Antibiotic Recommendations for Second-Degree Burns
Routine systemic or topical antibiotic prophylaxis is NOT recommended for second-degree burns, as antibiotics provide no benefit in preventing infection and may actually worsen outcomes. 1, 2, 3, 4
Key Evidence Against Antibiotic Use
The most recent and highest quality evidence demonstrates that:
Topical antibiotics have no beneficial effects on reducing infection or mortality in burn patients based on a comprehensive Cochrane review of 36 RCTs involving 2,117 participants 3, 4
Silver sulfadiazine specifically increases harm: It is associated with significantly increased burn wound infection (OR 1.87,95% CI: 1.09-3.19) and longer hospital stays (mean difference 2.11 days) compared to simple dressings 3, 4
Sustained systemic antibiotic prophylaxis should be avoided in burn patients without signs of infection, as it increases risk of antimicrobial resistance and drug-related adverse effects without clinical benefit 1
Recommended Wound Management Instead of Antibiotics
Immediate First Aid (First 20 Minutes)
- Cool the burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce infection risk 1, 3
- Remove jewelry before swelling occurs to prevent vascular compromise 1
- Monitor children for hypothermia during cooling interventions 1
Wound Preparation
- Leave intact blisters alone as the detached epidermis acts as a biological dressing 2
- Decompress tense blisters by piercing and expressing fluid while preserving the blister roof—do not completely remove the roof as this significantly increases infection risk 2
- Clean with tap water or isotonic saline before dressing application 2
Dressing Application for Small Burns Managed at Home
Apply petrolatum-based products (with or without topical antibiotics like polymyxin) to open burn wounds, followed by a non-adherent dressing 1, 2
Alternative options include:
- 50% white soft paraffin with 50% liquid paraffin 2
- Honey or aloe vera 1, 3
- Non-adherent dressings like Mepitel or Telfa 2
Limited Topical Antimicrobial Use
- Apply topical antimicrobials ONLY to sloughy areas, not to the entire burn surface 2
- Avoid silver sulfadiazine for prolonged periods on superficial burns as it delays healing 2, 5, 3
When Systemic Antibiotics ARE Indicated
Antibiotics should only be started when there are clinical signs of infection, not prophylactically:
- Increased pain, redness, swelling, or purulent discharge 2
- Fever with positive wound or blood cultures 6, 7
- Clinical signs of burn wound sepsis or invasive infection 1, 6
Empirical Antibiotic Selection (When Infection Present)
Based on institutional resistance patterns, common pathogens in burn wounds include:
- Pseudomonas species (most common, often resistant to ceftriaxone and ampicillin-sulbactam; sensitive to imipenem, amikacin, vancomycin) 6, 7
- Staphylococcus species including MRSA (sensitive to linzolid and vancomycin) 6, 7
Critical Referral Criteria
Immediate referral to a burn center is required for: 1, 2
- Burns involving face, hands, feet, or genitalia (regardless of size)
- Burns >10% body surface area in adults (>5% in children)
- Signs of inhalation injury (facial burns, difficulty breathing, soot around nose/mouth)
- Full-thickness (third-degree) burns
Pain Management (Not Antibiotics)
- Over-the-counter NSAIDs or acetaminophen for pain control 1, 5
- Multimodal analgesia with titrated medications for severe pain 5
- Non-pharmacological cooling and covering with fatty dressings reduces pain 5
Common Pitfalls to Avoid
- Do not apply ice directly to burns—causes further tissue damage 2, 5, 3
- Do not use butter, oil, or home remedies 2, 3
- Do not prescribe prophylactic antibiotics for clean second-degree burns 1, 2, 3, 4
- Do not use silver sulfadiazine routinely—it worsens outcomes 2, 5, 3, 4
- Re-evaluate dressings daily and monitor for signs of infection 2, 5