Burn wound infection and sepsis
- Gerd G Gauglitz, MMS, MD
Gerd G Gauglitz, MMS, MD
- Department of Dermatology and Allergology
- Ludwig Maximilians University, Munich, Germany
- Shahriar Shahrokhi, MD, FRCSC, FACS
Shahriar Shahrokhi, MD, FRCSC, FACS
- Attending Surgeon, Ross Tilley Burn Centre
- Sunnybrook Health Sciences Centre
- Assistant Professor, University of Toronto
- Division of Plastic and Reconstructive Surgery
- Felicia N Williams, MD
Felicia N Williams, MD
- Assistant Professor
- Department of Surgery
- North Carolina Jaycee Burn Center
Infection remains the most common cause of morbidity and mortality in burn patients. The diagnosis and management of burn wound infection remains challenging due to the many physiologic features unique to burn injury. A variety of factors increase the risk of developing burn wound infection, and individuals who sustain a severe burn have a particularly high risk for burn wound sepsis.
Any rapid change in the burn wound appearance or the clinical condition of the burn patient may herald burn wound infection or sepsis. The different categories of burn wound infection are characterized based on clinical features and depth of invasion, which is determined through cultures and histopathology of tissue obtained by burn wound biopsy. A diagnosis of burn wound infection relies on the demonstration of >105 bacteria per gram tissue (or recovery of mold or yeast by culture). Specific criteria that include the presence of microbial invasion into adjacent normal tissue, among other criteria, have been suggested by the American Burn Association (ABA) to define burn wound sepsis.
The most common organisms remain Staphylococcus and Pseudomonas; however, the epidemiology of burn wound infections has changed with time and also depends on geography. It is imperative to be aware of the flora and susceptibility of organisms in each burn unit to be able to treat burn wound infections effectively.
Depending upon the burn wound category, treatment of burn wound infection/sepsis consists of a combination of wound cleansing, debridement, topical or systemic antimicrobial therapy, and burn wound debridement or excision.
The clinical manifestations, diagnosis, and treatment of burn wound infection and sepsis are reviewed here. Sepsis related to other conditions is reviewed elsewhere. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Sørensen B, Fisker NP, Steensen JP, Kalaja E. Acute excision or exposure treatment? Final results of a three-year randomized controlled clinical trial. Scand J Plast Reconstr Surg 1984; 18:87.
- Herndon DN, Barrow RE, Rutan RL, et al. A comparison of conservative versus early excision. Therapies in severely burned patients. Ann Surg 1989; 209:547.
- Posluszny JA Jr, Conrad P, Halerz M, et al. Surgical burn wound infections and their clinical implications. J Burn Care Res 2011; 32:324.
- Pruitt BA Jr, McManus AT, Kim SH, Goodwin CW. Burn wound infections: current status. World J Surg 1998; 22:135.
- Richards C, Emori TG, Edwards J, et al. Characteristics of hospitals and infection control professionals participating in the National Nosocomial Infections Surveillance System 1999. Am J Infect Control 2001; 29:400.
- Fitzwater J, Purdue GF, Hunt JL, O'Keefe GE. The risk factors and time course of sepsis and organ dysfunction after burn trauma. J Trauma 2003; 54:959.
- Branski LK, Al-Mousawi A, Rivero H, et al. Emerging infections in burns. Surg Infect (Larchmt) 2009; 10:389.
- Hospital and prehospital resources for optimal care of patients with burn injury: guidelines for development and operation of burn centers. American Burn Association. J Burn Care Rehabil 1990; 11:98.
- Erol S, Altoparlak U, Akcay MN, et al. Changes of microbial flora and wound colonization in burned patients. Burns 2004; 30:357.
- Church D, Elsayed S, Reid O, et al. Burn wound infections. Clin Microbiol Rev 2006; 19:403.
- Altoparlak U, Erol S, Akcay MN, et al. The time-related changes of antimicrobial resistance patterns and predominant bacterial profiles of burn wounds and body flora of burned patients. Burns 2004; 30:660.
- Schultz L, Walker SA, Elligsen M, et al. Identification of predictors of early infection in acute burn patients. Burns 2013; 39:1355.
- Öncül O, Öksüz S, Acar A, et al. Nosocomial infection characteristics in a burn intensive care unit: analysis of an eleven-year active surveillance. Burns 2014; 40:835.
- Barret JP, Herndon DN. Effects of burn wound excision on bacterial colonization and invasion. Plast Reconstr Surg 2003; 111:744.
- Alexander JW. Mechanism of immunologic suppression in burn injury. J Trauma 1990; 30:S70.
- Griswold JA. White blood cell response to burn injury. Semin Nephrol 1993; 13:409.
- Hansbrough JF, Field TO Jr, Gadd MA, Soderberg C. Immune response modulation after burn injury: T cells and antibodies. J Burn Care Rehabil 1987; 8:509.
- Heideman M, Bengtsson A. The immunologic response to thermal injury. World J Surg 1992; 16:53.
- Halstead FD, Rauf M, Moiemen NS, et al. The Antibacterial Activity of Acetic Acid against Biofilm-Producing Pathogens of Relevance to Burns Patients. PLoS One 2015; 10:e0136190.
- Halstead FD, Rauf M, Bamford A, et al. Antimicrobial dressings: Comparison of the ability of a panel of dressings to prevent biofilm formation by key burn wound pathogens. Burns 2015; 41:1683.
- Silver dressings--do they work? Drug Ther Bull 2010; 48:38.
- Guggenheim M, Zbinden R, Handschin AE, et al. Changes in bacterial isolates from burn wounds and their antibiograms: a 20-year study (1986-2005). Burns 2009; 35:553.
- Rezaei E, Safari H, Naderinasab M, Aliakbarian H. Common pathogens in burn wound and changes in their drug sensitivity. Burns 2011; 37:805.
- Azzopardi EA, Azzopardi SM, Boyce DE, Dickson WA. Emerging gram-negative infections in burn wounds. J Burn Care Res 2011; 32:570.
- Greenhalgh DG, Saffle JR, Holmes JH 4th, et al. American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res 2007; 28:776.
- D'Avignon LC, Saffle JR, Chung KK, Cancio LC. Prevention and management of infections associated with burns in the combat casualty. J Trauma 2008; 64:S277.
- Miranda BH, Ali SN, Jeffery SL, Thomas SS. Two stage study of wound microorganisms affecting burns and plastic surgery inpatients. J Burn Care Res 2008; 29:927.
- Wibbenmeyer LA, Kealey GP, Latenser BA, et al. Emergence of the USA300 strain of methicillin-resistant Staphylococcus aureus in a burn-trauma unit. J Burn Care Res 2008; 29:790.
- Pruitt BA Jr. The diagnosis and treatment of infection in the burn patient. Burns Incl Therm Inj 1984; 11:79.
- Foley FD, Greenawald KA, Nash G, Pruitt BA Jr. Herpesvirus infection in burned patients. N Engl J Med 1970; 282:652.
- Pruitt BA Jr, Lindberg RB, McManus WF, Mason AD Jr. Current approach to prevention and treatment of Pseudomonas aeruginosa infections in burned patients. Rev Infect Dis 1983; 5 Suppl 5:S889.
- Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2.
- Jeschke MG, Gauglitz GG, Kulp GA, et al. Long-term persistance of the pathophysiologic response to severe burn injury. PLoS One 2011; 6:e21245.
- Jeschke MG, Chinkes DL, Finnerty CC, et al. Pathophysiologic response to severe burn injury. Ann Surg 2008; 248:387.
- Ren H, Li Y, Han C, Hu H. Serum procalcitonin as a diagnostic biomarker for sepsis in burned patients: a meta-analysis. Burns 2015; 41:502.
- Lavrentieva A, Papadopoulou S, Kioumis J, et al. PCT as a diagnostic and prognostic tool in burn patients. Whether time course has a role in monitoring sepsis treatment. Burns 2012; 38:356.
- Clec'h C, Fosse JP, Karoubi P, et al. Differential diagnostic value of procalcitonin in surgical and medical patients with septic shock. Crit Care Med 2006; 34:102.
- Quantitative Bacteriology: Its Role in the Armamentarium of the Surgeon, 1st ed, Heggers JP, Robson MC, Phillips LG, et al. (Eds) (Eds), CRC Press, Boca Raton, FL 1991.
- McManus AT, Kim SH, McManus WF, et al. Comparison of quantitative microbiology and histopathology in divided burn-wound biopsy specimens. Arch Surg 1987; 122:74.
- Pruitt BA Jr, McManus AT. The changing epidemiology of infection in burn patients. World J Surg 1992; 16:57.
- De Pauw B, Walsh TJ, Donnelly JP, et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis 2008; 46:1813.
- Kallstrom G. Are quantitative bacterial wound cultures useful? J Clin Microbiol 2014; 52:2753.
- Mann-Salinas EA, Baun MM, Meininger JC, et al. Novel predictors of sepsis outperform the American Burn Association sepsis criteria in the burn intensive care unit patient. J Burn Care Res 2013; 34:31.
- van Duin D, Strassle PD, DiBiase LM, et al. Timeline of health care-associated infections and pathogens after burn injuries. Am J Infect Control 2016; 44:1511.
- Khundkar R, Malic C, Burge T. Use of Acticoat dressings in burns: what is the evidence? Burns 2010; 36:751.
- Nash G, Foley FD, Goodwin MN Jr, et al. Fungal burn wound infection. JAMA 1971; 215:1664.
- Spebar MJ, Walters MJ, Pruitt BA Jr. Improved survival with aggressive surgical management of noncandidal fungal infections of the burn wound. J Trauma 1982; 22:867.
- Cancio LC, Howard PA, McManus AT, et al. Burn wound infections. In: Surgical Treatment: Evidence-Based and Problem Oriented, Holzheimer RG, Mannick JA (Eds), Zuckschwerdt, 2001. p.NBK6970.
- Greenhalgh DG. Topical antimicrobial agents for burn wounds. Clin Plast Surg 2009; 36:597.
- Avni T, Levcovich A, Ad-El DD, et al. Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ 2010; 340:c241.
- Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H. Topical silver for preventing wound infection. Cochrane Database Syst Rev 2010; :CD006478.
- Vermeulen H, van Hattem JM, Storm-Versloot MN, Ubbink DT. Topical silver for treating infected wounds. Cochrane Database Syst Rev 2007; :CD005486.
- Jull AB, Rodgers A, Walker N. Honey as a topical treatment for wounds. Cochrane Database Syst Rev 2008; :CD005083.
- Aikins K, Prasad N, Menon S, et al. Pediatric burn wound impetigo after grafting. J Burn Care Res 2015; 36:e41.
- http://www.cdc.gov/hicpac/2007IP/2007ip_appendA.html (Accessed on February 12, 2015).
- Ballard J, Edelman L, Saffle J, et al. Positive fungal cultures in burn patients: a multicenter review. J Burn Care Res 2008; 29:213.
- Moore EC, Padiglione AA, Wasiak J, et al. Candida in burns: risk factors and outcomes. J Burn Care Res 2010; 31:257.
- Struck MF, Stiller D, Corterier CC, et al. Fulminant, undetected Candida sepsis after an apparently survivable burn injury. J Burn Care Res 2009; 30:894.
- Horvath EE, Murray CK, Vaughan GM, et al. Fungal wound infection (not colonization) is independently associated with mortality in burn patients. Ann Surg 2007; 245:978.
- EPIDEMIOLOGY AND RISK FACTORS
- Risk factors
- CLINICAL FEATURES
- Physical examination
- - Burn wound appearance
- - Systemic signs
- Laboratory findings
- Tissue biopsy and histopathology
- Burn wound categories
- - Wound colonization
- - Noninvasive infection
- - Invasive infection
- American Burn Association criteria for burn wound sepsis
- DIFFERENTIAL DIAGNOSIS
- Medication-related mucocutaneous reactions
- Hypermetabolic response to thermal burn
- Other cause of sepsis
- Systemic antimicrobial therapy
- Local burn wound care
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS