|Year : 2012 | Volume
| Issue : 1 | Page : 18-22
Burn wound infection: Current problem and unmet needs
Shobha Chamania, Nanda Hemvani, Sankelp Joshi
Department of Burns and General Surgery, Choithram Hospital and Research Center, Indore, India
|Date of Web Publication||13-May-2013|
23, Aditya Nagar, AB Road, Indore - 452 017, Madhya Pradesh
Source of Support: Choithram Hospital and Research Center, Indore,
Madhya Pradesh, Conflict of Interest: None
Introduction: The need to focus on reducing the incidence of burn wound infection in the low and middle income countries is highlighted. The high income countries (HIC) have been working towards achieving this objective and in the process have improved their burn outcomes remarkably. In India there are vast variations in the incidences of gram positive and gram negative infections, with some centers reporting a very high incidence of fungal infections responsible for higher mortality. These challenges were faced by the hospitals in HICs but they worked aggressively towards curtailing it and improving survivals. Materials and Methods: A retrospective analysis of the burn wound infection at the Burn unit of the Choithram hospital Indore, was done from 1 st July to 31 st December 2011. Aims: 1. To analyze incidence of multi drug resistance (MDR) organisms in burn patients, and 2. To co-relate sepsis induced mortality with underlying MDR infection. Results: The highest incidence was of Pseudomonas aeruginosa (43%). Methicillin resistant Staphylococcus Aureus (MRSA) was seen in 12% patients. We did not have any fungal infection in our patients. Sixty three point fifteen percent of these reports had multi drug resistance (MDR) infection. Overall mortality in the current study was 33.33% and mortality due to sepsis was 19.6%. Challenges and problems faced by the low and middle income countries (LMICs) burn care facilities are discussed and how it affects the outcomes. Conclusion: To overcome these challenges, strategies for training, education, motivation and resource allocation by the hospital administration are suggested to ensure a comprehensive burn care program from prevention to rehabilitation.
Keywords: Burns, infection, sepsis, wound
|How to cite this article:|
Chamania S, Hemvani N, Joshi S. Burn wound infection: Current problem and unmet needs. Indian J Burns 2012;20:18-22
| Introduction|| |
Approximately 95% of burns occur in low to middle income countries (LMICs), regions that generally lack the resources and know-how to focus on burn prevention. ,, The high income countries (HICs) have been able to reduce the problem of burns and wound infection by developing a focus on prevention and early wound closure, bringing an end to the source. (The terms low and middle income countries and high income countries have been commonly used by the WHO documents,  in some publications,  and deliberations of International society of burn injuries. More appropriate terminology could be a resource poor and resource rich health services regions). Clinton K Murray  has shown that excision of deep dermal and full thickness burn wound at the earliest followed by skin cover reduces burn wound sepsis and related morbidity and mortality. Mortality due to sepsis was reduced from 14% to 3% in five year period. 
The HICs have a prevention program to identify problems and find solutions which are then legally enforced. This reduces the burden of burn injury. Additionally resourced burn care facilities adhering to standards of burn care ensure timely wound closure. This development has been known as the 'Standard of care' for full thickness burns for last four decades. The HICs have formulated infection control strategies and isolation services for managing infected wounds. This has lead to improving outcomes in those setups reducing the morbidity and the mortality.
It is time for us to identify the real issues behind the problem of burn wound infection in our setting and develop a plan to solve them with available resources.
Macmillan  from Cincinnati USA in 1981 had reported that gram positive organisms grew in 80% of their cultures and that the fungal infections were fatal. Clinton Murray  in 2008 confirmed the mortality due to fungal infection was 5.3%. However in India, N Agnihotri  after analyzing their data of five years has shown an incidence of 57% of Pseudomonas infection in burn wounds and a rising incidences of multi drug resistant organisms (MDR) in their unit at Chandigarh. Sarabahi  in 2011 had reported a frightening situation of changing candida infection in their center in Delhi. In 2001-2003 they showed a 54% incidence of Candida albicans, while subsequently in their pilot study to evaluate the situation they were surprised to see 0% Candida albicans but 90% candida non albicans. Out of these, 33% grew Candida tropicalis and 40% Candida krusei. These are deep fungal infections associated with high mortality and indicate nosocomial infection, unlike Candida albicans which is a normal commensal.
The propensity for fungal infection increases the longer the wound is present. 
| Materials and Methods|| |
We conducted a retrospective review of our in-patients' data to evaluate burn wound infection and its outcome.
- To analyze incidence of multi drug resistance (MDR) organisms in burn patients.
- To co-relate sepsis induced mortality with underlying MDR infection.
One hundred and two patients admitted between 1 st July 2011 and 31 st December 2011 at our Burn Unit.
Statistical analysis used
The sensitivity, specificity, positive predictive value and negative predictive value were calculated.
All superficial and deep dermal flame/scald/electrical burns <70% total body surface area burn injury, irrespective of their age and gender status.
≥70% TBSA burn injury. These patients are offered Comfort Care' in our set up. Since we are not able to salvage these extensive burns, we offer them round the clock analgesia, intravenous fluids and oral feeds as desired. These patients are not taken for early excisional surgery. Topical dressings however are continued.
Method of data collection
Institutional ethical clearance was obtained. We retrieved the patients' data of the said period and reviewed their inpatient files to gather required information about each patient.
In our unit, we planned an early excision and grafting by the 2 nd to the 5 th post burn day.
Swab culture is done on admission for preoperative work-up and repeated later, if the patient has fever, shows signs and symptoms of sepsis, any changes in the burn wound color/discharge/odors etc. Baseline complete blood count, electrolytes. Blood sugar and serum creatinine are evaluated.
Blood cultures are not sent as a routine. In patients who develop fever while on central line, which has been in place for more than 6-7 days, the policy is to remove the catheter and send the tip for culture.
Blood culture in such a febrile patient is done if the patient is a child. Neonates and the children up to three years are more prone to develop bacteremia following a minor infection because they undergo hematological dissemination much faster. The immunologic basis of this is not clearly known.
Burn wound biopsy for histology to document the invasive pathogen responsible for invasive wound sepsis is not done as a routine. They are done only in specific situations when the wound color has changed with or without the ectopic necrotic patches on the skin. The clinical signs of sepsis may support the diagnosis. Histopathological evidence of invasion of microorganism confirms the diagnosis of invasive sepsis.
Bharadwaj and colleagues also assessed the value of blood cultures in the diagnosis of burn wound sepsis compared to burn wound cultures by either swab or tissue biopsy. Blood cultures have also been shown to be a late sign of invasive burn wound infection even when they are positive. 
No prophylactic antibiotic is used on admission.
Antibiotics are administered for perioperative prophylaxis for early excision and skin grafting. If the burn is small (<5%) then single dose of antibiotic is given preoperatively. In moderate burn injury (6-20% TBSA) where the surgery is performed early and full closure of the wound is obtained by means of skin grafting after excising and biological dressing for superficial burns; antibiotics are administered for 24 h and then stopped. This is to emphasize that antibiotics must be used for a short period and selectively in burns. 
Antibiotics are given for a longer period if the patient has non-excised full thickness burn wound remaining which is getting infected, until they are debrided and covered with auto or homograft. This leads to complications. 
In case of impending or full blown sepsis antibiotics are given in the maximum safe doses according to the antibiogram sent by the microbiology department every quarterly. They are then changed according to the culture sensitivity reports after 48 h. Liaison between the treating surgeon and the microbiologist is essential in making the antibiotic choice in burns. 
For this study, culture reports were evaluated and the assessment of sepsis causing mortality was based on cause/complications (pneumonia, febrile illness, sudden changes in wounds, multi organ dysfunction etc.) leading to the fatal outcome.
Our center gets a significant number of delayed admissions (delay varying from weeks to months) with associated challenges of MDR infection, poor nutrition, depression, pressure sores and contractures. These patients pose challenges on managing infection control in the unit, as well as managing their very fragile condition.
In case of major burn injury, the technique of meek micro grafting in selective extensive burns, meshed autograft with homograft in majority of the cases is the routine surgical protocol.
| Results|| |
The highest incidence was of Pseudomonas aeruginosa (43%). Other gram negative organisms include polymicrobial (23%), Citrobacter (17%), Klebsiella (9%) and Acenatobacter baumannii (11%). Gram positive organisms were seen in 26% cultures either very early or much later, towards discharge time. MRSA was seen in 12% patients only [Figure 1]. We did not have any fungal infection in our patients, may be due to early wound closure, early mortality (before 30 days) in extensive burns and due to restricted antibiotic policy of the unit.
Mortality due to sepsis
Overall mortality was 33.33% during this study period. Mortality due to sepsis was 19.6%. Fifty seven point fifty seven percent was the incidence of culture positive reports. Sixty three point fifteen percent of these reports had multi drug resistant (MDR) organisms and 36.84% are non multi drug resistant (NMDR) ones.
If we compare our own data of 2011 with the data of 2004 of 172 patients which was presented at the annual conference of the International Society of Burn Injuries (ISBI) in 2005, then we notice that in 2004, 26.16% had no growth on admission but all studied patients had cultures positive later. Forty five point three percent (79/172) were MDR and 54.06% (93/172) were Non MDR [Figure 2].
| Discussion|| |
Thermal destruction of the skin barrier and concomitant depression of local and systemic host cellular and humoral immune responses are pivotal factors contributing to infectious complications in patients with severe burns. 
Our mortality from sepsis is 19.6% which was 28.05%in 2004. Other reports from northern India (Chandigarh) claim it to be as high as 75% in 2004 and 65% in 2006.  Whereas the mortality from sepsis reported by Macmillan in 1981 was 5%; it fell from 14% in 1976.  Therapeutic measures used to control burn wound sepsis by this group consisted of prevention of contamination from exogenous sources, control of burn wound pathogens, early recognition of invasive burn wound sepsis, aggressive management of the burn wound, and optimal nutritional support. During this period the extent of burn associated with a survival of 50% has risen from 50% in 1970 to 80% in 1976. This improvement in survival is directly related to progressive improvement in local and systemic measures available for the control of infection. 
The HICs have developed specialized burn care centers where the patient arrives at the earliest due to compulsory burn registry and a network of the facilities all over the country. Patient transport is quick, and resuscitation begins en route. The patients are either in a government supported system or are insured. They are provided the 'standard care' which includes resuscitation, early excision and wound closure and good nutritional support started early on. These centers also run continuous education and training programs for the members of the burn care team. Education and training of the team members translates into better understanding of the dos and don'ts of infection control. ,,,
Their focus on prevention help to reduce incidence of burn injuries and thereby the workload. ,
A good nurse-patient ratio, discipline of hand washing and a policy of no visitors in the burn care area have helped to control infection in HICs.  Along with the clinical efforts there is better overall literacy and public awareness.
In contrast, challenges of LMICs have been on the rise. With some education and training in the district hospitals the transport of the patients is being expedited to the burn care facilities; however there is room for improvement by professional management en route. Standard of care in majority of LMICs continues to be conservative management when the accepted standard of care is early excision and closure to bring an end to the source of infection. Possible reasons for procrastinating the wound closure may be lack of training and experience and paucity of homografts or other materials for temporary wound closure. 
Unscrupulous use of systemic antibiotics is causing multi drug resistance (MDR) and emergence of invasive fungal infections. We will have to go by standards to avoid this problem. Burn units may rotate the use of various topical antimicrobial preparations on a regular basis to decrease the potential for development of antibiotic resistance. 
Pre burn malnutrition, dietary prejudices, ignorance regarding the importance of nutrition are some of the challenges. 
These must be met with concrete plans of nutrition provision to help the wounds heal faster and improve outcomes.
Nurse to patient ratio is an important pillar to tilt the balance of infection control measures in the day to day patient care. Ratios 1:5 during the day and 1:8 during the night represent the staffing of the public institutions and reasonably good private facilities. To support the nursing needs of the patient, their family members come forward who are not formally educated in caring for a vulnerable burn patient. For reducing the incidence of infection regular disinfection, surveillance of the facility, segregation of the infected patients, priority of dressings based on infection status and strict hand washing discipline must be practiced. All members of the team must be responsible for enforcing the discipline of hand washing. ,,
Risk factors for acquisition of an antibiotic-resistant organism include receipt of antibiotics prior to the development of infection, extended duration of hospitalization, previous hospitalization, invasive procedures, comatose state, and advancing age. 
Effective communication with the team and with the families of the patients highlighting the need of hand washing to prevent infection goes a long way in helping the cause. The protocols for venous access, urinary catheters and ventilators are defined and must be adhered to in practice.
Burn incidence in the LMICS and especially in India is rising because of inadequate focus on burn prevention. , Unless we try and reduce the incidence primarily by prevention we will not be able to focus on improving care and outcomes.  Majority of the patients belong to the low socio economic strata; they can ill afford the treatment or medical insurance.
This is a huge gap in burn care globally and we have to strive to bridge this gap. This can only be done by accepting standards of burn care and implementing them rigorously.
Interburns, an International network for training, education and research in burns, has developed standards of burn care following a consensus meeting of representatives from 30 countries having a mix of HICs and LMICs.  It is now planning to offer the document to the LMICs, and encourage them to get it implemented. Over the time we may review its impact on the burn morbidity and mortality.
| Conclusion|| |
Emerging antimicrobial resistance trends in burn wound bacterial pathogens represent a serious therapeutic challenge for clinicians caring for burn. 
Excision and wound closure is not universally accepted leading to high incidence of infection and high mortality from sepsis. 
Those surviving the infection develop contractures and deformities affecting burn outcomes from the present state of care. 
Changing outcomes may possibly attract some physicians to explore this as a career.
There is inadequate emphasis on burn care in general surgery and plastic surgery training therefore they are not motivated to accept this as their career. There is a crying need to have education and training in this field in order to deal with the rising incidence of burns in LMICs.
Increased public awareness about prevention and first aid will reduce the incidence and depth of injury. Based on the epidemiology of the region an educational program must be designed by the team and it must reach out to masses periodically utilizing all forms of media. Encouraging a partnership of all members of the team and all sections of the society in this endeavor can change the state of ignorance that prevails today. ,
Attention to acute burn care in most public hospitals continues to be the last priority. Well defined protocols for managing burns will improve care and improve outcomes; better rehab will develop a satisfied survivors' population which will boost the reputation of the hospital. This can be a win-win situation for both.
Emphasis on infection control protocols should be mandatory for the staff of burn care facility, as this is one area of the hospital that has the highest load of microorganisms. Clinical methods of providing isolation care with individualized monitoring equipments and minimal shifting to other wards has shown reduction in wound infection. 
There is ongoing research on using essential oils for disinfecting the wounds and they have found them useful in vitro. Tea tree oil and lavender oil have shown antibacterial, anti-viral and antifungal activity and are being looked into their use in vivo. ,,
Standards for burn care.  are developed that can be globally applicable and ensuring its implementation will change hopefully the burn outcomes globally. This is top priority because the majority of burn incidences and mortality thereof are happening in the LMICs.
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[Figure 1], [Figure 2]