What are the recommendations for antibiotics as prophylaxis for burns?

Antibiotic Prophylaxis for Burns: Evidence-Based Recommendations

Routine systemic antibiotic prophylaxis should NOT be administered to burn patients, as it does not reduce infection risk and promotes multidrug-resistant organisms. 1, 2

Core Principles

Systemic Antibiotic Prophylaxis: NOT Recommended

• The American College of Surgeons and Surviving Sepsis Campaign explicitly recommend against routine systemic antibiotic prophylaxis in burn patients because evidence shows no clear benefit in reducing infections or mortality while significantly increasing selection of multidrug-resistant bacteria. 3, 2

• The evidence base is weak: only three small randomized trials exist, with two showing no reduction in infection risk and one suggesting possible pneumonia reduction—insufficient to support routine prophylaxis. 2

• Antibiotics should be reserved exclusively for documented or strongly suspected infections, not for prophylaxis in the absence of clinical signs. 2

Topical Antibiotic Prophylaxis: NOT Recommended

• Topical antibiotic prophylaxis has no beneficial effects on reducing infection or mortality in burn patients according to a comprehensive review of 36 RCTs involving 2,117 participants. 4

• Silver sulfadiazine specifically is associated with increased burn wound infection (OR 1.87,95% CI: 1.09-3.19) and longer hospital stays (mean difference 2.11 days, 95% CI: 1.93-2.28) compared to dressings or skin substitutes. 3, 5

• Prolonged use of silver sulfadiazine on superficial burns delays healing. 1

Exception: Mechanically Ventilated Patients with Severe Burns

• One Japanese propensity-matched cohort study (232 matched pairs) found that prophylactic antibiotics may reduce 28-day mortality in mechanically ventilated severe burn patients (47.0% vs 36.6%, difference 10.3%, 95% CI: 1.4-19.3). 6

• This represents the only potential exception where systemic prophylaxis might be considered, though the evidence remains uncertain and requires clinical judgment. 1

• No mortality benefit was observed in burn patients not requiring mechanical ventilation. 6

Perioperative Prophylaxis

• Limited perioperative prophylaxis (administered only during surgical procedures) reduced wound infections but did not reduce mortality. 3

• Perioperative systemic antibiotic prophylaxis had no significant effect on burn wound infection, sepsis, or mortality in pooled analyses. 5

What TO Do Instead

Non-Pharmacological Management (Priority)

• Early excision of necrotic tissue and eschar is the cornerstone of preventing invasive burn wound infection—this is more important than any antibiotic strategy. 1, 2

• Proper wound care includes cleaning with tap water, isotonic saline, or antiseptic solution before dressing application. 1

• Early enteral nutrition (within 12 hours) should be initiated to attenuate the hypermetabolic response and reduce infection risk. 2

Topical Wound Management

• For small partial-thickness burns managed at home, apply petrolatum, petrolatum-based ointment, honey, or aloe vera to open burn wounds and cover with clean nonadherent dressing. 4

• Antiseptic dressings (not antibiotic-containing) may be appropriate for large or contaminated burns. 1

When Infection Develops: Antibiotic Selection

• Obtain bacterial cultures to guide antibiotic selection when infection is suspected. 1

• Treatment should target both Gram-positive and Gram-negative facultative organisms as well as anaerobes when infection is confirmed. 1

• Critical pharmacokinetic consideration: Burn patients have altered drug disposition due to hypermetabolic state, requiring dosage optimization. 2, 7

• For aminoglycosides in burn patients with preserved renal function, once-daily dosing (5-7 mg/kg daily gentamicin equivalent) optimizes peak concentrations while minimizing renal toxicity. 2

• Therapeutic drug monitoring should be performed to optimize pharmacokinetic-pharmacodynamic parameter achievement in individual burn patients due to high variability. 7

Critical Pitfalls to Avoid

• Do not use fusidic acid as topical antibiotic for burns—it provides no benefit and contributes to antimicrobial resistance. 4

• Prolonged or inappropriate antibiotic use promotes colonization with multidrug-resistant organisms, which are challenging to treat and associated with worse outcomes. 2

• Non-absorbable antibiotics for selective decontamination of the digestive tract significantly increased MRSA rates (RR 2.22,95% CI: 1.21-4.07). 5

• Failure to adjust antibiotic dosages based on altered pharmacokinetics in burn patients leads to subtherapeutic levels. 1

Monitoring Strategy

• Regular reassessment of wounds is necessary, with dressings ideally evaluated daily. 1

• Reserve antibiotics for documented infections with systemic signs (fever, hemodynamic instability, elevated inflammatory markers) rather than colonization alone. 2

• When antibiotics are indicated, treatment duration should typically be 7-10 days, with monitoring of renal, auditory, and vestibular functions if extended beyond 10 days. 8