Unusual development of granulomas on the healing surface of burn wounds associated with MRSA infections

Usage of negative pressure wound therapy in pseudoepitheliomatous hyperplasia secondary to burn injury: a case series

Pseudoepitheliomatous hyperplasia (PEH) is a reactive epithelial proliferation secondary to a wide range of stimuli, including traumatic injury, inflammation, infection, and tumors of the skins. PEH secondary to burn injury is rarely reported. We report 3 cases of PEH patients after burn injury. All three cases were confirmed with the existence of bacterial infection, and all these cases were second or third degree burns. All 3 patients were treated with negative pressure wound therapy after wound debridement or tangential excision. All the wounds healed without split-thickness skin grafting and recurrence.

Antimicrobial Selection in the Face of Nasal Methicillin-Resistant Staphylococcus aureus-Polymerase Chain Recombination Testing in Thermal Injury Patients

Emergence of resistance to vancomycin and the increasing incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) warrant careful initiation of antimicrobial agents after nasal swab polymerase chain recombination (PCR) MRSA positive screen. Current MRSA PCR nasal swab (PCR) screening does not distinguish non-hospital-acquired strains. A retrospective, institutional review board-approved study of collected PCR screenings among 826 burn center admissions over a 23-month period assessed culture results, antimicrobial agents chosen, and patient demographics. Seventy-seven of the 826 were known chronic carriers (n = 11); had MRSA on initial PCR (n = 48); or converted to positive PCR screen on later testing (n = 18). The 48 patients with initial positive PCR were decolonized with mupirocin. MRSA carriers were not decolonized. The 18 patients who became PCR positive were also not decolonized with 10 having positive cultures. The 48 initial PCR nasal swab positive patients represented 5.8% of admissions. Demographic data did not differ among chronic carriers, initial PCR positive patients, nor those converting to PCR positive. Length of stay was shorter for initial PCR positive decolonized patients (P << .05) and they had a 35% of decrease in MRSA infection. All 11 chronic carriers became infected with MRSA; however, five had non-hospital-acquired MRSA and two solely non-hospital-acquired MRSA. For the 48 PCR positive patients, 17 had isolated MRSA and one having exclusively non-hospital-acquired MRSA. Of the 39 patients with isolated MRSA, 20 (43%) non-hospital-acquired MRSA. Non-hospital-acquired MRSA was 43%, however PCR fails to distinguish hospital-acquired MRSA from community-acquired MRSA.

Focal injection of vancomycin combined with surgical debridement-dermatoplasty in the treatment of pseudo-epitheliomatous granuloma

BACKGROUND

Pseudo-epitheliomatous granuloma (PEG) can occur in some small skin wounds with secondary infections resulting from improper treatments. It is difficult to heal and can easily relapse.

OBJECTIVES

This study explores the clinical and pathological characteristics of PEG and effective treatments.

PATIENTS AND METHODS

Tissue specimens of PEG obtained from 11 patients (age range: 2-67 years) were sent for microbial examination and histological observation. The local lesions were treated by focal injection of vancomycin combined with surgical debridement-dermatoplasty.

RESULTS

The diagnosis of PEG was based on histological examination, which revealed long epithelial peduncle encapsulated granulation tissue-like honeycomb in which more vessels, macrophages, lymphocytes and mast cells and less extracellular matrix were distributed. Bacteria such as Staphylococcus aureus, Bacillus pyocyaneus, ethylene-type Streptococcus, stool Streptococcus and F-citric acid Bacillus were found in the microbial culture of the specimens. They were tolerant to celbenin but sensitive to vancomycin. PEG could be cured by focal application of vancomycin combined with free skin or skin flap after thorough debridement. The relapse of PEG could be prevented by the therapy.

CONCLUSION

Focal injection of vancomycin combined with surgical debridement-dermatoplasty is an effective therapy for PEG.

Pseudoepitheliomatous hyperplasia formation after skin injury

Pseudoepitheliomatous hyperplasia (PEH) is characteristic of reactive epithelial downward proliferation into the dermis. To explore the mechanism of PEH formation, we investigated the cause, clinical characteristics, histopathologic change, and clinical treatment of PEH, the expression characteristics of stem cell factor (SCF), and its receptor c-Kit in PEH and normal skin of PEH edge (PEH-N). The clinical data of 11 patients with PEH were reviewed, and biopsy examination and bacterial cultures were performed. The histological features of PEH and expression levels of SCF, c-Kit were examined with the pathological method and immunohistochemical methods. The results showed that in each case, histological examination revealed epidermal hyperplasia with irregular cords of epithelial cells extending into the dermis. The bacteria could be cultured and isolated from all PEH biopsies. These bacteria were resistant to several antibiotics, except vancomycin. Radical excision and daily dressing with vancomycin could cure PEH. SCF protein was expressed at stronger levels in sweat gland epithelial cells and interstitial cells of the PEH group vs. the PEH-N group. c-Kit was more strongly expressed by interstitial cells in PEH than in PEH-N. It was concluded that the improper management of cutaneous wounds might cause PEH formation, which can be cured by surgical excision and administration of effective antibiotics. SCF and c-Kit might be involved in the epidermal hyperplasia observed in PEH.

Staphylococcal septicaemia in burns

This study analyses staphylococcal septicaemia in a series of 1516 burn patients who were admitted to the burn unit of the Al-Babtain Centre for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait over a period of 6.5 years (1 June 1992-31 December 1998). One hundred and nine patients (7.2%) developed clinically and microbiologically proven septicaemia, of which 80 (73.4%) showed one or the other type of Staphylococcus in their blood. Fifty (62.5%) of them were males and 30 (37.5%) females, with a mean age of 26 years and the mean total body surface area of burns (TBSA) of 45% (range 1-93%). Preschool age children comprised 27.5% of the patients. Flame was the dominant (80%) cause of burn. Of the 80 patients who had 91 episodes of septicaemia, 52 (65%) had MRSA, 8 (10%) MSSA, 11 (13.8%) MRSE and 5 (6.2%) MSSE and 4 (5%) others had mixed organisms. Only the patients with MRSA had multiple episodes. Eight patients (10%) showed septicaemic episodes within only 48 h of admission; however, the majority of the patients (77.5%) had a septicaemic attack within 2 weeks postburn. Of the 52 MRSA septicaemic cases, 39 (75%) survived and 13 (25%) died. Four patients with septicaemia due to mixed infections died. A total of 19 patients were intubated, 14 due to inhalation injury and 5 because of septicaemia; all in the former group died. Glycopeptide therapy (vancomycin/teicoplanin) was instituted immediately following the detection of staphylococci in the blood. No significant difference was noted in relation to mortality amongst the septicaemic patients, whether or not on prophylactic antibiotic. Fifty-six (70%) of the 80 patients had 139 sessions of skin grafting and survived. Of the 52 MRSA patients, 40 had 101 sessions of skin grafting and 33 of them survived. The apparent low mortality was probably due to early detection of the organism, appropriate antibiotic therapy, care for nutrition and early wound cover. This study indicates a high incidence of staphylococcal septicaemia (especially due to MRSA) in the burn unit. A surface wound is the likely source of entry to the blood stream in these immunocompromised patients. The organism could be detected in blood as early as 48 h postburn and in as little TBSA burn as 1% in this MRSA endemic unit. Inhalation injury with major burns and added staphylococcal septicaemia invariably proved to be fatal.

Methicillin-resistant Staphylococcus aureus versus the burn patient

Methicillin-resistant Staphylococcus aureus (MRSA) has become a frequent cause of nosocomial infection, its increasing prevalence posing serious therapeutic and infection control problems within the hospital environment. MRSA is a major challenge to the burn patient, with potential to cause significant morbidity and mortality. Burn patients have been shown to become colonised and infected more readily than other patient groups. Extensive burn injuries are particularly susceptible to infection as a result of the disruption of the normal skin barrier and accompanying depression of immune responses. Extended hospitalisation and antibiotic therapy have been identified as additional risk factors for MRSA carriage and infection. Microbial surveillance, epidemiological studies and the introduction of strict infection control regimes can reduce the prevalence of MRSA but may be insufficient for eradication or prevention of outbreak situations. Recognition of the clinical importance of MRSA to the burn patient highlights the need to take appropriate measures to minimise transmission and infection in this vulnerable group of patients.