Hospital-acquired infection

thumbnail image: Hospital acquired infections  

Introduction

Hospital- or healthcare-acquired infections (HAI) are new infections that patients acquire as a result of healthcare interventions to treat other conditions. Estimates of prevalence of HAIs are difficult to compare between studies, due to differences in definitions used and means of data collection. Although some high-income countries have national surveillance systems for HAIs, there are fewer data available from low- and middle-income countries.  Recent systematic reviews have estimated hospital-wide prevalence of HAIs in high-income countries at 7.6% and in low and middle-income countries at 10.1%.[1]

Various factors may contribute to an increased risk of infection among hospitalised patients, including decreased patient immunity due to illness, invasiveness of medical procedure, overcrowding and poor infection control practices. Some HAI are caused by antibiotic-resistant micro-organisms, which can be more challenging to treat. Although this special collection concentrates on diagnosis, treatment and prevention of HAI in the hospital setting, it should be remembered that patterns of antibiotic use and/or overuse in the community influence antibiotic resistance seen in hospital infections.

This special collection presents a selection of Cochrane Reviews assessing:

The Cochrane Reviews highlighted in this special collection have been prepared by authors and editors from a diverse range of Cochrane Review Groups including the Cochrane Colorectal group, the Cochrane Acute Respiratory Infections group, the Cochrane Incontinence group, the Cochrane Effective Practice and Organisation of Care group, the Cochrane Wounds group, the Cochrane Oral Health group, the Cochrane Cystic Fibrosis and Genetic disorders group, the Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders group, the Cochrane Pregnancy and Childbirth group, the Cochrane Bone group, the Cochrane Joint and Muscle Trauma group, and the Cochrane Hepato-Biliary group.

Acknowledgements: Thanks to Richard Nelson, Chris del Mar, Liz Dooley, Cathryn Glazener, Imran Omar, Alain Mayhew, Joan Webster and Susan Furness for their help with selecting the reviews included in this special collection, and for comments and edits on the text.

References

[1] World Health Organisation (WHO). (2011) Report on the Burden of Endemic Health Care-Associated Infection Worldwide. A systematic review of the literature. Available at http://www.who.int/en/ [Accessed 22/08/2013]

INTERVENTIONS TO PREVENT INFECTION:

MRSA

Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers 
Staphylococcus aureus (S. aureus) is the leading hospital-acquired pathogen in hospitals throughout the world. Traditionally, control of S. aureus has been focused on preventing cross-infection between patients, however, it has been shown repeatedly that a large proportion of nosocomial S. aureus infections originate from the patient's own flora. Nasal carriage of S. aureus is now considered a well defined risk factor for subsequent infection in various groups of patients. This systematic review aimed to determine whether the use of mupirocin nasal ointment in patients with identified S. aureus nasal carriage reduced S. aureus infection rates.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people 
Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistantStaphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection prevention and control strategies are important in preventing and controlling MRSA transmission. This systematic review aimed to determine the effects of infection prevention and control strategies for preventing the transmission of MRSA in nursing homes for older people.

Hospital-acquired pneumonia

Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care 
The incidence of pneumonia in intensive care unit (ICU) patients ranges between 7% and 40%, and the crude mortality from ventilator-associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in ICUs independently of other factors that are also strongly associated with such deaths. This systematic review aimed to assess the effects of prophylactic antibiotic regimens, such as selective decontamination of the digestive tract (SDD) for the prevention of respiratory tract infections (RTIs) and overall mortality in adults receiving intensive care.

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia
Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in persons who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care, using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions may reduce the risk of VAP in these patients. This systematic review aimed to assess the effects of oral hygiene care on the incidence of VAP in critically ill patients receiving mechanical ventilation in intensive care units in hospitals.

Urinary tract infections

Antibiotic policies for short-term catheter bladder drainage in adults 
Urinary tract infections account for about 40% of hospital-acquired infections, and about 80% of urinary tract infections acquired in hospital are associated with urinary catheters. This systematic review aimed to determine if certain antibiotic prophylaxes are better than others in terms of prevention of urinary tract infections, complications, quality of life and cost-effectiveness in short-term catheterised adults.

Prophylactic antibiotics to reduce the risk of urinary tract infections after urodynamic studies
There is a risk that people who have invasive urodynamic studies (cystometry) will develop urinary tract infections or bacteria in the urine or blood. This systematic review aimed to assess the effectiveness and safety of administering prophylactic antibiotics in reducing the risk of urinary tract infections after urodynamic studies.

Urinary catheter policies for long-term bladder drainage
People requiring long-term bladder draining commonly experience catheter-associated urinary tract infection and other problems. This systematic review aimed to determine if certain catheter policies (including the use of prophylactic antibiotics) are better than others in terms of effectiveness, complications, quality of life and cost-effectiveness in long-term catheterised adults and children. 

Surgical infections

Skin preparation for preventing infection following caesarean section 
The risk of maternal mortality and morbidity (particularly postoperative infection) is higher for caesarean section than for vaginal birth. This systematic review aimed to compare the effects of different agent forms and methods of preoperative skin preparation for preventing post-caesarean infection.

Preoperative bathing or showering with skin antiseptics to prevent surgical site infection
Surgical site infections are wound infections that occur after invasive (surgical) procedures. Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). It is less clear whether reducing skin microflora leads to a lower incidence of surgical site infection. This systematic review aimed to assess the evidence for preoperative bathing or showering with antiseptics for preventing hospital-acquired surgical site infections.

Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures
Surgical site infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures. This systematic review aimed to determine whether the prophylactic administration of antibiotics in people undergoing surgical management of hip or other closed long bone fractures reduces the incidence of surgical site and other hospital-acquired infections.

Antimicrobial prophylaxis for colorectal surgery 
Research shows that administration of prophylactic antibiotics before colorectal surgery prevents postoperative surgical wound infection (SWI). The best antibiotic choice, timing of administration and route of administration remain undetermined. This systematic review aimed to establish the effectiveness of antimicrobial prophylaxis for the prevention of SWI in patients undergoing colorectal surgery.

Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy 
Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure performed to maintain nutrition in the short- or long-term. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and to the debate surrounding antibiotic prophylaxis for PEG tube placement. This systematic review aimed to establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomy tubes.

Methods of preventing bacterial sepsis and wound complications for liver transplantation 
Bacterial sepsis and wound complications after liver transplantation increase mortality, morbidity, hospital stay, and overall transplant costs. This systematic review aimed to assess the benefits and harms of different methods aimed at preventing bacterial sepsis and wound complications in patients undergoing liver transplantation.

Peri-operative glycaemic control regimens for preventing surgical site infections in adults 
Peri-operative hyperglycaemia has been associated with increased surgical site infections (SSIs) and previous recommendations have been to treat glucose levels above 200 mg/dL. However, recent studies have questioned the optimal glycaemic control regimen to prevent SSIs. This systematic review aimed to summarise the evidence for the impact of glycaemic control in the peri-operative period on the incidence of surgical site infections, hypoglycaemia, level of glycaemic control, all-cause and infection-related mortality, and hospital length of stay and to investigate for differences of effect between different levels of glycaemic control.

Different classes of antibiotics given to women routinely for preventing infection at caesarean section 
Caesarean section increases the risk of postpartum infection for women and prophylactic antibiotics have been shown to reduce the incidence; however, there are adverse effects. This systematic review aimed to determine, from the best available evidence, the balance of benefits and harms between different classes of antibiotic given prophylactically to women undergoing caesarean section.

Use of plastic adhesive drapes during surgery for preventing surgical site infection 
Surgical site infection has been estimated to occur in about 15% of clean surgery and 30% of contaminated surgery cases. Using plastic adhesive drapes to protect the wound from organisms that may be present on the surrounding skin during surgery is one strategy used to prevent surgical site infection. This systematic review aimed to assess the effect of adhesive drapes used during surgery on surgical site infection, cost, mortality and morbidity.

Antibiotic prophylaxis for operative vaginal delivery 
Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. This systematic review aimed to assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps deliveries, or both.

Antibiotics versus placebo for prevention of postoperative infection after appendicectomy
Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. Despite improved asepsis and surgical techniques, postoperative complications, such as wound infection and intraabdominal abscess, still account for a significant morbidity. This systematic review aimed to evaluate the use of antibiotics compared to placebo or no treatment in patients undergoing appendectomy.

CHANGING BEHAVIOUR TO PREVENT INFECTION:

Interventions to improve hand hygiene compliance in patient care 
Hand hygiene is regarded as an effective preventive measure against health care-associated infection. This systematic review aimed to assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes 
Inspection systems are used in health care to promote quality improvements, i.e. to achieve changes in organisational structures or processes, healthcare provider behaviour and patient outcomes. This systematic review aimed to evaluate the effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour and patient outcomes.

Interventions to improve professional adherence to guidelines for prevention of device-related infections 
Important risk factors associated with healthcare-associated infections (HAIs) are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. This systematic review aimed to assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

Interventions to improve antibiotic prescribing practices for hospital inpatients 
The two objectives of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second support professionals and patients to reduce unnecessary use and minimize collateral damage. This systematic review aimed to estimate the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial-resistant pathogens or Clostridium difficile infection and their impact on clinical outcome.

DIAGNOSIS AND TREATMENT:

MRSA:

Antimicrobial drugs for treating methicillin-resistant Staphylococcus aureus colonization
Eradication strategies for methicillin-resistant Staphylococcus aureus (MRSA) are variable. This systematic review aimed to assess the effects of topical and systemic antimicrobial agents on nasal and extra-nasal MRSA carriage, adverse events, and incidence of subsequent MRSA infections.

Antibiotic therapy for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in surgical wounds
Methicillin-resistant Staphylococcus aureus (MRSA) infection after surgery is usually rare, but incidence can be up to 33% in certain types of surgery. Postoperative MRSA infection can occur as surgical site infections, chest infections, or bloodstream infections (bacteraemia). This systematic review aimed to compare the benefits and harms of various antibiotic treatments in people with established surgical site infections caused by MRSA.

Interventions for the eradication of methicillin-resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis
Chronic pulmonary infection with Methicillin-resistant Staphylococcus aureus (MRSA) is thought to confer cystic fibrosis patients with a worse overall clinical outcome and, in particular, result in an increased rate of decline in lung function. This systematic review aimed to evaluate the effectiveness of treatment regimens designed to eradicate MRSA and to determine whether the eradication of MRSA confers better clinical and microbiological outcomes for people with cystic fibrosis.

Clostridium difficile:

Antibiotic treatment for Clostridium difficile-associated diarrhea in adults
Clostridium difficile is recognized as a frequent cause of antibiotic-associated diarrhoea and colitis. This systematic review aimed to investigate the efficacy of antibiotic therapy for C. difficile-associated diarrhoea (CDAD).

Hospital-acquired pneumonia:

Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults
Pneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit. However, the optimal duration of antibiotic therapy for hospital-acquired pneumonia (HAP) is uncertain. This systematic review aimed to assess the effectiveness of short versus prolonged-course antibiotic administration for HAP in critically ill adults, including patients with ventilator-associated pneumonia (VAP).

Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia
Ventilator-associated pneumonia (VAP) is a common infectious disease in intensive care units (ICUs). The best diagnostic approach to resolve this condition remains uncertain. This systematic review aimed to evaluate whether quantitative cultures of respiratory secretions are effective in reducing mortality in immunocompetent patients with VAP, compared with qualitative cultures. It also considered changes in antibiotic use, length of ICU stay and mechanical ventilation.


Image credit: JIM VARNEY/SCIENCE PHOTO LIBRARY, M520/0216

Date published: 30 August 2013

Contact: Cochrane Editorial Unit (editorial-unit@cochrane.org)

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