The ENGAGE Protocol: ENzymatic debridement with NexoBrid® Followed by Grafting After Graded early Excision - A Retrospective Cohort Study

ABSTRACT Enzymatic debridement with NexoBrid® has become a cornerstone of modern burn care due to its selective tissue-sparing properties. However, the optimal timing and strategy for surgical intervention following enzymatic treatment remain debated. We aimed to evaluate the clinical outcomes of the ENGAGE protocol (ENzymatic debridement with NexoBrid®, followed by Grafting After Graded early Excision), a structured algorithm integrating enzymatic debridement with scheduled wound reassessment and selective early excision. This before and after observational study included adult burn patients treated with NexoBrid® between January 2020 and October 2025 (2020–2022 received standard NexoBrid® management; 2023–2025 received the ENGAGE protocol, featuring day-7 reassessment and selective excision). Endpoints included autologous grafting rate, length of hospital stay (LOS), mortality, and number of surgical procedures. Eighty-eight patients were analyzed (27 standard NexoBrid® management, 61 ENGAGE). Baseline characteristics and burn etiologies were comparable. The ENGAGE group showed a significantly shorter LOS (mean±SD: 24±13.8 vs 32±19.2 days, median: 23 vs 27 days, p=0.03) with no increase in grafting rate (60.7% vs 59.3%, p=0.54) or mortality (9.8% vs 7.4%, p0.5). The number of surgical procedures per patient was higher in the ENGAGE group (4.36±3.82 vs 2.74±3.82, p=0.029), reflecting planned early reassessment and targeted intervention rather than increased morbidity. The ENGAGE protocol reduces hospital stay without compromising grafting or survival outcomes. By incorporating early, biologically guided excision after enzymatic debridement, it offers a structured and effective refinement of modern burn wound management.