Speaker : Dr. Faiza Rasheed Public Health Specialist MEEQAT GENERAL HOSPITAL , MADINAH, KSA

1. SURVEILLANCEofhealthcare
associatedinfection(HAIS)
Speaker : Dr. Faiza Rasheed
Public Health Specialist
MEEQAT GENERAL HOSPITAL , MADINAH, KSA

2. Healthcare-AssociatedInfections -HAIs
 HAIs are the infections acquired by the patients in a hospital or health care
facility while receiving course of treatment for any medical or surgical
condition usually after 02 calendar days.
 Infection was NOT present or incubating at the time of admission to the
health care setting.
 Also called nosocomial or hospital acquired Infections. It also includes the
infections which staff or the visitors can acquire.
 PATIENTS should not acquire any infection from hospital
 HCWs should not acquire infection from the hospital
 VISITORS should not acquire infection from the hospital

3. CHAIN OF
INFECTION
MRSA
MDR -
PSEUD
VRE
CRE

4. IMPACTOFHAIS
Impact on Patients:
Increased morbidity & mortality
Increased length of stay
Emotional Stress
Increased medical cost.
Impact on Hospital :
Decreased Patient turnover / Revenue
Bad Name / Image
Impact on Community :
Increasing Drug Resistance

5. PREVENTIONOFHAIS
H-E-L-P - C-A-R-E
H.----- HAND HYGIENE
E.------- EDUCATION & TRAINING
L.------- LEADERSHIP COMMITMENT
P.------- PERSONAL PROTECTIVE EQUIPMENTS
C.------- CLEAN & SAFE ENVIRONMENT
A.--------ANTIBIOTIC STEWARDSHIP
R.--------RESPIRATORY HYGIENE / COUGH ETTIQUETE
E. ------ EVALUATION
SMARTAPPROACH
SURVEILLNACE
MONITORING & AUDITING
ANTIBIOTIC Steward ship
REPROTING & ISOLATION OF
DISEASES
TRAINING & EDUCAION

6. WHATISSURVEILLANCE?
 Systematic ,Continuous , Ongoing process of
data collection, consolidation, and analysis of data
concerning the distribution and determinants of a
given disease or event.
 Dissemination of this information to those who
can improve the outcome.

7. SurveillanceMethodology
Surveillance uses the following methodology:
1. Active Vs. Passive
2. Patient-based Vs. Laboratory based
3. Prospective Vs. Retrospective
4. Targeted Vs. Hospital Wide

8. WHYSURVEILLANCE?
 Determine the endemic occurrence rate of a
disease or event.
 Timely review of data to initiate infection
prevention interventions to reduce adverse
patient outcomes.
 Detect and investigate clusters or outbreaks of a
disease.
 Compare HAI rates within/between health care
facilities

9. No
Event
Data
InformationIntervention
Identification of HAI
using CDC / NHSN
Criteria
Feedback
SurveillanceProcess
Event
Patient admitted to
hospital is under
surveillance

10. EPIDEMIOLOGICALLYSIGNIFICANTHAI
1-Device-AssociatedModule
1. Ventilator-Associated Pneumonia
(VAP) Event
2. Central Line-Associated Bloodstream
Infection (CLABSI) Event
3. Catheter-Associated Urinary Tract
Infection (CAUTI) Event
2-Procedure-AssociatedModule
Surgical Site Infection (SSI) Event
HEALTHCAREBundles
• Central Line Bundle
• Ventilator Bundle
• Urinary catheter Bundle
• Surgical Bundle
• MDROs Bundle

11. NATIONAL
CLABSI RATE = 1.75
NATIONAL
VAP RATE = 3.2
NATIONAL
CAUTI RATE =
1.21

12. IdentifyingHealthcare-associatedInfections(HAI)forNHSNSurveillance
Key SURVEILLANCETerms
Present on Admission (POA)
Healthcare-associated Infection (HAI)
Infection Window Time Period
Date of Event (DOE)
Repeat Infection Timeframe (RIT)
Secondary Attribution Period

13. POA versus HAI
InfectionsthatarePOA,areNOTHAIsandarenotreportedinHESN
POA: Present on Admissions VS
Infection is considered POA if the date
of event of the CDC/NHSN site-specific
infection is The first 2 calendar days of
admission to an inpatient location.
HAIs: Health care associated Infections
An infection is considered to be HAI if
the date of event occurs on or after the
3rd calendar day of admission to the
facility, with the day of admission to an
inpatient location being calendar day 1.

14. (VAP SURVEILLANCE)

15. Ventilator-Associated Pneumonia (VAP) Event:
A VAP is a pneumonia (PNEU) where the patient is on mechanical
ventilation for >2 calendar days on the date of event identified by
using a combination of radiologic, clinical and laboratory criteria.
&
The ventilator has to be in place for >2 days and in place at the date
of event or the day before.
A)Ventilator-AssociatedPneumonia(VAP)?

17. Ventilator
CDC defines ventilator as any
device used to support, assist or
control respiration (inclusive of
the weaning period) through the
application of positive pressure
to the airway when delivered via
an artificial airway, either
endotracheal or tracheostomy
tube.

19. DefiningPneumonia
BASEDONCDC–NHSNCRITERIA
PNEU 1
PNEU 2
PNEU 3

20. PNEU1
Clinically Defined–(AnyPatient)
1: X-ray image:
Patient with underlying diseases has 2
or more serial chest imaging test
results with one of the following:
•New or progressive and persistent
infiltrate
•Consolidation
•Cavitation
•Pneumatoceles, in <1 y. o.
OR
Patient without underlying pulmonary or
cardiac diseases has 1 definitive imaging
test result with one of the following:
•New or progressive and persistent
infiltrate
•Consolidation
•Cavitation
•Pneumatoceles, in <1 y. o.
AND

21. PNEU1: ClinicallyDefined-Any
Patient
2: SYMPTOMS AND SIGNS
At least one of the following:
•Fever (>38.0° C/100.4° F) with no
other cause
•Leukopenia (< 4,000 WBC/mm3)
or leukocytosis (>12,000
WBC/mm3)
•Altered mental status with no
other cause, in > 70 y. o.
AND
At least two of the following:
•New onset of purulent sputum, or
change in character of sputum, or
increased respiratory secretions, or
increased suctioning requirements
•New onset or worsening cough,
or dyspnea, or tachypnea.
•Rales or bronchial breath sounds
•Worsening gas exchange (e.g., O2
desaturations [e.g.,
PaO2/FiO2≤240], increased O2
requirement, or increased
ventilator demand)

22. •
PNEU2- Radiology FindinGS
PNEU2– SignandSymptoms
Imaging criteria & Sings / symptoms are
are exactly the same as for PNU1

23. PNEU2-Specific Laboratory
Findings
At least ONE of the following:
•Positive blood culture
•Positive pleural fluid culture
•Positive quantitative culture from
minimally contaminated LRT specimen
(e.g., BAL or protected specimen brushing)
ETT aspiration culture
•> 5% BAL-obtained cells contain
intracellular bacteria on direct microscopic
exam
•Positive quantitative culture of lung
tissue
Histopathologic exam shows one of the
following:
•Abscess formation or foci of
consolidation with intense PMN
accumulation in bronchioles and alveoli
•Evidence of lung parenchyma invasion
by fungal hyphae or pseudohyphae

24. PNEU3- Immunocompromised
Patient
Imaging criteria are exactly the
same as for PNU1 and PNU2

25. PNEU3 -ImmunocompromisedPatient – SIGNS&
SYMPTOMS
At least ONE of the following in
an immunocompromised
patient:
•Fever (> 38.0° C/100.4◦ F)
•Altered mental status with no
other cause, in > 70 y.o.
•New onset of purulent sputum,
or change in character of sputum,
or increased respiratory
secretions, or increased suctioning
requirements.
•New onset or worsening cough, or
dyspnea, or tachypnea
•Rales or bronchial breath sounds
•Worsening gas exchange (e.g., O2
desats [e.g., PaO2/FiO2 < 240],
increased O2 requirement, or
increased ventilation demand)
•Hemoptysis
•Pleuritic chest pain

26. PNU3-ImmunocompromisedPatient
Laboratory:
At least one of following:
•Matching positive blood and
sputum or endotracheal aspirate
cultures with Candida spp.
Evidence of fungi or from minimally
contaminated LRT specimen (e.g.,
BAL or protected specimen
brushing) from one of the
following:
•Direct microscopic exam
•Positive culture of fungi
•Non-culture diagnostic laboratory
test

27. VAP PREVENTION STARTEGIES
VAP CARE BUNDLE
A care bundle refers to a group of evidence-
based interventions related to a particular
condition which when applied together
significantly improves patient outcome.
ALL OR NONE PRINCIPLE

28. 1:STRATEGY to PreventAspiration:
 Maintain patients in semi
recumbent position (30-45
elevation of the head of the bed)
unless there are contraindications
Better ventilation
Reduces risk of gastric aspiration
Keep the head of the patient s
bed raised between 30 to 45
degrees.

29. 2:StrategiestoReduceDurationofVentilation
Conduct “sedation vacations” / Daily Sedation interruption
(SDI)
Assess readiness to wean from vent daily & target early
extubation.
Conduct spontaneous breathing trials (SBT)
Prolonged use of sedatives can impede patients ability to
swallow effectively which prevent effective clearance of
secretions from oral cavity and can migrate via micro aspiration
into lungs.

30. 3:StrategiestoReduceColonizationoftheRespiratoryandDigestive
Tract:
ORALCARE
Perform regular oral care with an antiseptic solution
(chlorhexidine) at least twice per day.
Decreases bacterial colonization of oropharynx , aspiration of
colonized saliva & formation of dental plaques.

31. 4:PEPTICULCERPROPHYLAXIS
PREVENT STRESS ULCERS
5:DVTPROPHYLAXIS
PREVENTS THE CLOT FORMATION AND IMPROVES VENOUS RETURN TO
HEART.

32. Centrallineassociated BLOODSTREAMINFECTION
(CLABSI) SURVEILLANCE

33. A CLABSI is a Primary Blood Stream Infection identified by using a
combination of laboratory and clinical criteria that occurs in a
patient who is on central line or umbilical catheter.
And
The Central line / UC has to be in place for >2 days and in place at
the date of event or the day before.
Centrallineassociated BLOODSTREAM INFECTION
(CLABSI)

34. PATHOGENESIS OF CLABSI

35. KeyTerms: CentralLine
An intravascular catheter that
terminates at or close to the
heart or in one of the great
vessels
Used for infusion, withdrawal
of blood, or hemodynamic
monitoring usually for longer
period of time.

36. Greatvesselsforthepurposeofreportingcentrallineinfections
• 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

37. CDC–NHSN CRITERIA
LCBI - Criterion1
Patient of any age
Recognized pathogen identified from one or more
blood cultures
Organism cultured from blood is not related to
infection at any other site.
Not the NHSN common commensal

38. Patient of any age
Patient has at least
one of the following
signs or symptoms:
fever (>38.0°C),
chills, or
hypotension
Organism cultured
from blood is not
related to an infection
at another siteAND
CDC–NHSN CRITERIA
LCBI - Criterion2

39. LCBI - Criterion2
COMMON COMMENSALS:
Coagulase-negative staphylococci [including S. epidermidis ], viridans
group
Streptococci, Aerococcus spp., Micrococcus spp. Etc
 Identified from two or more consecutive blood
cultures drawn on separate occasions.

40. LCBICriterion3:Neonates/Infants
Patient <1 year of age has at least one of the following signs or symptoms :
Fever (>38.0°C) hypothermia (<36.0°C), apnea, or bradycardia
AND
Organism cultured from blood is not related to an infection at another site
AND
Common commensals identified by 2 or more consecutive blood cultures
drawn on separate occasions.

43. Insertion
?
Maintenance
?
BSI
Rate
OUTPUT
# CVC
Inserted
INPUT
Process of CVC Care
43

44. Process VS Outcome Surveillance
Hand
Hygiene
Daily
Review
Skin
Disinfection
Maximum
Barrier
Precautions
Optimal
catheter site
selection
OUTCOME
SURVEILLANCE
Counting number of
CLABSI
PROCESS SURVEILLANCE
Monitoring compliance with CVC care bundle elements

45. HowtoreduceCLABSI
The following interventions decrease the risk for CLABSIs:
 Appropriate hand hygiene
 Use of chlorhexidine for skin preparation
 Use of full-barrier precautions during central venous catheter
insertion
 Avoid using the femoral vein for central venous catheters in
adult patients
 Removing unnecessary central venous catheters

46. CATHETERASSOCIATEDURINARYTRACT INFECTION
(CAUTI) SURVEILLANCE

47. CAUTI
A UTI where an indwelling urinary catheter was in place for >2
calendar days on the date of the event, with day of device
placement being Day 1
AND
An indwelling urinary catheter was in place on the date of event
or the day before. If an indwelling urinary catheter was in place
for >2 calendar days and then removed, the date of event for
the UTI must be the day of discontinuation or the next day for
the UTI to be catheter-associated.

48. CDC–NHSN
UrinaryTractInfections
 Symptomatic Urinary Tract Infection (SUTI)
criteria,
 Asymptomatic Bacteremic UTI (ABUTI)
criterion,
 Urinary System Infection (USI) criteria.

49. CDCNHSN -UTICRITERIA
SUTI 1: Catheter associated urinary tract infection (CAUTI)
SUTI 2: CAUTI or Non- CAUTI in pts. 1 year of age or less
ABUTI: Asymptomatic Bacteremic Urinary Tract Infection
( with or without catheter but no signs and symptoms)

50. SUTI 1 Criterion1(CAUTI)
.
B) Patient has at least one of the
following signs or symptoms:
• Fever (>38°C)
• Suprapubic tenderness*
• Costovertebral angle pain or
tenderness*
• Urinary urgency*
• Urinary frequency*
• Dysuria*
C) Patient has a positive urine
culture with no more than 2 species
of organisms at least one of which
is a bacterium of >105 colony-
forming units (CFU)/ml.
All elements of the UTI criterion
must occur during the Infection
Window Period.
AND
A) Patient had an indwelling urinary catheter that had
been in place for more than 2 consecutive days
+

51. AsymptomaticBacteremicUTI(ABUTI)
Patient must meet 1, 2, and 3 below:
1. Patient with or without an indwelling urinary catheter has no signs or
symptoms .
And
2. Patient has a positive urine culture with no more than 2 species of
organisms, at least one of which is a bacterium of >105 CFU/ml .
AND
3. Patient has a positive blood culture matching at least 1 bacteria present
at >105 CFU/ml in the urine culture, or meets LCBI criterion 2 (with
hypotension or chills) and matching common commensal(s) in the urine.

52. URIANRYCATHETERCAREBUNDLE
Indwelling urinary catheter: A drainage tube that is inserted into the
urinary bladder through the urethra, is left in place, and is connected
to a closed collection system. Also called Foleys .
 Does not include Condom or straight in-and-out catheters are not
 Does not include suprapubic catheters
1. Avoid urinary catheter use if not indicated
2. Insert using aseptic technique
3. Maintain catheter based on guidelines (Daily review)
4. Review necessity daily and remove promptly
52

53. THANK YOU