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

722 views
584 views

Published on

Published in: Health & Medicine, Business
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
722
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
25
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

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

  1. 1. INFECTION CONTROL IN BURNS DR SUNIL KESWANI National Burns Centre Mumbai Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  2. 2. Burns … high risk nosocomial infection Burn wound injury Respiratory tract injury Prolonged intubation Broad spectrum antibiotics Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  3. 3. 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, nbcairoli@gmail.com
  4. 4. Diagnosis of BWI 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% Dr. Sunil Keswani, National Burns - costly & labor intensive Centre, www.burns-india.com,  Sine qua non nbcairoli@gmail.com
  5. 5. Organisms causing infections Endogenous & Exogenous  Staph aureus incl MRSA  Enterococci & Gp A Streptococci  CoNS  Pseudomonas aeruginosa  Enterobacter / E-coli  Klebsiella / Serratia  Candida  Filamentous fungi Dr. Sunil Keswani,  Viruses as HSV,VZV,CMV National Burns Centre, www.burns-india.com, nbcairoli@gmail.com Gram Pos Gram Neg
  6. 6. Prevention of infection in burns  Architectural design  Contained perimeter to limit through traffic  Individual 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, nbcairoli@gmail.com
  7. 7. 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 careDr. Sunil Keswani,isolated to isolated areas from www.burns-india.com, non National Burns Centre, nbcairoli@gmail.com
  8. 8. 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 infection Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  9. 9. 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 Dr. Cups, bedpans, Sunil Keswani, National Burns kept dry urinals etc. to be Centre, www.burns-india.com, nbcairoli@gmail.com
  10. 10. 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, nbcairoli@gmail.com
  11. 11. 2.Care of the Bed space  Hand wash solutions at each bedside  Bed / side table / rails / IV poles cleaned with Na hypochlorite for every new patient & twice daily  Mattresses covered with a impervious cover  Dedicated equipment  No stuffed toys/flowers  Cooked food Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  12. 12. Handrub.. the best antimicrobial Hands should be cleaned before donning & after removing gloves Self drying solution Alcohol ( 70 %) +  Chlorhexidine( 0.5 %) Soap & Water Cheap ? user friendly Needs drying Soap & drying agent contaminated towel or tissue Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  13. 13. 2.Care of the Bed space Walls cleaned daily Clean floors x 3 daily (with stabilised hydrogen peroxide) Curtains (windows) changed every week Linen changed daily + SOS Contaminated dressings/ linen bagged & removed Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  14. 14. 2.Care of the Bed space…contd •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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  15. 15. 3. Care of Patient Contact  Wash hands before any patient contact  Re-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, nbcairoli@gmail.com
  16. 16. 3. Care of Patient Contact - Procedures  Separate trolley – NO common trolley – Separate trolley cleaned and loaded before a bedside procedure is done  Surface cleaned with disinfectant  Surface completely covered with a sterile drape Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  17. 17. 4.Care of Indwelling Devices  Wash hands before (& after contact)  Minimal disconnection  Appropriate dressing care protocol  Discourage line changes over guidewire  Avoid “ routine ” changes – Urinary catheters  Appropriate sterile precautions for insertion Dr. Sunil – Tracheal tubes Centre, Keswani, National Burns www.burns-india.com, nbcairoli@gmail.com
  18. 18. 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 fluids National Burns Dr. Sunil Keswani, Centre, www.burns-india.com, nbcairoli@gmail.com
  19. 19. 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 changing Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  20. 20. 5.Care of External Devices - Suction Aseptic technique Use sterile gloves One hand sterile technique Sequence must be endotracheal-nasal- oral For long term ventilation closed suction system(stericath) to be used Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  21. 21. 7.Preventing Endogenous Infection Early wound closure & grafting Early and complete resuscitation to ensure adequate bowel & other organ perfusion Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  22. 22. 7.Preventing Endogenous Infection  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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  23. 23. 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, nbcairoli@gmail.com
  24. 24. Diagnosis of infection in the burn patient can be 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 Centre, www.burns-india.com, nbcairoli@gmail.com
  25. 25. Wound Swabs and Cultures and Sensitvity  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. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  26. 26. WARNING SIGN OF SEPSIS 1. 2.     Temperature spikes Any change in the patient’s status : hypotension, altered mental status. intolerance of tube feeds. hyper and hypoglycemia. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  27. 27. CULTURE SITES 1. 2. 3. 4. 5. urine, sputum, blood, central lines wound Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  28. 28. common sites of infection  blood,  urine, lungs,  patients with a prolonged intensive care unit course can also develop sinus infections, pancreatitis,cholecystitis, meningitis, and endocarditis.  Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  29. 29.  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. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  30. 30.  Antibiotics -3rd gen Cephalosporin and Aminoglycoside as first line and then “targetted antibiotic therapy”  Antifungals-Fluconazole/Echinocandins like Caspofungin Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  31. 31. Conclusions - Obsession is the rule  Clear policies & protocols – Need to be followed by all personnel – Need to be enforced by director & Infection Control Committee  Concentrate on point of patient contact  Antibiotics are not a substitute for Infection Control  General cleanliness important Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com  QC of sterilizing solutions necessary
  32. 32. 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 Sunil Keswani, National Burns Dr. Centre, www.burns-india.com, nbcairoli@gmail.com
  33. 33. Thank you! Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com

×