carl p. hubbard · infect control hosp epidemiol 2012; 33:235–40. impact of electronic faucets...

Physiotherapy

Carl P. Hubbard

1927

Tannic acid bath

E.C.Davidson

1933

Brown J.B. Blair V.P. Surg.Gynec.&.Obst. 60:379-389 1935

In: Henry N. Harkins, The treatment of Burns,C.C.Thomas Ed. 1942

Saline Bath

1935

Sir Archibald Mac Indoe

1940(Royal Society of Medicine)

Sir Harold Gillies

R.A.F World War II

At East Grinstead

Saline at

105°F

1940

In : Artz,Moncrief,The treatment of burns,1957

1957

Showering Trolley 2019

U.S.A & Canada. 2010

59 burn centers (out of 142)

Survey on Current Hydrotherapy Use Among North American Burn Centers

Peter G. Davison, BSc, Frederick B. Loiselle, MD, PhD, Duncan Nickerson, MD, FRCSC

(J Burn Care Res 2010;31:393–399)

No Hydrotherapy: 10

Hydrotherapy: 49

Immersion only: 5

Immersion & showering: 17

Showering only: 26

27/28 Burn Care Providers

use hydrotherapy

(Immersion: 21)

J.Langschmidt et al.

Burns 2014,860-864

U.K.&Ireland 2014

Mena KD,Gerba CP. Risk assessment of

Pseudomonas aeruginosa in water.

Rev Environ Contam Toxicol

2009,201 :71-115

« Aqueous medias are the natural

environment of Pseudomonas »

« Water,water, everywhere... »

Mortality

Pseudomonas

Surg Clin North Am. 1978 Dec;58(6):1119-32.

Use of systemic antibiotics in the burned patient.

Haburchak DR, Pruitt BA Jr

Deadly outbreaks

https://www.ncbi.nlm.nih.gov/pubmed/252820https://www.ncbi.nlm.nih.gov/pubmed/?term=Haburchak DR[Author]&cauthor=true&cauthor_uid=252820https://www.ncbi.nlm.nih.gov/pubmed/?term=Pruitt BA Jr[Author]&cauthor=true&cauthor_uid=252820

1987 St Luc LyonJ.L Foyatier

J.Latarjet

Comm. ISBI World meeting New Dehli 1990.

Nosocomial infections Pseudomonas nosocomial

infections

Septicaemias Pseudomonas septicaemias

E. Tredget & al ,J.F Burke, Edmonton, Alberta.

Epidemiology of Infections with Pseudomonas aeruginosa in Burn Patients: The Role of Hydrotherapy

Edward E. Tredget, Heather A. Shankowsky, A. Mark Joffe, Thelma I. Inkson, Kathy Volpel, William Paranchych,

Pamela C. Kibsey, J. D. MacGregor Alton, and John F. Burke

Clinical Infectious Diseases 1992;15:941-9 © 1992

,

Outbreak of a Multiresistant Pseudomonas identified by

its serotype (011) and its pilin gene (DNA probe)

Recovered in the hydrotherapy equipment.

.

1985-1989


Epidemiology of Infections with Pseudomonas aeruginosa in Burn Patients: The Role of Hydrotherapy

Edward E. Tredget, Heather A. Shankowsky, A. Mark Joffe, Thelma I. Inkson, Kathy Volpel, William Paranchych,

Pamela C. Kibsey, J. D. MacGregor Alton, and John F. Burke


,

1985-89: outbreak of deadly MR Pseudomonas identified by its serotype (011)

and its pilin gene (DNA probe)

Recovered in the hydrotherapy equipment.

1989: stop hydrotherapy.

Epidemiology of Infections with Pseudomonas aeruglnosa in Burn Patients: The Role of Hydrotherapy

Edward E. Tredget, Heather A. Shankowsky, A. Mark Joffe, Thelma I. Inkson, Kathy Volpel, William

Paranchych, Pamela C. Kibsey, J. D. MacGregor Alton, and John F. Burke

From the Firefighters' Burn Treatment Unit, Division ofPlastic Surgery,



Epidemiology of Infections with Pseudomonas aeruglnosa in Burn Patients: The Role of Hydrotherapy

Edward E. Tredget, Heather A. Shankowsky, A. Mark Joffe, Thelma I. Inkson, Kathy Volpel, William Paranchych, Pamela C. Kibsey,

J. D. MacGregor Alton, and John F. Burke

Infection after Burn Injury 2016Multidrug resistance

Clin. Infect. Diseases,2017 Dec 15; 65(12): 2130–2136.

Bacterial Infections After Burn Injuries: Impact of Multidrug Resistance

A. Lachiewicz, D.Van Duin & al.

National Burn Repository 2016

(North America)

• 40 000 hospitalized burn patients/year

• 3 275 deaths

Infection :

Cause of death in 42 to 65% . (last ten years litterature)

(Risk of death X 2 in infected patients)

Clin. Infect. Diseases,2017 Dec 15; 65(12): 2130–2136.

Bacterial Infections After Burn Injuries: Impact of Multidrug Resistance

Anne Lachiewicz ,D.Van Duin& al.

Timeline of infection

Pseudomonas isolates

1st week: 8% of Gram

Bacterial outbreaks in burn centers

New genotyping method discovers sustained nosocomial

Pseudomonas aeruginosa outbreak in an I.C.U.

Tissot F. et al

J. Hosp. Infect. 2016,94,2-7.

Journal of Hospital Infection 100 (2018) e239-e245

Burns 2019 Jun;45(4):983-989.

Common hydrotherapy practices and the prevalence of burn wound bacterial

colonisation at the University Teaching Hospital in Lusaka, Zambia.

Ziwa M & al..

. Ann Burns Fire Disasters, 2019 Mar 31;32(1):47-55.

Extensively drug-resistant Pseudomonas Aeruginosa outbreak in a burn unit: management and solutions.

Aguilera-Saez J. & al

https://www.ncbi.nlm.nih.gov/pubmed/?term=burns+aguilera+pseudomonas++outbreak

Ann Burns Fire Disasters, 2019 Mar 31;32(1):47-55.

Extensively drug-resistant Pseudomonas Aeruginosa

outbreak in a burn unit: management and solutions.

Aguilera-Saez J. et al.

Outbreak: April-July 2016

10 patients(7 infected)

2 deaths (septic shock)

Germ: Pseudomonas . XDR-PA

MDR (Colistine-S)

Equipment (contaminated)

- tap aerators

- tap plumbing

- Drains

Place:

Patients rooms

Hydrotherapy room

Nursing station

Pseudomonas Aeruginosa

Burns 30 (2004) 3–26 Review

Pseudomonas infections in the thermally injured patient Edward E. Tredget,∗, Heather A. Shankowsky, Robert Rennie, Robert E. Burrell, Sarvesh Logsetty

Pseudomonas mucoid

alginate capsula Macrophage

Mutations

Biofilms

Can the hospital water supply

be dangerous?

The Hospital Water Environment as a Reservoir for Carbapenem-

Resistant Organisms Causing Hospital Acquired Infections—A

Systematic Review of the Literature Alice E. Kizny Gordon et al.

50% > 2010

CID 2017:64 (15 May) • 1435-1439

1996-2015

• 32 studies. 27 outbreaks

• Mostly I.C.U. (2 burn units.)

• 926 colonised patients(189 infected)

• Mean mortality: 25,7%

• Pseudomonas,

Acinetobacter,enterobacteriaceae,Klebsiella

The Hospital Water Environment as a Reservoir for Carbapenem-Resistant

Organisms Causing Hospita lAcquired Infections—A Systematic Review of the

Literature Alice E. Kizny Gordon et al.

CID 2017:64 (15 May) • 1435-1439


Organisms Causing Hospital Acquired Infections—A Systematic Review of the

Literature Alice E. Kizny Gordon et al. CID 2017:64 , 1435-1439

Faucets

Showers

Drains 17/32

Sinks

H. Kanamori et al.

Healthcare outbreaks associated with a water

reservoir and infection prevention

strategies.

Clinical Infectious Diseases, 2016,62,(11)1423-1435

Oxbow lake

Halabi M, Wiesholzer-Pittl M, Schoberl J,

Mittermayer H. Non-touch fittings in

hospitals: a possible source of

Pseudomonas aeruginosa and

Legionella spp. J Hosp Infect 2001;

49:117–21. 94.

Merrer J, Girou E, Ducellier D, et al.

Should electronic faucets be used in

intensive care and hematology units?

Intensive Care Med 2005; 31:1715–8. 95.

Sydnor ER, Bova G, Gimburg A, Cosgrove

SE, Perl TM, Maragakis LL.

Electronic-eye faucets: Legionella

species contamination in healthcare

settings. Infect Control Hosp Epidemiol

2012; 33:235–40

Impact of electronic faucets and water

quality on the occurrence of Pseudomonas

aeruginosa in water: a multi-hospital study.

Charron D. et al. Infect Control Hosp

Epidemiol 2015,36,311-9

* Resistant Pseudomonas was predominant in reservoirs( 41% of studies).

* The Eradication of the outbreak responsible germfrom the reservoir was obtained in only one third of the studies.

*Resistance: Environmental Intergenera plasmid exchange in thereservoirs is possible.


Organisms Causing HospitalAcquired Infections—A Systematic Review of the

Literature Alice E. Kizny Gordon, Amy J. Mathers, Elaine Y. L. Cheong,

Thomas Gottlieb, Shireen Kotay, A. Sarah Walker, Timothy E. A. Peto Derrick

W. Crook and Nicole Stoesser. CID 2017,64,1435-1439.

Betteridge T, Merlino J, Natoli J, Cheong EY, Gottlieb T, Stokes HW. Plasmids and

bacterial strains mediating multidrug-resistant hospital-acquired infections are

coresidents of the hospital environment. Microb Drug Resist 2013; 19:104–9.

Tofteland S, Naseer U, Lislevand JH, Sundsfjord A, Samuelsen O. A long-term low-

frequency hospital outbreak of KPC-producing Klebsiella pneumoniae involving

intergenus plasmid diffusion and a persisting environmental reservoir. PLoS One 2013;

8:e59015.

Crucial points

*The Evidence of cross transmission between patients and environment was found in all studies

(phenotypic/molecular typing).


be dangerous?

Yes!


be dangerous?

August 2019

Upstream prefiltration necessary

(plugging)

Lifetime?

Possibility of retrograde contamination

Cost: 60-70€

Can terminal 0,2µ filters help?

Faucets

Showers

« Dry » Bathing: « No water ICU! »?

(What do you need tap water for ?)

CHG Bathing in I.C.U.’s ??(« Dry » Bathing)

Climo MW, Yokoe DS, Warren DK, Perl TM, Bolon M, Herwaldt

LA, et al. Effect of daily chlorhexidine bathing on hospital-

acquired infection. N Engl J Med. 2013;368(6):533–542.

Frost SA, Hou YC, Lombardo L, Metcalfe L, Lynch JM, Hunt L,

Alexandrou E, Brennan K, Sanchez D, Aneman A, Christensen M.

Evidence for the effectiveness of chlrohexidine bathing and health

care associated infections among adult intensive care patients , a

trial sequential metaanalysis.

BMC Infect Dis. 2018 Dec 19;18(1):679.

1987 St Luc LyonJ.L Foyatier

J.Latarjet

Burn dressings

At bedside

or

In standard operating theatre

St Luc Burn Center. Dressings.

(Cleaning with Washclothes)

Antiseptic: : Povidone iodine (scrub) or chlorhexidine(aqueous)

Dilution: Saline serum.

Total quantity of liquid (Adult):

0.5 ml/% BSA (10%: 0,5 liter)

BSA > 40%: no more than 2 liters

Conclusions

- Sepsis kills burned patients

-Tap water may enhance sepsis.

Ban Tap water for the local treatment of Burn

W.C. Fields (American alcoholic film actor) :

« I do not like water

because the fishes f….in it. »

Burn Care Res 2007 Nov-Dec;28(6):776-90.

American Burn Association consensus conference to define

sepsis and infection in burns.

https://www.ncbi.nlm.nih.gov/pubmed/?term=american+burn+association+consensus+conference+to+define+sepsisn+and+infection+in+burns+JBCR

93. Halabi M, Wiesholzer-Pittl M, Schoberl

J, Mittermayer H. Non-touch fittings in

hospitals: a possible source of

Pseudomonas aeruginosa and

Legionella spp. J Hosp Infect 2001;

49:117–21. 94.

Merrer J, Girou E, Ducellier D, et al.

Should electronic faucets be used in

intensive care and hematology units?

Intensive Care Med 2005; 31:1715–8. 95.

Sydnor ER, Bova G, Gimburg A, Cosgrove

SE, Perl TM, Maragakis LL.

Electronic-eye faucets: Legionella

species contamination in healthcare

settings. Infect Control Hosp Epidemiol

2012; 33:235–40

Impact of electronic faucets and water quality on the occurrence of Pseudomonas

aeruginosa in water: a multi-hospital study.

Charron D. et al. Infect Control Hosp Epidemiol 2015,36,311-9

Faucets

Sinks

H. Kanamori et al.

Healthcare outbreaks associated with a water rservoir and infection prevention

strategies.

Clinical Infectious Diseases, 2016,62,(11)1423-1435

Gram-negative bacterias can survive 250 days in water.

C.Teplitz:

> 30% BSA deep burns

after 10 days:

100% septicemias

J Surg Res. 1964 May;4:217-22.

PSEUDOMONAS BURN WOUND SEPSIS. II HEMATOGENOUS

INFECTION AT THE JUNCTION OF THE BURN WOUND AND THE

UNBURNED HYPODERMIS.

TEPLITZ C, DAVIS D, WALKER HL, RAULSTON GL, MASON AD

Jr, MONCRIEF JA

https://www.ncbi.nlm.nih.gov/pubmed/14160480https://www.ncbi.nlm.nih.gov/pubmed/?term=TEPLITZ%20C%5BAuthor%5D&cauthor=true&cauthor_uid=14160480https://www.ncbi.nlm.nih.gov/pubmed/?term=DAVIS%20D%5BAuthor%5D&cauthor=true&cauthor_uid=14160480https://www.ncbi.nlm.nih.gov/pubmed/?term=WALKER%20HL%5BAuthor%5D&cauthor=true&cauthor_uid=14160480https://www.ncbi.nlm.nih.gov/pubmed/?term=RAULSTON%20GL%5BAuthor%5D&cauthor=true&cauthor_uid=14160480https://www.ncbi.nlm.nih.gov/pubmed/?term=MASON%20AD%20Jr%5BAuthor%5D&cauthor=true&cauthor_uid=14160480https://www.ncbi.nlm.nih.gov/pubmed/?term=MONCRIEF%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=14160480

The Hospital Water Environment as a Reservoir for Carbapenem-Resistant Organisms Causing HospitalAcquired Infections—A

Systematic Review of the Literature Alice E. Kizny Gordon, Amy J. Mathers, Elaine Y. L. Cheong, Thomas Gottlieb, Shireen Kotay, A.

Sarah Walker, Timothy E. A. Peto Derrick W. Crook and Nicole Stoesser

50%

The Hospital Water Environment as a Reservoir for Carbapenem-Resistant Organisms Causing HospitalAcquired

Infections—A Systematic Review of the Literature Alice E. Kizny Gordon, Amy J. Mathers, Elaine Y. L. Cheong,

Thomas Gottlieb, Shireen Kotay, A. Sarah Walker, Timothy E. A. Peto Derrick W. Crook and Nicole Stoesser

CID 2017:64 (15 May) • 1434-1439

J Trauma. 2007;63:164–171

The Impact of Nosocomially-Acquired Resistant Pseudomonas aeruginosa Infection in a Burn Unit Alexis D. Armour, MD, FRCSC, MSc, Heather A. Shankowsky, RN, Todd Swanson, MD, Jonathan Lee, MD, and Edward E.

Tredget, MD, MSc, FRSCS

The Impact of Nosocomially-Acquired Resistant Pseudomonas aeruginosa Infection in a Burn Unit Alexis D. Armour, MD, FRCSC, MSc, Heather A. Shankowsky, RN, Todd Swanson, MD, Jonathan Lee, MD, and Edward E.

Tredget, MD, MSc, FRSCS

J Trauma. 2007;63:164–171

Five stages of biofilm development: (1) Initial attachment, (2) Irreversible attachment, (3) Maturation I, (4)

Maturation II, and (5) Dispersion. Each stage of development in the diagram is paired with a photomicrograph of a

developing P. aeruginosa biofilm. All photomicrographs are shown to the same scale.

D. Davis - From: D. Monroe. "Looking for Chinks in the Armor of

Bacterial Biofilms". PLoS Biology 5 (11, e307)

https://en.wikipedia.org/wiki/Photomicrographhttp://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.0050307

Showers

Daily patient washing in I.C.U:

2% Chlorhexidine vs Soap & Water

• Effectiveness of Chlorhexidine Bathing to Reduce Catheter-Associated Bloodstream Infections in Medical

Intensive Care Unit Patients

• Susan C. Bleasdale, MD; William E. Trick, MD; Ines M. Gonzalez, MD; Rosie D. Lyles, MD; Mary K. Hayden, MD;

Robert A. Weinstein, M. Arch.Intern Med.167(19)2017

Daily patient washing in I.C.U:

2% Chlorhexidine vs Soap & Water

Effectiveness of Chlorhexidine Bathing to Reduce Catheter-Associated Bloodstream Infections in Medical Intensive Care Unit

Patients

Susan C. Bleasdale, MD; William E. Trick, MD; Ines M. Gonzalez, MD; Rosie D. Lyles, MD; Mary K. Hayden, MD; Robert A.

Weinstein, M

Radical eradication of potential Reservoir….

U.S.A & Canada. 2010

59 burn centers (out of 142)

Survey on Current Hydrotherapy Use Among North American Burn Centers

Peter G. Davison, BSc, Frederick B. Loiselle, MD, PhD, Duncan Nickerson, MD, FRCSC

(J Burn Care Res 2010;31:393–399)

No Hydrotherapy: 10 ?Hydrotherapy: 49

Immersion only: 5

Immersion & showering: 17

Showering only: 26

Five stages of biofilm development: (1) Initial attachment, (2) Irreversible attachment, (3) Maturation I, (4)

Maturation II, and (5) Dispersion. Each stage of development in the diagram is paired with a photomicrograph of a

developing P. aeruginosa biofilm. All photomicrographs are shown to the same scale.

D. Davis - From: D. Monroe. "Looking for Chinks in the Armor of

Bacterial Biofilms". PLoS Biology 5 (11, e307)

https://en.wikipedia.org/wiki/Photomicrographhttp://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.0050307

* Resistant Pseudomonas most frequently found in reservoirs( 41% of studies).

*Evidence of cross transmission betweenpatients and environment found in all studies

(phenotypic/molecular typing).

* Eradication of the outbreak responsible germfrom the reservoir obtained in only one third of studies.

*Resistance: Environmental Intergenera plasmid exchange is possible.

The Hospital Water Environment as a Reservoir for Carbapenem-Resistant Organisms Causing HospitalAcquired Infections—A

Systematic Review of the Literature Alice E. Kizny Gordon, Amy J. Mathers, Elaine Y. L. Cheong, Thomas Gottlieb, Shireen Kotay, A.

Sarah Walker, Timothy E. A. Peto Derrick W. Crook and Nicole Stoesser. CID 2017,64,1435-1439.

Betteridge T, Merlino J, Natoli J, Cheong EY, Gottlieb T, Stokes HW. Plasmids and

bacterial strains mediating multidrug-resistant hospital-acquired infections are

coresidents of the hospital environment. Microb Drug Resist 2013; 19:104–9.

Tofteland S, Naseer U, Lislevand JH, Sundsfjord A, Samuelsen O. A long-term low-

frequency hospital outbreak of KPC-producing Klebsiella pneumoniae involving

intergenus plasmid diffusion and a persisting environmental reservoir. PLoS One 2013;

8:e59015.

Crucial points

Invasive infection of fat cells

in deep Dermis

carl p. hubbard · infect control hosp epidemiol 2012; 33:235–40. impact of electronic faucets...

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