Patients with acute skin loss: are they best managed on a burns unit?
Patients who are critically ill and have large areas of skin loss or breakdown present a difficult management problem. They require the combination of intensive therapy facilities to support failing organs and specialized skin care, sometimes including extensive debridement and reconstruction. The expertise required for both aspects of treatment are found uniquely on a burns unit. We present five patients with large areas of cutaneous loss or damage secondary to a variety of non-burn aetiologies who were managed on a burns unit. We suggest that a burns unit may be the most appropriate place for such patients to be treated during both the acute phase of their illness and the later stages of surgical reconstruction and physical rehabilitation. (+info)
Persistence of a clone of methicillin-resistant Staphylococcus aureus in a burns unit.
A total of 128 MRSA isolates from a burns unit in 1992 and 1997 was studied by resistotyping, plasmid analysis and pulsed-field gel electrophoresis (PFGE) of SmaI-digested chromosomal DNA to ascertain whether a clone of MRSA had persisted in the unit or whether different clones had been introduced at different times. All the MRSA isolates produced beta-lactamase and had high MICs to methicillin (>256 mg/L). All were resistant to tetracycline, kanamycin, cadmium acetate and mercuric chloride. Most were resistant to gentamicin, neomycin, erythromycin, chloramphenicol, trimethoprim, ciprofloxacin, propamidine isethionate and ethidium bromide, and were susceptible to minocycline, vancomycin and teicoplanin. None of the 1992 isolates was resistant to mupirocin, but 56% and 19% of the 1997 isolates expressed high- and low-level mupirocin resistance, respectively. Many of the 1997 isolates had acquired a 38-kb plasmid encoding high-level mupirocin resistance. The 1992 isolates had two main PFGE patterns; 82% of them belonged to PFGE pattern 1. The 1997 isolates had PFGE pattern 1, the same as the majority of the 1992 isolates. All MRSA isolates from both years carried the mecA gene in the same SmaI fragment. These findings demonstrated that a clone of MRSA that was prevalentin the burns unit in 1992 had persisted and became the predominant clone in 1997. (+info)
Treatment before transfer: the patient with burns.
OBJECTIVES: To review pre-burns centre management, including assessment, resuscitation, and transfer. METHODS: A retrospective analysis of the notes of all the UK patients admitted to the Burns Centre in 1998, who had a body surface area burn of over 15% in adults (10% in children). RESULTS: There were 31 patients, 21 adults and 10 children, and the average burn size was 32% (12-96%). Fourteen were overestimated (average of 9%) and 13 underestimated by 7.5%. Twenty nine received intravenous fluids, 18 specified a formula, but it was only applied correctly in 10. The average time to the Burns Centre from the burn was 10 hours, and the time for resuscitation and transfer, eight hours. Documentation was generally poor. CONCLUSION: There has previously been considerable variation in the standard of initial burn management and there have been problems with burn percentage assessment and resuscitation formula application. A new proforma has been introduced to tackle these issues. (+info)
Outcome analysis of 286 severely burned patients: retrospective study.
OBJECTIVE: To evaluate the outcomes of severely burned patients treated at a regional burns unit and to develop a predictive model for survival and length of hospital stay for major burn patients in Hong Kong. DESIGN: Retrospective study. SETTING: Burns unit of a regional public hospital, Hong Kong. PATIENTS: Two hundred and eighty-six severely burned patients treated from March 1993 to February 2000. MAIN OUTCOME MEASURES: Details of demographics, mechanism of burn, extent of burn, incidence of inhalation injury, length of hospital stay, and mortality rate were recorded and entered into a database. Stepwise logistic regression and linear regression were applied to develop a predictive model for mortality and morbidity, respectively. RESULTS: Of 286 major burn patients treated in this 7-year period, 25 patients died from their injuries, yielding a mortality rate of 8.7%. Stepwise logistic regression was applied to develop a predictive model for mortality. We found that inhalation injury, age, and total body surface area involvement were independent significant predictors of death. Accuracy of this predictive model reached 93%. Similarly, stepwise linear regression was used to develop a predictive model for length of hospital stay. Sex, inhalation injury, total body surface area of burn, and total body surface area(2) of burn were significant predictors of length of hospital stay (R(2)=0.2). Only three patients' duration of hospital stay was more than three standard deviations from the predicted length of hospital stay. CONCLUSION: A predictive model for mortality and length of hospital stay has been developed for major burn patients in Hong Kong. This model may help clinicians to counsel patients and relatives at an early stage of care, to provide a basis from which new treatment plans can be compared, and to facilitate efficient allocation of valuable medical resources. (+info)
Detection of methicillin and mupirocin resistance in Staphylococcus aureus isolates using conventional and molecular methods: a descriptive study from a burns unit with high prevalence of MRSA.
AIMS: To compare conventional phenotypic methods for the detection of methicillin and mupirocin resistance in Staphylococcus aureus in routine laboratory practice with reference to an established molecular method. METHODS: This study was conducted on a selection of 65 isolates of methicillin resistant Staphylococcus aureus (MRSA) from a burns unit in India which is endemic for MRSA. The Kirby-Bauer and modified Stokes disc diffusion tests and the Vitek breakpoint minimum inhibitory concentration (MIC) were performed on all isolates using the presence of the mecA gene as the reference standard. Gel based and colorimetric polymerase chain reaction (PCR) assays were evaluated as molecular methods for the diagnosis of MRSA. A commercial latex agglutination test, the Mastalex, was assessed for the detection of penicillin binding protein 2a (PBP2a), the mecA gene product. Conventional disc diffusion and molecular methods were investigated for the detection of mupirocin resistance. RESULTS: Fifty one of 65 isolates were positive for the mecA gene. All three phenotypic methods showed high sensitivity (> 96.2%), whereas the specificity varied: 50% for Kirby-Bauer, 87.5% for modified Stokes, and 93.3% for Vitek. The colorimetric PCR was less cumbersome than the gel based PCR; there was complete concordance between both systems. The Mastalex kit showed good correlation with PCR. One isolate was found to be mupirocin resistant and harboured the mupA gene. CONCLUSIONS: The specificity of routine laboratory tests for MRSA detection was variable. mecA gene detection, the "gold standard" to confirm ambiguous results, is difficult to perform in routine diagnostic laboratories. The Mastalex kit for the detection of PBP2a is an alternative that could be used in most laboratories. High level mupirocin resistance can be confirmed with genotypic methods. (+info)
Molecular epidemiology of Pseudomonas aeruginosa colonization in a burn unit: persistence of a multidrug-resistant clone and a silver sulfadiazine-resistant clone.
To study the epidemiology of Pseudomonas aeruginosa colonization in a 32-bed burn wound center (BWC), 321 clinical and 45 environmental P. aeruginosa isolates were collected by prospective surveillance culture over a 1-year period and analyzed by serotyping, drug susceptibility testing, and amplified fragment length polymorphism (AFLP) analysis. Among 441 patients treated at the center, 70 (16%) were colonized with P. aeruginosa, including 12 (17%) patients who were colonized on admission and 58 (83%) patients who acquired the organism during their stay. Of the 48 distinct AFLP genotypes found, 21 were found exclusively in the environment, 15 were isolated from individual patients only, and 12 were responsible for the colonization of 57 patients, of which 2 were also isolated from the environment, but secondary to patient carriage. Polyclonal P. aeruginosa colonization with strains of two to four genotypes, often with different antibiotic susceptibility patterns, was observed in 19 patients (27%). Two predominant genotypes were responsible for recurrent outbreaks and the colonization of 42 patients (60% of all colonized patients). The strain with one of those genotypes appeared to be endemic to the BWC and developed multidrug resistance (MDR) at the end of the study period, whereas the strain with the other genotype was antibiotic susceptible but resistant to silver sulfadiazine (SSD(r)). The MDR strain was found at a higher frequency in sputum samples than the SSD(r) strain, which showed a higher prevalence in burn wound samples, suggesting that anatomic habitat selection was associated with adaptive resistance to antimicrobial drugs. Repeated and thorough surveys of the hospital environment failed to detect a primary reservoir for any of those genotypes. Cross-acquisition, resulting from insufficient compliance with infection control measures, was the major route of colonization in our BWC. In addition to the AFLP pattern and serotype, analysis of the nucleotide sequences of three (lipo)protein genes (oprI, oprL, and oprD) and the pyoverdine type revealed that all predominant strains except the SSD(r) strain belonged to recently identified clonal complexes. These successful clones are widespread in nature and therefore predominate in the patient population, in whom variants accumulate drug resistance mechanisms that allow their transmission and persistence in the BWC. (+info)
A review of burns patients admitted to the Burns Unit of Hospital Universiti Kebangsaan Malaysia.
This is a retrospective review of 110 patients admitted to the Burns Units between October 1999 and November 2001. The aim was to determine the burns pattern of patients admitted to hospital UKM. There was an increasing trend for patients admitted. Female to male ratio was 1:2. Children consisted 34% of the total admission. Children had significant higher number of scald burns as compare to adult (p < 0.01). Domestic burns were consist of 75% overall admission. Mean percentage of TBSA (total body surface area) burns was 19%. Thirty percent of patients sustained more than 20% of TBSA. Sixty percent of patients had scald burns. Ninety percents of patients with second degree burns that were treated with biologic membrane dressing or split skin graft. Mean duration of hospital stay was 10 days. Over 70% of patients were discharged within 15 days. Overall mortality rate was 6.3%. The patients who died had significantly larger area of burns of more than 20% TBSA (p < 0.05) and a higher incidence of inhalation injury (p < 0.02). Hence, this study suggests a need for better preventive measures by the authority to prevent burns related accident and the expansion of the service provided by the Burns Unit. (+info)
Burns associated with fondues.
OBJECTIVE: To describe the causes of burns associated with fondues. DESIGN: Descriptive case series. PATIENTS: All 17 patients admitted to a burn centre between Apr. 1, 1985, and Mar. 31, 1990, whose burns were associated with fondue. Eleven agreed to complete a telephone interview. RESULTS: The age of the 17 patients varied from 2 to 56 (mean 27) years. Two causes were identified: spilling of the contents of the fondue pot and explosion of the fondue fuel when added to the burner during a meal. The telephone interview revealed that eight people other than the respondents were burned during the same accidents. CONCLUSION: Although we identified only badly burned patients the problem may be more extensive. The knowledge of specific causes of burns from handling fondue equipment indicates that preventive action should be undertaken. More epidemiologic information is needed to obtain a precise estimate of the magnitude of this public health problem. (+info)