Pavel Brychta

Epidemiology of childhood burns at the Burn Centre in Brno, Czech Republic

Three hundred and ninety-four children were admitted to the burn centre in Brno over a 3-year period. The overall incidence was 31 children per 100,000 children aged 0-14 years. The majority of patients were aged 1-3 years and almost 80 per cent of them were scalded. Proportionally more boys than girls were injured, in most cases at home in the presence of one or both parents. The highest risk time for injuries was between 16.00 and 18.00 h. Seasonal variations had no significant influence on the increased number of admissions to the burn centre. Sixty-six per cent of the children had minor burns. Four children died of the consequences of burns during the period studied. Social and economic factors had a significant influence on the incidence of childhood burns.

Staphylococcal scalded skin syndrome in the Czech Republic: an epidemiological study

OBJECTIVE To identify the basic epidemiological characteristics of children hospitalized with diagnosis of Staphylococcal scalded skin syndrome in the Czech Republic in the years 1994-2009. INTRODUCTION Staphylococcal scalded skin syndrome (SSSS) is a relatively rare disease in childhood. This syndrome was first defined in 1878 by Baron Gottfried Ritter von Rittershainem and belongs to the group of diseases called Burn-like syndromes. It is a bullous skin disease caused by exfoliative toxins which are produced by certain types of Staphyloccocus aureus. Typical structures affected by these toxins are desmosome proteins called Desmoglein-1 located in the stratum granulosum of epidermis. Unlike in Lyells syndrome or Stevens-Johnsons syndrome, the exfoliation is caused by loss of adhesivity particularly in the stratum granulosum and not by induction of apoptosis in the dermo-epidermal junction. MATERIAL AND METHODS This retrospective study was conducted on patients hospitalized in the Czech Republic in the period from 1.1.1994 to 31.12.2009. The basic condition for the inclusion in the retrospective study was age under 1 year and hospitalization due to SSSS. A total of 399 children (177 girls) fulfilled the criteria for inclusion into the study. Information was obtained from a central data depository, the Department of Health Information and Statistics, Czech Republic. RESULTS A total of 399 children under 1 year were hospitalized for the diagnosis of SSSS in the study period. The group included 177 girls and 222 boys. M:F ratio was 1.25:1. The average incidence of SSSS in the Czech Republic was 25.11 cases per 100,000 children under 1 year of age. The highest recorded incidence in the followed period was in 1994, when a total of 57 cases of SSSS was reported, namely 53.47 per 100,000 children. By contrast, in 2003, there were reported only 12 cases and the incidence of 12.81 per 100,000 children. The average length of hospitalization was 6.39 days. In 1995, the highest average length of hospitalization was reported, which was 8.1 days, and then in 2007, the lowest average length of hospitalization, 4.4 days. There was no significant difference in the length of hospitalization in boys and girls. None of the 399 children in the population died. CONCLUSION In our retrospective study, we established basic epidemiological characteristics of a group of children aged under 1 year with diagnosis of SSSS. As epidemiological data show, the occurrence of this syndrome is not sporadic, but steady.

The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997-2009.

UNLABELLED The aim of this study was to determine the basic epidemiological characteristics of severely burned children who were admitted to the intensive care unit (ICU), Department of Burns and Reconstructive Surgery Faculty Hospital Brno, Czech Republic in the years 1997-2009. METHODS We collected and evaluated epidemiological data such as age, sex, burn etiology, length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic strategies, the use of mechanical ventilation and its duration, day and month of injury and the extent of burned area. RESULTS In total 383 children (253 boys, 130 girls) aged 0-14 years, underwent intensive care for at least 48h. Male to female ratio was 1.95:1. The average range of burn area in the group was 16.43±12.86% TBSA (total body surface area). During the reporting period, 16 children were admitted with burns over 50% TBSA. 328 children suffered burns indoors, with 55 children being burned outdoors. Indoor/outdoor ratio was set at 5.96:1. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in this group was 312 (81.46%). Mechanical ventilation was used in 96 cases (25.07% of all the admitted patients). The duration of mechanical ventilation in these patients was 8.03±5.67 days in average. The average length of stay in ICU was 10.71±10.92 days and total length of hospital stay was an average of 21.55±14.55 days. A total of 184 patients (48.04%) were treated surgically and therefore required necrectomy and skin grafting. The other 199 (51.96%) patients were treated conservatively. During the reporting period 3 children died (0.78%). CONCLUSION In our report we identify basic epidemiological data defined in the aim of this study for burned children requiring intensive care.

European practice guidelines for burn care: Minimum level of burn care provision in Europe

Clinical practice guidelines (CPG’s) are currently a regular part of a clinician’s armamentarium in virtually all branches of medicine. These guidelines are constantly upgraded and expanded through the work of physicians around the world. GPG’s in burn medicine also play an important role in successful burn treatment. European Burns Association (EBA) and namely its Executive Committee recognize the value of GPG’s, but have identified duplicity and varying levels of quality in the different national and other Practical Guidelines for Burn Care [1–18].

Toxic epidermal necrolysis data from the CELESTE multinational registry. Part I: Epidemiology and general microbiological characteristics

INTRODUCTION Toxic epidermal necrolysis (TEN) is a rare, life-threatening autoimmune disease predominantly manifested in the skin and mucous membranes. Today, infectious complications have the dominant share in mortality of TEN patients. Due to the nature of the therapy and administration of immunosuppressive medications, a wide range of potentially pathogenic microorganisms, which cause infectious complications in different compartments in these patients, is not surprising. MATERIAL AND METHODOLOGY This is a multicentric study, which included all patients with TEN hospitalized between 2000-2015 in specialized centres in the Czech Republic and Slovakia. The total catchment area was over 12.5 million inhabitants. The actual implementation of the project was carried out using data obtained from the registry CELESTE (Central European LyEll Syndrome: Therapeutic Evaluation), when specific parameters relating to epidemiological indicators and infectious complications in patients with TEN were evaluated in the form of a retrospective analysis. RESULTS In total, 39 patients with TEN were included in the study (12 patients died, mortality was 31%), who were hospitalized in the monitored period. The median age of patients in the group was 63 years (the range was 4-83 years, the mean was 51 years), the median of the exfoliated area was 70% TBSA (total body surface area) (range 30-100%, mean 67%). SCORTEN was calculated for 38 patients on the day of admission. Its median in all patients was 3 (range 1-6; mean 3). Any kind of infectious complication in the study group was recorded in 33 patients in total (85%). In total, 30 patients (77%) were infected with gram-positive cocci, 27 patients (69%) with gram-negative rods, and yeast cells or fibrous sponge were cultivated in 12 patients (31%). A total of 32 patients (82%) were found to have infectious complications in the exfoliated area, 15 patients (39%) had lower respiratory tract infections, 18 patients (46%) urinary tract infections and 15 patients (39%) an infection in the bloodstream. The most common potentially pathogenic microorganism isolated in our study group was coagulase neg. Staphylococcus, which caused infectious complications in 24 patients. Enterococcus faecalis/faecium (19 patients), Pseudomonas aeruginosa (17 patients), Staphylococcus aureus (11 patients) and Escherichia coli (11 patients) were other most frequently isolated micro-organisms. CONCLUSION The published data were obtained from the unique registry of TEN patients in Central Europe. In the first part, we have succeeded in defining the basic epidemiological indicators in the group of patients anonymously included in this registry. The study clearly confirms that infectious complications currently play an essential role in TEN patients, often limiting the chances of survival. The study also shows a high prevalence of these complications in the period after 15days from the start of hospitalization, when most patients already have completely regenerated skin cover.

Effect of timing of tracheostomy on changes in bacterial colonisation of the lower respiratory tract in burned children

OBJECTIVE The study aims to evaluate the impact of early and late tracheostomy on microbiological changes in the airways in severely burned children. MATERIALS AND METHODS Early tracheostomy is sometimes performed within 3 days after the start of mechanical ventilation regular microbiological surveillance of the respiratory tract was done in all patients. From each sputum, tracheobronchial aspirate and bronchoalveolar lavage (BAL), a microscopic slide was made and the material was seeded in a culture medium. The standard culture media used for the growth of respiratory pathogens are blood agar, McConkey agar, VL agar and chocolate agar. The obtained values were statistically analysed. RESULTS In the observed period, a total of 68 children underwent mechanical ventilation in our department. A total of 31 (45.59%) children had undergone surgical tracheostomy (18 patients with early tracheostomy and 13 patients with late tracheostomy). The most common bacterium isolated from the lower respiratory tract in patients with early and late tracheostomy was Acinetobacter baumannii (31.53% resp. 44.30% of all bacterial strains). In patients with early tracheostomy, the ratio of G+/G- during the 6-7th day of mechanical ventilation was 1.29:1 and during the 8-10th day, 1:1.43. In patients with late tracheostomy the G+/G- ratio was 1:2.25 and during the 8-10th day, 1:2.25. There was not any statistically significant deviation in the G+/G- ratio in patients with early and late tracheostomy in any of the monitored periods. CONCLUSION The main reasons for performing early tracheostomy are: extent, localisation and depth of the burn. Difficult weaning in an uncooperative patient, failure of extubation with subsequent reintubation and other complications may be an indication for late tracheostomy. The study confirms that the use of appropriately indicated early tracheostomy provides a microbiological benefit for burned children.

The first isolation of Westerdykella dispersa in a critically burned patient

Patients with critical thermal trauma belong to one of the most high-risk groups for development of infectious complications. Fungal infections are not among frequent complications during therapy of patients with thermal trauma, yet their incidence dramatically aggravates the prognosis for patients with this disorder. In the case report, we present the case of a young man with a critical burn, where Westerdykella dispersa was isolated. Identification of the pathogen was provided with a combination of cultivation and molecular biological confirmation. In this case, the distinction between infection and colonization was very complicated. Histopathological examination for definitive diagnosis of infection was not performed because the material from unburned soft tissue sampling could further compromise the function of the hand. Repeated cultivation and molecular identification W. dispersa before and after the necrectomy is indicative of infection rather than colonization. It is the second documented case of positive cultivation with this pathogen in humans and the first such case in a non-neutropenic host.

Toxic epidermal necrolysis data from the CELESTE multinational registry. Part II: Specific systemic and local risk factors for the development of infectious complications

The aim of the study was to identify the most important systemic and local risk factors for the development of infectious complications in patients with toxic epidermal necrolysis (TEN). MATERIAL AND METHODOLOGY This is a multicentric study that included all patients with TEN who were hospitalized between 2000-2015 in specialized centres in the Czech Republic and Slovakia. The total catchment area included a population of over 12.5 million inhabitants. The actual implementation of the project was carried out using data obtained from the CELESTE (Central European LyEll Syndrome: Therapeutic Evaluation) registry, wherein specific parameters related to epidemiological indicators and infectious complications in patients with TEN were evaluated as a retrospective analysis. RESULTS A total of 38 patients (97%) of the group were treated with corticosteroids. The comparison of patients with different doses of corticosteroids did not exhibit a statistically significant effect of corticosteroid administration on the development of infectious complications (p=0.421). There was no effect of the extent of the exfoliated area on the development of infectious complications in this area. The average extent of the exfoliated area was 66% TBSA (total body surface area) in patients with reported infectious complications and 71% TBSA (p=0.675) in patients without infectious complications. In the case of the development of an infectious complication in the bloodstream (BSI), the increasing effect of the SCORTEN (SCORe of Toxic Epidermal Necrosis) value was monitored during hospitalization. Within 5days from the beginning of the hospitalization, the average SCORTEN value was 2.7 in 6 patients with BSI and 3.0 in 32 patients without BSI (p=0.588). In the period after the 15th day of hospitalization, 7 patients with BSI had an average SCORTEN value of 3.4, and 16 patients without BSI had an average SCORTEN value of 2.5 (p=0.079). In the case of low respiratory tract infection (LRTI), the effects of the necessity for artificial pulmonary ventilation and the presence of tracheostomy were monitored. The statistically significant effect of mechanical ventilation on the development of LRTI occurred only during the period of 11-15days from the beginning of the hospitalization (p=0.016). The effect of the tracheostomy on the development of LRTI was proven to be more significant. CONCLUSION We did not find any statistically significant correlation between the nature of immunosuppressive therapy and the risk of developing infectious complications. We failed to identify statistically significant risk factors for the development of BSI. Mechanical ventilation and tracheostomy increase the likelihood of developing LRTIs in patients with TEN.

Severe bullous diseases in the Czech Republic

Aim: The study is to establish basic epidemiological characteristics of patients hospitalized in the Czech Republic with a diagnosis of toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS). Material and methods: This is a retrospective multicenter study including hospitalized patients in the Czech Republic in the period from 1st January 1994 to 31st December 2010. The basic condition for inclusion in the study is TEN (L512) or SJS (L511) as the primary diagnosis according to International Classification of Diseases 10th version (ICD–10). The two diseases have similar clinical presentations, but have different nosological codes, which were retrieved from our database. Information was obtained from a central data depository-Department of Health Information and Statistics (National Registry of hospitalized patients). Results: A total of 626 patients were hospitalized in our followed period. Of these, 163 patients were hospitalized with toxic epidermal necrolysis and 463 patients with Stevens-Johnson syndrome. The overall M:F ratio in the sample was 1:1.15. In the group of patients with TEN M:F ratio was 1:1.31 and in the SJS group M:F ratio was 1:1.11. The mean incidence in the period in patients with TEN was 0.93 cases/million inhabitants per year. In patients with SJS, the average incidence was 2.64 cases/million inhabitants per year. The average age was 39.2 years, in patients with TEN it was 40.1 years (SD±21.5) and in patients with SJS 38.4 years (SD±11.98). The average length of hospitalization was 11.3 days. In patients with TEN, the average length of hospitalization was slightly higher (11.8 days (SD±3.11)) when compared with SJS group (10.7 days (SD±6.48)). From the total of 626 patients, 54 patients died. Of these, it was 47 patients with TEN and 7 patients with SJS. Conclusion: In a retrospective study confirms that SJS and TEN are rare diseases and their incidence in the Czech Republic closer to the results of most large epidemiological studies.

Resorption and elimination kinetics of benzoic acid during chemical necrectomy in deep burns

Abstract Objective: Chemical necrectomy is an alternative to the surgical or sharp necrectomy for the removal of necrotic parts of the skin in the treatment of deep burns. The aim of our work was to monitor the dynamics of resorption and elimination of benzoic acid applied to the burnt skin. Methods: The set consisted of 10 patients (9 men; 1 woman) aged 25–57 years with IIb-III-degree skin burns. 40% benzoic acid in white petrolatum was applied to the burnt area to the extent of 3–5% of TBSA (total body surface area) for a period of 48 hours. The concentrations of benzoic acid, hippuric acid, and glycine in the serum was monitored at the 10th, 20th, 60th, 120th, 240th and 360th minute thereafter and further at the 12th, 24th, 48th, and 72nd hour; the excretion of hippuric acid in urine was monitored in six 12-hour intervals. Results: The highest concentration of benzoic acid in the serum was detected in the 60th minute sample (0.094±0.074 mmol/L) and of hippuric acid in the 120th minute sample (0.234±0.088 mmol/L) from the application of benzoic acid to the burnt skin. In the period between the 6th and 48th hour, the average concentration of benzoic acid in the serum ranged between 0.042 and 0.03 mmol/L. In this period there was also a significant decrease in serum glycine concentration (p<0.05). During the 48-hour application of benzoic acid to the burnt skin, 46.0–145 mmol of hippuric acid was excreted in urine. Conclusion: Chemical necrectomy with the use of 40% benzoic acid led only to a moderate increase of its concentration in the serum. After its resorption from the wound area it is transformed to hippuric acid, which is promptly excreted in urine.