Current approach to prevention and treatment of Pseudomonas aeruginosa infections in burned patients.

The extensively burned or severely injured patient is at increased risk of wound infection as well as of infection of other organs as a result of various degrees of impairment of host defense mechanisms. The incidence of burn wound and other infections increases as the severity of injury increases. The ease with which gram-negative, opportunistic organisms, especially Pseudomonas aeruginosa of either endogenous or exogenous origin, can colonize and invade the immunosuppressed patient demands an active infection-surveillance program. Topical therapy for burn wounds with any of three available agents has significantly reduced the occurrence of invasive pseudomonas burn-wound sepsis, but none of the agents sterilize the burn wound, and the microbial flora of the burns of any given patient may escape from control and invade viable tissue. Clinical identification and biopsy confirmation of invasive burn-wound sepsis necessitates changes in both wound and general care, with surgical and antibiotic treatment guided by the extent and depth of wound invasion. Immunologic prophylaxis and treatment of pseudomonas infections, although attractive, remain of unverified clinical effectiveness. Effective treatment of pseudomonas septicemia secondary to invasive burn-wound sepsis and of pseudomonas infections in other organs is dependent on early diagnosis, appropriate antibiotic therapy guided by sensitivity testing, and adequate surgical intervention when required.

Fungal infection of the burn wound.

Six of 92 patients with invasive mycotic infection of the burn wound survived. These patients demonstrate the value of prompt diagnosis and expdeitious debridement of the infected tissue in successfully managing this dangerous infection.

The relationship of central venous and pulmonary artery catheter position to acute right-sided endocarditis in severe thermal injury.

Autopsies of 1,105 burned patients completed from January 1951 through March 1977 were reviewed at the United States Army Institute of Surgical Research to investigate the relationship between central venous and pulmonary artery cannula use and the incidence of endocarditis. The incidence of endocarditis increased from 3.4 to 9.4% after 1969 when cardiac injury attributed to central venous cannula use was first noticed at autopsy. Since 1969, right heart nonbacterial and bacterial endocarditis has dramatically increased and the right heart has become the prevalent site of the cardiac lesions. Review of premortem chest roentgenograms from 14 recent autopsy cases with right heart endocardial injury confirmed that central venous catheter tips were placed in the vicinity of the right atrium or right ventricle in 86% of the cases. Pathogenetically, the majority of the infected right heart lesions are probably the result of cannula-induced injury, with subsequent thrombosis and later bacterial colonization during episodes of bacteremia which are common in burned patients.

Ocular flora in the severely burned patient.

One hundred six eyes of 53 patients with severe thermal burns were studied with serial conjunctival cultures during a four-month period. A dramatic shift of the normal conjunctival flora from the preponderance of Staphylococcus epidermidis and Corynebacterium to S aureus and Gram-negative bacilli was observed. This commonly occurred on the fifth to sixth postburn day and represented colonization of the conjunctiva by bacteria recovered from other sites in the body. Despite the high incidence of Pseudomonas aeruginosa isolates (34%) of these eyes, deleterious effects were noted in only three eyes in two patients in whom infectious corneal ulcers developed before these patients died.

Isolation of Vibrio alginolyticus from wounds and blood of a burn patient.

Isolation of Vibrio alginolyticus from the wounds and blood of a burn patient is reported. Numerous tissue biopsy sites as well as one blood culture yielded the organism. The case history and a review of the hospital course of the patient is provided where relevant to the presence and identification of the organism. The bacteriologic, biochemical, and anti-microbial identification of the organism is described. Taxonomy, habitat, and pathogenicity of V. alginolyticus are discussed.

The quantitative swab culture and smear: A quick, simple method for determining the number of viable aerobic bacteria on open wounds.

The quantitative swab culture is a reliable method for quantifying the number of viable bacteria colonizing open wounds. For open wounds in burn patients, the swab bacterial count is linearly related to biopsy quantification of viable bacteria in the underlying tissue. This technique is simple and requires no surgical manipulation of the wound. For a wound of uniform appearance, the standard deviation of a single swab culture from the mean log bacterial count for a series of cultures from widely spaced areas on the wound is +/- 0.85 logs; 95% confidence limits are +/- 1.7 logs from the mean. A Gram-stained smear from a wound swab requires less than 10 minutes to prepare. Visualization of bacteria on the smear indicates that 106 or more bacteria per swab are present. The value of the smear and swab techniques for predicting safe wound closure may be inferred from the published reports of others and the direct relationship between the swab and biopsy counts of viable bacteria for open wounds.