Nosocomial infection

Nosocomial infection

see also Nosocomial meningitis.

Hospital-acquired infection (HAI) — also known as nosocomial infection — is an infection whose development is favored by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff.

In a single-center, retrospective analysis of critically ill pediatric trauma patients, nosocomial infections were more frequently observed in patients admitted following polytrauma with traumatic brain injury than in patients with isolated traumatic brain injury or trauma without traumatic brain injury 1).

In the last few decades, there has been a tremendous advancement in foetal and maternal care, and it has led to premature babies born as early as 25 weeks of gestation being nursed and cared for in neonatal and pediatric intensive care units. However, these children can pick up a number of uncommon and rare hospital-acquired infections including central nervous system infections.

Wagh and Sinha have given their own insight as to the prevention of healthcare-associated infections in paediatric intensive care settings and reviewed the current literature on the topic.

Healthcare-associated infections are largely preventable provided adequate prevention and protective measures are put in place and prevention guidelines are stritctly followed 2).

In the United States, the Centers for Disease Control and Prevention estimated roughly 1.7 million hospital-associated infections, from all types of microorganisms, including bacteria, combined, cause or contribute to 99,000 deaths each year.

In Europe, where hospital surveys have been conducted, the category of gram-negative infections are estimated to account for two-thirds of the 25,000 deaths each year. Nosocomial infections can cause severe pneumonia and infections of the urinary tract, bloodstream and other parts of the body. Many types are difficult to attack with antibiotics, and antibiotic resistance is spreading to gram-negative bacteria that can infect people outside the hospital.

Hospital-acquired infections are an important category of hospital-acquired conditions. HAI is sometimes expanded as healthcare associated infection to emphasize that infections can be correlated with health care in various settings (not just hospitals), which is also true of hospital-acquired conditions generally.

Data on nosocomial bloodstream infections (NBSI) in neurosurgery is limited. A study aimed to analyze the epidemiology, microbiology, outcome, and risk factors for death in neurosurgical patients with NBSI in a multidrug resistant setting.

Neurosurgical patients with a confirmed NBSI within the period 2003-2012 were retrospectively analyzed. NBSI was diagnosed when a pathogen was isolated from a blood sample obtained after the first 48 h of hospitalization. Patients’ demographic, clinical, and microbiological data were recorded and analyzed using univariate and multivariate analysis.

A total of 236 patients with nosocomial infection (NI) were identified and 378 isolates were recovered from blood cultures. Incidence of NI was 4.3 infections/1000 bed-days. Gram negative bacteria slightly predominated (54.5 %). The commonest bacteria were coagulase-negative Staphylococcus (CoNS, 26 %), Klebsiella pneumoniae (15.3 %), Pseudomonas aeruginosa (14.8 %), and Acinetobacter baumannii(13.2 %). Carbapenem resistance was found in 90 % of A. baumannii, in 66 % of P. aeruginosa, and in 22 % (2003-2007) to 77 % (2008-2012) of K. pneumoniae isolates (p < 0.05). Most CoNS and Staphylococcus aureus isolates (94 and 80 %, respectively) were methicillin-resistant. All Gram-negative isolates were sensitive to colistin and all Gram-positive isolates were sensitive to vancomycin and linezolid. Antimicrobial consumption decreased after 2007 (p < 0.05). Overall mortality was 50.4 %. In multivariate analysis, advanced age and stay in an Intermediate Care Unit (IMCU) were independent risk factors for in-hospital mortality (p < 0.05).

Overall, high incidence of NBSI and considerable resistance of Gram positive and particularly Gram negative bacteria were noted in neurosurgical patients. Mortality was high with advanced age and stay in IMCU being the most important death-related factor 3).

Case series

In one hundred fifty-three patients with aSAH. Delayed cerebral ischemia (DCI) was identified in 32 patients (20.9%). Nosocomial infection (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.09-11.2, p = 0.04), ventriculitis (OR 25.3, 95% CI 1.39-458.7, p = 0.03), aneurysm re-rupture (OR 7.55, 95% CI 1.02-55.7, p = 0.05), and clinical vasospasm (OR 43.4, 95% CI 13.1-143.4, p < 0.01) were independently associated with the development of DCI. Diagnosis of nosocomial infection preceded the diagnosis of DCI in 15 (71.4%) of 21 patients. Patients diagnosed with nosocomial infection experienced significantly worse outcomes as measured by the modified Rankin Scale score at discharge and 1 year (p < 0.01 and p = 0.03, respectively).

Nosocomial infection is independently associated with DCI. This association is hypothesized to be partly causative through the exacerbation of systemic inflammation leading to thrombosis and subsequent ischemia 4).



Sribnick EA, Hensley J, Moore-Clingenpeel M, Muszynski JA, Thakkar RK, Hall MW. Nosocomial Infection Following Severe Traumatic Injury in Children. Pediatr Crit Care Med. 2020 Feb 25. doi: 10.1097/PCC.0000000000002238. [Epub ahead of print] PubMed PMID: 32106190.

Wagh A, Sinha A. Prevention of healthcare associated infections in pediatric intensive care unit. Childs Nerv Syst. 2018 Aug 18. doi: 10.1007/s00381-018-3909-4. [Epub ahead of print] PubMed PMID: 30121831.

Tsitsopoulos PP, Iosifidis E, Antachopoulos C, Anestis DM, Karantani E, Karyoti A, Papaevangelou G, Kyriazidis E, Roilides E, Tsonidis C. Nosocomial bloodstream infections in neurosurgery: a 10-year analysis in a center with high antimicrobial drug-resistance prevalence. Acta Neurochir (Wien). 2016 Sep;158(9):1647-54. doi: 10.1007/s00701-016-2890-5. Epub 2016 Jul 25. PubMed PMID: 27452903.

Foreman PM, Chua M, Harrigan MR, Fisher WS 3rd, Vyas NA, Lipsky RH, Walters BC, Tubbs RS, Shoja MM, Griessenauer CJ. Association of nosocomial infections with delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Neurosurg. 2016 Dec;125(6):1383-1389. PubMed PMID: 26871202.

Spinal epidural abscess

Spinal epidural abscess

Spinal infection in the epidural space.


Spinal epidural abscess epidemiology.


It is possible to distinguish two types of SEA: primary SEA due to pathogen hematogenous dissemination and secondary SEA resulting from direct inoculation of pathogen. This entity, very uncommon, shows a prevalence peak between the 5th and the 7th decade of life with predominance in males 1).

see Cervical spinal epidural abscess.

see Lumbar spinal epidural abscess.


Spinal epidural abscess etiology.


Spinal epidural abscess pathophysiology.

Clinical features

Spinal epidural abscess clinical features.


Spinal epidural abscess diagnosis.

Differential diagnosis

Spinal epidural abscess differential diagnosis.


Spinal epidural abscess treatment.


Spinal epidural abscess outcome.

Case series

Spinal epidural abscess case series.

Case reports

Spinal epidural abscess case reports.


Maiese A, Volonnino G, Viola RV, Nelson Cavallari E, Fazio V, Arcangeli M, La Russa R. A rare case of Spinal Epidural Abscess following mesotherapy: a challenging diagnosis and the importance of clinical risk management. Considerations concerning uncommon risk factor for development of Spinal Epidural Abscess and its prevention. Clin Ter. 2020 Jan-Feb;170(1):e15-e18. doi: 10.7417/CT.2020.2183. PubMed PMID: 31850479.

Rhinocladiella mackenziei

Rhinocladiella mackenziei

Rhinocladiella mackenziei is a pigmented fungus.

Primary cerebral phaeohyphomycosis due to Rhinocladiella mackenziei is an extremely rare infection carrying more than 80% mortality, with most cases reported from the Middle East region. This darkly pigmented black yeast is highly neurotropic, aggressive and refractory to most antifungal agents.

Cerebral abscess due to pigmented moulds are a rare but usually fatal infection occasionally seen in transplant recipients.

Rhinocladiella mackenziei was believed to be endemic solely to the Middle East, due to the first cases of infection being limited to the region. However, cases of R. mackenziei infection are increasingly reported from regions outside the Middle East. The agent is dissimilar to typically opportunistic agents of fungal disease in that the majority of cases have been reported from immunologically normal people.

A 67 year old male of Iraqi origin underwent a deceased donation renal transplant for renal failure and 2 months later was diagnosed with an abscess in the left posterior frontal lobe of his brain. Subsequent biopsy proved this to be due to the mould Rhinocladiella mackenziei. Further interventions included two operations to aspirate the lesion, voriconazole, then liposomal amphotericin B, then a combination of posaconazole and flucytosine which he continued for over four years. He also suffered from right ankle pain and was diagnosed with septic arthritis; R. mackenziei was isolated from pus aspirated from the ankle joint. He responded well to the treatment and has had little loss of function, and on CT the cerebral lesion has stabilised. Beta-D-glucan, initially at very high levels proved useful to monitor response over the 5 years and the latest sample was negative (38 pg/mL). This case is notable for the first disseminated case of this infection, its favourable outcome on a novel antifungal combination and a new approach to monitoring the course of disease 1).

Barde et al. analyzed posaconazole concentrations in plasma and multiple CNS specimens taken from a patient who received posaconazole because of cerebral phaeohyphomycosis. Low posaconazole concentrations were obtained in CNS specimens, with sample-to-plasma ratios between 5% and 22%. This case highlights the role of neurosurgery during cerebral phaeohyphomycoses, even those caused by posaconazole-susceptible black fungi. 2).

Yusupov et al. presented an immunocompetent elderly male, presenting with multiple brain abscesses, with R. mackenziei confirmed by nuclear ribosomal repeat region sequencing, who was successfully treated by surgical debridement and intravenous voriconazole. To our knowledge this is the first case reported from the United Kingdom. We also present a review of all such cases so far reported in the English literature world-wide, which we believe is a step further to understanding the pathogenesis and establishing effective treatment of this rare, yet often fatal disease 3).

Cristini et al. described the case of a native Afghan woman living in France who presented with brain abscesses due to R. mackenziei 4).



Hardman N, Young N, Hobson R, Sandoe J, Wellberry-Smith M, Thomson S, Barton R. Prolonged survival after disseminated Rhinocladiella infection treated with surgical excision and posaconazole. Transpl Infect Dis. 2020 Feb 13:e13264. doi: 10.1111/tid.13264. [Epub ahead of print] PubMed PMID: 32053285.

Barde F, Billaud E, Goldwirt L, Horodyckid C, Jullien V, Lanternier F, Lesprit P, Limousin L, Cohen JF, Lortholary O. Low Central Nervous System Posaconazole Concentrations during Cerebral Phaeohyphomycosis. Antimicrob Agents Chemother. 2019 Oct 22;63(11). pii: e01184-19. doi: 10.1128/AAC.01184-19. Print 2019 Nov. PubMed PMID: 31427294; PubMed Central PMCID: PMC6811437.

Yusupov N, Merve A, Warrell CE, Johnson E, Curtis C, Samandouras G. Multiple brain abscesses caused by Rhinocladiella mackenziei in an immunocompetent patient: a case report and literature review. Acta Neurochir (Wien). 2017 Sep;159(9):1757-1763. doi: 10.1007/s00701-017-3141-0. Epub 2017 Apr 1. Review. PubMed PMID: 28365816.

Cristini A, Garcia-Hermoso D, Celard M, Albrand G, Lortholary O. Cerebral phaeohyphomycosis caused by Rhinocladiella mackenziei in a woman native to Afghanistan. J Clin Microbiol. 2010 Sep;48(9):3451-4. doi: 10.1128/JCM.00924-10. Epub 2010 Jun 30. PubMed PMID: 20592148; PubMed Central PMCID: PMC2937739.

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