Fatal progression of multifocal infection of Aspergillus sp. and multi-resistant Pseudomonas aeruginosa in a patient with toxic epidermal necrolysis and renal cancer.

Toxic epidermal necrolysis is an autoimmune disease expressed predominantly on the skin and mucous membranes. It is a serious bullous disease manifesting itself by induction of apoptosis in the dermo-epidermal junction. In most cases,it is attributable to the use of some drug. The basic approach to stopping progression of the disease is immunosuppression. Unfortunately, patients with such extensive loss of epidermis and defective mucosa are confronted by a variety of opportunistic, potentially pathogenic microorganisms. Unsurprisingly, infectious complications are today a predominant cause of death in patients thusly affected. Despite thorough review of the literature, we found no comprehensive case report concerning the development of multifocal Aspergillus infection in patients with this disease.

OUR EXPERIENCE WITH THE USE OF 40% BENZOIC ACID FOR NECRECTOMY IN DEEP BURNS.

INTRODUCTION: Chemical necrectomy of deep burns using 40% benzoic acid has been used extensively by the Department of Burns and Reconstructive Surgery at the University Hospital since its establishment in 1982. In spite of definite advantages for the patient and medical staff, hard data concerning benzoic acid absorption through skin necrosis and patient safety was missing. MATERIAL AND METHODS: We examined 22 burn patients in collaboration with the University Hospital Brno, Department of Clinical Biochemistry. The plasmatic levels of benzoic acid, hippuric acids and glycine, which is consumed during the metabolism of benzoic acid, were measured. Urine samples were collected to determine the total amount of hippuric acid that is excreted. We were able to determine the total amount of absorbed and excreted benzoic acid from these values. RESULTS: We consistently found that there was a rapid and short-term increase of plasmatic levels of benzoic acid (maximum 1.3 mmol/l). This value is about 5 times lower than the minimum toxic level of this acid (6.5 mmol/l). The same course has been observed in hippuric acid. The level of glycine dropped slightly, but was still within the normal range. DISCUSSION: Typical and atypical courses of the levels of both acids were discussed as well as the correlation of the dynamics of elimination with the extent of benzoic acid application in relationship with the clinical status of the patient. The effectiveness and safety of this method was evaluated. CONCLUSION: After summarizing the observations, it was demonstrated that chemical necrectomy using 40% benzoic acid is a selective method comparable with other types of sharp necrectomy. Chemical necrectomy is inexpensive, easy to perform and also reduces blood loss. Toxicity of absorbed benzoic acid is clinically negligible. Furthermore, benzoic acids antimycotic and antibacterial properties prevent the development of wound infection.

High voltage electrical injury: an 11-year single center epidemiological study.

The aim of our study was to retrospectively evaluate the epidemiological characteristics of patients with high voltage electrical injury from 1999 to 2009. The Clinic of Burns and Reconstructive Surgery, Faculty Hospital Brno is located in a region of 2,505,000 inhabitants. In total 13,911 patients (including both children and adults, and outpatients as well as hospitalized patients) were treated at our burn center during the period of study. Of these patients, 1,030 were hospitalized for burns treatment. For the purposes of this study, we have included only patients with high voltage electrical trauma, of which there were 58, 2 of whom were female. Basic epidemiological indicators were gathered on these patients, including age, gender, place of accident, extent of trauma, mortality and whether the injury was occupational or non-occupational. Electrical burns (caused by both low-voltage and high-voltage electric current) made up 1.10% of all burns treated in our burn center and high voltage electrical injuries represented 0.42% of all burn injuries. The average incidence of high voltage electrical trauma was 0.21 cases/100,000 inhabitants. The average age of the patients was 28.59 years. Nine patients died and the mortality was fixed at 15.52%. The average length of hospitalization was 53.43 days. The average extent of burnt area was 35.01% TBSA. In our study, we were able to define the basic epidemiological parameters in 58 patients with high voltage electrical trauma. We also have to highlight the still disappointingly high number of non-occupational electrical injuries affecting those in the lower age groups, especially children. However, preventive programmes for educating specific risk groups have shown positive results.

Le but de notre étude était d'évaluer rétrospectivement les caractéristiques épidémiologiques des patients présentant les lésions électriques causées par la haute tension de 1999 à 2009. La Clinique de « Burns and Reconstructive Surgery ¼, Faculty Hospital Brno, est située dans une région de 2.505.000 habitants. Au total, 13 911 patients (y compris les enfants et les adultes, et ambulatoires ainsi que les patients hospitalisés) ont été traités dans notre centre pendant la période d'étude. Parmi ces patients, 1.030 ont été hospitalisés pour le traitement des brûlures. Aux fins de cette étude, nous avons inclus seulement les patients avec un traumatisme électrique à haute tension, il y en avait 58, dont 2 étaient des femmes. Des indicateurs épidémiologiques de base ont été recueillies sur ces patients, dont l'âge, le sexe, le lieu de l'accident, l'ampleur du traumatisme, de la mortalité et si la blessure était liée ou non au travail. Les brûlures électriques (causée par une basse tension et le courant électrique à haute tension) représentaient 1,10% de toutes les brûlures traitées dans notre centre, et des blessures électriques à haute tension représenté 0,42% de toutes les brûlures. L'incidence moyenne de traumatisme électrique à haute tension est de 0,21 cas pour 100,000 habitants. L'âge moyen des patients était de 28,59 années. Neuf patients sont décédés et la mortalité a été fixée à 15,52%. La durée moyenne d'hospitalisation était de 53,43 jours. La moyenne surface corporelle brûlée était 35.01% de la SCT. Dans notre étude, nous avons pu définir les paramètres épidémiologiques de base chez 58 patients atteints de traumatismes électrique à haute tension. Nous devons également mettre en évidence le nombre toujours élevé de blessures électriques non-professionnelles affectant ceux dans les groupes d'âge inférieures, surtout les enfants. Toutefois, les programmes de prévention pour sensibiliser les groupes à risque spécifiques ont montré des résultats positifs.

[Epidemiology of critical burns in southern Moravia]. / Epidemiologie kritických popálenin na jizní Morave

UNLABELLED: The aim of the study was to define the principal and additional characteristics of critical burns and to evaluate the effect of an increasing Abbreviated Burn Severity Index (ABSI) on mortality in burn patients admitted to the Department of Burns and Reconstructive Surgery, University Hospital in Brno. MATERIAL AND METHODS: This retrospective monocentric study included all patients older than 18 years with critical burns involving more than 40% of the total body surface area (TBSA) who were admitted to the Department of Burns and Reconstructive Surgery, University Hospital in Brno, in the period from January 1, 2001 to December 31, 2010. The epidemiological data evaluated included: age, gender, size of burn injury, mechanism of injury, required surgical intervention, mortality, length of hospital stay and the presence of inhalation injury. The results were statistically analysed. RESULTS: A total of 2 479 adult patients were admitted to the Department in the period under study, and 112 (4.5%) of them had critical burns. In this patient group, the average age was 48.7 years, the average burned surface area was 62.8% TBSA, and the average length of hospital stay was 37.2 days. The male-to-female ratio was 2.39:1. Inhalation injury was diagnosed in 92 patients (82.1%). Of the 112 patients with burn injury, 59 died (52.7%). The lowest mortality rate was in the age category of 31 to 40 years (21.1%) and the highest rate in the patients aged over 71 years. No patient with the ABSI . 8 died while, amongst the patients with the ABSI .13, the mortality rate was 87.8%. DISCUSSION: No study dealing comprehensively with this topic in a patient group of this size has so far been published in the Czech Republic. Our results showed that the patients with critical burns accounted for about 5% of all patients with thermal trauma. The ABSI has proved to be a valuable and reliable predictor of survival in patients with critical burns. The extent of burned area and age were risk factors affecting mortality. On the other hand, the effect of inhalation injury on mortality, as a single risk factor, is disputable because this develops with an increasing burned surface area. CONCLUSIONS: The most important epidemiological data on patients with critical burns were evaluated. The study shows that although the number of patients annually admitted to hospital with severe burns is still high, it has nevertheless decreased recently.

The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997-2009.

UNLABELLED: The aim of this study was to determine the basic epidemiological characteristics of severely burned children who were admitted to the intensive care unit (ICU), Department of Burns and Reconstructive Surgery Faculty Hospital Brno, Czech Republic in the years 1997-2009. METHODS: We collected and evaluated epidemiological data such as age, sex, burn etiology, length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic strategies, the use of mechanical ventilation and its duration, day and month of injury and the extent of burned area. RESULTS: In total 383 children (253 boys, 130 girls) aged 0-14 years, underwent intensive care for at least 48h. Male to female ratio was 1.95:1. The average range of burn area in the group was 16.43±12.86% TBSA (total body surface area). During the reporting period, 16 children were admitted with burns over 50% TBSA. 328 children suffered burns indoors, with 55 children being burned outdoors. Indoor/outdoor ratio was set at 5.96:1. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in this group was 312 (81.46%). Mechanical ventilation was used in 96 cases (25.07% of all the admitted patients). The duration of mechanical ventilation in these patients was 8.03±5.67 days in average. The average length of stay in ICU was 10.71±10.92 days and total length of hospital stay was an average of 21.55±14.55 days. A total of 184 patients (48.04%) were treated surgically and therefore required necrectomy and skin grafting. The other 199 (51.96%) patients were treated conservatively. During the reporting period 3 children died (0.78%). CONCLUSION: In our report we identify basic epidemiological data defined in the aim of this study for burned children requiring intensive care.

Epidemiology of ventilator-associated tracheobronchitis and vantilator-associated pneumonia in patients with inhalation injury at the Burn Centre in Brno (Czech Republic).

Aim. The aim of this work is to determine the incidence of ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP) and to define the define the most important respiratory pathogens in patients with inhalation injury. Introduction. Infectious complications in severely burned patients present serious problems. Patients with inhalation injuries are exposed to greater risk owing to the possible development of infectious complications in the lower respiratory tract. VAP is the predominant cause of death in these patients. This is due to the increasing resistance of strains of Gram-negative bacteria such as Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae. Design. Retrospective, monocentric. Setting. A five-bed burn intensive care unit. Material and methods. Between 2004 and 2009, 348 adult patients were hospitalized in the intensive care unit of the Department of Burns and Reconstructive Surgery, Brno University Hospital, Czech Republic. Of these, 127 (36.49%) were diagnosed by bronchoscopy as having inhalation injury. The prerequisite for inclusion in the cohort was an inhalation injury requiring artificial ventilation for at least 48 h. The lower airway microbiological condition was monitored regularly by sampling biological material for cultures (sputum, tracheobronchial aspirates, etc.). For the diagnosis of VAP and VAT we used the Centers for Disease Control and Prevention criteria and the Clinical Pulmonary Infection Score. Results. The average age of the 127 patients (31 women/96 men) included in the study was 38.4 yr (range, 21-69 yr) and the average total body surface area (TBSA) burned was 29.3% (range, 2-75%). The average length of hospital stay was 49.4 days (range, 4-150 days) and the duration of mechanical ventilation 8.7 days; 18 patients (14.2%) died. In patients with inhalation injury, 309 strains of bacteria were cultivated from the lower respiratory tract, of which 234 were Gram-negative. All of these bacterial strains were isolated in significant quantities for lower respiratory tract infection. The most common bacteria isolated from the lower respiratory tract was Klebsiella pneumoniae (78 times), followed by Pseudomonas aeruginosa (49x), and Acinetobacter baumannii (28x). VAT was diagnosed in 109 patients (85.8%) in the cohort. The incidence of VAT was calculated to be 98.8 per 1000 days of mechanical ventilation. VAP was diagnosed in 34 patients in the cohort (26.8%). The incidence of VAP was calculated as being 30.8 cases per 1,000 days of mechanical ventilation. In eight patients (23.5%), VAP was diagnosed within 5 days of initiation of mechanical ventilation (early onset) and in 26 patients (76.5%) after a longer period (late onset). The most common aetiological agent of VAT and VAP was Klebsiella pneumoniae (respectively 41.3% and 35.3%). Conclusion. In this study we were able to determine the incidence of VAP and VAT in patients with inhalation injury. In spite of the advances in diagnostics and therapy, inhalation injury is still burdened with disappointingly high morbidity and mortality rates. For this reason, the treatment of VAP remains a major challenge for all physicians caring for patients with inhalation injury.

[Changes in the bacterial spectrum in severe burn wounds]. / Zmena bakteriálního spektra na ranných plochách u tezce popálených pacientu.

STUDY OBJECTIVE: To determine the time axis for increase in Gram negative bacterial strains in burn wounds during hospitalization. STUDY TYPE: Retrospective. MATERIAL AND METHODS: Eighty-five patients hospitalized at the Clinic of burns and reconstructive surgery between 2006 and 2008 were enrolled in the study. The major criteria for enrolment were more than 15% of total body surface area (TBSA) burned, hospital stay of 1 month or more and age over 18 years. Specimens for microbiological examination were collected on days 2, 6, 10, 14 and 20 after admission. RESULTS: A total of 777 bacterial strains were isolated from the study patients, with 64.6% of these strains being Gram positive and 35.4% Gram negative. The most frequently isolated Gram positive pathogens were coagulase-negative Staphylococcus (260 strains) and Bacillus sp. (113 strains), while the most common Gram negative pathogens were Pseudomonas aeruginosa (81 strains), Escherichia coli (63 strains) and Acinetobacter calcoaceticus-baumannii complex (57 strains). CONCLUSION: The study provided data that supports the assumption of increase in Gram negative bacterial strains in burn wounds during hospitalization. Nevertheless, even on day 20 after admission, such strains did not predominate.

Prevalence and resistance of Pseudomonas aeruginosa in severely burned patients: a 10-year retrospective study.

BACKGROUND: Infection complications caused by gram-negative bacteria nowadays constitute the dominant mortality cause in severely burned patients. Pseudomonas aeruginosa is the most feared nosocomial pathogen among burn centers worldwide, with the highest mortality. MATERIAL AND METHODS: The study involved adult patients hospitalized at the Intensive Care Unit at the Department of Burns and Reconstructive Surgery, University Hospital Brno, between the years 2000 and 2009. These patients were hospitalized for thermal injuries. Retrospectively we have evaluated the extent of the burned areas, ages, depth of injury at admission and at discharge or in dissection (histology) and length of hospitalization on the Intensive Care Unit. By completing regular swabs we monitored and evaluated the microbiological situation not only at the burned areas but also in the lower respiratory system, in the urinary tract and in the blood stream. RESULTS: The study involved a total of 640 adults hospitalized at the Intensive Care Unit at the Department of Burns and Reconstructive Surgery, University Hospital Brno, for burn trauma between the years 2000 and 2009. The average extent of the burned area in patients was 36.2% TBSA (2-97% TBSA), average age was 36.7% years (18-92 years), average length of hospitalization at the Intensive Care Unit was 27.1 days (1-151 days). We isolated a total of 2,958 strains of Pseudomonas aeruginosa (including repeated isolation of pseudomonas strains in the same patients) in these patients. The most frequently found of these was Pseudomonas aeruginosa isolated from the burned area (1,301 strains), from the lower respiratory system (651) and from the urinary tract (592 strains). During the monitored period the number of strains isolated in our patients increased (146 strains in 2000, 521 strains in 2009). Furthermore, we noticed increased resistance to all available antibiotics except Polymyxins. All of the Pseudomonas aeruginosa strains in the monitored years maintained 100% sensitivity to Colistin. Of the routinely used antibiotics Meropenem showed the greatest increase of resistance (in 2000 this comprised a total of 18% of the resistant Pseudomonas aeruginosa strains, and in 2009 58% of the strains). Ceftazidime shows similar results (in 2000 12%, in 2009 39% of resistant strains). Amikacin displayed a relatively good effect against pseudomonas infections; in 2009 we registered total of 34% of the resistant strains of Pseudomonas aeruginosa to this aminoglycoside. In 2000 there were 13 multiresistant strains (i.e. 8.9%) of Pseudomonas aeruginosa, in 2009 the figure was 171 strains (i.e. 32.82%). CONCLUSION: In our study we point to the increasing trend not only in the prevalence but also in the resistance of Pseudomonas aeruginosa strains. This limits our choices for suitable antibiotic therapy. This is why infection complications play such a significant role in morbidity and mortality in severely burned patients.

One-year experience with tigecycline in treating serious infections in severely burned patients.

Tigecycline is a new semi-synthetic antibiotic from the glycylcycline class of antibiotics. In the Czech Republic this preparation is registered only primarily for complicated skin infections and infection of soft tissues, along with complicated intra-abdominal infections. In future its indications will perhaps widen to include respiratory tract infections, as is the case in the USA. So far we don't have sufficient data about the use of tigecycline in the treatment of critically ill patients, and in these patients it should not be the treatment of first choice. However, it remains to be seen whether increasing resistance and insufficient new types of antibiotics will force us to use tigecycline in these indications as well. Bacterial infections still present a huge threat to severely burned patients. Lately, in patients with burn trauma, as the source of infection complications have begun to dominate significantly multiresistant strains of bacteria. These bacteria originate from gram positive as well as gram negative spectrum. In severely burned patients the early and correct indication of antibiotic treatment, as well as the appropriate choice of antibiotics, forms one of the foundations of successful treatment. At the Department of Burns and Reconstructive Surgery we first used tigecycline on August 9th 2008 in the treatment of non-healing defects after autotransplant with dermo-epidermal grafts in the face, where the source of infection was identified as mixed bacterial microflora. The treatment was successful. Since then tigecycline has become a standard antibiotic at our workplace. In the observed period of 12 months we have used the antibiotic in 11 patients. Thanks to a wide antibacterial spectrum, monotherapy with tigecycline constitutes an interesting alternative to the frequently difficult combination of antibiotics used in other treatments. In this work we present our clinical experience, results, indications as well as difficulties in tigecycline treatment.

Mutilating electrotrauma--case report.

The passage of electric current through a human body causes polarization changes in cell membranes, which can possibly lead to the death of these cells. At the same time, electric energy is transformed to thermal energy, primarily in high resistance tissues. We present a case report of a 22-year-old male who was hit by an electric current with a voltage of 22 kV when he was working on a high-voltage overhead line tower. Primary treatment which included fasciotomies was completed two hours after the injury. Fasciotomies and revisions of all muscle groups were completed on the left upper extremity and right shank. On the right upper extremity fasciotomies were completed on the forearm. Retinaculum flexorum was cut in the area of both wrists. Despite the complex therapy including higher doses of a low-molecular-weight heparin, ischemization of the whole left upper extremity and distal part of right shank and foot occurred. On the sixth day after the injury it was necessary to amputate the right lower extremity in shank and on the eighth day after injury to amputate the left upper extremity below the shoulder, and on the fourteenth day, due to progressive ischemic necrosis, it was necessary to complete exarticulation of the left shoulder. The 45th day after the injury our team of micro-surgeons closed the defect of soft tissues in the distal part of right forearm and radial part of right hand by transferred parascapular fasciocutaneous flap. The right median nerve appeared to be necrotic in the distal part of forearm even at the day of injury. Four months after the injury the 12 cm long defect of the right median nerve was bypassed by a graft from the suralis nerve. Outpatient care followed as well as physical and psychological rehabilitation. The support of the family was admirable. One and a half years after the injury reconstruction of the right thumb flexor tendon was completed. Two years after the injury function of the right hand in terms of grip function was satisfactory (patient was able to complete pinch grip and sign). Gait with the prosthesis was very good.

Long-term follow-up of chimerical state of the patients transplanted for different haematologic diseases.

Long-term follow-up of peripheral cellular chimerism in patients treated with BMT or PBSCT revealed the usefulness of their continuous monitoring at molecular level. Our results are based on monitoring of 120 patients, who were followed for at least 24 months. Comparison of the patients treated for chronic myelogenous leukemia (CML), acute myelocytic leukemia (AML), acute lymphocytic leukemia (ALL), myelodysplastic syndromes (MDS) and aplastic anaemia (AA) revealed that mixed chimerism was practically absent in MDS and relatively long-lasting in ALL and AA (regardless to substantially different post-transplantation treatment). The first disease relapses signalized by molecular checking of mixed peripheral chimerism were observed also after a period of remission lasting for several years. Molecular watching enables us to detect relapses at their very beginning that would remain hidden to less sensitive methods. We believe that all of the transplanted patients ought to be monitored for residual disease i.e. cellular chimerism using molecular methods without time limits. On the other hand low level of mixed cellular chimerism is not necessarily a sign of disease progression and can remain unchanged as "status quo" for a very long period.

Reconstructive surgeries after extensive burns in children.

The authors' aim is to summarize and generalize the knowledge acquired in the course of the last eight years of work with children with extensive burns. Reconstructive surgeries show a certain specific feature consisting in the considerable extent of the scarred area often exceeding 50% of the body surface, and with the gradual increase in number of operations they are gaining importance.

Successful treatment of a critically burned patient (case report).

The objective of this study was to document that treatment of a critically burned patient could be, although with some problems, ultimately very successful. The commonplace of such successful therapy is certainly not only current, up-to-date and most intensive care, but also good teamwork and professionalism of the whole team in the specialized workplace--Burn and Reconstructive Surgery Departments of the Faculty Hospital in Brno.

Special features of burn injuries in elderly patients.

Types of burns and other aspects of burn injuries and case outcomes were assessed in a group of geriatric patients (> 60 years) and a younger group of patients (40-59 years). Between 1990 and 1999, 137 geriatric patients (47 [34%] males and 90 [66%] females) were admitted to the Burn Centre and Reconstructive Surgery Centre at University Hospital in Brno. We compared findings in this elderly group to those in 176 younger burn patients (126 [72%] males and 50 [28%] females) who were treated at the centre during the same time period. Age and concomitant chronic disease contribute to the high mortality and a higher frequency of complications in geriatric patients who suffer burn injuries. In this study, the complication rates for geriatrics during hospitalization (44% in males and 32% in females) and the elderly patients' mortality rates (26% in males and 17% in females) differed statistically from the corresponding rates in the younger patient group. It is important to know the special needs of elderly burn patients because this patient group is expected to grow in parallel with the rising average age of the Czech Republic's population.