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Background: Infection related skin graft loss still remains as a common problem even with the use of systemic antibiotics. Mafenide acetate (Sulfamylon) is a topical antimicrobial agent with a wide spectrum of antimicrobial activity. Since mafenide acetate has the ability to penetrate the burn eschar, it was preferred in the treatment of infected full-thickness skin grafts. We investigated the effects of topical Mafenide acetate application on graft survival in an experimental model of contaminated wound beds in rats., Materials and Methods: Twenty-eight male Wistar albino rats were included in the study. A full-thickness skin graft (FTSG) was harvested from the back region and the wound bed was inoculated with Pseudomonas aeruginosa. The same FTSG was sutured in place. Rats were divided into 4 groups. In groups 1 and 2, wound care was performed with gauze and hydrofiber dressings respectively. In groups 3 and 4, Mafenide acetate soaked hydrofiber and Mafenide acetate soaked gauze dressings were used respectively. The dressings were closed for 4 days in all groups. The rats in groups 1 and 2 received dressing changes every day. The dressing of the rats in group 3 was changed once every two days. The dressing of the rats in group 4 was changed twice a day., Results: In groups 3 and 4, the graft survival rates decreased significantly from day 7 to day 14 in all groups. Histologically, detachment at the dermoepidermal junction, disorganization of collagen along with increased numbers of fibroblasts and a decrease in graft adhesion to the wound bed were determined in Mafenide acetate-treated groups., Conclusion: In rats treated with Mafenide acetate, graft survival was higher on day 7 and gradually decreased towards day 14. Application of a 2.5% solution of Mafenide acetate longer than 7 days on inoculated skin grafts in a rat model causes significant cytotoxicity and graft loss., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2023 Elsevier Ltd and International Society of Burns Injuries. All rights reserved.)

Sulfur mustard burns are characterized by delayed symptoms, slow healing, and recurrence after closure. Incomplete debridement at the level of the basement membrane is the postulated cause. Graham pioneered laser debridement of mustard burns. For field or mass-casualty use, saline wet-to-wet or antibiotic-soak debridement is more practical. In this study, we compared laser, saline, and antibiotic debridement in a porcine model of deep partial-thickness injury. Deep-dermal sulfur mustard burns were produced in 18 anesthetized Gottingen minipigs using 10-μl saturated vapor cap exposure time of 90 minutes. Debridement was started 48 hours postinjury and consisted of a single laser treatment; 5 days of 5% aqueous mafenide acetate wet-to-wet dressings; or 7 to 12 days of saline wet-to-wet dressings. Wounds were treated with daily silver sulfadiazine for 30 days and, then, assessed by histopathology, silver-ion analysis, colorimetry, and evaporimetry. All wounds healed well with no sign of infection. Antibiotic debridement showed no advantage over saline debridement. There were no significant differences between groups for colorimetry or evaporimetry. Histopathology was graded on a mustard-specific scale of 1 to 15 where higher values indicate better healing. Mean histology scores were 13.6 for laser, 13.9 for mafenide, and 14.3 for saline. Saline debridement statistically outperformed laser (P < .05) but required the longest debridement time. Laser debridement had the benefit of requiring a single treatment rather than daily dressing changes, significantly decreasing need for wound care and personnel resources. Development of a ruggedized laser for field use is a countermeasures priority., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Mafenide acetate is used in some burn wounds for its ability to penetrate eschar but requires frequent uncomfortable dressing changes for its application. The authors hypothesize that hydrofiber dressings will hold mafenide acetate solution for an extended period of time and maintain antimicrobial activity longer than traditional gauze, thus possibly obviating the need for frequent dressing changes. Four experimental arms included: 1) hydrofiber, stored on a dry well plate as control, 2) gauze saturated with 2.5% mafenide acetate, stored on nonsterile porcine skin, 3) hydrofiber saturated with mafenide acetate, stored on dry well plate, and 4) hydrofiber saturated with mafenide acetate, stored on nonsterile porcine skin. At 0, 24, 48, and 72 hours, a 1-cm disk was cut from the dressing sheet of each study arm, placed on agar plates seeded with Staphylococcus aureus and Pseudomonas aeruginosa, and incubated for 24 hours, and the zone of inhibition was measured. A zone of 2 mm or greater was indicative of susceptibility. Each arm of the experiment was performed four times to demonstrate reproducibility. Plain hydrofiber (control) demonstrated no zone of inhibition at any time point, thereby possessing no antimicrobial activity alone. Gauze saturated with mafenide acetate did not reliably demonstrate antimicrobial activity beyond 0 hours. Hydrofiber saturated with mafenide acetate, whether stored on a dry well plate or nonsterile porcine skin, consistently possessed sustained antimicrobial activity as demonstrated by zones of inhibition greater than 2 mm to both S. aureus and P. aeruginosa. Mafenide acetate-soaked hydrofiber dressings stay moist and maintain antimicrobial activity against S. aureus and P. aeruginosa for at least 72 hours without repeated soaks.

Mafenide acetate is an antimicrobial agent used to decrease the bacterial load for burn wounds. The 5% solution is more commonly used yet double the cost of its 2.5% counterpart. This study aims to evaluate outcomes and cost associated with the use of 2.5 vs 5% mafenide acetate formulation in the adult burn population. Adult patients (≥18 years) receiving 2.5% mafenide acetate during an 11-month period between 2014 and 2015, corresponding to a policy change in favor of the use of 2.5% mafenide acetate, were queried. Historical controls, patients receiving 5% mafenide acetate, were also reviewed during an 11-month period between 2013 and 2014. A retrospective review was performed comparing wound infection rate, bacteremia, sepsis, pneumonia, duration of mafenide therapy, length of hospital stay, mortality, and cost. A total of 54 and 65 patients received 2.5 and 5% mafenide acetate, respectively. There was no difference in wound infection, bacteremia, sepsis, pneumonia, duration of treatment, and mortality between the two groups. No adverse events occurred in either group directly related to mafenide. Candida and Staph species were the two most common isolates in the 2.5% group, whereas Pseudomonas and Staph species were the most common in the 5% arm. The mean cost of 2.5% mafenide therapy was $1494.92 compared with $3741.39 for 5% mafenide acetate. The 2.5% concentration demonstrates to be an equally efficacious and cost-effective alternative to the 5% concentration. Burn centers should consider the use of the more dilute preparation for burn wound infection prophylaxis as it may reduce the cost without compromising patient safety.

Burns are frequently encountered on the modern battlefield, with 5% - 20% of combat casualties expected to sustain some burn injury. Addressing immediate life-threatening conditions in accordance with the MARCH protocol (massive hemorrhage, airway, respirations, circulation, hypothermia/head injury) remains the top priority for burn casualties. Stopping the burning process, total burn surface area (TBSA) calculation, fluid resuscitation, covering the wounds, and hypothermia management are the next steps. If transport to definitive care is delayed and the prolonged field care stage is entered, the provider must be prepared to provide for the complex resuscitation and wound care needs of a critically ill burn casualty., (2015.)

The authors report two cases of patients presenting with chemical frostbite-like injuries to the hands and wrists after contact exposure to Freon liquid. Although the history and initial physical presentations were quite similar, the severity of these injuries varied widely from superficial bullae to deep tissue injuries, requiring skin grafting and amputation of several digits. Freon is a widely used coolant in refrigerators, air conditioners, freezers, and water coolers, with a boiling point of -41°C. Although several cases of Freon-induced inhalational injury have been reported, few case reports of Freon-associated contact skin injury exist in the literature. The authors detail the broad diversity of injuries resulting from Freon contact as well as the first report of severe Freon injury necessitating skin grafting and amputation of multiple digits.

Despite advances in treatment of burn injuries and their consequent pain, wound care is the main source of the pain associated with burn injury. This two-part article explores burn pain and its treatment from a nursing perspective. Last month, Part 1 provided an overview of burn injury and addressed the wound care-related causes of burn pain, as well as its assessment and treatment. Part 2, presented here, provides a more in-depth discussion of pain management; topical medications and the psychological aspects of burn pain are also discussed.

For regenerative medicine to gain clinical acceptance, the effects of commonly used treatment regimens on bioengineered organs must be considered. The antibiotics mafenide acetate (mafenide) and neomycin plus polymyxin (neo/poly) are routinely used to irrigate postoperative skin grafts on contaminated wounds. The effects of these clinically used antibiotics were investigated using tissue-engineered human skin substitutes generated with primary human keratinocytes or the near-diploid human keratinocyte cell line, Near-diploid Immortal Keratinocytes. Following topical or dermal treatment, the skin substitutes were assayed for viability, tissue morphology, glycogen content, and the expression of active caspase 3. Mafenide, but not neo/poly, induced morphological and biochemical changes in tissue-engineered skin substitutes. Keratinocytes in all histological layers of mafenide-treated skin substitutes exhibited ballooning degeneration and glycogen depletion. Mafenide-treatment also triggered separation of basal keratinocytes from the underlying dermis. None of the antibiotic treatments induced apoptosis, as measured by active caspase 3 immunostaining. The results demonstrate that mafenide, but not neo/poly, is detrimental to the viability and structural integrity of tissue-engineered human skin substitutes. These findings highlight the need to identify treatment regimens that are compatible with and hence enable the therapeutic efficacy of first-generation bioengineered organs such as skin.

Burn patients with extensive involvement of body surface area (BSA >30%) represent a challenge in wound treatment. Multiple topical agents may be used for cleansing, barrier protection, and antimicrobial control leading to complications of contact and/or irritant dermatitis, which may further complicate re-epithelization and eventual wound healing. We present 4 patients who sustained extensive burns during Operation Iraqi Freedom/Operation Enduring Freedom and later developed contact dermatitis to mafenide acetate, a common topical antimicrobial used in burn care treatment, also known as Sulfamylon (alpha-amino-p-toluenesulfonamide monoacetate). All patients who were patch tested to mafenide acetate 7% solution were positive. A rechallenge with mafenide acetate resulted in recrudescence of the eruption in 2 out of the 4 patients. Though cutaneous reactions to mafenide acetate were reported by Yaffe and Dressler in 1969, the most recent case reports are from 1995. This paper presents more recent examples of cutaneous reactions to mafenide acetate, while also reviewing the literature.

Wound infections, especially those associated with methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, offer considerable challenges for clinicians. Our laboratory has recently developed novel composite biomaterials (DRDC) for wound dressing applications, and demonstrated their in vitro bactericidal efficacy. In the present study, we assessed the proliferation of planktonic and sessile Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus in porcine full-thickness wounds covered for up to 48 h with either saline- or mafenide acetate-loaded DRDC puffs and meshes. All biomaterials were applied 4 h following bacterial inoculation of the wounds with methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, to allow colonization of the tissues and initiation of biofilm formation. The drug-loaded biomaterials eradicated both the planktonic and biofilm bacteria in the wounds within 24 h (p <. 05), irrespective of the bacterial strain or architecture of the dressing. While the wound bioburdens increased in the ensuing 24 h, they remained approximately 2 log(10) colony-forming units (CFU) below (p <. 05) their respective baseline values. Similarly, less than 4 log(10) CFU was recovered in the drug-loaded DRDC biomaterials throughout the study. These data show that the DRDC puffs and meshes are effective in delivering certain medications, such as antimicrobial agents, to the wound bed, suggesting considerable value of this material for treating wounds, especially those with irregular shapes, contours, and depths.

Aim: To assess the effectiveness of RescuDerm, an amorphous, water-soluble burn gel in controlling Pseudomonas aeruginosa growth in rat full-thickness wounds contaminated with 10(3), 10(5) or 10(7) CFU/g tissue., Method: Wounds were treated daily for 72 hours with a placebo gel, a 5% w/w mafenide acetate gel (MAF), or with four modalities of RescuDerm application., Results: All RescuDerm treatments were equally effective within 24 hours in preventing further Pseudomonas aeruginosa growth in wounds contaminated with 10(3) CFU/g tissue. Pseudomonas aeruginosa levels remained at or below this baseline count for 72 hours in all but one of the RescuDerm treatments. The bioburdens in MAF-treated wounds were negligible, averaging 0.14 +/- 0.09 log10 CFU/g tissue. While RescuDerm and MAF remained bacteriostatic in wounds contaminated with 10(5) CFU/g tissue, this property disappeared at higher bioburdens., Conclusion: RescuDerm can be used for the management of cutaneous injuries sustained in environments deemed marginally or moderately contaminated. Heavily contaminated wounds would require irrigation prior to application to reduce their bioburden below 10(5) CFU/g tissue.

The bilayered dermal substitute Integra (Integra Life Sciences Corp., Plainsboro, NJ) was developed and has been widely used as primary coverage for excised acute burns. Our take has been slightly different, finding it most useful in the management of complex soft-tissue loss and threatened extremities as the result of tendon, joint, or bone exposure. Often tasked to fill significant volume loss, we have become adept at stacked multiple-layer applications. Creative use of this material has resulted in unexpected successes with distal limb salvage; the technique takes its place beside adjacent tissue transfer, composite flaps, and vascular pedicle flaps in our burn reconstructive practice. A prospective registry (44 patients) has been kept during the past 7 years that catalogs wounds with complex soft-tissue loss treated with Integra grafts. Many of these patients were at risk of extremity loss because of exposed tendons, joints, or bone. Integra was applied after 1:1 meshing. With profound soft-tissue defects, multiple layers of Integra were serially applied 1 to 2 weeks apart for reconstitution of soft-tissue contours. Local Integra graft infections were managed by silicone unroofing followed by topical sulfamylon liquid dressings. Wounds addressed included fourth-degree burns, necrotizing fasciitis, pit-viper envenomations, and total abdominal wall avulsion in one patient after being run over by a bus. Patients generally were free of pain from their wounds during the maturation phase of the Integra neodermis. Restoration of tissue contour was significantly better when using multiple layers for deep defects. Second and third layers of Integra were successfully applied after an abbreviated first graft maturation period of 7 days. Epithelial autografts on multilayer Integra applications frequently "ghosted"; they would auto-digest to dispersed cells followed subsequently by the reappearance of a confluent epithelial layer. Final grafted skin morphology over palmar and plantar surfaces assumed the type and fingerprint pattern of the original tissues. Infections were readily visible. Early recognition kept them to easily treated circumscribed areas, which did not jeopardize the entire wound. Lengths of stay were long (range, 2-246 days) but not significantly greater than with traditional techniques. The specific reconstructive use of Integra permitted unexpected salvage of several threatened extremities by protecting exposed tendons, bones and joints. Long-term histologic examination revealed unexpected persistence of Integra collagen. Large volume loss wounds benefited from the ability to fill voids with multilayered applications.

Prosthetic vascular graft infections portend grave consequences if not treated expediently. Despite the low incidence of infection, the potential for limb loss or death greatly magnifies this complication. The surgical management of prosthetic graft infections has evolved over the last 2 decades. With the myriad therapeutic options now available, an algorithm is necessary to provide the optimal surgical treatment of Samson groups 1 through 5 extracavitary infected vascular prostheses. An extensive review of the literature was undertaken to evaluate the most effective management schemes. The authors found that 3 factors--Samson classification, bacteriology, and patient vascular anatomy--are vital to the surgical strategy. These 3 criteria were examined, and an algorithm was developed based on successful clinical and experimental results. This review provides a step-by-step rationale for the surgical management of extracavitary prosthetic graft infections according to the most successful reported outcomes.

Background: Whereas Sulfamylon is effective in treatment of burn wound infection, controversy exists regarding its effect on the healing process., Methods: A partial thickness skin donor site wound was created on the back and indwelling catheters were placed in the carotid artery and jugular vein in rabbits under general anesthesia. Sulfamylon cream (8.5%, BERTEK Pharmaceuticals Inc., Morgantown, W Va) was applied on the wound, with either open or occlusive dressing. The control wound was covered with dressings only. On day 7 after injury, stable isotope tracers were infused to determine the fractional synthetic rate (FSR) of DNA, and FSR and fractional breakdown rate (FBR) of protein in the wound., Results: In the Sulfamylon-open dressing group, the DNA FSR was 1.3 +/- 0.6%/day, the protein FSR was 8.0 +/- 3.5%/day, and the net protein deposition (FSR - FBR) was -0.3 +/- 3.7%/day. These values were lower (P < .01 to .05) than the corresponding values in the control group (DNA FSR: 2.9 +/- 0.9%/day; protein FSR: 20.5 +/- 8.4%/day; net protein deposition: 7.9 +/- 6.0%/day). Sulfamylon cream selectively inhibited DNA FSR from the de novo base synthesis pathway (2.3 +/- 1.2 vs 0.8 +/- 0.5%/day, P < .05 vs control). With the occlusive dressing Sulfamylon cream did not decrease wound DNA FSR due to a stimulation of the base salvage pathway, but still decreased protein FSR (11.5 +/- 5.1%/day, P < .05 vs control). Histologic slides indicated that Sulfamylon cream inhibited re-epithelialization, collagen formation, and angiogenesis in the wound., Conclusions: Topical Sulfamylon cream application inhibited DNA and protein synthesis in the wound, which would be expected to retard the healing process.

Background: Topical antimicrobial agents have proven efficacy in preventing life-threatening invasive burn wound infection. Under wartime or mass-casualty conditions, however, there may be an inadequate supply of these agents. This study aimed to identify those patients most likely to benefit therefrom., Methods: Logistical regression analysis of data from the U.S. Army Burn Center was performed. Mortality data for the period immediately preceding the introduction of topical mafenide acetate (MA) (1950-1963) were compared with data for the subsequent period (1964-1968). During the second period, MA was routinely applied but treatment was otherwise similar. The mortality decrement attributed to MA was determined for various ages and burn sizes., Results: For patients of combatant age (20-50 years), MA was associated with a greater than 10% reduction in mortality for those with burns of 40-79% of the total body surface area (TBSA). Only a minimal effect on mortality was noted for those patients with burns smaller than 40% or greater than 79%., Conclusions: When resources are limited, topical therapy (specifically, MA) is likely to confer the greatest survival benefit for combatants with burns of 40-79% TBSA.

Acute chondritis has a strong predilection for recurrence. Mafenide acetate has been implicated in causing reactions that mimic this condition; however, these hypersensitivity reactions lack fever, fluctuance, and pain. The authors report a case of mafenide acetate allergy presenting as recurrent chondritis in a patient who had previously been treated successfully for this condition. In this patient, the allergic response resolved within 3 days after cessation of mafenide acetate. If unappreciated, it may have led to unnecessary operative intervention. Therefore, auricular edema and erythema, without fever, fluctuance, and pain, must be recognized by surgeons as a possible mafenide acetate allergy and must be considered in the differential diagnosis for patients who present with recurrent acute suppurative chondritis.

It is not unusual for practitioners to prescribe off-label drugs for their patients--that is, drugs that have not yet been approved by the Food and Drug Administration to treat the patient's particular condition. The decision to use off-label drugs should be based on a clear understanding of the risks and benefits to the patient. This issue is pertinent to WOC nurses because they may work with physicians who prescribe off-label drugs for their wound care patients. In addition, WOC nurses who are also nurse practitioners and have prescribing privileges may be intimately involved in the decision to prescribe off-label drugs. A review of the literature related to off-label drug use and mafenide acetate was conducted. This article presents the issues related to off-label use of mafenide acetate (Sulfamylon) and possible implications for patients with chronic infected wounds.

Results previously reported using the Wet Disc Topical Antimicrobial Assay (WDA) suggested that adding nystatin (NY) to a 0.5% mafenide acetate (MA) suspension or genitourinary irrigant (double antibiotic [DAB]) to expand their antimicrobial activity to include Candida sp. antagonized the antibacterial effect of MA but not DAB. We use DAB solution as described by the authors of the previous study, also, but we use a 5% commercially available mafenide acetate solution instead of the in-house prepared 0.5% mafenide acetate suspension that they used. Further, we use both the WDA and the Agar Well Diffusion Topical Antimicrobial Assay (AWDA) to test topical antimicrobials at this institution. In light of the previously reported results, this study 1) examined whether adding nystatin to DAB or the 5% mafenide acetate solution used at this institution caused any interference in the ability of these substances to migrate through the agar matrices and cause zones of growth inhibition in the two test assay systems and 2) compared the assessment of microbial susceptibility (by very precise definition) between the two systems. The addition of nystatin did not interfere with the ability of either DAB or mafenide acetate to migrate through the agar matrices and cause clear zones. However, on the assessment of susceptibility a significantly larger number of organisms were judged susceptible using the AWDA than the WDA. We believe that the disparity is caused by a large difference in agar diffusion kinetics between the two assays. Therefore, we recommend the AWDA rather than the WDA for susceptibility studies.

The burn unit establishment in a Vietnamese military hospital (1970 to 1971) is an example of the management of burns under conditions of limited resources. The problems encountered and methods used in their solution are still relevant. This is the first (and possibly still the only) instance of such clinical use of topical Sulfamylon (mafenide) aqueous spray as the sole pregraft antibacterial agent for patients with deep partial-thickness and full-thickness burns (and associated injuries). The mafenide spray open treatment resulted in a bacteriostatic film permitting eschars to remain uninfected while more superficial burns healed and general status improved, enabling delayed grafting to be effective. Use of operating rooms, supplies, and personnel was minimized. The study group contained 211 patients; 86 (approximately 40%) had burns that exceeded 20% body surface area, and 26 (approximately 12%) had burns that exceeded 40% body surface area. As the procedures became fully established, all of the last 110 patients of this series survived. Only 17 deaths occurred in the total series; none were attributed to infection.

Recent evidence from in vitro and in vivo experiments suggests that topical antimicrobials may be toxic to fibroblasts and keratinocytes and retard wound healing. The purpose of this study was to determine the effects of Aloe, a potential wound-healing agent, on wound contraction in excisional wounds treated with topical antimicrobials. Sprague-Dawley rats were prepared with four 1.5 cm2 dorsal defects through the skin and panniculus. The animals were divided into five groups (n = 10 per group): (1) Aloe, (2) NaOCl solution (0.025%), (3) mafenide acetate, (4) mafenide acetate + Aloe, and (5) control. Wounds were treated topically for 14 days 3 times a day. Serial standard photographs and serial wound planimetry were performed weekly. Following healing, the breaking strength of each resultant scar was determined using an Instron tensiometer. Kruskal-Wallis, ANOVA, and multiple comparison methods were used for data analysis. Aloe and NaOCl solution significantly accelerated wound contraction (p < 0.05). In the mafenide acetate + Aloe group, contraction was similar to the control, whereas the mafenide acetate alone retarded wound healing. The addition of Aloe in combination and alone in wounds increased the breaking energy when compared to controls (p < 0.05). Aloe appears to expedite wound contraction and neutralize the wound retardant effect seen with the topical mafenide acetate alone. This effect appears to be due to an increased collagen activity, which is enhanced by a lectin, consequently improving the collagen matrix and enhancing the breaking strength.

Spontaneous wound healing occurs partly by wound contraction, a process that requires intact functioning fibroblasts, and collagen production. Disruption of fibroblasts by the topical antimicrobials, silver sulfadiazine and mafenide acetate has been demonstrated in vitro. An acute rat wound model was used to show that wound contraction in vivo is significantly impeded by silver sulfadiazine and mafenide acetate.

We tested two topical antimicrobial agents (TAAs), silver sulfadiazine and mafenide acetate, to determine their cytotoxic effects when human lymphocytes and neutrophils were incubated with the agents in vitro for 30 minutes. Dilute concentrations of both TAAs markedly inhibited neutrophil respiratory burst activity and mitogen-stimulated lymphocyte proliferation (p < 0.05). The components of silver sulfadiazine (silver and sulfadiazine) were separately tested, and each component inhibited both neutrophil and lymphocyte functions. Mafenide acetate markedly decreased intracellular Ca+2 flux in lymphocytes. The effects of the TAAs were partially reversed when cells were washed and resuspended in medium after they were exposed in vitro to the TAAs. Commonly used TAAs may contribute to local immune dysfunction in the patient with burns. Because evidence suggests that T lymphocytes may participate in wound healing, prolonged treatment with TAAs may also effect certain aspects of wound healing.

A 5% mafenide acetate solution was used in the treatment of 669 patients with thermal injuries. This solution was used as the initial topical antibacterial agent in the treatment of the acute burn wound in 276 patients. It was initiated during the intermediate and chronic phases of burn wound therapy in 393 patients. Acid-base derangements did not occur. Discontinuation of therapy because of the patient's pain was necessary in fewer than 1% (17 of 669) of all patients treated. The incidence of rash and pruritus was extremely low. Effective antibacterial activity was achieved. This solution appears to be an effective, safe, and versatile antibacterial agent that produces minimal side effects and is useful in all phases of burn wound management.

Silvadene cream and Sulfamylon make up the treatment regimen for one contributor (Dr. Crumley). No systemic antibiotics would be given. Any areas of obvious third-degree burns would be debrided and grafted. The tympanic membrane perforation would be treated with antibiotic/steroid drops. The second author concurs with use of Silvadene cream and would avoid any pressure on the area (Dr. Abemayor). While he agrees that systemic antibiotics should be avoided, he also would not prescribe ear drops. He recommends evaluation for a pulmonary or ophthalmologic injury. There is a disagreement regarding imaging studies. One expert would order a CT scan to rule out facial fractures (Dr. Crumley). His counterpart would not order a CT but would check a baseline chest x-ray if there were any sign of pulmonary compromise (Dr. Abemayor). Both experts would obtain an audiogram after the acute problems are treated. In the case of foul drainage, burn reconstruction would be delayed. In addition to treating the otorrhea with ear drops, one physician would add oral antibiotics (Dr. Abemayor). The other author believes tympanoplasty should be performed prior to reconstruction (Dr. Crumley). There were several procedures suggested for the reconstruction. Both authors discuss a method of creating a postauricular pocket, burying the ear pedicle, and using costal cartilage for an inlay helical graft. Another approach involves minimal debridement of the cartilage and letting the wound mature for 6 to 8 months. At that time the area would be debrided and the postauricular skin used for external coverage (Dr. Crumley). If the facial scar is a cosmetic problem 1 year after the injury, triamcinolone injections and local massage should be considered.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of algin-based drugs--algipor, algimaf, teralgim--on the course of maxillofacial purulent wounds healing were under study. Cytologic and morphometric data and findings of pH measurements evidence a high efficacy of teralgim and of algipor and algimaf combinations with trypsin immobilized on a cloth base during the first phase of the wound process. Application of these drugs was conducive to a sooner wound purification and to stimulation of the reparative processes.

Between January 1, 1984, and December 31, 1988, 35 patients at the Los Angeles County + University of Southern California Burn Center had postoperative cultures from their burn wounds that grew Aspergillus species; clinical burn-wound aspergillosis occurred in 66% of these cases and death occurred in 53% of these cases. Beginning in November 1984, several modifications in the air-conditioning system and topical antimicrobial wound therapy were undertaken. Cleaning and 8Cu-quinolinolate treatment of air ducts every 2 months did not reliably clear Aspergillus species from the air in patient care areas. Several changes in topical therapeutic regimen failed to prevent both burn wound culture positivity and clinical aspergillosis. Finally, installation of high-efficiency particulate air filters, installation of new air ducts, and inception of wound irrigation with a solution of mafenide hydrochloride plus nystatin both during and after operation were associated with a reduction in wound culture positivity rate to one occurrence in 1988 (Poisson probability less than 0.01 versus the rate in 1984) and no occurrences during the 18 months after the false ceiling of the burn ward was sealed.

Silver sulphadiazine 1 per cent (SS), silver sulphadiazine 1 per cent plus chlorhexidine digluconate 0.2 per cent (SS + CD 0.2 per cent) and mafenide acetate 8.5 per cent (MA) were compared to assess the antibacterial effect of once daily application on experimental rat 20 per cent full skin thickness burn wounds seeded 24 h earlier with 10(8) microorganisms originally isolated from infected wounds of burned patients. Separate series evaluated Staph. aureus, Enterococcus faecalis, Enterobacter cloacae and Ps. aeruginosa. The mean concentration of all four organisms recovered after 1 week from full thickness biopsies of eschar and from separate biopsies of subjacent muscle was less in MA and SS + CD 0.2 per cent treated animals compared with those treated with SS alone. The mean concentration in muscle and eschar following treatment with MA was less for wounds seeded with Staph. aureus and Ps. aeruginosa than with SS + CD 0.2 per cent treatment, while the mean concentration in eschar application of SS + CD 0.2 per cent was less than with MA for E. faecalis seeded wounds.

To evaluate our experience with fungal burn wound infection, we performed a 10-year review for comparison with our experience with bacterial burn wound infection. During the study period, a marked decline occurred in bacterial wound infection but not in fungal wound infection. Patients with either bacterial or fungal burn wound infection had massive injury, with burn size averaging greater than 50% of the total body surface area. Factors that appear to have markedly reduced bacterial burn wound infection, including patient isolation, topical chemotherapeutic agents, and burn wound excision, do not appear to have had a similar effect on fungal wound infection. The mechanism of spread and colonization of fungi, and the lack of effective topical chemotherapeutic antifungal agents, may explain in part our findings.

The process of treatment of 20 spinal patients with 26 decubituses of different localization by means of applications of alginatous coating "Alghimaf" has been observed. The results of treatment are as follows: 22 wounds healed with formation of soft elastic cicatrix, 2 patients have been discharged from hospital with actively epithelializing wounds, 2 patients were subjected to epidermatoplasty. The method of control: chnic observation, planimetry, citologic, microbiologic investigations. It has been demonstrated "Alghimaf" efficiency in treating of decubituses.

Four antimicrobial agents (triple sulfa cream, doxycycline, ampicillin, and metronidazole) were studied by double-blind techniques to determine their effectiveness in the treatment of Hemophilus vaginalis vaginitis, documented by vaginal culture in 96 patients. Cure was confirmed by negative vaginal cultures 7 weeks after the start of therapy. Metronidazole proved to be effective in 20 of 22 couples (90.9%) treated. Sulfa cream, doxycycline, and ampicillin were effective in 47.8 to 63.6% of patients treated.

In a double-blind triple cross-over clinical study, 37 patients were exposed to several formulations of mafenide acetate (Sulfamylon Cream) and their pain responses were recorded and converted to a semiquantitative pain index. The 11.2% concentration in cream was two to three times more painful than the 5% concentration. Hypertonicity and not the pH level appears to be the cause of the pain produced by the high (11.2%) concentration. The tonicity of the cream carrier and 11.2% mafenide acetate are 1,080 mOsm/kg and 1,100 mOsm/kg, respectively, for a total of 2,180 mOsm/kg. The carrier cream without glycerol and a 5% concentration of mafenide cream were much less painful than the 11.2% concentration of mafenide. Both afforded a great deal of relief to the patients who received the medications.

The results of an in vivo evaluation of 8.5% mafenide dry foam are described. Using burned guinea pigs infected with Pseudomonas aeruginosa, mafenide was applied every 12 hr as the dry foam or as the commercially available ointment. After 156 hr of therapy with the medicated dosage forms, the previously infected areas did not demonstrate the presence of Pseudomonas. However, all nonmedicated, infected controls produced positive cultures. Both medicated dosage forms demonstrated equivalent efficacy in the inhibition of Pseudomonas on burn wounds.

In this chapter the local therapy for burns is discussed. Between 400 and 500 children with burns are treated every year at the Red Cross War Memorial Children's Hospital in Cape Town, but in only 10% of them do the burns affect over 20% of the body surface. These latter patients are treated in special rooms equipped for intensive therapy. Open and closed methods of treatment for burns used in addition to early excision are compared. The first aim is early skin cover for areas with skin loss preserving as much function as possible and achieving the best possible cosmetic result. Local therapy must be atraumatic to prevent extension of the skin lesion. Bacterial contamination must be prevented as far as possible by keeping the wound clean. Emergency treatment and the course of wound healing up to the third week after the injury using the appropriate dressings are described. Early excision until the fifth day after the accident should be used mainly for burns of the hand, deep second degree burns of up to 10% of the body surface, deep second degree burns over the joints and deep second degree burns of the neck. It must be admitted that the depth of the burn can only be definitely estimated between the seventh and tenth day after the accident. If no autografts are available homografts or grafts from animals are used. The age of the patient, associated injuries, associated diseases and the extent of the burn all play a role in determining the prognosis. Furthermore endogenous bacterial infections, absorption of local therapeutic agents and the state of the surrounding skin do also influence the healing process. Finally the various local therapeutic agents like sulphamylon, silver sulphadiazine and betadine are discussed. A 0.05% solution of silver nitrate is also active against gram-negative infections. Skin transplants are disinfected with a solution containing one third 0.25% acetic acid, one third 3% cent hydrogen peroxide and one third saline. Hydrogen peroxide must not be applied to burns that are healing spontaneously. A classification of burns to help to choose the appropriate local therapy is proposed.

Seven burn patients treated with silver nitrate dressings were studied during the first 10 days after injury. Minute ventilation, oxygen consumption, and ventilatory equivalent were measured. Minute ventilation was increased two- to threefold, as was oxygen consumption. Ventilatory equivalent was only slightly increased. THree patients were initially treated with silver nitrate, and then, when clinically stable, were switched to Sulfamylon. They showed a 50% rise in ventilation, tidal volume, ventilatory equivalent, and a slight increase in respiratory rate and VD/VT. In addition, their PO2 increased and base excess fell. Five normal subjects were then given Diamox, and their minute ventilation, O2 consumption, and ventilatory equivalent were measured at rest, with a standard exercise, and with an added dead space. Diamox produced only a 25% increase in minute ventilation and ventilatory equivalent. The results suggest that, although some of the increased ventilation of Sulfamylon is due to carbonic anhydrase inhibition, another factor, such as pain casued by the topical agent, also plays a role.

Those factors that have contributed most to the control of burn wound sepsis in the burn patient since 1930 have been the advent of penicillin, the institution of burn center care, the availability of aminoglycosides and antifungal agents, the advent of topical therapy, the aggressive treatment of the burn wound by excisional therapy, a better understanding of respiratory therapy, the support of immune competence, and the recognition of the importance of nutritional support (Fig. 1). At the Shriners Cincinnati Unit, the extent of burn associated with a survival rate of 50 per cent has risen from 70 per cent in 1970 to 80 per cent in 1978. The better chance of survival for burn patients during this period can be directly related to a progressive improvement in the local and systemic measures available for the control of infection.

Formerly, death due to burns was usually caused by shock in 50% of the cases. Today only 5% of the deaths are caused by shock; 95% of all deaths are due to infection and half of these deaths are due to septicaemia. The treatment of infections depends on two factors: -- Prevention of contamination -- Prevention of bacterial growth. Contamination can be prevented by early skin grafts, a no-touch method when applying dressings, nursing in ventilated rooms and local antiseptics. The history of the use of various antiseptics starting with penicillin V and ending with cerium nitrate is discussed. For the prevention of bacterial growth chemotherapy, active and passive immunisation, and such general methods as the correct treatment of associated diseases and a high calory diet are necessary. Chemotherapy should only be given when there are definite indications. Indiscriminate chemotherapy is dangerous. The most useful immunisation methods are vaccinations against pseudomonas as these vaccinations are also active against other gram-negative bacteria. In children the diagnosis of septicaemia is often difficult. As septicaemia may develop very quickly in children, it is sometimes necessary to start chemotherapy blindly before the results of the blood culture are known.

Serum levels of total complement CH 50 and the complement components C1, C1 inactivator, C2, C4, C3c, and C3 activator were measured in 20 patients with burn injuries. The findings were assessed for any possible correlations between the results of serological investigations, severity of burns and clinical aspects of the patients.

The United States leads industrialized nations in per capita fire deaths. The most recent U.S. statistics are from 1978. Two hundred thousand burn and inhalation injuries, 70,000 hospitalizations, and 12,000 deaths occurred that year [56]. Burn care has traditionally been the general surgeon's responsibility. However, the interest and commitment of plastic and reconstructive surgeons has increased considerably over the past fifteen years. During this time, major advancements have occurred in five areas: assessment, resuscitation, control of burn wound sepsis, wound closure, and burn team management.

In previous reports, 5% sulfamylon solution has been utilized on unexcised burns and granulation tissue. We prospectively evaluated 67 burn patients to determine graft take and the incidence of side effects with use of sulfamylon solution dressings after excision and grafting. Of patients excised and grafted, the mean graft take for a total of 100 procedures was 86%. Rash occurred in 18% of patients and sulfamylon was discontinued with no sequelae. Twenty-five percent had at least one positive fungal wound culture, yet only 3% required treatment for candidemia. Those patients who developed a rash and fungal colonization had a significantly larger percent burn and were treated with sulfamylon for a longer period of time. Pain intensity was rated on a Visual Analog Scale with a mean score of 2.4; in no case was the pain considered severe enough by the patient to terminate treatment. Acidosis was present in 3% of patients but felt to be unrelated to the sulfamylon treatment. As an antimicrobial agent, 5% sulfamylon solution is a viable alternative for fresh autografts with excellent graft take and acceptable side effects.