by Dr. Arthur Dessie E. Roman

1. 02/19/2016
1
Healthcare-associated
Infections:
Definitions and Standardizations
Arthur Dessi Roman MD MTM
Internal 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)

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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.
?

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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

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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

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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(no fluids infused, pushed, nor withdrawn)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

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

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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

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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.

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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 pRBC
via 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 (viridans
streptococci on final report).
Is this CAUTI?

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Surgical Site Infections (SSIs)
SSIs: Types
•Superficial incisional SSI
•Deep incisional SSI
•Organ/Space SSI

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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.

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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.

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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?

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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

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Ventilator-associated
pneumonia (VAP)
New surveillance definition
Ventilator-associated
pneumonia (VAP)

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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

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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 40C 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.