An Ounce of Prevention Saves Tons of Lives: Infection in Burns

Prevention and Management of Wound Infections in Burn Patients

The leading cause of morbidity in burn patients is infection with pneumonia, urinary tract infection, cellulitis, and wound infection being the most common cause. High mortality is due to the immunocompromised status of patients and abundance of multidrug-resistant organisms in burn units. Despite the criteria set forth by American Association of Burn, the diagnosis and treatment of burn infections are not always straightforward. Topical antimicrobials, isolation, hygiene, and personal protective equipment are common preventive measures. Additionally medical and nutritional optimization of the patients is crucial to reverse the immunocompromised status triggered by burn injury.

Topical Antimicrobial Agents for the Prevention of Burn-Wound Infection. What Do International Guidelines Recommend? A Systematic Review

Background

Choosing adequate topical antimicrobial agents in burn patients still represents a challenge. Therefore, this systematic review was conducted to compile and evaluate current recommendations in international clinical practice guidelines (CPGs) to develop more consistent clinical guidance.

Methods

A systematic search for CPGs was conducted independently by two reviewers using PubMed, EMBASE, Google Scholar, and external citations. The quality of the selected CPGs was evaluated separately using the AGREE II instrument, and intraclass correlation coefficients were calculated. Statistical analysis was performed using R V 1.4.1 statistical software.

Results

Eleven CPGs were included in the study. Most guidelines tend to recommend silver-containing dressings over antiseptics or antibiotics, regardless of the depth of the burn. Silver sulfadiazine is the most recommended topical antimicrobial in low-resource settings. An overall mean appraisal AGREE II score of 68.2% was obtained. The global intraclass correlation coefficient was 0.62 (95% confidence intervals 0.54-0.69), which corresponds to a substantial global concordance between both appraisers.

Conclusions

Great heterogeneity was found between recommendations and CPGs. The three determining factors considered to issue a recommendation were the clinical scenario, burn-wound depth, and burn severity. There is consensus among the guidelines to use topical antimicrobials as a tool to prevent infection, and most of these recommend the use of silver-containing dressings for most scenarios. However, there is currently no ideal topical antimicrobial agent that can be recommended for all clinical scenarios. The development of more consistent recommendations is warranted to standardize clinical practice.

Satisfaction and Functional Outcome of Surgical Treatment in Patients with Brachial Plexus Injury: A Decade of Retrospective Comparative Study

Background

Brachial plexus injury (BPI) is a severe peripheral nerve injury resulting in physical disability. Few studies have investigated the postoperative functional status. We aimed to evaluate the satisfaction with surgical treatment in patients with BPI referred to the Panzdah-e Khordad Hospital, Tehran, Iran from 2011 to 2021.

Methods

In this descriptive-analytical retrospective comparative study, physical examination, along with BrAT, and DASH questionnaires were used to evaluate the patients' status. Then the collected data on the patients' functional status and movements were collected. To compare the mean of quantitative variables before and after the surgery, the dependent t-student was used.

Results

Generally, the patients stated that they still had considerable difficulty doing most of the items of the questionnaires. Nevertheless, there was a significant difference between the following variables before and after surgery; shoulder abduction goniometry (0-150) and force (M0:M5), shoulder external rotation goniometry (0-90) and force (M0:M5)), shoulder forward flexion goniometry (0-180) and force (M0:M5)), elbow flexion goniometry (0- 150), elbow extension force (M0:M5), and wrist and finger muscle force (M0:M5) (P<0.001).

Conclusion

Posterior approach in BPI surgery was associated with good outcomes in terms of shoulder external rotation and abduction. However, patients still suffered from difficulties in daily activities.

Lipid engineered nanoparticle therapy for burn wound treatment

INTRODUCTION

Skin is the largest organ of the human body protecting the underlying organs and tissues from any foreign attack. Any damage caused in the skin may sometimes result in serious consequences within the internal body tissues. Burn is one such issue that damage the layers of skin and thereby makingthe skin vulnerableand pronefor any foreign matter to enter and cause serious diseases.

METHODS

An online literature assessment was steered for the lipid nanoparticles, burn wound treatments, and different types of nanoformulation. Appropriate information was taken from different electronic scientific databases such as Web of Science, Elsevier, Science Direct, Springer, PubMed, Google Scholar etc.,Additional data was summarized from textbooks, local prints and scripts.

RESULTS

Recent innovations and developments in nanotechnology-based drug delivery systems has shown promising results in minimizing the drawbacks associated with conventional therapies. Lipid based nanoparticles possess capabilities to deliver active agents to their target site without the possibility of degradation. Conventional therapy of burn wound is costly and the treatment is long lasting, making the patient uncomfortable. Moreover, italso doesn't yield satisfactory results or narrow effects.Encapsulation of bioactives inside the lipid core protects the active entity from pH and enzymatic degradations.

CONCLUSION

This review highlights the drawbacks associated with the conventional dosage forms. A lot of consideration is focused on the advancement of nanomaterials using innovative methods in wound care for treating burn wounds with the faster healing effect.This review article highlights recent developments in lipid based nanoformulations for treatment of burn wound injury.

Contemporary Aspects of Burn Care

The past one hundred years have seen tremendous improvements in burn care, allowing for decreased morbidity and mortality of this pathology. The more prominent advancements occurred in the period spanning 1930-1980; notably burn resuscitation, early tangential excision, and use of topical antibiotic dressings; and are well documented in burn literature. This article explores the advancements of the past 40 years and the areas of burn management that are presently topics of active discussion and research.

Particulate-Aggregated Adhesives with Exudate-Sensitive Properties and Sustained Bacteria Disinfection to Facilitate Wound Healing

Wound-associated infections create additional suffering and come at a high cost for patients and their families, which urgently require wound disinfection biomaterials with improved healing efficacy. Here, we report an adhesive with sustained bacteria disinfection ability, which is aggregated from hydrogen-bonded polymer particulates. The particulate-aggregated adhesive shows strong binding ability on different surfaces from rigid substrates to soft skins. Moreover, water-sensitive mechanical properties are shown in wound exudates, resulting from the dissociation of hydrogen bonds under the competition of water and thus the sustained release of particulates. Synergizing with the strong binding ability, exudate-sensitive behaviors, and sustained release of antibacterial particulates, the adhesive achieves sustained bactericidal activity and can facilitate the healing process in bacteria-infected skin wounds.

Trends in microbial profile of burn patients following an event of dust explosion at a tertiary medical center

Background

Microbial infection is the main cause of increased morbidity and mortality in burn patients, especially infections caused by multiple drug-resistant organisms (MDRO). The purpose of this study was to explore major microbial trends in burn patients.

Methods

This retrospective study was conducted at burn wards and intensive care units, where burn patients were admitted following an event of dust explosion. Data were collected for a number of variables including severity of burns, demographic and clinical characteristics, laboratory data, and therapeutic devices.

Results

A total of 1132 specimens were collected from 37 hospitalized burn patients with mean TBSA of 46.1%.The most commonly isolated species were Staphylococcus spp. (22.4%). The highest rate of antibiotic resistance was observed in carbapenem–resistant A. baumannii (14.6%), followed by methicillin-resistant S. aureus (11.3%). For each additional 10% TBSA, the isolation of MDRO increased 2.58–17.57 times (p < 0.05); for each additional 10% of the third-degree burn severity, the risk of MDRO significantly decreased by 47% (95% CI, 0.38–0.73, p < 0.001) by Cox model.

Conclusions

The proportion of overall microbial isolates increased with the increase in TBSA and duration of time after burns. The extent of TBSA was the most important factor affecting MDRO.

Evaluation of burn wound healing activity of novel fusidic acid loaded microemulsion based gel in male Wistar albino rats

The objective of the present research was to examine the possible usage of microemulsion based gel for fusidic acid (FA) dermal application as burn wound treatment. During the preparation of microemulsion, ethyl oleate as oil phase, tween 80 as a surfactant, ethanol as co-surfactant, water as aqueous phase were used. The prepared microemulsions were evaluated for clarity, pH, viscosity and FA content. Moreover, stability, sterility, antibacterial activity, in vitro release of the formulations were also evaluated. The results showed that the FA loaded microemulsion and microemulsion based gel formation and characteristics were related to many parameters of the components. The performed optimized microemulsion-based gel showed good stability over a period of 3 months. The antibacterial activity of microemulsion-based gel was found to be comparable with marketed cream. RAW 264.7 macrophages were used to determine cell viability (MTT assay) and nitric oxide production. MBG and FA-MBG significantly inhibit the production of the inflammatory mediator NO in LPS-stimulated RAW 264.7 cells in a concentration-dependent manner. The wound healing property was evaluated by histopathological examination and by measuring the wound contraction. The % of wound area in rats treated with FA (2%) loaded microemulsion based gel ranged from 69.30% to 41.39% in the period from 3 to 10 days. In conclusion, FA loaded microemulsion based gel could be offered as encouraging strategy as dermal systems for the burn wound treatment.

Muramyl Dipeptide Enhances Thermal Injury-Induced Autophagy and Inflammatory Cytokine Response of Lungs via Activation of NOD2/Rick Signaling Pathway in Rats

OBJECTIVE

Nucleotide-binding oligomerization domain 2 (NOD2) is the innate receptor of muramyl dipeptide (MDP). Our previous study revealed that MDP could enhance thermal injury-induced inflammatory cytokine production and organ function injury in rats. The present study was to determine the effect of MDP on autophagy and NOD2/receptor-interacting serine/threonine protein kinases (RICK) signaling pathway of lung injury after thermal injury.

METHODS

Forty male Sprague-Dawlay rats were randomly divided into four groups: normal control (NC) group, MDP group, Scald group, and MDP + Scald group. Scald group only suffered 20% total body surface area third-degree (TBSA) thermal injury. MDP group was only administered 5.0 mg/kg MDP through the left femoral vein; 5.0 mg/kg MDP was administered through the left femoral vein at 24 h after thermal injury in the MDP + Scald group.

RESULTS

TBSA thermal injury (20%) not only significantly increased the plasma inflammatory cytokines production, but also elevated the expression of LC3-I/II, the accumulation of autophagosome in the lung tissue. Compared with the Scald group, MDP + Scald double hit led to more serious inflammatory responses and higher expression of NOD2 mRNA, RICK, NF-κB p65, LC3-I/II, and the accumulation of more autophagosome in the lung tissue.

CONCLUSIONS

MDP enhances thermal injury-induced autophagy and proinflammatory cytokine response of lung injury, which could be achieved via activating the NOD2/RICK signaling pathway in rats.

Incidence and mortality of healthcare-associated infections in hospitalized patients with moderate to severe burns

PURPOSE

This study was to examine the incidence of different types, and isolated pathogens, of healthcare-associated infections (HAIs), and also to determine their prognostic factors for mortality.

METHODS

Prospective surveillance was conducted in a medical center from 2005 through to 2016. Multiple logistic regression analysis was performed to assess prognostic factors of mortality.

RESULTS

A total of 709 patients with moderate to severe burns were hospitalized. There were 83 patients (11.7%) with HAIs (158 episodes) and 203 isolated pathogens. The most common HAI types were bloodstream infection (BSI) at 39.2% (8.7% of all patients) and central line-associated BSI (mean 4.8 per 1000 central line days). Overall, S. aureus (13.8%) were the most common isolated pathogens, while the most commonly found type of multidrug-resistant pathogen was carbapenems-resistant Enterobacteriaceae (23%). The crude mortality rate was 15.7%, and the independent factors (p < .05) for mortality were BSI (Odds ratio [OR] 2.70), intensive care unit (OR 5.19) and total body surface area with full-thickness injuries ≥50% (OR 5.22).

CONCLUSIONS

Burn patients with BSI were the most common HAI sites, and this was an independent factor for mortality. Effective integrated care and appropriate infection control can reduce the incidence of infection and death.

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.

Sericin hydrogels promote skin wound healing with effective regeneration of hair follicles and sebaceous glands after complete loss of epidermis and dermis

Full-thickness skin injury affects millions of people worldwide each year. It often leads to scar formation and loss of skin appendages even after clinical treatment. The majority of wound dressings currently used cannot achieve scarless skin regeneration with complete recovery of appendages such as hair follicles and sebaceous glands. Functional regeneration of these skin appendages is a great challenge. However, we achieved this goal by the successful development and utilization of a photo-crosslinkable sericin hydrogel (SMH) as a new type of wound dressing for repairing full-thickness skin injury. SMH implanted in a mouse full-thickness skin injury model promoted scarless wound healing with effective regeneration of hair follicles and sebaceous glands. By employing techniques of molecular biology, biochemistry, and in vivo cell tracing, we revealed the underlying repair mechanisms: SMH inhibited inflammation, stimulated angiogenesis during healing process, prevented scar tissue formation via regulating the expressions of TGF-β1 and TGF-β3, and recruited mesenchymal stem cells to injury sites for regeneration of skin appendages. Collectively, in this study, we developed a sericin-based hydrogel as a wound dressing for full-thickness skin injury repair, uncovered the functional roles of sericin hydrogels in promoting scarless skin regeneration along with effective recovery of skin appendages, and thus unveiled sericin's potential for skin wound healing.

Extensive colonization with carbapenemase-producing microorganisms in Romanian burn patients: infectious consequences from the Colectiv fire disaster

Health care of severe burn patients is highly specialized and may require international patient transfer. Burn patients have an increased risk of developing infections. Patients that have been hospitalized in countries where carbapenemase-producing microorganisms (CPMO) are endemic may develop infections that are difficult to treat. In addition, there is a risk on outbreaks with CPMOs in burn centers. This study underlines that burn patients may extensively be colonized with CPMOs, and it provides best practice recommendations regarding clinical microbiology and infection control. We evaluated CPMO-carriage and wound colonization in a burn patient initially treated in Romania, and transported to the Netherlands. The sequence types and acquired beta-lactamase genes of highly-resistant microorganisms were derived from next generation sequencing data. Next, we searched literature for reports on CPMOs in burn patients. Five different carbapenemase-producing isolates were cultured: two unrelated OXA-48-producing Klebsiella pneumoniae isolates, OXA-23-producing Acinetobacter baumanii, OXA-48-producing Enterobacter cloacae, and NDM-1-producing Providencia stuartii. Also, multi-drug resistant Pseudomonas aeruginosa isolates were detected. Among the sampling sites, there was high variety in CPMOs. We found 46 reports on CPMOs in burn patients. We listed the epidemiology of CPMOs by country of initial treatment, and summarized recommendations for care of these patients based on these reports and our study.

Burn injury: Challenges and advances in burn wound healing, infection, pain and scarring

Severe burn injuries are the most traumatic and physically debilitating injuries affecting nearly every organ system and leading to significant morbidity and mortality. Early burn wound excision and skin grafting are common clinical practices that have significantly improved the outcomes for severe burn injured patients by reducing mortality rate and days of hospital stay. However, slow wound healing, infection, pain, and hypertrophic scarring continue to remain a major challenge in burn research and management. In the present article, we review and discuss issues in the current treatment of burn injuries; the advances and novel strategies developed in the past decade that have improved burn management; and also, pioneer ideas and studies in burn research which aims to enhance burn wound care with a focus on burn wound infection, pain management, treatments for scarring and skin tissue engineering.