INFECTION CONTROL IN

BURNS PATIETNS
DR.T.V.RAO MD

Dr.T.V.Rao MD

4/10/16

 Infection in the burn

patient is a leading
cause of morbidity
and mortality and
remains one of the
most challenging
concerns for the burn
team. The importance
of preventing
infection has been
recognized in
organized burn care
since its inception
and has followed

INTRODUCTION

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ASEPTIC TECHNIQUES
ISincluded
A
These
GREAT PRIORITYstrict aseptic

Dr.T.V.Rao MD

technique, use of
sterile gloves and
dressing materials,
wearing masks for
dressing changes,
and spacial
separation of
patients, either
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EPIDEMIOLOGY OF INFECTIONS
The development
of
IN BURNS
PATIENTS
infection depends on the
presence of three
conditions, a source of
organisms; a mode of
transmission; and the
susceptibility of the
patient. Infection risk for
burn patients is different
from other patients in
several important
respects

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RISK FACTORS FOR THE DEVELOPMENT OF A

BURN WOUND INFECTION ARE AS FOLLOWS

Extremes of age
Comorbidities such as obesity and diabetes
Immunosuppression (eg, due to AIDS)
Invasive devices (eg, catheters)
Burns involving greater than 30% total body surface area (TBSA)
Full-thickness burns
Failure to cover burns or failed skin graft resulting in prolonged open burn wounds
Improper early burn care
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MEASURES TO COMBAT INFECTION MUST

Special
care must
taken
to
BE REINFORCED
INbe
BURN
CENTRES

prevent infections in patients with

deep or extensive burns; as hospital
stay is prolonged, the risk of
infection clearly increases in bum
patients; attention should centre on
S. aureus, S. epidermidis, and,
particularly, on Pseudomonas; bums
caused by electric current cause
great internal damage, and are thus

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WOUND INFECTION SIGNS ARE

AS FOLLOWS
Suppurative separation of the
eschar
Graft loss with involvement of
unburned tissue or the
presence of a systemic
response consistent with sepsis
Change in wound color (focal
areas of red, brown, or black)
Green discoloration of the
Dr.T.V.Rao MD
subcutaneous
fat

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CELLULITIS SIGNS ARE AS

FOLLOWS
Erythema
(Erythema alone
may not require
treatment.)
Induration
Warmth
Tenderness
Dr.T.V.Rao MD

Sepsis (occasionally)

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NECROTIZING INFECTION/FASCIITIS SIGNS INCLUDE

AGGRESSIVE INVASIVE INFECTION WITH INVOLVEMENT OF
STRUCTURES BELOW THE SKIN (EG, MUSCLE, BONE,
ORGANS).
Temperature greater than
39C or less than 36.5C
Progressive tachycardia
(>110 beats per minute)
Progressive tachypnea More than 25 breaths per
minute without assisted
ventilation; minute
ventilation greater than 12
L/min if intubated and
Dr.T.V.Rao MD
mechanically ventilated

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NECROTIZING
INFECTION/FASCIITIS
Thrombocytopenia (< 100,000/L; does not apply
immediately after initial resuscitation)
Hyperglycemia (in the absence of pre-existing
diabetes mellitus) - Plasma glucose levels greater
than 200 mg/dL in the absence of treatment;
significant resistance to insulin (>25% increase in
insulin requirement)
Inability to continue enteral feedings for more
than 24 hours - Abdominal distension, high gastric
residuals, uncontrollable diarrhoea
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 Sources of organisms are

found in the patients
own endogenous
(normal) flora, from
exogenous sources in the
environment, and from
healthcare personnel.
Exogenous organisms
from the hospital
environment are
generally more resistant
to antimicrobial agents
than endogenous

SOURCES OF ORGANISMS

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ASSOCIATED
WITH
The INFECTIONS
typical burn wound
is initially colonized
predominantly BURN
with gram-positive
organisms, which are
INJURIES
fairly quickly replaced by antibiotic-susceptible gramnegative organisms, usually within a week of the burn
injury. If wound closure is delayed and the patient
becomes infected, requiring treatment with broadspectrum antibiotics, these flora may be replaced by
yeasts, fungi, and antibiotic-resistant bacteria.
Organisms associated with infection in burn patients
include gram-positive, gram-negative, and yeast/fungal
organisms. The distribution of organisms changes over
time in the individual patient and such changes can be
ameliorated with appropriate management of the burn
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 Modes of
transmission include
contact, droplet and
airborne spread. In
burn patients the
primary mode is
direct or indirect
contact, either via the
hands of the
personnel caring for
the patient or from
contact with
inappropriately
decontaminated

MODE OF TRANSMISSION

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Burn patients are unique

MICROBIAL COLONIZATION
in their susceptibility to

Dr.T.V.Rao MD

colonization from
organisms in the
environment as well as in
their propensity to
disperse organisms into
the surrounding
environment. In general,
the larger the burn injury,
the greater the volume of
organisms that will be
dispersed into the
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environment from the
patient

ORGANISMS FREQUENTLY CAUSING

INVASIVE BURN WOUND INFECTION
Gram-positive bacteria S aureus, including
MRSA; coagulasenegative
Staphylococcus species;
Enterococcus species,
including vancomycinresistant species
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 Gram-negative
bacteria - P
GRAM-NEGATIVE BACTERIA
aeruginosa,
Klebsiella
species,
Acinetobacter
species,
Escherichia coli,
Serratia
marcescens,
Enterobacter
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 Fungi (Burn wounds

complicated by fungal
infections constitute an
independent predictor
for mortality in patients
with a burned TBSA of
30-60% - Candida
species; Aspergillus
species; Fusarium
species;
Phaeohyphomycetes
(fungi with dark cell
walls); Mucorales (eg,
Rhizopus, Mucor,

FUNGI

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VIRUSES

Dr.T.V.Rao MD

Viruses
(Cutaneous
disease typically
occurs in healing
partial-thickness
burns and donor
sites.) - Herpes
simplex virus,
varicella-zoster
virus
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MULTI-DRUG RESISTANT
Against this back-drop,
ORGANISMS
(MDROS)
IS
A
the increasing
prevalence of
multiMAJOR
PROBLEM
drug resistant
organisms (MDROs) is a
major problem. MDROs
have been shown to
restrict therapeutic
options resulting in
elevated morbidity and
mortality, higher costs
and extended length of
stay in the hospital by
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Dr.T.V.Rao MD

Burns patients can

BURNS PATIENTS
NEED
A
be at a major risk
SPECIALISED CARE
from hospital
associated
pathogens which
can lead to poor
recoveries and
even death.
Additionally, Burns
Units can be a
significant cost to
a hospital due to
the specialized
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ACINETOBACTER BAUMANNII
INCREASES COSTS OF TREATMENTS
Acinetobacter

baumannii and
ends up staying
on the burns
ICU for, say, a
increased
burden and
costs
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CULTURING AND
Culturing and
SURVEILLANCE
surveillance
guidelines are more
stringent for the burn
patient, particularly
the patient with
larger injuries,
because of the
increased propensity
for transmission and
infection in this
population.

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CULTURING
AND
Burn wound
flora and antibiotic
susceptibility
patterns change during the
SURVEILLANCE
course of the patients hospitalization so
that the purposes of obtaining routine
surveillance cultures are: - to provide
early identification of organisms
colonizing the wound - to monitor the
effectiveness of current wound treatment
- to guide perioperative or empiric
antibiotic therapy - to detect any crosscolonizations which occur quickly so that
further transmission can be prevented.
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 To provide early
CULTURING AND
identification of
SURVEILLANCE
organisms colonizing the
wound to monitor the
effectiveness of current
wound treatment to guide
perioperative or empiric
antibiotic therapy to detect
any cross-colonizations
which occur quickly so
that further
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ROUTINE SURVEILLANCE

Routine surveillance
wound cultures
should be obtained
when the patient is
admitted and at least
weekly until the
wound is closed.
Many burn centres
recommend obtaining
wound cultures two or
three time a week for
patients with large
burn injuries
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CULTURING THE SPECIMENS WHEN

Admission cultures
TRANSFERRED FROM OTHER
UNITS
are particularly

Dr.T.V.Rao MD

important for patients

transferred from
other facilities, as
they may be colonized
with multiply
resistant organisms
and serve as an
unsuspected reservoir
for cross-transmission
to other patients on
the unit
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CULTURING SPECIMENS FROM

For paediatric patients,
PAEDIATRIC
PATIENTS
admission throat cultures
are also recommended
as about 5% of the
population will be
colonized with Group A
beta-hemolytic
Streptococcus
(S.pyogenes) which can
have serious
consequences if it is
transmitted to the burn
wound.

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METHODS OF BURN
WOUND
Methods
of burn
CULTURING wound culturing

Dr.T.V.Rao MD

include obtaining a
semi-quantitative
swab culture or a
quantitative biopsy
specimen. Semiquantitative swab
cultures provide
information on the
type of organisms
present on the burn
wound, as well as the
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A general rule is to obtain a swab culture

for each 10% of open
burn
to identify
SIGNIFICANCE
OF
CULTURING
organisms of significance on the wound.
Quantitative cultures are used to define
invasive infection based on bacterial
count of 100,000 colonies or more per
gram of tissue. However, further study
has revealed that this technique is not
precise, as 50% of patients with

quantitative counts of greater than

100,000 organisms do not have
histologic evidence of invasive

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HISTOPATHOLOGICAL EXAMINATION
Quantitative
is
OFculturing
INFECTED
MATERIAL

more costly and laborintensive than swab

cultures, and their routine
use to identify colonizing
organisms on appropriately
debrided wounds is rarely
indicated. Accurate
diagnosis of invasive burn
wound infection is best
determined by clinical
criteria, supported when
possible by histopathologic
Dr.T.V.Rao MD
examination
if the patients
condition is suspicious for

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EFFECTIVE SURVEILLANCE REDUCES

of infection
THE MORBIDITY AND Surveillance
MORTALITY

Dr.T.V.Rao MD

has been shown to

diminish the rate of
nosocomial infection as
well as reduce cost.
Surveillance of infection in
burn patients should be
done to monitor incidence
and rates which have been
appropriately risk adjusted
by size of burn injury and
invasive device use
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COLLECTION OF DATA ON
ASSOCIATED INFECTION

At a minimum, surveillance
should include collection of
data on burn wound
infection, urinary tract
infection, pneumonia, and
bloodstream infection.
Systematic collection of data
allows the burn unit to
monitor changes in infection
rates over time, identify
Dr.T.V.Rao MD
trends,
and evaluate current
treatment methods.

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ROUTINE ENVIRONMENTAL
Routine environmental
SURVEILLANCE CULTURING
surveillance culturing is

Dr.T.V.Rao MD

not generally
recommended on units
with burn patients. The
exception may be the
hydrotherapy room and
common treatment room
used in burn wound care.
Environmental culturing
is important as part of
any outbreak
investigation which
is
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done on the burn Unit

IF
ENVIRONMENTAL
CULTURING
If environmental
culturing is considered;
IS NEEDED
either for routine use in
hydrotherapy/treatmen
t rooms, in outbreaks,
or for educational
purposes; the
hospitals infection
control department
should be consulted for
guidance on the
location, types, and
frequency of culturing
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INCIDENCE
OF
INFECTION

Catheter-associated BSI rates for burn

intensive care units (ICUs) enrolled in the
National Nosocomial Infections Surveillance
(NNIS) System, Centers for Disease Control and
Prevention (CDC) in the United States from
January 1995 to June 2002 were 8.8 per 1000
central venous catheter days (CVC), compared
with pooled mean rates of 7.4 for paediatric
ICUs, 7.9 for trauma ICUs, and 5.2 for surgical
ICUs. These rates include both adult and
pediatric burn patients

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WISH TO REDUCE INFECTIONS IN

BURNS PATIENTS
THERE IS NO TRUTH GREATER THAN
The importance of handHAND WASHING

Dr.T.V.Rao MD

hygiene with use of gloves,

masks and caps is essential
while handling burns
patients. Unnecessary
antimicrobials should not
be encouraged in burn
patients as many wounds
would have colonizers
rather than infective
pathogens
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WE STILL NOT PERFECT IN REDUCING THE

INFECTIONS
However,
more IN BURNS PATIENTS
studies are
required for the
most effective
combination of
aspects of
infection control
precautions in
burn patients

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FUTURE CHALLENGES IN
IDENTIFICATION OF INFECTION IN
BURNS PATIENTS
An important area for future
study relates to the clinical
problem of appropriate
precaution strategies,
particularly for patients
colonized with multiply
resistant organisms, with the
goal to be identification of
cost-effective measures that
prevent outbreaks involving
other patients on the unit.
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THE WORLD IS HEADING FOR MANY

CENTRES SPECIALISING IN BURNS RESEARCH

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REFERENCES
INFECTION CONTROL IN BURN PATIENTS
Authors: Joan Weber, RN, BSN, CIC
Infection Control Coordinator etal
WEB resources on infections in Burns
patients
CDC reviewed information
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 Program created by Dr.T.V.Rao MD

for Medical and Paramedical
students for Basic principles of
Infections in Burns patients
Email
doctortvrao@gmail.com
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