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The aim of fluid resuscitation is to restore tissue perfusion, ameliorate cellular injury, increase tissue perfusion and oxygenation, and improve end-organ functions. Many researches in the field of fluid resuscitation strategy have been made in the last decade, but vigorous debate on optimal method of resuscitation still exists. The hypotensive resuscitation strategy is particularly applicable in patients with uncontrollable hemorrhage, whereas, it is uncertain whether the theory could be used in burn shock management. Resuscitation using both colloid and crystalloid has a better outcome in treating extensive burns and septic shock. Caution should be exercised when using higher concentrations of artificial colloid and lactated Ringer's solution, of which some adverse effects have been observed. Along with the increasing use of novel hemodynamics monitoring in intensive care, parameters including stroke volume variation (SVV), intrathoracic blood volume index (ITBVI), and cardiac index (CI) have been examined as indexes of resuscitation endpoint. However, further studies should be made when applying SVV, ITBVI, and CI in guiding fluid resuscitation in burns.

Fungal infection is one of the serious complications of severely burned patients with high mortality. Application of antifungal agents timely and rationally is very important to control the infection. Antifungal agents including polyenes,triazoles, and echinocandins have been used widely in burned patients and are proved to be effective. Since diagnosis of fungal infection remains difficult, prophylactic and empirical therapies appear to be particularly necessary. In order to improve the efficacy and safety of antifungal agents, the factors of fungal strains, infection sites, hepatic and renal functions, and age, etc. should be considered in selecting antifungal agents.

Objective: To evaluate the effect of FLAMIGEL (hydrogel dressing) on the repair of residual burn wound., Methods: Sixty burn patients with residual wounds hospitalized in 6 burn units from November 2011 to May 2012 were enrolled in the multi-center, randomized, and self-control clinical trial. Two residual wounds of each patient were divided into groups T (treated with FLAMIGEL) and C (treated with iodophor gauze) according to the random number table. On post treatment day (PTD) 7 and 14, wound healing rate was calculated, with the number of completely healed wound counted. The degree of pain patient felt during dressing change was evaluated using the visual analogue scale (VAS). The mean numbers of wounds with score equal to zero, more than zero and less than or equal to 3, more than 3 and less than or equal to 6, more than 6 and less than or equal to 10 were recorded respectively. Wound secretion or exudate samples were collected for bacterial culture, and the side effect was observed. Data were processed with repeated measure analysis of variance, t test, chi-square test, and nonparametric rank sum test., Results: Wound healing rate of groups T, C on PTD 7 was respectively (67 ± 24)%, (45 ± 25)%, and it was respectively (92 ± 16)%, (72 ± 23)% on PTD 14. There was statistically significant difference in wound healing rate on PTD 7, 14 between group T and group C (F = 32.388, P < 0.01). Ten wounds in group T and four wounds in group C were healed completely on PTD 7, with no significant difference between them (χ(2) = 0, P > 0.05). Forty-two wounds in group T and seven wounds in group C healed completely on PTD 14, with statistically significant difference between them (χ(2) = 42.254, P < 0.01). Patients in group T felt mild pain during dressing change for 37 wounds, with VAS score higher than zero and lower than or equal to 3. Evident pain was observed in patients of group C during dressing change for 43 wounds, and it scored higher than 3 and less than or equal to 6 by VAS evaluation. There was statistically significant difference in mean number of wounds with different grade of VAS score between group T and group C (Z = -4.638, P < 0.01). Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, E. coli, Baumanii, and Staphylococcus epidermidis were all detected in both groups, but there was no statistical difference between group T and group C (χ(2) = 0.051, P > 0.05). No side effect was observed in either of the two groups during the whole trial., Conclusions: FLAMIGEL can accelerate the healing of residual burn wounds and obviously relieve painful sensation during dressing change.

Objective: To study the changes in expression of quorum sensing gene aba I in Acinetobacter baumannii (AB) strains isolated from burn patients during biofilm formation process, and its influences on the extracellular matrix of biofilm and drug resistance of AB., Methods: Six drug-resistant and five drug-sensitive AB strains isolated from wound excretion, blood and venous catheter were collected from burn patients hospitalized in Ruijin hospital of Shanghai Jiao Tong University School of Medicine from January to October 2011. The AB standard strain ATCC 19606 was used as control. (1) Clinical strains and standard strain were normally cultured 10, 24, and 48 h respectively in vitro. The bacteria samples were stained with propidium iodide to measure biofilm thickness with confocal laser scanning microscope. (2) Clinical strains and standard strain were cultured in tubes 10, 24, and 48 h respectively in vitro under shaking condition. The bacteria floating in the medium were regarded as free bacteria, while those adhered to the tube wall as the bacteria within biofilm (biofilm bacteria). Relative expression value of genes aba I and pgaB was detected by real-time fluorescent quantitative PCR with the expression value of the standard strain set at 1. Data were processed with analysis of variance., Results: (1) At post culture hour (PCH) 10, 24, 48, biofilm thickness of clinical strains was thicker than that of standard strain; biofilm thickness of drug-resistant strains [(28.8 ± 0.6), (31.7 ± 1.1), and (38.1 ± 3.1) µm] was respectively thicker than that of drug-sensitive strains [(17.1 ± 0.4), (20.1 ± 1.6), and (25.8 ± 1.7) µm, with F value respectively 1274.38, 206.60, and 61.73, P values all below 0.05]. (2) Biofilm bacteria: at PCH 10, 24, 48, expression values of aba I in drug-resistant strains (6.6 ± 1.7, 25.7 ± 3.5, 9.8 ± 3.6) were much higher than those of drug-sensitive strains (2.7 ± 1.0, 15.0 ± 3.5, 4.7 ± 3.2, with F value respectively 21.82, 25.24, and 6.22, P values all below 0.05); expression values of pgaB in drug-resistant strains (37.4 ± 1.1, 44.5 ± 3.6, 33.1 ± 11.5) were obviously higher than those of drug-sensitive strains (14.6 ± 0.8, 20.0 ± 6.9, 18.7 ± 6.8, with F value respectively 1488.44, 57.26, and 6.01, P values all below 0.05). (3) Free bacteria: at PCH 10, 24, 48, there was no significant statistical difference between drug-resistant strains and drug-sensitive strains in expression value of aba I (with F value respectively 0.24, 2.33, and 0.11, P values all above 0.05); expression values of pgaB in drug-resistant strains (13.8 ± 3.8, 12.5 ± 2.9, 23.7 ± 2.1) were obviously higher than those of drug-sensitive strains (7.0 ± 5.9, 5.0 ± 1.3, 15.6 ± 6.7, with F value respectively 5.44, 28.42, and 7.76, P values all below 0.05). (4) Comparison between biofilm bacteria and free bacteria in resistant strains: expression value of aba I in biofilm bacteria at each time point was respectively higher than that of free bacteria (with F value respectively 43.69, 286.61, and 9.98, P values all below 0.05); expression values of pgaB in biofilm bacteria at PCH 10, 24 were higher than those in free bacteria (with F value respectively 214.26 and 283.20, P values below 0.05). (5) Comparison between biofilm bacteria and free bacteria in sensitive strains: expression value of aba I in BF bacteria at PCH 24 was higher than that of free bacteria (F = 70.28, P < 0.05); expression values of pgaB in biofilm bacteria at PCH 10, 24 were higher than those of free bacteria (with F value respectively 8.03 and 22.62, P values below 0.05)., Conclusions: During biofilm formation process, the increasing expression of quorum sensing gene aba I in drug-resistant AB strains isolated from burn patients may up-regulate the expression of gene pgaB, which leads to high production of extracellular matrix and biofilm formation, and enhances drug resistance of AB.

Objective: To observe the antimicrobial activity of topical agents commonly used for burns on Acinetobacter baumannii (AB) in both free and biofilm states, and their synergistic effect with ambroxol on AB within biofilm., Methods: Eleven AB strains were isolated from wound excretion, respiratory tract, and blood of patients hospitalized in our hospital from August 2005 to April 2007. (1) The minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) of mafenide acetate and chlorhexidine acetate to free AB (including drug-resistant, drug-sensitive, and standard strains) were determined by dilution method. (2) AB was cultured with LB or TSB medium for 12, 24, and 48 h to form biofilm, and it was treated with above-mentioned two topical agents in MBC (mafenide group and chlorhexidine group) for 30 min. Biofilm not treated by topical agent was used as control group. The biofilm thickness was determined with confocal laser scanning microscope. The proportion of living bacteria in biofilm was calculated. AB biofilm in each topical agent group was mixed and inoculated into LB culture dish to observe the growth of bacteria. (3) AB was cultured with LB medium for 48 h to form biofilm, which was respectively treated by above-mentioned two topical agents in MBC (mafenide group and chlorhexidine group) and combination of each topical agent with 3.75 mg/mL ambroxol solution (ambroxol + mafenide group and ambroxol + chlorhexidine group) for 30 min. Biofilm not treated by topical agents was used as control group. Growth of bacteria in biofilm was detected with MTT method (denoted as absorbance value). Data were processed with one-way analysis of variance and LSD-t test., Results: (1) MIC of mafenide acetate and chlorhexidine acetate for free AB was respectively 25.00 mg/mL and 0.03 mg/mL. MBC of both agents for free AB was the same as their MIC. (2) Among three groups, the thickness of biofilm of sensitive AB was thicker than that of drug-resistant bacteria at most of the time points. Compared with those in control group, biofilm thickness and proportion of living bacteria in biofilm were slightly decreased in mafenide and chlorhexidine groups. The growth of bacteria was abundant in each group. (3) Absorbance value of drug-resistant bacteria in control, mafenide, and chlorhexidine groups was respectively 0.776 ± 0.071, 0.625 ± 0.063, and 0.420 ± 0.068. Absorbance value of drug-resistant bacteria in ambroxol + mafenide group (0.174 ± 0.089) was significantly lower than that of control group (t = 11.823, P = 0.000) and mafenide group (t = 9.248, P < 0.01). Absorbance value of ambroxol + chlorhexidine group (0.178 ± 0.044) was significantly lower than that of control group (t = 16.009, P = 0.000) and chlorhexidine group (t = 6.681, P < 0.01)., Conclusions: Drug-resistant AB forms biofilm readily, which prevents topical agents from killing the bacteria inside. Combined use of ambroxol with topical agents gives synergistic effect on killing AB in biofilm in the wound.

Objective: To monitor genotypes and drug-resistance trend of Acinetobacter baumannii (AB) isolated from burn wards., Methods: Twenty-six strains of AB isolated from wound secretion, venous catheter, and blood were collected from burn patients hospitalized in our burn wards from November 2008 to February 2009, and June to September 2010. Homogeneous genotype analysis was performed with repetitive extragenic palindromic PCR, and drug-resistance rate to 13 antibiotics including amikacin, gentamicin, etc., which were commonly used in clinic, was tested by K-B paper disk diffusion. The data of drug-resistance rate were processed with chi-square test., Results: (1) Sixteen AB strains were multi-drug resistant (MDR), 9 AB strains were pan-drug resistant (PDR). Among all strains, the resistance rate to gentamicin, piperacillin, piperacillin/tazobactam, cefuroxime, cefotaxime, ceftazidime, cefepime, ciprofloxacin, imipenem, and meropenem was respectively higher than 90.00%; the resistance rate against cefoperazone/sulbactam was the lowest (11/26, 42.31%). There were obvious difference among the drug-resistance rates of AB strains to 13 antibiotics (with rates from 42.31% to 100.00%, χ(2) = 97.371, P < 0.05). (2) There were 7 genotypes among 26 AB strains, respectively type A (17), type B (3), type C (2), type D (1), type E (1), type F (1), and type G (1). Out of the 17 AB strains in A genotype, 1 strain was from 2008, 1 strain was from 2009, 15 strains were from 2010, and among them 11 strains were collected from wound secretion and 6 strains were obtained from blood and venous catheter., Conclusions: AB strains in A genotype are dominant in our burn wards in recent years, which are MDR or PDR to commonly used antibiotics. Cefoperazone/sulbactam is the drug of choice for burn patients with AB infection.

Objective: To observe expressions of pgaABC gene clusters and changes in biofilm (BF) phenotype in Acinetobacter baumannii (AB) isolated from burn patients., Methods: From January 2009 to October 2010, 24 strains of AB isolated from burn patients hospitalized in our burn wards were collected for the study, while the standard strain ATCC 19606 was used as control. Expressions of pgaABC gene clusters were detected by real time fluorescence quantitative RT-PCR. All strains were cultured for 16 hours in vitro, BF with semi-quantitative detection was respectively evaluated by modified microtiter-plate test under stable condition and tube test under shaking condition for expression of absorbance value. All strains were cultured for 48 hours in vitro, then stained with fluorescent agent and collected for measurement of BF thickness with confocal laser scanning microscopy (CLSM). Data were processed with t test., Results: (1) The expression of pgaB gene (27.91 ± 7.93) in clinical AB strains was much higher than that of standard strain ATCC 19606 (1.00, t = 5.77, P < 0.05). There was no statistical difference in expression of pgaA and pagC genes between standard strain ATCC 19606 (1.00) and clinical AB strains (1.01 ± 0.28, 1.15 ± 0.38, with t value respectively 0.04, 0.64, P values all above 0.05). (2) After being cultured for 16 hours, BF of clinical AB strains cultured under shaking condition formed distinct "purple circle", and its absorbance value (1.25 ± 0.31) was higher than that in standard strain ATCC 19606 (0.76 ± 0.03, t = 2.67, P < 0.05). There was no obvious difference in absorbance value between clinical AB strains and standard strain ATCC19606 cultured under stable condition. (3) After being culture for 48 hours, green fluorescence intensity and distribution in extracellular matrix of clinical AB strains were stronger as compared with those of standard strain ATCC 19606, and BF thickness in clinical AB strains [(27.3 ± 9.4)µm] was thicker than that in standard strain ATCC 19606 [(15.6 ± 1.7) µm, t = 2.09, P < 0.05]., Conclusions: The high expression of pgaB gene in AB strains isolated from burn patients can induce production of extracellular matrix, which may be related to increase in the ability and thickness of BF formation.

Infections caused by Acinetobacter baumannii (AB) have emerged as a knotty clinical problem in the burn wards due to its omni-resistance to antibiotics and high prevalence. Although our knowledge in regard to the pathogenesis and the resistance mechanisms of AB is increasing, the available treatment remains much limited. Measures to effectively control nosocomial infection are warranted. Meanwhile, development of novel therapeutic agents or combination of antibiotics should be considered.

Objective: To observe the biofilm (BF) formation of Staphylococcus aureus (SA), Acinetobacter baumannii (AB) and Pseudomonas aeruginosa (PA) on the surface of deep vein catheters in burn patients after infection., Methods: The bacteria from deep vein catheters in 20 patients hospitalized from November 2008 to August 2009 were isolated, and were compared with their respective standard stains. Catheters tips were examined with scanning electron microscope (SEM). The semi-quantitative adhesion assay of bacterial BF was performed with modified microtiter-plate test, and the thickness of BF was scanned and measured by confocal laser scanning microscopy (CLSM) after double fluorescence staining, after being cultured in vitro for 12, 24, 48, 72 hours and 5 days, respectively. Data were processed with grouped t test., Results: Six strains of SA, 8 strains of AB, and 6 strains of PA, all drug resistant, were isolated from the deep vein catheters. SEM showed that the BF structures on the inner surfaces of catheters were in diverse in their shape and degree, characterized by adherence and flake formation, and embedded in polysaccharide matrix. BF gathered in clusters, forming three-dimensional structure, in which small amount of red blood cells were found. A small number of bacteria were incompletely embedded, with some bacteria adhered to them. The absorbance values for SA after 24, 48 and 72 hours of culture (PCH) were above the cut-off value, the same for AB at PCH 12, 24, 48 and 72, and PA after PCH 48. Except for PA standard strain, CLSM showed scattered green fluorescence, mainly close to the bottom of plate, while the red fluorescence was observed in full scope at PCH 24 for each strain. At PCH 48 green fluorescence increased obviously and extended upward from the bottom, overlapping partly with red fluorescence, forming yellow fluorescence, and among the bacteria it was most obvious in AB culture, with SA the next. Compared with those of the standard stains, the intensity and quantity of fluorescence from the clinical strains were stronger; at PCH 72 the green fluorescence increased obviously especially for PA and its standard strain, while the yellow fluorescence was full of the scope for other strains. On in vitro culture day 5, the green fluorescence was dispersed and was obvious on the bottom of the plate. BF mature time for AB and SA was PCH 48, and for PA was PCH 72. The BF thickness of AB was (18.2 +/- 3.6) microm at PCH 72, which was thicker than that [(9.4 +/- 2.6) microm] of its standard strain (t = 5.42, P < 0.05), and was also the thickest among the three clinically found strains., Conclusions: SA, AB and PA, which are commonly found bacteria in burn patients, can form BF in deep vein catheters. Their ability to form BF seems to be stronger than other usually pathogenic strains, especially AB, which is the important pathogen leading to catheter related infection.

Infection is still the major cause of death in severe burn patients, thus the optimization of antibiotic therapy is an important approach to the annihilation of pathogenic bacteria and the decrease of drug-resistance bacteria. It is urgent for burn surgeons to face the selection pressure of antibiotics and the fungous infections following the incorrect use of antibiotics. Regardless of its complexity, the treatment of sepsis associated with post-burn bacterial infections should be systematical. Besides the effective anti-shock therapy, early enteral feeding, excision of necrotic tissues, and effective anti-infection treatment, the immunological regulation and the prevention and cure of coagulation disorders are necessary in the treatment of severely burned patients.

Objective: To evaluate the therapeutic effect of silver nitrate ointment on partial-thickness burn wounds, and observe its side-effects., Methods: Multi-center, randomized, positive drug paralleled self-controlled trial was carried out. Eighty patients with superficial partial-thickness burns, and 40 with deep-partial thickness burns were randomized into AgNO3 group and SD-Ag group according to drug topically applied to the wounds. The wound healing time, wound healing rate and bacterial culture of the wound, the effect and safety of the drug, as well as drug irritation to the wounds were studied in these two groups., Results: For the patients with superficial partial-thickness burn wounds, the wound healing time in silver nitrate group was (9.5 +/- 2.7) days, which was obviously shorter than that in SD-Ag group [(10.8 +/- 3.4) days, P <0.01]. The wound healing rate in silver nitrate group on 7 post-burn day ( PBD) was (77.9 +/- 20.5)%, which was obviously higher than that in SD-Ag group [(67.3 +/- 22.6) %, P < 0.01]. For those with deep-partial thickness burn wounds, the wound healing time in silver nitrate group was (21.5 +/- 4.8) days, which was evidently shorter than that in SD-Ag group [(23.3 +/- 6.4) days, P <0.01]. The wound healing rate in silver nitrate group on 20 PBD was (86.6 +/- 15.9)%, which was evidently higher than that in SD-Ag group [(78.5 +/- 17.7)%, P < 0.01]. Silver nitrate ointment has the same antibacterial effect as 1% SD-Ag cream, but it was less painful when applied to the open wounds., Conclusion: Silver nitrate ointment is an effective and safe medicament for the clinical management of partial-thickness burn wounds.

Objective: To evaluate the safety and long-term effect of recombinant human epithelial growth factor (rhEGF) on deep partial-thickness burn wounds., Methods: Thirty-seven burn patients were enrolled in this study and were observed by randomized, double-blinded and placebo-controlled protocol. An area of deep partial-thickness burn wounds from each patient was divided into control (C) and treatment (T) portions. The wound in C was treated with normal saline while that in T with rhEGF. The patients were followed-up for 1 and 4 years after wound healing. The healed wounds were evaluated by modified Vancouver scar scale in terms of scar index (SI)., Results: 1 year after wound healing, it was found that the SI in T group (7.19 +/- 1.67) was obviously lower than that in C group (8.92 +/- 1.78, P < 0.01). The SI in T group (6.12 +/- 1.54) was still evidently lower than that in C group (8.09 +/- 1.81, P < 0.01) four years after wound healing. There were no signs of development of tumor or cancer in all the tested burn wound areas., Conclusion: External application of rhEGF might be beneficial to the healing quality of deep partial-thickness burn wound with less scar formation and better long-term effects, and it is safe.