Etiology

Types of Healthcare-Associated Infection (HAI)

Responsible pathogens originate from a variety of different sources and are represented by different types of HAI. The Centers for Disease Control and Prevention broadly categorizes the types of HAI as follows:

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Other types of HAI include non-ventilator-associated hospital-acquired pneumonia (NV-HAP), gastrointestinal infections (including Clostridioides difficile), other primary bloodstream infections—not associated with central catheter use, and other urinary tract infections—not associated with catheter use. HAI may also be grouped by affected systems such as ear, eye, nose and throat infections, lower respiratory tract infections (including bronchitis, tracheobronchitis, bronchiolitis, tracheitis, lung abscess or empyema without evidence of pneumonia), skin and soft-tissue infections, cardiovascular infection, bone and joint infections, central nervous systems infection, and reproductive tract infections.

A point-prevalence survey conducted in the United States in 2015 showed that the most common HAI in acute hospital settings is pneumonia, followed by gastrointestinal infections, SSI, other infections of the systems, as mentioned earlier, bloodstream infections, and urinary tract infections.[1] The prevalence of these types of infections has changed from point-prevalence surveys in 2011, which showed pneumonia (21.8%) and SSI (21.8%) as the most common, followed by gastrointestinal (17.1%), urinary tract (12.9%), bloodstream (9.9%) and other infections.[1][5] Interestingly, this same study showed that NV-HAP is the most common type of HAI in the acute health care setting, which is consistent with studies conducted in Europe.[2][6]

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Causative Organisms

Pathogens responsible for nosocomial infections include bacteria, viruses, and fungi. Specific microorganisms have unique characteristics that favor particular types of infections in susceptible hosts. The prevalence of infections caused by particular microorganisms varies depending on the healthcare facility location, healthcare setting, and patient population. Overall, bacteria are the most common pathogens, followed by fungi and viruses.

Bacteria

Bacteria may originate from an exogenous or endogenous source as part of the natural flora. Opportunistic bacterial infections occur when there is a breakdown of the host immune system functions. Common Gram-positive organisms include coagulase-negative Staphylococci, Staphylococcus aureus, Streptococcus species, and Enterococcus species (e.g. faecalis, faecium). Of all HAI associated pathogens, C.difficile accounts for the most commonly reported pathogen in US hospitals (15% of all infections with a reported pathogen).[1][5] Common Gram-negative organisms include species of the Enterobacteriaceae family, including Klebsiella pneumoniae and Klebsiella oxytoca, Escherichia coli, Proteus mirabilis, and Enterobacter species; Pseudomonas aeruginosa, Acinetobacter baumanii, and Burkholderia cepacian. Acinetobacter baumanii is associated with high mortality within the intensive care setting owing to its inherent multi-drug resistant properties.[7][8][9]

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Multidrug-resistant bacteria are commonly seen in HAI and are associated with significant mortality.[9] One study found that approximately 20% of all reported pathogens show multidrug-resistant patterns.[10] Notorious pathogens include methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-intermediate Staphylococcus aureus (VISA) and Vancomycin-resistant Staphylococcus aureus (VRSA), Enterobacteriaceae with extended-spectrum cephalosporin resistance consistent with extended-spectrum beta-lactamase (ESBL) production, vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Enterobacteriaceae and Acinetobacter species, and multi-drug resistant Pseudomonas aeruginosa.

Fungi

Fungal pathogens are usually associated with opportunistic infections in immunocompromised patients and those with indwelling devices, such as central lines or urinary catheters. Candida species, such as C. albicans, C. parapsilosis, C.glabrata are the most commonly encountered fungal organisms associated with HAI.[1] Candida auris poses a serious problem as a globally emerging multidrug-resistant organism with high morbidity and mortality due to difficulty with diagnoses and high rates of treatment failure.[11] Altogether, Candida species make up the fourth most common pathogen across all types of HAIs.[12] Aspergillus fumigatus may be acquired by airborne environmental contamination in areas of healthcare construction. However, infected hospitalized patients may be a primary source.[13][14]

Viruses

Infections due to viral pathogens are the least reported, making up 1-5% of all HAIs pathogens.[15] Healthcare-acquired hepatitis B and C and human deficiency virus (HIV) has been implicated in unsafe needle practices. Globally 5.4% of all HIV infections are healthcare-associated and frequently occur in developing countries.[16] Other reported viral pathogens include rhinovirus, cytomegalovirus, herpes simplex virus, rotavirus, and influenza.

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