Treatment of infection in burns
Infections remain a leading cause of death in burn patients. For patients with burn size greater than 40 % TBSA, 75 % of all deaths are due to infection [1]. Many features unique to burn patients make diagnosis and management of infection especially diffi
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Department of Dermatology and Allergy, Ludwig Maximilian University, Munich, Germany Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Department of Surgery, Division of Plastic Surgery, University of Toronto, ON, Canada
Introduction Infections remain a leading cause of death in burn patients. For patients with burn size greater than 40 % TBSA, 75 % of all deaths are due to infection [1]. Many features unique to burn patients make diagnosis and management of infection especially difficult. Burn injury represents the most extreme endpoint along the spectrum of traumatic injury and as such is associated with profound alterations in host defense mechanisms and immune function. These derangements predispose thermally injured patients to local and systemic invasion by microbial pathogens. The burn wound represents a susceptible site for opportunistic colonization by organisms of endogenous and exogenous origin. A broad variety of patient factors such as age, immunosuppressed status, extent of injury, and depth of burn in combination with microbial factors such as type and number of organisms, enzyme and toxin production and motility determine the likelihood of invasive burn wound infection. Burn wound infections can be classified on the basis of the causative organism, the depth of invasion, and the tissue response. Diagnostic procedures and therapy must be based on an understanding of the pathophysiology of the burn wound and the pathogenesis of the various forms of burn wound infection. The purpose of this chapter is to depict the diagnosis and management of burn wound infections,
helping to provide the burn surgeon with a clinical guide to assist in clinical judgment.
Clinical management strategies Many of the clinical signs and symptoms used to diagnose infection in other settings are unreliable in the burn intensive care unit since they are often present even in the absence of true underlying infection. Advances in critical care such as earlier resuscitation and support of the hypermetabolic response have decreased burn mortality, but infections are still pervasive in severely burned patients and account for significant morbidity and mortality. With regards to burn wound infection, the cornerstone of management continues to be aggressive early debridement of devitalized and infected tissue. Unfortunately, burn patients are rapidly colonized by nosocomial pathogens and foci of invasive infection must be identified and treated quickly with appropriate antimicrobial therapy. Additionally, other potential foci for invasive infection include the tracheobronchial tree, the lungs, the gastrointestinal tract, central venous catheters and the urinary tract. Once an infection is disseminated hematogenously and becomes established in a burn patient, it is very difficult to eradicate, even with large does of broad-spectrum antimicrobial therapy. Traditional thinking would argue for beginning broad-spectrum coverage at the first
221 Marc G. Jeschke et al. (eds.), Handbook of Burns © Springer-Verlag/Wien 2012
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