SPECIAL ARTICLE

CDC definitions for nosocomial

infections, 1988
Julia S. Garner, R.N., MN.
William R. Jan&, M.D.
T. Grace Emori, R.N., M.S.
Teresa C. Horan, M.P.H., CIC
James M. Hughes, M.D.
Atlanta, Georgia

The Centers for Disease Control (CDC) has developed a new set of definitions for
surveillance of nosocomial infections. The new definitions combine specific clinical
findings with results of laboratory and other tests that include recent advances
in diagnostic technology; they are formulated as algorithms. For certain infections
in which the clinical or laboratory manifestations are different in neonates and
infants than in older persons, specific criteria are included. The definitions include
criteria for common nosocomial infections as well as infections that occur
infrequently but have serious consequences. The definitions were introduced into
hospitals participating in the CDC National Nosocomial Infections Surveillance
System (NNIS) in 1987 and were modified based on comments from infection control
personnel in NNIS hospitals and others involved in surveillance, prevention, and
control of nosocomial infections. The definitions were implemented for surveillance
of nosocomial infections in NNIS hospitals in January 1988 and are the current
CDC definitions for nosocomial infections. Other hospitals may wish to adopt or
modify them for use in their nosocomial infections surveillance programs. (AM
J INFECT CONTROL 1988;16:128-40)

During the past two decades, the Centers for
Disease Control (CDC) has published several
sets of definitions for nosocomial infections.
The definitions used during the Comprehensive
Hospital Infections Project (CHIP) from 1969 to
1972 and in the National Nosocomial Infections
Study (NNIS) from 1970 to 1974 appeared in
the Proceedings of the First International Con-
ference on Nosocomial Infections conducted by
CDC in 1970.’ They were subsequently ex-
panded in 1974 for hospitals participating in
NNIS? Algorithms were used for diagnosing in-
fections in the Study on the Efficacy of Noso-
comial Infection Control (SENIC Project)3 in
1975-1976.
From the Hospital Infections Program, Center for Infectious
Diseases, Centers for Disease Control, Public Health Service,
US. Department of Health and Human Services.
Reprint information on p, 140.
The Hospital Infections Program, Center for
Infectious Diseases, CDC, has developed a new
set of definitions for surveillance of nosoco-
mial infections. The definitions were intro-
duced into hospitals participating in NNIS in
1987 and were modified based on comments
from infection control personnel in NNIS hos-
pitals and others involved in surveillance, pre-
vention, and control of nosocomial infections.
The definitions were implemented in NNIS hos-
pitals in January 1988 and are the current CDC
definitions for nosocomial infections.
PRINCIPLES USED IN DEFINITIONS
The definitions are based on several impor-
tant principles. First, information used to de-
termine the presence and classification of an
infection involves various combinations of clin-
ical findings and results of laboratory and other
diagnostic tests. Clinical evidence is derived
Volume 16 Number 3
June 1988 CDC definitions for nosocomial infection:;, 1988 129

from direct observation of the patient or review Fifth, except for a few situations that are re-
of information in the patient’s chart or other ferred to in the definitions, no specific time dur-
ward or unit records, for example, temperature ing or after hospitalization is given to deter-
sheet or Kardex. Laboratory evidence consists mine whether an infection is nosocomial or
of results of cultures, antigen- or antibody- community-acquired. Thus each infection must
detection tests, and microscopic visualization be assessed for evidence that links it to hospi-
methods. Supportive data are derived from talization.
other diagnostic studies, such as results of
x-ray studies, ultrasound examination, com- DEFINITIONS FOR NOSOCOMlAL
puted tomography (CT) scan, magnetic reso- INFECTIONS
nance imaging, radiolabel scans, endoscopic Definitions for surgical wound infection, pri-
procedures, biopsies, and needle aspiration. For mary bloodstream infection, pneumonia, and
infections in which clinical manifestations are urinary tract infection are presented first and
different in neonates and infants than in older are followed by other sites of infection listed
persons, specific criteria are included. alphabetically.
Second, a physician’s or surgeon’s diagnosis
of infection derived from direct observation SURGICAL WOUND INFECTION
during surgery, endoscopic examination, or Surgical wound infection includes incisional
other diagnostic study, or based on clinical surgical wound infection and deep surgical
judgment, is an acceptable criterion for an in- wound infection.
fection, unless there is compelling evidence to Incisional surgical wound infection must
the contrary (e.g., information written on the meet the following criterion: Infection occurs
wrong patient’s record or a presumptive diag- at incision site within 30 days after surgery AND
nosis that was not substantiated by subsequent involves skin, subcutaneous tissue, or muscle
studies). For infections at some sites, however, located above the fascial layer AND any of the
a physician’s clinical diagnosis in the absence following:
of supportive data must be accompanied by ini- 1. Purulent drainage from incision or drain lo-
tiation of appropriate antimicrobial therapy to cated above fascial layer
satisfy the criterion. 2. Organism isolated from culture of fluid from
Third, for an infection to be defined as nos- wound closed primarily
ocomial, there must be no evidence that the 3. Surgeon deliberately opens wound, unless
infection was present or incubating at the time wound is culture-negative
of hospital admission. An infection that occurs 4. Surgeon’s or attending physician’s diagnosis
in the following special situations is considered of infection
nosocomial: (1) infection that is acquired in the Deep surgical wound infection must meet the
hospital and becomes evident after hospital dis- following criterion: Infection occurs at opera-
charge and (2) newborn infection that is the tive site within 30 days after surgery if no im-
result of passage through the birth canal. plant” is left in place or within 1 year if implant
Fourth, infection that occurs as the result of is in place AND infection appears related to sur-
the following special situations is not consid- gery AND infection involves tissues or spaces
ered nosocomial: (1) infection that is associated at or beneath fascial layer AND any of the
with a complication or extension of infection(s) following:
already present on admission, unless a change 1. Purulent drainage from drain placed be-
in pathogen or symptoms strongly suggests neath fascial layer
the acquisition of a new infection and (2) in- 2. Wound spontaneously dehisces or is delib-
fection in an infant that is known or proved
to have been acquired transplacentally (e.g.,
*A nonhuman-derived implantable foreign body (e.g., pros-
herpes simplex, toxoplasmosis, rubella, cyto- thetic heart valve, nonhuman vascular graft, rrechanical heart,
megalovirus, and syphilis) and becomes evident or hip prosthesis) that is permanently placed ir a patient during
shortly after birth. surgery
 American Journal of
130 Gamer et al. INFECTIONCONTROL

erately opened by surgeon when patient has (~37” C), apnea, or bradycardia AND any of
fever (>38” C) and/or localized pain or ten- the following:
derness, unless wound is culture-negative a. Common skin contaminant isolated from
3. An abscess or other evidence of infection seen two blood cultures drawn on separate oc-
on direct examination, during surgery, or by casions AND organism is not related to in-
histopathologic examination fection at another site”
4. Surgeon’s diagnosis of infection b. Common skin contaminant isolated from
blood culture from patient with intravas-
PBWARY BLOODSTREAM INFECTION
cular access device AND physician insti-
Primary bloodstream infection includes tutes appropriate antimicrobial therapy
laboratory-confirmed bloodstream infection c. Positive antigen test on blood AND patho-
and clinical sepsis. The definition of clinical gen is not related to infection at another
sepsis is intended primarily for infants and site
neonates. Clinical sepsis must meet either of the follow-
Laboratory-confirmed bloodstream infection ing criteria:
must meet one of the following criteria: 1. One of the following clinical signs or symp-
1. Recognized pathogen isolated from blood toms with no other recognized cause: fe-
culture AND pathogen is not related to infec- ver (>38” C), hypotension (systolic pressure
tion at another site.” ~90 mm Hg), or oliguria (~20 ml/hr) AND
2. One of the following: fever (~38” C), chills, all of the following:
or hypotension AND any of the following: a. Blood culture not done or no organism or
a. Common skin contaminantt isolated antigen detected in blood
from two blood cultures drawn on sepa- b. No apparent infection at another site
rate occasions AND organism is not re- c. Physician institutes appropriate antimi-
lated to infection at another site* crobial therapy for sepsis
b. Common skin contaminant isolated from 2. Patient ~12 months of age has one of the
blood culture from patient with intravas- following clinical signs or symptoms with no
cular access device AND physician insti- other recognized cause: fever (>38” C), hy-
tutes appropriate antimicrobial therapy pothermia (~37” C), apnea, or bradycardia
c. Positive antigen test on blood$ AND or- AND all of the following:
ganism is not related to infection at an- a. Blood culture not done or no organism or
other site antigen detected in blood
3. Patient 612 months of ages has one of b. No apparent infection at another
the following: fever (>38” C), hypothermia site
c. Physician institutes appropriate antimi-
crobial therapy for sepsis
*When an organism isolated from blood culture is compatible
with a related nosocomial infection at another site, the blood- PNEUMONIA
stream infection is classified as a secondary bloodstream in-
fection Exceptions to this are intravascular device-associated Pneumonia is defined separately from other
bloodstream infections, all of which are classified as primary infections of the lower respiratory tract. The
even if localized signs of infection are present at the access criteria for pneumonia involve various combi-
site. nations of clinical, radiographic, and labora-
TOrganisms that are normal skin flora (e.g., diphtheroids, Ba- tory evidence of infection. In general, expecto-
cillus sp., Propionibacterium sp., coagulase-negative staphy-
lococci, or micrococci).
*Detection of bacterial, fungal, or viral antigen (e.g., Cancfida *When an organism isolated from blood culture is compatible
sp., herpes simplex, varicella zoster, Haemophilus influenzae, with a related nosocomial infection at another site, the blood-
Streptococcus pneumoniae, Neisseria meningitidis, group B stream infection is classified as a secondary bloodstream in-
streptococci) by rapid diagnostic test (e.g., counterimmuno- fection. Exceptions to this are intravascular device-associated
electrophoresis, coagulation, or latex agglutination). bloodstream infections, all of which are classified as primary
§These criteria apply specifically to infants ~12 months of age: even if localized signs of infection are present at the access
they may infrequently apply to older infants and children. site.
Volume 16 Number 3
June 1988 CDC definitions for nosocomial infections, 1988 131

rated sputum cultures are not useful in diag- 4. Patient s 12 months of age has chest radio-
nosing pneumonia but may help identify the logic examination that shows new or pro-
etiologic agent and provide useful antimicro- gressive infiltrate, cavitation, coasolidation,
bial susceptibility data. Findings from serial or pleural effusion AND any of the fol-
chest x-ray studies may be more helpful than lowing:
those from a single x-ray film. a. Increased production of respiratory se-
Pneumonia must meet one of the following cretions
criteria: b. New onset of purulent sputurn or change
1. Rales or dullness to percussion on physical in character of sputum
examination of chest AND any of the fol- Organism isolated from blood culture
lowing: ii: Isolation of pathogen from specimen ob-
a. New onset of purulent sputum or change tained by transtracheal aspirate, bron-
in character of sputum chial brushing, or biopsy
b. Organism isolated from blood culture e. Isolation of virus or detection of viral an-
c. Isolation of pathogen from specimen ob- tigen in respiratory secretions
tained by transtracheal aspirate, bron- f. Diagnostic single antibody titer (IgM) or
chial brushing, or biopsy fourfold increase in paired serum sam-
2. Chest radiographic examination shows new ples (IgG) for pathogen
or progressive infiltrate, consolidation, cav- g* Histopathologic evidence of pneumonia
itation, or pleural effusion AND any of the
following: URINARY TRACT INFECTION
a. New onset of purulent sputum or change Urinary tract infection includes symptomatic
in character of sputum urinary tract infection, asymptomatic bacteri-
b. Organism isolated from blood culture uria, and other infections of the urinary tract.
c. Isolation of pathogen from specimen ob- Symptomatic urinary tract infection must
tained by transtracheal aspirate, bron- meet one of the following criteria:
chial brushing, or biopsy 1. One of the following: fever (>38” C), urgency,
d. Isolation of virus or detection of viral an- frequency, dysuria, or suprapubic tender-
tigen in respiratory secretions ness AND a urine culture” of alO colo-
e. Diagnostic single antibody titer (IgM) or nies/ml urine with no more than two species
fourfold increase in paired serum sam- of organisms
ples (IgG) for pathogen 2. Two of the following: fever (>38” C), urgency,
f. Histopathologic evidence of pneumonia frequency, dysuria, or suprapubic tender-
3. Patient ~12 months of age has two of the ness AND any of the following:
following: apnea, tachypnea, bradycardia, a. Dipstick test positive for leukocyte ester-
wheezing, rhonchi, or cough AND any of the ase and/or nitrate
following: b. Pyuria (310 white blood cells [WBC]/mP
a. Increased production of respiratory se- or ~3 WBC/high-power field of unspun
cretions urine)
b. New onset of purulent sputum or change c. Organisms seen on Gram stai:n of unspun
in character of sputum urine
Organism isolated from blood culture d Two urine cultures with repeated iso-
;: Isolation of pathogen from specimen ob- lation of the same uropathogent with
tained by transtracheal aspirate, bron- ~10~ colonies/ml urine in nonvoided
chial brushing, or biopsy specimens
e. Isolation of virus or detection of viral an-
tigen in respiratory secretions
*For urine specimens to be of value in determining whether a
f. Diagnostic single antibody titer (IgM) or nosocomial infection exists, they must be obtained aseptically
fourfold increase in paired serum sam- using an appropriate technique, such as clean catch collection,
ples (IgG) for pathogen bladder catheterization, or suprapubic aspiration.

g. Histopathologic evidence of pneumonia tGram-negative bacteria or Staphylococcus saprophyticus

 American Journal of
132 Garner et al. INFECTION CONTROL

e. Urine culture with ~10’ colonies/ml the retroperitoneal or perinephric spaces) must
urine of single uropathogen in patient meet one of the following criteria:
being treated with appropriate antimi- 1. Organism isolated from culture of fluid (other
crobial therapy than urine) or tissue from affected site
f. Physician’s diagnosis 2. An abscess or other evidence of infection seen
g. Physician institutes appropriate antimi- on direct examination, during surgery, or by
crobial therapy histopathologic examination
3. Patient < 12 months of age has one of 3. Two of the following: fever (~38” C), local-
the following: fever (>38” C), hypothermia ized pain, or tenderness at involved site AND
(~37” C), apnea, bradycardia, dysuria, leth- any of the following:
argy, or vomiting AND urine culture of 210’ a. Purulent drainage from affected site
colonies/ml urine with no more than two b. Organism isolated from blood culture
species of organisms c. Radiographic evidence of infection*
4. Patient ~12 months of age has one of d. Physician’s diagnosis
the following: fever (>38” C), hypothermia e. Physician institutes appropriate antimi-
(~37” C), apnea, bradycardia, dysuria, leth- crobial therapy
argy, or vomiting AND any of the follow- 4. Patient s 12 months of age has one of
ing: the following: fever (>38” C), hypothermia
a. Dipstick test positive for leukocyte ester- (~37” C), apnea, bradycardia, lethargy, or
ase and/or nitrate vomiting AND any of the following:
b. Pyuria a. Purulent drainage from affected site
c. Organisms seen on Gram stain of unspun b. Organism isolated from blood culture
urine c. Radiographic evidence of infection
d. Two urine cultures with repeated isola- d. Physician’s diagnosis
tion of same uropathogen with 3102 or- e. Physician institutes appropriate therapy
ganisms/ml urine in nonvoided spec-
imens BONE AND JOINT INFECTION
e. Urine culture with ~10~ colonies/ml Bone and joint infection includes osteomy-
urine of a single uropathogen in patient elitis, joint or bursa infection, and vertebral
being treated with appropriate antimi- disk infection.
crobial therapy Osteomyelitis must meet one of the following
f. Physician’s diagnosis criteria:
g. Physician institutes appropriate antimi- 1. Organism cultured from bone
crobial therapy 2. Evidence of osteomyelitis seen during sur-
Asymptomatic bacteriuria must meet either gery or by histopathologic examination
of the following criteria: 3. Two of the following with no other recog-
1. An indwelling urinary catheter is present nized cause: fever (>38” C), localized swell-
within 7 days before urine is cultured AND ing, tenderness, heat, or drainage at sus-
patient has no fever (>38” C), urgency, fre- pected site of infection AND any of the fol-
quency, dysuria, or suprapubic tenderness lowing:
AND has urine culture of >1O5 organisms/ml a. Organism isolated from blood culture
urine with no more than two species of or- b. Positive antigen test on blood
ganisms . c. Radiographic evidence of infection
2. No indwelling urinary catheter is present Joint or bursa infection must meet one of the
within 7 days before the first of two urine following criteria:
cultures with 3105 organisms/ml urine of 1. Organism isolated from culture of joint fluid
the same organism with no more than two or synovial biopsy
species of organisms, AND patient has no fe- 2. Evidence of joint or bursa infection seen
ver (>38” C), urgency, frequency, dysuria, or
suprapubic tenderness. “Radiographic evidence of infection includes abnormal results
Other infections of the urinary tract (kidney, of ultrasound examination, CT scan, magnetic resonance im-
ureter, bladder, urethra, or tissues surrounding aging, or radiolabel scan (e.g., gallium or technetium).
Volume 16 Number 3
June 1988 CDC definitions for nosocomial infections, I988 133

during surgery or by histopathologic exam- b. Blood culture not done or no organism

ination isolated from blood culture
3. Two of the following with no other recog- 4. Purulent drainage at involved vascular site
nized cause: joint pain, swelling, tenderness, AND blood culture not done or no organism
heat, evidence of effusion or limitation of isolated from blood culture
motion AND any of the following: 5. Patient < 12 months of age has one of
a. Organisms and white blood cells seen on the following: fever (>38” C), hypothermia
Gram stain of joint fluid (~37” C), apnea, bradycardia, lethargy, pain,
b. Positive antigen test on blood, urine, or erythema, or heat at involved vascular site
joint fluid AND both of the following:
c. Cellular profile and chemistries of joint a. More than 15 colonies cultured from in-
fluid compatible with infection and not ex- travascular cannula tip using semiquan-
plained by underlying rheumatologic dis- titative culture method
order b. Blood culture not done or no organism
d. Radiographic evidence of infection isolated from blood culture
Vertebral disk space infection must meet one Endocarditis of natural or prosthetic heart
of the following criteria: valve must meet one of the follow:lng criteria:
1. Organism isolated from culture of involved 1. Organism isolated from culture of valve or
site tissue obtained during surgery or needle vegetation
aspiration 2. Two of the following with no other recog-
2. Evidence of infection at involved site seen nized cause: fever (>38” C), new or chang-
during surgery or by histopathologic exam- ing murmur; embolic phenomena, skin man-
ination ifestations (i.e., petechiae, splinter he-
3. Fever (>38” C) with no other recognized morrhages, painful subcutaneous nodules),
cause or pain at involved site AND radio- congestive heart failure, or cardiac conduc-
graphic evidence of infection tion abnormality AND physician institutes
4. Fever (~38” C) with no other recognized appropriate antimicrobial therapy if diag-
cause AND pain at involved site AND positive nosis is made antemortem ANI) any of the
antigen test on blood or urine. following:
a. Organism isolated from two blood
CARDIOVASCULAR SYSTEM INFECTION cultures
Cardiovascular system infection includes ar- b. Organisms seen on Gram stain of valve
terial or venous infection, endocarditis, myo- when culture is negative or not done
carditis or pericarditis, and mediastinitis. Me- c. Valvular vegetation seen during surgery
diastinitis is grouped with cardiovascular sys- or autopsy
tem infections because it most often occurs after d. Positive antigen test on blood or urine
cardiac surgery. e. Evidence of new vegetation seen on echo-
Arterial or venous infection must meet one of cardiogram
the following criteria: 3. Patient s 12 months of age has two or more
1. Organism isolated from culture of arteries of the following with no other recognized
or veins removed during surgery AND blood cause: fever (>38” C), hypothermia (~37” C),
culture not done or no organism isolated apnea, bradycardia, new or changing mur-
from blood culture mur, embolic phenomena, skin manifesta-
2. Evidence of infection at involved vascular tions, congestive heart failure, or cardiac
site seen during surgery or by histopatho- conduction abnormality AND physician in-
logic examination stitutes appropriate antimicrobial therapy if
3. One of the following: fever (>38” C), pain, diagnosis is made antemortem AND any of
erythema, or heat at involved vascular site the following:
AND both of the following: a. Organism isolated from two blood
a. More than 15 colonies cultured from in- cultures
travascular cannula tip using semiquan- b. Organisms seen on Gram stain of valve
titative culture method when culture is negative or not done
 American Journal of
134 Garner et al. INFECTION CONTROL

c. Valvular vegetation seen during surgery 2. Evidence of mediastinitis that is seen dur-
or autopsy ing surgery or by histopathologic exami-
d. Positive antigen test on blood or urine nation
e. Evidence of new vegetation seen on echo- 3. One of the following: fever (>38” C), chest
cardiogram pain, or sternal instability AND any of the
Myocarditis or pericarditis must meet one of following:
the following criteria: a. Purulent drainage from mediastinal area
1. Organism isolated from culture of pericar- b. Organism isolated from blood culture or
dial tissue or fluid obtained by needle aspi- culture of drainage from mediastinal area
ration or during surgery c. Mediastinal widening on x-ray exam-
2. Two of the following with no other recog- ination
nized cause: fever (~38” C), chest pain, par- 4. Patient s 12 months of age has one of
adoxical pulse, or increased heart size AND the following: fever (>38” C), hypothermia
any of the following: (~37” C), apnea, bradycardia, or sternal in-
a. Abnormal electrocardiogram (ECG) con- stability AND any of the following:
sistent with myocarditis or pericarditis a. Purulent drainage from mediastinal area
b. Positive antigen test on blood b. Organism isolated from blood culture or
C. Evidence of myocarditis or pericardi- culture of drainage from mediastinal area
tis on histologic examination of heart c. Mediastinal widening on x-ray exam-
tissue ination
d. Fourfold rise in type-specific antibody
with or without isolation of virus from
pharynx or feces CENTRAL NERVOUS SYSTEM INFECTION
e. Pericardial effusion identified by echo- Central nervous system infection includes in-
cardiogram, CT scan, magnetic resonance tracranial infection, meningitis or ventriculitis,
imaging, angiography, or other radio- and spinal abscess without meningitis.
graphic evidence of infection Intracranial infection (brain abscess, sub-
3. Patient s 12 months of age has two of the dural or epidural infection, and encephalitis)
following with no other recognized cause: must meet one of the following criteria:
fever (>38” C), hypothermia (~37” C), apnea, 1. Organism isolated from culture of brain tis-
bradycardia, paradoxical pulse, or increased sue or dura
heart size AND any of the following: 2. Abscess or evidence of intracranial infection
a. Abnormal ECG consistent with myocar- seen during surgery or by histopathologic ex-
ditis or pericarditis amination
b. Positive antigen test on blood 3. Two of the following with no other re-
c. Histologic examination of heart tissue cognized cause: headache, dizziness, fever
shows evidence of myocarditis or peri- (>38” C), localizing neurologic signs, chang-
carditis ing level of consciousness, or confusion, AND
d. Fourfold rise in type-specific antibody physician institutes appropriate antimicro-
with or without isolation of virus from bial therapy if diagnosis is made antemor-
pharynx or feces tern AND any of the following:
e. Pericardial effusion identified by echo- a. Organism seen on microscopic examina-
cardiogram, CT scan, magnetic resonance tion of brain or abscess tissue obtained
imaging, angiography, or other radio- by needle aspiration or by biopsy during
graphic evidence of infection surgery or autopsy
Mediastinitis must meet one of the following b. Positive antigen test on blood or urine
criteria: c. Radiographic evidence of infection
1. Organism isolated from culture of medias- d. Diagnostic single antibody titer (IgM) or
tinal tissue or fluid obtained during surgery fourfold increase in paired serum sam-
or needle aspiration ples (IgG) for pathogen
Volume 16 Number 3
June 1988 CDC definitions for nosocomial infections, 1988 135

4. Patient ~12 months of age has two of the d. Positive antigen test on CSF, blood, or
following with no other recognized cause: urine
fever (>38” C), hypothermia (~37” C), apnea, e. Diagnostic single antibody t:iter (IgM) or
bradycardia, localizing neurologic signs, or fourfold increase in paired serum sam-
changing level of consciousness AND physi- ples (IgG) for pathogen
cian institutes appropriate antimicrobial Spinal abscess without meningitis (an ab-
therapy if diagnosis is made antemortem scess of the spinal epidural or sub,dural space,
AND any of the following: without involvement of the CSF or adjacent
a. Organisms seen on microscopic exami- bone structures) must meet one of the following
nation of brain or abscess tissue obtained criteria:
by needle aspiration or by biopsy during 1. Organism isolated from culture Iof abscess in
surgery or autopsy spinal epidural or subdural space
b. Positive antigen test on blood or urine 2. Abscess in spinal epidural or subdural space
specimen seen during surgery or autopsy or by histo-
c. Radiographic evidence of infection pathologic examination
d. Diagnostic single antibody titer (IgM) or 3. One of the following with no other recog-
fourfold increase in paired serum sam- nized cause: fever (~38” C), back pain, focal
ples (IgG) for pathogen tenderness, radiculitis, paraparesis, or para-
Meningitis or ventriculitis must meet one of plegia AND physician institutes appropriate
the following criteria: antimicrobial therapy if diagnosis is made
1. Organism isolated from culture of cerebro- antemortem AND either of the following:
spinal fluid (CSF) a. Organism isolated from blood culture
2. One of the following with no other recog- b. Radiographic evidence of spinal abscess
nized cause: fever (~38” C), headache, stiff
neck, meningeal signs, cranial nerve signs, EYE, EAR, NOSE, THROAT, AND
or irritability, AND physician institutes ap- MOUTH INFECTION
propriate antimicrobial therapy if diagnosis Eye infection includes conjunctivitis and
is made antemortem AND any of the fol- other eye infections. Ear infections include oti-
lowing: tis externa, otitis media, otitis interna, and mas-
a. Increased white cells, elevated protein, toiditis. Nose, throat, and mouth infections in-
and/or decreased glucose in CSF clude oral cavity infections, upper respiratory
b. Organisms seen on Gram stain of CSF infections, and sinusitis.
c. Organism isolated from blood culture Conjunctivitis must meet either of the follow-
d. Positive antigen test on CSF, blood, or ing criteria:
urine 1. Pathogen isolated from culture of purulent
e. Diagnostic single antibody titer (IgM) or exudate obtained from conjunctiva or con-
fourfold increase in paired serum sam- tiguous tissues, such as eyelid, cornea, mei-
ples (IgG) for pathogen bomian glands, or lacrimal glands
3. Patient 6 12 months of age has one of the 2. Pain or redness of conjunctiva or around eye
following with no other recognized cause: AND any of the following:
fever (~38” C), hypothermia (~37” C), apnea, a. WBCs and organisms seen on Gram stain
bradycardia, stiff neck, meningeal signs, cra- of exudate
nial nerve signs, or irritability AND physician b. Purulent exudate
institutes appropriate antimicrobial therapy c. Positive antigen test on exudate or con-
if diagnosis is made antemortem AND any of junctival scraping
the following: d. Multinucleated giant cells seen on micro-
a. Increased white cells, elevated protein, scopic examination of conjunctival exu-
and/or decreased glucose in CSF date or scrapings
b. Organisms seen on Gram stain of CSF e. Positive viral culture on conjunctival ex-
c. Organism isolated from blood culture udate

136 Gamer et al.
f. Diagnostic single antibody titer (IgM) or
fourfold increase in paired serum sam-
ples (IgG) for pathogen
Eye infections other than conjunctivitis
meet either of the following criteria:
1. Organism isolated from culture of anterior
or posterior chamber or vitreous fluid
2. Two of the following with no other recog-
nized cause: eye pain, visual disturbance, or
hypopyon AND any of the following:
a. Physician’s diagnosis
b. Positive antigen test on blood
c. Organism isolated from blood culture
Otitis externa must meet either of the follow-
ing criteria:
1. Pathogen isolated from culture of purulent
drainage from ear canal
2. One of the following: fever (>38” C), pain,
redness, or drainage from ear canal AND or-
ganisms seen on Gram stain of purulent
drainage
Otitis media must meet either of the follow-
ing criteria:
1. Organism isolated from culture of fluid from
middle ear obtained by tympanocentesis
surgery
2. Two of the following: fever (>38” C), pain in
eardrum, inflammation, retraction or de-
creased mobility of eardrum, or fluid behind
eardrum
Otitis intema must meet either of the follow-
ing criteria:
1. Organism isolated from culture of fluid from
inner ear obtained at surgery
2. Physician’s diagnosis
Mastoiditis must meet either of the following
criteria:
1. Organism isolated from culture of purulent
drainage from mastoid
2. Two of the following with no other recog-
nized cause: fever (>38” C), pain, tenderness,
erythema, headache, or facial paralysis AND
either of the following:
a. Organisms seen on Gram stain of puru-
lent material from mastoid . 2. Abscess seen on direct examination,
b. Positive antigen test on blood
Oral cavity infection (mouth, tongue, or
gums) must meet one of the following
teria:
1. Organism isolated from culture of purulent
material from tissues or oral cavity
American Journal of
INFECTION CONTROL
2. Abscess or other evidence of oral cavity in-
fection seen on direct examination, during
surgery, or by histopathologic examination
must 3. One of the following: abscess, ulceration, or
raised white patches on inflamed mucosa, or
plaques on oral mucosa AND any of the fol-
lowing:
a. Organisms seen on Gram stain
b. Positive potassium hydroxide (KOH)
stain
c. Multinucleated giant cells seen on micro-
scopic examination of mucosal scrapings
d. Positive antigen test on oral secretions
e. Diagnostic single antibody titer (IgM) or
fourfold increase in paired serum sam-
ples (IgG) for pathogen
f. Physician’s diagnosis and treatment with
topical or oral antifungal therapy
Sinusitis must meet either of the following
criteria:
1. Organism isolated from culture of purulent
material obtained from sinus cavity
2. One of the following: fever (>38” C), pain or
tenderness over the involved sinus, head-
or ache, purulent exudate, or nasal obstruction
AND either of the following:
a. Positive transillumination
b. Radiographic evidence of infection
Upper respiratory tract infection (pharyngi-
tis, laryngitis, epiglottis) must meet one of the
following criteria:
1. Two of the following: fever (>38” C),
erythema of pharynx, sore throat, cough,
hoarseness, or purulent exudate in throat,
AND any of the following:
a. Organism isolated from culture of spe-
cific site
b. Organism isolated from blood culture
c. Positive antigen test on blood or respi-
ratory secretions
d. Diagnostic single antibody titer (IgM) or
fourfold increase in paired serum sam-
ples (IgG) for pathogen
e. Physician’s diagnosis
during
surgery, or by histopathologic examination
3. Patient =Z12 months of age has two of
cri- the following: fever (>38” C), hypothermia
(~37” C), apnea, bradycardia, nasal dis-
charge, or purulent exudate in throat, AND
any of the following:
Volume 16 Number 3
June 1988 CDC definitions for nosocomial infections, 1988 f 37

a. Organism isolated from culture of spe- 3. Cytomegalovirus (CMV) detected in urine or

cific site oropharyngeal secretions
b. Organism isolated from blood culture Infant necrotizing enterocolitis must meet
C. Positive antigen test on blood or respi- the following criterion: Two of the following
ratory secretions with no other recognized cause: vomiting, ab-
d. Diagnostic single antibody titer (IgM) or dominal distention, or prefeeding residuals AND
fourfold increase in paired serum sam- persistent microscopic or gross blood in stools
ples (IgG) for pathogen AND any of the following abdominal radio-
e. Physician’s diagnosis graphic abnormalities:
1. Pneumoperitoneum
QASTROINTLSTINAL SYSTEM INFECTlOW 2. Pneumotosis intestinalis
Gastrointestinal system infections include 3. Unchanging “rigid” loops of small
gastroenteritis, hepatitis, necrotizing entero- bowel
colitis, gastrointestinal tract infections, and Gastrointestinal (GI) tract infection (esoph-
intraabdominal infections not specified agus, stomach, small bowel, large bowel, and
elsewhere. rectum), excluding gastroenteritis, and appen-
Gastroenteritis must meet either of the fol- dicitis, must meet either of the following cri-
lowing criteria: teria:
1. Acute onset of diarrhea (liquid stools for 1. Abscess or other evidence of infection seen
more than 12 hours) with or without vom- during surgery or by histopathologic exam-
iting or fever (>38” C) AND no likely nonin- ination
fectious cause (e.g., diagnostic tests, thera- 2. Two of the following with no other re-
peutic regimen, acute exacerbation of a cognized cause and compatible with infec-
chronic condition, psychologic stress) tion of the organ or tissue involved: fever
2. Two of the following with no other recog- (>38” C), nausea, vomiting, abdominal pain,
nized cause: nausea, vomiting, abdominal or tenderness AND any of the following:
pain, or headache AND any of the fol- a. Organism isolated from culture of drain-
lowing: age or tissue obtained during surgery
a. Enteric pathogen isolated from stool cul- or endoscopy or from surgically placed
ture or rectal swab drain
b. Enteric pathogen detected by routine or b. Organisms seen on Gram or KOH stain
electron microscopy examination or multinucleated giant cells seen on mi-
c. Enteric pathogen detected by antigen or croscopic examination of drainage or tis-
antibody assay on feces or blood sue obtained during surgery or endoscopy
d. Evidence of enteric pathogen detected or from surgically placed drain
by cytopathic changes in tissue culture c. Organism isolated from blood culture
(toxin assay) d. Radiographic evidence of infection
e. Diagnostic single antibody titer (IgM) or e. Pathologic findings on endoscopic ex-
fourfold increase in paired serum sam- amination (e.g., Can&da esophagitis or
ples (IgG) for pathogen proctitis)
Hepatitis must meet the following criterion: Intraabdominal infection (including gall-
Two of the following with no other recognized bladder, bile ducts, liver [other tha.n viral hep-
cause: fever (>38” C), anorexia, nausea, vom- atitis], spleen, pancreas, peritoneum, sub-
iting, abdominal pain, jaundice, or history of phrenic or subdiaphragmatic space, or other in-
transfusion within the previous 3 months AND traabdominal tissue or area not specified
any of the following: elsewhere) must meet one of the following cri-
1. Positive antigen or antibody test for hepa- teria:
titis A, hepatitis B, or delta hepatitis 1. Organism isolated from culture of puru-
2. Abnormal liver function tests (e.g., ele- lent material from intraabdominal space
vated alanine/aspartate aminotransferase obtained during surgery or needle aspi-
[ALT/AST] and bilirubin) ration
 American Journal of
138 Garner et al. INFECTION CONTROL

2. Abscess or other evidence of intraabdominal Other infections of the lower respiratory tract
infection seen during surgery or by histo- must meet one of the following criteria:
pathologic examination 1. Organisms seen on smear or isolated from
3. Two of the following with no other recog- culture of lung tissue or fluid, including pleu-
nized cause: fever (>38” C), nausea, vomit- ral fluid
ing, abdominal pain, or jaundice AND any of 2. Lung abscess or empyema seen during sur-
the following: gery or by histopathologic examination
a. Organism isolated from culture of drain- 3. Abscess cavity seen on radiographic exami-
age from surgically placed drain (e.g., nation of lung
closed suction drainage system, open
drain, or T-tube drain) REPRODUCTIVE TRACT INFECTION
b. Organisms seen on Gram stain of drain- A group of infections that occur in obstetric
age or tissue obtained during surgery or and gynecology patients and in male urology
needle aspiration patients is defined as reproductive tract infec-
c. Organism isolated from blood culture tion. Such infections include endometritis, epis-
and radiographic evidence of infection iotomy infection, vaginal cuff infection, and
other infections of the male or female repro-
LOWER RESPIRATORY TRACT INFECTION ductive tract.
(EXCLUDING PNEUMONIA) Endometritis must meet either of the follow-
Lower respiratory tract infection (excluding ing criteria:
pneumonia) includes infections such as bron- 1. Organism isolated from culture of fluid or tis-
chitis, tracheobronchitis, bronchiolitis, trache- sue from endometrium obtained during
itis, lung abscess, and empyema. surgery, by needle aspiration, or by brush
Bronchitis, tracheobronchitis, bronchiolitis, biopsy
tracheitis, without evidence of pneumonia, 2. Purulent drainage from uterus AND two of
must meet either of the following criteria: the following: fever (~38” C), abdominal
1. Patient has no clinical or radiographic evi- pain, or uterine tenderness
dence of pneumonia AND has two of the fol- Episiotomy site infection must meet either of
lowing: fever (~38” C), cough, new or in- the following criteria:
creased sputum production, rhonchi, wheez- 1. Purulent drainage from episiotomy
ing, AND either of the following: 2. Episiotomy abscess
a. Organism isolated from culture obtained Vaginal cuff infection must meet one of the
by deep tracheal aspirate or bron- following criteria:
choscopy 1. Purulent drainage from vaginal cuff
b. Positive antigen test on respiratory se- 2. Abscess at vaginal cuff
cretions 3. Pathogen isolated from culture of fluid or tis-
2. Patient ~12 months of age has no clini- sue obtained from vaginal cuff
cal or radiographic evidence of pneumonia Other infections of the male or female repro-
AND has two of the following with no ductive tract (epididymis, testes, prostate, va-
other recognized cause: fever (>38” C), gina, ovaries, uterus, or other deep pelvic tis-
cough, new or increased sputum produc- sues, excluding endometritis or vaginal cuff in-
tion, rhonchi, wheezing, respiratory dis- fection) must meet one of the following criteria:
tress, apnea, or bradycardia AND any of the 1. Organism isolated from culture of tissue or
following: fluid from affected site
a. Organism isolated from culture of mate- 2. Abscess or other evidence of infection seen
rial obtained by deep tracheal aspirate or during surgery or by histopathologic exam-
bronchoscopy ination
b. Positive antigen test on respiratory se- 3. Two of the following: fever (>38” C), nausea,
cretions vomiting, pain, tenderness, or dysuria AND
c. Diagnostic single antibody titer (IgM) or either of the following:
fourfold increase in paired serum sam- a. Organism isolated from blood culture
ples (IgG) for pathogen b. Physician’s diagnosis
Volume 16 Number 3
June 1988
SKIN AND SOFT TISSUE INFECTION
Skin and soft tissue infection includes skin
infection (other than incisional wound infec-
tion), soft tissue infection, decubitus ulcer in-
fection, burn infection, breast abscess or mas-
titis, omphalitis, infant pustulosis, and new-
born circumcision infection. Separate criteria
are presented for each infection.
Skin infection must meet either of the follow-
ing criteria:
1. Purulent drainage, pustules, vesicles, or
boils
2. Two of the following at affected site: local-
ized pain or tenderness, swelling, redness, or
heat AND any of the following:
a. Organism isolated from culture of aspi-
rate or drainage from affected site; if or-
ganism is normal skin flora, must be pure
culture of single organism
b. Organism isolated from blood culture
c. Positive antigen test on infected tissue or
blood
d. Multinucleated giant cells seen on micro-
scopic examination of affected tissue
e. Diagnostic single antibody titer (IgM) or
fourfold increase in paired serum sam-
ples (IgG) for pathogen
Soft tissue infection (necrotizing fasciitis, in-
fectious gangrene, necrotizing cellulitis, infec-
tious myositis, lymphadenitis, or lymphangitis)
must meet one of the following criteria:
1. Organism isolated from culture of tissue or
drainage from affected site
2. Purulent drainage from affected site
3. Abscess or other evidence of infection seen
during surgery or by histopathologic exam-
ination
4. Two of the following at affected site: local-
ized pain or tenderness, redness, swelling, or
heat AND any of the following:
a. Organism isolated from blood culture
b. Positive antigen test on blood or urine
c. Diagnostic single antibody titer (IgM) or
fourfold increase in paired serum sam-
ples (IgG) for pathogen
Decubitus ulcer infection, including both su-
perficial and deep infection, must meet the fol-
lowing criterion: Two of the following: redness,
tenderness, or swelling of wound edges AND ei-
ther of the following:
1. Organism isolated from culture of fluid ob-
CDC definitions for nosocomial infections, 1988 139
tained by needle aspiration or biopsy of tis-
sue obtained from ulcer margin
2. Organism isolated from blood culture
Bum infection must meet one of the following
criteria:
1. Change in burn wound appearance or char-
acter, such as rapid eschar separation, or
dark brown, black, or violaceous discolor-
ation of the eschar, or edema al: wound mar-
gin, AND histologic examination of burn bi-
opsy specimen that shows invasion of organ-
isms into adjacent viable tissule
2. Change in burn wound appearance or char-
acter, such as rapid eschar separation, or
dark brown, black, or violaceous discolor-
ation of the eschar, or edema at wound mar-
gin AND either of the following:
a. Organism isolated from blood culture in
absence of other identifiable infection
b. Isolation of herpes simplex virus, histo-
logic identification of inclusions by light
or electron microscopy, or .visualization
of viral particles by electron micros-
copy in biopsy specimens or lesion
scrapings
3. Burn patient has two of the following: fever
(>38” C) or hypothermia (~36” C), hypoten-
sion (systolic pressure 690 mm Hg), oliguria
(~20 ml/hr), hyperglycemia at previously
tolerated level of dietary carbohydrate, or
mental confusion AND any of the fol-
lowing:
a. Histologic examination of burn biopsy
specimen that shows invasion of organ-
isms into adjacent viable tissue
b. Organism isolated from bloold culture
c. Isolation of herpes simplex virus, histo-
logic identification of inclusions by light
or electron microscopy, or visualization
of viral particles by electron microscopy
in biopsy specimens or lesion scrapings
Breast abscess or mastitis must meet one of
the following criteria:
1. Organism isolated from culture of affected
breast tissue or fluid obtained by incision and
drainage or needle aspiration
2. Breast abscess or other evidence of infection
seen during surgery or by histopathologic ex-
amination
3. Fever (>38” C), local inflammation of the
breast, and physician’s diagnosis
 American Journal of
140 Gamer et al. INFECTION CONTROL

Omphalitis in newborn ( ~30 days of age)
must meet either of the following criteria:
1. Erythema and/or serous drainage from um-
bilicus and either of the following:
a. Organism isolated from culture of drain-
age or needle aspirate
b. Organism isolated from blood culture
2. Erythema and purulent drainage at um-
bilicus
Pustulosis in infant ( ~12 months of age)
must meet the following criterion:
1. Infant has pustules AND physician’s diag-
nosis or
2. Physician institutes appropriate antimicro-
bial therapy
Circumcision infection in new born ( ~30
days of age) must meet one of the following
criteria:
1. Newborn has purulent drainage from cir-
cumcision site.
2. Newborn has one of the following: erythema,
swelling, or tenderness at circumcision
AND pathogen isolated from culture of site.
3. Newborn has one of the following: erythema,
swelling, or tenderness at circumcision
and skin contaminant isolated from culture
of site AND physician’s diagnosis or physi-
cian institutes appropriate antimicrobial
therapy.
SYSTEMIC INFECTION
Systemic infection is defined as infection that
involves multiple organs or systems, without an
apparent single site of infection. Such infections
are usually of viral origin and can usually be
identified by clinical criteria alone (e.g., mea-
sles, mumps, rubella, and varicella); they occur
infrequently as nosocomial infections.
COMMENTS
Although the definitions presented here were
developed for use in hospitals participating in
NNIS to standardize and improve the quality
of nosocomial infection data reported to CDC,
other hospitals may wish to adopt these defi-
nitions for use in their surveillance programs.
By doing so and by using similar surveillance
methods, comparisons may be made with NNIS
data. In addition to use in routine surveillance
programs for endemic nosocomial infections,
these definitions can be used for prevalence
surveys, special studies, and outbreak inves-
tigations.
Our thanks to infection control practitioners in NNIS hos-
pitals, pediatric infection control practitioners, and mem-
bers of the Scientific Liaison Committee of the Surgical
Infection Society for critical review and comments, to
Karen Foster for editorial assistance, and to Patricia
site Skousen for preparing the manuscript.
References
site, Gamer JS, Bennett JV, Scheckler WE, Maki DG, Brach-
man PS. Surveillance of nosocomial infections. In: Pro-
ceedings of the International Conference on Nosocomial
Infections, Atlanta, Center for Disease Control, August
1970. Chicago: American Hospital Association, 1971:
171-81.
Center for Disease Control. National Nosocomial Infec-
tion Study site definitions manual (unpublished). At-
lanta; Center for Disease Control, 1975.
Haley RW, Quade D, Freeman H, et al. Study on the
efficacy of nosocomial infection control (SENIC Project):
summary of study design. Appendix E. Algorithms for
diagnosing infection. Am .I Epidemiol 1980;111:635-43.

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