05/01/2023Dr.T.V.Rao MD 1

INFECTION CONTROL IN BURNS PATIETNS

DR.T.V.RAO MD

05/01/2023Dr.T.V.Rao MD 2

INTRODUCTION• Infection in the burn patient is

a leading cause of morbidity and mortality and remains one of the most challenging concerns for the burn team. The importance of preventing infection has been recognized in organized burn care since it’s inception and has followed recurring themes through the years

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ASEPTIC TECHNIQUES IS A GREAT PRIORITY

• These included strict aseptic technique, use of sterile gloves and dressing materials, wearing masks for dressing changes, and spacial separation of patients, either using private rooms or cubicles

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EPIDEMIOLOGY OF INFECTIONS IN BURNS PATIENTS

• The development of infection depends on the presence of three conditions, a source of organisms; a mode of transmission; and the susceptibility of the patient. Infection risk for burn patients is different from other patients in several important respects

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RISK FACTORS FOR THE DEVELOPMENT OF A BURN WOUND INFECTION ARE AS FOLLOWS

• Extremes of age • • Comorbidities such as obesity and diabetes • • Immunosuppression (eg, due to AIDS) • • Invasive devices (eg, catheters) • • Burns involving greater than 30% total body surface area (TBSA) • • Full-thickness burns • • Failure to cover burns or failed skin graft resulting in prolonged open burn wounds • • Improper early burn care

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MEASURES TO COMBAT INFECTION MUST BE REINFORCED IN BURN CENTRES

• •Special care must be taken to prevent infections in patients with deep or extensive burns; as hospital stay is prolonged, the risk of infection clearly increases in bum patients; attention should centre on S. aureus, S. epidermidis, and, particularly, on Pseudomonas; bums caused by electric current cause great internal damage, and are thus especially vulnerable to infection

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WOUND INFECTION SIGNS ARE AS FOLLOWS

• Suppurative separation of the eschar • • Graft loss with involvement of

unburned tissue or the presence of a systemic response consistent with sepsis

• • Change in wound color (focal areas of red, brown, or black)

• • Green discoloration of the subcutaneous fat

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CELLULITIS SIGNS ARE AS FOLLOWS

• Erythema (Erythema alone may not require treatment.) • • Induration • • Warmth • • Tenderness • • Sepsis (occasionally)

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NECROTIZING INFECTION/FASCIITIS SIGNS INCLUDE AGGRESSIVE INVASIVE INFECTION WITH INVOLVEMENT OF

STRUCTURES BELOW THE SKIN (EG, MUSCLE, BONE, ORGANS).

• Temperature greater than 39°C or less than 36.5°C

• • Progressive tachycardia (>110 beats per minute)

• • Progressive tachypnea - More than 25 breaths per minute without assisted ventilation; minute ventilation greater than 12 L/min if intubated and mechanically ventilated

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NECROTIZING INFECTION/FASCIITIS

• Thrombocytopenia (< 100,000/μL; does not apply immediately after initial resuscitation)

• • Hyperglycemia (in the absence of pre-existing diabetes mellitus) - Plasma glucose levels greater than 200 mg/dL in the absence of treatment; significant resistance to insulin (>25% increase in insulin requirement)

• • Inability to continue enteral feedings for more than 24 hours - Abdominal distension, high gastric residuals, uncontrollable diarrhoea

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SOURCES OF ORGANISMS • Sources of organisms are found in

the patient’s own endogenous (normal) flora, from exogenous sources in the environment, and from healthcare personnel. Exogenous organisms from the hospital environment are generally more resistant to antimicrobial agents than endogenous organisms

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INFECTIONS ASSOCIATED WITH BURN INJURIES

• The typical burn wound is initially colonized predominantly with gram-positive organisms, which are fairly quickly replaced by antibiotic-susceptible gram-negative organisms, usually within a week of the burn injury. If wound closure is delayed and the patient becomes infected, requiring treatment with broad-spectrum antibiotics, these flora may be replaced by yeasts, fungi, and antibiotic-resistant bacteria.

• Organisms associated with infection in burn patients include gram-positive, gram-negative, and yeast/fungal organisms. The distribution of organisms changes over time in the individual patient and such changes can be ameliorated with appropriate management of the burn wound and patient

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MODE OF TRANSMISSION • Modes of transmission include

contact, droplet and airborne spread. In burn patients the primary mode is direct or indirect contact, either via the hands of the personnel caring for the patient or from contact with inappropriately decontaminated equipment

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MICROBIAL COLONIZATION • Burn patients are unique in their

susceptibility to colonization from organisms in the environment as well as in their propensity to disperse organisms into the surrounding environment. In general, the larger the burn injury, the greater the volume of organisms that will be dispersed into the environment from the patient

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ORGANISMS FREQUENTLY CAUSING INVASIVE BURN WOUND INFECTION• Gram-positive bacteria -

S aureus, including MRSA; coagulase-negative Staphylococcus species; Enterococcus species, including vancomycin-resistant species

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GRAM-NEGATIVE BACTERIA • Gram-negative bacteria

- P aeruginosa, Klebsiella species, Acinetobacter species, Escherichia coli, Serratia marcescens, Enterobacter species, Proteus species

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FUNGI• Fungi (Burn wounds complicated

by fungal infections constitute an independent predictor for mortality in patients with a burned TBSA of 30-60% - Candida species; Aspergillus species; Fusarium species; Phaeohyphomycetes (fungi with dark cell walls); Mucorales (eg, Rhizopus, Mucor, Absidia, and Apophysomyces species)

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VIRUSES• Viruses (Cutaneous

disease typically occurs in healing partial-thickness burns and donor sites.) - Herpes simplex virus, varicella-zoster virus

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MULTI-DRUG RESISTANT ORGANISMS (MDROS) IS A

MAJOR PROBLEM• Against this back-drop, the increasing prevalence of multi-drug resistant organisms (MDROs) is a major problem. MDROs have been shown to restrict therapeutic options resulting in elevated morbidity and mortality, higher costs and extended length of stay in the hospital by patients

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BURNS PATIENTS NEED A SPECIALISED CARE• Burns patients can be at a

major risk from hospital associated pathogens – which can lead to poor recoveries and even death. Additionally, Burns Units can be a significant cost to a hospital due to the specialized care needed

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ACINETOBACTER BAUMANNII INCREASES COSTS OF TREATMENTS

•Acinetobacter baumannii and ends up staying on the burns ICU for, say, a increased burden and costs

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CULTURING AND SURVEILLANCE

• Culturing and surveillance guidelines are more stringent for the burn patient, particularly the patient with larger injuries, because of the increased propensity for transmission and infection in this population.

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CULTURING AND SURVEILLANCE • Burn wound flora and antibiotic susceptibility patterns

change during the course of the patient’s hospitalization so that the purposes of obtaining routine surveillance cultures are: - to provide early identification of organisms colonizing the wound - to monitor the effectiveness of current wound treatment - to guide perioperative or empiric antibiotic therapy - to detect any cross-colonizations which occur quickly so that further transmission can be prevented.

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CULTURING AND SURVEILLANCE

• To provide early identification of organisms colonizing the wound - to monitor the effectiveness of current wound treatment - to guide perioperative or empiric antibiotic therapy - to detect any cross-colonizations which occur quickly so that further transmission can be prevented

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ROUTINE SURVEILLANCE • Routine surveillance wound

cultures should be obtained when the patient is admitted and at least weekly until the wound is closed. Many burn centres recommend obtaining wound cultures two or three time a week for patients with large burn injuries

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CULTURING THE SPECIMENS WHEN TRANSFERRED FROM OTHER UNITS

• Admission cultures are particularly important for patients transferred from other facilities, as they may be colonized with multiply resistant organisms and serve as an unsuspected reservoir for cross-transmission to other patients on the unit

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CULTURING SPECIMENS FROM PAEDIATRIC PATIENTS

• For paediatric patients, admission throat cultures are also recommended as about 5% of the population will be colonized with Group A beta-hemolytic Streptococcus (S.pyogenes) which can have serious consequences if it is transmitted to the burn wound.

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METHODS OF BURN WOUND CULTURING

• Methods of burn wound culturing include obtaining a semi-quantitative swab culture or a quantitative biopsy specimen. Semi-quantitative swab cultures provide information on the type of organisms present on the burn wound, as well as the approximate amount and antimicrobial susceptibility

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SIGNIFICANCE OF CULTURING • A general rule is to obtain a swab culture for each 10% of

open burn to identify organisms of significance on the wound. Quantitative cultures are used to define invasive infection based on bacterial count of 100,000 colonies or more per gram of tissue. However, further study has revealed that this technique is not precise, as 50% of patients with quantitative counts of greater than 100,000 organisms do not have histologic evidence of invasive infection.

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HISTOPATHOLOGICAL EXAMINATION OF INFECTED MATERIAL

• Quantitative culturing is more costly and labor-intensive than swab cultures, and their routine use to identify colonizing organisms on appropriately debrided wounds is rarely indicated. Accurate diagnosis of invasive burn wound infection is best determined by clinical criteria, supported when possible by histopathologic examination if the patient’s condition is suspicious for this infection.

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EFFECTIVE SURVEILLANCE REDUCES THE MORBIDITY AND MORTALITY

• Surveillance of infection has been shown to diminish the rate of nosocomial infection as well as reduce cost. Surveillance of infection in burn patients should be done to monitor incidence and rates which have been appropriately risk adjusted by size of burn injury and invasive device use

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COLLECTION OF DATA ON ASSOCIATED INFECTION

• At a minimum, surveillance should include collection of data on burn wound infection, urinary tract infection, pneumonia, and bloodstream infection. Systematic collection of data allows the burn unit to monitor changes in infection rates over time, identify trends, and evaluate current treatment methods.

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ROUTINE ENVIRONMENTAL SURVEILLANCE CULTURING

• Routine environmental surveillance culturing is not generally recommended on units with burn patients. The exception may be the hydrotherapy room and common treatment room used in burn wound care. Environmental culturing is important as part of any outbreak investigation which is done on the burn Unit

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IF ENVIRONMENTAL CULTURING IS NEEDED

• If environmental culturing is considered; either for routine use in hydrotherapy/treatment rooms, in outbreaks, or for educational purposes; the hospital’s infection control department should be consulted for guidance on the location, types, and frequency of culturing and interpretation of results

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INCIDENCE OF INFECTION • Catheter-associated BSI rates for burn intensive care units (ICUs)

enrolled in the National Nosocomial Infections Surveillance (NNIS) System, Centers for Disease Control and Prevention (CDC) in the United States from January 1995 to June 2002 were 8.8 per 1000 central venous catheter days (CVC), compared with pooled mean rates of 7.4 for paediatric ICUs, 7.9 for trauma ICUs, and 5.2 for surgical ICUs. These rates include both adult and pediatric burn patients

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WISH TO REDUCE INFECTIONS IN BURNS PATIENTS

THERE IS NO TRUTH GREATER THAN HAND WASHING

• The importance of hand-hygiene with use of gloves, masks and caps is essential while handling burns patients. Unnecessary antimicrobials should not be encouraged in burn patients as many wounds would have colonizers rather than infective pathogens

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WE STILL NOT PERFECT IN REDUCING THE INFECTIONS IN BURNS PATIENTS

• However, more studies are required for the most effective combination of aspects of infection control precautions in burn patients

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FUTURE CHALLENGES IN IDENTIFICATION OF INFECTION IN

BURNS PATIENTS • An important area for future study

relates to the clinical problem of appropriate precaution strategies, particularly for patients colonized with multiply resistant organisms, with the goal to be identification of cost-effective measures that prevent outbreaks involving other patients on the unit.

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THE WORLD IS HEADING FOR MANY CENTRES SPECIALISING IN BURNS RESEARCH

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REFERENCES • INFECTION CONTROL IN BURN PATIENTS Authors:

Joan Weber, RN, BSN, CIC Infection Control Coordinator etal • WEB resources on infections in Burns patients • CDC reviewed information

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• Program created by Dr.T.V.Rao MD for Medical and Paramedical students for Basic principles of

Infections in Burns patients • Email

• doctortvrao@gmail.com