Protocol for a systematic review of quantitative burn wound microbiology in the management of burns patients

BACKGROUND: Sepsis from burn injuries can result from colonisation of burn wounds, especially in large surface area burns. Reducing bacterial infection will reduce morbidity and mortality, and mortality for severe burns can be as high as 15 %. There are various quantitative and semi-quantitative techniques to monitor bacterial load on wounds. In the UK, burn wounds are typically monitored for the presence or absence of bacteria through the collection and culture of swabs, but no absolute count is obtained. Quantitative burn wound culture provides a measure of bacterial count and is gaining increased popularity in some countries. It is however more resource intensive, and evidence for its utility appears to be inconsistent. This systematic review therefore aims to assess the evidence on the utility and reliability of different quantitative microbiology techniques in terms of diagnosing or predicting clinical outcomes. METHODS/DESIGN: Standard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. Bibliographic databases and ongoing trial registers will be searched and conference abstracts screened. Studies will be eligible if they are prospective studies or systematic reviews of burn patients (any age) for whom quantitative microbiology has been performed, whether it is compared to another method. Quality assessment will be based on quality assessment tools for diagnostic and prognostic studies and tailored to the review as necessary. Synthesis is likely to be primarily narrative, but meta-analysis may be considered where clinical and methodological homogeneity exists. DISCUSSION: Given the increasing use of quantitative methods, this is a timely systematic review, which will attempt to clarify the evidence base. As far as the authors are aware, it will be the first to address this topic. TRIAL REGISTRATION: PROSPERO, CRD4201502390

Acute management of skin tears with mesh grafting: a prospective study and cost-benefit analysis

**Background**: Skin tears cause a significant burden to the patient and healthcare system. Acute management has traditionally comprised of operative debridement and formal skin grafting, which is costly, invasive and often followed by admission for five to seven days. In a 2014 pilot study by Vandervord and colleagues, a protocol for re-laying the skin tear as a meshed skin graft (mesh protocol) was proposed, which has not been validated to date. Our study aims to compare a prospective cohort to the original pilot study to determine validity in clinical practice and provide an updated cost-benefit analysis. **Method**: All patients who presented with acutely sustained skin tears at Northern Beaches Hospital, NSW, Australia, were prospectively entered into the mesh protocol as described by Vandervord and colleagues. An updated cost-benefit analysis was performed using a national hospital cost data collection report produced by the Independent Hospital Pricing Authority (IHPA). **Results**: We enrolled 53 patients onto the protocol who had sustained a total of 64 discrete skin tears, with 11 patients sustaining more than one skin tear. The average age of patients was 86, and the most common location of the skin tear was pretibial, followed by forearm/hand. Only one patient required a return to theatre for debridement and formal skin grafting, and three patients required long-term dressings for partial mesh graft loss. The cost to the healthcare system is consistent with the pilot study, with a significant difference between discharge from the emergency department post-procedure and formal grafting and admission for five to seven days. **Conclusion**: Use of the mesh protocol creates wound coverage and prevents the need for formal skin grafting, and reduces costs associated with formal operations and hospital admissions

A systematic review of quantitative burn wound microbiology in the management of burns patients.

BACKGROUND The early diagnosis of infection or sepsis in burns are important for patient care. Globally, a large number of burn centres advocate quantitative cultures of wound biopsies for patient management, since there is assumed to be a direct link between the bioburden of a burn wound and the risk of microbial invasion. Given the conflicting study findings in this area, a systematic review was warranted. METHODS Bibliographic databases were searched with no language restrictions to August 2015. Study selection, data extraction and risk of bias assessment were performed in duplicate using pre-defined criteria. Substantial heterogeneity precluded quantitative synthesis, and findings were described narratively, sub-grouped by clinical question. RESULTS Twenty six laboratory and/or clinical studies were included. Substantial heterogeneity hampered comparisons across studies and interpretation of findings. Limited evidence suggests that (i) more than one quantitative microbiology sample is required to obtain reliable estimates of bacterial load; (ii) biopsies are more sensitive than swabs in diagnosing or predicting sepsis; (iii) high bacterial loads may predict worse clinical outcomes, and (iv) both quantitative and semi-quantitative culture reports need to be interpreted with caution and in the context of other clinical risk factors. CONCLUSION The evidence base for the utility and reliability of quantitative microbiology for diagnosing or predicting clinical outcomes in burns patients is limited and often poorly reported. Consequently future research is warranted