Diagnosis and Treatment of Infections in the Burn Patient

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The Authors present a review on the diagnosis and treatment of infections in burn patients. The manuscript is very well written, scientific and very didactic, certainly deserving publication in EJB. However, in my opinion, there are some pertinent observations that can be made.

 

A – Major remarks

1. Pg 3, lines 136-149: in my opinion, this paragraph does not add much to the manuscript and should be shortened. As the authors state, there are many differences in burn sepsis compared to sepsis in the general population and therefore references to the Surviving Sepsis Campaign are very extensive.

 

2. Pg 4, lines 168-169 (Table 1): perhaps a table putting side by side the definitions of sepsis according to the American Burns Association (ABA), European Burns Association (EBA) and Surviving Sepsis After Burns Campaign (SSABC ) would be more interesting to readers than just the ABA one.

 

3. Pg 4, line 187: “actual burn infection is relatively uncommon in the modern era”, please add, “particularly in developed countries”. As you know, the panorama is not the same in LMIC countries.

 

4. Page 5, lines 206-224: as most potential readers of the article are familiar with the usual surgical treatment of burns, this paragraph could be shortened.

 

5. Pg 6, line 253: “Pseudomonas aeruginosa is a common colonizer of burns” (…), change to “Pseudomonas aeruginosa is a common colonizer of burns, especially after the second week of hospitalization, coming from the digestive tract of the patient of from cross-contamination the healthcare personnel” (…).

 

6. Pg 7, line 266: as the Authors know, silver sulfadiazine combined with cerium nitrate, in a cream formulation, also penetrates the burn eschar, preventing the proliferation of microorganisms and the invasion of deeper tissues. Furthermore, its application is less painful than that of mafenide acetate, and it is currently the state of the art in European countries. This information must be added to the manuscript.

 

7. Page 7, line 270: instead of “True fungal infections” (…), which may be misleading, change to “Filamentous fungal (mold) infections”

 

8. Pg 10, lines 311-320: This paragraph, regarding the diagnosis of sepsis, should be completely rewritten in accordance with SSABC guidelines. On the other hand, and agreeing that the clinical examination is the core of the diagnosis, a reference to laboratory biomarkers of sepsis must be included, not because they can replace the clinical examination, but because they can help to confirm the diagnosis which, as the Authors wisely say, is not always simple. The use of biomarkers (such as PCT, PSP, P-sep, Pro-Adm, etc., and not even referring to omics techniques) can also help in stratifying and determining the prognosis of patients, as well as monitoring antimicrobial therapy and its suspension.

 

B – Minor Observations

Page 5, line 189: “the risks of destructive infections is diminished”, change to “the risks of destructive infections are diminished”.

Author Response

please see attachment 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for sending me this work for review. The study is well prepared and quite remarkable. I congratulate the authors for preparing such a beautiful work. The Figures in the study are quite striking. I would like to give a few recommendations to the authors.

The risk of infection is likely to be low in a burn clinic where optimal conditions are present. Infections may include catheter infection and burn wound infection. However, in the country where I live, the occurrence of pneumonia without flame burn and inhalation damage in patients with severe burns is an important problem. The situation that attracts my attention the most is excessive fluid resuscitation due to incorrect estimation of weight and burn area in patients with severe burns. This situation may lead to pulmonary edema-respiratory distress-intubation-pneumonia, especially after resuscitation. Intubation in the acute period in patients with burns may often be related to this condition. Pneumonia that develops as a result of excessive fluid resuscitation can be an important cause of sepsis for burn patients. Can you please advise on this situation in your study? In many burn clinics my country, patients are treated without a weight measuring device, by estimating the weight of the patients incorrectly.

 

1-      Dulhunty JM, Boots RJ, Rudd MJ, Muller MJ, Lipman J. Increased fluid resuscitation can lead to adverse outcomes in major-burn injured patients, but low mortality is achievable. Burns. 2008 Dec;34(8):1090-7. doi: 10.1016/j.burns.2008.01.011. Epub 2008 May 12. PMID: 18468802.

2-      Giretzlehner M, Ganitzer I, Haller H. Technical and Medical Aspects of Burn Size Assessment and Documentation. Medicina (Kaunas). 2021 Mar 5;57(3):242. doi: 10.3390/medicina57030242. PMID: 33807630; PMCID: PMC7999209.

3-      Duek OS, Ben Naftali Y, Bar-Lavie Y, Bahouth H, Ullmann Y. Pneumonia Risk in Urgently Intubated Burn Patients. Isr Med Assoc J. 2018 Dec;20(12):737-740. PMID: 30550001.

Author Response

please see attachment 

Author Response File: Author Response.pdf