Professional Documents
Culture Documents
infections.3,4 In the USA, the Centers for Medicare and Medicaid areas these organisms are not confined to hospitals but are also
Services has reduced payments to hospitals for certain compli- found in healthy individuals and in the environment. Factors
cations judged to be reasonably preventable e including several contributing to spread include antibiotic over-use in both the
nosocomial infections.5 hospital and the community, veterinary use of antibiotics
allowing resistant organisms to enter the food chain, availability
Predisposing factors in nosocomial infection of over-the-counter antibiotics in some countries, and increased
travel, migration and health tourism.7 Antibiotic resistance is
It is helpful to consider the causes of nosocomial infection under
further discussed in the article on pages 642-648 of this issue.
three headings: patient factors, medical/surgical interventions,
and the hospital microbial environment, as follows. Common syndromes and problems in nosocomial infection
Underlying patient factors Most nosocomial infections fall into a few common categories.
Many patients are intrinsically vulnerable to infection: they are at Specialist units (e.g. burns, transplant, neurosurgery) see
the extremes of age, debilitated, or have an underlying immuno- different infections, in addition to the problems described below.
deficiency (e.g. HIV). Neurological illness may lead to aspiration Infections in transplant patients are discussed in the article on
pneumonia; and immobility and dehydration may encourage pages 000e000 of this issue.
urinary tract infection (UTI). Skin disease and bedsores allow
organisms to enter subcutaneous tissue. In addition, and impor- Line-associated infections and bacteraemia
tantly, the normal flora of all patients includes potential pathogens In most settings, one-quarter to one-third of cases of nosocomial
such as Escherichia coli in the gut and S. aureus in the nose. bacteraemia arise from an intravenous device, a similar propor-
tion are from an unknown source, and the remainder have
Medical and surgical interventions various sources, including the urinary tract, the gut and
Surgical incisions and intravascular devices provide means of ventilator-associated pneumonia.8
entry for pathogens. Urinary catheterization often causes UTIs. Intravenous devices provide both a break in the skin, allowing
Prosthetic joints and heart valves provide a protected niche for entry of organisms, and a protected site for bacterial growth
bacterial growth, and immunosuppressive therapy allows even shielded by a biofilm of platelets, fibrin and bacterial slime. The
low-virulence organisms to assume a dangerously pathogenic role. risk is greater with increasing age of the line, central and multi-
Less obvious ways in which medical therapy can facilitate lumen lines, and poor insertion technique or line care, which can
infection include anaesthesia and ventilation (which predispose lead to infection of the insertion site or hub. Pre-existing skin
to nosocomial pneumonia) and antibiotics (which alter normal disease and colonization with pathogens such as MRSA also in-
flora, reducing resistance to colonization by hospital organisms). crease the risk of infection. The heavy normal flora of the groin
Inadequately disinfected endoscopes can transmit pathogens means that femoral lines generally become infected, despite
such as Mycobacterium tuberculosis and Salmonella, as well as careful insertion technique.
hepatitis viruses.6 Almost 50% of nosocomial bacteraemia isolates are staphy-
lococci (either coagulase-negative or S. aureus, including MRSA)
Hospital microbial environment and these are most likely to be line-associated. The remainder are
Patients may become infected with new organisms, from other mainly Gram-negative (E. coli, Klebsiella, Enterobacter, Proteus
patients, staff or the environment. Transient hand carriage by and Pseudomonas), with small numbers of enterococci and
medical or nursing staff is thought to be the main route of spread, Candida (not bacteria, but generally included in reviews of
but occasionally other routes are involved (e.g. airborne route for ‘bacteraemia’). Gram-negatives may be line-associated, but are
respiratory pathogens). Overcrowding, understaffing and poor more likely to have a urinary source, or to arise from the gut in
hygiene, particularly hand washing, increase the risk of cross- patients with intra-abdominal pathology or neutropenia.
infection.
Antibiotic use in hospital has selected resistant organisms that Presentation and diagnosis: line infections present with septi-
readily colonize and infect patients (Table 1). Many (e.g. caemia or obvious infection of the exit site or tunnel, or are si-
coagulase-negative staphylococci, enterococci) are of relatively lent. Other sequelae (which may manifest only after line
low virulence, but can cause severe illness in compromised pa- removal) include endocarditis and disseminated abscesses (e.g.
tients; some (e.g. MRSA) can be as virulent as their more sen- spinal, ophthalmic). Blood cultures and culture of the line tip are
sitive counterparts. Multi-resistant Gram-negative organisms the usual means of diagnosis.
have increased in relative importance. Such organisms include
members of the Enterobacteriaceae such as E. coli and Klebsiella, Management: line infections (except some with coagulase-
in addition to Pseudomonas aeruginosa. These bacteria often negative staphylococci) are almost never eradicated by antibi-
carry multiple resistance elements, including extended-spectrum otics unless the line is also removed. Infected lines are sometimes
beta-lactamases or carbapenemases that confer resistance to left in situ when intravenous access is difficult, but this increases
broad-spectrum cephalosporins and/or carbapenems such as the risk of septicaemic complications.
meropenem; they may also be resistant to aminoglycosides such
as gentamicin, and to ciprofloxacin. As a consequence, treatment Nosocomial chest infections
of these infections can be extremely difficult, and there may be Pneumonia is responsible for about 25% of all nosocomial in-
significant associated mortality. Global epidemics of such resis- fections, but the diagnosis is often uncertain; in severely ill pa-
tant strains of bacteria are increasingly recognized, and in some tients, there may be other explanations for fever, hypoxia and
Meticillin-resistant Nasal or cutaneous Antibiotic use, skin lesions, Skin/wound, orthopaedic, Occasional case reports
Staphylococcus carriage overcrowding, poor infection intravenous devices, of developing resistance
aureus control bacteraemia, endocarditis, to glycopeptides, which
respiratory tract, prosthetic are the agents of choice
devices for invasive infections
Enterococci and Gut, hospital Antibiotics e particularly Low virulence; typically, Vancomycin-resistant
vancomycin- environment cephalosporins, vulnerable ICU patients enterococci are more
resistant enterococci glycopeptides or renal patients, in whom correctly, but rarely,
use of glycopeptide antibiotics termed ‘glycopeptide-
is common resistant enterococci’; heat
and disinfectant tolerant,
so survive well in hospital
environment
Clostridium Gut, hospital Antibiotics (especially Antibiotic-associated Large outbreaks with fatal
difficile environment, cephalosporins, quinolones), diarrhoea/pseudomembranous cases reported; predisposed
elderly care wards poor hygiene colitis by loss of natural bowel
flora, hence several
suggested ‘alternative’
remedies based on the
principle of replacing this
flora (e.g. live yoghurt,
donor faeces)
Multi-resistant Gut, hospital Antibiotics, poor hygiene, Intra-abdominal, respiratory and Various species (e.g.
Gram-negatives environment, movement of patients between bloodstream infections in Acinetobacter, Klebsiella,
high-dependency hospitals and between vulnerable patients Enterobacter,
units countries Stenotrophomonas);
many are indolent
opportunists, but some
(e.g. Klebsiella,
Pseudomonas aeruginosa)
can cause aggressive,
virulent infections
NB: most nosocomial infections are caused by the patient’s own flora or by cross-infection with more sensitive organisms not listed above.
Table 1
pulmonary infiltrates on radiography (e.g. pulmonary oedema, because of the possibility of outbreaks. Any sputum-smear-
shock lung, segmental collapse). Furthermore, the respiratory positive TB patient who is not adequately isolated may spread
tract of hospitalized patients is often colonized with various or- the organism to other patients; unrecognized multi-drug-resistant
ganisms, and it is difficult to distinguish colonization from TB poses the greatest risk, because these patients are likely to
genuine pneumonia. remain infectious for longer. All contacts are at risk, but the
Most studies implicate a variety of Gram-negative organisms greatest risk of progression to disease is in HIV-positive and other
as the predominant causative agents, with doubts about the severely immunosuppressed contacts.10
significance of culture results as described above. S. aureus, Legionella infection is acquired from the environment; trans-
particularly MRSA, is the only commonly implicated Gram- mission between patients does not occur. The organism normally
positive organism; pneumococci are seldom isolated, but may inhabits water, preferably at 20e40 C; sources in hospitals
be under-diagnosed. Thus, empirical treatment guidelines for include water-cooled ventilation systems (formerly the cause of
nosocomial pneumonia assume Gram-negatives to be the likely large outbreaks), shower heads and tap water. Patients most at
cause and generally recommend agents with activity against risk include the elderly, those with chronic respiratory disease,
Gram-negative organisms.9 and the immunosuppressed, particularly recent transplant re-
cipients. The infection presents as severe pneumonia; the or-
Hospital-acquired tuberculosis (TB) and Legionnaire’s dis- ganism grows poorly, so diagnosis usually depends on urinary
ease: these are rare, but important because of their severity and antigen detection.
them, but it was realized that carriers were often unrecognized. 3 Millar M, Coast J, Ashcroft R. Are methicillin-resistant Staphylococcus
Accordingly, the concept of ‘universal precautions’ has evolved, aureus bloodstream infection targets fair to those with other types of
based on the fact that any patient or sample might contain blood- healthcare-associated infection or cost-effective? J Hosp Infect 2008;
borne viruses and should be handled with this risk in mind. 69: 1e5.
Contaminated sharps waste should be disposed of in specific 4 Duerden B. Opinion on Millar, et al. ‘Are meticillin-resistant Staphy-
yellow, rigid (needle-proof) containers, which are then inciner- lococcus aureus bloodstream infection targets fair to those with
ated. Re-sheathing of needles after use was formerly a major other types of healthcare-associated infection or cost-effective?’.
cause of sharps injuries and is now strongly discouraged. J Hosp Infect 2008; 69: 6e7.
5 Rosenthal MB. Nonpayment for performance? Medicare’s new reim-
Controlling and preventing nosocomial infections bursement rule. N Engl J Med 2007; 357: 1573e5.
6 Spach DH, Silverstein FE, Stamm WE. Transmission of infection by
The methods of controlling and preventing hospital infections are
gastrointestinal endoscopy and bronchoscopy. Ann Intern Med 1993;
as varied and complex as the infections themselves, and range
118: 117e28.
from engineering aspects of hospital design and maintenance, to
7 Sandora TJ, Goldmann DA. Preventing lethal hospital outbreaks of
political decisions concerning vaccination policies, to personal
antibiotic-resistant bacteria. N Engl J Med 2012; 367: 2168e70.
hygiene by staff and patients.12 The major interventions are sum-
8 Jerassy Z, Yinnon AM, Mazouz-Cohen S, et al. Prospective hospital
marized in Table 2, and some have already been discussed above.
wide studies of 505 patients with nosocomial bacteraemia in 1997
Some interventions such as asepsis in wound care and ster-
and 2002. J Hosp Infect 2006; 62: 230e6.
ilization of surgical instruments are long established. Other
9 Masterton RG, Galloway A, French G, et al. Guidelines for the
measures such as universal mandatory hand hygiene or antibi-
management of hospital-acquired pneumonia in the UK: report of
otic restrictions are more recent and may be more challenging to
the working party on hospital-acquired pneumonia of the British
introduce, as they may conflict with long-established custom and
Society for Antimicrobial Chemotherapy. J Antimicrob Chemother
practice.
2008; 62: 5e34.
In recent years, infection control has been seen in the wider
10 Breathnach AS, de Ruiter A, Holdsworth GM, et al. An outbreak of
context of improving patient safety, and there has been recog-
multi-drug-resistant tuberculosis in a London teaching hospital.
nition that prevention of nosocomial infections may depend on
J Hosp Infect 1998; 39: 111e7.
several complementary interventions and control measures. This
11 Warren JW. Catheter-associated urinary tract infections. Int J Anti-
has led to the introduction of ‘care bundles’ for several nosoco-
microb Agents 2001; 17: 299e303.
mial infections: combinations of practices that collectively reduce
12 Ayliffe GA, Fraise A, Geddes AM, Mitchell K. Control of hospital
the risk of infection, along with checklists or audit tools to ensure
infection. 4th edn. London: Arnold, 2000.
compliance.13
13 Aboelela SW, Stone PW, Larson EL. Effectiveness of bundled
behavioural interventions to control healthcare-associated in-
Conclusion
fections: a systematic review of the literature. J Hosp Infect 2007;
Nosocomial infections remain common. While some are prob- 66: 101e8.
ably unavoidable, recent experience has shown that improved
attention and care can lead to significant improvements in FURTHER READING
infection rates. Such improvements need a commitment at every Ayliffe G, Fraise A. Ayliffe’s control of healthcare-associated infection: a
level of healthcare, from politicians to hospital executives to practical handbook. 5th edn. Hodder Arnold, 2009.
ward staff. A Wilson J. Infection control in clinical practice. 3rd edn. Bailliere Tindall,
2006.
WEBSITES
REFERENCES http://www.cdc.gov/hai/. Centers for Disease Control Hospital Infection
1 Smyth ET, McIlvenny G, Enstone JE, et al. Four country healthcare Program; US government web site dealing with all aspects of hospital
associated infection prevalence survey 2006: overview of the results. infections.
J Hosp Infect 2008; 69: 230e48. www.hpa.org.uk. UK Health Protection Agency; includes a section on
2 Plowman R, Graves N, Griffin MA, et al. The rate and cost of hospital healthcare-associated infection. http://www.hpa.org.uk and http://
acquired infections occurring in patients admitted to selected spe- www.gov.uk/phe.
cialties of a district general hospital in England and the national www.his.org.uk. UK Healthcare Infection Society.
burden imposed. J Hosp Infect 2001; 47: 198e209. www.hps.scot.nhs.uk/haiic/index.aspx. Scottish infection control website.