Healthcare-Associated and Hospital Acquired Infections

Definition and principles 

Intravascular catheter infections

Short-term central venous catheter infection

Surgical wound infections

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP)

Urinary tract infections, catheter associated

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DEFINITION AND PRINCIPLES

Patients with healthcare associated and hospital acquired infections are at increased risk of being infected with drug resistant organisms. A hospital acquired infection is a new infection that develops after at least 48 hours of hospitalisation without evidence that the infection was present or incubating at the time of admission. Healthcare-associated infections should also be considered in persons with extensive healthcare contact such as: residence in a nursing home or other long-term care facility, hospitalisation in an acute care hospital for >2 days during the prior 90 days, or attendance at a hospital or haemodialysis clinic during the prior 30 days.

It is essential to obtain specimens for culture and sensitivity testing in all cases before starting antibiotics.

Empiric therapy suggestions below are only rough guidelines due to heterogeneity of resistance patterns between facilities and over time. Close liaison with regional microbiologists and regular review of hospital antibiotic policy based on local resistance patterns are essential.

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INTRAVASCULAR CATHETER INFECTIONS

ICD-10 code: L53.9/T80.2 + (B95.8/Y84.8/B37.8)

PERIPHERAL LINE INFECTION:
Common organisms:

• coagulase negative staphylococci particularly S. epidermis
• S. aureus 

GENERAL MEASURES

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NB: Always remove the intravascular line at the site of infection.
- Small, localised areas of erythema at the catheter insertion site will usually resolve without antibiotic therapy after catheter removal.

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MEDICINE TREATMENT

Patients with larger areas of erythema and tenderness extending beyond the insertion site who are systemically well:

• Clindamycin, oral, 450 mg 8 hourly for 5 days.

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If patients are systemically unwell, they should be treated as for a central venous catheter related systemic blood infection.

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SHORT-TERM CENTRAL VENOUS CATHETER INFECTION

GENERAL MEASURES

Obtain microbiologic specimens: peripheral blood culture, blood culture from central catheter prior to removal, and culture of the catheter tip.

If peripheral blood culture is negative but central catheter culture is positive:

• Monitor closely for signs of infection and repeat peripheral blood cultures accordingly.
• If central line has grown S. aureus, 5-7 days of treatment is recommended (provided that peripheral blood cultures remain negative).

If peripheral blood culture is positive:

• Remove catheter, and treat with systemic antibiotics, guided by the culture results.
• Duration of antibiotic therapy should generally be for 48–72 hours after resolution of fever except for:
  • confirmed S. aureus infection and
  • candidaemia,
    where treatment should be continued for 2 weeks after the 1^st negative blood culture.

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• For candidaemia and S. aureus infection, perform blood cultures every 2-3 days after therapy has been initiated until 2 consecutive cultures are negative, and 2 weeks after the 1st negative blood culture.

Empiric antibiotic therapy (prior to obtaining susceptibility results): S. aureus infection
ICD-10 code: (B95.8/Y84.8)

• Vancomycin, IV, 25–30 mg/kg, empirically as a loading dose.
  • Follow with 15–20 mg/kg/dose 12 hourly. (See: guidance on prescribing and therapeutic drug monitoring).
  • Tailor therapy to drug-susceptibility results.

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Candidaemia
ICD-10 code: (B37.8/Y84.8)

• Candida isolated from blood culture should always be treated, even if the fever has settled after line removal because of a high risk of late complications.
• Candidaemia with species other than Candida albicans is becoming increasingly common – these species are often resistant to azoles.
• Treatment duration should extend for a minimum of two weeks following the first negative blood culture.

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Empiric antifungal therapy:

• Amphotericin B, IV, 0.7 mg/kg daily.
  • Ensure adequate hydration to minimise nephrotoxicity (See: preventing, monitoring and management of toxicity).

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Follow up susceptibility:
Once improved, if sensitive, complete course with:

• Fluconazole, oral, 400 mg daily.

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If invasive candidiasis (resistant to fluconazole/amphotericin B or renal impairment is present and amphotericin B cannot be used):

• Echinocandins. (Specialist motivation).

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REFERRAL/CONSULTATION

• S. aureus endocarditis.

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SURGICAL WOUND INFECTIONS

ICD-10 code: T81.4 + (Y83.0-6/Y83.8-9/B95.6/U82.1)

DESCRIPTION

Gram positive bacteria, especially S. aureus, are the commonest cause. Gram negative and anaerobic bacteria are important causes following gynaecological and intestinal surgery.

GENERAL MEASURES

• Microbiologic specimen (in patients with a larger area of erythema or systemic evidence of infection): deep wound swab (NOT a superficial swab), aspirate of pus, or tissue biopsy, and blood culture.
• Suture removal plus incision and drainage is essential.
• Antibiotics are not usually necessary unless there is marked surrounding cellulitis or features of systemic infection.

MEDICINE TREATMENT

Empiric antibiotic therapy:
Total duration of therapy should not exceed 7 days.

If surrounding cellulitis or systemic sepsis does not involve the gastro-intestinal (GI) or female genital tract:

• Cefazolin, IV, 1 g 8 hourly.

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Check Gram stain of exudate. If organism is gram negative:

STOP cefazolin and give:

• Piperacillin/tazobactam, IV, 4.5 g 8 hourly.

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Follow with oral therapy as soon as patient can swallow and the temperature is <37.8°C for 24 hours:

• Flucloxacillin, oral, 500 mg 6 hourly.

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Severe penicillin allergy:
ICD-10 code: (Z88.0)

• Clindamycin, IV, 600 mg 8 hourly.

Check Gram stain of exudate. If organism is gram negative:

ADD:

• Ertapenem, IV, 1 g daily.

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Follow with oral therapy as soon as patient can swallow and the temperature has been <37.8°C for 24 hours, based on culture results:

• Clindamycin, oral, 450 mg 8 hourly.

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If surgery involved female uro-genital tract open GIT:
ICD-10 code: T81.4 + (Y83.6/Y83.8)

• Ceftriaxone, IV, 2 g daily.

AND

• Metronidazole, IV, 500 mg 8 hourly.

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Methicillin (cloxacillin) resistant S. aureus (MRSA):
ICD-10 code: T81.4 + (B95.6+U82.1+Y83.9)

• Vancomycin, IV, 25–30 mg/kg as a loading dose.
  • Follow with 15–20 mg/kg/dose 12 hourly. See: guidance on prescribing and monitoring.

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HOSPITAL-ACQUIRED PNEUMONIA (HAP) AND VENTILATOR-ASSOCIATED PNEUMONIA (VAP)

ICD-10 code: J12.0-3/J12.8-9/J13/J14/J15.0-9/J16.0/J16.8/J18.0-2/J18.8-9 + (Y95)

DESCRIPTION

HAP is defined as a new lung infiltrate (not present on admission) plus clinical evidence that the infiltrate is an infection (e.g. new onset of fever, purulent sputum, leukocytosis) occurring >48 hours after admission to hospital. HAP has a high morbidity and mortality; early appropriate antibiotic therapy is essential.

Infection may be due to multi-drug resistant organisms, particularly in patients with prior intravenous antibiotic use within 90 days.

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Ventilator-associated pneumonia (VAP) occurs >48 hours after intubation. VAP is more often due to multi-drug resistant organisms than HAP.

GENERAL MEASURES

• Microbiologic specimens: blood culture and sputum/tracheal aspirate bacterial culture. Therapy should be adjusted according to culture result. A good quality Gram stain may be useful in guiding the choice of initial therapy.
• If patient is neutropenic – See: Febrile neutropenia.

MEDICINE TREATMENT
Empiric antibiotic therapy

• Treatment duration: 7 days.

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• Antibiotic choice should be based on local susceptibility patterns (See National Institute for Communicable Diseases (NICD) AMR Dashboard: www.nicd.ac.za).
  • Piperacillin/tazobactam, IV, 4.5 g 8 hourly.

AND

• Amikacin, IV, 15 mg/kg daily (See: individual dosing and monitoring for response and toxicity).

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OR ALTERNATIVELY:

• Cefepime, IV, 2 g 12 hourly as monotherapy. (See: guidance on dosing in renal impairment).

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If high local resistance rates to the above regimens, then consider carbapenem with activity against Pseudomonas:

• Imipenem/cilastatin, IV, 1000/1000 mg 8 hourly as monotherapy.

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OR

• Meropenem, IV, 2 g 8 hourly as monotherapy.

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Note:

- De-escalate as soon as the culture is available. 
- For severe penicillin allergy, consult an infectious diseases specialist or microbiologist.

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URINARY TRACT INFECTIONS, CATHETER ASSOCIATED

ICD-10 code: T83.5 + (Y84.6+N39.0)

DESCRIPTION

• Common organisms: resistant aerobic gram-negative bacteria.
• Microbiologic specimen: blood culture and Mid-stream/Catheter specimens of urine (MSU/CSU) for microscopy and bacterial culture.
• In most patients with long-term catheters, bacteria cultured on CSU represent colonisation rather than infection – only treat with antibiotics if features of sepsis or pyelonephritis are present.

GENERAL MEASURES

• Remove catheter.

MEDICINE TREATMENT
Empiric antibiotic therapy:

• Amikacin, IV, 15 mg/kg daily for 7 days.

OR 

If local resistance patterns show low level resistance to ciprofloxacin or culture shows sensitivity:

• Ciprofloxacin, oral, 500 mg 12 hourly for 7 days.

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Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.2_20 January 2025

Chapter 9 Systemic and Healthcare-Associated Infections_9.1 Healthcare-Associated and Hospital Acquired Infections