The management of 12 Italian patients with severe burns from a fire on 1 January 2026 at the Crans-Montana ski resort in Switzerland provided a real-world demonstration of emerging strategies for treating severe burns.
Treated at the Niguarda Hospital Burns Center near Milan, Italy, these cases underscore the value of a multidisciplinary approach, including enzymatic debridement, novel antibiotics, and advanced skin replacement technologies, for improving outcomes in complex emergencies, offering actionable insights for clinicians worldwide.
Enzymatic Debridement
One cornerstone of pharmacologic management is NexoBrid, a concentrate of proteolytic enzymes enriched with bromelain, manufactured by the Israeli biotechnology company MediWound. The drug was authorised by the European Medicines Agency in 2012 and by the US Food and Drug Administration (FDA) in December 2022. It offers a nonsurgical alternative to eschar removal for deep second- and third-degree burns.
Speaking with Univadis Italy, part of the Medscape Professional Network, Franco Bassetto, MD, professor of plastic, reconstructive, and aesthetic surgery, and director of the Clinic of Plastic and Reconstructive Surgery at Azienda Ospedale Università di Padova in Padua, Italy, and president of the Italian Society of Reconstructive-Regenerative Plastic Surgery, said, "Bromelain has very intense enzymatic activity and is able to break the protein bonds that form in the eschar, meaning the tissue necrotised by the burn itself.
“It is a gel that is applied to the area being treated and, within 4 hours, separates devitalised tissue from still-viable tissue.”
The clinical evidence supporting the NexoBrid is robust. The DETECT randomised controlled trial included 175 adult patients with deep partial-thickness or full-thickness burns involving 3%-30% of the total body surface area. Complete eschar removal of at least 95% was achieved in 93.3% of patients treated with NexoBrid compared with 4% in the placebo group.
A comparison with standard surgical care further highlights their clinical impact. Only 4% of patients treated with NexoBrid required subsequent surgical eschar removal, compared with 72% of those treated with conventional methods. According to a recent paediatric study published in Burns that included 145 patients 0-18 years of age, the median time to complete eschar removal was 1 day with NexoBrid vs 6 days with standard care.
“The drug induces enzymatic escharolysis, dissolving the burn eschar and avoiding massive blood loss that would otherwise compromise patient survival,” said Giuseppe Perniciaro, MD, director of the Burns Center and Plastic Surgery Department at Villa Scassi Hospital, Genoa, Italy. His centre provided 15 vials of NexoBrid, with an estimated value of approximately €20,000.
Drug Shortages
Despite European approval dating back to 2012, NexoBrid is currently listed by the Italian Medicines Agency as a drug in short supply. For the 2-g formulation of NexoBrid, "permanent discontinuation" of marketing was reported in October 2025. For the 5-g formulation, production problems were reported, and on 21 November 2025 the agency issued an import authorisation by referencing comparable products already approved internationally.
“As with skin reserves from tissue banks, there is strong collaboration between hospitals in Italy to ensure that what is needed arrives when stocks run low,” Bassetto said.
NexoBrid has been used in approximately 45 countries to treat more than 16,000 patients worldwide and retains orphan biological drug status because it targets rare conditions such as severe burns.
Although Italy was not among the earliest adopters, several Italian centres of excellence certified by the European Burns Association have accumulated substantial experience with enzymatic debridement. This expertise enabled the rapid activation of a national sharing network during the emergency in Crans-Montana.
Last-Line Antibiotics
The clinical complexity of treating fire victims also requires advanced antimicrobial strategies. In at least one case, a patient hospitalised in Milan developed an infection with carbapenem-resistant Acinetobacter baumannii, a multidrug-resistant pathogen associated with high mortality in intensive care units.
Mortality related to carbapenem-resistant A baumannii infection in critically ill patients can reach 50%. In Italy, healthcare-associated infections caused by this organism have increased by an estimated 15%-20% over the past 5 years.
To address this threat, clinicians have turned to sulbactam-durlobactam, marketed as Xacduro. This combination antibiotic was approved by the US FDA in May 2023 but is not yet marketed in Europe.
In an interview with Corriere della Sera, Italy's leading daily newspaper, Michele Bartoletti, MD, head of the Infectious Diseases Unit at Humanitas Research Hospital and a professor at Humanitas University, both in Rozzano, Italy, described sulbactam-durlobactam as a new-generation drug that effectively inhibits the defence mechanisms of the bacterium, which is quite common in patients with severe burns.
Trial Evidence
Efficacy data for sulbactam-durlobactam were obtained from the phase 3 ATTACK trial, which evaluated Xacduro against colistin in patients with hospital-acquired pneumonia caused by carbapenem-resistant A baumannii. Published in The Lancet Infectious Diseases, this randomised study included 181 patients and addressed a major unmet need in the treatment of multidrug-resistant gram-negative infections.
Twenty-eight-day mortality was lower in the sulbactam-durlobactam group (19%; 12 of 63 patients) than in the colistin group (32%; 20 of 62 patients). The absolute difference of -13.2% (95% CI, -30.0 to 3.5) between the groups met the prespecified criterion for noninferiority.
Nephrotoxicity was significantly less frequent with sulbactam-durlobactam than with colistin (13% vs 38%; P <.001).
"Colistin-related nephrotoxicity is one of the main therapeutic limitations in patients who are already critically ill,” Bartoletti said. "Xacduro will become the drug of choice once it is approved in Italy."
The absence of an Italian distributor necessitates complex logistics. At Humanitas Research Hospital in Rozzano, Italy, the antibiotic was available because it had been imported from the United States for potential use. Because delivery to Niguarda Hospital would have taken several days, the hospital activated an interhospital loan system in which unused packages were returned after local stock arrived.
Additional doses were provided by Ospedale Policlinico San Martino in Genoa, Italy, in coordination with Bassetto. In parallel, the Lombardy regional government, the health authority in northern Italy's most populous region, initiated direct importation from the manufacturer.
The use of these advanced therapies has been facilitated by faster microbiological diagnostics. Thanks to gene sequencing technologies, the identification of pathogens responsible for healthcare-associated infections can now be achieved within a day. Until a few years ago, this process took up to 4 or 5 days.
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