Point Prevalence Survey of Hospital-Acquired Infections & Antimicrobial Use in Ireland

1. Point Prevalence Survey of Hospital-Acquired Infections & Antimicrobial Use in Ireland PPS Data Collector Training April 2012 HAI Case Definitions & HAI Case Studies Presentation 3

2. Acknowledgements – Case Studies • Dr Sarah Bergin, Specialist Registrar, Microbiology • Dr Caroline Fielding, Specialist Registrar, Microbiology • Ms Siobhan Barrett, Antimicrobial Pharmacist • All cases are fictional

3. Hospital-acquired infection • Hospital-acquired infection and healthcare-associated infection are not the same • This PPS is concerned with active infection acquired DURING or AS A CONSEQUENCE OF admission to an acute hospital • Infections acquired in nursing homes or long term care facilities (HCAI) are not captured in this PPS • Date of admission = Date patient arrived/presented at the hospital • Date of admission = Day 1 • Admitted to ward at 23:50 on 05/05/12 = Day 1 • 00:00 on 06/05/12 = Day 2

4. Hospital-acquired infection • Develops in this hospital during the current admission • Develops in another acute hospital and patient transferred to this hospital with active HAI • Develops in the community in a patient recently discharged from acute hospital and results in patient being readmitted to this hospital Acute hospital = This hospital or another acute hospital

5. Hospital-acquired infection • Infection arising Day 3 onwards • If a patient is readmitted to hospital within two days of discharge from an acute hospital with an infection or infection develops on Day 1 or Day 2 of this readmission, then the infection is hospital-acquired if the case definition for infection is met • C. difficile infection (CDI) may develop up to 28 days following discharge from hospital • Surgical site infection (SSI) related to non-implant surgery may develop up to 30 days following date of surgery • SSI related to implant surgery may develop up to one year following date of surgery

6. What is an active infection? • Infection is ACTIVE when signs and symptoms of infection are present on the PPS date OR • There is documentation that signs and symptoms of infection were present in the past and the patient continues to receive antimicrobial* therapy for that infection on the survey date *Antimicrobials = antibacterials & antifungals Antivirals and treatment of TB are not included

7. When is an infection hospital-acquired? AND

8. How do I decide date of onset?Decision hierarchy • Date of onset = date of documentation of first symptoms or signs of infection OR if not documented, date of onset as discussed with treating clinician • If symptoms or signs not documented and the clinician is not available to discuss, if patient has recent relevant positive microbiology results, take date of onset as date of relevant positive microbiology results (e.g. Pneumonia with sputum culture positive) • If symptoms or signs not documented and patient does not have relevant positive microbiology results, take date of onset as date treatment started

9. Infection arising DAY 3 onwardsis HAI DATE OF ADMISSION TO THIS HOSPITAL (DAY 1) TRANSFERRED TO THIS HOSPITAL FROM ANOTHER ACUTE HOSPITAL? ADMITTED TO THIS HOSPITAL WITHIN 30 DAYS OF DISCHARGE FROM AN ACUTE HOSPITAL? ADMITTED TO HOSPITAL WITHIN ONE YEAR OF DATE OF IMPLANT SURGERY? NO INFECTION ARISING DAY 3 ONWARDS = HAI

10. Infection arising DAY 3 onwards • Donald Duck admitted via ED 08/05/12 (DAY 1) • 10/5/12 (DAY 3) – Develops dysuria, fever 380C • MSU & blood cultures taken and commenced empirically on IV co-amoxiclav for suspected UTI • PPS team arrive on ward 11/5/12 (DAY 4) • ACTIVE URINARY TRACT INFECTION • HOSPITAL-ACQUIRED - ONSET DAY 3

11. Can a HAI arise on DAY 1 or DAY 2? Yes, in certain circumstances

12. HAI arising on DAY 1 & DAY 2 AND

13. Infection arising DAY 1 & DAY 2 DATE OF ADMISSION TO THIS HOSPITAL (DAY 1) TRANSFERRED TO THIS HOSPITAL FROM ANOTHER ACUTE HOSPITAL? ADMITTED TO THIS HOSPITAL WITHIN 30 DAYS OF DISCHARGE FROM AN ACUTE HOSPITAL? ADMITTED TO HOSPITAL WITHIN ONE YEAR OF DATE OF IMPLANT SURGERY? YES INFECTION ARISING ON DAY 1 & DAY 2 MAY BE HOSPITAL ACQUIRED IF: PATIENT ADMITTED TO THIS HOSPITAL WITHIN 28 DAYS OF DISCHARGE FROM ACUTE HOSPITAL & INFECTION MEETS CDI CASE DEFINITION

14. Infection arising DAY 1 & DAY 2 DATE OF ADMISSION TO THIS HOSPITAL (DAY 1) TRANSFERRED TO THIS HOSPITAL FROM ANOTHER ACUTE HOSPITAL? ADMITTED TO THIS HOSPITAL WITHIN 30 DAYS OF DISCHARGE FROM AN ACUTE HOSPITAL? ADMITTED TO HOSPITAL WITHIN ONE YEAR OF DATE OF IMPLANT SURGERY? YES INFECTION ARISING ON DAY 1 & DAY 2 MAY BE HOSPITAL ACQUIRED IF: PATIENT ADMITTED TO THIS HOSPITAL WITHIN 30 DAYS OF DATE OF SURGERY PERFORMED IN ACUTE HOSPITAL & INFECTION MEETS SSI CASE DEFINITION PATIENT ADMITTED TO THIS HOSPITAL WITHIN ONE YEAR OF DATE OF IMPLANT SURGERY & INFECTION MEETS SSI CASE DEFINITION

15. HAI arising on DAY 1 or DAY 2 • Minnie Mouse was discharged home well from this hospital 05/05/12 following a laparotomy and small bowel resection performed 29/04/12 • Minnie represents to ED 17/05/12 (DAY 1) complaining of purulent drainage from lower end of laparotomy wound and on examination the infection extends down to the fascia • Minnie is commenced on empiric IV cefuroxime and oral metronidazole, a wound swab is taken and she is admitted to general surgical ward • PPS team arrive on the ward 18/5/12 (DAY 2) • ACTIVE SURGICAL SITE INFECTION • HOSPITAL ACQUIRED – PRESENTING 20 DAYS POST SURGERY

16. HAI arising on DAY 1 & DAY 2 • Yogi Bear was transferred to ICU in this hospital 16/05/12 for management of acute kidney injury arising secondary to severe Clostridium difficile infection diagnosed in referring hospital 08/05/12 • On arrival, 16/05/12 (DAY 1) Yogi is prescribed oral vancomycin since 08/05/12 • PPS team arrive in ICU 17/5/12 (DAY 2) • ACTIVE CDI, ACQUIRED IN OTHER ACUTE HOSPITAL

17. Infection arising DAY 1 & DAY 2 DATE OF ADMISSION TO THIS HOSPITAL (DAY 1) INFECTION ARISING ON DAY 1 & DAY 2 MAY BE HOSPITAL ACQUIRED IF: YES HAI is C-CVC or CRI3-CVC and CVC in situ OR HAI isC-PVC or CRI3-PVC and PVC in situ HAI is UTI and urethral catheter in situ HAI is pneumonia and patient is intubated

18. HAI arising on DAY 1 & DAY 2 • Lisa Simpson transferred to this ICU 8/05/12 (DAY 1) from ICU St Elsewhere for management of worsening acute cardiac failure secondary to viral myocarditis • On arrival, she has been intubated since 04/05/12 • During early hours 09/05/12, noted to be febrile to 390C, WCC 17^, purulent secretions and she is also tachypnoeic • CXR demonstrates bilateral diffuse infiltrates which are more evident in comparison to CXR prior to transfer • PPS team visit ICU 09/05/12 (DAY 2) • ACTIVE PNEUMONIA, ACQUIRED IN OTHER HOSPITAL • RELATED TO INTUBATION

19. HAI arising on DAY 1 & DAY 2NEONATAL AND INFECTION ARISING AT ANY TIME FOLLOWING BIRTH WHILST NEONATE REMAINS IN HOSPITAL IS HOSPITAL-ACQUIRED IF MEETS CASE DEFINITION OF INFECTION

20. Postnatal mastitis/breast abscess AND PROVIDED CHILDBIRTH OCCURED IN HOSPITAL Note if woman had a home delivery and is subsequently admitted to hospital with mastitis or breast abscess within 7 days – the infection is not a HAI

21. Case Definitions of HAI • HAI case definitions are in PPS protocol Appendix B • Case definitions of infection are surveillance definitions • Surveillance definitions are not the same as clinical impression/judgement • Case definitions should be strictly applied to ensure consistency in reporting • PN1 in Scotland = PN1 in Latvia = PN1 in Italy

22. Case Definitions of HAI • For PPS, case definitions have been taken from Europe, where definitions exist and US CDC/NHSN where no European definitions exist • HELICS – PN, SSI, BSI, CRI, UTI • ECDC – CDI • KISS – Specific neonatal case definitions • US CDC/NHSN – Where no European case definitions available • Your job is to decide if patient has active infection, if infection is hospital-acquired and if infection meets a HAI case definition

23. Case Definitions of HAI • Case definitions are NOT perfect • There will be cases where you feel patient has HAI and case definition is not met • There will be cases where the clinician feels the patient has a HAI and case definition is not met • Please take note and feedback the number of times this happens during your PPS • Case definitions should be strictly applied

24. Preliminary PPS data:submitted to ECDC at 28/2/12 • Most common HAI types reported from participating hospitals to date: • Pneumonia • Surgical site infection • Urinary tract infection • Bloodstream infection • Gastrointestinal infection • Systemic infections • Skin & soft tissue infection • All other infection types Preliminary data only - for information

25. Pneumonia - PN • THREE PARTS TO PNEUMONIA DEFINITION • RADIOLOGY PLUS • PATIENT SYMPTOMS PLUS • MICROBIOLOGY • To diagnose PN, you need positive findings in each of the three parts

26. PN – Appendix B P60RADIOLOGY & PATIENT SYMPTOMS Rx = Radiology

27. PN – APPENDIX B P60MICROBIOLOGY

28. BACK TO LISA • Lisa Simpson transferred to this ICU 8/05/12 (DAY 1) from ICU St Elsewhere for management of worsening acute cardiac failure secondary to viral myocarditis • On arrival, she has been intubated since 04/05/12 • During early hours 09/05/12, noted to be febrile to 390C, WCC 17^, purulent secretions and she is also tachypnoeic • CXR demonstrates bilateral diffuse infiltrates which are more evident in comparison to CXR prior to transfer • PPS team visit ICU 09/05/12 (DAY 2) • No microbiology results back on secretions sent in early hours

29. Lisa’s Patient Form (Form C)Section 5: HAI Data

30. Also review Practice Case 1

31. Surgical Site Infection - SSI • Timing of HAI onset is VERY important for SSI category • Non-implant surgery: SSI arising up to 30 days postop is HAI • Implant surgery: SSI arising up to one year postop is HAI • If you think patient has SSI – Record date of operation & date of infection onset • Three categories of SSI • Superficial • Deep • Organ space

32. SSI – APPENDIX B P66

33. SSI – APPENDIX B P66

34. SSI – APPENDIX B P66

35. BACK TO MINNIE... • Minnie Mouse was discharged home well from this hospital 05/05/12 following a laparotomy and small bowel resection performed 29/04/12 • Twenty days post-op: Minnie represents to ED 17/05/12 (DAY 1) complaining of purulent drainage from lower end of laparotomy wound and on examination the infection extends down to the fascia • Minnie is commenced on empiric IV cefuroxime and oral metronidazole, a wound swab is taken and she is admitted to general surgical ward • PPS team arrive on the ward 18/5/12 (DAY 2) • Wound swab result is pending

36. Minnie’s Patient Form (Form C)Section 5 – HAI data

37. Also review Practice Case 2

38. Urinary Tract Infection - UTI • There are two types of UTI: • Microbiologically-confirmed UTI & patient has symptoms of UTI: At least one symptom and positive urine culture OR • Not microbiologically-confirmed & patient has symptoms of UTI: At least two symptoms and one other diagnostic criteria

39. UTI Appendix B P62

40. Back to Donald... • Donald Duck admitted via ED 08/05/12 (DAY 1) • 10/5/12 (DAY 3) – Develops dysuria, fever 380C • MSU & blood cultures taken and commenced empirically on IV co-amoxiclav for suspected UTI • PPS team arrive on ward 11/5/12 (DAY 4) • Donald’s MSU result is pending

41. Donald’s Patient Form (Form C) Section 5: HAI data

42. Also review Practice Case 3:HAI 1

43. Bloodstream Infection (BSI) • To have BSI, patient MUST have positive blood cultures • Significant pathogen – ONE positive blood culture • Organism normally regarded as skin contaminant – TWO positive blood cultures AND at least one of Fever >380C, chills or hypotension

44. Bloodstream Infection (BSI) • If a patient has a BSI, you should try and decide what the source/origin of the BSI was: • Primary BSI of unknown source/origin following review of available information • Primary BSI due to infected vascular catheter • BSI secondary to infection elsewhere • BSI source unknown because no information available or information missing

45. BSI – Protocol P67

46. BSI Protocol P67

47. BSI Case Study • Molly Malone, 82 year-old, ED admission 05/05/12 with community-acquired pneumonia and acute kidney injury • Empirically treated with IV co-amoxiclav & PO clarithromycin • 10/05/12 (Day 6) – febrile, hypotension • Elevated CRP, WCC 22 (^from 15 09/05/12) • Repeat CXR – no new changes • Blood cultures and MSU taken, empiric vancomycin added 1gm bd IV

48. BSI Case Study • 11/05/12 (Day 7) – Ongoing pyrexia, co-amoxiclav changed to IV piperacillin- tazobactam 4.5gm tds • 11/05/12 pm – Yeasts seen in blood cultures • Caspofungin 70mg IV stat dose given – for further once daily dosing of 50mg • No CVC, no intraabdominal concerns, renal ultrasound normal, MSU WCC 0, no growth • 13/05/12 – Microbiology laboratory confirm Candida parapsilosis from blood cultures • 14/05/12 – PPS team arrive on ward

49. Molly’s Patient Form CSection 5: HAI Data

50. Also review Practice Cases1 (HAI 2) & 3 (HAI 2)