| Ann.
Medit. Burns Club - voL VIII - n. I - March 1995
INFECTION IN BURNS: EXPERIENCE OF A
TEACHING HOSPITAL IN SYRIA
Dayoub A, Zeidan F, Radidy S..
Al-Kindy Teaching Hospital, Burns and Plastic
Surgery Department, Aleppo, Syria
SUMMARY. Infection
continues to be the major cause of death in bum patients. In a retrospective survey
covering a 15-year period (1978-1993) we found that 71 % of our hospitalized
bum patients' deaths were due to wound sepsis, septicaemia and complications of
septicaemia. Staphylococcus aureus and other gram-positive cocci isolated from
infected sites were the dominant organisms causing infection in the first week of
hospitalization. In the second week and subsequently, Pseudomonas organisms
dominated the picture and were responsible for most of the complications of septicaemia.
The aim of this paper is to describe this long period of experience in a large teaching
hospital in Syria, with regard to epidemiology, methods of diagnosis, management, and
infective complications in bums.
Material and methods
This retrospective work covers all the
burned individuals seen and hospitalized in a large teaching hospital in Aleppo - the
second most important city in Syria - over a period of some 15 years (1978-1993).
All the data were retrieved from the patient files. Out of a total patient admission to
the hospital of 46,217 persons, 613 (1.3%) were admitted for burns (299 fernales and 314
males). Five hundred and four patients accepted or continued treatment. Of these patients
102 died (20.2%). All patients were thoroughly examined, investigated and appropriately
managed. This paper will focus on infections in this particular group and on the
consequences deriving from them.
Result
As shown in Table 1, 613 patient files were
analysed (299 females and 314 males). Thirty-five per cent of the patients were aged
less than 5 years and 43% were in the age group ranging between 15 and 45 years (Table
II). The total body surface area (BSA) bumed was less than 40% in children under 5
years and 40-60% in adult patients (Table III).
| Period covered: |
1978-1993 |
| Place of study: |
Al-Kindy Teaching Hospital, Aleppo,
Syria |
| Total number patients admitted: |
46,217 |
|
| Total admission burn patients: |
613 |
(1.3%) |
| Burn patients treated: |
504 |
(82.2%) |
| Burn patients refusing treatment |
109 |
(17.8%) |
| Deaths in treated group: |
102 |
(20.2%) |
|
| Table 1 - Epidemiological data |
|
Children
Table IV shows that the probability of suffering
from septicaemia and septic shock during the first week of hospitalization was directly
linked to the percentage of 13SA burned. Most children had septicaemia and septic shock
when the percentage of 13SA burned exceeded 80%. Table V shows that in the second
week of hospitalization 40% of children who had external infection suffered from
septicaemia and/or septic shock.
Percentage
BSA burned |
Total
number |
External
infection |
Septicaemia
shock |
Septic |
| <20 |
48 |
25(52%) |
6(12.5%) |
1(2%) |
| 20-40 |
80 |
57(71%) |
14(17.5%) |
3(3.7%) |
| 40-60 |
32 |
23(72%) |
8(25%) |
4(12.5%) |
| 60-80 |
11 |
9(82%) |
5(45%) |
4(36%) |
| >80 |
6 |
6(100%) |
5(83%) |
5(83%) |
| Total |
177 |
120(67.7%) |
38(21%) |
17(9.6%) |
Comment: In the first week of hospitalization, the probability of a patient
suffering from septicaemia and septic shock was directly proportional to the percentage of
BSA burned. Septicaemia and septic shock occurred in the majority of children with more
than 80% BSA burned. |
|
| Table IV - Infection in burned children (<5 years of
age), during first week of hospitalization, by percentage BSA burned |
|
Percentage
BSAburned |
Total
number |
External
infection |
Septicaemia
shock |
Septic |
| <20 |
29 |
12(41%) |
3(10%) |
12(6.8%) |
| 20-40 |
60 |
28(47%) |
9(19%) |
17(11.6%) |
| 40-60 |
23 |
13(56%) |
7(30%) |
15(21.7%) |
| 60-80 |
4 |
2(40%) |
2(40%) |
12(40%) |
| Total |
116 |
55(47%) |
21(18%) |
16(13.8%) |
|
| Table V - Infection of burned children aged under 5 years,
during second week of hospitalization, by percentage BSA burned |
|
CommentAn the second week of
hospitalization, 40% of children suffering from external infection presented septicaemia
and/or septic shock.
Percentage
BSA burned |
Total
number |
External
infection |
Septicaemia
shock |
Septic |
| <20 |
32 |
13(40%) |
2(6%) |
|
| 20-40 |
33 |
15(45.5%) |
2(6%) |
1 (3%) |
| 40-60 |
119 |
61(51%) |
13(11%) |
3(2.5%) |
| 60-80 |
19 |
14(74%) |
5(26%) |
1(62%) |
| >80 |
8 |
7(87%) |
7(87%) |
5(62%) |
| Total |
211 |
110(52%) |
29(14%) |
10(4.7%) |
| Comment: In the
first week of hospitalization, septicaernia occurred in less than 10% of adults with less
than 6001o BSA burned and in about one in every four adults with more than 60% BSA
burned.Septic shock occurred in less than 5% of adults during the first week of
hospitalization. |
|
| Table VI - Infection in burned adults (16-45 years), during
first week of hospitalization, by percentage BSA burned |
|
Percentage
B SA burned |
Total
number |
External
infection |
Septicaemia
shock |
Septic |
| <20 |
11 |
6(54.5%) |
2(18%) |
1 (19%) |
| 20-40 |
15 |
10(66.5%) |
3(20%) |
1(7%) |
| 40-60 |
101 |
72(72%) |
31(30%) |
7(7%) |
| 60-80 |
16 |
11 (69%) |
7(44%) |
4(25%) |
| Total |
143 |
99(69%) |
43(30%) |
13(9%) |
Comment: The probability of an adult patient suffering from
septicaemia and septic shock during the second week of hospitalization was double the
probability during the first week. In the second week of hospitalization the probability
of a patient suffering from external infection, septicaemia and septic shock was about
equal in all adults with less than 60% BSA burned. However, the probability increased
greatly when the BSA burned exceeded 60%. |
|
| Table VII - Infection in burned adults (16-45 years) during
second week of hospitalization, by percentage BSA burned |
|
Type
of
organism |
Children |
Adults |
| |
I st week |
2nd week |
I st week |
2nd week |
Total |
120 |
55 |
110 |
99 |
| Staphylcocci |
47(39%) |
13(24%) |
64(58%) |
23(23%) |
| Streptococci |
9(7.5%) |
2(3.6%) |
12(11%) |
4(4%) |
| H. Influenza |
4(13%) |
1(2%) |
1 (0.9%) |
|
| Enterobacter |
22(18%) |
5(9%) |
5(4.5%) |
7(7%) |
| E. Coli |
26(22%) |
8(14.5%) |
8(7%) |
7(7%) |
| Pseudomonas |
6(5%) |
22(40%) |
11(10%) |
45(45%) |
| Candida |
2(l.6%) |
18(33%) |
5(4.5%) |
21(21%) |
| Others |
6(5%) |
2(3.6%) |
9(8%) |
7(7%) |
Comment: In the
first week of hospitalization, the dominant organism in burn infection in children were Staphylococcus
aureus, E. coli and Enterobacter, and Staphylococcus aureus an
Pseudomonas in adults.
In the second week of hospitalization, the dominant organism in both adults and children
were Pseudonionas and Candida. |
|
| Table VIII - Types of organism causing infection in the
different groups of patients during hospitalization |
|
Adults
Table W shows that in the first week
of hospitalization septicaemia occurred in less than 10% of adults with less than 60% 13SA
burned and in about one in every four adults with more than 60% 13SA. Septic shock
occurred in less than 5% of adults during the first week of hospitalization.
Table VII demonstrates that the probability of suffering from septicaemia and
septic shock during the second week of hospitalization was twice as great as during the
first week. In the second week of hospitalization the probability of external infection,
septicaemia and septic shock was about equal in all adults with less than 60% 13SA burned.
However, this probability increased greatly in patients with more than 60% 13SA burned.
Type of organisms
Table VIII shows that in the
first week of hospital stay the dominant organisms in burn infection in children were Staphylococcus
aureus, E. coli and Enterobacter, and in adults Staphylococcus aureus and
Pseudomonas. In the second week the dominant organisms in both children and adults
were Pseudomonas and Candida.
Discussion
Infection in burns is one of the most
important factors determining the prognosis of the burn disease. Mortality depends closely
on the extent of infection, and in particular of septicaemia (1, 2, 3). Survival has
improved tremendously with the control and prevention of exogenous sources of infection
(4, 5) and with various methods of elimination of endogenous sources (6, 7). The emphasis
on the proper and intelligent use of antibiotics is of major importance if a good outcome
is to be achieved.
In this study we have sought to throw some light on the continuing high incidence of
infection in burns, in spite of proper management, extensive antibiotic therapy, and other
supportive measures. Our findings allowed the following conclusions to be drawn with
regard to infection:
In children, the probability of
developing septicaemia and septic shock was positively related to the percentage of 13SA,
and occurred in nearly all children with more than 80% 13SA.
In adults, septicaemia and septic shock
occurred in 10% of cases with less than 60% 13SA and in 25% with over 60%.
In the first week of hospital stay the
main organisms causing infection were Staphylococcus aureus, E. coli and other Enterobacters;
in the second week Pseudomonas and Candida were the dominant organisms.
RESUME. L'infection
continue à être la cause principale de la mort des patients brûlés. Dans une étude
rétrospective portant sur une période de 15 ans (1978-1993) les auteurs ont trouvé que
71% des dé&s des patients brûlés hospitalisés dans leur hôpital étaient causés
par la sepsis des lésions, la septicémie et les complications de la septicémie. Les
organismes prédominants qui causaient l'infection pendant la première semaine de
l'hospitalisation étaient le Staphylococcus aureus et d'autres cocci Gram négatifs
isolés dans les sites infectés. Pendant la deuxième semaine et ensuite les organismes
Pseudomonas étaient prédominants, étant responsables de la plupart des complications de
la septicémie. Le but de cet article est de décrire la longue expérience des auteurs
dans un grand CHU en Syrie pour ce qui concerne l'épidémiologie, les méthodes de
diagnose, la gestion, et les complications infectives des brûlures.
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