Burns

How can infections in burn patients be prevented?

Burn patients are at higher risk for all types of infections secondary to loss of the skin barrier as well as immunosuppression experienced because of a systemic inflammatory response triggered by the injured tissue.

Key principles to preventing infections in burn patients focus around infection prevention that is common to all patients as well as certain principles specific to burn.

Importance should be placed on:

good hand hygiene

removal of unnecessary intravascular catheters or urinary catheters

prevention of healthcare associated pneumonia

environmental infection control

isolation protocols

Barrier protection has received considerable attention as a means of preventing spread of bacteria from healthcare workers to patients and vice versa. This includes caps, masks, gowns, gloves, aprons, and shoe covers.
Early excision for burn wounds
Immersion hydrotherapy has grown out of favor as it has been linked to multiple bacterial outbreaks.
Spray hydrotherapy is believed to decrease the risk of transmitting bacteria between patients; however, there are reports in the literature of outbreaks reported with spray hydrotherapy.
Topical antimicrobials are a key to controlling colonization and prevention of burn wound infections. These include the following:
Nanocrystalline silver dressing: newest, covers gram negative and gram-positive organisms. Lowest toxicity profile.

Mafenide Acetate: covers gram negative and anaerobic organisms. Toxicity includes metabolic acidosis. Limited coverage of Staphalococcus aureus. Does not require wound dressings. Used with nystatin or other antifungals.

Nystatin: used in combination with other agents. Effective at preventing wound fungal infections.

Silver sulfadiazine: most commonly used. Broad-spectrum activity. Does not penetrate eschar. May hinder burn wound assessment secondary to pseudoeschar it creates.

Cerium: used in combination with silver sulfadiazene. Shown to improve healing time. May decrease inflammatory response.

Silver nitrate: old therapy. Rarely used secondary to limited antibacterial activity. Potential for electrolyte imbalances.

What are the conclusions of clinical trials and meta-analyses regarding infection control in burn patients?

Early versus late excision: a 2006 meta-analysis showed mortality and LOS decreased with early excision while blood loss increased leading to increased transfusions.

Topical wound care: a 2009 systematic review of nanocrystalline silver dressings found them to be superior to silver nitrate and silver sulfadiazine in reducing infections. Secondary findings included decreased cost and pain. These results were not found for pediatric patients; however, they did find a shorter LOS.
Ventilator associated pneumonia: In 2009, the American Burn Association concluded that burn patients are at high risk for VAP; therefore, burn units should closely follow CDC guidelines for prevention of health-care-associated pneumonia.
Selective digestive decontamination (SDD): two randomized, placebo-controlled double blind studies examined this topic and found differing results.
The first study published in 2001 involved 23 pediatric patients and found SDD did not decrease bacterial colonization and subsequent infectious episodes.

The second study published in 2005 enrolled 107 adult patients and documented a decrease in mortality and pneumonia.

What are the consequences of ignoring infection control in burn patients?

Hydrotherapy tanks are associated with bacterial outbreaks.

Shower systems do not provide the same reservoir for bacteria as hydrotherapy tubs do, however there have been reports of bacterial outbreaks associated with them.
Multiple organ dysfunction (MOD) is the leading cause of death in burn patients who survive the first 24 hours. Sepsis is the leading risk factor for developing MOD.
Burn patients are among the groups most at risk for ventilator-associated pneumonia (VAP), and as such meticulous care must be taken in preventing VAP.
Burn patients with blood stream infections have a five-fold mortality increase compared with burn patients who do not have a blood stream infection.
Delayed excision of burn wounds leads to greater incidence of burn wound infection, systemic infection, and higher mortality.

What other information supports the conclusions of studies on infection control in burn patients, e.g., case-control studies and case series?

Sepsis:

The majority of septic events occur in the first two weeks post burn.
Multiple risk factors have been indentified including: age >= 50 years, female gender, TBSA >50%, use of hydrotherapy tanks, prior infection, and the presence of inhalation injury.
Sepsis is the most likely cause of patients who experience MOD.

Candidemia:

Burn unit patients are among the highest risk groups for blood-borne fungal infections.
Topical nystatin has been shown to decrease fungal burn wound infections, and may be able to treat systemic infections.
Early excision of burn wounds has been shown to decrease systemic Candida infections.

Isolation:

Several burn centers have shown the ability to control outbreaks of resistant bacteria with simple isolation techniques.
45% of burn centers surveyed in 2006 stated they used routine isolation for new patients.

Hydrotherapy:

Immersion hydrotherapy has grown out of favor secondary to its association with cross-contamination between patients.
Antimicrobial agents may be added to tank water (e.g. sodium hypochlorite) however there is poor tolerance by patients and staff secondary to mucosal irritation.

Summary of current controversies.

Infection control: There is no consensus on infection control practices in burn units to prevent transmission of infections among patients. Questions regarding single-bed rooms, air handling and filtration, beds, and barrier precautions have not been fully answered although there are case studies that use the described methods as a means to control outbreaks.

Burn wound culture: There are two methods of wound culture – surface swab and biopsy. Both have been shown to be useful in the diagnosis of burn wound infection, however neither can be used alone to diagnose a burn wound infection. The criteria for defining a burn wound infection do not use wound culture as a major criteria because differentiating pathologic bacteria versus colonizing bacteria is difficult. It is also important to note that studies show that multiple pathogens can be grown from multiple swabs or biopsies from the same patient.

Prophylactic antibiotics: There are no specific guidelines regarding systemic prophylactic antibiotics for burn patients. A meta-analysis looking at 17 trials concluded that systemic prophylactic antibiotics were beneficial in regards to all cause mortality but noted that the quality of the data they used was weak. However, a review noted that an argument can be made for using systemic prophylactic antibiotics for short periods of time for patients with >40% TBSA burns during which the wound is being manipulated. The controversy stems from several studies which show varying percentages of patients with hematogenous bacterial isolates following burn wound manipulation.

GI prophylaxis: Given that the gastrointestinal tract is one reservoir for bacteria that are found to frequently infect burn wounds, there has been great interest in whether or not selective digestive decontamination (SDD) has any benefit. Several studies have examined different bowel decontamination regiments with mixed results.

What is the impact of infection control in burn patients, relative to infections in other patient populations?

Multi-drug resistant (MDR) organisms are increasing in numbers each year with burn units seeing the highest rates of these MDR organisms. Multiple studies have looked at Methicillin Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), MDR Acinetobacter, and Pseudomonas Aeruginosa isolates in burn units and have concluded the following:

Meticulous adherence to infection control practices is paramount for preventing transmission to new patients.

It should be noted that P. aeruginosa is highly prevalent in a burn unit compared to other areas of the hospital, but S. aureus and coagulase-negative staphylococcus are the most common pathogens found colonizing a burn wound.

MRSA has been shown to persist in burn units for years. Enterococcus was found in 15% of patients admitted to one burn unit; however, VRE did not begin to appear in serial swabs until two weeks.

VRE acquisition is associated with Foley catheters.

MRSA acquisition is associated with younger age and prior treatment with vancomycin.

There should be burn unit protocols for antibiotic use, removal of unnecessary intravascular and bladder catheters, and definitions for infection versus colonization.

Other recommendations found in the literature include screening all patients on admission and continuing surveillance throughout a patient’s stay.

(a) This is further emphasized from a study that sought to determine risk factors for acquiring VRE or MRSA. Once the study identified risk factors, it attempted to validate these risk factors and determine the sensitivity associated with creating a screening program for these “high risk” individuals. Unfortunately, the sensitivity was poor at 59%, thus concluding that all patients should be screened.

Overview of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and burns.

Table I, Table II, Table III, and Table IV describe the research regarding infection control in burn patients.

Table I.

Author	Year	Number of Patients	Key Conclusions
Gracia	2001	60	Study comparing silver sulfadiazine (SSD) and SSD combined with cerium nitrate (SSD-CN). The found that while wound infection rate did not differ between groups those with SSD-CN had faster re-epithelialization and lower mortality.
Barret	2001	23	Study comparing selective digestive tract decontamination with polymyxin E, tobramycin, and amphotericin B versus no treatment in pediatric patients and found no effect on colonization or infectious episodes.
De la Cal	2005	107	Study comparing selective digestive tract decontamination with cefotaxime, polymyxin E, tobramycin, amphotericin B versus no treatment in adult patients and found decreased mortality and pneumonia.

Table II.

Author	Year	Number of Patients	Key Conclusions
Avni et al	2010	1113	Systemic antibiotic administration in the first 4-14 days reduces all cause mortality. Limitations include poor methodology of studies used for meta-analysis.
Gravante et al	2009	285	Nanocrystalline silver dressings provide superior prevention of infections in burn patients.
Ong et al	2006	288	Early excision decreased mortality but no conclusion could be made regarding sepsis. Burn wound infection was not examined. There was increase blood loss in the early excision group.

Table III.

Author	Year	Number of Patients	Key conclusions
Burke	1974	200	Patients who had early excision of burn wound had decreased rates of mortality, wound infection, septicemia, and respiratory failure.
Deutsch	1990	30	Study comparing selective digestive tract decontamination with neomycin, erythromycin and nystatin between two groups of 15 patients found no benefit in survival between the groups.
Desai et al	1992	2441	Burn wound prophylaxis with topical nystatin decreased the incidence of Candida wound infection and eradicated systemic candidiasis.
Wurtz	1995	52	Deaths due to infection in burn patients has decreased over the last several decades, however, infections are still a significant source of morbidity and mortality for burn patients. There was a high rate of pneumonia in burn patients in this study.
Wright et al	1998	In vitro study	Silver is effective at killing bacteria on burn wounds including those antibiotic-resistant strains. Silver-coated dressings are the most effective at killing and have a broader range than does silver nitrate and silver sulfadiazine.
Wisplinghoff et al	1999	87	Independent risk factors for nosocomial bloodstream infections due to acinetobacter baumannii were identified to be female gender, TBSA > 50%, prior nosocomial infection with the organism at a distant site, and the use of hydrotherapy.
Mousa et al	1999		There was a higher incidence of fungi in the burn unit than the control areas around the hospital.
Bang et al	2002	147	Prophylactic antibiotics do not affect septicemia or mortality. This study also found that improved resuscitation, continuous observation, appropriate antibiotics, nutrition, and early wound coverage improved patient mortality.
Xiao et al	2002	157	Early excision of burn wounds within 48 hours decreases wound closure time, rates of invasive wound infection, and sepsis.
Hart et al	2003	46	Early burn wound excision and concurrent aggressive feeding decrease risk for sepsis and patients have lower bacterial counts in burn wounds.
Barret et al	2003	20	Burn wound excision significantly reduces bacterial colonization. Patients who do undergo topical treatment and delayed burn wound excision have higher burn wound colonization and rates of infection.

Table IV.

Author	Year	Number of Patients	Key Conclusions
Mayhall et al	1979	75	An outbreak of enterobacter cloacae that caused septicemia in 15 patients was attributed to contamination of the hydrotherapy tanks.
Cardany et al	1985	22	Adding NaCl to hydrotherapy tanks decreased the number of bacteria on both burn and non-burned skin however it caused increased discomfort of burned skin and when patients became agitated caused mucosal irritation of both patients and hospital personnel.
Schlech et al	1986	69	An outbreak of pseudomonas aeruginosa was attributed to a swimming pool in the physiotherapy unit.
Manson et al	1987	48	Selective digestive tract decontamination was evaluated using polymyxin andamphotericin B with co-trimaxazole, cefradin, or tobramycin sometimes added. This study found a decrease in infectious complications.
Sittig et al	1988	32	Increased mortality in bacteremic patients was associated with increase in burn size, presence of inhalation injury, polymicrobial bacteremia, and gram-negative bacteremia.
Still et al	1995	29	Invasive fungal infection, identified by fungemia, should be treated with early use of amphotericin B.
Matsumura et al	1996	231	MRSA was effectively controlled in a burn unit using isolation techniques for colonized patients, which included gowns, gloves, masks, caps, and hand washing.
Steer et al	1996	74	Correlation between surface swab and biopsy of a burn wound is poor (54%); however, surface swab has high sensitivity in detecting the most common pathogens (S. aureus – 95% and P. aeruginosa –92%). Surface swabs are also more reproducible than are biopsy cultures.
Steer et al	1996	47	This biopsy study found that high bacterial counts do not correlate with sepsis and suggests that high bacterial counts do not predict sepsis or graft loss. This study did not examine specimens for histology.
Rodgers et al	2000	70	The most common infections occurring in children are burn wound infections and catheter-associated septicemia. Risk factors for infectious complications include children with flame and inhalational injury, TBSA burned >30% and full thickness burns.
Mozingo et al	1997	19	This study calls into question the need for perioperative antibiotics for wound cleansing and wound excision in patients with less than 40% TBSA burns.
Barrett et al	1999	4	Angioinvasive fungal infections secondary to burn wound infection were successfully treated with use of high dose (6,000,000 units/g) nystatin powder.
Barrett et al	1999	62	Foreign patients from third world countries admitted to burn units have a low rate of infestations (bacteria, fungus or parasites). Patients at risk can be identified by laboratory studies. Hand washing is the best method for preventing spread of disease.
Cumming et al	2001	85	Severe MOD and severe sepsis/septic shock are both related to burn size, age, male sex, ICU length of stay, and mechanical ventilation.
Embil et al	2001	6	An MRSA outbreak in a burn unit was attributed to contamination of a showerhead at the surface of the bathing stretcher in the hydrotherapy room.
Simor et al	2002	31	Risk factors for acquisition of a multiresistant strain of Acinetobacter baumannii at a Canadian tertiary-care teaching hospital were receipt of blood products; procedure performed in the hydrotherapy room, and increased duration of mechanical ventilation.
Fitzwater et al	2003	175	Elevated base deficit at 24 hours and septic shock were the most important factors associated with death after burn trauma.
Ballard et al	2008	456	Fungal infections in burn patients are seen regularly and contribute significantly to morbidity and mortality. Despite the increasing incidence, it is still difficult in many centers to determine if the burn wound is the source of an invasive fungal infection. Burn patients typically have risk factors that are common among all critically ill patients at risk for fungal infections, namely neutropenia, systemic steroids, central venous access, TPN, hemodialysis, diabetes mellitus, and urinary catherization. This study raised important questions such as how best to define a fungal infection, when to treat, and the role of antifungal prophylaxis.

Controversies in detail.

Infection control:

There is no consensus on infection control practices in burn units to prevent transmission of infections among patients. Questions regarding single-bed rooms, air handling and filtration, beds, and barrier precautions have not been fully answered although there are case studies that use the described methods as a means to control outbreaks.

Multiple studies have attributed bacterial outbreaks to several factors such as hydrotherapy.
According to a survey published in 2006, many burn units still use a form of hydrotherapy.
While there have been reports of outbreaks related to the new shower-related hydrotherapy system, there are few epidemiological studies to determine the impact this change has had.

Burn wound culture:

There are two methods of wound culture – surface swab and biopsy.

Surface swabs can provide qualitative or semi-quantitative results. Concurrent surface swabs of burn wounds correlate better, therefore, they have better reproducibility.
Burn wound biopsy can be evaluated quantitatively or histologically. Quantitative evaluation was first developed in the 1970s as a means to diagnose burn wound infections, however subsequent studies showed that the result could vary among the same patient when a sample was taken from two different locations at the same time.

Histology provides depth of invasion as well as more accurate assessment of burn depth.

Neither surface swab nor biopsy has been shown to be superior in identifying pathologic bacteria present in burn wounds.

Prophylactic antibiotics:

There are no specific guidelines regarding systemic prophylactic antibiotics for burn patients.
A meta-analysis reviewing 17 trials concluded that systemic prophylactic antibiotics were beneficial in regards to all cause mortality but noted that the quality of the data used was weak. However, another review noted that an argument can be made for using systemic prophylactic antibiotics for short periods of time for patients with >40% TBSA burns during which the wound is being manipulated.
Several studies showed varying percentages of patients with hematogenous bacterial isolates following burn wound manipulation (1.6% to 20.6%). This may lead one to believe that giving perioperative antibiotics would be beneficial, however given the varying degrees of proven bacteremia the answer to this question is not clear.

GI prophylaxis:

Given that the gastrointestinal tract is one reservoir for bacteria that are found to frequently infect burn wounds, there has been great interest in whether or not selective digestive decontamination (SDD) has any benefit.
Several studies have examined different bowel decontamination regimens with mixed results. These are listed in Table V.

Table V.

Manson	1987	48	This study demonstrated delayed wound colonization and fewer infectious complications. The antibiotics used were inconsistent. These included polymyxin, sometimes additional antibiotics such asco-trimoxazole, cefradin, tobramycin, and amphotericin B.
Deutsch	1990	30	This study did not demonstrate a difference in wound colonization or survival in patients with 20%TBSA burns or greater. Treatment was 10 days of the following antibiotics: neomycin, erythromycin, and nystatin.
Barret	2001	23	This study did not show a difference in wound colonization or infectious episodes in severely burned (>30% TBSA, full-thickness) pediatric patients. This was a randomized double-blind placebo-controlled trial using the following antibiotics: polymixin E, tobramycin, and amphotericin B.
De la Cal	2005	107	This study demonstrated a significant decrease in mortality and pneumonia in burn patients with ³ 20% TBSA burned. It was a randomized, placebo-controlled, double-blinded trial comparing selective digestive tract decontamination with cefotaxime, polymyxin E, tobramycin, amphotericin B versus no treatment.

What national and international guidelines are related to infection control for burn patients?

Burn patients are at high risk for developing ventilator associated pneumonia (VAP), therefore the American Burn Association (ABA) has published guidelines for the prevention, diagnosis, and treatment of VAP. These closely follow recommendations published by the CDC.

Prevention focuses on avoiding unnecessary intubation, having ventilator weaning protocols in place, oral care, suctioning, and unnecessary red blood cell transfusions.
Diagnosis should center around clinical findings and respiratory culture.
Treatment consists of early use of broad-spectrum antibiotics with appropriate de-escalation once speciation and sensitivities are known.
For the complete ABA guidelines please see the following pubmed link (PUBMED:19826271).
For the complete CDC guidelines please see the following pubmed link (PUBMED:15048056).

Burn patients will have a significant inflammatory response from the burn itself, so distinguishing a systemic response to the burn from sepsis can be difficult. The American Burn Association Consensus Conference to Define Sepsis and Infection in Burns has published criteria for defining sepsis in a burn patient:

The consensus conference has defined parameters for Severe Inflammatory Response Syndrome (SIRS), Sepsis, Septic Shock, Smoke Inhalation Injury, Pneumonia, and Burn Wound Infection among others.
Sepsis is an important distinction since it is the point at which suspicion is raised regarding infection as well as the point at which antibiotics are begun. It is defined by at least three “triggers” which include temperature, heart rate, respiratory rate, thrombocytopenia, hyperglycemia, and intolerance of enteral feeding.
For the complete guidelines please see the following pubmed link (PUBMED:17925660).

The current burn wound infection classification was put forth in 1998 by Peck et al in response to change in management techniques seen in the 1980s (i.e., early excision).

The four categories include burn wound impetigo, burn wound cellulitis, burn-related surgical wound infection, and invasive infection in unexcised burn wounds. The full definitions can be found by following the pubmed link (PUBMED:9789171).

What other consensus group statements exist, and what do key leaders advise?

The Centers for Disease Control and Prevention (CDC) has published several general guidelines for the healthcare setting whose importance cannot be overstated due to the loss of the skin barrier and immunosuppression of a burn patient. Importance should be placed on good hand hygiene, removal of necessary intravascular catheters and urinary catheters, prevention of healthcare associated pneumonia, environmental infection control, and isolation.

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