Hospital-Onset Infections in Burn Patients: A Complex Quality Measure

Hospital-onset bacteremia and fungemia (HOB) are increasingly scrutinized as quality indicators in healthcare, tied to value-based purchasing programs. Although, emerging data suggest that applying this metric to burn patients may be misleading. Burn patients, due to the severity of their injuries and the intensive treatments they require, face a uniquely elevated risk of bloodstream infections that may not reflect deficiencies in care quality.

The Challenge of Assessing Quality in Burn Care

Bacteremia, a bloodstream infection, is a serious complication for burn patients, contributing to significant illness and mortality. Many of these infections develop after hospitalization, prompting consideration of HOB – defined as positive blood cultures diagnosed after the initial three days of hospitalization – as a preventable quality measure.¹ However, unlike many other hospitalized populations, burn patients experience extensive skin barrier disruption, undergo frequent surgical procedures, and often require prolonged central venous access. These factors inherently increase infection risk, regardless of the quality of care provided.

Study Findings: HOB Prevalence and Risk Factors

A recent study analyzing data from 1,612 burn intensive care unit admissions between September 2018 and December 2024 revealed that 88.6% of the 202 bacteremia episodes identified met the criteria for HOB.¹ The incidence of bacteremia increased substantially with the total body surface area (TBSA) burned. Patients with minimal burns (1%-10% TBSA) experienced infrequent bacteremia, while those with burns exceeding 30% TBSA faced dramatically higher rates and longer hospital stays. The median time to the first bacteremia episode was 8 days, with more extensive injuries correlating with later onset.

Common Pathogens in Burn Patient Infections

The most frequently isolated organisms in these bloodstream infections included Pseudomonas aeruginosa (18.2%), methicillin-resistant Staphylococcus aureus (15%), methicillin-sensitive Staphylococcus aureus (8%), and the Klebsiella pneumoniae complex (6.6%).¹ Fungal bloodstream infections, primarily Candida species, were likewise observed. While central lines were common, only 19 episodes met the National Healthcare Safety Network criteria for central line–associated bloodstream infection, indicating that most bacteremia events were not directly linked to preventable device-related causes.

The Link Between Surgery and Bacteremia

A striking finding was the strong association between bacteremia and soft tissue surgical procedures. More than one-third of all bacteremia episodes, and 36.8% of hospital-onset cases, occurred within two days of procedures like wound excision or debridement.¹ This pattern was particularly pronounced in patients with larger TBSA burns, suggesting that the physiological consequences of extensive tissue manipulation and microbial translocation, rather than lapses in infection prevention, play a significant role.

Implications for Quality Measurement

These findings align with previous research demonstrating a frequent link between burn wound care and subsequent bacteremia, even with robust prophylactic strategies. The authors argue that HOB in burn patients is heavily influenced by factors like burn size, the necessity of repeated surgical interventions, and prolonged hospitalization.¹ They suggest that HOB may be more reflective of patient characteristics and the intensity of required care than a direct indicator of substandard care.

Future Directions and Considerations

While the study was limited by its single-center, retrospective design, it raises important questions for policymakers and hospital administrators. Applying uniform quality benchmarks across diverse patient populations may inadvertently penalize specialized centers that treat the most complex cases. Further multicenter research is needed to identify modifiable risk factors and determine whether burn populations should be excluded from, or uniquely adjusted within, future quality measurement frameworks.

REFERENCE

1. Sood G, Caffrey J, Werthman E, Cabrera A, Dougherty G, Schuster A. Hospital-onset bacteremia and fungemia in a regional burn intensive care unit. Am J Infect Control. Published online January 28, 2026. Doi:10.1016/j.ajic.2026.01.022