STAPH, STREP, AND GENERAL WOUND CARE

Basic wound care is the same whether you've been cut by a kitchen knife or bitten by a barracuda. In marine wounds, however, the risk of infection is high. Warm ocean water, and the mouths and skins of marine animals, host numerous bacteria including species of Staphylococcus (Staph) and Streptococcus (Strep). These wide-ranging bacteria, also common on land and human skin, are the leading cause of marine infections in Hawai`i. Some wounds are complicated by venoms, broken teeth, other animals parts, or by bacteria found only in water, for example, Mycobacterium marinum and Vibrio.

MECHANISM OF INJURY

Most marine wounds are superficial cuts and scrapes, only slightly breaking the skin. Even the slightest abrasion, however, creates an infection risk from bacteria, always present in ocean water, and on human and animal skin.
 

Although warm, bacteria-laden water soaks all marine wounds, only some of these wounds become infected. Factors influencing infection rates include:
 

Wound location. Some areas of the body are more prone to infection than others. Wounds on the scalp and face are the least likely to get infected, wounds on the hands and feet the most.
 

Wound type. Crush injuries resulting in injured and dead tissue have higher rates of infection than sharp cuts. Deeper, larger wounds expose more tissue to bacteria, thus increase the risk of infection. Skin flaps on a wound can trap bacteria and thus create areas that foster infection.
 

Number of bacteria. Usually, it takes large numbers of bacteria to infect a wound. These numbers, however, are not constant. Scalp wounds, for instance, need more bacteria to become infected than hand wounds. Wounds with any object in them (such as tooth fragments, pieces of coral skeleton, or sutures) need less bacteria inside to start an infection than wounds with nothing in them. When bacteria in any wound reach high enough numbers to overwhelm the body's natural defense system, an infection occurs. This can happen even in healthy people who practice meticulous wound care.
 

Individual immune systems. People with damaged immune systems, liver disease, diabetes, AIDS, and those who have had their spleens removed, or are taking steroids, have a higher risk of wound infection than others. Also, people with abnormal heart valves have an increased risk of getting a blood-borne infection in the heart after a marine wound.
 

INCIDENCE

Anyone spending time in Hawaii's ocean waters will eventually get some type of infection. Usually, these are small and superficial Staph or Strep infections. Occasionally, other types of bacteria infect marine wounds: e.g., Fish Handlers Disease, Seal Finger, Mycobacterium marinum, and Vibrio Infections.
 

Rarely, Staph, Strep, or other types of bacteria spread throughout the bloodstream, causing severe tissue damage, and occasionally, death. Even more rarely, a type of Strep invades the body's deep tissues, causing an illness popularly called a "flesh eating" infection.

PREVENTION

Meticulous scrubbing helps reduce the risk of marine infections. See First Aid in this section for scrubbing and cleaning techniques.
 

SIGNS AND SYMPTOMS

Symptoms of most marine infections appear from a few hours to several days after the injury. (Mycobacterium marinum is an exception, sometimes appearing months after an injury). Typical signs of infection are redness, swelling, warmth, pus, and pain.
 

Any size wound may have an object, such as a piece of coral, embedded inside. Suspect this in wounds that heal poorly, hurt out of proportion to the injury, or remain persistently infected. Numbness or inability to move a finger or toe may be a sign of tendon or nerve damage. Infections can spread throughout the body, some (particularly Vibrio) extremely quickly. Massive swelling of an area, fever, and ultimately collapse are signs of a potentially life-threatening infection.
 

FIRST AID

Use the following guidelines to decrease the risk of infection in minor marine wounds:
 

TO CLEAN A WOUND:

• Gently pull the edges of the skin open and remove embedded material either by rinsing or using tweezers.
• Then, rub directly inside the cut with clean gauze or a cloth soaked in clean water. Actively scrub. Rinsing does not remove as many bacteria from wounds as scrubbing.
• After scrubbing, rinse thoroughly. Don't delay scrubbing and rinsing for lack of sterile supplies. If only tap water is available, use it. The bacteria count in tap water is extremely low. Never scrub an open wound with ocean water, which often contains large numbers of bacteria.
• Antiseptics check the growth of bacteria on, or in, living tissue. One common antiseptic is povidone-iodine solution. This substance reduces the risk of wound infections by slowing the growth of bacteria present in a wound. Full strength povidone-iodine, however, can cause tissue damage.
• The old-fashioned notion that if it burns it must be beneficial is not true. To make a safe antiseptic solution for scrubbing and rinsing wounds, dilute one part of full-strength povidone-iodine with 10 parts of water. (You can buy povidone-iodine already diluted -- check the label.) Use such solutions as an addition to wound scrubbing, not as a substitute.
• Cut off loose, superficial skin flaps. Such flaps create moist, dark areas that can harbor and promote bacteria growth. Don't cut off deep skin or tissue flaps. These often grow back when taped or sutured in place.

CONTROLLING BLEEDING: For bleeding wounds, press a clean cloth directly against the wound until bleeding stops. If bleeding persists, or the edges of a wound are jagged or gaping, the victim likely needs stitches. Taping a cut shut is often an appropriate alternative to stitching. Taping, however, may leave a more visible scar than a sutured wound. Wrap tape tightly enough about a wound to close the edges and stop bleeding, but not so tight the wrapping cuts off circulation. Check that fingers or toes near any taped wound remain pink and warm.

TO CLEAN A PUNCTURE WOUND: Puncture wounds differ from open wounds in that dirt, venom, and bacteria may be pushed deep into the flesh during the injury. Since it's difficult to scrub or rinse these substances out of such wounds, punctures are prone to infection. No evidence exists showing that the folk remedy of squeezing a puncture wound to make it bleed decreases the rate of infection. Clean and rinse puncture wounds like any other wound, being particularly alert for embedded objects. If you suspect something is inside a wound, see a doctor immediately. Objects left inside often cause infections.
 

ABOUT ANTIBIOTICS: Antibiotics are substances that can kill or greatly inhibit the action of bacteria. Most antibiotic ointments are available without a prescription (over-the-counter). Studies show that antibiotic ointments may decrease the rate of infection. Avoid ointments containing neomycin, which frequently causes skin irritation. Mupirosin, a prescription antibiotic ointment, treats some superficial infections as well as oral antibiotics. Your doctor may prescribe this for minor skin infections. Once an infection starts, scrubbing with soap, iodine, hydrogen peroxide, or any other disinfectant is not enough. Staph and Strep, as well as all other bacterial infections, need antibiotic treatment.
 

Advanced infections, especially with fever and chills, can be medical emergencies. Seek help immediately.
 

All ocean wounds, large and small, carry the risk of tetanus (lockjaw), a deadly bacterial infection. Update your tetanus booster shot approximately every 5 years if you get frequent marine cuts. If you aren't sure about the date of your last tetanus shot, get a booster.
 

ABOUT BANDAGES: Bandages (dressings) help control bleeding, and protect cuts from sand and dirt. However, bandages can also hide early signs of infection. Check under all bandages for redness and swelling, the first signs of infection.
 

ABOUT SCARS: After a scab falls off, scars from most wounds are pink and raised. Such scars fade, soften, and shrink for approximately six months. During this time, sun exposure can cause permanent darkening of a scar. Apply waterproof sunscreen, 30 SPF or higher, daily to minimize discoloration. See a doctor for large wounds, objects embedded in wounds, or at the first sign of infection.