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Colonization with Multidrug-Resistant Enterobacteriaceae is Associated with Increased Mortality Following Burn Injury in Sub-Saharan Africa

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Abstract

Background

Multidrug-resistant (MDR) bacteria are an emerging international concern in low- and middle-income countries that threaten recent public health gains. These challenges are exacerbated in immunocompromised hosts, such as those with burn injury. This study sought to describe the epidemiology and associated clinical outcomes of burn wound colonization in a Malawian tertiary burn center.

Methods

This is a prospective analysis of burn patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, within 72 h of burn injury. A swab of each patient’s primary wound was collected at admission and each subsequent week. The primary exposure was burn wound colonization with MDR bacteria, particularly Enterobacteriaceae. The primary outcome was in-hospital mortality. A log binomial model estimated the association between the exposure and outcome, adjusted for confounders.

Results

Ninety-nine patients were enrolled with a median age of 4 years (IQR 2–12) and a male preponderance (54%). Median total body surface area burn (TBSA) was 14% (IQR 9–25), and crude in-hospital mortality was 19%. Enterobacteriaceae were the most common MDR bacteria with 36% of patients becoming colonized. Wound colonization with MDR Enterobacteriaceae was associated with increased in-hospital mortality with a risk ratio of 1.86 (95% CI 1.38, 2.50, p < 0.001) adjusted for TBSA, burn type (scald vs. flame), sex, age, length of stay, and methicillin-resistant Staphylococcus aureus colonization.

Conclusion

MDR bacteria, especially Enterobacteriaceae, are common and are associated with worse burn injury outcomes. In resource-poor environments, a greater emphasis on prevention of MDR bacterial colonization, improved isolation precautions, affordable diagnostics, and antibiotic stewardship are imperative.

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Data availability

Jared R. Gallaher, MD, MPH and Anthony G. Charles, MD, MPH had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Funding

Funding was provided by the North Carolina Jaycee Burn Center in the Department of Surgery at the University of North Carolina and a grant from the UNC Womack Surgical Society. A.M.L is supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2TR001109. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

Author information

Authors and Affiliations

  1. Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA

    Jared R. Gallaher & Anthony G. Charles

  2. Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi

    Wone Banda & Anthony G. Charles

  3. Department of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA

    Anne M. Lachiewicz & Robert Krysiak

  4. North Carolina Jaycee Burn Center, Department of Surgery, School of Medicine, University of North Carolina, 4008 Burnett Womack Building, CB# 7600, Chapel Hill, NC, USA

    Bruce A. Cairns & Anthony G. Charles

  5. School of Medicine, University of North Carolina, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA

    Anthony G. Charles

Authors
  1. Jared R. Gallaher
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  2. Wone Banda
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Contributions

JRG, MD, MPH contributed to this paper by design of study, acquisition, analysis, and interpretation of data, drafting and revision of the manuscript, and statistical analysis. AML, MD, MPH contributed to this paper by interpretation of data, critical drafting and revision of the manuscript, and statistical analysis. WB, MB, BS contributed to this paper by design of study, critical revision of the manuscript for important intellectual content, and administrative and technical support. RK, MS contributed to this paper by design of study, acquisition of data, critical revision of the manuscript for important intellectual content, and administrative and technical support. BAC, MD contributed to this paper by design of the study, revision of the manuscript for important intellectual content, supervision, and the obtaining of funding. AGC, MD, MPH contributed to this paper by conception and design of the study, acquisition, analysis, and interpretation of data, drafting and revision of the manuscript, statistical analysis, obtaining of funding, and supervision.

Corresponding author

Correspondence to Anthony G. Charles.

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Conflict of interest

The authors have no conflict of interest to disclose. The authors have no financial relationships to disclose. A.M.L.: Destum Partners and KPB Biosciences, Consulting. GlaxoSmithKline, Research funding. No other disclosures.

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Gallaher, J.R., Banda, W., Lachiewicz, A.M. et al. Colonization with Multidrug-Resistant Enterobacteriaceae is Associated with Increased Mortality Following Burn Injury in Sub-Saharan Africa. World J Surg 42, 3089–3096 (2018). https://doi.org/10.1007/s00268-018-4633-7

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  • DOI: https://doi.org/10.1007/s00268-018-4633-7

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