Page 17 - Read Online

Page 12 of 16 Tejiram et al. Plast Aesthet Res. 2025;12:9 https://dx.doi.org/10.20517/2347-9264.2024.109

data produced from abdominal-based surgeries but have been adapted to a wide variety of surgical
procedures among various surgical subspecialties. Burn injuries are inherently different from other trauma,
surgically created wounds, and chronic wounds due to the nature of the injury, mechanism of burn wound
infection, and management of associated burn wound sepsis. Furthermore, this patient population presents
in an immunocompromised state due to the severe inflammatory response following burn injuries and the
loss of skin integrity, making them especially susceptible to opportunistic pathogens and organisms. The
serial grafting procedures that often hallmark burn care mean some degree of open wound burden, and
thus, the opportunity for invasive organisms to flourish remains high. As a result, antibiotic use in this
population is rigorously regimented to avoid the development of resistant bacterial species . Despite this,
[12]
preoperative antibiotic use in burn injury remains debated, often in the context of the classic teaching of
preoperative antibiotic use, as previously mentioned. Antibiotic administration, even as a single dose prior
to surgery, risks the development of resistant bacterial species in burn-injured patients.

Cefazolin is a cephalosporin commonly used as a prophylactic antibiotic in surgical interventions to prevent
surgical site infection. A single high-concentration dose administered intravenously is above the minimum
inhibitory concentrations (MIC) of most commensal pathogens that are the cause of initial infection, such
as Staphylococcus aureus, Staphylococcus epidermis, and Escherichia coli, making the perioperative dose
[43]
advantageous compared to a continuous infusion . In this study, antibiotics did not affect LOS,
reepithelization, or graft loss. The LOS of ABX patients and no-ABX patients was similar, with a median of
6 days (IQR: 4-7). All wounds were mostly epithelized at follow-up, which occurred at an average of 14 days
post grafting (IQR: 8-27). This finding is corroborated by the literature. For example, Hill et al. found that
antibiotic administration in less severe burns (< 20% TBSA) was unneeded antimicrobial exposure and did
not change the success rate as measured by graft loss, bacteremia, or surgical site infection . However, this
[44]
study did not examine changes in biodiversity or wound microbiome following preoperative antibiotic
administration, making our assessment unique in this context.

Superfluous antibiotic administration should not be disregarded as there is an abundance of literature
highlighting the development of MDRO through inappropriate antibiotic prophylaxis [2,9,11,22,43,45] . Not only
has the increasing incidence of MDRO been reported in burn centers, but the effects of antibiotics on the
[41]
resident microbiome due to antibiotic misuse are also becoming more prevalent . Putra et al. discovered in
a retrospective analysis that the use of prophylactic antibiotics such as cefazolin, ceftazidime, and
ceftriaxone during burn wound debridement led to an increase in MDROs . Moreover, Timmons et al.
[43]
argued that systemic antibiotic administration is ineffective at discretely targeting avascular burn eschar
where organisms such as S. aureus and P. aeruginosa are favored to grow . This work examining the
[46]
microbiome of groups following antibiotic administration shows that even short-course single antibiotic
administration can have a major effect on bacterial taxonomy.

Preoperative antibiotics and burn wound bed microbiome
Commensal microbes can protect the wound bed from infection and aid in healing. Common commensals
such as Propionibacterium and Cutibacterium were enriched in the wound bed swabs of ABX patients
intraoperatively (results not shown). It has been shown that Propionibacterium provides protective effects
against Pseudomonas infection, with lower abundances of Propionibacterium leading to an increase in
Pseudomonas infection [1,47,48] . However, in the wound beds at dressing takedown in the ABX group, rather
than commensal microbes, the bacteria most significantly enriched were predominantly extremophiles such
as Anoxybaccillus, Effusibacillus, Meiothermus, and Thermoflavifilum. Plichta et al. describe a similar
manifestation of thermophiles in the wound post burn injury. They hypothesized that cutaneous ionic and
osmolarity imbalances create an environment in the burn eschar that is more favorable to these types of
[1]
organisms where normal skin is prohibitive . Another hypothesis for extremophile colonization of the