TY - JOUR
AU - Franco-Cendejas,, Rafael
AB - Abstract Electrical burn injuries are one of the most severe forms of trauma. This study aims to investigate the infection complications in electrical burn patients in a referral hospital in Mexico City. A longitudinal retrospective study was conducted, involving electrical burn patients admitted from April 2011 to December 2016. Demographic and clinical data including type of electric burns, infection complications, and mortality was sought. Data were collected at admission and daily until discharge. Number and type of infections and microorganism isolations were sought. Risk factors for death were analyzed. A total of 111 patients were included, of which 96.4% were males, mean age of 31.6±16.22, most injuries were high voltage associated. The total body surface area average was 27.8% ± 19.63. The overall infection rate was 72.9 cases per 100 patients. Mortality was observed in 4 (3.6%) patients. About 59.1% (443/749) had growth for Gram-negative bacteria. Multidrug-resistant Pseudomonas aeruginosa was the most frequent microorganism isolated. Fungi were present in 4.9% of cases. Electrical burn injuries occurred in young males in our study. Infection was frequent, most of them caused by Gram-negative rods with an important rate of antimicrobial resistance; however, an important microbial diversity was present. Burns are one of the most common and devastating forms of trauma.1 In 2014, the World Health Organization ranked burns injuries at the 7th place of all traumatic injuries worldwide, with a mortality crude rate of 5%, compared with a quarter of total deaths due to traffic accidents.2,3 Electrical burn injuries are relatively infrequent; however, they are potentially devastating and are associated with high rates of morbidity and mortality.4 They are the fourth leading cause of traumatic work-related deaths, and lightning injuries are the second one of weather-related deaths.5,6 Electrical burns occur due to contact with low-voltage current, high-voltage current, and less frequent to lightning and voltaic arc. Low voltage is defined as an electrical shock less than 600 V, high-voltage more than 1000 V, and the electrical power of a lightning is greater than 30 × 106 V.6,7 The amount of voltage, amperage, current type, resistance in path, path traveled by the current through the body, duration of contact, and individual tissue susceptibility are related with tissue’s damage severity.4 Mortality rates vary according to different country reports: 2.5% in Iran,8 1.6% in China,9 2% in the United States,10 3.2% in France,11 8.1% in Brazil,12 and 23.1% in Ghana5,13; however, there is no published information about electrical burn injuries in Mexico. Burn wound infections are one of the most important and potentially serious complications that may occur in the acute period following the injury,1 and they are associated with high cost and length of hospital stay (LOS), as well as the need for multiple surgical procedures and specific management.8,14,15 In a prospective study, Sokhal et al4 reported bloodstream infections complications in 24.4%, wound infection in 19.2%, and a mortality rate of 8.9% in this type of burn injury. Epidemiological data about microorganisms’ isolation from patients with burn injury different to electrical is diverse and hospital dependent. There are microorganisms associated with hospital environment causing the leading infection complications such as Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus aureus, Enterobacter spp., Klebsiella spp., and Candida albicans,1,16 which have also been related to antimicrobial resistance. Antibiotic resistance is a natural phenomenon associated with selective pressure due to antibiotics usage. Once patients have been treated with antibiotics, resistant bacteria are selected, increasing the risk of infection, besides the colonization chance during the hospital stay. There have been some studies regarding multidrug-resistant bacteria in burned patients and their associated complications.17–21 There is scarce information about the type of microorganisms, antibiotic susceptibility profile, and their clinical manifestation complicating this specific trauma. The aim of this study was to describe infectious complications, their associated microbiology, and clinical outcome. MATERIALS AND METHODS Patient Selection This was a retrospective study performed from April 2011 to December 2016, carried out at Centro Nacional de Investigación y Atención de Quemados of the Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra in Mexico City, Mexico. We sought all clinical records with electrical burn injury diagnosis. Data Collection and Definitions Demographic relevant variables such as gender, comorbidities, burned body surface, LOS, number of surgical treatments, amputations, and hospital discharge were obtained. The 28-bed burn unit is divided into a 12 intensive care unit (ICU) and 16 intermediate care section, this unit is a national referral center. It is run by intensive care specialists and surgeons since its opening. Hospitalization is considered for patients with >20% of total body surface area, and special burned areas, inhalation injury, or those burns depending on medical criteria. Patients received fluid resuscitation according to guidelines recommendations.22 Escharotomy is executed as early as possible; autograft is performed as a final procedure, and some patients receive heterologous skin transplant as an interim measure. Patients were followed along with their hospitalization by the epidemiology unit and infectious diseases team. Microbiological samples were taken as part of clinical treatment, in those patients with symptoms and signs of infection. All the infection processes were diagnosed according to the CDC/NHSN (Atlanta, GA)23 recommendations. Microbiology samples were processed for aerobes, anaerobes, and fungi depending on the sample type. Wounds swabs were inoculated onto 5% blood sheep agar and MacConkey agar, then were incubated aerobically to 37°C. Biopsies were processed with a tissue homogenizer (T10 Basic S1 Ultra Turrax, IKA). Abscesses and biopsies were inoculated onto 5% blood sheep agar and MacConkey agar plates and incubated aerobically at 37°C. Anaerobes recovery was performed in phenyl ethyl alcohol agar plates with 5% blood sheep plates and incubated at 37°C anaerobically. Dextrose Sabouraud with ceftazidime and amikacin agar slant tubes were used to recover fungi and were incubated at room temperature. Bacteria and yeast identification were performed with a semi-automated system Vitek® 2 Compact (Biomerieux, France). Susceptibility test was performed with the same system according to Clinical and Laboratory Standards Institute cut-offs.24 Multidrug resistance (MDR) was defined as having three or more resistant drugs from a different family. Finally, we compared differences between infected and noninfected patients, in order to identify risk factors related to this complication. Statistical Analysis Frequencies and percentages were estimated for qualitative variables, and average and the standard deviation for quantitative variables. The chi-squared test was used for the analysis of proportional data. The Fisher’s test was preferred whenever conditions for a χ 2 test were not optimal. Differences among groups of patients with infection and without infection were evaluated using the Mann–Whitney U-test (P < 0.05). The data were analyzed with IBM SPSS Statistics 23. The study was performed with the approval of the relevant ethics committee. RESULTS Demographic and Clinical Characteristics A total of 997 patients with burn injuries were treated during the study period; among them, 176 (17.6%) were diagnosed with an electrical burn. We excluded 16 (9%) who were hospitalized for burn electrical sequels and 49 (27.8%) who did not have any microbiology sample. Finally, 111 (11.1%) patients with electric burns were evaluated for this study. The majority of patients were males 107 (96.4%); the average age was 31.6 years (min 5, max 81); 4 (3.6%) were between 5 and 9 years; 9 (8.1%) between 10 and 14 years; 16 (14.4%) between 15 and 19 years old; 76 (68.4%) were >20 to 59 years, and 6 (5.3%) were between 60 and 80 years. The average TBAS was 27.8% ± 19.63. The most common etiology was electric burn as a consequence of high voltage injury 90 (81.1%). The mean of LOS was 36.01 ± 26.51 days, with a mean LOS in ICU of 10.77 ± 22.46 days. Infection and Mortality The overall infection rate was 72.9 cases per 100 patients and 52.2 patients with infection per 100 patients. From the 111 burn patients, 50 had nosocomially acquired infections, with a total of 81 infection episodes. The most common infection type was skin graft infection in 30 (37.0%) cases, followed by burned wound infection 18 (22.2%). There were 22 (27.1%) cases associated with invasive devices (Table 1). Mortality occurred in four (3.6%) patients, and three of them had at least one infectious process, the other one died secondary to rhabdomyolysis, developing acute kidney injury and myocardial injury on the fifth day of hospitalization. Infectious complications in died patients were as follow: the first one was complicated with skin graft infection and central venous catheter infection by P. aeruginosa resistant to colistin. The second one developed ventilation associated pneumonia by multidrug-resistant A. baumannii and extended-spectrum beta-lactamase producer (ESBL) Escherichia coli, and bloodstream infection by MDR P. aeruginosa. The third one had a bloodstream infection with the isolation of carbapenem-resistant P. aeruginosa. The lethal infection rate was 5.1 per 100 patients. Table 1. Infections associated with electrical burn injuries Type of infections Number of patients Wound infection related to burn 30 Soft tissue infection related to burn 18 Urinary tract infection 10 Bloodstream infection related to venous central catheter 10 Clostridioides difficile infection 3 Ventilator-associated pneumonia 2 Pneumonia associated with health care attention 2 Conjunctivitis 2 Fungemia 1 Type of infections Number of patients Wound infection related to burn 30 Soft tissue infection related to burn 18 Urinary tract infection 10 Bloodstream infection related to venous central catheter 10 Clostridioides difficile infection 3 Ventilator-associated pneumonia 2 Pneumonia associated with health care attention 2 Conjunctivitis 2 Fungemia 1 Open in new tab Table 1. Infections associated with electrical burn injuries Type of infections Number of patients Wound infection related to burn 30 Soft tissue infection related to burn 18 Urinary tract infection 10 Bloodstream infection related to venous central catheter 10 Clostridioides difficile infection 3 Ventilator-associated pneumonia 2 Pneumonia associated with health care attention 2 Conjunctivitis 2 Fungemia 1 Type of infections Number of patients Wound infection related to burn 30 Soft tissue infection related to burn 18 Urinary tract infection 10 Bloodstream infection related to venous central catheter 10 Clostridioides difficile infection 3 Ventilator-associated pneumonia 2 Pneumonia associated with health care attention 2 Conjunctivitis 2 Fungemia 1 Open in new tab We found a statistically significant difference between patients with infection related to the median LOS in the intensive unit care as well as in the total median LOS, the number of surgical treatments, and amputation (Table 2). Table 2. Demographic and clinical variables related to infection presentation Infection (n = 58) Non-Infection (n = 53) P < .05 Age† 35.12 (17.4) 27.7(13.9) 0.270 TBSA† 30.96 (21.85) 24.21(16.99) 0.159 Hospitalization length stay† 43.0(30.26) 28.37(19.22) 0.000 Intensive unite care stay† 17.27(29.27) 3.66(5.39) 0.002 Surgical treatment† 6.29(4.34) 2.88(2.81) 0.004 Diabetes % 8.6(5) 3.8(2) 0.294 Alcoholism % 31(18) 17(9) 0.085 Hypertension % 5.2(3) 3.8(2) 0.723 Smoking % 20.7(12) 22.6(12) 0.803 Obesity % 19(11) 17(9) 0.786 Drug addiction % 5.2(3) 5.7(3) 0.91 Burn degree  Second % 24.1(14) 32.1(17) 0.352  Third % 67.2(39) 66.1(35) 0.893  Fourth % 3.4(2) 1.9(1) 0.612 Airway inhalation injury 8.6(5) 5.7(3) 0.547 High-voltage injuries 77.6(45) 86.8(46) 0.207 Amputations 31(18) 13.2(7) 0.025 Infection (n = 58) Non-Infection (n = 53) P < .05 Age† 35.12 (17.4) 27.7(13.9) 0.270 TBSA† 30.96 (21.85) 24.21(16.99) 0.159 Hospitalization length stay† 43.0(30.26) 28.37(19.22) 0.000 Intensive unite care stay† 17.27(29.27) 3.66(5.39) 0.002 Surgical treatment† 6.29(4.34) 2.88(2.81) 0.004 Diabetes % 8.6(5) 3.8(2) 0.294 Alcoholism % 31(18) 17(9) 0.085 Hypertension % 5.2(3) 3.8(2) 0.723 Smoking % 20.7(12) 22.6(12) 0.803 Obesity % 19(11) 17(9) 0.786 Drug addiction % 5.2(3) 5.7(3) 0.91 Burn degree  Second % 24.1(14) 32.1(17) 0.352  Third % 67.2(39) 66.1(35) 0.893  Fourth % 3.4(2) 1.9(1) 0.612 Airway inhalation injury 8.6(5) 5.7(3) 0.547 High-voltage injuries 77.6(45) 86.8(46) 0.207 Amputations 31(18) 13.2(7) 0.025 †Mean (SD); P < .05 Mann–Whitney U-test. % (n) Accurate method for independent proportions. Open in new tab Table 2. Demographic and clinical variables related to infection presentation Infection (n = 58) Non-Infection (n = 53) P < .05 Age† 35.12 (17.4) 27.7(13.9) 0.270 TBSA† 30.96 (21.85) 24.21(16.99) 0.159 Hospitalization length stay† 43.0(30.26) 28.37(19.22) 0.000 Intensive unite care stay† 17.27(29.27) 3.66(5.39) 0.002 Surgical treatment† 6.29(4.34) 2.88(2.81) 0.004 Diabetes % 8.6(5) 3.8(2) 0.294 Alcoholism % 31(18) 17(9) 0.085 Hypertension % 5.2(3) 3.8(2) 0.723 Smoking % 20.7(12) 22.6(12) 0.803 Obesity % 19(11) 17(9) 0.786 Drug addiction % 5.2(3) 5.7(3) 0.91 Burn degree  Second % 24.1(14) 32.1(17) 0.352  Third % 67.2(39) 66.1(35) 0.893  Fourth % 3.4(2) 1.9(1) 0.612 Airway inhalation injury 8.6(5) 5.7(3) 0.547 High-voltage injuries 77.6(45) 86.8(46) 0.207 Amputations 31(18) 13.2(7) 0.025 Infection (n = 58) Non-Infection (n = 53) P < .05 Age† 35.12 (17.4) 27.7(13.9) 0.270 TBSA† 30.96 (21.85) 24.21(16.99) 0.159 Hospitalization length stay† 43.0(30.26) 28.37(19.22) 0.000 Intensive unite care stay† 17.27(29.27) 3.66(5.39) 0.002 Surgical treatment† 6.29(4.34) 2.88(2.81) 0.004 Diabetes % 8.6(5) 3.8(2) 0.294 Alcoholism % 31(18) 17(9) 0.085 Hypertension % 5.2(3) 3.8(2) 0.723 Smoking % 20.7(12) 22.6(12) 0.803 Obesity % 19(11) 17(9) 0.786 Drug addiction % 5.2(3) 5.7(3) 0.91 Burn degree  Second % 24.1(14) 32.1(17) 0.352  Third % 67.2(39) 66.1(35) 0.893  Fourth % 3.4(2) 1.9(1) 0.612 Airway inhalation injury 8.6(5) 5.7(3) 0.547 High-voltage injuries 77.6(45) 86.8(46) 0.207 Amputations 31(18) 13.2(7) 0.025 †Mean (SD); P < .05 Mann–Whitney U-test. % (n) Accurate method for independent proportions. Open in new tab Microbiology Isolations and Their Susceptibility A total of 87 (78%) out of the 111 patients had at least one positive culture. Table 3 shows the microbiologically positive sample type distribution. Quantitative biopsies and swab cultures were the more yielding samples with 245 (73.8%) and 240 (64.3%) positive results, respectively. Gram-negative bacteria were the most frequent type of microorganism, 443 (59.1%); with P. aeruginosa being the principal isolated bacteria in 114 (15.2%) samples, followed by A. baumannii in 104 (13.9%). Regarding Enterobacteriaceae, E. coli with 76 (10.1%) and Klebsiella pneumoniae 43 (5.7%) isolates were the leading bacteria of this family group. Gram-positive bacteria were recovered in 263 (35.1%) cultures, where cocci forms the prominent group with 263 (89.7%) isolates, among them Enterococcus faecalis and S. aureus were isolated in 96 (12.8%) and 44 (5.9%) samples, respectively. There were six (0.8%) anaerobic bacteria isolated. We found 37 (4.9%) fungal isolates, of them 30 (81.1%) were yeasts and 7 (18.9%) filamentous fungi (Table 4). Fungi represented 4.9% of all isolates, with yeasts being the main cause of fungal infections; they were found in 37 (5%) of blood culture (data not shown). The median isolated bacterial isolates per patient were 3.2 ± 3.1. Regarding antimicrobial resistance, P. aeruginosa had the highest rates of resistance to any family of antibiotics included, and A. baumannii also showed high resistance rates. More than half of E. coli and K. pneumoniae were extended-spectrum β-lactamases producers, 55% and 72%, respectively (Table 5). Unlike K. pneumoniae, E. coli had resistance to carbapenems which were corroborated with carbapenems inhibition modified method and method with an inhibitor of carbapenemases24–26 (data not shown). About 69% of S. aureus isolates were resistant to methicillin, most of them also showed resistance to quinolones (71%); however, there was no resistance to vancomycin (Table 5). Enterococcus faecalis strains were susceptible to penicillin and ampicillin, 80% and 84%, respectively; more than a half-showed susceptibility to quinolone family and only 2% were resistant to vancomycin. Table 3. Positive sample distribution among infected electrical patients Origin of Clinical Sample Culture Total n = 1703 % Positive Results n = 749 % Blood 551 32.35 79 14.34 Swabs 373 21.90 240 64.34 Quantitative biopsy 332 19.50 245 73.80 Urine 181 10.63 38 20.99 Central venous catheter 129 7.57 35 27.13 Qualitative biopsy 87 5.11 78 89.66 Low airway tract 32 1.88 19 59.38 Abscesses 17 1.00 15 88.24 Origin of Clinical Sample Culture Total n = 1703 % Positive Results n = 749 % Blood 551 32.35 79 14.34 Swabs 373 21.90 240 64.34 Quantitative biopsy 332 19.50 245 73.80 Urine 181 10.63 38 20.99 Central venous catheter 129 7.57 35 27.13 Qualitative biopsy 87 5.11 78 89.66 Low airway tract 32 1.88 19 59.38 Abscesses 17 1.00 15 88.24 Open in new tab Table 3. Positive sample distribution among infected electrical patients Origin of Clinical Sample Culture Total n = 1703 % Positive Results n = 749 % Blood 551 32.35 79 14.34 Swabs 373 21.90 240 64.34 Quantitative biopsy 332 19.50 245 73.80 Urine 181 10.63 38 20.99 Central venous catheter 129 7.57 35 27.13 Qualitative biopsy 87 5.11 78 89.66 Low airway tract 32 1.88 19 59.38 Abscesses 17 1.00 15 88.24 Origin of Clinical Sample Culture Total n = 1703 % Positive Results n = 749 % Blood 551 32.35 79 14.34 Swabs 373 21.90 240 64.34 Quantitative biopsy 332 19.50 245 73.80 Urine 181 10.63 38 20.99 Central venous catheter 129 7.57 35 27.13 Qualitative biopsy 87 5.11 78 89.66 Low airway tract 32 1.88 19 59.38 Abscesses 17 1.00 15 88.24 Open in new tab Table 4. Microorganism recovery from positive samples associated with infection Organism Positive cultures Group % Global % Abscesses Qualitative biopsy Quantitative biopsy Blood culture Swabs Central venous catheter Urine Low airway tract Group 1. Gram-positive n = 263/749 (35.1%) Group 1.1. Gram-positive cocci n = 236/263 (89.7%) Enterococcus faecalis 96 36.5 12.8 3 11 41 6 24 2 9 Staphylococcus aureus 44 16.7 5.9 1 4 14 1 21 2 1 Staphylococcus epidermidis 26 9.9 3.5 0 4 6 8 4 4 Enterococcus faecium 19 7.2 2.5 0 2 10 0 6 1 Enterococcus gallinarum 14 5.3 1.9 1 2 7 1 3 Enterococcus avium 8 3 1.1 0 4 2 2 Enterococcus casseliflavus 6 2.3 0.8 0 2 2 2 Staphylococcus haemolyticus 6 2.3 0.8 1 1 2 2 Staphylococcus simulans 4 1.5 0.5 4 0 Streptococcus agalactiae 4 1.5 0.5 1 3 Enterococcus durans 3 1.1 0.4 1 2 Leuconostoc pseudomesenteroides 1 0.4 0.1 1 Staphylococcus cohnii subsp. cohnii 1 0.4 0.1 1 Staphylococcus lugdunensis 1 0.4 0.1 1 Staphylococcus sciuri 1 0.4 0.1 1 Staphylococcus lentus 1 0.4 0.1 1 Streptococcus mitis 1 0.4 0.1 1 Group 1.2. Gram-positive rods n = 27/263 (10.3%) Bacillus cereus 16 6.1 2.1 2 9 5 Corynebacterium striatum 11 4.2 1.5 3 7 1 Group 2. Gram-negative n = 443/749 (59.1%) Pseudomonas aeruginosa 114 25.7 15.2 2 16 27 7 40 5 8 9 Acinetobacter baumannii 104 23.5 13.9 1 9 29 13 36 10 0 6 Escherichia coli 76 17.2 10.1 2 4 18 11 30 2 8 1 Klebsiella pneumonia 43 9.7 5.7 2 12 4 25 Enterobacter cloacae complex 36 8.1 4.8 1 2 10 7 12 1 2 1 Citrobacter freundii 14 3.2 1.9 2 4 6 2 Stenotrophomonas maltophilia 14 3.2 1.9 1 6 1 4 2 Morganella morganii subsp morganii 10 2.3 1.3 2 3 1 3 1 Serratia marcescens 9 2 1.2 1 2 2 1 3 Klebsiella oxytoca 6 1.4 0.8 1 2 2 1 Proteus vulgaris 4 0.9 0.5 0 3 1 Burkholderia cepacia 3 0.7 0.4 2 0 1 Proteus mirabilis 2 0.5 0.3 1 1 Acinetobacter haemolyticus 1 0.2 0.1 1 Aeromonas hydrophila 1 0.2 0.1 1 Pantoea spp. 1 0.2 0.1 1 Pseudomonas fluorescens 1 0.2 0.1 1 Pseudomonas putida 1 0.2 0.1 1 Pseudomonas stutzeri 1 0.2 0.1 1 Serratia fonticola 1 0.2 0.1 1 Shewanella algae 1 0.2 0.1 1 Group 3. Fungi n = 37/749 (4.9%) Group 3.1 Yeast n = 30/37 (81.1 %) Candida albicans 11 29.7 1.5 2 4 4 1 Candida parapsilosis 9 24.3 1.2 2 4 4 1 Candida tropicalis 6 16.2 0.8 4 2 Candida glabrata 2 5.4 0.3 1 1 Candida dubliniensis 1 2.7 0.1 2 4 4 1 Geotrichum candidum 1 2.7 0.1 1 Group 3.2 Filamentous fungi n = 7/37 (18.9 %) Alternaria spp 3 8.1 0.4 0 3 Fusarium spp 2 5.4 0.3 0 2 Mucor spp 2 5.4 0.3 2 Group 4. Anaerobes n = 6/749 (0.8%) Finegoldia magna 5 83.3 0.7 1 2 2 Anaerococcus lactolyticus 1 16.7 0.1 1 Organism Positive cultures Group % Global % Abscesses Qualitative biopsy Quantitative biopsy Blood culture Swabs Central venous catheter Urine Low airway tract Group 1. Gram-positive n = 263/749 (35.1%) Group 1.1. Gram-positive cocci n = 236/263 (89.7%) Enterococcus faecalis 96 36.5 12.8 3 11 41 6 24 2 9 Staphylococcus aureus 44 16.7 5.9 1 4 14 1 21 2 1 Staphylococcus epidermidis 26 9.9 3.5 0 4 6 8 4 4 Enterococcus faecium 19 7.2 2.5 0 2 10 0 6 1 Enterococcus gallinarum 14 5.3 1.9 1 2 7 1 3 Enterococcus avium 8 3 1.1 0 4 2 2 Enterococcus casseliflavus 6 2.3 0.8 0 2 2 2 Staphylococcus haemolyticus 6 2.3 0.8 1 1 2 2 Staphylococcus simulans 4 1.5 0.5 4 0 Streptococcus agalactiae 4 1.5 0.5 1 3 Enterococcus durans 3 1.1 0.4 1 2 Leuconostoc pseudomesenteroides 1 0.4 0.1 1 Staphylococcus cohnii subsp. cohnii 1 0.4 0.1 1 Staphylococcus lugdunensis 1 0.4 0.1 1 Staphylococcus sciuri 1 0.4 0.1 1 Staphylococcus lentus 1 0.4 0.1 1 Streptococcus mitis 1 0.4 0.1 1 Group 1.2. Gram-positive rods n = 27/263 (10.3%) Bacillus cereus 16 6.1 2.1 2 9 5 Corynebacterium striatum 11 4.2 1.5 3 7 1 Group 2. Gram-negative n = 443/749 (59.1%) Pseudomonas aeruginosa 114 25.7 15.2 2 16 27 7 40 5 8 9 Acinetobacter baumannii 104 23.5 13.9 1 9 29 13 36 10 0 6 Escherichia coli 76 17.2 10.1 2 4 18 11 30 2 8 1 Klebsiella pneumonia 43 9.7 5.7 2 12 4 25 Enterobacter cloacae complex 36 8.1 4.8 1 2 10 7 12 1 2 1 Citrobacter freundii 14 3.2 1.9 2 4 6 2 Stenotrophomonas maltophilia 14 3.2 1.9 1 6 1 4 2 Morganella morganii subsp morganii 10 2.3 1.3 2 3 1 3 1 Serratia marcescens 9 2 1.2 1 2 2 1 3 Klebsiella oxytoca 6 1.4 0.8 1 2 2 1 Proteus vulgaris 4 0.9 0.5 0 3 1 Burkholderia cepacia 3 0.7 0.4 2 0 1 Proteus mirabilis 2 0.5 0.3 1 1 Acinetobacter haemolyticus 1 0.2 0.1 1 Aeromonas hydrophila 1 0.2 0.1 1 Pantoea spp. 1 0.2 0.1 1 Pseudomonas fluorescens 1 0.2 0.1 1 Pseudomonas putida 1 0.2 0.1 1 Pseudomonas stutzeri 1 0.2 0.1 1 Serratia fonticola 1 0.2 0.1 1 Shewanella algae 1 0.2 0.1 1 Group 3. Fungi n = 37/749 (4.9%) Group 3.1 Yeast n = 30/37 (81.1 %) Candida albicans 11 29.7 1.5 2 4 4 1 Candida parapsilosis 9 24.3 1.2 2 4 4 1 Candida tropicalis 6 16.2 0.8 4 2 Candida glabrata 2 5.4 0.3 1 1 Candida dubliniensis 1 2.7 0.1 2 4 4 1 Geotrichum candidum 1 2.7 0.1 1 Group 3.2 Filamentous fungi n = 7/37 (18.9 %) Alternaria spp 3 8.1 0.4 0 3 Fusarium spp 2 5.4 0.3 0 2 Mucor spp 2 5.4 0.3 2 Group 4. Anaerobes n = 6/749 (0.8%) Finegoldia magna 5 83.3 0.7 1 2 2 Anaerococcus lactolyticus 1 16.7 0.1 1 Open in new tab Table 4. Microorganism recovery from positive samples associated with infection Organism Positive cultures Group % Global % Abscesses Qualitative biopsy Quantitative biopsy Blood culture Swabs Central venous catheter Urine Low airway tract Group 1. Gram-positive n = 263/749 (35.1%) Group 1.1. Gram-positive cocci n = 236/263 (89.7%) Enterococcus faecalis 96 36.5 12.8 3 11 41 6 24 2 9 Staphylococcus aureus 44 16.7 5.9 1 4 14 1 21 2 1 Staphylococcus epidermidis 26 9.9 3.5 0 4 6 8 4 4 Enterococcus faecium 19 7.2 2.5 0 2 10 0 6 1 Enterococcus gallinarum 14 5.3 1.9 1 2 7 1 3 Enterococcus avium 8 3 1.1 0 4 2 2 Enterococcus casseliflavus 6 2.3 0.8 0 2 2 2 Staphylococcus haemolyticus 6 2.3 0.8 1 1 2 2 Staphylococcus simulans 4 1.5 0.5 4 0 Streptococcus agalactiae 4 1.5 0.5 1 3 Enterococcus durans 3 1.1 0.4 1 2 Leuconostoc pseudomesenteroides 1 0.4 0.1 1 Staphylococcus cohnii subsp. cohnii 1 0.4 0.1 1 Staphylococcus lugdunensis 1 0.4 0.1 1 Staphylococcus sciuri 1 0.4 0.1 1 Staphylococcus lentus 1 0.4 0.1 1 Streptococcus mitis 1 0.4 0.1 1 Group 1.2. Gram-positive rods n = 27/263 (10.3%) Bacillus cereus 16 6.1 2.1 2 9 5 Corynebacterium striatum 11 4.2 1.5 3 7 1 Group 2. Gram-negative n = 443/749 (59.1%) Pseudomonas aeruginosa 114 25.7 15.2 2 16 27 7 40 5 8 9 Acinetobacter baumannii 104 23.5 13.9 1 9 29 13 36 10 0 6 Escherichia coli 76 17.2 10.1 2 4 18 11 30 2 8 1 Klebsiella pneumonia 43 9.7 5.7 2 12 4 25 Enterobacter cloacae complex 36 8.1 4.8 1 2 10 7 12 1 2 1 Citrobacter freundii 14 3.2 1.9 2 4 6 2 Stenotrophomonas maltophilia 14 3.2 1.9 1 6 1 4 2 Morganella morganii subsp morganii 10 2.3 1.3 2 3 1 3 1 Serratia marcescens 9 2 1.2 1 2 2 1 3 Klebsiella oxytoca 6 1.4 0.8 1 2 2 1 Proteus vulgaris 4 0.9 0.5 0 3 1 Burkholderia cepacia 3 0.7 0.4 2 0 1 Proteus mirabilis 2 0.5 0.3 1 1 Acinetobacter haemolyticus 1 0.2 0.1 1 Aeromonas hydrophila 1 0.2 0.1 1 Pantoea spp. 1 0.2 0.1 1 Pseudomonas fluorescens 1 0.2 0.1 1 Pseudomonas putida 1 0.2 0.1 1 Pseudomonas stutzeri 1 0.2 0.1 1 Serratia fonticola 1 0.2 0.1 1 Shewanella algae 1 0.2 0.1 1 Group 3. Fungi n = 37/749 (4.9%) Group 3.1 Yeast n = 30/37 (81.1 %) Candida albicans 11 29.7 1.5 2 4 4 1 Candida parapsilosis 9 24.3 1.2 2 4 4 1 Candida tropicalis 6 16.2 0.8 4 2 Candida glabrata 2 5.4 0.3 1 1 Candida dubliniensis 1 2.7 0.1 2 4 4 1 Geotrichum candidum 1 2.7 0.1 1 Group 3.2 Filamentous fungi n = 7/37 (18.9 %) Alternaria spp 3 8.1 0.4 0 3 Fusarium spp 2 5.4 0.3 0 2 Mucor spp 2 5.4 0.3 2 Group 4. Anaerobes n = 6/749 (0.8%) Finegoldia magna 5 83.3 0.7 1 2 2 Anaerococcus lactolyticus 1 16.7 0.1 1 Organism Positive cultures Group % Global % Abscesses Qualitative biopsy Quantitative biopsy Blood culture Swabs Central venous catheter Urine Low airway tract Group 1. Gram-positive n = 263/749 (35.1%) Group 1.1. Gram-positive cocci n = 236/263 (89.7%) Enterococcus faecalis 96 36.5 12.8 3 11 41 6 24 2 9 Staphylococcus aureus 44 16.7 5.9 1 4 14 1 21 2 1 Staphylococcus epidermidis 26 9.9 3.5 0 4 6 8 4 4 Enterococcus faecium 19 7.2 2.5 0 2 10 0 6 1 Enterococcus gallinarum 14 5.3 1.9 1 2 7 1 3 Enterococcus avium 8 3 1.1 0 4 2 2 Enterococcus casseliflavus 6 2.3 0.8 0 2 2 2 Staphylococcus haemolyticus 6 2.3 0.8 1 1 2 2 Staphylococcus simulans 4 1.5 0.5 4 0 Streptococcus agalactiae 4 1.5 0.5 1 3 Enterococcus durans 3 1.1 0.4 1 2 Leuconostoc pseudomesenteroides 1 0.4 0.1 1 Staphylococcus cohnii subsp. cohnii 1 0.4 0.1 1 Staphylococcus lugdunensis 1 0.4 0.1 1 Staphylococcus sciuri 1 0.4 0.1 1 Staphylococcus lentus 1 0.4 0.1 1 Streptococcus mitis 1 0.4 0.1 1 Group 1.2. Gram-positive rods n = 27/263 (10.3%) Bacillus cereus 16 6.1 2.1 2 9 5 Corynebacterium striatum 11 4.2 1.5 3 7 1 Group 2. Gram-negative n = 443/749 (59.1%) Pseudomonas aeruginosa 114 25.7 15.2 2 16 27 7 40 5 8 9 Acinetobacter baumannii 104 23.5 13.9 1 9 29 13 36 10 0 6 Escherichia coli 76 17.2 10.1 2 4 18 11 30 2 8 1 Klebsiella pneumonia 43 9.7 5.7 2 12 4 25 Enterobacter cloacae complex 36 8.1 4.8 1 2 10 7 12 1 2 1 Citrobacter freundii 14 3.2 1.9 2 4 6 2 Stenotrophomonas maltophilia 14 3.2 1.9 1 6 1 4 2 Morganella morganii subsp morganii 10 2.3 1.3 2 3 1 3 1 Serratia marcescens 9 2 1.2 1 2 2 1 3 Klebsiella oxytoca 6 1.4 0.8 1 2 2 1 Proteus vulgaris 4 0.9 0.5 0 3 1 Burkholderia cepacia 3 0.7 0.4 2 0 1 Proteus mirabilis 2 0.5 0.3 1 1 Acinetobacter haemolyticus 1 0.2 0.1 1 Aeromonas hydrophila 1 0.2 0.1 1 Pantoea spp. 1 0.2 0.1 1 Pseudomonas fluorescens 1 0.2 0.1 1 Pseudomonas putida 1 0.2 0.1 1 Pseudomonas stutzeri 1 0.2 0.1 1 Serratia fonticola 1 0.2 0.1 1 Shewanella algae 1 0.2 0.1 1 Group 3. Fungi n = 37/749 (4.9%) Group 3.1 Yeast n = 30/37 (81.1 %) Candida albicans 11 29.7 1.5 2 4 4 1 Candida parapsilosis 9 24.3 1.2 2 4 4 1 Candida tropicalis 6 16.2 0.8 4 2 Candida glabrata 2 5.4 0.3 1 1 Candida dubliniensis 1 2.7 0.1 2 4 4 1 Geotrichum candidum 1 2.7 0.1 1 Group 3.2 Filamentous fungi n = 7/37 (18.9 %) Alternaria spp 3 8.1 0.4 0 3 Fusarium spp 2 5.4 0.3 0 2 Mucor spp 2 5.4 0.3 2 Group 4. Anaerobes n = 6/749 (0.8%) Finegoldia magna 5 83.3 0.7 1 2 2 Anaerococcus lactolyticus 1 16.7 0.1 1 Open in new tab Table 5. Susceptibility pattern of the most common Gram-negative rods and Gram-positive cocci isolated from electrical burned patients Antimicrobial Resistance (+) MO Gram-negative ESBL (%) SAM (%) PTZ (%) CAZ (%) FEP (%) AZT (%) ERT (%) MEM (%) IMP (%) AK (%) GN (%) NN (%) CIP (%) LVX (%) COL (%) Pseudomonas aeruginosa (n = 114) NR IR 80 (70.1) 79 (69.2) 80 (70.1) 83 (72.8) IR 66 (57.8) 97 (85.0) 91 (79.8) 91 (79.8) 91 (79.8) 98 (85.9) 99 (86.8) 1 (0.87) Acinetobacter baumannii (n = 104) NR 64 (61.5) 96 (92.3) 101 (97.1) 97 (93.2) IR IR 91 (87.5) 85 (81.7) 20 (19.2) 78 (75.0) 94 (90.3) 97 (93.2) 93 (89.4) 0 Escherichia coli (n = 76) 42 (55.2) 60 (78.9) 13 (17.1) 34 (44.7) 34 (44.7) 34 (44.7) 5 (6.5) 2 (2.6) 2 (2.6) 4 (5.2) 42 (55.2) 44 (57.8) 52 (68.4) 49 (64.4) 0 Klebsiella pneumoniae (n = 43) 31 (72.0) 33 (76.7) 15 (34.8) 12 (27.9) 12 (27.9) 12 (27.9) 0 0 0 3 (6.9) 17 (39.5) 27 (62.7) 19 (44.2) 19 (44.2) 0 MO Gram-positive PEN (%) AMP (%) OXA (%) GN (%) CIP (%) LVX (%) MOX (%) E (%) CC (%) SYN (%) LZD (%) VA (%) TE (%) TYG (%) RIF (%) SXT (%) Staphylococcus aureus (n = 44) 43 (97.7) NR 30 (68.1) 3 (6.87) 31 (70.4) 31 (70.4) 30 (68.1) 36 (81.8) 36 (81.8) 0 0 0 2 (4.5) 0 1 (2.2) 3 (6.8) Enterococcus faecalis (n = 96) 19 (19.7) 15 (15.63) NR NR 33 (34.3) 26 (27.0) 25 (26.0) 73 (76.0) IR IR 3 (3.1) 2 (2.0) 71 (73.9) 2 (2.0) NR IR Antimicrobial Resistance (+) MO Gram-negative ESBL (%) SAM (%) PTZ (%) CAZ (%) FEP (%) AZT (%) ERT (%) MEM (%) IMP (%) AK (%) GN (%) NN (%) CIP (%) LVX (%) COL (%) Pseudomonas aeruginosa (n = 114) NR IR 80 (70.1) 79 (69.2) 80 (70.1) 83 (72.8) IR 66 (57.8) 97 (85.0) 91 (79.8) 91 (79.8) 91 (79.8) 98 (85.9) 99 (86.8) 1 (0.87) Acinetobacter baumannii (n = 104) NR 64 (61.5) 96 (92.3) 101 (97.1) 97 (93.2) IR IR 91 (87.5) 85 (81.7) 20 (19.2) 78 (75.0) 94 (90.3) 97 (93.2) 93 (89.4) 0 Escherichia coli (n = 76) 42 (55.2) 60 (78.9) 13 (17.1) 34 (44.7) 34 (44.7) 34 (44.7) 5 (6.5) 2 (2.6) 2 (2.6) 4 (5.2) 42 (55.2) 44 (57.8) 52 (68.4) 49 (64.4) 0 Klebsiella pneumoniae (n = 43) 31 (72.0) 33 (76.7) 15 (34.8) 12 (27.9) 12 (27.9) 12 (27.9) 0 0 0 3 (6.9) 17 (39.5) 27 (62.7) 19 (44.2) 19 (44.2) 0 MO Gram-positive PEN (%) AMP (%) OXA (%) GN (%) CIP (%) LVX (%) MOX (%) E (%) CC (%) SYN (%) LZD (%) VA (%) TE (%) TYG (%) RIF (%) SXT (%) Staphylococcus aureus (n = 44) 43 (97.7) NR 30 (68.1) 3 (6.87) 31 (70.4) 31 (70.4) 30 (68.1) 36 (81.8) 36 (81.8) 0 0 0 2 (4.5) 0 1 (2.2) 3 (6.8) Enterococcus faecalis (n = 96) 19 (19.7) 15 (15.63) NR NR 33 (34.3) 26 (27.0) 25 (26.0) 73 (76.0) IR IR 3 (3.1) 2 (2.0) 71 (73.9) 2 (2.0) NR IR ESBL, extended spectrum beta lactamase; SAM, ampicillin/sulbactam; TZP, piperacillin/tazobactam; CAZ, ceftazidime; FEP, cefepime; AZT, aztreonam; ERT, ertapenem; MEM, meropenem; IMP, imipenem; AK, amikacin; GN, gentamycin; NN, tobramycin; CIP, ciprofloxacin; LVX, levofloxacin; MOX, moxifloxacin; COL, colistin; PEN, penicillin; AMP, ampicillin; OXA, oxacillin; MOX, moxifloxacin; E, erythromycin; CC, clindamycin; SYN, quinupristin/dalfopristin; LZD, linezolid; VA, vancomycin; TE, tetracycline; TYG, tigecycline; RIF, rifampicin; SXT, sulfamethoxazole/trimethoprim; IR, intrinsic resistance; S, susceptible; R, resistant; NP, not performed. Open in new tab Table 5. Susceptibility pattern of the most common Gram-negative rods and Gram-positive cocci isolated from electrical burned patients Antimicrobial Resistance (+) MO Gram-negative ESBL (%) SAM (%) PTZ (%) CAZ (%) FEP (%) AZT (%) ERT (%) MEM (%) IMP (%) AK (%) GN (%) NN (%) CIP (%) LVX (%) COL (%) Pseudomonas aeruginosa (n = 114) NR IR 80 (70.1) 79 (69.2) 80 (70.1) 83 (72.8) IR 66 (57.8) 97 (85.0) 91 (79.8) 91 (79.8) 91 (79.8) 98 (85.9) 99 (86.8) 1 (0.87) Acinetobacter baumannii (n = 104) NR 64 (61.5) 96 (92.3) 101 (97.1) 97 (93.2) IR IR 91 (87.5) 85 (81.7) 20 (19.2) 78 (75.0) 94 (90.3) 97 (93.2) 93 (89.4) 0 Escherichia coli (n = 76) 42 (55.2) 60 (78.9) 13 (17.1) 34 (44.7) 34 (44.7) 34 (44.7) 5 (6.5) 2 (2.6) 2 (2.6) 4 (5.2) 42 (55.2) 44 (57.8) 52 (68.4) 49 (64.4) 0 Klebsiella pneumoniae (n = 43) 31 (72.0) 33 (76.7) 15 (34.8) 12 (27.9) 12 (27.9) 12 (27.9) 0 0 0 3 (6.9) 17 (39.5) 27 (62.7) 19 (44.2) 19 (44.2) 0 MO Gram-positive PEN (%) AMP (%) OXA (%) GN (%) CIP (%) LVX (%) MOX (%) E (%) CC (%) SYN (%) LZD (%) VA (%) TE (%) TYG (%) RIF (%) SXT (%) Staphylococcus aureus (n = 44) 43 (97.7) NR 30 (68.1) 3 (6.87) 31 (70.4) 31 (70.4) 30 (68.1) 36 (81.8) 36 (81.8) 0 0 0 2 (4.5) 0 1 (2.2) 3 (6.8) Enterococcus faecalis (n = 96) 19 (19.7) 15 (15.63) NR NR 33 (34.3) 26 (27.0) 25 (26.0) 73 (76.0) IR IR 3 (3.1) 2 (2.0) 71 (73.9) 2 (2.0) NR IR Antimicrobial Resistance (+) MO Gram-negative ESBL (%) SAM (%) PTZ (%) CAZ (%) FEP (%) AZT (%) ERT (%) MEM (%) IMP (%) AK (%) GN (%) NN (%) CIP (%) LVX (%) COL (%) Pseudomonas aeruginosa (n = 114) NR IR 80 (70.1) 79 (69.2) 80 (70.1) 83 (72.8) IR 66 (57.8) 97 (85.0) 91 (79.8) 91 (79.8) 91 (79.8) 98 (85.9) 99 (86.8) 1 (0.87) Acinetobacter baumannii (n = 104) NR 64 (61.5) 96 (92.3) 101 (97.1) 97 (93.2) IR IR 91 (87.5) 85 (81.7) 20 (19.2) 78 (75.0) 94 (90.3) 97 (93.2) 93 (89.4) 0 Escherichia coli (n = 76) 42 (55.2) 60 (78.9) 13 (17.1) 34 (44.7) 34 (44.7) 34 (44.7) 5 (6.5) 2 (2.6) 2 (2.6) 4 (5.2) 42 (55.2) 44 (57.8) 52 (68.4) 49 (64.4) 0 Klebsiella pneumoniae (n = 43) 31 (72.0) 33 (76.7) 15 (34.8) 12 (27.9) 12 (27.9) 12 (27.9) 0 0 0 3 (6.9) 17 (39.5) 27 (62.7) 19 (44.2) 19 (44.2) 0 MO Gram-positive PEN (%) AMP (%) OXA (%) GN (%) CIP (%) LVX (%) MOX (%) E (%) CC (%) SYN (%) LZD (%) VA (%) TE (%) TYG (%) RIF (%) SXT (%) Staphylococcus aureus (n = 44) 43 (97.7) NR 30 (68.1) 3 (6.87) 31 (70.4) 31 (70.4) 30 (68.1) 36 (81.8) 36 (81.8) 0 0 0 2 (4.5) 0 1 (2.2) 3 (6.8) Enterococcus faecalis (n = 96) 19 (19.7) 15 (15.63) NR NR 33 (34.3) 26 (27.0) 25 (26.0) 73 (76.0) IR IR 3 (3.1) 2 (2.0) 71 (73.9) 2 (2.0) NR IR ESBL, extended spectrum beta lactamase; SAM, ampicillin/sulbactam; TZP, piperacillin/tazobactam; CAZ, ceftazidime; FEP, cefepime; AZT, aztreonam; ERT, ertapenem; MEM, meropenem; IMP, imipenem; AK, amikacin; GN, gentamycin; NN, tobramycin; CIP, ciprofloxacin; LVX, levofloxacin; MOX, moxifloxacin; COL, colistin; PEN, penicillin; AMP, ampicillin; OXA, oxacillin; MOX, moxifloxacin; E, erythromycin; CC, clindamycin; SYN, quinupristin/dalfopristin; LZD, linezolid; VA, vancomycin; TE, tetracycline; TYG, tigecycline; RIF, rifampicin; SXT, sulfamethoxazole/trimethoprim; IR, intrinsic resistance; S, susceptible; R, resistant; NP, not performed. Open in new tab DISCUSSION Burn injuries are one of the hardest medical challenges. In this study, electrical burn injuries was a very frequent cause of trauma, more than previously reported (5.8% to 11%) of all type of burn injuries.27–29 In our study, almost all patients were men in working age (68%), as it is been seen in other studies30,31 having a significant socioeconomic impact.27–32 The amount of high voltage injuries is remarkably high, and it would be associated with the poor demographic architecture of a light network, as well as, poor economic conditions which make people perform risky works on streets or near high voltage lamp posts. There is an urgent need to educate people in accordance to avoid doing dangerous maneuvers to have electricity and to be careful while making house improvements, as well. Crowded cities of low-level income countries are associated with more accidents,33 and burn injuries as a consequence. There has been an important increase in the success rates of burn shock treatment with an improvement of scientific knowledge, better understanding of burn physiology and developments in both medical monitoring and ICU patient management, and consequently the decrease of morbidity and mortality rates. Nevertheless, the infection continues being one of the leading complications in this pathology. Most of our patients had severe burns with more risk to have multiple complications, such as infections. Infection prevalence was high, 52.2 per 100 patients; however, in accordance with other units that report infection rates between 36 and 53.4 per 100 patients.27,29,34 Burn patients are prone to be infected because they lost their primary barrier. In addition, the more depth and amount of BSA, as was seen in these patients, is associated with more immunosuppression and probability to be colonized, and consequently to get infected by different organisms. The mortality rate of 3.6% was significantly consistent with that reported in other publications35,36 and is significantly lower than reported in patients with flame (45%) or scald (44%) burns in some series.37,38 Three out of four deaths were associated with infection by MDR microorganisms (P. aeruginosa resistant to colistin, A. baumannii resistant to carbapenems, and ESBLs Enterobacteriaceae). Associated variables related to MDR bacteria have been previously described, highlighting, immunosuppression, use of antibiotics, medical devices, surgery, and high LOS. According to this, dead patients had all mentioned variables associated with MDR bacteria. This is the first descriptive Mexican study of microorganism distribution associated with infection in electrical burned patients. The amount of laboratory samples that are requested to these patients is enormous, with a median microbiological sampling per patient was 15.3 tests, and therefore increasing the cost of their hospitalization. Like other studies, the most frequent microbiologic isolate was P. aeruginosa followed by A. baumannii.27,29,34 Unlike has been reported in other studies in regard to Gram-positive cocci in our study E. faecalis was the most frequent isolated, instead of S. aureus. It has been described the importance that burn injury causes an important inflammation at mucous intestinal layer, increasing permeability and decreasing expression of tight junctions’ proteins.39 Most of the time, sepsis is caused by autogenous infections and it is still the main reason for mortality in burns patients. The gastrointestinal epithelial barrier is destroyed after burns, leading to the translocation of endotoxins and bacteria that are only supposed to exist in this tract, that is why this might be a possible explanation of the more frequent presence of Enterococcus spp. as a cause of infection, instead of Staphylococcal spp. Microbiome alteration has been focused as an important role in infection association, not only for Gram-positive’s microorganisms, but also for Gram-negative’s ones.40 As mentioned above, the most frequent microorganism related to infection during all process of patient’s hospitalization was P. aeruginosa. Its resistance rates were higher than other microorganisms because of its ability to adapt to different environments and respond quickly to different stresses and besides has different resistance mechanism. Acinetobacter baumannii was the second nosocomial microorganism with a high MDR prevalence as well. Both microorganisms have called the attention of the World Health Organization due to their higher rates of resistance and that characteristic gave as a result of an alert emitted by that international organization.41 It is important to mention that 103 (92.7%) patients were transferred from other hospital centers, with a mean previous hospital stay of 10.31 ± 37.13, assuming that they might have been colonized before to our hospital arrival; however, we did not perform MDR screen colonization to all patients at that time, as we do nowadays. Despite contact precautions were implemented in all patient since the unit was opened, the feasibility that all health care personal performed appropriately is unknown, because of lack of adherence or economical resources. An antibiotic stewardship program has been implemented as it is internationally recommended in order to decrease our own MDR prevalence. Murray et al42 described that infections due to anaerobic microorganisms are typically secondary to electrical burns, however, in our case we found anaerobic bacteria related in only 0.7%; we think that this might be because plastics surgeons still prefer sending swabs rather than biopsies in most of the cases and microorganism recovery could be less yielding. Regarding fungal infections, there is an alarming presence of this type of complications. Molds have been associated with trauma mechanism, because some patients try to stop burning to lie and thrash about on the floor which is also present in electrical burns; however, yeast complications are a severe and devastating complication that presents after the second or third week of hospital stay. This study shows that we have predominantly two types of Candida species complications, C. albicans as the main one and Candida parapsilosis as the following. In contrast to bacteria and positively, antimicrobial resistance to azoles is scarce. Some study limitations need to be mention, the first one is our retrospective methodology; however, we consider that the number of included patients is significant, and study clinical infections definitions were performed as they are recommended by guidelines. Legal-medical autopsy examination results were not mentioned in this study and it would be important to inform the real cause of death for those four patients. The second limitation is that we did not perform deep molecular epidemiology study to our isolates, in order to look for potential in-hospital outbreaks. We can conclude that electrical burn injuries are a common cause of trauma requiring hospitalization in our center. They may complicate with infections, more often at the skin and soft tissue. Antimicrobial resistance is alarming present in burn units, so there must exist standardized local and national protocols to decrease its presence. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest: Arturo Mondragón Eguiluz is on the speaker’s bureau for Stendhal pharma. Luis Esaú López-Jácome, Melissa Hernández-Durand, and Rafael Franco-Cendejas are on the speaker’s bureau of Pfizer and have received honoraria from Pfizer. For the remaining authors, none are declared. REFERENCES 1. Church D , Elsayed S , Reid O , Winston B , Lindsay R . Burn wound infections . Clin Microbiol Rev 2006 ; 19 ( 2 ): 403 – 34 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Wardhana A , Basuki A , Prameswara ADH , Rizkita DN , Andarie AA , Canintika AF . The epidemiology of burns in Indonesia’s national referral burn center from 2013 to 2015 . Burns Open 2017 ; 1 ( 2 ): 67 – 73 . Google Scholar Crossref Search ADS WorldCat 3. World Health Organization . Disease burden and mortality estimates 2000 –2016. Available from https://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html. Google Preview WorldCat COPAC 4. Sokhal AK , Lodha KG , Kumari M , Paliwal R , Gothwal S . Clinical spectrum of electrical burns—a prospective study from the developing world . Burns 2017 ; 43 ( 1 ): 182 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Li H , Tan J , Zhou J et al. . Wound management and outcome of 595 electrical burns in a major burn center . J Surg Res 2017 ; 214 : 182 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Koumbourlis AC . Electrical injuries . Crit Care Med 2002 ; 30 ( 11 Suppl ): S424 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Carloni R , Pechevy L , Quignon R , Yassine AH , Forme N , Zakine G . Electrical flash burns, about 33 cases. A 10-year retrospective study. Epidemiology, treatment and prevention . Ann Chir Plast Esthet 2015 ; 60 ( 2 ): 123 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Ghavami Y , Mobayen MR , Vaghardoost R . Electrical burn injury: a five-year survey of 682 patients . Trauma Mon 2014 ; 19 ( 4 ): e18748 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Sun CF , Lv XX , Li YJ et al. . Epidemiological studies of electrical injuries in Shaanxi province of China: a retrospective report of 383 cases . Burns 2012 ; 38 ( 4 ): 568 – 72 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Matt SE , Shupp JW , Carter EA , Shaw JD , Jordan MH . Comparing a single institution’s experience with electrical injuries to the data recorded in the National Burn Repository . J Burn Care Res 2012 ; 33 ( 5 ): 606 – 11 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Piotrowski A , Fillet AM , Perez P et al. . Outcome of occupational electrical injuries among French electric company workers: a retrospective report of 311 cases, 1996–2005 . Burns 2014 ; 40 ( 3 ): 480 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Luz DP , Millan LS , Alessi MS et al. . Electrical burns: a retrospective analysis across a 5-year period . Burns 2009 ; 35 ( 7 ): 1015 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Agbenorku P , Agbenorku E , Akpaloo J , Obeng G , Agbley D . Electrical burns: the trend and risk factors in the Ghanaian population . Ann Burns Fire Disasters 2014 ; 27 ( 4 ): 176 – 83 . Google Scholar PubMed WorldCat 14. Nguyen BH , MacKay M , Bailey B , Klassen TP . Epidemiology of electrical and lightning related deaths and injuries among Canadian children and youth . Inj Prev 2004 ; 10 ( 2 ): 122 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Sahin I , Ozturk S , Alhan D , Açikel C , Isik S . Cost analysis of acute burn patients treated in a burn centre: the Gulhane experience . Ann Burns Fire Disasters 2011 ; 24 ( 1 ): 9 – 13 . Google Scholar PubMed WorldCat 16. Santucci SG , Gobara S , Santos CR , Fontana C , Levin AS . Infections in a burn intensive care unit: experience of seven years . J Hosp Infect 2003 ; 53 ( 1 ): 6 – 13 . Google Scholar Crossref Search ADS PubMed WorldCat 17. Davies J , Davies D . Origins and evolution of antibiotic resistance . Microbiol Mol Biol Rev 2010 ; 74 ( 3 ): 417 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat 18. van Langeveld I , Gagnon RC , Conrad PF et al. . Multiple-drug resistance in burn patients: a retrospective study on the impact of antibiotic resistance on survival and length of stay . J Burn Care Res 2017 ; 38 ( 2 ): 99 – 105 . Google Scholar Crossref Search ADS PubMed WorldCat 19. Glasser JS , Guymon CH , Mende K , Wolf SE , Hospenthal DR , Murray CK . Activity of topical antimicrobial agents against multidrug-resistant bacteria recovered from burn patients . Burns 2010 ; 36 ( 8 ): 1172 – 84 Google Scholar Crossref Search ADS PubMed WorldCat 20. Lachiewicz AM , Hauck CG , Weber DJ , Cairns BA , van Duin D . Bacterial infections after burn injuries: impact of multidrug resistance . Clin Infect Dis 2017 ; 65 ( 12 ): 2130 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 21. Millan LS , Benedette CEMd , Maximo LZ , Almeida PCCd , Gomes DS , Gemperli R et al. . Infecções de corrente sanguínea por bactérias multirresistentes em UTI de tratamento de queimados: experiência de 4 anos . Rev Bras Cir Plást 2012 ; 27 ( 3 ): 374 – 8 . Google Scholar Crossref Search ADS WorldCat 22. Pham TN , Cancio LC , Gibran NS ; American Burn Association . American Burn Association practice guidelines burn shock resuscitation . J Burn Care Res 2008 ; 29 ( 1 ): 257 – 66 . Google Scholar Crossref Search ADS PubMed WorldCat 23. Horan TC , Andrus M , Dudeck MA . CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting . Am J Infect Control 2008 ; 36 ( 5 ): 309 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 24. Clinical and Laboratory Standards Institute . Performance standards for antimicrobial susceptibility testing . 2018 ; available from http://em100.edaptivedocs.info/GetDoc.aspx?doc=CLSI%20M100%20ED28:2018&scope=user. 25. van der Zwaluw K , de Haan A , Pluister GN , Bootsma HJ , de Neeling AJ , Schouls LM . The carbapenem inactivation method (CIM), a simple and low-cost alternative for the Carba NP test to assess phenotypic carbapenemase activity in gram-negative rods . PLoS One 2015 ; 10 ( 3 ): e0123690 . Google Scholar Crossref Search ADS PubMed WorldCat 26. Robert J , Pantel A , Merens A , Meiller E , Lavigne JP , Nicolas-Chanoine MH ; ONERBA’s carbapenem resistance study group . Development of an algorithm for phenotypic screening of carbapenemase-producing Enterobacteriaceae in the routine laboratory . BMC Infect Dis 2017 ; 17 ( 1 ): 78 . Google Scholar Crossref Search ADS PubMed WorldCat 27. Ramirez-Blanco CE , Ramirez-Rivero CE , Diaz-Martinez LA , Sosa-Avila LM . Infection in burn patients in a referral center in Colombia . Burns 2017 ; 43 ( 3 ): 642 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 28. Schultz L , Walker SA , Elligsen M et al. . Identification of predictors of early infection in acute burn patients . Burns 2013 ; 39 ( 7 ): 1355 – 66 . Google Scholar Crossref Search ADS PubMed WorldCat 29. Zampar EF , Anami EHT , Kerbauy G et al. . Infectious complications in adult burn patients and antimicrobial resistance pattern of microorganisms isolated . Ann Burns Fire Disasters 2017 ; 30 ( 4 ): 281 – 5 . Google Scholar PubMed WorldCat 30. Gündüz T , Elçioğlu O , Cetin C . Intensity and localization of trauma in non-fatal electrical injuries . Ulus Travma Acil Cerrahi Derg 2010 ; 16 ( 3 ): 237 – 40 . Google Scholar PubMed WorldCat 31. Brandão C , Vaz M , Brito IM et al. . Electrical burns: a retrospective analysis over a 10-year period . Ann Burns Fire Disasters 2017 ; 30 ( 4 ): 268 – 71 . Google Scholar PubMed WorldCat 32. Vierhapper MF , Lumenta DB , Beck H , Keck M , Kamolz LP , Frey M . Electrical injury: a long-term analysis with review of regional differences . Ann Plast Surg 2011 ; 66 ( 1 ): 43 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 33. Patil RR . Urbanization as a determinant of health: a socioepidemiological perspective . Soc Work Public Health 2014 ; 29 ( 4 ): 335 – 41 . Google Scholar Crossref Search ADS PubMed WorldCat 34. Öncül O , Öksüz S , Acar A et al. . Nosocomial infection characteristics in a burn intensive care unit: analysis of an eleven-year active surveillance . Burns 2014 ; 40 ( 5 ): 835 – 41 . Google Scholar Crossref Search ADS PubMed WorldCat 35. Arnoldo BD , Purdue GF , Kowalske K , Helm PA , Burris A , Hunt JL . Electrical injuries: a 20-year review . J Burn Care Rehabil 2004 ; 25 ( 6 ): 479 – 84 . Google Scholar Crossref Search ADS PubMed WorldCat 36. Bahemia IA , Muganza A , Moore R , Sahid F , Menezes CN . Microbiology and antibiotic resistance in severe burns patients: a 5 year review in an adult burns unit . Burns 2015 ; 41 ( 7 ): 1536 – 42 . Google Scholar Crossref Search ADS PubMed WorldCat 37. Cheng W , Shen C , Zhao D , Zhang H , Tu J , Yuan Z et al. . The epidemiology and prognosis of patients with massive burns: a multicenter study of 2483 cases . Burns 2019 ; 45 ( 3 ): 705 – 16 . Google Scholar Crossref Search ADS PubMed WorldCat 38. Al-Shamsi M , Othman N . The epidemiology of burns in Basra, Iraq . Ann Burns Fire Disasters 2017 ; 30 ( 3 ): 167 – 71 . Google Scholar PubMed WorldCat 39. Osborn TM , Tracy JK , Dunne JR , Pasquale M , Napolitano LM . Epidemiology of sepsis in patients with traumatic injury . Crit Care Med 2004 ; 32 ( 11 ): 2234 – 40 . Google Scholar Crossref Search ADS PubMed WorldCat 40. Huang G , Sun K , Yin S et al. . Burn injury leads to increase in relative abundance of opportunistic pathogens in the rat gastrointestinal microbiome . Front Microbiol 2017 ; 8 : 1237 . Google Scholar Crossref Search ADS PubMed WorldCat 41. WHO publishes list of bacteria for which new antibiotics are urgently needed. 2017 . Available from http://www.who.int/mediacentre/news/releases/2017/bacteria-antibiotics-needed/en/. 42. Murray PM , Finegold SM . Anaerobes in burn-wound infections . Rev Infect Dis 1984 ; 6 ( Suppl 1 ): S184 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat © American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Microbiology and Infection Profile of Electric Burned Patients in a Referral Burn Hospital in Mexico City
JO - Journal of Burn Care & Research
DO - 10.1093/jbcr/irz177
DA - 2020-02-19
UR - https://www.deepdyve.com/lp/oxford-university-press/microbiology-and-infection-profile-of-electric-burned-patients-in-a-gHeC9bAtxk
SP - 390
VL - 41
IS - 2
DP - DeepDyve
ER -