Common clinical presentations and antimicrobial resistance pattern among burn patients, at Addis Ababa Burn and Emergency Trauma Hospital (AaBET), Addis Ababa, Ethiopia

doi:10.21203/rs.3.rs-2712438/v1

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Research Article

Common clinical presentations and antimicrobial resistance pattern among burn patients, at Addis Ababa Burn and Emergency Trauma Hospital (AaBET), Addis Ababa, Ethiopia

https://doi.org/10.21203/rs.3.rs-2712438/v1

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Background: Burn is a very devastating form of trauma, which is responsible for a significant percentage of morbidities and mortalities caused by injury and accidents worldwide. Thermal injury destroys the skin barrier that normally prevents invasion of microorganisms and makes burn wounds susceptible site for colonization by microorganisms of endogenous and exogenous origin.

Methods:A prospective cross-sectional study was held at Addis Ababa Burn, Emergency and Trauma (AaBET) Hospital, Addis Ababa, Ethiopia, from December 01, 2020 to November 30, 2021. Data collected using structured and pretested questionnaire through face-to-face interview. Then, by observing standard procedures wound swabs collected from all consented participants and evaluated for possible microbial isolates and their antibiotic resistance and sensitivity pattern. The extracted data analyzed using SPSS 20.1. This study was conducted following approval of the Saint Paul’s Hospital Millennium Medical College Institutional Review Board.

Result: From a total of 75 patients who consented for the study, males account 53.3% (n=42), and age ranged from 6 months to 76 years, with the median age being 19 years. Children less than 15 years old account 42.7% (n=32). Flame burn was the leading cause (n=30, 40%) followed by a scald burn (n=22, 29.3%) and high voltage electric burn (n=21, 28%). Pseudomonas aeruginosa was the commonest isolate (42 isolates; 61.7%) followed by Staphylococcus aureus (18 isolates; 26.4%). A significant percentage of the positive swab results were monomicrobial (84.7%) as compared to those polymicrobial isolates (15.3%). Pseudomonas aeruginosa was found to be highly sensitive to Meropenem, Tobramycin, Gentamycin, and Ciprofloxacillin, while it showed high resistance to ceftriaxone and ceftazidime, Cotrimoxazole, Amoxicillin-clavulanic acid.

Conclusion: Pseudomonas aeruginosa is the most common bacteria isolate from burn wounds of the study participants and it is sensitive to Meropenem, Tobramycin, Gentamycin and Ciprofloxacillin; but resistant to Ceftriaxone and Ceftazidime.

Burn

Microorganisms

Antimicrobial Resistance

Addis Ababa

Ethiopia

Burn is a very devastating form of trauma which is responsible for a significant percentage of morbidities and mortalities caused by injury and accidents. AS the WHO report indicates on the year 2004 globally there were 11 million burn accidents which were severe enough to need for medical attention. Globally every year an estimated amount of 180,000 death occurs due burns, among which the vast majority occur in low- and middle-income countries [1]. Although, multiple causes can be sited as an immediate cause of mortality in severely injured burn patients, burn wound infection followed by sepsis remains an important cause by being responsible for 75% the deaths [2]. Thermal injury destroys the skin barrier that normally prevents invasion of microorganisms, and makes burn wound susceptible site for colonization by microorganisms of endogenous and exogenous origin. In addition, decreased vascularity found in burned surfaces will significantly decrease the effectiveness host immune defense and systemically administered antibiotics. These factors contribute for development of invasive burn wound infections, which are the most frequent origin of sepsis in burn patients [1–3].

Invasive burn wound infections are largely associated with various host factors including age of the patient, extent of injury, and depth of burn. In addition, microbial factors such as type and number of organisms, enzyme and toxin production and systemic dissemination of the colonizing organisms could also determine the severity of burn infections [4, 5].

According to research reports gram-positive bacteria from the patient’s endogenous skin flora or the external environment are the first ones to colonize the burn wound [6, 7]. Then in the first few days following injury burn wound will be colonized by endogenous gram-negative bacteria from the patient’s gastrointestinal flora. Burn wound colonization by yeasts and fungi tends to appear last and usually preceded by prior use broad spectrum antimicrobial agents [8, 9]. In the face of the complex nature of microbiology of burn wound infection the commonly identified microorganisms include Staphylococcus aureus, Coagulase-negative staphylococci, Pseudomonas aeruginosa, Eshersha coli, Klebsiella pneumoniae, Proteus species, Enterobacter spp. and Acinetobacter species. In addition, administration of topical antimicrobial agents and systemic antibiotics has shown to influence the type and nature of microbial identified in burn wound [10–12,].

Being mostly hospital acquired in origin, the causative agents in burn wound infection differ from one center to the other. In addition, in any given burn unit there is a constant change of the infective microorganisms. New microorganisms which will be brought by the wounds of newly admitted burn patient will persist and become resident flora of the unit. These latter will be replaced by another group of microorganisms after a variable period of time which will transmit to newly admitted burn patients form the hospital environment [13–16]. Furthermore, there is a constantly aggregating challenge on the treatment of burn wound infections due to emergence of antibiotic resistant microorganisms. As the effort to treat burn wound infection is further compromised by the limited availability of effective antimicrobial agents, availability of data that determines the commonly identified microorganisms and their antibiotic resistance pattern of a given burn unit is an essential input for improving the quality of care. It is proven in other burn centers that knowing the common microorganisms and their antibiotic resistance pattern has a significant impact on reduction of morbidity and mortality of the victims [17–19].

In this study we will report the common clinical presentation, antimicrobial resistance pattern and associated factors among burn patients admitted to AaBET Hospital burn unit. The reports of the study will be used as an essential input for improving the quality of care delivered for burn patients. It is proven in other burn centers that knowing the common microorganisms and their antibiotic resistance pattern has a significant impact on reduction of morbidity and mortality of the victims.

Study area

AaBET Hospital is found in the Arada sub city of Addis Ababa, Ethiopia. AaBET hospital is the burn, trauma and emergency wing of St. Paul’s Hospital Millennium Medical College. AaBET hospital has four service delivering specialties in it, which are Plastic and Reconstructive Surgery (Burn Unit), Neurosurgery, Orthopedics Surgery and Emergency Medicine. The burn unit at AaBET is second burn unit in Addis Ababa city with a capacity of 20 beds for adults and children. SPHMMC is the second to largest public hospital in Ethiopia, built by the Emperor Haile Selassie in 1961 with the help of the German Evangelical Church. It has 500 beds, with catchment population of more than 5 million.

Study Design And Period

A prospective cross-sectional study was held from December 01, 2020 to November 30, 2021 at Addis Ababa Burn, Emergency and Trauma (AaBET) Hospital, Addis Ababa, Ethiopia. All patients who visited the hospital were the source population, and all patients admitted to AaBET burn unit with the diagnosis acute burn and met the inclusion criteria were the study population.

Inclusion And Exclusion Criteria

All acute burn patients who underwent treatment at AaBET Hospital during the stated study period were included this study. Patients with chronic burn wound, patients who already stayed in the burn unit for more than 3 weeks before the start of the study and burn patients presented to the burn center after three weeks of the initial injury were excluded from the study.

Variables

Common clinical presentations and antimicrobial resistance pattern among presumptive patients were dependent variables. Whereas, socio-demographic characteristics, possible co- morbidities and complications were independent variables.

Sample Size And Sampling Technique

To get the maximum sample size, we included all acute burn patients admitted to AaBET Hospital burns unit during the study period; based on a non-probability consecutive sampling method.

Data Collection Procedure

Data collectors were given training and instructions on how to collect the needed information. The study participants' socio-demographic status and related variables were collected using a structured and pretested questionnaire (following its approval by the SPHMMC - IRB office), by means of in-person interviews. For each patient with a diagnosis acute burn, wound swab was taken on the 7th day of admission by observing all the necessary aseptic precautions.

Laboratory Procedures

The collected and inoculated burn wound swabs were transported in sterile, leak- proof container to the microbiology laboratory. Regular culture media like MacConkey agar, Blood agar, Nutrient agar and Triptic Soya agar were used for bacterial isolation and identification. In addition, special media such as pseudomonas agar, Salmonella- Shigella agar, MacConkey agar, Mannitol salt agar and Eosin methylene blue agar were used. All specimens were inoculated on 5% blood agar, MacConkey agar and Chocolate agar plates and incubated overnight at 37 ˚C aerobically. Then standard microbiological techniques were used to identify the microbial pathogens and antimicrobial susceptibility of the sample were determined by using Mueller- Hinton agar, based on the conventional disk diffusion method on different antibiotic batteries.

Data Quality Assurance

The questionnaire used for the study was pre-tested and proper training was given for data collectors. The quality of data was maintained following the pre-analytical, analytical and post-analytical steps through each day supervision using standard laboratory procedures (SOPs).

Data Analysis And Interpretation

After coding the data obtained from participants of the study, all the necessary procedures needed for data clearance and consistency check were done. Then, the sorted data exported and analyzed using SPSS Version 20.1windows software computer program for analysis. The data analysis results are presented as the means ± SDs for continuous variables and as proportions for categorical variables. Demographic and clinical data will be described. We used p = 0.5, with CI = 95% and margin of error 0.05.

Ethical Considerations

Ethical approval for undertaking of this study was requested and obtained from the SPHMMC institutional review board. Written informed consent was secured from each participant greater than 18 years old and acceptances were obtained from parents/ guardians, for those less than 18 years old. Confidentiality of patients’ information obtained during the study period were maintained throughout the study and during research finding disseminations.

Operational Definition

Acute Burn- defined as a burn injury that occurred within the past three weeks due to a sudden exposure to a thermal, electrical or chemical energy; with an injury to the skin or other organs.

Burn Wound Infection- is defined as occurrence change in burn wound appearance or character and histological examination of burn biopsy specimen reveals invasion of organisms into adjacent viable tissue with quantitative cultures that yielded more than 10⁵ colony forming units /gram of tissue.

Sociodemographic characteristics

A total of 91 patients were admitted to the burn unit during the study period. Out of which, 75 of them consented and enrolled in the study. Among the participants of the study males accounted for 53.3% (n = 42) of admissions with a male to female ratio of 1.14:1. (The age ranged from 6 months to 76 years, with the median age being 19 years (Interquartile range, IQR = 21.0), and children less than 15 years old accounted for 42.7% (n = 32). The occupational status of the patients was as follows: Farmer, government worker, electrician, mechanic/machine operator, daily laborer, and housemaid. Epilepsy was the most common co-morbid and/or predisposing condition identified in our patients (Table 1).

Table 1

Sociodemographic characteristics of burn patients admitted to Addis Ababa Burn, Emergency, and Trauma (AaBET) hospital, Addis Ababa, from December 01, 2020 to November 30, 2021
Characteristics	Description	Total, n = 75
		Frequency(n)	Percent (%)
Sex	Male	42	53.3
	Female	33	46.7
Age, in years	≤ 15	32	42.7
	16–49	38	50.7
	≥ 50	5	6.7
Marital status	Married	16	21.3
	Single	28	37.3
	Widowed	2	2.7
	Not applicable (children, < 15 years)	29	38.7
Occupational status	Farmer	8	10.7
	Government worker	3	4.0
	Electrician	4	5.3
	Mechanic/machine operator	2	2.7
	Daily laborer	4	5.3
	House maid	1	1.3
	Other private business	2	2.7
	House wife	8	10.7
	Student	18	24.0
	Children (≤ 5)	25	33.3
Comorbidities	Epilepsy	15	20
	Psychiatric Condition	1	1.3
	Malnutrition	1	1.3
Origin of referrals	From health centers	41	54.7
	From primary hospitals	21	28.0
	From referral hospitals	13	17.3

Clinical Presentations

All of the admissions to the burn unit were after patients completed resuscitation at the emergency room which is the initial 24 hours post-burn injury. The median time of injury to admission to the burn unit was 3 days (range, 1–55 days; IQR = 3). Majority (n = 48, 64%) of the patients were admitted to the burn unit within 3 days of injury. Of the 75 patients that got admitted, 54 (72%) sustained the burn injury at home while 16 (21.3%) got burnt at the workplace. Other places where patients sustained the injury includes streets, neighbors’ house, and farmland.

The median estimated total body surface area (TBSA) of the burn wound was 22% (range, 5% − 56%; IQR = 7). A majority (n = 39, 52%) of the patients had a TBSA burn between 20% and 30%. Nine (11.8%) of the patients had TBSA burn greater than 30%. Regarding the causal agent, flame burn was the leading cause (n = 30, 40%) followed by a scald burn (n = 22, 29.3%) and high voltage electric burn (n = 21, 28%). However, there are differences according to age. In the underage population (≤ 15 years), the most common cause was injury due to scald burn (n = 18, 56.3%) and many of these children (n = 28, 87.5%) sustained the burn injury accidentally while playing. Given this age difference, we present the clinical characteristics of burn agents by age group. Eight (10.7%) patients were found to have an inhalational injury, all of which were diagnosed based on clinical suspicion (Table 2)

Table 2

Clinical characteristics of patients who were admitted for an acute burn management to AaBET hospital Addis Ababa from December 01, 2020 to November 30, 2021
Variables		Age ≤ 15 years, n = 32 No. (%)	16–49 years, n = 38 No. (%)	≥ 50 years, n = 5 No. (%)	Total
Variables		Age ≤ 15 years, n = 32 No. (%)	16–49 years, n = 38 No. (%)	≥ 50 years, n = 5 No. (%)	Frequency (n)	Percent (%)
Where did the injury occur?	Home	29 (90.6%)	20 (52.6%)	5 (100%)	54	72.0
	Work place	-	16 (42.1%)	-	16	21.3
	Streets	2 (6.3%)	-	-	2	2.7
	Neighbors’ house	1 (3.1%)	1 (2.6%)	-	2	2.7
	Farm land	-	1 (2.6%)	-	1	1.3
How did the injury occur?	Accidentally while cooking	3 (9.4%)	19 (50.0%)	4 (80.0%)	26	34.7
	Accidentally while playing	28 (87.5%)	2 (5.3%)	-	30	40.0
	Accidentally while fixing electric system	-	12 (31.6%)	-	12	16.0
	Contact with electric line	1 (3.1%)	3 (7.9%)	1 (20.0%)	5	6.6
	Fire accident at work area	-	2 (5.3%)	-	2	2.7
Cause of burn	Flame	6 (18.8%)	21 (55.3%)	3 (60.0%)	30	40.0
	Scald	18 (56.3%)	3 (7.9%)	1 (20.0%)	22	29.3
	Hot surface (contact)	1 (3.1%)	-	-	1	1.3
	Low voltage electric burn	-	1 (2.6%)	-	1	1.3
	High voltage electric burn	7 (21.9%)	13 (34.2%)	1 (20.0%)	21	28.0
Inhalational injury	Yes	1 (3.1%)	7 (18.4%)	-	8	10.7
	No	31 (96.9%)	31 (31.6%)	5 (100%)	67	89.3
TBSA	< 10%	3 (9.4%)	2 (5.3%)	-	5	6.7
	10 - <20%	15 (46.9%)	5 (13.2%)	2 (40.0%)	22	29.3
	20 - <30%	12 (37.5%)	24 (63.2%)	3 (60.0%)	39	52.0
	≥ 30	2 (6.3%)	7 (18.4%)	-	9	12.0

Interventions

All the 75 patients were treated at the burn unit after admission, the data of which was collected at the discharge of the patients. All 75 patients received wound care once a day. Normal saline was a solution used for wound cleaning. A honey-based antibiotic ointment (Moist Exposed Burn Ointment, MEBO) was applied to the wound before the final wound dressing. More than two-thirds of patients (n = 53, 70.7%) were operated on. Escharotomy was needed in 19 (25.3%) patients while fasciotomy and amputation(s) were done in 12(16%) and 13 (17.3%) patients respectively (Table 3).

Table 3

Interventions done for patients admitted for an acute burn management to the burn unit of AaBET hospital, Addis Ababa, Ethiopia from December 01, 2020 to November 30, 2021
Interventions done		Frequency, n	Percent, %
Operated	Yes	53	70.7
	No	22	29.3
Escharotomy	Yes	19	25.3
	No	56	74.7
Fasciotomy	Yes	12	16.0
	No	63	84.0
Amputation(s)	Yes	13	17.3
	No	62	82.7
ICU care	Yes	9	12.0
	No	66	88.0
Ventilated	Yes	9	12.0
	No	66	88.0
Limb splinting	Yes	25	33.3
	No	50	66.7
Physiotherapy	Yes	46	61.3
	No	29	38.7
Administration of systemic antibiotics	Yes	16	21.3
	No	59	78.7

Complications

A total of 46 patients (61.3%) developed complications before and/or while being treated at our burn unit. These included wound infection, graft loss, sepsis, acute kidney injury, malnutrition, pressure ulcer, and limb compartment syndrome. Wound infection was the commonest complication, occurring in 31 (41.3%) of patients. Of these patients who developed complications, some had more than one complication occurring concurrently (Table 4).

Table 4

list of complications developed in patients admitted to AaBET Hospital for acute burn management between December 01, 2020 and November 30, 2021
No	Complications	Frequency, n	Percent, %
1	Wound infection	31	41.3
2	Graft loss	22	29.3
3	Sepsis	9	12.0
4	AKI	1	1.3
5	Malnutrition	1	1.3
6	Pressure ulcer	4	5.3
7	Limb compartment syndrome	12	16

Isolated Micro-organisms And Their Resistance Pattern To Antimicrobials

A total of 75 swabs were taken from the burn wounds. Fifty-nine positive swab samples were identified from which 68 micro-organisms were isolated. Pseudomonas aeruginosa was the commonest isolate (42 isolates; 61.7%) followed by Staphylococcus aureus (18 isolates; 26.4%). Other isolates were Klebsiella pneumoniae (4 isolates; 6.1%), Aspergillus (3 isolates; 4.6%), and Kingella kingae (1 isolate; 1.5%) (Fig. 1). A significant percentage of the positive swab results were monomicrobial (84.7%) as compared to those polymicrobial infections (15.3%). The most commonly found polymicrobial infections were Pseudomonas aeruginosa with Staphylococcus aureus (n = 5, 8.5%) and Staphylococcus aureus with Klebsiella pneumoniae (n = 3, 5.1%).

Pseudomonas aeruginosa was found to be highly sensitive to Meropenem (n = 12, 100%), Tobramycin (n = 11, 100%), Gentamycin (n = 37, 94.9%), and Ciprofloxacillin (n = 22, 84.6%) while showed high resistance to ceftriaxone (n = 5, 100%) and ceftazidime (n = 28, 87.5%), Cotrimoxazole (n = 2, 100%), Amoxicillin-clavulanic acid (n = 2, 100%). Staphylococcus aureus was found to be sensitive to vancomycin (n = 16, 100%), tetracycline (n = 7, 87.5%), meropenem (n = 4, 100%), and linezolid (n = 3, 100%) while showed resistance to erythromycin (n = 10, 100%), clindamycin (n = 5, 83.3%), penicillin(n = 1, 100%), cotrimoxazole(n = 11, 78.6%), Ciprofloxacillin(n = 9, 69.3%), gentamycin(n = 9, 56.3%), ampicillin(n = 2, 100%), amoxicillin-clavulanic acid(n = 2, 100%), and oxacillin(n = 2, 100%). Klebsiella pneumoniae were found to be resistance to all of the tested antibiotics (Ciprofloxacillin, cotrimoxazole, gentamycin, clindamycin, ampicillin, amoxicillin-clavulanic acid and oxacillin) except meropenem (n = 2, 100%), tetracycline (n = 2, 100%), and linezolid (n = 3, 100%) (Table 5).

Table 5

antibiotic susceptibility and resistance pattern among acute burn patients admitted to the burn unit of AaBET Hospital between December 01, 2020 and November 30, 2021
Antibiotics tested	Pseudomonas Aeruginosa, n = 42			Staphylococcus Aureus, n = 18			Klebsiella Pneumoniae, n = 4			Aspergillus, n = 3			Kingella Kingae, n = 1
Antibiotics tested	Number of cassettes used	Sensitive, (Number, %)	Resistant, (Number, %)	Number of cassettes used	Sensitive, (Number, %)	Resistant, (Number, %)	Number of cassettes used	Sensitive, (Number, %)	Resistant, (Number, %)	Number of cassettes used	Sensitive, (Number, %)	Resistant, (Number, %)	Number of cassettes used	Sensitive, (Number, %)	Resistant, Number (%)
Ceftazidime	32	4, 12.5%	28, 87.5%	1	0	1, 100%	1	0	1, 100%	3	0	3, 100%	1	0	1, 100%
Cefepime	23	13, 56.5%	10, 43.5%	-	-	-	-	-	-	-	-	-	-	-	-
Ceftriaxone	5	0	5, 100%	-	-	-	-	-	-	3	0	3, 100%	1	0	1, 100%
Ciprofloxacillin	26	22, 84.6%	4, 15.4%	13	4, 30.7%	9, 69.3%	3	0	3, 100%	1	0	1, 100%	1	0	1, 100%
Co-trimoxazole	2	0	2, 100%	14	3, 21.4%	11, 78.6%	4	0	4, 100%	-	-	-	1	1, 100%	0
Gentamycin	39	37, 94.9%	2, 5.1%	16	7, 43.7%	9, 56.3%	3	0	3, 100%	3	3, 100%	0	1	1, 100%	0
Tobramycin	11	11, 100%	0	-	-	-	-	-	-	-	-	-	-	-	-
Meropenem	12	12, 100%	0	4	4, 100%	0	2	2, 100%	0	3	3, 100%	0	1	1, 100%	0
Imipenem	2	2, 100%	0	-	-	-	-	-	-	-	-	-	-	-	-
Tetracycline	-	-	-	8	7, 87.5%	1, 12.5%	2	2, 100%	0	-	-	-	-	-	-
Piperacillin+ Tazobactam	1	1, 100%	0	-	-	-	-	-	-	1	0	1, 100%	1	0	1, 100%
Vancomycin	-	-	-	16	16, 100%	0	-	-	-	-	-	-	-	-	-
Erythromycin	-	-	-	10	0	10, 100%	-	-	-	-	-	-	-	-	-
Clindamycin	-	-	-	6	1, 16.7%	5, 83.3%	3	0	3, 100%	-	-	-	-	-	-
Ampicillin	-	-	-	2	0	2, 100%	3	0	3, 100%	-	-	-	-	-	-
Amoxicillin/ clavulanic acid	2	0	2, 100%	2	0	2, 100%	3	0	3, 100%	-	-	-	-	-	-
Linezolid	-	-	-	3	3, 100%	0	3	3, 100%	0	-	-	-	-	-	-
Oxacillin	-	-	-	2	0	2, 100%	2	0	2, 100%	-	-	-	-	-	-
Amikacin	-	-	-	1	1, 100%	0	1	1, 100%	0	-	-	-	-	-	-
Penicillin	-	-	-	1	0	1, 100%	1	0	1, 100%	-	-	-	-	-	-
Cloxacillin	-	-	-	1	1, 100%	0	-	-	-	-	-	-	-	-	-
Azithromycin	-	-	-	1	1, 100%	0	-	-	-	-	-	-	-	-	-

Throughout the world, infection followed by sepsis is responsible for 50–60% mortalities among burn patients. In case of developing countries, it is estimated that 75% burn mortalities are due to sepsis. It is reported that overcrowding, lack of essential elements for optimal burn care and delayed presentation of patients are among the common factors for increased burn related complications and mortalities in developing countries [20]. Studies undertaken in the 1950s through 1990 have contributed a lot for our current understanding on the epidemiology of burn wound infections and associated complications. That era was characterized by burn care practices of delayed excision of burn eschar and limited use of topical antibiotics. Consequently, it has been reported that the overall morbidity and mortality following burn wound infections, tissue invasion, and secondary sepsis were extremely high, with case fatality rate of 40% and above following severe burn injury [21–22].

According to the result of our study a total of 46 patients (61.3%) developed complications before and/or while being treated at our burn unit. These included wound infection, graft loss, sepsis, acute kidney injury, malnutrition, pressure ulcer, and limb compartment syndrome. Burn wound infection was the commonest complication identified among the study, occurring in 31 (41.3%) of patients. Of these patients who developed complications, some had more than one complication occurring concurrently.

There are multiple factors which play major roles on impacting the final outcome of burn wound infections and associated complications. These factors include patient demographics, burn severity, obesity, diabetes, immunosuppression; and use of topical antibiotics, early excision and infection prevention measures taken in the burn’s unit. A number of research reports from various centers indicate that the very young and the very old members of the population have an increased risk of developing a worse clinical outcome following burn injury than patients in other age groups [23–25].

The presence of significant percentage of young patients in our study indicates that, our study population were most likely to develop a worse clinical outcome following burn injury. In addition, majority (n = 39, 52%) of the patients had a TBSA burn between 20% and 30%, while nine (11.8%) of the patients had TBSA burn greater than 30%. These findings indicate that there were multiple risk factors among our study population, which could lead to a number of severe burn complications.

Among victims of severe burn injury there will be destruction of skin, which result in loss of its barrier function. After enduring sterile for the first 48hrs following injury, burn wounds will eventually become colonized with various microorganisms [26–28]. Gram-positive bacteria which reside deep in the skin adnexa are the first to heavily colonize the wound surface. Then after an average of 5 to 7 days burn wounds will further become colonized with other microbes, which includes gram-positive bacteria, gram-negative bacteria, and yeasts derived from the host's normal gastrointestinal and upper respiratory flora. Additionally, colonization of burn wound could result due to transfer of nosocomial microbes from the hospital environment [29]. Introduction of penicillin during the 1950s resulted in significant reduction of Streptococcus pyogenes caused burn wound infection among the severely burned patients. Consequently, Staphylococcus aureus became the principal etiological agent of burn wound infections in the decades following 1950s. In addition, the decades following the introduction of antibiotics is marked by a gradual increment in identification of less common microbes as a cause for burn wound infection which includes other gram-positive and gram-negative bacteria, anaerobic bacteria, fungi, and viruses [30–32].

In our study, Pseudomonas aeruginosa was found to be the commonest isolate followed by Staphylococcus aureus, Klebsiella pneumoniae, Aspergillus, and Kingella kingae. In addition, we identified more monomicrobial positive swabs than polymicrobial. These findings of our study are comparable with reports of a number of other studies held in other centers [33–38].

Now a days effective treatment of burn wound infection is being severely challenged due to the emergence antimicrobial resistant pathogens causing burn wound infections [36]. The presence of nosocomial isolates which include MRSA, methicillin-resistant coagulase-negative staphylococci, vancomycin-resistant enterococci, and multiply resistant gram-negative bacteria that possess several types of beta-lactamases, including extended-spectrum beta-lactamases, ampC beta-lactamases, and metallo-beta-lactamases, in burn centers have resulted in the occurrence of invasive and life-threatening infections among hospitalized burn patients [37]. Additionally amplified use of broad spectrum topical and systemic antibiotics for the treatment of burn infections resulted in increased identification of opportunistic pathogens, particularly Candida spp. which have showed increasing degrees of antifungal drug resistance [38].

Based on the study conducted in a burn treatment facility in Bangladesh, Pseudomonas aeruginosa isolates were found to be moderately resistant to ciprofloxacin (52.17%), and to Amikacin (39.83%), but with higher resistance to other antimicrobials, which include Doxycycline (78.3%), tetracycline (65.57%), and Gentamicin (53.6%). Investigators of the study have also reported that Staphylococcus aureus have showed strikingly higher resistant to Amikacin, and Gentamicin (100%); but a moderate resistance to Doxycycline (72%), Oxacillin (78.8%) and Tetracycline (87.7%) and a reduced resistance to Chloramphenicol (23.57%) and Ciprofloxacin (39.66%). Similarly, Klebsiella spp. were found to be resistant to all of the antibiotics used in the study except for Ciprofloxacin where it showed a 100% sensitivity [37]. Another prospective study was conducted in a burn treatment facility in Saudi Arabiya, which showed that Staphylococcus aureus was resistant to 15 different antibiotics but fully sensitive to oxacillin, vancomycin, and ampicillin/sulbactam. [38]

The findings of our study are comparable to the above-mentioned findings in other centers, where we found Pseudomonas aeruginosa to be highly sensitive to Meropenem, Tobramycin, Gentamycin, and Ciprofloxacillin, while it showed high resistance to ceftriaxone and ceftazidime, Cotrimoxazole, Amoxicillin-clavulanic acid. Similarly, the sensitivity pattern of Staphylococcus aureus at our burn center was found to be similar to the other centers, where we found it to be sensitive to vancomycin, tetracycline, meropenem, and linezolid, while it showed resistance to erythromycin, clindamycin, penicillin, cotrimoxazole, Ciprofloxacillin, gentamycin, ampicillin, amoxicillin-clavulanic acid, and oxacillin. Additionally, based on the findings of our study Klebsiella pneumoniae was found to be resistance to most of the tested antibiotics (Ciprofloxacillin, cotrimoxazole, gentamycin, clindamycin, ampicillin, amoxicillin-clavulanic acid and oxacillin) except for meropenem, tetracycline, and linezolid. Therefore, findings of our study and its comparison against results from other centers indicates that, there is a comparable antibiotic sensitivity and resistance pattern at out burn unit.

In conclusion, Pseudomonas Aeruginosa is found to be the most common bacteria isolate from the wounds of our study participants and it is found to be sensitive to Meropenem, Tobramycin, Gentamycin and Ciprofloxacillin; but resistant to Ceftriaxone and Ceftazidime. Based on the findings of our study we recommend that, standard treatments of burn wound infections and associated sepsis should target the common bacterial isolates according to their antibiotic sensitivity pattern. In addition, we recommend a large-scale study to be conducted in the unit, to identify the common microbial residual sites, contamination points and to further characterize the common bacterial isolates.

AaBET = Addis Ababa Burn, Emergency and Trauma Hospital

AIDS = Acquired Immune Deficiency Syndrome

DM = Diabetes Mellitus

E. coli = Eshersha Coli

GI = Gastro- Intestine

HTN = Hypertension

IRB = Institutional Review Board

MRSA = Methicillin Resistant Staphylococcus Aureus

SPHMMC = St. Paul’s Hospital Millennium Medical College

Spp.= species

TBSA % = Total Body Surface Area Percentage of burn

WHO = World Health Organization

Acknowledgements

We are very much grateful to all the participants of our study for their willingness in providing the necessary information. The authors also acknowledge the staff of AaBET Hospital burn unit for their cooperation during data collection for the study.

Consent for publication

Further, informed consent for publication were also obtained from each study participant under the consent form by mentioned for all of them that the data will be published in international journals. So, this is to confirm that informed consent for publication was obtained from all the study participants. The collected data is kept confidentially under the primary investigator and co-investigators.

Authors’ contributions

AB, AG, SU, IK and MB were involved starting from conceiving the idea, developing the proposal, the study design, reviewed the article. AB and IK involved in data cleaning, analysis, report writing and write up of the manuscript; AG, SU and MB involved in data analysis and review of the drafted manuscript. All authors read and approved the final manuscript submitted to this journal.

Funding

The authors did not receive funds or grant for conducting this study.

Competing interest

All authors read and approved the final manuscript. The authors declare that they have no competing interests.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Peck, M.D., 2011. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns, 37(7), pp.1087-1100.
Church, D., Elsayed, S., Reid, O., Winston, B. and Lindsay, R., 2006. Burn wound infections. Clinical microbiology reviews, 19(2), pp.403-434.
Manson, W.L., Pernot, P.C.J., Fidler, V., Sauer, E.W. and Klasen, H.J., 1992. Colonization of burns and the duration of hospital stay of severely burned patients. Journal of hospital Infection, 22(1), pp.55-63.
Lionelli, G.T., Pickus, E.J., Beckum, O.K., Decoursey, R.L. and Korentager, R.A., 2005. A three-decade analysis of factors affecting burn mortality in the elderly. Burns, 31(8), pp.958-963.
Memmel, H., Kowal-Vern, A. and Latenser, B.A., 2004. Infections in diabetic burn patients. Diabetes Care, 27(1), pp.229-233.
Barret, J.P. and Herndon, D.N., 2003. Effects of burn wound excision on bacterial colonization and invasion. Plastic and reconstructive surgery, 111(2), pp.744-750.
Manson, W.L., Coenen, J.M., Klasen, H.J. and Horwitz, E.H., 1992. Intestinal bacterial translocation in experimentally burned mice with wounds colonized by Pseudomonas aeruginosa. The Journal of trauma, 33(5), pp.654-658.
Burdge, J.J., Rea, F. and Ayers, L., 1988. Noncandidal, fungal infections of the burn wound. The Journal of Burn Care & Rehabilitation, 9(6), pp.599-601.
Revathi, G., Puri, J. and Jain, B.K., 1998. Bacteriology of burns. Burns, 24(4), pp.347-349.
Agnihotri, N., Gupta, V. and Joshi, R.M., 2004. Aerobic bacterial isolates from burn wound infections and their antibiograms—a five-year study. Burns, 30(3), pp.241-243.
Frame, J.D., Kangesu, L. and Malik, W.M., 1992. Changing flora in burn and trauma units: experience in the United Kingdom. The Journal of burn care & rehabilitation, 13(2), pp.281-286.
Appelgren, P., Björnhagen, V., Bragderyd, K., Jonsson, C.E. and Ransjö, U., 2002. A prospective study of infections in burn patients. Burns, 28(1), pp.39-46.
Edwards-Jones, V., Greenwood, J.E. and Manchester Burns Research Group, 2003. What’s new in burn microbiology? James Laing memorial prize essay 2000. Burns, 29(1), pp.15-24.
Richard, P., Floch, R.L., Chamoux, C., Pannier, M., Espaze, E. and Richt, H., 1994. Pseudomonas aeruginosa outbreak in a burn unit: role of antimicrobials in the emergence of multiply resistant strains. Journal of Infectious Diseases, 170(2), pp.377-383.
Desai, M.H. and Herndon, D.N., 1988. Eradication of Candida burn wound septicemia in massively burned patients. Journal of Trauma and Acute Care Surgery, 28(2), pp.140-145.
Gales, A.C., Jones, R.N., Turnidge, J., Rennie, R. and Ramphal, R., 2001. Characterization of Pseudomonas aeruginosa isolates: occurrence rates, antimicrobial susceptibility patterns, and molecular typing in the global SENTRY Antimicrobial Surveillance Program, 1997–1999. Clinical Infectious Diseases, 32(Supplement_2), pp. S146-S155.
Fitzwater, J., Purdue, G.F., Hunt, J.L. and O’Keefe, G.E., 2003. The risk factors and time course of sepsis and organ dysfunction after burn trauma. Journal of Trauma and Acute Care Surgery, 54(5), pp.959-966.
Ryan, C.M., Schoenfeld, D.A., Thorpe, W.P., Sheridan, R.L., Cassem, E.H. and Tompkins, R.G., 1998. Objective estimates of the probability of death from burn injuries. New England Journal of Medicine, 338(6), pp.362-366.
Rennie, R.P., Jones, R.N., Mutnick, A.H. and SENTRY Program Study Group, 2003. Occurrence and antimicrobial susceptibility patterns of pathogens isolated from skin and soft tissue infections: report from the SENTRY Antimicrobial Surveillance Program (United States and Canada, 2000). Diagnostic microbiology and infectious disease, 45(4), pp.287-293.
Weinstein, R.A. and Mayhall, C.G., 2003. The epidemiology of burn wound infections: then and now. Clinical infectious diseases, 37(4), pp.543-550.
Mason, A.D., McManus, A.T. and Pruitt, B.A., 1986. Association of burn mortality and bacteremia: a 25-year review. Archives of Surgery, 121(9), pp.1027-1031.
Wood, F. and Judkins, K., 2020. The burned patient. Oxford Textbook of Plastic and Reconstructive Surgery, p.139.
Pruitt, B.A., Wolf, S.E. and Mason, A.D., 2012. Epidemiological, demographic, and outcome characteristics of burn injury. Total burn care, 4, pp.15-45.
Sjöberg, T., Mzezewa, S., Jönsson, K. and Salemark, L., 2004. Immune response in burn patients in relation to HIV infection and sepsis. Burns, 30(7), pp.670-674.
McCampbell, B., Wasif, N., Rabbitts, A., Staiano-Coico, L., Yurt, R.W. and Schwartz, S., 2002. Diabetes and burns: retrospective cohort study. The Journal of burn care & rehabilitation, 23(3), pp.157-166.
Heideman, M. and Bengtsson, A., 1992. The immunologic response to thermal injury. World journal of surgery, 16, pp.53-56.
Nasser, S., Mabrouk, A. and Maher, A., 2003. Colonization of burn wounds in Ain Shams University burn unit. Burns, 29(3), pp.229-233.
Wysocki, A.B., 2002. Evaluating and managing open skin wounds: colonization versus infection. AACN Advanced Critical Care, 13(3), pp.382-397.
Wurtz, R., Karajovic, M., Dacumos, E., Jovanovic, B. and Hanumadass, M., 1995. Nosocomial infections in a burn intensive care unit. Burns, 21(3), pp.181-184.
NC, L., LR, K. and WH, A., 1954. Infection in burns. II. The pathogenicity of streptococci. Surgery, Gynecology & Obstetrics, 98(6), pp.693-699.
Lilly, H.A., Lowbury, E.J.L., Wilkins, M.D. and Cason, J.S., 1979. Staphylococcal sepsis in a burns unit. Epidemiology & Infection, 83(3), pp.429-435.
Becker, W.K., Cioffi, W.G., McManus, A.T., Kim, S.H., McManus, W.F., Mason, A.D. and Pruitt, B.A., 1991. Fungal burn wound infection: a 10-year experience. Archives of Surgery, 126(1), pp.44-48.
Altoparlak, U., Erol, S., Akcay, M.N., Celebi, F. and Kadanali, A., 2004. The time-related changes of antimicrobial resistance patterns and predominant bacterial profiles of burn wounds and body flora of burned patients. Burns, 30(7), pp.660-664.
Embil, J.M., McLeod, J.A., Al-Barrak, A.M., Thompson, G.M., Aoki, F.Y., Witwicki, E.J., Stranc, M.F., Kabani, A.M., Nicoll, D.R. and Nicolle, L.E., 2001. An outbreak of methicillin resistant Staphylococcus aureus on a burn unit: potential role of contaminated hydrotherapy equipment. Burns, 27(7), pp.681-688.
Kuhn, D.M. and Ghannoum, M.A., 2004. Candida biofilms: antifungal resistance and emerging therapeutic options. Current opinion in investigational drugs (London, England: 2000), 5(2), pp.186-197.
Abbas, H.A., El-Masry, E.M., Shaker, G.H. and Mohsen, I., 2013. Bacterial etiology and antimicrobial resistance of burn wound infections in a burn unit in Hehia General Hospital in Egypt. International Journal of Biological & Pharmaceutical Research, 4(12), pp.1251-1255.
Magnet, M.D.M.H., Arongozeb, M.D., Khan, G.M. and Ahmed, Z., 2013. Isolation and identification of different bacteria from different types of burn wound infections and study their antimicrobial sensitivity pattern. International Journal of Research in Applied, Natural and Social Sciences, 1(3), pp.125-132.
Al-Aali, K.Y., 2016. Microbial profile of burn wound infections in burn patients, Taif, Saudi Arabia. Arch Clin Microbiol, 7(2), pp.1-9.

No competing interests reported.

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Common clinical presentations and antimicrobial resistance pattern among burn patients, at Addis Ababa Burn and Emergency Trauma Hospital (AaBET), Addis Ababa, Ethiopia

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Abstract

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Background

Materials And Methods

Study area

Study Design And Period

Inclusion And Exclusion Criteria

Variables

Sample Size And Sampling Technique

Data Collection Procedure

Laboratory Procedures

Data Quality Assurance

Data Analysis And Interpretation

Ethical Considerations

Operational Definition

Results

Sociodemographic characteristics

Clinical Presentations

Interventions

Complications

Isolated Micro-organisms And Their Resistance Pattern To Antimicrobials

Discussion

Abbreviations

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