HAI Definitions

A nosocomial infection / Healthcare Associated Infection (HAI) is:

1. An infection which is acquired during hospitalization and which was not present or incubating at the time of admission 2. An infection which is acquired in the hospital and becomes evident after discharge from the hospital 3. A newborn infection which is the result of passage through the birth canal

Practically - to establish that an infection is hospital acquired, SHOW THAT the patient: 1. HAS AN INFECTION, not a simple colonization 2. WAS NOT infected at the time of admission 3. HAD SUFFICIENT TIME to develop infection

TRUE INFECTION, NOT COLONIZATION, NOT CONTAMINATION Infections are accompanied by signs and symptoms:  fever, malaise  in localized infections: swelling due to inflammation, heat, pain, erythema (tumor, dolor, rubor, calor) Use definitions which establish minimum characteristics for infection Remember: Immunocompromised patients do not show signs of infection as normal patients. Neutropenic patients (  500 neutrophils /mm3) show no pyuria, no purulent sputum, little infiltrate and no large consolidation on chest X-ray

NO INFECTION AT THE TIME OF ADMISSION establish prior negativity Excluded: check history, symptoms and signs •Transplacental infections documented at time of admission, lab tests & chest X-rays done •Reactivation of old infections - normal physical examination (ex Shingles) - absence of signs and symptoms •Infections considered -normal chest X-ray extensions of infections - negative culture or lack of culture present at admission Example: If urine cultures are collected at day 7 of hospitalization and none was collected before, it implies that no signs of infection were present in urine before

SUFFICIENT TIME TO DEVELOP INFECTION Diseases with specific incubation period: stay in hospital  incubation period Numerous infections do not have well set incubation periods (for example, staphylococci, E.coli infections) These infections rarely develop in less than 2 days

To establish a nosocomial infection, meeting the definition criteria is sufficient. There is no need to have proof beyond the shadow of a doubt

CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting Teresa C. Horan, MPH, Mary Andrus, RN, BA, CIC, and Margaret A. Dudeck, MPH Atlanta, Georgia

Am J Infect Control 2008; 36:309-32.

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748 The BIG Ones

This is an overview. 1.BSI Bloodstream infection Check CDC website for 2.PNEU Pneumonia* up-to-date details 3.UTI Urinary tract infection 4.SSI Surgical site infection

SSI SURGICAL SITE INFECTION BSI BLOOD STREAM INFECTION 1.SIP Superficial incisional primary 1.BSI Primary lab confirmed /pathogen 2.SIS Superficial incisional secondary 2.BSI Primary lab confirmed /Contaminant 3.DIP Deep incisional primary 3.BSI Primary lab confirmed /pediatric 4.DIS Deep incisional secondary 4.Clinical sepsis 5.Organ/space

PNEU PNEUMONIA VENTILATOR UTI URINARY TRACT INFECTION ASSOCIATED 1.SUTI Symptomatic urinary tract infection 1.PNU1 Clinically defined pneumonia 2.ASB Asymptomatic bacteriuria 2.PNU2 Pneumonia with specific laboratory 3.OUTI Other infections of the urinary findings tract (Bacterial only) 3.PNU3 Pneumonia in immuno-compromised patient

BJ Bone and joint infection EENT Eye, ear, nose, throat, or mouth infection BONE Osteomyelitis CONJ Conjunctivitis JNT Joint or bursa EYE Eye, other than conjunctivitis DISC Disc space EAR Ear, mastoid CNS Central nervous system ORAL Oral cavity (mouth, tongue, or gums) IC Intracranial infection SINU Sinusitis MEN Meningitis or ventriculitis UR Upper respiratory tract, pharyngitis, laryngitis, epiglottitis SA Spinal abscess without meningitis REPR Reproductive tract infection CVS Cardiovascular system infection EMET Endometritis VASC Arterial or venous infection EPIS Episiotomy ENDO Endocarditis VCUF Vaginal cuff CARD Myocarditis or pericarditis OREP Other infections of the male or female reproductive tract MED Mediastinitis SST Skin and soft tissue infection LRI Lower respiratory tract infection, other than SKIN Skin pneumonia ST Soft tissue BRON Bronchitis, tracheobronchitis, tracheitis, without DECU Decubitus ulcer evidence of pneumonia BURN Burn LUNG Other infections of the lower respiratory tract BRST Breast abscess or mastitis GI Gastrointestinal system infection UMB Omphalitis GE Gastroenteritis PUST Pustulosis GIT Gastrointestinal (GI) tract CIRC Newborn circumcision HEP Hepatitis SYS Systemic Infection IAB Intraabdominal, not specified elsewhere DI Disseminated infection NEC Necrotizing enterocolitis

These definitions and reporting requirements are constantly being refined. Check on the CDC website for frequent updates https://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748 Blood Stream Infections BSI

PRIMARY LAB CONFIRMED BSI 1 - Pathogen 1.Recognized pathogen from 1 or more blood culture 2.Not related to infection at other site Specimen collection considerations Ideally, blood specimens for culture should be obtained from 2 to 4 blood draws from separate venipuncture sites (e.g., right and left antecubital veins), not through a vascular catheter. These blood draws should be performed simultaneously or over a short period of time (i.e., within a few hours). If the facility does not currently obtain specimens using this technique, work with appropriate personnel to facilitate better specimen collection practices for blood cultures.

PRIMARY LAB CONFIRMED BSI 2 - CONTAMINANT AND Common skin contaminant OR One of following: . from 2 or more blood cultures . fever >38°C . drawn on separate occasions . or chills . or hypotension <90 mm AND Common skin contaminant PRIMARY LAB CONFIRMED BSI 3-PEDIATRIC .from 1 or more blood cultures One of following: .with intravascular line . fever >38°C .tx prescribed for infection . or chills . or hypotension <90 mm AND positive antigen in blood for OR .Haemophilus influenzae Skin Contaminants: Diphtheroids, Corynebacterium spp, .or Neisseria meningitidis Bacillus [not B anthracis] spp, Propionibacterium spp, .or group B streptococci coagulase-negative staphylococci [including S epidermidis], Viridans group streptococci, Aerococcus spp, Micrococcus spp)

CLINICAL SEPSIS ADULT CLINICAL SEPSIS PEDIATRIC One of following: One of following: . Fever >38°C . Fever >38°C rectal . or hypotension <90 mm . or hypothermia <37°C . or Oliguria <20mL/hr . or apnea AND no blood culture or negative blood culture . or bradycardia AND no infection related to other site AND no blood culture or negative blood culture AND Tx ordered for sepsis AND no infection related to other site AND Tx ordered for sepsis

SECONDARY BSI .Recognized pathogen from 1 or more blood culture(s) .Related to infection at other site

CATHETER -RELATED BSI . Similar microorganism in catheter colonization and blood culture . Clinical evidence of BSI . Fever or hypothermia . ± hypotension, tachycardia, tachypnea, confusion

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748 Surgical Site Infection SSI

CLEAN /CONTAMINATED /DIRTY Clean site: Contaminated site: No inflammation Accidental wound with major breach in No penetration asepsis Closed or with closed drainage Wound with massive GI spill Clean Contaminated site: Sites entered with urinary, biliary infection, Respiratory, GI, genital or urinary tracts entered acute non-purulent infection under controlled conditions with no unusual Dirty & Infected: contamination Old wound with devitalized tissue, foreign Specific site: biliary tract, appendix, vaginal, bodies, fecal contamination oropharynx Perforated viscus, Pus TIMING Not Superficial SSI Infection occurs within 30 days after the operation if no implant is left in .Stab wound –report as skin place or .Stitch abscess within 1 year if implant is in place and the infection appears to be .Episiotomy, circumcision infection related to the operation .Infected burn wound report as burn

SUPERFICIAL SSI .PURULENT DRAINAGE from superficial incision (Culture not indispensable) or .Positive culture from a closed surgical site obtained aseptically or .1 of : Pain /tenderness, localized swelling, redness, heat, dehiscence, abscess and of infection & wound reopening or .Medical diagnosis of SSI .Not Superficial SSI: Stitch abscess, Episiotomy, circumcision infection, Infected burn wound

Superficial incisional primary (SIP): a superficial incisional SSI that is identified in the primary incision in a patient who has had an operation with 1 or more incisions (eg, C-section incision or chest incision for coronary artery bypass graft with a donor site [CBGB]). Superficial incisional secondary (SIS): a superficial incisional SSI that is identified in the secondary incision in a patient who has had an operation with more than 1 incision (eg, donor site [leg] incision for CBGB)

DEEP INCISIONAL SSI Infection involves deep soft tissues (e.g., facial and muscle layers) AND at least 1of the following: 1. Purulent drainage from deep incision but not from organ/space 2. Deep incision dehiscence or opened by surgeon when patient has at least one of: fever (>38ºC), localized pain, or tenderness, unless site is culture-negative 3. Abscess or other evidence of infection of deep incision on direct examination, re-operation, histopathologic or radiologic exam 4. Diagnosis of a deep incisional SSI by physician .Report infection that involves both superficial and deep incision sites as deep incisional SSI .Report an organ/space SSI that drains through the incision as a deep incisional SSI ORGAN /SPACE SSI Infection involves organs or spaces (other than incision) opened or manipulated during an operation and at least one of the following: 1. Purulent drainage from a drain that is placed through a stab wound into the organ/space 2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space 3. An abscess or other evidence of infection organ/space on direct examination, re-operation, histopathologic or radiologic examination 4. Diagnosis of an organ/space SSI by physician.

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748 Urinary Tract Infection UTI

Patient Catheter and at least and NOTES Adult Yes 1 S&S Pos Uculture Adult Removed 1 S&S Pos Uculture . Positive culture of urinary catheter tip not acceptable laboratory test to Adult None 1 S&S Pos Uculture diagnose UTI Adult Yes 1 S&S 1 UTI Lab test . Urine cultures must be obtained Adult Removed 1 S&S 1 UTI Lab test using appropriate technique Adult None 1S&S 1UTI Lab test . Adult: clean catch collection or Infant Yes or No 1 Infant S&S Pos Ucculture catheterization

Infant Yes or No 1 Infant S&S 1 UTI Lab test . Infants: bladder catheterization or With Cat: Patient had an With Removed Cat: . suprapubic aspiration indwelling urinary catheter 1a2-Patient had an . Positive urine culture from bag is in place for >2 calendar indwelling urinary catheter unreliable and should be confirmed days, with day of device in place for >2 calendar placement being Day 1, days and had it removed and catheter was in place the day of or the day before when all elements of this all elements of this criterion criterion were first present were first present together together.

Adult S&S: fever Infant S&S: fever >38°C; suprapubic >38°C core; tenderness; hypothermia <36°C ; costovertebral angle pain apnea; bradycardia; or tenderness with no dysuria; lethargy; other recognized cause vomiting; with no other recognized cause Pos U Culture: ≥10^5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms. UTI Lab Test: -positive dipstick for leukocyte esterase and/or nitrite -pyuria (urine specimen with ≥10 white blood cells [WBC]/mm3 of unspun urine or >5 WBC/high power field of spun urine) -microorganisms seen on Gram’s stain of unspun urine and a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms.

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748 Pneumonia

1. Physician diagnosis of pneumonia alone is not an acceptable criterion for health care-associated pneumonia.

2. Pediatric patients: Although specific criteria are included for infants and children, pediatric patients may meet any of the other pneumonia specific site criteria.

3. Ventilator-associated pneumonia (i.e., pneumonia in persons who had a device to assist or control respiration continuously through a tracheostomy or by endotracheal intubation within the 48-hour period before the onset of infection, inclusive of the weaning period) should be so designated when reporting data. 4. Other conditions: When assessing a patient for presence of pneumonia, it is important to distinguish between changes in clinical status due to other conditions such as myocardial infarction, pulmonary embolism, respiratory distress syndrome, atelectasis, malignancy, chronic obstructive pulmonary disease, hyaline membrane disease, bronchopulmonary dysplasia, etc. Also, care must be taken when assessing intubated patients to distinguish between tracheal colonization, upper respiratory tract infections (eg, tracheobronchitis), and early onset pneumonia. Finally, it should be recognized that it may be difficult to determine health care-associated pneumonia in the elderly, infants, and immunocompromised patients because such conditions may mask typical signs or symptoms associated with pneumonia

5. Early /late onset: Health care–associated pneumonia can be characterized by its onset: early or late. - Early onset pneumonia occurs during the first 4 days of hospitalization and is often caused by Moraxella catarrhalis, H influenzae, and S pneumoniae. - Late onset causative agents are frequently Gram-negative bacilli or S aureus, including methicillin-resistant S aureus. Viruses (eg, influenza A and B or respiratory syncytial virus) can cause early and late onset nosocomial pneumonia, whereas yeasts, fungi, legionellae, and Pneumocystis carinii are usually pathogens of late onset pneumonia.

6. Pneumonia due to gross aspiration (for example, in the setting of intubation in the emergency room or operating room) is considered health care associated if it meets any specific criteria and was not clearly present or incubating at the time of admission to the hospital. 7. Multiple episodes of HAI pneumonia may occur in critically ill patients with lengthy hospital stays. When determining whether to report multiple episodes of health care-associated pneumonia in a single patient, look for evidence of resolu- tion of the initial infection. The addition of or change in pathogen alone is not indicative of a new episode of pneumonia. The combination of new signs and symptoms and radiographic evidence or other diagnostic testing is required.

8. Microscopy: Positive Gram stain for bacteria and positive KOH (potassium hydroxide) mount for elastin fibers and/or fungal hyphae from appropriately collected sputum specimens are important clues that point toward the etiology of the infection. However, sputum samples are frequently contaminated with airway colonizers and therefore must be interpreted cautiously. In particular, Candida is commonly seen on stain, but infrequently causes healthcare-associated pneumonia.

New onset of purulent Organisms cultured Organisms cultured from specimen sputum or change in from blood obtained by transtracheal aspirate, sputum character bronchial brushing, or biopsy

Single antibody titer (IgM) Isolation of virus or viral or x4  in paired IgG Histopathologic evidence of antigen in respiratory pneumonia secretions

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748 Pneumonias PNU1: Clinically-defined pneumonia

PNU2: Pneumonias with common bacterial or filamentous fungal pathogens and specific lab findings

PNU2: Pneumonias with legionella, chlamydia, mycoplasma, and other uncommon pathogens and specific lab findings

PNU3: Pneumonias in immune-compromised

Other Lower Respiratory Tract Infection Other infections of the lower respiratory tract must meet at least one of the following criteria: . Patient has organisms seen on smear or cultured from lung tissue or fluid, including pleural fluid or . Patient has a lung abscess or empyema seen during a surgical operation or histopathologic examination or . Patient has an abscess cavity seen

Do not report chronic bronchitis in a patient with chronic lung disease as an infection unless there is evidence of an acute secondary infection, manifested by change in organism

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748 Pneumonia

PNU1 PNU2ComPath PNU2SpecPath PNU3ImmComp

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748 Other Infections

BJ Bone and joint infection EENT Eye, ear, nose, throat, or mouth infection BONE Osteomyelitis CONJ Conjunctivitis JNT Joint or bursa EYE Eye, other than conjunctivitis DISC Disc space EAR Ear, mastoid CNS Central nervous system ORAL Oral cavity (mouth, tongue, or gums) IC Intracranial infection SINU Sinusitis MEN Meningitis or ventriculitis UR Upper respiratory tract, pharyngitis, laryngitis, SA Spinal abscess without meningitis epiglottitis CVS Cardiovascular system infection REPR Reproductive tract infection VASC Arterial or venous infection EMET Endometritis ENDO Endocarditis EPIS Episiotomy CARD Myocarditis or pericarditis VCUF Vaginal cuff MED Mediastinitis OREP Other infections of the male or female reproductive LRI Lower respiratory tract infection, other tract than pneumonia SST Skin and soft tissue infection BRON Bronchitis, tracheobronchitis, tracheitis, SKIN Skin without evidence of pneumonia ST Soft tissue LUNG Other infections of the lower respiratory DECU Decubitus ulcer tract BURN Burn GI Gastrointestinal system infection BRST Breast abscess or mastitis GE Gastroenteritis UMB Omphalitis GIT Gastrointestinal (GI) tract PUST Pustulosis HEP Hepatitis CIRC Newborn circumcision IAB Intraabdominal, not specified elsewhere SYS Systemic Infection NEC Necrotizing enterocolitis DI Disseminated infection

http://www.infectiousdisease.dhh.louisiana.gov (800) 256-2748