A systematic review of quantitative burn wound microbiology in the management of burns patients

Nanofabrication of chitosan-based dressing to treat the infected wounds: in vitro and in vivo evaluations

Aim: Here, an innovative kind of antibacterial nanocomposite film is developed by incorporating graphene oxide and zinc oxide into chitosan matrix. Materials & methods: Our dressing was fabricated using the solution casting method. Fourier transform infrared spectra and TGA-DTG clearly confirmed the structure of film dressing. Results & conclusion: Our results showed the tensile strength and elongation at the break of the films were 20.1 ± 0.7 MPa and 36 ± 10%, respectively. Our fabricated film could absorb at least three-times the fluid of its dry weight while being biocompatible, antibacterial, non-irritant and non-allergic. In addition, it accelerated the healing process of infected wounds by regulating epithelium thickness and the number of inflammatory cells, thus it may be useful for direct application to damaged infected wounds.

Consensus on the treatment of second-degree burn wounds (2024 edition)

Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.

Infections in Burn Patients

Infections are the leading cause of mortality in burn patients who survive their initial resuscitation. Burn injury leads to immunosuppression and a dysregulated inflammatory response which can have a prolonged impact. Early surgical excision along with support of the multidisciplinary burn team has improved mortality in burn patients. The authors review diagnostic and therapeutic challenges as well as strategies for management of burn related infections.

Changes in Burn Wound Microbiology Profile Over 14 Years of an Adult Tertiary Burn Center

Burn wound colonization can progress to invasive infection. During 14 years of this study, the burn center was relocated to a center with improved infrastructure. This study investigates the association that infrastructure, geography, and time may have on colonization. Data were collected from October 2004 to August 2018, and relocation took place in June 2010, defining the two study periods. Admission swabs were within 48 hours. Unique isolates and resistance data were analyzed and compared statistically between the two study periods. In total, 2001 patients with 24,226 wound swabs were included. Median age was 45.4 (IQR 30.2-61.6), length of stay was 11 days (IQR 6-21), and %TBSA was 5.5 (IQR 2.5-11). Staph. aureus (33.7/100 patients) and Pseudomonas spp. (13.1/100 patients) were the most prevalent bacterial growths. After admission, the prevalence of methicillin resistant Staph. aureus, Coliform spp., and Aci. baumanni was greater in the first site, and Candida spp. colonization was higher in the second study period site. The prevalence of patients affected by multi-drug-resistant organisms was lower in the second study site (13.5/100 patients vs 16.6/100 patients; P < .05). There are differences in burn wound colonization across time, within the same region. Candida spp. growth has been shown to be increased over time and represents an added challenge. Awareness facilitates effective empirical antimicrobial therapies and protocols locally.

Alginate dressings continuously for fourteen days on uncontaminated, superficial, partial thickness burns

Calcium alginate dressings are commonly used on split-thickness skin donor sites, where they are typically removed after 14 days. Alginates have been used previously on superficial, partial thickness burns, but changed every 3-4 days. In this study, alginates were applied to superficial, partial thickness burns on adults within 36 hours of injury, then left intact for up to 14 days. Wound healing (≥95% wound epithelialisation) and pain were measured. Twenty-one burns were reviewed on ten patients. Per the initial protocol, six patients were reviewed every 3-5 days, with removal of only secondary dressings, until day 13-14, when the alginate dressings were removed. One patient was reviewed every 3-5 days until day 10, when a clinic nurse removed the alginate dressing. Restrictions on movement during the COVID pandemic necessitated a protocol change, with only one review at approximately day 14 for removal of alginate and secondary dressings; three patients were reviewed in this manner. Burns on all patients were 100% epithelialised at the time of final review and there were no complications, such as scarring, infection, or need for grafting. Following initial debridement and dressings, patients reported minimal pain. Dressing costs appeared to be significantly decreased. This protocol may be particularly useful for patients managed in rural and remote locations, with telemedicine support if required.

Choosing wisely in burn care

BACKGROUND

The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices.

METHODS

The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™.

RESULTS

Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations.

CONCLUSIONS

The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

The Chronic Wound Phageome: Phage Diversity and Associations with Wounds and Healing Outcomes

Two leading impediments to chronic wound healing are polymicrobial infection and biofilm formation. Recent studies have characterized the bacterial fraction of these microbiomes and have begun to elucidate compositional correlations to healing outcomes. However, the factors that drive compositional shifts are still being uncovered. The virome may play an important role in shaping bacterial community structure and function. Previous work on the skin virome determined that it was dominated by bacteriophages, viruses that infect bacteria. To characterize the virome, we enrolled 20 chronic wound patients presenting at an outpatient wound care clinic in a microbiome survey, collecting swab samples from healthy skin and chronic wounds (diabetic, venous, arterial, or pressure) before and after a single, sharp debridement procedure. We investigated the virome using a virus-like particle enrichment procedure, shotgun metagenomic sequencing, and a k-mer-based, reference-dependent taxonomic classification method. Taxonomic composition, diversity, and associations with covariates are presented. We find that the wound virome is highly diverse, with many phages targeting known pathogens, and may influence bacterial community composition and functionality in ways that impact healing outcomes.

IMPORTANCE Chronic wounds are an increasing medical burden. These wounds are known to be rich in microbial content, including both bacteria and bacterial viruses (phages). The viruses may play an important role in shaping bacterial community structure and function. We analyzed the virome and bacterial composition of 20 patients with chronic wounds. The viruses found in wounds are highly diverse compared to normal skin, unlike the bacterial composition, where diversity is decreased. These data represent an initial look at this relatively understudied component of the chronic wound microbiome and may help inform future phage-based interventions.

Practical extended use of antimicrobial silver (PExUS)

BACKGROUND

Antimicrobial silver has had a role in wound antisepsis throughout history and, with the rise in acquired antibiotic resistance, silver dressings are once again commonly used. Issues with silver dressings include the important environmental consideration of nanoparticle manufacture, and the significant financial cost of these products. One solution to these problems may be to adopt an opened-but-unused model of wound care whereby dressing materials are used in piecemeal fashion and excess stored in between dressing changes. Due to a lack of literature on the topic, this project was designed with the aim of testing the antimicrobial efficacy of available silver dressings during storage after opening.

METHODS

Four commonly used silver dressings were tested for antimicrobial activity using a zone of inhibition assay against clinically important pathogens. The assay was performed on opening of dressings and repeated over 3 months in storage at 4, 25 or 37°C. Analysis was performed using repeated measures ANOVA. Swab cultures were taken at each simulated dressing change to detect microbial contamination of the dressings during storage.

RESULTS

There was no effect of time or storage temperature on the zone of inhibition over the 12 week test period. No swabs taken returned culture consistent with microbial contamination of stored dressings.

CONCLUSION

Opened silver dressings maintain antimicrobial activity for at least 12 weeks in storage and are resistant to contamination. An opened-but-unused model for wound care is likely to improve cost-effectiveness while preserving effectiveness and safety.

Evaluation of Burn Wound Infection in a Referral Center in Colombia

Introduction  Burn wound infection (BWI) is the second most important cause of death in burn patients. There is currently limited data about the incidence and clinical presentation of BWI using quantitative techniques as quantitative biopsy culture (QBC) to prevent progress to burn wound sepsis (BWS).

Methods  This is a prospective cohort study of patients diagnosed with BWI, confirmed by QBC, from February 2018 to July 2019 at University Hospital of Santander (HUS). The primary outcome was to determine clinical, microbiological, and histopathological characteristics of patients diagnosed with BWI along with a positive QBC and their relationship with early diagnosis and progression to BWS.

Results  525 patients were admitted to HUS Burn Center. Of those, 44/525 (8.23%) presented a clinical diagnosis of BWI (median age, 20.5 years [1–67 years]; 25/44 [56.8%] male). QBC was positive in 26/44 (59%), Staphylococcus aureus 14/44 (31.8%), and Pseudomonas aeruginosa 7/44 (15.9%) were the mainly etiological agents isolated. Bacterial resistance to antibiotics was mostly to beta-lactams in 14/44 (31.8%), corresponding to methicillin-resistant Staphylococcus aureus (MRSA). Clinical signs more related to infection were erythema in 33/44 (61.3%). As many as 10/44 (22.7%) progressed to sepsis and 2/44 (6%) died.

Conclusion  BWI increases hospitalization time and number of surgeries, increasing the risk of sepsis and death. The QBC allows an accurate diagnosis with lesser false-positive cases that impact antibiotic resistance and mortality. Protocols targeting this problem are needed to decrease the impact of this.

Wound infection: A review of qualitative and quantitative assessment modalities

Surgical site infections (SSI) and chronic wounds represent a burden to patients and the health care system. One in 24 surgical patients will develop an SSI, making SSI the most common nosocomial infection in the USA. Early detection and monitoring of wound infection are critical for timely healing and return to normal function. However, the mainstay of wound infection diagnostic entails subjective clinical examination and semi-quantitative, invasive microbiological tests. In this review, we present current wound infection assessment modalities in the clinical and translational fields. There is a need for a point-of-care assessment tool that provides fast, accurate, and quantitative information on wound status, with minimal to no contact with the patient. In the next ten years, the evolution of wound diagnostic tools reported here may allow medical providers to optimize patient care while minimizing patient discomfort.

Antimicrobial silver dressings: a review of emerging issues for modern wound care

Skin is an important barrier to pathogenic microorganisms and plays a critical role in a ctivation of innate immune responses. When the skin barrier is breached following wounding or burn injury, pathogens can invade and complicate healing with infection resulting in delayed healing and symptomatic scarring. Wound infection is a significant problem after burn injury and in patients with chronic wounds. Antimicrobial silver has had a significant role in wound antisepsis throughout history and, given the rise in community acquired antibiotic resistance, silver dressings are now commonly used to combat wound infection. The multi-modal mechanism of action, low potential for toxicity and formation of microbial resistance makes silver dressings suitable tools against a wide array of clinically important microbes. There are, however, a number of issues with silver dressings including a conflicting evidence base, the important environmental consideration of nanoparticle manufacture, and the significant cost of these products. One solution may be to adopt an 'opened-but-unused' means of wound care whereby bulk dressing materials are used piecemeal and stored in between dressing changes to increase the cost-effectiveness and reduced wastage. There is, however, little literature on this topic and so in vitro and clinical research must be performed to consider the efficacy of active ingredient dressings in wound care including silver dressings once opened and stored.

Caffeic Acid Phenethyl Ester Loaded Electrospun Nanofibers for Wound Dressing Application

Electrospinning is an advantageous method with a wide usage area, which enables the production of materials consisting of nano-thickness fibers. In this study, caffeic acid phenethyl ester (CAPE) molecule was loaded onto the poly(lactic-co-glycolic acid) (PLGA) nanofibers and obtained nanofibers were physicochemically and biologically investigated for the first time in the literature. The existence of CAPE molecules, loaded on PLGA membranes by dropping and spraying methods, was evaluated by a comparative investigation of Fourier-transform infrared (FTIR) spectra and X-Ray diffraction (XRD) patterns. Fiber morphology of the membranes was investigated by scanning electron microscope (SEM). CAPE release and swelling behaviors of the membranes were studied in vitro. The radical scavenging activity of CAPE-loaded wound dressing materials was determined by using an antioxidant assay. The antimicrobial properties of PLGA and CAPE-loaded PLGA membranes were evaluated against S. aureus, P. aeruginosa and C. albicans strains by the time-kill method. The biocompatibility study of the obtained CAPE-loaded fibers conducted on human fibroblast cell line and wound healing promoting effect of the fibers was investigated in vitro scratch assay. The results show that CAPE-loaded PLGA membranes are highly antimicrobial against all strains used in the experiment. Additionally, the results show that they are biocompatible and have wound healing properties on human fibroblasts.

An Integrated HOCl-Producing E-Scaffold Is Active against Monomicrobial and Polymicrobial Biofilms

Oxidizing agents like hypochlorous acid (HOCl) have antimicrobial activity. We developed an integrated electrochemical scaffold, or e-scaffold, that delivers a continuous low dose of HOCl aimed at targeting microbial biofilms without exceeding concentrations toxic to humans as a prototype of a device being developed to treat wound infections in humans. In this work, we tested the device against 33 isolates of bacteria (including isolates with acquired antibiotic resistance) grown as in vitro biofilms alongside 12 combinations of dual-species in vitro biofilms. Biofilms were grown on the bottoms of 12-well plates for 24 h. An integrated e-scaffold was placed atop each biofilm and polarized at 1.5 V for 1, 2, or 4 h. HOCl was produced electrochemically by oxidizing chloride ions (Cl^-) in solution to chlorine (Cl₂); dissolved Cl₂ spontaneously dissociates in water to produce HOCl. The cumulative concentration of HOCl produced at the working electrode in each well was estimated to be 7.89, 13.46, and 29.50 mM after 1, 2, and 4 h of polarization, respectively. Four hours of polarization caused an average reduction of 6.13 log₁₀ CFU/cm² (±1.99 log₁₀ CFU/cm²) of viable cell counts of monospecies biofilms and 5.53 log₁₀ CFU/cm² (±2.31 log₁₀ CFU/cm²) for the 12 dual-species biofilms studied. The described integrated e-scaffold reduces viable bacterial cell counts in biofilms formed by an array of antibiotic-susceptible and -resistant bacteria alone and in combination.

The SPaCE diagnostic: a pilot study to test the accuracy of a novel point of care sensor for point of care detection of burn wound infection

BACKGROUND

Wound infection in burn patients is common and has an impact on outcomes. There is no objective method to diagnose infection at point of care (PoC). Early diagnosis prevents progression to sepsis. Diagnostic subjectivity supports over-diagnosis, unnecessary hospitalization, and antibiotic overuse.

AIM

This pilot study aimed to investigate the accuracy of a novel PoC wound infection diagnostic in burn patients.

METHODS

We produced, and in vitro tested, a PoC diagnostic for early wound infection diagnosis. The prototype SPaCE diagnostic uses a patented lipid vesicle suspension into which a clinical swab is placed. The diagnostic delivers a colour-response to Staphylococcus aureus, Pseudomonas aeruginosa, Candida species and Enterococcus faecalis at toxin release. A pilot clinical diagnostic accuracy study was undertaken. The reference standard was a retrospective decision made by an expert clinical panel using routinely available data.

FINDINGS

Data was available from 33 of 34 patients. Of these, 52% were considered to have a wound infection, 42% not, and two (6%) were equivocal. The diagnostic results showed 24% were infected, 42% were not and 33% produced intermediate results. Agreement between clinical judgement and diagnostic result, assessed using a weighted Kappa, was 0.591 suggesting moderate agreement. If the intermediate results were excluded, 22 sets of data with definitive results achieved a Kappa statistic of 0.81 suggesting 'almost perfect' agreement. Sensitivity and specificity were 57% (8/14) and 71% (12/17), respectively.

CONCLUSION

This pilot study provided evidence that the SPaCE diagnostic could provide valuable and timely data to support clinical decision-making at PoC for wound infection.

Mechanisms underlying the wound healing and tissue regeneration properties of Chenopodium album

In the current study, aerial parts (leaves, stem and shoots) of C. album were extracted with methanol and subjected to phytochemical and HPLC analysis. Agar well diffusion method was used for anti-bacterial activity against Gram-negative strains Escherichia coli, Salmonella typhi, Klebsiella, Pseudomonas aeruginosa and Gram-positive Bacillus cereus, Staphylococcus aureus, Methicillin-resistant Staphylococcus aureus. Burn was induced through flame heated metal rod on mice. C. album ointment (2% w/w), Vaseline (vehicle) and silver sulfadiazine (standard) were topically applied thrice daily for 15 days. Wound area was measured on day 0, 5, 10 and 15. On last day, the wound tissues were excised and subjected to histopathological, quantitative PCR and immunohistochemical analysis. Phenols, alkaloids, phytosterols, tannins, saponins, flavonoids, carbohydrates and glycosides were detected in phytochemical analysis. HPLC chromatogram displayed peaks for rutin, quercetin, ascorbic acid, gallic acid and various other phyto-constituents. The extract exhibited zone of inhibition in millimeter (mm) against E. coli (12.3 ± 0.57), S. typhyi (14.6 ± 1.52), Klebsiella (11.8 ± 0.76), P. aeruginosa (12.3 ± 0.57), B. cereus (12.5 ± 1.29), S. aureus (18.3 ± 2.08), and MRSA (11.8 ± 0.76). The wound area in C. album group was significantly (60%) reduced as compared to vehicle group (11%). Histological analysis showed complete re-epithelialization and fine tissue in extract treated group. qPCR data revealed up-regulation of EGF, PDGF and TGF-β1 genes in extract treated group. Similarly, immunohistochemistry results confirmed heightened EGFR expression in extract treated group. Our findings suggest that C. album can promote wound healing and tissue regeneration through control of burns related infection and modulation of growth factors and its receptors.

Burn Infection and Burn Sepsis

Background: Infection is the most common complication and cause of death in patients suffering burn injuries. These patients are susceptible to infection and burn wound sepsis secondary to the alterations in their physiology. Diagnosis and management of infections rely on physical examination, cultures, and the pathology of the burn wound. Method: We performed an electronic search for articles in the Google Scholar and PubMed databases using the search terms "burn sepsis," "burn infection," and "burn critical care." Results: Multiple factors increase burn patients' risk of invasive infection and sepsis, including underlying factors and co-morbidities, the percent total body surface area of the burn, delays in burn wound excision, and microbial virulence/bacterial count. Organisms causing burn wound infection differ, depending on the time since injury and its location; and diagnosis is multi-factorial. The most common pathogens remain Staphylococcus and Pseudomonas spp. Conclusion: Overall, the recognition of burn sepsis is based on clinical findings. Treatment consists of a combination of local dressings, early burn excision, and systemic antimicrobial therapy. The mortality rate has decreased significantly over the past 10 years, but continued efforts at timely management and infection prevention are essential.

Microbial predictors of healing and short-term effect of debridement on the microbiome of chronic wounds

Chronic wounds represent a large and growing disease burden. Infection and biofilm formation are two of the leading impediments of wound healing, suggesting an important role for the microbiome of these wounds. Debridement is a common and effective treatment for chronic wounds. We analyzed the bacterial content of the wound surface from 20 outpatients with chronic wounds before and immediately after debridement, as well as healthy skin. Given the large variation observed among different wounds, we introduce a Bayesian statistical method that models patient-to-patient variability and identify several genera that were significantly enriched in wounds vs. healthy skin. We found no difference between the microbiome of the original wound surface and that exposed by a single episode of sharp debridement, suggesting that this debridement did not directly alter the wound microbiome. However, we found that aerobes and especially facultative anaerobes were significantly associated with wounds that did not heal within 6 months. The facultative anaerobic genus Enterobacter was significantly associated with lack of healing. The results suggest that an abundance of facultative anaerobes is a negative prognostic factor in the chronic wound microbiome, possibly due to the increased robustness of such communities to different metabolic environments.

In vitro antimicrobial efficacy of two medical grade honey formulations against common high-risk meticillin-resistant staphylococci and Pseudomonas spp. pathogens

BACKGROUND

Antimicrobial resistance is a problem in human and animal healthcare. Honey may be used for its wound healing properties and antimicrobial effects.

OBJECTIVE

To investigate the antimicrobial activity of two commercially available medical grade honeys (MGHs) against Staphylococcus spp. and Pseudomonas spp. isolates.

METHODS AND MATERIALS

Two formulations, MGH1 (40% w/v honey) and MGH2 (80% w/v Manuka honey), were tested in vitro for minimal inhibitory concentrations (MIC) and minimal bactericidal concentrations (MBC) against 11 Staphylococcus and 11 Pseudomonas isolates at low [1.5 × 10⁴  colony forming units (cfu)/well] and high (1.5 × 10⁶  cfu/well) concentrations of inoculum, representing systemic and cutaneous bacterial loads during infection, respectively.

RESULTS

MGH2 showed a lower MIC against staphylococci than MGH1, although this was not statistically significant. MGH1 had stronger bactericidal effects against staphylococci than MGH2, although this effect was statistically significant only at the higher bacterial concentration (P < 0.01). For Pseudomonas spp., MGH1 had significantly higher antimicrobial activity (both MIC and MBC) than MGH2 against all isolates tested and at both bacterial concentrations (P < 0.05).

CONCLUSIONS AND CLINICAL IMPORTANCE

Both MGHs were effective in vitro against common cutaneous pathogens including meticillin-resistant staphylococci and Pseudomonas species. The higher efficacy of the MGH1 formulation against Pseudomonas and its consistent effects against staphylococci, while containing only half of the amount of honey compared to MGH2, invites further investigation of the mechanisms and clinical applications of MGH1.

The relation between positive screening results and MRSA infections in burn patients

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA) is a key pathogen in burn patients. Several factors put them at increased risk of MRSA infection: partial loss of the skin barrier, the immune-compromising effects of burns, prolonged hospital stays, and invasive procedures. This study aims to find the relation between MRSA screening swab cultures taken within 48 h of admission, weekly surveillance cultures, and MRSA infection secondary to colonization.

METHODS

The data of all burns patients admitted to the referral centre for burns from 2012 to 2016 were reviewed. MRSA cultures taken at admission and on weekly surveillance screening, including nasal, perianal, and wound swabs, were reviewed. To determine associations between MRSA colonization and infection rates, both MRSA-positive and MRSA-negative swab cultures were included in the analysis. Several risk factors were considered: age, gender, ethnicity, %TBSA, BAUX index, inhalational injury, ICU admission and days, need for ventilator support and days, length of stay (LOS) in hospital, and complications. Univariate and multiple logistic regression analyses were used to predict correlations between positive swab cultures and risk factors.

RESULTS

Data from 396 patients were reviewed. The median age at admission for the burn patients was 46 (IQR: 31-59) years. On admission, 2.5% of patients were MRSA positive, whereas 17.9% were found to be MRSA positive on weekly surveillance screening. At surveillance, 60.6% developed an infection secondary to MRSA colonization. An MRSA infection was not identified for any patient who did not have at least one positive admission or surveillance swab. A statistically significant association was found between any positive swab and MRSA infection (P < 0.001). The median number of complications reported in the MRSA-positive group was 2 (IQR: 1-3) versus 0 (IQR: 0-1) in the MRSA-negative group and the median length of hospital stay in the MRSA-positive group was 34.5 (IQR: 20.25-56.25) days versus 7 (IQR: 3-16) days in the MRSA-negative group (P < 0.001).

CONCLUSION

Nosocomial MRSA colonization rates are high, and patients incurring infections experience a greater than average LOS in hospital and complications. Over 60% of patients who had a positive swab culture at surveillance developed an infection, whereas, no patient with a negative MRSA swab status developed an infection. Hence, pragmatic prevention strategies have to be implemented.

Protocol for the development of a core indicator set for reporting burn wound infection in trials: ICon-B study

INTRODUCTION

Systematic reviews of high-quality randomised controlled trials are necessary to identify effective interventions to impact burn wound infection (BWI) outcomes. Evidence synthesis requires that BWI is reported in a consistent manner. Cochrane reviews investigating interventions for burns report that the indicators used to diagnose BWI are variable or not described, indicating a need to standardise reporting. BWI is complex and diagnosed by clinician judgement, informed by patient-reported symptoms, clinical signs, serum markers of inflammation and bacteria in the wound. Indicators for reporting BWI should be important for diagnosis, frequently observed in patients with BWI and assessed as part of routine healthcare. A minimum (core) set of indicators of BWI, reported consistently, will facilitate evidence synthesis and support clinical decision-making.

AIMS

The Infection Consensus in Burns study aims to identify a core indicator set for reporting the diagnosis of BWI in research studies.

METHODS

(1) Evidence review: a systematic review of indicators used in trials and observational studies reporting BWI outcomes to identify a long list of candidate indicators; (2) refinement of the long list into a smaller set of survey questions with an expert steering group; (3) a two-round Delphi survey with 100 multidisciplinary expert stakeholders, to achieve consensus on a short list of indicators; (4) a consensus meeting with expert stakeholders to agree on the BWI core indicator set.

ETHICS AND DISSEMINATION

Participants will be recruited through professional bodies, such that ethical approval from the National Health Service (NHS) Health Research Authority (HRA) is not needed. The core indicator set will be disseminated through peer-reviewed publication, co-production with journal editors, research funders and professional bodies, and presentation at national conferences.

PROSPERO REGISTRATION NUMBER

CRD42018096647.

The optimal timing of outpatient Biobrane™ application for superficial and mid dermal partial thickness burns: Evidence for the '12-hour rule'

BACKGROUND

Biobrane™ is a skin substitute used for the definitive management of partial thickness burns. No studies have examined the optimal timing of Biobrane™ application in this setting. The purpose of this study was to determine whether there was a clinically significant difference in applying Biobrane to a superficial and mid dermal partial thickness burn within 12h after burn.

METHODS

From August 2016-February 2017, 29 consecutive superficial and mid dermal partial thickness burn injuries were prospectively treated with Biobrane™ within 12h of the injury. This 'early Biobrane™' cohort was compared to a historical cohort of 148 patients who were treated with Biobrane™ for superficial and mid dermal burns after 12h after injury during 2015 to 2016. Multivariate regression analysis was used to determine the difference in time to re-epithelialisation and number of outpatient visits between the two cohorts.

RESULTS

In the 'early Biobrane™' group, the mean TBSA was 3.5±2.7%. and the mean time to Biobrane™ application was 7.1±2.7h after burn injury. The mean time to re-epithelialisation in this group was 9.1±3.0 days, and no patients underwent skin grafting. In the 'delayed Biobrane™' group, the mean TBSA was 2.6±2.8% and the mean time to Biobrane™ application was 35.1±21.4h. The mean time to re-epithelialisation was 14.8±8.7 days, with 3 patients undergoing skin grafting. Regression analysis demonstrated a statistically significant 63% reduction in time to re-epithelialisation (95% CI=0.23-0.60; P<0.0001) with early Biobrane™ application.

CONCLUSION

Patients treated with application of Biobrane™ within 12h of superficial and mid dermal partial thickness burns have a statistically significant reduction in healing time when compared to patients treated with standard Biobrane™ practice.

Management of bacterial skin and skin structure infections with polymicrobial etiology

INTRODUCTION

Skin and Soft Tissue Infections (SSTIs) are some of the most commonly occurring bacterial infections, with a wide range of possible etiological pathogens and a considerable variety of clinical presentations and severity; from mild to severe life-threatening infections. Several classifications have been proposed based on a specific variable, such as anatomical localization, skin extension, progression rate, clinical presentation, severity, and etiological agent. Areas covered: The last criteria allows the differentiation of SSTIs as monomicrobial and polymicrobial. Among them, especially those infections with a long lasting or chronic course can be sustained by multiple microbial etiology. Most polymicrobial SSTIs can be included in the following: diabetes foot infections (DFIs), pressure ulcers infection, burn infection, and infected chronic ulcers. Expert commentary: The medical management of these infections comprises the administration of wide a spectrum antibiotic, taking into consideration the frequent occurrence of multidrug resistant microorganisms as responsible agents. An appropriate deep tissue specimen for microbiological examination is a very important issue, especially for polymicrobial infections, sometimes permitting the distinction between real pathogens and contaminants avoiding more complex antibiotic treatments. This aspect must be strongly emphasized, as frequently superficial swabs remain the specimen of choice because they are easy to obtain.

Acidic Dressing Based on Agarose/Cs2.5H0.5PW12O40 Nanocomposite for Infection Control in Wound Care

Regulation of wound pH from alkaline to acidic is a simple and powerful approach to reduce wound microbial colonization and infection. Here, we present a nanocomposite material possessing intrinsic acidic surface pH as an innovative antimicrobial wound dressing. This material comprises an agarose matrix nanocomposite containing nanoparticles (NPs) of the cesium salt of phosphotungstic heteropolyacid (Cs_2.5H_0.5PW₁₂O₄₀). Self-supporting films were prepared by a casting method incorporating 5-20 wt % Cs_2.5H_0.5PW₁₂O₄₀ NPs into the matrix. Films are flexible with tensile strengths between 28.55 and 32.15 MPa and exhibit broad biocidal activity against neutralophilic pathogens, including Gram-positive bacteria, Gram-negative bacteria, yeast, and filamentous fungi. The nano-antimicrobial Cs_2.5H_0.5PW₁₂O₄₀ functions as an efficient and self-controlled proton delivery agent that lowers the surface pH of the nanocomposites to the range 7.0 > pH ≥ 3.0. Nanocomposite films containing 20 wt % Cs_2.5H_0.5PW₁₂O₄₀ NPs presented a surface pH of 3.0 and highest antimicrobial activity. Using quantitative reverse transcription polymerase chain reaction, we demonstrated that the antimicrobial mechanism of the nanocomposites is acid-induced because of the transcriptional induction of glutamate-dependent acid resistance genes in Escherichia coli. Additionally, nanocomposite films do not damage skin according to an in vivo rabbit skin model with no derived edema or erythema. The wound care safety of this material is due to low release of heavy metal heteropolyanions ([PW₁₂O₄₀]^3-), no nanoparticle leaching, and proton controlled release resulting in nonirritating acid levels for human skin models.