This document discusses infection control in burn units. It notes that infections are a leading cause of morbidity and mortality in burn patients due to their loss of protective skin barrier and immunosuppression. It outlines the epidemiology of infections in burn units, including common sources, modes of transmission, and susceptible patient populations. The document then discusses principles of prevention, including identifying and isolating infected patients, practicing asepsis, performing wound cultures, and following standard precautions like hand hygiene. It also provides guidance on disinfection and cleaning of equipment.

1. Infection Control in Burn Unit
Dr. Kanwal Deep Singh Lyall
M.D. Microbiology

2. • Burns - commonest & devastating trauma.
• Infections in a burn patient are leading cause of
morbidity & mortality & a challenge for burn team
• Immediate specialized care

3. Causes of infection in burn patients
• Loss of protective barrier
• Thrombosis of subcutaneous blood vessels
• Avascular bed
– excellent medium to support growth of microorganisms
– prevents penetration of systemic antibiotics
• Alteration in defense mechanisms - Predisposes burn
patients to infectious complications.
– Significant thermal injuries - a state of immunosuppression.
– Both innate & adaptive immune responses affected.

4. Epidemiology of Infection
Infection
Source of
organism
Mode of
transmission
Susceptible
patients

5. Sources of infection
• Endogenous -normal flora
• Exogenous - environment & HCWs
– Colonized patients – major reservoir
– Contaminated hydrotherapy instruments
– Common treatment areas
– Water sources
– Contaminated equipment
– Mattresses
– Hands & apron area of HCWs

7. Organisms
• Bacteria, Viruses, Fungi & Parasites
• MDR strains of bacteria (MRSA, VRSA, VRE,
ESBL & MBL producing bacteria, MDR
Klebsiella & P. aeruginosa)

8. Modes of Transmission
• Contact, droplet & airborne spread
• 1° mode - direct or indirect contact - hands of HCWs or
equipment.
• Burn patients- high susceptibility to colonization & to
disperse organisms
• Larger the burn injury, the greater the volume of
organisms dispersed – cross contamination

9. Patient Susceptibility
• Very young children and the elderly
• Disabled & obese
• Underlying medical condition
• Other types of severe immunosuppression
• Individuals with deliberate self-inflected burn
injuries
• > 25% burns or invasive devices

10. Pathogenesis of burn wound infection
The typical burn wound - initially colonized predominantly with
gram-positive organisms
↓
Antibiotic-susceptible gram-negative organisms ≈ 1 week.
↓
Wound closure delayed - patient becomes infected, requiring
treatment with broad-spectrum antibiotics
↓
Yeasts, fungi, and antibiotic-resistant bacteria

11. Principles of prevention of HAI in Burn Patients
• 3 basic principles to prevent HAIs
1. Identify & isolation of known infected or
colonized
2. Asepsis to eliminate or minimize potential
routes of transmission (Pt – Pt, Pt – HCW,
HCW – Pt)
3. Standard precautions

12. Identification by Wound Cultures
Burn wound flora & antibiotic susceptibility patterns change
during the course of the patient’s hospitalization
• Early identification of organisms colonizing the wound
• Monitor the effectiveness of current wound treatment
• Guide perioperative or empiric antibiotic therapy
• Detect any cross-colonizations
• Prevent transmission

13. Wound Cultures
• At time of admission & at least weekly until
wound is closed.
• 2 – 3 times a week for patients with large burn
injuries.
• Admission cultures - transfers from other facilities
• May serve as an unsuspected reservoir for cross-
transmission
• For paediatrics patients, admission throat
cultures are also recommended (ß – HS)

14. Methods of wound culture
• Semi-quantitative swab culture - approx.
bacterial count & AST
• Quantitative – define invasive infection (≥105
colonies / gram of tissue)

15. Environmental Surveillance
• Not generally recommended for burn units
• Except hydrotherapy rooms & common
treatment rooms
• Environmental culturing – outbreak
investigation

16. Isolation guidelines
• Open wound = ↑ environmental contamination
• Amount of contamination – directly
proportional to size of open wound &
colonization and Inversely proportional to
distance b/w patients

17. Isolation Precautions for Infected Patients
• Standard precautions
• Separate room/ cabin or less preferred – placement of
patient at end of the ward, close to basin / Cohorting
patients
• Assigned nursing staff/Attending the patient at the last
• Hand hygiene
• Separate or adequately sterilized/ disinfected instruments
• Cleaning/disinfection of area after discharge of patient
• Visitor policy

18. • > 25% burns – preferably dressing at bedside
• Boston, Shriners Burn Hosp. – all patients dressing at
bedside - ↓risk of cross -contamination & cross -
infection (Incidence of cross infection < 5% for 25
years)
• Plants & flowers should not be allowed
• Pediatrics patients – non-washable toys not allowed
(non-porous , washable)

19. Standard Precautions
• Simple standards of infection control practices
& certain protecting measures
• Used by health workers while taking care of all
patients, at all times, while providing
professional services

20. Standard Precautions Include
1. Hand-washing with soap and water before and after procedures
2. Use of protective barriers (PPE)
3. Safe disposal of waste contaminated with blood or body fluids
(BMW management)
4. Safe handling and disposal of needles and sharp instruments
5. Proper disinfection of instruments and other contaminated
equipment
6. Proper handling of soiled linen

22. Your 5 Moments for Hand Hygiene

23. Hand Wash Technique

24. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Doctors Staff nurses Ancillary staff
33%
64%
60%
75%
88%
75%
Percentage
Hand Hygiene Compliance - BICU
June
July

25. BMW Management
GREEN BAG RED BAG YELLOW BAG
WHITE
CONTAINER
BLUE BAG
General Waste
(Non-infectious)
Infectious Waste
Infectious Cotton/
Anatomical Waste
Sharp Waste
(Infectious)
Sharp Waste
(Infectious)
Paper Waste
Cartons
Packaging material
Plastic sheets
News paper
Waste food items
Blood bags
Gloves
Urine bags
Disposables like
Catheters, I/V
Drip sets, Ryles
tube, Airways
etc.
Bandages/ Dressings
Cotton Swabs
Plastic casts
Napkins soiled with
blood or body fluids of
patients
Linen material
Human tissues, organs,
body parts, placenta
etc.
Needles should be
destroyed at
generation point
Lancets/ Blades
I/V Drip
bottles/
Injection Vials,
Ampoules
Syringes to be
discarded after
destroying the
needle tip and
removing plunger
in 1% sodium
hypochlorite sol.

26. Disinfection/Cleaning of Patient Care Equipment

27. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Enter or penetrate sterile tissue,
cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
Non-critical Contact with intact skin Low-level Disinfection

28. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Entry or penetration into sterile
tissue, cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
(minimum contact time
of ≥ 20 minutes)
Non-critical Contact with intact skin Low-level Disinfection
Object: Sterile
Level of germicidal action: Kill all
microorganisms, including bacterial
spores.
Examples: Surgical instruments
and devices; cardiac catheters;
implants; etc.
Method: Steam, gas, hydrogen
peroxide plasma or chemical
sterilization.

29. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Entry or penetration into sterile
tissue, cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
(minimum contact time
of ≥ 20 minutes)
Non-critical Contact with intact skin Low-level Disinfection
Glutaraldehyde (> 2.0%)
Hydrogen peroxide-HP (7.5%)
Peracetic acid-PA (0.2%)
HP (1.0%) and PA (0.08%)
HP (7.5%) and PA (0.23%)
Glut (1.12%) and Phenol/phenate
(1.93%)
Exposure time per manufacturers’
recommendations

30. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Enter or penetrate sterile tissue,
cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
Non-critical Contact with intact skin Low-level Disinfection

31. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Entry or penetration into sterile
tissue, cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
(minimum contact time
of ≥ 20 minutes)
Non-critical Contact with intact skin Low-level Disinfection
Object: Free of all microorganisms except
high numbers of bacterial spores.
Level of germicidal action: Kill all
microorganisms except high numbers of
bacterial spores.
Examples: Respiratory therapy and
anesthesia equipment, GI endoscopes,
endocavitary probes, etc.
Method: High-level disinfection

32. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Entry or penetration into sterile
tissue, cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
(minimum contact time
of ≥ 20 minutes)
Non-critical Contact with intact skin Low-level Disinfection
Glutaraldehyde > 2.0%
Ortho-phthalaldehyde (12 m) 0.55%
Hydrogen peroxide* 7.5%
Hydrogen peroxide and peracetic acid*
1.0%/0.08%
Hydrogen peroxide and peracetic acid*
7.5%/0.23%
Hypochlorite (free chlorine)* 650-675 ppm
Glut and phenol/phenate 1.21%/1.93%
Exposure Time > 12 m-30m ,20° C
*May cause cosmetic and functional damage

33. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Enter or penetrate sterile tissue,
cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
Non-critical Contact with intact skin Low-level Disinfection
Treat non – critical as semi-critical in burn patients

34. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Entry or penetration into sterile
tissue, cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
(minimum contact time
of ≥ 20 minutes)
Non-critical Contact with intact skin Low-level Disinfection
Object: Can be expected to be
contaminated with some micro-organims.
Level of germicidal action: Kill vegetative
bacteria, fungi and lipid viruses.
Examples: Bedpans; crutches; bed rails; EKG
leads; bedside tables; walls, floors and
furniture.
Method: Low-level disinfection (or
detergent for housekeeping surfaces)

35. Level of Disinfection/Cleaning Required for
Patient Care Equipment
Spaulding
Classification of
Objects
Application Level of Germicidal
Action Required
Critical Entry or penetration into sterile
tissue, cavity or bloodstream
Sterilization
Semi-critical Contact with mucous
membranes, or non-intact skin
High-level Disinfection
(minimum contact time
of ≥ 20 minutes)
Non-critical Contact with intact skin Low-level Disinfection
Ethyl or isopropyl alcohol 70-90%
Chlorine 100ppm (1:500 dilution)
Phenolic UD
Iodophor UD
Quaternary ammonium UD
Exposure time > 1 min
UD=Manufacturer’s recommended use dilution

36. Recommendations for cleaning of
various equipment

37. Equipment Recommendation
Bed ends, frames & Curtain
Rails, Hand Basins
• Detergent and water.
Bowls-Bedpans / Urinals • Heat disinfection (82°C for 2 mins)
• or 3-5% Na hypochlorite solution x 30 mins - soap
and water & dry in sunlight.
Lockers, Clinic Trolleys • Detergent and water (as necessary and after patient
discharge.)

38. Equipment Recommendation
Mattresses and
Pillows
• Cover with an impervious plastic cover
• Wipe with detergent and water if visibly contaminated.
• Mattresses should be cleaned regularly
• If possible keep in sunlight for 24 hours.
• Plastic and rubber covers of mattresses and pillows - wash with soap &
water, cleaned with a suitable disinfectant e.g.7% Lysol.
Mop Heads • Clean daily & at completion of each task of floor mopping
• Send detachable mop heads to laundry
• Reusable mops In hot soapy water, then left to dry, ideally in the sun.
• The bucket is to be turned upside down to allow overnight drainage.
Walls • Remove visible soiling with detergent as necessary.

39. Equipment Recommendation
Cleaning cloths,
brushes
• Supplied daily from the laundry and then discarded to wash.
• Wash brushes and buckets in detergent and water, then store dry.
Ventilator Exterior
(including the touch
screen and flex arm)
• Wipe clean with damp cloth and mild solution.
• Use water to rinse off chemical residue as necessary.
• Mild dishwashing detergent, Isopropyl alcohol (70% solution),
Bleach (10% solution), Ammonia (15% solution), H2O2(3%
solution), Glut. 3.% solution can be used
Ventilator circuit
tubing
• Disassemble and clean, chemically disinfect or ETO
• May use a fresh circuit for each patient
Thermometer • Individual for each patient.
• Disinfect - wiping with 70% isopropyl alcohol.
• Each thermometer is kept in a separate dry holder.

40. Environmental fogging clarification statement
• No longer recommended by CDC (Guideline for
Disinfection & Sterilization in Healthcare Facilities, 2003
& 2008 )
• These include formaldehyde, phenol based agents or
quaternary ammonium compounds etc.
• Lack of microbicidal efficacy of quaternary ammonium
compounds in mist applications
• Formalin is Grade III carcinogen
• A false sense of security
• No substitute for vigorous cleaning of surfaces

41. Infections Associated With IV Lines
• Occur more often in burn patients
• IV devices ≈ 50% of nosocomial bacteremia
• CVC account for 80%-90% of these infections
• ≈ 5%( case fatality> 50%)
• The resident or transient cutaneous flora - source of infection
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
CRBSI
0 0 0
Rateper1000devicedays
May
June
July

42. Prevention of CRBSI in burn patients
• Avoiding catheterization
• Limiting duration
• Hands hygiene, maximal barrier precautions for CVC insertion
• Catheters placed through unburned skin & at distance from the
burn wound
• Chlorhexidine-containing cutaneous antiseptics
• Transparent, semipermeable dressings
• Non-occlusive povidone-iodine dressing
• Same antimicrobial for insertion site & surrounding wound
• Change every 3 – 7 days
• Arterial catheters – low infection rate
• Femoral catheter in children preferred

43. Prevention of pneumonia in burn patients
• Significant morbidity & mortality
• Esp. in adults with preexisting lung disease &
children with smoke inhalation
0
0.2
0.4
0.6
0.8
1
VAP
0 0 0
Rateper1000devicedays
May
June
July

44. Prevention of HAP in burn patients
• Chest physiotherapy,
• Turning, coughing, deep breathing,
• Suctioning , chlorhexidine mouth wash
• Antibiotics based on sputum c/s,

45. Prevention of VAP in burn patients
• Effective hand washing and PPE
• Semi-recumbent position of patient
• Avoidance of large gastric volumes
• Oral (non-nasal) ventilation
• Routine maintenance of ventilator circuits and
suction equipment
• Continuous subglottic suctioning
• Respiratory physiotherapy
• Chlorhexidine mouth wash

46. CAUTI in burn patients
• 2 – 4% bacteremia & 3 times case fatality rate
• Risk factors – perineal burns & prolonged
catheterization.
0
5
10
15
20
25
30
35
CAUTI
21.5
0
30.3
Rateper1000devicedays
May
June
July

47. Prevention of CAUTI in burn patients
• Insert catheters only when indicated
• Limiting duration
• Insertion & maintenance by trained persons
• Use aseptic technique & sterile equipment
• Maintain a closed drainage system
• Maintain unobstructed urine flow
• Hand hygiene and standard precautions

48. Prevention of burn wound infection
• Assessment of wound at each dressing change
• Strict aseptic technique
• Debriding dressing for necrotizing wound
• Protective dressing for clean healing wound
• Invasive infection – surgical excision &
systemic antimicrobials

49. Antibiogram - BICU
Jan – July 2013

50. • E. coli, – MDR –AK (67%), IMI, PB (100%)
• Pseudomonas spp. – MDR - TOB, PB
(100%)
• Acinetobacter spp. – LEX, GEN, AK, IMI –
50%, PB – 100%
• Klebsiella spp. – MDR – IMI, PB (100%)
• MRSA –NIT, VAN, LZ (100%)
• Pseudomonas spp. – TOB (44%), CPM
(50%), AK (60%), TZP (87%), PB (100%)
• Acinetobacter spp. – MDR – IMI (50%), PB,
TGC (100%)
• Klebsiella spp. – MDR – IMI (65.2%), PB,
TGC (100%)
• E. coli – AK (59%), IMI, PB (83%), TGC
(100%)
• S. aureus – 50% MRSA – VAN, LZ (100%)
E. coli
46%
Pseudomonas
spp.
23%
Acinetobacter
spp.
15%
Klebsiella
spp.
8%
S. aureus
8%
Urinary isolates (n = 13)
Pseudomonas
spp.
28%
Acinteobacter
spp.
23%
Klebsiella spp.
19%
E. coli
14%
S. aureus
13%
Others
3%
Isolates from Exudates (n=127)

51. Isolates from blood Isolates form resp. samples
S.
epidermidis
29%
A. baumannii
17%K.
pneumoniae
9%
Pseudomona
s spp.
8%
S. aureus
8%
Others
29%
(n = 24)
Acinetobacter
spp.
25%
E. coli
25%
Klebsiella spp.
25%
Pseudomonas
spp.
25%
(n= 4)
• Acinetobacter spp., K. pneumoniae, Pseudomonas spp. – MDR
• Susceptible to Colistin & Tigecycline
• S. aureus – susceptible to Vancomycin, Linezolid
• S. epidermidis – significance to be correlated
• Paired blood sample required for diagnosis of BSI

52. Antimicrobials & Burns
• Burn wound always colonized with organisms until wound
closure
• colonization not eliminated by systemic antimicrobials, but
rather promote emergence of resistant organisms.
• Systemic antimicrobials indicated to treat documented
infections.
• Empirical therapy to treat fever – strongly discouraged
• Prophylactic – only for immediate peri-op period

53. Thank You