Guideline for the management of nosocomial infections

The Southern African Journal of Epidemiology and Infection 2006; 21 (4):152-160 Guideline for the management of nosocomial
infections in South Africa*
A Brink, C Feldman, A Duse, D Gopalan, D Grolman, M Mer, S Naicker, G Paget,
O Perovic, G Richards
Objective: To write a guideline for the management and prevention of nosocomial infections
in South Africa in view of the following: i) nosocomial infections are a common and
increasing problem globally, including South Africa; ii) widely varying standards of
prevention and management of these important infections; iii) increasing and emerging
antimicrobial resistance among commonly isolated pathogens, and iv) the significant
economic burden of these infections on the healthcare system as well as their impact on
patient morbidity and mortality. The main aims of the guideline are to provide
recommendations for the initial choice of antimicrobial agents and the appropriate
management of these infections encompassing the following conditions: i) nosocomial
pneumonia, healthcare-associated pneumonia and ventilator-associated pneumonia; (ii)
nosocomial bloodstream infections; (iii) nosocomial intravascular infections; (iv)
nosocomial urinary tract infections; (v) nosocomial intra-abdominal infections; and (vi)
nosocomial surgical skin and soft-tissue infections. Evidence: Working group of clinicians
from relevant disciplines, following detailed literature review. Recommendations: These
include details of the likely pathogens, an appropriate diagnostic approach, antibiotic
treatment options and appropriate preventive strategies. Endorsement: The guideline
document was endorsed by the South African Thoracic Society, the Critical Care Society of
Southern Africa and the Federation of Infectious Diseases Societies of Southern Africa.
Guideline sponsor: The meeting of the Working Group and the guideline publication were
sponsored by an unrestricted educational grant from Sanofi Aventis South Africa.
Process of guideline development
The complete and detailed background guideline was published in the June 2005 issue of the Southern African The South African Thoracic Society (SATS) was offered an Journal of Epidemiology and Infection (SAJEI 2005; 20: 37-
unconditional educational grant from Sanofi-Aventis to 76 (www.fidssa. co.za), link to guidelines). The guideline develop a guideline for the management of nosocomial presented here is a summarised version, and includes infections in South Africa. Prof Charles Feldman, as Council antibiotic dosages.
Member of SATS, offered to organise the development of such a guideline. On invitation, Prof Guy Richards (Critical Care Society of Southern Africa) and Dr Adrian Brink (Infectious Diseases Society of South Africa) agreed to co- This statement is published for educational purposes only. organise the guideline development.
The recommendations are based on currently available scientific evidence together with the consensus opinion of the Members of the editorial board prepared draft documents on authors and the working group. The guideline is not meant to the various topics. These were circulated initially to the replace clinical judgement, but rather to give logical editorial board for comment and then to a working group framework to the evaluation of patient management.
drawn from professionals around the country, representing the private and public sector and including individuals from Authors of the guideline
various disciplines, viz. physicians, infectious disease specialists, pulmonologists, intensivists, trauma surgeons, Adrian Brink, Charles Feldman, Adriano Duse, Dean cardiothoracic surgeons, clinical microbiologists, and Gopalan, David Grolman, Mervyn Mer, Sarala Naicker, Graham Paget, Olga Perovic, Guy Richards.
A workshop meeting was held at Caesar's Palace, Working group members
Johannesburg, in February 2005 at which the papers were presented to the group, critiqued, and specific final decisions The authors above plus: V Ballhausen, AL Biebuyck, DJ du were taken on the various recommendations. Changes were Toit, PJ du Toit, L Fingelson, P Grolman, G Hammond, E made to the original draft documents by the editorial team, Hodgson, I Hunt, J Kilian, G Kretsmer, L Krige, G Lups, G and the documents were then re-circulated to the workshop Maartens, A Mackinlay, D Muckart, H Pahad, A Pieterse, A group for comment.
Roodt, G Schleicher, MA Seedat, M Senekal, W Sieling, M Sussman, M van der Heiden, H van Straaten, JA Venter, LA Venter, P Williams.
Correspondence to: Dr Adrian J Brink, PO Box 1873, Houghton, 2041Johannesburg. Tel. 011-726-6260, e-mail: [email protected] * Reprinted with the kind permission of the South African Medical Journal.
South Afr J Epidemiol Infect 2006; Vol 21 (4)
Management of nosocomial infections Infection control in developing countries, with particular
time and fairly close contact with patients (within 1 - 2 m) is emphasis on South Africa
required for transmission to occur. Organisms such as Neisseria meningitidis, Streptococcus pneumoniae and Healthcare-associated infections (HAIs) are a cause of Mycoplasma pneumoniae, infections such as pneumonic significant morbidity and mortality in patients receiving plague and streptococcal pharyngitis and viral infections healthcare, and the costs (direct and indirect) of these such as influenza virus infections are spread via this route.
infections deplete the already limited financial resources ! Airborne spread occurs when droplets less than 5
allocated to healthcare delivery.
microns in size are produced by coughing, sneezing, or consequent to procedures such as bronchoscopy and ! Approximately one in seven patients entering South suctioning. These small droplets desiccate to form droplet African hospitals are at high risk of acquiring an HAI.
nuclei that remain suspended in the air for long periods and ! Lower respiratory tract infections, urinary tract infections, travel long distances. The airborne nature of these bloodstream infections and post-surgical infections account contaminated droplet nuclei enables them to infect for the majority (about 80%) of HAIs.
susceptible hosts several metres away from where they are ! Indiscriminate and inappropriate use of antibiotics leads produced. Organisms typically spread by this route include to the selection of antimicrobial-resistant organisms.
Mycobacterium tuberculosis, measles virus and varicella- ! Bi-directional flow of resistance from hospitals into zoster virus.
communities and vice versa makes it difficult to distinguish community-acquired multidrug-resistant pathogens from Prevention and control of HAIs those that are nosocomial.
! To counter the emergence and spread of multidrug- ! All patients presenting to healthcare facilities, irrespective resistant pathogens the only feasible strategy is the of their diagnoses, must be treated using standard implementation of an effective and integrated programme precautions. These include hand washing (using either that involves antimicrobial resistance surveillance, a rational aqueous or non-aqueous hand decontamination agents), antimicrobial-use programme, and infection control.
wearing of personal protective equipment as necessary ! Infection control activities on their own are primarily (gloves, masks, gowns, and eye protection), safe disposal of centred around the goal of decreasing or preventing the waste, appropriate cleaning, disinfection or sterilisation of transmission of nosocomial (healthcare-associated) equipment and patient-care items as well as appropriate pathogens to patients and staff, irrespective of whether these decontamination of linen and the environment. Stringent organisms are multidrug-resistant or not.
attention to aseptic technique is crucial.
! To further reduce and control the emergence of ! In addition to standard precautions, additional patient antimicrobial resistance it is therefore essential that infection isolation procedures (contact isolation, droplet isolation and control activities be coupled with an optimised, effective and airborne isolation) are required, depending on the mode of highly restrictive antimicrobial-use programme.
transmission of the suspected micro-organism.
! Most importantly, such a programme must be realistic, ! The judicious use of preoperative prophylaxis to prevent adaptable, and take cognisance of the severe limitation of post-surgical infections cannot be overemphasised.
resources characteristic of many developing countries.
Infection control and prevention programmes In order to develop simple, effective and sensible infection control interventions it is necessary to understand the sources ! The efficacy of infection control and prevention of HAIs and their modes of transmission.
programmes in decreasing HAIs (especially in outbreak situations), patient morbidity and mortality, and cost to Transmission of HAIs healthcare institutions is well established.
! Regrettably the implementation and/or quality of such HAIs are transmitted in three ways.
programmes is variable across South African healthcare ! Contact spread involves skin-to-skin contact and the
direct physical transfer of micro-organisms from one patient ! Good and standardised surveillance systems for HAIs are to another or by a healthcare worker (HCW). Examples of not currently in place in most South African healthcare direct contact include patient examination, with cross- infection occurring from contaminated hands of the HCW. ! HAIs are under-reported and data on antimicrobial Although hand washing is singly the most important, resistance trends are only available for academic hospitals evidence-supported intervention for the prevention of and from private-sector microbiology laboratories.
transmission of organisms as a consequence of direct contact, ! It is crucial that the true impact of HAIs and of compliance is only 40% in intensive care units (ICUs). antimicrobial resistance on healthcare delivery be Indirect contact refers to contact with inanimate objects or documented accurately and that strategies be formulated to surfaces such as bedpans, thermometers, etc that are minimise these problems.
contaminated with microbes. Organisms such as methicillin- ! Education on infection control and correct antimicrobial resistant Staphylococcus aureus, vancomycin-resistant prescribing is often neglected in undergraduate curricula of enterococci, extended-spectrum beta-lactamase (ESBL)- the health sciences.
producing Gram-negatives, and Clostridium difficile are typically spread by direct and/or indirect contact routes.
Multiple interventions are available that may help to ! Droplet spread involves spread of pathogens by
minimise or control nosocomial infections and the respiratory droplets produced during coughing, sneezing, development and spread of microbial resistance to talking, respiratory therapy and procedures such as antimicrobial agents. Strategies to prevent and control the bronchoscopy. Respiratory droplets larger than 5 microns do emergence and spread of antimicrobial-resistant micro- not remain suspended (airborne) in the air for long periods of organisms may be grouped into those aimed at optimising South Afr J Epidemiol Infect 2006; Vol 21 (4)
A Brink, C Feldman, A Duse, et al antimicrobial use and those preventing the transmission of ! An increase in multidrug-resistant Escherichia coli.
! Emerging resistance among Gram-positive isolates including an increased prevalence of methicillin-resistant S. Interventions aimed at optimising antimicrobial use aureus (MRSA) and emergence of glycopeptide-resistant enterococci (GRE).
! Optimising antimicrobial prophylaxis for operative procedures.
Antibiotic resistance is an inevitable consequence of the ! Optimising the choice and duration of empirical inappropriate use of antibiotics, and impacts on every hospital to varying degrees.
! Improving antimicrobial prescribing by educational and administrative means.
Risk factors for inappropriate antibiotic use ! Monitoring and providing feedback on antibiotic resistance.
! Not using local epidemiological and antibiotic ! Defining and implementing healthcare delivery system guidelines for important types of antimicrobial use.
! Use of broad-spectrum antibiotics when not absolutely necessary.
Interventions aimed at preventing nosocomial transmission ! Treatment of contamination or colonisation rather than of resistant organisms invasive infection.
! Inappropriate surgical prophylaxis.
! Developing systems to recognise and report trends in ! Excessive antimicrobial treatment (i.e. continuing antimicrobial resistance within institutions.
antibiotics when infection is cured).
! Developing systems to rapidly detect and report resistant micro-organisms in individual patients and ensuring rapid Recommendations for the antimicrobial management of response by caregivers.
! Increasing adherence to basic infection control policies and procedures.
! Early appropriate empirical antibiotic therapy for severe ! Incorporating detection, prevention, and control of nosocomial infections reduces mortality.
antimicrobial resistance into institutional strategic goals and ! Timeous broad-spectrum empirical therapy must be providing the required resources.
utilised for nosocomial infections until the pathogen is ! Developing a plan for identifying, transferring, discharging, and readmitting patients colonised with specific ! Prescribe an initial antibacterial regimen that will cover the most likely pathogens associated with infection, based on local surveillance (‘ know your bugs').
As we are seeing increasing numbers of vulnerable ! However, increased use of antimicrobial therapy with this individuals at our healthcare facilities we should be practice (‘getting it right the first time') may inevitably lead continuously aware of the consequences of poor infection to increase in resistance.
control practices and the misuse and abuse of the ! Therefore antibiotic therapy is subsequently scaled down, antimicrobial armamentarium. Good infection control de-escalated or tailored to a narrow spectrum once identity practices can usually contain the majority of infections, and susceptibility patterns of the infecting pathogen(s) are including those caused by multidrug-resistant organisms, using simple measures. An infection control programme is as ! Shorter duration of therapy is currently recommended effective as the personnel responsible for its implementation: because antibiotics that are continued after an infection has dedication, knowledge, education, constructive feedback and resolved are harmful in that they predispose to superinfection sensitivity to the needs of both patients and healthcare with more resistant bacteria.
workers are essential. Furthermore, rational and restrictive antibiotic prescribing strategies together with continuing General principles for the duration of antibiotic treatment developments in the search for new antimicrobials must ensure that these so-called miracle drugs will retain their ! If a response to a particular antibiotic is seen within 48 value in the treatment of infections in years to come. hours, treatment should be continued for another 5 - 7 days Education in infection control practices, nosocomial after which it should be discontinued.
infection epidemiology, and antimicrobial resistance is ! Prolonged use beyond a week is therefore strongly critically important. The development of these guidelines is a discouraged for most nosocomial infections.
step in the right direction.
! If no response is seen in 48 hours: ! Discontinue the antibiotic Antimicrobial resistance in nosocomial infections in
! Re-culture the patient South Africa
! Review source control! Switch to another class of antibiotic.
In South Africa the following patterns of antimicrobial ! If septic markers worsen on an antibiotic, resistance resistance have recently been noted: should be considered and a change to another class also ! A dramatic increase in ESBL production, particularly in Klebsiella and Enterobacter spp.
! An increase in carbapenem resistance, including Measures to reduce nosocomial infections multidrug resistance in Pseudomonas aeruginosa and Acinetobacter baumanii.
In the past not enough attention was given to prevention of ! Emergence of carbapenem resistance in strains of infection. Accepted practices include: Enterobacter spp and Klebsiella pneumoniae.
! Elevation of the head of the bed in ventilated patients South Afr J Epidemiol Infect 2006; Vol 21 (4)
Management of nosocomial infections ! Perioperative normothermia hospital admission that was neither present nor incubating at ! Restriction of blood transfusions the time of admission to hospital.
! Early enteral nutrition ! VAP is a pneumonia occurring in a patient undergoing ! Avoidance of urinary catheters wherever possible mechanical ventilation that was neither present nor ! Recently, intensive insulin therapy in critically ill patients incubating at the time of intubation (occurring > 48 hours has been shown to reduce mortality after intubation).
! Implementation of special ‘programmes' such as for the ! Healthcare-associated pneumonia (HCAP) is a prevention of ventilator-associated pneumonia (VAP) or pneumonia occurring in a patient who has: (i) been central venous catheter infections.
hospitalised in an acute care hospital for 2 or more days within 90 days of the infection; (ii) resided in a nursing home Dilemmas in the antimicrobial management of nosocomial or long-term care facility (LTCF); or (iii) received intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection, or attended a ! Combination versus monotherapy - ‘should antibiotics be hospital or haemodialysis clinic.
! There is no evidence that a combination of antibiotics Microbiology of nosocomial pneumonia increases efficacy or decreases resistance, particularly when using the newer antimicrobial agents such as the ! Early-onset bacterial NP occurring within the first 4 days 4th generation cephalosporins (i.e. cefepime), in patients with no risk factors for multidrug-resistant betalactam/betalactamase inhibitor combination agents bacteria is more frequently due to S. pneumoniae, (i.e. piperacillin/tazobactam), fluoroquinolones (i.e. Haemophilus influenzae, methicillin-sensitive S. aureus and ciprofloxacin, levofloxacin) and the carbapenems (i.e. Moraxella catarrhalis and antibiotic-sensitive aerobic, enteric Gram-negative bacilli. The latter include ! Controversy still currently exists with regard to Enterobacter spp, E. coli, Klebsiella spp, Proteus spp, and whether mono- or combination therapy is optimal for Serratia marcescens (‘core pathogens').
pseudomonal infections, particularly in the critically ill ! Late-onset bacterial NP can occur with the same pathogens but is more commonly due to MRSA and ! Antibiotic cycling ‘should antibiotics be rotated?' multidrug-resistant pathogens including Pseudomonas spp, ! Antibiotic cycling has been suggested as a means of Acinetobacter spp and Klebsiella spp (including isolates reducing antibiotic pressure and selection of resistant producing ESBLs).
mutants. A recent review of antibiotic cycling or ! The elderly residents of LTCFs have a spectrum of rotation concluded that studies do not permit reliable pathogens that more closely resemble that of late-onset HAP conclusions regarding efficacy of cycling. Therefore or VAP than early-onset HAP.
routine implementation of cycling as a means of reducing antibiotic resistance rates is currently not ! The most commonly used clinical definition of NP A systematic approach in selecting an antibiotic for includes the following: ! New or progressive radiographical shadowing plus at least two of the following: A systematic approach in selecting an antibiotic promotes ! Fever > 38.3ºC or hypothermia < 35ºC appropriate antimicrobial use. The following should be ! Leukocytosis > 12 x 109/l or leukopenia < 4 x 109/l ! Purulent respiratory secretions.
! Which pathogens are likely to be encountered? ! Although a controversial area, more recent studies and ! What are the likely susceptibility patterns of these guidelines suggest that invasive diagnostic techniques are not essential or routinely recommended for diagnosis of VAP.
! What is the antimicrobial spectrum of the chosen ! A fresh specimen of lower respiratory secretions should be submitted at the time of clinical diagnosis of possible NP (eg. ! Use appropriate dosing schedules based on the through a sterile suction catheter in patients who are pharmacokinetic and pharmacodynamic properties of the intubated), before initiating antibiotic treatment.
chosen agent.
! A chest radiograph, blood cultures and evaluation of ! What are the pharmacological considerations in the oxygenation should also be undertaken and may be helpful in management of these cases.
! Direct therapy to a narrow spectrum once microbiology results are available.
! But foremost, always consider whether an antibiotic is really necessary.
! Initiate antibiotics as soon as possible once the presence of an active infection is suspected as the early initiation of Management of nosocomial pneumonia, healthcare-
antibiotics (within 24 hours and preferably 12 hours) to associated pneumonia, and ventilator-associated
which the causative organisms are sensitive is associated with the best outcome.
! In the choice of empirical antibiotic therapy, consideration should be given to which antibiotics the patient has had in the recent past; it is preferable that an agent from a different class ! Nosocomial pneumonia (NP) or hospital-acquired pneumonia (HAP) is a pneumonia occurring > 48 hours after ! Factors to consider in empirical therapy include: South Afr J Epidemiol Infect 2006; Vol 21 (4)
A Brink, C Feldman, A Duse, et al ! Whether the pneumonia is of ‘early' or ‘late' onset ! The severity of illness of the individual patient, including a consideration of whether the patient is in or ! The most important currently recommended preventive out of the ICU, and measures for VAP are: ! Whether there are any specific risks factors for infection with severe Gram-negative pathogens such as ! Application of general infection control measures Acinetobacter and Pseudomonas spp.
! General aseptic techniques ! In patients not in an ICU, with an early and/or mild to ! Judicious antibiotic use moderately severe NP, and without specific risk factors for ! Semi-recumbent patient positioning resistant pathogens such as Pseudomonas and Acinetobacter ! Oral endotracheal tube spp, initial antibiotic treatment should target the so-called ! Oral gastric tube ‘core pathogens', which may be accomplished with the ! Aseptic tracheal suctioning following various agents: ! Avoiding unplanned extubation ! 3rd generation cephalosporins, particularly in regional ! Less frequent ventilator tube changing centres outside the central academic and private sectors ! Heat and moisture exchangers with bacteriological (i.e. ceftazidime, ceftriaxone, or cefotaxime) Management of nosocomial bloodstream infections
! Group 1 carbapenem (i.e. ertapenem) ! Fluoroquinolones (i.e. ciprofloxacin or levofloxacin), particularly if there is severe allergy to beta-lactams.
! Bloodstream infection is referred to as being primary ! In patients with additional risk factors for specific when there is no obvious source, or secondary when arising pathogens, cover for the ‘core pathogens' and add specific as a complication of infection elsewhere.
treatment indicated below, if also required: ! Anaerobes - piperacillin/tazobactam or ertapenem Microbiology of nosocomial bloodstream infections alone will be sufficient, or add metronidazole or clindamycin to cephalosporin- or fluoroquinolone- ! The micro-organisms responsible include Gram-positive containing regimens and Gram-negative bacteria and/or fungi.
! S. aureus - for methicillin-sensitive isolates add ! The most common Gram-positive organisms include S. cloxacillin and for methicillin-resistant isolates add a aureus, coagulase-negative staphylococci and enterococci glycopeptide (teicoplanin or vancomycin) or linezolid ! The most common Gram-negative organisms include ! ESBL-producing isolates - ertapenem.
Enterobacter spp., P. aeruginosa, E. coli, Klebsiella spp, and ! In patients with severe HAP, particularly those treated in the ICU, cases with VAP and cases with risk factors for infections with resistant Gram-negative pathogens, treatment should be instituted using one of the following agents: ! 4th generation cephalosporin (i.e. cefepime) ! Seek a potential source of origin.
! Institute appropriate source control measures.
! The importance of source control cannot be ! Group 2 carbapenem (i.e. meropenem or ! Initiate appropriate antimicrobial therapy.
! Fluoroquinolone (ciprofloxacin or levofloxacin) ! Give suitable supportive interventions and care.
! ± combinations of the above, such as with the addition ! Factors involved in the initial antimicrobial choice should of an aminoglycoside ! Add vancomycin only if MRSA is strongly suspected. ! Consideration of the site of infection Alternatives include teicoplanin and linezolid. There is ! Knowledge of prevalent and likely pathogens and their some emerging evidence of the possible advantage of susceptibility patterns linezolid over vancomycin for the treatment of proven ! Whether or not the patient is immunosuppressed.
HAP or VAP due to MRSA.
! Specific risk factors for resistant pathogens such as Management of nosocomial intravascular infections
Pseudomonas and Acinetobacter spp. include: ! Recent antibiotic treatment (preceding 90 days) ! Present hospitalisation for a period of > 5 days! Structural lung disease ! Catheter colonisation: growth of > 15 colony-forming ! High levels and frequency of antibiotic resistance in the units (semi-quantitative culture) or > 10 colony-forming community or the specific unit units (quantitative culture) from a proximal or distal catheter ! Immunosuppression segment in the absence of local or systemic infection.
! Local infection: erythema, tenderness, induration or purulence within 2 cm of the skin-insertion site of the Duration of therapy catheter.
! Catheter-related bloodstream infection (CRBSI): ! The general consensus is that treatment of NP, including isolation of the same organism (i.e. the identical species as VAP, has traditionally been longer than is required and the per antibiogram) from culture (semi-quantitative or currently recommended treatment duration is 5 - 7 days.
quantitative) of a catheter segment and from the blood of a patient with accompanying clinical symptoms and signs of South Afr J Epidemiol Infect 2006; Vol 21 (4)
Management of nosocomial infections bloodstream infection and no other apparent source of Duration of central venous catheter (CVC) use ! The duration of CVC use has remained controversial.
Microbiology of nosocomial intravascular infections ! Several studies have shown the duration of catheterisation to be a risk factor for infection.
! Coagulase-negative staphylococci ! Scheduled replacement remains widely practised.
! S. aureus ! No catheter should be left in place longer than absolutely ! Candida spp ! Acinetobacter spp ! Over the past few years, antimicrobial-impregnated ! P. aeruginosa catheters have been introduced in an attempt to limit catheter- ! Stenotrophomonas maltophilia related infections (CRIs) and increase the time that CVCs can ! Klebsiella spp safely be left in place.
! Enterobacter spp! S. marcescens ! Citrobacter freundii! Enterococcus spp ! The protocol for insertion and maintenance of CVCs and ! Bacillus spp. (especially JK strains) recommendations regarding insertion, maintenance and use of intravascular devices in general, may be found in the original publication (www.fidssa.co.za).
! Strict adherence to hand washing and aseptic technique ! The clinical features are generally nonspecific and include remains the cornerstone of prevention of CRI.
fever, rigors, hypotension and confusion.
! Infusion therapy teams. ! Fundoscopy should always form part of the clinical ! Maximum sterile barriers with use of gloves, gowns, masks, cap and large drape for line insertion.
! Blood cultures are central to the diagnosis of CRBSI.
! Cutaneous antimicrobials and antiseptics for skin ! Paired quantitative cultures, which involve taking blood decontamination before line insertion.
from both the catheter and a peripheral site, may be ! Dressing: there has been ongoing debate concerning the particularly useful where luminal colonisation is best method of catheter dressing.
predominant.
! The most widely used laboratory technique for culturing Management of nosocomial urinary tract infections
the catheter is the semi-quantitative roll-plate method.
! Newer diagnostic culture techniques include the endoluminal brush and the Gram's stain and acridine-orange leukocyte cytospin (AOLC) test.
The urinary tract is usually sterile except for the distal urethra.
! Colonisation is defined as the presence of micro- ! Treatment depends on the stage of infection and the organism/s in the urine without clinical manifestations.
! Urinary tract infection (UTI) is defined as invasive disease ! As a general rule, if CRBSI is suspected, the catheter must by micro-organisms, inducing an inflammatory response and be removed and replaced only if necessary.
symptoms and signs such as fever >38 C, urgency, ! Most of the infectious complications are self-limited and frequency, and dysuria without any other cause.
resolve after removal of the catheter.
! Nosocomial urinary tract infection (NUTI) refers to a UTI ! Empirical antibiotic therapy is not recommended unless acquired in a hospital setting.
there are specific indications. Indications for antibiotic therapy include: Microbiology of NUTI ! Persistent sepsis despite catheter removal! Evidence of septic thrombosis of the great veins ! Gram-negative pathogens, especially E. coli (50% of ! Clinical or echocardiographic evidence of endocarditis infections), also Klebsiella, Proteus, Enterobacter spp.
! Metastatic foci of infection ! Underlying valvular heart disease (especially ! S. aureus (including MRSA) prosthetic valves) ! Coagulase-negative staphylococci.
! Underlying immunosuppressed state.
! In the setting of uncomplicated S. aureus CRBSI, the ! Enterococcus faecalis.
catheter should be removed and at least 2 weeks (and ! P. aeruginosa.
preferably 4 weeks) of parenteral antibiotics given because of ! Candida spp.
a higher relapse rate with shorter courses.
! Urinary tract pathogens such as S. marcescens and ! Systemic antifungal therapy (together with removal of the Burkholderia cepacia have special epidemiological catheter) should be given in all cases of catheter-related significance; their isolation from catheterised patients candidaemia in view of the potentially significant sequelae. suggests acquisition from an exogenous source.
Amphotericin B and fluconazole (except for fluconazole-resistant organisms such as Candida glabrata and C. krusei) for at least 14 days have been shown to be equally effective. Newer antifungal agents such as voriconazole may also be ! Non-catheterised patients ! In non-catheterised patients, significant bacteriuria associated with signs and symptoms of infection.
South Afr J Epidemiol Infect 2006; Vol 21 (4)
A Brink, C Feldman, A Duse, et al ! Catheterised patients ! The treatment should be shorter for UTIs without ! Diagnosis of UTI in catheterised patients is problematic parenchymatous infection or in patients without a urinary ! Clinical symptoms are the key to diagnosis of infection catheter, for a minimum of 7 days.
in catheterised patients.
! Pyelonephritis requires a 10 - 14-day treatment regimen.
! Symptoms indicative of infection in immunocompetent patients include fever and haematuria.
! There is no indication for systemic antifungal treatment in Candida spp. colonisation. Removing or changing the Urinary colonisation: urinary catheter is mandatory in Candida spp. colonisation.
! Candiduria may be a marker for disseminated candidiasis ! This is not an indication for systemic antibiotic treatment, in ICU patients presenting with several colonised sites, in whether the patient is catheterised or not, diabetic, elderly, or which case patients should be treated with systemic presenting with urinary bladder dysfunction due to antifungals (amphotericin B as continuous infusion or ! Nevertheless treatment of urinary colonisation may be ! An amphotericin B bladder washout may be useful where necessary in some specific cases: continued catheterisation is required and there is no evidence ! When it poses a risk of morbidity and mortality in of upper urinary tract infection.
neutropenic, immunosuppressed, and pregnant ! A positive blood culture warrants systemic therapy as ! In patients in a preoperative situation: surgery and urological explorations, implanting prostheses.
! In patients with a joint, vascular, or cardiac prosthesis, when undergoing invasive procedures.
! The urinary catheter should be removed as soon as it is no longer necessary, or changed when drainage is mandatory.
! The indications for an indwelling urinary catheter and its duration must be limited and reassessed every day.
All bacterial NUTIs should be treated, irrespective of ! The isolation of infected or colonised catheterised patients whether the patient has a urinary catheter or not.
is recommended.
! It is strongly recommended that hands be disinfected with Antibiotic therapy: a hand sanitiser.
! For catheterised patients: ! In patients who are not severely ill: ! It is mandatory to use closed systems ! Insertion of a permanent catheter must be performed ! Fluoroquinolones (ciprofloxacin, levofloxacin) under strict aseptic technique ! A 2nd (cefuroxime) or 3rd generation cephalosporin ! Urine bags must be kept below the patient for gravity (cefotaxime, ceftriaxone, ceftazidime) which may be preferable in pregnant women Management of nosocomial intra-abdominal infections
! Patients can be switched to oral therapy with a fluoroquinolone if culture results support the change of ! The switch to oral therapy can be made when the patient Nosocomial intra-abdominal infection (IAI) is defined as an has no nausea or vomiting, no fever and no evidence of IAI occurring more than 48 hours after hospital admission that was neither present nor incubating at the time of the ! Once culture results are known, antibiotic therapy can patient's visit or admission to hospital. It may be be adjusted if required.
postoperative or non-postoperative.
! In patients who are severely ill with urosepsis: ! 3rd generation cephalosporin (cefotaxime, ceftriaxone, Microbiology of nosocomial intra-abdominal infections ! 4th generation cephalosporin (cefepime) ! The most common organisms encountered are Gram- negative bacilli (E. coli, P. aeruginosa, A. baumanii, ! Amikacin or another aminoglycoside (monitor levels) Klebsiella spp.), Gram-positive cocci (enterococci, S. ! Fluoroquinolone (ciprofloxacin, levofloxacin). Avoid aureus), anaerobic bacteria (Bacteroides spp.) and fungi in pregnancy and children and rather consider a 3 or 4 (Candida spp.) generation cephalosporin ! Commonly encountered resistant organisms are: ! If infection with an ESBL-producing micro-organism ! ESBL-producing Klebsiella and Enterobacter spp. is suspected, treatment with a carbapenem (e.g. Including E. coli ertapenem) should be initiated. This is particularly ! Enterococci, including those that are glycopeptide- likely to occur in elderly residents of long-term care resistant although these are infrequent in South Africa facilities. Carbapenems may also be used as part of ! P. aeruginosa directed therapy based on microbiological testing.
! A. baumanii! S. aureus, especially those resistant to cloxacillin Duration of treatment ! Coagulase-negative staphylococci (CoNS) ! This depends on the site of infection.
! Candida spp South Afr J Epidemiol Infect 2006; Vol 21 (4)
Management of nosocomial infections ! Device-associated infections are frequently due to SSIs involving fascia and muscle with or without superficial resistant S. aureus, CoNS, E. faecalis and E. faecium (including glycopeptide-resistant species), ESBL ! Superficial SSIs occur within 30 days of a surgical producers and fungi.
operative incision.
! Deep SSIs usually occur within one month of the operation, but may present as much as one year later with implants or prostheses.
! Surgery remains the mainstay of treatment.
! Source control is the cornerstone in treating these Microbiology of nosocomial surgical skin and soft-tissue infections successfully and failure to achieve this is associated with a very high mortality rate.
! Antibiotic therapy should be commenced empirically ! The vast majority of SSIs are caused by skin commensals, based on knowledge of the common causative organisms, usually S. aureus and coagulase-negative staphylococci surveillance data, and the prevalence and sensitivity of organisms within each unit.
! Patients who have recently been hospitalised or on ! Where possible, therapy should be culture-driven.
antibiotics, those currently in hospital and those from LTCFs ! In this regard cultures should be performed initially and at are at risk for infection with more resistant organisms such as each re-look laparotomy.
methicillin-resistant S. aureus (MRSA) or resistant Gram- ! There is also emerging evidence that antifungal preventive negative organisms, Klebsiella spp., Enterobacter spp, therapy (amphotericin B or fluconazole) may be beneficial Pseudomonas spp, etc.
especially in cases of necrotising pancreatitis and in patients ! In patients undergoing hollow visceral or mucous with complicated IAIs, i.e. those with delayed initial surgery, membrane surgery, the endogenous flora usually cause those with anastomotic dehiscence, those requiring multiple subsequent infections. Usual pathogens are Gram-negative re-look procedures and those who have received multiple aerobic bacilli, enterococci, and occasionally anaerobes. courses of antibiotics.
Infections by staphylococci, Pseudomonas, Proteus, ! The Gram-negative fluoroquinolones (ciprofloxacin, Clostridia, streptococci and Candida species are also not levofloxacin) and cephalosporins have inadequate anaerobic activity when used as monotherapy.
! In patients who have been in ICU additional pathogens to ! Additional anaerobic cover is unnecessary with the consider besides MRSA and Pseudomonas spp are carbapenems or with piperacillin/tazobactam.
Enterobacter and Acinetobacter spp.
! In cases of suspected or confirmed ESBL infections, the carbapenems, and in particular ertapenem, are the agents of choice.
! Monotherapy is adequate for Gram-negative sepsis. Some ! Debridement and source control are essential.
practitioners may add an aminoglycoside or quinolone in the ! Culture is mandatory for all SSIs.
case of pseudomonal sepsis although the evidence for this ! If the SSI is superficial and there is no evidence of practice is lacking.
systemic sepsis, an antibiotic is not necessary. Otherwise the ! A glycopeptide (teicoplanin or vancomycin) should be antibiotic choice is determined by sensitivity or the potential added empirically, should there be a significant chance of for resistance and the site of surgery.
staphylococcal infection (MRSA or CoNS). De-escalation is ! Organisms cultured from patients who have been essential if the organism is proved to be Gram-negative or if it hospitalised or on antibiotics recently, those currently in is sensitive to less broad-spectrum agents.
hospital and those from LTCFs are particularly likely to be ! In the scenario of nosocomial IAI, where cultures reveal resistant. If Gram-positive organisms are isolated, a an isolated enterococcal infection, this should be treated glycopeptide (teicoplanin or vancomycin) or linezolid is according to sensitivity.
reasonable until sensitivities are available. If Gram-negative, ! Linezolid should be reserved for VRE and VREF a broad-spectrum agent such as a carbapenem, infections, but may be used as second-line therapy for piperacillin/tazobactam, fluoroquinolone (ciprofloxacin, staphylococcal infection, which does not respond to levofloxacin) or cefepime is indicated. De-escalate antibiotic glycopeptide therapy (review source control).
therapy whenever possible.
! In patients who have had hollow visceral surgery or Duration of therapy mucous membrane surgery, amoxycillin/clavulanate or a 2 generation cephalosporin (cefuroxime) or a fluoroquinolone Duration should be guided by clinical response and shorter courses of antibiotics are now advocated, with no evidence Metronidazole may be added as indicated. Alternatively having shown that therapy beyond 5 - 7 days is beneficial.
ertapenem may be an option.
! If resistance is likely, broad-spectrum agents may be Management of nosocomial surgical skin and soft-tissue
considered before availability of sensitivity.
! Preoperative antiseptic washing has been shown to ! Surgical site infections (SSIs) may be divided into organ decrease the skin microbial count, but there is no definitive or body cavity infections and skin/skin-related structures/soft evidence that this decreases postoperative wound infection.
tissue infections.
! Preoperative hair removal should be performed as close to ! SSIs may be further divided into those that are superficial, the operating time as possible. Clippers are preferable to i.e. involving only skin and subcutaneous tissue, and deep South Afr J Epidemiol Infect 2006; Vol 21 (4)
A Brink, C Feldman, A Duse, et al ! Proper surgical site preparation with chlorhexidine-based, Table 1: Currently recommended antibiotic dosing
alcohol-based or iodine-based antiseptic solutions is essential.
! Apply guidelines for theatre and instrument preparation.
! Amikacin, 20 mg/kg daily ! The wearing of scrub suits, surgical caps, shoe covers, ! Amoxycillin/clavulanate, 1.2 g 8-hourly! Amphotericin B, 0.75 - 1 mg/kg daily gowns, masks and gloves is standard worldwide.
! Ampicillin, 1 g 4 - 6-hourly‡ ! Meticulous adherence to asepsis is essential.
! Caspofungin, 70 mg loading followed by 50 mg daily ! The exact choice of agent for preoperative hand ! Cefepime, 1 - 2 g 8- or 12-hourly washing/scrubbing has not been shown to have a significant ! Cefotaxime, 1 - 2 g 8- or 12-hourly impact on SSI; alcohol, iodine and chlorhexidine solutions ! Ceftazidime, 1 - 2 g 8- or 12-hourly are all acceptable. Scrubbing itself is only of value under the ! Ceftriaxone, 1 - 4 g daily nails and to remove macroscopic organic matter.
! Cefuroxime, 1.5 g 8-hourly Preoperative MRSA screening for high-risk elective ! Ciprofloxacin, 400 mg 8-hourly surgical cases may be necessary including patients ! Clindamycin, 600 mg 6-hourly! Cloxacillin, 1 g 4- or 6-hourly transferred from other hospitals and institutions.
! Ertapenem, 1 g daily! Fluconazole, 800 mg 1st day followed by 400 - 800 mg daily Prophylactic antibiotic usage ! Gentamicin, 5 - 7 mg/kg daily! Imipenem/cilastatin, 500 mg or 1 g 6-hourly ! The choice of antibiotic depends on the site of surgery and ! Levofloxacin, 750 mg daily or 500 mg 12-hourly the pathogens likely to be encountered.
! Linezolid, 600 mg 12-hourly ! The best time to administer these antibiotics is within 30 ! Liposomal amphotericin, up to 3 mg/kg daily minutes of the commencement of the operation.
! Meropenem, 1 g 8-hourly ! A single dose has been shown to be adequate in most cases. ! Metronidazole, 500 mg 8-hourly IVI! Piperacillin/tazobactam, 4.5 g 6-hourly This should only be repeated if the duration of the operation ! Teicoplanin, 400 mg 12-hourly loading dose (day 1) followed by exceeds the half-life of the selected antibiotic. Benefit has not 400 mg 12 - 24-hourly thereafter been seen in further antibiotic dosing.
! Tobramycin, 5 - 7 mg/kg/day ! Most clean surgical procedures do not require ! Vancomycin, 500 mg 6-hourly or 1 g 12-hourly (adjust dose to maintain daily measured levels of 20 μg/ml) ! For elective surgery, cefazolin (2g) is usually ! Voriconazole, 6 mg/kg 12-hourly loading dose (day 1) followed by 3 - 4 mg/kg 12-hourly ! Clindamycin is a reasonable alternative for penicillin allergy.
* The higher recommended doses of the various antimicrobial agents should be considered for use in seriously ill patients and/or more severe infections.
! For bone surgery, a 1st generation cephalosporin like †Modifications may need to be made for alterations in renal and/or hepatic cefazolin is sufficient.
! Glycopeptides are only rarely necessary and their use ‡Only as directed therapy in cases of enterococcal infections.
should be discouraged.
! For hollow visceral or mucous membrane surgery, amoxicillin/clavulanate or 2nd generation cephalosporin Table 2: Alternative antibiotic options for multidrug- or
(cefuroxime) (1.5 g), with the addition of metronidazole or pan-resistant bacteria clindamycin to the latter, are the recommended agents.
! In patients who have been hospitalised for prolonged ! Aztreonam, 1 g 8-hourly periods of time, piperacillin/tazobactam may be indicated ! Polymixin B*,†, ‡ ! > 60 kg: 1 - 2 million units 8-hourly, maximum 6 million although skin commensals are still the most likely organisms. If a patient is known to be colonised with MRSA or has had ! < 60 kg: 50 000 units/kg/day divided in 3 doses, maximum MRSA sepsis a glycopeptide (teicoplanin or vancomycin) or 75 000 units/kg/day linezolid may be used.
! Tigecycline, 100 mg loading followed by 50 mg 12-hourly‡ ! Most patients in ICU are already on antibiotics and do not need additional cover. If the unit has a high incidence of * Nebulised polymixin B can also be in used in conjunction with the MRSA sepsis a glycopeptide (teicoplanin or vancomycin) or intravenous administration in cases of NP and VAP. Standard adult linezolid may be indicated.
dose is 2 million units 12-hourly (dissolved in 2 - 4 ml 0.9% sodium chloride solution). (Doses up to 2 million units 8-hourly have been found to be safe and effective in patients with cystic fibrosis.) †Dose adjustment in renal impairment: Tables 1 and 2 have been added to the summarised guideline Creatinine clearance (ml/min) > 60 kg body weight document and indicate the currently recommended standard 1 - 2 million units 8-hourly antibiotic dosing regimens as well as alternative antibiotic 1 million units every 12 - 18 hours options for the management of nosocomial infections.
1 million units every 18 - 24 hours ‡ As these antibiotics are not currently registered for routine use, requests need to be made to the Medicines Control Council (MCC) on the basis of compassionate grounds (www.mccza.com, tel. 012-312 0000). The following has to be faxed: (i) application form filled in by the attending doctor; (ii) consent form (patient or family, if not possible by the attending doctor); (iii) script; and (iv) a deposit of R200 in the MCC account.
South Afr J Epidemiol Infect 2006; Vol 21 (4)

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