Bacteriological cultures on admission of the burn patient: To do or not to do, that's the question.

INTRODUCTION: In many burn centers, routine bacteriological swabs are taken from the nose, throat, perineum, and the burn wound on admission, to check for the presence of microorganisms that require specific measures in terms of isolation or initial treatment. According to the Dutch policy of "search and destroy," for example, patients infected by multiresistant bacteria have to be strictly isolated, and patients colonized with ß-hemolytic Streptococcus pyogenes must receive antibiotic therapy to prevent failed primary closure or loss of skin grafts. In this respect, the role of bacteria cultured on admission in later infectious complications is investigated. The aim of this study is to assess systematic initial bacteriological surveillance, based on an extensive Dutch data collection. MATERIALS AND METHODS: A total of 3271 patients primarily admitted to the Rotterdam Burn Centre between January 1987 and August 2010 with complete bacteriological swabs from nose, throat, perineum, and the burn wounds were included. For this study, microbiological surveillance was aimed at identifying resistant microorganisms such as methicillin-resistant Staphylococcus aureus (MRSA), multiresistant Acinetobacter, and multiresistant Pseudomonas, as well as Lancefield A ß-hemolytic streptococci (HSA), in any surveillance culture. The cultures were labeled as "normal flora or non-suspicious" in the case of no growth or a typical low level of bacterial colonization in the nose, throat, and perineum and no overgrowth of one type of microorganism. Further, the blood cultures of 195 patients (6.0%) who became septic in a later phase were compared with cultures taken on admission to identify the role of the initially present microorganisms. Statistical analysis was performed using SPSS 20.0. RESULTS: Almost 61% of the wound cultures are "non-suspicious" on admission. MRSA was cultured in 0.4% (14/3271) on admission; 12 out of these 14 patients (85.7%) were repatriated. Overall, 9.3% (12/129) of the repatriated patients were colonized with MRSA. Multiresistant Acinetobacter or Pseudomonas was detected in 0.3% (11/3271 and 10/3271, respectively). In total, 18 of the 129 repatriated patients (14%) had one or more resistant bacteria in cultures taken within the first 24h after admission in our burn center. On admission, S. pyogenes was found in 3.6% of patients (117/3271), predominantly in children up to 10 years of age (81/1065=7.6%). CONCLUSIONS: Resistant bacteria or microorganisms that impede wound healing and cause major infections are found only in few bacteriological specimens obtained on admission of patients with burn wounds. However, the consequences in terms of isolation and therapy are of great importance, justifying the rationale of a systematic bacteriological surveillance on admission. Patients who have been hospitalized for several days in a hospital abroad and are repatriated show more colonization at admission in our burn center. The microorganisms identified are not only (multi)resistant bacteria, showing that a hospital environment can quickly become a source of contamination. These patients should receive special attention for resistant bacteria. HSA contamination is observed more frequently in younger children. Bacteria present at admission do not seem to play a predominant role in predicting later sepsis.

Successful control of widespread methicillin-resistant Staphylococcus aureus colonization and infection in a large teaching hospital in the Netherlands.

OBJECTIVE: The low prevalence of infection and colonization with methicillin-resistant Staphylococcus aureus (MRSA) in The Netherlands is ascribed to a national "search-and-destroy" policy. We describe the measures that were implemented to control widespread MRSA colonization and infection in a Dutch hospital. DESIGN: Descriptive intervention study. SETTING: Teaching medical center with a capacity of 679 beds, including 16 intensive care beds. INTERVENTIONS: MRSA colonization and infection were identified using conventional culture with a selective broth. Isolates were typed using pulsed-field gel electrophoresis. Measures to control the epidemic included screening of contacts (patients and hospital staff), screening of patients at readmission or discharge, strict isolation of MRSA-positive patients, decolonization of colonized staff and patients, the development of an electronic signal identifying MRSA-positive patients, and the development of a culture information-system for hospital personnel. RESULTS: Awareness of uncontrolled dissemination of MRSA began in November 2001. Because the clone involved had a low minimum inhibitory concentration for oxacillin, at first it was not recognized as MRSA. In February 2002, when major screening efforts started, it appeared that MRSA had spread all over the hospital and that many staff members were colonized. By the end of December 2005, a total of 600 patients and 135 staff members were found to be newly colonized. The yearly incidence of cases of MRSA colonization and infection decreased from 351 in 2002 to 56 in 2005. Typing of the isolates showed that 3 MRSA clones were predominant. Outbreaks of colonization involving these clones did not occur after 2003. CONCLUSION: Our observations show that strict application of "search-and-destroy" measures can effectively control a huge epidemic of MRSA colonization and infection.

[Clinical thinking and decision making in practice. A young woman with fever, arthralgia and exanthema]. / Klinisch denken en beslissen in de praktijk. Een jonge vrouw met koorts, artralgie en exantheem.

A 19-year-old woman was admitted because of high fever, rash, arthralgia and sore throat. On physical examination a diffuse skin rash was observed, leaving a facial mask unaffected. C-reactive protein and erythrocyte sedimentation rate were raised (114 mg/l and 26 mm in the first hour, respectively); white blood cell count was normal (6.2 x 10(9)/l) with an increased count of immature forms. An infective, metabolic or haematological cause was excluded. Serum ferritin turned out to be extremely elevated (4318 micrograms/l), so adult-onset Still's disease was diagnosed. The patient fulfilled the criteria of Cush et al. for adult-onset Still's disease. She was first treated with non-steroidal anti-inflammatory drugs (NSAIDs) and, at a later stage in the disease, with corticosteroids. All symptoms disappeared and blood test results normalised.