Belba M., Osmani Xh., Dauti I., Isaraj S., Xhepa G., Belba Gj.

Clinic of Burns and Plastic Surgery, Mother Teresa University Hospital Centre, Tirana, Albania

SUMMARY. A case is described of massive burns in a child four years old injured by flame. Special importance was concentrated on the treatment during the sepsis phase, with a complex therapy applying two or three antibiotics together. It is underlined that the initiation of antibiotic therapy in empirical manner is a correct and scientific act. This is because medical staff, thanks to their accumulated experience, are aware of the epidemiology of pathogens in their place of work. The results of the wound and blood cultures then allow the antibiotic therapy to be further consolidated.

Introduction

In our description of this clinical case, we wish to focus our attention on the complexity of the treatment of severe burns in children.1 After burn injury, resuscitation must begin as soon as possible and the patient should be transferred quickly to a specialized centre. For a better outcome it is necessary for the patient to successfully get through the pre-shock or shock phase of burn.2 During the septic phase, the authors of this paper recommend the tactics of the empirical application of wide-spectrum antibiotics. Later, after microbiological data have determined the pathogen responsible for passing on sepsis, the therapy is completed with more powerful antibiotics.3-6

When the patient’s clinical condition is stabilized, we take him to the operating theatre in order to debride necrotic tissue and to cover the wounds with transplants. During the prolonged course of the disease, the patient may suffer from numerous complications that require the modelling of therapy. The case we are considering here reflects the co-operation of medical staff until improvement of the clinical situation. A patient belongs to both the surgeon and the anaesthesiologist, and both alternately collaborate in the treatment until final convalescence.

Clinical case and discussion

The child A.Z., four years old, was burned with flame in a domestic environment on 30 September 2001. After first aid in a regional hospital, the patient, receiving intravenous therapy with isotonics, was transferred to our centre approximately 5 h post-burn. The diagnosis on admission was second- and third-degree 40% TBSA burns in the trunk, head, and extremities. The third-degree burns, in the posterior part of the trunk and extremities, were calculated as 30% TBSA. Resuscitation was performed immediately with Ringer’s lactate according to the Carvajal formula, i.e. 3.6 ml/kg/% in 24 h with a total Na+ load of 0.4 mEq/kg/%. The child successfully overcame the shock phase, with a mean urinary rate of 1.5 ml/kg/h. In this phase we observed generalized oedema in the head, which reduced after 48 h. On day 3 we observed the onset of the systemic inflammatory response syndrome (SIRS), with high values of temperature (> 39 °C), cardiac rate (> 100/min), respiratory rate (> 28/min), and leucocytosis (12,000/mm3. In the expectation of severe life-threatening sepsis, we decided to begin antimicrobial therapy as soon as possible and we therefore administered ceftazidime and amikacin intravenously. This scheme was applied because in recent times we have observed a rapid development of gram-negative pathogens in our patients. Our action was correct because on day 7 post-burn the wound culture confirmed gram-negative pathogens.

In describing this case we focus our discussion on two main problems:

• the pathogens we found during the septic phase;
• the kind of complications that occurred during this phase.

1. In the second week of treatment we again observed in the wound culture gram-negatives without differentiation, while in the third week Pseudomonas aeruginosa was verified. The blood culture was sterile. In conformity with antibiotic sensitivity and resistance, therapy was continued with claforan and rifampin (Table I).

The child was operated on under intravenous anaesthesia for the debridement of necrotic tissue. In the fourth week we observed a clinical improvement, presenting with a clean wound ready for a second intervention (Fig. 1).

This consisted in covering the wounds in the extremities with split-thickness skin grafts. After the fourth week we observed the presence of Staphylococcus aureus in the wound after the blood culture. The treatment with systemic antibiotics was performed with vancomycin. The child remained a carrier of Pseudomonas aeruginosa. During the following weeks, apart from the presence of Pseudomonas aeruginosa in the wound culture, the patient was considered to be stabilized. In the sixth week we performed the third intervention, which covered the remaining parts of the wound (Figs. 2,3).

The child was discharged from hospital on 25 January 2002, with recommendations to the parents as to the subsequent period of rehabilitation and restoration of the consequences of the burn.

2. The child was regularly monitored for blood count and biochemistry. During the course of the disease she presented low serum proteins, hepatic function alterations, and - sometimes - high levels of urea and creatinine in the urine, reflecting the state of catabolism (loss of weight) in the condition of sepsis. Our greatest attention was directed to the rigorous control of haematological data. As we were aware of the possibility of the rapid fall in the blood count after the shock phase, we adopted the tactic of checking this every two days (Table II).

The haematological values fell progressively after the second day and on day 7 registered as follows: red blood cells, 2.7 million/mm3; haemoglobin, 8 g/dl; haematocrit, 25%. These data confirm the presence of persistent anaemia. As can be seen in the graphs (Graphs 1-4), these three values remain lower, independently of the administration of blood every two or three days according to need.

Signs of general stabilization were seen especially in the interpretation of the graphic presentation of leucocytes. Analysis number 22, which corresponds to day 40 of treatment, shows a growing number of leucocytes, which is also reflected in the wound’s normal aspect.

We also want to emphasize that between the second and the third week the child’s clinical situation deteriorated, with the onset of meteorism and gastrointestinal disorders. These symptoms gradually ameliorated with the improvement of the general situation. In the fifth week of treatment chondritis of the left ear was observed, resulting from the deep head burns. The wound was debrided, with removal of the destroyed cartilage, using topical agents to enhance wound cicatrization. The final complication of sepsis was Pneumonia bilateralis, which was observed and treated in the sixth week of the illness. After this period the child had a quiet convalescence.

Conclusions

Clinical evidence and diagnostic evaluation of sepsis after severe burns are determined by the species of invading micro-organism. Microbiological diagnosis by means of wound and blood culture not only provides important information for the selection of the antibiotics but also serves as a valid epidemiological database.

In this particular child, also on the basis of our experience in curing other cases, the evidence of Pseudomonas aeruginosa or, in general, gram-negatives requires a combination of beta-lactams with aminoglucosides. The association of cephalosporins with amikacin has shown good results.8-10 The initiation of empirical therapy, with microbiological data being interpreted later, means immediate therapy rather than the sometimes harmful waiting for other schemes.

The establishment of general stabilization of the patient enables the medical staff to perform in due time the debridement of necrotic tissue and the covering of wounds with skin grafts. Careful treatment and follow-up of the patient create the basis for a good outcome and prevent the possible complications.

RESUME. Les Auteurs décrivent un cas de brûlures massives dans un enfant âgé de quatre ans lésé par des flammes. Ils dévouent une attention particulière au traitement pendant la phase du sepsis, quand ils ont utilisé une thérapie complexe avec l’emploi simultané de deux ou trois antibiotiques. Ils soulignent le fait que le commencement de la thérapie antibiotique en manière empirique soit un acte correct et scientifique parce que le personnel médical, grâce à l’expérience acquise, est conscient de l’épidémiologie des pathogènes au lieu de travail. Les résultats des cultures des lésions et du sang permettent ensuite que la thérapie antibiotique soit ultérieurement consolidée.

Bibliography

1. East M.K.: Epidemiology of burns in children. In: Carvajal H.F., Parks D.: “Burns in Children”, Paediatric Burns Management Year Book, Medical Publishers, Inc., Chicago, London, Boca Raton, 3-11, 1988.
2. Reig A., Tejerina C. et al: Infections in burns patients. Ann. Medit. Burns Club, 5: 91-55, 1992.
3. Giomarellou H.: Empiric therapy for infections in the febrile, neutropenic, compromised host. Med. Clin. North Am., 7: 559-80, 1995.
4. Korvick J.A., Peacock J.E. et al.: Addition of rifampin to combination antibiotic therapy for PA bacteraemia. Antimicrob. Agents Chemother., 36: 620-5, 1992.
5. Gwdiol F., Pallares R. et al.: Comparative clinical evaluation of azthreonam versus aminoglucosides in gram-negative septicaemia. J. Antimicrob. Chemother., 17: 661-71, 1986.
6. Bochud P.-Y., Glouser M.P. et al.: Antibiotics in sepsis. Intensive Care Med., 27: 533-48, 2001.
7. Holder J.A.: The burn wound: Microbiological aspects. In: Carvajal H.F., Parks D.H.: “Burns in Children”, Paediatric Burns Management Year Book, Medical Publishers, Inc., Chicago, London, Boca Raton, 213-22, 1988.
8. Richard P., Le F.R. et al.: Pseudomonas aeruginosa outbreak in a burn unit: Role of antimicrobials in the emergence of a multiply resistant strain. Infect. Dis., 170: 377-83, 1994.
9. Pruitt B.A., Lindberg R.B., McManus W.F. et al.: Current approach to prevention and treatment of Pseudomonas aeruginosa infections in burned patients. Rev. Infect. Dis., 5: 889-97, 1983.
10. Pollack M.: Pseudomonas aeruginosa. In: Mandell G.L., Benett J.E., Dolin R. (eds), “Principles and Practice of Infectious Diseases (4th ed.), Churchill Livingstone, New York, pp. 1980-2003, 1995.