What is the best course of treatment for a patient with an infected second-degree burn?

Management of Infected Second-Degree Burns

For an infected second-degree burn, initiate systemic antibiotics targeting polymicrobial flora (Gram-positive, Gram-negative, and anaerobes), perform surgical debridement of necrotic tissue, obtain bacterial cultures to guide antibiotic selection, and apply appropriate wound dressings—while recognizing that altered pharmacokinetics in burn patients require adjusted antibiotic dosing. 1

Immediate Assessment and Culture

• Obtain bacterial cultures immediately before starting antibiotics to identify pathogens and guide therapy, as burn wound infections are typically polymicrobial 1
• Look for clinical signs of infection: increased pain beyond expected levels, redness extending beyond burn margins, swelling, purulent discharge, and systemic signs including fever 2, 3
• Recognize that burn wounds are initially sterile but become colonized by Gram-positive bacteria from skin flora, then rapidly colonized by Gram-negative bacteria within one week of injury 1

Surgical Management

Surgical debridement is necessary to remove necrotic tissue and mechanically reduce pathogen burden 1

• Early excision of eschar substantially decreases the incidence of invasive burn wound infection 1
• Debride down to a clean ulcer base, removing all necrotic tissue 1
• This is the cornerstone of treatment and must not be delayed 1

Antibiotic Therapy

Critical distinction: Prophylactic antibiotics are NOT recommended for uninfected burns, but established infections require immediate systemic antibiotics 2, 1

Empiric Coverage

• Start broad-spectrum antibiotics covering polymicrobial flora: Gram-positive (including S. aureus, Enterococcus), Gram-negative (E. coli, Pseudomonas, Proteus), and anaerobes (Bacteroides, Clostridium) 1
• Consider MRSA coverage based on local epidemiology (areas with >20% MRSA in hospital isolates) or specific patient risk factors 1

Dosing Considerations

• Adjust antibiotic dosing to account for altered pharmacokinetic parameters in burn patients to maximize efficacy 1
• Burn patients have increased volume of distribution and enhanced renal clearance requiring higher doses 1

Culture-Directed Therapy

• Narrow antibiotic spectrum once culture results and sensitivities return 1
• Monitor for antibiotic-resistant organisms, which are common in burn units 4

Topical Antimicrobial Therapy

Topical antibiotics should be reserved for infected wounds only, not used prophylactically 2

Silver Sulfadiazine

• Apply once to twice daily to a thickness of approximately 1/16 inch 5
• Continue until satisfactory healing or wound is ready for grafting 5
• Avoid prolonged use on superficial second-degree burns as it is associated with delayed healing 2, 3

Mafenide Acetate

• Consider for deep second-degree burns with established infection 6
• Monitor acid-base balance closely, particularly in patients with extensive burns or pulmonary/renal dysfunction, as it inhibits carbonic anhydrase 6
• Use with caution in patients with acute renal failure 6

Wound Dressing Management

• Change dressings daily and reassess wound at each change 2, 3
• Use antiseptic dressings for contaminated or infected burns 2, 3
• Consider silver-impregnated dressings (Silvercel, Aquacell-Ag) to control infection while managing edema and exudate 4
• Vacuum-assisted closure with simultaneous antibiotic solution application may be beneficial for invasive wound infections 4

Infection Control Measures

• Implement strict infection control practices: physical isolation in private room, use of gloves and gowns during patient contact 4
• Perform routine microbial burn wound cultures for surveillance 4
• Monitor for nosocomial infections including urinary tract and bloodstream infections, which are now more common than wound infections in burn patients 4

Special Considerations for High-Risk Burns

Burns on feet, hands, face, or genitalia require specialized burn center consultation regardless of size 2, 3, 7

• These locations carry higher risk of functional impairment and infection complications due to contamination risk 2
• Burns involving >10% body surface area in adults (>5% in children) should be treated in specialized burn centers 2, 3

Critical Pitfalls to Avoid

• Do not use prophylactic antibiotics on uninfected burns—this promotes multidrug-resistant bacteria 2, 1
• Do not delay surgical debridement while waiting for culture results 1
• Do not use standard antibiotic dosing—burn patients require adjusted doses due to altered pharmacokinetics 1
• Avoid breaking intact blisters on uninfected areas, as this increases infection risk 2, 3
• Do not apply ice, butter, or oil to infected burns 2, 3, 7

Monitoring and Follow-up

• Monitor for fungal colonization, which may occur with reduction of bacterial growth, though systemic fungal infection is rare 6
• Watch for signs of sepsis: hypotension, tachycardia, altered mental status, oliguria 1
• Continue treatment until satisfactory healing occurs or wound is ready for grafting 5