Current pharmacotherapy for the treatment of severe burns

Interventions for postburn pruritus

BACKGROUND

Postburn pruritus (itch) is a common and distressing symptom experienced on healing or healed burn or donor site wounds. Topical, systemic, and physical treatments are available to control postburn pruritus; however, it remains unclear how effective these are.

OBJECTIVES

To assess the effects of interventions for treating postburn pruritus in any care setting.

SEARCH METHODS

In September 2022, we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus. We also searched clinical trials registries and scanned references of relevant publications to identify eligible trials. There were no restrictions with respect to language, publication date, or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that enrolled people with postburn pruritus to compare an intervention for postburn pruritus with any other intervention, placebo or sham intervention, or no intervention.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 25 RCTs assessing 21 interventions with 1166 randomised participants. These 21 interventions can be grouped into six categories: neuromodulatory agents (such as doxepin, gabapentin, pregabalin, ondansetron), topical therapies (such as CQ-01 hydrogel, silicone gel, enalapril ointment, Provase moisturiser, beeswax and herbal oil cream), physical modalities (such as massage therapy, therapeutic touch, extracorporeal shock wave therapy, enhanced education about silicone gel sheeting), laser scar revision (pulsed dye laser, pulsed high-intensity laser, fractional CO2 laser), electrical stimulation (transcutaneous electrical nerve stimulation, transcranial direct current stimulation), and other therapies (cetirizine/cimetidine combination, lemon balm tea). Most RCTs were conducted at academic hospitals and were at a high risk of performance, attrition, and detection bias. While 24 out of 25 included studies reported change in burn-related pruritus, secondary outcomes such as cost-effectiveness, pain, patient perception, wound healing, and participant health-related quality of life were not reported or were reported incompletely. Neuromodulatory agents versus antihistamines or placebo There is low-certainty evidence that doxepin cream may reduce burn-related pruritus compared with oral antihistamine (mean difference (MD) -2.60 on a 0 to 10 visual analogue scale (VAS), 95% confidence interval (CI) -3.79 to -1.42; 2 studies, 49 participants). A change of 2 points represents a minimal clinically important difference (MCID). Due to very low-certainty evidence, it is uncertain whether doxepin cream impacts the incidence of somnolence as an adverse event compared to oral antihistamine (risk ratio (RR) 0.64, 95% CI 0.32 to 1.25; 1 study, 24 participants). No data were reported on pain in the included study. There is low-certainty evidence that gabapentin may reduce burn-related pruritus compared with cetirizine (MD -2.40 VAS, 95% CI -4.14 to -0.66; 1 study, 40 participants). A change of 2 points represents a MCID. There is low-certainty evidence that gabapentin reduces the incidence of somnolence compared to cetirizine (RR 0.02, 95% CI 0.00 to 0.38; 1 study, 40 participants). No data were reported on pain in the included study. There is low-certainty evidence that pregabalin may result in a reduction in burn-related pruritus intensity compared with cetirizine with pheniramine maleate (MD -0.80 VAS, 95% CI -1.24 to -0.36; 1 study, 40 participants). A change of 2 points represents a MCID. There is low-certainty evidence that pregabalin reduces the incidence of somnolence compared to cetirizine (RR 0.04, 95% CI 0.00 to 0.69; 1 study, 40 participants). No data were reported on pain in the included study. There is moderate-certainty evidence that ondansetron probably results in a reduction in burn-related pruritus intensity compared with diphenhydramine (MD -0.76 on a 0 to 10 numeric analogue scale (NAS), 95% CI -1.50 to -0.02; 1 study, 38 participants). A change of 2 points represents a MCID. No data were reported on pain and adverse events in the included study. Topical therapies versus relevant comparators There is moderate-certainty evidence that enalapril ointment probably decreases mean burn-related pruritus compared with placebo control (MD -0.70 on a 0 to 4 scoring table for itching, 95% CI -1.04 to -0.36; 1 study, 60 participants). No data were reported on pain and adverse events in the included study. Physical modalities versus relevant comparators Compared with standard care, there is low-certainty evidence that massage may reduce burn-related pruritus (standardised mean difference (SMD) -0.86, 95% CI -1.45 to -0.27; 2 studies, 166 participants) and pain (SMD -1.32, 95% CI -1.66 to -0.98). These SMDs equate to a 4.60-point reduction in pruritus and a 3.74-point reduction in pain on a 10-point VAS. A change of 2 VAS points in itch represents a MCID. No data were reported on adverse events in the included studies. There is low-certainty evidence that extracorporeal shock wave therapy (ESWT) may reduce burn-related pruritus compared with sham stimulation (SMD -1.20, 95% CI -1.65 to -0.75; 2 studies, 91 participants). This equates to a 5.93-point reduction in pruritus on a 22-point 12-item Pruritus Severity Scale. There is low-certainty evidence that ESWT may reduce pain compared with sham stimulation (MD 2.96 on a 0 to 25 pressure pain threshold (PPT), 95% CI 1.76 to 4.16; 1 study, 45 participants). No data were reported on adverse events in the included studies. Laser scar revision versus untreated or placebo controls There is moderate-certainty evidence that pulsed high-intensity laser probably results in a reduction in burn-related pruritus intensity compared with placebo laser (MD -0.51 on a 0 to 1 Itch Severity Scale (ISS), 95% CI -0.64 to -0.38; 1 study, 49 participants). There is moderate-certainty evidence that pulsed high-intensity laser probably reduces pain compared with placebo laser (MD -3.23 VAS, 95% CI -5.41 to -1.05; 1 study, 49 participants). No data were reported on adverse events in the included studies.

AUTHORS' CONCLUSIONS

There is moderate to low-certainty evidence on the effects of 21 interventions. Most studies were small and at a high risk of bias related to blinding and incomplete outcome data. Where there is moderate-certainty evidence, practitioners should consider the applicability of the evidence for their patients.

Biofilms: Formation, Research Models, Potential Targets, and Methods for Prevention and Treatment

Due to the continuous rise in biofilm-related infections, biofilms seriously threaten human health. The formation of biofilms makes conventional antibiotics ineffective and dampens immune clearance. Therefore, it is important to understand the mechanisms of biofilm formation and develop novel strategies to treat biofilms more effectively. This review article begins with an introduction to biofilm formation in various clinical scenarios and their corresponding therapy. Established biofilm models used in research are then summarized. The potential targets which may assist in the development of new strategies for combating biofilms are further discussed. The novel technologies developed recently for the prevention and treatment of biofilms including antimicrobial surface coatings, physical removal of biofilms, development of new antimicrobial molecules, and delivery of antimicrobial agents are subsequently presented. Finally, directions for future studies are pointed out.

Enzymatic Debridement of Porcine Burn Wounds via a Novel Protease, SN514

Necrotic tissue generated by a thermal injury is typically removed via surgical debridement. However, this procedure is commonly associated with blood loss and the removal of viable healthy tissue. For some patients and contexts such as extended care on the battlefield, it would be preferable to remove devitalized tissue with a nonsurgical debridement agent. In this paper, a proprietary debridement gel (SN514) was evaluated for the ability to debride both deep-partial thickness (DPT) and full-thickness burn wounds using an established porcine thermal injury model. Burn wounds were treated daily for 4 days and visualized with both digital imaging and laser speckle imaging. Strip biopsies were taken at the end of the procedure. Histological analyses confirmed a greater debridement of the porcine burn wounds by SN514 than the vehicle-treated controls. Laser speckle imaging detected significant increases in the perfusion status after 4 days of SN514 treatment on DPT wounds. Importantly, histological analyses and clinical observations suggest that SN514 gel treatment did not damage uninjured tissue as no edema, erythema, or inflammation was observed on intact skin surrounding the treated wounds. A blinded evaluation of the digital images by a burn surgeon indicated that SN514 debrided more necrotic tissue than the control groups after 1, 2, and 3 days of treatment. Additionally, SN514 gel was evaluated using an in vitro burn model that used human discarded skin. Treatment of human burned tissue with SN514 gel resulted in greater than 80% weight reduction compared with untreated samples. Together, these data demonstrate that SN514 gel is capable of debriding necrotic tissue and suggest that SN514 gel could be a useful option for austere conditions, such as military multi-domain operations and prolonged field care scenarios.

Anabolic and anticatabolic agents used in burn care: What is known and what is yet to be learned

Major thermal injury induces profound metabolic derangements secondary to an inflammatory "stress-induced" hormonal environment. Several pharmacological interventions have been tested in an effort to halt the hypermetabolic response to severe burns. Insulin, insulin growth factor 1, insulin growth factor binding protein 3, metformin, human growth hormone, thyroid hormones, testosterone, oxandrolone, and propranolol, among others, have been proposed to have anabolic or anticatabolic effects. The aim of this broad analysis of pharmacological interventions was to raise awareness of treatment options and to help establishing directions for future clinical research efforts. A PubMed search was conducted on the anabolic and anticatabolic agents used in burn care. One hundred and thirty-five human studies published between 1999 and 2017 were included in this review. The pharmacological properties, rationale for the treatments, efficacy considerations and side effect profiles are summarized in the article. Many of the drugs tested for investigational purposes in the severely thermally injured are not yet gold-standard therapies in spite of their potential benefit. Propranolol and oxandrolone have shown great promise but further evidence is still needed to clarify their potential use for anabolic and anticatabolic purposes.

Management and prevention of drug resistant infections in burn patients

Introduction: Despite modern advances, the primary cause of death after burns remains infection and sepsis. A key factor in determining outcomes is colonization with multi-drug resistant (MDR) organisms. Infections secondary to MDR organisms are challenging due to lack of adequate antibiotic treatment, subsequently prolonging hospital stay and increasing risk of adverse outcomes. Areas covered: This review highlights the most frequent organisms colonizing burn wounds as well as the most common MDR bacterial infections. Additionally, we discuss different treatment modalities and MDR infection prevention strategies as their appropriate management would minimize morbidity and mortality in this population. We conducted a search for articles on PubMed, Web of Science, Embase, Cochrane, Scopus and UpToDate with applied search strategies including a combination of: "burns, 'thermal injury,' 'infections,' 'sepsis,' 'drug resistance,' and 'antimicrobials.' Expert opinion: Management and prevention of MDR infections in burns is an ongoing challenge. We highlight the importance of preventative over therapeutic strategies, which are easy to implement and cost-effective. Additionally, targeted, limited use of antimicrobials can be beneficial in burn patients. A promising future area of investigation within this field is post-trauma microbiome profiling. Currently, the best treatment strategy for MDR in burn patients is prevention.

Risk Factors Associated with the Development of Transaminitis in Oxandrolone-Treated Adult Burn Patients

Oxandrolone has proven benefits in thermal burn injury and has become a standard of care. Transaminitis is the most frequent side effect of oxandrolone use, although no risk factors have been identified that increase the risk of transaminitis. The objective was to evaluate the frequency of transaminitis while on oxandrolone and to identify risk factors leading to an increased risk of transaminitis in adult burn patients. This multicenter retrospective risk factor analysis compared two patient groups with and without occurrence of transaminitis, which was detected by an aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >100 mg/dL. Secondary outcomes included percentage increase from baseline for AST/ALT, length of stay, and mortality. After univariable analysis, a multivariable logistic regression analysis was performed to detect possible risk factors leading to transaminitis. A total of 309 patients were included, with transaminitis occurring in 128 patients (41.4%) after 13 (interquartile range [IQR] 8-23) days on oxandrolone. After multivariable analysis, age (odds ratio [OR] 0.91; 95% confidence interval [CI] 0.84-0.99 for a 5-year increase in age), intravenous vasopressor use (OR 1.85; 95% CI 1.05-3.27), and amiodarone use (OR 2.51; 95% CI 1.09-5.77) were independent predictors of transaminitis, controlling for TBSA%. Transaminitis was not significantly associated with length of stay or mortality after adjusting for age and TBSA%. We conclude that patients who are younger and have concurrent amiodarone or vasopressor use have the highest risk of developing oxandrolone induced transaminitis and should be monitored closely.

Incidence of oxandrolone induced hepatic transaminitis in patients with burn injury

The benefits of oxandrolone in burn patients has led to its accepted use in the burn care community, however details regarding the most common adverse effect, transaminitis, remains unclear. The purpose of this study was to determine the incidence of transaminitis in patients with burn injury and identify risk factors associated with the development of transaminitis. This single-center, retrospective risk factor analysis compared burn patients on oxandrolone with and without the development of transaminitis, defined as any aspartate aminotransferase or alanine aminotransferase value >100mg/dL. Patient demographics, past medical history, lab values, and burn characteristics were recorded. Overall 28 out of 66 (42%) patients developed transaminitis. The transaminitis group had a significantly higher proportion of other concomitant medications with a transaminitis risk (p=0.045). No significant difference in liver dysfunction or length of stay was observed between the two groups. Oxandrolone induced transaminitis is occurring in patients significantly more frequently than previously reported warranting further research to guide monitoring requirements, use of concomitant medications, and to determine if rechallenging after resolution should be considered.

Alcohol Modulation of the Postburn Hepatic Response

The widespread and rapidly increasing trend of binge drinking is accompanied by a concomitant rise in the prevalence of trauma patients under the influence of alcohol at the time of their injury. Epidemiological evidence suggests up to half of all adult burn patients are intoxicated at the time of admission, and the presence of alcohol is an independent risk factor for death in the early stages post burn. As the major site of alcohol metabolism and toxicity, the liver is a critical determinant of postburn outcome, and experimental evidence implies an injury threshold exists beyond which burn-induced hepatic derangement is observed. Alcohol may lower this threshold for postburn hepatic damage through a variety of mechanisms including modulation of extrahepatic events, alteration of the gut-liver axis, and changes in signaling pathways. The direct and indirect effects of alcohol may prime the liver for the second-hit of many overlapping physiologic responses to burn injury. In an effort to gain a deeper understanding of how alcohol potentiates postburn hepatic damage, the authors summarize possible mechanisms by which alcohol modulates the postburn hepatic response.

Status and Challenges of Predicting and Diagnosing Sepsis in Burn Patients

Burns are a common form of trauma that account for more than 300,000 deaths each year worldwide. Survival rates have improved over the past decades because of improvements in nutritional and fluid support, burn wound care, and infection control practices. Death, however, remains unacceptably high. The primary cause of death has changed over the last decades from anoxic causes to now predominantly infections and sepsis. Sepsis and septic complications are not only major contributors to poor outcomes, but they further result in longer hospital stay and higher healthcare costs. Despite the importance of infections and sepsis, the diagnosis and prediction remain a major challenge. To date, no clear diagnostic criteria or predictive formula exist that can predict reliably the occurrence of sepsis and infections. This review will highlight and discuss current definitions and criteria for diagnosis as well as predictive biomarkers of sepsis in patients with burns. It will also present the diagnostic tools employed, such as procalcitonin, C-reactive protein, and cytokines. We will discuss the benefits and shortcomings of different treatment modalities in the context of sepsis prevention. Last, we identify new therapeutic strategies for sepsis prediction and present future considerations to prevent sepsis in patients with burns. Minimizing and preventing septic complications through early detection would significantly benefit patients and necessitate continued research to unravel new biomarkers and mechanisms. Subsequent studies need to take a fresh perspective and consider the implementation of patient-centered therapeutic strategies.

The efficacy and safety of adrenergic blockade after burn injury: A systematic review and meta-analysis

BACKGROUND

The hypermetabolic state after severe burns is a major problem that can lead to several pathophysiologic changes and produce multiple sequelae. Adrenergic blockade has been widely used to reverse these changes and improve outcomes in burned patients but has not been rigorously evaluated. The aim of this systematic review was to investigate the efficacy and safety of the use of adrenergic blockade after burn injury.

METHODS

The databases MEDLINE via OVID, PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science were searched from inception to December 2014 with search terms including burns and beta-blockers with appropriate synonyms. Articles were restricted to those published in English, French, or Spanish. Randomized controlled trials, nonrandomized controlled trials, and systematic reviews were screened. After an independent screening and full-text review, 10 articles were selected, and an appraisal of risk of bias was performed.

RESULTS

From 182 articles screened, 9 randomized controlled trials and 1 nonrandomized controlled trial met the inclusion criteria. Pooled analyses were performed to calculate effect sizes and 95% confidence intervals (CIs). There was a positive effect favoring propranolol use that significantly decreased resting energy expenditure (g = -0.64; 95% CI, -0.8 to -0.5; p < 0.001) and trunk fat (g = -0.3; 95% CI, -0.4 to -0.1; p < 0.001) as well as improved peripheral lean mass (g = 0.45; 95% CI, 0.3-0.6; p < 0.001) and insulin resistance (g = -1.35; 95% CI, -2.0 to -0.6; p < 0.001). Occurrence of adverse events was not significantly different between the treated patients the and controls.

CONCLUSION

Limited evidence suggests beneficial effects of propranolol after burn injury, and its use seems safe. However, further trials on adult population with a broader range of outcome measures are warranted.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Hybrid wound dressings with controlled release of antibiotics: Structure-release profile effects and in vivo study in a guinea pig burn model

Over the last decades, wound dressings have evolved from a crude traditional gauze dressing to tissue-engineered scaffolds. Many types of wound dressing formats are commercially available or have been investigated. We developed and studied hybrid bilayer wound dressings which combine a drug-loaded porous poly(dl-lactic-co-glycolic acid) top layer with a spongy collagen sublayer. Such a structure is very promising because it combines the advantageous properties of both layers. The antibiotic drug gentamicin was incorporated into the top layer for preventing and/or defeating infections. In this study, we examined the effect of the top layer's structure on the gentamicin release profile and on the resulting in vivo wound healing. The latter was tested on a guinea pig burn model, compared to the neutral non-adherent dressing material Melolin® (Smith & Nephew) and Aquacel® Ag (ConvaTec). The release kinetics of gentamicin from the various studied formulations exhibited burst release values between 8% and 38%, followed by a drug elution rate that decreased with time and lasted for at least 7 weeks. The hybrid dressing, with relatively slow gentamicin release, enabled the highest degree of wound healing (28%), which is at least double that obtained by the other dressing formats (8-12%). It resulted in the lowest degree of wound contraction and a relatively low amount of inflammatory cells compared to the controls. This dressing was found to be superior to hybrid wound dressings with fast gentamicin release and to the neat hybrid dressing without drug release. Since this dressing exhibited promising results and does not require frequent bandage changes, it offers a potentially valuable concept for treating large infected burns.

The regenerative potential of epithelial stem cells in tissue repair

Acute and chronic wounds encompass devastating injuries with significant physical, emotional and economic costs at both the individual and societal level. The pathogenesis of chronic wounds is as varied as the potential causes; however, contributing factors include repetitive ischaemia/reperfusion injury coupled with bacterial infection, inflammation and matrix degradation at the wound site. Similarly, the acute physical damage of burns may leave patients vulnerable to dehydration and infection, and in certain cases this may be followed by a body-wide systemic response with debilitating consequences. Epithelial stem cells provide a promising avenue for the treatment of burns and chronic wounds. This is exemplified by recent achievements such as the restoration of corneal epithelium using limbal stem cells, and the treatment of epidermolysis bullosa via a gene therapy approach. Nevertheless, many technical and regulatory challenges remain to be addressed. This article is part of a Directed Issue entitled: Regenerative Medicine: the challenge of translation.

IPNs from Cyclodextrin:Chitosan Antioxidants: Bonding, Bio-Adhesion, Antioxidant Capacity and Drug Release

IPNs are unique “alloys” of cross-linked polymers in which at least one network is synthesized and/or cross-linked in the presence of the other. IPNs are also known as entanglements of polymer networks that are ideally held together only by permanent topological interactions. The objectives of this study are to evaluate novel chitosan-based functional drug delivery systems that can be successfully incorporated into “dual action bioactive tooth restorative materials”. These materials should be capable of inducing an improved wound healing prototype. The novel hydrogels will be investigated with respect to the antioxidant capacity of conventional antioxidants, such as resveratrol, β-carotene and propolis, as a designer drug delivery system, with the use of SEM imaging for the characterization of the surfaces, bio-adhesive property, antioxidant capacity, free radical defence, antioxidant, active ingredient stability and reactive features of novel materials. The additional benefit of the site-specific “functional restorative material” for use in dressings to deliver antibiotics to wound sites can provide tissue compatibility and reduced interference with wound healing. The materials were tested using an effective in vitro free radical generation model as functional additive prototypes for further development of “dual function restorative wound healing materials”. We quantified the effects of functional designer biomaterials on the dentin bond strength of a composite and evaluated the bio-adhesive capacity of the materials in the two separate “in vitro” systems. The added benefits of the chitosan/vitamin C/cyclodextrin (CD) host:guest complex-treated hydrogels involved a positive influence on the tetracycline release, increased dentin bond strength, as well as a demonstrated in vitro “built-in” free radical defence mechanism and, therefore, acting as a “proof of concept” for functional multi-dimensional restorative wound healing materials with a built-in free radical defence mechanism. Based on our results, we can conclude that the CD:chitosan-antioxidant-containing hydrogels are a suitable carrier for tetracycline to be slow-released. Within the limitations of the study design, chitosan-based hydrogels are suitable materials for functional restorative and wound healing applications in vitro. Cytotoxicity data are currently being evaluated in our laboratory.

Antimicrobial resistance pattern of bacterial isolates from burn wounds in an Iranian University Hospital

Objective:

About 73% of death cases in the first 5 days after burning are due to infection complications. The aim of this study was to identify the causing agents of infections in burn patients and the sensitivity pattern of them to the commonly used antimicrobials in an Iranian Burn center University Hospital.

Methods:

In this cross-sectional study, patients who were admitted to one of the Iranian Burn center University hospitals in 2009 and had nosocomial infection due to burn wound, whom received antimicrobial agents for therapeutic reasons, with a hospitalization period of more than 48 hours were enrolled. Gram stain analyses were performed to help identifying growing colonies. Differential tests for identification of pathogenic bacteria species were performed following primary tests. E-test strips of each antimicrobial were placed on the culture medium plate in order to determine the minimum inhibitory concentration Studied antimicrobials for isolated Gram-negative bacteria were meropenem, piperacillin/tazobactam, ceftriaxone, cotrimoxazole, and for Staphylococcus aureus, vancomycin, piperacillin/tazobactam, cotrimoxazole, and cephalothin.

Findings:

Only 16% of Pseudomonas aeruginosa species were sensitive to meropenem, and 13% were sensitive to piperacillin/tazobactam. Ten out of 29 Klebsiella species (34%) were sensitive to meropenem and piperacillin/tazobactam. All isolated strains of Staphylococcus aureus were sensitive to vancomycine while they were all resistant to cotrimoxazole.

Conclusion:

Pseudomona, Klebsiella and Staphylococcoci are the most common species causing burn infection in this medical center. Results showed the importance of limiting irrational use of wide-spectrum antimicrobials and recommends strict management of infections in burn injury centers.

The endocrine response to severe burn trauma

The endocrine system is frequently altered after a major burn trauma. Besides the endocrine response to stress characterized by hypercortisolism, several hypothalamus-hypophysis-target gland axes are rapidly perturbed within a few days. These alterations can persist in the long term and deserve an appropriate treatment. Disturbances in water clearance and glucidic metabolism are also common and need to be diagnosed and corrected to decrease morbidity in such patients. Bone and mineral metabolism is deeply compromised and requires correction of mineral abnormalities in order to improve symptoms and prevent bone loss. No large prospective and/or intervention trials are available to date to elaborate age-related, evidence-based recommendations to monitor and treat burn-related endocrine alterations.

Antibiotic prophylaxis for preventing burn wound infection

BACKGROUND

Infection of burn wounds is a serious problem because it can delay healing, increase scarring and invasive infection may result in the death of the patient. Antibiotic prophylaxis is one of several interventions that may prevent burn wound infection and protect the burned patient from invasive infections.

OBJECTIVES

To assess the effects of antibiotic prophylaxis on rates of burn wound infection.

SEARCH METHODS

In January 2013 we searched the Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE - In-Process & Other Non-Indexed Citations (2013); Ovid EMBASE; EBSCO CINAHL and reference lists of relevant articles. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated the efficacy and safety of antibiotic prophylaxis for the prevention of BWI. Quasi-randomised studies were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted relevant data. Risk ratio (RR) and mean difference (MD) were estimated for dichotomous data and continuous data, respectively. When sufficient numbers of comparable RCTs were available, trials were pooled in a meta-analysis to estimate the combined effect.

MAIN RESULTS

This review includes 36 RCTs (2117 participants); twenty six (72%) evaluated topical antibiotics, seven evaluated systemic antibiotics (four of these administered the antibiotic perioperatively and three administered upon hospital admission or during routine treatment), two evaluated prophylaxis with non absorbable antibiotics, and one evaluated local antibiotics administered via the airway.The 11 trials (645 participants) that evaluated topical prophylaxis with silver sulfadiazine were pooled in a meta analysis. There was a statistically significant increase in burn wound infection associated with silver sulfadiazine compared with dressings/skin substitute (OR = 1.87; 95% CI: 1.09 to 3.19, I(2) = 0%). These trials were at high, or unclear, risk of bias. Silver sulfadiazine was also associated with significantly longer length of hospital stay compared with dressings/skin substitute (MD = 2.11 days; 95% CI: 1.93 to 2.28).Systemic antibiotic prophylaxis in non-surgical patients was evaluated in three trials (119 participants) and there was no evidence of an effect on rates of burn wound infection. Systemic antibiotics (trimethoprim-sulfamethoxazole) were associated with a significant reduction in pneumonia (only one trial, 40 participants) (RR = 0.18; 95% CI: 0.05 to 0.72) but not sepsis (two trials 59 participants) (RR = 0.43; 95% CI: 0.12 to 1.61).Perioperative systemic antibiotic prophylaxis had no effect on any of the outcomes of this review.Selective decontamination of the digestive tract with non-absorbable antibiotics had no significant effect on rates of all types of infection (2 trials, 140 participants). Moreover, there was a statistically significant increase in rates of MRSA associated with use of non-absorbable antibiotics plus cefotaxime compared with placebo (RR = 2.22; 95% CI: 1.21 to 4.07).There was no evidence of a difference in mortality or rates of sepsis with local airway antibiotic prophylaxis compared with placebo (only one trial, 30 participants).

AUTHORS' CONCLUSIONS

The conclusions we are able to draw regarding the effects of prophylactic antibiotics in people with burns are limited by the volume and quality of the existing research (largely small numbers of small studies at unclear or high risk of bias for each comparison). The largest volume of evidence suggests that topical silver sulfadiazine is associated with a significant increase in rates of burn wound infection and increased length of hospital stay compared with dressings or skin substitutes; this evidence is at unclear or high risk of bias. Currently the effects of other forms of antibiotic prophylaxis on burn wound infection are unclear. One small study reported a reduction in incidence of pneumonia associated with a specific systematic antibiotic regimen.

Burns: an update on current pharmacotherapy

INTRODUCTION

The worldwide occurrence of burn injuries remains high despite efforts to reduce injury incidence through public awareness campaigns and improvements in living conditions. In 2004, almost 11 million people experienced burns severe enough to warrant medical treatment. Advances over the past several decades in aggressive resuscitation, nutrition, excision and grafting have reduced morbidity and mortality. Incorporation of pharmacotherapeutics into treatment regimens may further reduce complications of severe burn injuries.

AREAS COVERED

Severe burn injuries, as well as other forms of stress and trauma, trigger a hypermetabolic response that, if left untreated, impedes recovery. In the past two decades, use of anabolic agents, β-adrenergic receptor antagonists and anti-hyperglycemic agents has successfully counteracted post-burn morbidities including catabolism, the catecholamine-mediated response and insulin resistance. Here, the authors review the most up-to-date information on currently used pharmacotherapies in the treatment of these sequelae of severe burns and the insights that have expanded the understanding of the pathophysiology of severe burns.

EXPERT OPINION

Existing drugs offer promising advances in the care of burn injuries. Continued gains in the understanding of the molecular mechanisms driving the hypermetabolic response will enable the application of additional existing drugs to be broadened to further attenuate the hypermetabolic response.

Improved burns therapy: liposomes-in-hydrogel delivery system for mupirocin

Wounds, particularly burns, are prone to colonization of potentially life-threatening bacteria. Local delivery of antimicrobial agents in sufficient quantities and over longer period of time can reduce risk of burn infections. Mupirocin-in-liposomes-in-hydrogels were proposed as advanced delivery system for improved burn therapy. Mupirocin was entrapped in phosphatidylcholine liposomes of various sizes, namely larger (micron size) vesicles entrapping 74% of drug and sonicated vesicles (below 300 nm) entrapping 49% of drug. Liposomes containing mupirocin were incorporated in chitosan hydrogels (10%, w/w). Incorporation of liposomes in hydrogels resulted in prolonged release of liposomally associated mupirocin, as observed in both in vitro and ex vivo studies. The drug release was affected by the vesicle size. Microbiological evaluation of newly developed system confirmed its antimicrobial potential against Staphylococcus aureus and Bacillus subtilis. Bioadhesiveness of the system was compared with the marketed cream containing mupirocin. Our system exhibited superior bioadhesiveness and sustained mupirocin release profiles to marketed product.

Garlic ointment inhibits biofilm formation by bacterial pathogens from burn wounds

When thermal injury damages the skin, the physical barrier protecting underlying tissues from invading micro-organisms is compromised and the host's immune system becomes supressed, facilitating colonization and infection of burn wounds with micro-organisms. Within the wound, bacteria often develop biofilms, which protect the bacteria from the immune response and enhance their resistance to antibiotics. As the prophylactic use of conventional antibiotics drives selection of drug-resistant strains, the use of novel agents to prevent biofilm formation by wound pathogens is essential. In the present study, we utilized our recently developed in vitro wound biofilm model to examine the antibiofilm activity of garlic (Allium sativum). Wound pathogens were inoculated on sterile cellulose discs, exposed to formulated garlic ointment (GarO) or ointment base, and incubated to allow biofilm development. Biofilms were quantified and visualized microscopically. GarO prevented biofilm development by Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae, and caused a 2-5 log reduction of the bioburden within Enterococcus faecalis biofilms. Additionally, GarO disrupted partially developed biofilms produced by S. aureus, S. epidermidis and A. baumannii. The antistaphylococcal activity of GarO was stable for over 3 months at room temperature. Thus, GarO could be used as a prophylactic therapy to prevent wound biofilms caused by both Gram-negative and Gram-positive bacteria from forming, and may be a potential therapy for disrupting established staphylococcal biofilms.

Potentials of chitosan-based delivery systems in wound therapy: bioadhesion study

Chitosan is currently proposed to be one of the most promising polymers in wound dressing development. Our research focuses on its potential as a vehicle for nano-delivery systems destined for burn therapy. One of the most important features of wound dressing is its bioadhesion to the wounded site. We compared the bioadhesive properties of chitosan with those of Carbopol, a synthetic origin polymer. Chitosan-based hydrogels of different molecular weights were first analyzed by texture analysis for gel cohesiveness, adhesiveness and hardness. In vitro release studies showed no difference in release of model antimicrobial drug from the different hydrogel formulations. Bioadhesion tests were performed on pig ear skin and the detachment force, necessary to remove the die from the skin, and the amount of remaining formulation on the skin were determined. Although no significant difference regarding detachment force could be seen between Carbopol-based and chitosan-based formulations, almost double the amount of chitosan formulation remained on the skin as compared to Carbopol formulations. The findings confirmed the great potential of chitosan-based delivery systems in advanced wound therapy. Moreover, results suggest that formulation retention on the ex vivo skin samples could provide deeper insight on formulation bioadhesiveness than the determination of detachment force.

Is there a difference in clinical outcomes, inflammation, and hypermetabolism between scald and flame burn?

OBJECTIVE

Severe thermal injury induces inflammatory and hypermetabolic responses that are associated with morbidity and mortality. However, it is not well-documented whether the causes of burns affect inflammation, hypermetabolism, and morbidity. The aim of the present study was to determine whether there is a difference in degree of inflammation, hypermetabolism, endocrine and acute-phase response, and clinical outcome between pediatric patients with scald and flame burns.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Children with burns requiring surgical intervention were enrolled in this cohort study and divided into two groups, scald or flame burn. In a second assignment, we analyzed the study populations in representative subgroups containing individuals with third-degree burns of 40% to 60% total body surface area. We determined clinical outcomes, resting energy expenditures, cytokine profiles, acute-phase proteins, constitutive proteins, and hormone panels. Statistical analysis was evaluated by analysis of variance, Student's t test corrected with the Bonferroni post hoc test, and the propensity score. Statistical significance was set at p < .05. A total of 912 patients were identified. Six hundred seventy-four had a flame burn and 238 had a scald burn. There was a significant difference (p < .05) in burn size (flame, 48% ± 23%; scald, 40% ± 21%), third-degree burn (flame, 39% ± 27%; scald 22% ± 25%), age (flame, 8 ± 5 yrs; scald, 3 ± 3 yrs), and mortality between groups. Propensity analysis confirmed the type of burn as a significant risk factor for morbidity and mortality. Subanalysis conducted in a representative patient group suffering from 40% to 60% burn total body surface area revealed that flame burns lead to significantly increased hypermetabolic, inflammatory, and acute-phase responses when compared to scald burns (p < .05). The frequency of sepsis was 3% in the scald burn group, while it was 14% in the flame group (p < .001). Multiorgan failure occurred in 14% of the scald patients, while it occurred in 17% of flame patients. The mortality in patients suffering from a scald burn was 3% compared to 6% in the flame-burned group (p < .05).

CONCLUSION

The type of burn affects hypermetabolism, inflammation, acute-phase responses, and mortality postburn.

Novel biodegradable composite wound dressings with controlled release of antibiotics: results in a guinea pig burn model

Approximately 70% of all people with severe burns die from related infections despite advances in treatment regimens and the best efforts of nurses and doctors. Silver ion-eluting wound dressings are available for overcoming this problem. However, there are reports of deleterious effects of such dressings due to cellular toxicity that delays the healing process, and the dressing changes needed 1-2 times a day are uncomfortable for the patient and time consuming for the stuff. An alternative concept in wound dressing design that combines the advantages of occlusive dressings with biodegradability and intrinsic topical antibiotic treatment is described herewith. The new composite structure presented in this article is based on a polyglyconate mesh and a porous poly-(dl-lactic-co-glycolic acid) matrix loaded with gentamicin developed to provide controlled release of antibiotics for three weeks. In vivo evaluation of the dressing material in contaminated deep second degree burn wounds in guinea pigs (n=20) demonstrated its ability to accelerate epithelialization by 40% compared to an unloaded format of the material and a conventional dressing material. Wound contraction was reduced significantly, and a better quality scar tissue was formed. The current dressing material exhibits promising results, does not require frequent bandage changes, and offers a potentially valuable and economic approach to treating the life-threatening complication of burn-related infections.

In vitro microbial inhibition and cellular response to novel biodegradable composite wound dressings with controlled release of antibiotics

About 70% of all people with severe burns die from related infections, despite advances in treatment regimens and the best efforts of nurses and doctors. Although silver-eluting wound dressings are available for addressing this problem, there is growing evidence of the deleterious effects of such dressings in delaying the healing process owing to cellular toxicity. A new concept of antibiotic-eluting composite wound dressings is described here. These dressings are based on a polyglyconate mesh coated with a porous poly-(dl-lactic-co-glycolic acid) matrix loaded with antibiotic drugs. The effect of antibiotic release on bacterial inhibition was studied, and cell cytotoxicity was examined. The dressings resulted in a 99.99% decrease in the viable counts of Pseudomonas aeruginosa and Staphylococcus albus at very high initial inoculations of 10⁷-10⁸ CFU ml⁻¹ after only 1 day, while such a decrease in Staphylococcus aureus was obtained within 3 days. Bacterial inhibition zones around the dressing material were found to persist for 2 weeks, indicating a long-lasting antimicrobial effect. Despite severe toxicity to bacteria, the dressing material was found to have no toxic effect on cultured fibroblasts, indicating that the new antibiotic-eluting wound dressings represent an effective option for selective treatment of bacterial infections.

The selenium status of pediatric patients with burn injuries

BACKGROUND

Dietary selenium (Se) requirements during critical illness are not well known. The objective of this study was to assess the longitudinal Se status of pediatric patients with burns.

METHODS

Twenty patients admitted to our hospital with burns exceeding 10% of their total body surface area were studied longitudinally during the first 8 weeks of admission or until 95% wound closure was achieved. Dietary Se intake was calculated daily, and plasma and urine samples were collected weekly for analyses of plasma Se, urinary Se, and glutathione peroxidase activity.

RESULTS

Patients included in this study were individuals with an average age of 6.5 years ± 5.3 years and with burn injury of a mean total body surface area of 42% ± 21%. Dietary Se intake throughout the study (mean = 60 μg/d ± 39 μg/d) was consistent with established standards for healthy children and did not change throughout the study. Plasma Se (mean = 1.08 μmol/L ± 0.34 μmol/L) and plasma glutathione peroxidase (mean = 3.2 U/g protein ± 1.42 U/g protein) were below reported normal values for healthy American children. Mean urinary Se excretion (65.9 μg/L ± 50 μg/L) exceed dietary Se intake. Plasma Se was inversely related to incidence of total infection (p = 0.04).

CONCLUSIONS

Results from this study indicate that Se status is depressed among pediatric patients with burns and that recommended Se intake for healthy children is likely insufficient for this population. Further studies are necessary to elucidate the amount of dietary Se required to maximize Se stores among pediatric patients with burn injuries.

Topical antimicrobials for burn wound infections

Throughout most of history, serious burns occupying a large percentage of body surface area were an almost certain death sentence because of subsequent infection. A number of factors such as disruption of the skin barrier, ready availability of bacterial nutrients in the burn milieu, destruction of the vascular supply to the burned skin, and systemic disturbances lead to immunosuppression combined together to make burns particularly susceptible to infection. In the 20th century the introduction of antibiotic and antifungal drugs, the use of topical antimicrobials that could be applied to burns, and widespread adoption of early excision and grafting all helped to dramatically increase survival. However the relentless increase in microbial resistance to antibiotics and other antimicrobials has led to a renewed search for alternative approaches to prevent and combat burn infections. This review will cover patented strategies that have been issued or filed with regard to new topical agents, preparations, and methods of combating burn infections. Animal models that are used in preclinical studies are discussed. Various silver preparations (nanocrystalline and slow release) are the mainstay of many approaches but antimicrobial peptides, topical photodynamic therapy, chitosan preparations, new iodine delivery formulations, phage therapy and natural products such as honey and essential oils have all been tested. This active area of research will continue to provide new topical antimicrobials for burns that will battle against growing multidrug resistance.

Extent and magnitude of catecholamine surge in pediatric burned patients

Increased catecholamine (CA) levels after severe burn are associated with stress, inflammation, hypermetabolism, and impaired immune function. The CA secretion profiles in burned patients are not well described. Mechanisms, duration, and extent of CA surge are unknown. The purpose of this large unicenter study was to evaluate the extent and magnitude of CA surge after severe burn in pediatric patients. Patients admitted between 1996 and 2008 were enrolled in this study. Twenty-four-hour urine collections were performed during acute hospitalization and up to 2 years postburn. Results from the samples collected from 12 normal, healthy volunteers were compared with the data from the burned patients. Relevant demographic and clinical information was obtained from medical records. Student t-test and one-way ANOVA were used to analyze the data where appropriate. Significance was accepted at P < 0.05. Four hundred thirteen patients were enrolled in this study; 17 patients died during acute hospitalization. Burn caused a marked stress and inflammatory response, indicated by massive tachycardia and elevated proinflammatory cytokines. In burned patients, CA levels are consistently and significantly modulated after burn when compared with the levels in normal, healthy volunteers. Catecholamine levels were significantly higher in boys compared with girls, correlated with burn size in burns greater than 40%, and were increased in older children. There were differences over time in survivors versus nonsurvivors, with CA levels significantly higher in nonsurvivors at two time points. Inflammatory cytokines show a similar profile during the study period. Our study gives clinicians a useful insight into the extent and magnitude of CA elevation to better design treatment strategies.

Burn wounds infected by contaminated water: case reports, review of the literature and recommendations for treatment

First-aid education for the management of burns advocates cool running water over burnt skin to limit soft tissue damage. However, the water used may itself constitute a risk. We report three cases of severe invasive and necrotizing infection in patients who used or immersed themselves in contaminated water in an attempt to extinguish the fire following acute major burns. Wound cultures from all patients yielded Aeromonas hydrophila and two yielded Bacillus cereus. One patient had a complex polymicrobial infection, including zygomycosis with Rhizomucor variabilis. All patients were treated aggressively with wound débridement, including one patient who required bilateral lower limb amputations to control progressive infection. All infections were successfully treated and all patients survived their burn injuries. We review the management of burns complicated by exposure to contaminated water leading to burn wound infections. We describe commonly reported organisms from various water sources, the appropriate initial empirical antimicrobial chemotherapy and present the clinician with a proposed algorithm for managing these serious infections.

Oxandrolone treatment in adults with severe thermal injury

Severe thermal injury is associated with hypermetabolism and hypercatabolism, leading to skeletal muscle breakdown, lean body mass loss, weight loss, and negative nitrogen balance. Muscle protein catabolism in patients with severe thermal injury is the result of stress-induced increased release of cytokines and counterregulatory hormones. Coupled with decreased serum anabolic hormone concentrations such as testosterone and growth hormone along with the presence of insulin resistance, anabolism in patients with severe thermal injury is inefficient or impossible during the acute postburn period. This causes difficulty in restoring lean body mass and regaining lost body weight, as well as poor healing of the burn wound and delayed patient recovery. Oxandrolone, a synthetic derivative of testosterone, has been used in adult patients with severe thermal injury to enhance lean body mass accretion, restore body weight, and accelerate wound healing. In clinical studies, oxandrolone 10 mg orally twice/day improved wound healing, restored lean body mass, and accelerated body weight gain. During the rehabilitation period, oxandrolone therapy with adequate nutrition and exercise improved lean body mass, increased muscle strength, and restored body weight. However, most data on oxandrolone use in adult patients with severe thermal injury are derived from single-center studies, many of which enrolled a relatively small number of subjects and some of which had a poor design. Multicenter, prospective, randomized studies are needed to better define the optimal oxandrolone dosage and to confirm the efficacy and safety of this drug in adult patients with severe thermal injury.

Metabolic implications of severe burn injuries and their management: a systematic review of the literature

BACKGROUND

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiologic stress and an overwhelming systemic metabolic response. A major component of severe burn injury is a hypermetabolic state associated with protein losses and a significant reduction of lean body mass. The second prominent component is hyperglycemia. Reversal of the hypermetabolic response by manipulating the patient's physiologic and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacologic doses, is emerging as an essential component of the state of the art in severe burn management. The present review aims at summarizing the new treatment modalities established to reduce the catabolic burden of severe burn injuries, for which there is some evidence-based support.

METHODS

A systematic review of the literature was conducted. Search tools included Elsevier ScienceDirect, EMBASE.com, Medline (OVID), MedlinePlus, and PubMed. Topics searched were Nutrition and Burns, Metabolic Response and Burns, Hypermetabolism and Burns, Hyperglycemia and Burns, and several more specific topics when indicated. With a focus on the most recently published articles, abstracts were reviewed and, when found relevant, were included as references. Full text articles, whenever available, were retrieved.

RESULTS

Many issues remain unanswered. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined, and these will certainly have some practical applications but above all will dictate future research in the field.

Trace element supplementation after major burns modulates antioxidant status and clinical course by way of increased tissue trace element concentrations

BACKGROUND

After major burns, patients can develop nutritional deficiencies including trace element (TE) deficiencies. Various complications, such as infections and delayed wound healing, influence the clinical course of such patients.

OBJECTIVES

We aimed to investigate the effects of large, intravenous doses of TE supplements on circulating and cutaneous TE tissue concentrations, on antioxidant status, and on clinical outcome after major burns.

DESIGN

This was a prospective, randomized, placebo-controlled trial in 21 patients aged 35 +/- 11 y (x +/- SD) with burns on 45 +/- 21% of their body surface area. Intravenous copper, selenium, and zinc (TE group) or vehicle (V group) was given with a saline solution for 14-21 d. Blood and urine samples were collected until day 20, and skin biopsy specimens were collected on days 3, 10, and 20.

RESULTS

The age of the patients and the severity of their burns did not differ significantly between the groups. Plasma TE concentrations were significantly higher in the TE group. In burned areas, skin contents of both selenium (P=0.05) and zinc (P=0.04) increased significantly by day 20. Plasma and tissue antioxidant status was improved by supplementation. The number of infections in the first 30 d was significantly lower in the TE group (P=0.015), with a median number of 2 versus 4 infections per patient in the TE and V groups, respectively, as a result of a reduction in pulmonary infections (P=0.03). Wound healing was improved in the TE group, with lower requirements for regrafting (P=0.02).

CONCLUSIONS

TE supplementation was associated with higher circulating plasma and skin tissue contents of selenium and zinc and improved antioxidant status. These changes were associated with improved clinical outcome, including fewer pulmonary infections and better wound healing.

A role of PPAR-gamma in androstenediol-mediated salutary effects on cardiac function following trauma-hemorrhage

OBJECTIVE

To examine the mechanism by which androstenediol improves cardiac function following trauma-hemorrhage (T-H).

SUMMARY BACKGROUND DATA

Androstenediol administration improves cardiovascular function and attenuates proinflammatory cytokine production following T-H. Activation of the peroxisome proliferator-activated receptor-gamma (PPAR-gamma) has been shown to be protective following ischemic conditions. We hypothesized that PPAR-gamma activation plays a role in the androstenediol-mediated salutary effects on cardiac function following T-H.

METHODS

Male rats underwent laparotomy and hemorrhagic shock (40 mm Hg for 90 minutes), followed by resuscitation with 4 times the shed blood volume in the form of Ringer's lactate. Androstenediol (1 mg/kg body weight, i.v.) was administrated at the end of resuscitation. In a separate group of animals, a PPAR-gamma antagonist (GW9662) was administered simultaneously with androstenediol and animals were killed at 5 hours thereafter.

RESULTS

A decrease in cardiac function and an increase in IL-6 and iNOS gene expression were observed following T-H. Androstenediol treatment normalized cardiac function, increased PPAR-gamma DNA binding activity, attenuated IL-6 and iNOS gene expressions, and reduced plasma IL-6. Plasma 15-deoxy-Delta12, 14-prostaglandin J2 (PGJ2, an endogenous PPAR-gamma agonist) levels were also increased in androstenediol-treated T-H rats, but these levels were lower than those observed in shams. Coadministration of PPAR-gamma antagonist along with androstenediol, however, prevented the androstenediol-mediated reduction in cardiac iNOS and IL-6 expressions and abolished the improvements in cardiac function.

CONCLUSION

The androstenediol-mediated salutary effects on cardiac function following T-H appear to be mediated at least in part via PPAR-gamma activation, which down-regulates IL-6 and iNOS gene expression in the heart.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.