McGeer Criteria: An Update

1 1/18/20131 McGeer criteria : An UpdateMcGeer criteria : An UpdateSuzanne F. Bradley, F. Bradley, of Internal MedicineProfessor of Internal MedicineInfectious Diseases & GeriatricsInfectious Diseases & GeriatricsUniversity of Michigan Medical SchoolUniversity of Michigan Medical SchoolStone ND et al. ICHE 2012;33:965 Stone ND et al. ICHE 2012;33 CriteriaMcGeer CriteriaBackgroundBackground Consensus discussions Multidisciplinary team Unstructured literature review Based on NNIS definitionsMcGeer A et al. AJIC 1991; 19 CriteriaMcGeer CriteriaTarget PopulationTarget Population Older Adults Skilled nursing care Assistance activities daily living (ADLs) Supervision cognitively impaired Therapeutic options (IVs) limited Onsite diagnostics uncommonMcGeer A et al. AJIC 1991; 19 Revise, Why Now?Why Revise, Why Now?RationaleRationale Increase evidence-based literature Improved diagnostics for surveillance Changing pt populations in this setting Updated NHSN hospital definitions.

2 HICPAC method/structured review done Grading not performedLTCF CriteriaGuiding Principles Infection surveillance only Highly specific Applied retrospectively Focus on transmissible/preventable inf. Not for case finding Not for diagnostic purposes Not for clinical decision making1/18/20134 LTCF Surveillance DefinitionsLTCF Surveillance DefinitionsAll Conditions Must Be MetAll Conditions Must Be Met All symptoms must be new or acutely worse Alternative non-infectious causes of signs and symptoms should be considered first No infection can be based on a single piece of evidence Dx by a physician insufficientLTCF Surveillance ProgramsLTCF Surveillance ProgramsWhat to Include?What to Include?Points to consider InfectionsCommentsA. Infections which should not be routinely included in surveillanceLimited 1. Transmissibility2. PreventabilityEar, sinus, oral infections, fungal or viral (herpetic) skin infectionsRarely transmittedAssociated co-morbid conditionsAt Risk PopulationsPost-op, CLABSI, VAPNHSN definitionsB.

3 Infections that should be routinely included in surveillance1. Transmission evident2. Prevention possibleILI, C. difficile,viral gastroenteritis & conjunctivitisAssociated outbreaks in patients & HCW3. Significant clinicallyLRTI, UTI, SSTIs,pressure ulcersAssociated morbidity & hospitalizations4. Serious outbreaksGr A Strep, scabies, flu, viral hepatitis, norovirusRare, highly contagious1/18/20135 Surveillance in LTCFS urveillance in LTCFR evised Signs and SymptomsRevised Signs and SymptomsA. Fever1. Oral single > C [>100 F] or2. Oral repeated > C [99 F] or3. Any site* > C (2 F) over baselineB. Leukocytosis (New!)1. Leukocytosis > 14,000 wbc/mm3or2. Left shift (>6% bands or >1500 bands/mm3)High K et al. Clin Infect Dis 2009;48:149-171 Surveillance in LTCFS urveillance in LTCFP roposed New Signs and SymptomsProposed New Signs and Assessment Method - MS change from baseline 1. acute onset and fluctuating course2.

4 Inattention AND3. Eitherdisorganized thought oraltered level of consciousness D. Acute functional decline1. New 3 point increase in total ADL score a. 0-4 points per activityb. 0-28 points per total score2. Activitiesbed mobility, transfers, locomotion, dressing, eatingtoileting, personal hygieneInouye SK et al. Ann Intern Med 1990;113:941, Minimum Data Set 1 What are statements meet constitutional criteria ? resident must have a temperature > 101 resident doesn t seem to be herself hasn t been ambulatory for 3 of the aboveRevised McGeer CriteriaRevised McGeer CriteriaDefinitions Not ChangedDefinitions Not ChangedLimited evidence to change definitions for: Conjunctivitis Ear Infections Sinusitis Cold syndromes/pharyngitis Cellulitis Gastroenteritis Systemic infections Unexplained febrile episode1/18/20137 InfluenzaInfluenza--Like IllnessLike IllnessProposed Revised DefinitionProposed Revised DefinitionBothof the following criteria must be met:1.

5 Or morenew or increasing signs or sxa) chillsb) headache or eye painc) myalgiasd) malaise or anorexiae) sore throatf) dry coughRemoved stipulation that Dxcan only be made during flu season PneumoniaPneumoniaProposed Revised DefinitionProposed Revised DefinitionAllof the following criteria must be positivefor:a) pneumonia or new or moreresp S/Sa) cough new/increasedb) sputum new/increasedc) 02 sat < 94% or reduced 3% from baselined) abnl lung exam new or changede) pleuritic chest painf) RR > 25 or moreconstitutional S/SAbsence of other conditions such as CHF that could account for symptomsLim WS et al. Eur Respir J 2001;18 (Bronchitis, Tracheitis)LRTI (Bronchitis, Tracheitis)Proposed Revised DefinitionProposed Revised DefinitionAllof the following criteria must be not done or negativefor:a) pneumonia or new or moreresp S/Sa) cough new/increasedb) sputum new/increasedc) 02 sat < 94% or reduced 3% from baselined) abnl lung exam new or changede) pleuritic chest painf) RR > 25 S/SAbsence of other conditions such as CHF that could account for symptomsQuestion 2 What statements meet criteria for ILI o respiratory tract infection?

6 1. Influenza can be diagnosed any time2. Pneumonia requires an abnormal CXR3. Pneumonia and LRTI criteria cannot be met if other conditions are present that can account for findings4. All of the above. 1/18/20139 UTI (No Catheter)UTI (No Catheter)Proposed Revised DefinitionProposed Revised Definition1. AnyOneof the following:a) Acute dysuria ORacute pain/swelling testes, epididymis, or prostateb) Fever ORWBC AND One or moreof the following: CVA or SP pain/tendernessgross hematurianew or marked increase:frequency, urgency, incontinencec)Two or more new or increased:frequency, urgency,incontinence, SP pain, new gross hematuriaAND UTI (No Catheter)UTI (No Catheter)Proposed Revised Definition (2)Proposed Revised Definition (2)2. Voided urine culture witha) >105cfu/ml any bug (s)UTI = Localizing S/S &urine culture (+)If no localizing S/S, UTI Dx made if:blood + & urine same bugwithout alternate sourcePyruria does NOTdifferentiate Sx UTI from ASBA bsence of pyuria excludesUTI DxIn the absence of a clear source, fever or rigors with a positive urine culture are often treated.

7 Evidence suggests that most episodes are NOTfrom a urinary M et al. Br Med J 2006;351 (Catheter*)UTI (Catheter*)Proposed Revised DefinitionProposed Revised Definition1. AnyOne of the following:a) Fever, rigors, ORnew onset hypotension with NOalternate site of infectionb)Eitheracute change MS OR acute functional decline with NOalternate diagnosis ANDWBCc)Newonset SP or CVA paind) Purulent discharge around catheter or acute pain, swelling, tenderness testes, epididymis, or prostateAND2. Urine has >105 cfu/ml of any organism(s). Obtained after catheter replaced if in > 14 days* Chronic indwelling cathetersIn the absence of a clear source, acute confusion in a patient with a catheter and a positive urine culture are often treated, but evidence suggests that most episodes are NOTfrom a urinary catheter trauma, obstruction,or new onset hematuria are useful localizing signs consistent with UTI, but not necessary for diagnosis.

8 Question 3 A resident without a catheter meets criteria for UTI present when UA shows pyuria & bacteriuria and:1. No symptoms are present2. One new or worsening non-focal S/S is present without fever or leukocytosis3. Two new or worsening non-focal S/S are present without fever or leukocytosis4. All of the above1/18/201311 Question 4 What is true in the resident with a catheter and UA shows pyuria & bacteriuria:1. UTI can be present with no S/S2. If in place for more than 2 wks, the catheter should be changed before culture is obtained. 3. UTI criteria are met if leukocytosis and new change in MS or function without alternative source4. 2 and 3 are trueCellulitis/Soft Tissue/Wound InfectionCellulitis/Soft Tissue/Wound InfectionProposed Revised DefinitionProposed Revised DefinitionOneof the following criteria present at a wound, skin, or soft tissue or more new or increasingsigns or sx at the sitea) heatb) rednessc) swellingd) tenderness or paine) serous drainagef)one constitutional S/SOne or more beta hemolyticstreptococcal infections may suggest an outbreakUse NHSN SSI criteriaSuperficial cultures of pressure ulcers are not sufficient for the diagnosis of infection1/18/201312 ScabiesScabiesProposed Revised DefinitionProposed Revised DefinitionBoth of the following criteria maculopapular and/or itching the following.

9 A) physician diagnosisb) scraping or biopsy +ORc) epidemiological linkage to acase of scabies with lab confirmationRule out non-infectiousskinconditions such as eczema,allergyand = common sourceexposure, temporally-relatedonset, & geographic proximityto the facility Fungal Oral/Perioral/Skin InfectionsFungal Oral/Perioral/Skin InfectionsProposed Revised DefinitionProposed Revised candidiasisBoth of the following criteria met:a) presence of raised white patches on inflamed mucosa ORplaques on oral mucosaANDb) medical ORdental infectiona) characteristic rash ORskin lesionsANDb) either medical provider dx OR lab confirmed smear, culture ORbxMucocutaneous candida infectionsare due to co-morbidconditions orantibiotic fungal infections rare & outbreaks Viral Skin InfectionsHerpes Viral Skin InfectionsCurrent Definition Current Definition simplexBoth of the following criteria met:a) vesicular rashANDb) either physician dx ORlab zosterBothof the following criteria met:a) vesicular rashANDb) either physician dx ORlab confirmationReactivation of H.

10 Simplex and H. zoster NOTconsidered an HAIP rimary herpes viral skin infections uncommonQuestion 5 criteria for cellulitis/SSI in a leg is met when the resident has:1. A chronic ulcer with redness, pain, swelling, and drainage for 2 months2. A incision is opened and pus is found3. New onset of redness, fever, pain, and swelling without hx burn or clot4. Both 2 and 3 are true1/18/201314 Question 6 What statements of fungal and viral skin infections are true?1. Fungi are generally endogenous infections worsened by co-morbid conditions, antibiotics, or steroids2. Most herpetic lesions are due to reactivation of remote infections3. Transmission to other residents or HCW is unusual4. All of the Definition Current Definition -- UnchangedUnchangedOnecriteria must be or moreloose or watery stools above pt baseline in 24 or moreepisodes of vomiting in 24 hrs the following1. Stool specimen + for bacterial or viral pathogenAND1.