Burn septicaemia in Kuwait: associated demographic and clinical factors

Objective: To study the demographic and clinical factors associated with burn septicaemia patients in Kuwait. Materials and Methods: All burn in-patients, who developed septicaemia at the Burns Unit, Al-Babtain Centre for Burns and Plastic Surgery, Kuwait, during a 9-year period (June 1992 to May 2001) were included in the study. The data were recorded for age, sex, nationality, cause and percentage of burns, inhalation injury, resuscitation, number of episodes, septicaemia on post-burn day, the microorganisms responsible in each episode, treatment and outcome for statistical analysis. Using SPSS (PC version 11.0) software, a probability level of p<0.05 was considered significant. Results: Of the 2,082 patients treated in the Burns Unit, 166 [8%; 99 (60%) males and 67 (40%) females] with a mean age of 26 years (range 1-70) had septicaemia. Significantly higher (p <0.001) cases were recorded among Kuwaiti children (≤14 years) and non-Kuwaitis (25-59 years) than other corresponding age groups. The total body surface area burned ranged from 2 to 95% (mean 42%) and the main cause of burn was flame (77.1%). Inhalation injury was diagnosed in 39 (23.5%) patients. A total of 253 septicaemic episodes occurred in all patients. The majority, 123 (74.1%), had a single episode and the remaining 43 (25.6%) had multiple (2-10) episodes. One hundred and fifty-five (61.3%) episodes were due to gram-positive organisms, mainly methicillin-resistant Staphylococcus aureus, and 32 (12.7%) were polymicrobial. One hundred and twenty-four (74.7%) patients had wound excision and skin grafting procedures and their survival was significantly higher (OR=4.3; 95% CI: 1.98-9.31) than nonsurgically treated patients. Thirty-nine (23.5%) patients died mainly due to multi-organ failure. Conclusion: The findings indicate that the patients with extensive flame burns were prone to developing septicaemia due mainly to gram-positive bacteria. The surgical excision of eschar and wound covering improved the outcome of the patients while prophylactic antibiotic treatment had no role in the incidence and outcome of the burn patients

Production and characterisation of Campylobacter jejuni enterotoxin in a synthethic medium and its assay in rat ileal loops

A synthetic medium for production of Campylobacter jejuni enterotoxin was developed for the purposes of its purification by modifying syncase medium, replacing sucrose with glucose, and supplementing with 0.025% sodium pyruvate, 0.25% sodium metabisulphite, 0.001% ferric chloride and 0.1% l-cysteine, adjusted to pH 6.7. Culture filtrates of a human diarrhoeal and a chicken isolate, grown in this medium caused fluid accumulation ranging between 0.50-0.70 ml/cm of rat ileal loop. The kinetics of toxin production indicated a peak at 36 h and decline by 72 h, coinciding with the period of release of protease by the organism. At least 0.4 rat ileal loop units of enterotoxic activity was recovered per ml of culture filtrates and one unit of this toxin contained only 14 μg of protein. The toxin is heat-labile, pH dependent, nonhaemolytic, resistant to trypsin, sensitive to papain and pronase and may show subunit molecular weight analogy with CT subunits

Septicaemia after burn injury: a comparative study

Seventy-nine (8.4%) patients during June 1992–May 1996 (Group-1) and 68 (7.2%) patients from June 1996 to May 2000 (Group-2) who developed septicaemia at the burns unit of Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, were retrospectively studied and compared. The mean age of 26 years, male predominance, flame burns as main aetiology and mean burn percentage of ≥40% was observed in both the groups. Both groups revealed extensive flame burn, inhalation injury, intubation and difficult resuscitation as the risk factors. The proportion of satisfactory resuscitation increased significantly (P<0.001) in Group-2. The septicaemia commonly occurred within 2 weeks postburn but the number of episodes during 5 days postburn was less in Group-2. The surface wound was found to be the likely source of entry of the organisms into the blood stream in both the groups. The gram positive organisms were dominant aetiologic factor in both groups but an increase frequency of Acnetobacter was found in Group-2. The proportion of MRSE and Pseudomonas septicaemia was significantly higher (P<0.01) in the Group-1. The rate of survivors, in both the groups was higher among operated patients but it was significantly higher (P<0.001) in the Group-1. A mortality rate 20.6% in Group-2 decreased against Group-1, which can be attributed to better resuscitation, nutritional care, early detection of septicaemia, appropriate antibiotics and early wound excision and skin grafting. MOF was the cause of death of 60.9% in Group-1 and 85.7% in Group-2. There was no role of prophylactic antibiotic in burn patients in the incidence of septicaemia and mortality

Burn septicaemia: an analysis of 79 patients

Out of 943 patients treated from June 92 to May 96 at the burns unit of the Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, 280 (30%) required admission to the burns intensive care unit (ICBU) and were studied retrospectively. Seventy-nine (28.2%) developed clinically and microbiologically proven septicaemia. Forty-four (56%) were males, 35 (44%) females with a mean age of 26 years (range 45 days to 75 years) and mean total body surface area burn (TBSA) of 46% (range 10-90%). Sixty-two had flame burns, 16 a scald and one had an electric burn. These 79 patients had a total of 118 septicaemic episodes. Sixty (76%) had only one and 19 (24%) had multiple episodes of septicaemia. Fifty-four (68%) had their first episode within 2 weeks, though the maximum number of episodes was between 6 and 10 days postburn. Septicaemia was also observed in 13% of patients within 3 days postburn. Out of the 118 episodes, 48 were due to methicillin resistant Staphylococcus aureus (MRSA), 17 due to methicillin resistant Staphylococcus epidermidis (MRSE), 15 to Pseudomonas, 12 to Acinetobacter, four to Streptococcus, another four to Enterococci, two to Klebsiella, one due to Serratia and 15 to more than one organism. Once the septicaemia was diagnosed appropriate therapy was instituted. Fifty-six (71%) patients had 143 sessions of skin grafting and the mortality was low in operated patients. Twenty-three (29.1%) patients died. The low mortality rate was probably due to factors such as continuous clinical and microbiological surveillance leading to quick detection of aetiology, appropriate antibiotic therapy, care for nutrition and early wound cover. This study suggests that flame burn patients are more vulnerable to sepsis. Onset of septicaemia may be as early as 3 days and commonly within 2 weeks. A surface wound is the likely source of entry to the blood stream. Gram positive organisms are dominant in the aetiology. Early detection and appropriate treatment including wound coverage result in a better outcome

Pseudomonas aeruginosa septicaemia in burns

Out of 1415 patients treated as inpatients at Al-Babtain Center for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait spanning over a period of 6 years from June 1992 to June 1998, 102 developed clinically and microbiologically proven septicaemia. Only 15 out of them had either single or multiple episodes of septicaemia due to Pseudomonas aeruginosa and were studied during their stay in the hospital. Five of them were males and 10 females, with a mean age of 26 years (range 3-51 years) and mean total body surface area of burns (TBSA) of 66% (range 25-90%). All of them had flame burns and resuscitation was found to be difficult in eight patients either due to delayed hospitalization or accompanied inhalation injury. Seven patients were intubated, four due to inhalation injury and three for septicaemic complications. Among the 15 patients under study, a total of 36 septicaemic episodes were detected of which 21 were due to P. aeruginosa. This organism was found in the first episodes in nine patients, in second episodes in six, in third episodes in three and fourth, fifth and sixth episodes in one patient, each at a variable postburn day. Ten patients had 38 sessions of excision and skin grafting, six of them survived. Nine of the 15 patients under study died due to septicaemia, but only six of them had P. aeruginosa as the last isolate. Except for one, all patients had >40% TBSA burn, two had difficult resuscitation and four were intubated. The day of death varied between 3 to 52 days postburn (mean 19 days). This study showed that females with flame burns are susceptible to P. aeruginosa septicaemia. Difficult resuscitation and intubation also proved to be important risk factors. Septicaemia could occur quite early in the postburn days and the mortality due to this organism was quite high. Early excision and grafting with other effective management may result in a better outcome

Beta-haemolytic Streptococcus infection in burns

Group A beta haemolytic Streptococcus has been one of the most serious infections in the burn patients resulting in severe cellulitis and sepsis. Penicillin has been used ever since its introduction as prophylaxis against these conditions. Penicillin prophylaxis was used in our burn unit as well without any serious evaluation until December 1992. This prospective study was therefore, undertaken to evaluate the incidence of beta haemolytic Streptococcus infection in burn patients, and its clinical outcome over a period of 5 years in the absence of prophylaxis with penicillin. 14 of the 1213 burn patients admitted to the Al-Babtain Centre for Plastic Surgery and Burns from January 1993 to December 1997 had either colonization or infection with Streptococcus spp. Their mean age was 15 years (range 1 month to 52 years) and the mean burn surface area was 20% (range 5 to 90%). Streptococci were isolated from burn wounds in 10 patients, throat in 3 and blood culture in 1. Group A Streptococcus was found in 5, group C in 3 and group D in 6 patients. In all patients except one the organisms were isolated ≥72 h post burn. The infections were successfully controlled by antibiotic and no detrimental effect was observed either on wound healing or skin graft take. There was no mortality amongst these 14 patients. The study showed that only 1.1% of the burn patients in our unit acquired Streptococcus of which only one third comprised of group A. This study thus demonstrates that the practice of penicillin prophylaxis during the first five post burn days may not be of any value and therefore, deserves discontinuation in units where the incidence of this organism is minuscule