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INFECTION CONTROL IN INFECTION CONTROL IN BURNSBURNS
Dr SM Keswani,National Burns Centre
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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]
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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,
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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 Dr. Sunil Keswani, National Burns
Centre, www.burns-india.com, [email protected]
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
Dr. Sunil Keswani, National Burns
Centre, www.burns-india.com, [email protected]
Components of Protocols
1) Care of the unit
2) Care of the Bed space
3) Care at point of staff contact with patient
4) Care of indwelling devices
5) Care of external devices
6) Detection of epidemics
7) Prevention of endogenous infectionDr. Sunil Keswani, National Burns
Centre, www.burns-india.com, [email protected]
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
Handrub.. the best antimicrobialHands should be cleaned before donning & after removing gloves Self drying solution
Alcohol ( 70 %) + Chlorhexidine( 0.5 %)
Soap & WaterCheap ? user friendlyNeeds dryingSoap & drying agent contaminated towel or tissue
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
2.Care of the Bed space
Clean floors x 3 daily (with stabilised hydrogen peroxide)
Walls cleaned dailyCurtains (windows) changed every weekLinen changed daily + SOSContaminated dressings/ linen bagged
& removedDr. Sunil Keswani, National Burns
Centre, www.burns-india.com, [email protected]
•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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
4.Care of Indwelling Devices
Appropriate sterile precautions for insertionWash hands before (& after contact)Minimal disconnectionAppropriate dressing care protocolDiscourage line changes over guidewireAvoid “ routine ” changes
– Urinary catheters– Tracheal tubes
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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
Centre, www.burns-india.com, [email protected]
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
Centre, www.burns-india.com, [email protected]
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 usedDr. Sunil Keswani, National Burns
Centre, www.burns-india.com, [email protected]
7.Preventing Endogenous Infection
Early wound closure & graftingEarly and complete resuscitation to
ensure adequate bowel & other organ perfusion
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
7.Preventing Endogenous InfectionEarly 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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
7.Preventing Endogenous Infection
Tight Glycemic Control in Medical Patients
NICE study (Normoglycemia in Intensive Care Evaluation)
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
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
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,