Module I EpidEmiological SurvEillancE of HEaltHcarE ...

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EpidEmiological SurvEillancE of HEaltHcarE-aSSociatEd infEctionS

Module I

acknowledgements

this project was possible thanks to contribution from the canadian international development agency, according to what was agreed upon in the subsidy 026140 - immEdiatE rESponSE to H1n1 influEnZa.

Also published in Spanish as:

Vigilancia epidemiológica de las infecciones asociadas a la atención en salud

PAHO HQ Library Cataloguing-in-Publication

Pan American Health Organization,

“Epidemiological Surveillance of Healthcare Associated Infections”.

Washington, D. C.: PAHO, © 2011.

ISBN 978-92-75-13147-3

I. Title

1. EPIDEMIOLOGIC SURVEILLANCE – statistics & numeral data

2. HEALTH SURVEILLANCE OF HEALTH SERVICES

3. CROSS INFECTION – prevention & control

4. EPIDEMIOLOGIC STUDIES

5. INFECTION CONTROL - standards

6. PROGRAM EVALUATION - standards

7. QUALITY OF HEALTH CARE

8. LATIN AMERICA

NLM WC 195.DA15

The Pan American Health Organization welcomes requests for permission to reproduce or translate its

publications, in part or in full. Applications and inquiries should be addressed to Editorial Services, Area of

Knowledge Management and Communications (KMC), Pan American Health Organization, Washington, D.C.,

U.S.A., which will be glad to provide the latest information on any changes made to the text, plans for new

editions, and reprints and translations already available.

©Pan American Health Organization, 2011

Publications of the Pan American Health Organization enjoy copyright protection in accordance with the

provisions of Protocol 2 of the Universal Copyright Convention. All rights are reserved.

The designations employed and the presentation of the material in this publication do not imply the expression

of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning

the status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers

or boundaries.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed

or recommended by the Pan American Health Organization in preference to others of a similar nature that

are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by

initial capital letters.

5M O D U L E I

I . I n t r o d u c t I o n a n d r at I o n a l e page 7

1 evaluation of programs for the prevention and control of healthcare-associated infections in latin america page 7

2 core components of programs for the prevention and control of healthcare-associated infections page 8

3 Burden of disease and proposal page 10

I I . S u rv e I l l a n c e M e t h o d o l o g y page 13

1 Minimum capacity of participating hospitals page 14

2 device-associated hospital infection 16

I I I . I n f e c t I o n S S u B j e c t

t o S u rv e I l l a n c e page 19

1 Pneumonia (Pneu) page 19

2 urinary tract Infection (utI) page 29

3 Bloodstream Infection (BSI) page 33

I v. I n d I c at o r S page 39

table of contents

Abb

reviati

ons

BAC laboratory-confirmedbloodstreaminfection

BAL bronchoalveolarlavage

BSI bloodstreaminfection

CPAP continuouspositiveairwaypressure

PSB protected-specimenbrushing

IUC indwellingurinarycatheter

CVC centralvenouscatheterorcentralline

FIO2 fractionofinspiredoxygen

ET-CPAP endotrachealcontinuouspositiveairwaypressure

IPPB intermittentpositivepressurebreathing

MINI BAL synonymforNB-BAL

NB-BAL nonbronchoscopicbronchoalveolarlavage

ml milliliter

PAHO PanAmericanHealthOrganization

PaO2 partialpressureofoxygeninarterialblood

P-BAL protectedbronchoalveolarlavage

PMN polymorphonuclearleukocyte

ICU intensivecareunit

CFU/ml colonyformingunitspermilliliter

MV mechanicalventilation

* PEEP positiveend-expiratorypressure

RSV respiratorysyncytialvirus

introduction and rationale

1 / Evaluation of programs for the preventionand control of healthcare-associated infections in Latin America

In order to improve country capacity to detect and respond effectively and quickly to infectious disease, the Pan american health organization (Paho) has worked in the region of the americas to strengthen epidemiological surveillance systems for both health-facilities and laboratories.

Between 2006 and 2007, Paho, in partnership with national experts, conducted an assessment of the status of programs for the prevention and control of healthcare-associated infections in 67 hospitals in seven countries in the region (1). as a result of that evaluation, the countries adopted measures to improve their programs. Paho is addressing the issue at the regional level.

epidemiological surveillance and the diagnosis of healthcare-associated infections (haIs) were among the areas found to require additional attention. Issues with diagnosis were affecting intervention measures, which were implemented based on flawed data. an analysis of surveillance indicator data obtained through the evaluations revealed that these intervention measures needed improvement in over half of participating institutions.

epidemiological surveillance in hospitals generates data on the principal problems of infectious etiology present at each facility, and on invasive procedures primarily associated with these

Iv. d ata a n a ly S I S a n d I n f o r M at I o n

S y S t e M S page 41

v I . r e f e r e n c e S page 44

a P P e n d I c e S

appendix 1. form for device-associated Infection Monitoring page 46

appendix 2. denominators page 48

appendix 3. healthcare-associated Infections data collection table - hospital page 50

appendix 4. healthcare-associated Infections data collection table - Ministry of health page 52

appendix 5. form for Sending data to the Pan american health organization page 54

appendix 6. etiologic agents of healthcare-associated Infections and antibiotic Susceptibility Profile of Microorganisms page 56

appendix 7. Specimen collection page 58

r e f e r e n c e s page 69B i b l i o g r a p h y page 71

7M O D U L E I6 E p I D E M I O LO g I c a L S U rv E I L L a n c E

meeting, the issue of healthcare-associated infection surveillance regained international visibility.

With regard to surveillance, the group of experts recommended that national health authorities should collect and document data available on healthcare-associated infections; define national objectives for surveillance efforts; establish priorities for surveil-lance of healthcare-associated infections and pathogens; de-termine what data should be provided to the health authority and in what form; and comply with reporting requirements of stakeholders regarding the national state of healthcare-associated infection and during special disease events. national health au-thorities would also be responsible for standardizing case defini-tions and surveillance methods, and promoting the assessment of infection prevention practices and other relevant processes.

In addition, the principal duties of each healthcare facility are to document the state of healthcare-associated infections and processes related to their prevention and control; define institutional objectives for surveillance that align with national objectives; establish priorities for surveillance according to the scope of care provided by the facility; determine what data must be collected; apply existing national definitions and methods; detect outbreaks and coordinate an appropriate response; pro-mote practices for the prevention and control of healthcare-associated infections and related aspects of organizational culture without retaliation; and produce and disseminate information on healthcare-associated infections and other related events to local stakeholders and health authorities.

cases of infection. Surveillance also helps detect outbreaks and epidemics, and can be used to measure the impact of prevention and control measures.

from the results of the evaluations, it cannot be determined whether the limitations found in the evaluated hospitals are present in other facilities, since the former were not selected as a representative sample of the hospital universe in each country. on the other hand, the hospitals selected for evaluation by each country’s Ministry of health or social security system tended to be the largest in either the capital or a particular geographical region.

2 / Core components of programs for the prevention and control of healthcare-associated infections*

In 2008, the World health organization convened a meeting of experts on the control of healthcare-associated infections in order to identify core components of national and healthcare facility-based programs for the prevention and control of healthcare-associated infections (2). The group concluded that the core components of such a program are: organization, technical guidelines, trained human resources, surveillance of healthcare-associated infections, assessment of compliance with international recommendations, support from microbiology laboratories, the environment, program evaluation, and collaboration with public health or other services. following the

9M O D U L E I

* Any further mention of infection

in this document refers to

healthcare-associated infection (HAI).

8 E p I D E M I O LO g I c a L S U rv E I L L a n c E

It is recommended that, with modifications appropriate to the region, the definitions and criteria of the united States centers for disease control and Prevention (cdc)* be used, given that they are widely known and have a long history of use.

Several experts in the prevention and control of healthcare-associated infections in the region of the americas collaborated with Paho during the development of this proposal in order to guarantee its applicability and usefulness.

* Available at http://www.cdc.gov/ncidod/dhqp/pdf/nnis/

NosInfDefinitions.pdf

Horan TC, Andrus M and Dudeck MA. CDC/NHSN surveillance

definition of health care–associated infection and criteria for

specific types of infections in the acute care setting. Am J Infect

Control 2008;36:309-32. Available at http://www.cdc.gov/

ncidod/dhqp/pdf/nnis/NosInfDefinitions.pdf

11M O D U L E I

Surveillance that has been systematized and documented in this way will provide health facilities and authorities with the means for early outbreak detection and response, as well as with data to document the status of healthcare-associated infections and initiate the implementation of preventive measures.

3 / Burden of disease and proposal

In the americas, the burden of disease from healthcare-associated infections is unknown. The data available are from targeted studies that reflect specific situations in healthcare facilities or, at best, in some countries. The availability of data in the region varies dramatically. Some countries have very good surveillance of healthcare-associated infections in health facilities, but do not have national data; others have data from healthcare facilities and national data; and others have neither structured surveillance in healthcare facilities nor data at the national level. as a result of this wide range of situations, the impact of actions in the region cannot be adequately evaluated.

Because of this, and with the aim of strengthening the capacity of healthcare facilities and local and national governments to identify outbreaks and to understand the burden of disease caused by healthcare-associated infections, a surveillance system for these infections and methods for its implementation are proposed. The system will be flexible enough that each country can determine its priorities with regard to the infections and pathogens to monitor, and will provide case definitions and instruments for the active surveillance of infections. Instruments will be offered for systematic evaluation of efforts to prevent and control healthcare-associated infections, with the aim of detecting and promptly responding to outbreaks.

1 0 E p I D E M I O LO g I c a L S U rv E I L L a n c E

Surveillance methodology

Place: all information reported through this surveillance system will come from intensive care units.

Country capacity: In order to participate, countries must have the capacity to collect and analyze data. to this end, it is essential that they have professionals who are devoted to collecting and analyzing data provided by hospitals, and who can make deci-sions about the problems detected. countries that already have their own surveillance system with definitions and information sys-tems are requested to provide those national definitions to Paho.

Healthcare-associated infections: a healthcare-associated in-fection is an infection that is not present or incubating at the time of admission to a healthcare setting, but which is observed during the patient’s hospital stay or after the patient’s time of discharge.

Healthcare-associated infections in the intensive care unit (ICU): a healthcare-associated infection that was not present or incubating at the time of admission to the Icu that might be as-sociated with a patient’s stay in the Icu, and might be detected after discharge from the Icu.

Healthcare-associated infection in the ICU and associated with an invasive procedure: a healthcare-associated infection that was not present or incubating at the time of admission to the Icu and that might be associated with a patient’s stay in that unit and with invasive procedures undergone during the patient’s stay.

I I

1 3M O D U L E I

to the monitoring and control of healthcare-associated infections:

1. review the charts of patients with exposure factors in order to detect infections.

2. In the event that an infection is suspected, use case defini-tion criteria to classify it as such, if appropriate.

3. record infection information for all confirmed cases (nume-rators): pneumonia, urinary tract infection, or bloodstream infection (dates and etiologic agents).

4. for patients with confirmed haI record epidemiological information in order to establish numerators: patient iden-tification, name, hospital identification, bed, primary un-derlying disease (Icd-9 or Icd-10) (optional), sex, age, date of Icu admission, date of Icu discharge, reason for discharge, and length of exposure to mechanical ven-tilation, indwelling urinary catheter, or central venous catheter. Keep information for later consolidation.

the professional in charge of surveillance should have the time necessary to perform tasks and receive training. the time that surveillance activities require depends on the number of patients and the quality of records kept by the facility or hospital, as well as on the frequency of surveillance rounds in the intensive care units. there is no universal, precise ratio of minutes per patient. this decision is generally made locally. however, experience has shown that 15 to 20 minutes per inpatient per week, with at least two weekly rounds, may be required. In other words, a 10-bed Icu could require between 150 and 200 dedicated minutes per week.

1 5M O D U L E I

Microbiological data should be analyzed by unit of care where the infection was identified.

1 / Minimum capacity of participating hospitals

Intensive care unit: In order to be included in reporting systems, a hospital must have at least one intensive care unit. for this purpose, an intensive care unit is defined as the hospital unit in which beds are reserved for the care of critically ill patients who require specialized medical and nursing care 24 hours a day, in addition to specialized life-support equipment (3). this excludes intermediate therapies (without mechanical respiratory assistance).

Program for the prevention of healthcare-associated infec-tions: hospitals should also have a program for the prevention and control of healthcare-associated infections that is responsible for setting policy, objectives, strategies, and legal and scientific bases for the prevention and control of hospital infections. The program will also be responsible for the surveillance of those in-fections. The hospital program should have qualified, dedicated staff with defined responsibilities and duties, and have a budget sufficient to meet the tasks programmed in their work plans (2).

Trained local staff: The responsibilities of these staff members are to detect cases (numerators) and identify the exposed population (denominators), keep records, and consolidate and analyze collected data. In general, these duties are carried out by nursing personnel dedicated to infection control, although other clinicians familiar with the topic may participate depending on the organization of the facility or hospital and of the surveillance system. the following is a more detailed list of the responsibilities of staff dedicated


devIce-aSSocIated InfectIon MonItorIng—healthcare-

aSSocIated InfectIon SurveIllance.

Denominator: the infection prevention and control professional will record the device-day counting the number of patient with mechanical ventilation, indwelling urinary catheter, or central venous catheter at Icu, on the forM In

aPPendIX 1 and tItled, denoMInatorS

Devices inserted outside the unit under surveillance: Infections that develop within 48 hours of a patient’s arrival and that are related to devices inserted outside the intensive care unit will not be counted in the numerator.

retrospective chart reviews should be used only when patients have been discharged before all necessary information can be obtained. use the attached form (appendix 1) to record the data.

Frequency of surveillance: It is recommended that sur-veillance be carried out in intensive care units at least twice a week. data should be consolidated monthly for the hospi-tal’s use, and forwarded to the Ministry of health following its analysis. the Ministry of health should ensure that all hospitals providing data do so in a standardized way and ac-cording to a regular timetable.

1 7M O D U L E I

2 / Device-associated hospital infection

Methodology: Surveillance of device-associated infections in intensive care units should be active, selective, prospective, and patient-based.

Case-finding: a properly trained infection prevention and control professional will identify patients suspected of having a device-associated infection and collect the corresponding denominator data.

Numerator: the infection prevention and control profes-sional will find infections incurred during the patient’s stay using different sources, including: temperature charts, anti-biotic use, cultures performed, physician’ instructions, and the suspicion of attending clinicians.

Monitoring of any haI is no longer required after the patient is discharged from the Icu.

Case confirmation: In patients suspected of having a device-associated infection, the infection prevention and control professional will confirm the infection based on case definition criteria using: records from the laboratory, pharmacy, patient admission, discharge, and transfer, and radiology (imaging); pathological anatomy databases and patient charts, including interviews, physical exam notes, and notes taken by physicians and nurses (4). laboratory surveillance data should not be used in isolation, unless all possible criteria for diagnosing an infection are determined by laboratory evidence alone.

the collection of data on the infection should be completed for all confirmed cases (numerators) — pneumonia, urinary tract infection, or bloodstream infection (dates and etiologic agents) — on the form in appendix 1 and titled, forM for


infections Subject to Surveillance

1 / Pneumonía (PNEU)

Pneumonia is diagnosed through a combination of radiologic, clinical, and laboratory criteria. the following paragraphs describe the various assessment criteria that may be used for meeting the surveillance definition of nosocomial pneumonia. for cases of ventilator-associated pneumonia, a patient has to be intubated and ventilated at the time of onset of symptoms, or have been ventilated up to 48 hours prior to the onset of infection.NOTE: There isnominimumlengthof timethemechanicalventilatorhastobeinplaceforthepneumoniatobeassociatedwithmechanicalventilation.Casesof infectionshouldbeanalyzedonacasebycasebasis.Mechanicalventilationcanbeassociatedwithinfectionevenifit

wasinplaceover48 hours beforetheonsetofinfection.

Setting: Pneumonia surveillance will be conducted in the Icu. Monitoring of ventilation-associated pneumonia is no longer required after the patient is discharged from the Icu.

Requirements: Surveillance of ventilator-associated pneumonia should be conducted in at least one Icu in the healthcare facility. Ideally, monitoring should be conducted year-round. however, if surveillance is scheduled to occur only during specific periods, monitoring should take place during at least one calendar month.

I I I

1 9M O D U L E I

Criteria for defining nosocomial pneumonia

Generalcomments

1. Physician’sdiagnosisofpneumoniaaloneis notanacceptable

criterionfornosocomialpneumonia.

2. Althoughtherearespecificcriteriafor infantsandchildren,pe-

diatricpatientsareincludedandmaymeetanyoftheotherpneu-

monia-specificcriteria.

3. Ventilator-associatedpneumoniashouldbesodesignatedwhen

reportingdata.

4. Whenassessingapatient for thepresenceofpneumonia, it is

importanttodistinguishbetweenchangesinclinicalstatusdue

tootherconditions,suchasmyocardialinfarction,pulmonary

embolism,respiratorydistresssyndrome,atelectasis,malignan-

cy,chronicobstructivepulmonarydisease,hyalinemembrane

disease,bronchopulmonarydysplasia,etc.Also,caremustbe

takenwhenassessingintubatedpatientstodistinguishbetween

trachealcolonization,upperrespiratorytractinfections(e.g.tra-

cheobronchitis),andearly-onsetpneumonia.Finally,itshouldbe

recognizedthatitmaybedifficulttodeterminenosocomialpneu-

monia in the elderly, infants, and immunosuppressed patients

since such conditionsmaymask typical signs and symptoms

associatedwithpneumonia.

5. Nosocomialpneumoniacanbecharacterizedbyitsonset:early

orlate.Earlyonsetpneumoniaoccursduringthefirstfourdaysof

hospitalization,andisoftencausedbystrainsofMoraxella cata-

rrhalis, Haemophilus influenzae, and Streptococcus pneumoniae.

Causativeagentsoflate-onsetpneumoniaarefrequentlygram-

negativebacilliorStaphylococcusaureus,includingmethicillin-

resistantS.aureus.Viruses(e.g.InfluenzaAandBorRespiratory

2 1M O D U L E I

Definiciones

Mechanical ventilator: a device used to assist or control respi-ration continuously, inclusive of the weaning period, through a tracheostomy or by endotracheal or nasotracheal intubation. NOTE: Lungexpansiondevicessuchasintermittentpositive-pressurebreathing(IPPB);nasalpositiveend-expiratorypressure(PEEP);andcontinuousnasalpositiveairwaypressure (CPAP)arenot consideredmechanical ventilators unless delivered via tracheostomy or

endotrachealintubation(e.g.ET-CPAP).

cases are those patients who have or have had an invasive device to assist or control respiration continuously through a tracheostomy or invasive intubation (endotracheal or nasotracheal tube) or who have or have had a non-invasive device (with nose, nose and mouth, or full-face mask). Pneumonia in patients who have used non-invasive ventilation is not considered ventilator-associated and is not considered part of the numerator or denominator.


Pne

umon

ia c

ase

defin

ition

for

surv

eilla

nce

Cri

teri

on

1:

a)Rad

iologicaldata:Twoorm

oreserialchestx-rayswithatleaston

eofthefo

llowing(1,2

):-

New

orprogressiveand

persistentinfiltrate

- Con

solidation

- Cavitation,

and

(NOTE:Inpatientsw

ith

ou

t underlyingpulm

onaryorca

rdiacdisea

se(e.g.resp

iratorydistresssyndrome,bronch

opulm

onarydyspla

-

sia,pulm

onaryed

ema,orch

ronicobstructivepulm

onarydisea

se),onedefinitivech

estx-rayisacc

eptable[1].)

b)A

tleast

one

ofthefo

llowingsign

sorsym

ptoms:

- Fever(>38°C)w

ithnootherrecogn

ized

kno

wncause

- eukopenia(<

4000W

BC/m

m3 )orleukocytosis(>

12,000

WBC/m

m3 )

- Fo

rad

ults>70yearsold,alteredm

entalstatuswithnootherrecogn

ized

cause,a

ndc)Atleast

twoofthefo

llowing:

- New

onsetofp

urulentsputum

(3),orchang

eincharacterofsputum

(4),orincreasedrespiratorysecretions,orincreasedsuc

-tioning

req

uirements

- New

onsetorworsening

cou

gh,o

rdyspnea,ortachypnea(5)

- Rales(6)orbronchialbreathsounds

- Worsening

gasexchang

e[e.g.O

2desaturations(e.g.P

aO2/FiO

2<240

)(7),increased

oxygenrequirements,o

rincreasedm

e-

chanicalventilatordem

and]

2 3M O D U L E I

SyncytialVirus)cancauseearlyandlateonsetnosocomialpneu-

monia,whereas yeasts, fungi, legionellae, and P. jirovecii are

usuallypathogensoflate-onsetpneumonia.

6. PositiveGramstainforbacteriaandpositivepotassiumhydroxi-

de (KOH)mount forelastinfibersand/or fungalhyphae from

appropriatelycollectedsputumspecimensare importantclues

thatpointtowardtheetiologyoftheinfection.However,sputum

samplesarefrequentlycontaminatedwithairwaycolonizersand

thereforemustbe interpretedcautiously. Inparticular,Candida

iscommonlyseenonstain,butinfrequentlycausesnosocomial

pneumonia.

7. Pneumoniaduetogrossaspirationisconsiderednosocomialif

itmeetstheaforementionedcriteria,andwasnotclearlypresent

orincubatingatthetimeofadmissiontothehospital.

8. Multipleepisodesofnosocomialpneumoniamayoccurincriti-

callyillpatientswithlengthyhospitalstays.Whendetermining

whether to reportmultiple episodesof nosocomial pneumonia

inasinglepatient,lookforresolutionoftheinitialinfection.The

additionoforchangeinpathogenaloneisnotindicativeofanew

episodeofpneumonia.Thecombinationofnewsignsandsymp-

tomsand radiographicevidence,orotherdiagnostic testing is

required.


d)

Atleast

on

eofthefollowingla

boratoryfindings:

- positivegrow

thinblood

culture(8)notrelated

toanothersourceofinfection

-Positivegrowthincultureofp

leuralfluid

-Positivequantitativeculture(9)fromm

inimallycon

taminated

lowerrespiratorytractspecimen(e.g.b

roncho

alveolarlavageor

protected

specimenbrushing)

-≥5%

broncho

alveolarlavage-obtained

cellscon

tainintracellularbacteriaondirectm

icroscop

icexam(e.g.G

ramstain)

-Histopatho

logicexam

sho

wsatleaston

eofthefo

llowingevidencesofpneum

onia:

.Abscessform

ationorfo

ciofc

onsolidationwithintensepolym

orpho

nuclearleukocyte(PMN)accum

ulationinbronchioles

andalveoli

.Positivequantitativeculture(9)oflungparenchym

a.

Evidenceoflungparenchym

ainvasion

byfung

alhyphaeorpseud

ohyphae

2 5M O D U L E I

Cri

teri

on

2:

a)

Rad

iologicaldata:Twoormoreserialc

hestradiographswithatleastoneofthefollowing(1,2):

-New

orprogressiveand

persistentinfiltrate

-Con

solidation

-Cavitation

(NOTE:Inpatients

wit

ho

utunderlyingpulm

onaryorca

rdiacdisea

se(e.g.resp

iratorydistresssyndrome,bronch

opulm

onary

dysplasia,pulm

onaryed

ema,orch

ronicobstructivepulm

onarydisea

se),onedefinitivech

estradiographisacc

eptable(1).

b)

Atleast

on

eofthefollowingsignsorsymptoms:

-Fever(>38°C)w

ithnootherknow

ncause

-Leukop

enia(<

4000W

BC/m

m3 )orleukocytosis(>

12,000

WBC/m

m3 )

-Fo

rad

ults>70yearsold,alteredm

entalstatuswithnootherrecogn

ized

cause,a

nd

c)

Atleast

on

eofthefollowing:

- n

ewonsetofp

urulentsputum

(3),orchang

eincharacterofsputum

(4),orincreasedrespiratorysecretions,o

rincreasedsuc

-tioning

req

uirements

-New

onsetorworsening

cou

gh,o

rdyspnea,ortachypnea(5)

-Rales(6)orbronchialbreathsounds

-Worsening

gasexchang

e[e.g.O

2desaturations(e

.g.PaO

2/FiO

2<24

0)(7

),increasedoxygenrequirements,orincreasedm

e-chanicalventilatordem

and],

and


7. Thismeasureofarterialoxygenationisdefinedastheratioofthearterialtension(PaO2)totheinspiratoryfractionofoxygen(FiO2).

8. Caremustbetakentodeterminetheetiologyofpneumonia inapatientwithpositivebloodculturesandradiographicevidenceofpneumonia,especiallyifthepatienthasinvasivedevicesinplacesuchasintravascular linesoraurinarycatheter. Ingeneral, inanimmunocompetentpatient,bloodculturespositiveforcoagulase-negative staphylococci, common skin contaminants, and yeastswillnotbetheetiologicagentofthepneumonia.

9. Oncelaboratory-confirmedcasesofpneumoniaduetorespiratorysyncytialvirus(RSV),adenovirus,orinfluenzavirushavebeenidenti-fiedinahospital,aclinician’spresumptivediagnosisofthesepatho-gensinsubsequentcaseswithsimilarclinicalsignsandsymptomsisanacceptablecriterionforpresenceofhospitalinfection.

10. Scant orwatery sputum is commonly seen in adultswith pneu-monia due to viruses andMycoplasma although sometimes thesputummaybemucopurulent.Ininfants,pneumoniaduetoRSVorinfluenzayieldscopioussputum.Patients,exceptprematurein-fants,withviralormycoplasmalpneumoniamayexhibitfewsignsorsymptomsevenwhensignificantinfiltratesarepresentonradio-graphicexam.

11. FewbacteriamaybeseenonstainsofrespiratorysecretionsfrompatientswithpneumoniaduetoLegionella spp.,mycoplasma,orviruses.

12. Immunocompromisedpatientsincludethosewithneutropenia(ab-soluteneutrophilcount<500/mm3),leukemia,lymphoma,HIVwithCD4count<200,or splenectomy; thosewhohavehada recenttransplant; and thosewhoareoncytotoxic chemotherapyorondailydosesofsteroidsfor>2weeks(e.g.>20mgprednisoneoritsequivalent).

13. Bloodandsputumspecimensmustbecollectedwithin48hoursofeachother.

14. Semiquantitative or nonquantitative cultures of sputumobtainedbydeepcough,induction,aspiration,orlavageareacceptable.Ifquantitative culture results are available, refer to algorithms thatincludesuchspecificlaboratoryfindings.

2 7M O D U L E I

NOTES:

1. Occasionally, innonventilatedpatients, thediagnosisofnosoco-mialpneumoniamaybequiteclearonthebasisofsymptoms,sig-ns,andasingledefinitivechestradiograph.However, inpatientswithpulmonaryorcardiacdisease(e.g.interstitiallungdiseaseorcongestiveheartfailure),thediagnosisofpneumoniamaybepar-ticularly difficult. Other noninfectious conditions (e.g. pulmonaryedema fromdecompensatedcongestiveheart failure)maysimu-latethepresentationofpneumonia.Inthesemoredifficultcases,serial chest radiographsmust be examined to help separate in-fectiousfromnoninfectiouspulmonaryprocesses.Tohelpconfirmdifficultcases,itmaybeusefultoreviewradiographsonthedayofdiagnosis,threedayspriortothediagnosis,andondaystwoandsevenafter thediagnosis.Pneumoniamayhaverapidonsetandprogression,butdoesnotresolvequickly.Radiographicchangesofpneumoniapersist forseveralweeks.Asa result, rapid radio-graphicresolutionsuggeststhatthepatientdoesnothavepneu-monia,butratheranoninfectiousprocess,suchasatelectasisorcongestiveheartfailure.

2. Note that there aremanywaysof describing the radiographicappearanceofpneumonia.Examples include,butarenot limitedto, “air-space disease”, focal opacification, and patchy areas ofincreaseddensity.Althoughperhapsnotspecificallydelineatedaspneumonia by the radiologist, in the appropriate clinical setting,thesealternativedescriptivewordingsshouldbeseriouslyconsi-deredaspotentiallypositivefindings.

3. Anadequatesampleforcultureinanimmunocompromisedpatientis onewith aGramstain of ≥25neutrophils and≤10 squamousepithelialcellsperlowpowerfield(x100).

4. Asinglenotationofeitherpurulentsputumorchangeincharacterofthesputumisnotmeaningful;repeatednotationsovera24-hourperiodwouldbemoreindicativeoftheonsetofaninfectiousprocess.Changeincharacterofthesputumreferstocolor,consis-tency,odor,andquantity.

5. Inadults,tachypneaisdefinedasrespirationrate>25breathsperminute.Tachypneaisdefinedas>75breathsperminuteinprema-tureinfantsbornat<37weeksgestationanduntilthe40thweek;>60breaths/minuteinpatients<2monthsold;>50breaths/minuteinpatients2-12monthsold;and>30breaths/minuteinchildren>1yearold.

6. Ralesmaybedescribedas“crackles”.


Data analysis: The rate of ventilator-associated pneumonia per 1,000 mechanical ventilator-days is calculated by dividing the number of cases of ventilator associated pneumonia by the number of mechanical ventilator-days and multiplying the re-sult by 1,000. These calculations are performed separately for each Icu.

2 / Urinary Tract Infection (UTI)

urinary tract infections are diagnosed through a combination of clinical and laboratory criteria. utIs will be counted only for patients with an indwelling urinary catheter or an infection related to its use; in other words, the patient had a urinary catheter inserted at the time of, or within seven days before, the onset of infection.NOTE:Thereisnoaminimumlengthoftimethatthecatheterhasto

beinplaceforaUTItobeconsideredcatheter-associated.

for the purposes of hospital infection surveillance systems, case definitions for urinary tract infections are divided into symptomatic and asymptomatic infections. In this proposal, only data on symptomatic urinary tract infections will be compiled.

Setting: Surveillance will take place in the intensive care units. Monitoring of patients following their discharge from the Icu is not required.

Requirements: Surveillance for urinary tract infection is performed in at least one Icu in the healthcare facility for at least one calendar month. Ideally, monitoring should be conducted year-round. however, if surveillance is scheduled to occur only during specific periods, monitoring should take place during at least one calendar month.

2 9M O D U L E I

Collection of culture specimens* used in the diagnosis of pneumonia, and threshold values

Specimen type Value

Lungparenchyma(openlungbiopsyspecimensandimmediatepost-mortemspecimensobtainedbytransthoracicortransbronchialbiopsy)

≥104 CFU/gtissue

Endotrachealaspirate 105o106CFU

Bronchoscopically(B)obtainedspecimens

-Bronchoalveolarlavage(B-BAL) ≥104UFC/ml

-Protectedbronchoalveolarlavage(BP-BAL) ≥104UFC/ml

-Protectedspecimenbrushing(B-PSB) ≥103UFC/ml

Non-bronchoscopically(NB)obtained(blind)specimens-NB-BALorMINIBAL ≥104UFC/ml

-NB-PSB ≥103UFC/ml

*Forspecimencollectiontechniques,seeAppendix7.

Numerator data: The form included in appendix 1 is used to collect and report on every case of ventilator-associated pneu-monia that is identified during the month selected for surveil-lance. The form includes patient demographic information and information regarding the use of mechanical ventilation. addi-tional data include whether the patient died, thewhat micro-organisms were isolated from cultures and their antimicrobial susceptibilities. (See Section II on surveillance methodology.)

Denominator data: the number of patients managed with a ventilation device is collected on the appendix 2. The pa-tient count is obtained daily. The sum of these daily counts is reported monthly. the data are compiled separately for each intensive care unit identified. (See Section II on surveillance methodology.)


Urin

ary

Trac

t Inf

ectio

n C

ase

Defi

nitio

n

Asym

ptomaticurinarytractinfectionmustmeetatleaston

eofthefo

llowingcriteria:

Cri

teri

on

1:

a)Clinicaldata:atleast

one

ofthefo

llowingsign

sorsym

ptomswithnootherrecogn

ized

cause:

-fever(>38°C)

-urgency(urinary)

-increasedurinaryfreq

uency

-dysuriaorsuprapub

ictenderness, a

nd

b)Thefo

llowinglaboratorycriterio

n:

-positiveurineculture(i.e.>

105 microorganism

s/cm

3 ofurinewithnomorethantwospeciesofm

icroorganism

s).

3 1M O D U L E I

Definitions

Indwelling urinary catheter (IUC): a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system; also called a foley catheter. does not include straight in-and-out catheters.

Closed urine collection system: a closed system that does not allow any type of disconnection (bag-tube) no matter how brief. Systems remain connected even during urine removal or specimen collection.


Numerator data: The form included in appendix 1 is used to collect the information and report each urinary tract infection that is identified during the month selected for surveillance. the utI form includes patient demographic information and information on whether or not a urinary catheter was present. additional data include whether the patient died, what microorganisms were isolated from cultures and their antimicrobial susceptibilities. (See Section II on surveillance methodology.)

Denominator data: The number of patients managed with an indwelling urinary catheter is collected on appendix 2. The patient count is obtained daily. The sum of these daily counts is reported monthly. The data are compiled separately for each intensive care unit identified. (See Section II on surveillance methodology.)

Data analysis: the urinary tract infection rate per 1,000 catheter-days is calculated by dividing the number of infections by the number of catheter-days and multiplying the result by 1,000. this calculation is performed separately for each intensive care unit.

3 / Bloodstream Infection (BSI)

Bloodstream infections are classified according to clini-cal and laboratory criteria, either as laboratory-confirmed bacteremia (Bac) or clinical sepsis (cSeP). a bloodstream infection is considered either primary or secondary depend-ing on whether it is caused by an infection at another site. for surveillance, only laboratory-confirmed, primary, intra-vascular catheter-associated bacteremia will be recorded.

3 3M O D U L E I

Cri

teri

on

2:

a)Atleasttwoofthefo

llowingsign

sorsym


ized

cause:

-ever(>

38°C),

-urgency(urinary)

-increasedurinaryfreq

uency

-dysuriaorsuprapub

ictenderness,a

nd

b)Atleaston

eofthefo

llowing:

-positivedipstickforleukocyteesteraseornitrate

-pyuria(urinespecimenwith>10

leukocytes/m

m3 or>3leukocytes/high-pow

erfieldofu

nspun

urine)

-organism

sseenonGramstainofu

nspunurine

-≤10

5 colon

ies/mlofasingleurop

atho

gen(Gram-negativebacteriaorS

. sap

rop

hytic

us)inapatientbeing

treated

withaneffectiveantim

icrobialagentfo

raurinarytractinfection

-physiciandiagn

osisofaurinarytractinfection

-physicianinstitutestreatm

entforaurinarytractinfection

NO

TE

:Apositivecu

ltureofaurinarycathetertipisnotan

accep

tablelaboratorytesttodiagno

seaurin

arytractinfection.Urin

ecu

lturesmustb

eobtained

using

appropria

tetech

nique

,suc

hasclean

-catch

collectionorc

athe

terization.(S

eeAppen

dix7).


and common femoral veins.

Temporary central line: a non-tunneled catheter.

Permanent central line: Includes tunneled catheters, including dialysis catheters, and implanted catheters, including port-a-cath. NOTES:

1. Anintroducerisnotconsideredanintravascularcatheter.

2. Neitherthelocationoftheinsertionsitenorthetypeofdevicemaybeusedtodetermineifalinequalifiesasacentralline.Thedevicemustterminateinoneofthegreatvesselsorinornearthehearttoqualifyasacentralline.

3. Pacemakerwiresandothernonlumeneddevicesinsertedintocen-tral blood vessels or the heart are not considered central lines,becausefluidsarenotinfused,pushed,orwithdrawnthroughsuch

devices.

Infusion: The introduction of a solution through a blood vessel via a catheter lumen. this may include drip phleboclysis, as in the case of nutritional fluids or medications, or intermittent infusions such as flushes or intravenous antimicrobial administration, or blood, in the case of transfusion or hemodialysis.

3 5M O D U L E I

Setting: Surveillance will occur in intensive care units. Monitoring of bloodstream infections after the patient is discharged from the Icu is not required.

Requirements: Surveillance for bloodstream infection in at least one Icu in the healthcare institution for at least one calendar month. Ideally, monitoring should be conducted year-round. however, if surveillance is scheduled to occur only during specif ic periods, monitoring should take place during at least one calendar month. only bloodstream infections associated to central catheter are reported.

Definitions

Primary BSI: BSI not related to an infection at another site.

Central line-associated BSI: Primary BSI in a patient with a central line or catheter in place at the time of detection or no more than 48 hours before the onset of infection. NOTE:Thereisnorequiredminimumlengthoftimethecentrallinemust

beinplacefortheinfectiontobeconsideredcentralline-associated.

Central line (CVC): an intravascular catheter that termi-nates at or close to the heart or in one of the great vessels that is used for infusion, withdrawal of blood, or hemo-dynamic monitoring. the following are considered great vessels for the purpose of reporting central-line infections and counting central-line days: aorta, pulmonary artery, su-perior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external ileac veins,


Numerator data: The form included in appendix 1 includes patient demographic information and information on the central line. The form is also used to record whether the patient died, what microorganisms were isolated from blood cultures and their antimicrobial susceptibilities. (See Section II on surveillance methodology.)

Denominator data: denominator data are collected using the form included in appendix 2. Since the patient may have more than one bloodline, data will need to be recorded for all blood lines during the patient’s entire stay in the Icu. (See Section II on surveillance methodology.)

• If a patient has more than one temporary central line on a given day, this is counted only as one central-line day.

• If a patient has both a temporary and a permanent central line on the same day, this is counted as one temporary-central-line day.

• If a patient has only one permanent central line, include it in the daily permanent central-line day count, beginning on the day of first access and continuing through the entire stay.

Data analysis: the bloodstream infection rate per 1,000 central-line days is calculated by dividing the number of BSIs by the number of central-catheter days multiplied by 1,000. These calculations are performed separately for each intensive care unit.

3 7M O D U L E I

Bac

terr

mia

* D

efini

tion

Crit

eria

Laboratory-confirm

edbacteremiam

ustmeetatleaston

eofthefo

llowingcriteria:

Cri

teri

on

1:

a)Apatho

genwasidentified

inoneormoreblood

culturesofthepatient,excep

tforcommon

skincontam

inantmicroorga

-nism

s(seeCriterion2below

),an

d

b)Th

emicroorganism

culturedfrom

theblood

isnotrelated

toinfectionsatothersites.

Cri

teri

on

2:

a)Clinicaldata:patienthasatleaston

eofthefo

llowingsign

sorsym


ized

cause:

-fever(>

38°C)

-ch

ills

-hypotension,a

nd

b)P

ositivelaboratoryresultsarenotrelated

toaninfectionatano

thersite,a

nd

c)Thefollowinglaboratorycriterio

n:com

mon

skincontam

inant(e.g.d

iphtheroids[C

oryn

ebac

teriu

m spp.],B

acill

us[notB.

anth

raci

s]spp.,

Pro

pio

nib

acte

riumspp.,coagulase-negativestap

hylococci[includ

ingS.

epid

erm

idis],

virid

ansgrou

p

Str

epto

cocc

i,A

eroc

occu

sspp.,

Mic

roco

ccusspp.)culturedfrom

tw

o o

r m

oreblood

sam

plesdrawnon

sep

arateoc

-casion

s.(S

eeAppendix7fo

rspecimencollectiontechnique.)


indicators

Indicators for Calculating ICU Healthcare Associated Infection Rates

Infection and Indicator

Description Calculation

Ventilator-associatedpneumonia

Incidenceofven-tilator-associatedpneumonia

Numberofcasesofpneumoniainpa-tientswithmechani-calventilation/Numberofmecha-nicalventilator-daysx1000

Indwellingurinarycatheterassociatedurinarytractinfection

Incidenceofindwe-llingurinarycatheter-associatedurinarytractinfections

Numberofurinarytractinfectionsinpa-tientswithindwellingurinarycatheters/NumberofIUC-daysx1000

Centralvenouscatheter-associatedbloodstreaminfection

Incidenceofcentralvenouscatheter- associatedbloods-treaminfection

Numberofbloods-treaminfectionsinpatientswithcentralvenouscatheter/Numberofcentralvenouscatheter-daysx1000

I v

3 9M O D U L E I

data analysis and information Systems

Infections subject to surveillance:

1. Mechanical ventilator-associated pneumonia2. Indwelling urinary catheter-associated symptomatic urinary

tract infection3. central venous catheter-associated, laboratory-confirmed

bloodstream infection.

Data: data will only be collected from intensive care units during the patient’s stay; infections occurring after the patient’s discharge from the Icu will not be counted, even if they are related to the patient’s stay in the intensive care unit. Microbiology data are compiled separately for each intensive care unit identified.

Numerator: numerators will be collected in the intensive care unit at least twice per week through active surveillance under the responsibility of the infection prevention and control team.

The following information should be recorded for all confirmed cases (numerators): pneumonia (date and etiologic agent), urinary tract infection (date and etiologic agent), bloodstream infection (date and etiologic agent). These data will be recorded on the form in appendix 1.

Denominator: denominator data to be used for calculating rates will be: mechanical ventilation days; indwelling urinary

v

4 1M O D U L E I

The health authority will receive the hospital’s identification and demographic data and:

• Incidence density for indwelling urinary catheter-associated urinary infections

• Incidence density for central venous catheter-associated bloodstream infections

• Incidence density for mechanical ventilation-associated pneumonias

With this information, the health authority can calculate the 10th, 25th, 50th, 75th, and 90th percentiles for each of the rates of infection under surveillance appendix 4. It is recommended that this analysis be done monthly in addition to an annual report.

Pan American Health Organization: Paho requests that the national health authority send the annual data on the form included in appendix 5 (form for Submission of data to the Pan american health organization). together with the data, health authorities should provide the hospital infection definitions being used in the country and the demographic information requested in appendix 4.

4 3M O D U L E I

catheter days; central venous catheter days; and total patient days per month and per intensive care unit.

Information system: The information system has three levels: first, the local level, or healthcare facility; second, the national health authority; and third, the Pan american health organization.

Hospital: The hospital is responsible for compiling the data (numerators and denominators), for its analysis, and for calcu-lating indicators. analysis should be conducted by the surveil-lance unit or the intensive care unit, preferably monthly. The hospital should send aggregate data for mechanical ventilation-associated pneumonia, indwelling urinary catheter-associated urinary tract infection, and central venous catheter-associated bloodstream infection to the health authority on a monthly basis. The hospital will fill out the form in appendix 1.

the patient should be monitored until departure from the intensive care unit. data from the form will be entered into the computer program to produce the necessary reports (appendix 3).

the hospital will send data from the table for Submission of data to health authorities (appendix 3) to the health authority, preferably monthly.

Health authority: The health authority will receive the aggregated information from each hospital, on the form in appendix 3. The information will be the sum of the data collected from all of the intensive care units in the hospital within a given time period. the health authority should determine the frequency with which data should be sent from each hospital. We recommend, at a maximum, quarterly reports.


Appendices

references

1. GrupoPanamericanodeEvaluacióndelaInfecciónHospitalaria.Evaluacióndelainfecciónhospitalariaensietepaíseslatinoame-ricanos.RevPanamInfectol2008;10(4Supl1):S112-122.

2. FernandoOtaíza,CarmemPessoa-SilvaEd.Corecomponentsfor infectionpreventionandcontrolprogrammesInfectionPre-ventionandControlinHealthcareInformalNetworkReportoftheSecondMeeting,26–27June2008,Geneva,Switzerland.WorldHealthOrganization2009.

3. Preparacióndelosestablecimientosdesaludantecasoinusita-dooimprevistooconglomeradodeinfecciónrespiratoriaagudagrave–IRAG.VersiónABRIL/2009.OrganizaciónPanamericanadelaSalud.

4. BRASIL.Ministério da Saúde. Padronização daNomenclaturanoCensoHospitalar.PortariaNº312demaiode2002.

5. Horan,Andrus,andDudeck.CDC/NHSNSurveillanceDefinitionofHealthcare-AssociatedInfectionandCriteriaforSpecificTy-pesofInfectionsintheAcuteCareSetting.AmJInfectControl2008,36:309-32.

6. Manualdeorientaçõesecritériosdiagnósticossistemadevigi-lânciaepidemiológicadasinfecçõeshospitalaresdoestadodeSãoPaulo.Março2009.SecretariadeestadodasaúdedeSãoPaulo.CoordenadoriadeControledeDoenças–CCD.Centrodevigilânciaepidemiológica“prof.AlexandreVranjac”.DivisãodeInfecçãoHospitalar.

7. Guíadeevaluaciónrápidadeprogramasdeinfeccionesintrahos-pitalarias.Washington,D.C.Juliode2005.Áreadeprevenciónycontroldeenfermedadesunidaddeenfermedadestransmisi-bles.OrganizaciónPanamericanadelaSalud.

8. Zuritaycolaboradores.GuiadeTomadeMuestrasparaMicro-biologia.Zuritaandcols.OPS2010.Inpress.

v I


Uri

nar

y tr

act

infe

ctio

n (U

TI)

IndwellingurinarycatheterYES(1)/NO(0)

IndwellingurinarycatheterYES(1)/NO(0)

DateofIU

Cstart:(dd/m

m/aaaa)

DateofIU

Cstart:(dd/m

m/aaaa)

DateofIU

Cend

s:(d

d/m

m/aaaa)

DateofIU

Cend

s:(d

d/m

m/aaaa)

IUCdays:

IUCdays:

SyntomaticUrinarytractinfection?

YES(1)/NO(0)

SyntomaticUrinarytractinfection?

YES(1)/NO(0)

UTIdate:

UTIdate:

Etiologicalagent:

Etiologicalagent:

Blo

od

stre

am in

fect

ion

(BS

I)

Centralvenou

scatheterYES(1)/NO(0)

Centralvenou

scatheterYES(1)/NO(0)

DateofCVCstart:(dd/m

m/aaaa)

DateofCVCstart:(dd/m

m/aaaa)

DateofCVCend

s:(dd/m

m/aaaa)

DateofCVCend

s:(d

d/m

m/aaaa)

CVCdays:

CVCdays:

Blood

stream

infection?Y

ES(1)/NO(0)

Blood

stream

infection?Y

ES(1)/NO(0)

BSId

ate:

BSId

ate:

Etiologicalagent:

Etiologicalagent:

4 7M O D U L E I

Appen

dix1.F

orm

fo

r D

evic

e-A

sso

ciat

ed In

fect

ion

Mo

nit

ori

ng

Nu

mer

ato

r an

d D

eno

min

ato

r C

olle

ctio

n F

orm

Infection1:

IncomingICUdate:

Pat

ient

iden

tifc

atio

n:DischargeIC

Udate:

Nam

e:Gender:(F)o(M

)

Patientidentification:

Dischargem

otive:dischargeofh

ospital(0),

transfertoanotherho

spital(1)†,d

ischargeof

ICU(2),death(3)†.

Age:

Incomingdisease:

Bed

num

ber:

Pn

eum

on

ia (P

NE

U)

MechanicalVentilationYES(1)/NO(0)

MechanicalVentilationYES(1)/NO(0)

DateofM

Vstart:(dd/m

m/aaaa)

DateofM

Vend

s:(dd/m

m/aaaa)

DateofM

Vend

s:(d

d/m

m/aaaa)

DateofM

Vend

s:(dd/m

m/aaaa)

MVdays:

MVdays:

Pneum

onia?YES(1)/NO(0)

Pneum

onia?YES(1)/NO(0)

Pneum

oniadate:

Pneum

oniadate:

Etiologicalagent:

Etiologicalagent:


Mon

th/Day

#patientew/CVC

#patientew/IUC

#patientew/MV

#Patient

15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Tota

l

4 9M O D U L E I

Appen

dix2.D

eno

min

ato

rs

Ho

spit

al

ICU

Mon

th/Day

#patientew/CVC

#patientew/IUC

#patientew/MV

#Patient

1 2 3 4 5 6 7 8 9 10 1 1

12 13 14


Incidence

PNEU/M

VBAC/CVC

UTI/IUC

%USEM

V%USECVC

%USEIU

C

Tota

l Ho

spit

al

5 1M O D U L E I

Appen

dix3.H

ealt

hca

re-A

sso

ciat

ed In

fect

ion

s D

ata

Co

llect

ion

Tab

le-H

osp

ital

Year

Intensive

careunit

Num

berof

mechanical

ventilation

associated

pneum

onia

Num

berof

indwellinguri-

narycatheter

associated

urinarytract

Num

berof

centralvenou

scatheter

associated

blood

stream

infection

Ventilation-

days

CVC-days

IUC-days

Tota

l patient-days

Tota

l


Incidence

PNEU/M

VBAC/CVC

UTI/IUC

%USEM

V%USECVC

%USEIU

C

Tota

l Co

untr

y

5 3M O D U L E I

Appen

dix4.H

ealt

hca

re-A

sso

ciat

ed In

fect

ion

s D

ata

Co

llect

ion

Tab

le-M

inis

try

of

Hea

lth

Year

/Mo

nth

Hospitalnam

eNum

berof

mechanical

ventilation

associated

pneum

onia

Num

berof

indwellinguri-

narycatheter

associated

urinarytract

infections

Num

berof

centralvenou

scatheter

associated

blood

stream

infection

ventilation-

days

CVC-days

IUC-days

Tota

l patient-days

Tota

l Co

untr

y


Hea

lth

care

-ass

oci

ated

infe

ctio

ns

in IC

U

Year

Inci

den

ce D

ensi

ty (p

er 1

000

dev

ice

day

s). P

erce

nti

l

Infe

ctio

ns

und

er

surv

eilla

nce

1025

5075

90

Mechanical

ventilation-

associated

pneum

onia

Indwellinguri-

narycatheter-

associated

urinarytract

infection

Centralve-

nouscatheter-

associated

blood

stream

infection

5 5M O D U L E I

Appen

dix5. F

orm

fo

r S

end

ing

Dat

a to

th

e P

an A

mer

ican

Hea

lth

Org

aniz

atio

n

An

nu

al C

ou

ntr

y R

epo

rt

Cou

ntry:

Totalpop

ulation:

Year:

Totalnum

berofh

ospitalsrep

orting:

Num

berofICUs:

Administrativecatego

ry:

Num

berofp

ublichospitals:

Num

berofp

rivateho

spitals:

Num

berofu

niversityhospitals:

Num

berofo

ther:

Totalnum

berofb

eds:

Laboratory:

Num

berofintensivecareunit(IC

U)b

eds:

Num

berofisolates/year:

Num

berIC

U/adults:

Num

berofantibiogram

s/year:

Num

berIC

U/ped

iatrics:

Num

berIC

U/neonatology:


40K

leb

siel

la p

neum

onia

e resistanttothird

generationcephalosporins

54P

seud

omon

asspmipenem

-resistant

64S

taph

yloc

occu

s au

reus

oxacillin-resistant

65/66

S. e

pid

erm

idisand

otheroxacillin-resistant

coagulase-negativestap

hylococcus

5 7M O D U L E I

Appen

dix6.E

tio

log

ic A

gen

ts o

f H

ealt

h-A

sso

ciat

ed In

fect

ion

s an

d A

nti

bio

tic

Su

scep

tib

ility

Pro

file

of

Mic

roo

rgan

ism

s

Mic

roo

rgan

ism

C

od

eM

icro

org

anis

m a

nd

resi

stan

ce p

rofi

leN

umb

er o

f is

ola

tes

Pne

umo

nia

Bac

tere

mia

Uri

nary

tra

ct

infe

ctio

n

1A

cine

tob

acte

r b

aum

aniiimipenem

-resistant

10C

and

ida

alb

ican

s

11C

and

idano

nalbicans

12C

and

idasp(fillon

lywhenno

speciesis

identified

bythelaboratory)

32E

sche

richi

a co

li resistanttothirdgeneration

cephalosporins

31E

nter

ococ

cussprvancom

ycin-resistant


Withanendotrachealaspirate,thesampleistakenbyaspirationofrespiratorysecretionsthrou

ghtheend

otrachealtub

eusinga

DeLeetrap.T

hetrap,w

hichholdsthesample,issenttothelaboratory.Nosalinesolutionshou

ldbeinstilled

,sinceitsintrod

uction

wou

lddilutethesecretionsand

alterthebacterialcou

nt.A

sam

plecanalsobetakenthroug

hatracheostomy.Intheabsenceofa

DeLeetrap,asuctioncathetercanbeused

,and

thesam

pleobtained

senttothelaboratoryinasterilecontainer.Th

esuctiontube

shou

ldnotbesenttothelaboratory.

Labelthesam

ple,indicatingthesuspecteddiagn

osisand

theantimicrobiald

rugsthepatientisreceiving

.Dono

trefrigeratethe

sample,and

transportitimmed

iatelytothelaboratory.

Allendotrachealaspiratesshou

ldbeprocessed

forbacterialcou

nt,w

hichsho

uldbeinclud

edinthelaboratoryreport.

Bro

ncho

alve

ola

r La

vag

e (B

AL)

Broncho

alveolarlavageisaninvasiveprocedureforob

tainingasample,whichm

eansthatanexhaustivesearchform

icroorgan-

ismsisjustified

regardlessofthequalityofth

esample().Th

issam

pleisobtained

byaspecialist.Them

etho

disusedto

washcells

inairw

aysthatcanno

tbeaccessed

throu

ghtheuseofabroncho

scop

e.Thegoalistowashtheaffected

lobe,althou

ghbilateral

washing

increasesthelikelihoo

dofrecoveryofcertainpatho

gens.Inad

dition

tobeing

particularlyusefulfordiagn

osingventilator-

associated

pneum

oniainpatientswithm

echanicallyassistedventilation,itisalsousefulinHIVorAIDScasesand

,toalesser

extent,forpatientswithpneum

onia2,3,4).ABALprocedurerequiresthefollowing:

1.

Adou

ble-lum

enbroncho

scop

ewithatelescop

ingdou

blecatheterand

adistalpolyethyleneglycolplugforcollectingthewash.

Theinvolved

areaofthelung

sho

uldbeaccessible.

2.

Lidocaine(2%)foranesthesia,delivered

locallythrou

ghthelumenofthefibroscop

e.

3.

Ringer’slactateorsalinesolutionforwashing

.4.

ALukenstrap

inwhichtoplacethesam

ple.

5.

Anintravenou

ssedativetoim

provethepatient´stoleranceoftheprocedure.

5 9M O D U L E I

Appen

dix7.S

pec

imen

Co

llect

ion

VE

NT

ILA

TO

R-A

SS

OC

IAT

ED

PN

EU

MO

NIA

Pneum

oniadiagn

osiscanbeperform

edth

roug

hconventional,no

n-invasivem

etho

dssuchasthecollectionofasputum

sam

pleor

trachealaspirate(trachealtub

eortracheostom

y)using

aDeLeetrapand

moreaggressivem

etho

dsthatreq

uireaninvasiveproce

-dure.Invasivem

etho

dsforob

tainingsamplesare:

•End

otrachealaspirate

•Bronchialwashing

•Broncho

alveolarlavage

•Protected

specimenbrushing

•Mini-BAL

•Lung

biopsy

End

otrachealaspirate,b

roncho

alveolarlavage,and

protected

specimenbrushing,inthatorder,g

ofrom

highesttolowestsensitiv-

ity,b

utleasttogreatestspecificity.T

hequantitativecultureproduced

byanend

otrachealaspirateisveryusefulinligh

tofthefact

thatabroncho

scop

eandpersonneltrained

initsusearenecessaryformoreinvasivem

easures.

End

otr

ache

al A

spir

ate:

Thistechniqueisusedwhenapatientisunabletoexpectorate,thepotentialpatho

genisunkno

wn,orthereisapoo

rrespon

seto

treatm

ent.Itisth

esimplestm

etho

dfo

rob

tainingtracheob

ronchialsecretionsinth

epatientwithm

echanicalrespiratoryassistance.


Thead

vantageofthistechniqueisthatisdoesno

trequiretheuseofafibrobroncho

scop

e.Itisofferedasanalternativetoother

techniquesforthediagn

osisofventilator-associatedpneum

onia.A

ccordingtoastudybyRou

by(5),theusefulnessofm

ini-BALfor

diagn

osingventilator-associated

pneum

oniawasfou

ndtobelow.Th

eprocedurehasanLR+of2.2andanLR

-of0.43andlacks

thereliabilityofend

otrachealaspirates,broncho

alveolarlavage,and

protected

bronchialbrushing.

Pro

tect

ed B

ronc

hial

Bru

shin

g (P

BB

):

Thisprocedureissimilartothebroncho

alveolarlavage,withtheexcep

tionthatthebroncho

scop

eisadvanced

throu

ghadou

ble-

sheathed

,balloon

-tipped

,plugg

edcatheter.Th

epreviou

slyinflatedballoon

tipisusedto

protectthesamplefrom

possiblecon

tami-

nationbyfloraintheupperrespiratorytract(6,7).

•Insertthecytolog

ybrushintothechannelopeningofthebroncho

scop

eandadvancethebrushthrou

ghit.

•Rem

ovetheplugatitstip

and

insertthecatheterintotheinfected

area.Collectthesam

pleand

rem

ovethecatheter.

•Placetheentirebrushingunitinatransportmed

ium,w

hichcanbelactated

Ringer’ssolutionorsaline(1ml).

•Sendtothelaboratory.

•Fo

rped

iatricpatients,proceed

aswithadults.

Lung

Bio

psy

:

Histopatho

logicalstudiesofth

elung

havebeenconsidered

thego

ldstand

ardbyamajorityofstudiesthathaveevaluatedth

esuc-

cessofdiversediagn

osticm

etho

dsforventilator-associated

pneum

onia(2).Notwithstanding,therep

roducibilityofthism

etho

d

hasbeendrawnintoquestiongiventhelackofagreementinthehistopatho

logicalresultsproduced

bythesameop

eratororthose

ofthreedifferenttechnicians(8).Th

emetho

dcanbeperform

edthrou

ghaneedlebiopsyoranopenbiopsy.Intheform

er,e

ithera

computerized

tomog

raphyorthoraciccavityx-raycanbeused

toidentifytheexactlocationofth

ebiopsy.T

helatterta

kesplacein

anoperatingroom

und

ergeneralanesthesia.

6 1M O D U L E I

Appen

dix7.S

pec

imen

Co

llect

ion

(Co

ntin

ued

)

Inorderto

perform

theBAL,tiltthepatientintoasem

i-Fo

wler´sposition

.Lub

ricatethebroncho

scop

ewith2%xylocainejelly,avoid

-ingthedistaltip.Introducethebroncho

scop

etransnasally.A

ttachtheLukenstraptothebroncho

scop

e.

Whentreatinganadult,stron

glyinstill100m

lofsterilesalinesolutionthroug

hthechannelopeningin20mlaliquo

ts.F

orped

iatric

patients,instillnomorethan1to2ml/kgofweigh

t.Generally,few

erthan10m

loffluidareretrievedfrom

children.(Ifm

orethan10

mlareretrieved,sam

plecentrifugationimprovesrecoveryinthecultureand

visualizationinthestains).

Ifconvenient,afterthethirdorfourthinstillation,the70mltrapcanbereplacedwitha40mltrap.B

othcollectiontrap

sshou

ldbe

senttothelaboratory(label70mland

40mltrap).Th

efirsttraptobecollected

isthem

ostcontam

inated

withpurulentrespiratory

secretionsand

isveryusefulfordetectingfung

us,mycob

acteriaand

P.

jirov

eci;thesecond

trapisusefulforquantitativecultures

andbacterialstudies.Forthisreason

,inthecaseofventilator-associated

pneum

onia,o

nlythesecond

trapisreq

uired.Instead

of

send

ingthetrap

stoth

elaboratory,itisalsopossibleto

withdraw10mlofliquidfrom

eachtrap

,placing

them

insteriletubes.These

tubes,lab

eled

1and

2,aresenttothelabusing

thesam

egu

idelinesfo

rsend

ingtrap

s.

Sam

plesarenottoberefrigerated.Theyaresenttothelabo

ratoryim

mediatelyand

shouldbeprocessedwithintw

ohoursofcollection.

Min

i-B

al:

Atelescopiccatheterisintroduced

intothebronchialtreeandadvanced

untilmetw

ithresistance.Theinternalcatheteristhen

advanced

,and25mlofnormalsalineareinstilled

using

asyringe.Th

easpiratedfluidand

theinternalcathetertipareusedfor

microbiologicalstudies.


Tran

spo

rt a

nd C

ons

erva

tio

n o

f R

esp

irat

ory

Sam

ple

s:

End

otrachealaspiratesam

plesshou

ldbesenttothelaboratoryinaDeLeetrap;BALsamplesshou

ldbesentinLukenstraps;

mini-BALsamplesshou

ldbesentinasterilized

con

tainer;and

bronchialbrushingsamplessentprotected

in1m

lsalinesolutionor

lactated

Ringer’ssolution.Ifnotrap

sareavailable,sam

plesmaybesentinsterilized

,well-sealed

,screw

-top

con

tainerswithintwo

hoursofhavingbeencollected

.Biopsytissuesamplesshou

ldbedivided

intotwo;onefractionshou

ldbesenttothelaboratoryin

10%fo

rmaldehydeforhistop

atho

logicalstudy,and

theother,insalinesolutionformicrobiologicalstudy(9).

UR

INA

RY

TR

AC

T IN

FEC

TIO

N

Pat

ient

s w

ith

bla

dd

er c

athe

ter:

Inpatientswithanindwellingcatheter,urinewillbetakenwithasterileneed

leand

syringe.Th

ecatheterand

theclosedsystem

areem

ptiedand

thenclam

ped

for5m

inutes,subsequentlydisinfectingwithalcoh

olanap

propriateareatopuncture.Theareais

punctured

withtheneedleand

syringe,and

approximately10m

lofurineareextracted.U

rineshou

ldbetakenbyaspirationwitha

need

lefrom

adisinfected

pointinth

econnection,butnotfrom

thecollectionbag,orbydisconnectingthecatheterfrom

thecollec-

tiontube.Ifnoplacefo

rpuncturingexistsontheextension,thecatheterispunctured

atitssoftestspotwithaneedleand

syringe.

Approximately10m

lofu

rineareextracted.Ifacatheterisused,d

ono

tsend

thetipoftheFoleycatheterforculture(10).

Itispreferableto

obtainth

esamplefrom

thefirsturinevoided

inth

emorning

(1).Atthistim

ethebacterialcou

ntwillbehigh

er,since

bacteriacanm

ultip

lyastheyincubateovernigh

t(every20minutes).Otherwise,wait4ho

ursafterthepatient’slastvoidingbefore

collectingthesample.U

rinationshou

ldnotbeforced

withliquids,butifitis,itshou

ldbestated

ontheordersheet.U

rinecollected

6 3M O D U L E I

Appen

dix7.S

pec

imen

Co

llect

ion

(Co

ntin

ued

)

Nee

dle

Bio

psy

:

Ifthebiopsyiscon

ductedusing

com

puterized

tom

ography,thepatientm

ustremainho

rizon

talduringtheexam

.Alung

biopsycan

alsobecond

uctedbypricking

thepatientduringabroncho

scop

yorm

ediastinoscopy.

Theskiniscleansedand

localanesthesiainjected

.Thepatientisasked

toremainstilland

withou

tcoug

hing

forthedurationofthe

biopsy.A

smallincisionofapproximately3mmism

adeintheskin.Thebiopsyneedleisinserted

intothepulmon

arytissue.

Asmalltissuesampleiscollected

withtheneedleand

senttoalaboratoryforanalysis.Sendonepulmon

arytissuefragmentin

form

aldehyde(10%

)forhistopatho

logicalstudyandano

therinsalinesolutionformicrobiologicalstudy.

Pressureisappliedtothesiteand

,on

cethebleed

inghasstop

ped

,abandageisapplied.Anx-rayofthetho

raciccavityistaken

immed

iatelyafterthebiopsy.

Theprocedureno

rmallytakesbetween30and

60minutes.T

helaboratoryanalysiscantakeafewdays.

Op

en B

iop

sy:

Acatheterisinserted

throu

ghtthepatient´soralcavitytotheairways.Aftercleaningthepatient’sskin,thesurgeon

makesaninci

-sion

inth

ethorax,rem

ovesasmallamou

ntoflungtissue,and

suturesth

eincision

.Chesttu

besm

ayre

maininplacefo

ron

eortw

odaysinorderto

preventthelung

sfrom

collapsing

.Thereisbothariskofinfection,and

ariskthatairmayleakintothethoraxthroug

hapuncture,whichdep

endson

whetherthepatientdoesordoesno

talread

yhavepulmon

arydisease.


Cat

eriz

ació

n:

Urethralcatheterizationisrecom

mended

asaroutinesamplingmetho

dfo

rurineculture.

1.

Personneltakingthesamplem

ustwashtheirhand

s.

2.

Externalgenitaliaarewashedgentlyusing

awet,soapycompressorgauze.

3.

Afterwashing

,genitaliaarerinsedwithwaterand

driedwithsterilegauze.

4.

Thecatheterisinserted

using

aseptictechnique.

Sam

ple

Tra

nsp

ort

:

Oncetheurinesampleiscollected

itsho

uldbeprocessed

immed

iately.Ifthisisnotpossible,thesam

plem

aybestored

inarefrig

-eratorat4oCforam

aximum

of24hou

rs.Refrig

erationpreventsbacterialgrowth.Collectioncontainersthatinclud

epreservatives

intab

letform

arecom

merciallyavailable.Ifthiscom

mercialm

etho

disnotavailable,thesamplecanbepreserved

inboricacid.

Anyofthesem

etho

dscanbeused

ifitisinevitablethatthesamplerem

ainatroo

mtem

peratureforseveralhou

rsprio

rtoorduring

transporttothelaboratory.Thus,theorganismcanbepreserved

withou

tfacilitatingthegrow

thofcontam

inantsthatmighthave

beenintrod

uced

intothesam

ple.

6 5M O D U L E I

Appen

dix7.S

pec

imen

Co

llect

ion

(Co

ntin

ued

)

withou

ttheprecautionofcleansing

thegenitalsbeforehandcanleadtofalsepositiveresults.Fo

rad

ults,thepossiblesam

pling

metho

dsare:

Sp

ont

aneo

us u

rina

tio

n:

Thism

etho

dcanbeused

withadultsand

childrenwho

alread

yhavesphinctercontrol.Th

efollowingcollectionmetho

dissuitable

forad

ultwom

en:

1.Personnelcollectingthesamplem

ustwashtheirhand

s.2.Thepatient´sexternalgenitaliaarewashedgentlyusing

soapy,wetcom

pressorgauze;antisep

ticsshou

ldbeavoided

sinceth

ey

canmixwithth

eurineandgivefalsenegativeresults.W

ashbyspread

ingthelegsand

spread

ingthelabiawithonehandwhile

washing

theareagentlywiththeotherhandfrom

fron

ttobackusingon

egauzeatatime.

3.Afterwashing

,rinsewithwaterand

drywithatow

elusing

thesam

emovem

entsdetailedabove.

4.Keepingthelabiasep

arated

,thepatientsho

uldstarturinating,discardingtheinitialstreamofurine,whichm

echanicallyflushes

theurethralchannel.Thesecon

dparto

furination(midstream

)(11)w

illbecollected

inasterilewide-mou

thcon

tainer,w

hichwill

beimmed

iatelyclosedand

willbedelivered

tothelaboratoryforprocessing.

Inm

ales,urinecollectionissimpler.Instructuncircum

cisedm

alestoretracttheforeskin.Oncetheglanshasbeencleansed

and

thendriedwithagauzeorcompress,urineisalsocollected

midstream

,discardingthefirstportionoftheurine.


1.

Wheneverpossible,informthepatientabou

ttheprocedure.

2.

Washanddryhandsproperly.

3.

Thorou

ghlycleansetheselectedsiteontheskinwith70%

isop

ropylorethylalcoh

ol.

4.

Spread

anantisep

ticonthesite(1-2%iodinetincture,orp

ovidon

eiodine,or2

%chlorhexidine).C

leansing

isdon

einacircular

motion,startingtowardsthecenterand

movingou

tward.Itisimportantto

allowtimefortheantisep

tictodryfo

rittowork;do

notwipetheareawhilestillw

et.

5.

Disinfecttherub

berstopperonthebottlewithalcoh

oloranotherantisep

ticbeforepuncturingthebottle.W

aitforittodry.

6.

Putonsterilegloves.

7.

Dono

tpalpatethevenipuncturesitewithfing

ers,and

dono

tspeakorcou

ghwhiledrawingblood

.Som

etimespalpatingthe

veincanno

tbeavoided

;ifisthecase,thecollector’sfing

erm

ustundergo

thesam

ecleansinganddisinfectionprocedure,or

sterileglovesmustbeworntoperform

theprocedure.

8.

Inserttheneedleintotheselectedveintoextractthereq

uiredvolum

eofblood

.9.

Oncetheblood

iswithdrawn,inoculatethebottleim

med

iatelybyperforatingitverticallywiththeneedleinordertoavoidco-

agulationoftheblood

inthesyringe.Ino

culateslowlytopreventhem

olysis.Ifavacuum

extractionsystem

isbeing

used,the

blood

candirectlyinoculatethebottlesoftheautomated

system.Thevacuuminthistypeofbottlerapidlyextractsthecontents

ofthesyringe;o

ncethepatienthasstopped

bleed

ing,withdrawtheneedle.

10.Itisnotnecessarytoreplacetheneedlebeforeinoculatingtheblood

inthebottle(11).

11.Placethecottonballonthepuncturesite,m

aintainpressureforafewm

inutes,and

thenap

plyanad

hesivebandage.

Theblood

sam

plesho

uldbesenttothemicrobiologylab

oratoryimmed

iately.Ifthisisno

tpossible,itshou

ldbeincubated

at

35o C-37oC.Ifno

stoveisavailableforincubation,itsho

uldbeleftatroom

tem

perature(dono

trefrigerate)untiltransferredtothe

laboratory.Sam

plesaretransportedatroom

tem

perature.

6 7M O D U L E I

Appen

dix7.S

pec

imen

Co

llect

ion

(Co

ntin

ued

)

BLO

OD

CU

LTU

RE

Theblood

culturesam

pleistakenthrou

ghvenipuncturefollowingpropercleansing

ofthesitewheretheskinistobepunctured

.

Materialsneeded

forthedrawingshou

ldbeprepared

onaworktrayand

sho

uldinclud

e:•

Alcoh

olal70%

,•

70%alcoh

ol

•Antisep

ticsolution

•10or20m

lsyringesorVacutainer®system

•Needlesforvenipuncture

•Gauzeorcotton

balls

•Examinationgloves

•Adhesivetap

e•

Adhesivebandages

•Blood

culturebottlesforaerobesand

anaerob

espreviou

slylabeled

withthepatient’snam

e,bed

num

ber,room

,tim

eofblood

drawing,and

chartnum

ber.Ifanautomated

systemisbeing

used,avoidwritingon

orplacing

stickersoverthebottlebarcod

e.

Eachblood

sam

plewillbeob

tained

from

adifferentvenipuncture,th

epointsforw

hichwillbeselected

beforehand.Theveinsofthe

forearmareusuallyusedfo

rthispurpose.

Rou

tineblood

extractionshou

ldnotbedon

ethroug

hacatheter,exceptincaseswherecatheter-associated

sep

sisissuspected,

inwhichcaseitisim

portanttoob

tainperipheralblood

sam

plesatthesam

etim

e.Theprocedurefordrawingblood

isasfollows:


references

1. ChastreJ,FagonJY,Bornet-LescoMetal.Evaluationofbron-choscopictechniquesforthediagnosisofnosocomialpneumo-nia.AmJRespirCritCareMed1995;152:231-240.

2. TorresA,El-EbiaryM.Diagnosticapproachesandhospital-ac-quiredpneumonia.SemRespirCritCareMed1997;18:149-161.

3. WimberlyN.FalingLJ,Bartlett JG.Afiberopticbronchoscopytechniquetoobtainuncontaminatedlowerairwaysecretionsforbacterialculture.AmRevRespirDis.1979;119:337-342.

4. BroaddusC,DakeMD,StulburgMS,etal.Bronchoalveolarla-vageandthransbronchialbiopsyforthediagnosisofpulmonaryinfections intheacquired immunodeficiencysyndrome.AmIn-ternMed.1986;102:742-752.

5. Rouby J J,RossignonMD,NicolásMHet al. Aprospectivestudyofprotectedbroncho-alveolar lavage in thediagnosisofnosocomialpneumonia.Anesthesiology1989;71:679-685.

6. ChastreJ,ViauF,BrunP,etal.Prospectiveevaluationofthepro-tectedspecimenbrushforthediagnosisofpulmonaryinfectionsinventilatedpatients.AmRevRespirDis1984;130:924–929.

7. WilmberlyNW,BassJB,BoydBW,etal.Useofbronchoscopicprotectedcatheterbrushfor thediagnosisofpulmonary infec-tions.Chest.1982;81:556-582

8. ReimerLG,CarrollKC:Roleofthemicrobiologylaboratoryinthediagnosisoflowerrespiratorytractinfections.ClinInfectDis1998;26:742–748.

9. Madeo M, Barlow G. Reducing blood-culture contaminationrates by the use of a 2% chlorhexidine solution applicator inacuteadmissionunits.JHospInfect2008;69:307–309.

10. ClarridgeJE,PezzloMT,VostiKL.Laboratorydiagnosisofurinarytractinfections.InWeissfeldAS,coordinatingeditor.1987Cumi-tech2A.AmericanSocietyforMicrobiology,Washington,D.C.

6 9M O D U L E I

Appen

dix7.S

pec

imen

Co

llect

ion

(Co

ntin

ued

)

Thequantityofb

lood

iscurrentlyregarded

ason

eofthem

ostcriticalvariablesintheincreaseinpositivityofb

lood

cultures(13,14,

15).Becausethem

ajorityofbacteremiasareoflowm

agnitude(<1-10CFU

/ml),highersamplevolum

elead

stogreatersensitivity

ofth

eblood

culture.Foreachad

dition

almlofsam

pleth

atisinoculated

inth

ebottle,p

ositivityincreases2%

-5%.M

ermeland

Maki

(16)dem

onstratedasignificantreduction(p<0.001)inblood

culturepositivitywhenanaverageof2.7ml(69%)w

ereob

tained

in

comparison

with8.7m

l(92%).Th

eimportanceofthevolum

eofblood

holdsevenwhenusingautomated

equipment(15,17,18).

Thegenerallyaccep

tedvolum

eofcultureblood

is10mlp

erextractionforad

ults.Innew

bornsand

prematurebab

ies,1m

l;inin

-fants,between2and3m

l;inprescho

olchildrenandschoo

lchildren,3to5ml;andinadolescents,10ml(12).

Ifthepatientistakingantim

icrobiald

rugs,b

lood

culturebottlescontaining

resins(autom

ated

systems)sho

uldbeused

inorderto

neutralizethedrugsadministeredtothepatient.

Therecommendationisforgrowingtwoblood

culturesin24ho

urswitha30-90m

inuteintervalbetweenthem

(19,20).Incasesof

meningitisorsepticsho

ck,asetoftwoblood

cultureswithanintervalof3

0minutesorlesscanbetaken.Ifthepatientisgoing

to

requireim

med

iateantimicrobialtreatment,twoblood

culturescanbeob

tained

atthesametim

e,butfrom

differentpuncturesites.


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2. JourdainB,NovaraA,Joly-GuillouML,DombretMC,CalvatS, Trouillet J L et al. Role of quantitative cultures of endotra-chealaspiratesinthediagnosisofnosocomialpneumonia.AmJRespirCritCareMed1995;152:241-246.

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Module I EpidEmiological SurvEillancE of HEaltHcarE ...

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