1672 Section XV: Organization and Implementation of Infection Control Programs insic risk-adjusted rates of adverse outcomes. Failure to do so will certainly make interhospital comparisons meaningless or From: Horan TC, Gaynes RP. Surveillance of nosocomial infections. In:Hospital Epidemiology and Infection Control, CVS Cardiovascular System Infection 3rd ed., Mayhall CG, editor. Philadelphia:Lippincott VASC Arterial or venous infection Williams & Wilkins, 2004:1659-1702.ve n misleading (27). ENDO Endocarditis CARD Myocarditis or pericarditis MED Mediastinitis APPENDIX A-1. CDC DEFINITIONS OF EENT Eye, Ear, Nose, Throat, or Mouth Infection NOSOCOMIALINFECTIONS[EXCLUDING CONJ Conjunctivitis PNEUMONIA (SEE APPENDIX A-2)] EYE Eye Other than conjunctivitis EAR Ear Mastoid Listing of Major and Specific Site Codes and ORAL Oral Cavity (mouth, tongue, or gums) Descriptions SINU Sinusitis UTI Urinary Tract Infection UR Upper respiratory tract, pharyngitis, SUTI Symptomatic urinary tract infection laryngitis, epiglottitis ASB Asymptomatic bacteriuria GI Gastrointestinal System Infection OUTI Other infections of the urinary tract GE Gastroenteritis GIT Gastrointestinal (GI) tract SSI Surgical Site Infection HEP Hepatitis SKIN Superficial incisional site, except after IAB Intraabdominal, not specified elsewhere CBGB1 NEC Necrotizing enterocolitis SKNC After CBGB, report SKNC for superficial LRI Lower Respiratory Tract Infection, Other Than incisional infection at chest incision site Pneumonia SKNL After CBGB, report SKNL for superficial BRON Bronchitis, tracheobronchitis, tracheitis, incisional infection at leg (donor) site without evidence of pneumonia ST Deep incisional surgical site infection, LUNG Other infections of the lower respiratory except after CBGB tract STC After CBGB, report STC for deep REPR Reproductive Tract Infection incisional surgical site infection at chest EMET Endometritis incision site EPIS Episiotomy STL After CBGB, report STL for deep VCUF Vaginal cuff incisional surgical site infection at leg OREP Other infections of the male or female (donor) site reproductive tract Organ/Space Surgical Site Infection SST Skin and Soft Tissue Infection Indicate specific site: SKIN Skin BONE, BRST, CARD, DISC, EAR, ST Soft tissue EMET, ENDO, EYE, GIT, IAB, IC, JNT, DECU Decubitus ulcer LUNG, MED, MEN, ORAL, OREP, BURN Burn OUTI, SA, SINU, UR, VASC, VCUP. BRST Breast abscess or mastitis UMB Omphalitis PNEU Pneumonia (See Appendix A:2) PUST Infant pustulosis PNU 1 CIRC Newborn circumcision PNU 2 SYS Systemic Infection PNU 3 DI Disseminated infection BSI Bloodstream Infection LCBI Laboratory-confirmed bloodstream infection Definitions of Infection Sites CSEP Clinical sepsis INFECTION SITE: Symptomatic urinary tract infection BJ Bone and Joint Infection CODE: UTI-SUTI BONE Osteomyelitis DEFINITION: A symptomatic urinary tract infection must JNT Joint or bursa meet at least one of the following criteria: DISC Disc space Criterion 1: Patient has at least one of the following signs or CNS Central Nervous System Infection symptoms with no other recognized cause: fever IC Intracranial infection (Ͼ38 ЊC), urgency, frequency, dysuria, or su- MEN Meningitis or ventriculitis prapubic tenderness SA Spinal abscess without meningitis and patient has a positive urine culture, that is, Ն10 5 microorganisms per cm 3 of urine with no more 1 CBGB, coronary artery bypass graft with both chest and donor site inci- than two species of microorganisms. sions. Criterion 2: Patient has at least two of the following signs or Chapter 94: Surveillance of Nosocomial Infections 1673

symptoms with no other recognized cause: fever ᭿ Urine cultures must be obtained using appropriate technique, (Ͼ38 ЊC), urgency, frequency, dysuria, or su- such as clean catch collection or catheterization. prapubic tenderness ᭿ In infants, a urine culture should be obtained by bladder and catheterization or suprapubic aspiration; a positive urine cul- at least one of the following: ture from a bag specimen is unreliable and should be con- a. Positive dipstick for leukocyte esterase and/or firmed by a specimen aseptically obtained by catheterization nitrate or suprapubic aspiration. b. Pyuria (urine specimen with Ն10 WBC/mm 3 or Ն3 WBC/high power field of unspun urine) INFECTION SITE: Asymptomatic bacteriuria c. Organisms seen on Gram stain of unspun urine CODE: UTI-ASB d. At least two urine cultures with repeated isola- DEFINITION: An asymptomatic bacteriuria must meet at least tion of the same uropathogen (gram-negative one of the following criteria: bacteria or S. saprophyticus ) with Ն10 2 colo- Criterion 1: Patient has had an indwelling urinary catheter nies/mL in nonvoided specimens within 7 days before the culture e. Յ10 5 colonies/mL of a single uropathogen and patient has a positive urine culture, that is, Ն10 5 (gram-negative bacteria or S. saprophyticus ) in 3 a patient being treated with an effective antimi- microorganisms per cm of urine with no more crobial agent for a urinary tract infection than two species of microorganisms f. Physician diagnosis of a urinary tract infection and patient has no fever (Ͼ38 ЊC), urgency, frequency, g. Physician institutes appropriate therapy for a dysuria, or suprapubic tenderness. urinary tract infection Criterion 2: Patient has not had an indwelling uri- Criterion 3: Patient Յ1 year of age has at least one of the fol- nary catheter within 7 days before the first positive lowing signs or symptoms with no other recog- culture nized cause: fever (Ͼ38 ЊC), hypothermia and (Ͻ37 ЊC), apnea, bradycardia, dysuria, lethargy, or patient has had at least two positive urine cultures, vomiting that is, Ն10 5 microorganisms per cm 3 of urine and with repeated isolation of the same microorganism patient has a positive urine culture, that is, Ն10 5 and no more than two species of microorganisms microorganisms per cm 3 of urine with no more and than two species of microorganisms. patient has no fever (Ͼ38 ЊC), urgency, frequency, Criterion 4: Patient Յ1 year of age has at least one of the fol- dysuria, or suprapubic tenderness. lowing signs or symptoms with no other recog- nized cause: fever (Ͼ38 ЊC), hypothermia COMMENTS: (Ͻ37 ЊC), apnea, bradycardia, dysuria, lethargy, or vomiting ᭿ A positive culture of a urinary catheter tip is not an acceptable and laboratory test to diagnose bacteriuria. at least one of the following: ᭿ Urine cultures must be obtained using appropriate technique, a. Positive dipstick for leukocyte esterase and/or such as clean catch collection or catheterization. nitrate b. Pyuria (urine specimen with Ն10 WBC/mm 3 INFECTION SITE: Other infections of the urinary tract (kid- or Ն3 WBC/high power field of unspun urine) ney, ureter, bladder, urethra, or tissues surrounding the retroper- c. Organisms seen on Gram stain of unspun urine itoneal or perinephric spaces) d. At least two urine cultures with repeated isola- CODE: SUTI-OUTI tion of the same uropathogen (gram-negative DEFINITION: Other infections of the urinary tract must meet bacteria or S. saprophyticus ) with Ն10 2 colo- at least one of the following criteria: nies/mL in nonvoided specimens Criterion 1 Patient has organisms isolated from culture of e. Յ10 5 colonies/mL of a single uropathogen fluid (other than urine) or tissue from affected site. (gram-negative bacteria or S. saprophyticus ) in Criterion 2: Patient has an abscess or other evi- a patient being treated with an effective antimi- dence of infection seen on direct examination, crobial agent for a urinary tract infection during a surgical operation, or during a histopath- f. Physician diagnosis of a urinary tract infection ologic examination. Criterion 3: Patient has at least two of the following signs or g. Physician institutes appropriate therapy for a urinary tract infection symptoms with no other recognized cause: fever (Ͼ38 ЊC), localized pain, or localized tenderness COMMENTS: at the involved site and ᭿ A positive culture of a urinary catheter tip is not an acceptable at least one of the following: laboratory test to diagnose a urinary tract infection. a. Purulent drainage from affected site 1674 Section XV: Organization and Implementation of Infection Control Programs

b. Organisms cultured from blood that are com- tained culture of fluid or tissue from the super- patible with suspected site of infection ficial incision c. Radiographic evidence of infection, for exam- c. At least one of the following signs or symptoms ple, abnormal ultrasound, computed tomogra- of infection: pain or tenderness, localized swell- phy (CT), magnetic resonance imaging (MRI), ing, redness, or heat, and superficial incision is or radiolabel scan (gallium, technetium) deliberately opened by surgeon, unless incision d. Physician diagnosis of infection of the kidney, is culture-negative ureter, bladder, urethra, or tissues surrounding d. Diagnosis of superficial incisional SSI by the the retroperitoneal or perinephric space surgeon or attending physician e. Physician institutes appropriate therapy for an REPORTING INSTRUCTIONS: infection of the kidney, ureter, bladder, ure- thra, or tissues surrounding the retroperitoneal ᭿ Do not report a stitch abscess (minimal inflammation and or perinephric space discharge confined to the points of suture penetration) as an Criterion 4: Patient Յ1 year of age has at least one of the infection. following signs or symptoms with no other recog- ᭿ Do not report a localized stab wound infection as SSI, instead nized cause: fever (Ͼ38 ЊC), hypothermia report as skin or soft tissue infection, depending on its depth. (Ͻ37 ЊC), apnea, bradycardia, lethargy, or vom- ᭿ Report infection of the circumcision site in newborns as SST- iting CIRC. Circumcision is not an NNIS operative procedure. and ᭿ Report infection of the episiotomy site as REPR-EPIS. Episi- at least one of the following: otomy is not an NNIS operative procedure. a. Purulent drainage from affected site ᭿ Report infected burn wound as SST-BURN. b. Organisms cultured from blood that are com- ᭿ If the incisional site infection involves or extends into the patible with suspected site of infection fascial and muscle layers, report as a deep incisional SSI. c. Radiographic evidence of infection, for exam- ᭿ Classify infection that involves both superficial and deep inci- ple, abnormal ultrasound, CT, MRI, or ra- sion sites as deep incisional SSI. diolabel scan (gallium, technetium) ᭿ Report culture specimen from superficial incisions as ID (inci- d. Physician diagnosis of infection of the kidney, sional drainage). ureter, bladder, urethra, or tissues surrounding the retroperitoneal or perinephric space INFECTION SITE: Surgical site infection (deep incisional) e. Physician institutes appropriate therapy for an CODE: SSI-[ST (soft tissue)] except following the NNIS opera- infection of the kidney, ureter, bladder, ure- tive procedure, CBGB. For CBGB only, if infection is at chest thra, or tissues surrounding the retroperitoneal site, use STC (soft tissue-chest) or if at leg (donor) site, use STL or perinephric space (soft tissue-leg) DEFINITION: A deep incisional SSI must meet the following REPORTING INSTRUCTION: criteria: Infection occurs within 30 days after the operative procedure if ᭿ Report infections following circumcision in newborns as SST- no implant b is left in place or within 1 year if implant is in place CIRC. and the infection appears to be related to the operative procedure INFECTION SITE: Surgical site infection (superficial inci- and sional) involves deep soft tissues (e.g., fascial and muscle layers) of the CODE: SSI-(SKIN) except following the NNIS operative proce- incision dure, CBGB. For CBGBa only, if infection is at chest site, use and SKNC (skin-chest) or if at leg (donor) site, use SKNL (skin- patient has at least one of the following: leg) a. Purulent drainage from the deep incision but DEFINITION: A superficial SSI must meet the following cri- not from the organ/space component of the teria: surgical site Infection occurs within 30 days after the operative procedure b. A deep incision spontaneously dehisces or is and deliberately opened by a surgeon when the pa- involves only skin and subcutaneous tissue of the incision tient has at least one of the following signs or Ͼ Њ and symptoms: fever ( 38 C) or localized pain or patient has at least one of the following: tenderness, unless incision is culture-negative a. Purulent drainage from the superficial incision c. An abscess or other evidence of infection in- b. Organisms isolated from an aseptically ob- volving the deep incision is found on direct

b A nonhuman-derived implantable foreign body (e.g., prosthetic heart a CBGB, coronary artery bypass graft with both chest and donor site inci- valve, nonhuman vascular graft, mechanical heart, or hip prosthesis) that sions. is permanently placed in a patient during surgery. Chapter 94: Surveillance of Nosocomial Infections 1675

examination, during reoperation, or by histo- EMET Endometritis pathologic or radiologic examination ENDO Endocarditis d. Diagnosis of a deep incisional SSI by a surgeon EYE Eye, other than conjunctivitis or attending physician GIT GI tract IAB Intraabdominal, not specified elsewhere REPORTING INSTRUCTIONS: IC Intracranial, brain abscess or dura ᭿ Classify infection that involves both superficial and deep inci- JNT Joint or bursa sion sites as deep incisional SSI. LUNG Other infections of the lower respiratory tract ᭿ Report culture specimen from deep incisions as ID. MED Mediastinitis MEN Meningitis or ventriculitis INFECTION SITE: Surgical site infection (organ/space) ORAL Oral cavity (mouth, tongue, or gums) CODE: SSI-(Specific site of organ/space) OREP Other male or female DEFINITION: An organ/space SSI involves any part of the OUTI Other infections of the urinary tract body, excluding the skin incision, fascia, or muscle layers, that SA Spinal abscess without meningitis is opened or manipulated during the operative procedure. Spe- SINU Sinusitis cific sites are assigned to organ/space SSI to further identify the UR Upper respiratory tract location of the infection. Listed later are the specific sites that VASC Arterial or venous infection must be used to differentiate organ/space SSI. An example is VCUF Vaginal cuff appendectomy with subsequent subdiaphragmatic abscess, which would be reported as an organ/space SSI at the intraab- INFECTION SITE: Pneumonia (See Appendix A-2) dominal specific site (SSI-IAB). INFECTION SITE: Laboratory-confirmed bloodstream infec- An organ/space SSI must meet the following criteria: tion Infection occurs within 30 days after the operative procedure if b CODE: BSI-LCBI no implant is left in place or within 1 year if implant is in place DEFINITION: Laboratory-confirmed bloodstream infection and the infection appears to be related to the operative procedure must meet at least one of the following criteria: and Criterion 1: Patient has a recognized pathogen cultured from infection involves any part of the body, excluding the skin inci- one or more blood cultures sion, fascia, or muscle layers, that is opened or manipulated and during the operative procedure organism cultured from blood is not related to an and infection at another site. patient has at least one of the following: Criterion 2: Patient has at least one of the following signs or a. Purulent drainage from a drain that is placed symptoms: fever (Ͼ38 ЊC), chills, or hypotension through a stab wound into the organ/space and b. Organisms isolated from an aseptically ob- at least one of the following: tained culture of fluid or tissue in the organ/ a. Common skin contaminant (e.g., diphthe- space roids, Bacillus sp., Propionibacterium sp., coag- c. An abscess or other evidence of infection in- ulase-negative staphylococci, or micrococci) is volving the organ/space that is found on direct cultured from two or more blood cultures examination, during reoperation, or by histo- drawn on separate occasions pathologic or radiologic examination b. Common skin contaminant (e.g., diphthe- d. Diagnosis of an organ/space SSI by a surgeon roids, Bacillus sp., Propionibacterium sp., coag- or attending physician ulase-negative staphylococci, or micrococci) is REPORTING INSTRUCTIONS: cultured from at least one blood culture from a patient with an intravascular line, and the ᭿ Occasionally, an organ/space infection drains through the in- physician institutes appropriate antimicrobial cision. Such infection generally does not involve reoperation therapy and is considered a complication of the incision. Therefore, c. Positive antigen test on blood (e.g., Haemophi- it is classified as a deep incisional SSI. lus influenzae, Streptococcus pneumoniae, Neisse- ᭿ Report culture specimen from organ/space as DD (deep ria meningitidis, or group B Streptococcus) drainage). and The following are specific sites of an organ/space SSI: signs and symptoms and positive laboratory results are not related to an infection at another site. Code Site Criterion 3: Patient Յ1 year of age has at least one of the fol- BONE Osteomyelitis lowing signs or symptoms: fever ( Ͼ38 ЊC), hypo- BRST Breast abscess or mastitis thermia (Ͻ37 ЊC), apnea, or bradycardia CARD Myocarditis or pericarditis and DISC Disc space at least one of the following: EAR Ear, mastoid a. Common skin contaminant (e.g., diphthe- 1676 Section XV: Organization and Implementation of Infection Control Programs

roids, Bacillus sp., Propionibacterium sp., coag- INFECTION SITE: Osteomyelitis ulase-negative staphylococci, or micrococci) is CODE: BJ-BONE cultured from two or more blood cultures DEFINITION: Osteomyelitis must meet at least one of the fol- drawn on separate occasions lowing criteria: b. Common skin contaminant (e.g., diphthe- Criterion 1: Patient has organisms cultured from bone. roids, Bacillus sp., Propionibacterium sp., coag- Criterion 2: Patient has evidence of osteomyelitis ulase-negative staphylococci, or micrococci) is on direct examination of the bone during a surgi- cultured from at least one blood culture from cal operation or histopathologic examination. a patient with an intravascular line, and physi- Criterion 3: Patient has at least two of the follow- cian institutes appropriate antimicrobial ing signs or symptoms with no other recognized therapy cause: fever (Ͼ38 ЊC), localized swelling, tender- c. Positive antigen test on blood (e.g., H. influen- ness, heat, or drainage at suspected site of bone zae, S. pneumoniae, N. meningitidis, or group infection B Streptococcus) and and at least one of the following: signs and symptoms and positive laboratory re- a. Organisms cultured from blood sults are not related to an infection at another b. Positive blood antigen test (e.g., H. influenzae, site. S. pneumoniae ) c. Radiographic evidence of infection, for exam- REPORTING INSTRUCTIONS: ple, abnormal findings on x-ray, CT, MRI, ra- ᭿ Report purulent phlebitis confirmed with a positive semi- diolabeled scan (gallium, technetium, etc.) quantitative culture of a catheter tip, but with either negative INFECTION SITE: Joint or bursa or no blood culture, as CVS-VASC. CODE: BJ-JNT ᭿ Report organisms cultured from blood as BSI-LCBI when no DEFINITION: Joint or bursa infections must meet at least one other site of infection is evident. of the following criteria: ᭿ Pseudobacteremias are not nosocomial infections. Criterion 1: Patient has organisms cultured from joint fluid or synovial biopsy. INFECTION SITE: Clinical sepsis Criterion 2: Patient has evidence of joint or bursa infection CODE: BSI-CSEP seen during a surgical operation or histopathologic DEFINITION: Clinical sepsis must meet at least one of the examination. following criteria: Criterion 3: Patient has at least two of the following signs or Criterion 1: Patient has at least one of the following clinical symptoms with no other recognized cause: joint signs or symptoms with no other recognized cause: pain, swelling, tenderness, heat, evidence of effu- fever (Ͼ38 ЊC), hypotension (systolic pressure Յ sion or limitation of motion 90 mm Hg), or oliguria ( Ͻ20 cm 3/hr) and and at least one of the following: blood culture not done or no organisms or antigen a. Organisms and white blood cells seen on Gram detected in blood stain of joint fluid and b. Positive antigen test on blood, urine, or joint no apparent infection at another site fluid and c. Cellular profile and chemistries of joint fluid physician institutes treatment for sepsis. compatible with infection and not explained by Criterion 2: Patient Յ1 year of age has at least an underlying rheumatologic disorder one of the following clinical signs or symptoms d. Radiographic evidence of infection, for exam- with no other recognized cause: fever ( Ͼ38 ЊC), ple, abnormal findings on x-ray, CT, MRI, ra- hypothermia (Ͻ37 ЊC), apnea, or bradycardia diolabel scan (gallium, technetium, etc.) and INFECTION SITE: Disc space blood culture not done or no organisms or antigen CODE: BJ-DISC detected in blood DEFINITION: Vertebral disc space infection must meet at least and one of the following criteria: no apparent infection at another site Criterion 1: Patient has organisms cultured from vertebral disc and space tissue obtained during a surgical operation physician institutes treatment for sepsis. or needle aspiration. REPORTING INSTRUCTION: Criterion 2: Patient has evidence of vertebral disc space infec- tion seen during a surgical operation or histopath- ᭿ Report culture-positive infections of the bloodstream as BSI- ologic examination. LCBI. Criterion 3: Patient has fever ( Ͼ38 ЊC) with no other recog- Chapter 94: Surveillance of Nosocomial Infections 1677

nized cause or pain at the involved vertebral disc c. Radiographic evidence of infection, for exam- space ple, abnormal findings on ultrasound CT, and MRI, radionuclide brain scan, or arteriogram radiographic evidence of infection, e.g., abnormal d. Diagnostic single antibody titer (IgM) or four- findings on x-ray, CT, MRI, radiolabel scan with fold increase in paired sera (IgG) for pathogen gallium or technetium. Criterion 4: Patient has fever ( Ͼ38 ЊC) with no REPORTING INSTRUCTION: other recognized cause and pain at the involved ᭿ If meningitis and a brain abscess are present together, report vertebral disc space the infection as IC. and positive antigen test on blood or urine (e.g., H. INFECTION SITE: Meningitis or ventriculitis influenzae, S. pneumoniae, N. meningitidis, or CODE: CNS-MEN group B Streptococcus) DEFINITION: Meningitis or ventriculitis must meet at least INFECTION SITE: Intracranial infection (brain abscess, subd- one of the following criteria: ural or epidural infection, encephalitis) Criterion 1: Patient has organisms cultured from cerebrospinal CODE: CNS-IC fluid (CSF). DEFINITION: Intracranial infection must meet at least one of Criterion 2: Patient has at least one of the following signs of the following criteria: symptoms with no other recognized cause: fever Ͼ Њ Criterion 1: Patient has organisms cultured from brain tissue ( 38 C), headache, stiff neck, meningeal signs, or dura. cranial nerve signs, or irritability Criterion 2: Patient has an abscess or evidence of intracranial and infection seen during a surgical operation or histo- if diagnosis is made antemortem, physician insti- pathologic examination. tutes appropriate antimicrobial therapy Criterion 3: Patient has at least two of the following signs or and symptoms with no other recognized cause: head- at least one of the following: ache, dizziness, fever (Ͼ38 ЊC), localizing neuro- a. Increased white cells, elevated protein and/or logic signs, changing level of consciousness, or decreased glucose in CSF confusion b. Organisms seen on Gram stain of CSF and c. Organisms cultured from blood if diagnosis is made antemortem, physician insti- d. Positive antigen test of CSF, blood, or urine tutes appropriate antimicrobial therapy e. Diagnostic single antibody titer (IgM) or four- and fold increase in paired sera (IgG) for pathogen Յ at least one of the following: Criterion 3: Patient 1 year of age has at least one of the fol- a. Organisms seen on microscopic examination lowing signs or symptoms with no other recog- Ͼ Њ of brain or abscess tissue obtained by needle nized cause: fever ( 38 C), hypothermia Ͻ Њ aspiration or by biopsy during a surgical opera- ( 37 C), apnea, bradycardia, stiff neck, menin- tion or autopsy geal signs, cranial nerve signs, or irritability b. Positive antigen test on blood or urine and c. Radiographic evidence of infection, for exam- if diagnosis is made antemortem, physician insti- ple, abnormal findings on ultrasound, CT, tutes appropriate antimicrobial therapy MRI, radionuclide brain scan, or arteriogram and d. Diagnostic single antibody titer (IgM) or four- at least one of the following: fold increase in paired sera (IgG) for pathogen a. Positive CSF examination with increased white Criterion 4: Patient Յ1 year of age has at least two of the cells, elevated protein, and/or decreased glucose following signs or symptoms with no other b. Positive Gram stain of CSF recognized cause: fever (Ͼ38 ЊC), hypothermia c. Organisms cultured from blood (Ͻ37 ЊC), apnea, bradycardia, localizing neuro- d. Positive antigen test of CSF, blood, or urine logic signs, or changing level of consciousness e. Diagnostic single antibody titer (IgM) or four- and fold increase in paired sera (IgG) for pathogen if diagnosis is made antemortem, physician insti- REPORTING INSTRUCTIONS: tutes appropriate antimicrobial therapy and ᭿ Report meningitis in the newborn as nosocomial unless there at least one of the following: is compelling evidence indicating the meningitis was acquired a. Organisms seen on microscopic examination transplacentally. of brain or abscess tissue obtained by needle ᭿ Report CSF shunt infection as SSI-MEN if it occurs Յ1 year aspiration or by biopsy during a surgical opera- of placement; if later, report as CNS-MEN. tion or autopsy ᭿ Report meningoencephalitis as MEN. b. Positive antigen test on blood or urine ᭿ Report spinal abscess with meningitis as MEN. 1678 Section XV: Organization and Implementation of Infection Control Programs

INFECTION SITE: Spinal abscess without meningitis other recognized cause: fever (Ͼ38 ЊC), hypother- CODE: CNS-SA mia (Ͻ37 ЊC), apnea, bradycardia, lethargy, or DEFINITION: An abscess of the spinal epidural or subdural pain, erythema, or heat at involved vascular site space, without involvement of the CSF or adjacent bone struc- and tures, must meet at least one of the following criteria: more than 15 colonies cultured from intravascular Criterion 1: Patient has organisms cultured from abscess in the cannula tip using semiquantitative culture method spinal epidural or subdural space. and Criterion 2: Patient has an abscess in the spinal epidural or blood culture not done or no organisms cultured subdural space seen during a surgical operation or from blood. at autopsy of evidence of an abscess seen during a histopathologic examination. REPORTING INSTRUCTIONS: Criterion 3: Patient has at least one of the following signs or ᭿ Report infections of an arteriovenous graft, shunt, or fistula symptoms with no other recognized cause: fever or intravascular cannulation site without organisms cultured Ͼ Њ ( 38 C), back pain, focal tenderness, radiculitis, from blood as CVS-VASC. paraparesis, or paraplegia ᭿ Report intravascular infections with organisms cultured from and the blood as BSI-LCBI. if diagnosis is made antemortem, physician insti- tutes appropriate antimicrobial therapy INFECTION SITE: Endocarditis involving either a natural or and prosthetic heart valve at least one of the following: CODE: CVS-ENDO a. Organisms cultured from blood DEFINITION: Endocarditis of a natural or prosthetic heart b. Radiographic evidence of a spinal abscess, for valve must meet at least one of the following criteria: example, abnormal findings on myelography, Criterion 1: Patient has organisms cultured from valve or vege- ultrasound, CT, MRI, or other scans (gallium, tation. technetium, etc.) Criterion 2: Patient has two or more of the following signs or symptoms with no other recognized cause: fever REPORTING INSTRUCTION: (Ͼ38 ЊC), new or changing murmur, embolic phe- ᭿ Report spinal abscess with meningitis as MEN. nomena, skin manifestations (i.e., petechiae, splin- ter hemorrhages, painful subcutaneous nodules), INFECTION SITE: Arterial or venous infection congestive heart failure, or cardiac conduction ab- CODE: CVS-VASC normality DEFINITION: Arterial or venous infection must meet at least and one of the following criteria: if diagnosis is made antemortem, physician insti- Criterion 1: Patient has organisms cultured from arteries or tutes appropriate antimicrobial therapy veins removed during a surgical operation and and at least one of the following: blood culture not done or no organisms cultured a. Organisms cultured from two or more blood from blood. cultures Criterion 2: Patient has evidence of arterial or ve- b. Organisms seen on Gram stain of valve when nous infection seen during a surgical operation or culture is negative or not done histopathologic examination. c. Valvular vegetation seen during a surgical oper- Criterion 3: Patient has at least one of the following signs or ation or autopsy symptoms with no other recognized cause: fever d. Positive antigen test on blood or urine (e.g., (Ͼ38 ЊC), pain, erythema, or heat at involved vas- H. influenzae, S. pneumoniae, N. meningitidis, cular size or group B Streptococcus) and e. Evidence of new vegetation seen on echocar- more than 15 colonies cultured from intravascular diogram cannula tip using semiquantitative culture method Criterion 3: Patient Յ1 year of age has two or more of the and following signs or symptoms with no other recog- blood culture not done or no organisms cultured nized cause fever (Ͼ38 ЊC), hypothermia from blood. (Ͻ37 ЊC), apnea, bradycardia, new or changing Criterion 4: Patient has purulent drainage at in- murmur, embolic phenomena skin manifestations volved vascular site (i.e., petechiae, splinter hemorrhages, painful sub- and cutaneous nodules), congestive heart failure, or blood culture not done or no organisms cultured cardiac conduction abnormality from blood. and Criterion 5: Patient Յ1 year of age has at least if diagnosis is made antemortem, physician insti- one of the following signs or symptoms with no tutes appropriate antimicrobial therapy Chapter 94: Surveillance of Nosocomial Infections 1679

and DEFINITION: Mediastinitis must meet at least one of the fol- at least one of the following: lowing criteria: a. Organisms cultured from two or more blood Criterion 1: Patient has organisms cultured from mediastinal cultures tissue or fluid obtained during a surgical operation b. Organisms seen on Gram stain of valve when or needle aspiration. culture is negative or not done Criterion 2: Patient has evidence of mediastinitis seen during a c. Valvular vegetation seen during a surgical oper- surgical operation of histopathologic examination. ation or autopsy Criterion 3: Patient has at least one of the following signs or d. Positive antigen test on blood or urine (e.g., symptoms with no other recognized cause: fever H. influenzae, S. pneumoniae, N. meningitidis, (Ͼ38 ЊC), chest pain, or sternal instability or group B Streptococcus) and e. Evidence of new vegetation seen on echocar- at least one of the following: diogram a. Purulent discharge from mediastinal area INFECTION SITE: Myocarditis or pericarditis b. Organisms cultured from blood or discharge CODE: CVS-CARD from mediastinal area DEFINITION: Myocarditis or pericarditis must meet at least c. Mediastinal widening on x-ray one of the following criteria: Criterion 4: Patient Յ1 year of age has at least one of the fol- Criterion 1: Patient has organisms cultured from pericardial lowing signs or symptoms with no other recog- tissue or fluid obtained by needle aspiration or nized cause: fever (Ͼ38 ЊC), hypothermia during a surgical operation. (Ͻ37 ЊC), apnea, bradycardia, or sternal instability Criterion 2: Patient has at least two of the following signs or and symptoms with no other recognized cause: fever at least one of the following: Ͼ Њ ( 38 C), chest pain, paradoxical pulse, or in- a. Purulent discharge from mediastinal area creased heart size b. Organisms cultured from blood or discharge and from mediastinal area at least one of the following: c. Mediastinal widening on x-ray a. Abnormal electrocardiogram (ECG) consistent with myocarditis or pericarditis REPORTING INSTRUCTION: b. Positive antigen test on blood (e.g., H. influen- ᭿ zae, S. pneumoniae ) Report mediastinitis following cardiac surgery that is ac- c. Evidence of myocarditis or pericarditis on his- companied by osteomyelitis as SSI-MED rather than SSI- tologic examination of heart tissue BONE. d. Fourfold rise in type-specific antibody with or INFECTION SITE: Conjunctivitis without isolation of virus from pharynx or feces CODE: EENT-CONJ e. Pericardial effusion identified by echocardio- DEFINITION: Conjunctivitis must meet at least one of the gram, CT, MRI, or angiography Յ following criteria: Criterion 3: Patient 1 year of age has at least two of the fol- Criterion 1: Patient has pathogens cultured from purulent exu- lowing signs of symptoms with no other recog- date obtained from the conjunctiva or contiguous nized cause: fever (Ͼ38 ЊC), hypothermia Ͻ Њ tissues, such as eyelid, cornea, meibomian glands, ( 37 C), apnea, bradycardia, paradoxical pulse, or lacrimal glands. or increased heart size Criterion 2: Patient has pain or redness of con- and junctiva or around eye at least one of the following: and a. Abnormal ECG consistent with myocarditis or at least one of the following: pericarditis a. WBCs and organisms seen on Gram stain of b. Positive antigen test on blood (e.g., H. influen- exudate zae, S. pneumoniae ) b. Purulent exudate c. Histologic examination of heart tissue shows c. Positive antigen test [e.g., enzyme-linked im- evidence of myocarditis or pericarditis munosorbent assay (ELISA) or immunofluo- d. Fourfold rise in type-specific antibody with or rescence (IF) for Chlamydia trachomatis, herpes without isolation of virus from pharynx or feces simplex virus, adenovirus) on exudate or con- e. Pericardial effusion identified by echocardio- junctival scraping gram, CT, MRI, or angiography d. Multinucleated giant cells seen on microscopic COMMENT: examination of conjunctival exudate or scrap- ᭿ Most cases of postcardiac surgery or postmyocardial infarction ings pericarditis are not infectious. e. Positive viral culture INFECTION SITE: Mediastinitis f. Diagnostic single antibody titer (IgM) or four- CODE: CVS-MED fold increase in paired sera (IgG) for pathogen 1680 Section XV: Organization and Implementation of Infection Control Programs

REPORTING INSTRUCTIONS: and at least one of the following: ᭿ Report other infections of the eye as EYE. a. Organisms seen on Gram stain of purulent ma- ᭿ Do not report chemical conjunctivitis caused by silver nitrate terial from mastoid (AgNO ) as a nosocomial infection. 3 b. Positive antigen test on blood ᭿ Do not report conjunctivitis that occurs as a part of a more INFECTION SITE: Oral cavity (mouth, tongue, or gums) widely disseminated viral illness (e.g., measles, chickenpox, or CODE: EENT-ORAL a URI). DEFINITION: Oral cavity infections must meet at least one of INFECTION SITE: Eye, other than conjunctivitis the following criteria: CODE: EENT-EYE Criterion 1: Patient has organisms cultured from purulent ma- DEFINITION: An infection of the eye, other than conjunctivi- terial from tissues of oral cavity. tis, must meet at least one of the following criteria: Criterion 2: Patient has an abscess or other evidence of oral Criterion 1: Patient has organisms cultured from anterior or cavity infection seen on direct examination, dur- posterior chamber of vitreous fluid. ing a surgical operation, or during a histopatho- Criterion 2: Patient has at least two of the follow- logic examination. ing signs or symptoms with no other recognized cause: eye pain, visual disturbance, or hypopyon Criterion 3: Patient has at least one of the following signs or and symptoms with no other recognized cause: abscess, at least one of the following: ulceration, or raised white patches on inflamed a. Physician’s diagnosis of an eye infection mucosa, or plaques on oral mucosa b. Positive antigen test on blood (e.g., H. influen- and zae, S. pneumoniae ) at least one of the following: c. Organisms cultured from blood a. Organisms seen on Gram stain INFECTION SITE: Ear, mastoid b. Positive potassium hydroxide (KOH) stain CODE: EENT-EAR c. Multinucleated giant cells seen on microscopic DEFINITION: Ear and mastoid infections must meet the fol- examination of mucosal scrapings lowing applicable criteria: d. Positive antigen test on oral secretions Otitis externa must meet at least one of the following criteria: e. Diagnostic single antibody titer (IgM) or four- Criterion 1: Patient has pathogens cultured from purulent fold increase in paired sera (IgG) for pathogen drainage from ear canal. f. Physician diagnosis of infection and treatment Criterion 2: Patient has at least one of the follow- with topical or oral antifungal therapy ing signs or symptoms with no other recognized cause: fever (Ͼ38 ЊC), pain, redness, or drainage REPORTING INSTRUCTION: from ear canal ᭿ Report nosocomial primary herpes simplex infections of the and oral cavity as ORAL; recurrent herpes infections are not noso- organisms seen on Gram stain of purulent comial. drainage. Otitis media must meet at least one of the following criteria: INFECTION SITE: Sinusitis Criterion 1: Patient has organisms cultured from fluid from CODE: EENT-SINU middle ear obtained by tympanocentesis or at sur- DEFINITION: Sinusitis must meet at least one of the following gical operation. criteria: Criterion 2: Patient has at least two of the following signs or Criterion 1: Patient has organisms cultured from purulent ma- symptoms with no other recognized cause: fever terial obtained from sinus cavity. (Ͼ38 ЊC) pain in the eardrum, inflammation, re- Criterion 2: Patient has at least one of the following signs or traction or decreased mobility of eardrum, or fluid symptoms with no other recognized cause: fever behind eardrum. (Ͼ38 ЊC), pain or tenderness over the involved Otitis interna must meet at least one of the following criteria: sinus, headache, purulent exudate, or nasal ob- Criterion 1: Patient has organisms cultured from fluid from struction inner ear obtained at surgical operation. and Criterion 2: Patient has a physician’s diagnosis of inner ear at least one of the following: infection. a. Positive transillumination Mastoiditis must meet at least one of the following criteria: b. Positive radiographic examination Criterion 1: Patient has organisms cultured from purulent INFECTION SITE: Upper respiratory tract, pharyngitis, laryn- drainage from mastoid. gitis, epiglottitis Criterion 2: Patient has at least two of the following signs or CODE: EENT-UR symptoms with no other recognized cause: fever DEFINITION: Upper respiratory tract infections must meet at (Ͼ38 ЊC), pain, tenderness, erythema, headache, least one the following criteria: or facial paralysis Criterion 1: Patient has at least two of the following signs or Chapter 94: Surveillance of Nosocomial Infections 1681

symptoms with no other recognized cause: fever large bowel, and rectum) excluding gastroenteritis and appendi- (Ͼ38 ЊC), erythema of pharynx, sore throat, citis cough, hoarseness, of purulent exudate in throat CODE: GI-GIT and DEFINITION: Gastrointestinal tract infections, excluding gas- at least one of the following: troenteritis and appendicitis, must meet at least one of the fol- a. Organisms cultured from the specific site lowing criteria: b. Organisms cultured from blood Criterion 1: Patient has an abscess or other evidence of infec- c. Positive antigen test on blood or respiratory tion seen during a surgical operation or histopath- secretions ologic examination. d. Diagnostic single antibody titer (IgM) or four- Criterion 2: Patient has at least two of the following signs or fold increase in paired sera (IgG) for pathogen symptoms with no other recognized cause and e. Physician’s diagnosis of an upper respiratory compatible with infection of the organ or tissue infection involved: fever (Ͼ38 ЊC), nausea, vomiting, ab- Criterion 2: Patient has an abscess seen on direct examination, dominal pain, or tenderness during a surgical operation, or during a histopath- and ologic examination. at least one of the following: Criterion 3: Patient Յ1 year of age has at least two of the fol- a. Organisms cultured from drainage or tissue ob- lowing signs or symptoms with no other recog- tained during a surgical operation or endoscopy nized cause: fever (Ͼ38 ЊC), hypothermia or from a surgically placed drain (Ͻ37 ЊC), apnea, bradycardia, nasal discharge, or b. Organisms seen on Gram or KOH stain or purulent exudate in throat multinucleated giant cells seen on microscopic and examination of drainage or tissue obtained dur- at least one of the following: ing a surgical operation or endoscopy or from a. Organisms cultured from the specific site a surgically placed drain b. Organisms cultured from blood c. Organisms cultured from blood c. Positive antigen test on blood or respiratory d. Evidence of pathologic findings on radiologic secretions examination d. Diagnostic single antibody titer (IgM) or four- e. Evidence of pathologic findings on endoscopic fold increase in paired sera (IgG) for pathogen examination (e.g., Candida esophagitis or proc- e. Physician’s diagnosis of an upper respiratory titis) infection INFECTION SITE: Hepatitis INFECTION SITE: Gastroenteritis CODE: GI-HEP CODE: GI-GE DEFINITION: Hepatitis must meet the following criterion: DEFINITION: Gastroenteritis must meet at least one of the Patient has at least two of the following signs or symptoms with following criteria: no other recognized cause: fever ( Ͼ38 ЊC), anorexia, nausea, Criterion 1: Patient has an acute onset of diarrhea (liquid stools vomiting, abdominal pain, jaundice, or history of transfusion for more than 12 hours) with or without vomiting within the previous 3 months or fever ( Ͼ38 ЊC) and no likely noninfectious and cause (e.g., diagnostic tests, therapeutic regimen, at least one of the following: acute exacerbation of a chronic condition, or psy- a. Positive antigen or antibody test for hepatitis chologic stress). A, hepatitis B, hepatitis C, or delta hepatitis Criterion 2: Patient has at least two of the following signs or b. Abnormal liver function tests (e.g., elevated ala- symptoms with no other recognized cause: nausea, nine/aspartate aminotransferases, bilirubin) vomiting, abdominal pain, or headache and c. Cytomegalovirus detected in urine or oropha- at least one of the following: ryngeal secretions a. An enteric pathogen is cultured from stool or REPORTING INSTRUCTIONS: rectal swab b. An enteric pathogen is detected by routine or ᭿ Do not report hepatitis or jaundice of noninfectious origin electron microscopy (alpha-1 antitrypsin deficiency, etc.). c. An enteric pathogen is detected by antigen or ᭿ Do not report hepatitis or jaundice that results from exposure antibody assay on blood or feces to hepatotoxins (alcoholic or acetaminophen-induced hepati- d. Evidence of an enteric pathogen is detected by tis, etc.). cytopathic changes in tissue culture (toxin ᭿ Do not report hepatitis or jaundice that results from biliary assay) obstruction (cholecystitis). e. Diagnostic single antibody titer (IgM) or four- fold increase in paired sera (IgG) for pathogen INFECTION SITE: Intraabdominal, including gallbladder, bile INFECTION SITE: GI tract (esophagus, stomach, small and ducts, liver (excluding viral hepatitis), spleen, pancreas, perito- 1682 Section XV: Organization and Implementation of Infection Control Programs neum, subphrenic or subdiaphragmatic space, or other intraab- patient has at least two of the following signs or dominal tissue or area not specified elsewhere symptoms with no other recognized cause: fever CODE: GI-IAB (Ͼ38 ЊC), cough, new or increased sputum pro- DEFINITION: Intraabdominal infections must meet at least duction, rhonchi, wheezing one of the following criteria: and Criterion 1: Patient has organisms cultured from purulent ma- at least one of the following: terial from intraabdominal space obtained during a. Positive culture obtained by deep tracheal aspi- a surgical operation or needle aspiration. rate or bronchoscopy Criterion 2: Patient has abscess or other evidence of intraab- b. Positive antigen test on respiratory secretions dominal infection seen during a surgical operation Criterion 2: Patient Յ1 year of age has no clinical or radio- or histopathologic examination. graphic evidence of pneumonia Criterion 3: Patient has at least two of the following signs or and symptoms with no other recognized cause: fever patient has at least two of the following signs or (Ͼ38 ЊC), nausea, vomiting, abdominal pain, or symptoms with no other recognized cause: fever jaundice (Ͼ38 ЊC), cough, new or increased sputum pro- and duction, rhonchi, wheezing, respiratory distress, at least one of the following: apnea, or bradycardia a. Organisms cultured from drainage from surgi- and cally placed drain (e.g., closed suction drainage at least one of the following: system, open drain, T-tube drain) a. Organisms cultured from material obtained by b. Organisms seen on Gram stain of drainage or deep tracheal aspirate or bronchoscopy tissue obtained during surgical operation or b. Positive antigen test on respiratory secretions needle aspiration c. Diagnostic single antibody titer (IgM) or four- c. Organisms cultured from blood and radio- fold increase in paired sera (IgG) for pathogen graphic evidence of infection, for example, ab- normal findings on ultrasound, CT, MRI, or REPORTING INSTRUCTION: radiolabel scans (gallium, technetium, etc.) or ᭿ Do not report chronic bronchitis in a patient with chronic on abdominal x-ray lung disease as an infection unless there is evidence of an acute REPORTING INSTRUCTION: secondary infection, manifested by change in organism. ᭿ Do not report pancreatitis (an inflammatory syndrome charac- INFECTION SITE: Other infections of the lower respiratory terized by abdominal pain, nausea, and vomiting associated tract with high serum levels of pancreatic enzymes) unless it is CODE: LRI-LUNG determined to be infectious in origin. DEFINITION: Other infections of the lower respiratory tract must meet at least one of the following criteria: INFECTION SITE: Necrotizing enterocolitis Criterion 1: Patient has organisms seen on smear or cultured CODE: GI-NEC from lung tissue or fluid, including pleural fluid. DEFINITION: Necrotizing enterocolitis in infants must meet Criterion 2: Patient has a lung abscess or empyema seen during the following criteria: a surgical operation or histopathologic examina- Infant has at least two of the following signs or symptoms with tion. no other recognized cause: vomiting, abdominal distention, or Criterion 3: Patient has an abscess cavity seen on radiographic prefeeding residuals examination of lung. and persistent microscopic or gross blood in stools REPORTING INSTRUCTIONS: and ᭿ Report concurrent lower respiratory tract infection and pneu- at least one of the following abdominal radiographic abnormali- monia with the same organism(s) as PNEU. ties: ᭿ Report lung abscess or empyema without pneumonia as a. Pneumoperitoneum LUNG. b. Pneumatosis intestinalis c. Unchanging ‘‘rigid’’ loops of small bowel INFECTION SITE: Endometritis INFECTION SITE: Bronchitis, tracheobronchitis, bronchio- CODE: REPR-EMET litis, tracheitis, without evidence of pneumonia DEFINITION: Endometritis must meet at least one of the fol- CODE: LRI-BRON lowing criteria: DEFINITION: Tracheobronchial infections must meet at least Criterion 1: Patient has organisms cultured from fluid or tissue one of the following criteria: from endometrium obtained during surgical oper- Criterion 1: Patient has no clinical or radiographic evidence of ation, by needle aspiration, or by brush biopsy. pneumonia Criterion 2: Patient has at least two of the following signs or and symptoms with no other recognized cause: fever Chapter 94: Surveillance of Nosocomial Infections 1683

(Ͼ38 ЊC), abdominal pain, uterine tenderness, or REPORTING INSTRUCTIONS: purulent drainage from uterus. ᭿ Report endometritis as EMET. REPORTING INSTRUCTION: ᭿ Report vaginal cuff infections as VCUF. INFECTION SITE: Skin ᭿ Report postpartum endometritis as a nosocomial infection CODE: SST-SKIN unless the amniotic fluid is infected at the time of admission DEFINITION: Skin infections must meet at least one of the or the patient was admitted 48 hours after rupture of the following criteria: membrane. Criterion 1: Patient has purulent drainage, pustules, vesicles, INFECTION SITE: Episiotomy or boils. CODE: REPR-EPIS Criterion 2: Patient has at least two of the following signs or DEFINITION: Episiotomy infections must meet at least one of symptoms with no other recognized cause: pain the following criteria: or tenderness, localized swelling, redness, or heat Criterion 1: Postvaginal delivery patient has purulent drainage and from the episiotomy. at least one of the following: Criterion 2: Postvaginal delivery patient has an episiotomy ab- a. Organisms cultured from aspirate or drainage scess. from affected site; if organisms are normal skin flora (e.g., coagulase negative staphylococci, REPORTING INSTRUCTION: micrococci, diphtheroids) they must be a pure culture ᭿ Episiotomy is not a NNIS operative procedure; do not report b. Organisms cultured from blood as an SSI. c. Positive antigen test performed on infected tis- sue or blood (e.g., herpes simplex, varicella zos- INFECTION SITE: Vaginal cuff ter, H. influenzae, N. meningitidis ) CODE: REPR-VCUF d. Multinucleated giant cells seen on microscopic DEFINITION: Vaginal cuff infections must meet at least one examination of affected tissue of the following criteria: e. Diagnostic single antibody titer (IgM) or four- Criterion 1: Posthysterectomy patient has purulent drainage fold increase in paired sera (IgG) for pathogen from the vaginal cuff. COMMENT: Criterion 2: Posthysterectomy patient has an abscess at the vag- inal cuff. ᭿ Nosocomial skin infections may be the result of exposure to Criterion 3: Posthysterectomy patient has pathogens cultured a variety of procedures performed in the hospital. Superficial from fluid or tissue obtained from the vaginal cuff. incisional infections after surgery are identified separately as SSI-SKIN unless the operative procedure is a CBGB. If the REPORTING INSTRUCTION: chest incision site after a CBGB becomes infected, the specific site is denoted SKNC; if the donor site becomes infected, the ᭿ Most vaginal cuff infections are SSI-VCUF. specific site is denoted SKNL. Other skin infections associated ᭿ Ͼ Report only late onset ( 30 days after hysterectomy) VCUF with important exposures are identified with their own sites as REPR-VCUF. and are listed in the section on reporting instructions.

INFECTION SITE: Other infections of the male or female re- REPORTING INSTRUCTIONS: productive tract (epididymis, testes, prostate, vagina, ovaries, uterus, or other deep pelvic tissues, excluding endometritis or ᭿ Report omphalitis in infants as UMB. vaginal cuff infections) ᭿ Report infections of the circumcision site in newborns as CODE: REPR-OREP CIRC. ᭿ DEFINITION: Other infections of the male or female reproduc- Report pustules in infants as PUST. ᭿ tive tract must meet at least one of the following criteria: Report infected decubitus ulcers as DECU. ᭿ Criterion 1: Patient has organisms cultured from tissue or fluid Report infected burns as BURN. ᭿ from affected site. Report breast abscesses or mastitis as BRST. Criterion 2: Patient has an abscess or other evidence of infec- INFECTION SITE: Soft tissue (necrotizing fascitis, infectious tion of affected site seen during a surgical opera- gangrene, necrotizing cellulitis, infectious myositis, lymphadeni- tion or histopathologic examination. tis, or lymphangitis) Criterion 3: Patient has two of the following signs or symptoms CODE: SST-ST with no other recognized cause: fever ( Ͼ38 ЊC), DEFINITION: Soft tissue infections must meet at least one of nausea, vomiting, pain, tenderness, or dysuria the following criteria: and Criterion 1: Patient has organisms cultured from tissue or at least one of the following: drainage from affected site. a. Organisms cultured from blood Criterion 2: Patient has purulent drainage at affected site. b. Diagnosis by physician Criterion 3: Patient has an abscess or other evidence of infec- 1684 Section XV: Organization and Implementation of Infection Control Programs

tion seen during a surgical operation or histopath- Criterion 2: Patient has a change in burn wound appearance ologic examination. or character, such as rapid eschar separation; dark Criterion 4: Patient has at least two of the following signs of brown, black, or violaceous discoloration of the symptoms at the affected site with no other recog- eschar; or edema at wound margin nized cause: localized pain or tenderness, redness, and swelling, or heat at least one of the following: and a. Organisms cultured from blood in the absence at least one of the following: of other identifiable infection a. Organisms cultured from blood b. Isolation of herpes simplex virus, histologic b. Positive antigen test performed on blood or identification of inclusions by light or electron urine (e.g., H. influenzae, S. pneumoniae, N. microscopy or visualization of viral particles by meningitidis, group B Streptococcus, Candida electron microscopy in biopsies or lesion scrap- sp.) ings c. Diagnostic single antibody titer (IgM) or four- Criterion 3: Patient with a burn has at least two of the following fold increase in paired sera (IgG) for pathogen signs or symptoms with no other recognized cause: fever (Ͼ38 ЊC) or hypothermia ( Ͻ36 ЊC), hypo- REPORTING INSTRUCTIONS: tension, oliguria (Ͻ20 cm 3/hr), hyperglycemia at ᭿ Report surgical site infections that involve both the skin and previously tolerated level of dietary carbohydrate, deep soft tissue (at or beneath the fascial or muscle layer) as or mental confusion SSI-ST (soft tissue) unless the operative procedure is a CBGB. and For CBGB, if skin and deep soft tissue at the chest incision at least one of the following: site become infected, the specific site is STC and if skin and a. Histologic examination of burn biopsy shows deep soft tissue at the donor site become infected, the specific invasion of organisms into adjacent viable site is STL. tissue ᭿ Report infected decubitus ulcers as DECU. b. Organisms cultured from blood ᭿ Report infection of deep pelvic tissues as OREP. c. Isolation of herpes simplex virus, histologic INFECTION SITE: Decubitus ulcer, including both superficial identification of inclusions by light or electron and deep infections microscopy, or visualization of viral particles CODE: SST-DECU electron microscopy in biopsies or lesion scrap- DEFINITION: Decubitus ulcer infections must meet the fol- ings lowing criterion: COMMENTS: Patient has at least two of the following signs or symptoms with ᭿ Purulence alone at the burn wound site is not adequate for no other recognized cause: redness, tenderness, or swelling of the diagnosis of burn infection; such purulence may reflect decubitus wound edges incomplete wound care. and ᭿ Fever alone in a burn patient is not adequate for the diagnosis at least one of the following: of a burn infection because fever may be the result of tissue a. Organisms cultured from properly collected trauma or the patient may have an infection at another site. fluid or tissue (see later) ᭿ Surgeons in Regional Burn Centers who take care of burn b. Organisms cultured from blood patients exclusively, may require Criterion 1 for diagnosis COMMENTS: burn infection. ᭿ Hospitals with Regional Burn Centers may further divide ᭿ Purulent drainage alone is not sufficient evidence of an infec- burn infections into the following: burn wound site, burn tion. graft site, burn donor site, burn donor site-cadaver; the NNIS ᭿ Organisms cultured from the surface of a decubitus ulcer are system, however, will code all of these as BURN. not sufficient evidence that the ulcer is infected. A properly INFECTION SITE: Breast abscess or mastitis collected specimen from a decubitus ulcer involves needle CODE: SST-BRST aspiration of fluid or biopsy of tissue from the ulcer margin. DEFINITION: A breast abscess or mastitis must meet at least INFECTION SITE: Burn one of the following criteria: CODE: SST-BURN Criterion 1: Patient has a positive culture of affected breast DEFINITION: Burn infections must meet one of the following tissue or fluid obtained by incision and drainage criteria: or needle aspiration. Criterion 1: Patient has a change in burn wound appearance Criterion 2: Patient has a breast abscess or other evidence of or character, such as rapid eschar separation; dark infection seen during a surgical operation or histo- brown, black, or violaceous discoloration of the pathologic examination. char; or edema at wound margin Criterion 3: Patient has fever ( Ͼ38 ЊC) and local inflammation and of the breast histologic examination of burn biopsy shows inva- and sion of organisms into adjacent viable tissue. physician’s diagnosis of breast abscess. Chapter 94: Surveillance of Nosocomial Infections 1685

COMMENT: circumcision site: erythema, swelling, or tender- ness ᭿ Breast abscesses occur most frequently after childbirth. Those and that occur within 7 days after childbirth should be considered skin contaminant (coagulase-negative staphylo- nosocomial. cocci, diphtheroids, Bacillus sp., or micrococci) is INFECTION SITE: Omphalitis cultured from circumcision site CODE: SST-UMB and DEFINITION: Omphalitis in a newborn ( Յ30 days old) must physician diagnosis of infection or physician insti- meet at least one of the following criteria: tutes appropriate therapy. Criterion 1: Patient has erythema and/or serous drainage from REPORTING INSTRUCTION: umbilicus and ᭿ Newborn circumcision is not an NNIS operative procedure; at least one of the following: do not report as an SSI. a. Organisms cultured from drainage or needle INFECTION SITE: Disseminated infection aspirate CODE: SYS-DI b. Organisms cultured from blood. DEFINITION: Disseminated infection is infection involving Criterion 2: Patient has both erythema and purulence at the multiple organs or systems, without an apparent single site of umbilicus. infection, usually of viral origin, and with signs or symptoms REPORTING INSTRUCTIONS: with no other recognized cause and compatible with infectious involvement of multiple organs or systems. ᭿ Report infection of the umbilical artery or vein related to umbilical catheterization as CVS-VASC if blood culture is REPORTING INSTRUCTIONS: negative or not done. ᭿ This code should be used primarily for viral infections involv- ᭿ Report as nosocomial if infection occurs in a newborn within ing multiple organ systems (e.g., measles, mumps, rubella, 7 days of hospital discharge. varicella, erythema infectiosum). These infections often can INFECTION SITE: Infant pustulosis be identified by clinical criteria alone. Do not use this code CODE: SST-PUST for nosocomial infections with multiple metastatic sites, such DEFINITION: Pustulosis in an infant ( Յ12 months old) must as with bacterial endocarditis; only the primary site of these meet at least one of the following criteria: infections should be reported. ᭿ Criterion 1: Infant has one or more pustules Do not report fever of unknown origin (FUO) as DI-SYS. ᭿ and Report neonatal ‘‘sepsis’’ as BSI-CSEP. ᭿ physician diagnosis of skin infection. Report viral exanthems or rash illness as DI-SYS. Criterion 2: Infant has one or more pustules and physician institutes appropriate antimicrobial APPENDIX A-2. CRITERIA FOR DEFINING therapy. NOSOCOMIAL PNEUMONIA REPORTING INSTRUCTIONS: General Comments Applicable to All Pneumonia Specific Site Criteria ᭿ Do not report erythema toxicum and noninfectious causes of pustulosis. 1. Physician’s diagnosis of pneumonia alone is not an acceptable ᭿ Report as nosocomial if pustulosis occurs in an infant within criterion for nosocomial pneumonia. 7 days of hospital discharge. 2. Although specific criteria are included for infants and chil- dren, pediatric patients may meet any of the other pneumonia INFECTION SITE: Newborn circumcision specific site criteria. CODE: SST-CIRC 3. Ventilator-associated pneumonia (i.e., pneumonia in persons DEFINITION: Circumcision infection in a newborn ( Յ30 days who had a device to assist or control respiration continuously old) must meet at least one of the following criteria: through a tracheostomy or by endotracheal intubation within Criterion 1: Newborn has purulent drainage from circumci- the 48-hour period before the onset of infection) should be sion site. so designated when reporting pneumonia data. Criterion 2: Newborn has at least one of the following signs 4. When assessing a patient for presence of pneumonia, it is or symptoms with no other recognized cause at important to distinguish between changes in clinical status circumcision site: erythema, swelling, or tender- resulting from other conditions such as myocardial infarc- ness tion, pulmonary embolism, respiratory distress syndrome, at- and electasis, malignancy, chronic obstructive pulmonary disease, pathogen cultured from circumcision site. hyaline membrane disease, bronchopulmonary dysplasia, and Criterion 3: Newborn has at least one of the following signs so forth. Also, care must be taken when assessing intubated or symptoms with no other recognized cause at patients to distinguish between tracheal colonization, upper 1686 Section XV: Organization and Implementation of Infection Control Programs

respiratory tract infections (e.g., tracheobronchitis), and early ples are frequently contaminated with airway colonizers and, onset pneumonia. Finally, it should be recognized that it therefore, must be interpreted cautiously. In particular, Can- may be difficult to determine nosocomial pneumonia in the dida is commonly seen on stain but infrequently causes noso- elderly, infants, and immunocompromised patients because comial pneumonia. such conditions may mask typical signs or symptoms associ- ated with pneumonia. Alternate specific criteria for the el- derly, infants and immunocompromised patients have been Abbreviations included in this definition of nosocomial pneumonia. BAL—bronchoalveolar lavage 5. Nosocomial pneumonia can be characterized by its onset: EIA—enzyme immunoassay early or late. Early onset pneumonia occurs during the first FAMA—fluorescent-antibody staining of membrane antigen 4 days of hospitalization and is often caused by Moraxella IFA—immunofluorescent antibody catarrhalis, H. influenzae, and S. pneumoniae. Causative LRT—lower respiratory tract agents of late onset pneumonia are frequently gram-negative PCR—polymerase chain reaction bacilli or Staphylococcus aureus, including methicillin-resistant PMN—polymorphonuclear leukocyte S. aureus. Viruses (e.g., influenza A and B or respiratory syn- RIA—radioimmunoassay cytial virus) can cause early and late onset nosocomial pneu- monia, whereas yeasts, fungi, legionellae, and Pneumocystis carinii are usually pathogens of late onset pneumonia. Reporting Instructions 6. Pneumonia resulting from gross aspiration (e.g., in the setting of intubation in the emergency room or operating room) is ᭿ There is a hierarchy of specific site categories within the major considered nosocomial if it meets any specific criteria and site pneumonia. Even if a patient meets criteria for more than was not clearly present or incubating at the time of admission one specific site, report only one: • to the hospital. If a patient meets criteria for both PNU1 and PNU2, report 7. Multiple episodes of nosocomial pneumonia may occur in PNU2. critically ill patients with lengthy hospital stays. When deter- • If a patient meets criteria for both PNU2 and PNU3, report mining whether to report multiple episodes of nosocomial PNU3. pneumonia in a single patient, look for evidence of resolution • If a patient meets criteria for both PNU1 and PNU3, report of the initial infection. The addition of or change in pathogen PNU3. alone is not indicative of a new episode of pneumonia. The ᭿ Report concurrent lower respiratory tract infection (e.g., ab- combination of new signs and symptoms and radiographic scess or empyema) and pneumonia with the same organism(s) evidence or other diagnostic testing is required. as pneumonia. 8. Positive Gram stain for bacteria and positive KOH mount ᭿ Report lung abscess or empyema without pneumonia as for elastin fibers and/or fungal hyphae from appropriately LUNG. collected sputum specimens are important clues that point ᭿ Report acute bronchitis, tracheitis, tracheobronchitis, or toward the etiology of the infection. However, sputum sam- bronchiolitis without pneumonia as BRON. Chapter 94: Surveillance of Nosocomial Infections 1687

APPENDIX A-2. PNEUMONIA ALGORITHMS

Major Site: Pneumonia (PNEU) Site-Specific Algorithms for Clinically Defined Pneumonia (PNU1)

Radiology Signs/symptoms/laboratory Code

Two or more serial chest PNU1 radiographs with at least one FOR ANY PATIENT, at least one of the following: of the following 1,2 : • Fever ( Ͼ38°C or Ͼ100.4°F) with no other recognized cause • New or progressive • Leukopenia ( Ͻ4,000 WBC/mm 3) or leukocytosis ( Ն12,000 WBC/mm 3) • • • • and persistent infiltrate • For adults Ն70 years old, altered mental status with no other recognized cause Consolidation and Cavitation At least two of the following: Pneumatoceles, in infants • New onset of purulent sputum 3, or change in character of sputum 4, or increased respiratory Յ1 year old secretions, or increased suctioning requirements • New onset or worsening cough, or dyspnea, or tachypnea 5 • Rales 6 or bronchial breath sounds 7 •Worsening gas exchange (e.g., O 2 desaturations [e.g., PaO 2/FiO 2 Յ240] , increased oxygen requirements, or increased ventilation demand)

ALTERNATE CRITERIA FOR INFANT Յ1 YEAR OLD: NOTE: In patients without Worsening gas exchange (e.g., O 2 desaturations, increased oxygen requirements, or increased underlying pulmonary or ventilator demand) cardiac disease (e.g., and respiratory distress syndrome, at least three of the following: bronchopulmonary dysplasia, • Temperature instability with no other recognized cause pulmonary edema, or chronic • Leukopenia ( Ͻ4,000 WBC/mm 3) obstructive pulmonary or leukocytosis ( Ն15,000 WBC/mm 3) and left shift ( Ն10% band forms) disease), one definitive chest • New onset of purulent sputum 3, or change in character of sputum 4, or increased respiratory radiograph is acceptable 1. secretions, or increased suctioning requirements • Apnea, tachypnea 5, nasal flaring with retraction of chest wall, or grunting •Wheezing, rales 6, or rhonchi • Cough • Bradycardia ( Ͻ100 beats/min) or tachycardia ( Ͼ170 beats/min)

ALTERNATE CRITERIA FOR CHILD Ͼ1 OR Յ12 YEARS OLD, at least three of the following: • Fever ( Ͼ38.4°C or Ͼ101.1°F) or hypothermia ( Ͻ37°C or Ͻ97.7°F) with no other recognized cause • Leukopenia ( Ͻ4,000 WBC/mm 3) or leukocytosis ( Ն15,000 WBC/mm 3) • New onset of purulent sputum 3, or change in character of sputum 4, or increased respiratory secretions, or increased suctioning requirements • New onset or worsening cough or dyspnea, apnea, or tachypnea 5 • Rales 6 or bronchial breath sounds •Worsening gas exchange (e.g., O 2 desaturations [e.g., pulse oximetry Ͻ94%], increased oxygen requirements, or increased ventilation demand)

Major Site: Pneumonia (PNEU ) Specific Site Algorithms for Pneumonia with Common Bacterial or Filamentous Fungal Pathogens and Specific Laboratory Findings (PNU2)

Radiology Signs/symptoms Laboratory Code

Two or more serial chest At least one of the following: At least one of the following: PNU2 radiographs with at least one • Fever ( Ͼ38°C or Ͼ100.4°F) with no other • Positive growth in blood culture 8 not related of the following 1,2 : recognized cause to another source of infection • New or progressive • Leukopenia ( Ͻ4,000 WBC/mm 3) or leukocytosis • Positive growth in culture of pleural fluid and persistent infiltrate (Ն12,000 WBC/mm 3) • Positive quantitative culture 9 from minimally • Consolidation • For adults Ն70 years old, altered mental status contaminated LRT specimen (e.g., BAL or • Cavitation with no other recognized cause protected specimen brushing) and • Ն5% BAL-obtained cells contain intracellular At least one of the following: bacteria on direct microscopic exam (e.g., NOTE: In patients without • New onset of purulent sputum 3, or change in Gram stain) underlying pulmonary or character of sputum 4, or increased respiratory • Histopathologic exam shows at least one of cardiac disease (e.g., secretions, or increased suctioning requirements the following evidences of pneumonia: respiratory distress syndrome, • New onset or worsening cough, or dyspnea, or Abscess formation or foci of consolidation bronchopulmonary dysplasia, tachypnea 5 with intense PMN accumulation in pulmonary edema, or chronic • Rales 6 or bronchial breath sounds bronchioles and alveoli 9 obstructive pulmonary •Worsening gas exchange (e.g., O 2 desaturations Positive quantitative culture of lung 7 disease), one definitive chest [e.g., PaO 2/FiO 2 Յ240] , increased oxygen parenchyma radiograph is acceptable 1. requirements, or increased ventilation demand) Evidence of lung parenchyma invasion by fungal hyphae or pseudohyphae 1688 Section XV: Organization and Implementation of Infection Control Programs

Major Site: Pneumonia (PNEU) Specific Site Algorithms for Pneumonia with Viral, Legionella, Chlamydia, Mycoplasma , and Other Uncommon Pathogens and Specific Laboratory Findings (PNU2)

Radiology Signs/symptoms Laboratory Code

Two or more serial chest At least one of the following: At least one of the following 10–12 : PNU2 radiographs with at least • Fever ( Ͼ38°C or Ͼ100.4°F) with no other • Positive culture of virus or Chlamydia from one of the following 1,2 : recognized cause respiratory secretions • New or progressive • Leukopenia ( Ͻ4,000 WBC/mm 3) or leukocytosis • Positive detection of viral antigen or and persistent infiltrate (Ն12,000 WBC/mm 3) antibody from respiratory secretions (e.g., • Consolidation • For adults Ն70 years old, altered mental status EIA, FAMA, shell vial assay, PCR) • Cavitation with no other recognized cause • Fourfold rise in paired sera (IgG) for and pathogen (e.g., influenza viruses, Chlamydia ) NOTE: In patients without At least one of the following: • Positive PCR for Chlamydia or Mycoplasma underlying pulmonary or • New onset of purulent sputum 3, or change in • Positive micro-IF test for Chlamydia cardiac disease (e.g., character of sputum 4, or increased respiratory • Positive culture or visualization by micro-IF of respiratory distress syndrome, secretions, or increased suctioning requirements Legionella spp. from respiratory secretions or bronchopulmonary dysplasia, • New onset or worsening cough, dyspnea, or tissue pulmonary edema, or chronic tachypnea 5 • Detection of Legionella pneumophila obstructive pulmonary • Rales 6 or bronchial breath sounds serogroup 1 antigens in urine by RIA or EIA disease), one definitive chest •Worsening gas exchange (e.g., O 2 desaturations • Fourfold rise in L. pneumophila serogroup 1 1 Յ 7 radiograph is acceptable . [e.g., PaO 2/FiO 2 240] , increased oxygen antibody titer to Ն1 : 128 in paired acute and requirements, or increased ventilation demand) convalescent sera by indirect IFA

Major Site: Pneumonia (PNEU ) Specific Site Algorithm for Pneumonia in Immunocompromised Patients (PNU3)

Radiology Signs/symptoms Laboratory Code

Two or more serial chest Patient who is immunocompromised 13 has at least At least one of the following: PNU3 radiographs with at least one one of the following: • Matching positive blood and sputum cultures of the following 1,2 : • Fever ( Ͼ38°C or Ͼ100.4°F) with no other with Candida spp. 14,15 • New or progressive and recognized cause • Evidence of fungi or Pneumocytis carinii from persistent infiltrate • For adults Ն70 years old, altered mental status minimally contaminated LRT specimen (e.g., • Consolidation with no other recognized cause BAL or protected specimen brushing) from • Cavitation • New onset of purulent sputum 3, or change in one of the following: character of sputum 4, or increased respiratory – Direct microscopic exam NOTE: In patients without secretions, or increased suctioning requirements – Positive culture of fungi underlying pulmonary or • New onset or worsening cough, or dyspnea, or Any of the following from: cardiac disease (e.g., tachypnea 5 LABORATORY CRITERIA DEFINED UNDER PNU2 respiratory distress syndrome, • Rales 6 or bronchial breath sounds

bronchopulmonary dysplasia, •Worsening gas exchange (e.g., O 2 desaturations 7 pulmonary edema, or chronic [e.g., PaO 2/FiO 2 Յ240] , increased oxygen obstructive pulmonary requirements, or increased ventilation demand) disease), one definitive chest • Hemoptysis radiograph is acceptable 1. • Pleuritic chest pain

1. Occasionally, in nonventilated patients, the diagnosis of nosocomial pneumonia may be quite clear on the basis of symptoms, signs, and a single defini- tive chest radiograph. However, in patients with pulmonary or cardiac disease (e.g., interstitial lung disease or congestive heart failure), the diagnosis of pneumonia may be particularly difficult. Other noninfectious conditions (e.g., pulmonary edema from decompensated congestive heart failure) may simulate the presentation of pneumonia. In these more difficult cases, serial chest radiographs must be examined to help separate infectious from non- infectious pulmonary processes. To help confirm difficult cases, it may be useful to review radiographs on the day of diagnosis, 3 days prior to the diag- nosis, and on days 2 and 7 after the diagnosis. Pneumonia may have rapid onset and progression but does not resolve quickly. Radiographic changes of pneumonia persist for several weeks. As a result, rapid radiograph resolution suggests that the patient does not have pneumonia but rather a noninfec- tious process such as atelectasis or congestive heart failure. 2. Note that there are many ways of describing the radiographic appearance of pneumonia. Examples include, but are not limited to, air-space disease, fo- cal opacification, and patchy areas of increased density. Although perhaps not specifically delineated as pneumonia by the radiologist, in the appropri- ate clinical setting these alternative descriptive wordings should be seriously considered as potentially positive findings. 3. Purulent sputum is defined as secretions from the lungs, bronchi, or trachea that contain Ն25 neutrophils and Յ10 squamous epithelial cells per low power field ( ϫ100). If your laboratory reports these data qualitatively (e.g., many WBCs or few squames), be sure their descriptors match this definition of purulent sputum. This laboratory confirmation is required because written clinical descriptions of purulence are highly variable. 4. A single notation of either purulent sputum or change in character of the sputum is not meaningful; repeated notations over a 24-hour period would be more indicative of the onset of an infectious process. Change in character of sputum refers to the color, consistency, odor, and quantity. Chapter 94: Surveillance of Nosocomial Infections 1689

Footnotes Continued. 5. In adults, tachypnea is defined as respiration rate Ͼ25 breaths per minute. Tachypnea is defined as Ͼ75 breaths per minute in premature infants born at Ͻ37 weeks’ gestation and until the 40th week; Ͼ60 breaths per minute in patients Ͻ2 months old; Ͼ50 breaths per minute in patients 2–12 months old; and Ͼ30 breaths per minute in children Ͼ1 year old. 6. Rales may be described as crackles. 7. This measure of arterial oxygenation is defined as the ratio of the arterial tension (PaO 2) to the inspiratory fraction of oxygen (FiO 2). 8. Care must be taken to determine the etiology of pneumonia in a patient with positive blood cultures and radiographic evidence of pneumonia, espe- cially if the patient has invasive devices in place such as intravascular lines or an indwelling urinary catheter. In general, in an immunocompetent pa- tient, blood cultures positive for coagulase negative staphylococci, common skin contaminants, and yeasts will not be the etiologic agent of the pneu- monia. 9. Refer to Table A-2.1 for threshold values of bacteria from cultured specimens. An endotracheal aspirate is not a minimally contaminated specimen. Therefore, an endotracheal aspirate does not meet the laboratory criteria. 10. Once laboratory-confirmed cases of pneumonia due to respiratory syncytial virus (RSV), adenovirus, or influenza virus have been identified in a hospital, clinician’s presumptive diagnosis of these pathogens in subsequent cases with similar clinical signs and symptoms is an acceptable criterion for presence of nosocomial infection. 11. Scant or watery sputum is commonly seen in adults with pneumonia due to viruses and Mycoplasma although sometimes the sputum may be mucopuru- lent. In infants, pneumonia due to RSV or influenza yields copious sputum. Patients, except premature infants, with viral or mycoplasmal pneumonia may exhibit few signs or symptoms, even when significant infiltrates are present on radiographic exam. 12. Few bacteria may be seen on stains of respiratory secretions from patients with pneumonia due to Legionella spp, Mycoplasma , or viruses. 13. Immunocompromised patients include those with neutropenia (absolute neutrophil count Ͻ500/mm 3), leukemia, lymphoma, HIV with CD4 count Ͻ200, or splenectomy; those who are in their transplant hospital stay; and those who are on cytotoxic chemotherapy, high dose steroids, or other immunosup- pressives daily for Ͼ2 weeks [e.g., Ͼ40mg of prednisone or its equivalent ( Ͼ160mg hydrocortisone, Ͼ32mg methylprednisolone, Ͼ6mg dexamethasone, Ͼ200mg cortisone)]. 14. Blood and sputum specimens must be collected within 48 hours of each other. 15. Semiquantitative or nonquantitative cultures of sputum obtained by deep cough, induction, aspiration, or lavage are acceptable. If quantitative culture results are available, refer to algorithms that include such specific laboratory findings.

TABLE A-2.1. THRESHOLD VALUES FOR CULTURED SPECIMENS USED IN THE DIAGNOSIS OF PNEUMONIA

Specimen Collection/Technique Values Comment

Lung parenchyma Ն10 4 CFU/g tissue 1 Bronchoscopically (B) obtained specimens Bronchoalveolar lavage (B-BAL) Ն10 4 CFU/mL Protected BAL (B-PBAL) Ն10 4 CFU/mL Protected specimen brushing (B-PSB) Ն10 3 CFU/mL Nonbronchoscopically (NB) obtained (blind) specimens NB-BAL Ն10 4 CFU/mL NB-PSB Ն10 3 CFU/mL

1, open-lung biopsy specimens and immediate postmortem specimens obtained by transthoracic or trans- bronchial biopsy; CFU, colony-forming units; g, gram; mL, milliliter. Potential Healthcare Acquired Infection Measures Acronym Measure Numerator(s) Denominator(s) Source(s) CAUTI Catheter-associated urinary tract 1. Number of cases 1. Pts with a urinary cath. 1. CMS* infections 2. Number of cases 2. Pt-days for pts with a urinary cath. 2. 3. Number of cases 3. ICU pts with a urinary cath. 3. 4. Number of cases 4. ICU pt-days for pts with a urinary cath. 4. 5. Number of cases 5. Urinary catheter days 5. NHSN CLABI Central line-associated bloodstream 1. Number of cases 1. Pts with a central line 1. CMS* infections 2. Number of cases 2. Pt-days for pts with a central line 2. 3. Number of cases 3. ICU pts with a central line 3. McKibben 4. Number of cases 4. ICU pt-days for pts with a central line 4. 5. Number of cases 5. Central line days 5. NHSN, IHI, NQF CLIP Central line insertion practices 1. Proper hand hygiene used 1. Pts with a central line 1. IHI 2. Maximal sterile barriers were used 2. Pts with a central line 2. McKibben, IHI 3. Skin antiseptic used 3. Pts with a central line 3. McKibben, IHI 4. Optimal site selection 4. Pts with a central line 4. IHI 5. Daily review of necessity 5. Pts with a central line 5. IHI 6. Compliance with all five elements 6. Pts with a central line 6. IHI, NQF SSI Surgical site infections 1. Number of cases for a specific type 1. Pts receiving a specific type of high- 1. McKibben of high-volume surgery volume surgery 2. CMS* 2. Mediastinitis in CABG pts 2. Pts receiving CABG surgery 3. IHI 3. Number of cases in “clean” surgery 3. “Clean” surgery pts 4. NHSN pts. 4. Pts receiving NHSN procedures 5. NHSN 4. Number of superficial SSIs 5. Pts receiving NHSN procedures 6. NHSN 5. Number of deep-incision SSIs 6. Pts receiving NHSN procedures 7. NQF 6. Number of organ/space SSIs 7. Pts receiving NHSN procedures 7. Total number of deep-incision and organ/space SSIs SAMP Surgical antimicrobial prophylaxis 1. Pt received AMP within 1 hr of 1. Surgical pts 1. McKibben, IHI, SCIP** (AMP) incision 2. Surgical pts 2. McKibben, IHI, SCIP** 2. Pt received recommended AMP 3. Surgical pts 3. McKibben, IHI, SCIP** 3. AMP discontinued within 24 hrs of 4. Surgical pts 4. IHI, NHQM, NQF surgery end time 5. Major cardiac surgery pts 5. IHI, NHQM, NQF 4. Appropriate hair removal 6. Colorectal surgery pts 6. IHI, NHQM 5. Post-op glucose control 6. Post-op normothermia VAP Ventilator-associated pneumonia 1. Number of cases 1. Pts receiving mechanical ventilation 1. 2. Number of cases 2. Pt-days for pts receiving mechanical 2. 3. Number of cases ventilation 3. NHSN, IHI 3. Ventilator days MVP Mechanical ventilation practices 1. Elevate head of bed 30-45 degrees 1. Pts receiving mechanical ventilation 1. IHI 2. Assess readiness to extubate daily 2. Pts receiving mechanical ventilation 2. IHI 3. PUD prophylaxis 3. Pts receiving mechanical ventilation 3. IHI 4. DVT prophylaxis 4. Pts receiving mechanical ventilation 4. IHI 5. Compliance with all four elements 5. Pts receiving mechanical ventilation 5. IHI, NQF FLUVAX Influenza vaccination given to 1. Pt vaccinations 1. Eligible pts 1. McKibben eligible patients or staff 2. Staff vaccinations 2. Eligible staff 2. McKibben, NQF MRSA Methicillin-resistant Staphylococcus 1. Number of cases 1. Admissions 1. IHI aureus infections 2. Number of cases 2. Pt-days 2. IHI MTP MRSA transmission precautions 1. Proper hand hygiene used 1. Admissions 1. IHI 2. Active surveillance of pts 2. Admissions 2. IHI 3. Contact precautions used 3. Infected and colonized pts 3. IHI 4. Proper decontamination performed 4. Infected and colonized pts 4. IHI * - Refers to FY 2008 Inpatient Prospective Payment System final rule ** - Also HQA, NQF, and NHQM (the Leapfrog Group endorses the NQF measures).

Other acronyms:

AMP: anti-microbial prophylaxis CABG: coronary artery bypass graft CMS: Centers for Medicare and Medicaid Services DVT: deep vein thrombosis ICU: intensive care unit IHI: Institute for Healthcare Improvement HQA: Hospital Quality Alliance Pt: patient PUD: peptic ulcer disease NQF: National Quality Forum NHQM: National Hospital Quality Measures NHSN: National Healthcare Safety Network SCIP: Surgical Care Improvement Project Cascade Healthcare Community (CHC)

Health Care Acquired Infections Advisory Committee November 13, 2007

The vision to publicly report quality data ƒ Local media relentless ƒ Reporting 2 year old data ƒ Lack of educational component

ƒ Discussions started about one year ago o Pam Steinke, VP Quality of CHC o Jim Diegel, CEO of CHC o Board of Directors ƒ Transparency, openness, honesty, integrity – CHC goals ƒ Approach is to over-report, rather than under-report

Decision to collaborate with local media ƒ Started meeting with local media in March and April 2007 ƒ Commitment made to local media ƒ Meet quarterly ƒ Provide current information and statistics

Choosing processes and outcomes to report: ƒ Potentially publicly reported ƒ Evidence based ƒ Data currently being tracked

Published first quality reports on external website in June 2007 -- www.scmc.org

R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 1 A Message About Quality from James A. Diegel, FACHE, President/CEO Cascade Healthcare Community “To improve the health of those we serve in a spirit of love and compassion” is the mission of Cascade Healthcare Community. We accomplish this through the dedication of our physicians and caregivers and their commitment to compassion, excellence, relationships, customer service, sanctuary, and stewardship. CHC is an excellent, award-winning healthcare system that leads the nation in a number of areas of quality. Yet, like any complex organization, we can be even better.

This Web site is one avenue for CHC’s “transparency commitment” to keep the public informed about what we do well and also where we need to improve. We will use the best data we have available and focus whenever possible on standard national metrics that provide regional and national comparisons. This website will be under constant construction as we add more and more information, update data periodically, and refine our reports to best meet your needs.

What does “transparency” mean? It means having the courage to be open and honest about what we do and how we do it. It means celebrating publicly both our large and smaller successes, even if we might sometimes appear boastful. It means acknowledging where we need to improve and having clear action plans to do it. It means letting our community inside our quality improvement efforts and seeking their input on solutions. It means fostering an internal culture that strikes a balance between rewarding courage and demanding accountability.

Why is transparency important? Consumers deserve to know if they are receiving a high-quality product or service. In addition to the ethical imperative of providing quality information, it can help consumers decide where to spend their money. CHC believes healthcare consumers should not be an exception, although historically they have been considered so. Undoubtedly, measuring key aspects of quality such as safety, effectiveness, reliability, and efficiency is more difficult in healthcare than other industries. There are many uncontrollable factors that make it difficult to compare hospitals apples-to-apples, such as patient differences and vast disparities in federal funding across the United States. Nevertheless, transparency is a journey that is in everyone’s best interest and we must use the best metrics available currently, with the trust that accuracy will improve with practice.

Hospitals are interested in transparency for another important reason: it helps us know which hospitals are the best, and, more importantly, what we can learn from them. A culture of courage includes always trying to be better by seeking out the best and replicating their successes. At CHC, we coined the phrase “Be the Benchmark” to reflect this constant striving for top-tier performance.

What will our transparency look like to you? You will see more data on a regular basis about CHC’s quality, customer service, and charges as compared to other hospitals in Oregon and nationally. Will we be opening up our internal records completely? Of course not. Patient privacy will be our first priority, so we will release aggregate statistics only, making it impossible to identify an individual patient. Also, even though CHC is not- for-profit, healthcare can be a ferociously competitive industry. In such an environment, we must maintain responsible business acumen.

What do we need from you, our community? First, we need your trust. CHC has always been a not-for-profit organization and healthcare above all is a “caring” profession, so you can assume good intentions on our part. Second, we need your

R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 2 understanding that healthcare will never be perfect. However, this will not deter us from pursuing perfection and that is what you should expect from us. Third, we need you to be an advocate for quality healthcare. Educate yourself about standards of good care by visiting websites of major quality organizations such as the Institute for Healthcare Improvement, National Quality Forum, Agency for Healthcare Research and Quality, Department of Health and Human Services, and the Joint Commission.

When you visit a doctor or come to our hospitals, don’t be embarrassed to ask about quality and safety practices. This can be as simple as “I’ve read that there are some basic things that nurses and doctors can do to keep patients from getting an infection during their visit. What do you do here?” We will be able to tell you. Fourth, we need you to take good care of yourself. Exercise regularly, eat well-balanced meals, and don’t smoke. Get regular check-ups with your doctor and follow their advice for keeping healthy. Responsible self-care is the first and most important step in preventing overuse of the American healthcare system.

Cascade Healthcare Community’s commitment to you—our patients, our customers, our community—is simply this: In a spirit of love and compassion, we will do our best to improve your health.

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R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 3 Quarterly Community Update September 15th, 2007

At Cascade Healthcare Community (CHC) we have a “transparency commitment” to keep the public informed about what we do well and also where we need to improve. This Web site is one avenue we use to keep that commitment to our patients and their families. We will use the best data we have available and focus whenever possible on standard national metrics that provide regional and national comparisons. This Web site will be under constant construction as we add more and more information, update data periodically and refine our reports to best meet your needs.

So, we encourage you to check back often for the latest in quality information from CHC.

What’s new this quarter?

x The summary scorecard (below) provides a quick gauge of how CHC compares nationally, if we are improving and if we have met our lofty “stretch targets”—since we do not aim for average quality. x A quality report for the St. Charles Regional Cancer Treatment Center shows our performance on the four national cancer quality measures endorsed recently by the National Quality Forum. x Patient satisfaction data from our outpatient surgery centers and our emergency room. x Updated quality data for heart attack, heart failure, pneumonia and surgical care sites. We also changed the format of these reports so we now report the same time period for both hospitals and show the overall average across all measures.

Summary Performance Scorecard (updated September 2007):

Area Exceeding national Improving (or at Meeting our STRETCH (click area to view report) average? top)? target?

Bend Redmond Bend Redmond Bend Redmond

QUALITY AND PATIENT SAFETY

HEART ATTACK CARE

HEART FAILURE CARE

PNEUMONIA CARE

R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 4 SURGICAL CARE

CANCER CARE

INFECTION PREVENTION

CUSTOMER SERVICE

INPATIENT SATISFACTION

OUTPATIENT SURGERY

SATISFACTION ER PATIENT

SATISFACTION

* Regional treatment program based in Bend.

“Stretch” target defined as being in top 10 th percentile

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R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 5 Infection Control Department Quality Overview ƒ Process measures – ƒ Outcomes measures – ƒ Decision made early on to only provide annual report… o doesn’t match up well with other data being reported in Surgical Care report

ƒ Data originates from Infection Control Department’s data base ƒ CDC definitions used to determine hospital acquired infections (with additional input by epidemiologist ƒ No risk stratification performed ƒ Organism stratification done, but not reported publicly

ƒ St. Charles Medical Center – Bend o Targeted surveillance o Ventilator Associated Pneumonias o C. difficile infections o Non-peripheral IV infections – including PICC line infections, over the wire infections, MD inserted catheters, CVC combined, NICU line infections o Surgical Site Infections ƒ Look at all SSI’s by service (only publicly report SCIP measure procedures) ƒ Rely on culture results and/or readmissions to identify SSI’s after discharge ƒ Cultures processed for 3 county region ƒ # of SSI’s may be higher than reported ƒ Considering F/U phone calls with CABG patients

ƒ St. Charles Medical Center – Redmond o Total house surveillance o Ventilator and non-ventilator associated pneumonias o All IV infections o Surgical site ƒ Look at all by service (only publicly report SCIP measure procedures) ƒ Rely on culture results and/or readmissions to identify SSI’s after discharge ƒ Cultures processed for 3 county region ƒ # of SSI’s may be higher than reported o C.difficile o UTI ƒ Difficult to get accurate # catheter days

R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 6 CHC Quality Reporting Information about Infection Control

The risk of wound infection after surgery can significantly be reduced by making sure patients get the right medications at the right time on the day of their surgery.

Quality and Safety Cascade Community Healthcare is committed to providing safe, high quality care. Measuring how we provide patient care allows us to evaluate and improve care. We measure care that experts agree is the best treatment for each condition .

CHC Quality Reporting Infection Control Quality Report

The risk of wound infection after surgery can significantly be reduced by making sure patients get the right medications at the right time on the day of their surgery.

HOSPITAL ACQUIRED INFECTIONS St. Charles-BEND St. Charles-REDMOND COMPARISON GROUPS Procedure Procedures Infections Rate Change Procedures Infections Rate Change Oregon U.S. Top (2006) (2006) per from (2006) (2006) per from 10% 1000 2005 1000 2005 Coron. Artery 198 1 5.05 -9.51 0 n/a n/a n/a n/a n/a n/a Bypass Graft (CABG) Total Hip 306 3 9.80 2.79 46 0 0.00 0.00 n/a n/a n/a Replacement Total Knee 529 3 5.67 -0.97 57 0 0.00 0.00 n/a n/a n/a Replacement Hysterectomy 365 5 13.70 7.34 60 0 0.00 0.00 n/a n/a n/a Central Lines 11,534 19 1.65 -0.17 n/a 1 n/a n/a n/a n/a n/a (Central Venous (lines days) Catheters) AVERAGE ACROSS ALL MEASURES 7.17 -0.10 0.00 0.00

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R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 7 CHC Quality Reporting Information about Surgical Care Improvements

Hospitals can improve surgical care and reduce the risk of wound infection after surgery by providing the right medicines at the right time on the day of surgery.

There are also steps that you, as a patient, can take to make sure the surgery is as safe as possible. For example, your doctor or nurse can tell you how to wash with an antibiotic soap the day before surgery. You can also give your doctor or nurse a list of all your medications, including vitamins, herbal medicines, and over-the-counter medications. You should also tell your doctor or nurse about any allergies and bad reactions to anesthesia.

Sometimes patients get an infection after surgery, even if the hospital took steps to prevent it. Here are signs to look out for:

x The surgical wound is red, hot, and swollen. x You have a fever of over 100 degrees after you go home. x A smelly or yellow/green fluid is coming out of the wound. x Your pain is increasing even though you are taking pain medication.

Call your doctor or local hospital immediately if you have any of these signs.

More information about surgery

x “THINKING ABOUT SURGERY?” x ST. CHARLES SURGERY INFO CENTER x AMERICAN LUNG ASSOCIATION x THE NATIONAL LIBRARY OF MEDICINE AND THE NATIONAL INSTITUTES OF HEALTH

Information from WWW.HOSPITALCOMPARE.GOV .

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R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 8 Surgical Care and Surgical Infection Prevention Quality Report

Getting an antibiotic within one hour before surgery reduces the risk of wound infections. Hospitals should check to make sure surgery patients get antibiotics at the right time.

It is important for hospitals to stop giving preventative antibiotics within 24 hours after surgery to avoid side effects and other problems associated with antibiotic use. For certain surgeries, however, antibiotics may be needed for a longer time. # = too few patients to report a rate.

SURGICAL CARE St. Charles-BEND St. Charles-REDMOND COMPARISONS (Oct 2005-Sept 2006) Measure 4Q 1Q 2007 4Q 1Q 2007 Change Change Oregon U.S. Top 10% 2006 (N/D) 2006 (N/D)

Percent 83% 87% (183/211) 3.7% 91% 94% (46/49) 2.9% 71% 77% 95% of Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision

Percent 97% 97% (205/212) -0.3% 91% 94% (46/49) 2.9% 89% 90% 100% of Surgery Patients who Received the Appropriate Preventative Antibiotic(s) for Their Surgery

Percent 83% 84% (136/162) 1.0% 75% 76% (31/41) 0.6% 65% 72% 95% of Surgery Patients Whose Preventative Antibiotic(s) are Stopped Within 24 hours After Surgery

Surgery Patients 90% 85% (147/173) -5.0% 94% 80% (37/46) -13.6% n/a n/a n/a with Recommended Venous Thromboembolism Prophylaxis Ordered

Surgery Patients 90% 80% (139/173) -9.7% 94% 70% (32/46) -24.4% n/a n/a n/a Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to

R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 9 Surgery to 24 Hours After Surgery AVERAGE 89% 87% -2% 89% 83% -6% 75% 80% 97% ACROSS ALL MEASURES

Data from IHI SCIP procedures.

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R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 10 Barriers / Challenges

ƒ Resources to get data o 2.5 FTE’s to gather CMS data (abstraction, collection of core measures) o inpatient only o unknown when we will gather outpatient data o How to educate public in a way that’s understandable to broad audience ƒ one size doesn’t fit all

ƒ Infection Control department o 1.5 FTE’s o 80% of time spent gathering data o No automated system – everything is manual o Lag time from submission of data to CMS reports o Lack of epidemiology software program with our current EMR system

ƒ CHC hospitals serve unique populations and treat varied conditions and illnesses ƒ CHC hospitals offer different services, specialties and expertise

ƒ Government data may be two or three years old… doesn’t mean it’s wrong, but much may be changed since it was reported o Public can’t really compare apples to apples

Ideas / discussion ongoing: ƒ Surveillance cultures – o Which patients? o Which sites? o Who pays? o Hospital wide versus unit specific versus procedure specific?

ƒ Report specific organisms – o MRSA o VRE o C. Difficile o Others

Public reaction to external reporting: ƒ Media (attached) ƒ Written letters ƒ Inquiries to IC nurses and other caregivers ƒ Physician offices

R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 11 Future state:

ƒ Develop quality portals under CHC quality reporting on website o www.cascadehealthcare.org o St. Charles Medical Center – Bend (SCMC-B) o St. Charles Medical Center – Redmond (SCMC-R) o Pioneer Memorial Hospital – Prineville (PMH) o Mountain View Hospital – Madras (MVH)

ƒ January / February 2008 o Initiate public launch to actively promote the new sites through the media and our own marketing tools, including FOCUS magazine

R:\HAI\Committee\Agendas\Meeting materials\November\HCAIAC 111307_ CHC public reporting.doc 12