Abstract
Infections and sepsis have been present for centuries in surgical, critically ill, and burn patients. However, the awareness and the recognition that infection and sepsis contribute profoundly to patient outcomes have gained substantial momentum over the last two decades, particularly when several studies causally linked the presence of infections and sepsis to clinical outcomes. The increased presence of multi-drug–resistant organisms further enhanced awareness and research because these organisms substantially worsen outcomes of burns and critically ill patients.
For some time, our concern has been: how do we diagnose or identify infections early and prevent progression to sepsis? There has been a synchronized or concerted effort to diagnose and identify sepsis in critically ill patients starting at the end of the twentieth century. The critical care community subsequently developed a sepsis definition that has been updated three times.
In the burn community, the American Burn Association (ABA) organized a consensus conference to define sepsis in burns in 2007, and subsequently the first definition was developed. There have been modifications and alterations of the ABA definition and a new version is expected for 2020/2021. Additionally, other investigators developed a new definition altogether, for example Mann-Salinas. As these definitions still lack strong diagnostic power, numerous groups undertook efforts to use biomarkers, cytokines, or tissue markers to better diagnose and personalize treatment for sepsis.
It is well documented that burn injury incites an inflammatory response that mimics the signs of sepsis; this makes it challenging to identify whether a burn patient is septic or not. But early initiation of sepsis treatment improves outcomes by a significant margin. The challenge we face as burn care providers is to determine if a burn patient is septic and if we should start antibiotics. Time saves lives and providers should start antibiotic treatment as soon as they have any concerns about sepsis. However, if we misuse antibiotic agents on patients with a non-infectious inflammatory response, we will further add to the burden of antibiotic resistance. Therefore, defining true sepsis in the burn patient is important and an incorrect diagnosis has numerous consequences.
In addition, once we identify sepsis, and certainly want to start treating sepsis, the next challenge is how best to treat burn patients with infections and sepsis. Multi-resistant organisms, opportunistic infection, fungal, and viral infections, are all playing an increasing role. Unnecessarily administering antibiotic agents has been shown to induce multi-drug–resistant organisms, overuse of antibiotic agents, and cause other morbidities such as acute kidney injury. Thus, it is not only the aspect of diagnosing infection and sepsis, but also treating infections and sepsis in burn patients.
Although we understand parts of the responses and the outcomes of sepsis, we still lack the exact physiologic and pathophysiologic responses that occur with sepsis. This is despite identifying how bacterial, viral, or fungal organisms induce signalling pathways that lead to alterations. However, we still do not understand the complex pathways that are present when a burn patient becomes septic, preventing us from adequately personalizing and treating patients with burn sepsis.
This dedicated issue explores all aspects of infections and sepsis in burn patients with the goal of delineating these complex themes. This unique issue of Surgical Infections provides up-to-date coverage on topics such as topical antimicrobial agents, the innovation of antimicrobial agents, diagnosing and detection of sepsis, and sepsis definitions. We also cover contamination versus infection versus sepsis, infection in specific burn populations such as pediatrics, adults, and geriatrics. We also describe bacterial, yeast, fungal, and opportunistic infections. Then we move into the pharmacokinetics and pharmacodynamics of antimicrobial agents, multi-drug–resistant organisms, and experimental treatments. We believe this will provide the reader with a strong overview of current treatment standards, future needs, and potential for further study.