What antibiotics are used to treat infections in burn patients?

Antibiotic Use in Burn Patients

Sustained systemic antibiotic prophylaxis should NOT be routinely administered to burn patients without evidence of infection, as this approach lacks mortality benefit and promotes antimicrobial resistance. 1

Key Principles for Antibiotic Management in Burns

When NOT to Use Antibiotics

• Avoid prolonged prophylactic systemic antibiotics in burn patients without signs of infection, as recent meta-analyses demonstrate questionable clinical benefit and increased risk of resistant pathogen colonization 1
• The inflammatory response from burn injury alone does not mandate antimicrobial therapy 1
• Topical antibiotic prophylaxis (including silver sulfadiazine) has shown no beneficial effects on mortality or infection rates 1
• Silver sulfadiazine specifically increases burn wound infection rates compared to dressings/skin substitutes (OR 1.87) and prolongs hospital stay 1

When Antibiotics ARE Indicated

For severe burns requiring mechanical ventilation:

• Systemic antibiotic prophylaxis administered in the first 4-14 days significantly reduced all-cause mortality by nearly half in patients with severe burns 1
• Trimethoprim-sulfamethoxazole demonstrated significant reduction in pneumonia (RR 0.18) in ventilated burn patients 1

For documented infections:

• Initiate antimicrobials immediately when sepsis or septic shock is suspected, targeting likely pathogens 1
• Burn wound infections are typically polymicrobial, initially colonized by Gram-positive bacteria from skin flora, then rapidly colonized by Gram-negative bacteria within one week 1

Antibiotic Selection for Burn Infections

Empiric coverage should target:

• Gram-positive organisms: Staphylococcus aureus (including MRSA), Streptococcus species 1
• Gram-negative organisms: Pseudomonas aeruginosa, Acinetobacter species, E. coli, Klebsiella pneumoniae, Proteus mirabilis 1
• Anaerobes in deep tissue infections 1

Specific antibiotic considerations:

• Bacterial cultures must guide therapy, especially given altered pharmacokinetics in burn patients requiring dose adjustments 1
• For multi-drug resistant Gram-negative infections (Pseudomonas, Acinetobacter), colistin has re-emerged as highly effective 2
• Vancomycin remains critical for MRSA coverage 2
• Fluoroquinolones (levofloxacin 750 mg every 24 hours, ciprofloxacin 600 mg every 12 hours) should be optimized to peak concentrations for Gram-negative coverage 1, 3
• Aminoglycosides (gentamicin 5-7 mg/kg daily) should be dosed once daily for patients with preserved renal function 1

Critical Caveats

Pharmacokinetic alterations in burn patients:

• Burn patients exhibit significantly altered drug metabolism requiring dose adjustments based on therapeutic drug monitoring when available 1, 4
• Standard dosing often results in subtherapeutic levels due to increased volume of distribution and enhanced renal clearance 4

Perioperative prophylaxis:

• Limited perioperative prophylaxis (single dose) reduces wound infections during excision and grafting procedures 1
• Extended perioperative prophylaxis beyond 24 hours shows no additional benefit 1

Source control is paramount:

• Surgical excision of necrotic tissue and eschar removal substantially decreases invasive burn wound infection risk 1
• Antibiotics cannot be the sole therapeutic modality for burn wound infections due to poor eschar penetration 5

Duration of Therapy

• Antibiotics should be continued only long enough to produce clinical effect, typically 7-10 days for most infections 1
• De-escalate to narrowest effective agent once cultures and sensitivities return 1
• For culture-negative suspected infections with clinical improvement, discontinue antibiotics promptly to minimize resistance development 1