What is the recommended antibiotic management for a burned patient?

Antibiotic Management in Burned Patients

Systemic antibiotic prophylaxis is not recommended for burn patients unless there are signs of infection, as sustained antimicrobial prophylaxis has questionable clinical benefit and may lead to antimicrobial resistance. 1

Initial Assessment and Management

• Burn wound infections are among the most important complications in the acute period following burn injury and are associated with high mortality rates 1
• Infections preceded multiorgan dysfunction in 83% of patients with severe burns and were considered the direct cause of death in 36% of patients 1
• Early excision of eschar and proper wound management can substantially decrease the incidence of invasive burn wound infection 1

Antibiotic Prophylaxis Recommendations

When NOT to Use Prophylactic Antibiotics

• Sustained systemic antimicrobial prophylaxis should be avoided in burn patients without suspected infection to minimize the risk of antimicrobial-resistant pathogens and drug-related adverse effects 1
• Recent meta-analyses suggest questionable clinical benefit with prolonged systemic antimicrobial prophylaxis in burn patients 1
• Current burn management guidelines do not support sustained antimicrobial prophylaxis 1

When Antibiotics ARE Indicated

• Antibiotics should be administered in severely burned patients when there are signs of sepsis or septic shock 1
• Brief antibiotic prophylaxis may be appropriate for specific invasive procedures in burn patients 1
• Systemic antibiotic prophylaxis administered in the first 4-14 days has been shown to significantly reduce all-cause mortality by nearly half in some studies 1
• Limited perioperative prophylaxis has been shown to reduce wound infections but not mortality 1

Microbiology Considerations

• Burn wound infections are typically polymicrobial 1
• Initial colonization is usually by Gram-positive bacteria from the patient's endogenous skin flora or external environment 1
• Rapid colonization by Gram-negative bacteria typically occurs within a week of burn injury 1
• Common pathogens include multidrug-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter species 2

Antibiotic Selection and Dosing

• When infection is suspected or confirmed, antibiotic therapy should be optimized based on pharmacokinetic/pharmacodynamic principles specific to burn patients 1
• Dosing strategies must account for the highly abnormal physiologic features of burn patients, which can greatly affect pharmacokinetic disposition 3
• Evidence suggests that both high doses and continuous infusion of broad-spectrum beta-lactams may be needed to achieve adequate pharmacokinetic/pharmacodynamic targets in burn patients 4
• For severe infections with Pseudomonas aeruginosa, combination therapy with an extended-spectrum β-lactam and either an aminoglycoside or a fluoroquinolone is recommended 1
• Vancomycin and clindamycin are important reserve antibiotics for methicillin-resistant Staphylococcus aureus infections 2
• Colistin has re-emerged as an effective antibiotic against multidrug-resistant Pseudomonas and Acinetobacter infections in burns 2

Duration of Therapy

• Empiric combination therapy should not be administered for more than 3 to 5 days 1
• De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known 1
• Typical duration of therapy is 7 to 10 days; longer courses may be appropriate in patients with slow clinical response, undrainable foci of infection, or immunologic deficiencies 1

Monitoring and Adjustment

• Bacterial cultures can aid in the selection of appropriate antibiotics, especially in cases of bacterial drug resistance 1
• Therapeutic drug monitoring is recommended to optimize pharmacokinetic-pharmacodynamic parameter achievement in individual patients due to high variability in burn patients 3
• Dosages must be adjusted based on serum concentrations when serum assays are available 5

Pitfalls and Caveats

• Doses recommended in standard package inserts may not achieve pharmacokinetic-pharmacodynamic parameters associated with optimal infectious outcomes in burn patients 3
• Multiagent therapy may have the untoward effect of predisposing to superinfection by yeast, fungi, or resistant organisms 5
• The penetration of systemic antibiotics into burn eschar remains an area not fully studied; hence, they cannot be the only therapeutic modality used to treat burn wound infection 5
• Topical antibiotic prophylaxis applied to burn wounds has shown no beneficial effects in some studies 1
• Silver sulfadiazine has been associated with a statistically significant increase in burn wound infection compared with dressings/skin substitutes in some studies 1