Infection control by Dr. Sunil Keswani, National Burns Centre, Airoli

INFECTION CONTROL IN INFECTION CONTROL IN BURNSBURNS

DR SUNIL KESWANINational Burns Centre

Mumbai

Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]

Burns … high risk nosocomial infection

Burn wound injuryRespiratory tract injuryProlonged intubationBroad spectrum antibiotics

Dr. Sunil Keswani, National Burns

Centre, www.burns-india.com, [email protected]

Burn Wound Infection - BWI

BW Colonization - presence of organisms within the eschar

BWI - bacterial invasion of viable tissue adjacent to the eschar

Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,

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Diagnosis of BWI

Sine qua non is Histopath showing tissue invasion Semiquantitative swabs 1 swab for 10% of open burn capillary gauze tech agar contact Quantitative biopsy >105/gm of tissue - a negative quant <105 correlates well with HP but a positive

culture & HP may correlate with as low as 37% - costly & labor intensive


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Organisms causing infections

Endogenous & Exogenous Staph aureus incl MRSA Enterococci & Gp A Streptococci CoNS Pseudomonas aeruginosa Enterobacter / E-coli Klebsiella / Serratia Candida Filamentous fungi Viruses as HSV,VZV,CMV

Gram Pos

Gram Neg


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Prevention of infection in burns

Architectural design Contained perimeter to limit through trafficIndividual strict isolation units with all intensive & burn

care procedures (including vent & operative ) within the center

Single room delays colonization by 10 days Strict compliance with environmental control - enforced hand wash - monitoring & diagnostic equipment housed within each

patients room


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Prevention of infection in burns

Cross contamination kept to a minimum Cohort nursing Convalescent patients separated from acute Category specific precautions for Patients > 30% TBSA & Resistance isolation - separate nursing staff

- supplies arranged to maximise care

- physician care from non isolated to isolated areas


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Components of Protocols

1) Care of the unit 2) Care of the Bed space3) Care at point of staff contact with patient 4) Care of indwelling devices 5) Care of external devices6) Detection of epidemics7) Prevention of endogenous infection


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1.Care of the unit

General Cleaning of unit– Clean twice daily with detergent

• Thorough machine cleaning once weekly– Clean with disinfectant

( stabilised hydrogen peroxide )– May be cleaned with detergent & water– Hydrotherapy agitators – Addition of Na hypochlorite to hydrotherapy water– Cups, bedpans, urinals etc. to be kept dry


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1. Care of the unit - disinfecting solutions

For cleaning contaminated material – Sputum cups, bedpans, urinals etc. – Sodium Hypochlorite 5% solution

• 75 ml. of this diluted in 12L of water• This gives 325 PPM of Cl • Recommendation is > 100 PPM• Checked for potency with Chlorosticks daily• Fresh solution prepared every shift


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2.Care of the Bed space

Hand wash solutions at each bedsideBed / side table / rails / IV poles cleaned with Na

hypochlorite for every new patient & twice dailyMattresses covered with a impervious coverDedicated equipment No stuffed toys/flowersCooked food


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Handrub.. the best antimicrobialHands should be cleaned before donning & after removing gloves

Self drying solutionAlcohol ( 70 %) + Chlorhexidine( 0.5 %)

Soap & WaterCheap ? user friendlyNeeds dryingSoap & drying agent contaminated towel or tissue


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2.Care of the Bed space

Walls cleaned dailyClean floors x 3 daily (with stabilised hydrogen

peroxide)

Curtains (windows) changed every weekLinen changed daily + SOSContaminated dressings/ linen bagged &

removedDr. Sunil Keswani, National Burns


•Separate AMBU bag, face mask , stethoscope & BP cuff per bed•Cleaned with disinfectant for each new patient•Suction bottles cleaned every shift with sod hypo•New tubing for each patient

2.Care of the Bed space…contd


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3. Care of Patient Contact

Wash hands before any patient contactRe-wash when contact with

• Vascular catheter & its connections• Tracheal tube & its connections

Stericath: for tracheal tube suction Change patients position regularly

– Prevents hypostatic pneumonia, bedsores


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Separate trolley– NO common trolley – Separate trolley cleaned and loaded before a

bedside procedure is doneSurface cleaned with disinfectant Surface completely covered with a sterile drape

3. Care of Patient Contact - Procedures


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4.Care of Indwelling Devices

Wash hands before (& after contact)Minimal disconnectionAppropriate dressing care protocolDiscourage line changes over guidewireAvoid “ routine ” changes

– Urinary cathetersAppropriate sterile precautions for insertion

– Tracheal tubesDr. Sunil Keswani, National Burns


5.Care of External Devices-IV sets, Infusions

Suppurative thrombophlebitis decreased by regular rotation

Care of intravenous infusion sets– TPN through separate dedicated set / port– Fluids & drug infusions changed after 24 hours – Infusion set changed- on admission - every 24 hours for TPN and - every 72 for other fluidsDr. Sunil Keswani, National Burns


5.Care of External Devices -Ventilator Circuits

Ventilator & tubing – Disposable circuits if feasible – No routine change of circuit

HMEF at Y-connection for all patients– HMEF & catheter mounts to be changed 24-72

hours– HMEF not to be removed from circuit except at time

of changingDr. Sunil Keswani, National Burns


5.Care of External Devices - Suction

Aseptic techniqueUse sterile glovesOne hand sterile techniqueSequence must be endotracheal-nasal-oralFor long term ventilation closed suction

system(stericath) to be used


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7.Preventing Endogenous Infection

Early wound closure & graftingEarly and complete resuscitation to ensure

adequate bowel & other organ perfusion


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Early Enteral nutrition & Immune enhancing feeds– Gut is source of organisms– Gut wall is vulnerable in critical illness– Early nutrition preserves gut function– Modified feeds preserve or enhance gut function


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Tight Glycemic Control in Medical Patients

NICE study (Normoglycemia in Intensive Care Evaluation)


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Diagnosis of infectionDiagnosis of infectionin the burn patient can be in the burn patient can be challenging:challenging:

. Fevers and leukocytosis can result from the systemic inflammatory response to burn injury and not necessarily infection.

Thrombocytosis is also frequently observed in stable burn patients.

Nearly all patients with greater than 15% TBSA burns are febrile within the first 72 hours. Dr. Sunil Keswani, National Burns


Wound Swabs and Cultures and Wound Swabs and Cultures and SensitvitySensitvity

Routine culture of these patients in this early time period is unnecessary. However, following the initial 72 to 96 hours, periodic cultures are important in making a diagnosis of infection.


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WARNING SIGN OF SEPSIS WARNING SIGN OF SEPSIS

1. Temperature spikes

2. Any change in the patient’s status : hypotension, altered mental status. intolerance of tube feeds. hyper and hypoglycemia.


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CULTURE SITESCULTURE SITES

1. urine,

2. sputum,

3. blood,

4. central lines

5. wound


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common sites of infectioncommon sites of infection

blood, urine, lungs, patients with a prolonged intensive care

unit course can also develop sinus infections, pancreatitis,cholecystitis, meningitis, and endocarditis.


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Management of infections in burn patients must be culture driven.

Presumptive broad-spectrum antimicrobial coverage is fraught with potential complications, including:

breeding resistant organisms increasing the risk of fungal infections.


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Antibiotics -3rd gen Cephalosporin and Aminoglycoside as first line and then “targetted antibiotic therapy”

Antifungals-Fluconazole/Echinocandins like Caspofungin


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Conclusions - Obsession is the rule

Clear policies & protocols– Need to be followed by all personnel– Need to be enforced by director & Infection Control

CommitteeConcentrate on point of patient contactAntibiotics are not a substitute for Infection Control General cleanliness important QC of sterilizing solutions necessary


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Burns care - what’s in…..

Aseptic technique Sterile gowns , gloves, mask Spatial separation Cohort patient care Frequent wound evaluation Choice of antibiotic dictated by current flora & specifically by pts wound flora Aggressive necrotic tissue debridement & early wound closure


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Thank you!


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Health & Medicine

Infection control by Dr. Sunil Keswani, National Burns Centre, Airoli