Abstract
Paediatric burn wounds are challenging conditions to manage for both the doctors and patients and can cause several complications entailing a complicated treatment and recovery process. This study aims to evaluate sociodemographic conditions and antibiogram culture results of paediatric burn wounds. Our study retrospectively evaluated 419 paediatric patients with burns regarding age, gender, burn area and degree, total days spent in hospital, surgical history, final condition, additional disease history, previous attempts, and culture results with their antibiotic resistances, haemogram results, C‐reactive protein results, sociocultural conditions, burned region of the body, and structure of the burn. The prominent observations were an increased rate of incidence in male patients and patients with low socioeconomic conditions, the highest incidence of burns from scalding and domestic accidents, and the highest incidence of third‐degree burns. Furthermore, even though the most encountered burn types were extremity burns, the burn types with the highest culture growth ratio were the perineum burns. The dominant culture growth bacterial group was coagulase‐negative staphylococcus, and the ratio of medication resistance was 67.8%. It is imperative to raise awareness regarding domestic accidents to prevent paediatric burn wounds. The mortality risk can be reduced by carefully monitoring multiple organ involvement and providing timely treatment. Moreover, appropriate wound care is warranted to avoid infection from skin flora.
Keywords: burn wound features, culture antibiogram, paediatric burns
1. INTRODUCTION
Burn wounds are challenging medical conditions to manage for both doctors and patients because this condition can trigger several complications with ensuing complicated treatment and recovery process.1 Burn wounds are a serious public health problem in some countries, particularly for paediatric patients.2 Burn wounds can destroy the skin—the vital shield of the body that protects against environmental microorganisms.1, 3 Notably, the contamination by microbial agents is based on factors like patient's age and the area and depth of the burn wound.2
This study aimed to evaluate the characteristics of paediatric burns by assessing the parameters such as patient demographics (age, gender, and socioeconomic conditions), causes and features of the burn (type of burn, area and degree of burn, and burned region of the body), hospital procedures after burn (the amount of time spent in hospital, need for intensive care unit (ICU), surgical history, any additional organs affected, existence of microorganism growth, type of microorganisms and its antibiotic resistance, final condition), the biochemistry, haemogram, and C‐reactive protein (CRP).
2. METHODS
The necessary approvals for this study were obtained from our hospital's ethical committee. The study was conducted in accordance with the principles of the Declaration of Helsinki.
The parameters of age, gender, burn area and degree, total days spent in hospital, surgical history, final condition, additional disease history, previous attempts, culture results and its antibiotic resistances, haemogram results, CRP results, sociocultural conditions, burned region of the body, and structure of the burn for cases between May 2017 and May 2018 were retrospectively evaluated in this study.
Bivariant correlation (Pearson's R test and Spearman test) was used to evaluate the correlation between the data. The chi‐square test was used for categorical data. SPSS for Windows (20.0 version) was used for analysis. P values lower than .05 were considered statistically significant.
3. RESULTS
Culture results of 59 patients (14%) out of 419 study patients with burns were positive. Overall, 86.4% of the samples with culture growth were taken from wounded regions of the body, whereas the others were blood and urine culture samples.
Wound dressings were regularly changed according to the degree of the burn. Chlorhexidine (sterile cloth with chlorhexidine, paraffin‐absorbed chlorhexidine cloth), a wide range of antiseptics, nitrofurazone pomade, and antibiotic pomade with bacitracin and neomycin are typically used for second‐degree burns, whereas pomades with silver sulphadiazine are used for third‐degree burns in our clinic. Prophlaxic antibiotherapy was not applied when there was not clinical findings of infection detected at patients.
3.1. Patient demographics and culture results
The study comprised 252 (60.1%) males and 167 (39.9%) females. Out of the patients that had positive culture growth, 39 (66.1%) were males, and 20 (33.9%) were females.
The average age of the patients was 49.2 months—the youngest being 9 months old and the oldest 9 years old. The youngest and oldest patients to have positive culture results were 9 months old and 9 years old, respectively; however, the average age for patients with positive culture results was 60.3 months.
Overall, 256 (61.1%) patients were from neighbourhoods that had low socioeconomic conditions, whereas 70 (16.7%) were from middle socioeconomic conditions and 93 (22.2%) were from high socioeconomic conditions. Positive culture results were found in 39 (66.1%) patients from the neighbourhood that had low socioeconomic conditions, 7 (11.9%) from middle socioeconomic conditions, and 13 (22%) from high socioeconomic conditions. This finding was noted to be statistically nonsignificant upon data comparison.
3.2. Burn wound features and culture results
The most frequent cause of burn was hot water as evidenced in 187 (44.6%) patients, whereas burns in 118 (28.2%) cases were caused by hot beverages such as hot tea or milk besides other causes including hot objects, hot meals, hot oil, flame, electricity, chemicals, sun, and embers. Most burn wounds with positive culture results were caused by hot water evidenced by 24 (40.7%) cases followed by those caused by hot beverages with 15 (25.4%) cases, and the rest caused by other reasons such as hot objects, hot meals, hot oil, flame, electricity, chemicals, sun, and embers.
Overall, 4 (1%) of the burn wounds were first degree, 147 (35.1%) were second degree, and 268 (63.9%) were third degree (the highest degree of the burn was considered for the cases with multiple‐degree burn wounds). Among the cases with positive culture results, 1 (1.7%) was the first degree burn, 20 were the second degree burn, and 38 (64.4%) were the third‐degree burns. Notably, 25% of the patients with first‐degree burn wounds, 13.6% of the patients with second‐degree burn wounds, and 14.1% of the patients with third‐degree burn wounds had positive culture results, which were not considered statistically significant.
Assessment of the burned area size revealed that 256 (61.1%) patients had burned area size under 10%, 149 (35.6%) had burned area size between 20% and 30%, 1 patient had burned area size between 30 and 40%, and another one had burned area size between 40 and 50%. The comparison between burned area sizes and positive culture results of the patients was not statistically significant.
The most frequently encountered burned region of the body was noted to be isolated extremities evidenced by 225 (53.7%) patients. Overall, 5.5% of the cases had burn wounds of the head‐torso‐perineum region, whereas the rest of the patients had multiple region burn wounds. The second most frequent regions were torso and extremities noted in 47 (11.2%) patients. The burn regions encountered were those involving the head in 73 (17.2%), torso in 121 (28.8%), extremities in 381 (90.9%), and perineum in 64 (15.2%) patients. Furthermore, positive cultures were noted in 8 (13.6%), 20 (33.8%), 58 (98.3%), and 18 (30.5%) patients with the burned area involving the head, torso, extremities, and perineum, respectively.
3.3. Laboratory results
When the blood parameters of the patients were considered, alanine transaminase results were between 3 and 77 U/L with an average value of 16.7 U/L, whereas aspartate transaminase results were between 12 and 67 U/L with an average value of 31.1 U/L. Albumin values were between 1.2 and 5.6 g/L with an average value of 4.3 g/L. Furthermore, only three patients had albumin value under 2.5 g/L, whereas 22 patients had values between 2.5 and 3.5 g/L. Creatinine values were between 0.2 and 1.1 mg/dL with an average value of 0.7 mg/dL. Haemoglobin values were between 6.5 and 22.7 g/dL with an average value of 12.1 g/dL according to the haemogram results. Only one patient needed a transfusion during treatment. Overall, four patients needed a transfusion during the hospital stay. White blood cell values were between 3.7 × 103 and 48.9 × 103 μL with an average value of 14.4 × 103 μL. Neutrophil count was between 1.2 and 19.6 × 103 μL with an average value of 8.5 × 103 μL, whereas lymphocyte count was between 1.07 and 170.8 × 103 μL with an average value of 5.1 × 103 μL. CRP values were between 0.01 and 170.8 mg/L with an average value of 14.3 mg/L. The lab values of 159 patients were noted to be over the reference values. No correlation was observed between the blood parameters and the type, degree, and area of the burn wounds.
3.4. Hospital history and culture results
The length of hospital stay was recorded between 1 and 35 days with an average of 5.49 days. Patients often stayed in the hospital between 3 and 6 days. The length of hospital stay of the patients with positive culture results was recorded between 2 and 14 days, with the positive culture results encountered most often after 4 or 5 days (50.8%) in the hospital.
The patients who required surgery (74.9%) were often operated between the first 24 and 72 hours (85.6%). A correlation was noted between positive culture results and the surgery period; however, it was statistically nonsignificant.
Only two patients (0.5%) required ICU stay with only one having a positive culture result. This patient required ICU admission, was intubated on the seventh day, and was connected to the mechanical ventilator. Nourishment was supplied using a Foley catheter (FC), a nasogastric tube (NT), a central venous catheter (CVC), and a peripheral venous catheter, and the drainage tube was inserted during surgery. The total body surface area (TBSA) of the burn was 10%, and the cause of the burn wound was electricity.
Notably, one patient had endocrinological pathology, and three had neurological decay; however, no other organ failure was observed. Overall, 12 (2.9%) patients required FC, which was held between 2 and 7 days. Four (6.8%) patients with positive culture results required FC placement, which was not found to be statistically significant (P > .05).
CVC was inserted in 15 (3.6%) patients with 5 (8.4%) of them noted to have positive culture results, which was not statistically significant. Three patients were given parenteral nutrition with only one of them found to have a positive culture result, which was not statistically significant.
All the patients were discharged from the hospital without any exitus cases.
3.5. Culture antibiogram and treatment
When the culture results of the patients were examined, no fungal growth was noted. However, 38 (64.4%) positive results were gram‐positive bacterial growth and 21 (35.6%) were gram‐negative bacterial growth. The most frequently noted bacterial growth was that of coagulase‐negative staphylococcus (CNS) observed in 22 (37.2%) cases. Moreover, Staphylococcus aureus growth was noted in 12 (20.3%) cases and Escherichia coli in 7 (11.8%) cases, whereas the other bacterial growth cases under 5% were that of Klebsiella spp, Acinetobacter spp, Enterobacter spp, Proteus spp, Kocuria spp, Diphtheroid bacilli, Ewingella spp, Sphyngomonas spp, and Pantoea spp.
When the antibiotic resistances were evaluated, there were 19 (32.3%) cases with penicillin resistance; 18 (30.5%) with methicillin/oxacillin resistance; 17 (28.8%) with erythromycin resistance; 13 (22%) with cefoxitin resistance; 12 (20.3%) with clindamycin resistance; 11 (18.6%) with trimethoprim/sulfamethoxazole resistance; 7 (11.8%) with ciprofloxacin/levofloxacin resistance; 7 (11.8%) with tetracycline resistance; 6 (10.1%) with gentamycin resistance; 5 (8.4%) with fusidic acid resistance; 4 (6.7%) with cefazolin resistance; 3 (5%) with extended‐spectrum beta‐lactamase (ESBL) resistance; 3 (5%) with ceftazidime resistance; 3 (5%) with piperacillin/tazobactam resistance; and 1 (1.6%) each with meropenem, vancomycin, fosfomycin, and teicoplanin resistance. Methicillin resistance was found to be 54.5% for CNS and 41.6% for S aureus, whereas ESBL (+) ratio was 42.8% for E coli. No antibiotic resistance was encountered in 19 (32.2%) cases.
Notably, 61 (14.6%) patients were treated with ampicillin/sulbactam, 11 (2.6%) with third‐generation cephalosporines, 6 (1.4%) with carbapenem, 2 (0.5%) with aminoglycoside, 2 (0.5%) with linezolid, and 5 (1.2%) with a combination of these antibiotics.
4. DISCUSSION
Paediatric burn wounds cause morbidity and mortality and entail a complicated treatment process for doctors, parents, and patients. However, these are preventable.
Alnababtah et al conducted a study for investigating sociodemographics and possible causes of burn wounds and observed a male/female ratio of 1.41—similar to our study result of 1.51.4 Several studies in the literature had evidenced the male predominance.5, 6, 7 The reasons for this dominance can be attributed to exhibitionism of young males before their friends, high risk‐taking attitude, and an overt tendency to display their talents and stunts.7, 8
Karan et al evaluated the cultural factors and socioeconomic conditions in their study of paediatric patients with burn wounds and pointed out that low socioeconomic conditions increase the risk of burn wounds.5 Our study also supported similar results wherein the patients from neighbourhoods with low socioeconomic conditions in the same city had a higher risk of sustaining burn wounds.
The most encountered cause of burn was spill with a ratio of 84%, whereas the ratio of burns from hot object contact, electricity, and fire was 8.8%, 2.6%, and 5.9%, respectively. Notably, most of the burns resulted from domestic accidents. Dissanaike and Rahimi mentioned similar results regarding the relation between domestic accidents and paediatric burn wounds in their study on burn wounds.7
Based on the degrees of burn wounds, third‐degree burns were the most encountered with a ratio of 63.9% because ambulatory treatment is provided to most of the first‐degree and second‐degree burns that have small burned areas.
Moehrlen et al evaluated 749 paediatric patients with burn wounds in their study and stated that 75.4% of the patients had burns with TBSA under 10%, whereas 21.3% of them had TBSA between 10% and 30% and 3.7% of them had TBSA over 45%.9 However, compared with this study, the TBSA data of our study were higher. The probable reason for this inconsistent comparison could be the socioeconomic profile of the included patients.
Moehrlen et al also stated that the most affected body regions were thorax, face, and upper limbs. However, 31.5% of the cases had one affected region, 26% had two affected regions, and 16.7% had three affected regions.9 On the other hand, the extremities were noted to be the most frequently affected region in our study. Moreover, the cases with a single affected region were encountered very few times, and 94.5% of the cases were with double or triple affected regions. Additionally, perineum was involved in 15.4% of the cases in our study.
Our study observed no effect on the liver and kidney function tests upon evaluation of laboratory parameters in the context of multiple organ damage and the stress reaction of the body because of burn wounds. The presence of albumin is because of the massive increase in capillary permeability, and the presence of hypoalbuminemia is because of the extravascular leak of fluids that may be encountered in burn wound cases. Hypoalbuminaemia was encountered in 25 cases of our study. Notably, erythrocytes are aggregated after thermal damage depending on the magnitude and depth of the wound. Approximately 8% to 12% of erythrocytes may be lost daily in the cases with wide‐area burn wounds.10 Therefore, it is imperative to assess the haemoglobin values during and after treatment. In our study, only one patient needed a transfusion during treatment. Furthermore, four patients required a transfusion during hospital procedures because of the decrease in the haemoglobin value. Overall, 159 patients had a high level of CRP (>5 mg/L), which is an acute phase reactant; however, no correlation was detected between CRP values and the type, TBSA, and degree of the burn wounds.
In their study on nosocomial infections, Qadar and Muhamad found that the most encountered pathogen was S aureus, whereas the most encountered gram‐negative bacteria was Pseudomonas aeruginosa. Furthermore, CNS was encountered in 8% of the cases, whereas E coli was encountered in 2% of the cases. Moreover, they stated that the multidrug resistance ratio was 50.4%, whereas the methicillin resistance of S aureus and ESBL of E coli was over 80%.2 Based on the results of the culture antibiogram, our study found that the most observed bacteria among the positive culture cases were CNS, S aureus, and E coli with the most resistances encountered against the antibiotics, such as penicillin, methicillin, and erythromycin. The overall methicillin resistance was 30.5% with a ratio for the Staphylococcus spp detected as 43.9%, and the E coli ESBL resistance ratio was found to be 42%. For E coli, the overall resistance ratio against any of the antibiotics was detected as 67.8%. Despite the low methicillin resistance and ESBL (+) E coli ratio, the overall drug resistances were noted to be at a higher ratio in our hospital.
Ergun et al compared the culture results of the paediatric patients who were divided into two groups based on the type of prophylaxis provided and found that the most frequently encountered bacteria were S aureus, Enterobacter spp, P aeruginosa, and E coli. Despite the high culture growth ratio among the patients with high TBSA for both groups, we could not detect any relation between culture growth results and TBSA. Furthermore, the most frequently used antibiotics in both studies were ampicillin/sulbactam.11
Ramos et al stated that antibiotic treatment is ineffective in patients with low‐ to mild‐degree burns, whereas it may be effective in the patients on a mechanical ventilator with high‐degree burns.12 A study conducted by Chahed et al revealed an infection ratio of 20% in the group prophylactically treated with amoxicillin/clavulanic acid and 15% in those treated with oxacillin.13 Even though the patients in our study were not provided prophylactic antibiotherapy, growth was noted in 14% of the cultures, thereby raising the question whether prophylactic antibiotherapy is indeed warranted.
Our study investigated the possible causes of infection in paediatric burn patients, although statistical evaluation identifies this population to be the only one with an increased rate of infection. Even though our study observed the most common burns to be that of extremities, the rate of culture growth was significantly higher in cases with perineal burns.
Paediatric burn wounds are preventable. In the absence of necessary precautions, domestic accidents are the most common reason for paediatric burn wounds, which may cause morbidity and mortality. Additionally, domestic accidents are closely related to the socioeconomic conditions, the number of children, and the education level of the parents. The patient profile of this study is consistent with that of families with a high number of children and low socioeconomic conditions. Therefore, it is imperative to raise awareness regarding domestic accidents and educate regarding the necessary precautions. Therefore, this study aims to provide a basis for awareness practices.
Careful consideration of multiple organ damage and follow‐up of biochemical parameters during burn wounds may decrease the morbidity and mortality.
Nonetheless, a wide range of studies are warranted because our study had a less number of patients requiring mechanical ventilators and no prophylactic antibiotic use despite detection.
CONFLICT OF INTEREST
The authors declare no potential conflict of interest.
Asena M, Aydin Ozturk P, Ozturk U. Sociodemographic and culture results of paediatric burns. Int Wound J. 2020;17:132–136. 10.1111/iwj.13244
REFERENCES
- 1. Guldogan CE, Kendirci M, Tikici D, Gundogdu E, Yastı AC. Clinical infection in burn patients and its consequences. Ulus Travma Acil Cerrahi Derg. 2017;23:466‐471. [DOI] [PubMed] [Google Scholar]
- 2. Qadar AR, Muhamad AJ. Nosocomial infection in Sulaimani burn hospital, Irak. Ann Burns Fire Disasters. 2010;23:177. [PMC free article] [PubMed] [Google Scholar]
- 3. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound infections. Clin Microbiol Rev. 2006;19:403‐434. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Alnababtah KM, Davies P, Jackson CA, Ashford RL, Filby M. Burn injuries among children from a region‐wide paediatric burns unit. Br J Nurs. 2011;20:156‐162. [DOI] [PubMed] [Google Scholar]
- 5. Karan A, Amado V, Vitorino P, Kulber D, Taela A, Ugarte D. Evaluating the socioeconomic and cultural factors associated with pediatric burn injuries in Maputo, Mozambique. Pediatr Surg Int. 2015;31:1035‐1040. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Delgado J, Ramírez‐Cardich M, Gilman R, et al. Risk factors for burns in children: crowding, poverty, and poor maternal education. Inj Prev. 2002;8:38‐41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Dissanaike S, Rahimi M. Epidemiology of burn injuries: highlighting cultural and socio‐demographic aspects. Int Rev Psychiatry. 2009;21:505‐511. [DOI] [PubMed] [Google Scholar]
- 8. Kendrick D, Watson M, Mulvaney C, Burton P. How useful are home safety behaviours for predicting childhood injury? A cohort study. Health Educ Res. 2005;20:709‐718. [DOI] [PubMed] [Google Scholar]
- 9. Moehrlen T, Szucs T, Landolt MA, Meuli M, Schiestl C, Moehrlen U. Trauma mechanisms and injury patterns in pediatric burn patients. Burns. 2017;44:326‐334. [DOI] [PubMed] [Google Scholar]
- 10. Koltka K. Burn injuries: burn depth, physiopathology and burning variations. J Turk Soc Intens Care. 2011;9:1‐6. [Google Scholar]
- 11. Ergun O, Celik A, Ergun G, Ozok G. Prophylactic antibiotic use in pediatric burn units. Eur J Pediatr Surg. 2004;14:422‐426. [DOI] [PubMed] [Google Scholar]
- 12. Ramos G, Cornistein W, Cerino GT, Nacif G. Systemic antimicrobial prophylaxis in burn patients: systematic review. J Hosp Infect. 2017;97:105‐114. [DOI] [PubMed] [Google Scholar]
- 13. Chahed J, Ksia A, Selmi W, et al. Burns injury in children: is antibiotic prophylaxis recommended? Afr J Paediatr Surg. 2014;11:323‐325. [DOI] [PubMed] [Google Scholar]