Chapter 21 : Hospital-Associated Infections

MyBook is a cheap paperback edition of the original book and will be sold at uniform, low price.

Preview this chapter:
Zoom in

Hospital-Associated Infections, Page 1 of 2

| /docserver/preview/fulltext/10.1128/9781555815455/9781555813970_Chap21-1.gif /docserver/preview/fulltext/10.1128/9781555815455/9781555813970_Chap21-2.gif


The immunocompromised host is at increased risk of acquiring hospital-associated infections (HAIs), resulting in excessive morbidity and mortality, prolonged length of stay (LOS), and considerable cost to medical facilities. Traditionally, infections are classified as either hospital acquired (nosocomial), when symptoms manifest after 72 hours of hospital admission, or community acquired, when infections occur before this time frame. The chapter presents an overview of the prominent emerging pathogens that cause sepsis and respiratory disease-related HAIs in immunocompromised patients. The clinical impact of evolving antimicrobialresistant strains and their financial burden are discussed, along with the critical role of the diagnostic microbiology laboratory in providing tests that detect and identify these pathogens in a clinically relevant time frame. One report that examined early transplant-related mortality after cord blood transplantation from unrelated donors cited a rate close to 50%, mainly due to infectious complications. In this study, infections due to multidrug resistance (MDR) spp. demonstrated a higher mortality rate than those due to cytomegalovirus disease. The majority of patients with ventilator-associated pneumonia (VAP) can be divided into two subgroups according to the time of onset of the disease. Targeted strategies that have been employed with the aim of reduction of selection of MDR gram-negative pathogens include intense monitoring of trends in high-risk units, modifications of formularies, massive education of prescribers, and strict enforcement of infection control practices. The majority of clinical microbiology laboratories still rely on culture-dependent methodologies for the isolation, identification, and antimicrobial susceptibility testing of respiratory tract pathogens.

Citation: Wu F, Whittier S, Della-Latta P. 2009. Hospital-Associated Infections, p 429-440. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch21
Highlighted Text: Show | Hide
Loading full text...

Full text loading...


1. American Thoracic Society and Infectious Diseases Society of America. 2005. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am. J. Respir. Crit. Care Med. 171: 388416.
2. Aubry, A.,, R. Porcher,, J. Bottero,, S. Touratier,, T. Leblanc,, B. Brethon,, P. Rousselot,, E. Raffpix,, J. Menotti,, F. Derouin,, P. Ribaud and, A. Sulahian. 2006. Occurrence and kinetics of false-positive Aspergillus galactomannan test results following treatment with beta-lactam antibiotics in patients with hematological disorders. J. Clin. Microbiol. 44: 389394.
3. Baden, L. R.,, W. Thiemke,, A. Skolnik,, R. Chambers,, J. Strymish,, H. S. Gold,, R. C. Moellering, Jr., and, G. M. Eliopoulos. 2001. Prolonged colonization with vancomycin-resistant Enterococcus faecium in long-term care patients and the significance of “clearance.” Clin. Infect. Dis. 33: 16541660.
4. Bekeris, L. G.,, J. A. Tworek,, M. K. Walsh, and, P. N. Valenstein. 2005. Trends in blood culture contamination: a College of American Pathologists Q-Tracks study of 356 institutions. Arch. Pathol. Lab. Med. 129: 12221225.
5. Blot, S. I.,, K. H. Vandewoude,, E. A. Hoste, and, F. A. Colardyn. 2002. Outcome and attributable mortality in critically ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Arch. Intern. Med. 162: 22292235.
6. Bordigoni, P.,, A. S. Carret,, V. Venard,, F. Witz, and, A. Le Faou. 2001. Treatment of adenovirus infections in patients undergoing allogeneic hematopoietic stem cell transplantation. Clin. Infect. Dis. 32: 12901297.
7. Bradford, P. A.,, S. Bratu,, C. Urban,, M. Visalli,, N. Mariano,, D. Landman,, J. J. Rahal,, S. Brooks,, S. Cebular, and, J. Quale. 2004. Emergence of carbapenem-resistant Klebsiella species possessing the class A carbapenem-hydrolyzing KPC-2 and inhibitor-resistant TEM-30 beta-lactamases in New York City. Clin. Infect. Dis. 39: 5560.
8. Carter B. A.,, S. J. Karpen,, R. E. Quiros-Tejeira,, I. F. Chang,, B. S. Clark,, G. J. Demmler,, H. E. Heslop,, J. D. Scott,, P. Seu, and, J. A. Goss. 2002. Intravenous cidofovir therapy for disseminated adenovirus in a pediatric liver transplant recipient. Transplantation 74: 10501052.
9. Centers for Disease Control and Prevention. 2005. Pseudomonas bloodstream infections associated with a heparin/saline flush—Missouri, New York, Texas, and Michigan, 2004–2005. MMWR Morb. Mortal Wkly. Rep. 54: 269272.
10. Cloud, J. L.,, K. C. Carroll,, P. Pixton,, M. Erali, and, D. R. Hillyard. 2000. Detection of Legionella species in respiratory specimens using PCR with sequencing confirmation. J. Clin. Microbiol. 38: 17091712.
11. Combes, A.,, C. Figliolini,, J. L. Trouillet,, N. Kassis,, M. Wolff,, C. Gibert, and, J. Chastre. 2002. Incidence and outcome of polymicrobial ventilator-associated pneumonia. Chest 121: 16181623.
12. Cook, D.,, and L. Mandell. 2000. Endotracheal aspiration in the diagnosis of ventilator-associated pneumonia. Chest 117: 195197.
13. Couch, R. B.,, J. A. Englund, and, E. Whimbey. 1997. Respiratory viral infections in immunocompetent and immunocompromised persons. Am. J. Med. 102: 29.
14. Della-Latta, P.,, P. Pancholi,, K. Pavletich and, F. Wu. 2005. Detection of MRSA directly from blood cultures using realtime PCR, abstr. P1391. ECCMID, Copenhagen, Denmark.
15. Domingo, P.,, and A. Fontanet. 2001. Management of complications associated with totally implantable ports in patients with AIDS. AIDS Patient Care STDS 15: 713.
16. European Organization for Research and Treatment of Cancer and International Antimicrobial Therapy Cooperative Group. 1989. Empiric antifungal therapy in febrile granulocytopenic patients. Am. J. Med. 86: 668672.
17. Feja, K. N.,, F. Wu,, K. Roberts,, M. Loughrey,, M. Nesin,, E. Larson,, P. Della-Latta,, J. Haas,, J. Cimiotti, and, L. Saiman. 2005. Risk factors for candidemia in critically ill infants: a matched case-control study. J. Pediatr. 147: 156161.
18. Foca, M.,, K. Jakob,, S. Whittier,, P. Della-Latta,, S. Factor,, D. Rubenstein, and, L. Saiman. 2000. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N. Engl. J. Med. 343: 695700.
19. Friedman, N. D.,, K. S. Kaye,, J. E. Stout,, S. A. McGarry,, S. L. Trivette,, J. P. Briggs,, W. Lamm,, C. Clark,, J. MacFarquhar,, A. L. Walton,, L. B. Reller, and, D. J. Sexton. 2002. Health care-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann. Intern. Med. 137: 791797.
20. Garner, J. S.,, W. R. Jarvis,, T. G. Emori,, T. C. Horan, and, J. M. Hughes. 1988. CDC definitions for nosocomial infections. Am. J. Infect. Control 16: 128140.
21. Gonzalez-Barca, E.,, A. Fernandez-Sevilla,, J. Carratala,, A. Granena, and, F. Gudiol. 1996. Prospective study of 288 episodes of bacteremia in neutropenic cancer patients in a single institution. Eur. J. Clin. Microbiol. Infect. Dis. 15: 291296.
22. Gupta, A.,, P. Della-Latta,, B. Todd,, P. San Gabriel,, J. Haas,, F. Wu,, D. Rubenstein, and, L. Saiman. 2004. Outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails. Infect. Control Hosp. Epidemiol. 25: 210215.
23. Haley, R. W.,, D. H. Culver,, J. W. White,, W. M. Morgan,, T. G. Emori,, V. P. Munn, and, T. M. Hooton. 1985. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am. J. Epidemiol. 121: 182205.
24. Hall, K. K.,, and J. A. Lyman. 2006. Updated review of blood culture contamination. Clin. Microbiol. Rev. 19: 788802.
25. Johanson, W. G., Jr.,, A. K. Pierce,, J. P. Sanford, and, G. D. Thomas. 1972. Nosocomial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract. Ann. Intern. Med. 77: 701706.
26. Jones, R. N. 2006. Microbiological features of vancomycin in the 21st century: minimum inhibitory concentration creep, bactericidal/static activity, and applied breakpoints to predict clinical outcomes or detect resistant strains. Clin. Infect. Dis. 42: S13S24.
27. Kinchington, P. R.,, E. G. Romanowski, and, Y. J. Gordon. 2005. Prospects for adenovirus antivirals. J. Antimicrob. Chemother. 55: 424429.
28. King, M. D.,, B. J. Humphrey,, Y. F. Wang,, E. V. Kourbatova,, S. M. Ray, and, H. M. Blumberg. 2006. Emergence of community-acquired methicillin-resistant Staphylococcus aureus USA 300 clone as the predominant cause of skin and soft-tissue infections. Ann. Intern. Med. 144: 309317.
29. Klein, M. A.,, D. Kadidlo,, J. McCullough,, D. H. McKenna, and, L. J. Burns. 2006. Microbial contamination of hematopoietic stem cell products: incidence and clinical sequelae. Biol. Blood Marrow Transplant. 12: 11421149.
30. Knirsch, C. A.,, K. Jakob,, D. Schoonmaker,, J. A. Kiehlbauch,, S. J. Wong,, P. Della-Latta,, S. Whittier,, M. Layton, and, B. Scully. 2000. An outbreak of Legionella micdadei pneumonia in transplant patients: evaluation, molecular epidemiology, and control. Am. J. Med. 108: 290295.
31. Kuehnert, M. J.,, V. R. Roth,, N. R. Haley,, K. R. Gregory,, K. V. Elder,, G. B. Schreiber,, M. J. Arduino,, S. C. Holt,, L. A. Carson,, S. N. Banerjee, and, W. R. Jarvis. 2001. Transfusion-transmitted bacterial infection in the United States, 1998 through 2000. Transfusion 41: 14931499.
32. Larson, E. L.,, J. P. Cimiotti,, J. Haas,, M. Nesin,, A. Allen,, P. Della-Latta, and, L. Saiman. 2005. Gram-negative bacilli associated with catheter-associated and non-catheter-associated bloodstream infections and hand carriage by healthcare workers in neonatal intensive care units. Pediatr. Crit. Care Med. 6: 457461.
33. Lautenbach, E.,, W. B. Bilker, and, P. J. Brennan. 1999. Enterococcal bacteremia: risk factors for vancomycin resistance and predictors of mortality. Infect. Control Hosp. Epidemiol. 20: 318323.
34. Lion, T.,, R. Baumgartinger,, F. Watzinger,, S. Matthes-Martin,, M. Suda,, S. Preuner,, B. Futterknecht,, A. Lawitschka,, C. Peters,, U. Potschger, and, H. Gadner. 2003. Molecular monitoring of adenovirus in peripheral blood after allogeneic bone marrow transplantation permits early diagnosis of disseminated disease. Blood 102: 11141120.
35. Lucas, K. G.,, A. E. Brown,, D. Armstrong,, D. Chapman, and, G. Heller. 1996. The identification of febrile, neutropenic children with neoplastic disease at low risk for bacteremia and complications of sepsis. Cancer 77: 791798.
36. Lyytikainen, O.,, V. Golovanova,, E. Kolho,, P. Ruutu,, A. Sivonen,, L. Tiittanen,, M. Hakanen, and, J. Vuopio-Varkila. 2001. Outbreak caused by tobramycin-resistant Pseudomonas aeruginosa in a bone marrow transplantation unit. Scand. J. Infect. Dis. 33: 445449.
37. Mayhall, C. G. 1997. Nosocomial pneumonia. Diagnosis and prevention. Infect. Dis. Clin. N. Am. 11: 427457.
38. Mayhall, C. G. 2001. Ventilator-associated pneumonia or not? Contemporary diagnosis. Emerg. Infect. Dis. 7: 200204.
39. McKibben, L.,, T. Horan,, J. I. Tokars,, G. Fowler,, D. M. Cardo,, M. L. Pearson,, P. J. Brennan, et al. 2005. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Am. J. Infect. Control 33: 217226.
40. Mendoza Sánchez, M. C.,, J. Ruiz-Contreras,, J. L. Vivanco,, F. Fernández-Carrión,, M. Baro Fernández,, J. T. Ramos,, J. R. Otero, and, D. Folgueira. 2006. Respiratory virus infections in children with cancer or HIV infection. J. Pediatr. Hematol. Oncol. 28: 154159.
41. Moland, E. S.,, N. D. Hanson,, J. A. Black,, A. Hossain,, W. Song, and, K. S. Thomson. 2006. Prevalence of newer beta-lactamases in gram-negative clinical isolates collected in the United States from 2001 to 2002. J. Clin. Microbiol. 44: 33183324.
42. Naimi, T. S.,, K. H. LeDell,, K. Como-Sabetti,, S. M. Borchardt,, D. J. Boxrud,, J. Etienne,, S. K. Johnson,, F. Vandenesch,, S. Fridkin,, C. O’Boyle,, R. N. Danila, and, R. Lynfield. 2003. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA 290: 29762984.
43. Patel, R.,, K. E. Piper,, M. S. Rouse,, J. R. Uhl,, F. R. Cockerill, and, J. M. Steckelberg. 2000. Frequency of isolation of Staphylococcus lugdunensis among staphylococcal isolates causing endocarditis: a 20-year experience. J. Clin. Microbiol. 38: 42624263.
44. Paterson, D. L.,, L. Mulazimoglu,, J. M. Casellas,, W. C. Ko,, H. Goossens,, A. V. Gottberg,, S. Mohapatra,, G. M. Trenholme,, K. P. Klugman,, J. G. McCormack, and, V. L. Yu. 2000. Epidemiology of ciprofloxacin resistance and its relationship to extended-spectrum β-lactamase production in Klebsiella pneumoniae isolates causing bacteremia. Clin. Infect. Dis. 30: 473478.
45. Pfaller, M. A.,, R. N. Jones,, S. A. Messer,, M. B. Edmond, and, R. P. Wenzel. 1998. National surveillance of nosocomial blood stream infection due to Candida albicans: frequency of occurrence and antifungal susceptibility in the SCOPE Program. Diagn. Microbiol. Infect. Dis. 31: 327332.
46. Pizzo, P. A. 1999. Fever in immunocompromised patients. N. Engl. J. Med. 341: 893900.
47. Raad, I.,, A. Alrahwan, and, K. Rolston. 1998. Staphylococcus epidermidis: emerging resistance and need for alternative agents. Clin. Infect. Dis. 26: 11821187.
48. Rahal, J. J. 2000. Extended-spectrum beta-lactamases: how big is the problem? Clin. Microbiol. Infect. 6 (Suppl. 2): 26.
49. Rahal, J. J.,, C. Urban, and, S. Segal-Maurer. 2002. Nosocomial antibiotic resistance in multiple gram-negative species: experience at one hospital with squeezing the resistance balloon at multiple sites. Clin. Infect. Dis. 34: 499503.
50. Rodriguez-Martinez, J. M.,, and A. Pascual. 2006. Antimicrobial resistance in bacterial biofilms. Rev. Med. Microbiol. 17: 6575.
51. Rolston K. V.,, Y. Jiang,, and M. Matar. 2007. VRE fecal colonization/infection in cancer patients. Bone Marrow Transplant. 39: 567568.
52. Rubio, M.,, L. Palau,, J. R. Vivas,, E. del Potro,, J. Diaz-Mediavilla,, A. Alvarez,, R. Martinez, and, J. J. Picazo. 1994. Predominance of gram-positive microorganisms as a cause of septicemia in patients with hematological malignancies. Infect. Control Hosp. Epidemiol. 15: 101104.
53. Saavedra, S.,, G. F. Sanz,, I. Jarque,, F. Moscardo,, C. Jimenez,, I. Lorenzo,, G. Martin,, J. Martinez,, J. De La Rubia,, R. Andreu,, S. Molla,, I. Llopis,, M. J. Fernandez,, M. Salavert,, B. Acosta,, M. Gobernado, and, M. A. Sanz. 2002. Early infections in adult patients undergoing unrelated donor cord blood transplantation. Bone Marrow Transplant. 30: 937943.
54. Safdar, A.,, V. Chaturvedi,, B. S. Koll,, D. H. Larone,, D. S. Perlin, and, D. Armstrong. 2002. Prospective, multicenter surveillance study of Candida glabrata: fluconazole and itraconazole susceptibility profiles in bloodstream, invasive, and colonizing strains and differences between isolates from three urban teaching hospitals in New York City ( Candida susceptibility trend study, 1998 to 1999). Antimicrob. Agents Chemother. 46: 32683272.
55. Shorr, A. F.,, Y. P. Tabak,, A. D. Killian,, V. Gupta,, L. Z. Liu, and, M. H. Kollef. 2006. Healthcare-associated bloodstream infection: a distinct entity? Insights from a large U.S. database. Crit. Care Med. 34: 25882595.
56. Siegman-Igra, Y.,, B. Fourer,, R. Orni-Wasserlauf,, Y. Golan,, A. Noy,, D. Schwartz, and, M. Giladi. 2002. Reappraisal of community-acquired bacteremia: a proposal of a new classification for the spectrum of acquisition of bacteremia. Clin. Infect. Dis. 34: 14311439.
57. Singh, N.,, and D. L. Paterson. 2005. Aspergillus infections in transplant recipients. Clin. Microbiol. Rev. 18: 4469.
58. Stone, P. W.,, A. Gupta,, M. Laughrey,, P. Della-Latta,, J. Cimiotti,, E. Larson,, D. Rubenstein, and, L. Saiman. 2003. Attributable costs and length of stay of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae outbreak in a neonatal intensive care unit. Infect. Control Hosp. Epidemiol. 24: 601606.
59. Tacconelli, E.,, M. Tumbarello,, M. Pittiruti,, F. Leone,, M. B. Lucia,, R. Cauda, and, L. Ortona. 1997. Central venous catheter-related sepsis in a cohort of 366 hospitalized patients. Eur. J. Clin. Microbiol. Infect. Dis. 16: 203209.
60. Thompson, R. L.,, I. Cabezudo, and, R. P. Wenzel. 1982. Epidemiology of nosocomial infections caused by methicillin-resistant Staphylococcus aureus. Ann. Intern. Med. 97: 309317.
61. Tokars, J. I. 2004. Predictive value of blood cultures positive for coagulase negative staphylococci: implications for patient care and health care quality assurance. Clin. Infect. Dis. 39: 333341.
62. Trouillet, J. L.,, J. Chastre,, A. Vuagnat,, M. L. Joly-Guillou,, D. Combaux,, M. C. Dombret, and, C. Gibert. 1998. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am. J. Respir. Crit. Care Med. 157: 531539.
63. Tsay, R.-W.,, L. K. Siu,, C.-P. Jung, and, F.-Y. Chang. 2002. Characteristics of bacteremia between community-acquired and nosocomial Klebsiella pneumoniae. Infect. Arch. Intern. Med. 162: 10211027.
64. Urban, C.,, S. Segal-Maurer, and, J. J. Rahal. 2003. Considerations in control and treatment of nosocomial infections due to multidrug-resistant Acinetobacter baumannii. Clin. Infect. Dis. 36: 12681274.
65. Visca, P.,, P. Goldoni,, P. C. Luck,, J. H. Helbig,, L. Cattani,, G. Giltri,, S. Bramati, and, M. Castellani Pastoris. 1999. Multiple types of Legionella pneumophila serogroup 6 in a hospital heated-water system associated with sporadic infections. J. Clin. Microbiol. 37: 21892196.
66. Vuong, C.,, and M. Otto. 2002. Staphylococcus epidermidis infections. Microbes Infect. 4: 481489.
67. Wisplinghoff, H.,, T. Bischoff,, S. M. Tallent,, H. Seifert,, R. P. Wenzel, and, M. B. Edmond. 2004. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin. Infect. Dis. 39: 309317.
68. Wisplinghoff, H.,, H. Seifert,, R. P. Wenzel, and, M. B. Edmond. 2003. Current trends in the epidemiology of nosocomial bloodstream infections in patients with hematological malignancies and solid neoplasmas in hospitals in the United States. Clin. Infect. Dis. 36: 11031110.
69. Zafar, N.,, C. M. Wallace,, P. Kieffer,, P. Schroeder,, M. Schootman, and, A. Hamvas. 2001. Improving survival of vulnerable infants increases neonatal intensive care unit nosocomial infection rate. Arch. Pediatr. Adolesc. Med. 155: 10981104.
70. Zetola N.,, J. S. Francis,, E. L. Nuermberger, and, W. R. Bishai. 2005. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect. Dis. 5: 275286.


Generic image for table
Table 1.

Major pathogen distribution by infection site in immunocompromised patients

Citation: Wu F, Whittier S, Della-Latta P. 2009. Hospital-Associated Infections, p 429-440. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch21
Generic image for table
Table 2.

Distribution of major pathogens in bloodstream infections in immunocompromised and immunocompetent patients

Citation: Wu F, Whittier S, Della-Latta P. 2009. Hospital-Associated Infections, p 429-440. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch21
Generic image for table
Table 3.


Citation: Wu F, Whittier S, Della-Latta P. 2009. Hospital-Associated Infections, p 429-440. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch21
Generic image for table
Table 4.

Direct laboratory identification of species

Citation: Wu F, Whittier S, Della-Latta P. 2009. Hospital-Associated Infections, p 429-440. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch21
Generic image for table
Table 5.

Comparison of MRSA real-time PCR assays

Citation: Wu F, Whittier S, Della-Latta P. 2009. Hospital-Associated Infections, p 429-440. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch21

This is a required field
Please enter a valid email address
Please check the format of the address you have entered.
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error