Suhas Sanyal

To study the demographic and clinical factors associated with burn septicaemia patients in Kuwait. All burn in-patients, who developed septicaemia at the Burns Unit, Al-Babtain Centre for Burns and Plastic Surgery, Kuwait, during a 9-year period (June 1992 to May 2001) were included in the study. The data were recorded for age, sex, nationality, cause and percentage of burns, inhalation injury, resuscitation, number of episodes, septicaemia on post-burn day, the microorganisms responsible in each episode, treatment and outcome for statistical analysis. Using SPSS (PC version 11.0) software, a probability level of p < 0.05 was considered significant. Of the 2,082 patients treated in the Burns Unit, 166 [8%; 99 (60%) males and 67 (40%) females] with a mean age of 26 years (range 1-70) had septicaemia. Significantly higher (p < 0.001) cases were recorded among Kuwaiti children (< or =14 years) and non-Kuwaitis (25-59 years) than other corresponding age groups. The total body surface area burned ranged from 2 to 95% (mean 42%) and the main cause of burn was flame (77.1%). Inhalation injury was diagnosed in 39 (23.5%) patients. A total of 253 septicaemic episodes occurred in all patients. The majority, 123 (74.1%), had a single episode and the remaining 43 (25.6%) had multiple (2-10) episodes. One hundred and fifty-five (61.3%) episodes were due to gram-positive organisms, mainly methicillin-resistant Staphylococcus aureus, and 32 (12.7%) were polymicrobial. One hundred and twenty-four (74.7%) patients had wound excision and skin grafting procedures and their survival was significantly higher (OR = 4.3; 95% CI: 1.98-9.31) than non-surgically treated patients. Thirty-nine (23.5%) patients died mainly due to multi-organ failure. The findings indicate that the patients with extensive flame burns were prone to developing septicaemia due mainly to gram-positive bacteria. The surgical excision of eschar and wound covering improved the outcome of the patients while prophylactic antibiotic treatment had no role in the incidence and outcome of the burn patients.

Out of 943 patients treated from June 92 to May 96 at the burns unit of the Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, 280 (30%) required admission to the burns intensive care unit (ICBU) and were studied retrospectively. Seventy-nine (28.2%) developed clinically and microbiologically proven septicaemia. Forty-four (56%) were males, 35 (44%) females with a mean age of 26 years (range 45 days to 75 years) and mean total body surface area burn (TBSA) of 46% (range 10-90%). Sixty-two had flame burns, 16 a scald and one had an electric burn. These 79 patients had a total of 118 septicaemic episodes. Sixty (76%) had only one and 19 (24%) had multiple episodes of septicaemia. Fifty-four (68%) had their first episode within 2weeks, though the maximum number of episodes was between 6 and 10 days postburn. Septicaemia was also observed in 13% of patients within 3 days postburn. Out of the 118 episodes, 48 were due to methicillin resistant Staphylococcus aureus (MRSA), 17 due to methicillin resistant Staphylococcus epidemidis (MRSE), 15 to Pseudomonas, 12 to Acinetobacter, four to Streptococcus, another four to Enterococci, two to Klebsiella, one due to Serratia and 15 to more than one organism. Once the septicaemia was diagnosed appropriate therapy was instituted. Fifty-six (71%) patients had 143 sessions of skin grafting and the mortality was low in operated patients. Twenty-three (29.1%) patients died. The low mortality rate was probably due to factors such as continuous clinical and microbiological surveillance leading to quick detection of aetiology, appropriate antibiotic therapy, care for nutrition and early wound cover. This study suggests that flame burn patients are more vulnerable to sepsis. Onset of septicaemia may be as early as 3 days and commonly within 2 weeks. A surface wound is the likely source of entry to the blood stream. Gram positive organisms are dominant in the aetiology. Early detection and appropriate treatment including wound coverage result in a better outcome.

This study analyses staphylococcal septicaemia in a series of 1516 burn patients who were admitted to the burn unit of the Al-Babtain Centre for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait over a period of 6.5 years (1 June 1992-31 December 1998). One hundred and nine patients (7.2%) developed clinically and microbiologically proven septicaemia, of which 80 (73.4%) showed one or the other type of Staphylococcus in their blood. Fifty (62.5%) of them were males and 30 (37.5%) females, with a mean age of 26 years and the mean total body surface area of burns (TBSA) of 45% (range 1-93%). Preschool age children comprised 27.5% of the patients. Flame was the dominant (80%) cause of burn. Of the 80 patients who had 91 episodes of septicaemia, 52 (65%) had MRSA, 8 (10%) MSSA, 11 (13.8%) MRSE and 5 (6.2%) MSSE and 4 (5%) others had mixed organisms. Only the patients with MRSA had multiple episodes. Eight patients (10%) showed septicaemic episodes within only 48 h of admission; however, the majority of the patients (77.5%) had a septicaemic attack within 2 weeks postburn. Of the 52 MRSA septicaemic cases, 39 (75%) survived and 13 (25%) died. Four patients with septicaemia due to mixed infections died. A total of 19 patients were intubated, 14 due to inhalation injury and 5 because of septicaemia; all in the former group died. Glycopeptide therapy (vancomycin/teicoplanin) was instituted immediately following the detection of staphylococci in the blood. No significant difference was noted in relation to mortality amongst the septicaemic patients, whether or not on prophylactic antibiotic. Fifty-six (70%) of the 80 patients had 139 sessions of skin grafting and survived. Of the 52 MRSA patients, 40 had 101 sessions of skin grafting and 33 of them survived. The apparent low mortality was probably due to early detection of the organism, appropriate antibiotic therapy, care for nutrition and early wound cover. This study indicates a high incidence of staphylococcal septicaemia (especially due to MRSA) in the burn unit. A surface wound is the likely source of entry to the blood stream in these immunocompromised patients. The organism could be detected in blood as early as 48 h postburn and in as little TBSA burn as 1% in this MRSA endemic unit. Inhalation injury with major burns and added staphylococcal septicaemia invariably proved to be fatal.