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Burn in a 2 year-old child with beneficial microbe topical therapy.


Piotr Kochan1, Anna Kochan2



Introduction

Every year, more than half a million thermal injuries occur in the US alone. Most of these burns are not severe, although as many as 50.000 patients will still need hospitalisation in a burn centre [1]. Thermal injuries are a significant reason for morbidity and hospitalisation in children, especially up to 4 years-old. In the UK they are the fourth leading cause of injury-related hospitalisation [2]. The number of thermal injuries in Poland is approximately 300.000-400.000, up to 70% being paediatric and the biggest group within those youngsters are children up to 4 years of age [3]. Most burns in children occur at home and are easily preventable, majority are due to inadequate supervision combined with child curiosity, and parental errors but rarely deliberate. Most of these burns are caused by hot liquid, touching hot objects and less often by flame. Other causes of burns include: cold, electricity, chemicals, radiation and friction [1, 4]. They are costly to treat and cause heavy psychological burden on the patient and the patient’s family [2]. Burns are classified according to:
- cause and mechanism of injury,
- depth,
- size (TBSA), and
- associated conditions.

Better treatment outcomes may be attributed to early (home) cooling, specialised care in burn centres, adequate critical care management and resuscitation, better wound care, improvements in treatment of infections, management of inhalation injury and burn-induced hypermetabolic syndrome [1-5].


Patient description

In 2013, a 2 year-old boy living in Cracow suffered a burn to the forearm by reaching for and toppling over a cup with boiling water. The hot liquid covered the arm in a circumferential pattern. The mother who was present in the kitchen when the incident happened was washing dishes and immediately took the baby to the bathroom and placed the arm under running cool water for over 20 min. After that period the arm was placed in clean towel, acetaminophen syrup was administered and the mother drove her son to the local emergency (ER) department. The initial cooling with water and medication turned out to be a very good decision since the 2nd degree burn was contained in the initial phase. The mother reports >3-hour waiting period in the ER waiting room before the wound was taken care of, i.e. cleansed and a dressing made. The burn location is shown in figure 1.


Treatment, i.e. beneficial microbe dressings

Probiotics are live microbes that bring benefit to the host upon administration in adequate amounts. Over the recent years there were reports in the literature on the use of probiotic strains in the supplemental treatment of wounds, including gunshot wounds and burns [6-9]. The majority of these microbes were administered orally with improved outcomes in wound healing, but there are also recent reports on the successful topical use of these beneficial microorganisms in animal models [10, 11].

Long before the above publications on the local use of probiotics became available, after thorough consideration and informed consent decision, we have decided to use an experimental clinical protocol of topical therapy using probiotics, with sole responsibility on the physician. The probiotic strain we used: Lactobacillus plantarum PL 02, came from our previous microbiological study performed at the Chair of Microbiology JUMC in 2011/2012. It was grown under required conditions on MRS agar and then the colonies were collected from the surface and suspended in lukewarm, previously boiled water at a an initial density of 1 in McFarland standard and on day 2 it was increased to 2 in McFarland standard. The dressings were soaked in Lactobacillus strains-containing fluid and changed every 6 hours (Figure 2). Each time the wound was washed with saline and closely inspected. Initially the wound was reddened but became paler along the treatment course (Figure 3). The patient was administered acetaminophen syrup for the pain for the first 3 days, at standard dosage for the age. The course was uneventful and the healing rapid. The dressings were used for 7 days


Follow-up

The scar was initially slightly red but became paler and even-surfaced with time. In figure 4 the scar is seen after 2 years. The next follow-up photograph was taken when the boy was 6 years-old, just before beginning his primary school. After 4 years since the incident it’s barely visible, only when the patient becomes really cold or is exposed to sun (Figure 5). Overall the cosmetic outcome is fantastic.


Images

figure1
Figure 1. The 2 year-old shows his forearm with the circumferential boiling water scalding.
[please click on the image to enlarge]


figure2
Figure 2. The wound dressing containing Lactobacillus strains.
[please click on the image to enlarge]


figure3
Figure 3. The burn during healing and consecutive probiotic dressing changes. One can see remnants of blisters and a small necrotic focus which was removed.
[please click on the image to enlarge]


figure4
Figure 4. Follow-up of the scar after 2 years. Patient here was 4 years-old.
[please click on the image to enlarge]










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figure5
Figure 5. Follow-up of the scar after 4 years. Patient here was 6 years-old.
[please click on the image to enlarge]


Discussion with conclusions

Despite the fact that in the developed countries survival of burn victims is often over 90% (Table 1), the developing world statistics show disturbing numbers. Not only some areas in Southeast Asia but also Africa may show an actual increase of mortality. In some regions of the world, like Transkei region in South Africa, the number of deaths as a result of burning has more than doubled in the last 20 years (1996-2015) [12]. Often, the statistics don’t fully encompass violence-related burns (de facto homicides). My personal experiences from apartheid South Africa in the 90’s involve some very sad cases and burn victims, with autopsies performed by my father. One horrifying death I remember, which was accompanied by amateur filming of the whole incident, was that of a lynching of a young black woman and her baby. The woman was the wife of a black policeman and she was surrounded by black mob. She had an infant strapped to her back. That didn’t stop the attackers who threw a tyre over her body, doused her with a flammable liquid and lit her garments. She screamed as she moved in circles, with the baby crying horribly, the crowd kicked her and the baby, as she became charred. The film was used as evidence. All perpetrators involved were lower social class members and her neighbours. This left a horrible psychological mark on many persons involved in the incident, including the police and medical personnel. Not many persons in Europe realize that in the new millennium, the violence and racial retaliations owing to huge social gaps in new South Africa have become a significant problem, fuelled by some politicians. Violence against white farmers, with lethal attacks on whole families, was reported, often involving thermal injuries: killing babies in boiling water and using hot irons to torture the victims. Currently Southern Africa is not only the leading region when it comes to global HIV/AIDS prevalence, but also the most violent region when it comes to homicides in Africa, with two countries leading the statistics: Lesotho and Republic of South Africa [13]. A lot of work needs to be done, both medically and politically, in order to improve the situation there and make these countries safe again.

Table 1. US Statistics from the years 2005-2014 with admissions to burn centres [4].
table1

Since mankind has reached its optimal options when it comes to antimicrobial therapy [14], having in mind the current efforts and ongoing studies, beneficial microbes may become an important supportive therapy in burns [6-10]. In the recent animal model study with topical use of probiotics by Argenta et al., such therapy was shown not only to improve the outcome but prevent sepsis and death resulting from burn wound infection with Pseudomonas aeruginosa, lowering the mortality from >90% to less than 10% [10].

Our case description may be the first one to describe successful topical use of these strains in a human burn. This is just a single instance of successful probiotic therapy on a relatively small 2nd degree burn, so for scientific proof and best strain selection, as well as dosage optimization, one needs to think of future well designed human clinical trials.

But the point needs to be stressed again – probiotic strains may play an important role in the future therapy of biofilm infections and burn wound prophylaxis [6-10, 15]. Such therapies may be of huge benefit especially in the developing countries, where burns tend to be really high in statistics.


References

[1] Jeschke MG, Herndon DN. Burns in children: standard and new treatments. Lancet 2014;383:1168-78.
[2] Baker R, Tata LJ, Kendrick D, Burch T, Kennedy M, Orton E. Differing patterns in thermal injury incidence and hospital-isations among 0-4 year old children from England. Burns 2016; 42:1609-16.
[3] Barczykowska E, Cyran M, Zreda-Pikies A, Kowalczyk M, Ślusarz R, Kurylak A. Evaluation of the frequency of childhood hospitalization due to thermal injuries in the Provincial Polyclinical Hospital in Toruń, Poland, 2007-2011. Ann Agric Environ Med 2018; 25:26-30.
[4] ABA National Burn Repository 2015. Access valid on June 30, 2018: http://ameriburn.org/who-we-are/media/burn-incidence-fact-sheet/
[5] Baartmans MG, de Jong AE, van Baar ME, Beerthuizen GI, van Loey NE, Tibboel D, Nieuwenhuis MK. Early management in children with burns: Cooling, wound care and pain management. Burns 2016; 42:777-82.
[6] Nikitenko VI. Infection prophylaxis of gunshot wounds using probiotics. J Wound Care 2004; 13:363-6.
[7] Gudadappanavar AM, Hombal PR, Timashetti SS, Javali SB. Influence of Lactobacillus acidophilus and Lactobacillus plantarum on wound healing in male Wistar rats - an experimental study. Int J Appl Basic Med Res 2017; 7:233-8.
[8] El-Ghazely MH, Mahmoud WH, Atia MA, Eldip EM. Effect of probiotic administration in the therapy of pediatric thermal burn. Ann Burns Fire Disasters 2016; 29:268-72.
[9] Slepykh NI, Tret'iakov AA, Stadnikov AA, Petrov SV. Effectiveness of sporobacterin in the prevention and treatment (of postoperative wound infections). Vestn Khir Im I I Grek 2003; 162:65-9.
[10] Argenta A, Satish L, Gallo P, Liu F, Kathju S. Local Application of Probiotic Bacteria Prophylaxes against Sepsis and Death Resulting from Burn Wound Infection. PLoS ONE 2016; 11:e0165294.
[11] Satish L, Gallo PH, Johnson S, Yates CC, Kathju1 S. Local Probiotic Therapy with Lactobacillus plantarum Mitigates Scar Formation in Rabbits after Burn Injury and Infection. Surg Infect 2017; 18:119-27. [12] Meel BL. A 20-year (1996-2015) trend in deaths as a result of burns in the Transkei subregion of South Africa. Med Sci Law 2018; 1:25802418776129.
[13] Kochan A. Radical approach to vehicle passenger safety and some of the most striking clinical trauma cases – from over 35-years of experience as a trauma surgeon. World J Med Images Videos Cases 2017; 3:e16-30.
[14] Przewodnik Terapii Przeciwdrobnoustrojowej Sanforda 2018. Kochan P. (ed.), Kraków 2018.
[15] Høiby N, Bjarnsholt T, Moser C, Bassi GL, Coenye T, Donelli G, Hall-Stoodley L, Holá V, Imbert C, Kirketerp-Møller K, Lebeaux D, Oliver A, Ullmann AJ, Williams C; ESCMID Study Group for Biofilms and Consulting External Expert Werner Zimmerli. ESCMID guideline for the diagnosis and treatment of biofilm infections 2014. Clin Microbiol Infect 2015; 21:S1-25.

Conflict of interest: PK is Editor-in-Chief of WJOMI.

Authors’ affiliations:
1 Chair of Microbiology, Department of Bacteriology, Microbial Ecology and Parasitology, Jagiellonian University Medical College in Cracow, Poland
2 KOHASSO Private Medical Practice, Cracow, Poland


Corresponding author:
Piotr Kochan, M.D., Ph.D.
Chair of Microbiology
Jagiellonian University Medical College
18 Czysta Str.
31-121 Cracow
Poland
Ph. +4812 633 25 67
e-mail: pkochan@cm-uj.krakow.pl

To cite this article: Kochan P, Kochan A. Burn in a 2 year-old child with beneficial microbe topical therapy. World J Med Images Videos Cases 2018; 4:e34-40.

Submitted for publication: 2 April 2018
Accepted for publication: 14 May 2018
Published on: 30 June 2018



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