HAI Surveillance & Definitions In LTCF

1. HAI Surveillance & Definitions In LTCF Infectious Disease Epidemiology Section Office of Public Health Louisiana Dept of Health & Hospitals 800-256-2748 www.infectiousdisease.dhh.louisiana.gov Your taxes at work

2. HAI Surveillance • Surveillance is the focal point for infection control activities. The term surveillance implies that the observational data are regularly analyzed. •  Surveillance provides valuable epidemiologic data such as • identification of epidemics, • priorities for infection control activities, • shifts in microbial pathogens, • infection rates • outcomes of hospital-acquired infection. • Surveillance • Increase in infection control team visibility • Opportunity for informal consultation and education to unit nurses & physicians.

3. HAI Surveillance • Infection control surveillance is • NOT ABOUT FINDING CAUSE OF HAI • NOT ABOUT ASSIGNING BLAME • NOT ABOUT FAIRNESS • Infection control surveillance is • ABOUT EVALUATING A SYSTEM • ABOUT IDENTIFYING PREVENTIVE MEASURES

4. Active Surveillance • Active surveillance = trained personnel • Use various data source to accumulate information • Decide whether or not a HAI has occurred using standardized definitions • Using active surveillance, increases the sensitivity of identifying infections to 0.85 to 1.0; whereas, using passive methods had produced a sensitivity of 0.15 to 0.35. IP = Infection preventionist

5. HAI Definitions

6. What is a Nosocomial Infection ? • An infection which is acquired during hospitalization and which was not present or incubating at the time of admission • An infection which is acquired in the hospital and becomes evident after discharge from the hospital • A newborn infection which is the result of passage through the birth canal

7. What is a Nosocomial Infection ? Practically - to establish that an infection is hospital acquired, SHOW THAT the patient: 1. HAS AN INFECTION, not a simple colonization 2. WAS NOT infected at the time of admission 3. HAD SUFFICIENT TIME to develop infection

8. 1 True Infection NOT Colonization • Infections are accompanied by signs and symptoms:  fever, malaise  in localized infections: swelling due to inflammation, heat, pain, erythema (tumor, dolor, rubor, calor) • Use definitions which establish minimum characteristics for infection • Note: Immunocompromised patients do not show signs of infection as normal patients. Neutropenic patients (  500 neutrophils /mm3) show no pyuria, no purulent sputum, little infiltrate and no large consolidation on chest X-ray

9. 2 NO Infection at Time of Admission • establish prior negativity • check history, symptoms & signs • documented at time of admission, lab tests & chest X-rays done -normal physical examination -absence of signs and symptoms -normal chest X-ray -negative culture or lack of culture Example: If urine cultures are collected at day 7 of hospitalization and none was collected before, it implies that no signs of infection were present in urine before • Excluded: • Transplacental infections • Reactivation of old infections (ex Shingles) • Infections considered extensions of infections present at admission

10. Sufficient Time to Develop Infection 3 • diseases with specific incubation period: stay in hospital  incubation period • numerous infections do not have well set incubation periods (for example, staphylococci, E.coli infections) - these infections rarely develop in less than 2 days

11. To establish a nosocomial infection, meeting the definition criteria is sufficient. There is no need to have proof beyond the shadow of a doubt

12. Case Definitions CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Horan TC, Andrus M, Dudeck, MA, 2008. Am J Infect Control 36:309-32.

13. The 4 BIG Ones • BSI Bloodstream infection • PNEU Pneumonia • UTI Urinary tract infection • SSI Surgical site infection

14. Asymptomatic Bacteriuria -1- • Patient with indwelling urinary catheter within 7 days before first culture and • Positive urine culture  105 microorganisms per mL with no more than two species of microorganisms and • Patient has no fever ( 38° C), urgency, frequency, dysuria, or suprapubic tenderness

15. Asymptomatic Bacteriuria -2- •  Patient with NO indwelling urinary catheter within 7 days before first culture and • Patient with at least 2 positive urine cultures  105 microorganisms /mL of urine with repeated isolation of same microorganism and no more than two species of microorganisms and • Patient has no fever ( 38° C), urgency, frequency, dysuria, or suprapubic tenderness

16. Symptomatic UTI -1- • Patient has at least one of the following signs or symptoms with no other recognized cause: -fever (  38° C), -urgency, -frequency, -dysuria, -suprapubic tenderness and • Positive urine culture  105 microorganisms per mL with no more than two species of microorganisms

17. Symptomatic UTI -2- • Positive dipstick for • leukocyte esterase • or nitrate • Pyuria (w  10 wbc/mm3 • or  3 wbc/HPF unspun urine) • Microorganisms on Gram stain of unspun urine • At least 2 urine cultures with repeated isolation of same uropathogen (G neg bacteria or S. saprophyticus) with  102 colonies/mL in non-voided specimens •  105 colonies/ml of single uropathogen (G neg bacteria or S. saprophyticus) in patient treated with UTI antimicrobial • Physician diagnosis of UTI or institutes Tx for UTI • Patient has at least 2 of the following signs or symptoms with no other recognized cause: -fever (  38° C), -urgency, -frequency, -dysuria, -suprapubic tenderness and at least 1 of the following:

18. Note: UTI • Positive culture of urinary catheter tip not acceptable laboratory test to diagnose UTI • Urine cultures must be obtained using appropriate technique • Adult: clean catch collection or catheterization • Positive urine culture from bag is unreliable and should be confirmed

19. OUTI -1,2- OUTI-Other infections of the urinary tract (kidney, ureter, bladder, urethra, or tissue surrounding retroperitoneal or perinephric space Other infection of the urinary tract must meet at least 1 of the following criteria: 1. Patient has organisms isolated from culture of fluid (other than urine) or tissue from affected site. 2. Patient has an abscess or other evidence of infection seen on direct examination, during a surgical operation, or during a histopathologic examination.

20. OUTI -3- Patient has at least 2 of the following signs or symptoms with no other recognized cause: fever (>38.8C), localized pain, or localized tenderness at the involved site And at least 1 of the following: • Purulent drainage from affected site • Organisms cultured from blood compatible with suspected site of infection • Radiographic evidence of infection (eg, abnormal ultrasound, CT scan, MRI, or radiolabel scan [gallium, technetium], • Physician diagnosis of infection of kidney, ureter, bladder, urethra, or tissues surrounding the retroperitoneal or perinephric space • Physician institutes appropriate therapy for infection of these sites