Systemic Antibiotics

In the past, streptococcal cellulitus was a frequent early complication of burn injury and, therefore, intravenous penicillin was recommended to be given on a prophylactic basis for the first three to five days postburn (27). However, the use of early prophylactic antibiotics may not prevent infection and may be harmful and establish resistant flora (28). It is, therefore, recommended that systemic antimicrobial agents should be administered only when systemic infection is strongly suspected and should be based on the information gained whenever possible from bacteriologic cultures. Because anaerobic bacteria frequently are associated with burns especially in areas adjacent to the mucous membrane surfaces, the physician should consider their presence when a local or systemic invasive involvement by these organisms is present.

Using appropriate aerobic and anaerobic microbiological techniques in monitoring the bacterial colonization of burns can help the physician select proper therapy if complications occur. The presence of penicillin-resistant anaerobic bacteria may warrant the administration of appropriate antimicrobials for the organisms, including such agents as clindamycin, chlor-amphenicol, cefoxitin, metronidazole, a carbapenem, or the combination of a beta-lactamase inhibitor and a penicillin. Local debridement of the wound should be done with application of local therapy of silver sulfadiazine 1%, mafenide acetate, or aqueous silver nitrate 0.5% (28).

In cases of invasive burn wound sepsis or septicemia, the wound should be examined, and a meticulous search made for subeschar abscesses. If no abscesses are found, multiple incisions through the eschar are made, to provide open drainage and to allow the antibacterial cream access to the deeper tissues.

General supportive measures should include evaluation of other sources of invasion (urinary tract infection, thrombophlebitis, pneumonia, etc.) as indications for intravenous fluid therapy and ventilatory assistance.

Broad-spectrum antibiotics should be administered parenterally until culture reports are available. This includes an aminoglycoside, a fourth-generation cephalosporin effective against Pseudomonas such as cefepime for coverage of enteric gram-negative rods, and a synthetic penicillin or cephalosporin for coverage of beta-hemolytic streptococci, enterococci, and S. aureus. If anaerobes are suspected, adequate coverage should include one of the agents previously mentioned. Broad-spectrum antimicrobial therapy should be used with caution, as it may have the untoward effect of predisposing to superinfection by yeast, fungi, or resistant organisms. Antibiotics should be used long enough to produce an effect but not long enough to allow for emergence of opportunistic or resistant organisms.

Burn patients have altered antibiotics pharmacokinetics due to the multiple burn-related pathophysiologic changes (29). These differences must be considered in the selection of agent(s) and their optimal dosage. Patients who are not immunized against tetanus should have both active and passive immunization. Intravenous immunoglobulin and hyperimmunoglobulin G against P. aeruginosa and S. aureus has been used as adjunctive treatment for septicemia in burn patients with beneficial effect (30,31). Viral infections (Herpes simplex and cytomegaloviruses) can complicate burn infections.

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