Infectious Diseases in Critical Care Medicine

changes increase the risk of shearing with loss of grafts or underlying healing cells. Soaks will
remain effective because antibiotic solution can be added without removing the dressing,
however, the underlying wound and skin can become macerated. Topical antibiotic salves
include 11.1% mafenide acetate (Sulfamylon), 1% silver sulfadiazine (Silvadene), polymyxin B,
neomycin, bacitracin, mupirocin, and the antifungal agent nystatin (Table 1). No single agent is
completely effective, and each has advantages and disadvantages.
Silver sulfadiazine is the most commonly used topical agent. It has a broad spectrum of
activity from its silver and sulfa moieties covering gram-positives, most gram-negatives, and
some fungal forms. SomePseudomonasspecies possess plasmid-mediated resistance. It is
relatively painless upon application, has a high patient acceptance, and is easy to use.
Occasionally, patients will complain of some burning sensation after it is applied, and a
substantial number of patients will develop a transient leukopenia three to five days following
its continued use. This leukopenia is generally harmless, and resolves with or without
cessation of treatment.
Mafenide acetate 11.1% cream, which also has a broad spectrum of activity particularly
against resistantPseudomonasandEnterococcusspecies and readily diffuses into eschar, can
control, and even reduce the density of bacteria in a burn wound in which delayed initiation of
topical antimicrobial therapy has permitted intraeschar proliferation of microorganisms.
Control of the microbial density in the burn wound by topical therapy not only decreases the
occurrence of burn wound infection per se but also permits burn wound excision to be carried
out with marked reduction of intraoperative bacteremia and endotoxemia. These two conditions
formerly compromised the effectiveness of burn wound excision performed on other than the
day of injury. Disadvantages include transient pain following application to skin with sensation,

Table 1 Topical Antimicrobials Commonly Used in Burn Care

Salves Advantages Disadvantages

Silver sulfadiazine
(Silvadene 1%)

l Broad-spectrum

l Relatively painless on application

lTransient leucopenia

lDoes not penetrate eschar

lMay tattoo dermis with black flecks

Mafenide acetate
(Sulfamylon 11%)

l Broad-spectrum

l Penetration of eschar

lTransient pain upon application to

partial thickness burns

lMay cause an allergic rash

lCarbonic anhydrase inhibition

Polymyxin B/neomycin/
bacitracin

l Wide spectrum

l Painless on application

l Colorless allowing direct inspection

of the wound

lAntimicrobial coverage less

than alternatives

Mupirocin (Bactroban) l Broad-spectrum (especially
Staphylococcusspecies)

lExpensive

Nystatin l Broad antifungal coverage lMay inactivate other antimicrobials
(Sulfamylon)

Soaks
Silver nitrate (0.5%) l Complete antimicrobial coverage
l Painless

lBlack staining when exposed to light

lElectrolyte leaching

lMethemoglobinemia

Mafenide acetate
(Sulfamylon 5%)

l Same as salve lSame as salve

Sodium hypochlorite
(Dakin’s 0.05%)

l Broad-spectrum coverage lInactivated with protein contact

lCytotoxic

Acetic acid l Broad-spectrum coverage
(especiallyPseudomonas)

lCytotoxic

Infections in Burns in Critical Care 361