Features of nosocomial infections in patients with severe burn injury

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Nosocomial infections (NI) in patients with burn injury is one of the leading problems of modern healthcare. In terms of prevalence, they exceed those in patients with any other pathology. In the conditions of man-made disasters and in everyday life, violation of safety rules leads to burn injury. To study the prevalence of NI in patients with burns, identify risk factors and evaluate the effectiveness of the existing system of epidemiological surveillance of these infections, an analysis of publications on this topic on several information resources was carried out: eLibrary.RU, Google Scholar, PubMed and NCBI.

It was found that the most common form of NI in burn patients is a burn wound infection, which is treated by 38.8%, lower respiratory tract infections, including those associated with ventilation aids (19.7%), are in the second position, and bloodstream infections (8.1%) are in the third position. Urinary tract infections do not occupy such a significant place, however, their significant prevalence among patients outside the ICU has been noted in foreign literature. Despite the available data on the prevalence of certain clinical forms of NI, data on risk factors and a number of problematic issues that may be the subject of discussion and require their solution remain controversial. The risks of death are high due to the specifics of burn injury, with its frequent combination with inhalation trauma.

The system of epidemiological surveillance of NI in burn centers, including in the ICU, has some differences in approaches to identifying, recording, registering, and collecting information about the place and time of the greatest risk.

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Burn injury is one of the main causes of mortality and socio–economic losses in society [1, 2]. In the structure of the most common types of injuries, burn injury is found after road accidents, falls and injuries due to violence. According to WHO, approximately 6 million people annually seek medical help with burns. At the same time, the frequency of burns in the countries of the Organizations for Economic Cooperation and Development (OECD) currently reaches 1:1000 of the population per year [3]. In Russia, more than 0.5 million are registered annually. patients with burns, of which 71.5% are over 18 years old. In recent years, there has been a tendency to increase the number of victims with extensive and deep burns among other age groups, namely children under 3 years of age and the elderly [4, 5].
In some countries, special hospital registers of patients with burns have been developed. The register of patients with burns consists of detailed information about the characteristics of the injury, complications and methods of treatment. Data from national and international registers are actively used to determine the possibilities of organizational accessibility and to improve the quality of inpatient treatment of patients with burn injury. The most well-known are such registers as NBR (National Burn Repository), which combines data from burn centers in Canada and the USA, as well as Bi-NBR (Bi-National Burn Registry) - the register of Australia and New Zealand. There is no unified register of patients with burn injury in Russia, although there are reports on the activities of individual burn centers [6].
Burn injury has the most unfavorable clinical outcomes. For example, the mortality rate from burn injury per 100 thousand inhabitants in the USA ranges from 3.9 to 4.5, in Europe this indicator ranges from 2.8 to 35.4, in northeast Asia it is 18.4. Another indicator is hospital mortality, which with deep body burns in the Russian Federation is approximately 8.7% [4.7]. Similar results are given by a group of researchers from Harvard, who analyzed the frequency of deaths among patients with burns in the Department of surgery at Massachusetts General Hospital and found that with a burn injury it is 8.4 ± 2.6%. Risk factors for death from complications of burn injury are age over 60 years, burn area of more than 40% of the body surface and the presence of inhalation trauma [8]. In recent years, due to the improvement of protocols for the management of patients with burn injury, the frequency of deaths has been constantly decreasing. Thus, according to the NBR register, in the period from 2001 to 2010, there was a tendency to reduce the mortality from burns from 5.7% to 3.3% [4.6]. In one of the burn centers in Turkey, the mortality rate was 7.5% and varied among patients of different age groups. Thus, it was 3.9% among children, 12% among patients aged 18 to 64, and 24% in the group of people over 65, with p <0.001 [9]. V.A. Samartsev and co-authors in [10] noted an even higher, up to 75.0%, frequency of deaths after receiving thermal injury due to the addition of infectious complications. One of the main causes of death in patients with thermal trauma is infection [11]. With the addition of nosocomial infections and the development of sepsis, mortality according to domestic authors can be up to 41.9% [12, 13]. V.B. Turkutyukov et al. [14] found that purulent-septic infections (GSI) occur in 45.0% of patients of the burn center, which indicates the constant danger of contamination of the burn wound conditionally pathogenic microflora. N.V.Novitskaya and co-authors in [15] indicated that the incidence of GSI in the ICU of burn centers was significantly higher than the incidence in the ICU of other surgical departments and amounted to 339.8±9.0%.
According to a number of European clinics [16], the frequency of hospital infections in patients with burn injury averages 125.5%. Other sources confirm the importance of infectious complications as the causes of adverse outcomes in patients with burn injury and present the frequency of occurrence of the most common infectious conditions [17, 18]. According to the data of the majority of authors [13, 20, 21], among GSI in patients with thermal trauma, the largest share in the structure is accounted for by IOR (38.6%). So Joseph A. Posluszny Jr at al. It was shown that the proportion of IOR on average is 38.0%, while among operated patients the incidence was 4.38%, and among patients who did not undergo surgery - 1.55%, with p=0.012 [20]. According to [22], the IOR debut occurs on 5-7 days of the patient's stay in the department.
Another most frequent complication in patients with burn injury is nosocomial pneumonia, which, according to [23], occurs in 34.0% of patients, which coincides with INICC data [24]. In ICU patients of burn centers with ventilators, the frequency of VAP is 22.2% (95% CI 4.5 - 63.7) and more than 2 times higher than that in the surgical ICU - 11.0% (95% CI 9.7-12.5).
Bloodstream infections according to a number of European clinics [25] in terms of incidence density are 3 per 1000 days of hospitalization or 11.7 per 1000 days of vascular catheterization. Satosova N.V. [26] in her dissertation showed that in ICU patients of the burn center of St. Petersburg, the incidence of CAIC was 80.3 % (95% CI 70.9-90.6). According to INICC reports [24], the frequency of CAIC in the ICU of burn departments is no more than 0.004% (95% CI 0.002-0.01), and CAIMVP 5.0 % (95% CI 0.6–17.9). Specialists of the Center for Control of Infectious Diseases (USA) [27] compared the frequency of various ISMS among patients in the ICU of burn clinics and patients who were not in the ICU, and found that the frequency of CAIC in patients hospitalized in the ICU was 4 times higher than among patients of other departments of burn centers - 3.7 % (95%CI 1.2-5.8) vs. 0.8%. While CAIMVP occurred more often among patients of the burn department (4.8%) than among patients hospitalized in the ICU - 4.1% (95% CI 2.8-9.6). Risk factors for the development of CAIC, according to [26] were: inhalation trauma OR=1.81 (95%CI 1.03-3.2) p=0.02, repeated vascular catheterization OR=7.93 (95%CI 3.73-17.31) p=0.001, chronic alcoholism - OR=5.01 (95%CI 1.87-18.18) p=0.001. The author also conducted a correlation analysis, which showed that the frequency of CAIC depended on the duration of hospitalization (r=0.592, p=0.001), the depth of the burn (r=0.625, p=0.001) and its area (r=0.438, p=0.001). The CAIC debut occurred on 7-8 days from the moment of hospitalization, and the median duration of stay in the ICU of patients with CAIC was 18 days (from 2 to 152 days), whereas without it - on average 7 days (from 20 to 51 days).

Burn injury violates the integrity of the skin and mucous membranes, causing coagulation necrosis of the epidermis, various layers of the dermis and nearby tissues. The discharge of a burn wound is an ideal environment for the development of microorganisms, which leads to massive microbial invasion by both the endogenous (normal) microflora of the patient as a result of violation of natural barriers, and exogenous microflora, including hospital strains [21, 19, 28]. The overwhelming majority of authors indicate that conditionally pathogenic, gram-negative microorganisms (78.5%) from among the NGOB, such as P.aeruginosa and A.baumannii, predominate in the microbial "landscape" of ISMP pathogens in the ICU [21, 28]. The frequency of nosocomial infections caused by Pseudomonas spp. in the ICU, it ranged from 14.7% to 28.9%, depending on the geographical region [29].
Infection of the burn wound of patients with thermal trauma is more often caused by conditionally pathogenic microorganisms, which, due to their natural resistance to environmental factors, have formed, among other things, resistance to antibiotics. Currently, there is no consensus on which microorganisms are more often etiological agents of IOR. A number of authors [30, 32] in their publications cite data that gram-positive microflora plays a leading role in the etiology of IOR, which, according to [30], is 63.2% (95% CI 59.8-66.6%) in the crops of biomaterial from a burn wound. Among gram–positive microorganisms, bacteria of the genus Staphylococcus spp. - S. aureus and S.epidermidis are leading, and less often enterococci E.faecalis and E.faecium [13, 19, 28, 30]. Other authors note a tendency to increase in the etiology of IOR of gram-negative microorganisms, with a decrease in the etiological role of gram-positive bacteria [31]. In the publication [32], the authors point to the equivalent role of gram-positive and gram-negative microorganisms in the etiology of IOR. Among gram-negative bacteria, NGOB, such as P. aeruginosa, A. baumannii are considered the most significant in the etiology of IOR [23, 33, 34, 35]. With a relatively small proportion of microorganisms of the Enterobacteria family in the etiology of IOR, among them there is a tendency to increase antibiotic-resistant strains of microorganisms [23, 33, 34, 35, 36]. The authors note that among the enterobacteria contaminating the burn wound, the leading positions belong to the bacteria of the genus Klebsiella, the proportion of which corresponded to 47.2%, including 89.0% of them was K. pneumoniae. Other representatives of this family were distinguished much less frequently, for example, E. coli in 9.8%, and others - even less often. Participation of K. pneumoniae in the development of IOR was not relevant until recently, however, in recent years, IOR associated with K. rpeimopiae have become an independent problem not only due to an increase in the frequency of detection of this pathogen in a burn wound, but also due to the presence of antibiotic resistance in 89.7% of K. rpeimopiae strains due to ESBL production [36, 37].
Other authors are more inclined to believe that IOR cannot etiologically be associated with any one microorganism and is more often caused by their association [10]. Most often, IOR was caused by a combination of S. aureus with NGOB (P. aeruginosa, A. baumannii) and the Enterobacteriaceae family - K. pneumonia, E. coli. We agree with these authors, although we believe that the association may include not only bacteria, but also other representatives of the microcosm: fungi, viruses and protozoa [38]. Other publications [10] show that 60.0% of the associations are gram-negative microorganisms. In the course of treatment of burn patients, due to the duration of their stay in the hospital and the impact of many invasive diagnostic and therapeutic procedures, secondary contamination of the burn wound, including hospital eco-cookers, is possible. It has been established that the delayed elimination of pathogens from a burn wound and the development of mixed and superinfection is a characteristic feature of infectious complications in kombustiology [10].
With INDP, the microflora also has specific features. So according to Lazareva E.B. et al. [39] its structure is dominated by NGOB, among which bacteria of the genus Acinetobacter spp., P.aeruginosa, and Klebsiella spp. are more common. At the same time, polyresistant strains, as a rule, prevail among NGOB and enterobacteria [39].
In a study [26] devoted to CAIC in the ICU of the burn center, it was found that in their etiology, S. aigeis were leading in 26.8% and in 12.0% of cases - P. aegidiposa and A. baumannii.
Another urgent problem for ICU burn centers is the resistance of microorganisms to antibiotics. Due to the peculiarities of the course of the infectious process, different terms of hospitalization, operations and the existence of microorganisms in the form of biofilms, the microflora is transformed and often becomes highly virulent, multi-resistant and even pan-resistant to most antibiotics used in the treatment. Parviz Owlia et al. A study of antibiotic resistance of A. baumannii strains was conducted among adult patients with burns hospitalized in clinics in Iran [40]. The authors noted a high prevalence of A. baumannii resistant to carbapenems, in particular to imipenem in 85.0%. Also, extremely high resistance rates were noted to fluoroquinolones (ciprofloxacin) - 95.1%, and aminoglycosides (amikacin) – 93.0%. Resistance to gentamicin (62.0%) and tobramycin (58.0%) was somewhat less pronounced [120]. According to N.A. Gordinskaya et al. the level of antibiotic resistance of A. baumannii strains isolated from the burn wound of patients was lower than that of Parviz Owlia et al. [40], and was 58.9% to meropenem, 53.5% to imipenem and 88.5% to ciprofloxacin. According to INICC and US NHSN data, from 30.5% to 42.1% of P. aeruginosa strains were resistant to antibiotics from the fluoroquinolone group, to piperacillin/tazobactam – from 20.2% to 36.2%, to imipenem/meropenem – from 23.0% to 47.2%, to cefepime – from 12% to 100% [24]. According to the REVANCHE and RIORITA studies conducted in Russia, the frequency of P.aeruginosa isolation in the ICU among all gram-negative microorganisms reaches 29.9–34.6%, while strains resistant to ciprofloxacin account for 65.1%, piperacillin/tazobactam – 42.4%, imipenem – 39%, and cefepime - 58.6% [29].
According to [26], during the study of the epidemic process of CAIC caused by S.aureus, P.aegidiposa and A.baumannii, genetic typing of strains of microorganisms isolated not only from the blood of patients, but also from the hospital environment, hands, clothing of medical personnel and air of the intensive care unit was carried out. The leading factors of nosocomial infection of CAIC were the hands of staff, objects of the external environment. The author considered the hands and clothes of the staff to be an important factor in the transfer of S.aureus strains to the ICU. For P.aegidiposa, the main objects in the transfer were the objects of the external environment - a solution for the rehabilitation of the tracheobronchial tree, a treatment table. The objects for the spread of A.baumannii are the surfaces of the respiratory circuit, equipment for probe feeding, air conditioning doors in the ward, clean sheets and mattresses, table surfaces in the operating room, an intubation blade. In the same study, the resistance of strains of microorganisms isolated from patients' blood to antibiotics was analyzed. The data obtained testified to the belonging of microorganisms to hospital strains and the need for microbiological monitoring to determine the so-called "microbiological portrait" of the department, which makes it possible to form an antibacterial therapy strategy based on the identification of patients with an increased risk of CAIC, as well as to determine the scheme of empirical therapy together with a clinical pharmacologist [26]. The author has identified such patterns in the work of personnel that affect the occurrence of CAIC, as the repeated use of disposable consumables (probe and solution for the rehabilitation of the tracheobronchial tree, a syringe for the sanitation of the bladder); the absence or non-compliance with algorithms for the care of the CVC, MC, respiratory circuit; the absence or non-compliance with algorithms for the assembly of the system and preparation of solutions for intravenous injections and infusions, blood collection for analysis from the CVC. Such procedures also contribute to the implementation of the contact mechanism and the direct route of transmission of the causative agent of CAIC from the source to the susceptible patient. The author believed that the main mechanism of transmission of KAIK pathogens is contact, and the main factor is the hands of medical personnel. In order to timely identify the sources and establish the ways of transmission of GSI, the author recommended conducting prospective epidemiological surveillance of patients with burn injury using a standard case definition [26].
Carrying out risk-oriented anti-epidemic measures in medical organizations allows minimizing the likelihood of the development of GSI, although it is impossible to completely eliminate it. It is not possible to provide individual isolation of patients with nosocomial infections, especially caused by multi-resistant hospital strains of microorganisms [29, 33, 35, 36, 43]. Anti-epidemic measures in the ICU of the burn center should be directed to the second and third links of the epidemic process, i.e., on the transmission path, as well as to susceptible contingents, i.e., patients and staff of the Ministry of Defense. Although some authors believe that the prevention of GSI should be focused on a multimodal strategy and include a whole range of anti-epidemic measures. [46].

ai antiepidemic measures allowed to minimize the frequency of GSI, although it is not possible to completely eliminate the risk of infection. According to the authors, the most promising of the GSI control measures in the ICU are those aimed at the pathways, factors of transmission of infection and at patients, staff of medical organizations. Although some authors believe that the prevention of GSI should be focused on a multimodal strategy and include a whole range of anti-epidemic measures.

Thus, GSI is especially relevant for patients with severe burn injury hospitalized in the ICU. The incidence of GSI in the ICU of burn centers exceeds that in the ICU of other surgical departments, which is due to the specifics of the thermal lesions themselves, as well as a high degree of aggression of the therapeutic and diagnostic process. Regarding the etiology, most authors point to the predominance of opportunistic pathogens. Antibiotic resistance is an equally urgent problem for ICU burn centers. The introduction of a risk-based approach to the organization of anti-epidemic measures in medical organizations has made it possible to minimize the frequency of GSI, although it is not possible to completely eliminate the risk of infection. According to the authors, the most promising of the GSI control measures in the ICU are those aimed at the pathways, factors of transmission of infection and at patients, staff of medical organizations. Although some authors believe that the prevention of GSI should be focused on a multimodal strategy and include a whole range of anti-epidemic measures.

Additional information

Financing. The search and analytical work was carried out at the personal expense of the author's team.

Conflict of interest. The authors declare that there is no conflict of interest.

Participation of authors. All the authors made a significant contribution to the search and analytical work and preparation of the article, read and approved the final version before publication.


About the authors

Yuliya Kutlaeva

Ural State Medical University

Author for correspondence.
Email: nostra.87@mail.ru
ORCID iD: 0000-0002-7090-3534
SPIN-code: 6072-1637

Candidate of Medical Sciences, Associate Professor of the Department of Hygiene and Ecology Ural State Medical University, Epidemiologist of the Department of Clinical Epidemiology Center for Public Health and Medical Prevention

Russian Federation

Alla Alexandrovna Golubkova

Email: allagolubkova@yandex.ru


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Свидетельство о регистрации СМИ № 014448 от 08.02.1996 г. выдано Федеральной службой по надзору в сфере связи, информационных технологий и массовых коммуникаций (Роскомнадзор). 
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