Indeterminate toxin or antigen tests should be confirmed with the use of NAAT. However, findings of pseudomembranous colitis are highly suggestive of CDI. Radiographic imaging may be warranted for patients with severe illness and suspected toxic megacolon or perforation. CVC catheter removal should be considered in specific circumstances and depending on the cultured organism.
CVC infected with Candida, S. Antimicrobial therapy and duration are dictated by the specific organism that is cultured and severity of the infection.
Further workup to evaluate for metastatic infections should be considered depending on the implicated organism and persistence of bacteremia after catheter removal. The second set of blood cultures should always be obtained to confirm clearance. Experienced operators should practice good hand hygiene, skin disinfection with chlorhexidine, and maintain aseptic techniques throughout the procedure.
Minimizing the use and duration of indwelling catheters is the most important preventive step. Daily assessment of indications and the need for continued catheterization should be done. Intermittent catheterization is associated with lower rates of CAUTI and should be considered in patients who definitely need it.
In the setting of CAUTI, removal of the urinary catheter is recommended after two weeks of use due to biofilm formation and inadequate response to antimicrobial therapy. Antimicrobial therapy should be based on cultures and susceptibility testing. Providers should use hospital or community antibiograms to direct initial treatment. There is no clear consensus on the use of antiseptic-coated urinary catheters or collection bags or antimicrobial catheter irrigation; in fact, there is suspicion that this may lead to increased antimicrobial resistance.
SSI is treated by debridement of devitalized tissue and drainage of infected fluids, including abscesses.
Anti-microbial therapy should initially be chosen with broad coverage for the most common pathogens associated with the specific site of infection. Preventive measures for developing SSI may be broken down into pre-operative, intra-operative, and post-operative. Pre-operative preventative measures include reducing host-modifiable risk factors, administering pre-operative antibiotics if indicated, and de-colonization of specific pathogens.
Hair removal is not usually necessary, and shaving the area may cause microtrauma and introduce bacteria more deep-seated in the epithelium. Intra-operative measures towards prevention include maintaining euthermia temperature higher than Intra-operative antibiotics may be re-dosed as needed depending on the duration of surgery. Post-operative measures involve maintaining hygiene to the area, monitoring dressings, incision sites, post-operative drains.
Prophylactic postoperative antibiotics may be indicated in dirty or contaminated wound, where there is already a presumed infection, or in immunocompromised patients. If a sample can not be obtained, empiric anti-microbial treatment should be started based on the hospital guidelines and hospital antibiograms for HAP and VAP.
Patients should be reassessed daily for the need for continued anti-microbial therapy and depending on the level of suspicion of disease.
Dual anti-pseudomonal coverage may be necessary based on patient risk factors and the hospital antibiogram to treat VAP. In the setting of suspected aspiration pneumonia coverage for oral anaerobes should be started.
Antibiotics should be de-escalated based on culture results and clinical stability of the patient. If symptoms don't improve within 72 hours or the patient is rapidly deteriorating after appropriate treatment is started, further investigation into complications or alternate sources of infection should be considered.
Steps to prevent VAP pneumonia include limiting exposure to mechanical ventilation, decreasing the duration on the ventilator, titrating to low levels of effective sedation, and early mobilization. If the infection is associated with antibiotic use, the initial step is to discontinue the inciting antibiotic if feasible. Oral vancomycin, oral fidaxomicin, and metronidazole are active against C.
Providers should follow the most recent guidelines for the treatment and management of CDI. Duration of therapy depends on concomitant antibiotic use, the severity of illness, recurrent disease.
Surgical evaluation and fecal microbiota transplantation may be warranted in severe disease. Prevention strategies are targeted toward early detection, prompt isolation, and implementation of contact precautions, proper hand hygiene, environmental cleaning and disinfection, and anti-microbial stewardship.
The differential diagnoses of healthcare-associated infection HAI depend on the presenting symptoms, type of infection, and risk factors for developing a specific kind of infection. Differentiating a community-acquired infection versus one that is attributed to healthcare acquisition is essential because associated pathogens and anti-microbial resistance patterns differ between HAI and non-HAI. Having a correct distinction between HAI and community-acquired infections guides the clinician to treat and manage the patient appropriately.
For this reason, a careful review of symptom onset is essential. Different types of infections develop after a specific exposure, for example, broad-spectrum antibiotic use, presence of a CVC, or urinary catheter. The timing of symptoms can tell us if the infection was present before or after the specific intervention or hospitalization. In this way, many types of HAI can mimic the community-acquired version of the infection. If bacteremia develops in the setting of indwelling CVC, other causes of infection should be ruled out.
Bacteremia may arise from a variety of sources, for example, wound infection, urinary tract infection, pneumonia, and endocarditis. The clinical presentation and timing of symptoms onset should be carefully evaluated, and symptoms should have started in the presence of a CVC or within 48 hours after removal.
Urinary tract infections may present as lower urinary tract infections, such as acute cystitis or urethritis, or upper urinary tract infections, pyelonephritis, nephrolithiasis, and ureteritis. Skin and Soft Tissue Infection SSI : Post-operative fever may occur in atelectasis with pneumonia, urinary tract infection, medication side-effect, or drug reaction.
Other localizing conditions may produce pain at the surgical site but are not necessarily considered SSI, such as wound dehiscence, wound herniation, cellulitis, burns, gas gangrene or myonecrosis, tumor or neoplastic process, and septic thrombophlebitis.
SSI typically develop within 30 to 90 days after surgery. The diagnosis of SSI requires both clinical features of infection plus diagnostic criteria, such as purulent drainage, positive cultures, or radiographic imaging.
The criteria vary depending on the class of infection. Pneumonia: As with other HAI, the timing of onset of respiratory symptoms should guide the clinician to diagnose community-acquired versus hospital-acquired pneumonia.
HAP will have a symptom onset after 48 hours of hospitalization or ventilation. Upper respiratory tract infections may also mimic pneumonia symptoms. Differential diagnoses for VAP include acute respiratory distress syndrome, pneumonitis, pulmonary hemorrhage, pulmonary embolism, infiltrative tumor, and drug reaction.
Hospital-Acquired C. Antibiotic-associated diarrhea not associated with C. Infectious diarrhea may be associated with viral, fungal, or bacterial pathogens.
Antibiotic-associated diarrhea may also be due to S. Other types of HAI outside of the five major groups of HAI, such as soft tissue, upper respiratory tract, central nervous system, and reproductive tract infections are less common but may occur.
In general, any infection in which the symptoms begin after healthcare delivery may be attributed to HAI. The differential is broad and would mimic the community-acquired version of the infection. The prognosis of healthcare-associated infection HAI varies on the type of HAI, the severity of illness, and the implicated pathogen. Worldwide morbidity and mortality are not well established due to limited surveillance and analysis. However, multiple studies over the years allow for estimates of the global burden of HAI.
The mortality, length of stay, and associated costs associated with HAI are discussed below. In the estimated deaths among US hospitals that were associated with HAI were 98, and varied by the type of infection: pneumonia 35, , bloodstream infections 30, , UTI 13, , SSI 8, , and other sites of infection 11, Analysis of surveillance models in a German hospital showed that additional length of hospital stay LOS was sensitive to the location of acquisition and the type of HAI.
Complications of healthcare-associated infection HAI are broad and depend on the type of infection, the severity of illness, and implicated pathogen. The list of complications of each type of HAI can be extensive, below a few of the more common complications of each HAI are listed. Hand hygiene is the most important aspect of infection control and prevention of healthcare-associated infection HAI. Pathogenic microorganisms that are transiently on the healthcare worker are readily removed with routine hand hygiene and limit the risk of transmission to the patient.
Hand hygiene also prevents colonization and infection in the healthcare worker and the contamination of the environment. The World Health Organization has identified five moments in which hand hygiene should always be practiced: [53]. Alcohol-based hand sanitizers are preferred over soap and water washing except when hands are visibly soiled, contact with body fluids after using the toilet, or there is exposure to spore-forming pathogens such as C. Standard precautions should be practiced to protect healthcare workers.
This includes the use of personal protective equipment such as gloves, gowns, masks, and eye protection to protect from blood and body fluids. Transmission based precautions should be used to prevent airborne, droplet, and contact transmission. A fit-tested N respirator should be worn and patient placement in an isolated negative pressure room to prevent airborne transmission.
Surgical masks and physical distancing are precautions to prevent droplet transmission. Patient placement in a single room and healthcare worker gown and gloves are worn to avoid contact transmission of MDRO and C. Aseptic techniques should be practiced for invasive procedures and surgery. Environmental contamination is a potential source of pathogens that may be transmitted through contact.
One study found that hospital water taps, door handles, and working surfaces had the highest number of microbes. Hospital waste often acts as a reservoir for pathogenic bacteria. Antimicrobial stewardship involves monitoring appropriate antimicrobial use and antibiotic resistance and implementing antibiotic control policies. Patients should be informed about the potential risk of developing HAI when receiving care.
Healthcare workers should assess the patient's risk factors for developing a specific infection and identify and address ways to limit modifiable risk factors. Patients with modifiable risk factors should be educated on ways that they can reduce their risk of developing HAI. For example, smoking habits, cleaning, and not shaving the area before a surgical procedure can reduce SSI.
Providers should be careful and cautious with the use of devices and the need for invasive interventions. Patients should be educated on appropriate antibiotic use and indications to prevent potential antibiotic misuse.
At one time, healthcare-associated infection HAI was viewed as an unavoidable risk of care. Progress towards the elimination of HAI is the goal of healthcare teams. Efforts are being made by the World Health Organization to implement infection prevention and control programs and better surveillance systems in developing countries to reduce HAI. Infection prevention and control programs are rooted in quality improvement activities that use protocols and interventions to decrease the risk of acquisition and transmission of infection within healthcare settings.
Infection prevention teams work with healthcare providers and staff to develop, implement, and monitor protocols and interventions that aim to limit HAI. Education of healthcare providers, hand hygiene, cleaning and disinfecting medical equipment, environmental contamination prevention, isolation precautions, and surveillance of data analysis are examples of such interventions. These interventions should start with staff who are directly in contact with the patients, such as nurses, providers, medical technicians, and environmental service staff.
Pharmacists may be involved through the monitoring of antimicrobial stewardship programs to limit inappropriate antibiotic use and help to prevent resistant pathogens. Laboratory technicians can help with keeping track of antibiograms and susceptibility patterns to facilitate antibiotic stewardship programs. Studies have shown that implementing infection prevention and control programs can reduce the length of stay and avoid additional costs.
Most recent studies show a pay-off for healthcare systems to adopting HAI reduction programs. With the growing body of evidence for monitoring HAI within the United States, the prevalence has significantly decreased in the last decade.
The prevalence of pneumonia and CDI had little change in prevalence. This addresses a need for continued improvement in infection prevention and control programs.
This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Affiliations 1 Rosalind Franklin.
Continuing Education Activity This article provides a review of the critical features of nosocomial infections. Introduction Nosocomial infections also referred to as healthcare-associated infections HAI , are infection s acquired during the process of receiving health care that was not present during the time of admission. Epidemiology Nosocomial infections affect a substantial number of patients globally, leading to increased mortality and financial impact on healthcare systems.
Pathophysiology Routes of Transmission Pathogens associated with healthcare-associated infection HAI may have different routes of transmission. Pneumonia Hospital-acquired pneumonia is pneumonia that develops after 48 hours of admission. When these elements are present and practiced consistently, the risk of infection among patients and healthcare personnel is reduced.
The Infection Control Assessment Tools were developed by CDC to assist health departments in assessing infection prevention practices and guide quality improvement activities e. These tools may also be used by healthcare facilities to conduct internal quality improvement audits.
While the same infection prevention elements are included in both the checklist and assessment tool, the facility demographics sections differ slightly. The assessment tool is intended for health department use whereas the checklist is intended primarily for healthcare facility use. Skip directly to site content Skip directly to page options Skip directly to A-Z link. Section Navigation. Facebook Twitter LinkedIn Syndicate. The financial incentive for hospitals to prevent nosocomial infections under the prospective payment system.
JAMA ; Hospital infection control: recent progress and opportunities under prospective payment. Am J Infect Control ; Inglehart JK. The new era of prospective payment for hospitals. New Engl J Med ; In: Daschner F. Proven and unproven methods in hospital infection control: proceedings of an international workshop at Baiersbronn, September , New York: Gustav Fischer Verlag Joint Commission on Accreditation of Hospitals. The Joint Commissions' agenda for change. Public Health Service.
Healthy people national health promotion and disease prevention objectives. PHS CDC definitions for nosocomial infections, National Nosocomial Infections Surveillance System.
Nosocomial infection rates for interhospital comparison: limitations and possible solutions. Infect Control Hosp Epidemiol ; Lederberg J, Shope RE, eds. Emerging infections: microbial threats to health in the United States. This conversion may have resulted in character translation or format errors in the HTML version.
An original paper copy of this issue can be obtained from the Superintendent of Documents, U.
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