What is the preferred topical antibiotic for burns, mupiricin (Mupirocin) or silver nitrate?

Topical Antimicrobial Selection for Burns: Neither Silver Nitrate Nor Mupirocin Should Be Used Routinely

For burn wound management, topical antibiotics including both mupirocin and silver-containing agents should NOT be used as routine prophylaxis, as they provide no mortality benefit and may worsen outcomes. 1

Primary Recommendation: Avoid Topical Antibiotic Prophylaxis

• Topical antibiotics have no beneficial effects on reducing infection or mortality in burn patients, based on a comprehensive review of 36 randomized controlled trials involving 2,117 participants 1
• Silver sulfadiazine (the most commonly used silver-containing topical agent) is specifically associated with increased burn wound infection rates (OR 1.87,95% CI: 1.09-3.19) and longer hospital stays (mean difference 2.11 days) 1
• The 2020 Anaesthesia guidelines explicitly state that topical antibiotics should not be used as first-line treatment but should be dedicated to infected wounds only 2

When Topical Antimicrobials May Be Considered

For Established MRSA Infection (Not Prophylaxis)

If burn wounds become infected with methicillin-resistant Staphylococcus aureus (MRSA) despite appropriate wound care:

• Mupirocin 2% ointment can be used for documented MRSA burn wound infection in burns <20% total body surface area 3, 4
• Apply twice daily under occlusive dressings for a maximum of 5 days only 3
• Mupirocin achieves 98.3% reduction in intra-eschar viable MRSA organisms within 36 hours 4
• Safety and efficacy in burns >20% TBSA has not been established 3

For Minor Secondarily Infected Skin Lesions

• Mupirocin 2% topical ointment is appropriate for minor skin infections (impetigo) and secondarily infected lesions (eczema, ulcers, lacerations) in both adults and children 2
• This recommendation applies to infected skin lesions, not prophylaxis of clean burn wounds 2

Recommended Burn Wound Management Instead

Initial Burn Care (First 5-20 Minutes)

• Cool thermal burns immediately with clean running water for 5-20 minutes to reduce infection risk and promote healing 1
• Monitor children for hypothermia during cooling 1

Wound Dressing for Small Partial-Thickness Burns

For burns managed at home, apply:

• Petrolatum or petrolatum-based ointment 1
• Honey 1
• Aloe vera 1
• Cover with clean nonadherent dressing 1

For Larger or Complicated Burns

• Antiseptic dressings may be appropriate for large or contaminated burns 2
• Clean wounds with tap water, isotonic saline, or antiseptic solution before dressing 2
• Systemic antibiotic prophylaxis (not topical) has shown mortality benefit in burn patients 1

Critical Pitfalls to Avoid

• Do not use silver sulfadiazine for prolonged periods on superficial burns - it is associated with prolonged healing 2
• Do not use fusidic acid - WHO recommends against it as it provides no benefit and may contribute to antimicrobial resistance 1
• Do not delay wound care for antibiotic application - wound care should only be performed after adequate resuscitation 2
• Do not use mupirocin prophylactically - reserve it only for documented MRSA infection in limited burn areas 3

When to Seek Immediate Medical Care

Transfer to burn center or emergency services for: 1

• Burns involving face, hands, feet, or genitals
• Burns >10% body surface area in adults (>5% in children)
• Any signs of inhalation injury (facial burns, difficulty breathing, soot around nose/mouth)