The use of oral antibiotic suppression for control of infections in patients with thermal injuries

Selective decontamination of the digestive tract in burn patients: Protocol for a systematic review

BACKGROUND

Nosocomial infections contribute significantly to mortality and morbidity in burn patients. Selective decontamination of the digestive tract is an infection prevention measure that has been shown to improve survival in mechanically ventilated intensive care unit (ICU) patients. It has been hypothesized that burn patients may benefit from selective decontamination of the digestive tract.

METHODS/DESIGN

We will conduct a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials (RCTs) assessing the patient-important effects of selective decontamination of the digestive tract in burn patients, as compared with placebo or no intervention/standard of care. The primary outcome will be 30-day mortality. Secondary outcomes include serious adverse events, anti-microbial resistance, pneumonia, blood stream infections, ICU- and hospital-free days and 90-day mortality. We will search the following databases: CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science and CINAHL and follow the recommendations provided by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The certainty of evidence will be assessed according to the GRADE approach: Grading of Recommendations Assessment, Development and Evaluation.

DISCUSSION

There is clinical equipoise about the use of selective decontamination of the digestive tract in burn patients. In the outlined systematic review and meta-analysis, we will assess the desirable and undesirable effects of selective decontamination of the digestive tract in burn patients.

Burn Wound Sepsis

Wound sepsis remains perhaps the most feared sequela in the patient who has suffered major burn injuries and leads to overwhelming mortality among patients with extensive burn wounds. The presence of large areas of devitalized, necrotic tissue, coupled with the profound immunosuppression that usually follows major injury, sets the stage for rapid microbial proliferation in the wound; when microbes invade subjacent, previously vi able tissues, invasive burn wound sepsis is defined. Top ical antimicrobial drugs probably have only a limited effect in preventing wound sepsis, and organisms now frequently emerge that are resistant to the commonly used topical agents. Salient factors in the diagnosis and treatment of invasive wound sepsis are discussed in this review. Prevention of wound sepsis, however, is one of the primary objectives of current burn care. Early burn wound excision and immediate wound closure with autograft or a suitable biologic dressing has emerged as the best means for prevention of generalized wound sepsis.

Infections in burned patients

Prevention and treatment of burn wound infection requires knowledge of the epidemiology of such infections. Prevention of infection rests on removal of reservoirs or sources of microorganisms from the burn patient's environment and interruption of transfer of microorganisms to the surface of the wound. When prevention fails and burn wound infection develops, successful therapy may depend on an understanding of the epidemiology of the burn wound during therapy. Contrary to the oft stated concept that antibiotics penetrate the avascular burn wound poorly, our study demonstrated that gentamicin and tobramycin achieved therapeutic concentrations in burn wound tissue. As in other types of infections, susceptible microorganisms were eradicated and resistant microorganisms persisted. Of most importance was the observation that resistant microorganisms may repopulate the wound within four days of starting therapy. It would appear that failure of therapy is not due to failure of antibiotics to penetrate the burn wound but rather to rapid development of superinfection during therapy.