对烧伤感染的认识过程

1958年，全民大炼钢铁的年代，大面积烧伤患骤然增多。我是首批受命跟随黎鳌院士进入第三军医大学西南医院烧伤病房的医务人员之一，至今已48年。回顾几十年来的历程，感受良多，此处只就防治烧伤感染方面谈点个人的体会。     

烧伤患者感染的防治

烧伤,尤其是大面积深度烧伤,由于皮肤损害、创面裸露,加之创伤应激、休克、固有免疫功能抑制等因素同时或相继发生,创面极易发生感染,轻者可贻误愈合,重则可诱发脓毒症,甚至多脏器功能衰竭,成为烧伤死亡的主要原因,因此烧伤感染一直是烧伤临床工作所关注研究的热点。     

浅谈临床防治烧伤感染对策

Prevention and treatment of infection in burn patients involve a wide range of issues. This present article is to introduce only briefly clinical experience focusing on this problem. Among them, satisfactory timely prevention and treatment of burn shock is imperative because it exerts tremendous impact on homeostasis, including especially deterioration of immune functions. Early gastro-intestinal feeding is known to help restore gastro-intestinal circulation after shock, and it is an important avenue to give important nutritional elements like glutamine. It is also very important to excise devitalized tissue, followed by total coverage of all open wounds as early as possible, so that nidus of infection is removed. Rational use of antibiotic, immunological modulation and other measured were also important contributory factors in successfully preventing and treating infection in patients with major burns.     

烧伤绿脓杆菌感染免疫防治的研究进展

本文综述了近年来烧伤绿脓杆菌感染免疫防治的现状,包括免疫制剂的种类、成份、免疫方法和临床疗效的观察,为临床防治绿脓杆菌感染提供新措施。     

防治烧伤感染还需要新理念新措施

当代,危重烧伤患者的最终死亡原因虽然多数是多器官功能衰竭,但烧伤引发多器官功能衰竭的主要原因仍然是感染。由于强调及时纠正休克、早期切痂植皮,危重患者的治愈率明显提高,但要进一步提高,需要有新理念和新措施。近期国内学术会议和本期杂志发表的有关防治感染的论文值     

从烧伤感染论外科感染的防治

烧伤感染在外科感染中是一较突出的问题。历经曲折的过程，认识到防治的关键在于外科干预。救治过程中应全面重视潜在的感染途径，包括肠源性感染。外科抗生素的应用应重视应用的时机和时限。对重症感染、抗凝疗法、强化胰岛素治疗和糖皮质激素用法的改进值得关注。     

防治烧伤感染，提高烧伤救治水平

烧伤后全身性感染一直是烧伤患者的主要死亡原因，约占７０％。许多烧伤中心的统计也都证实，因感染及其并发症所致死亡者占死亡原因的５０％以上。因此，烧伤感染始终是烧伤界关注的热门课题。一、烧伤创面感染创面感染不仅导致全身病理生理变化，诱发高代谢反应与骨髓抑...     

烧伤感染防治对策

Infection is still the major cause of death in severe burn patients, thus the optimization of antibiotic therapy is an important approach to the annihilation of pathogenic bacte-ria and the decrease of drug-resistance bacteria. It is urgent for burn surgeons to face the selection pressure of antibiotics and the fungous infections following the incorrect use of antibiotics. Re-gardless of its complexity, the treatment of sepsis associated with post-burn bacterial infections should be systematical. Besides the effective anti-shock therapy, early enteral feeding, excision of necrotic tissues, and effective anti-infection treatment, the immunological regulation and the prevention and cure of coagula-tion disorders are necessary in the treatment of severely burned patients.     

也谈严重烧伤感染治疗

Nowadays, it is necessary to emphasize the three basic inseparable elements in the treatment of severe burn infection, which are systemic care, burn wound care, and ra-tional use of antimicrobia/s topically or systematically. Systemic care has been shifted from simple nutritional support to maintai-ning the systemic homeostasis, including balancing immune-in-flammatory response, and protecting organs from dysfunction.Some work focused on regulating systemic immune response in the initial phase and the balance of inflammatory response after occurrence of severe burn infection have been reported. These results at least broaden our thinking to recognize that treatment should not only destroy microbes, but also balance the response of the body. Escharectomy in earlier phase has been a consen-sus. Currently, we turn our vision into how to use "damage con-trol surgery (DCS)" concept in management of severe burn.DCS in burn care includes the evaluation of perioperative situa-tion more accurate to make a more appropriate surgical decision. Meanwhile, an overall strategy should be established to confront the rapidly increasing drug resistance of the pathogens. The re-lease of endotoxin after use of antimicrobials, which has been studied widely, should be explored further.     

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 expeditious debridement of the infected tissue in successfully managing this dangerous infection.     

巨噬细胞在烧伤感染中的作用研究

感染和炎症反应是烧伤过程中重要的病理变化。近年来的研究表明 ,创伤或烧伤患者因体表生理防御屏障功能损害以及创伤、烧伤本身造成的应激反应 ,使机体免疫功能下降是导致细菌侵入、繁衍、增殖 ,引起全身性感染最终因脓毒症、多器官功能衰竭而死亡的主要原因之一[1-4] 。换言之 ,创伤后引起的较高死亡率与感染密切相关。炎症是白细胞、血浆蛋白在感染部位的聚集和激活 ;炎症反应也是一把双刃剑 ,适度的炎症可以动员机体的免疫防御机制 ,有利于控制感染保护宿主 ,但失控的、过强的炎症反应则会导致组织损伤疾病[5] 。巨噬细胞指单核吞噬细胞…     

The use of topical, un-buffered sodium hypochlorite in the management of burn wound infection

Background

Burn wound infections are a major cause of morbidity and mortality. The bactericidal action of sodium hypochlorite has been known for centuries and it has been in clinical practice for over 70 years. Whereas a buffered sodium hypochlorite solution is not universally available, an un-buffered solution is cheap and easy to prepare.

Aim

The aim of this study was to determine the optimum concentration with regard to safety and efficacy, as well as shelf life of an un-buffered sodium hypochlorite solution for the topical management of burn wound infections.

Methods

Human fibroblasts were exposed to serial dilutions of un-buffered sodium hypochlorite solutions for 30 min and assessed for viability. Isolates of Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus pyogenes were exposed to the same dilutions of un-buffered sodium hypochlorite to establish the minimum bactericidal concentration. The pH, osmolality and electrolyte concentrations were measured. These experiments were repeated with solution stored at room temperature for 6 consecutive days.

Results

24% of fibroblasts were viable after exposure to a 0.025% solution and 98.9% with a 0.003% solution. The MBC for the P. aeruginosa isolates was 0.003%, for S. aureus was 0.006% and for S. pyogenes was 0.0015%. This remained constant for 6 consecutive days. The un-buffered 0.0025% solution has a pH of 10, an osmolality of 168 sodium concentration of 89 mmol/dl and chloride of 84 mmol/dl. This remained stable for 14 days.

Conclusions

An un-buffered solution of sodium hypochlorite with a concentration of 0.006% would be suitable for the topical management of burn wound infections caused by common pathogens. It has a shelf life of at least 6 days.     

Aspergillus infection of the burn wound.

During a 15-year period, 18 patients with major burns developed a wound infection due to Aspergillus. Ages averaged 28 years, extents of burn were 54% (14-97%) BSA for total surface involvement and 42% (14-85%) BSA for full-thickness injury. Pseudomonas sepsis preceded Aspergillus infection in 16 cases. Thirteen of the episodes occurred in three epidemics, each apparently related to contaminated air-conditioner ducts and filters. Treatment was based upon wound excision in all 18 patients, with recurrence initially in each. Topical and parenteral antifungal agents were never individually successful in controlling the infection. Whenever fungal sepsis involved an extremity alone and thus amputation could rid the body of the entire infected site, survival could then be achieved. The overall mortality rate was 78%. Protection of the wound from Aspergillus colonization appeared to be the only reliable method of preventing this often lethal fungus infection.     

Impact of Acinetobacter infection on the mortality of burn patients

BACKGROUND: Acinetobacter calcoaceticus-baumannii complex (Acb) is recognized as an important cause of nosocomial infections. Although Acb can be associated with multidrug resistance, its impact on mortality in burn patients has not been fully elucidated. STUDY DESIGN: In a retrospective cohort study assessing medical records and microbiology laboratory data at a US military tertiary care burn center, we evaluated all patients admitted to the burn center between January 2003 and November 2005. Data collected included age, severity of burn, comorbidities, length of stay, and survival to hospital discharge. In addition, microbiology data were reviewed to determine which patients were infected with Acb during this time frame. These data were then used to compare patients infected with Acb to patients not infected. Multivariate analysis using logistic regression was performed to determine which patient characteristics were associated with increased mortality. RESULTS: There were 802 patients included in the study. Fifty-nine patients met the case definition for infection. An additional 52 patients were found to be colonized with Acb. Patients with Acb infection had more severe burns and comorbidities, and had longer lengths of stay compared with patients without Acb or those with Acb colonization. Mortality in infected patients was higher compared with those without infection (relative risk = 2.86, p = 0.001). On multivariate analysis, infection with Acb was not statistically associated with mortality. CONCLUSIONS: Multidrug-resistant Acb is a common cause of nosocomial infection in the burn patient population. Despite this, it does not independently affect mortality.     

对烧伤感染的认识

Burn infection occurs when pathogenic bacte-ria colonized on the burn wound surfate,and they then invaded the viable tissue causing sepsis or sepsis with blood stream inva-sion.This infection pattern is particular to burn injury.Both in a model of pseudomonas burn wound sepsis and a clinical study of early eschar excision for bacteria quantification indicate that the bacteria not only are located on the burn wound surface but also invaded the deeper tissues.Finally,the bacteria penetrate into the neighboring viable tissue and even blood ves-sels.Therefore,we can say that burn infection is from local wound infection to invasive infection.and finally sepsis is devel-oped,and it is termed as burn wound sepsis.The cutoff count of subeschar tissue bacteria is 105/g.However,the burn wound sepsis may not occur when the number of subeschar tissue bacteria reaches 105/g.The criteria for the diagnosis of burn wound sepsis are mainly listed as below:(1)The number of bacteria in the subes-char reaches≥105/g.(2)Bacteria can be detected in the biopsy specimen.(3)Sepsis associated symptoms and signs.However,the sepsis associated symptoms and signs must be obvious in patients to make the clinical diagnosis of burn wound sepsis.If the sepsis associated symptoms and signs do not ap-pear.we should not make the diagnosis of burn wound sepsis e-ven with the number of bacteria in the subeschar tissue reaching 105/g or bacteria can be found in the biopsy specimen.Sepsis has been defined as the body's response to bacteria and their products.The occurrence of sepsis depends primarily on immune function and stress response intensity.and it is closely related to wound infection degree such as bacteria density and invasion depth in the burn wound,or plasma endotoxin level to certain extent.     

Effects of environment on infection in burn patients

Burn patients in an early cohort (n = 173) treated in an intensive care ward without separate enclosures were compared with a later cohort (n = 213) treated in a renovated unit with separate bed enclosures. The number of patients developing infection was significantly reduced in the late group. Observed mortality was compared with mortality predicted on the basis of burn size and age alone. Reduction in observed compared with predicted mortality, inapparent in the early group, was seen in the late group and was restricted to the subgroup of patients with predicted mortality of 25% to 75%, in which the observed mortality of 28.3% was less than the predicted mortality of 48.7%. The incidence of infected patients was reduced from 58.1% in the early cohort to 30.4% in the late cohort. In comparison of the early cohort with the late cohort, the overall proportion of patients with bacteremia was reduced from 20.1% to 9.4%, while the incidences of both pneumonia and burn wound invasion remained unchanged. Providencia and Pseudomonas species, endemic in the early cohort, were eliminated in the late cohort. Reduction of infection by environmental manipulation in burn patients was possible and was associated with improved survival.