Healthcare-Associated Infections — UKMLA Guide 2026

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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

Healthcare-associated infection (HCAI): infection occurring ≥48 hours after hospital admission (or within 30 days of surgery). Includes: catheter-associated UTI (CAUTI), surgical site infection (SSI), ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), C. difficile
MRSA: screen all elective admissions (nasal swab), decolonise (mupirocin nasal ointment + chlorhexidine body wash) before surgery. Treat MRSA infection with vancomycin, teicoplanin, linezolid, or daptomycin
Antimicrobial stewardship (NICE NG15): use narrow-spectrum antibiotics where possible, review at 48-72 hours, de-escalate based on cultures, document indication/duration/review date, follow local guidelines
Key resistant organisms: MRSA, ESBL-producing Enterobacteriaceae, VRE, carbapenem-resistant organisms (CPE/CRO) — hospital infection control policies are critical
Infection prevention: hand hygiene (WHO 5 moments), isolation precautions, aseptic technique, care bundles for lines/catheters, surveillance and audit

Overview

Healthcare-associated infections (HCAIs) are a major cause of morbidity, mortality, and increased healthcare costs. In the UK, approximately 300,000 patients develop an HCAI each year. Antimicrobial resistance (AMR) is recognised as one of the greatest threats to global health — the inappropriate and excessive use of antibiotics drives resistance. Antimicrobial stewardship programmes aim to optimise antibiotic use, reduce unnecessary prescribing, and slow the emergence of resistance. Every doctor has a responsibility to prescribe antibiotics appropriately.

Epidemiology

CAUTI is the most common HCAI (accounts for ~40% of HCAIs), followed by SSI, pneumonia, and BSI. MRSA bacteraemia rates in England have fallen dramatically (>80% reduction since 2007) due to mandatory screening and decolonisation. C. difficile rates have also fallen significantly. However, Gram-negative resistance (ESBL, CPE) is rising and is now a greater concern than MRSA in many settings. The UK Government's 5-year AMR strategy targets a 50% reduction in inappropriate antibiotic prescribing.

Clinical Features

Symptoms

CAUTI: new-onset dysuria, fever, confusion (elderly) in catheterised patient >48 hours after catheter insertion

SSI: wound pain, erythema, discharge, dehiscence within 30 days of surgery (or 1 year if implant)

VAP: new fever, purulent respiratory secretions, deteriorating oxygenation in ventilated patient >48 hours after intubation

CLABSI: fever, rigors, line-site erythema/discharge in patient with central venous catheter

Signs

Fever developing ≥48 hours after admission

Signs of localised infection at device site (line, catheter, wound)

New sepsis markers (tachycardia, hypotension, confusion)

Investigations

First-line

Appropriate cultures BEFORE antibioticsBlood cultures, urine culture (from catheter port, not bag), wound swab, sputum, line-tip culture (if line removed)

FBC, CRP, lactateInflammatory markers, sepsis markers

Second-line

MRSA screeningNasal swab (± groin, axilla, wounds) — screen all elective admissions and emergency admissions per local policy

CPE/CRO screeningRectal swab for carbapenem-resistant organisms — screen patients transferred from abroad or high-risk settings

Specialist

Antimicrobial susceptibility testingEssential for resistant organisms — guides targeted therapy. Includes ESBL, carbapenemase, MRSA detection

Management

NICE NG15 (Antimicrobial Stewardship, 2015) + NICE NG139 (HCAI) + PHE

Antimicrobial stewardship principles (NICE NG15)

Prescribe antibiotics only when there is a clear clinical indication — not "just in case"
Use narrow-spectrum antibiotics where possible
Follow local antibiotic guidelines (hospital formulary) — not personal preference
Document: indication, dose, route, duration, and review date in patient notes
Review at 48-72 hours: switch IV to oral (IVOS/OPAT), de-escalate based on cultures, stop if no longer indicated
Prescribe for the shortest effective duration

MRSA management

Screening: nasal swab ± groin/axillae for all elective and high-risk emergency admissions
Decolonisation (if MRSA-positive): mupirocin 2% nasal ointment TDS for 5 days + chlorhexidine 4% body wash daily for 5 days — before surgery
Treatment of MRSA infection: IV vancomycin (target trough 15-20 mg/L), teicoplanin, linezolid, or daptomycin depending on site

Infection prevention and control

Hand hygiene: WHO 5 moments (before patient contact, before aseptic procedure, after body fluid exposure, after patient contact, after contact with patient surroundings)
Standard precautions for ALL patients. Contact/droplet/airborne precautions as indicated
Care bundles: ventilator bundle (head elevation, sedation breaks, oral care, DVT prophylaxis), central line bundle (maximal barrier precautions, chlorhexidine skin prep, daily line review), catheter bundle (insertion aseptic technique, daily review of need — remove ASAP)

Device-related infection prevention

Remove unnecessary urinary catheters — the single most effective intervention for CAUTI prevention
Daily review of IV lines and remove when no longer needed
Aseptic non-touch technique (ANTT) for all procedures
Surgical antibiotic prophylaxis: single dose at induction of anaesthesia (typically cefuroxime) per local protocol

Complications

Antimicrobial resistance: MRSA, ESBL, VRE, CPE — increasingly difficult-to-treat infections with limited antibiotic options
Increased mortality: HCAIs increase hospital mortality, particularly bacteraemia and VAP
Prolonged hospital stay: Average 10 additional bed days per HCAI episode
C. difficile outbreaks: Particularly in elderly care settings — driven by broad-spectrum antibiotic use

UKMLA Exam Tips

1WHO 5 moments of hand hygiene: before patient contact, before aseptic procedure, after body fluid exposure, after patient contact, after contact with surroundings
2MRSA decolonisation: mupirocin nasal ointment + chlorhexidine body wash for 5 days before elective surgery
3The single best intervention to reduce CAUTI is to REMOVE unnecessary urinary catheters — document daily review of need
4Antimicrobial stewardship: review ALL antibiotics at 48-72 hours — stop, switch IV→oral, or de-escalate
5ESBL organisms: resistant to cephalosporins and penicillins. Treat with carbapenems (meropenem) — but this drives further resistance
6CPE/CRO: resistant to CARBAPENEMS — extremely limited treatment options (colistin, tigecycline). Major public health threat

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