INTRODUCTION
Burns are considered a public health problem due to their high prevalence1. They are responsible for around 180,000 deaths per year worldwide2 and are classified as the fourth most common type of trauma, second only to traffic
accidents, falls, and interpersonal violence 3. They mainly affect low-income and developing countries, where mortality is up to
11 times higher than in developed countries3. The United States has the highest burn victim mortality rate among industrialized
countries. In Brazil, according to the Sociedade Brasileira de Queimaduras (SBQ Brazilian Burns Society), burns are responsible for approximately 1,000,000
accidents, more than 100,000 hospitalizations, and 2,500 deaths per year4-7.
Among the causes of morbidity and mortality of burned patients, infections stand out
(the leading cause of mortality in Brazil and worldwide)8. Therefore, 75% of deaths in patients with 40% or more surface area body burns are
due to secondary infections9.
It is inferred, therefore, that knowledge of the microbiological profile responsible
for infections in this group of patients and the choice of the most effective antibiotics
in their treatment, would result in a decrease in morbidity and mortality rates and
a shorter hospital stay and a lower number of interventions, thus resulting in a reduction
in public spending.
OBJECTIVE
To analyze the microbiological and antimicrobial resistance profile of patients admitted
to the Burns Unit of the General Hospital “José Pangella” in Vila Penteado, during the period from 2011 to 2018.
METHODS
The study was submitted to the Ethics and Research Committee of the General Hospital
of Grajaú - Associação Congregação de Santa Catarina (Opinion Number: 3,635,831) and, after its approval (CAAE 23032719.9.0000.5447),
we were given access to the clinical records of patients admitted to the Burns Unit.
This one is a retrospective, cross-sectional study, through the analysis of all microbiological
exams of patients hospitalized for burns at the Burn Unit of the General Hospital
“José Pangella” in Vila Penteado, located in the city of São Paulo, from January 2011 to the end of December 2018.
All patients were submitted to the Free and Informed Consent Form (FICF) and agreed
with it.
Patients of both sexes, aged between 8 and 91 years, were evaluated. The burned body
surface varied according to each patient.
The patients were admitted to the burn unit in the period analyzed, according to the
following admission criteria: partial-thickness burns> 10% of the burned body surface
(BBS); burns in particular regions (face, hands, feet, genitals, perineum, neck, or
large joints); partial or full-thickness deep burns at any age; circumferential burns
at any age; electrical, chemical burns, suspected of inhalation injury, associated
with trauma or concomitant disease; In addition to critically ill patients who needed
intensive care10.
Four hundred twenty-six culture exams of a total of 250 patients admitted to the unit
in the specified period were analyzed. Such samples were collected during the entire
period of hospitalization of the patient, both at the time of admission and at times
with an infectious clinic.
Cultures of blood samples (247 samples), urine (31 samples), tracheal discharge (2
samples), vaginal discharge (1 sample), anal swab (12 samples), axillary swab (2 samples),
oral swab (1), nasal swab (2 samples), discharge from the lesion (77 samples) and
catheter tip (51 samples) were analyzed. All the samples were collected following
the collection rules of the Hospital Infection Control Center (CCIH) of the hospital,
so that there was no contamination, and they were sent and processed by the laboratory
of the Associação Fundo de Incentivo à Pesquisa (AFIP Incentive Association for Research), located in the city of Sao Paulo The collected
samples were seeded in specific culture media (blood agar, chocolate agar, and MacConkey
agar) and were identified after growth.
In addition to counting the microorganisms present, their sensitivity to the antibiotics
currently used in the corresponding groups was also verified, reading their respective
antibiograms. These antibiograms, as well as the cultures, were also analyzed and
released by the laboratory of the Associação Fundo de Incentivo à Pesquisa (AFIP), located in the city of São Paulo.
RESULTS
Four hundred twenty-six microbiological examinations of 250 different patients who
were admitted to the Burned Unit of the General Hospital “José Pangella” in Vila Penteado from January 2011 to the end of December 2018 were evaluated. From these tests, 495
microorganisms were isolated, 436 bacteria (88,080%) and 59 fungi (11,919%) (Table 1).
Table 1 - Distribution of microbiological tests.
| |
2011 |
2012 |
2013 |
2014 |
2015 |
2016 |
2017 |
2018 |
Total |
| Patients |
6 |
30 |
43 |
14 |
17 |
36 |
65 |
39 |
250 |
| Cultures |
7 |
61 |
88 |
17 |
30 |
51 |
105 |
67 |
426 |
| Microorganisms |
7 |
67 |
97 |
17 |
30 |
62 |
130 |
85 |
495 |
| Bacterias |
5 |
58 |
73 |
17 |
28 |
60 |
122 |
73 |
436 |
| Fungi |
2 |
9 |
24 |
0 |
2 |
2 |
8 |
12 |
59 |
Table 1 - Distribution of microbiological tests.
Of these 426 microbiology exams, they were evaluated 247 blood culture samples (57.891%),
31 urine cultures (7.276%), 51 catheter tip cultures (11.971%), 2 tracheal secretion
samples (0.449%), 1 of vaginal secretion (0.234%), 12 samples of anal swab (2.816%),
2 samples of axillary swab (0.469%), 1 oral swab (0.234%), 2 nasal swab (0.469%) and
77 samples of secretion from burned injuries (18.075%).
From these exams, we can highlight blood cultures, catheter tip samples (associated
with another positive blood culture) and urine cultures (total of 355 samples or 77.138%
of the total) as representative of systemic infection with laboratory microbiological
evidence, since they represented circulation of the microorganisms and were collected
at moments compatible with the patient’s infectious clinical condition. These samples
were called, by the author, clinically relevant to the study.
Among the samples analyzed, the highest prevalence was Staphylococcus sp. (130 cases or 26.262%), followed by Pseudomonas sp. (102 cases or 20.606%) and Klebsiella sp. (61 cases or 12.323%), with Candida sp. (58 cases or 11.717%) and Acinetobacter sp. (57 cases or 11.515%) (Figure 1).
Figure 1 - Prevalence of positive samples as a percentage in the period 2011 to 2018.
Figure 1 - Prevalence of positive samples as a percentage in the period 2011 to 2018.
There was also an increase in the positivity of the samples in recent years, with
Staphylococcus sp., Pseudomonas sp., Acinetobacter sp., and Klebsiella sp. (Figure 2).
Figure 2 - Positive samples of the main microorganisms from 2011 to 2018.
Figure 2 - Positive samples of the main microorganisms from 2011 to 2018.
The antibiotic sensitivity profiles of the five most common microorganisms in the
study (Staphylococcus sp., Pseudomonas sp., Klebsiella sp., Acinetobacter sp. and Enterobacter sp.) were also analyzed, disregarding Candida sp., since antifungigram is not routinely performed, as the mutation profile for resistance
to yeast antifungals is low (28). The strains of Staphylococcus sp. were sensitive to Vancomycin (128 out of 130 microbiological tests or 98.461%),
Linezolid (124 out of 130 or 95.384%) and Teicoplanin (120 out of 130 or 92.307%),
while being resistant to Penicillin (123 out of 130 or 94.615%), Erythromycin (88
out of 130 or 67.692%) and Clindamycin and Oxacillin (84 out of 130 or 64.615%). Pseudomonas sp. was sensitive to Polymyxin B (96 in 102 or 94,117%), Amikacin (40 in 102 or 39,215%)
and Imipenem (37 in 102 or 36,274%), while being resistant to Ceftazidime (81 in 102
or 79,411%), Ciprofloxacin (79 in 102 or 77,450%), Meropenem (76 in 102 or 74,509%)
and Piperazine-Tazobactam (73 in 102 or 71,568%). Klebsiella sp. was sensitive to Amikacin (44 in 61 or 72.131%), Imipenem (30 in 61 or 49.180%),
Gentamicin (29 in 61 or 47.540%) and Meropenem (27 in 61 or 44.262%), while being
resistant to Ampicillin (57 in 61 or 93.442%), Ciprofloxacin 46 in 61 or 75.409%),
Cefepime (45 in 61 or 73.770%) and Ceftriaxone (44 in 61 or 72.131%). Acinetobacter sp. was sensitive to Polymyxin B (56 in 57 or 98.245%), Amikacin (43 in 57 or 75.438%)
and Gentamicin (42 in 57 or 73.684%), while being resistant to Ceftriaxone (49 in
57 or 85.964%), Ceftazidime (41 out of 57 or 71.929%) and Cefepime, Imipenem and Meropenem
(39 out of 57 or 68.421%). Finally, Enterobacter sp. was sensitive to Amikacin and Imipenem (25 in 27 or 92.592%), Ertapenem and Meropenem
(24 in 27 or 88.888%) and Ciprofloxacin (20 in 27 or 74.074%), while being resistant
to Ampicillin (25 in 27 or 92.592%) %), Ceftazidime (24 out of 27 or 88.888%) and
Ceftriaxone (23 out of 27 or 85.185%) (Figures 3 and 4).
Figure 3 - Bacteria sensitive to antibiotics.
Figure 3 - Bacteria sensitive to antibiotics.
Figure 4 - Bacteria resistant to antibiotics.
Figure 4 - Bacteria resistant to antibiotics.
DISCUSSION
The infection of the burn patient remains a significant cause of morbidity and mortality
in this group of patients despite having decreased in incidence in recent years due
to improvements in diagnosis and treatment. It mostly affects the male population
with 63% of cases11 and, around 50% of patients with the burned body surface, 20% develop sepsis12, while 75% of deaths in patients with 40% or more of burned body surface are due
to secondary infections9. Other literatures point out infections as responsible for about 75% of all deaths
in this group13-15, preferentially affecting the extremes of age groups, such as children (mainly 0-10
years old) and the elderly13,16,17. Some studies mention that burns in the child population represent up to 50% of all
severe burns, in addition to the population up to 5 years old, representing 50-80%
of all childhood burns1.
According to Coutinho et al., 201518, the average body surface burned in 171 patients admitted to the ICU was 28%.
In Brazil, data from the Ministry of Health show that spending on burn victims can
reach up to one million reais per month19, with daily expenses of US $ 1,000 per day20 for non-fatal cases and more than R $ 1,620.00 for those who die21,22.
Despite being the fourth most common type of trauma, behind traffic accidents, falls,
and interpersonal violence3, burns have the third place in accidental deaths in the world21, hence its great importance in public health worldwide. Its leading cause of hospitalization
in adults is fire and flammable burns and scalds in pediatric patients1,10. According to the National Burn Information Exchange (1996), 60% of accidents happen
in the home environment. Luiz Philipe Molina Vana, plastic surgeon and president of
SBQ, says that this figure rises to 77%.
The risk of the burned patient contracting an infection varies according to the extent
and depth of the injury14,23. These lesions, to a greater or lesser degree, are responsible for breaking the protective
barrier of the skin, which facilitates the entry of microorganisms, in addition to
the immunological depression caused in these patients, the formation of necrosis as
a favorable environment for bacterial proliferation, of the various invasive procedures,
the extended hospital stay of these patients, the gastrointestinal bacterial translocation,
among others13. There is also vascular obstruction caused by thermal injury, which hinders the arrival
of both antimicrobials and components of the immune system to the burned area15.
Contaminated wounds usually present phlogistic characteristics, such as hyperemia,
heat, and discharge of secretion, in addition to, in cases of bacteremia, dysthermias
and leukocytosis. Necrosis is a crucial culture medium for the growth of opportunistic
microorganisms and needs to be removed as soon as possible. In the first 48 hours,
the wounds are already colonized by gram-positive bacteria, which can be reduced with
the use of topical antimicrobials. After about 5 to 7 days, however, they are colonized
by gram-negative bacteria, of hospital origin or origin of the gastrointestinal or
respiratory tracts24,25, which can have severe consequences for the patient, such as serious infections and
increased morbidity and mortality.
According to Nasser et al., 200326, in the first week of hospitalization, gram-negative bacteria were predominant (55.7%)
against gram-positive bacteria (40.3%), whereas, in the second week, this predominance
of gram-negatives becomes even more evident (72.7% x 22.7%). Among bacterial pathogens,
we must highlight the microorganisms that potentially cause serious infections, such
as the gram-positive methicillin-resistant Staphylococcus aureus (MRSA) and the gram-negative Pseudomonas aeruginosa, requiring broad-spectrum antibiotic coverage. Its use on a large scale, however,
favors the growth of fungal microorganisms, such as Candida, Aspergillus, and Mucor9.
Staphylococcus aureus, the most prevalent pathogen in wounds and blood cultures after the advent of Penicillin,
has a mortality rate of up to 30% and can reach 45% when it comes to MRSA. The group
A Beta Hemolytic Streptococcus, group A, the primary pathogen present in burn wounds
before the development of Penicillin, stands out as a gram-positive27,28.
Of the gram-negatives, P. aeruginosa (most prevalent), Acinetobacter baumanniie, and Enterococcus spp stand out9,15,29.
The importance of these pathogens lies, in addition to their higher virulence, in
the great capacity to develop resistance to the antibiotic treatments currently used.
The use of broad-spectrum drugs should be used carefully to try to avoid the spread
of these pathogens, which corroborates the importance of research related to microbiological
profiles. Studies show that, of the patients infected with Acinetobacter baumanniie, 46% develop bloodstream infection and, of these, 38% end up dying30, showing the high virulence of the microorganism. Severe patients in the ICU or on
mechanical ventilation for more than 24 hours are more likely to develop fungal infections,
such as C. tropicalis, C. parapsilosis, C. krusei, and C. glabrata31. Thus, the knowledge of the profile of the most common microorganisms in each Burn
Unit is essential to restrict the proliferation of these resistant pathogens.
The present study, as well as in the literature, demonstrates the prevalence of Staphylococcus sp. (26.262%), Pseudomonas sp. (20.606%) and Acinetobacter sp. (11.515%), in addition to highlighting the importance of others, such as Klebsiella sp. (12.323%) and Candida sp. (11.717%). It also shows a predominance of gram-negative (73.737%) over gram-positive
(26.262%)9.
CONCLUSION
The handling of burn victims remains a significant challenge for burn treatment centers.
Identifying the pathogens responsible for infections, as well as the appropriate choice
of antibiotic therapy, can lead to an optimization of treatment and, thus, reduce
the morbidity and mortality of these patients.
The rationalization of antimicrobial therapy is a mainstay of antibiotic administration
programs and is associated with fewer side effects and lesser appearance of resistant
microorganisms, in addition to significantly reducing hospital stay and costs.
Besides, it is observed that the number of positive cultures and infections remain
high in the population studied, corroborating the importance of studying microbiological
profiles.
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1. Hospital Geral “José Pangella” de Vila Penteado, Departamento de Cirurgia Plástica
e Queimaduras, São Paulo, SP, Brazil.
Corresponding author:
Adriano Fernandes Araújo, Rua Juquis, nº391 - Apto 154B - Indianópolis, SP, Brazil, Zip Code: 040811-10. E-mail:
adrianowb@hotmail.com
Article received: October 20, 2019.
Article accepted: February 22, 2020.
Conflicts of interest: none.
