By the bioMérieux Connection Editors
Each year in the United States, nearly half a million people receive medical care for burn injuries, and around 40,000 require hospitalization, according to the American Burn Association. Patients who are admitted to the hospital with large burn injuries are at especially high risk for developing hospital-associated infections, and the longer a patient stays in the hospital, the more likely they are to acquire a resistant infection.
While cuts, scrapes, and other types of wounds may also become infected, burns present special challenges. Besides the significant loss of or damage to the skin—the body’s natural physical barrier against infection—severe burn injuries can lead to issues with a patient’s immune system that increase the risk of infection. People who have suffered a severe burn may have lung injuries related to smoke inhalation, as well as the infection risks that come with intubation, use of urinary catheters, and other measures that may be required during treatment.
Infections are the Leading Cause of Death Among Burn Patients.
Infections are the leading cause of death in patients with extensive burn injuries, with studies showing 42%-65% of burn deaths attributable to infection. The three most common types of infections in burn patients are pneumonia, urinary tract infections (UTI), and cellulitis (skin infection), according to the 2016 National Burn Repository Report.
In the first few days of hospitalization for burn injury, most infection-causing microbes are Gram-positive organisms that are more susceptible to antibiotics. However, as the length of hospital stay increases, patients are more likely to be infected with resistant, Gram-negative organisms, which may be difficult to treat.
Burn Patients are Uniquely Susceptible to Multidrug-Resistant Infections.
Antimicrobial-resistant pathogens that are especially concerning for burn patients include multidrug-resistant strains of P. aeruginosa, Acinetobacter baumanii, and Stenotrophomonas maltophilia, as well as methicillin-resistant S. aureus (MRSA). Healthcare facilities have also documented outbreaks of carbapenem-resistant Enterobacteriaceae in burn units. In one hospital, a comparison of respiratory infections in intensive care units found that 41% of isolates were multidrug-resistant, while only 14% were multidrug-resistant in other units.
While the severity and extent of a patient’s injuries often dictate length of hospital stay, a longer stay increases the risk of acquiring a multidrug-resistant infection for the patient. Further, studies indicate that burn center length of stay is also a risk factor. The same risk factors for multidrug-resistant infections that exist for other types of patients also affect burn patients. Chiefly, those include previous antibiotic exposure and use of invasive medical devices such as urinary catheters.
Infection Control Practices, Antimicrobial Stewardship Programs, and Diagnostics Help Prevent, Screen, Diagnose, Treat, and Monitor Burn Patients.
Standard infection control procedures like hand hygiene, environmental cleaning/disinfection, evaluation of invasive device need and early removal, and other practices all help reduce healthcare-acquired infections, including those that are drug-resistant.
Diagnosing infections in burn patients is often complex. Multiple pathogens may be involved, and one study found that a single quantitative swab or biopsy may not reveal all organisms. Recognizing sepsis in burn patients is also challenging because many of the symptoms of sepsis are already present in burn patients who do not have any infection. Because of the high rates of multidrug-resistant pathogens in burn units, patients may benefit from rapid diagnostics that indicate the presence or absence of multidrug-resistance, both for screening purposes and infection diagnosis.
Treatment prior to identifying the infecting pathogen depends on a combination of clinical signs and symptoms, the patient’s lab results, and environmental factors such as the most common pathogens in the hospital’s burn unit. The local burn unit’s antibiogram (a report that shows how often specific bacterial species are susceptible to specific antibiotics) may be much different from the rest of the hospital, so it is important that physicians have that knowledge when considering treatment options.
Hospital antimicrobial stewardship programs (ASPs) can help improve prescribing practices and identify resistance patterns. Additionally, the International Society for Burn Injury recommends that burn centers utilize local ASPs to track patient outcomes and antimicrobial resistance specifically among hospital burn patients. A multidisciplinary approach that includes infectious diseases specialists, pharmacists, and burn surgeons is essential to improve patient outcomes and reduce the spread of antimicrobial resistance.
Opinions expressed in this article are not necessarily those of bioMérieux, Inc.