Infection control nabicon 13 by Dr. Sunil Keswani, Nat

INFECTION CONTROL IN
BURNS
Dr SM Keswani,
National Burns Centre

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

nbcairoli@gmail.com

Burns care - what’s in…..
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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
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
 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
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
 Viruses as HSV,VZV,CMV
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
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 care from non isolated to isolated areas
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
nbcairoli@gmail.com
– Cups, bedpans, urinals etc. to be kept dry

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 Dr. Sunil Keswani, National Burns
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
Clean floors x 3 daily (with stabilised
hydrogen peroxide)
Walls cleaned daily
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
 Appropriate sterile precautions for insertion
 Wash hands before (& after contact)
 Minimal disconnection
 Appropriate dressing care protocol
 Discourage line changes over guidewire
 Avoid “ routine ” changes

– Urinary catheters
Dr.
– Tracheal tubes Sunil Keswani, National Burns
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 otherSunil Keswani, National Burns
Dr. fluids
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

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

Thank you!
nbcairoli@gmail.com

Infection control nabicon 13 by Dr. Sunil Keswani, Nat

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