Hospital-Acquired Infections Clinical Presentation

Updated: Oct 21, 2021
  • Author: Haidee T Custodio, MD; Chief Editor: Russell W Steele, MD  more...
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Healthcare-associated infections are most commonly caused by viral, bacterial, and fungal pathogens. These pathogens should be investigated in all febrile patients who are admitted for a nonfebrile illness or those who develop clinical deterioration unexplained by the initial diagnosis.

Most patients who have healthcare-associated infections caused by bacterial and fungal pathogens have a predisposition to infection caused by invasive supportive measures such as endotracheal intubation and the placement of intravascular lines and urinary catheters. Ninety-one percent of bloodstream infections were in patients with central intravenous lines (CVL), 95% of pneumonia cases were in patients under going mechanical ventilation, and 77% of urinary tract infections were in patients with urinary tract catheters. [13]

Risk factors for the development of catheter-associated bloodstream infections in neonates include catheter hub colonization, exit site colonization, catheter insertion after the first week of life, duration of parenteral nutrition, and extremely low birth weight (< 1000 g) at the time of catheter insertion. [1] In patients in the PICU, risks for catheter-associated bloodstream infections increase with neutropenia, prolonged catheter dwell time (>7 d), use of percutaneously placed CVL (higher than tunneled or implanted devices), and frequent manipulation of lines. [2] Disruption of catheter dressings has also been shown to increase risk for catheter-related infections. [31]

Candida spp are increasingly important pathogens in the NICU. Risk factors for the development of candidemia in neonates include gestational age less than 32 weeks, 5-min Apgar scores of less than 5, shock, disseminated intravascular coagulopathy, prior use of intralipids, parenteral nutrition administration, CVL use, H2 blocker administration, intubation, or length of stay longer than 7 days. [3]

Risk factors for the development of ventilator-associated pneumonia (VAP) in pediatric patients include reintubation, genetic syndromes, immunodeficiency, and immunosuppression. [4, 5] In neonates, a prior episode of bloodstream infection is a risk factor for the development of VAP. [6]

Risk factors for the development of healthcare-associated urinary tract infection in pediatric patients include bladder catheterization, prior antibiotic therapy, and cerebral palsy. [7]


Physical Examination

In addition to the presence of systemic signs and symptoms of infection (eg, fever, tachycardia, tachypnea, skin rash, general malaise), the source of healthcare-associated infections may be suggested by the instrumentation used in various procedures. For example, an endotracheal tube may be associated with sinusitis, tracheitis, and pneumonia; an intravascular catheter may be the source of phlebitis or line infection; and a Foley catheter may be associated with a urinary tract infection.

Patients with pneumonia may have fever, cough, purulent sputum and abnormal chest auscultatory findings such as decreased breath sounds, crackles or wheezes.

Patients with urinary tract infection may present with or without fever. Patients with cystitis can have suprapubic tenderness while those with pyelonephritis can have costovertebral tenderness. Upon inspection, their urine can be cloudy and foul-smelling.

Neonates on the other hand usually do not present with any of the above findings and may have very subtle and nonspecific signs of infection. Fever may or may not be present. Signs of infection can include temperature and/or blood pressure instability, apnea, bradycardia, lethargy, fussiness, and feeding intolerance.