eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Hospital-Acquired Infections: Treatment & Medication
Updated: Jan 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Symptomatic treatment of shock, hypoventilation, and other complications should be provided, along with the administration of empiric broad-spectrum antimicrobials, antifungals, and antivirals.
Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are not worse than those caused by susceptible S aureus. MRSA requires treatment with different families of antibiotics. Although the pathogenicity does not generally differ from that of susceptible strains of S aureus, MRSA strains that carry the loci for Panton-Valentine leukocidin can be hypervirulent and can cause lymphopenia, rapid tissue necrosis, and severe sepsis.
- Bloodstream infections
- Line removal should be considered if the line is suspected in the cause of sepsis.
- Broad-spectrum antibiotics should be selected according to the local epidemiologic patterns of microbial susceptibility.
- Antifungals (eg, fluconazole, caspofungin, voriconazole, amphotericin B) are added to empiric antibiotics in some cases.
- Antivirals (eg, ganciclovir, acyclovir) could be used in the treatment of suspected disseminated viral infections.
- Pneumonia
- Change nasotracheal tubes to orotracheal tubes, if feasible.
- Broad-spectrum antibiotics are administered with guidance from the results of rapid examination of the sputum, endotracheal suction material, and bronchial lavage wash.
- Macrolide antibiotics are indicated in legionellosis.
- Antivirals (neuraminidase inhibitors for both influenza A and influenza B) are used if viral pneumonia is suspected. Since the 2005-2006 influenza season, the CDC has not recommended amantadine and rimantadine because of resistance. Laboratory testing by the CDC on the predominant strain of influenza (H3N2) currently circulating in the United States shows that it is resistant to these drug.
- Indications for the use of neuraminidase inhibitors in children have been defined for oseltamivir phosphate (approved for treatment and prophylaxis in children >1 y) and zanamivir (approved for treatment in children ≥7 y and for prophylaxis in children ≥5 y).
- Anti-influenza therapy has been used to treat symptomatic patients and patients with immunodeficiency or chronic lung diseases to limit morbidity and mortality.
- Oseltamivir (Tamiflu) resistance has emerged in the United States during the 2008-2009 influenza season.
- The CDC has issued revised interim recommendations for antiviral treatment and prophylaxis of influenza. Preliminary data from a limited number of states indicate a high prevalence of influenza A (H1N1) virus strains resistant to oseltamivir (Tamiflu). Because of this, zanamivir (Relenza) is recommended as the initial choice for antiviral prophylaxis or treatment when influenza A infection or exposure is suspected. A second-line alternative is a combination of oseltamivir plus rimantadine, rather than oseltamivir alone. Local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice.
- Influenza A viruses, including 2 subtypes (H1N1 and H3N2), and influenza B viruses currently circulate worldwide; the prevalence of each can vary among communities and within a single community over the course of an influenza season. In the United States, 4 prescription antiviral medications (oseltamivir, zanamivir, amantadine, rimantadine) are approved for treatment and chemoprophylaxis of influenza. Since January 2006, the neuraminidase inhibitors (oseltamivir, zanamivir) have been the only recommended influenza antiviral drugs because of widespread resistance to the adamantanes (amantadine, rimantadine) among influenza A (H3N2) virus strains. The neuraminidase inhibitors have activity against influenza A and B viruses, whereas the adamantanes have activity against only influenza A viruses.
- In 2007-2008, a significant increase in the prevalence of oseltamivir resistance was reported among influenza A (H1N1) viruses worldwide. During the 2007-2008 influenza season, 10.9% of H1N1 viruses tested in the United States were resistant to oseltamivir. Complete recommendations are available from the CDC.
- Overall, the most cost-effective prevention measure is seasonal vaccination against influenza A and B. The 2007-2008 vaccine strains consist of A/Solomon Island/3/2006 (H1N1)–like, A/Wisconsin/67/2005 (H3N2)–like, and B/Malaysia/2506/2004–like antigens.
- Urinary tract infection
- Indwelling catheters should be removed, if feasible.
- Empiric antibiotic and antifungal therapy is based on the preliminary results of urinalysis and urine Gram staining.
- Surgical-site infections: These should be managed with a combination of surgical care and aggressive antibiotic therapy guided by the results of deep-tissue Gram staining and culturing. Fasciitis is of special concern because it is associated with mucoid group A streptococci and high morbidity and mortality rates.
- C difficile colitis: Management of C difficile colitis includes the discontinuation of the offending antibiotics and the use of oral metronidazole or vancomycin. Macrobiotics may be beneficial.
Surgical Care
- Surgical debridement is an integral part of management of surgical-site infections or superinfected decubitus ulcers. Tissue sample should be processed using appropriate stains and cultures to identify the pathogen and its susceptibility.
Consultations
- Many patients with nosocomial infections require expert care from an ICU team.
- Infectious disease specialists, burn care specialists, and surgical teams are usually involved in the care of these complicated cases.
Medication
Pharmacologic treatment depends on the underlying etiology.
More on Hospital-Acquired Infections |
| Overview: Hospital-Acquired Infections |
| Differential Diagnoses & Workup: Hospital-Acquired Infections |
 Treatment & Medication: Hospital-Acquired Infections |
| Follow-up: Hospital-Acquired Infections |
| References |
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References
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Further Reading
Keywords
hospital-acquired infections, health care–acquired infections, nosocomial infection, vancomycin-resistant enterococcus, VRE, methicillin-resistant Staphylococcus aureus, MRSA, Pseudomonas, candidiasis, Legionella, respiratory syncytial virus, thrush, Clostridium difficile, viral respiratory infections, influenza, parainfluenza, sinusitis, otitis, tracheitis, phlebitis, line infection, bloodstream infection, ventilator-associated pneumonia, urinary tract infection, UTI, surgical-site infection, coagulase-negative staphylococci, enterococci, fungi, , pseudomonads,
