Medical Care

Symptomatic treatment of shock, hypoventilation, and other complications should be provided, along with administration of empiric broad-spectrum antimicrobial therapy.

Bloodstream infections

Line removal should be considered if the line is no longer needed; if the infection is caused by S aureus, Candida species, or mycobacteria; if the patient is critically ill; if the patient fails to clear bacteremia in 48-72 hours; if symptoms of bloodstream infection persist beyond 48-72 hours; and if noninfectious valvular heart disease, endocarditis, metastatic infection, or septic thrombophlebitis is present.^[8]

Antibiotics with coverage against gram-positive and gram-negative organisms, including Pseudomonas, should be empirically started and then tailored according to susceptibility pattern of isolated organisms.

Antifungal therapy (eg, fluconazole, caspofungin, voriconazole, amphotericin B) in some cases are added to empiric antibiotic coverage. Antiviral therapy (eg, ganciclovir, acyclovir) can be used in the treatment of suspected disseminated viral infections.

Duration of therapy depends on several factors, including isolated pathogen, retention of catheter, or presence of complications (endocarditis, sepsis). For most bacterial organisms, the duration of therapy is 10-14 days after blood cultures become negative.

Pneumonia

Initial empiric antibiotic therapy should be broad and later on streamlined based on results of examination and cultures of sputum, endotracheal suction material and bronchial lavage wash. The choice of empiric antibiotic coverage should take into consideration the risk for multidrug-resistant (MDR) pathogens. Risk factors for MDR include antimicrobial therapy over the past 90 days, current hospitalization of 5 days or more, high frequency of antibiotic resistance in the community, or hospital and immunosuppression.^[33]

No clear consensus has been reached as to the duration of antimicrobial therapy for ventilator-associated pneumonia (VAP). Many experts treat for 14-21 days. However, shorter course of antibiotic therapy (about 1 wk) may be adequate therapy for some cases.^[34]

Antiviral medications against influenza have been used to treat symptomatic patients and patients with immunodeficiency or chronic lung diseases to limit morbidity and mortality.

Urinary tract infection

Indwelling catheters should be removed if possible, to avoid persistence and recurrence of infection. In some cases, removal of catheter may result in spontaneous resolution of bacteriuria or asymptomatic cystitis.

Empiric antibiotic and antifungal therapy should be considered to avoid major complications, including pyelonephritis, renal damage, and bloodstream infections. Duration of therapy is controversial. Most experts recommend at least 10-14 days of therapy for children with sepsis, pyelonephritis, or urinary tract abnormalities.

A study by Mullin et al implemented interventions aimed at reducing catheter-associated urinary tract infection (CAUTI) rates. The intervention included following CDC protocols for positioning, maintenance, and removal of catheters as well as following the American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines that recommend that when evaluating fever in the critically ill, urine culture testing should only be indicated for patients who are at high risk for invasive infections. The interventions resulted in a decrease in the CAUTI rate from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014.^{[35, 36]}

Surgical-site infection

Surgical-site infections (SSIs) should be managed with a combination of surgical care and antibiotic therapy. Antibiotic coverage should be modified once culture results are available.

Severe infections such as streptococcal gangrene and extensive tissue necrosis need aggressive surgical intervention. For these kinds of infections, antibiotics alone may not work.

Other healthcare-associated infections

Rotavirus gastroenteritis is a self-limited disease and only needs supportive care. Medical management should focus on preventing dehydration.

Treatment is not necessary for asymptomatic carriers of Clostridium difficile. For those who have mild symptoms, discontinuance of antibiotics alone may result in resolution of symptoms. For those who have more severe diarrhea, oral metronidazole is the preferred treatment. Oral vancomycin is reserved for treatment failure with metronidazole. Clinical improvement is usually seen within 2 days of initiating therapy, and duration of treatment is usually 10 days.

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

Infectious disease specialists, burn care specialists, and surgical teams are usually involved in the care of complicated cases. Patients with complicated and severe healthcare-associated infections may require expert care from an ICU team.

Medication

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