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Second Edition November 2013

HEALTHCARE ASSOCIATED INFECTION (HCAI) SURVEILLANCE

Quality in Medical Care Section Medical Development Division

Ministry of Health

Point Prevalence Survey

for

Healthcare Associated Infection

Surveillance

Manual

DRAFT

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PAGE Abbreviations 3

Committee Members 4

Background 5

Objectives 6

Methodology a. Design b. Population under surveillance c. Definitions d. Calculation of Prevalence Rate e. Inclusion and Exclusion criteria f. Survey Instrument

6 6 7 9

10 11

Data Collection 12

Compilation of data and report 14

Algorithm for Healthcare Associated Infection Surveillance through PPS

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APPENDIX 1: Definitions Of Healthcare Associated Infection

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APPENDIX 2: Healthcare Associated Infection Surveillance Form (HCAI-PPS/MOH/2013/1)

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APPENDIX 3: Healthcare Associated Infection Surveillance Reporting Form Section A (HCAI-PPS/MOH/2013/2)

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APPENDIX 4: Healthcare Associated Infection Surveillance Reporting Form Section B (HCAI-PPS/MOH/2013/3)

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APPENDIX 5: Line Listing For HCAI Surveillance - PPS

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References 42

Contents

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A&E Accident and emergency

AMR Antimicrobial resistance

BSI Bloodstream infection

CDC Centre for Disease Control and Prevention

CFU Colony-forming units

CVC Central vascular catheter

ESBL Extended-spectrum beta-lactamase

HCAI Healthcare-associated infections

ICN Infection control nurse

ICU Intensive care unit

MOH Ministry of Health

PPS Point Prevalence Survey

PVC Peripheral vascular catheter

SSI Surgical site infections

WHO World Health Organization

Abbreviations

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Dr Zubaidah Abdul Wahab Senior Consultant Clinical Microbiologist Hospital Sungai Buloh, Selangor Dr Nurahan Maning Senior Consultant Clinical Microbiologist Hospital Raja Perempuan Zainab II, Kota Bharu Datin Dr R. Ganeswrie Senior Consultant Clinical Microbiologist Hospital Sutanah Aminah, Johor Bahru Dr Shahnaz Shah Firdaus Khan Senior Consultant Nephrologist Hospital Tengku Ampuan Rahimah, Klang Dato’ Dr Sapari Satwi Senior Consultant Physician (Infectious Disease) Hospital Tengku Ampuan Afzan, Kuantan Dr Kamarul Azahar Mohd Razali Senior Consultant Paediatrician (Infectious Disease) Hospital Kuala Lumpur Dr Ker Hong Bee Consultant Physician (Infectious Disease) Hospital Raja Permaisuri Bainun, Ipoh Dr Jamaludin Mohamad Consultant Paediatrician Hospital Tuanku Fauziah, Kangar Dr Tuan Suhaila Tuan Soh Clinical Microbiologist Hospital Sungai Buloh, Selangor

Dr Suraya Amir Husin Senior Principal Assistant Director Infection Control Unit Medical Development Division

Dr Suhaila Hanapiah Clinical Microbiologist National Cancer Institute, Putrajaya Dr Sahlawati Mustakim Clinical Microbiologist Hospital Tengku Ampuan Rahimah, Klang

Dr Anis Baidura Azal Senior Assistant Director Infection Control Unit Medical Development Division

Pn Hadijah Mohd Taib Pharmacist Hospital Kuala Lumpur Pn Saabah Rosnan Nursing Sister Infection Control Unit Medical Development Division Pn Zawiah Mamat@ Mohd Dris Nursing Sister Infection Control Unit Medical Development Division

Committee Members

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The prevalence of hospital infections in Malaysia is being observed through the Healthcare

Associated Infections (HCAI) surveillance programme. The HCAI prevalence is determined

through a one-day hospital wide point prevalence survey (PPS) which is conducted twice a year

in March and September. The PPS started in 2003 involving 14 Ministry of Health (MOH) and 3

university hospitals. Currently the surveillance data from 20 MOH and 3 university hospitals is

analysed twice a year.

The HCAI are categorized into the common types of infection occurring in hospitals, which are

the urinary tract infections (UTI), pneumonia, surgical site infections (SSI), blood stream

infections (BSI) and clinical sepsis (CS).

The first survey conducted in September 2003 showed that the national HCAI rate was 6.3 per

100 patients surveyed. The 10 years trend has shown progressive reduction to 1.51 per 100

patients surveyed in September 2012. Since the first survey, pneumonia had always been the

most common type of infection occurring in the hospitals followed by either SSI or BSI.

The objective of HCAI surveillance is to reduce HCAI rates. Surveillance can be carried out by

prevalence studies or incidence studies. Incidence studies are essentially cohort studies which

require much more workload. In general, incidence study is better for surveillance as it is

ongoing. It allows for risk factor analysis and gives more robust data. Incidence studies can be

carried out concentrating on a specific infection type eg. BSI, UTI or VAP or on a specific unit eg.

Intensive Care Unit.

Prevalence study on the other hand is essentially cross sectional and for surveillance purposes,

repeated prevalence studies eg. Point prevalence studies are necessary.

The information on infection rates, main infection sites, common microorganisms and the use

of antibiotics varies from one centre to another. For example, a study in the Netherlands

showed that the most common HCAI was SSI (4.8%), followed by respiratory tract infections

1.1%, UTI (1.7%) and BSI (0.5%) (1). A Canadian study reported that the most common HCAI was

UTI (3.4%), followed by pneumonia (3.0%), SSI (2.5%), BSI (1.6%) and Clostridium difficile-

associated diarrhoea (1%)(2). In short, choosing the best method for HCAI surveillance in a

hospital depends on the following factors:

Background

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Analysis of the baseline situation (prevalence data, earlier results, outbreaks)

Characteristics of the hospital (famous for a specific operation type)

Which resources are available (manpower)

Formulation of clear objectives (eg. To decrease SSI rates following hip operation)

General objective: To reduce healthcare associated infection prevalence / incidence rate

Specific objective:

1. To estimate the total burden (prevalence) of HCAI in hospitals participating in PPS.

2. To determine the characteristic of infection - types of HCAI and organism, pattern of

antibiotic usage, invasive procedures and other predisposing factors of HCAI

3. To provide a standardized tool for hospitals to identify targets for quality improvement

a) Design

It is a hospital wide cross sectional, point prevalence survey. The survey is conducted twice a

year, one day in the month of March and September

b) Population under surveillance

Population under surveillance is all in-patients on the survey day

c) Definitions of an active HCAI

An active healthcare associated infection present on the day of the survey is defined as follows:

1. Signs and symptoms of the infection are present on the survey date OR signs and

symptoms were previously present and the patient is still receiving treatment for that

infection on the survey date AND

Objectives

Methodology

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2. The onset of infection was after 48 hours of admission OR

3. The onset of infection (SSI) was less than 48 hours of admission but patient has

undergone surgical procedure within one month or one year (with implant) OR

4. Patient presents with an infection but has been readmitted within 48 hours after a

previous discharge from hospital OR

5. Infections occurring in infants that result from passage through the birth canal are

considered HCAIs if they meet the definition of HCAI.

SUMMARY OF HCAI CASE DEFINITION

Onset of HCAI1 Case definition

After 48 hours AND Meets the case definition on the day of survey

OR

Before 48 hours: SSI criteria met at any time after admission (including previous surgery 30 days/1 year)

OR

OR Before 48 hours AND patient discharged from hospital in preceding 48 hours

OR

Before 48 hours AND patient discharged from hospital in preceding 28 days if CDI2

present

Patient is receiving treatment3 and HCAI has previously met the case definition before 48 hours of treatment and survey day OR

Before 48 hours AND patient has relevant device inserted on this admission prior to onset

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1. Date of onset of HCAI: date of first signs or symptoms of the infection; if unknown, record the date when treatment was started for this infection or the date the first diagnosis sample was taken. If no treatment or sample, please estimate. Not to be recorded if signs/symptoms are present at admission

2. CDI : Clostridium difficile infection 3 . Any kind of treatment, not necessarily antimicrobial Definitions of the most common HCAI are listed as in Appendix 1. The method of case

confirmation can be made through clinical signs and symptoms or laboratory investigations.

Since this is a hospital wide infection, all patients present in the hospital at the time of survey

are included. The total number of patients is collected in the early morning census from each

ward obtained from the ward sister excluding the psychiatric ward and labour room.

d) Calculation of HCAI Prevalence

Numerator: Any patient that met the criteria in Appendix 1

Denominator: Number of hospitalized patients in the hospital on the day of survey**

Ward HCAI prevalence = No. of patient with HCAI in the ward on the day of survey X 100 No. of hospitalized patients in the ward on the day of survey

Department / discipline HCAI prevalence = No. of patient with HCAI in the department on the day of survey X 100 No. of hospitalized patients in the department on the day of survey

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Hospital HCAI prevalence = Total no. of patient with HCAI in the hospital on the day of survey X 100 No. of hospitalized patients in the hospital on the day of survey ** Total number of hospitalized patients present at 8.00 am in the hospital on the day of survey

excluding the psychiatric ward and labour room.

e) Inclusion and Exclusion criteria

Ward

Include:

All wards in the hospitals

Exclude:

Psychiatric ward

Labour room/suite

Department

Include:

All Departments in the hospitals

Exclude:

A & E departments (except for wards attached to A&E departments where patients are

monitored for more than 24 hours)

Psychiatric Department

Hospitals

Include:

All selected MOH hospitals and University hospitals

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Include:

All patients admitted to the ward before or at 8 a.m. and not discharged from the ward

at the time of the survey; in practice, this means that patients transferred in/out after 8

a.m. from/to another ward should not be included.

Neonates on pediatric and O&G wards if born before/at 8 a.m.

Patients who are temporarily off from the ward for diagnostic investigations or

procedures; if patient does not return to the ward before the end of the PPS day and

information about patient is not available at 8 a.m., please revisit ward.

Exclude:

Patients undergoing same day treatment or surgery

Patients seen at outpatient department

Dialysis patients (outpatients)

f) Survey Instrument

Data on infection are obtained from the patients records. HCAI cases are to be supported with

other pertinent information which are being collected in the survey. This includes the

microbiological report, indicating the type of specimen where organism(s) was isolated and the

organism antibiotic susceptibility results.

Information regarding antibiotic treatment received in the past 2 weeks as well as current

antibiotic treatment ie. the patient is still receiving antibiotics for an infection on the day of the

survey is also documented. The current antibiotic treatment indicates that the infection is

active.

It is important to determine the possible source or point where the infection was introduced

during his stay in the hospital. Therefore, information on various types of devices that the

patient had been subjected to is also recorded. Besides the devices, the other possible

contributing factors such as patient’s underlying disease, immunosuppressive therapy,

prolonged hospitalisation, invasive procedures, pre-maturity and low birth weight are looked

into.

Patients

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Data collection process

Pre survey task

Data collection activity in the hospitals will be handled by the hospital infection control

committee that consists of:

Infection Control Doctor / Clinical Microbiologist

Ward Doctors

Matron / Nurse Manager Infection Control Unit

Infection Control Sister

Infection Control Nurses

Ward Sisters In Charge

Link Nurses

The committee will organized the pre-survey training program if required, scheduling of survey,

coordinate survey data collection (resources identification) until data compilation and report at

the hospital level.

National level

Choose date for survey

Send letter informing date of survey to all participating hospitals address to Director of

Hospital and Infection Control Nurse.

Hospital Level

Inform the administrators and managers of the PPS date

Recruit surveyors

Prepare pre-survey briefing – explain case definition, go through on how format should be

filled

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Day of survey

Post survey task

Train team to review medical and nursing charts and interview the ward staff.

Assign groups to wards, prepare timetable

Prepare enough copies of formats and forms required

Identify and designate ward sisters to help surveyors

Inform ward sisters to have patient folders at bedside with all investigation reports available

Hospital Level

Visit every patient in the hospital on the survey day at 8 am

Identify infected patients through the case notes (BHT, nursing observation forms,

prescription sheets and laboratory results)

Fill the appropriate surveillance form

For ward sister in charge:

Prepare ward census of patients at 8 am

Identify patients who are temporarily not in the ward (e.g to OT, X ray, rehab , HD)and

inform team when they return to the ward

Hospital Level

Compile all filled forms from team members and send them to state

Tabulate data and calculate HCAI rates

Presentation of result at hospital infection control committee

Disseminate and use data in decision making at hospital level

Formulate Infection control strategies and policies

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Compilation of data and report

State Level

Collect data from the hospitals in state and send to national secretariat

Tabulate data at state level and calculate HCAI rates

Presentation of result at state infection control committee

Disseminate and use data in decision making at state level

Formulate infection control strategies and policies

National level

Compile all data from the state.

Data analysis and reporting at national level

Presentation of the result during technical and national infection and antibiotic control

committee meeting

Disseminate and use data in decision making at national level

Formulate infection control strategies and policies

Once a case is being identified from the case notes (case identification is made based on the

definition as discussed earlier) the ward infection / link nurse need to fill in the HCAI-

PPS/MOH/2013/1 form as in Appendix 2. Data from each format are then entered and

tabulated according to the form HCAI-PPS/MOH/2013/2 [Excel Format] as in Appendix 3.

Individual form of HCAI-PPS/MOH/2013/1 and HCAI-PPS/MOH/2013/2 are to be sent to

hospital infection control nurse (ICN). The ICN will then compile the data using HCAI-

PPS/MOH/2013/3 [Excel Format] as in Appendix 4 and complete the line listing. Completed

HCAI-PPS/MOH/2013/3 form to be e-mailed to ICN State Coordinator for compilation.

State Coordinator will compile HCAI-PPS/MOH/2013/3 from all hospitals and e-mail them to

the Infection Control Unit, Medical Development Division within 1 month of the PPS date.

However, hospitals are most welcome to produce their own performance report.

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The national secretariat will compile all the data from the state and produce a report on the

national performance of the HCAI. The flow chart for the case finding and process of the

surveillance is shown in Algorithm for Healthcare Associated Infection Surveillance through

PPS.

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Surveillance team arrives in the

ward. Record start date and time.

Collect denominator data on all

patients in ward before 8 am

Walk around ward. For each patient,

observe for invasive devices (UC, PVC,

CVC, ventilation)

Collect ONE set of patient notes (medical, nursing,

observation, I/O, drug chart, etc.)

Confirm HCAI according to standard definitions

Ward link nurse to fill in HCAI-PPS/MOH/2013/1 form

Complete data collection for all patients

Compile all the forms and get the no. of

HCAI cases according to type of

infection. Complete the HCAI-

PPS/MOH/2013/2.

ICN to fill in the HCAI-PPS/MOH/2013/3 format based on HCAI-PPS/MOH/2013/2

compiled from the ward.

1) Compilation of HCAI-PPS/MOH/2013/1 to be sent

to hospital ICN

2) Completed HCAI-PPS/MOH/2013/2 to be sent to

ICN in soft copy

State Coordinator to e-mail HCAI-PPS/MOH/2013/3 to

Infection Control Unit, MOH within 1 month of PPS date

Line listing to be filled and kept

at the hospital

If note are unclear, ask

for clarification of sign

and symptom from

nursing/medical team

ICN to send the HCAI-PPS/MOH/2013/3 to state coordinator

ICN to complete the line listing

Data management by

Infection Control Unit, MOH

Algorithm for healthcare associated infection surveillance through PPS

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DEFINITIONS OF HEALTHCARE ASSOCIATED INFECTIONS – FIRST EDITION 2013

This document has been adapted from the CDC/NHSN Surveillance Definition of Healthcare Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting and European Centre for Disease Prevention and Control, Point prevalence survey of healthcare associated infections and antimicrobial use in European acute care hospitals- protocol version 4.3. Stockholm: ECDC; 2012 Most HCAI becomes evident 48 hours (i.e., the typical incubation period) or more after admission. However, because the incubation period varies with the type of pathogen, nature of infection and the patient’s underlying conditions, each patient must be assessed individually for evidence that links it to the hospitalization. The diagnosis of a HCAI is based on a combination of clinical and laboratory findings. There are two special situations in which an infection is considered HCAI:

1. Infection that is acquired in the hospital but does not become evident until after hospital discharge.

2. Infections occurring in infants that result from passage through the birth canal are considered HCAIs if they meet the definition of HCAI above

There are two special situations in which an infection is not considered HCAI:

1. Infection that is associated with a complication or extension of infection already present on admission, unless a change in pathogen or symptoms strongly suggests the acquisition of a new infection.

2. In an infant an infection that is known or proved to have been acquired transplacentally (e.g., toxoplasmosis, rubella, cytomegalovirus, or syphilis) and becomes evident at or before 48 hours after birth.

For the purpose of our survey, only the most common HCAI i.e. urinary tract infection, pneumonia, surgical site infections, blood stream infections and clinical sepsis will be defined precisely. For other HCAI record them as OTHERS and briefly describe the nature of the infection as best you can. The following pages contain the criteria to be used for diagnosing the common HCAI. If you are in doubt PLEASE CONSULT THE ATTENDING DOCTOR OR MICROBIOLOGIST

APPENDIX 1

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INFECTION SITE: Symptomatic urinary tract infection CODE: UTI DEFINITION: A symptomatic urinary tract infection must meet at least one of the following criteria:

Criterion Description

1 Patient had an indwelling urinary catheter in place for >48 hours, with day of device placement being Day 1, and catheter was in place at the time when all elements of this criterion were first present together. And at least 1 of the following signs or symptoms: fever (>38°C); suprapubic tenderness*; costovertebral angle pain or tenderness* And a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms. OR Patient had an indwelling urinary catheter in place for >48 hours and had it removed the day of or the day before all elements of this criterion were first present together And at least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*; dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness* And a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms. *With no other recognized cause

2 Patient had an indwelling urinary catheter in place for >48 hours, with day of device placement being Day 1 and catheter was in place when all elements of this criterion were first present together And

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at least 1 of the following signs or symptoms: fever (>38°C); suprapubic tenderness*; costovertebral angle pain or tenderness* And at least 1 of the following findings: a. positive dipstick for leukocyte esterase and/or nitrite b. pyuria (urine specimen with ≥10 white blood cells [WBC]/mm3 of unspun urine or >5 WBC/high power field of spun urine) c. microorganisms seen on Gram’s stain of unspun urine And a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms. OR Patient with an indwelling urinary catheter in place for > 48 hours and had it removed the day of or the day before all elements of this criterion were first present together And at least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*; dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness* And at least 1 of the following findings: a. positive dipstick for leukocyte esterase and/or nitrite b. pyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or >5 WBC/high power field of spun urine c. microorganisms seen on Gram’s stain of unspun urine And a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms. *With no other recognized cause

For patient ≤1 year of age

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Criterion Description

3 Patient ≤1 year of age with** or without an indwelling urinary catheter has at least 1 of the following signs or symptoms: fever (>38°C core); hypothermia (<36°C core); apnea*; bradycardia*; dysuria*; lethargy*; vomiting* And a positive urine culture of ≥105 CFU/ml with no more than 2 species of microorganisms. Elements of the criterion must occur within a timeframe that does not exceed a gap of 1 calendar day. *With no other recognized cause ** Patient had an indwelling urinary catheter in place for > 48 hours, with day of device placement being Day 1, and catheter was in place when all elements of this criterion were first present together.

4 Patient ≤1 year of age with** or without an indwelling urinary catheter has at least 1 of the following signs or symptoms: fever (>38°C core); hypothermia (<36°C core); apnea*; bradycardia*; dysuria*; lethargy*; vomiting* And at least 1 of the following findings: a. positive dipstick for leukocyte esterase and/or nitrite b. pyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or >5 WBC/high

power field of spun urine c. microorganisms seen on Gram’s stain of unspun urine And a positive urine culture of between ≥103 and <105 CFU/ml with no more than two species of microorganisms. *With no other recognized cause ** Patient had an indwelling urinary catheter in place for > 48 hours, with day of device placement being Day 1 and catheter was in place when all elements of this criterion were first present together

INFECTION SITE: Asymptomatic bacteriuria

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CODE: ASB DEFINITION: An asymptomatic bacteriuria must fulfill the criterion described below

Criterion Description

Patient with* or without an indwelling urinary catheter has no signs or symptoms (i.e., for any age patient, no fever (>38°C); urgency; frequency; dysuria; suprapubic tenderness; costovertebral angle pain or tenderness OR for a patient ≤1 year of age; no fever (>38°C core); hypothermia (<36°C core); apnea; bradycardia; dysuria; lethargy; or vomiting) And a positive urine culture of ≥105 CFU/ml with no more than 2 species of uropathogen microorganisms** (see Comments section below). And a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture, or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin commensal. *Patient had an indwelling urinary catheter in place for > 48 hours, with day of device placement being Day 1, and catheter was in place when all elements of this criterion were first present together. **Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus spp., yeasts, beta-hemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae, and Corynebacterium (urease positive)+. +Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C. urealyticum (CORUR) if so speciated.

INFECTION SITE: Surgical Site Infection (Superficial Incisional)

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CODE: SSI-(Skin)

DEFINITION: A superficial SSI must meet the following criterion:

Infection occurs within 30 days after any operative procedure 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. organsims isolated from an aseptically-obtained culture of fluid or tissue from the

superficial incision

c. superficial incision that is deliberately opened by a surgeon and is culture-positive or

not cultured

and

patient has at least one of the following signs or symptoms of infection: pain or

tenderness; localized swelling; redness; or heat. A culture negative finding does not

meet this criterion

d. diagnosis of superficial incisional SSI by the surgeon or attending physician

INFECTION SITE: Surgical site infection (Deep incisional)

CODE: SSI-(Soft Tissue)

DEFINITION: A deep incisional SSI must meet the following criterion:

Infection occurs within 30 days after the NHSN operative procedure according to the list in

Table 1

Or

Infection occurs within 90 days after the NHSN operative procedure according to the list in

Table 2

And

Involve 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

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b. a deep incision that spontaneously dehisces or is deliberately opened by a surgeon 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 is found on direct examination, during invasive procedure, or by histopathologic examination or imaging test. d. diagnosis of a deep incisional SSI by a surgeon or attending physician. Table 1. 30 day Surveillance Period for Deep Incisional or Organ/Space SSI Following Selected NHSN Operative Procedure Categories

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30-day Surveillance

Code Operative Procedure Code Operative Procedure

AAA Abdominal aortic aneurysm repair

LAM Laminectomy

AMP Limb amputation LTP Liver transplant

APPY Appendix surgery NECK Neck surgery

AVSD Shunt for dialysis NEPH Kidney surgery

BILI Bile duct, liver or pancreatic surgery

OVRY Ovarian surgery

CEA Carotid endarterectomy

PRST Prostate surgery

CHOL Gallbladder surgery REC Rectal surgery

COLO Colon surgery SB Small bowel surgery

CSEC Cesarean section SPLE Spleen surgery

GAST Gastric surgery THOR Thoracic surgery

HTP Heart transplant THYR Thyroid and/or parathyroid surgery

HYST Abdominal hysterectomy

VHYS Vaginal hysterectomy

KTP Kidney transplant XLAP Exploratory laparotomy

OTH Other operative procedures not included in the NHSN categories

Table 2. 90 day Surveillance Period for Deep Incisional or Organ/Space SSI Following Selected NHSN Operative Procedure Categories

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90-day Surveillance

Code Operative Procedure

BRST Breast surgery

CARD Cardiac surgery

CBGB Coronary artery bypass graft with both chest and donor site incisions

CBGC Coronary artery bypass graft with chest incision only

CRAN Craniotomy

FUSN Spinal fusion

FX Open reduction of fracture

HER Herniorrhaphy

HPRO Hip prosthesis

KPRO Knee prosthesis

PACE Pacemaker surgery

PVBY Peripheral vascular bypass surgery

RFUSN Refusion of spine

VSHN Ventricular shunt

INFECTION SITE: Surgical site infection (organ/space) CODE: SSI-(Specify site of organ/space)

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DEFINITION: An organ/space SSI involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure. An organ/space SSI must meet the following criterion: Infection occurs within 30 days after the NHSN operative procedure according to the list in Table 1 Or Infection occurs within 90 days after the NHSN operative procedure according to the list in Table 2 And Infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure And Patient has at least 1 of the following: a. purulent drainage from a drain that is placed into the organ/space 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 found on direct

examination, during invasive procedure, or by histopathologic examination or imaging test d. diagnosis of an organ/space SSI by a surgeon or attending physician. And meets at least one criterion for a specific organ/space infection site listed in Table 3. Table 3. Specific Site of Organ/Space SSI

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Code Site Code Site

BONE Osteomyelitis JNT Joint or bursa

BRST Breast abscess or mastitis LUNG Other infections of the respiratory tract

CARD Myocarditis or pericarditis MED Mediastinitis

DISC Disc space MEN Meningitis or ventriculitis

EAR Ear, mastoid ORAL Oral cavity (mouth, tongue, or gums)

EMET Endometritis OREP Other infections of the male or female reproductive tract

ENDO Endocarditis OUTI Other infections of the urinary tract

EYE Eye, other than conjunctivitis

SA Spinal abscess without meningitis

GIT GI tract SINU Sinusitis

HEP Hepatitis UR Upper respiratory tract

IAB Intraabdominal, not specified elsewhere

VASC Arterial or venous infection

IC Intracranial, brain abscess or dura

VCUF Vaginal cuff

Wound class An assessment of the degree of contamination of a surgical wound at the time of the operation. Wound class should be assigned by a person involved in the surgical procedure, e.g., surgeon, circulating nurse, etc. The wound class system used in NHSN is an adaptation of the American College of Surgeons wound classification schema. Wounds are divided into four classes: 1. Clean An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. NOTE:

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The following NHSN operative procedure categories are NEVER considered to have a clean wound classification: APPY, BILI, CHOL, COLO, REC, SB, and VHYS. 2. Clean Contaminated An operative wounds in which the respiratory, alimentary, genital or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. Includes female and male reproductive tracts. 3. Contaminated Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category. 4. Dirty or Infected Includes old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation INFECTION SITE: Pneumonia CODE: PNEU DEFINITION:

1. Clinically-defined pneumonia which must fulfill the following criteria:

Radiology Signs/Symptoms/Laboratory

Two or more serial chest radiographs with at least one of the following: • New or progressive and persistent infiltrate • Consolidation • Cavitation

FOR ANY PATIENT, at least one of the following: • Fever (>38°C) • Leukopenia (<4000 WBC/mm3) or leukocytosis (≥12,000 WBC/mm3) • For adults ≥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 requirements • New onset or worsening cough, or dyspnea, or tachypnea

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• Pneumatoceles, in infants ≤1 year old NOTE: In patients without underlying pulmonary or cardiac disease (e.g., respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), one definitive chest radiograph is acceptable.1

• Rales or bronchial breath sounds • Worsening gas exchange (e.g., O2 desaturations (e.g., PaO2/FiO2 ≤240)7, increased oxygen requirements, or increased ventilator demand)

ALTERNATE CRITERIA, for infants <1 year old: Worsening gas exchange (e.g., O2 desaturations [e.g., pulse oximetry <94%], increased oxygen requirements, or increased ventilator demand) and at least three of the following: • Temperature instability • Leukopenia (<4000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3) and left shift (≥10% band forms) • New onset of purulent sputum or change in character of sputum4, or increased respiratory secretions or increased suctioning requirements • Apnea, tachypnea , nasal flaring with retraction of chest wall or grunting • Wheezing, rales, or rhonchi • Cough • Bradycardia (<100 beats/min) or tachycardia (>170 beats/min)

ALTERNATE CRITERIA, for child >1 year old or ≤12 years old, at least three of the following: • Fever (>38.4°C) or hypothermia (<36.5°C) • Leukopenia (<4000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3) • New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements • New onset or worsening cough, or dyspnea, apnea, or tachypnea. • Rales or bronchial breath sounds • Worsening gas exchange (e.g., O2 desaturations [e.g., pulse oximetry <94%], increased oxygen requirements, or increased ventilator demand)

29

Radiology

Signs/Symptoms

Laboratory

Two or more serial chest radiographs with at least one of the following1,2: New or progressive and

persistent infiltrate Consolidation Cavitation Pneumatoceles, in infants

≤1 year old NOTE: In patients without underlying pulmonary or cardiac disease (e.g., respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), one definitive chest radiograph is acceptable.1

At least one of the following:

Fever (>38°C or >100.4°F)

Leukopenia (<4000 WBC/mm3) or leukocytosis (≥12,000 WBC/mm3)

For adults ≥70 years old, altered mental status with no other recognized cause

and at least one of the following:

New onset of purulent sputum3, or change in character of sputum4, or increased respiratory secretions, or increased suctioning requirements

New onset or worsening cough, or dyspnea or tachypnea5

Rales6 or bronchial breath sounds

Worsening gas exchange (e.g., O2 desaturations [e.g., PaO2/FiO2 ≤240]7, increased oxygen requirements, or increased ventilator demand)

At least one of the following: • Positive growth in blood

culture8 not related to another source of infection

• Positive growth in culture

of pleural fluid • Positive quantitative

culture9 from minimally contaminated LRT specimen (e.g., BAL or protected specimen brushing)

• ≥5% BAL-obtained cells

contain intracellular bacteria on direct microscopic exam (e.g., Gram’s stain)

• Histopathologic exam

shows at least one of the following evidences of pneumonia:

Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli

Positive quantitative culture9 of lung parenchyma

Evidence of lung parenchyma invasion by fungal hyphae or pseudohyphae

2. Specific Site Algorithms for Pneumonia with Common Bacterial or Filamentous Fungal Pathogens and Specific Laboratory Findings (PNU2)

30

Table 4. Threshold Values for Cultured Specimens Used in the Pneumonia Criteria

Specimen collection/technique Values

Lung parenchyma* ≥104 CFU/g tissue

Bronchoscopically (B) obtained specimens

Bronchoalveolar lavage (B-BAL) ≥104 CFU/ml

Protected BAL (B-PBAL) ≥104 CFU/ml

Protected specimen brushing (B-PSB) ≥103 CFU/ml

Nonbronchoscopically (NB) obtained (blind) specimens

NB-BAL >104 CFU/ml

NB-PSB ≥103 CFU/ml

CFU = colony forming units g = gram ml = milliliter * Open-lung biopsy specimens and immediate post-mortem specimens obtained by transthoracic or transbronchial biopsy INFECTION SITE: Ventilator-associated PNEU (VAP) CODE: VAP DEFINITION: A pneumonia where the patient is on mechanical ventilation for >48 hours on the date of event, with 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 a facility on a ventilator, the day of admission is considered Day1. and Fulfill either Criteria in Table 1 or 2

31

Ventilator: A device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal intubation. NOTE: Lung expansion devices such as intermittent positive-pressure breathing (IPPB); nasal positive

end-expiratory pressure (PEEP); and continuous nasal positive airway pressure (CPAP,

hypoCPAP) are not considered ventilators unless delivered via tracheostomy or endotracheal

intubation (e.g., ET-CPAP).

32

INFECTION SITE: Laboratory-confirmed bloodstream infection (LCBI) CODE: BSI DEFINITION: Laboratory-confirmed bloodstream infection must meet at least one of the following criteria:

Criterion Description

LCBI 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.

LCBI 2 Patient has at least one of the following signs or symptoms: fever (>38°C), chills*, or hypotension* And positive laboratory results are not related to an infection at another site And common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., and Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. Criterion elements must occur within a timeframe that does not exceed a gap of 1 calendar day *With no other recognized cause

LCBI 3 Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever (>38oC core) hypothermia (<36°C core), apnea*, or bradycardia* And positive laboratory results are not related to an infection at another site And common skin commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. Criterion elements must occur within a timeframe that does not exceed a gap of 1 calendar day *With no other recognized cause

33

INFECTION SITE: Catheter Associated Blood Stream Infection (CABSI) CODE: CABSI DEFINITION: A laboratory-confirmed bloodstream infection where a catheter either central or peripheral

was in place for >48 hours on the date of event, with day of device placement being Day 1.

and

a central or peripheral catheter was in place on the date of event or the day before. If a

catheter was in place for >48 hours and then removed, the LCBI criteria must be fully met on

the day of discontinuation or the next day. If the patient is admitted or transferred into a

facility with a central line in place (e.g., tunneled or implanted central line), day of first access is

considered Day 1.

EXAMPLES:

• Patient in ICU has central line inserted/accessed on June 1. On June 3, the central line is still in

place and the patient has positive blood culture with S. aureus. This is a CLABSI because the

central line was in place for >2 calendar days when all elements of LCBI Criterion 1 were first

present together (date of event).

• Patient has a central line inserted on June 1. On June 3, the central line is removed and on

June 4 the patient has a positive blood culture with S. aureus. This is a CLABSI because the

central line was in place for >2 calendar days (June 1, 2, and 3) and was in place the day before

all elements of LCBI Criterion 1 were first present together (date of event).

• On June 3, central line is removed and on June 4 patient spikes a fever of 38.3°C. Two blood

culture sets collected on June 5 are positive for S. epidermidis. This is may be a healthcare-

associated bloodstream infection but it is not a CLABSI because the central line was not place

the day of or the day before all elements of LCBI Criterion 2 were first present together (June

5).

LABORATORY DIAGNOSIS

1. For suspected CRBSI, paired blood samples, drawn from the catheter and a peripheral

vein, should be cultured before initiation of antimicrobial therapy, and the bottles

34

should be appropriately marked to reflect the site from which the samples were

obtained

2. If a blood sample cannot be drawn from a peripheral vein, it is recommended that 2

blood samples should be drawn through different catheter lumens. It is unclear whether

blood cultures should be drawn through all catheter lumens in such circumstances.

3. A definitive diagnosis of CRBSI requires that the same organism grow from at least 1

percutaneous blood culture and from a culture of the catheter tip, or that 2 blood

samples be drawn (one from a catheter hub and the other from a peripheral vein) that,

when cultured, meet CRBSI criteria for quantitative blood cultures or differential time to

positivity (DTP).

4. Alternatively 2 quantitative blood cultures of samples obtained through 2 catheter

lumens in which the colony count for the blood sample drawn through one lumen is at

least 3-fold greater than the colony count for the blood sample obtained from the

second lumen should be considered to indicate possible CRBSI

5. For DTP, growth of microbes from a blood sample drawn from a catheter hub at least 2

h before microbial growth is detected in a blood sample obtained from a peripheral vein

best defines CRBSI

6. For quantitative blood cultures, a colony count of microbes grown from blood obtained

through the catheter hub that is at least 3-fold greater than the colony count from

blood obtained from a peripheral vein best defines CRBSI.

7. Catheter cultures should be performed when a catheter is removed for suspected

catheter-related bloodstream infection (CRBSI. For central venous catheters (CVCs), the

catheter tip should be cultured.

8. Growth of >15 colony-forming units (cfu) from a 5-cm segment of the catheter tip by

semiquantitative (roll plate) culture or >102 cfu from a catheter by quantitative

(sonication) broth culture reflects catheter colonization

35

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. The following are considered great vessels for the purpose of reporting CLABSI or CABSI • 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.

NOTES:

1. Neither the insertion site nor the type of device may be used to determine if a line

qualifies as a central line. The device must terminate in one of the great vessels or in or

near the heart and be used for one of the purposes outlined above, to qualify as a

central line.

2. An introducer is considered an intravascular catheter, and depending on the location of

its tip and use, may be a central line.

3. Pacemaker wires and other nonlumened devices inserted into central blood vessels or

the heart are not considered central lines, because fluids are not infused, pushed, nor

withdrawn through such devices.

4. The following devices ARE NOT considered central lines:

• Extracorporeal membrane oxygenation (ECMO)

36

• Femoral arterial catheters

• Intraaortic balloon pump (IABP) devices.

Infusion: The introduction of a solution through a blood vessel via a catheter lumen. This may include continuous infusions such as nutritional fluids or medications, or it may include intermittent infusions such as flushes, IV antimicrobial administration, or blood transfusion or hemodialysis. Umbilical catheter: A central vascular device inserted through the umbilical artery or vein in a neonate. Temporary central line: A non-tunneled or implanted catheter. Permanent central line: Includes

• Tunneled catheters, including certain dialysis catheters

• Implanted catheters (including ports)

INFECTION SITE: Clinical Sepsis CODE: CS DEFINITION: Infection involving multiple organs or systems, without an apparent single site of infection in

adults and children in which the patient has at least one of the following criteria:

− clinical signs or symptoms with no other recognised cause;

− fever (38 °C);

− hypotension (systolic pressure < 90 mm);

− or oliguria (20 cm3(ml)/hr);

And − blood culture not done or no organisms or antigen detected in blood; And − no apparent infection at another site; And

37

− Physician institutes treatment for sepsis. Clinical sepsis in neonates All of the three following criteria:

• supervising physician started appropriate antimicrobial therapy for sepsis for at least five

days;

• no detection of pathogens in blood culture or not tested;

• no obvious infection at another site;

And two of the following criteria (without other apparent cause):

− fever (> 38 °C) or temperature instability (frequent post-set of the incubator) or hypothermia

(< 36.5°C);

− tachycardia (> 200/min) or new /increased bradycardia (< 80/min);

− capillary refilling time (CRT) > 2s;

− new or increased apnoea(s) (> 20s);

− unexplained metabolic acidosis;

− new-onset hyperglycemia (> 140mg/dl);

− another sign of sepsis (skin colour (only if the CRT is not used), laboratory signs (CRP,

interleukin) and increased oxygen requirement (intubation), unstable general condition of the

patient, apathy)

38

Healthcare Associated Infection Surveillance Form

(HCAI-PPS/MOH/2013/1)

A. CASE IDENTIFICATION DATA

Name : _______________________________

I/C or Passport No: ______________________

RN :___________________________________

Gender : Male/ Female

Age: _____

Hospital :______________________________

Department : ___________________________

Ward:_________________________________

Date of Admission:_______________________

B. CLINICAL DATA

i. Clinical Diagnosis

____________________________________________________________________

ii. General predisposing risk factors [√ where appropriate]

a. Underlying disease (eg; Diabetes/ Malignancy/ Kidney Disease) Specify

b. Immunosuppressive therapy

c. Prolonged hospitalization > 2 weeks

d. Prematurity / Low Birth Weight

e. Surgery within 1 month / 1 year (with implant)

f. Others Specify

APPENDIX 2

39

iii. Type of devices used before the onset of HCAI [ √ where appropriate ]

Device Date of insertion

a. Indwelling urinary catheter _________________

b. Mechanical ventilator _________________

c. Tracheostomy _________________

d. Central venous catheter _________________

e. Arterial line _________________

f. Peripheral venous line _________________

g. Other drainage catheters _________________

Specify……………………………………………………

iv. Antibiotic therapy given in the past 2 weeks [ √ where appropriate ]

No. Name and Group of

Antibiotic

Indication

Date commenced

Route of admission

Duration (days)

Meet local

policy

(Y/N/NK)*

Emp

iric

al

Ther

apeu

tic

Pro

ph

ylax

is

* Y-YES, N-NO, NK-Not known

C. MICROBIOLOGICAL DATA (Please attach the relevant positive C&S report)

Date of collection

Date of lab report

Type of specimen

Organism isolated

Antibiotic susceptibility report

40

D. OUTCOME DATA [ √ where appropriate ]

Type of infection

Method of detection

Clinical Laboratory

1. Surgical site infection (SSI)

Type of SSI

a. Superficial incisional

b. Deep incisional

c. Organ or space

Type of SSI wound

a. Clean wound

b. Clean contaminated wound

c. Contaminated wound

d. Dirty wound

2. Urinary tract infection

3. Pneumonia

a. Hospital acquired pneumonia (other than VAP)

b. Ventilator associated pneumonia (VAP)

4. Blood stream infection

a. Blood stream infection (other than CABSI)

b. Catheter associated blood stream infection (CABSI)

5. Clinical sepsis

6. Others Specify ………………………………………………………

Reported by: Signature: ________________________ Name and Designation:_____________________ Date: ____________________________

41

APPENDIX 3

42

43

44

APPENDIX 4

45

Device No. of Patient Percentage

a. Indwelling urinary catheter #DIV/0!

b. Mechanical ventilator #DIV/0!

c. Tracheostomy #DIV/0!

d. Central venous catheter #DIV/0!

e. Arterial line #DIV/0!

f. Peripheral venous line #DIV/0!

g. Other drainage catheters #DIV/0!

Antibiotic Therapy No. of Patient Percentage

a. Aminoglycosides #DIV/0!

b. Carbapenems #DIV/0!

c. Cephalosporins #DIV/0!

d. Penicillins #DIV/0!

e. Vancomycin #DIV/0!

f. B-lactam/B-lactamase inhibitor #DIV/0!

g. Fluoroquinolones #DIV/0!

a. Empirical #DIV/0!

b. Therapeutic #DIV/0!

c. Prophylaxis #DIV/0!

a. Less than 3 days #DIV/0!

b. 3 to 7 days #DIV/0!

c. More than 3 days #DIV/0!

4. Meet Local policy #DIV/0!

a. Yes #DIV/0!

b. No #DIV/0!

c. Not known #DIV/0!

3. Duration of Antibiotic

2. Indication of Antibiotic

1. Group of Antibiotic

46

Organism isolated No. of Patient Percentage

MRSA #DIV/0!

Staph. aureus #DIV/0!

P.Aeruginosa - MRO #DIV/0!

P.Aeruginosa - Non MRO #DIV/0!

K.Pneumo - ESBL #DIV/0!

K.Pneumo - Non ESBL #DIV/0!

E.coli - ESBL #DIV/0!

E.coli - Non ESBL #DIV/0!

CON Staph #DIV/0!

Acineto spp- MRO #DIV/0!

Acineto spp- Non MRO #DIV/0!

Enterobac gp #DIV/0!

CRE #DIV/0!

Others #DIV/0!

HCAI Rate for the Hospital =

= #VALUE!

Reported by: Verified by:

Date:___________________________________ Date:______________________________________

No. of patient in the Hospital on the Day of Survey

Signature: ______________________________ Signature: _________________________________

Name and Designation:___________________ Name and Designation: ______________________

______________No. of Patient with HCAI ___________ x 100

47

APPENDIX 5

48

References

1. Mermel LA et al. Clinical Practice Guidelines for the Diagnosis and Management of

Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases

Society of America: Clinical Infectious Diseases 2009; 49:1–45

2. Van der Kooi TII et al. Prevalence of nosocomial infections in The Netherlands, 2007-

2008: results of the first four national studies. Journal of Hospital Infection 75 (2010)

168-172

3. Gravel D et al. Point prevalence survey for healthcare-associated infections within

Canadian adult acute-care hospitals. Journal of Hospital Infection 67 (2007) 243-248

4. European Centre for Disease Prevention and Control. Point prevalence survey of

healthcareassociated infections and antimicrobial use in European acute care

hospitals – protocol version 4.3. Stockholm: ECDC; 2012

5. CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for

Specific Types of Infections in the Acute Care Setting, January 2013

6. July 2013 CDC/NHSN Protocol Clarifications

7. Fourth National Point Prevalence Survey on Healthcare Associated Infections and

First National Point Prevalence Survey on Antimicrobial Use and Quality Indicators in

England July 2011