Summary
Burn injury remains a major global health issue. An estimated 180,000 people die annually due to burn injury, and most cases occur in low- and middle-income countries, including Indonesia. Several complications of burns may lead to mortality, and sepsis is one of the major threats, with the risk of developing multi organ dysfunction syndrome. This study applied a descriptive-retrospective method on 3-year medical records of severe burn injury patients. The data were classified according to age, etiology, outcome, antibiotic resistance, and pathogens of sepsis. There were 100 medical records of severe burn injury, and 55% of them were accompanied by sepsis. The highest number of sepsis cases was found in the age category of 40-50 years old. Nearly 80% of the cases were fire-related burns. Blood and burn wound culture of recovered patients showed 55% contamination with gram-positive bacteria, and 50% of them with Staphylococcus hominis. Contamination of blood and burn wound culture of deceased patients with gram-negative bacteria was 100%, 60% of them with Pseudomonas Aeruginosa. There is a more than 50% chance of severe burn patients falling into septic conditions. More than half of the patients were infected with gram-negative bacteria. Pseudomonas aeruginosa remains the main culprit of septic burn-related death.
Keywords: burn injury, sepsis, profile
Abstract
Les brûlures demeurent un problème de santé publique, responsable d’environ 180 000 morts chaque année, survenant préférentiellement dans les pays à IDH bas ou moyen- bas, dont l’Indonésie. Parmi les complications pouvant conduire au décès, le sepsis en est une majeure, avec le risque de développer une défaillance multiviscérale. Nous présentons une étude descriptive et rétrospective ayant étudié cent dossiers de patients sévèrement brûlés répartis sur 3 ans, dont 55% ont développé un sepsis. Nous avons répertorié l’âge, l’étiologie de la brûlure, la bactérie en cause et son phénotype ainsi que l’évolution. Environ 80% des brûlures étaient dues à une flamme. La majorité des sepsis était observée dans la classe 40- 50 ans. Les prélèvements sanguins et cutanés de ces patients retrouvaient une bactérie à Gram positif dans 55% des cas, identifiée Staphylococcus hominis 1 fois sur 2. Ces mêmes prélèvements étaient toujours positifs à Gram négatif chez les patients décédés ; il s’agissait de Pseudomonas æruginosa dans 60% des cas. Un patient sévèrement brûlés a plus d’un risque sur 2 de développer un sepsis, plus d’une fois sur 2 à Gram positif, mais le principal responsable de la mortalité d’origine septique reste Pseudomonas æruginosa.
Introduction
Burn injury remains a massive and devastating global health issue. Severe burn injury stimulates immunosuppression, predisposing burn patients to infectious complications that may lead to mortality. An estimated 180,000 people die of burns annually, mostly in low- and middle-income countries.1,2 The mortality rate for burns in South East Asia is 11.6%.3 In Indonesia, burn-related death is recorded for approximately 195,000 people a year.4 Previous data showed that sepsis has been one of the major contributors to burn-related death.5,6
This study was a single-center study and included only severe burn injury patients diagnosed with sepsis. To date, there have been significant gaps in our national data on mortality rate in people with burn injury, especially due to sepsis. This retrospective study was performed in the burn center of Hasan Sadikin General Hospital in Bandung, to determine the characteristics of severe burn injury with sepsis, and to acknowledge mortality rate along with the pathogens involved.
Methods
The method of this study was descriptive retrospective. Medical records of severe burn injury patients in Hasan Sadikin General Hospital between 2015 and 2017 were taken. The data were classified according to the demographics and etiology of the severe burn injury patients, including age. Subsequently, they were grouped as sepsis and non-sepsis patients. The sepsis group included patients with burns >20% total body surface area (TBSA) and SIRS (systemic inflammatory response syndrome), defined as the presence of three or more of the following criteria:
Temperature >39 °C or <36.5 °C
Progressive tachycardia >110 beats per minute
Progressive tachypnea >25 breaths per minute or minute ventilation >12 L/min
Thrombocytopenia <100,000/mcl (does not apply until 3 days after burn)
Hyperglycemia in the absence of pre-existing diabetes mellitus (untreated plasma glucose >200 mg/dl or intravenous insulin >7 units/hr IV, significant resistance to insulin [>25% increase in insulin requirements over 24 h])
Inability to continue enteral feedings >24 h (abdominal distension, enteral feeding intolerance [two times feeding rate], uncontrollable diarrhea [>2500 ml/day]).7
Data on pathogens of the sepsis group were then collected. Medical records were excluded if data on pathogens were incomplete. For outcome, the patients were grouped into recovered and deceased.
Results
There were 373 medical records of patients with burn injury. Following inclusion and exclusion criteria, only 100 medical records were included in the study. The percentage of severe burn injury patients with sepsis was 55%, higher than the non-sepsis patients (Fig. 1).
Fig. 1. Percentage of sepsis in severe burn injury.
The age of the severe burn injury patients with sepsis ranged between 3 to 94 years old (Fig. 2). The highest incidence falls in the 40-50 year-old category (30), followed by the 20-30 year-old group (18) and then the 60 year-old group (14).
Fig. 2. Age distribution of severe burn injury patients with sepsis .
In the etiology category, 74% of the severe burn injuries were due to flame (Fig. 3). The others were caused by electricity (15%), scald (7%), and steam (4%). Approximately 52% of severe burn injury patients with sepsis died, and the others recovered (Fig. 4).
Fig. 3. Etiologies of severe burn injury.
Fig. 4. Percentage of mortality of severe burn injury with sepsis.
There were multiple microorganisms found in the wounds of severe burn injury patients. Thirty-seven percent of the wounds contained Pseudomonas aeruginosa (Fig. 5). The other bacteria were Acinetobacter baumannii (25%), Klebsiella pneumoniae (13%), Proteus mirabilis (12%) and Providencia stuartii (13%). In the recovered group, 50% of the patients were infected by mixed gram-negative and positive bacteria, followed by infection by gram-positive alone (30%) and gram-negative alone (20%). In the deceased group, 75% of the patients were infected by gram-negative bacteria (Fig. 6). The gram-negative pathogens found in 42% of the deceased patients were Pseudomonas aeruginosa, followed by Acinetobacter baumannii and Enterobacter cloacae, each accounting for 17% (Fig. 7).
Fig. 5. Percentage of pathogens in severe burn injury wound.
Fig. 6. Percentage of types of gram-stain bacteria in the recovered and deceased group.
Fig. 7. Percentage of gram-negative pathogens in blood culture of deceased patients.
Patients were then selected who fulfilled the criteria of burn sepsis and did not have any complications such as urinary tract infection, hospital acquired pneumonia, infections or inflammatory complications associated with peripheral/central venous catheters or any other diseases. There were 12 patients who had the same blood and wound culture. Eight out of the 12 patients were infected with gram-negative bacteria, and about 33% patients were infected with Pseudomonas aeruginosa (Table I).
Table I. Characteristics of Burn Sepsis.
Discussion
Severe burn injury may lead to a catastrophic condition, leading to mortality. Layers of skin, the body’s natural defense mechanism, are disrupted by the trauma, followed by activation of localized and systemic immune responses. Consequently, the body is prone to pathogen exposure, and at the same time, massive inflammatory responses reduce the protective ability of the body to microorganisms.7 These events lead the patient into a state of immunological suppression. This condition is devastating because it predisposes the victim to infectious complications, including sepsis.8 Rech et al. performed a retrospective cohort study on the outcome of burn patients with sepsis.9 The case-rate for sepsis was 39%, including patients experiencing septic shock. In another single-center study performed by Macedo et al.,10 only 19.4% of the patients were found to have sepsis. In this study, the number is much higher, with 55% of the patients falling into a septic condition. As the patient becomes septic, development of multiple organ dysfunction syndrome may be inevitable, and there will be a higher risk of mortality.11 Several studies showed that more than 50% of all deaths in severe burn injury patients were mainly caused by invasive infection, leading to a septic condition. 5,12-15 These findings support this study, which shows that 52% of burn patients with sepsis died. This means only half of the burn patients with sepsis survived. However on the contrary, the lethality rate of a study in a Brazilian Burn Unit was only 24.5%10, almost half the number of our study. According to Surviving Sepsis Campaign Bundles,16 early management has to be applied within 3 hours, including administration of broad-spectrum antibiotics, right after the blood culture is obtained. The result will show the most appropriate antibiotics to fight the pathogen. In this study, multiple microorganisms were found on the burn wound. The most commonly found microorganisms were Pseudomonas aeruginosa (n=37), followed by Acinetobacter baumannii (n=25) and Klebsiella pneumoniae (n=13). We then grouped the bacteria into gram-negative bacteria and gram-positive bacteria, and we studied the involvement of the bacteria in the recovered patients and deceased patients. In the recovered group, half of the patients were colonized by mixed types of gram stain bacteria. On the other hand, 75% of the patients in the deceased group were colonized by gram-negative bacteria. Furthermore, we studied the types of gram-negative bacteria in the blood culture of the deceased group. Again, Pseudomonas aeruginosa was the predominantly found type, followed by Acinetobacter baumannii, Enterobacter cloacae, Aeromonas hydrophilla and Klebsiella pneumoniae, respectively. We then studied the data and categorized burn sepsis, where sepsis was caused by the same pathogen in the burn wound. There were ten burn sepsis patients. Seven out of the 10 patients were colonized by gram-negative bacteria, and three of them were Pseudomonas aeruginosa. This is a rod-shaped normal gut flora that naturally exists in the environment. In a vigorous individual, the action of this bacteria can be suppressed, however immunocompromised patients are vulnerable to its infection. This bacteria adapts and spreads well,17 while forming biofilm,18 limiting the potency of antibiotics. This bacteria is well known as being the microorganism most responsible for burn-related death due to sepsis, which supports the finding of this study.12,19 However, other studies have confirmed a declining trend in pseudomonal sepsis,20-22 which may be because of antibiotic effectiveness or less adaptability to other bacteria. Meanwhile, another study by Macedo et al. showed that gram-positive bacteria Staphylococcus aureus is the predominant bacteria found.10 This interesting finding means that each burn unit may have different harboring bacteria, which can become a source of infection. Another frequently found bacteria is Acinetobacter baumannii. This bacteria was also found to be second to Pseudomonas aeruginosa in previous studies.23,24 In another study, the incidence of this bacteria was 12.1%,10 which was the third most commonly found microorganism. Its ability to survive in dry or wet conditions increases its survival.23 In an immunocompromised human, it can cause numerous opportunistic infections, such as urinary tract infections or pneumonia25. The culture result of this bacteria on septic patients should raise a warning for extensive use of antibiotics due to its multi-resistant characteristics.
Conclusion
Severe burn injury is a major challenge for the burn physician. There is a 50% probability of death in sepsis-related burns. In the deceased group of sepsis-accompanying burns, about three-quarter of the patients were infected by gram-negative bacteria. Pseudomonas aeruginosa remains the main culprit of septic burn-related death.
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