Adjunctive hyperbaric oxygen therapy for chronic burn injuries complicated by MRSA and multidrug-resistant infections: a case report

Abstract

Introduction and importance:

Burn injuries are frequently complicated by multidrug-resistant (MDR) organisms and methicillin-resistant Staphylococcus aureus (MRSA), leading to delayed healing and increased morbidity. Hyperbaric oxygen therapy (HBOT) has been proposed as an adjunctive modality to enhance tissue oxygenation, promote angiogenesis, and improve infection control, yet evidence for its use in chronic MDR-infected burns remains limited.

Case presentation:

A 43-year-old male sustained lava-related burns involving 15% of total body surface area, affecting the lower back and bilateral lower extremities. Initial management included antibiotics and surgical debridement; however, persistent MDR infection developed, including MRSA and extensively drug-resistant Acinetobacter baumannii. Serial debridement was performed every 48 h, totaling 21 procedures. HBOT was initiated on day 17, delivered in a monoplace chamber at 2.4 ATA for 90 min daily over 30 sessions. Targeted intravenous antibiotics, multimodal analgesia, and structured rehabilitation were concurrently administered. Microbiological surveillance demonstrated progressive narrowing of pathogens, culminating in near-complete clearance of MRSA and Pseudomonas aeruginosa.

Clinical discussion:

HBOT likely contributed to enhanced wound healing through increased tissue oxygenation, promotion of granulation, neutrophil activation, and disruption of bacterial biofilms. The combined approach of HBOT, repeated debridement, targeted antibiotics, pain management, and rehabilitation facilitated near-complete epithelialization (~90%) and functional recovery. Safety was ensured through rigorous monitoring, with no adverse events reported.

Conclusion:

Adjunctive HBOT may enhance infection control and accelerate healing in chronic burn injuries complicated by MDR organisms. Early integration with surgical and antimicrobial management should be considered in complex, non-healing burns, particularly when conventional therapy is insufficient.

Introduction

Burn injuries represent a major global health concern, with more than 9 million injuries and approximately 120 000 deaths annually^[1^]. Burn wounds are frequently complicated by persistent bacterial colonization, particularly from multidrug-resistant (MDR) organisms and methicillin-resistant Staphylococcus aureus (MRSA)^[2,3^]. Globally, MDR organisms now represent a significant burden in burn units, with colonization rates reported between 30% and over 60% among hospitalized burn patients^[4,5^]. MRSA, Pseudomonas aeruginosa, and Acinetobacter baumannii are among the most frequently encountered resistant pathogens, contributing substantially to delayed recovery and increased mortality^[6^]. Disruption of the skin barrier, combined with burn-induced immune dysfunction, creates an environment highly conducive to pathogenic invasion, ultimately delaying wound healing and increasing the risk of severe complications^[7,8^]. Although standard management, such as surgical debridement and antibiotic therapy, remains essential, these measures often fall short when confronted with entrenched MDR pathogens.

Hyperbaric oxygen therapy (HBOT) has emerged as a promising adjunctive modality for complex burn wounds. By improving tissue oxygenation, modulating inflammation, promoting angiogenesis, and supporting immune cell function, HBOT may contribute meaningfully to infection control and wound repair^[9,10^]. Despite these potential advantages, evidence specifically examining its role in chronic burn wounds complicated by MDR organisms and MRSA remains limited^[11^]. Additional clinical data are therefore needed to clarify its utility in these high-risk cases.

This report presents the use of adjunctive HBOT in a patient with a chronic burn wound infected with MRSA and MDR pathogens. This case is noteworthy as one of the first documented reports from Indonesia describing the application of HBOT in a lava-related thermal burn complicated by both MRSA and MDR infections. This report aims to demonstrate the clinical utility of HBOT as an adjunctive therapy in managing chronic burn wounds complicated by MRSA and MDR infections, highlighting its potential to enhance infection control and accelerate healing. The case is detailed in accordance with the Surgical CAse REport (SCARE) 2025 guidelines^[12^].

Case presentation

A 43-year-old male nickel industry worker presented with severe pain in the lower back and bilateral lower extremities after sustaining burns from hot lava exposure while working in a nickel processing facility. The injury occurred 15 days prior, involving the lower back and both legs, with an estimated total body surface area of 15%. He had no significant medical history. Initially treated at Weda Bay Medical Center, he was referred to Tidore Hospital, where he underwent his first debridement 1 day after the incident. However, infection has been realized. His history of medication included Levofloxacin 500 mg per oral twice daily and Ceftriaxone 1 g intravenous twice daily.

HIGHLIGHTS

• This case describes the management of a chronic burn wound complicated by MDR and MRSA coinfection.

• Adjunctive HBOT was associated with reduced bacterial burden and accelerated granulation in this patient.

• Daily surgical debridement, targeted antibiotics, and HBOT together contributed to progressive epithelialization and improved wound stability.

• The report provides detailed HBOT protocol parameters and safety considerations that may guide clinicians in similar complex cases.

• This case illustrates potential clinical benefits of integrating HBOT early when standard therapy alone does not adequately control infection.

On admission, the patient was conscious and hemodynamically stable. Examination revealed partial-thickness burns on the right lumbar and gluteal regions and deep partial-thickness burns on the right foot and lower leg (Fig. 1). Over the following days, a clinically significant burn wound infection became established, characterized by increasing necrotic tissue, malodor, and purulent exudate. Given the progression, he was scheduled for urgent serial debridement, necrotomy, and escharotomy under general anesthesia. The patient underwent serial sharp surgical debridement every 48 h, totaling 21 procedures, to systematically remove devitalized tissue and reduce the bacterial burden. After each debridement, the wounds were dressed using a standardized multilayer regimen composed of sterile paraffin gauze as the primary non-adherent layer, covered with moist saline gauze and a secondary absorbent dressing, secured with elastic bandaging for structural support and exudate control. Dressing changes were conducted daily using a sterile technique performed by the plastic surgeon and senior residents, ensuring minimal disturbance to newly forming granulation tissue. Adjustments were made only when wound moisture levels or microbial growth patterns indicated a need for modification.

Figure 1.

Clinical presentation of the burn wound after the first debridement. The image displays Grade IIa–IIb burns on the patient’s lower back and gluteal region 15 days post-injury. Note the extensive necrotic tissue and eschar formation, indicative of severe infection, prior to the first debridement at the treating facility.

Persistent MDR infection despite serial debridement prompted the initiation of HBOT on day 17. HBOT was performed in a monoplace chamber, with 100% oxygen administered at 2.4 ATA. Each session lasted 90 min, conducted daily for 30 consecutive sessions. During therapy, the patient’s vital signs were closely monitored before, during, and after each session to ensure safety and promptly detect potential complications, such as barotrauma or oxygen toxicity. No adverse effects were observed. The patient remained bedridden on an anti-decubitus mattress and used customized pressure garments over the lower legs throughout hospitalization. Wound evaluation after the seventh debridement revealed a marked reduction in necrotic tissue burden and the emergence of healthy granulation tissue, attributable to the combined effect of debridement, targeted antimicrobial therapy, and HBOT (Fig. 2).

Figure 2.

Wound status following the seventh debridement procedure. This image, taken approximately 2 weeks into the treatment course, shows a significant reduction in necrotic tissue and the emergence of healthy granulation tissue after multiple debridements and concurrent hyperbaric oxygen therapy sessions.

Given the patient’s significant pain associated with deep partial-thickness burns, frequent debridement, and HBOT sessions, a multimodal analgesic regimen was implemented. This included intravenous opioids (morphine or fentanyl), acetaminophen, and NSAIDs as appropriate, titrated according to patient-reported pain scores. Senior residents conducted regular numerical pain assessments, adjusting therapy to optimize comfort. To maintain joint mobility, prevent contractures, and support functional recovery, early physical and occupational therapy were initiated, including range-of-motion exercises, in-bed mobilization, and gradual ambulation. Despite these interventions, the patient’s low pain tolerance and reluctance to reduce opioid use contributed to the prolonged length of stay (101 days).

Laboratory assessments revealed mild anemia and fluctuating leukocyte counts throughout hospitalization (Table 1). Microbiological findings played a crucial role in guiding the patient’s management. On 28 October, MRSA screening was positive, and pus cultures identified S. aureus and extensively drug-resistant A. baumannii. By 11 November, MRSA screening was negative, though P. aeruginosa and A. baumannii persisted in wound cultures. By 25 November, only A. baumannii remained, reflecting a narrowing infectious burden.

Table 1.

Key laboratory values during hospitalization.

Date	Hemoglobin (g/dl)	Hematocrit (%)	WBC (×103/μl)	Notes
28 October	11.3	33.6	6.8	Initial admission labs
5 November	10.9	32.1	6.5	During meropenem therapy
11 November	10.5	31.2	5.3	MRSA negative, persistent P. aeruginosa and A. baumannii
16 November	10.8	32.0	6.0	Mid-HBOT sessions
25 November	10.4	30.8	6.3	Only A. baumannii remains
12 December	10.7	32.4	7.1	Near-complete epithelialization
16 December	10.1	30.8	6.3	Pre-discharge assessment

Despite challenges in eradicating infection, wound healing progressed remarkably well. The patient received targeted intravenous antibiotic therapy, including meropenem (26 October–5 November), followed by vancomycin and tigecycline (5 November–15 November). By late November, infection control measures had effectively reduced the bacterial load.

Clinically, near the end of treatment following the 15th debridement and completion of 30 HBOT sessions, the wound exhibited a well-vascularized, granulating base with near-complete epithelialization progressing from the margins (approximately 90% closure), indicating a favorable response to adjunctive hyperbaric therapy (Fig. 3). The sequential progression of injury characteristics, interventions, microbiological results, and wound healing milestones is summarized in Table 2, providing a structured visual overview of the patient’s clinical trajectory. After discharge, the patient gradually resumed light occupational duties and continued outpatient rehabilitation, ultimately achieving satisfactory functional recovery.

Figure 3.

Advanced wound healing near the completion of therapy. The wound bed after the 15th debridement and 30 sessions of hyperbaric oxygen therapy. The image demonstrates a well-vascularized, granulated base with near-complete epithelialization advancing from the wound margins, indicating a positive response to the adjunctive treatment.

Table 2.

Timeline of clinical events, antibiotic therapy, microbiology results, and interventions.

Date/day	Clinical event	Intervention/antibiotics/microbiology
Day 0 (injury day)	Lava burn injury at nickel facility	Immediate first aid; referred to Weda Bay Medical Center
Days 1–2	Initial management at Weda Bay	Started Ceftriaxone 1 g IV twice daily and Levofloxacin 500 mg PO twice daily
Day 2	First surgical debridement	Surgical debridement performed at Weda Bay Medical Center
Days 3–14	Progressive wound colonization	Continued Ceftriaxone + Levofloxacin (days 1–14); increasing necrosis and exudate
Day 15 (admission to Tidore Hospital)	Referred due to worsening infection	Partial-thickness burns on lower back and gluteal region; deep partial-thickness burns on right foot and lower leg; clinically significant infection
Day 16	Serial wound surgery initiated	Debridement + necrotomy + escharotomy every 48 h
Day 17	HBOT initiated	2.4 ATA, 90 min/session, daily × 30 sessions
Day 17	Antibiotic adjustment	Ceftriaxone discontinued; began targeted antibiotics per culture
28 October (approx. day 18)	First microbiology	MRSA positive; S. aureus and XDR A. baumannii isolated
Days 18–32	Ongoing treatment	Continued serial debridements, daily HBOT, and tailored antibiotics
11 November (approx. day 32)	Repeat microbiology	MRSA negative; P. aeruginosa and A. baumannii persisted
25 November (approx. day 46)	Final microbiology before closure	Only A. baumannii remained
Late November (days 45–50)	Healing milestone	Near-complete epithelialization; well-granulated wound bed following 15 debridements + 30 HBOT sessions

Discussion

Burn injuries disrupt the skin barrier and create a hospitable environment for bacterial colonization, increasing susceptibility to MDR and MRSA infections. Delayed initial care and extensive tissue damage further elevate this risk^[13^]. MDR organisms such as P. aeruginosa and A. baumannii complicate treatment because of their biofilm formation and resistance mechanisms, often limiting the effectiveness of standard antibiotics and surgical debridement. These challenges highlight the need for adjunctive modalities to enhance infection control and support wound healing in complex burn cases^[14^].

HBOT was administered to this patient in a monoplace chamber with 100% oxygen at 2.4 ATA for 90 min daily over 30 sessions, with vital-sign monitoring before, during, and after each exposure. HBOT likely contributed to clinical improvement by increasing tissue oxygen tension, promoting angiogenesis and granulation, augmenting neutrophil oxidative killing, and disrupting bacterial biofilms through the generation of reactive oxygen species^[10,15–17^]. In this case, these mechanisms correlated with progressive narrowing of the infecting flora (MRSA → P. aeruginosa/A. baumannii → A. baumannii only) and near-complete epithelialization. After completing 30 HBOT sessions, epithelialization reached approximately 90% closure, with remaining defects limited to pressure-exposed regions. This trajectory is consistent with experimental and clinical evidence supporting the antimicrobial and tissue-restorative properties of HBOT^[18–20^].

The literature on HBOT for infected burns and MDR organisms comprises experimental studies, case reports, and small series rather than large randomized trials. Several studies describe improved wound healing and infection control when HBOT is used adjunctively in severe or refractory burn wounds or necrotizing soft-tissue infections, though study designs are heterogenous and outcomes are often observational. Systematic reviews and narrative reviews conclude that HBOT shows promise, particularly for necrotizing infections and refractory soft-tissue infections, but emphasize a lack of high-quality randomized data specific to thermal burns with MDR pathogens^[21^]. In vitro and animal studies likewise demonstrate oxygen-dependent enhancement of antibiotic efficacy and direct suppression of bacterial growth (including MRSA) under hyperbaric conditions. Taken together, current evidence supports HBOT as a plausible adjunct in selected, refractory cases but does not yet permit generalized recommendations for routine use.

A study reports of HBOT assisting management of severe infected wounds and of in vitro/animal evidence of HBOT’s antimicrobial effects^[10,22^], but reports specifically describing HBOT for lava-related thermal burns complicated by concurrent MRSA and MDR Gram-negative infections are exceedingly rare or not identified in the contemporary literature. Therefore, this case adds clinical value by documenting (1) application of a defined HBOT protocol (2.4 ATA, 90 min, 30 sessions) in a patient with a complex polymicrobial MDR infection and (2) the integrated role of HBOT alongside repeated surgical debridement, sequential targeted antibiotics, multimodal analgesia, and structured rehabilitation. This combined approach and the temporal microbiological data (serial cultures showing narrowing flora) help illustrate how HBOT can be incorporated into multidisciplinary care for complex burn infections.

HBOT at pressures above 2.0 ATA carries a recognized risk profile (barotrauma, oxygen toxicity, transient visual, or pulmonary effects), and the likelihood of adverse events increases with higher pressures and longer courses^[23^]. In this patient, rigorous pre- and intra-session monitoring detected no adverse events; nevertheless, clinicians must adhere to institutional safety protocols and monitor for neurologic or pulmonary signs of oxygen toxicity during multi-session regimens. The available systematic assessments reinforce that careful selection and monitoring mitigate risk and permit safe delivery in most patients when indicated.

Pain management is a critical component of comprehensive burn care, as uncontrolled pain can delay wound healing and prolong hospitalization. In this patient, multimodal analgesia including intravenous opioids, acetaminophen, and NSAIDs was administered and titrated according to patient-reported pain scores. Senior residents conducted regular numerical pain assessments, adjusting therapy to optimize comfort. Early physical and occupational therapy supported joint mobility, prevented contractures, and facilitated functional recovery. Despite these interventions, the patient’s low pain tolerance and reluctance to reduce opioid use contributed to a prolonged length of stay (101 days). This emphasizes the importance of individualized pain management strategies alongside surgical and adjunctive interventions in complex burn cases.

HBOT and meticulous supportive care, including targeted antibiotic therapy, effective pain management, and rehabilitation, worked synergistically to optimize outcomes. The patient’s wounds demonstrated near-complete epithelialization and a well-vascularized, granulated wound bed, with only minor delays in healing at pressure-prone areas. This case illustrates that adjunctive HBOT, when combined with comprehensive supportive care, can effectively enhance infection control and accelerate recovery in severe burns complicated by MRSA and MDR infections.

Limitations include the delayed referral and prior antibiotic exposure, which may have influenced the persistence of MDR pathogens. Nevertheless, this report describes a single uncontrolled clinical case, which restricts inference about causality between HBOT and clinical improvement. The patient simultaneously underwent extensive serial debridement, sequential broad-spectrum antibiotics (including meropenem, vancomycin, and tigecycline), and structured rehabilitation, each a potential confounding factor influencing microbial clearance and wound healing. In addition, changes in antimicrobial regimens based on evolving culture data make it difficult to isolate the specific contribution of HBOT to the observed decline in bacterial burden. Variability in the timing of initial burn management before referral also introduces uncertainty regarding the natural healing trajectory. These factors collectively highlight the need for prospective controlled studies to determine optimal HBOT timing, dosing, and patient selection in MDR-infected burn wounds.

Beyond clinical considerations, the use of HBOT raises important questions about accessibility in low-resource settings. Hyperbaric facilities require significant investment in equipment, trained personnel, and maintenance, limiting availability to major referral centers. Many burn patients in remote or underserved regions may experience delayed access or may not receive HBOT at all despite the potential benefit. Addressing these disparities requires cost-effectiveness evaluations, expansion of referral networks, and strategic placement of hyperbaric units to support equitable access for patients with complex wounds.

The clinical course in this case suggests that HBOT may be considered earlier in the management of non-healing or infection-complicated burns, particularly when MDR pathogens constrain treatment options. Early integration of HBOT alongside debridement and pathogen-specific antimicrobial therapy may enhance granulation, improve tissue oxygenation, and shorten time to wound closure. Additionally, coordinated incorporation of structured rehabilitation and pain management protocols may further optimize functional outcomes. These practice implications highlight the need for multidisciplinary collaboration and timely referral when hyperbaric services are available.

Conclusions

This case highlights the potential role of HBOT as an effective adjunct in managing deep burn injuries complicated by MDR infection. In this patient, HBOT contributed to measurable clinical improvement, including approximately 90% epithelialization after 30 sessions and progressive reduction of microbial burden. Early initiation of HBOT following adequate debridement appeared to support faster wound stabilization, while its integration with targeted antibiotic therapy likely enhanced antimicrobial effectiveness. The coordinated approach combining HBOT, surgical management, optimized pharmacotherapy, and structured rehabilitation facilitated functional recovery and return to light occupational activities. Although limited by its single-case design, these observations underscore the value of considering HBOT earlier in the treatment pathway for non-healing, infection-complicated burns, particularly in settings where MDR organisms restrict therapeutic options.

Ethical approval

This case report received ethical clearance from the Siloam Hospitals Manado Ethics Committee No. 111/Ethical Committee/SH-MN/IV/2025.

Consent

Written informed consent was obtained from the patient for publication of this case report and all accompanying images. The patient was informed that all potentially identifying information would be anonymized.

Sources of funding

No external funding was received for this work.

Author contributions

MHO and MCO: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Supervision, and Methodology. CTH and VS: Project administration, Resources, Software, and Validation. MHO, MCO, CTH, VS, and MF: Visualization, Writing – original draft, Writing – review & editing. All authors validated the study and approved the final version of the manuscript.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Guarantor

Mendy Hatibie Oley and Maximillian Christian Oley.

Research registration unique identifying number (UIN)

Not available.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.