Predicting and managing sepsis in burn patients: current perspectives

Recent alcohol intake impacts microbiota in adult burn patients

Alcohol use is associated with an increased incidence of negative health outcomes in burn patients due to biological mechanisms that include a dysregulated inflammatory response and increased intestinal permeability. This study used phosphatidylethanol (PEth) in blood, a direct biomarker of recent alcohol use, to investigate associations between a recent history of alcohol use and the fecal microbiota, short chain fatty acids, and inflammatory markers in the first week after a burn injury for nineteen participants. Burn patients were grouped according to PEth levels of low or high and differences in the overall fecal microbial community were observed between these cohorts. Two genera that contributed to the differences and had higher relative abundance in the low PEth burn patient group were Akkermansia, a mucin degrading bacteria that improves intestinal barrier function, and Bacteroides, a potentially anti-inflammatory bacteria. There was no statistically significant difference between levels of short chain fatty acids or intestinal permeability across the two groups. To our knowledge, this study represents the first report to evaluate the effects of burn injury and recent alcohol use on early post burn microbiota dysbiosis, inflammatory response, and levels of short chain fatty acids. Future studies in this field are warranted to better understand the factors associated with negative health outcomes and develop interventional trials.

Barriers and co-designed strategies for the implementation of negative pressure wound therapy in acute pediatric burn care in Australia: A mixed method study

PURPOSE

Pediatric burn injuries are a global clinical issue causing significant morbidity. Early adjunctive negative pressure wound therapy improves re-epithelialization rates in children with burns, yet adoption in acute burn care is inconsistent. This investigation aimed to determine barriers to the implementation of adjunctive negative pressure wound therapy for the acute management of pediatric burns and co-design targeted implementation strategies.

METHODS

A sequential mixed methods design was used explore barriers to adjunctive negative pressure wound therapy implementation in acute pediatric burn care. An online questionnaire was disseminated to healthcare professionals within four major Australian pediatric hospitals, each with a dedicated burns service. Barriers were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews with senior clinicians tailored implementation strategies to local contexts. A stakeholder consensus meeting consolidated implementation strategies and local processes.

RESULTS

Sixty-three healthcare professionals participated in the questionnaire, and semi-structured interviews involved nine senior burn clinicians. We identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change, patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies, intervention complexity, and poor implementation planning.

CONCLUSION

Multiple contextual factors affect negative pressure wound therapy uptake in acute pediatric burn settings. Results will inform a multi-state stepped-wedge cluster randomized controlled trial. Additional resources, education, training, updated policies, and guidelines are required for successful implementation. It is anticipated that adjunctive negative pressure wound therapy, in conjunction with tailored implementation strategies, will enhance adoption and sustainability.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12622000166774. Registered 1 February 2022.

Patterns of antibiotic administration in patients with burn injuries: A TriNetX study

BACKGROUND

In the advent of increasing antibiotic resistance, several studies sought to determine antibiotic prescription trends; however, no pattern has been firmly identified particularly for the burned population. We performed a query of burned patients in a large established database to understand differences in antibiotic use related to patient-specific factors.

METHODS

Burned patients with systemic antibiotics given within 7 days of injury were identified on the TriNetX database. The patient population was stratified by age, 1-year time intervals of antibiotic prescription from 2004 to 2019, time of antibiotic prescription in 1-day intervals after injury, and % TBSA burned in 10% intervals ranging from < 10% to > 90%. Data were analyzed using χ2 with p < 0.05 considered significant. Pearson coefficients (r2) values were used to correlate differences in antibiotic prescription between age groups and to changes over time.

RESULTS

Stratification by age revealed higher use of antibiotics in older burned patients compared to younger patients. Surprisingly, 87.6% of burn patients of those who received antibiotic therapy was on the day of injury. Penicillins and beta-lactam antimicrobials were used most often at a frequency of 64%. No statistically significant differences in rates of antibiotic therapy were observed in burned patients when stratified by %TBSA burned.

CONCLUSIONS

The study elucidates current patterns of antibiotic use in burn care in the United States, allowing for improved understanding of both past and present patterns of antibiotic prescription.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Identification of immune-related lncRNA in sepsis by construction of ceRNA network and integrating bioinformatic analysis

BACKGROUND

Sepsis is a high mortality disease which seriously threatens human life and health, for which the pathogenetic mechanism still unclear. There is increasing evidence showed that immune and inflammation responses are key players in the development of sepsis pathology. LncRNAs, which act as ceRNAs, have critical roles in various diseases. However, the regulatory roles of ceRNA in the immunopathogenesis of sepsis have not yet been elucidated.

RESULTS

In this study, we aimed to identify immune biomarkers associated with sepsis. We first generated a global immune-associated ceRNA (IMCE) network based on data describing interactions pairs of gene-miRNA and miRNA-lncRNA. Afterward, we excavated a dysregulated sepsis immune-associated ceRNA (SPIMC) network from the global IMCE network by means of a multi-step computational approach. Functional enrichment indicated that lncRNAs in SPIMC network have pivotal roles in the immune mechanism underlying sepsis. Subsequently, we identified module and hub genes (CD4 and STAT4) via construction of a sepsis immune-related PPI network. Then, we identified hub genes based on the modular structure of PPI network and generated a ceRNA subnetwork to analyze key lncRNAs associated with sepsis. Finally, 6 lncRNAs (LINC00265, LINC00893, NDUFA6-AS1, NOP14-AS1, PRKCQ-AS1 and ZNF674-AS1) that identified as immune biomarkers of sepsis. Moreover, the CIBERSORT algorithm and the infiltration of circulating immune cells types were performed to identify the inflammatory state of sepsis. Correlation analyses between immune cells and sepsis immune biomarkers showed that the LINC00265 was strongly positive correlated with the macrophages M2 (r = 0.77).

CONCLUSION

Collectively, these results may suggest that these lncRNAs (LINC00265, LINC00893, NDUFA6-AS1, NOP14-AS1, PRKCQ-AS1 and ZNF674-AS1) played important roles in the immune pathogenesis of sepsis and provide potential therapeutic targets for further researches on immune therapy treatment in patients with sepsis.

The Burn Wound

Skin serves as a protective barrier against infection, prevents excessive fluid and electrolyte losses, performs crucial thermoregulation, and provides tactile feedback of surroundings. The skin also plays an essential role in human perception of body image, personal appearance, and self-confidence. With these many diverse functions, understanding normal anatomic composition of skin is pivotal to evaluating the extent of its disruption from burn injury. This article discusses the pathophysiology, initial evaluation, subsequent progression, and healing of burn wounds. By delineating the various microcellular and macrocellular alterations of burn injury, this review also augments providers' capacity to deliver patient-centered, evidence-based burn care.

Amino acid solution mitigates hypothermia response and intestinal damage following exertional heat stroke in male mice

Increased gut permeability is implicated in the initiation and extent of the cytokine inflammatory response associated with exertional heat stroke (EHS). The primary objective of this study was to determine if a five amino acid oral rehydration solution (5AAS), specifically designed for the protection of the gastrointestinal lining, would prolong time to EHS, maintain gut function and dampen the systemic inflammatory response (SIR) measured during EHS recovery. Male C57/BL6J mice instrumented with radiotelemetry were gavaged with 150 μL of 5AAS or H2 O, and ≈12 h later were either exposed to an EHS protocol where mice exercised in a 37.5°C environmental chamber to a self-limiting maximum core temperature (Tc,max) or performed the exercise control (EXC) protocol (25°C). 5AAS pretreatment attenuated hypothermia depth and length (p < 0.005), which are indicators of EHS severity during recovery, without any effect on physical performance or thermoregulatory responses in the heat as determined by percent body weight lost (≈9%), max speed (≈6 m/min), distance (≈700 m), time to Tc,max (≈160 min), thermal area (≈550°C∙min), and Tc,max (42.2°C). EHS groups treated with 5AAS showed a significant decrease in gut transepithelial conductance, decreased paracellular permeability, increased villus height, increased electrolyte absorption and changes in tight junction protein expression pattern suggestive of improved barrier integrity (p < 0.05). No differences were witnessed between EHS groups in acute phase response markers of liver, circulating SIR markers, or indicators of organ damage during recovery. These results suggest that a 5AAS improves Tc regulation during EHS recovery through maintaining mucosal function and integrity.

Pediatric First-Degree Burn Management With Honey and 1% Silver Sulfadiazine (Ag-SD): Comparison and Contrast

Background The cardinal area of managing fire wounds is guided by adequately evaluating the burn-induced lesion's profundity and size. Superficial second-degree burns are often treated through daily reinstating with fresh sterile bandaging with appropriate topical antimicrobials to allow rapid spontaneous epithelialization. Around the world, a wide variety of substances are used to treat these wounds, from honey to synthetic biological dressings. Objective This study intended to determine honey's therapeutic potential compared with 1% silver sulfadiazine (Ag-SD) in arsenal-caused contusion medicament fulfillment. Methods A total of 70 cases were evaluated in this research work after fulfilling the required selection criteria during the study period of January 2014 to December 2014 and January 2017 to December 2017. Purposive selection criteria were adopted in the study to select research patients. The patients in Group-1 (n = 35) relied on honey as medication, while patients in Group-2 (n = 35) relied on 1% Ag-SD. Results In Group-1, exudation (68.4%) and sloughing (82.9%) were substantially reduced by Days 3 and 5 of therapeutic intervention, respectively. However, in Group-2, a reduction of exudation (17.1%) and sloughing (22.9%) occurred after Days 3 and 5 of treatment, respectively. Completion of the epithelialization process was observed among Group-1 and Group-2 cases. It was detected after Days 7 and 10 of treatment at 36.3% and 77% (Group-1) and 27% and 67% (Group-2), respectively. Around 3 ml of 1% honey was required per body surface area per dressing in Group-1. On the other hand, in Group-2, 2 gm Ag-SD was needed per body surface area per dressing. Conclusion Patients treated with honey found better clinical outcomes in managing superficial partial-thickness burns.

Characteristics of bloodstream infection and initial antibiotic use in critically ill burn patients and their impact on patient prognosis

To investigate the bacterial epidemiology of blood cultures taken during the treatment of critically ill burn patients, the use of antibiotics at admission and before the observation of positive blood cultures, and their effect on prognosis. A retrospective study method was used. From January 1, 2010, to December 31, 2019, burn patients who met the inclusion criteria and were treated at the Burn Department, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, were enrolled in the study. Data were collected from the patients' electronic medical records. General patient information, including length of hospital stay, length of intensive care unit (ICU) stay, in-hospital mortality, the bacteria epidemiological characteristics of blood cultures, and the use of antibiotics within 24 h after admission and before a positive blood culture was observed, was collected. Independent sample t tests and χ² tests were used to compare the effects of a positive blood culture and the use of appropriate antibiotics within 24 h after admission and before the observation of a positive blood culture on prognosis. (1) The three most frequently detected bacteria in the blood cultures were Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii, and the amount of K. pneumoniae detected increased gradually. (2) Compared with the group of patients who were negative for bloodstream infection , the positive bloodstream infection group had a larger total body burn surface area (TBSA) (t = - 5.097, P = 0.000) and third-degree burn area (t = - 5.133, P = 0.000), a significantly longer length of hospital stay (t = 3.003, P = 0.003) and the length of ICU stay (t = 4.258, P = 0.000), and a significantly higher rate of in-hospital mortality (χ² = 8.485, P = 0.004). When K. pneumoniae was detected, the length of hospital stay (t = 2.148, P = 0.035) and the length of ICU stay (t = 2.880, P = 0.005) were significantly prolonged. (3) The two antibiotics that were most frequently used in patients with acute burns within 24 h after admission were lincomycin (90 cases, 29.32%) and carbapenems (79 cases, 25.73%). Comparing the clinical characteristics of the lincomycin group and the carbapenem group, the TBSA (t = - 3.34, P = 0.001) and the third-degree burn area (t = - 6.08, P = 0.000) of the patients in the carbapenem group were larger, and the length of hospital stay (t = - 2.136, P = 0.035) and length of ICU stay (t = - 5.18, P = 0.000) were longer, but the difference in in-hospital mortality was not statistically significant (χ² = 1.983, P = 0.159). (4) Comparing the group with appropriate initial antibiotic use within 24 h of admission to the inappropriate use group, the TBSA (t = - 0.605, P = 0.547), the third-degree burn area (t = 0.348, P = 0.729), the length of hospital stay (t = - 0.767, P = 0.445), the length of ICU stay (t = - 0.220, P = 0.827) and in-hospital mortality (χ² = 1.271, P = 0.260) were not significantly different. (5) Comparing the group with appropriate antibiotic use before a positive blood culture was observed to the group with inappropriate antibiotic use, the TBSA (t = - 0.418, P = 0.677), the third-degree burn area (t = 0.266, P = 0.791), the length of hospital stay, the length of ICU stay (t = 0.995, P = 0.322) and in-hospital mortality (χ² = 1.274, P = 0.259) were not significantly different. We found that patients with a positive blood culture had a larger burn area and a worse prognosis; that the greater the amount of K. pneumoniae in the bloodstream of burn patients was, the longer the hospital and ICU stays were; that whether appropriate antibiotics were administered to acute critical burn patients 24 h after admission had no effect on the prognosis; and that whether appropriate antibiotics were administered before a positive blood culture was observed had no effect on prognosis.

Identification of Immune-Related Key Genes as Potential Diagnostic Biomarkers of Sepsis in Children

Objective

The pathogenesis of sepsis is still unclear due to its complexity, especially in children. This study aimed to analyse the immune microenvironment and regulatory networks related to sepsis in children at the molecular level and to identify key immune-related genes to provide a new basis for the early diagnosis of sepsis.

Methods

The GSE145227 and GSE26440 datasets were downloaded from the Gene Expression Omnibus. The analyses included differentially expressed genes (DEGs), functional enrichment, immune cell infiltration, the competing endogenous RNA (ceRNA) interaction network, weighted gene coexpression network analysis (WGCNA), protein–protein interaction (PPI) network, key gene screening, correlation of sepsis molecular subtypes/immune infiltration with key gene expression, the diagnostic capabilities of key genes, and networks describing the interaction of key genes with transcription factors and small-molecule compounds. Finally, real-time quantitative PCR (RT–qPCR) was performed to verify the expression of key genes.

Results

A total of 236 immune-related DEGs, most of which were enriched in immune-related biological functions, were found. Further analysis of immune cell infiltration showed that M0 macrophages and neutrophils infiltrated more in the sepsis group, while fewer activated memory CD4⁺ T cells, resting memory CD4⁺ T cells, and CD8⁺ T cells did. The interaction network of ceRNA was successfully constructed. Six key genes (FYN, FBL, ATM, WDR75, FOXO1 and ITK) were identified by WGCNA and PPI analysis. We found strong associations between key genes and constructed septic molecular subtypes or immune cell infiltration. Receiver operating characteristic analysis showed that the area under the curve values of the key genes for diagnosis were all greater than 0.84. Subsequently, we successfully constructed an interaction network of key genes and transcription factors/small-molecule compounds. Finally, the key genes in the samples were verified by RT–qPCR.

Conclusion

Our results offer new insights into the pathogenesis of sepsis in children and provide new potential diagnostic biomarkers for the disease.

Specific patterns of vital sign fluctuations predict infection and enable sepsis diagnosis in pediatric burn patients

Early recognition of the clinical signs of bloodstream infection in pediatric burn patients is key to improving survival rates in the burn unit. The objective of this study was to propose a simple scoring criteria that used readily available temperature, heart rate (HR) and mean arterial pressure (MAP) data to accurately predict bloodstream infection in pediatric burn patients. A retrospective chart review included 100 patients admitted to the pediatric burn unit for >20% total body surface area (TBSA) burn injuries. Each patient had multiple blood culture tests, and each test was treated as a separate and independent “infection event” for analysis. The time at each blood culture draw was time 0 for that event, and temperature, HR and MAP data was collected for 24 hours after the blood culture was drawn. “Infection events” included in this study had at least six complete sets of temperature, HR and MAP data entries. Median temperature, HR and MAP, as well as mean fever spikes, HR spikes and MAP dips, were compared between infection group (positive blood cultures) and control group (negative blood cultures). These vital sign fluctuations were evaluated individually and as a combination of all three as timely predictors of bloodstream infection. In addition, we tested the prediction of Gram-negative bacteria versus Gram-positive or fungi present in blood cultures. Patients in the infection group had significantly higher median temperatures (p<0.001), mean fever spikes (p<0.001) and mean HR spikes (p<0.001), compared to the control group. Using the combination scoring criteria to predict bloodstream infection, the strongest predictive values in the 24-hour timeframe had high sensitivity (93%) and specificity (81%). The predictive test metric based on vital sign spikes predicted Gram-negative bacteria, but with limited sensitivity (57%) and specificity (44%). A simple scoring criteria using a combination of fever spikes, HR spikes and MAP dips predicted bloodstream infection in pediatric burn patients, and can be feasibly implemented in routine clinical care. There is also potential to use the predictive metric to detect a few select organisms based on vital signs, however further work is necessary to enhance accuracy to levels that would allow consideration for clinical use.

Burn Wound Healing: Clinical Complications, Medical Care, Treatment, and Dressing Types: The Current State of Knowledge for Clinical Practice

According to the World Health Organization (WHO), it is estimated that each year approximately 11 million people suffer from burn wounds, 180,000 of whom die because of such injuries. Regardless of the factors causing burns, these are complicated wounds that are difficult to heal and are associated with high mortality rates. Medical care of a burn patient requires a lot of commitment, experience, and multidirectional management, including surgical activities and widely understood pharmacological approaches. This paper aims to comprehensively review the current literature concerning burn wounds, including classification of burns, complications, medical care, and pharmacological treatment. We also overviewed the dressings (with an emphasis on the newest innovations in this field) that are currently used in medical practice to heal wounds.

The Interplay between Host Defense, Infection, and Clinical Status in Septic Patients: A Narrative Review

Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Despite significant morbidity and mortality throughout the world, its pathogenesis and mechanisms are not clearly understood. In this narrative review, we aimed to summarize the recent developments in our understanding of the hallmarks of sepsis pathogenesis (immune and adaptive immune response, the complement system, the endothelial disfunction, and autophagy) and highlight novel laboratory diagnostic approaches. Clinical management is also discussed with pivotal consideration for antimicrobic therapy management in particular settings, such as intensive care unit, altered renal function, obesity, and burn patients.

On the Nonspecific Resistance in Burn Injury: Pathophysiological Aspects (Review)

An analysis of nonspecific resistance in burn patients is conducted. The role of subpopulations of neutrophils and monocytes/ macrophages in severe burn injury is discussed. The significance of blood cells for the burn-induced immune dysfunction, susceptibility to sepsis and multiple organ failure is underscored. The involvement of secondary complications in the development of morbidity and mortality in patients with burn injury is shown. New approaches to identifying individuals with a risk of adverse outcome are considered.

Multicentre, longitudinal, observational cohort study to examine the relationship between neutrophil function and sepsis in adults and children with severe thermal injuries: a protocol for the Scientific Investigation of the Biological Pathways Following Thermal Injury-2 (SIFTI-2) study

INTRODUCTION

Burn-induced changes in the phenotype and function of neutrophils, cells which provide front-line protection against rapidly dividing bacterial infections, are emerging as potential biomarkers for the early prediction of sepsis. In a longitudinal study of adult burns patients, we recently demonstrated that a combined measurement of neutrophil phagocytic capacity, immature granulocyte (IG) count and plasma cell-free DNA (cfDNA) levels on the day of injury gave good discriminatory power for the prediction of later sepsis development. However, limited by a small sample size, single-centre design and focus on adult burns patients, these biomarkers require prospective validation in a larger patient cohort. The Scientific Investigation of the Biological Pathways Following Thermal Injury-2 study aims to prospectively validate neutrophil phagocytic activity, IG count and plasma cfDNA levels as early prognostic biomarkers of sepsis in thermally injured adult and paediatric patients.

METHODS AND ANALYSIS

This multicentre, longitudinal, observational cohort study will enrol 245 paediatric and adult patients with moderate to severe burns within 24 hours of injury. Blood samples will be obtained at 19 postinjury time points (days 1-14, day 28, months 3, 6, 12 and 24) and analysed for neutrophil phagocytic activity, IG count and cfDNA levels. Patients will be screened daily for sepsis using the 2007 American Burn Association diagnostic criteria for sepsis. In addition, daily multiple organ dysfunction syndrome and Sequential Organ Failure Assessment Scores will be recorded relationships between neutrophil phagocytic activity, IG count and plasma cfDNA levels on day 1 of injury and the development of sepsis will be examined using logistic regression models.

ETHICS AND DISSEMINATION

This study received ethics approval from the West Midlands, Coventry and Warwickshire Research Ethics Committee (REC reference:16/WM/0217). Findings will be presented at national and international conferences, and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04693442.

Real-time detection of volatile metabolites enabling species-level discrimination of bacterial biofilms associated with wound infection

Aims

The main aim of this study was to investigate the real‐time detection of volatile metabolites for the species‐level discrimination of pathogens associated with clinically relevant wound infection, when grown in a collagen wound biofilm model.

Methods and Results

This work shows that Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pyogenes produce a multitude of volatile compounds when grown as biofilms in a collagen‐based biofilm model. The real‐time detection of these complex volatile profiles using selected ion flow tube mass spectrometry and the use of multivariate statistical analysis on the resulting data can be used to successfully differentiate between the pathogens studied.

Conclusions

The range of bacterial volatile compounds detected between the species studied vary and are distinct. Discrimination between bacterial species using real‐time detection of volatile metabolites and multivariate statistical analysis was successfully demonstrated.

Significance and Impact of the Study

Development of rapid point‐of‐care diagnostics for wound infection would improve diagnosis and patient care. Such technological approaches would also facilitate the appropriate use of antimicrobials, minimizing the emergence of antimicrobial resistance. This study further develops the use of volatile metabolite detection as a new diagnostic approach for wound infection.

Terminological subset of the International Classification for Nursing Practice for patients hospitalized due to burns

OBJECTIVE

To develop a proposal of a terminological subset of the International Classification for Nursing Practice for burned patients.

METHOD

This is a methodological study following the steps: identification of clinical findings; mapping of terms; construction of statements of diagnoses/results and nursing interventions; content validation of statements; and structuring of the subset with the theoretical model of Basic Human Needs. Content validation was performed by 26 specialist nurses, through the Content Validity Index, with statements ≥ 0.80 being considered validated.

RESULTS

A total of 36 diagnoses/results and 119 interventions were validated. Among these, the ones with the highest index were: Respiratory System Function, Impaired/Respiratory System Function, Effective; Volume of Fluids, Impaired/Volume of Fluids, Effective; Burn Wound/Wound Healing, Effective; Pain, Acute/Pain, Absent, and as interventions: To Monitor Vital Signs; to Monitor Fluid Balance; to Treat Skin Condition; to Assess Response to Pain Management (Control).

CONCLUSION

The validated statements depict the burned people basic human needs, with the psychobiological ones being the most prevalent.

Management of a pediatric burn center during the covid-19 pandemic

The aim of this study was to evaluate the results of an algorithm that was created to prevent coronavirus disease-2019 (COVID-19) transmission during the management of children with burns in a tertiary pediatric burn center. Children admitted to the burn center between May 2020 and November 2020 were prospectively evaluated for cause, burn depth, total body surface area (TBSA), length of stay, symptoms suggesting COVID-19, suspicious contact history, history of travel abroad, and COVID-19 polymerase chain reaction (PCR) test results. Patients were divided into two groups: unsuspected (Group 1) and suspected (Group 2), depending on any history of suspicious contact, travel abroad, and/or presence of symptoms. A total of 101 patients were enrolled in the study, which included 59 boys (58.4%) and 42 girls (41.6%). Group 1 included 79 (78.2%) patients, and Group 2 consisted of 22 (21.8%) patients. The most common cause of the burns was scald injuries (74.2%). The mean age, TBSA, and length of stay were 4.5 years, 12.0%, and 13.2 days, respectively. Four patients (3.9%) had a positive PCR test (two patients in each group). Comparing groups, males were more commonly found in Group 2 (p=0.042), but no differences were found for the other variables. No patients or burn center staff members developed COVID-19 during the course of hospitalization. In conclusion, every child should be tested for COVID-19 upon admission to a burn unit, and a modified algorithm should be constructed for the handling and management of pediatric burn patients.

High Level of Multidrug-Resistant Gram-Negative Pathogens Causing Burn Wound Infections in Hospitalized Children in Dar es Salaam, Tanzania

Background

Bacterial infection remains the most common cause of morbidity and mortality in pediatric patients with burn wounds. The increase in infection and multidrug-resistant (MDR) pathogens necessitates a periodic review of antimicrobial susceptibility patterns in the burn units. The study aimed to determine the magnitude of multidrug-resistant Gram-negative (MDRGN) bacteria in children with burn wound infections and describe the resistance patterns in the tertiary and regional hospitals in Dar es Salaam, Tanzania.

Materials and Methods

The study was a hospital-based cross-sectional study design conducted between May 2017 and February 2018. Bacterial isolates from 103 wound swabs of pediatric patients with burn wounds were identified using conventional methods and API 20E. The antimicrobial susceptibility pattern was determined by the Kirby-Bauer disc diffusion method. Data were analyzed using Statistical Package for Social Science (SPSS) version 23.0.

Results

A total of 136 pathogenic Gram-negative organisms were isolated from burn wound infections in pediatric patients. The most isolated Gram-negative bacterium was Pseudomonas aeruginosa (39.0%), followed by Acinetobacter spp. (28.7%) and Klebsiella spp. (16.2%). MDRGN strains made up 80.1% of all Gram-negative isolates. All (100%) Klebsiella spp. and E. coli were MDR, while 69.2% and 79.2% of Acinetobacter spp. and P. aeruginosa, respectively, displayed MDR strains. We observed high levels of resistance to commonly prescribed antibiotics. Among P. aeruginosa isolates, highest resistance (81.8%) was seen toward meropenem and piperacillin, 79.5% of Acinetobacter spp. showed resistance to aztreonam, while 93-100% of Klebsiella spp and E. coli displayed resistance to amoxyclavulanic acid, ceftriaxone, and ceftazidime. The proportion of extended-spectrum beta-lactamase producers among Enterobacteriaceae was 78.6%. There was a significant higher rate of infection with MDRGN organisms in pediatric patients with a higher percentage of total burn surface area (TBSA) than patients with lower TBSA (p = 0.016).

Conclusions

P. aeruginosa, Acinetobacter spp., and Klebsiella spp. are the common Gram-negative pathogens causing burn wound infections in hospitalized pediatric patients in our setting. A high proportion of these organisms were multidrug resistant. The findings appeal for regular antimicrobial resistance surveillance in burn wound infection to inform empirical therapy.

PCT Kinetics in the First Week Postburn for Sepsis Diagnosis and Death Prognosis-An Accuracy Study

Despite continuous advances in burn care, sepsis is still the main cause of death in burn patients. Procalcitonin (PCT) has been reported as an accurate sepsis biomarker and also as a fair predictor of death. The aim of this study was to assess PCT kinetics in the first week postburn regarding sepsis diagnosis and death prognosis. Sample included 142 patients with ≥15% TBSA, admitted from January 2011 to December 2014 at Coimbra Burns Unit, Portugal. Sepsis diagnosis was done according to American Burn Association criteria. PCT range and median values in the first 7 days after burns were statistically analyzed for its potential for sepsis diagnosis and death prognosis. A subanalysis was done regarding TBSA, sex, age, and inhalation injury. First week PCT range and median were significant for sepsis diagnosis and death prognosis, but the median area under the curve was greater in the last case. TBSA influenced PCT accuracy, which was greater for TBSA less than 40% either for diagnosis or prognosis. Age was inversely related to the accuracy, being better in younger than 40 years in both cases. PCT diagnostic accuracy was not affected by sex, opposing to the prognostic one which is better in women. Inhalation injury had no effect on diagnostic accuracy, but it happens with prognostic accuracy. PCT levels' variation is related to sepsis evolution and outcome. Its median performs better than its range. Always coupled with clinical examination, monitoring PCT levels kinetics may help early sepsis detection, potentially reducing morbidity and mortality, being also useful for death prognosis.

The predictive role of Interleukin 6 in burn patients with positive blood cultures

Interleukin 6 (IL-6) is an established biomarker of inflammation with one of the earliest responses in sepsis. Serum levels can easily be measured within a few hours. The clinical significance of IL-6 in the early stage of sepsis in burned patients has not yet been confirmed. The purpose of our research was to investigate the predictive value of IL-6 for positive blood cultures in comparison to Procalcitonin (PCT), white blood cell (WBC) count, body temperature and the Sequential Organ Failure Assessment (SOFA) score in the presence of suspected sepsis in burn patients. In a retrospective study, we included all patients admitted to a regional burn centre in a 7-year period. Patients with a clinical suspicion of sepsis and complete laboratory tests underwent further analysis. Patients were categorized following culture results into either positive or negative bloodstream infection (BSI or non-BSI) groups. 39 of the 101 included patients had positive blood cultures (BSI). The serum IL-6 levels were significantly higher in the BSI group [1047 (339.9; 9000.5) vs. 198.5 (112.4; 702.5) ng/l; P = 0.001]. Receiver operating characteristic (ROC) curve analysis showed an AUC of 0.7 (59; 80.8%). The optimal IL-6 cut-off level was 312.8 ng/l (sensitivity 79.5%, specificity 56.5%). Other biomarkers (PCT, WBC), the maximum body temperature and increase of SOFA score were not different between the groups. IL-6 can be used to predict a positive blood culture even in the early stage of suspected sepsis in burned patients. In this context, other biomarkers (PCT, WBC) and body temperature are of limited clinical utility.

Early protein C activation is reflective of burn injury severity and plays a critical role in inflammatory burden and patient outcomes

BACKGROUND

Navigating the complexities of a severe burn injury is a challenging endeavour where the natural course of some patients can be difficult to predict. Straddling both the coagulation and inflammatory cascades that feature strongly in the burns systemic pathophysiology, we propose the pleiotropic protein C (PC) system may produce a viable biomarker to assist traditional evaluation methods for diagnostic and prognostic purposes.

METHODS

We enrolled 86 patients in a prospective observational cohort study. Over three weeks, serial blood samples were taken and measured for PC, activated (A)PC, their receptor endothelial protein C receptor (EPCR), and a panel of inflammatory cytokines including C-reactive protein (CRP), tumour necrosis factor-α, interleukin (IL)-1β, IL-6, IL-8, and IL-17. Their temporal trends were analysed alongside clinical factors including burn size, burn depth, presence of inhalational injury, and a composite outcome of requiring increased support.

RESULTS

(i) APC increased from a nadir on Day 3 (2.3±2.1ng/mL vs 4.1±2.5ng/mL by Day 18, p<0.0005), only becoming appropriately correlated to PC from Day 6 onwards (r=0.412-0.721, p<0.05 for all Days 6-21). (ii) This early disturbance in the PC system was amplified in the more severe burns (≥30% total body surface area, predominantly full thickness, or with inhalational injury), which were characterised by a marked fall in PC activation (approximated by APC/PC ratio) and APC levels during Days 0-3 with low unchanged PC levels. Critically low levels of this cytoprotective agent was associated with greater inflammatory burden, as reflected by significantly elevated CRP, IL-6, and IL-8 levels in the more severe compared to less severe burns, and by negative correlations between both PC and APC with most inflammatory cytokines. (iii) Alongside clinical markers of severity at admission (burn size, burn depth, and presence of inhalational injury), only Day 0 APC/PC ratio (OR 1.048 (1.014-1.083), p=0.006), APC (OR 1.364 (1.032-1.803), p=0.029), PC (OR 0.899 (0.849-0.953), p<0.0005), and not any inflammatory cytokines were predictive markers of requiring increased support. Uniquely, decreased Day 0 PC was further individually associated with each increased total length of stay, ICU length of stay, intravenous fluid resuscitation, and total surgeries, as well as possibly mortality.

CONCLUSION

An early functional depletion of the cytoprotective PC system provides a physiological link between severe burns and the cytokine storm, likely contributing to worse outcomes. Our findings on the changes in APC, PC and PC activation during this pathological state support APC and PC as early diagnostic and prognostic biomarkers, and provides a basis for their therapeutic potential in severe burn injuries.

Variations in insulin requirements can be an early indicator of sepsis in burn patients

INTRODUCTION

A >25% increase in daily insulin dosing is suggestive of possible sepsis in burn patients, however, no conclusive evidence is available regarding the time point at which insulin dosing begins to increase. The purpose of this study is to determine the exact time point at which the insulin requirement increases among non-diabetic burn patients with sepsis.

METHODS

A retrospective chart review in non-diabetic burn patients with ≥20% total body surface area burned (TBSA) during 2010-2018 who received a blood culture for suspected sepsis. Absolute insulin dosing at intervals (0, 24, 48, 72, and 96 h prior to blood culture) were Box-Cox transformed and compared vs.-96 h reference using mixed-effects models accounting for within-patient dependencies.

RESULTS

Fifty-eight patients (84% males, age 44 ± 17 years, TBSA% 49 ± 17.5) were included. When cube root of daily insulin dosing was regressed on each time point in a mixed-effects model, statistically significant increase in insulin dosing compared to baseline was observed for -48 (p = 0.018), -24 (p = 0.011), and 0 h (p = 0.008).

CONCLUSION

Daily insulin dosing increases 48 h prior to development of other clinical signs of sepsis and can be used as a sensitive early marker.

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.

Antibiotic Usage After Procalcitonin-Guided Therapy Algorithm Implementation In A Burn Intensive Care Unit

The study investigated antibiotic utilization after the implementation of a procalcitonin (PCT)-guided antibiotic algorithm in the burn intensive care unit (BICU) to minimize antibiotic exposure appropriately. An algorithm established the ordering of an initial procalcitonin level, an additional level following 48 hours post-admission, and upon suspicion of sepsis. The primary endpoint was the percent of days on antibiotics in the BICU. Secondary endpoints were the percent of patients reinitiated on antibiotics, length of BICU and hospital stay, and 30-day mortality. Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR) methodology aided in antibiotic usage evaluation. The retrospective and prospective phases involved five and seven patients in the final analysis, respectively. The median percent of days on antibiotics in the BICU was 33.3% versus 14.3% in the retrospective and prospective phases, respectively (p=0.222). Secondary outcomes evaluated were percent of patients reinitiated on antibiotics at 80.0% versus 28.6% (p=0.242), the median length of BICU stay at 38 days versus 31 days (p=0.465), the median duration of hospital stay at 39 days versus 37 days (p=0.624) and 30-day mortality of one versus zero cases (p=0.417) in the retrospective and prospective group, respectively. The probability of better DOOR with a PCT-guided antibiotic algorithm versus the control group was 95.7% (95% CI, 81.4-99.5%). The benefit of a PCT-guided antibiotic algorithm implementation cannot be determined based on the small sample size producing a lack of internal validity. Future studies warrant utilizing DOOR/RADAR to evaluate antibiotic stewardship strategies in the burn patient population.

Initial white blood cell count and revised Baux score predict subsequent bloodstream infection in burn patients: A retrospective analysis of severe burn patients from the Formosa color dust explosion of 2015

BACKGROUND

Infections are the most common complications among hospitalized severe burn patients. However, limited literature reports early effective predictors of bloodstream infections (BSI) among burn patients. This study aimed to identify cost-effective biomarkers and valuable clinical scoring systems in the emergency department (ED) for the prediction of subsequent BSI in mass burn casualties.

METHODS

In 2015, a flammable cornstarch-based powder explosion resulted in 499 burn casualties in Taiwan. A total of 35 patients were admitted at Taipei Veterans General Hospital. These severe burn patients (median total body surface area [TBSA] 54%) were young and previously healthy. We assessed the potential of various parameters to predict subsequent BSI, including initial laboratory tests performed at the ED, TBSA, and multiple scoring systems.

RESULTS

Fourteen patients (40.0%) had subsequent BSI. The most common causative pathogen was the Acinetobacter baumannii (Ab) group, mostly carbapenem resistant and associated with a poor outcome. The area under the receiver operating characteristic curve revealed that the revised Baux score, TBSA, and initial white blood cell count had excellent discrimination ability in predicting subsequent BSI (0.898, 0.889, and 0.821, respectively). The rate of subsequent BSI differed significantly at the cut-off points of revised Baux score >76, TBSA >55%, and WBC count >16,200/mm³.

CONCLUSION

The initial WBC count at the ED, TBSA, and revised Baux score were good and cost-effective biomarkers for predicting subsequent BSI after burn injuries.

Candidemia in pediatric burn patients: Risk factors and outcomes in a retrospective cohort study

Background and Purpose :

Despite advances in burn care and management, infections are still a major contributor to morbidity and mortality rates in patients with burn injuries. Regarding this, the present study was conducted to investigate the prevalence and importance of candidemia in pediatric burn patients.

Materials and Methods:

Blood samples were collected from the patients and cultured in an automated blood culture system. Candida species were identified using specific culture media. The relationship between candidemia and possible risk factors was evaluated and compared to a control group.

Results:

A total of 71 patients with the mean age of 4.52±3.63 years were included in the study. Blood cultures showed candidemia in 19 (27%) patients. Based on the results, C. albicans was the most common fungus among patients with and without candidemia. The results of statistical analysis also showed that candidemia was significantly correlated with total body surface area (TBSA), mechanical ventilation, duration of total parenteral nutrition, length of intensive care unit (ICU) stay, presence of neutropenia, and R-Baux score (all P≤0.001). In this regard, TBSA, length of ICU stay, R-Baux score, and Candida score were identified as the determinant factors for mortality due to candidemia.

Conclusion:

Candidemia increases the mortality and morbidity rates associated with burn injuries. Prompt diagnostic and prevention measures can reduce the unfortunate outcomes via controlling the possible risk factors.

Review of Sepsis in Burn Patients in 2020

Background: Severe burn injury results in substantial damage to the skin, inhibiting its ability to perform as the primary barrier to infection. Additionally, severe burn injury can lead to critical illness and extensive time in the intensive care unit (ICU). These two factors work to increase the risk of sepsis in the burn patient compared with other hospitalized patients. The increased risk of sepsis is compounded by the difficulty of diagnosing sepsis in severely burned patients because the pathophysiology of large burns mimics sepsis, leading to possible delay in diagnosis and initiation of treatment. Methods: A literature review was performed to discuss and review the diagnostic difficulties and criteria used to identify patients with sepsis. Additionally, the most current management of sepsis was reviewed and described in caring for burn patients with sepsis. Results: The incidence of sepsis in patients with more than 20% total body surface area (TBSA) burns is between 3% and 30% and is the most common cause of death in the burn patient, with pneumonia being the most common etiology. Several different diagnostic criteria for diagnosing sepsis in burn patients exist, however, none of these criteria have proven to be superior to clinical diagnosis by an experienced burn surgeon. As with sepsis in other patient populations, prompt diagnosis, initiation of antibiotic agents, and source control remain the standard management of sepsis in the burn patient. Conclusions: Because of the loss of the primary infection barrier function of the skin after a substantial burn injury, this patient population is at increased risk for sepsis. Because of the pathophysiology of burn injuries, diagnosing sepsis in the burn population remains challenging. Understanding the most common etiologies of sepsis in burn patients may help with more expedient diagnosis and initiation of treatment.

Clinical Utility of PNA-FISH for Burn Wound Diagnostics: A Noninvasive, Culture-Independent Technique for Rapid Identification of Pathogenic Organisms in Burn Wounds

Burn injury results in an immediate compromised skin state, which puts the affected patient at an immediate risk for infection, including sepsis. For burn patients that develop infections, it is critical to rapidly identify the etiology so that an appropriate treatment can be administered. Current clinical standards rely heavily on culture-based methods for local and systemic infection testing, which can often take days to complete. While more advanced methods (ie, MALDI or NAAT) have improved turnaround times, they may still suffer from either the need for pure culture or sensitivity and specificity issues. Peptide nucleic acid fluorescent in situ hybridization (PNA-FISH) offers a way to reduce this time from days to hours and provide species-specific identification. While PNA-FISH has had great utility in research, its use in clinical microbiology diagnostics has been minimal (including burn wound diagnostics). This work describes a nonculture-based identification technique using commercial available U.S. FDA-approved PNA-FISH probes for the identification of common clinical pathogens, Pseudomonas aeruginosa and Staphylococcus aureus, present in burn wound infections. Additionally, calcofluor white was included for identification of Candida albicans. All three pathogens were identified from a tri-species infected deep-partial thickness rat burn wound model. These species were clearly identifiable in swab and tissue samples that were collected, with minimal autofluorescence from any species. Although autofluorescence of the tissue was present, it did not interfere or was otherwise minimized through sample preparation and analysis. The methodology developed was done so with patient care and diagnostic laboratories in mind that it might be easily transferred to the clinical setting.

Detection of Infection and Sepsis in Burns

Background: Infection is the most frequent complication after severe burns and has a propensity to progress into sepsis then septic shock and multiple organ dysfunction syndrome (MODS). Improving outcomes in acute burn care depends on early detection of infection to allow prompt interventions. Diagnosis of sepsis in severe burns is uniquely challenging because otherwise-typical clinical signs are masked by the hypermetabolic state and systemic inflammation induced by the burn itself. For this reason, burns have historically been excluded from high-impact studies on the diagnosis and treatment of sepsis. Methods: This article provides a comprehensive three-fold review of current findings and guidelines pertinent to the early detection of infection and sepsis in severe burns. Results: First, evidence-based detection of the most common infections encountered in the burn intensive care unit is reviewed. Second, we analyze the evolution of the diagnostic criteria for sepsis and the evidence regarding their utility in severe burns. Last, we examine the development of biomarkers, from procalcitonin to molecular genomics, for the detection of sepsis. Conclusions: Although gold standard methods of early detection of sepsis in burn patients have yet to be identified, improved understanding and appropriate application of the available diagnostic criteria and assays are paramount to providing effective care of patients with severe burns.

Pediatric Burn Infection

Background: Severe burns lead to a profound hypermetabolic, hypercatabolic, hyper-inflammatory state. Pediatric burn patients are at significantly increased risk for infection and sepsis secondary to loss of the skin barrier and subsequent immunosuppression. Infection is the most common cause of morbidity and death in pediatric burn patients, and the mortality rate from sepsis remains high. Methods: Review of pertinent English-language literature pertaining to infection among pediatric burn patients. Results: Established risk factors for infection in pediatric burn patients are the depth of injury, presence of inhalation injury, indwelling devices, and total body surface area burned. Total body surface area remains one of the most important risk factors for the development of infectious complications, and mortality risks increase significantly if the burn size is >40%. The predominant colonization of burn wound starts with gram-positive organisms, which are replaced later by gram-negative organisms. Most cases of sepsis in burn patients originate from infected burn wounds. Treatment options include topical and systemic antimicrobial drugs, but surgical intervention often is the most definitive treatment. Excision of burn eschar to remove the source of potential infection is a key component of the treatment as well as prevention of infection. Conclusion: Key principles in improving outcomes for septic pediatric burn patients is early recognition, resuscitation, and adherence to management strategies such as prompt antimicrobial drug administration and source control.

Bacterial Virulence Factors and Their Contribution to Pathophysiology after Thermal Injury

Background: Bacterial infections are the leading cause of morbidity and mortality in burn-injured patients. Pseudomonas aeruginosa and Staphylococcus aureus are among the most common pathogens responsible for infections in thermally injured patients. These and other pathogens have developed a variety of virulence factors to colonize and infect hosts. Methods: A comprehensive literature review was conducted to best summarize the current knowledge of how virulence factors contribute to bacterial pathogenicity. Results: The review highlights the unique mechanisms bacteria utilize to evade host defense systems and further complicate the treatment of burn-injured patients. Conclusion: Further research on virulence factors and their contribution to bacterial pathogenicity is warranted and could potentially lead to development of neutralizing pharmacotherapy that would complement antimicrobial treatment.

Nutritional management of a kitten with thermal burns and septicaemia

Case summary

A 3-month-old entire female British Shorthair cat presented for further management of thermal burns after falling into a bath of scalding water. On presentation to the primary care clinician the kitten was obtunded, markedly painful and relatively bradycardic, consistent with a state of shock. The haircoat was wet, with erythematous skin and sloughing from the digital pads and anal mucosa. The primary care clinician administered opioid analgesia, sedation, antibiotics and started intravenous (IV) fluid therapy prior to referral. On arrival to the referral hospital the kitten was obtunded with respiratory and cardiovascular stability but was overtly painful and resistant to handling. The kitten required intensive management with IV and regional analgesia, IV broad-spectrum antibiosis, IV fluid therapy, enteral nutrition and wound management, including surgical debridement and topical antibiotic therapy. Septicaemia developed during the hospitalisation. Multidrug-resistant Escherichia coli and Pseudomonas aeruginosa were cultured, and antibiosis was escalated to IV imipenem. Acute respiratory distress syndrome was suspected following the development of dyspnoea. Early enteral nutrition within 24 h of admission was initiated using an oesophageal feeding tube and a veterinary therapeutic liquid diet. Over the ensuing 72 h the kitten started voluntary intake of food alongside oesophageal tube feeds. The kitten experienced continued weight loss despite the provision of nutritional support to meet, and then later exceed, the estimated resting energy requirements. Caloric intake was gradually increased to a total of 438% of the calculated resting energy requirement using the most recent daily body weight, eventually resulting in stabilisation of weight loss and weight gain.

Relevance and novel information

There is limited published information on the nutritional management of veterinary patients with thermal burn injury. Hypermetabolic states related to burn injuries are induced and maintained by complex interactions of catecholamines, stress hormones and inflammatory cytokines on proteolysis, lipolysis and glycogenolysis. Secondary infections are common following burn injury and the subsequent proinflammatory state perpetuates hypermetabolism and catabolism. These states present a challenge in both predicting and providing adequate nutrition, particularly in a paediatric septic patient. This subset of patients should be monitored closely during hospitalisation to ensure body weight and condition are maintained (while taking into consideration hydration status), and caloric intake is adjusted accordingly to meet nutritional support goals. Extensive research exists regarding the nutritional requirements and metabolic derangements of people with thermal burns. However, the importance of maintaining body weight and body condition in veterinary burn patients, and the association between nutritional support and reduced morbidity and mortality, has not been investigated and remains to be elucidated.

Specific Patterns of Postoperative Temperature Elevations Predict Blood Infection in Pediatric Burn Patients

Using readily available temperature data, we seek to propose a scoring criteria that can facilitate accurate and immediate prediction of blood infection. The standard in diagnosing blood infection is a positive blood culture result that may take up to 3 days to process, requiring providers to make a prediction about which febrile patient is actually bacteremic. This prediction is difficult in burned children as systemic inflammation can cause fever in the absence of infection. An ability to make this prediction more accurate using readily available information would be useful. A retrospective chart review was performed for 28 pediatric patients, with a burn size 20% or greater, admitted to the burn unit between 2010 and 2014. All children had blood cultures drawn. They were divided into either infection (positive blood cultures) or control (negative blood cultures) groups. Median temperature and mean number of temperature elevations were compared between the two groups. We evaluated the predictive accuracy of using temperature elevation, pattern, and timing to predict blood infection. A significant difference was seen in the mean number of temperature elevations above 39°C. This was significant for each time stage, especially in the 0- to 24-hour post-surgery period. We found the most predictive accuracy in the 0- to 12-, 12- to 38-, and 12- to 48-hour time periods. We found a strong association between mean number of fever spikes above 39°C and blood infection, especially 12 to 24 hours after surgery. This readily available data can be useful to clinicians as they access children with burns.

New markers for sepsis caused by Pseudomonas aeruginosa during burn infection

INTRODUCTION

Sepsis is a leading cause of mortality in burn patients. One of the major causes of sepsis in burn patients is Pseudomonas aeruginosa. We hypothesized that during dissemination from infected burn wounds and subsequent sepsis, P. aeruginosa affects the metabolome of the blood resulting in changes to specific metabolites that would serve as biomarkers for early diagnosis of sepsis caused by P. aeruginosa.

OBJECTIVES

To identify specific biomarkers in the blood after sepsis caused by P. aeruginosa infection of burns.

METHODS

Gas chromatography with time-of-flight mass spectrometry was used to compare the serum metabolome of mice that were thermally injured and infected with P. aeruginosa (B-I) to that of mice that were neither injured nor infected, mice that were injured but not infected, and mice that were infected but not injured.

RESULTS

Serum levels of 19 metabolites were significantly increased in the B-I group compared to controls while levels of eight metabolites were significantly decreased. Thymidine, thymine, uridine, and uracil (related to pyrimidine metabolism), malate and succinate (a possible sign of imbalance in the tricarboxylic acid cycle), 5-oxoproline (related to glutamine and glutathione metabolism), and trans-4-hydroxyproline (a major component of the protein collagen) were increased. Products of amino acid metabolism were significantly decreased in the B-I group, including methionine, tyrosine, indole-3-acetate, and indole-3-propionate.

CONCLUSION

In all, 26 metabolites were identified, including a unique combination of five metabolites (trans-4-hydroxyproline, 5-oxoproline, glycerol-3-galactoside, indole-3-acetate, and indole-3-propionate) that could serve as a set of biomarkers for early diagnosis of sepsis caused by P. aeruginosa in burn patients.

SEPSIS. Educational and Best Practice Frontiers. Beyond the Boundaries of Fatality, Enhancing Clinical Skills and Precision Medicine

Dissemination and exploitation of knowledge regarding affordable clinical skills and innovative precision medicine, two current topics in active development in medicine, may contribute to improve also sepsis management. Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection. Sepsis is strongly related to all body organs or to systemic diseases and to the quality of the best-practice in use, which is particularly critical in surgical or intervention techniques. Trauma, surgical and mini-invasive procedures, vascular or endoscopic interventions, otolaryngology, obstetrics-gynecological and urological procedures, malnutrition, dental, skin, chronic liver, kidney and respiratory disease are frequently involved. Accordingly, apart from the clinical risk analysis and management of the process of care, the actual factors that may be easily neglected are the techniques used, the personal skills of the health professionals and the quality of the equipment. The quest for biomarkers consistent with the unmet needs of medical doctors and of their patient and the efforts for overcoming bacterial antibiotic resistances are currently the main foci of medical research. In addition, in this regard, research and innovation would benefit from greater knowledge, skills and use of bioinformatics and omics. The caveats related to in-silico approaches must be flagged: algorithms may equally warrant scientific innovations or hide the lack of them; a patient is more than a set of covariates. Epidemiology and prevention includes all the actions suitable for achieving an adequate hygiene and immunization of populations and for safer hospital policies and procedures during Patients’ stays. In any subset, the most unresolved critical point in sepsis is a timely diagnosis. This is impaired by low degrees of suspicion for the possibility of emerging sepsis, by the shortage of use of the simplest microbiological testing but, equally or more, by the insufficient diffusion of non-invasive imaging skills suitable to detect and monitor the emerging sites and sources of infection. In primary care, in emergency facilities, in hospital wards and in intensive care units, inclusion of appropriate knowledge, skills, expertise and imaging equipment must be extended as much as possible. The low cost of UltraSound machines and of increasing bioinformatics literacy by e-learning, makes such investments affordable even in limited-resources contexts. Frontier educational and best practice intervention enhancing affordable clinical skills and innovative precision medicine may lead beyond the boundaries of fatal outcomes in sepsis.

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Comparative Analysis of the Host Response in a Rat Model of Deep-Partial and Full-Thickness Burn Wounds With Pseudomonas aeruginosa Infection

Burn wound injury affects soldiers and civilians alike, often resulting in a dynamic, but un-orchestrated, host response that can lead to infection, scarring, and potentially death. To mitigate these factors, it is important to have a clinically relevant model of burn wound infection that can be utilized for advancing burn wound treatments. Our previous reports have demonstrated the ability of Pseudomonas aeruginosa to generate a biofilm infection within a modified Walker-Mason rat burn model of deep-partial (DPT) and full-thickness (FT) burn wounds (10% total body surface area) in male Sprague-Dawley rats (350–450 g). Here, we further define this model with respect to the host response when challenged with P. aeruginosa infection between the two burn types. Following burn injury and immediate surface exposure to P. aeruginosa, inflammation at the local and systemic levels were monitored for an 11 days period. Compared to burn-only groups, infection with P. aeruginosa further promoted local inflammation in both DPT and FT burn wounds, which was evident by enhanced cellular influx (including neutrophils and monocytes), increased levels of several pro-inflammatory cytokines (IL-1β, IL-6, GRO/KC, andMIP-1α), and reduced IL-10. Systemically, only minor changes were seen in circulating white blood cells and cytokines; however, increases in high mobility group box-1 (HMGB-1) and hyaluronan, as well as decreases in fibronectin were noted particularly in FT burns. Compared to the burn-only group, P. aeruginosa infection resulted in sustained and/or higher levels of HMGB-1 and hyaluronan. Combined with our previous work that defined the burn depth and development of P. aeruginosa biofilms within the wound, this study further establishes this model by defining the host response to the burn and biofilm-infection. Furthermore, this characterization shows several similarities to what is clinically seen and establishes this model for future use in the development and testing of novel therapeutics for burn wound treatment at home and on the battlefield.

Sprayable and biodegradable, intrinsically adhesive wound dressing with antimicrobial properties

Conventional wound dressings are difficult to apply to large total body surface area (TBSA) wounds, as they typically are prefabricated, require a layer of adhesive coating for fixation, and need frequent replacement for entrapped exudate. Large TBSA wounds as well as orthopedic trauma and low-resource surgery also have a high risk of infection. In this report, a sprayable and intrinsically adhesive wound dressing loaded with antimicrobial silver is investigated that provides personalized fabrication with minimal patient contact. The dressing is composed of adhesive and biodegradable poly(lactic-co-glycolic acid) and poly(ethylene glycol) (PLGA/PEG) blend fibers with or without silver salt (AgNO3). in vitro studies demonstrate that the PLGA/PEG/Ag dressing has antimicrobial properties and low cytotoxicity, with antimicrobial silver controllably released over 7-14 days. In a porcine partial-thickness wound model, the wounds treated with both antimicrobial and nonantimicrobial PLGA/PEG dressings heal at rates similar to those of the clinical, thin film polyurethane wound dressing, with similar scarring. However, PLGA/PEG adds a number of features beneficial for wound healing: greater exudate absorption, integration into the wound, a 25% reduction in dressing changes, and tissue regeneration with greater vascularization. There is also modest improvement in epidermis thickness compared to the control wound dressing.

Impact of oral resuscitation on circulating and splenic leukocytes after burns

BACKGROUND

Hemodynamic aberrations after severe burns are treated with aggressive intravenous (IV) fluid resuscitation however, oral resuscitation has been proposed in resource poor scenarios. Previously we have shown that animals receiving oral fluid following burns were able to recover kidney function. However, immune function such as circulating and splenic immune cell populations after oral or intravenous fluid administration was not examined. Herein, we perform a follow up analysis of splenic tissue and plasma from the previous animal study to examine the splenic response following these resuscitation strategies after burn injury.

METHODS

Eighteen anesthetized Yorkshire swine receiving 40%TBSA contact burns were randomized to receive either: (1) no fluids (Fluid Restricted; negative control), (2) 70 mL/kg/d Oral Rehydration Salt solution (Oral), or (3) 2 mL/kg/%TBSA/d of lactated Ringer's solution IV. Blood was drawn for blood cell analysis, and CT scans were performed before and 48 h post-burn, at which point spleens were harvested for histological, Western blot, and RT-PCR analyses.

RESULTS

Splenic artery diameter decreased by -0.97 ± 0.14 mm in fluid-restricted animals, while IV led to an increase of 0.68 ± 0.30 mm. No significant differences were detected in white and red pulp. IV fluids reduced the population of splenic monocytes (CD163; P = 0.001) and neutrophils (MPO protein; P = 0.13), as well as cytokines IL-8 (P = 0.003), IFN-γ (P = 0.11) and TNFα (P = 0.05). Additionally, withholding IV fluids consistently decreased the expression of FoxP3, CCR6, and IL17β in spleen, suggesting a shift in T-cell phenotype with IV resuscitation.

CONCLUSIONS

The route of fluid administration has a minor influence on the changes in circulating and splenic leukocytes post-burn in the acute phase. Further research is needed to help guide resuscitation approaches using immunologic markers of splenic function following burns.

Management and prevention of drug resistant infections in burn patients

Introduction: Despite modern advances, the primary cause of death after burns remains infection and sepsis. A key factor in determining outcomes is colonization with multi-drug resistant (MDR) organisms. Infections secondary to MDR organisms are challenging due to lack of adequate antibiotic treatment, subsequently prolonging hospital stay and increasing risk of adverse outcomes. Areas covered: This review highlights the most frequent organisms colonizing burn wounds as well as the most common MDR bacterial infections. Additionally, we discuss different treatment modalities and MDR infection prevention strategies as their appropriate management would minimize morbidity and mortality in this population. We conducted a search for articles on PubMed, Web of Science, Embase, Cochrane, Scopus and UpToDate with applied search strategies including a combination of: "burns, 'thermal injury,' 'infections,' 'sepsis,' 'drug resistance,' and 'antimicrobials.' Expert opinion: Management and prevention of MDR infections in burns is an ongoing challenge. We highlight the importance of preventative over therapeutic strategies, which are easy to implement and cost-effective. Additionally, targeted, limited use of antimicrobials can be beneficial in burn patients. A promising future area of investigation within this field is post-trauma microbiome profiling. Currently, the best treatment strategy for MDR in burn patients is prevention.

Epigenetics in Sepsis: Understanding Its Role in Endothelial Dysfunction, Immunosuppression, and Potential Therapeutics

Sepsis has a complex pathophysiology in which both excessive and refractory inflammatory responses are hallmark features. Pro-inflammatory cytokine responses during the early stages are responsible for significant endothelial dysfunction, loss of endothelial integrity, and organ failure. In addition, it is now well-established that a substantial number of sepsis survivors experience ongoing immunological derangement and immunosuppression following a septic episode. The underpinning mechanisms of these phenomena are incompletely understood yet they contribute to a significant proportion of sepsis-associated mortality. Epigenetic mechanisms including DNA methylation, histone modifications, and non-coding RNAs, have an increasingly clear role in modulating inflammatory and other immunological processes. Recent evidence suggests epigenetic mechanisms are extensively perturbed as sepsis progresses, and particularly play a role in endothelial dysfunction and immunosuppression. Whilst therapeutic modulation of the epigenome is still in its infancy, there is substantial evidence from animal models that this approach could reap benefits. In this review, we summarize research elucidating the role of these mechanisms in several aspects of sepsis pathophysiology including tissue injury and immunosuppression. We also evaluate pre-clinical evidence for the use of "epi-therapies" in the treatment of poly-microbial sepsis.

Plasma protein C levels are directly associated with better outcomes in patients with severe burns

Protein C circulates in human plasma to regulate inflammation and coagulation. It has shown a crucial role in wound healing in animals, and low plasma levels predict the presence of a wound in diabetic patients. However, no detailed study has measured protein C levels in patients with severe burns over the course of a hospital admission. A severe burn is associated with dysfunction of inflammation and coagulation as well as a significant risk of morbidity and mortality. The current methods of burn assessment have shortcomings in reliability and have limited prognostic value. The discovery of a biomarker that estimates burn severity and predicts clinical events with greater accuracy than current methods may improve management, resource allocation and patient counseling. This is the first study to assess the potential role of protein C as a biomarker of burn severity. We measured the plasma protein C levels of 86 patients immediately following a severe burn, then every three days over the first three weeks of a hospital admission. We also analysed the relationships between burn characteristics, blood test results including plasma protein C levels and clinical events. We used a primary composite outcome of increased support utilisation defined as: a mean intravenous fluid administration volume of five litres or more per day over the first 72 h of admission, a length of stay in the intensive care unit of more than four days, or greater than four surgical procedures during admission. The hypothesis was that low protein C levels would be negatively associated with increased support utilisation. At presentation to hospital after a severe burn, the mean plasma protein C level was 76 ± 20% with a range of 34-130% compared to the normal range of 70-180%. The initial low can be plausibly explained by impaired synthesis, increased degradation and excessive consumption of protein C following a burn. Levels increased gradually over six days then remained at a steady-state until the end of the inpatient study period, day 21. A multivariable regression model (Nagelkerke's R² = 0.83) showed that the plasma protein C level on admission contributed the most to the ability of the model to predict increased support utilisation (OR = 0.825 (95% CI = 0.698-0.977), P = 0.025), followed by burn size (OR = 1.252 (95% CI = 1.025-1.530), P = 0.027), burn depth (partial thickness was used as the reference, full thickness OR = 80.499 (1.569-4129.248), P = 0.029), and neutrophil count on admission (OR = 1.532 (95% CI = 0.950-2.473), P = 0.08). Together, these four variables predicted increased support utilisation with 93.2% accuracy, 83.3% sensitivity and 97.6% specificity. However if protein C values were disregarded, only 49.5% of the variance was explained, with 82% accuracy, 63% sensitivity and 91.5% specificity. Thus, protein C may be a useful biomarker of burn severity and study replication will enable validation of these novel findings.

Burn-induced neuroepithelial changes as a delayed cause of mortality in major burns: a case report and literature review

BACKGROUND

Mortality in major burns is caused mainly by multisystem organ failure. Brain lesions in burn patients are rare and predominantly traumatic in nature. Here, we present an unusual case of burn-induced glioma causing rapid neurological deterioration and death.

CASE PRESENTATION

A 33-year-old male, with 85% total body surface area (TBSA) flame burns, presented initially with inhalation injury and acute compartment syndrome with no other associated injuries. Based on the initial assessment, the patient's cognitive status was not affected, with a Glasgow coma scale (GCS) on admission of 15/15 and normal brain computed tomography (CT) images. The patient was resuscitated and immediately admitted to the burns unit where he underwent multiple sessions of debridement and skin grafting. The patient's neurological status deteriorated dramatically, and brain magnetic resonance imaging (MRI) confirmed the presence of a heterogenous mass, highly suggestive of a high-grade glioma, that was not present during the initial assessment. Unfortunately, the patient died shortly afterwards as a result of cardiac asystole.

CONCLUSIONS

Multiple studies have demonstrated a connection between chronic inflammatory processes and gliomagenesis. The case presented here supports the notion that high-grade gliomas can progress rapidly in immunocompromised patients, thus further reducing survival rates. Therefore, patients with inflammatory conditions combined with neurological symptoms/signs should be investigated thoroughly to evaluate the presence and extent of such pathology. Newly developed radiological modalities can help in early detection and timely management of the condition.

Valuable prognostic indicators for severe burn sepsis with inhalation lesion: age, platelet count, and procalcitonin

Background

Severe burn sepsis can lead to high mortality. We explored the valuable prognostic indicators for severe burn sepsis with inhalation lesion.

Methods

Thirty-eight severe burn patients with sepsis who were admitted to the Third Affiliated Hospital of Soochow University from August 2014 to December 2017 were retrospectively analyzed. Among them, 22 patients were assigned to the death group and 16 patients to the survival group. Their general information, vital signs, and blood index including serum procalcitonin (PCT) and C-reactive protein (CRP) levels at admission, diagnosis of sepsis, and 1-week post-diagnosis of sepsis were compared.

Results

Patients in the death group were older and had lower platelet count (PLT) at diagnosis of sepsis and 1-week post-diagnosis as well as higher PCT level at 1-week post-diagnosis than patients in the survival group (all p < 0.05). According to receiver operating characteristic (ROC) curves, the above four indicators could be used to predict the prognosis, and the area under the curve (AUC) of PLT at diagnosis and 1-week post-diagnosis was larger (0.888 and 0.911), and PLT at diagnosis had the highest sensitivity and specificity (0.842 and 0.937). In addition, these patients were divided into two groups by the optimal cutoff age of 38 years. According to multivariate logistic regression analysis and COX regression analysis, only age group and PLT at diagnosis were statistically significant (all p < 0.05). The risk of death in the older group was 28 times higher than that in the younger group, and the risk of death increased by 3% for each unit reduction in PLT at diagnosis. Moreover, age group was an independent factor affecting the patients’ survival (β = − 1.370, p = 0.026). Considering the survival time after sepsis, the mortality risk was lower for patients in the older group than for patients in the younger group (hazard ratio (HR) = 0.254, 95% confidence interval (CI) 0.076–0.851).

Conclusion

Age, PLT at diagnosis of sepsis, and 1-week post-diagnosis as well as PCT level at 1-week post-diagnosis are indicators for the evaluation of prognosis of severe burn sepsis with inhalation lesion. Among them, PLT at diagnosis has the greatest prognostic value. In addition, age can predict the patients’ mortality and survival time after sepsis.

Procalcitonin kinetics after burn injury and burn surgery in septic and non-septic patients - a retrospective observational study

BACKGROUND

Early sepsis diagnosis is crucial for the correct management of burn patients, and it clearly influences outcomes. The systemic inflammatory response triggered by burns mimics sepsis presentation and complicates early sepsis diagnosis. Biomarkers were advocated to aid the diagnosis of early sepsis. Serum procalcitonin (PCT) exhibits fair accuracy and good correlation with sepsis severity, being used in diverse clinical settings. However, few studies have evaluated perioperative changes in PCT levels in burn patients. The present study evaluated PCT kinetics during the first days after burn injury and subsequent surgical interventions to assess PCT utility in distinguishing septic from non-septic inflammatory responses.

METHODS

This study was a retrospective observational study of all burn patients admitted to the Coimbra Burns Unit (Portugal) between January 2011 and December 2014 who presented with a total burn surface area ≥ 15% and who underwent subsequent surgery. PCT kinetics were investigated a) during the first five days after burn injury and b) preoperatively during the five days after surgery in three subsets of patients, including those with no preoperative and no postoperative sepsis (NN), no preoperative but postoperative sepsis (NS), and preoperative and postoperative sepsis (SS). A total of 145 patients met the selection criteria and were included in the analysis.

RESULTS

PCT levels in the first five days after burn injury were significantly higher in patients who developed at least one sepsis episode (n = 85) compared with patients who did not develop sepsis (n = 60). PCT values > 1.00 ng/mL were clearly associated with sepsis. Study participants (n = 145) underwent a total of 283 surgical interventions. Their distribution by preoperative/postoperative sepsis status was 142 (50.2%) in NN; 62 (21.9%) in NS; and 79 (27.9%) in SS. PCT values exhibited a parallel course in the three groups that peaked on the second postoperative day and returned to preoperative levels on the third day or later. The lowest PCT values were found in NN, and the highest values were observed in SS; the NS values were intermediate.

CONCLUSIONS

PCT kinetics coupled with a clinical examination may be helpful for sepsis diagnosis during the first days after burn injury and burn surgery.

Checking procalcitonin suitability for prognosis and antimicrobial therapy monitoring in burn patients

Background

Due to greater infection susceptibility, sepsis is the main cause of death in burn patients. Quick diagnosis and patient stratification, early and appropriated antimicrobial therapy, and focus control are crucial for patients' survival. On the other hand, superfluous extension of therapy is associated with adverse events and arousal of microbial resistance. The use of biomarkers, necessarily coupled with close clinical examination, may predict outcomes, stratifying patients who need more intensive care, and monitor the efficacy of antimicrobial therapy, allowing faster de-escalation or stop, reducing the development of resistance and possibly the financial burden, without increasing mortality. The aim of this work is to check the suitability of procalcitonin (PCT) to fulfill these goals in a large sample of septic burn patients.

Methods

One hundred and one patients, with 15% or more of total body surface area (TBSA) burned, admitted from January 2011 to December 2014 at Coimbra Burns Unit (CBU), in Portugal were included in the sample. All patients had a diagnosis of sepsis, according to the American Burn Association (ABA) criteria. The sample was factored by survival (68 survivors and 33 non-survivors). The maximum value of PCT in each day was used for statistical analysis. Data were summarized by location measures (mean, median, minimum, maximum, quartiles) and dispersion measures (standard error and range measures). Statistical analysis was performed with SPSS© 23.0 IBM© for Windows©.

Results

There were statistically significant differences between PCT levels of patients from the survivor and non-survivor groups during the first and the last weeks of hospitalization as well as during the first week after sepsis suspicion, being slightly higher during this period. During the first 7 days of antimicrobial therapy, PCT was always higher in the non-survivor, still without reaching statistical significance, but when the analysis was extended till the 15th day, PCT increased significantly, rapidly, and steadily, denouncing therapy failure.

Conclusion

Despite being not an ideal biomarker, PCT proved to have good prognostic power in septic burn patients, paralleling the evolution of the infectious process and reflecting the efficacy of antimicrobial therapy, and the inclusion of its serial dosing may be advised to reinforce antimicrobial stewardship programs at burn units; meanwhile, more accurate approaches are not available.