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Infectious Diseases Essentials MJA Practice
Infectious Diseases
Essentials
2: Hospital-acquired infections
Denis W Spelman
Sound infection control practice and prudent antibiotic use will reduce antimicrobial-resistant
organisms and hospital-acquired infections
catheterisation is the most important predictor of catheter- These clinical features arise most commonly while the
associated bacteriuria. Catheter obstruction in the presence cannula is in place, but may occur after its removal and
of infected urine may result in septicaemia. patient discharge from hospital. Patients who are receiving
A patient who develops infection while the catheter is in home therapy with intravenous antibiotics may also present
place may complain of urethral discomfort, frequency, fever to their general practitioners during treatment.
and pericatheter discharge. Infection occurring after If a patient develops signs of phlebitis, then the
catheter removal causes the usual symptoms of urinary tract intravenous cannula should be removed, a swab should be
infection. The causative organisms include those that are taken of any purulent discharge for culture, and, if fever is
usual in urinary tract infection (eg, Escherichia coli), as well present, blood should be cultured (case report, Box 2).
as hospital-acquired organisms (eg, methicillin-resistant Removal of the cannula and oral antistaphylococcal
Staphylococcus aureus [MRSA] and antibiotic-resistant gram- antibiotic therapy (eg, dicloxacillin) usually result in
negative bacilli). resolution of symptoms and signs. If local signs or fever
The presence of asymptomatic catheter-associated persist, then further investigation and management should
bacteriuria should not generally indicate a need for
antimicrobial therapy. Possible exceptions include immuno-
compromised patients and patients undergoing urological 2: Case report sepsis associated with an
surgery. Asymptomatic catheter-associated candiduria often intravenous cannula
reflects vaginal or gastrointestinal carriage. History: A 41-year-old woman had a peripheral intravenous cannula
When symptoms are present, the catheter should be inserted at her right wrist at the time of a laparoscopic
removed if possible, a urine sample sent for culture, and a cholecystectomy. The surgery was complicated and needed to be
short course of antibiotic therapy given. If the urinary converted to a laparotomy. On the fifth postoperative day, she
catheter must be kept in place then antibiotic therapy may developed fever and complained of pain at the cannula site.
relieve the symptoms, but the organism is likely to persist. Investigations: Clinical examination revealed fever (38.5oC) and
Prolonged antibiotic therapy in the presence of an indwelling redness at the cannula site. There were no other abnormal clinical
findings. Full blood examination revealed leukocytosis of 14.0x
catheter will result in the emergence of antibiotic-resistant 109/L (reference range, 4.511.0x109/L), and blood cultures
organisms. subsequently grew methicillin-sensitive Staphylococcus aureus
Measures to prevent catheter-associated infections (MSSA).
include: Management: The cannula was removed and cultured: MSSA was
avoiding unnecessary catheterisation; isolated from its tip. After two days therapy with intravenous
using aseptic and atraumatic insertion technique; cephazolin, the patient was discharged.
minimising duration of catheterisation; Further course: The patient presented to her general practitioner
minimising catheter manipulation; and seven days later with a recrudescence of fever. The GP detected a
new early diastolic murmur suggesting aortic regurgitation, took
maintaining a closed drainage system.
blood for culture, and referred her back to the treating hospital with
a diagnosis of probable endocarditis.
Infections related to intravenous cannulas Blood cultures again grew MSSA, and a transthoracic
echocardiogram revealed aortic valve vegetation. She was treated
The presence of an intravenous cannula can result in with a four-week course of intravenous flucloxacillin and made an
localised or systemic sepsis. In an Australian study, systemic uneventful recovery.
sepsis occurred for 0.36 of every 1000 peripheral catheters Strategies that may have prevented phlebitis and septicaemia or
used, and for 23 of every 1000 central vein catheters.4 allowed earlier diagnosis of endocarditis include:
The causative organisms originate from skin flora: either Daily inspection and palpation of cannula insertion site;
patients own flora (eg, coagulase-negative staphylococci) or Adherence to recommended policy of changing intravenous
that acquired from hospital organisms (eg, MRSA). Skin cannulas every 48 hours regardless of whether there is evidence
microorganisms can adhere to the cannula and gain entry of infection;
into tissues and, less commonly, the circulation, causing 10 to 14 days of intravenous antimicrobial therapy in all cases of
staphylococcal septicaemia; and
bacteraemia. Localised phlebitis with pain, tenderness,
Routine echocardiogram (preferably transoesophageal) in all
redness or pus at the site, or systemic sepsis with fever or
cases of staphylococcal septicaemia.
hypotension, may result.
be considered (eg, blood cultures, ultrasound examination within four weeks of surgery, without other localising
to detect a pus collection which may require surgical features, is likely to be caused by infection at the surgical
drainage and intravenous antibiotic therapy). site. Superficial wound infection may resolve with or without
Non-infective complications, such as phlebitis or catheter- antibiotics. Deeper or organ-space infection may require
associated thrombosis, may mimic localised infection. If imaging for diagnosis, surgical drainage and antimicrobial
central-line-associated thrombosis is suspected, then a therapy guided by culture of purulent material.
Doppler ultrasound examination should be considered. The likely causative organisms depend on the location and
Measures to prevent cannula-associated infection include: type of surgery. Most common is S. aureus, with MRSA
use of aseptic cannula insertion technique; common in some hospitals. For gastrointestinal or genito-
minimising duration of cannulation; urinary tract surgery, gram-negative bacilli (eg, E. coli) are
regular examination for redness, pain, tenderness or more common causes of infection.
purulence and, if detected, removal of the cannula. A general practitioner should consider the following steps
change or removal of peripheral intravenous cannulas for a surgical wound infection presenting after hospital
every 4872 hours, as the risk of phlebitis is high after this discharge:
time. Long central catheters (eg, peripherally inserted swab wound discharge for microscopy and culture;
central catheters) do not need routine replacement. perform full examination and culture of blood if fever is
present;
Surgical wound infections commence a course of antistaphylococcal antibiotic
therapy (eg, dicloxacillin); and
Surgical wound infections occur in up to 10% of patients notify and discuss with surgeon.
undergoing clean surgery, with the incidence varying with Strategies shown to decrease the risk of surgical wound
complexity of surgery, intrinsic patient risk and surgical infection include antibiotic prophylaxis, short preoperative
skills. Most surgical wound infections result from contami- hospital stay, optimisation of patients risk factors (eg,
nation of the surgical wound with the patients own flora or diabetes control), and surveillance of surgical-site infections
that of operating-room personnel or environment at the time with feedback to the operating teams.
of the surgery. Postoperative haematogenous seeding of the
wound site is uncommon.
Causative organisms
Infection may present clinically during hospitalisation.
However, the current trend to shorter postoperative stays The organisms that cause hospital-acquired infections
and day surgery result in more than 50% of surgical wound usually originate from the patients own microbial flora,
infections becoming apparent after discharge from hospital which may be altered by the addition of hospital-based
(case report, Box 3).5 Clinical infection may occur up to four organisms. The causative organisms cover a spectrum, with
weeks after deep surgery (eg, CABG) and up to 12 months the relative importance of individual species varying over
after surgery involving an implanted prosthesis (eg, joint time, between units and hospitals, and between countries.
replacement). In Australia, MRSA has been a major hospital-acquired
The common clinical features of surgical wound infection pathogen since the 1980s, especially in the larger tertiary
are localised pain, redness and discharge. Fever that occurs hospitals. In some hospitals, more than 50% of S. aureus
isolates are resistant to methicillin. These isolates are usually development of antibiotic resistance and preventing the
resistant to multiple antibiotic classes in addition to spread of resistant organisms between patients.
methicillin (ie, flucloxacillin and dicloxacillin). MRSA is a
common cause of hospital-acquired bacteraemia, surgical Preventing antibiotic resistance
wound infection and catheter-related sepsis. These infec-
tions generally require at least initial treatment with a Antibiotic use selects for antibiotic-resistant organisms.
glycopeptide antibiotic, such as vancomycin. Methicillin Minimising this selective pressure requires continuing
resistance also occurs in Staphylococcus epidermidis (MRSE), education or re-education of prescribers, their adherence to
which is associated with infections of intravenous devices, agreed policies and practices, and ideally involvement in
renal dialysis catheters and orthopaedic prostheses. ongoing surveillance of antibiotic use and antibiotic
The selective pressure generated by antibiotic use has led resistance patterns. Some common practices, such as use of
to the development of new antibiotic-resistant hospital broader rather than narrow spectrum antimicrobials,
microorganisms (Box 4). These new and emerging need to be reversed.
pathogens have several features in common: they are The widespread use of antibiotics in animal husbandry
resistant to commonly used classes of antibiotics, and they and potential transmission of antibiotic-resistant organisms
cause both endemic and epidemic hospital outbreaks, to humans is also of increasing concern. The common use of
resulting in significant patient morbidity and mortality. avoparcin as a growth promoter in animal husbandry and its
There is also concern that these organisms may spread from possible role in the development of vancomycin-resistant
hospitals into the general community, as evidence suggests enterococci (VRE) in humans has led to withdrawal of this
MRSA has done, especially into long-term care facilities antibiotic from veterinary use. Recently, veterinary and
such as nursing homes. other use of antimicrobial agents has been critically
examined in Australia by the Joint Expert Technical
Advisory Committee on Antibiotic Resistance (JETACAR),
Preventing hospital-acquired infections
with subsequent recommendations on areas such as
Up to a third of hospital-acquired infections are preventa- regulatory controls, monitoring and surveillance and
ble.10 The two main arms of prevention are stopping the infection prevention strategies and hygiene measures.11
Preventing organism spread organisms, thereby clarifying the clonal or polyclonal nature
of apparent outbreaks. Findings can then direct infection
Many of the principles for preventing spread of hospital-
control practices.2 Molecular testing has confirmed that
acquired organisms are well known. There is no single
some apparently endemic infections (eg, MRSA infec-
successful recipe, and the approach for individual hospitals
tions) are in fact a series of mini-outbreaks. Each outbreak
must be based on the epidemiology of the organism and the
arises when a single breach in infection control practice
resources available. Important ingredients of a program to
transmits an organism to one or a small number of patients.2
prevent hospital-acquired infections are summarised in Box
Surveillance systems need to evolve with changes in the
5, illustrating the breadth of such prevention programs. Staff
healthcare system. Early hospital discharge after surgery
should use preventive measures at all times, not only for
means that surveillance for inpatient surgical wound
patients considered infectious.
infections may need to be supplemented by post-discharge
Surveillance: The cornerstone of successful hospital infection surveillance. Similarly, infections that occur in the hospital
control is surveillance. This includes prospective collection in the home or home nursing setting may need to be
of high quality data, their analysis, and timely feedback to considered in surveillance systems.
healthcare practitioners. To achieve this, hospital surveil- There is an ongoing need for surveillance programs to
lance systems need to be prospective, targeted and risk- identify individual risk factors that contribute to specific
adjusted, to use validated definitions and methods, and to be hospital-acquired infections. For example, diabetes and
open to valid interhospital comparison. Effective surveil- obesity have recently been demonstrated to be independent
lance for hospital-acquired infection is an example of quality predictors of surgical-site infection in CABG surgery.15
improvement: a problem is identified by surveillance (eg, Such findings may direct interventions to decrease incidence
peripheral intravenous line sepsis), the data can suggest an of this infection.
intervention (eg, automatic removal of intravenous cannulas All patient-care staff, in both hospitals and the commu-
at 48 hours), and ongoing surveillance documents the nity, have a role in day-to-day surveillance. Events such as an
effectiveness of that intervention. unexpected case or concern about poor infection control
Recently developed Australian surveillance projects aim to practice should be discussed with infection control staff.
allow valid comparison of rates of specific hospital-acquired
infections between hospitals. The Victorian Infection Infection control team: In the 21st century, the specialty of
Control Surveillance Project (VICSP) has achieved this aim, infection control requires a breadth of expertise that no sole
with each participating hospital accepting standardised practitioner can possess. A multidisciplinary team is needed,
methods and definitions. VICSP has reported comparative including infection control practitioners, a hospital epidemi-
interhospital surgical-site infection rates for CABG and total ologist, biostatistician, infectious diseases physician and
knee and hip replacement surgery.13 In New South Wales, microbiologist, as well as access to a molecular biology
the Hospital Infection Standardised Surveillance (HISS) laboratory. The effectiveness of such a team was demon-
program has also reported data across hospitals.14 strated recently in a 683-bed hospital in the United States;
A further recent advance in hospital infection surveillance an enhanced, integrated infection control program with
is the use of molecular methods to identify and type access to a molecular typing laboratory decreased hospital-