Pre-Grafting Infection Biomarker Burden and Autologous Skin Graft Take in Adults with Severe Burns: A Single-Center Retrospective Cohort Study

Summary

This study presents a reproducible retrospective workflow for integrating pre-grafting inflammatory biomarkers, endotoxin, β-D-glucan, and wound culture into a composite score associated with autologous skin graft take in adults with severe burns.

Abstract

Autologous split-thickness skin grafting is a principal method of definitive wound closure in patients with severe burns, but graft take may be compromised by systemic inflammation, local microbial burden, and wound-bed instability. This retrospective cohort study evaluated whether a composite pre-grafting infection biomarker burden score was associated with graft take after definitive autologous grafting. Adult patients with severe or extremely severe burns treated at Ganzhou People’s Hospital between January 1, 2022, and December 31, 2025, were screened. The score assigned one point each for C-reactive protein ≥ 150 mg/L, procalcitonin ≥ 1.5 ng/mL, endotoxin ≥ 0.25 EU/mL, fungal β-D-glucan ≥ 100 pg/mL, and a positive pre-grafting wound culture. The primary outcome was graft take rate at the first formal assessment within postoperative days 5–10, using postoperative day 7 when available. Among 84 included patients, the mean age was 46.2 ± 15.3 years, the mean total body surface area burned was 50.6% ± 10.5%, and the mean graft take rate was 87.5% ± 9.5%. Thirty-four patients achieved graft take ≥ 90%. Mean graft take declined from 92.5% ± 6.0% in patients with scores of 0–1 to 75.7% ± 11.8% in those with scores of 4–5. After adjustment for prespecified clinical covariates, each one-point increase in the score was associated with a 3.84-percentage-point decrease in graft take rate. Higher pre-grafting infection biomarker burden was therefore associated with poorer graft take and may support structured perioperative risk assessment in adults with severe burns.

Introduction

Burn injury remains a major cause of preventable mortality, disability, disfigurement, and long-term functional impairment worldwide, with the greatest clinical burden occurring among patients with extensive or deep burns requiring specialized surgical treatment¹. Severe burns simultaneously produce tissue destruction, fluid and protein loss, systemic inflammation, metabolic stress, immune dysfunction, and increased susceptibility to infection². Timely wound closure is therefore essential not only for reconstruction but also for reducing exposed wound area, limiting ongoing fluid and heat loss, controlling microbial inva....

Protocol

The study protocol was reviewed and approved by the Ethics Committee of Ganzhou People’s Hospital (Approval No. SZITCM-EC-2025-017; approval date: 2025.04.12). The requirement for individual written informed consent was waived because the study involved retrospective analysis of routinely collected clinical data without additional sampling, intervention, treatment allocation, or patient contact.

Study design, setting, ethics, and data protection

This single-center retrospective cohort study was conducted in the Department of Burns, Plastic Surgery, and Wound Repair, Ganzhou People’s H....

Results

Patient selection

A total of 286 burn-related inpatient records were screened between January 1, 2022, and December 31, 2025. After excluding patients younger than 18 years, patients treated for non-burn wounds, and repeated admissions for previous burn episodes, 242 records underwent burn-severity assessment. Among these, 155 patients met the operational criteria for severe or extremely severe burns. Patients who did not undergo definitive autologous split-thickness skin graf.......

Discussion

This single-center retrospective cohort study found that greater pre-grafting infection biomarker burden was associated with poorer autologous split-thickness skin graft take in adults with severe or extremely severe burns. Patients with graft take < 90% had higher pre-grafting C-reactive protein, procalcitonin, and endotoxin concentrations and were more likely to have a positive wound culture. Graft take rate decreased progressively across infection biomarker burden score categories, and the score remained inversely.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Cobas e 411 immunoassay analyzer	Roche Diagnostics	4775279001	Automated electrochemiluminescence immunoassay analyzer used for procalcitonin measurement.
Columbia agar with 5% sheep blood	bioMérieux	43041	Ready-to-use blood agar plates used for primary isolation, colony morphology, and hemolysis assessment of wound isolates. Package contains 20 plates.
C-reactive protein assay, Tina-quant C-Reactive Protein IV	Roche Diagnostics	7876033190	Immunoturbidimetric assay for quantitative determination of C-reactive protein in human serum or plasma. Compatible with cobas c 311, c 501, and c 502 systems.
Endotoxin assay kit for human plasma	Xiamen Bioendo Technology Co., Ltd.	KTE20	Kinetic turbidimetric assay for quantitative determination of endotoxin in human plasma. Each kit contains materials for 20 tests, including single-test lysate vials and sample-treatment solution.
ESwab liquid Amies collection and transport system	COPAN Diagnostics	480C	Regular flocked swab supplied with 1 mL liquid Amies medium for collection and transport of aerobic, anaerobic, and fastidious bacteria.
Fungi (1→3)-β-D-glucan detection kit	Xiamen Bioendo Technology Co., Ltd.	KCG50	Kinetic chromogenic assay for quantitative β-D-glucan measurement. Analytical range: 25–1,000 pg/mL; 50 tests per kit.
Kinetic incubating microplate reader	Xiamen Bioendo Technology Co., Ltd.	ELX808IULALXH	Temperature-controlled kinetic microplate reader suitable for turbidimetric endotoxin and chromogenic β-D-glucan assays.
MacConkey agar with crystal violet	bioMérieux	43141	Selective and differential culture medium used for recovery and preliminary differentiation of gram-negative bacilli, including Enterobacterales. Package contains 20 plates.
Procalcitonin assay, Elecsys BRAHMS PCT	Roche Diagnostics	9318712190	Electrochemiluminescence immunoassay for quantitative determination of procalcitonin in human serum or plasma. One reagent pack provides 100 tests and is compatible with cobas e 411, e 601, and e 602 analyzers.
Pyrogen-free pipette tips, 1,000 µL	Xiamen Bioendo Technology Co., Ltd.	PT10004	Low-endotoxin pipette tips used for sample dilution and reagent transfer during endotoxin and β-D-glucan assays.
Pyrogen-free pipette tips, 200 µL	Xiamen Bioendo Technology Co., Ltd.	PT2005	Low-endotoxin pipette tips used for standards, samples, lysate reagent, and control preparation.
R statistical software	R Foundation for Statistical Computing	Version 4.3.2	Used for descriptive analyses, group comparisons, correlation analyses, multivariable regression, receiver operating characteristic analysis, sensitivity analyses, and figure preparation. RRID: SCR_001905.
Sabouraud gentamicin chloramphenicol 2 agar	bioMérieux	43651	Selective culture medium used for recovery of yeasts and filamentous fungi from wound specimens. Package contains 20 plates.
VITEK 2 Compact identification and susceptibility system	bioMérieux	VITEK 2 Compact	Automated system used for identification of bacterial and yeast isolates and, when performed, antimicrobial susceptibility testing.
VITEK 2 GN identification card	bioMérieux	21341	Identification card for clinically relevant gram-negative bacteria, including Enterobacterales and non-fermenting gram-negative bacilli. Package contains 20 cards.
VITEK 2 GP identification card	bioMérieux	21342	Identification card for clinically relevant gram-positive bacteria. Package contains 20 cards.
VITEK 2 YST identification card	bioMérieux	21343	Identification card for clinically relevant yeasts and yeast-like organisms. Package contains 20 cards.