Dear Readers: Patients hospitalized with burn wounds face special challenges. Host, environmental, and organism factors increase burn patient risk of developing infection and may prolong the course of infection, once acquired. For example, host immune, circulatory, and respiratory systems are often compromised. Most admitted burn patients have third-degree or full-thickness burns, requiring granulation and/or grafting for acceptable repair. The zone of necrosis surrounding the burned tissue may continue to expand for up to 48 hours after injury, enlarging and deepening the path for pathogen invasion. Hospital environments may contain resistant strains of pathogenic organisms. Recent research summarized below provides insight into addressing these challenges, shortening hospital stays, and reducing the likelihood of hospital-acquired infections in patients with burn wounds.
The Evidence for Burn Wound Excision Reference: Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns. 2006;32(2):145–150.
Rationale: Treatment with early excision and grafting is reported to have improved burn wound patient outcomes significantly since its inception. It is time for a close look at what aspects of efficacy early excision and grafting improve and the safety issues clinicians face in performing these procedures.
Objective: The objective of this study was to compare effects of early excision and grafting versus conservative treatment on a variety of outcomes for burn patients to clarify efficacy and safety of early excision and grafting.
Methods: The authors conducted a meta-analysis of randomized controlled trials (RCTs) found in MEDLINE, EMBASE, and Cochrane database searches from 1966–2004 comparing early excision and grafting to conservative management of burn patients. Six of the identified 15 RCTs met the inclusion criteria. Outcomes measured included mortality, operating hours, complications of surgery, burn wound healing time, duration of sepsis, length of hospital stay, blood transfusion requirements, and long-term morbidity including joint contractures and hypertrophic scarring.
Results: Early excision was associated with lower mortality in patients without inhalation injury and shorter hospital stays for all burn patients. Patients treated with early excision also had more blood transfusions than those receiving traditional care. The evidence was insufficient to draw clear conclusions regarding effects on healing time, duration of sepsis, or skin graft take.
Conclusion: Early excision reduces mortality in burn patients without inhalation injury and shortens hospital stay for all burn patients. The only significant drawback is that early excision results in greater blood loss than is experienced during traditional burn care.
Reducing Hospital-Acquired Infections in Burn Patients Reference: Wibbenmeyer L, Danks R, Faucher L, et al. Prospective analysis of nosocomial infection rates, antibiotic use, and patterns of resistance in a burn population. J Burn Care Res. 2006;27(2):152–160.
Rationale: Infection remains a major cause of morbidity and mortality in burn patients despite major advances in burn care. There is a need to identify and alleviate causes of hospital-acquired infection in patients hospitalized with burns.
Objective: The objectives of this study were to determine accurate infection rates in hospitalized burn patients, including those caused by resistant organisms, and identify risk factors for infection and interventions to decrease antimicrobial drug use.
Methods: Prospective data were collected from 157 patients admitted to a Midwestern university burn center from October 2001–October 2002. Nosocomial infections were identified by surgeon and infection control center criteria, and a standardized list of risk factors was recorded for all subjects as well as infecting organisms. Multiple logistic regression analysis identified key risk factors associated with hospital-acquired infections.
Results: Infection control assessments agreed with surgeon assessments of nosocomial infections for 70% of burn wound infections, 70% of bloodstream infections, 57% of urinary tract infections, and 17% of pneumonias. Primary factors significantly related to hospital-acquired infection as identified by both surgeon and infection control criteria were body surface area burned, comorbidities, and use of invasive devices. Staphylococcus aureus and Pseudomonas aeruginosa were the most common antibiotic-resistant organisms identified.
Conclusions: Surgeons could decrease antimicrobial use by utilizing explicit infection control criteria for identifying patients with hospital-acquired infections, limiting perioperative antibiotic prophylaxis to patients at highest risk of infection, limiting use of invasive devices, and strictly adhering to aseptic technique.
Clinical Perspective This research strengthens the evidence for managing burn patients as follows:
1. Excise necrotic tissue early with strict adherence to aseptic technique and hemostasis procedures
2. All staff involved in burn patient care can minimize hospital-acquired infection through rigorous use of infection control procedures including hand washing1
3. Limit perioperative prophylactic antibiotic use to patients at high risk of infection including those with larger burns, invasive devices, and/or inhalation injury
4. Clinical burn study protocols will ideally stratify burn patients according to these risk factors and include early necrotic tissue excision and consistent use of all infection control procedures.
As with much good science, these studies raise several questions for further research. More definitive research is needed on effects of early excision on healing time, duration, or likelihood of sepsis and skin graft take outcomes. Further research is needed to determine why adherence to hand washing remains a major challenge for physicians and ancillary staff in US burn units.1
Some of these findings parallel chronic wound evidence, though the cause(s) of chronic wounds continue to wreak their damage until addressed. Chronic wound area2,3 and depth3,4 are strongly correlated with time to heal. Could a similar trend in burn patients prolong hospital exposure, causing the observed increase in likelihood of hospital-acquired infection? Would necrotic tissue removal reduce the length of stay or improve healing5 for chronic wound patients if the cause of tissue damage were consistently alleviated? Effects of comorbidities and use of invasive devices as factors associated with nosocomial infection in patients with chronic wounds merits further study, bearing in mind that these include more than wound infections. The evidence is clear on many aspects of burn and chronic wound management, and patients need us to use it.
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References
1. Hodle AE, Richter KP, Thompson RM. Infection control practices in U.S. burn units. J Burn Care Res. 2006;27(2):142–151.
2. Phillips TJ, Machado F, Trout R, Porter J, Olin J, Falanga V. Prognostic indicators in venous ulcers. J Am Acad Dermatol. 2000;43(4):627–630.
3. Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. Diabetic neuropathic foot ulcers: the association of wound size, wound duration, and wound grade on healing. Diabetes Care. 2002;25(10):1835–1839.
4. Bolton L, McNees P, van Rijswijk L, et al. Wound-healing outcomes using standardized assessment and care in clinical practice. J Wound Ostomy Continence Nurs. 2004;31(2):65–71.
5. Saap LJ, Falanga V. Debridement performance index and its correlation with complete closure of diabetic foot ulcers. Wound Repair Regen. 2002;10(6):354–359.
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