Infectious complications of burns in the intensive care unit

Severe burn injury is associated with profound physiological derangement and remains a major cause of infection-related morbidity and mortality worldwide. Disruption of the skin barrier sustained immune dysregulation, prolonged intensive care unit (ICU) exposure, and extensive use of invasive devices create a uniquely infection-prone host environment. Infectious complications, particularly those caused by multidrug-resistant organisms (MDROs), continue to account for a substantial proportion of deaths in critically ill burn patients despite advances in surgical and critical care management.

This narrative review aims to provide a comprehensive, clinically focused overview of infectious complications in critically ill burn patients, integrating current evidence on epidemiology, pathophysiology, microbial dynamics, diagnostic strategies, and contemporary management approaches relevant to daily ICU practice.

A narrative synthesis of the published literature was performed, including international guidelines, observational studies, randomised trials, systematic reviews, and translational research focusing on burn-related infections, antimicrobial resistance, diagnostics, and emerging therapies.

The review examines the multifactorial pathophysiology underlying infection susceptibility following major burns, including loss of the cutaneous barrier, hyperinflammatory responses followed by immune paralysis, and burn-induced hypermetabolism. Dynamic patterns of microbial colonisation, biofilm formation, microbiome disruption, and the global rise of MDROs are explored. Diagnostic challenges in distinguishing colonisation from invasive infection are discussed, alongside traditional and advanced diagnostic modalities such as quantitative tissue cultures, biomarkers, multiplex molecular assays, and next-generation sequencing. Contemporary management strategies are reviewed, emphasising early surgical source control, pharmacokinetically optimised antimicrobial therapy, antimicrobial stewardship, and rigorous infection prevention and control practices. Emerging adjunctive therapies, including bacteriophage therapy, nanotechnology-based antimicrobials, microbiome-directed interventions, and immunomodulatory approaches, are also highlighted.

Effective infection management in burn patients requires an integrated, multidisciplinary approach that combines rapid diagnosis, early surgical intervention, tailored antimicrobial therapy, and robust infection prevention strategies. Advances in molecular diagnostics, precision medicine, and microbiome science hold promise for improving outcomes and mitigating the growing burden of antimicrobial resistance in burn ICUs.

Infectious complications remain a leading determinant of outcome following severe burn injury. Optimising infection care through early recognition, precise diagnostics, coordinated surgical and antimicrobial strategies, and emerging precision-based interventions is essential to reduce infection-related morbidity and mortality in this vulnerable patient population.