CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting

 
 
CDC/NHSN surveillance definition
  of health care–associated infection
  and criteria for specific types of
  infections in the acute care setting
  Teresa C. Horan, MPH, Mary Andrus, RN, BA, CIC, and Margaret A. Dudeck, MPH
      Atlanta, Georgia




BACKGROUND                                                             population for which clinical sepsis is used has been re­
                                                                       stricted to patients #1 year old. Another example is that
   Since 1988, the Centers for Disease Control and                     incisional SSI descriptions have been expanded to spec­
Prevention (CDC) has published 2 articles in which nos­                ify whether an SSI affects the primary or a secondary in­
ocomial infection and criteria for specific types of nos­               cision following operative procedures in which more
ocomial infection for surveillance purposes for use in                 than 1 incision is made. For additional information about
acute care settings have been defined.1,2 This document                 how these criteria are used for NHSN surveillance, refer
replaces those articles, which are now considered obso­                to the NHSN Manual: Patient Safety Component Protocol
lete, and uses the generic term ‘‘health care–associated               available at the NHSN Web site (www.cdc.gov/ncidod/
infection’’ or ‘‘HAI’’ instead of ‘‘nosocomial.’’ This doc­            dhqp/nhsn.html). Whenever revisions occur, they will
ument reflects the elimination of criterion 1 of clinical               be published and made available at the NHSN Web site.
sepsis (effective in National Healthcare Safety Network
[NHSN] facilities since January 2005) and criteria for lab­
oratory–confirmed bloodstream infection (LCBI). Spe­                    CDC/NHSN SURVEILLANCE DEFINITION OF
cifically for LCBI, criterion 2c and 3c, and 2b and 3b,                 HEALTH CARE–ASSOCIATED INFECTION
were removed effective in NHSN facilities since January
                                                                          For the purposes of NHSN surveillance in the acute
2005 and January 2008, respectively. The definition of
                                                                       care setting, the CDC defines an HAI as a localized or
‘‘implant,’’ which is part of the surgical site infection
                                                                       systemic condition resulting from an adverse reaction
(SSI) criteria, has been slightly modified. No other infec­
                                                                       to the presence of an infectious agent(s) or its toxin(s).
tion criteria have been added, removed, or changed.
                                                                       There must be no evidence that the infection was pre­
There are also notes throughout this document that
                                                                       sent or incubating at the time of admission to the acute
reflect changes in the use of surveillance criteria since
                                                                       care setting.
the implementation of NHSN. For example, the
                                                                          HAIs may be caused by infectious agents from
                                                                       endogenous or exogenous sources.
 From the National Healthcare Safety Network, Division of Healthcare     d   Endogenous sources are body sites, such as the skin,
 Quality Promotion, Centers for Disease Control and Prevention,              nose, mouth, gastrointestinal (GI) tract, or vagina
 Atlanta, GA.
                                                                             that are normally inhabited by microorganisms.
 Address correspondence to Teresa C. Horan, MPH, Division of Health-     d   Exogenous sources are those external to the pa­
 care Quality Promotion, Centers for Disease Control and Prevention,
 Mailstop A24, 1600 Clifton Road, NE, Atlanta, GA 30333. E-mail:
                                                                             tient, such as patient care personnel, visitors, pa­
 thoran@cdc.gov.                                                             tient care equipment, medical devices, or the
 Am J Infect Control 2008;36:309-32.                                         health care environment.
 0196-6553/$34.00                                                         Other important        considerations    include   the
 Copyright ª 2008 by the Association for Professionals in Infection    following:
 Control and Epidemiology, Inc.
                                                                         d   Clinical evidence may be derived from direct ob­
 doi:10.1016/j.ajic.2008.03.002
                                                                             servation of the infection site (eg, a wound) or

                                                                                                                             309
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      review of information in the patient chart or other      USE OF THESE CRITERIA FOR PUBLICLY
      clinical records.                                        REPORTED HAI DATA
  d   For certain types of infection, a physician or sur­
      geon diagnosis of infection derived from direct ob­         Not all infections or infection criteria may be appro­
      servation during a surgical operation, endoscopic        priate for use in public reporting of HAIs. Guidance on
      examination, or other diagnostic studies or from         what infections and infection criteria are recommen­
      clinical judgment is an acceptable criterion for an      ded is available from other sources (eg, HICPAC [http:
      HAI, unless there is compelling evidence to the          //www.cdc.gov/ncidod/dhqp/hicpac_pubs.html]; National
      contrary. For example, one of the criteria for SSI       Quality Forum [http://www.qualityforum.org/]; profes­
      is ‘‘surgeon or attending physician diagnosis.’’ Un­     sional organizations).
      less stated explicitly, physician diagnosis alone is
      not an acceptable criterion for any specific type         UTI-URINARY TRACT INFECTION
      of HAI.
  d   Infections occurring in infants that result from         SUTI-Symptomatic urinary tract infection
      passage through the birth canal are considered
                                                                  A symptomatic urinary tract infection must meet
      HAIs.
                                                               at least 1 of the following criteria:
  d   The following infections are not considered health
      care associated:                                           1. Patient has at least 1 of the following signs or
       s Infections associated with complications or ex­            symptoms with no other recognized cause: fever
          tensions of infections already present on ad­             (.388C), urgency, frequency, dysuria, or suprapu­
          mission, unless a change in pathogen or                   bic tenderness
          symptoms strongly suggests the acquisition of             and
          a new infection;                                          patient has a positive urine culture, that is, $105
       s infections in infants that have been acquired              microorganisms per cc of urine with no more
          transplacentally (eg, herpes simplex, toxoplas­           than 2 species of microorganisms.
          mosis, rubella, cytomegalovirus, or syphilis)          2. Patient has at least 2 of the following signs or symp­
          and become evident #48 hours after birth; and             toms with no other recognized cause: fever
       s reactivation of a latent infection (eg, herpes zos­        (.388C), urgency, frequency, dysuria, or suprapu­
          ter [shingles], herpes simplex, syphilis, or              bic tenderness
          tuberculosis).                                            and
  d   The following conditions are not infections:                  at least 1 of the following
       s Colonization, which means the presence of mi­                 a. positive dipstick for leukocyte esterase and/
          croorganisms on skin, on mucous membranes,                       or nitrate
          in open wounds, or in excretions or secretions               b. pyuria (urine specimen with $10 white
          but are not causing adverse clinical signs or                    blood cell [WBC]/mm3 or $3 WBC/high­
          symptoms; and                                                    power field of unspun urine)
       s inflammation that results from tissue response                 c. organisms seen on Gram’s stain of unspun
          to injury or stimulation by noninfectious                       urine
          agents, such as chemicals.                                   d. at least 2 urine cultures with repeated
                                                                           isolation of the same uropathogen (gram­
CRITERIA FOR SPECIFIC TYPES OF INFECTION                                   negative bacteria or Staphylococcus sapro­
                                                                           phyticus) with $102 colonies/mL in non-
   Once an infection is deemed to be health care associ­                   voided specimens
ated according to the definition shown above, the spe­                  e. #105 colonies/mL of a single uropathogen
cific type of infection should be determined based on                      (gram-negative bacteria or S saprophyticus)
the criteria detailed below. These have been grouped                      in a patient being treated with an effective
into 13 major type categories to facilitate data analysis.                antimicrobial agent for a urinary tract
For example, there are 3 specific types of urinary tract                   infection
infections (symptomatic urinary tract infection, asymp­                f. physician diagnosis of a urinary tract
tomatic bacteriuria, and other infections of the urinary                  infection
tract) that are grouped under the major type of Urinary                g. physician institutes appropriate therapy for
Tract Infection. The specific and major types of infec­                     a urinary tract infection.
tion used in NHSN and their abbreviated codes are listed         3. Patient #1 year of age has at least 1 of the fol­
in Table 1, and the criteria for each of the specific types          lowing signs or symptoms with no other recog­
of infection follow it.                                             nized cause: fever (.388C rectal), hypothermia
Horan, Andrus, and Dudeck                                                                                     June 2008        311


Table 1. CDC/NHSN major and specific types of health                  Table 1. Continued
care–associated infections                                           EENT             Eye, ear, nose, throat, or mouth infection
UTI           Urinary tract infection                                                 CONJ                  Conjunctivitis
              SUTI                   Symptomatic urinary                              EYE                   Eye, other
                                       tract infection                                                         than conjunctivitis
              ASB                    Asymptomatic bacteriuria                         EAR                   Ear, mastoid
              OUTI                   Other infections                                 ORAL                  Oral cavity
                                       of the urinary tract                                                    (mouth, tongue, or gums)
SSI           Surgical site infection                                                 SINU                  Sinusitis
              SIP                    Superficial incisional                            UR                    Upper respiratory
                                       primary SSI                                                             tract, pharyngitis,
              SIS                    Superficial incisional                                                     laryngitis, epiglottitis
                                       secondary SSI
              DIP                    Deep incisional                 GI               Gastrointestinal system infection
                                       primary SSI                                    GE                    Gastroenteritis
              DIS                    Deep incisional                                  GIT                   Gastrointestinal (GI) tract
                                       secondary SSI                                  HEP                   Hepatitis
              Organ/space            Organ/space SSI. Indicate                        IAB                   Intraabdominal, not specified
                                       specific type:                                                           elsewhere
                                                                                      NEC                   Necrotizing enterocolitis
                                     d   BONE             d   LUNG
                                     d   BRST             d   MED    LRI              Lower respiratory tract infection, other
                                     d   CARD             d   MEN                       than pneumonia
                                                                                      BRON                 Bronchitis, tracheobronchitis,
                                     d   DISC             d   ORAL
                                                                                                             tracheitis, without
                                     d   EAR              d   OREP                                           evidence of pneumonia
                                     d   EMET             d   OUTI                    LUNG                 Other infections
                                     d   ENDO             d   SA                                             of the lower
                                                                                                             respiratory tract
                                     d   EYE              d   SINU
                                     d   GIT              d   UR     REPR             Reproductive tract infection
                                     d   IAB              d   VASC                    EMET                 Endometritis
                                                                                      EPIS                 Episiotomy
                                     d   IC               d   VCUF
                                                                                      VCUF                 Vaginal cuff
                                     d   JNT                                          OREP                 Other infections
BSI           Bloodstream infection                                                                          of the male
              LCBI                Laboratory-confirmed                                                        or female reproductive
                                    bloodstream infection                                                    tract
              CSEP                Clinical sepsis
                                                                     SST              Skin and soft tissue infection
PNEU          Pneumonia                                                               SKIN                   Skin
              PNU1                   Clinically defined pneumonia                      ST                     Soft tissue
              PNU2                   Pneumonia with                                   DECU                   Decubitus ulcer
                                       specific laboratory findings                     BURN                   Burn
              PNU3                   Pneumonia in                                     BRST                   Breast abscess
                                       immunocompromised                                                       or mastitis
                                       patient                                        UMB                    Omphalitis
                                                                                      PUST                   Pustulosis
BJ            Bone and joint infection                                                CIRC                   Newborn circumcision
              BONE                  Osteomyelitis
              JNT                   Joint or bursa                   SYS              Systemic Infection
              DISC                  Disc space                                        DI                     Disseminated infection

CNS           Central nervous system
              IC                   Intracranial infection
                                                                             (,378C rectal), apnea, bradycardia, dysuria, leth­
              MEN                  Meningitis or ventriculitis               argy, or vomiting
              SA                   Spinal abscess                            and
                                      without meningitis                     patient has a positive urine culture, that is, $105
                                                                             microorganisms per cc of urine with no more
CVS           Cardiovascular system infection
              VASC                Arterial or venous infection
                                                                             than two species of microorganisms.
              ENDO                Endocarditis                            4. Patient #1 year of age has at least 1 of the follow­
              CARD                Myocarditis or pericarditis                ing signs or symptoms with no other recognized
              MED                 Mediastinitis                              cause: fever (.388C), hypothermia (,378C), ap­
                                                        Continued            nea, bradycardia, dysuria, lethargy, or vomiting
312    Vol. 36 No. 5                                                                  Horan, Andrus, and Dudeck


      and                                                        d   Urine cultures must be obtained using appropriate
      at least 1 of the following:                                   technique, such as clean catch collection or
         a. positive dipstick for leukocyte esterase and/            catheterization.
             or nitrate                                          d   In infants, a urine culture should be obtained by
         b. pyuria (urine specimen with $10 WBC/mm3                  bladder catheterization or suprapubic aspiration;
             or $3 WBC/high-power field of unspun                     a positive urine culture from a bag specimen is un­
             urine)                                                  reliable and should be confirmed by a specimen
         c. organisms seen on Gram’s stain of unspun                 aseptically obtained by catheterization or supra­
            urine                                                    pubic aspiration.
         d. at least 2 urine cultures with repeated
             isolation of the same uropathogen (gram­
             negative bacteria or S saprophyticus)             OUTI-Other infections of the urinary tract
             with $102 colonies/mL in nonvoided                (kidney, ureter, bladder, urethra, or tissue
             specimens                                         surrounding the retroperitoneal or perinephric
         e. #105 colonies/mL of a single uropathogen           space)
            (gram-negative bacteria or S saprophyticus)
                                                                  Other infections of the urinary tract must meet at
            in a patient being treated with an effective
                                                               least 1 of the following criteria:
            antimicrobial agent for a urinary tract
            infection                                            1. Patient has organisms isolated from culture of
         f. physician diagnosis of a urinary tract                  fluid (other than urine) or tissue from affected site.
            infection                                            2. Patient has an abscess or other evidence of infec­
         g. physician institutes appropriate therapy for            tion seen on direct examination, during a surgical
             a urinary tract infection.                             operation, or during a histopathologic
                                                                    examination.
                                                                 3. Patient has at least 2 of the following signs or
ASB-Asymptomatic bacteriuria                                        symptoms with no other recognized cause: fever
   An asymptomatic bacteriuria must meet at least 1 of              (.388C), localized pain, or localized tenderness at
the following criteria:                                             the involved site
                                                                    and
  1. Patient has had an indwelling urinary catheter                 at least 1 of the following:
     within 7 days before the culture                                  a. purulent drainage from affected site
     and                                                               b. organisms cultured from blood that are
     patient has a positive urine culture, that is, $105                  compatible with suspected site of infection
     microorganisms per cc of urine with no more                       c. radiographic evidence of infection (eg, ab­
     than 2 species of microorganisms                                     normal ultrasound, computerized tomogra­
     and                                                                  phy [CT] scan, magnetic resonance imaging
     patient has no fever (.388C), urgency, frequency,                    [MRI], or radiolabel scan [gallium, techne­
     dysuria, or suprapubic tenderness.                                   tium], etc)
  2. Patient has not had an indwelling urinary cathe­                  d. physician diagnosis of infection of the
     ter within 7 days before the first positive culture                   kidney, ureter, bladder, urethra, or tissues
     and                                                                  surrounding the retroperitoneal or peri­
     patient has had at least 2 positive urine cultures,                  nephric space
     that is, $105 microorganisms per cc of urine                      e. physician institutes appropriate therapy for
     with repeated isolation of the same micro­                           an infection of the kidney, ureter, bladder,
     organism and no more than 2 species of                               urethra, or tissues surrounding the retroper­
     microorganisms                                                       itoneal or perinephric space.
     and                                                         4. Patient #1 year of age has at least 1 of the follow­
     patient has no fever (.388C), urgency, frequency,              ing signs or symptoms with no other recognized
     dysuria, or suprapubic tenderness.                             cause: fever (.388C rectal), hypothermia (,378C
                                                                    rectal), apnea, bradycardia, lethargy, or vomiting
                                                                    and
Comments
                                                                    at least 1 of the following:
  d   A positive culture of a urinary catheter tip is not an           a. purulent drainage from affected site
      acceptable laboratory test to diagnose a urinary                 b. organisms cultured from blood that are
      tract infection.                                                    compatible with suspected site of infection
Horan, Andrus, and Dudeck                                                                                  June 2008        313


         c. radiographic evidence of infection (eg, ab­      Reporting instructions
            normal ultrasound, CT scan, MRI, or radiola­
                                                                  d   Do not report a stitch abscess (minimal inflamma­
            bel scan [gallium, technetium])
                                                                      tion and discharge confined to the points of suture
         d. physician diagnosis of infection of the kid­
                                                                      penetration) as an infection.
            ney, ureter, bladder, urethra, or tissues sur­
                                                                  d   Do not report a localized stab wound infection as
            rounding        the     retroperitoneal     or
                                                                      SSI, instead report as skin (SKIN), or soft tissue
            perinephric space
                                                                      (ST), infection, depending on its depth.
         e. physician institutes appropriate therapy for
                                                                  d   Report infection of the circumcision site in new­
            an infection of the kidney, ureter, bladder,
                                                                      borns as CIRC. Circumcision is not an NHSN oper­
            urethra, or tissues surrounding the retroper­
                                                                      ative procedure.
            itoneal or perinephric space.
                                                                  d   Report infected burn wound as BURN.
                                                                  d   If the incisional site infection involves or extends
Reporting instruction                                                 into the fascial and muscle layers, report as a
                                                                      deep incisional SSI.
  d   Report infections following circumcision in new­
                                                                  d   Classify infection that involves both superficial
      borns as CIRC.
                                                                      and deep incision sites as deep incisional SSI.

SSI-SURGICAL SITE INFECTION                                  DIP/DIS-Deep incisional surgical site infection
SIP/SIS-Superficial incisional surgical site
                                                                A deep incisional SSI (DIP or DIS) must meet the fol­
infection
                                                             lowing criterion:
A superficial incisional SSI (SIP or SIS) must meet the          Infection occurs within 30 days after the operative
following criterion:                                         procedure if no implant1 is left in place or within
Infection occurs within 30 days after the operative          1 year if implant is in place and the infection appears
procedure                                                    to be related to the operative procedure
and                                                          and
involves only skin and subcutaneous tissue of the            involves deep soft tissues (eg, fascial and muscle layers)
incision                                                     of the incision
and                                                          and
patient has at least 1 of the following:                     patient has at least 1 of the following:
   a. purulent drainage from the superficial incision            a. purulent drainage from the deep incision but not
   b. organisms isolated from an aseptically obtained              from the organ/space component of the surgical
      culture of fluid or tissue from the superficial                site
      incision                                                  b. a deep incision spontaneously dehisces or is de­
   c. at least 1 of the following signs or symptoms of             liberately opened by a surgeon and is culture-pos­
      infection: pain or tenderness, localized swelling,           itive or not cultured when the patient has at least
      redness, or heat, and superficial incision is delib­          1 of the following signs or symptoms: fever
      erately opened by surgeon and is culture positive            (.388C), or localized pain or tenderness. A cul­
      or not cultured. A culture-negative finding does              ture-negative finding does not meet this criterion.
      not meet this criterion.                                  c. an abscess or other evidence of infection involving
   d. diagnosis of superficial incisional SSI by the sur­           the deep incision is found on direct examination,
      geon or attending physician.                                 during reoperation, or by histopathologic or radi­
                                                                   ologic examination
There are 2 specific types of superficial incisional SSI:
                                                                d. diagnosis of a deep incisional SSI by a surgeon or
  d Superficial incisional primary (SIP): a superficial in­
                                                                   attending physician.
    cisional SSI that is identified in the primary inci­
    sion in a patient who has had an operation with          There are 2 specific types of deep incisional SSI:
    1 or more incisions (eg, C-section incision or chest          d   Deep incisional primary (DIP): a deep incisional SSI
    incision for coronary artery bypass graft with a do­              that is identified in a primary incision in a patient
    nor site [CBGB]).
  d Superficial incisional secondary (SIS): a superficial

    incisional SSI that is identified in the secondary in­     1
                                                               A nonhuman-derived object, material, or tissue (eg, prosthetic heart
    cision in a patient who has had an operation with         valve, nonhuman vascular graft, mechanical heart, or hip prosthesis)
    more than 1 incision (eg, donor site [leg] incision       that is permanently placed in a patient during an operative procedure
                                                              and is not routinely manipulated for diagnostic or therapeutic purposes.
    for CBGB).
314    Vol. 36 No. 5                                                                Horan, Andrus, and Dudeck


      who has had an operation with one or more inci­                 s CARD                         s MEN
      sions (eg, C-section incision or chest incision for             s DISC                         s ORAL
      CBGB); and                                                      s EAR                          s OREP
  d   Deep incisional secondary (DIS): a deep incisional              s EMET                         s OUTI
                                                                      s ENDO                         s SA
      SSI that is identified in the secondary incision in
                                                                      s EYE                          s SINU
      a patient who has had an operation with more                    s GIT                          s UR
      than 1 incision (eg, donor site [leg] incision for              s IAB                          s VASC
      CBGB).                                                          s IC                           s VCUF
                                                                      s JNT

Reporting instruction                                         d   Occasionally an organ/space infection drains
  d   Classify infection that involves both superficial            through the incision. Such infection generally
      and deep incision sites as deep incisional SSI.             does not involve reoperation and is considered a
                                                                  complication of the incision; therefore, classify it
Organ/space-Organ/space surgical site infection                   as a deep incisional SSI.

   An organ/space SSI involves any part of the body,        BSI-BLOODSTREAM INFECTION
excluding the skin incision, fascia, or muscle layers,      LCBI-Laboratory-confirmed bloodstream
that is opened or manipulated during the operative          infection
procedure. Specific sites are assigned to organ/space
SSI to identify further the location of the infection.        LCBI criteria 1 and 2 may be used for patients of any
Listed below in reporting instructions are the specific      age, including patients #1 year of age.
sites that must be used to differentiate organ/space          LCBI must meet at least 1 of the following criteria:
SSI. An example is appendectomy with subsequent               1. Patient has a recognized pathogen cultured from
subdiaphragmatic abscess, which would be reported                1 or more blood cultures
as an organ/space SSI at the intraabdominal specific              and
site (SSI-IAB).                                                  organism cultured from blood is not related to an
  An organ/space SSI must meet the following criterion:          infection at another site. (See Notes 1 and 2.)
                                                              2. Patient has at least 1 of the following signs or
   Infection occurs within 30 days after the operative           symptoms: fever (.388C), chills, or hypotension
procedure if no implant1 is left in place or within              and
1 year if implant is in place and the infection appears          signs and symptoms and positive laboratory re­
to be related to the operative procedure                         sults are not related to an infection at another site
and                                                              and
infection involves any part of the body, excluding the           common skin contaminant (ie, diphtheroids
skin incision, fascia, or muscle layers, that is opened          [Corynebacterium spp], Bacillus [not B anthracis]
or manipulated during the operative procedure                    spp, Propionibacterium spp, coagulase-negative
and                                                              staphylococci [including S epidermidis], viridans
patient has at least 1 of the following:                         group streptococci, Aerococcus spp, Micrococcus
   a. purulent drainage from a drain that is placed              spp) is cultured from 2 or more blood cultures
      through a stab wound into the organ/space                  drawn on separate occasions. (See Notes 3
   b. organisms isolated from an aseptically obtained            and 4.)
      culture of fluid or tissue in the organ/space            3. Patient #1 year of age has at least 1 of the follow­
   c. an abscess or other evidence of infection involv­          ing signs or symptoms: fever (.388C, rectal), hy­
      ing the organ/space that is found on direct exam­          pothermia (,378C, rectal), apnea, or bradycardia
      ination, during reoperation, or by histopathologic         and
      or radiologic examination                                  signs and symptoms and positive laboratory re­
   d. diagnosis of an organ/space SSI by a surgeon or            sults are not related to an infection at another site
      attending physician.                                       and
Reporting instructions                                           common skin contaminant (ie, diphtheroids [Cor­
                                                                 ynebacterium spp], Bacillus [not B
  d   Specific sites of organ/space SSI (see also criteria        anthracis] spp, Propionibacterium spp, coagulase-
      for these sites)                                           negative staphylococci [including S epidermidis],
          s BONE                        s LUNG                   viridans group streptococci, Aerococcus spp, Mi­
          s BRST                        s MED                    crococcus spp) is cultured from 2 or more blood
Horan, Andrus, and Dudeck                                                                                         June 2008      315


     cultures drawn on separate occasions. (See Notes         Table 2. Examples of ‘‘sameness’’ by organism speciation
     3 and 4.)
                                                              Culture                             Companion Culture            Report as.

                                                              S epidermidis                       Coagulase-negative           S epidermidis
Notes                                                                                                staphylococci
  1. In criterion 1, the phrase ‘‘1 or more blood cul­        Bacillus spp (not anthracis)        B cereus                     B cereus
                                                              S salivarius                        Strep viridans               S salivarius
     tures’’ means that at least 1 bottle from a blood
     draw is reported by the laboratory as having
     grown organisms (ie, is a positive blood culture).       Table 3. Examples of ‘‘sameness’’ by organism
  2. In criterion 1, the term ‘‘recognized pathogen’’         antibiogram
     does not include organisms considered common
     skin contaminants (see criteria 2 and 3 for a list of    Organism Name                 Isolate A       Isolate B        Interpret as.
     common skin contaminants). A few of the recog­           S epidermidis                 All drugs S     All drugs S         Same
     nized pathogens are S aureus, Enterococcus spp, E        S epidermidis                 OX R            OX S                Different
     coli, Pseudomonas spp, Klebsiella spp, Candida                                         CEFAZ R         CEFAZ S
     spp, and others.                                         Corynebacterium spp           PENG R          PENG S              Different
                                                                                            CIPRO S         CIPRO R
  3. In criteria 2 and 3, the phrase ‘‘2 or more blood cul­
                                                              Strep viridans                All drugs S     All drugs S         Same
     tures drawn on separate occasions’’ means (1) that                                                        except
     blood from at least 2 blood draws were collected                                                       ERYTH R
     within 2 days of each other (eg, blood draws on
                                                              S, sensitive; R, resistant.
     Monday and Tuesday or Monday and Wednesday
     would be acceptable for blood cultures drawn on
                                                                              and a companion culture is identified with
     separate occasions, but blood draws on Monday
                                                                              only a descriptive name (ie, to the genus
     and Thursday would be too far apart in time to
                                                                              level), then it is assumed that the organisms
     meet this criterion) and (2) that at least 1 bottle
                                                                              are the same. The speciated organism
     from each blood draw is reported by the labora­
                                                                              should be reported as the infecting patho­
     tory as having grown the same common skin con­
                                                                              gen (see examples in Table 2).
     taminant organism (ie, is a positive blood culture).
                                                                           b. If common skin contaminant organisms
     (See Note 4 for determining sameness of
                                                                              from the cultures are speciated but no anti­
     organisms.)
                                                                              biograms are done or they are done for only
        a. For example, an adult patient has blood
                                                                              1 of the isolates, it is assumed that the orga­
            drawn at 8 AM and again at 8:15 AM of the
                                                                              nisms are the same.
            same day. Blood from each blood draw is in­
                                                                           c. If the common skin contaminants from the
            oculated into 2 bottles and incubated (4 bot­
                                                                              cultures have antibiograms that are differ­
            tles total). If 1 bottle from each blood draw
                                                                              ent for 2 or more antimicrobial agents, it is
            set is positive for coagulase-negative staph­
                                                                              assumed that the organisms are not the
            ylococci, this part of the criterion is met.
                                                                              same (see examples in Table 3).
        b. For example, a neonate has blood drawn
                                                                           d. For the purpose of NHSN antibiogram re­
            for culture on Tuesday and again on Satur­
                                                                              porting, the category interpretation of inter­
            day, and both grow the same common
                                                                              mediate (I) should not be used to distinguish
            skin contaminant. Because the time be­
                                                                              whether 2 organisms are the same.
            tween these blood cultures exceeds the
            2-day period for blood draws stipulated           Specimen collection considerations
            in criteria 2 and 3, this part of the criteria
            is not met.                                          Ideally, blood specimens for culture should be ob­
        c. A blood culture may consist of a single bot­       tained from 2 to 4 blood draws from separate veni­
           tle for a pediatric blood draw because of vol­     puncture sites (eg, right and left antecubital veins),
           ume constraints. Therefore, to meet this           not through a vascular catheter. These blood draws
           part of the criterion, each bottle from 2 or       should be performed simultaneously or over a short
           more draws would have to be culture posi­          period of time (ie, within a few hours).3,4 If your facility
           tive for the same skin contaminant.                does not currently obtain specimens using this tech­
  4. There are several issues to consider when deter­         nique, you may still report BSIs using the criteria and
     mining sameness of organisms.                            notes above, but you should work with appropriate
        a. If the common skin contaminant is identi­          personnel to facilitate better specimen collection prac­
            fied to the species level from 1 culture,          tices for blood cultures.
316    Vol. 36 No. 5                                                                Horan, Andrus, and Dudeck


Reporting instructions                                                c. radiographic evidence of infection (eg, ab­
                                                                         normal findings on x-ray, CT scan, MRI, ra­
  d   Purulent phlebitis confirmed with a positive semi-
                                                                         diolabel scan [gallium, technetium, etc]).
      quantitative culture of a catheter tip, but with ei­
      ther negative or no blood culture is considered a
      CVS-VASC, not a BSI.                                   Reporting instruction
  d   Report organisms cultured from blood as BSI–LCBI
      when no other site of infection is evident.              d   Report mediastinitis following cardiac surgery
                                                                   that is accompanied by osteomyelitis as SSI-MED
                                                                   rather than SSI-BONE.
CSEP-CLINICAL SEPSIS
   CSEP may be used only to report primary BSI in ne­        JNT-Joint or bursa
onates and infants. It is not used to report BSI in adults
and children.                                                   Joint or bursa infections must meet at least 1 of the
   Clinical sepsis must meet the following criterion:        following criteria:
   Patient #1 year of age has at least 1 of the following      1. Patient has organisms cultured from joint fluid or
clinical signs or symptoms with no other recognized               synovial biopsy.
cause: fever (.388C rectal), hypothermia (,378C rec­           2. Patient has evidence of joint or bursa infection
tal), apnea, or bradycardia                                       seen during a surgical operation or histopatho­
and                                                               logic examination.
blood culture not done or no organisms detected in             3. Patient has at least 2 of the following signs or
blood                                                             symptoms with no other recognized cause: joint
and                                                               pain, swelling, tenderness, heat, evidence of effu­
no apparent infection at another site                             sion or limitation of motion
and                                                               and
physician institutes treatment for sepsis.                        at least 1 of the following:
                                                                     a. organisms and white blood cells seen on
Reporting instruction                                                   Gram’s stain of joint fluid
                                                                     b. positive antigen test on blood, urine, or joint
  d   Report culture-positive infections of the blood­
                                                                        fluid
      stream as BSI-LCBI.
                                                                     c. cellular profile and chemistries of joint fluid
                                                                        compatible with infection and not ex­
PNEU-PNEUMONIA                                                          plained by an underlying rheumatologic
                                                                        disorder
  See Appendix.                                                      d. radiographic evidence of infection (eg, ab­
                                                                        normal findings on x-ray, CT scan, MRI, ra­
BJ–BONE AND JOINT INFECTION                                             diolabel scan [gallium, technetium, etc]).
BONE-Osteomyelitis
                                                             DISC-Disc space infection
   Osteomyelitis must meet at least 1 of the following
criteria:                                                       Vertebral disc space infection must meet at least 1 of
                                                             the following criteria:
  1. Patient has organisms cultured from bone.
  2. Patient has evidence of osteomyelitis on direct           1. Patient has organisms cultured from vertebral
     examination of the bone during a surgical opera­             disc space tissue obtained during a surgical oper­
     tion or histopathologic examination.                         ation or needle aspiration.
  3. Patient has at least 2 of the following signs             2. Patient has evidence of vertebral disc space infec­
     or symptoms with no other recognized cause:                  tion seen during a surgical operation or histo­
     fever (.388C), localized swelling, tenderness,               pathologic examination.
     heat, or drainage at suspected site of bone               3. Patient has fever (.388C) with no other recog­
     infection                                                    nized cause or pain at the involved vertebral
     and                                                          disc space
     at least 1 of the following:                                 and
        a. organisms cultured from blood                          radiographic evidence of infection, (eg, abnormal
        b. positive blood antigen test (eg, H influenzae,          findings on x-ray, CT scan, MRI, radiolabel scan
           S pneumoniae)                                          [gallium, technetium, etc]).
Horan, Andrus, and Dudeck                                                                         June 2008     317


  4. Patient has fever (.388C) with no other recog­                     b. positive antigen test on blood or urine
     nized cause and pain at the involved vertebral                     c. radiographic evidence of infection, (eg, ab­
     disc space                                                            normal findings on ultrasound, CT scan,
     and                                                                   MRI, radionuclide brain scan, or arteriogram)
     positive antigen test on blood or urine (eg, H influ­               d. diagnostic single antibody titer (IgM) or 4­
     enzae, S pneumoniae, N meningitidis, or Group B                       fold increase in paired sera (IgG) for
     Streptococcus).                                                       pathogen
                                                                    and
                                                                    if diagnosis is made antemortem, physician insti­
CNS-CENTRAL NERVOUS SYSTEM INFECTION                                tutes appropriate antimicrobial therapy.
IC-Intracranial infection (brain abscess,                     Reporting instruction
subdural or epidural infection,
encephalitis)                                                   d   If meningitis and a brain abscess are present to­
                                                                    gether, report the infection as IC.
  Intracranial infection must meet at least 1 of the fol­
lowing criteria:
                                                              MEN-Meningitis or ventriculitis
  1. Patient has organisms cultured from brain tissue            Meningitis or ventriculitis must meet at least 1 of the
     or dura.                                                 following criteria:
  2. Patient has an abscess or evidence of intracranial
     infection seen during a surgical operation or his­         1. Patient has organisms cultured from cerebrospi­
     topathologic examination.                                     nal fluid (CSF).
  3. Patient has at least 2 of the following signs or           2. Patient has at least 1 of the following signs or
     symptoms with no other recognized cause: head­                symptoms with no other recognized cause: fever
     ache, dizziness, fever (.388C), localizing neuro­             (.388C), headache, stiff neck, meningeal signs,
     logic signs, changing level of consciousness, or              cranial nerve signs, or irritability
     confusion                                                     and
     and                                                           at least 1 of the following:
     at least 1 of the following:                                      a. increased white cells, elevated protein, and/
                                                                          or decreased glucose in CSF
         a. organisms seen on microscopic examina­                     b. organisms seen on Gram’s stain of CSF
            tion of brain or abscess tissue obtained by                c. organisms cultured from blood
            needle aspiration or by biopsy during a sur­               d. positive antigen test of CSF, blood, or urine
            gical operation or autopsy                                 e. diagnostic single antibody titer (IgM) or 4-fold
         b. positive antigen test on blood or urine                       increase in paired sera (IgG) for pathogen
         c. radiographic evidence of infection, (eg, ab­           and
            normal findings on ultrasound, CT scan,                 if diagnosis is made antemortem, physician insti­
            MRI, radionuclide brain scan, or arteriogram)          tutes appropriate antimicrobial therapy.
         d. diagnostic single antibody titer (IgM) or 4­        3. Patient #1 year of age has at least 1 of the
            fold increase in paired sera (IgG) for pathogen        following signs or symptoms with no other rec­
     and                                                           ognized cause: fever (.388C rectal), hypother­
     if diagnosis is made antemortem, physician insti­             mia (,378C rectal), apnea, bradycardia, stiff
     tutes appropriate antimicrobial therapy.                      neck, meningeal signs, cranial nerve signs, or
  4. Patient #1 year of age has at least 2 of the follow­          irritability
     ing signs or symptoms with no other recognized                and
     cause: fever (.388C rectal), hypothermia (,378C               at least 1 of the following:
     rectal), apnea, bradycardia, localizing neurologic                a. positive CSF examination with increased
     signs, or changing level of consciousness                            white cells, elevated protein, and/or de­
     and                                                                  creased glucose
     at least 1 of the following:                                      b. positive Gram’s stain of CSF
                                                                       c. organisms cultured from blood
        a. organisms seen on microscopic examina­                      d. positive antigen test of CSF, blood, or urine
           tion of brain or abscess tissue obtained by                 e. diagnostic single antibody titer (IgM) or 4­
           needle aspiration or by biopsy during a sur­                   fold increase in paired sera (IgG) for
           gical operation or autopsy                                     pathogen
318    Vol. 36 No. 5                                                                Horan, Andrus, and Dudeck


      and                                                          and
      if diagnosis is made antemortem, physician insti­            blood culture not done or no organisms cultured
      tutes appropriate antimicrobial therapy.                     from blood.
                                                              2.   Patient has evidence of arterial or venous infec­
Reporting instructions                                             tion seen during a surgical operation or histo­
                                                                   pathologic examination.
  d   Report meningitis in the newborn as health care-        3.   Patient has at least 1 of the following signs or
      associated unless there is compelling evidence               symptoms with no other recognized cause: fever
      indicating the meningitis was acquired                       (.388C), pain, erythema, or heat at involved vas­
      transplacentally.                                            cular site
  d   Report CSF shunt infection as SSI-MEN if it occurs           and
      #1 year of placement; if later or after manipula­            more than 15 colonies cultured from intravascu­
      tion/access of the shunt, report as CNS-MEN.                 lar cannula tip using semiquantitative culture
  d   Report meningoencephalitis as MEN.                           method
  d   Report spinal abscess with meningitis as MEN.                and
                                                                   blood culture not done or no organisms cultured
SA-Spinal abscess without meningitis                               from blood.
                                                              4.   Patient has purulent drainage at involved vascu­
   An abscess of the spinal epidural or subdural space,            lar site
without involvement of the cerebrospinal fluid or adja­             and
cent bone structures, must meet at least 1 of the follow­          blood culture not done or no organisms cultured
ing criteria:                                                      from blood.
  1. Patient has organisms cultured from abscess in           5.   Patient #1 year of age has at least 1 of the follow­
     the spinal epidural or subdural space.                        ing signs or symptoms with no other recognized
  2. Patient has an abscess in the spinal epidural or              cause: fever (.388C rectal), hypothermia (,378C
     subdural space seen during a surgical operation               rectal), apnea, bradycardia, lethargy, or pain, ery­
     or at autopsy or evidence of an abscess seen dur­             thema, or heat at involved vascular site
     ing a histopathologic examination.                            and
  3. Patient has at least 1 of the following signs or              more than 15 colonies cultured from intravascu­
     symptoms with no other recognized cause: fever                lar cannula tip using semiquantitative culture
     (.388C), back pain, focal tenderness, radiculitis,            method
     paraparesis, or paraplegia                                    and
     and                                                           blood culture not done or no organisms cultured
     at least 1 of the following:                                  from blood.
         a. organisms cultured from blood
         b. radiographic evidence of a spinal abscess       Reporting instructions
            (eg, abnormal findings on myelography, ul­
            trasound, CT scan, MRI, or other scans [gal­      d    Report infections of an arteriovenous graft, shunt,
            lium, technetium, etc]).                               or fistula or intravascular cannulation site without
     and                                                           organisms cultured from blood as CVS-VASC.
     if diagnosis is made antemortem, physician insti­        d    Report intravascular infections with organisms
     tutes appropriate antimicrobial therapy.                      cultured from the blood as BSI-LCBI.

Reporting instruction                                       ENDO-Endocarditis
  d   Report spinal abscess with meningitis as MEN.
                                                              Endocarditis of a natural or prosthetic heart valve
                                                            must meet at least 1 of the following criteria:
CVS-CARDIOVASCULAR SYSTEM INFECTION
                                                              1. Patient has organisms cultured from valve or
VASC-Arterial or venous infection                                vegetation.
                                                              2. Patient has 2 or more of the following signs or
   Arterial or venous infection must meet at least 1 of
                                                                 symptoms with no other recognized cause: fever
the following criteria:
                                                                 (.388C), new or changing murmur, embolic phe­
  1. Patient has organisms cultured from arteries or             nomena, skin manifestations (ie, petechiae, splin­
     veins removed during a surgical operation                   ter hemorrhages, painful subcutaneous nodules),
Horan, Andrus, and Dudeck                                                                      June 2008    319


     congestive heart failure, or cardiac conduction              and
     abnormality                                                  at least 1 of the following:
     and                                                             a. abnormal EKG consistent with myocarditis
     at least 1 of the following:                                       or pericarditis
         a. organisms cultured from 2 or more blood                  b. positive antigen test on blood (eg, H influen­
            cultures                                                    zae, S pneumoniae)
         b. organisms seen on Gram’s stain of valve                  c. evidence of myocarditis or pericarditis on
            when culture is negative or not done                        histologic examination of heart tissue
         c. valvular vegetation seen during a surgical               d. 4-fold rise in type-specific antibody with or
            operation or autopsy                                        without isolation of virus from pharynx or
         d. positive antigen test on blood or urine (eg, H              feces
            influenzae, S pneumoniae, N meningitidis, or              e. pericardial effusion identified by echocardi­
            Group B Streptococcus)                                      ogram, CT scan, MRI, or angiography.
         e. evidence of new vegetation seen on                 3. Patient #1 year of age has at least 2 of the follow­
            echocardiogram                                        ing signs or symptoms with no other recognized
     and                                                          cause: fever (.388C rectal), hypothermia (,378C
     if diagnosis is made antemortem, physician insti­            rectal), apnea, bradycardia, paradoxical pulse, or
     tutes appropriate antimicrobial therapy.                     increased heart size
  3. Patient #1 year of age has 2 or more of the follow­          and
     ing signs or symptoms with no other recognized               at least 1 of the following:
     cause: fever (.388C rectal), hypothermia (,378C                 a. abnormal EKG consistent with myocarditis
     rectal), apnea, bradycardia, new or changing mur­                  or pericarditis
     mur, embolic phenomena, skin manifestations                     b. positive antigen test on blood (eg, H influen­
     (ie, petechiae, splinter hemorrhages, painful sub­                 zae, S pneumoniae)
     cutaneous nodules), congestive heart failure, or                c. histologic examination of heart tissue shows
     cardiac conduction abnormality                                     evidence of myocarditis or pericarditis
     and                                                             d. 4-fold rise in type-specific antibody with or
     at least 1 of the following:                                       without isolation of virus from pharynx or
         a. organisms cultured from 2 or more blood                     feces
            cultures                                                 e. pericardial effusion identified by echocardi­
         b. organisms seen on Gram’s stain of valve                     ogram, CT scan, MRI, or angiography.
            when culture is negative or not done
         c. valvular vegetation seen during a surgical
            operation or autopsy                             Comment
         d. positive antigen test on blood or urine (eg, H     d   Most cases of postcardiac surgery or postmyocar­
            influenzae, S pneumoniae, N meningitidis, or            dial infarction pericarditis are not infectious.
            Group B Streptococcus)
         e. evidence of new vegetation seen on
            echocardiogram                                   MED-Mediastinitis
     and
                                                                Mediastinitis must meet at least 1 of the following
     if diagnosis is made antemortem, physician insti­
                                                             criteria:
     tutes appropriate antimicrobial therapy.
                                                               1. Patient has organisms cultured from mediastinal
                                                                  tissue or fluid obtained during a surgical opera­
CARD-Myocarditis or pericarditis                                  tion or needle aspiration.
                                                               2. Patient has evidence of mediastinitis seen during a
   Myocarditis or pericarditis must meet at least 1 of
                                                                  surgical operation or histopathologic examination.
the following criteria:
                                                               3. Patient has at least 1 of the following signs or
  1. Patient has organisms cultured from pericardial              symptoms with no other recognized cause: fever
     tissue or fluid obtained by needle aspiration or              (.388C), chest pain, or sternal instability
     during a surgical operation.                                 and
  2. Patient has at least 2 of the following signs or             at least 1 of the following:
     symptoms with no other recognized cause: fever                  a. purulent discharge from mediastinal area
     (.388C), chest pain, paradoxical pulse, or in­                  b. organisms cultured from blood or discharge
     creased heart size                                                 from mediastinal area
320    Vol. 36 No. 5                                                                Horan, Andrus, and Dudeck


        c. mediastinal widening on x-ray.                     EYE-Eye, other than conjunctivitis
  4. Patient #1 year of age has at least 1 of the follow­
     ing signs or symptoms with no other recognized             An infection of the eye, other than conjunctivitis,
     cause: fever (.388C rectal), hypothermia (,378C          must meet at least 1 of the following criteria:
     rectal), apnea, bradycardia, or sternal instability        1. Patient has organisms cultured from anterior or
     and                                                           posterior chamber or vitreous fluid.
     at least 1 of the following:                               2. Patient has at least 2 of the following signs or
        a. purulent discharge from mediastinal area                symptoms with no other recognized cause: eye
        b. organisms cultured from blood or discharge              pain, visual disturbance, or hypopyon
           from mediastinal area                                   and
        c. mediastinal widening on x-ray.                          at least 1 of the following:
                                                                      a. physician diagnosis of an eye infection
Reporting instruction                                                 b. positive antigen test on blood (eg, H influen­
                                                                         zae, S pneumoniae)
  d   Report mediastinitis following cardiac surgery
                                                                      c. organisms cultured from blood.
      that is accompanied by osteomyelitis as SSI-MED
      rather than SSI-BONE.
                                                              EAR-Ear mastoid
EENT-EYE, EAR, NOSE, THROAT, OR MOUTH                            Ear and mastoid infections must meet at least 1 of
INFECTION                                                     the following criteria:
CONJ-Conjunctivitis                                              Otitis externa must meet at least 1 of the following
                                                              criteria:
   Conjunctivitis must meet at least 1 of the following
criteria:                                                       1. Patient has pathogens cultured from purulent
                                                                   drainage from ear canal.
  1. Patient has pathogens cultured from purulent ex­           2. Patient has at least 1 of the following signs or
     udate obtained from the conjunctiva or contigu­               symptoms with no other recognized cause: fever
     ous tissues, such as eyelid, cornea, meibomian                (.388C), pain, redness, or drainage from ear
     glands, or lacrimal glands.                                   canal
  2. Patient has pain or redness of conjunctiva or                 and
     around eye                                                    organisms seen on Gram’s stain of purulent
     and                                                           drainage.
     at least 1 of the following:
        a. WBCs and organisms seen on Gram’s stain               Otitis media must meet at least 1 of the following
            of exudate                                        criteria:
        b. purulent exudate                                     1. Patient has organisms cultured from fluid from
        c. positive antigen test (eg, ELISA or IF for Chla­        middle ear obtained by tympanocentesis or at
           mydia trachomatis, herpes simplex virus,                surgical operation.
           adenovirus) on exudate or conjunctival               2. Patient has at least 2 of the following signs or
           scraping                                                symptoms with no other recognized cause: fever
        d. multinucleated giant cells seen on micro­               (.388C), pain in the eardrum, inflammation, re­
            scopic examination of conjunctival exudate             traction or decreased mobility of eardrum, or
            or scrapings                                           fluid behind eardrum.
        e. positive viral culture
        f. diagnostic single antibody titer (IgM) or 4-fold      Otitis interna must meet at least 1 of the following
           increase in paired sera (IgG) for pathogen.        criteria:
                                                                1. Patient has organisms cultured from fluid from
Reporting instructions
                                                                   inner ear obtained at surgical operation.
  d   Report other infections of the eye as EYE.                2. Patient has a physician diagnosis of inner ear
  d   Do not report chemical conjunctivitis caused by              infection.
      silver nitrate (AgNO3) as a health care–associated
                                                                 Mastoiditis must meet at least 1 of the following
      infection.
                                                              criteria:
  d   Do not report conjunctivitis that occurs as a part of
      a more widely disseminated viral illness (such as         1. Patient has organisms cultured from purulent
      measles, chickenpox, or a URI).                              drainage from mastoid.
Horan, Andrus, and Dudeck                                                                    June 2008    321


  2. Patient has at least 2 of the following signs or            and
     symptoms with no other recognized cause: fever              at least 1 of the following:
     (.388C), pain, tenderness, erythema, headache,                 a. positive transillumination
     or facial paralysis                                            b. positive radiographic examination (includ­
     and                                                               ing CT scan).
     at least 1 of the following:
        a. organisms seen on Gram’s stain of purulent
           material from mastoid                            UR-Upper respiratory tract, pharyngitis,
        b. positive antigen test on blood.                  laryngitis, epiglottitis
ORAL-Oral cavity (mouth, tongue, or gums)                      Upper respiratory tract infections must meet at least
                                                            1 of the following criteria:
  Oral cavity infections must meet at least 1 of the fol­
lowing criteria:                                              1. Patient has at least 2 of the following signs or
                                                                 symptoms with no other recognized cause: fever
  1. Patient has organisms cultured from purulent
                                                                 (.388C), erythema of pharynx, sore throat,
     material from tissues of oral cavity.
                                                                 cough, hoarseness, or purulent exudate in throat
  2. Patient has an abscess or other evidence of oral
                                                                 and
     cavity infection seen on direct examination, dur­
                                                                 at least 1 of the following:
     ing a surgical operation, or during a histopatho­
                                                                    a. organisms cultured from the specific site
     logic examination.
                                                                    b. organisms cultured from blood
  3. Patient has at least 1 of the following signs or
                                                                    c. positive antigen test on blood or respiratory
     symptoms with no other recognized cause: ab­
                                                                       secretions
     scess, ulceration, or raised white patches on in­
                                                                    d. diagnostic single antibody titer (IgM) or 4­
     flamed mucosa, or plaques on oral mucosa
                                                                       fold increase in paired sera (IgG) for
     and
                                                                       pathogen
     at least 1 of the following:
                                                                    e. physician diagnosis of an upper respiratory
        a. organisms seen on Gram’s stain
                                                                       infection.
        b. positive KOH (potassium hydroxide) stain
                                                              2. Patient has an abscess seen on direct examina­
        c. multinucleated giant cells seen on micro­
                                                                 tion, during a surgical operation, or during a his­
           scopic examination of mucosal scrapings
                                                                 topathologic examination.
        d. positive antigen test on oral secretions
                                                              3. Patient #1 year of age has at least 2 of the follow­
        e. diagnostic single antibody titer (IgM) or 4­
                                                                 ing signs or symptoms with no other recognized
           fold increase in paired sera (IgG) for
                                                                 cause: fever (.388C rectal), hypothermia (,378C
           pathogen
                                                                 rectal), apnea, bradycardia, nasal discharge, or
        f. physician diagnosis of infection and treat­
                                                                 purulent exudate in throat
           ment with topical or oral antifungal therapy.
                                                                 and
                                                                 at least 1 of the following:
Reporting instruction                                               a. organisms cultured from the specific site
  d   Report health care–associated primary herpes                  b. organisms cultured from blood
      simplex infections of the oral cavity as ORAL; re­            c. positive antigen test on blood or respiratory
      current herpes infections are not health care–                   secretions
      associated.                                                   d. diagnostic single antibody titer (IgM) or 4­
                                                                       fold increase in paired sera (IgG) for
                                                                       pathogen
SINU-Sinusitis                                                      e. physician diagnosis of an upper respiratory
   Sinusitis must meet at least 1 of the following                     infection.
criteria:
                                                            GI-GASTROINTESTINAL SYSTEM INFECTION
  1. Patient has organisms cultured from purulent
     material obtained from sinus cavity.                   GE-Gastroenteritis
  2. Patient has at least 1 of the following signs or
                                                               Gastroenteritis must meet at least 1 of the following
     symptoms with no other recognized cause: fever
                                                            criteria:
     (.388C), pain or tenderness over the involved si­
     nus, headache, purulent exudate, or nasal                1. Patient has an acute onset of diarrhea (liquid
     obstruction                                                 stools for more than 12 hours) with or without
322   Vol. 36 No. 5                                                                 Horan, Andrus, and Dudeck


     vomiting or fever (.388C) and no likely noninfec­       HEP-Hepatitis
     tious cause (eg, diagnostic tests, therapeutic regi­
     men other than antimicrobial agents, acute                 Hepatitis must meet the following criterion:
     exacerbation of a chronic condition, or psycho­            Patient has at least 2 of the following signs or
     logic stress).                                          symptoms with no other recognized cause: fever
  2. Patient has at least 2 of the following signs or        (.388C), anorexia, nausea, vomiting, abdominal pain,
     symptoms with no other recognized cause: nau­           jaundice, or history of transfusion within the previous
     sea, vomiting, abdominal pain, fever (.388C), or        3 months
     headache                                                and
     and                                                     at least 1 of the following:
     at least 1 of the following:                                  a. positive antigen or antibody test for hepatitis
        a. an enteric pathogen is cultured from stool                 A, hepatitis B, hepatitis C, or delta hepatitis
           or rectal swab                                          b. abnormal liver function tests (eg, elevated ALT/
        b. an enteric pathogen is detected by routine                 AST, bilirubin)
           or electron microscopy                                  c. cytomegalovirus (CMV) detected in urine or or­
        c. an enteric pathogen is detected by antigen                 opharyngeal secretions.
           or antibody assay on blood or feces
        d. evidence of an enteric pathogen is detected
                                                             Reporting instructions
           by cytopathic changes in tissue culture
           (toxin assay)                                       d   Do not report hepatitis or jaundice of noninfec­
        e. diagnostic single antibody titer (IgM) or 4­            tious origin (alpha-1 antitrypsin deficiency, etc).
           fold increase in paired sera (IgG) for              d   Do not report hepatitis or jaundice that results
           pathogen.                                               from exposure to hepatotoxins (alcoholic or acet­
                                                                   aminophen-induced hepatitis, etc).
GIT-Gastrointestinal tract (esophagus, stomach,                d   Do not report hepatitis or jaundice that results
small and large bowel, and rectum) excluding                       from biliary obstruction (cholecystitis).
gastroenteritis and appendicitis
   Gastrointestinal tract infections, excluding gastroen­    IAB-Intraabdominal, not specified elsewhere
teritis and appendicitis, must meet at least 1 of the fol­   including gallbladder, bile ducts, liver
lowing criteria:                                             (excluding viral hepatitis), spleen, pancreas,
  1. Patient has an abscess or other evidence of infec­      peritoneum, subphrenic or subdiaphragmatic
     tion seen during a surgical operation or histo­         space, or other intraabdominal tissue or area
     pathologic examination.                                 not specified elsewhere
  2. Patient has at least 2 of the following signs or
                                                                Intraabdominal infections must meet at least 1 of the
     symptoms with no other recognized cause and
                                                             following criteria:
     compatible with infection of the organ or tissue
     involved: fever (.388C), nausea, vomiting, ab­            1. Patient has organisms cultured from purulent
     dominal pain, or tenderness                                  material from intraabdominal space obtained
     and                                                          during a surgical operation or needle aspiration.
     at least 1 of the following:                              2. Patient has abscess or other evidence of intraab­
        a. organisms cultured from drainage or tissue             dominal infection seen during a surgical opera­
           obtained during a surgical operation or en­            tion or histopathologic examination.
           doscopy or from a surgically placed drain           3. Patient has at least 2 of the following signs or
        b. organisms seen on Gram’s or KOH stain or               symptoms with no other recognized cause: fever
           multinucleated giant cells seen on micro­              (.388C), nausea, vomiting, abdominal pain, or
           scopic examination of drainage or tissue ob­           jaundice
           tained during a surgical operation or                  and
           endoscopy or from a surgically placed drain            at least 1 of the following:
        c. organisms cultured from blood                             a. organisms cultured from drainage from sur­
        d. evidence of pathologic findings on radio­                     gically placed drain (eg, closed suction
           graphic examination                                          drainage system, open drain, T-tube drain)
        e. evidence of pathologic findings on endo­                   b. organisms seen on Gram’s stain of drainage
           scopic examination (eg, Candida esophagitis                  or tissue obtained during surgical operation
           or proctitis).                                               or needle aspiration
Horan, Andrus, and Dudeck                                                                     June 2008   323


         c. organisms cultured from blood and radio­             (.388C rectal), cough, new or increased sputum
            graphic evidence of infection (eg, abnormal          production, rhonchi, wheezing, respiratory dis­
            findings on ultrasound, CT scan, MRI, or ra­          tress, apnea, or bradycardia
            diolabel scans [gallium, technetium, etc] or         and
            on abdominal x-ray).                                 at least 1 of the following:
                                                                    a. organisms cultured from material obtained
Reporting instruction                                                  by deep tracheal aspirate or bronchoscopy
  d   Do not report pancreatitis (an inflammatory syn­               b. positive antigen test on respiratory
      drome characterized by abdominal pain, nausea,                   secretions
      and vomiting associated with high serum levels                c. diagnostic single antibody titer (IgM) or 4­
      of pancreatic enzymes) unless it is determined to                fold increase in paired sera (IgG) for
      be infectious in origin.                                         pathogen.

NEC-Necrotizing enterocolitis
                                                           Reporting instruction
   Necrotizing enterocolitis in infants must meet the
                                                             d   Do not report chronic bronchitis in a patient with
following criterion:
                                                                 chronic lung disease as an infection unless there is
   Infant has at least 2 of the following signs or symp­
                                                                 evidence of an acute secondary infection, mani­
toms with no other recognized cause: vomiting, ab­
                                                                 fested by change in organism.
dominal distention, or prefeeding residuals
and
persistent microscopic or gross blood in stools            LUNG-Other infections of the lower respiratory
and                                                        tract
at least 1 of the following abdominal radiographic
abnormalities:                                               Other infections of the lower respiratory tract must
   a. pneumoperitoneum                                     meet at least 1 of the following criteria:
   b. pneumatosis intestinalis                               1. Patient has organisms seen on smear or cul­
   c. unchanging ‘‘rigid’’ loops of small bowel.                tured from lung tissue or fluid, including pleural
                                                                fluid.
LRI-LOWER RESPIRATORY TRACT INFECTION,                       2. Patient has a lung abscess or empyema seen dur­
OTHER THAN PNEUMONIA                                            ing a surgical operation or histopathologic
BRON-Bronchitis, tracheobronchitis,                             examination.
bronchiolitis, tracheitis, without evidence of               3. Patient has an abscess cavity seen on radio­
pneumonia                                                       graphic examination of lung.

   Tracheobronchial infections must meet at least 1 of
the following criteria:                                    Reporting instructions
  1. Patient has no clinical or radiographic evidence of     d   Report concurrent lower respiratory tract infec­
     pneumonia                                                   tion and pneumonia with the same organism(s)
     and                                                         as PNEU.
     patient has at least 2 of the following signs or        d   Report lung abscess or empyema without pneu­
     symptoms with no other recognized cause: fever              monia as LUNG.
     (.388C), cough, new or increased sputum pro­
     duction, rhonchi, wheezing                            REPR-REPRODUCTIVE TRACT INFECTION
     and
     at least 1 of the following:                          EMET-Endometritis
        a. positive culture obtained by deep tracheal
                                                              Endometritis must meet at least 1 of the following
           aspirate or bronchoscopy
                                                           criteria:
        b. positive antigen test on respiratory
           secretions.                                       1. Patient has organisms cultured from fluid or tis­
  2. Patient #1 year of age has no clinical or radio­           sue from endometrium obtained during surgical
     graphic evidence of pneumonia                              operation, by needle aspiration, or by brush
     and                                                        biopsy.
     patient has at least 2 of the following signs or        2. Patient has at least 2 of the following signs or
     symptoms with no other recognized cause: fever             symptoms with no other recognized cause: fever
324    Vol. 36 No. 5                                                              Horan, Andrus, and Dudeck


      (.388C), abdominal pain, uterine tenderness, or        3. Patient has 2 of the following signs or symptoms
      purulent drainage from uterus.                            with no other recognized cause: fever (.388C),
                                                                nausea, vomiting, pain, tenderness, or dysuria
                                                                and
Reporting instruction                                           at least 1 of the following:
  d   Report postpartum endometritis as a health care–             a. organisms cultured from blood
      associated infection unless the amniotic fluid is             b. physician diagnosis.
      infected at the time of admission or the patient
      was admitted 48 hours after rupture of the           Reporting instructions
      membrane.                                              d   Report endometritis as EMET.
                                                             d   Report vaginal cuff infections as VCUF.
EPIS-Episiotomy
  Episiotomy infections must meet at least 1 of the fol­
                                                           SST-SKIN AND SOFT TISSUE INFECTION
lowing criteria:                                           SKIN-Skin
  1. Postvaginal delivery patient has purulent drain­         Skin infections must meet at least 1 of the following
     age from the episiotomy.                              criteria:
  2. Postvaginal delivery patient has an episiotomy
     abscess.                                                1. Patient has purulent drainage, pustules, vesicles,
                                                                or boils.
                                                             2. Patient has at least 2 of the following signs or
Comment
                                                                symptoms with no other recognized cause: pain
  d   Episiotomy is not considered an operative proce­          or tenderness, localized swelling, redness, or
      dure in NHSN.                                             heat
                                                                and
VCUF-Vaginal cuff                                               at least 1 of the following:
                                                                   a. organisms cultured from aspirate or drain­
   Vaginal cuff infections must meet at least 1 of the                age from affected site; if organisms are
following criteria:                                                   normal skin flora (ie, diphtheroids [Coryne­
  1. Posthysterectomy patient has purulent drainage                   bacterium spp], Bacillus [not B anthracis]
     from the vaginal cuff.                                           spp, Propionibacterium spp, coagulase-neg­
  2. Posthysterectomy patient has an abscess at the                   ative staphylococci [including S epidermi­
     vaginal cuff.                                                    dis],     viridans    group     streptococci,
  3. Posthysterectomy patient has pathogens cultured                  Aerococcus spp, Micrococcus spp), they
     from fluid or tissue obtained from the vaginal                    must be a pure culture
     cuff.                                                         b. organisms cultured from blood
                                                                   c. positive antigen test performed on infected
Reporting instruction                                                 tissue or blood (eg, herpes simplex, varicella
                                                                      zoster, H influenzae, N meningitidis)
  d   Report vaginal cuff infections as SSI-VCUF.                  d. multinucleated giant cells seen on micro­
                                                                      scopic examination of affected tissue
OREP-Other infections of the male or female                        e. diagnostic single antibody titer (IgM) or 4­
reproductive tract (epididymis, testes, prostate,                     fold increase in paired sera (IgG) for
vagina, ovaries, uterus, or other deep pelvic                         pathogen.
tissues, excluding endometritis or vaginal cuff
infections)
                                                           Reporting instructions
   Other infections of the male or female reproductive
                                                             d   Report omphalitis in infants as UMB.
tract must meet at least 1 of the following criteria:
                                                             d   Report infections of the circumcision site in new­
  1. Patient has organisms cultured from tissue or               borns as CIRC.
     fluid from affected site.                                d   Report pustules in infants as PUST.
  2. Patient has an abscess or other evidence of infec­      d   Report infected decubitus ulcers as DECU.
     tion of affected site seen during a surgical opera­     d   Report infected burns as BURN.
     tion or histopathologic examination.                    d   Report breast abscesses or mastitis as BRST.
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