Nosocomial Infections in A Brazilian Burn Unit: Jefferson Lessa Soares de Macedo, Joa o Barberino Santos
Nosocomial Infections in A Brazilian Burn Unit: Jefferson Lessa Soares de Macedo, Joa o Barberino Santos
Nosocomial Infections in A Brazilian Burn Unit: Jefferson Lessa Soares de Macedo, Joa o Barberino Santos
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Abstract
In 1-year prospective study, bacterial and fungal infections presenting in burned patients were registered. Two-hundred and seventy-eight
patients were included. The median total body surface area burned was 14% (range 1–100%). The median length of hospital stay was 12 days
(range 1–86 days). Eighty-six patients had in all 148 infections. Seventy-two bloodstream infections (BSI) occurred in 57 patients; most
common microorganisms were coagulase-negative staphylococci and methicillin-sensitive Staphylococcus aureus. Forty-nine (17.6%)
patients had burn wound infections and 18 (6.5%) had pneumonia. Antibiotics were given to only 30% of the burn patients. Overall mortality
rate was 5.0% (14/278). The database can be used to evaluate the effects of changes in burn treatment, staffing and design of burn units, and
antimicrobial resistance development in relation to antibiotic usage.
# 2005 Elsevier Ltd and ISBI. All rights reserved.
generally admitted to the Burns Unit if they were adults, or management of a burn victim are followed carefully. Only
less than 10% if they were children. Patients with full skin burn wound infections already present on admission were
thickness burns of small extent (5% of the body surface excluded. Infections were grouped in three major classes:
area), were also treated as outpatients until the wound was bloodstream infection (BSI), pneumonia and burn wound
ready for excision and grafting by members of plastic infection. The diagnosis of infection in burn patients is based
surgery team. Commonly admission to the Burns Unit only on clinical and laboratory parameters. The criteria for
occurred with severely burned patients (>25–30% of the infections were mainly based on those given by the Center
body surface area). for Disease Control, Atlanta, USA [3,13].
At direct patient contact a protective gown and disposable Infection were suspected when a patient showed signs of
gloves were used. Hands were washed with conventional disorientation, hyperpyrexia or hypothermia, circulatory
soap when necessary, and disinfected with 70% ethanol/ embarrassment, petechial hemorrhages, black and dark
glycerol before and after patient contact. discoloration in a previously clean appearing burn wound,
Fluid replacement was given according to a modified early and rapid eschar separation, bleeding into the
Parkland formula [8]. Plasma was given from the second subcutaneous tissues, and increasing edema in surrounding
day. Central venous catheters were placed in the subclavian areas or leukocytosis in white blood cells counts.
or femoral vein at the discretion of the anesthetist. The If there was any doubt about the diagnosis, a final
catheters were removed on clinical grounds: no further decision was reached by consensus between the infectious
indication, mechanical failure or suspected catheter infec- disease consultant (author) and the burn surgeon directly in
tion. Catheters were not changed routinely. charge of the patient. Whenever we found positive blood
Early excision and skin grafting was performed within cultures a BSI was registered even if the patient at the same
the first 5 days in full thickness burns when the patients time had pneumonia and/or wound infection, which were
condition permitted. also registered.
All catheter tips were cultured when removed. On The evaluation of lymphocyte population of patients was
suspicion of blood stream infection, two to three sets of performed by the flow cytometer at seven days post burn.
blood cultures were drawn by syringe from a peripheral vein The FITC—stained (flouroescein isothiocyanate) lympho-
and one culture from any suspected focus of infection. cytes emit yellow-green light (at 515 nm, CD4 surface
Microbial cultures were processed according to current antigen) while the PE—stained (phyoerytrin) lymphocytes
methods. The bacteriological isolation was carried out in the emit red-orange light (at 580 nm, CD8 surface antigen). All
microbiology laboratory of the Hospital Regional da Asa data were processed with SimulTest IMK Plus software
Norte, Brası́lia. The swabs were dipped in Stuart́s transport program.
medium then plated on blood agar, chocolate agar, Statistical methods used were Fisher’s exact test, Chi-
MacConkey, and Sabouraud́s dextrose agar media (Difco). square analysis with Yateścorrection and logistic regression
After incubation for 18–48 h at 37 8C, the isolates were analysis. This study was approved by the Ethical Committee
identified using conventional protocol. Afterwards, the of the Secretary of State for Health of Brası́lia, Federal
sensitivity to the antibiotics was accomplished by automated District.
method bioMèrieux Vitek. The confirmation of precision
and accuracy of the procedures to evaluate the antimicrobial
susceptibility was made using ATCC (American Type 3. Results
Culture Collection) standard strains. When isolated Staphy-
lococcus aureus oxacillin resistant, Acinetobacter sp and Two-hundred and seventy-eight patients with burns,
Pseudomonas aeruginosa multiresistant were confirmed by consecutively admitted to the Burn Unit of Hospital
disc, by agar diffusion method according to the rules Regional da Asa Norte during 2004, 86 female and 160
established by NCCLS [10]. male patients were included in the study. Median age for the
Fungal cultures were obtained on Sabouraud dextrose 278 patients was 24 years (range 1–82). Median TBSAB
agar (Difco) and on ‘‘mycogel’’ agar (Oxoid) at 378 and was 14% (range 1–100%). One-hundred and fifty-two
observed daily for 20 days. The characterization of fungi (54.7%) of the patients had flame injuries, 96 (34.5%) were
was done by the germ tube test, morphological examination scald injuries, 25 (9%) electrical injuries and 5 (1.8%)
and automated method Vitek YBC yeast identification chemical injuries. Seven (3.9%) patients had smoke
system (bioMèrieux Vitek, Inc., MI, USA) [11]. However, inhalation injury.
antibiotic sensitivity of fungi can not be done due to Two-hundred and forty-five patients stayed >72 h in the
technical problems. unit. The median length of stay was 12 days (range 1–86
Infections in all patients, admitted and treated for burns, days).
have been registered prospectively, according to previously Two-hundred and thirty-four patients were admitted on
defined criteria [3,12]. Prophylactic antimicrobial therapy the day of injury and eight had been treated in another
was not given. All infections were registered, starting at the hospital before admission. Twenty-eight patients were
day of admittance. Any infections manifested during the infected on admission. Of these, all had wound infections.
J.L.S. de Macedo, J.B. Santos / Burns 32 (2006) 477–481 479
Table 1
Comparison between infected and uninfected patients
Infected Uninfected P
Patient (no.) 86 192
Age (years, median, standard deviation) 28.3 23.6 21.5 19.1 0.021
Flame injuries (% patients) 69.8 50.5 0.002
TBSAB % (median, standard deviation) total 23.1 20.6 9.0 6.5 <0.001
Self-damage (no patients) 11 4 0.001
Length of stay (days, median, standard deviation) 19.3 11.9 8.7 5.9 <0.001
Three or more catheters (no patients) 16 0 <0.001
Necessity of transfusion (no patients) 50 30 <0.001
Multiresistant bacteria in the wound (no patients) 51 34 <0.001
Fungi in the wound (no patients) 31 11 <0.001
Hemoglobin 9 g/dl (no patients) 50 29 <0.001
Serum albumin 2.0 g/dl (no patients) 16 2 <0.001
Platelets 100.000 (no patients) 9 0 <0.001
Number of CD4+ cells (median, standard deviation) 361 261 553 230 <0.001
No operation (median, standard deviation) 3.2 1.7 2.1 1.1 <0.001
Mortality (no patients) 13 1 <0.001
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