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INCLUSION CRITERIA - CLABSI

Patient Name : Age/sex : Reg.No :


Bed No/ Ward : Consultant's Name :
Date of CVC Insertion : Date of CVC Removed :
Diagnosis : Date of culture sent:
SL . NO CRITERIA YES NO

SIGNS AND SYMPTOMS (FOR ADULTS)


1 Temperature > 38˚ C(100.4˚F)
2 Chills
3 Hypotension ≤ (90 / 60 mmHg)
4 Catheter site swelling
5 Inflammation at catheter site
6 Any Discharge from catheter exit site
CULTURE EVALUATION
1 Blood culture sent on :
2 No.of culture positivity :
3 Organism isolated :
4 Sensitive to :
5 Resistance if any :
6 Treated With :
SIGNS AND SYMPTOMS (FOR PATIENT ≤ 1 YEAR)
1 Temperature > 38˚C / 100.4 F
2 Hypothermia (Temp < 36˚C / 97 F)
3 Bradycardia ( HR<100 beats / mt )
4 Catheter site swelling
5 Inflammation at catheter site
6 Any Discharge from catheter exit site
CULTURE EVALUATION
1 Blood culture sent on :
2 No.of culture positivity :
3 Organism isolated :
4 Sensitive to :
5 Resistance if any :

Signature of the Doctor

Infection Control Officer Head-HIPC


COMMENTS :

SL.NO SCENARIO

1 Blood Culture Negative; Catheter tip Negative

2 Blood Culture Positive; Catheter tip Negative

3 Blood Culture Positive; Catheter tip Positive

Blood Culture Negative; Catheter tip Positive


4
DIAGNOSIS

Look for another source

CVC related BSI( If no other source)

CVC related BSI

Colonization ( Consider CVC related BSI if


accompanied by features and no source of
evident
INCLUSION CRITERIA - VAP (ADULTS )
Patient Name : Age/sex : Reg.No :
Bed No:
Consultant's Name : Date of Intubation/Ventilation :
Date of Weaning : Culture sent on :
CATEGORY CRITERIA 0 1 2
Mark the scoring for a=0, b=1 and c=2
I TEMPERATURE
a) > 98 F and < 101 F
b) ≥ 101.3 F and 102.2 F
c) ≥103 F and ≤ 97 F
II TC COUNT
a) ≥ 4,000 and ≤ 11,000
b) ≥ 11,000 and ≤ 15,000
c) ≥ 16,000 and ≤ 4,000
III SECRETIONS
a) Mild
b) Moderate/Purulent
c) Abundant, thick, purulent
IV PaO2/FiO2
a) > 240 and ARDS
b) > 240 and no ARDS
c) ≤ 240 and no evidence of ARDS
V CHEST X-RAY
a) No infiltrate
b) Diffuse or patchy infiltrate
c) Localised infiltrate
VI CULTURE GROWTH
a) No Growth
b) Pathogenic bacteria cultured > 1+
c) Same organism seen on Gram Stain
Treatment Detail:
Total Score
COMMENTS :
-Do not send suction tips for culture
- Two or more serial chest radiographs with atleast one of the above mentioned symptoms in category
V is acceptable
- In patients without underlying pulmonary or cardiac disease, one definitive chest x-ray is acceptable
- Score more than 6 is considered as VAP
- Confirm VAP with the treating Consultant and Intensivist
Signature of the Doctor :
___________________ ______________
Infection Control Officer Head, HPCC
INCLUSION CRITERIA - VAP (INFANTS & CHILDREN)
Patient Name : Age/sex : Reg.No :
Bed No/Ward : Diagnosis :
Consultant's Name : Date of Intubation/Ventilation :
Date of Weaning : Culture sent on :
CATEGORY CRITERIA YES NO

I RADIOLOGIC EXAMINATION
a) New or progressive and persistent infiltrate
b) Consolidation

c) Cavitation

d) Pneumatoceles , in ≤ 1 year
II A OTHER SYMPTOMS (FOR INFANTS)

a) Worsening gas exchange

b) Temperature Instability
c) Leukopenia ( < 4, 000 ) or Leucocytosis ( ≥ 15 ,000 )
New onset of purulent sputum or change in the character of the sputum or Increased
d) respiratory secretions

e) Apnea or Tachypnea or Nasal flaring with retraction of chest wall

f) Wheezing, rales or Rhonchi

g) Cough

h) Bradycardia (< 100 Beats/min ) or Tachycardia (> 170 Beats/min )


II B FOR CHILDREN >1 OR ≤ 12 YEARS OF AGE
a) Hyperthermia (> 101.4 F ) or Hypothermia ( < 97.7 F )

b) Leukopenia ( < 4, 000 ) or Leucocytosis ( ≥ 15 ,000 )


New onset of purulent sputum or change in the character of the sputum or Increased
c) respiratory secretions

d) New onset or worsening cough or Dyspnea,Apnea or Tachypnea

e) Rales or Bronchial breath sounds

f) Worsening gas exchange

COMMENTS :
-Patient should have atleast one symptom in the category I and three symptoms in the
category II A or II B
-In patients without underlying pulmonary or cardiac disease, one definitive chest x-ray is acceptable
-Confirm VAP with the Treating Consultant and Intensivist
Signature of the Doctor :

_______________________ _______________
Infection Control Officer Head, HPCC
______________________ _______________
Head, HICC
INCLUSION CRITERIA - CAUTI
Patient name : Age/ Sex: Reg.No
Bed/ Ward No : Date of culture sent: consultant:
Date & time of catheter insertion : Date & time of catheter removal:
Diagnosis :
I If patient had indwelling catheter at the time of specimen collection
Signs and Symptoms Yes No
a) Temperature > 38˚ C/ 100.4 F
b) Suprapubic tenderness
c) Costovertebral angle pain /tenderness
Urine Analysis Positive Negative
a) Dipstick for leukocyte esterase / nitrite
b) Pyuria
c) Gram`s stain of unspun urine
Culture Evaluation :
a) Urine culture : cfu/ml
b) Organism isolated : Resistance if any :
c) Sensitive To :
d) Treated with :
II If urine sample collected 48 hrs after catheter removal
Signs and Symptoms Yes No
a) Temperature > 38˚ C/ 100.4 F
b) Suprapubic tenderness
c) Costovertebral angle pain /tenderness
d) Urgency
e) Frequency
f) Dysuria
Urine Analysis Positive Negative
a) Dipstick for leukocyte esterase / nitrite
b) Pyuria
c) Gram`s stain of unspun urine
Culture Evaluation :
a) Urine culture : cfu/ml
b) Organism isolated : Resistance if any :
c) Sensitive To :
III If patient is < 1 year of age with indwelling catheter
Signs and Symptoms Yes No
a) Temperature > 38˚ C (core)
b) Hypothermia < 36˚ C (core)
c) Apnea
d) Bradycardia
e) Dysuria
f) Lethargy
g) Vomiting
Urine Analysis Positive Negative
a) Dipstick for leukocyte esterase / nitrite
b) Pyuria
c) Gram`s stain of unspun urine
Culture Evaluation :
a) Urine culture : cfu/ml
b) Organism isolated : Resistance if any :
c) Sensitive To :
Analysis :
Primary Consultant :
Infection Control Officer : Head -HIPC :

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