Page 23 - Medicine and Surgery

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Chapter 1: Infections 19

massage and transcutaneous electrical nerve stimulation a major cause of concern. Some examples include the
(TENS) can often help with pain. following:
Methicillin resistant Staph. aureus (MRSA) is resistant

to flucloxacillin and most other commonly used anti
Infections Staphylococcal agents. It is treated by vancomycin or
teicoplanin. Nasal colonisation and skin clearance is
achieved by topical cream and antiseptic washes.
Nosocomial infections
Vancomycin resistant Enterococcus (VRE) is increas-
Infections acquired during a hospital stay are called ingly common.
nosocomialinfections.Usuallyaninfectionisconsidered Vancomycin-intermediate/resistant Staph. aureus
to be nosocomial if it arises >72 hours after admission, (VISA/VRSA) emerged with cases of VISA in the late
as earlier infections are usually presumed to have been 1990s and VRSA in 2002. It is still rare, but of concern.
acquired in the community. For patients who are only It is also called GISA (glycopeptide-intermediate SA)
briefly admitted the infection may only become manifest because vancomycin is a glycopeptide.
after discharge.
Approximately 10% of patients admitted to a hospital
Prevention of nosocomial infections
in the United Kingdom acquire a nosocomial infection.
The principles are to avoid transmission by always wash-
Infections may be spread by droplet inhalation or direct
ing hands after examining a patient, strict aseptic care
hand contact from hospital staff or equipment. The pa-
of central lines and isolation of cases in a side-room or
tients most at risk are those at extremes of age, those
even by ward. Certain patients are given prophylactic an-
with significant co-morbidity, the immunosuppressed
tibiotics, e.g. preoperatively, where possible indwelling
and those with recent surgery. Risk factors also depend
urinary catheters or central lines should be avoided or
on the site, for example pneumonia is more common in
the duration of use minimised. Early mobilisation and
patients who are ventilated, who are bedbound or who discharge also help to reduce the period of risk. Once pa-
have had thoracic or abdominal surgery. Instrumenta- tients are identified as having diarrhoea or being infected
tion such as urinary catherisation or central lines can
with resistant organisms they should be barrier nursed
introduce infections.
in a separate room. Staff and visitors should wear gloves,
The commonest sites of nosocomial infections are
aprons and where appropriate masks whilst in the room,
urinary tract infections,

and disinfect their hands following the visit with alcohol
respiratory tract infections,

gel. Patients at high risk because of neutropenia are also
surgical site infections (see page 16),

isolated and reverse barrier nursed to try to protect them
bacteraemia,

from exposure to infections.
skin infections, e.g. of burns and

In addition, overuse of antibiotics particularly broad-
gastrointestinal infections.

spectrum antibiotics should be avoided. Where the de-
Nosocomial infections are most commonly bacterial,
velopment of resistance is likely, combination antibiotics
particularly Staph. aureus, Pseudomonas and Escherichia
are used.
coli. Clostridium difficile is a common cause of diarrhoea
in patients given broad-spectrum antibiotics (see page
150). Viruses are also important, e.g. small round struc- Pyrexia of unknown origin (PUO)
tured viruses (SRSV), which have caused outbreaks of
Definition
diarrhoeainsomehospitals,influenzaandotherrespira-
An intermittent or continuous fever >38˚C lasting more
tory infections can affect patients and staff alike (as dra-
than 3 weeks and without diagnosis despite initial inves-
matically highlighted by the outbreak of SARS in 2003).
tigations.
Fungi, particularly Candida and Aspergillus,are also be-
coming more important.
Many of the pathogens that cause nosocomial infec- Aetiology
tions have a high level of antibiotic resistance, which is See Table 1.6.