![]() In contrast, deeper burns are covered by an avascular layer of moist and protein-rich dead skin (the eschar), which fosters bacterial proliferation and invasion, leading to burn wound infection. Since superficial burns have a preserved blood supply and perfusion through much of the dermis, they typically will become colonized but less frequently develop invasive burn wound infections. Colonization should be distinguished from a burn wound infection, in which large numbers of bacteria (> 105 organisms/gm of tissue) populate the wound and produce clinically apparent disease that features local signs and symptoms (e.g., surrounding redness, pain, swelling, wound discoloration, and early eschar separation) as well as systemic manifestations (e.g., fever, leukocytosis, sepsis). While almost all burn wounds will become colonized with microorganisms, this does not always cause harm. Later, yeasts and fungi may appear, which is always an ominous sign connected with heightened mortality. Unfortunately, the full spectrum of emerging antibiotic-resistant bacteria including methicillin-resistant Staphylococcus aureus (MRSA) and multiresistant Acinetobacter are now frequently encountered in the burn wound at this stage. These are usually gram-negative organisms such as Pseudomonas aeruginosa, Enterobacter species, Proteus, and Escherichia coli. ![]() By 5–7 days post-burn, other organisms originating from the patient’s normal gastrointestinal or respiratory flora, or the hospital environment, appear and begin to dominate. Within 48 h of injury, gram-positive bacteria that are normally found in the skin such as Staphylococcus aureus, Corynebacterium, and Streptococcus species colonize the wound surface. Initially, but only transiently, the wound is sterile. The appearance of microbes in the burn wound follows a predictable pattern. General principles Microbiology of the burn wound This article will discuss the general principles surrounding the use of topical antimicrobials on burn wounds and will review the most common agents currently in use. Especially relevant to the pediatric burn patient are the antimicrobial agent’s properties related to causing pain or irritation and the required frequency of application and dressings. Thus, while topical antimicrobial agents are indicated for most if not all burn wounds, the choice of a topical agent must consider many factors such as the wound depth, anticipated time to healing, need for surgical intervention, and the known cytotoxicity of the agent. Paradoxically, many of the topical antimicrobial agents currently in use also have cytotoxic effects on keratinocytes and fibroblasts and have the potential to delay wound healing. Therefore, regardless of burn depth, topical antimicrobials are most importantly indicated when there is clinical suspicion of risk of infection, or when a wound infection is evident. Even superficial burns which are expected to heal may benefit from the use of topical antimicrobial agents since microbial proliferation in a burn wound has the potential to significantly delay healing, the main consequence of which is increased scarring. Currently, while the problem of invasive burn wound infection has largely been eliminated by early surgical excision and closure of deep second-degree and third-degree burns, topical antimicrobial control in these wounds prior to definitive surgical debridement is still necessary. The introduction of topical antimicrobial agents was a major advancement in burn care and proved to be responsible for important reductions in mortality from burn wound sepsis. Aside from the recognized threat of burn wound sepsis, burn wound infections also may lead to wound conversion, skin graft failure, and prolonged hospitalization. Invasive infection of the burn wound leading to sepsis and death was commonplace. In that era, deeper burn wounds were treated by gradual debridement of the burn eschar using immersion hydrotherapy, and topical antimicrobial agents were integral to this approach to help control microbial proliferation in the wound. Topical antimicrobial agents for the burn wound were developed in the 1950s and 1960s to deal with the problem of invasive infection of the burn wound.
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