Hospital-Onset Bacteremia in Burn Patients May Be a Poor Quality Metric, Study Finds

Hospital-onset bacteremia and fungemia (HOB) has increasingly been proposed as a quality indicator tied to value-based purchasing programs. However, new data from a high-volume regional burn center suggest that this metric may not accurately reflect the quality of care for burn patients, whose risk of bloodstream infections is largely driven by injury severity and necessary surgical interventions.

Bacteremia remains a well-recognized and serious complication among patients with burn injuries, contributing significantly to morbidity and mortality. “Many of these episodes of bacteremia occur after hospitalization and may be preventable. [HOB], defined as positive blood cultures diagnosed after the initial 3 days of hospitalization, has been proposed as a quality measure for value-based purchasing programs,” wrote the authors of a recent study published in the American Journal of Infection Control. Unlike many other hospitalized populations, burn patients experience profound skin barrier disruption, require repeated surgical procedures, and often depend on prolonged central venous access—all factors that elevate infection risk regardless of care quality.

However, the general belief is that HOB is preventable. “In a survey of hospital epidemiologists, 61% believe that HOB generally is preventable, and 54% believe that this metric reflects quality of care,” the authors wrote. “A large multicenter study that included 18 burn patients and 40 patients with desquamative skin disease determined that 36% of nonskin organisms were potentially preventable, and 74% of skin organisms were preventable.”

To better understand the epidemiology and characteristics of HOB in this population and consider this belief, investigators analyzed data from 1612 burn intensive care unit admissions between September 2018 and December 2024. Using burn registry data, electronic medical records, and national benchmarking data, researchers identified 202 episodes of bacteremia among 89 patients, representing 5.6% of all admissions. Notably, 88.6% of these episodes met the definition of HOB, occurring more than 3 days after admission.

The burden of bacteremia rose sharply with increasing total body surface area (TBSA) burned. Patients with minimal burns (1%-10% TBSA) experienced bacteremia infrequently, whereas those with burns exceeding 30% TBSA faced dramatically higher rates, often accompanied by prolonged hospital stays. The median time to first bacteremia episode was 8 days, with later onset seen in patients with more extensive injuries.

Microbiologic analysis revealed a pathogen profile consistent with prior burn center studies. The most frequently isolated organisms included Pseudomonas aeruginosa, methicillin-resistant and methicillin-sensitive Staphylococcus aureus, and Klebsiella pneumoniae complex. Fungal bloodstream infections, primarily Candida species, were also observed. Although central lines were common, only 19 episodes met National Healthcare Safety Network criteria for central line–associated bloodstream infection, suggesting that most bacteremia events were not attributable to preventable device-related causes.

One of the most striking findings was the strong temporal association between bacteremia and surgical wound procedures. More than one-third of all bacteremia episodes and 36.8% of hospital-onset cases occurred within 2 days of a soft tissue surgical procedure, such as wound excision or debridement. This pattern was particularly pronounced among patients with larger TBSA burns, reflecting the physiologic consequences of extensive tissue manipulation and microbial translocation rather than lapses in infection prevention practices.

These findings align with prior research demonstrating that bacteremia frequently follows burn wound care, even in settings with aggressive prophylactic strategies. In this context, labeling such infections as failures of care may oversimplify a complex clinical reality.

The authors argue that HOB in burn patients is heavily influenced by nonmodifiable factors, including burn size, need for repeated surgical intervention, and prolonged hospitalization. “[HOB is] common in burn patients, and the number of episodes varies with [TBSA] burn,” the authors wrote. As a result, “HOB in burn patients may be more related to patient characteristics than an indicator of quality of care in this patient population.”

Although the study is limited by its single-center design and retrospective methodology, it raises important concerns for policymakers and hospital leaders. Applying uniform quality benchmarks across heterogeneous patient populations may inadvertently penalize specialized centers that care for the most complex cases.

Ultimately, the findings suggest that HOB in burn patients reflects the severity of injury and intensity of required care more than preventable failures. Further multicenter research is needed to better define modifiable risk factors and determine whether burn populations should be excluded or uniquely adjusted in 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