ReviewInfection control in the burn unit☆
Introduction
Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care to minimize morbidity and mortality. Data from the National Center for Injury Prevention and Control in the United States shows that approximately 2 million fires are reported each year resulting in 1.2 million burn injuries [1], [2], [3]. Moderate to severe burns requiring hospitalization account for approximately 100,000 of these cases and about 5000 patients die annually from burn-related complications [1], [2], [3], [4], [5], [6]. In Canada, the estimated number of burn injuries and deaths in serious cases are proportionally smaller on a per capita basis [7], [8], [9].
The survival rate for burn patients has improved substantially in the last decade due in part to advances in intensive care management in specialized burn centers. Improved outcome for severely burned patients has been attributed to advances in fluid resuscitation, nutritional support, pulmonary care, burn wound care and infection control practices. As a result, burn-related deaths, depending on the extent of injury, have decreased in the past 40 years [3], [6], [10], [11], [12]. In patients with burns over more than 40% of the total body surface area (TBSA), 75% of all deaths are currently related to sepsis from burn wound infection or other infectious complications and/or inhalation injury [13], [14], [15], [16], [17].
The experience accumulated over the past three decades in the early interventional treatment of burn patients has dramatically changed the cause of death; it is now estimated that about 75% of the mortality following burns is related to infections, rather than burn shock and hypovolemia [17]. Knowledge of the responsible bacterial flora of burn wounds, its prevalence, and bacterial resistance becomes of crucial importance for fast and reliable therapeutic decisions [17].
This review focuses on the current epidemiology, diagnosis, management and prevention of burn wound infections and sepsis. Recent factors contributing to the development of burn wound infection including the nature and extent of the burn injury, secondary immunosuppression, prevention of burn wound infection and therapeutic strategies employed by specialized burn care facilities will be reviewed.
Section snippets
Epidemiology
Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury [18], [19], [20]. The most important patient characteristics that influence morbidity and mortality from burn wound infection and sepsis include large TBSA wounds (>30%), significant amounts of full-thickness burns, prolonged open wounds or delayed initial burn wound care. Factors that have favorably impacted the incidence of burn wound infection include
Source of organisms
Sources of organisms may be endogenous (patient's own normal flora) or exogenous (environmental or from health care personnel). Organisms associated with infection in burn patients include gram-positive, gram-negative and yeast or fungal organisms. The distribution of organisms changes over time in individual patients, however, these changes can be ameliorated with appropriate management of the burn wound and the patient [25].
The typical burn wound is initially colonized predominantly with
Mode of nosocomial pathogen transmission
Modes of transmission include contact, droplet and airborne. In burn patients the primary mode is direct or indirect contact, either by the hands of the personnel caring for the patient or from contact with inappropriately decontaminated equipment. Burn patients are unique in their susceptibility to colonization from organisms in the environment and in their propensity to disperse organisms into the surrounding environment. In general, the larger the burn injury, the greater the volume of
Patient susceptibility
Very young children and the elderly have an increased risk of poor clinical outcome than patients in other age groups [11], [23], [39]. Individuals with self-inflicted burn injuries and the disabled have been shown to have more severe injuries with longer hospital stays than those with accidental injuries [40]. Obese adults and those who have underlying medical conditions, such as diabetes, have also been shown to have higher morbidity and mortality [41], [42]. AIDS patients seem to have more
Incidence of infection
Specific sites of infection that are particularly important for burn patients include bloodstream infection, pneumonia, burn wound infection and urinary tract infection. Fever, a highly specific indicator of infection for many patient populations, often does not correlate well with the presence of infection in burn patients, because of core temperature increases and an increase in heat production, associated with the onset of a hypermetabolic response [47]. As a result, fever alone, in the
Burn unit outbreaks
Outbreaks of cross-colonization and infection are a major challenge in burn units, requiring a clear understanding of how and why they occur if they are to be prevented and controlled. Common features associated with burn unit outbreaks over the past 25 years include, strains that are resistant to multiple antibiotics, the closure of units for decontamination and cleaning, permanent closure of centers or the reservoir identified e.g.: hydrotherapy discontinued. The exact cause for many of these
Culturing and surveillance
Surveillance of infection has been reported to diminish the rate of nosocomial infection [49], [50], [51]. Systematic collection of data allows the burn unit to monitor changes in infection rates over time, identify trends and evaluate current treatment methods. Culturing and surveillance guidelines have to be more stringent for the burn patient, particularly those with large TBSA involvement, because of the increased propensity for infection and its transmission [29]. Burn wound flora and
Isolation and unit design
Standard precautions should be followed when caring for all patients with burn injury. The effectiveness of simple protective barrier precautions in reducing nosocomial colonization and infection was shown in a study by Klein et al. [53] in a pediatric ICU. Most burn units also support the concept of barrier techniques and isolation; although there was no consensus about which type was preferable [54]. The presence of large, open burn wounds appears to increase the environmental contamination
Impact of nosocomial infections on outcome
Although the recognition of infection in the burn population should include the cardinal signs of infection, pyrexia or fever alone can not be a reliable indicator of infection in burns. Moreover, burn wound infection in these patients should be diagnosed by regular, frequent evaluation of the wounds in addition to the other clinical signs of systemic infection. Patients with burn wounds greater than 15–20% TBSA usually develop signs and symptoms of a hypermetabolic state that can include low
Prevention
Prevention of burn wound infection involves assessment of the wound at each dressing change for changes in the character, odor or amount of wound drainage. Strict aseptic technique should be used when handling the open wound and dressing materials and frequency of dressing should be based on wound condition. If the wound has necrotic material present, a debriding dressing should be chosen, whereas a protective dressing is preferable for clean healing wounds. Treatment of an existing wound
Infection control
Treatment of pneumonia should be started promptly, with systemic antibiotic selection modified when culture and sensitivity results are available. Treatment should also include vigorous chest physiotherapy, turning, deep breathing, coughing and suctioning. Newer ventilatory strategies, such as high-frequency ventilation and permissive hypercapnia, to prevent or treat patients with pneumonia and severe respiratory compromise have also been recommended [58].
Treatment of catheter-associated
Conflict of interest
None.
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This work was supported by the Firefighters’ Burn Trust Fund of the University of Alberta Hospital.