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DMJ • Fall 2015 • 42(1) | 13
REVIEW
Infection is the main cause of delayed wound healing
in primary closure, traumatic wounds, burns,
and chronic skin ulcers.1 Pseudomonas aeruginosa
is an opportunistic infectious pathogen that poses
a management challenge while carrying significant
morbidity and mortality.1-4 Part of the challenge is
the fact that excessive antibiotic use can promote the
selection and multiplication of resistant isolates. P.
aeruginosa is a ubiquitous nosocomial infection in burn
patients and multi-drug resistant strains are common
in burn units, leading to a high mortality rate. It is the
most common cause of bacteremia in burn patients,
and 14-33% of burn wounds are colonized with P.
aeruginosa within 10 days of admission.1,3-5
Risk of infection in burn patients is related to
the surface area of the burn (>30% total body area),
preexisting disease, or complications preventing
surgical excision of the eschar or closure of the wound.1,6
e key to prevention and treatment of burn wound
sepsis is rapid and thorough debridement. P. aeruginosa
permeates subcutaneous lymphatics, multiplies and
invades the surrounding viable adjacent tissue.7 e
poorly perfused avascular tissue does not benefit from
systemic therapies, therefore topical antiseptics agents
are routinely used to assist in the eradication of P.
aeruginosa wound and burn infections.1,8 Tolerability
must be balanced with the antimicrobial activity. Ideal
topical antimicrobials reduce colony-forming units
without inhibiting cellular wound healing.1
ere are a variety of topical antimicrobials or
antiseptics used to treat P. aeruginosa wound infection.
Examples include acetic acid, silver based topical
treatments, and mafenide acetate. Agents such as
mafenide acetate are reported to be extremely painful
to apply, and may result in a metabolic acidosis and
hyperventilation secondary to its activity as a carbonic
anhydrase inhibitor.8,9 However, mafenide acetate is
water-soluble and can penetrate the burn eschar and
underlying tissues to reduce microbial density.6
Silver based therapies have silver ions that react
with sulfhydryl groups of bacterial enzymes and
deoxyribonucleic acid, to elicit bactericidal and
bacteriostatic action.4,9 Silver sulfadiazine is a relatively
safe, simple and eective agent against a range of
gram- negative and positive organisms. However, it is
considered less penetrative and has less antibacterial
eectiveness than other topical treatments.8 Similarly,
silver nitrate has not been proven eective in
established burn wound infection, is nonpenetrative
and can complicate fluid and electrolyte management
with leaching of ions into the dressing. However,
proponents of silver nitrate claim it has moderate
eective antimicrobial properties, is painless, and
decreases heat loss.1,8,10
Pseudomonas aeruginosa wound infections: a critical appraisal
of topical antiseptics
Haley Augustine MScOT MD1, Joshua Gillis MD2, Jason Williams MEd MD2
1Class of 2015, Faculty of Medicine, Dalhousie University
2Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Dalhousie University
Abstract
Background: Pseudomonas aeruginosa infection is a serious complication of burns and wounds with a high degree of
morbidity and mortality. This paper reviews the literature on the use of topical antiseptics for the treatment of P.
aeruginosa wound infections.
Methods: Embase and PubMed were searched, yielding 119 results that were reviewed. Inclusion criteria were all
papers that assessed patients with confirmed P. aeruginosa wound infection treated with topical antiseptics and
reported the eradication of the pathogen.
Results: Three papers met the inclusion criteria, with a total sample size of 33. All of the studies analyzed acetic
acid for the treatment of P. aeruginosa wound infection. The pooled data demonstrated that 84.8% of confirmed P.
aeruginosa wound infections were effectively treated with acetic acid.
Conclusions: P. aeruginosa remains a serious infection complicating burn and wound healing. Treatment commonly
includes topical antiseptics; however, there is a paucity of clinical based trials to support this. Three small trials
demonstrated some evidence for the use of acetic acid as a topical treatment. More evidence is required to
demonstrate the efficacy of topical antiseptics as well as recommend specific types of topical treatment for this
pathogen.
DMJ • Fall 2015 • 42(1) | 14
Acetic acid is another topical antiseptic that has
been used to treat chronic wounds, and has shown
ecacy in treating gram-negative bacteria, especially
P. aeruginosa. In vitro studies have demonstrated
toxicity to fibroblasts; however, when studied in animal
models, acetic acid was well tolerated and eective
against P. aeruginosa.3,11 A concentration of at least 0.5%
is required for clinical antimicrobial ecacy, and the
ecacy is suggested to be secondary to a lowering of
the pH to make the wound environment unsuitable for
P. aeruginosa growth.3,12
In our centre, over a 17-year period from 1996
to 2012, there were a total of 46 confirmed burns
complicated with pseudomonas infection (9.62%).
Of those confirmed infections, the majority (34 of 46
infections [74%]) were treated with acetic acid (Table
1). Due to the significant morbidity of P. aeruginosa,
this study was performed to evaluate and compare the
dierent topical antimicrobial treatments for wound or
burn infections complicated by P. aeruginosa in order to
guide future treatment approaches.
Treatment Frequency (%)
Acetic Acid 34 (73.91%)
Silver-containing 6 (13.04%)
Other 4 (8.70%)
Unknown 1 (2.17%)
None 1 (2.17%)
Total 46 (100.0%)
Literature Review
All published data assessing topical antimicrobials for
the treatment of P. aeruginosa wound infections were
reviewed with no limits applied for year of publication.
Embase and PubMed databases were accessed on June
25, 2014 using the following search criteria, specifying
human studies: pseudomonas, wound, mafenide
acetate, sulfadizine silver, silver nitrate, silvercel, acetic
acid, wound infection, local anti-infective agents, and
burns.
is search string yielded 119 results from Embase
and 971 results from PubMed, three of which were
included in this review (Figure 1). e inclusion
criteria were defined as patients with confirmed P.
aeruginosa wound infection (burn, wound, ulcer, or
unspecified), treated with topical antiseptics (acetic
acid, silver containing topicals, mafenide, or other),
and the study had to report outcomes from treatment,
specifically the eradication of P. aeruginosa. Studies
were excluded if they did not specify the microbial
pathogen as P. aeruginosa, the design of the study was in
vitro or in vivo, if they were non-human studies, topical
antimicrobials were used as prophylactic prevention of
infection, or the studies did not report sucient data
(details of treatment, patient population, intervention,
and outcomes). Case reports were excluded, however
were commented on in the discussion.
Results
ree studies met the inclusion and exclusion criteria,
described above, and are summarized in Table 2. In the
prospective, randomized trial by Phillips et al. patients
with confirmed P. aeruginosa wound infection were
randomized to either acetic acid or chlorohexidine/
hypochlorite treatment groups.13 Ten patients were
included in each group and they received a course of
seven days of treatment in addition to antibiotics. After
seven days of treatment with acetic acid 7/10 patients
had no evidence of infection, compared to 1/10 in
the chlorohexidine/hypochlorite group (P-value not
stated).
In the prospective study by Sloss et al. eight patients
with P. aeruginosa infected ulcers and eight burn
wound infections were treated with topical 1-5% acetic
acid, along with 0.5% soaks for the burn patients.5 All
of the patients tolerated the treatment well; however,
some complained about stinging on application of the
5% solution, but this did not interrupt treatment. e
authors found that the 5% concentration of acetic acid
was the most eective for eliminating P. aeruginosa and
that the time to elimination ranged from 2 to 14 days.
Of the patients included in this study, 14 of 16 were
eectively treated with acetic acid (P-value not stated).
e prospective study by Nagoba et al. included
seven patients that had P. aeruginosa wound infections
not responding to traditional therapy for more than
10 days.12 P. aeruginosa was isolated from the exudate
and in vitro susceptibility of acetic acid was tested.
e susceptibility was tested by culturing the bacteria
with nutrient broth and 1-5% acetic acid for varying
time points and then plated and incubated. e lowest
concentration of acetic acid to inhibit growth was
recorded. No antibiotics were given to the patients
during the course of topical treatment. ey found that
the isolated strains of P. aeruginosa were resistant to
four or more antibacterial agents; however, six of the
seven cases were inhibited by 3% acetic acid in vitro.
All patients were thus successfully treated with topical
3-5% acetic acid within a range of 2-12 applications
without any adverse eects (P-value not stated).
P. Aeruginosa wound infections
Table 1. Summary of topical antimicrobial treatments for
Pseudomonas burn wound infections from the Halifax Infirmary
burn ward, Halifax, Nova Scotia from 1996 to 2012.
DMJ • Fall 2015 • 42(1) | 15
Pooled data from these studies had total sample of
33 patients with wound, burn or ulcers infected with
P. aeruginosa all treated with topical acetic acid.5,12,13
e concentration of acetic acid ranged from 0.5-5%
and duration ranged from 7-28 days. P. aeruginosa was
eradicated from the infection site in 84.8% of the cases (28/33).
Discussion
Based on the literature review, it is evident that there
is a lack of randomized controlled trials evaluating
the utility of topical antimicrobials or antiseptics. As
such, the question remains what is the best approach to
treatment for pseudomonas infections.
In addition to the studies included in this review,
there were several case reports that described the use
of topical antiseptics. One report done by Nagoba et
al. described the use of acetic acid to successfully treat
P. aeruginosa wound infection as the sole antiseptic.14
ere were three case reports demonstrating topical
silver dressings as eective treatment for P. aeruginosa
wound infection. ese cases either reported the
successful eradication of infection or it was implied by
full recovery in absence of repeat wound cultures.16,17
Two cases used silver sulfadiazine and one used
Actisorb Plus 25 (Johnson & Johnson, New Jersey,
USA) to eectively treat pseudomonas wound and burn
infections.16,17 e research conducted by Stanford
et al., prophylactically treated all patients presenting
with burns with 1% silver sulfadiazine.16 ree patients
included in the study had established pseudomonas
infection prior to treatment that subsequently converted
to negative cultures. Additionally, Stanford et al.,
reported a case of a 40-year-old female with burns (65%
total body area) treated with 1% silver sulfadiazine that
was discontinued in preparation for skin grafts, after
which she developed pseudomonas infection.16 She
was then eectively treated with 1% silver sulfadiazine.
One case series by Tessler et al. that described a 75%
mortality rate in four patients despite antibiotic and
silver nitrate therapy secondary to burn infections.7
In these cases the patients sustained significant burns
(total body area ranged from 39-88%) complicated
by pseudomonas infection. e details of the topical
silver nitrate treatment were not clear, and therefore
did not meet inclusion criteria in this review. However
they found that 0.5% topical silver nitrate might keep
wounds deceptively clean and non-malodorous despite
infection.
A Cochrane review evaluating the utility of
silver treatments and dressings for treatment of
contaminated or infected wounds only found 3
randomized control trials.18 ese randomized trials
were not specific to P. aeruginosa infection and were
limited by short follow-up periods and methodological
issues regarding how wound healing was measured.
is study reported that silver-containing dressings did
not significantly increase wound healing as compared
to standard dressings or best local practices. Similarly
there were no significant dierences in pain, patient
satisfaction, and length of hospital stay or cost. e
authors concluded that there is insucient evidence to
recommend silver-containing dressings for treatment
of infected or contaminated chronic wounds.18 Another
paper recommended the use of mafenide acetate for the
treatment of superficial P. aeruginosa burn infection,
with debridement and subsequent application of 5%
mafenide acetate for invasive burn wound infections
caused by P. aeruginosa.10 However, there was no data to
support these recommendations from clinical trials or
from the centre where these practices were employed.
ere are several studies that evaluate topical
antimicrobials for prophylaxis of infection to reduce the
bioburden of open wounds and burns.1,9,19,20 Prophylactic
silver based topical treatments are most commonly
studied and used for limiting bacterial proliferation.
ere does not appear to be any superiority between
dierent types of silver topical antimicrobials.9,19,20
However, an in vivo study supported the use of
silver sulfadiazine over silver nitrate solution (0.5%)
or mafenide (10%) as prophylaxis against infection in
burned mice.21 Assessing other antimicrobials, one
P. Aeruginosa wound infections
Study Design Infection
type
Treatment
duration
Sample
size
Treatment Eradication
rate
Nagoba 200812 Prospective
case series
Wound
ulcer
Unknown 7 Acetic acid 3-5%, 2-12
applications
100.0%
Sloss 19935Prospective
case series
Burn (8),
Ulcer (8)
7-14 days 16 Acetic acid 0.5-5% BID 87.5%
Phillips 196813 Prospective,
randomized,
non-blinded
Wound 7 days 10 Acetic acid 5% BID 70.0%
Burn 7 days 10 Chlorohexidine /hypochlorite 10.0%
Table 2. Description of the studies that met inclusion criteria and summary of results.
DMJ • Fall 2015 • 42(1) | 16
study done by MacMillan et al. demonstrated that
mafenide and silver based topical treatment might
reduce septic complications and mortality after
sustaining thermal injuries.19 Comparing these topical
treatment modalities, the authors concluded that these
agents can be used interchangeably for prophylaxis and
that one treatment did not demonstrate superiority.
Topical treatments have an important theoretical
utility, while infected dead tissue from burns or
other types of wounds do not benefit from the
systemic antibiotic treatments with limited vascular
supply. ese dressings act as an adjunct to surgical
debridement, help to absorb exudate and have
antimicrobial action.15 Reviews and editorials report
that topical treatment for active wound infection
controls P. aeruginosa colony forming units and hastens
the infectious course and time to recovery. However,
this critical review demonstrates the limited clinical
evidence to support this treatment in practice. e use
of these topical agents is important to help decrease
the use of systemic antibiotics and decrease subsequent
adverse eects of these antibiotics. It is important to
prevent the promotion of resistant microorganisms by
limiting systemic antibiotic use with the use of broad-
spectrum topical agents. Acetic acid added topically to
burn wounds acts locally against multi-drug resistant
strains of P. aeruginosa and thus, could help to avoid
these complications by reducing the need for systemic
antibiotics. is would need to be tested definitively
through larger, more rigorous trials.
e few clinical trials conducted demonstrated that
acetic acid oers a nontoxic, well tolerated, inexpensive
and ecient approach to wound infection complicated
with P. aeruginosa.5,12,13 Similarly, in vitro studies have
shown that 0.5% acetic acid was bactericidal to all
isolated bacteria from cultured pseudomonas wound
infections, with multiple drug resistance patterns.11 is
is important with the increasing antibiotic resistance of
bacterial skin flora, especially in critical care patients
such as those with burn wounds, and the need for
antibiotic stewardship. Also, it is dicult for systemic
antibiotics to appropriately treat P. aeruginosa infections
due to its ability to form resistant biofilms, which
topical agents may be more eective.22 Madhusudhan
prospectively randomized the use of acetic acid
versus saline to treat chronic wounds infected with P.
aeruginosa and found that those treated with acetic
acid were cleared of pseudomonal infection earlier (4.5
versus 11.5 days). e acetic acid group had a higher
proportion of multi-drug resistant P. aeruginosa, but
the duration of treatment until infection was cleared
was the same regardless of susceptibilities, as opposed
to the saline treatment group, which took longer.22
To produce a 0.5% solution of acetic acid, one
simply needs to dilute 1 mL of acetic acid into 199 mL of
sterile normal saline. Sterile gauze is then soaked in this
solution and applied to the burn wounds. Dressings are
typically changed once or twice a day, depending on the
amount of drainage of the wound itself. e limitations
of acetic acid are that application of the dressings can
be painful in higher concentrations, and it has been
show in vitro to temporarily disrupt epithelialization,
although this has not been replicated in human or
animal experiments.22
Conclusion
e advantages of topical antiseptics are to prevent
and treat resistant strains of pseudomonas. ere are
no clinical trials that directly compare the dierent
topical antimicrobials. However, there is some limited
evidence to support topical acetic acid treatment for
active pseudomonas wound infection and some studies
to support silver based therapies for the prophylaxis
of infection. It is obvious from this review that further
clinical trials are recommended to evaluate various
topical antimicrobials to help guide treatment for P.
aeruginosa infected wounds.
References
1. Leaper DJ. Silver dressings: their role in wound management. Int
Wound J 2006;3(4):282-94.
2. MacMillan BG, Hill EO, Altemeier WA. Use of topical silver nitrate,
mafenide, and gentamicin in the burn patient: a comparative study.
Arch Surg 1967;95(3):472-81.
3. Nagoba BS, Selkar SP, Wadher BJ, Gandhi RC. Acetic acid treatment
P. Aeruginosa wound infections
Figure 1. Search strategy used to identify appropriate papers
demonstrating topical antiseptic therapy for Pseudomonas
aeruginosa infections.
DMJ • Fall 2015 • 42(1) | 17
of pseudomonal wound infections: a review. J Infect Public Health
2013;6(6):410-5.
4. Steinstraesser L, Schubert C, Jacobsen F, Al-Benna S. Editorial:
glycyrrhizin against multi-resistant bacteria? J Leukoc Biol
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5. Sloss JM, Cumberland N, Milner SM. Acetic acid used for the
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6. Pruitt BA, McManus AT, Kim SH, Goodwin CW. Burn wound
infections: current status. World J Surg. 1998;22(2):135-45.
7. Tessler R, Polk HC. Pseudomonas burn sepsis in patients treated with
aqueous silver nitrate (0.5 percent). Surgery 1967;61(5):705-10.
8. Ollstein RN, McDonald C. Topical and systemic antimicrobial agents
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South-West Ethiopia. Ann Clin Microbiol Antimicrob 2014;13:1.
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Pseudomonal wound infections. Eur J Gen Med 2008;5(2):104-6.
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treatment of superficial wounds infected by Pseudomonas aeruginosa.
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dressings over a skin-grafted infected wound. Burns 2011;37(2):360-1.
16. Stanford W, Rappole BW, Fox CL. Clinical experience with silver
sulfadiazine, a new topical agent for control of pseudomonas infections
in burns. J Trauma 1969;9(5):377-88.
17. Withers JN. Control of pseudomonas infections in burns with silver
sulfadiazine. Hawaii Med J 1970;29(4):298-300.
18. Vermeulen H, Van Hattem JM, Storm-Versloot MN, Ubbink DT.
Topical silver for treating infected wounds. Cochrane Database Syst
Rev 2009;1:CD005486.
19. MacMillan BG, Hill EO, Altemeier WA. Use of topical silver nitrate,
mafenide, and gentamicin in the burn patient: a comparative study.
Arch Surg 1967;95(3):472-81.
20. Ollstein RN, Symonds FC, Crikelair GF, Pelle L. Alternate case study
of topical sulfamylon and silver sulfadiazine in burns. Plast Reconstr
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in burns: therapy of Pseudomonas infection in burns. Arch Surg
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P. Aeruginosa wound infections
... However, there is an increasing concern in an incidence of rise of antibiotic resistant microorganisms caused by indiscriminate usage of antibiotics, presenting serious health concerns worldwide [4][5][6]. As a result, antiseptic treatments are becoming increasingly necessary in controlling bacterial contamination in health care systems [7]. Antimicrobial materials (biocides) have been used as antiseptic treatments for centuries and are regaining their importance due to their advantages over antibiotics. ...
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Aim: Pseudomonas aeruginosa is a classic opportunistic pathogen with innate resistance to many antibiotics and disinfectants. It is ubiquitous in hospital environment and because of its ability to survive in hospital environment it creates threat to patient's care.The antibacterial effect of acetic acid against multiple antibiotic resistant strains of Pseudomonas aeruginosa isolated from nosocomial wound infection cases was studied. Methods: For this study, seven hospitalized patients with wound infections, not responding to traditional therapy for more than 10 days, were selected. A specimen of pus was collected before application of acetic acid and after completion of treatment (only one reculture was done) and processed for culture study. Seven clinical isolates of P. aeruginosa were studied for in vitro susceptibility to acetic acid and all were found to be inhibited by 3 % acetic acid. Results: The pus culture yielded isolation of P. aeruginosa in all seven cases under study. No other bacterium was isolated from these cases; hence they were labeled as pseudomonal wound infections. All isolates were found to be resistant to four or more antibacterial agents but all of them were found to be inhibited by 3% acetic acid in vitro when exposed for 15 minutes or more. Topical application of 3 to 5% acetic acid to wounds for 2 to 12 times successfully eliminated P. aeruginosa from wounds. Conclusion: The use of acetic acid is therefore recommended for effective elimination of multiple antibiotic resistant strains of P. aeruginosa from infection site.
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Background: Topical silver treatments and silver dressings are increasingly used for the local treatment of contaminated or infected wounds, however, there is a lack of clarity regarding the evidence for their effectiveness. Objectives: To evaluate the effects on wound healing of topical silver and silver dressings in the treatment of contaminated and infected acute or chronic wounds. Search strategy: We sought relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Wounds Group Specialised Register in March 2006 and in MEDLINE, EMBASE, CINAHL, and digital dissertations databases up to September 2006. In addition, we contacted companies, manufacturers and distributors for information to identify relevant trials. Selection criteria: Randomised controlled trials (RCTs) assessing the effectiveness of topical silver in the treatment of contaminated and infected acute or chronic wounds. Data collection and analysis: Eligibility of trials, assessment of trial quality and data extraction were undertaken by two authors independently. Disagreements were referred to a third author. Main results: Three RCTs were identified, comprising a total of 847 participants. One trial compared silver-containing foam (Contreet®) with hydrocellular foam (Allevyn®) in patients with leg ulcers. The second trial compared a silver-containing alginate (Silvercel®) with an alginate alone (Algosteril®). The third trial compared a silver-containing foam dressing (Contreet®)) with best local practice in patients with chronic wounds. The data from these trials show that silver-containing foam dressings did not significantly increase complete ulcer healing as compared with standard foam dressings or best local practice after up to four weeks of follow-up, although a greater reduction of ulcer size was observed with the silver-containing foam. The use of antibiotics was assessed in two trials, but no significant differences were found. Data on pain, patient satisfaction, length of hospital stay, and costs were limited and showed no differences. Leakage occurred significantly less frequently in patients with leg ulcers and chronic wounds treated with a silver dressing than with a standard foam dressing or best local practice in one trial. Authors' conclusions: Only three trials with a short follow-up duration were found. There is insufficient evidence to recommend the use of silver-containing dressings or topical agents for treatment of infected or contaminated chronic wounds. Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Article
Inclusion criteria: All patients with chronic wounds infected with P. aeruginosa. Exclusion criteria: Wounds due to massive burns, suspected malignancy, immunocompromised individuals and individuals with sepsis. A total of 32 patients enrolled in the study. Subjects were randomised equally to the 1% acetic acid group and saline dressing group. None of the patients received any systemic antibiotics during the study period and received twice daily dressings. The endpoint of the treatment was wounds free of P. aeruginosa. The duration of treatment required to eliminate the Pseudomonas from the wounds in the acetic acid group was on an average 7 days less than that required by the saline group. P value was <0·001. In the 1% acetic acid group irrespective of the sensitivity of the organism to antibiotics, Pseudomonas organisms were eliminated within the same time period - 4·5 days. In the saline group, susceptible organisms were eliminated within 11·5 days and multidrug-resistant organisms were eliminated by 15·5 days. 1% acetic acid is a simple, safe and effective topical antiseptic that can be used in the elimination of P. aeruginosa from chronic infected wounds.
Article
Pseudomonas aeruginosa is a significant cause of burn wound infections and, skin and soft tissue infections. The antiseptic management is an integral part of the management of wound infections and is essential to control wound infection. Although commonly used, concerns have been raised. Available experimental data suggest that many commonly used antiseptic agents may be toxic to the cells involved in wound healing process and may affect the process of normal tissue repair. In view of this, the present review summarized the various organic acids commonly used as a substitute for antiseptics to control pseudomonal wound infections with special reference to acetic acid and their role in the process of wound healing. Acetic acid is to be kept in mind as one of the alternatives when infection is caused by multiple antibiotic resistant strains of P. aeruginosa. At a time when bacterial resistance to antibiotics is a matter of increasing concern, the value of topical agents such as acetic acid should not be forgotten.
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A remarkable contribution towards new leads for the fight against multiresistant microorganisms is discussed.
Article
Patients with burns or superficial wounds infected by Pseudomonas aeruginosa were allocated at random to treatment with dressings soaked with acetic acid (ten patients) or with chlorhexidine or hypochlorite (ten patients). Lesions were swabbed once a day for seven days, and after overnight incubation growth was scored as none (0) to very heavy (5). In ten patients treated with acetic acid the mean growth score fell from 4.1 on day 0 to 0.7 on day 7: in the control group the score remained much the same (3.0/3.8) throughout the trial period. In only one of the acetic-acid-treated patients was therapy completely unsuccessful.
Article
The use of silver sulphadiazine in the topical treatment of the burn wound in 169 patients has proved effective in decreasing the mortality and the eradication of infection, especially of Pseudomonas pyocyanea, from the burn wound. It also proves to be a relatively cheap method of treating the burn wound.