HAI Surveillance

HAI surveillance
Catheter Associated Urinary Tract Infection (CAUTI)
Present on admission (POA)
VS
Healthcare Associated Infection (HAI)
• Present on admission (POA)- date of events occurs on the day of admission
or the day after admission
* The POA time period continues to include the day of admission, 2 days
before and the day after admission
• Healthcare Associated Infection (HAI)- date of events occurs on or after the
3rd calendar day of admission
Hospital Day Criterion P

Date 1 O

2 A
of 3 H
Event 4 A

5 I
Catheter Associated Urinary Tract Infection (CAUTI)
Symptomatic Urinary tract infection with catheter in place
• Patient must meet 1,2, and 3
1. The patient has an indwelling urinary catheter in place for the entire
day on the date of events and such catheter had been in place for > 2
calendar days on that date (day of device placement = Day 1)
2. Patient has at least one of following signs and symptoms
- fever (> 38.00C)
- Suprapubic tenderness
- Costovertebral angel pain and tenderness
3. 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
Catheter Associated Urinary Tract Infection (CAUTI)
Symptomatic Urinary tract infection with catheter recently removed
• Patient must meet 1,2, and 3
1. The patient has an indwelling urinary catheter in place for greater than 2
days which was removed on the day of or the day before the date of
events
2. Patient has at least one of following signs and symptoms
- fever (> 38.00C)
- Suprapubic tenderness
- Costovertebral angel pain and tenderness
- Urinary urgency / Urinary frequency / Dysuria
3. 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
Catheter Associated Urinary Tract Infection (CAUTI)
Symptomatic Urinary tract infection ( one year or < one year)
• Patient must meet 1,2, and 3
1. The patient is one year or less than one year ( with or without indwelling
urinary catheter)
2. Patient has at least one of following signs and symptoms
- fever (> 38.00C)
- Hypothermia (< 36.00C)
- Apnea
- Bradycardia
- Lethargy
- Suprapubic tenderness
- Vomiting
3. 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
Catheter Associated Urinary Tract Infection (CAUTI)
Device Associated Example # 1
Day 5 - Foley inserted; Asymptomatic
Day 6 –Foley remains in place; Fever 38.20C
Day 7 – Fever 38.60C
Day 8 – 100000 CFU E.Coli in urine

Is this SUTI catheter associated ?

1. Yes
2. No
Catheter Associated Urinary Tract Infection (CAUTI)
Device Associated Example # 2
Day 1 – Admit to ICU
Day 4 –Foley inserted
Day 8 –Foley removed; Asymptomatic
Day 9 – No Foley in place; Fever 100.50C
Day 10- Fever 100.50C ,Urine(+) 100000 CFU/ml, E. Faecium

Is this SUTI catheter associated ?

1. Yes
2. No
Catheter Associated Urinary Tract Infection (CAUTI)
Device Associated Example # 3
Day 1 – Admit to ICU
Day 4 –Foley inserted
Day 8 –Foley removed
Day 9 – Foley inserted
Day 10- Fever 100.60C ,Urine(+) 100000 CFU/ml, E. Coli

Is this SUTI catheter associated ?

1. Yes
2. No
Central Line Associated Blood Stream Infection (CLABSI)
Central Line Associated BSI (CLABSI)- A laboratory confirmed blood stream
infection where central line or umbilical catheter was in place for > 2 calendar
days on the date of events with day of device placement being day 1
And
a CL or UC was in place on the date of event or the day before. If the CL or UC
was in place for more than 2 calendar days and than removed the date of event
of LCBI must be the date of discontinuation or the next day

LCBI- Criterion 1
• Patient has a recognized pathogen cultured from one or more blood cultures
and
• Organism cultured from blood is not related to an infection at another site
Central Line Associated Blood Stream Infection (CLABSI)
LCBI- Criterion 2
• Patient has at least one of the following signs or symptoms: fever (>38.00C),
chills and hypotension
And
• Organisms cultured from blood are not related to an infection at another site
And
• the same common commensal (i.e.diptheroids [Corynebacterium Spp.],
Bacillus [not B. Anthracis] Spp.,Propionibacterium Spp., coagulase negative
staphylococci [including S. Epidermidis ], viridans group streptococci,
Aerococcus Spp., micrococcus Spp.) is cultured from two or more blood
culture drawn on separate occasion (same or consecutive days) within the
7 day Infection Window Period
Central Line Associated Blood Stream Infection (CLABSI)
LCBI- Criterion 3
• Patient 1year or less than 1 year of age, has at least one of the following signs
or symptoms: fever (>38.00C), hypothermia (< 36.00C) or bradycardia
And
• Organisms cultured from blood are not related to an infection at another site
And
• the same common commensal (i.e.diptheroids [Corynebacterium Spp.],
Bacillus [not B. Anthracis] Spp.,Propionibacterium Spp., coagulase negative
staphylococci [including S. Epidermidis ], viridans group streptococci,
Aerococcus Spp., micrococcus Spp.) is cultured from two or more blood
culture drawn on separate occasion (same or consecutive days) within the
7 day Infection Window Period
Central Line Associated Blood Stream Infection (CLABSI)
LCBI Example # 1
Day 1 – Central line inserted
Day 4 – Patient had hypotension and raised WBC
Day 5 – Blood culture sent which showed growth of E.Faecalis

No other source of E. Faecalis infection is present

Is this LCBI ?
1. Yes
2. No
Central Line Associated Blood Stream Infection (CLABSI)
LCBI Example # 2
Day 1 – Central line inserted
Day 4 – Patient had hypotension and raised WBC
Day 5 – 2 blood cultures sent which showed growth of coagulase negative
staphylococcus and other staphylococcus epidermidis

No other source of infection is present

Is this LCBI ?
1. Yes
2. No
 Ventilator Associated Pneumonia (VAP)
Ventilator is defined as a device to assist or control respiration inclusive
of the weaning period through a tracheotomy or by endotracheal intubation
Episode of mechanical ventilator –a period of days during which the patient
was mechanically ventilated for some portion of each consecutive day. A break
in mechanical ventilator of at least one full calendar day followed by reintubation
or re-initiation of mechanical ventilation during the same hospitalization is new
episode
Ventilator Associated Pneumonia- A pneumonia where the patient is on
mechanical ventilation for > calendar days on the date of event ,with the day
of ventilator placement being day 1
And
the ventilator was in place on the date of event or the day before. If the patient is
admitted or transferred into the facility on a ventilator ,the day of admission is
considered day 1
 Ventilator Associated Pneumonia (VAP)
The patient is on mechanical ventilation for > calendar days and
Imaging test evidence Sign/Symptoms/Laboratory

Two or more serial chest imaging
test results with at least one of
following
• New or progressive and
persistent infiltrate
• Consolidation
• Cavitation
• Preumatoceles in infant one
year of less than one year of age
Note: In patient without underlying
pulmonary or cardiac disease one
definitive imaging test result is
acceptable
For any patient at least one of following:
• Fever (>38.00C OR > 100.40F)
• Leucopenia (< 4000 WBC/ mm3) or leucocytosis
(≥ 12000 WBC/ mm3)
• For adult ≥ 70 years old, altered mental status with no other
recognized cause
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
requirement
• New onset or worsening cough or dyspnea or tachypnea
• Rales or bronchial breath sound
• Worsening gas exchange(e.g.O2 desaturations [PaO2/FiO2 <
240], increased oxygen requirement or increased ventilator
demand)
 Ventilator Associated Pneumonia (VAP)
Imaging test Sign/Symptoms/Laboratory
evidence
Alternate Criteria for infants one year old or less than that
Worsening gas exchange(e.g.O2 desaturations [Pulse Oxymeter < 94%],
increased oxygen requirement or increased ventilator demand)
And least three of the following:
• Temperature instability
• Leucopenia (< 4000 WBC/ mm3) or leucocytosis
(≥ 15000 WBC/ mm3) and left shift (≥ 10% band forms)
•New onset of purulent sputum or change in character of sputum
or increased respiratory secretions or increased suctioning
requirement
• Apnea or tachypnea,nasal flaring with retraction of chest wall or
grunting
• Cough, wheezing, rales,ronchii
• Bradycardia (< 100 beats/ min) or tachycardia (> 170 beats/min)
 Ventilator Associated Pneumonia (VAP)
Specific site Algorithms for Viral, Legionella and other Bacterial Pneumonia with
definite lab finding
ITE Sign/Symptoms/Laboratory Laboratory

Same At least one of following: At least one of the following:

• Fever (>38.00C OR > 100.40F)
as • Leucopenia (< 4000 WBC/ mm3) or leucocytosis
above
(≥ 12000 WBC/ mm3)
• For adult ≥ 70 years old, altered mental status with no
other recognized cause
And at least one of the following
• New onset of purulent sputum or change in character of
sputum or increased respiratory secretions or increased
suctioning requirement
• New onset or worsening cough or dyspnea or tachypnea
• Rales or bronchial breath sound
• Worsening gas exchange(e.g.O2 desaturations[PaO2/FiO2
< 240], increased oxygen requirement or increased
ventilator demand
• Positive growth in blood culture not related with
another source of infection
• Positive growth in culture of plural fluid
• Positive quantitative from minimally contaminated
LRT specimen
• ≥ 5% BAL obtained cells contain intracellular bacteria
on direct microscopic examination (e.g.Gram stain)
• Positive quantitative culture of lung tissue
Histopathologic exams shows at least one of following
evidences of pneumonia
• Abscess formation or foci of consolidation of with
intense PMN accumulation in bronchioles and alveoli
• Evidences of lung parenchyma invasion by fungal
hyphae or psedohyphae
 Ventilator Associated Pneumonia (VAP)

Specific site Algorithms for Viral, Legionella and other Bacterial Pneumonia with
definite lab finding
ITE Sign/Symptoms/Laboratory Laboratory

Same as At least one of following: At least one of the following:

above • Fever (>38.00C OR > 100.40F)
• Leucopenia (< 4000 WBC/ mm3) or leucocytosis
(≥ 12000 WBC/ mm3)
• For adult ≥ 70 years old, altered mental status with no
other recognized cause
And at least one of the following
• New onset of purulent sputum or change in character of
sputum or increased respiratory secretions or increased
suctioning requirement
• New onset or worsening cough or dyspnea or tachypnea
• Rales or bronchial breath sound
• Worsening gas exchange(e.g.O2 desaturations[PaO2/FiO2
< 240], increased oxygen requirement or increased
ventilator demand
• Positive growth of virus, Legionella or Chlamydia
from respiratory secretion
• Positive non culture diagnostic laboratory test of
respiratory secretions or tissue for virus, Bordetella
Chlamydia, Mycoplasma, Legionella (e.g. EIA,FAMA,
shell vial assay, PCR, micro-IF)
• Four fold rise in paired sera (IgG) for pathogen
(Influenza viruses ,Chlamydia)
• Four fold rise in Legionella pneumophila serogroup 1
antibody titer to ≥1:128 in paired acute and
convalescent sera by indirect IFA
• Detection of L.Pneumophila serogroup 1antigen in
urine by RIA oe EIA
 Ventilator Associated Pneumonia (VAP)
Specific site Algorithms for Pneumonia in Immunocompromised Patients
ITE Sign/Symptoms/Laboratory
Same Immunocompromised patient has at least one of following
• Fever (>38.00C OR > 100.40F)
as • For adult ≥ 70 years old, altered mental status with no
above
other recognized cause
And at least one of the following
• New onset of purulent sputum or change in character of
sputum or increased respiratory secretions or increased
suctioning requirement
• New onset or worsening cough or dyspnea or tachypnea
• Rales or bronchial breath sound
• Worsening gas exchange(e.g.O2 desaturations[PaO2/FiO2
< 240], increased oxygen requirement or increased
ventilator demand
• Heomptysis
• Pleuritic chest pain
Laboratory
At least one of the following:
• Matching positive blood and sputum or endotrachael
aspirate culture with Candida spp.
• Evidence of Fungi from minimally contaminated –
LRT specimen from one of the following
- Direct microscopin exams
- Positive culture of Fungi
- Non culture diagnostic laboratory test
+
Any of the following from:
Laboratory criteria defined in previous slide
 Surgical Site Infection (SSI)
Superficial Incisional SSI-Infection occur within 30 days after operative procedure
( where day 1= the procedure date) and involves only skin and sun- cutaneous tissue
of the incision and patient has one of the following:
a) Purulent drainage from the superficial incision
b) Organism isolated from aseptically obtained culture from the superficial incision
or sub cutaneous 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 one of the following sign and 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
 Surgical Site Infection (SSI)
Deep Incisional SSI-Infection occur within 30 or 90 days after operative procedure
( where day 1= the procedure date) and involves deep tissue (facial and muscles
layers) of the incision and patient has one of the following:
a) Purulent drainage from the superficial incision
b) 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 one of the following sign and symptoms : fever (> 380C),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 ,hystopathologic exams or imaging test .
 Pressure ulcer
Stages of pressure ulcer

Category/Stage I: Non-blanchable erythema,Intact skin with non-blanchable redness of a

localized area usually over a bony prominence. Darkly pigmented skin may not have visible
blanching; its color may differ from the surrounding area. The area may be painful, firm, soft,
warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect
in individuals with dark skin tones. May indicate “at risk” persons.

Category/Stage II: Partial thickness,Partial thickness loss of dermis presenting as a shallow

open ulcer with a red pink wound bed, without slough. May also present as an intact or
open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry
shallow ulcer without slough or bruising*. This category should not be used to describe skin
tears, tape burns, incontinence associated dermatitis, maceration or excoriation.
*Bruising indicates deep tissue injury.
 Pressure ulcer

Category/Stage III: Full thickness skin loss,Full thickness tissue loss. Subcutaneous fat may
be visible but bone, tendon or muscle are not exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining and tunneling. The depth of
a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III
ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep
Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable

Category/Stage IV: Full thickness tissue loss,Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be present. Often includes undermining and
tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The
bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and
these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or
supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis
likely to occur. Exposed bone/muscle is visible or directly palpable.

* The National Pressure Ulcer Advisory Pane (USA,2007)