8/4/2015

BurnWoundInfectionsClinicalPresentation

BurnWoundInfectionsClinicalPresentation
Author:DuaneRHospenthal,MD,PhD,FACP,FIDSA,FASTMHChiefEditor:BurkeACunha,MD
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Updated:Aug28,2014

History
TheAmericanBurnAssociation(ABA)recentlypublishedcriteriaforsepsisandwoundinfections. [14]Regular
monitoringofburnwoundsallowsfortheearlyrecognitionofinfection.Prolongedinpatientstayisoneofthe
strongestriskfactorsforthedevelopmentofcolonizationorinfection,aslongerhospitalizationsincreasethe
potentialexposuretoothercolonizedorinfectedpatientsandtoenvironmentalcontamination.Largeburninjuries
areanotherstrongriskfactor,asopenwoundsareknowntoharborbacteria. [15]
Localsignsofburnwoundinfectionincludeconversionofapartialthicknessinjurytofullthicknesswound,
worseningcellulitisofsurroundingnormaltissue,escharseparation,andtissuenecrosis.
AccordingtotheABA,thevarioustypesofburnwoundinfectionsincludewoundcolonization,woundinfection,
invasiveinfection,cellulitis,andnecrotizinginfection/fasciitis. [14]
Woundcolonizationischaracterizedbythepresenceoflowconcentrationsofbacteriaonthesurfacewithout
invasionorsystemicsignsorsymptomsofinfection.Tissuebiopsiesobtainedfromcolonizedbutnotinfectedskin
usuallyreveallessthan105bacteriapergramoftissue.
Woundinfectionisassociatedwithhigherconcentrationofbacteria(>105bacteriapergramoftissue)withinthe
woundorwoundescharbutnotadeeplyinvasiveinfection.
Aninvasiveinfectionincludesconcentrationsofbacteria(frequently>105bacteriapergramoftissue)atan
appropriatedepthoftheburnwoundtocausesuppurativeseparationoftheescharorgraftlosswithinvolvementof
unburnedtissueorthepresenceofasystemicresponseconsistentwithsepsis.
Cellulitismanifestsaserythema,induration,warmth,andtendernessinthetissuesurroundingtheburnwoundor
woundescharandoccasionallythepresenceofsepsis.Erythemaalonemaynotindicatecellulitis.
Necrotizinginfection/fasciitisinvolvesanaggressiveinvasiveinfectionwithinvolvementofstructuresbelowtheskin.
Burnwoundinfectionscommonlyoccurinthefirstweeksofhospitalization.Saureusisthemostcommonpathogen
infectingburnedpatients,asitisanearlycolonizer.Kpneumoniaewoundinfectionsoccuraroundthesametimeas
infectionsbySaureusandseemtobemoreprevalentintheinstitutionsthatusesystemicperioperativeprophylaxis.
Aswouldbeexpected,infectionsbythenosocomialorganismsPaeruginosaandAbaumanniiappearlaterinthe
courseofthehospitalization(after2wkofadmission). [9]
Sepsisisanindependentriskfactorofmortalityintheburnedpatient.Thisisadiagnosticchallengebecausethe
signsofsepsis(ie,elevatedtemperature,tachycardia,tachypnea,leukocytosis)maybepresentintheburned
patientwithoutunderlyinginfection. [16]Recognizingthisdifficulty,theABApublishedburnspecificsepsiscriteria
withatotalof6variablestoconsider.Meeting3ofthesecriteriashouldmaketheclinicianconsiderthepresenceof
aclinicallysignificantinfectionandinitiateempiricalantimicrobialtherapy.Apatientmeetsthedefinitionofsepsisif
thesecriteriaarecoupledwithadocumentedinfection(definedasapositiveculture,confirmatoryhistopathology,or
aclinicalresponsetoantimicrobials). [14]

Physical
Woundinfectionsignsareasfollows[14]:
Suppurativeseparationoftheeschar
Graftlosswithinvolvementofunburnedtissueorthepresenceofasystemicresponseconsistentwithsepsis
Changeinwoundcolor(focalareasofred,brown,orblack)
Greendiscolorationofthesubcutaneousfat
Cellulitissignsareasfollows[14]:
Erythema(Erythemaalonemaynotrequiretreatment.)
Induration
Warmth
Tenderness
Sepsis(occasionally)
Necrotizinginfection/fasciitissignsincludeaggressiveinvasiveinfectionwithinvolvementofstructuresbelowthe
skin(eg,muscle,bone,organs).
Signsofsepsisareasfollows[6]:
Temperaturegreaterthan39Corlessthan36.5C
Progressivetachycardia(>110beatsperminute)
ProgressivetachypneaMorethan25breathsperminutewithoutassistedventilationminuteventilation
greaterthan12L/minifintubatedandmechanicallyventilated
Thrombocytopenia(<100,000/Ldoesnotapplyimmediatelyafterinitialresuscitation)
Hyperglycemia(intheabsenceofpreexistingdiabetesmellitus)Plasmaglucoselevelsgreaterthan200

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BurnWoundInfectionsClinicalPresentation

mg/dLintheabsenceoftreatmentsignificantresistancetoinsulin(>25%increaseininsulinrequirement) [2]
Inabilitytocontinueenteralfeedingsformorethan24hoursAbdominaldistension,highgastricresiduals,
uncontrollablediarrhea

Causes
Riskfactorsforthedevelopmentofaburnwoundinfectionareasfollows[2]:
Extremesofage
Comorbiditiessuchasobesityanddiabetes
Immunosuppression(eg,duetoAIDS)
Invasivedevices(eg,catheters)
Burnsinvolvinggreaterthan30%totalbodysurfacearea(TBSA)
Fullthicknessburns
Failuretocoverburnsorfailedskingraftresultinginprolongedopenburnwounds
Improperearlyburncare
Organismsfrequentlycausinginvasiveburnwoundinfectionareasfollows[9]:
GrampositivebacteriaSaureus,includingMRSAcoagulasenegativeStaphylococcusspecies
Enterococcusspecies,includingvancomycinresistantspecies
GramnegativebacteriaPaeruginosa,Klebsiellaspecies,Acinetobacterspecies,Escherichiacoli,Serratia
marcescens,Enterobacterspecies,Proteusspecies
Fungi(Burnwoundscomplicatedbyfungalinfectionsconstituteanindependentpredictorformortalityin
patientswithaburnedTBSAof3060% [5])CandidaspeciesAspergillusspeciesFusariumspecies
Phaeohyphomycetes(fungiwithdarkcellwalls)Mucorales(eg,Rhizopus,Mucor,Absidia,and
Apophysomycesspecies)
Viruses(Cutaneousdiseasetypicallyoccursinhealingpartialthicknessburnsanddonorsites.)Herpes
simplexvirus,varicellazostervirus

ContributorInformationandDisclosures
Author
DuaneRHospenthal,MD,PhD,FACP,FIDSA,FASTMHAdjunctProfessorofMedicine,Departmentof
Medicine,UniversityofTexasHealthScienceCenteratSanAntonio
DuaneRHospenthal,MD,PhD,FACP,FIDSA,FASTMHisamemberofthefollowingmedicalsocieties:Alpha
OmegaAlpha,AmericanCollegeofPhysicians,AmericanMedicalAssociation,AmericanSocietyfor
Microbiology,AmericanSocietyofTropicalMedicineandHygiene,ArmedForcesInfectiousDiseasesSociety,
InfectiousDiseasesSocietyofAmerica,InternationalSocietyforHumanandAnimalMycology,International
SocietyforInfectiousDiseases,InternationalSocietyofTravelMedicine,andMedicalMycologySocietyofthe
Americas
Disclosure:Nothingtodisclose.
Coauthor(s)
JairoAFonseca,MDResearcher,InfectionsandHealthintheTropicsResearchGroup,NationalUniversityof
ColombiaSchoolofMedicine,Colombia
JairoAFonseca,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FredALopez,MDAssociateProfessorandViceChair,DepartmentofMedicine,AssistantDeanforStudent
Affairs,LouisianaStateUniversitySchoolofMedicine
FredALopez,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
PhysiciansAmericanSocietyofInternalMedicine,InfectiousDiseasesSocietyofAmerica,andLouisianaState
MedicalSociety
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
CharlesVSanders,MDEdgarHullProfessorandChairman,DepartmentofInternalMedicine,Professorof
Microbiology,ImmunologyandParasitology,LouisianaStateUniversitySchoolofMedicineatNewOrleans
MedicalDirector,MedicineHospitalCenter,CharityHospitalandMedicalCenterofLouisianaatNewOrleans
ConsultingStaff,OchsnerMedicalCenter
CharlesVSanders,MDisamemberofthefollowingmedicalsocieties:AllianceforthePrudentUseof
Antibiotics,AlphaOmegaAlpha,AmericanAssociationfortheAdvancementofScience,AmericanAssociation
ofUniversityProfessors,AmericanClinicalandClimatologicalAssociation,AmericanCollegeofPhysician
Executives,AmericanCollegeofPhysicians,AmericanFederationforMedicalResearch,AmericanFoundation
forAIDSResearch,AmericanGeriatricsSociety,AmericanLungAssociation,AmericanMedicalAssociation,
AmericanSocietyforMicrobiology,AmericanThoracicSociety,AmericanVenerealDiseaseAssociation,
AssociationforProfessionalsinInfectionControlandEpidemiology,AssociationofAmericanMedicalColleges,
AssociationofAmericanPhysicians,AssociationofProfessorsofMedicine,InfectiousDiseaseSocietyfor
ObstetricsandGynecology,InfectiousDiseasesSocietyofAmerica,LouisianaStateMedicalSociety,Orleans
ParishMedicalSociety,RoyalSocietyofMedicine,SigmaXi,SocietyofGeneralInternalMedicine,
SoutheasternClinicalClub,SouthernMedicalAssociation,SouthernSocietyforClinicalInvestigation,and
SouthwesternAssociationofClinicalMicrobiology

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BurnWoundInfectionsClinicalPresentation

Disclosure:Nothingtodisclose.
ChiefEditor
BurkeACunha,MDProfessorofMedicine,StateUniversityofNewYorkSchoolofMedicineatStonyBrook
Chief,InfectiousDiseaseDivision,WinthropUniversityHospital
BurkeACunha,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofChestPhysicians,
AmericanCollegeofPhysicians,andInfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
AdditionalContributors
ClintonMurray,MDProgramDirector,InfectiousDiseaseFellowship,SanAntonioUniformedServicesHealth
EducationConsortium
ClintonMurray,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysiciansAmerican
SocietyofInternalMedicine,AmericanMedicalAssociation,AmericanSocietyforMicrobiology,American
SocietyofTropicalMedicineandHygiene,AssociationofMilitarySurgeonsoftheUS,andInfectiousDiseases
SocietyofAmerica
Disclosure:Nothingtodisclose.

References
1. LatenserBA,MillerSF,BesseyPQ,BrowningSM,CarusoDM,GomezM,etal.NationalBurnRepository
2006:atenyearreview.JBurnCareRes.SepOct200728(5):63558.[Medline].
2. ChurchD,ElsayedS,ReidO,WinstonB,LindsayR.Burnwoundinfections.ClinMicrobiolRev.Apr
200619(2):40334.[Medline].
3. KeenEF3rd,RobinsonBJ,HospenthalDR,AldousWK,WolfSE,ChungKK,etal.Prevalenceof
multidrugresistantorganismsrecoveredatamilitaryburncenter.Burns.September201036:81925.
[Medline].
4. AlbrechtMC,GriffithME,MurrayCK,ChungKK,HorvathEE,WardJA.ImpactofAcinetobacterinfection
onthemortalityofburnpatients.JAmCollSurg.October2006203:54650.[Medline].
5. HorvathEE,MurrayCK,VaughanGM,ChungKK,HospenthalDR,WadeCE,etal.Fungalwound
infection(notcolonization)isindependentlyassociatedwithmortalityinburnpatients.AnnSurg.Jun
2007245(6):97885.[Medline].[FullText].
6. SarabahiS,TiwariVK,AroraS,CapoorMR,PandeyA.Changingpatternoffungalinfectioninburn
patients.Burns.Jun201238(4):5208.[Medline].
7. KastenKR,MakleyAT,KaganRJ.Updateonthecriticalcaremanagementofsevereburns.JIntensive
CareMed.JulAug201126(4):22336.[Medline].
8. MayhallCG.Theepidemiologyofburnwoundinfections:thenandnow.ClinInfectDis.Aug15
200337(4):54350.[Medline].
9. KeenEF3rd,RobinsonBJ,HospenthalDR,AldousWK,WolfSE,ChungKK,etal.Incidenceand
bacteriologyofburninfectionsatamilitaryburncenter.Burns.Jun201036(4):4618.[Medline].
10. KennedyP,BrammahS,WillsE.Burns,biofilmandanewappraisalofburnwoundsepsis.Burns.Feb
201036(1):4956.[Medline].
11. SchofieldCM,MurrayCK,HorvathEE,CancioLC,KimSH,WolfSE,etal.Correlationofculturewith
histopathologyinfungalburnwoundcolonizationandinfection.Burns.May200733(3):3416.[Medline].
12. RegulesJA,CarlsonMD,WolfSE,MurrayCK.Analysisofanaerobicbloodculturesinburnedpatients.
Burns.Aug200733(5):5614.[Medline].
13. MistryRM,PasisiL,ChongS,StewartJ,SheRB.Socioeconomicdeprivationandburns.Burns.May
201036(3):4038.[Medline].
14. GreenhalghDG,SaffleJR,HolmesJH4th,GamelliRL,PalmieriTL,HortonJW.AmericanBurn
Associationconsensusconferencetodefinesepsisandinfectioninburns.JBurnCareRes.NovDec
200728(6):77690.[Medline].
15. KaiserML,ThompsonDJ,MalinoskiD,LaneC,CinatME.Epidemiologyandriskfactorsforhospital
acquiredmethicillinresistantStaphylococcusaureusamongburnpatients.JBurnCareRes.MayJun
201132(3):42934.[Medline].
16. ShankarR,MelstromKAJr,GamelliRL.Inflammationandsepsis:past,present,andthefuture.JBurn
CareRes.JulAug200728(4):56671.[Medline].
17. MurrayCK,HoffmasterRM,SchmitDR,HospenthalDR,WardJA,CancioLC.Evaluationofwhiteblood
cellcount,neutrophilpercentage,andelevatedtemperatureaspredictorsofbloodstreaminfectioninburn
patients.ArchSurg.Jul2007142(7):63942.[Medline].
18. LavrentievaA,PapadopoulouS,KioumisJ,KaimakamisE,BitzaniM.PCTasadiagnosticandprognostic
toolinburnpatients.Whethertimecoursehasaroleinmonitoringsepsistreatment.Burns.May
201238(3):35663.[Medline].
19. MannEA,WoodGL,WadeCE.Useofprocalcitoninforthedetectionofsepsisinthecriticallyillburn
patient:asystematicreviewoftheliterature.Burns.Jun201137(4):54958.[Medline].
20. UppalSK,RamS,KwatraB,GargS,GuptaR.Comparativeevaluationofsurfaceswabandquantitative
fullthicknesswoundbiopsycultureinburnpatients.Burns.Jun200733(4):4603.[Medline].

http://emedicine.medscape.com/article/213595clinical

3/4

8/4/2015

BurnWoundInfectionsClinicalPresentation

21. AvniT,LevcovichA,AdElDD,LeiboviciL,PaulM.Prophylacticantibioticsforburnspatients:systematic
reviewandmetaanalysis.BMJ.Feb152010340:c241.[Medline].[FullText].
22. ChongSJ,AhmedS,TayJM,SongC,TanTT.5yearanalysisofbacteriologycultureinatropicalburns
ICU.Burns.Dec201137(8):134953.[Medline].
23. PidcokeHF,WadeCE,WolfSE.Insulinandtheburnedpatient.CritCareMed.Sep200735(9
Suppl):S52430.[Medline].
24. RodriguezNA,JeschkeMG,WilliamsFN,KamolzLP,HerndonDN.Nutritioninburns:Galveston
contributions.JPENJParenterEnteralNutr.Nov201135(6):70414.[Medline].
25. WolfSE.Nutritionandmetabolisminburns:stateofthescience,2007.JBurnCareRes.JulAug
200728(4):5726.[Medline].
26. EsselmanPC.Burnrehabilitation:anoverview.ArchPhysMedRehabil.Dec200788(12Suppl2):S36.
[Medline].
27. OngYS,SamuelM,SongC.Metaanalysisofearlyexcisionofburns.Burns.Mar200632(2):14550.
[Medline].
MedscapeReference2011WebMD,LLC

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