1. Surveillance definitions of CLABSI, VAP, SSI and CAUTI: A summary of definition criteria in the CDC NHSN Manual

2. CDC National Healthcare Safety Network
Before reporting an HAI (healthcare-associated infection), it must satisfy the specific criteria
It is very important to use the criteria consistently to achieve accuracy of reporting of infections
Use clinical, laboratory, pharmacy, radiology and other diagnostic information as well as patient charts and notes
DO NOT USE LABORATORY RESULTS ALONE!
(as these may indicate colonization only)
Physician’s diagnosis alone, in absence of other available criteria, is acceptable except for pneumonia

3. HAI ( Healthcare-associated Infection)
A localized or systemic condition resulting from adverse reaction to the presence of an infectious agent/s or its toxin/s
There must be no evidence that the infection was present or incubating at the time of admission
The source of the infection may be endogenous or exogenous
Infections in infants that result from the passage through the birth canal are HAI’s

4. Infections that are NOT HAI
Complications or extensions of infections already present on admission, UNLESS a change of pathogen or symptoms strongly suggests the acquisition of a new infection ( a new event)
Infections in infants that are acquired trans-placentally, eg. rubella, CMV, syphilis, AND become evident < 48 hours after birth.
Re-activation of a latent infection eg. Herpes zoster
(shingles), herpes simplex, syphilis, TB

5. Conditions that are NOT infections
Colonizations: presence of microbes but no adverse clinical signs and symptoms eg. positive Microscopy on urine report
Inflammation in response to tissue injury or chemicals & other non-infectious agents

6. CLABSI Event
Primary bloodstream infections that are associated with the presence of a central line (or umbilical catheter in neonates) at the time of or within 48 hours before the onset of the event (infection)
There is no minimum time that the line must be in place before the event
LCBI (Laboratory-confirmed bloodstream infection) or CSEP( clinical sepsis) in <1 year-olds
Location of attribution ( where the event became evident) and transfer rule( exception) – see details in NHSN Manual.

7. What is a central line?
An intravascular catheter that terminates at or close to the heart or in one of the great vessels (aorta, pulmonary artery, superior & inferior vena cava, brachio-cephalic veins, internal jugular veins, subclavian veins, external iliac veins and common femoral veins)
Neonates: umbilical artery or vein
Must be a lumened device through which fluids are infused, pushed or withdrawn. May be temporary or permanent (e.g. dialysis tunneled or implanted catheters, including ports)

8. LCBI – must meet 1 of 3 criteria
Criterion 1 and 2 apply for all ages, including babies
Criterion 1:
Pt has a RECOGNIZED pathogen cultured from 1/more blood
cultures AND
the organism in the blood is NOT related to an infection at
another site
Recognized pathogens: S. aureus, Enterococcus spp, E.coli, Pseudomonas spp, Candida spp.

9. What if it is a common skin contaminant?
(Coagulase negative staphylococci, diptheroids, Bacillus spp, viridans group streptococci, Propionibacterium spp, Micrococcus & Aerococcus spp)
It must have been identified in 2 or more blood cultures
Drawn on separate occasions ( but within 2 days of each other) AND
Patient must have symptoms AND not related to other site.

10. LCBI – must meet 1 of 3 criteria Criterion 1 and 2 apply for all ages, including babies
Patient has at least 1 of the following S/S:
fever ( >38 for adults: 38 rectal or tympanic, 37 oral or 36 axilliary for babies ), chills, or hypotension AND
S/S and pos lab results are not related to infection at another site
AND
common skin contaminant cultured from 2 or more blood cultures drawn at different times

11. LCBI (Laboratory confirmed bloodstream infection)
Positive catheter tip cultures alone DO NOT indicate a BSI (bloodstream infection)
Purulent phlebitis with positive culture of catheter tip and NO or negative blood culture is reported as CVS-VASC, not a BSI
Only report as a primary BSI if there is no other site of infection. Secondary BSI’s are associated with an infection at another site with the same antibiogram

12. CSEP ( Clinical sepsis in babies)
Criterion 3:
Patient under 1 year of age has at least one of the following clinical S/S with no other recognized cause:
Fever ( >38 rectal), hypothermia ( <37 rectal), apnea, or bradycardia
AND
Blood culture not done or no organisms detected
No apparent infection at another site
Physician commences treatment for sepsis
Temperature: 38 rectal/tympanic/temporal artery = 37 oral = 36 axillary
37 rectal/tympanic/temporal artery = 36 oral = 35 axillary

13. VAP (Ventilator Associated Pneumonia) event
Diagnosed on radiological, clinical and laboratory criteria
Report PNEU’s that are ventilator-associated if the patient was intubated and ventilated at the time of surveillance, OR within 48 hours before the onset of the event, including the weaning period
There is no minimum period of time the ventilator must be in place in order for the PNEU to be considered VAP
Location of attribution: Where patient was on the date PNEU was identified (eg. Operating room cannot be allocated)
Pt extubated and discharged from hospital A. Admitted hospital B next day with PNEU. = VAP for hospital A
Transfer rule for internal transfers: if VAP develops within 48 hours of transfer, it is attributed to the transferring location
Physician’s diagnosis ALONE is NOT acceptable, except in outbreaks of respiratory syncitial virus, influenza or adenovirus

14. Definition of a ventilator
A device to assist or control respiration continuously,
Through a tracheostomy or
By endotracheal intubation
Lung expansion devices like:
Intermittent positive pressure breathing ( IPPB) or
Nasal positive end-expiratory pressure ( PEEP) or
Continuous nasal pos airway pressure ( CPAP or hypoCPAP)
Are not considered ventilators UNLESS
Delivered via tracheostomy or endotracheal intubation
(e.g. ET- CPAP)

15. When it is not PNEU When clinical status changes are due to:
Myocardial infarction, pulmonary embolism, RDS, atalectasis, malignancy, COAD, hyaline membrane disease, broncho-pulmonary dysplasia, etc.
Intubated patients with tracheal colonization or URTI
(eg. tracheo-bronchitis) rather than early onset PNEU
Patients with tracheitis, tracheo-bronchitis, or bronchiolitis without pneumonia are reported as BRON
Patients with lung abscess or empyema without pneumonia are reported as LUNG
When patient is elderly, an infant, or immuno-compromised, typical S/S of pneumonia may be masked – see algorithms
Interpret sputum samples carefully – may be contaminated with airway colonizers, eg. Candida (However Gram stain can be an important clue)

16. Nosocomial pneumonia Characterised by onset: including MRSA
Early onset: occurs within the first 4 days of hospitalization
Moraxella catarrhalis, H. influenzae, S. pneumoniae
Late onset: often caused by gram negative bacteria and S. aureus,
including MRSA
Viruses can cause early and late onset
Yeasts, fungi, legionellae and Pneumocystis carinii usually cause late onset
Pneumonia due to gross aspiration is considered nosocomial if it meets any specific criteria and was not present at admission
Multiple episodes of pneumonia may occur in critically ill patients with long ICU stays.
If the episode resolved and a new episode occurred, it is a new event.
Change in pathogen alone is NOT indicative of a new event – there must be new S/S and radiographic evidence.
Refer NHSN Manual for Algorithms:P18–21 and footnotes P21 – 22 and flow diagrams: P

17. Footnotes to algorithms for VAP
The diagnosis of HAI PNEU in non-ventilated patients is not always easy.
Pulmonary or cardiac disease will cloud the clinical picture, eg. Pulmonary oedema from CCF may simulate S/S of pneumonia
Thus serial X-rays are necessary to confirm the diagnosis.
Look at X-rays 3 days prior to the diagnosis and on days 2 and 7 after the diagnosis
Pneumonia may have a rapid onset and progression, but it does not resolve quickly. Radiographic changes persist for weeks
If X-rays confirm rapid resolution, then it is probably NOT a pneumonia, but a non-infectious process like atalectasis or CCF .

18. Footnotes to algorithms for VAP
X-ray terminology that may indicate PNEU:
Air-space disease; focal opacification; patchy areas of increased density
Purulent sputum:
Secretions from lungs / bronchi / trachea that contain > 25 neutrophils and <10 squamous epithelial cells per low power field ( x100)
A single notation of purulent sputum or change in character of sputum is not meaningful – changes must be documented over a 24 hour period before they can be seen as indicative of the onset of disease
Patients with pneumonia due to viruses & mycoplasma will have scant or watery sputum ( or sometimes muco-purulent), few S/S, changes will only be seen on X-rays.
Infants with RSV or influenza may produce copious sputum
Patients with pneumonia due to Legionella spp, mycoplasma or viruses: few bacteria seen on gram stain

19. Footnotes to algorithms for VAP
Tachypnoea:
Adults: > 25 breaths per minute
Prems : > 75 breaths/min
Under 2 months old: > 60 breaths / min
2-12 months: > 50 breaths / min
Children > 1 year old: > 30 breaths / min
“Rales” = crackles
An endo-tracheal aspirate is NOT a minimally contaminated specimen, therefore, it does NOT meet the laboratory criteria
Semi-quantitative or non-quantitative cultures of sputum obtained by deep cough, induction, aspiration, or lavage are acceptable

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

21. Algorithms for VAP
PNU 1: an algorithm used for clinically defined pneumonia
PNU 2: Table 5: Pneumonia with common bacterial or filamentous fungal pathogens and specific laboratory findings
Table 6: Pneumonia with viral, Legionella, Chlamydia, Mycoplasma and other uncommon pathogens and specific laboratory findings
PNU 3: Pneumonia in immunocompromised patients

22. CAUTI event
Catheter-associated UTI’s are classified into 2 groups: SUTI and ASB. ( excludes OUTI)
Report UTI’s that are catheter-associated if the patient had an in-dwelling catheter at the time or within 7 days before the onset of the event
There is no minimum time the catheter must be in situ in order for the UTI to considered catheter-associated
Location of attribution and transfer rule as per VAP

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

24. SUTI (Symptomatic Urinary Tract Infection)
Must meet at least 1 of the following:
Criterion 1:
Patient has at least 1 of the following S/S with no other recognized cause:
fever > 38, urgency, frequency, dysuria, or suprapubic tenderness
and
Patient has positive urine culture, i.e. > 100,000 microorganisms per ml of urine with no more than 2 species of microorganism

25. SUTI (Symptomatic Urinary Tract Infection)
Criterion 2:
Patient has at least 2 of the following S/S with no other recognized cause:
fever>38, urgency, frequency, dysuria, or suprapubic tenderness
and at least 1 of the following:
positive dipstick for leukocyte esterase &/or nitrate
pyuria ( > 10 wbc/cubic mm)
organisms seen on gram stain of unspun urine
at least 2 urine cultures with repeated isolation of same uropathogen ( G negative bacteria or S. saprophyticus) with >100 cfu/ml in non-voided specimens
< cfu/ml of a single uropathogen in a patient on antibiotics for UTI
Physician diagnosis of UTI
Physician commences specific therapy for UTI

26. SUTI (Symptomatic Urinary Tract Infection)
Criterion 3:
Patient under 1 year has at least one of the following S/S with no other recognized cause:
fever ( >38 rectal), hypothermia ( <37 rectal), apnea, bradycardia, dysuria, lethargy, or vomiting
and
Patient has positive urine culture, > cfu/ml with no more than 2 species of microorganisms

27. SUTI (Symptomatic Urinary Tract Infection)
Criterion 4:
Patient < 1 year has at least one of the following with no other recognized cause:
fever > 38 rectal, hypothermia < 37 rectal, apnea, bradycardia, dysuria, lethargy, or vomiting
and
At least one of the following:
Positive dipstick for leukocytes &/or nitrate
Pyuria ( > 10 wbc/ cubic mm)
Organisms seen on gram stain of unspun urine
At least 2 cultures with repeated isolation of the same uropathogen with > 100 cfu/ml in non-voided specimens
< cfu/ml of a single uro-pathogen in a patient on specific UTI antibiotics
Physician diagnosis or physician commences specific UTI therapy

28. Comments on UTI
A culture of a urinary catheter tip is NOT an acceptable laboratory test to diagnose UTI
Urine cultures must be obtained appropriately:
clean catch or catheterization
In infants, a urine culture should be obtained by bladder catheterization or suprapubic aspiration; a bag culture is NOT reliable.

29. ASB : Asymptomatic Bacteriuria
Patient has had an indwelling catheter within 7 days before the culture
AND
patient has positive urine culture;
> organisms per ml
with no more than 2 species
patient has no fever, urgency, dysuria, suprapubic tenderness

30. SSI (Surgical Site Infection) Event
Definition of an operation:
takes place in an operating room
during a single trip to the OR( operating room)
where the surgeon makes at least one incision through the skin or mucous membrane,
including laparoscopy
and closes the incision before the pt leaves the operating room
An OR includes an operating room, C-section room, interventional radiology room, cardiac cath lab
An implant includes any non-human foreign body that is permanently placed in a patient, including screws, mesh, wires that are left permanently.

31. Superficial incisional SSI
Infection occurs within 30 days after the operation
AND
involves only skin and subcutaneous tissue of the incision
patient has at least one of the following:
Purulent drainage
Report organisms isolated from wound swabs as follows: ( Prof Duse criteria)
if mono-microbial growth ( one organism)
if a Strep. pyogenes ( beta haemolytic Strep Group A) isolated
if 2 organisms, must be known wound pathogens in a quantity 2+ or more
if > 2 organisms, report only the one associated with predominant growth, provided that pus cells were seen on microscopy
if 3 or more organisms, do not report unless found on a repeat specimen or wound aspirate
At least one of the following:
pain / tenderness, localized swelling, redness/ heat and the incision is deliberately opened by surgeon and is culture pos or not cultured.
If culture neg, it does not meet this criterion.
Diagnosis of superficial SSI by surgeon
There are 2 types:
SIP (primary incision) . Patient has more than 1 incision for the operation, eg. Chest incision for CABG
SIS (secondary incision) eg. Donor site incision on leg or arm for CABG

32. Reporting instructions for SSI
Do not report a stitch abscess
Do not report a localized stab wound infection as SSI – it is reported as skin or soft tissue
Cellulitis, by itself, does not meet the criteria for SSI
Infected circumcision site is reported as CIRC
Infected burn wound is reported as BURN and not SSI
If incisional site infection extends into fascial or muscle layers, report as deep ( DIP / DIS)

33. Deep Incisional SSI Infection occurs within 30 days if no implant or
Within 1 year if implant is placed and infection is related to the operative procedure AND
Involves deep soft tissues ( fascia / muscle)
AND
Patient has at least ONE of the following:
Purulent drainage from deep incision, but not organ / space
Deep incision spontaneously dehisces or
Is opened by surgeon and
Is culture-pos or not cultured when the pt has at least one of the following S/S:
Fever>38, localized pain/tenderness
( A culture-negative finding does not meet this criterion)
An abscess or other evidence of infection found by direct exam / x-rays / histopathologic exam
Diagnosis by a surgeon
2 Types: DIP (primary incision), and DIS ( secondary incision)

34. Organ / space SSI
Involves any part of the body ( including skin incision, fascia, muscle layer) that is opened and manipulated during an operative procedure
Specific additional sites are assigned to organ/space SSI’s to identify the location e.g.
Appendectomy with sub-diaphragmatic abscess = SSI – IAB
(intra-abdominal specific site)
SSI - BONE
( Table on P 37, NHSN Manual)

35. Organ / space SSI
Infection occurs within 30 days after the operation if no implant and within 1 year if implant is placed & infection is related to operative procedure
AND
Infection involves any part of the body, excluding skin incision, fascia, muscle) that is opened or manipulated during the operation
Patient has at least one of the following:
Purulent drainage from a drain placed through a stab wound into the organ / space
Organisms obtained from aseptically obtained culture of fluid or tissue in the organ / space
Abscess found on direct examination or x-rays or histopathology examination
Diagnosis by surgeon or physician