Indian J Med Res 126, December 2007, pp 541-544

Bacterial infections in burn patients at a burn hospital in Iran

Alireza Ekrami & Enayat Kalantar*
Department of Laboratory Medical Sciences, School of Paramedical Sciences, Ahvaz Jundi-Shapour University
of Medical Sciences, Ahvaz & *Department of Microbiology, School of Medicine, Kurdestan University of
Medical Sciences, Sanandaj, Iran
Received January 24, 2007

Background & objectives: The major challenge for a burn team is nosocomial infection in burn
patients, which is known to cause over 50% of burn deaths. Most studies on infection in burn patients
focus on burn wound infection, whereas other nosocomial infections in these patients are not well
described. We undertook this study to determine three types of nosocomial infections viz., burn
wound infection, urinary tract infection, and blood stream infection in burn patients in a burn
hospital in Iran.
Methods: During the one year period (May 2003 to April 2004), 182 patients were included in this
study. Blood, urine and wound biopsy samples were taken 7 and 14 days after admission to Taleghani
Burn hospital. Isolation and identification of microorganisms was done using the standard procedure.
Disk diffusion test were performed for all the isolates for antimicrobial susceptibility.
Results: Of the 182 patients, 140 (76.9%) acquired at least one type of infection of the 140, 116
patients (82.8%) were culture positive on day 7 while 24 (17.2%) on 14 days after admission. Primary
wound infection was most common (72.5%), followed by blood stream (18.6%) and urinary tract
infections (8.9 %).
The microorganisms causing infections were Pseudomonas aeruginosa (37.5%), Staphylococcus
aureus (20.2%), and Acinetobacter baumanni (10.4%). Among these isolates P. aeruginosa was found
to be 100 per cent resistant to amikacin, gentamicin , carbenicillin, ciprofloxacin, tobramycin and
ceftazidime; 58 per cent of S. aureus and 60 per cent of coagulase negative Staphylococcus were
methicillin resistant.
Interpretation & conclusions: High prevalence of nosocomial infections and the presence of multidrug
resistant bacteria, and methicillin resistant S. aureus in patients at Taleghani Burn Hospital suggest
continuous surveillance of burn infections and develop strategies for antimicrobial resistance control
and treatment of infectious complications.

Key words Antimicrobial resistance - burn wounds - nosocomial infection

be directly or indirectly caused by septic processes1.

Different patient groups such as burn patients and
trauma patients have unique predisposition to different
infections. In a Swedish study 2, the most common

In spite of considerable advances in the treatment

of burns, infection continues to pose the greatest danger
to burn patients. Approximately 73 per cent of all death
within the first five days post-burn have been shown to
541

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INDIAN J MED RES, DECEMBER 2007

infection was burn wound infection (60%) followed by

blood stream infection (20%), urinary tract infection
(20%), and pneumonia (10%). This distribution of
infections is strikingly different from the study by Wurtz
et al3 in which over 50 per cent of infections were
pneumonia followed by urinary tract infection, blood
stream infectioin and wound infection.
The common pathogens isolated from burn
patients include Pseudomonas aeruginosa,
Staphylococcus aureus, Klebsillea spp, and various
coliform bacilli. Fungi (Candida albicans, Aspergillus
fumigatus) can also cause infection4-8. Multidrugresistant bacteria have frequently been reported as the
cause of nosocomial outbreaks of infection in burn
units or as colonizers of the wounds of burn patients9,10.
Similarly, antimicrobial resistance in some of the most
frequent bacterial species isolated from burn patients
in Iran such as S. aureus or P. aeruginosa, and other
Gram negative bacilli has reached to a worrying
level 11,12. Based on National Nosocomial Infection
Surveillance System (NNIS) criteria, all the burn
patients are required to follow the distribution of
bacterial species among burn isolates, and the
antimicrobial susceptibility of the pathogens in order
to adapt empirical antibiotic strategies13. This study
was carried out to determine three types of nosocomial
infections viz., burn wound infection, urinary tract
infection, and blood stream infection caused by
bacterial pathogens isolated from burned patients at
Taleghani Burn Hospital in Khuzestan province,
Ahvaz, Iran as also the susceptibility of these isolates
to various antibiotics.
Material & Methods
A total of 182 patients were admitted to the
Taleghani Burn Hospital which is an academic
educational hospital affiliated to Ahvaz JundiShapour University of Medical Sciences during the
one year period (from May 2003 to April 2004). This
hospital is the only referral centre for Khuzestan
province, Iran.
None of the patients included in the study had any
sign and symptoms of urinary tract infection (UTI),
blood stream infection (BSI), and wound infection (WI)
based on NNIS system criteria13 within the first 48 h
after the admission.
Blood, urine and wound biopsy samples were taken
on day 7 and 14 after admission, and then cultured on

blood agar and MacConkey agar. Isolation and

identification of microorganisms was done according
to standard procedure14.
Disk diffusion test were performed for all the
isolates by the method recommended by Clinical and
Laboratory Standard Institute (CLST)15. A suspension
of each isolate was made so that the turbidity was
equal to 0.5 McFarland standard and then plated onto
Muller-Hinton agar (Difcos) plate. Antibiotic disk
(Oxoid) was applied to each plate (Table). After
incubation at 35oC for 24 h, zone size was measured.
Reference strains included were ATCC 25923
(S. aureus) and ATCC 35218 (Escherichia coli),
obtained from Jundishapour University of Medical
Sciences, Ahvaz, Iran. The analysis of the data was
performed with the SPSS 10 (SPSS inc, Chicago, IL).
This work was approved by the Ethical Committee
of the Ahvaz Jundishapour University of Medical
Sciences, Ahvaz, Iran.
Results
The mean age of patients was 19.3 17.05 yr (< 170 yr). There were 108 males (59.3 %) and 74 females
(40.6 %) with a male to female ratio 1.45:1.
Culture positivity on 7 and 14 days after admission
was seen in 116 (82.8%) and 24 (17.2%) patients,
respectively. Of the 182 patients, 140 (77.3 %) suffered
at least one type of nosocomial infection (UTI, BSI and
WI). The wound infection was the most frequent
(76.9%), followed by blood infection (18.6%) and
urinary tract infection (8.9%).
A total of 173 bacterial isolates were obtained. The
most predominant bacterial isolate was Pseudomonas
aeruginosa 65 (37.5%) followed by Staphylococcus
aureus 35 (20.2%), Acinetobacter baummanni 18
(10.4%), Escherichia coli 10 (5.7%), Proteus mirabilis
9 (5.2%), coagulase negative Staphylococus 9 (5.2%),
Enterobacter aerogenes 9 (5.2%), Klebsiella
pneumoniae 6 (3.4%), Enterococcus spp. 4 (2.3%),
Citrobacter freundii 3(1.7%), Serratia marcescens
2 (1.1%), Alcaligenes spp. 2(1.1), haemolytic group
A Streptococcus 1(0.5%).
It is worth to note that 58 per cent of S. aureus and
60 per cent of coagulase negative Staphylococcus were
methicillin resistant. However, these isolates were
susceptible to vancomycin and teicoplanin.
P. aeruginosa was resistant to gentamicin, cephalothin,

EKRAMI & KALANTAR: BACTERIAL INFECTIONS AMONG BURN PATIENTS

Table. Antibiotic susceptibility pattern (%) of isolates in burn
patients
Organism (s)

Antibiotic

Concentration/ S. aureus Enterobac- P. aeru- A. baudisk (/l)

teriaceae ginosa manni
Gentamicin
10
Cephalothin
30
Ciprofloxacin
05
Cephalexin
30
Clindamycin
02
Oxacillin
01
Vancomycin
30
Amikacin
30
Ampicillin
10
Carbenicillin
100
Cotrimoxazol 1.25/23.75
Ceftazidine
30
Tobramycin
10

73.3
73.3
73.3
74
75
58
0.0
ND
95
ND
89
75
ND

70
28.5
19
95
ND
ND
ND
42.3
100
42
38
55
65

100
100
100
98
ND
ND
ND
100
ND
100
ND
100
100

100
100
85
90
ND
ND
ND
100
ND
100
ND
100
70

To conclude, burn patients were most commonly

infected with P. aeruginosa and S. aureus and they were
resistant of most of the antibiotics tested. A nosocomial
infection surveillance system may be introduced to
reduce the rate of nosocomial infections among burn
patients, and for better therapeutic options.
Acknowledgment
Authors acknowledge Ahvaz Jundi-Shapour University of
Medical Sciences, Ahvaz, Iran, for financial support.

References
1.

Tancheva D, Hadjiiski O. Effect to early nutritional support

on clinical course and septic complications in patients with
severe burns. Ann Burns Fire Disasters 2005; 18 : 74-9.

2.

Appelgren P. Bjornhagen V, Bragderyd K. A prospective study

of infections in burn patients. Burns 2002; 28 : 39-46.

3.

Wurtz R, Karajovic M, Dacumos E, Jovanovic B, Hanumadass

M. Nosocomial infections in a burn intensive care unit. Burns
1995; 21 : 181-4.

4.

Revathi G, Puria J, Jaid K. Bacteriology of burns. Burns 1998;

24 : 347-9.

5.

Skoll PJ, Hudson DA, Simpson JA. Aeromonas hydrophila in

burn patients. Burns 1998; 24 : 350-3.

6.

Lawrence J. Burn bacteriology during the past 50 years. Burns

1994; 18 : 23-9.

7.

Nudegusio L, Algimantas T, Rytis R, Minmdaugas K. Analysis

of burn patients and the isolated pathogens. Lithuanian Surg
2004; 2 : 190-3.

8.

Shahid M, Malik A. Resistance due to aminoglycoside

modifying enzymes in Pseudomonas aeruginosa isolates from
burns patients. Indian J Med Res 2005; 122 ; 324-9.

9.

Karlowsky JA, Jones ME, Draghi DC, Thornsberry C, Sahm

DF, Volturo GA. Prevalence and antimicrobial susceptibilities
of bacteria isolated from blood cultures of hospitalized patients
in the United States in 2002. Ann Clin Microbiol Antimicrob
2004; 3 : 3-7.

ND: not done

ciprofloxacin, amikacin, carbenicilin, ceftazidime,

tobramycin (100%) and cephalexin (98) respectively
(Table).
Discussion
Despite significant improvement in the survival
of burn patients, infectious complications continue
to be the major cause of morbidity and mortality16.
Though control of invasive bacterial burn wound
infection, strict isolation techniques and infection
control policies have significantly minimized the
occurrence of burn wound infection 17 , our study
showed high prevalence of bacterial infections among
burn patients as compared to another study from
Iran18.
Our study indicated that the wound infection was
the most common cause of nosocomial infection.
Rastegar et al11 at Tohid Burn Center in Tehran, Iran,
reported the same. Askarian et al18 also reported the
wound infection as the most common cause of
nosocomial infection was followed by BSI and UTI.
Our study showed P. aeruginosa as a common cause
of nosocomial infection, similar to our earlier study16.
Other studies also showed that nosocomial infection
caused by P. aeruginosa was the major danger in burn
patients in Iran11,12.
In our study 58 per cent of S. aureus MRSA were
methicillin resistant. This pathogen has been reported
as a major cause of nosocomial infection in Europe19,20.

543

10. Agnihotri N, Gupta V, Joshi RM. Aerobic bacterial isolates

from burn wound infections and their antibiograms-a fiveyear study. Burns 2004; 30 : 241-3.
11. Rastegar A, Alaghehbandan R, Akhlaghi L. Burn wound
infection and antimicrobial resistance in Tehran, Iran: An
increasing problem. Ann Burn Fire Disasters 2005; 18 : 11158.
12. Rastegar A, Bahrami H, Alaghehbandan R. Pseudomonas
infection in Tohid burn centre, Iran. Burns 1998; 24 : 637-41.
13. Garner J, Jarvis W, Emori T. CDC definition for nosocomial
infections. Am J Infect Control 1988; 16 : 128-40.
14. Baron J, Finglod S. Methods for identification of ethiologic
agents of infections diseases. In : Baliy & Scotts diagnostic
microbiology . 10th ed. St. Louis, USA: Mosby, Inc; 1996. p.
327-529.

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INDIAN J MED RES, DECEMBER 2007

15. Clinical and Laboratory Standard Institute. Performance

standards for antimicrobial disk susceptibility tests. NCCLS
documents M 100 S15. Wayne, PA, USA: Clinical and
Laboratory Standard Institute; 2005.
16. David W, Albert T, Basil A. Infection of burn wounds. In:
Bennett J, Brachman P, Hospital Infections, 4 th ed.
Philadelphia: Lippincott - Raven; 1998. p. 587-601.
17. Amin M, Kalantar E. Bacteriological monitoring of hospital
borne septicemia in burn patients in Ahvaz , Iran. Burn
Surgical Wound Care 2004; 3 : 4-8.

18. Askarian M, Hossseini R. Incidence and outcome of

nosocomial infections in female burn patients in Shiraz , Iran.
Am J Infect Control 2004; 32 : 25 -8.
19. EARSS management team. Susceptibility of S. aureus. EARSS
Newslett 2002; 4 : 4-5.
20. Wildemauee C, Godard C, Vershragen G, Claeys G, Duyck C,
De Beenhouwer H. Ten years phage typing of Belgian Clinical
methicillin-resistant S. aureus isolates. J Hosp Infect 2004;
56 : 16-21.

Reprint requests: Dr Kalantar E, Department of Microbiology, School of Medicine, Kurdestan University of Medical Sciences
Kurdestan, Iran
e-mail: kalantar_enayat@yahoo.com; ekalantar@hotmail.com