Burn Wound Colonization, Infection, and Sepsis

Background: Infection is a major cause of morbidity and mortality among burn patients, and it is important to understand the progression of wound colonization to wound infection to systemic sepsis. Methods: After a review of the literature we describe the clinical characteristics of burn wound colonization, infection, and sepsis, and conclude with best practices to decrease these complications. Results: Burn wounds are initially sterile after the thermal insult but become colonized by gram-positive organisms and subsequently by gram-negative organisms. Some populations are especially susceptible to initial or subsequent colonization by drug-resistant organisms. An increase in fungal colonization has been observed because of the widespread use of topical antibiotic agents. Male gender, older age, lower extremity burn, scald burn, full-thickness burn, delay in treatment, and pre-existing diabetes place patients at increased risk of infection. These infections range from cellulitis that requires systemic antibiotic agents, to invasive burn wound infection that requires prompt treatment with antibiotic agents and excision. Fungal wound infections pose a special challenge and cause substantial morbidity. Infection that leads to systemic sepsis is difficult to define in burn patients because of the body's compensatory hypermetabolic response to the burn injury. Potential sources of sepsis include wound infections and common nosocomial infections. The American Burn Association Sepsis criteria, defined in 2007, has demonstrated poor specificity for identifying sepsis and septic shock. The best approach to decrease wound infections is prevention. Practices that have been beneficial include isolation rooms, handwashing, appropriate wound care, early excision and grafting, antibiotic stewardship, and nutritional support. Conclusions: A burn patient remains at a substantial risk of wound infection despite advances in care. A burn care provider must understand the natural progression of colonization to infection to sepsis, and the multidisciplinary approach to wound care to limit the morbidity and mortality from these infectious.