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Infection Prevention and Control in Burn Units · The SHEA Podcast

• 0:02
  SPEAKER_02: Come home to your ID community at ID Week 2025, October 19th to 22nd in Atlanta, Georgia.
• 0:09
  SPEAKER_02: ID Week brings together IDSA, Shea, HIVMA, PIDS, and SIDP for the premier infectious diseases meeting of the year.
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• 0:50
  SPEAKER_00: I'm Dr.
• 0:51
  SPEAKER_00: Madre Sorparada, Medical Director and Chief of Infection Prevention at Parkland Health, and an associate professor of infectious diseases at UT Southwestern in Dallas, Texas.
• 1:02
  SPEAKER_00: I'm the chair of Shay's Infection Prevention and Control Burn Unit Special Interest Group.
• 1:08
  SPEAKER_00: This special interest group was recently started by Shay to focus on this niche special population and the special needs it presents to ensure a greater focus on the IPC needs.
• 1:20
  SPEAKER_00: This podcast is one of the ideas from this group, and I'm pleased to bring it to life and serve in the role of moderator for today's session.
• 1:28
  SPEAKER_00: We have the privilege of being joined by some leading experts.
• 1:32
  SPEAKER_00: Will really allow us to hear some of the great work being done in this area.
• 1:37
  SPEAKER_00: Starting with Dr.
• 1:38
  SPEAKER_00: Samuel Mandel, who is an associate professor from the Department of Surgery at UT Southwestern Medical Center.
• 1:45
  SPEAKER_00: Dr.
• 1:45
  SPEAKER_00: Mandel has the Laurel and Gary F.
• 1:47
  SPEAKER_00: Perju Chair in Burn Care.
• 1:50
  SPEAKER_00: He specializes in trauma surgery, surgical critical care, and comprehensive care of burn injured patients and serves as Burn Section Chief and Director of the Parkland Regional Burn Center.
• 2:01
  SPEAKER_00: Welcome, Dr.
• 2:02
  SPEAKER_00: Mandel.
• 2:03
  SPEAKER_03: Thanks for having me.
• 2:05
  SPEAKER_00: Also joining us is Dr.
• 2:06
  SPEAKER_00: Weber, the Charles Addison and Elizabeth Ann Sanders Distinguished Professor of Medicine Chair and Associate Chief Medical Officer at UNC Medical Center.
• 2:16
  SPEAKER_00: Dr.
• 2:17
  SPEAKER_00: Weber also serves as the medical director in the Department of Infection Prevention at UNC Medical Center, and he's currently the SHA Board of Trustees President.
• 2:26
  SPEAKER_00: Welcome, Dr.
• 2:27
  SPEAKER_00: Weber.
• 2:28
  SPEAKER_01: Thank you for having me.
• 2:30
  SPEAKER_00: I'm thrilled to have you both with us today, sharing your opinions on the importance of specialized knowledge that's needed in burn unit infection prevention and control.
• 2:41
  SPEAKER_00: We are looking forward to hearing how you both approach what I see as this really important nature of practice setting that really requires special treatment for good patient outcomes.
• 2:54
  SPEAKER_00: So let's start with this.
• 2:56
  SPEAKER_00: What do you guys think makes burn unit infection prevention and control different?
• 3:01
  SPEAKER_01: I'm happy to start with that from an infectious uh disease standpoint.
• 3:06
  SPEAKER_01: I think, of course, and here I'm talking about patients with large body surface area burns and or inhalation injuries at the same time.
• 3:14
  SPEAKER_01: It leads to an immune suppression.
• 3:16
  SPEAKER_01: We don't usually think of uh burn patients uh as being immune suppressed in the general literature, but they are.
• 3:23
  SPEAKER_01: Interestingly enough, at the University of North Carolina, we have an immunocompromised infectious disease consult service, and it does most other centers includes uh cancer patients as well as solid organ transplant patients.
• 3:36
  SPEAKER_01: But because of the immune suppression, they also cover our burn patients.
• 3:40
  SPEAKER_01: Other things, of course, are that they're uh particularly the large burn, spend uh weeks to months uh in the uh uh in the hospital.
• 3:48
  SPEAKER_01: By definition, they have denuded skin, which is, of course, a major barrier to infection.
• 3:53
  SPEAKER_01: They often at the same time are ventilation injuries predisposing them to pneumonia or ventilator-associated pneumonia.
• 4:00
  SPEAKER_01: They usually require central lines and for a long period of time, and many times those lines have to be put in through a damaged skin.
• 4:08
  SPEAKER_01: They undergo multiple surgeries, each of which, of course, gives them a risk potentially for surgical site infections.
• 4:15
  SPEAKER_01: There's difficulty in diagnosing both skin infections and on burned skin and diagnosing pneumonia in people who have an inhalation injury because of the x-ray changes.
• 4:25
  SPEAKER_01: And of course, when you do draw cultures, you either end up having to draw them often through the central lines with a higher risk of contamination and potential false positives, or through damaged skin.
• 4:37
  SPEAKER_01: What makes them different, I'll just mention to infection prevention, then, are multiple risk factors for infection, long-term hospitalization, need for central lines and often ventilation, frequent and long-term use of antimicrobials, a high risk of uh multidrug resistant organisms, both because of the nature of the burn and transmission within the burn unit, inability to do the routine daily clohexatine baths that we do for ICU patients, frequent use of shared medical equipment such as x-rays every day, uh, bronchoscopy carts going in the room.
• 5:14
  SPEAKER_01: As they get better, they need to leave the room for uh going to uh surgery or rehab, uh, introduces other exposures.
• 5:22
  SPEAKER_01: I already mentioned the difficulties in diagnosing many of the infections.
• 5:25
  SPEAKER_01: Separating colonization from infection is difficult and they often get treated over treated, in fact, with a broad spectrum antimicrobial.
• 5:35
  SPEAKER_01: We actually have limited, well-designed studies of the effectiveness of our infection prevention interventions to really know if what we do in standard ICUs or other patients really is equally applicable to burn patients.
• 5:49
  SPEAKER_03: Yeah, I think all of that is true.
• 5:51
  SPEAKER_03: And, you know, even from a practical standpoint, one of the main differences is when you look at the duration of the hospitalization and what the burn patient is doing during that hospitalization, it makes it very challenging to implement a lot of standard infection prevention things like isolation.
• 6:10
  SPEAKER_03: And why is that?
• 6:11
  SPEAKER_03: Because burn patients have to move through multiple settings.
• 6:15
  SPEAKER_03: So even though we talk about them being in the burn center, within that they will often have to go to a different place for wound care.
• 6:22
  SPEAKER_03: Uh, very often they will have to go to the operating room multiple times, you know, which usually requires a journey through the hospital.
• 6:29
  SPEAKER_03: And each one of those transitions is another opportunity for transmission of infection.
• 6:37
  SPEAKER_03: And the earlier we start things like therapies, which are essential for adequate burn recovery, so we have to start them right away.
• 6:44
  SPEAKER_03: It's more people uh that need to be in the room very frequently.
• 6:48
  SPEAKER_03: And we have that same challenge with families.
• 6:52
  SPEAKER_03: These are often uh patients who are younger and uh we have a lot of visitation, and keeping all of those infection control practices across such broad populations can be very challenging.
• 7:03
  SPEAKER_00: So I absolutely agree with you.
• 7:06
  SPEAKER_00: You know, when outbreaks talking about burn units, what areas are often overlooked, you think, when looking for vectors of infection risk?
• 7:15
  SPEAKER_01: Well, we've done a lot of a number of outbreaks.
• 7:17
  SPEAKER_01: We have second largest burn unit at ICU in the United States here in North Carolina.
• 7:21
  SPEAKER_01: And of course, all the standard things that uh you can find for causes of uh infection.
• 7:27
  SPEAKER_01: Of course, most thing you worry about is the uh transmission patient to patient by the hands or gloves of providers or by shared medical equipment.
• 7:36
  SPEAKER_01: So that's one.
• 7:37
  SPEAKER_01: You know, certainly we've had issues with broncharts being wheeled into room because uh the patients who have uh inhalation injuries get frequent bronchoscopies.
• 7:45
  SPEAKER_01: Uh almost all of them get x-rayed every day.
• 7:48
  SPEAKER_01: So you have x-ray carts going in and out of uh multiple rooms.
• 7:51
  SPEAKER_01: Uh so that is another potential source.
• 7:54
  SPEAKER_01: Of course, unlike most patients uh who uh uh don't uh you know sort of get a sponge bath in the ICU, you have tub rooms and water sources there.
• 8:03
  SPEAKER_01: That can really be an issue if they're undergoing uh therapy with the tub rooms, and you have to worry about poor decontamination of the tubs between patients as well as the water sources itself coming into the water, such as particularly things like uh non-tuberculous mycobacteria, uh contaminated antiseptics.
• 8:22
  SPEAKER_01: There's a belief that uh antiseptics are self-disinfecting.
• 8:26
  SPEAKER_01: They're not, and there are certainly many outbreaks related to contaminated antiseptics with the damaged skin.
• 8:34
  SPEAKER_01: We do see an increased risk of uh fungal infections compounded by long hospital stays and broad spectrum antimicrobials.
• 8:41
  SPEAKER_01: We did link a number of cases of fungal infection in our patients.
• 8:45
  SPEAKER_01: We had a dedicated elevator for our burn unit that does ran them down a couple of floors to uh the OR.
• 8:51
  SPEAKER_01: And we did find, of course, in an elevator there's an open duct at the top of the elevator, so as it goes up or down, the air can go in and out.
• 8:59
  SPEAKER_01: And we did find moderately high levels, high levels of fungi in our elevator.
• 9:03
  SPEAKER_01: I think we probably have the world's only HEPA-filtered elevator shaft in the world, and that did eliminate uh some of our uh infections uh uh there.
• 9:13
  SPEAKER_01: Similarly, you can have uh infections from poor laundry practices and contaminated uh laundry, where it's uh a laundry with with fungi, with small numbers of fungi wouldn't affect people with intact uh skin.
• 9:26
  SPEAKER_01: So linens could be uh an issue there.
• 9:30
  SPEAKER_01: So I think those are just some of the more interesting and unusual types.
• 9:34
  SPEAKER_01: And of course, uh these patients are particularly prone to multidrug resistant pathogens.
• 9:38
  SPEAKER_01: Again, long stays, multiple antibiotics, and they can get colonized for long periods of time and not placed on isolation because they haven't yet developed a clinical infection.
• 9:48
  SPEAKER_01: And so you can then have hidden transmission from patient to patient.
• 9:52
  SPEAKER_01: And we have also seen, normally, we culture the stool when we're looking for a gram-negative, multidrug-resistant organism, klebsiella, for instance.
• 10:01
  SPEAKER_01: Uh, but uh, we've seen in these burn patients that at times they can get colonized and then infected on the skin, but at least initially the standard stool cultures will not reveal the multidrug-resistant gram-negative organism, which would be uncommon in just say a medicine ICU patient.
• 10:18
  SPEAKER_01: So those are some of the things that we have looked at uh over time in our burn unit leading to outbreaks.
• 10:25
  SPEAKER_03: Yeah, I think the elevator example is kind of a nice uh a nice example of that traveling through the hospital that burn patients have to do.
• 10:32
  SPEAKER_03: So you can do all this work to isolate somebody in the ICU, you know, with uh with positive pressure rooms.
• 10:38
  SPEAKER_03: You can do all that same work in the operating room, but they still have to get there.
• 10:42
  SPEAKER_03: Uh and it's hard to, you know, it's hard to isolate that whole kind of chain of uh of travel.
• 10:50
  SPEAKER_03: I think some other areas, you know, when you're thinking about an outbreak uh in the burn unit, so something that's unusual, often you first go to a lot of those usual factors.
• 11:02
  SPEAKER_03: Um, I think some areas that you know people don't often think of as vectors for infection, but can be critical in the burn unit, uh just things like sinks and drains in the rooms and the splashing that can come out of those.
• 11:16
  SPEAKER_03: Anywhere where there's recent construction.
• 11:18
  SPEAKER_03: So, you know, we had that example of the elevator shaft, but when you have construction in your hospital or even across the street, you know, and people are tearing out old walls, tearing down uh old construction, remodeling rooms, that can release a lot of those fungal elements uh into the air.
• 11:36
  SPEAKER_03: And that can be a big problem for burn patients who, as we've already talked about, don't have their natural skin barrier, especially in larger areas.
• 11:44
  SPEAKER_03: And then I think some of the other things that can be really challenging in burn units is you're talking about small numbers.
• 11:50
  SPEAKER_03: Uh and so if you have uh even a hundred percent increase in your fungal infections in your unit, you may not see it as all of a sudden there are 10 patients with the problem.
• 12:02
  SPEAKER_03: It may be from you know one to two or just a couple of patients that you're seeing over the course of a month.
• 12:09
  SPEAKER_03: And so sometimes your traditional surveillance won't necessarily pick that up or or flag it immediately.
• 12:16
  SPEAKER_03: And uh you have to be very careful about that, particularly with some of these more rare infections, that when you start to see them at a uh, you know, even kind of going from none to, oh, you know, we sort of have one patient like this all the time now, that may be a flag, a red flag that you have a problem.
• 12:33
  SPEAKER_00: Yeah, great points, uh excellent points.
• 12:36
  SPEAKER_00: You know that doing surveillance on a daily basis in our own units here, it's absolutely like Dr.
• 12:44
  SPEAKER_00: Mando, what you mentioned about the rarity of uh these infections happening, you know, and that brings me to the next question.
• 12:54
  SPEAKER_00: How do you determine, right, with the kind of you know, low number of infections occurring, how do you determine if it's an outbreak or just what's expected given the immunocompromised nature of burn units?
• 13:08
  SPEAKER_01: Well, I think you know, this is really where obviously good surveillance, just standard surveillance and epidemiologic methods are first.
• 13:15
  SPEAKER_01: But second, using the newer techniques of molecular epidemiology, particularly whole genome sequencing, we did find that we had an ongoing outbreak, actually in two phases that lasted over two years, that really had not been for whole genome sequencing, uh, we wouldn't have uh uh detected uh there.
• 13:34
  SPEAKER_01: But I do think that's really the best way of linking things from patient to patient, and as was just mentioned, things like finding the source.
• 13:42
  SPEAKER_01: Is it in the drains?
• 13:44
  SPEAKER_01: Is it in the tub room?
• 13:46
  SPEAKER_01: Again, if you're gonna do environmental cultures, I can guarantee you're gonna find gram negatives in the sink in the P trap.
• 13:52
  SPEAKER_01: But again, this is where uh genome, whole genome sequencing can either link things together or say that they're they're unrelated, particularly when you get to more common organisms like MRSA.
• 14:03
  SPEAKER_01: Again, is it really an outbreak or just a natural occurrence uh in patients who are burned?
• 14:09
  SPEAKER_01: And uh there again, uh that's probably the best molecular uh method we can use, but it doesn't substitute for just good uh uh epidemiologic surveillance in the first place and paying attention to what's happening uh among the clinical infections in in the burn unit.
• 14:26
  SPEAKER_03: I 100% agree.
• 14:27
  SPEAKER_03: That's that's yeah, sort of the way that we have you know tracked related infections, you know, so that you can tell whether you are dealing with the same organism uh spreading or different one-off infections.
• 14:41
  SPEAKER_03: That does get a little bit more challenging in the rare infections like the fungi and molds.
• 14:46
  SPEAKER_03: And again, there uh we combine the surveillance with, I pay a lot of attention to people reporting their clinical experience at the bedside, where you know it's you see an unusual concentration of cases uh or something is uh something seems off as a red flag that we have to investigate something.
• 15:11
  SPEAKER_03: And, you know, for example, uh when you see an infection that we don't see very often at all, uh something like Canada Auris.
• 15:19
  SPEAKER_03: Uh we had a uh when we had the initial case of Canada Ourus that came from an outside facility, that's something we paid a lot of attention to, not necessarily because it was an outbreak, but because that's a new organism that was coming in, and we needed to make sure that we didn't see it or have something that spread out of control uh without us uh being aware of it.
• 15:40
  SPEAKER_00: Absolutely.
• 15:41
  SPEAKER_00: You know, it becomes so hard when you have you know one infection a month or one to once every two months.
• 15:50
  SPEAKER_00: And what's also challenging is a lot of places uh do not have are not equipped to do whole genome sequencing.
• 15:57
  SPEAKER_00: I hope that you know in the future things will move towards uh that direction.
• 16:04
  SPEAKER_00: And uh, you know, are there optimal burn unit designs to mitigate infection?
• 16:13
  SPEAKER_03: I don't know about optimal uh designs, but I think that there are some standard things uh that can help mitigate infection that uh that are good practice, uh, many of which uh we sort of touched on here that can be done without redesigning your entire institution.
• 16:29
  SPEAKER_03: Uh so for example, the the patients who are at largest risk, so those with very large open wounds, say greater than 20%, uh we put all of those patients in uh standard contact precautions.
• 16:41
  SPEAKER_03: So gown, gloves, uh mask, just prophylactically uh to help protect uh the patients.
• 16:48
  SPEAKER_03: And you know, one of the things that we learned over time is that can be challenging for staff.
• 16:53
  SPEAKER_03: And so we actually expand that so it's just standard for any ICU patient in our unit to be treated that way to help uh prevent lapses.
• 17:03
  SPEAKER_03: Outside of that, I think having positive pressure runes uh on units, just like in the operating rooms, uh, can help.
• 17:13
  SPEAKER_03: And then paying very, very careful attention to your cleaning protocols and ensuring that all things uh within the unit that come in contact with patients have standard cleaning protocols that are compliant with their manufacturer.
• 17:29
  SPEAKER_03: And I mean that sounds kind of anal and silly, but there are so many cracks and crevices when you get into using a hydrotherapy room or um, you know, wound care centers where you have patients going in and out, you have coiled hoses, you know, the water has to uh make sure that the water doesn't get stagnant in those areas, that all the drain lines are cleaned appropriately.
• 17:53
  SPEAKER_03: There's just so many uh nooks and crannies that paying attention to really good infection control practices, I think, can sometimes be even more important than uh than having the absolute newest or greatest equipment.
• 18:09
  SPEAKER_01: Yeah, uh other things I would add is, you know, these really are sick patients that require lots of ancillary equipment and support.
• 18:17
  SPEAKER_01: So having rooms that are sized appropriately to allow, you know, the dialysis machine plus the ventilator, uh, plus people being able to direct their care, the rooms have to be larger than certainly our standard hospital room and and uh uh appropriately so.
• 18:34
  SPEAKER_01: So that's one thing you I think you need to do.
• 18:36
  SPEAKER_01: The other, of course, is being able to have a directional airflow when necessary, negative or positive pressure.
• 18:42
  SPEAKER_01: And finally, I think you know, water is certainly a major possible source of infection, uh, and designing sinks so that you can't get easy backflow and spray from the drain.
• 18:53
  SPEAKER_01: So have a sink instead where you have a flat piece of uh on the top so the water flows down and the drain is hidden so it can't actually backsplash would be useful, uh, as well as uh in the tubroom considering using a water filter.
• 19:09
  SPEAKER_01: So, because even though the water will meet drinking water standards, drinking water standards are not good enough for bathing a burn patient.
• 19:15
  SPEAKER_01: You really ideally would like pathogen-free uh water.
• 19:19
  SPEAKER_01: So uh being able to use a water filter on there that captures bacteria would be something else that you could do uh as well in terms of uh design.
• 19:28
  SPEAKER_03: I think it's important also to note that some of those things can be retrofitted.
• 19:32
  SPEAKER_03: If you're in a place where you're taking care of a lot of the these patients and uh you're concerned, filters can be added to uh you know sinks and other areas that don't need to be centralized.
• 19:44
  SPEAKER_03: Splash guards can be added to uh to sinks, uh, which is actually something that we've gone back and done throughout uh our unit, where we had sinks that weren't designed well to separate where people were trying to put uh clean supplies or patient care equipment from the sinks.
• 20:01
  SPEAKER_03: Uh, we installed splash guards to make sure that those areas were staying separate.
• 20:06
  SPEAKER_03: And those kinds of things can be done uh fairly easily uh without necessarily a whole redesign or thinking you should design a whole unit from scratch.
• 20:17
  SPEAKER_00: Great points.
• 20:18
  SPEAKER_00: You know, the splash guards was something that, you know, Dr.
• 20:22
  SPEAKER_00: Mandel, you know, that we work together so we know that uh those having the clean supplies next to the sinks uh seems to be a big challenge uh anywhere you know you uh go.
• 20:33
  SPEAKER_00: And uh some of the, you know, those are some great thoughts, insights from you guys there.
• 20:38
  SPEAKER_00: What are some key research areas that are unexplored that would really help us with patient safety in burn units?
• 20:46
  SPEAKER_01: Well, I one of the first things I would say is uh, you know, we focused here on uh true burns, meaning skull burns and flames and other things.
• 20:53
  SPEAKER_01: I just want to say one of the things we do at UNC is when we have patients essentially with denuded skin from other reasons like toxic echrodermal necrolysis as an example from, say, drugs or mycoplasm, we put all of our patients into the burn unit uh if they have uh denuded skin, regardless of the cause.
• 21:13
  SPEAKER_01: And we have found, you know, really a dermatologist is not equipped to handle a patient with severe TEN.
• 21:18
  SPEAKER_01: The burn, our burn surgical colleagues are much better at that.
• 21:22
  SPEAKER_01: We usually often have one or two patients that are there for other reasons uh than uh the classic burn injury.
• 21:28
  SPEAKER_01: So that's the first thing I would say, that we could probably get better data on uh how much better the care is by our wonderful bird surgeons for those patients, letting them be managed by medicine doctors and uh skin doctors out on the floors.
• 21:42
  SPEAKER_01: Obviously, we don't have a lot of data on the standard things that we know about on the floors for burn patients.
• 21:49
  SPEAKER_01: So, for instance, uh you know, there are uh multiple studies showing that changing IV lines over guide wires routinely, uh not for malfunction, is Not helpful, but some of our burn surgeons want to do that.
• 22:03
  SPEAKER_01: We don't have data on that, for instance, and burn patients there.
• 22:08
  SPEAKER_01: As was just mentioned, you know, whether we should put burn patients at a certain burn size on routine uh isolation.
• 22:16
  SPEAKER_01: Uh it certainly makes sense, but again, I'm not aware of a randomized trial that has looked at uh that.
• 22:22
  SPEAKER_01: And is it just gloves or gloves gown?
• 22:24
  SPEAKER_01: Gloves, gown, and mask has not been uh well uh uh well looked at.
• 22:29
  SPEAKER_01: Uh routine surveillance for multidrug resistant organisms, whether it's dual for VRE or CRE or nose for staph aureus.
• 22:39
  SPEAKER_01: I'm not aware that we have good data on, again, randomized trials about the benefits or harms of uh uh of that, how to better provide antisepsis of the skin, uh, when are prophylactic antibiotics uh indicated, and for uh for how long.
• 22:56
  SPEAKER_01: So I think one of the problems, of course, is as was mentioned, even big birth centers have relatively few patients compared to standard ICU patients.
• 23:05
  SPEAKER_01: All of those studies will need to be done uh in a multi-facility uh group.
• 23:12
  SPEAKER_01: And you know, I know for instance we're part of a big group that studies cystic fibrosis at multiple centers.
• 23:19
  SPEAKER_01: I'm not aware we have a well-supported research enterprise.
• 23:23
  SPEAKER_01: We're all familiar with the ACTGs for HIV patients.
• 23:26
  SPEAKER_01: We lack that for burn care, being able to use multiple centers to really uh look at that data.
• 23:32
  SPEAKER_01: So the first thing I think we need to do is set up a good infrastructure, and then we need to prioritize appropriate uh uh interventions, not just infection prevention interventions, but other general care interventions as well.
• 23:45
  SPEAKER_03: Yeah, I think I would I would sort of split this into two parts.
• 23:49
  SPEAKER_03: And one is uh, as Dr.
• 23:51
  SPEAKER_03: Weber just mentioned, the randomized controlled trial is a bit of a unicorn in the burn population.
• 23:57
  SPEAKER_03: There are rare, there are rare things, and you know, there are a whole bunch of reasons for that.
• 24:01
  SPEAKER_03: But I think one of the things that we do need more of, and hopefully uh we'll have in the future is data on the things that we are already doing, like contact precautions that seem to make sense, but we don't actually have the information on it.
• 24:17
  SPEAKER_03: I do think that the American Burn Association um does have some uh infrastructure for multi-center clinical trials.
• 24:25
  SPEAKER_03: Um I think uh there are some existing frameworks that we can leverage for that.
• 24:29
  SPEAKER_03: Um of course, funding is always going to be uh is gonna be a challenge.
• 24:33
  SPEAKER_03: You know, saying that you want to fund a study to look at contact precautions in the unit is not exactly the sexiest thing.
• 24:40
  SPEAKER_03: And so uh so I think that's why we haven't necessarily seen some of that basic work done.
• 24:47
  SPEAKER_03: You know, in the future, you know, are there other things that one uh might consider that we haven't talked about?
• 24:54
  SPEAKER_03: Yeah, I think actually we also know relatively little about what the normal microbiome after a burn wound is, right?
• 25:02
  SPEAKER_03: So, in what sequence do bacteria repopulate the wounds?
• 25:06
  SPEAKER_03: How quickly do we get, or are there good commensal bacteria in the burn wound that can help us prevent pathogenic contamination or subsequent infection?
• 25:16
  SPEAKER_03: What's the role of biofilm in burn wounds?
• 25:19
  SPEAKER_03: And you know, are there new ways of combating it, both mechanical uh as well as with topicals?
• 25:26
  SPEAKER_03: Uh and then, you know, other people have looked at imaging for uh diagnosis of biofilm or early infection, you know, with things like fluorescence uh and other tools.
• 25:37
  SPEAKER_03: You know, I think there's a there's a lot of unknowns, and I think we may see some of those newer technologies coming in the future.
• 25:46
  SPEAKER_03: Um, and I think there are also people who in, you know, we've touched on the multi-drug-resistant organisms a lot.
• 25:52
  SPEAKER_03: You know, that always kind of brings people back around to phage therapy, which has been around for forever and people have talked about.
• 25:58
  SPEAKER_03: So I think there are new things that are going to be coming.
• 26:02
  SPEAKER_03: I think one of the challenges we have in the burn community, as Dr.
• 26:05
  SPEAKER_03: Weber said, is some of the kind of basics are still unknown and we don't have those to build on uh as some of these new things come out, and that can complicate the picture.
• 26:16
  SPEAKER_00: Right.
• 26:17
  SPEAKER_00: And sometimes it seems like we are basing a lot of our protocols on expert opinions and you know common sense.
• 26:28
  SPEAKER_03: I think one of the things that's really important about that point is not only is that a challenge in the sense that it's based on expert opinion, which sometimes is what we have.
• 26:39
  SPEAKER_03: And so it might be better than doing nothing.
• 26:42
  SPEAKER_03: But I think what it really also presents is the challenge of when you do get good information, right?
• 26:48
  SPEAKER_03: When we do get uh good science on some of these things, do we recognize it and do we change our practice uh in accordance with that new information?
• 26:56
  SPEAKER_03: And that is also a challenge that we face in the burn community.
• 27:01
  SPEAKER_00: Yeah, great points.
• 27:02
  SPEAKER_00: Great points.
• 27:03
  SPEAKER_00: What do you think is the future of burn units, patient safety, and infection prevention?
• 27:09
  SPEAKER_01: Obviously, I think as uh as starting with the public health aspects, being advocates for strategies to reduce burns in the first place is uh something that we can do, making the public aware of the risks of burns and uh trying what we can do to reduce some of those risks.
• 27:27
  SPEAKER_01: Uh, you know, for instance, we see more and more hurricanes and flooding, and then people uh bring their uh they run out of heat or light, and uh so they bring their uh grill into the house and start grilling in the house as examples, uh scald injuries to children because people, children reaching up and turning pots of hot water on themselves.
• 27:46
  SPEAKER_01: So I guess, you know, just first uh general public health and being advocates for preventing burn injuries uh there.
• 27:53
  SPEAKER_01: Uh beyond that, obviously, as we already talked about, improved diagnostic methods, I think, learning more about the natural floor of the burn skin and diagnosing uh burn wound infections, as well as uh getting better diagnostic tools uh uh that help us separate uh what we see on the X-ray with just uh uh uh inhalation versus uh actual uh infection.
• 28:16
  SPEAKER_01: Improved stewardship, obviously, uh get our stewardship teams involved so we use the proper antibiotics to the proper time for the uh at the proper uh doses, improve methods, which we've certainly done much better recently over the last 20 years in uh rapid uh uh surgeries and improvement in uh methods for covering the skin.
• 28:36
  SPEAKER_01: It would be better to have better antiseptics that we know work on the skin are safe, and maybe novel methods using gases or other things to uh provide better burn wound uh antisepsis there.
• 28:49
  SPEAKER_01: Evaluation of routine studies for colonization, I think would be uh enormously useful there.
• 28:56
  SPEAKER_01: And you know, can we actually decolonize people?
• 29:00
  SPEAKER_01: I think all of those things are things for the future, as well as, as I already said, developing uh guidelines specifically, evidence-based guidelines based on good letter literature that will guide us who those of us who take care of severely burned patients frequently.
• 29:16
  SPEAKER_03: Yeah, I think that I think those are really key points.
• 29:19
  SPEAKER_03: And and what I would add to them, I think, would be for the future, not necessarily a treatment for infection specifically, but treatments that allow us to close the wounds faster.
• 29:32
  SPEAKER_03: So developments in things like skin substitutes or artificial skin coverages that don't require subsequent grafting, those may help us close wounds faster in the future, which of course reduces the overall risk of having a burn wound infection.
• 29:51
  SPEAKER_03: We know that it's it's the larger the open area you have and the longer you have it, uh the risk of infection goes way, way up.
• 30:00
  SPEAKER_03: And so shortening that time uh may help us uh get there.
• 30:04
  SPEAKER_03: And I think the other thing that's really going to be key uh hopefully in the future, at least in the short-term future, is better topical uh agents that help us combat either uh established infection uh or prevent those infections.
• 30:19
  SPEAKER_03: I mean, when you think about what we're using today, we're basically using similar technologies that have been around for, you know, 50 years or more.
• 30:29
  SPEAKER_03: And one of those, which was maffinide solution, isn't even available any longer.
• 30:34
  SPEAKER_03: And so I think new topicals in the short term will really be uh helpful in terms of treating infections uh kind of in the near future.
• 30:45
  SPEAKER_03: And then actually establishing a common language around what constitutes a burn infection and how we diagnose it.
• 30:54
  SPEAKER_03: We've been uh we've been sort of discussing that back and forth for also nearly 30 years.
• 31:00
  SPEAKER_03: And the last guideline was published uh over 12 years ago.
• 31:03
  SPEAKER_03: Uh and so hopefully we can get some newer uh consensus thinking around what defines an infection and therefore how we might use our antimicrobials and actually practice the stewardship that we've been talking about.
• 31:18
  SPEAKER_00: Absolutely, a lot of work to do in the future, and I think that's the reason why this was such an important topic to discuss here.
• 31:28
  SPEAKER_00: Thank you very much, Dr.
• 31:29
  SPEAKER_00: Mandel and Dr.
• 31:30
  SPEAKER_00: Weber, for sharing your perspectives and experiences.
• 31:34
  SPEAKER_00: Uh, this was a great discussion.
• 31:36
  SPEAKER_01: Thank you for inviting us.
• 31:38
  SPEAKER_01: I've really enjoyed the ability to participate in this, and it's uh really wonderful to have an expert burn surgeon as part of our Shay webinar.
• 31:47
  SPEAKER_03: Oh, thank you for having me.
• 31:49
  SPEAKER_03: I really enjoyed it and really appreciate the discussion and the time.
• 31:53
  SPEAKER_00: Well, thank you both.
• 31:54
  SPEAKER_00: And that concludes this episode of the SHA podcast.
• 31:58
  SPEAKER_00: Thank you for tuning in.