HN Summary

•High risk of sepsis after burns: More than 20% of burn patients in Ontario developed sepsis, often within two weeks of injury, making it a common and deadly complication.

•Surprising gender and timing differences: Women aged 18–59 were more likely than men to die from sepsis, and patients who developed sepsis earlier after their burn had worse outcomes.

•Risk factors and next steps: Larger burns, respiratory damage, and older age increased sepsis risk and death rates. Researchers say findings could shape new guidelines to improve survival in burn patients.

A person’s skin is a vital protective barrier as well as their first line of defense against an infection that could trigger life-threatening sepsis. So what does this mean for burn patients, whose skin is seriously damaged or destroyed?

A groundbreaking study from Hamilton Health Sciences’ (HHS) Centre for Burn Research looked at the connection between major burns and sepsis, which is caused by an out-of-control response to an infection where the body starts damaging its own organs like the lungs, kidneys, or heart. Sepsis is the deadliest health condition in the world, killing more people globally than cancer, and is a common complication for burn patients.

The study looked at hospital records of 1,465 adult patients dating back to 2006, who had burn injuries covering at least five per cent of their body and were cared for at one of the province’s two Regional Burn Centres, located at HHS Hamilton General Hospital and Sunnybrook Health Sciences Centre in Toronto.

The study found that more than 20 per cent of these patients showed signs of sepsis, with half being diagnosed less than two weeks after their burn injury. Researchers were surprised to discover that female burn patients were more likely than their male counterparts to die from sepsis. The team was also surprised to find that the earlier a patient showed signs of sepsis, the more likely they were to die from this complication.

The burn-sepsis connection

When an infection spreads into the bloodstream, the immune system may overreact, causing sepsis. It’s much easier for bacteria to enter the body when the skin is damaged or destroyed. Damaged tissue and exposed wounds are also ideal places for bacteria to grow, increasing the risk of infection.

Meanwhile, the body’s immune system is weakened after a major burn, so it’s harder to fight off infection. Once sepsis develops, it can quickly turn deadly.

The study aimed to discover what factors make sepsis more likely in burn patients; compare outcomes such as recovery and death rates between patients who develop sepsis and those who don’t; and look at differences across age groups to see if sepsis affects younger and older burn patients differently.

Patients were divided into two age groups – 1,094 adults aged 18 to 59 and 371 adults aged 60 and over. Within each age group, researchers compared patients who developed sepsis during their hospital stay with those who did not. 

The research team looked for patterns in complex data to figure out which factors increase the risk of getting sepsis, and which factors predict death in patients who develop sepsis.

Key findings

With patients aged 60 plus, about one in four, or 22.9 per cent, showed signs of sepsis, and half were diagnosed just 11 days after their burn injury. (The median time to a sepsis diagnosis in older adults was 11 days, meaning half were diagnosed within 11 days of their burn injury). Among patients aged 18 to 59, one in five, or 20.1 per cent, showed signs of sepsis, with half diagnosed within 10 days of their burn injury.

Female burn patients aged 18 to 59 were more likely than their male counterparts to die from sepsis. “This was very surprising to us,” says Diana Tedesco, who led the study. Tedesco, formerly the clinical research coordinator with the HHS Centre for Burn Research, is now a master’s student at McMaster University. “Our study is the first to reveal this discovery in female burn patients with sepsis,” says Tedesco. However, with older burn patients, ages 60 plus, death rates from sepsis were about equal for females and males.

“Another key finding was the importance of timing,” says Tedesco. The study found that the earlier a patient develops sepsis, the worse their outcomes and the higher their chance of dying from this complication.

“We expected to see the opposite,” says Tedesco, adding that more research is needed to understand the link between early onset of sepsis and poorer outcomes, including death. More research is also needed to understand why more women than men in the 18 to 59 age range die from sepsis.

Factors that increased the risk of developing sepsis included a larger burn size, since big burns place more stress on the body and create more opportunities for bacteria to set in. Burns damaging the respiratory system also increase the risk of sepsis, since this affects the moist, protective lining of the lungs and air passages, creating opportunities for bacteria to enter.

The study found that older burn patients, aged 60 plus, were more likely to die from sepsis. “Unfortunately, this was expected because we know from earlier research that older patients suffering a severe burn are at a much higher risk of dying than younger patients with the same type of injury,” says Tedesco.

Improving survival rates for older adults is a key area of focus for the HHS Centre for Burn Research.

International recognition for next generation of researchers

A paper sharing the study’s findings, titled Sepsis in burn care: incidence and outcomes, was published this month in Military Medical Research, a top-tier research journal that publishes cutting-edge findings with applications for military and civilian health care. Tedesco was the paper’s lead author.

“Being published in this level of research journal is a tremendous accomplishment,” says Dr. Marc Jeschke, a globally recognized HHS burn surgeon and researcher, and the study’s supervisor. Jeschke is HHS’ vice president of research and innovation, and chief

scientific officer. He’s listed as a co-author of the paper along with McMaster master’s students Fadi Khalaf and Zachary Ricciuti, who both also work at the HHS Centre for Burn Research, and Dr. Maria Fernanda Hutter, a visiting physician-researcher from Austria.

Learning from world leaders

HHS is a top 10 Canadian research hospital and one of the country’s top-ranked teaching hospitals. It’s also home to national sepsis expert Dr. Alison-Fox Robichaud.

“The fact that three of the five authors of this important paper are McMaster students working under a world-leading burn surgeon and researcher speaks volumes about the high quality of hands-on learning opportunities provided by HHS,” says Fox-Robichaud, director of medical education for HHS and a professor of medicine at McMaster. Fox-Robichaud is the scientific director of Sepsis Canada, an HHS critical care physician, HHS chair in sepsis research, and a sepsis researcher at the Thrombosis & Atherosclerosis Research Institute (TaARI) of McMaster and HHS.

“Findings from this study could lay the groundwork for researchers to create new and better ways to identify and treat sepsis in burn patients,” says Fox-Robichaud. For example, sepsis guidelines for caring for burn patients could be tailored based on gender and age. An emphasis could also be placed on very early screening for sepsis.

By Lise Diebel
Lise Diebel works in communications at HHSC.