Current guidelines for the treatment and prevention of nosocomial infections.

Nosocomial infections (NIs) are among the most difficult problems confronting clinicians who deal with severely ill patients. The incidence of these hospital-acquired infections varies with the size of hospitals, with specialities of wards, and with many other factors such as length of hospital stay, local trends in antibiotic usage, nursing and hygiene conditions, hospital design and geographical distribution of patients at risk. An average incidence of NI can be estimated at 5 to 10%, with higher rates in large university hospitals, reaching up to 28% in the intensive care unit (ICU). Changing epidemiology of NI and emerging resistance problems have resulted in evolving strategies of antibiotic usage in patients at risk. Several recent antibiotic resistance problems have been identified, for instance in Gram-positive organisms, and have been surveyed, in addition to those previously well known in Gram-negative bacilli. The choice of empiric antibiotic therapy for the treatment of any NI before microbiology is available has become a difficult challenge, requiring: (i) surveillance data on a regular basis of predominant organisms in units at risk; (ii) surveillance of the current resistance patterns of these organisms; (iii) identification of outbreaks involving the prevalent organisms, using modern molecular techniques for typing the strain and assess cross-contamination. In documented infection, monotherapy vs combination therapy has been often discussed in the treatment of serious Gram-negative hospital infections, but these concepts vary with the site of infection, the nature of organism involved and its pattern of resistance, the kind of antibiotic which may more or less quickly select resistant mutants. Antibiotic therapy concepts vary significantly between countries, and combinations either empirical or based on laboratory data are often preferred in European countries than in the US. Frequent collaborative studies and an increasing communication between experts of different countries, make guidelines and consensus conferences, established in a particular country, useful elsewhere and may contribute to improvement in the management of NI. Guidelines for the prevention and the control of NI are well established in many developed countries and they may have resulted in the improvement of the prevention and the treatment of NI. However, there is still potential progress that should be made, including individual preventive practices, improvement in nursing practices, control of antibiotic use, trend to shorten the hospital stay and early discharge from hospital, which results in significant cost savings.