Burn Wound Sepsis Research Articles

Predictors of infectious complications after burn injuries in children.

Infections are the major life-threatening complication of burn injury and occur with the greatest frequency in children. Knowledge of their occurrence and management, however, is extrapolated from studies in adults. We performed a prospective study of infectious complications in burned children. To delineate epidemiology, risk factors and microbiology of infections in burned children where burn care and surgical interventions are optimal. Children hospitalized for burns were entered into prospective study. Characteristics of the burn injury were assessed, and active surveillance for infections was performed. Seventy patients were entered [mean age, 42 months; mean total body surface area (TBSA), burn 15%]. Twenty-seven percent of patients developed 39 infections: 13 involved the burn wound (burn wound sepsis, 6; graft loss, 5; and cellulitis, 2); 13 were catheter-associated septicemia; 13 involved other sites (i.e. pneumonia, 4; urinary tract infection, 3; bacteremia, 2; endocarditis, 1; myocardial abscess, 1; toxin-mediated syndrome, 1; and otitis media, 1). Twenty-three infections were caused by a single organism, 9 infections by more than 1 organism and in 7 infections defined by CDC criteria no organism was recovered. Organisms causing infection were: Staphylococcus aureus, 19; Candida albicans, 4; Pseudomonas aeruginosa, 4; coagulase-negative Staphylococcus, 4; Enterococcus sp., 3; Escherichia coli, 1; Klebsiella oxytoca, 1; Serratia marcescens, 1; Streptococcus pneumoniae, 1; Streptococcus pyogenes, 1; Aspergillus fumigatus, 1; and Candida parapsilosis, 1. Burn mechanism (flame and inhalation), extent (TBSA >30%) and depth (full thickness) were risk factors for infection; young age and site of burn were not. The most common infections occurring in burn children are burn wound infections and catheter-associated septicemia. Characteristics of burn injury predict risk of infection. Children with flame and inhalation injury, TBSA burned >30% and full thickness burns are at high risk of infectious complications.

Effectiveness of electrolyzed oxidized water irrigation in a burn-wound infection model.

The purpose of the study was to determine whether electrolyzed oxidized water (EOW) functions as a bactericide in burn injury with Pseudomonas aeruginosa infection in a rat burn-wound model. Anesthetized Sprague-Dawley rats (n = 31) were subjected to third-degree burns to 30% of total body surface area. Two days after injury, all rats were infected with P. aeruginosa using 1 mL of a suspension containing 1 x 10(8) colony-forming units. Rats were assigned to one of three groups: no irrigation (group I), irrigation with physiologic saline (group II), or irrigation with EOW (group III). Blood culture, endotoxin levels, and survival rates were determined. Survival rate was significantly higher in group III than in groups I or II (p < 0.0001). Serum endotoxin levels on day 3 after infection in group III were significantly lower than the levels in group I (p < 0.01) and group II (p < 0.01). There were significant differences between the three groups in the culture of P. aeruginosa (p < 0.05). Irrigation and disinfection with EOW may become useful in preventing burn-wound sepsis.

Osteomyelitis in burn patients requiring skeletal fixation

Deep and severe burns often present with the exposure of musculoskeletal structures and severe deformities. Skeletal fixation, suspension and/or traction are part of their comprehensive treatment. Several factors put burn patients at risk for osteomyelitis, osteosynthesis material being one of them. In order to determine the safety of skeletal fixation, we reviewed all pediatric patients treated with pin insertion during the past 10 years. Forty-one severely burned children (61±3% TBSA full thickness burns), had a total of 357 skeletal fixation procedures. Pins were maintained an average of 25.3±1.7 days. Thirteen pins (3.6%) were loose before the expected time of removal, two patients (4.8%) presented with cellulitis of the pin site and two patients (4.8%) presented with osteomyelitis. Loose pins, pin site cellulitis, burn wound infection and sepsis were not associated with ostemyelitis. Skeletal fixation in severely burned patients presents with a low incidence of infectious complications. Its use should be considered in patients affected by severe burns that present with exposed deep structures and for positioning purposes. The exact timing for pin removal in burned patients is still to be defined.

Pathogenetic effects of platelet activating factor on enterogenic endotoxemia after burn.

Previous clinical and experimental studies have indicated that an early endotoxemia occurred after a major burn. It is unlikely that burn wound sepsis is the source of circulating endotoxin in less than 12 h after burn. Increasing evidence demonstrates that the bacteria and endotoxin in the gastrointestinal tract can pass through the gut barrier into blood circulation to form enterogenic endotoxemia following burn[1-3]. However, its pathogenesis remains poorly understood. Platelet activating factor (PAF), an endogenous phospholipid mediator, has recently been proposed as a critical mediator in shock, sepsis and multiple organ failure[4,5]. In this study, the relationship between changes of PAF and enterogenic endotoxemia was observed on rat models with 30% TBSA III burn. The purpose was to investigate the pathogenetic effects of PAF on the occurrence of enterogenic endotoxemia after burn.

Designed Antimicrobial Peptides (DAP) in the Prevention of Pseudomonal Burn Wound Sepsis

Designed Antimicrobial Peptides (DAP) in the Prevention of Pseudomonal Burn Wound Sepsis

The development of the International Society for Burn Injuries and progress in burn care: the whole is greater than the sum of its parts

Book, 7th International Congress on Burn Injuries, Melbourne, Australia, 1986. A 151 [abstract]. [59] Saisy R, Lioret N, Mazanes MJ, Kirsch JM, Baux S. Fiberoptic bronchoscopy and respiratory sequelae after inhalation injury. Programme and Abstract Book, 7th International Congress on Burn Injuries, Melbourne, Australia, 1986. A 187 [abstract]. [60] Vaughan G, Plymate SR, Mason AD Jr. Testosterone (T), sex hormone binding globulin (SHBG), luteinizing hormone (LH) and thyroid hormones in burn patients. Programme and Abstract Book, 7th International Congress on Burn Injuries, Melbourne, Australia, 1986. A 241 [abstract]. [61] Klasen H. Early oral feeding in patients with extensive burns. Programme and Abstract Book, 7th International Congress on Burn Injuries, Melbourne, Australia, 1986. A 59 [abstract]. [62] Clark CJ, Kinsella J, Gemmell CG, Reid WH. Airway reactivity and bronchoalveolar cell pro®les in ®re victims. Programme and Abstract Book, 8th International Congress on Burn Injuries, New Delhi, India, 1990. p. 339 [abstract]. [63] Gueugniaud P, Bouchard C, Marin-La Fleche I, Durand F, Vaudelin T, Bernard F, Petit P. Cerebral Edema: a new complication of resuscitation in acutely critical burned patients. The teaching of a usual management of the intracranial pressure (ICP) and cerebral perfusion (CPP). Programme and Abstract Book, 8th International Congress on Burn Injuries, New Delhi, India, 1990. p. 158 [abstract]. [64] Session IB, Epidermal culture. Programme and Abstract Book, 8th International Congress on Burn Injuries, New Delhi, India, 1990. p. 20±21 [abstract]. [65] Chu C-S, McManus AT, Guymon CH. Iontophoretic treatment of burn wound sepsis using silver nylon dressings. Programme and Abstract Book. 8th International Congress on Burn Injuries, New Delhi, India, 1990. p. 319 [abstract]. [66] Becker WE, LeVoyer TE, Cio WG, Kim SH, McManus AT, McManus WF, Mason AD, Pruitt BA Jr. Fungal colonization and infection of the burn wound. Programme and Abstract Book, 8th International Congress on Burn Injuries, New Delhi, India, 1990. p. 420 [abstract]. [67] Vaughan GM, Vaughan MK, Waymack JP. Altered TSHthyroid axis control in burned rats. Programme and Abstract Book, 8th International Congress on Burn Injuries, New Delhi, India, 1990. p. 119 [abstract]. [68] Cio WG, Carlson DE, Mason AD, McManus WF, Pruitt BA Jr. Resting metabolism in thermally injured patients. Programme and Abstract Book, 8th International Congress on Burn Injuries, New Delhi, India, 1990. p. 219 [abstract]. [69] Mozingo DW, Cio WG Jr, Becker WK, Mason AD Jr, Pruitt BA Jr. The e€ect of timing of administration of a Trinositol (PP56) on burn wound edema and albumin extravaB.A. Pruitt Jr. / Burns 25 (1999) 683±696 694

Efficacy of locally delivered polyclonal immunoglobulin against Pseudomonas aeruginosa infection in a murine burn wound model

The leading cause of morbidity and mortality in severe burn wound patients is infection. Treatment of burn wound infection is complicated by the emergence of antibiotic resistant organisms. A potential therapeutic alternative to antibiotic drugs is the local administration of polyclonal antibodies, termed passive local immunotherapy (PLI), directly to the burned tissue. A mouse burn wound infection model to simulate full thickness burn wound infection was used to evaluate the efficacy of passive local immunotherapy as a viable prophylactic or therapeutic agent. Pooled human immunoglobulins (IgG), delivered locally to the site of infection, are shown to be more effective at preventing fatal burn wound sepsis than treatment by intravenous infusion of IgG. A single 10 mg dose of human IgG administered locally to the burned, infected tissue site, either 24 hours prior to bacterial challenge, or within 3 hours after bacterial challenge, enhanced animal survival significantly ( P<0.001 and P<0.05 respectively) compared to control animals. In addition, reduced levels of bacteria were found in local and systemic tissues of IgG-treated mice compared to control mice ( P<0.05). These data support the local use of polyclonal immunoglobulin preparations as an efficacious and cost effective means to prevent and treat burn wound infections.

The comparison of early fluid therapy in extensive flame burns between inhalation and noninhalation injuries

Over the last half century, advances in treatment have changed the principal cause of death in burn patients from burn shock and wound sepsis to pulmonary sepsis, of which inhalation injury has always played a key role in morbidity and mortality. Even though Navar et al., Am. J. Surg. 1985;150:716–720 have noted that patients with inhalation injury had a mean fluid requirement of 5.8 ml/kg/% burn to achieve resuscitation from early burn shock, while patients without inhalation injury required only a mean fluid of 4.0 ml/kg/% burn, to achieve successful resuscitation in inhalation injured patients with minimum but adequate fluid has always been a challenge. To further define the difference of early fluid therapy between inhalation and noninhalation in extensively burned patients, a retrospective analysis was carried out in the Tri-Service General Hospital. Sixty-two flame burned patients (aged from 16 to 81 years-old with a mean age of 33.2±15.1 years; with burn size ranging from 30% to 98% TBSA with a mean burn size of 60.5±22.7%; 26 with inhalation injury; noninhalation 36) were reviewed during a 5-year period. The Parkland formula is the initial choice of fluid regimen with 4 ml/kg/% burn and the amount of replacement is monitored by urine output and is titrated to maintain urine output between 0.5 and 1.0 ml/kg/h. The mean amounts of fluid requirements of both inhalation and noninhalation burned patients were 3.1±1.0 and 2.3±0.8 ml/kg/% burn respectively ( p<0.05). Our study showed less fluid requirement for both inhalation and noninhalation injured patients in comparison with the Navar study and Parkland predictions in the first 24 h postburn. Furthermore, the inhalation injured patients definitely required volumes of fluid in excess of those required in noninhalation injured cases.

Improvement in survival with peptidyl membrane interactive molecule D4B treatment after burn wound infection.

To examine the effects of peptidyl membrane interactive molecule D4B in a murine model of lethal burn wound infection. Four experiments were performed: (1) growth inhibition assays of Pseudomonas aeruginosa treated with D4B, 0 to 100 micromol/L; (2) in vitro coculture of bone marrow cells with D4B, 0 to 100 micromol/L; (3) D4B treatment survival studies after burn injury only or burn wound infection in mice; and (4) peripheral white blood cell count, burn wound tissue bacterial culture, and burn wound morphological analysis at days 1, 2, and 3 after injury. University medical center laboratory. Groups of B6D2F1 male mice (20 each) were studied. Full-thickness scald burn, 15% of total body surface area, with P aeruginosa topical infection, and subeschar injections of D4B at 200 microg or 0.25 mL of placebo per mouse at 2 and 24 hours after injury. Animal survival after thermal burn wound bacterial infection, circulating leukocyte numbers, in vitro clonal cell culture of granulocyte-macrophage progenitor cells, and wound histopathological analysis. The survival rate in the D4B-treated group was nearly 2-fold greater than that in controls (P<.01) during 14 days of study. Bacterial quantitative wound cultures disclosed significant reductions in bacterial numbers at days 1, 2, and 3 in D4B-treated animals as compared with controls (P<.05 to <.01). D4B induced a dose-dependent inhibition of bacterial cell growth when added to in vitro P aeruginosa cultures (P<.01). Granulocyte-macrophage progenitor cell growth in culture was not altered by D4B treatment. D4B-treated animals displayed no signs of toxic effects or impairment in wound healing. The peptidyl membrane interactive molecule D4B had the ability to improve survival after gram-negative burn wound sepsis via direct antimicrobial effects. Peptidyl membrane interactive molecules may offer the potential of alternative treatments to standard topical agents or in patients with drug-resistant microbes.

Aerobic, anaerobic and fungal burn wound infections

One hundred and twenty-seven patients were studied prospectively for aerobic, anaerobic and fungal burn wound infections. All cases yielded organisms on culture. A total of 377 isolates were recovered (239 aerobes, 116 anaerobes and 22 fungi). Aerobic bacteria alone were present in 49 patients (38·6%). Anaerobic bacteria alone were present in four patients (3·2%). Candida sp. alone was present in one patient (0·8%). Mixed aerobic and/or anaerobic bacteria and/or fungi were present in 73 patients (57·5%). Fungi were isolated from 21 patients (23·9%) of 88 patients having fungal cultures. The predominant isolates recovered in descending order of frequency were: Pseudomonas aeruginosa, Staphylococcus aureus, Bacteroides sp., Klebsiella sp. and Peptostreptococcus sp. There were 70 patients (55·1%) infected with anaerobic bacteria. The rate of recovery of anaerobes was higher in patients with open wound dressings (72·7%) than in patients with occlusive wound dressings (41·7%), ( P < 0·01). Seventeen patients presented with septic shock, 15 of them (88·2%) yielding positive anaerobic cultures. Bacteroides sp. were isolated from 14 patients with septic shock, and were recovered from the four patients who had anaerobic infection alone. These results indicate a significant role of Bacteroides sp. in burn wound sepsis.

Hypernatremic suppression of neutrophils

Phagocytic and bactericidal activities are important functions of the human polymorphonuclear leucocytes (PMNL) as the host defence against burn wound infection. The zone of stasis, just below the zone of coagulation, is a site of interaction between invading bacteria and PMNL. For many reasons the osmotic pressure at this site is elevated. In this study we evaluated the in vitro phagocytic and bactericidal activities of PMNL under hypernatremic conditions. At a sodium concentration of 180 mEq/l, phagocytic activity was suppressed. Although on average superoxide production was maintained within the normal range, it was suppressed in three of the ten cases studied. We conclude that the hypernatremic condition may weaken local defence against burn wound infection at the zone of stasis and may be a risk factor for burn wound sepsis.

Effects of granulocyte colony-stimulating factor on bacterial translocation due to burn wound sepsis.

The presence of certain defects in both cellular and humoral immunity after thermal injury has been established. Likewise, the translocation of enteric bacteria to the mesenteric lymph nodes and to distant organs has also been observed following serious thermal injury. The effects of granulocyte colony-stimulating factor (G-CSF) on bacterial translocation, the small bowel mucosa, and cecal bacterial content were investigated in a rat model of burn wound sepsis in which albino Wistar rats were scalded over 30% of their bodies, after which the lesions were infected by 1 x 10(8) colony-forming units (cfu) Pseudomonas aeruginosa. The control group was treated with 5% dextrose solution subcutaneously starting 2 days preburn, while the treatment group received 100 microg/kg human G-CSF subcutaneously. On the 4th day post burn all animals were killed to examine the bowel and culture of the mesenteric lymph nodes (MLN), livers, and spleens. No significant differences were observed between the groups regarding the cecal bacterial content and small bowel; however, a difference was seen in the ratio of translocation in the MLN liver and spleen and quantitative MLN cultures. Based on these findings, G-CSF was thus found to be significantly effective in reducing bacterial translocation due to burn wound sepsis.

Treatment of a severe alkali burn

The case history of a 20-year-old male patient who sustained an 85 per cent total body surface area alkali burn to his skin, after falling into a caustic lime pit, is reported. Considerable problems regarding the correct estimate of burn wound depth, predominant location of the deepest burn on the posterior half of the body, appropriate wound coverage, and lack of sufficient skin graft donor sites required a complex treatment plan. Excisions to fascia and intradermal debridement were required to achieve an appropriate bed for wound closure. Five per cent mafenide acetate solution (Sulfamylon) was applied to prevent burn wound sepsis. Human allografts and Biobrane were used extensively to achieve temporary wound closure, to provide mechanical protection of freshly autografted wounds, and to prevent desiccation following application of cultured epidermal autografts on to debrided wounds and split thickness skin grafted donor sites. The case illustrates a number of problems associated with the evaluation and treatment of patients suffering severe alkali burns, and demonstrates the implementation of both established and evolving technologies in the management of these injuries.

Recombinant human granulocyte colony-stimulating factor treatment improves macrophage suppression of granulocyte and macrophage growth after burn and burn wound infection.

Granulocyte and macrophage production after burn injury or burn wound infection is significantly reduced and further compromised by endotoxin (ET). Moreover, the macrophage seems to be the major source of this bone marrow suppression. We sought to determine if recombinant human granulocyte colony-stimulating factor (rhG-CSF), a hematopoietic growth factor that is capable of improving survival after experimental burn wound sepsis, altered postburn macrophage-mediated marrow suppression. Groups of male BDF1 mice (n = 6 to 10) receiving a 15% total body surface area burn +/- infection (B or B + I) with Pseudomonas aeruginosa were injected with 100 ng rhG-CSF twice daily. On day 3, peritoneal-elicited macrophages (5 x 10(6) cells/mL) from either rhG-CSF-treated or control (5% dextrose in water) mice were incubated +/- ET (300 ng/mL). The resultant macrophage supernatant was added to cultures of target marrow granulocyte-macrophage progenitor cells (GM-CFC) at a volume of 1:10. The GM-CFC growth as a percentage of cultures not containing macrophage supernatant were compared and reductions in the number of GM-CFC taken as an index of marrow suppression. Macrophages obtained from B and B + I animals reduced target GM-CFC growth, compared with macrophages from normal animals (B vs. normal animals p < 0.05). In addition, ET-stimulated macrophages induced further bone marrow suppression for all three groups (p < 0.01). Macrophages from granulocyte colony-stimulating factor-treated animals caused significantly less bone marrow suppression, compared with untreated animals for all groups (p < 0.05 to 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Ion-pair chromatographic method for the analysis of mafenide acetate

Mafenide acetate (Sulfamylon) is an antibacterial agent used to prevent and treat burn wound sepsis. No LC method is currently available for the analysis of this drug. A simple LC method was developed and validated for the analysis of sulfamylon. The chromatographic separation was achieved on a reversed-phase, C 18 column with UV detection at 270 nm. This isocratic system was operated at ambient temperature and required a 6-min run-time. The mobile phase consisted of methanol-phosphate buffer pH 5.0 (65:35, v/v) and 2 m M 1-heptanesulfonic acid as the ion-pairing agent. The flow-rate was maintained at 1.0 ml/min. Standard curves were linear over the concentration range of 2 to 100 mg l −1. Within-day and day-to-day relative standard deviations were less than 2.4% and 4.4%, respectively. This method was used to quantify mafenide acetate in pharmaceutical formulation.

Opsonic activity of sera and blister fluid from severely burned patients evaluated by a chemiluminescence method.

Burn wound sepsis is the most common and severe complication in the patients with severe burn. To know the systemic and local defect in immunity of burned patients, we measured the luminol-enhanced chemiluminescence (CL) response of normal polymorphonuclear leukocytes (PMNs) upon exposure to zymosan particles, bacteria or Candida albicans that were opsonized with any of patient's serum, blister fluid of burn wound or pooled normal serum (blood type AB). Sera from patients exhibited lower opsonic activities than those of pooled normal serum in the early postburn days. The levels of serum immunoglobulins, complement components and plasma fibronectin were found to correlate well with opsonin-index (OI), which was determined based on the CL response data obtained during the course of infusion therapy with fresh frozen plasma. Furthermore, patient's blister fluid showed much lower opsonic activity against bacteria such as Pseudomonas aeruginosa than patient's own serum. These results indicate that blister fluid is also not effective to opsonize bacteria because of the marked depression of the levels of immunoglobulins and complement components. Destruction of the skin barrier by thermal injury and impairment of systemic or local humoral immunity may predispose these patients to burn wound sepsis.

A Comparative Study and Assessment of Burn Wound Sepsis Using Surface Swab, Fine Needle Aspiration and Wound Biopsy Cultures

SummaryThe purpose of this study was to evaluate a simple standardized fine needle aspiration method for bacteriologic assessment of burn wound and to determine whether this method is as reliable and useful as the classic invasive biopsy culture method1. Considering the high correlation with the organism in all three methods, viz. swab, aspiration and wound biopsy culture techniques, we feel fine needle aspiration culture has a place in bacteriological assessment of burn wound as it is simple, easy and less painful compared to the more conventional wound biopsy culture technique.

A Comparative Study and Assessment of Burn Wound Sepsis Using Surface Swab, Fine Needle Aspiration and Wound Biopsy Cultures

A Comparative Study and Assessment of Burn Wound Sepsis Using Surface Swab, Fine Needle Aspiration and Wound Biopsy Cultures

Translocation of gut bacteria in rats with cirrhosis to mesenteric lymph nodes partially explains the pathogenesis of spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis is a common infection of ascitic fluid that develops in cirrhosis. The offending organisms are predominantly of enteric origin. However, the mechanism and route by which bacteria exit from the gut and enter the fluid remain unclear. "Translocation" of bacteria from the gut to extraintestinal sites has been postulated in the pathogenesis of gram-negative sepsis in intensive care unit patients, burn-wound sepsis, and sepsis associated with chemotherapy. Translocation is defined by culture-positivity (with enteric flora) of mesenteric lymph nodes. In this study we assessed the frequency of translocation in a carbon tetrachloride-induced rat model of cirrhosis, ascites, and spontaneous bacterial peritonitis. We determined that translocation was more common in rats with cirrhosis (78.1%) than in normal controls (4.3%) (p < 0.001). Escherichia coli and other gram-negative enteric organisms were cultured. Translocation of enteric bacteria in rats with cirrhosis to extraintestinal sites may be an important early step in the pathogenesis of spontaneous bacterial peritonitis.

Immune Consequences of Burn Injury

The purpose of the immune system is to protect cells from invasion by microorganisms. The body has three equally important interactive immune defense systems, all of which are profoundly disrupted with major burn injury. The immune response to burn injury is immediate, prolonged, and severe. The end result in individuals surviving burn shock is immunosuppression, with increased susceptibility to potentially fatal systemic burn wound or pulmonary sepsis. Nursing actions to support the humoral and cell-mediated immune system of the burned patient include providing nutritional support to maintain serum protein levels at optimal levels; measures to decrease edema and promote angiogenesis in areas of partial-thickness injury; meticulous treatment of the wound to prevent infection and promote healing; monitoring of antibiotic use; conservative use of invasive techniques, including intubation and vascular access devices; maintenance of fluid and electrolyte balance and body temperature; and energy conservation measures.