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1672 Section XV: Organization and Implementation of Infection Control Programs

insic risk-adjusted rates of adverse outcomes. Failure to do so


will certainly make interhospital comparisons meaningless or
From: Horan TC, Gaynes RP. Surveillance of nosocomial
infections. In:Hospital Epidemiology and Infection Control, CVS Cardiovascular System Infection
3rd ed., Mayhall CG, editor. Philadelphia:Lippincott VASC Arterial or venous infection
Williams & Wilkins, 2004:1659-1702. ven misleading (27). ENDO Endocarditis
CARD Myocarditis or pericarditis
MED Mediastinitis
APPENDIX A-1. CDC DEFINITIONS OF EENT Eye, Ear, Nose, Throat, or Mouth Infection
NOSOCOMIAL INFECTIONS [EXCLUDING CONJ Conjunctivitis
PNEUMONIA (SEE APPENDIX A-2)] EYE Eye Other than conjunctivitis
EAR Ear Mastoid
Listing of Major and Specific Site Codes and ORAL Oral Cavity (mouth, tongue, or gums)
Descriptions SINU Sinusitis
UTI Urinary Tract Infection UR Upper respiratory tract, pharyngitis,
SUTI Symptomatic urinary tract infection laryngitis, epiglottitis
ASB Asymptomatic bacteriuria GI Gastrointestinal System Infection
OUTI Other infections of the urinary tract GE Gastroenteritis
GIT Gastrointestinal (GI) tract
SSI Surgical Site Infection HEP Hepatitis
SKIN Superficial incisional site, except after IAB Intraabdominal, not specified elsewhere
CBGB1 NEC Necrotizing enterocolitis
SKNC After CBGB, report SKNC for superficial LRI Lower Respiratory Tract Infection, Other Than
incisional infection at chest incision site Pneumonia
SKNL After CBGB, report SKNL for superficial BRON Bronchitis, tracheobronchitis, tracheitis,
incisional infection at leg (donor) site without evidence of pneumonia
ST Deep incisional surgical site infection, LUNG Other infections of the lower respiratory
except after CBGB tract
STC After CBGB, report STC for deep REPR Reproductive Tract Infection
incisional surgical site infection at chest EMET Endometritis
incision site EPIS Episiotomy
STL After CBGB, report STL for deep VCUF Vaginal cuff
incisional surgical site infection at leg OREP Other infections of the male or female
(donor) site reproductive tract
Organ/Space Surgical Site Infection SST Skin and Soft Tissue Infection
Indicate specific site: SKIN Skin
BONE, BRST, CARD, DISC, EAR, ST Soft tissue
EMET, ENDO, EYE, GIT, IAB, IC, JNT, DECU Decubitus ulcer
LUNG, MED, MEN, ORAL, OREP, BURN Burn
OUTI, SA, SINU, UR, VASC, VCUP. BRST Breast abscess or mastitis
UMB Omphalitis
PNEU Pneumonia (See Appendix A:2) PUST Infant pustulosis
PNU 1 CIRC Newborn circumcision
PNU 2 SYS Systemic Infection
PNU 3 DI Disseminated infection
BSI Bloodstream Infection
LCBI Laboratory-confirmed bloodstream infection Definitions of Infection Sites
CSEP Clinical sepsis INFECTION SITE: Symptomatic urinary tract infection
BJ Bone and Joint Infection CODE: UTI-SUTI
BONE Osteomyelitis DEFINITION: A symptomatic urinary tract infection must
JNT Joint or bursa meet at least one of the following criteria:
DISC Disc space Criterion 1: Patient has at least one of the following signs or
CNS Central Nervous System Infection symptoms with no other recognized cause: fever
IC Intracranial infection (⬎38⬚C), urgency, frequency, dysuria, or su-
MEN Meningitis or ventriculitis prapubic tenderness
SA Spinal abscess without meningitis and
patient has a positive urine culture, that is, ⱖ105
microorganisms per cm3 of urine with no more
1
CBGB, coronary artery bypass graft with both chest and donor site inci- than two species of microorganisms.
sions. Criterion 2: Patient has at least two of the following signs or
Chapter 94: Surveillance of Nosocomial Infections 1673

symptoms with no other recognized cause: fever 䊏 Urine cultures must be obtained using appropriate technique,
(⬎38⬚C), urgency, frequency, dysuria, or su- such as clean catch collection or catheterization.
prapubic tenderness 䊏 In infants, a urine culture should be obtained by bladder
and catheterization or suprapubic aspiration; a positive urine cul-
at least one of the following: ture from a bag specimen is unreliable and should be con-
a. Positive dipstick for leukocyte esterase and/or firmed by a specimen aseptically obtained by catheterization
nitrate or suprapubic aspiration.
b. Pyuria (urine specimen with ⱖ10 WBC/mm3
or ⱖ3 WBC/high power field of unspun urine) INFECTION SITE: Asymptomatic bacteriuria
c. Organisms seen on Gram stain of unspun urine CODE: UTI-ASB
d. At least two urine cultures with repeated isola- DEFINITION: An asymptomatic bacteriuria must meet at least
tion of the same uropathogen (gram-negative one of the following criteria:
bacteria or S. saprophyticus) with ⱖ102 colo- Criterion 1: Patient has had an indwelling urinary catheter
nies/mL in nonvoided specimens within 7 days before the culture
e. ⱕ105 colonies/mL of a single uropathogen and
(gram-negative bacteria or S. saprophyticus) in patient has a positive urine culture, that is, ⱖ105
a patient being treated with an effective antimi- microorganisms per cm3 of urine with no more
crobial agent for a urinary tract infection than two species of microorganisms
f. Physician diagnosis of a urinary tract infection and
patient has no fever (⬎38⬚C), urgency, frequency,
g. Physician institutes appropriate therapy for a
dysuria, or suprapubic tenderness.
urinary tract infection
Criterion 2: Patient has not had an indwelling uri-
Criterion 3: Patient ⱕ1 year of age has at least one of the fol-
nary catheter within 7 days before the first positive
lowing signs or symptoms with no other recog-
culture
nized cause: fever (⬎38⬚C), hypothermia
and
(⬍37⬚C), apnea, bradycardia, dysuria, lethargy, or
patient has had at least two positive urine cultures,
vomiting
that is, ⱖ105 microorganisms per cm3 of urine
and
with repeated isolation of the same microorganism
patient has a positive urine culture, that is, ⱖ105
and no more than two species of microorganisms
microorganisms per cm3 of urine with no more
and
than two species of microorganisms.
patient has no fever (⬎38⬚C), urgency, frequency,
Criterion 4: Patient ⱕ1 year of age has at least one of the fol-
dysuria, or suprapubic tenderness.
lowing signs or symptoms with no other recog-
nized cause: fever (⬎38⬚C), hypothermia COMMENTS:
(⬍37⬚C), apnea, bradycardia, dysuria, lethargy, or
vomiting 䊏 A positive culture of a urinary catheter tip is not an acceptable
and laboratory test to diagnose bacteriuria.
at least one of the following: 䊏 Urine cultures must be obtained using appropriate technique,
a. Positive dipstick for leukocyte esterase and/or such as clean catch collection or catheterization.
nitrate
b. Pyuria (urine specimen with ⱖ10 WBC/mm3 INFECTION SITE: Other infections of the urinary tract (kid-
or ⱖ3 WBC/high power field of unspun urine) ney, ureter, bladder, urethra, or tissues surrounding the retroper-
c. Organisms seen on Gram stain of unspun urine itoneal or perinephric spaces)
d. At least two urine cultures with repeated isola- CODE: SUTI-OUTI
tion of the same uropathogen (gram-negative DEFINITION: Other infections of the urinary tract must meet
bacteria or S. saprophyticus) with ⱖ102 colo- at least one of the following criteria:
nies/mL in nonvoided specimens Criterion 1 Patient has organisms isolated from culture of
e. ⱕ105 colonies/mL of a single uropathogen fluid (other than urine) or tissue from affected site.
(gram-negative bacteria or S. saprophyticus) in Criterion 2: Patient has an abscess or other evi-
a patient being treated with an effective antimi- dence of infection seen on direct examination,
crobial agent for a urinary tract infection during a surgical operation, or during a histopath-
f. Physician diagnosis of a urinary tract infection ologic examination.
Criterion 3: Patient has at least two of the following signs or
g. Physician institutes appropriate therapy for a
symptoms with no other recognized cause: fever
urinary tract infection
(⬎38⬚C), localized pain, or localized tenderness
COMMENTS: at the involved site
and
䊏 A positive culture of a urinary catheter tip is not an acceptable at least one of the following:
laboratory test to diagnose a urinary tract infection. a. Purulent drainage from affected site
1674 Section XV: Organization and Implementation of Infection Control Programs

b. Organisms cultured from blood that are com- tained culture of fluid or tissue from the super-
patible with suspected site of infection ficial incision
c. Radiographic evidence of infection, for exam- c. At least one of the following signs or symptoms
ple, abnormal ultrasound, computed tomogra- of infection: pain or tenderness, localized swell-
phy (CT), magnetic resonance imaging (MRI), ing, redness, or heat, and superficial incision is
or radiolabel scan (gallium, technetium) deliberately opened by surgeon, unless incision
d. Physician diagnosis of infection of the kidney, is culture-negative
ureter, bladder, urethra, or tissues surrounding d. Diagnosis of superficial incisional SSI by the
the retroperitoneal or perinephric space surgeon or attending physician
e. Physician institutes appropriate therapy for an
REPORTING INSTRUCTIONS:
infection of the kidney, ureter, bladder, ure-
thra, or tissues surrounding the retroperitoneal 䊏 Do not report a stitch abscess (minimal inflammation and
or perinephric space discharge confined to the points of suture penetration) as an
Criterion 4: Patient ⱕ1 year of age has at least one of the infection.
following signs or symptoms with no other recog- 䊏 Do not report a localized stab wound infection as SSI, instead
nized cause: fever (⬎38⬚C), hypothermia report as skin or soft tissue infection, depending on its depth.
(⬍37⬚C), apnea, bradycardia, lethargy, or vom- 䊏 Report infection of the circumcision site in newborns as SST-
iting CIRC. Circumcision is not an NNIS operative procedure.
and 䊏 Report infection of the episiotomy site as REPR-EPIS. Episi-
at least one of the following: otomy is not an NNIS operative procedure.
a. Purulent drainage from affected site 䊏 Report infected burn wound as SST-BURN.
b. Organisms cultured from blood that are com- 䊏 If the incisional site infection involves or extends into the
patible with suspected site of infection fascial and muscle layers, report as a deep incisional SSI.
c. Radiographic evidence of infection, for exam- 䊏 Classify infection that involves both superficial and deep inci-
ple, abnormal ultrasound, CT, MRI, or ra- sion sites as deep incisional SSI.
diolabel scan (gallium, technetium) 䊏 Report culture specimen from superficial incisions as ID (inci-
d. Physician diagnosis of infection of the kidney, sional drainage).
ureter, bladder, urethra, or tissues surrounding
the retroperitoneal or perinephric space INFECTION SITE: Surgical site infection (deep incisional)
e. Physician institutes appropriate therapy for an CODE: SSI-[ST (soft tissue)] except following the NNIS opera-
infection of the kidney, ureter, bladder, ure- tive procedure, CBGB. For CBGB only, if infection is at chest
thra, or tissues surrounding the retroperitoneal site, use STC (soft tissue-chest) or if at leg (donor) site, use STL
or perinephric space (soft tissue-leg)
DEFINITION: A deep incisional SSI must meet the following
REPORTING INSTRUCTION: criteria:
Infection occurs within 30 days after the operative procedure if
䊏 Report infections following circumcision in newborns as SST- no implantb is left in place or within 1 year if implant is in place
CIRC. and the infection appears to be related to the operative procedure
INFECTION SITE: Surgical site infection (superficial inci- and
sional) involves deep soft tissues (e.g., fascial and muscle layers) of the
CODE: SSI-(SKIN) except following the NNIS operative proce- incision
dure, CBGB. For CBGBa only, if infection is at chest site, use and
SKNC (skin-chest) or if at leg (donor) site, use SKNL (skin- patient has at least one of the following:
leg) a. Purulent drainage from the deep incision but
DEFINITION: A superficial SSI must meet the following cri- not from the organ/space component of the
teria: surgical site
Infection occurs within 30 days after the operative procedure b. A deep incision spontaneously dehisces or is
and deliberately opened by a surgeon when the pa-
involves only skin and subcutaneous tissue of the incision tient has at least one of the following signs or
and symptoms: fever (⬎38⬚C) or localized pain or
patient has at least one of the following: tenderness, unless incision is culture-negative
a. Purulent drainage from the superficial incision c. An abscess or other evidence of infection in-
b. Organisms isolated from an aseptically ob- volving the deep incision is found on direct

b
A nonhuman-derived implantable foreign body (e.g., prosthetic heart
a
CBGB, coronary artery bypass graft with both chest and donor site inci- valve, nonhuman vascular graft, mechanical heart, or hip prosthesis) that
sions. is permanently placed in a patient during surgery.
Chapter 94: Surveillance of Nosocomial Infections 1675

examination, during reoperation, or by histo- EMET Endometritis


pathologic or radiologic examination ENDO Endocarditis
d. Diagnosis of a deep incisional SSI by a surgeon EYE Eye, other than conjunctivitis
or attending physician GIT GI tract
IAB Intraabdominal, not specified elsewhere
REPORTING INSTRUCTIONS:
IC Intracranial, brain abscess or dura
䊏 Classify infection that involves both superficial and deep inci- JNT Joint or bursa
sion sites as deep incisional SSI. LUNG Other infections of the lower respiratory tract
䊏 Report culture specimen from deep incisions as ID. MED Mediastinitis
MEN Meningitis or ventriculitis
INFECTION SITE: Surgical site infection (organ/space)
ORAL Oral cavity (mouth, tongue, or gums)
CODE: SSI-(Specific site of organ/space)
OREP Other male or female
DEFINITION: An organ/space SSI involves any part of the
OUTI Other infections of the urinary tract
body, excluding the skin incision, fascia, or muscle layers, that
SA Spinal abscess without meningitis
is opened or manipulated during the operative procedure. Spe-
SINU Sinusitis
cific sites are assigned to organ/space SSI to further identify the
UR Upper respiratory tract
location of the infection. Listed later are the specific sites that
VASC Arterial or venous infection
must be used to differentiate organ/space SSI. An example is
VCUF Vaginal cuff
appendectomy with subsequent subdiaphragmatic abscess,
which would be reported as an organ/space SSI at the intraab- INFECTION SITE: Pneumonia (See Appendix A-2)
dominal specific site (SSI-IAB). INFECTION SITE: Laboratory-confirmed bloodstream infec-
An organ/space SSI must meet the following criteria: tion
Infection occurs within 30 days after the operative procedure if CODE: BSI-LCBI
no implantb is left in place or within 1 year if implant is in place DEFINITION: Laboratory-confirmed bloodstream infection
and the infection appears to be related to the operative procedure must meet at least one of the following criteria:
and Criterion 1: Patient has a recognized pathogen cultured from
infection involves any part of the body, excluding the skin inci- one or more blood cultures
sion, fascia, or muscle layers, that is opened or manipulated and
during the operative procedure organism cultured from blood is not related to an
and infection at another site.
patient has at least one of the following: Criterion 2: Patient has at least one of the following signs or
a. Purulent drainage from a drain that is placed symptoms: fever (⬎38⬚C), chills, or hypotension
through a stab wound into the organ/space and
b. Organisms isolated from an aseptically ob- at least one of the following:
tained culture of fluid or tissue in the organ/ a. Common skin contaminant (e.g., diphthe-
space roids, Bacillus sp., Propionibacterium sp., coag-
c. An abscess or other evidence of infection in- ulase-negative staphylococci, or micrococci) is
volving the organ/space that is found on direct cultured from two or more blood cultures
examination, during reoperation, or by histo- drawn on separate occasions
pathologic or radiologic examination b. Common skin contaminant (e.g., diphthe-
d. Diagnosis of an organ/space SSI by a surgeon roids, Bacillus sp., Propionibacterium sp., coag-
or attending physician ulase-negative staphylococci, or micrococci) is
REPORTING INSTRUCTIONS: cultured from at least one blood culture from
a patient with an intravascular line, and the
䊏 Occasionally, an organ/space infection drains through the in- physician institutes appropriate antimicrobial
cision. Such infection generally does not involve reoperation therapy
and is considered a complication of the incision. Therefore, c. Positive antigen test on blood (e.g., Haemophi-
it is classified as a deep incisional SSI. lus influenzae, Streptococcus pneumoniae, Neisse-
䊏 Report culture specimen from organ/space as DD (deep ria meningitidis, or group B Streptococcus)
drainage). and
The following are specific sites of an organ/space SSI: signs and symptoms and positive laboratory results are not related
to an infection at another site.
Code Site Criterion 3: Patient ⱕ1 year of age has at least one of the fol-
BONE Osteomyelitis lowing signs or symptoms: fever (⬎38⬚C), hypo-
BRST Breast abscess or mastitis thermia (⬍37⬚C), apnea, or bradycardia
CARD Myocarditis or pericarditis and
DISC Disc space at least one of the following:
EAR Ear, mastoid a. Common skin contaminant (e.g., diphthe-
1676 Section XV: Organization and Implementation of Infection Control Programs

roids, Bacillus sp., Propionibacterium sp., coag- INFECTION SITE: Osteomyelitis


ulase-negative staphylococci, or micrococci) is CODE: BJ-BONE
cultured from two or more blood cultures DEFINITION: Osteomyelitis must meet at least one of the fol-
drawn on separate occasions lowing criteria:
b. Common skin contaminant (e.g., diphthe- Criterion 1: Patient has organisms cultured from bone.
roids, Bacillus sp., Propionibacterium sp., coag- Criterion 2: Patient has evidence of osteomyelitis
ulase-negative staphylococci, or micrococci) is on direct examination of the bone during a surgi-
cultured from at least one blood culture from cal operation or histopathologic examination.
a patient with an intravascular line, and physi- Criterion 3: Patient has at least two of the follow-
cian institutes appropriate antimicrobial ing signs or symptoms with no other recognized
therapy cause: fever (⬎38⬚C), localized swelling, tender-
c. Positive antigen test on blood (e.g., H. influen- ness, heat, or drainage at suspected site of bone
zae, S. pneumoniae, N. meningitidis, or group infection
B Streptococcus) and
and at least one of the following:
signs and symptoms and positive laboratory re- a. Organisms cultured from blood
sults are not related to an infection at another b. Positive blood antigen test (e.g., H. influenzae,
site. S. pneumoniae)
c. Radiographic evidence of infection, for exam-
REPORTING INSTRUCTIONS:
ple, abnormal findings on x-ray, CT, MRI, ra-
䊏 Report purulent phlebitis confirmed with a positive semi- diolabeled scan (gallium, technetium, etc.)
quantitative culture of a catheter tip, but with either negative INFECTION SITE: Joint or bursa
or no blood culture, as CVS-VASC. CODE: BJ-JNT
䊏 Report organisms cultured from blood as BSI-LCBI when no DEFINITION: Joint or bursa infections must meet at least one
other site of infection is evident. of the following criteria:
䊏 Pseudobacteremias are not nosocomial infections. Criterion 1: Patient has organisms cultured from joint fluid or
synovial biopsy.
INFECTION SITE: Clinical sepsis Criterion 2: Patient has evidence of joint or bursa infection
CODE: BSI-CSEP seen during a surgical operation or histopathologic
DEFINITION: Clinical sepsis must meet at least one of the examination.
following criteria: Criterion 3: Patient has at least two of the following signs or
Criterion 1: Patient has at least one of the following clinical symptoms with no other recognized cause: joint
signs or symptoms with no other recognized cause: pain, swelling, tenderness, heat, evidence of effu-
fever (⬎38⬚C), hypotension (systolic pressure ⱕ sion or limitation of motion
90 mm Hg), or oliguria (⬍20 cm3/hr) and
and at least one of the following:
blood culture not done or no organisms or antigen a. Organisms and white blood cells seen on Gram
detected in blood stain of joint fluid
and b. Positive antigen test on blood, urine, or joint
no apparent infection at another site fluid
and c. Cellular profile and chemistries of joint fluid
physician institutes treatment for sepsis. compatible with infection and not explained by
Criterion 2: Patient ⱕ1 year of age has at least an underlying rheumatologic disorder
one of the following clinical signs or symptoms d. Radiographic evidence of infection, for exam-
with no other recognized cause: fever (⬎38⬚C), ple, abnormal findings on x-ray, CT, MRI, ra-
hypothermia (⬍37⬚C), apnea, or bradycardia diolabel scan (gallium, technetium, etc.)
and INFECTION SITE: Disc space
blood culture not done or no organisms or antigen CODE: BJ-DISC
detected in blood DEFINITION: Vertebral disc space infection must meet at least
and one of the following criteria:
no apparent infection at another site Criterion 1: Patient has organisms cultured from vertebral disc
and space tissue obtained during a surgical operation
physician institutes treatment for sepsis. or needle aspiration.
REPORTING INSTRUCTION: Criterion 2: Patient has evidence of vertebral disc space infec-
tion seen during a surgical operation or histopath-
䊏 Report culture-positive infections of the bloodstream as BSI- ologic examination.
LCBI. Criterion 3: Patient has fever (⬎38⬚C) with no other recog-
Chapter 94: Surveillance of Nosocomial Infections 1677

nized cause or pain at the involved vertebral disc c. Radiographic evidence of infection, for exam-
space ple, abnormal findings on ultrasound CT,
and MRI, radionuclide brain scan, or arteriogram
radiographic evidence of infection, e.g., abnormal d. Diagnostic single antibody titer (IgM) or four-
findings on x-ray, CT, MRI, radiolabel scan with fold increase in paired sera (IgG) for pathogen
gallium or technetium.
Criterion 4: Patient has fever (⬎38⬚C) with no REPORTING INSTRUCTION:
other recognized cause and pain at the involved 䊏 If meningitis and a brain abscess are present together, report
vertebral disc space the infection as IC.
and
positive antigen test on blood or urine (e.g., H. INFECTION SITE: Meningitis or ventriculitis
influenzae, S. pneumoniae, N. meningitidis, or CODE: CNS-MEN
group B Streptococcus) DEFINITION: Meningitis or ventriculitis must meet at least
INFECTION SITE: Intracranial infection (brain abscess, subd- one of the following criteria:
ural or epidural infection, encephalitis) Criterion 1: Patient has organisms cultured from cerebrospinal
CODE: CNS-IC fluid (CSF).
DEFINITION: Intracranial infection must meet at least one of Criterion 2: Patient has at least one of the following signs of
the following criteria: symptoms with no other recognized cause: fever
Criterion 1: Patient has organisms cultured from brain tissue (⬎38⬚C), headache, stiff neck, meningeal signs,
or dura. cranial nerve signs, or irritability
Criterion 2: Patient has an abscess or evidence of intracranial and
infection seen during a surgical operation or histo- if diagnosis is made antemortem, physician insti-
pathologic examination. tutes appropriate antimicrobial therapy
Criterion 3: Patient has at least two of the following signs or and
symptoms with no other recognized cause: head- at least one of the following:
ache, dizziness, fever (⬎38⬚C), localizing neuro- a. Increased white cells, elevated protein and/or
logic signs, changing level of consciousness, or decreased glucose in CSF
confusion b. Organisms seen on Gram stain of CSF
and c. Organisms cultured from blood
if diagnosis is made antemortem, physician insti- d. Positive antigen test of CSF, blood, or urine
tutes appropriate antimicrobial therapy e. Diagnostic single antibody titer (IgM) or four-
and fold increase in paired sera (IgG) for pathogen
at least one of the following: Criterion 3: Patient ⱕ1 year of age has at least one of the fol-
a. Organisms seen on microscopic examination lowing signs or symptoms with no other recog-
of brain or abscess tissue obtained by needle nized cause: fever (⬎38⬚C), hypothermia
aspiration or by biopsy during a surgical opera- (⬍37⬚C), apnea, bradycardia, stiff neck, menin-
tion or autopsy geal signs, cranial nerve signs, or irritability
b. Positive antigen test on blood or urine and
c. Radiographic evidence of infection, for exam- if diagnosis is made antemortem, physician insti-
ple, abnormal findings on ultrasound, CT, tutes appropriate antimicrobial therapy
MRI, radionuclide brain scan, or arteriogram and
d. Diagnostic single antibody titer (IgM) or four- at least one of the following:
fold increase in paired sera (IgG) for pathogen a. Positive CSF examination with increased white
Criterion 4: Patient ⱕ1 year of age has at least two of the cells, elevated protein, and/or decreased glucose
following signs or symptoms with no other b. Positive Gram stain of CSF
recognized cause: fever (⬎38⬚C), hypothermia c. Organisms cultured from blood
(⬍37⬚C), apnea, bradycardia, localizing neuro- d. Positive antigen test of CSF, blood, or urine
logic signs, or changing level of consciousness e. Diagnostic single antibody titer (IgM) or four-
and fold increase in paired sera (IgG) for pathogen
if diagnosis is made antemortem, physician insti- REPORTING INSTRUCTIONS:
tutes appropriate antimicrobial therapy
and 䊏 Report meningitis in the newborn as nosocomial unless there
at least one of the following: is compelling evidence indicating the meningitis was acquired
a. Organisms seen on microscopic examination transplacentally.
of brain or abscess tissue obtained by needle 䊏 Report CSF shunt infection as SSI-MEN if it occurs ⱕ1 year
aspiration or by biopsy during a surgical opera- of placement; if later, report as CNS-MEN.
tion or autopsy 䊏 Report meningoencephalitis as MEN.
b. Positive antigen test on blood or urine 䊏 Report spinal abscess with meningitis as MEN.
1678 Section XV: Organization and Implementation of Infection Control Programs

INFECTION SITE: Spinal abscess without meningitis other recognized cause: fever (⬎38⬚C), hypother-
CODE: CNS-SA mia (⬍37⬚C), apnea, bradycardia, lethargy, or
DEFINITION: An abscess of the spinal epidural or subdural pain, erythema, or heat at involved vascular site
space, without involvement of the CSF or adjacent bone struc- and
tures, must meet at least one of the following criteria: more than 15 colonies cultured from intravascular
Criterion 1: Patient has organisms cultured from abscess in the cannula tip using semiquantitative culture method
spinal epidural or subdural space. and
Criterion 2: Patient has an abscess in the spinal epidural or blood culture not done or no organisms cultured
subdural space seen during a surgical operation or from blood.
at autopsy of evidence of an abscess seen during
a histopathologic examination. REPORTING INSTRUCTIONS:
Criterion 3: Patient has at least one of the following signs or 䊏 Report infections of an arteriovenous graft, shunt, or fistula
symptoms with no other recognized cause: fever or intravascular cannulation site without organisms cultured
(⬎38⬚C), back pain, focal tenderness, radiculitis, from blood as CVS-VASC.
paraparesis, or paraplegia 䊏 Report intravascular infections with organisms cultured from
and the blood as BSI-LCBI.
if diagnosis is made antemortem, physician insti-
tutes appropriate antimicrobial therapy INFECTION SITE: Endocarditis involving either a natural or
and prosthetic heart valve
at least one of the following: CODE: CVS-ENDO
a. Organisms cultured from blood DEFINITION: Endocarditis of a natural or prosthetic heart
b. Radiographic evidence of a spinal abscess, for valve must meet at least one of the following criteria:
example, abnormal findings on myelography, Criterion 1: Patient has organisms cultured from valve or vege-
ultrasound, CT, MRI, or other scans (gallium, tation.
technetium, etc.) Criterion 2: Patient has two or more of the following signs or
symptoms with no other recognized cause: fever
REPORTING INSTRUCTION: (⬎38⬚C), new or changing murmur, embolic phe-
䊏 Report spinal abscess with meningitis as MEN. nomena, skin manifestations (i.e., petechiae, splin-
ter hemorrhages, painful subcutaneous nodules),
INFECTION SITE: Arterial or venous infection congestive heart failure, or cardiac conduction ab-
CODE: CVS-VASC normality
DEFINITION: Arterial or venous infection must meet at least and
one of the following criteria: if diagnosis is made antemortem, physician insti-
Criterion 1: Patient has organisms cultured from arteries or tutes appropriate antimicrobial therapy
veins removed during a surgical operation and
and at least one of the following:
blood culture not done or no organisms cultured a. Organisms cultured from two or more blood
from blood. cultures
Criterion 2: Patient has evidence of arterial or ve- b. Organisms seen on Gram stain of valve when
nous infection seen during a surgical operation or culture is negative or not done
histopathologic examination. c. Valvular vegetation seen during a surgical oper-
Criterion 3: Patient has at least one of the following signs or ation or autopsy
symptoms with no other recognized cause: fever d. Positive antigen test on blood or urine (e.g.,
(⬎38⬚C), pain, erythema, or heat at involved vas- H. influenzae, S. pneumoniae, N. meningitidis,
cular size or group B Streptococcus)
and e. Evidence of new vegetation seen on echocar-
more than 15 colonies cultured from intravascular diogram
cannula tip using semiquantitative culture method Criterion 3: Patient ⱕ1 year of age has two or more of the
and following signs or symptoms with no other recog-
blood culture not done or no organisms cultured nized cause fever (⬎38⬚C), hypothermia
from blood. (⬍37⬚C), apnea, bradycardia, new or changing
Criterion 4: Patient has purulent drainage at in- murmur, embolic phenomena skin manifestations
volved vascular site (i.e., petechiae, splinter hemorrhages, painful sub-
and cutaneous nodules), congestive heart failure, or
blood culture not done or no organisms cultured cardiac conduction abnormality
from blood. and
Criterion 5: Patient ⱕ1 year of age has at least if diagnosis is made antemortem, physician insti-
one of the following signs or symptoms with no tutes appropriate antimicrobial therapy
Chapter 94: Surveillance of Nosocomial Infections 1679

and DEFINITION: Mediastinitis must meet at least one of the fol-


at least one of the following: lowing criteria:
a. Organisms cultured from two or more blood Criterion 1: Patient has organisms cultured from mediastinal
cultures tissue or fluid obtained during a surgical operation
b. Organisms seen on Gram stain of valve when or needle aspiration.
culture is negative or not done Criterion 2: Patient has evidence of mediastinitis seen during a
c. Valvular vegetation seen during a surgical oper- surgical operation of histopathologic examination.
ation or autopsy Criterion 3: Patient has at least one of the following signs or
d. Positive antigen test on blood or urine (e.g., symptoms with no other recognized cause: fever
H. influenzae, S. pneumoniae, N. meningitidis, (⬎38⬚C), chest pain, or sternal instability
or group B Streptococcus) and
e. Evidence of new vegetation seen on echocar- at least one of the following:
diogram a. Purulent discharge from mediastinal area
INFECTION SITE: Myocarditis or pericarditis b. Organisms cultured from blood or discharge
CODE: CVS-CARD from mediastinal area
DEFINITION: Myocarditis or pericarditis must meet at least c. Mediastinal widening on x-ray
one of the following criteria: Criterion 4: Patient ⱕ1 year of age has at least one of the fol-
Criterion 1: Patient has organisms cultured from pericardial lowing signs or symptoms with no other recog-
tissue or fluid obtained by needle aspiration or nized cause: fever (⬎38⬚C), hypothermia
during a surgical operation. (⬍37⬚C), apnea, bradycardia, or sternal instability
Criterion 2: Patient has at least two of the following signs or and
symptoms with no other recognized cause: fever at least one of the following:
(⬎38⬚C), chest pain, paradoxical pulse, or in- a. Purulent discharge from mediastinal area
creased heart size b. Organisms cultured from blood or discharge
and from mediastinal area
at least one of the following: c. Mediastinal widening on x-ray
a. Abnormal electrocardiogram (ECG) consistent
with myocarditis or pericarditis REPORTING INSTRUCTION:
b. Positive antigen test on blood (e.g., H. influen-
zae, S. pneumoniae)
䊏 Report mediastinitis following cardiac surgery that is ac-
c. Evidence of myocarditis or pericarditis on his- companied by osteomyelitis as SSI-MED rather than SSI-
tologic examination of heart tissue BONE.
d. Fourfold rise in type-specific antibody with or INFECTION SITE: Conjunctivitis
without isolation of virus from pharynx or feces CODE: EENT-CONJ
e. Pericardial effusion identified by echocardio- DEFINITION: Conjunctivitis must meet at least one of the
gram, CT, MRI, or angiography following criteria:
Criterion 3: Patient ⱕ1 year of age has at least two of the fol- Criterion 1: Patient has pathogens cultured from purulent exu-
lowing signs of symptoms with no other recog- date obtained from the conjunctiva or contiguous
nized cause: fever (⬎38⬚C), hypothermia tissues, such as eyelid, cornea, meibomian glands,
(⬍37⬚C), apnea, bradycardia, paradoxical pulse, or lacrimal glands.
or increased heart size Criterion 2: Patient has pain or redness of con-
and junctiva or around eye
at least one of the following: and
a. Abnormal ECG consistent with myocarditis or at least one of the following:
pericarditis a. WBCs and organisms seen on Gram stain of
b. Positive antigen test on blood (e.g., H. influen-
exudate
zae, S. pneumoniae)
b. Purulent exudate
c. Histologic examination of heart tissue shows
c. Positive antigen test [e.g., enzyme-linked im-
evidence of myocarditis or pericarditis
munosorbent assay (ELISA) or immunofluo-
d. Fourfold rise in type-specific antibody with or
rescence (IF) for Chlamydia trachomatis, herpes
without isolation of virus from pharynx or feces
simplex virus, adenovirus) on exudate or con-
e. Pericardial effusion identified by echocardio-
junctival scraping
gram, CT, MRI, or angiography
d. Multinucleated giant cells seen on microscopic
COMMENT:
examination of conjunctival exudate or scrap-
䊏 Most cases of postcardiac surgery or postmyocardial infarction ings
pericarditis are not infectious. e. Positive viral culture
INFECTION SITE: Mediastinitis f. Diagnostic single antibody titer (IgM) or four-
CODE: CVS-MED fold increase in paired sera (IgG) for pathogen
1680 Section XV: Organization and Implementation of Infection Control Programs

REPORTING INSTRUCTIONS: and


at least one of the following:
䊏 Report other infections of the eye as EYE.
a. Organisms seen on Gram stain of purulent ma-
䊏 Do not report chemical conjunctivitis caused by silver nitrate
terial from mastoid
(AgNO3) as a nosocomial infection.
b. Positive antigen test on blood
䊏 Do not report conjunctivitis that occurs as a part of a more
INFECTION SITE: Oral cavity (mouth, tongue, or gums)
widely disseminated viral illness (e.g., measles, chickenpox, or
CODE: EENT-ORAL
a URI).
DEFINITION: Oral cavity infections must meet at least one of
INFECTION SITE: Eye, other than conjunctivitis the following criteria:
CODE: EENT-EYE Criterion 1: Patient has organisms cultured from purulent ma-
DEFINITION: An infection of the eye, other than conjunctivi- terial from tissues of oral cavity.
tis, must meet at least one of the following criteria: Criterion 2: Patient has an abscess or other evidence of oral
Criterion 1: Patient has organisms cultured from anterior or cavity infection seen on direct examination, dur-
posterior chamber of vitreous fluid. ing a surgical operation, or during a histopatho-
Criterion 2: Patient has at least two of the follow- logic examination.
ing signs or symptoms with no other recognized
cause: eye pain, visual disturbance, or hypopyon Criterion 3: Patient has at least one of the following signs or
and symptoms with no other recognized cause: abscess,
at least one of the following: ulceration, or raised white patches on inflamed
a. Physician’s diagnosis of an eye infection mucosa, or plaques on oral mucosa
b. Positive antigen test on blood (e.g., H. influen- and
zae, S. pneumoniae) at least one of the following:
c. Organisms cultured from blood a. Organisms seen on Gram stain
INFECTION SITE: Ear, mastoid b. Positive potassium hydroxide (KOH) stain
CODE: EENT-EAR c. Multinucleated giant cells seen on microscopic
DEFINITION: Ear and mastoid infections must meet the fol- examination of mucosal scrapings
lowing applicable criteria: d. Positive antigen test on oral secretions
Otitis externa must meet at least one of the following criteria: e. Diagnostic single antibody titer (IgM) or four-
Criterion 1: Patient has pathogens cultured from purulent fold increase in paired sera (IgG) for pathogen
drainage from ear canal. f. Physician diagnosis of infection and treatment
Criterion 2: Patient has at least one of the follow- with topical or oral antifungal therapy
ing signs or symptoms with no other recognized
cause: fever (⬎38⬚C), pain, redness, or drainage REPORTING INSTRUCTION:
from ear canal 䊏 Report nosocomial primary herpes simplex infections of the
and oral cavity as ORAL; recurrent herpes infections are not noso-
organisms seen on Gram stain of purulent comial.
drainage.
Otitis media must meet at least one of the following criteria: INFECTION SITE: Sinusitis
Criterion 1: Patient has organisms cultured from fluid from CODE: EENT-SINU
middle ear obtained by tympanocentesis or at sur- DEFINITION: Sinusitis must meet at least one of the following
gical operation. criteria:
Criterion 2: Patient has at least two of the following signs or Criterion 1: Patient has organisms cultured from purulent ma-
symptoms with no other recognized cause: fever terial obtained from sinus cavity.
(⬎38⬚C) pain in the eardrum, inflammation, re- Criterion 2: Patient has at least one of the following signs or
traction or decreased mobility of eardrum, or fluid symptoms with no other recognized cause: fever
behind eardrum. (⬎38⬚C), pain or tenderness over the involved
Otitis interna must meet at least one of the following criteria: sinus, headache, purulent exudate, or nasal ob-
Criterion 1: Patient has organisms cultured from fluid from struction
inner ear obtained at surgical operation. and
Criterion 2: Patient has a physician’s diagnosis of inner ear at least one of the following:
infection. a. Positive transillumination
Mastoiditis must meet at least one of the following criteria: b. Positive radiographic examination
Criterion 1: Patient has organisms cultured from purulent INFECTION SITE: Upper respiratory tract, pharyngitis, laryn-
drainage from mastoid. gitis, epiglottitis
Criterion 2: Patient has at least two of the following signs or CODE: EENT-UR
symptoms with no other recognized cause: fever DEFINITION: Upper respiratory tract infections must meet at
(⬎38⬚C), pain, tenderness, erythema, headache, least one the following criteria:
or facial paralysis Criterion 1: Patient has at least two of the following signs or
Chapter 94: Surveillance of Nosocomial Infections 1681

symptoms with no other recognized cause: fever large bowel, and rectum) excluding gastroenteritis and appendi-
(⬎38⬚C), erythema of pharynx, sore throat, citis
cough, hoarseness, of purulent exudate in throat CODE: GI-GIT
and DEFINITION: Gastrointestinal tract infections, excluding gas-
at least one of the following: troenteritis and appendicitis, must meet at least one of the fol-
a. Organisms cultured from the specific site lowing criteria:
b. Organisms cultured from blood Criterion 1: Patient has an abscess or other evidence of infec-
c. Positive antigen test on blood or respiratory tion seen during a surgical operation or histopath-
secretions ologic examination.
d. Diagnostic single antibody titer (IgM) or four- Criterion 2: Patient has at least two of the following signs or
fold increase in paired sera (IgG) for pathogen symptoms with no other recognized cause and
e. Physician’s diagnosis of an upper respiratory compatible with infection of the organ or tissue
infection involved: fever (⬎38⬚C), nausea, vomiting, ab-
Criterion 2: Patient has an abscess seen on direct examination, dominal pain, or tenderness
during a surgical operation, or during a histopath- and
ologic examination. at least one of the following:
Criterion 3: Patient ⱕ1 year of age has at least two of the fol- a. Organisms cultured from drainage or tissue ob-
lowing signs or symptoms with no other recog- tained during a surgical operation or endoscopy
nized cause: fever (⬎38⬚C), hypothermia or from a surgically placed drain
(⬍37⬚C), apnea, bradycardia, nasal discharge, or b. Organisms seen on Gram or KOH stain or
purulent exudate in throat multinucleated giant cells seen on microscopic
and examination of drainage or tissue obtained dur-
at least one of the following: ing a surgical operation or endoscopy or from
a. Organisms cultured from the specific site a surgically placed drain
b. Organisms cultured from blood c. Organisms cultured from blood
c. Positive antigen test on blood or respiratory d. Evidence of pathologic findings on radiologic
secretions examination
d. Diagnostic single antibody titer (IgM) or four- e. Evidence of pathologic findings on endoscopic
fold increase in paired sera (IgG) for pathogen examination (e.g., Candida esophagitis or proc-
e. Physician’s diagnosis of an upper respiratory titis)
infection INFECTION SITE: Hepatitis
INFECTION SITE: Gastroenteritis CODE: GI-HEP
CODE: GI-GE DEFINITION: Hepatitis must meet the following criterion:
DEFINITION: Gastroenteritis must meet at least one of the Patient has at least two of the following signs or symptoms with
following criteria: no other recognized cause: fever (⬎38⬚C), anorexia, nausea,
Criterion 1: Patient has an acute onset of diarrhea (liquid stools vomiting, abdominal pain, jaundice, or history of transfusion
for more than 12 hours) with or without vomiting
within the previous 3 months
or fever (⬎38⬚C) and no likely noninfectious
and
cause (e.g., diagnostic tests, therapeutic regimen,
at least one of the following:
acute exacerbation of a chronic condition, or psy-
a. Positive antigen or antibody test for hepatitis
chologic stress).
A, hepatitis B, hepatitis C, or delta hepatitis
Criterion 2: Patient has at least two of the following signs or
b. Abnormal liver function tests (e.g., elevated ala-
symptoms with no other recognized cause: nausea,
nine/aspartate aminotransferases, bilirubin)
vomiting, abdominal pain, or headache
and c. Cytomegalovirus detected in urine or oropha-
at least one of the following: ryngeal secretions
a. An enteric pathogen is cultured from stool or REPORTING INSTRUCTIONS:
rectal swab
b. An enteric pathogen is detected by routine or 䊏 Do not report hepatitis or jaundice of noninfectious origin
electron microscopy (alpha-1 antitrypsin deficiency, etc.).
c. An enteric pathogen is detected by antigen or 䊏 Do not report hepatitis or jaundice that results from exposure
antibody assay on blood or feces to hepatotoxins (alcoholic or acetaminophen-induced hepati-
d. Evidence of an enteric pathogen is detected by tis, etc.).
cytopathic changes in tissue culture (toxin 䊏 Do not report hepatitis or jaundice that results from biliary
assay) obstruction (cholecystitis).
e. Diagnostic single antibody titer (IgM) or four-
fold increase in paired sera (IgG) for pathogen INFECTION SITE: Intraabdominal, including gallbladder, bile
INFECTION SITE: GI tract (esophagus, stomach, small and ducts, liver (excluding viral hepatitis), spleen, pancreas, perito-
1682 Section XV: Organization and Implementation of Infection Control Programs

neum, subphrenic or subdiaphragmatic space, or other intraab- patient has at least two of the following signs or
dominal tissue or area not specified elsewhere symptoms with no other recognized cause: fever
CODE: GI-IAB (⬎38⬚C), cough, new or increased sputum pro-
DEFINITION: Intraabdominal infections must meet at least duction, rhonchi, wheezing
one of the following criteria: and
Criterion 1: Patient has organisms cultured from purulent ma- at least one of the following:
terial from intraabdominal space obtained during a. Positive culture obtained by deep tracheal aspi-
a surgical operation or needle aspiration. rate or bronchoscopy
Criterion 2: Patient has abscess or other evidence of intraab- b. Positive antigen test on respiratory secretions
dominal infection seen during a surgical operation Criterion 2: Patient ⱕ1 year of age has no clinical or radio-
or histopathologic examination. graphic evidence of pneumonia
Criterion 3: Patient has at least two of the following signs or and
symptoms with no other recognized cause: fever patient has at least two of the following signs or
(⬎38⬚C), nausea, vomiting, abdominal pain, or symptoms with no other recognized cause: fever
jaundice (⬎38⬚C), cough, new or increased sputum pro-
and duction, rhonchi, wheezing, respiratory distress,
at least one of the following: apnea, or bradycardia
a. Organisms cultured from drainage from surgi- and
cally placed drain (e.g., closed suction drainage at least one of the following:
system, open drain, T-tube drain) a. Organisms cultured from material obtained by
b. Organisms seen on Gram stain of drainage or deep tracheal aspirate or bronchoscopy
tissue obtained during surgical operation or b. Positive antigen test on respiratory secretions
needle aspiration c. Diagnostic single antibody titer (IgM) or four-
c. Organisms cultured from blood and radio- fold increase in paired sera (IgG) for pathogen
graphic evidence of infection, for example, ab-
normal findings on ultrasound, CT, MRI, or REPORTING INSTRUCTION:
radiolabel scans (gallium, technetium, etc.) or 䊏 Do not report chronic bronchitis in a patient with chronic
on abdominal x-ray lung disease as an infection unless there is evidence of an acute
REPORTING INSTRUCTION: secondary infection, manifested by change in organism.

䊏 Do not report pancreatitis (an inflammatory syndrome charac- INFECTION SITE: Other infections of the lower respiratory
terized by abdominal pain, nausea, and vomiting associated tract
with high serum levels of pancreatic enzymes) unless it is CODE: LRI-LUNG
determined to be infectious in origin. DEFINITION: Other infections of the lower respiratory tract
must meet at least one of the following criteria:
INFECTION SITE: Necrotizing enterocolitis Criterion 1: Patient has organisms seen on smear or cultured
CODE: GI-NEC from lung tissue or fluid, including pleural fluid.
DEFINITION: Necrotizing enterocolitis in infants must meet Criterion 2: Patient has a lung abscess or empyema seen during
the following criteria: a surgical operation or histopathologic examina-
Infant has at least two of the following signs or symptoms with tion.
no other recognized cause: vomiting, abdominal distention, or Criterion 3: Patient has an abscess cavity seen on radiographic
prefeeding residuals examination of lung.
and
persistent microscopic or gross blood in stools REPORTING INSTRUCTIONS:
and 䊏 Report concurrent lower respiratory tract infection and pneu-
at least one of the following abdominal radiographic abnormali- monia with the same organism(s) as PNEU.
ties: 䊏 Report lung abscess or empyema without pneumonia as
a. Pneumoperitoneum LUNG.
b. Pneumatosis intestinalis
c. Unchanging ‘‘rigid’’ loops of small bowel INFECTION SITE: Endometritis
INFECTION SITE: Bronchitis, tracheobronchitis, bronchio- CODE: REPR-EMET
litis, tracheitis, without evidence of pneumonia DEFINITION: Endometritis must meet at least one of the fol-
CODE: LRI-BRON lowing criteria:
DEFINITION: Tracheobronchial infections must meet at least Criterion 1: Patient has organisms cultured from fluid or tissue
one of the following criteria: from endometrium obtained during surgical oper-
Criterion 1: Patient has no clinical or radiographic evidence of ation, by needle aspiration, or by brush biopsy.
pneumonia Criterion 2: Patient has at least two of the following signs or
and symptoms with no other recognized cause: fever
Chapter 94: Surveillance of Nosocomial Infections 1683

(⬎38⬚C), abdominal pain, uterine tenderness, or REPORTING INSTRUCTIONS:


purulent drainage from uterus. 䊏 Report endometritis as EMET.
REPORTING INSTRUCTION: 䊏 Report vaginal cuff infections as VCUF.
INFECTION SITE: Skin
䊏 Report postpartum endometritis as a nosocomial infection CODE: SST-SKIN
unless the amniotic fluid is infected at the time of admission DEFINITION: Skin infections must meet at least one of the
or the patient was admitted 48 hours after rupture of the following criteria:
membrane. Criterion 1: Patient has purulent drainage, pustules, vesicles,
INFECTION SITE: Episiotomy or boils.
CODE: REPR-EPIS Criterion 2: Patient has at least two of the following signs or
DEFINITION: Episiotomy infections must meet at least one of symptoms with no other recognized cause: pain
the following criteria: or tenderness, localized swelling, redness, or heat
Criterion 1: Postvaginal delivery patient has purulent drainage and
from the episiotomy. at least one of the following:
Criterion 2: Postvaginal delivery patient has an episiotomy ab- a. Organisms cultured from aspirate or drainage
scess. from affected site; if organisms are normal skin
flora (e.g., coagulase negative staphylococci,
REPORTING INSTRUCTION: micrococci, diphtheroids) they must be a pure
culture
䊏 Episiotomy is not a NNIS operative procedure; do not report b. Organisms cultured from blood
as an SSI. c. Positive antigen test performed on infected tis-
sue or blood (e.g., herpes simplex, varicella zos-
INFECTION SITE: Vaginal cuff ter, H. influenzae, N. meningitidis)
CODE: REPR-VCUF d. Multinucleated giant cells seen on microscopic
DEFINITION: Vaginal cuff infections must meet at least one examination of affected tissue
of the following criteria: e. Diagnostic single antibody titer (IgM) or four-
Criterion 1: Posthysterectomy patient has purulent drainage fold increase in paired sera (IgG) for pathogen
from the vaginal cuff. COMMENT:
Criterion 2: Posthysterectomy patient has an abscess at the vag-
inal cuff. 䊏 Nosocomial skin infections may be the result of exposure to
Criterion 3: Posthysterectomy patient has pathogens cultured a variety of procedures performed in the hospital. Superficial
from fluid or tissue obtained from the vaginal cuff. incisional infections after surgery are identified separately as
SSI-SKIN unless the operative procedure is a CBGB. If the
REPORTING INSTRUCTION: chest incision site after a CBGB becomes infected, the specific
site is denoted SKNC; if the donor site becomes infected, the
䊏 Most vaginal cuff infections are SSI-VCUF. specific site is denoted SKNL. Other skin infections associated
䊏 Report only late onset (⬎30 days after hysterectomy) VCUF with important exposures are identified with their own sites
as REPR-VCUF. and are listed in the section on reporting instructions.
INFECTION SITE: Other infections of the male or female re- REPORTING INSTRUCTIONS:
productive tract (epididymis, testes, prostate, vagina, ovaries,
uterus, or other deep pelvic tissues, excluding endometritis or 䊏 Report omphalitis in infants as UMB.
vaginal cuff infections) 䊏 Report infections of the circumcision site in newborns as
CODE: REPR-OREP CIRC.
DEFINITION: Other infections of the male or female reproduc- 䊏 Report pustules in infants as PUST.
tive tract must meet at least one of the following criteria: 䊏 Report infected decubitus ulcers as DECU.
Criterion 1: Patient has organisms cultured from tissue or fluid
䊏 Report infected burns as BURN.
from affected site.
䊏 Report breast abscesses or mastitis as BRST.
Criterion 2: Patient has an abscess or other evidence of infec- INFECTION SITE: Soft tissue (necrotizing fascitis, infectious
tion of affected site seen during a surgical opera- gangrene, necrotizing cellulitis, infectious myositis, lymphadeni-
tion or histopathologic examination. tis, or lymphangitis)
Criterion 3: Patient has two of the following signs or symptoms CODE: SST-ST
with no other recognized cause: fever (⬎38⬚C), DEFINITION: Soft tissue infections must meet at least one of
nausea, vomiting, pain, tenderness, or dysuria the following criteria:
and Criterion 1: Patient has organisms cultured from tissue or
at least one of the following: drainage from affected site.
a. Organisms cultured from blood Criterion 2: Patient has purulent drainage at affected site.
b. Diagnosis by physician Criterion 3: Patient has an abscess or other evidence of infec-
1684 Section XV: Organization and Implementation of Infection Control Programs

tion seen during a surgical operation or histopath- Criterion 2: Patient has a change in burn wound appearance
ologic examination. or character, such as rapid eschar separation; dark
Criterion 4: Patient has at least two of the following signs of brown, black, or violaceous discoloration of the
symptoms at the affected site with no other recog- eschar; or edema at wound margin
nized cause: localized pain or tenderness, redness, and
swelling, or heat at least one of the following:
and a. Organisms cultured from blood in the absence
at least one of the following: of other identifiable infection
a. Organisms cultured from blood b. Isolation of herpes simplex virus, histologic
b. Positive antigen test performed on blood or identification of inclusions by light or electron
urine (e.g., H. influenzae, S. pneumoniae, N. microscopy or visualization of viral particles by
meningitidis, group B Streptococcus, Candida electron microscopy in biopsies or lesion scrap-
sp.) ings
c. Diagnostic single antibody titer (IgM) or four- Criterion 3: Patient with a burn has at least two of the following
fold increase in paired sera (IgG) for pathogen signs or symptoms with no other recognized cause:
fever (⬎38⬚C) or hypothermia (⬍36⬚C), hypo-
REPORTING INSTRUCTIONS:
tension, oliguria (⬍20 cm3/hr), hyperglycemia at
䊏 Report surgical site infections that involve both the skin and previously tolerated level of dietary carbohydrate,
deep soft tissue (at or beneath the fascial or muscle layer) as or mental confusion
SSI-ST (soft tissue) unless the operative procedure is a CBGB. and
For CBGB, if skin and deep soft tissue at the chest incision at least one of the following:
site become infected, the specific site is STC and if skin and a. Histologic examination of burn biopsy shows
deep soft tissue at the donor site become infected, the specific invasion of organisms into adjacent viable
site is STL. tissue
䊏 Report infected decubitus ulcers as DECU. b. Organisms cultured from blood
䊏 Report infection of deep pelvic tissues as OREP. c. Isolation of herpes simplex virus, histologic
INFECTION SITE: Decubitus ulcer, including both superficial identification of inclusions by light or electron
and deep infections microscopy, or visualization of viral particles
CODE: SST-DECU electron microscopy in biopsies or lesion scrap-
DEFINITION: Decubitus ulcer infections must meet the fol- ings
lowing criterion: COMMENTS:
Patient has at least two of the following signs or symptoms with 䊏 Purulence alone at the burn wound site is not adequate for
no other recognized cause: redness, tenderness, or swelling of the diagnosis of burn infection; such purulence may reflect
decubitus wound edges incomplete wound care.
and 䊏 Fever alone in a burn patient is not adequate for the diagnosis

at least one of the following: of a burn infection because fever may be the result of tissue
a. Organisms cultured from properly collected trauma or the patient may have an infection at another site.
䊏 Surgeons in Regional Burn Centers who take care of burn
fluid or tissue (see later)
b. Organisms cultured from blood patients exclusively, may require Criterion 1 for diagnosis
COMMENTS: burn infection.
䊏 Hospitals with Regional Burn Centers may further divide
䊏 Purulent drainage alone is not sufficient evidence of an infec- burn infections into the following: burn wound site, burn
tion. graft site, burn donor site, burn donor site-cadaver; the NNIS
䊏 Organisms cultured from the surface of a decubitus ulcer are system, however, will code all of these as BURN.
not sufficient evidence that the ulcer is infected. A properly
INFECTION SITE: Breast abscess or mastitis
collected specimen from a decubitus ulcer involves needle
CODE: SST-BRST
aspiration of fluid or biopsy of tissue from the ulcer margin.
DEFINITION: A breast abscess or mastitis must meet at least
INFECTION SITE: Burn one of the following criteria:
CODE: SST-BURN Criterion 1: Patient has a positive culture of affected breast
DEFINITION: Burn infections must meet one of the following tissue or fluid obtained by incision and drainage
criteria: or needle aspiration.
Criterion 1: Patient has a change in burn wound appearance Criterion 2: Patient has a breast abscess or other evidence of
or character, such as rapid eschar separation; dark infection seen during a surgical operation or histo-
brown, black, or violaceous discoloration of the pathologic examination.
char; or edema at wound margin Criterion 3: Patient has fever (⬎38⬚C) and local inflammation
and of the breast
histologic examination of burn biopsy shows inva- and
sion of organisms into adjacent viable tissue. physician’s diagnosis of breast abscess.
Chapter 94: Surveillance of Nosocomial Infections 1685

COMMENT: circumcision site: erythema, swelling, or tender-


ness
䊏 Breast abscesses occur most frequently after childbirth. Those and
that occur within 7 days after childbirth should be considered skin contaminant (coagulase-negative staphylo-
nosocomial. cocci, diphtheroids, Bacillus sp., or micrococci) is
INFECTION SITE: Omphalitis cultured from circumcision site
CODE: SST-UMB and
DEFINITION: Omphalitis in a newborn (ⱕ30 days old) must physician diagnosis of infection or physician insti-
meet at least one of the following criteria: tutes appropriate therapy.
Criterion 1: Patient has erythema and/or serous drainage from REPORTING INSTRUCTION:
umbilicus
and 䊏 Newborn circumcision is not an NNIS operative procedure;
at least one of the following: do not report as an SSI.
a. Organisms cultured from drainage or needle INFECTION SITE: Disseminated infection
aspirate CODE: SYS-DI
b. Organisms cultured from blood. DEFINITION: Disseminated infection is infection involving
Criterion 2: Patient has both erythema and purulence at the multiple organs or systems, without an apparent single site of
umbilicus. infection, usually of viral origin, and with signs or symptoms
REPORTING INSTRUCTIONS: with no other recognized cause and compatible with infectious
involvement of multiple organs or systems.
䊏 Report infection of the umbilical artery or vein related to
umbilical catheterization as CVS-VASC if blood culture is REPORTING INSTRUCTIONS:
negative or not done. 䊏 This code should be used primarily for viral infections involv-
䊏 Report as nosocomial if infection occurs in a newborn within ing multiple organ systems (e.g., measles, mumps, rubella,
7 days of hospital discharge. varicella, erythema infectiosum). These infections often can
INFECTION SITE: Infant pustulosis be identified by clinical criteria alone. Do not use this code
CODE: SST-PUST for nosocomial infections with multiple metastatic sites, such
DEFINITION: Pustulosis in an infant (ⱕ12 months old) must as with bacterial endocarditis; only the primary site of these
meet at least one of the following criteria: infections should be reported.
Criterion 1: Infant has one or more pustules
䊏 Do not report fever of unknown origin (FUO) as DI-SYS.
and
䊏 Report neonatal ‘‘sepsis’’ as BSI-CSEP.
physician diagnosis of skin infection.
䊏 Report viral exanthems or rash illness as DI-SYS.
Criterion 2: Infant has one or more pustules
and
physician institutes appropriate antimicrobial APPENDIX A-2. CRITERIA FOR DEFINING
therapy. NOSOCOMIAL PNEUMONIA
REPORTING INSTRUCTIONS: General Comments Applicable to All
Pneumonia Specific Site Criteria
䊏 Do not report erythema toxicum and noninfectious causes of
pustulosis. 1. Physician’s diagnosis of pneumonia alone is not an acceptable
䊏 Report as nosocomial if pustulosis occurs in an infant within criterion for nosocomial pneumonia.
7 days of hospital discharge. 2. Although specific criteria are included for infants and chil-
dren, pediatric patients may meet any of the other pneumonia
INFECTION SITE: Newborn circumcision specific site criteria.
CODE: SST-CIRC 3. Ventilator-associated pneumonia (i.e., pneumonia in persons
DEFINITION: Circumcision infection in a newborn (ⱕ30 days who had a device to assist or control respiration continuously
old) must meet at least one of the following criteria: through a tracheostomy or by endotracheal intubation within
Criterion 1: Newborn has purulent drainage from circumci- the 48-hour period before the onset of infection) should be
sion site. so designated when reporting pneumonia data.
Criterion 2: Newborn has at least one of the following signs 4. When assessing a patient for presence of pneumonia, it is
or symptoms with no other recognized cause at important to distinguish between changes in clinical status
circumcision site: erythema, swelling, or tender- resulting from other conditions such as myocardial infarc-
ness tion, pulmonary embolism, respiratory distress syndrome, at-
and electasis, malignancy, chronic obstructive pulmonary disease,
pathogen cultured from circumcision site. hyaline membrane disease, bronchopulmonary dysplasia, and
Criterion 3: Newborn has at least one of the following signs so forth. Also, care must be taken when assessing intubated
or symptoms with no other recognized cause at patients to distinguish between tracheal colonization, upper
1686 Section XV: Organization and Implementation of Infection Control Programs

respiratory tract infections (e.g., tracheobronchitis), and early ples are frequently contaminated with airway colonizers and,
onset pneumonia. Finally, it should be recognized that it therefore, must be interpreted cautiously. In particular, Can-
may be difficult to determine nosocomial pneumonia in the dida is commonly seen on stain but infrequently causes noso-
elderly, infants, and immunocompromised patients because comial pneumonia.
such conditions may mask typical signs or symptoms associ-
ated with pneumonia. Alternate specific criteria for the el-
derly, infants and immunocompromised patients have been Abbreviations
included in this definition of nosocomial pneumonia. BAL—bronchoalveolar lavage
5. Nosocomial pneumonia can be characterized by its onset: EIA—enzyme immunoassay
early or late. Early onset pneumonia occurs during the first FAMA—fluorescent-antibody staining of membrane antigen
4 days of hospitalization and is often caused by Moraxella IFA—immunofluorescent antibody
catarrhalis, H. influenzae, and S. pneumoniae. Causative LRT—lower respiratory tract
agents of late onset pneumonia are frequently gram-negative PCR—polymerase chain reaction
bacilli or Staphylococcus aureus, including methicillin-resistant PMN—polymorphonuclear leukocyte
S. aureus. Viruses (e.g., influenza A and B or respiratory syn- RIA—radioimmunoassay
cytial virus) can cause early and late onset nosocomial pneu-
monia, whereas yeasts, fungi, legionellae, and Pneumocystis
carinii are usually pathogens of late onset pneumonia. Reporting Instructions
6. Pneumonia resulting from gross aspiration (e.g., in the setting
of intubation in the emergency room or operating room) is 䊏 There is a hierarchy of specific site categories within the major
considered nosocomial if it meets any specific criteria and site pneumonia. Even if a patient meets criteria for more than
was not clearly present or incubating at the time of admission one specific site, report only one:
to the hospital. • If a patient meets criteria for both PNU1 and PNU2, report
7. Multiple episodes of nosocomial pneumonia may occur in PNU2.
critically ill patients with lengthy hospital stays. When deter- • If a patient meets criteria for both PNU2 and PNU3, report
mining whether to report multiple episodes of nosocomial PNU3.
pneumonia in a single patient, look for evidence of resolution • If a patient meets criteria for both PNU1 and PNU3, report
of the initial infection. The addition of or change in pathogen PNU3.
alone is not indicative of a new episode of pneumonia. The 䊏 Report concurrent lower respiratory tract infection (e.g., ab-
combination of new signs and symptoms and radiographic scess or empyema) and pneumonia with the same organism(s)
evidence or other diagnostic testing is required. as pneumonia.
8. Positive Gram stain for bacteria and positive KOH mount 䊏 Report lung abscess or empyema without pneumonia as
for elastin fibers and/or fungal hyphae from appropriately LUNG.
collected sputum specimens are important clues that point 䊏 Report acute bronchitis, tracheitis, tracheobronchitis, or
toward the etiology of the infection. However, sputum sam- bronchiolitis without pneumonia as BRON.
Chapter 94: Surveillance of Nosocomial Infections 1687

APPENDIX A-2. PNEUMONIA ALGORITHMS

Major Site: Pneumonia (PNEU)


Site-Specific Algorithms for Clinically Defined Pneumonia (PNU1)

Radiology Signs/symptoms/laboratory Code

Two or more serial chest PNU1


radiographs with at least one FOR ANY PATIENT, at least one of the following:
of the following1,2: • Fever (⬎38°C or ⬎100.4°F) with no other recognized cause
New or progressive • Leukopenia (⬍4,000 WBC/mm3) or leukocytosis (ⱖ12,000 WBC/mm3)
• • • • •

and persistent infiltrate • For adults ⱖ70 years old, altered mental status with no other recognized cause
Consolidation and
Cavitation At least two of the following:
Pneumatoceles, in infants • New onset of purulent sputum3, or change in character of sputum4, or increased respiratory
ⱕ1 year old secretions, or increased suctioning requirements
• New onset or worsening cough, or dyspnea, or tachypnea5
• Rales6 or bronchial breath sounds
• Worsening gas exchange (e.g., O2 desaturations [e.g., PaO2/FiO2 ⱕ240]7, increased oxygen
requirements, or increased ventilation demand)

ALTERNATE CRITERIA FOR INFANT ⱕ1 YEAR OLD:


NOTE: In patients without Worsening gas exchange (e.g., O2 desaturations, increased oxygen requirements, or increased
underlying pulmonary or ventilator demand)
cardiac disease (e.g., and
respiratory distress syndrome, at least three of the following:
bronchopulmonary dysplasia, • Temperature instability with no other recognized cause
pulmonary edema, or chronic • Leukopenia (⬍4,000 WBC/mm3)
obstructive pulmonary or leukocytosis (ⱖ15,000 WBC/mm3) and left shift (ⱖ10% band forms)
disease), one definitive chest • New onset of purulent sputum3, or change in character of sputum4, or increased respiratory
radiograph is acceptable1. secretions, or increased suctioning requirements
• Apnea, tachypnea5, nasal flaring with retraction of chest wall, or grunting
• Wheezing, rales6, or rhonchi
• Cough
• Bradycardia (⬍100 beats/min) or tachycardia (⬎170 beats/min)

ALTERNATE CRITERIA FOR CHILD ⬎1 OR ⱕ12 YEARS OLD, at least three of the following:
• Fever (⬎38.4°C or ⬎101.1°F) or hypothermia (⬍37°C or ⬍97.7°F) with no other recognized
cause
• Leukopenia (⬍4,000 WBC/mm3) or leukocytosis (ⱖ15,000 WBC/mm3)
• New onset of purulent sputum3, or change in character of sputum4, or increased respiratory
secretions, or increased suctioning requirements
• New onset or worsening cough or dyspnea, apnea, or tachypnea5
• Rales6 or bronchial breath sounds
• Worsening gas exchange (e.g., O2 desaturations [e.g., pulse oximetry ⬍94%], increased
oxygen requirements, or increased ventilation demand)

Major Site: Pneumonia (PNEU)


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

Radiology Signs/symptoms Laboratory Code

Two or more serial chest At least one of the following: At least one of the following: PNU2
radiographs with at least one • Fever (⬎38°C or ⬎100.4°F) with no other • Positive growth in blood culture8 not related
of the following1,2: recognized cause to another source of infection
• New or progressive • Leukopenia (⬍4,000 WBC/mm3) or leukocytosis • Positive growth in culture of pleural fluid
and persistent infiltrate (ⱖ12,000 WBC/mm3) • Positive quantitative culture9 from minimally
• Consolidation • For adults ⱖ70 years old, altered mental status contaminated LRT specimen (e.g., BAL or
• Cavitation with no other recognized cause protected specimen brushing)
and • ⱖ5% BAL-obtained cells contain intracellular
At least one of the following: bacteria on direct microscopic exam (e.g.,
NOTE: In patients without • New onset of purulent sputum3, or change in Gram stain)
underlying pulmonary or character of sputum4, or increased respiratory • Histopathologic exam shows at least one of
cardiac disease (e.g., secretions, or increased suctioning requirements the following evidences of pneumonia:
respiratory distress syndrome, • New onset or worsening cough, or dyspnea, or Abscess formation or foci of consolidation
bronchopulmonary dysplasia, tachypnea5 with intense PMN accumulation in
pulmonary edema, or chronic • Rales6 or bronchial breath sounds bronchioles and alveoli
obstructive pulmonary • Worsening gas exchange (e.g., O2 desaturations Positive quantitative culture9 of lung
disease), one definitive chest [e.g., PaO2/FiO2 ⱕ240]7, increased oxygen parenchyma
radiograph is acceptable1. requirements, or increased ventilation demand) Evidence of lung parenchyma invasion by
fungal hyphae or pseudohyphae
1688 Section XV: Organization and Implementation of Infection Control Programs

Major Site: Pneumonia (PNEU)


Specific Site Algorithms for Pneumonia with Viral, Legionella, Chlamydia, Mycoplasma, and Other Uncommon Pathogens and Specific Laboratory
Findings (PNU2)

Radiology Signs/symptoms Laboratory Code

Two or more serial chest At least one of the following: At least one of the following10–12: PNU2
radiographs with at least • Fever (⬎38°C or ⬎100.4°F) with no other • Positive culture of virus or Chlamydia from
one of the following1,2: recognized cause respiratory secretions
• New or progressive • Leukopenia (⬍4,000 WBC/mm3) or leukocytosis • Positive detection of viral antigen or
and persistent infiltrate (ⱖ12,000 WBC/mm3) antibody from respiratory secretions (e.g.,
• Consolidation • For adults ⱖ70 years old, altered mental status EIA, FAMA, shell vial assay, PCR)
• Cavitation with no other recognized cause • Fourfold rise in paired sera (IgG) for
and pathogen (e.g., influenza viruses, Chlamydia)
NOTE: In patients without At least one of the following: • Positive PCR for Chlamydia or Mycoplasma
underlying pulmonary or • New onset of purulent sputum3, or change in • Positive micro-IF test for Chlamydia
cardiac disease (e.g., character of sputum4, or increased respiratory • Positive culture or visualization by micro-IF of
respiratory distress syndrome, secretions, or increased suctioning requirements Legionella spp. from respiratory secretions or
bronchopulmonary dysplasia, • New onset or worsening cough, dyspnea, or tissue
pulmonary edema, or chronic tachypnea5 • Detection of Legionella pneumophila
obstructive pulmonary • Rales6 or bronchial breath sounds serogroup 1 antigens in urine by RIA or EIA
disease), one definitive chest • Worsening gas exchange (e.g., O2 desaturations • Fourfold rise in L. pneumophila serogroup 1
radiograph is acceptable1. [e.g., PaO2/FiO2 ⱕ240]7, increased oxygen antibody titer to ⱖ1 : 128 in paired acute and
requirements, or increased ventilation demand) convalescent sera by indirect IFA

Major Site: Pneumonia (PNEU)


Specific Site Algorithm for Pneumonia in Immunocompromised Patients (PNU3)

Radiology Signs/symptoms Laboratory Code

Two or more serial chest Patient who is immunocompromised13 has at least At least one of the following: PNU3
radiographs with at least one one of the following: • Matching positive blood and sputum cultures
of the following1,2: • Fever (⬎38°C or ⬎100.4°F) with no other with Candida spp.14,15
• New or progressive and recognized cause • Evidence of fungi or Pneumocytis carinii from
persistent infiltrate • For adults ⱖ70 years old, altered mental status minimally contaminated LRT specimen (e.g.,
• Consolidation with no other recognized cause BAL or protected specimen brushing) from
• Cavitation • New onset of purulent sputum3, or change in one of the following:
character of sputum4, or increased respiratory – Direct microscopic exam
NOTE: In patients without secretions, or increased suctioning requirements – Positive culture of fungi
underlying pulmonary or • New onset or worsening cough, or dyspnea, or Any of the following from:
cardiac disease (e.g., tachypnea5 LABORATORY CRITERIA DEFINED UNDER PNU2
respiratory distress syndrome, • Rales6 or bronchial breath sounds
bronchopulmonary dysplasia, • Worsening gas exchange (e.g., O2 desaturations
pulmonary edema, or chronic [e.g., PaO2/FiO2 ⱕ240]7, increased oxygen
obstructive pulmonary requirements, or increased ventilation demand)
disease), one definitive chest • Hemoptysis
radiograph is acceptable1. • Pleuritic chest pain

1. Occasionally, in nonventilated patients, the diagnosis of nosocomial pneumonia may be quite clear on the basis of symptoms, signs, and a single defini-
tive chest radiograph. However, in patients with pulmonary or cardiac disease (e.g., interstitial lung disease or congestive heart failure), the diagnosis of
pneumonia may be particularly difficult. Other noninfectious conditions (e.g., pulmonary edema from decompensated congestive heart failure) may
simulate the presentation of pneumonia. In these more difficult cases, serial chest radiographs must be examined to help separate infectious from non-
infectious pulmonary processes. To help confirm difficult cases, it may be useful to review radiographs on the day of diagnosis, 3 days prior to the diag-
nosis, and on days 2 and 7 after the diagnosis. Pneumonia may have rapid onset and progression but does not resolve quickly. Radiographic changes of
pneumonia persist for several weeks. As a result, rapid radiograph resolution suggests that the patient does not have pneumonia but rather a noninfec-
tious process such as atelectasis or congestive heart failure.
2. Note that there are many ways of describing the radiographic appearance of pneumonia. Examples include, but are not limited to, air-space disease, fo-
cal opacification, and patchy areas of increased density. Although perhaps not specifically delineated as pneumonia by the radiologist, in the appropri-
ate clinical setting these alternative descriptive wordings should be seriously considered as potentially positive findings.
3. Purulent sputum is defined as secretions from the lungs, bronchi, or trachea that contain ⱖ25 neutrophils and ⱕ10 squamous epithelial cells per low
power field (⫻100). If your laboratory reports these data qualitatively (e.g., many WBCs or few squames), be sure their descriptors match this definition
of purulent sputum. This laboratory confirmation is required because written clinical descriptions of purulence are highly variable.
4. A single notation of either purulent sputum or change in character of the sputum is not meaningful; repeated notations over a 24-hour period would
be more indicative of the onset of an infectious process. Change in character of sputum refers to the color, consistency, odor, and quantity.
Chapter 94: Surveillance of Nosocomial Infections 1689

Footnotes Continued.
5. In adults, tachypnea is defined as respiration rate ⬎25 breaths per minute. Tachypnea is defined as ⬎75 breaths per minute in premature infants born at
⬍37 weeks’ gestation and until the 40th week; ⬎60 breaths per minute in patients ⬍2 months old; ⬎50 breaths per minute in patients 2–12 months old;
and ⬎30 breaths per minute in children ⬎1 year old.
6. Rales may be described as crackles.
7. This measure of arterial oxygenation is defined as the ratio of the arterial tension (PaO2) to the inspiratory fraction of oxygen (FiO2).
8. Care must be taken to determine the etiology of pneumonia in a patient with positive blood cultures and radiographic evidence of pneumonia, espe-
cially if the patient has invasive devices in place such as intravascular lines or an indwelling urinary catheter. In general, in an immunocompetent pa-
tient, blood cultures positive for coagulase negative staphylococci, common skin contaminants, and yeasts will not be the etiologic agent of the pneu-
monia.
9. Refer to Table A-2.1 for threshold values of bacteria from cultured specimens. An endotracheal aspirate is not a minimally contaminated specimen.
Therefore, an endotracheal aspirate does not meet the laboratory criteria.
10. Once laboratory-confirmed cases of pneumonia due to respiratory syncytial virus (RSV), adenovirus, or influenza virus have been identified in a hospital,
clinician’s presumptive diagnosis of these pathogens in subsequent cases with similar clinical signs and symptoms is an acceptable criterion for presence
of nosocomial infection.
11. Scant or watery sputum is commonly seen in adults with pneumonia due to viruses and Mycoplasma although sometimes the sputum may be mucopuru-
lent. In infants, pneumonia due to RSV or influenza yields copious sputum. Patients, except premature infants, with viral or mycoplasmal pneumonia
may exhibit few signs or symptoms, even when significant infiltrates are present on radiographic exam.
12. Few bacteria may be seen on stains of respiratory secretions from patients with pneumonia due to Legionella spp, Mycoplasma, or viruses.
13. Immunocompromised patients include those with neutropenia (absolute neutrophil count ⬍500/mm3), leukemia, lymphoma, HIV with CD4 count ⬍200,
or splenectomy; those who are in their transplant hospital stay; and those who are on cytotoxic chemotherapy, high dose steroids, or other immunosup-
pressives daily for ⬎2 weeks [e.g., ⬎40mg of prednisone or its equivalent (⬎160mg hydrocortisone, ⬎32mg methylprednisolone, ⬎6mg dexamethasone,
⬎200mg cortisone)].
14. Blood and sputum specimens must be collected within 48 hours of each other.
15. Semiquantitative or nonquantitative cultures of sputum obtained by deep cough, induction, aspiration, or lavage are acceptable. If quantitative culture
results are available, refer to algorithms that include such specific laboratory findings.

TABLE A-2.1. THRESHOLD VALUES FOR CULTURED SPECIMENS USED IN THE


DIAGNOSIS OF PNEUMONIA

Specimen Collection/Technique Values Comment

Lung parenchyma ⱖ104 CFU/g tissue 1


Bronchoscopically (B) obtained specimens
Bronchoalveolar lavage (B-BAL) ⱖ104 CFU/mL
Protected BAL (B-PBAL) ⱖ104 CFU/mL
Protected specimen brushing (B-PSB) ⱖ103 CFU/mL
Nonbronchoscopically (NB) obtained (blind) specimens
NB-BAL ⱖ104 CFU/mL
NB-PSB ⱖ103 CFU/mL

1, open-lung biopsy specimens and immediate postmortem specimens obtained by transthoracic or trans-
bronchial biopsy; CFU, colony-forming units; g, gram; mL, milliliter.