in Great Britain Bums (1990)16,(6)445-448 Printed
445
Infection control in a Third World burn facility J. R. Bowen-Jones’, Y. M. CoovadiaZ and E. J. Bowen-Jones3 ‘Department of Nursing, of Natal, South Africa.
2Department
of Microbiology
and ‘Department
A study of wound co&ration by bacteria in 49 comexutive admissions was coruiuctedover a z-month period in patients with bums at King Award WI and Ckzirwood Hosp’taL, Durban, neither 4 which poem proper burn units. Specimensfor culture were collected j?om patients, staff and the environment. Bacteria most frequently isolated unx Staph.
aureus, Klebsiella spp., Ps. aeruginosa
and Ertterobacter spp.
Cross-infection occurred due to breakdaon of aseptic technique. Staff hands and contaminated bath and benches were also implicated. RecommenUions to reduce cross-infection are prtziented#
Introduction
Materials and methods Demography
Patients with burns are admitted to King Edward VIII Hospital Durban, for resuscihtion and are subsequently transferred to Clairwood Hospital for after-care and skin grafting. There is no burn unit at either hospital. At any given time there may be between 40 and 85 burn cases, 0305/4179/90/060445+J4
Surgery, University
according to season. Patients are nursed in overcrowded open surgical wards, housing 60 patients. Beds are approximately 6Oan apart and some patients are nursed on mattresses under the beds. There are approximately eight nurses on duty in the morning and four in the afternoon and evening. Patients are bathed before dressings are applied and loose slough is removed. Superficial burns are dressed with silver sulphadiazine cream on alternate days whereas deep partial skin thickness and full skin thickness bums are dressed daily with 5 per cent povidone iodine cream. Early surgical excision of the burn wound and skin grafting is limited to small areas of deep burns. Methods
Burn injuries are a major problem in developing countries, accounting for 5 per cent or more of the total number of hospital inpatients at any given time. Burns occur commonly in the lower socioeconomic groups where there are less safe means of cooking, heating, fewer safety restraints upon small children and where burns are inflickd as a means of assault. The burn wound is highly susceptible to infedion which is the main cause of death in burned patients. In developing countries, hospitals tend to be overcrowded and understaffed which compounds the danger of crossinfection. Much has been written about burns and infection control in sophisticated burn units but there is little literature from developing countries. Because of limited available resources it is necessary to know which measures are cost-effective in controlling burn infections in a Third World hospital. With this end in mind a study of colonization and infection of bum wounds was undertaken at King Edward VIII Hospital (KEH), Durban, South Africa. The aims of the study were to investigate: the microbiology of the burn wound, the reservoirs of the infection and attempt to determine the means of spread of infection and to examine nursing and other procedures which may contribute to nosocomial burn wound infection.
0 1990 Buttenuorth-Heinemann
of Plastic and Reconstructive
Ltd
Specimens were collected from patients, staff and the environment. Nursing and other procedures related to infection control were observed. Details of the patients’ progress and subsequent treatment were recorded. Specimens for bacteriological culture were collected from the nose, throat and rectum of each patient on admission and weekly thereafter. Wound swabs were collected daily for 4 days and thereafter twice weekly. Catheter specimens of urine were collected daily for 5 days and thereafter weekly. Nose and throat swabs from doctors, nurses and physiotherapists were collected and cultured for staphylococcal and streptococcal colonization. Hand swabs were cultured for Gram-negative bacteria (GNB) and Gram-positive cocci (GPC). Settle plates were exposed for 3Omin in wards, dressing rooms and bathrooms during dressing procedures. Swabs from baths, mattresses and other patient equipment which might harbour pathogens were collected for culture. Patients
Forty-nine consecutive patients admitted with burns to KEH during a 2-month low period (summer) were included in the study. The group comprised 29 children, 12 adult female and eight adult males. The age range was from 5 months to 70 years (43 per cent of patients were under 5 years). The extent of the burn varied from 2 per cent to 87 per cent of total body surface area (TBSA). Thirty-seven (76 per cent) patients had scalds, six (12 per cent) were the result of petrol bombs and six (12 per cent) were other domestic accidents. Antibiotics were administered to three (15 per cent) adults and 15 (52 per cent) children. The mortality rate was 12.2 per cent (X&k I). Half of the deaths were attributed to septicaemia; two of the patients having been admitted with septicaemia from other hospitals.
Bums (1990) Vol. 16/No. 6
446
Table I. Clinical data on six patients who died Body surface area burned (W
Age
Time of death postbum 24h 30d 13d 5d lid 21 d
12 18
1 yr 3 mth 11 mth 42yr’ 49 yr 40 yr 1 yr 2 mth’
:: 30 18
Cause of death
Antibiotics
Unknown Septicaemia Septicaemia Operation-related hypothermia Operation-related hypothermia Pneumonia/septicaemia
0 Ampicillin/amikacin 0 Amikacin 0 Ampicillin/amikacin
6 (12.2%) mortality rate (3 adults and 3 children). ‘Patient admitted from another hospital with septicaemia.
Table III. Colonization of burn wounds with potential pathogens as documented by wound swabs
Table II. Presence of S. uureus On admission
Nose swab Wound swab Throat swab
Acquired
MSSA
MRSA
MSSA
MRSA
7
1 2 0
8
5 8 0
:
:
Total by end of study
z: 3
Total number of patients affected = 34 (69 per cent). MSSA. methicillin-sensitive S. aureus: MRSA, methicillin-resistant S. aureus.
Results Patients Sfaph. uwus was cultured from the anterior nares of eight patients on admission (Z&!e U). During the study period a further eight patients acquired methicillin-sensitive Sfuph. aurars (MSSA) in their noses and five methicillin-resistant Staph. uureus (MRSA). Staph. uureus was identified in wound cultures of six patients on admission (two were MESA) and a further nine patients acquired MSSA and eight MRSA in their wounds. Some patients had staphylococci cultured from both nose and wound swabs. A total of 34 (69 per cent) patients harboured Staph. uu~eus (Tide II). The frequency of colonization of the bum wound with potentially pathogenic micro-organisms and the antibioticresistance pattern are shown in Tuble 111The most frequently isolated micro-organisms were Sfuph. uurew in 49 per cent of patients, Klebsiellu spp. in 26 per cent and Ps. ueruginasu in 18 per cent Some of the organisms were resistant to methicillin and aminoglycosides respectively. Mean colonization time with GPC was 3.7 days after admission and with GNB 5.6 days after admission (Tuble IV). Rectal swabs were obtained on admission from 42 patients, 25 of which cultured GNB including E. co/i in 19, KIebsieIlu spp. in 12, Enferobucfer spp. in five and Proteus mirubilis in two (two of the Klebsiellu spp. and two F! mirubilis were resistant to gerkamicin). Subsequent collection proved logistically impossible. Five patients were catheterized, one of whom cultured Klebsiella spp. on day 5. staff Fifty-seven staff members underwent random swabbing of nose, throat and hands (the latter when they were meant to be ‘clinically clean’) (Table VI. Seventeen of them carried Sfuph. uureus in their nares. Potential pathogens were not detected in the throat but nine were found to have Staph. uureus on their hands, eight of which were methicillin resistant. In addition, five Acinetobuckr spp. were isolated from the hands of five staff members (fwo of which were resistant to aminoglycosides).
Patients Pathogen
No.
%
Staphylococcus aureus Klebsiella spp.
23 13
49 26
Pseudomonas aeruginosa
9
18
Enterobacterspp. Acinetobacter anitratus Proteus mirabilis Escherichia coli Streptococcus pyogenes Fungi Other
4 3 3 3 3 4 7
8 6 6 6 6 8 14
Resistance pattern 18 4 1 4
MRSA gentamicin r. also amikacin r. gentamicinll also amikacin r.
r., resistant.
environment (Table VI) Settle plates yielded growths of Klebsiella spp., Enferobucter spp., Streptococcus viriukns and Staph. aureus. Baths, bathboards (wooden boards across baths on which patients sit after bathing awaiting dressing) and wooden benches were frequently contaminated with tibsiella spp., Enterobucfer spp., E. coli and Staph. uuret(s. Mattresses yielded no pathogens. The
Nursing procedures Much of the study was spent observing nursing and other procedures. There was a frequent breakdown of non-touch techniques during dressing change; sometimes this was due to overcrowding and lack of space which made contamination almost inevitable. Doctors’ ward rounds were another area of weakness. When dressings had been removed for wound inspection patients waited in close proximity and thus direct physical contact could occur. There was a shortage of wash-basins in relation to the number of patients. This presented difficulty in hand washing between patient contacts. A handspray of chlorhexidine 0.5 per cent in 70 per cent alcohol was usually available for hand disinfection.
Discussion Burn wound colonization may occur from a variety of sources; namely the patients’ endogenous flora, organisms from other patients, staff or the environment. It may be spread by direct contact, airborne spread, corkarninated formites or carried by unit personnel (Ayliffe and Lilly, 1985.)
Bowen-Jones et al.: Infection control in a third world burn facility
447
Table Iv. Patients with potential pathogens as documented by wound swabs Patients No. 23 19
Potential pathogens in wound swabs
%
Mean day of colonization after admission
Range (days)
3.7 5.6
1-19 1-19
Gram-positive bacteria Gram-negative bacteria
49 39
Table V. Colonization of unit personnel
Table VI. Potential pathogens from environment
Colonized Site
No. cultured
Site No.
%
Nose
57
17
31
Hands
57
16
29
Specimens (no.)
Positive Potential cultures pathogens isolated
Potential pathogens 15 MSSA 1 MRSA 1 Streptococcus pyogenes 1 MSSA 8 MRSA 1 Streptococcus pyogenes 1 Citrobacter spp. 5 Acinetobacter spp. (2 Gentamicin and amikacin r.)
MSSA, methicillin-sensitive S. aureus; MRSA, methicillin-resistant S. aufeus; r., resistant.
Endogenous flora Much of the burn wound colonization was with organisms found in the patients’ intestinal tracts, namely Klebsida spp., Enfembucter spp. and E. cc& These same organisms were disseminated into the environment and were found in settle plates, baths and benches. Without subsequent rectal swabs no conclusions could be reached. Direct contact The probability of contact spread is increased with overcrowding both in dressing rooms and on the ward. This can be minimized by reducing the number of patients in the dressing room at a time. Whilst awaiting doctor’s inspection the bum wound should be exposed and covered with a plastic sheet (Lendrum and Bowen-Jones, 1976) and the patient should return to his/her bed. Wooden surfaces were found to harbour potential pathogens (especially intestinal flora), therefore bench tops should be covered with plastic which can be disinfected. Baths should be thoroughly cleaned and disinfected between patient use. Airborne spread Lowbury (1954) demonstrated a very significant decrease in bum wound infection in wounds dressed in filtered air. Staphylococcal infection occurred one and a half times more frequently and pseudomonas and proteus infection twice as frequently in patients dressed in unfiltered air. Our settle plates demonstrated the presence of both GNB and GPC in the atmosphere in wards and dressing rooms. It is necessary to conduct dressings in strict order of cleanliness and minimize the length of time the bum wound is exposed to the atmosphere. Unit personnel There was a disturbingly high incidence of pathogens isolated from the hands of staff members. This is best illustrated with Staph. atlracs. In a busy overcrowded unit with inadequate handwashing facilities the use of chlorhexidine in alcohol handspray is recommended (Coovadia, 198.5). It is imperative that staff be reminded of the importance of disinfecting hands between patient contact.
Clean bath
6
3
Bath board
5
5
Dressing bench
6
4
13
8
Settle plates
Klebsiefla spp. (2) Enterobacterspp. S. aureus Strep. viridans (2) E. coli Klebsiella spp. Enterobacterspp. S. aureus S. aureus Enterobacter spp. Strep. viridans (5) Enterobacter spp. S. aureus (4)
Dressing trolley Betadine and Flamazine creams Bath cleanser Nail brush Barrier gown Bath gloves Mattresses
Pathogenic organisms The pattern of colonization of bum wounds in our study is similar to that in studies from both developed and developing countries (Korlof, 1956; Thomsen, 1970; Sowemimo, 1983; Ramakrishnan et al., 1985; Mabogunje et al., 1987). Even in developing countries S/rep. pyogerzs is no longer the scourge it was (Cruickshank, 1935; Anatol, 1985). Strep. pyogenes was isolated from only three bum wounds and from two staff members but this was the begining of an outbreak, such as occurs sporadically on our unit. Staph. acireti infection is the most common pathogen in bum wounds in all the surveys reviewed, 68 per cent (Ramakrishnan et al., 1985) in a series in India, 60 per cent in a series in Denmark (Thomsen, 1970), 21 per cent in two different series in Nigeria (Sowemimo, 1983; Mabogunje et al., 1987) and occurred in 49 per cent of our cases. Sraph. artrew infections may cause septicaemia and shock in the early stages after a bum (MacMillan et al., 1986), although in most cases there is only surface colonization. In our series Staph. aurew was isolated from only a small number of patients (18 per cent) on admission but by the end of the study was present in 69 per cent of patients. Nearly half of these were MRSA, the resistant hospital organism. Staphylococcal colonization well illustrates the potential paths of cross-infection. Staph. uurells was present in a large proportion of hands of staff members (seven out of 14 cultured from one ward on one day), their anterior nares, in baths, benches and settle plates. Whereas Heggers et al. (1988) found 57 per cent of patients were carrying MRSA on admission and concluded that MRSA infections arise from endogenous flora at the time of injury, we concluded from
Bums (1990)Vol. 16/No. 6
448
our study in a Third World environment that colonization occurs as a result of cross-infection. ZUebsielIaspp. was the second most common organism occurring in 26 per cent of patients, unlike most other studies which reported pseudomonas and proteus infection more frequently (Sowemimo, 1983; Mabogunje et al., 1987). None of the GNB cultured from patients on admission in our series were resistant to aminoglycosides but during the course of the study 19 Gram-negative pathogens acquired aminoglycoside resistance. Five of the nine Ps. aeruginosa identified in our study were resistant to gentarnicin. Although it is accepted practice in modem burn units to control infection by early excision and skin grafts, this procedure has proved hazardous in our situation due to the lack of a dedicated theatre, high care ward and experienced staff. We suspect this is the situation in most developing countries (Anatol, 198% Ramakrishnan et al., 1985; Onuba and Udoidio, 1987). The conditions at KEH and Clairwood Hospital are rudimentary in comparison to sophisticated units but are typical of developing countries and better than many. Despite the overcrowding, shortage of staff, absence of individual cubicles and laminar airflow the nosocomial infection rate compares not too unfavourably with that of many modem units. Cross-infection may be further reduced by the simple and inexpensive measures sumrnan‘zed below. A further study to assess the effectiveness of these suggestions is currently being conducted.
Conclusion and recommendations Ina Third World situation the burned patient is at greater risk of acquiring nosocomial infection of the burn wound due to lack of adequate facilities, overcrowding and understaffing. This study has demonstrated the presence of pathogens on the hands of unit personnel, in the atmosphere, in baths and on benches. It was observed that patients came into direct physical contact whilst awaiting dressing, and the wounds were exposed for up to an hour whilst awaiting redressing. All these factors increased the risk of crossinfection. In the absence of a modem bum unit the following measures may help to control cross-infection: 1.
2. 3. 4. 5.
Promoting the importance of disinfecting hands between patient contact and providing the means to do so, e.g. provision of handspray or wash handbasins, soap and paper towels. Adequately cleaning and disinfecting baths. Covering wooden benches with plastic sheeting which can be disinfected. Reducing the time-lapse between removal and reapplication of dressings, and covering with plasticized PVC sheet (‘clingfilm’) in the meantime. Avoidance of overcrowding in dressing rooms leading
to direct patient contact.
Acknowledgements We would like to thank the Director of Hospital Services, Natal for his permission to conduct and publish this work, the nursing and medical staff for their assistance and cooperation and especially the Department of Microbiology of King Edward VIII Hospital Durban on whose laboratory work this investigation depended and Mrs B. Heeraman for typing the script. This study was financially supported by ICI Pharmaceuticals, Pty Ltd (South Africa).
References Anatol T. (1985) A survey of children with burns in South Trinidad West lndian Iv&d.J. 34,29. Ayliffe, G. A. J. and Lilly H. A. (1985) Cross infection and its prevention. J. Hosp. I$ 6,(Suppl. B), 47. Coovadia Y. M. (1985) Goss infection in special care units - a study conducted at King Edward VIII Hospital. Infect. Dis. Nezu&er 2,2 (Publication of the Infectious Diseases Society of Southern Africa). Cruickshank R. (1935) The bacterial infection of burns.]. PathBad. 41,367. Heggers J. P., Phillips L. G., Boertman J. A. et al. (1988) The epidemiology of methicillin resistant Staphylococcusuureus in a burncentre.I. Bum CareRehubil. 9,610. Korlof 8. (1956) Infection of bums. Acfa. Chit-.Scati. Suppl. 209. LendrumJ. and Bowen-JonesE. J. (1976) A new dressing for bums. Enclosure in a plasticised PVC sheet. Bum 2,86. Lowbury E. J. L. (1954) Air conditioning with filtered air for dressing burns. Lanret i, 292. Mabogunje 0. A., Khwaja M. S. and Lawrie J. H. (1987) Childhood burns in Zaria, Nigeria. Bums 13,298. MacMillan B. G., Holder I. A. and Alexander J. W. (1986) Infections of bum wounds. In: Bennet J. V. and Bra&man P. S. (eds),HospitalInfections,2nd ed. Boston: Little Brown, chap.30, p.465. Onuba 0. and Udoidio K. E. (1987)Hospital management of massive bums in the developing countries. Burns 13,386. Ramakrishnan M. K., Rao D.K., Doss C. R. et al. (1985) Incidence of bum wound sepsis in 600 burned patients treated in a developing country. Bums 11,404. Sowemimo G. 0. A. (1983) Bum injuries in Lagos. Bums 9,280. Thomsen M. (1970) The bums unit in Copenhagen VI. Infection rates. Scatuf.J. Plast. Reconstr.Surg. 4,53.
Paper accepted 14 July 1990.
Correspondence shouldbe addressedto: Mr E. BowenJones, Department of Plastic Surgery, Wentworth Hospital, PO Jacobs 4026, Durban, South Africa.
445
Infection control in a Third World burn facility J. R. Bowen-Jones’, Y. M. CoovadiaZ and E. J. Bowen-Jones3 ‘Department of Nursing, of Natal, South Africa.
2Department
of Microbiology
and ‘Department
A study of wound co&ration by bacteria in 49 comexutive admissions was coruiuctedover a z-month period in patients with bums at King Award WI and Ckzirwood Hosp’taL, Durban, neither 4 which poem proper burn units. Specimensfor culture were collected j?om patients, staff and the environment. Bacteria most frequently isolated unx Staph.
aureus, Klebsiella spp., Ps. aeruginosa
and Ertterobacter spp.
Cross-infection occurred due to breakdaon of aseptic technique. Staff hands and contaminated bath and benches were also implicated. RecommenUions to reduce cross-infection are prtziented#
Introduction
Materials and methods Demography
Patients with burns are admitted to King Edward VIII Hospital Durban, for resuscihtion and are subsequently transferred to Clairwood Hospital for after-care and skin grafting. There is no burn unit at either hospital. At any given time there may be between 40 and 85 burn cases, 0305/4179/90/060445+J4
Surgery, University
according to season. Patients are nursed in overcrowded open surgical wards, housing 60 patients. Beds are approximately 6Oan apart and some patients are nursed on mattresses under the beds. There are approximately eight nurses on duty in the morning and four in the afternoon and evening. Patients are bathed before dressings are applied and loose slough is removed. Superficial burns are dressed with silver sulphadiazine cream on alternate days whereas deep partial skin thickness and full skin thickness bums are dressed daily with 5 per cent povidone iodine cream. Early surgical excision of the burn wound and skin grafting is limited to small areas of deep burns. Methods
Burn injuries are a major problem in developing countries, accounting for 5 per cent or more of the total number of hospital inpatients at any given time. Burns occur commonly in the lower socioeconomic groups where there are less safe means of cooking, heating, fewer safety restraints upon small children and where burns are inflickd as a means of assault. The burn wound is highly susceptible to infedion which is the main cause of death in burned patients. In developing countries, hospitals tend to be overcrowded and understaffed which compounds the danger of crossinfection. Much has been written about burns and infection control in sophisticated burn units but there is little literature from developing countries. Because of limited available resources it is necessary to know which measures are cost-effective in controlling burn infections in a Third World hospital. With this end in mind a study of colonization and infection of bum wounds was undertaken at King Edward VIII Hospital (KEH), Durban, South Africa. The aims of the study were to investigate: the microbiology of the burn wound, the reservoirs of the infection and attempt to determine the means of spread of infection and to examine nursing and other procedures which may contribute to nosocomial burn wound infection.
0 1990 Buttenuorth-Heinemann
of Plastic and Reconstructive
Ltd
Specimens were collected from patients, staff and the environment. Nursing and other procedures related to infection control were observed. Details of the patients’ progress and subsequent treatment were recorded. Specimens for bacteriological culture were collected from the nose, throat and rectum of each patient on admission and weekly thereafter. Wound swabs were collected daily for 4 days and thereafter twice weekly. Catheter specimens of urine were collected daily for 5 days and thereafter weekly. Nose and throat swabs from doctors, nurses and physiotherapists were collected and cultured for staphylococcal and streptococcal colonization. Hand swabs were cultured for Gram-negative bacteria (GNB) and Gram-positive cocci (GPC). Settle plates were exposed for 3Omin in wards, dressing rooms and bathrooms during dressing procedures. Swabs from baths, mattresses and other patient equipment which might harbour pathogens were collected for culture. Patients
Forty-nine consecutive patients admitted with burns to KEH during a 2-month low period (summer) were included in the study. The group comprised 29 children, 12 adult female and eight adult males. The age range was from 5 months to 70 years (43 per cent of patients were under 5 years). The extent of the burn varied from 2 per cent to 87 per cent of total body surface area (TBSA). Thirty-seven (76 per cent) patients had scalds, six (12 per cent) were the result of petrol bombs and six (12 per cent) were other domestic accidents. Antibiotics were administered to three (15 per cent) adults and 15 (52 per cent) children. The mortality rate was 12.2 per cent (X&k I). Half of the deaths were attributed to septicaemia; two of the patients having been admitted with septicaemia from other hospitals.
Bums (1990) Vol. 16/No. 6
446
Table I. Clinical data on six patients who died Body surface area burned (W
Age
Time of death postbum 24h 30d 13d 5d lid 21 d
12 18
1 yr 3 mth 11 mth 42yr’ 49 yr 40 yr 1 yr 2 mth’
:: 30 18
Cause of death
Antibiotics
Unknown Septicaemia Septicaemia Operation-related hypothermia Operation-related hypothermia Pneumonia/septicaemia
0 Ampicillin/amikacin 0 Amikacin 0 Ampicillin/amikacin
6 (12.2%) mortality rate (3 adults and 3 children). ‘Patient admitted from another hospital with septicaemia.
Table III. Colonization of burn wounds with potential pathogens as documented by wound swabs
Table II. Presence of S. uureus On admission
Nose swab Wound swab Throat swab
Acquired
MSSA
MRSA
MSSA
MRSA
7
1 2 0
8
5 8 0
:
:
Total by end of study
z: 3
Total number of patients affected = 34 (69 per cent). MSSA. methicillin-sensitive S. aureus: MRSA, methicillin-resistant S. aureus.
Results Patients Sfaph. uwus was cultured from the anterior nares of eight patients on admission (Z&!e U). During the study period a further eight patients acquired methicillin-sensitive Sfuph. aurars (MSSA) in their noses and five methicillin-resistant Staph. uureus (MRSA). Staph. uureus was identified in wound cultures of six patients on admission (two were MESA) and a further nine patients acquired MSSA and eight MRSA in their wounds. Some patients had staphylococci cultured from both nose and wound swabs. A total of 34 (69 per cent) patients harboured Staph. uu~eus (Tide II). The frequency of colonization of the bum wound with potentially pathogenic micro-organisms and the antibioticresistance pattern are shown in Tuble 111The most frequently isolated micro-organisms were Sfuph. uurew in 49 per cent of patients, Klebsiellu spp. in 26 per cent and Ps. ueruginasu in 18 per cent Some of the organisms were resistant to methicillin and aminoglycosides respectively. Mean colonization time with GPC was 3.7 days after admission and with GNB 5.6 days after admission (Tuble IV). Rectal swabs were obtained on admission from 42 patients, 25 of which cultured GNB including E. co/i in 19, KIebsieIlu spp. in 12, Enferobucfer spp. in five and Proteus mirubilis in two (two of the Klebsiellu spp. and two F! mirubilis were resistant to gerkamicin). Subsequent collection proved logistically impossible. Five patients were catheterized, one of whom cultured Klebsiella spp. on day 5. staff Fifty-seven staff members underwent random swabbing of nose, throat and hands (the latter when they were meant to be ‘clinically clean’) (Table VI. Seventeen of them carried Sfuph. uureus in their nares. Potential pathogens were not detected in the throat but nine were found to have Staph. uureus on their hands, eight of which were methicillin resistant. In addition, five Acinetobuckr spp. were isolated from the hands of five staff members (fwo of which were resistant to aminoglycosides).
Patients Pathogen
No.
%
Staphylococcus aureus Klebsiella spp.
23 13
49 26
Pseudomonas aeruginosa
9
18
Enterobacterspp. Acinetobacter anitratus Proteus mirabilis Escherichia coli Streptococcus pyogenes Fungi Other
4 3 3 3 3 4 7
8 6 6 6 6 8 14
Resistance pattern 18 4 1 4
MRSA gentamicin r. also amikacin r. gentamicinll also amikacin r.
r., resistant.
environment (Table VI) Settle plates yielded growths of Klebsiella spp., Enferobucter spp., Streptococcus viriukns and Staph. aureus. Baths, bathboards (wooden boards across baths on which patients sit after bathing awaiting dressing) and wooden benches were frequently contaminated with tibsiella spp., Enterobucfer spp., E. coli and Staph. uuret(s. Mattresses yielded no pathogens. The
Nursing procedures Much of the study was spent observing nursing and other procedures. There was a frequent breakdown of non-touch techniques during dressing change; sometimes this was due to overcrowding and lack of space which made contamination almost inevitable. Doctors’ ward rounds were another area of weakness. When dressings had been removed for wound inspection patients waited in close proximity and thus direct physical contact could occur. There was a shortage of wash-basins in relation to the number of patients. This presented difficulty in hand washing between patient contacts. A handspray of chlorhexidine 0.5 per cent in 70 per cent alcohol was usually available for hand disinfection.
Discussion Burn wound colonization may occur from a variety of sources; namely the patients’ endogenous flora, organisms from other patients, staff or the environment. It may be spread by direct contact, airborne spread, corkarninated formites or carried by unit personnel (Ayliffe and Lilly, 1985.)
Bowen-Jones et al.: Infection control in a third world burn facility
447
Table Iv. Patients with potential pathogens as documented by wound swabs Patients No. 23 19
Potential pathogens in wound swabs
%
Mean day of colonization after admission
Range (days)
3.7 5.6
1-19 1-19
Gram-positive bacteria Gram-negative bacteria
49 39
Table V. Colonization of unit personnel
Table VI. Potential pathogens from environment
Colonized Site
No. cultured
Site No.
%
Nose
57
17
31
Hands
57
16
29
Specimens (no.)
Positive Potential cultures pathogens isolated
Potential pathogens 15 MSSA 1 MRSA 1 Streptococcus pyogenes 1 MSSA 8 MRSA 1 Streptococcus pyogenes 1 Citrobacter spp. 5 Acinetobacter spp. (2 Gentamicin and amikacin r.)
MSSA, methicillin-sensitive S. aureus; MRSA, methicillin-resistant S. aufeus; r., resistant.
Endogenous flora Much of the burn wound colonization was with organisms found in the patients’ intestinal tracts, namely Klebsida spp., Enfembucter spp. and E. cc& These same organisms were disseminated into the environment and were found in settle plates, baths and benches. Without subsequent rectal swabs no conclusions could be reached. Direct contact The probability of contact spread is increased with overcrowding both in dressing rooms and on the ward. This can be minimized by reducing the number of patients in the dressing room at a time. Whilst awaiting doctor’s inspection the bum wound should be exposed and covered with a plastic sheet (Lendrum and Bowen-Jones, 1976) and the patient should return to his/her bed. Wooden surfaces were found to harbour potential pathogens (especially intestinal flora), therefore bench tops should be covered with plastic which can be disinfected. Baths should be thoroughly cleaned and disinfected between patient use. Airborne spread Lowbury (1954) demonstrated a very significant decrease in bum wound infection in wounds dressed in filtered air. Staphylococcal infection occurred one and a half times more frequently and pseudomonas and proteus infection twice as frequently in patients dressed in unfiltered air. Our settle plates demonstrated the presence of both GNB and GPC in the atmosphere in wards and dressing rooms. It is necessary to conduct dressings in strict order of cleanliness and minimize the length of time the bum wound is exposed to the atmosphere. Unit personnel There was a disturbingly high incidence of pathogens isolated from the hands of staff members. This is best illustrated with Staph. atlracs. In a busy overcrowded unit with inadequate handwashing facilities the use of chlorhexidine in alcohol handspray is recommended (Coovadia, 198.5). It is imperative that staff be reminded of the importance of disinfecting hands between patient contact.
Clean bath
6
3
Bath board
5
5
Dressing bench
6
4
13
8
Settle plates
Klebsiefla spp. (2) Enterobacterspp. S. aureus Strep. viridans (2) E. coli Klebsiella spp. Enterobacterspp. S. aureus S. aureus Enterobacter spp. Strep. viridans (5) Enterobacter spp. S. aureus (4)
Dressing trolley Betadine and Flamazine creams Bath cleanser Nail brush Barrier gown Bath gloves Mattresses
Pathogenic organisms The pattern of colonization of bum wounds in our study is similar to that in studies from both developed and developing countries (Korlof, 1956; Thomsen, 1970; Sowemimo, 1983; Ramakrishnan et al., 1985; Mabogunje et al., 1987). Even in developing countries S/rep. pyogerzs is no longer the scourge it was (Cruickshank, 1935; Anatol, 1985). Strep. pyogenes was isolated from only three bum wounds and from two staff members but this was the begining of an outbreak, such as occurs sporadically on our unit. Staph. acireti infection is the most common pathogen in bum wounds in all the surveys reviewed, 68 per cent (Ramakrishnan et al., 1985) in a series in India, 60 per cent in a series in Denmark (Thomsen, 1970), 21 per cent in two different series in Nigeria (Sowemimo, 1983; Mabogunje et al., 1987) and occurred in 49 per cent of our cases. Sraph. artrew infections may cause septicaemia and shock in the early stages after a bum (MacMillan et al., 1986), although in most cases there is only surface colonization. In our series Staph. aurew was isolated from only a small number of patients (18 per cent) on admission but by the end of the study was present in 69 per cent of patients. Nearly half of these were MRSA, the resistant hospital organism. Staphylococcal colonization well illustrates the potential paths of cross-infection. Staph. uurells was present in a large proportion of hands of staff members (seven out of 14 cultured from one ward on one day), their anterior nares, in baths, benches and settle plates. Whereas Heggers et al. (1988) found 57 per cent of patients were carrying MRSA on admission and concluded that MRSA infections arise from endogenous flora at the time of injury, we concluded from
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our study in a Third World environment that colonization occurs as a result of cross-infection. ZUebsielIaspp. was the second most common organism occurring in 26 per cent of patients, unlike most other studies which reported pseudomonas and proteus infection more frequently (Sowemimo, 1983; Mabogunje et al., 1987). None of the GNB cultured from patients on admission in our series were resistant to aminoglycosides but during the course of the study 19 Gram-negative pathogens acquired aminoglycoside resistance. Five of the nine Ps. aeruginosa identified in our study were resistant to gentarnicin. Although it is accepted practice in modem burn units to control infection by early excision and skin grafts, this procedure has proved hazardous in our situation due to the lack of a dedicated theatre, high care ward and experienced staff. We suspect this is the situation in most developing countries (Anatol, 198% Ramakrishnan et al., 1985; Onuba and Udoidio, 1987). The conditions at KEH and Clairwood Hospital are rudimentary in comparison to sophisticated units but are typical of developing countries and better than many. Despite the overcrowding, shortage of staff, absence of individual cubicles and laminar airflow the nosocomial infection rate compares not too unfavourably with that of many modem units. Cross-infection may be further reduced by the simple and inexpensive measures sumrnan‘zed below. A further study to assess the effectiveness of these suggestions is currently being conducted.
Conclusion and recommendations Ina Third World situation the burned patient is at greater risk of acquiring nosocomial infection of the burn wound due to lack of adequate facilities, overcrowding and understaffing. This study has demonstrated the presence of pathogens on the hands of unit personnel, in the atmosphere, in baths and on benches. It was observed that patients came into direct physical contact whilst awaiting dressing, and the wounds were exposed for up to an hour whilst awaiting redressing. All these factors increased the risk of crossinfection. In the absence of a modem bum unit the following measures may help to control cross-infection: 1.
2. 3. 4. 5.
Promoting the importance of disinfecting hands between patient contact and providing the means to do so, e.g. provision of handspray or wash handbasins, soap and paper towels. Adequately cleaning and disinfecting baths. Covering wooden benches with plastic sheeting which can be disinfected. Reducing the time-lapse between removal and reapplication of dressings, and covering with plasticized PVC sheet (‘clingfilm’) in the meantime. Avoidance of overcrowding in dressing rooms leading
to direct patient contact.
Acknowledgements We would like to thank the Director of Hospital Services, Natal for his permission to conduct and publish this work, the nursing and medical staff for their assistance and cooperation and especially the Department of Microbiology of King Edward VIII Hospital Durban on whose laboratory work this investigation depended and Mrs B. Heeraman for typing the script. This study was financially supported by ICI Pharmaceuticals, Pty Ltd (South Africa).
References Anatol T. (1985) A survey of children with burns in South Trinidad West lndian Iv&d.J. 34,29. Ayliffe, G. A. J. and Lilly H. A. (1985) Cross infection and its prevention. J. Hosp. I$ 6,(Suppl. B), 47. Coovadia Y. M. (1985) Goss infection in special care units - a study conducted at King Edward VIII Hospital. Infect. Dis. Nezu&er 2,2 (Publication of the Infectious Diseases Society of Southern Africa). Cruickshank R. (1935) The bacterial infection of burns.]. PathBad. 41,367. Heggers J. P., Phillips L. G., Boertman J. A. et al. (1988) The epidemiology of methicillin resistant Staphylococcusuureus in a burncentre.I. Bum CareRehubil. 9,610. Korlof 8. (1956) Infection of bums. Acfa. Chit-.Scati. Suppl. 209. LendrumJ. and Bowen-JonesE. J. (1976) A new dressing for bums. Enclosure in a plasticised PVC sheet. Bum 2,86. Lowbury E. J. L. (1954) Air conditioning with filtered air for dressing burns. Lanret i, 292. Mabogunje 0. A., Khwaja M. S. and Lawrie J. H. (1987) Childhood burns in Zaria, Nigeria. Bums 13,298. MacMillan B. G., Holder I. A. and Alexander J. W. (1986) Infections of bum wounds. In: Bennet J. V. and Bra&man P. S. (eds),HospitalInfections,2nd ed. Boston: Little Brown, chap.30, p.465. Onuba 0. and Udoidio K. E. (1987)Hospital management of massive bums in the developing countries. Burns 13,386. Ramakrishnan M. K., Rao D.K., Doss C. R. et al. (1985) Incidence of bum wound sepsis in 600 burned patients treated in a developing country. Bums 11,404. Sowemimo G. 0. A. (1983) Bum injuries in Lagos. Bums 9,280. Thomsen M. (1970) The bums unit in Copenhagen VI. Infection rates. Scatuf.J. Plast. Reconstr.Surg. 4,53.
Paper accepted 14 July 1990.
Correspondence shouldbe addressedto: Mr E. BowenJones, Department of Plastic Surgery, Wentworth Hospital, PO Jacobs 4026, Durban, South Africa.
