ORIGINAL ARTICLE
Pediatric Burn Wound Impetigo After Grafting Kimberly Aikins, MB BS, Narayan Prasad, MB BS, Seema Menon, MB ChB BAO, John G. Harvey, FRCS, FRACS, Andrew J. A. Holland, PhD, FRACS, FACS
Modern burn care techniques have reduced the risk of infection of the acute burn wound, resulting in more rapid healing and a lower incidence of graft loss. Secondary breakdown may still occur. The loss of epithelium in association with multifocal superficial abscesses and ulceration has been termed burns impetigo. This may result in considerable morbidity and require prolonged treatment. The events preceding development, the impact on the patient, and the ideal treatment appear unclear and poorly reported. In 5 years, between 2006 and 2011, 406 pediatric burns were treated with skin grafts, with 7% developing burns impetigo. Time to resolution ranged from 5 to 241 days: the mean time to complete healing was greatest with conservative management (96 days), followed by antibacterial dressings (37 days), oral antibiotics (36 days), topical steroids (16 days), and oral antibiotics in combination with topical steroids (13.5 days). Burns impetigo resulted in significant morbidity, requiring multiple visits to the treatment center and prolonged symptoms. Delay in diagnosis and treatment resulted in worse outcomes. Prompt consideration of burns impetigo should occur when postgraft patients present with suggestive clinical signs and treatment with oral antibiotics plus topical steroids should be considered. (J Burn Care Res 2015;36:e41–e46)
Improvements in burn care have significantly reduced the incidence of bacterial colonization and infection of the acute burn wound. Although burn wound infections still occur, most burn units (BUs) now report a low incidence of graft loss secondary to wound sepsis.1 Despite these advances, subsequent breakdown of healed burns, whether spontaneously or after grafting, remains problematic, especially in the pediatric population. Although in some cases this may occur as a result of mechanical trauma including scratching, friction, or movement; loss of the epithelium of the healed burn wound occasionally occurs in association with the formation of multifocal, superficial (usually From the Burns Unit and The Children’s Hospital at Westmead Burns Research Institute, Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital Westmead, Sydney Medical School, The University of Sydney, New South Wales, Australia. Presented at the 35th Annual Scientific Meeting of the Australian and New Zealand Burn Association, Brisbane, Queensland, 4–7 October, 2011. Address correspondence to Andrew J. A. Holland, Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital at Westmead, The University of Sydney, Locked Bag 4001, Westmead, NSW 2145, Australia. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000070
Staphylococcal sp.) skin microabscesses, a condition termed burns impetigo.2 Although nonburns–related impetigo remains a well-described phenomenon, there appears to be few reports in the burns literature addressing this issue. Staphylococcus aureus represents the most important causative organism.3 It may be classified as primary (direct bacterial invasion of previously normal skin) or secondary (infection at sites of skin trauma such as abrasions, minor trauma, insect bites, or underlying skin conditions such as eczema). Impetigo has been most frequently reported in children aged 2 to 5 years, occurs in warm, humid conditions and is easily spread among individuals in close contact, hence the lay term “school sores.”4 Impetigo can be bullous or nonbullous, the latter typically occurring in burns. Nonbullous impetigo represents the host response to infection.5 The clinical presentation typically consists of an initial single red macule or papule. This becomes a vesicle, which ruptures to form an erosion: the contents then dry, resulting in honey-colored crusts that may be pruritic.6 The diagnosis can be made clinically and confirmed by subsequent wound culture. Treatments used for impetigo include topical disinfectants and antibiotic or oral antibiotics. As a result of the infection, extensive graft loss may occur, requiring considerable additional medical and e41
Journal of Burn Care & Research March/April 2015
e42 Aikins et al
nursing care. It seems that topical and oral antibiotics have the same efficacy, and topical disinfectants are no better than placebo.7,8 Despite being well recognized, risk factors for burns impetigo and its optimal care remain poorly documented. We review the experience of our center in the management of children with burns impetigo.
thickness of this depended on the age of the patient and donor site. When these grafts were meshed they were put through a skin mesher with the ratio ranging from 2:1 to 6:1 based on the extent of the burn injury. Grafts were secured with sutures, generally absorbable, staples, Histoacryl® tissue adhesive (TissueSeal, Ann Arbor, MI) or Hypafix® (Smith and Nephew).
METHODS
Burn Dressings
Setting A retrospective medical record review was performed at The Children’s Hospital at Westmead during a 5-year period between April 2006 and April 2011. Our institution represents the pediatric arm of the New South Wales Statewide Burn Injury Service, serving a combined population of 7.6 million in New South Wales and the Australian Capital Territory.
Population The records of all children who sustained burns that required grafting during the study period were reviewed. Burns impetigo was defined as loss of epithelium in association with multifocal superficial abscesses and ulceration on a skin graft or donor site in a burns patient after the initial wound had healed.9,10 Those patients in whom the grafted burn or donor site broke down after the wound had healed were included for further analysis. Data were collected on patient characteristics; the nature of the burn, including mechanism, depth and TBSA; evidence of preoperative wound infection and antibiotic prophylaxis; operative management of the burn; presentation and treatment of burns impetigo. Simple descriptive statistical analysis was performed using Excel (Microsoft, Redmond, WA). The study was approved by the ethics committee of our institution.
Burn Treatment Antibiotics were intravenously administered at induction of anesthesia based on positive preoperative wound swab cultures, or administered under the direction of the treating clinician if the burn wound was considered clinically infected at the time of surgical debridement. Burns were debrided by sharp dissection, such as with a Goulian blade, Versajet® (Smith and Nephew, Mount Waverley, Victoria, Australia), dermabrasion, or a combination of techniques. The burns were managed with nonmeshed split-skin grafts, meshed split-skin grafts, and full-thickness skin grafts. Full-thickness grafts included the epidermis and the entire thickness of the dermis. Split-skin grafts included the epidermis and a part of the dermis—the
Standard dressings used on grafted areas were Bactigras® (paraffin gauze impregnated with 0.5% w/w chlorhexidine acetate; Smith and Nephew), Kerlix® (Covidien, Lane Cove, New South Wales, Australia), Webril® (Covidien), and crepe bandage and Omiderm® (ITG-Medev, San Francisco, CA) with Lyofoam® (Molnlycke Health Care, Gothenburg, Sweden) or Mepilex® (Molnlycke, Gothenburg, Sweden) and Kerlix® (Covidien), Webril® (Covidien), and crepe bandage on donor sites. Once healing was complete, patients were enrolled in a scar-management program, with a combination of regular application of a topical moisturizer (10% gylcerin, Sorbolene; Johnson and Johnson®, New Brunswick, NJ) and pressure therapy with a combination of DuoDerm® (ConvaTec, Skillman, NJ), silicone, Tubigrip® (Molnlycke) and pressure garments.
RESULTS During the 5-year study period, 4897 patients were treated for burns at our institution, with 406 requiring skin grafting. The mean age of all patients presenting with burns was 23 months, with a male to female ratio of 1.5:1. Of those patients grafted, 28 (7%) developed burns impetigo. The mean age of these patients was 4.3 years (range 12 months–14 years) and the majority were male (67%; Table 1). Four patients (14%) had more than one site affected by impetigo: two were different graft sites (1 both hands, and the other chest and thigh) and two the draft and donor sites. The most common mechanism of injury in those suffering from impetigo was a scald burn (50%), followed by flame (29%), contact (11%), and friction (10%). The estimated TBSA ranged from
Pediatric Burn Wound Impetigo After Grafting Kimberly Aikins, MB BS, Narayan Prasad, MB BS, Seema Menon, MB ChB BAO, John G. Harvey, FRCS, FRACS, Andrew J. A. Holland, PhD, FRACS, FACS
Modern burn care techniques have reduced the risk of infection of the acute burn wound, resulting in more rapid healing and a lower incidence of graft loss. Secondary breakdown may still occur. The loss of epithelium in association with multifocal superficial abscesses and ulceration has been termed burns impetigo. This may result in considerable morbidity and require prolonged treatment. The events preceding development, the impact on the patient, and the ideal treatment appear unclear and poorly reported. In 5 years, between 2006 and 2011, 406 pediatric burns were treated with skin grafts, with 7% developing burns impetigo. Time to resolution ranged from 5 to 241 days: the mean time to complete healing was greatest with conservative management (96 days), followed by antibacterial dressings (37 days), oral antibiotics (36 days), topical steroids (16 days), and oral antibiotics in combination with topical steroids (13.5 days). Burns impetigo resulted in significant morbidity, requiring multiple visits to the treatment center and prolonged symptoms. Delay in diagnosis and treatment resulted in worse outcomes. Prompt consideration of burns impetigo should occur when postgraft patients present with suggestive clinical signs and treatment with oral antibiotics plus topical steroids should be considered. (J Burn Care Res 2015;36:e41–e46)
Improvements in burn care have significantly reduced the incidence of bacterial colonization and infection of the acute burn wound. Although burn wound infections still occur, most burn units (BUs) now report a low incidence of graft loss secondary to wound sepsis.1 Despite these advances, subsequent breakdown of healed burns, whether spontaneously or after grafting, remains problematic, especially in the pediatric population. Although in some cases this may occur as a result of mechanical trauma including scratching, friction, or movement; loss of the epithelium of the healed burn wound occasionally occurs in association with the formation of multifocal, superficial (usually From the Burns Unit and The Children’s Hospital at Westmead Burns Research Institute, Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital Westmead, Sydney Medical School, The University of Sydney, New South Wales, Australia. Presented at the 35th Annual Scientific Meeting of the Australian and New Zealand Burn Association, Brisbane, Queensland, 4–7 October, 2011. Address correspondence to Andrew J. A. Holland, Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital at Westmead, The University of Sydney, Locked Bag 4001, Westmead, NSW 2145, Australia. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000070
Staphylococcal sp.) skin microabscesses, a condition termed burns impetigo.2 Although nonburns–related impetigo remains a well-described phenomenon, there appears to be few reports in the burns literature addressing this issue. Staphylococcus aureus represents the most important causative organism.3 It may be classified as primary (direct bacterial invasion of previously normal skin) or secondary (infection at sites of skin trauma such as abrasions, minor trauma, insect bites, or underlying skin conditions such as eczema). Impetigo has been most frequently reported in children aged 2 to 5 years, occurs in warm, humid conditions and is easily spread among individuals in close contact, hence the lay term “school sores.”4 Impetigo can be bullous or nonbullous, the latter typically occurring in burns. Nonbullous impetigo represents the host response to infection.5 The clinical presentation typically consists of an initial single red macule or papule. This becomes a vesicle, which ruptures to form an erosion: the contents then dry, resulting in honey-colored crusts that may be pruritic.6 The diagnosis can be made clinically and confirmed by subsequent wound culture. Treatments used for impetigo include topical disinfectants and antibiotic or oral antibiotics. As a result of the infection, extensive graft loss may occur, requiring considerable additional medical and e41
Journal of Burn Care & Research March/April 2015
e42 Aikins et al
nursing care. It seems that topical and oral antibiotics have the same efficacy, and topical disinfectants are no better than placebo.7,8 Despite being well recognized, risk factors for burns impetigo and its optimal care remain poorly documented. We review the experience of our center in the management of children with burns impetigo.
thickness of this depended on the age of the patient and donor site. When these grafts were meshed they were put through a skin mesher with the ratio ranging from 2:1 to 6:1 based on the extent of the burn injury. Grafts were secured with sutures, generally absorbable, staples, Histoacryl® tissue adhesive (TissueSeal, Ann Arbor, MI) or Hypafix® (Smith and Nephew).
METHODS
Burn Dressings
Setting A retrospective medical record review was performed at The Children’s Hospital at Westmead during a 5-year period between April 2006 and April 2011. Our institution represents the pediatric arm of the New South Wales Statewide Burn Injury Service, serving a combined population of 7.6 million in New South Wales and the Australian Capital Territory.
Population The records of all children who sustained burns that required grafting during the study period were reviewed. Burns impetigo was defined as loss of epithelium in association with multifocal superficial abscesses and ulceration on a skin graft or donor site in a burns patient after the initial wound had healed.9,10 Those patients in whom the grafted burn or donor site broke down after the wound had healed were included for further analysis. Data were collected on patient characteristics; the nature of the burn, including mechanism, depth and TBSA; evidence of preoperative wound infection and antibiotic prophylaxis; operative management of the burn; presentation and treatment of burns impetigo. Simple descriptive statistical analysis was performed using Excel (Microsoft, Redmond, WA). The study was approved by the ethics committee of our institution.
Burn Treatment Antibiotics were intravenously administered at induction of anesthesia based on positive preoperative wound swab cultures, or administered under the direction of the treating clinician if the burn wound was considered clinically infected at the time of surgical debridement. Burns were debrided by sharp dissection, such as with a Goulian blade, Versajet® (Smith and Nephew, Mount Waverley, Victoria, Australia), dermabrasion, or a combination of techniques. The burns were managed with nonmeshed split-skin grafts, meshed split-skin grafts, and full-thickness skin grafts. Full-thickness grafts included the epidermis and the entire thickness of the dermis. Split-skin grafts included the epidermis and a part of the dermis—the
Standard dressings used on grafted areas were Bactigras® (paraffin gauze impregnated with 0.5% w/w chlorhexidine acetate; Smith and Nephew), Kerlix® (Covidien, Lane Cove, New South Wales, Australia), Webril® (Covidien), and crepe bandage and Omiderm® (ITG-Medev, San Francisco, CA) with Lyofoam® (Molnlycke Health Care, Gothenburg, Sweden) or Mepilex® (Molnlycke, Gothenburg, Sweden) and Kerlix® (Covidien), Webril® (Covidien), and crepe bandage on donor sites. Once healing was complete, patients were enrolled in a scar-management program, with a combination of regular application of a topical moisturizer (10% gylcerin, Sorbolene; Johnson and Johnson®, New Brunswick, NJ) and pressure therapy with a combination of DuoDerm® (ConvaTec, Skillman, NJ), silicone, Tubigrip® (Molnlycke) and pressure garments.
RESULTS During the 5-year study period, 4897 patients were treated for burns at our institution, with 406 requiring skin grafting. The mean age of all patients presenting with burns was 23 months, with a male to female ratio of 1.5:1. Of those patients grafted, 28 (7%) developed burns impetigo. The mean age of these patients was 4.3 years (range 12 months–14 years) and the majority were male (67%; Table 1). Four patients (14%) had more than one site affected by impetigo: two were different graft sites (1 both hands, and the other chest and thigh) and two the draft and donor sites. The most common mechanism of injury in those suffering from impetigo was a scald burn (50%), followed by flame (29%), contact (11%), and friction (10%). The estimated TBSA ranged from
