Hospital-Acquired Infections

A hospital-acquired infection is usually one that first appears three days after a patient is admitted to a hospital or other health care facility. Infections acquired in a hospital are also called nosocomial infections.

About 5-10% of patients admitted to hospitals in the United States develop a nosocomial infection. The Centers for Disease Control and Prevention (CDC) estimate that more than two million patients develop hospital-acquired infections in the United States each year. About 90,000 of these patients die as a result of their infections. Hospital-acquired infections usually are related to a procedure or treatment used to diagnose or treat the patient's illness or injury. About 25% of these infections can be prevented by healthcare workers taking proper precautions when caring for patients.

Hospital-acquired infections can be caused by bacteria, viruses, fungi, or parasites. These microorganisms may already be present in the patient's body or may come from the environment, contaminated hospital equipment, health care workers, or other patients. Depending on the causal agents involved, an infection may start in any part of the body. A localized infection is limited to a specific part of the body and has local symptoms. For example, if a surgical wound in the abdomen becomes infected, the area of the wound becomes red, hot, and painful. A generalized infection is one that enters the bloodstream and causes general systemic symptoms such as fever, chills, low blood pressure, or mental confusion.

Hospital-acquired infections may develop from surgical procedures, catheters placed in the urinary tract or blood vessels, or from material from the nose or mouth that is inhaled into the lungs. The most common types of hospital-acquired infections are urinary tract infections (UTIs), pneumonia, and surgical wound infections.

All hospitalized patients are susceptible to contracting a nosocomial infection. Some patients are at greater risk than others—young children, the elderly, and persons with compromised immune systems are more likely to get an infection. Other risk factors for getting a hospital-acquired infection are a long hospital stay, the use of indwelling catheters, failure of healthcare workers to wash their hands, and overuse of antibiotics.

Any type of invasive procedure can expose a patient to the possibility of infection. Common causes of hospital-acquired infections include:

• urinary bladder catheterization
• respiratory procedures
• surgery and wounds
• intravenous (IV) procedures

Urinary tract infection (UTI) is the most common type of hospital-acquired infection. Most hospital-acquired UTIs happen after urinary catheterization. Catheterization is the placement of a catheter through the urethra into the urinary bladder. This procedure is done to empty urine from the bladder, relieve pressure in the bladder, measure urine in the bladder, put medicine into the bladder, or for other medical reasons.

The healthy urinary bladder is sterile, which means it doesn't have any bacteria or other microorganisms in it. There may be bacteria in or around the urethra but they normally cannot enter the bladder. A catheter can pick up bacteria from the urethra and allow them into the bladder, causing an infection to start.

Bacteria from the intestinal tract are the most common type to cause UTIs. Patients with poorly functioning immune systems or who are taking antibiotics are also at risk for infection by a fungus called Candida.

Pneumonia is the second most common type of hospital-acquired infection. Bacteria and other microorganisms are easily brought into the throat by respiratory procedures commonly done in the hospital. The microorganisms come from contaminated equipment or the hands of health care workers. Some of these procedures are respiratory intubation, suctioning of material from the throat and mouth, and mechanical ventilation. The introduced microorganisms quickly colonize the throat area. This means that they grow and form a colony, but do not yet cause an infection. Once the throat is colonized, it is easy for a patient to inhale the microorganisms into the lungs.

Patients who cannot cough or gag very well are most likely to inhale colonized microorganisms into their lungs. Some respiratory procedures can keep patients from gagging or coughing. Patients who are sedated or who lose consciousness may also be unable to cough or gag. The inhaled microorganisms grow in the lungs and cause an infection that can lead to pneumonia.

Surgical procedures increase a patient's risk of getting an infection in the hospital. Surgery directly invades the patient's body, giving bacteria a way into normally sterile parts of the body. An infection can be acquired from contaminated surgical equipment or from healthcare workers. Following surgery, the surgical wound can become infected. Other wounds from trauma, burns, and ulcers may also become infected.

Many hospitalized patients need a steady supply of medications or nutrients delivered to their bloodstream. An intravenous (IV) catheter is placed in a vein and the medication or other substance is infused into the vein. Bacteria transmitted from the surroundings, contaminated equipment, or healthcare workers' hands can invade the site where the catheter is inserted. A local infection may develop in the skin around the catheter. The bacteria also can enter the blood through the vein and cause a generalized infection. The longer a catheter is in place, the greater the risk of infection.

Other hospital procedures that put patients at risk for nosocomial infection are gastrointestinal procedures, obstetric procedures, and kidney dialysis.

Fever is often the first sign of infection. Other symptoms and signs of infection are rapid breathing, mental confusion, low blood pressure, reduced urine output, and a high white blood cell count.

Patients with a UTI may have pain when urinating and blood in the urine. Symptoms of pneumonia may include difficulty breathing and coughing. A localized infection causes swelling, redness, and tenderness at the site of infection.

An infection is suspected any time a hospitalized patient develops a fever that cannot be explained by a known illness. Some patients, especially the elderly, may not develop a fever. In these patients, the first signs of infection may be rapid breathing or mental confusion.

Diagnosis of a hospital-acquired infection is based on:

• symptoms and signs of infection
• examination of wounds and catheter entry sites
• review of procedures that might have led to infection
• laboratory test results

A complete physical examination is conducted in order to locate symptoms and signs of infection. Wounds and the skin where catheters have been placed are examined for redness, swelling, or the presence of pus or an abscess. The physician reviews the patient's record of procedures performed in the hospital to determine if any posed a risk for infection.

Laboratory tests are done to look for signs of infection. A complete blood count can reveal if the white blood cell count is high. White blood cells are immune system cells that increase in numbers in response to an infection. White blood cells or blood may be present in the urine when there is a UTI.

Cultures of blood, urine, sputum, other body fluids, or tissue are done to look for infectious microorganisms. If an infection is present, it is necessary to identify the microorganism so the patient can be treated with the correct medication. A sample of the fluid or tissue is placed in a special medium that bacteria will grow in. Other tests can also be done on blood and body fluids to look for and identify bacteria, fungi, viruses, or other microorganisms responsible for an infection.

If a patient has symptoms suggestive of pneumonia, a chest x ray is done to look for infiltrates of white blood cells and other inflammatory substances in the lung tissue. Samples of sputum can be studied with a microscope or cultured to look for bacteria or fungi.

Once the source of the infection is identified, the patient is treated with antibiotics or other medication that kills the responsible microorganism. Many different antibiotics are available that are effective against different bacteria. Some common antibiotics are penicillin, cephalosporins, tetracyclines, and erythromycin. More and more commonly, some types of bacteria are becoming resistant to the standard antibiotic treatments. When this happens, a different, more powerful antibiotic must be used. Two strong antibiotics that have been effective against resistant bacteria are vancomycin and imipenem, although some bacteria are developing resistance to these antibiotics as well.

Fungal infections are treated with antifungal medications. Examples of these are amphotericin B, nystatin, ketoconazole, itraconazole, and fluconazole.

A number of antiviral drugs have been developed that slow the growth or reproduction of viruses. Acyclovir, ganciclovir, foscarnet, and amantadine are examples of antiviral medications.

Hospital-acquired infections are serious illnesses that cause death in about 1% of cases. Rapid diagnosis and identification of the responsible microorganism is necessary, so treatment can be started as soon as possible.

Hospitals and other healthcare facilities have developed extensive infection control programs to prevent nosocomial infections. These programs focus on identifying high risk procedures and other possible sources of infection. High risk procedures such as urinary catheterization should be performed only when necessary and catheters should be left in for as little time as possible. Medical instruments and equipment must be properly sterilized to ensure they are not contaminated. Frequent handwashing by healthcare workers and visitors is necessary to avoid passing infectious microorganisms to hospitalized patients. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced it would make prevention of nosocomial infections a major goal in 2004 and the coming years. JCAHO, the body that inspects hospitals for quality and accredits them accordingly, issued an alert stating that hospital-acquired infections are seriously underreported. The problem has become more serious for hospitals to address as many bacteria are becoming resistant to antibiotics.

Antibiotics should be used only when necessary. Use of antibiotics creates favorable conditions for infection with the fungal organism Candida. Overuse of antibiotics is also responsible for the development of bacteria that are resistant to antibiotics.

Abscess — A localized pocket of pus at a site of infection.

Candida — A yeast-like fungal organism.

Catheter — A thin, hollow tube inserted into the body at specific points in order to inject or withdraw fluids from the body.

Generalized infection — An infection that has entered the bloodstream and has general systemic symptoms such as fever, chills, and low blood pressure.

Localized infection — An infection that is limited to a specific part of the body and has local symptoms.

Nosocomial infection — An infection acquired in the hospital.

Burke, John P. "Infection Control—A Problem for Patient Safety." The New England Journal of Medicine February 13, 2003: 651-656.

"Hospital-Acquired Infections are Being Underreported." RN March 2003: 16.

"Nosocomial Infection (From the Editor)." Health Care Food & Nutrition Focus June 2003: 2.