HEALTH CARE–ASSOCIATED INFECTIONS   78A

A 71-year-old man is admitted to the intensive care unit for pneumonia, sepsis, and acute respiratory distress syndrome. He is treated with intravenous (IV) ceftriaxone. An initial improvement occurs in his sepsis symptoms and lung function, but on hospital day 6, he develops fever (39°C), tachycardia, and hypotension. His femoral central venous catheter site is noted to be erythematous and draining pus. The catheter is removed and IV vancomycin is administered with resolution of his fever, tachycardia, and hypotension. Blood cultures drawn from the catheter grow methicillin-resistant Staphylococcus aureus (MRSA).

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: New sepsis in hospital despite initial improvement; fever, tachycardia, hypotension; central venous catheter with erythema and drainage; blood cultures showing MRSA; resolution with vancomycin

How to think through: What major causes of new fever, tachycardia and hypotension should be considered in this case besides the purulent femoral line? (Medication toxicity, pulmonary embolism, and infection. Within the category of infection, treatment of the pneumonia may be inadequate because of an improper antibiotic choice, dosing, or penetration of the infected tissue [e.g., with development of an empyema].) The patient may have also developed a new health care–associated infection; possibilities include ventilator-associated pneumonia, infection spread by contact such as Clostridium difficile, Foley catheter–associated urinary tract infection, and IV catheter–associated bloodstream infection. In this case, the latter (a femoral venous catheter infection) is the leading possibility. Line placement at a femoral site has a higher infection risk than one at a subclavian or internal jugular site. Removal of a central line is not a trivial consideration; venous access may be difficult to obtain, and it may be essential for treatment. When should a central line be removed? (If there is purulence at the exit site; if the organism is Staphylococcus aureus, a gram-negative rod, or a Candida species; if there is persistent bacteremia; or if septic thrombophlebitis, endocarditis, or metastatic abscesses occur.)

HEALTH CARE–ASSOCIATED INFECTIONS   78B

What are the essentials of diagnosis and general considerations regarding health care–associated infections?

Essentials of Diagnosis

Acquired during the course of receiving treatment for other conditions more than 48 hours after admission

Most health care–associated infections are preventable; hand washing is most effective

General Considerations

Often result from devices for monitoring or therapy such as IV catheters, Foley catheters, drainage catheters, orotracheal tubes for ventilation; early removal reduces infection

Often occur in critically ill patients with long hospitalizations and broad-spectrum antibiotic therapy

Causative organisms are often multidrug resistant and different from those in community-acquired infections: MRSA, Staphylococcus epidermidis, Enterococcus faecium resistant to ampicillin and vancomycin; resistant gram-negative infections caused by Pseudomonas, Citrobacter, Enterobacter, Acinetobacter, and Stenotrophomonas spp.

Stay updated, free articles. Join our Telegram channel

Join