Challenges in Antimicrobial Treatment and Antimicrobial Stewardship in Hospital-Acquired Infections in Adult Burn Patients

Background: Hospital-acquired infections (HAIs) represent the most significant complications in patients hospitalized for severe burn injuries, after the immediate post-burn resuscitation phase, and are associated with substantial morbidity and mortality. Methods: This is a narrative review. Evidence was extracted mainly with an in-depth search of MEDLINE, focusing on guidelines, randomized controlled trials, and relevant observational studies published in the last 25 years. The reference lists of the most relevant publications were screened to retrieve additional relevant information. Results: Wound infections, bloodstream infections, pneumonia, and urinary tract infections account for the majority of infectious complications. Their diagnosis can be challenging, particularly in the context of wound infections and sepsis. Burn severity and the resulting disruption of tissue and organ homeostasis can alter the pharmacokinetic and pharmacodynamic (PK/PD) properties of antibiotics, rendering standard dosing and administration strategies inadequate. Higher doses, prolonged or continuous infusions, and therapeutic drug monitoring may be required to optimize antibiotic exposure. The emergence of multidrug-resistant (MDR) pathogens (particularly MDR Gram-negative bacilli) has been widely reported across diverse epidemiological settings and occurs frequently in patients with prolonged hospitalization, further complicating treatment. As a result, the use of broad-spectrum antibiotics is substantial, both for empirical therapy and for targeted treatment. Although antimicrobial stewardship programs can promote more appropriate antibiotic use, evidence on how to effectively implement these strategies in Burn Intensive Care Units remains limited. Conclusions: HAIs in burn patients represent a highly complex clinical scenario. Clinical severity is often significant, diagnosis can be challenging, and MDR pathogens are very prevalent, with high consumption of broad-spectrum antibiotics. Moreover, PK/PD properties of antibiotics can be altered. Antimicrobial stewardship can promote appropriate antimicrobial use, but implementation in this setting has not been adequately studied. Close multidisciplinary collaboration between burn specialists and infectious diseases physicians is essential to ensure effective patient management.