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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 127-137

Healthcare-associated infections in the surgical setting: How to prevent and treat them

Department of Surgery, Macerata Hospital; Global Alliance for Infections in Surgery, Macerata, Italy

Date of Submission12-Mar-2022
Date of Acceptance12-Mar-2022
Date of Web Publication09-May-2022

Correspondence Address:
Massimo Sartelli
Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata 62100
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aihb.aihb_53_22

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Healthcare-associated infections (HAIs) are infections that patients can get while receiving medical care. These infections are often preventable and represent one of the most common adverse events in health care. Patients with medical devices (central lines, urinary catheters and ventilators) or who undergo surgical procedures are at risk of acquiring HAIs. The most common HAIs are surgical site infections, urinary tract infections, pneumonia, bloodstream infections and Clostridioides difficile infections. This review takes into consideration the aspects of both prevention and treatment of the most common HAIs and the aspects related to a possible behavior change among health-care workers in the surgical setting.

Keywords: Healthcare, infection, prevention

How to cite this article:
Sartelli M. Healthcare-associated infections in the surgical setting: How to prevent and treat them. Adv Hum Biol 2022;12:127-37

How to cite this URL:
Sartelli M. Healthcare-associated infections in the surgical setting: How to prevent and treat them. Adv Hum Biol [serial online] 2022 [cited 2022 May 25];12:127-37. Available from: https://www.aihbonline.com/text.asp?2022/12/2/127/345025

  Introduction Top

Healthcare-associated infections (HAIs) are those infections that patients acquire during receiving medical care and are not present or incubating at the time of admission. They are considered one of the most common adverse events in health care.

The term HAIs was initially referred to those infections acquired in an acute-care hospital (earlier called hospital-acquired infections). The term now includes infections acquired also in the other settings where patients receive health care such as long-term care and ambulatory care.[1]

The most frequently reported types of HAIs are surgical site infections (SSIs), urinary tract infections (UTIs), pneumonia, bloodstream infections and Clostridioides difficile infections (CDI). Although some HAIs can be treated easily, others can seriously affect patients' health, increasing their hospital stay and causing considerable distress to the patients.

Hospitalised patients may have multiple risk factors for the acquisition of HAIs.[2] The intensity of patient care in acute care facilities can facilitate the development of HAIs.[3] Moreover, in acute care facilities, patients are more susceptible to serious consequences of HAIs due to their comorbid illnesses.

HAIs in surgical patients are particularly frequent. Patients having medical devices such as central lines catheters, urinary catheters ad ventilators or undergoing surgical procedures are at risk of HAIs. SSIs and three other types of infections including central-line associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs) and ventilator-associated pneumonia/hospital-acquired pneumonia (HAP/VAP), account for more than 80% of all HAIs.

Many HAIs are preventable; therefore, HAIs may be considered an important indicator of the quality of patient care and a patient safety issue in health care. In 2018, Schreiber et al. published a systematic review and meta-analysis of studies between 2005 and 2016 evaluating the results of multifaceted interventions to reduce CAUTIs, CLABSIs, SSIs, VAP and HAP in acute care or long-term care settings.[4] Of the 5226 articles identified, 144 studies were considered for the final analysis. The meta-analysis demonstrated a potential reduction of HAIs rates from 35% to 55% implementing multifaceted interventions regardless of the country's income level.

HAIs continue to escalate at an alarming rate. HAIs result in significant patients' morbidity and mortality, prolong the duration of hospital stay, and necessitate additional diagnostic and therapeutic interventions, causing high supplementary costs to those already sustained due to the patient's underlying disease. However, the phenomenon is not yet sufficiently perceived from both healthcare workers (HCWs) and patients, resulting in inadequate responses.[2] Although HAIs are the most frequent adverse events in health care, their true global burden remains unknown because of the difficulty in gathering reliable data. Most countries lack surveillance systems for HAIs, and the countries having them, often, struggle with the difficulty in applying them and the lack of uniformity of criteria.[5]

Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAIs prevention even more important nowadays. Many HAIs are caused by multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, extended-spectrum beta-lactamase-producing Gram-negative bacilli, or carbapenemase-producing Gram-negative bacilli (CRE). Preventing HAIs, assisting with prompt detection of MDROs, and promoting compliance with standard and transmission-based precautions are mandatory to combat antimicrobial resistance.

The enhanced Recovery After Surgery (ERAS) Society consensus statements and guidelines are powerful tools that have been implemented across hospitals and health-care systems worldwide to improve the quality of surgical care. The ERAS approach was initially conceived by a group of surgeons in northern Europe and has progressively spread around the world.[6] Due to their demonstrated efficacy in the optimisation of patient's physiologic function and perioperative medical care, ERAS protocols should be integrated with the principles of infection prevention and control (IPC) because they can act synergistically to reduce the occurrence of HAIs during the surgical pathway.[6] A meta-analysis and systematic review about the impact of ERAS and fast track surgery for abdominal or pelvic surgery on HAIs was published in 2017. The results suggested that ERAS protocols were powerful tools to prevent HAIs.[7]

This narrative review takes into consideration the aspects related to both prevention and management of the most common HAIs and the aspects related to a possible behavioural change in the prevention and management of HAIs across the surgical pathway. A literature search, using the PubMed database, was performed without the restriction of time or type of manuscript. The search was limited to English-language publications.

  Pathogenesis of Healthcare-Associated Infections Top

Three main factors are related to the pathogenesis of HAIs including host factors, agent factors and environmental factors.

Host factors can affect the risk of exposure. Patients in acute care facilities can be in a poor state of health, with weakened defences against bacteria. Advanced age or immunodeficiency present a general risk, while some diseases present specific risks. For instance, chronic obstructive pulmonary disease can increase the possibility of respiratory tract infections. Moreover, other host factors associated with an increased risk of HAIs include malignancies, infection with human immunodeficiency virus (HIV), severe burns, severe malnutrition, diabetes mellitus and trauma.

The majority of HAIs are caused by bacteria. Some bacteria belonging to the patient's natural flora can cause the infection only when the patient's immune system becomes susceptible to infection. Gram-positive bacteria include staphylococci, streptococci and Clostridioides difficile. Gram-negative include Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter and Klebsiella pneumoniae). Many of these bacteria can survive on surfaces for a long time. Viruses and fungi are occasionally involved. Environmental factors are extrinsic factors affecting both the infectious agent and patients.

Environmental factors related to the development of HAIs can include both animate and inanimate factors. The animate factors refer to HCWs, other patients in the same unit, families, and visitors. Inanimate factors refer to medical instruments and equipment, diagnostic and therapeutic procedures, and environmental surfaces.

The interaction between an infectious agent and a susceptible host can result into an infection. This interaction occurs through contact between the infectious agent and the host and may be affected by the environment. The best way to prevent HAIs is generally to break the chain of infection by interrupting the transmission.

  Surgical Site Infections Top

SSIs represent one of the most common adverse events occurring in patients across the surgical pathway, regardless of the advances in preventive procedures.[1] Preventing SSIs is a global priority. Bacteria are becoming increasingly resistant to antibiotics, making the prevention of SSIs even more important nowadays.[8]

SSIs are the most common HAIs in surgical patients and represent a major clinical problem worldwide due to the related morbidity, mortality, length of hospital stay, and overall direct and not-direct costs.[9],[10]

The prevention of SSIs should require the integration of a range of measures before, during, and after surgery. Both the World Health Organisation (WHO)[11],[12] and the Centers for Disease Control and Prevention (CDC)[13] have published guidelines for the prevention of SSIs.

The 2016 WHO Global guidelines for the prevention of SSIs are evidence-based including systematic reviews presenting evidence-based recommendations in support of actions to improve practice.

In these guidelines, 29 recommendations are reported. Thirteen recommendations refer to the prevention of SSIs in the pre-operative period and 16 recommendations to the prevention of SISs during and after surgery. They range from simple precautions such as ensuring that patients bathe or shower before surgery, appropriate way for surgical teams to clean their hands, guidance on how and when to use prophylactic antibiotics, which disinfectants to use before incision at the surgical site and which sutures to use.

The key recommendations of these guidelines should be respected by all HCWs throughout all stages of the patient's surgical pathway.

SSIs are generally classified according to the CDC criteria. SSIs are divided into superficial incisional infection, deep incisional infection and organ space infection.[14] Superficial incisional SSIs are the most common type of SSIs. Deep incisional and organ/space are the types of SSIs causing the most morbidity.

SSIs are the results of several factors. All wound surgical sites can be contaminated by the bacteria, but only a minority can develop clinical SSIs.[15]

Colonisation occurs when the bacteria replicate and adhere to the wound surgical site. If the host's immune response is not sufficient to eliminate or overcome the effects of the colonisation, infection occurs. In most patients, the infection does not develop because host defences are efficient to eliminate colonising bacteria at the wound surgical site; however, in some patients, host defences fail protect them from the development of SSIs. It is well known that surgical trauma increases inflammatory response and counter-regulatory mechanisms decrease in post-operative immune response, promoting SSIs.

The bacteria isolated from SSIs can differ depending on the type of surgical procedure. In clean-contaminated or contaminated surgical procedures, the aerobic and anaerobic bacteria of the endogenous microflora of the surgically opened organ are the most frequently isolated bacteria. In patients undergoing clean surgical procedures, in which the gastrointestinal, gynaecologic and respiratory tracts have not been opened, bacteria from the patient's skin flora are the most frequently isolated. Nevertheless, the skin of some specific areas of the body such as the groin can also be colonised by enteric flora.[15]

The diagnosis of incisional SSI is clinical. Signs and symptoms may be localised erythema, induration, warmth and pain at the surgical site. Purulent wound drainage may occur. Some patients present systemic signs of infection. Adequate treatment of incisional SSIs should always include the following:

Surgical incision and drainage of the abscess

Debridement of necrotic tissue, if present

Appropriate wound care

Adequate empiric antibiotic therapy when indicated

De-escalation when antibiogram is available.

Information on the microbiological species isolated in the wound is crucial for targeting antibiotic treatment and predicting the clinical response to treatment. Therefore, SSIs should be always sampled. Lack of standardised criteria for diagnostic microbiology of SSIs may be a challenge to monitor the global epidemiology of SSIs.

Superficial incisional SSIs that have been drained should not be managed by antibiotics. However, in patients with signs of systemic inflammatory response or in immunocompromised patients, empiric broad-spectrum antibiotic treatment covering the expected flora at the surgical site should be administered. Definitive antibiotic treatment should be driven by the patient's conditions and, when available, by the results of the culture and the antibiogram. The spread of antimicrobial resistance has made the antibiotic management of SSIs more difficult.

  Catheter-Acquired Urinary Infections Top

Among all HAIs the UTIs are the most common. Most UTIs are due to the use of an indwelling urethral catheter. In recent years, CA-UTIs have received significantly less attention than other HAIs, such as SSIs, HAP, VAP and catheter-related bloodstream infections (CRBSIs) probably because CA-UTIs present generally lower morbidity and mortality compared with the other HAIs, as well as have a lower financial impact. However, because they are very common, it should be important to consider their large cumulative impact.[16]

The indwelling urethral catheter is essential for many hospitalised patients. It is inserted for several reasons including perioperative management of selected surgical patients. However, it may cause a predictable and unavoidable risk of UTIs.[17]

From 10% to 25% of patients, during the hospitalisation, receive indwelling urinary catheters and many of them develop CA-UTIs.[16]

A comprehensive set of guidelines for the prevention of CA-UTI were published in 2009 by Health Infection Control Practices Advisory Committee.[18] These guidelines updated the previous CDC Guidelines for the Prevention of CAUTI published in 1981.[19]

For patients undergoing surgical interventions, the guidelines suggested the benefit of avoiding urinary catheterisation. The evidence did not reveal data on the impact of catheterisation on peri-operative haemodynamic management.

Best practices for catheter insertion and management may prevent the acquisition of CA-UTIs and decrease risks of symptomatic infections. Best practices should include correct insertion techniques to minimise contamination and maintaining a closed drainage system to avoid catheter colonisation.

Multifaceted interventions including evidence-based best practices, engagement of both the medical and nursing staff and education have been shown to be more effective than single intervention.[20] Therefore, CA-UTI prevention strategies have been 'bundled' into a composite of multimodal sets of interventions.[21],[22]

However, despite some early success in implementing a bundle strategy, CA-UTI prevention is still a real challenge. Fortunately, most CA-UTIs are asymptomatic and do not require antibiotic therapy.

Guidelines for diagnosis, prevention and treatment of CA-UTI in adults were published in 2009 by the Infectious Diseases Society of America (IDSA).[23]

Asymptomatic bacteriuria was defined as culture growth of ≥105 colony forming units (cfu)/mL of bacteria in the absence of symptoms related to UTI in a patient having indwelling urethral, indwelling suprapubic, or intermittent catheterisation.

CA-UTI is defined as culture growth of ≥103 cfu/mL of uro-pathogenic bacteria in the presence of symptoms or signs compatible with UTI without another identifiable source in a patient having indwelling urethral, indwelling suprapubic or intermittent catheterisation.[23] Symptoms can include fever, suprapubic or costovertebral angle tenderness. Unexplained systemic symptoms such as altered mental status, hypotension can suggest ongoing sepsis.

The diagnosis of CA-UTI is usually made by the presence of bacteriuria in a catheterised patient having signs and symptoms of UTI or systemic infection that are otherwise unexplained.

The treatment of CA-UTIs should include both antibiotic therapy and catheter management.

CA-UTIs are often polymicrobial infections and may be caused by MDROs. Urine cultures should be always performed before starting the antibiotic treatment. They can confirm the appropriate coverage of the empirical therapy and drive therapy based on antibiotic susceptibility data. Gram-negative organisms are the predominant bacteria in CA-UTIs.

Bacteriuria in the absence of symptoms is very common among catheterised patients. Antibiotic therapy for asymptomatic bacteriuria should not be administered because it does not affect patient outcome, and can increase the emergence of antimicrobial resistance. Thus, with few exceptions such as immunocompromised patients, antibiotic therapy for catheterised patients with asymptomatic bacteriuria is not suggested. Removal of the catheter allows the resolution of bacteriuria in most cases.

Empiric antibiotic therapy for patients with CA-UTIs depends on patients' clinical conditions and whether the infection has proceeded beyond the bladder (which generally can distinguish acute complicated UTIs from acute uncomplicated UTIs).

Moreover, empirical antibiotic selection for CA-UTIs should take into account risk factors for resistant infection (past urine cultures, previous antibiotic therapy, health care exposures and health-care setting resistance patterns).

Once culture and antimicrobial susceptibility testing results are available, the antibiotic regimen should be tailored to the specific bacteria isolated.[24]

The repetitive inappropriate administration of antibiotics can lead to the development of antimicrobial resistance. CA-UTIs lead to biofilm formation on both the extraluminal and intraluminal catheter surface, largely from extraluminal microorganisms. The biofilm defends bacteria from both antibiotics and hosts defence mechanisms. Although morbidity from CA-UTI with short-term catheter use is limited if catheters are appropriately inserted, in patients with long-term indwelling catheters, CA-UTIs are common.

The optimal duration of antibiotic therapy is uncertain. Seven days is the recommended duration of antibiotic treatment for patients with CA-UTI who have a prompt resolution of symptoms, and 10–14 days of treatment is recommended for those with a delayed response. Oral therapy can be used for antibiotic treatment if the patient is susceptible and the patient is well enough to take the oral medication with adequate absorption.

Patients with CA-UTIs who no longer require catheterisation should remove the catheter and receive appropriate antibiotic therapy. Patients requiring extended catheterisations should be always managed by intermittent catheterisation if it is possible. If long-term catheterisation is needed and intermittent catheterisation is not feasible, the catheter should be replaced at the initiation of antibiotic therapy.

The two most important strategies to prevent CA-UTI are not to use a urinary catheter and, if a catheter is necessary, to remove it promptly, when no longer needed. Catheters should be inserted only when they are truly needed and removed as soon as when they are no longer indicated.

Systemic antibiotic prophylaxis should not be routinely used in patients with both short-term or long-term catheterisation, including patients who undergo surgical procedures.

CA-UTIs must be acknowledged as an important patient safety issue, and the indwelling urethral catheter must be treated as an invasive intervention that carries a risk for patients. Attention to limiting catheter use, minimising the duration of use, and supporting optimal practices for catheter care should be implemented worldwide.

  Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia Top

Nosocomial pneumonia is usually classified into HAP and VAP.

They represent the second most frequent hospital-acquired infection and the first in terms of morbidity and mortality.

In recent years, two different sets of guidelines for the management of HAP and VAP were published: The (2016) Clinical Practice Guidelines by the IDSA and the American Thoracic Society[25] and the (2017) Guidelines of the European Respiratory Society, European Society of Intensive Care Medicine, European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax.[26]

HAP refers to pneumonia occurring at least 48 h after hospital admission, not in incubation at the time of admission.

VAP is pneumonia occurring in patients treated by mechanical ventilation for at least 48 h. VAP is a frequent issue in intensive care unit (ICU) patients. VAP has a great impact on morbidity, mortality and cost of care. Treating VAP is a difficult task, and initial empirical antibiotics to treat it have to be appropriate and prompt.

The term healthcare-associated pneumonia (HCAP) was reported in the previous guidelines to identify patients coming from community settings at risk for MDROs. However, the HCAP definition was not included in recent guidelines due to increasing evidence that aetiology in HCAP patients is similar to that of community-acquired pneumonia and that patients with HCAP are not at high risk for MDROs.

A significant number of patients develop pneumonia after surgery.[27] Post-operative pneumonia has been described as one of the leading complications of all types of surgery. The pathogenesis of post-operative pneumonia is multifactorial and is typically associated with the colonisation of the aero-digestive tract and the aspiration of the contaminated secretions. Diminished host defences (critical illness, co-morbidities, or medications and surgical procedures) may contribute to the pathogenesis of post-operative pneumonia. It is usually caused by bacteria, sometimes polymicrobial, especially in patients who are at risk for aspiration.[27] Most of the post-operative pneumonia cases are caused by Gram-negative, aerobic bacteria including Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter species. Among Gram-positive bacteria, Staphylococcus aureus is the most common cause. Troubling is the growing resistance to antibiotics, thereby making the treatment of pneumonia more difficult.[24]

The concomitant illnesses of the hospitalised patients are a risk for nosocomial pneumonia. In hospitalised patients, the modifications in immune function make patients more susceptible to invasive infections. Many hospitalised patients are in poor nutritional status that can increase their risk for pneumonia. Patients' severe illness and haemodynamic compromise can be associated with increased rates of nosocomial pneumonia. Aspiration of oropharyngeal secretions plays a significant role in the development of nosocomial pneumonia. Moreover, the combination of altered immune function, impaired mucociliary clearance of the respiratory tract and its colonisation can make aspiration an important contributor to pneumonia. Supine positioning can contribute greatly to the risk of aspiration.

Risk factors for pneumonia also include prolonged hospital length of stay, poor oral care, cigarette smoking, increasing age, uraemia, alcohol consumption, major surgery, malnutrition, multiple organ-system failures, neutropenia.

The use of stress ulcer prophylaxis, such as proton pump inhibitors (PPIs) commonly used in critically ill patients, is associated with the risk of nosocomial pneumonia.[28]

Finally, foreign bodies, such as endotracheal and nasogastric tubes, may provide a source for colonisation allowing the migration of pathogen bacteria to the lower respiratory tract.[29]

Intubation and mechanical ventilation can increase the risk of VAP from 6 to 21-fold. Long time on ventilation and the occurrence of reintubation are important risk factors for the development of VAP. Other risk factors include body position during ventilation, enteral feeding, mechanical ventilation for more than 7 days and Glasgow Coma Scale scores of <9.[28]

The effects of oral hygiene care (OHC) on the incidence of VAP in critically ill patients receiving mechanical ventilation in hospital ICUs was assessed by a Cochrane review published in 2016.[30] The review demonstrated that OHC including chlorhexidine mouthwash or gel reduced the risk of VAP in critically ill patients from 24% to about 18%. However, the review did not demonstrate differences in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay.

Studies have shown that a VAP bundles strategy can significantly decrease VAP rates. The bundle components can include head of the bed elevation, closed suctioning and subglottic drainage, daily assessment of readiness to extubate, stopping unnecessary PPIs and antacids, deep venous thrombosis prophylaxis, and accurate oral care.[31] However, to achieve zero incidence of VAP a higher than 95% compliance rate with the VAP bundle is needed[32] and periodic assessment of both the medical and nursing staff is often recommended to improve long-term compliance.[33]

The clinical manifestations of HAP and VAP are non-specific and there are no specific signs or symptoms for these conditions. Symptoms can include fever, shortness of breath, chest pain, cough, sputum production and hypoxia. The clinical manifestations of HAP and VAP may be mimicked by other clinical conditions such as pulmonary embolism and congestive heart failure.

To guide empirical antibiotic treatment cultures from respiratory secretions and blood cultures should be always obtained in patients with suspected HAP or VAP. Non-invasive techniques such as endotracheal aspiration are more rapid than invasive sampling. They have fewer complications and need fewer resources. However, they may lead to an over-identification of bacteria. Invasive bronchoscopic techniques such as bronchoalveolar lavage (BAL) or protected specimen brush (PSB) require qualified clinicians and may compromise gas exchange during the procedure.

Microbiology can be confirmed by semiquantitative culture results. The growth of microorganism(s) is reported as light/few, moderate or abundant/many. Quantitative culture results refer to the growth thresholds and are considered significant at 103 CFU/mL for PSB or 104 CFU/mL for BAL. There is no still consensus as to whether these specimens should be cultured quantitative, or by a semiquantitative approach.

Once HAP or VAP is suspected clinically, empiric antibiotic therapy should be started. In patients with sepsis or septic shock, antibiotics should be started as soon as possible.

Delaying empiric antibiotic treatment and failing to administer an appropriate regimen are both associated with higher mortality rates.

Choice of a specific regimen for empiric therapy should be based on:

Patient's clinical conditions

Knowledge of the prevailing pathogens within the health-care setting

The individual patient's risk factors for antimicrobial resistance.

Knowledge of the local epidemiology, and particularly the susceptibility patterns of the predominant local bacteria, should greatly impact the choice of empiric therapy. Awareness and knowledge of local resistance patterns are crucial to decide the empiric antibiotic therapy for HAP and VAP.

A narrow-spectrum empiric antibiotic therapy with activity against non-resistant Gram-negative bacteria and methicillin-sensitive S. aureus is suggested in low-risk patients and early-onset HAP/VAP. Low-risk patients are those who present HAP/VAP without septic shock and with no risk factors for MDROs.

Conversely, a broader-spectrum initial empiric therapy including antibiotics against MRSA and Pseudomonas aeruginosa is suggested in high-risk patients. High-risk patients are those patients with septic shock and/or who have risk factors for MDROs infection such as hospitalisation in settings with high rates of MDROs, previous antibiotic use, recent prolonged hospital stay and previous colonisation with MDROs.

Beta-lactam antibiotics are time-dependent antibiotics and the traditional intermittent dosing of certain beta-lactam antibiotics used to treat VAP may be replaced with prolonged infusions to optimize pharmacokinetic/pharmacodynamic principles, especially in critically ill patients with infections caused by Gram-negative bacteria and overall, for those patients with infections caused by Gram-negative bacteria that have elevated but susceptible MICs to the chosen antibiotics.

A longer course of treatment can increase the risks of both CDI and antimicrobial resistance. A 7-day course of antibiotic therapy in patients with HAP/VAP without comorbidities such as immunodeficiency, cystic fibrosis, empyema, lung abscess, cavitation or necrotising pneumonia and with a good clinical response to therapy is generally suggested. Prolonged regimens do not improve patient outcomes.

Once microbiology culture and antibiotic susceptibility results are noted antibiotic therapy should be de-escalated and therapy should be targeted toward the pathogen(s) causing disease. De-escalation is a core component of antimicrobial stewardship and refers to changing from a broad-spectrum antibiotic regimen to a narrower-spectrum antibiotic regimen. Targeted therapy helps to prevent complications of antibiotic therapy, including CDI and the development of MDROs.

  Central-Venous-Catheter-Related Bloodstream Infections Top

About half of nosocomial bloodstream infections occur in ICUs, and most of them are associated with intravascular devices. Central-venous-CRBSIs are an important cause of HAIs.[34]

The use of central venous catheters (CVCs) is very common in modern clinical practice. CVCs are usually used for the administration of fluids, blood products, medication, nutritional solutions and for haemodynamic monitoring in critically ill patients. They are the main cause of bacteraemia in hospitalised patients and therefore should be used only if they are really necessary.

Risk factors for CRBSI may be patient-, catheter-, and operator-related factors.

CVC, arterial catheters are inserted in 3 out of 4 critically ill patients' ICU including, very often, surgical patients. Complications CVC-related include local insertion site complications, infections and thrombosis.[35] CRBIs are responsible for heavy morbidity and mortality and additional costs, although they can be avoided in a great part of cases. Healthcare improvement programmes and quality improvement strategies have been shown to be effective to prevent complications related to intravascular catheters,[34] especially when there the local compliance with the measures.

The catheter itself can be involved in four different pathogenic pathways: [35]

Colonisation of the catheter by microorganisms from the patient's skin and occasionally the hands of HCWs

Intraluminal or hub contamination

Secondary seeding from a bloodstream infection, and, rarely

Administration of contaminated infusate or additives

The U.S. CDC developed specific guidelines that are widely recognised as the document that better synthesizes current evidence for preventing CRBIs.[36]

An evidence-based set of guidelines for the management of intravascular catheters in the ICU was recently published.[37] Recommendations about the prevention of CRBSIs included the preferential use of subclavian central vein, one-step skin disinfection using 2% chlorhexidine gluconate-alcohol, and the implementation of a quality improvement program.

The use of antimicrobial-impregnated catheters, using either antisepticagents (chlorhexidine, silver sulphadiazine) or antibiotic agents (minocycline–rifampin combination) has been proposed to reduce the rate of CRBSIs. A Cochrane meta-analysis and systematic review of randomised controlled trials comparing antimicrobial-impregnated CVCs versus standard CVCs was published in 2016.[38] The meta-analysis called for caution in routinely recommending the use of antimicrobial-impregnated CVCs.

The onset of CRBSIs can be reduced by a range of measures including closed infusion systems, aseptic technique during insertion and management of the central venous line, early removal of central venous lines and appropriate site selection. Several studies have shown that CRBIs can be prevented by implementing a care bundle strategy and the simultaneous application of multiple best practices has been associated with a significant reduction in CRBSI rates.[39]

The diagnosis of CRBSI is often suspected clinically in a patient using a CVC who presents with fever or chills, unexplained hypotension, and no other localising sign.

Diagnosis of CRBSI is based on establishing the presence of a bloodstream infection related to the catheter.

Blood cultures should not be drawn solely from the catheters' port as these can be colonised with skin contaminants, thereby increasing the likelihood of false-positive bloodstream cultures.

According to IDSA guidelines, the definitive diagnosis of CRBSI requires a culture of the same organism from both the catheter tip and at least one percutaneous blood culture.[40]

Alternatively, the culture of the same organism from at least two blood samples should include one culture from a catheter hub and the other from a peripheral vein (or a second lumen) and should meet the criteria for quantitative blood cultures or differential time to positivity. Most laboratories do not perform quantitative blood cultures, but many laboratories can determine a differential time to positivity. Quantitative blood cultures with a colony count from the catheter hub sample ≥3-fold higher than the colony count from the peripheral vein sample (or a second lumen) confirm a diagnosis of CRBSI. Differential time to positivity refers to the growth detected from the catheter hub sample at least 2 h before the growth detected from the peripheral vein sample.

CVC salvage should be attempted for all bacterial CRBSIs in stable and not critically ill patients.

The CVC should be removed and cultured if the patient has unexplained sepsis or erythema overlying the catheter insertion site or purulence at the catheter insertion site.

Moreover, CVC should be removed in the case of bloodstream infection continuing despite >72 h of antibiotic therapy to which the infecting bacteria are susceptible, or infections due to MRSA, Pseudomonas aeruginosa, fungi or mycobacteria.

Initial antibiotic therapy for catheter-related infection is empiric. The initial choice of antibiotics should depend on the severity of the patient's clinical disease, and the likely bacteria associated with the CVC. It is important to provide coverage for both Gram-positive bacteria (including coagulase-negative staphylococci) and Gram-negative bacteria empirically.

Resistance to antibiotic therapy due to biofilm formation also has an important role in the management of bacteraemia. The nature of biofilm structure makes bacteria difficult to eradicate and confer an inherent resistance to antibiotics.

Antibiotic lock therapy should be used for catheter salvage.

In general, antibiotic lock solutions should combine a highly concentrated antibiotic with an anticoagulant to allow for local instillation into the catheter lumen.

Because parenteral nutrition may provide an infective milieu for organism growth, CVC should not be used for parenteral support while salvage is attempted. However, it depends on the availability of other peripheral accesses. If peripheral access is limited, intravenous fluid and electrolytes rather than parenteral nutrition can be administered via the CVC during the salvage, with the continuation of the antibiotic lock therapy.

Education and training of HCWs, and adherence to standardised protocols for insertion and management of intravascular catheters significantly reduce the incidence of CRBSIs and represent the most important preventive measures.

  Clostridioides Difficile Infection Top

In the last two decades, the increase in the incidence of CDI in many countries worldwide has made CDI a global health burden. CDI is a concern in surgical patients. Surgery predisposes patients to CDI. Moreover, the surgery itself is necessary to treat severe cases of CDI.

Optimisation of CDI management in the peri-operative setting has become increasingly necessary to increase patient outcomes and decrease the cost resulting from CDI.

C. difficile is an anaerobic, spore-forming Gram-positive bacillus. It may form part of the normal intestinal microbiota in healthy newborns. However, it is rarely present in the gut of healthy adults. C. difficile is spread via the oral-faecal route. In hospitalised patients, it may be acquired through the ingestion of spores or vegetative bacteria and can spread to patients by health-care personnel or from the environment. CDI is a toxin-mediated infection; therefore, toxins negative C. difficile strains are non-pathogenic.

In 2019, the World Society of Emergency Surgery updated the previous guidelines for the management of Clostridioides (Clostridium) difficile infection in surgical patients.[41]

Risk factors for CDI may be divided into three general categories including host factors (immune status, co-morbidities), exposure to C. difficile spores (hospitalisations, community sources, long-term care facilities) and factors that disrupt the normal colonic microbiome (antibiotics, other medications and surgery). Reported risk factors include age more than 65 years, comorbidity or underlying conditions, inflammatory bowel diseases (IBD), immunodeficiency (including HIV infection), malnutrition, and low serum albumin level. Patients with IBD are at increased risk of developing CDI. These patients may have worse outcomes, including higher rates of colectomy, and high rates of CDI recurrence.

It is well known that antibiotics play a central role in the pathogenesis of CDI. Presumably, they can disrupt the normal gut flora, providing a perfect setting for the proliferation of C. difficile. Although nearly all antibiotics can be associated with CDI, clindamycin, third-generation cephalosporins, penicillins and fluoroquinolones have been considered at great risk. A debated risk factor is represented by gastric acid-suppressive medications, such as histamine-2 blockers and PPIs. Recent studies suggested the association between CDI and the use of stomach acid-suppressive medications, primarily PPIs.[41]

The spectrum of symptomatic CDI can range from a mild disease characterised by diarrhoea to severe disease or fulminant colitis. Patients may develop recurrent CDI. Diarrhoea is the hallmark symptom, however, patients may not present initially with diarrhoea because of colonic dysmotility either from previous underlying conditions or possibly from the disease process itself. Diarrhoea may be absent in some patients. This is especially important in surgical patients who may have a concomitant ileus. Therefore, in surgical patients, it is important to have a high index of suspicion. Diarrhoea usually may be accompanied by abdominal pain and when it is prolonged may result in altered electrolyte balance and dehydration.

Severe forms of the disease are associated with increased abdominal pain and signs of systemic inflammation, such as fever, leukocytosis and hypoalbuminaemia. Diarrhoea may be absent in some patients with CDI. Sometimes the absence of diarrhoea may sign the progression of the infection to its fulminant form. The progression to fulminant C. difficile colitis is very infrequent (1%–3% of all CDI); however, mortality in patients with the fulminant disease is high due to the development of toxic megacolon and colonic perforation, with subsequent organ dysfunction. Patients with severe CDI progressing to systemic toxicity should undergo early surgical consultation and should be evaluated for potential emergency surgical intervention. Resection of the entire colon should be always considered to manage patients with fulminant colitis. However, diverting loop ileostomy with colonic lavage may be a useful alternative to colectomy.[42],[43],[44]

Prompt diagnosis is an important aspect of effective management of CDI. Early identification of CDI allows early treatment and prompt and effective IPC measures. Glutamate dehydrogenase (GDH) screening tests for C. difficile are sensitive but do not differentiate between toxigenic and non-toxigenic strains. They may be used in association with toxin A/B enzyme immunoassays testing. Algorithms including screening with a test for GDH followed by a toxin assay may be suggested.

Nucleic acid amplification tests (NAAT) for C. difficile toxin genes appear to be sensitive and specific and may be used as a standard diagnostic test for CDI. NAAT as a single-step algorithm can increase detection of asymptomatic colonisation, therefore it should be performed in patients with high suspicion for CDI.[41]

Rapid isolation of infected patients is important in controlling the transmission of C. difficile.

This is particularly important to reduce environmental contamination as spores can survive for months in the environment. Contact precautions in managing patients with CDI should be maintained until the resolution of diarrhoea. Patients with known or suspected CDI should ideally be isolated in a private room with en-suite hand washing and toilet facilities. If a private room is not available, as often occurs, known CDI patients may be cohorted in the same area through the theoretical risk of transfection with different strains exists.

Hand hygiene with soap and water and the use of contact precautions along with good cleaning and disinfection of the environment and patient equipment should be used by all HCWs contacting all patients with known or suspected CDI.[45] Hand hygiene is a cornerstone of the prevention of HAIs, including C. difficile. Alcohol-based hand sanitisers are highly effective against non-spore-forming organisms, but they may not kill C. difficile spores or remove C. difficile from the hands.

The most effective way to remove them from hands is through handwashing with soap and water.

In 2021 ESCMID: 2021 updated the treatment guidance document for CDI in adults.[46]

Important changes compared with the previous guideline include but are not limited to: (1) metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, (2) fidaxomicin is the preferred agent for the treatment of initial CDI and the first recurrence of CDI when available and feasible, (3) FMT or bezlotoxumab in addition to Standard of Care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, (4) bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and (5) bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with a high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.

  The Need for Surveillance Top

HAIs are an important hospital and public health concern around the world. The prevalence of both MDROs and of a vulnerable and immunocompromised population of patients is increasing in hospitals. A large percentage of HAIs are preventable and the scientific literature has established that incorporating surveillance systems into IPC activities is a means to reduce the frequency of these events.

Despite the availability of standard procedures and evidence-based guidelines aiming at reducing the impact of HAIs, the implementation of those into routine practice appears as the biggest challenge.[47] Every health-care facility should provide quality and safe care.

HAI surveillance and timely feedback of results are strongly recommended by WHO as part of the core components of effective IPC programmes.[48]

Surveillance and feedback of infection rates to HCWs is a cornerstone of HAI prevention programs and should be considered as integrated into a comprehensive and multimodal infection and prevention and control strategy. Conducting high-quality surveillance is crucial to assess the safety level of the surgical workflow, detect criticalities and diffuse warnings to trigger the response capability of health-care organisations. Feedback on achievements should be constantly monitored and timely disseminated throughout the levels of the organisation.[49],[50] Surveillance of HAIs is a fundamental aspect, in particular, when HAIs are identified as a target for improvement. Haley's 1980 landmark Study on the Efficacy of Nosocomial Infection Control (SENIC Project)[51] demonstrated that a comprehensive, organised surveillance system was associated with reduced rates of HAI. Haley's study also found that feedback of infection rates to surgeons was an essential surveillance component to reduce SSIs.

  Behaviour Changes in Preventing and Managing Healthcare-Associated Infections Top

Despite strong pieces of evidence, compliance with HAIs prevention strategies is uniformly poor and major difficulties arise when evidence-based guidelines are introduced into daily clinical practice. The incidence of HAIs can be reduced by adhering to IPC guidelines. In health-care settings, IPC programs are effective in preventing many HAIs.[52]

However, high rates of inappropriate IPC practices across the surgical pathway continue to be reported. Because of cognitive dissonance (recognising that an action is necessary without implementing it), changing behaviour is extremely challenging. In hospitals, cultural and behavioural determinants influence clinical daily practice. Improving surgeons' behaviours in preventing HAIs remains a challenge.

There are generally three primary levels of influence related to behaviours improvement IPC. They include the followings:

  1. Intrapersonal factors
  2. Interpersonal factors
  3. Institutional or organisational factors.

On an individual level, surgeons should have the necessary knowledge to implement effective IPC practices. Increasing knowledge may influence surgeons' perceptions and motivate them to change behaviours. Education and training represent an important component for the accurate implementation of recommendations. Education of surgeons in preventing HAIs should begin at the undergraduate level and should be consolidated with further training throughout the postgraduate years. Hospitals are responsible for educating all HCWs including surgeons about IPC. Active education techniques, including academic detailing, consensus building sessions and educational workshops, should be implemented in each hospital according to its resources. However, increasing knowledge alone may not be sufficient for implementing effective IPC and maybe not sufficient to effect behavioural changes especially considering the multifaceted nature of HAIs.

Peer-to-peer role modelling and 'champions' strategy has been shown to positively influence behavioural changes in IPC practices. Identifying a local opinion leader serving in a surgical department as a champion may be important because the “champion” may integrate best clinical practices, drive the colleagues in changing behaviours, work on a day-to-day basis and promote a culture in which IPC is of high importance. Surgeons with satisfactory knowledge in surgical infections may provide feedback to their colleagues, integrate the best practices among colleagues, implement change within their own sphere of influence and interact directly with the IPC team participating in its activities.[53],[54]

Organisational obstacles may influence IPC implementation. Many different hospital professionals are typically involved in IPC teams,[52] making collaboration essential. IPC teams have been shown to be both clinically effective in improving patient outcome, and cost-effective providing important cost savings in terms of fewer HAIs. Raising awareness of IPC to stakeholders is a crucial factor in changing behaviours. Probably surgeons are more likely to comply with guidelines when they have been involved in developing the recommendations. One way to involve surgeons in guidelines development is to translate practice recommendations into a local protocol or pathway that specifies and coordinates responsibilities and timing for particular actions among a multidisciplinary team. There is now substantial evidence that effective teamwork in healthcare contributes to improved quality of care. Leading international organisations, such as the WHO, support the collaborative practice. It is essential for achieving a concerted approach to providing care that is appropriate to meet the needs of patients, thus optimising individual health outcomes and overall service delivery of health care. The use of such approaches reinforces the concept that each one brings with them their particular expertise and is responsible for their respective contributions to patient care. In this context, the direct involvement of surgeons may be crucial.

  Conclusions Top

HAIs are infections that patients get while receiving treatment for medical or surgical conditions, and many HAIs are preventable. Modern healthcare employs many types of invasive devices and procedures to treat patients and help them recover. HAIs can be associated with procedures (like surgery) and the devices used in medical procedures, such as catheters or ventilators. HAIs are important causes of morbidity and mortality and are associated with a substantial increase in health-care costs each year. The risk of HAIs can be reduced by adhering to IPC guidelines. However, high rates of inappropriate practices in surgery continue to be reported in the literature. Changing behaviour is extremely challenging. In hospitals, cultural, contextual and behavioural determinants influence clinical practice. Improving behaviour in preventing HAIs remains a challenge and understanding how to implement health-care workers' behaviour is crucial to develop effective reduction in HAIs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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