Treatment of infection in burns

photosensitivity, and transient ocular toxicity, a unique phenomenon that has been studied extensively. The following visual disturbances have been described: blurred vision, photophobia, altered color vision, and perception of increased brightness of light. Up to one third of patients treated with voriconazole have describes such visual disturbances, which typically occur early in the course of therapy, begin 15–30 minutes after a dose, and resolve within 30 minutes [26]. No histopathologic changes have been seen in the retinas of treated patients, and there have been no permanent sequelae of voriconzole induced visual disturbances [26].

Because these azole drugs are metabolized by the hepatic cytochrome P450 system, a variety of interactions can occur between these agents and other medications, The azoles inhibit the metabolism of the sulfonyureasm warfarin, digoxin, phenytoin, cyclosporine, sirolimus, tacrolimus, omeprazole, and cisapride, resulting in increased serum concentrations of these medications and the potential for drug toxicity. Conversely, serum concentrations of the triazoles are decreased by rifampin, isoniazid, phenytoin, and fosphenytoin, as well as carbamazepine [39].

Echinocandin antifungals

Caspofungin, an echinocandin antifungal, inhibits formation of ß 1, 3 glucan of the fungal cell wall. Caspofungin is effective in vitro against Candida species, including azole resistant isolates, and Aspergillus species.

Caspofungin therapy is usually well tolerated. Rash or GI toxicity occurs rarely. There are relatively few drug-drug interactions with caspofungin, which is neither an inducer nor an inibitor of the cytochrome P450 system. Caspofungin does reduce the area under the curve and peak serum concentrations of tacrolimus by 20% to 25%, so tacrolimus serum concentrations should be monitored in patients taking caspofungin [26]. Cyclosporin increases the area under the curve of caspofungin by 35% [26]. It is suggested that caspofungin and cyclosporine not be co-administered.

Nucleoside analog antifungal (Flucytosine)

Flucytosine, the only available nucleoside analog, acts as an antifungal by disrupting pyrimidine metabolism in the fungal cell nucleus. Flucytosine is fungicidal in vitro against Candida species and C. neoformans but not against other commonly encountered fungi. Unfortunately, resistance emerges rapidly during flucytosine montherapy, so use of this drug s limited to combination therapy [26].

Flucytosine can cause bone marrow suppression and GI toxicity, although these side effects are seen less frequently with the current recommended dosage (100 mg/kg/day in 4 divided doses) than with the higher dosage that was used for many years (150 mg/ kg/day in 4 divided doses). Flucytosine does not have any significant drug interactions.

Conclusion

Current techniques of burn patient management and burn wound care have reduced not only the incidence of invasive burn wound infections but also the occurrence of all infections in burn patients. Even so, infection in sites other than the burn wound, principally the lungs, remains the most common cause of death in burn patients [40]. The use of effective topical antimicrobial therapy, early burn wound excision, the availability of effective biologic dressings, the wound monitoring and surveillance program described above, and the overall improvements in the care of critically ill patients over the past four decades have each made a contribution to the reduction in morbidity and the improved survival of burn patients, including those who develop infections.

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Correspondence: Gerd G. Gauglitz, M.D., MMS, Department of Dermatology and Allergy, Ludwig-Maximilians-University

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