Colonization of burns and the duration of hospital stay of severely burned patients

Multi-resistant organisms in burn patients: an end or a new beginning

Infections are a major cause of morbidity and mortality in burn patients, and the rise of multidrug-resistant organisms (MDROs) has made it more challenging to manage and prevent infections. This review examines the available treatment options for MDROs in burn patients and anticipates the future challenges posed by their increasing prevalence. The review covers new antibiotics, such as Eravacycline and Plazomicin, as well as non-antibiotic therapies, such as bacteriophages and nanoparticles. Future research should focus on examining the long-term efficacy, cost-effectiveness, and in vivo efficacy of different treatment modalities. The potential of alternative therapies, such as probiotics and low-frequency magnetic fields, should also be explored. Accurate and rapid diagnostic and monitoring tools for detecting MDROs in burn patients should be developed. The emergence of MDROs in burn care is a challenge and a new beginning in infection innovation and novel treatments.

Evolution of Microbial Flora Colonizing Burn Wounds during Hospitalization in Uruguay

(1) Background: Infections are a main cause of morbidity and mortality among burn patients. The spectrum of microorganisms depends on the epidemiological context and treatment practices. We aimed to describe the evolution of microbial flora colonizing burn wounds among patients hospitalized during 15 or more days at the National Burn Center in 2015. (2) Methods: Demographic data, length of stay, total body surface area burn, and status at discharge were collected from electronic records and culture results from the laboratory database. (3) Results: Among 98 included patients, 87 were colonized. The mean length of stay was 39 days overall and 16 days in the ICU. Acinetobacter spp., Enterococcus spp., and Staphylococcus aureus predominated. Fifty-six patients harbored multidrug-resistant bacteria and had a significantly greater TBSA. The mean time to colonization was 6 days overall and 14 days for multidrug-resistant bacteria; it was significantly longer for methicillin-resistant S. aureus than for methicillin-susceptible S. aureus. (4) Conclusions: This is the first report describing the dynamics of microbial colonization of burn wounds in Uruguay. Similarities were found with reports elsewhere, but early colonization with yeasts and the absence of Streptococcus pyogenes were unique. Each burn center needs to monitor its microbial ecology to tailor their antimicrobial strategies effectively.

Prevalence of Multidrug-Resistant Organism in ICU Burns Patients at Tertiary Care Hospital

Burns carries a high-risk of mortality and morbidity. This with increased chances of drug-resistant infections makes the management complicated. Hence this study was conducted to find out the prevalence of multidrug-resistant organisms (MDRO) in burns patients admitted to the intensive care unit at a tertiary care hospital. A 2-year retrospective study was conducted where burn patients reporting MDRO were included. Statistical analysis was performed using SPSS version 26 where a P-value < .05 was considered statistically significant. Out of 97 patients, tissue cultures of 65 patients revealed the presence of MDRO in 27 (27.8%) patients. A male predominance (17, 63.0%) was noted with a mean age of 29.0-year-old. Fire burn (15, 55.6%) was reported to be the most common cause of burn with an average of 29.9% of Total Body Surface Area (TBSA) involved. MDR Pseudomonas aeruginosa was the commonest organism reported in 12 (44%) patients. The average length of stay (LOS) was noted to be 11.3 days with a mortality rate of 48.1% (overall, in all MDRO'S infections). Patients who reported MDRO showed a tendency for longer hospitalization with a higher risk of mortality as the TBSA increased. However, in presence of other factors in burns like higher TBSA, inhalation injury and lack of advanced skin substitute these mortality figures, and their association can be debated. Lastly, the implementation of control measures, as basic as hand hygiene, should be partaken to reduce the burden of MDR infections.

Factors Influencing Length of Hospital Stay and Predictors Affecting Probability of Requiring Surgery in Severely Pediatric Burn Patients

Although many researches have explored the prognostic factors associated with length of hospital stay (LOS) of adult burn patients, fewer reports concerning pediatric burn patients have been conducted. The present study employed pediatric burn data to identify factors related to LOS and developed a novel model to assess the possibility of requiring surgery. A total of 750 children admitted for burns met the criteria for enrollment. We have analyzed the medical records using multivariable linear regression and logistic regression. The pediatric patients were stratified into medical (nonsurgical) and surgical groups, respectively. The median LOS was 27.11 ± 17.91 days (range: 6-107 days). Following multiple linear regression, surgery (P < .001; 95% confidence interval [CI]: 6.485, 11.918), percent total BSA (%TBSA) (P < .001; 95% CI: 0.271, 0.459), days to surgery (P < .001; 95% CI: 0.349, 0.648), etiology (P < .001; 95% CI: -15.801, -9.422), infection (P < .001; 95% CI: 4.163, 8.329), and erythrocyte loss (P < .001; 95% CI: 1.923, 4.017) were significantly associated with LOS. After logistic regression, the percent full thickness (%FT) (P < .001; odds ratio [OR]: 2.358; 95% CI: 1.680, 3.311), infection (P < .001; OR: 2.935; 95% CI: 2.014, 4.278), and erythrocyte loss (P < .001; OR: 0.572; 95% CI: 0.470, 0.696) within 5 days postadmission were independently related to the probability of requiring surgery. In conclusion, in pediatric patients admitted with burn size of TBSA ≥20%, factors independently influencing LOS were surgery, %TBSA, days to surgery, etiology, erythrocyte loss, and infection. Furthermore, the pivotal predictors of probability requiring surgery were %FT, infection, and erythrocyte loss.

A predictive model for prolonged hospital length of stay in surgical burn patients

BACKGROUND

Improvement in the care of burn patients has led to decreased mortality. Length of stay (LOS) has been used as a marker for quality of care in this population. However, the historical association of LOS as correlating only with % burn surface area (BSA) injury has been questioned with retrospective data suggesting other factors may also be associated with LOS. A model to predict prolonged LOS does not exist but could provide important information for clinicians and patients.

METHODS

Data from January 2014 to December 2016 was used to develop a predictive model utilizing multivariable logistic regression. Prolonged hospital LOS was the outcome used with multiple covariates utilized to identify various associations. Odds ratios (OR) and their associated 95% confidence interval (CI) were reported for each covariate in the final regression model. Model performance in both the training and validation sets was evaluated using area under the receiver operating characteristic (ROC) curve (AUC) for discrimination and the Hosmer-Lemeshow (HL) test for goodness-of-fit.

RESULTS

A total of 441 patients was included in the final analysis, 296 (67.1%) of which were in the training set. Within the training set, the median hospital LOS was 14 days with a range of 4 to 205 days. Patient age (in decades), hypertension, total BSA, involvement of perineum, and abnormal white blood cell count were independent risk factors for prolonged hospital length of stay. When using this separate dataset, the model had an AUC of 0.81 (95% CI 0.74-0.88) and had good calibration based on the HL-test (p=0.10).

CONCLUSIONS

Prolonged hospitalization following burns is predicted by patient age (in decades), TBSA, hypertension, perineal involvement, and abnormal white blood cell count.

Active surveillance at the time of hospital admission for multidrug-resistant microorganisms among patients who had recently been hospitalized at health care facilities

BACKGROUND

This study aimed to investigate the epidemiology of multidrug-resistant microorganism (MDRO) carriage at hospital admission and to identify risk factors for MDRO influx into hospital settings.

METHODS

This cohort study was conducted at a 1,051-bed university-affiliated hospital in the Republic of Korea between July 1 and December 31, 2017. Active surveillance for MDRO carriage was performed within 48 hours of hospitalization in all adult patients who had prior hospitalization within the preceding 3 months.

RESULTS

During the study, 575 patients were admitted with a hospitalization history within 3 months. Active surveillance at hospital admission was performed in 192 eligible patients. Thirty-three (17.2%) patients with MDRO carriage were identified from active surveillance. In the multivariate logistic regression analysis, prior exposure to antibiotics within 90 days, hospitalization for ≥60 days before admission, cognitive dysfunction, percutaneous drainage, and underlying pulmonary diseases were identified as independent risk factors for MDRO influx.

CONCLUSIONS

Our findings suggest a significant prevalence of MDRO acquisition at acute care hospital admission in patients who had been recently hospitalized. To control the spread of MDRO, collaborations among health care institutions and targeted screening at hospital admission according to patient risk factors are warranted.

Management and prevention of drug resistant infections in burn patients

Introduction: Despite modern advances, the primary cause of death after burns remains infection and sepsis. A key factor in determining outcomes is colonization with multi-drug resistant (MDR) organisms. Infections secondary to MDR organisms are challenging due to lack of adequate antibiotic treatment, subsequently prolonging hospital stay and increasing risk of adverse outcomes. Areas covered: This review highlights the most frequent organisms colonizing burn wounds as well as the most common MDR bacterial infections. Additionally, we discuss different treatment modalities and MDR infection prevention strategies as their appropriate management would minimize morbidity and mortality in this population. We conducted a search for articles on PubMed, Web of Science, Embase, Cochrane, Scopus and UpToDate with applied search strategies including a combination of: "burns, 'thermal injury,' 'infections,' 'sepsis,' 'drug resistance,' and 'antimicrobials.' Expert opinion: Management and prevention of MDR infections in burns is an ongoing challenge. We highlight the importance of preventative over therapeutic strategies, which are easy to implement and cost-effective. Additionally, targeted, limited use of antimicrobials can be beneficial in burn patients. A promising future area of investigation within this field is post-trauma microbiome profiling. Currently, the best treatment strategy for MDR in burn patients is prevention.

Analysis of factors impacting length of stay in thermal and inhalation injury

OBJECTIVES

Several studies have analyzed single or combinations of variables for impact on length of stay (LOS) in thermally-injured patients. The objective of this study was to evaluate a multitude of established variables and potentially identify novel variables associated with LOS in a single study.

METHODS

This two-year, retrospective study included all patients admitted to the burn center between January 2015 and December 2016. Exclusions included death during admission, lack of thermal or inhalation injury, age less than 18 years, readmission(s), and if pregnant or incarcerated. Baseline demographics and pertinent data were collected using electronic medical records. Regression analysis was used to determine the most predictive variables.

RESULTS

Six hundred twenty-nine patients were admitted during the inclusion period and 354 patients remained for analysis after exclusion. Univariable analysis revealed 32 variables significantly associated with LOS. Using multivariable regression, the best-fit baseline demographic model included: percent total body surface area (TBSA) injured, lower/middle socioeconomic status, clotting disorders, anemia, admission serum creatinine, and percent third degree injured (r² = 0.557). The best-fit combined model (incorporating baseline demographics and early in-hospital variables) included: acute kidney injury, infection and received vasopressor(s), percent TBSA injured, admission serum ethanol level, maximum C-reactive protein, and maximum total bilirubin (r² = 0.828).

CONCLUSIONS

There are multiple factors associated with the increased LOS seen in patients with thermal and inhalation injury. This study confirmed and identified novel factors not previously discussed in the literature that were significantly associated with LOS. Expansion of the data submitted to the National Burn Repository and the Burn Quality Improvement Program may be warranted. This study confirms claims from previous studies on inadequacy of current data submitted for benchmarking and under-reimbursement for the care of such a complex population.

Burn injury and multiple sclerosis: A retrospective case-control study

OBJECTIVES

The purpose of this study was to determine whether having a previous diagnosis of multiple sclerosis (MS) changed acute care needs in burn-injured patients.

METHODS

This was a retrospective case-control study that included adult (aged ≥18years) patients with an acute burn injury. Control patients were matched with eleven patients with a history of MS at a 4:1 ratio. Outcomes included fluid resuscitation volumes, temperature, heart rate, mean arterial pressure, in-hospital complications, and hospital length of stay (LOS).

RESULTS

There were fifty-five patients included and of those, eleven had a documented history of MS. Fluid resuscitation volumes, temperature, heart rate, and mean arterial pressure were similar between groups during the resuscitation period (p>0.05). LOS was similar between both groups (12, IQR: 2-17 vs. median 16, IQR: 12-21; p=0.090). However, when normalized to % TBSA burn, patients with MS had a significantly higher median LOS/% TBSA burned (1.2, IQR: 0.7-2.0 vs. 2.1, IQR: 1.1-7.1; p=0.031).

CONCLUSIONS

Patients with concurrent burn injuries and MS have a significantly longer LOS/% TBSA burn suggesting that more time is required to heal their wounds. Surprisingly, there were no other significant differences in the after the burn acute phase between these two cohorts.

Methicillin Resistant Staphylococcus aureus Transmission in a Ghanaian Burn Unit: The Importance of Active Surveillance in Resource-Limited Settings

Objectives:Staphylococcus aureus infections in burn patients can lead to serious complications and death. The frequency of S. aureus infection is high in low- and middle-income countries presumably due to limited resources, misuse of antibiotics and poor infection control. The objective of the present study was to apply population genomics to precisely define, for the first time, the transmission of antibiotic resistant S. aureus in a resource-limited setting in sub-Saharan Africa.

Methods:Staphylococcus aureus surveillance was performed amongst burn patients and healthcare workers during a 7-months survey within the burn unit of the Korle Bu Teaching Hospital in Ghana.

Results: Sixty-six S. aureus isolates (59 colonizing and 7 clinical) were obtained from 31 patients and 10 healthcare workers. Twenty-one of these isolates were ST250-IV methicillin-resistant S. aureus (MRSA). Notably, 25 (81%) of the 31 patients carried or were infected with S. aureus within 24 h of admission. Genome comparisons revealed six distinct S. aureus clones circulating in the burn unit, and demonstrated multiple transmission events between patients and healthcare workers. Further, the collected S. aureus isolates exhibited a wide range of genotypic resistances to antibiotics, including trimethoprim (21%), aminoglycosides (33%), oxacillin (33%), chloramphenicol (50%), tetracycline (59%) and fluoroquinolones (100%).

Conclusion: Population genomics uncovered multiple transmission events of S. aureus, especially MRSA, within the investigated burn unit. Our findings highlight lapses in infection control and prevention, and underscore the great importance of active surveillance to protect burn victims against multi-drug resistant pathogens in resource-limited settings.

Critical care polyneuropathy in burn injuries: An integrative review

Polyneuropathy is a debilitating condition which may be associated with large burns. The aim of this integrative review is to identify factors that contribute to the development of critical care polyneuropathy in patients admitted to an intensive care unit with a severe burn injury. PubMed, Scopus, CINHAL and EMBASE were searched up until July 2016. Studies/case reports focusing on critical care polyneuropathy for burn injured patients were included. The ten studies, included a total of 2755 burns subjects and identified 128 critical care polyneuropathy patients with an incidence of 4.4%. Three case reports identified prolonged ventilation and development of critical care neuropathy. Overall, factors identified as contributing to the development of critical care polyneuropathy in burn injured patients included prolonged ventilation (>7 days), large and deep total body surface area burns (mean TBSA 40%), and sepsis. Critical care polyneuropathy in burn patients remains challenging to diagnose and treat. To date, there is a lack of long term studies describing the impact of critical care polyneuropathy on functional performance or participation in activities of daily living in the burns population and this is consistent with the general literature addressing the lack of follow up assessments and long term consequences of persistent muscle weakness.

Burn-associated bloodstream infections in pediatric burn patients: Time distribution of etiologic agents

BACKGROUND

Infections are the leading cause of morbidity and mortality in patients with burns in burn units. Bloodstream infections (BSIs) in patients with burns may result from burn wound infection, use of invasive devices such as central venous catheters, and translocation of the gastrointestinal flora.

OBJECTIVE

In this study, we investigated the distribution and antimicrobial drug resistance of causative pathogens in children with burns and the durational changes of microorganisms in the distribution of BSIs in children.

METHODS

This study was conducted at the Pediatric Burn Unit (PBU) of Dr. Behçet Uz Children Research and Training Hospital during the period of November 2008-April 2015. The study subjects were all the patients admitted to the PBU, in whom microorganisms were isolated at least from one of the cultures, including blood and catheter cultures.

RESULTS

Gram-positive bacteria were the most common causative agents of BSI in patients with burns (66.4%), followed by gram-negative bacteria (22.1%) and fungi (11.5%). The median duration of development of BSIs caused by gram-positive bacteria from the time of burn was 5 days (ranging from 2 to 54 days of burn), which was significantly shorter than that of BSIs caused by gram-negative bacteria (12 days) and fungal pathogens (13 days).

CONCLUSION

The etiologic agents of BSIs in children may differ from those in adults. Gram-negative drug-resistant bacteria such as multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii were important agents of BSI in patients with burns, especially in the long term; however, gram-positive bacteria should also be considered while deciding the antimicrobial therapy, especially in the early periods of burn.

Surveillance of antibiotic susceptibility in a Swedish Burn Center 1994-2012

Patients with burn trauma are at risk for infections caused by antibiotic resistant bacteria (ABR) with subsequent increase in morbidity and mortality. As part of the Swedish strategic program against antibiotic resistance in intensive care (ICU-Strama), we have surveyed the distribution of species and ABR in isolates from patients admitted to a Swedish burn center at Linköping University Hospital from 1994 through 2012. In an international comparison Strama has been successful in reducing the antibiotic consumption among animals and humans in primary care. The aim of this study was to investigate the antibiotic consumption pressure and resistance rates in a Swedish burn unit.

METHODS

Microbiology data, total body surface area (TBSA), patient days, and mortality were collected from a hospital database for all patients admitted to the Burn Center at the University Hospital of Linköping from April 1994 through December 2012.

RESULTS

A total of 1570 patients were admitted with a mean annual admission rate of 83 patients (range: 57-152). 15,006 microbiology cultures (approximately 10 per patient) were collected during the study period and of these 4531 were positive (approximately 3 per patient). The annual mean total body surface area (TBSA) was 13.4% (range 9.5-18.5) with an annual mortality rate of 5.4% (range 1-8%). The MRSA incidence was 1.7% (15/866) which corresponds to an MRSA incidence of 0.34/1000 admission days (TAD). Corresponding figures were for Escherichia coli resistant to 3(rd) generation cephalosporins (ESBL phenotype) 8% (13/170) and 0.3/TAD, Klebsiella spp. ESBL phenotype 5% (6/134) and 0.14/TAD, carbapenem resistant Pseudomonas aeruginosa 26% (56/209) and 1.28/TAD, and carbapenem resistant Acinetobacter spp. 3% (2/64) and 0.04/TAD.

CONCLUSIONS

Our results show a sustained low risk for MRSA and high, although not increasing, risk for carbapenem resistant P. aeruginosa.

Major Transcriptome Changes Accompany the Growth of Pseudomonas aeruginosa in Blood from Patients with Severe Thermal Injuries

Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen that causes serious infections in immunocompromised hosts including severely burned patients. After multiplying within the burn wound, P. aeruginosa translocate into the bloodstream causing bacterial sepsis frequently leading to organ dysfunction and septic shock. Although the pathogenesis of P. aeruginosa infection of thermally-injured wounds has been extensively analyzed, little is known regarding the ability of P. aeruginosa to adapt and survive within the blood of severely burned patients during systemic infection. To identify such adaptations, transcriptome analyses (RNA-seq) were conducted on P. aeruginosa strain PA14 that was grown in whole blood from a healthy volunteer or three severely burned patients. Compared with growth in blood from healthy volunteers, growth of PA14 in the blood from severely burned patients significantly altered the expression of 2596 genes, with expression of 1060 genes enhanced, while that of 1536 genes was reduced. Genes whose expression was significantly reduced included genes related to quorum sensing, quorum sensing-controlled virulence factors and transport of heme, phosphate, and phosphonate. Genes whose expression was significantly enhanced were related to the type III secretion system, the pyochelin iron-acquisition system, flagellum synthesis, and pyocyanin production. We confirmed changes in expression of many of these genes using qRT-PCR. Although severe burns altered the levels of different blood components in each patient, the growth of PA14 in their blood produced similar changes in the expression of each gene. These results suggest that, in response to changes in the blood of severely burned patients and as part of its survival strategy, P. aeruginosa enhances the expression of certain virulence genes and reduces the expression of others.

Burns infection profile of Singapore: prevalence of multidrug-resistant Acinetobacter baumannii and the role of blood cultures

BACKGROUND

With various changes implemented such as perioperative antibiotics for tangential excision, this retrospective study reviews the infection profile of burn patients at Singapore's only centralized burns unit. Worldwide, the appearance of multidrug-resistant (MDR) strains of Acinetobacter baumannii (A. baumannii) continues to worsen patient outcomes. This study also surveys the role of blood cultures in burns at our unit.

METHODS

Four hundred fifty-two burn patients admitted to the unit between 2011 and 2013, and with cultures performed, were included in the study. The yields of various cultures were evaluated and 2684 samples were amassed, of which 984 (36.7 %) were positive. Patient variables for predictors of MDR A. baumannii infection acquisition and bacteremia were evaluated through multivariate analyses.

RESULTS

Pseuodomonas aeruginosa (P. aeruginosa) (67 patients) was the most common organism in those with total body surface area (TBSA) burn <20 % while MDR A. baumannii (39 patients) was most prevalent in those with TBSA burn ≥20 %. We found a yield of 1.1 % positive blood cultures for TBSA burn <20 % and a yield of 18.6 % positive cultures in TBSA burn ≥20 %. The median time between surgery and bacteremia was 6.5 days (range -18 to 68 days, interquartile range 4.5); 2.9 and 8.8 % of bacteremic episodes occurred within 24 and 48 h, respectively. This is a decrease from a predeceasing study (45.3 % for 24 h and 60 % for 48 h). Multivariate analysis revealed that length of hospital stay and TBSA burn ≥20 % were predictors of MDR A. baumannii infection and positive blood cultures.

CONCLUSIONS

MDR A. baumannii infection burdens patient management, especially in those with TBSA burn ≥20 % and longer hospital stay. Prophylactic antibiotics may reduce perioperative bacteremia, but their role in MDR infections needs to be evaluated. The role of blood cultures in TBSA burn <20 % needs reconsideration.

The Role of CHI3L1 (Chitinase-3-Like-1) in the Pathogenesis of Infections in Burns in a Mouse Model

In severe burn injury the unique setting of a depleted, dysfunctional immune system along with a loss of barrier function commonly results in opportunistic infections that eventually proof fatal. Unfortunately, the dynamic sequence of bacterial contamination, colonization and eventually septic invasion with bacteria such as Pseudomonas species is still poorly understood although a limiting factor in clinical decision making. Increasing evidence supports the notion that inhibition of bacterial translocation into the wound site may be an effective alternative to prevent infection. In this context we investigated the role of the mammalian Chitinase-3-Like-1 (CHI3L1) non-enyzmatic protein predominately expressed on epithelial as well as innate immune cells as a potential bacterial-translocation-mediating factor. We show a strong trend that a modulation of chitinase expression is likely to be effective in reducing mortality rates in a mouse model of burn injury with superinfection with the opportunistic PA14 Pseudomonas strain, thus demonstrating possible clinical leverage.

Highly drug-resistant pathogens implicated in burn-associated bacteremia in an Iraqi burn care unit

OBJECTIVE

In low- and middle-income countries, bloodstream infections are an important cause of mortality in patients with burns. Increasingly implicated in burn-associated infections are highly drug-resistant pathogens with limited treatment options. We describe the epidemiology of bloodstream infections in patients with burns in a humanitarian surgery project in Iraq.

METHODS

We performed a retrospective, descriptive study of blood culture isolates identified between July 2008 and September 2009 among patients with burns in a single hospital in Iraq who developed sepsis.

RESULTS

In 1169 inpatients admitted to the burn unit during the study period, 212 (18%) had suspected sepsis, and 65 (6%) had confirmed bacteremia. Sepsis was considered the primary cause of death in 198 patients (65%; 95% CI 65-70) of the 304 patients that died. The most commonly isolated organisms were Pseudomonas aeruginosa (22 isolates [34%]), Staphylococcus aureus (17 [26%]), Klebsiella pneumoniae (8 [12%]), Staphylococcus epidermidis (7 [11%]), Acinetobacter baumannii (6 [9%]), and Enterobacter cloacae (5 [8%]). A high proportion of Enterobacteriaceae strains produced extended-spectrum beta-lactamase and S. aureus isolates were uniformly methicillin-resistant. For gram-negative bacteria, the most reliably active antibiotics were imipenen and amikacin.

CONCLUSIONS

Burn patients with sepsis in Iraq were commonly found to have bloodstream pathogens resistant to most antibiotics available locally. Effective empirical therapy of burn sepsis in this region of Iraq would consist of vancomycin or teicoplanin and a carbapenem-class antibiotic with antipseudomonal activity.

The evaluation of nasal mupirocin to prevent Staphylococcus aureus burn wound colonization in routine clinical practice

BACKGROUND

Staphylococcus aureus wound colonization frequently occurs in patients with burns and can cause impaired wound healing. Nasal mupirocin application may contribute to the reduction of burn wound colonization of endogenous origin, whereas colonization by the exogenous route can be reduced by blocking cross-infection from other sources. In this study we evaluated whether the implementation of routine treatment of patients and burn center personnel using nasal mupirocin ointment reduces S. aureus burn wound colonization.

METHODS

We composed three study groups, consisting of a control period (Control), a mupirocin period (MUP), in which patients with burns were all receiving nasal mupirocin at admission, and a mupirocin+personnel period (MUP+P), in which we also screened the burn center personnel and decolonized S. aureus carriers by nasal mupirocin.

RESULTS

The patients who carried S. aureus in their nose and did not have S. aureus burn wound colonization at admission were considered as patients susceptible for the use of nasal mupirocin. In these patients, the S. aureus burn wound colonization rate was the same in all study groups. S. aureus nasal carriage was a significant independent risk factor for burn wound colonization (OR: 3.3; 95% CI: 1.4-7.6) when analyzed within the three study groups.

CONCLUSION

Although S. aureus carriage is a significant risk factor for developing burn wound colonization, the routine use of nasal mupirocin did not contribute to a reduction of burn wound colonization.

Predicting length of stay in thermal burns: a systematic review of prognostic factors

BACKGROUND

Continued improvement in all aspects of the management of thermal injury has resulted in marked improvements in the traditionally reported outcome of mortality. This has resulted in the search for alternative parameters that can be monitored to indicate the performance of burn services. Length of stay (LOS) in hospitalised burn patients has long been considered reflective of injury-associated morbidity, cost and the quality of care, which can be monitored consistently across services.

AIM

We undertook a systematic review of published literature pertaining to LOS prognostication in thermal burns to identify the relevant factors, quantify the risk associated with these factors and identify predictive prognostic models.

METHODS

Electronic searches were performed on MEDLINE, CINHAL, EMBASE, Web of Science, the Cochrane collection and a general web search was performed using Google. The searches were complemented by a manual search of the contents of leading burns journals. Quality of the studies included in the review was evaluated against published standards for prognostic studies.

RESULTS

Fourteen studies were included in the review after meeting the inclusion/exclusion criteria. Age and %TBSA were the strongest predictors of LOS in these studies. Other significant predictors included % full thickness burn, female gender, inhalation injury, surgery including escharotomy and the depth of burn. Nine studies reported multivariate models for predicting LOS in patients sustaining thermal injury. None of these models were validated and the goodness-of-fit statistic (R2) ranged from 0.15 to 0.75.

CONCLUSION

This review has demonstrated that %TBSA and age are the best predictors of LOS in published literature. Current prognostic models do not explain a significant proportion of variation in LOS.

Antimicrobial susceptibility of bacterial isolates from burn units in Gaza

BACKGROUND

Bacterial infections continue to be a leading cause of morbidity and mortality among burn patients despite intensive prophylaxis and treatment. Often treatment is complicated by the emergence of antimicrobial resistance pathogens. There are no reports or published data on the susceptibility profiles of bacteria isolated from burn patients in the Gaza strip.

PATIENTS AND METHODS

A cross sectional study was performed in the two burn units of Al-Shifa and Naser hospitals for 6 months from October 2010 to March 2011. A total of 118 wound samples from burn patients, 97 environmental samples and 28 samples from health care workers (HCWs) were collected and cultured according to the standard microbiological procedures. The bacterial isolates were identified by conventional methods and the antibiotic susceptibility profiles were determined by the standard disc diffusion method according to CLSI guidelines.

RESULTS

The overall percentage of positive cultures from both hospitals was 45.8%, where Nasser burn unit revealed higher positive cultures than Al-Shifa burn unit. Pseudomonas aeruginosa was the most common pathogen isolated (50%) followed by Enterobacter cloacae (28.3%). Meanwhile, fingers and nasal samples that collected from HCWs showed 78.6% and 32.3% positive cultures respectively, where P. aeruginosa was the highest pathogen isolated (32.3%), followed by Coagulase Negative Staphylococci (CoNS) (29%). Environmental samples also showed higher isolation rate of Pseudomonas and CoNS. Pseudomonas isolates from patients samples were found to be resistant to most of antimicrobials used except for piperacillin-tazobactam. The family Enterobacteriaceae isolated from patients and environmental samples were resistant to most of the tested antimicrobials. However, the Enterobacteriaceae isolates from HCWs samples were sensitive to the most of the tested antimicrobials. The incidence of methicillin-resistant Staphylococci according to oxacillin sensitivity test was 60% in patient's samples, 77.8% in HCWs samples and 90% in environmental samples.

CONCLUSION

High percentage of resistance was found among clinical isolates in general to the commonly used antibiotics with a notable increase in MRSA incidence among both patients and environmental samples as well as HCWs.

Burden of different beta-lactamase classes among clinical isolates of AmpC-producing Pseudomonas aeruginosa in burn patients: A prospective study

Background:

Pseudomonas aeruginosa is one of the most common pathogens causing infections in burns, and shows increasing resistance to β-lactam antibiotics by producing different classes of beta-lactamases. It is also not unusual to find a single isolate that expresses multiple β-lactamase enzymes, further complicating the treatment options. Thus, in this study, we aimed to determine the coexistence of different beta-lactamase enzymes in clinical isolates of P. aeruginosa in the burn ward.

Materials and Methods:

A total of 101 clinical isolates of P. aeruginosa from the burn ward were identified and tested for the presence of different beta-lactamase enzymes (extended spectrum beta lactamase (ESBL), Amp C and metallo β-lactamases (MBL) from October 2006 to May 2009. In vitro susceptibility pattern of antipseudomonal antibiotics was done by the Kirby Bauer disc diffusion method.

Results:

A total of 33 (32.7%) isolates were confirmed to be positive for AmpC beta-lactamase. Co-production of AmpC along with ESBL and MBL was reported in 24.5% and 45.5% isolates, respectively. A total of 12 (11.9%) isolates were resistant to three or more antibiotic classes (multidrug resistance). Imipenem and piperacillin/tazobactum showed high sensitivity, with 86.1% and 82.2%, respectively.

Conclusion:

This study reveals the high prevalence of multidrug- resistant P. aeruginosa producing beta-lactamase enzymes of different mechanisms in this region from burn patients. The emerging antimicrobial resistance in burn wound pathogens poses serious therapeutic challenge. Thus proper antibiotic policy and measures to restrict the indiscriminate use of cephalosporins and carbapenems should be taken to minimize the emergence of this multiple beta -lactamase producing pathogen.

Blood stream infections (BSI) in severe burn patients--early and late BSI: a 9-year study

Bloodstream infections (BSI) and sepsis are among the most common complications occurring in severe burn patients. This study was designed to evaluate changes in BSI pathogens over almost a decade in severe burn patients at Rambam Healthcare Campus, and BSI occurrence during early and late hospitalization periods. Retrospective computerized data was retrieved from all severe burn patients hospitalized in our institution during the years 2001-2009. BSI in the first week was defined as early BSI, and in the second week and beyond, late BSI. Of 159 severe burns patients, 74 had at least one BSI episode. Most first BSI episodes were diagnosed during the first week of hospitalization. In late BSI, an increased prevalence of resistant bacteria (methicillin-resistant Staphylococcus aureus [MRSA], carbapenem-resistant Klebsiella pneumoniae [CRKP], imipenem-resistant Pseudomonas aeruginosa [PSE-IMP]) and Candida spp. were observed. However, over the 9-year study period, only CRKP increased significantly. In summary, except for the sudden appearance and increase in CRKP (8% increase; p=0.045), we did not observe a significant change in the BSI pathogen profile over the 9-year period. Nevertheless, over the hospitalization period, there is a clear change in the BSI bacteria profile, especially after 4 weeks of hospitalization.

Factors associated with duration of hospitalization and outcome in burns patients: a cross sectional study from Government Tertiary Care Hospital in Karachi, Pakistan

OBJECTIVE

Burns are important contributors toward mortality in trauma related injuries in Karachi, Pakistan. The aim of the present study was to delineate the factors contributing to the duration of hospitalization and mortality in such patients.

METHODS

We performed a single center retrospective study of patients admitted during a 2 year period (January 2009 till December 2010) in Burns Center, Karachi. Patients with incomplete record were excluded. Variables included were age and gender of the patient, the percent total body surface area (%TBSA) burn, the cause of the burn and the body parts affected along with the micro-organisms isolated from the burn wounds. The relationship of these variables with the duration of hospitalization and the outcome of patients was assessed by means of Pearson Chi Square test in SPSS version 14.

RESULTS

Mean age of patients was 26.64 years (± 13.430). More males (56.6%) were admitted than females (43.4%), giving a male to female ratio of 1.3:1. Mean percent total body surface area (%TBSA) burnt and mortality were 24.69% and 26.38% respectively with both having higher values in females (p<0.001). Males had a mean longer duration of hospitalization compared to females (35.94 days vs. 27.63 days). The most common micro-organism colonizing the wounds was found to be Staphylococcus aureus. Factors significantly (p<0.05) associated with increased duration of hospitalization and mortality include the age and gender of the patient, the cause of burn, inhalation injury, the region affected and %TBSA burnt.

CONCLUSION

The relationship of age and gender of the patient, the cause of burn, inhalation injury, the region affected and %TBSA burnt are important factors in determining the duration of hospitalization of the patients and whether the patients will survive or succumb to injuries.

Bacteriology of infected burn wounds in the burn wards of a teaching hospital in Southwest Nigeria

BACKGROUND

Burns are characterized by the loss of varying proportions of the protective layers of the skin, depression of immune responses, and increased wound susceptibility to infection. Wound infection is a major cause of morbidity and mortality in burn cases. This study characterizes those factors that predispose burn wounds to infection and the bacteriology of the microorganisms in our environment.

PATIENTS AND METHODS

Prospective study of burns patients that were admitted and treated at the Lagos State University Teaching Hospital (LASUTH), Ikeja-Lagos, Nigeria between January 1 and May 31, 2010 was carried out. Information about the demographics, aetiology/mechanism of burns, interval between the time of injury and admission, microbial studies, and antibiotic therapy were collected and analyzed.

RESULTS

A total of 74 patients consisting of 43 males and 31 females were seen. The ages range between one week and 95 ± 22.42 years. Wound infections were confirmed in 28 patients (infection rate of 37.84 per 100 patients). Delayed presentation at LASUTH and length of hospital stay were significantly related to the development of wound infection. Pseudomonas aeruginosa and Proteus mirabilis were the most common infective organisms occurring in 53.6 and 10.7 percentages respectively. The isolated organisms were resistant to the beta-lactam antibiotics and mostly sensitive to carbapenem and aztreonam preparations.

CONCLUSION

Factors predisposing to invasive wound infections in our environment were highlighted and suggestions made on methods that could reduce the infections and thus reduce morbidity and mortality in burns.

Fungal urinary tract infection in burn patients with long-term foley catheterization

Purpose

It is well known that fungi become predominant microorganisms in the urine of patients with long-term Foley catheters. This study was conducted to evaluate the lengths of time for fungi to cause urinary tract infection (UTI) and to identify predictors of fungal UTI in burn patients with long-term Foley catheters.

Materials and Methods

A total of 93 patients who did not have infection at the time of admission but later had fugal UTI were evaluated. Urinalysis, urine culture, and Foley catheter indwelling were done at admission. All patients were administered prophylactic antibiotics from admission. Urine cultures were run every week, and catheters were changed every 2 weeks for each patient.

Results

Three of the 93 patients (3.2%) displayed fungal UTI at the 1st week of catheter indwelling. However, most patients (78.5%) displayed fungal UTI from 2nd to 5th week after catheter indwelling. The most prevalent fungus identified was Candida tropicalis (60.2%). By univariate logistic regression analysis, only the total body surface area burned (TBSAB) was predictive of fungal UTI in burn patients (p=0.010). By multivariate logistic regression analysis, underlying disease (p=0.032) and TBSAB (p=0.036) were predictors of fungal UTI. Patients with higher TBSAB were more likely to display shorter intervals from Foley catheterization to fungal UTI.

Conclusions

Fungal UTI was initially found at the 1st week of urinary catheter indwelling, but the majority of cases occurred after the 1st week and appeared earlier in patients with underlying disease or higher TBSAB. Underlying disease and TBSAB were predictors of early fungal UTI.

Incidence and bacteriology of burn infections at a military burn center

Considerable advancements in shock resuscitation and wound management have extended the survival of burned patients, increasing the risk of serious infection. We performed a 6-year review of bacteria identification and antibiotic susceptibility records at the US Army Institute of Surgical Research Burn Center between January 2003 and December 2008. The primary goal was to identify the bacteria recovered from patients with severe burns and determine how the bacteriology changes during extended hospitalization as influenced by population and burn severity. A total of 460 patients were admitted to the burn ICU with 3507 bacteria recovered from 13,727 bacteriology cultures performed. The most prevalent organisms recovered were Acinetobacter baumannii (780), Pseudomonas aeruginosa (703), Klebsiella pneumoniae (695) and Staphylococcus aureus (469). A. baumannii was most often recovered from combat-injured (58%) and S. aureus the most frequent isolate from local (46%) burn patients. Culture recovery rate of A. baumannii and S. aureus was highest during the first 15 hospital days (73% and 71%); while a majority of P. aeruginosa and K. pneumoniae were recovered after day 15 (63% and 53%). All 4 pathogens were recovered throughout the course of hospitalization. A. baumannii was the most prevalent pathogen recovered from patients with total body surface area (TBSA) burns less than 30% (203) and 30-60% (338) while P. aeruginosa was most prevalent in patients with burns greater than 60% TBSA (292). Shifting epidemiology of bacteria recovered during extended hospitalization, bacteriology differences between combat-injured and local burn patients, and impact of % TBSA may affect patient management decisions during the course of therapy.

Bacteriology of the burn wound at the Bai Jerbai Wadia Hospital for children, Mumbai, India-A 13-year study, Part I-Bacteriological profile

AIM

To study which organisms were prevalent in our burn unit and their antibiotic sensitivity pattern in brief.

METHOD

Microbiological data of 1534 patients admitted to the burns unit of the Bai Jerbai Wadia Hospital for Children, Mumbai over a period of 13 years (1994-2006) was reviewed retrospectively. A total of 9333 swabs were cultured and antibiotic sensitivities to the isolated organisms determined. The age group of patients admitted to our facility ranged from one month to 15 years.

RESULT

Klebsiella was the predominant organism in our set-up (33.91%), closely followed by Pseudomonas (31.84%). The antibiotic sensitivities of the isolated organisms are discussed in detail in the text.

CONCLUSION

Every treatment facility has microorganisms unique to it and these change with time. It is therefore of paramount importance to have an in-depth knowledge of the resident organisms and their antibiotic sensitivity pattern so that infection-related morbidity and mortality are improved.

The role of nasal carriage in Staphylococcus aureus burn wound colonization

Thermal injury destroys the physical skin barrier that normally prevents invasion of microorganisms. This and concomitant depression of local and systemic host cellular and humoral immune responses are important factors that contribute to colonization and infection of the burn wound. One of the most common burn wound pathogens is Staphylococcus aureus. Staphylococcus aureus is both a human commensal and a frequent cause of infections leading to mild to life-threatening diseases. Despite a variety of infection control measures, for example patient cohorting and contact precaution at burn centres, S. aureus is still frequently encountered in burn wounds. Colonization with S. aureus has been associated with delayed wound healing, increased need for surgical interventions, and prolonged length of stay at burn centres. In this minireview, we focus on S. aureus nasal carriage in relation to S. aureus burn wound colonization and subsequent infection, and its impact on strategies for infection control.

Prevention of Staphylococcus aureus burn wound colonization by nasal mupirocin

BACKGROUND

There are two important routes for the transmission of Staphylococcus aureus to the burn wound. In the endogenous route, patients naturally carrying S. aureus colonize their own wounds, whereas in the exogenous route burn wounds are cross-infected from other sources. In this study we evaluated the effect of blocking the endogenous route on S. aureus burn wound colonization by mupirocin application in the nose of patients at the time of admission.

METHODS

From September 2000 to January 2002 all patients with burns admitted to a single dedicated Burn Centre received nasal mupirocin upon admission. This period was compared to two control periods (C1: July 1999 to July 2000 and C2: January 2002 to January 2003) for S. aureus burn wound colonization. The colonization risk was analysed, adjusting for confounding, with Cox proportional hazard regression.

RESULTS

A total of 98 patients did not have S. aureus burn wound colonization at the time of admission and were, thus, considered at risk for S. aureus acquisition during their stay. As compared to C1, the relative risk of acquiring S. aureus in their wound was 0.48 (95% CI: 0.24-0.97) in the mupirocin period and 0.55 (95% CI: 0.28-1.1) during the C2 period. S. aureus nasal/pharyngeal colonization was a significant independent risk factor for wound colonization (RR: 2.3; 95% CI: 1.2-4.2).

CONCLUSION

Nasal mupirocin may contribute to risk reduction of S. aureus wound colonization in patients with burns.

Infection in patients with severe burns: causes and prevention thereof

The better understanding of burn pathophysiology has resulted in effective fluid resuscitation in the acute stage, but the morbidity and mortality of burn patients are mostly linked to the burn wound consequences. Once the initial acute phase is over, the burn wound becomes the source of virtually all ill effects, local and systemic. The dysfunction of the immune system, a large cutaneous bacterial load, the possibility of gastrointestinal bacterial translocation, prolonged hospitalization, and invasive diagnostic and therapeutic procedures all contribute to infectious complications. Wound infection may lead to septicemia that may not only consume additional resources but is associated with significant morbidity and mortality despite the advances in burn care.

Analysis of prognostic indexes and other parameters to predict the length of hospitalization in thermally burned patients

BACKGROUND

In a retrospective study the influence of several clinical data and prognostic indexes on the length of hospital stay in burned patients was investigated.

METHODS

We recorded all admitted patients from January 2004 to December 2005 except for electrical and chemical injuries or patients that died during recovery. Age, gender, weight, height, body surface area, fluid, caloric and protein delivery, Total Burn Surface Area, full thickness burn surface area, Roi index, Baux score, Unit Burn Standard index, Abbreviated Burn Severity Index and the length of hospitalization were registered. A univariate and multivariate analysis was performed to look for correlations between these parameters and the length of hospitalization.

RESULTS

We recorded eligible 233 patients. The univariate analysis showed that age, protein and caloric delivery, Roi index and ABSI were significantly related with the length of hospitalization while, at the multivariate analysis, only Roi index was related (p<0.05). However, Roi index was able to predict only 5.5-6% of cases.

CONCLUSIONS

A correlation exists between the length of hospital stays and the Roi index in burned patients but does not explain the bulk of evidence. Further studies are required to investigate this relation, to screen other parameters and to correlate them with measures of outcome, i.e. functional (the range of motion of articulations) or aesthetic (patient's self assessment of his body image).

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Infections in burn patients--experience in a tertiary care hospital

A retrospective study was conducted at the Kanchi Kamakoti Childs Trust Hospital to analyze the bacterial isolates from the wounds of patients admitted to the Burns Unit and to determine the sensitivity patterns of the commonly cultured organisms over a 6-year period, December 1998 to December 2004. A total of 535 samples were analysed. Single isolates were more common. Pseudomonas was the most commonly cultured organism followed by Staphylococcus aureus. Escherechia coli and Klebsiella were seen in equal numbers. ESBL rates were 37%. Antibiotic sensitivity patterns and periodic ESBL surveillance helped in selection of appropriate antibiotics.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Povidone-iodine ointment: no effect of split skin graft healing time

In major burns, local treatment of the split skin graft after a burn injury is important to prevent serious infectious complications. Topical burn wound therapy may improve the bacteriological condition of the wound, which in turn may improve the successful take of a skin graft. Delay of wound healing is an undesired side effect of these topical anti-microbial agents. It is known that povidone-iodine has many clinical advantages. In view of this, the total healing time of the freshly grafted burn wound was studied. In this prospective study, comparable areas of the same patient were treated with povidone-iodine ointment or with simple vaseline gauze. There was no statistical difference in the total wound healing time between the treated and the control group.

The time-related changes of antimicrobial resistance patterns and predominant bacterial profiles of burn wounds and body flora of burned patients

To examine the bacterial isolates from the burn patients and to compare the antibiograms of the predominant bacteria isolated from 51 patients who were hospitalized at least 3 weeks or more over a period of 7 months, a prospective study was undertaken. Periodic swabs were taken from burn wound, nasal, axillary, inguinal, and umbilical region of the patients on admission and on 7th, 14th, and 21st days of hospitalization. Mean hospital stay was 36.5 days. A total of 1098 microbial isolates were detected during the study period. Coagulase-negative staphylococci (CNS, 63.0%) and Staphylococcus aureus (19.7%) were the most prevalent isolates in admission cultures. During the next weeks, these bacteria were superceded by mainly Pseudomonas aeruginosa. Between admission and 21st day, the rates of methicillin resistance of staphylococci strains increased steadily. There was no vancomycin resistance in any staphylococci strains, although nine of the S. aureus isolates (2.7%) were resistant to teicoplanin. There were no strains producing inducible beta lactamase (IBL) among P. aeruginosa strains. One extended-spectrum beta-lactamase (ESBL)-producing strain was recovered on admission, although strains producing IBL and ESBL were detected at rates of 79.6 and 57.1%, respectively, on the 21st day. The nature of microbial wound colonization, flora changes, and antimicrobial sensitivity profiles should be taken into consideration in using empirical antimicrobial therapy of burned patients.

Changes of microbial flora and wound colonization in burned patients

To determine time related changes of microbial colonization of burn wounds and body flora of burned patients, a prospective study was carried out. Fifty-one patients who were hospitalized at least 3 weeks were enrolled in the study. Periodic swabs were taken from burn wound, nasal, axillary, inguinal, and umbilical regions of the patients on admission and 7th, 14th, and 21st days of hospitalization. The mean body surface area burned was 22.9%. A total of 1098 microbial isolates were detected during the study period. Coagulase-negative staphylococci (CNS, 63.0%) and Staphylococcus aureus (19.7%) were the most prevalent isolates in admission cultures. There was a gradual decrease in the number of isolates of CNS and a marked increase in the numbers of S. aureus and Pseudomonas aeruginosa from admission to 21st day. At the 21st day, the most frequent organisms were S. aureus (37.6%), CNS (34.7%), and P. aeruginosa (16.2%). Methicillin resistance of staphylococci strains were increased constantly in study period. While 35.3% of burn wounds were sterile on admission, microbial colonization reached 86.3% within the first week. Nasal carriage of methicillin resistant S. aureus increased from 3.9% to 62.7% at 21st day. The nature of microbial wound colonization and flora changes should be taken into consideration in empirical antimicrobial therapy of burned patients.

Aerobic bacterial isolates from burn wound infections and their antibiograms--a five-year study

A retrospective study of major aerobic bacterial isolates from pus/wound swabs taken from patients admitted to the burn unit at Govt. Medical College Hospital, Chandigarh, India, over a period of 5 years (June 1997-May 2002) was undertaken. The study was carried out to determine the bacterial profile and antimicrobial susceptibility of the isolates and to describe the change in trends over the study period. The pus/wound swabs yielded very high culture positivity (96%) for 665 total isolates. Pseudomonas aeruginosa was found to be most common isolate (59%) followed by Staphylococcus aureus (17.9%), Acinetobacter spp. (7.2%), Klebsiella spp. (3.9%), Enterobacter spp. (3.9%), Proteus spp. (3.3%) and others (4.8%). Although P. aeruginosa continued to remain the predominant isolate over the five years, a constant and significant increase in the incidence of Acinetobacter spp. was found. Amikacin was found to be the most effective drug against gram negative bacteria, however, resistance to it was significantly increased over 5 years. For S. aureus and P. aeruginosa netilmicin and piperacillin were found to be the most effective drugs. Most of the isolates showed high level resistance to antimicrobial agents.

Molecular epidemiology of Staphylococcus aureus colonization in a burn center

The aim of this study was to investigate carriage of Staphylococcus aureus by patients and health care workers (HCW) and to define the genetic relationship of S. aureus strains isolated from burn wounds. At admission, 19/55 (34.5%) patients carried S. aureus in their nose and/or throat. Of this group, 95% subsequently colonized their burn wounds with S. aureus. Molecular analysis showed that in 78% of these cases the burn-wound colonizing strain was identical to the strain carried at admission. Importantly, 23/36 (64%) patients who did not carry S. aureus at admission also developed burn-wound colonization. In this group, three dominant genotypes were identified as colonizing strains of burn wounds. These clones represented also the majority (59%) of S. aureus strains cultured from the nose and/or throat of health care workers and patients. If patients were admitted to one of the Intensive Care rooms burn wounds of non-carriers were not colonized with S. aureus as long as they remained in such isolation. Only patients who carried S. aureus at admission developed burn-wound colonization with that genotype they carried in the nose or throat. Both carriage in patients and health care workers and auto-infection play a crucial role in (cross-) colonization events.

Bacteriology of burns at the Queen Elizabeth Central Hospital, Blantyre, Malawi

A retrospective study to determine the bacterial profile and antibiotic susceptibility pattern of burn isolates at the Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi was undertaken. While a total of 1825 burn patients were admitted to the hospital over a 6-year period (January 1994 to December 1999) only 317 (17.4%) specimens selected from as many patients were processed. One hundred and seventy (170/53.6%) specimens yielded single while the rest (147/46.4%) had multiple isolates giving a total of 535 bacterial isolates. Of this number, 236 (44.1%) were Gram-negatives and 299 (55.9%), Gram-positives. Among the Gram-negatives, Pseudomonas aeruginosa, Proteus mirabilis, Coliforms/Escherichia coli and Klebsiella pneumoniae were the most common accounting for 94.1% while in the Gram-positive group, staphylococcal and streptococcal spp. predominated (100%). However, the three most common isolates were Staphylococcus aureus (37.6%), P. aeruginosa (22.4%) and beta-haemolytic streptococci (13.6%). While S. aureus and beta-haemolytic streptococci were most susceptible to penicillin (33.3 and 64.4% susceptibility, respectively), gentamycin appeared most effective against P. aeruginosa (53.3%). A general broad-spectrum resistance to panels of antibiotics used in the study was however observed among the bacterial isolates. From these results, S. aureus, P. aeruginosa, streptococcal spp., P. mirabilis, Coliforms and K. pneumoniae representing 96.4% of all isolates were the most common in the Burns Unit.

Colonization of burn wounds in Ain Shams University Burn Unit

A prospective study was carried out on 70 burned patients admitted to the Burn Unit, Ain Shams University Hospital, Cairo, with the aim to verify the pattern of microbial colonization of burn wounds. Throughout the study period starting from 1 June 1999 till 31 May 2001, 281 sampling procedures (surface swabs) were performed from the burn wounds. A total of 301 microbial isolates were grown in cultures. Eight different species of bacteria, and only one species of Candida (C. albicans) were detected. There was no incidence of recovery of anaerobic microorganisms. Our results revealed that the most frequent isolate was Pseudomonas aeruginosa (21.6%), followed by Klebsiella pneumoniae (15.2%), then Escherichia coli (13.6%), Staphylococcus aureus (13.2%), coagulase-negative Staphylococci (11.6%), Streptococcus pyogenes (8.3%), Enterobacter species (6.6%), and lastly Streptococcus faecalis and Candida albicans (5.9 and 3.6%, respectively). Studying the time-related changes in burn wound microbial colonization showed an initial predominance of gram-positive cocci upon admission (70.7%) over gram-negative bacilli (27.6%). During the first 5 days, gram-negative bacilli started to predominate (55.7%) over gram-positive cocci (40.3%). Burn wound sampling performed starting from the sixth day onwards, revealed further prevalence of gram-negative bacilli (72.7%) over gram-positive cocci (22.7%). As for Candida albicans, there was a gradual increase in the frequency of its recovery as time elapsed from admission. It is crucial for every burn institution to determine the specific pattern of burn wound microbial colonization, the time-related changes in the dominant flora, and the antimicrobial sensitivity profiles. This would enable early treatment of imminent septic episodes with proper empirical systemic antibiotics, without waiting for culture results, thus improving the overall infection-related morbidity and mortality.

Changing trends in bacteriology of burns in the burns unit, Delhi, India

A retrospective study of bacterial isolates from the wounds of patients admitted to burns unit, was undertaken at Guru Tegh Bahadur Hospital, University College of Medical Sciences, Delhi, India, over a period of 5 years between July 1997 and April 2002. The study compared the results obtained with the previous 5 years data (June 1993-June 1997) from the same unit to determine the changing patterns and emerging trends of bacterial isolates and their antimicrobial susceptibilities. Pseudomonas species (31%) and Staphylococcus aureus (22%) were the most common pathogens followed by Klebsiella species (19%). Multi-drug resistant (MDR) Acinetobacter species (9%) have emerged as an important nosocomial pathogen in our burn unit. Most of the gram-negative isolates obtained were found to be multi-drug resistant and 61% of the tested isolates were extended spectrum beta-lactamase (ESBL) producers. Concomitant resistance to penicillin and aminoglycosides was observed in 61% of Enterococcus fecalis isolates. When compared with the results of previous 5 years (June 1993-June 1997) Pseudomonas spp. was still the commonest pathogen in the burns unit. However, isolation of this organism and other gram-negative organisms has decreased in comparison to previous years. The incidence of antimicrobial resistance has markedly increased over the past years resulting in limitation of therapeutic options.