Annexure D: Healthcare Associated Infections Surveillance and Definitions
Supporting the Antimicrobial Resistance Strategy Framework and the Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach and Governance, 2018
Definitions of HAIs can follow either the United States Centers for Disease Control and Prevention (CDC) or Institute for Healthcare Improvement (IHI) definitions below:
HAI | CDC | IHI |
Central Line- associated Blood Stream Infections (CLABSI) | A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1, AND the line was also in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then removed, the date of event of the LCBI must be the day of discontinuation or the next day to be a CLABSI. If the patient is admitted or transferred into a facility with an implanted central line (port) in place, and that is the patient’s only central line, day of first access in an inpatient location is considered Day 1. “Access” is defined as line placement, infusion or withdrawal through the line. Such lines continue to be eligible for CLABSI once they are accessed until they are either discontinued or the day after patient discharge (as per the Transfer Rule). Note that the “de-access” of a port does not result in the patient’s removal from CLABSI surveillance.54 | Primary bloodstream infection occurring in a patient: Criterion 1: with a central line# in situ; OR where infection occurs within 48 hours of the removal of the central line; and Criterion 2: where no other possible source of the bloodstream infection is identified (i.e. does not include secondary bloodstream infections). There is no minimum period of time that the central line must be in place in order for the bloodstream infection to be considered central line-associated. There must be no evidence that the infection was present or incubating at the time of insertion. # Central line: an intravascular catheter that terminates at or close to the heart or in one of the great vessels (aorta, pulmonary artery, superior & inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins and common iliac or femoral veins; neonates: umbilical artery or vein). Must be a lumened device which is used for infusion, withdrawal of blood or hemodynamic monitoring. May be temporary or permanent (e.g. dialysis tunnelled or implanted catheters, including ports). |
| Catheter- associated Urinary Tract Infections (CAUTI) | A UTI where an indwelling urinary catheter was in place for >2 calendar days on the date of event, 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. If an indwelling urinary catheter was in place for > 2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next day for the UTI to be catheter-associated.55 | UTI in a patient • with an in-dwelling urinary catheter# at the time or within 48 hrs before onset of the event, where a positive culture is available; OR • the patient has signs and symptoms of a UTI with no other possible cause and a positive urine culture of >100 000 CFU/ml with no more than 2 species of microorganisms (uropathogens##); OR • the patient has NO signs or symptoms of UTI but DOES have a positive urine culture of >100 000 CFU/ml with no more than 2 species of uropathogen and has a positive blood culture with at least one matching uropathogen. • There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated. • There must be no evidence that the infection was present or incubating at the time of catheter placement. #In-dwelling catheter: A drainage tube that is inserted into the urinary bladder through the urethra AND is left in place AND is connected to a closed drainage system. Straight in-and-out catheters, condom catheters and supra-pubic catheters are not included in the definition. ## Uropathogens are: Gram-negative bacilli, Staphylococcus spp, yeasts, Beta haemolytic Streptococcus spp, Enterococcus spp, G. vaginalis, Aerococcus urinae and Corynebacterium (urease positive) |
| Surgical site infection (SSI) | A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material. | An infection related to a surgical intervention or operation# • that occurs within thirty days of surgery; OR • within one year of surgery if an implantable device or non-human foreign body is placed. # An operation: takes place in an operating room, during a single trip, where the surgeon makes at least one incision through the skin or mucous membranes and the incisions are closed before the patient leaves the operating room. Includes laparoscopy. Debridement of burns or pressure ulcers and skin grafts are NOT included. SSI’s are further differentiated as superficial, deep incisional or organ space, depending on the location of the infection within the wound. There must be no evidence that the infection was present or incubating at the time of incision. |
| Ventilator associated pneumonia (VAP) | Pneumonia occurring in a patient: • requiring continuous assisted ventilation# through either a tracheostomy or endotracheal tube; • where the infection occurs during the period of ventilation or within 48 hours of the removal of the assisting device. Diagnosis of pneumonia is based on radiological features as well as clinical features of infection. There is no minimum period of time that the ventilator must be in place in order for the pneumonia to be considered ventilator-associated. There must be no evidence that the infection was present or incubating at the time of intubation. # Ventilator: a device to assist or control respiration continuously through a tracheostomy or by endotracheal intubation. Lung expansion devices like: intermittent positive pressure breathing (IPPB) or nasal positive end-expiratory pressure (PEEP) or continuous nasal positive airway pressure (CPAP or hypoCPAP) are NOT considered ventilators unless delivered via tracheostomy or endotracheal intubation (e.g. ETCPAP). | Pneumonia in a patient intubated and ventilated at the time of or within 48 hours before the onset of the event. (There is no minimum period of time that the ventilator must be in place in order for the pneumonia to be considered ventilator-associated.)56 |
Measurement of HAI rates per type:
CLABSI rate = (Number of central line associated bloodstream infections / number of central line days) x 1000
Goal: Reduce CLABSI rate by 40% in one year
CAUTI rate = (Number of catheter associated urinary tract infections / number of urinary catheter days) x1000
Goal: Reduce CAUTI by 25% in one year
SSI Rate = (Number of surgical site infections in a specific discipline / number of surgeries in that discipline) x 1000
Goal: Reduce SSI rate by 30% in one year OR number of cases between surgical site infections
VAP rate = (Number of ventilator associated pneumonias / number of ventilator days) x 1000
Goal: Reduce VAP rate by 25% in one year
54 Centers for Disease Prevention and Control. Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Noncentral Line Associated Bloodstream Infection), 2018. Available from https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf.
55 Centers for Disease Prevention and Control. Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non- Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events, 2018. Available from www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf.
56 Institute for Healthcare Improvement, accessible at www.ihi.org