Selection of appropriate empiric gram-negative coverage in a multinational pediatric burn hospital

The choice of appropriate empiric antimicrobial therapy for burn patients with suspected multidrug-resistant organisms remains a challenge. Burn patients transferred from outside the United States seem to be at particularly high risk. Given this perceived risk of multidrug resistance among our international patient population, we set out to determine which empiric antimicrobial therapy should be used at admission. A retrospective analysis was conducted of all burn patients admitted to a pediatric burn specialty hospital between 2006 and 2010. Patients with burns >10% TBSA were included. Demographics, burn data, and routine/nonroutine culture data were collected. Of the 385 total patients, 133 (34.5%) were international. International patients had significantly larger burns (39.73 vs 22.80% TBSA; P < .001) and more inhalational injuries (27.1 vs 16.3%; P < .03) than their U.S. counterparts. International patients presented with a higher incidence of infection in general (66.9 vs 2%; P < .001) as well as a higher prevalence of infection caused by multidrug-resistant bacteria (51.2 vs 1%; P < .001) and pan-multidrug-resistant bacteria (13.5 vs 1.1%; P < .001). Bacterial resistance was not related to the length of time after burn injury or to a delay in transfer. In conclusion, multidrug-resistant and pan-resistant organisms seem to be more prevalent among the international pediatric burn population when compared with the U.S. pediatric burn population. Given the relatively high incidence of pan-resistant gram-negative organisms among international transfers, colistin seems to be a reasonable choice for empiric antimicrobial coverage for presumed infections.