Dasar diagnostik BSI & VAP

Bambang Wahjuprajitno
Dept. of Anesthesiology & Reanimation
Faculty of Medicine - Univ. of Airlangga
ICU - Dr. Soetomo General Hospital
Surabaya - INDONESIA
E-mail: wprano@yahoo.com

Laboratory-Confirmed
Bloodstream Infection (LCBI 1)
 Laboratory-Confirmed Bloodstream Infection
(LCBI 1)

• Patient has a recognized pathogen cultured from

one or more blood cultures
and
• organism cultured from blood is not related to an
infection at another site

Laboratory-Confirmed Bloodstream Infection

(LCBI 2)
• 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
• the same 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 (see comment 3a below). Criterion elements
must occur within a timeframe that does not exceed a gap of 1
calendar day between two adjacent elements.

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 Laboratory-Confirmed Bloodstream Infection
(LCBI 3)
• Patient ≤ 1 year of age has at least one of the following signs or symptoms:
fever (>38oC core), hypothermia (<36o C core), apnea, or bradycardia
and
• positive laboratory results are not related to an infection at another site
and
• the same 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., Micrococcus spp.) is cultured from
two or more blood cultures drawn on the same or consecutive days and
separate occasions (see Comment 3a below). Criterion elements must
occur within a timeframe that does not exceed a gap of 1 calendar day
between two adjacent elements

Mucosal Barrier Injury Laboratory-Confirmed

Bloodstream Infection (MBI-LCBI)

Untuk:
• Allogeneic hematopoietic stem cell transplant recipient
• Pasien dengan neutropenia

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 Petunjuk Pelaporan

1. Report organisms cultured from blood as BSI–LCBI

when no other site of infection is evident
2. Catheter tip cultures are not used to determine
whether a patient has a primary BSI
3. Purulent phlebitis confirmed with a positive
semiquantitative culture of a catheter tip, but with
either negative or no blood culture is considered a
CVS-VASC, not a BSI, SST-SKIN, or a ST infection

Petunjuk Pelaporan
4. Occasionally a patient with both peripheral and central IV
lines develops a primary bloodstream infection (LCBI) that
can clearly be attributed to the peripheral line (e.g., pus at
the insertion site and/or matching pathogen from pus and
blood). In this situation, enter “Central Line = No” in the NHSN
application. You should, however, include the patient’s
central line days in the summary denominator count
5. If your state or facility requires that you report healthcare-
associated BSIs that are not central line-associated, enter
“Central Line = No” in the NHSN application when reporting
these BSIs. You should, however, include all of the patient’s
central line days in the summary denominator count
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 Central Line-Associated
Bloodstream Infection (CLABSI)
Event

Central line-associated BSI (CLABSI)

• A laboratory-confirmed bloodstream infection (LCBI) where
central line (CL) or umbilical catheter (UC) was in place for >2
calendar days on the date of event, with day of device
placement being Day 1,
and
• a CL or UC was in place on the date of event or the day before. If
a CL or UC was in place for >2 calendar days and then removed,
the 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), and that is the patient’s only central line, day of first
access as an inpatient is considered Day1.
“Access” is defined as line placement, infusion or withdrawal through the line
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 Pneumonia

Pneumonia

• Pneumonia (PNEU) is identified by using a

combination of criteria:
• radiologic,
• clinical and
• laboratory

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 Pneumonia:
Radiologic Criteria
• Two or more serial chest radiographs with at least one
of the following:
• New or progressive and persistent infiltrate
• 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

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Clinically Defined Pneumonia:

Signs/Symptoms/Laboratory
For ANY PATIENT, at least one of the following:
• Fever (>38°C or >100.4°F)
• Leukopenia (<4000 WBC/mm ) or leukocytosis (>12,000 WBC/mm )
3 3

• For adults >70 years old, altered mental status with no other recognized cause
and
at least two of the following:
• 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, or tachypnea
• Rales or bronchial breath sounds
• Worsening gas exchange (e.g., O desaturations (e.g., PaO /FiO
2 2 2 <240),
increased oxygen requirements, or increased ventilator demand)

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 Clinically Defined Pneumonia:
Signs/Symptoms/Laboratory
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 sputum, or increased respiratory
secretions or increased suctioning requirements
• Apnea, tachypnea, nasal flaring with retraction of chest wall or nasal flaring with grunting
• Wheezing, rales, or rhonchi
• Cough
• Bradycardia (<100 beats/min) or tachycardia (>170 beats/min)
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Clinically Defined Pneumonia:

Signs/Symptoms/Laboratory
ALTERNATE CRITERIA, for child >1 year old or ≤12 years old:
at least three of the following:
• Fever (>38.4°C or >101.1°F) or hypothermia (<36.5°C or <97.7°F)
• 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., O desaturations [e.g., pulse oximetry
2
<94%], increased oxygen requirements, or increased ventilator
demand)
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 Mechanical Ventilation

• 300,000 pts dapat mechanical ventilation di US setap

tahun
• Resiko penyulit dan kematian
• Penyulit-penyulit MV:
• Ventilator-associated pneumonia (VAP)
• Acute Respiratory Distress Syndrome (ARDS)
• Sepsis, pulmonary embolism, barotrauma, dan pulmonary edema
• Mortalitas: 24% pd usia 15-19 tahun sampai 60% ≥ 85
tahun

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Kompleksitas masalah VAP

• Tidak ada definisi VAP yang valid dan reliable
• Untuk identifikasi VAP memerlukan:
• Pemeriksaan CXR yang tidak akurat
• Menggantungkan pada tanda & gejala klinis spesifik
• Tehnik radiograph, interpretasi dan pelaporan bervariasi dan
subyektif
• Kriteria diagnosis Pneumonia dari NHSN: definisi multipel, kriteria
khusus untuk anak dan pasien immunokompromis
• Tidak cocok digunakan untuk laporan publik, perbandingan antar
fasilitas, dan program pay-for-reporting dan pay-for-performance

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 Catatan untuk VAE definition algorithm

• Digunakan untuk kepentingan surveillance

• Tidak untuk kegunaan pengelolaan klinis pasien
• Lokasi penggunaan:
• Lokasi perawatan dewasa di acute care hospitals
• Long term acute care hospitals
• Fasilitas rehabilitasi rawat inap dimana data denominator
(ventilator dan patient days) dapat dikumpulkan

• Termasuk disini: critical/intensive care units (ICU), specialty care

areas (SCA), step-down units, wards, dan long term care units

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Algoritme surveillance VAE

• 2011 CDC membentuk Working Group:
• Critical Care Societies Collaborative (the American Association of
Critical-Care Nurses, the American College of Chest Physicians, the
American Thoracic Society, and the Society for Critical Care Medicine)

• American Association for Respiratory Care

• Association of Professionals in Infection Control and Epidemiology
• Council of State and Territorial Epidemiologists
• Healthcare Infection Control Practices Advisory Committee’s
Surveillance Working Group

• Infectious Diseases Society of America

• Society for Healthcare Epidemiology of America
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 Algoritme

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 Kultur kuantitatif

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 Terima kasih atas perhatian anda

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