Definition of HAI and Criteria For Specific Types of Infections CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting What follows are the NHSN criteria for all healthcare-associated infections (HAIs). These criteria include those for the “Big Four” (surgical site infection [SSI], pneumonia [PNEU], bloodstream infection [BSI] and urinary tract infection [UTI]), outlined in earlier chapters of this NHSN manual, as well as criteria for other types of HAIs. Of particular importance, this chapter provides further required criteria for the specific event types that constitute organ/space SSIs (e.g. mediastinitis [MED] following coronary artery bypass graft, intra­ abdominal abscess [IAB] following colon surgery, etc.). NOTE: The article which is included does not include the updated criteria for UTI which became effective beginning in January, 2009. Instead these criteria are included in the pages that follow the article. Please use these definitions in yourProtocol NHSN surveillance. NOTE: As of January 1, 2010, Clinical Sepsis (CSEP) is no longer an NHSN Specific Event for BSI. Please disregard the information included on page 316 regarding CSEP, and do not report such events in NHSN. The definitions will be updated with the next publication. Current Use—Not Not Do March 1, 2010 17-1 CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting Teresa C. Horan, MPH, Mary Andrus, RN, BA, CIC, and Margaret A. Dudeck, MPH Atlanta, Georgia BACKGROUND population for which clinicalProtocol sepsis is used has been re­ stricted to patients #1 year old. Another example is that Since 1988, the Centers for Disease Control and incisional SSI descriptions have been expanded to spec­ Prevention (CDC) has published 2 articles in which nos­ ify whether an SSI affects the primary or a secondary in­ ocomial infection and criteria for specific types of nos­ cision following operative procedures in which more ocomial infection for surveillance purposes for use in 1,2 than 1 incision is made. For additional information about acute care settings have been defined. This document how these criteria are used for NHSN surveillance, refer replaces those articles, which are now considered obso­ to the NHSN Manual: Patient Safety Component Protocol lete, and uses the generic term ‘‘health care–associated availableCurrent at the NHSN Web site (www.cdc.gov/ncidod/ infection’’ or ‘‘HAI’’ instead of ‘‘nosocomial.’’ This doc­ dhqp/nhsn.html). Whenever revisions occur, they will ument reflects the elimination of criterion 1 of clinical be published and made available at the NHSN Web site. sepsis (effective in National Healthcare Safety Network [NHSN] facilities since January 2005) and criteria for lab­ oratory–confirmed bloodstream infection (LCBI). Spe­ CDC/NHSN SURVEILLANCE DEFINITION OF cifically for LCBI, criterion 2c and 3c, and 2b and 3b, HEALTH CARE–ASSOCIATED INFECTION were removed effective in NHSN facilities since January For the purposes of NHSN surveillance in the acute 2005 and January 2008, respectively. The definition of care setting, the CDC defines an HAI as a localized or ‘‘implant,’’ which is part of the surgical site infection systemic condition resulting from an adverse reaction (SSI) criteria, has been slightly modified.Use—Not No other infec­ to the presence of an infectious agent(s) or its toxin(s). tion criteria have been added, removed, or changed. There must be no evidence that the infection was pre­ There are also notes throughout this document that sent or incubating at the time of admission to the acute reflect changes in the use of surveillance criteria since care setting. the implementation of NHSN.Not For example, the HAIs may be caused by infectious agents from endogenous or exogenous sources. From the National HealthcareDo Safety Network, Division of Healthcare d Endogenous sources are body sites, such as the skin, Quality Promotion, Centers for Disease Control and Prevention, nose, mouth, gastrointestinal (GI) tract, or vagina Atlanta, GA. that are normally inhabited by microorganisms. Address correspondence to Teresa C. Horan, MPH, Division of Health- d Exogenous sources are those external to the pa­ care Quality Promotion, Centers for Disease Control and Prevention, Mailstop A24, 1600 Clifton Road, NE, Atlanta, GA 30333. E-mail: tient, such as patient care personnel, visitors, pa­ [email protected]. tient care equipment, medical devices, or the Am J Infect Control 2008;36:309-32. health care environment. 0196-6553/$34.00 Other important considerations include the Copyright ª 2008 by the Association for Professionals in Infection following: Control and Epidemiology, Inc. d Clinical evidence may be derived from direct ob­ doi:10.1016/j.ajic.2008.03.002 servation of the infection site (eg, a wound) or 309 310 Vol. 36 No. 5 Horan, Andrus, and Dudeck review of information in the patient chart or other USE OF THESE CRITERIA FOR PUBLICLY clinical records. REPORTED HAI DATA d For certain types of infection, a physician or sur­ geon diagnosis of infection derived from direct ob­ Not all infections or infection criteria may be appro­ servation during a surgical operation, endoscopic priate for use in public reporting of HAIs. Guidance on examination, or other diagnostic studies or from what infections and infection criteria are recommen­ clinical judgment is an acceptable criterion for an ded is available from other sources (eg, HICPAC [http: HAI, unless there is compelling evidence to the //www.cdc.gov/ncidod/dhqp/hicpac_pubs.html]; National contrary. For example, one of the criteria for SSI Quality Forum [http://www.qualityforum.org/]; profes­ is ‘‘surgeon or attending physician diagnosis.’’ Un­ sional organizations). less stated explicitly, physician diagnosis alone is not an acceptable criterion for any specific type UTI-URINARY TRACT INFECTION of HAI. d Infections occurring in infants that result from SUTI-Symptomatic urinary tract infection passage through the birth canal are considered A symptomatic urinary tract infection must meet HAIs. at least 1 of the following criteria: d The following infections are not considered health care associated: 1. Patient has at least 1 of the following signs or s Infections associated with complications or ex­ symptoms with no otherProtocol recognized cause: fever tensions of infections already present on ad­ (.388C), urgency, frequency, dysuria, or suprapu­ mission, unless a change in pathogen or bic tenderness symptoms strongly suggests the acquisition of and a new infection; patient has a positive urine culture, that is, $105 s infections in infants that have been acquired microorganisms per cc of urine with no more transplacentally (eg, herpes simplex, toxoplas­ than 2 species of microorganisms. mosis, rubella, cytomegalovirus, or syphilis) 2. Patient has at least 2 of the following signs or symp­ and become evident #48 hours after birth; and Currenttoms with no other recognized cause: fever s reactivation of a latent infection (eg, herpes zos­ (.388C), urgency, frequency, dysuria, or suprapu­ ter [shingles], herpes simplex, syphilis, or bic tenderness tuberculosis). and d The following conditions are not infections: at least 1 of the following s Colonization, which means the presence of mi­ a. positive dipstick for leukocyte esterase and/ croorganisms on skin, on mucous membranes, or nitrate in open wounds, or in excretions or secretions b. pyuria (urine specimen with $10 white but are not causing adverse clinical signs or blood cell [WBC]/mm3 or $3 WBC/high­ symptoms; and power field of unspun urine) s inflammation that results fromUse—Not tissue response c. organisms seen on Gram’s stain of unspun to injury or stimulation by noninfectious urine agents, such as chemicals. d. at least 2 urine cultures with repeated isolation of the same uropathogen (gram­ CRITERIA FOR SPECIFICNot TYPES OF INFECTION negative bacteria or Staphylococcus sapro­ phyticus) with $102 colonies/mL in non- Once an infection is deemed to be health care associ­ voided specimens ated according to Dothe definition shown above, the spe­ e. #105 colonies/mL of a single uropathogen cific type of infection should be determined based on (gram-negative bacteria or S saprophyticus) the criteria detailed below. These have been grouped in a patient being treated with an effective into 13 major type categories to facilitate data analysis. antimicrobial agent for a urinary tract For example, there are 3 specific types of urinary tract infection infections (symptomatic urinary tract infection, asymp­ f. physician diagnosis of a urinary tract tomatic bacteriuria, and other infections of the urinary infection tract) that are grouped under the major type of Urinary g. physician institutes appropriate therapy for Tract Infection. The specific and major types of infec­ a urinary tract infection. tion used in NHSN and their abbreviated codes are listed 3. Patient #1 year of age has at least 1 of the fol­ in Table 1, and the criteria for each of the specific types lowing signs or symptoms with no other recog­ of infection follow it. nized cause: fever (.388C rectal), hypothermia Horan, Andrus, and Dudeck June 2008 311 Table 1. CDC/NHSN major and specific types of health Table 1. Continued care–associated infections EENT Eye, ear, nose, throat, or mouth infection UTI Urinary tract infection CONJ Conjunctivitis SUTI Symptomatic urinary EYE Eye, other tract infection than conjunctivitis ASB Asymptomatic