Candida tropicalis burn wound sepsis: A series of histopathology-confirmed cases

Abstract

Fungal infection in severely burned patients is a serious problem due to various factors, such as the extensive application of antibiotics. In this study, we report on the course of severely burned patients with Candida tropicalis burn wound sepsis. Five such cases were reviewed. The patients were treated with itraconazole intravenously and simultaneous antibiotics to prevent bacterial infections. In addition, dermabrasion was used to excise the eschar and the wound surface was covered immediately with dermatoplasty. Meanwhile, the skin necrosis related to the fungal infection was removed. The wound surfaces of all five patients were healed well and the parameters of laboratory examination went back to normal. We assume that prompt diagnosis and timely treatment including extensive debridement of necrosis, antifungal drugs, and antibiotics were the key points leading to favourable outcome.

Introduction

Fungal infection in severely burned patients is a serious problem partly related to the excessive use of antibiotics (Struck and Gille, 2013). Mortality among burn patients with fungal infections is high (Ballard et al., 2008, Horvath et al., 2007). Therapeutic approaches to burn wounds has been changed dramatically in the past decades and the prognosis of these patients is improved, but nevertheless, there are still many drawbacks in the current treatment (Belgian Outcome in Burn Injury Study Group, 2009, Brusselaers et al., 2010a, Sarabahi et al., 2012). In order to counter the deleterious effect of Candida infections, four antifungal-based therapeutic options have been described: prophylaxis, pre-emptive, empiric and definite antifungal therapy (Blot and Vandewoude, 2004). Prophylaxis is a preventive approach for the patients based on primary diagnosis instead of individual risk factors. Pre-emptive antifungal therapy is justified in the presence of Candida colonisation and multiple risk factors for invasive candidiasis. Generally, at least two major or three minor risk factors should be present when applying pre-emptive therapy. Major risk factors include extensive burns covering more than 50% of the total body surface area, immunosuppression, neutropenia, prolonged antibacterial therapy, intestinal perforation, diarrhoea or ileus, major abdominal surgery, total parenteral nutrition and renal replacement therapy. Minor risk factors include length of intensive care unit (ICU) stay of more than 10 days, renal insufficiency, older age (or neonates), multilumen central venous catheters, the presence of a urinary bladder catheter, diabetes mellitus and candiduria (>10⁵ cfu/mL). In clinical practice, several of these risk factors are often present in severely burned patients thereby justifying either pre-emptive or empiric antifungal therapy in case of an overt risk profile. In this paper we reported on the course of five severely burned patients whose burn unit stay was complicated by Candida tropicalis wound sepsis.