Prevention and Management of Infection among Burn Patients - Research Paper Example

Prevention and Management of Infection among Burn Patients Problem Identification Infection is a major issue among burn patients. Controlling it is also a significant challenge among nurses and other health care professionals. In the US, on an annual basis, about 500,000 individuals seek treatment for burns. Among these individuals, 40,000 are often hospitalized for their injuries, with about 25,000 of these patients being admitted to specialized burn centers (Murray, 2011). On the average, about 4,000 individuals perish from fire and burns year after year, and of these, 3500 deaths are attributed to residential fires, and the rest are caused by motor vehicle accidents, electrical injuries, chemical exposures, hot-liquids and substance spills (Murray, 2011). In general 75% of the fatalities are usually seen at the scene of the incident itself, and for those reaching medical care, infection is the major cause of mortality and illness (Murray, 2011). Since majority of the skin is exposed to the elements and to the atmosphere, protecting it from infection and bacteria is a major challenge. For those with burn injuries, this challenge is even bigger. The type and quantity of microorganisms which colonize the burn wounds are also known to affect the patient’s future risk for would infection. The pathogens which infect the wound are mostly gram-positive bacteria which include methicillin-resistant Staphylococcus aureus (MRSA) and gram-negative bacteria Acinetobacter baumannii-calcoaceticus complex, Pseudomonas aeruginosa and Klebsiella species (Murray, 2011). These infective agents often increase the resistance of a person to various antimicrobials. Moreover, burns are usually infected with fungus infective agents, making the infection process on burn wounds even more difficult to prevent and manage. In recent years, the survival rates and the infection rates for infection among burn patients have improved with the introduction of modern medical practices. These medical practices now include advances in fluid resuscitation, nutritional support, pulmonary care, burn wound care, and infection control (Church, et.al., 2006). Despite these improvements, there are still improvements which can be made to the practice. The intact skin is important to the preservation of the body’s homeostasis and thermoregulation; it also is the most appropriate and crucial means of protecting a person against infection (Church, et.al., 2006). The skin also has immunological, neurosensory, as well as metabolic functions for the body. Burn injuries cause a break in the surface of the skin and destabilize these functions. It is therefore important to prevent infections among burn patients (Church, et.al., 2006). There are various preventive and management processes for infection control among burn injury patients. It is the task of nurses and other health practitioners to ensure that the processes and interventions being applied are based on the best evidence and are set to bring about the most improvement on the patients. Literature review This literature review on the prevention and management of infection among burn patients will be started by using key words and related terms through the medical libraries and database of the Texas Resource’s Harris Methodist Hospital, and via internet databases of the Mayo Clinic, Texas Women’s University, as well as the University of Texas Southwestern Medical Center. The search would include a review of the databases: CINAHL, Cochrane Library, PubMed, Mayo Clinic, Science Direct, and OVID. The search shall mostly focus on burns and infection prevention measures among these patients. In order to ensure the comprehensive nature of this review, this literature review would call for the use of key and search words which include the following or a combination of the following: burn infection, burns infection prevention, burn infection management, burns infection prevention and management. After reviewing the references set aside for this study, more specific articles relevant to this study were reviewed. Information on this study was gained from the articles reviewed, as well as articles from other sources like textbooks, electronic medical records, as well as interviews from burn specialists. In the literature review, the latest and most appropriate studies related to burn infection prevention and management was evaluated. Articles were drawn from various credible journals like the New England Journal of Medicine, American Journal of Nursing, Burns, The Lancet, Annals of Internal Medicine, Journal of Nursing Practitioners, as well as other relevant journals from the Google Scholar search engine. The studies included in this review shall include the inpatient and outpatient settings, including the emergency trauma departments. The studies considered in this review are the most recent, covering January 2004 to August 2011. Based on the articles reviewed, five studies emerged which were relevant to the current study on infection control among burn patients. The research studies discussed the means of prevention and management of burn patients in relation to infection. One of the studies was a systematic review, two were case control studies, one was a prospective non-randomized study, and one was comparative patient care audit. A review of the researches included establishes that there is evidence to support the intervention on the use of silver sulphadiazine in the infection control and management process of burn patients. Critical Analysis and Evaluation of Literature A critical analysis and evaluation of the literature are seen in the attached Table. 1. One of the studies was a systematic review, two were case control studies, one was a prospective non-randomized study, and one was comparative patient care audit. One study recommended the use of silver sulphadiazine in the infection control of burn patients (Bishara, et.al., 2007). Another study recommended the use of honey dressings for burn patients to facilitate healing and control infection (Bangroo, et.al., 2005). Another study recommended the use of insulin-therapy in the management of blood glucose levels and the prevention of infection among these burn patients (Hemmill, et.al., 2008). The use of levofloxacin was also suggested by another study (Kiser, et.al., 2006). And the study by Fong, et.al., (2005) suggested the use of silver coated dressings for burns as effective interventions in the control of infection among burn patients. The systematic review provides separate and comprehensive details which can be used as basis for this study, and the results of the review also support the recommended intervention. Formulation of Intervention Protocol for Clinical Problem Burn infection is one of the common problems encountered among burn patients (Weber and McManus, 2004). It makes the recovery and healing process more difficult and longer for the burn patient. Although there are current medical and technological processes which are available for the prevention and management of burn infections, burn patients still often experience these infections. These infections cause burdens among these patients, and often increase their hospital stay (Weber and McManus, 2004). In reviewing the research on this topic, there are several interventions which seem to indicate much promise in addressing the current issue. Proposed intervention The proposed intervention for the topic of prevention and management of burn infections is the application of silver dressings for burn patients. Such silver dressings are meant to decrease and manage infection among infected burn patients. The specific details of this intervention include: 1. Isolating patients who have burns, placing them in a sterile room and preventing their contact with other people and the contaminated air (Weber and McManus, 2004). 2. Utilizing the review on the use of silver sulphadiazine in order to determine the uses of this silver in the patient’s dressing (Atiyeh, et.al., 2007). 4. Carrying out details on infection control measures which the patient and family members can apply. Such measures include regular hand washing, avoiding touching burned area, monitoring area for signs of infection or severe inflammation (Weber and Mcmanus, 2004). The evidence gives strong support for the interventions in reducing infection and managing burn infections. Outcomes and Associated Evaluation Criteria Health facilities expecting to use this intervention are expected to reduce the incidents of infection among burn patients. Moreover, these patients would likely reduce their number of days in the hospital and even avoid readmissions (Weber and McManus, 2004). The most appropriate evidence establishes that using silver dressings can reduce the impact and the incidence of infection among burn patients. The outcome which calls for specific assessment when applying the silver dressing program is: the incidents of infection of burns; the number of days – until recovery from burn infections is seen. These outcomes can be seen by reviewing the patient’s medical records, counting the number of days when recovery was delayed by infection, and counting the number of cases when infection set in among these burn patients (Weber and McManus, 2004). Numbers gained from such evaluation would establish the efficacy of the silver dressings in preventing the onset of infection, and managing the actual infection. Table 1 Critical Analysis of Quantitative Research Articles 1. Title 2. Principal Investigators/Authors 3. Date 4. Country 5. Patient Population 6. Sample Size 7. Intervention of Interest 8. Design 9. Level of Evidence 10. Comparison of Interest 11. Outcome of Interest 12. Results of Study 13. Conclusion 14. Strengths 15. Weaknesses A. 1. Effect of silver on burn wound infection control and healing: Review of the literature 2 Bishara S. Atiyeh, Michel Costagliola, Shady N. Hayek, Saad A. Dibo 3. 2007 4. USA 5. Studies on wound/burns infection control using silver 6. 88 studies 7. Topical use of silver sulfadiazine 8. Literature Review 9. Level 10. 11. Determine the practical therapeutic balance between antimicrobial activity and cellular toxicity using silver sulfadiazine 12. Silver sulfadiazine is appropriate in a slow-sustained release medium. Silver can ensure fast and efficient healing, but may be toxic to area which is not burned. Silver is not selective in its degradation of bacteria. 13. The use of silver requires much caution. And the choice of a product must be one with a superior profile of antimicrobial activity over cellular toxicity, and silver has superior antimicrobial activity. 14. Provides a detailed discussion on studies which provide support for the use of silver in management of infection. 15. Information gathered has not been clinically tested by the authors. They are all second-hand data reviewed by the author. B. 1. Honey dressing in pediatric burns 2. Bangroo AK, Khatri Ramji, Chauhan Smita 3. 2005 4. India 5. Patients less than 12 years of age, sustained superficial thermal burns involving less than 50% of the body surface area 6. 64 7. Honey dressing for burn pediatric patients 8. Case-control study 9. Level IIIa 10. Case group—burn wounds dressed with honey, while those in Group B had silver sulphadiazine application on the burnt surface. 11. Reduction of infection and facilitation of healing 12. Forty-nine patients had swab culture positive at the time of admission. Out of 28 patients presenting within 6 h of injury, only 14 patients had positive swab culture. Ninety-three percent patients presenting between 6 and 12 h of injury had positive swab culture. All patients presenting after 12 h of injury had their swab culture positive. In Group A, 25 patients who had positive swab cultures at the time of admission, 23 were sterile after 1 week of treatment with honey. Two patients in this group showed persistent infection. In Group B, only three patients had sterile swab culture after treatment for 1 week and the remaining 21 patients had persistence of infection. The organisms isolated in 49 positive swab cultures from both the groups were Pseudomonas, Klebsiella , Staphylococcus aureus, Streptococci, and E. coli. 13. Honey acts mainly as a hyperosmolar medium and prevents bacterial growth 14. This study includes random processes as well as clear ethical research applications 15. Limited subjects, may not be applicable to a larger population. C. 1. Intensive insulin therapy is associated with reduced infectious complications in burn patients 2. Mark R. Hemmil, Michael A. Taddonio, Saman Arbabi, Paul M. Maggio, & Wendy L. Wahl 3. 2008 4. USA 5. Burn patients admitted to our American College of Surgeons verified burn center ICU from 7/1/2004 to 6/30/2006 6. 152 patients 7. Intensive insulin therapy in burn-injured ICU patients 8. Case-control study 9. Level IIIa 10. Control versus intensive insulin therapy groups 11. Control of blood glucose levels to reduce morbidity in surgical ICU patients 12. No difference in mortality was evident between the control and intensive insulin therapy groups. The intensive insulin therapy group was found to have a decreased rate of pneumonia, ventilator-associated pneumonia, and urinary tract infection. In patients with a maximum glucose value of greater than 140 mg/dL, the risk for an infection was significantly increased. The presence of a maximum glucose value greater than 140 mg/dL was associated with a sensitivity of 91% and specificity of 62% for an infectious complication. 13. Intensive insulin therapy for burn-injured patients admitted to the ICU was associated with a reduced incidence of pneumonia, ventilator-associated pneumonia, and urinary tract infection. 14. Research process represents randomized study processes which increases the reliability of this study 15. Reviews blood glucose levels only as factors affecting infection control. Other factors are not reviewed by the authors. D. 1. Levofloxacin Pharmacokinetics and Pharmacodynamics in Patients with Severe Burn Injury 2. Tyree H. Kiser, Dorie W. Hoody, Marilee D. Obritsch, Colleen O. Wegzyn, Paulus C. Bauling, and Douglas N. Fish 3. 2006 4. USA 5. Adult patients admitted to the University of Colorado Hospital Burn Unit who were >18 years of age, had thermal injuries involving ≥30% total body surface area (TBSA) and creatinine clearance (CLCR) rates of ≥50 ml/minute, and who were prescribed intravenous levofloxacin as part of their required medical care 6. 11 patients 7. Levofloxacin Pharmacokinetics and Pharmacodynamics 8. Prospective, open-label, nonrandomized study 9. Level 10. Patients received levofloxacin at 500 mg or 750 mg once daily 11. Reduce infection from gram-positive and gram-negative pathogens 12. No differences in pharmacokinetic parameters between day 1 and day 4. Levofloxacin pharmacokinetics in burned patients was similar to those reported in other critically ill populations. Levofloxacin at 750 mg achieved >90% PTA for gram-negative and gram-positive pathogens with MICs of ≤0.5 μg/ml and MICs of ≤1 μg/ml, respectively. However, satisfactory PTA was not obtained with less-susceptible gram-negative organisms with MICs of 1 μg/ml or any organism with a MIC of ≥2 μg/ml. 13. Levofloxacin should be administered at 750 mg/day for treatment of systemic infections in severely burned patients. 14. Use of antimicrobial therapy is applied by the authors to the clinical setting serving as source of data for future application in the clinical setting. 15. The study is non-randomized, hence is less reliable. The respondents are also few, affects generalizability of results. E. 1. A silver coated dressing reduces the incidence of early burn wound cellulitis and associated costs of inpatient treatment: Comparative patient care audits 2. J. Fong, F. Wood, B. Fowler 3. 2005 4. Australia 5. Burn patients admitted from 2000 and 2002, at the Royal Perth Hospital (RPH) Burn Unit, Western Australia 6. 70 7. Silver coated dressing for burns 8. Comparative patient care audits 9. Level 10. Silvazine (silver sulphadiazine and chlorhexidine digluconate cream) and Acticoat, a new dressing product for in-patient treatment of early burn wounds 11. Incidence of burn wound cellulitis, antibiotic use and cost of treatment 12. When using Acticoat, the incidence of infection and antibiotic use fell from 55% (28/51) and 57% (29/51) in 2000 to 10.5% (2/19) and 5.2% (1/19) in 2002. The total costs (excluding antibiotics, staffing and surgery) for those treated with Silvazine were US$ 109,357 and those treated with Acticoat were US$ 78,907, demonstrating a saving of US$ 30,450 with the new treatment. The average length of stay (LOS) in hospital was 17.25 days for the Silvazine group and 12.5 days for the Acticoat group—a difference of 4.75 days. 13. Acticoat results in a reduced incidence of burn wound cellulitis, antibiotic use and overall cost compared to Silvazine in the treatment of early burn wounds. 14. Study thoroughly compares two antibiotic treatments with specific points of comparison 15. Authors did not specify their ethical processes in using the treatments on the patients. Reference Atiyeh, B., Costagliola, M., Hayek, S. & Dibo, S. (2007). Effect of silver on burn wound infection control and healing: Review of the literature. Burns, volume 33, pp. 139-148 Bangroo, A., Ramji, K., & Smita, C. (2005). Honey dressing in pediatric burns. Journal of Indian Association of Pediatric Surgeons, volume 10(3), pp.172-175 Church, D., Elsayed, S., Reid, O., Winston, B. & Lindsay, R. (2006). Burn Wound Infections. Clinical Microbiology Reviews, volume 19(2), pp. 403-434. Fong J, Wood F, & Fowler B. (2005). A silver coated dressing reduces the incidence of early burn wound cellulitis and associated costs of inpatient treatment: comparative patient care audits. Burns, volume 31(5): pp. 562-7. Hemmila, M., Taddonio, M., Arbabi, S., Maggio, P., Wahl, W. (2008). Intensive insulin therapy is associated with reduced infectious complications in burn patients. Surgery, volume 144(4), pp. 629-637. Kiser, T., Hoody, D., Obritsch, M., Wegzyn, C., Bauling, P., & Fish, D. (2006). Levofloxacin Pharmacokinetics and Pharmacodynamics in Patients with Severe Burn Injury. Antimicrob Agents Chemother, volume 50(6): pp. 1937–1945. Murray, C. (2011). Burn Wound Infections Medication. Medscape. Retrieved 22 September 2011 from http://emedicine.medscape.com/article/213595-medication Weber, J. & McManus, A. (2005). Infection control in burn patients. Burns, volume 31(5), pp. 562-567. Read More