis: an outbreak and
review. Rev Infect Dis 1983; 5:1-8.
Comprehensive review of the newly recognized
syndrome.
D. Carithers HA. Cat-scratch disease. An over-
view based on a study of 1200 patients. Am J
Dis Child 1985;139:1124-33.
An extensive review of this disease based on one
person's experience with 1200 patients in 30
years of practice.
E. English CK, Wear D J, Margileth AM, Lissner
CR, Walsh GP. Cat-scratch disease. Isolation
and culture of the bacterial agent. J A M A
1988;259:1347-52.
A gram-negative bacillus or its cell-wall defec-
tive variants were cultured from lymph nodes of
10 patients with cat-scratch disease. Patients
with recent infection demonstrated an antibody
response to the organism, and inoculation of the
bacteria into the skin of an armadillo produced
Journal of the
American Academy of
Dermatology
lesions identical to those seen in human dis-
ease.
A. Vibrio vulnificus and K parahaemolyticus
reach human beings from sea water and fish
where the organisms reside. V. parahaemolyti-
cus, a common cause of gastroenteritis, rarely
causes wound infections and cellulitis. V. vulnif-
icus typically infects wounds incurred in a
marine environment. The cellulitis may be
aggressive, causing necrosis and sepsis. Primary
sepsis and resultant cellulitis from the organism
occur in patients with liver disease and in
immunosuppressed patients after ingestion of
raw oysters. Much of the often extreme viru-
lence of V. vulnificus is related to. exotoxin
production.
B, Pasteurella multocida, a small gram-negative
coccobacillus, is part of the oral flora of cats
and dogs. After cat or dog bites or scratches,
cellulitis or abscess formation occurs. Serious
local complications may develop; rarely sepsis
or septic loci result. Penicillin and drainage are
the appropriate treatments.
C. Haemophilus influenzae type B is a common
cause of cellulitis in the young child. The
process is acute and usually involves the face,
presumably because the focus is the respiratory
tract. A violaceous discoloration of the overly-
ing skin is described but probably occurs in a
small percentage of patients with H. influenzae
cellulitis. As with other infections with this
organism, adult cases are not common.
D. P. aeruginosa is found in the environment in
wet areas and can colonize in moist areas of the
body. Characteristic cutaneous lesions include
external otitis (swimmer's ear), paronychia
with green/blue nail discoloration (in persons
whose hands are frequently in water), erosive
interdigital infections, and folliculitis associated
with hot tubs or similar environmental expo-
sure.
E. In diabetic persons, P. aeruginosa rarely can
cause invasive otitis externa, a serious infection
that begins superficially and then spreads into
soft tissue and sometimes bone, causing pain,
drainage, and often cranial nerve palsies. The
external auditory canal is nearly always red and
swollen and contains granulation tissue. Treat-
ment requires systemic antibiotics.
F. P. aeruginosa also can cause cellulitis and
osteomyelitis of the foot after puncture wounds.
The organism resides in the soles of used, but
now new, shoes and may be inoculated into the
tissues of the foot when its wearer steps on a
Volume 20
Number 3
March 1989
nail. Treatment requires systemic antibiotics
and surgical therapy.
G. Aeromonas hydrophila can cause serious cellu-
litis and wound infections, usually after trau-
matic exposure to water or moist soil, the
normal habitat of this gram-negative bacillus.
H. Gram-negative folliculitis, an infection of the
pilosebaeeous units, usually occurs in the course
of antibiotic treatment for acne. It is caused by
gram-negative bacilli, either Enterobacteria-
ceae or Pseudornonas sp. Therapy involves
systemic antibiotics based on the antimicrobial
susceptibility of the organism or isotretinoin in
difficult cases.
I. Most patients with cat-scratch disease are chil-
dren with exposure to cats. At the primary site
of inoculation an erythematous papule develops
and remains for weeks. Within 2 weeks, lymph
node enlargement appears proximal to the
inoculation site. The lymph nodes may be
tender and 20% suppurate. This lymph node
enlargement resolves over several months.
Fever may be present, but other systemic
involvement is uncommon. There is no known
specific therapy.
GANGRENOUS AND CREPITANT
CELLULITIS
I. Textbook reference
A. Finegold SM. Infections of skin, soft tissue, and
muscle. In: Anaerobic bacteria in human dis-
ease. New York: Academic Press, 1977.
A scholarly, encyclopedic reference work on
anaerobic bacteria and the diseases they
cause.
II. Journal references
A. Feingold DS. Gangrenous and crepitant celluli-
tis. J AM ACAD DERMATOL 1982;6:289-99.
Emphasis on classification, clinical diagnosis,
and treatment of this group of soft tissue
infections.
B. Giuliano A, Lewis F Jr., Hadley K, Blaisdell
FW. Bacteriology of necrotizing fasciitis. Am J
Surg 1977;134:52-7.
In 16 patients the bacteriology of the infection
was examined. In 3 patients the etiology was S.
pyogenes (group A streptococcus). In the others
there was synergistic infection with enteric
gram-negative bacilli and anaerobic bacilli.
C. Stamenkovic I, Lew PD. Early recognition of
potentially fatal necrotizing fasciitis. N Engl J
Med 1984;310;1689-93.
Frozen section soft tissue biopsy provided early
diagnosis of necrotizing fasciitis, resulting in a
significantly improved cure rate when com-
Bacterial infections of the skin 473
pared with cases diagnosed on clinical crite-
ria.
D. Darke SG, King AM, Slack WK, et al. Gas
gangrene and related infection: classification,
clinical features and etiology, management and
mortality. A report of 88 cases. Br J Surg
1977;64:104-12.
The important role of hyperbaric oxygen in the
management of gas gangrene is emphasized in
this large series of patients.
E. Gorbach SL. Case records of the Massachu-
setts General Hospital. N Engl J Med 1979;
301:1276-81.
A brilliant discussion of gas gangrene that
resulted from bacteremic spread of Clostridium
organisms from bowel perforation at the site of
a malignaney.
III. Key points
A. The infections considered here are character-
ized by prominent necrosis and/or gas produc-
tion in the soft tissues. They often originate at
sites of tissue damage (e.g., ischemia, trauma,
surgery, and malignancy). Diabetes frequently
is present. Hydrogen and nitrogen gases, prod-
ucts of anaerobic metabolism, accumulate in
soft tissue, where rapid bacterial growth is
occurring under hypoxic conditions.
B. Crepitant cellulitis caused by clostridia or vari-
ous gram-negative bacilli occurs as a wound
infection of subcutaneous tissue. The presence
of gas demands surgical exploration to define
whether the infection involves fascia, muscle, or
subcutaneous fat. If the infection is limited to
subcutaneous fat, simple debridement and anti-
biotics are curative.
C. Necrotizing fasciitis is an acute cellulitis involv-
ing superficial fascia as well as subcutaneous
tissue, resulting in extensive undermining and
necrosis. It usually is a rapidly progressive, se-
verely painful infection with systemic toxicity
and variable amounts of cutaneous erythema,
anesthesia, and gangrene. With group A strep-
tococcal infection, no gas or putrid odor is
present; with mixed infection by enteric bacilli
and anaerobes, both occur. Extensive unroofing
of the undermined areas is required. Fournier's
gangrene is a form of necrotizing fasciitis that
initially infects the perineum and genitalia.
D. Gas gangrene or clostridial myonecrosis is a
dramatic infection, rapid in tempo, and causing
severe local pain and extreme systemic toxicity.
Various amounts of cutaneous bronze discolor-
ation, edema, buUae, or necrosis may be seen.
The diagnosis may be made by a Gram stain of
a tissue aspiration, which reveals gram-positive

474 Feingold et al.
bacilli. Hyperbaric oxygen may limit the spread
and reduce toxicity, but all involved muscle
must be removed for cure.
E. Myonecrosis occasionally may occur with other
organisms including group A streptococci and
anaerobic streptococci.
F. Postoperative progressive gangrene is the best
descriptive name for the distinctive ulcerating
condition that also is commonly called Melen-
ey's ulcer or progressive bacterial synergistic
gangrene. It always occurs at an operative site,
usually originating at wire retention sutures.
Relentless expansion of the painful ulcers with
purplish undermined borders is characteristic.
An aerobic streptococcus regularly is cultured
from the periphery and S. aureus or a gram-
negative bacillus from the central ulcer. Antibi-
otics and removal of the retention sutures are
necessary; wide excision also may be required.
CUTANEOUS ABSCESSES
I. Journal references
A. Meislin HW, Lerner SA, Graves MH, et al.
Cutaneous abscesses. Anaerobic and aerobic
bacteriology and outpatient management. Ann
Intern Med 1977;87;145-9.
Cultures of 135 cutaneous abscesses yielded
aerobes alone in most hand abscesses, but
anaerobes alone or mixed aerobic-anaerobic
growth predominated in all other sites. S.
aureus, usually in pure culture, grew from only
24% of abscesses.
B. Whitehead SM, Leach RD, Eykyn S J, Phillips
I. The aetiology of scrotal sepsis. Br J Surg
1982;69:729-30.
In 26 patients, 30 scrotal abscesses, mostly
superficial, grew anaerobic bacteria in 90%; of
these 60% also yielded aerobes. Aerobic growth
alone occurred in only 10%. Peptococcus and
Bacteroides species were preeminent. Most
cases were "spontaneous" or followed scrotal
surgery.
C. Whitehead SM, Eykyn S J, Phillips I. Anaero-
bic paronychia. Br J Surg 1981;68:420-2.
Cultures of 105 finger paronychias grew aer-
obes alone in 69%, mixed aerobes and anaer-
obes in 27%, and solely anaerobes in 4%. S.
aureus by far was the commonest isolate. Most
anaerobes were oropharyngeal commensals,
suggesting that many paronyehias probably
arise from nail biting, finger biting, or licking.
D. Whitehead SM, Leach RD, Eykyn S J, Phillips
I. The aetiology of perireetal sepsis. Br J Surg
1982;69:166-8.
Most perirectal abscesses grew anaerobes alone
Journal of the
American Academy of
Dermatology
or mixed aerobes and anaerobes. Although
coliforms and bowel-derived anaerobes were
frequent in all abscesses, they were significantly
more common with concomitant anal fistulae.
E. Macfie J, Harvey J. The treatment of acute
superficial abscesses: a prospective clinical trial.
Br J Surg 1977;64:264-6.
In this randomized trial of 219 superficial
abscesses, oral antibiotics did not hasten healing
time or reduce recurrence rates in patients
treated by incision and open drainage or by
incision, curettage, and primary suture.
II. Key points
A. S. aureus, usually in pure growth, causes
approximately one fourth of cutaneous
abscesses. The remainder, especially those in
the anogenital region, grow other organisms,
usually anaerobes alone or mixed aerobes and
anaerobes. These bacteria, usually part of the
normal regional skin flora, individually possess
little cutaneous virulence. When combined and
introduced into the dermis or subcutaneous
tissue by trauma or other mechanisms, they
may become pathogenic.
B. In most patients with normal host defenses,
incision, drainage, and packing of the cutaneous
abscess should suffice as treatment. Gram
stain, culture, and antibiotic therapy usually are
unnecessary unless extensive cellulitis, cutane-
ous gangrene, or systemic manifestations of
infection are present.
VENOUS ULCERS
I. Journal references
A. Eriksson G, Eklund A.E, Kallinger LO. The
clinical significance of bacterial growth in
venous leg ulcers. Scand J Infect Dis 1984;
16:175-80.
In 53 patients with venous ulcers, S. aureus
alone grew in 63%, gram-negative bacilli in
13%, a combination in 15%, and other organ-
isms in the rest. The individual patient's flora
usually remained constant over time irrespec-
tive of the type of local therapy. The species and
concentration of bacteria did not correlate with
the presence or absence of purulence or the rate
of heating.
B. AfinoviA, Bassissi P, Pini M. Systemic admin-
istration of antibiotics in the management of
venous ulcers. A randomized clinical trial. J AM
AeAD D~MATOL 1986;15:186-91.
In a controlled trial of 47 patients with venous
ulcers, all treated with standard compressive
therapy, 23 received treatment for 10 days with
an antibiotic active against the organisms iso-
Volume 20
Number 3
March 1989
lated from the ulcers. The antimicrobial agents
did not significantly increase the rate of healing
or influence the bacteriology of the ulcers.
II. Key points
A. S. aureus and various aerobic gram-negative
bacilli alone or in combination are the most
common organisms present in venous ulcers.
This flora generally remains constant in the
individual ulcer, despite local therapy or sys-
temic antibiotics, until healing occurs.
B. The quantity and type of organisms do not
correlate with the appearance of the ulcers:
purulence does not suggest a specific bacterial
cause or microbial concentration.
C. Unless local cellulitis or systemic signs of infec-
tion are present, antibiotic therapy does not
accelerate healing and is not indicated. Similar-
ly, bacterial cultures of venous ulcerations are
not warranted unless those complications
Occur.
DIABETIC AND DECUBITUS ULCERS
II. Key points
I. Journal references
A. Louie T J, Bartlett JG, Tally FP, Gorbach S L
Aerobic and anaerobic bacteria in diabetic foot
ulcers. Ann Intern Med 1976;85:461-3.
Cultures of foot ulcers in 20 patients yielded an
average of 5.8 bacterial species per specimen
(3.2 aerobes, 2.6 anaerobes). The most common
anaerobes were Peptococcus, Bacteroides, and
Clostridium species; the most frequent aerobes
were Proteus sp., enterococci, S. aureus, and
Escherichia coli. The bacteriology of stable and
complicated ulcers was similar, and no patho-
genic significance was obvious for individual
bacterial species.
B. Sapico FL, Canawati HN, Witte JL, Mont-
gomerie JZ, Wagner FW, Bessmann AN.
Bacterial infections o f the skin 475
Quantitative aerobic and anaerobic bacteriolo-
gy of infected diabetic feet. J Clin Microbiol
1980;12:413-20.
In 13 patients with infected diabetic ulcers
undergoing amputation, deep-tissue specimens
yielded an average of 4.7 species per specimen
(2.4 anaerobes, 2.3 aerobes). The most common
aerobes were enteric gram-negative bacilli and
group D streptococci; the most common anaer-
obes, Bacteroides and Clostridium sps.
C. Galpin JE, Chow AW, Bayer AS, Guze LB.
Sepsis associated with decubitus ulcers. Am J
Med 1976;61:346-50.
In 21 patients with sepsis attributed to decubi-
tus ulcers, blood cultures, positive in 16, grew
predominantly Bacteroides, Peptococcus, Pep-
tostreptococcus, and Staphylococcus aureus
organisms. The most common organisms cul-
tured from the ulcers were Proteus, group D
streptococcus, E. coil S. aureus, and Pseudo-
monas species.
A. In both diabetic foot ulcers and decubitus ulcers
a complex flora of aerobic and anaerobic bac-
teria is present, probably representing contami-
nation with both skin and fecal organisms.
B. The bacteriology of chronic, stable diabetic
ulcers is similar to that of ulcers with extensive
surrounding cetlulitis. Chronic diabetic or decu-
bitus ulcers with minimal surrounding cellulitis
do not require routine cultures or systemic
antibiotic therapy, which should be reserved for
substantial involvement of adjacent soft tissue,
osteomyelitis, or signs of systemic infection.
When these are present, cultures of both pus
and blood are appropriate, and surgical thera-
py, in addition to antibiotics, usually is re-
quired.