Discussion

This pilot survey evaluated MRSA prevention practices in 12 US burn units through the SHEA Research Network. It demonstrated substantial variability in surveillance, decolonization, and wound-care practices. This variation may reflect the limited burn-specific evidence base and reliance on practices extrapolated from general ICU infection prevention practices.

Burn patients are highly susceptible to infection with multidrug-resistant organisms due to loss of the skin protective barrier, need for invasive devices and mechanical ventilation, repeated wound excision and grafting surgeries, antibiotic exposures, and prolonged hospitalizations. ^{Reference van, Gagnon and Conrad1,Reference Lachiewicz, Hauck, Weber, Cairns and van Duin3} MRSA is one of the most frequently encountered pathogens in burn wounds. Infections caused by MRSA can be severe and associated with sepsis, surgical graft loss, prolonged hospital length of stay, and increased mortality, especially in high-percent total body surface area burns. ^{Reference Kalligeros, Shehadeh, Karageorgos, Zacharioudakis and Mylonakis4} Colonization is often associated with subsequent MRSA infection in this population. ^{Reference Pangli and Papp5} Thus, early identification and reduction of MRSA colonization to prevent infection is an important target in this population. In this study, the median MRSA bacteremia rate reported by nine facilities was 0.400 per 1,000 patient-days, with variation between centers. The factors contributing to this variation were not assessed.

Nasal decolonization, universal skin decolonization, routine surveillance, and multimodal MRSA IP bundles have been assessed, each in small, single-center studies but mostly in non-burn ICU populations. ^{Reference Huang6,Reference Huang, Septimus and Kleinman7} While these approaches may support reductions in MRSA transmission and infection, there is limited evidence to support each of these IP practices either separately or combined in burn patients. ^{Reference Xun, Modica and Payne8} Burn patients notably differ from typical ICU patients due to open wounds and specialized wound-care practices, and evidence from ICU populations may not be fully generalizable to burn units.

The most common interventions utilized for decolonization, chlorhexidine baths and nasal mupirocin, mirror strategies utilized in ICU infection prevention bundles. More research is needed about the frequency with which surveillance should occur and regarding the practice of decolonization. Finally, burn units also reported using different antiseptic agents during wound care, including diluted or undiluted chlorhexidine, pure hypochlorous acid, and specific wound cleanser sprays. These varied practices may reflect different institutional wound care protocols or surgeon preferences. There are limited data comparing these different wound care antiseptics specifically for MRSA prevention, although small studies exist comparing some products with sterile saline. Notably, chlorhexidine, which was used by many burn centers for open wounds, may be associated with cytotoxicity and chemical burns, although clinical data in burn wounds are limited. ^{Reference Abdel-Sayed, Tornay, Hirt-Burri, de Buys Roessingh, Raffoul and Applegate9} The successful application of universal decolonization with intra-nasal mupirocin and hypochlorous acid bathing in burn patients has been described in a single-center retrospective study. ^{Reference Gray, Foster and Cruz10} There is also a registered randomized controlled trial comparing sterile saline, chlorhexidine, and pure hypochlorous acid in children with burn wounds (NCT06941571).

Limitations of this survey-based study include response and sampling biases. Survey response was modest, and those who responded may reflect different medical center types or resources compared with those who did not. The responding institutions for which hospital type was reported included a select group of US academic medical centers. Only SRN-affiliated centers were surveyed, which may not capture a representative cohort of American Burn Association-verified burn centers. In addition, survey responses were self-reported and were not independently validated. Responses varied by survey item, resulting in changing denominators. The survey assessed reported practices but did not measure adherence to these practices or determine whether specific practices were associated with lower MRSA bacteremia rates or other patient outcomes.

Burn units currently rely on institution-specific MRSA prevention strategies, and a lack of standardized guidance may lead to varied prevention practices. Therefore, prospective, multicenter studies are needed to assess these variations and standardize best practices. These studies should inform guidance about the utility of active versus passive surveillance, universal versus targeted decolonization, and the effectiveness of antiseptic wound care agents for prevention of MRSA infections.