Burn Wound Infections Treatment & Management

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.

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.

Consultation with an infectious disease specialist is suggested if multidrug-resistant bacteria are present.

The basal metabolic rate increases as the percentage of TBSA burned increases. Early enteral feeds should be started.^[7]

Patients may be as active as they can tolerate. Aggressive physical and occupational therapy of extremity injuries is necessary to prevent long-term morbidity.