Burns 30 (2004) 357361

Changes of microbial ora and wound colonization in burned patients

Serpil Erol a, , Ulku Altoparlak b , Mude N. Akcay c , Fehmi Celebi c , Mehmet Parlak a
a

Department of Clinical Bacteriology and Infectious Diseases, Ataturk University, Medical School, 25100, Erzurum, Turkey b Department of Microbiology and Clinical Microbiology, Ataturk University, Medical School, Erzurum, Turkey c Department of General Surgery, Burn Unit, Ataturk University, Medical School, Erzurum, Turkey Accepted 12 December 2003

Abstract To determine time related changes of microbial colonization of burn wounds and body ora of burned patients, a prospective study was carried out. Fifty-one patients who were hospitalized at least 3 weeks were enrolled in the study. Periodic swabs were taken from burn wound, nasal, axillary, inguinal, and umblical regions of the patients on admission and 7th, 14th, and 21st days of hospitalization. The mean body surface area burned was 22.9%. A total of 1098 microbial isolates were detected during the study period. Coagulase-negative staphylococci (CNS, 63.0%) and Staphylococcus aureus (19.7%) were the most prevalent isolates in admission cultures. There was a gradual decrease in the number of isolates of CNS and a marked increase in the numbers of S. aureus and Pseudomonas aeruginosa from admission to 21st day. At the 21st day, the most frequent organisms were S. aureus (37.6%), CNS (34.7%), and P. aeruginosa (16.2%). Methicillin resistance of staphylococci strains were increased constantly in study period. While 35.3% of burn wounds were sterile on admission, microbial colonization reached 86.3% within the rst week. Nasal carriage of methicillin resistant S. aureus increased from 3.9% to 62.7% at 21st day. The nature of microbial wound colonization and ora changes should be taken into consideration in empirical antimicrobial therapy of burned patients. 2004 Elsevier Ltd and ISBI. All rights reserved.
Keywords: Microbial ora; Wound; Burned patients

1. Introduction Patients with burn injuries represent a highly susceptible population for infection as a result of the disruption of the normal skin barrier and accompanying depression of immune responses. Furthermore, burn surface, which contains a large amount of necrotic tissue and protein-rich wound exudate, provides a rich growth medium. Infection remains the principal cause of death in this population [1,2]. Before invasion of viable subcutaneous tissue, the surface of a burn wound is generally colonized by microorganisms. The colonization occurs within the rst 48 h. Colonizing microorganisms are mainly derived from the patients body ora as well as from the hospital environment. The spectrum of colonizing or infecting agents may vary in each institution, in the same institution at different time points and related to duration of hospitalization [3]. Surveillance of wound colonization in a burn unit permits early administration of appropriate empiric antimicrobial therapy before the results of

cultures are available. However, most of the previous studies had been focused the colonization only on burn wounds [38]. We believe that, in addition to the burn wound, colonization of the other body regions by some pathogens may be important in the development of infections in burned patients. In this study, to determine the time related changes of microbial colonization of burn wounds and body ora of burned patients, we have carried out a prospective survey.

2. Patients and method A prospective study was carried out in the burn unit of a University hospital, Erzurum, Turkey. Patients who were hospitalized for at least 3 weeks or more over the study period of 7 months (May to November 2002) were consecutively enrolled in the study. Exclusion criteria were transfer from another healthcare facility, admission >12 h after burn trauma and length of stay in the burn unit less than 21 days. Periodic swabs were taken from burn wound, nasal, axillary, inguinal, and umblical regions of the patients on admission

Corresponding author. Tel.: +90-442-3166333/2026. E-mail address: mkerol@superonline.com (S. Erol).

0305-4179/$30.00 2004 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2003.12.013

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and 7th, 14th, and 21st days of hospitalization. During the study period, a total of 80 patients were admitted. A topical antimicrobial agent, silver sulphadiazine (Silverdin, Deva, Turkey) was applied to burn wounds of all patients. During the study period, the most commonly used antibiotics were meropenem/imipenem, amikacin, netilmicin, vancomycin, and cefaperazone-sulbactam, respectively. Vancomycin was used in the infections caused by methicillin resistant staphyloccocci, and meropenem/imipenem or cefaperazone-sulbactam was used in combination either amikacin or netilmicin for infections caused by Pseudomonas aeruginosa in guidance of antibiotic susceptibility tests. For other microorganisms, treatment was arranged due to their antibiotic susceptibility. In the initial empirical therapy of severe infections, meropenem/imipenem was used in combination with an aminoglycosides. Sampling procedure for burn wounds: swabs were taken from various areas of a wound before cleansing and applying of the topical antimicrobial agent on admission. Later samplings were performed before daily wound cleansing or debridment and after scraped away of the residue of topical agent. Sampling procedures for other body regions: swab samples were taken from anterior nares, axilla, inguinal region, and umblicus of each patients if the skin was intact on these sites. If the skin was burned, samples were considered as burn wounds. Except for the umblicus, single swabs were
Table 1 Microorganisms isolated from burn wounds and body ora (%) Microorganisms CNSa MSCNS MRCNS S. aureusb MSSA MRSA P. aeruginosa Enterobacter spp. Candida spp. Diphteroids Escherichia coli Pneumococcus Klebsiella spp Acinetobacter spp. -Haemolytic streptococci Bacillus spp. Non-haemolytic streptococci Citrobacter spp. Neisseria spp. Enterococcus spp. Proteus vulgaris -Haemolytic streptococci Total Admission 160 (63.0) 137 (53.9) 23 (9.1) 50 (19.7) 45 (17.7) 5 (2.0) 5 4 3 8 3 4 0 0 6 5 1 0 3 0 2 0 (2.0) (1.6) (1.2) (3.1) (1.2) (1.6) (0) (0) (2.3) (2.0) (0.4) (0) (1.2) (0) (0.8) (0) 7th day 124 (45.1) 65 (23.6) 59 (21.5) 74 (26.9) 36 (13.1) 38 (13.8) 38 10 7 4 5 4 5 0 0 0 2 0 0 1 0 1 (13.8) (3.6) (2.5) (1.4) (1.8) (1.5) (1.8) (0) (0) (0) (0.7) (0) (0) (0.4) (0) (0.4)

used to sample two different sites (the nares, axilla, and groin on both side). Swabs moistened in sterile saline immediately prior to sampling were used to obtain nasal and skin samples. Identication of isolates was performed according to conventional bacteriologic methods or using commercial identication kits. Methicillin susceptibility test was performed according to the criteria of National Committee for Clinical Laboratory Standards (NCCLS) by disk diffusion method [9].

3. Results Fifty-one patients were included in the study. The mean age was 15 years (range, 7 months60 years) and the mean body surface area burned was 22.9% (range, 575%). Mean hospital stay time was 36.5 days (range, 21100 days). A total of 1098 microbial isolates were detected during the study period (254 were on admission, 275 at 7th, 266 at 14th, and 303 at 21st days). Coagulase-negative staphylococci (CNS, 63.0%) and Staphylococcus aureus (19.7%) were the most prevalent isolates in admission cultures followed by diphteroids (3.1%). The time related changes of microbial ora showed a gradual decrease in the number of isolates of CNS while there was a marked increase in the numbers of S. aureus and P. aeruginosa from admission to

14th day 97 (36.5) 29 (10.9) 68 (25.6) 96 (36.1) 18 (6.8) 78 (29.3) 45 7 4 4 3 2 1 3 0 0 1 2 0 0 0 1 (16.9) (2.6) (1.5) (1.5) (1.1) (0.8) (0.4) (1.1) (0) (0) (0.4) (0.8) (0) (0) (0) (0.4)

21st day 105 (34.7) 25 (8.3) 80 (26.4) 114 (37.6) 14 (4.6) 100 (33.0) 49 8 7 4 4 1 3 4 0 0 1 2 0 1 0 0 (16.2) (2.6) (2.3) (1.3) (1.3) (0.3) (1.9) (1.3) (0) (0) (0.3) (0.7) (0) (0.3) (0) (0)

Total 486 (44.3) 256 (23.4) 230 (20.9) 334 (30.4) 113 (10.3) 221 (20.1) 137 29 21 20 15 11 9 7 6 5 5 4 3 2 2 2 (12.5) (2.6) (1.9) (1.8) (1.4) (1.0) (0.8) (0.6) (0.5) (0.5) (0.5) (0.4) (0.3) (0.2) (0.2) (0.2)

254 (100)

275 (100)

266 (100)

303 (100)

1098 (100)

MSCNS, Methicillin sensitive coagulase negative staphylococcus; MRCNS, methicillin resistant coagulase negative staphylococcus; MRSA, Methicillin resistant S. aureus. a CNS, coagulase negative staphylococcus. b MSSA, methicillin sensitive S. aureus.

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Fig. 1. The distribution to body regions of the microorganisms isolated at admission day. (MSCNS, methicillin sensitive coagulase negative staphylococcus; MRCNS, methicillin resistant coagulase negative staphylococcus; MSSA, methicillin sensitive S. aureus; MRSA, methicillin resistant S. aureus). At admission day, the most frequent organism was MSCNS on all body regions and staphylococci were the only isolated organism from the burn wounds (MSCNS: 67.5%; MRCNS: 7.5%; MSSA: 22.5%; and MRSA: 3.3%).

Fig. 2. The distribution to body regions of the microorganisms isolated at 7th day. At this day, the rate of methicillin sensitive staphylocci was increased on all body regions. On the burn wounds, colonization with microorganisms other than staphylocci was evident and the most frequent was P. aeruginosa (32.6%).

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21st day. On admission, 85.6% of CNS and 90% S. aureus isolates were sensitive to methicillin. At the 7th day, CNS decreased to 45.1%, S. aureus increased to 26.9%, and P. aeruginosa was the third most frequent isolate (13.8%). At

that time, 51.3% of S. aureus strains and 48.0% of CNS were resistant to methicillin. During the next 2 weeks, a gradual increase in the numbers of isolates of methicillin resistant staphylococci continued. At the 21st day, the most frequent

Fig. 3. The distribution to body regions of the microorganisms isolated at 14th day. The rates of P. aeruginosa and MRSA, the most frequent isolates, reached 40.7 and 16.7%, respectively on the burn wounds. The rate of MRSA was 40.7% on the nasal cultures and 47.8% on umblical cultures.

Fig. 4. The distribution to body regions of the microorganisms isolated at 21st day. The most frequent isolates were P. aeruginosa on the burn wounds (40.6%), MRSA on the nasal and umblical cultures (47.0 and 42.9%, respectively), MRCNS on the axillar and inguinal cultures (46.3 and 32.8%, respectively).

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organisms were S. aureus (37.6%), CNS (34.7%), and P. aeruginosa (16.2%) followed by Enterobacter spp. (2.6%) and Candida spp. (2.3%). Unfortunately, the rates of methicillin resistance of these two staphylococci strains were increased constantly (1087.7% in S. aureus strains, and 14.476.2% in CNS strains). Isolation of other organisms was uncommon by comparison (Table 1). In addition, the study revealed that while 35.3% of burn wounds were sterile on admission, microbial colonization reached 86.3% within the rst week and 100% within 2 weeks after admission. Nasal carriage of methicillin resistant S. aureus increased from 3.9 to 21.6% at 7th day, and to 62.7% at 21st day. The distributions of microorganisms as to isolation time and isolation region are presented in Figs. 14.

S. aureus colonization and accompanying methicillin resistance in this study is worrying. Candida species are the most common fungi isolated from burned patients [3,11]. In a previous report [3], the highest frequency was found at the 2140 days after injury. In our series, Candida species accounted for 1.9% of the isolates and time related increase of its isolation was not detected. Surface swabs taken from burn wounds and other body regions does not indicate a causative pathogen for an infection but can provide information regarding the microorganisms predominating in a burn unit. Thus, the nature of microbial wound colonization and ora changes should be taken into consideration in empirical antimicrobial therapy of burned patients. References
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4. Conclusion The study revealed a time related increase in the colonization of burn wounds. The only colonizing bacteria were staphylococci in admission cultures of burn wounds. At that time, nasal carriage of S. aureus was less compared to the following days. Interestingly, when the rate of S. aureus reached the highest level (50.0%) in nasal ora at the 21st day, its rate decreased (18.8%) in burn wounds (Figs. 14). Coagulase negative staphylococci continued to become the most frequently isolated microorganism at the 7th day, and S. aureus was the second. At this time, S. aureus was more prevalent in umblical cultures compared to other sites. However, we found a marked increase in the colonization of P. aeruginosa and Enterobacter strains in 7th day cultures of burn wounds. Acinetobacter strains were isolated for the rst time from the 14th day cultures of burn wounds and umblical region. At the 14th and 21st days, the most prevalent colonizing bacteria was P. aeruginosa on burn wounds while it was methicillin resistant S. aureus in nasal ora. Our study did not indicate a correlation for colonizing bacteria between burn wound and other body regions. As S. aureus is responsible for the majority of documented infections in burn units [5,10,11], the high frequency of