Ramos GE. J Infectiology.

2018; 1(1): 1-5

Journal of Infectiology Journal of
Infectiology

Mini Review Open Access

Antibiotic Prophylaxis in Burn Patients: A Review of Current Trends and

Recommendations for Treatment
Guillermo Enrique Ramos*
Department of Intensive Care Medicine, Argerich Hospital, Buenos Aires City, Argentina

Article Info Abstract

Article Notes As nosocomial infections in burn patients are prevalent and dangerous,
Received: May 18, 2018 systemic antibiotic prophylaxis has been considered, beside other interventions.
Accepted: June 13, 2018 However, this kind of therapy has been questioned due to controversy related
*Correspondence:
to its effectiveness and complications, such as drug toxicity and development
Dr. Guillermo Enrique Ramos of multidrug-resistance. This review includes evidence reported during the
Intensive Care Unit, Argerich Hospital, Buenos Aires City, period 1966-2016. The quality of evidence and strength of recommendation of
Argentina; these guidelines are based on the GRADE system. Early post-burn prophylaxis
Email: [email protected] showed no effectiveness for toxic shock syndrome or burn wound infection
prevention (Grade 1C) in non-severe burn patients but it could be useful for
© 2018 Ramos GE. This article is distributed under the terms of
the Creative Commons Attribution 4.0 International License.
those who had severe burns and require mechanical ventilation (Grade 2B).
Perioperative prophylaxis would neither have indications for wound cleaning
 nor for devitalized tissue debridement of most burn patients (Grade 2B), but
there is not enough evidence to make a strong recommendation to those who
have extensive burns. Finally, prophylaxis could be used to prevent skin graft
infections in selected procedures (Grade 2B).

Introduction
Nosocomial infections are prevalent in burn patients and reach
rates of 10 to 20 per 1000 patient days in Burn Intensive Care Units1.
Healthcare-associated Infections remain a major cause of
potentially serious complications, and recurrent sepsis predisposes
to multiple organ failure, lengthens hospital stays, and increases
costs2. Therefore, improvements on infection prevention and
treatment are increasingly important.
Burn patients are susceptible to infections due to epithelial
barrier loss, hypermetabolic/ hypercatabolic states and
immunosuppression3. Moreover, vital organ support requires the
use of invasive procedures that undermine the body´s defense
even more. As a consequence, nosocomial infection rates, including
intravascular catheter-related infections and ventilator-associated
pneumonia, are reflected in the literature to be higher in Burn Units
than other Medical or Surgical Units4.
As nosocomial infections in burn patients have been shown to
be prevalent and life threatening, systemic antibiotic prophylaxis
has been considered, beside other interventions5, 6. However,
doubts about effectiveness and risk of complications, such as drug
toxicity and development of multidrug-resistance, have made its
recommendation controversial7-9.
In order to analyze this issue, the quality of evidence and strength

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of recommendation of these guidelines are based on the Severe burn patients

GRADE system and interventions are stratified according Multiple infectious sources can be identified in patients
to the following subgroups: period of prophylaxis, burn with major thermal injury and include central venous and
severity, age and type of procedures10. arterial catheters, urinary catheters, ventilator support, as
Early Post Burn Prophylaxis well as the burn wound itself.
Burn wound infections are closely related to morbidity
Non-severe burn patients
and mortality in severe burn patients. Thus preventing or
Toxic shock syndrome (TSS) is a rare, but life- delaying them is a desirable goal. Ugburo et al. conducted
threatening complication of early bacterial infection that a prospective randomized trial in adult patients, where 3
could be developed following any burn size. It is mediated groups were assigned; one without antibiotics, another
by exotoxin released mainly by Staphylococcus aureus or with ampicillin/cloxacillin within the first 6 hours and a
Streptococcus pyogenes. Although it can occur at any age, third one with erythromycin/gentamycin after the 3rd
it is more common in children because of their immune day and for 2 weeks. It was reported a great incidence of
immaturity11. In 2001, a single antibiotic dose protocol heavy colonization after the third day post burn. Systemic
(Flucloxacillin) was introduced for burned children at antibiotics neither prevented burn wound infection nor
referral emergency department with the aim of preventing delayed colonization or infection occurrence. Otherwise,
TSS12. As not many patients presented or developed TSS this study showed that the use of systemic antibiotics
during the protocol phase, therefore this study was not could be dangerous because it might favor the growth
conclusive in showing effectiveness. Recently, Mulgrew et of microorganisms of difficult eradication, such as P.
al. did not find morbidity differences in children using other aeruginosa18.
prophylaxis protocols (Flucloxacillin or Erythromycin for
5 days post burn) comparing intervention cohorts from In severe burn patients, endotoxemia has been
different period of time13. documented since early stages of burn originating in the
burn wound or the intestinal tract. Subtherapeutic doses
Burn wound infection predisposes the delay of of Polymyxin B have been reported to bind endotoxin. Two
epidermal maturation and the development of pathologic studies assessed Polymyxin B as systemic intravenous
scars. It also leads to microorganism’s invasion into prophylaxis during early post burn period. One of them
the tissue layers conditioning bacteremia, sepsis, and assessed the effect of immunological support, with
multiple-organ dysfunction2. As preventing wound burn Immunoglobulin G (IVIG), plus endotoxin binding, with
infection is essential, systemic antibiotic prophylaxis Polymyxin B, in severe burn at two pediatric burn centers
has been proposed, together with appropriate local during a period of five years19. Patients from Hospital A
management5, 6. Antibiotic prophylactic administration were treated with IVIG and low-dose Polymyxin B, whereas
was widely used, particularly in children, who have high patients from Hospital B were not. Outcome analysis had
rates of beta-hemolytic streptococci carriage, until many several limitations because of intercohort basal differences
trials highlighted its lack of effectiveness7. Sheridan et among hospitals. In spite of this, they described differences
al. published in 2001 a large study in pediatrics mild in sepsis episodes per patient (1.2 vs 1.9, p= 0.01) and
burned patients, with no wound infection differences hospital stays (77.1 vs 103.8 days, p= 0.04), but they did
being described using either Penicillin or Erythromycin not find differences in mortality.
versus no antibiotics in sequential intervention periods14.
Previously, two trials -Timmons et al. in children, and The other study compared only systemic Polymyxin B
Durtschi et al. in adults- had already reported low efficacy versus placebo in a prospective randomized trial at adult
in wound infection prophylaxis using the same antibiotics15, population20. Although it showed a reduction on endotoxin
16
. Recently, Chahed et al. using Amoxicillin-Clavulanic or levels either in perioperative or post burn injury, the data
Oxacillin as prophylaxis vs no prophylaxis have also shown was not strong enough to assess important clinical impact.
no wound infection shrinkage in pediatric burn patients at Another potential source of infection in severe burn
a prospective randomized single center trial17. patients is gastrointestinal tract. Translocation of bowel
As severe infections are uncommon in mild to moderate microorganisms due to increased intestinal permeability
burn patients and systemic antibiotic prophylaxis did not has been associated to burn wound colonization and
seem to affect the outcome, there is no current evidence infection21. In 1990 Deutsch et al. used erythromycin plus
to support its indication. Although most of the reported non absorbable gastrointestinal antibiotics -Neomycin and
trials have low quality score, the lack of prophylaxis Nystatin- in order to decontaminate the digestive tract
effectiveness was consistent across them. Consequently, and prevent wound infections. They showed not only lack
not using prophylactic antibiotics in this group should be of effectiveness, but risk due to an earlier P. aeruginosa
considered as a strong recommendation (Grade 1C). wound colonization22. Furthermore, intolerance was

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reported, being diarrhea the most common complication using cephalosporins, only in extensive burns29. Later,
that forced treatment suspension. In 2005, another article Rodgers et al. also described that cephalosporins were not
with selective digestive decontamination (SDD) in burn useful during procedures with non-extensive burns30. Steer
patients was published23. In this study, de la Cal et al. et al. also published a significant reduction in perioperative
combined non-absorbable antibiotics to decolonize the bacteremia rates using Teicoplanin as prophylaxis in
mouth and the gastrointestinal tract, with intravenous 1997, although no differences in clinical post-operative
third generation cephalosporin in Intensive Care Burn complications (fever with rigors, hypotension or severe
Unit. Strikingly, a reduction mostly at primary endogenous sepsis) were observed. Most of them were non-severe burn
infections (caused by microorganisms that were carried patients31.
in throat and/or gut upon admission), was shown. In this
Therefore, available evidence does not allow
trial, treatment with SDD was associated with a significant
recommending the use of prophylaxis for wound burn
reduction of early pneumonia and mortality. Pneumonia
cleaning or debridement. Nevertheless, there is not enough
has been described as one of the most common causes of
support to make any recommendations in severe burn
nosocomial infection in severely burned patients, and with
patients who require aggressive procedures (Grade 2B).
an attributable mortality rate of between 20% and 50%24.
As many centers in Japan had high incidence of Skin grafting
methicillin-resistant Staphylococcus aureus ventilator- Skin grafting represents the most rapid and effective
associated pneumonia, systemic prophylaxis method for closure of excised full-thickness burns. This
(Trimethoprim – Sulfamethoxazole) was used at Burn procedure may be unsuccessful because of numerous
Center. In this trial, Kimura et al. reported early pneumonia reasons, especially those that prevent temporary
decrease and trend towards reducing mortality25. Recently, anchors to the wound bed, like hematoma, seroma, graft
Tagami et al., analyzing a Japanese database, described displacement or poor recipient site (poor vasculature or
beneficial effects of antibiotics prophylaxis in a subgroup bacterial infection)32.
of severe burn patients who required early mechanical
ventilation (28-day in-hospital mortality)26. In 1990, Livingston et al. showed the efficacy of local
antimicrobial agents to improve graft takes in early
At this point we can conclude that systemic antibiotics tangential excision followed by skin grafting. Neomycin
in patients with severe burns and high risk of pneumonia plus Bacitracin was as effective as silver nitrate and more
may be indicated. However, trials neither showed an agreed effective than Ringer Lactate for non-extensive burns, but
antibiotic scheme nor evaluated consistently antimicrobial the antibiotics were associated with rapid emergence of
related risks, thus making a strong recommendation not drug-resistant organisms whereas silver nitrate was not33.
possible (Grade 2B).
Systemic prophylaxis to prevent skin grafted infections
Perioperative Prophylaxis was reported in many trials. In 1982, Alexander et al.
Perioperative prophylaxis is also a controversial issue, addressed the efficacy of cephalothin for prophylaxis of
particularly in severe burn patients who require multiple skin grafting procedures in reconstructive surgery. In
surgical procedures over several weeks in order to remove this trial, antibiotic prophylaxis was effective in reducing
devitalized tissue, to prepare the wound bed and to perform infections, graft loss and hospital stays34. However, skin
the split-thickness skin graft to heal the burn wound. graft was placed over surgical wound instead of burn
wound, with a considerable lower density of wound
Wound cleaning or debridement bacterial colonization.
Even though bacteremia could be released by any Few trials have evaluated the efficacy of systemic
wound intervention, those most prone to suffer it are: antibiotic prophylaxis for skin grafting surgeries in
extensive burn, late post burn procedure, heavy colonized acute wound burns. Alexander et al, in 1984, showed no
or infected wound and aggressive surgical procedure27. differences in graft takes with or without antibiotics35.
In order to restrain prophylaxis recommendations, A few years later, Griswold et al. reported less donor site
Mozingo et al. described a group with low risk of infection and a tendency to reduce skin graft infection in
perioperative bacteremia which included patients with those who received antibiotics, in a retrospective study36.
burns involving less than 40% of total burn surface area Another study described a non-significant skin graft
and procedure done during the first 10 post burn days28. infections reduction associated to Teicoplanin use, but
This criteria could exclude to great number of burn few procedures were included31. Ramos et al. described a
patients from prophylaxis, but this trial was not designed significant skin graft loss shrinkage when prophylaxis was
to evaluate prophylaxis efficacy in those with higher risk. In used. In this study, half of the burn wounds were colonized
1985, Piel et al. showed that bacteremia incidence lessened before grafting37. No other clinical outcome was assessed.

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We conclude that while prophylaxis might be effective in 12. Rashid A, Brown A, Khan K. On the use of prophylactic
preventing graft loss due to infection, its clinical relevance antibiotics in prevention of toxic shock syndrome. Burns.
2005; 31: 981–985.
in acute burns is not clearly demonstrated. Hence, systemic
antimicrobial prophylaxis for perioperative skin grafting 13. Mulgrew S, Khoo A, Cartwright R, et al. Morbidity in pediatric
should be considered as a weak recommendation. (Grade burns, toxic shock syndrome, and antibiotic prophylaxis: a
2B) retrospective comparative study. Ann Plast Surg. 2014; 72:
34-37. 
Conclusion 14. Sheridan R, Weber J, Pasternack M, et al. Antibiotic prophylaxis
Systemic antibiotic prophylaxis during early post-burn for group A streptococcal burn wound infection is not
necessary. J Trauma. 2001; 51: 352-355.
period would not have indication in most burn patients
but it could be useful in patients with severe burns and 15. Timmons M. Are systemic prophylactic antibiotics necessary
requirement of mechanical ventilation. Perioperative for burns. Ann R Coll Surg Engl. 1983; 65: 80-82.
prophylaxis during resection of devitalized tissue would 16. Durtschi M, Orgain C, Counts G, et al. A prospective study of
not have indications in most burn patients. However, there prophylaxic penicillin in acutely burned hospitalized patients.
is not enough evidence to make a recommendation on J Trauma. 1982; 22: 11-14.
extensive burns. Finally, prophylaxis could be useful for the 17. Chahed J, Ksia A, Selmi W, et al. Burns injury in children: is
prevention of split-thickness skin graft infection in selected antibiotic prophylaxis recommended?. Afr J Paediatr Surg.
procedures. 2014; 11: 323-325.

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