1. Manual on Point Prevalence Survey

DRAFT
Manual
HEALTHCARE ASSOCIATED INFECTION
(HCAI) SURVEILLANCE
Point Prevalence Survey
for
Healthcare Associated Infection
Surveillance
Second Edition
November 2013
Quality in Medical Care Section
Medical Development Division
Ministry of Health
1
Contents
Abbreviations
PAGE
3
Committee Members
4
Background
5
Objectives
6
Methodology
a. Design
b. Population under surveillance
c. Definitions
d. Calculation of Prevalence Rate
e. Inclusion and Exclusion criteria
f. Survey Instrument
6
6
7
9
10
11
Data Collection
12
Compilation of data and report
14
Algorithm for Healthcare Associated
Infection Surveillance through PPS
16
APPENDIX 1: Definitions Of Healthcare
Associated Infection
17
APPENDIX 2: Healthcare Associated
Infection Surveillance Form (HCAIPPS/MOH/2013/1)
33
APPENDIX 3: Healthcare Associated
Infection Surveillance Reporting Form
Section A (HCAI-PPS/MOH/2013/2)
36
APPENDIX 4: Healthcare Associated
Infection Surveillance Reporting Form
Section B (HCAI-PPS/MOH/2013/3)
38
APPENDIX 5: Line Listing For HCAI
Surveillance - PPS
40
References
42
2
Abbreviations
A&E
Accident and emergency
AMR
Antimicrobial resistance
BSI
Bloodstream infection
CDC
Centre for Disease Control and Prevention
CFU
Colony-forming units
CVC
Central vascular catheter
ESBL
Extended-spectrum beta-lactamase
HCAI
Healthcare-associated infections
ICN
Infection control nurse
ICU
Intensive care unit
MOH
Ministry of Health
PPS
Point Prevalence Survey
PVC
Peripheral vascular catheter
SSI
Surgical site infections
WHO
World Health Organization
3
Committee Members
Dr Zubaidah Abdul Wahab
Senior Consultant Clinical Microbiologist
Hospital Sungai Buloh, Selangor
Dr Nurahan Maning
Senior Consultant Clinical Microbiologist
Hospital Raja Perempuan Zainab II, Kota Bharu
Datin Dr R. Ganeswrie
Senior Consultant Clinical Microbiologist
Hospital Sutanah Aminah, Johor Bahru
Dr Shahnaz Shah Firdaus Khan
Senior Consultant Nephrologist
Hospital Tengku Ampuan Rahimah, Klang
Dato’ Dr Sapari Satwi
Senior Consultant Physician (Infectious Disease)
Hospital Tengku Ampuan Afzan, Kuantan
Dr Kamarul Azahar Mohd Razali
Senior Consultant Paediatrician (Infectious
Disease)
Hospital Kuala Lumpur
Dr Ker Hong Bee
Consultant Physician (Infectious Disease)
Hospital Raja Permaisuri Bainun, Ipoh
Dr Jamaludin Mohamad
Consultant Paediatrician
Hospital Tuanku Fauziah, Kangar
Dr Suraya Amir Husin
Senior Principal Assistant Director
Infection Control Unit
Medical Development Division
Dr Suhaila Hanapiah
Clinical Microbiologist
National Cancer Institute, Putrajaya
Dr Sahlawati Mustakim
Clinical Microbiologist
Hospital Tengku Ampuan Rahimah,
Klang
Dr Anis Baidura Azal
Senior Assistant Director
Infection Control Unit
Medical Development Division
Pn Hadijah Mohd Taib
Pharmacist
Hospital Kuala Lumpur
Pn Saabah Rosnan
Nursing Sister
Infection Control Unit
Medical Development Division
Pn Zawiah Mamat@ Mohd Dris
Nursing Sister
Infection Control Unit
Medical Development Division
Dr Tuan Suhaila Tuan Soh
Clinical Microbiologist
Hospital Sungai Buloh, Selangor
4
Background
The prevalence of hospital infections in Malaysia is being observed through the Healthcare
Associated Infections (HCAI) surveillance programme. The HCAI prevalence is determined
through a one-day hospital wide point prevalence survey (PPS) which is conducted twice a year
in March and September. The PPS started in 2003 involving 14 Ministry of Health (MOH) and 3
university hospitals. Currently the surveillance data from 20 MOH and 3 university hospitals is
analysed twice a year.
The HCAI are categorized into the common types of infection occurring in hospitals, which are
the urinary tract infections (UTI), pneumonia, surgical site infections (SSI), blood stream
infections (BSI) and clinical sepsis (CS).
The first survey conducted in September 2003 showed that the national HCAI rate was 6.3 per
100 patients surveyed. The 10 years trend has shown progressive reduction to 1.51 per 100
patients surveyed in September 2012. Since the first survey, pneumonia had always been the
most common type of infection occurring in the hospitals followed by either SSI or BSI.
The objective of HCAI surveillance is to reduce HCAI rates. Surveillance can be carried out by
prevalence studies or incidence studies. Incidence studies are essentially cohort studies which
require much more workload. In general, incidence study is better for surveillance as it is
ongoing. It allows for risk factor analysis and gives more robust data. Incidence studies can be
carried out concentrating on a specific infection type eg. BSI, UTI or VAP or on a specific unit eg.
Intensive Care Unit.
Prevalence study on the other hand is essentially cross sectional and for surveillance purposes,
repeated prevalence studies eg. Point prevalence studies are necessary.
The information on infection rates, main infection sites, common microorganisms and the use
of antibiotics varies from one centre to another. For example, a study in the Netherlands
showed that the most common HCAI was SSI (4.8%), followed by respiratory tract infections
1.1%, UTI (1.7%) and BSI (0.5%) (1). A Canadian study reported that the most common HCAI was
UTI (3.4%), followed by pneumonia (3.0%), SSI (2.5%), BSI (1.6%) and Clostridium difficileassociated diarrhoea (1%)(2). In short, choosing the best method for HCAI surveillance in a
hospital depends on the following factors:
5

Analysis of the baseline situation (prevalence data, earlier results, outbreaks)

Characteristics of the hospital (famous for a specific operation type)

Which resources are available (manpower)

Formulation of clear objectives (eg. To decrease SSI rates following hip operation)
Objectives
General objective: To reduce healthcare associated infection prevalence / incidence rate
Specific objective:
1. To estimate the total burden (prevalence) of HCAI in hospitals participating in PPS.
2. To determine the characteristic of infection - types of HCAI and organism, pattern of
antibiotic usage, invasive procedures and other predisposing factors of HCAI
3. To provide a standardized tool for hospitals to identify targets for quality improvement
Methodology
a) Design
It is a hospital wide cross sectional, point prevalence survey. The survey is conducted twice a
year, one day in the month of March and September
b) Population under surveillance
Population under surveillance is all in-patients on the survey day
c) Definitions of an active HCAI
An active healthcare associated infection present on the day of the survey is defined as follows:
1. Signs and symptoms of the infection are present on the survey date OR signs and
symptoms were previously present and the patient is still receiving treatment for that
infection on the survey date AND
6
2. The onset of infection was after 48 hours of admission OR
3. The onset of infection (SSI) was less than 48 hours of admission but patient has
undergone surgical procedure within one month or one year (with implant) OR
4. Patient presents with an infection but has been readmitted within 48 hours after a
previous discharge from hospital OR
5. Infections occurring in infants that result from passage through the birth canal are
considered HCAIs if they meet the definition of HCAI.
SUMMARY OF HCAI CASE DEFINITION
Onset of HCAI1
After 48 hours
OR
Case definition
AND
Meets the case definition on the day
of survey
Before 48 hours: SSI criteria met at any
time after admission (including previous
surgery 30 days/1 year)
OR
Before 48 hours AND patient discharged
from hospital in preceding 48 hours
OR
OR
Before 48 hours AND patient discharged
from hospital in preceding 28 days if CDI2
present
OR
Patient is receiving treatment3 and
HCAI has previously met the case
definition before 48 hours of
treatment and survey day
Before 48 hours AND patient has relevant
device inserted on this admission prior to
onset
7
1. Date of onset of HCAI: date of first signs or symptoms of the infection; if unknown, record
the date when treatment was started for this infection or the date the first diagnosis sample
was taken. If no treatment or sample, please estimate. Not to be recorded if
signs/symptoms are present at admission
2. CDI : Clostridium difficile infection
3 . Any kind of treatment, not necessarily antimicrobial
Definitions of the most common HCAI are listed as in Appendix 1. The method of case
confirmation can be made through clinical signs and symptoms or laboratory investigations.
Since this is a hospital wide infection, all patients present in the hospital at the time of survey
are included. The total number of patients is collected in the early morning census from each
ward obtained from the ward sister excluding the psychiatric ward and labour room.
d) Calculation of HCAI Prevalence
Numerator:
Any patient that met the criteria in Appendix 1
Denominator: Number of hospitalized patients in the hospital on the day of survey**
Ward HCAI prevalence
=
No. of patient with HCAI in the ward on the day of survey X 100
No. of hospitalized patients in the ward on the day of survey
Department / discipline HCAI prevalence
= No. of patient with HCAI in the department on the day of survey X 100
No. of hospitalized patients in the department on the day of survey
8
Hospital HCAI prevalence
= Total no. of patient with HCAI in the hospital on the day of survey X 100
No. of hospitalized patients in the hospital on the day of survey
** Total number of hospitalized patients present at 8.00 am in the hospital on the day of survey
excluding the psychiatric ward and labour room.
e) Inclusion and Exclusion criteria
Ward
Include:
 All wards in the hospitals
Exclude:
 Psychiatric ward

Labour room/suite
Department
Include:
 All Departments in the hospitals
Exclude:
 A & E departments (except for wards attached to A&E departments where patients are
monitored for more than 24 hours)
 Psychiatric Department
Hospitals
Include:
 All selected MOH hospitals and University hospitals
9
Patients
Include:
 All patients admitted to the ward before or at 8 a.m. and not discharged from the ward
at the time of the survey; in practice, this means that patients transferred in/out after 8
a.m. from/to another ward should not be included.
 Neonates on pediatric and O&G wards if born before/at 8 a.m.
 Patients who are temporarily off from the ward for diagnostic investigations or
procedures; if patient does not return to the ward before the end of the PPS day and
information about patient is not available at 8 a.m., please revisit ward.
Exclude:
 Patients undergoing same day treatment or surgery
 Patients seen at outpatient department
 Dialysis patients (outpatients)
f) Survey Instrument
Data on infection are obtained from the patients records. HCAI cases are to be supported with
other pertinent information which are being collected in the survey. This includes the
microbiological report, indicating the type of specimen where organism(s) was isolated and the
organism antibiotic susceptibility results.
Information regarding antibiotic treatment received in the past 2 weeks as well as current
antibiotic treatment ie. the patient is still receiving antibiotics for an infection on the day of the
survey is also documented. The current antibiotic treatment indicates that the infection is
active.
It is important to determine the possible source or point where the infection was introduced
during his stay in the hospital. Therefore, information on various types of devices that the
patient had been subjected to is also recorded. Besides the devices, the other possible
contributing factors such as patient’s underlying disease, immunosuppressive therapy,
prolonged hospitalisation, invasive procedures, pre-maturity and low birth weight are looked
into.
10
Data collection process
Data collection activity in the hospitals will be handled by the hospital infection control
committee that consists of:

Infection Control Doctor / Clinical Microbiologist

Ward Doctors

Matron / Nurse Manager Infection Control Unit

Infection Control Sister

Infection Control Nurses

Ward Sisters In Charge

Link Nurses
The committee will organized the pre-survey training program if required, scheduling of survey,
coordinate survey data collection (resources identification) until data compilation and report at
the hospital level.
Pre survey task
National level

Choose date for survey

Send letter informing date of survey to all participating hospitals address to Director of
Hospital and Infection Control Nurse.
Hospital Level

Inform the administrators and managers of the PPS date

Recruit surveyors

Prepare pre-survey briefing – explain case definition, go through on how format should be
filled
11

Train team to review medical and nursing charts and interview the ward staff.

Assign groups to wards, prepare timetable

Prepare enough copies of formats and forms required

Identify and designate ward sisters to help surveyors

Inform ward sisters to have patient folders at bedside with all investigation reports available
Day of survey
Hospital Level

Visit every patient in the hospital on the survey day at 8 am

Identify infected patients through the case notes (BHT, nursing observation forms,
prescription sheets and laboratory results)

Fill the appropriate surveillance form
For ward sister in charge:

Prepare ward census of patients at 8 am

Identify patients who are temporarily not in the ward (e.g to OT, X ray, rehab , HD)and
inform team when they return to the ward
Post survey task
Hospital Level

Compile all filled forms from team members and send them to state

Tabulate data and calculate HCAI rates

Presentation of result at hospital infection control committee

Disseminate and use data in decision making at hospital level

Formulate Infection control strategies and policies
12
State Level

Collect data from the hospitals in state and send to national secretariat

Tabulate data at state level and calculate HCAI rates

Presentation of result at state infection control committee

Disseminate and use data in decision making at state level

Formulate infection control strategies and policies
National level

Compile all data from the state.

Data analysis and reporting at national level

Presentation of the result during technical and national infection and antibiotic control
committee meeting

Disseminate and use data in decision making at national level

Formulate infection control strategies and policies
Compilation of data and report
Once a case is being identified from the case notes (case identification is made based on the
definition as discussed earlier) the ward infection / link nurse need to fill in the HCAIPPS/MOH/2013/1 form as in Appendix 2. Data from each format are then entered and
tabulated according to the form HCAI-PPS/MOH/2013/2 [Excel Format] as in Appendix 3.
Individual form of HCAI-PPS/MOH/2013/1 and HCAI-PPS/MOH/2013/2 are to be sent to
hospital infection control nurse (ICN). The ICN will then compile the data using HCAIPPS/MOH/2013/3 [Excel Format] as in Appendix 4 and complete the line listing. Completed
HCAI-PPS/MOH/2013/3 form to be e-mailed to ICN State Coordinator for compilation.
State Coordinator will compile HCAI-PPS/MOH/2013/3 from all hospitals and e-mail them to
the Infection Control Unit, Medical Development Division within 1 month of the PPS date.
However, hospitals are most welcome to produce their own performance report.
13
The national secretariat will compile all the data from the state and produce a report on the
national performance of the HCAI. The flow chart for the case finding and process of the
surveillance is shown in Algorithm for Healthcare Associated Infection Surveillance through
PPS.
14
Algorithm for healthcare associated infection surveillance through PPS
Surveillance team arrives in the
ward. Record start date and time.
Walk around ward. For each patient,
observe for invasive devices (UC, PVC,
CVC, ventilation)
Collect denominator data on all
patients in ward before 8 am
Collect ONE set of patient notes (medical, nursing,
observation, I/O, drug chart, etc.)
Confirm HCAI according to standard definitions
If note are unclear, ask
for clarification of sign
and symptom from
nursing/medical team
Ward link nurse to fill in HCAI-PPS/MOH/2013/1 form
Complete data collection for all patients
Compile all the forms and get the no. of
HCAI cases according to type of
infection. Complete the HCAIPPS/MOH/2013/2.
Line listing to be filled and kept
at the hospital
1) Compilation of HCAI-PPS/MOH/2013/1 to be sent
to hospital ICN
2) Completed HCAI-PPS/MOH/2013/2 to be sent to
ICN in soft copy
ICN to complete the line listing
ICN to fill in the HCAI-PPS/MOH/2013/3 format based on HCAI-PPS/MOH/2013/2
compiled from the ward.
ICN to send the HCAI-PPS/MOH/2013/3 to state coordinator
Data management by
Infection Control Unit, MOH
State Coordinator to e-mail HCAI-PPS/MOH/2013/3 to
Infection Control Unit, MOH within 1 month of PPS date
15
APPENDIX 1
DEFINITIONS OF HEALTHCARE ASSOCIATED INFECTIONS – FIRST EDITION 2013
This document has been adapted from the CDC/NHSN Surveillance Definition of Healthcare
Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting and
European Centre for Disease Prevention and Control, Point prevalence survey of healthcare
associated infections and antimicrobial use in European acute care hospitals- protocol version
4.3. Stockholm: ECDC; 2012
Most HCAI becomes evident 48 hours (i.e., the typical incubation period) or more after
admission. However, because the incubation period varies with the type of pathogen, nature of
infection and the patient’s underlying conditions, each patient must be assessed individually for
evidence that links it to the hospitalization. The diagnosis of a HCAI is based on a combination
of clinical and laboratory findings.
There are two special situations in which an infection is considered HCAI:
1. Infection that is acquired in the hospital but does not become evident until after
hospital discharge.
2. Infections occurring in infants that result from passage through the birth canal are
considered HCAIs if they meet the definition of HCAI above
There are two special situations in which an infection is not considered HCAI:
1. Infection that is associated with a complication or extension of infection already present
on admission, unless a change in pathogen or symptoms strongly suggests the
acquisition of a new infection.
2. In an infant an infection that is known or proved to have been acquired transplacentally
(e.g., toxoplasmosis, rubella, cytomegalovirus, or syphilis) and becomes evident at or
before 48 hours after birth.
For the purpose of our survey, only the most common HCAI i.e. urinary tract infection,
pneumonia, surgical site infections, blood stream infections and clinical sepsis will be defined
precisely. For other HCAI record them as OTHERS and briefly describe the nature of the
infection as best you can.
The following pages contain the criteria to be used for diagnosing the common HCAI. If you are
in doubt PLEASE CONSULT THE ATTENDING DOCTOR OR MICROBIOLOGIST
16
INFECTION SITE: Symptomatic urinary tract infection
CODE: UTI
DEFINITION: A symptomatic urinary tract infection must meet at least one of the following
criteria:
Criterion
Description
1
Patient had an indwelling urinary catheter in place for >48 hours, with day of device
placement being Day 1, and catheter was in place at the time when all elements of
this criterion were first present together.
And
at least 1 of the following signs or symptoms: fever (>38°C); suprapubic
tenderness*; costovertebral angle pain or tenderness*
And
a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2
species of microorganisms.
OR
Patient had an indwelling urinary catheter in place for >48 hours and had it
removed the day of or the day before all elements of this criterion were first
present together
And
at least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*;
dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness*
And
a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2
species of microorganisms.
*With no other recognized cause
2
Patient had an indwelling urinary catheter in place for >48 hours, with day of device
placement being Day 1 and catheter was in place when all elements of this criterion
were first present together
And
17
at least 1 of the following signs or symptoms: fever (>38°C); suprapubic
tenderness*; costovertebral angle pain or tenderness*
And
at least 1 of the following findings:
a. positive dipstick for leukocyte esterase and/or nitrite
b. pyuria (urine specimen with ≥10 white blood cells [WBC]/mm3 of unspun urine
or >5 WBC/high power field of spun urine)
c. microorganisms seen on Gram’s stain of unspun urine
And
a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of
microorganisms.
OR
Patient with an indwelling urinary catheter in place for > 48 hours and had it
removed the day of or the day before all elements of this criterion were first
present together
And
at least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*;
dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness*
And
at least 1 of the following findings:
a. positive dipstick for leukocyte esterase and/or nitrite
b. pyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or >5 WBC/high
power field of spun urine
c. microorganisms seen on Gram’s stain of unspun urine
And
a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of
microorganisms.
*With no other recognized cause
For patient ≤1 year of age
18
Criterion
3
Description
Patient ≤1 year of age with** or without an indwelling urinary catheter has at least
1 of the following signs or symptoms: fever (>38°C core); hypothermia (<36°C core);
apnea*; bradycardia*; dysuria*; lethargy*; vomiting*
And
a positive urine culture of ≥105 CFU/ml with no more than 2 species of
microorganisms. Elements of the criterion must occur within a timeframe that does
not exceed a gap of 1 calendar day.
*With no other recognized cause
** Patient had an indwelling urinary catheter in place for > 48 hours, with day of
device placement being Day 1, and catheter was in place when all elements of this
criterion were first present together.
4
Patient ≤1 year of age with** or without an indwelling urinary catheter has at least
1 of the following signs or symptoms: fever (>38°C core); hypothermia (<36°C core);
apnea*; bradycardia*; dysuria*; lethargy*; vomiting*
And
at least 1 of the following findings:
a. positive dipstick for leukocyte esterase and/or nitrite
b. pyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or >5 WBC/high
power field of spun urine
c. microorganisms seen on Gram’s stain of unspun urine
And
a positive urine culture of between ≥103 and <105 CFU/ml with no more than two
species of microorganisms.
*With no other recognized cause
** Patient had an indwelling urinary catheter in place for > 48 hours, with day of
device placement being Day 1 and catheter was in place when all elements of this
criterion were first present together
INFECTION SITE: Asymptomatic bacteriuria
19
CODE: ASB
DEFINITION: An asymptomatic bacteriuria must fulfill the criterion described below
Criterion
Description
Patient with* or without an indwelling urinary catheter has no signs or
symptoms (i.e., for any age patient, no fever (>38°C); urgency; frequency;
dysuria; suprapubic tenderness; costovertebral angle pain or tenderness
OR
for a patient ≤1 year of age; no fever (>38°C core); hypothermia (<36°C
core); apnea; bradycardia; dysuria; lethargy; or vomiting)
And
a positive urine culture of ≥105 CFU/ml with no more than 2 species of
uropathogen microorganisms** (see Comments section below).
And
a positive blood culture with at least 1 matching uropathogen
microorganism to the urine culture, or at least 2 matching blood cultures
drawn on separate occasions if the matching pathogen is a common skin
commensal.
*Patient had an indwelling urinary catheter in place for > 48 hours, with day
of device placement being Day 1, and catheter was in place when all
elements of this criterion were first present together.
**Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus
spp., yeasts, beta-hemolytic Streptococcus spp., Enterococcus spp., G.
vaginalis, Aerococcus urinae, and Corynebacterium (urease positive)+.
+Report Corynebacterium (urease positive) as either Corynebacterium
species unspecified (COS) or as C. urealyticum (CORUR) if so speciated.
INFECTION SITE: Surgical Site Infection (Superficial Incisional)
20
CODE: SSI-(Skin)
DEFINITION: A superficial SSI must meet the following criterion:
Infection occurs within 30 days after any operative procedure and involves only skin and
subcutaneous tissue of the incision and patient has at least one of the following:
a. purulent drainage from the superficial incision
b. organsims isolated from an aseptically-obtained culture of fluid or tissue from the
superficial incision
c. superficial incision that is deliberately opened by a surgeon and is culture-positive or
not cultured
and
patient has at least one of the following signs or symptoms of infection: pain or
tenderness; localized swelling; redness; or heat. A culture negative finding does not
meet this criterion
d. diagnosis of superficial incisional SSI by the surgeon or attending physician
INFECTION SITE: Surgical site infection (Deep incisional)
CODE: SSI-(Soft Tissue)
DEFINITION: A deep incisional SSI must meet the following criterion:
Infection occurs within 30 days after the NHSN operative procedure according to the list in
Table 1
Or
Infection occurs within 90 days after the NHSN operative procedure according to the list in
Table 2
And
Involve deep soft tissues of the incision (e.g., fascial and muscle layers)
And
Patient has at least one of the following:
a. purulent drainage from the deep incision
21
b. a deep incision that spontaneously dehisces or is deliberately opened by a surgeon and
is culture-positive or not cultured
And
Patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or
tenderness. A culture-negative finding does not meet this criterion.
c. an abscess or other evidence of infection involving the deep incision is found on direct
examination, during invasive procedure, or by histopathologic examination or imaging test.
d. diagnosis of a deep incisional SSI by a surgeon or attending physician.
Table 1. 30 day Surveillance Period for Deep Incisional or Organ/Space SSI Following Selected
NHSN Operative Procedure Categories
22
30-day Surveillance
Code
Operative Procedure
Code
AAA
Abdominal aortic
aneurysm repair
Limb amputation
Appendix surgery
Shunt for dialysis
Bile duct, liver or
pancreatic surgery
Carotid
endarterectomy
Gallbladder surgery
Colon surgery
Cesarean section
Gastric surgery
Heart transplant
LAM
Operative
Procedure
Laminectomy
LTP
NECK
NEPH
OVRY
Liver transplant
Neck surgery
Kidney surgery
Ovarian surgery
PRST
Prostate surgery
REC
SB
SPLE
THOR
THYR
Abdominal
hysterectomy
Kidney transplant
VHYS
Rectal surgery
Small bowel surgery
Spleen surgery
Thoracic surgery
Thyroid and/or
parathyroid surgery
Vaginal
hysterectomy
Exploratory
laparotomy
Other operative
procedures not
included in the
NHSN categories
AMP
APPY
AVSD
BILI
CEA
CHOL
COLO
CSEC
GAST
HTP
HYST
KTP
XLAP
OTH
Table 2. 90 day Surveillance Period for Deep Incisional or Organ/Space SSI Following Selected
NHSN Operative Procedure Categories
23
90-day Surveillance
Code
BRST
CARD
CBGB
CBGC
CRAN
FUSN
FX
HER
HPRO
KPRO
PACE
PVBY
RFUSN
VSHN
Operative Procedure
Breast surgery
Cardiac surgery
Coronary artery bypass graft with both chest and donor site incisions
Coronary artery bypass graft with chest incision only
Craniotomy
Spinal fusion
Open reduction of fracture
Herniorrhaphy
Hip prosthesis
Knee prosthesis
Pacemaker surgery
Peripheral vascular bypass surgery
Refusion of spine
Ventricular shunt
INFECTION SITE: Surgical site infection (organ/space)
CODE: SSI-(Specify site of organ/space)
24
DEFINITION: An organ/space SSI involves any part of the body, excluding the skin incision,
fascia, or muscle layers, that is opened or manipulated during the operative procedure.
An organ/space SSI must meet the following criterion:
Infection occurs within 30 days after the NHSN operative procedure according to the list in
Table 1
Or
Infection occurs within 90 days after the NHSN operative procedure according to the list in
Table 2
And
Infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that
is opened or manipulated during the operative procedure
And
Patient has at least 1 of the following:
a. purulent drainage from a drain that is placed into the organ/space
b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space
c. an abscess or other evidence of infection involving the organ/space that is found on direct
examination, during invasive procedure, or by histopathologic examination or imaging test
d. diagnosis of an organ/space SSI by a surgeon or attending physician.
And
meets at least one criterion for a specific organ/space infection site listed in Table 3.
Table 3. Specific Site of Organ/Space SSI
25
Code
BONE
BRST
Site
Osteomyelitis
Breast abscess or mastitis
Code
JNT
LUNG
CARD
DISC
EAR
Myocarditis or pericarditis
Disc space
Ear, mastoid
MED
MEN
ORAL
EMET
Endometritis
OREP
ENDO
Endocarditis
OUTI
EYE
Eye, other than
conjunctivitis
GI tract
Hepatitis
Intraabdominal, not
specified elsewhere
Intracranial, brain abscess
or dura
SA
GIT
HEP
IAB
IC
SINU
UR
VASC
Site
Joint or bursa
Other infections of the
respiratory tract
Mediastinitis
Meningitis or ventriculitis
Oral cavity (mouth, tongue,
or gums)
Other infections of the
male or female
reproductive tract
Other infections of the
urinary tract
Spinal abscess without
meningitis
Sinusitis
Upper respiratory tract
Arterial or venous infection
VCUF
Vaginal cuff
Wound class
An assessment of the degree of contamination of a surgical wound at the time of the operation.
Wound class should be assigned by a person involved in the surgical procedure, e.g., surgeon,
circulating nurse, etc. The wound class system used in NHSN is an adaptation of the American
College of Surgeons wound classification schema. Wounds are divided into four classes:
1. Clean
An uninfected operative wound in which no inflammation is encountered and the respiratory,
alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are
primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds
that follow nonpenetrating (blunt) trauma should be included in this category if they meet the
criteria.
NOTE:
26
The following NHSN operative procedure categories are NEVER considered to have a clean
wound classification: APPY, BILI, CHOL, COLO, REC, SB, and VHYS.
2. Clean Contaminated
An operative wounds in which the respiratory, alimentary, genital or urinary tracts are entered
under controlled conditions and without unusual contamination. Specifically, operations
involving the biliary tract, appendix, vagina, and oropharynx are included in this category,
provided no evidence of infection or major break in technique is encountered. Includes female
and male reproductive tracts.
3. Contaminated
Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique
(e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in
which acute, nonpurulent inflammation is encountered are included in this category.
4. Dirty or Infected
Includes old traumatic wounds with retained devitalized tissue and those that involve existing
clinical infection or perforated viscera. This definition suggests that the organisms causing
postoperative infection were present in the operative field before the operation
INFECTION SITE: Pneumonia
CODE: PNEU
DEFINITION:
1. Clinically-defined pneumonia which must fulfill the following criteria:
Radiology
Signs/Symptoms/Laboratory
Two or more serial
FOR ANY PATIENT, at least one of the following:
chest radiographs with • Fever (>38°C)
at least one of the
• Leukopenia (<4000 WBC/mm3) or leukocytosis (≥12,000 WBC/mm3)
following:
• For adults ≥70 years old, altered mental status with no other
• New or progressive
recognized cause
and persistent
infiltrate
and
at least two of the following:
• Consolidation
• New onset of purulent sputum, or change in character of sputum, or
increased respiratory secretions, or increased suctioning requirements
• Cavitation
• New onset or worsening cough, or dyspnea, or tachypnea
27
• Pneumatoceles, in
infants ≤1 year old
NOTE: In patients
without underlying
pulmonary or cardiac
disease (e.g.,
respiratory distress
syndrome,
bronchopulmonary
dysplasia, pulmonary
edema, or chronic
obstructive pulmonary
disease), one
definitive chest
radiograph is
acceptable.1
• Rales or bronchial breath sounds
• Worsening gas exchange (e.g., O2 desaturations (e.g., PaO2/FiO2
≤240)7, increased oxygen requirements, or increased ventilator
demand)
ALTERNATE CRITERIA, for infants <1 year old:
Worsening gas exchange (e.g., O2 desaturations [e.g., pulse oximetry
<94%], increased oxygen requirements, or increased ventilator
demand)
and
at least three of the following:
• Temperature instability
• Leukopenia (<4000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3)
and left shift (≥10% band forms)
• New onset of purulent sputum or change in character of sputum4, or
increased respiratory secretions or increased suctioning requirements
• Apnea, tachypnea , nasal flaring with retraction of chest wall or
grunting
• Wheezing, rales, or rhonchi
• Cough
• Bradycardia (<100 beats/min) or tachycardia (>170 beats/min)
ALTERNATE CRITERIA, for child >1 year old or ≤12 years old, at least
three of the following:
• Fever (>38.4°C) or hypothermia (<36.5°C)
• Leukopenia (<4000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3)
• New onset of purulent sputum, or change in character of sputum, or
increased respiratory secretions, or increased suctioning requirements
• New onset or worsening cough, or dyspnea, apnea, or tachypnea.
• Rales or bronchial breath sounds
• Worsening gas exchange (e.g., O2 desaturations [e.g., pulse oximetry
<94%], increased oxygen requirements, or increased ventilator
demand)
28
2. Specific Site Algorithms for Pneumonia with Common Bacterial or Filamentous
Fungal Pathogens and Specific Laboratory Findings (PNU2)
Radiology
Signs/Symptoms
Laboratory
Two or more serial chest
radiographs with at least one
of the following1,2:
 New or progressive and
persistent infiltrate
At least one of the following:
 Fever (>38°C or >100.4°F)
 Leukopenia (<4000
WBC/mm3) or
leukocytosis (≥12,000
WBC/mm3)
 For adults ≥70 years old,
altered mental status with
no other recognized cause
At least one of the following:
• Positive growth in blood
culture8 not related to
another source of
infection

Consolidation

Cavitation

Pneumatoceles, in infants
≤1 year old
NOTE: In patients without
underlying pulmonary or
cardiac disease (e.g.,
respiratory distress syndrome,
bronchopulmonary dysplasia,
pulmonary edema, or chronic
obstructive pulmonary
disease), one definitive chest
radiograph is acceptable.1
and
at least one of the following:
 New onset of purulent
sputum3, or change in
character of sputum4, or
increased respiratory
secretions, or increased
suctioning requirements
 New onset or worsening
cough, or dyspnea or
tachypnea5
 Rales6 or bronchial breath
sounds
 Worsening gas exchange
(e.g., O2 desaturations
[e.g., PaO2/FiO2 ≤240]7,

increased oxygen
requirements, or
increased ventilator
demand)


•
Positive growth in culture
of pleural fluid
•
Positive quantitative
culture9 from minimally
contaminated LRT
specimen (e.g., BAL or
protected specimen
brushing)
•
≥5% BAL-obtained cells
contain intracellular
bacteria on direct
microscopic exam (e.g.,
Gram’s stain)
•
Histopathologic exam
shows at least one of the
following evidences of
pneumonia:
Abscess formation or foci of
consolidation with intense
PMN accumulation in
bronchioles and alveoli
Positive quantitative culture9
of lung parenchyma
Evidence of lung parenchyma
invasion by fungal hyphae or
pseudohyphae
29
Table 4. Threshold Values for Cultured Specimens Used in the Pneumonia Criteria
Specimen collection/technique
Values
Lung parenchyma*
≥104 CFU/g tissue
Bronchoscopically (B) obtained specimens
Bronchoalveolar lavage (B-BAL)
≥104 CFU/ml
Protected BAL (B-PBAL)
≥104 CFU/ml
Protected specimen brushing (B-PSB)
≥103 CFU/ml
Nonbronchoscopically (NB) obtained (blind) specimens
NB-BAL
>104 CFU/ml
NB-PSB
≥103 CFU/ml
CFU = colony forming units
g = gram
ml = milliliter
* Open-lung biopsy specimens and immediate post-mortem specimens obtained by
transthoracic or transbronchial biopsy
INFECTION SITE: Ventilator-associated PNEU (VAP)
CODE: VAP
DEFINITION:
A pneumonia where the patient is on mechanical ventilation for >48 hours on the date of event,
with day of ventilator placement being Day 1,
and
the ventilator was in place on the date of event or the day before. If the patient is admitted or
transferred into a facility on a ventilator, the day of admission is considered Day1.
and
Fulfill either Criteria in Table 1 or 2
30
Ventilator:
A device to assist or control respiration continuously, inclusive of the weaning period, through
a tracheostomy or by endotracheal intubation.
NOTE:
Lung expansion devices such as intermittent positive-pressure breathing (IPPB); nasal positive
end-expiratory pressure (PEEP); and continuous nasal positive airway pressure (CPAP,
hypoCPAP) are not considered ventilators unless delivered via tracheostomy or endotracheal
intubation (e.g., ET-CPAP).
31
INFECTION SITE: Laboratory-confirmed bloodstream infection (LCBI)
CODE: BSI
DEFINITION: Laboratory-confirmed bloodstream infection must meet at least one of the
following criteria:
Criterion Description
LCBI 1
Patient has a recognized pathogen cultured from one or more blood cultures
And
LCBI 2
organism cultured from blood is not related to an infection at another site.
Patient has at least one of the following signs or symptoms: fever (>38°C), chills*, or
hypotension*
And
positive laboratory results are not related to an infection at another site
And
LCBI 3
common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae],
Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulase-negative
staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus
spp., and Micrococcus spp.) is cultured from two or more blood cultures drawn on
separate occasions. Criterion elements must occur within a timeframe that does not
exceed a gap of 1 calendar day
*With no other recognized cause
Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever
(>38oC core) hypothermia (<36°C core), apnea*, or bradycardia*
And
positive laboratory results are not related to an infection at another site
And
common skin commensal (i.e., diphtheroids [Corynebacterium spp. not C.
diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulasenegative staphylococci [including S. epidermidis], viridans group streptococci,
Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures
drawn on separate occasions. Criterion elements must occur within a timeframe
that does not exceed a gap of 1 calendar day
*With no other recognized cause
32
INFECTION SITE: Catheter Associated Blood Stream Infection (CABSI)
CODE: CABSI
DEFINITION:
A laboratory-confirmed bloodstream infection where a catheter either central or peripheral
was in place for >48 hours on the date of event, with day of device placement being Day 1.
and
a central or peripheral catheter was in place on the date of event or the day before. If a
catheter was in place for >48 hours and then removed, the LCBI criteria must be fully met on
the day of discontinuation or the next day. If the patient is admitted or transferred into a
facility with a central line in place (e.g., tunneled or implanted central line), day of first access is
considered Day 1.
EXAMPLES:
• Patient in ICU has central line inserted/accessed on June 1. On June 3, the central line is still in
place and the patient has positive blood culture with S. aureus. This is a CLABSI because the
central line was in place for >2 calendar days when all elements of LCBI Criterion 1 were first
present together (date of event).
• Patient has a central line inserted on June 1. On June 3, the central line is removed and on
June 4 the patient has a positive blood culture with S. aureus. This is a CLABSI because the
central line was in place for >2 calendar days (June 1, 2, and 3) and was in place the day before
all elements of LCBI Criterion 1 were first present together (date of event).
• On June 3, central line is removed and on June 4 patient spikes a fever of 38.3°C. Two blood
culture sets collected on June 5 are positive for S. epidermidis. This is may be a healthcareassociated bloodstream infection but it is not a CLABSI because the central line was not place
the day of or the day before all elements of LCBI Criterion 2 were first present together (June
5).
LABORATORY DIAGNOSIS
1. For suspected CRBSI, paired blood samples, drawn from the catheter and a peripheral
vein, should be cultured before initiation of antimicrobial therapy, and the bottles
33
should be appropriately marked to reflect the site from which the samples were
obtained
2. If a blood sample cannot be drawn from a peripheral vein, it is recommended that 2
blood samples should be drawn through different catheter lumens. It is unclear whether
blood cultures should be drawn through all catheter lumens in such circumstances.
3. A definitive diagnosis of CRBSI requires that the same organism grow from at least 1
percutaneous blood culture and from a culture of the catheter tip, or that 2 blood
samples be drawn (one from a catheter hub and the other from a peripheral vein) that,
when cultured, meet CRBSI criteria for quantitative blood cultures or differential time to
positivity (DTP).
4. Alternatively 2 quantitative blood cultures of samples obtained through 2 catheter
lumens in which the colony count for the blood sample drawn through one lumen is at
least 3-fold greater than the colony count for the blood sample obtained from the
second lumen should be considered to indicate possible CRBSI
5. For DTP, growth of microbes from a blood sample drawn from a catheter hub at least 2
h before microbial growth is detected in a blood sample obtained from a peripheral vein
best defines CRBSI
6. For quantitative blood cultures, a colony count of microbes grown from blood obtained
through the catheter hub that is at least 3-fold greater than the colony count from
blood obtained from a peripheral vein best defines CRBSI.
7. Catheter cultures should be performed when a catheter is removed for suspected
catheter-related bloodstream infection (CRBSI. For central venous catheters (CVCs), the
catheter tip should be cultured.
8. Growth of >15 colony-forming units (cfu) from a 5-cm segment of the catheter tip by
semiquantitative (roll plate) culture or >102 cfu from a catheter by quantitative
(sonication) broth culture reflects catheter colonization
34
Central line:
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.
The following are considered great vessels for the purpose of reporting CLABSI or CABSI
• Aorta
• Pulmonary artery
• Superior vena cava
• Inferior vena cava
• Brachiocephalic veins
• Internal jugular veins
• Subclavian veins
• External iliac veins
• Common iliac veins
• Femoral veins
• In neonates, the umbilical artery/vein.
NOTES:
1. 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 the great vessels or in or
near the heart and be used for one of the purposes outlined above, to qualify as a
central line.
2. An introducer is considered an intravascular catheter, and depending on the location of
its tip and use, may be a central line.
3. Pacemaker wires and other nonlumened 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.
4. The following devices ARE NOT considered central lines:
• Extracorporeal membrane oxygenation (ECMO)
35
• Femoral arterial catheters
• Intraaortic balloon pump (IABP) 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, IV antimicrobial administration, or blood transfusion or hemodialysis.
Umbilical catheter: A central vascular device inserted through the umbilical artery or vein in a
neonate.
Temporary central line: A non-tunneled or implanted catheter.
Permanent central line: Includes
• Tunneled catheters, including certain dialysis catheters
• Implanted catheters (including ports)
INFECTION SITE: Clinical Sepsis
CODE: CS
DEFINITION:
Infection involving multiple organs or systems, without an apparent single site of infection in
adults and children in which the patient has at least one of the following criteria:
− clinical signs or symptoms with no other recognised cause;
− fever (38 °C);
− hypotension (systolic pressure < 90 mm);
− or oliguria (20 cm3(ml)/hr);
And
− blood culture not done or no organisms or antigen detected in blood;
And
− no apparent infection at another site;
And
36
− Physician institutes treatment for sepsis.
Clinical sepsis in neonates
All of the three following criteria:
• supervising physician started appropriate antimicrobial therapy for sepsis for at least five
days;
• no detection of pathogens in blood culture or not tested;
• no obvious infection at another site;
And
two of the following criteria (without other apparent cause):
− fever (> 38 °C) or temperature instability (frequent post-set of the incubator) or hypothermia
(< 36.5°C);
− tachycardia (> 200/min) or new /increased bradycardia (< 80/min);
− capillary refilling time (CRT) > 2s;
− new or increased apnoea(s) (> 20s);
− unexplained metabolic acidosis;
− new-onset hyperglycemia (> 140mg/dl);
− another sign of sepsis (skin colour (only if the CRT is not used), laboratory signs (CRP,
interleukin) and increased oxygen requirement (intubation), unstable general condition of the
patient, apathy)
37
APPENDIX 2
Healthcare Associated Infection Surveillance Form
(HCAI-PPS/MOH/2013/1)
A. CASE IDENTIFICATION DATA
Name : _______________________________
I/C or Passport No: ______________________ RN :___________________________________
Gender : Male/ Female
Age: _____
Hospital :______________________________
Department : ___________________________
Ward:_________________________________ Date of Admission:_______________________
B. CLINICAL DATA
i. Clinical Diagnosis
____________________________________________________________________
ii. General predisposing risk factors [√ where appropriate]
a. Underlying disease (eg; Diabetes/ Malignancy/ Kidney Disease)
Specify
b. Immunosuppressive therapy
c. Prolonged hospitalization > 2 weeks
d. Prematurity / Low Birth Weight
e. Surgery within 1 month / 1 year (with implant)
f. Others
Specify
38
iii. Type of devices used before the onset of HCAI [ √ where appropriate ]
Device
Date of insertion
a. Indwelling urinary catheter
_________________
b. Mechanical ventilator
_________________
c. Tracheostomy
_________________
d. Central venous catheter
_________________
e. Arterial line
_________________
f. Peripheral venous line
_________________
g. Other drainage catheters
_________________
Specify……………………………………………………
iv. Antibiotic therapy given in the past 2 weeks [ √ where appropriate ]
Prophylaxis
Name and Group of
Antibiotic
Therapeutic
No.
Empirical
Indication
Date
commenced
Route of
admission
Duration
(days)
Meet
local
policy
(Y/N/NK)*
* Y-YES, N-NO, NK-Not known
C. MICROBIOLOGICAL DATA (Please attach the relevant positive C&S report)
Date of
collection
Date of
lab report
Type of
specimen
Organism
isolated
Antibiotic susceptibility
report
39
D. OUTCOME DATA [ √ where appropriate ]
Type of infection
Method of detection
Clinical
Laboratory
1. Surgical site infection (SSI)
Type of SSI
a. Superficial incisional
b. Deep incisional
c. Organ or space
Type of SSI wound
a. Clean wound
b. Clean contaminated wound
c. Contaminated wound
d. Dirty wound
2. Urinary tract infection
3. Pneumonia
a. Hospital acquired pneumonia (other than VAP)
b. Ventilator associated pneumonia (VAP)
4. Blood stream infection
a. Blood stream infection (other than CABSI)
b. Catheter associated blood stream infection
(CABSI)
5. Clinical sepsis
6. Others
Specify ………………………………………………………
Reported by:
Signature: ________________________
Name and Designation:_____________________
Date: ____________________________
40
APPENDIX 3
41
42
43
APPENDIX 4
44
Device
No. of Patient
Percentage
a. Indwelling urinary catheter
#DIV/0!
b. Mechanical ventilator
#DIV/0!
c. Tracheostomy
#DIV/0!
d. Central venous catheter
#DIV/0!
e. Arterial line
#DIV/0!
f. Peripheral venous line
#DIV/0!
g. Other drainage catheters
#DIV/0!
Antibiotic Therapy
No. of Patient
Percentage
1. Group of Antibiotic
a. Aminoglycosides
#DIV/0!
b. Carbapenems
#DIV/0!
c. Cephalosporins
#DIV/0!
d. Penicillins
#DIV/0!
e. Vancomycin
#DIV/0!
f. B-lactam/B-lactamase inhibitor
#DIV/0!
g. Fluoroquinolones
#DIV/0!
2. Indication of Antibiotic
a. Empirical
#DIV/0!
b. Therapeutic
#DIV/0!
c. Prophylaxis
#DIV/0!
3. Duration of Antibiotic
a. Less than 3 days
#DIV/0!
b. 3 to 7 days
#DIV/0!
c. More than 3 days
#DIV/0!
4. Meet Local policy
#DIV/0!
a. Yes
#DIV/0!
b. No
#DIV/0!
c. Not known
#DIV/0!
45
Organism isolated
No. of Patient
Percentage
MRSA
#DIV/0!
Staph. aureus
#DIV/0!
P.Aeruginosa - MRO
#DIV/0!
P.Aeruginosa - Non MRO
#DIV/0!
K.Pneumo - ESBL
#DIV/0!
K.Pneumo - Non ESBL
#DIV/0!
E.coli - ESBL
#DIV/0!
E.coli - Non ESBL
#DIV/0!
CON Staph
#DIV/0!
Acineto spp- MRO
#DIV/0!
Acineto spp- Non MRO
#DIV/0!
Enterobac gp
#DIV/0!
CRE
#DIV/0!
Others
#DIV/0!
HCAI Rate for the Hospital
=
______________No. of Patient with HCAI ___________ x 100
No. of patient in the Hospital on the Day of Survey
=
#VALUE!
Reported by:
Verified by:
Signature: ______________________________
Signature: _________________________________
Name and Designation:___________________
Name and Designation: ______________________
Date:___________________________________
Date:______________________________________
46
APPENDIX 5
47
References
1. Mermel LA et al. Clinical Practice Guidelines for the Diagnosis and Management of
Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases
Society of America: Clinical Infectious Diseases 2009; 49:1–45
2. Van der Kooi TII et al. Prevalence of nosocomial infections in The Netherlands, 20072008: results of the first four national studies. Journal of Hospital Infection 75 (2010)
168-172
3. Gravel D et al. Point prevalence survey for healthcare-associated infections within
Canadian adult acute-care hospitals. Journal of Hospital Infection 67 (2007) 243-248
4. European Centre for Disease Prevention and Control. Point prevalence survey of
healthcareassociated infections and antimicrobial use in European acute care
hospitals – protocol version 4.3. Stockholm: ECDC; 2012
5. CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for
Specific Types of Infections in the Acute Care Setting, January 2013
6. July 2013 CDC/NHSN Protocol Clarifications
7. Fourth National Point Prevalence Survey on Healthcare Associated Infections and
First National Point Prevalence Survey on Antimicrobial Use and Quality Indicators in
England July 2011
48