CDC definition of health-care associated infection

ผู้ช่วยศาสตราจารย์ ศิริลักษณ์ อภิวาณิชย์

โรงพยาบาลรามาธิบดี คณะแพทยศาสตร์ โรงพยาบาลรามาธิบดี

Definitions of healthcare-associated infection

1. Surveillance definitions

2. Site specific types of healthcare-associated infection

- BSI

- UTI

- RTI

Surveillance definitions

• Infection criterion were not present the admission time period But all present on or after the 3rd calendar day of admission to facility

• “ Day 1, day of facility admission”

Surveillance definitions

• Symptom must be documented in the chart by a healthcare professional during POA (present on admission)

• Physician diagnosis can be accepted as evidence of an infection that is POA only

Healthcare-associated infection

• All elements of a CDC site specific infection criterion were not present during the POA

• But all present on or after the 3rd calendar day

of admission to the facility

• The day of hospital admission is calendar day 1

• All elements of a CDC site specific infection criterion are present on the day of discharge or the next day, the infection is attributed to the discharging location

Other important considerations:

• Clinical evidence may be derived from direct observation of the infection site or clinical records or Pts’ chart

• A physician or surgeon Dx.of infection from direct observation during an invasive procedure, endoscopic or other diagnostic studies may be accept for an HAI

Healthcare-associated infection

• HAI, clinical information must be utilized to determine that original infection had resolved before reporting a second infection at the same site.

• if the original infection had not resolved before subsequent positive cultures are collected from the same site, add the pathogens recovered from the subsequent cultures to those reported for the first infection, if it was HAI.

Healthcare-associated infection

• The infection has resolved includes

- signs and symptom

- results from diagnostic testing

- completion of antimicrobial therapy

1. Pt had an indwelling urinary catheter in place > 2 calendar days and catheter was place on the date of event

At least 1 of following : Fever > 38C, suprapubic tenderness,Costovertebral angle pain or tenderness

At least 1 of following : - Positive for leukocyte esterase and /or nitrite -pyuria (urine specimen with WBC ≥ 10/mm3 of unspun or ≥ 5 /high power field of spun urine- microorganisms seen on gram stain of unspun urine

Urine culture ≥ 10 5 CFU/ mlwith no more than 2 species

Urine culture ≥ 10 3 CFU/ ml and < 10 5with no more than 2 species

SUTI = CAUTI SUTI = CAUTI

2. Pt had an indwelling urinary catheter in place>2 calendar days and had it removed the day of or the day before

the date of event

At least 1 of following : Fever > 38C, urgency, frquency, suprapubic tenderness, Costovertebral angle pain or tenderness

At least 1 of following : - Positive for leukocyte esterase and /or nitrite -pyuria (urine specimen with WBC ≥ 10/mm3 of unspun or ≥ 5 /high power field of spun urine- microorganisms seen on gram stain of unspun urine

Urine culture ≥ 10 5 CFU/ mlwith no more than 2 species

Urine culture ≥ 10 3 CFU/ ml and < 10 5with no more than 2 species

SUTI = CAUTI SUTI = CAUTI

3. Pt did not have an indwelling urinary catheter that had been in place > 2 calendar days and in place at the time of or before the date of event

At least 1 of following : Fever > 38C (in Pt 65 years of age), urgency, frquency, suprapubic tenderness, Costovertebral angle painor tenderness

At least 1 of following : - Positive for leukocyte esterase and /or nitrite -pyuria (urine specimen with WBC ≥ 10/mm3 of unspun or ≥ 5 /high power field of spun urine- microorganisms seen on gram stain of unspun urine

Urine culture ≥ 10 5 CFU/ mlwith no more than 2 species

Urine culture ≥ 10 3 CFU/ ml and < 10 5with no more than 2 species

SUTI SUTI

4. Pt 1 yr of age (with or without an indwelling urinary catheter)

At least 1 of following : Fever (> 38C core), hypothermia(<36 C core)apnea, bradycardia, dysuria, lethargy, vomiting

At least 1 of following : - Positive for leukocyte esterase and /or nitrite -pyuria (urine specimen with WBC ≥ 10/mm3 of unspun or ≥ 5 /high power field of spun urine- microorganisms seen on gram stain of unspun urine

Urine culture ≥ 10 5 CFU/ mlwith no more than 2 species

Urine culture ≥ 10 3 CFU/ ml and < 10 5with no more than 2 species

SUTI = CAUTI SUTI

indwelling urinary catheter in place>2 calendar days and had it removed the day of or the day before the date of event

yes No

5. with or without an indwelling urinary catheterPts of any age

None of the signs and symptoms

A positive urine culture ≥ 10 5 CFU/ mlwith no more than 2 species

A positive blood culture with at least 1 match uropathogenmicroorganism to the urine culture or at least 2 match blood culture

Asymtomatic Bacteremic Urinary Tract Infection (ABUTI)

Was an indwelling urinary catheter in place > 2 days before the date of event

yes No

ABUTI (catheter-associated) ABUTI (not catheter-associated)

Uropathogen microorganisms are:

• Gram- negative, Staphylococus spp, yeasts,

• beta- hemolytic streptococus, Enterococcusspp, G. vaginalis, Corynebacterium, Aerococcus urinae.

Bloodstream Infection (CLABSI)

• Central line: an intravascular catheter that terminates at or closes to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring;

– Aota, pulmonary artery, SVC, IVC, ITJ, SCV, FV etc

– In neonates, the UVC, UAC

Central line-associated BSI (CLABSI)

• A central line was place for> 2 calendar days on the date of event, with day of device placement being day 1.

• If CVC was in place for > 2 calendar days and the removed, the LBCI criteria must be fully met on the day of remove or the next day.

Examples:

Day 1 Day 2 Day 3 Day 4 Day 5 Infection is

CVC CVC CVCBlood +

CLBSI

CVC CVC CVC RemoveCVC and

Blood +

CLBSI

CVC CVC RemoveCVC

Temp>38C

Blood + BSI

1. Laboratory-confirmed BSI criteria (LCBI1)

• Pt has a recognized pathogen cultured from one or more blood cultures

• And organism cultured is not related to an infection at another site.

2. Laboratory-confirmed BSI criteria (LCBI 2)

• Pt has at least one of the following signs and symptoms: fever > 38C, chill or hypotension

and

• Positive blood culture are not related to an infection at another site and

• The same common commensal is cultured from 2 cultures drawn on separate occasions

common commensal

• เช่น diphtheroids Corynebacterium spp. ,

Bacillus spp not B. anthracis,

Propionibacterium spp, coagulase-negative staphylococci including S.epidermidis, viridans group streptococci, Aerococcus spp, Micrococcus spp)

separate occasions

separate occasions คือ 2 specimens

- ในวันเดียวกัน

- วันที่ติดกัน

- ต าแหน่งต่างกัน

Examples:

1/6/14 2/6/14 3/6/14 4/6/14 Date of event =

Fever > 38C

No LCBIelement

S.epidermidis

(1 of 2)

S.Epidermidis

(1 of 2)

3/6/14

3. Laboratory-confirmed BSI criteria (LCBI 3)

• Pt 1 yr has at least one of the followingssigns and symptoms: fever (> 38C core),hypothermia (< 36C core), apnea, or breadycardia and

• Positive blood culture are not related to an infection at another site and

• The same common commensal is cultured from 2 cultures drawn on separate occasions

Mucosal Barrier LCBI

• ในกลุ่มผู้ป่วยที่มีหลักฐานที่แสดงว่า มีภูมิต้านทานต่ า เช่นในผู้ป่วย ปลูกถา่ยไต หรือ เม็ดเลือดขาวต่ า

• LCBI 1 พบเชื้อที่อยูใ่นล าไส้ (1 specimen ขึ้นไป) เช่น bacteriodes spp., Candida spp., Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., or Enterobacteriaceae

• LCBI 2 and 3: blood culture only viridans group streptococci with no other organisms isolated

Comments

• In LCBI criteria1 and 2 and Mucosal Barrier LCBI used for Pts of any age including those Pts 1 yr

• Specimens collection considerations: although blood cultures drawn through central lines can have a higher rate of contamination than blood cultures collected through peripheral veinupucture all positive blood culture , regardless of sites from which they were collected, must be included when con conducting in-plan CLABSI surveillance

Comments

• Catheter tip cultures are not used to determine whether a pts has a primary BSI

• When there is a positive blood culture and clinical signs or symptoms of localized infection at a vascular access site, but no other infection can be found, the infection is considered a primary BSI

Secondary BSI guide: 1. blood and site match for at least one organism

HAI criteria for SUTI Blood culture for the same date

Infection is

> 10 5 E.coli E.coli HAI SUTI with Secondary BSI

> 10 5 E.coli E.coli , P.eruginosa

HAI SUTI with Secondary BSI are E.coli & P.eruginosa

since P.eruginosa is a logical pathogen for this site of infection

Secondary BSI guide: 1. blood and site match for at least one organism

HAI criteria for SUTI Blood culture for the same date

Infection is

> 10 5 E.coli E.coli HAI SUTI with Secondary BSI

> 10 5 E.coli E.coli , S.epidermidis

HAI SUTI with Secondary BSI are E.coli since the single S.epidermidisby it self dose not meet BSI

Secondary BSI guide: 2. blood and site do not match organism

• Post-op Pt becomes febrile, nausea, abd pain

T-tube culture = E.coli A CT scan= fluid collectionsuggest infection

Blood culture= bacteroides fragilis

No primary BSI

Secondary BSI guide: 2. blood and site do not match organism

• Post-op Pt has an Intra-abdominal abscess (IAB)

During re-operative

Purulent = E.coli Pt spikes a fever 2 day later

and blood= bacteroides fragilis

A primary BSI would be report

Secondary BSI guide: 2. blood and site do not match organism

• Pt with a foley catheter and CVC for past 4 days a spikes fever

Urine = 10 5E.coli Sputum= normal flora

and blood= enterococcus faecium

A primary BSI would be report

No site- specific specimen culture, only a positive blood culture

• Post-operative pt has abscess in small bowel note during re-operation,

• Only specimen culture is blood culture = bacteroides fragilis is a logical pathogen

The BSI= Secondary BSI

Ventilator-associated pneumonia (VAP) event

• Ventilator-associated pneumonia: a pneumonia where the Pt is on mechanical ventilator for 2 days on the date of event, with day of ventilator placement being Day 1

Definition of pneumonia

Chest x-ray

Signs and symptoms

Laboratory

Chest x-ray for pneumonia

1. New or progressive and persistent infiltration

2. Consolidation

3. Cavitation

4. Pneumatoceles, in 1 yr

Patients with underlying disease – 2 or more abnormal CXR

Patients without underlying disease – 1 or more abnormal CXR

Signs, symptoms, and laboratory

FOR ANY PATIENT, at least one of the following:

1. Fever (38°C or 100.4°F) with no other recognized cause

2. Leukopenia (4,000 WBC/mm3) or

leukocytosis (12,000 WBC/mm3)

3. For adults 70 years old, altered mental status with no other recognized cause

• And at least two of the following:

Signs, symptoms, and laboratory

1. New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements

2. New onset or worsening cough, or dyspnea, or tachypnea

3. Rales or bronchial breath sounds

4. Worsening gas exchange (e.g., O2 desaturations[e.g., PaO2/FiO2 240], increased oxygen requirements, or increased ventilation demand)

Ventilator- Associated Condition (VAC)

• Pt has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days or decreasing daily minimum FiO2 or PEEP values. The baseline period is define as the two calendar days and

Ventilator- Associated Condition (VAC)

• After a period of stability or improvement on ventilator and at least 1 of the following indicated of worsening oxygenation:

- Increase in daily minimum* FiO2 of ≥ 0.20 (20 points) over the daily minimum FiO2 in the baseline period, sustained for ≥ 2 calendar days.

- Increase in daily minimum* PEEP values of ≥ 3 cmH2O over the daily minimum PEEP in the baseline period ,sustained for ≥ 2 calendar days.

Infection-related Ventilator- Associated Complication Condition (IVAC)

• Pt meet criteria for VAC and meet both the following criteria:

1. Fever (38°C or 100.4°F) with no other recognized cause Leukopenia (4,000 WBC/mm3) or leukocytosis (12,000 WBC/mm3)

2. A new ATB agent is started and is continued for 4 days

Possible VAP – possible ventilator- Associated Pneumonia

• Pt meets criteria for VAC and IVAC

Purulent sputum

Purulent sputum is defined as secretions from the lungs, bronchi, or trachea that contain >25 neutrophils and <10 squamous epithelial cells per low power field (x100). Or

“many WBC” or “few squamous epithelial cells”

Purulent sputum

Repeated notations of either purulent sputum or change in character over a 24-hour period would be more indicative of the onset of an infectious process than a single one.

Change in character of sputum refers to the color, consistency, odor and quantity.

Hospital-acquired pneumonia

Reporting multiple episodes of HAP in a single patient: evidence of resolution of the initial

infection. new signs and symptoms and radiographic

evidence

The addition of or change in pathogen alone is not indicative of a new episode of pneumonia

comments

“Physician diagnosis” ไม่ใช่เกณฑ์การวินิจฉัยที่ดีพอ

ถ้าผู้ป่วยมีโรคหัวใจ โรคปอด หรือ ARDS จะต้องมีความระมัดระวังเป็นพิเศษในการวินิจฉัย

ในรายที่มีปญัหาในการวนิิจฉัย การเปรียบเทียบ CXR 3 วันก่อนการวินิจฉัย วันที่วินิจฉัย และ 2-7 วันหลังจากให้การวินิจฉัย เพื่อช่วยในการวนิิจฉัยได้

SSI- surgical site infection

• Deep incisional and organ /space SSI: infection occurs within 30-90 days after the NHSN operative procedure

• Superficial SSI: infection occurs within 30-90 days after the NHSN operative procedure

(day 1 = the procedure date)

Thanks for Your Attention

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