Microorganisms Responsible
for Wound Infection on Human Skin
S.K.Purohit*, R. Solanki
Ex-Director,
College of Veterinary and Animal Science, Rajasthan
*Corresponding Author E-mail: solankirenu@yahoo.com
ABSTRACT:
Skin is the major
organ of the human body which plays a vital role in maintaining health of human
being. Certain diseases defined as infectious or communicable or transmissible
diseases are caused by pathogenic microorganisms. Some of the most common
causative microorganisms related with infections include Staphylococcus aureus, Streptococcus pyogenes, Enterococci,
Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa.
Most of the diseases spread by the bacteria which invade inside the body
through skin. Bacterial infections on skin are the common ailment for
generation of other diseases in the body. Bacterial diseases are type of
infectious diseases caused by pathogenic bacteria. Symptoms and complications
related with bacterial infections such as chills, headache, wound, vomiting and
organ failure generally affects the patient’s life. Wound on skin can occur in
all ages of persons and can causes harm in number of ways. Wound and skin
infections represent the invasion of tissues by one or more species of microorganisms.
These infections disturbs the body immune system and causes inflammation,
tissue damage and thus resulting in
delayed wound healing process. This article throws light on three aspects first
on various types of microorganisms found responsible for causing wound
infection on the skin, second on laboratory tests to diagnose the responsible
microorganisms for wound infections and on choice of treatment for wound
healing.
KEYWORDS: Skin, symptoms, bacteria, types of wound infection, diagnostic test, antibiotics.
INTRODUCTION:
Skin is the major
organ of the human body. It collects sensory information from the environment
and functions as a protective barrier to the human body organs. It helps in
maintaining the proper body temperature. Bacterial infections on skin are the
common ailment for generation of other diseases in the body. Specially, the
wound on skin caused by bacteria produces very chronic results, if it is not
properly treated on time. The wound on skin
can occur in all ages of persons and can causes harm in number of ways.
Therefore for correct antimicrobial therapy for the treatment of wound, proper
identification of microorganism is necessary so that wound healing activity can
be accelerated in less period of time1, 2. Wound is a break in the
integrity of the skin and tissues. It may be a superficial cut, scrap or
scratch. It may also include puncture, burn or may be the result of surgical or
dental procedures. The microorganisms which are likely to infect the skin and
tissues depend on the wound extent, its depth, the environment in which it
occurs and the types of microorganisms present on the person skin.
The skin consists
of three layers: the outer epidermis, the dermis where many hair follicles and
sweat glands are found and the fatty subcutaneous layer. Below these layers are
membranes that protect connective tissues, muscles and bones. Wound can
penetrate any of these layers and can cause skin infections3-5.Wound
and skin infections represent the invasion of tissues by one or more species of
microorganisms.
This infection disturbs the body immune system and causes inflammation,
tissue damage thus resulting in delayed wound healing process. Many infections
remain confined to a small area like an infected scratch or hair follicle which
usually heals on their own. Others may persist and if kept untreated may
increase in severity and may become cause of other chronic diseases. Wound
healing itself is a complex process which involves many related systems,
chemicals and cells working together so as to clean the wound, heal its edges
and to produce new tissues and blood vessels6-9.
Signs and symptoms:
Common signs
and symptoms
of wound infection include redness, warmth, swelling, tenderness and pus
drainage from the skin. Sometimes the skin may also become harden or tighten in
that particular area and red streaks may radiate from the wound. Wound
infections may also cause fevers, especially when spread to the blood. Skin
infections may also cause pustules, pain, scaling, and itching in that
particular wounded area10.
Types of wound infections and types of
microorganisms responsible for wound infection:
Wounds may be typed according to their
cause, their extent, the environment in which they occur and whether they are
clean or contaminated. The microorganisms
that infects skin and wound generally depends on immune system of the person,
depth of the wound and the conditions of the surrounding environment.
Bacteria, virus and fungi can cause wound
infections on skin (table 1, 2). Bacteria can be classified as per the
environment in which they grow: aerobic
(grow in air), microaerophilic (grow in reduced oxygen environment)
and anaerobic
(grow in little to no oxygen). Microaerophilic and
anaerobic bacterias are generally found in deeper
wounds and abscesses11-
13.
Wound infections on superficial skin areas:
Superficial infections occur in the outer
layer of the skin but may also
extend deeper into the subcutaneous
layer. They are caused by aerobic microorganisms; deeper wounds may also be
infected with anaerobic microbes. Bacterial infections are typically caused by
bacteria like Staphylococcus (Staph) and Streptococcus (Strep).
They may also be caused by antibiotic resistant bacteria like MRSA (Methicillin Resistant Staphylococcus aureus).
Brackish water wound infection occurs due to waterborne Vibrio
or Aeromonas species. Hot tub-associated
infection occurs by Pseudomonas aeruginosa.
When wounds are deeper, the possible pathogens would be anaerobes like Bacteroides and Clostridium species. Necrotizing
fasciitis a serious but uncommon type of infection often involves Group A
Streptococci, which are sometimes called as “flesh-eating bacteria. Other
common skin infections such as ringworm and athlete’s foot are not caused by
bacteria but by fungi. Yeast infections occur by Candida species which
is generally found in the mouth (thrush) or on other moist areas of the skin.
Wound infections through bites:
A wound infection due to animal bites tends
to reflect the microorganisms which are generally present in oral cavity of
animal which created the bite wound. They may involve aerobic, anaerobic and microaerophilic microorganisms. The most of the animal
bites are from dogs and cats. The common bacteria found in these animals oral
cavity is Pasteurella multocida.
Wound infections through trauma:
Trauma is a type of injury which occurs by
the physical force applied on the skin. It includes injuries from motor vehicle
accidents, cuts from knives or other sharp instruments and gunshot wounds etc.
The type of wound infections that trauma victims acquires depend basically on
the environment in which the injury occurred, the extent of the injury, the
microorganisms present on the affected person skin and the immune status of the
infected person. A deep puncture wound occurs mostly by anaerobic bacteria such
as Clostridium tetani.
Wound infections through burns:
Burns are generally caused by flammable
liquids, fires, chemicals and electricity. First-degree burns involve the
epidermis. Second-degree burns involve the dermis. Third-degree burns involve
all the layers of the skin and thus damages the tissues below it. Initial
infections tend to 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 occur14-15.
Wound infections after surgery:
Surgical sites are most commonly infected by
exposure to microorganisms in the hospital environment. Hospital-acquired
bacteria like MRSA. Deep surgical wounds become infected both superficially
with aerobic microorganisms and deep within the body by anaerobes.
Table
1: Microorganisms related with wound infections and their frequency of
occurrence on skin
Pathogens |
Frequency (%) |
Staphylococcus aureus |
20 |
Coagulase-negative
staphylococci |
14 |
Enterococci |
12 |
Escherichia coli |
8 |
Pseudomonas aeruginosa |
8 |
Enterobacter species |
7 |
Klebsiella
pneumoniae |
3 |
Streptococci |
3 |
Candida albicans |
3 |
Other gram-positive aerobes |
2 |
Table
2: Some potential wound pathogens category responsible for wound infection
Pathogen Category |
Name of pathogen |
Gram-positive cocci |
Beta Haemolytic
Streptococci (Streptococcus pyogenes)* |
Enterococci (Enterococcus faecalis) |
|
Staphylococci (Staphylococcus aureus/
MRSA)* |
|
Gram-negative
aerobic rods |
Pseudomonas aeruginosa* |
Gram-negative
facultative rods |
Enterobacter species |
Escherichia coli |
|
Klebsiella species |
|
Anaerobes |
Bacteroides |
Fungi |
Yeasts (Candida) |
Aspergillus |
*Most common causative microorganisms
related with wound infections
Laboratory
tests to diagnose the microorganisms responsible for wound infections:
A clinical evaluation cannot definitively
tell the doctor which microorganism
is causing a wound infection or what treatment it is likely to be susceptible
to. For that, laboratory testing is required. 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 to collect cells or pus
with a needle and syringe or biopsy16-18.
For fungal evaluation, scrapings of the skin may be collected. Test includes
bacterial wound culture, gram staining, antimicrobial susceptibility test and
fungal as well as urine cultures.
It is a primary test which is used to diagnose the
bacterial infection. The sample is streaked onto nutrient
media and is then incubated at body temperature so as to grow and
identify bacteria if any present in the sample or not. Growth and
identification of bacterial wound cultures is usually available within 24-48
hrs from the time the sample is received in the lab while for slow growing
microorganisms, such as fungi it may take several weeks for growth and its
identification19-20.
After the growth of microorganism in the culture media,
staining allows bacteria to be evaluated under the microscope. It involves
smearing individual colony types onto glass slides and treating them with a
special stain. Under the microscope, the bacteria can be classified into
gram-positive and gram-negative organisms, there they are distinguished by
their shape such as cocci (spheres) or rods (bacilli)
and are easily separated by color into gram positive or gram-negative
microorganisms. This test provides preliminary information about the quality
and potentiality of microorganisms that may be causing the infection 21-26.
When a pathogen is identified and isolated using the
wound culture, this test is used to determine the bacteria likely
susceptibility to certain drug treatments. This information helps in selecting
appropriate antibiotics for the treatment27-
31. Other tests may includes
Fungal culture:
It is performed when a fungal infection is
suspected32.
It is performed when a urinary tract infection is suspected.
Treatments:
The risk of wound infection can be minimized with
prompt and proper wound cleansing and treatment. Most wound infections
that do occur can be successfully resolved. Many superficial bacterial and viral infections will resolve on their own
without any kind of treatment. Other bacterial infections may require some type
of topical antimicrobial drugs treatment. Deeper infections typically require
oral antimicrobial therapy. The choice of which type antimicrobials drug
is to be used is based upon the data results of wound culture and antimicrobial susceptibility tests.
Patients with antibiotic resistant bacteria or with an infection which is
located in difficult area for drug therapy to penetrate (such as bone) may
require treatment with intravenous medications. The antimicrobial drugs may act by destroying the bacteria
(bactericidal) or by inhibiting the growth of bacteria (bacteriostatic).
The mechanism of action of these drugs can be divided into four groups33-36.
Drugs
interfering with cell wall synthesis:
Penicillin, cephalosporin, bacitracin, vancomycin and cycloserine. All b-lactum antibiotics bind
to receptors (penicillin binding protein at the cell wall -cell membrane
interface). After attachment of the b-lactum
drug to the receptor there is interference with the synthesis of peptidoglycan of cell wall. This makes the cell membrane
vulnerable to damage by solutes of the environment (plasma). The cell walls of
gram negative bacteria being more complex, these drugs cannot penetrate the
cell in adequate concentration.
Drugs affecting cytoplasmic membrane:
Polymxcin B and colistin bind
selectively with outer membranes of gram negative bacteria that are rich in phoshatidylethanolamine and act as cationic detergents. The
inhibition of cell membrane function leads to escape of macro molecules and
ions from the cell resulting in cell damage or death. Polyenes
are effective against fungus which contains sterol on cell membrane. Bacteria
generally do not contain sterol on cell membrane and hence polyene
is ineffective in bacterial infection.
Drugs inhibiting protein synthesis
and impairment of function of the ribosomes:
Aminoglycosides, tetracyclines,
chloramphenicol and macrolide
antibiotics lincomycin inhibit protein synthesis in
bacterial ribosomes (70 S) without any major effect
on mammalian ribosomes (80 S).
Drugs inhibiting synthesis of
nucleic acid:
These drugs interfere with transcription of genetic information on the ribosomes. Rifampin binds with
DNA- dependent RNA polymerase, actinomycin binds with
deoxyguanosine residues and quinolones
block the DNA gyrase and thus they inhibit DNA
synthesis of bacteria.
Choice of treatment:
The choice of which antimicrobials drugs to be used
is generally based upon the results of wound culture and antimicrobial
susceptibility tests. Susceptibility testing is used to determine which antibiotic or
antibiotic combinations will be most effective in treating the different types
of bacteria causing the wound infection 37, 38, 39. The test include following three
terms:
Susceptible: Likely,
but not guaranteed to inhibit the pathogenic microorganism;
may be an appropriate choice for treatment.
Intermediate: May be effective at a higher dosage or
more frequent dosage or effective only in specific body sites where the
antibiotic penetrates to provide adequate concentrations but drugs may produce
higher risk for medication side effects.
Resistant: Not effective at inhibiting the growth of
the organism; may not be an appropriate choice for treatment. A combination of
antibiotics that work together to inhibit the bacteria when neither one alone will be
effective.
CONCLUSION:
Bacterial infections are one of the most prominent
causes of chronic diseases and physical disabilities around the world. The most
common causative microorganisms related with wound infections include Staphylococcus aureus/MRSA,
Streptococcus pyogenes, Enterococci,
Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa.
These pathogens can be easily detected and identified by using designed
laboratory testing procedures and methods. Thus by the help of wound culture and antimicrobial
susceptibility tests, we can easily find out appropriate antimicrobial therapy
for the particular pathogen responsible for causing wound infection on human
skin.
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Received on 31.03.2013 Accepted on 28.04.2013
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Asian J. Res. Pharm.
Sci. 2013; Vol. 3: Issue 2, Pg 68-71