Friday, January 20, 2017

Trouble in Paradise

Written by  Dr. Eva Hersh, MD

Dear Dr. Eva,

I was recently in Hawaii. One afternoon I foolishly went snorkeling when the wind had come up and the water was rough. I was thrown up against a coral reef, and scraped my leg badly. I was careful to clean the area with alcohol and treated it with antibiotic ointment for several days. Fortunately, my efforts paid off and the abrasions healed without problems.

My question is this: although everyone knows it’s important to clean a wound to avoid infection, I can’t find any information about how quickly this needs to be done, except for the unhelpful “…as soon as possible.” In addition to whatever germs lurk in seawater, I have heard that that staph germs are always present on our skin and that when the skin is torn, it becomes an open door for germs to infect the skin and deeper tissues. How quickly can bacteria or viruses invade an opening in our bodies? Do we have seconds, minutes, or even hours to scrub or pour on disinfectant, before it’s too late and further medical intervention is necessary? Also, are there similar concerns if the skin is broken and there is exposure to mold, fungus, or other invasive life forms?  Finally, I have heard that wounds exposed to seawater should be washed with urine-any truth to that?

The Snorkel Staph

Dear S.S,

Multiple factors are involved in whether or not a wound will become infected. These factors include the immune status and general health of the injured person, the size of the wound, the depth of the wound, which organisms are likely to infect the wound, and the amount of each infecting organism that gets into the wound. One key principle to understand is that wound infections are prevented mainly by the protective actions of our own immune system, not by washing the infectious agents out of the wound.

Virus and bacteria infections can get started very fast. We know for example that the HIV virus, a virus which the human immune system unfortunately is not effective against, can be found in the bloodstream of monkeys within hours of exposure.

Person factors – The younger a person is the more likely they are to heal quickly. People with any type of immune deficiency, such as diabetes, kidney disease, or HIV disease, are at greater risk both for wound infections and delayed healing. Malnutrition also delays wound healing.

Wound factors – The deeper into the skin and underlying tissues a wound goes, the more likely it is to become infected. This is true even if the surface area of the wound is small. For example, a wound caused by stepping on a nail may cause a very small opening in the skin but extend over an inch deep into the foot. This is called a penetrating wound. Penetrating wounds, especially when caused by an object which has been in contact with soil, are at highest risk for tetanus infection, also called lockjaw. If there is any doubt as to whether a person with a penetrating wound has had a tetanus booster in the last five years, they should go to an emergency room or urgent care center and get a diphtheria-tetanus booster within a day of the injury.

• Wound scenario – risk of infection and the types of organisms likely to cause infection vary depending on where and how the injury occurred. Bites from dogs, cats, and humans are all at high risk for infection because of the many types of bacteria in animal mouths. Because of the high risk of bacterial infection, people with bite wounds are given antibiotics right away rather than monitoring the wound to see if it appears infected. Wounds that take place in freshwater or salt water each have characteristic types of organisms, and different antibiotics are needed for each if they become infected. Molds and funguses have not been reported to grow in human wounds.

Cleaning wounds – in the past, it was thought to be a good idea to use antibacterial cleansers like iodine solutions, alcohol, or peroxide to rinse open wounds to kill bacteria and viruses. It is now understood that these harsh chemicals cause more damage than benefit because they further injure the damaged tissues. Current recommendations are to wash a fresh wound with large amounts of water, for example holding it under a faucet or hose for several minutes or pouring a gallon of water into it. This is effective in washing out most potential infectious agents as well as removing debris like rust or wood splinters. Alcohol or peroxide can be used to disinfect the intact skin up to the edges of the wound to decrease the likelihood of skin organisms getting into the wound, but washing the area with mild soap and water is equally effective.

How to know if it’s becoming infected – The key signs of infection are increasing pain, redness, warmth, swelling, and a hard feeling in the skin around the edges of the wound. Eventually a wound with a bacterial infection may drain pus, but nowadays most people get to medical attention before a wound infection becomes that severe. It’s important to be aware that wounds – including surgical incisions as well as accidental injuries – tend to look worse on the second and third day after the injury. This does not mean the wound is getting infected – it is just the normal response of the immune system. The shift of white blood cells and antibacterial chemicals to the area causes signs of inflammation for the first several days even if there is no infection.

• Urinating in wounds – urine is not a disinfectant. However, the chemicals in urine do counteract the poison in jellyfish stings. That would be the only situation in which urinating on a wound might be helpful; most scuba divers prefer to rinse the area with large amounts of water instead.

Eva Hersh is a Baltimore family physician. Send your comments and questions to her by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .


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