What are the primary recommendations for burn prophylaxis and anabolic therapy in burn patients?

Burn Prophylaxis Antibiotic Therapy

Primary Recommendation

Systemic antibiotic prophylaxis should NOT be administered routinely to burn patients due to lack of proven benefit and significant risk of selecting multidrug-resistant bacteria, particularly MRSA. 1, 2, 3

Core Principles of Infection Prevention

The cornerstone of burn infection prevention is early surgical excision of necrotic tissue and eschar, not prophylactic antibiotics. 2 This surgical approach, combined with proper wound care, provides superior infection prevention compared to any antibiotic regimen.

When Systemic Antibiotic Prophylaxis Should Be Avoided

• Routine prophylaxis in non-ventilated burn patients: Multiple randomized trials demonstrate no reduction in infection rates, and one study showed a 2.22-fold increase in MRSA rates when non-absorbable antibiotics plus cefotaxime were used. 2, 3
• Prolonged prophylaxis beyond 24 hours post-surgery: Treatment duration should be limited to no more than 24 hours after adequate source control in the absence of clinical signs of active infection. 2
• Topical silver sulfadiazine as routine prophylaxis: Meta-analysis of 11 trials (645 participants) showed silver sulfadiazine significantly increased burn wound infection rates (OR = 1.87; 95% CI: 1.09 to 3.19) and prolonged hospital stay by 2.11 days compared to dressings/skin substitutes. 4

Limited Exceptions Where Prophylaxis May Be Considered

Mechanically Ventilated Burn Patients

• Trimethoprim-sulfamethoxazole prophylaxis may reduce pneumonia risk in mechanically ventilated patients (RR = 0.18; 95% CI: 0.05 to 0.72), though this is based on one small study of 40 patients. 2, 4
• A Japanese cohort study suggested systemic prophylaxis might decrease mortality risk in this specific subgroup. 1

Perioperative Prophylaxis for Skin Grafting

• Single-dose perioperative prophylaxis may be considered for skin grafting procedures, but should be limited to the surgical procedure itself. 2
• This is not indicated for excision-graft surgery in the first 48 hours, which is rarely performed. 1

Treatment of Confirmed Infections (Not Prophylaxis)

When infection is clinically evident, the approach differs entirely from prophylaxis:

Antibiotic Selection Strategy

• Culture-directed therapy is mandatory: Selection must be based on bacterial cultures, not empirical guessing. 2, 5
• Initial broad-spectrum coverage: Cover both Gram-positive and Gram-negative facultative organisms plus anaerobes until cultures return. 2

Specific Oral Antibiotic Options for Confirmed Infections

For Staphylococcus aureus (including MRSA):

• Dicloxacillin, cefalexin, clindamycin, doxycycline, or sulfamethoxazole-trimethoprim 2, 5

For contaminated wounds (animal/human bites):

• Amoxicillin-clavulanic acid is preferred 2, 5

For diabetic patients with mild infected burns:

• Dicloxacillin, clindamycin, cefalexin, levofloxacin, amoxicillin-clavulanic acid, or doxycycline 2, 5

Duration of Treatment

• Time-limited approach: No more than 24 hours after adequate source control if no active infection signs persist. 2
• Source control (adequate debridement and removal of necrotic tissue) is more important than antibiotic duration. 2, 5

Critical Dosing Considerations

Standard antibiotic doses are often inadequate in burn patients due to altered pharmacokinetics from hypermetabolic state and augmented renal clearance. 2 For broad-spectrum beta-lactams specifically:

• High doses are required to achieve adequate PK/PD targets. 6
• Continuous infusion is preferred over intermittent dosing for beta-lactams like meropenem, piperacillin-tazobactam, ceftazidime, and cefepime. 6
• Therapeutic drug monitoring should guide dosing when available. 6

Nutritional Support (Anabolic Therapy)

Early Nutritional Intervention

Start nutritional support within 12 hours after burn injury via oral or enteral routes (preferred over parenteral). 1 This timing is associated with:

• Attenuation of neuro-hormonal stress response and hypermetabolic response 1
• Increased immunoglobulin production 1
• Reduced incidence of stress ulcers 1
• Reduced risk of energy and protein deficiency 1

Specific Nutritional Requirements

Energy requirements:

• Adults: Use Toronto formula 1
• Children: Use Schofield formula 1

Protein requirements:

• Adults: 1.5–2 g/kg/day 1
• Children: Up to 3 g/kg/day 1

Glutamine supplementation:

• Associated with reduced gram-negative bacteremia, shorter hospital length of stay, and decreased hospital mortality 1

Micronutrient supplementation:

• Vitamins B, C, D, and E should be supplemented early in both adults and children, as oral/enteral nutrition cannot cover the high micronutrient requirements of burn patients 1

Common Pitfalls to Avoid

Distinguishing Colonization from Infection

Burn wounds become colonized within days, but colonization does not equal infection. 2, 3 Obtaining bacterial cultures when infection is suspected guides appropriate therapy rather than treating colonization. 2

Inadequate Source Control

Failure to adequately debride and remove necrotic tissue is more detrimental than any antibiotic choice. 2, 3 Daily wound assessment with dressings evaluated daily for signs of infection is essential. 2, 5

Resistance Development

Routine prophylaxis significantly increases antimicrobial resistance, particularly MRSA, and should be avoided to preserve antibiotic effectiveness for when true infections occur. 2, 3, 4