Rev. Soc. Bras. Med. Trop. vol.24 número3

R e v is ta d a S o c ie d a d e B r a s ile ir a d e M e d ic in a T ro p ic a l 2 4 ( 3 ): ] 6 3 -1 6 8 , j u l- s e t, 19 9 1

BACTERIOLOGICAL EVALUATION OF WOUNDS IN

SERIOUSLY BURNED HOSPITALIZED PATIENTS.

S u e l i d e L o u r d e s N o g u e i r a V i l e l a S i l v a , O s w a ld o G o n t ij o M a c e d o , C a r lo s A m é r i c o V e i g a D a m a s c e n o , M a r ia A u x i l i a d o r a R o q u e d e C a r v a l h o a n d

E d u a r d o O s ó r io C is a lp in o .

During the period between May and December 1988, 21 patients w ere studied

bacteriologically at Hospital João XXIII’s burn’s unit which belongs to “Fundação

H ospitalar do Estado de Minas G erais” in Belo Horizonte, Brazil. A qualitative and

quantitative evaluation o f aerobic and facultative bacteria from burn wounds was carried out

by the standard filter paper disc technique, including antibiotic susceptibility. At the same

time an evaluation o f those bacteria isolated from the environmental unit was perform ed. The

most common organisms recovered from wounds o f patients were: P se u d o m o n a s a e r u g in o s a ,

frequent strain recovered from environmental specimens. In nearly all patients specimens

(16 in total) from whom P. a e r u g in o s a was isolated, the rate o f CFU/cm2 o f skin was above

102. In nine o f these, it reached 105, wich is equivalent to 107 CFU/g of burned tissue.

Key-words: Nosocomial infection. Burn wounds infection.

A ccording to Sucena24 in 1982, in the

U nited States o f Am erica, two m illion cases of

b u m s are registered per year, 200,000 o f which

require hospitalization, w ith a mortality o f 12,000.

In B razil, (w here statistics are very poor), Russo22

registered a total o f 871,692 labor accidents in

São P aulo (in 1975), 27,894 o f which were

burned patients. Tw enty percent o f these (6.189)

had to be hospitalized. It was estim ated that

hospitalization o f these burned patients led to

836,820 lost w orking days. Nosocomial infections

have probably been m ore prevalent follow ing

m ajor burns than is any o ther condition in

medicine. A ccording to the inform ation available,

infection has been the leading cause o f death in

F ro m th e D e p a rtm e n t o f M ic ro b io lo g y , In stitu te o f B io lo g ic a l S c ie n c e s , F e d e ra l U n iv e rsity o f M inas G e ra is, B élo H o riz o n te , M G , B razil.

F in a n c ia l S u p p o rt o f C A P E S , C N P q , P R P q /U F M G , F IN E P .

A d d r e s s f o r r e p r i n t s : D ra . M a ria A u x ilia d o ra R. C a rv a lh o , D e p a rtm e n t o f M ic ro b io lo g y , IC B /U FM G C am p u s P a m p u lh a , 30161 Belo H o riz o n te , M G , B razil. R e ce b id o p a ra p u b lic a ç ã o em 2 0 /0 3 /9 1 .

this type o f injury611 14 . As b u m w ounds are

invariably contam inated, it’s not easy to determ ine

the presence and degree o f infection. On the other

hand, m ultiple organism s are often involved in

bum wound infections, and it is not difficult to find

two or m ore bacteria associated w ith septicem ia or

other types o f invasive infection. It therefore

becomes essential to control infection in high-risk

patients910.

It is estim ated that 80 percent o f w ounds

are colonized by m icroorganism s from the p atie n t’s

own gastrointestinal and respiratory tracts. The

rem aining 20 percent are colonized by cross -

contam ination. In both groups, h a lf o f the cases

result in sepsis'5.

In the 5 0 ’s and 6 0 ’s the increasing am ount

o f antibiotic - resistant bacteria becam e an additional

problem to burned patients. T hus, resistence o f

G ram negative and Gram positive bacteria in one

patient m ight cause serious consequences for other

patients in a same bum s unit. This should therefore

influence the selection o f antibiotics for the treatment

o f suspected sepsis in these other patients9.

S ilv a S L N V , M a c e d o O G , D a m a s c e n o CA V, C a r v a lh o M A R , C isa lp in o E O . B a c te r io lo g ic a l e v a lu a tio n o f w o u n d s in s e r io u s ly b u r n e d h o s p ita liz e d p a tie n ts . R e v is ta d a S o c ie d a d e B r a s ile ir a d e M e d ic in a T r o p ic a l 2 4 :1 6 3 -1 6 8 , ju l-s e t, 1991

streptococci and staphylococci were becoming

p ro m in e n t m ic ro o rg a n is m s in b u rn w o u n d

infection, along w ith Gram negative aerobic rods.

A fter penicillin was discovered, during the 1950’s,

S . a u r e u s

becom e predominant. By theearly 1960’s,

P . a e r u g in o s a

outnum bered

followed

by o ther G ram negative and facultative rods. Since

the 1960’s

sp and

o th e r fu n g i hav e a p p eared w ith in creasin g

frequency. F urther the oportunistic viruses (CM V,

H erpes) have becom e notew orthy in the 1980’s1419.

W hile resistant G ram negative organism s clearly

becam e clinically im portant in the 1970’s, the

resistant G ram positive cocci became more frequent

in the 1980’s. This also occured in thebum s unit925.

T h u s, in th e a n tib io tic era,b a c teria l

resistance has becom e a factor. The changing

bacterial patterns in burn w ounds infections are

secondary to the recurrent use o f both topical and

system ic antim icrobial agents. In other w ords,

changing bacterial patterns often reflect changing

m ethods o f therapy, m ore than any other factor.

This is specially affected by the method o f drug

utiliazation8 14 2\

T he purpose o f this paper is to present

m icrobiological data w hich help develop both

effective prophylactic and active infection control

program m es for hospitalized burned patients.

M A T ER IA L AND M ETHODS

Patients w ith serious burns were selected

according to extent o f area injury and depth2124.

The age range consisted o f adults and children of

both sexes. T he m ajority o f burns was due to

accidents w ith alcohol, com bustible and fireworks,

or suicide and hom icide.

D uring the period between M ay and

D e c e m b e r 198 8 , 21 p a tie n ts w e re stu d ie d

bacteriologically at H ospital João X X III’s b u rn ’s

unit w hich belongs to “Fundação H ospitalar do

Estado de M inas G erais” in Belo Horizonte, Brazil.

E nvironm ent specim ens o f six differenrt sources

in the same unit w ere also studied.

The C F U /cm 2 o f skin w as evaluated

a c c o rd in g to W illia m s et a l26 in 1984, by

innoculation o f one standard filter paper disc,

w hich w as used to collect specimens, in a 10 ml

thioglycollate broth. Successive dilutions up to 10

10, after hom ogenization in m echanic sh ak er

(V ortex), were then perfom ed. F rom previously

established dilution, 0.03 ml doubled volumes were

subcultured in blood agar plates. After 24h o f

incubation at 30°C and 37°C, the colony count was

made26.

The isolated colonies w ere subcultured in

brain heart infusion broth to get pure culture. T he

tests for presum ptive identification w ere made

according to what is precognized for each group o f

bacteria251218.

Susceptibility profiles o f isolates were

determ ined following Bauer - K irby disk agar

d iffu sio n m eth o d 3, u sin g p ro p e rly se le c te d

antibiotic11, including those used in the hospital. -

Strains o f reference w ere used as control:

p n e u m o n ia e

ATCC 27736 and

ATCC 25923.

RESULTS

The most com m on organism s recovered

from w ounds o f patients were:

a e r u g i n o s a , S t a p h y l o c o c c u s a u r e u s

and

(T a b le 1).

was the most frequent strain recovered

from environmental specimens (Table 2). In nearly

all patients specimens (16 in total) from w hom

a e r u g in o s a

was isolated, the rate o f C FU /cm 2 o f

skin was above 102. In nine o f these, itreach ed 1 0\

T a b le 1 - B a c te r ia l o r g a n is m s is o la te d f r o m b u r n w o u n d s o f c h ild a n d a d u lt p a tie n ts d u r in g th e p e r io d s tu d ie d .

N° of

° rgamsms_______________________________ patients

Gram negative aerobic an facultative bacteria

P se u d o m o n a s a e r u g in o s a P se u d o m o n a s sp K le b sie lla sp P r o te u s sp C itr o b a c te r sp E s c h e r ic h ia co li

A c in e to b a c te r c a lc o a c e tic u s subsp. a n itr a tu s

Gram positive aerobic and facultative bacteria

S ta p h y lo c o c c u s a u r e u s

5

S ta p h y lo c o c c u s e p id e r m id is 4

E n te r o c o c c u s f a e c a li s

2

16

1

2

2

1

2

1

S i l v a S L N V , M a c e d o O G , D a m a s c e n o C A V , C a r v a l h o M A R , C i s a l p i n o E O . B a c t e r i o l o g i c a l e v a l u a t i o n o f w o u n d s

in s e r i o u s l y b u r n e d h o s p i t a l i z e d p a t i e n t s . R e v i s t a d a S o c i e d a d e B r a s i l e i r a d e M e d i c i n a T r o p i c a l 2 4 : 1 6 3 1 6 8 , j u l

-s e t , 1 9 9 1

Antimicrobial susceptibility tests showed

multiple drug resistence (M D R = resistent to at

least two aminoglycosides, amplicillin and first

generation cephalosporins9) in 87 percent of P .

strains isolated from burn - wounds

(Table 3).

strains recovered from

environmental specimens (soap, floor and shower

h o se) w ere se n sitiv e to am in o g ly co sid es;

moderately sensitive to cefotaxime and resistent to

all other tested antibiotics.

DISCUSSION

It is accepted that the number o f 103

bacteria/cm* of skin in burned patients, equivalent

to 105 bacteria/g of burned tissue, is indicative of

im pending sepsis for aerobic and facultive

bacteria“ . Other reports suggest that there is c r i t i c a l

of bacteria, between 104 and 106 organisms/

g of burned tissue10. This figure is compatible with

the existence of category intermediate between

colonization and invasion" which would correspond

to 102 - 104 microorganisms/cm2 o f skin, with the

disc techique used in this work. Reports o f 103

CFU/cm2 of skin, (Witch would be equivalent to

105 organisms per gram of tissue), are compatible

with, but not diagnostic of, bum wound infection1

10 20. Though less diagnostic, surface cultures do

give information which is useful for surveillance

and epidemiologic control1.

In nearly all patient specimens from which

P . a e r u g i n o s a

(16 patients; Table 1) was isolated,

the rate of CFU/cm2 of skin was above 102, In 9 of

these, it reached 10', which is equivalent to 107

T a b le 3 - I n v i t r o a n tim ic r o b ia l s u s c e p tility o f P . a e r u g i n o s a s t r a in s is o la t e d fro m b u rn - w o u n d s a s d e te rm in ed b y K irb y - B a u e r d is c d iffusio n .

P a t i e n t s t r a i n s A n t i m i c r o b i a l d r u g s

.1 . 2 3 4 5 6 7 8 9 1 0 11 1 2 1 3 1 4 1 5 1 6

A m i k a c i n S R R R R R R S S S R R R R R R

A m o x ic i ll i n R R R R R R R R R R R R R R R R

A m p i c i l li n R R R R R R R R R R R R R R R R

C a r b e n i c i l l i n R R R R R R R S S S R R R R R R

C e f o t a x i m e R M S M S R R M S R M S M S M S R M S R R M S R

C e p h a l o r i d i n e R R R R R R R R R R R R R R R R

C e p h a t o t h i n R R R R R R R R R R R R R R R R

C h l o r a m p h e n i c o l R R R R R R R R R R R R R R R R

G e n t a m i c i n R R R R R R R S S S R R R R R R

K a n a m y c i n R R R R R R R R R R R R R R R R

P e n i c i l li n G R R R R R R R R R R R R R R R R

T e t r a c y c l i n e R R R R R R R R R R R R R R R R T r i m e t h o p r i n

-s u l f a m e t h o x a z o l e R R R R R R R R R R R R R R R R

S i l v a S L N V , M a c e d o O G , D a m a s c e n o C A V , C a r v a l h o M A R , C i s a l p i n o E O . B a c t e r i o l o g i c a l e v a l u a t i o n o f w o u n d s

in s e r i o u s l y b u r n e d h o s p i t a l i z e d p a t i e n t s . R e v i s t a d a S o c i e d a d e B r a s i l e i r a d e M e d i c i n a T r o p i c a l 2 4 : 1 6 3 1 6 8 , j u l -s e t , 1 9 9 1

CFU /g o f burned tissue. The high CFU/cm2 rates

found in nearly half o f the patients examined are

also important when one takes into consideration

the high level o f susceptibility o f burned patients,

and the potencial source o f cross - contamination

(as observed by MacMillan et al14 in 1986).

It’s thought that from the time o f bum

injury the infection of wound follows a set sequence,

with respect to aetiological agent and the duration

o f infection. Firstly, it is invaded by S t r e p t o c o c c u s

sp and

days later by Gram-negative rods, which are future

pathogens. At end of this process, after the patient

has been furnished with broaspectrum antibiotics,

the fungi appear'7. According to information

available, in the majority o f burn infections one

strain of Gram negative bacteria (

sp) predominates. However, a great number of

other organisms have been replacing P . a e r u g i n o s a

in importance1315. The present results show that in

Brazil, P . a e r u g i n o s a

still requires special care for

its control, for it is still the most frequent organism,

occurring in approximately 75 per cent of patients.

T he

g re a t

m a jo rity

o f

th ese

microorganisms were shown to be resistant to all

antibiotics tested. According to Muir et all16 in

1987, 30 per cent o f burned patients develop

infection, but, in recent years, only 5

per cent o f pacients have been given anti-

pseudom ona antibiotcs (aminoglycosides). A

rational and firmly enforced antibiotic policy is

essential, both for the management o f the individual

patient and to prevent the development of antibiotic

- resistant strains o f organisms in the ward

environment.

Studies about epidemiology and control

o f m u ltire sista n t strain s, have shown that

aminoglycoside resistence has occurred with higher

frequency in isolates o f wounds and sputum,

which usually have poor penetration. It’s thought

therefore, that the presence of sub inhibitory

levels o f drugs in these situations contributes to the

production o f multiresistant strains. The resistance

of the isolates to aminoglycosides has been also

related to inadequade dosage2'. However, there is

some controversy as to the relation between

amikacin use and resistance, as some hospitals

have used amikacin extensively,without noticing

any increase in resistance. Therefore, the incidence

depends, in any situation, on the prevalence o f the

various inativating amikacin enzimes in organisms

o f th e h o s p ita l, as w e ll as on a d e q u ate

aminoglycosides dosing7 25.

P s e u d o m o n a s p s e u d o m a l l e i isolated from

enviro n m en t spcim ens show ed a d iffe ren t

susceptibility from those of

isolated

from patients. These

invariably

shown to be sensitive to amikacin, gentamicin,

and kanamycin; moderately sensitive to cefotaxime

and resistant to all other tested antibiotics.

The sepsis prevention in wound burns

depend on maintenance o f a low concentration of

bacteria in the injury4 21. A wide variety o f topical

agents are available to inhibit the bacterial growth

in bums but no one has fulfilled all the requirements

for an ideal topical agent91623. With the extended

use of any of these agents (silver nitrate, 0.5%.

silversulfadiazine, mafemideof sodium, povidone-

iodine), resistant organisms inevitably appear.

The use o f topic antibiotic agents has

decreased mortality among patients with less than

40% of corporal area burned. In most o f the

burned patients centers, topic agents are now used

in association with debridement or surgical excision

for serious injury11314.

A fundamental aspect to be considered is

the situation o f the

subject in medical

courses, at the moment included as a small topic.

The little time devoted to this matter is a consequence

o f the subject not being considered as a speciality.

Thus, no other group of drugs has such a remarkable

effect in the community as a result of its misuse in

term s o f both cost and increased bacterial

resistance8.

Antibiotic proliferation, the availability

of other drugs and the existence o f several different

sources of information about drugs, has made it

difficult to secure rational orientation and controlled

prescription8. However efforts must be made in

this d irec tio n ,m ain ly by Infection C ontrol

Comissions.

Additional studies, correctly structured,

in the field of microbiology, in different centers

for burned patients are therefore necessary in

Brazil. With the microbiologic data from the data

S i l v a S L N V , M a c e d o O G , D a m a s c e n o C A V, C a r v a l h o M A R , C i s a l p i n o E O . B a c t e r i o l o g i c a l e v a l u a t i o n o f w o u n d s in s e r i o u s l y b u r n e d h o s p i t a l i z e d p a t i e n t s . R e v i s t a d a S o c i e d a d e B r a s i l e i r a d e M e d i c i n a T r o p i c a l 2 4 : 1 6 3 1 6 8 , j u l

-s e t , 1 9 9 1

obtained, it will be possible to provide better

infection control to the burned patient.

RESUMO

N o p e r í o d o d e m a i o a d e z e m b r o d e 1 9 8 8 , f o r a m a v a l i a d o s b a c t e r i o l o g i c a m e n t e 21 p a c i e n t e s da U n i d a d e d e Q u e i m a d o s d o H o s p i t a l J o ã o X X I I I p e r t e n c e n t e à F u n d a ç ã o H o s p i t a l a r d o E s t a d o d e M i n a s G e r a i s , e m B e l o H o r i z o n t e , B r a s i l . A a v a l i a ç ã o q u a l i t a t i v a e q u a n t i t a t i v a d e b a c t é r i a s a e r ó b i c a s e f a c u l t a t i v a s d e q u e i m a d u r a s foi r e a l i z a d a a t r a v é s da t é c n i c a d o d i s c o d e p a p e l de f ilt r o p a d r o n i z a d o , i n c l u i n d o a s u s c e p t i b i l i d a d e a a n t i m i c r o b i a n o s . A o m e s m o t e m p o , foi r e a l i z a d a u m a a v a l i a ç ã o d a s b a c t é r i a s i s o l a d a s d o a m b i e n t e d a U n i d a d e . O s m i c r o r g a n i s m o s m a i s f r e q u e n t e m e n t e r e c u p e r a d o s d a s f e r i d a s d o s p a c i e n t e s f o r a m : P s e u d o m o n a s a e r u g i n o s a , S t a p h y l o c o c c u s a u r e u s , S t a p h y l o c o c c u s e p i d e r m i d i s . A e s p é c i e P .

p s e u d o m a l l e i fo i a m a i s f r e q u e n t e n o s e s p é c i m e s a m b i e n t a i s . E m q u a s e t o d o s o s e s p é c i m e s de p a c i e n t e s d o s q u a i s P . a e r u g i n o s a (1 6 p a c i e n t e s ) foi i s o l a d a , a t a x a C F U / c m 2 d e p e l e e s t a v a a c i m a d e IO2. E m n o v e d e s t e s , a l c a n ç o u 10s, o q u e e q u i v a l e a 1 0? C F U / g de t e c i d o q u e i m a d o .

P a l a v r a s - c h a v e s : I n f e c ç ã o h o s p i t a l a r . I n f e c ç ã o d e q u e i m a d u r a s .

ACKNOWLEDGMENTS

The authors are indebted to Dr. Nelson

Luis Figueiredo Caescaes for his cooperation,

helpful suggestions and critical reading the

m anuscript and Luzia Rosa Resende for the

technical help. The authors wish to thank the staffs

o f Bum Unit o f Hospital Joào XXIII for their

excellent cooperation.

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1 3 . L u te rm a n A , D a c s o C C , C u r r e r i P W . I n f e c t io n s in

b u rn p a tir e n ts . A m e r ic a n J o u r n a l o f M e d ic i n e 81

(S u p p l 1 A ): 4 5 - 5 2 , 1 9 8 6 .

1 4 . M a c M i ll a n B G , H o l d e r I A , A l e x a n d e r J W . I n f e c t io n s o f b u r n w o u n d s . In: B e n n e t t J V , B ra ch m a n P S (e d s ) H o s p it a l I n f e c t io n s , 2 n d e d it io n , L it t le B r o w a n d C o m p a n y , B o s t o n p . 4 6 5 - 4 8 2 , 1 9 8 6 .

1 5 . M c M a n u s W F , G o o d w in C W , M a s o n A D , P ru itt J r B A . B u m w o u n d in f e c t io n . J o u r n a l o f T r a u m a 2 1 : 7 5 3 - 7 5 6 , 1 9 8 1 .

1 6 . M u i r l l K , B a r c la y T L , S e t t le J A D . L o c a l tr e a tm e n t o f t h e b u r n w o u n d . In: B u r n s a n d th e ir tr e a t m e n t,

3 rd e d it io n B u t te r w o r th s , L o n d o n p . 5 5 - 1 1 2 , 1 9 8 7 . 1 7 . M u rr a y P M , F in e g o ld S M . A n a e r o b e s in b u m -w o u n d in f e c t io n s . R e v ie -w s I n f e c t io n D i s e a s e s 6 ( s u p p l 1): S 1 8 4 - S 1 8 6 , 1 9 8 4 .

1 8 . P e s s o a G V A , S ilv a E A M . M e io s d e R u g a i e L is in a - m o t ilid a d e c o m b in a d o s e m u m s ó tu b o p a ra a id e n t if i c a ç ã o p r e s u n t iv a d e e n t e r o b a c t é r ia s .

R e v is t a d o In stitu to A d o lp h o L u tz 3 2 : 9 7 - 1 0 0 , 1 9 7 2 .

S i l v a S L N V , M a c e d o O G , D a m a s c e n o C A V , C a r v a l h o M A R , C i s a l p i n o E O . B a c t e r i o l o g i c a l e v a l u a t i o n o f w o u n d s

in s e r i o u s l y b u r n e d h o s p i t a l i z e d p a t i e n t s . R e v i s t a d a S o c i e d a d e B r a s i l e i r a d e M e d i c i n a T r o p i c a l 2 4 : 1 6 3 1 6 8 , j u l -s e t , 1 9 9 1

2 0 . P r u it t J R B A , M c M a n u s A T . O p p o r t u n is t ic

i n f e c t i o n s in s e v e r e l y b u r n e d p a t ie n t s . T h e

A m e r ic a n J o u r n a l M e d ic i n e 7 6 : 1 4 6 - 1 5 4 , 1 9 8 4 .

2 1 . R o b e r t s o n K E , C r o s s P J , T e r r y J C . T h e c r u c ia l

fir s t d a y s . A m e r ic a n J o u r n a l N u r s e r y 8 5 : 3 0 - 4 5 , 1 9 8 5 .

2 2 . R u s s o A C . Q u e im a d u r a s “ A c id e n t e s d e T r a b a lh o ”

( s u b s íd i o s à s u a p r e v e n ç ã o ) . J o r n a l B r a s ile ir o d e M e d ic i n a 4 4 : 2 7 - 3 5 , 1 9 8 3 .

2 3 . S ta n f o r d W , R a p p o le B W , F o x C L . C lin ic a i

e x p e r i e n c e w ith s i l v e r s u lf a d ia z in e , a n e w to p ic a l

a g e n t fo r c o n t r o l o f P s e u d o m o n a s in f e c t io n s in

b u r n s . J o u r n a l o f T r a u m a 9 : 3 7 7 - 3 8 8 , 1 9 6 9 .

2 4 . S u c e n a R C . F is i o p a t o l o g i a e t r a t a m e n t o d a s

q u e im a d u r a s . L iv r a r ia R o c a , S ã o P a u lo , 1 9 8 2 .

2 5 . W e i n s t e i n R A . M u l t i p l y r e s i s t a n t s t r a i n s :

e p i d e m i o l o g y a n d c o n t r o l . I n : B e n n e t t J V ,

B r a c h a m a n P S ( e d s ) H o s p it a l I n f e c t io n s , 2 n d

e d it io n . L it t le B r o w n , B o s t o n p . 1 5 1 - 1 6 9 , 1 9 8 6 .

2 6 . W illia m s H B , B r e id e n b a c h W C , C a lla g h a n W B ,

R ic h a r d s G K . P r e n tis J J . A r e b u r n w o u n d b io p s ie s

o b s o l e t e ? A c o m p a r a t i v e s t u d y o f b a c t e r i a l

q u a n tita tio n in b u rn p a t ie n t s u s i n g t h e a b s o r v e n t

d is c a n d b io p s y t e c h n i q u e s . A n n a ls o f P la s t ic

S u r g e r y 1 3: 3 8 8 - 3 9 5 , 1 9 8 4 .