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 ~  Abstract
 ~ Introduction
 ~  Healthcare-Assoc...
 ~  Central Line-Ass...
 ~  Catheter-Associa...
 ~  Ventilator-Assoc...
 ~ Conclusion
 ~  References
 ~  Article Figures
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  Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 36  |  Issue : 1  |  Page : 18-25
 

Changing panorama for surveillance of device-associated healthcare infections: Challenges faced in implementation of current guidelines


1 Department of Microbiology, Institute of Human Behavior and Allied Sciences, New Delhi, India
2 Department of Neuro Psychopharmacology, Institute of Human Behavior and Allied Sciences, New Delhi, India
3 Department of Microbiology, Lady Hardinge Medical College, New Delhi, India

Date of Web Publication2-May-2018

Correspondence Address:
Dr. Renu Gupta
Department of Microbiology, Institute of Human Behavior and Allied Sciences, Dilshad Garden, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_18_50

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 ~ Abstract 

Healthcare-associated infections (HAI) are preventable in up to 30% of patients with evidence-based infection prevention and control (IPC) activities. IPC activities require effective surveillance to generate data for the HAI rates, defining priority areas, identifying processes amenable for improvement and institute interventions to improve patient's safety. However, uniform, accurate and standardised surveillance methodology using objective definitions can only generate meaningful data for effective execution of IPC activities. The highly exhaustive, complex and ever-evolving infection surveillance methodology pose a challenge for effective data capture, analysis and interpretation by ground level personnel. The present review addresses the gaps in knowledge and day-to-day challenges in surveillance faced by infection control team for effective implementation of IPC activities.


Keywords: Catheter-associated urinary tract infection, central line-associated bloodstream infection, healthcare infections, surveillance, ventilator-associated events, ventilator-associated pneumonia


How to cite this article:
Gupta R, Sharma S, Parwez, Saxena S. Changing panorama for surveillance of device-associated healthcare infections: Challenges faced in implementation of current guidelines. Indian J Med Microbiol 2018;36:18-25

How to cite this URL:
Gupta R, Sharma S, Parwez, Saxena S. Changing panorama for surveillance of device-associated healthcare infections: Challenges faced in implementation of current guidelines. Indian J Med Microbiol [serial online] 2018 [cited 2018 Nov 17];36:18-25. Available from: http://www.ijmm.org/text.asp?2018/36/1/18/231683



 ~ Introduction Top


Healthcare-associated infections (HAI) are major safety concern for both healthcare providers and patients with estimated prevalence of 15.5/100 patients in developing countries.[1] HAI account for significant mortality (more than 100,000 deaths/year), morbidity and increased cost of treatment but are preventable in up to 30% of patients with evidence-based infection prevention and control (IPC) activities.[1],[2],[3],[4],[5] Efficient IPC activities require uniform surveillance data collected using standardised methods. Accurate estimates of the burden of HAI are highly limited in India and not comparable across different institutes due to absence of reliable surveillance data.

Centre for Disease Control and Prevention (CDC) has taken a lead for increasing awareness of IPC activities in other countries by initiating National Health Control Care Safety Network and making access to modules for surveillance and IPC activities free of cost.[6] Although extensive information about HAI surveillance is freely available on web but implementation at ground level by infection control team (ICT) is still far from ideal as information provided is quite exhaustive, complex, dynamic and undergo frequent revisions in light of emerging evidences and feedbacks from global partners.[6] Moreover, paucity of clinical microbiologists, lack of trained infection control personnel, highly labour-intensive and time-consuming procedures/activities with lack of clarity in principles of infection control has jeopardised the gains so far achieved. As it is becoming increasingly mandatory for healthcare establishments to monitor HAI rates for accreditation purposes and cater to health insurance policies, it has become all the more pertinent for healthcare workers to keep abreast with latest surveillance methodology so as to minimise subjective clinical judgment in identifying HAI.[7]

Although many articles emphasising the importance of surveillance and HAI surveillance systems have been published in recent times, none of the articles to best of our knowledge have addressed the ground level difficulties encountered by ICT in collecting and interpreting data for meaningful use.[4],[5],[8],[9] The objective of this review is to address the gaps in knowledge about current surveillance definitions, criteria, methods and day-to-day challenges faced by ICT, so as to enable them to effectively capture data for IPC and patients safety.[10],[11] There are several techniques/methods for capturing different type of events associated with medical devices, surgical procedures, use of antimicrobial agents and multidrug-resistant organisms; however, the present review is restricted to device-associated infections as they constitute most common and objective parameters for the measurement of outcomes and allow for interhospital comparisons.[6],[10]


 ~ Healthcare-Associated Infections Top


CDC defines HAI as a localised or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) without any evidence of its being present or in incubation at the time of admission.[10],[11],[12] HAI also includes infections appearing after discharge and occupational infections among healthcare workers but does not include colonisation or inflammation resulting from tissue response to injury or non-infectious agents.[11],[12]

An infection is attributed as HAI if date of event occurs on or after 3rd calendar day (CL) of admission where day of admission is counted as CL 1.[10] CL refers to a period from midnight to midnight. This is not to be confused with 48 h after admission as referred in earlier guidelines which was changed to CL because of difficulty experienced in documenting exact time of admission and investigations drawn.[10],[13],[14]

Issue: Difficulty in deciding date of event to delineate healthcare-associated infections

Delineating date of the event (DOE) is the most critical as it helps in deciding whether infection was present on admission (POA) or is HAI and also to decide the hospital location (ward, intensive care unit etc.) where infection is to be attributed. ICT often finds it difficult to understand and to decide DOE as it has undergone amendments several times in the previous years.[13],[15],[16] DOE is the date when the first element of infection (as defined in the site-specific infection criteria) appears in the infection window period (IWP) [defined in [Table 1].[10] It may sometimes be (not always) the date of first positive diagnostic test when this appears as first element of infection.[10] It is not the date of the last element, as well as not the date of sample collection as used previously.[13],[15] [Table 1] summarises the key terms and definitions which are essential for any surveillance.[10] It needs to be emphasised that currently all elements required to meet site specific infection must occur in 7 days IWP and must not be mixed up with previously laid criterion which allowed all elements to occur within a gap of 1 CL between elements.[10],[13],[15]
Table 1: Key terms and definitions for defining healthcare-associated infections

Click here to view


Issue: New episodes of infection in a patient with previous documented healthcare-associated infections

ICT often finds it difficult in assigning new infections in a patient with previous documented HAI. To cater to this CDC (2014) introduced repeat infection timeframe (RIT), a 14-day time period starting from DOE counted as day 1 (not from 1st diagnostic test) during which no new infections of the same type are reported. Any pathogen identified in RIT of a specific infection is added to the original event and no new event is created.[15] This RIT applies at major type of infections for bloodstream infection (BSI), urinary tract infection (UTI) and ventilator-associated pneumonia (VAP). If a RIT is created for BSI (criteria LCBSI 1), appearance of any new element, isolation of new pathogen or meeting of any other subcriteria (LCBSI 2/LCBSI 3) for BSI is not counted as separate event but any new pathogen isolated is added to the original event.[10] However, if UTI event occurs in BSI RIT, UTI is counted as separate event and new RIT is created for UTI. RIT applies at specific level for other infections such as skin infection and decubitus ulcer where separate RIT is created for each infection.[10]

This time frame applies to determine both POA and HAI. In case of readmission or transfer to new location, RIT applies in accordance with transfer rules [Table 1]. RIT does not apply to ventilator-associated events (VAEs).

Issue: Defining time period for attributing any healthcare-associated infections to a device and counting device days

ICT is quite often not clear in attributing an infection to device, especially when DOE occurs after discontinuation of the device and counting device days when it is removed for some period of time and reinserted. Any infection is considered to be device associated if a patient has been with medical device for >2 CLs and DOE occurs on or after 3 CL (day of device placement is counted as day 1) of device placement. In case where the device is discontinued, and DOE occurs on the day of device removal or next day after device removal, infection is attributed to device but not afterwards.[10],[14]

If a device is removed and reinserted on the same day or next day device days counting continues, including previous device days whereas if reinserted after a gap of at least one full CL (not to be read as 24 h), the device day count will start new from day 1.[10],[15]

Other major amendments and clarifications

ICT must be also be aware of some important amendments applicable for all CDC modules from January 2016.[16] These amendments are highlighted in [Table 2] along with comment/rational for these amendments.
Table 2: General amendments applicable to all surveillance (Centre for disease control and prevention/National Healthcare Safety Network Surveillance 2016)

Click here to view



 ~ Central Line-Associated Blood Stream Infection Top


CDC advocates surveillance for central line-associated bloodstream infection (CLABSI) rather than catheter-associated BSI as relative risk of getting BSI is 64 times greater as compared to with peripheral venous catheters.[17] CLABSI is defined as a laboratory-confirmed BSI (LCBI) occurring in the presence of central line but all LCBI in the presence of central line are not CLABSI resulting in wrong or overreporting of CLABSI by ICT. Conventionally, LCBI is defined by three criteria; LCBI 1, LCBI 2 and LCBI 3 but recently, three subsets of LCBI have been added for Mucosal Barrier Injury (MB): MB-LCBI 1, MB-LCBI 2 and MB-LCBI 3 for haematopoietic stem cell transplant recipient and immune-compromised patients.[10],[13] [Table 3] depicts an overview of criteria for defining LCBSI. It is to be noted that currently surveillance for CLABSI is not to be done for patients on high frequency ventilation or extracorporeal life support.[18]
Table 3: Summary of elements defining laboratory-confirmed bloodstream infection

Click here to view


Issue: Defining central lines and counting central line days specifically when line is not accessed and in presence of >1 central lines

ICT often confuses central line with a peripheral line. Central line is defined as an intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood or haemodynamic monitoring.[10] A peripherally inserted line can be a central line provided it terminates at locations described above. [Table 4] lists central lines and non-central lines.
Table 4: Intravascular lines to be considered central and non-central

Click here to view


'Access' of a central line is defined as line placement, insertion of needle into the port, infusion or withdrawal through the line and day of the first access is counted as day 1 for CLABSI surveillance.[10] Daily central line access is not necessary after first access for the purpose of CLABSI surveillance and central line day count will continue until line is removed or patient is discharged irrespective of it being accessed or not after first access.[10] In the presence of two or more central lines, only one line is counted for device-associated days whereas if both temporary and permanent central lines are present only temporary lines are counted as these are accessed more frequently.[10]

Issue: Difficulty in attributing a pathogen to central line

CLABSI is always a primary BSI occurring in the presence of a central line and can never be a secondary BSI which occurs due to seeding of bloodstream from any other site-specific infection. The ICT face difficulty in distinguishing a primary bloodstream from secondary BSI.[19] In addition, a primary BSI may not actually be due to central line particularly in patients with mucosal barrier injury (MBI) (MB LCBI criteria) where translocation of intestinal pathogens from inflamed mucosa may result in bacteraemia.[18],[19],[20],[21] Similarly, it becomes problematic to attribute infection to a central line in patient with both central and peripheral line where peripheral line is also accessed.

Blood stream infection in presence of some other site-specific infection

To attribute any pathogen as secondary to some other site-specific infection (hence not CLABSI) either of the following two rules must be met:[10],[19]

Rule 1 – The bloodstream pathogen must be a matching pathogen to the organism identified from site-specific infection and this pathogen must be an element of site-specific infection criteria and the organism from blood must be identified in the secondary BSI attribution period (defined below) of the site-specific infection. Secondary BSI attribution period is the time period inclusive of IWP and RIT for a site specific infection. This varies from 14 to 17 days depending on DOE occurring in IWP. If DOE is same as date of first diagnostic test, this period is of 14 days but if DOE occurs on 1st day of IWP; this period becomes 17 days. There can be no secondary BSI attribution period for primary BSI.

Rule 2 – The bloodstream pathogen is non matching pathogen to site-specific infection; however, the identified pathogen from blood stream is an element of site-specific infection criterion and this must be isolated in IWP of site-specific infection (Not to be confused with secondary BSI attribution period as in case of matching pathogen).

Mucosal barrier injury

MBI LCBI criteria were introduced by CDC in 2013 to cater to BSIs in haematopoietic stem cell transplant recipient and immune-compromised patients [Box 1].[13] Bacteraemia in these patients is most often due to translocation of intestinal organisms to bloodstream as a result of MBI, hence, not directly attributable to central line.[16] Although countries reporting CLABSI data to CDC are also reporting MB LCBI, the same is not being used to calculate CLABSI event.[10],[17],[18],[19]



Access of any other vascular lines

Any blood stream pathogen cannot be attributed to central line if there is any evidence of observed or suspected injection into any other vascular access lines within 7 days IWP of a BSI event. The event is reported as LCBSI and not CLABSI.[22]

Issue: Creating Repeat infection timeframe for primary versus secondary bloodstream infection and reporting multiple bloodstream infection criteria in one repeat infection timeframe

ICT often creates RIT for both primary and secondary BSI. It is important to emphasise that RIT can be defined only for primary BSI but not for secondary BSI. If a bloodstream pathogen is identified to be a secondary pathogen to some other infection, pathogen is added to the original site-specific infection and no RIT is created.[10]

In addition, CDC has recently clarified that in case of more than one LCBI criteria occurring in one RIT, LCBI 1 is to be reported when both LCBI 1 and LCBI 2 are met and MBI-LCBI 1 to be reported if both MBI-LCBI 1 and MBI-LCBI 2 are met simultaneously.[22]

Issue: Other major amendments and clarifications

Isolation of Campylobacter spp., Clostridium difficile, Enteropathogenic Escherichia coli, Salmonella spp., Shigella spp., Listeria spp., and Yersinia species have been recently excluded from BSI event along with community-acquired fungal pathogen. In neonates during the first 6 days, Group B Streptococcus is also excluded from BSI event.[10],[20],[22]


 ~ Catheter-Associated Urinary Tract Infection Top


Issue: Colony count and urine analysis in defining catheter-associated urinary tract infection

Catheter-associated UTI (CAUTI) criteria have undergone major amendments with respect to signs and symptoms, colony count of isolated pathogens, urinalysis (leucocyte esterase/pyuria/Gram-stain positivity) results and pathogen exclusion.[23] Frequency, burning and urgency have been removed as signs and symptoms in catheterised patients but not for patients without catheter (2016) as these signs and symptoms are non-specific and can occur due to the presence of catheter itself.[16] Suprapubic pain has been included whereas general abdominal pain has been removed as element in signs and symptoms.[20],[21] Urine cultures must have colony count of ≥105 colony-forming unit (CFU)/ml as against 103 CFU/ml in earlier criteria.[10],[15] Urine analysis results are no longer required to meet any UTI criteria for surveillance.[16] Major defining characteristics for the CAUTI are summarised in [Table 5]. Surveillance for asymptomatic bacteriuria has been removed for defining UTI/CAUTI since 2009.
Table 5: Criteria for catheter-associated urinary tract infection (centre for disease control and prevention/National Healthcare Safety Network Surveillance 2016)

Click here to view



 ~ Ventilator-Associated Pneumonia/Ventilator-Associated Event Top


Surveillance for VAP based on clinical, radiological and microbiological criteria was being done for all patients irrespective of age before 2013.[24],[25] VAP surveillance was associated with high subjectivity resulting in highly variable sensitivity and specificity.[24] To overcome this, CDC recommended new objective definitions for capturing VAEs in patients >18 years of age.[26] It is quite likely that surveillance for VAP may be replaced by VAE in coming years as more objective evidence emerges to support discontinuation of VAP surveillance.[27],[28] The objective criteria for VAE surveillance enabled the monitoring of any respiratory event irrespective of infective aetiology in patients with mechanical ventilation.[25],[26],[27] VAEs are described by three stages representing the continuity of severity of disease from one level to another and are not mutually exclusive [Figure 1]:[10],[26]
Figure 1: Algorithm for surveillance of Ventilator associated events

Click here to view


  • Ventilator-associated condition (VAC) – defined by two CLs of worsening of oxygenation
  • Infection-related ventilator-associated complication (IVAC) – evidence of infection or inflammation in patient with VAC
  • Laboratory evidence of respiratory infection – Microbiological or histopathological evidence of infection in patient with VAC.


Issue: When and where ventilator-associated pneumonia/ventilator-associated event surveillance?

CDC has recently cleared that VAP, VAE surveillance will be done on the basis of patient location rather than age-based surveillance as done earlier.[26]

Ventilator-associated pneumonia (VAP)

  • Surveillance of paediatric inpatient locations (PedVAP) excluding neonatal locations[10]
  • Surveillance of pneumonia in ventilated or non-ventilated patients in any patient location[10]
  • For determining if a BSI is secondary to lower respiratory site for patients in adult, paediatric and neonatal locations whether ventilated or not ventilated.[10]


Ventilator-associated events

Surveillance for adult inpatient locations only and in acute care locations.

VAE surveillance definitions are only for surveillance but never for the clinical judgment of ventilated patients. Patients on high-frequency ventilation or extracorporeal life support are excluded from VAP/VAE surveillance.

Issue: Recent changes for ventilator-associated pneumonia surveillance

Some amendments and clarifications which have recently been introduced for VAP surveillance are as under: [22]

  • Any chest imaging test (besides chest X-ray) is now eligible for diagnosing VAP since 2017
  • For pneumonia to be POA, only one (previously two) eligible chest imaging test is required, regardless of patient having underlying pulmonary or cardiac disease
  • For defining VAP, two imaging tests are required in patient with underlying pulmonary or cardiac disease and finding(s) on chest imaging must be new and persistent or progressive and persistent with no evidence of resolution. The two imaging tests must be done with in gap of 14 days and not necessarily in IWP.


Issue: Ventilator-associated event-defining baseline period of stability, worsening of oxygenation

Surveillance for VAE has been introduced recently, and ICT finds it difficult to understand and interpret basic terms used to define different stages of VAEs.

Briefly, oxygen demand on ventilator is measured by fraction of inspired oxygen (FiO2) or positive end-expiratory pressure (PEEP) [Box 2]. An increase in FiO2 and/ or PEEP suggests worsening whereas decrease in FiO2 and PEEP suggests improvement on ventilator.



Minimum fraction of inspired oxygen or positive end-expiratory pressure

FiO2 and PEEP values are recorded at hourly interval and lowest value that is maintained for more than 1 h during one CL is considered as minimum FiO2 or PEEP for that day.[18] If no value is maintained for full 1 h, the lowest recorded value is considered minimum for that CL.

Baseline period

A patient on ventilator must be stable or improving on ventilator for at least 2 CL (evidenced by stable or decrease oxygen demand) before worsening (increased oxygen demand) to qualify for VAE surveillance.

VAC is defined as worsening of oxygenation sustained for at least 2 CL immediately after the baseline period of stability or improvement (2 days). The first possible day for any patient to fulfil VAC criteria is day 4 as worsening of oxygenation must be sustained for 2 CLs after 2 CLs of stability. VAE date is date of worsening of oxygenation and thus cannot occur before day 3 of mechanical ventilation.

Thus, any patient for <3 CLs on ventilator is not eligible for VAE surveillance.

Issue: Confusion in ventilator-associated event window period with Infection window period

ICT is quite often perplexed with VAE window period and IWP (other device associated infections). This VAE window period is not same as IWP defined for other device-associated infections. VAE window period is set around VAE date which is usually a 5-day period (2 days before, the day of VAE event and the 2 days after). Initial 2 days of ventilator are not included in VAE window period as this is a minimum qualifying period for VAE. For example when VAE event date corresponds to 3rd/4th mechanical ventilation day, the window period is 3/4 day, respectively.[10]

Issue: Defining infection-related ventilator-associated complications and qualifying antimicrobial day's criteria

Criteria for defining IVAC are mentioned in [Box 3]. Both of the criteria must occur in the VAE window period regardless of their presence on admission or outside the VAE window period.



Sometimes determination of 4 days antimicrobial qualifying period (qualifying antimicrobial day's) becomes difficult when antimicrobial agents are changed or discontinued in between. CDC has clarified these as follows:[10],[29]

  • There is no compulsion for the antimicrobial agent to be same on all 4 CL. If an antimicrobial is started as a result of deescalation or because of a switch from one agent to another in the same drug class it is still considered new
  • CL need not be consecutive and gap of one CL in between is ignored for antimicrobial period of 4 days to be qualified
  • If there is a gap of only 1 day in between administrations of the same drug, the gap is ignored to count the CL of antibiotic administration but if the gap is of 1 day and antimicrobial agent is changed to a new class the same does not qualify the 4 days period of new antimicrobial.


Issue: Defining possible ventilator-associated pneumonia

Possible VAP (PVAP) is defined as microbiological or histopathological evidence of infection in patient with IVAC. The criteria's required to meet PVAP are summarised in [Table 6].
Table 6: Criteria for defining possible ventilator-associated pneumonia

Click here to view



 ~ Conclusion Top


Surveillance for HAI is the backbone for strengthening of any IPC activity but is still in infancy in India. Robust surveillance data emerging from standardised reporting of HAI can only bring about sustained solutions not only for patient safety but also for containment of antimicrobial resistance. The present review has addressed the major difficulties encountered by ICT in the implementation of current guidelines to shorten the learning curve of the healthcare workers at the ground level besides updating most recent requirements for surveillance of HAI in view of dynamic and constantly evolving surveillance methodology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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2004 - Indian Journal of Medical Microbiology
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