Principles of infection management in community-based burns care

Transcription

1 Principles of infection management in community-based burns care White R et al (2012) Principles of infection management in community-based burns care. Nursing Standard. 27, 2, Date of acceptance: August Abstract The development of infection in a burn can lead to poor healing outcomes and possibly sepsis. Although most patients with burns treated in the primary care setting are unlikely to develop life-threatening infections, clinicians would still benefit from an understanding of the factors that may increase the risk of infection, signs and symptoms of infection, and when to seek specialist advice. Authors Richard White Professor of tissue viability, University of Worcester. Beverley Swales Burns educator in Yorkshire and Humber. Martyn Butcher Independent tissue viability and wound care consultant, Devon. Correspondence to: m.butcher_woundcare@hotmail.com Keywords Burns, dressings, infection, primary care, sepsis, wound care Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Online Guidelines on writing for publication are available at For related articles visit the archive and search using the keywords above. The skin ACTS AS a barrier to the external environment, protecting the delicate structures of the body from trauma, desiccation and infection. When this barrier is breached, for example as a result of a burn, this protection is lost, exposing tissues to the environment and potentially enabling pathogenic organisms to multiply and cause infection. Infection is considered one of the primary complications of a burn (Norman 2003). There is a vast spectrum of burns that may be seen in clinical practice, ranging from those that are superficial to those that are severe, extensive and life-threatening, necessitating surgical reconstruction. Therefore, the potential for severe sepsis the destruction of tissues by pathogenic bacteria or their toxins differs depending on the type of burn. Risk of infection All burns have the potential to become infected. At the time of injury, the burn wound is practically sterile, but it rapidly acquires bacterial flora (bioburden) (Zellner and Bugyi 1985). Whether this bioburden progresses into infection depends on many factors. Burns factors Factors relating to the burn itself that may increase the risk of infection include: Size of the burn the greater the area of the body affected, the greater the demands placed on the body s immune system (Rawlins 2011). In addition, there is increased opportunity for bacterial contamination (Santaniello et al 2004). Depth of the burn deep dermal and full-thickness burns result in significant tissue necrosis, providing a source of denatured protein and encouraging bacterial proliferation (Williams 2002). Cause of the burn burn aetiology is a determinant of burn depth (Rawlins 2011). Exposure to high temperature is more likely to result in full-thickness damage (Zadeh et al 2008). Similarly, electrical burns may result in tissue damage and necrosis some distance away from the visible entry and exit point wounds (Hermans 2005). Location of the burn some areas of the body, such as the perineum, have a naturally high skin flora. These areas form a bacterial reservoir able to colonise the burn (Cooper 2003). In addition, some areas have reduced skin thickness, such as the dorsum of the hands and feet, potentially increasing the depth of damage (Hermans 2005). Patient factors Patient factors that may increase the risk of infection include: 64 september 12 :: vol 27 no 2 :: 2012 NURSING STANDARD / RCN PUBLISHING

2 Age of the person younger and older patients have thinner skin, increasing the risk of full-thickness burns (Dowsett 2002). In addition, these individuals may have reduced immune status, which affects the body s ability to control bioburden (Castle 2000, Holt and Jones 2000). Pre-existing co-morbidities the presence of systemic disease, for example circulatory and respiratory disease, may affect the patient s ability to maintain adequate tissue oxygenation or the body s immune response (Parker 2002). Management factors Management factors that may increase the risk of infection include: First aid failure to provide adequate cooling of the burn immediately after injury can result in progression of tissue damage through heat transference to deeper tissues (Yuan et al 2007). Cooling the burn with a contaminated water supply may increase the number of pathogens present in the wound (Williams 2009). Age of the burn at presentation exposure of the burn to environmental contamination, which tends to occur when the individual presents late to the healthcare setting, can lead to high levels of bioburden. Fluid resuscitation inadequate fluid resuscitation leads to peripheral shutdown and can result in increasing burn depth and full-thickness skin loss (Benson et al 2006). Topical treatments inappropriate dressing selection can result in burn desiccation, increasing burn depth; insufficient burn coverage, enabling bacterial contamination; and dressing adherence, causing trauma to the burn and surrounding tissues, and pain (Hermans 2005). The presence of infection in a burn may increase the depth of tissue damage, complicate recovery and delay healing (Butcher 2011). Robson (1979) identified infection as a particular concern in large deep dermal and full-thickness burns as a result of impaired local and systemic immunity and the presence of devitalised tissue. Hudspith and Rayatt (2004) stated that in non-complex burns, the risk and prevalence of infection are low. This reduced risk is attributed to the scale of the insult to skin barrier function, the expected length of time needed to re-establish skin integrity through healing and the amount of debris or necrotic burden in the wound. However, the term non-complex burn can be difficult to interpret. Complexity is a relative term that relates to the depth and extent of a burn, but also includes factors such as the location of the wound, ability of the patient to self-care, need for surgical reconstruction and risk of infection. The National Network for Burn Care (NNBC) (2012) guidelines provide information about when specialist burns care advice should be sought and when patients should be referred for expert assessment and treatment. Reducing the risk of infection There are several areas where the risk of infection in a burn can be reduced. Patients presenting with a burn require up-to-date tetanus prophylaxis (Rawlins 2011). Debris in the wound provides an ideal environment for bacterial proliferation and the clinician should remove as much debris as possible (Alsbjörn et al 2007). Cleansing should be gently carried out with a warm soap and water or sodium chloride solution (Alsbjörn et al 2007). It is considered acceptable to leave burn blisters less than 1cm in diameter intact (Hudspith and Rayatt 2004). Larger blisters should be aspirated and aseptically removed using scissors (Dowsett 2002), therefore reducing the risk of necrotic tissue forming a site for the development of infection (Senarath-Yapa and Enoch 2009). However, the burn area and all blisters should be covered with an appropriate sterile wound dressing (Hermans 2005). The majority of burns managed in the primary care setting will be epidermal and/or superficial partial-thickness wounds (NNBC 2012). These burns affect only the outermost areas of the skin and are likely to heal within two weeks, provided that a moist wound environment is maintained and infection is prevented (Papini 2004). Some localised deeper burns may be managed in the community following discussion with a specialist burns consultant and where surgical reconstruction is contraindicated as a result of existing co-morbidities (NNBC 2012). Butcher (2011) identified that dressings used to treat burns should be able to maintain a moist wound environment, and manage exudate, bioburden and pain. The beneficial role of dressings capable of maintaining a moist wound environment in superficial burns management is recognised (Lloyd et al 2012). Extensive research and clinical experience has established that moist wound healing is safe and effective (Alsbjörn et al 2007). Desiccation of the wound bed impedes delivery of nutrients and immune defences to the wound surface, as well as the capability of cells to migrate across the wound surface. In superficial burn healing, this epidermal migration results in wound repair (Papini 2004). Re-epithelialisation on a dry surface may be slow as the cells must advance beneath the scab or eschar. Semi-occlusive dressings such as semi-permeable film dressings and hydrocolloid dressings act as an artificial epidermis, providing a barrier to reduce fluid loss, NURSING STANDARD / RCN PUBLISHING september 12 :: vol 27 no 2 ::

3 maintaining a moist environment and excluding environmental contaminants and bacteria (Dowsett 2002). The burn affects the microcirculation, leading to increased capillary permeability. This results in oedema and high exudate levels in the immediate post-injury period (24-72 hours) (Rawlins 2011). Dressings need to be able to absorb exudate without saturation. If saturation occurs, exudate can leak through the outer layers of the dressing (strike-through) and provides a route for bacterial ingress. Alginate and hydrofibre dressings have been used successfully to manage burn exudate (Dowsett 2002, Green 2011). However, these dressings require secondary wound care products to maintain a moist environment and enable dressing retention (Alsbjörn et al 2007). Foam dressings, particularly when combined with an atraumatic wound interface material, can control wound exudate, prevent bacterial contamination and protect delicate tissues from desiccation and trauma during dressing changes (Butcher 2011, Green 2011). Conservative management of localised, full-thickness burns requires a moist wound environment where autolysis (natural sloughing) of the devitalised tissue can take place to reduce necrotic and bacterial burden (Young 2011). These burns may also benefit from the use of hydrocolloid or film dressings (Stephen-Haynes and Thompson 2007). However, it may be necessary to increase moisture levels to encourage autolysis. This type of full-thickness burn may benefit from the use of hydrogel dressings (Edwards 2010). Where burns are contaminated or there is an increased risk of bacterial colonisation and infection, dressings with antimicrobial properties are indicated (Wounds UK 2011, Wounds International 2012). The frequency of dressing change is also an important factor. The burn requires regular inspection until the full extent of burn depth is realised. However, once burn depth is accurately estimated, reduced frequency of dressing change is indicated to minimise the risk of bacterial contamination and trauma to the wound (Senarath-Yapa and Enoch 2009). Recognising infection It is important that the clinician remains vigilant to the signs and symptoms of infection. Although severe sepsis in burns managed in the community setting is rare (Hudspith and Rayatt 2004), the clinician should seek advice from a specialist burns consultant if infection is suspected (NNBC 2012). Identifying infection in burns can be difficult. Many of the cardinal signs of infection, such as erythema, high levels of exudate and pain (Cutting and Harding 1994) may be present in the non-infected burn as part of the normal response to burns trauma. Additional signs of infection may include increasing wound exudate or opaque exudate, development of discolouration in the burn or surrounding skin, malodour, increasing burn depth or spreading skin loss, or fragility of the wound bed with bleeding (European Wound Management Association (EWMA) 2005). Swabs should be taken to refine treatment interventions by identifying causative organisms and specific antibiotic sensitivities, however these will take time to process. The diagnosis of infection should not be delayed and will be based on clinical presentation. It is also important to be aware of the risk of toxic shock syndrome (TSS). This life-threatening complication can arise in the burn if infection with specific strains of Staphylococcus aureus occurs. Although uncommon, TSS typically affects young children with a burn of less than 10% of the total body surface area, which might otherwise be expected to heal uneventfully (White et al 2005). The nnbc (2012) guidelines state that if there are any suspicions that the patient with a burn injury has TSS, he or she should be referred to a specialist burns unit immediately. Managing infection If infection occurs, it may be necessary to hospitalise the patient. However, localised infection may be managed in the primary care setting (NNBC 2012). Appropriate antibiotics should be commenced and antimicrobial dressings should be used to reduce bioburden (EWMA 2006). The burn may become infected with a variety of organisms, including S. aureus, Streptococcus spp., Pseudomonas aeruginosa and other microorganisms such as Acinetobacter baumannii, S. epidermidis, Aeromonas hydrophila and anaerobic bacteria (Thomas et al 2005). Historically, the focus of treatment of infection in burns has been on large and severe burns and on the use of parenteral antibiotics. However, antibiotics should be reserved for the management of confirmed sepsis (Mertens et al 1997, Fowler 2006). Topical treatments such as the use of dressings containing antimicrobial properties can be used to control bioburden (EWMA 2005). This may be appropriate for individuals at particular risk of infection or where significant contamination of the burn has occurred (Wounds UK 2011). Management of this nature is safe and inexpensive and ensures only bacteria within the burn are targeted, therefore eliminating the 66 september 12 :: vol 27 no 2 :: 2012 NURSING STANDARD / RCN PUBLISHING

4 potential side effects of antibiotic use and reducing the development of resistant bacterial strains (Wounds UK 2011). Wounds UK (2011) suggests that the ideal wound antiseptic should be: Effective against likely pathogens. Fast acting, with prolonged residual activity after a single dose. Inexpensive. Incapable of selecting for bacterial resistance. Unlikely to be absorbed systemically. Non-carcinogenic and non-teratogenic to host cells. Non-toxic. Widely available. It should be noted that concern has arisen over the cost, effectiveness and safety of long-term antimicrobial use (Denyer 2009, Michaels et al 2009). However, reviews have found antimicrobials to be safe and effective if used correctly (White et al 2006, Lipsky and Hoey 2009). Guidance on the use of antimicrobials includes product selection, criteria for judging effectiveness and recommendations for duration of use (Wounds UK 2011). Antimicrobial activity has been recognised as an essential component of the ideal burn dressing (Selig et al 2012). Povidone iodine (Norman 2003), honey (Wijesinghe et al 2009, Malik et al 2010) and polihexanide (Daeschlein et al 2007, Dissemond et al 2011) have been used successfully in the treatment of burns. The most common agent used in burns management is silver, for example silver sulfadiazine 1% cream (Hermans 2007). However, this cream is relatively short acting, requires at least daily re-application, and is time consuming and messy to apply and remove. It can also lead to build up of discoloured slurry on the wound making assessment difficult (Silverstein et al 2011). The use of silver sulfadiazine 1% cream for minor burns is not recommended (Chung and Herbert 2001). Indeed, detailed analysis of evidence has found that silver sulfadiazine References Alsbjörn B, Gilbert P, Hartmann B et al (2007) Guidelines for the management of partial-thickness burns in a general hospital or community setting recommendations of a European working party. Burns. 33, 2, Benson A, Dickson WA, Boyce DE (2006) ABC of wound healing: burns. British Medical Journal. 332, 7542, Butcher M (2011) Meeting the clinical challenges of burns management: a review. British Journal of Nursing. 20, 15, S44-S51. Castle SC (2000) Clinical relevance of age-related immune dysfunction. Clinical Infectious Diseases. 31, 2, Chung JY, Herbert ME (2001) Myth: silver sulfadiazine is the best treatment for minor burns. Western Journal of Medicine. 175, 3, Cooper R (2003) The contribution of microbial virulence to wound infection. In White RJ (Ed) The Silver Book. Quay Books, Bath, Cutting KF, Harding KG (1994) Criteria for identifying wound infection. 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5 1% cream may prolong healing times and increase pain (Wasiak et al 2008). The development of dressings that combine elemental silver or silver-releasing compounds has provided additional antimicrobial options. The core dressing functions, for example non-adherence to the wound bed, absorption of exudate and/or atraumatic removal, are retained with the benefits of antimicrobial activity. Specific guidelines on the use of silverbased antimicrobial products are available (Wounds International 2012). These dressings should only be used if clinically indicated to manage bioburden and they should be discontinued when no longer required. Treatment should be limited to two weeks initially (Wounds UK 2011, Wounds International 2012). Continuation after this point should be subject to regular reassessment. However, the nnbc (2012) guidelines state that if burns managed in the community have not healed after two weeks then further discussion or referral to a specialist burns unit is indicated. Conclusion Because of the compromised integrity of the skin caused by a burn, infection may have serious consequences if not managed correctly. However, it is important to recognise that severe sepsis is rare in patients whose burns are suitable for management in the community setting. Clinicians need to reduce the risk of infection developing in the burn by reducing potential contamination and bioburden. It is vital that clinicians are aware of the signs and symptoms of infection so that the patient can be referred to a specialist burns unit if necessary NS Conflict of interest This article was supported by Mölnlycke Health Care Journal of Nursing. 12, Suppl 6, S30-S36.Papini R (2004) ABC of burns: management of burn injuries of various depth. British Medical Journal. 329, 7458, Parker L (2002) Applying the principles of infection control to wound care. In: White R, Harding K (Eds) Trends in Wound Care. Quay Books, Bath, Rawlins JM (2011) Management of burns. 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