Wound and skin infections



Last Review Date: August 14, 2017


What are wound and skin infections?

Infections of skin and wounds are the consequence of invasion of tissues by one or more species of microorganisms. This infection triggers a response by the body's immune system, causes inflammation and tissue damage, and slows the healing process. Many infections remain confined to a small area, such as seen with an infected superficial skin scratch or hair follicle, and these often resolve on their own. Other infections may persist and, if untreated, increase in severity and spread further and/or deeper into the body. Some infections spread to other organs or cause septicaemia.

Skin is the body's largest organ and is its first line of defence. Even when clean, the surface of the skin is not sterile but is populated with a mixture of microorganisms called normal flora. This normal flora forms a dynamic barrier that helps to keep other more harmful microorganisms (pathogens) at bay. At any one time, a certain percentage of the general population will be carriers of a pathogen that displaces some of their normal flora and “colonises” locations like the mucous membranes of the nose. Most of the time normal flora and colonising pathogens do not cause illness, however if there is a break in the skin or if the immune system becomes compromised, then any of the microorganisms normally present can cause a wound or skin infection.

Wounds are breaks in the integrity of the skin and tissues. They may be superficial cuts, scrapes or scratches but also include more invasive insults such as punctures, burns or be the result of a surgical or dental procedure. The microorganisms likely to infect the wound depend on several factors:

  • on the wound's location on the body and its extent and depth
  • the external environment in which the wound occurs, such as water or soil
  • the injurious agent such as a thorn in gardening injuries or the bitumen in road trauma
  • the microorganisms present on the person's skin

The skin has three layers: the outer epidermis, the dermis (where many hair follicles and sweat glands are located), and the fatty subcutaneous layer. Below these layers are membranes that protect connective tissues, muscle and bone. Wounds can penetrate any of these layers and skin infections can spread directly into them. Wound healing is a complex process that involves many related systems, chemicals, and cells working together to clean the wound, seal its edges, and to produce new tissues and blood vessels.

Skin and wound infections interfere with this healing process and often create additional tissue damage. These infections can affect anyone, but people with underlying conditions such as poor circulation or a suppressed immune system are at greater risk of slowed wound healing  and subsequently at higher risk of infection. The infection may become a chronic infection if it penetrates deep into body tissues such as bone, or when the infection occurs in tissue that has inadequate circulation.


Types of Wound Infections and Microorganisms

Wounds may be grouped according to the cause, the environment in which they occur, their extent, and whether they are clean or contaminated. The microorganisms that typically infect wounds and the skin depend on what is present in the environment, the state of the person's immune system, and the depth of the wound.

Bacteria, fungi and viruses can cause skin and wound infections. Bacteria may be divided according to the environment in which they grow: those that grow in air (aerobic), those that grow in reduced oxygen environments (microaerophilic), and those that grow in little to no oxygen (anaerobic). Microaerophilic and anaerobic bacteria may be found in deeper wounds and abscesses.

Superficial skin infections
Superficial infections occur primarily in the outer layers of the skin but may extend deeper into the subcutaneous layer.

Bacterial infections are typically caused by normal flora bacteria, such as species of Staphylococcus (Staph) and Streptococcus (Strep). They may also be caused by colonising bacteria which may be resistant to some antibiotics, such as MRSA (Methicillin Resistant Staphylococcus aureus). Brackish water wound infections may be due to waterborne Vibrio or Aeromonas species. Hot tub-associated infections may be caused by Pseudomonas aeruginosa. When wounds are deeper, the possible pathogens include anaerobes such as Bacteroides and Clostridium species.

Typical bacterial skin infections include:

  • Folliculitis, furuncles, and carbuncles
  • Impetigo - skin lesions and vesicles
  • Pressure sores (bed sores) and ulcers - these may be found in patients who have been immobilised for long periods of time such as long-term care facility patients. These types of wounds may be colonised by many different types of bacteria and culturing them often does not provide useful information as to how the patient should be treated.
  • Cellulitis - an infection often involving the subcutaneous and connective tissue of skin causing redness, heat, pain and swelling
  • Necrotising fasciitis - a serious but uncommon infection that can spread rapidly and destroy skin, fat, muscle tissue and fascia (the layer of tissue covering muscle groups). This type of infection often involves Group A streptococci, which are sometimes referred to as “flesh-eating bacteria”.

Other common superficial skin infections such as ringworm and athlete's foot are not caused by bacteria but by fungi such as Trychophyton sp. However, fungi can be found on thorns, splinters and dead vegetation and can lead to deep invasive wound infections that require special cultures for detection and identification. Yeast infections caused by Candida species may occur on moist areas of the skin such as in nappy rash.

A variety of warts, such as common and plantar warts, are due to human papilloma virus (HPV).

Bites
Wound infections due to bites tend to reflect the microorganisms present in the saliva and oral cavity of the human or animal that created the bite wound.

Human bites may become infected with a variety of aerobic and anaerobic bacteria that are part of the normal oral flora. The majority of animal bites are from dogs and cats, and the most common bacteria recovered from these cultures is Pasteurella multocida. Although rare, there is a risk of a rabies viral infection with bites from unvaccinated animals and should be considered if the bite occurs outside Australia (although even in the wild the prevalence of rabies is low). In Australia, if bitten or scratched by a bat, then prophylaxis against Australian Bat Lyssa Virus should be considered by your health care provider.

Trauma
Trauma is a wide category of injuries caused by physical force. It includes everything from burns to injuries from motor vehicle accidents, crushing injuries, cuts from knives and other sharp instruments, and gunshot wounds. The type of infections that trauma victims acquire depend primarily on the environment in which the injury took place, the extent of the injury, the microorganisms present on the skin of the affected person, the microorganisms the person is exposed to during wound healing, and the person's general health and immune status.

Wounds that are initially contaminated such as with the dirt that may be acquired during a motor vehicle accident or that involve extensive damaged tissue - such as a severe burn - are at an increased risk of becoming infected. It is not uncommon for deep and contaminated wounds to have more than one aerobic and/or anaerobic microorganism present.

A deep puncture wound could allow anaerobic bacteria such as Clostridium tetani (the cause of tetanus) to grow. Because most people in Australia are immunised against tetanus, this is a rare event but need to be considered. Routine vaccination of adults every 10 years is no longer recommended but you should discuss this with your health care provider. Re-vaccination is often done in the emergency room where patients are treated after incurring a deep wound that may need stitches particularly if more than 5 years has elapsed since the last dose.

Post surgical
Surgical sites are most commonly infected with the patient's normal skin and/or gastrointestinal flora - the same organisms seen with superficial infections. They may also become infected by exposure to microorganisms in the hospital environment. Hospital-acquired bacteria, such as MRSA, often have an increased resistance to antibiotics. Deep surgical wounds may become infected both superficially with aerobic microorganisms and deep within the body by anaerobes.

Burns
Burns may be caused by scalding or flammable liquids, fires and other sources of heat, chemicals, sunlight, electricity, and very rarely by nuclear radiation. First-degree burns involve the epidermis. Second-degree burns penetrate to the dermis. Third-degree burns penetrate through all of the layers of the skin and frequently damage the tissues below it.

Burn wounds are initially sterile but because of the dead tissue at their centre - the eschar (scab) - and the loss of the skin's protection, they are quickly colonised by the patient's normal flora. The affected person is at an increased risk for wound infection, septicaemia, and for multiple organ failure. Initial infections tend to be bacterial. Fungal infections due to Candida, Aspergillus, Fusarium, and other species may arise later since they are not inhibited by antibacterial treatment. Viral infections, such as those caused by the herpes simplex virus, may also occur.


Signs and symptoms

General signs and symptoms of a wound infection include redness, swelling, warmth, tenderness and pus drainage. The skin may also harden or tighten in the area and red streaks may radiate from the wound. Wound infections may also cause fevers, especially when they spread to the blood. Skin infections often redden or discolour the skin and may cause pustules, scaling, pain and/or itching. Skin infections caused by other agents (viruses, fungi) have a wide variety of possible presentations, that may be hard to distinguish from other causes of skin rash.


Tests

Many minor and superficial skin and wound infections are diagnosed by the doctor based on a clinical evaluation and their experience. In addition to general symptoms, many skin infections have characteristic signs, such as the appearance of a plantar wart, and typical locations on the body, such as athlete's foot between the toes. A clinical evaluation cannot, however, definitively tell the doctor which microorganism is causing a wound infection or the treatment to which this microorganism is likely to be susceptible. For that, laboratory testing is sought but does not always yield a result. When a result is given it will usually guide therapy.

Laboratory tests
Laboratory testing is primarily used to diagnose bacterial wound infections, to identify the microorganism responsible, and to determine its likely susceptibility to specific antimicrobial agents. Sometimes testing is also performed to detect and identify fungal infections. Sample collection may involve swabbing the surface of a wound, aspiration of fluid or pus with a needle and syringe, and/or the collection of a tissue biopsy. If anaerobic microorganisms are suspected, then special collection and transport measures must be used to keep the sample from being exposed to oxygen. For fungal evaluation, scrapings of the skin may be collected.

Testing may include:

  • Gram stain - used along with the wound culture. Special staining allows bacteria to be evaluated under the microscope. They may be distinguished by their shape - cocci (spheres) or bacilli (rods) - and separated by colour into gram positive or gram-negative microorganisms. The results of this test should be available the same day the specimen is received in the laboratory and can give the doctor preliminary information about the quality of the specimen and potential organisms that may be causing the infection.
  • Bacterial wound culture - this is the primary test used to determine the cause of a bacterial infection. The sample is streaked onto or into nutrient media and incubated at body temperature to grow and identify any bacteria present in the sample. Part of this test includes the identification of MRSA when it is present. Results of bacterial wound cultures are usually available within 48 hours from the time the specimen is received in the laboratory. Results of special cultures for slow growing organisms, such as fungi or mycobacteria, may require several weeks.
  • Antimicrobial susceptibility - a follow-up test to the wound culture. When a pathogen is identified and isolated using the wound culture, this test is used to determine the bacteria's likely susceptibility to certain drug treatments. This information helps guide the doctor in selecting appropriate antibiotics for treatment. These results are typically available within 24 hours after identification of the microorganism that is causing the infection.

Other microbiological tests that may be ordered include:

  • KOH prep - a rapid test performed to microscopically detect fungal elements (cellular structures) in a sample.
  • Fungal culture - ordered when a fungal infection is suspected. Many fungi are slow-growing and may take several weeks to identify.
  • AFB culture and smear - ordered when a mycobacterial infection is suspected.
  • Blood culture - ordered when septicaemia is suspected.
  • Urine culture - ordered when a urinary tract infection is suspected.
  • DNA or RNA testing to detect genetic material of a specific organism.

Non-laboratory tests
Imaging scans such as ultrasounds or x-rays may be ordered to evaluate the extent of tissue damage and to look for areas of fluid/pus in selected cases.


Treatment

Many risks of superficial wound infection can be minimised with prompt and proper wound cleansing and treatment.

Many superficial bacterial infections and viral infections will resolve on their own without treatment, however more invasive or persistent infections may require treatment. This may range from prescription of a topical or oral antimicrobial agent, to incision and drainage or surgical debridement (removal of dead tissue) of the wound site, to intravenous medications or an extended duration of antibiotics. The choice of treatment is based upon the duration and site of infection, organisms growing from wound culture and antimicrobial susceptibility tests. Patients with antibiotic resistant bacteria or with an infection in a location that is difficult for drug therapy to penetrate (such as bone) may require extended treatment and/or treatment with intravenous medications.

Topical antimicrobials and debridement are often used for burn treatment. With extensive injuries, grafting and other surgeries may be required.


Related pages

On this site
Tests: Bacterial wound culture, Gram stain, susceptibility testing, blood culture, MRSA screening, AFB smear and culture
Conditions: Staph wound infections and Methicillin resistant Staphylococcus aureus

Elsewhere on the web
Healthdirect Australia: Wound & skin infections
Australian Immunisation Handbook: Tetanus

US sites
CDC: Methicillin-resistant Staphylococcus Aureus (MRSA) Infections
JAMA Patient Page: Wound Infections
National Insititute of General Medicine: Burns Factsheet
CDC: Healthcare-associated infections
Wound Healing Society
CDC: Injury Center