Nosocomial infections in pediatric patients with burns

Ten-Year Analysis of Bacterial Colonisation and Outcomes of Major Burn Patients with a Focus on Pseudomonas aeruginosa

A retrospective descriptive study included patients admitted with severe burns over the course of 10 years (2008-2018). Across all patients, there were 39 different species of bacteria, with 23 species being Gram-negative and 16 being Gram-positive bacteria, with also five different species of fungi cultured. Pseudomonas aeruginosa was the most commonly isolated organism, with 57.45% of patients having a positive culture. There was a significant difference in the number of P. aeruginosa isolated from patients that acquired their burns at work, in a garden, inside a vehicle, in a garage or in a public place. In patients that were positive for P. aeruginosa, the number of operations was higher (2.4) and the length of stay was significantly increased (80.1 days). Patients that suffered from substance abuse demonstrated significantly higher numbers of isolated P. aeruginosa (14.8%). Patients that suffered from both mental health illness and substance abuse demonstrated significantly higher numbers of P. aeruginosa isolated (18.5%). In the P. aeruginosa-negative group, there were significantly fewer patients that had been involved in a clothing fire. Furthermore, in the P. aeruginosa-negative patient cohort, the mortality rate was significantly higher (p = 0.002). Since the incidence of P. aeruginosa was also associated with a decreased mortality rate, it may be that patients admitted to hospital for shorter periods of time were less likely to be colonised with P. aeruginosa. This study demonstrates novel factors that may increase the incidence of P. aeruginosa isolated from burn patients.

The implementation of an infection control bundle within a Total Care Burns Unit

AIM

To evaluate the impact of the implementation of a best practice infection prevention and control bundle on healthcare associated burn wound infections in a paediatric burns unit.

BACKGROUND

Burn patients are vulnerable to infection. For this patient population, infection is associated with increased morbidity and mortality, thereby representing a significant challenge for burns clinicians who care for them.

METHODS

An interrupted time series was used to compare healthcare associated burn wound infections in paediatric burn patients before and after implementation of an infection prevention and control bundle. Prospective surveillance of healthcare associated burn wound infections was conducted from 2012 to 2014. Other potential healthcare associated infection rates were also reviewed over the study period, including urinary tract infections, pneumonia, upper respiratory tract infections and sepsis. An infection prevention and control bundle developed in collaboration between the paediatric burn unit and infection control clinicians was implemented in 2013 in addition to previous standard practice.

RESULTS

During the study period a total of 626 patients were admitted to the paediatric burns unit. Healthcare associated burn wound infections reduced from 34 in 2012 to 0 in 2014 following the implementation of the infection prevention and control bundle. Pneumonia and sepsis also reduced to 0 in 2013 and 2014, however one upper respiratory tract infection occurred in 2013 and urinary tract infections persisted in 2013.

CONCLUSION

The implementation of an infection prevention and control bundle was effective in reducing healthcare associated burn wound infections, pneumonia and sepsis within our paediatric burns unit. Urinary tract infections remain a challenge for future improvement.

Does early bloodstream infection pose a significant risk of in-hospital mortality in adults with burns?

BACKGROUD/PURPOSE

Bloodstream infections (BSI) are common in patients with major burns, but its effect on mortality remains controversial. This study was aimed to investigate if BSI is significant risk factor of mortality?

METHODS

This is a retrospective chart review study included 266 adult patients admitted to our burn center from 2000 to 2019. Age, sex, inhalation injuries, total burn surface area (TBSA), duration of stay in intensive care unit, BSI and mortality were variables studied. Fisher exact test, Mann-Whitney test and logistic regression was used for statistical analysis.

RESULTS

There were 234 survivors and 32 non-survivors. Male was predominant. The overall incidence of BSI was 18.8%, and the overall crude mortality was 12%. Burns ≥30% TBSA and BSI were significant risk factors. A predictive function based on30% TBSA and BSI within 14 days after the onset of burns (BSI-14) was derived. The function has a sensitivity of 0.97, specificity of 0.42 and achieved a maximum Youden Index at functional value ≥0.05727. The mortality probability of BSI-14 in burns ≥30% TBSA was 40.8%.

CONCLUSIONS

BSI and burns ≥30% TBSA were significant risk factors of mortality. Early detection of BSI-14 is critical in burn care as its probability of mortality can be as high as 40% in patients ≥30% TBSA of burns. To reduce the risk of mortality, early in ventilator withdrawal, invasive lines and tubes removal, and early grafting should be emphasized besides infection control and appropriate use of antibiotics.

Pediatric Burn Infection

Background: Severe burns lead to a profound hypermetabolic, hypercatabolic, hyper-inflammatory state. Pediatric burn patients are at significantly increased risk for infection and sepsis secondary to loss of the skin barrier and subsequent immunosuppression. Infection is the most common cause of morbidity and death in pediatric burn patients, and the mortality rate from sepsis remains high. Methods: Review of pertinent English-language literature pertaining to infection among pediatric burn patients. Results: Established risk factors for infection in pediatric burn patients are the depth of injury, presence of inhalation injury, indwelling devices, and total body surface area burned. Total body surface area remains one of the most important risk factors for the development of infectious complications, and mortality risks increase significantly if the burn size is >40%. The predominant colonization of burn wound starts with gram-positive organisms, which are replaced later by gram-negative organisms. Most cases of sepsis in burn patients originate from infected burn wounds. Treatment options include topical and systemic antimicrobial drugs, but surgical intervention often is the most definitive treatment. Excision of burn eschar to remove the source of potential infection is a key component of the treatment as well as prevention of infection. Conclusion: Key principles in improving outcomes for septic pediatric burn patients is early recognition, resuscitation, and adherence to management strategies such as prompt antimicrobial drug administration and source control.

Mathematical model predicts anti-adhesion-antibiotic-debridement combination therapies can clear an antibiotic resistant infection

As antimicrobial resistance increases, it is crucial to develop new treatment strategies to counter the emerging threat. In this paper, we consider combination therapies involving conventional antibiotics and debridement, coupled with a novel anti-adhesion therapy, and their use in the treatment of antimicrobial resistant burn wound infections. Our models predict that anti-adhesion–antibiotic–debridement combination therapies can eliminate a bacterial infection in cases where each treatment in isolation would fail. Antibiotics are assumed to have a bactericidal mode of action, killing bacteria, while debridement involves physically cleaning a wound (e.g. with a cloth); removing free bacteria. Anti-adhesion therapy can take a number of forms. Here we consider adhesion inhibitors consisting of polystyrene microbeads chemically coupled to a protein known as multivalent adhesion molecule 7, an adhesin which mediates the initial stages of attachment of many bacterial species to host cells. Adhesion inhibitors competitively inhibit bacteria from binding to host cells, thus rendering them susceptible to removal through debridement. An ordinary differential equation model is developed and the antibiotic-related parameters are fitted against new in vitro data gathered for the present study. The model is used to predict treatment outcomes and to suggest optimal treatment strategies. Our model predicts that anti-adhesion and antibiotic therapies will combine synergistically, producing a combined effect which is often greater than the sum of their individual effects, and that anti-adhesion–antibiotic–debridement combination therapy will be more effective than any of the treatment strategies used in isolation. Further, the use of inhibitors significantly reduces the minimum dose of antibiotics required to eliminate an infection, reducing the chances that bacteria will develop increased resistance. Lastly, we use our model to suggest treatment regimens capable of eliminating bacterial infections within clinically relevant timescales.

Since the development of the first antibiotics, bacteria have utilised and developed resistance mechanisms, helping them to avoid being eliminated and to survive within a host. Traditionally, the solution to this problem has been to treat with multiple antibiotics, switching to a new type when the one currently in use proves ineffective. However, the development of antibiotics has slowed significantly in the past two decades, while multi-drug resistant strains, otherwise known as ‘super bugs’, are on the rise. In answer to this challenge, alternative approaches, such as anti-adhesion therapy, are being developed as a complement or alternative to traditional antimicrobials. In this paper we formulate and analyse a mathematical model of a combination therapy, applied in the context of an infected burn wound, bringing together antibiotics, anti-adhesion therapy and debridement (the physical cleaning of a wound). We use our models to make sense of how these treatments interact to combat a bacterial infection, to predict treatment outcomes for a range of strategies and to suggest optimal treatment regimens. It is hoped that this study will guide future experimental and clinical research, helping biomedical researchers to identify the most promising approaches to treatment.

Predictive modelling of a novel anti-adhesion therapy to combat bacterial colonisation of burn wounds

As the development of new classes of antibiotics slows, bacterial resistance to existing antibiotics is becoming an increasing problem. A potential solution is to develop treatment strategies with an alternative mode of action. We consider one such strategy: anti-adhesion therapy. Whereas antibiotics act directly upon bacteria, either killing them or inhibiting their growth, anti-adhesion therapy impedes the binding of bacteria to host cells. This prevents bacteria from deploying their arsenal of virulence mechanisms, while simultaneously rendering them more susceptible to natural and artificial clearance. In this paper, we consider a particular form of anti-adhesion therapy, involving biomimetic multivalent adhesion molecule 7 coupled polystyrene microbeads, which competitively inhibit the binding of bacteria to host cells. We develop a mathematical model, formulated as a system of ordinary differential equations, to describe inhibitor treatment of a Pseudomonas aeruginosa burn wound infection in the rat. Benchmarking our model against in vivo data from an ongoing experimental programme, we use the model to explain bacteria population dynamics and to predict the efficacy of a range of treatment strategies, with the aim of improving treatment outcome. The model consists of two physical compartments: the host cells and the exudate. It is found that, when effective in reducing the bacterial burden, inhibitor treatment operates both by preventing bacteria from binding to the host cells and by reducing the flux of daughter cells from the host cells into the exudate. Our model predicts that inhibitor treatment cannot eliminate the bacterial burden when used in isolation; however, when combined with regular or continuous debridement of the exudate, elimination is theoretically possible. Lastly, we present ways to improve therapeutic efficacy, as predicted by our mathematical model.

Humankind is engaged in an arms race; one we are in danger of losing. Since the development and application of the first antibiotics, resistant strains of bacteria have steadily emerged. As the rate of discovery of new antibiotics slows, the threat increases. At present, 700,000 individuals globally die each year due to antimicrobial resistance and this number is predicted to rise to 10 million per year by 2050 unless fresh action is taken. It is important, therefore, that we explore alternative treatment strategies to replace or complement traditional antimicrobials. Here we use mathematical models to explain and predict the effects of a novel anti-adhesion therapy applied to infected burn wounds. This theoretically resistance-proof therapy operates by impeding bacteria from binding to host cells by blocking the host cell binding sites. This prevents bacteria from accessing nutrients and renders them susceptible to artificial clearance. Fitting our model to experimental data, we identify a number of valid parameter sets, and predict the conditions under which treatment will be effective for each set. These predictions are experimentally testable, and could be used to guide the development and application of anti-adhesion treatments in a clinical setting.

Co-administration of vancomycin and piperacillin-tazobactam is associated with increased renal dysfunction in adult and pediatric burn patients

Background

Burn patients are prone to infections which often necessitate broad antibiotic coverage. Vancomycin is a common antibiotic after burn injury and is administered alone (V), or in combination with imipenem-cilastin (V/IC) or piperacillin-tazobactam (V/PT). Sparse reports indicate that the combination V/PT is associated with increased renal dysfunction. The purpose of this study was to evaluate the short-term impact of the three antibiotic administration types on renal dysfunction.

Methods

All pediatric and adult patients admitted to our centers between 2004 and 2016 with a burn injury were included in this retrospective review if they met the criteria of exposition to either V, V/IC, or V/PT for at least 48 h, had normal baseline creatinine, and no pre-existing renal dysfunction. Creatinine was monitored for 7 days after initial exposure; the absolute and relative increase was calculated, and patient renal outcomes were classified according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria depending on creatinine increases and estimated creatinine clearance. Secondary endpoints (demographic and clinical data, incidences of septicemia, and renal replacement therapy) were analyzed. Antibiotic doses were modeled in logistic and linear multivariable regression models to predict categorical KDIGO events and relative creatinine increase.

Results

Out of 1449 patients who were screened, 718 met the inclusion criteria, 246 were adults, and 472 were children. Between the study cohorts V, V/IC, and V/PT, patient characteristics at admission were comparable. V/PT administration was associated with a statistically higher serum creatinine, and lower creatinine clearance compared to patients receiving V alone or V/IC in adults and children after burn injury. The incidence of KDIGO stages 1, 2, and 3 was higher after V/PT treatment. In children, the incidence of KDIGO stage 3 following administration of V/PT was greater than after V/IC. In adults, the incidence of renal replacement therapy was higher after V/PT compared with V or V/IC. Multivariate modeling demonstrated that V/PT is an independent predictor of renal dysfunction.

Conclusion

Co-administration of vancomycin and piperacillin-tazobactam is associated with increased renal dysfunction in pediatric and adult burn patients when compared to vancomycin alone or vancomycin plus imipenem-cilastin. The mechanism of this increased nephrotoxicity remains elusive and warrants further scientific evaluation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1899-3) contains supplementary material, which is available to authorized users.

Rehabilitation in the Acute Versus Outpatient Setting

Rehabilitation of patients with burn injuries aims to restore strength, coordination, and mobility as closely to normal as possible and should begin immediately after initial admission. In the acute phase, baseline assessments are made against which all subsequent rehabilitation success is held. In the intermediate phase, active, full range-of-motion movement, ambulation of steadily increasing distances, and resistive exercise and stretching aid in the prevention of muscle and bone atrophy and preserve muscle memory and coordination. In the long-term outpatient rehabilitation phase, individualized patient-centered exercise programs can be advantageous in achieving measurable and lasting positive rehabilitation outcomes.

Epidemiology of infections in a burn unit, Albania

BACKGROUND

Many types of nosocomial infections (NIs) can be present in the burned patient. The purpose of this study is to calculate the rates for NI in the Intensive Care Unit of the Service of Burns and Plastic Surgery in University Hospital Centre (UHC) in Tirana, Albania.

METHOD

The study is prospective, clinical and analytical. The study is continued/longitudinal because monitors all patients with severe burns during a specified time period (1year). For data analysis was used SPSS 19.0.

RESULTS

The infection prevalence rate was 12 infected patients per 100 patients. The colonisation prevalence rate was 43 colonised patients for 100 patients. The most frequent infection microorganisms were Pseudomonas aeruginosa and Staphylococcus aureus (67% and 24%). Incidence of BSI was 3 BSI for 1000 hospitalization days. Incidence of catheter-related bloodstream infection (CRBSI) was 11.7 BSI for 1000 catheter days. Colonisation of the tip of the central catheter (CTC) was 15.6 for 1000 catheter days.

CONCLUSIONS

The epidemiology of burn wound infections as well as the definitions have changed due to important changes in burn wound treatment but further studies should be done documented the factors that can reduce the burn wound infection rates.

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.

[Risk factors for nosocomial infection in pediatric burn patients]

OBJECTIVE

The aim of our study was to determine risk factors associated with nosocomial infections in children hospitalized for skin burn.

STUDY DESIGN

Prospective study including children hospitalized for skin burn.

METHODS

We collected demographic characteristic, mode of admission, mechanism of burn, extent of burn surface by the tables of Lund and Browder, depth of the lesions according to clinical criteria and evolution, type of invasive care (urinary catheterization, central catheterization or mechanical ventilation), nosocomial infection and its time of occurrence, prescription of empirical antibiotic therapy and evolution during hospitalization. The criteria for "American Burn Association" were used to define a severe burn in children.

RESULTS

One hundred eighty-two children were included. In univariate analysis, six risk factors were significantly associated with the occurrence of nosocomial infection: extent of burn surface, severe burn, urinary catheterization and its duration and central catheterization and its duration. Extent of burn surface greater than 10% of total body surface is an independent factor of the occurrence of nosocomial infection (P=0.009) in Multivariate analysis.

CONCLUSION

In our study, extent of burn surface greater than 10% of total body surface is as an independent risk factor for the occurrence of nosocomial infection.

Epidemiology of bloodstream infections in burn-injured patients: a review of the national burn repository

Bloodstream infections (BSIs) are a major cause of morbidity and mortality in thermally injured patients. However, these infections have not been well defined in this patient population. Therefore, the authors performed a retrospective case-control study to characterize the epidemiology, microbiology, and outcomes of burn-associated BSIs. A retrospective review of all patients in the National Burn Repository (NBR) between the years 1981 and 2007 was performed. All cases that had infection listed under complications were included in this study. For each case, two randomly selected patients from the same time period served as controls. Patient demographic data, extent of %TBSA, and type of infection were extracted. Primary end point was mortality. Secondary endpoints were hospital length of stay (LOS), intensive care unit LOS, total ventilator days, and hospital charges. Further analysis of the data involved case-matching patients by TBSA deciles, adjustment for the effects of TBSA and other potential confounders, and a sensitivity analysis of the effects of including or excluding sites that might have failed to consistently capture BSI information. A total of 11,793 patients (3931 cases and 7862 control) were included in the study. Of cultures revealing a Gram-positive organism, Staphylococcus aureus (32%) was the most common. From samples where isolation of a Gram-negative species occurred, Pseudomonas aeruginosa (35%) was more prominent. Infected patients were older (40.9 vs 32.8, P < .05) and had higher %TBSA (22.2 vs 7.9, P < .05). BSI was associated with significantly higher mortality (21.9% vs 3.09%), hospital LOS (47.4 vs 8.8 days) intensive care unit LOS (30.8 vs 2.6 days), ventilator days (29.2 vs 1.4 days), and hospital charge ($339,909.91 vs $33,272.43); P < .001 for all values. On evaluation of case-matched controls, mortality was higher for patients with BSI only <50% TBSA strata. Conclusions were unaffected by adjustment for TBSA and other possible confounders and was not influenced by possible failure of some sites to consistently capture BSI information. Development of BSI in hospitalized burn patients is associated with significant increases in morbidity, mortality, and resource utilization.

Infection control in the burn unit

The survival rates for burn patients have improved substantially in the past few decades due to advances in modern medical care in specialized burn centers. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury. In addition to the nature and extent of the thermal injury influencing infections, the type and quantity of microorganisms that colonize the burn wound appear to influence the future risk of invasive wound infection. The focus of medical care needs to be to prevent infection. The value of infection prevention has been acknowledged in organized burn care since its establishment and is of crucial importance. This review focuses on modern aspects of the epidemiology, diagnosis, management, and prevention of burn wound infections and sepsis.

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.

Upper airway mucus deposition in lung tissue of burn trauma victims

Previous study in an ovine model of smoke inhalation and burn (S + B) injury has shown distal migration of upper airway mucus. This study examines the localization of an upper airway gland specific mucus, mucin 5B (MUC5B) in lung autopsy tissues of burn-only injury and in victims of S + B injury. We hypothesize that victims with S + B injury would exhibit increased distal migration of MUC5B than that seen in victims of burn-only injury. Autopsy lung tissue from victims of burn injury alone (n = 38) and combined S + B injury (n = 22) were immunostained for MUC5B. No normal lung tissues were included in the study. Semiquantitative analysis of the extent of MUC5B in bronchioles and parenchyma was performed on masked slides. Irrespective of injury conditions, all victims showed MUC5B in bronchioles. Mucin 5B was seen in the parenchyma except in two burn victims. No statistically significant difference was seen in the mean bronchiolar and parenchyma MUC5B scores between S + B and burn-only victims (P > 0.05). No strong statistical correlation of MUC5B scores with days postinjury or to the number of ventilatory days was evident. The percentage of pneumonia, identified histologically, was also similar between study groups. This study did not confirm our results in an ovine model of S + B injury. In contrast, virtually all pediatric burn victims, regardless of concomitant inhalation injury, showed MUC5B in their bronchioles and parenchyma. Increased mucus synthesis and/or impaired mucociliary function may contribute to the pulmonary pathophysiology associated with burn injury.

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.

The impact of nosocomially-acquired resistant Pseudomonas aeruginosa infection in a burn unit

BACKGROUND

Nosocomially-acquired Pseudomonas aeruginosa remains a serious cause of infection and septic mortality in burn patients. This study was conducted to quantify the impact of nosocomially-transmitted resistant P. aeruginosa in a burn population.

METHODS

Using a TRACS burn database, 48 patients with P. aeruginosa resistant to gentamicin were identified (Pseudomonas group). Thirty-nine were case-matched to controls without resistant P. aeruginosa cultures (control group) for age, total body surface area, admission year, and presence of inhalation injury. Mortality and various morbidity endpoints were examined, as well as antibiotic costs.

RESULTS

There was a significantly higher mortality rate in the Pseudomonas group (33% vs. 8%, p < 0.001) compared with in the control group. Length of stay was increased in the Pseudomonas group (73.4 +/- 11.6 vs. 58.3 +/- 8.3 days). Ventilatory days (23.9 +/- 5.4 vs. 10.8 +/- 2.4, p < 0.05), number of surgical procedures (5.2 +/- 0.6 vs. 3.4 +/- 0.4, p < 0.05), and amount of blood products used (packed cells 51.1 +/- 8.0 vs. 21.1 +/- 3.4, p < 0.01; platelets 11.9 +/- 3.0 vs. 1.4 +/- 0.7, p < 0.01) were all significantly higher in the Pseudomonas group. Cost of antibiotics was also significantly higher ($2,658.52 +/- $647.93 vs. $829.22 +/- $152.82, p < 0.01).

CONCLUSIONS

Nosocomial colonization or infection, or both, of burn patients with aminoglycoside-resistant P. aeruginosa is associated with significantly higher morbidity, mortality, and cost of care. Increased resource consumption did not prevent significantly higher mortality rates when compared with that of control patients. Thus, prevention, identification, and eradication of nosocomial Pseudomonas contamination are critical for cost-effective, successful burn care.

Central venous catheter infections in burn patients with scheduled catheter exchange and replacement

INTRODUCTION

Consensus in the general critical care patient population is that routine central venous catheter change is not necessary, and that central lines should not be rewired in the setting of possible infection. This concept has not carried over into the burn realm. In burn patients the rewiring of lines may lead to increased infection rates.

METHODS

Fifty-nine consecutive critically ill burn patients requiring central line placement were included: 277 central lines and 1691 catheter days. Standard care protocol was followed in all patients, with lines being placed initially by new site insertion, changed over a guidewire on day 6, and moved to a new site on day 12. New sites were used for all suspected or documented line infections. All other care was the same. New site placements were compared to guidewire exchanges. Pediatric patients (under the age of 18) were considered with and separate from adults.

RESULTS

There was no difference in the incidence of catheter-related bloodstream infections (CRBSI) between lines placed by new site access (15.4/1000 catheter days) or by guidewire exchange (15.4/1000). Considering the 979 pediatric line days, there was a distinct difference, with new sites having 16.6/1000, and rewires 25.2/1000. Adults revealed the opposite trend, rewires having no occurrences of CRBSI, and new sites 13.7/1000. Children had a higher rate of CRBSI, 19.4/1000 days, compared to adults at 9.8/1000 days. Children had larger burns (P < 0.0001), more femoral lines (P = 0.0003), and lines closer to the burn wound (P = 0.001).

CONCLUSIONS

In pediatric patients guidewire exchange increased the incidence of infection. This was not noted in adult patients. The utility of guidewire exchange needs to be further investigated in adults, although this data would imply that it may be safe to use routine rewire of lines in adult burn patients. Pediatric patients require an increase in vigilance to minimize CRBSI. Central venous catheters should be removed as soon as not needed and routine change of lines in burn patients needs continued evaluation.

Mechanical and Infectious Complications of Central Venous Cannulation in Children: Lessons Learned From a 10-Year Experience Placing More Than 1000 Catheters

We sought to better describe the expected incidence of mechanical and infectious complications associated with central venous cannulation of critically ill children. We undertook a retrospective analysis of a prospective data collection of 1056 consecutive percutaneous central venous catheters inserted under the supervision of an experienced surgeon. There were 245 (23%) subclavian (SC), 118 (11%) internal jugular (IJ), and 693 (66%) femoral (F) catheters placed in 289 children with an average age of 6.4 +/- 5.1 years (range, 4 weeks to 18 years) admitted to a burn intensive care unit. Catheter sepsis occurred in 7.4% of SC, 7.6% of IJ, and 4.9% of F catheters (NS, P = .25), for an overall sepsis rate of 5.8%. The number of catheter lumens did not impact infection rate. Infection rates increased in catheters left in situ more than 10 days, increasing to 37.5% at 14 days. Acute mechanical complications occurred in three insertions (0.3%), including two (0.8%) SC, zero (0%) IJ, and one (0.1%) F catheters (NS, P = .20). All three were arterial cannulations that were recognized and treated successfully without surgery. There were no pneumothoraces, vascular lacerations, acute thromboses, or catheter emboli. There were six (0.6%) cases of deep venous thrombosis that occurred in cannulated sites: one (0.4%) SC, two (1.6.%) IJ, and three (0.4%) F sites (NS, P = .23). Patient age did not influence complication rates. A total of 239 (23%) of the CVCs were placed in infants less than 24 months; 273 (26%) 2 to 5 years, 259 (25%) 6 to 10 years, and 285 (27%) >10 to 18 years. Catheter sepsis occurred in 6.7%, 5.9%, 6.2%, and 4.6%, respectively (NS, P = .75). There was no difference in rates of infection or mechanical complication between younger and older children. When closely supervised by an experienced surgeon, a low rate of infection (5.8%), acute mechanical complication (0.3%), and deep venous thrombosis (0.6%) accompanies central venous cannulation of critically ill children.

Ventilator-Associated Pneumonia After Combined Burn and Trauma Is Caused by Associated Injuries and Not the Burn Wound

An increased risk of ventilator-associated pneumonia (VAP) has previously been demonstrated in trauma patients urgently intubated in the prehospital (ie, field) and emergency department (ED) settings. This study investigated the impact of urgent intubation on subsequent VAP in patients who sustained both a burn injury and a traumatic injury. We undertook a retrospective review of both trauma registry data and medical records for all patients with combined thermal and traumatic injuries admitted to a single verified burn center and level I trauma center. Patients undergoing field or ED intubation during the 5-year period ending December 2002 were identified and studied. Data abstracted included admission demographics and vital signs, presence of inhalation injury, location at the time of intubation, presence of associated injury, percentage TBSA burn, hospital and intensive care unit length of stay, and hospital day of VAP diagnosis. Seventy-eight of the 3388 patients (2.3%) admitted during the study period sustained a combination of burn wounds and trauma and underwent urgent field or ED intubation. The majority of patients were men (71%), with a mean age of 46 +/- 24 years. There was one failed oral intubation, which required cricothyroidotomy. The location of the patient at the time of intubation was ED, 66%; burn center ED, 17%; and field, 17%. Eighty percent of all patients were diagnosed with an inhalation injury. VAP was diagnosed in 39 patients (50%), with a mean time to diagnosis of 10 +/- 9 days. TBSA burn, smoke inhalation, and time (in days) to diagnosis of VAP were not independent risk factors for the occurrence of pneumonia in any of the 3 groups. However, those intubated at the initial ED were more likely to develop VAP (P = .028) compared to those intubated in the field or in the burn center. The incidence of associated injuries was significantly greater (P < .0001) in the initial ED group. Only a small percentage of burn patients also sustain blunt trauma. VAP occurs in 50% of the patients requiring urgent intubation. Independent risk factors appear to be intubation at an initial ED before transfer and associated injuries.

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.

Infection control in pediatric extended care facilities

Pediatric extended care facilities provide for the biopsychosocial needs of patients younger than 21 years of age who have sustained self-care deficits. These facilities include long-term and residential care facilities, chronic disease and specialty hospitals, and residential schools. Infection control policies and procedures developed for adult long-term care facilities, primarily nursing homes for elderly people, are not applicable to long-term care facilities that serve pediatric patients. This article reviews the characteristics of pediatric extended care facilities and their residents, and the epidemic and endemic nosocomial infections, infection control programs, and antimicrobial resistance profiles found in pediatric extended care facilities.

Delayed death in burns and the allegations of medical negligence

Burns and deaths due to burns to remain an important public health and social problem in India. Most of the victims, who survive the initial 24h after burns, succumb to infection of the burnt area and its complications. Burns cause devitalization of tissues, leaving extensive raw areas, which usually remain moist due to the outflow of serous exudate. This exposed, moist area along with the dead and devitalized tissue provides the optimum environment favoring colonization and proliferation of numerous microorganisms, which is further enhanced by the depression of the immune response. All these factors, i.e., disruption of the skin barrier, a large cutaneous bacterial load, the possibility of the normal bacterial flora turning into opportunistic pathogens and the severe depression of the immune system, contribute towards sepsis in a burns victim, which usually is life threatening. Despite various advances in infection control measures, early detection of microorganisms and newer, broader spectrum antibiotics, management of burn septicemia still remains a challenge. Pulmonary, cardiac and other complications also contribute to the delayed deaths following severe burn.

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.

Impact of tight glycemic control in severely burned children

BACKGROUND

Control of hyperglycemia has been shown to decrease mortality in critically ill adults, but the benefits of strict glucose control have not been established in children. Since January 2002, our pediatric burn center has adopted a policy of 'intensive' insulin therapy to achieve blood glucose levels 90 to 120 mg/dL. The purpose of this study was to examine the impact of this practice on patient outcomes.

METHODS

We reviewed the records of children with > or =30% total body surface area (TBSA) burn injury admitted to our regional pediatric burn center from July 1, 2000 to June 31, 2003. Patients were grouped into 'conventional insulin therapy' for the 2000 to 2001 period (n = 31) and into 'intensive insulin therapy' for the 2002 to 2003 period (n = 33). The efficacy of glucose control, infection rates, and patient survival were compared for the two therapies.

RESULTS

The demographic characteristics and injury severity were similar between the conventional and intensive insulin therapy groups. Children receiving intensive insulin therapy had glucose levels of 90 to 120 mg/dL more consistently than those in the conventional insulin therapy group. There was a significant decrease in urinary tract infections among intensive insulin therapy patients. TBSA burn, percent full-thickness burn, and Pediatric Risk of Mortality scores were negatively related to survival; intensive insulin therapy was positively associated with survival.

CONCLUSION

Intensive insulin therapy to maintain normoglycemia in severely burned children can be safely and effectively implemented in the burn unit. This therapy seems to lower infection rates and improve survival. Intensive insulin therapy should be considered for children with severe burn injuries.

Defining urinary tract infection in the critically ill child

OBJECTIVE

To define urinary tract infections in critically ill children in the intensive care unit setting for the purpose of surveillance of infection, enrollment of children in sepsis trials, and for trials of therapy and prevention.

DESIGN

Summary of the literature with review and consensus by experts in the field.

RESULTS

A variety of definitions, only some of which have been validated for use in children, were identified. The Centers for Disease Control criteria for the definition of nosocomial infection have been used to establish surveillance data for inter-institutional comparison. Validated definitions for the febrile child were identified. Using the known characteristics of symptoms, signs, and laboratory criteria for urinary tract infections, definitions for definite, possible, and probable urinary tract infection were derived.

CONCLUSIONS

Definitions for definite, probable, and possible urinary tract infection were achieved by consensus that can be used for surveillance and enrolment in sepsis trials. Future research should determine the utility of these definitions in the critically ill child and adapt them accordingly.

Sepsis in pediatric burn patients

OBJECTIVE

To review the specific infections common in pediatric burns, including their categorization, diagnosis, and treatment.

DESIGN

Review of the literature and expert opinion.

RESULTS

Children with serious burns are prone to a host of septic complications. This proclivity to infection is secondary to the immunosuppressive effect of burn injury, the loss of the skin and mucosal physical barriers, and the requirement for invasive support devices.

CONCLUSION

Sepsis is common in the pediatric burn patient and can markedly increase morbidity and mortality. Anticipation, prompt diagnosis of infection, and effective therapy can result in successful outcomes for many of these children.

Utility of Gram stain for the microbiological analysis of burn wound surfaces

CONTEXT

Surface swab cultures have attracted attention as a potential alternative to biopsy histology or quantitative culture methods for microbiological burn wound monitoring. To our knowledge, the utility of adding a Gram-stained slide in this context has not been evaluated previously.

OBJECTIVE

To determine the degree of correlation of Gram stain with culture for the microbiological analysis of burn wound surfaces.

DESIGN

Prospective laboratory analysis.

SETTING

Urban health region/centralized diagnostic microbiology laboratory.

PATIENTS

Burn patients hospitalized in any Calgary Health Region burn center from November 2000 to September 2001.

INTERVENTION

Gram stain plus culture of burn wound surface swab specimens obtained during routine dressing changes or based on clinical signs of infection.

MAIN OUTCOME MEASURES

Degree of correlation (complete, high, partial, none), including weighted kappa statistic (kappa(w)), of Gram stain with culture based on quantitative microscopy and degree of culture growth.

RESULTS

A total of 375 specimens from 50 burn patients were evaluated. Of these, 239 were negative by culture and Gram stain, 7 were positive by Gram stain only, 89 were positive by culture only, and 40 were positive by both methods. The degree of complete, high, partial, and no correlation of Gram stain with culture was 70.9% (266/375), 1.1% (4/375), 2.4% (9/375), and 25.6% (96/375), respectively. The degree of correlation for all 375 specimens, as expressed by the weighted kappa statistic, was found to be fair (kappa(w) = 0.32).Conclusion.-The Gram stain is not suitable for the microbiological analysis of burn wound surfaces.

Incidence of urinary tract and bloodstream infections in Ghotbeddin Burn Center, Shiraz 2000-2001

Though burn wound infections have been extensively studied, other nosocomial infections (NIs) in burn patients have received less attention. Invasive diagnostic procedures (vascular and bladder catheterization) make the burn patients more susceptible to different nosocomial infections. The aim of this study was to determine the rate of bloodstream and urinary tract infections associated with i.v. line and urinary catheter (UC) in Ghotbeddin Burn Center and also to compare these rates with those of the National Nosocomial Infections Surveillance System (NNIS) in the USA. This study was conducted over 11 months, from 21st December 2000 to 21st November 2001. All the patients who were admitted for more than 48 h and did not have evidence of infection at the time of admission were included in the study. For diagnosis of urinary tract and bloodstream infections, the standard definitions from the Center for Diseases Control (CDC) were used. Of the total 106 qualifying patients, 91 study patients acquired nosocomial infections (85.85%). Urinary catheter-associated urinary tract infection (UC-UTI) rate was 30 per 1000 urinary catheter days and i.v. line-associated bloodstream infection (i.v. line-BSI) rate was 17 per 1000 i.v. line days. Comparison of incidence rates of UC-UTI and i.v. line-BSI in Ghotbeddin Hospital and NNIS showed that rate of infection to be higher in Ghotbeddin Hospital while device utilization ratio (urinary catheter and central line) was higher in the NNIS hospitals. To reduce the rate of infection at Ghotbeddin Burn Center, education, development of standardized guidelines for the use of invasive devices and introduction of a nosocomial infections surveillance system are necessary.

Infections in a burn intensive care unit: experience of seven years

The objective of this study is to describe infections in a specialized burns intensive care unit from 1993 to 1999. The criteria for admission to the unit are: children with burns involving at least 10% or adults with burns involving at least 20% of total body surface; burns affecting face, perineum or feet; suspected or proven airway injury; electric or chemical burns; age less than one year or above 50; or pre-existing disease with any extent of burns. Surveillance of hospital-acquired infection was prospective. Hospital-acquired infection criteria used were those modified from the Centers for Disease Control and Prevention. Diagnosis of infection using skin biopsy was not done. Over the study period, 320 patients were admitted to our burns intensive care unit. One hundred and seventy-five (55%) developed 388 hospital-acquired infections. The rate for vascular catheter-associated bloodstream infections was 34 per 1,000 central line-days. The rate of ventilator associated pneumonia was 26 infections per 1,000 ventilator-days. Primary bloodstream was the most common infection with 189 episodes (49%); followed by 83 burn wound infections (21%) and 56 pneumonias (14%). In 76% of these infections and in 97% of the primary bloodstream infections, aetiological agents were identified. The micro-organisms causing infections were S taphylococcus aureus (24%), Pseudomonas aeruginosa (18%), Acinetobacter spp. (14%) and coagulase-negative staphylococci (12%). Candida spp. caused 8% of infections. Gram-positive and Gram-negative organisms exhibited resistance to most antimicrobial agents used for therapy. During the first three days of hospitalization in the burns intensive care unit there were eight infections caused by S. aureus and three of these were resistant to oxacillin. These data provide background information regarding extensive burn patients on which decisions for control and prevention of hospital-acquired infections can be made.

Comparison of hospital-acquired infection rates in paediatric burn patients

The objective of the present study was to determine risk factors for development of the most common hospital-acquired infections in paediatric burn patients in order to give recommendations for surveillance. The prospective cohort study in a paediatric burn centre was conducted over a period of two years using uni- and multivariate analysis for risk factor identification. In a group of 41 children with an mean total burn surface area (TBSA) of 18.9% 42 hospital-acquired infections were observed. The overall infection rate was 59.7 nosocomial infections per 1000 patient days, the device-associated nosocomial infection rates per 1000 device days were 55.2 for pneumonia, 8.9 for primary bloodstream infections and 41.7 for urinary tract infections. The incidence density of burn wound infections was 18.5 per 1000 patient days. The percentage of TBSA was a significant risk factor for burn wound infections, but percentage of TBSA was not a risk factor for the device-associated infections. Duration of urinary catheter use and ventilation were identified as risk factors for the corresponding hospital-acquired infection. Surveillance of hospital-acquired infections in burn intensive care units should be performed in the same way as other intensive care unit types, as recommended by the National Nosocomial Infections Surveillance system, without consideration of the percentage of TBSA. In addition, burn wound infections should be recorded using the percentage of TBSA for stratification of burn wound infection rates.

Burns

During the past 20 yrs, as burn care has evolved as a specialty of surgery, survival and outcome quality have soared. Public expectations for survival and long-term outcomes are at previously unprecedented levels. These changes are the result of a number of advances in aspects of burn care that have occurred in parallel and have fostered increasing regionalization of this resource-intensive activity into fewer specialized centers. These are complex hospitalizations and can be divided into four phases: initial evaluation and resuscitation, initial wound excision and biological closure, definitive wound closure, and rehabilitation and reconstruction.

Nosocomial pneumonia in pediatric patients: practical problems and rational solutions

Nosocomial pneumonia is a common hospital-acquired infection in children, and is often fatal. Risk factors for nosocomial pneumonia include admission to an intensive care unit, intubation, burns, surgery, and underlying chronic illness. Viruses, predominantly respiratory syncytial virus (RSV), are the most common cause of pediatric nosocomial respiratory tract infections. Gram-negative bacteria (Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa) are the predominant bacterial pathogens, and are associated with a high mortality rate. Staphylococcus aureus and Staphylococcus epidermidis are the most common Gram-positive bacteria causing nosocomial pneumonia; infections with these organisms have a better outcome than those with Gram-negative organisms. An increasing problem is the emergence of multiresistant Gram-positive and Gram-negative nosocomial pathogens. Distinguishing nosocomial pneumonia from other pulmonary processes may be difficult; diagnosis is based on clinical signs, radiological findings, and microbiological results. Recommended empiric therapy should consider factors such as the time of onset of illness, severity of disease, and specific risk factors for nosocomial pneumonia, including use of mechanical ventilation, underlying disease, or recent use of antibacterials. The resident local hospital flora should be considered when selecting therapy for nosocomial pneumonia. Early initiation of appropriate empiric therapy reduces morbidity and mortality. For empiric treatment of bacterial nosocomial pneumonia, an intravenous antibacterial regimen that includes coverage of Gram-negative bacilli and Gram-positive organisms should be used. A carbapenem or ureidopenicillin derivative (piperacillin) plus a beta-lactamase inhibitor should be used where extended spectrum beta-lactamase-producing Enterobacteriaceae are endemic. Therapy should be modified when a specific pathogen and its antimicrobial susceptibility are identified. Effective prevention of nosocomial pneumonia requires infection control measures that affect the environment, personnel, and patients. Of these, hand hygiene, appropriate infection control policies, and judicious use of antibacterials are essential.

Overview of catheter-related infections with special emphasis on prevention based on educational programs

Intra-vascular access is an unavoidable tool in sophisticated modern medical practice, and catheter-related infection remains a leading cause of nosocomial infections, particularly in intensive care units where it is associated with significant patient morbidity, mortality, and additional hospital costs. The incidence of catheter-related bloodstream infection ranges from 2 to 14 episodes per 1000 catheter-days. On average, microbiologically documented, device-related bloodstream infections complicate the use of a central venous line in three to five per 100 cases. But this represents only the visible part of the iceberg and most episodes of clinical sepsis are nowadays considered to be catheter-related. We briefly review the pathophysiology of these infections, highlighting the importance of the skin insertion site and the intravenous line hub as principal sources of colonization and infection. Principles of therapy are briefly addressed. A large proportion of these infections are preventable and this has been the objective of creating precise guidelines. It was recently suggested that the situation may evolve with the introduction of antibiotic/antiseptic-coated devices, whose impact on the epidemiology of antibiotic resistance remains to be determined. Recently, educational programs and/or a global preventive strategy based on the strict application of specific preventive measures and careful control of all factors associated with infection proved to be even more effective than coated devices in reducing rates of infection. Practical aspects regarding educational approaches will help clinicians to adapt and incorporate educational programs into clinical practice.

An outbreak due to multiresistant Acinetobacter baumannii in a burn unit: risk factors for acquisition and management

OBJECTIVES

To describe the investigation and management of an outbreak due to multiresistant Acinetobacter baumannii and to determine risk factors for acquisition of the organism.

SETTING

A 14-bed regional burn unit in a Canadian tertiary-care teaching hospital.

DESIGN

Case-control study with multivariate analysis of potential risk factors using logistic regression analysis. Surveillance cultures were obtained from the hospital environment, from noninfected patients, and from healthcare providers.

RESULTS

A total of 31 (13%) of 247 patients with acute burn injuries acquired multiresistant A. baumannii between December 1998 and March 2000; 18 (58%) of the patients were infected. The organism was recovered from the hospital environment and the hands of healthcare providers. Significant risk factors for acquisition of multiresistant A. baumannii were receipt of blood products (odds ratio [OR], 10.8; 95% confidence interval [CI95], 3.4 to 34.4; P < .001); procedures performed in the hydrotherapy room (OR, 4.1; CI95, 1.3 to 13.1; P = .02); and increased duration of mechanical ventilation (OR, 1.1 per day; CI95, 1.0 to 1.1; P= .02).

INTERVENTIONS

Improved compliance with hand hygiene, strict patient isolation, meticulous environmental cleaning, and temporary closure of the unit to new admissions.

CONCLUSIONS

Acquisition of multiresistant A. baumannii was likely multifactorial, related to environmental contamination and contact with transiently colonized healthcare providers. Control measures addressing these potential sources of multiresistant A. baumannii were successful in terminating the outbreak. Ongoing surveillance and continued attention to hand hygiene and adequate environmental cleaning are essential to prevent recurrent outbreaks due to antibiotic-resistant bacteria in burn units.

Infection control in the ICU

Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.

Antibiotic prophylaxis for group A streptococcal burn wound infection is not necessary

BACKGROUND

Historically, group A beta-hemolytic streptococci (GAS) burn wound infection has been a major source of morbidity and mortality in burn patients and has prompted the prophylactic administration of antibiotics to children with burns. Wound monitoring, surveillance cultures, and early excision of deep wounds may have changed this. Our objective in this project was to determine the efficacy of routine antibiotic prophylaxis in the era of early excision and closure of deep burn wounds.

METHODS

Two cohorts of burned children were compared: all children admitted during calendar years 1992 through 1994 (group 1) and during calendar years 1995 through 1997 (group 2). All group 1 children received routine GAS antibiotic prophylaxis. Only those group 2 children with documented positive admission or surveillance cultures for GAS were treated.

RESULTS

There were 511 children in group 1 and 406 children in group 2. They were well matched for age (4.7 +/- 0.21 years vs. 5.3 +/- 0.26 years, p = 0.06) and burn size (11.0% +/- 0.7% vs. 12.4% +/- 0.8%, p = 0.18). GAS species were recovered at admission or during hospitalization from 11 (2.6%) of group 1 children and 18 (4.4%) of group 2 children (p = 0.05), indicating a marginally higher rate of carriage in group 2. Nevertheless, in group 1 there were three (0.6%) who developed GAS wound infection and in group 2 there were four (0.98%, p = 0.71). The incidence of GAS infection in those patients with positive admission cultures was three (27%) of group 1 and four (22%) of group 2. No child developed fulminant GAS infection.

CONCLUSION

Routine antibiotic prophylaxis of burn wounds in children in not effective in further reducing a low baseline incidence of GAS wound infection if admission screening by culture is used to identify those children who carry the organism and early excision of deep burns is practiced.

Unique epidemiology of nosocomial urinary tract infection in children

BACKGROUND

Nosocomial urinary tract infection (NUTI) occurs with varying frequency in children and is thought to be associated with urethral instrumentation. In response to changing infection control resources at our facility, we reviewed NUTI to determine whether the frequency of NUTI, associated complications, or presence of a remediable risk factor (instrumentation) justified ongoing routine infection control surveillance.

METHODS

Prospective surveillance was conducted on all wards 8 months per year from January 1991 through December 1997 by an infection control nurse coordinator. NUTI was defined by laboratory evidence according to Center for Disease Control and Prevention definitions and detected 48 hours after admission. Urinary catheterization in the previous 7 days was categorized as continuous/indwelling or intermittent.

RESULTS

NUTI was the fifth most common nosocomial infection (129/1375; approximately 9%) and decreased in frequency during the decade from 0.9 to approximately 0.6 cases/1000 patient days. Incidence was equal among men and women. Only 50% of cases had prior instrumentation of the urinary tract. NUTI occurred disproportionately in newborns and infants (P <.001). The most common pathogen was Escherichia coli (28%; 38/132), followed by Candida sp (18%; 24/134), Enterococcus (13%; 18/134), gram-negative nonfermenters (13%; 17/132), Enterobacter (approximately 10%; 13/134), Pseudomonas (9.7%; 13/134), and other (16%; 22/134). Three cases of secondary bacteremia occurred (2.3%; 95% confidence interval 0.5-6.6); there was no mortality.

CONCLUSIONS

NUTI poses a less significant burden of illness (incidence, associated morbidity) than other nosocomial infection in children. If resources do not permit hospital-wide surveillance, high-risk children with urethral instrumentation and newborns and infants could be targeted. Although E coli remains the most common cause of pediatric NUTI, fungi have become the second most common pathogen in this tertiary care population. Risk factors for NUTI in noncatheterized children remain to be delineated.