Risk factors for nosocomial infection and mortality in burn patients: 10 years of experience at a university hospital

Distribution of Nosocomial Pathogens and Antimicrobial Resistance among Patients with Burn Injuries in China: A Comprehensive Research Synopsis and Meta-Analysis

INTRODUCTION

Over the past decade, numerous studies have described the types of pathogens and their antibiotic resistance patterns in patients with burn injuries in China; however, the findings have generally been inconsistent. We conducted a literature search and meta-analysis to summarize the infection spectra and antimicrobial resistance patterns in patients with burn injuries.

METHODS

We searched the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, China Biomedical Literature, Wanfang, and Weipu databases for relevant articles published between January 2010 and December 2023. The DerSimonian-Laird random-effects model was used to estimate the proportions and 95% confidence intervals (CIs) of pathogens among Chinese patients with burn injuries. Meta-regression analyses were performed to explore differences in the proportions of pathogens among different subgroups and their resistance patterns. This study was registered with PROSPERO (CRD42024514386).

RESULTS

The database searches yielded 2017 records; after removing duplicates and conducting initial screening, 219 articles underwent full-text screening. Ultimately, 60 studies comprising a total of 62,819 isolated strains reported the proportions of pathogens in patients with burn injuries and were included in this meta-analysis. Meta-analyses were conducted on 18 types of pathogens. The most common pathogens causing infections in Chinese patients with burn injuries were Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Staphylococcus epidermidis. Similar results were observed in the subgroup analysis focusing on wound infections. Since 2015, there has been a significant decrease in the proportion of Pseudomonas aeruginosa (R2 = 4.89%) and a significant increase in the proportion of Klebsiella pneumoniae (R2 = 9.60%). In terms of antibiotic resistance, there has been a significant decrease in the resistance of Staphylococcus aureus to multiple antibiotics and an increasing trend in the resistance of Klebsiella pneumoniae.

CONCLUSIONS

We systematically summarized the epidemiological characteristics and antibiotic resistance patterns of pathogens among individuals suffering from burns in China, thus providing guidance for controlling wound infections and promoting optimal empirical antimicrobial therapy. The observed high levels of antibiotic resistance underscore the need for ongoing monitoring of antibiotic usage trends.

Impacts of intelligent monitoring technology installation and additional modalities on hand hygiene compliance in a burn center: A quasi-experimental longitudinal trial

BACKGROUND

The increasing development of intelligent technologies for hand hygiene (HH) compliance audit has the potential to create an alternative to direct observation (DO), which is still considered the gold standard but has disadvantages such as lack of standardized monitoring practices, Hawthorne effect, insufficient sample size, and time/resource consumption. We aimed to share our preliminary results on the impacts of intelligent monitoring technology installation (IMTI) and additional modalities on healthcare workers' (HCWs') HH compliance in a Burn Center, according to the "5 Moments of HH" concept defined by the World Health Organization (WHO).

METHODS

A quasi-experimental longitudinal trial was conducted over eleven months.The first phase of the three-stage study evaluated basic HH compliances obtained by DO. The system-defined HH performances, which IMTI recorded, were assessed in the second phase. Finally, the effect of IMTI and additional modalities was determined in the third stage.

RESULTS

15202 HH events were performed by 41 HCWs, and a total of 20095 HH opportunities were observed. Four hundred fifty-five opportunities were in the preinstallation phase, and 19640 were during the total post-installation period. IMTIdefined performance rates in both Phase 2 (71.2%) and Phase 3 (80.5%) were generally considerably higher than HH compliances obtained from DO (58.5%). Nurses, physical therapy /anesthesia technicians, and housekeeping personnel showed significant increases, which was insignificant in physicians in phase 2. Meanwhile, a sustained increase was observed regarding IMTI and additional modalities of HH compliance of all HCWs in Phase 3.

CONCLUSION

IMTI has significantly increased HH performance rates. Furthermore, combining the IMTI with additional modalities as components of a multimodal strategy recommended by WHO appears to affect the sustainability of the increasing trend of HCWs' HH compliance.

Acinetobacter baumannii as an oro-dental pathogen: a red alert!!

OBJECTIVES

This review highlights the existence and association of Acinetobacter baumannii with the oro-dental diseases, transforming this systemic pathogen into an oral pathogen. The review also hypothesizes possible reasons for the categorization of this pathogen as code blue due to its stealthy entry into the oral cavity.

METHODOLOGY

Study data were retrieved from various search engines reporting specifically on the association of A. baumannii in dental diseases and tray set-ups. Articles were also examined regarding obtained outcomes on A. baumannii biofilm formation, iron acquisitions, magnitude of antimicrobial resistance, and its role in the oral cancers.

RESULTS

A. baumannii is associated with the oro-dental diseases and various virulence factors attribute for the establishment and progression of oro-mucosal infections. Its presence in the oral cavity is frequent in oral microbiomes, conditions of impaired host immunity, age related illnesses, and hospitalized individuals. Many sources also contribute for its prevalence in the dental health care environment and the presence of drug resistant traits is also observed. Its association with oral cancers and oral squamous cell carcinoma is also evident.

CONCLUSIONS

The review calls for awareness on the emergence of A. baumannii in dental clinics and for the need for educational programs to monitor and control the sudden outbreaks of such virulent and resistant traits in the dental health care settings.

High-Intensity Blue Light (450-460 nm) Phototherapy for Pseudomonas aeruginosa-Infected Wounds

Background: Nosocomial wound infection with Pseudomonas aeruginosa (PA) is a serious complication often responsible for the septic mortality of burn patients. Objective: High-intensity antimicrobial blue light (aBL) treatment may represent an alternative therapy for PA infections and will be investigated in this study. Methods: Antibacterial effects of a light-emitting diode array (450-460 nm; 300 mW/cm2; 15/30 min; 270/540 J/cm2) against PA were determined by suspension assay, biofilm assay, and a human skin wound model and compared with 15-min topically applied 3% citric acid (CA) and wound irrigation solution (Prontosan®; PRT). Results: aBL reduced the bacterial number [2.51-3.56 log10 colony-forming unit (CFU)/mL], whereas PRT or CA treatment achieved a 4.64 or 6.60 log10 CFU/mL reduction in suspension assays. aBL reduced biofilm formation by 60-66%. PRT or CA treatment showed reductions by 25% or 13%. Here, aBL reduced bacterial number in biofilms (1.30-1.64 log10 CFU), but to a lower extend than PRT (2.41 log10 CFU) or CA (2.48 log10 CFU). In the wound skin model, aBL (2.21-2.33 log10 CFU) showed a bacterial reduction of the same magnitude as PRT (2.26 log10 CFU) and CA (2.30 log10 CFU). Conclusions: aBL showed a significant antibacterial efficacy against PA and biofilm formation in a short time. However, a clinical application of aBL in wound therapy requires effective active skin cooling and eye protection, which in turn may limit clinical implementation.

Analysis of the Epidemiological Features and Treatment Results of Burn Injuries in a Burn Center in Turkey

The aim of the study was to reveal the epidemiological characteristics and clinical course of burn patients who were hospitalized in our burn center between 2015 and 2020 and to compare the results between nationalities. The data were retrospectively evaluated in terms of age, gender, time of admission, the total body surface area burned, the degree of burn, the accident location, the presence of wound infection, surgical intervention, length of hospital stay, mortality, educational status of the parents, and nationality; 59.8% of 1496 cases were male, mean age was 40.38 months. The most common age range was 0-2 years. 78.4% were admitted within the first 24 hours; 50.5% of the admissions were from İzmir and its districts. Burn trauma most commonly occurred indoors in all age groups. The most common cause was scalding. Isolation of microorganism in wound cultures was most commonly detected in second degree burns. The most common infection agent was Pseudomonas aeruginosa. The surgical intervention rate was 19%. The mean length of hospitalization was 14.46 ± 12.17 days. Total burned surface, hospitalization time, the infection, and mortality rate were higher in patients who underwent surgical intervention. Parents were mostly primary school graduates. 11.6% of the patients were of foreign nationality. No significant difference was found in the analyzed parameters between nationalities. In conclusion; burn trauma is most commonly seen in the 0-2 age group, regardless of parental education levels. Therefore, it is of great importance to provide training on burns to families and those responsible for the care of children.

The Antimicrobial Efficacy of Topically Applied Mafenide Acetate, Citric Acid and Wound Irrigation Solutions Lavanox and Prontosan against Pseudomonas aeruginosa

Since burn wound infections caused by Pseudomonas aeruginosa (PA) lead to major complications and sepsis, this study evaluates the antimicrobial efficacy of the wound irrigation solutions Prontosan (PRT), Lavanox (LAV), citric acid (CA) and mafenide acetate (MA) using microbiology assays and an ex vivo skin wound model. In suspension assays, all the solutions showed significant reductions in bacterial number (log10 reduction: CA 5.77; LAV 4.91; PRT 4.74; MA 1.23). The biofilm assay revealed that PRT and LAV reduced biofilm formation by ~25% after a 15 min treatment, while PRT was most effective after a 24 h treatment (~68%). The number of PA in biofilms measured directly after a 15 min treatment was reduced most effectively with CA and LAV (log10 reductions ~2.5), whereas after a 24 h treatment, all solutions achieved only 1.36-1.65 log10 reductions. In the skin wound model, PRT and LAV provided the highest bacterial reduction after a 15 min treatment (log10 reduction 1.8-1.9), while MA was more effective after a 22 h treatment (log10 reduction 3.6). The results demonstrated the antimicrobial efficacy of all solutions against PA. Further investigation is needed to explore the potential clinical applications of a combination or alternating use of these solutions for infection prophylaxis and treatment of wound infections caused by PA.

Clinical Indications of Cultured Epithelial Autografts

ABSTRACT

Cultured epithelial autografts (CEAs) have been used for decades as a treatment for massive burn injuries. Cultured epithelial autografts allow for wounds to heal by taking a small sample and growing a patient's own epithelium in culture to create large, graftable sheets. This technique is especially useful in large wounds where donor sites are limited compared with conventional skin grafting. However, CEAs have a variety of uses in wound healing and reconstruction and have the potential to aid in the closure of several types of defects. Cultured epithelial autografts have shown applicability in large burns, chronic nonhealing wounds, ulcerating wounds of various etiologies, congenital defects, wounds requiring specialized epithelium to replace like by like, and wounds in critically ill patients. Several factors must be considered when using CEAs, such as time, cost, and outcomes. In this article, we detail the various clinical applications of CEAs and how they can be situationally advantageous outside of their original purpose.

Efficacy and optimal dose of acetic acid to treat colonised burns wounds: protocol for a pilot randomised controlled trial

INTRODUCTION

Despite of recent advancement in the burns wound management, burn wound infection (BWI) is still one of the major cause of burns mortality. Patients who survive their burns injury still suffers from BWI related complication like delayed wound healing and poor scarring. BWI has been treated by application of topical antimicrobial agents or systemic antibiotics. Due to the global risk of developing systemic antibiotics resistance, medical research focuses on identifying single topical agent which has effective antimicrobial activity, easily available and cost effective. One such agent is acetic acid (AA). AA has been used as a topical antibacterial agent for the treatment of burns wounds for many years and has shown to have activity against gram-negative organisms including Pseudomonas aeruginosa. So far there has been no consensus on optimal concentration that has effective antimicrobial activity, frequency of application, duration of treatment and most importantly good patient's tolerability. A randomised control study is required to answer all these questions.

OBJECTIVE

To investigate the efficacy and tolerability of 0.5% and 2% of AA when applied to colonised burns wounds for 3 days after admittance to the Queen Elizabeth Hospital Birmingham.

METHODS AND ANALYSIS

This is a double-blinded, prospective, randomised, controlled, single-centre trial. Patients will be screened for eligibility in the inpatient area and those who are found to be eligible will be randomly assigned to one of two treatment groups: group 1: 0.5% AA (10 patients); group 2: 2% AA (10 patients); total number: 20 patients.

OUTCOME MEASURES

Primary outcome: Efficacy will be assessed by measuring the bacterial load from microbiology wound swabs for three consecutive days.Secondary outcomes: (1) The assessment of antimicrobial activity of AA and the minimum inhibitory concentrations. (2) Patient's tolerance by assessing Visual Analogue Scale pain score. (3) Time to 95% wound healing of treatment area. (4) Patient's perceived treatment allocation.

ETHICS AND DISSEMINATION

AceticA trial protocol was approved by the National Research Ethics Service (West Midlands-Edgbaston Research Ethics Committee; 17/WM/0407; IRAS 234132). This article refers to protocol version 5.0 dated 6 July 2020. The analysed results will be presented at national and international conferences related to management of burn patients. The generated articles based on the trial results will be submitted to peer review journals for publication.

TRIAL REGISTRATION NUMBER

ISRCTN11636684.

Risk Factors and Pathogens of Wound Infection in Burn Inpatients from East China

BACKGROUND

Infection is the predominant contributor to morbidity and mortality in burn patients, and burn wound infection (BWI) is the most common reason. The objective of this research was to analyze the incidence, factors and progression of BWI, in terms of events and bacteria.

METHODS

Clinical variables of all qualified patients admitted to burn wards were analyzed retrospectively in 2021 at a tertiary hospital in eastern China through univariate analysis and multivariate logistic regression. The Kaplan-Meier method was also used for plotting survival curves. Isolates and resistance data were evaluated to demonstrate the evolution of targeted antibiotics of strains from BWI.

RESULTS

A total of 580 (median age, 39.5 years (23-56 years); 372/580 (64.14%) male) patients were evaluated, 348 (60.0%) of whom experienced BWI. A variety of factors are associated with BWI. Multivariate logistic regression analysis showed that depth and area of burn and duration from burn to first hospitalization are independent risk factors for BWI. For BWI onset in these patients, 47.24% (274/580) occurred in the first week. The most frequently isolated causative organism was Staphylococcus aureus (15.7%) in patients with BWI. The duration of transition from Gram-positive strains (median 3 days, (2-7 days)) to Gram-negative (median 10 days, (4-17 days)) ones isolated from burn wound shrunk. Hospital length of stay was considered as a protective factor for BWI.

CONCLUSION

The precise assessment of factors affecting BWI in burn patients enhances prompt and suitable management. Swab cultures for surveillance could be utilized to monitor the microbiological status of burn patients.

Multidrug-Resistant Pathogens in Burn Wound, Prevention, Diagnosis, and Therapeutic Approaches (Conventional Antimicrobials and Nanoparticles)

Multidrug-resistant pathogens are one of the common causes of death in burn patients and have a high risk of nosocomial infections, especially pneumonia, urinary tract infections, and cellulitis. The role of prolonged hospitalization and empirical antibiotics administration in developing multidrug-resistant pathogens is undeniable. In the early days of admitting burn patients, Gram-positive bacteria were the dominant isolates with a more sensitive antibiotic pattern. However, the emergence of Gram-negative bacteria that are more resistant later occurs. Trustworthy guideline administration in burn wards is one of the strategies to prevent multidrug-resistant pathogens. Also, a multidisciplinary therapeutic approach is an effective way to avoid antibiotic resistance that involves infectious disease specialists, pharmacists, and burn surgeons. However, the emerging resistance to conventional antimicrobial approaches (such as systemic antibiotic exposure, traditional wound dressing, and topical antibiotic ointments) among burn patients has challenged the treatment of multidrug-resistant infections, and using nanoparticles is a suitable alternative. In this review article, we will discuss different aspects of multidrug-resistant pathogens in burn wounds, emphasizing the full role of these pathogens in burn wounds and discussing the application of nanotechnology in dealing with them. Also, some advances in various types of nanomaterials, including metallic nanoparticles, liposomes, hydrogels, carbon quantum dots, and solid lipid nanoparticles in burn wound healing, will be explained.

Etiology and Multi-Drug Resistant Profile of Bacterial Infections in Severe Burn Patients, Romania 2018-2022

Infections in severe burns and their etiology are and will remain a big concern for the medical field. The multi-drug resistant strains of bacteria are a challenge of today's medicine. The aim of our study was to identify the etiological spectrum of bacterial infections in severe burn patients in Romania and their multi-drug resistant patterns. We performed a prospective study that included 202 adult patients admitted to the intensive care unit (ICU) of the Clinical Emergency Hospital of Plastic, Reconstructive Surgery and Burns, Bucharest, Romania (CEHPRSB), from 1 October 2018 to 1 April 2022, a period which includes the first 2 years of the outbreak of COVID-19. From each patient, wound swabs, endotracheal aspirates, blood for blood culture, and urine were collected. The most frequently isolated bacterium was Pseudomonas aeruginosa (39%), followed by Staphylococcus aureus (12%), Klebsiella spp. (11%), and Acinetobacter baumannii (9%). More than 90% of Pseudomonas aeruginosa and Acinetobacter baumannii were MDR, regardless of the clinical specimen from which they were isolated.

A PREVENTIVE TOOL FOR PREDICTING BLOODSTREAM INFECTIONS IN CHILDREN WITH BURNS

ABSTRACT

Introduction: Despite significant advances in pediatric burn care, bloodstream infections (BSIs) remain a compelling challenge during recovery. A personalized medicine approach for accurate prediction of BSIs before they occur would contribute to prevention efforts and improve patient outcomes. Methods: We analyzed the blood transcriptome of severely burned (total burn surface area [TBSA] ≥20%) patients in the multicenter Inflammation and Host Response to Injury ("Glue Grant") cohort. Our study included 82 pediatric (aged <16 years) patients, with blood samples at least 3 days before the observed BSI episode. We applied the least absolute shrinkage and selection operator (LASSO) machine-learning algorithm to select a panel of biomarkers predictive of BSI outcome. Results: We developed a panel of 10 probe sets corresponding to six annotated genes ( ARG2 [ arginase 2 ], CPT1A [ carnitine palmitoyltransferase 1A ], FYB [ FYN binding protein ], ITCH [ itchy E3 ubiquitin protein ligase ], MACF1 [ microtubule actin crosslinking factor 1 ], and SSH2 [ slingshot protein phosphatase 2 ]), two uncharacterized ( LOC101928635 , LOC101929599 ), and two unannotated regions. Our multibiomarker panel model yielded highly accurate prediction (area under the receiver operating characteristic curve, 0.938; 95% confidence interval [CI], 0.881-0.981) compared with models with TBSA (0.708; 95% CI, 0.588-0.824) or TBSA and inhalation injury status (0.792; 95% CI, 0.676-0.892). A model combining the multibiomarker panel with TBSA and inhalation injury status further improved prediction (0.978; 95% CI, 0.941-1.000). Conclusions: The multibiomarker panel model yielded a highly accurate prediction of BSIs before their onset. Knowing patients' risk profile early will guide clinicians to take rapid preventive measures for limiting infections, promote antibiotic stewardship that may aid in alleviating the current antibiotic resistance crisis, shorten hospital length of stay and burden on health care resources, reduce health care costs, and significantly improve patients' outcomes. In addition, the biomarkers' identity and molecular functions may contribute to developing novel preventive interventions.

Epidemiology and Early Bacteriology of Extremely Severe Burns from an LPG Tanker Explosion in Eastern China

The incidence of liquefied petroleum gas (LPG)-related accidents in China has increased over the recent years. In addition, infection remains a big challenge in cases of severe burns. Therefore, the present study aimed to provide valuable information for a better control of infections in the event of such disasters. In this study, a total of 16 patients who suffered extremely severe burns after an LPG tanker explosion were included. Thereafter, bacteriological culture results were collected within a week. Of 16 patients, 13 (81.25%) were male and the average age of all patients was 60.63 years. In addition, the mean burned area was 83.03% TBSA. Additionally, a total of 553 organism cultures were conducted out of which 287 isolates (51.90%) showed positive results. Notably, 38.52% were Gram-negative bacteria, 7.59% were Gram-positive bacteria and 5.79% were fungi. Moreover, the most prevalent Gram-negative bacteria were Stenotrophomonas maltophilia (28.97%) followed by Acinetobacter baumannii (28.53%), and Klebsiella pneumoniae (14.02%). On the other hand, the three most predominant Gram-positive bacteria were Enterococcus faecalis (33.33%), Staphylococcus aureus (28.89%) and Staphylococcus sciuri (17.78%). Furthermore, the most common fungi included Candida (38.24%), Fusarium (20.59%) and Aspergillus fumigatus (14.71%). With regard to the bacterial resistance patterns, carbapenem-resistant organisms included Acinetobacter baumannii (97.80%), Pseudomonas aeruginosa (67.57%), and Klebsiella pneumoniae (75.56%). In addition, Staphylococcus sciuri, Staphylococcus epidermidis, and Staphylococcus haemolyticus were identified to be methicillin-resistant. This study revealed that there was a high incidence of infection in victims of severe burns as a result of mass burn accidents, accompanied by early fungal infection.

Outbreak of Carbapenemase-Producing Enterobacteriaceae in a Regional Burn Center

Antimicrobial resistance is an increasing problem in hospitals worldwide; however, the prevalence of carbapenemase-producing Enterobacteriaceae (CPE) in our region is low. Burn patients are vulnerable to infection because of the loss of the protective skin barrier, thus burn centers prioritize infection prevention and control (IP&C). This report describes a CPE outbreak in a regional burn center. In a period of 2.5 months, four nosocomial cases of CPE were identified, three containing the Klebsiella pneumoniae carbapenemase (KPC) gene and one Verona integrin-encoded metallo-β-lactamase (VIM) gene. The first two cases were identified while there was no CPE patient source on the unit. CPE KPC gene was then isolated in sink drains of three rooms. In addition to rigorous IP&C practices already in place, we implemented additional outbreak measures including restricting admissions to patients with complex burns or burns ≥10% TBSA, admitting patients to other in-patient units, and not permitting elective admissions. We began cohorting patients using nursing team separation for CPE-positive and -negative patients and geographical separation on the unit. Despite aggressive IP&C measures already in place, hospital-acquired CPE colonization/infection occurred. Given that CPE contaminated sinks of the same enzyme were identified, we believe hospital sink drains may the source. This highlights the importance of sink design and engineering solutions to prevent the formation of biofilm and reduce splashing. CPE infections are associated with poor outcomes in patients and significant health system costs due to a longer length of stay and additional institutional resources.

A Nonlethal Full-Thickness Flame Burn Produces a Seroma Beneath the Forming Eschar, Thereby Promoting Pseudomonas aeruginosa Sepsis in Mice

The World Health Organization estimates ~180,000 deaths occur annually from burn-related injuries. Many victims who survive the initial burn trauma succumb to bacterial infections that lead to sepsis during treatment. Although advancements in burn care continue to improve in high-income countries due to their burn centers and advanced research, low and middle-income countries continue to see high frequencies of burn injuries and burn-related deaths due to secondary infections. Bacterial-derived sepsis is the most life-threatening danger for people that survive burn injuries. Here we provide evidence for the first time that a subeschar seroma forms postburn even in the absence of infection in mice. The seroma fills with a volume estimated at 500 µL of fluid, 25% of the blood supply, free of red blood cells. The seroma fluid supports robust Pseudomonas aeruginosa (PA) growth and contains inflammatory cytokines and chemokines, which recruit immature neutrophils and monocytes to the seroma in the absence of endothelial breakdown. These immune cells fail to contain PA expansion and dissemination. This recruitment of monocytes and immature neutrophils may result in sequestering these critical immune cells away from other tissues during a pivotal time during bacterial dissemination, promoting PA-mediated sepsis.

Colistin Therapy, Survival and Renal Replacement Therapy in Burn Patients: A 10-Year Single-Center Cohort Study

Purpose

Patients and Methods

Results

Conclusion

AB569, a Novel, Topical Bactericidal Gel Formulation, Kills Pseudomonas aeruginosa and Promotes Wound Healing in a Murine Model of Burn Wound Infection

Cutaneous thermal injuries from burns/explosives are a major cause of morbidity and mortality and represent a monumental burden on our current health care system. Injury severity is predominantly due to potentially lethal sepsis caused by multidrug-resistant (MDR) bacteria such as Pseudomonas aeruginosa (MDR-PA). Thus, there is a critical need to develop novel and effective antimicrobials for the (i) prevention, (ii) treatment, and (iii) healing of such wounds that are complicated by MDR-P. aeruginosa and other bacterial infections. AB569 is a novel bactericidal tandem consisting of acidified NaNO₂ (A-NO_2-) and Na₂-EDTA. Here, we first show that AB569 acts synergistically to kill all human burn wound strains of P. aeruginosa in vitro. This was found to be due, in part, to the generation of A-NO_2--mediated nitric oxide (NO) formation coupled with the metal chelating properties of Na₂-EDTA. Using a murine scald burn wound model of P. aeruginosa infection, an AB569-Solosite gel formulation eradicated all bacteria. Futher, we also demonstrate enhanced AB569-mediated wound healing by not only accelerating wound contraction, but also by reducing levels of the proinflammatory cytokines interleukin-6 (IL-6) and IL-1β while increasing the levels of anti-inflammatory cytokine, IL-10, and granulocyte-colony-stimulating factor (G-CSF). We also observed better epidermal restoration in AB569-treated wounds. Taken together, we conclude that this study provides solid foundational evidence that AB569 can be used topically to treat highly problematic dermal insults, including wound, burn, blast, and likely, diabetic infections in civilian and military populations, and help relieve the economical burden that MDR organisms have on the global health care system.

Gut Microbial Changes and their Contribution to Post-Burn Pathology

ABSTRACT

Burn injuries are a common form of traumatic injury that leads to significant morbidity and mortality worldwide. Burn injuries are characterized by inflammatory processes and alterations in numerous organ systems and functions. Recently, it has become apparent that the gastrointestinal bacterial microbiome is a key component of regulating the immune response and recovery from burn and can also contribute to significant detrimental sequelae after injury, such as sepsis and multiple organ failure. Microbial dysbiosis has been linked to multiple disease states; however, its role in exacerbating acute traumatic injuries, such as burn, is poorly understood. In this article, we review studies that document changes in the intestinal microbiome after burn injury, assess the implications in post-burn pathogenesis, and the potential for further discovery and research.

In vivo evaluation of a recombinant N-acylhomoserine lactonase formulated in a hydrogel using a murine model infected with MDR Pseudomonas aeruginosa clinical isolate, CCASUP2

Failure in the treatment of P. aeruginosa, due to its broad spectrum of resistance, has been associated with increased patient mortality. One alternative approach for infection control is quorum quenching which was found to decrease virulence of such pathogen. In this study, the efficiency of a recombinant Ahl-1 lactonase formulated as a hydrogel was investigated to control the infection of multidrug resistant (MDR) P. aeruginosa infected burn using a murine model. The recombinant N-acylhomoserine lactonase (Ahl-1) was formulated as a hydrogel. To test its ability to control the infection of MDR P. aeruginosa, a thermal injury model was used. Survival rate, and systemic spread of the infection were evaluated. Histopathological examination of the animal dorsal skin was also done for monitoring the healing and cellular changes at the site of infection. Survival rate in the treated group was 100% relative to 40% in the control group. A decrease of up to 3 logs of bacterial count in the blood samples of the treated animals relative to the control group and a decrease of up to 4 logs and 2.3 logs of bacteria in lung and liver samples, respectively were observed. Histopathological examination revealed more enhanced healing process in the treated group. Accordingly, by promoting healing of infected MDR P. aeruginosa burn and by reducing systemic spread of the infection as well as decreasing mortality rate, Ahl-1 hydrogel application is a promising strategy that can be used to combat and control P. aeruginosa burn infections.

The Impact of Multidrug-Resistant Organisms Infection on Outcomes in Burn Injury Patients at Sanglah General Hospital, Bali

BACKGROUND: Research related to the impact of multidrug resistant organisms (MDRO) infection on clinical outcomes in burns is still limited. AIM: This study evaluated the effect of MDRO infection on morbidity and mortality of burn patients. METHODS: A single-center retrospective cohort study was conducted on burn patients admitted to the burn unit of Sanglah General Hospital, Bali, between 2018 and 2020. MDRO patients were described as those who had at least one positive MDRO culture. All other patients were included in the non-MDRO group. Measurement and analysis included mortality and five indicators of morbidity: length of stay, duration of antibiotic therapy, sepsis, pneumonia, and acute kidney injury (AKI). RESULTS: Significant associations of MDRO infection were found for duration of antibiotic therapy (0 vs. 7 days), sepsis (odds ratio [OR] 13.90 [95% Confidence interval (CI) 95% 2.88–67.10]), pneumonia (OR 12,67 [95% CI 3.26–49.23]), and mortality (OR 9.75 [95% CI 2.00–47.50]). No significant association was found for the length of stay and the incidence of AKI. Multivariate analysis found that MDRO infection increased risk of sepsis (OR 36.53 [95% CI 2.05–652.45], pneumonia (OR 10.75 [95% CI 1.87–61.86]) and mortality (OR 57.09 [95% CI 1.41–2318.87]). Multivariate analysis of MDRO infection with duration of antibiotic therapy found no independent variables that were significantly related. CONCLUSION: These research findings suggest that MDRO infections are associated with increasing length of antibiotic treatment, sepsis, pneumonia, and mortality in burn patients.

Factors related to the composition and diversity of wound microbiota investigated using culture-independent molecular methods: a scoping review

All open wounds are often colonized by commensal microbes as a loss of skin can provide a ready portal of entry for microorganisms. Although the wound microbiota is known to be associated with wound infection and with delayed healing, the factors related to the formations of wound microbiota contributing to such poor clinical outcomes are not clear and have not led to effective infection prevention interventions. This review aimed to scope the factors related to the composition and diversity of wound microbiota that have been investigated using culture-independent molecular methods. Original articles on wound microbiota published from January 1986 to February 2020 were included in this review. Thirty-one articles met the inclusion criteria and were grouped according to wound types: chronic, acute, and animal model wounds. The factors identified were categorized according to patient characteristics, wound characteristics, treatment, and sampling. Although some studies reported the effect size of the factors, the values were small. No studies elucidated the mechanism of wound microbiota formation. The results of this scoping review highlight that the factors associated with the diversity of wound microbiota are poorly understood and that further studies are needed.

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.

Use of ovine acellular peritoneal matrix combined with honey and ovine fetal skin extract in the healing of full-thickness infected burn wounds in a rat model

Treatment of infected burn wounds remains a challenge in burn units. Silver-sulfadiazine (SSD) is the most commonly used topical antimicrobial agent in managing these wounds. We aimed to accelerate the healing of burn wounds by combined application of ovine acellular peritoneal matrix (OAPM), honey (H), and ovine fetal skin extract (OFSE). Sixty-four standardized burn wounds were created on the dorsum of 16 rats and were subsequently inoculated with Staphyloccocus aureus and Pseudomonas aeruginosa. After 48 hr, the wounds were surgically debrided and received either physiologic saline (control group) or SSD, OAPM+SSD, OAPM+H+SSD, and OAPM+H+OFSE+SSD. The healing wounds were evaluated for size, bacterial counts, histopathology, and biomechanical properties on days 3, 7, 14, 21, and 28 after surgery. All treatments had effectively reduced the level of S. aureus and P. aeruginosa on wounds compared to the control group by day 3 and 7. The wounds treated with combined application of OAPM+H+OFSE+SSD demonstrated considerable inflammation reduction, fibroplasia, complete re-epithelialization, and wound contraction together with significantly lesser scar tissue formation. Treatment with OAPM+H+OFSE+SSD showed superior biomechanical properties of the healing wounds. The findings suggested that the synergistic effect of dressing the wounds with OAPM, H, and OFSE was a very effective approach in accelerating the healing process of the experimentally induced infected full-thickness burn wounds in rats.

Weaning of Children With Burn Injury by Noninvasive Ventilation: A Clinical Experience

The aim of this study was to report the respiratory management of a cohort of infants admitted to a Pediatric Intensive Care Unit (PICU) over a 7-year period due to severe burn injury and the potential benefits of noninvasive ventilation (NIV). A retrospective review of all pediatric patients admitted to PICU between 2009 and 2016 was conducted. From 2009 to 2016, 118 infants and children with burn injury were admitted to our institution (median age 16 months [IQR = 12.2-20]); 51.7% of them had face burns, 37.3% underwent tracheal intubation, and 30.5% had a PICU stay greater than 7 days. Ventilated patients had a longer PICU stay (13 days [IQR = 8-26] vs 4.5 days [IQR = 2-13]). Both ventilation requirement and TBSA% correlated with PICU stay (r = .955, p < .0001 and r = .335, p = .002, respectively), while ventilation was best related in those >1 week (r = .964, p < .0001 for ventilation, and r = -.079, p = .680, for TBSA%). NIV was introduced in 10 patients, with the aim of shorten the invasive ventilation requirement. As evidenced in our work, mechanical ventilation is frequently needed in burned children admitted to PICU and it is one of the main factors influencing PICU length of stay. No difference was found in terms of PICU length of stay and invasive mechanical ventilation time between children who underwent NIV and children who did not, despite children who underwent NIV had a larger burn surface. NIV can possibly shorten the total invasive ventilation time and related complications.

The Safety and Efficacy of Phage Therapy for Superficial Bacterial Infections: A Systematic Review

Superficial bacterial infections, such as dermatological, burn wound and chronic wound/ulcer infections, place great human and financial burdens on health systems globally and are often complicated by antibiotic resistance. Bacteriophage (phage) therapy is a promising alternative antimicrobial strategy with a 100-year history of successful application. Here, we report a systematic review of the safety and efficacy of phage therapy for the treatment of superficial bacterial infections. Three electronic databases were systematically searched for articles that reported primary data about human phage therapy for dermatological, burn wound or chronic wound/ulcer infections secondary to commonly causative bacteria. Two authors independently assessed study eligibility and performed data extraction. Of the 27 eligible reports, eight contained data on burn wound infection (n = 156), 12 on chronic wound/ulcer infection (n = 327) and 10 on dermatological infections (n = 1096). Cautionary pooled efficacy estimates from the studies that clearly reported efficacy data showed clinical resolution or improvement in 77.5% (n = 111) of burn wound infections, 86.1% (n = 310) of chronic wound/ulcer infections and 94.14% (n = 734) of dermatological infections. Over half of the reports that commented on safety (n = 8/15), all published in or after 2002, did not express safety concerns. Seven early reports (1929-1987), described adverse effects consistent with the administration of raw phage lysate and co-administered bacterial debris or broth. This review strongly suggests that the use of purified phage to treat superficial bacterial infections can be highly effective and, by various routes of administration, is safe and without adverse effects.

Microbiome in the setting of burn patients: implications for infections and clinical outcomes

Burn damage can lead to a state of immune dysregulation that facilitates the development of infections in patients. The most deleterious impact of this dysfunction is the loss of the skin’s natural protective barrier. Furthermore, the risk of infection is exacerbated by protracted hospitalization, urinary catheters, endotracheal intubation, inhalation injury, arterial lines and central venous access, among other mainstays of burn care. Currently, infections comprise the leading cause of mortality after major burn injuries, which highlights the improvements observed over the last 50 years in the care provided to burn victims. The need to implement the empirical selection of antibiotic therapy to treat multidrug-resistant bacteria may concomitantly lead to an overall pervasiveness of difficult-to-treat pathogens in burn centres, as well as the propagation of antimicrobial resistance and the ultimate dysregulation of a healthy microbiome. While preliminary studies are examining the variability and evolution of human and mice microbiota, both during the early and late phase burn injury, one must consider that abnormal microbiome conditions could influence the systemic inflammatory response. A better understanding of the changes in the post-burn microbiome might be useful to interpret the provenance and subsequent development of infections, as well as to come up with inferences on the prognosis of burn patients. This review aims to summarise the current findings describing the microbiological changes in different organs and systems of burn patients and how these alterations affect the risks of infections, complications, and, ultimately, healing.

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.

Epidemiology, prevalence and risk factors for infections in burn patients: results from a regional burn centre's analysis

Burn patients are at high risk of infections due to severe impairment of immunity and loss of skin barrier function. We aimed to describe the epidemiology, incidence and risk factors for infection in a cohort of burns patients. Two hundred patients were retrospectively enrolled and subdivided into infected (N = 81) and uninfected groups (N = 119). The cumulative prevalence of infections was 27% on day 7 and 43.8% on day 28. Skin and soft tissue infections (32%) were the most frequent. Carbapenem-resistant Acinetobacter baumannii (28%), Pseudomonas aeruginosa (26%) and methicillin-resistant Staphylococcus aureus (25%) infections were most prevalent. An indwelling central venous catheter (CVC; sub-hazard ratio [SHR] 7.41, 95% confidence interval [CI] 3.78-14.62) and revised Baux score (RBS; SHR 2.08, 95% CI 0.98-4.42) were associated with higher incremental infection rate while surgical treatment resulted in a protective factor (SHR 0.45, 95% CI 0.29-0.75). RBS may be useful to stratify the infection risk: a strict collaboration between surgeons and infectious disease specialists is needed to implement source control and antimicrobial surveillance.

Three Year Study of Infection Profile and Antimicrobial Resistance Pattern from Burn Patients in Southwest Iran

Introduction

Burn wound infections, as one of the most important risk factors, cause serious complications in burns. Hence, the focus of medical care should be preventing infections and resistant isolates. The current study investigates the prevalence of infectious agents and antimicrobial resistance patterns during three years.

Materials and Methods

A total of 960 isolates were collected from different sample kinds cultured for 615 burn patients who were hospitalized during January 2016 to December 2018 in Amir-Al-Momenin Burn Center. The type of microorganism and their antibiotic resistance patterns were identified by microbiological tests and the standard disk-diffusion method according to the introduced standard techniques.

Results

Incidence of positive growth was seen more in males than in females. Most of the burns encountered were due to flame injuries (35.4%). Based on the diversity of bacterial isolates, Pseudomonas aeruginosa was the most frequent pathogen (49.9%), followed by Klebsiella sp. (9.7%), Acinetobacter sp. (7.2%) and Staphylococcus aureus (6.5%). The trend of resistance of meropenem was declining in P. aeruginosa isolates. Klebsiella sp. as the second most prevalent agent showed a high level of resistance to the studied antibiotics. The antibiogram results for S. aureus isolates showed an increasing trend in MRSA isolates.

Conclusion

By evaluating the infectious agent, it was found that although frequencies of microorganisms and resistant isolates were a little high, performing a multidisciplinary approach controls the trend during the study period. These achievements have been gained due to a strict politicized infection control and stewardship program in the appointed burn center.

Bacterial infection profile and predictors among patients admitted to a burn care center: A retrospective study

BACKGROUND

Infection is the main cause of mortality and complications in burn patients. The present study was the first to examine the local profile and antecedents of bacterial infections among patients admitted to a Lebanese burn care center.

METHODS

The present study was a retrospective analysis of the occurrence and recurrence of infection, its characteristics as well as antimicrobial susceptibility among 475 patients admitted to the Burn Centre at the Lebanese Geitaoui Hospital between January 2014 and December 2018.

RESULTS

55% of patients contracted at least one infection during their hospitalization. Length of stay (LOS), sepsis, wound dressing under anesthesia, blood transfusion and female sex independently and positively predicted infection in burn patients. Infection was predominately caused by Staphylococcus aureus (48.7%), followed by Pseudomonas aeruginosa (22.6%) and Acinetobacter baumannii (15.7%). Bacterial isolates were predominately multi-drug or extensively drug resistant and showed variable antimicrobial susceptibility patterns. Recurrent infections occurred in 44.1% of infected burn patients, and were independently predicted by LOS (p = 0.004), sepsis (p = 0.001), surgery (p = 0.003), burn excision and skin grafting (p = 0.019), and central line insertion (p = 0.004).

CONCLUSION

Existing burn management and infection control measures must be revised in order to reduce the incidence and improve the treatment of infections in burn patients.

An overview of healthcare-associated infections in a tertiary care hospital in Egypt

Background

Healthcare-associated infection (HAI) is a major problem in healthcare facilities and is associated with increased morbidity and mortality and prolonged hospital stay. This study aims to determine the incidence rate, risk factors, and bacterial aetiology of HAI in a tertiary care hospital in Mansoura, Egypt.

Methods

This is a prospective observational study carried out over 12 months in different departments of Mansoura New General Hospital (MNGH). Data were collected from patient's records and laboratory results of the ongoing HAI surveillance program.

Results

The incidence of HAI was 3.7% among 6912 patients studied. The independent predictors of HAI were multiple devices (AOR=88.1), central venous catheter (CVC) (AOR=34), urinary catheter (AOR=28.9) and length of stay >20 days (AOR=3.1). Surgical site infections (SSI) were the most frequent (24%) followed by catheter associated urinary tract infections (CAUTI) (20%). The most frequently isolated pathogens were Klebsiella spp. (27.2%), and E. coli (18%).

Conclusions

HAI is a significant problem in MNGH. Klebsiella spp. were the predominant causative organisms of HAI, as has been described in other studies from developing countries.

Prevalence and prognostic impact of inhalation injury among burn patients: A systematic review and meta-analysis

BACKGROUND

The objective of our study was to perform a systematic review and meta-analysis aimed at assessing the prevalence of inhalation injury in burn patients and its prognostic value in relation to in-hospital mortality.

METHODS

We searched the PubMed and EMBASE databases for noninterventional studies published between 1990 and 2018 investigating in-hospital mortality predictors among burn patients.The primary meta-analysis evaluated the association between inhalation injury and mortality. A secondary meta-analysis determined the global estimate of the prevalence of inhalation injury and the rate of mortality. Random effects models were used, and univariate meta-regressions were used to assess sources of heterogeneity. This study is registered in the PROSPERO database with code CRD42019127356.

FINDINGS

Fifty-four studies including a total of 408,157 patients were selected for the analysis. A pooled inhalation prevalence of 15.7% (95% confidence interval, 13.4%-18.3%) was calculated.The summarized odds ratio of in-hospital mortality secondary to an inhalation injury was 3.2 (95% confidence interval, 2.5-4.3). A significantly higher odd of mortality was found among the studies that included all hospitalized burn patients, those that included a lower proportion of male patients, those with a lower mean total body surface area, and those with a lower prevalence of inhalation injury.

CONCLUSION

Despite our study's limitations due to the high risk of bias and the interstudy heterogeneity of some of our analyses, our results revealed a wide range of prevalence rates of inhalation injury and a significant association between this entity and in-hospital mortality in burn patients. However, this association is not significant if adjusted for disease severity.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.

Implications of chlorhexidine use in burn units for wound healing

Chlorhexidine is known to be a potent antiseptic with evidence of a beneficial role in burn care. Nevertheless, several in vitro studies have reported cytotoxicity on cultured cells, while in vivo and clinical data seem to show more controversial results. In the frame of this work, we aimed to evaluate the use of chlorhexidine in burn units worldwide be sending a survey to professionals of the field. We associated survey results to those perspectives reported in the literature to update recommendations for the use of chlorhexidine in specific protocols for burn management. The survey results showed that there is no clear consensus on the use of chlorhexidine regarding the concentrations, the type of excipient and the cleansing after application. Literature searches showed evidence that the skin of premature infants appears to be more sensitive to chlorhexidine that adult skin, with more reported cases of adverse effects. It was also determined that aqueous formulations of chlorhexidine do not appear to be necessarily less efficient than with alcohol as an excipient, and that lower concentrations are as efficient as higher concentrations. In view of this study, we have adjusted our protocols for the use of aqueous formulations at low concentrations and investigated further the role of washing after application in order to standardize the indication of chlorhexidine and minimize the probability of adverse effects.

Infections in Pediatric Burn Patients: An Analysis of One Hundred Eighty-One Patients

Background: Infectious complications are one of the most life-threatening complications and result in substantial mortality and morbidity in children who have been burned. The goal of the study is to assess the risk factors for sepsis in pediatric burn patients in a referral hospital. Methods: This study was performed at the Pediatric Burn Unit of Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital during the period between January 2014 and June 2017. The patients were evaluated for age, sex, burn etiology, burned body surface area (BSA), the presence of inhalation injury, sepsis, positive cultures, the micro-organisms cultured samples, and septic focus. Results: A total of 181 patients were included in the study. The most common cause of burns was scalds in 120 patients (66.3%). Forty-one patients (22.7%) developed health-care-associated infection and sepsis. Gram-negative micro-organisms were isolated in 40 (97.6%) patients (Acinetobacter spp., Pseudomonas aeruginosa, Klebsiella pneumonia) with sepsis. Carbapenem resistance was detected in 31 (93.8%) of 40 patients. Mortality was observed in 11 patients (6.1%) in the group with sepsis. Burn surface area, burn depth, C-reactive protein (CRP) values, mortality, Garcés index, and Baux index were higher in the group with sepsis (p < 0.05). Multiple regression analysis revealed that mechanism of injury (flame), burned BSA ≥25%, C-reactive protein ≥6 mg/dL (area under the curve [AUC]: 0.76 p < 0.001 and AUC: 0.90, p < 0.001, respectively) at admission were independent parameters for development of sepsis in pediatric burn patients. Conclusion: Multi-drug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii were important agents of blood stream infection in burned children. Burned BSA ≥25% and CRP ≥6 mg/dL were risk factors for developing sepsis in pediatric burn patients.

Modifiable risk factors for multidrug-resistant Gram-negative infection in critically ill burn patients: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis to identify potentially modifiable risk factors for multidrug-resistant Gram-negative colonization or infection in critically ill burn patients.

METHODS

A systematic search was conducted of PubMed, Embase, CINAHL, Web of Science and Central (Cochrane). Risk factors including antibiotic use and hospital interventions were summarized in a random-effects meta-analysis. Risk of publication bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation method and funnel plots.

RESULTS

A total of 11 studies met the inclusion criteria. We identified several potentially modifiable risk factors and were able to grade their importance based on effect size. Related to prior antibiotic exposure, extended-spectrum cephalosporins (pooled odds ratio (OR) 7.00, 95% confidence interval (CI) 2.77-17.67), carbapenems (pooled OR 6.65, 95% CI 3.49-12.69), anti-pseudomonal penicillins (pooled OR 4.23, 95% CI 1.23-14.61) and aminoglycosides (pooled OR 4.20, 95% CI 2.10-8.39) were most significant. Related to hospital intervention, urinary catheters (pooled OR 11.76, 95% CI 5.03-27.51), arterial catheters (pooled OR 8.99, 95% CI 3.84-21.04), mechanical ventilation (pooled OR 5.49, 95% CI 2.59-11.63), central venous catheters (pooled OR 4.26, 95% CI 1.03-17.59), transfusion or blood product administration (pooled OR 4.19, 95% CI 1.48-11.89) and hydrotherapy (pooled OR 3.29, 95% CI 1.64-6.63) were most significant.

CONCLUSION

Prior exposure to extended-spectrum cephalosporins and carbapenems, as well as the use of urinary catheters and arterial catheters pose the greatest threat for infection or colonization with multidrug-resistant Gram-negative organisms in the critically ill burn patient population.

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.

Predictors of mortality in cases of thermal burns admitted to Burn Unit, Ain Shams University Hospitals, Cairo

In cases of death due to burn injury, it may be of great medico-legal importance to determine if the death is caused by fatal burn injury or due to other factors related to treatment. Therefore, this study aimed to investigate early predictors of mortality in patients with thermal burns admitted to Burn Unit, Ain Shams University Hospitals during a period of one year (2011). The study included 152 cases, mortalities represented 20.4% of the included cases (31 cases). Binary logistic regression analysis showed that, total body surface area (TBSA) of the burns and APACHE III score were significant predictors of mortality. This model resulted in accurate classification of 95.9% of the cases. Further multi-centric studies on larger sample sizes are recommended to validate the results of this study. Also, it is important to study the effect of co-morbidities as confounding factors on the prediction of mortality in patients with thermal burns.

Targeting bacterial quorum sensing shows promise in improving intestinal barrier function following burn‑site infection

Burn-site infections, commonly due to Pseudomonas aeruginosa, have been associated with deranged intestinal integrity, allowing bacteria and their products to translocate from the gut to the circulatory system. The P. aeruginosa quorum sensing (QS) transcription factor MvfR (PqsR) controls the expression of numerous virulence factors, and the synthesis of several toxic products. However, the role of QS in intestinal integrity alterations, to the best of our knowledge, has not been previously investigated. Using a proven anti-MvfR, anti-virulence agent, the in vivo results of the present study revealed that inhibition of MvfR function significantly decreased Fluorescein Isothiocyanate-Dextran (FITC-Dextran) flow from the intestine to the systemic circulation, diminished bacterial translocation from the intestine to mesenteric lymph nodes (MLNs), and improved tight junction integrity in thermally injured and infected mice. In addition, the MvfR antagonist administration alleviates the intestinal inflammation, as demonstrated by reduced ileal TNF-α and fecal lipocalin-2 concentrations. In addition, it is associated with lower levels of circulating endotoxin and decreased P. aeruginosa dissemination from the burn wound to the ileum. Collectively, these results hold great promise that the inhibition of this QS system mitigates gut hyperpermeability by attenuating the derangement of morphological and immune aspects of the intestinal barrier, suggesting that MvfR function is crucial in the deterioration of intestinal integrity following P. aeruginosa burn-site infection. Therefore, an anti-virulence approach targeting MvfR, could potentially offer a novel therapeutic approach against multi-drug resistant P. aeruginosa infections following thermal injuries. Since this approach is targeting virulence pathways that are non-essential for growth or viability, our strategy is hypothesized to minimize the development of bacterial resistance, and preserve the beneficial enteric microbes, while improving intestinal integrity that is deranged as a result of burn and infection.

Using competing risk and multistate model to estimate the impact of nosocomial infection on length of stay and mortality in burn patients in Southeast China

OBJECTIVE

Due to the defects in skin barrier function and immune response, burn patients who survive the acute phase of a burn injury are at a high risk of nosocomial infection (NI). The aim of this study is to evaluate the impacts of NI on length of stay (LOS) and hospital mortality in burn patients using a multistate model.

DESIGN AND SETTING

A retrospective observational study was conducted in burn unit and intensive care unit in the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.

PARTICIPANTS

Data were obtained from 1143 records of patients admitted with burn between 1 January 2013 and 31 December 2016.

METHODS

Risk factors for NIs were determined by binary logistic regression. The extended Cox model with time-varying covariates was used to determine the impact of NIs on hospital mortality, and cumulative incidence functions were calculated. Multiple linear regression analysis was applied to detect the variables associated with LOS. Using a multistate model, the extra LOS due to NI were determined.

RESULTS

15.8% of total burn patients suffered from NIs and incidence density of NIs was 9.6 per 1000 patient-days. NIs significantly increased the rate of death (HR 4.266, 95% CI 2.218 to 8.208, p=0.000). The cumulative probability of death for patients with NI was greater that for those without NI. The extra LOS due to NIs was 17.68 days (95% CI 11.31 to 24.05).

CONCLUSIONS

Using appropriate statistical methods, the present study further illustrated that NIs were associated with the increased cumulative incidence of burn death and increased LOS in burn patients.

Bacterial Infections After Burn Injuries: Impact of Multidrug Resistance

Patients who are admitted to the hospital after sustaining a large burn injury are at high risk for developing hospital-associated infections. If patients survive the initial 72 hours after a burn injury, infections are the most common cause of death. Ventilator-associated pneumonia is the most important infection in this patient population. The risk of infections caused by multidrug-resistant bacterial pathogens increases with hospital length of stay in burn patients. In the first days of the postburn hospitalization, more susceptible, Gram-positive organisms predominate, whereas later more resistant Gram-negative organisms are found. These findings impact the choice of empiric antibiotics in critically ill burn patients. A proactive infection control approach is essential in burn units. Furthermore, a multidisciplinary approach to burn patients with a team that includes an infectious disease specialist and a pharmacist in addition to the burn surgeon is highly recommended.

Impact of Real-Time Therapeutic Drug Monitoring on the Prescription of Antibiotics in Burn Patients Requiring Admission to the Intensive Care Unit

As pharmacokinetics after burn trauma are difficult to predict, we conducted a 3-year prospective, monocentric, randomized, controlled trial to determine the extent of under- and overdosing of antibiotics and further evaluate the impact of systematic therapeutic drug monitoring (TDM) with same-day real-time dose adaptation to reach and maintain antibiotic concentrations within the therapeutic range. Forty-five consecutive burn patients treated with antibiotics were prospectively screened. Forty fulfilled the inclusion criteria; after one patient refused to participate and one withdrew consent, 19 were randomly assigned to an intervention group (patients with real-time antibiotic concentration determination and subsequent adaptations) and 19 were randomly assigned to a standard-of-care group (patients with antibiotic administration at the physician's discretion without real-time TDM). Seventy-three infection episodes were analyzed. Before the intervention, only 46/82 (56%) initial trough concentrations fell within the range. There was no difference between groups in the initial trough concentrations (adjusted hazard ratio = 1.39 [95% confidence interval {CI}, 0.81 to 2.39], P = 0.227) or the time to reach the target. However, thanks to real-time dose adjustments, the trough concentrations of the intervention group remained more within the predefined range (57/77 [74.0%] versus 48/85 [56.5%]; adjusted odd ratio [OR] = 2.34 [95% CI, 1.17 to 4.81], P = 0.018), more days were spent within the target range (193 days/297 days on antibiotics [65.0%] versus 171 days/311 days in antibiotics [55.0%]; adjusted OR = 1.64 [95% CI, 1.16 to 2.32], P = 0.005), and fewer results were below the target trough concentrations (25/118 [21.2%] versus 44/126 [34.9%]; adjusted OR = 0.47 [95% CI, 0.26 to 0.87], P = 0.015). No difference in infection outcomes was observed between the study groups. Systematic TDM with same-day real-time dose adaptation was effective in reaching and maintaining therapeutic antibiotic concentrations in infected burn patients, which prevented both over- and underdosing. A larger multicentric study is needed to further evaluate the impact of this strategy on infection outcomes and the emergence of antibiotic resistance during long-term burn treatment. (This study was registered with the ClinicalTrials.gov platform under registration no. NCT01965340 on 27 September 2013.).

Risk factors for health care-associated infection in hospitalized adults: Systematic review and meta-analysis

BACKGROUND

Health care-associated infections (HAIs) are a public health problem that increase health care costs. This article aimed to systematically review the literature and meta-analyze studies investigating risk factors (RFs) independently associated with HAIs in hospitalized adults.

METHODS

Electronic databases (MEDLINE, Embase, and LILACS) were searched to identify studies from 2009-2016. Pooled risk ratios (RRs) or odds ratios (ORs) or mean differences (MDs) and 95% confidence intervals (CIs) were calculated and compared across the groups. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Of 867 studies, 65 met the criteria for review, and the data of 18 were summarized in the meta-analysis. The major RFs independently associated with HAIs were diabetes mellitus (RR, 1.76; 95% CI, 1.27-2.44), immunosuppression (RR, 1.24; 95% CI, 1.04-1.47), body temperature (MD, 0.62; 95% CI, 0.41-0.83), surgery time in minutes (MD, 34.53; 95% CI, 22.17-46.89), reoperation (RR, 7.94; 95% CI, 5.49-11.48), cephalosporin exposure (RR, 1.77; 95% CI, 1.30-2.42), days of exposure to central venous catheter (MD, 5.20; 95% CI, 4.91-5.48), intensive care unit (ICU) admission (RR, 3.76; 95% CI, 1.79-7.92), ICU stay in days (MD, 21.30; 95% CI, 19.81-22.79), and mechanical ventilation (OR, 12.95; 95% CI, 6.28-26.73).

CONCLUSIONS

Identifying RFs that contribute to develop HAIs may support the implementation of strategies for their prevention, therefore maximizing patient safety.

Antiseptics for burns

BACKGROUND

Burn wounds cause high levels of morbidity and mortality worldwide. People with burns are particularly vulnerable to infections; over 75% of all burn deaths (after initial resuscitation) result from infection. Antiseptics are topical agents that act to prevent growth of micro-organisms. A wide range are used with the intention of preventing infection and promoting healing of burn wounds.

OBJECTIVES

To assess the effects and safety of antiseptics for the treatment of burns in any care setting.

SEARCH METHODS

In September 2016 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions based on language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people with any burn wound and assessed the use of a topical treatment with antiseptic properties.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included 56 RCTs with 5807 randomised participants. Almost all trials had poorly reported methodology, meaning that it is unclear whether they were at high risk of bias. In many cases the primary review outcomes, wound healing and infection, were not reported, or were reported incompletely.Most trials enrolled people with recent burns, described as second-degree and less than 40% of total body surface area; most participants were adults. Antiseptic agents assessed were: silver-based, honey, Aloe Vera, iodine-based, chlorhexidine or polyhexanide (biguanides), sodium hypochlorite, merbromin, ethacridine lactate, cerium nitrate and Arnebia euchroma. Most studies compared antiseptic with a topical antibiotic, primarily silver sulfadiazine (SSD); others compared antiseptic with a non-antibacterial treatment or another antiseptic. Most evidence was assessed as low or very low certainty, often because of imprecision resulting from few participants, low event rates, or both, often in single studies. Antiseptics versus topical antibioticsCompared with the topical antibiotic, SSD, there is low certainty evidence that, on average, there is no clear difference in the hazard of healing (chance of healing over time), between silver-based antiseptics and SSD (HR 1.25, 95% CI 0.94 to 1.67; I² = 0%; 3 studies; 259 participants); silver-based antiseptics may, on average, increase the number of healing events over 21 or 28 days' follow-up (RR 1.17 95% CI 1.00 to 1.37; I² = 45%; 5 studies; 408 participants) and may, on average, reduce mean time to healing (difference in means -3.33 days; 95% CI -4.96 to -1.70; I² = 87%; 10 studies; 979 participants).There is moderate certainty evidence that, on average, burns treated with honey are probably more likely to heal over time compared with topical antibiotics (HR 2.45, 95% CI 1.71 to 3.52; I² = 66%; 5 studies; 140 participants).There is low certainty evidence from single trials that sodium hypochlorite may, on average, slightly reduce mean time to healing compared with SSD (difference in means -2.10 days, 95% CI -3.87 to -0.33, 10 participants (20 burns)) as may merbromin compared with zinc sulfadiazine (difference in means -3.48 days, 95% CI -6.85 to -0.11, 50 relevant participants). Other comparisons with low or very low certainty evidence did not find clear differences between groups.Most comparisons did not report data on infection. Based on the available data we cannot be certain if antiseptic treatments increase or reduce the risk of infection compared with topical antibiotics (very low certainty evidence). Antiseptics versus alternative antisepticsThere may be some reduction in mean time to healing for wounds treated with povidone iodine compared with chlorhexidine (MD -2.21 days, 95% CI 0.34 to 4.08). Other evidence showed no clear differences and is of low or very low certainty. Antiseptics versus non-antibacterial comparatorsWe found high certainty evidence that treating burns with honey, on average, reduced mean times to healing in comparison with non-antibacterial treatments (difference in means -5.3 days, 95% CI -6.30 to -4.34; I² = 71%; 4 studies; 1156 participants) but this comparison included some unconventional treatments such as amniotic membrane and potato peel. There is moderate certainty evidence that honey probably also increases the likelihood of wounds healing over time compared to unconventional anti-bacterial treatments (HR 2.86, 95% C 1.60 to 5.11; I² = 50%; 2 studies; 154 participants).There is moderate certainty evidence that, on average, burns treated with nanocrystalline silver dressings probably have a slightly shorter mean time to healing than those treated with Vaseline gauze (difference in means -3.49 days, 95% CI -4.46 to -2.52; I² = 0%; 2 studies, 204 participants), but low certainty evidence that there may be little or no difference in numbers of healing events at 14 days between burns treated with silver xenograft or paraffin gauze (RR 1.13, 95% CI 0.59 to 2.16 1 study; 32 participants). Other comparisons represented low or very low certainty evidence.It is uncertain whether infection rates in burns treated with either silver-based antiseptics or honey differ compared with non-antimicrobial treatments (very low certainty evidence). There is probably no difference in infection rates between an iodine-based treatment compared with moist exposed burn ointment (moderate certainty evidence). It is also uncertain whether infection rates differ for SSD plus cerium nitrate, compared with SSD alone (low certainty evidence).Mortality was low where reported. Most comparisons provided low certainty evidence that there may be little or no difference between many treatments. There may be fewer deaths in groups treated with cerium nitrate plus SSD compared with SSD alone (RR 0.22, 95% CI 0.05 to 0.99; I² = 0%, 2 studies, 214 participants) (low certainty evidence).

AUTHORS' CONCLUSIONS

It was often uncertain whether antiseptics were associated with any difference in healing, infections, or other outcomes. Where there is moderate or high certainty evidence, decision makers need to consider the applicability of the evidence from the comparison to their patients. Reporting was poor, to the extent that we are not confident that most trials are free from risk of bias.

A prospective study evaluating tobramycin pharmacokinetics and optimal once daily dosing in burn patients

BACKGROUND

Once-daily aminoglycoside dosing (ODA) is used in most patient populations to optimize antibacterial activity and reduce toxicity. Unfortunately, burn patients are excluded from ODA due to concerns over altered pharmacokinetics resulting in a shortened half-life and low peak aminoglycoside concentrations. Retrospective studies suggest that ODA may be appropriate if higher milligram/kilogram doses are used. However, no prospective clinical trials in burn patients exist to confirm these findings.

OBJECTIVE

To determine the adequacy of once daily tobramycin dosed at 10mg/kg in adult burn patients.

METHODS

This prospective single dose pharmacokinetic clinical trial was conducted at the Ross Tilley Burn Centre. Patients with a total burn surface area (TBSA) of <20% and creatinine clearance ≥50mL/min were eligible. A first-order one compartment model was used to determine the pharmacokinetic profile from 3 or 5 tobramycin levels over a 24h period per patient. Monte Carlo simulation (MCS) was performed to determine the probability of target level attainment.

RESULTS

The mean percent TBSA, partial, and full thickness burn were 10%, 6%, and 4%, respectively. Nine of the ten patients recruited achieved peak concentrations of ≥20mg/L (mean of 29.4±5.7mg/L) and all patients had a trough level ≤0.5mg/L. The mean half-life, volume of distribution, and clearance were 2.58h, 0.33L/kg, and 7.40L/h, respectively. The MCS determined probability of attaining target peak concentrations with the 10mg/kg dose was 97%, which almost doubled that predicted with the usual 7mg/kg dose.

CONCLUSION

Burn patients with adequate renal function and <20% TBSA are candidates for ODA. Tobramycin half-life was similar to healthy, non-burn patients. The larger than normal volume of distribution supports the use of the higher empiric dose of 10mg/kg total body or adjusted weight in non-obese and obese patients, respectively, with further dose adjustment based on therapeutic drug monitoring.