The Microbiology of

Wounds
Neal R. Chamberlain, Ph.D.,
Department of Microbiology/Immunology
KCOM

Microbes and Chronic

Wounds
All chronic wounds are contaminated by
bacteria.
Wound healing occurs in the presence of
bacteria.
Certain bacteria appear to aid wound
healing.
It is not the presence of organisms but their
interaction with the patient that determines
their influence on wound healing.

Definitions
Wound contamination: the presence
of non-replicating organisms in the
wound.
All chronic wounds are contaminated.
These contaminants come from the
indigenous microflora and/or the environment.
Most contaminating organisms are not able to
multiply in a wound. (Ex. Most organisms in
the soil wont grow in a wound).

Definitions
Wound colonization: the presence of
replicating microorganisms adherent to the
wound in the absence of injury to the host.
This is also very common.
Most of these organisms are normal skin flora.
Staphylococcus epidermidis, other coagulase
negative Staph., Corynebacterium sp.,
Brevibacterium sp., Proprionibacterium acnes,
Pityrosporum sp..

Definitions
Wound Infection: the presence of
replicating microorganisms within a
wound that cause host injury.
Primarily pathogens are of concern here.
Examples include; Staphylococcus aureus,
Beta-hemolytic Streptococcus (S. pyogenes,
S. agalactiae), E. coli, Proteus, Klebsiella,
anaerobes, Pseudomonas, Acinetobacter,
Stenotrophomonas (Xanthomonas).

Microbiology of Wounds
The microbial flora in wounds appear
to change over time.
Early acute wound; Normal skin flora
predominate.
S. aureus, and Beta-hemolytic
Streptococcus soon follow. (Group B
Streptococcus and S. aureus are common
organisms found in diabetic foot ulcers)

Microbiology of Wounds
After about 4 weeks
Facultative anaerobic gram negative rods will
colonize the wound.
Most common ones= Proteus, E. coli, and
Klebsiella.

As the wound deteriorates deeper

structures are affected. Anaerobes
become more common. Oftentimes
infections are polymicrobial (4-5).

Microbiology of Wounds
Long-term chronic wounds oftentimes
contain more anaerobes than aerobes.
Aerobic gram-negative rods also infect
wounds late in the course of chronic
wound degeneration. Usually acquired
from exogenous sources; bath and foot
water
Ex. Pseudomonas, Acinetobacter,
Stenotrophomonas (Xanthomonas).

Microbiology of Wounds
Organisms like Pseudomonas are not
very invasive unless the patient is
highly compromised (ex. Ecthyma
gangrenosum in neutropenic
patients).
These organisms are associated with
marked wound deterioration due to
endotoxin, enzymes, and exotoxins.

Microbiology of Wounds
As the wounds go deeper and
become more complex they can
infect the underlying muscles and
bone causing osteomyelitis.
Coliforms and anaerobes are
associated with osteomyelitis in
these patients. You also see
Staphylococcus aureus.

Microbiology of Wounds
Enterococcus and Candida are often
isolated from wounds.
Treating a patient for these
organisms is only indicated if there
are no other pathogens present and
the organisms are present in high
concentrations (106 CFUs per gram
of tissue)

Microbiology of Wounds
In summary: early chronic wounds
contain mostly gram-positive
organisms.
Wounds of several months duration
with deep structure involvement will
have on average 4-5 microbial
pathogens, including anaerobes (see
more gram-negative organisms).

From Colonization to
Infection?
Many factors affect the progress of
microorganisms in a wound from
colonization to infection:
Infection= dose X virulence
__________host resistance
The number of organisms.
The virulence factors they produce.
The resistance of the host to infection.

Dose of Bacteria
Differs depending on the organism
involved.
Some organisms would need to be in high
concentrations. (ex. Candida,
Enterococcus)
Various combinations of bacterial species
result in more host damage (synergy)
Example; Group B Streptococcus (S.
agalatiae) and Staphylococcus aureus.

Dose of Bacteria
Organisms that should be treated
regardless of the numbers present.
Beta-hemolytic streptococci,
Mycobacteria sp., Bacillus anthracis,
Yersinia pestis, Corynebacterium
diphtheriae, Erysipelothrix rhusiopathiae,
Leptospira sp., Treponema sp., Brucella
sp., Clostridium sp., VZV, HSV, dimorphic
fungi, Leishmaniasis.

Bacterial Problems to
Consider
Streptococcus pyogenes
Can result in necrotizing fasciitis or
streptococcal toxic shock syndrome.
Not very common. Only about 520
cases per year of each condition.
More common to see cellulitis and
erysipelas after infection of a chronic
wound.

Bacterial Problems to
Consider
Clostridium tetani
Contamination of chronic wounds by
exogenous sources is common.
Of the 41 cases of tetanus that occurred in
1998, a total of 16 (39%) were among
persons aged greater than or equal to 60
years.
Make sure your patients have gotten their
tetanus vaccination.

Bacterial Problems to
Consider
Erysipelothrix rhusiopathiae can
infect chronic wounds. Associated
with hog farmers and people who
fish.
Mycobacteria marinum and M.
ulcerans can infect chronic wounds.
Think of people who have aquariums,
pools, go fishing, etc..

Virulence
Factors an organism produces can
result in host damage.
Ex. Hyaluronidase (Streptococcus
pyogenes), proteases (Staphylococcus
aureus, Pseudomonas aeruginosa),
toxins (Streptococcus pyogenes,
Staphylococcus aureus), endotoxin
(gram negative organisms).

Virulence
Some organisms produce few virulence
factors.
However, synergy between different
bacterial factors can cause host
damage.
Group B Streptococcus and
Staphylococcus aureus: Synergy
between two toxins results in hemolysis.

Host Resistance
Host resistance is the single
most important determinant in
wound infection.
Local and Systemic factors both
play a role in increasing the chances
a wound will become infected.

Host Resistance
Local factors that increase chances of wound
infection:

Large wound area

Increased wound depth
Degree of chronicity
Anatomic location (distal extremity, perineal)
Foreign body
Necrotic tissue
Mechanism of injury (bites, perforated viscus)
Reduced perfusion

Wound Depth can Result in

Different Diseases

Host Resistance
Systemic factors that increase chances of
wound infection:

Vascular disease
Edema
Malnutrition
Diabetes
Alcoholism
Prior surgery or radiation
Corticosteroids
Inherited neutrophil defects

How do you know when a

wound is infected?
This can be very difficult.
A continuum exists between when
pathogens colonize the wound and
then start to cause damage.
There is no absolutely foolproof
laboratory test that will aid in this
diagnosis.

How do you know when a

wound is infected?
One feature is common to all infected
chronic wounds;
The failure of the wound to heal
and progressive deterioration of
the wound.
Unfortunately, wound infections are
not the only reasons for poor wound
healing.

How do you know when a

wound is infected?
The typical features of wound infections:

increased exudate
increased swelling
increased erythema
increased pain
increased local temperature
Periwound cellulitis, ascending infection,
change in appearance of granulation tissue
(discoloration, prone to bleed, highly friable).

Specimen Collection and

Culture Techniques.
There is a good deal of controversy
concerning specimen collection.
The gold standard collection method
is to do a tissue biopsy or needle
aspirate of the leading edge of the
wound after debridement.
>105 CFU/gm of tissue= greater
likelihood of sepsis developing.

Specimen Collection and

Culture Techniques.
Indicate the specific anatomic site the
biopsy is collected from.
Indicate whether this is a surface or deep
wound. Ask for a smear and gram stain of
the tissue.
Surface wounds are NOT cultured for
anaerobes.
Deep wounds are cultured for anaerobes.

Specimen Collection and

Culture Techniques.
If a tissue biopsy is not possible;
cleanse the wound with sterile saline
vigorously swab the base of the lesion
Surface wounds place the swab in a
sterile container for transport.
Deep wounds place the swab in a sterile
anaerobic container for transport.

Thank You
I would like to thank
KCOM
Department of Continuing Medical Education

The following article is a helpful review of

this topic: Dow, G., Browne, A., and
Sibbald, R.G. Infection in Chronic Wounds:
Controversies in Diagnosis and Treatment.
Ostomy/Wound Management.
1999;45(8):23-40.