Changing pattern of fungal infection in burn patients
Introduction
Despite all advances in the field of medical care, in patients with severe burns, 75% of all deaths are currently related to sepsis from infection in the burn wounds or its other complications. Till a few years ago the burned surface was considered to be a suitable site for opportunistic colonization and invasion by bacteria of both exogenous and endogenous source, only because of large surface area involved and long duration of hospital stay. But early wound excision and skin grafting and use of effective topical and systemic antimicrobial therapy has led to a significant decline in the morbidity and mortality from bacterial burn wound infection.
However, secondary opportunistic infections still continue to complicate and alter the course of recovery of patient from burns. Amongst these, invasive wound infection due to Candida spp., Aspergillus spp. and other opportunistic fungi are now emerging as important causes of late onset morbidity and mortality in patients with major burns whose immune system is severely perturbed [1], [2], [3], [4], [5], [6], [7]. Lowered body immunity due to burns especially in extremes of age groups and large BSA burnt (30–60%), diabetes, inhalation injury, prolonged hospital stay, artificial ventilation and other co morbidities increase the risk for fungal infection in burn wound [8]. These infections usually occur in or after the second week of thermal injury in patients who have received multiple antimicrobials. The fungi colonizing the burn wounds are found either in the surrounding environment or as in case of Candida spp. as commensals from the patient's own gastrointestinal tract or respiratory tract flora [1], [3]. The actual problem of fungal infection in burns has till now been neglected and available data is only the tip of an iceberg. No study highlights the problem in developing countries even though it is a growing menace.
The true incidence and significance of fungal infections in burns is difficult to determine because of problems with detection. Contamination of urine, respiratory tract and skin by fungal organisms particularly Candida albicans is also extremely common. There are no specific signs and symptoms nor appearance of wounds linked specifically to fungal infection. Certain signs like fever, diarrhoea, vomiting, etc. are not discriminatory for only fungal or bacterial infection alone in burn patients. Fungal infections are therefore notoriously difficult to diagnose on clinical evidence alone [9]. The clinical data pertaining to fungal infection in burn wound in different units has not been documented in the past mainly because of this reason and also because of lack of clinical awareness coupled with scarcity of mycology laboratories.
The purpose of this multiphase study is to (1) evaluate the extent of the problem of fungal wound invasion in burn patients in our unit, (2) its impact on mortality, (3) to determine features predictive of this infection and (4) formulating a treatment protocol for the patients suffering from FWI.
Section snippets
Method
The current studies were conducted in the Department of Burns and Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, which is famous for having one of the largest dedicated burn unit in Asia with an average of more than 2000 burn admissions per year, in association with Department of microbiology. The studies followed a pilot study which was done in our unit over 1 year (Jan 2008–March 2009). The exclusion criteria and methodology for diagnosis of FWI was the same in
Results
In our first study of 100 patients, wound biopsy of 12 patients (12%) was positive for fungal growth and concomitantly urine and blood culture was positive in 8 cases (8%) and 4 cases (4%) respectively. No urine or blood sample tested positive for fungal pathogen in whom the wound biopsy specimen was negative. There was no significant predilection of fungal infection for any particular age group though majority of the patients (8 patients – 66.7%) growing fungus in their wounds belonged to the
Discussion
A tenfold rise in fungal burn wound infection has been observed globally since 1960s due to the introduction of topical and systemic broad spectrum antimicrobial agents. Invasive burn wound sepsis has been known to be most commonly caused by fungi since 1992 as reported by Pruitt and McManus [6]. It is the ubiquity of fungi in environment along with suppression of normal bacterial flora which promotes fungal super infection in burns. But these are usually missed because of lack of clinical
Summary
A lot of effort has been put into treating life threatening gram negative bacterial septicaemia in burns but often the bacterial culture is negative yet the patients deteriorate, develop fever and sepsis and finally die. No attention was paid towards the cause for this increasing mortality for a long time till we started the hunt for a new organism responsible for these unfortunate events. Our investigations and study suggested that all such patients are usually suffering from fungal sepsis
Conflict of interest
The authors have no conflict of interest to declare.
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