Caring for burn patients: Unique challenges for ID physicians and infection control

Burn patients pose unique challenges for infectious diseases physicians and for infection control practitioners. Many of us did not have the opportunity to care for burn patients during our fellowship training, and this unique patient population deserves special consideration.

Drawing from the literature and our experiences caring for these patients in a regional high-volume burn center, we offer some key takeaways.

Infection versus inflammation

It can be difficult to determine if burn patients are infected because burn injury itself results in tachycardia, tachypnea, fever and changes to white blood cell count. (1, 2) Multiple studies have shown that the systemic inflammatory response syndrome criteria and Sequential Organ Failure Assessment scores are not helpful identifying infection in this patient population. (3-5, 6). This makes it more challenging to identify when patients are clinically infected from the background of immune activation from burn injury.

Burn wounds cause complex local and systemic inflammatory and immune changes. Damaged cells release damage-associated molecular patterns that increase the activation of the immune response and can cause burn wound deepening, SIRS and multi-organ dysfunction acutely. (7) Studies show that early excision is needed for optimal healing and to reduce vulnerability to infections, although the exact timing of early excision is less clear. (8)  

Bacteremia

Bacteremia frequently complicates wound manipulation even in the absence of clinical infection. In one prospective study, 44.6% of procedures (50/112) in 28 patients were complicated by bacteremia. (9) Our data from a regional high-volume burn center showed that 5.6% of patients admitted to the burn unit developed bacteremia and that 36.8% of hospital-onset bacteremias occurred after a skin and soft tissue surgical procedure. (10) It can be challenging to distinguish transient bacteremia from clinical infections.

Infection prevention

Burn wounds are heavily colonized with pathogenic bacteria. (11) Wound care has been shown to aerosolize bacterial pathogens and thus patient rooms are likely to become contaminated. (12) As these patients may stay in their ICU room for weeks and even months, more aggressive environmental decontamination may be needed in burn units. Additionally, burn patients have prolonged use of invasive devices such as central lines.

Although studies have shown no benefit for routine line changes in ICU patients (13), the median duration of line placement in the control arm of these studies is much shorter than the median duration of line placement in burn patients. There are many remaining unanswered questions on optimal infection control practices and device management in this patient population. (14)

Collaboration

The most important lesson in caring for burn patients is the importance of collaboration. The complexity and interdependence of so many complications from severe burn injury require experts from almost every discipline. Experts from nutrition, rehabilitation medicine, critical care medicine, pain management, pulmonary medicine, social work, infectious diseases and burn surgery are all essential in the successful management of burn patients.

References

1. Burgess M, Valdera F, Varon D, et al. The Immune and Regenerative Response to Burn Injury. Cells. 2022;11(19): 3073.
2. Greenhalgh DG. Management of Burns. N Engl J Med. 2019;380(24):2349-59.
3. Yoon J, Kym D, Hur J, et al. Comparative Usefulness of Sepsis-3, Burn Sepsis, and Conventional Sepsis Criteria in Patients With Major Burns. Crit Care Med. 2018;46(7):e656-e62.
4. Yoon J, Kym D, Hur J, et al. Validation of Sepsis-3 using survival analysis and clinical evaluation of quick SOFA, SIRS, and burn-specific SIRS for sepsis in burn patients with suspected infection. PLoS One. 2023;18(1):e0276597.
5. Hogan BK, Wolf SE, Hospenthal DR, et al. Correlation of American Burn Association sepsis criteria with the presence of bacteremia in burned patients admitted to the intensive care unit. J Burn Care Res. 2012;33(3):371-8.
6. Yan J, Hill WF, Rehou S, et al. Sepsis criteria versus clinical diagnosis of sepsis in burn patients: A validation of current sepsis scores. Surgery. 2018;164(6):1241-5.
7. Korkmaz HI, Flokstra G, Waasdorp M, et al. The Complexity of the Post-Burn Immune Response: An Overview of the Associated Local and Systemic Complications. Cells. 2023;12(3):345.
8. Daugherty THF, Ross A, Neumeister MW. Surgical Excision of Burn Wounds: Best Practices Using Evidence-Based Medicine. Clin Plast Surg. 2017;44(3):619-25.
9. Vindenes H, Bjerknes R. The frequency of bacteremia and fungemia following wound cleaning and excision in patients with large burns. J Trauma. 1993;35(5):742-9.
10. Sood G, Caffrey J, Werthman E, et al. Hospital-Onset Bacteremia and Fungemia in a Regional Burn Intensive Care Unit. Am J Infect Control. 2026. Published online Jan. 28, 2026.
11. Ladhani HA, Yowler CJ, Claridge JA. Burn Wound Colonization, Infection, and Sepsis. Surg Infect. 2021;22(1):44-8.
12. Bache SE, Maclean M, Gettinby G, et al. Airborne bacterial dispersal during and after dressing and bed changes on burns patients. Burns. 2015;41(1):39-48.
13. Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med. 1992;327(15):1062-8.
14. Siegel JD, Rhinehart E, Jackson M, et al. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-164.