Effectiveness of Bacteria-Controlled Nursing Units in Preventing Cross-Colonization With Resistant Bacteria in Severely Burned Children

Antibiotic prophylaxis for preventing burn wound infection

BACKGROUND

Infection of burn wounds is a serious problem because it can delay healing, increase scarring and invasive infection may result in the death of the patient. Antibiotic prophylaxis is one of several interventions that may prevent burn wound infection and protect the burned patient from invasive infections.

OBJECTIVES

To assess the effects of antibiotic prophylaxis on rates of burn wound infection.

SEARCH METHODS

In January 2013 we searched the Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE - In-Process & Other Non-Indexed Citations (2013); Ovid EMBASE; EBSCO CINAHL and reference lists of relevant articles. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated the efficacy and safety of antibiotic prophylaxis for the prevention of BWI. Quasi-randomised studies were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted relevant data. Risk ratio (RR) and mean difference (MD) were estimated for dichotomous data and continuous data, respectively. When sufficient numbers of comparable RCTs were available, trials were pooled in a meta-analysis to estimate the combined effect.

MAIN RESULTS

This review includes 36 RCTs (2117 participants); twenty six (72%) evaluated topical antibiotics, seven evaluated systemic antibiotics (four of these administered the antibiotic perioperatively and three administered upon hospital admission or during routine treatment), two evaluated prophylaxis with non absorbable antibiotics, and one evaluated local antibiotics administered via the airway.The 11 trials (645 participants) that evaluated topical prophylaxis with silver sulfadiazine were pooled in a meta analysis. There was a statistically significant increase in burn wound infection associated with silver sulfadiazine compared with dressings/skin substitute (OR = 1.87; 95% CI: 1.09 to 3.19, I(2) = 0%). These trials were at high, or unclear, risk of bias. Silver sulfadiazine was also associated with significantly longer length of hospital stay compared with dressings/skin substitute (MD = 2.11 days; 95% CI: 1.93 to 2.28).Systemic antibiotic prophylaxis in non-surgical patients was evaluated in three trials (119 participants) and there was no evidence of an effect on rates of burn wound infection. Systemic antibiotics (trimethoprim-sulfamethoxazole) were associated with a significant reduction in pneumonia (only one trial, 40 participants) (RR = 0.18; 95% CI: 0.05 to 0.72) but not sepsis (two trials 59 participants) (RR = 0.43; 95% CI: 0.12 to 1.61).Perioperative systemic antibiotic prophylaxis had no effect on any of the outcomes of this review.Selective decontamination of the digestive tract with non-absorbable antibiotics had no significant effect on rates of all types of infection (2 trials, 140 participants). Moreover, there was a statistically significant increase in rates of MRSA associated with use of non-absorbable antibiotics plus cefotaxime compared with placebo (RR = 2.22; 95% CI: 1.21 to 4.07).There was no evidence of a difference in mortality or rates of sepsis with local airway antibiotic prophylaxis compared with placebo (only one trial, 30 participants).

AUTHORS' CONCLUSIONS

The conclusions we are able to draw regarding the effects of prophylactic antibiotics in people with burns are limited by the volume and quality of the existing research (largely small numbers of small studies at unclear or high risk of bias for each comparison). The largest volume of evidence suggests that topical silver sulfadiazine is associated with a significant increase in rates of burn wound infection and increased length of hospital stay compared with dressings or skin substitutes; this evidence is at unclear or high risk of bias. Currently the effects of other forms of antibiotic prophylaxis on burn wound infection are unclear. One small study reported a reduction in incidence of pneumonia associated with a specific systematic antibiotic regimen.

Evolving changes in the management of burns and environmental injuries

Burns and environmental injuries are common as primary or secondary problems in survivors of natural disasters, terrorist incidents, and combat operations. In recent years, intensive military medical experience has resulted in substantial progress in treatment of these important problems. This article reviews practical applications of this new knowledge.

Infection control in the burn unit

The survival rates for burn patients have improved substantially in the past few decades due to advances in modern medical care in specialized burn centers. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury. In addition to the nature and extent of the thermal injury influencing infections, the type and quantity of microorganisms that colonize the burn wound appear to influence the future risk of invasive wound infection. The focus of medical care needs to be to prevent infection. The value of infection prevention has been acknowledged in organized burn care since its establishment and is of crucial importance. This review focuses on modern aspects of the epidemiology, diagnosis, management, and prevention of burn wound infections and sepsis.

Bacteremia in Stevens-Johnson syndrome and toxic epidermal necrolysis: epidemiology, risk factors, and predictive value of skin cultures

Toxic epidermal necrolysis (TEN) is a rare drug-related life-threatening acute condition. Sepsis is the main cause of mortality. Skin colonization on top of impaired barrier function promotes bloodstream infections (BSI). We conducted this study to describe the epidemiology, identify early predictors of BSI, and assess the predictive value for bacteremia of routine skin surface cultures. We retrospectively analyzed the charts of all patients with Stevens-Johnson syndrome (SJS) and TEN hospitalized over an 11-year period. Blood cultures and skin isolates were recovered from the microbiology laboratory database. Early predictors of BSI were identified using a Cox model. Sensitivity, specificity, and negative and positive predictive values of skin cultures for the etiology of BSI were assessed. The study included 179 patients, classified as having SJS (n = 54; 30.2%), SJS/TEN overlap (n = 59; 33.0%), and TEN (n = 66; 36.9%). Forty-eight episodes of BSI occurred, yielding a rate of 15.5/1000 patient days. In hospital mortality was 13.4% (24/179). Overall, 70 pathogens were recovered, mainly Staphylococcus aureus (n = 23/70; 32.8%), Pseudomonas aeruginosa (n = 15/70; 21.4%), and Enterobacteriaceae organisms (n = 17/70; 24.3%). Variables associated with BSI in multivariate analysis included age >40 years (hazard ratio [HR], 2.5; 95% confidence interval [CI], 1.35-4.63), white blood cell count >10,000/mm3 (HR, 1.9; 95% CI, 0.96-3.61), and percentage of detached body surface area >or=30% (HR, 2.5; 95% CI, 1.13-5.47). Skin cultures had an excellent negative predictive value for bacteremia due to S aureus (especially methicillin-resistant strains) and P aeruginosa, but not for those due to Enterobacteriaceae organisms. In contrast, the positive predictive value was low for all pathogens studied.To our knowledge, this is the largest study describing the epidemiology and risk factors of BSI in patients with SJS/TEN. The body surface area involved is the main predictor of BSI. Excellent negative predictive values of skin cultures for S aureus and P aeruginosa bacteremia should help clinicians consider targeted empirical antibiotic choices when appropriate.

Infection in patients with severe burns: causes and prevention thereof

The better understanding of burn pathophysiology has resulted in effective fluid resuscitation in the acute stage, but the morbidity and mortality of burn patients are mostly linked to the burn wound consequences. Once the initial acute phase is over, the burn wound becomes the source of virtually all ill effects, local and systemic. The dysfunction of the immune system, a large cutaneous bacterial load, the possibility of gastrointestinal bacterial translocation, prolonged hospitalization, and invasive diagnostic and therapeutic procedures all contribute to infectious complications. Wound infection may lead to septicemia that may not only consume additional resources but is associated with significant morbidity and mortality despite the advances in burn care.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Infection control in pediatric extended care facilities

Pediatric extended care facilities provide for the biopsychosocial needs of patients younger than 21 years of age who have sustained self-care deficits. These facilities include long-term and residential care facilities, chronic disease and specialty hospitals, and residential schools. Infection control policies and procedures developed for adult long-term care facilities, primarily nursing homes for elderly people, are not applicable to long-term care facilities that serve pediatric patients. This article reviews the characteristics of pediatric extended care facilities and their residents, and the epidemic and endemic nosocomial infections, infection control programs, and antimicrobial resistance profiles found in pediatric extended care facilities.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Pseudomonas infections in the thermally injured patient

Pseudomonas aeruginosa, remains a serious cause of infection and septic mortality in burn patients, particularly when nosocomially acquired. A prototypic burn patient who developed serious nosocomially acquired Pseudomonas infection is described as an index case which initiated investigations and measures taken to identify the source of the infection. The effect of changes in wound care to avoid further nosocomial infections was measured to provide data on outcome and cost of care. The bacteriology of Pseudomonas is reviewed to increase the burn care providers understanding of the behaviour of this very common and serious pathogen in the burn care setting, before reviewing the approach to detection of the organism and treatment both medically and surgically. After controlling the nosocomial spread of Pseudomonas in our burn unit, we investigated the morbidity and mortality associated with nosocomial infection with an aminoglycoside resistant Pseudomonas and the associated costs compared to a group of case-matched control patients with similar severity of burn injury, that did not acquire resistant Pseudomonas during hospitalization at our institution. We found a significant increase in the mortality rate in the Pseudomonas group compared to controls. The morbidity in terms of length of stay, ventilator days, number of surgical procedures, and the amount of blood products used were all significantly higher in the Pseudomonas group compared to controls. Costs associated with antibiotic requirements were also significantly higher in the Pseudomonas group. Despite this increased resource consumption necessary to treat Pseudomonas infections, these efforts did not prevent significantly higher mortality rates when compared to control patients who avoided infection with the resistant organism. Thus, in addition to the specific measures required to identify and treat nosocomial Pseudomonas infections in burn patients, prevention of infection through modification of treatment protocols together with continuous infection control measures to afford early identification and eradication of nosocomial Pseudomonas infection are critical for cost-effective, successful burn care.