Surveillance definitions of CLABSI, VAP, SSI and CAUTI:

A summary of definition criteria in the CDC NHSN Manual

CDC National Healthcare Safety Network

Before reporting an HAI (healthcare-associated infection), it must satisfy the specific criteria

It is very important to use the criteria consistently to achieve accuracy of reporting of infections

Use clinical, laboratory, pharmacy, radiology and other diagnostic information as well as patient charts and notes

DO NOT USE LABORATORY RESULTS ALONE! (as these may indicate colonization only) Physician’s diagnosis alone, in absence of other

available criteria, is acceptable except for pneumonia

HAI ( Healthcare-associated Infection) A localized or systemic condition resulting from adverse

reaction to the presence of an infectious agent/s or its toxin/s There must be no evidence that the infection was present or

incubating at the time of admission

The source of the infection may be endogenous or exogenous

Infections in infants that result from the passage through the birth canal are HAI’s

Infections that are NOT HAI

Complications or extensions of infections already present on admission, UNLESS a change of pathogen or symptoms strongly suggests the acquisition of a new infection ( a new event)

Infections in infants that are acquired trans-placentally, eg. rubella, CMV, syphilis, AND become evident < 48 hours after birth.

Re-activation of a latent infection eg. Herpes zoster

(shingles), herpes simplex, syphilis, TB

Conditions that are NOT infections

Colonizations: presence of microbes but no adverse clinical signs and symptoms eg. positive Microscopy on urine report

Inflammation in response to tissue injury or chemicals & other non-infectious agents

CLABSI Event Primary bloodstream infections that are associated with

the presence of a central line (or umbilical catheter in neonates) at the time of or within 48 hours before the onset of the event (infection)

There is no minimum time that the line must be in place before the event

LCBI (Laboratory-confirmed bloodstream infection) or CSEP( clinical sepsis) in <1 year-olds

Location of attribution ( where the event became evident) and transfer rule( exception) – see details in NHSN Manual.

What is a central line?

An intravascular catheter that terminates at or close to the heart or in one of the great vessels (aorta, pulmonary artery, superior & inferior vena cava, brachio-cephalic veins, internal jugular veins, subclavian veins, external iliac veins and common femoral veins)

Neonates: umbilical artery or vein

Must be a lumened device through which fluids are infused, pushed or withdrawn. May be temporary or permanent (e.g. dialysis tunneled or implanted catheters, including ports)

LCBI – must meet 1 of 3 criteria

Criterion 1 and 2 apply for all ages, including babies

Criterion 1: Pt has a RECOGNIZED pathogen cultured from 1/more blood

cultures AND the organism in the blood is NOT related to an infection at

another site

Recognized pathogens: S. aureus, Enterococcus spp, E.coli, Pseudomonas spp, Candida spp.

What if it is a common skin contaminant?

(Coagulase negative staphylococci, diptheroids, Bacillus spp, viridans group streptococci, Propionibacterium spp, Micrococcus & Aerococcus spp)

It must have been identified in 2 or more blood cultures Drawn on separate occasions ( but within 2 days of each

other) AND Patient must have symptoms AND not related to other

site.

LCBI – must meet 1 of 3 criteria

Criterion 1 and 2 apply for all ages, including babies

Criterion 2: Patient has at least 1 of the following S/S:

fever ( >38 for adults: 38 rectal or tympanic, 37 oral or 36 axilliary for babies ), chills, or hypotension AND

S/S and pos lab results are not related to infection at another site

AND common skin contaminant cultured from 2 or more blood cultures

drawn at different times

LCBI (Laboratory confirmed bloodstream infection)

Positive catheter tip cultures alone DO NOT indicate a BSI (bloodstream infection)

Purulent phlebitis with positive culture of catheter tip and NO or negative blood culture is reported as CVS-VASC, not a BSI

Only report as a primary BSI if there is no other site of infection. Secondary BSI’s are associated with an infection at another site with the same antibiogram

CSEP ( Clinical sepsis in babies)

Criterion 3:

Patient under 1 year of age has at least one of the following clinical S/S with no other recognized cause:

Fever ( >38 rectal), hypothermia ( <37 rectal), apnea, or bradycardia

AND Blood culture not done or no organisms detected

AND No apparent infection at another site

AND Physician commences treatment for sepsis

Temperature: 38 rectal/tympanic/temporal artery = 37 oral = 36 axillary

37 rectal/tympanic/temporal artery = 36 oral = 35 axillary

VAP (Ventilator Associated Pneumonia) event Diagnosed on radiological, clinical and laboratory criteria

Report PNEU’s that are ventilator-associated if the patient was intubated and ventilated at the time of surveillance, OR within 48 hours before the onset of the event, including the weaning period

There is no minimum period of time the ventilator must be in place in order for the PNEU to be considered VAP

Location of attribution: Where patient was on the date PNEU was identified (eg. Operating room cannot be allocated)

Pt extubated and discharged from hospital A. Admitted hospital B next day with PNEU. = VAP for hospital A

Transfer rule for internal transfers: if VAP develops within 48 hours of transfer, it is attributed to the transferring location

Physician’s diagnosis ALONE is NOT acceptable, except in outbreaks of respiratory syncitial virus, influenza or adenovirus

Definition of a ventilator

A device to assist or control respiration continuously, Through a tracheostomy or By endotracheal intubation Lung expansion devices like:

Intermittent positive pressure breathing ( IPPB) or Nasal positive end-expiratory pressure ( PEEP) or

Continuous nasal pos airway pressure ( CPAP or hypoCPAP)

Are not considered ventilators UNLESS Delivered via tracheostomy or endotracheal intubation

(e.g. ET- CPAP)

When it is not PNEU When clinical status changes are due to:

Myocardial infarction, pulmonary embolism, RDS, atalectasis, malignancy, COAD, hyaline membrane disease, broncho-pulmonary dysplasia, etc.

Intubated patients with tracheal colonization or URTI (eg. tracheo-bronchitis) rather than early onset PNEU Patients with tracheitis, tracheo-bronchitis, or

bronchiolitis without pneumonia are reported as BRON Patients with lung abscess or empyema without

pneumonia are reported as LUNG When patient is elderly, an infant, or immuno-

compromised, typical S/S of pneumonia may be masked – see algorithms

Interpret sputum samples carefully – may be contaminated with airway colonizers, eg. Candida (However Gram stain can be an important clue)

Nosocomial pneumonia

Characterised by onset: Early onset: occurs within the first 4 days of hospitalization

Moraxella catarrhalis, H. influenzae, S. pneumoniae Late onset: often caused by gram negative bacteria and S. aureus,

including MRSA Viruses can cause early and late onset Yeasts, fungi, legionellae and Pneumocystis carinii usually cause

late onset Pneumonia due to gross aspiration is considered nosocomial if it

meets any specific criteria and was not present at admission Multiple episodes of pneumonia may occur in critically ill patients

with long ICU stays. If the episode resolved and a new episode occurred, it is a new event. Change in pathogen alone is NOT indicative of a new event – there must be new

S/S and radiographic evidence. Refer NHSN Manual for Algorithms:P18–21 and footnotes P21 – 22 and flow diagrams: P 23 - 24

Footnotes to algorithms for VAP

The diagnosis of HAI PNEU in non-ventilated patients is not always easy.

Pulmonary or cardiac disease will cloud the clinical picture, eg. Pulmonary oedema from CCF may simulate S/S of pneumonia Thus serial X-rays are necessary to confirm the diagnosis. Look at X-rays 3 days prior to the diagnosis and on days 2 and

7 after the diagnosis Pneumonia may have a rapid onset and progression, but

it does not resolve quickly. Radiographic changes persist for weeks

If X-rays confirm rapid resolution, then it is probably NOT a pneumonia, but a non-infectious process like atalectasis or CCF

.

Footnotes to algorithms for VAP X-ray terminology that may indicate PNEU:

Air-space disease; focal opacification; patchy areas of increased density

Purulent sputum: Secretions from lungs / bronchi / trachea that contain > 25 neutrophils

and <10 squamous epithelial cells per low power field ( x100) A single notation of purulent sputum or change in character of sputum is

not meaningful – changes must be documented over a 24 hour period before they can be seen as indicative of the onset of disease

Patients with pneumonia due to viruses & mycoplasma will have scant or watery sputum ( or sometimes muco-purulent), few S/S, changes will only be seen on X-rays.

Infants with RSV or influenza may produce copious sputum Patients with pneumonia due to Legionella spp, mycoplasma or

viruses: few bacteria seen on gram stain

Footnotes to algorithms for VAP

Tachypnoea: Adults: > 25 breaths per minute Prems : > 75 breaths/min Under 2 months old: > 60 breaths / min 2-12 months: > 50 breaths / min Children > 1 year old: > 30 breaths / min

“Rales” = crackles An endo-tracheal aspirate is NOT a minimally

contaminated specimen, therefore, it does NOT meet the laboratory criteria

Semi-quantitative or non-quantitative cultures of sputum obtained by deep cough, induction, aspiration, or lavage are acceptable

Footnotes to algorithms for VAP

Immunocompromised patients include: Neutropaenia (absolute neutrophil count < 500/cubic mm) Leukaemia Lymphoma HIV with CD 4 count < 200 Splenectomy Early post-transplant Cytotoxic chemotherapy High dose steroids

Algorithms for VAP

PNU 1: an algorithm used for clinically defined pneumonia

PNU 2: Table 5: Pneumonia with common bacterial or filamentous fungal pathogens and specific laboratory findings

Table 6: Pneumonia with viral, Legionella, Chlamydia, Mycoplasma and other uncommon pathogens and specific laboratory findings

PNU 3: Pneumonia in immunocompromised patients

CAUTI event

Catheter-associated UTI’s are classified into 2 groups: SUTI and ASB. ( excludes OUTI)

Report UTI’s that are catheter-associated if the patient had an in-dwelling catheter at the time or within 7 days before the onset of the event

There is no minimum time the catheter must be in situ in order for the UTI to considered catheter-associated

Location of attribution and transfer rule as per VAP

Definition of an in-dwelling catheter

A drainage tube That is inserted into the urinary bladder Through the urethra Is left in place And is connected to a closed drainage system Does NOT include straight in-and-out catheters

SUTI (Symptomatic Urinary Tract Infection)

Must meet at least 1 of the following:

Criterion 1: Patient has at least 1 of the following S/S with no other

recognized cause: fever > 38, urgency, frequency, dysuria, or suprapubic

tenderness

and Patient has positive urine culture, i.e. > 100,000

microorganisms per ml of urine with no more than 2 species of microorganism

SUTI (Symptomatic Urinary Tract Infection)Criterion 2:

Patient has at least 2 of the following S/S with no other recognized cause:

fever>38, urgency, frequency, dysuria, or suprapubic tenderness and at least 1 of the following:

positive dipstick for leukocyte esterase &/or nitrate pyuria ( > 10 wbc/cubic mm) organisms seen on gram stain of unspun urine at least 2 urine cultures with repeated isolation of same uropathogen

( G negative bacteria or S. saprophyticus) with >100 cfu/ml in non-voided specimens

< 100 000cfu/ml of a single uropathogen in a patient on antibiotics for UTI

Physician diagnosis of UTI Physician commences specific therapy for UTI

SUTI (Symptomatic Urinary Tract Infection)

Criterion 3: Patient under 1 year has at least one of the following S/S

with no other recognized cause: fever ( >38 rectal), hypothermia ( <37 rectal), apnea,

bradycardia, dysuria, lethargy, or vomiting

and Patient has positive urine culture, >100 000 cfu/ml with

no more than 2 species of microorganisms

SUTI (Symptomatic Urinary Tract Infection)Criterion 4:

Patient < 1 year has at least one of the following with no other recognized cause:

fever > 38 rectal, hypothermia < 37 rectal, apnea, bradycardia, dysuria, lethargy, or vomiting

and

At least one of the following: Positive dipstick for leukocytes &/or nitrate Pyuria ( > 10 wbc/ cubic mm) Organisms seen on gram stain of unspun urine At least 2 cultures with repeated isolation of the same uropathogen

with > 100 cfu/ml in non-voided specimens < 100 000 cfu/ml of a single uro-pathogen in a patient on specific UTI

antibiotics Physician diagnosis or physician commences specific UTI therapy

Comments on UTI

A culture of a urinary catheter tip is NOT an acceptable laboratory test to diagnose UTI

Urine cultures must be obtained appropriately: clean catch or catheterization

In infants, a urine culture should be obtained by bladder catheterization or suprapubic aspiration; a bag culture is NOT reliable.

ASB : Asymptomatic Bacteriuria

Patient has had an indwelling catheter within 7 days before the culture

AND

patient has positive urine culture; > 100 000 organisms per ml with no more than 2 species

AND patient has no fever, urgency, dysuria, suprapubic

tenderness

SSI (Surgical Site Infection) Event Definition of an operation:

takes place in an operating room during a single trip to the OR( operating room) where the surgeon makes at least one incision through the skin

or mucous membrane, including laparoscopy and closes the incision before the pt leaves the operating room

An OR includes an operating room, C-section room, interventional radiology room, cardiac cath lab

An implant includes any non-human foreign body that is permanently placed in a patient, including screws, mesh, wires that are left permanently.

Superficial incisional SSI Infection occurs within 30 days after the operation AND involves only skin and subcutaneous tissue of the incision AND patient has at least one of the following:

Purulent drainage

Report organisms isolated from wound swabs as follows: ( Prof Duse criteria) if mono-microbial growth ( one organism) if a Strep. pyogenes ( beta haemolytic Strep Group A) isolated if 2 organisms, must be known wound pathogens in a quantity 2+ or more if > 2 organisms, report only the one associated with predominant growth, provided that pus cells were seen on microscopy if 3 or more organisms, do not report unless found on a repeat specimen or wound aspirate

At least one of the following: pain / tenderness, localized swelling, redness/ heat and the incision is deliberately opened by surgeon and is culture pos or not

cultured. If culture neg, it does not meet this criterion.

Diagnosis of superficial SSI by surgeon

There are 2 types: SIP (primary incision) . Patient has more than 1 incision for the operation, eg. Chest incision for CABG SIS (secondary incision) eg. Donor site incision on leg or arm for CABG

Reporting instructions for SSI

Do not report a stitch abscess Do not report a localized stab wound infection as SSI – it

is reported as skin or soft tissue Cellulitis, by itself, does not meet the criteria for SSI Infected circumcision site is reported as CIRC Infected burn wound is reported as BURN and not SSI If incisional site infection extends into fascial or muscle

layers, report as deep ( DIP / DIS)

Deep Incisional SSI Infection occurs within 30 days if no implant or Within 1 year if implant is placed and infection is related to the

operative procedure AND Involves deep soft tissues ( fascia / muscle) ANDPatient has at least ONE of the following: Purulent drainage from deep incision, but not organ / space Deep incision spontaneously dehisces or Is opened by surgeon and Is culture-pos or not cultured when the pt has at least one of the

following S/S: Fever>38, localized pain/tenderness

( A culture-negative finding does not meet this criterion) An abscess or other evidence of infection found by direct exam /

x-rays / histopathologic exam Diagnosis by a surgeon 2 Types: DIP (primary incision), and DIS ( secondary incision)

Organ / space SSI

Involves any part of the body ( including skin incision, fascia, muscle layer) that is opened and manipulated during an operative procedure

Specific additional sites are assigned to organ/space SSI’s to identify the location e.g. Appendectomy with sub-diaphragmatic abscess = SSI – IAB

(intra-abdominal specific site) SSI - BONE

( Table on P 37, NHSN Manual)

Organ / space SSI

Infection occurs within 30 days after the operation if no implant and within 1 year if implant is placed & infection is related to operative procedure

AND Infection involves any part of the body, excluding skin incision,

fascia, muscle) that is opened or manipulated during the operation AND Patient has at least one of the following:

Purulent drainage from a drain placed through a stab wound into the organ / space

Organisms obtained from aseptically obtained culture of fluid or tissue in the organ / space

Abscess found on direct examination or x-rays or histopathology examination

Diagnosis by surgeon or physician