Basic Diagnosis and Algoritme of HAIs

Base on NHSN 2017

Agung Dwi Wahyu Widodo
Department of Clinical Microbiology, Faculty of Medicine, Airlangga University
Dr Soetomo General Hospitals Surabaya
 Subject
Diagnosis HAIs
Diagnosis CAUTI
Diagnosis SSI
Diagnosis HAP/ VAP
Diagnosis BSI
Algoritme dan Kesimpulan
 Definisi HAIs
Healthcare associated infection (HAI) is a
localized or systemic condition resulting from an
adverse reaction to the presence of an infectious
agent(s) or its toxin(s) that was not present on
admission to the acute care facility.
Infection is considered an HAI if all elements of a
CDC/NHSN site -specific infection criterion were first
present together on or after the 3rd calendar day of
admission to the facility ( the day of hospital
admission is day 1)
 HAIs Criteria
For an HAI, an element of the infection
criterion may be present during the first 2
calendar days of admission as long as it is also
present on or after calendar day 3.
All elements used to meet the infection
criterion must occur within a timeframe that
does not exceed a gap of 1 calendar day
between two adjacent elements.
 Berdasarkan Sumber HAIs
HAIs may be caused by infectious agents from
endogenous or exogenous sources:
Endogenous sources a re body sites, such as the
skin, nose, mouth, gastrointestinal (GI) tract, or
vagina that are normally inhabited by
microorganisms.
Exogenous sources are those external to the
patient, such as patient care personnel, visitors,
patient care equipment, medic al devices, or the
healthcare environment.
 Not HAIs
The following infections are not considered healthcare
associated:
Infections associated with complications or extensions of
infections already present on admission, unless a change in
pathogen or symptoms strongly suggests the acquisition of a
new infection .
Infections in infants that have been acquired transplacentally
(e.g., herpes simplex, toxoplasmosis, rubella, cytomegalovirus,
or syphilis) and become evident on the day of birth or the next
day .
Reactivation of a latent infection (e.g., herpes zoster
[shingles], herpes simplex, syphilis, or tuberculosis).
 BUKAN Infeksi (NOT Infections)
The following conditions are not infections:
Colonization, which means the presence of
microorganisms on skin, on mucous membranes,
in open wounds, or in excretions or secretions but
are not causing adverse clinical signs or symptoms.
Inflammation that results from tissue res ponse to
injury or stimulation by noninfectious agents, such
as chemicals.
Diagnosis CAUTI
 Urinary Tract Infection
UTI-CAUTI
Terdiri atas:
SUTI 1a CAUTI
SUTI 1b Non-CAUTI
SUTI 2 CAUTI and Non CAUTI
ABUTI
 UTI dan CAUTI
Urinary tract infections (UTI) are defined using
symptomatic urinary tract infection (SUTI) criteria or
Asymptomatic Bacteremic UTI (ABUTI) criteria
Catheter-associated UTI (CAUTI): A UTI where an
indwelling urinary catheter was in place for >2 calendar
days when all elements of the UTI infection criterion were
first present together, with day of device placement
being Day 1 ,
and
an indwelling urinary catheter was in place on the date of
event or the day before.
 SUTI 1a
Catheter-associated Urinary Tract Infection
(CAUTI)
Patient must meet 1, 2, and 3 below:
1. Patient had an indwelling urinary catheter that had been in place for > 2
days on the date of event (day of device placement = Day 1) AND was either:
Present for any portion of the calendar day on the date of event , OR
Removed the day before the date of event
2. Patient has at least one of the following signs or symptoms:
fever (>38.0C)
suprapubic tenderness*
costovertebral angle pain or tenderness*
urinary urgency ^
urinary frequency ^
dysuria ^
3. Patient has a urine culture with no more than two species of organisms
identified, at least one of which is a bacterium of 10 5 CFU/ml
 SUTI 1b
Non-Catheter-associated Urinary Tract Infection
(Non-CAUTI)
Patient must meet 1, 2, and 3 below:
1. One of the following is true: Patient has/had an indwelling urinary
catheter but it has/had not been in place >2 calendar days on the date of
event OR Patient did not have a urinary catheter in place on the date of
event nor the day before the date of event
2. Patient has at least one of the following signs or symptoms:
fever (>38C) in a patient that is 65 years of age
suprapubic tenderness*
costovertebral angle pain or tenderness*
urinary frequency ^
urinary urgency ^
dysuria ^
3. Patient has a urine culture with no more than two species of organisms
identified, at least one of which is a bacterium of 10 5 CFU/ml.
 SUTI 2
CAUTI or Non-CAUTI in patients 1 year of age or
less
Patient must meet 1, 2, and 3 below:
1. Patient is 1 year of age (with or without an indwelling urinary
catheter)
2. Patient has at least one of the following signs or symptoms:
fever (>38.0C)
hypothermia (<36.0C)
apnea*
bradycardia*
lethargy*
vomiting*
suprapubic tenderness*
3. Patient has a urine culture with no more than two species of
organisms identified, at least one of which is a bacterium of 10 5
CFU/ml.
 Asymptomatic Bacteremic Urinary Tract
Infection (ABUTI)
Patient must meet 1, 2, and 3 below:
1. Patient with* or without an indwelling urinary catheter has no
signs or symptoms of SUTI 1 or 2 according to age (Note:
Patients > 65 years of age with a non-catheter-associated ABUTI
may have a fever and still meet the ABUTI criterion)
2. Patient has a urine culture with no more than two species of
organisms identified, at least one of which is a bacterium of 10 5
CFU/ml
3. Patient has organism identified from blood specimen with at
least one matching bacterium to the bacterium identified in the
urine specimen, or meets LCBI criterion 2 (without fever) and
matching common commensal(s) in the urine.
Diagnosis Surgical Site Infection
 Surgical Site Infections (SSI)
Stratifikasi SSI:
Wound Class
ASA Score
Lama Operasi
Jenis Operasi
Klasifikasi SSI:
SSI Superficial
SSI Deep
SSI Organ/ Space
 Wound Classes -1 and 2
Wounds are divided into four classes:
First Class
Clean: An u ninfected operative wound in which no inflammation is
encountered and the respiratory, alimentary, genital, or uninfected
urinary tracts are not entered. In addition, clean wounds are primarily
closed and, if necessary, drained with closed drainage. Operative
incisional wounds that follow nonpenetrating (blunt) trauma should be
included in this category if they meet the criteria.
Second Class
Clean-Contaminated: Operative wounds in which the respiratory,
alimentary, genital, or urinary tracts are entered under controlled
conditions and without unusual contamination. Specifically, operations
involving the biliary tract, appendix, vagina, and oropharynx are
included in this category, provided no evidence of infection or major
break in technique is encountered.
 Wound Classes-3 and 4
Third Class
Contaminated: Open, fresh, accidental wounds. In addition,
operations with major breaks in sterile technique (e.g., open cardiac
massage) or gross spillage from the gastrointestinal tract, and
incisions in which acute, nonpurulent inflammation is encountered
including necrotic tissue without evidence of purulent drainage
(e.g., dry gangrene) are included in this category.
Fourth Class
Dirty or Infected: Includes old traumatic wounds with retained
devitalized tissue and those that involve existing clinical infection or
perforated viscera. This definition suggests that the organisms
causing postoperative infection were present in the operative field
before the operation.
 ASA physical status
ASA physical status : Assessment by the anesthesiologist of the
patients preoperative physical condition using the American
Society of Anesthesiologists (ASA) Cl assification of Physical Status.
Patient is assigned one of the following:
1. A normally healthy patient
2. A patient with mild systemic disease
3. A patient with severe systemic disease
4. A patient with severe systemic disease that is a constant threat to life
5. A moribund patient who is not expected to survive without the
operation.
6. A declared brain-dead patient whose organs are being removed for donor
purposes
 Superficial incisional SSI
Infection occurs within 30 days after any NHSN operative procedure
(where day 1 = the procedure date) , including those coded as OTH
and
involves only skin and subcutaneous tissue of the incision
and
patient has at least one of the following:
a. purulent drainage from the superfici al incision.
b. organi sms isolated from an aseptically -obtained culture of fluid or
tissue from the superficial incision .
c. superficial incision that is deliberately opened by a surgeon , attending
physician or other designee and is culture positive or not cultured and
patient has at least one of the following signs or symptoms: pain or
tenderness; localized swelling; redness ; or heat . A culture negative finding
does not meet this criterion.
d. diagnosis of a superficial incisional SSI by the surgeon or attending
physician or other designee
Surveillance Period for Superficial Incisional
SSI
 Deep incisional SSI
Infecti on occurs within 30 or 90 days after the NHSN operative procedure
(where day 1 = the procedure date)
and
involves deep soft tissues of the incision (e.g., fascial and muscle layers)
and
patient h as at least one of the following:
a. purulent drainage from the deep incision.
b. a deep incision that spontaneously dehisces or is deliberately opened by a
surgeon, attending physician or other designee and is culture-positive or not cultured
and
patient has at least one of the following signs or symptoms: fever (>38C); localized
pain or tenderness. A culture -negative finding does not meet this criterion.
c. an abscess or other evidence of infection involving the deep incision that
is detected on direct examination, during invasive procedure , or by
histopathologic examination or imaging test.
Surveillance Period for Deep Incisional SSI
Surveillance Period for Deep Incisional SSI
 Organ/Space SSI
Infection occurs within 30 or 90 days after the NHSN operative procedure
(where day 1 = the procedure date)
and
infection involves any part of the body, excluding the skin incision, fascia, or
muscle layers, that is opened or manipulated during the operative procedure
and
patient has at least one of the following:
a. purulent drainage from a drain that is placed into the organ/space
b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the
organ/space
c. an abscess or other evidence of infection involving the organ/space that is
detected on direct examination, during invasive procedure , or by histopathologic
examination or imaging test
and
meets at least one criterion for a specific organ / space infection site
Surveillance Period for Organ/Space Incisional SSI
Surveillance Period for Organ/Space Incisional SSI
Specific Sites of an Organ/Space SSI
Diagnosis HAP/ VAP
 Pneumoniae
Pneumoniae and VAP
Categories
Kategori Pneumoniae
PNU1
PNU 2
PNU 3
Kategori VAP
VAE
VAC
IVAC
PVAP
 Pneumoniae and VAP
Pneumonia (PNEU) is identified by using a combination of
radiologic, clinical and laboratory criteria.
Ventilator-associated PNEU (VAP): A pneumonia where the
patient is on mechanical ventilation for >2 calendar days
on the date of event , with day of ventilator placement
being Day 1,
and
the ventilator was in place on the date of event or the day
before. If the patient is admit ted or transferred into a
facility on a ventilator, the day of admission is considered
Day1.
 Categories*
There are three pneumonia categories:
PNU1
X-ray changes and clinical signs and symptoms
laboratory findings
PNU2
X-ray changes, clinical signs and symptoms,
microbiological results
PNU3
pneumonia in immuncompromised

December 1, 2013 33
 Kriteria Dx Pneumoniae
CDC (2017), Terdapat 3 tipe spesifik
Pneumonia:
Clinically defined pneumonia (PNU1),
Pneumonia with specific laboratory findings
(PNU2)
Pneumonia in immunocompromised patients
(PNU3).
 Pemeriksaan Radiologi
Dua atau lebih radiograf thorax/ Chest serial dengan paling
sedikit satu dari berikut:
Infiltrat baru atau progresif dan persistent
Consolidasi
Cavitasi
Pneumatoceles, pada bayi berusia 1 tahun
Catatan: pada penderita tanpa underlying disease
pulmonari atau cardiac (misalnya, respiratory distress
syndrome, bronchopulmonary dysplasia, pulmonary
edema, atau chronic obstructive pulmonary disease),
Radiograf Chest definitif dapat diterima.
 Tanda / Gejala
Untuk Semua penderita,
paling sedikit satu dari berikut:
Demam (38C ) tanpa sebab lain
Leukopenia (4000 lekosit/mm3) atau leukositosis (12,000 lekosit/mm3)
Untuk dewasa berumur 70 tahun, gangguan status mental tanpa sebab lain
dan
paling sedikit 2 hal berikut:
Onset baru sputum yang purulen atau perubuhan karakter/ sifat sputum
atau peningkatan sekresi respiratori atau peningkatan penggunaan suction
Onset baru atau batuk memburuk atau dyspnea, atau tachypnea
Rales atau suara nafas bronchial
Pertukaran gas yang memburuk (mis, Desaturasi O2 [mis, PaO2/FiO2 240],
peningkatan penggunaan oksigen atau peningkatan kebutuhan ventilator)
 Pneumonia dengan temuan spesifik
laboratorium (PNU2)
Ada 2 bentuk PNU 2. yaitu:
Pneumonia dengan pathogen berupa bacterial atau fungi berfilamen
disertai temuan spesifik laboratorium (Pneumonia with common
bacterial atau filamentous fungal pathogens and specific laboratory
findings)
Pneumonia dengan pathogen berupa viral, Legionella, Chlamydia,
Mycoplasma, dan pathogen tidak umum disertai temuan spesifik
laboratorium (Pneumonia with viral, Legionella, Chlamydia,
Mycoplasma, and other uncommon pathogens and specific laboratory
findings )
Keduanya memiliki Kriteria yang sama yaitu Pemeriksaan radiologi
yang sama demikian juga tanda dan gejalanya, yang membedakan
adalah criteria laoboratorisnya.
 Pneumonia dengan pathogen berupa bacterial
atau fungi berfilamen disertai temuan spesifik
laboratorium
Kriteria Laboratoris, Paling sedikit satu dari berikut:
Bikan positif dari darah tanpa sebab infeksi lain
Biakan positif dari cairan pleura
Bikan kuantitatif Positive dari specimen minimally contaminated LRT
(mis, BAL atau protected specimen brushing)
5% BAL-terdapat sel yang berisi bakteri intraseluler pada pemeriksaan
langsung mikroskopis (misalnya, pengecatan Gram)
Pemeriksaan Histopathologis menunjukkan paling sedikit satu dari
berikut bukti adanya pneumonia:
Pembentukan Abscess atau focus konsolidasi dengan intense akumulasi
PMN pada bronchioli dan alveoli
Biakan Kuantitatif positif dari parenkim paru
Bukti adanya invasi hifa atau psudohyphae fungi pada parenchim
 Pneumonia dengan pathogen berupa viral,
Legionella, Chlamydia, Mycoplasma, dan
pathogen tidak umum disertai temuan spesifik
laboratorium
Kriteria Laboratoris, Paling sedikit 1 dari berikut:
Biakan positif virus atau Chlamydia dari sekresi saluran nafas
Deteksi positif antigen viral atau antibodi dari sekresi saluran nafas (contoh, EIA,
FAMA, shell vial assay, PCR)
Peningkatan 4 kali sera berpasangan (IgG) untuk patogen (misalnya, influenza
viruses, Chlamydia)
PCR positif untuk Chlamydia atau Mycoplasma
Mikro-IF test positif untuk Chlamydia
Biakan positif atau visualization dari micro-IF dari Legionella spp, dari sekresi
saluran nafas atau jaringan
Deteksi antigen Legionella pneumophila serogroup 1 pada urine urine
menggunakan RIA atau EIA
Peningkatan 4 kali pada antibody L pneumophila serogroup 1 antibody titer 1:128
pada sera berpasangan acute dan convalescent dengan metode indirect IFA
 Pneumonia pada penderita dengan
imunokompromis (PNU3)
Tanda / Gejala
paling sedikit satu dari berikut:
Demam (38C ) tanpa sebab lain
Leukopenia (4000 lekosit/mm3) atau leukositosis (12,000 lekosit/mm3)
Untuk dewasa berumur 70 tahun, gangguan status mental tanpa sebab lain
dan
paling sedikit 2 hal berikut:
Onset baru sputum yang purulen atau perubuhan karakter/ sifat sputum atau
peningkatan sekresi respiratori atau peningkatan penggunaan suction
Onset baru atau batuk memburuk atau dyspnea, atau tachypnea
Rales atau suara nafas bronchial
Pertukaran gas yang memburuk (mis, Desaturasi O2 [mis, PaO2/FiO2 240],
peningkatan penggunaan oksigen atau peningkatan kebutuhan ventilator)
Hemoptysis
Nyeri Dada Pleuritik
 Pneumonia pada penderita dengan
imunokompromis (PNU3)
Kriteria Laboratoris
Paling sedikit 1 dari berikut:
Kecocokan biakan darah dan sputuh positif dengan
Candida spp
Bukti adanya fungi atau Pneumocystis carinii dari
spesimen minimally contaminated LRT (mis, BAL atau
protected specimen brushing) dari satu hal berikut:
Pemeriksaan mikroskopis langsung
Biakan positif fungi
Kriteria laboratoris lain pada PNU2
Ventilator-Associated Events (VAE)
VAEs are identified by using a combination of
objective criteria: deterioration in respiratory
status after a period of stability or improvement
on the ventilator, evidence of infection or
inflammation, and laboratory evidence of
respiratory infection.
VAC
IVAC
Possible VAP
Ventilator Associated Condition
Infection-related Ventilator-Associated
Complication (IVAC)
Possible VAP
Diagnosis BSI
 CA-BSI
Cath associated Bloodstream Infection
CA-BSI
Primary bloodstream infections (BSI ):
Laboratory - confirmed bloodstream infections
(LCBI) that are not secondary to an infection at
another body site
Terdiri atas:
LCBI-1
LCBI-2
LCBI-3
 LCBI-1
Patient has a recognized pathogen identified
from one or more blood specimens by a culture
or non-culture based microbiologic testing
method which is performed for purposes of
clinical diagnosis or treatment (e.g., not Active
Surveillance Culture/Testing (ASC/AST).
AND
Organism(s) identified in blood is not related to
an infection at another site
 LCBI-2
Patient has at least one of the following signs or symptoms: fever (>38.0oC),
chills, or hypotension
AND
Organism(s) identified from blood is not related to an infection at another
site
AND
the same common commensal (i.e., diphtheroids [Corynebacterium spp. not
C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp.,
coagulase-negative staphylococci [including S. epidermidis], viridans group
streptococci, Aerococcus spp., and Micrococcus spp.) is identified from two
or more blood specimens drawn on separate occasions, by a culture or non-
culture based microbiologic testing method which is performed for purposes
of clinical diagnosis or treatment (e.g., not Active Surveillance
Culture/Testing (ASC/AST).
 LCBI-3
Patient 1 year of age has at least one of the following signs or symptoms:
fever (>38.0oC), hypothermia (<36.0oC), apnea, or bradycardia
AND
Organism(s) identified from blood is not related to an infection at another
site
AND
the same common commensal (i.e., diphtheroids [Corynebacterium spp.
not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp.,
coagulase-negative staphylococci [including S. epidermidis], viridans group
streptococci, Aerococcus spp., and Micrococcus spp.) is identified from two
or more blood specimens drawn on separate occasions, by a culture or
non-culture based microbiologic testing method which is performed for
purposes of clinical diagnosis or treatment (e.g., not Active Surveillance
Culture/Testing (ASC/AST).
Agungs Algoritme Diagnosis HAIs
Pasien

Infeksi Non Infeksi

-Inflamasi
-Kolonisasi

HAIs Non HAIs

-Community
-Complication, transplacental or
latent activation

BSI CAUTI SSI Pneumoniae/ VAP

 Karakteristik HAIs
HAIs CAUTI BSI HAP/VAP SSI
Device / Alat Cath urethra Cath IV/ CVC Mech Vent -
Procedure - - - Operation
Diagnosis
Klinis Klinis Klinis Klinis Klinis
Radiologis - - Radiologis -
Laboratoris Urinalisis DL DL -DL
Kultur Kultur Kultur Kultur Kultur
Infeksi Simptomatis Tidak ada Pnue 1 klinis Tergantung
Asimptomatis infeksi di tem Pnue 2 lab Site
pat lain Pnue 3 Superficial
LCBSI imunkromp Deep
VAE-VAP Organ/
rongga
Arigato-gozaimasu