02/19/2016

1

Healthcare-associated Infections:

Definitions and Standardizations

Arthur Dessi Roman MD MTMInternal Medicine – Infectious Diseases and Tropical Medicine

PHICNA Skills Fair, Lung Center of the Philippines

18 September 2015

References

• CDC/NHSN Surveillance Definitions. January 2015 (Modified April 2015)

• YouTube Channel: US Centers for Disease Control and Prevention (CDC)

02/19/2016

2

Five (5) figures required by DOH

1. HAI rate (%)

2. CAUTI rate (per 1000 catheter days)

3. VAP rate (per 1000 ventilator days)

4. CRBSI rate (per 1000 central line days)

5. SSI rate (%)

Surveillance of HAIs

Healthcare-Associated Infection (HAI)

Infection that occurs on or after the 3rd calendar day of admission to an inpatient location where day of

admission is calendar Day 1

Day 1 Day 2 Day 3 Day 4 Day 5

Day of admission

Date of event

U.S. CDC NSHN Surveillance. Identifying Healthcare-associated Infections (HAI) for

NHSN Surveillance. January 2015.

?

02/19/2016

3

Healthcare-Associated Infection (HAI)

All criteria should be fulfilled within a 7-day window period

For VAP, it’s just 5 days.

Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11

Date of event

Day 3 Day 4 Day 5 Day 6 Day 7

Date of event

Healthcare-Associated Infections

1. CLABSI

2. CAUTI

3. VAP

4. SSI

5. HAP

Device-associated infections

02/19/2016

4

Central Line

An intravascular catheter that terminates at or close to the heart or in one of the great

vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring.

Great vessels• Aorta

• Pulmonary artery

• Superior vena cava

• Inferior vena cava

• Brachiocephalic veins

• Internal jugular veins

• Subclavian veins

• External iliac veins

• Common iliac veins

• Femoral veins

• In neonates, the umbilical artery/vein

02/19/2016

5

Central Lines

NOT Central Lines

• Pacemaker wires and other non-lumened devices (no fluids infused, pushed, nor withdrawn)

• Extracorporeal membrane oxygenation (ECMO)

• Femoral arterial catheters

• Intra-aortic balloon pump (IABP) devices.

• Hemodialysis reliable outflow (HeRO) dialysis catheters

02/19/2016

6

Central line-associated bloodstream infection (CLABSI)• CL in place for >2 calendar days on the date of

infection/growth, with day of device placement being Day 1 AND the CL was in place:oOn the date of event OR

o the day before

• Organism cultured from blood is not related to an infection at another site

Same common commensal (i.e., diphtheroids[Corynebacterium spp. not C. diphtheriae],

Bacillus spp., Propionibacterium spp., CONS, viridans group streptococci, Aerococcus spp., and Micrococcus spp.) is cultured from two or more

blood cultures drawn on separate occasions

Patient has a recognized pathogen cultured from

one or more blood cultures

1. Blood and site-specific specimen cultures match for at least one organism.

Ex: Patient with symptomatic UTI (suprapubic tenderness and >105 CFU/ml of E. coli) and blood culture collected grows E. coli and P. aeruginosa. This is an HAI SUTI with a secondary BSI and the reported organisms are E. coli and P. aeruginosa, since both site and blood culture are positive for at least one matching pathogen.

2. Blood and site-specific specimen cultures do not match BUT the blood isolate can be attributed to the distant site of infection.

Ex1: Post-op patient becomes develops fever and abdominal pain. Blood and an aseptically-obtained T-tube drainage specimen are collected for culture. A CT scan done that day shows fluid collection suggestive of infection. Culture results show E. coli from the T-tube drainage specimen and blood grows Bacteroides fragilis.

Ex2: Patient has new-onset fever, cough and new infiltrates on CXR. Blood and BAL cultures are collected. Culture results show Klebsiella pneumoniae > 104 cfu/ml from the BAL and Pseudomonas aeruginosa from the blood.

• CL in place for >2 calendar days on the date of infection/growth, with day of device placement being Day 1 AND the CL was in place:oOn the date of event OR

o the day before

• Organism cultured from blood is not related to an infection at another site

02/19/2016

7

Central lines that are removed and reinserted

• If, after CL removal, the patient is without a central line for at least one full calendar day (NOT to be read as 24 hours), then the CL day count will start anew. If instead, a new central line is inserted before a full calendar day without a central line has passed, the central line day count will continue.

Central lines that are removed and reinserted

= risk for CLABSI

02/19/2016

8

Sample

Patient with severe leptospirosis was admitted in MICU on May 31. The following day, he was still oliguric despite hydration and administration of Furosemide. His doctor decided to do HD and inserted an IJ catheter.

By June 3, the patient was still oliguric and HD is still warranted. He also spiked fever as high as T=40 C. They requested for a repeat CXR, urinalysis and blood cultures. CXR was still normal and urinalysis was also clear. The following day, the blood culture grew Gram (+) cocci which was eventually identified as S. aureus.

Is this CLABSI?

Catheter-associated UTI (CAUTI)

All three (3) parameters should be present:

1. Patient had an indwelling urinary catheter that had been in place for > 2 days and either:

Still present on the date of event† OR

Removed the day before the date of event‡

2. Patient has at least one of the following signs or symptoms• Fever (>38.0°C)• suprapubic tenderness• Costovertebral angle pain or tenderness*• Urinary urgency*• Urinary frequency*• Dysuria

3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of ≥105 CFU/ml.

02/19/2016

9

Sample

• An 84 year-old woman with mild Alzheimer’s disease was admitted in the ward due to upper GI bleeding secondary to PUD. She was resuscitated initially with fluids and later on with 2 units pRBCvia a subclavian catheter. An IFC was also inserted to guide her response to hydration.

• On hospital day 3, her records indicate that she was hemodynamically stable but both catheters were still in place.

Sample

• On day 6, she became unresponsive and hypotensive. She was nasally intubated placed on a ventilator, and transferred to the ICU. WBCs were 15K. Temp was 40 C. Two sets of blood cultures were drawn (10 minutes apart) and urine collected for culture.

• 49 hours later, both sets of blood cultures and the urine (>105CFU/ml) were reported to be positive for Gram-positive cocci in chains (viridansstreptococci on final report).

Is this CAUTI?

02/19/2016

10

Surgical Site Infections (SSIs)

SSIs: Types

• Superficial incisional SSI

•Deep incisional SSI

•Organ/Space SSI

02/19/2016

11

Superficial Incisional SSIs:

Infection occurs within 30 days after operative procedure (where day 1 = the procedure date)

AND

involves only skin and subcutaneous tissue of the incision

AND

patient has at least one of the following:

a. purulent drainage from the superficial incision.

b. organisms isolated from an aseptically-obtained culture from the superficial incision or subcutaneous tissue.

c. superficial incision that is deliberately opened by a surgeon, attending physician** or other designee and is culture positive or not cultured

AND

patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; erythema; or heat. A culture negative finding does not meet this criterion.

d. diagnosis of a superficial incisional SSI by the surgeon or attending physician** or other designee.

Deep Incisional SSIs:Infection occurs within 30 days after operative procedure (where day 1 = the

procedure date)

AND

involves deep soft tissues of the incision (e.g., fascial and muscle layers)

AND

patient has at least one of the following:

a. purulent drainage from the deep incision.

b. a deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician** or other designee and is culture positive or not cultured

AND

patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or

tenderness. A culture negative finding does not meet this criterion.

c. an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam, or imaging test.

02/19/2016

12

Organ/Space SSIs:

Infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according to the list in Table 3

AND

infection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure

AND

patient has at least one of the following:

a. purulent drainage from a drain that is placed into the organ/space (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage)

b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space

c. an abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test

AND

Finding consistent with infection of that particular organ involved

Surgical Site Infections (SSIs)

• You may opt to monitor only certain types of procedure. List them in your report.

• You may also categorize the operative procedure (denominator) based on:• ASA• +/- DM• Duration of OR• Wound class• Infection present at the time of surgery

• If there is multi-level infection, report the deepest level of infection.

02/19/2016

13

Sample

• Jesse, 26/male experienced RUQ postprandial pain for 3 months. A surgeon he consulted advised him to undergo open cholecystectomy to which he consented. The surgery performed on Oct 10 was unremarkable and he was discharged on October 13 days.

• Two days after, he noted that there was a minimal yellowish discharge in one of the suture points. He just continued cleaning the wound.

Sample

• By October 17, his scheduled follow-up with the surgeon, there was wound dehiscence and the surgeon was able to express greening purulent material on the upper portion of the wound.

• Jesse was readmitted an underwent debridement. An intra-op wound specimen sent grew Pseudomonas aeruginosa.

• Is this SSI? How many days post op did the SSI develop?

02/19/2016

14

Ventilator-associated pneumonia (VAP)

Clinical definition

Pneumonia that occurs 48-72 hours or thereafter following endotracheal intubation, characterized by the presence of a new or progressive infiltrate, signs

of systemic infection (fever, altered WBC count), changes in sputum characteristics, and detection of a

causative agent

American Thoracic Society, Infectious Diseases Society of America: Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005, 171:388-416

Ventilator-associated pneumonia (VAP)

Old surveillance definition

02/19/2016

15

Ventilator-associated pneumonia (VAP)

New surveillance definition

Ventilator-associated pneumonia (VAP)

02/19/2016

16

Probable VAP

Patient meets criteria for VAC and IVAC

AND

On or after calendar day 3 of MV and within 2 calendars before OR after the onset of worsening

oxygenation, ONE of the ff. is met:

Probable VAP

Criterion 1

02/19/2016

17

Probable VAP

Criterion 2

Healthcare-associated pneumonia (HAP)

• Pneumonia that occurs 48 hours or more after hospital admission and that was not present at the time of admission.

• HCAP includes patients who have recently been hospitalized within 90 days of the infection, resided in a nursing home or long-term care facility, or received parenteral antimicrobial therapy, chemotherapy, or wound care within 30 days of pneumonia.

• The term HAP is often used to represent both VAP and HCAP.

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388–416.

02/19/2016

18

Healthcare-associated pneumonia (HAP)

• For practical purposes, most principles for HAP, VAP, and HCAP overlap.

• Healthcare–associated pneumonia can be characterized by its onset: early or late. Early-onset pneumonia occurs during the first 4 days of hospitalization

Sample 1

• A 69/male was admitted for cervical spinal cord injury secondary to vehicular crash. He had to be intubated because the respiratory muscles are paralyzed. FiO2 was subsequently downtitrated by Day 3. He underwent tracheostomy on Day 5 because the neurosurgeon was not expecting any improvement in the patient’s respiratory drive.

• On Day 7, he developed desaturations as low as 30% so his FiO2 was maintained at 60%. He was started on Cefepime and ETA CS, CXR, CBC were requested.

02/19/2016

19

Sample 1

• On Day 8, ETA showed heavy growth of Gram (-) mucoid organisms which was eventually identified as Klebsiella.

• Blood culture also grew Klebsiella.

• On Day 9, O2 sats improved.

• On Day 14, Cefepime completed

• On Day 15, shifted to Trache mask

• On Day 17, patient was discharged.

Sample 2

• Ynna is a 25/female who underwent cholecystectomy on April 4. The post-op course was unremarkable.

• On April 5, she developed fever and cough. She was complaining of post-op pain. WBC 12,000. CXR showed bilateral lower lobe atelectasis.

• She was not able to produce sputum until April 9.

• April 11: Sputum CS showed S. epidermidis

• April 13: Pt was discharged

02/19/2016

20

Additional Pointers

1. Provide details about your report (in the title):• Time period

• Location

• Type of surveillance performed

“Healthcare-associated infection rates in the [ICU/MICU/Ward] Section of [name of hospital] from [indicate time period] generated through [type of surveillance] surveillance conducted [frequency of surveillance, e.g. monthly, quarterly, etc.]

Additional Pointers

2. Clinical diagnosis of HAIs may not be consistent with the surveillance diagnosis. In such cases, the infection control physician shall make the final call if the case is an HAI or not.

02/19/2016

21

Additional Pointers

3. In reporting the HAI rate (%), describe your numerator.

No. of infections

HAI = -----------------------------------

No. of discharges

e.g.1. The number of HAIs reported is the sum of all device-related infections and SSIs only.

e.g.2. The number reported above represents the sum of all HAIs which include device-related infections, SSIs and HAPs.

Quiz10 items

Please get a piece of paper.

02/19/2016

22

Instructions

• For each item, write YES if there is HAI and NO if none based on the definitions.

• If there is an HAI, indicate what type (SSI, VAP, HAP, CLABSI, CAUTI)

No. 1

• A 35/male with four day history of fever, headache and abdominal pain was admitted for low platelet and positive Dengue NS1. After a few hours, he was hypotensive and hemoconcentrated. His peripheral veins were all collapsed. A femoral catheter was inserted for immediate and adequate resuscitation.

• On March 22, the central line is removed. The patient’s VS were back to normal and platelet count is improving.

• On March 24, he developed fever, chills and hypotension. A set of blood cultures were requested and 26 hours later, they were positive for MR S. aureus.

02/19/2016

23

No. 2

• 58 year old patient is admitted to the ED on May 18 with GI bleed. Foley inserted was accurate monitoring of hydration response.

• May 19: Patient spikes temp of 38.6°C Indwelling catheter remains in place. Urine specimen is sent.

• May 20: Culture results 100,000 CFU/ml Pseudomonas aeruginosa.

No. 3

• Mr. Smith is a trauma patient who had a spinal fusion procedure. Later on the day of surgery, he is complaining of intense “itching” from at the site of his back incision. When the dressing is changed, the patient’s back is noted to be mildly red and the incision site intact with a moderate amount of light yellow drainage.

• On post-op day 1, Mr. Smith states his back incision is now tender and “burning”. When the dressing is changed, noted are a 1.0 cm long by 0.25 cm deep open area on the incision line and a small amount of purulent drainage. An aseptically obtained culture of the wound is obtained before redressing. The culture does not grow any organisms.

02/19/2016

24

No. 4

• a 45/female cervical cancer patient underwent radiotherapy. 3 days after, she develops mucositis and was unable to eat and swallow. A central line is placed then for TPN on May 30th. On June 3, the central line is removed and on June 5 patient spikes a fever of 38.3°C.

• Two blood culture sets collected on June 6 are positive for S. epidermidis.

No. 5

02/19/2016

25

No. 5

No. 6

• 50/F with pancreatic CA with liver & bone mets admitted to hospital with advance directive for comfort care and antibiotics only. You inserted a foley catheter because she is unable to void spontaneously already, peripheral IV and nasal cannula inserted as well.

• Day 4: Foley remains in place; patient is febrile to 38.0°C and has suprapubic tenderness; IV Pip-Tazo started after urine obtained for culture.

• Day 5: difficulty breathing; CXR=pleural effusion, massive, L>R

• Day 6: urine culture results = 105 CFU/ml E coli.

• Day 7: CBC shows WBC 3400/mm3 ; continued episodes of dyspnea

• Day 11: Patient expired.

02/19/2016

26

No. 7

• 8/27: 65/M admitted for stroke

• 9/3: Noted with high WBC 15,800/mm3, Temperature: 37.6°C., breath sounds occasional rhonchi, minimal clear sputum. Urine unchanged. Blood, endotracheal and urine specimens collected.

• No suprapubic or CVA pain noted.

• 9/4: Blood and endotracheal cultures no

• growth. Urine + 100,000 CFU/ml E. faecium.

No. 8

• Nilo is a 45/male with weight loss and low grade fever. He has a SI mass and was admitted to your hospital on April 12 for elective small bowel resection. You note several scar on his chest, back and abdomen which they said was secondary to frequent skin infections.

• The post-operative course was unremarkable ans.• The patient was discharged on April 16.• On April 30, you received word from another hospital

that the patient was admitted to that facility on April 29 with a red, “angry” surgical wound. The medical staff opened the incision down to (but not including) the fascia and sent a swab for culture. MRSA grew from the specimen.

02/19/2016

27

No. 9

• 54/F admitted for GBS paralysis. She was intubated and FiO2 downtitration was started on Day 2. They were eventually able to reach 30% FiO2.

• By the following day, they had to suction more often and she started to develop fever with Tmax-38.9C. She developed desaturations so they had to increase the FiO2 and maintain it at 80%. They requested for a CBC, ETA GSCS and CXR on that day. WBC was 20.1 with PMN 90% and CXR showed right lower lobe reticular infiltrates.

• Two days later, the ETA CS revealed heavy growth was positive for A. baumanii. She developed hypotension and eventually died.

No. 10

• On December 5, a 35 year old man involved in a motor vehicle accident sustains multiple internal and external traumatic injuries. On arrival at the emergency department, a triple-lumen subclavian line and Foley catheter are placed. Once stabilized, the patient is transferred to the intensive care unit.

• On December 8, the patient spikes a temperature to 40C and is pan-cultured, including two blood cultures.

• On December 10, the subclavian line is discontinued, and the catheter tip is sent for culture. Later that afternoon, the blood culture results from December 8 are reported as Staphylococcus hominis in both sets, with different susceptibility profiles. The physician notes: ‘‘Positive blood culture contaminant; no antibiotics required.’’ All other specimens cultured are negative.

• On December 12, catheter tip results are reported as Staphylococcus epidermidis.