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World Journal of Surgery

, Volume 16, Issue 1, pp 57–67 | Cite as

The changing epidemiology of infection in burn patients

  • Basil A. PruittJr.
  • Albert T. McManus
World Progress In Surgery

Abstract

Topical chemotherapy, prompt excision, and timely closure of the burn wound have significantly reduced the occurrence of invasive burn wound infection and its related mortality. Since wound protection is imperfect and invasive wound infection may still occur in patients with massive burns in whom wound closure is delayed, scheduled wound surveillance and biopsy monitoring are necessary to assess the microbial status of the burn wound and identify wound infections caused by resistant bacteria or non-bacterial opportunists at a stage when therapeutic intervention can control the process.

As a reflection of the systemic immunosuppressive effects of burn injury, infection remains the most common cause of morbidity and mortality even though the occurrence of wound infections has been significantly decreased. Pneumonia is the most frequent infection occurring in burn patients today but the improvements in patient management, wound care, and infection control have made bronchopneumonia the most common form of this infection and gram-positive organisms the most common causative agents. The organisms causing bacteremia that exert a species specific effect on the mortality related to extent of burn injury and patient age have changed in concert with changes in wound flora.

Infection control procedures, including scheduled surveillance cultures, utilization of cohort patient care methodology, strict enforcement of patient and staff hygiene, and patient monitoring have been effective in eliminating endemic resistant microbial strains, preventing the establishment of newly introduced resistant organisms, diagnosing infection in a timely fashion, instituting antibiotic and other necessary therapy in a prompt manner, and documenting the effectiveness of present day burn patient care and the improved survival of burn patients.

Keywords

Wound Infection Bronchopneumonia Surveillance Culture Wound Protection Species Specific Effect 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Des antibiotiques locaux, une excision rapide et une couverture cutanée ont contribué à réduire de façon significative la fréquence des infections des plaies et la mortalité qui en découle. La protection des plaies est cependant encore imparfaite et l'invasion massive des plaies est un risque réel chez les brûlés dont la fermeture cutanée est retardée. Une surveillance des plaies avec prélèvements systématiques à intervalles répétés est nécessaire pour évaluer la flore microbienne de la brûlure et identifier les infections provoquées par des souches bactériennes résistantes ou des germes opportunistes non bactériens à un stade oú l'intervention thérapeutique peut étre utile. Du fait de la dépression des fonctions immunologiques chez le brûlé, l'infection reste la cause la plus fréquente de morbidité et de mortalité même si la fréquence de survenue même des infections a diminué. Les infections pulmonaires sont la complication la plus fréquente chez le brûlé aujourd'hui malgré les améliorations dans le traitement global des plaies et surtout dans celui de l'infection. Les germes gram positif sont le plus souvent en cause. Le type de germes provoquant une bactériémie, responsable d'une mortalité variable suivant l'âge et l'étendue des lésions, a changé en même temps que la flore des plaies s'est modifiée. Les procédés de maîtrise de l'infection, comme mises en culture systématique des prélèvements, l'utilisation d'une méthodologie de cohortes, l'exigence d'une hygiène stricte pour les patients et le personnel ainsi que la surveillance des patients ont permis de gros progrès. L'élimination des souches microbiennes endémiques résistantes, la limitation de l'introduction de nouveaux germes résistants, la précocité du diagnostic d'infection, l'institution d'un traitement antibiotique approprié et l'évaluation de l'efficacité des soins quotidiens ont ainsi amélioré la survie des brûlés.

Resumen

La terapia tópica, la resección temprana y el oportuno cierre de la quemadura han reducido en forma significativa la infección invasiva de la herida y su concomitante mortalidad. Puesto que la protección de la herida es imperfecta y la infección invasiva puede occurrir en los pacientes con quemaduras masivas en quienes el cierre de la herida se ha retardado, se hace necesario realizar vigilancia programada de la herida y monitoría mediante biopsia para determinar el estado microbiológico de la quemadura e identificar infecciones por bacterias resistentes o por organismos oportunísticos no bacterianos en una etapa en que la intervención terapéutica pueda controlar el proceso.

Como un reflejo de los efectos immunosupresores sistémicos de la lesión térmica, la infección se mantiene como la causa más común de morbilidad y mortalidad, a pesar de que la incidencia de infección de la quemadura ha disminuido en forma significativa. Actualmente la neumonía es la infección más frecuente en el paciente quemado, pero los avances en el tratamiento total del paciente, en el manejo de la herida y en el control de la sepsis han hecho de la bronconeumonía la forma más común de este tipo de infección y de los microogranismos gram positivos los agentes causales más comunes. Los gérmenes causantes de bacteremia que ejercen un efecto específico sobre la mortalidad relacionada con la extensión de la quemadura y la edad del paciente han variado en concierto con los cambios en la flora de la herida.

Los procedimeientos de control de la infección, incluso la vigilancia programada mediante cultivos, la utilización de metodologías basadas en cohortes de pacientes, la estricta implementación de medidas de higiene del paciente y del personal y la monitoría del paciente han resultado eficaces en eliminar las cepas endémicas resistentes, en prevenir el establecimiento de gérmenes resistentes recientemente introducidos, en diagnosticar la infección en forma oportuna, en instituir antibioticoterapia y otras formas de terapia precozmente y en documentar la eficacia del manejo actual del paciente quemado y mejorar su supervivencia.

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References

  1. 1.
    Pruitt, B.A., Jr.: Advances in fluid therapy and the early care of the burn patient. World J. Surg.2:139, 1978PubMedGoogle Scholar
  2. 2.
    Pruitt, B.A. Jr., Goodwin, C.W. Jr.: Stress ulcer disease in the burn patient. World J. Surg.5:209, 1981PubMedGoogle Scholar
  3. 3.
    Pruitt, B.A., Jr.: The diagnosis and treatment of infection in the burn patient. Burns11:79, 1984Google Scholar
  4. 4.
    Pruitt, B.A. Jr., O'Neill, J.A. Jr., Moncrief, J.A., Lindberg, R.B.: Successful control of burn wound sepsis. J.A.M.A.203:105, 1968Google Scholar
  5. 5.
    Order, S.E., Mason A.D. Jr., Switzer, W.E., Moncrief, J.A.: Arterial vascular occlusion and devitalization of burn wounds. Ann. Surg.161:502, 1965PubMedGoogle Scholar
  6. 6.
    Pruitt, B.A. Jr.: Infections of burns and other wounds caused by Pseudomonas aeruginosa. In Pseudomonas Aeruginosa: The Organism, Diseases It Causes, and Their Treatment, L.D. Sabath, editor, Vienna, Hans Huber, 1980, pp 55–70Google Scholar
  7. 7.
    Pruitt, B.A., Jr., Lindberg, R.B.: Pseudomonas aeruginosa infections in burn patients. In Pseudomonas Aeruginosa, R.G. Doggett editor, New York, Academic Press, 1979, pp 339–366Google Scholar
  8. 8.
    Pruitt, B.A. Jr.: “Can ... the leopard change his spots?” Br. J. Surg.77:1081, 1990PubMedGoogle Scholar
  9. 9.
    Pruitt, B.A. Jr.: Burn patient: II. Later care and complications of thermal injury. Curr. Probl. Surg.16:6, 1979Google Scholar
  10. 10.
    McManus, A.T., Moody, E.E., Mason, A.D.: Bacterial motility: A component in experimental Pseudomonas aeruginosa burn wound sepsis. Burns6:235, 1980Google Scholar
  11. 11.
    Bruck, H.S., Nash, G., Stein, J.M., Lindberg, R.B.: Studies on the occurrence and significance of yeast and fungi in the burn wound. Ann. Surg.176:108, 1972PubMedGoogle Scholar
  12. 12.
    Pruitt, B.A., Jr.: The burn patient: II. Later care and complications of thermal injury. Curr. Probl. Surg.16:16, 1979Google Scholar
  13. 13.
    Bruck, H.M., Nash, G., Foley, F.D., Pruitt, B.A. Jr.: Opportunistic fungal infection of the burn wound with Phycomycetes and Aspergillus: A clinical-pathologic review. Arch. Surg.102:476, 1971PubMedGoogle Scholar
  14. 14.
    McManus, W.F., Mason, A.D. Jr., Pruitt, B.A. Jr.: Excision of the burn wound in patients with large burns. Arch. Surg.124:718, 1989PubMedGoogle Scholar
  15. 15.
    Pruitt, B.A. Jr.: Host-opportunist interactions in surgical infection. Arch. Surg.121:13, 1986PubMedGoogle Scholar
  16. 16.
    McManus, A.T., Kim S.H., McManus, W.F., Mason, A.D. Jr., Pruitt, B.A. Jr.: Comparison of quantitative microbiology and histopathology in divided burn wound biopsy specimens. Arch. Surg.122:74, 1987PubMedGoogle Scholar
  17. 17.
    Pruitt, B.A. Jr., Foley, F.D.: The use of biopsies in burn patient care. Surgery73:887, 1973PubMedGoogle Scholar
  18. 18.
    Kim, S.H., Hubbard, G.B., McManus, W.F., Mason, A.D., Pruitt, B.A. Jr.: Frozen section technique to evaluate early burn wound biopsy: A comparison with the rapid section technique. J. Trauma25:1134, 1985PubMedGoogle Scholar
  19. 19.
    Kim, S.H., Hubbard, G.B., Worley, B.L., McManus, W.F., Mason, A.D. Jr., Pruitt, B.A. Jr.: A rapid section technique for burn wound biopsy. J. Burn Care Rehabil.6:433, 1985PubMedGoogle Scholar
  20. 20.
    Teplitz, C.: Pathogenesis of Pseudomonas vasculitis in septic lesions. Arch. Path.80:297, 1965PubMedGoogle Scholar
  21. 21.
    Zaske, D.E., Sawchuk, R.D., Gerding, D.N., Strate, R.G.: Increased dosage requirements of gentamicin in burn patients. J. Trauma16:824, 1976PubMedGoogle Scholar
  22. 22.
    McManus, W.F., Goodwin, C.W. Jr., Pruitt, B.A. Jr.: Subeschar treatment of burn wound infection. Arch. Surg.118:291, 1983PubMedGoogle Scholar
  23. 23.
    McManus, A.T.: Pseudomonas aeruginosa: A controlled burn pathogen? Antibiot. Chemother.42:103, 1989PubMedGoogle Scholar
  24. 24.
    Becker, W.K., Cioffi, W.G. Jr., McManus, A.T., Kim, S.H., McManus, W.F., Mason, A.D., Pruitt, B.A. Jr.: Fungal burn wound infection: A ten year experience. Arch. Surg.126:44, 1991PubMedGoogle Scholar
  25. 25.
    Pruitt, B.A. Jr.: Phycomycotic infections. In Problems in General Surgery, J.W. Alexander, editor, Philadelphia, J. B. Lippincott Co., 1984, pp 664–678Google Scholar
  26. 26.
    Foley, F.D., Greenawald, K.A., Nash, G., Pruitt, B.A. Jr.: Herpesvirus infection in burned patients. N. Engl. J. Med.282:652, 1970PubMedGoogle Scholar
  27. 27.
    Brandt, S.J., Tribble, C.G., Lakeman, A.D., Hayden, F.G.: Herpes simplex burn wound infections: Epidemiology of a case cluster and responses to acyclovir therapy. Surgery98:338, 1985PubMedGoogle Scholar
  28. 28.
    Bale, J.F., Jr., Kealey, G.P., Massanari, R.M., Strauss, R.G.: The epidemiology of cytomegalovirus infection among patient with burns. Infect. Control Hosp. Epidemiol.11:17, 1990PubMedGoogle Scholar
  29. 29.
    Gross, P.A., Neu, H.C., Aswapokee, P., Van Antwerpen, C., Aswapokee, N.: Deaths from nosocomial infections: Experience in a university hospital and a community hospital. Am. J. Med.68:219, 1990Google Scholar
  30. 30.
    Pruitt, B.A. Jr., Flemma, R.J., DiVincenti, F.C., Foley, F.D., Mason, A.D. Jr.: Pulmonary complications in burn patients. J. Thorac. Cardiovasc. Surg.59:7, 1970PubMedGoogle Scholar
  31. 31.
    Pruitt, B.A. Jr., McManus, A.T.: Opportunistic infections in severely burned patients. Am. J. Med76:146, 1984Google Scholar
  32. 32.
    Shirani, K.Z., Pruitt, B.A. Jr., Mason, A.D. Jr.: The influence of inhalation injury and pneumonia on burn mortality. Ann. Surg,205:82, 1987PubMedGoogle Scholar
  33. 33.
    Cioffi, W.G. Jr., Rue, L.W. III, Graves, T.A., McManus, W.F., Mason, A.D. Jr., Pruitt, B.A. Jr.: Prophylactic use of high frequency percussive ventilation in patients with inhalation injury. Ann. Surg. (in press).Google Scholar
  34. 34.
    Bartlett, J.G., Ryan, K.J., Smith, T.F., Wilson, W.R.: Laboratory diagnosis of lower respiratory tract infections. Cumitech 7A, American Society for Microbiology, Washington, DC, 1987, pp 9–10Google Scholar
  35. 35.
    Springmeyer, S.C., Hackman, R.C., Holle, R., Greenberg, G.M., Weems, C.E., Myerson, D., Meyers, J.D., Thomas, E.D.: Use of bronchoalveolar lavage to diagnosis acute diffuse pneumonia in the immunocompromised host. J. Infect. Dis.154:604, 1986PubMedGoogle Scholar
  36. 36.
    Pruitt, B.A., Jr., Stein, J.M., Foley, F.D., Moncrief, J.A., O'Neill, J.A.: Intravenous therapy in burn patients: Suppurative thrombophlebitis and other life-threatening complications. Arch. Surg.100:399, 1970PubMedGoogle Scholar
  37. 37.
    Welch, G.W., McKeel, D.W. Jr., Silverstein, P., Walker, H.L.: The role of catheter composition in the development of thrombophlebitis. Surg. Gynecol. Obstet138:421, 1974PubMedGoogle Scholar
  38. 38.
    O'Neill, J.A. Jr., Pruitt, B.A. Jr., Foley, F.D., Moncrief, J.A.: Suppurative thrombophlebitis: A lethal complication of intravenous therapy. J. Trauma8:256, 1968PubMedGoogle Scholar
  39. 39.
    Missavage, A.E., McManus, W.F., Pruitt, B.A. Jr.: Suppurative thrombophlebitis. In Current Therapy in Vascular Surgery, C.B. Ernst, J.C. Stanley, editors, Philadelphia, B. C. Decker, Inc., 1987, pp 450–453Google Scholar
  40. 40.
    Pruitt, B.A. Jr., McManus, W.F., Kim, S.H., Treat, R.C.: Diagnosis and treatment of cannula related intravenous sepsis in burn patients. Ann. Surg.191:546, 1980PubMedGoogle Scholar
  41. 41.
    Sasaki, T.M., Welch, G.W., Herndon, D.N., Kaplan, J.Z., Lindberg, R.B., Pruitt, B.A. Jr.: Burn wound manipulation-induced bacteremia. J. Trauma19:46, 1979PubMedGoogle Scholar
  42. 42.
    Kiehn, T.E., Armstrong, D.: Changes in the spectrum of organisms causing bacteremia and fungemia in immunocompromised patients due to venous access devices. Eur. J. Clin. Microbiol. Infect. Dis.9:869, 1990PubMedGoogle Scholar
  43. 43.
    Mason, A.D. Jr., McManus, A.T., Pruitt, B.A. Jr.: Association of burn mortality and bacteremia. Arch. Surg.121:1027, 1986PubMedGoogle Scholar
  44. 44.
    McManus, A.T. Mason, A.D. Jr, McManus, W.F. Pruitt, B.A. Jr.: What's in a name? Is methicillin-resistant Staphylococcus aureus just another S. aureus when treated with vancomycin? Arch. Surg.124:1456, 1989PubMedGoogle Scholar
  45. 45.
    Meers, P.D., Leong, K.Y.: The impact of methicillin: An aminoglycoside-resistant Staphylococcus aureus on the pattern of hospital-acquired infection in an acute hospital. J. Hosp. Infect.16:231, 1990PubMedGoogle Scholar
  46. 46.
    McManus, A.T., McManus, W.F., Mason, A.D. Jr., Aitcheson, A.R., Pruitt, B.A. Jr.: Microbial colonization in a new intensive care burn unit. Arch. Surg.120:217, 1985PubMedGoogle Scholar
  47. 47.
    Shirani, K.Z., McManus, A.T., Vaughan, G.M., McManus, W.F., Pruitt, B.A. Jr., Mason, A.D. Jr.: Effects of environment on infection in burn patients. Arch. Surg.121:31, 1986PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 1992

Authors and Affiliations

  • Basil A. PruittJr.
    • 1
  • Albert T. McManus
    • 1
  1. 1.Library Branch, U.S. Army Institute of Surgical ResearchFort Sam HoustonUSA

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