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Drug-resistant organisms in a burns unit
73
Abstracts complications are major pulmonary embolism, pneumonia and adult respiratory distress syndrome. In this series, 25 patients (89 per cent) developing pulmonary complications died. The critical role of serial chest radiographs in the evaluation and management of burn victims is emphasized. Kangarloo H., Beachley M. C. and Ghahremani G. G. (1977) The radiographic spectrum of pulmonary complications in burn victims. Am. J. Roentgenol. Radium Ther. N~rcl. Med. 128,441.
Nicotinic
acid in burned
children
The excretions of two metabolites of nicotinic acid, N’-methylnicotinamide and N’-methyl-2-pyridone-Scarboxamide, have been measured at varying times after sustaining burns in 27 children with burns covering between 7 and 55 per cent of the body surface. Compared with control patients the excretions of both of these metabolites were significantly raised, suggesting that the utilization of nicotinic acid is increased. Barlow G. B., Sutton J. L. and Wilkinson A. W. (1977) Metabolism of nicotinic acid in children with burns and scalds. C/in. Chim. Acta 75, 337.
Hexachlorophene
in burns
Hexachlorophene (2,2’methylenebis [3,4,6,-trichlorophenol]) with bacteriostatic properties against staphylococci is used in a number of products applied to the skin. Absorption through normal and damaged human skin has been observed and neurological changes have been described in experimental animals. Instances of human toxicity have been reported infrequently. A IO-year-old boy who sustained a 25 per cent partial skin loss burn did well initially but died during the second week after hyperthermia, lower extremity weakness and cerebral oedema. His treatment had included frequent applications of hexachlorophene. Analysis of post-mortem tissue revealed the presence of toxic levels of hexachlorophene in the blood (2.2 pg/g) and brain (2.2 pg/g), with storage in skin (25 bg/g), liver (4.4 lg/g) and fat (6.0 VP/g). This case suggests that topical applications of hexachlorophene in man may be followed by extensive absorption with fat storage and a fatal encephalopathy. Chilcote R., Curley A., Loughlin H. H. et al. (1977) Hexachlorophene storage in a burn patient associated with encephalopathy. Pediatrics 59, 457
Treatment
of severe burns
The article reviews the early fluid therapy of over 1000 patients having a wide range of ages and degrees of burn and the volumes of urine produced by over 700 of the patients. Detailed metabolic studies in 4 severely burned patients showed a direct relationship between the severity of the burn, the therapeutic requirements and the metabolic responses. The observed increase in the rate of energy production was probably mediated by noradrenaline and required
a diet rich in energy to limit to reasonable values the mobilization of the patients’ body stores of fat and protein. When the oral intake of nutrients was deemed insufficient the intravenous route was used, often intensively. In some patients, however, in spite of considerable inputs of energy and nitrogen, there was substantial evidence that body stores of fat and protein were being mobilized and catabolized. There was an increased level of plasma free fatty acids (derived from adipose tissue) and a persistent negative nitrogen balance derived mainly from the catabolism of preformed tissue protein. Metabolic studies with radioactive-iodine-labelled plasma proteins clearly demonstrated an increased rate of catabolism of these proteins. These increased rates of catabolism could be minimized by adequate nutrition of the patients and treatment in a very warm dry environment. Davies J. W. L., Lamke L. 0. and Liljedahl SO. (1977) Pathophysiology and treatment of patients with burns covering 30-60 per cent of the body surface. Acta Chir. &and. Suppl. 468, p. 5.
Antibiotic-resistant
staphylococci
Strains of Staphylococcus aurercs isolated from the nose and skin lesions of patients in dermatology wards and from the burns of patients in the burns unit of Birmingham Accident Hospital over an 8-year period ending in 1975 showed a high incidence of multiple antibiotic-resistant strains in both environments. Over 20 per cent of the strains isolated from patients on admission to the dermatology wards were multi-resistant. Resistance to benzylpenicillin, tetracycline, erythromycin and fusidic acid was common in the dermatology wards. A smaller proportion of strains were resistant to lincomycin and a few before 1972 were resistant to methici!lin. Resistance to novobiocin and chloramphenicol was uncommon. In the burns unit resistance to fusidic acid was uncommon, whereas resistance to benzylpenicillin. tetracycline, erythromycin, novobiocin, neomycin, methicillin and lincomycin was common. Several of the antibiotics to which resistance was common in the burns unit were rarely if ever used there. Strains resistant to these antibiotics probably remained common in the ward through the frequent use of other antibiotics, especially erythromycin, to which these strains were also resistant. Ayliffe G. A. J., Green W., Livingston R. et al. Staphylococcus uure~~.sin (1977) Antibiotic-resistant dermatology and burn wards. J. C/in. Pathol. 30. 40.
Drug-resistant unit
organisms
in a burns
Topical chemoprophylaxis of extensive burns with silver sulphadiazine led to a large increase in the proportion of sulphadiazine-resistant Gram-negative bacteria in a burns unit. When all sulphonamide treatment in the ward ceased, the incidence of sulphonamide-resistant strains decreased to levels
74
Burns Vol. ~/NO.
similar to those recorded before treatment with silver sulphadiazine was introduced. This was associated with a large reduction in the incidence of resistance of certain Gram-negative organisms (especially species of klebsiella) to several antibiotics. Transferable resistance to sulphadiazine, shown by conjugation experiments with Escherichia co/i K12, was found in a majority of the strains of klebsiella species tested and in some other species. A pattern of transferable resistance to tetracycline, cephaloridine, chloramphenicol, ampicillin, carbenicillin and sulphadiazine was found in 4 of the 22 strains of klebsiella tested and closely related patterns were transferred by 5 other strains. These patterns of resistance were commonly found in species of klebsiella isolated from burns in the period before the withdrawal of sulphonamides from the ward but were found in none of the klebsiella strains isolated in the first 6 months after that period. Strains of acinetobacter and proteus, in which transferable resistance was not found, showed no appreciable fall or rise in sulphadiazine resistance; there was no fall in resistance of these organisms to tetracycline, cephaloridine, chloramphenicol, ampicillin or carbenicillin on withdrawal of sulphonamides from use on the ward, but there were substantial falls in resistance of acinetobatter to kanamycin, gentamicin, trimethoprim and tetracycline which were probably not caused by the withdrawal of sulphonamides. Bridges K. and Lowbury E. J. L. (1977) Drug resistance in relation to use of silver sulphadiazine cream in a burns unit. J. Clin. Puthol. 30, 160.
Evaluation
of burn care
Studies are reported from 73 of the 220 hospitals in the state of Florida in an attempt to determine whether additional facilities were required for the care of burned patients. Data were collected over a period of 12 months, indicating that 1656 patients with burns were admitted to the hospitals during this time. With due allowance for mortality probabilities there was no evidence that any particular hospital, whether it had a special burns unit or not, gave a better standard of treatment. Considerable evidence was obtained that additional education was needed for improvement in the care of burned patients. Many hospital records were poor, some admissions were inappropriate, some patients with minor burns stayed too long in hospital. Some patients with more severe burns received inadequate early fluid therapy resulting in a prolonged period of raised morbidity. Linn B. S., Stephenson S. E. and Smith J. (1977) Evaluation of burn care in Florida. N. Et&. J. Med. 296, 311.
Treatment
of post-burn
candidiasis
Systemic candidiasis has become a major cause of death in burn patients. Before 1971 treatment of systemic candidiasis with systemic amphotericin B was rarely successful, partly owing to a lack of sufficiently early recognition of the infection and
1
partly to a delay in the initiation of appropriate systemic therapy. Between 1971 and 1975, 15 patients were treated with systemic amphotericin B, only 1 of whom died. No fatalities from candidiasis have been observed since 1972. No serious complications attributable to the use of amphotericin B were observed. Prompt initiation of therapy with intravenous amphotericin B is advised for burn patients in whom systemic candidiasis is present. Gauto A., Law E. J., Holder I. A. et al. (1977) Experience with amphotericin B in the treatment of systemic candidiasis in burn patients. Am. J. Surg. 133, 174.
Studies
of leucocyte
function
Various polymorphonuclear leucocyte functions were studied in a group of 7 adult patients with burns covering lo-27 per cent of the body surface and in another group of 9 adult patients with burns covering 34-66 per cent of the body surface. The studies were made twice a week during the first 3-4 weeks after burning. Bactericidal capacity was impaired in 12 of the 16 patients. Chemotaxis was decreased in 7 of the 9 patients with burns covering more than 30 per cent but increased in 5 of the 7 patients with less extensive burns. Random migration was decreased in 12 of the 16 patients. The maximum disturbances in polymorphonuclear functions occurred during the second week after burning, coinciding with maximal bacterial growth on the burn wounds. Ransjo U., Forsgren A. and Arturson G. (1977) Neutrophil leucocyte functions and wound bacteria in burn patients. Burns 3, 171.
Scalds with
hot coffee
A report which indicates the number of patients treated in Denmark for scalds due to hot coffee during three 12-month periods commencing 1 January 1971 (112 burned patients), 1 April 1973 (38 burned patients) and 1 April 1974 (65 burned patients). The reduction in the number of burns from this cause during the year 1973-74 followed an intensive advertising campaign stating the hazards of the various methods of making coffee. During the subsequent year the number of accidents increased considerably, suggesting that the advertising campaign had little prolonged effect. Attempts are now being made to ensure that a safer design of coffee maker is produced. Sorensen B., Werner H. and Asmussen C. F. (1977) Coffee scalds-pursuant prophylaxis. Burns 3, 166.
Measurements loss
of evaporative
water
The evaporative water loss from burns, granulating wounds and skin donor sites was calculated from measurements of the vapour pressure gradient of the air layer close to the skin. Soon after burning the mean rate of evaporation from partial thickness burns
Abstracts complications are major pulmonary embolism, pneumonia and adult respiratory distress syndrome. In this series, 25 patients (89 per cent) developing pulmonary complications died. The critical role of serial chest radiographs in the evaluation and management of burn victims is emphasized. Kangarloo H., Beachley M. C. and Ghahremani G. G. (1977) The radiographic spectrum of pulmonary complications in burn victims. Am. J. Roentgenol. Radium Ther. N~rcl. Med. 128,441.
Nicotinic
acid in burned
children
The excretions of two metabolites of nicotinic acid, N’-methylnicotinamide and N’-methyl-2-pyridone-Scarboxamide, have been measured at varying times after sustaining burns in 27 children with burns covering between 7 and 55 per cent of the body surface. Compared with control patients the excretions of both of these metabolites were significantly raised, suggesting that the utilization of nicotinic acid is increased. Barlow G. B., Sutton J. L. and Wilkinson A. W. (1977) Metabolism of nicotinic acid in children with burns and scalds. C/in. Chim. Acta 75, 337.
Hexachlorophene
in burns
Hexachlorophene (2,2’methylenebis [3,4,6,-trichlorophenol]) with bacteriostatic properties against staphylococci is used in a number of products applied to the skin. Absorption through normal and damaged human skin has been observed and neurological changes have been described in experimental animals. Instances of human toxicity have been reported infrequently. A IO-year-old boy who sustained a 25 per cent partial skin loss burn did well initially but died during the second week after hyperthermia, lower extremity weakness and cerebral oedema. His treatment had included frequent applications of hexachlorophene. Analysis of post-mortem tissue revealed the presence of toxic levels of hexachlorophene in the blood (2.2 pg/g) and brain (2.2 pg/g), with storage in skin (25 bg/g), liver (4.4 lg/g) and fat (6.0 VP/g). This case suggests that topical applications of hexachlorophene in man may be followed by extensive absorption with fat storage and a fatal encephalopathy. Chilcote R., Curley A., Loughlin H. H. et al. (1977) Hexachlorophene storage in a burn patient associated with encephalopathy. Pediatrics 59, 457
Treatment
of severe burns
The article reviews the early fluid therapy of over 1000 patients having a wide range of ages and degrees of burn and the volumes of urine produced by over 700 of the patients. Detailed metabolic studies in 4 severely burned patients showed a direct relationship between the severity of the burn, the therapeutic requirements and the metabolic responses. The observed increase in the rate of energy production was probably mediated by noradrenaline and required
a diet rich in energy to limit to reasonable values the mobilization of the patients’ body stores of fat and protein. When the oral intake of nutrients was deemed insufficient the intravenous route was used, often intensively. In some patients, however, in spite of considerable inputs of energy and nitrogen, there was substantial evidence that body stores of fat and protein were being mobilized and catabolized. There was an increased level of plasma free fatty acids (derived from adipose tissue) and a persistent negative nitrogen balance derived mainly from the catabolism of preformed tissue protein. Metabolic studies with radioactive-iodine-labelled plasma proteins clearly demonstrated an increased rate of catabolism of these proteins. These increased rates of catabolism could be minimized by adequate nutrition of the patients and treatment in a very warm dry environment. Davies J. W. L., Lamke L. 0. and Liljedahl SO. (1977) Pathophysiology and treatment of patients with burns covering 30-60 per cent of the body surface. Acta Chir. &and. Suppl. 468, p. 5.
Antibiotic-resistant
staphylococci
Strains of Staphylococcus aurercs isolated from the nose and skin lesions of patients in dermatology wards and from the burns of patients in the burns unit of Birmingham Accident Hospital over an 8-year period ending in 1975 showed a high incidence of multiple antibiotic-resistant strains in both environments. Over 20 per cent of the strains isolated from patients on admission to the dermatology wards were multi-resistant. Resistance to benzylpenicillin, tetracycline, erythromycin and fusidic acid was common in the dermatology wards. A smaller proportion of strains were resistant to lincomycin and a few before 1972 were resistant to methici!lin. Resistance to novobiocin and chloramphenicol was uncommon. In the burns unit resistance to fusidic acid was uncommon, whereas resistance to benzylpenicillin. tetracycline, erythromycin, novobiocin, neomycin, methicillin and lincomycin was common. Several of the antibiotics to which resistance was common in the burns unit were rarely if ever used there. Strains resistant to these antibiotics probably remained common in the ward through the frequent use of other antibiotics, especially erythromycin, to which these strains were also resistant. Ayliffe G. A. J., Green W., Livingston R. et al. Staphylococcus uure~~.sin (1977) Antibiotic-resistant dermatology and burn wards. J. C/in. Pathol. 30. 40.
Drug-resistant unit
organisms
in a burns
Topical chemoprophylaxis of extensive burns with silver sulphadiazine led to a large increase in the proportion of sulphadiazine-resistant Gram-negative bacteria in a burns unit. When all sulphonamide treatment in the ward ceased, the incidence of sulphonamide-resistant strains decreased to levels
74
Burns Vol. ~/NO.
similar to those recorded before treatment with silver sulphadiazine was introduced. This was associated with a large reduction in the incidence of resistance of certain Gram-negative organisms (especially species of klebsiella) to several antibiotics. Transferable resistance to sulphadiazine, shown by conjugation experiments with Escherichia co/i K12, was found in a majority of the strains of klebsiella species tested and in some other species. A pattern of transferable resistance to tetracycline, cephaloridine, chloramphenicol, ampicillin, carbenicillin and sulphadiazine was found in 4 of the 22 strains of klebsiella tested and closely related patterns were transferred by 5 other strains. These patterns of resistance were commonly found in species of klebsiella isolated from burns in the period before the withdrawal of sulphonamides from the ward but were found in none of the klebsiella strains isolated in the first 6 months after that period. Strains of acinetobacter and proteus, in which transferable resistance was not found, showed no appreciable fall or rise in sulphadiazine resistance; there was no fall in resistance of these organisms to tetracycline, cephaloridine, chloramphenicol, ampicillin or carbenicillin on withdrawal of sulphonamides from use on the ward, but there were substantial falls in resistance of acinetobatter to kanamycin, gentamicin, trimethoprim and tetracycline which were probably not caused by the withdrawal of sulphonamides. Bridges K. and Lowbury E. J. L. (1977) Drug resistance in relation to use of silver sulphadiazine cream in a burns unit. J. Clin. Puthol. 30, 160.
Evaluation
of burn care
Studies are reported from 73 of the 220 hospitals in the state of Florida in an attempt to determine whether additional facilities were required for the care of burned patients. Data were collected over a period of 12 months, indicating that 1656 patients with burns were admitted to the hospitals during this time. With due allowance for mortality probabilities there was no evidence that any particular hospital, whether it had a special burns unit or not, gave a better standard of treatment. Considerable evidence was obtained that additional education was needed for improvement in the care of burned patients. Many hospital records were poor, some admissions were inappropriate, some patients with minor burns stayed too long in hospital. Some patients with more severe burns received inadequate early fluid therapy resulting in a prolonged period of raised morbidity. Linn B. S., Stephenson S. E. and Smith J. (1977) Evaluation of burn care in Florida. N. Et&. J. Med. 296, 311.
Treatment
of post-burn
candidiasis
Systemic candidiasis has become a major cause of death in burn patients. Before 1971 treatment of systemic candidiasis with systemic amphotericin B was rarely successful, partly owing to a lack of sufficiently early recognition of the infection and
1
partly to a delay in the initiation of appropriate systemic therapy. Between 1971 and 1975, 15 patients were treated with systemic amphotericin B, only 1 of whom died. No fatalities from candidiasis have been observed since 1972. No serious complications attributable to the use of amphotericin B were observed. Prompt initiation of therapy with intravenous amphotericin B is advised for burn patients in whom systemic candidiasis is present. Gauto A., Law E. J., Holder I. A. et al. (1977) Experience with amphotericin B in the treatment of systemic candidiasis in burn patients. Am. J. Surg. 133, 174.
Studies
of leucocyte
function
Various polymorphonuclear leucocyte functions were studied in a group of 7 adult patients with burns covering lo-27 per cent of the body surface and in another group of 9 adult patients with burns covering 34-66 per cent of the body surface. The studies were made twice a week during the first 3-4 weeks after burning. Bactericidal capacity was impaired in 12 of the 16 patients. Chemotaxis was decreased in 7 of the 9 patients with burns covering more than 30 per cent but increased in 5 of the 7 patients with less extensive burns. Random migration was decreased in 12 of the 16 patients. The maximum disturbances in polymorphonuclear functions occurred during the second week after burning, coinciding with maximal bacterial growth on the burn wounds. Ransjo U., Forsgren A. and Arturson G. (1977) Neutrophil leucocyte functions and wound bacteria in burn patients. Burns 3, 171.
Scalds with
hot coffee
A report which indicates the number of patients treated in Denmark for scalds due to hot coffee during three 12-month periods commencing 1 January 1971 (112 burned patients), 1 April 1973 (38 burned patients) and 1 April 1974 (65 burned patients). The reduction in the number of burns from this cause during the year 1973-74 followed an intensive advertising campaign stating the hazards of the various methods of making coffee. During the subsequent year the number of accidents increased considerably, suggesting that the advertising campaign had little prolonged effect. Attempts are now being made to ensure that a safer design of coffee maker is produced. Sorensen B., Werner H. and Asmussen C. F. (1977) Coffee scalds-pursuant prophylaxis. Burns 3, 166.
Measurements loss
of evaporative
water
The evaporative water loss from burns, granulating wounds and skin donor sites was calculated from measurements of the vapour pressure gradient of the air layer close to the skin. Soon after burning the mean rate of evaporation from partial thickness burns