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For further information, see CMDT Part 30-03: Health Care–Associated Infections

Key Features

Essentials of Diagnosis

  • Health care–associated infections are acquired during the course of receiving health care treatment for other conditions

  • Hospital-associated infections are defined as those not present or incubating at the time of hospital admission and developing at least 48 hours or more after admission

  • Most health care–associated infections are preventable

  • Hand washing is the most effective means of preventing health care–associated infections and should be done routinely even when gloves are worn

General Considerations

  • Although most fevers are due to infections, about 25% of patients with fever will have a noninfectious origin

  • Many infections are a direct result of the use of invasive devices for monitoring or therapy such as

    • Intravenous catheters

    • Indwelling urinary catheters

    • Drainage catheters placed by interventional radiology

    • Orotracheal tubes for ventilatory support

  • Early removal of such devices reduces infection

  • Patients in whom health care–associated infections develop

    • Are often critically ill

    • Have been hospitalized for extended periods

    • Have received several courses of broad-spectrum antibiotic therapy

  • As a result, the causative organisms are often multidrug resistant and different from those in community-acquired infections

    • Staphylococcus aureus and Staphylococcus epidermidis (a frequent cause of prosthetic device infection) may be resistant to methicillin and most cephalosporins (except ceftaroline, which is the only cephalosporin active against methicillin-resistant S aureus) and require vancomycin for therapy

    • Enterococcus faecium is resistant to ampicillin and vancomycin

    • Gram-negative infections caused by Pseudomonas, Citrobacter, Enterobacter, Acinetobacter, Stenotrophomonas, and extended-spectrum beta-lactamase (ESBL)–producing Escherichia coli and Klebsiella and carbapenem-resistant Enterobacteriaceae may be resistant to most antibacterials


  • Worldwide, approximately 10% of patients who enter the hospital free of infection acquire a health care–associated infection resulting in

    • Prolongation of the hospital stay

    • Increase in cost of care

    • Significant morbidity and mortality

Clinical Findings

Symptoms and Signs

  • Those of the underlying disease

Differential Diagnosis

  • Noninfectious

    • Drug fever

    • Nonspecific postoperative fevers (tissue damage or necrosis)

    • Hematoma

    • Pancreatitis

    • Pulmonary embolism

    • Myocardial infarction

    • Ischemic bowel

  • Urinary tract infections

  • Pneumonia

  • Gastrointestinal tract infections, eg, Clostridioides difficile colitis

  • Bacteremia, eg, from indwelling catheter, wound, abscess, pneumonia, genitourinary or gastrointestinal tract

  • Wound infection, eg, pressure injury


Laboratory Tests

  • Blood cultures are universally recommended

  • A properly prepared sputum Gram stain and semi-quantitative sputum cultures may be useful in selected patients where there is a high pretest probability of pneumonia

  • Unreliable or uninterpretable specimens are often obtained for culture and result in unnecessary use of antibiotics

    • The best example is the diagnosis of line-related or bloodstream infection in the febrile patient

    • A blood culture from an unidentified site, a single blood culture from any site, ...

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