Annals of the MBC - vol. 3 - n'4 - December 1990


Herruzo-Cabrera R. *, Lenguas Portero F. **, Martinez-Ratero S. **, Garcia Torres V. **, Rey Calero J. *

* Preventive Medicine Service, La Paz. Hospital, Madrid, Spain
** Burn Unit, La Paz. Hospital, Madrid, Spain

SUMMARY. The authors studied the incidence of mortality and hospital infection (together with the consumption of antibiotics and financial saving) in a Burn Unit, over a 4-year period, in relation to various modifications introduced into therapeutical management. Mortality was reduced after the second year and the incidence of infection was lower every year (in the fourth year it was 25% that of the first). The aetiology and site of infection also modified: local bum infection reduced to 25% in the period, with only P. aerugmosa and & epidermidis retaining an appreciable incidence; sepsis was similar in evolution to local bum infection; urinary tract infection had a very low incidence in all the period; other soft tissue infection became predominant in the fourth year, owing to an appreciable reduction of the more classic infections. The evolution of the consumption of antibiotics is not related to the infection rate, owing to the great use of third-generation cephalosporins in the central years of the period. A comparison, after direct standardization, between the events in the overall period and those in the fourth year shows that there has been a considerable financial saving (9-28 million pesetas), as a result of the new therapeutic measures introduced.


Infection is one of the most frequent and severe complications in patients who have ' sustained burns, and particularly so in the case of those whose burned body surface area exceeds 30% of the total (1, 2), It is also the main cause of death in these patients after the aspiration syndrome, ranging between 50 and 75% according to Lutterman and al. (3).
Foremost among the predisposing factors for infection in bum patients are the destruction of skin and mucosal barriers to micro-organism penetration, the elimination of the normal resident flora, the loss of antibodies and other proteins into the exudate (which in itself constitutes an excellent bacteriological culture medium), the reduction of the fibronectin and complement levels, and the derangement of specific and non-specific cell mediated immunity, which induces a transient immunosuppression (4-9).
The aetiological agents of infection in bum patients have changed, as in other nosocomial infections, from a predominance of Gram-positive germs to a predominance of Gram-negatives (enterobacteria, Pseudomonas, multiresistant enterobacteria) and the presence of yeasts, as a consequence of the greater selective pressure of antibiotics (1, 10, 11).
Regarding the correct- management of these patients, one should stress the crucial importance of early debridement and occlusive covering of the burn (12, 13) and other measures such as perioperatory prophylaxis, local prophylaxis and/or therapy with antiseptic creams to minimize bacterial colonization (14, 15), selective intestinal decolonization with non-absorbable drugs so as to control the number and type of micro-organisms in their greatest reservoir and to prevent the distortions of this flora caused by various factors such as intestinal stasis, intercurrent antibiotic therapy, etc. (16, 17, 18), and rhino-oropharyngeal decolonization (19). The purpose of these measures is to reduce the colonization of these areas and hence the possibility that they may become the source of contamination and/or infection of other more critical ones, such as the bums themselves, the respiratory tract (by germs from the pharyngeal contents, particularly in intubated patients), catheters, etc. (29); a prerequisite to this purpose is an adequate bacteriological surveillance and monotorization from the moment of admission into the burn unit, so as to diagnose the infections and study the colonizing flora and thus make possible an intervention directed at the more pathogenic or resistant organisms, with the least possibile effect on the more harmless ones.

The purpose of the present communication is to present our experience in the preventive and therapeutical management of infection in bum patients, analysing the results over the past four years and discussing the successive modifications introduced into the therapeutic management.

Material and methods

The population studied comprises all the patients admitted to the critical area of the Bum Unit at the La Paz Hospital in adrid over the years 1984-1987. The pertinent data were recorded in a standard chart (Tab. 1) and then transformed into monthly or three-monthly reports depending on the number of cases. For the present work, these data have been grouped on a yearly basis.

Name ..........................................…………..
Age Date of admission…………………….

Date of discharge …….
Died (Yes / No)

Depth of bum and % body surface area burned ...............
Cause of bum .. ~ ............................................
Elapsed time between bum and immediate therapy .........
Previous admission in another hospital (Yes / No)
Received antibiotics prior to admission in this bum unit
(Yes / No / Unknown)
Previous / associated disease ..................................


Urinary catheter (dates) ....................................…
Parenteral nutrition (dates) ....................................
Assisted ventilation (dates) ....................................
Surgery (date, type) ........................................…
Other ...............................……………….....

Clinical data

Fever (dates) :
Isolates (micro-organism, date and sample) ............
Type of antimicrobial .....................................
Dose per day ................................................
Dates when given ...........................................
Intestinal decolonization (Yes / No)
Immune stimulation (Thymostimulin - Autovaccine)
Plasmapheresis (dates) ................……………..

Table I Epidemiological infection surveillance chart for nosocomial infections in the critical area of the Burn Unit, La Paz Hospital, Madrid

The incidence of infections was studied in two ways: as cumulative incidence (%) and as incidence density per patient/month (21).
The antimicrobial drug consumption was assessed in terms of pesetas/antibiotics, pesetas/treated patient and DDD 100 bed-days (22).
Mortality was divided into "overall" and "non -immediate" mortality, the latter being defined as that occurring beyond the period of 48 hours after admission; this allows for inclusion of those patients in whom the presence or absence of therapeutic effect can be best observed.
For the statistical analysis of the data the Chi-square test and the differences of means and percentages were applied (21, 23). Some variables along the four years of the study period were standardized by the direct method (24), using the 1987 population as reference.
The criteria used for diagnosis of infection were those laid down by Bennett (25) and Halley (26).
The microbiological analysis of burn, pharyngeal and rectal swabs was carried out at weekly intervals; that of other specimens (urine, sputum, catheters, etc.) was performed according to the clinical situation and requirements. The results governed the prophylactic and therapeutic interventions.
The four years included in the study period differed in some aspects:

  • from 1985 onwards, three trained intensive care physicians were assigned to the Unit;
  • in 1985, intestinal decolonization was carried out with collmycin, 16.5 mg t.i.d., and surgery was performed more often than in 1984;
  • in 1986, intestinal decolonization with colimycin was increased to 33 mg t.i.d. (substituting norfloxacin in the case of bacterial species or strains with natural resistance, such as Proteus or Serratia), and immunological stimulation was attempted with pla§mapheresis (7.2%) and thymostimulin (28%). Recourse to surgery also increased, and chlorhexidine (0.5%) was substituted for silver sulphadiazine in resistant cases.

Perioperatory prophylaxis was instituted, with a beta-lactam plus an aminoglycoside, starting one hour before surgery and continuing for 48 hours; pharyngeal decolonization with hexetidine was performed in all patients requiring respiratory assistance.
In 1987 the use of thymostimulin was reduced to a minimum, as the drug was not available over most of the year, and decolonization was performed as explained in Tab. 2. The frequence of surgery (per patient) was similar to that of the previous year.


The 947 patients forming the study population are classified in Tab. 3 according to age, percentage of body surface area burned and year. The percentage distribution is similar for the four years (no significant difference in the Chi-square test), although in the last two years there is a marked increase in the number of admissions, particularly in the older age groups.

A) Perioperatory prophylaxis

Cephazoline 2 g + tobramycin 100 mg i.v. 30 minutes before surgery; repeat after six hours.

B) Intestinal decontamination (as long as manipulations such as i.v. lines, assisted ventilation, bladder catheterization, etc. are being applied)

Colimycin, 33 mg p.o.. q.i.d. Nistatin, 1 MU p.o., t.i.d.
Erythromycin, 500 mg p.o., t.i.d.

C) Rhinopharyngeal decontamination (as long as mampulatiow, are being applied)

Chlorhexidine, 0.5% cream, in nares (in Gram-negative colonization)
Fusicid acid, cream, in nares (in Gram-positive colonisation)
Hexetidine, swabbed onto orodental folds and sprayed onto oropharynx

D) Decontamination of burn and neighbouring area (until bum is covered)

Chlorhexidine, 0.51Yo cream (rotating weekly with Silver sulphadiazine, 1%)

Table 2 - Infection prophylaxis in burn patients


TABLE 3-1, 1984



< 16 years 16-64 years > 65 years TOTAL






30 -





11 -















TABLE 3-2, 1985



<16 years 16-64 years >65 years TOTAL
>. 60% 1 5 1 7
  0.5% 2.6% 0.5% 3. 7
30- 3 32 4 39
59% 1.6% 16.7% 2% 20.4
11- 2 30 6 38
29% 1% 15.7% 3.1% 18.9
<=10% 21 72 21 114
  11% 37.7% 11% 59.7
TOTAL 27 133 31 191
  14.1% 69.6% 16.2% 100

TABLE 3-3, 1986



<16 years 16-64 years >65 years TOTAL
~:60% 3 9 1 13
  1% 2.9% 0.3% 4.2
30- 5 24 2 31
59% 1.6% 7.8% 0.6% 10.1
H- 8 33 8 49
29% 2.6% 10.8% 2.6% 16%
:510% 20 152 41 213
  6.5% 49.7% 13.4% 69.6
TOTAL 36 218 52 306
  11.8% 71.2% 17% 100

TABLE 3-4, 1987



<16 years 16-64 years >65 years TOTAL
>=60% 0 11 4 15
  0% 3.8% 1.4% 5.7
30- 2 27 1 30
59%) 0.7% 9.3% 0.3% 10.3
11- 3 34 12 49
29% 1% 11.7% 4.1% 16.9
< 10% 14 155 27 196
  4.8% 5 3.4% 9.3% 67.6
TOTAL 19 227 44 290
  6.6% 78.3% 15.2% 100

Table 3 - Distribution of the studied population (n = 947) by age, percentage of body surface area burned (b.s.a.b.) and year



1984 1985 1986 1987
Absolute mortality 25 22 20 31
Relative mortality 16.6% 11.5% 6.5% 10.7%
Relative non immediate mortality 13.1% 6.6% 50% 9.4%
Mean age of dead 49.4+/-6.3 50.9+/-6.3 56.1 +/- 5.8 58.9+/-4.6
Mean percentage of body surface area burned in the dead 43.2+/-6.2 51.3+/-6.1 38.3+/-7.6 46.9+/-5.7
Number of patients with electrical bums 4 (2.6%) 9 (4.7%) 19 (6.2%) 23 (7.5%)

Table 4 - Mortality



1984 1985 1986 1987
Bladder catheter 15 33 46.5 64
Intravenous fluids 20 56.7 62.4 35%
Parenteral nutrition 10 31.3 32.5 26
Assisted ventilation n.d. 4.5 10.8 37
Surgery (N. of interventions/100 patients/month) 30 67 101 99

Table 5 - Manipulations




1984 1985 1986 1987
Mean number of patients/month with admission ~24h 12 18 20 17
Cumulative incidence of infection (%) 41.3 36.4 24.2 24
Incidence density of infection (patients/month) 1.85 1.61 0.99 0.51
Mean duration of admission/month for infected patients 19.6 17.9 19.1 19.9
Mean duration of admission/month for nominfected patients 7.7 7.8 8.8 9.9
Incidence density for burn Infection
* TOTAL 1.04 0.831 0:38 0.116
* P. aeruginosa 0.355 0.392 0.142 0.1
• Enterobacteria 0.646 0.435 0.157 0
• Staphylococcus:        
- Total 0.525 0.176 0.079 0.014
-S. aureus 0.525 0.145 0.079 0
- S. epidermidis 0 0.033 0 0.014
• Anaerobes 0.148 0.176 0.016 0
• Fungi 0.031 0 0 0.014
• Other micro-organisms 0.18 0.226 0.132 0.014
Incidence density for sepsis        
* TOTAL 0.659 0.614 0.17 0.116
* P. aeruginosa 0.061 0.165 0 0.043
• Enterobacteria 0.182 0.148 0 0
• Staphylococcus:        

- Total

0.326 0.29 0.111 0.028

-S. aureus

0.239 0.072 0.016 0.014

- S. epidermidis

0.086 0.217 0.095 0.014
• Anaerobes 0.024 0 0 0.014
• Fungi 0 0.035 0.063 0
• Other micro-organisms 0.106 0.064 0.047 0.029
Incidence densityfor other soft tissue infection
* TOTAL 1.062 0.18 0.27 0.173
* P. aeruginosa 0 0 0.016 0.173
• Enterobacteria 0 0.015 0.016 0.029
• Staphylococcus:        

- Total

0.062 0.09 0.126 0.058

- S. aureus

0.062 0.03 0.063 0

- S. epidermidis

0 0.06 0.063 0.058
• Anaerobes 0 0.03 0 0
• Fungi 0.031 0 0.03 0.047
• Other micro-organisms 0 0.015 0.063 0.043
Incidence density for urinary tract infection
* TOTAL 0.185 0.033 0.11 0.043
* P. aeruginosa 0 0 0.031 0.014
• Enterobacteria 0.031 0.033 0.064 0.029
• Staphylococcus:        

- Total

0 0 0.016 0

- S. aureus

0 0 0.016 0

- S. epidermidis

0 0 0 0
• Anacrobes 0 0 0 0
• Fungi 0.031 0 0 0
• Other micro-organisms 0.092 0 0.031 0

Table 6 - Incidence, aetiology and site of infection


INDEX STUDIED/1987 1984 1985 1986
1. Excess admissions due to infection
(inf. = infection)
1328 1144 471
(+ 101 inf.) (+ 114 inf.) (+ 46 inf.)
2. Admission costs, Ptas, due to infection (mill. = 1000000, Ptas = pesetas) 33.2 mill. 28.6 mill. 11.8 mill.
3. Antimicrobial costs, Ptas 1.74 mill. 2.72 mill. 4.37 mill.
4. Saved excess admissions in infected patients (earlier discharge) - 60 - 144 - 48
5. Admission costs, Ptas, due to 4. 1.5 mill. 3.6 mill 1.2 mill
6. Saved excess admissions in non infected patients (earlier discharge) - 185 7.6 mill. 5 mill.
7. Admission costs, Ptas, due to 6. - 4.6 mill. 7.6 mill. 5 mill.
Total difference in expenditures: (2 + 3 - 5 - 7) + 27.9 mill. + 19.1 mill. + 9 mill.

Table 7 Economical repercussions of infection

The mortality data are collected in Tab. 4, which shows that the two intermediate years differ significantly form the first (but not from the fourth) in non-immediate mortality. There were no significant differences in age and burned body surface area percentage among the fatal cases over the four years. In 1987 the number of patients with electrical burns was greater than in the preceding years, although the ditTerence is only significant for the comparison with 1984, due to the small size of the sample. Tab. 5 summarizes the manipulations performed on the patients. There was an increase in time for most manipulations, which was greatest for assisted ventilation and blader catheterization. Surgical interventions also increased 100% from 1984 1986-1987. Tab. 6 shows the incidence, aetiology and site of infections. These data are graphically summarized in Figs. 1, 2 and 3. A striking observation is the decline of infection, both when considered as cumulative incidence and as incidence density, during the last two years, and even more so in 1987, when the infections per patient per month represent only one quarter of the figure for 1984. Furthermore, the most frequent infection in this last year (in spite of the decline as compared to the previous ones) is that in "other soft tissues" (with non-significant differences between 1984-87), due to the even more drastic reduction of infections of other sites (particularly bum P < 0.001). As to the aetiology of infections, there was a very marked fall of all organisms in burn infections (p < 0.001), and only Pseudomonas retain an appreciable incidence (although this is only 25% of that during the first two years). Enterobacteria, the main cause of burn infections, disappeared in 1987. There has also been an inversion of the relative frequencies of both types of staphylococcl (S. aureus and S. epidermidis), as S. aureus, which was more frequent in previous years, disappeared, and only S. epidermidis had a small representation in the last year of the study.
The cases of sepsis indicate an overall reduction to one sixth of the initial incidence (p < 0.001); the main causative agent is now Pseudomonas for even though its incidence is lower than in the first two years it has become predominant due to the greater reduction (p < 0.001) of the other organisms (except anaerobes and fungi: non-significant difference).
In 1984, sepsis due to Gram-positive cocci was caused mainly by S. aureus. Over the following two years S. epidermidis predominated, in spite of the overall reduction of this type of infection, and in 1987 both types of staphylococci were isolated with similar low frequency.
Infections of the soft tissues were those which benefited least from the therapeutic measures introduced in 1987, with a non-significant reduction, although S. aureus was no longer represented as an aetiological agent and there was a slight increase in the incidence of Gram-negative rods.
Infection of the urinary tract also showed a reduction (p < 0.001 between 1984-87), while other infections hardly need to be mentioned; foremost among these are the infections of the respiratory tract.
When calculating the overall germ-specific incidence of infection, regardless of site, there is a clear decline for all micro-organisms in 1987, as compared to previous years: 330-1340% for enterobacteria, 10-1230% for anaerobes, 1240-5300% for S. aureus, 10-370% for fungi, 0-240% for Pseudomonas, 30-430% for S. epidermidis, and 300-470% for other organisms (mainly S. faecalis).
Consumption of antibiotics, which is represented in Figs. 4, 5 and 6, declines in parallel to the incidence of infection with the exception of years 1985-86, where consumption was high due to increased use of third-generation cephalosporins and aminoglycosides.
Finally, Tab. 7 compares several indices of the four years, standardized with 1987 as the reference year. This comparison shows a "saving" of 46-114 infections and of 9-28 million pesetas (admissions plus antimicrobial drugs) as an effect of the introduction of the new therapeutic measures.


The foremost and most remarkable finding of this retrospective review is the dramatic decrease in the number of infections achieved during the last two years of the study period, when double prophylaxis (intestinal and perioperatory) was applied, and most particularly in 1987, when perioperatory prophylaxis was reduced to a valid minimum (two doses) and intestinal prophylaxis was carried out with three drugs and associated to local action on the pharynx.
These procedures achieved a striking reduction of all infecting micro-organisms, and the reduction is rather less striking only in the case of infections of other tissues due to Pseudomonas, in spite of the particular attention paid to the protective measures (27).
The great impact that prophylaxis achieved on the incidence of infections demonstrates the endogenous origin of the immense majority of these complications in this type of patient (28); only in a few cases of nonfermenting bacilli was an endogenous infection suspected, although we were unable to demonstrate the mechanism of transmission (hands of nursing staff, inert carriers, etc.).
We also had some failures in intestinal decolonization, in spite of the established prophylaxis, which were caused in most cases by multiresistant

Fig. 1 - Distribution of Hospital Infection (measured in incidence density). Fig. 2 - Aetiology of Hospital Infection (incidence in density of incidence).
Fig. 1 - Distribution of Hospital Infection (measured in incidence density). Fig. 2 - Aetiology of Hospital Infection (incidence in density of incidence).
Fig. 3 - Aetiology of Hospital Infection (continuation) (incidence i density of incidence). Fig. 4 - Density of infection incidence in relation to antibiotic use (expressed in DDD per 100 Bed-days).
Fig. 3 - Aetiology of Hospital Infection (continuation) (incidence i density of incidence). Fig. 4 - Density of infection incidence in relation to antibiotic use (expressed in DDD per 100 Bed-days).


This may be explained by the fact that the dose of colimycin used for prophylaxis was too low for this organism, although it was fully effective for controlling enterobacteria. For this reason, in 1988 we introduced prophylaxis with colimycin at a dose of 600-800 ing/day (18), using oral norfloxacin or tobramycin if bacteria were selected which are naturally resistant to colimycin, such as Proteus or Serratia.
As shown in Fig. 3, the incidence of fungal infections increased (non-significantly) in 1986. This was a consequence of the increased consumption of antibiotics, mainly third-generation cephalosporins. The incidence of fungi as aetiological agents again diminished in 1987, for two reasons: reduction of the use of selected antibiotics (for instance, two instead of five doses for perioperatory prophylaxis) and association of an antifungal agent (Nistatin) for decolonization of the intestinal reservoir, although the dose we used was lower than that suggested by Stovtenbeek (17) and Clasener (18); even so, it was highly effective in preventing infection by these organisms. In 1988 the dose of Nistatin was increased when Candida was isolated from stools, and so far all detected colonizations have been eradicated.
Staphylococcus epidermidis infections are mainly associated to intravenous fluids and catheters, and increase in parallel with these manipulations. The greater attention materials has led infections and aureus has develonment paid to these manoeuvres and to a reduction in the number of to a change in their aetiology, where S. replaced S. epidermidis, but the of such infection must be further reduced, an aim we hope to achieve through the new measures (local application of 0.5% chlorhexidine cream onto the area of insertion of catheter: the initial results of this procedure have been optimal).

Fig. 5 - Antibiotic use. Description. Fig. 6 - Betalactarn. Antibiotic use.
Fig. 5 - Antibiotic use. Description. Fig. 6 - Betalactarn. Antibiotic use.

In spite of the large proportion of patients requiring assisted ventilation (33% in 1987), the incidence of respiratory infections was minimal; we believe this finding to decolonization with demonstrated in a study intensive care unit (19).
The striking reduction of the infections cannot be explained solely by the greater recourse to surgery. The number of surgical interventions increased over the first three years of the study period, but in the fourth year, with a similar proportion of surgical interventions per patient, there was a reduction of the infections to half the number of the previous year. Furthermore, the decline of infections achieved between 1985 and 1986 was much greater than the increase in the frequency of surgery, which was similar to that from 1984 to 1985. These observations underline the importance of global decolonization in the early management of the bum patient.
The increased mortality in 1987 as compared to the two preceding years, although non-significant, might be due to the greater age of the patients who died (2-9 years), to the worse state on admission (increased frequency of aspiration syndrome) and/or to multisystem failure, as suggested by the increase be related to pharyngeal hexitidine, as already carried out in a different (3.4 to 8.2 times) of the proportion of patients requiring assisted ventilation, and to the greater number of patients with electrical bums (4-14).
With regard to antimicrobial drug consumption, in 1987 there was a reduction in both the overall consumption and the consumption per patient; there was also a change in antimicrobial usage, from the predominantly therapeutic usage during the first years of the study to the mainly prophylactic usage in 1987.
The increased expenditure on antimicrobials observed in 1985-86 was primarily due to the use of first- and third-generation cephalosporins (Figs. 5 and 6) which, in the case of perioperatory prophylaxis (first-generation cephalosporins), might imply a link-up with that of a second intervention, if this took place three or four days after the previous one.
This problem was obviated in 1987, when only two doses were given (before and after surgery), so that even though a greater number of perioperatory prophylaxis regimens were given, both the overall usage of antimicrobials and the selection of resistant strains in the intestine decreased.
Finally, when translating the balance of the infection rates in the unit into "pesetas", a considerable saving effect becomes evident (9 to 29 million pesetas, according to the various years), together with a further saving that is not easily amenable to economical measurements, i.e. that of suffering, of sequelae and also of mortality, which would have been the consequence of the 46 to 101 infections that did not occur.
We therefore stress the great interest of the global prophylactic regime used (Tab. 2), together with the two modifications described in the text, for reducing, together with surgery, the number of infections of all origins in patients sustaining bum injuries.

RÉSUMÉ. Les Auteurs ont étudié la fréquence de la mortalité et de l'infection hospitalière (et en même temps la consommation des antibiotiques et l'épargne économique) chez une Unité de Brûlures, pendant une période de 4 ans, par rapport aux diverses modifications introduites dans la gestion thérapeutique. La mortalité était réduite après le deuxième an, et la fréquence de l'infection était plus basse tous les ans (au quatrième an elle était 25% par rapport au premier an). Il y a eu aussi des modifications pour ce qui concerne l'étiologie et le site de l'infection: l'infection locale causée par la brûlure a diminué à 25% dans la période, et seulement P. aeruginosa et S. epidermis ont maintenu une fréquence sensible; les infections généralisées ont eu une évolution semblable à celle des infections locales des brûlures; l'infection aux voies urinaires a eu une fréquence très basse pendant toute la période; les autres infections du tissu mou sont devenues prédominantes au quatrième an à cause d'une réduction des infections plus classiques. L'évolution de la consommation des antibiotiques n'est pas corrélée au taux d'infection, à cause de l'emploi très large des céphalosporines de la troisième génération pendant les années centrales de la période; une comparaison, après la standardisation directe, entre les évènements pendant la période complessive et ceux de l'an final indique une épargne économique considérable (9-28 millions de pesetas), comme conséquence de l'introduction des nouvelles techniques thérapeutiques.


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