Risk factors of emerging multidrug resistant Acinetobacter baumannii in burn patients at burn Unit of Dr. Soetomo Hospital.

INTRODUCTION: Burn injury patients are at high risk of infection as a result of the nature of the burn injury itself, including prolonged hospital stays, antibiotics use, treatment procedures, etc. In this era, nosocomial infections caused by Acinetobacter baumannii (A.ba) have increased significantly. This study was conducted to investigate the micro-organism pattern and the risk factors for burn patients with multi-drug resistant (MDR) Acinetobacter baumannii (A.ba) in the Burn Unit at Dr. Soetomo Hospital. MATERIALS AND METHODS: We conducted a retrospective, observational study among burn patients with A.ba admitted to the Burn Unit at Dr. Soetomo Hospital from January 2020 to December 2021. Potential risk factors for MDR-A.ba were analysed by univariate and multivariate analysis. The patients diagnosed with MDR-A.ba wound infection were included in the case group. The patients diagnosed with non MDR, these are: (1) the patients isolated micro-organisms other than A.ba, (2) sterile isolates, and (3) the patients isolated as A.ba but not MDR, were included in the control group. RESULTS: A total of 120 burn patients were included in this study. During this study, 24% burn patients were found to have Acinetobacter baumannii and 79% (from 24% of Acinetobacter baumannii) had MDR-A.ba. According to univariate analysis, risk factors that significant were: Abbreviated Burn Severity Index (ABSI) (p = 0,002; OR: 6.10; CI: 1,68 - 21,57); hospital Length Of Stay (LOS) (p < 0,000; OR: 6.95; CI: 2,56 - 18,91) and comorbid (p = 0,006; OR: 3,72; CI: 1,44 - 9,58). But, after analysed by multivariate analysis, only ABSI was the significant factor (p = 0,010; OR: 1,70; CI: 1,23 - 2,36). CONCLUSION: Based on univariate analysis, the significant risk factors for MDR-A.ba were: ABSI, hospital length of stay and comorbid. But after adjusted by multivariate analysis, only ABSI was the significant factor.

Effects Of Oxandrolone On Lean Body Mass (Lbm) In Severe Burn Patients: A Randomized, Double Blind, Placebo-Controlled Trial.

In severe burns, hyper-metabolic conditions due to elevation of pro-inflammatory cytokines and stress hormones usually occur. Unregulated hypermetabolism can lead to muscle protein catabolism, inducing weakness, infection, and delayed wound healing. Oxandrolone is known as an anabolic agent with minor side effects. This study aims to determine the effect of oxandrolone on lean body mass (LBM) in severe burn patients. A randomized, double blind and placebo controlled trial was conducted in the burn centre of the Dr. Soetomo Hospital. Severe burn patients who met the inclusion criteria were randomized into two groups, oxandrolone and placebo group. Oxandrolone was given with a dose 0.1 mg/kg twice a day for 14 consecutive days. Estimated lean body mass (eLBM) for each group was measured on admission (day 0) and day 14. Fourteen burn patients were enrolled in this study. Lean body mass reduced significantly from 48.69±7.71 to 46.70±7.96 in the placebo group (p-value 0.008) by independent t-test. There was no significant decrease of LBM in the oxandrolone group. Delta LBM (Δ eLBM) before and after treatment was 0.38±1.64 in the oxandrolone group, and -1.32±1.23 in the placebo group (p-value = 0.049). There were no adverse effects during the administration to the oxandrolone group. In severe burn patients, oxandrolone could prevent reduction of LBM compared to placebo and is relatively safe. These findings suggest the efficacy of oxandrolone in preventing muscle catabolism as a part of hypermetabolism in burn patients.

Un état hypermétabolique, dû à l'élévation des cytokines pro- inflammatoires et des hormones du stress, est habituel. Il peut être à l'origine d'un catabolisme musculaire (responsable d'une faiblesse musculaire), d'infections et de retard de cicatrisation. L'oxandrolone est un agent anabolisant ayant peu d'effets secondaires. Cette étude a pour but d'étudier son effet sur la MM des brûlés graves. Il s'agit d'une étude randomisée en double aveugle contre placebo, conduite dans le CTB de l'hôpital Dr Soetomo auprès de 14 patients. L'oxandrolone était prescrite à la posologie de 0,1 mg/kg x 2/j pendant 14 j. La MM estimée (MMe) était notée à l'admission (J0) et à la fin du traitement (J14). La MMe baissait significativement de 48,69 +/- 7,71 à 46,70 +/- 7,96 kg (p = 0,008 ; test t) chez les témoins quand cette variation n'était pas significative sous oxandrolone. La variation de MM (ΔMM) entre J0 et J14 était de 0,38 +/- 1,64 kg dans le groupe oxandrolone et de ­ 1,32 +/- 1,23 kg dans le groupe témoin (p = 0,049). Aucun effet indésirable n'a été observé dans le groupe oxandrolone. Chez les patients gravement brûlés, l'oxandrolone pourrait prévenir la perte de MM et est relativement sûre, nos données suggérant son efficacité sur la lyse musculaire liée à leur hypermétabolisme.

Rifle Criteria For Acute Kidney Injury In Burn Patients: Prevalence And Risk Factors.

Acute kidney injury is one of the severe complications after burns. The purpose of this study was to identify prevalence, risk factors to the development of acute kidney injury (AKI) in burn patients and mortality, using RIFLE classification: risk (R), injury (I), failure (F), loss (L), and end-stage kidney disease (E). This 3-year retrospective study was conducted in burn patients admitted to the Dr. Soetomo Hospital Burn Center between January 2018 and September 2020. Burn patients aged >18 years old and diagnosed with acute kidney injury during hospitalization were enrolled in this study. Factors influencing AKI and its mortality were assessed using bivariate and multivariate logistic regression analysis. Eighty-nine burn patients were available for analysis, and 18 (20%) of them developed AKI according to the RIFLE classification: risk in 6 (33%), injury in 7 (39%) and failure in 5 (28%). Patients with AKI had a significantly higher age and % of TBSA than those without AKI (p-value <0.05). Age more than 60 years old was significantly associated as a risk factor to develop AKI (OR=25.553, p value=0.014). The mortality rate of patients with AKI was 83% (15 deaths from 18 patients), with the overall mortality of patients 16.8%. Chi-square analysis indicated inhalation injury, % of TBSA, and age as risk factors for mortality (p-value < 0.05). The conclusion of our study was that the incidence of AKI in burn patients was relatively high. Older age as a risk factor to develop AKI and inhalation injury, TBSA, and age were associated with mortality.

La défaillance rénale aiguë (DRA) est une des complications graves des brûlures. Cette étude a pour d'évaluer sa prévalence, les facteurs de risque de sa survenue et sa mortalité, en utilisant la classification RIFLE : R (Risk- Risque), I (Injury- Lésion), F (Failure- Défaillance), L (Loss- Perte de fonction), E (End stage- Terminale). Cette étude rétrospective a concerné les patients hospitalisés dans le CTB de l'hôpital Dr Soetomo durant 3 ans (janvier 2018- décembre 2020). Elle a concerné tous les patients de plus de 18 ans ayant subi une DRA. Les facteurs de risque ont été évalués par analyses uni- et multivariées. Quatre- vingt- dix- neuf patients étaient éligibles, dont 18 ont développé une DRA (6- 33%- R ; 7- 39%- I et 5- 28%- F). Les patients avec DRA étaient plus âgés et brûlés plus extensivement, en particulier, l'âge de plus de 60 ans avait un OR de 25,553 ; p= 0,014). La mortalité des patients avec DRA était de 83% (15 morts sur 18) alors que la mortalité globale était de 16,8%. L'analyse par C² montrait que l'âge, la surface brûlée et l'inhalation de fumée étaient des facteurs de mortalité (p<0,05). L'incidence de DRA est relativement élevée et corrèle avec l'âge quand la mortalité globale reste liée à l'âge, la surface brûlée et l'inhalation de fumées.

"Off-Label" Medicine Use In Burned Children: Three-Year Retrospective Study.

Burn patients, especially children, experience many problems during their hospitalization. Because of their unique physiologic and altered pharmacokinetic profile, children receive more off-label prescribing than adults. The aim of this study was to analyze the incidence of off-label prescribing in burned children. This was a retrospective observational study conducted in the Dr. Soetomo General Hospital from December 2019 to March 2020. Data were collected from the medical records of burned children hospitalized over a 3-year period, from January 2017 to December 2019. Burn patients under 18 years old who received at least one prescribing medication were enrolled in this study. Twenty-six burned children met the inclusion criteria. A total of 215 medications were prescribed during this study and 35% of them were classified as off-label. The term off-label for age range was the highest among the off-label prescribing medicines, as much as 53%, with 30% classified for an unapproved indication, 15% for an unapproved dosage, and 2% for an unapproved dosage form. The prevalence of off-label prescribing was higher in children from 2 to 12 years old than in adolescents. Analgesics were the therapeutic classes most often prescribed as off-label in burned children. Most burned children are administered off-label medication with uncertain evidence. Further research is needed in this population to focus on several medications with high risk potential.

Les brûlés, particulièrement les enfants, ont une hospitalisation émaillée d'incidents. En raison de leurs profils physiologique et pharmacocinétique spécifique, les enfants ont plus souvent des prescriptions hors AMM que les adultes, que cette étude a pour but d'analyser. Il s'agit d'une étude rétrospective observationnelle réalisée à l'hôpital général Dr Soetomo entre décembre 2017 et mars 2020 en revoyant les dossiers des 26 enfants (< 18 ans) hospitalisés pour brûlure. Deux cent quinze prescriptions ont été retrouvées, dont 35% hors AMM. C'est la non prise en compte de l'âge qui était la cause la plus fréquente de sortie de l'AMM (53%), suivie de 30% d'utilisation hors indication, 15% de posologie inappropriée et 2% d'utilisation non adaptée à la galénique. L'utilisation hors AMM était plus fréquente entre 2 et 12 ans. Les analgésiques était la classe la plus fréquemment utilisée hors AMM. L'utilisation hors AMM n'est pas fondée sur des preuves solides et doit être plus largement explorée, en particulier concernant les médicaments les plus potentiellement dangereux.

Effects of empirical antibiotic administration on the level of C-Reactive protein and inflammatory markers in severe burn patients.

Severe burns lead to a high level of inflammation and high risk of infection. Inflammatory biomarkers are usually used to predict the severity of inflammation or infection and to assess the efficacy of antibiotics. The use of antibiotics in burns is still controversial. The aim of this study is to assess the effects of empirical antibiotics on level of C-reactive protein (CRP) and other inflammatory markers (leucocytes, neutrophils, lymphocytes, and ratio of neutrophils-lymphocytes) in severe burn patients. This cohort study was conducted in the burn unit of Dr. Soetomo Hospital between April and November 2019. CRP and other inflammatory markers were measured on admission, day 5, and day 7 after the administration of empirical antibiotics. Fifteen severe burn patients were enrolled in this study. All patients received Ceftazidime, 3x1 gram during seven days of hospitalization. CRP level reduced from 15,78±7,5 mg/dl to 14,98±10,29 mg/dl (p=0,705) by paired-t-test. There were no significant differences in mean decline of CRP between day 0-5 and 0-7. There was no decrease in inflammatory markers, including leucocytes, neutrophils, lymphocytes and ratio of neutrophils-lymphocytes during seven days of empirical antibiotic administration. Our conclusions are that the administration of ceftazidime as an empirical antibiotic lowers CRP level, although not significantly, while there is no decrease in several inflammatory markers.

Les brûlures étendues sont responsables d'une inflammation systémique et d'un risque élevé d'infection. Les biomarqueurs sont fréquemment utilisés pour évaluer la sévérité de l'inflammation ou de l'infection et surveiller l'efficacité de l'antibiothérapie. Le but de cette étude était d'évaluer les effets d'une antibiothérapie probabiliste sur les niveaux de CRP et d'autres marqueurs de l'inflammation (leucocytes, neutrophiles, lymphocytes, rapport neutrophiles/lymphocytes) chez des patients gravement brûlés. Il s'agissait d'une étude de cohorte conduite chez 15 patients hospitalisés dans le CTB de l'hôpital Dr Soetomo entre avril et novembre 2019. Ils recevaient 1 g x 3 de ceftazidime IV pendant 7 jours, les marqueurs de l'inflammation étant mesurés à l'entrée, à J5 et à J7 de l'antibiothérapie. La CRP passait de 157,8 +/- 75 à 149,8 +/- 10,29 mg/L (NS, test t apparié). Il n'y avait aucune baisse significative de quelque marqueur que ce soit sous ceftazidime. Nous en concluons que l'administration systématique de ceftazidime n'a pas d'effet significatif sur les marqueurs de l'inflammation.

Effects of probiotic administration on IGA and IL-6 level in severe burn patients: a randomized trial.

Severe burn injuries are associated with systemic inflammation or even sepsis. A beneficial effect of probiotics on burn patients is reported by regulating the function of the intestinal barrier and reducing inflammation. Immunoglobulin A (IgA) acts as an anti-inflammation antibody, and interleukin 6 (IL-6) as a pro-inflammatory mediator, released extensively in burns. The aim of this study was to investigate the effect of single and mixed strain probiotics on the level of IgA and IL-6 in severe burn patients. A randomized double-blind trial was conducted in the burn centre of the Dr. Soetomo Hospital. Severe burn patients with more than 20% total body surface area burned were randomized into two groups. Group one received a single strain and the second group received mixed strain probiotics, once daily for fourteen days. Serum levels of IgA and IL-6 were measured on day 4 post burn injury (before treatment) and day 19 (after treatment). Seventeen burn patients were enrolled in this study. IgA increased significantly from 1.01±0.67 to 1.89±0.98 mg/mL (p<0.001) in the single strain group, and 0.96±0.48 to 2.10±1.09 mg/mL (p=0.025) in the mixed strain group by paired t-test. There was no significant decrease in IL-6 in either group. No significant differences between the two groups were observed for IgA or IL-6. Administration of single and mixed strain probiotics increased IgA level, while there was no decrease in IL-6 level.

Les patients sévèrement brûlés développent SIRS et sepsis. Un effet positif des probiotiques chez ces patients a été évoqué. Il repose sur la régulation de la barrière intestinale et sur un effet anti inflammatoire. IgA est anti inflammatoire, IL-6, secrétée en très grande quantité chez le brûlé, comme pro inflammatoire. Le but de cette étude randomisée en double aveugle réalisée dans le CTB de l'hôpital Dr Soetomo était d'évaluer l'effet de probiotiques (1 ou plusieurs souches) sur les taux d'IgA et d'IL-6 de 17 patients gravement brûlés (> 20% SCT). Le groupe G1 recevait une seule souche de probiotique, le groupe G2 un mélange de souches, 1 fois par jour pendant 2 semaines. Les taux d'IgA et d'IL-6 étaient mesurés à J4 post-brûlure (avant traitement) et à J19 (après traitement). Les 2 groupes étaient statistiquement comparables. L'augmentation d'IgA était significative dans les 2 groupes : 1,01 +/- 0,67 puis 1,89 +/- 0,98 ; p< 0,001 dans le groupe G1 ; 0,98 +/- 0,48 puis 2,1 +/- 1,09 ; p=0,25 dans le groupe G2. Les variations d'IL6 n'étaient pas significatives. Donc l'administration de 1 ou plusieurs souches de probiotiques augmente les taux d'IgA et ne diminue pas ceux d'IL6.

Evaluation of antibiotic use and bacterial profile in Burn Unit Patients at the dr. Soetomo General Hospital.

The high inaccuracy of antibiotic prescribing in Dr. Soetomo General Hospital Surabaya, Indonesia, is one of the factors triggering the increasing prevalence of antibiotic-resistant pathogenic bacteria. The World Health Organization (WHO) showed that bacterial resistance to antibiotics was a threat to people's health around the world. Burn injuries are susceptible to infection and need appropriate antibiotics. The purpose of this study was to obtain a germ map for our burn patients and to evaluate the antibiotic therapy that had been used to treat them. This was a descriptive observational study, conducted in the Burn Unit at the Dr. Soetomo General Hospital. The study used data from burn patients who were treated there from February to May 2018. The patients' medical records, records of drug usage (antibiotics) and culture results data (bacterial sensitivity test for antibiotics) were examined. Total antibiotic usage was calculated using the Defined Daily Dose (DDD) method per 100 days. The quality of antibiotic usage was assessed using the Gyssens method. Bacterial profile was obtained from culture swab. According to our findings, the most widely used antibiotic is ceftazidim with DDD / 100 days of 22.25. Based on the qualitative analysis using the Gyssens method, 33.3% were in category VI-0. The most common bacteria obtained from the swabs were Bacillus cereus and Acinetobacter baumanni, found in 12% of the patients. Antibiotics are still not used wisely in the Burn Unit at the Dr. Soetomo General Hospital.

La grande fréquence des antibiothérapies inappropriées est un des facteurs de la forte prévalence de bactéries résistantes dans l'hôpital Dr Soetomo de Surabaya (Indonésie). L'OMS a montré que la résistance bactérienne représentait un danger mondial de santé publique. Les patients brûlés sont particulièrement à risque d'infections, nécessitant une antibiothérapie appropriée. Cette étude prospective observationnelle avait pour but d'étudier l'écologie des infections dans le CTB de cet hôpital et les antibiotiques utilisés, entre février et mai 2018. Les dossiers des patients, de la pharmacie (antibiotiques) et de la bactériologie (germes et antibiogrammes sur cultures d'écouvillons) ont été revues. La consommation d'antibiotiques a été exprimée en Dose Définie Journalière (DDJ) pour 100 jours-patients. La qualité d'utilisation des antibiotiques était évaluée selon la méthode de Gyssens. La ceftazidime était l'antibiotique le plus utilisés (22,25 DDJ/100 j-pat.). Un tiers des prescriptions étaient dans la catégorie VI-0 de Gyssens. Les bactéries les plus fréquentes étaient B. cereus et A. baumannii (12%). Les antibiotiques ne sont toujours pas utilisés larga manu dans le CTB de l'hôpital Dr Soetomo.