Is there a role for empiric antibiotics in patients with burns?

From the Guidelines

Empiric antibiotics should not be routinely administered prophylactically to burn patients, but rather reserved for specific situations where there is a high suspicion of infection or sepsis, as supported by the most recent guidelines 1. The use of empiric antibiotics in burn patients is a complex issue, and the decision to administer them should be based on a thorough assessment of the patient's condition. According to the Surviving Sepsis Campaign guidelines, sustained systemic antimicrobial prophylaxis is not recommended for patients with severe inflammatory states of noninfectious origin, such as burn injury 1.

Key considerations for the use of empiric antibiotics in burn patients include:

• The presence of signs of infection, such as fever, increased pain, or change in wound appearance
• The extent of the burn, with patients having >40% total body surface area being at higher risk of infection
• The need for mechanical ventilation, which increases the risk of pneumonia and other infections
• The presence of sepsis or septic shock, which requires prompt and effective antibiotic therapy

When empiric antibiotics are necessary, the choice of agent should be guided by the likely pathogens involved and the patient's individual risk factors. Coverage should include gram-positive organisms, such as Staphylococcus aureus, with agents like cefazolin or vancomycin, and gram-negative organisms, with agents like piperacillin-tazobactam or cefepime.

The duration of antibiotic therapy should be based on the clinical response and culture results, typically ranging from 7-10 days. It is essential to narrow the antibiotic spectrum as soon as possible to minimize the risk of resistant organisms and other adverse effects.

Proper wound care, early excision and grafting, and infection control measures are the cornerstones of preventing infection in burn patients, and empiric antibiotics should be used judiciously and only when necessary, as supported by the most recent evidence 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of meropenem for injection and other antibacterial drugs, meropenem for injection should only be used to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy

The role of empiric antibiotics in burn patients is not directly addressed in the provided drug labels. However, the labels suggest that empiric therapy can be considered in certain situations, such as:

• In the absence of culture and susceptibility information, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy 2
• For febrile neutropenic patients, empiric therapy with cefepime can be considered 3 It is essential to note that the decision to use empiric antibiotics should be made cautiously and based on the individual patient's situation, taking into account the risk of developing drug-resistant bacteria.
• Burn patients may require empiric antibiotics in certain situations, but the decision should be made on a case-by-case basis, considering the severity of the burn, the presence of signs of infection, and the local epidemiology of antibiotic-resistant organisms.
• Key considerations include the potential benefits and risks of empiric antibiotic therapy, as well as the need for careful monitoring and adjustment of therapy based on culture and susceptibility results.

From the Research

Role of Empiric Antibiotics in Burn Patients

• The use of empiric antibiotics in burn patients is a topic of ongoing debate, with some studies suggesting a potential role in preventing infection and sepsis 4, 5.
• A prospective study published in 2017 found that empirical systemic antibiotics were effective in preventing infection in burn patients, with Pseudomonas being the most common organism responsible for bacteraemia 4.
• However, another study published in 2019 highlighted the importance of preventative over therapeutic strategies in managing multi-drug resistant (MDR) infections in burn patients, suggesting that targeted, limited use of antimicrobials can be beneficial 5.
• A review of current findings and guidelines on the early detection of infection and sepsis in severe burns emphasized the need for improved understanding and appropriate application of diagnostic criteria and assays to provide effective care 6.
• A systematic review published in 2013 found that topical silver sulfadiazine was associated with a significant increase in burn wound infection and longer length of hospital stay, while systemic antibiotic prophylaxis had no effect on rates of burn wound infection 7.
• Current practices in burn care have increased survivability even from massive burns, and initial evaluation and treatment of acute severe burn injury remains an ongoing area of study 8.

Key Findings

• Pseudomonas is a common organism responsible for bacteraemia in burn patients, with high resistance to commonly used antibiotics 4.
• MDR infections are a significant challenge in burn patients, and preventative strategies are crucial in minimizing morbidity and mortality 5.
• Early detection of infection and sepsis is critical in providing effective care for burn patients, and improved understanding of diagnostic criteria and assays is needed 6.
• Topical silver sulfadiazine is not recommended due to its association with increased burn wound infection and longer length of hospital stay 7.
• Systemic antibiotic prophylaxis may have a role in preventing pneumonia, but its effectiveness in preventing burn wound infection is unclear 7.