Burns 32 (2006) 477–481

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Nosocomial infections in a Brazilian Burn Unit

Jefferson Lessa Soares de Macedo a,*, João Barberino Santos b
a
Hospital Regional da Asa Norte, Secretaria de Saúde do Distrito Federal, SMHN, AE 1,
Bloco A, 70000-000, Brası́lia, DF, Brasil
b
Núcleo de Medicina Tropical, Unıversidade de Brası́lia, Brası́lia, DF, Brasil

Abstract

In 1-year prospective study, bacterial and fungal infections presenting in burned patients were registered. Two-hundred and seventy-eight
patients were included. The median total body surface area burned was 14% (range 1–100%). The median length of hospital stay was 12 days
(range 1–86 days). Eighty-six patients had in all 148 infections. Seventy-two bloodstream infections (BSI) occurred in 57 patients; most
common microorganisms were coagulase-negative staphylococci and methicillin-sensitive Staphylococcus aureus. Forty-nine (17.6%)
patients had burn wound infections and 18 (6.5%) had pneumonia. Antibiotics were given to only 30% of the burn patients. Overall mortality
rate was 5.0% (14/278). The database can be used to evaluate the effects of changes in burn treatment, staffing and design of burn units, and
antimicrobial resistance development in relation to antibiotic usage.
# 2005 Elsevier Ltd and ISBI. All rights reserved.

Keywords: Nosocomial infections; Bloodstream infection; Burns

1. Introduction was a predominance of pneumonia [4,7] or wound infection

Infection is the most common cause of death following
burn. Burn victims are obviously at high risk for nosocomial
infection due to the nature of the burn injury itself. The burn
wound consisting of moist necrotic tissue represents an ideal
culture medium for a wide variety of microorganisms.
Furthermore, immunocompromising effects of burns,
prolonged hospital stays, and intensive diagnostic and
therapeutic procedures contribute significantly to nosoco-
mial infections in these patients. Bacterial infections in burn
patients are widely known. The time-related changes in the
predominant flora of the burn wound from gram-positive to
gram-negative recapitulate the history of burn wound
infection [1,2].
Infection rates in burn patients have been rarely reported
[3–7]. A study conducted in Brazil which included a
considerable number of infections occurring over 7 years
showed that bloodstream infection was the most common
infection in contrast to other countries in which there
* Corresponding author. Tel.: +55 61 3245 6974; fax: +55 61 327 8415.
E-mail address: jlsmacedo@yahoo.com.br (J.L.S. de Macedo).
[3,6].
The gains of established infection control measures are
now being felt in the developed countries with a purpose-
built burns unit. However, in developing countries, establish-
ing such measures is hindered by poverty, ignorance, poor
management and lack of personnel [8].
In this prospective study, we describe the results from one
year of registration of infection in a consecutive series of
burn patients.
2. Materials and methods
Burn patients consecutively admitted to the Burn Unit of
Hospital Regional da Asa Norte during 2004 were included
in this prospective study. The patients were followed to
discharge or death.
The total body surface area burned (TBSAB) was
calculated by Lund & Bowder chart, adding percentages of
dermal and subdermal burns [9].
Since 1980, patients having partial skin thickness burns
covering less than 25% of the body surface area, were not

0305-4179/$30.00 # 2005 Elsevier Ltd and ISBI. All rights reserved.

doi:10.1016/j.burns.2005.11.012
478 J.L.S. de Macedo, J.B. Santos / Burns 32 (2006) 477–481
generally admitted to the Burns Unit if they were adults, or
less than 10% if they were children. Patients with full skin
thickness burns of small extent (5% of the body surface
area), were also treated as outpatients until the wound was
ready for excision and grafting by members of plastic
surgery team. Commonly admission to the Burns Unit only
occurred with severely burned patients (>25–30% of the
body surface area).
At direct patient contact a protective gown and disposable
gloves were used. Hands were washed with conventional
soap when necessary, and disinfected with 70% ethanol/
glycerol before and after patient contact.
Fluid replacement was given according to a modified
Parkland formula [8]. Plasma was given from the second
day. Central venous catheters were placed in the subclavian
or femoral vein at the discretion of the anesthetist. The
catheters were removed on clinical grounds: no further
indication, mechanical failure or suspected catheter infec-
tion. Catheters were not changed routinely.
Early excision and skin grafting was performed within
the first 5 days in full thickness burns when the patients
condition permitted.
All catheter tips were cultured when removed. On
suspicion of blood stream infection, two to three sets of
blood cultures were drawn by syringe from a peripheral vein
and one culture from any suspected focus of infection.
Microbial cultures were processed according to current
methods. The bacteriological isolation was carried out in the
microbiology laboratory of the Hospital Regional da Asa
Norte, Brası́lia. The swabs were dipped in Stuart́s transport
medium then plated on blood agar, chocolate agar,
MacConkey, and Sabouraud́s dextrose agar media (Difco).
After incubation for 18–48 h at 37 8C, the isolates were
identified using conventional protocol. Afterwards, the
sensitivity to the antibiotics was accomplished by automated
method bioMèrieux Vitek. The confirmation of precision
and accuracy of the procedures to evaluate the antimicrobial
susceptibility was made using ATCC (American Type
Culture Collection) standard strains. When isolated Staphy-
lococcus aureus oxacillin resistant, Acinetobacter sp and
Pseudomonas aeruginosa multiresistant were confirmed by
disc, by agar diffusion method according to the rules
established by NCCLS [10].
Fungal cultures were obtained on Sabouraud dextrose
agar (Difco) and on ‘‘mycogel’’ agar (Oxoid) at 378 and
observed daily for 20 days. The characterization of fungi
was done by the germ tube test, morphological examination
and automated method Vitek YBC yeast identification
system (bioMèrieux Vitek, Inc., MI, USA) [11]. However,
antibiotic sensitivity of fungi can not be done due to
technical problems.
Infections in all patients, admitted and treated for burns,
have been registered prospectively, according to previously
defined criteria [3,12]. Prophylactic antimicrobial therapy
was not given. All infections were registered, starting at the
day of admittance. Any infections manifested during the
management of a burn victim are followed carefully. Only
burn wound infections already present on admission were
excluded. Infections were grouped in three major classes:
bloodstream infection (BSI), pneumonia and burn wound
infection. The diagnosis of infection in burn patients is based
on clinical and laboratory parameters. The criteria for
infections were mainly based on those given by the Center
for Disease Control, Atlanta, USA [3,13].
Infection were suspected when a patient showed signs of
disorientation, hyperpyrexia or hypothermia, circulatory
embarrassment, petechial hemorrhages, black and dark
discoloration in a previously clean appearing burn wound,
early and rapid eschar separation, bleeding into the
subcutaneous tissues, and increasing edema in surrounding
areas or leukocytosis in white blood cells counts.
If there was any doubt about the diagnosis, a final
decision was reached by consensus between the infectious
disease consultant (author) and the burn surgeon directly in
charge of the patient. Whenever we found positive blood
cultures a BSI was registered even if the patient at the same
time had pneumonia and/or wound infection, which were
also registered.
The evaluation of lymphocyte population of patients was
performed by the flow cytometer at seven days post burn.
The FITC—stained (flouroescein isothiocyanate) lympho-
cytes emit yellow-green light (at 515 nm, CD4 surface
antigen) while the PE—stained (phyoerytrin) lymphocytes
emit red-orange light (at 580 nm, CD8 surface antigen). All
data were processed with SimulTest IMK Plus software
program.
Statistical methods used were Fisher’s exact test, Chi-
square analysis with Yateścorrection and logistic regression
analysis. This study was approved by the Ethical Committee
of the Secretary of State for Health of Brası́lia, Federal
District.
3. Results
Two-hundred and seventy-eight patients with burns,
consecutively admitted to the Burn Unit of Hospital
Regional da Asa Norte during 2004, 86 female and 160
male patients were included in the study. Median age for the
278 patients was 24 years (range 1–82). Median TBSAB
was 14% (range 1–100%). One-hundred and fifty-two
(54.7%) of the patients had flame injuries, 96 (34.5%) were
scald injuries, 25 (9%) electrical injuries and 5 (1.8%)
chemical injuries. Seven (3.9%) patients had smoke
inhalation injury.
Two-hundred and forty-five patients stayed >72 h in the
unit. The median length of stay was 12 days (range 1–86
days).
Two-hundred and thirty-four patients were admitted on
the day of injury and eight had been treated in another
hospital before admission. Twenty-eight patients were
infected on admission. Of these, all had wound infections.
 J.L.S. de Macedo, J.B. Santos / Burns 32 (2006) 477–481 479

Table 1
Comparison between infected and uninfected patients
Infected Uninfected P
Patient (no.) 86 192
Age (years, median, standard deviation) 28.3  23.6 21.5  19.1 0.021
Flame injuries (% patients) 69.8 50.5 0.002
TBSAB % (median, standard deviation) total 23.1  20.6 9.0  6.5 <0.001
Self-damage (no patients) 11 4 0.001
Length of stay (days, median, standard deviation) 19.3  11.9 8.7  5.9 <0.001
Three or more catheters (no patients) 16 0 <0.001
Necessity of transfusion (no patients) 50 30 <0.001
Multiresistant bacteria in the wound (no patients) 51 34 <0.001
Fungi in the wound (no patients) 31 11 <0.001
Hemoglobin 9 g/dl (no patients) 50 29 <0.001
Serum albumin 2.0 g/dl (no patients) 16 2 <0.001
Platelets  100.000 (no patients) 9 0 <0.001
Number of CD4+ cells (median, standard deviation) 361  261 553  230 <0.001
No operation (median, standard deviation) 3.2  1.7 2.1  1.1 <0.001
Mortality (no patients) 13 1 <0.001

Fourteen (5.0%) patients died during their stay in the Table 2

Number of micro-organisms that caused bloodstream, wound infection and
burns unit. Median age for those patients was 37.9  27.1
pneumonia
years. TBSAB was median 47.5  28.6%. Ten patients had
Micro-organisms Bloodstream Wound Pneumonia
signs of severe infections at the time of death. The main
contributing factors to death in patients without infection Coagulase-negative staphylococci 19 10 2
Staphylococcus aureus 14 12 5
were pulmonary and cardiac failure.
Pseudomonas aeruginosa 5 8 4
Eighty-six patients had in total 148 infections, whereas Klebsiella pneumoniae 5 6 3
192 patients were not infected. Comparison between Acinetobacter baumannii 4 2 1
infected and not infected patients are given in Table 1. Enterobacter cloacae 3 5 2
One-hundred and forty-eight infections in 278 burn Serratia marcescens 1 1 1
Escherichia coli 1 1 0
patients is equivalent to an infection ratio of 53.2 infections
Aeromonas hydrophila 1 1 0
per 100 patients. Patients with infection were significantly Enterococcus faecalis 1 1 0
older and had larger burns. Infected patients were submitted Streptococcus pyogenes 1 0 0
to more procedures such as skin grafting. Patients with Cedecea sp. 0 0 1
infections stayed longer in the unit. Furthermore, infected Candida sp. 5 1 0
patients needed more frequently catheters and transfusion.
The most common laboratory findings of the infected
patients were anemia, hypoalbuminemia, thrombocytope- median length of stay was 25 days. The most common
nia and lower median number of CD4+ cells (lymphocytes) microorganisms causing pneumonia were Pseudomonas
on first week of stay. The isolation of multiresistant aeruginosa and methicillin resistant Staphylococcus aureus.
bacteria or fungi in the wound were more likely in infected Seven of 14 patients died with pneumonia.
patients. Forty-nine patients had burn wound infections. Their
Fifty-seven of 84 blood-cultured patients (67.9%) had 72 median age was 30.3  23.8 years. TBSAB was median
episodes of BSI. Their median age was 25.2  23.1 years. 17.6  15.6%. Their median length of stay was 21.6  13.1
Their median TBSAB was 29.1  22.1%. Their median days. Three hundred and sixty four sampling procedures
length of stay was 20.9  3.9 days. (surface swabs) were performed from the burn wounds.
The microorganisms causing BSI are listed in Table 2. The microorganisms causing burn wound infection are
Coagulase-negative staphylococci (CoNS) were the most listed in Table 2. The most frequent organism causing
common microorganisms causing BSI, and next in wound infection was oxacillin sensitive Staphylococcus
frequency were oxacillin sensitive Staphylococcus aureus, aureus, and next in frequency were Coagulase-negative
Klebsiella pneumoniae and Pseudomonas aeruginosa. The staphylococci.
mortality rate for patients with verified and strongly Eighty-four of the 278 patients (30%) received antibiotics
suspected BSI (21%, 12/57) was 20 times greater than for during their stay in the Burn Unit, with a median duration
the non septic patients (0.9%, 2/221) (P < 0.0001). of 14 days. Cefepime  amikacin and vancomycin 
Eighteen patients developed pneumonia. Median age was amikacin were the most common antibacterial combinations
29 years (range 3–65). Median TBSAB was 27%. The in empirical therapy.
480 J.L.S. de Macedo, J.B. Santos / Burns 32 (2006) 477–481
4. Discussion
Despite advances in the use of topical and parenteral
antimicrobial therapy, and the practice of early tangential
excision, bacterial infection remains a major problem in
the management of burn victims today. Few patients are
as susceptible to the development of infections as burn
patients. Severe dysfunction of the immune system, a large
cutaneous colonization, the possibility of gastrointestinal
translocation, a prolonged hospitalization and invasive
diagnostic and therapeutic procedures, all contribute to
infections.
Although any organism is a potential pathogen in burned
patients, coagulase-negative staphylococci and S. aureus
were the most common pathogens causing infection in our
burn unit and was also most common in other reports [2–5].
This is in contrast to some other studies, which report
P. aeruginosa as the most predominant organism in burn
infection [6,14,15].
Most of the patients with BSI blood isolates were similar
to those that colonized/infected the burn wound surface.
Thus the main source of BSI in these patients appeared to be
the burn wound itself [2].
Antimicrobial therapy can cause severe problems with
resistance mainly against cephalosporins and other beta-
lactams. This calls for an urgent institution of an antibiotic
policy at local and national levels, amongst other measures
to check antibiotic misuse. A strict antibiotic policy is of
importance in the control of antibiotic resistance. It is
possible to reserve antibiotics for proven infection and to
limit the use of broad-spectrum drugs. Therefore, only 30%
of the patients admitted to the Burn Unit of Hospital
Regional da Asa Norte received antibiotics.
The pattern of bacterial sensitivities is subject to frequent
modifications. As such frequent assessment and institution
of other simple infection control measures like handwashing
before and after attending to a patient and restriction of
movements of personnel within a burns ward should be
carried out.
The mortality rate in our study of burn patients is
consistent with those reported from other studies [2,3,6].
Infected patients were older, had larger burns, longer stay
in hospital, more operations and a larger number of catheters
compared to uninfected patients. In agreement, Appelgren
et al. [3] showed equivalent comparisons.
Furthermore, anemia, hypoalbuminemia, thrombocyto-
penia and lower median number of CD4+ cells (lympho-
cytes) on first week of stay were more likely in infected
patients. Also, a strong correlation was determined between
infectious complications and flame injuries, self-damage
and necessity of transfusions.
Infection after burns could be accompanied by anemia,
thrombocytopenia and lower number of CD4+ T lympho-
cytes but the mechanisms responsible have not been clearly
identified. The possible factors for those laboratory
parameters in infected patients could de direct bone marrow
suppression, increased cells destruction, presence of
endotoxins, production of autoantibodies, drugs used in
the management of the burn patient (penicillin, vancomycin,
diazepam morphine, tetanus toxoid), hypersplenism, hae-
mophagocytosis and accelerated consumption [2].
The study showed a rate of infection of 53.2 per 100
patients, whereas other studies showed 38.1 [6], 64 [16], 77
[4] and 90 [7] infections per 100 discharges and deaths. In
most of the studies, a higher nosocomial infection rate than
observed in this study were found among burned patients. In
bigger hospitals, a higher proportion of patients with severe
underlying diseases are treated, and more invasive methods
are applied.
The majority of infections were bloodstream infections,
followed by wound infections, which is consistent with other
study in Brazil [5]. Otherwise, in Sweden, in a 3-year
prospective study, Appelgren et al. [3] registered wound
infection as the most common infection, followed by
bloodstream infection. As well as, in Turkey, Oncul et al. [6],
in 1-year prospective study, observed that the majority of
infections were wound infections.
Infection rates in burns have been reported to be high,
compared to other intensive care units, which have ranged
from 15 to 50% of the admissions [3,6]. The burn patient
is infection-prone and very contagious when infected.
Furthermore, one or more surgical procedures, might also
allow burn patient to be colonized with multiresistant
organisms. The isolation of multiresistant bacteria or
fungi in the wound were more likely in infected patients
(P < 0.001).
The isolation care in general is important in the
prevention of nosocomial transmission of infection.
Cross-transmission of multiresistant microorganisms is
common in intensive care units. This cross-transmission
is an indicator of patient crowing and/or poor compliance
with infection control guidelines by patient care personnel.
Simple barrier precautions using gloves and gown at patient
contact is more effective than elaborate isolation care.
At present the main infection control measures in the
burn unit are early excision and grafting, improved barrier
nursing and regular microbiological analysis of the
hospital’s environment and staff.
Microbiological surveillance of burn patients when is
routinely done helps in learning about the types of organisms
and facilitates the choice of antibiotic. Each individual unit
varies in its baseline population of microorganisms over
time, and generalizations from one unit may have little
applicability to others.
Measures to prevent and treat infections are essential for
the survival of patients with extensive burns and infection is
correlated to mortality. Besides, in patients with less
extensive burns, infections may increase morbidity and
hospital stay. Infection is one indicator of outcome in the
field of quality assurance in burn management.
Careful surveillance of infection, good isolation techni-
ques and procedure routines, and a restrictive antimicrobial
 J.L.S. de Macedo, J.B. Santos / Burns 32 (2006) 477–481
policy can keep antimicrobial resistance rates and infection
rates low in infection-prone burn patients.
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