|Year : 2015 | Volume
| Issue : 1 | Page : 71-75
Bacterial and fungal profile of burn wound infections in Tertiary Care Center
Sapana G Mundhada, Prakash H Waghmare, Prachala G Rathod, Kishore V Ingole
Department of Microbiology, Dr. V. M. Government Medical College, Solapur, Maharashtra, India
|Date of Web Publication||11-Dec-2015|
Dr. Sapana G Mundhada
Department of Microbiology, Dr. V. M. Government Medical College, Solapur, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Burn patients are at high risk for infection, and it has been estimated that 75% of all deaths following burns are related to infection. It is, therefore, essential for a burn institution to determine its specific pattern of burn wound microbial colonization, time-related changes in predominant flora and antimicrobial profiles. Aim: To find out the bacterial and fungal profile of burn wound and evaluate the antimicrobial susceptibility pattern of the organism isolated. Materials and Methods: The present study was conducted in the Department of Microbiology, Dr. V. M. Government Medical College, Solapur, Maharashtra from December 2012 to December 2014. The wound swabs were collected from 50 patients, having total body surface area of burn in between 20% and 40% on the 4 th , 10 th , and 16 th day. Total 202 wound swabs were collected aseptically and cultured for the growth of bacteria and the fungi. Bacterial growths were then subjected to various biochemical tests for identification and antibiotic sensitivity testing. Results: Single isolates were present in 71.28%, and multiple isolates were noted in 18.31% of wound swabs. The isolation rate of Gram-negative organisms was high. The most common isolate was Klebsiella pneumoniae (34.40%) followed by Pseudomonas aeruginosa (23.94%), Staphylococcus aureus (22.94%), Escherichia coli (7.34%), Acinetobacter spp. (2.75%), Proteus mirabilis (2.75%), and Citrobacter species (1.38%). Candida species (4.59%) was the only fungus isolated, of which Candida albicans (50%) was the most common. Gram-negative bacteria were the most sensitive to imipenem (93.67%) and amikacin (75.94%) while Gram-positive bacteria were the most sensitive to linezolid (100%) and vancomycin (100%). Conclusion: K. pneumoniae was found to be the most common bacterial agent involved. The results of the present study will be helpful in understanding the pattern of burn wound microbial infection, the dominant bacterial and fungal flora, and the antimicrobial resistance.
Keywords: Antimicrobial susceptibility, bacteriological profile, burns, fungal profile
|How to cite this article:|
Mundhada SG, Waghmare PH, Rathod PG, Ingole KV. Bacterial and fungal profile of burn wound infections in Tertiary Care Center. Indian J Burns 2015;23:71-5
|How to cite this URL:|
Mundhada SG, Waghmare PH, Rathod PG, Ingole KV. Bacterial and fungal profile of burn wound infections in Tertiary Care Center. Indian J Burns [serial online] 2015 [cited 2020 Jan 29];23:71-5. Available from: http://www.ijburns.com/text.asp?2015/23/1/71/171661
| Introduction|| |
Infection is a major cause of morbidity and mortality in hospitalized burn patients.  Sources of organisms are found in the patient's own endogenous (normal) flora, from exogenous sources in the environment and healthcare personnel. Overcrowding in burn units is an important cause of cross infection.  Exogenous organisms from the hospital environment are generally more resistant to antimicrobial agents than endogenous organisms. Organisms associated with infection in burn patients include Gram-positive, Gram-negative, and fungal organisms. The distribution of organisms changes over time in the individual patient and such changes can be ameliorated with appropriate management of the burn wound and patient. The typical burn wound is initially colonized predominantly with Gram-positive organisms, which are quickly replaced by antibiotic-susceptible Gram-negative organisms within a week of the burn injury. If wound closure is delayed and the patient becomes infected, this flora may be replaced by yeasts, fungi, and antibiotic resistant bacteria.  Microorganisms routinely isolated from burn wounds include aerobic organisms such as Staphylococcus aureus, Streptococcus pyogenes, Escherichia More Details coli, Klebsiella spp., Proteus spp., and anaerobic organisms such as Bacteroides fragilis, Peptostreptococcus, Propionibacterium spp., Fusobacterium spp., and fungi such as Aspergillus niger, Candida spp., and Zygomycetes. 
In view of the above literature, the present study is undertaken to identify the common pathogens causing burn wound infection (BWI) in our setting and to decide the measures to be taken to reduce the morbidity and mortality in burn patients.
The study is undertaken with the following aims and objectives:
- To identify the bacterial and fungal profile of BWI.
- To evaluate the antibiotic sensitivity of bacteria cultured and isolated.
| Materials and Methods|| |
The present study was carried out in the Department of Microbiology, Dr. V M Government Medical College, Solapur, Maharashtra from December 2012 to July 2014. The wound swabs were collected from 50 adult patients having total body surface area (TBSA) of burn in between 20% and 40% (according to rule of nine) on the 4 th , 10 th , and 16 th day of admission in burn ward of Shri Chatrapati Shivaji Maharaj General Hospital Solapur, Maharashtra.
A total of 202 wound swabs were collected and processed without delay in the following manner.
- For bacterial pathogens: ,
- Gram stain microscopy.
- Inoculation on culture media (Blood agar, MacConkey agar).
- Preliminary identification of the growth (Gram stain, catalase test, oxidase test, motility, etc.).
- Routine biochemical tests.
- Antimicrobial susceptibility testing. 
- For fungal pathogens: 
- Direct microscopic examination of Gram-stained smear and KOH mount.
- Inoculation of sample on sabouraud dextrose agar (plain and with antibiotics).
- Lactophenol cotton blue mount examination.
- If yeast, then identification by Dalmau technique on cornmeal agar, germ tube test, sugar fermentation, and assimilation.
- If mold, identification by slide culture.
| Results|| |
A total of 202 swabs were taken from 50 patients admitted in the burn unit in our hospital over a period of 18 months. They were studied to identify the aerobic bacteriological and fungal profile of BWIs. The most common age group involved was between 20 and 30 years. Females (54%) preponderance was seen over males (46%). The burning agent was predominantly flames (54%) followed by scalds (26%), chemicals (12%), electric (4%), and friction (4%). About 18% (9) patients of 50 expired, 6 patients of that had TBSA of burn in between 36% and 40%, 2 had 31-35%, and 1 had 26-30%. It was observed that the chances of mortality increase with increase in TBSA of burn.
Of 202 swabs, 181 swabs revealed growth while 21 swabs showed no growth. The overall isolation rate was 89.60% (181/202). A total of 218 organisms were isolated from 181 swabs. It was observed that single isolates 144 (71.28%) were seen more commonly than multiple isolates 37 (18.31%). Overall, Gram-negative bacteria 158 (72.47%) were more common than Gram-positive bacteria 50 (47.62%), followed by fungal isolates 10 (4.59%). Klebsiella pneumoniae (34.40%) was the most common isolate followed by Pseudomonas aeruginosa (23.85%), S. aureus (22.94%), E. coli (7.34%), Proteus mirabilis (2.75%), Acinetobacter spp. (2.75%), and Citrobacter spp. (1.38%), and Candida spp. (4.59%) was the only fungus isolated. In the 1 st week following burn injury, Gram-positive cocci (S. aureus) were more predominant whereas later, the frequency of isolation of Gram-negative bacilli increased (in the 2 nd week K. pneumoniae and in the 3 rd week K. pneumonia and P. aeruginosa) and that of Gram-positive organisms decreased [Table 1].
|Table 1: Frequency of organisms isolated from burn wounds on different days after admission|
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The antimicrobial sensitivity pattern of the organisms to different antimicrobials agent varied depending on the isolate as shown in [Table 2]. Overall Gram-negative organisms were found to show maximum susceptibility to imipenem (93.67%) and amikacin (88%) and least sensitivity to tetracycline (30.18%) and cefotaxime (30.37%), while Gram-positive bacteria were found the most sensitive to linezolid (100%) and vancomycin (100%), followed by ciprofloxacin (70%), cefoxitin (66%), gentamicin (60%), and trimethoprim-sulfamethoxazole (44%) and least sensitive to penicillin (8%).
|Table 2: Antibiotic susceptibility pattern of Gram-negative isolates from burn wound|
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In this study of total 218 isolates, 10 (4.59%) were fungal isolates and all of them were yeast. Among them, Candida albicans (5) was the most common isolate followed by Candida tropicalis (3), Candida glabrata (1), and Candida parapsilosis (1).
| Discussion|| |
Burn patients are at a high risk of infection as a result of the nature of the burn injury itself, the immunocompromizing effects of burns, prolonged hospital stays, and intensive diagnostic and therapeutic procedures. In the present study, about 70% of the patients were in the 20-30 years age group. Females (54%) were the most affected compared to males (46%). This is probably due to occupational hazards of working in the kitchen as the kitchen is the most common place prone to burn accidents. Burn due to flame (54%) was the predominant cause among patients in our study. Similar results were recorded in other studies by Shahzad et al.  and De Macedo and Santos.  In this study, mortality rate was low (18%), which is comparable to study by Lari et al. (19.6%).  This can be because of the fact that we are dealing with patients having TBSA of burn between 20% and 40%.
In the present study, the overall isolation rate was found to be 89.60%, which is comparable with findings of Srinivasan et al. (86.3%)  and Modi et al. (85.07).  It is noted that single isolates were more common (71.28%) than multiple. This is comparable to other studies by Shahzad et al.  and De Macedo and Santos.  According to Pruitt et al.,  there are time-related changes in the predominant flora of the burn wound. Initially, sparse predominant Gram-positive flora is replaced by predominantly dense Gram-negative flora that in turn may be supplanted by nonbacterial flora. In the present study, similar time-related changes were noted, Gram-positive cocci were the most common isolate from wound swab taken on the 4 th day, while Gram-negative bacilli were recorded more when swabs taken on the 10 th and 16 th day. In fungal isolates, Candida species were isolated from swabs taken on the 16 th day after burn, which was similar to result recorded by the study of De Macedo and Santos. 
In the present study, we found that the most common isolates were K. pneumoniae (34.40%), followed by P. aeruginosa (23.94%), S. aureus (22.94%), E. coli (7.34%), Acinetobacter species (2.75%), P. mirabilis (2.75%), Citrobacter species (1.38%), and Candida species (4.59%). Other studies by Srinivasan et al.,  Kehinde et al.,  and Mohammed et al.  also recorded that Klebsiella species is the most common isolate similar to our study. In contrast, other studies by Kaur et al.  and Rajput et al.  noted that P. aeruginosa is the most common isolate from BWI. While studies by Bhat et al.  and De Macedo and Santos  recorded that S. aureus is the most common isolate.
In the present study, isolation rate of E. coli was low (7.34%). This is in accordance with the studies by Bhat et al. (6.2%)  and De Macedo and Santos (2.3%).  According to Srinivasan et al.,  the prevalence rate of E. coli was on the rise from 2001 to 2004, and it has started to wean off from 2005 to 2006 in the successive years.
In the present study, an isolation rate of P. mirabilis was 2.75%, which is comparable with other studies done by Mehta et al. (2.3%)  and Mohammed et al.  Higher incidence was recorded by Bhat et al. (12.4%). 
Acinetobacter species has also gained importance nowadays as an emerging nosocomial pathogen of burn wounds and is a cause for much concern because of rapid increase in resistance to a variety of antimicrobial agents. In the present study, isolation rate of Acinetobacter species (2.75%) was low, which is in accordance with the study by De Macedo and Santos (3.9%). 
On antibiotic susceptibility testing of Gram-negative bacteria, they were found the most susceptible to imipenem (93.67%) and amikacin (75.94%). The susceptibility for gentamicin, ciprofloxacin, and trimethoprim-sulfamethoxazole was 53.79%, 55.69%, and 42.45%, respectively. They were found to be resistant to cefotaxime (69.62%) and Tetracycline (69.81%). According to Saxena et al.,  high level of drug resistance was observed for cefotaxime, ceftazidime, and cotrimoxazole among Gram-negative pathogens. Imipenem, piperacillin/tazobactam, amikacin, and ciprofloxacin were found to be the most effective. Similar finding was noted in the present study.
The isolates of S. aureus were sensitive to linezolid (100%), vancomycin (100%), gentamicin (60%), and ciprofloxacin (70%) whereas resistant to penicillin (92%), tetracycline (72%), and trimethoprim-sulfamethoxazole (66%). Mehta et al.  and Saxena et al.  also recorded similar findings in their study.
It is necessary to know the sensitivity of different bacteria in BWI for following reasons:
- To select the appropriate antibiotics to avoid the emergence or overgrowth of resistant bacteria to currently used antimicrobial agents.
- These resistant bacteria can transmit their resistance to other bacteria.
Which will cause multidrug resistant infection to other patient.
According to the study of Cooper et al.,  TBSA (30-60%) of burn wound, open dressing, prolonged hospital stay, central venous catheter, and prolonged antibiotics therapy are the major risk factors for the development of fungal infection in burn wound. In the present study, we found that those patients who developed fungal BWI were exposed to two or more of these risk factors.
According to the study of De Macedo and Santos,  infection of the burn wound with fungi is not a surprising phenomenon in view of the changes in microbial flora induced by systemic and topical antimicrobial chemotherapy. In their study, the fungal infection was seen in the 3 rd and 4 th week postburn, which is similar to finding in the present study where Candida species were isolated from swabs taken on the 16 th day (3 rd week).
In this study, all fungi isolated from BWI were yeast. Of total 218 isolates, 10 (4.59%) were yeast. This is comparable to the study by Moussa and Al-Bader,  where yeast isolation rate in burn patient was 7.6%. Of 10 yeast isolated, C. albicans (5) was the most common isolate, followed by C. tropicalis (3), C. glabrata (1), and C. parapsilosis (1). This is in accordance with the study by Gupta et al.  and Ha et al.  who also noted C. albicans as the most common isolate.
Another important fact, which was noted in the present study, was equal rate of infection caused by C. albicans (50%) and non-albicans Candida (50%). This signifies that there is a shift of fungal BWI from common organism like C. albicans to newly arising non-albicans Candida species. This is comparable with the study by Sarabahi et al. 
The colonization of the wounds with Candida species does not validate the start of antifungal therapy in burned patients. Systemic antifungal therapy is initiated when the appearance of the wound is suggestive of invasive fungal infection, i.e., separation of eschar and blackening of the tissue.
| Conclusion|| |
The results of the present study will be helpful in understanding the pattern of burn wound microbial infection, the dominant bacterial and fungal flora in these instances. K. pneumoniae was found to be the most common bacterial agent involved. Both Gram-positive and Gram-negative bacteria showed a high degree of resistance to antibiotics. The high prevalence of antibiotic resistance in burn infection necessitates the judicial use of antibiotics and stringent infection control practices such as repeated hand washing, avoiding sharing of equipment among patients, use of barrier techniques (gloves, masks, etc.), surgical excision and closure of wound, and use of topical antibiotics thus, improving the overall infection related morbidity and mortality.
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Conflicts of interest
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[Table 1], [Table 2]
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