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Tejiram et al. Plast Aesthet Res. 2025;12:9 https://dx.doi.org/10.20517/2347-9264.2024.109 Page 3 of 16

[12]
this population . Even small or short-course antibiotics may select resistant organisms that can become
problematic for antibiotic selection later in a patient’s hospital course [1,2,13] .

Examination of small or short-course antibiotic use in burn-injured patients may provide a novel and
innovative way to examine the influence of antibiotics on outcomes and the microbiome. One such example
of short-course antibiotic use is in preoperative antibiotic selection. Much has been written about the
benefits of preoperative antibiotic use to avoid surgical site infections and other complications in abdominal
surgery. However, the role of systemic antibiotic prophylaxis is debated in burn care. Preoperative
antibiotics, in general, are employed for the prevention of surgically acquired infections. It has been
suggested that the timing of these antibiotics helps reduce wound bed infection, maintain graft adherence,
and prevent more invasive bloodstream infections from occurring [14-16] . However, duration postoperatively,
dose, and antimicrobial selection are still debated. In a review by Ramos et al., the use of systemic antibiotic
prophylaxis for burn patients requiring mechanical ventilation and/or split-thickness skin grafts was
[17]
suggested to be beneficial . In a study conducted from October 2001 to October 2006, the autograft
survival rate was 97% in patients with preoperative and perioperative antibiotic administration, whereas it
was significantly lower at 87% in those with no antibiotic treatment . Skin colonizing microbiota may play
[15]
a role in maintaining skin homeostasis but may contribute to aberrant wound healing when disrupted .
[18]
One study by Jung et al. noted permanent changes in healed skin microbiomes following burn injury and
suggested that specific skin microorganisms correlated with biomechanical scar dynamics .
[19]
Empiric antibiotic use is sometimes employed in the management of burn wounds following mass casualty
incidents, or in severe burns with concomitant trauma where burn wounds are more likely to be
contaminated by contact with the external environment [11,20-22] . In mass casualty incidents, adherence to the
well-studied standards of burn care, such as frequent dressing changes with topical antimicrobials and early
excision and grafting, becomes difficult secondary to logistic constraints in the delivery of nursing and
surgical care, respectively. Hemodynamic and respiratory stabilization is often a longer process in these
cases when concurrent traumas may need to be assessed as well. These combined factors make systemic
antibiotic treatment favorable even before wounds are cultured to proactively counteract the expected onset
of infection [11,20,21,23] . One study investigating the use of systemic antibiotic prophylaxis after a mass casualty
burn incident caused by a cornstarch explosion demonstrated a 45% reduction in wound infection rate at
one week postburn. Moreover, despite the development of bloodstream infections in some patients, no
mortality occurred in more severe higher total body surface area (TBSA) burn patients .
[11]
Despite these findings, literature on the long-term effects of systemic antibiotic administration in burn
patients is limited. In the previously mentioned study on burn mass casualty, though antibiotic prophylaxis
usage lowered rates of wound infection, it was associated with the development of fungal and MDRO
infections . In another study, systemic antibiotic prophylaxis was associated with subsequent growth of
[11]
P. aeruginosa in the wound bed , while a meta-analysis by Csenkey et al. found systemic antibiotic
[23]
prophylaxis not effective in preventing infection in pediatric burn patients matched by age, TBSA, or
country income level . Most literature on systemic antibiotic prophylaxis in burn management focuses on
[24]
larger burn injuries where a significant TBSA warrants the use of antibiotics to prevent infection, sepsis, and
shock. Furthermore, there remains a paucity of literature examining the effect of this antibiotic practice on
patient microbiomes and a better understanding of this may guide improved antimicrobial practice and
selection. The objective of this study was to investigate the effect of preoperative antibiotics on the bacterial
microbiome of burn-injured patients and their associated clinical outcomes.