Incidence of non-candidal fungal infections in severe burn injury: an Australian perspective

Fusariosis in burn patients: A systematic review of case reports

Burns can cause skin damage, facilitating the entry of fungi and other microorganisms into the body, leading to infections. Fusarium is a fungus capable of infecting individuals with burn injuries. Diagnosing and treating Fusarium infections in burn patients can be challenging due to the manifestation of nonspecific symptoms. This study aims to investigate case reports and case series from published literature describing Fusarium infection in burned patients, in order to assess treatment regimens, clinical outcomes, and make recommendations for future management. We conducted searches on Web of Science, PubMed, ScienceDirect, and Medline for all case reports and case series containing keywords 'Burn', 'Burns', 'Burned', 'Fusarium', or 'Fusariosis' in the title or abstract. All burn patients who developed Fusarium fungal infections between January 1974 and March 2023 were included in the study. Demographic and clinical data were analyzed retrospectivity. The final analysis incorporates 24 case reports encompassing a total of 87 burn patients with Fusarium infection. Patient ages ranged from one to 85 years, with the majority being male (53%). The median percentage of burn surface area was 78%, and the skin in the face, upper limbs, and lower limbs were the most commonly infected sites. Fungal infections appeared around 10 days after the burn injury on average. The majority of the patients were identified through culture or histopathology. The Fusarium dimerum species complex, which was found in nine patients, was the most frequently identified Fusarium species complex. Amphotericin B was the most preferred treatment drug, followed by voriconazole, and 62% of patients underwent debridement. In our study, 23 patients (37%) died from fungal infections. Implementing early and effective treatment protocols targeting Fusarium spp. in burn treatment units can significantly reduce mortality rates. It is critical to enhance the understanding of fusariosis epidemiology and emphasize the importance of maintaining a high clinical suspicion for this condition in burn patients.

Extensive primary cutaneous fusariosis in a patient with burns: A case report and review of the literature

BACKGROUND

Fusarium species can cause a broad spectrum of human infections, ranging from superficial and locally invasive to disseminated, depending on the immune status of the host and portal of entry. Although several cases of cutaneous fusariosis in burn victims have been reported, molecular identification for pathogen recognition has been used only in a few cases.

CASE DESCRIPTION

In this report, we describe an uncommon case of extensive primary cutaneous fusariosis caused by Fusarium keratoplasticum in a patient who sustained injuries during stubble burning.

FINDINGS

A review of cases of cutaneous fusariosis in burn victims revealed that this uncommon infection could be lethal, and treatment strategies should focus on both surgical debridement and the initiation of systemic antifungal therapy. Furthermore, because skin defects can serve as a portal of entry for Fusarium species in burn victims, early and aggressive treatment is crucial to prevent serious consequences.

Mucormycosis following burn injuries: A systematic review

INTRODUCTION

Mucormycosis is an opportunistic fungal infection with a high mortality rate. Though typically associated with diabetes and other conditions that affect innate immune function, infections can also be precipitated by conditions such as trauma and burns. Burn patients are particularly susceptible to fungal infections due to the immune dysfunction that often accompany their wounds. Indeed case series have described mucormycosis to occur in patients with burn injuries, however the factors contributing to mortality have not been well described. Thus, the purpose of our review was to identify factors contributing to morbidity and mortality in burn patients with Mucormycosis.

METHODS

A systematic review of the literature of mucormycosis infection in burn injury patients was performed on Pubmed and Google Scholar using the keywords: Mucor, Mucorales, Mucormycosis, Mucormycotina, Zygomycosis and burn or thermal injury. Clinical trials, observational studies, case reports, and case reviews were included if they provided information regarding mortality in adult and pediatric burn patients diagnosed with mucormycosis, review articles, non-English articles, and articles without patient information were excluded. No time limit was placed on our review. Individual patient data was stratified based on mortality. Statistical analysis was performed to investigate the relationship between patient risk factors and mortality, and the Oxford Level of Evidence was used to evaluate study quality.

RESULTS

46 articles were included in our final review, encompassing 114 patients. On average, survivors had a total body surface area (TBSA)% of 46 (SD 19.8) while non-survivors had a TBSA of 65% (SD 16.4), and this difference was significant (p < .001). Patients with disseminated mucormycosis experienced an 80% mortality rate compared to 36% mortality rate in patients with localized disease (p < .001). We found no statistically significant difference in mean age (p > .05), diabetes (p > .05), mean delay in diagnosis (p > .05), time to antifungal therapy (p > .05), or type of therapy used (p > .05) between survivors and non-survivors. Our review was limited by the lack of prospective, controlled trials; thus, our review primarily consists of case reports.

CONCLUSION

Disseminated infections and higher TBSA both increased the risk of mortality in burn patients with mucormycosis, while diabetes did not increase mortality risk. The severity of the initial injury and infection locations must be taken into consideration to inform patient prognosis.

Mucormycosis in burns: a review

Mucormycosis is a rare fungal infection with a high mortality rate. It presents with scattered black/necrotic ulcers, white fungal elements, and progression of wounds despite seemingly adequate debridement. Diagnosis is confirmed on wound histology, however this is often delayed. There is currently no comprehensive review of burn related mucormycosis within the literature, making this the first paper to provide evidence-based treatment guidance. We performed a review of publications from 1946 - present. There were 151 cases of mucormycosis complicating burns. The mortality rate was 54.5%, and there was a significant increase in mortality with axial body site involvement compared with isolated peripheral involvement. The standard treatment was prompt and radical debridement. Utilisation of frozen section to guide debridement aided in clinical decision making. No systemic treatment reached statistical significance, however amphotericin B trended towards significance. Although there is no strong evidence for topical amphotericin B or hyperbaric oxygen, there may be benefit in some cases. This study recommends early radical debridement in conjunction with the European Confederation of Medical Mycology guidelines of IV liposomal/lipid complex amphotericin B >5mg/kg/day, with posaconazole 800mg daily in divided doses as a salvage or oral step-down 1.

Effects of resveratrol on the growth and enzyme production of Stenotrophomonas maltophilia: a burn wound pathogen

OBJECTIVE

The purpose of this study was to identify the potential of resveratrol in inhibiting the growth and production of two enzymes, hyaluronidase and protease, in Stenotrophomonas maltophilia, which has become a burn wound pathogen of great significance.

METHOD

Stenotrophomonas maltophilia (ATCC 17666) was cultured in nutrient broth and the microbial load was standardised to 0.5 McFarland standard at 600nm. The study included antimicrobial assays (well diffusion and resazurin dye binding method), hyaluronidase expression regulation assay (hyaluronic acid hydrolysis assay and turbidity assay) and protease expression regulation assay (casein hydrolysis assay and determination of specific activity of protease using tyrosine standard).

RESULTS

The minimum inhibitory concentration (MIC) of resveratrol against Stenotrophomonas maltophilia was found to be 125µg/ml. Hyaluronidase production in the organism treated with resveratrol was found to be half that in the untreated organism. The specific activity of protease produced by the organism treated with resveratrol was found to be one-quarter that in the untreated organism, as analysed by the tyrosine standard estimation protocol.

CONCLUSION

Resveratrol was found to be a potent compound to treat Stenotrophomonas maltophilia infections. In addition to the antimicrobial and enzyme-regulatory properties of resveratrol, it also shows anti-oxidant and anti-inflammatory properties. This finding has great scope clinically as resveratrol may prove to be an ideal drug to treat burn wound infections.

Trichoderma longibrachiatum and Aspergillus fischeri Infection as a Cause of Skin Graft Failure in a Patient with Critical Burns after Liver Transplantation

Infectious complications are responsible for the majority of mortalities and morbidities of patients with critical burns. Although bacteria are the predominant etiological agents in such patients, yeasts and fungi have become relatively common causes of infections over the last decade. Here, we report a case of a young man with critical burns on 88% TBSA (total body surface area) arising as a part of polytrauma. The patient's history of orthotopic liver transplantation associated with the patient's need to use combined immunosuppressant therapy was an additional complication. Due to deep burns in the forearm region, we have (after a suitable wound bed preparation) applied a new bi-layered dermal substitute. The patient, however, developed a combined fungal infection in the region of this dermal substitute caused by Trichoderma longibrachiatum and Aspergillus fischeri (the first case ever reported). The infection caused the loss of the split-thickness skin grafts (STSGs); we had to perform repeated hydrosurgical and mechanical debridement and a systemic antifungal treatment prior to re-application of the STSGs. The subsequent skin transplant was successful.

Fungal Infection in Burn Patents: A Review of 36 Case Reports

OBJECTIVES

The aims of this study were to review recent fungal infection case reports published, evaluate the treatment regimens and clinical outcomes, and provide recommendations for future management.

METHODS

A review of case reports published over the last decade was conducted. PubMed was searched to collect the relevant citations using a combination of the key words ("burn," "burned," "burns," "fungal," "fungi," and "fungus") in title or abstract. Case series, reviews, guidelines, and experimental and non-English studies were excluded. Statistical analyses were performed using Microsoft Excel 2019.

RESULTS

A total of 36 case reports encompassing a total of 44 burn patients with fungal infection were included in the final analysis. Ablative surgeries, including surgical excision, debridement, skin graft, vitrectomy, teeth extraction, valve replacement, or amputation, were performed in 38 cases after the suspicion or identification of fungal infection. Twenty-nine of them were eventually discharged, yielding a survival rate of 76.3%. In the remaining 6 cases, ablative surgery was not mentioned and 3 of them eventually died, yielding a survival rate of 50%. The total mortality was 27.27%. Among the 12 death cases, 1 was infected with Candida albicans, 1 with non-albicans Candida, 2 with Aspergillus spp, 2 with Fusarium spp, 4 with Zygomycetes, and 2 with other fungal species.

CONCLUSIONS

The overall mortality of fungal wound infection is still high in burn patients around the world, especially those infected with non-Candida species. Early diagnosis of fungal infection, early initiation of appropriate antifungal therapy, and effective surgical intervention are key measures to improve the treatment effect and reduce the mortality of fungal infection in burn patients.

The pathogenesis and diagnosis of sepsis post burn injury

Burn is an under-appreciated trauma that is associated with unacceptably high morbidity and mortality. Although the survival rate after devastating burn injuries has continued to increase in previous decades due to medical advances in burn wound care, nutritional and fluid resuscitation and improved infection control practices, there are still large numbers of patients at a high risk of death. One of the most common complications of burn is sepsis, which is defined as “severe organ dysfunction attributed to host's disordered response to infection” and is the primary cause of death in burn patients. Indeed, burn injuries are accompanied by a series of events that lead to sepsis and multiple organ dysfunction syndrome, such as a hypovolaemic state, immune and inflammatory responses and metabolic changes. Therefore, clear diagnostic criteria and predictive biomarkers are especially important in the prevention and treatment of sepsis and septic shock. In this review, we focus on the pathogenesis of burn wound infection and the post-burn events leading to sepsis. Moreover, the clinical and promising biomarkers of burn sepsis will also be summarized.

Microbiology of secondary infections in Buruli ulcer lesions; implications for therapeutic interventions

Background

Buruli ulcer (BU) is a skin disease caused by Mycobacterium ulcerans and is the second most common mycobacterial disease after tuberculosis in Ghana and Côte d’Ivoire. M. ulcerans produces mycolactone, an immunosuppressant macrolide toxin, responsible for the characteristic painless nature of the infection. Secondary infection of ulcers before, during and after treatment has been associated with delayed wound healing and resistance to streptomycin and rifampicin. However, not much is known of the bacteria causing these infections as well as antimicrobial drugs for treating the secondary microorganism. This study sought to identify secondary microbial infections in BU lesions and to determine their levels of antibiotic resistance due to the prolonged antibiotic therapy required for Buruli ulcer.

Results

Swabs from fifty-one suspected BU cases were sampled in the Amansie Central District from St. Peters Hospital (Jacobu) and through an active case surveillance. Forty of the samples were M. ulcerans (BU) positive. Secondary bacteria were identified in all sampled lesions (N = 51). The predominant bacteria identified in both BU and Non-BU groups were Staphylococci spp and Bacilli spp. The most diverse secondary bacteria were detected among BU patients who were not yet on antibiotic treatment. Fungal species identified were Candida spp, Penicillium spp and Trichodema spp. Selected secondary bacteria isolates were all susceptible to clarithromycin and amikacin among both BU and Non-BU patients. Majority, however, had high resistance to streptomycin.

Conclusions

Microorganisms other than M. ulcerans colonize and proliferate on BU lesions. Secondary microorganisms of BU wounds were mainly Staphylococcus spp, Bacillus spp and Pseudomonas spp. These secondary microorganisms were less predominant in BU patients under treatment compared to those without treatment. The delay in healing that are experienced by some BU patients could be as a result of these bacteria and fungi colonizing and proliferating in BU lesions. Clarithromycin and amikacin are likely suitable drugs for clearance of secondary infection of Buruli ulcer.

Fungal Infections in Burn Patients

Background: Fungal burn wound infections are among the most devastating complications in patients who are severely burned. Increasing incidence of burn wound infections caused by fungi led to new challenges in diagnostic and therapeutic approaches. The wide use of broad-spectrum antibiotic agents, an increased prevalence of molds and non-Candida albicans spp., and the variety of available antifungal agents underline the importance of identifying the causative species, to initiate adequate therapy within an adequate timeframe. Methods: Review of the pertinent English and German literature. Results: Fungal burn wound infections go along with a delay of identifying the causative fungus species and can be mistaken for early bacterial burn wound infection. Recently, an increase of uncommon fungal pathogens and fungi resistance against antifungal agents has been reported. Amphotericin B and voriconazole remain the antifungal drugs used most commonly. Conclusions: Adequate therapy remains challenging. Early radical debridement and wound closure play an imperative part, particularly in preventing infections caused by yeasts and molds or any other agent. Prophylactic empiric pharmacologic treatment is reserved for those highly at risk for invasive burn wound infection only. Because of the emergence of drug-resistant fungi, the development of new antifungal drugs is essential for the battle against fungal burn wound infections.

Difficult to Treat Infections in the Burn Patient

Background: Unusual infections can lead to complications in more severely burned patients and pose major challenges in treatment. Methods: The published literature of retrospective reviews and case series of the uncommon infections of osteomyelitis, polymicrobial bacteremia, recurrent bacteremia, endocarditis, central nervous system (CNS), and rare fungal infections in burned patients have been summarized and presented. Results: When compared with infections occurring in the non-burn population, these infections in burn patients are more likely to be because of gram-negative bacteria or fungi. Because of hyperdynamic physiology and changes in immunomodulatory response secondary to burns, the clinical presentation of these infections in a patient with major burns differs from that of the non-burn patient and may not be identified until the post-mortem examination. Some of these infections (osteomyelitis, endocarditis, CNS, rare fungal infections) may necessitate surgical intervention in addition to antimicrobial therapy to achieve cure. The presence of the burn and allograft can also present unique challenges for surgical management. Conclusions: These difficult and unusual infections in the severely burned patient necessitate an index of suspicion, appropriate diagnosis, identification and sensitivities of the putative pathogen, effective systemic antimicrobial therapy, and appropriate surgical intervention if recovery is to be achieved.

Outcome and characteristics of invasive fungal infections in critically ill burn patients: A multicenter retrospective study

BACKGROUND

Characteristics and outcome of invasive fungal infection (IFI) in critically ill burn patients have been poorly explored.

OBJECTIVES

We report the factors associated with 90-day mortality in a multicentre retrospective European study.

PATIENTS/METHODS

All burn patients with confirmed IFI admitted between 1 January 2010 to 31 December 2015 in 10 centres in France and Belgium were included.

RESULTS

Ninety-four patients were enrolled with 110 cases of IFIs: 79 (71.8%) were yeasts IFI and 31 (28.2%) filamentous IFI. Incidence was 1% among admitted patients. The 90-day mortality was 37.2% for all IFIs combined, 52% for filamentous infection and 31.9% for yeast infection. Patients with more than one IFI had a higher 90-day mortality than patients with only one episode (61.5% vs 33.5% (P = .006)). In multivariate analysis, higher Simplified Acute Physiology Score II (OR = 1.05 (95% CI: 1.02-1.09) P = .003), bacterial co-infection (OR = 3.85 (95% CI: 1.23-12.01), P = .014) and use of skin allografts at the time of IFI diagnosis (OR = 3.87 (95% CI: 1.31-11.42), P = .021) were associated with 90-day mortality.

CONCLUSIONS

Although rare, invasive fungal infections remain associated with poor outcome in burn patients. Bacterial co-infection and presence of allograft were potentially modifiable factors independently associated with outcome.

A Rare Case of Fungal Burn Wound Infection Caused by Fusarium solani in Vietnam

A patient with extensive burn injuries was admitted to the National Hospital of Burns in Hanoi, Vietnam, and diagnosed with fungal wound infection by histological examination of skin biopsy samples. Fusarium solani was isolated and identified by analysis of its morphological features and the sequence of the internal transcribed spacer region. The isolation showed in vitro resistant to fluconazole, voriconazole, itraconazole, amphotericin B, and caspofungin. Invasive fusariosis is difficult to treat due to its angioinvasive property and its lacking amenability to treatment with antifungal drugs. This infection is rare and has not been reported so far in Vietnam.

Fusarium Solani Infection Following Burn Injury: A Case Report

Fungal infections are becoming increasingly recognized among burn patients. Infection with Fusarium, a filamentous mold, is rarely encountered and mainly seen in immunocompromised patients. High mortality and morbidity were reported with these virulent infections. We present a rare case of refractory septic shock from upper extremity fungal infection with Fusarium solani in a burn patient. Multiple operative debridements and below elbow amputation caused resolution of septic shock. Closure was achieved with a split thickness skin graft. Aggressive approach should be adopted in managing burn patients with Fusarium infection. Serial debridements and extremity amputation should be considered in attempts to improve survival.

Mucormycosis in Burn Patients

Patients with extensive burns are an important group at risk for cutaneous mucormycosis. This study aimed to perform a systematic review of all reported mucormycosis cases in burn patients from 1990 onward. A Medline search yielded identification of 7 case series, 3 outbreaks, and 25 individual cases reports. The prevalence reached 0.04%–0.6%. The median age was 42–48 in the case series and outbreaks, except for the studies from military centers (23.5–32.5) and in individual reports (29.5). The median total body surface area reached 42.5%–65%. Various skin lesions were described, none being pathognomonic: the diagnosis was mainly reached because of extensive necrotic lesions sometimes associated with sepsis. Most patients were treated with systemic amphotericin B or liposomal amphotericin B, and all underwent debridement and/or amputation. Mortality reached 33%–100% in the case series, 29%–62% during outbreaks, and 40% in individual cases. Most patients were diagnosed using histopathology and/or culture. Mucorales qPCR showed detection of circulating DNA 2–24 days before the standard diagnosis. Species included the main clinically relevant mucorales (i.e., Mucor, Rhizopus, Absidia/Lichtheimia, Rhizomucor) but also more uncommon mucorales such as Saksenaea or Apophysomyces. Contact with soil was reported in most individual cases. Bandages were identified as the source of contamination in two nosocomial outbreaks.

Microbiological Profile of Infections in a Tertiary Care Burns Unit

Background

The burden of infections among burns patients is higher in healthcare settings due to partial or complete loss of skin as a physical barrier among these patients. We intend to present microbiological profile of patients admitted to a tertiary care hospital in South India.

Aim

To describe microbiological profile of infections and antimicrobial susceptibility pattern of clinical isolates from burns patients in our tertiary care hospital.

Materials and methods

This retrospective analysis was done on consecutive patients admitted with burns over a period of three years at Apollo Specialty Hospitals, a tertiary care facility in Vanagaram, Chennai. Data analysis included clinical isolates from blood, urine, tissue, pus and tracheal aspirate. Types of bloodstream infections, urosepsis and antibiogram are described.

Results

Among 219 clinical isolates from various samples, 75% were gram-negative, 19% gram-positive and 6% were yeast like fungi. Among bloodstream infections, 32% were polymicrobial. Urosepsis was observed in 39% patients. Wound infections with sepsis was seen in 39% patients. Gram-negative isolates showed better susceptibility to amikacin, carbapenems, beta lactam – beta lactamase inhibitor combinations. Gram-positive isolates had better susceptibility to macrolides, doxycycline, glycopeptides.

Conclusion

The high prevalence of gram-negative, polymicrobial infections and multidrug resistant bacteria noted in our patients and the sensitivity patterns would help with appropriate decision on initial antibiotic therapy. However escalation and de-escalation of antibiotics should be planned based on culture reports.

How to cite this article

Ebenezer R, Princess I, Vadala R, Kumar S, Ramakrishnan N, Krishnan G. Microbiological Profile of Infections in a Tertiary Care Burns Unit. Indian J Crit Care Med 2019;23(9):405–410.

Candida parapsilosis isolates from burn wounds can penetrate an acellular dermal matrix

We isolated and identified yeasts from burn wounds and evaluated the ability of Candida parapsilosis isolates from burn wounds to penetrate an acellular dermal matrix (ADM). A prospective study was conducted with patients from the burn treatment center of North Paraná University Hospital in Londrina, Brazil from February 2015 to January 2016. Yeast cultures were obtained from the tissue of burn wounds that had been debrided and cleansed with 2% chlorhexidine. After identification and confirmation of the purity of the culture, the yeasts were placed on ADM fragments and incubated for three or seven days. During the study period, 273 patients were treated, and 36 of these patients fulfilled the inclusion criteria and provided samples for culture. Yeasts were isolated in 19.44% (n = 7) of the cultures, and the following species were identified: C. parapsilosis (57.1%), C. albicans (28.6%), and C. glabrata (14.3%). C. parapsilosis, the most frequent species, was chosen for the ADM tests. We demonstrated active penetration of the ADM by the yeast isolates from burn wounds. C. parapsilosis grew on ADM and penetrated the matrix, indicating that this yeast, which is common in skin and cutaneous wounds, has the potential to colonize and pass through ADM, a medical device that is frequently used to dress and regenerate burn wounds.

Real-time polymerase chain reaction detection of Lichtheimia species in bandages associated with cutaneous mucormycosis in burn patients

BACKGROUND

Cutaneous mucormycoses, mainly due to Lichtheimia (Absidia), have occurred on several occasions in the Burn Unit of the University Hospital of Lille, France.

AIM

To investigate the potential vector role of non-sterile bandages used to hold in place sterile gauze used for wound dressing.

METHODS

Mycological analysis by conventional culture, Mucorales real-time polymerase chain reaction (qPCR), and Lichtheimia species-specific qPCR were performed on eight crepe and six elasticized bandages that were sampled on two independent occasions in March 2014 and July 2016. Characteristics of the seven Lichtheimia mucormycoses which occurred in burn patients between November 2013 and July 2016 were also collected to assess the epidemiological relationship between potentially contaminated bandages and clinical infections.

FINDINGS

One Lichtheimia corymbifera strain was isolated from a crepe bandage by culture, and Lichtheimia spp. qPCR was positive in six out of eight crepe and four out of six elasticized bandages. Using species-specific qPCR, Lichtheimia ramosa, Lichtheimia ornata, and L. corymbifera were identified in six out of ten, five out of ten, and four out of ten bandages, respectively. In patients with mucormycosis, L. ramosa and L. ornata were present in five and two cases, respectively.

CONCLUSION

Our data support the utility of Mucorales qPCR for epidemiological investigations, the potential role of these bandages in cutaneous mucormycoses in burn patients in our centre, and, consequently, the need for sterile bandages for the dressing of extensive wounds.

Cutaneous mucormycosis in advanced HIV disease

Angionvasive mucormycosis is an emerging fungal disease known to affect mainly diabetics or subjects with profound neutropenia. Infection usually occurs through the inhalation route, but cutaneous inoculation may occur after trauma or burns. However, mucormycosis remains unusual in HIV infection. We report a fatal case of cutaneous mucormycosis due to Rhizopus arrhizus involving the scalp following herpes zoster infection. The patient was a 42-year-old man with advanced AIDS failing on salvage antiretroviral therapy. The fungus was diagnosed on the basis of histopathology and culture. Our case emphasizes the need to consider mucormycosis in the differential diagnosis of necrotic cutaneous lesions in patients with late-stage HIV disease.