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ScienceDirect

journal homepage: www.elsevier.com/locate/burns

Role of systemic antibiotic prophylaxis in acute

burns: A retrospective analysis from a tertiary
$
care center

Vamseedharan Muthukumar a, * , Praveen Kumar Arumugam a,

Rahul Bamal a,b
a
Department of Burns, Plastic & Maxillofacial Surgery, VM Medical College & Safdarjung hospital, Delhi, India
b
Griffith University, Australia

article info abstract

Article history: Introduction: Burns is a worldwide problem, majority of them occurs in low and middle-
Available online xxx income countries. The hurdles in treatment of burns in the resource restricted setting are
much unique and challenging. The role of intravenous antibiotics in reducing mortality and
morbidity related to infection and sepsis has not been studied extensively in the Indian sub-
Keywords: continent.
Antibiotic Materials and methods: This was a retrospective study that was conducted at a tertiary burn
Prophylaxis care centre in India over a period of six months with follow up of one month from the day of
Inhalational burn burn injury.
Sepsis Results: Data from a total of 157 patients were collected and analysed. In Prophylaxis group
Pneumonia (n = 77), sepsis was detected in 33 patients and 38 patients expired. In No Prophylaxis group
Mortality (n = 80), sepsis was detected in 37 patients and 40 patients expired. In Inhalational burns
subgroup, patients belonging to prophylaxis group (n = 30) had 20 patients diagnosed with
pneumonia while 22 patients did not survive till 30th post burn day. Patients in No
Prophylaxis group who had inhalational burns were 38 in number. Pneumonia was
diagnosed in 29 of them while 27 did not survive till 30th post burn day. In Pneumonia
subgroup, patients belonging to Prophylaxis group had lower mortality rate as compared to
No Prophylaxis group.
Conclusion: Our study does not support the routine usage of antibiotic prophylaxis in patients
with burn injuries, but their administration can be considered in certain specific subgroups
like patients with inhalational burns and patients developing pneumonia. Pneumonia is an
independent risk factor for mortality when no antibiotic prophylaxis is used in burn patients.
© 2019 Elsevier Ltd and ISBI. All rights reserved.

$
Place of study: Department of Burns, Plastic & Maxillofacial Surgery, Vardhman Mahavir Medical College & Safdarjung hospital, Delhi.
* Corresponding author at: Department of Plastic, Burns & Maxillofacial Surgery, V.M. Medical College & Safdarjung Hospital, Delhi, 110029,
India.
E-mail addresses: drvamseedharan@gmail.com (V. Muthukumar), praveen.k2423@gmail.com (P.K. Arumugam),
rahulturbo@yahoo.co.uk (R. Bamal).
https://doi.org/10.1016/j.burns.2019.12.004
0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: V. Muthukumar, et al., Role of systemic antibiotic prophylaxis in acute burns: A retrospective
analysis from a tertiary care center, Burns (2020), https://doi.org/10.1016/j.burns.2019.12.004
JBUR 6002 No. of Pages 6
2 burns xxx (2020) xxx
1. Introduction
Burns is a worldwide public health issue, accounting for an
estimated 1,80,000 deaths annually [1]. Low and middle-
income countries especially, African and South East Asia
regions contribute to around two thirds of the burn cases
globally. Developed countries have made substantial im-
provement in reducing rates of burn deaths, through a
combination of prevention policies and developments in the
care of people affected by burns [2]. The concept of early
wound excision and coverage of the wound with backup of
blood bank services, biological skin covers and other
logistics, has considerably reduced the incidence of sepsis
and its sequelae in their practice. Early excision and grafting
for burns is infrequently done in this part of the world due to
logistical problems, lack of facilities and heavy patient load.
In developing countries, the hurdles in treating burns
patients are plenty and unique in comparison to the
developed world. This can result in increased use of
antibiotics to prevent as well as treat infections resulting
in enhancement of their rates in burn patients. Therefore,
drug resistant organisms become a problem in the hospital
environment [3]. Burn wound reportedly, can contain up to
100 million organisms per gram of tissue after 2 days of
injury [3,4]. It is estimated that about 65% of the deaths in
burn patients is caused by septicaemia and it remains the
major cause of death in burn patients [5,6]. The role of
intravenous antibiotics in reducing mortality and morbidity
related to infection and sepsis has not been extensively
studied in the Indian sub-continent and none of the
published guidelines address these problems that are
unique to the developing countries. The aim of the study
was to analyse the role of prophylactic antibiotics in burn
patients with respect to infection and survival.
2. Methodology
2.1. Study setting
The study was retrospective in design and was conducted at
Department of Burns, Plastic & Maxillofacial Surgery, Var-
dhman Mahavir Medical College & Safdarjung hospital, Delhi,
a tertiary burn care centre in India over a period of six months.
Burn department has 15 Intensive care unit beds, 17 High
dependency unit beds and 32 ward beds. The burn department
is managed by 18 faculty members, 30 trainee residents and
6 non trainee residents.
2.2. Study population
The study population included patients between 18 50 years
who presented to the Department of Burns and Plastic Surgery
with thermal burns and scalds burns with total body surface
area involving 30% 60%. All the patients were followed up for
the duration of one month from the day of burn injury. The
exclusion criteria included were: documented pre burn
infection, diabetes mellitus, organ failure and comorbidities
related to respiratory tract.
Please cite this article in press as: V. Muthukumar, et al., Role of systemic antibiotic prophylaxis in acute burns: A retrospective
analysis from a tertiary care center, Burns (2020), https://doi.org/10.1016/j.burns.2019.12.004
xxx
2.3. Data and definitions
Anonymous data for all eligible patients were collected at the
time of admission using a preformed template of Microsoft
Excel 2010 (Microsoft, USA).
Sepsis was considered when three or more of the following
criteria are met: tachycardia (heart rate >90 beats/min),
tachypnea (respiratory rate >20 breaths/min), fever or hypo-
thermia (temperature >38 or <36  C), and leukocytosis or
leukopenia (white blood cells >12,000/mm3 or <4000/mm3
respectively) along with documented infection or clinical
suspicion of infection [7]. Microbiological cultures and sensitiv-
ity were obtained by surface swabs after cleansing or biopsies
from burnt area, sputum samples and endotracheal tube
cultures when applicable. Multidrug resistance was defined
as non-susceptibility to at least one antimicrobial agent from at
least three different antimicrobial classes [8]. The diagnosis of
inhalational burns was based on history of closed space burns
and clinical findings that included facial burns, singed nasal
hair, carbonaceous sputum, hoarseness of voice and features of
upper airway obstruction [9]. The diagnosis of pneumonia was
based on presence of persistent fever, purulent sputum,
leukocytosis or leukopenia, and decline in oxygenation along
with a new or progressive infiltrate on chest radiograph [10]. The
Abbreviated Burn Severity Index score (ABSI) consists of five
variables (sex of patient, age, presence of inhalation injury,
presence of full thickness burn, percentage of total body surface
area burned) and demonstrates predictive power for classifying
patients according to their risk [11].
Antibiotics that included injectable penicillin with beta
lactam or third generation cephalosporin were started at the
time of admission or <24 h of burn in prophylaxis group.
2.4. Statistical analysis
The population was divided into Prophylaxis and No Prophy-
laxis groups. The incidence of the wound infection, sepsis and
mortality was calculated and data were analysed for any
association among the variables under study. The skewed data
were represented as mean and/or median. The continuous
variables were analysed with t test. A p value <0.05 was
considered statistically significant. Tukey’s multiple compar-
ison test for variables with individual and multiple variables
(Age, sex, weight, total body surface area (TBSA) burnt, Length
of hospital stay, Inhalational injury, Full-thickness burn, ABSI,
Time from burn to arrival, Fluid received prior to arrival (ml),
Fluid deficit according to modification of Brooke formula (2ml/
kg/%TBSA [max 50%] crystalloid plus maintanence fluid @
50ml/kg crystalloid over 24 hours that is used as standard at
our centre) on arrival (ml), Sepsis, Mortality (30 days),
Pneumonia, Mortality (pneumonia, inhalational burn, sepsis),
Urinary tract infection (UTI), Central line infection, Wound
culture positivity, Blood culture positivity, Fever appearance)
in combination were done and analysis having significant
differences were reported.
3. Results
Data from a total of 157 patients were collected and analysed.
The mean age of cohort was 31.36 years (18 50 years) with the
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burns xxx (2020) xxx xxx 3

majority of the population in 20 29 year age group (40%) and

male population contributing to 51 percent of the total
number. 76 percent burns were sustained due to accidental
injuries and mean TBSA involved was 47.26%. The average
duration of hospital stay was 21.48 days (11 35 days).
Inhalational burns were diagnosed in 68 patients while sepsis
developed in 70 patients during the course of their treatment
(Table 1).
In Prophylaxis group, the mean Abbreviated Burn Severity
Index (ABSI) — was 10 in a total of 77 patients. The patients
arrived on average 428.5 min from time of burn with fluid
deficit of 1800 ml. Sepsis was clinically detected in 33 patients
with mean detection day as 6th day and 38 patients expired
during the first post burn month. First febrile episode was Graph 1 – Population characteristics (Prophylaxis vs No
noted on a mean of 5th day and the average duration of prophylaxis group).
hospital stay was 22 days.
In No Prophylaxis group, the mean ABSI was 11 in a total of
80 patients. The patients arrived on average 543.1 min from
time of burn with fluid deficit of 2300 ml. Sepsis was clinically
detected in 37 patients with mean detection day as 7th day and
40 patients expired during the first post burn month. Anti-
biotics were started on the 6th day (mean) and the first febrile
episode was noted on the 6th day. The average duration of
hospital stay was 19.9 days. (Graph 1 ). Pseudomonas
aeruginosa was seen in 15 isolates compared to 30 in
Prophylaxis group but there was no difference in multi-drug
resistance organism isolates between both groups (24 in
prophylaxis and 22 in no prophylaxis group).
Subgroup analysis was done for patients with inhalational
burns and pneumonia. All patients were clinically assessed
for inhalational burns while 108 patients had adequate
records for evaluating pneumonia. In Inhalational Burns
Graph 2 – Subgroup-inhalational burns.
subgroup, patients belonging to Prophylaxis group (n = 30)
had average hospital stay of 24 days, sepsis was seen in
18 patients, pneumonia was diagnosed in 20 patients and
22 patients did not survive till 30th post burn day. Patients expired as compared to No Prophylaxis group (n = 32) where
belonging to No Prophylaxis group in Inhalational Burns 27 patients did not survive in first post burn month. (Graph 3 )
subgroup (n = 38) had average hospital stay of 26 days, sepsis Incidence of sepsis, mortality and pneumonia in No
was seen in 21 patients, pneumonia was diagnosed in Prophylaxis group were significantly higher as compared to
29 patients and 27 patients did not survive till 30th post Prophylaxis group in patients with inhalational burns. Onset of
burn day (Graph 2 ). fever in patients with inhalational burns was earlier in No
In Pneumonia subgroup, patients belonging to Prophylaxis Prophylaxis group when compared to Prophylaxis group and
group (n = 22) had lower mortality rate in which 10 patients the difference was statistically significant.

Table 1 – Population characteristics.

Parameters Prophylaxis group No prophylaxis group p-value

(n = 77) (n = 80)
Mean : (Range)
Age 31.59: (18 50) 31.21 (18 50) 0.9
Male / Female 42/35 39/41
Weight in kg, mean 62.5 : (38 82) 67.2 (39 86) 0.64
TBSA burnt 45.32 : (30 60) 48.89 : (30 60) 0.078
Length of hospital stay (Days) 22.3 : (15 59) 19.9 : (14 54) 0.043
Inhalational injury present 30 38 0.08
Full-thickness burn present 24 30 0.32
ABSI, mean 10 11 0.88
Time from burn to arrival (minutes), mean 428.5 543.1 0.038
Fluid received prior to arrival (ml), mean 3200 3900 0.0473
Fluid deficit according to modification of Brooke on arrival (ml), mean 1800 2300 0.0519

Please cite this article in press as: V. Muthukumar, et al., Role of systemic antibiotic prophylaxis in acute burns: A retrospective
analysis from a tertiary care center, Burns (2020), https://doi.org/10.1016/j.burns.2019.12.004
JBUR 6002 No. of Pages 6

4 burns xxx (2020) xxx xxx

antibiotic prophylaxis in burns patients especially for systemic

Graph 3 – Subgroup-pneumonia.
Similarly in Pneumonia subgroup, incidence of sepsis and
mortality rates was significantly higher in No prophylaxis
group as compared to prophylaxis group. There is no statisti-
cally significant difference in mortality in pneumonia sub-
group patients belonging to No Prophylaxis group irrespective
of presence of inhalational burns. Therefore, pneumonia was
identified as an independent risk factor for mortality in No
Prophylaxis Group on multivariate analysis (Table 2).
4. Discussion
Burns and intensive care patients have quite a few similarities
among themselves [6]. Populations belonging to both the groups
are critically ill and bacterial translocation is an important
source of infection among them. There is documented reduc-
tion in incidence of ventilator associated pneumonia, mortality
and bacteremia in patients of intensive care units who are
receiving antibiotics. Damage of the skin is an additional source
of infection in burn patient population and they also have a
higher degree of immunosuppression [5]. Recommendations
for management of burn patients do not provide clear guidance
on whether the prophylactic antibiotics should be administered
or not. [12,13]. Nevertheless, uniform consensus in the current
literature is to do away with systemic antibiotics prophylaxis in
burns (Table 3).
In general, there are not much data available in published
literature from the developing countries regarding the
antibiotics. However, Practical Handbook of Burns Manage-
ment released by National Programme for Prevention, Man-
agement and Rehabilitation of Burn Injuries (NPPMRBI) India
states that prophylactic use of antibiotics normally should be
avoided as it has not been found to reduce chances of infection
[12]. But there is no quote about the evidence on which the
statement is based.
A randomized control trial conducted in Nigeria found that
systemic antibiotic prophylaxis had no effect in controlling
burn wound infection in patients managed in surgical wards
[17]. The authors also suggested that there was no significant
beneficial effect on the time of occurrence and in prevention of
colonization or infection of burns. We also did not find any
beneficial effect of prophylactic antibiotics on burn wound
colonization. Furthermore, the findings indicated that there
was increased cumulative occurrence of growth of Pseudomo-
nas aeruginosa in burn wounds in patients receiving antibiotic
prophylaxis. The increased incidence of Pseudomonas in
prophylactic antibiotic group was also seen in this study and
the difference was statistically significant.
Prospective cohort study done in Northern America
concluded that the low incidence of Group A Streptococci
infection in burns patients did not warrant penicillin prophy-
laxis in the first five post-burn days [19]. Another study
conducted in Europe stated that there was no significant
difference in the infection rates between the treated and
untreated patients and the authors agreed that prophylactic
systemic antibiotics did not reduce the risk of wound
infections and mortality rates [15]. Similarly, there was no
significant difference in the day of identification of clinical
sepsis among Prophylaxis and No Prophylaxis group in our
study. These two studies from developed countries had
documented low baseline incidence of streptococcal infec-
tions and sepsis, which is not the situation in resource
restricted countries where rates of infection are much higher.
Our study also showed a high sepsis rate (44.5%).
A retrospective cohort study from United Kingdom re-
viewed that the selective use of systemic prophylaxis to high-
risk burns patients would be more beneficial with less actual
infection rates. High risk burn patients included patients gross
wound contamination, extreme age groups, lower extremity
burns, 24 h or more from burns and patients with comorbid-
ities [16]. Studies from Japan reported that in prophylactic
antibiotic group, the early pneumonia and mortality rates
were low and documented beneficial effects of antibiotics

Table 2 – Tukeys multiple comparison test for variables.

Tukey's multiple comparisons test Mean Diff. Adjusted p Value
Inhalational injury present and Sepsis Prophylaxis vs No prophylaxis 14.5 vs 21 0.0167
Inhalational injury present and Mortality Prophylaxis vs No prophylaxis 13.8 vs 19.5 0.0055
Inhalational injury present and Pneumonia Prophylaxis vs No prophylaxis 20 vs 31.5 0.0008
Inhalational injury present and Fever appearance (Day) Prophylaxis vs No prophylaxis 15.9 vs 27.6 0.0014
Sepsis and Mortality (30 days) (Inhalational injury present) Prophylaxis vs No prophylaxis 10.1 vs 13.5 0.0381
Pneumonia present and Sepsis Prophylaxis vs No prophylaxis 33.1 vs 44.5 0.0037
Pneumonia present and Mortality (30 days) Prophylaxis vs No prophylaxis 21 vs 33 0.0289
Inhalational burn and pneumonia present vs Mortality No prophylaxis 45.2 0.0033
Inhalational burn absent and pneumonia present vs Mortality No prophylaxis 45 0.0034

Please cite this article in press as: V. Muthukumar, et al., Role of systemic antibiotic prophylaxis in acute burns: A retrospective
analysis from a tertiary care center, Burns (2020), https://doi.org/10.1016/j.burns.2019.12.004
JBUR 6002 No. of Pages 6

burns xxx (2020) xxx xxx 5

Table 3 – Summary of studies.

S.No Study Year Antibiotics used Results Remarks
1. Durtschi [14] 1982 Penicillin No benefit of systemic Not applicable
prophylaxis
2. Timmons MJ [15] 1983 Not available No significant differences in Outpateint; Loss to follow
infection rates between up -46%
groups
3. Boss WK et al. [16] 1985 Not available Infection rates were low to Poor statistical work
substantiate use of antibi-
otic prophylaxis
4. Munster [12] 1986 Polymyxin B No benefit of systemic Not applicable
prophylaxis
5. Ugburo et al. [17] 1992 Ampicillin, Cloxacillin, No beneficial effect on col- Increased incidence of
Erythromycin, Gentamicin onization and infection Pseudomonas growth
6. Kimura et al. [18] 1998 Sulfamethoxazole - trimethoprim Reduction in mortality and Not applicable
pneumonia in prophylaxis
group
7. Sheridan et al. [19] 2001 Penicillin Low incidence of Group A No uniform
Streptococci, does not war- systemic antibiotic use
rant prophylaxis
8. De la Cal [20] 2005 Cefotaxime Prophylaxis reduces mor- Selective decontamina-
tality and pneumonia tion of digestive tract
incidence included
9. Avni et al. [21] 2010 Meta analysis Reduced rate of pneumonia Not applicable
and a reduced rate of burn
wound infections when
given antibiotic prophylaxis
10. Barajas-Nava et al. [22] 2013 Meta analysis Effects of systemic antibiotic Not applicable
prophylaxis on burn wound
infection are unclear
11. Tagami et al. [23] 2016 Not available Mortality rates reduced in Not applicable
mechanically ventilation in
prophylaxis group

prophylaxis in a subgroup that required early mechanical
ventilation in severe burn patients [18,23]. A systematic review
and meta-analysis from Israel revealed reduced rate of
pneumonia, burn wound infections and significant decrease
in all-cause mortality with systemic antibiotic prophylaxis for
4 14 days among patients with burns [21]. The incidence of
pneumonia was significantly reduced in Prophylaxis group
when the inhalational injury subgroup was considered in our
study. We did not find any significant difference in mortality
among Prophylaxis group and No Prophylaxis group that was
in contradiction to the findings in literature of reduction in
overall mortality.
A Cochrane systematic review concluded that the antibiotic
prophylaxis does not demonstrate reduction in burn wound
infection, invasive infections, or mortality associated with
infection [22]. The findings from the review suggested a reduction
in the incidence of pneumonia. In No Prophylaxis group of our
study, the incidence of pneumonia and deaths among the
patients with pneumonia was significantly higher when com-
pared to that group who received prophylactic antibiotics.
ISBI practice guidelines 2016 also states that prophylactic
systemic antibiotics do not reduce sepsis and should be
avoided. For resource limited settings, their recommendations
state to monitor wound microbiology and prescribing antibi-
otic prophylaxis may be beneficial [24]. The recommendation
to lower the threshold for initiating antibiotic prophylaxis in
these settings contradicts the practice of evidence based
medicine practice largely because of lack of evidence in
developing economies and regional data to encourage or
discourage the use of prophylaxis. None of the published
literature documents increasing antibiotic resistance patterns
solely due to the use of antibiotic prophylaxis. It is important to
note that most of the studies on which current recommen-
dations are based are from developed economies where the
incidence of infection is less, source reduction surgery rates
are high and hence the rate of sepsis is significantly low. But in
our setting, the incidence of burns is high, burn injuries are
more extensive and deeper, early excision surgeries for acute
burns are uncommon, sepsis incidence is high and nutritional
status of patient is not adequate. It is true that the thought
about increasing incidence of antibiotic resistance is a
concern, the targeted antibiotic prophylaxis may be the way
forward in these situations.
4.1. Limitations
This was a single centre study with limited population and
duration eligible for the study. Retrospective nature of the
study is another limitation of this work. Burn is multifactorial
disease process influenced by many parameters which affect
their outcomes. We have studied limited commonly used
parameters and there can be confounding parameters which
we have not studied here. Inhalational burns were diagnosed
on clinical grounds due to lack of availability of bronchoscopy
facilities. Excretion of antibiotic and half-life calculation was
not done as this was a retrospective study. Antibiotic dosages

Please cite this article in press as: V. Muthukumar, et al., Role of systemic antibiotic prophylaxis in acute burns: A retrospective
analysis from a tertiary care center, Burns (2020), https://doi.org/10.1016/j.burns.2019.12.004
JBUR 6002 No. of Pages 6
6 burns xxx (2020) xxx
were not standardized to the body weight of the patients
(Amoxycillin + Clavulinic acid 1-1.2 gQ8h, Cefotaxim 1-1.5
gQ8h, Ceftriaxone1-1.5 gQ8h, Cefoperazone+Sulbactum 1-1.5
gQ8h; Weight 43 110 kg).
5. Conclusion
Our retrospective analysis suggests against routine usage of
antibiotic prophylaxis in burns patients, but there seems to be
benefit in certain subgroups like patients with inhalational
burns and pneumonia complicating burns. Pneumonia was
identified as an independent risk factor for mortality when no
antibiotic prophylaxis is used in burn patients. There should be
better designed multicentric randomized control study to assess
the implications of antibiotic prophylaxis in burn patients and
formulate recommendations in developing countries based on
the evidence rather than the lack of it as presently done.
Authors' contributions
RB contributed to conceptualisation, methodology, supervi-
sion and reviewing & editing the manuscript ; VM and PK
contributed in data collection, data analysis and writing the
original draft; All authors read and approved the final
manuscript. There was no writing assistance obtained.
Funding
There was no direct or indirect funding received by authors.
Conflict of interests
The authors declare that they have no competing or conflict of
interests.
Acknowledgements
No acknowledgement.
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