DTIC ADA629397: Central Nervous System Infections in Patients with Severe Burns

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1. REPORT DATE 2. REPORT TYPE 3. DATES COVERED
01 AUG 2010 N/A -
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Central nervous system infections in patients with severe burns
5b. GRANT NUMBER
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
Calvano T. P., Hospenthal D. R., Renz E. M., Wolf S. E., Murray C. K.,
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7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
United States Army Institute of Surgical Research, JBSA Fort Sam REPORT NUMBER
Houston, TX
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Standard Form 298 (Rev. 8-98)
Prescribed by ANSI Std Z39-18
burns 36 (2010) 688 691 689
(CNS)[2].CNSinfectionsinpatientswithoutburns,suchas 3. Results
bacterial meningitis, are typically community onset with
infections due to Streptococcus pneumoniae and Neisseria ThetotalnumberofadmissionstotheBurnUnitforthermal
meningitis. In the case of head trauma resulting in shunts burns was 1964 with 694 patients from Operation Enduring
ordirectCNSpenetration,nosocomialinfectionscanoccur Freedom/OperationIraqiFreedom,97.8%malesandamedian
with gram negative organisms (over 50% of cases) such as ageof38(range19 52).Ofthe1270civilianandmilitary(not
Pseudomonas aeruginosa and Acinetobacter, and also Staphylo Operation Iraqi Freedom/Operation Enduring Freedom)
coccus species (25% of cases) [4 6]. The rate of developing patients,78.8%weremaleswithasoverallmedianageof54
nosocomial meningitis is rare in the hospital without (range11 96).Fromalladmissions,12patientshadsuspected
antecedentheadtraumaorpriorinfection[7,8].Burnreviews CNSinfectionsbychartreview,ofwhom2patients(0.1%ofall
have reported facial burns and head trauma as being burn admissions)werenoted to have bacteria isolatedfrom
associated with CNS infection [4]. There are several case theirCSFculture,confirmingCNSinfection(Table1).Bothof
reports that correlate burns with brain abscesses [9]; these patients were Operation Iraqi Freedom/Operation
however, incidence and etiologies are not known. A post Enduring Freedom soldiers who had sustained facial burns
mortem study examining CNS complications of thermal andheadtraumarequiringintracranialsurgerywithcraniec
burnsfrom1992reported10.1%ofcaseswithbrainabscess; tomies. In addition, both patients had bacteremia with
however,thisfindingwasnotpresentinamorerecentburn identical microorganisms as isolated from CSF (Acinetobacter
autopsy review [2]. Current published literature is not baumannii and methicillin resistant Staphylococcus aureus
available and prior literature fails to identify incidence (MRSA).
andrateofCNSinfectioninassociationwiththermalburns Ofallpatientswithburnswhowereadmitted,560(28.5%)
and head injury. We set out to find the incidence of CNS hadheadornecktraumaandburns.Twenty sevenpatients
infections in a burn unit and identify any associated risk (4.8%ofallthosewithheadorneckburns)alsohadheador
factors,includingfacialburnsorCNStrauma. necktrauma.Of1964patientsadmitted,only0.1%hadaCNS
infection, 100% of whom also had trauma and burns to the
headandneckandweresoldiers.Onehundredandtwenty
2. Methods five patients had a surgical procedure to either harvest the
scalpordebridethescalpinthesettingofscalpburns,outof
TheUSArmyInstituteofSurgicalResearchBurnCenterisa40 which 9 patients had an invasive surgical procedure that
bed burn unit which serves both Department of Defense involvedpenetrationoftheskull.Fouroutofthose9patients,
beneficiaries,includingcasualtiesfromthewarsinIraqand receivedcraniectomiesand5patientshadtrephinationofthe
Afghanistan, and a local civilian population from southern skullduringtheprocessofdebridement.Outof125patients
Texas.Burnpatientcareconsistsofaggressiveresuscitation withsurgicalproceduresofthehead,onlytwopatients,who
uponarrivalwithearlywounddebridementandskingrafting. underwent craniotomies, had evidence of CNS infections.
Intravenous perioperative antibiotics are administered to Therefore, scalp harvesting donor sites did not pose an
patientsundergoingsurgicalprocedures,andtypicallyconsist increasedriskfordevelopmentofCNSinfections.
ofvancomycinandamikacin.Topicalantimicrobialtherapies
are applied to the burns, the selection of which is at the
discretionoftheattendingphysician.Allpatientshavecentral 4. Discussion
venous access with routine replacement of central lines,
typically every 3 days. Patients are cared for in individual Infectionsaretheleadingcauseofmortalityinpatientswho
rooms under contact precautions during their entire hospi sustainsevereburns[1 3].Multiplefactorsareassociatedwith
talization. propensityofinfectioninburnedpatient.Extensivedestruc
Duringtheperiodof1July2003to30June2008,inpatient tionofprotectivecutaneousbarrier,presenceofnecroticand
electronicmedicalrecordswerescreenedforthepresenceof edematous tissues which tend to harbor microorganism
CNSinfectioninburnpatientsandtheclinicalmicrobiology growth, use of equipment for invasive monitoring during
records were screened for anyone with a culture obtained resuscitation, and impaired immunity are just a few con
from the CNS or from cerebrospinal fluid (CSF). Medical tributingfactorstoinfection[10].Thisstudywasdesignedto
recordswerereviewedforpatientdemographics(age,gender, describetheincidenceofCNSinfectionsinthesettingofburns
mechanism of injury, site of injury, injury as a result of and associated risk factors as current data is lacking in the
military operations), percentage of total body surface area literature.Ourstudyrevealsaverylowrateof0.1%forallburn
burnaswellasfullthicknessburnsandbodyregionofburn. patients,andlowrateseveninpotentiallyhigherriskpatient,
Evidence of polytrauma was identified in individual burn populations,includingthosewithfacial/headburns(0.35%)or
patients and all patients with facial or head injuries were directheadtrauma(1.3%),buthighrate(22.2%)ifthecranium
identified. Patients with neurosurgical procedures or any waspenetrated.
surgical procedure involving penetration of the skull, were Bacterial CNS infections (meningitis) are associated with
identified. CSF gram stains, cultures and antibiotic therapy significantmortalityandmorbidity,withthemajorityofacute
(both systemic and intrathecal), as well as duration of meningitiscasesinthecommunityduetoS.pneumoniaeand
antibiotictherapywerereviewed.CNSinfectionwasdefined Neisseriameningitidis,withanincidenceof2 3/100,000[2,11].Of
asoneormorepositiveCSFortissuecultures,withisolationof all meningitis, the incidence of nosocomial meningitis is
specificmicroorganisms. reportedtobeapproximately60%[12].Approximately30%of

burns 36 (2010) 688 691 691
patientswithCNSinfectionswereOperation IraqiFreedom/ [5] TangL,ChenS,HsuW,LyuR.Acutebacterialmeningitisin
Operation Enduring freedom soldiers who sustained head adults:ahospital basedepidemiologicalstudy.QJMed
1999;92:719 25.
traumaandunderwentinvasiveintracranialproceduresthat
[6] RamosL,CastedoJ,GalvanR,Garc´ıaC,IribarrenJ,Jime´nez
involved penetration of the skull, CNS infections were not
J.Incidenceofnosocomialinfectioninpatientswith
identifiedinthecivilianpopulationthatwasincludedinthe nontraumaticortraumaticcoma.CritCare2008;12:12.
study. [7] WeisfeltM,vandeBeekD,SpanjaardL,deGansJ.
IntheabsenceofsystematicallycollectedCSFonpatients Nosocomialbacterialmeningitisinadults:aprospective
withsystemicinfections,itisnotpossibletocorrelatewhether seriesof50cases.JHospitInfect2007;66:71 8.
[8] LeferingR,PaffrathT,LinkerR,BouillonG,NeugebauerE.
systemicongoinginfectionsareassociatedwithconcomitant
Headinjuryandoutcome whatinfluencedoconcomitant
CNSinfectionsorwhethertheseinfectionswereclearedwith
injurieshave?JTrauma2008;65:1036 44.
antibiotictherapy.
[9] SuzukiT,UekiI,IsagoT,NozakiM,HirayamaT,Kawanami
Inconclusion,CNSinfectionsinburnpatientsareveryrare O.Multiplebrainabscessescomplicatingtreatmentofa
andcompriseofonly0.1%patientswithburnsand0.35%of severeburninjury:anunusualcasereport.JBurnCare
patients with head/neck burns. However, in the small Rehab1992;13:446 50.
numbersinwhomtheskullwaspenetratedduringasurgical [10] AnserminoM,HemsleyC.ABCofburns:intensivecare
managementandcontrolofinfection.BMJ2004;329:
procedure22%ofthepatientsbecameinfected.Understand
221 3.
ingtheincidenceofCNSinfectionsinburnpatientsprovides
[11] HusseinAS,ShafranSD.Acutebacterialmeningitisinadults:
guidelines for preventative, diagnostic and therapeutic
a12yearreview.Med(Baltimore)2000;79:360 8.
actionsandaddressstrategiestoimproveoverallburncare. [12] KhwannimitB,ChayakulP,GeaterA.Acutebacterial
meningitisinadults:a20yearreview.SEAsianJTropMed
2004;35:886 92.
Conflict of interest [13] O’SheaM,CrandonI,HardingH,DonaldsonG,BruceC,
EhikhametalorK.Infectionsinneurosurgicalpatients
admittedtotheintensivecareunitattheUniversity
Theauthorshavenoconflictofinteresttoreport.
HospitaloftheWestIndies.WIndMedJ2004;53:159 63.
[14] PednonomosM,TsirantonakiM,PsomaG,KatsarelisN,
references KoukoulitsiosG,LafazanosS.Earlyandlateonset
nosocomialinfectionsinICUpatientswithheadinjury.Crit
Care2006;10:99.
[15] VartzeliP,YiambidesA,DaskalakisK,MoukasM,Schulpis
[1] RessnerR,MurrayC,GrffithM,RasnakeMS,Hospenthal K,MandragosK.Comparativestudyoninfectionofthe
DR,WolfSE.Outcomesofbacteremiainburnpatients centralnervoussysteminpatientswithheadtraumaand
involvedincombatoperationsoverseas.JAmCollSurg spontaneouscerebralhemorrhage.CritCare2008;12:13.
2008;206:439 44. [16] NgJ,GosbellIB,KellyJA,BoyleMJ,FergusonJK.Cureof
[2] GomezR,MurrayC,HospenthalD,CancioC,RenzE, multiresistantAcinetobacterbaumanniicentralnervous
HolcombJ,etal.Causesofmortalitybyautopsyfindingsof systeminfectionswithintraventricularorintrathecal
combatcasualtiesandcivilianpatientsadmittedtoaburn colistin:caseseriesandliteraturereview.JAntimicrob
unit.JAmCollSurg2009;208:348 54. Chemother2006;58:1078 81.
[3] D’AvignonL,SaffleJ,ChungK,CanacioL.Preventionand [17] AlbrechtMC,GriffithME,MurrayCK,ChungKK,Horvath
managementofinfectionsassociatedwithburnsinthe EE,WardJA,etal.ImpactofAcinetobacterinfectionon
combatcasualty.JTrauma2008;64:277 86. themortalityofburnpatients.JAmCollSurg2006;203:
[4] WinkelmanM,GallowayP.Centralnervoussystem 546 50.
complicationsofthermalburnsapostmortemstudyof139 [18] BleckTP, Nosocomial, Meningitis. Clin Infect Dis
patients.Med(Baltimore)1992;71:271 83. 2007;9:1 2.