Health Care—Associated Infection (HAI): A Critical Appraisal of the Emerging Threat—Proceedings of the HAI Summit
Marin H. Kollef
()
1
3
Lena M. Napolitano
0
Joseph S. Solomkin
7
Richard G. Wunderink
6
In-Gyu Bae
4
Vance G. Fowler
4
Robert A. Balk
5
Dennis L. Stevens
9
James J. Rahal
2
8
Andrew F. Shorr
11
12
Peter K. Linden
10
Scott T. Micek
1
3
0
University of Michigan Health Center
,
Ann Arbor
1
Barnes-Jewish Hospital
,
St. Louis, Missouri
2
Weill Medical College of Cornell University
,
New York, New York
3
Washington University School of Medicine
4
Duke University Medical Center
,
Durham, North Carolina
5
Rush University Medical Center and Rush Medical College
,
Chicago, Illinois
6
Feinberg School of Medicine, Northwestern University
7
University of Cincinnati College of Medicine
, Cincinnati,
Ohio
8
New York Hospital Queens
, Flushing
9
Veterans Affairs Medical Center
, Boise,
Idaho
10
University of Pittsburgh Medical Center
,
Pittsburgh, Pennsylvania
11
Washington Hospital Center
12
Georgetown University
,
Washington, DC
During the Health Care-Associated Pneumonia Summit conducted in June 2007, it was found that there is a need for educational efforts in several areas of health care-associated infections (HAI) that extend beyond pneumonia. This supplement to Clinical Infectious Diseases represents the proceedings of the HAI Summit, a diverse panel of clinical investigators whose goal was to assess the quality of evidence regarding issues surrounding HAI and to discuss potential implications for its diagnosis and treatment in the future.
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The classification of bacterial infections is in a state of
flux. Most of the prior classification schemes have
segregated these infections according to the site of
infection (e.g., lung, urinary tract, soft tissue and skin, and
intra-abdominal) and the location of the patient at the
time the infection developed. The latter has historically
been divided into community-acquired and nosocomial
(hospital-acquired) infections [1, 2]. Unfortunately,
this simple classification scheme is no longer adequate,
because of changing patient demographics and risk
profiles for infection with potentially
antibiotic-resistant bacteria, which historically have been encountered
primarily in the hospital setting.
Patients with serious infections (e.g., pneumonia,
bacteremia, and septic shock) should be given
treatment initially with antibiotics active against the
bacterial pathogens causing the infection (i.e., appropriate
antibiotic therapy). Additionally, appropriate antibiotic
therapy should be administered in a timely manner to
optimize the likelihood of a clinical response. The
support for these recommendations comes from
investigations demonstrating that patients initially given
treatment with antibiotic regimens that are not active against
the causative bacterial species (i.e., inappropriate
antibiotic therapy) have a greater risk for in-hospital
mortality than do patients receiving appropriate therapy [3
5]. Classification schemes should assist clinicians in
identifying patients at risk for antibiotic-resistant
infections, thereby requiring initial treatment with
broadspectrum antimicrobials. The recognition of potentially
antibiotic-resistant infections occurring outside the
hospital setting has resulted in the formulation of the
new category, termed health careassociated
infections (HAIs). Implicit in the definition of HAIs is that
patients will require initial therapy with more
broadspectrum antibiotics, compared with patients with
community-acquired infections.
HAIs have been defined using various criteria (table
1). Friedman et al. [6] evaluated patients admitted to
the hospital with bloodstream infections (BSIs) and
showed that individuals with HAI risk factors were
statistically more likely than were patients with
community-acquired infections to be infected with
anti
Infection type [source] and criteria
Bacteremia [6]
Health careassociated BSI was defined by a positive culture
result for a blood specimen obtained from a patient at the
time of hospital admission or within 48 h after admission
if the patient fulfilled any of the following criteria:
1. Received intravenous therapy at home; received wound
care or specialized nursing care through a health care
agency, family, or friends; or had self-administered
intravenous medical therapy in the 30 days before the BSI.
Patients whose only home therapy was oxygen use were
excluded.
2. Attended a hospital or hemodialysis clinic or received intra
venous chemotherapy in the 30 days before the BSI
3. Was hospitalized in an acute care hospital for 2 days in the 90 days before the BSI
4. Resided in a nursing home or long-term-care facility
Pneumonia [7]
HCAP was defined as a diagnosis of pneumonia in patients with
a first positive bacterial respiratory culture finding within
2 days of admission and any of the following:
1. Admission source indicates a transfer from another health care facility
2. Receiving long-term hemodialysis
3. Prior hospitalization within 30 days for those whose condi
tion does not meet VAP definition
P (...truncated)