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

INFECTION CONTROL IN
BURNS
DR SUNIL KESWANI
National Burns Centre
Mumbai
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

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

Burn Wound Infection - BWI
BW Colonization - presence of organisms within
the eschar
BWI - bacterial invasion of viable tissue adjacent
to the eschar

nbcairoli@gmail.com

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%
- costly & labor intensive
 Sine qua non

nbcairoli@gmail.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
Dr. Sunil Keswani,
 Viruses as HSV,VZV,CMV National Burns
nbcairoli@gmail.com

Gram Pos
Gram Neg

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
nbcairoli@gmail.com

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

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
nbcairoli@gmail.com

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
nbcairoli@gmail.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
nbcairoli@gmail.com

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
nbcairoli@gmail.com

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
nbcairoli@gmail.com

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

nbcairoli@gmail.com

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

nbcairoli@gmail.com

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
nbcairoli@gmail.com

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

nbcairoli@gmail.com

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

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,
nbcairoli@gmail.com

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
nbcairoli@gmail.com

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
nbcairoli@gmail.com

7.Preventing Endogenous Infection
Early wound closure & grafting
Early and complete resuscitation to ensure

adequate bowel & other organ perfusion

nbcairoli@gmail.com

 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

nbcairoli@gmail.com

 Tight Glycemic Control in Medical Patients
 NICE study (Normoglycemia in Intensive Care

Evaluation)

nbcairoli@gmail.com

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.
nbcairoli@gmail.com

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.

nbcairoli@gmail.com

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.
nbcairoli@gmail.com

CULTURE SITES
1.
2.
3.
4.
5.

urine,
sputum,
blood,
central lines
wound

nbcairoli@gmail.com

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.


nbcairoli@gmail.com

 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.
nbcairoli@gmail.com

 Antibiotics

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

 Antifungals-Fluconazole/Echinocandins

like Caspofungin
nbcairoli@gmail.com

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

nbcairoli@gmail.com

 QC of sterilizing solutions necessary

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.
nbcairoli@gmail.com

Thank you!
nbcairoli@gmail.com

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

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