eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections
Burn Wound Infections: Treatment & Medication
Updated: Apr 16, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The focus of medical care is to prevent infection. Once infection develops, aggressive surgical excision involving wound closure with autograft, allograft, or skin substitutes and antimicrobial therapy are needed.
Although early excision appears to be the primary surgical method for improving infection outcomes, the cumulative data for this are not very strong. However, a recent meta-analysis of all available randomized controlled studies found that early excision reduced mortality rates in all patients with burns who did not have an inhalation injury.6
Wound care should be directed at thoroughly removing devitalized tissue, debris, and previously placed topical antimicrobials. A broad-spectrum surgical antimicrobial topical scrub such as chlorhexidine gluconate should be used along with adequate analgesia and preemptive anxiolytic in order to permit adequate wound care. The most commonly used topical antimicrobials for the prevention and treatment of burn wound infection include mafenide acetate, silver sulfadiazine, silver nitrate solution, and silver-impregnated dressings. These various therapies differ in their ability to penetrate eschars, antimicrobial activities, and adverse-event profiles. However, they may be associated with drug pressure, resulting in infections with resistant bacteria or fungus.
Antibiotic prophylaxis has also been studied in burn surgery at the time of wound manipulation, but few studies have supported this use of systemic antibiotics during acute burn surgery. Antibiotics appear to be of no value in the prophylaxis of wound infections accompanying surgery for small to moderate burns. However, few studies have evaluated surgical prophylaxis in patients with burns over more than 40% TBSA.
When an infection is identified, antimicrobial therapy should be directed at the pathogen recovered on culture. In the setting of invasive infection or evidence of sepsis, empiric therapy is often initiated. A local burn facility's antibiogram must be established to help direct empiric therapy. If fungus is detected on histopathology, culture samples to detect the infecting genus and species are necessary because the growing armamentarium of antifungal agents have varying activity. Amphotericin B was once the agent of choice, but some facilities have seen increased rates of infections with Fusarium species and Aspergillus terreus, which are innately resistant to amphotericin B. In these cases, voriconazole is often used. A new agent, posaconazole, may have broader antifungal activity but is limited as it is available only in an oral formulation.
Patients with burns are also at risk for tetanus. Tetanus vaccination plus antitetanus immunoglobulin should be administered to patients who have no history of vaccination with booster tetanus toxoid vaccination given at 4 weeks and 6 months.
Surgical Care
This is fundamental to the care of the patient. Systemic and local antibiotics have limited effect in improving morbidity and mortality unless they are used in combination with adequate surgical care.
Consultations
Consultation with an infectious disease specialist is suggested if multidrug-resistant bacteria are present.
Diet
The basal metabolic rate increases as the percentage of TBSA burned increases. Early enteral feeds should be started.7
Activity
Patients may be as active as they can tolerate. Aggressive physical and occupational therapy of extremity injuries is necessary to prevent long-term morbidity.
Medication
The goals of antimicrobial therapy are to treat an underlying infection, to reduce morbidity, and to prevent mortality. Topical therapy is often applied to prevent infection and to treat ongoing infections or used as an adjunct to surgical treatment and systemic antibiotics. Systemic antimicrobial agents should be directed at the underlying pathogen recovered from culture or determined empirically from the local burn unit’s antibiogram while culture results are pending.
Antifungal agents may also be used. However, pathogen identification is necessary in order to determine the ideal antifungal agent, as amphotericin B is not active against all fungal infections.
Antibacterial, Topical
Topical therapy is typically applied to prevent infection and to treat infection when adequate surgical management is not possible.
Silver sulfadiazine (Silvadene, SSD, SSD-AF, Thermazene)
Useful in prevention of infections from second- or third-degree burns. Has bactericidal activity against many gram-positive and gram-negative bacteria, including yeast. It has poor eschar penetration.
Adult
Apply qd/bid to a thickness of 1/16th; burned area should be covered with medication continuously
Pediatric
Apply as in adults
Effect of proteolytic enzymes is reduced when used concomitantly with this product
Documented hypersensitivity; neonates and infants <2 years
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in G-6-PD deficiency and renal insufficiency; a decrease in the neutrophil count has been observed with initiation of therapy (this effect typically resolves even when the agent is continued and rarely necessitates discontinuation of therapy)
Silver nitrate
Coagulates cellular protein and removes granulation tissue. It exhibits activity against gram-positive bacteria, gram-negative bacteria, and Candida species. The major drawbacks are that it has poor penetration of eschar, requires the use of occlusive dressings, and turns black upon contact with tissues.
Adult
Apply to affected area or lesion for approximately 5 d
Pediatric
Apply as in adults
Decreases effects of sulfacetamide preparations
Documented hypersensitivity; broken skin or cuts
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not for internal use; depletes cations due to leeching across open wound into hypotonic solution (phenomenon may result in hyponatremia, hypocalcemia, hypokalemia, and hypomagnesemia; close monitoring of electrolytes is necessary)
Mafenide (Sulfamylon)
Topical sulfonamide. Diffuses freely into the eschar and is highly effective against gram-negative organisms, including Pseudomonas species.
Adult
Apply cream to open wounds bid/tid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; renal impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Pain or burning may occur upon application; metabolized to a carbonic anhydrase inhibitor (p-carboxybenzene-ulfonamide), which may result in metabolic acidosis
More on Burn Wound Infections |
| Overview: Burn Wound Infections |
| Differential Diagnoses & Workup: Burn Wound Infections |
 Treatment & Medication: Burn Wound Infections |
| Follow-up: Burn Wound Infections |
| References |
| Further Reading |
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References
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Pidcoke HF, Wade CE, Wolf SE. Insulin and the burned patient. Crit Care Med. Sep 2007;35(9 Suppl):S524-30. [Medline].
Horvath EE, Murray CK, Vaughan GM, Chung KK, Hospenthal DR, Wade CE, et al. Fungal wound infection (not colonization) is independently associated with mortality in burn patients. Ann Surg. Jun 2007;245(6):978-85. [Medline].
Murray CK, Hoffmaster RM, Schmit DR, Hospenthal DR, Ward JA, Cancio LC, et al. Evaluation of white blood cell count, neutrophil percentage, and elevated temperature as predictors of bloodstream infection in burn patients. Arch Surg. Jul 2007;142(7):639-42. [Medline].
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Greenhalgh DG, Saffle JR, Holmes JH 4th, Gamelli RL, Palmieri TL, Horton JW, et al. American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res. Nov-Dec 2007;28(6):776-90. [Medline].
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Regules JA, Glasser JS, Wolf SE, Hospenthal DR, Murray CK. Endocarditis in burn patients: Clinical and diagnostic considerations. Burns. Oct 26 2007;[Medline].
Schofield CM, Murray CK, Horvath EE, Cancio LC, Kim SH, Wolf SE, et al. Correlation of culture with histopathology in fungal burn wound colonization and infection. Burns. May 2007;33(3):341-6. [Medline].
Shankar R, Melstrom KA Jr, Gamelli RL. Inflammation and sepsis: past, present, and the future. J Burn Care Res. Jul-Aug 2007;28(4):566-71. [Medline].
Keywords
burn wound cellulitis, burn wound infection, invasive burn wound infection, burn injury, thermal injury, wound colonization, necrotizing infection/fasciitis, house fire, electrical injury, chemical exposure, burn infection, burn complications
