Key learning points:
– Early recognition and treatment of burn wound infections in children are essential
– Burn wound infections and toxic shock syndrome must always be considered in an unwell child following a burn injury
– Confirmed diagnosis of burn wound infection in children is retrospective in most cases
Minor burns and/or scalds in children are a frequent injury in the first two years of life. A total of 50,000 children are seen in emergency departments and 5,000 to 6,000 are admitted to burn services annually in England and Wales. Most of these injuries are attributed to an inability of the child to foresee danger in conjunction with immature motor skills and a momentary lapse in supervision by a parent or carer. These injuries usually occur in the home (primarily the kitchen)1 and are caused by hot liquids, or contact with hot objects (radiators, ovens, hobs or hair straighteners etc).2 Flame burns in children are less frequent and these usually occur in the older age group (male adolescents primarily). Major burns of large surface area in children are rare and are usually scald injuries from hot baths, running taps or larger amounts of hot liquid spills.
The skin has a number of important functions; fluid homeostasis, thermoregulation, vitamin D synthesis, as well as providing a barrier to infection. Any breach in the integrity of the skin may alter these functions. A burn on a large surface area will impair all of these functions, and a smaller burn will still leave the child at risk of infection. A minor or non-complex burn can be defined as one that is likely to heal within a maximum of 14 days.3 However, a burn of any size is at risk of infection prior to complete re-epithelialisation (healing). Gallagher et al reported that bacterial growth will occur within a wound until healing is complete.4 Children, unlike adults, are more prone to infection due to their immature immune system.
The use of antibiotic prophylaxis after burn injury continues to be debated. Much of the published evidence – including randomised controlled trials – does not support the use of intravenous, oral, or topical prophylactic antibiotics (including the use of silver sulfadiazine or flamazine) in the routine management of burn wounds.4,5 Overuse of unnecessary antibiotics is a key driver for bacterial resistance, which is an international concern.6,7 More research is needed to provide a better evidence base for antibiotic use after burn injury.
Wound management
The ideal environment for wound healing is one that is moist and clean. Antimicrobial cleaning products and dressings are considered good practice. Healthcare professionals are often bombarded with a plethora of choice when it comes to woundcare products. However, the evidence base for these products is often weak and not specific to burns or children.8 For minor burns that do not require excision and skin-grafting, wound cleaning with water (hydrotherapy) continues to be a common practice in many burn care services.9 This includes bathing, or more commonly, showering to remove surface debris and clean the wound as well as the surrounding skin. Tap water that is drinkable is considered as effective as sterile water or saline in this respect.10 For children, bathing is often used as a wound cleaning practice in burn services worldwide. In most cases the bath is normally an enjoyable experience and children are quite content to be bathed. Involvement of the parent/carer in this procedure is a vital part of children’s burn care. The frequency of bathing is more debatable and ranges from daily, every three to five days or ‘whenever it is needed’.9 Similarly the ‘ideal’ burn wound dressing has been debated for many years. It may be defined as non-adherent, absorbent, with antimicrobial properties, easy to remove, changeable twice a week and comes in a range of sizes.11 However, what is missing in the published literature is knowledge of the combined importance and effect of adequate/frequent wound cleansing/debris removal, alongside a supportive dressing that aids healing and reduces infection.
Types of burn wound infections
Burn wound infections can be categorised into two types; local and systemic. Localised infections occur at and/or around the wound site. If recognised and treated early, the child will remain well. If a localised wound infection is not treated early, this may progress to systemic sepsis. Systemic infections (sepsis) initiate a systemic inflammatory response (SIR) and the child will become progressively unwell with multi-organ involvement. Failure to diagnose and treat systemic infections will result in a poor outcome including mortality.
Localised infection
All burn wounds will have organisms that reflect the normal skin flora. The presence of bacteria in a burn wound without clinical signs of infection is termed colonisation. A burn wound infection can be identified pathologically if high numbers of bacteria are found histologically in burn tissue from a skin biopsy. However, this technique is not commonly undertaken. A wound swab with bacteria present is not sufficient to diagnose infection, as wounds may simply be colonised. Wound infection is therefore usually diagnosed clinically in the presence of advancing erythema, warmth and tenderness. The wound may also have characteristic smells. Management is with fastidious wound cleaning. Antibiotics are only used if there is cellulitis, sepsis (proven) or toxic shock syndrome (TSS).
Burn wound cellulitis
This is characterised by extending erythema into healthy skin surrounding the wound site. Other signs and symptoms can include localised pain or tenderness, swelling or heat at the affected site, progression of erythema and swelling, and signs of lymphangitis and/or lymphadenitis extending from the affected skin area along routes of lymphatic drainage to the area.10
Burn wound infection
This is characterised by purulent exudate that is culture positive; there are bacteria present as shown by wound swabs with clinical signs of infection.12 This can start as a bacterial biofilm and has the ability to prevent antimicrobial dressings from working, as well as stopping the normal action of the body’s defence system in destroying bacteria.13
In these situations, judicious use of topical and systemic antibiotics in conjunction with thorough wound cleansing and antimicrobial dressings will prevent these local infections from progressing further. The need to clean the wound as well as giving antibiotics is vital.
Systemic infection (sepsis)
Burn wound-related bacteraemia/septicaemia/sepsis
This is a blood stream infection caused by invasive organisms that have colonised the wound site and overwhelmed the child’s defence mechanisms. A positive blood culture will confirm the bacteria type and provide sensitivities, thus determining which antibiotic(s) will be required to treat the infection. Blood cultures take at least 48 hours to provide a definitive diagnosis and it is usually necessary to use antibiotics before the results are known, based on the most common bacteria likely to be present. The treatment for blood stream infections is best described in the Surviving Sepsis Campaign recommendations.14 It states the importance of early and aggressive infection source control and prompt treatment with appropriate intravenous antibiotics (within one hour).
Burn wound related toxic shock syndrome
Toxic shock syndrome is a toxin-related disease usually
secondary to the toxins of S aureus. If it’s not diagnosed and treated promptly it can lead to progressive illness. There is a mortality rate of 50% in the full-blown disease. Children are more susceptible to TSS than adults due to their lack of circulating antibodies to the responsible toxins.14 Increased awareness of the condition has improved over the years, but it still gets confused with other childhood illnesses – especially those of gastro-intestinal origin. This is particularly the case when, on wound inspection, the burn looks clean and there are no obvious signs of infection. Blood cultures are usually negative.
Complex criteria exist for the diagnosis of toxic shock and burn wound sepsis,15,16 but these often seek to confuse the issue and have the potential to delay treatment. Simpler criteria enables healthcare professionals to make a faster presumptive diagnosis.17 The typical presentation is in a toddler with a recent, small, ‘clean-looking’ burn who acutely develops a high temperature (>39⁰c), becomes lethargic, clinically unwell and commonly has a fine widespread rash.17 Laboratory tests are likely to show a low lymphocyte cell count and hyponatraemia.
Toxic shock syndrome requires different treatment to other septic conditions, as it is a toxin-related disease and children do not usually have bacteria in the blood stream. The key management points include use of intravenous antibiotics to get rid of the bacterial trigger (bacteria in the wound), but more importantly, thorough wound cleaning and treatment of the anti-toxin. Children will not get better with antibiotics alone. Children lack immunity to the specific toxin and so immunity must be provided with intravenous immunoglobulin or fresh frozen plasma (collected from adults who have the antitoxin). Supportive measures are also required with careful fluid resuscitation. Children will require either conscious sedation or a surgical procedure to achieve the necessary wound cleaning. Children suspected of having toxic shock need urgent transfer to specialist burn care.18
There are a number of other childhood illnesses that can occur when a child has an open burn wound. The combination of an immature immune system and immunosuppression as a result of the burn4 makes children more susceptible to picking up other childhood illnesses and can confuse the clinical picture: viruses, gastric illnesses, upper respiratory tract infections, ear and throat infections and urinary infections may present in the same way as burn wound infections. It is an important clinical skill to be able to differentiate between a burn wound infection and other childhood illnesses.
The role of the primary care nurse
The primary care nurse is best placed to provide wound care support and advice to children and their families after burn injury especially for those who have not presented directly or have been referred to specialist burn care services. The role is multi-factorial and may also include providing psychological support to the child/family where anxiety and guilt is expressed, and liaison/referral to social care if the family require an increased level of support and guidance. From an infection prevention and control perspective, the following practice is recommended:
– Support parents/carers with appropriate wound cleaning and dressing application to reduce the risk of infection.
– Prioritise patients to be reviewed whenever key signs and symptoms of infection are reported, for example; fever (>39⁰C), vomiting +/- loose stools, increased pain at the wound site, reduced oral intake, irritability and/or general malaise.14,17
– Prompt liaison with the local burn care service if there is any likelihood that the infection is burn-related.18
– Administer treatment as advised and/or arrange for transfer to the local specialised burn care service if a higher level of care is necessary.18
Conclusion
Burn wound infections in children can have serious consequences if they are not diagnosed and treated promptly. Understanding the signs of infection and the need to prioritise these over other childhood conditions is vital. Complications of missed wound infection and TSS can range from delayed healing and increased scarring to, at worst, mortality if poorly managed. Thorough and regular wound cleansing alongside antimicrobial dressings can reduce the risk of burn wound infections. However, the practicalities in achieving this in the primary care setting with adequate pain control may be challenging. Having the confidence to recognise potential burn wound infection in children will ensure the right treatment is given, in the right place, and at the right time in order to achieve the best possible outcome for the child and their families.
References
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