Bacteriological cultures on admission of the burn patient: To do or not to do, that's the question.

INTRODUCTION: In many burn centers, routine bacteriological swabs are taken from the nose, throat, perineum, and the burn wound on admission, to check for the presence of microorganisms that require specific measures in terms of isolation or initial treatment. According to the Dutch policy of "search and destroy," for example, patients infected by multiresistant bacteria have to be strictly isolated, and patients colonized with ß-hemolytic Streptococcus pyogenes must receive antibiotic therapy to prevent failed primary closure or loss of skin grafts. In this respect, the role of bacteria cultured on admission in later infectious complications is investigated. The aim of this study is to assess systematic initial bacteriological surveillance, based on an extensive Dutch data collection. MATERIALS AND METHODS: A total of 3271 patients primarily admitted to the Rotterdam Burn Centre between January 1987 and August 2010 with complete bacteriological swabs from nose, throat, perineum, and the burn wounds were included. For this study, microbiological surveillance was aimed at identifying resistant microorganisms such as methicillin-resistant Staphylococcus aureus (MRSA), multiresistant Acinetobacter, and multiresistant Pseudomonas, as well as Lancefield A ß-hemolytic streptococci (HSA), in any surveillance culture. The cultures were labeled as "normal flora or non-suspicious" in the case of no growth or a typical low level of bacterial colonization in the nose, throat, and perineum and no overgrowth of one type of microorganism. Further, the blood cultures of 195 patients (6.0%) who became septic in a later phase were compared with cultures taken on admission to identify the role of the initially present microorganisms. Statistical analysis was performed using SPSS 20.0. RESULTS: Almost 61% of the wound cultures are "non-suspicious" on admission. MRSA was cultured in 0.4% (14/3271) on admission; 12 out of these 14 patients (85.7%) were repatriated. Overall, 9.3% (12/129) of the repatriated patients were colonized with MRSA. Multiresistant Acinetobacter or Pseudomonas was detected in 0.3% (11/3271 and 10/3271, respectively). In total, 18 of the 129 repatriated patients (14%) had one or more resistant bacteria in cultures taken within the first 24h after admission in our burn center. On admission, S. pyogenes was found in 3.6% of patients (117/3271), predominantly in children up to 10 years of age (81/1065=7.6%). CONCLUSIONS: Resistant bacteria or microorganisms that impede wound healing and cause major infections are found only in few bacteriological specimens obtained on admission of patients with burn wounds. However, the consequences in terms of isolation and therapy are of great importance, justifying the rationale of a systematic bacteriological surveillance on admission. Patients who have been hospitalized for several days in a hospital abroad and are repatriated show more colonization at admission in our burn center. The microorganisms identified are not only (multi)resistant bacteria, showing that a hospital environment can quickly become a source of contamination. These patients should receive special attention for resistant bacteria. HSA contamination is observed more frequently in younger children. Bacteria present at admission do not seem to play a predominant role in predicting later sepsis.

Epidemiology and trends in severe burns in the Netherlands.

INTRODUCTION: The aim of this study was to characterize the epidemiology of severe burns in the Netherlands, including trends in burn centre admissions, non burn centre admissions and differences by age. METHODS: Patients with burn-related primary admission in a Dutch centre from 1995 to 2011 were included. Nationwide prospectively collected data were used from three separate historical databases and the uniform Dutch Burn Repository R3 (2009 onwards). General hospital data were derived from the National Hospital Discharge Register. Age and gender-adjusted rates were calculated by direct standardization, using the 2005 population as the reference standard. RESULTS: The annual number of admitted patients increased from 430 in 1995 to 747 in 2011, incidence rates increased from 2.72 to 4.66 per 100,000. Incidence rates were high in young children, aged 0-4 years and doubled from 10.26 to 22.96 per 100,000. Incidence rates in persons from 5 up to 59 increased as well, in older adults (60 years and older) admission rates were stable. Overall burn centre mortality rate was 4.1%, and significantly decreased over time. There was a trend towards admissions of less extensive burns, median total burned surface area (TBSA) decreased from 8% to 4%. Length of stay and length of stay per percent TBSA decreased over time as well. CONCLUSIONS: Data on 9031 patients admitted in a 17-year period showed an increasing incidence rate of burn-related burn centre admissions, with a decreasing TBSA and decreasing in-burn centre mortality. These data are important for prevention and establishment of required burn care capacity.

Reduction in skin grafting after the introduction of hydrofiber dressings in partial thickness burns: a comparison between a hydrofiber and silver sulphadiazine.

AIM/PURPOSE: The aim of this study was to compare clinical outcome of children with scald burns treated with a hydrofiber dressing (Aquacel(®), Convatec Inc.) with the former standard of care with silver sulfadiazine (Flammazine(®); Solvay Pharmaceuticals), considering surgical intervention and length of stay (LOS). METHODS: A retrospective study of all consecutive children from zero to four years with primary scald burns up to 10% admitted to the Burn Centre of the Maasstad Hospital Rotterdam between January 1987 and January 2010 were reviewed. For data collection a prospective computerized database was used. For comparison the study period was divided into two periods representing the period before and after the introduction of the hydrofiber dressing (HFD), respectively 1987-1999 (period 1) and 1999-2010 (period 2). RESULTS: Over the whole study period 27.3% of 502 patients treated with silver sulfadiazine (Ag-SD) underwent surgery, while before the introduction of HFD 30.5% of 338 Ag-SD treated patients were operated upon. After the introduction of the HFD 20.7% of 164 patients treated with Ag-SD eventually underwent skin grafting, a significant difference with the 11.6% of 302 patients whose wounds were dressed with HFD (p<0.01). CONCLUSIONS: Compared to silver sulfadiazine treatment a reduced number of surgical interventions was observed in mixed partial thickness scald burns up to 10% TBSA burned in children aged 0-4 years after the introduction of hydrofiber dressings. The mode of treatment with this wound dressing also limited hospital length of stay.

Accuracy of burn size assessment prior to arrival in Dutch burn centres and its consequences in children: a nationwide evaluation.

BACKGROUND: Total body surface area (TBSA) burned, expressed as percentage is one of the most important aspects of the initial care of a burn victim. It determines whether transfer to a burn centre is necessary as well as the need for, and amount of, intravenous fluid resuscitation. Numerous studies, however, have highlighted inaccuracies in TBSA assessment. Therefore, the differences in burn size estimates between referrers and burn centre's in children and its consequences in terms of transfer and intravenous fluid resuscitation were investigated. METHODS: This study involved two time periods from January 2002 until March 2004 and January 2007 until August 2008. All referred children admitted to a Dutch Burn centre within 24h post burn were eligible. Data were obtained from patient records retrospectively and in part prospectively. RESULTS: A total of 323 and 299 children were included in periods 1 and 2, respectively. Referring physicians overestimated burn size with a factor two (mean difference: 6% TBSA ± 5.5). About one in five children was referred to a burn centre without fulfilling the criteria for referral with regard to burn size (assessed by burn specialists) special localisation or inhalation trauma. Proportions of children receiving intravenous fluid resuscitation regardless of indication increased from 33% to 49% (p<0.01). The received volumes tended to be higher than necessary. CONCLUSIONS: Referring physicians overestimate burn size in children admitted to Dutch burn centres. This has little negative consequences, however, in terms of unindicated transfers to a burn centre or unnecessary fluid resuscitation.

Quality of life after burns in childhood (5-15 years): children experience substantial problems.

The aim of our study was to assess prevalence and correlates related to sub optimal outcome after pediatric burns and to make a comparison with pediatric injuries not related to burns. We conducted a cross-sectional study on quality of life (QOL) after burns in a sample (n=138; median 24 months post-burn) of Dutch and Flemish children (5-15 years) with an admission to a burn center. QOL was assessed with the Burn Outcomes Questionnaire (BOQ). The generic EuroQol-5D was used to allow for a comparison with children after injuries not related to burns. More than half of the children had long-term limitations. According to the BOQ, children frequently (>50%) experienced sub optimal functioning on 5 out of 12 dimensions, concerning 'appearance', 'parental concern', 'itch', 'emotional health' and 'satisfaction with current state'. Children with a high total burned surface area (TBSA ≥10%) showed significantly more sub optimal functioning on 'upper extremity function' (OR=5.3; ≥20% TBSA), 'appearance' (OR=5.5; ≥10-20% TBSA), 'satisfaction with current state' (OR=3.4; ≥10-20% TBSA) and 'parental concern' (OR=3.4; ≥10-20% TBSA), compared to children with less than 10% TBSA. Burn victims at 9 months post-injury appeared to be worse off at several health dimensions. After 24 months generic quality of life of in pediatric burns was more comparable to pediatric injuries not related to burns. Children after burns experience substantial problems, mainly on itch and appearance and several psychosocial dimensions. More extensive burns are related to sub optimal functioning. These problems are in part specific for burns and not picked up by generic measures.

Mortality and causes of death in a burn centre.

Mortality rates are important outcome parameters after burn, and can serve as objective end points for quality control. Causes of death after severe burn have changed over time; in the international literature, multisystem organ failure is seen as the most important cause, but the exact distribution of causes of death remains unknown. Insight into underlying agents of mortality can be directive in research and prevention programmes. This comparison between results from the Rotterdam Burn Centre (RBC) and the American National Burn Repository (NBR) examines the most important predictive parameters for fatal outcome, i.e. age, total body surface area involved and presence of inhalation injury. Causes of death were attributed for all fatal outcomes treated in the RBC from 1996 to 2006. The mortality rate at the RBC was 6.9% and at the NBR was 5.6%, with almost no differences in age or total body surface area involved. The discrepancy in mortality rate might have been due to the high incidence of inhalation injury among the RBC population. However, the mortality rate at the RBC after admission with intention to treat decreased to 4.9%. The most frequent cause of death appeared to be multisystem organ failure, in 64.9% of cases; 93% of these had systemic inflammatory response syndrome at time of death and, in 45.9%, infection was deemed responsible for the fatal clinical deterioration (in 21.3% sepsis was proved and in 24.6% was highly suspected). To compare mortality rates between different burn centres and periods of time, uniform classifications are needed, particularly for presence of inhalation injury and for causes of death. Prevention of multisystem organ failure, by better management of infection and systemic inflammatory response syndrome, might do most to decrease mortality after burn.

Reliability and validity of the Health Outcomes Burn Questionnaire for infants and children in The Netherlands.

The Health Outcomes Burn Questionnaire (HOBQ) is a self-administered questionnaire to monitor outcome after burns in young children. This study aimed to assess feasibility, reliability and validity of the Dutch version of the HOBQ. The HOBQ was adapted into Dutch and tested in a population of children aged 0-4 years with a primary admission to a Dutch burn centre in March 2001-February 2004. Parents of 413 children were sent a questionnaire. To assess validity, a generic outcome instrument was included, the Infant Toddler Quality of Life Questionnaire (ITQOL). The response rate was 50.0% (n=196). Mean self-reported completion time was 16.7 min. The internal consistency of all the HOBQ-scales was good (Cronbach's alpha's>0.69). Test-retest results showed no differences in 7 out of 10 scales. High correlations between HOBQ-scales and conceptually equivalent ITQOL and scales were found in 5 out of 7 comparisons. The majority of the HOBQ-scales (7 out of 10) showed significant differences in the expected direction between children with a long versus short length of stay. Our data support the reliability and validity of the Dutch HOBQ. The HOBQ can be used as a research tool, to monitor functional outcome after burns in young children. Further research in other samples is recommend to fully establish the reliability and validity of the HOBQ.

Functional outcome after burns: a review.

We conducted a Medline search (1966-11/2003) on empirical studies into the consequences of burns. The International Classification of Functioning, disabilities and health (ICF) was used to classify dimensions of functional outcome. We included 50 studies, reporting a wide spectrum of ICF-dimensions. The current state of knowledge on the functional outcome after burns was hard to summarise, due to the wide variety in study designs and outcome assessment methods. Some indications on the major functional problems after burns were gained. Problems in mental function were described in subgroups of patients, both in children/adolescents and adults. Restrictions in range of motion were observed in about one-fifth of burn patients, even 5 years after injury. Problems with appearance were reported often (up to 43%), even in patients with minor burns (14%). Problems with work were reported in 21-50% of the adult patients, with permanent incapacity for work in 1-5%. None of the publications gave sufficient information to fully estimate the functional consequences of burns. We recommend the development of a standard core set for measurement and reporting of functional outcome after burns.

[Use of trauma triage teams at the cafe fire in Volendam]. / De inzet van traumatriageteams bij de cafébrand in Volendam.

For large-scale accidents, and for specific categories of wounds there is, in addition to the extramural assistance provided by helicopter teams and mobile medical teams, a need for secondary triage so that patients can be transferred as quickly as possible and the use of limited treatment capacity for specific injuries (such as serious burns) is optimised. After the cafe fire in Volendam, 203 patients were admitted to 27 hospitals. In almost all of these cases it concerned burns, often complicated by inhalation injury. Burns triage teams selected in the second instance patients with 30-80% surface burns who required artificial respiration, for admission to one of the burn centres in the Netherlands, Belgium or Aachen (Germany). The mortality under 75 patients with burns and an inhalation trauma who underwent a planned curative treatment was just 5.3%. Trauma triage teams should be officially recognised within the chain of the project 'Medical assistance in accidents and disasters' (Dutch acronym: GHOR) so that together with the uniform guidelines for the treatment of specific injuries that are present in casualty departments (for example the 'emergency management of severe burns (ESMB) protocol', a protocol for the care of patients with serious burns) the quality of care can be improved.

Spontaneous regression of clinical inguinal hernias in preterm female infants.

PURPOSE: This is a prospective study of 8 clinically apparent inguinal hernias in 7 preterm infant girls. METHODS: The diagnosis was made clinically and confirmed by ultrasonography, which also showed the contents of the hernia. RESULTS: One hernia contained an ovary, the other 7 intestinal loops. The hernias with only intestinal loops regressed spontaneously when the girls were between the ages of 2 and 6 months postpartum. This was confirmed by ultrasonography. At follow-up 2 to 6 years later there has been no recurrence. The hernia that contained the ovary did not regress, and hernia repair (confirming the presence of the ovary) was carried out uneventfully. CONCLUSIONS: The authors suggest that preterm infant girls with an inguinal hernia should have ultrasonography performed at presentation. Surgery probably will be required when the hernia contains structures such as an ovary. When the hernia contains only intestinal loops an expectant policy may be advisable. Larger studies are needed to validate these findings.

Three-dimensional dynamic external fixation of distal radial fractures. A prospective study.

This prospective study describes the experience with a new dynamic external fixator which provides three degrees of freedom, while the centre of rotation of all these movements is located in the wrist. 44 patients with unstable fractures of the distal radius were included. During the period of dynamisation, with a median flexion of 30 degrees, extension of 18 degrees, radial deviation of 0 degree and ulnar deviation of 20 degrees the range of motion needed to perform activities of daily living was approached. In spite of early mobilisation reduction was maintained. The radiological result was excellent or good in 82% of the patients and the functional result was excellent or good in 92% of the cases. Pin track infections were noted rather frequently, possibly related to the interaction between the soft tissues and the fixator pins. Based on the experiences of the study the device needs further improvement.

Diabetic patients with foot burns.

We describe six patients with non-insulin dependent (Type 2) diabetes mellitus (NIDDM) and thermal foot injury admitted to the Burn Centre in Rotterdam. They were all male with a mean age of 56.8 (range 47-63) years. The median patients' delay before admission was 27 (range 1-56) days. Five patients needed amputation. Healing of the wounds took a mean period of 9.5 (range 2-27) months. In two patients healing of the wounds took more than 1 year; these two patients also had recurrent foot burns. Neurological evaluation in four patients confirmed severe polyneuropathy and severe loss of heat pain, warmth, and cold sensation.

Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement.

In a retrospective study 37 patients were surgically treated for 38 fractures (27 actual and 11 impending) caused by metastatic lesions of the humerus shaft. A comparison between plate osteosynthesis with bone cement (20 cases) and intramedullary nailing (18 cases) was made. There was no mortality related to the surgical procedure. The patients' survival rate was 61% after 3 months and 44% after 6 months; six were alive after 1 year. Overall, a subjective and objective relief of pain was achieved in 92% and 79%, respectively. Restoration of arm function was improved in 95%. The operative course was complicated in six patients after plate osteosynthesis (three local and three systemic complications) and in four patients after intramedullary nailing (one local and three systemic complications). Fixation failed in four patients, instability developed twice after intramedullary fixation without bipolar static locking. No significant difference in survival rate, pain relief, restoration of function and complications were associated with methods of treatment, or with operation of actual or impending pathological fractures. Despite the poor life expectancy our results indicate that intramedullary nailing with bipolar static locking and post-operative irradiation or plate osteosynthesis with bone cement for treatment of pathological (impending) fractures of the humerus shaft are safe ways to restore arm function and improve quality of life.

Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial.

BACKGROUND: The efficacy of prophylactic antibiotics in fracture surgery remains controversial for lack of well-documented prospective studies. We report here the findings of the Dutch Trauma Trial, a prospective, randomised, double-blind, placebo-controlled study of antibiotic prophylaxis in the primary operative treatment of limb fractures. Ceftriaxone was chosen because of its pharmacokinetic profile, including high serum levels, high tissue penetration, and long elimination half-life, makes it suitable for single-dose prophylaxis. METHODS: Patients aged 18 years or more, attending one of fourteen Dutch centres for acute treatment of closed fractures, were randomly allocated to a single preoperative dose of ceftriaxone 2 g or placebo, and evaluated for development of wound infection and nosocomial infection at 10 days, 30 days, and 120 days. To assess the effects of drop-outs and withdrawals, best-case and worst-case analyses were performed. FINDINGS: A total of 2195 patients were included. The incidence of superficial and deep wound infections after placebo was 8.3%, compared with 3.6% in the ceftriaxone group (p < 0.001, Pearson chi 2-test). The rate of nosocomial infection in the first month was 10.2% with placebo and 2.3% with ceftriaxone (p < 0.001, Pearson chi 2-test). Gram-positive bacteria were found in 74.5% of wound infections and 13.4% of nosocomial infections. INTERPRETATION: Adequate single-dose prophylaxis with a long-acting broad-spectrum antibiotic substantially reduces the incidence of wound infection and early nosocomial infection after surgery for closed fractures.

Outbreak of group A streptococci in a burn center: use of pheno- and genotypic procedures for strain tracking.

In a burn center, an outbreak of group A streptococci (GAS) colonizations involving 13 patients and two staff members occurred. Adverse events due to GAS, loss of skin graft after initial take (secondary loss) and partial take, occurred in patients who underwent surgery before the colonization was detected. GAS isolates from nine patients and one staff member were stored and subsequently pheno- and genotyped by T serotyping, gas chromatography, M genotyping, and random amplified polymorphic DNA typing. The outbreak was caused by two types of GAS, identified as T4/28-M48 and T13-M77 by T serotyping and M genotyping. Random amplified polymorphic DNA typing and gas chromatography distinguished both clusters accurately. One subcluster indicated by gas chromatography could be linked to the acquisition of GAS from a roommate. The T13-M77 cluster was characterized by rapid spread through the center compared with the T4/28-M48 cluster. One patient contracted the T13-M77 strain while in protective isolation, indicating a role for staff members in the transmission. Our standard GAS control policy, consisting of twice weekly screening of all burned patients and immediate isolation and treatment, proved efficacious in preventing further spread of GAS. Reporting by staff members of signs and symptoms compatible with GAS infection was reenforced.

Tannic acid as a topical agent in burns: historical considerations and implications for new developments.

The usage of tannic acid (TA) as a topical agent in burns in the past and the present is described. Its introduction by Davidson in 1925 led to the widespread use of TA. The high infection risk during times of war and reports of liver damage after application of high doses of undefined TA mixtures brought discredit to the TA treatment. German and Chinese authors have been able to refute these claims and propagate a safe therapeutic regimen. Recent animal experimental and clinical investigations confirm the many advantages: pain reduction, rapid haemodynamic stabilization, delayed primary excision, early mobilization and good cosmetic results.

Impending and actual pathological fractures in patients with bone metastases of the long bones. A retrospective study of 233 surgically treated fractures.

OBJECTIVE: Analysis of short-term and long-term complications after cemented osteosynthesis for pathological fractures. DESIGN: Retrospective study. SETTING: South Municipal Hospital and the Daniël den Hoed Cancer Centre, Rotterdam, The Netherlands. SUBJECTS: 199 patients consecutive surgically treated between 1978 to 1990 for 233 fractures (161 actual and 72 impending) caused by metastatic lesions of the femur, humerus and tibia. INTERVENTIONS: Local resection of the tumour was followed by endoprostheses (n = 52) and by internal plate osteosynthesis (n = 167); 14 fractures were treated with intramedullary nails. Bone cement was added in 211 cases (91%). MAIN OUTCOME MEASURES: Pain relief, mobilisation, complications. RESULTS: Pain relief was achieved in about 90%. 145 (76%) who were treated for fractures of the lower extremity were able to walk again. There were 13 local complications: 26 (11%) implanted devices failed (cumulative probability 40%, after 60 months). In 11 cases the fixation failed after 7 weeks. The failure rate was 16% in the subtrochanteric region treated with an angled blade (probability 70% after four years). The patients' survival rate was 55% after six months and 20% at two years. CONCLUSION: Despite the poor life expectancy, our results indicate that hemiarthroplasty or osteosynthesis with bone cement for treatment of pathological (impending) fractures is a safe way to restore limb function and to improve quality of life.