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McGeer Criteria: An Update

McGeer Criteria: An Update. Suzanne F. Bradley, M.D. Professor of Internal Medicine Division of Infectious Diseases University of Michigan Medical School Program Director, Infection Control VA Ann Arbor Healthcare System. McGeer Criteria Background. Consensus discussions

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McGeer Criteria: An Update

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  1. McGeer Criteria: An Update Suzanne F. Bradley, M.D. Professor of Internal Medicine Division of Infectious Diseases University of Michigan Medical School Program Director, Infection Control VA Ann Arbor Healthcare System

  2. McGeer CriteriaBackground • Consensus discussions • Multidisciplinary team • Unstructured literature review • Based on NNIS definitions McGeer A et al. AJIC 1991; 19:1-7.

  3. McGeer CriteriaTarget Population • Older Adults • Skilled nursing care • Assistance activities daily living (ADLs) • Supervision – cognitively impaired • Therapeutic options (IVs) limited • Onsite diagnostics uncommon McGeer A et al. AJIC 1991; 19:1-7.

  4. Why Revise, Why Now?Rationale • Increase evidence-based literature • Improved diagnostics for surveillance • Changing pt populations in this setting • Updated NHSN hospital definitions. • HICPAC method/structured review done • Grading not performed

  5. LTCF CriteriaGuiding Principles • Infection surveillance only • Highly specific • Applied retrospectively • Focus on transmissible/preventable inf. • Not for case finding • Not for diagnostic purposes • Not for clinical decision making

  6. LTCF Surveillance DefinitionsAll Conditions Must Be Met • All symptoms must be new or acutely worse • Alternative non-infectious causes of signs and symptoms should be considered first • No infection can be based on a single piece of evidence • Dx by a physician insufficient

  7. LTCF Surveillance ProgramsWhat to Include?

  8. Surveillance in LTCFRevised Signs and Symptoms • Fever 1. Oral single > 37.8◦C [>100◦F] or 2. Oral repeated > 37.2◦C [99◦F] or 3. Any site* > 1.1◦C (2◦F) over baseline • Leukocytosis (New!) • Neutrophilia > 14,000 wbc/mm3 or • Left shift (>6% bands or >1500 bands/mm3) High K et al. Clin Infect Dis 2009;48:149-171

  9. Surveillance in LTCFNew Signs and Symptoms C. Confusion Assessment Method - MS change from baseline 1. acute onset and fluctuating course 2. inattention AND 3. Either disorganized thought or altered level of consciousness D. Acute functional decline • New 3 point increase in total ADL score • 0-4 points per activity • 0-28 points per total score • Activities bed mobility, transfers, locomotion, dressing, eating toileting, personal hygiene Inouye SK et al. Ann Intern Med 1990;113:941, Minimum Data Set 3.0

  10. Infection in LTCF ResidentsFever Threshold? • Three different thresholds • sensitivity • specificity • likelihood ratio • Suggested redefine fever: > 2o F over baseline > 99o F po or 99.5o F pr (repeated measures) Castle S. Aging Immunol Inf Dis, 1993;4:67 % Likelihood Ratio D> 2.4oF > 101oF > 100oF > 99oF D>1.4oF

  11. Diagnostic Tests CBC with Differential • Older adults infected vs no infection Infection (RR) leukocytosis (> 14,000/mm3)3.7 neutrophilia (> 90% PMNs)4.7  % bands (> 6%) 7.5  absolute bands (> 1500/mm3 ) 14.5 Wasserman et al J Am Geriatr Soc 1989;37:537

  12. Revised McGeer CriteriaDefinitions Not Changed Limited evidence to change definitions for: • Conjunctivitis • Ear Infections • Sinusitis • Cold syndromes/pharyngitis • Cellulitis • Gastroenteritis • Systemic infections • Unexplained febrile episode

  13. Both of the following criteria must be met: Fever Three or more new or increasing signs or sx chills headache or eye pain myalgias malaise or anorexia sore throat dry cough Removed stipulation about Dx only during flu season Did not mention lab-confirmed ILI! Influenza-Like IllnessRevised Definition

  14. Pneumonia in LTCF Chest Radiography • An infiltrate on chest x-ray • most reliable Dx method for pneumonia • despite poor film quality • lack of prior film • predictive hospitalization and death • performed more often in university-affiliates • CXR (+) in 75-90% suspected pneumonia Mednia-Walpole et al., JAGS,1999;47:1005; Medina-Walpole et al., JAGS 1998;46:187; Zimmer, et al. JAGS,1986;34:703; Chan CSB et al. JAGS 2007;55:414

  15. Respiratory Tract Infection in LTCFPulse Oximetry • Hypoxemia (PaO2 < 60 mm Hg): • predicts severity and mortality in CAP and NH pts • Hypoxemia (O2 saturation < 90 %) • along with RR > 25 breaths/min • predicts impending respiratory failure Fine,et al. N Engl J Med,1997;336:243; Mylotte, et al. J Am Geriatr Soc, 1998;46:1538; Chan CSB et al. JAGS 2007;55:414.; Kaye KS Am J Med Sci 2002;324:237.

  16. All of the following criteria must be met: CXR positive for: a) pneumonia or new infiltrate One or more resp S/S cough new/increased sputum new/increased 02 sat < 94% or reduced 3% from baseline abnl lung exam new or changed e) pleuritic chest pain f) RR > 25 breaths/min 3.One or more constitutional S/S Absence of other conditions that could account for Sx, e.g., CHF PneumoniaRevised Definition Lim WS et al. Eur Respir J 2001;18:362-368.

  17. All of the following criteria must be met: CXR not done or negative for: a) pneumonia or new infiltrate Twoor more resp S/S cough new/increased sputum new/increased 02 sat < 94% or reduced 3% from baseline abnl lung exam new or changed e) pleuritic chest pain f) RR > 25 breaths/min 3.One constitutional S/S Absence of other conditions that could account for Sx, e.g., CHF LRTI (Bronchitis, Tracheitis)Revised Definition

  18. Asymptomatic BacteriuriaASB - Prevalence • Young girls ~1% • Premenopausal married women 5% • Pregnant women 2-7% • Diabetic women 8-14% • Comm-dwelling men > 75 yrs 6-15% • Comm-dwelling women > 80 yrs > 20% • Hemodialysis 28% • Spinal cord patients > 50%

  19. PyuriaPrevalence-Asymptomatic Pts • Young women 32% • Pregnant women 30-70% • Diabetic women 70% • Institutionalized elderly 90% • Hemodialysis pts 90% • Short term catheters 30-75% • Long-term catheters 50-100% Nicolle et al. Clin Infect Dis 2005;40:643-654.

  20. PyuriaOther Causes • Any inflammatory cause • Tuberculosis (sterile pyuria) • STDs • Interstitial nephritis legionella, leptospirosis, atheroemboli, granulomatous dis (sarcoid), allergy • Irritation - stones, catheters • Degree of pyuria not helpful re-Rx

  21. Significance of BacteriuriaIndwelling Catheters • Prevalence catheter use US NH residents: 100,000 in use Acute care: 15-25% • Prevalence bacteriuria per day catheterization 3-8% short term 9-23% > 30 days 100% • Complications BSI < 1% deaths due to BSI 1-4% Hooton TM et al. IDSA Guideline, CID 2010;50:625

  22. Loeb M. et al. BMJ 2005;Sept 8th.

  23. AnyOne of the following: Acute dysuria OR acute pain/swelling testes, epididymis, or prostate Fever OR WBC AND One or more of the following: CVA or SP pain/tenderness gross hematuria new or marked increase: frequency, urgency, incontinence c)Two or more new or increased: frequency, urgency, incontinence, SP pain, new gross hematuria. AND UTI (No Catheter)Revised Definition

  24. Voided urine culture with a) > 105 cfu/ml any bug (s) UTI = Localizing S/S and (+) urine culture If no S/S, (+) UTI Dx if: blood & urine organisms the same no alternate source Pyuria does not differentiate Sx UTI from ASB Absence of pyuria excludes UTI Dx In the absence of a clear source: Fever or rigors & (+) urine culture often leads to Rx Evidence suggests that most episodes are NOT from a urinary source UTI (No Catheter)Revised Definition (2) Loeb M et al. Br Med J 2006;351:669-671.

  25. AnyOne of the following: Fever, rigors, OR new onset hypotension with NO alternate site of infection b) Either acute change MS OR acute functional decline with NO alternate diagnosis AND WBC c) New onset SP or CVA pain d) Purulent discharge around catheter or acute pain, swelling, tenderness testes, epididymis, or prostate AND 2. Urine has > 105 cfu/ml of any organism(s). Obtained after catheter replaced if in > 14 days * Chronic indwelling catheters In the absence of a clear source in the catheterized pt: Acute confusion & (+) urine culture often leads to Rx Evidence suggests that most episodes are NOT from a urinary source Other localizing signs consistent with UTI are not necessary for Dx e.g., recent catheter trauma obstruction new onset hematuria UTI (Catheter*)Revised Definition

  26. Vascular thrombophlebitis Dermatologic Sweet Syndrome Eosinophilic cellulitis Drug reactions Envenomations/Bites Contact dermatitis Rheumatic Gout Immunological Erythromelalgia Relapsing polychondritis Malignant CA erysipelatoides Familial FMF, FHF Foreign-Body mesh metallic implants granulomatous Common ImpersonatorsInfectious Cellulitis Falagas ME et al. Ann Intern Med 2005;142:47-55.

  27. Venous EczemaStasis Dermatitis • Underlying diseases • venous insufficiency • phlebitis • renal, cardiac disease • Pathophysiology • edema, trauma • capillary leak, inflammation • reduced oxygenation • Distal legs • pitting edema, serous exudate • scaling, crusting • pruritis, excoriation • Hyperpigmentation • erythema – often dependent • Rx • compression/elevation • barrier creams/topical steroids

  28. One of the following criteria met: Pus present at a wound, skin, or soft tissue site. Four or more new or increasing signs or sx at the site heat redness swelling tenderness or pain serous drainage one constitutional S/S One or more beta hemolytic streptococcal infections may suggest an outbreak Use NHSN SSI criteria Superficial cultures of pressure ulcers are not sufficient for Dx Cellulitis/Soft Tissue/Wound InfectionRevised Definition

  29. Bothof the following criteria met: A maculopapular and/or itching rash AND 2. One of the following: physician diagnosis scraping or biopsy + OR c) epidemiological linkage to a case of scabies with lab confirmation Rule out noninfectious skin conditions such as eczema, allergy, and irritation. Epi link = common source exposure, temporally related onset, & geographic proximity ScabiesRevised Definition

  30. Oral candidiasis Bothof the following criteria met: a) presence of raised white patches on inflamed mucosa OR plaques on oral mucosa AND b) medical or dental diagnosis 2. Fungal infection characteristic rash or skin lesions AND b) either medical provider dx or lab confirmed smear, culture or bx Mucocutaneous candida infections are due to comorbid conditions or antibiotics. Non-candidal fungal infections rare & outbreaks uncommon. Fungal Oral/Perioral/Skin InfectionsRevised Definition

  31. Herpes simplex Bothof the following criteria met: a) vesicular rash AND b) either physician diagnosisORlab confirmation Herpes zoster Bothof the following criteria met: a) vesicular rash AND b) either physician diagnosisORlab confirmation Reactivation of H. simplex and H. zoster not considered an HAI Primary herpes viral skin infections uncommon Herpes Viral Skin InfectionsCurrent Definition - Unchanged

  32. One criteria must be met: Two or more loose or watery stools above pt baseline in 24 hrs Two or more episodes of vomiting in 24 hrs Both of the following Stool specimen + for bacterial or viral pathogen AND At leastonecompatible gi symptom such as: nausea, vomiting, pain, diarrhea Exclude non-infectious causes of symptoms due to medications or gallbladder disease GastroenteritisCurrent Definition - Unchanged

  33. Both criteria must be met: Two or more loose or watery stools above pt baseline OR two or more episodes of unexplained vomiting in 24 hrs Stool specimen + for norovirus by EM, ELISA, or molecular test (PCR) - In an outbreak, confirm the cause - No confirmation, assume Dx by Kaplan Criteria All criteria must be met: vomiting > 50% affected mean (median) incubation period 24-48 hrs mean (median) duration illness 12-60 hrs no bacterial cause ID’d Norovirus GastroenteritisNew Definition Lopman BA et al. CID 2004;39:318-324. Kaplan JE et al. Ann Intern Med 1982;96:756-761.

  34. Both criteria must be met: Diarrhea = 3 or more loose or watery stools above pt baseline within 24 hrs, or the presence of toxic megacolon by x-ray 2. One of the following: Stool + for toxin A or B, or by PCR. PMC found at endo-scopy, surgery, or by biopsy Primary episode no prior episode or > 8 wks prior 2. Recurrent episode < 8 wks prior and sx had resolved Clostridium difficile InfectionNew Definition McDonald LC et al. ICHE 2007;28:140-145.

  35. Infection SurveillanceAttribution to LTCF • No evidence of incubation on admission • based documentation of signs and symptoms • not just by screening microbiology data • Onset > 3 calendar days post admission • Debate surrounding C. difficile • Consistent acute care reporting

  36. HAI National Action PlanPhase 3: LTC Priority Area #1 Enrollment NHSN #2 C. difficile infection #3 Vaccination residents #4 Vaccination HCW #5 CAUTI and catheter care Fed Register 2012;77:43086-43087

  37. Metrics over 5 yrs 5% LTCF enrolled standardized tools 190 SNF (10/6/14) 1.2% LTCF-onset CDI rates Standardized lab testing Incidence CA-SUTI Report utilization ratio catheter & resident days HAI National Action PlanPhase 3: LTC Priority/Area #1 Enrollment NHSN QPI demonstration 2013 #2 C. difficile infection CMS requirement acute care #5 CAUTI catheter care CMS retained catheter indicator MDS reporting UTI & catheter retention

  38. www.cdc.gov/nhsn/longtermcare

  39. www.cdc.gov/nhsn/longtermcare

  40. Infection Surveillance in LTCFSummary Most McGeer Criteria retained. Most changes minor UTI revisions more specific New definitions for norovirus New definitions for C. difficile

  41. Surveillance in LTCFSummary • Involvement multiple stakeholders • VA, CMS, CDC, others • Recognition NHAIs in LTCF important • Priority areas identified • overlapping areas of interest • mechanisms to “encourage” participation • Development of a LTCF network • assist in performance improvement • adopt/validate new definitions

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