Extensive colonization with carbapenemase-producing microorganisms in Romanian burn patients: infectious consequences from the Colectiv fire disaster.

Health care of severe burn patients is highly specialized and may require international patient transfer. Burn patients have an increased risk of developing infections. Patients that have been hospitalized in countries where carbapenemase-producing microorganisms (CPMO) are endemic may develop infections that are difficult to treat. In addition, there is a risk on outbreaks with CPMOs in burn centers. This study underlines that burn patients may extensively be colonized with CPMOs, and it provides best practice recommendations regarding clinical microbiology and infection control. We evaluated CPMO-carriage and wound colonization in a burn patient initially treated in Romania, and transported to the Netherlands. The sequence types and acquired beta-lactamase genes of highly-resistant microorganisms were derived from next generation sequencing data. Next, we searched literature for reports on CPMOs in burn patients. Five different carbapenemase-producing isolates were cultured: two unrelated OXA-48-producing Klebsiella pneumoniae isolates, OXA-23-producing Acinetobacter baumanii, OXA-48-producing Enterobacter cloacae, and NDM-1-producing Providencia stuartii. Also, multi-drug resistant Pseudomonas aeruginosa isolates were detected. Among the sampling sites, there was high variety in CPMOs. We found 46 reports on CPMOs in burn patients. We listed the epidemiology of CPMOs by country of initial treatment, and summarized recommendations for care of these patients based on these reports and our study.

Severe flucloxacillin-induced acute generalized exanthematous pustulosis (AGEP), with toxic epidermal necrolysis (TEN)-like features: does overlap between AGEP and TEN exist? Clinical report and review of the literature.

Acute generalized exanthematous pustulosis (AGEP) and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) are rare but severe cutaneous adverse drug reactions. Especially in TEN, large areas of the skin and mucosae may become detached. Although AGEP and SJS/TEN are distinct entities with a different clinical picture, pathogenesis, prognosis and treatment, they may share some features, raising the hypothesis of overlap between both entities. We present a severe case of AGEP, caused by flucloxacillin, clinically presenting with TEN-like features and pronounced systemic symptoms with haemodynamic and respiratory instability. Furthermore, we present a review of the literature on cases of AGEP with features resembling SJS/TEN or a supposed overlap with SJS/TEN.

Prevention of Staphylococcus aureus burn wound colonization by nasal mupirocin.

BACKGROUND: There are two important routes for the transmission of Staphylococcus aureus to the burn wound. In the endogenous route, patients naturally carrying S. aureus colonize their own wounds, whereas in the exogenous route burn wounds are cross-infected from other sources. In this study we evaluated the effect of blocking the endogenous route on S. aureus burn wound colonization by mupirocin application in the nose of patients at the time of admission. METHODS: From September 2000 to January 2002 all patients with burns admitted to a single dedicated Burn Centre received nasal mupirocin upon admission. This period was compared to two control periods (C1: July 1999 to July 2000 and C2: January 2002 to January 2003) for S. aureus burn wound colonization. The colonization risk was analysed, adjusting for confounding, with Cox proportional hazard regression. RESULTS: A total of 98 patients did not have S. aureus burn wound colonization at the time of admission and were, thus, considered at risk for S. aureus acquisition during their stay. As compared to C1, the relative risk of acquiring S. aureus in their wound was 0.48 (95% CI: 0.24-0.97) in the mupirocin period and 0.55 (95% CI: 0.28-1.1) during the C2 period. S. aureus nasal/pharyngeal colonization was a significant independent risk factor for wound colonization (RR: 2.3; 95% CI: 1.2-4.2). CONCLUSION: Nasal mupirocin may contribute to risk reduction of S. aureus wound colonization in patients with burns.

Clinical outcome of patients with self-inflicted burns.

INTRODUCTION: Patients with self-inflicted burns (SIB) are thought to have a longer length of stay compared to patients with accidental burns. However, other predictors for a longer length of stay are often not taken into account, e.g. percentage of the body surface area burned, age or comorbidities. Therefore, we wanted to study the outcome of patients with SIB at our burn center. METHODS: A retrospective, observational study was conducted. All adult patients with acute burns admitted to the burn center of the Martini Hospital Groningen, between January 1, 2009 and December 31, 2013 were included. Data on characteristics of the patient, injury, and outcome (LOS, mortality, discharge destination) were collected. In patients with SIB, suicide attempts (SA) were distinguished from self-harm without the intention to die (non-suicidal self-injury, NSSI). To evaluate differences in outcome, each patient with SIB was matched on variables and total score of the Abbreviated Burn Severity Index (ABSI) to a patient with accidental burns (AB). RESULTS: In total 29 admissions (21 SA and 8 NSSI) were due to SIB and 528 due to accidents. Overall, when compared to AB, there were significant differences with respect to mortality and LOS for SA and/or NSSI. Mortality was higher in the SA group, while the LOS was higher in both the SA and NSSI groups compared to the AB group. However, after matching on ABSI, no statistical significant differences between the SA and SA-match or the NSSI and NSSI-match group were found. CONCLUSION: With the right and timely treatment, differences in mortality rate or length of stay in hospital could all be explained by the severity of the burn and the intention of the patient.

Partial-thickness scalds in children: A comparison of different treatment strategies.

AIM: The aim of this study was to compare the clinical outcomes of different treatment strategies for children with partial-thickness scalds at two burn centers. At the first burn center, these burns were treated with a hydrofiber dressing (Aquacel®, Convatec, Inc.®, Princeton, NJ, USA) or silver sulfadiazine (SSD, Flammazine®, Sinclair IS Pharma, London, UK Pharmaceuticals), while at the second burn center, cerium nitrate-silver sulfadiazine (CN-SSD, Flammacerium®, Sinclair IS Pharma, London, UK Pharmaceuticals) was used. METHODS: A two-center retrospective study was conducted of children admitted between January 2009 and December 2013 for partial-thickness scalds up to 10% TBSA who were treated primarily with a hydrofiber dressing or silver sulfadiazine (Burn Center Rotterdam) vs. cerium nitrate-silver sulfadiazine (Burn Center Groningen). The Dutch Burn Repository R3 and the electronic medical records of the study population were used for data extraction. The primary outcome was the time to wound healing. The secondary outcomes were the length of hospital stay, wound infection, and surgical treatment. RESULTS: The time to wound healing differed between the groups (HR=1.46, 95%CI 1.17-1.82); the shortest time to wound healing was observed in the patients treated with CN-SSD (median 13 days), compared with 15 days for the patients treated with hydrofiber and 16 days for the patients treated with SSD (p<0.01). The length of stay was significantly shorter for the hydrofiber patients (medians: hydrofiber 3 days, SSD 10 days and CN-SSD 7 days; p<0.01), but their outpatient treatment period was significantly longer (medians: hydrofiber 12 days, SSD 6 and CN-SSD 4 days; p<0.01). The proportion of surgeries and the mean time to surgery was similar between the burn centers. CONCLUSIONS: This study compared different burn centers' treatment strategies for children with partial-thickness scalds and found a shorter time to wound healing in the CN-SSD group. Patients treated with hydrofiber had a shorter clinical period in comparison with the SSD and CN-SSD patients. The results of CN-SSD are promising and warrant further study. A prospective study is needed to gain full insight into the merits and drawbacks of the treatment strategies. This will allow clinicians to make full use of the strengths of particular treatments to benefit specific patients.

Effect and mechanism of hydrocortisone on organ function in patients with severe burns.

INTRODUCTION: In patients with severe burns, resuscitation with large volumes of fluid is needed, partly because of an increase in capillary leakage. Corticosteroids might be beneficial by diminishing capillary leakage. This study aimed to assess in severely burned nonseptic patients whether hydrocortisone (HC) improved outcome and diminished capillary leakage. METHODS: Retrospective analyses of a prospectively collected database were performed, including 39 patients (age 52 [35-62] years, 72% male). Patients were divided based on HC therapy. First, in patients in whom HC was started late, that is when deteriorating (late; 5-12 days postburn) data before and after start of HC were compared. Second, patients in whom HC was started day 0 or 1 postburn (upfront; within 48 hours) were compared with patients who did not receive HC (control). Outcome was assessed as organ dysfunction by Denver Multiple Organ Failure (MOF) score and Sequential Organ Failure Assessment (SOFA) score. As markers for capillary leakage and hydration state, proteinuria, B-type natriuretic peptide (BNP), and fluid administration were assessed. Follow-up was 20 days postburn. Possible adverse effects including mortality were recorded. Repeated measurement regression analyses were performed using MLwiN. RESULTS: In the late group, Denver MOF and SOFA scores significantly decreased after HC (P<.001). Proteinuria tended to decrease (P=.13), BNP increased on the days HC was used (P<.001), and amounts of fluids diminished (P<.001). In the upfront vs control group, Denver MOF and SOFA scores (P<.001) decreased more quickly. Proteinuria (P=.006) and administered fluids decreased more rapidly (P<.001). Mortality rate, numbers of positive blood cultures, incidence of pneumonia, and graft loss were similar in all groups. CONCLUSIONS: Hydrocortisone treatment in severe burned patients without sepsis might improve organ dysfunction possibly because of a reduction in capillary leakage, as reflected by a decrease of proteinuria, an increase of BNP, and diminished fluid resuscitation volumes.

Early management in children with burns: Cooling, wound care and pain management.

INTRODUCTION: Early management in burns, i.e. prior to admission in a burn center, is essential for an optimal process and outcome of burn care. Several publications have reported suboptimal early management, including low levels of pain medication after trauma, especially in children. The aim of this study was to evaluate the current practice in the Netherlands and factors related to early management in pediatric burns, i.e. cooling, wound covering and pain management. To study possible change and improvement over time, two study periods were compared. METHODS: This study involved two periods; January 2002-March 2004 (period 1) and January 2007-August 2008 (period 2). All children (0-15 years of age) with acute burns admitted within 24h after burn to one of the three Dutch Burn centers with a formal referral were eligible. Data were obtained from patient records, both retrospectively and prospectively. RESULTS: A total of 323 and 299 children were included in periods 1 and 2, respectively. The vast majority of children in both study periods had been cooled before admission (>90%). Over time, wound covering increased significantly (from 64% to 89%) as well as pain treatment (from 68% to 79%). Predominantly paracetamol and morphine were used. Referral from ambulance services (OR=41.4, 95%CI=16.6-103.0) or general practitioners (OR=59.7, 95%CI=25.1-141.8) were strong independent predictors for not receiving pre-burn center pain medication. On the other hand, flame burns (OR=0.2, 95%CI=0.1-0.5) and more extensive burns (TBSA 5-10%: OR=0.4, 95%CI=-0.2 to 0.8; TBSA≥10%: OR=0.2, 95%CI=0.1-0.4) were independent predictors of receiving pain medication. CONCLUSION: Referring physicians of children with burns were overall well informed: they cool the wound after burns and cover it before transport to prevent hypothermia and reduce the pain. Additional studies should be conducted to clarify the duration and temperature for cooling to be effective. Furthermore, there is room and a need for improvement regarding early pain management.

Early detection of shock in critically ill patients by skeletal muscle PO2 assessment.

The usefulness of skeletal muscle PO2 assessment in monitoring patients at risk of shock was evaluated in 20 critically ill patients. A shock score, inotropic score, and combined inotropic-shock score were calculated. If the median skeletal muscle PO2 assessment was more than 31.5 mm Hg, no shock occurred in the period from 4 hours before to 6 hours after the measurement. The risk of shock occurring during the first 2 hours after the skeletal muscle PO2 assessment was 2.2 times higher if median skeletal muscle PO2 assessment was below 22.5 mm Hg. If inotropes were administered, no significant difference was found in the incidence of shock if skeletal muscle PO2 was below or above 22.5 mm Hg. Skeletal muscle PO2 assessment enables the determination of the severity of shock and determination of risk of shock in critically ill patients, provided no treatment with inotropes has been instituted.

Perfusion of burn wounds assessed by laser doppler imaging is related to burn depth and healing time.

Average perfusion in various burn wounds was assessed using Laser Doppler Imaging (LDI). The time necessary for a complete healing of the wound was compared to the results of the LDI measurements. A certain depth of burn was associated with a typical pattern of perfusion in the course of time. There was a significant difference between average perfusion in a full thickness burn requiring surgical treatment and burns with regenerative capacities.

[Fire-eaters, a breath-taking act?]. / Vuurspuwen, een adembenemende act?

Burns due to fire-eating are relatively rare. In a short period (6 months) four patients (men aged 9, 22, 27, and 15) were sent to the Burns Centre of the Martini Hospital of Groningen, the Netherlands. They had used car petrol in stead of paraffin oil. Their burns were not very severe but they were hospitalized because of the risk of an inhalation injury, especially oedema of the glottis. Signs related to inhalation injury are: burned hairs of the nose, smut on the mucous membrane in the mouth and nose or in the sputum, hoarseness, increase of tachypnoea and dyspnoea. Burns in the face are suggestive of an inhalation injury, of which there are three forms: oedema of the glottis, tracheobronchitis, and acute respiratory distress syndrome (ARDS). The four patients did not develop inhalation injury and recovered completely.

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.

Epidemiology of children admitted to the Dutch burn centres. Changes in referral influence admittance rates in burn centres.

BACKGROUND: In the Beverwijk Burn Centre a remarkable rise has been noted in the number of paediatric admissions since 2000. To investigate if this is a national trend and, if so, what may have caused it, a retrospective epidemiological study has been undertaken. MATERIALS AND METHODS: The databases of the three Dutch burn centres were combined. Data on the population at risk for admission in a burn centre and data on burns related hospital admissions were added. Two age groups, 0-4 years and 5-17 years and two time periods, 1995-1999 and 2000-2007, were compared. RESULTS: The mean number of paediatric admissions in the Dutch burn centres per year increased by 44.0% and 44.3% for the younger children (0-4 years) and the older children (5-17 years), respectively, whereas the number of paediatric burn admissions in other hospitals in the Netherlands decreased. The percentage of children that was referred from other hospitals increased in both age groups, and for the younger children this was significant. CONCLUSION: There has been a shift in paediatric burn care towards a greater volume of admissions in specialized burn care of especially young children with less severe burns. A possible explanation for the increased number of referred children may be the introduction of the EMSB course in 1998, since EMSB guidelines dictate stricter and generally accepted referral criteria.

Risk of postoperative septic complications after abdominal surgical treatment in relation to perioperative blood transfusion.

A group of 548 patients was analyzed retrospectively to determine risk factors, particularly the perioperative administration of blood, for postoperative septic complications after intra-abdominal operations. Of the entire group, 198 (36.1 per cent) had at least one complication. The postoperative mortality rate was 0.9 per cent. Using univariate analysis, blood transfusion, serum protein concentration, gastric malignant disease, total gastrectomy, anastomotic dehiscence, diabetes mellitus, the surgeon and perioperative antibiotics were significant factors influencing the rate of postoperative septic complications. After adjustment for all these factors, logistic regression analysis was used to study the effect of perioperative blood transfusion. Age, serum protein concentration, antibiotics, extended malignant disease of the colon, gastric operation, total colectomy, operation performed by staff members and anastomotic dehiscence were significant independent factors. Blood transfusion per se was not significant (p = 0.07). In patients who received more than 3 units of blood, the postoperative septic complication rate was significantly elevated (p = 0.003). We conclude that the perioperative administration of blood may negatively influence the risk of developing postoperative septic complications after intra-abdominal operations.

Bacterial translocation and its relationship to visceral blood flow, gut mucosal ornithine decarboxylase activity, and DNA in pigs.

The relationship of bacterial translocation to gut blood flow and mucosal integrity was studied in pigs. Three groups of miniature pigs were studied: sham injured (controls) (n = 7), 50% mechanical reduction in blood flow to the superior mesenteric artery (SMA) and celiac artery (CA) (n = 6), and a 40% third-degree cutaneous flame burn (n = 9). Forty-eight hours after injury, animals were killed and organ samples obtained for analysis. Bacteria of the same biotype as that found in the intestinal lumen were present in the mesenteric lymph nodes (MLN) of 9 of 9 burned pigs and 5 of 6 pigs undergoing partial vascular occlusion. The DNA content and ornithine decarboxylase (ODC) activity were increased in the colon mucosa of animals from both the reduced-flow and burn-injured groups compared with control animals. Decreased blood flow to the gut may contribute to the development of bacterial translocation. In addition, intestinal regenerative capacity remains intact 48 hours after injury.

The effect of packed cells and whole blood transfusions on survival after curative resection for colorectal carcinoma.

The effect of perioperative blood transfusions on survival after curative resection for colorectal carcinoma was studied retrospectively on 270 patients with special emphasis on whole blood transfusion. Eighty-six (32 percent) patients did not receive blood transfusions, whereas the remaining 110 (41 percent) received packed cells and 74 (27 percent) received at least 2 units of whole blood. The recurrence-free and overall 5-year survival rates for the transfused group were 58 and 57 percent, respectively, and for the non-transfused group, 78 and 72 percent, respectively. These differences were highly significant (log rank test, P less than 0.001). The recurrence-free and overall 5-year survival rates for patients who received only whole blood or a combination of whole blood and packed cells was 51 percent, and of those who received only packed cells was 63 percent. The difference was not statistically significant (log rank test, P = 0.08, P = 0.35). Administration of more than 6 units of blood is attended with a significantly worse 5-year disease-free survival rate than administration of a smaller volume. The survival was not decreased if 6 or more units of whole blood were given. The authors conclude that perioperative blood transfusions have a significant detrimental effect on survival after curative resection for colorectal carcinoma. This effect is not enhanced by whole blood transfusions.

Renal trauma and hypertension.

A retrospective study (1972-1983) was made of 622 consecutive patients who suffered renal trauma, in order to assess the incidence and prevalence of post-traumatic renal hypertension. In 435 (76%) of the 569 survivors long-term followup data and blood pressure recordings were obtained, 13 months to 12 years after trauma (mean, 5.6 years). Renal trauma could not be linked to an increased incidence of hypertension: on first control, only 94 patients (21%) demonstrated a casual elevated blood pressure (greater than 140/90 mm Hg). The presence of a fixed hypertension was validated in only 14 patients. Twelve of them were extensively screened in the Department of Internal Medicine. In none of these patients could a definite relationship between hypertension and renal trauma be documented. Furthermore, an extensive review was done of 223 cases of post-traumatic renal hypertension reported in the literature from 1951 until 1984. Careful analysis of these previously described cases (71 publications) leads us to criticize the widespread accepted cause-effect condition with regard to post-traumatic renal hypertension. It is concluded that adequate management of renal injuries with early diagnosis and individualised surgical treatment can prevent this extremely rare complication.