The body is very susceptible to infection after burns, and it lasts for a long time throughout the whole process of burn treatment. It is impossible to try to eliminate pathogenic bacteria with a certain antibiotic or a combination of antibiotics, but it is also unrealistic not to apply antibiotics for large deep burns. If antibiotics are used irrationally, it will lead to more serious drug-resistant bacterial infections or even secondary infections, which will have bad consequences.
The current clinical use of antibiotics for burns has many problems:
(1) The indications are not strictly controlled. Blindly, uninterrupted use of antibiotics, and even gradually escalate, take turns to change drugs, not only to achieve the therapeutic effect, but also to promote the formation of drug-resistant strains.
(2) The choice of medication is unreasonable. The development of antibiotics, a variety of new and old antibiotics, and even the lack of understanding of the differences between the varieties, the choice of target is not strong.
(3) Improper combination of drugs. The lack of understanding of the mechanism of action of antibiotics, the application of antibiotics that have a mutually offsetting effect.
(4) unreasonable dosing scheme. The dose of antibiotics, the route of administration, the method of administration is inappropriate, resulting in failure to achieve effective concentration, causing adverse reactions.
(5) Not to consider the drug resistance situation, ignore the monitoring measures. Therefore, the author emphasizes that the use of antibiotics in the clinical treatment of burns should be divided into two cases: prophylactic and therapeutic.
I. Principles of prophylactic use of antibiotics
1. grasp the indications: the indications are:
(1) large area of deep burns.
(2) burn compound injury: such as burns combined with inhalation injury, fracture, visceral injury, etc.
(3) Large burns with one of the following conditions: advanced age, malnutrition, diabetes mellitus, abnormal immune function, delayed resuscitation, etc.
(2) The timing of prophylactic medication selection:
(1) Early post-burn period: start applying antibiotics within 24 hours after injury, the drug can penetrate deep burn tissue, the earlier the drug is used, the higher the concentration of the drug in the tissue, the better the effect of preventing and controlling infection. About 1 week after the injury is the reabsorption period, most of the trauma surface has not been eliminated, coupled with surgery and other factors, the possibility of infection is very high. Therefore, it is necessary to use antibiotics prophylactically during this period.
(2) Before and after major surgery: When large scab implantation, anesthesia, surgery, bleeding, etc. cause serious blow to the body, resulting in decreased resistance, and pathogenic bacteria may enter the blood through the trauma during the surgery. Therefore, antibiotics should be given during surgery to maintain effective concentrations in blood and tissues at all times. Specifically, antibiotics should be given 20-30 min before the start of surgery (i.e., during induction of anesthesia) to ensure that the antibiotic concentration is maintained throughout the surgery. Depending on the half-life of the antibiotic in the serum, the decision to administer an additional dose during surgery is made.
(The antibiotics should be continued for 2 to 3 days for the purpose of treatment for those who have large scabs or large wounds, and for those who have wounds on the face, head and neck, perineum and other special areas that cannot be removed together during surgery and have signs of infection. The misconception of prophylactic use of antibiotics is that “intraoperative use is not used after surgery”; continuous use of drugs for several days after surgery or even until the wound heals is not only unhelpful, but also harmful, which is not desirable.
Second, the principles of therapeutic use of antibiotics
1. correct judgment of the disease: antibiotic treatment is generally obtained before the results of bacterial culture drug sensitivity began, is empirical drug use, with a certain blindness. Therefore, first of all, it is necessary to clarify the type of strains causing the infection, as well as which antibiotics these strains are generally sensitive or resistant to, and then select the drugs accordingly. Generally speaking, burn patients who show mental depression, hypothermia, and reduced white blood cell count are mostly G- bacillus infections; while those who are mentally excited, agitated, and have high fever that does not subside, and whose white blood cell count increases dramatically, are mostly G+ coccus infections. In clinical work, there are often dual infections, such as G- bacillus mixed fungal infection, G+ coccus mixed fungal infection; sometimes there are both G- bacillus infection, G+ coccus mixed fungal infection, and mixed anaerobic bacillus infection. In these cases, the clinical manifestations of patients are complex, and it is often difficult to specify what kind of pathogenic infection. In this case, according to the patient’s previous use of antibiotics, clinical manifestations, comprehensive analysis and judgment, the corresponding antibiotic treatment.
2. Careful selection of antibiotics, targeted drug use: careful selection of antibiotics is based on the pathogenic investigation. Therefore, the infection specimens should be collected, such as traumatic secretions, sputum, blood and even subscab tissue, for bacterial culture and drug sensitivity test, according to the results of targeted drug use. If you can use narrow-spectrum, do not use broad-spectrum drugs. Particular attention should be paid to the drug resistance of bacteria. During the course of treatment, bacteria and their sensitivity to antibiotics may be in a constant state of change, therefore, it is necessary to carry out follow-up monitoring, be especially vigilant to the strong drug-resistant strains of bacteria, and carefully select the medication. In particular, it is important to take into account the needs of the disease, not to stick to the “gradual escalation” of a certain rule, and not to abuse highly effective drugs, new drugs and expensive drugs.
3. Observe the effect, timely adjustment: after the implementation of antibiotic measures, to closely observe the patient’s response to treatment. The pathogenic bacteria are sensitive to the antibiotics used or not, and clinical efficacy is closely related. If the clinical efficacy is good, but the bacteria in the test report are not sensitive to the antibiotics used, do not believe the results, but consider that the test report may be wrong, for example, the isolated culture of bacteria is not the main pathogenic bacteria, but contaminated bacteria or secondary pathogens, should continue the original treatment. On the contrary, if all the bacteria are sensitive to the antibiotics used, but the clinical efficacy is not good, do not be blindly optimistic and believe in the test report, but should look for the reasons from various aspects, such as whether the pathogenic bacteria are constantly entering the bloodstream, whether the trauma is its root cause, whether the various tubes set up for treatment are the pathways of infection, etc. It is important to emphasize that a set of antibiotic regimen should be used for 3 days before evaluating its efficacy, and should not be changed frequently.