Managing skin infections in burn patients: principles and pitfalls

Burn wound infections pose a major challenge in both critical care and surgical settings, owing to the complex interplay of host immune dysfunction, altered pharmacokinetics, surgical wound dynamics, and the high prevalence of multidrug-resistant (MDR) organisms. This review summarizes current evidence on diagnosis, antimicrobial therapy, and multidisciplinary management of burn wound infections, highlighting common pitfalls and strategies to mitigate them.

Burn patients display a distinct microbiological profile that evolves over time: Gram-positive cocci initially predominate, whereas nonfermenting Gram-negative bacilli such as Pseudomonas aeruginosa and Acinetobacter baumannii become increasingly prevalent during hospitalization. Differentiating colonization from infection remains a major diagnostic challenge. Although tissue biopsy is the gold standard for confirming wound infection, it is not uniformly implemented across centers. Therefore, a comprehensive clinical and microbiological evaluation involving infectious disease specialists, intensivists, and surgeons is essential for accurate interpretation of wound status. Antimicrobial stewardship interventions, including pharmacokinetic/pharmacodynamic optimization, therapeutic drug monitoring, carbapenem-sparing regimens, shorter antibiotic courses, and avoidance of redundant combination therapies, are key components of burn infection management. New agents, such as β-lactam/β-lactamase inhibitor combinations and novel tetracyclines, show promise against MDR nonfermenting Gram-negative pathogens.

A structured, multidisciplinary team offers the most effective framework for improving outcomes in burn wound infections. Optimizing diagnostics, individualizing antimicrobial therapy, and aligning surgical timing with infection control measures are fundamental pillars. Future research should focus on prospective validation of integrated care pathways and on evaluating the real-world effectiveness of novel antimicrobial agents in burn-injured patients.