ECDC TECHNICAL DOCUMENT
Surveillance of healthcare-associated
infections and prevention indicators in
European intensive care units
HAI-Net ICU protocol, version 2.2
This technical document of the European Centre for Disease Prevention and Control (ECDC) was coordinated by
Carl Suetens.
Contributing authors
Anne Savey, Alain Lepape (France), Mercedes Palomar (Spain), Antonella Agodi (Italy), Michael Hiesmayr
(Austria), Anna-Pelagia Magiorakos, Pete Kinross, Tommi Kärki, Diamantis Plachouras, Carl Suetens (ECDC)
In accordance with the Staff Regulations for Officials and Conditions of Employment of Other Servants of the
European Union and the ECDC Independence Policy, ECDC staff members shal not, in the performance of their
duties, deal with a matter in which, directly or indirectly, they have any personal interest such as to impair their
independence.
Acknowledgements:
ECDC would like to thank the HAI-Net ICU operational contact points and Member States experts for providing
input during meetings (October 2013, February 2014, February 2015), as wel as the European Society of
Intensive Care Medicine (Infection Section) for reviewing and commenting on the structure and process
indicators of the protocol (Members: Jean-Francois Timsit (France, Infection Section Chair), Christian Brun-
Buisson (France), Massimo Antonel i (Italy), Despoina Koulenti (Greece/Australia), José Artur Paiva (Portugal),
Stijn Blot (Belgium), Jan De Waele (Belgium, Chair from January 2015).
The current HAI-Net ICU protocol v2.2 is the final version of the new HAI-Net ICU protocol, slightly adapted after
the pilot version 2.0 in the fal of 2015.
Suggested citation: European Centre for Disease Prevention and Control. European surveil ance of healthcare-
associated infections and prevention indicators in intensive care units – HAI-Net ICU protocol, version 2.2.
Stockholm: ECDC, 2017.
Stockholm, 2017
© European Centre for Disease Prevention and Control, 2017
Reproduction is authorised, provided the source is acknowledged.
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TECHNICAL DOCUMENT
HAI-Net ICU protocol, version 2.1
Table of contents
Abbreviations ................................................................................................................................................ v
Introduction and objectives............................................................................................................................. 1
1 HAI-Net ICU protocol v2.2: summary of main changes ................................................................................... 3
2 Patient-based (standard option) versus unit-based (light option) surveil ance of ICU-acquired infections ............. 3
3 Case definitions of ICU-acquired infections .................................................................................................... 5
3.1 Definition of key terms .......................................................................................................................... 5
3.1.1 ICU-acquired .................................................................................................................................. 5
3.1.2 Second infection episode ................................................................................................................. 5
3.1.3 Device-associated HAI ..................................................................................................................... 5
3.2 Bloodstream infection ............................................................................................................................ 6
3.2.1 Case definition ................................................................................................................................ 6
3.2.2 Origin of BSI ................................................................................................................................... 6
3.3 Pneumonia (PN 1–PN 5) ........................................................................................................................ 7
X-ray ....................................................................................................................................................... 7
Symptoms .............................................................................................................................................. 7
Microbiology ........................................................................................................................................... 7
3.4 Urinary tract infection ............................................................................................................................ 8
3.4.1 UTI-A: microbiologically confirmed symptomatic urinary tract infection (UTI) ....................................... 8
3.4.2 UTI-B: not microbiologically confirmed symptomatic UTI .................................................................... 8
3.5 Catheter-related infection (CRI) .............................................................................................................. 8
3.5.1 CRI1-CVC: local CVC-related infection (no positive blood culture) ........................................................ 8
3.5.2 CRI2-CVC: general CVC-related infection (no positive blood culture) .................................................... 8
3.5.3 CRI3-CVC: microbiologically confirmed CVC-related bloodstream infection ............................................ 8
3.6 Other HAI types .................................................................................................................................... 9
3.7 Other definitions ................................................................................................................................. 10
3.6.1 Central vascular catheter ............................................................................................................... 10
3.6.2 Type of hospital ............................................................................................................................ 10
4 Data collection .......................................................................................................................................... 11
4.1 Eligibility criteria for intensive care units ................................................................................................ 11
4.2 Inclusion of patients ............................................................................................................................ 11
4.3 Infections under surveil ance ................................................................................................................ 12
4.4 Methods and data sources ................................................................................................................... 12
4.4.1 Structure and process indicators ..................................................................................................... 12
4.4.2. Patient and HAI data .................................................................................................................... 13
4.5 Data processing .................................................................................................................................. 13
4.6 Levels of data requirement .................................................................................................................. 13
5 Hospital/unit data (standard and light options) ............................................................................................ 14
5.1 Hospital and unit characteristics – Form HU ........................................................................................... 14
5.2 ICU denominator data – Form HU ......................................................................................................... 14
5.3 Structure and process indicators – Form HU .......................................................................................... 15
6. Patient-based data (standard option) – Form PT ......................................................................................... 18
6.1. ICU admission and discharge data (second level) .................................................................................. 18
6.2 Exposure data (third level) ................................................................................................................... 19
6.3 Antimicrobial use data (third level) ....................................................................................................... 19
iii
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7. HAI data (standard and light options) – Form INF ....................................................................................... 22
7.1. Infection data (third level) .................................................................................................................. 22
7.2 Microorganism and antimicrobial resistance data (fourth level) ................................................................ 23
8 Outcome indicators of ICU-acquired infections ............................................................................................. 27
9 Confidentiality ........................................................................................................................................... 27
9.1 Patient confidentiality .......................................................................................................................... 27
9.2 Hospital and unit confidentiality ............................................................................................................ 27
9.3 Publication policy ................................................................................................................................ 27
References .................................................................................................................................................. 28
Annex 1: Microorganisms code list ................................................................................................................. 29
Annex 2. Extended antimicrobial resistance data for ICU-acquired infections ..................................................... 33
Annex 3: Healthcare-associated infections code list ......................................................................................... 34
Annex 4: Antimicrobial ATC codes ................................................................................................................. 35
Diagnosis (site) code list for antimicrobial use ............................................................................................. 41
Annex 5: Risk scores definitions: SAPS II, APACHE II, Glasgow ........................................................................ 42
SAPS II score ........................................................................................................................................... 42
APACHE II score ....................................................................................................................................... 43
Glasgow Coma Score ................................................................................................................................ 44
Other scoring systems ............................................................................................................................... 45
Annex 6: List of HAI outcome indicators ......................................................................................................... 46
Annex 7: Structure and process prevention indicators: definition, rationale and references ................................. 47
Hand hygiene: Consumption of alcohol-based hand rub solution ................................................................ 47
ICU staffing: staff to patient ratio ........................................................................................................... 48
Antimicrobial stewardship: Re-assess antimicrobial therapy after 48-72 hours ............................................ 48
Intubation: Cuff pressure ....................................................................................................................... 49
Intubation: Oral decontamination .......................................................................................................... 49
Intubation: Patient position ................................................................................................................... 49
CVC: Catheter dressing observation ....................................................................................................... 50
iv
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HAI-Net ICU protocol, version 2.1
Abbreviations
AMR
Antimicrobial resistance
APACHE score
Acute physiology, age, chronic health evaluation score
BAL
Broncho-alveolar lavage
BSI
Bloodstream infection
CDC
Centers for Disease Control and Prevention (USA)
CFU
Colony-forming units
CRI
Catheter-related infection
CVC
Central vascular catheter
EU
European Union
HAI
Healthcare-associated infection
HAI-Net
Healthcare-Associated Infections surveil ance Network (at ECDC)
HELICS
Hospitals in Europe Link for Infection Control through Surveil ance project
ICU
Intensive care unit
IPSE
Improving Patient Safety in Europe project
LRTI
Lower respiratory tract infection
NHSN
National Healthcare Safety Network
PN
Pneumonia
SAPS
Simplified acute physiology score
SSI
Surgical site infection
UTI
Urinary tract infection
WBC
White blood cells
v
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HAI-Net ICU protocol, version 2.1
Introduction and objectives
The Council Recommendation of 9 June 2009 on patient safety (2009/C 151/01) including the prevention and
control of healthcare-associated infections (HAIs), recommends ‘performing the surveil ance of the incidence of
targeted infection types’, ‘using surveil ance methods and indicators as recommended by ECDC and case definitions
as agreed upon at Community level in accordance with the provisions of Decision No 2119/98/EC
’ [1-3]. In 2000–2002, harmonised methods for the surveil ance of two targeted infection types, surgical site infections
(SSI) and HAIs in intensive care units (ICUs), were developed by the network HELICS (Hospitals in Europe Link for
Infection Control through Surveil ance), funded by the European Commission’s Directorate-General for Health and
Consumers (DG SANCO), and progressively implemented in Member States by HELICS and later as part of the
Improving Patient Safety in Europe (IPSE) project. Surveil ance of HAIs in intensive care units was previously
chosen as a component for European surveil ance based on the existence of such networks in several EU Member
States, on the fact that patients admitted to intensive care are at 5 to 10 times higher risk of acquiring a HAI due
to both intrinsic (e.g. immune-depression) and extrinsic (e.g. mechanical ventilation) risk factors, and because the
ICU is often the epicentre of emerging problems of HAIs and antimicrobial resistance in the hospital.
In July 2008, the coordination of the European surveil ance of HAIs was transferred to the European Centre for
Disease Prevention and Control (ECDC) in accordance with ECDC’s mandate. ECDC continued HAI surveil ance as in
HELICS in 2008 and 2009. Minor changes to the HELICS-ICU protocol were agreed with MS experts in 2010 and
led to the release of the first ECDC HAI-Net ICU protocol (Version 1.01) in December 2010 (later published as
version 1.
02 [4]).
In 2013, the European Commission requested ECDC to col ect additional data on structure and process indicators
for HAIs as well as data on mortality from HAIs, based on the ECDC PPS results and in accordance with the Council
recommendation 2009/C 151/01 of 9 June 2009 on patient safety, including the prevention and control of HAIs.
From October 2013 to February 2015, structure and process indicators for the prevention of HAIs and antimicrobial
resistance in ICUs were developed by ECDC and HAI-Net ICU experts and agreed during the HAI-Net ICU network
meeting in February 2015 (see Annex 7).
The current version 2.1 of the HAI-Net ICU protocol describes the methods for the surveil ance of HAIs and
prevention indicators in intensive care units as agreed in February 2015. Changes compared to protocol version
1.02 are described in Section 1. Changes in version 2.1 compared to version 2.0 which was piloted in 2015 are
minor. All ICUs can participate to the surveillance. To do so, please contact the national HAI surveillance
coordinating centre in your country or ECDC HAI-Net a
t xxxxxxx@xxxx.xxxxxx.xx. A free software with the HAI-
Net ICU (HelicsWin.Net) is available on the ECDC website
[5].
The main objective of this protocol is to ensure standardisation of definitions, data col ection and reporting
procedures for hospitals participating in the national/regional surveil ance of HAIs in ICUs across Europe, in order
to contribute to the EU surveil ance of HAIs and to improve the quality of care in the ICU in a multicentre setting.
The protocol aims at describing methods for the participating ICUs and the national coordinating centres for the
surveil ance of HAIs.
Specific objectives at the level of the intensive care unit and the hospital are:
• to monitor the size of the HAI problem in a unit and identify the areas where prevention activities are
needed;
• to compare the results of the unit with its previous ones, and for inter-unit comparison, and to compare
groups of patients stratified for infection risk, in order to be able to identify areas where the quality of
care can be improved;
• to sensitise personnel to infection problems (microorganisms, antibiotic resistance, etc.) and set local
targets for prevention;
• to promote prevention of HAIs and antimicrobial resistance in European ICUs
• to compare and follow-up the implementation of key preventive measures
• to provide relevant information to monitor and target infection control policies, to measure compliance with
existing guidelines and good practices, to correct or improve specific practices or to develop, implement
and evaluate new practices.
Participation in the European network will also produce gains at the local level from international comparisons that
may provide insights that would not be revealed by regional or national-level surveil ance.
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Specific objectives at the level of regional or national network coordination are:
• to provide the necessary reference data to make comparisons of risk-adjusted rates between
units/hospitals;
• to follow-up epidemiological trends in time:
−
identification of important healthcare-associated pathogens
−
epidemiology of emerging infections, antimicrobial resistance
• to identify and follow-up risk factors of HAIs;
• to promote HAI/AMR prevention through surveil ance
• to compare and follow-up the implementation of key preventive measures between ICUs and between
EU/EEA countries
• to improve the quality of data collection.
Specific objectives at the European level are:
• to promote prevention of HAIs and antimicrobial resistance in European ICUs by providing European
reference data for adjusted SSI rates and compliance with key preventive measures;
• to monitor the burden of HAIs and antimicrobial resistance in European ICUs, in terms of incidence and
attributable mortality;
• to monitor and describe the epidemiology of HAIs in European ICUs;
• to identify emerging healthcare-associated pathogens in the ICU;
−
to follow-up the incidence and the geographical spread of HAIs by type and pathogen in the ICU;
−
to identify regions or countries at higher need of EU support with regard to surveil ance and control of
HAIs;
−
to ensure communication of relevant data on HAIs to the European Commission as a complement to
data transmissions by national health authorities;
• to facilitate the communication and exchange of experience between national/regional networks for the
surveil ance of HAIs;
• to stimulate the creation of national/regional coordination centres for the surveil ance of HAIs in the ICU
where these centres/networks do not exist;
• to provide methodological and technical support to the national/regional HAI surveil ance coordination
centres;
• to improve surveillance methodology, data validation and utilisation;
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HAI-Net ICU protocol, version 2.1
1 HAI-Net ICU protocol v2.2: summary of
main changes
The main changes compared to the previous protocol (HAI-Net ICU protocol v1.02) can be summarised as fol ows:
• Ward data: addition of structure and process indicators of prevention of HAIs and antimicrobial resistance,
measured at the unit level in both standard and light surveil ance options (see Annex 7 for rationale and
references):
o
Alcohol hand rub consumption in previous year;
o
Staffing levels (in a period of 7 days) of registered nurses and nurse aides in the ICU;
o
Audit in approximately 30 patients for following indicators:
Post-prescription review within 72 hours after prescription;
Prevention of pneumonia in intubated patients: control of cuff pressure, oral
decontamination, patient position;
CVC maintenance care: catheter site dressing is not damp, loose or visibly soiled.
• Patient data (standard surveil ance option only): addition of a variable allowing to select a second severity
score (from a list, in addition to SAPS II) and enter its value, deletion of: APACHE II, date of hospital
admission, coronary care, site of previous surgery, parenteral nutrition, addition of birth weight and
gestational age for neonates (optional).
• Exposure and antimicrobial use data (standard surveil ance option only): removal of exposure to parenteral
nutrition; antimicrobial use: updated ATC code list, optional specification of indication and anatomical site
(diagnosis) according to HAI-Net PPS categories
• HAI data (standard and light surveillance options):
o
Addition of PDR (pandrug resistance) in the antimicrobial resistance data:
no PDR: susceptible to at least one antimicrobial;
possible PDR: resistant to al antimicrobials tested in the hospital;
confirmed PDR: resistant to al antimicrobials confirmed by the reference laboratory.
o
Other minor changes to the ‘target’ antimicrobial resistance list for HAIs in ICUs: addition of
colistin (COL) as AMR marker for Enterobacteriaceae, removal of ESBL for Enterobacteriaceae
(not well reported, therefore no added value over susceptibility to third generation
cephalosporins), replacement of ‘PIP’ (piperacil in) by ‘TZP’ (piperacil in-tazobactam) for P.
aeruginosa and re-introduction of ‘CAZ’ (ceftazidime) for Acinetobacter spp. (removed in 2010
revision of HAI-Net ICU protocol);
o
Relationship of death to HAI in patients with an ICU-acquired infection that die – further details
regarding methodology wil be addressed in a specific study on validity and reproducibility of HAI
mortality review data.
o
Addition of Candida auris to the microorganism list
o
Possibility to report other HAI infection types (optional)
• Variables to improve consistency/quality of the data: indication at the level of (each) ICU:
o
HAI types included in the surveil ance: this information replaces the information about the
included HAI types that was col ected at the national (DataSource) level;
o
Optional antimicrobial use data col ected or not at the patient level (standard option only).
2 Patient-based (standard option) versus
unit-based (light option) surveillance of ICU-
acquired infections
Since 2001–2002, the protocol for the surveil ance of ICU-acquired infections includes two options, a patient-based
and a unit-based option. The patient-based surveillance option, also referred to as the ‘standard’ option, allows
advanced risk adjustment of HAI rates for inter-hospital comparisons. The unit-based, or ‘light’ option, provides a
less labour-intensive solution, producing partial y the same indicators as the patient-based option for follow-up of
trends as well as the same descriptive results about infections and antimicrobial resistance, but with less possibility
for risk-adjusted comparisons.
Case definitions and included patients are the same for both options, but in the patient-based option, risk factors
are col ected for each patient (infected or not) whereas in the light option, denominator data are aggregated at the
unit (ICU) level. Infection data, including antimicrobial resistance data and mortality review data and structure and
process indicators (col ected at the unit level) are also identical in both options.
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Table 1.
Comparison between patient-based (standard) and unit-based (light) surveillance options
Patient-based (Standard option)
Unit-based (Light option)
Hospital/Unit data
Hospital characteristics
Hospital characteristics
(minimum for pilot
ICU characteristics
ICU characteristics
testing)
Aggregated denominator data (optional)
Aggregated denominator data (required)
Structure and process indicators
Structure and process indicators
(Form HU)
(Form HU)
Patient data
For al patients staying > two days:
For HAI cases only: demographic data
-
Risk factors on admission
(no separate form, integrated in infection
data, form INFb)
-
Exposure to invasive devices
-
Antimicrobial use data (optional)
(Form PT)
Infection data
Case-based HAI and AMR data
Case-based HAI and AMR data
Relationship death to HAI (optional)
Relationship death to HAI (optional)
(Form INFa)
(Form INFb)
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HAI-Net ICU protocol, version 2.1
3 Case definitions of ICU-acquired infections
The minimal requirement for HAI-Net surveillance of ICU-acquired infections is to include bloodstream infection
(BSI) and/or pneumonia (PN). It is strongly recommended to include both BSI and PN. Urinary tract infections and
catheter-related infections may be added optional y.
3.1 Definition of key terms
3.1.1 ICU-acquired
An infection is considered as ICU-acquired – i.e. healthcare-associated in the ICU - if it occurs in the ICU after
more than 48 hours. In practice, al infections with onset from day 3 onwards in the ICU should be reported. The
day of admission to the ICU is counted as day 1.
3.1.2 Second infection episode
To consider an infection as a new infection episode, the combination of a) new signs and symptoms and
b) radiographic evidence (for pneumonia) or other diagnostic testing is required.
3.1.3 Device-associated HAI
A device-associated, healthcare-associated infection is an HAI in a patient with a (relevant) device that was used
within the 48-hour period before onset of infection (even if it was used only intermittently)
[6]. The term ‘device-
associated’ is only used for pneumonia, bloodstream infections, and urinary tract infections. ‘Relevant device’ refers
to intubation, a central vascular catheter or an indwelling urinary catheter. If the interval is longer than 48 hours,
there must be compelling evidence that the infection was associated with device use. For catheter-associated UTI,
an indwelling urinary catheter must have been in place within seven days before positive laboratory results or signs
and symptoms meeting the criteria for UTI were evident.
Example: Pneumonia is defined as intubation-associated pneumonia (IAP) if an invasive respiratory device was
present (even intermittently) in the 48 hours preceding the onset of infection.
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3.2 Bloodstream infection
3.2.1 Case definition
• Patient has at least one positive blood culture for a recognised pathogen
– or –
• Patient has at least one of the fol owing signs or symptoms: fever (> 38 °C), chil s, or hypotension
and
two positive blood cultures for a common skin contaminant (from two separate blood samples, usual y
within 48 hours).
Skin contaminants = coagulase-negative staphylococci, Micrococcus spp., Propionibacterium acnes, Bacillus spp.,
Corynebacterium spp.
3.2.2 Origin of BSI
Both primary (bloodstream infection of unknown origin or catheter-related) and secondary BSI (secondary to
another infection site) should be reported. The origin of the BSI should be reported in a different variable:
• Catheter-related: the same microorganism was cultured from the catheter or symptoms improve within
48 hours after removal of the catheter.
−
C-CVC: central venous catheter
−
C-PVC: peripheral venous catheter
−
C-ART: arterial catheter
Note: if microbiologically confirmed, report BSI with origin C-CVC as a CRI3-CVC (see CRI3 definition); if
catheter-related infections (CRI) are not included in the surveil ance, or if catheter tip culture was not done
(only clinical evidence), then report as BSI with origin C-CVC.
• Secondary to another infection: the same microorganism was isolated from another infection site or strong
clinical evidence exists that bloodstream infection was secondary to another infection site, invasive
diagnostic procedure or foreign body.
−
Pulmonary (S-PUL)
−
Urinary tract infection (S-UTI)
−
Digestive tract infection (S-DIG)
−
Surgical site infection (S-SSI)
−
Skin and soft tissue (S-SST)
−
Other (S-OTH): e.g. central nervous system infection, bone infection (e.g. osteomyelitis, etc.), invasive
diagnostic procedure, foreign body
• Unknown (UO): BSI of unknown origin (origin was verified but no source could be found for the BSI).
• Missing, data unavailable (UNK): only use this code if data on the BSI origin is missing.
Notes:
• ‘Primary’ bloodstream infections include catheter-related BSI and BSI of unknown origin.
• A central line-associated bloodstream infection (CLABSI) according to CDC/NHSN definitions (different from
CVC-related BSI) is a primary BSI with central vascular catheter use (even intermittent) in the 48 hours
preceding the onset of the infection. Therefore the presence of ‘the relevant device’ in the 48 hours
before onset of infection is col ected even in the absence of microbiological confirmation.
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HAI-Net ICU protocol, version 2.1
3.3 Pneumonia (PN 1–PN 5)
-ray Two or more serial chest X-rays or CT-scans with a suggestive image of pneumonia for patients with
underlying cardiac or pulmonary disease* (in patients without underlying cardiac or pulmonary disease,
X one definitive chest X-ray or CT-scan is sufficient).
and at least one of the fol owing:
• fever > 38 °C with no other cause
• leukopenia (< 4 000 WBC/mm3) or leucocytosis (≥ 12 000 WBC/mm3).
toms and at least one of the fol owing (or at least two, if clinical pneumonia only = PN 4 and PN 5):
• new onset of purulent sputum, or change in character of sputum (colour, odour, quantity,
consistency)
Symp
• cough or dyspnea or tachypnea
• suggestive auscultation (rales or bronchial breath sounds), rhonchi, wheezing
• worsening gas exchange (e.g. O2 desaturation or increased oxygen requirements or increased
ventilation demand).
and
according to the used diagnostic method:
a) Bacteriologic diagnostic performed by:
Positive quantitative culture from minimally contaminated LRT specimen
(PN 1)
• Broncho-alveolar lavage (BAL) with a threshold of ≥ 104 colony forming units (CFU)/ml or ≥ 5%
of BAL-obtained cells contain intracellular bacteria on direct microscopic exam (classified on
the diagnostic category BAL)
• protected brush (PB Wimberley) with a threshold of ≥ 103 CFU/ml
• distal protected aspirate (DPA) with a threshold of ≥ 103 CFU/ml.
Positive quantitative culture from possibly contaminated LRT specimen
(PN 2)
• Quantitative culture of LRT specimen (e.g. endotracheal aspirate) with a threshold of
y
106 CFU/ml.
b) Alternative microbiology methods (PN 3)
iolog
• Positive blood culture not related to another source of infection
• positive growth in culture of pleural fluid
rob
• pleural or pulmonary abscess with positive needle aspiration
ic
• histologic pulmonary exam shows evidence of pneumonia
M
• positive exams for pneumonia with virus or particular germs (e.g. Legionella, Aspergil us,
mycobacteria, mycoplasma, Pneumocystis jiroveci [previously P. carini ]):
−
positive detection of viral antigen or antibody from respiratory secretions (e.g. EIA, FAMA,
shell vial assay, PCR)
−
positive direct exam or positive culture from bronchial secretions or tissue
−
seroconversion (example: influenza viruses, Legionella, Chlamydia)
−
detection of antigens in urine (Legionella).
c) Others
• Positive sputum culture or non-quantitative LRT specimen culture
(PN 4) • No positive microbiology
(PN 5).
Notes:
-
PN 1 and PN 2 criteria were validated without previous antimicrobial therapy. However, this does not
exclude the diagnosis of PN 1 or PN 2 in the case of previous antimicrobial use
-
*In case recent chest X-rays are available for patients with underlying cardiac or pulmonary disease, one
definitive chest X-ray or CT-scan during the current ICU stay may be sufficient.
Comment
The five subcategories of the definition of pneumonia al ow for the comparison of similar types of pneumonia
within and between networks. For scientific literature regarding the diagnostic categories, see references
[7,8]. It
is essential that al ICUs and networks also report PN 4 and PN 5 (clinical pneumonia without microbiological
evidence) in order to achieve overall comparability, even if microbiological exams yielded negative results (PN 5). It
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is also advised, both for clinical and surveil ance purposes, that networks promote microbiological confirmation (PN
1–3) as a routine practice in ICUs.
3.4 Urinary tract infection
3.4.1 UTI-A: microbiologically confirmed symptomatic urinary tract
infection (UTI)
• Patient has at least one of the fol owing symptoms with no other recognised cause: fever (> 38 °C),
urgency, frequency, dysuria, or suprapubic tenderness
and
• Patient has a positive urine culture, i.e. ≥ 105 microorganisms per ml of urine with no more than two
species of microorganisms.
3.4.2 UTI-B: not microbiologically confirmed symptomatic UTI
• Patient has at least two of the fol owing, with no other recognised cause: fever (> 38 °C), urgency,
frequency, dysuria, or suprapubic tenderness;
and at least one of the fol owing:
• positive dipstick for leukocyte esterase and/or nitrate
• pyuria urine specimen with ≥ 10 WBC/ml or ≥ 3 WBC/high-power field of unspun urine
• organisms seen on Gram stain of unspun urine
• at least two urine cultures with repeated isolation of the same uropathogen (Gram-negative bacteria or
S. saprophyticus) with ≥ 102 colonies/ml urine in non-voided specimens
• ≤ 105 colonies/ml of a single uropathogen (Gram-negative bacteria or S. saprophyticus) in a patient being
treated with effective antimicrobial agent for a urinary infection
• physician diagnosis of a urinary tract infection
• physician institutes appropriate therapy for a urinary infection.
Note: UTI-C (asymptomatic bacteriuria) is now excluded from the surveil ance of ICU-acquired infections.
However, bloodstream infections secondary to asymptomatic bacteriuria are reported as BSI with source (origin)
S-UTI.
3.5 Catheter-related infection (CRI)
3.5.1 CRI1-CVC: local CVC-related infection (no positive blood
culture)
• Quantitative CVC culture ≥ 103 CFU/m
l [9] or semi-quantitative CVC culture > 15 CFU
[10]
and
• pus/inflammation at the insertion site or tunnel.
3.5.2 CRI2-CVC: general CVC-related infection (no positive blood
culture)
• Quantitative CVC culture ≥ 103 CFU/ml or semi-quantitative CVC culture > 15 CFU
and
• clinical signs improve within 48 hours after catheter removal.
3.5.3 CRI3-CVC: microbiologically confirmed CVC-related bloodstream
infection
• BSI occurring 48 hours before or after catheter removal (if any)
and positive culture with the same microorganism of either:
• quantitative CVC culture ≥ 103 CFU/ml or semi-quantitative CVC culture > 15 CFU
or
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• quantitative blood culture ratio CVC blood sample/peripheral blood sample > 5
[11,12]
• differential delay of positivity of blood cultures [10]: CVC blood sample culture positive two hours or more
before peripheral blood culture (blood samples drawn at the same time)
[11,13]
• positive culture with the same microorganism from pus from insertion site.
Notes
• The inclusion of CRIs is optional in the HAI-Net ICU protocol, and the inclusion (or not) should be indicated
for each ICU; when CRIs are included, al 3 types of CRI-CVC should be reported
• Central vascular catheter colonisation should not be reported.
• A CRI3-CVC is also a bloodstream infection with source C-CVC; however, when a CRI3 is reported, the BSI
should not be reported separately; microbiological y confirmed catheter-related BSI should be reported as
CRI3.
• If CRIs are not included in the (national) surveillance protocol, always report CRI3-CVC as BSI with origin C-
CVC.
• Infections related to peripheral vascular catheters (arterial or venous) may be reported as CRI1-PVC, CRI2-
PVC and CRI3-PVC if case definition
s [14,15] are met, or as BSI with origin C-PVC or C-ART.
3.6 Other HAI types
Other HAI types can optional y be included in HAI-Net ICU surveil ance. Case definitions for other HAI types
(including neonatal case definitions) are published in the HAI-Net point prevalence survey protocol
[14] and in the
Commission Implementing Decision laying down case definitions for reporting communicable diseases
[15]. The
code list for other HAI types is provided in Annex 3.
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3.7 Other definitions
3.6.1 Central vascular catheter
A central vascular catheter (or central line) is 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 hemodynamic monitoring
[16]. The
fol owing are considered great vessels for the purpose of reporting central-line BSI and counting central-line days
in the NHSN system: aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins,
internal jugular veins, subclavian veins, external iliac veins, common iliac veins, common femoral veins, and in
neonates, the umbilical artery/vein.
Notes
• Neither the insertion site nor the type of device may be used to determine if a line qualifies as a central line.
The device must terminate in one of these vessels or in or near the heart to qualify as a central line.
• An introducer is considered an intravascular catheter.
• Pacemaker wires and other non-lumened devices inserted into central blood vessels or the heart are not
considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices.
Infusion
The introduction of a solution through a blood vessel via a catheter lumen. This may include continuous infusions
such as nutritional fluids or medications, or it may include intermittent infusions such as flushes or IV antimicrobial
administration, or blood, in the case of transfusion or haemodialysis.
Umbilical catheter
A central vascular device inserted through the umbilical artery or vein in a neonate.
Temporary central line
A non-tunneled catheter
Permanent central line
Includes:
• tunneled catheters, including certain dialysis catheters; and implanted catheters (including ports).
3.6.2 Type of hospital
Primary
• Often referred to as ‘district hospital’ or ‘first-level referral’
• Often corresponds to general hospital without teaching function
• Few specialities (mainly internal medicine, obstetrics-gynaecology, paediatrics, general surgery or only
general practice)
• Limited laboratory services are available for general, but not for specialised pathological analysis.
Secondary
• Often referred to as ‘provincial hospital’
• Often corresponds to general hospital with teaching function
• Highly differentiated hospital by function with five to 10 clinical specialities, such as haematology, oncology,
nephrology, ICU
• Takes some referrals from other (primary) hospitals
Tertiary
• Often referred to as ‘central’, ‘regional’ or ‘tertiary-level’ hospital
• Often corresponds to University hospitals
• Highly specialised staff and technical equipment (ICU, haematology, transplantation, cardio-thoracic
surgery, neurosurgery)
• Clinical services are highly differentiated by function
• Specialised imaging units
• Provides regional services and regularly takes referrals from other (primary and secondary) hospitals.
Specialised hospital
• Single clinical specialty, possibly with sub-specialties
• Highly specialised staff and technical equipment
• Examples: paediatric hospital, infectious diseases hospital.
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HAI-Net ICU protocol, version 2.1
4 Data collection
4.1 Eligibility criteria for intensive care units
The intensive care units admitted to the surveil ance networks must fit the definition established by the European
Society of Intensive Care Medicin
e [17]:
‘An ICU is a geographical y defined area in the hospital providing care for critically ill patients with specialised
personnel and complex equipment. […]
The ICU is staffed with a specific group of special y trained doctors, nurses and other al ied personnel (e.g.
physiotherapists, technicians) in appropriate numbers. […]
The ICU should provide at least facilities for temporary cardiac pacing and invasive haemodynamic monitoring,
ventilation supports and pump-controlled administration of infusions. Facilities for blood gas, haemoglobin and
electrolyte measurements should be provided in the ICU or in the immediate vicinity. An ICU should function 24
hours a day, seven days a week. There must be at least one doctor immediately available at al times who can
deal with al emergencies.’
Neonatal and paediatric ICUs can be included in the network, but results should be separately identified in the
analysis.
The aim should be to include as many units as possible. Since the range of units that fal within the definition is too
wide, clearly defined subgroups should be established which allow meaningful comparisons between the various
ICUs. Criteria for defining these subgroups wil be developed through a questionnaire to be fil ed in by al
participating ICUs.
4.2 Inclusion of patients
Only patients staying more than two calendar days are included in the surveil ance, according to the fol owing
algorithm:
Date of discharge from the ICU – Date of admission to the ICU + 1 > 2
Patients who stay less than three days in the ICU are excluded. These patients add many patient- and device-days
to the denominator, but are not at risk of developing an infection after two days in the ICU. Infections which
appear after discharge from the ICU (post-discharge) are excluded. Post-discharge surveil ance is time-consuming,
adds little to the performance of the surveil ance system and, in practice, is rarely done.
In the light option (unit-based surveil ance), patient-days are included in the denominator if patients have been
present for more than two days within the time window of the surveil ance, even if they were admitted before the
beginning of that period.
In the standard option (patient-based surveil ance), patients may be included as follows:
•
Prospective inclusion: patients are included if the ICU admission date fal s within the time window of the
surveil ance. After the end of the surveil ance period, patients stil under follow-up are ‘censored’ (arbitrarily
discharged) at the last day of the month fol owing the end of the surveil ance period (e.g. 31 July if
surveil ance runs from 1 January to 30 June) in order to al ow for data encoding and transmission to the
national/regional coordination centre. The follow-up of these patients may be completed, and data are sent
in for correction, for example at the end of the next surveil ance period.
•
Retrospective inclusion: patients are included if the ICU discharge date fal s within the time window of the
surveil ance. Censoring is not an issue in this case.
Note: The different inclusion methods result in slightly different denominator data for the same unit during the
same surveil ance period. In practice, however, these differences are very smal . Approximately 2–3% of patients
stay longer than 30 days in the ICU, and less than 0.05% stay more than three months. The difference between
unit-based and patient-based denominator data, such as patient-days, wil decrease as the surveil ance period
increases.
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4.3 Infections under surveillance
Al infections with date of onset after day 2 and later in the ICU should be reported and be regarded as ICU-
acquired infections, even if there are reasons to believe that the infection was acquired in another ward or in the
community. Infections occurring before day 3 may be recorded, but wil not be included in the analysis. It is
recommended to include, as a minimum, data on ICU-acquired bloodstream infection and pneumonia. Urinary tract
infections and catheter-related infections are optional.
Which HAI types are included in the surveil ance should be indicated at the ICU surveil ance year level. Usually the
inclusion of HAI types is defined by the national/regional surveil ance protocol, however some countries may leave
the choice to the ICUs. At the request of several Member States, the possibility to report other HAI types (other
than BSI, PN, UTI and CRI) has been added to the protocol and the HelicsWin.Net software.
In unit-based (light) surveillance, all ICU-acquired infections occurring (date of onset) within the time window of
the surveil ance period are included, even if the patient was admitted to the ICU before the start of the surveil ance
period. In patient-based surveil ance, infections may occur outside the time window, since the inclusion criterion is
either the ICU admission or discharge date of the patient.
4.4 Methods and data sources
4.4.1 Structure and process indicators
Structure and process indicators should be col ected at least once per year for each ICU participating in the
surveil ance. Data are col ected at the unit level (or unit-surveil ance period level) in both the standard and the light
surveil ance options. The data col ection for the indicators is estimated to last approximately 2 weeks, depending
on the size of the ICU.
The following priority topics and indicators were selected for the HAI-Net ICU protocol. Methods and data sources
differ according to the indicator.
-
Hand hygiene:
Alcohol hand rub consumption during the previous year in the ICU. The
consumption of alcohol-based hand rubs in intensive care units is col ected from the hospital pharmacy records
for the year prior to the surveil ance year.
-
ICU staffing: registered nurse-to-patient ratio and nursing assistant to patient ratio, calculated based on the
actual planning for 7 days during the evaluation period.
-
Antimicrobial stewardship: systematic review of prescribed antimicrobials within 72 hours. The percentage
of reviewed antimicrobial therapies within 72 hours is based on a retrospective study of 30 (minimum 20)
consecutive antimicrobial prescriptions of more than 3 days (before the evaluation period).
-
Prevention of intubation-associated pneumonia (IAP):
o
Endotracheal cuff pressure control ed and/or corrected at least twice a day.
o
Oral decontamination using oral antiseptics at least twice a day
The percentage of correct cuff pressure and oral decontamination records is col ected by 30
consecutive reviews of the files of intubated patients (each patient is observed once per day, the
same patient is observed for several consecutive days) during the evaluation period.
o Position of the patient not supine (direct observation)
-
Prevention of central line associated bloodstream infection (CLABSI): CVC maintenance – Catheter
site dressing is not damp, loose or visibly soiled (direct observation).
The position of the patient and the dressing of the central vascular catheter (CVC) are evaluated through 30
direct observations of patients with intubation and/or a CVC in place respectively (each patient is observed
once per day, the same patient may be observed for several consecutive days) during the evaluation period.
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HAI-Net ICU protocol, version 2.1
Figure 1. Time frame of the data collection for structure and process indicators of HAI/AMR
prevention in the ICU
4.4.2. Patient and HAI data
Different data sources should be consulted to determine whether a patient has an infection, such as the patient file
(medical and nursing notes), microbiological laboratory and pharmacy databases, X-ray data, ward rounds,
clarification of signs and symptoms with the nursing/medical team etc. The need to consult different data sources
also depends on whether ICU staff is involved in the data col ection as opposed to data col ection by the infection
prevention and control staff only. For the standard surveil ance option, it is recommended that ICU physicians are
involved or at least consulted for the col ection of patient risk factors on admission. In case automated systems are
set up to flag possible infections, it is recommended to confirm with the ICU physician in charge of the patient
whether signs and symptoms of an HAI are met. In order to determine the relationship of death to an HAI, it is
recommended to consult two physicians.
4.5 Data processing
Each country is at liberty to organise its own system for data col ection and processing. The standard surveil ance
option, however, foresees that data should be col ected on forms (see examples provided in this protocol) and
subsequently be entered in a computer system by the hospital staff after data verification. Countries may choose
to develop and use their own software system to do this. Alternatively, ECDC supports a free software tool
(HelicsWin.Net) for data entering at the hospital level
[5]. If HelicsWin.Net is used, data should be exported by the
hospitals and transferred to the national coordination centre. Data from different hospitals/ICUs can be appended
in HelicsWin.Net. National centres will submit the national database to ECDC, using ECDC’s TESSy system, or make
data available to ECDC via other agreed methods. National centres may also submit data from individual
hospital/ICUs one by one to TESSy.
4.6 Levels of data requirement
In ECDC’s TESSy system, variables are classified according to three levels of requirement:
•
Required true (error)
(E): Data will be rejected if this variable is missing (also cal ed ‘mandatory’).
•
Required true (warning)
(W): Variables are required for the correct interpretation of the results and/or
for routine analysis; a warning wil be produced if this variable is missing (also cal ed ‘required’).
•
Required false (F): No error if data are missing; data used for additional analysis (also called ‘optional’).
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5 Hospital/unit data (standard and light
options)
Hospital and unit (ICU) data are the same for the standard and light surveil ance options and use the same form
(Form HU). The only difference is that the aggregated ICU denominator data for patients staying more than 2 days
are optional for the standard option, but mandatory for the light option.
In the TESSy database, hospital and unit data are divided in data to be col ected once per surveil ance year (first
level) and data to be col ected for each surveil ance period (second level).
5.1 Hospital and unit characteristics – Form HU
Hospital and unit characteristics should be col ected once per year.
Hospital code (required): hospital identifier/code is assigned by the national/regional CDI surveillance
coordinator. Hospital codes should be unique within each surveil ance network, and, if possible, kept constant
between the ECDC Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) surveil ance protocols
and from one year to the next.
Year (required): surveil ance year
Hospital size (required): Total number of beds in the hospital
Hospital type (required): Type of hospital, definition see section 3.6.2. PRIM = Primary; SEC = Secondary;
TERT = Tertiary; SPEC = Specialised; UNK = Unknown hospital type.
ICU Id (required): Unique identifier for each intensive care unit within an hospital, should remain identical in
different surveil ance periods/years
ICU size (required): Number of beds in the ICU
ICU specialty (required): If 80% of the patients belong to a particular category, the ICU fal s within that
category, otherwise the specialty is ‘Mixed’. MIX = Mixed; MED = Medical; SURG = Surgical; CORO = Coronary;
BURN = Burns; NEUR = Neurosurgical; PED = Paediatric; NEON = Neonatal; O = Other; UNK = Unknown
Percentage of intubated patients in the ICU (required): Percentage of intubated patients over the past year
in the ICU. Measured or estimated average percentage (not: proportion) of patients with an invasive respiratory
device over the last year in the current ICU. Number from 0.00 to 100.00. This variable is used as a proxy for
severity of ICU case-mix and should also be col ected if pneumonia is not included in the surveil ance.
HAI types included in the surveillance: Indicate which of four HAI types are included in the current ICU
surveil ance year. Included HAI types should remain constant between different surveil ance periods within the
same surveil ance year. The information is stored in five separate yes/no variables for the inclusion of respectively
pneumonia, bloodstream infections, urinary tract infections, catheter-related infections and other HAI types.
5.2 ICU denominator data – Form HU
ICU denominator data should be col ected for each surveil ance period. Aggregated denominator data are optional
except for denominator data for patients staying more than 2 days in the ICU, which are absolutely required in the
light surveil ance option.
Surveillance period (required): start and end date of the ICU surveil ance period. The recommended minimal
surveil ance period is 3 months, maximum 1 year.
Number of admissions for patients staying more than 2 days in the ICU: Number of new admissions of
patients staying more than 2 days in the intensive care unit during the period. Main denominator for the indicator
‘cumulative incidence of HAIs’, required for light surveil ance; in the standard surveil ance option, this variable is
optional and allows verifying the exhaustiveness of the entered patient-based data.
Number of patient-days for patients staying more than 2 days in the ICU: Number of patient-days for
patients staying more than 2 days in the intensive care unit during the period. Main denominator for the indicator
‘incidence density of HAIs’, required for light surveillance; in the standard surveil ance option, this variable is
optional and allows verifying the sum of patient-days reported on patient level.
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Number of admissions, all ICU patients: Total number of new admissions in the intensive care unit during the
period. Used for burden estimates of HAIs in ICUs, assessing the ICU workload for patients staying 1 or 2 days in
the ICU and comparing some indicators with ICU surveil ance systems that include all ICU patients. Optional, but
strongly recommended.
Number of patient-days, all ICU patients: Total number of patient-days in the intensive care unit during the
period. Used for burden estimates of HAIs in ICUs, assessing the ICU workload for patients staying 1 or 2 days in
the ICU, comparing some indicators with ICU surveil ance systems that include al ICU patients and cross-checking
the plausibility of the denominator of the alcohol hand rub consumption and nurse-to-patient ratio indicators.
Optional, but strongly recommended.
5.3 Structure and process indicators – Form HU
Structure and process indicators can be col ected once per surveil ance period (minimum once per year), except for
the alcohol hand rub consumption which is always col ected once per year, for the previous year.
The indicators included in the current protocol are the selection proposed for the pilot study of the HAI-Net ICU
surveil ance protocol v2.0. The main objective of the pilot study is to test the feasibility of these indicators.
Alcohol hand rub consumption during the previous year: Total number of litres of alcohol-based hand rub
delivered to the intensive care unit (usual y by the hospital pharmacy) during the previous year.
Total number of patient-days during the previous year: Total number of patient-days during the year prior
to the current surveil ance year (patient-days for al patients, not only for patients staying more than 2 days in the
ICU). Short interruptions are not taken into account. Partial days count as one patient day. This variable is the
denominator of the indicator ‘alcohol-based hand rub consumption in the ICU per 1000 patient-days’.
Total number of registered nurse hours in ICU over 7 day period: Total number of hours of real presence
of registered nurses during a period of 7 days, including hours of presence during the night (presence of 1 ful -time
nurse 24/7=168 hours). Only include registered nurses involved in bedside patient care. Students are not included.
A ‘registered nurse’ is a nurse who has graduated from a col ege’s nursing program or from a school of nursing and
has passed a national licensing exam to obtain a nursing license. Also include ‘agency nurses’, ‘bank nurses’,
‘interim nurses’ or other registered nurses who are not permanently employed for that position in the hospital.
Total number of nursing assistant hours in ICU over 7 day period: Total number of hours of real presence
of nursing assistants during a period of 7 days, including hours of presence during the night (presence of 1 full-
time nursing assistant 24/7=168 hours). Only include nursing assistants involved in bedside patient care. Students
are not included. A ‘nursing assistant’ is also referred to as ‘nurses’ aide’, ‘healthcare assistant’, ‘nursing auxiliary’,
‘auxiliary nurse’, ‘patient care assistant’ or similar terms. Also include nursing assistants who are not permanently
employed for that position in the hospital.
Total number of patient-days over the same 7 day period: Total number of patient-days (all patients) over
the same 7 days used for the number of (registered/assistant) nurse hours. Short interruptions are not taken into
account. Partial days count as one patient day.
Practice evaluation period: Start date and end date of the period during which HAI prevention and
antimicrobial stewardship practices are evaluated.
For al indicators assessed by chart review or by direct observations during the practice evaluation period:
N of files/observations (# observations) = Denominator
N of compliant observations (# compliant) = Numerator
Antimicrobial stewardship: Review antimicrobial therapy within 72 hours (chart review): Verify, for 30
(minimum 20) consecutive patients with antimicrobial therapy whether the therapy was evaluated within 72 hours
after the start of the antimicrobial and has been documented in the patient file. Only consider first empiric or
documented antimicrobial therapies that were started in the current ICU. Only systemic antimicrobial therapy (IV,
IM, SC, oral) started since more than 72 hours are eligible for evaluation. Number of observations (denominator) =
Total number of audited antimicrobial therapies that were started more than 3 days ago; Number compliant
(numerator) = Number of antimicrobial therapies that were started more than 3 days ago and were re-assessed
within 72 hours after start of the antimicrobial.
Intubation: Endotracheal cuff pressure controlled and/or corrected at least twice a day (chart review):
Numerator=Number of intubation days (days of patients with intubation) during which the endotracheal cuff
pressure was verified and maintained between 20 and 30 cm H2O (and documented in the patient file) at least
twice per day; Denominator=Total number of observed intubation days. Source: medical or nurse patient file,
prospective review of 30 patient-days with intubation. One patient with intubation is included only once a day, but
the same patient can be included for several consecutive days.
Intubation: Oral decontamination using oral antiseptics at least twice a day (chart review):
Numerator=Number of intubation days (days of patients with intubation) during which oral decontamination with
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oral antiseptics has been performed (and documented in the patient file) at least twice per day;
Denominator=Total number of observed intubation days. Source: medical or nurse patient file, prospective review
of 30 patient-days with intubation. One patient with intubation is included only once a day, but the same patient
can be included for several consecutive days.
Intubation: Position of the patient not supine (direct observation): Numerator=Number of days of patients
with intubation during which the patient’s position was not supine (= was either prone or recumbent);
Denominator=Total number of observed intubation days. Source: Direct observation of the position of the patient
with intubation (in bed), up to 30 patient observations. One patient with intubation is included only once a day, but
the same patient can be included for several consecutive days. Observations should as much as possible be
perform at the same time during the day (e.g. at 16:00 in the afternoon). Patients in strict supine (dorsal
decubitus) position for specific indications (e.g. certain trauma patients) should be excluded.
CVC: Catheter site dressing is not damp, loose or visibly soiled (direct observation): Numerator = Number
of days of patients with a central vascular catheter during which the dressing of the CVC was not loose, damp or
visibly soiled ; Denominator = Total number of observed CVC days. Source: Direct observation of 30 patients with
at least one CVC in place, up to 30 patient observations. One patient with one or several CVCs is included only
once a day, but the same patient can be included for several consecutive days. Observations should as much as
possible be perform at the same time during the day (e.g. at 16:00 in the afternoon). For patients with several
CVCs in place, al CVC dressings need to be ok (not loose, damp nor visibly soiled).
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European Surveillance of ICU-acquired infections
Form HU. Hospital / ICU data (Standard & light option)
Hospital data
Hospital size
Hospital Code
Year:
(n of beds)
Hospital Type:
O primary O secondary O tertiary O specialised
ICU characteristics
ICU Id
Unique identifier for each intensive care unit w ithin an hospital
ICU size
Number of beds in the ICU
O Mixed O Medical O Surgical O Coronary O Burns O Neurosurgical
ICU specialty
O Pediatric O Neonatal O Other O Unknown
Percentage of intubated patients in year (true or estimated %):
%
HAI types included in surveillance: O Pneumonia (PN) O Bloodstream Infections (BSI)
O Urinary tract infections (UTI) O Catheter-related infections (CRI) O Other HAI types
ICU indicators and denominators
Surveillance Period
All Patients
Patients staying >2 days
N of
N of patient-
N of
N of patient-
Start date
End date
admissions
days
admissions
days
Recommended minimal surveillance period = 3 months, maximum 1 year; add one form for each period
STRUCTURE AND PROCESS INDICATORS
Alcohol hand rub consumption during the previous year
Litres
Total number of patient-days during the previous year
patient-days
ICU staffing ratio
Total number of registered nurse hours in ICU over 7 day period
nurse hours
Total number of nursing assistant hours in ICU over 7 day period
nurse hours
Total number of patient-days over the same 7 day period
patient-days
Practice evaluation: Start date __ / __ / _____
End date
__ / __ / _____
N of files /
N of compliant
observations
observations
Antimicrobial stewardship: Review antimicrobial therapy within
72 hours (chart review)
Intubation: Endotracheal cuff pressure controlled and/or corrected
at least twice a day (chart review)
Intubation: Oral decontamination using oral antiseptics at least
twice a day (chart review)
Intubation: Position of the patient not supine (direct observation)
CVC: Catheter site dressing is not damp, loose or visibly soiled
(direct observation)
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6. Patient-based data (standard option) –
Form PT
Patient-based data should be col ected in the standard surveil ance option, for each patient admitted to the ICU
during the surveil ance period AND staying more than two days in the ICU.
6.1. ICU admission and discharge data (second level)
Patient counter: Numeric Code for each patient, unique within hospital, anonymous. In the HelicsWin.Net
software, the patient counter is automatical y generated and a second field, which is not exported by default,
al ows entering an internal patient code. Required.
Age: Age of the patient on the date of admission to the ICU (in years). Required.
Gender: Gender of the patient. M = Male; F = Female; O = Other; UNK = Unknown. Required.
Date of ICU admission: Date of admission in the ICU. Required.
Date of ICU discharge: Date the patient was discharged from the ICU or date of in-ICU death or date of last
follow-up in the ICU. Required.
ICU discharge outcome: Patient status at discharge from the ICU or at end of fol ow-up in the ICU. A = Alive; D
= Dead in ICU; UNK = Unknown. Required.
Origin of the patient: Origin of the patient at the time he/she was admitted at the ICU HOSP = Ward in
this/other hospital. OICU = Other ICU; COM = Community (patient came from his home, via emergency or not);
LTC = Long-term care/nursing home; O = Other; UNK = Unknown.
Type of ICU admission: Type of admission as defined in SAPS II score: (medical: no surgery within one week of
admission to ICU; scheduled surgical: surgery was scheduled at least 24 hours in advance +/- 7 days ICU
admission; unscheduled surgical: patients added to the operating room schedule within 24 hours of the operation.
MED = Medical; SSUR = Scheduled surgical; USUR = Unscheduled surgical; UNK = Unknown.
Trauma patient: Intensive care unit admission resulted from blunt or penetrating traumatic injury to the patient,
with or without surgical intervention. Y = Yes; N = NO; UNK = Unknown
.
Impaired immunity: Impaired immunity as defined in APACHE II score: impaired immunity due to treatment
(chemotherapy, radiotherapy, immune suppression, corticosteroids long duration or high doses recently), due to
disease (leukaemia, lymphoma, AIDS), or < 500 PMN/mm3. Y = Yes; N = NO; UNK = Unknown.
Antibiotic treatment in 48 hours before or after ICU admission: Specify ‘yes’ if any antibiotic therapy in the
48 hours preceding ICU admission and/or during the first two days of ICU stay (=antibiotic therapy for an
infectious event around ICU admission, excl. antifungal and antiviral treatment) has been given; not: antimicrobial
prophylaxis, SDD, local treatment. Y = Yes; N = NO; UNK = Unknown
SAPS II score: Simplified Acute Physiology Score II on admission (first 24h of ICU stay). Severity of il ness score
developed to predict mortality. Integer number from 0 to 163.
Other severity score name and value: Add another severity of il ness score and the corresponding value.
Possible scores [and possible values]: APACHE = Acute Physiology and Chronic Health Evaluation score (APACHE II
[0-71], APACHE III [0-299], APACHE IV [0-286]), MPM = Mortality Prediction Model (MPM II [0-100], MPM III [0-
100]), McCabe score [0=non-fatal (survival >= 5 years); 1=ultimately fatal (survival < 5 years), 2=rapidly fatal
(survival<1 year); 9=unknown], SAPS 3 [0-217]; ASA = Physical Status Classification System of the American
Society of Anesthesiology [1=normal y healthy patient, 2=patient with mild systemic disease, 3=patient with
severe systemic disease that is not incapacitating, 4=patient with an incapacitating systemic disease that is a
constant threat to life, 5=moribund patient who is not expected to survive for 24 hours with or without operation];
Paediatric scores: PIM = Paediatric Index of Mortality (PIM [0-100], PIM II [0-100]); PRISM = Paediatric Risk of
Mortality score (PRISM [0-75], PRISM III, PRISM IV); Neonatal score: CRIB = Clinical Risk Index for Babies (CRIB
[0-23], CRIB II [0-27]), SNAP = Score for Neonatal Acute Physiology [0-127]; PDEATH = Predicted mortality
probability derived from any score [0-100].
Optional variables for neonates (infants less than one month old):
Birth weight: birth weight in grams; the birth weight is the weight of the infant at the time of birth and
should not be changed as the infant gains or loses weight.
Gestational age: gestational age in weeks (at time of birth)
18
TECHNICAL DOCUMENT
HAI-Net ICU protocol, version 2.1
Central vascular catheter in ICU: Patient had a central vascular catheter during the current ICU stay; if yes, fil
dates in corresponding exposure data. Y = Yes; N = NO; UNK = Unknown. Required.
Intubation in ICU: Patient was intubated (invasive respiratory device) during the current ICU stay; if yes, fill
dates in corresponding exposure data. Y = Yes; N = NO; UNK = Unknown. Required.
Urinary catheter in ICU: Patient had indwel ing urinary catheter during the current ICU stay; if yes, fill dates in
corresponding exposure data. Y = Yes; N = NO; UNK = Unknown. Required if UTI is included in surveil ance.
Antimicrobial received during ICU stay: Patient received any antimicrobial during ICU stay. If yes, fill
corresponding antimicrobial use data. Y = Yes; N = NO; UNK = Unknown. Optional.
Patient has at least one HAI included in surveillance: Patient has at least one healthcare-associated
infection (with onset on day three or later, see definition) included in the current surveillance-year. If yes, fil out
an HAI form for each infection. Y = Yes; N = NO; UNK = Unknown. Required.
6.2 Exposure data (third level)
In the standard surveil ance option, different types of data are attached to the patient (ICU admission) level.
Exposure data (RecordType HAIICU$PT$EXP) contain information on invasive device use and are col ected by
episode and by type of invasive device.
ParentId/Patient counter: Numeric Code for each patient, unique within hospital, anonymous. Necessary to
make the link between infections and patient data (second level). In the HelicsWin.Net software, the patient
counter is automatical y generated and should not be entered again for the exposure data. Required.
Type of exposure: Type of exposure (invasive device) for this exposure episode entry. In case of stop and restart
of an exposure type on the same day (e.g. re-intubation), start a new exposure episode. Overlapping exposure
episodes are al owed for CVC (more than one CVC on the same day), but not for intubation or indwel ing urinary
catheters. Urinary catheter episodes are only required when UTIs are included in the surveil ance year. In
HelicsWin.Net, the type of exposure is automatical y generated. CVC = Central vascular catheter; INT =
Intubation; UC = Urinary catheter.
Exposure start date: Start date exposure episode within the ICU.
Exposure end date: End date exposure episode within the ICU.
6.3 Antimicrobial use data (third level)
Patient-based data on antimicrobial use in the ICU (RecordType HAIICU$PT$AM) are optional in the HAI-Net ICU
protocol and can only be col ected in the standard surveil ance option. They are col ected by episode and for each
antimicrobial agent and indication.
ParentId/Patient counter: Numeric Code for each patient, unique within hospital, anonymous. Necessary to
make the link between infections and patient data (second level). In the HelicsWin.Net software, the patient
counter is automatical y generated and should not be entered again. Required.
Antimicrobial start date: Start date within the ICU of this antimicrobial agent/indication (days before ICU
admission should not be reported). For antimicrobials present on admission, enter date of ICU admission.
Antimicrobial end date: End date within the ICU of this antimicrobial agent/indication (days after ICU discharge
should not be reported). For antimicrobials continued after discharge, enter date of ICU discharge.
Antimicrobial ATC5 code: Antimicrobial coded as ATC5 code, include ATC2 classes J01 antibacterials, J02
antifungals and ATC4 A07AA, P01AB, D01BA and ATC5 J04AB02. See ATC5 list in Annex.
Indication for antimicrobial use: Indication for use of this antimicrobial episode. Mandatory if antimicrobial use
data are reported. If the indication changes (e.g. from empiric treatment to documented treatment), enter a new
line, even if the antimicrobial has not changed. If the same antimicrobial (ATC5 code) is used for different
indications, enter a line for each indication. P=Prophylaxis; E=Empiric treatment (not based on microbiological
results); M=Documented treatment (based on microbiological results with or without antimicrobial susceptibility
results); S=Selective digestive decontamination; O=Other; UNK=Unknown.
Indication specification: optional specification of indication for antimicrobial use according to HAI-Net PPS
categories. Patient receives systemic antimicrobials for:
•
Treatment intention: CI: community-acquired infection; LI: infection acquired in long-term care facility (e.g.
nursing home) or chronic-care hospital; HI: acute-hospital-acquired infection.
•
Surgical prophylaxis: SP1: single dose; SP2: one day; SP3: > 1 day: check if given in the 24 hours prior to
ICU admission – if yes, check if given on the day before as well.
•
MP. Medical prophylaxis.
•
O. Other indication (e.g. erythromycin use as a prokinetic agent).
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TECHNICAL DOCUMENT
•
UI. Unknown indication/reason (verified during PPS).
•
UNK. Unknown/missing, information on indication was not verified during PPS.
Diagnosis site: anatomical site of treated infection (diagnosis) or target infection site for prophylaxis: see site
code list. Optional.
20
TECHNICAL DOCUMENT
HAI-Net ICU protocol, version 2.1
European Surveillance of ICU-acquired infections
Form PT. Patient-based data (Standard option)
Hospital code
Patient Counter
ICU code (abbr name)
Patient data
Age in years: ____ yrs
Gender: M F UNK
Date of ICU admission:
___ / ___ / _______
Date of ICU discharge ___ / ___ / _______
ICU discharge outcome: O Alive O Dead O UNK
Origin of the patient
O Ward this/oth hosp O Other ICU O Community O LTCF O Other O UNK
Type of admission: O medical O scheduled surgical O unscheduled surgical O UNK
Trauma: O Yes O No O UNK
Impaired immunity: O Yes O No O UNK
Antimicrobial treatment +/- 48 Hrs around admission : O Yes O No O UNK
SAPS II score:
Other severity score name*:
Other severity score value:
* Other severity scores: APACHE II-IV, SAPS 3, MPM II-III, ASA score, McCabe score, PIM, PIM II, PRISM, PRISM III-IV,
CRIB, CRIB II, SNAP, PDEATH (predicted mortality probability 0-100)
Neonates (ioptional) :
Birth weight: _________grams
Gestational age: _____
weeks
Exposure to invasive devices in the ICU
Central vascular catheter in ICU: O Yes O No O Unk
If Yes: Start Date 1 : ___ / ___ / _______
End Date 1: ___ / ___ / _______
Start Date 2 : ___ / ___ / _______
End Date 2: ___ / ___ / _______
Intubation in ICU: O Yes O No O Unk
If Yes: Start Date 1 : ___ / ___ / _______
End Date 1: ___ / ___ / _______
Start Date 2 : ___ / ___ / _______
End Date 2: ___ / ___ / _______
Urinary catheter in ICU: O Yes O No O Unk
If Yes: Start Date 1 : ___ / ___ / _______
End Date 1: ___ / ___ / _______
Start Date 2 : ___ / ___ / _______
End Date 2: ___ / ___ / _______
Patient received
antimicrobial(s) during ICU stay (optional)
O Yes O No O Unkown
Antimicrobial name or ATC5
Ind1
Start date
End Date
Ind2
Site
Ind1: Indication (required):
P: prophylaxis
E: empiric treatment
M: documented treatment
S: SDD (Selective
Digestive Decontamination);
Ind2: Indication specification (HAI-Net PPS categories), optional: treatment intention
for community (CI), long-term care (LI) or acute hospital (HI) infection; surgical prophylaxis: SP1: single dose, SP2:
one day, SP3: >1 day; MP: medical prophylaxis; O: other; UI: Unknown indication;
Site: site of diagnosed infection or
target infection site for prophylaxis, optional (see site list in annex).
Patient has at least one HAI included in surveillance
O Yes O No O Unknown
if yes, fill out heathcare-associated infection (HAI) form
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TECHNICAL DOCUMENT
7. HAI data (standard and light options) –
Form INF
7.1. Infection data (third level)
Healthcare-associated infection (HAI) data (RecordTypes HAIICU$PT$INF and HAIICULIGHT$DENO$INF) are
col ected for each infection episode, by type of infection. For distinguishing between different infection episodes,
see Section 3.1 (definition of key terms). HAI data are the same in the standard (Forn INFa) and light (Form INFb)
surveil ance options, except for a few demographic patient variables that are added for each HAI in light
surveil ance.
ParentId/Patient counter: Anonymous patient number. Necessary to make the link between infections and
second level data. In the HelicsWin.Net software, the patient counter is automatical y generated and should not be
entered again. Required.
Demographic variables (Light surveillance option only):
Age: Age of the patient on the date of admission to the ICU (in years). Required.
Gender: Gender of the patient. M = Male; F = Female; O = Other; UNK = Unknown. Required.
Date of ICU admission: Date of admission in the ICU. Required.
Date of ICU discharge: Date the patient was discharged from the ICU or date of in-ICU death or date
of last follow-up in the ICU. Required.
Date of infection onset: Date of onset of symptoms or, if unknown, date treatment was started or date first
diagnostic examination was done. Required.
Case definition code (Site of infection): Required. Site of infection according the case definition (including
subcategory), taking into account signs and symptoms of the entire infection episode (not just day one of the
HAI). See Chapter 3 for case definitions. BSI = Bloodstream infection; PN = Pneumonia (unknown subcategory);
PN1 = Pneumonia (protected sample + quantitative culture); PN2 = Pneumonia (non-protected sample (ETA) +
quantitative culture); PN3 = Pneumonia (alternative microbiological criteria); PN4 = Pneumonia (sputum
bacteriology or non-quantitative ETA); PN5 = Pneumonia (no microbiology); UTI = Symptomatic urinary tract
infection (unknown subcategory); UTI-A = Symptomatic urinary tract infection (microbiologically confirmed); UTI-B
= Symptomatic urinary tract infection (not microbiologically confirmed); CRI1-CVC = CVC-related infection (local);
CRI2-CVC = CVC-related infection (generalised no positive haemoculture); CRI3-CVC = CVC-related infection
(generalised with positive haemoculture); [optional: infections related to peripheral vascular catheters: CRI1-PVC =
PVC-related infection (local); CRI2-PVC = PVC-related infection (generalised no positive haemoculture); CRI3-PVC
= PVC-related infection (generalised with positive haemoculture)]. If catheter-related infections (CRIs) are included
in the surveil ance, report a CVC-related BSI corresponding to the case definition of CRI3-CVC as CRI3-CVC (do not
report twice); OTH=Other HAI type. Other infection sites can be included in the HelicsWin.Net software.
Other case definition code: Optional. Specify other case definition code, see list in Annex.
Relevant invasive device in situ before onset: Relevant invasive device was present (even intermittently) in
the 48 hours preceding the infection (7 days for UTIs): intubation for pneumonia, central vascular catheter for
bloodstream infection, urinary catheter for urinary tract infections. Necessary to distinguish device-associated
infections. Y = Yes; N = No; UNK = Unknown. Required.
BSI: source of BSI: Source/origin of the bloodstream infection, required if the case definition code is BSI. C =
The same microorganism was cultured from the catheter or symptoms improve within 48 hours after removal of
the catheter. Exception: Report microbiological y confirmed CVC-related BSI as CRI3-CVC if optional CRIs are
included in the surveillance. C = Catheter, catheter type unknown; C-CVC = Central venous catheter; C-PVC =
Peripheral venous catheter; C-ART = Arterial catheter; S = Secondary to another site, primary site unknown; S-
PUL = Pulmonary infection; S-UTI = Urinary tract infection; S-SSI = Surgical site infection; S-DIG = Digestive tract
infection; S-SST = Skin/Soft Tissue infection; S-OTH = Other infection or procedure; UO= None of the above, BSI
of unknown origin; UNK=Unknown/Missing.
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TECHNICAL DOCUMENT
HAI-Net ICU protocol, version 2.1
Patient ICU outcome (relationship to HAI): relationship of HAI to ICU outcome in patients with HAI.
•
Discharged alive: patient was discharged alive; OR patient was stil in the hospital and alive at end of
follow-up during this hospital stay.
•
Death, HAI definitely contributed to death: use this category if a causal link between CDI and death
can be demonstrated.
•
Death, HAI possibly contributed to death: use this category if no causal link between CDI and this
case’s death can be demonstrated, but it is stil plausible that CDI was at least a contributory factor.
•
Death, unrelated to HAI: use this category if the cause of death can be demonstrated not to be related
to CDI.
•
Death, relationship to HAI unknown: use this category if no evidence of contributory factors to the
cause of death is available.
•
Unknown: unknown patient outcome.
7.2 Microorganism and antimicrobial resistance data (fourth
level)
Microorganisms and antimicrobial resistance data (RecordType HAIICU$PT$INF$RES) for a given infection episode
are reported at the fourth level. Although the data format al ows reporting of any bug-drug combination in a
flexible way, the protocol defines a list of minimal and recommended markers (target list) for antimicrobial
resistance in ICU-acquired infections. Networks may also choose to report extended antimicrobial resistance data,
which allows for a more detailed description of the AMR epidemiology (e.g. combined resistance, etc.). However,
the main emphasis should be on the target AMR list given below. See Annex 4 for extended AMR test codes.
Microorganism (Isolate result): Microorganism (MO) six letter code or negative code including reason why the
isolate result is not available. _NA = Results not available; _NOEXA = Examination not done; _NONID =
Microorganism not identified; _STERI = Sterile examination. See Code list in Annexes 2 and 3. It is recommended
to use the extended microorganism list, even though minimal list codes are also allowed. Minimum one code per
HAI is required, the recommended maximum per HAI is three microorganisms.
Antibiotic: Antibiotic code. Antimicrobial drug for which susceptibility was tested, depends on the microorganism.
In the HelicsWin.Net software, recommended antimicrobial codes are automatical y generated. _NOTEST=No
antimicrobial susceptibility data available.
Minimal and recommended antimicrobial resistance markers in the ICU
Staphylococcus aureus (STAAUR)
• Oxacillin (OXA)
– required (minimal)
Note: following antibiotics are equivalent to oxacillin as markers of MRSA and can also be reported:
meticillin (MET), cloxacillin (CLO), dicloxacillin (DIC), flucloxacillin (FLC) and cefoxitin (FOX)
• Glycopeptides (GLY) (vancomycin/VAN, teicoplanin/TEC)
– required (minimal)
Enterococci
• Aminopenicillins (AMP) (ampicillin/AMP and/or amoxicillin/AMX) – recommended
• Glycopeptides (GLY) (vancomycin/VAN, teicoplanin/TEC)
– required (minimal)
Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp., Citrobacter spp., Serratia
spp., Morganella spp.)
• Amoxicillin-clavulanic acid (AMC) - recommended
• Third-generation cephalosporins (C3G) (cefotaxim/CTX, ceftriaxone/CRO, ceftazidime/CAZ)
– required
(minimal)
• Carbapenems (CAR) (imipenem/IPM, meropenem/MEM, doripenem/DOR)
– required (minimal) • Colistin (COL) – recommended
P. aeruginosa
• Piperacillin-tazobactam (TZP) - recommended
• Ceftazidime (CAZ) - recommended
• Carbapenems (CAR) (imipenem/IPM, meropenem/MEM, doripenem/DOR)
– required (minimal)
• Colistin (COL) - recommended
23
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TECHNICAL DOCUMENT
Acinetobacter spp.
• Sulbactam (SUL) - recommended
• Ceftazidime (CAZ) - recommended
• Carbapenems (CAR) (imipenem/IPM, meropenem/MEM, doripenem/DOR)
– required (minimal)
• Colistin (COL) - recommended
SIR: Final interpretation result of al different susceptibility tests performed. If antibiotic code is _NOTEST,
SIR=NA. S = Susceptible; I = Intermediate; R = Resistant; UNK = Unknown; NA = Not applicable. Required.
PDR: Pandrug-resistant microorganism
[18].
-
N = Not PDR: susceptible to at least one antimicrobial agent tested
-
P = Possible PDR: non-susceptible (intermediate or resistant) to al antimicrobial agents tested in the
hospital
-
C = Confirmed PDR: non-susceptible (intermediate or resistant) to al agents in al antimicrobial categories,
confirmed by a reference or other clinical microbiology laboratory testing a supplemental panel of
antimicrobial agents beyond those routinely tested, in accordance with the definitions by microorganism
published in reference
[18]
-
UNK=Unknown
24
TECHNICAL DOCUMENT
HAI-Net ICU protocol, version 2.1
European Surveillance of ICU-acquired infections
Form INFa. HAI and AMR data (Standard option)
Patient Counter
ICU-acquired infections
HAI 1
HAI 2
HAI 3
Case definition code
Relevant device in
O Yes O No
O Yes O No
O Yes O No
situ before onset*
O Unknown
O Unknown
O Unknown
Date of onset
___ / ___ / ______
___ / ___ / ______
___ / ___ / ______
BSI: source of BSI**
MO-code
PDR
MO-code
PDR
MO-code
PDR
Micro-organism 1
Micro-organism 2
Micro-organism 3
*relevant device use (intubation for PN, CVC for BSI, urinary catheter for UTI) in 48 hours before onset of infection (even
intermittent use), 7 days for UTI; ** C-CVC, C-PVC, C-ART, S-PUL, S-UTI, S-DIG, S-SSI, S-SST, S-OTH, UNK; MO-code:
microorganism code; PDR: pandrug-resistant: Not PDR =N (susceptible to at least 1 antimicrobial), Possible PDR = P (I or R to
all antimicrobials tested in hospital), Confirmed PDR = C (I/R to all antimicrobials confirmed by reflab), U=Unknow n)
Patient ICU outcome: O discharged alive O death, HAI definitely contributed to death
O death, HAI possibly contributed to death O death, no relation to HAI O death, relationship to HAI unknown
Target antimicrobial resistance data in ICU-acquired infections
HAI1:
MO-Code
AB1
SIR1
AB2
SIR2
AB3
SIR3
AB4
SIR4
PDR
Staphylococcus aureus
OXA
GLY
Enterococcus spp.
AMP
GLY
Enterobacteriaceae
AMC
C3G
CAR
COL
AMC
C3G
CAR
COL
P.aeruginosa
TZP
CAZ
CAR
COL
Acinetobacter spp.
SUL
CAZ
CAR
COL
SIR: S,I,R or U; PDR: N,P,C or U
HAI2:
MO-Code
AB1
SIR1
AB2
SIR2
AB3
SIR3
AB4
SIR4
PDR
Staphylococcus aureus
OXA
GLY
Enterococcus spp.
AMP
GLY
Enterobacteriaceae
AMC
C3G
CAR
COL
AMC
C3G
CAR
COL
P.aeruginosa
TZP
CAZ
CAR
COL
Acinetobacter spp.
SUL
CAZ
CAR
COL
SIR: S,I,R or U; PDR: N,P,C or U
HAI3:
MO-Code
AB1
SIR1
AB2
SIR2
AB3
SIR3
AB4
SIR4
PDR
Staphylococcus aureus
OXA
GLY
Enterococcus spp.
AMP
GLY
Enterobacteriaceae
AMC
C3G
CAR
COL
AMC
C3G
CAR
COL
P.aeruginosa
TZP
CAZ
CAR
COL
Acinetobacter spp.
SUL
CAZ
CAR
COL
Bold=minimal resistance data; SIR: S=susceptible, I=intermediate resistance, R=resistant, U=unknow n
Antibiotic codes: AMC: amoxicil in-clavulanic acid, AMP: ampicil in, C3G: third-generation cephalosporins (cefotaxim/
cetriaxone/ceftazidim), CAR: carbapenems (imipenem/meropenem/doripenem), CAZ: ceftazidime, COL: colistin,
GLY: glycopeptides (vancomycin, teicoplanin), OXA: oxacil in, SUL: Sulbactam; TZP: piperacil in-tazobactam;
PDR: pandrug resistance: N=not PDR, P=possible, C=confirmed, U=unknow n
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HAI-Net ICU protocol, version 2.2
TECHNICAL DOCUMENT
European Surveillance of ICU-acquired infections
Form INFb. HAI and AMR form (Light option)
Patient Counter:
Date of admission in ICU:
___ / ___ / _____
Age in years: ____ yrs
Gender: M F UNK
Date of ICU discharge:
___ / ___ / _____
Patient ICU outcome: O discharged alive O death, HAI definitely contributed to death
O death, HAI possibly contributed to death O death, no relation to HAI O death, relationship to HAI unknown
ICU-acquired infections
HAI 1
HAI 2
HAI 3
Case definition code
Relevant device in
O Yes O No
O Yes O No
O Yes O No
situ before onset*
O Unknown
O Unknown
O Unknown
Date of onset
___ / ___ / ______
___ / ___ / ______
___ / ___ / ______
BSI: source of BSI**
MO-code
PDR
MO-code
PDR
MO-code
PDR
Micro-organism 1
Micro-organism 2
Micro-organism 3
*relevant device use (intubation for PN, CVC for BSI, urinary catheter for UTI) in 48 hours before onset of infection (even
intermittent use), 7 days for UTI; ** C-CVC, C-PVC, C-ART, S-PUL, S-UTI, S-DIG, S-SSI, S-SST, S-OTH, UNK; MO-code:
microorganism code; PDR: pandrug-resistant: Not PDR =N (susceptible to at least 1 antimicrobial), Possible PDR = P (I or R to
all antimicrobials tested in hospital), Confirmed PDR = C (I/R to all antimicrobials confirmed by reflab), U=Unknow n)
Target antimicrobial resistance data in ICU-acquired infections
HAI1:
MO-Code
AB1
SIR1
AB2
SIR2
AB3
SIR3
AB4
SIR4
PDR
Staphylococcus aureus
OXA
GLY
Enterococcus spp.
AMP
GLY
Enterobacteriaceae
AMC
C3G
CAR
COL
AMC
C3G
CAR
COL
P.aeruginosa
TZP
CAZ
CAR
COL
Acinetobacter spp.
SUL
CAZ
CAR
COL
SIR: S,I,R or U; PDR: N,P,C or U
HAI2:
MO-Code
AB1
SIR1
AB2
SIR2
AB3
SIR3
AB4
SIR4
PDR
Staphylococcus aureus
OXA
GLY
Enterococcus spp.
AMP
GLY
Enterobacteriaceae
AMC
C3G
CAR
COL
AMC
C3G
CAR
COL
P.aeruginosa
TZP
CAZ
CAR
COL
Acinetobacter spp.
SUL
CAZ
CAR
COL
SIR: S,I,R or U; PDR: N,P,C or U
HAI3:
MO-Code
AB1
SIR1
AB2
SIR2
AB3
SIR3
AB4
SIR4
PDR
Staphylococcus aureus
OXA
GLY
Enterococcus spp.
AMP
GLY
Enterobacteriaceae
AMC
C3G
CAR
COL
AMC
C3G
CAR
COL
P.aeruginosa
TZP
CAZ
CAR
COL
Acinetobacter spp.
SUL
CAZ
CAR
COL
Bold=minimal resistance data; SIR: S susceptible, I intermediate resistance, R resistant, U unknow n
Antibiotic codes: AMC: amoxicil in-clavulanic acid, AMP: ampicil in, C3G: third-generation cephalosporins (cefotaxim/
cetriaxone/ceftazidim), CAR: carbapenems (imipenem/meropenem/doripenem), CAZ: ceftazidime, COL: colistin,
GLY: glycopeptides (vancomycin, teicoplanin), OXA: oxacil in, SUL: Sulbactam; TZP: piperacil in-tazobactam;
PDR: pandrug resistance: N=not PDR, P=possible, C=confirmed, U=unknow n
26
TECHNICAL DOCUMENT
HAI-Net ICU protocol, version 2.1
8 Outcome indicators of ICU-acquired
infections
Unit-based (light) surveil ance represents the minimal dataset to be col ected and is intended for continuous
surveil ance. The denominator is col ected at the level of the unit and consists in the number of patient-days for
patients staying longer than two days in the ICU (unit-based surveil ance).
Unit indicators are intended for the fol ow-up of indicators within the same unit and for regional, national and
international follow-up of infection trends and possibly for pathogen-specific infection rates, such as incidence
density by type of ICU or by percentage of intubated patients in the ICU (proxy for case-mix severity). They offer
limited inter-unit comparability but only when stratified by type of ICU or by the case-mix severity, approximated
by the percentage of intubated patients.
Patient-based (standard option) surveil ance is intended for advanced risk-adjusted comparisons of infection rates
between ICUs, such as the device-associated infection rate and the standardised infection ratio, as a measure of
quality of care in terms of infection control. Risk factors are col ected for every patient staying more than two days
in the ICU, whether infected or not. In order to obtain sufficient precision of indicators for a single ICU, a
surveil ance period of 3–6 months is recommended, depending on the size of the ICU.
The list of HAI outcome indicators (comparing standard vs. light surveil ance options) can be found in Annex 6.
9 Confidentiality
9.1 Patient confidentiality
It wil not be possible to identify individual ICU patients with or without an HAI in the European database through
coding of patient information at the hospital level or at the level of the official networks in the countries. However,
for validation purposes, the hospitals should be able to trace back patients based on anonymous unique patient
numbers.
9.2 Hospital and unit confidentiality
A unique code is assigned to each hospital (unit) by the national surveil ance system. This unique code wil be used
for correspondence and feedback. The key, which links each hospital (unit) to the code submitted to ECDC remains
strictly within the national surveillance system to guarantee confidentiality. It is not to be transmitted to any other
organisation under any circumstance.
9.3 Publication policy
Data wil be published in ECDC’s online infectious disease surveil ance summaries (replacing the previously
published Annual Epidemiological Reports), in disease-specific reports on HAI surveil ance and as scientific
publications. If requested by a national surveillance network, publications have to acknowledge the data source
(i.e. the national surveillance networks) and provide contact information.
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HAI-Net ICU protocol, version 2.2
TECHNICAL DOCUMENT
References
1. Council recommendation of 9 June 2009 on patient safety, including the prevention and control of
healthcare-associated infections (HAI) (2009/C 151/01).
2. Decision No. 2119/98/EC of the European Parliament and of the Council of 24 September 1998 setting up
a network for the epidemiological surveil ance and control of communicable diseases in the Community.
Official Journal of the European Communities 1998:L268/1-6.
3. Decision No 1082/2013/EU of the European Parliament and of the Council of 22 October 2013 on serious
cross-border threats to health and repealing Decision No 2119/98/EC. Official Journal of the European
Communities 2013:L293/1-15.
4. European Centre for Disease Prevention and Control. European surveil ance of healthcare-associated
infections in intensive care units: HAI-Net ICU protocol, version 1.02. Available
fro
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protocol.pdf
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related sepsis. Critical level of quantitative tip cultures. Arch Intern Med 1987; 147(5):873-877.
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related infection. N Engl J Med 1977; 296:1305-1309.
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Cancer 2000; 8(4):287-292.
12. Quilici N, Audibert G, Conroy MC, Bollaert PE, Guillemin F, Welfringer P et al. Differential quantitative
blood cultures in the diagnosis of catheter-related sepsis in intensive care units. Clin Infect Dis 1997;
25(5):1066-1070.
13. Raad I, Hanna HA, Alakech B, Chatzinikolaou I, Johnson MM, Tarrand J. Differential time to positivity: a
useful method for diagnosing catheter-related bloodstream infections. Ann Intern Med. 2004 Jan 6;
140(1):18-25.
14. European Centre for Disease Prevention and Control. Point prevalence survey of healthcare-associated
infections and antimicrobial use in European acute care hospitals – protocol version 5.3. Stockholm:
ECDC; 2016.
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down case definitions for reporting communicable diseases to the Community network under Decision No
2119/98/EC of the European Parliament and of the Council. OJ L 262/1; 27.9.2012
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procedures for monitoring CLABSI. Atlanta: CDC; 2010. Available
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http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
17. Guidelines for the utilisation of intensive care units. European Society of Intensive Care Medicine.
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international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect.
2012 Mar; 18(3):268-81.
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Annex 1: Microorganisms code list
The microorganism code list is a selection of microorganisms based on their frequency of occurrence in HAIs
and/or on their public health importance. The minimal list represents the minimal level of detail that should be
provided by every network.
Microorganism selection and minimal list
Microorganism
Code
Minimal list
Gram-positive cocci
Staphylococcus aureus
STAAUR
STAAUR
Staphylococcus epidermidis
STAEPI
Staphylococcus haemolyticus
STAHAE
STACNS
Coag-neg. staphylococci, not specified
STACNS
Other coagulase-negative staphylococci (CNS)
STAOTH
Staphylococcus spp., not specified
STANSP
GPCTOT
Streptococcus pneumoniae
STRPNE
Streptococcus agalactiae (B)
STRAGA
Streptococcus pyogenes (A)
STRPYO
STRSPP
Other haemol. Streptococcae (C, G)
STRHCG
Streptococcus spp., other
STROTH
Streptococcus spp., not specified
STRNSP
Enterococcus faecalis
ENCFAE
Enterococcus faecium
ENCFAI
ENCSPP
Enterococcus spp., other
ENCOTH
Enterococcus spp., not specified
ENCNSP
Gram-positive cocci, not specified
GPCNSP
GPCTOT
Other Gram-positive cocci
GPCOTH
Gram-negative cocci Moraxel a catarrhalis
MORCAT
Moraxella spp., other
MOROTH
Moraxella spp., not specified
MORNSP
Neisseria meningitidis
NEIMEN
GNCTOT
Neisseria spp., other
NEIOTH
Neisseria spp., not specified
NEINSP
Gram-negative cocci, not specified
GNCNSP
Other Gram-negative cocci
GNCOTH
Gram-positive
Corynebacterium spp.
CORSPP
bacilli
Bacillus spp.
BACSPP
Lactobacillus spp.
LACSPP
GPBTOT
Listeria monocytogenes
LISMON
Gram-positive bacilli, not specified
GPBNSP
Other Gram-positive bacilli
GPBOTH
Enterobacteriaceae
Citrobacter freundii
CITFRE
Citrobacter koseri (e.g. diversus)
CITDIV
CITSPP
Citrobacter spp., other
CITOTH
Citrobacter
spp., not specified
CITNSP
Enterobacter cloacae
ENBCLO
Enterobacteriaceae
Enterobacter aerogenes
ENBAER
(continued)
ENBSPP
Enterobacter agglomerans
ENBAGG
Enterobacter sakazakii
ENBSAK
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TECHNICAL DOCUMENT
Microorganism
Code
Minimal list
Enterobacter gergoviae
ENBGER
Enterobacter spp., other
ENBOTH
Enterobacter spp., not specified
ENBNSP
Escherichia coli
ESCCOL
ESCCOL
Klebsiella pneumoniae
KLEPNE
Klebsiella oxytoca
KLEOXY
KLESPP
Klebsiella spp., other
KLEOTH
Klebsiella spp., not specified
KLENSP
Proteus mirabilis
PRTMIR
Proteus vulgaris
PRTVUL
PRTSPP
Proteus spp., other
PRTOTH
Proteus spp., not specified
PRTNSP
Serratia marcescens
SERMAR
Serratia liquefaciens
SERLIQ
SERSPP
Serratia spp., other
SEROTH
Serratia spp., not specified
SERNSP
Hafnia spp.
HAFSPP
Morganella spp.
MOGSPP
Providencia spp.
PRVSPP
Salmonella Enteritidis
SALENT
Salmonella Typhi or Paratyphi
SALTYP
Salmonella Typhimurium
SALTYM
ETBTOT
Salmonella spp., not specified
SALNSP
Salmonella spp., other
SALOTH
Shigella spp.
SHISPP
Yersinia spp.
YERSPP
Other Enterobacteriaceae
ETBOTH
Enterobacteriaceae, not specified
ETBNSP
Gram-negative
Acinetobacter baumanni
ACIBAU
bacilli
Acinetobacter calcoaceticus
ACICAL
Acinetobacter haemolyticus
ACIHAE
ACISPP
Acinetobacter lwoffi
ACILWO
Acinetobacter spp., other
ACIOTH
Acinetobacter spp., not specified
ACINSP
Pseudomonas aeruginosa
PSEAER
PSEAER
Stenotrophomonas maltophilia
STEMAL
STEMAL
Burkholderia cepacia
BURCEP
Pseudomonadaceae family, other
PSEOTH
PSETOT
Pseudomonadaceae family, not specified
PSENSP
Haemophilus influenzae
HAEINF
Haemophilus parainfluenzae
HAEPAI
HAESPP
Haemophilus spp., other
HAEOTH
Haemophilus spp., not specified
HAENSP
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Microorganism
Code
Minimal list
Gram-negative
Legionella spp.
LEGSPP
LEGSPP
bacilli
(continuation)
Achromobacter spp.
ACHSPP
Aeromonas spp.
AEMSPP
Agrobacterium spp.
AGRSPP
Alcaligenes spp.
ALCSPP
Campylobacter spp.
CAMSPP
Flavobacterium spp.
FLASPP
GNBTOT
Gardnerella spp.
GARSPP
Helicobacter pylori
HELPYL
Pasteurella spp.
PASSPP
Gram-negative bacilli, not specified
GNBNSP
Other Gram-negative bacilli, non enterobacteriaceae GNBOTH
Anaerobes
Bacteroides fragilis
BATFRA
Bacteroides other
BATOTH
BATSPP
Bacteroides spp., not specified
BATNSP
Clostridium difficile
CLODIF
Clostridium other
CLOOTH
Propionibacterium spp.
PROSPP
ANATOT
Prevotella spp.
PRESPP
Anaerobes, not specified
ANANSP
Other anaerobes
ANAOTH
Other bacteria
Mycobacterium, atypical
MYCATY
Mycobacterium tuberculosis complex
MYCTUB
Chlamydia spp.
CHLSPP
Mycoplasma spp.
MYPSPP
BCTTOT
Actinomyces spp.
ACTSPP
Nocardia spp.
NOCSPP
Other bacteria
BCTOTH
Other bacteria, not specified
BCTNSP
Fungi
Candida albicans
CANALB
Candida auris
CANAUR
Candida glabrata
CANGLA
Candida krusei
CANKRU
CANSPP
Candida tropicalis
CANTRO
Candida parapsilosis
CANPAR
Candida spp., other
CANOTH
Candida spp., not specified
CANNSP
Aspergil us fumigatus
ASPFUM
Aspergil us niger
ASPNIG
ASPSPP
Aspergil us spp., other
ASPOTH
Aspergil us spp., not specified
ASPNSP
Other yeasts
YEAOTH
Fungi other
FUNOTH
Fungi, not specified
FUNNSP
PARTOT
Filaments other
FILOTH
Other parasites
PAROTH
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Microorganism
Code
Minimal list
Viruses
Adenovirus
VIRADV
Cytomegalovirus (CMV)
VIRCMV
Enterovirus (polio, coxsackie, echo)
VIRENT
Hepatitis A virus
VIRHAV
Hepatitis B virus
VIRHBV
Hepatitis C virus
VIRHCV
Herpes simplex virus
VIRHSV
Human immunodeficiency virus (HIV)
VIRHIV
Influenza A virus
VIRINA
Influenza B virus
VIRINB
VIRTOT
Influenza C virus
VIRINC
Norovirus
VIRNOR
Parainfluenzavirus
VIRPIV
Respiratory syncytial virus (RSV)
VIRRSV
Rhinovirus
VIRRHI
Rotavirus
VIRROT
SARS virus
VIRSAR
Varicella-zoster virus
VIRVZV
Virus, not specified
VIRNSP
Other virus
VIROTH
Microorganism not identified or not found
_NONID
_NONID
Examination not done
_NOEXA
_NOEXA
Sterile examination
_STERI
_STERI
Result not (yet) available or missing
_NA
_NA
_NONID: evidence exists that a microbiological examination has been done, but the microorganism cannot be correctly classified
or the result of the examination cannot be found; _NOEXA: no diagnostic sample taken, no microbiological examination done;
_STERI: a microbiological examination has been done, but the result was negative (e.g. negative culture), _NA Result not (yet)
available or missing.
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Annex 2. Extended antimicrobial resistance
data for ICU-acquired infections
Networks may report extended antimicrobial resistance (AMR) data for a more detailed description of the AMR
epidemiology (e.g. combined resistance). However, priority should be given to the target AMR list given above.
The allowed AMR codes (in the ‘Antibiotic’ field) are:
AMB = Amphotericin B
GEH = Gentamicin-High
AMC = Amoxicillin-clavulanic acid
GEN = Gentamicin
AMK = Amikacin
GLY = Glycopeptides (vancomycin, teicoplanin)
AMP = Ampicillin
IPM = Imipenem
AMX = Amoxicillin
ITR = Itraconazole
AZM = Azithromycin
KET = Ketoconazole
C1G = Cephalosporins, first-generation (cefalotin or
LNZ = Linezolid
cefazolin)
C2G = Cephalosporins, second-generation (cefuroxime,
LVX = Levofloxacin
cefamandole, cefoxitin)
C3G = Cephalosporins, third-generation (cefotaxime,
MEM = Meropenem
ceftriaxone)
C4G = Cephalosporins, fourth-generation (cefepime,
MET = Meticillin
cefpirome)
CAR = Carbapenems (imipenem, meropenem,
MFX = Moxifloxacin
doripenem)
CAS = Caspofungin
NAL = Nalidic acid
CAZ = Ceftazidime
NET = Netilmicin
CIP = Ciprofloxacin
NOR = Norfloxacin
CLI = Clindamycin
OFX = Ofloxacin
CLO = Cloxacillin
OXA = Oxacillin
CLR = Clarithromycin
PEN = Penicillin
COL = Colistin
PIP = Piperacillin
CRO = Ceftriaxone
PIT = Piperacillin or ticarcillin
CTX = Cefotaxime
POL = Polymyxin B
DIC = Dicloxacillin
QDA = Quinupristin-dalfopristin
DAP = Daptomycin
RIF = Rifampin
DOR = Doripenem
SUL = Sulbactam
ETP = Ertapenem
SXT = Sulfamethoxazole-trimethoprim (cotrimoxazole)
ERY = Erythromycin
TCY = Tetracycline
ESBL = Extended beta-lactamase producing
TEC = Teicoplanin
FCT = Flucytosine (5-fluorocytosine)
TIG = Tigecycline
FEP = Cefepime
TOB = Tobramycin
FLC = Flucloxacillin
TZP = Piperacillin-tazobactam
FLU = Fluconazole
VAN = Vancomycin
FOS = Fosfomycin
FOX = Cefoxitin
FUS = Fusidic acid
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TECHNICAL DOCUMENT
Annex 3: Healthcare-associated infections
code list
HAI code
HAI label
PN1
Pneumonia, clinical + positive quantitative culture from minimally contaminated lower respiratory tract
specimen
PN2
Pneumonia, clinical + positive quantitative culture from possibly contaminated lower respiratory tract specimen
PN3
Pneumonia, clinical + microbiological diagnosis by alternative microbiology methods
PN4
Pneumonia, clinical + positive sputum culture or non-quantitative culture from lower respiratory tract
specimen
PN5
Pneumonia: clinical signs of pneumonia without positive microbiology
UTI-A
symptomatic urinary tract infection, microbiologically confirmed
UTI-B
symptomatic urinary tract infection, not microbiologically confirmed
BSI
Bloodstream infection (laboratory-confirmed), other than CRI3
CRI1-CVC
Local CVC-related infection (no positive blood culture)
CRI2-CVC
General CVC-related infection (no positive blood culture)
CRI3-CVC
Microbiologically confirmed CVC-related bloodstream infection
CRI1-PVC
Local PVC-related infection (no positive blood culture)
CRI2-PVC
General PVC-related infection (no positive blood culture)
CRI3-PVC
Microbiologically confirmed PVC-related bloodstream infection
Other HAI codes (optional)
BJ-BONE
Osteomyelitis
BJ-JNT
Joint or bursa
BJ-DISC
Disc-space infection
CNS-IC
Intracranial infection
CNS-MEN
Meningitis or ventriculitis
CNS-SA
Spinal abscess without meningitis
CVS-VASC
Arterial or venous infection
CVS-ENDO
Endocarditis
CVS-CARD
Myocarditis or pericarditis
CVS-MED
Mediastinitis
EENT-CONJ
Conjunctivitis
EENT-EYE
Eye, other than conjunctivitis
EENT-EAR
Ear mastoid
EENT-ORAL
Oral cavity (mouth, tongue, or gums)
EENT-SINU
Sinusitis
EENT-UR
Upper respiratory tract, pharyngitis, laryngitis, epiglottitis
GI-CDI
Clostridium difficile infection
GI-GE
Gastroenteritis (excluding CDI)
GI-GIT
Gastrointestinal tract (esophagus, stomach, small and large bowel, and rectum), excluding GE, CDI
GI-HEP
Hepatitis
GI-IAB
Intra-abdominal infection, not specified elsewhere
LRI-BRON
Bronchitis, tracheobronchitis, bronchiolitis, tracheitis, without evidence of pneumonia
LRI-LUNG
Other infections of the lower respiratory tract
REPR-EMET
Endometritis
REPR-EPIS
Episiotomy
REPR-VCUF
Vaginal cuff
REPR-OREP
Other infections of the male or female reproductive tract
SSI-S
Surgical site infection, superficial incisional
SSI-D
Surgical site infection, deep incisional
SSI-O
Surgical site infection, organ/space
SST-SKIN
Skin infection
SST-ST
Soft tissue (necrotizing fascitis, infectious gangrene, necrotizing cellulitis, infectious myositis, lymphadenitis, or
lymphangitis)
SST-DECU
Decubitus ulcer, including both superficial and deep infections
SST-BURN
Burn
SST-BRST
Breast abscess or mastitis
SYS-DI
Disseminated infection
SYS-CSEP
Treated unidentified severe infection in adults and children
NEO-CSEP
Clinical sepsis in neonates
NEO-LCBI
Laboratory-confirmed bloodstream infection in neonates, non-CNS
NEO-CNSB
Laboratory-confirmed bloodstream infection with coagulase-negative staphylococci in neonates
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HAI code
HAI label
NEO-PNEU
Pneumonia in neonates
NEO-NEC
Necrotising enterocolitis
Annex 4: Antimicrobial ATC codes
Antimicrobial agent: generic name
ATC 5th level code
Amikacin
J01GB06
Amoxicillin
J01CA04
Amoxicillin and enzyme inhibitor
J01CR02
Amphotericin B (oral)
A07AA07
Amphotericin B (parenteral)
J02AA01
Ampicillin
J01CA01
Ampicillin and enzyme inhibitor
J01CR01
Ampicillin, combinations
J01CA51
Anidulafungin
J02AX06
Arbekacin
J01GB12
Aspoxicillin
J01CA19
Azanidazole
P01AB04
Azidocillin
J01CE04
Azithromycin
J01FA10
Azithromycin, fluconazole and secnidazole
J01RA07
Azlocillin
J01CA09
Aztreonam
J01DF01
Bacampicillin
J01CA06
Bacitracin
J01XX10
Bekanamycin
J01GB13
Benzathine benzylpenicillin
J01CE08
Benzathine phenoxymethylpenicillin
J01CE10
Benzylpenicillin
J01CE01
Biapenem
J01DH05
Brodimoprim
J01EA02
Carbenicillin
J01CA03
Carindacillin
J01CA05
Carumonam
J01DF02
Caspofungin
J02AX04
Cefacetrile
J01DB10
Cefaclor
J01DC04
Cefadroxil
J01DB05
Cefalexin
J01DB01
Cefaloridine
J01DB02
Cefalotin
J01DB03
Cefamandole
J01DC03
Cefapirin
J01DB08
Cefatrizine
J01DB07
Cefazedone
J01DB06
Cefazolin
J01DB04
Cefbuperazone
J01DC13
Cefcapene
J01DD17
Cefdinir
J01DD15
Cefditoren
J01DD16
Cefepime
J01DE01
Cefepime and amikacin
J01RA06
Cefetamet
J01DD10
Cefixime
J01DD08
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Antimicrobial agent: generic name
ATC 5th level code
Cefmenoxime
J01DD05
Cefmetazole
J01DC09
Cefminox
J01DC12
Cefodizime
J01DD09
Cefonicide
J01DC06
Cefoperazone
J01DD12
Cefoperazone, combinations
J01DD62
Ceforanide
J01DC11
Cefotaxime
J01DD01
Cefotaxime, combinations
J01DD51
Cefotetan
J01DC05
Cefotiam
J01DC07
Cefoxitin
J01DC01
Cefozopran
J01DE03
Cefpiramide
J01DD11
Cefpirome
J01DE02
Cefpodoxime
J01DD13
Cefprozil
J01DC10
Cefradine
J01DB09
Cefroxadine
J01DB11
Cefsulodin
J01DD03
Ceftaroline fosamil
J01DI02
Ceftazidime
J01DD02
Ceftazidime, combinations
J01DD52
Ceftezole
J01DB12
Ceftibuten
J01DD14
Ceftizoxime
J01DD07
Ceftobiprole medocaril
J01DI01
Ceftolozane and enzyme inhibitor
J01DI54
Ceftriaxone
J01DD04
Ceftriaxone, combinations
J01DD54
Cefuroxime
J01DC02
Cefuroxime and metronidazole
J01RA03
Chloramphenicol
J01BA01
Chlortetracycline
J01AA03
Cinoxacin
J01MB06
Ciprofloxacin
J01MA02
Ciprofloxacin and metronidazole
J01RA10
Ciprofloxacin and ornidazole
J01RA12
Ciprofloxacin and tinidazole
J01RA11
Clarithromycin
J01FA09
Clindamycin
J01FF01
Clofoctol
J01XX03
Clometocillin
J01CE07
Clomocycline
J01AA11
Cloxacillin
J01CF02
Colistin (injection, infusion)
J01XB01
Colistin (oral)
A07AA10
Combinations of beta-lactamase sensitive penicillins
J01CE30
Combinations of intermediate-acting sulphonamides
J01EC20
Combinations of long-acting sulphonamides
J01ED20
Combinations of penicillins
J01CR50
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Antimicrobial agent: generic name
ATC 5th level code
Combinations of penicillins with extended spectrum
J01CA20
Combinations of short-acting sulphonamides
J01EB20
Combinations of tetracyclines
J01AA20
Cycloserine
J04AB01
Dalbavancin
J01XA04
Daptomycin
J01XX09
Demeclocycline
J01AA01
Dibekacin
J01GB09
Dicloxacillin
J01CF01
Dirithromycin
J01FA13
Doripenem
J01DH04
Doxycycline
J01AA02
Enoxacin
J01MA04
Epicillin
J01CA07
Ertapenem
J01DH03
Erythromycin
J01FA01
Ethambutol
J04AK02
Ethionamide
J04AD03
Faropenem
J01DI03
Fidaxomicin
A07AA12
Fleroxacin
J01MA08
Flomoxef
J01DC14
Flucloxacillin
J01CF05
Fluconazole
J02AC01
Flucytosine
J02AX01
Flumequine
J01MB07
Flurithromycin
J01FA14
Fosfomycin
J01XX01
Furazidin
J01XE03
Fusidic acid
J01XC01
Garenoxacin
J01MA19
Gatifloxacin
J01MA16
Gemifloxacin
J01MA15
Gentamicin
J01GB03
Grepafloxacin
J01MA11
Griseofulvin
D01BA01
Hachimycin
J02AA02
Hetacillin
J01CA18
Iclaprim
J01EA03
Imipenem and enzyme inhibitor
J01DH51
Isavuconazole
J02AC05
Isepamicin
J01GB11
Isoniazid
J04AC01
Itraconazole
J02AC02
Josamycin
J01FA07
Kanamycin
A07AA08
Kanamycin
J01GB04
Ketoconazole
J02AB02
Latamoxef
J01DD06
Levofloxacin
J01MA12
Levofloxacin, combinations with other antibacterials
J01RA05
Lincomycin
J01FF02
Linezolid
J01XX08
Lomefloxacin
J01MA07
Loracarbef
J01DC08
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Antimicrobial agent: generic name
ATC 5th level code
Lymecycline
J01AA04
Mandelic acid
J01XX06
Mecillinam
J01CA11
Meropenem
J01DH02
Metacycline
J01AA05
Metampicillin
J01CA14
Methenamine
J01XX05
Meticillin
J01CF03
Metronidazole (oral, rectal)
P01AB01
Metronidazole (parenteral)
J01XD01
Metronidazole, combinations
P01AB51
Mezlocillin
J01CA10
Micafungin
J02AX05
Miconazole
J02AB01
Midecamycin
J01FA03
Minocycline
J01AA08
Miocamycin
J01FA11
Moxifloxacin
J01MA14
Nafcillin
J01CF06
Nalidixic acid
J01MB02
Natamycin
A07AA03
Nemonoxacin
J01MB08
Neomycin (injection, infusion)
J01GB05
Neomycin (oral)
A07AA01
Neomycin, combinations (oral)
A07AA51
Netilmicin
J01GB07
Nifurtoinol
J01XE02
Nimorazole
P01AB06
Nitrofurantoin
J01XE01
Nitrofurantoin, combinations
J01XE51
Nitroxoline
J01XX07
Norfloxacin
J01MA06
Norfloxacin and tinidazole
J01RA13
Nystatin
A07AA02
Ofloxacin
J01MA01
Ofloxacin and ornidazole
J01RA09
Oleandomycin
J01FA05
Oritavancin
J01XA05
Ornidazole (oral)
P01AB03
Ornidazole (parenteral)
J01XD03
Oxacillin
J01CF04
Oxolinic acid
J01MB05
Oxytetracycline
J01AA06
Oxytetracycline, combinations
J01AA56
Panipenem and betamipron
J01DH55
Paromomycin
A07AA06
Pazufloxacin
J01MA18
Pefloxacin
J01MA03
Penamecillin
J01CE06
Penicillins, combinations with other antibacterials
J01RA01
Penimepicycline
J01AA10
Pheneticillin
J01CE05
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HAI-Net ICU protocol, version 2.1
Antimicrobial agent: generic name
ATC 5th level code
Phenoxymethylpenicillin
J01CE02
Pipemidic acid
J01MB04
Piperacillin
J01CA12
Piperacillin and enzyme inhibitor
J01CR05
Piromidic acid
J01MB03
Pivampicillin
J01CA02
Pivmecillinam
J01CA08
Polymyxin B
A07AA05
Polymyxin B
J01XB02
Posaconazole
J02AC04
Pristinamycin
J01FG01
Procaine benzylpenicillin
J01CE09
Propenidazole
P01AB05
Propicillin
J01CE03
Prulifloxacin
J01MA17
Pyrazinamide
J04AK01
Quinupristin/dalfopristin
J01FG02
Ribostamycin
J01GB10
Rifabutin
J04AB04
Rifampicin
J04AB02
Rifaximin
A07AA11
Rokitamycin
J01FA12
Rolitetracycline
J01AA09
Rosoxacin
J01MB01
Roxithromycin
J01FA06
Rufloxacin
J01MA10
Secnidazole
P01AB07
Sisomicin
J01GB08
Sitafloxacin
J01MA21
Solithromycin
J01FA16
Sparfloxacin
J01MA09
Spectinomycin
J01XX04
Spiramycin
J01FA02
Spiramycin and metronidazole
J01RA04
Streptoduocin
J01GA02
Streptomycin (oral)
A07AA04
Streptomycin (parenteral)
J01GA01
Streptomycin, combinations
A07AA54
Sulbactam
J01CG01
Sulbenicillin
J01CA16
Sulfadiazine
J01EC02
Sulfadiazine and tetroxoprim
J01EE06
Sulfadiazine and trimethoprim
J01EE02
Sulfadimethoxine
J01ED01
Sulfadimidine
J01EB03
Sulfadimidine and trimethoprim
J01EE05
Sulfafurazole
J01EB05
Sulfaisodimidine
J01EB01
Sulfalene
J01ED02
Sulfamazone
J01ED09
Sulfamerazine
J01ED07
Sulfamerazine and trimethoprim
J01EE07
Sulfamethizole
J01EB02
Sulfamethoxazole
J01EC01
Sulfamethoxazole and trimethoprim
J01EE01
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Antimicrobial agent: generic name
ATC 5th level code
Sulfamethoxypyridazine
J01ED05
Sulfametomidine
J01ED03
Sulfametoxydiazine
J01ED04
Sulfametrole and trimethoprim
J01EE03
Sulfamoxole
J01EC03
Sulfamoxole and trimethoprim
J01EE04
Sulfanilamide
J01EB06
Sulfaperin
J01ED06
Sulfaphenazole
J01ED08
Sulfapyridine
J01EB04
Sulfathiazole
J01EB07
Sulfathiourea
J01EB08
Sulfonamides, combinations with other antibacterials (excl. trimethoprim)
J01RA02
Sultamicillin
J01CR04
Talampicillin
J01CA15
Tazobactam
J01CG02
Tedizolid
J01XX11
Teicoplanin
J01XA02
Telavancin
J01XA03
Telithromycin
J01FA15
Temafloxacin
J01MA05
Temocillin
J01CA17
Terbinafine
D01BA02
Tetracycline
J01AA07
Tetracycline and oleandomycin
J01RA08
Thiamphenicol
J01BA02
Thiamphenicol, combinations
J01BA52
Ticarcillin
J01CA13
Ticarcillin and enzyme inhibitor
J01CR03
Tigecycline
J01AA12
Tinidazole (oral, rectal)
P01AB02
Tinidazole (parenteral)
J01XD02
Tobramycin
J01GB01
Trimethoprim
J01EA01
Troleandomycin
J01FA08
Trovafloxacin
J01MA13
Vancomycin (oral)
A07AA09
Vancomycin (parenteral)
J01XA01
Voriconazole
J02AC03
Xibornol
J01XX02
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Diagnosis (site) code list for antimicrobial use
Diagnosis
Examples
CNS
Infections of the central nervous system
EYE
Endophthalmitis
ENT
Infections of ear, nose, throat, larynx and mouth
BRON
Acute bronchitis or exacerbations of chronic bronchitis
PNEU
Pneumonia
CF
Cystic fibrosis
CVS
Cardiovascular infections: endocarditis, vascular graft
GI
Gastrointestinal infections (e.g. salmonellosis, antibiotic-associated diarrhoea)
IA
Intra-abdominal sepsis, including hepatobiliary
SST-SSI
Surgical site infection involving skin or soft tissue but not bone
SST-O
Cellulitis, wound, deep soft tissue not involving bone, not related to surgery
BJ-SSI
Septic arthritis, osteomyelitis of surgical site
BJ-O
Septic arthritis, osteomyelitis, not related to surgery
CYS
Symptomatic lower urinary tract infection (e.g. cystitis)
PYE
Symptomatic upper urinary tract infection (e.g. pyelonephritis)
ASB
Asymptomatic bacteriuria
OBGY
Obstetric or gynaecological infections, STD in women
GUM
Prostatitis, epididymo-orchitis, STD in men
BAC
Laboratory-confirmed bacteraemia
CSEP
Clinical sepsis (suspected bloodstream infection without lab confirmation/results are not available, no blood
cultures collected or negative blood culture), excluding febrile neutropenia
FN
Febrile neutropenia or other form of manifestation of infection in immunocompromised host (e.g. HIV,
chemotherapy, etc.) with no clear anatomical site
SIRS
Systemic inflammatory response with no clear anatomical site
UND
Completely undefined; site with no systemic inflammation
NA
Not applicable; for antimicrobial use other than treatment
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TECHNICAL DOCUMENT
Annex 5: Risk scores definitions: SAPS II,
APACHE II, Glasgow
SAPS II score1
The Simplified Acute Physiology Score II (SAPS II) is one of the most frequently used tools to predict hospital
mortality in ICUs and serves as a starting point for the evaluation of ICU efficiency. It includes 17 variables:
12 physiology variables and three underlying disease variables.
Variable
Definition
Comments
SAPS II
The SAPS II components should be measured 24 hours after admission to
The total score must be computed adding
the ICU. The worst values within those 24 hours are to be recorded; each
the weighted values
category of values has a weighted value in points
Age
Use the patient’s age (in years) at his last birthday
Heart rate
Use the worst value in 24 hours, either low or high heart rate; if it varied
from cardiac arrest (11 points) to extreme tachycardia (7 points), assign 11
points
Systolic blood pressure
Use the same method as for heart rate: e.g., if it varied from 60 mm Hg to
205 mm Hg, assign 13 points
Body temperature
Use the highest temperature in degrees centigrade or Fahrenheit
PaO2/FiO2 ratio
If ventilated or continuous pulmonary artery pressure, use the lowest value Only if the patient has been mechanical y
of the ratio
ventilated
Urinary output
Total urinary output in 24 hours
Serum urea or serum urea Use the highest value in mmol/L for serum urea, in mg/dL for serum urea
nitrogen level
nitrogen
WBC count
Use the worst (high or low) WBC count according to the scoring sheet
Serum potassium level
Use the worst (high or low) in mmol/L, according to the scoring sheet
Serum sodium level
Use the worst (high or low) in mmol/L, according to the scoring sheet
Serum bicarbonate level Use the lowest value in mEq/L
Bilirubin level
Use the highest value in µmol/L or mg/dL
Glasgow Coma score*
Use the lowest value; if the patient is sedated, record the estimated
This variable must be repeated on the
Glasgow Coma Score before sedation.
HELICS form
Type of admission
• Unscheduled surgical
• Patients added to the operating room
schedule within 24 hours of the
operation
• Scheduled surgical
• Patient whose surgery was scheduled
at least 24 hours in advance
• Medical
• Patients having no surgery within one
week of admission to ICU
AIDS
Select YES if HIV-positive with clinical complications such as Pneumocystis
carinni pneumonia, Kaposi’s sarcoma, lymphoma, tuberculosis, or
toxoplasma infection
Haematologic malignancy Select YES, if lymphoma, acute leukaemia or multiple myeloma
Metastatic cancer
Select YES, if proven metastasis by surgery, computed tomographic scan, or
any other method
SAPS II weights
Age (in years)
< 400
40–597
60–6912
70–7415
75–7916
≥ 8018
Heart rate (beats/min)
< 4011
40–692
70–119 0
120–1594
≥ 1607
Systolic BP (mm Hg)
<7013
70–995
100–1990
≥ 200 2
Body temperature (°C)
< 390
≥ 393
Only if ventilated or positive airway pressure (BPAP/CPAP)
– PaO2(mmHg)/FiO2 ratio
< 10011
100–1999
≥ 2006
e.g. 70 mmHg /0.5 = 140
– PaO2(Kpa)/FiO2 ratio
(< 13.3)
(13.2–26.4)
(≥ 26.5)
10 Kpa/0.5 = 20
Urinary output (ml/day)
< 50012
500–9994
≥ 10000
Serum urea (mg/dl)
< 600
< 60–1796
≥ 18010
(mmol/L)
(< 10.0)
(10.0–29.9)
(≥ 30.0)
WBC count (103/mm3)
< 1.012
1.0–19.90
≥ 20.03
Serum potassium (mEq/L)
< 3.03
3.0–4.90
≥ 5.03
Serum sodium (mEq/L)
< 1255
125–144 0
≥ 1451
Bicarbonate (mEq/L)
< 156
15–203
≥ 200
Bilirubin (mg/dl)
< 4.00
< 4.0–5.94
≥ 6.09
(µmol/L)
(<68.4)
(68.4-102.5)
(≥ 102.6)
Glasgow coma score
< 626
6–813
9–10 7
11–135
14–150
(if patient is sedated, estimate
status before sedation)
Chronic diseases
metastatic cancer9
haematol. malignancy10
AIDS17
Type of admission
medical6
scheduled surgical0
unscheduled surgical8
1 Le Gall JR, Lemeshow S, Saulnier F. A new simplified acute physiology score (SAPS II) based on a European/North American
Multicenter Study. JAMA 1993; 270:2957–2963.
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HAI-Net ICU protocol, version 2.1
APACHE II score2
The APACHE II severity of disease classification system
Physiologic variable
High abnormal range
Low abnormal range
+ 4
+ 3
+ 2
+ 1
0
+ 1
+ 2
+ 3
+ 4
TEMPERATURE – rectal (C°)
≥ 41°
39°–40.9°
38.5°–38.9° 36°–38.4°
34°–35.9°
323°–33.9°
30°–31.9°
≤ 29.9°
MEAN ARTERIAL PRESSURE – ≥ 160
130–159
110–129
70–109
50–69
≤ 49
mm Hg
HEART RATE
≥ 180
140 – 179
110–139
70–109
55 – 69
40–54
≤ 39
(ventricular response)
RESPIRATORY RATE – (non-
≥ 50
35–49
25–34
12–24
10–11
6–9
≤ 5
ventilated or ventilated)
OXYGENATION: A aDO2 or
≥ 500
350–499
200–349
<200
PaO2 (mm Hg)
O PO2 > 70 O PO2 61–70
O PO2 55–60 O PO2 < 55
a. FIO2 ≥ 0.5 record a A aDO2
b. FIO2 < 0.5 record only PaO2
ARTERIAL pH
≥ 7.7
7.6–7.69
7.5–7.59
7.33–7.49
7.25–7.32
7.15–7.24
< 7.15
SERUM SODIUM (mMol/L)
≥ 180
160–179
155–159
150–154
130–149
120–129
111–119
≤ 110
SERUM POTASIUM (mMol/L)
≥ 7
6–6.9
5.9–5.9
3.5–5.4
3–3.4
2.5–2.9
< 2.5
SERUM CREATININE
≥ 3.5
2–3.4
1.5–1.9
0.6–1.4
< 0.6
(mg/100ml)
(Double point score for acute
renal failure)
HEMATOCRIT (%)
≥ 60
50–59.9
46–49.9
30–45.9
20–29.9
< 20
WHITE BLOOD COUNT
≥ 40
20–39.9
15–19.9
3–14.9
1–2.9
< 1
(total/mm3)
(in 1.000s)
GLASGOW COMA SCORE (GCS)
Score = 15 minus actual GCS
A Total ACUTE PSYSIOLOGIC
SCORE (APS) Sum of the 12
individual variable points
Serum HCO2 (venous mMol/L) ≥ 52
41–51.9
32–40.9
22–31.9
18–21.9
15–17.9
< 15
(Not preferred, use if no ABGs)
AGE POINTS
Assign points to age as fol ows:
AGE (yrs)
Points
≤ 44
0
45–54
2
55–64
3
65–74
5
≥ 75
6
CHRONIC HEALTH POINTS
If the patient has a history of severe organ system insufficiency or is immunocompromised, assign points as
follows:
• for nonoperative or emergency postoperative patients – 5 points
• for elective postoperative patients – 2 points
DEFINITIONS
Organ insufficiency or immunocompromised state must have been evident prior to hospital admission and conform
to the following criteria:
• LIVER: Biopsy proven cirrhosis and documented portal hypertension, episodes of past upper GI bleeding
attributed to portal hypertension or prior episodes of hepatic failure/encephalopathy/coma
• CARDIOVASCULAR: New York Heart Association Class IV
• RESPIRATORY: Chronic restrictive, obstructive or vascular disease resulting in severe exercise restriction,
i.e. unable to climb stairs or perform household duties; or documented chronic hypoxia, hypercapnia,
secondary polycythaemia, severe pulmonary hypertension (> 40mmHg); or respirator dependency
• RENAL: Receiving chronic dialysis
• IMMUNOCOMPROMISED: The patient has received therapy that suppresses resistance to infection, e.g.
immunosuppression, chemotherapy, radiation, long-term or recent high dose steroids, or has a disease
that is sufficiently advanced to suppress resistance to infection, e.g. leukaemia, lymphoma, AIDS.
APACHE II score calculation
A + B + C
2 From Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Critical Care
Medicine 1985;13(10):818–29.
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A APS points
B Age points
C Chronic Health points
Total = APACHE II
Glasgow Coma Score3
Score Glasgow = Y + V + M
Best Eye Response
Best Verbal Response
Best Motor Response
(Y)
(V)
(M)
1. No eye opening
1. No verbal response
1. No motor response
2. Eye opening to pain
2. Incomprehensible sounds
2. Extension to pain
3. Eye opening to verbal command
3. Inappropriate words
3. Flexion to pain
4. Eyes open spontaneously
4. Confused
4. Withdrawal from pain
5. Orientated
5. Localising pain
6. Obeys commands
Please note that, for example, the phrase ‘GCS of 11’ is essential y meaningless. It is important to relate the
complete formula, e.g. Y3 V3 M5 = GCS 11. A Glasgow Coma Score of 13 or higher correlates with a mild brain
injury; 9 to 12 is a moderate injury; and 8 or less, a severe brain injury.
Glasgow Paediatric Coma Score4
The Paediatric GCS is scored between 3 and 15, with 3 being the worst and 15 the best. It is composed of three
parameters: Best Eye Response, Best Verbal Response and Best Motor Response:
• Best Eye Response (4)
−
No eye opening
−
Eye opening to pain
−
Eye opening to verbal command
−
Eyes open spontaneously
• Best Verbal Response (5)
−
No vocal response
−
Inconsolable, agitated
−
Inconsistently consolable, moaning
−
Cries but is consolable, inappropriate interactions
−
Smiles, oriented to sounds, fol ows objects, interacts
• Best Motor Response (6)
−
No motor response
−
Extension to pain
−
Flexion to pain
−
Withdrawal from pain
−
Localising pain
−
Obeys commands
Please note that, for example, the phrase ‘GCS of 11’ is essential y meaningless. It is important to relate the
complete formula, such as E3 V3 M5 = GCS 11. A Glasgow Paediatric Coma Score of 13 or higher correlates with a
mild brain injury; 9 to 12 is a moderate injury; and 8 or less, a severe brain injury.
3 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;13(2)7872:81–4.
4 http://www.trauma.org/scores/gpcs.html
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Other scoring systems
The list of other scoring systems may be adapted in the future as a function of new scientific developments.
Currently the HelicsWin.Net software and the TESSy metadata al ow for fol owing scores, to be measured on ICU
admission or within the first 24 hours:
-
APACHE = Acute Physiology and Chronic Health Evaluation score: APACHE II, APACHE III, APACHE IV
-
ASA = Physical Status Classification System of the American Society of Anesthesiology
-
MCCABE = McCabe score
-
MPM = Mortality Prediction Model: MPM II, MPM III
-
SAPS = Simplified Acute Physiology Score: SAPS II (separate variable, standard score for adult patients),
SAPS 3
-
Paediatric scores:
o
PIM: Paediatric Index of Mortality: PIM, PIM II
o
PRISM: Paediatric Risk of Mortality score: PRISM, PRISM III, PRISM IV
-
Neonatal scores:
o
CRIB = Clinical Risk Index for Babies: CRIB, CRIB II
o
SNAP = Score for Neonatal Acute Physiology
-
Predicted mortality (PDEATH): 0-100 (%), any severity score converted in its predicted mortality on ICU
admission (or first 24 hours)
References and calculators for severity scores can be found at Société Française d’Anesthésie et de Réanimation
(SFAR). Scoring systems for ICU and surgical patients. Available from
http://test-app.sfar.org/welcome-the-sfar-
website/scoring-systems-for-icu-and-surgical-patients/ .
Scores not included in this overview are e.g. APACHE III
http://www.ncbi.nlm.nih.gov/pubmed/1959406, APACHE
IV
http://www.ncbi.nlm.nih.gov/pubmed/16540951 , MPM III:
http://www.ncbi.nlm.nih.gov/pubmed/17255863
and SAPS 3
http://www.ncbi.nlm.nih.gov/pubmed/16132892 .
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Annex 6: List of HAI outcome indicators
Indicator
Definition
Unit-based Patient-based
(Light)
(Standard)
Bloodstream infection (BSI)
Incidence density of
# BSI (of al origin) >D2*1000/n of patient-days
X
X
healthcare-associated BSI
in the ICU
Pathogen-specific BSI
# BSI (of al origin, by pathogen) >D2*1000/n of
X
X
incidence rate
patient-days
Standardised BSI ratio
Observed n of patients with BSI/Expected n of
-
X
patients with bloodstream infection
Stratification of device-
Infection rates by ICU type
X
X
adjusted infection rates
Infection rates by risk factors
-
X
Pneumonia
Incidence density of
# pneumonia (of al origin) >D2*1000/n of patient-
X
X
healthcare-associated
days
pneumonia (clinical +
microbiologically confirmed)
in the ICU
% microbiologically
# PN with microbiologically documentation by semi-
X
X
confirmed pneumonia
quantitative (BAL,PB…) or quantitative culture of
endotracheal aspirate/total PN
Pathogen-specific
# pneumonia (of al origin, by pathogen)
X
X
pneumonia incidence rate >D2*1000/n of patient-days
Intubator-associated
# device-associated pneumonia*1000/n of
-
X
pneumonia rate in the ICU intubation days
Standardised pneumonia
Observed n of patients with pneumonia/Expected n
-
X
ratio
of patients with pneumonia
Stratification of infection
Infection rates by ICU type
X
X
rates
Infection rates by risk factors
-
X
Urinary tract infection
Incidence density of
# UTI >D2*1000/n of patient-days
X
X
healthcare-associated UTI
in the ICU
Pathogen-specific UTI
# UTI (of al origin, by pathogen) >D2*1000/n of
X
X
incidence rate
patient-days
Catheter-associated UTI
# device-associated UTI*1000/n of urinary catheter
-
X
rate in the ICU
days
Stratification of infection
Infection rates by risk factors
X
X
rates
Catheter infection
Incidence density of
# catheter-associated infections*1000/n of central
-
X
catheter infections in the
line days (catheter-total)
ICU
Antimicrobial use in the ICU
Antimicrobial treatment
N of antibiotic treatment days/N of patient-days
-
X
utilisation rate
Ratio documented
N of documented AB treatment days/N of empiric
-
X
treatment/empiric
AB treatment days
treatment
Stratified AM use
N of antibiotic treatment days/N of patient-days by
-
X
risk factors
Device use in the ICU
Central line utilisation rate N of central line days/N of patient-days
-
X
Intubation utilisation rate N of days with intubation/N of patient-days
-
X
Urinary catheter utilisation N of urinary catheter days/N of patient-days
-
X
rate
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HAI-Net ICU protocol, version 2.1
Annex 7: Structure and process prevention
indicators: definition, rationale and
references
Prevention indicators for surveil ance of HAIs in intensive care units (HAI-Net ICU) were developed during
meetings held on 24 October 2013 and on 19-20 February 2014 and by a HAI-Net ICU working group (Antonella
Agodi, Michael Hiesmayr, Alain Lepape, Mercedes Palomar, Anne Savey, Carl Suetens). Indicators were also
discussed with the Infection Section of the European Society of Intensive Care Medicine (ESICM Conference, 27-30
September 2014, Barcelona), reviewed by the ESICM Infection Section Members in October 2014 and suggestions
integrated by the working group. The proposal was discussed and agreed during the HAI-Net ICU sessions of the
Third Joint Meeting of the ARHAI Networks in Stockholm, 11-13 February 2015.
Hand hygiene: Consumption of alcohol-based hand rub solution
Definition
Number of litres of alcohol-based hand rub consumed during the previous year x 1000 / number of patient-days in
the ICU during the previous year
Rationale
The importance of hand hygiene as cornerstone of standard precautions for infection prevention and control has
been demonstrated since more than one century. The consumption of alcohol-based hand rubs (AHR) in litres per
1 000 patient-days is regarded as a good proxy indicator of hand hygiene compliance of healthcare workers. In a
review of literature, Boyce found that in 77% of studies looking at both indicators, AHR consumption and hand
hygiene compliance were correlated. Lack of correlation may occur for example when both indicators are measured
for different time period(s) and correlations within the same setting/institution (repeated measurement over time)
are stronger than correlations across institutions, e.g. because of inter-hospital variation in the type or
concentration of used products. Inter-hospital compliance/AHR use correlations may also be more subject to bias,
such as the Hawthorne effect bias of the compliance measurement (HCWs perform better when observed) on the
one hand, and the use of AHR for other purposes than hand hygiene (e.g. surface disinfection) or differences in
AHR volumes used per hand hygiene procedure on the other hand. Despite these limitations however, AHR
consumption was found to be associated with reduction of MRSA and HAI rates in several studies.
References
Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009
Dec;73(4):305-15.
Behnke M, Gastmeier P, Geffers C, Mönch N, Reichardt C. Establishment of a national surveillance system for alcohol-based
hand rub consumption and change in consumption over 4 years. Infect Control Hosp Epidemiol. 2012 Jun;33(6):618-20.
Boyce JM. Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. Infect Control
Hosp Epidemiol. 2011 Oct;32(10):1016-28.
Sroka S, Gastmeier P, Meyer E. Impact of alcohol hand-rub use on meticillin-resistant Staphylococcus aureus: an analysis of
the literature. J Hosp Infect. 2010 Mar;74(3):204-11.
Marimuthu K, Pittet D, Harbarth S. The effect of improved hand hygiene on nosocomial MRSA control. Antimicrobial
Resistance and Infection Control 2014, 3:34
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, Perneger TV. Effectiveness of a hospital-wide
programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000 Oct 14;356(9238):1307-
12.
Chen YC, Sheng WH, Wang JT, Chang SC, Lin HC, Tien KL, Hsu LY, Tsai KS. Effectiveness and limitations of hand hygiene
promotion on decreasing healthcare-associated infections. PLoS One. 2011;6(11):e27163.
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ICU staffing: staff to patient ratio
Definition
Sum of the number of registered nurse hours and number of nursing assistant hours in the ICU over a period of 7
days * 100 / number of patient-days in 7 days * 24 hours
Rationale
Understaffing is one of the main reasons for low quality of care due to a lack of organisation, stress, lack of time
and increase of urgent interventions and subsequent non-compliance with infection control procedures. It is one of
the indicators with the strongest evidence of an association with an increased risk of HAI incidence or cross-
transmission of nosocomial pathogens.
References
Schwab F, Meyer E, Geffers C, Gastmeier P. Understaffing, overcrowding, inappropriate nurse: ventilated patient ratio and
nosocomial infections: which parameter is the best reflection of deficits? J Hosp Infect 2012, 80(2): 133-139.
West E, Mays N, Rafferty AM, Rowan K, Sanderson C. Nursing resources and patient outcomes in intensive care: a
systematic review of the literature. Int J Nurs Stud 2009, 46(7): 993-1011.
Antimicrobial stewardship: Re-assess antimicrobial therapy after 48-
72 hours
Definition
Number of antimicrobial therapies that were started more than 3 days ago and were re-assessed within 72 hours
after start of the antimicrobial * 100 / Total number of audited antimicrobial therapies that were started more than
3 days ago
Source: medical or nurse patient file, retrospective review of 30 files patients receiving systemic antimicrobials for
therapeutic reasons.
Rationale
Re-assessing antimicrobial therapy after 48 to 72 hours using serial clinical and microbiological evaluations is
crucial to ensure appropriate treatment of the infection, de-escalate where possible and discontinue the therapy if
infection is unlikely. Reducing the duration of antimicrobial use and using narrower spectrum antimicrobials or
switching to monotherapy when possible limit the emergence and dissemination of drug-resistant strains and
minimize antibiotic-related toxicity. Post-prescription review by a physician, pharmacist or other staff member of an
antimicrobial after 48 hours from the initial order was also selected as a core Indicators for hospital antimicrobial
stewardship programs by the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR).
References
Garnacho-Montero J et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis
and septic shock. Intensive Care Med 2014, 40(1): 32-40.
Dellinger RP et al. Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis
Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013,
39(2): 165-228.
Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. Crit Care. 2014 Aug
13;18(5):480.
Transatlantic Taskforce on Antimicrobial Resistance (TATFAR). Report on the modified Delphi process for common structure
and process indicators for hospital antimicrobial stewardship programmes. Preliminary version. Aug 2014.
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TECHNICAL DOCUMENT
HAI-Net ICU protocol, version 2.1
Intubation: Cuff pressure
Definition
Number of intubation days (days of patients with intubation) during which the endotracheal cuff pressure was
verified and maintained between 20 and 30 cm H2O (and documented in the patient file) at least twice per day *
100 / total number of observed intubation days.
Rationale
Maintaining the endotracheal cuff pressure in the recommended range limits micro-inhalations while preserving the
mucosal integrity. The recommended range for the pressure varies between studies and guidelines: 25-30 cm H2O,
20-30 cm H2O or 15-22 mm Hg.
References
Guidelines for the management of adults with hospital acquired ventilator-associated, and healthcare-associated pneumonia.
Am J Respir Crit Care Med 2005,171:388-416.
Bouadma L, Wolff M, Lucet JC. Ventilator-associated pneumonia and its prevention. Curr Opin Infect Dis 2012, 25(4): 395-
404.
ML Sole. Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range. Am J Critical
Care 2011, 20: 109-118.
Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe
DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect
Control Hosp Epidemiol. 2014 Aug;35(8):915-36.
Intubation: Oral decontamination
Definition
Number of intubation days (days of patients with intubation) during which oral decontamination with oral
antiseptics has been performed (and documented in the patient file) at least twice per day * 100 / total number of
observed intubation days.
Rationale
Regular oropharyngeal decontamination with chlorhexidine or povidone-iodine reduces the number of
microorganisms colonising oropharyngeal secretions, which are involved in the development of ventilator-
associated pneumonia through aspiration in the lower respiratory tract in intubated patients.
References
Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral
antiseptics: a systematic review and meta-analysis. Lancet Infect Dis 2011, 11: 845–854
Shi Z, Xie H, Wang P, Zhang Q, Wu Y, Chen E, Ng L, Worthington HV, Needleman I, Furness S. Oral hygiene care for
critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2013 Aug 13;8:CD008367.
Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe
DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect
Control Hosp Epidemiol. 2014 Aug;35(8):915-36.
Intubation: Patient position
Definition
Number of days of patients with intubation during which the patient’s position was not supine (= was either prone
or recumbent) * 100 / total number of observed intubation days.
Rationale
Patients should not be maintained in supine position (except in case of specific indications) in order to reduce
micro-aspiration. The existing evidence mainly supports an elevated head of the bed to 30-45 degrees, the prone
positioning of the patient to prevent VAP is much more debated.
References
Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe
DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect
Control Hosp Epidemiol. 2014 Aug;35(8):915-36.
Alexiou VG, Ierodiakonou V, Dimopoulos G, Falagas ME. Impact of patient position on the incidence of ventilator-associated
pneumonia: a meta-analysis of randomized controlled trials. J Crit Care. 2009 Dec;24(4):515-22.
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HAI-Net ICU protocol, version 2.2
TECHNICAL DOCUMENT
CVC: Catheter dressing observation
Definition
Number of days of patients with a central vascular catheter during which the dressing of the CVC was not loose,
damp or visibly soiled * 100 / total number of observed CVC days.
Rationale
Daily clinical surveillance of CVC dressings is important to prevent CVC-related infections. SHEA recommendations
state “For non-tunneled CVCs in adults and adolescents, change transparent dressings and perform site care with a
chlorhexidine-based antiseptic every 5-7 days or more frequently if the dressing is soiled, loose, or damp; change
gauze dressings every 2 days or more frequently if the dressing is soiled, loose, or damp.” An indicator of CVC
maintenance was preferred over an indicator of CVC insertion because of feasibility, in particular the number of
observation opportunities is much higher for CVC maintenance (CVC days for al patients with CVC in the ICU) than
for CVC insertion (only newly inserted CVCs, CVC insertion often done outside the ICU).
References
Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL, Yokoe
DS. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control
Hosp Epidemiol. 2014 Sep;35 Suppl 2:S89-107.
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Document Outline