www.ecdc.europa.eu
Point prevalence survey of
healthcare-associated infections
and antimicrobial use in
European acute care hospitals
Protocol version 5.3
TECHNICAL DOCUMENT
ECDC TECHNICAL DOCUMENT
Point prevalence survey of healthcare-
associated infections and antimicrobial
use in European acute care hospitals
Protocol version 5.3, ECDC PPS 2016–2017
ii
Suggested citation: European Centre for Disease Prevention and Control. Point prevalence survey of healthcare-
associated infections and antimicrobial use in European acute care hospitals – protocol version 5.3. Stockholm:
ECDC; 2016.
Stockholm, October 2016
ISBN 978-92-9193-993-0
doi 10.2900/374985
TQ-04-16-903-EN-N
© European Centre for Disease Prevention and Control, 2016
Reproduction is authorised, provided the source is acknowledged.
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
iii
Contents
Abbreviations ............................................................................................................................................... vi
Background and changes to the protocol .......................................................................................................... 1
Objectives ..................................................................................................................................................... 3
Inclusion/exclusion criteria .............................................................................................................................. 4
Hospitals .................................................................................................................................................. 4
Wards ...................................................................................................................................................... 4
Patients ................................................................................................................................................... 4
Sample design ............................................................................................................................................... 5
Sampling of patients within the hospital ...................................................................................................... 5
Representative sampling of hospitals (for PPS coordinating centres only) ....................................................... 5
Steps ................................................................................................................................................... 5
Design effect and sample size ................................................................................................................ 5
Other sampling methods: reporting of results and data collection periods .................................................. 7
Data collection ............................................................................................................................................... 8
When? ..................................................................................................................................................... 8
Who will collect the data? .......................................................................................................................... 8
Training of surveyors ................................................................................................................................. 8
Data processing ........................................................................................................................................ 8
Overview of collected data .............................................................................................................................. 9
Light (unit-based) protocol ........................................................................................................................ 9
Standard (patient-based) protocol .............................................................................................................. 9
Hospital data ............................................................................................................................................... 10
Definition of hospital data ........................................................................................................................ 12
Hospital variables to be added by PPS coordinating centre before submission to ECDC’s TESSy ...................... 17
Ward data ................................................................................................................................................... 18
Definition of ward data ............................................................................................................................ 18
Patient data (standard protocol option) .......................................................................................................... 20
Definition of patient data ......................................................................................................................... 20
Antimicrobial use data and HAI data .............................................................................................................. 23
Antimicrobial use data ............................................................................................................................. 23
Definitions of antimicrobial use data ..................................................................................................... 23
Healthcare-associated infection data ......................................................................................................... 24
Key terms and notes ........................................................................................................................... 24
Definitions of healthcare-associated infection data ................................................................................. 25
Recommended case-finding algorithm for healthcare-associated infections............................................... 27
Numerator data in the light protocol ..................................................................................................... 28
National/regional data .................................................................................................................................. 29
Objectives .............................................................................................................................................. 29
Notes..................................................................................................................................................... 29
Definition of national/regional data ....................................................................................................... 29
Data structure and variable names ................................................................................................................ 31
Standard protocol option record types ...................................................................................................... 31
Light protocol option record types ............................................................................................................ 31
Note on microorganism and resistance data .............................................................................................. 31
Acknowledgements ...................................................................................................................................... 33
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
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Annex 1. Additional materials ........................................................................................................................ 39
Codebook............................................................................................................................................... 39
Forms .................................................................................................................................................... 39
TESSy variable definitions and validation rules ........................................................................................... 39
Note on case definitions of healthcare-associated infections ........................................................................ 39
Annex 2. Codebook ...................................................................................................................................... 40
Specialty code list ................................................................................................................................... 40
Diagnosis (site) code list for antimicrobial use ........................................................................................... 42
Indications for antimicrobial use ............................................................................................................... 42
Antimicrobial ATC codes (2016) ................................................................................................................ 43
Healthcare-associated infections: code lists ............................................................................................... 49
HAI code list, table ............................................................................................................................. 49
Definition of active HAI ....................................................................................................................... 50
HAI case definition codes, overview ..................................................................................................... 51
BSI origin (BSI source) code list ........................................................................................................... 52
Case definitions of healthcare-associated infections ................................................................................... 53
SSI: SURGICAL SITE INFECTION ......................................................................................................... 53
PN: PNEUMONIA ................................................................................................................................ 54
UTI: URINARY TRACT INFECTION........................................................................................................ 55
BSI: BLOODSTREAM INFECTION .......................................................................................................... 56
CRI: CATHETER-RELATED INFECTION .................................................................................................. 57
BJ: BONE AND JOINT INFECTION ........................................................................................................ 58
CNS: CENTRAL NERVOUS SYSTEM INFECTION ..................................................................................... 59
CVS: CARDIOVASCULAR SYSTEM INFECTION ....................................................................................... 60
EENT: EYE, EAR, NOSE, THROAT, OR MOUTH INFECTION ...................................................................... 62
LRI: LOWER RESPIRATORY TRACT INFECTION, OTHER THAN PNEUMONIA............................................. 64
GI: GASTROINTESTINAL SYSTEM INFECTION ....................................................................................... 65
REPR: REPRODUCTIVE TRACT INFECTION ........................................................................................... 67
SST: SKIN AND SOFT TISSUE INFECTION ............................................................................................. 68
SYS: SYSTEMIC INFECTION ................................................................................................................ 70
NEO: SPECIFIC NEONATAL CASE DEFINITIONS ..................................................................................... 71
Algorithm for diagnosis of catheter-related infections ................................................................................. 72
Microorganism code list ........................................................................................................................... 73
Microorganism code list (PPS selection), by category ............................................................................. 73
Antimicrobial resistance markers and codes .......................................................................................... 77
Surgery categories .................................................................................................................................. 78
NHSN surgery codes ........................................................................................................................... 78
Examples of non-NHSN surgery ........................................................................................................... 80
References .................................................................................................................................................. 81
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Figures
Figure 1. Examples of included and excluded patients in the point prevalence survey ........................................... 4
Figure 2. Increasing design effect (DEFF) as a function of cluster size (average acute care hospital size) in the
2011–2012 PPS database ............................................................................................................................... 6
Figure 3. Hospital data 1/3 (form H1) ............................................................................................................ 10
Figure 4. Hospital data 2/3 (form H2) ............................................................................................................ 11
Figure 5. Hospital data 3/3 (form H3, optional): Ward indicator data collected at hospital level ........................... 11
Figure 6. Ward data (form W) ....................................................................................................................... 18
Figure 7. Patient-based risk factors (form A): one form per patient, antimicrobial use and HAI data collected on
same form................................................................................................................................................... 20
Figure 8. Recommended case finding algorithm for healthcare-associated infections .......................................... 27
Figure 9. Antimicrobial use and HAI data form in the LIGHT option (form B2).................................................... 28
Figure 10. National/regional data (form N) ..................................................................................................... 29
Tables
Table 1. Number of hospitals and patients needed to estimate an HAI prevalence of 6% (5–7%) with design effect
depending on average acute care hospital size by country ................................................................................. 6
Table 2. Criteria to categorise the national PPS sample representativeness .......................................................... 7
Table 3. Conversion chart: PPS I protocol PPS antimicrobial marker data to the 4th
level TESSy format ................ 32
Table 4. Participants to ECDC PPS meetings on the first and second PPS protocol, by country and institution, 2009–
2015 ........................................................................................................................................................... 33
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
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Abbreviations
A&E Accidents and emergency
AM Antimicrobial/antimicrobial agent
AMR Antimicrobial resistance
ATC Anatomical Therapeutic Chemical classification system (WHO)
AU Antimicrobial use
BSI Bloodstream infection
CDC Centres for Disease Control and Prevention (Atlanta, USA)
CDI
Clostridium difficile
infections
CFU Colony-forming units
CVC Central vascular catheter
DSN Dedicated surveillance network
EARS-Net European Antimicrobial Resistance Surveillance Network (at ECDC)
ECDC European Centre for Disease Prevention and Control
EEA European Economic Area
EFTA European Free Trade Association
ESAC European Surveillance of Antimicrobial Consumption project
ESBL Extended-spectrum beta-lactamases
ESCMID European Society of Clinical Microbiology and Infectious Diseases
ESGARS ESCMID Study Group on Antimicrobial Resistance Surveillance
ESICM European Society of Intensive Care Medicine
FTE Full-time equivalent
HAI Healthcare-associated infections
HAI-Net Healthcare-Associated Infection surveillance Network (at ECDC)
HALT Healthcare-associated infections in long-term care facilities (ECDC-sponsored follow-up project
to IPSE WP7)
HCW Healthcare worker
HELICS Hospitals in Europe Link for Infection Control through Surveillance project
ICU Intensive care unit
IPSE Improving Patient Safety in Europe project
LTCF Long-term care facility
LRT Lower respiratory tract
MS Member States
NHSN National Healthcare Safety Network (at CDC)
PPS Point prevalence survey(also used as an abbreviation of the current survey)
PVC Peripheral vascular catheter
SPI Structure and process indicator
SSI Surgical site infection
TESSy The European Surveillance System (ECDC’s web-based data reporting system for the
surveillance of communicable diseases)
TRICE Training in Infection Control in Europe (ECDC-sponsored follow-up project to IPSE WP1)
WHO World Health Organization
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Background and changes to the protocol
In July 2008, the coordination of the EU-funded network IPSE (Improving Patient Safety in Europe) [1] and its
component for the surveillance of healthcare-associated infections, HELICS (Hospitals in Europe Link for Infection
Control through Surveillance), were transferred to ECDC to form ECDC’s healthcare-associated infections
surveillance network, HAI-Net. Later, ECDC adopted a plan to conduct EU-wide point prevalence survey (PPS) of
healthcare-associated infections (HAIs), based on the recommendations of the external evaluation of the IPSE
network and on the conclusions of an expert group that met in January 2009. It was also agreed to include the
hospital PPS component of the EU-funded ESAC project (European surveillance of antimicrobial consumption) in
the ECDC PPS protocol.
ECDC subsequently developed a protocol for PPSs of HAIs and antimicrobial use in acute care hospitals through
seven expert meetings held between 2009 and 2011. More than 100 experts and representatives from all EU
Member States, two EEA countries, four EU enlargement countries, international partners (the European Society of
Intensive Care Medicine, WHO Regional Office for Europe, the United States Centers for Disease Control and
Prevention), the ESAC project and ECDC contributed to the development of the PPS protocol. The first ECDC PPS
based on this protocol was conducted in 2011–2012 (version 4.2 and 4.3 of the protocol, see [2]).
The protocol provides a standardised methodology to Member States and hospitals in response to article II.8.c of
Council Recommendation 2009/C 151/01 of 9 June 2009 on patient safety, including the prevention and control of
healthcare-associated infections [3]. It also integrates the main variables of the ESAC hospital PPS protocol,
thereby also providing support to Council Recommendation 2002/77/EC of 15 November 2001 on the prudent use
of antimicrobial agents in human medicine.
Version 5.3 is the final protocol for the second EU-wide point prevalence survey 2016–2017. It contains major
changes compared to protocol version 4.3 (PPS 2011–2012). Compared to version 5.1 and version 5.2 (distributed
to EU/EEA Member States in January and May 2016, respectively), the current version only contains a few
corrections, editorial changes and clarifications.
Changes to the protocol were discussed during six ECDC meetings held between 2013 and 2015 (involving
153 participants, see Acknowledgements below). The new protocol further supports Council Recommendation
2009/C 151/01 by including more structure and process indicators for the prevention of HAIs and antimicrobial
resistance (AMR) in acute care hospitals, based on a systematic review of such indicators performed upon ECDC’s
request [4].
Indicators for antimicrobial stewardship are based on a consensus process carried out by a working group of the
Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) [5]. The new protocol also takes into account several
lessons learned from the first ECDC point prevalence survey in 2011–2012 [6].
The main changes compared to protocol version 4.3 (PPS 2011–2012) can be summarised as follows:
Inclusion criteria now include chronic care wards in acute care hospitals.
Inclusion of new structure and process indicators for HAI and AMR prevention at the hospital and ward
level.
Hospital data: Hospital ownership, more details on administrative hospital groups
Ward data: Simplified ward specialty variable
Patient data (standard protocol option only):
Birth weight for neonates
Surgery codes for patients with surgery since admission
Antimicrobial use data:
Date of start of the antimicrobial. Was the antimicrobial changed? If so, what was the reason for
changing the antimicrobial? What was the start date for the first antimicrobial given for this infection
episode? Information on the changed antimicrobials (plus reasons for the change) will allow for the
evaluation of taken measures to improve antimicrobial prescribing, thus adding value to the PPS at
the local hospital level. The start date (i.e. the date when the antimicrobial was first administered)
serves as proxy indicator of the validity (sensitivity and specificity) of the prevalence of HAIs and will
be used to estimate the total annual number of patients receiving antimicrobials in EU hospitals
(prevalence to incidence conversion); as indicator of data validity, this variable needs to be
interpreted together with the validation studies performed during the national PPS.
Dosage per day (number, strength and unit of doses per day): to inform EU/US comparisons and
updates of the defined daily dose (DDD) as set by the WHO Collaborating Centre for Drug Statistics
Methodology, Norwegian Institute of Public Health (www.whocc.no).
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
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HAI and AMR data:
HAI associated to current ward
AMR marker data collected as S/I/R/U rather than ‘susceptible/non-susceptible’, in addition to
‘pandrug resistant’ (PDR)
Codebook:
Specialty list: new ward specialty code list (with only main specialties), consultant/patient specialty
codes for healthy neonates added
Diagnosis (site) code list for antimicrobial use: surgical site infection (SSI) was added as a
subcategory of both skin or soft tissue infections (SST) and bone or joint infections (BJ); addition of
cystic fibrosis (CF) as a separate entry
Antimicrobial ATC codes: updated with new codes added since 2011
HAI case definitions:
Surgical site infection (SSI): follow-up period of deep incisional and organ/space SSIs after
implant surgery: changed from one year to 90 days
Pneumonia (PN): note added indicating that one definitive chest X-ray or CT-scan for the current
pneumonia episode may be sufficient in patients with underlying cardiac or pulmonary disease if
comparison with previous X-rays is possible
Clostridium difficile
infection (GI-CDI): definition is now aligned with the case definition in the
CDI surveillance protocol in order to account for other methods for detecting toxin-producing
C. difficile
organisms in stool.
SYS-CSEP: no change in the definition, but change of the name from ‘clinical sepsis’ to ‘treated
unidentified severe infection’ in adults and children, to differentiate this last-resort HAI case
definition from the modern concept of sepsis based on organ dysfunction.
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Objectives
The objectives of the ECDC point prevalence survey of healthcare-associated infections (HAIs) and antimicrobial
use (AU) in acute care hospitals are as follows:
to estimate the total burden (prevalence) of HAIs and antimicrobial use in acute care hospitals in the EU
to describe patients, invasive procedures, infections (sites, microorganisms including markers of
antimicrobial resistance) and antimicrobials prescribed (compounds, indications)
by type of patients, specialties or healthcare facilities and
by EU country, adjusted or stratified
to describe key structures and processes for the prevention of HAIs and antimicrobial resistance at the
hospital and ward level in EU hospitals
to disseminate results to those who need to know at local, regional, national and EU level:
to raise awareness
to enhance surveillance structures and skills
to identify common EU problems and set up priorities accordingly
to evaluate the effect of strategies and guide policies for the future at the local
1
/national/regional
level (repeated PPS)
to provide a standardised tool for hospitals1 to identify targets for quality improvement.
1
Results at the local (hospital) level should be interpreted carefully and take into account confidence intervals which are
influenced by the hospital size (number of patients) and the frequency of the event (relatively wider intervals for rare events).
Even if all patients in the hospital are included in the survey, one should consider that the survey day is only a sample of all
possible days in that period. The evaluation of the effects of interventions in-between two repeated surveys are more likely to be
more meaningful for interventions where important improvement can be expected (e.g. introduction of antimicrobial stop orders,
control of an epidemic of specific healthcare-associated infections). If point prevalence surveys are repeated over several years, it
will eventually become possible to interpret even weak trends.
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
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Inclusion/exclusion criteria
Hospitals
All acute care hospitals are eligible for inclusion. An acute care hospital is defined in accordance with national
definitions. There is no minimal size of hospitals.
For administrative hospital groups (hospital ‘mergers’ or ‘trusts’), data should ideally be collected by hospital site.
Wards
Include all wards in acute care facilities, including, for example, chronic care and long-term care wards, acute
psychiatric wards and neonatal ICUs.
Excluded are accident and emergency departments (except for wards attached to A&E departments where patients
are monitored for more than 24 hours).
The ward specialty is always recorded so that results can be stratified and standardised.
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 (see Figure 1). Include neonates on maternity and paediatric wards if born before/at 8 a.m. (see also
under
neonates
).
Exclude day cases:
patients undergoing same day treatment or surgery;
patients seen at outpatient department;
patients in the emergency room;
dialysis patients (outpatients).
Note: Decision to include/exclude patients is based on information available at 8 a.m. on the day of the survey.
Figure 1. Examples of included and excluded patients in the point prevalence survey
Legend. W1: ward 1, W2: ward 2
Note: Include patients who are temporarily off from the ward for diagnostic investigations, 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.
Include patients who are on the patient administration system but at home for a number of hours.
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Sample design
Sampling of patients within the hospital
All eligible patients will be included. This will enhance the local usefulness of the results because of the larger
sample size by hospital (see objectives).
Representative sampling of hospitals (for PPS coordinating
centres only)
In accordance with objective 1, the results of the PPS should ideally be based on data from hospitals that are
representative of all acute care hospitals in the European Union. However, to meet national objectives, results
should also be representative for each of the Member States’ total hospital population to be meaningful.
Representative samples will be drawn using a systematic sampling design.
Steps
1. Obtain a list (for example in Microsoft Excel format) of all acute care hospitals in the country, including the
number of acute care beds (use the total number of beds if the number of acute care beds is unknown).
2. Rank the list in ascending order of the number of beds.
3. Obtain the number of hospitals to be sampled from ECDC or from the tables and figures below.
4. Divide the total number of hospitals by the number to be sampled = sampling interval k.
5. Choose a random number between 1 and k = i.
6. Select the i
th
hospital, i
th
+k hospital, the i
th
+2k hospital etc.
7. Foresee substitution in the case of refusal of the first selected hospital: select the next hospital on the list (i
th
+1
hospital, i
th
+k +1 hospital, etc.); if more than one refusal is expected per selected hospital, make a second list of
reserve hospitals.
8. Invite the hospitals selected in step 6 to participate; replace them in the case of refusal to participate.
Systematic sampling procedure: Sorting the hospitals according to the number of beds before the selection process
ensures that hospitals of different sizes are represented in exactly the same way in the sample as in the
national/regional population of hospitals. Additional sorting according to hospital type (for example
primary/secondary/tertiary, or any other available national categories that are related to case-mix severity) is
recommended, as it ensures representativeness of the different types of hospitals. If the hospital type is available,
first sort the hospital list according to hospital type, then according to size, before starting the systematic sampling
procedure.
Design effect and sample size
The sample size is calculated to estimate an anticipated prevalence of 6% with a precision of +/- 1% at the
national level. The proposed precision of the results is similar for all Member States. The number of hospitals to be
included depends on the expected design effect and on the average hospital size in each country. The total number
of hospitals and patients in the country has only a small effect on the recommended sample size.
The selected hospitals can be considered as clusters of patients of the total acute care hospital patient population.
Therefore a correction for cluster surveys (design effect) has to be applied when calculating the sample size.
The design effect (DEFF) of a statistic is the ratio of actual variance for a given sample design over the variance if
the patients were selected randomly (i.e. from all, or a much larger number of hospitals). The higher the design
effect, the more patients have to be included in the sample to estimate the same prevalence with the same
precision. The design effect increases with the size of the clusters (average hospital size) and with the magnitude
(frequency) of the outcome under study (higher for antimicrobial use than for healthcare-associated infections).
The DEFF for HAI prevalence was calculated on the basis of data from the 2011–2012 ECDC PPS with the Stata 12
software package (using the survey prefix command ‘svy’). It was higher than expected compared with earlier
national point prevalence surveys and the pilot ECDC PPS: overall DEFF
PPS
=8.0 compared with DEFF=5.4 as
estimated earlier. Further simulations on subsamples from the database of the 2011–2012 ECDC PPS made it
possible to estimate the design effect for different hospital size categories (Figure 2).
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
6
Figure 2. Increasing design effect (DEFF) as a function of cluster size (average acute care hospital
size) in the 2011–2012 PPS database
Table 1 below shows the recommended sample size of patients and hospitals by country, using the national
denominator data provided during the 2011–2012 PPS and the estimated design effect for an estimated HAI
prevalence of 6% +/- 1% for different hospital sizes. If denominator data at the time of the PPS differ from the
ones presented in the table, it is recommended that the number of patients and hospitals to be sampled are
recalculated. For example, if national statistics report hospital groups (rather than hospital sites), but sampling for
the PPS is done by site (rather than by group), national PPS coordinators should adjust the estimated DEFF and the
number of hospitals (or hospital sites) to be sampled (Figure 2). This could, for example, result in a lower total
number of patients but a higher number of (smaller) hospital entities.
Table 1. Number of hospitals and patients needed to estimate HAI prevalence of 6% (5–7%), with
design effect depending on average acute care hospital size by country
Country
Number of acute
care hospitals
(a)
Number of
hospital beds
(a)
Average
hospital size
Estimated
DEFF
Recommended
sample size, patients
Number of
hospitals to be
sampled
Austria
189
53 371
282
6.0
12 493
44
Belgium
194
51 798
267
6.0
12 478
47
Bulgaria
241
44 164
183
5.7
11 773
64
Croatia
60
15 640
261
6.0
11 419
44
Cyprus
8
2 769*
346
6.8
2769
8
Czech Republic
158
57 756
366
6.8
14 201
39
Denmark
52
13 779
265
6.0
11 234
42
Estonia
40
4 685
117
4.1
4 685
40
Finland
59
9 601*
163
5.7
9 601
59
France
1558
314 598
202
5.7
12 265
61
Germany
1736
461 022
266
6.0
12 939
49
Greece
137
35 120
256
6.0
12 245
48
Hungary
108
69 466
643
10.5
22 062
34
Iceland
8
1 046
131
4.1
1 046
8
Ireland
60
12 398
207
5.7
10 514
51
Italy
1023
226 095
221
5.7
12 233
55
Latvia
17
6 975
410
8.0
6 975
17
Lithuania
92
20 867
227
5.7
11 189
49
Luxembourg
9
2 377
264
6.0
2 377
9
Malta
3
1 339
446
8.0
1 399
3
Netherlands
96
50 095*
522
8.0
16 615
32
Norway
60
16 282
271
6.0
11 474
42
Poland
795
181 077
228
5.7
12 204
54
Portugal
101
24 773
245
6.0
11 955
49
Romania
311
111 725
359
6.8
14 453
40
Slovakia
112
31 217
279
6.0
12 157
44
1.8
2.6
2.7
4.1
5.7 5.7
6
6.8
8
10.5
0
2
4
6
8
10
12
Design effect
Number of included patients in PPS by hospital (deciles)
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Country
Number of acute
care hospitals
(a)
Number of
hospital beds
(a)
Average
hospital size
Estimated
DEFF
Recommended
sample size, patients
Number of
hospitals to be
sampled
Slovenia
21
7 826
373
6.8
7826
21
Spain
550
117 504
214
5.7
12 126
57
Sweden
80
18 947*
237
6.0
11 667
49
UK-England
253
158 928*
628
10.5
22 444
36
UK-Northern Ireland
16
4 985
312
6.8
4 985
16
UK-Scotland
52
16 537
318
6.8
13 027
41
UK-Wales
89
9 952*
112
4.1
7 296
65
(a) Number of hospitals and hospital beds as reported in the ‘national denominator data’ in the 2011–2012 PPS. If not
available (*), Eurostat data for N of hospital beds (curative) are used. See: http://ec.europa.eu/eurostat/web/health/health-care.
Sample size calculations were made using OpenEpi software
(
www.openepi.com
)
; DEFF=design effect, estimated from the 2011–
2012 PPS database for different hospital sizes (deciles, see Figure 2); countries in italics need to include all hospitals.
Other sampling methods: reporting of results and data collection
periods
Although representative sampling remains strongly recommended for the ECDC point prevalence survey, some
countries may have difficulties to draw a representative sample of hospitals or may decide to use a different
method for hospital recruitment, e.g. because the data quality is expected to be affected if representative sampling
is used. Alternative methods of recruiting hospitals are voluntary participation after invitation of all hospitals,
‘convenience’ sampling (selection of hospitals by the PPS coordinating centre) or mandatory participation. The
hospital sampling/recruitment method(s) used is (are) recorded at the national/regional level and will be included
when country data are reported at the European level.
Moreover, some countries may want to include more hospitals than just those included in the sample, e.g. a
combination of a representative sample and voluntary participation after invitation of all hospitals. In this case, only
data of the representative sample will be used when European results are reported. However, if all data are
submitted, ECDC will provide the national coordinators with feedback reports for all participating hospitals by
comparing their results to the total national results. A variable at the hospital level indicates whether a hospital
belongs to the representative sample or not (this variable should be provided by the national coordinator). This
information will then be combined with the sampling method used at the national level to determine the sample for
which national results are reported at the European level. If the number of submitted hospitals exceeds the
recommended number for that country and information on whether the hospital is part of the representative
sample is missing, ECDC will draw a random sample of the required number of hospitals for the reporting at the
European level in order to obtain prevalence estimates with a similar precision as for other countries.
In order to increase the number of participating hospitals for the 2016–2017 ECDC PPS, hospitals may be included
in any of the four PPS periods: April–June 2016, September–November 2016, April–June 2017, and September–
November 2017. Although it is recommended that data collection should be organised during a single period for all
hospitals, data collection may also extend over several periods. The same hospital may only be included once over
the four periods.
The national sample representativeness is assigned one of four categories (optimal, good, poor and very poor;
Table 1) depending on compliance with the recommended sampling methodology.
Table 2. Criteria for national PPS sample representativeness
Optimal
• Systematic random sample of at least 25 hospitals or at least 75% of the number of hospitals specified in Table
1.
• Inclusion of at least 75% of all hospitals or occupied hospital beds in the country and recommended sample
size (Table 1) achieved
Good
• Selection of at least 25 hospitals or at least 75% of the number of hospitals and/or residents specified in
Table 1 using another methodology (e.g. voluntary participation);
• Recommended sample size not achieved, but inclusion of ≥75% of all hospitals or occupied hospital beds in
the country.
Poor
• Between 5 and 25 hospitals included in countries with more than 25 hospitals and recommended sample size
not achieved;
• Less than 5 hospitals included in countries with more than 5 hospitals but inclusion of 50–75% of all hospitals
or occupied hospital beds in the country.
Very poor
• Inclusion of less than 5 hospitals and less than 50% of all hospitals and less than 50% of all occupied hospital
beds.
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Data collection
Data collection includes variables at the national, hospital, ward and patient level. In the patient-based (standard)
protocol, denominator data are collected for each patient. In the unit-based (light) protocol, aggregated
denominator data are collected for each ward. In both protocol options, hospital and ward data (optional
indicators) are collected, and numerator data are collected for each patient with an active healthcare-associated
infection (related to acute care hospital stay) and/or receiving an antimicrobial drug at the time of the survey. The
patient-based and unit-based protocol may not be combined for the same PPS in a single hospital.
When?
Data should be collected in a single day for each ward/unit. The total time frame for data collection for all wards of
a single hospital should not exceed two to three weeks. It is practice in some hospital units to admit additional
patients on Mondays for elective procedures; it is therefore recommended to conduct the survey in these units
between Tuesday and Friday.
Who will collect the data?
The composition of the team responsible for data collection may vary from one hospital to another. It is
recommended that hospital infection control personnel as well as the team in charge of the patients are involved.
Training of surveyors
Training material for the personnel collecting the data is made available by ECDC. It is recommended that
national/regional PPS coordinators organise at least a one-day information and training session for participating
hospitals prior to the point prevalence survey.
Data processing
Each country is free to organise its own system for data collection and processing. The standard scenario however
foresees that data should be collected on forms (see examples provided in this protocol) and subsequently be
entered in a computer system by the hospital staff after data verification. Countries may choose to develop and
use their own software system to do this. Alternatively, ECDC supports a free software tool for data entering at the
hospital level (HelicsWin.Net). If HelicsWin.Net is used, data should be exported by the hospitals and transferred to
the national coordination centre. National centres will then submit the national database or individual hospital data
to ECDC, using ECDC’s TESSy, after which online reports will be made available by ECDC (see also chapter on
sample design for reporting of results at the European and hospital level).
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Overview of collected data
Data collected at the hospital level conform to the following two protocol types:
Light (unit-based) protocol
Hospital data (forms H1-H3): one form per hospital per PPS.
Ward data (form W): one form per ward, including structure and process indicators (optional) and
denominator data for all patients present in the ward at 8 a.m. and not discharged at the time of the survey
(mandatory).
Numerator data (form B): healthcare-associated infection data (to be collected for all patients with an
infection that matches the definition of active healthcare-associated infection) and/or antimicrobial use data
(to be collected for all patients receiving an antimicrobial agent), together with basic patient variables for
each patient with an HAI and/or receiving an antimicrobial agent.
National data (e.g. hospital denominator data) are collected by the PPS coordinating centre (form N).
Standard (patient-based) protocol
Hospital data (forms H1–H3): one form per hospital per PPS.
Ward data (form W): one form per ward, including structure and process indicators (optional) and
denominator data for all patients present in the ward at 8 a.m. and not discharged at the time of the survey
(optional).
Patient data (form A): one form per patient (for all patients present in the ward at 8 a.m. and not
discharged at the time of the survey) collecting risk factors for each eligible patient, with or without an HAI
or antimicrobial; healthcare-associated infection data (to be collected for all patients with an infection that
matches the definition of active healthcare-associated infection) and/or antimicrobial use data (to be
collected for all patients receiving an antimicrobial agent) are collected on the same form.
In addition to the hospital data, national data (e.g. hospital denominator data) are collected by the PPS
coordinating centre (form N).
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Hospital data
Hospital variables are collected in order to describe results by type and size of healthcare facilities and by the
average length of stay in the hospital, a variable which is known to influence prevalence figures because patients
with infections are known to stay longer in the hospital than the average hospital population.
The questionnaire also includes structure and process indicators (SPIs) at the hospital level in the context of
Council Recommendation 2009/C 151/01 of 9 June 2009 on patient safety, including the prevention and control of
healthcare-associated infections. For the selection process of SPIs and the scientific reference [4], see introduction.
Figure 3. Hospital data 1/3 (form H1)
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Figure 4. Hospital data 2/3 (form H2)
Figure 5. Hospital data 3/3 (form H3, optional): Ward indicator data collected at hospital level
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Definition of hospital data
Hospital code. Hospital identifier/code assigned by national/regional PPS coordinating centre; unique code per
surveillance/PPS network; should remain the same for all PPS periods/years.
Survey dates. Start and end date for the PPS in the entire hospital; the end date is the date the data were
collected in the last ward.
Hospital size. Total number of beds in the hospital. Include all beds that may generate (in)patient-days and
admissions/discharges. Exclude beds which are exclusively used for day cases (e.g. day-care wards).
Number of acute care beds. Number of acute care beds in the hospital (in accordance with to national
definition)
Number of ICU beds. Number of intensive care unit beds in the hospital. No ICU=0
Ward exclusion. Were any wards excluded for the PPS in your hospital? Yes/No.
Specify excluded wards. Specify which wards where excluded, if any; free text; please use specialty codes if
possible.
Total number of beds in included wards. Sum of the number of beds in wards that were included in the PPS.
Total number of patients included in PPS. Sum of the number of patients included in the PPS; variable used
to double-check the exhaustiveness of reported data, i.e. the sum of a ward’s total number of patients in the light
protocol option, or the total number of individual patients in the standard protocol option.
Hospital type. Hospital type – PRIM: primary, SEC: secondary, TERT: tertiary, SPEC: specialised (definitions see
below), missing=UNK; include specialisation if applicable; report the hospital type of the hospital site (single
hospital) here; the type of the administrative hospital group/trust (if applicable) is reported in a separate variable
(see variable ‘Administrative hospital group type’ below).
1 Primary
Often referred to as ‘district hospital’ or ‘first-level referral’.
Few specialities (mainly internal medicine, obstetrics-gynaecology, paediatrics, general surgery or only general
practice).
Limited laboratory services are available for general, but not for specialised pathological analysis.
Often corresponds to general hospital without teaching function.
2 Secondary
Often referred to as ‘provincial hospital’.
Hospital is highly differentiated by function with five to ten clinical specialities, such as haematology, oncology,
nephrology, ICU.
Takes some referrals from other (primary) hospitals.
Often corresponds to general hospital with teaching function.
3 Tertiary
Often referred to as ‘central’, ‘regional’ or ‘tertiary-level’ hospital.
Highly specialised staff and technical equipment (ICU, haematology, transplantation, cardio-thoracic surgery,
neurosurgery).
Clinical services are highly differentiated by function.
Specialised imaging units.
Provides regional services and regularly takes referrals from other (primary and secondary) hospitals.
Often a university hospital or associated to a university.
4 Specialised hospital
Single clinical specialty, possibly with sub-specialties.
Highly specialised staff and technical equipment.
Specify (e.g. paediatric hospital, infectious diseases hospital).
Hospital specialisation type. Free text. Include hospital specialty if specialised hospital (e.g. paediatric,
infectious diseases, etc.); please use specialty codes if possible
Hospital ownership. Hospital ownership as defined by WHO Regional Office for Europe [7], Eurostat [8] and OECD
[9]: PUB: Public, PRIVNFP: private, not-for-profit, PRIVFP: private, for profit, OTHUNK: other or unknown
Public: Hospitals that are owned or controlled by a government unit or a public corporation (where control is
defined as the ability to determine the general corporate policy).
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Private, not for profit: Hospitals that are legal or social entities created for the purpose of producing goods and
services, whose status does not permit them to be a source of income, profit, or other financial gain for the
unit(s) that establish, control or finance them.
Private, for profit: Hospitals that are legal entities set up for the purpose of producing goods and services and
are capable of generating a profit or other financial gain for their owners.
Other or unknown: Hospital ownership cannot be categorised as one of one of the above, or hospital
ownership is unknown.
Note: If applicable, prioritise ‘for profit’ over ownership of the building, e.g. if a hospital building is state-owned but the
management is private (for profit), select ‘private, for-profit’.
Hospital is part of administrative hospital group (AHG): The hospital is part of an administrative group of
hospitals (AHG, including entities referred to as ‘trusts’, ‘mergers’, ‘fusions’, ‘boards’, ‘chains’, etc.). Yes/No
Data apply to single hospital site or to AHG/trust. If the hospital is part of an administrative hospital group
(AHG), data apply to a single hospital (hospital with a single address, or a hospital site belonging to a trust) (S) OR
to an administrative group of hospitals (T).
AHG code. Unique code/identifier for the administrative hospital group; text allowed; please ensure that the AHG
code/identifier is identical for all hospital sites belonging to that AHG. Code is selected and generated by the
Member State and should remain identical in different surveillance/PPS periods/years; can be identical to the
hospital code if the data apply to an AHG.
Administrative hospital group type. If the hospital is part of an AHG, what is the hospital type, e.g. PRIM:
primary, SEC: secondary, TERT: tertiary, SPEC: specialised (see above for definition of hospital type). Report the
highest level of care, e.g. ‘tertiary’ if a group with three sites contains one specialised, one primary, one secondary
and one tertiary hospital. The combined services of the hospital sites belonging to a hospital group may also
change the level of care (e.g. combination of the clinical specialties of primary and/or specialised hospitals may
result in the AHG matching the definition of a secondary hospital).
Total number of beds in administrative hospital group. Total number of beds of the administrative hospital
group.
Number of acute care beds in administrative hospital group. Total number of acute care beds of the
administrative hospital group.
Hospital indicators:
Number of discharges/admissions. Number of hospital discharges in a given year (data from previous year if
available, specify year in second column), use number of admissions if discharges are not available; provide the
number for the included wards only (if not available, provide number for entire hospital; specify ‘included wards
only’ OR ‘total for hospital’ in last column).
Number of patient-days. Number of hospital patient-days in a given year (data from previous year if available,
specify year in second column). Provide data for the same year and wards (included wards only OR total for
hospital) as for the number of discharges/admissions.
Alcohol hand rub consumption.
Total number of litres of alcoholic hand rub used in a given year (data from
previous year if available, specify year in second column); provide the number for the included wards only (if
available, otherwise provide number for the entire hospital; specify ‘included wards only OR total for hospital’ in
last column).
Number of observed hand hygiene opportunities. Number of observed hand hygiene opportunities
performed in the previous year (or the most recent available year). Report the total number of observed
opportunities for hand hygiene, not only the compliant observations.
Number of blood cultures per year. Number of inpatient blood culture sets received and incubated by the
microbiological laboratory for the current hospital over the period of one year. Provide data for the previous year or
report the most recent available data (specify year data in a separate variable). If the number of blood culture sets
is not available, estimate by dividing the [total number of blood culture bottles processed] by the [total number of
bottles per blood culture request]. Count all blood culture sets per patient, not the number of patients for whom
≥1 set was processed. Count the number of blood culture sets actually received and incubated, not the number
sent to the laboratory for analysis.
Number of stool tests for CDI per year. Number of inpatient stool tests performed for
Clostridium difficile
infections (CDI) per year. Provide data for previous year or the most recent available data (specify year data in a
separate variable). Count all stool specimens per patient, not the number of patients for whom ≥1 test was
performed. Count the number of stool specimens actually processed by the laboratory (= at least one test for CDI
was performed on the sample), not the number sent to the laboratory for analysis.
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Number of FTE infection control nurses. Number of full-time equivalent (FTE) infection control nurses in the
hospital; infection control nurse=nurse with specialised training in infection control/hospital hygiene and usually
responsible for infection control/hospital hygiene tasks such as training of hospital employees in infection control,
elaboration and implementation of infection control procedures, management (implementation, follow-up,
evaluation) of an infection control work plan and projects, audits and evaluation of performance, procedures for
disinfection of medical devices etc.. Specify year of data collection (current year if available) and whether the
number of FTE infection control nurses is provided for the entire hospital or only for the included wards.
Number of FTE infection control doctors. Number of full-time equivalent (FTE) infection control doctors (or
pharmacists, hospital epidemiologists, etc.) in the hospital with specialised training in infection control/hospital
hygiene and usually responsible for infection control/hospital hygiene tasks such as identification and investigation
of outbreaks, analysis and feedback of infection control data, elaboration of an infection control work plan and
projects, design and management of surveillance systems, elaboration of infection control procedures etc.. Please
ensure that the reported number was collected for the same year and wards (included wards only OR total for
hospital) as the number of FTE infection control nurses.
Number of FTE antimicrobial stewardship consultants. Number of full-time equivalent antimicrobial
stewardship consultants in the hospital. FTE antimicrobial stewardship refers to the dedicated time of a consultant
(or pharmacist) employed by the hospital and specifically paid for antimicrobial stewardship tasks (e.g.
antimicrobial stewardship activities mentioned as part of his/her job description),
not
the time spent by treating
physicians on antimicrobial stewardship activities (e.g. post-prescription review) as part of their daily practice.
Deduct FTE from FTE infection control doctor if same person: in case antimicrobial stewardship tasks are an
integral part of the job description/daily activities of the infection control doctor (or equivalent), the estimated FTE
(proportion of his/her time) spent on antimicrobial stewardship activities should be deduced from the FTE infection
control doctors and be reported separately.
Number of FTE registered nurses. Number of full-time equivalent registered (graduated, qualified) nurses in
the hospital. A ‘registered nurse’ is a nurse who has graduated from a college’s nursing programme or from a
school of nursing and has passed a national licensing exam to obtain a nursing license. Also include ‘agency
nurses’, ‘bank nurses’, ‘interim nurses’ or other registered nurses who are not permanently employed for that
position in the hospital. Students are not included. Provide current situation if possible, or the situation for the
earliest available year (specify year) and specify if the number of FTEs is given for the entire hospital or for the
included wards only.
Number of FTE nursing assistants. Number of full-time equivalent nursing assistants in the hospital. A ‘nursing
assistant’ is also referred to as ‘nurses’ aide’, ‘healthcare assistant’, ‘nursing auxiliary’, ‘auxiliary nurse’, ‘patient care
assistant’ or similar terms. Also include nursing assistants who are not permanently employed for that position in
the hospital. Nursing assistants work under the supervision of nurses or physicians to address the most
fundamental elements of a patient’s care. In general, they feed, dress, bathe and groom patients, but they can
also perform more medically oriented but basic duties such as measuring and recording temperature, blood
pressure, and other vital signs. Other licensed health professionals such as dieticians, physiotherapists or speech or
occupational therapists, logistic personnel, students of any kind or volunteers who provide basic patient care
without pay should not be included. Provide current situation if possible, or the situation for the earliest available
year (specify year) and specify if the number of FTEs is given for the entire hospital or for the included wards only.
Number of FTE registered nurses in ICU. Number of full-time equivalent registered (graduated, qualified)
nurses in intensive care unit(s). A ‘registered nurse’ is a nurse who has graduated from a college’s nursing
programme or from a school of nursing and has passed a national licensing exam to obtain a nursing license. Also
include ‘agency nurses’, ‘bank nurses’, ‘interim nurses’ or other registered nurses who are not permanently
employed for that position in the hospital. Students are not included. Provide current situation if possible, or the
situation for the earliest available year (specify year) and specify if the number of FTEs is given for the entire
hospital or for the included wards only.
Number of FTE nursing assistants in ICU. Number of full-time equivalent nursing assistants in in intensive
care unit(s). A ‘nursing assistant’ is also referred to as ‘nurses’ aide’, ‘healthcare assistant’, ‘nursing auxiliary’,
‘auxiliary nurse’, ‘patient care assistant’ or similar terms. Also include nursing assistants who are not permanently
employed for that position in the hospital. Nursing assistants work under the supervision of nurses or physicians to
address the most fundamental elements of a patient’s care. In general, they feed, dress, bathe and groom
patients, but they can also perform more medically oriented but basic duties such as measuring and recording
temperature, blood pressure, and other vital signs. Other licensed health professionals such as dieticians,
physiotherapists or speech or occupational therapists, logistic personnel, students of any kind or volunteers who
provide basic patient care without pay should not be included. Provide current situation if possible, or the situation
for the earliest available year (specify year) and specify if the number of FTEs is given for the entire hospital or for
the included wards only.
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Number of airborne infection isolation rooms. Number of airborne infection isolation rooms in the hospital.
An airborne infection isolation room is defined as a hospital room provided with negative pressure and an
anteroom.
Annual IPC plan, approved by CEO. Is there an annual infection prevention and control (IPC) plan
and
if so,
was it approved by the hospital Chief Executive Officer (CEO, managing director) or by a senior executive officer?
Yes/No.
Annual IPC report, approved by CEO. Is there an annual infection prevention and control (IPC) report
and
if
so, was it approved by the hospital Chief Executive Officer (CEO, managing director) or by a senior executive
officer? Yes/No.
Participation in surveillance networks. Indicate (Yes/No) if your hospital participates in a national or regional
surveillance network for each of following surveillance modules: surveillance of surgical site infections (SSI),
surveillance of HAIs in intensive care (ICU), surveillance of
C. difficile
infections (CDI), surveillance of antimicrobial
resistance in accordance with the EARS-Net protocol (surveillance of antimicrobial resistance in invasive isolates of
S. pneumoniae
,
S. aureus
,
Enterococcus
spp.,
E. coli
,
K. pneumoniae
,
P. aeruginosa
and/or
A. baumannii
),
surveillance of antimicrobial consumption in the hospital (surveillance at 5th ATC level in defined daily dose (DDD)
per 1 000 patient-days) and other HAI or AMR surveillance modules (national/regional protocols for which a
European/ECDC protocol does not exist). Local surveillance without transmission of data to a national or regional
surveillance coordination centre for comparative analysis and feedback is not sufficient.
Other surveillance networks specification. Free text. Specify which other surveillance networks the hospital
participates in (free text).
Microbiological laboratory performance during weekends. At weekends, can clinicians request routine
microbiological tests and receive back results within the standard turnaround time? Report yes/no/unknown
separately for Saturdays and Sundays for clinical tests and screening tests, respectively.
Does your hospital have the following in place for HAI prevention or antimicrobial stewardship?
Indicate for each of the main HAI types and for antimicrobial stewardship which components of a multimodal
strategy are available at the hospital-wide level and specifically in intensive care (presence in at least one adult,
paediatric or neonatal ICU). Each cell of the table is a Yes/No/Unknown variable (28 variables for ICU + 35
variables hospital-wide/other non-ICU wards): mark Y=Yes, N=No or U=Unknown or ‘not assessed’ in each cell.
A multimodal strategy is defined as an intervention aiming at improving practice and offering education and
training at multiple levels (e.g. written information, leaflets, posters, bedside teaching, workshops, focus groups,
knowledge tests, competency assessments, surveillance and feedback, audits, checklists). The strategy must be
underpinned by written guidelines. Simple information sessions (e.g. for new staff), updating guidelines, or target
setting alone (even if communicated to staff but without combining it with education and training) are not
multimodal strategies.
Targets for multimodal strategies:
Pneumonia: prevention of healthcare-associated pneumonia. You should tick the box for pneumonia, even if
the components of your multimodal strategy only refer to device-associated pneumonia.
Bloodstream infections (BSIs): prevention of healthcare-associated BSIs. You should tick the box for
bloodstream infections, even if the components of your multimodal strategy only refer to catheter-
associated/related BSIs.
Surgical site infections (SSIs): prevention of SSIs. You should tick the box for surgical site infections, even if
the components of your multimodal strategy only refer to specific types of surgery.
Note: Prevention of SSIs in the ICU is assumed to be part of the hospital-wide SSI prevention strategy.
Urinary tract infections (UTIs): prevention of UTIs. You should tick the box for urinary tract infections, even
if the components of your multimodal strategy only refer to catheter-associated/related UTIs.
Antimicrobial use/stewardship: Antimicrobial stewardship refers to a coordinated programme that
implements interventions to ensure appropriate antimicrobial prescribing in order to improve clinical efficacy
of antimicrobial treatment, to limit AMR and to prevent
Clostridium difficile
infections. Antimicrobial
stewardship contributes to high quality and effective healthcare through decreasing unnecessary
antimicrobial-related morbidity and mortality and limiting selective pressure to minimise development of
resistance to currently effective antibiotics.
Multimodal strategy components: only report the existence of any of following components when evidence can be
presented, e.g. printed copies or electronic documents or tools.
Guideline: written guideline document available on the ward
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Care bundle: a care bundle is a structured way of improving the processes of care and patient outcomes:
a small, straightforward set of evidence-based practices — generally three to five — that, when performed
collectively and reliably, have been proven to improve patient outcomes [9]. Should be implemented as part
of a formally endorsed hospital programme.
Training: regular training, courses or other forms of education. Should be organised at least once per year.
Checklist: checklist is filled in by the healthcare workers (HCWs), as opposed to an audit (see directly
below).
Audit: evaluation of the implementation of prevention practices (process evaluation, observations, etc.) by
another person than the one/those who are supposed to implement the practices. An audit is a process
during which a practice is measured against a standard such as VAP/CLABSI prevention or antimicrobial
stewardship guidelines (e.g. intubation/catheterisation, tube care/catheter care). Includes giving verbal
feedback, e.g. between two clinicians. Formal feedback of printed/written results should be reported
separately under ‘feedback’.
Surveillance: surveillance of HAI type on a periodical or continuous basis, also including local surveillance
(not only as part of a surveillance network)
Feedback of surveillance and/or audit results to frontline HCWs. Only report ‘yes’ in the case of (yearly or
more frequently) written feedback, e.g. as part of an institutional infection prevention and control report.
Verbal feedback as part of an audit is not sufficient.
H3 form: optional
The variables on the third hospital form (H3) are normally collected at the ward level. However, countries which do
not collect indicators at the ward level may collect these data at the hospital level. Also, if some wards failed to
provide a complete set of ward-level indicators, hospital-level data make it possible to obtain a complete picture.
Provide data from the current year, or from the most recent available year.
Number of beds with AHR dispensers at point of care. Number of beds in the hospital with alcohol hand rub
(AHR) dispensers available at the point of care as recommended by the 2009 WHO
Guidelines on Hand Hygiene in
Health Care
. AHR dispensers at the entrance of the patient room only are
not
considered as ‘available at the point
of care’. The ‘point of care’ is the place where three elements come together: the patient, the HCW, and care or
treatment involving contact with the patient or his/her surroundings (within the patient zone). The concept
embraces the need to perform hand hygiene at recommended moments exactly where care delivery takes place.
This requires that a hand hygiene product (e.g. alcohol-based hand rub, if available) be easily accessible and as
close as possible – within arm’s reach of where patient care or treatment is taking place. Point-of-care products
should be accessible without having to leave the patient zone. Dispensers available at the point of care that are
empty on the PPS day should be included. Provide the number for the included wards only (if available, otherwise
provide number for the entire hospital; specify ‘included wards only OR total for hospital’ in last column).
Number of beds assessed for the presence of AHR dispensers. The denominator of the previous variable,
i.e. the total number of beds for which the presence of alcohol hand rub dispensers at the point of care was
checked. If all wards were assessed, then this number would in principle be the same as the total number of
hospital beds.
Total number of patient rooms. Total number of rooms in included wards or total for hospital. Provide the
number for the included wards only. If not available, provide number for the entire hospital; specify ‘included wards
only
or
total for hospital’ in last column.
Number of single patient rooms. Total number of single-bed rooms in included wards
or
total for hospital.
Please ensure that the number of single patient rooms was collected for the same year and wards (included wards
only OR total for hospital) as the total number of patient rooms. Rooms with more than one bed that are
designated for use as single occupancy and isolation rooms (e.g. for infection control purposes) should be included.
Number of single patient rooms with individual toilet and shower. Total number of single-bed rooms with
individual toilet and shower in included wards
or
total for hospital. Please ensure that the number was collected in
the same year and the same wards (included wards only
or
total for hospital) as the total number of patient rooms.
Rooms with more than one bed that are designated for use as single occupancy and isolation rooms (e.g. for
infection control purposes) should be included. Rooms which have toilet and shower in a communal area should
not be counted. An individual toilet alone or a commode (toilet chair) is not sufficient to qualify for this indicator.
Number of beds occupied at 00:01 on the day of the PPS. Number of hospital beds occupied at midnight on
the day of the PPS. Because the PPS for an entire hospital usually takes several days, this variable does not have to
be recorded at the beginning of the PPS data collection period; it should, however, not be recorded on weekends.
Number of beds assessed for occupancy at 00:01 on the day of PPS. Number of hospital beds that were
checked for occupancy at midnight on the day of the PPS. Denominator of the previous variable. If occupancy was
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checked for all beds, this variable normally equals the total number of beds in the hospital. Specify ‘included wards
only
or
total for hospital’ in the last column.
Percentage of healthcare workers in hospital that carry alcohol hand rub dispensers. Do healthcare
workers in your hospital carry AHR dispensers (e.g. in their pockets)? (If yes, please estimate percentage).
No=0%, Q0; 1–25%: Q1; 26–50%: Q2; 51–75%: Q3; >75%: Q4
Post-prescription review of antimicrobials in hospital. Is there a formal procedure in the hospital to review
the appropriateness of an antimicrobial within 72 hours (three calendar days) from the initial order in the hospital
(post-prescription review)? A formal post-prescription review procedure should be documented and adopted by the
hospital management and should be performed by a person or team other than the treating physician. The
procedure should at least address the prescription of broad-spectrum or reserve antimicrobials. Choose one
answer. YESALL = Yes, in all wards; YESSEL = Yes, in selected wards only (usually, but not necessarily, including
ICU); YESICU = Yes, in ICU only; N = No; UNK=Unknown.
General variables and notes:
Year data. Year for which different hospital data apply; to be specified for each variable.
Included wards only/total for hospital. Hospital data were collected for wards included in the PPS only (code:
Incl, this is the recommended case) or for the entire hospital (code: Tot); if all wards are included in the PPS
(Incl=Tot), mark ‘Incl’; to be specified for each variable.
Comments. Free text, comments, maximum 255 characters.
Note: Full-time equivalent (FTE) is the proportion of a full time position/job. One FTE = one full time position, but this could
also be the sum of 2 half-time (50%) positions of two different persons; 0.10 FTE is 10% of a full time position. FTEs are
reported ‘on the day of the PPS’ or as a ‘daily average’ for the previous year, depending on the variable. If only person-hours or
person-days are available for a year (e.g. for registered nurses), they should be converted to FTEs ‘per day’, taking into account
the local definition of a full-time position in terms of number of hours per day, week or month (and, if applicable, the number of
working days per month or per year).
Hospital variables to be added by PPS coordinating centre
before submission to ECDC’s TESSy
RecordId. Unique identifier for each hospital-PPS within each network (combination of
[NetworkId]+[HospitalId]+[DateStartSurvey]).
RecordType. The record type tells TESSy which protocol and level the data relate to. For the PPS, the record type
at hospital level (first level) is ‘HAIPPS’ for the standard protocol, and ‘HAIPPSLIGHT’ for the light protocol.
RecordTypeVersion. There may be more than one version of a record type.
Subject. ‘Disease’ to report. For PPS, ‘HAIPPS’ for all levels.
DataSource. One country can have several data sources. Should correspond to the name of the data source
defined in TESSy (e.g. CC-HAI, where ‘CC’ is a country code); one data source can be used to upload different HAI
data (e.g. SSI, ICU and PPS) if the coordinating centre is the same for different surveillance protocols.
ReportingCountry. Country reporting the record, codes see codebook.
DateUsedForStatistics. Start date of the survey in the hospital; this date allows to distinguish repeated surveys
for the same institution. Countries can upload more than one PPS in a single year.
Status. Status of reporting NEW/UPDATE or DELETE (deactivate). Default if omitted: NEW/UPDATE. If set to
DELETE, the record with the given RecordId will be deleted from the TESSy database (or, rather, invalidated). If set
to NEW/UPDATE or left blank, a new record is entered into the database.
NetworkId. Unique identifier for each surveillance/PPS network within the country, selected and generated by
Member State, e.g. EN, NI, SC, WA for United Kingdom or different CClin networks in France; this field is combined
with the hospital identifier to create a unique hospital code since different networks within one country may use
the same hospital code. Can be omitted if the hospital identifiers are unique within the reporting country.
Hospital location. Region (NUTS 1 code) where the hospital is located; NUTS 1 codes see codebook.
Hospital is part of national representative sample. ‘Yes’ if the hospital is part of a national representative
sample of hospitals (if the national sampling method provides a representative sample, only these hospitals will be
included for the national figures at the EU level; see chapter on sampling). To be provided by the national/regional
PPS coordinator.
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Ward data
Ward data can be collected in the standard and light protocol options. Ward-level indicators can optionally be
collected at the hospital level, for the entire hospital (form H3), instead of – or in addition to – collecting these
variables for each ward. Ward-level denominator data are optional for the standard option but mandatory for the
light option. Denominator data are collected for all patients admitted before or present at 8 a.m. in the ward and
not discharged from the ward at the time of the survey.
Figure 6. Ward data (form W)
Definition of ward data
Survey date. Date on which the data were collected in the ward. Data from a single ward should be collected on
one day; date dd/mm/yyyy.
Hospital code. Hospital identifier/code assigned by national/regional PPS coordinating centre; unique code per
surveillance/PPS network, should remain the same in different PPS periods/years.
Ward name (abbreviated)/unit ID. Unique identifier for each hospital unit (abbreviated ward name); essential
for linking between denominator and HAI/AU data; should be used consistently on all forms and should remain the
same in different PPS periods/years.
Ward specialty. Main ward specialty (≥ 80% of patients requiring this specialty). If fewer than 80%, report
‘mixed ward’ (MIX). PED=Paediatrics, NEO=Neonatal, ICU=Intensive Care, MED=Medicine, SUR=Surgery,
GO=Gynaecology/Obstetrics, GER=Geriatrics, PSY=Psychiatry, RHB=Rehabilitation, LTC=Long-term care,
OTH=Other, MIX=Mixed.
As a rule, the ward specialty code is composed of the three first letters of the main consultant/patient specialty,
with two exceptions: code ICUNEO (NICU) as ward specialty NEO and ICUPED (PICU) as ward specialty PED. The
ward specialty can be combined with patient specialty to refine specialties, e.g. in paediatrics: ward specialty PED
+ patient specialty: ICUPED = paediatric ICU, PED + SURCARD = paediatric cardiac surgery, PED + MEDONCO =
paediatric oncology.
A ward with healthy newborns must either be allocated to GO (GOBAB) when it is located in obstetrics, or to PED
(PEDBAB) if it is located in paediatrics.
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Note: How to code paediatric patients: Use the ward code PED for paediatric wards. If the ward specialty code is PED, then
patients should be coded as per consultant/patient specialty MEDGEN, MEDSUR, etc. The consultant/patient specialty PEDGEN
should normally only be used for paediatric patients on adult wards.
Total number of patients in ward. Total number of patients admitted to the ward before or at 8 a.m. that were
not discharged from the ward at the time of the survey. This is mandatory for the light protocol option, but optional
for the standard protocol option.
Number of patients in ward by consultant/patient specialty. Light protocol option only. Number of
patients admitted to the ward before or at 8 a.m. and not discharged from the ward at the time of the survey,
recorded separately for each consultant/patient specialty.
Consultant/patient specialty. Specialty of physician in charge of the patient, or main specialty for which the
patient was admitted to the hospital. See specialty list (six-letter codes). In ward data, this variable needs to be
completed in light protocol option only. Also see patient data.
Post-prescription review of antimicrobials in ward. Is there a formal procedure to review the
appropriateness of an antimicrobial within 72 hours from the initial order in this ward (post-prescription review)?
A formal post-prescription review procedure should be documented and adopted by the hospital management and
should be performed by a person or team other than the treating physician. The procedure should at least address
the prescription of broad-spectrum or reserve antimicrobials. Yes/no
Number of patient-days in ward. Number of patient-days in one year for current ward (data from previous year
if available, specify year in second column).
Alcohol hand rub consumption in wards (litres/year). Number of litres of alcohol hand rub delivered to the
ward in one year. Provide data for the same year as the number of patient-days in the ward.
Number of hand hygiene opportunities observed in ward/year. Number of hand hygiene opportunities
observed in the current ward in one year. Provide data for previous year or the most recent data available (specify
year in second column). Report the total number of observed opportunities for hand hygiene, not only the
compliant observations.
Number of beds in ward. Total number of beds in ward on the PPS day. Include ‘corridor beds’ and neonatal
beds.
Number of beds in ward with AHR dispensers at the point of care. Number of beds in the ward with
alcohol hand rub (AHR) dispensers available at the point of care as recommended by the 2009 WHO
Guidelines on
Hand Hygiene in Health Care
. AHR dispensers at the entrance of the patient room only are
not
considered as
‘available at the point of care’. The ‘point of care’ is the place where three elements come together: the patient, the
HCW, and care or treatment involving contact with the patient or his/her surroundings (within the patient zone).
The concept embraces the need to perform hand hygiene at recommended moments exactly where care delivery
takes place. This requires that a hand hygiene product (e.g. alcohol-based hand rub, if available) be easily
accessible and as close as possible – within arm’s reach of where patient care or treatment is taking place. Point-
of-care products should be accessible without having to leave the patient zone.
Number of HCWs on ward at time of PPS. Number of healthcare workers (HCWs) on ward at the time of PPS.
The purpose of this variable is to measure the denominator of those carrying AHR dispensers. Therefore, HCWs
should not be included if there is no information on the carriage of alcohol hand rub dispensers.
Number of HCWs on ward carrying AHR dispensers. Number of HCWs on ward carrying AHR dispensers
(e.g. in their pockets).
Number of rooms in ward. Total number of rooms in the ward on the PPS day.
Number of single rooms in ward. Total number of single-bed rooms in the ward on the PPS day. Rooms with
more than one bed that are designated for use as single occupancy and isolation rooms (e.g. for infection control
purposes) should be included.
Number of single rooms with individual toilet and shower. Total number of single-bed rooms with individual
toilet and shower in the ward. Rooms which have toilet and shower in a communal area should not be counted. An
individual toilet alone or a commode (toilet chair) is not sufficient to qualify for this indicator.
Number of beds occupied at 00:01 on the day of PPS. Number of ward beds occupied at midnight on the
day of the PPS (can also be measured at midnight after the PPS took place).
Comments/observations. Free text field to report, for example, feasibility issues, data quality problems, or
specific epidemiological information for the current ward.
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Patient data (standard protocol option)
In the standard (patient-based) protocol option, demographic data and risk factors are collected for each patient
present at/admitted to the ward before or at 8 a.m. and not discharged from the ward at the time of the survey
(including patients not receiving an antimicrobial and not presenting a healthcare-associated infection).
Figure 7. Patient-based risk factors (form A): one form per patient, antimicrobial use and HAI data
collected on same form
Definition of patient data
Hospital code. Hospital identifier/code assigned by national/regional PPS coordinating centre; unique code per
surveillance/PPS network.
Ward name. Abbreviated name of hospital ward: essential for linking between denominator and HAI/AU data;
should be used consistently on all forms and should remain the same in different PPS periods/years.
Ward specialty. Main ward specialty (≥ 80% of patients requiring this specialty). If fewer than 80%, choose
mixed ward (MIX). See more details under ward data and specialty code list. This variable can be omitted from the
patient data if ward data are provided. If ward data are not provided, it should be added on the patient form.
Survey date. Date on which data were collected in this ward. Data from a single ward should be collected on one
day (dd/mm/yyyy). This variable can be omitted from the patient data if ward data are provided. If ward data are
not provided, it should be added on the patient form.
Patient counter. Number: anonymised patient number makes it possible to establish a link between patient data
and HAI or antimicrobial use data. Not the actual patient identifier.
Age in years. Patient age in years.
Age in months. Patient age in months if the patient is less than two years old.
Sex. Gender of the patient: M (male), F (female), or UNK (unknown).
Date of hospital admission. Date on which the patient was admitted to the hospital for the current
hospitalisation (dd/mm/yyyy).
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Consultant/patient specialty. Specialty of physician in charge of the patient or main specialty for which the
patient was admitted to the hospital. If the consultant specialty differs from the patient specialty, give priority to
the patient specialty. For paediatric patients on a PED ward, use the subspecialty (MEDGEN, MEDSUR, etc.) (see
ward specialty). Please note that long-term care is a ward specialty and should only exceptionally be used as a
patient/consultant specialty.
Surgery since admission. Patient has undergone surgery during current hospitalisation. Surgery is defined as a
procedure performed primarily for therapeutic reasons where an incision is made (not just a needle puncture), with
breach of mucosa and/or skin – not necessarily in the operating theatre. Answer categories: No surgery; yes,
minimally invasive/non-NHSN surgery (examples see annex); yes, NHSN surgery – optionally specify NHSN surgery
code (ICD-9-CM code of the intervention is listed for the surveillance of surgical site infections in the NHSN system,
examples see annexes); unknown.
McCabe score. Classification of the severity of underlying medical conditions. Disregard the influence of acute
infections, e.g. if the patient has an active HAI, estimate the score the patient had before the infection. Answer
categories: Non-fatal disease (expected survival at least five years); ultimately fatal disease (expected survival
between one and five years); rapidly fatal disease (expected death within one year); unknown.
Although the prognosis of diseases varies in time and between hospitals due to changes in treatment options and
their availability, using McCabe scores can still be helpful. Some examples of diseases and their different McCabe
score categories are given below. These examples, in particular those of the second (ultimately fatal) category, are
not meant to be exhaustive but rather to serve as a guidance tool for the current protocol.
Examples of diseases for different McCabe score categories:
Rapidly fatal: < one year
End-stage haematological malignancies (unsuitable for transplant, or relapsed), heart failure (EF < 25%)
and end-stage liver disease (unsuitable for transplant with recalcitrant ascites, encephalopathy or varices)
Multiple organ failure on intensive care unit – APACHE II score > 30, SAPS II score > 70
Pulmonary disease with cor pulmonale
Ultimately fatal: one year to four years
Chronic leukaemias, myelomas, lymphomas, metastatic carcinoma, end-stage kidney disease (without
transplant)
Motor neuron disease, multiple sclerosis non-responsive to treatment
Alzheimer’s disease/dementia
Diabetes requiring amputation or post amputation
Non fatal: > five years
Diabetes
Carcinoma/haematological malignancy with > 80% five-year survival
Inflammatory disorders
Chronic GI, GU conditions
Obstetrics
Infections (including HIV, HCV, HBV – unless in above categories)
All other diseases
Birth weight: birth weight in grams, to be provided for neonates (infants less than one month old); the birth
weight is the weight of the infant at the time of birth and should not be changed as the infant gains or loses
weight.
Central vascular catheter. Patient has central vascular catheter in place on survey date; yes/no/unknown.
A central vascular catheter is defined by the CDC as 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 central-line BSI and counting central-line days in the NHSN system: Aorta,
pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins,
subclavian veins, external iliac veins, common iliac veins, femoral veins, and in neonates, the umbilical
artery/vein.
Notes: 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 these vessels or in or near the heart to qualify as a central line.
An introducer is considered an intravascular catheter, and depending on the location of its tip and use, may be a central line.
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Pacemaker wires and other non-lumened 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.
Source: CDC. Bloodstream infection event. January 2016. Available from: http//www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
Peripheral vascular catheter. Patient has peripheral vascular (venous or arterial catheter) in place;
yes/no/unknown.
Urinary catheter. Patient has indwelling urinary catheter in place at the date of the survey; yes/no/unknown.
Intubation. Patient is under intubation with or without mechanical ventilation (endotracheal tube or
tracheostomy) on survey date; yes/no/unknown.
Patient receives antimicrobial(s). Patient receives at least one systemic antimicrobial agent at the date of the
survey (given or planned treatment, including intermittent treatments, e.g. alternate day; or medical prophylaxis);
for surgical antimicrobial prophylaxis, check whether any surgical prophylaxis was given in the 24 hours prior to 8
a.m. on the day of the survey; yes/no. If yes, collect antimicrobial use data.
Patient has active HAI. Patient has an active healthcare-associated infection on survey date; yes/no. If yes,
collect HAI data.
Notes:
Patient data have to be collected for each patient admitted to the ward at 8 a.m. on the survey date, infected or not, only
excluding day cases (see inclusion criteria).
Maternity: both mother and neonate are counted if present at 8 a.m. on the day of the survey.
Neonates:
Count all infections after their birth.
Register consultant/patient specialty for healthy neonates as either GOBAB or PEDBAB.
Obstetrics: in the case of natural birth with no interventions/procedures/devices, a maternal infection is only considered
as an HAI if the date of onset is on day 3 or later.
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Antimicrobial use data and HAI data
Only collect information if the patient receives at least one antimicrobial at the time of the survey (except in the
24 hours prior to 8 a.m. on the day of the survey for surgical prophylaxis) or if the patient has an active infection
associated to an acute care hospital stay (current or another hospital).
The use of antimicrobials will often lead to the detection of a HAI. Some patients may have a HAI that is not
treated by an antimicrobial (e.g. viral infections, urinary tract infections, etc.), which makes it necessary to consult
other sources (see HAI case finding algorithm). In other cases, the physicians may treat an infection which does
not match the case definition. Therefore the diagnosis list for antimicrobial use differs from the HAI case definition
list (see codebook) and the indication list mentions treatment intention of an infection. It is not the objective of this
survey to relate the use of an antibiotic to the information on HAIs (such as microorganisms). Both types of data
are collected separately.
Antimicrobial use data
Surgical prophylaxis should be registered if given the day before the survey (i.e. in the 24 hours prior to 8 a.m. on
the day of the survey). For all other antimicrobial use (e.g. treatment, medical prophylaxis), any given or planned
(including intermittent treatments, e.g. alternate day) administration of antimicrobials should be registered at the
time of the survey only. If the antimicrobial agent given for treatment or medical prophylaxis was changed on the
day of the survey, only record the last antimicrobial agent at the time of the survey.
Note: The aim is to determine what the physicians think they are treating. In order to do so, we will look at all patient records
and may request additional information from nurses, pharmacists or doctors. The appropriateness of prescriptions will not be
discussed. Also, no attempts will be made to change prescriptions. At no time the staff should feel supervised.
Definitions of antimicrobial use data
Antimicrobial generic or brand name. Allowed are, for example, amoxicillin, but also national brand names;
include ATC codes (ATC2: J01 antibacterials, J02 antifungals; ATC4: A07AA, P01AB, D01BA; ATC5: J04AB02).
Treatment for tuberculosis is excluded but antituberculosis drugs are included when used for treatment of
mycobacteria other than tuberculosis (MOTT) or as reserve treatment for multidrug-resistant bacteria. Brand
names or drug names should be converted into ATC5 codes. See codebook for included antimicrobial agents.
Route. Route of administration of the antimicrobial agent; P=parenteral; O=oral; R=rectal; I=inhalation.
Indication for antimicrobial use. Patient receives systemic antimicrobials for :
Treatment intention: CI: community-acquired infection; LI: infection acquired in long-term care facility (e.g.
nursing home) or chronic-care hospital; HI: acute-hospital-acquired infection.
Surgical prophylaxis: SP1: single dose; SP2: one day; SP3: > 1 day: check if given in the 24 hours prior to 8
a.m. on the day of the survey – if yes, check if given on the day before yesterday or on the day of the
survey in order to determine duration.
MP. Medical prophylaxis.
O. Other indication (e.g. erythromycin use as a prokinetic agent).
UI. Unknown indication/reason (verified during PPS).
UNK. Unknown/missing, information on indication was not verified during PPS.
If the antimicrobial use is intended for treatment of an infection, fill in site of infection (diagnosis). Otherwise code
NA (not applicable).
Diagnosis (site). Diagnosis group by anatomical site: see diagnosis (site) code list for antimicrobial use. Should
only be recorded when the indication is ‘intention to treat an infection’; not recorded for prophylaxis or other
indications (use code NA=not applicable).
Reason in notes: yes/no. Yes if the reason for antimicrobial use was documented in the patient chart/notes.
Date start antimicrobial. Day on which the first dose of the current antimicrobial was administered. If the
patient received the antimicrobial on admission, record the date of admission.
Antimicrobial changed? (+ reason). Was the antimicrobial (or the route of administration) changed for this
infection episode, and if so, what was the reason? If the antimicrobial was changed more than once for the current
infection episode, report the reason of the last change. Changes should be considered for the entire treatment
regimen for one infection episode.
N=no change, antimicrobial was not changed.
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E=escalation: antimicrobial was escalated (or another antimicrobial was added) on microbiological and/or
clinical grounds, i.e. the isolated microorganism was not susceptible to the previous antimicrobial and/or
lack of clinical effect of previous antimicrobial; includes switch from oral to parenteral for the same
antimicrobial.
D=De-escalation: antimicrobial was de-escalated on microbiological and/or clinical grounds, i.e. the isolated
microorganism was susceptible to more narrow-spectrum or first-line antimicrobials than the previous
antimicrobial and/or the clinical situation of the patient allows changing to a more narrow-spectrum or to a
first-line antimicrobial. If other antimicrobials given for the same indication were stopped at the time of the
survey, report de-escalation for the remaining antimicrobial(s).
S=switch IV to oral; route of administration of same antimicrobial was changed from parenteral to oral.
A switch can also occur between antimicrobials belonging to the same antimicrobial class, e.g.
IV ampicillin/sulbactam to oral amoxicillin/clavulanate or IV ceftriaxone to oral cefuroxime axetil.
A=adverse effects; antimicrobial was changed because of observed or expected side or adverse effects of
the antimicrobial.
OU=change for other or unknown reason: the antimicrobial for that indication was changed for another
reason, or the antimicrobial was changed but the reason could not be determined by the surveyor.
U=unknown: no information on whether the antimicrobial was changed or not.
Date start first antimicrobial (if change): If the current antimicrobial replaces a previous one: date on which
the first dose of the first antimicrobial given for the same infection episode was administered. Leave blank if there
was no change (or if there is no information available). If the antimicrobial was changed more than once for the
current indication, report the start date of the first (not the previous) antimicrobial. If the patient received the first
antimicrobial on admission, record the date of admission. The main objectives of collecting this variable are 1)
estimation of the total annual number of patients receiving antimicrobials in acute care hospitals (prevalence to
incidence conversion) and 2) proxy validation of the prevalence of HAIs. Optional.
Dosage per day. Number and strength (in milligrams, grams, IU or MU) of doses of the current antimicrobial
given per day. Report as, for example, ‘4 x 1 g per day’ (three variables: number of doses, strength of one dose,
unit of one dose). When one dose of an antimicrobial is given every other day, report the number of doses as 0.5
(e.g. 0.5 x 1 g/day). The main objectives for collecting this variable are to provide information to 1) enable
comparisons of antimicrobial consumption between Europe and the US, and 2) enable updating the defined daily
doses (DDD) values as set by the WHO Collaboration Centre for Drug Statistics Methodology (Norwegian Institute
of Public Health, www.whocc.no). Report dosage as written in the patient records. Recoding (e.g. to inform DDD
updates) will be done in the analysis phase if needed (e.g. for combined products).
Healthcare-associated infection data
Key terms and notes
An active healthcare-associated infection (associated to acute care hospital stay) present on the day of the
survey is defined as follows:
An infection is active when signs and symptoms of the infection are present on the survey date
or
signs and
symptoms were present in the past and the patient is (still) receiving treatment for that infection on the
survey date. The presence of symptoms and signs should be verified until the start of the treatment in order
to determine whether the treated infection matches one of the case definitions of healthcare-associated
infection.
AND
The onset of symptoms was on Day 3 or later (day of admission = Day 1) of the current admission
or
the
patient presents with an infection but has been readmitted less than 48 hours after a previous admission to
an acute care hospital;
or
The patient has been admitted (or develops symptoms within two days) with an infection that meets the
case definition of an active surgical site infection (SSI), i.e. the SSI occurred within 30 days of the operation
(or in the case of surgery involving an implant, was a deep or organ/space SSI that developed within 90
days of the operation) and the patient either has symptoms that meet the case definition and/or is on
antimicrobial treatment for that infection;
or
The patient has been admitted (or develops symptoms within two days) with
C. difficile
infection less than
28 days after a previous discharge from an acute care hospital;
or
An invasive device was placed on Day 1 or Day 2, resulting in an HAI before Day 3.
Note: Results of tests/examinations that are not yet available on the survey date should neither be completed after the survey
date nor taken into account when establishing whether the case definition criteria are fulfilled. This will probably cause some
actual cases of HAI to be discarded, but this can be seen as compensation for the (potentially long) retrospective period
preceding the start of the treatment when no more signs or symptoms are present on the survey date.
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Device-associated HAI is an HAI in a patient with a (relevant) device that was used within the 48-hour period
before onset of infection (even intermittently). The term ‘device-associated’ is only used for pneumonia,
bloodstream infection and urinary tract infection. The ‘relevant devices’ are intubation, vascular (central/peripheral)
catheter and urinary catheter, respectively. If the interval is longer than 48 hours, there must be compelling
evidence that the infection was associated with device use. For catheter-associated UTI, the indwelling urinary
catheter must have been in place within seven days before positive laboratory results or signs and symptoms
meeting criteria for UTI were evident. See: Horan et al. Definitions of key terms used in the NNIS system. Am J
Infect Control 1997; 25:112-6.
A bloodstream infection (BSI and secondary BSI) is always registered as a separate HAI with specification of
the source in a separate field (peripheral or central catheter, other infection site – S-PUL, S-UTI, S-DIG, S-SSI, S-
SST, S-OTH; the only exceptions are a CRI3 (catheter-related bloodstream infection with microbiological
documentation of the relationship between the vascular catheter and the BSI) and neonatal bloodstream
infections: CRI3 and neonatal BSIs should not be reported twice in the point prevalence survey (see case
definitions). Microbiologically confirmed catheter-related BSI should be reported as a CRI3. Neonatal bloodstream
infections should be reported as NEO-LCBI or NEO-CNSB, together with BSI origin.
Definitions of healthcare-associated infection data
Case definition code. HAI case definition codes: specify subcategory, e.g. PN4, CVS-VASC (see code lists,
overview and HAI case definitions in Annex 2). A single-case definition code should only be provided once per
patient (no different infection episodes). For pneumonia and urinary tract infections, only fill in one subcategory
(priority pneumonia: PN1> PN2> PN3> PN4> PN5; urinary tract infections: UTI-A> UTI-B). For laboratory-
confirmed bloodstream infections, provide only one of BSI, CRI3 (priority CRI3> BSI), NEO-LCBI or NEO-CNSB
(priority NEO-LCBI> NEO-CNSB [> BSI]). All signs and symptoms since the onset of the infection until the time of
the survey should be considered to categorise the HAI.
Relevant device in situ: yes/no/unknown. To be specified for PN, BSI, NEO-LCBI, NEO-CNSB and UTI only.
Answer ‘Yes’ if a relevant invasive device was in situ (even intermittently) for any amount of time within a 48-hour
time period (seven days for UTIs) before onset of the infection, i.e. intubation for pneumonia, central/peripheral
vascular catheter for bloodstream infections, urinary catheter for UTI; Unk=unknown; used to apply CDC definition
of device-associated infection (see Horan TC, et al. Definitions of key terms used in the NNIS system. Am J Infect
Control 1997; 25:112-6).
Infection present at admission: yes/no. Signs and symptoms of the infection were present at admission to
the hospital; if not, provide date onset of infection.
Date of onset. Date of onset of the infection (dd/mm/yyyy). Not to be recorded if signs/symptoms are present at
admission, but mandatory if onset during current hospitalisation. Record the date of first signs or symptoms of the
infection; if unknown, record the date treatment was started for this infection or the date the first diagnostic
sample was taken. If no treatment or sample, please estimate.
Origin of the infection. Infection is associated with (1) current hospital; (2) another acute care hospital;
(3) other origin or unknown. Infections present at admission may be associated with a previous stay in your
hospital or a transfer from another acute care facility. The category ‘other origin or unknown’ can be used, for
example, for infections with an onset after day 2 of the current hospitalisation (= HAI by definition) which the
surveyor does not consider to be associated with the current hospital stay. However, the category should not be
used for long-term care-facility/nursing-home-associated infections, since only HAI associated with acute care
hospital stays are recorded in the ECDC PPS.
HAI associated to current ward. An HAI is associated with the current ward if the infection started on day 3 or
later after admission to the current ward (where the date of admission to the ward is day 1)
or
if the infection
started on day 1 or 2 after placement of an invasive device in the current ward
or
if the patient was readmitted
with an HAI present on admission associated to a previous stay in the same ward, within 30 days after operation
for surgical site infections (or 90 days for deep and organ/space SSI after implant surgery), less than 28 days after
discharge for
C. difficile
infections, less than 48 hours (two calendar days) after discharge for other HAIs.
If BSI: source. If lab-confirmed bloodstream infection, specify the origin: catheter-related (central: C-CVC,
peripheral C-PVC), secondary to another infection: pulmonary (S-PUL), urinary tract (S-UTI), digestive tract (S-
DIG), surgical site infection (S-SSI), skin and soft tissue infection (S-SST), other infection (S-OTH), or BSI of
(confirmed) unknown origin (UO); missing data, no information available=UNK; secondary BSI reported as
separate HAI, in addition to the primary infection if it matches the case definition.
Microorganisms. Collect microbiological results available on the survey date (do not wait for results not available
on the survey date). Specify up to three isolated microorganisms using six-letter microorganism codes (e.g.
STAAUR=
Staphylococcus aureus
); see codebook.
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Antimicrobial resistance phenotype. Specify susceptibility to selected antimicrobial resistance (AMR) marker
depending on microorganism.
Report S (susceptible), I (intermediate), R (resistant) or UNK (unknown) for the antimicrobial group (preferred) or
for tested antimicrobials within the group. Reporting group susceptibility requires that at least one antimicrobial
belonging to the group is tested.
If several antibiotics within the group were tested (e.g. carbapenems (CAR)), report the least susceptible result for
the group (e.g. meropenem R + imipenem I = CAR R).
If AMR markers are collected in accordance with the PPS I protocol methodology (still allowed but not
recommended), report S (susceptible), IR (non-susceptible) or U (unknown), except for MRSA, report non-
susceptibility to oxacillin (or equivalent) as R (resistant).
Staphylococcus aureus
: OXA, GLY
MRSA: Resistant to oxacillin (OXA) or other markers of meticillin-resistant S. aureus (MRSA), such as
cefoxitin (FOX), cloxacillin (CLO), dicloxacillin (DIC), flucloxacillin (FLC), methicillin (MET)
VRSA: Resistant to glycopeptides (GLY): vancomycin (VAN) or teicoplanin (TEC)
VISA: Intermediate to glycopeptides (GLY): vancomycin (VAN) or teicoplanin (TEC)
Enterococcus
spp.: GLY
VRE: Resistant to glycopeptides (GLY): vancomycin (VAN) or teicoplanin (TEC)
Enterobacteriaceae (Selection:
Escherichia coli
,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.,
Citrobacter
spp.,
Serratia
spp.,
Morganella
spp.): C3G, CAR
Third-generation cephalosporins (C3G): cefotaxime (CTX), ceftriaxone (CRO), ceftazidime (CAZ)
Carbapenems (CAR): imipenem (IPM), meropenem (MEM), doripenem (DOR)
Pseudomonas aeruginosa
: CAR
Carbapenems (CAR): imipenem (IPM), meropenem (MEM), doripenem (DOR)
Acinetobacter
spp.: CAR
Carbapenems (CAR): imipenem (IPM), meropenem (MEM), doripenem (DOR)
Pandrug-resistant (PDR). Microorganism is pandrug-resistant. Not PDR =N (susceptible to at least one
antimicrobial), possible PDR = P (I/R to all antimicrobials tested in hospital), confirmed PDR = C (I/R to all
antimicrobials confirmed by reference laboratory), UNK=Unknown.
Source: Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-
resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance.
Clin Microbiol Infect. 2012 Mar;18(3):268-81.
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Recommended case-finding algorithm for healthcare-associated
infections
Figure 8. Recommended case finding algorithm for healthcare-associated infections
UC=urinary catheter; PVC=peripheral vascular catheter; CVC=central vascular catheter
Surveillance team arrives on ward.
Record start date and time
Introduce yourself to ward manager.
Collect ward specialty type, number
of beds.
Request patient list.
Exclude patients from further data
collection if admitted after 8 a.m.
Walk around ward.
For each patient, observe for
invasive devices (UC, PVC, CVC,
ventilation)
Collect denominator data on all
patients in hospital before 8 a.m.
Pass on data forms to
local coordinator or data
entry facilitator.
Collect ONE set of patient notes (medical, nursing,
observation, drug, wound, pressure, stool charts, etc.)
If notes are unclear,
ask for clarification of
signs and
symptoms only
from nursing/medical
team
NO,
mark on form*
Complete data collection for all patients.
Once complete, thank ward manager and leave.
Record end time on forms
YES, fill in surveillance form*
If notes are
unclear, ask for
treatment
indication from
medical, pharmacy,
or nursing teams.
HAI according to standard
definitions?
On antimicrobials?
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Numerator data in the light protocol
Since in the light (unit-based) protocol option denominator data are collected at the aggregated (ward) level, some
additional patient and ward variables should be collected for patients receiving antimicrobials and/or patients with
an active healthcare-associated infection.
Hospital code. Hospital identifier/code assigned by national/regional PPS coordinating centre; unique code per
surveillance/PPS network, should remain the same in different PPS periods/years.
Ward name (abbreviated)/unit ID. Unique identifier for each hospital unit (abbreviated ward name); essential
for linking between denominator and HAI/AU data; should be used consistently in all forms and should remain the
same in different PPS periods/years.
Patient counter. Number: anonymised patient number allows establishing the link between patient data and HAI
or antimicrobial use data. Not the actual patient identifier.
Age in years. Patient age in years; number; if missing=UNK.
Age in months. Patient age in months if the patient is less than two years old.
Sex. Gender of the patient: M (male), F (female), or UNK.
Date of hospital admission. Date patient was admitted to the hospital for the current hospitalisation
(dd/mm/yyyy).
Consultant/patient specialty. Specialty of physician in charge of the patient or main specialty for which the
patient was admitted to the hospital. If the consultant specialty differs from the patient specialty, give priority to
the patient specialty. For paediatric patients on a PED ward, use the subspecialty (MEDGEN, MEDSUR etc) (see
ward specialty). LTC should only exceptionally be used as a patient/consultant specialty.
Patient receives antimicrobial: yes/no/unknown. Patient receives non-topical antibacterials or antifungals.
Prophylaxis: any patient who received one or more doses in the 24 hours prior to 8 a.m. on the day of the survey.
Patient has active HAI: yes/no/unknown. See definition of active infection above.
Figure 9. Antimicrobial use and HAI data form in the LIGHT option (form B2)
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National/regional data
(Applies only to PPS coordinating centres.)
Objectives
To assess the total number of acute care hospitals in a country and in the EU and to estimate the total
number of hospital admissions per year, in order to estimate the total burden of HAIs and antimicrobial use
in acute care hospitals.
To collect information on the sampling methodology used at the national level.
Notes
Data at the national level are preferred, but if needed or more appropriate, please provide data from
regional (sub-national) levels (e.g. England, Northern Ireland, Scotland and Wales for UK).
National/regional data are provided by the point prevalence survey coordinating centre before submitting
the national/regional hospital data to ECDC. They can be entered manually or be uploaded (one record) to
TESSy (ECDC’s surveillance system).
Figure 10. National/regional data (form N)
Definition of national/regional data
Country code. The country reporting the record.
Network ID. Code of the region or network for which data are provided (e.g. EN, NI, SC, WA for England,
Northern Ireland, Scotland and Wales); leave blank if data are provided for the entire country (national level).
Date start PPS. First date on which data were collected (by first hospital) or official launch date of the current
national/regional point prevalence survey, whichever comes first.
National/regional PPS coordination centre/institution. Name of PPS coordinating centre or institution (e.g.
national public health institute) in English (if available) or the local language.
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National/regional PPS coordination programme/unit, name. Name of PPS coordinating programme or unit
(e.g. name of national HAI surveillance programme) in English (if available) or local language; leave blank if not
relevant.
National/regional PPS coordination programme/unit, website. Web address (URL) of programme or unit
that coordinated the PPS (if available), regardless of specific PPS pages.
Total number of acute care hospitals (‘sites’). Total number of acute care hospitals (separate sites or
geographical entities) in your country/region, in accordance with national/regional definition of acute care
hospitals.
Number of administrative hospital groups/mergers. Total number of administrative hospital groups
(including at least one acute care hospital site) in your country or region; leave blank if not applicable in your
country/region; unknown= UNK.
Total number of beds in acute care hospitals. Total number of beds (including non-acute beds) in acute care
hospitals; unknown=UNK.
Total number of acute care beds. Total number of acute care beds (excluding non-acute beds) in acute care
hospitals; unknown=UNK.
Number of discharges/admissions, all. Total number of hospital discharges from acute care hospitals in your
country/region in the previous year (or the nearest year for which data are available); if discharges are not
available, report number of admissions to acute care hospitals; unknown=UNK.
Number of discharges/admissions, acute care beds only. If available: number of yearly hospital discharges
from acute care hospitals for acute care beds only (previous year or the nearest year for which data are available);
if discharges are not available, report admissions; unknown=UNK.
Number of patient-days, all. Total number of patient-days in acute care hospitals in the previous year (or the
nearest year for which data are available); unknown=UNK.
Number of patient-days, acute care beds only. If available: number of yearly patient-days in acute care
hospitals for acute care beds only (previous year or the nearest year for which data are available); unknown=UNK.
Year data. For each of the hospital statistics, report the year for which data apply; leave blank if data is unknown;
UNK=data available but year data unknown.
Method of sampling/recruitment of hospitals. Method used for sampling (or recruitment) of hospitals for the
national PPS; more than one answer is possible:
REPSRS=representative sample (recommended method): the necessary number of hospitals was selected
using systematic random sampling as described in the protocol under ‘sample design’.
REPOTH=other representative sampling method; please describe the method used under
‘comments/observations’.
CONSAM=convenience sample: selection of hospitals by coordinating centre (e.g. based on expectations of
high data quality).
ALLHOSP=all hospitals invited: all acute care hospitals were invited to participate in the national point
prevalence survey; can be combined with sample.
VOLUNT=voluntary participation; hospitals can freely choose whether they respond to the invitation to
participate.
MANDAT=mandatory participation; participation following invitation is mandatory.
Total number of hospitals in PPS. Total number of hospitals that participated in the national/regional PPS (if
not all data are submitted to ECDC, provide total number of hospitals), both for the light (unit-based) and standard
(patient-based) protocols.
Comments/observations. Free text; provide any comment you consider relevant or that should be taken into
account for the interpretation of the national/region data; for example, provide additional details on the sampling
method used.
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Data structure and variable names
Tables with the PPS data structure for the files to be uploaded to TESSy are available in a separate Excel
document. The structure is similar to that of other HAI-Net surveillance modules and has four hierarchical levels.
Data can be uploaded in XML format (one single file) or in CSV format (separate files for each level). In CSV files,
the RecordId in the superior level links to the ParentId in the underlying level. CSV file names should start with the
number indicating the level of the data subset in the database hierarchy. The record type (variable RecordType)
provides the level and data subset identity to TESSy. The record types for the PPS data are as follows:
Standard protocol option record types
HAIPPS (1st level): Hospital data, one record per hospital-survey
HAIPPS$WD (2nd level): Ward data, one record per ward-survey (optional); link ParentId to RecordId in
HAIPPS (1st level)
HAIPPS$PT (2nd level): Patient data, one record per patient; link ParentId to RecordId in HAIPPS (1st
level)
HAIPPS$PT$AM (3rd level): Antimicrobial use data, one record per antimicrobial agent-route indication;
link ParentId to RecordId in HAIPPS$PT (2nd level)
HAIPPS$PT$INF (3rd level): Healthcare-associated infection data, one record per HAI site; link ParentId
to RecordId in HAIPPS$PT (2nd level)
HAIPPS$PT$INF$RES (4th level): Microorganism and antimicrobial resistance data for healthcare-
associated infections; link ParentId to RecordId in HAIPPS$PT$INF (3rd level)
CSV files to be uploaded to TESSy: 1. HAIPPS.csv, 2. HAIPPSWD.csv (optional), 2. HAIPPSPT.csv,
3. HAIPPSPTAM.csv, 3. HAIPPSPTINF.csv, 4.HAIPPSPTINFRES.csv
Light protocol option record types
HAIPPSLIGHT (1st level): Hospital data, one record per hospital-survey
HAIPPSLIGHT$WD (2nd level): Ward data, one record per ward-survey (optional); link ParentId to
RecordId in HAIPPSLIGHT (1st level)
HAIPPSLIGHT$DENO (2nd level): Ward denominator data, one record per patient; link ParentId to
RecordId in HAIPPSLIGHT (1st level)
HAIPPSLIGHT$DENO$AM (3rd level): Antimicrobial use data, one record per antimicrobial agent-route
indication; link ParentId to RecordId in HAIPPSLIGHT$DENO (2nd level)
HAIPPSLIGHT$DENO$INF (3rd level): Healthcare-associated infection data, one record per HAI site; link
ParentId to RecordId in HAIPPSLIGHT$DENO (2nd level)
HAIPPSLIGHT$DENO$INF$RES (4th level): Microorganism and antimicrobial resistance data for
healthcare-associated infections; link ParentId to RecordId in HAIPPSLIGHT$DENO$INF (3rd level)
CSV files to be uploaded to TESSy: 1. HAIPPSLIGHT.csv, 2. HAIPPSLIGHTWD.csv (optional),
2. HAIPPSLIGHTDENO.csv, 3. HAIPPSLIGHTDENOAM.csv, 3. HAIPPSLIGHTDENOINF.csv,
4. HAIPPSLIGHTDENOINFRES.csv
National data: record type HAIPPSDENOM, denominator data and PPS data for the country (or region if the data
source is region-specific)
A new ward level with structure and process indicators was added at the second level in both the standard and the
light protocol options. Since ward indicator data are optional, this data level is optional; all other elements of the
data structure are identical to the first PPS: patient data and ward denominator data are directly linked to the
hospital level (not the ward level). It is crucial that the Ward ID code is identical (i.e. spelled exactly the same) at
all data levels.
Note on microorganism and resistance data
The TESSy format of the microorganism and resistance data follows the bug-drug structure as in EARS-Net, HAI-
Net SSI and HAI-Net ICU. The reasons for this are 1) consistency with other data in TESSy and 2) to allow for
changes in antimicrobial markers in future versions of the protocols.
In the current PPS II protocol, data are directly collected in the bug-drug format. Collection of S/I/R data for each
bug-drug combination will allow analysing the data exactly as in the EARS-Net report.
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
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If S/I/R data are not available, the PPS antimicrobial marker data can still be collected in accordance with the PPS I
protocol (code system, only indicating non-susceptibility, without detail on intermediate susceptibility or
resistance). In this case, they should be converted to the 4th level TESSy format as illustrated in the following
table.
Table 3. Conversion chart: PPS I protocol PPS antimicrobial marker data to the 4th
level TESSy
format
MO
Code
ResultIsolate
Antibiotic
SIR
Staphylococcus aureus
(STAAUR)
STAAUR
0
STAAUR
OXA
S
STAAUR
1
STAAUR
OXA
R
STAAUR
9
STAAUR
OXA
UNK
Enterococcus
spp.,
e.g.
Enterococcus faecium
(ENCFAI)
ENCFAI
0
ENCFAI
GLY
S
ENCFAI
1
ENCFAI
GLY
IR
ENCFAI
9
ENCFAI
GLY
UNK
Enterobacteriaceae*,
e.g.
Klebsiella pneumoniae
(KLEPNE)
KLEPNE
0
KLEPNE
C3G
S
KLEPNE
CAR
S
KLEPNE
1
KLEPNE
C3G
IR
KLEPNE
CAR
S
KLEPNE
2
KLEPNE
C3G
IR
KLEPNE
CAR
IR
KLEPNE
9
KLEPNE
C3G
UNK
KLEPNE
CAR
UNK
Pseudomonas aeruginosa
(PSEAER)
PSEAER
0
PSEAER
CAR
S
PSEAER
1
PSEAER
CAR
IR
PSEAER
9
PSEAER
CAR
UNK
Acinetobacter baumannii
(ACIBAU)
ACIBAU
0
ACIBAU
CAR
S
ACIBAU
1
ACIBAU
CAR
IR
ACIBAU
9
ACIBAU
CAR
UNK
* Enterobacteriaceae: only record antimicrobial susceptibility data for following selection:
Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.,
Citrobacter
spp.,
Serratia
spp.,
Morganella
spp.
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Acknowledgements
Participation to PPS protocol meetings
The protocol for the first ECDC point prevalence survey (PPS) of healthcare-associated infections and antimicrobial
use in European acute care hospitals (2011–2012) was established during the following meetings:
PPS working group at the 2009 Annual HAI Surveillance Meeting, 8–10 June 2009, ECDC, Stockholm
PPS expert meeting, 8–9 September 2009, ECDC, Stockholm
PPS expert meeting, 24–25 February 2010, ECDC, Stockholm
Two PPS working groups at the 2010 Annual HAI Surveillance Meeting, 7–9 June 2010, ECDC, Stockholm
PPS protocol meeting after pilot PPS, 6 October 2010, ECDC, Stockholm
PPS workshop at the conference ‘New strategies to monitor and control infections, antibiotic use and
resistance in healthcare facilities in the EU Member States’ organised by the Belgian EU Presidency
(BAPCOC) and ECDC, 8–10 November 2010
HAI-Net coordination group meeting, Prague, 3–4 March 2011
PPS train-the-trainer course for national PPS coordinators/trainers, London, 28–30 March 2011
Teleconference meetings, on sample design, as well as during and after the pilot PPS with the pilot PPS
support team
Changes to the protocol for the second ECDC point prevalence survey of healthcare-associated infections and
antimicrobial use in European acute care hospitals in 2016–2017 were discussed during following meetings:
PPS 2011–2012 Evaluation Meeting, 17–18 September 2013, ECDC, Stockholm
HAI-Net protocol meeting on structure and process indicators, 19–20 February 2014, ECDC, Stockholm
HAI-Net Coordination Committee meeting, 9 May 2014, Hospital del Mar, Barcelona
HAI-Net PPS sessions at the third Joint Meeting of the ARHAI Networks, 11–13 February 2015, Courtyard
Stockholm Kungsholmen, Stockholm
HAI-Net Coordination Committee meeting, 14–15 April 2015, ECDC, Stockholm
Meeting and workshop on the second ECDC point prevalence survey of healthcare-associated infections and
antimicrobial use in acute care hospitals, 2016–2017, 20–22 October 2015, ECDC, Stockholm
In total, 111 experts participated in at least one meeting regarding the first ECDC PPS and 153 experts participated
in at least one meeting regarding the protocol for the second ECDC PPS. Meeting participants (n=229) are listed by
country and institution in the table below together with the number of meetings to which they participated, in total
and for the first and second PPS separately (in brackets).
Table 4. Participants to ECDC PPS meetings on the first and second PPS protocol, by country and
institution, 2009–2015
Country
Name (Number of meetings total; PPS1/PPS2)
Institution
EU/EEA Member States
Austria
Alexander Blacky (6; 6/0), Elisabeth Presterl (3; 0/3), Michael Hiesmayr (1;
0/1)
Medical University Vienna
Reinhild Strauss (3; 1/2)
Federal Ministry of Health, Vienna
Rainer Hartl (1; 1/0)
Elisabethinen Hospital Linz
Belgium
Mat Goossens (3; 3/0), Katrien Latour (3; 0/3), Béatrice Jans (2; 1/1), Karl
Mertens (2; 2/0), Sofie Vaerenberg (2; 2/0), Sylvanus Fonguh (1; 0/1),
Natacha Viseur (1; 1/0)
Scientific Institute of Public Health,
Brussels
Bulgaria
Rossitza Vatcheva-Dobrevska (7; 7/0), Elina Dobreva (2; 0/2), Ivan Ivanov
(1; 0/1), Nadezhda Vladimirova (1; 0/1)
National Center of Infectious and
Parasitic Diseases, Sofia
Hristina Hitkova (1; 1/0)
Medical University Pleven
Croatia
Zrinka Bošnjak (7; 4/3), Ana Budimir (3; 0/3),
Domagoj Drenjancevic (1; 1/0), Smilja Kalenic (1; 1/0)
University Hospital Centre Zagreb
Arjana Tambic Andrasevic (1; 1/0)
University Hospital for Infectious
Diseases, Zagreb
Cyprus
Avgi Hadjiloukas (4; 4/0)
Ministry of Health, Nicosia
Niki Paphitou (1; 0/1)
Nicosia General Hospital/ Ministry of
Health, Nicosia
Emmelia Vounou (1; 1/0)
Limassol Hospital
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Country
Name (Number of meetings total; PPS1/PPS2)
Institution
Czech
Republic
Jana Prattingerová (4; 1/3)
Regional Public Health Authority,
Liberec; National Institute of Public
Health, National reference centre on
HAI, Prague
Miroslava Girod Schreinerova (4; 4/0)
Ministry of Health, department of
Epidemiology, Prague
Vlastimil Jindrák (3; 1/2)
National Institute of Public Health,
National reference centre on HAI,
Prague
Jan Sturma (2; 2/0)
National Institute of Public Health,
Prague
Hana Tkadlecová (1; 1/0)
Regional Public Heatlh Authority in Zlín
Václav Vaniš (1; 0/1)
Na Homolce Hospital, Prague
Denmark
Christian Stab Jensen (6; 4/2), Brian Kristensen (3; 0/3), Elsebeth
Tvenstrup Jensen (3; 3/0)
Statens Serum Institute, Copenhagen
Estonia
Pille Märtin (7; 4/3)
West-Tallinn Central Hospital
Piret Mitt (3; 1/2), Viivika Adamson (1; 1/0)
Tartu University Hospital
Annika Lemetsar (2; 2/0)
Health Board, Tallinn
Finland
Outi Lyytikäinen (11; 6/5), Dinah Arifulla (2; 0/2), Tommi Kärki (2; 2/0)
National Institute for Health and
Welfare, Helsinki
France
Bruno Coignard (8; 7/1), Sophie Vaux (2; 1/1)
Kathleen Chami (1; 0/1), Valérie Ponties (1; 0/1), Jean-Michel Thiolet (1;
1/0)
Institute for Public Health Surveillance,
Paris
Anne Savey (3; 0/3), Marine Giard (2; 0/2)
Centre de Coordination de la Lutte
contre les Infections Nosocomiales Sud-
Est, Lyon
Pascal Astagneau (1; 1/0)
C-Clin Nord, Université ParisVI, Paris
Germany
Sonja Hansen (7; 4/3), Brar Piening (5; 3/2), Petra Gastmeier (4; 1/3),
Michael Behnke (3; 1/2)
Institute of Hygiene and Environmental
Medicine, Charité-Universitätsmedizin,
Berlin
Martine Mielke (2; 1/1), Muna Abu Sin (1; 0/1), Jan Walter (1; 0/1)
Robert Koch Institute, Berlin
Greece
Achilleas Gikas (4; 3/1), Evangelos Kritsotakis (3; 2/1)
Medical School, University of Crete,
Heraklion
Xanthi Dedoukou (3; 1/2), Antonios Maragkos (2; 1/1), Paraskevi Tsounou
(1; 0/1), Flora Kontopidou (1; 1/0)
Hellenic Centre for Disease Control and
Prevention, Athens
Hungary
Karolina Böröcz (5; 4/1), Andrea Kurcz (4; 1/3)
Ágnes Hajdu (2; 1/1), Emese Szilágyi (2; 2/0), István Veress (1; 0/1)
National Centre for Epidemiology,
Budapest
Iceland
Ólafur Guðlaugsson (4; 1/3)
Landspitali University Hospital, Reykjavik
Ireland
Karen Burns (3; 1/2), Fidelma Fitzpatrick (2; 2/0), Stephen Murphan (2;
1/1), Fiona Roche (2; 1/1), Robert Cunney (1; 1/0), Sheila Donlon (1; 0/1)
Health Protection Surveillance Centre,
Dublin
Italy
Maria Luisa Moro (9; 5/4), Enrico Ricchizzi (3; 1/2), Angelo Pan (1; 1/0),
Davide Resi (1; 1/0)
Regional Health Agency Emilia-
Romagna, Bologna
Antonella Agodi (1; 0/1)
University of Catania
Michela Stillo (1; 0/1)
University of Turin
Latvia
Elina Dimina (6; 3/3), Raina Nikiforova (2; 1/1)
Centre for Disease Prevention and
Control of Latvia, Riga
Uga Dumpis (5; 5/0), Aija Vilde (1; 0/1)
Stradins University Hospital, Riga
Jelena Galajeva (1; 1/0)
Infectiology Center of Latvia, Riga
Marite Kula (1; 1/0)
Liepaja Regional Hospital
Lithuania
Rolanda Valintėlienė (9; 5/4), Greta Vizujė (3; 1/2), Jolanta Ašembergienė
(2; 0/2), Ramute Budginaitė (1; 1/0), Ieva Kisielienė (1; 0/1), Ruta
Markevicė (1; 1/0)
Institute of Hygiene, Vilnius
Nerija Kupreviciene (1; 0/1)
Ministry of Health, Vilnius
Luxem-
bourg
Elisabeth Heisbourg (2; 1/1), Martine Debacker (1; 0/1), Eliane Gelhausen
(1; 0/1)
Ministry of Health, Luxembourg
Robert Hemmer (1; 1/0)
Centre Hospitalier Luxembourg
Malta
Peter Zarb
1,2
(6; 5/1), Elizabeth Scicluna (5; 3/2), Rodianne Abela (1; 0/1),
Michael Borg (1; 0/1), Deborah Xuereb (1; 0/1)
Mater Dei Hospital, Msida
The
Nether-
lands
Titia Hopmans (4; 1/3), Mayke Koek (4; 1/3), Birgit Van Benthem (3; 3/0),
Sabine De Greeff (1; 0/1), Iralice Jansen (1; 1/0), Emma Smid (1; 0/1),
Tjallie Van der Kooi (1; 1/0)
National Institute for Public Health and
the Environment, Bilthoven
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Country
Name (Number of meetings total; PPS1/PPS2)
Institution
Norway
Nina Kristine Sorknes (5; 2/3), Janne Møller-Stray (4; 4/0), Thale Catherine
Berg (2; 0/2)
Torunn Alberg (1; 0/1), Horst Bentele (1; 1/0)
Jørgen Bjørnholt (1; 0/1), Hanne-Merete Eriksen (1; 0/1), Hege Line Løwer
(1; 1/0)
Norwegian Institute of Public Health,
Oslo
Poland
Aleksander Deptula (6; 2/4)
Nicolaus Copernicus University, Torun
Tomasz Ozorowski (3; 3/0)
Poznan Medical University
Waleria Hryniewicz (2; 1/1)
National Medicines Institute, Warsaw
Ewa Trejnowska (2; 1/1)
Regional Medical Centre, Opole
Jadwiga Wójkowska-Mach (1; 0/1)
Jagiellonian University Medical College,
Kraków
Portugal
Ana Cristina Costa (4; 4/0), Elaine Pina (3; 1/2)
Ana Paula Cruz (1; 0/1), Paulo Nogueira (1; 0/1), Maria Elena Noriega (1;
1/0)
Directorate General of Health, Lisbon
Paulo André Fernandes (2; 0/2)
National Authority of Medicines and
Health Products, Lisbon
José Artur Paiva (2; 1/1)
Director PPCIRA; Centro Hospitalar de
S.João, Porto
Romania
Roxana Serban (6; 3/3), Ionel Iosif (2; 0/2), Aurora Violeta Stanescu (1;
1/0)
National Institute of Public Health,
Bucharest
Camelia Ghita (1; 1/0)
Bucharest hospital
Gabriel Adrian Popescu (1; 0/1)
Carol Davila University of Medicine and
Pharmacy, Bucharest; National Institute
of Infectious Disease ‘Dr. Matei Bals’,
Bucharest
Slovak
Republic
Slavka Litvova (4; 4/0), Mária Štefkovicová (3; 0/3), Eva Kopšíková (1; 0/1)
Regional Public Health Authority, Trencin
Lukas Murajda (2; 2/0)
Comenius University, Jessenius Faculty
of Medicine, Martin
Jana Námešná (2; 0/2)
Regional Public Health Authority, Banska
Bystrica
Slovenia
Jana Kolman (11; 5/6), Irena Klavs (4; 2/2)
National Institute of Public Health,
Ljubljana
Božena Kotnik Kevorkijan (2; 2/0), Rajko Saletinger (1; 0/1)
University Medical Centre Maribor
Tatjana Lejko Zupanc (1; 1/0)
University Medical Centre Ljubljana
Spain
Josep Vaque Rafart (7; 4/3), Jose Angel Rodrigo Pendas (1; 1/0)
Vall d'Hebron University Hospital,
Barcelona
Angel Asensio Vegas (3; 2/1), Mireia Cantero Caballero (1; 0/1)
University Hospital Puerta de Hierro
Majadahonda, Madrid
Mercedes Palomar (3; 0/3)
Spanish Society of Intensive and Critical
Care Medicine; University Hospital Arnau
de Vilanova, Lleida
Sweden
Tomas Söderblom (4; 1/3), Inga Zetterqvist (2; 0/2), Jenny Hellman (1;
0/1), Johan Struwe (1; 1/0)
Public Health Agency of Sweden,
Stockholm
Mats Erntell (3; 3/0), Gunilla Skoog (1; 1/0)
Swedish Strategic Programme Against
Antibiotic Resistance, Stockholm
Dag Ström (1; 1/0)
Swedish Association of Local Authorities
and Regions, Stockholm
UK-
England
Susan Hopkins (9; 5/4), Jennie Wilson (3; 3/0), Andre Charlett (1; 1/0),
Elizabeth Sheridan (1; 1/0)
Public Health England, Colindale
UK-
Northern
Ireland
Gerard McIlvenny (4; 2/2), Lourda Geoghegan (2; 0/2), Ed Smyth (1; 1/0)
Public Health Agency, Nothern Ireland,
Belfast
UK-
Scotland
Jacqui Reilly (11; 5/6), Shona Cairns (4; 4/0)
Health Protection Scotland, Glasgow
Peter Davey
1
(1; 1/0)
University of Dundee
UK-Wales
Wendy Harrison (2; 0/2), Dafydd Williams (2; 1/1)
Public Health Wales, Cardiff
David Nicholas Looker (1; 1/0)
Glan Clwyd Hospital, Denbighshire
EU enlargement countries
Albania
Zahide Sulejmani (1; 0/1), Eugena Tomini (1; 0/1)
Institute of Public Health, Tirana
Pellumb Pipero (1; 1/0)
Ministry of Health, Tirana
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
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Country
Name (Number of meetings total; PPS1/PPS2)
Institution
Bosnia
and
Herze-
govina
Maja Ostojic (1; 0/1)
University Clinical Hospital Mostar
Aida Pitic (1; 0/1)
Clinical center University of Sarajevo
Kosovo
Agreta Gecaj-Gashi (1; 0/1)
University clinical center of Kosovo,
Intensive Care, Pristina
Lul Raka (1; 0/1)
National Institute of Public Health of
Kosovo, Pristina
The
former
Yugoslav
Republic
of
Macedoni
a
Gordana Kuzmanovska (1; 0/1), Kristina Stavridis (1; 0/1)
Institute of Public Health, Skopje
Katja Popovska (1; 0/1)
Institute of microbiology Medical faculty,
Skopje
Monte-
negro
Anton Duravcaj (1; 0/1), Gordana Mijovic (1; 1/0)
Institute for Public Health of
Montenegro, Podgorica
Miro Kneževic (1; 0/1)
Clinical Centre of Montenegro, Podgorica
Sanja Simovic (1; 0/1)
National Commission for hospital
infections
Republic
of Serbia
Gorana Cosic (1; 0/1)
Institute for Public Health, Novi Sad
Mitra Drakulovic (1; 0/1)
Institute of Public Health of Serbia "Dr
Milan Jovanovic Batut", Belgrade
Natasa Mazic (1; 0/1)
Clinical Center of Serbia, Belgrade
Turkey
Dilek Arman (1; 1/0)
Gazi University, Ankara
Fadime Callak Oku (1; 0/1)
General Directorate of Health Services,
Department of Health Service Standards
EU Neighbourhood Policy countries
Algeria
Amhis Wahiba (1; 0/1)
Etablissement Public Hospitalier
Bologhine, Alger
Armenia
Romella Abovyan (1; 0/1)
National Centre for Disease Control and
Prevention, Yerevan
Egypt
Khaled Hassanein (1; 0/1)
Ministry of Health and Population, Cairo
Georgia
Giorgi Chakhunashvili (1; 0/1)
National Centre for Disease Control and
Public Health, Tbilisi
Israel
Mitchell J. Schwaber (1; 0/1)
National Centre for Infection Control and
Antibiotic Resistance, Tel Aviv
Lebanon
Rima Moghnieh (2; 0/2)
Makassed General Hospital, Beirut
Tunesia
Ihlem Boutiba (1; 0/1)
Faculté de Médecine de Tunis
Ukraine
Maxym Pylypenko (1; 0/1), Aidyn Salmanov (1; 0/1)
P.L. Shupyk National Medical Academy
of Postgraduate Education, Kiev
Viktoriia Zadorozhna (1; 0/1)
Gromashevsky Institute of Epidemiology
and Infectious Diseases, Kiev
Individual experts
France
Arno Muller
1
(9; 6/3)
Individual expert, France; ECDC
consultant for ESAC-Net
France
Catherine Dumartin (1; 0/1)
Centre de Coordination de la Lutte
contre les Infections Nosocomiales Sud-
Ouest, Bordeaux
UK/PPS
Training
Barry Cookson (2; 2/0), Gareth Hughes (2; 2/0)
Berit Müller-Peabody (2; 2/0), Naomi Boxall (1; 1/0)
Public Health England, Colindale
United
Kingdom
Walter Zingg (3; 0/3)
Imperial College London
United
Kingdom
Mike Sharland
2
(1; 0/1)
St George's Healthcare NHS Trust,
London
International and European organisations/projects
European
Commissi
on
Nicole Heine (1; 0/1)
European Commission, Luxembourg
ESAC
Herman Goossens (5; 5/0), Nico Drapier (1; 1/0)
European Surveillance of Antimicrobial
Consumption (ESAC) project; University
of Antwerp, Antwerp
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Country
Name (Number of meetings total; PPS1/PPS2)
Institution
ESICM
Alain Lepape (4; 1/3)
European Society of Intensive Care
Medicine (ESICM), Infection Section;
CHU, Lyon
EUCIC
Evelina Tacconelli (1; 0/1)
European Society of Clinical Microbiology
and Infectious Diseases (ESCMID),
European Committee on Infection
Control (EUCIC)
USA/CDC
Shelley Magill (5; 3/2), Scott Fridkin (2; 2/0)
Centers for Disease Control and
Prevention, Atlanta
WHO
Regional
Office for
Europe
Ana Paula Coutinho (5; 3/2), Bernardus Ganter (2; 2/0)
World Health Organization, Regional
Office for Europe, Copenhagen
ECDC
Carl Suetens (14; 8/6), Jolanta Griškevičienė (8; 5/3), Pete Kinross (5; 0/5),
Dominique L. Monnet (5; 1/4), Klaus Weist (5; 3/2), Ole Heuer (4; 2/2),
Carlo Gagliotti (3; 3/0), Diamantis Plachouras (3; 0/3), Tommi Kärki (1;
0/1), Barbara Albiger (1; 0/1), Tommi Asikainen (1; 1/0), Anna-Pelagia
Magiorakos (1; 0/1), Sorin Ostafiev (1; 0/1), Vladimir Prikazsky (1; 1/0),
Luisa Sodano (1; 1/0)
European Centre for Disease Prevention
and Control, Stockholm
1
Also representing the ESAC project
2
Also representing the ESAC-Net Coordination Committee
In addition, seven teleconferences for the selection of structure and process indicators were organised with the
members of the HAI-Net PPS expert group: Outi Lyytikainen (Finland); Sonja Hansen (Germany); Maria-Louisa
Moro (Italy); Peter Zarb (Malta, ESAC-Net Coordination Group); Jana Kolman (Slovenia); Susan Hopkins (UK-
England); Jacqui Reilly (UK-Scotland); Walter Zingg (SIGHT project); Arno Muller (ESAC-Net consultant); Pete
Kinross (ECDC); Anna-Pelagia Magiorakos (ECDC), Diamantis Plachouras (ECDC), Carl Suetens (ECDC).
National PPS coordination teams during the first ECDC PPS are listed in the ECDC PPS 2011–2012 report [6].
Support projects
The following projects were outsourced in support of the first point prevalence survey.
1. Contract ECD.2172 following a call for tender entitled ‘Support to the pilot point prevalence survey of healthcare-
associated infections and antimicrobial use in European acute care hospitals’.
The support to the pilot PPS was outsourced to a consortium under coordination of the University of Antwerp,
Belgium, in collaboration with the National Institute for Public Health Surveillance (InVS) in Paris, France, and the
Scientific Institute of Public Health in Brussels, Belgium. The helpdesk team during the pilot PPS discussed
methodological issues during regular teleconferences and was composed of Herman Goossens (Team leader), Arno
Muller, Peter Zarb, Bruno Coignard, Boudewijn Catry, Sofie Vaerenberg, Mat Goossens, Susan Hopkins, Klaus Weist,
Jolanta Griškevičienė and Carl Suetens (ECDC PPS project manager). During the pilot PPS project, the ESAC web-
PPS software for hospitals was adapted to the ECDC protocol.
Participants in the pilot PPS tested V3.3 of the PPS protocol and are listed in Zarb et al [11].
2. Contract ECD.1842 following a call for tender entitled ‘Curriculum for course on epidemiology and analysis of
point prevalence studies of healthcare-associated infections’.
The development of PPS courses and teaching materials was outsourced to the Health Protection Agency, London
(Susan Hopkins (coordinator), Barry Cookson, Berit Müller-Pebody, Gareth Hughes, Naomi Boxall) with
collaboration of Health Protection Scotland (Jacqui Reilly, Shona Cairns). Some material developed by the training
curriculum team was integrated in the protocol.
3. Contract ECD.2218 following a request for an offer on ’HELICSwin Hospital Software Support’ was made with the
Belgian Scientific Institute of Public Health to develop a standalone software package for PPS data entry, export
and analysis (HELICSwin.Net).
4. Contract ECD.2971 following a call for tender entitled ‘Pilot validation study of the ECDC Point Prevalence Survey
of healthcare-associated Infections and Antimicrobial Use in European Acute Care Hospitals. OG/23/06/2011-
PROC/2011/060’.
The pilot PPS validation study was outsourced to a consortium under coordination of Glasgow Caledonian
University, Glasgow, United Kingdom (Jacqui Reilly, Lesley Price, Jon Godwin), in collaboration with Health
Protection Scotland, Glasgow, United Kingdom (Jacqui Reilly, Shona Cairns, William Malcolm), Public Health
England, London, United Kingdom (Susan Hopkins, Barry Cookson, Gareth Hughes), National Institute for Health
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
38
and Welfare, Helsinki, Finland (Outi Lyytikäinen), Institut de Veille Sanitaire, Saint-Maurice, France (Bruno
Coignard) and Charité University Medicine Berlin, Germany (Petra Gastmeier, Sonja Hansen).
Participants in the ECDC pilot validation study are listed in Reilly et al [12].
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Annex 1. Additional materials
Codebook
The codebook is attached to this publication as Annex 2 and contains the following:
specialty list (ward, Patient/consultant);
antimicrobial agent generic names and ATC-5 codes;
diagnosis site list for treatment intention with antimicrobials (adapted from ESAC);
HAI case definitions;
algorithm for the diagnosis of catheter-related infections;
microorganism codes;
antimicrobial resistance markers codes; and
surgery categories (NHSN/examples of non-NHSN).
Forms
A PowerPoint file with all forms is available as a separate download. It is intended for high quality printing and/or
the translation of forms.
TESSy variable definitions and validation rules
An Excel file containing the definition of variables for data upload to ECDC’s TESSy system is available as a
separate download from TESSy or on ECDC’s HAI-Net extranet. It can also be requested by email from
Note on case definitions of healthcare-associated infections
As recommended by the joint expert group in January 2009 and confirmed during the PPS expert meetings in 2009
and 2010, the ECDC PPS protocol uses existing European case definitions [13-17] and complements them by case
definitions from the Centers for Disease Control and Prevention (CDC), as used by CDC’s National Healthcare Safety
Network (NHSN, formerly NNIS)[18]. The concordance between US/CDC and EU/HELICS case definitions was
assessed by Hansen et al [19].
The European case definitions used in the ECDC PPS are:
HELICS/IPSE case definitions
Surgical site infection
Pneumonia
Bloodstream infection
Central vascular catheter related infection
Urinary tract infections
Clostridium difficile
infection
Specific neonatal definitions, as established by the KISS network:
Clinically suspected bloodstream infections (clinical sepsis)
Laboratory-confirmed bloodstream infection
Laboratory-confirmed bloodstream infection with coagulase-negative staphylococci
Pneumonia in neonates
Necrotising enterocolitis
Note: The CDC HAI case definitions in neonates were replaced by case definitions used in the Neo-KISS system. These definitions
were not established at the EU level, but they were preferred by the EU-PPS expert group.
All other case definitions are CDC/NHSN case definitions.
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
40
Annex 2. Codebook
Specialty code list
Specialty codes are used for following variables: Ward specialty, patient/consultant specialty, specialised hospital
(form H). Ward specialty codes are shown in the first column (in parentheses).
Categories (ward specialty)
Patient/consultant
specialty code
Patient/consultant specialty name
Surgical specialties (SUR)
SURGEN
General surgery
Surgical specialties (SUR)
SURDIG
Digestive tract surgery
Surgical specialties (SUR)
SURORTR
Orthopaedics and surgical traumatology
Surgical specialties (SUR)
SURORTO
Orthopaedics
Surgical specialties (SUR)
SURTR
Traumatology
Surgical specialties (SUR)
SURCV
Cardio surgery and vascular surgery
Surgical specialties (SUR)
SURCARD
Cardio surgery
Surgical specialties (SUR)
SURVASC
Vascular surgery
Surgical specialties (SUR)
SURTHO
Thoracic surgery
Surgical specialties (SUR)
SURNEU
Neurosurgery
Surgical specialties (SUR)
SURPED
Paediatric general surgery
Surgical specialties (SUR)
SURTRANS
Transplantation surgery
Surgical specialties (SUR)
SURONCO
Surgery for cancer
Surgical specialties (SUR)
SURENT
ENT
Surgical specialties (SUR)
SUROPH
Ophthalmology
Surgical specialties (SUR)
SURMAXFAC
Maxillo-facial surgery
Surgical specialties (SUR)
SURSTODEN
Stomatology/Dentistry
Surgical specialties (SUR)
SURBURN
Burns care
Surgical specialties (SUR)
SURURO
Urology
Surgical specialties (SUR)
SURPLAS
Plastic and reconstructive surgery
Surgical specialties (SUR)
SUROTH
Other surgery
Medical specialties (MED)
MEDGEN
General medicine
Medical specialties (MED)
MEDGAST
Gastroenterology
Medical specialties (MED)
MEDHEP
Hepatology
Medical specialties (MED)
MEDENDO
Endocrinology
Medical specialties (MED)
MEDONCO
Oncology
Medical specialties (MED)
MEDHEMA
Haematology
Medical specialties (MED)
MEDBMT
Bone marrow transplantation (BMT)
Medical specialties (MED)
MEDHEMBMT
Haematology/BMT
Medical specialties (MED)
MEDCARD
Cardiology
Medical specialties (MED)
MEDDERM
Dermatology
Medical specialties (MED)
MEDNEPH
Nephrology
Medical specialties (MED)
MEDNEU
Neurology
Medical specialties (MED)
MEDPNEU
Pneumology
Medical specialties (MED)
MEDRHEU
Rheumatology
Medical specialties (MED)
MEDID
Infectious diseases
Medical specialties (MED)
MEDTR
Medical traumatology
Medical specialties (MED)
MEDOTH
Other medical
Paediatrics (PED)
PEDGEN
Paediatrics general, not specialised
Neonatology (NEO)
PEDNEO
Neonatology (excl. healthy neonates)
Neonatology (NEO)
PEDBAB
Healthy neonates (paediatrics)
Neonatology (NEO)
ICUNEO
Neonatal ICU
Paediatrics (PED)
ICUPED
Paediatric ICU
Intensive care medicine (ICU)
ICUMED
Medical ICU
Intensive care medicine (ICU)
ICUSUR
Surgical ICU
Intensive care medicine (ICU)
ICUMIX
Mixed (polyvalent) ICU, general intensive or critical care
Intensive care medicine (ICU)
ICUSPEC
Specialised ICU
Intensive care medicine (ICU)
ICUOTH
Other ICU
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Categories (ward specialty)
Patient/consultant
specialty code
Patient/consultant specialty name
Gynaecology/Obstetrics (GO)
GOOBS
Obstetrics /maternity
Gynaecology/Obstetrics (GO)
GOGYN
Gynaecology
Gynaecology/Obstetrics (GO)
GOBAB
Healthy neonates (maternity)
Geriatrics (GER)
GER
Geriatrics, care for the elderly
Psychiatry (PSY)
PSY
Psychiatry
Rehabilitation (RHB)
RHB
Rehabilitation
Long-term care (LTC)
LTC*
Long-term care
OTHER (OTH)
OTH
Others not listed
Mixed (MIX)
MIX*
Combination of specialties
* LTC and MIX are in principle ward specialties and should only exceptionally be used as a patient/consultant specialty (e.g. for
LTC, use MEDGEN, GER, RHB instead; for MIX, use the specialty of the main disease of the patient only).
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
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Diagnosis (site) code list for antimicrobial use
Diagnosis
Examples
CNS
Infections of the central nervous system
EYE
Endophthalmitis
ENT
Infections of ear, nose, throat, larynx and mouth
BRON
Acute bronchitis or exacerbations of chronic bronchitis
PNEU
Pneumonia
CF
Cystic fibrosis
CVS
Cardiovascular infections: endocarditis, vascular graft
GI
Gastrointestinal infections (e.g. salmonellosis, antibiotic-associated diarrhoea)
IA
Intra-abdominal sepsis, including hepatobiliary
SST-SSI
Surgical site infection involving skin or soft tissue but not bone
SST-O
Cellulitis, wound, deep soft tissue not involving bone, not related to surgery
BJ-SSI
Septic arthritis, osteomyelitis of surgical site
BJ-O
Septic arthritis, osteomyelitis, not related to surgery
CYS
Symptomatic lower urinary tract infection (e.g. cystitis)
PYE
Symptomatic upper urinary tract infection (e.g. pyelonephritis)
ASB
Asymptomatic bacteriuria
OBGY
Obstetric or gynaecological infections, STD in women
GUM
Prostatitis, epididymo-orchitis, STD in men
BAC
Laboratory-confirmed bacteraemia
CSEP
Clinical sepsis (suspected bloodstream infection without lab confirmation/results are not available, no blood
cultures collected or negative blood culture), excluding febrile neutropenia
FN
Febrile neutropenia or other form of manifestation of infection in immunocompromised host (e.g. HIV,
chemotherapy, etc.) with no clear anatomical site
SIRS
Systemic inflammatory response with no clear anatomical site
UND
Completely undefined; site with no systemic inflammation
NA
Not applicable; for antimicrobial use other than treatment
Indications for antimicrobial use
Treatment
CI
Treatment of community-acquired infection (CI)
LI
Treatment of long-term care-acquired infection (LI)
HI
Treatment of hospital-acquired infection (HI)
Prophylaxis
MP
Medical prophylaxis
SP1
Surgical prophylaxis: single dose
SP2
Surgical prophylaxis: one day
SP3
Surgical prophylaxis: > 1 day
Other
O
Other reason (e.g. prokinetic erythromicin)
UI
Unknown indication (verified during PPS)
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Antimicrobial ATC codes (2016)
Antimicrobial agent: generic name
ATC5
Amikacin
J01GB06
Amoxicillin
J01CA04
Amoxicillin and enzyme inhibitor
J01CR02
Amphotericin B (oral)
A07AA07
Amphotericin B (parenteral)
J02AA01
Ampicillin
J01CA01
Ampicillin and enzyme inhibitor
J01CR01
Ampicillin, combinations
J01CA51
Anidulafungin
J02AX06
Arbekacin
J01GB12
Aspoxicillin
J01CA19
Azanidazole
P01AB04
Azidocillin
J01CE04
Azithromycin
J01FA10
Azithromycin, fluconazole and secnidazole
J01RA07
Azlocillin
J01CA09
Aztreonam
J01DF01
Bacampicillin
J01CA06
Bacitracin
J01XX10
Bekanamycin
J01GB13
Benzathine benzylpenicillin
J01CE08
Benzathine phenoxymethylpenicillin
J01CE10
Benzylpenicillin
J01CE01
Biapenem
J01DH05
Brodimoprim
J01EA02
Carbenicillin
J01CA03
Carindacillin
J01CA05
Carumonam
J01DF02
Caspofungin
J02AX04
Cefacetrile
J01DB10
Cefaclor
J01DC04
Cefadroxil
J01DB05
Cefalexin
J01DB01
Cefaloridine
J01DB02
Cefalotin
J01DB03
Cefamandole
J01DC03
Cefapirin
J01DB08
Cefatrizine
J01DB07
Cefazedone
J01DB06
Cefazolin
J01DB04
Cefbuperazone
J01DC13
Cefcapene
J01DD17
Cefdinir
J01DD15
Cefditoren
J01DD16
Cefepime
J01DE01
Cefepime and amikacin
J01RA06
Cefetamet
J01DD10
Cefixime
J01DD08
Cefmenoxime
J01DD05
Cefmetazole
J01DC09
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Antimicrobial agent: generic name
ATC5
Cefminox
J01DC12
Cefodizime
J01DD09
Cefonicide
J01DC06
Cefoperazone
J01DD12
Cefoperazone, combinations
J01DD62
Ceforanide
J01DC11
Cefotaxime
J01DD01
Cefotaxime, combinations
J01DD51
Cefotetan
J01DC05
Cefotiam
J01DC07
Cefoxitin
J01DC01
Cefozopran
J01DE03
Cefpiramide
J01DD11
Cefpirome
J01DE02
Cefpodoxime
J01DD13
Cefprozil
J01DC10
Cefradine
J01DB09
Cefroxadine
J01DB11
Cefsulodin
J01DD03
Ceftaroline fosamil
J01DI02
Ceftazidime
J01DD02
Ceftazidime, combinations
J01DD52
Ceftezole
J01DB12
Ceftibuten
J01DD14
Ceftizoxime
J01DD07
Ceftobiprole medocaril
J01DI01
Ceftolozane and enzyme inhibitor
J01DI54
Ceftriaxone
J01DD04
Ceftriaxone, combinations
J01DD54
Cefuroxime
J01DC02
Cefuroxime and metronidazole
J01RA03
Chloramphenicol
J01BA01
Chlortetracycline
J01AA03
Cinoxacin
J01MB06
Ciprofloxacin
J01MA02
Ciprofloxacin and metronidazole
J01RA10
Ciprofloxacin and ornidazole
J01RA12
Ciprofloxacin and tinidazole
J01RA11
Clarithromycin
J01FA09
Clindamycin
J01FF01
Clofoctol
J01XX03
Clometocillin
J01CE07
Clomocycline
J01AA11
Cloxacillin
J01CF02
Colistin (injection, infusion)
J01XB01
Colistin (oral)
A07AA10
Combinations of beta-lactamase sensitive penicillins
J01CE30
Combinations of intermediate-acting sulphonamides
J01EC20
Combinations of long-acting sulphonamides
J01ED20
Combinations of penicillins
J01CR50
Combinations of penicillins with extended spectrum
J01CA20
Combinations of short-acting sulphonamides
J01EB20
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
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Antimicrobial agent: generic name
ATC5
Combinations of tetracyclines
J01AA20
Cycloserine
J04AB01
Dalbavancin
J01XA04
Daptomycin
J01XX09
Demeclocycline
J01AA01
Dibekacin
J01GB09
Dicloxacillin
J01CF01
Dirithromycin
J01FA13
Doripenem
J01DH04
Doxycycline
J01AA02
Enoxacin
J01MA04
Epicillin
J01CA07
Ertapenem
J01DH03
Erythromycin
J01FA01
Ethambutol
J04AK02
Ethionamide
J04AD03
Faropenem
J01DI03
Fidaxomicin
A07AA12
Fleroxacin
J01MA08
Flomoxef
J01DC14
Flucloxacillin
J01CF05
Fluconazole
J02AC01
Flucytosine
J02AX01
Flumequine
J01MB07
Flurithromycin
J01FA14
Fosfomycin
J01XX01
Furazidin
J01XE03
Fusidic acid
J01XC01
Garenoxacin
J01MA19
Gatifloxacin
J01MA16
Gemifloxacin
J01MA15
Gentamicin
J01GB03
Grepafloxacin
J01MA11
Griseofulvin
D01BA01
Hachimycin
J02AA02
Hetacillin
J01CA18
Iclaprim
J01EA03
Imipenem and enzyme inhibitor
J01DH51
Isavuconazole
J02AC05
Isepamicin
J01GB11
Isoniazid
J04AC01
Itraconazole
J02AC02
Josamycin
J01FA07
Kanamycin
A07AA08
Kanamycin
J01GB04
Ketoconazole
J02AB02
Latamoxef
J01DD06
Levofloxacin
J01MA12
Levofloxacin, combinations with other antibacterials
J01RA05
Lincomycin
J01FF02
Linezolid
J01XX08
Lomefloxacin
J01MA07
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Antimicrobial agent: generic name
ATC5
Loracarbef
J01DC08
Lymecycline
J01AA04
Mandelic acid
J01XX06
Mecillinam
J01CA11
Meropenem
J01DH02
Metacycline
J01AA05
Metampicillin
J01CA14
Methenamine
J01XX05
Meticillin
J01CF03
Metronidazole (oral, rectal)
P01AB01
Metronidazole (parenteral)
J01XD01
Metronidazole, combinations
P01AB51
Mezlocillin
J01CA10
Micafungin
J02AX05
Miconazole
J02AB01
Midecamycin
J01FA03
Minocycline
J01AA08
Miocamycin
J01FA11
Moxifloxacin
J01MA14
Nafcillin
J01CF06
Nalidixic acid
J01MB02
Natamycin
A07AA03
Nemonoxacin
J01MB08
Neomycin (injection, infusion)
J01GB05
Neomycin (oral)
A07AA01
Neomycin, combinations (oral)
A07AA51
Netilmicin
J01GB07
Nifurtoinol
J01XE02
Nimorazole
P01AB06
Nitrofurantoin
J01XE01
Nitrofurantoin, combinations
J01XE51
Nitroxoline
J01XX07
Norfloxacin
J01MA06
Norfloxacin and tinidazole
J01RA13
Nystatin
A07AA02
Ofloxacin
J01MA01
Ofloxacin and ornidazole
J01RA09
Oleandomycin
J01FA05
Oritavancin
J01XA05
Ornidazole (oral)
P01AB03
Ornidazole (parenteral)
J01XD03
Oxacillin
J01CF04
Oxolinic acid
J01MB05
Oxytetracycline
J01AA06
Oxytetracycline, combinations
J01AA56
Panipenem and betamipron
J01DH55
Paromomycin
A07AA06
Pazufloxacin
J01MA18
Pefloxacin
J01MA03
Penamecillin
J01CE06
Penicillins, combinations with other antibacterials
J01RA01
Penimepicycline
J01AA10
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Antimicrobial agent: generic name
ATC5
Pheneticillin
J01CE05
Phenoxymethylpenicillin
J01CE02
Pipemidic acid
J01MB04
Piperacillin
J01CA12
Piperacillin and enzyme inhibitor
J01CR05
Piromidic acid
J01MB03
Pivampicillin
J01CA02
Pivmecillinam
J01CA08
Polymyxin B
A07AA05
Polymyxin B
J01XB02
Posaconazole
J02AC04
Pristinamycin
J01FG01
Procaine benzylpenicillin
J01CE09
Propenidazole
P01AB05
Propicillin
J01CE03
Prulifloxacin
J01MA17
Pyrazinamide
J04AK01
Quinupristin/dalfopristin
J01FG02
Ribostamycin
J01GB10
Rifabutin
J04AB04
Rifampicin
J04AB02
Rifaximin
A07AA11
Rokitamycin
J01FA12
Rolitetracycline
J01AA09
Rosoxacin
J01MB01
Roxithromycin
J01FA06
Rufloxacin
J01MA10
Secnidazole
P01AB07
Sisomicin
J01GB08
Sitafloxacin
J01MA21
Solithromycin
J01FA16
Sparfloxacin
J01MA09
Spectinomycin
J01XX04
Spiramycin
J01FA02
Spiramycin and metronidazole
J01RA04
Streptoduocin
J01GA02
Streptomycin (oral)
A07AA04
Streptomycin (parenteral)
J01GA01
Streptomycin, combinations
A07AA54
Sulbactam
J01CG01
Sulbenicillin
J01CA16
Sulfadiazine
J01EC02
Sulfadiazine and tetroxoprim
J01EE06
Sulfadiazine and trimethoprim
J01EE02
Sulfadimethoxine
J01ED01
Sulfadimidine
J01EB03
Sulfadimidine and trimethoprim
J01EE05
Sulfafurazole
J01EB05
Sulfaisodimidine
J01EB01
Sulfalene
J01ED02
Sulfamazone
J01ED09
Sulfamerazine
J01ED07
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Antimicrobial agent: generic name
ATC5
Sulfamerazine and trimethoprim
J01EE07
Sulfamethizole
J01EB02
Sulfamethoxazole
J01EC01
Sulfamethoxazole and trimethoprim
J01EE01
Sulfamethoxypyridazine
J01ED05
Sulfametomidine
J01ED03
Sulfametoxydiazine
J01ED04
Sulfametrole and trimethoprim
J01EE03
Sulfamoxole
J01EC03
Sulfamoxole and trimethoprim
J01EE04
Sulfanilamide
J01EB06
Sulfaperin
J01ED06
Sulfaphenazole
J01ED08
Sulfapyridine
J01EB04
Sulfathiazole
J01EB07
Sulfathiourea
J01EB08
Sulfonamides, combinations with other antibacterials (excl. trimethoprim)
J01RA02
Sultamicillin
J01CR04
Talampicillin
J01CA15
Tazobactam
J01CG02
Tedizolid
J01XX11
Teicoplanin
J01XA02
Telavancin
J01XA03
Telithromycin
J01FA15
Temafloxacin
J01MA05
Temocillin
J01CA17
Terbinafine
D01BA02
Tetracycline
J01AA07
Tetracycline and oleandomycin
J01RA08
Thiamphenicol
J01BA02
Thiamphenicol, combinations
J01BA52
Ticarcillin
J01CA13
Ticarcillin and enzyme inhibitor
J01CR03
Tigecycline
J01AA12
Tinidazole (oral, rectal)
P01AB02
Tinidazole (parenteral)
J01XD02
Tobramycin
J01GB01
Trimethoprim
J01EA01
Troleandomycin
J01FA08
Trovafloxacin
J01MA13
Vancomycin (oral)
A07AA09
Vancomycin (parenteral)
J01XA01
Voriconazole
J02AC03
Xibornol
J01XX02
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Healthcare-associated infections: code lists
HAI code list, table
HAI code
HAI label
SSI-S
Surgical site infection, superficial incisional
SSI-D
Surgical site infection, deep incisional
SSI-O
Surgical site infection, organ/space
PN1
Pneumonia, clinical + positive quantitative culture from minimally contaminated lower respiratory tract
specimen
PN2
Pneumonia, clinical + positive quantitative culture from possibly contaminated lower respiratory tract specimen
PN3
Pneumonia, clinical + microbiological diagnosis by alternative microbiology methods
PN4
Pneumonia, clinical + positive sputum culture or non-quantitative culture from lower respiratory tract
specimen
PN5
Pneumonia: clinical signs of pneumonia without positive microbiology
UTI-A
symptomatic urinary tract infection, microbiologically confirmed
UTI-B
symptomatic urinary tract infection, not microbiologically confirmed
BSI
Bloodstream infection (laboratory-confirmed), other than CRI3
CRI1-CVC
Local CVC-related infection (no positive blood culture)
CRI2-CVC
General CVC-related infection (no positive blood culture)
CRI3-CVC
Microbiologically confirmed CVC-related bloodstream infection
CRI1-PVC
Local PVC-related infection (no positive blood culture)
CRI2-PVC
General PVC-related infection (no positive blood culture)
CRI3-PVC
Microbiologically confirmed PVC-related bloodstream infection
BJ-BONE
Osteomyelitis
BJ-JNT
Joint or bursa
BJ-DISC
Disc-space infection
CNS-IC
Intracranial infection
CNS-MEN
Meningitis or ventriculitis
CNS-SA
Spinal abscess without meningitis
CVS-VASC
Arterial or venous infection
CVS-ENDO
Endocarditis
CVS-CARD
Myocarditis or pericarditis
CVS-MED
Mediastinitis
EENT-CONJ
Conjunctivitis
EENT-EYE
Eye, other than conjunctivitis
EENT-EAR
Ear mastoid
EENT-ORAL
Oral cavity (mouth, tongue, or gums)
EENT-SINU
Sinusitis
EENT-UR
Upper respiratory tract, pharyngitis, laryngitis, epiglottitis
LRI-BRON
Bronchitis, tracheobronchitis, bronchiolitis, tracheitis, without evidence of pneumonia
LRI-LUNG
Other infections of the lower respiratory tract
GI-CDI
Clostridium difficile
infection
GI-GE
Gastroenteritis (excluding CDI)
GI-GIT
Gastrointestinal tract (esophagus, stomach, small and large bowel, and rectum), excluding GE, CDI
GI-HEP
Hepatitis
GI-IAB
Intra-abdominal infection, not specified elsewhere
REPR-EMET
Endometritis
REPR-EPIS
Episiotomy
REPR-VCUF
Vaginal cuff
REPR-OREP
Other infections of the male or female reproductive tract
SST-SKIN
Skin infection
SST-ST
Soft tissue (necrotizing fascitis, infectious gangrene, necrotizing cellulitis, infectious myositis, lymphadenitis, or
lymphangitis)
SST-DECU
Decubitus ulcer, including both superficial and deep infections
SST-BURN
Burn
SST-BRST
Breast abscess or mastitis
SYS-DI
Disseminated infection
SYS-CSEP
Treated unidentified severe infection in adults and children
NEO-CSEP
Clinical sepsis in neonates
NEO-LCBI
Laboratory-confirmed bloodstream infection in neonates, non-CNS
NEO-CNSB
Laboratory-confirmed bloodstream infection with coagulase-negative staphylococci in neonates
NEO-PNEU
Pneumonia in neonates
NEO-NEC
Necrotising enterocolitis
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Definition of active HAI
Onset of HAI
1
Case definition
Day 3 onwards
AND
Meets the case definition on the day of survey.
OR
Day 1 (day of admission) or Day 2: SSI criteria met
at any time after admission (including previous
surgery 30 days/90 days).
OR
OR
Day 1 or Day 2 AND patient discharged from acute
care hospital in preceding 48 hours.
OR
Day 1 or Day 2 AND patient discharged from acute
care hospital in preceding 28 days if CDI
2
present.
Patient is receiving treatment
3
AND
HAI has previously met the case definition between
Day 1 of treatment and survey day.
OR
Day 1 or Day 2 AND patient has relevant device
inserted on this admission prior to onset.
1
Date of onset of HAI: 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 diagnostic 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.
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HAI case definition codes, overview
SSI
Surgical site infection
SSI-S
Superficial incisional
SSI-D
Deep incisional
SSI-O
Organ/space
PN
Pneumonia
PN1
Positive quantitative culture from minimally contaminated lower respiratory tract specimen
PN2
Positive quantitative culture from possibly contaminated lower respiratory tract specimen
PN3
Microbiological diagnosis by alternative microbiology methods
PN4
Positive sputum culture or non-quantitative culture from lower respiratory tract specimen
PN5
Clinical signs of pneumonia without positive microbiology
UTI
Urinary tract infection*
UTI-A
Microbiologically confirmed symptomatic UTI
UTI-B
Not microbiologically confirmed symptomatic UTI
* Asymptomatic bacteriuria are not within the scope of the PPS
BSI
Bloodstream infection (laboratory-confirmed)
Source of BSI:
C-CVC
Central vascular catheter (note: report as CRI3 if microbiological criteria are met)
C-PVC
Peripheral vascular catheter
S-PUL
Secondary to pulmonary infection
S-UTI
Secondary to urinary tract infection
S-DIG
Secondary to digestive tract infection
S-SSI
Secondary to surgical site infection
S-SST
Secondary to skin and soft tissue infection
S-OTH
Secondary to another infection
UO
BSI of (confirmed) unknown origin
UNK
No information/truly unknown
CRI-CVC
Central vascular catheter-related infection
CRI1-CVC
Local CVC-related infection (no positive blood culture)
CRI2-CVC
General CVC-related infection (no positive blood culture)
CRI3-CVC
Microbiologically confirmed CVC-related BSI
CRI-PVC
Peripheral vascular catheter-related infection
CRI1-PVC
Local PVC-related infection (no positive blood culture)
CRI2-PVC
General CRI (no positive blood culture)
CRI3-PVC
Microbiologically confirmed PVC-related BSI
CVS
Cardiovascular system infection
VASC
Arterial or venous infection
ENDO
Endocarditis
CARD
Myocarditis or pericarditis
MED
Mediastinitis
CNS
Central nervous system infection
IC
Intracranial infection
MEN
Meningitis or ventriculitis
SA
Spinal abscess without meningitis
EENT
Eye, ear, nose or mouth infection
CONJ
Conjunctivitis
EYE
Eye, other than conjunctivitis
EAR
Ear mastoid
ORAL
Oral cavity (mouth, tongue, or gums)
SINU
Sinusitis
UR
Upper respiratory tract, pharyngitis, laryngitis, epiglottitis
GI
Gastrointestinal system infections
CDI
Clostridium difficile
infection
GE
Gastroenteritis (excluding CDI)
GIT
Gastrointestinal tract (esophagus, stomach, small and large bowel, and rectum), excluding GE, CDI
HEP
Hepatitis
IAB
Intra-abdominal, not specified elsewhere
LRI
Lower respiratory tract infection, other than pneumonia
BRON
Bronchitis, tracheobronchitis, bronchiolitis, tracheitis, without evidence of pneumonia
LUNG
Other infections of the lower respiratory tract
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REPR
Reproductive tract infections
EMET
Endometritis
EPIS
Episiotomy
VCUF
Vaginal cuff
OREP
Other infections of the male or female reproductive tract
SST
Skin and soft tissue infections
SKIN
Skin
ST
Soft tissue (necrotising fascitis, infectious gangrene, necrotizing cellulitis, infectious myositis,
lymphadenitis, or lymphangitis)
DECU
Decubitus ulcer, including both superficial and deep infections
BURN
Burn
BRST
Breast abscess or mastitis
BJ
Bone and joint infection
BONE
Osteomyelitis
JNT
Joint or bursa
DISC
Disc space infection
SYS
Systemic infections
DI
Disseminated infection
CSEP
Treated unidentified severe infection in adults and children
NEO
CASE DEFINITIONS FOR NEONATES
CSEP
Clinical sepsis in neonates
LCBI
Laboratory-confirmed bloodstream infection in neonates, non-coagulase-negative staphylococci
CNSB
Laboratory-confirmed bloodstream infection with coagulase-negative staphylococci in neonates
PNEU
Pneumonia in neonates
NEC
Necrotising enterocolitis
BSI origin (BSI source) code list
Related to catheter
C-CVC
Central vascular catheter, clinical relationship (e.g. symptoms improve within 48 hours after
catheter removal)
C-PVC
Peripheral vascular catheter, clinical relationship (e.g. symptoms improve within 48 hours after
catheter removal)
*
CRI3-CVC, central vascular catheter, microbiologically confirmed
*
CRI3-PVC, peripheral vascular catheter, microbiologically confirmed
Secondary to another site
S-PUL
Pulmonary infection
S-UTI
Urinary tract infection
S-SSI
Surgical site infection
S-DIG
Digestive tract infection
S-SST
Skin soft tissue
S-OTH
Other infection (e.g. meningitis, osteomyelitis, etc.)
BSI of unknown origin
UO
None of the above; BSI confirmed to be of unknown origin
* Note: Do not report CRI3 as BSI with BSI origin C-CVC or C-PVC, but use CRI3-CVC or CRI3-PVC; see CRI definitions.
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Case definitions of healthcare-associated infections
SSI: SURGICAL SITE INFECTION
Superficial incisional (SSI-S)
Infection occurs within 30 days after the operation and infection involves only skin and subcutaneous tissue of the
incision and at least one of the following:
Purulent drainage with or without laboratory confirmation, from the superficial incision.
Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.
At least one of the following signs or symptoms of infection: pain or tenderness, localised swelling, redness,
or heat, and superficial incision is deliberately opened by surgeon, unless incision is culture-negative.
Diagnosis of superficial incisional SSI made by a surgeon or attending physician.
Deep incisional (SSI-D)
Infection occurs within 30 days after the operation if no implant is left in place, or within 90 days if implant is in
place and the infection appears to be related to the operation and infection involves deep soft tissue (e.g. fascia,
muscle) of the incision and at least one of the following:
Purulent drainage from the deep incision but not from the organ/space component of the surgical site.
A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least
one of the following signs or symptoms: fever (> 38 °C), localised pain or tenderness, unless incision is
culture-negative.
An abscess or other evidence of infection involving the deep incision is found on direct examination, during
reoperation, or by histopathologic or radiologic examination.
Diagnosis of deep incisional SSI made by a surgeon or attending physician.
Organ/space (SSI-O)
Infection occurs within 30 days after the operation if no implant is left in place, or within 90 days if implant is in
place and the infection appears to be related to the operation and infection involves any part of the anatomy (e.g.
organs and spaces) other than the incision which was opened or manipulated during an operation, and at least one
of the following:
purulent drainage from a drain that is placed through a stab wound into the organ/space;
organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space;
an abscess or other evidence of infection involving the organ/space that is found on direct examination,
during reoperation, or by histopathologic or radiologic examination;
diagnosis of organ/space SSI made by a surgeon or attending physician.
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Microbiology
PN: PNEUMONIA
Two or more serial chest X-rays or CT-scans with a suggestive image of pneumonia for patients with underlying
cardiac or pulmonary disease (in patients without underlying cardiac or pulmonary disease one definitive chest X-
ray or CT-scan is sufficient),
and at least one of the following:
fever > 38 °C with no other cause;
leukopenia (<4 000 WBC/mm
3
) or leucocytosis ( 12 000 WBC/mm
3
);
and at least one of the following (or at least two if clinical pneumonia only = PN 4 and PN 5):
new onset of purulent sputum, or change in character of sputum (colour, odour, quantity, consistency);
cough or dyspnea or tachypnea;
suggestive auscultation (rales or bronchial breath sounds), ronchi, wheezing;
worsening gas exchange (e.g. O2 desaturation or increased oxygen requirements or increased ventilation
demand);
and according to the used diagnostic method:
a) Bacteriologic diagnostic test performed by:
Positive quantitative culture from minimally contaminated LRT (lower respiratory tract) specimen (PN 1):
broncho-alveolar lavage (BAL) with a threshold of > 10
4
CFU
2
/ml or 5 % of BAL obtained cells
contain intracellular bacteria on direct microscopic exam (classified on the diagnostic category BAL);
protected brush (PB Wimberley) with a threshold of > 10
3
CFU/ml;
distal protected aspirate (DPA) with a threshold of > 10
3
CFU/ml.
Positive quantitative culture from possibly contaminated LRT specimen (PN 2):
Quantitative culture of LRT specimen (e.g. endotracheal aspirate) with a threshold of 10
6
CFU/ml
b) Alternative microbiology methods (PN 3):
positive blood culture not related to another source of infection;
Positive growth in culture of pleural fluid;
pleural or pulmonary abscess with positive needle aspiration;
histologic pulmonary exam shows evidence of pneumonia;
positive exams for pneumonia with virus or particular germs (
Legionella
,
Aspergillus
, mycobacteria,
mycoplasma,
Pneumocystis carinii
):
positive detection of viral antigen or antibody from respiratory secretions (e.g. EIA, FAMA, shell vial
assay, PCR);
positive direct exam or positive culture from bronchial secretions or tissue;
seroconversion (e.g. influenza viruses,
Legionella
,
Chlamydia
);
detection of antigens in urine (
Legionella
).
c) Others:
positive sputum culture or non-quantitative LRT specimen culture (PN 4);
no positive microbiology (PN 5).
Notes:
One definitive chest X-ray or CT-scan for the current pneumonia episode may be sufficient in patients with underlying cardiac or
pulmonary disease if comparison with previous X-rays is possible.
PN 1 and PN 2 criteria were validated without previous antimicrobial therapy. However, this does not exclude the diagnosis of
PN 1 or PN 2 in the case of previous antimicrobial use.
Comment: The subdivision of the pneumonia definition in five categories allows for the comparison of similar
entities of pneumonia within and between countries. It is essential that all hospitals report PN4 and PN5 (clinical
pneumonia without microbiological evidence) if appropriate in order to achieve overall comparability, even if a
microbiological exam was performed and yielded negative results. It is also advised, both for clinical and
surveillance purposes, that networks promote as microbiological confirmation (PN1–3) as a routine practice, at
least in the ICU.
2
Colony-forming units
Rx
Symptoms
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Intubation-associated pneumonia (IAP): a pneumonia is defined as intubation-associated (IAP) if an invasive
respiratory device was present (even intermittently) in the 48 hours preceding the onset of infection.
UTI: URINARY TRACT INFECTION
UTI-A: microbiologically confirmed symptomatic UTI
Patient has at least one of the following signs of symptoms with no other recognised cause: fever (> 38°C),
urgency, frequency, dysuria, or suprapubic tenderness
and
patient has a positive urine culture, that is, ≥ 10
5
microorganisms per ml of urine with no more than two
species of microorganisms.
UTI-B: not microbiologically confirmed symptomatic UTI
Patient has at least two of the following with no other recognised cause: fever (> 38°C), urgency,
frequency, dysuria, or suprapubic tenderness,
and
at least one of the following:
positive dipstick for leukocyte esterase and/or nitrate;
pyuria urine specimen with ≥ 10 WBC/ml or ≥ 3 WBC/high-power field of unspun urine;
organisms seen on Gram stain of unspun urine;
at least two urine cultures with repeated isolation of the same uropathogen (Gram-negative bacteria
or S. saprophyticus) with ≥ 102 colonies/ml urine in nonvoided specimens;
≤ 105 colonies/ml of a single uropathogen (Gram-negative bacteria or S. saprophyticus) in a patient
being treated with effective antimicrobial agent for a urinary infection;
physician diagnosis of a urinary tract infection;
physician institutes appropriate therapy for a urinary infection.
UTI-C: asymptomatic bacteriuria: EXCLUDED FOR PPS, not to be reported*
Patient has no fever (> 38°C), urgency, frequency, dysuria, or suprapubic tenderness
and
either of the following criteria:
Patient has had an indwelling urinary catheter within seven days before urine is cultured,
and
patient has a urine culture, that is, ≥ 105 microorganisms per ml of urine with no more than two species of
microorganisms;
patient has not had an indwelling urinary catheter within seven days before the first positive culture;
and
patient has had at least two positive urine cultures ≥ 105 microorganisms per mm3 of urine with repeated
isolation of the same microorganism and no more than two species of microorganisms.
* Note: Bloodstream infections secondary to asymptomatic bacteriuria are reported as BSI with source (origin) S-UTI
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BSI: BLOODSTREAM INFECTION
BSI: Laboratory-confirmed bloodstream infection
One positive blood culture for a recognised pathogen
or
patient has at least one of the following signs or symptoms: fever (> 38°C), chills, or hypotension
and
two positive blood cultures for a common skin contaminant (from two separate blood samples, usually
within 48 hours).
Skin contaminants = coagulase-negative staphylococci,
Micrococcus
sp.,
Propionibacterium acnes
,
Bacillus
sp.,
Corynebacterium
sp.
Note: This definition corresponds to the former HELICS BSI-A definition; BSI-B (single blood culture for skin contaminants in
patients with central vascular catheter and adapted treatment) was deleted following recommendations at an ECDC expert
meeting in January 2009 and subsequent confirmation at the annual meeting.
Sources of bloodstream infection:
Catheter related: the same microorganism was cultured from the catheter or symptoms improve within 48
hours after removal of the catheter (C-PVC: peripheral catheter, C-CVC: central vascular catheter).
Important: Report C-CVC or C-PVC BSI as CRI3-CVC or CRI3-PVC respectively if microbiologically confirmed;
see CRI3 definition.
Secondary to another infection: the same microorganism was isolated from another infection site, or strong
clinical evidence exists that bloodstream infection was secondary to another infection site, invasive
diagnostic procedure or foreign body:
pulmonary (S-PUL);
urinary tract infection (S-UTI);
digestive tract infection (S-DIG);
surgical site infection (S-SSI);
skin and soft tissue (S-SST);
other (S-OTH).
Unkown origin (UO): none of the above, bloodstream infection of unknown origin (verified during survey
and no source found)
Unknown (UNK): no information available about the source of the bloodstream infection or information
missing
Note:
Primary bloodstream infections include catheter-related BSI and BSI of unknown origin.
A CVC-associated bloodstream infection in accordance with CDC/NHSN definitions (as opposed to CVC-related BSI) is a primary
BSI with central venous catheter use (even intermittent) in the 48 hours preceding the onset of the infection: therefore the
presence of ‘the relevant device’ (central/peripheral vascular catheter) in the 48 hours before onset of infection is collected even
in the absence of microbiological confirmation. (See also AJIC, 1997;25:112-6).
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CRI: CATHETER-RELATED INFECTION
CRI1-CVC: local CVC-related infection (no positive blood culture)
Quantitative CVC culture 10
3
CFU/ml (1) or semi-quantitative CVC culture > 15 CFU (2)
and
pus/inflammation at the insertion site or tunnel.
CRI1-PVC: local PVC-related infection (no positive blood culture)
Quantitative PVC culture 10
3
CFU/ml or semi-quantitative PVC culture > 15 CFU
and
pus/inflammation at the insertion site or tunnel.
CRI2-CVC: General CVC-related infection (no positive blood culture)
Quantitative CVC culture 103 CFU/ml or semi-quantitative CVC culture > 15 CFU
and
clinical signs improve within 48 hours after catheter removal.
CRI2-PVC: General PVC-related infection (no positive blood culture)
Quantitative PVC culture 10
3
CFU/ml or semi-quantitative PVC culture > 15 CFU
and
clinical signs improve within 48 hours after catheter removal.
CRI3-CVC: microbiologically confirmed CVC-related bloodstream infection
BSI occurring 48 hours before or after catheter removal (if any)
and
positive culture with the same microorganism of either:
quantitative CVC culture 10
3
CFU/ml or semi-quantitative CVC culture > 15 CFU;
quantitative blood culture ratio CVC blood sample/peripheral blood sample > 5 (3);
differential delay of positivity of blood cultures (4): CVC blood sample culture positive two hours or
more before peripheral blood culture (blood samples drawn at the same time);
positive culture with the same microorganism from pus from insertion site.
CRI3-PVC: microbiologically confirmed PVC-related bloodstream infection
BSI occurring 48 hours before or after catheter removal (if any)
and
positive culture with the same microorganism of either:
quantitative PVC culture 10
3
CFU/ml or semi-quantitative PVC culture > 15 CFU;
positive culture with the same microorganism from pus from insertion site.
Notes:
CVC=central vascular catheter; PVC=peripheral vascular catheter.
Central vascular catheter colonisation should not be reported.
A CRI3 (-CVC or -PVC) is also a bloodstream infection with source C-CVC or C-PVC respectively; however when a CRI3 is
reported, the BSI should not be reported in the point prevalence survey; microbiologically confirmed catheter-related BSI
should be reported as CRI3.
References
(1) Brun-Buisson C, Abrouk F, Legrand P, Huet Y, Larabi S, Rapin M. Diagnosis of central venous catheter-related
sepsis. Critical level of quantitative tip cultures. Arch Intern Med 1987; 147(5):873-877.
(2) Maki DG, Weise C, Sarafin H. A semiquantitative culture method for identifying intravenous-catheter-related
infection. N Engl J Med 1977; 296:1305-1309.
(3) Blot F, Nitenberg G, Brun-Buisson C. New tools in diagnosing catheter-related infections. Support Care Cancer
2000; 8(4):287-292.
(4) Quilici N, Audibert G, Conroy MC, Bollaert PE, Guillemin F, Welfringer P et al. Differential quantitative blood
cultures in the diagnosis of catheter-related sepsis in intensive care units. Clin Infect Dis 1997; 25(5):1066-1070.
(5) Raad I, Hanna HA, Alakech B, Chatzinikolaou I, Johnson MM, Tarrand J. Differential time to positivity: a useful
method for diagnosing catheter-related bloodstream infections. Ann Intern Med. 2004 Jan 6;140(1):18-25.
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BJ: BONE AND JOINT INFECTION
BJ-BONE: osteomyelitis
Osteomyelitis must meet at least one of the following criteria:
patient has organisms cultured from bone;
patient has evidence of osteomyelitis on direct examination of the bone during a surgical operation or
histopathologic examination;
patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), localised swelling, tenderness, heat, or drainage at suspected site of bone infection;
and
at least one of the following:
organisms cultured from blood;
positive blood antigen test (e.g.
H. influenzae, S. pneumoniae
);
radiographic evidence of infection, e.g. abnormal findings on X-ray, CT scan, MRI, radiolabel scan
(gallium, technetium, etc.).
Reporting instructions: Report mediastinitis following cardiac surgery that is accompanied by osteomyelitis as
surgical site infection-organ/space (SSI-O).
BJ-JNT: joint or bursa
Joint or bursa infections must meet at least one of the following criteria:
patient has organisms cultured from joint fluid or synovial biopsy;
patient has evidence of joint or bursa infection seen during a surgical operation or histopathologic
examination;
patient has at least two of the following signs or symptoms with no other recognised cause: joint pain,
swelling, tenderness, heat, evidence of effusion or limitation of motion;
and
at least one of the following:
organisms and white blood cells seen on Gram’s stain of joint fluid;
positive antigen test on blood, urine, or joint fluid;
cellular profile and chemistries of joint fluid compatible with infection and not explained by an
underlying rheumatologic disorder;
radiographic evidence of infection, e.g. abnormal findings on X-ray, CT scan, MRI, radiolabel scan
(gallium, technetium, etc.).
BJ-DISC: disc space infection
Vertebral disc space infection must meet at least one of the following criteria:
patient has organisms cultured from vertebral disc space tissue obtained during a surgical operation or
needle aspiration;
patient has evidence of vertebral disc space infection seen during a surgical operation or histopathologic
examination;
patient has fever (> 38 °C) with no other recognised cause or pain at the involved vertebral disc space
and
radiographic evidence of infection, e.g. abnormal findings on X-ray, CT scan, MRI, radiolabel scan (gallium,
technetium, etc.);
patient has fever (> 38 °C) with no other recognised cause and pain at the involved vertebral disc space
and
positive antigen test on blood or urine (e.g.
H. influenzae,
S. pneumoniae
,
N. meningitidis
, or Group B
Streptococcus).
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CNS: CENTRAL NERVOUS SYSTEM INFECTION
CNS-IC: intracranial infection (brain abscess, subdural or epidural infection,
encephalitis)
Intracranial infection must meet at least one of the following criteria:
patient has organisms cultured from brain tissue or dura;
patient has an abscess or evidence of intracranial infection seen during a surgical operation or
histopathologic examination;
patient has at least two of the following signs or symptoms with no other recognised cause: headache,
dizziness, fever (> 38 °C), localising neurologic signs, changing level of consciousness, or confusion,
and
at least one of the following:
organisms seen on microscopic examination of brain or abscess tissue obtained by needle aspiration
or by biopsy during a surgical operation or autopsy;
positive antigen test on blood or urine;
radiographic evidence of infection, e.g. abnormal findings on ultrasound, CT scan, MRI, radionuclide
brain scan, or arteriogram;
diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen
and,
if diagnosis is made antemortem, physician institutes appropriate antimicrobial therapy.
Reporting instruction: If meningitis and a brain abscess are present together, report the infection as IC.
CNS-MEN: meningitis or ventriculitis
Meningitis or ventriculitis must meet at least one of the following criteria:
patient has organisms cultured from cerebrospinal fluid (CSF);
patient has at least one of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), headache, stiff neck, meningeal signs, cranial nerve signs, or irritability,
and
at least one of the following:
increased white cells, elevated protein, and/or decreased glucose in CSF;
organisms seen on Gram’s stain of CSF;
organisms cultured from blood;
positive antigen test of CSF, blood, or urine;
diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen
and,
if diagnosis is made antemortem, physician institutes appropriate antimicrobial therapy.
Reporting instructions:
Report CSF shunt infection as SSI if it occurs ≤90 days of placement; if >90 days or after
manipulation/access of the shunt, report as CNS-MEN if the infection meets the general case definition of
HAI
Report meningoencephalitis as MEN.
Report spinal abscess with meningitis as MEN.
CNS-SA: spinal abscess without meningitis
An abscess of the spinal epidural or subdural space, without involvement of the cerebrospinal fluid or adjacent
bone structures, must meet at least one of the following criteria:
patient has organisms cultured from abscess in the spinal epidural or subdural space;
patient has an abscess in the spinal epidural or subdural space seen during a surgical operation or at
autopsy or evidence of an abscess seen during a histopathologic examination;
patient has at least one of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), back pain, focal tenderness, radiculitis, paraparesis, or paraplegia,
and
at least one of the following:
organisms cultured from blood;
radiographic evidence of a spinal abscess, e.g. abnormal findings on myelography, ultrasound, CT
scan, MRI, or other scans (gallium, technetium, etc.);
and,
if diagnosis is made antemortem, physician institutes appropriate antimicrobial therapy.
Reporting instruction: Report spinal abscess with meningitis as meningitis.
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CVS: CARDIOVASCULAR SYSTEM INFECTION
CVS-VASC: arterial or venous infection
Arterial or venous infection must meet at least one of the following criteria:
patient has organisms cultured from arteries or veins removed during a surgical operation and blood culture
not done or no organisms cultured from blood;
patient has evidence of arterial or venous infection seen during a surgical operation or histopathologic
examination;
patient has at least one of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), pain, erythema, or heat at involved vascular site,
and
more than 15 colonies cultured from intravascular cannula tip using semiquantitative culture method,
and
blood culture not done or no organisms cultured from blood.
patient has purulent drainage at involved vascular site,
and
blood culture not done or no organisms cultured from blood.
Reporting instructions: Report infections of an arteriovenous graft, shunt, or fistula, or intravascular cannulation
site without organisms cultured from blood as CVS-VASC; report CVS-VASC matching the third criterion as CRI1 or
CRI2, as appropriate.
CVS-ENDO: endocarditis
Endocarditis of a natural or prosthetic heart valve must meet at least one of the following criteria:
patient has organisms cultured from valve or vegetation;
patient has two or more of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), new or changing murmur, embolic phenomena, skin manifestations (i.e. petechiae, splinter
haemorrhages, painful subcutaneous nodules), congestive heart failure, or cardiac conduction abnormality,
and at least one of the following:
organisms cultured from two or more blood cultures;
organisms seen on Gram’s stain of valve when culture is negative or not done;
valvular vegetation seen during a surgical operation or autopsy;
positive antigen test on blood or urine (e.g. H. influenzae, S. pneumoniae, N. meningitidis, or Group
B Streptococcus);
evidence of new vegetation seen on echocardiogramme;
and,
if diagnosis is made antemortem, physician institutes appropriate antimicrobial therapy.
CVS-CARD: myocarditis or pericarditis
Myocarditis or pericarditis must meet at least one of the following criteria:
patient has organisms cultured from pericardial tissue or fluid obtained by needle aspiration or during a
surgical operation;
patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), chest pain, paradoxical pulse, or increased heart size;
and
at least one of the following:
abnormal ECG/EKG consistent with myocarditis or pericarditis;
positive antigen test on blood (e.g.
H. influenzae
,
S. pneumoniae
);
evidence of myocarditis or pericarditis on histologic examination of heart tissue;
fourfold rise in type-specific antibody with or without isolation of virus from pharynx or feces;
pericardial effusion identified by echocardiogramme, CT scan, MRI, or angiography.
Note: Most cases of postcardiac surgery or postmyocardial infarction pericarditis are not infectious.
CVS-MED: mediastinitis
Mediastinitis must meet at least one of the following criteria:
patient has organisms cultured from mediastinal tissue or fluid obtained during a surgical operation or
needle aspiration;
patient has evidence of mediastinitis seen during a surgical operation or histopathologic examination;
patient has at least one of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), chest pain, or sternal instability;
and
at least one of the following:
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purulent discharge from mediastinal area;
organisms cultured from blood or discharge from mediastinal area;
mediastinal widening on X-ray.
Reporting instruction: Report mediastinitis following cardiac surgery that is accompanied by osteomyelitis as SSI-O.
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EENT: EYE, EAR, NOSE, THROAT, OR MOUTH INFECTION
EENT-CONJ: conjunctivitis
Conjunctivitis must meet at least one of the following criteria:
patient has pathogens cultured from purulent exudate obtained from the conjunctiva or contiguous tissues,
such as eyelid, cornea, meibomian glands, or lacrimal glands;
patient has pain or redness of conjunctiva or around eye;
and
at least one of the following:
WBCs and organisms seen on Gram stain of exudates;
purulent exudates;
positive antigen test (e.g. ELISA or IF for
Chlamydia trachomatis
, herpes simplex virus, adenovirus)
on exudate or conjunctival scraping;
multinucleated giant cells seen on microscopic examination of conjunctival exudate or scrapings
positive viral culture;
diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen.
Reporting instructions
Report other infections of the eye as EYE.
Do not report chemical conjunctivitis caused by silver nitrate (AgNO3) as a health care–associated infection.
Do not report conjunctivitis that occurs as a part of a more widely disseminated viral illness (such as
measles, chickenpox, or a URI).
EENT-EYE: eye, other than conjunctivitis
An infection of the eye, other than conjunctivitis, must meet at least one of the following criteria:
patient has organisms cultured from anterior or posterior chamber or vitreous fluid.
patient has at least two of the following signs or symptoms with no other recognised cause: eye pain, visual
disturbance, or hypopyon and at least one of the following:
physician diagnosis of an eye infection
positive antigen test on blood (e.g. H. influenzae, S. pneumoniae)
organisms cultured from blood.
EENT-EAR: ear mastoid
Ear and mastoid infections must meet at least one of the following criteria:
Otitis externa must meet at least one of the following criteria:
patient has pathogens cultured from purulent drainage from ear canal;
patient has at least one of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), pain, redness, or drainage from ear canal
and organisms seen on Gram’s stain of purulent drainage.
Otitis media must meet at least one of the following criteria:
patient has organisms cultured from fluid from middle ear obtained by tympanocentesis or at surgical
operation;
patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), pain in the eardrum, inflammation, retraction or decreased mobility of eardrum, or fluid
behind eardrum.
Otitis interna must meet at least one of the following criteria:
patient has organisms cultured from fluid from inner ear obtained at surgical operation;
patient has a physician diagnosis of inner ear infection.
Mastoiditis must meet at least one of the following criteria:
patient has organisms cultured from purulent drainage from mastoid;
patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), pain, tenderness, erythema, headache, or facial paralysis;
and
at least one of the following:
a. organisms seen on Gram stain of purulent material from mastoid;
b. positive antigen test on blood.
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EENT-ORAL: oral cavity (mouth, tongue, or gums)
Oral cavity infections must meet at least one of the following criteria:
patient has organisms cultured from purulent material from tissues of oral cavity;
patient has an abscess or other evidence of oral cavity infection seen on direct examination, during a
surgical operation, or during a histopathologic examination;
patient has at least one of the following signs or symptoms with no other recognised cause: abscess,
ulceration, or raised white patches on inflamed mucosa, or plaques on oral mucosa;
and
at least one of the following:
organisms seen on Gram’s stain;
positive KOH (potassium hydroxide) stain;
multinucleated giant cells seen on microscopic examination of mucosal scrapings;
positive antigen test on oral secretions;
diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen;
physician diagnosis of infection and treatment with topical or oral antifungal therapy.
Reporting instructions: Report healthcare-associated primary herpes simplex infections of the oral cavity as ORAL;
recurrent herpes infections are not healthcare-associated.
EENT-SINU: sinusitis
Sinusitis must meet at least one of the following criteria:
patient has organisms cultured from purulent material obtained from sinus cavity;
patient has at least one of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), pain or tenderness over the involved sinus, headache, purulent exudate, or nasal
obstruction;
and
at least one of the following:
positive transillumination;
positive radiographic examination (including CT scan).
EENT-UR: upper respiratory tract, pharyngitis, laryngitis, epiglottitis
Upper respiratory tract infections must meet at least one of the following criteria:
Patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), erythema of pharynx, sore throat, cough, hoarseness, or purulent exudate in throat;
and
at least one of the following:
organisms cultured from the specific site;
organisms cultured from blood;
positive antigen test on blood or respiratory secretions;
diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen;
physician diagnosis of an upper respiratory infection.
Patient has an abscess seen on direct examination, during a surgical operation, or during a histopathologic
examination.
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LRI: LOWER RESPIRATORY TRACT INFECTION, OTHER THAN
PNEUMONIA
LRI-BRON: bronchitis, tracheobronchitis, bronchiolitis, tracheitis, without
evidence of pneumonia
Tracheobronchial infections must meet at least one of the following criteria:
Patient has no clinical or radiographic evidence of pneumonia
and
patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), cough, new or increased sputum production, rhonchi, wheezing and at least one of the
following:
positive culture obtained by deep tracheal aspirate or bronchoscopy;
positive antigen test on respiratory secretions.
Reporting instruction: Do not report chronic bronchitis in a patient with chronic lung disease as an infection unless
there is evidence of an acute secondary infection, manifested by change in organism.
LRI-LUNG: other infections of the lower respiratory tract
Other infections of the lower respiratory tract must meet at least one of the following criteria:
patient has organisms seen on smear or cultured from lung tissue or fluid, including pleural fluid;
patient has a lung abscess or empyema seen during a surgical operation or histopathologic examination;
patient has an abscess cavity seen on radiographic examination of lung.
Reporting instructions: Report lung abscess or empyema without pneumonia as LUNG.
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GI: GASTROINTESTINAL SYSTEM INFECTION
GI-CDI:
Clostridium difficile
infection
A
Clostridium difficile
infection (previously also referred to as
Clostridium difficile
associated diarrhoea, or CDAD)
must meet at least one of the following criteria:
diarrhoeal stools
or toxic megacolon, and a positive laboratory assay for
C. difficile
toxin A and/or B in stools
or a toxin-producing
C. difficile
organism detected in stool via culture or other means, e.g. a positive PCR
result;
pseudomembranous colitis revealed by lower gastro-intestinal endoscopy;
colonic histopathology characteristic of
C. difficile
infection (with or without diarrhoea) on a specimen
obtained during endoscopy, colectomy or autopsy.
Note: If clinical signs of
Clostridium difficile
infection appear in 28 days after hospital discharge period, GI-CDI must be defined as
healthcare-associated infection.
(*) May be community- or healthcare-associated, depending on case’s history. If healthcare-associated, may have been acquired
in the same facility or imported.
GI-GE: gastroenteritis (excluding CDI)
Gastroenteritis must meet at least one of the following criteria:
Patient has an acute onset of diarrhoea (liquid stools for more than 12 hours) with or without vomiting or
fever (> 38 °C) and no likely non-infectious cause (e.g. diagnostic tests, therapeutic regimen other than
antimicrobial agents, acute exacerbation of a chronic condition, or psychological stress).
Patient has at least two of the following signs or symptoms with no other recognised cause: nausea,
vomiting, abdominal pain, fever (> 38 °C), or headache;
and
at least one of the following:
an enteric pathogen is cultured from stool or rectal swab;
an enteric pathogen is detected by routine or electron microscopy;
an enteric pathogen is detected by antigen or antibody assay on blood or feces;
evidence of an enteric pathogen is detected by cytopathic changes in tissue culture (toxin assay);
diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen.
GI-GIT: gastrointestinal tract (esophagus, stomach, small and large bowel, and
rectum) excluding gastroenteritis and appendicitis
Gastrointestinal tract infections, excluding gastroenteritis and appendicitis, must meet at least one of the following
criteria:
patient has an abscess or other evidence of infection seen during a surgical operation or histopathologic
examination;
patient has at least two of the following signs or symptoms with no other recognised cause and compatible
with infection of the organ or tissue involved: fever (> 38 °C), nausea, vomiting, abdominal pain, or
tenderness;
and
at least one of the following:
organisms cultured from drainage or tissue obtained during a surgical operation or endoscopy or
from a surgically placed drain;
organisms seen on Gram stain or KOH stain or multinucleated giant cells seen on microscopic
examination of drainage or tissue obtained during a surgical operation or endoscopy or from a
surgically placed drain;
organisms cultured from blood;
evidence of pathologic findings on radiographic examination;
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evidence of pathologic findings on endoscopic examination (e.g.
Candida
esophagitis or proctitis).
GI-HEP: hepatitis
Hepatitis must meet the following criterion:
Patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), anorexia, nausea, vomiting, abdominal pain, jaundice, or history of transfusion within the
previous three months;
and
at least one of the following:
positive antigen or antibody test for hepatitis A, hepatitis B, hepatitis C, or delta hepatitis;
abnormal liver function tests (e.g. elevated ALT/AST, bilirubin);
cytomegalovirus (CMV) detected in urine or oropharyngeal secretions.
Reporting instructions
Do not report hepatitis or jaundice of non-infectious origin (alpha-1 antitrypsin deficiency, etc).
Do not report hepatitis or jaundice that results from exposure to hepatotoxins (alcoholic or acetaminophen-
induced hepatitis, etc).
Do not report hepatitis or jaundice that results from biliary obstruction (cholecystitis).
GI-IAB: intra-abdominal, not specified elsewhere including gallbladder, bile ducts,
liver (excluding viral hepatitis), spleen, pancreas, peritoneum, subphrenic or
subdiaphragmatic space, or other intra-abdominal tissue or area not specified
elsewhere
Intra-abdominal infections must meet at least one of the following criteria:
patient has organisms cultured from purulent material from intra-abdominal space obtained during a
surgical operation or needle aspiration;
patient has abscess or other evidence of intra-abdominal infection seen during a surgical operation or
histopathologic examination;
patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), nausea, vomiting, abdominal pain, or jaundice;
and
at least one of the following:
organisms cultured from drainage from surgically placed drain (e.g. closed suction drainage system,
open drain, T-tube drain);
organisms seen on Gram stain of drainage or tissue obtained during surgical operation or needle
aspiration;
organisms cultured from blood and radiographic evidence of infection, e.g. abnormal findings on
ultrasound, CT scan, MRI, or radiolabel scans (gallium, technetium, etc.) or on abdominal X-ray.
Reporting instruction: Do not report pancreatitis (an inflammatory syndrome characterised by abdominal pain,
nausea, and vomiting associated with high serum levels of pancreatic enzymes) unless it is determined to be
infectious in origin.
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REPR: REPRODUCTIVE TRACT INFECTION
REPR-EMET: endometritis
Endometritis must meet at least one of the following criteria:
patient has organisms cultured from fluid or tissue from endometrium obtained during surgical operation, by
needle aspiration, or by brush biopsy;
patient has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C), abdominal pain, uterine tenderness, or purulent drainage from uterus.
Reporting instruction: Report postpartum endometritis as a health care-associated infection unless the amniotic
fluid is infected at the time of admission or the patient was admitted 48 hours after rupture of the membrane.
REPR-EPIS: episiotomy
Episiotomy infections must meet at least one of the following criteria:
postvaginal delivery patient has purulent drainage from the episiotomy;
postvaginal delivery patient has an episiotomy abscess.
REPR-VCUF: vaginal cuff
Vaginal cuff infections must meet at least one of the following criteria:
posthysterectomy patient has purulent drainage from the vaginal cuff;
posthysterectomy patient has an abscess at the vaginal cuff;
posthysterectomy patient has pathogens cultured from fluid or tissue obtained from the vaginal cuff.
Reporting instruction: Report vaginal cuff infections as SSI-O if other SSI criteria are met (within 30 days following
hysterectomy).
REPR-OREP: other infections of the male or female reproductive tract (epididymis,
testes, prostate, vagina, ovaries, uterus, or other deep pelvic tissues, excluding
endometritis or vaginal cuff infections)
Other infections of the male or female reproductive tract must meet at least one of the following criteria:
patient has organisms cultured from tissue or fluid from affected site;
patient has an abscess or other evidence of infection of affected site seen during a surgical operation or
histopathologic examination;
patient has two of the following signs or symptoms with no other recognised cause: fever (> 38 °C),
nausea, vomiting, pain, tenderness, or dysuria;
and
at least one of the following:
organisms cultured from blood;
physician diagnosis.
Reporting instructions
Report endometritis as EMET.
Report vaginal cuff infections as VCUF.
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SST: SKIN AND SOFT TISSUE INFECTION
SST-SKIN: skin infection
Skin infections must meet at least one of the following criteria:
patient has purulent drainage, pustules, vesicles, or boils;
patient has at least two of the following signs or symptoms with no other recognised cause: pain or
tenderness, localised swelling, redness, or heat;
and
at least one of the following:
organisms cultured from aspirate or drainage from affected site; if organisms are normal skin flora
(i.e. diphtheroids [
Corynebacterium
spp],
Bacillus
[not
B anthracis
] spp,
Propionibacterium
spp,
coagulase-negative staphylococci [including
S epidermidis
], viridans group streptococci,
Aerococcus
spp,
Micrococcus
spp), they must be a pure culture;
organisms cultured from blood;
positive antigen test performed on infected tissue or blood (e.g. herpes simplex, varicella zoster,
H.
influenzae
,
N. meningitidis
);
multinucleated giant cells seen on microscopic examination of affected tissue;
diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen.
Reporting instructions
Report infected decubitus ulcers as DECU.
Report infected burns as BURN.
Report breast abscesses or mastitis as BRST.
SST-ST: soft tissue (necrotizing fascitis, infectious gangrene, necrotizing cellulitis,
infectious myositis, lymphadenitis, or lymphangitis)
Soft tissue infections must meet at least one of the following criteria:
patient has organisms cultured from tissue or drainage from affected site;
patient has purulent drainage at affected site;
patient has an abscess or other evidence of infection seen during a surgical operation or histopathologic
examination;
patient has at least two of the following signs or symptoms at the affected site with no other recognised
cause: localised pain or tenderness, redness, swelling, or heat;
and
at least one of the following:
organisms cultured from blood;
positive antigen test performed on blood or urine (e.g.
H. influenzae
,
S. pneumoniae
,
N.
meningitidis
, Group B
Streptococcus
,
Candida
spp);
diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen.
Reporting instructions
Report infected decubitus ulcers as DECU.
Report infection of deep pelvic tissues as OREP.
SST-DECU: decubitus ulcer, including both superficial and deep infections
Decubitus ulcer infections must meet the following criterion:
patient has at least two of the following signs or symptoms with no other recognised cause: redness,
tenderness, or swelling of decubitus wound edges
and
at least one of the following:
organisms cultured from properly collected fluid or tissue (see comments below);
organisms cultured from blood.
Comments
Purulent drainage alone is not sufficient evidence of an infection.
Organisms cultured from the surface of a decubitus ulcer are not sufficient evidence that the ulcer is
infected. A properly collected specimen from a decubitus ulcer involves needle aspiration of fluid or biopsy
of tissue from the ulcer margin.
SST-BURN: burn
Burn infections must meet at least one of the following criteria:
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patient has a change in burn wound appearance or character, such as rapid eschar separation, or dark
brown, black, or violaceous discoloration of the eschar, or edema at wound margin and histologic
examination of burn biopsy shows invasion of organisms into adjacent viable tissue;
patient has a change in burn wound appearance or character, such as rapid eschar separation, or dark
brown, black, or violaceous discoloration of the eschar, or edema at wound margin;
and
at least one of the following:
organisms cultured from blood in the absence of other identifiable infection;
isolation of herpes simplex virus, histologic identification of inclusions by light or electron microscopy,
or visualisation of viral particles by electron microscopy in biopsies or lesion scrapings.
patient with a burn has at least two of the following signs or symptoms with no other recognised cause:
fever (> 38 °C) or hypothermia (< 36 °C), hypotension, oliguria (< 20 cc/hr), hyperglycemia at previously
tolerated level of dietary carbohydrate, or mental confusion;
and
at least one of the following:
histologic examination of burn biopsy shows invasion of organisms into adjacent viable tissue
organisms cultured from blood;
isolation of herpes simplex virus, histologic identification of inclusions by light or electron microscopy,
or visualisation of viral particles by electron microscopy in biopsies or lesion scrapings.
Comments
Purulence alone at the burn wound site is not adequate for the diagnosis of burn infection; such purulence
may reflect incomplete wound care.
Fever alone in a burn patient is not adequate for the diagnosis of a burn infection because fever may be the
result of tissue trauma or the patient may have an infection at another site.
Surgeons in regional burn centres who take care of burn patients exclusively may require Criterion 1 for
diagnosis of burn infection.
Hospitals with regional burn centres may further divide burn infections into the following: burn wound site,
burn graft site, burn donor site, burn donor site-cadaver; NHSN, however, will code all of these as BURN.
SST-BRST: breast abscess or mastitis
A breast abscess or mastitis must meet at least one of the following criteria:
patient has a positive culture of affected breast tissue or fluid obtained by incision and drainage or needle
aspiration;
patient has a breast abscess or other evidence of infection seen during a surgical operation or
histopathologic examination;
patient has fever (> 38 °C) and local inflammation of the breast and physician diagnosis of breast abscess.
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SYS: SYSTEMIC INFECTION
SYS-DI: disseminated infection
Disseminated infection is infection involving multiple organs or systems, without an apparent single site of
infection, usually of viral origin, and with signs or symptoms with no other recognised cause and compatible with
infectious involvement of multiple organs or systems.
Reporting instructions
Use this code for viral infections involving multiple organ systems (e.g. measles, mumps, rubella, varicella,
erythema infectiosum). These infections often can be identified by clinical criteria alone. Do not use this
code for healthcare-associated infections with multiple metastatic sites, such as with bacterial endocarditis.
Do not report fever of unknown origin (FUO) as DI.
Report viral exanthems or rash illness as DI.
SYS-CSEP: treated unidentified severe infection (formerly: clinical sepsis in adults
and children)
Patient has at least one of the following:
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
physician institutes treatment for sepsis.
Reporting instructions:
Do not use this code unless absolutely needed (last-resort definition).
For CSEP in neonates, use NEO-CSEP case definition (see below).
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NEO: SPECIFIC NEONATAL CASE DEFINITIONS
NEO-CSEP: clinical sepsis
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),
increased oxygen requirement (intubation), unstable general condition of the patient, apathy).
Note: A one-time detection of coagulase-negative staphylococci (CNS) in blood cultures should not exclude the diagnosis of
clinical sepsis. A clinical sepsis can also be diagnosed with a single positive blood culture with CNS, which is considered as a blood
culture contamination, while other criteria of CNS bloodstream infection are not met and criteria of clinical sepsis have been met.
NEO-LCBI: laboratory-confirmed BSI
At least two of: temperature > 38 °C or < 36.5 °C or temperature instability, tachycardia or bradycardia,
apnoea, extended capillary refilling time (CRT), metabolic acidosis, hyperglycaemia, other sign of BSI such
as apathy;
and
a recognised pathogen other than coagulase-negative staphylococci (CNS) cultured from blood or
cerebrospinal fluid (CSF; this is included because meningitis in this age group is usually haematogenous, so
positive CSF can be regarded as evidence of BSI even if blood cultures are negative or were not taken).
Note: In order to be consistent with BSI reporting in adults (including secondary BSI), the criterion ‘the organism is not related to
an infection at another site’ was removed from the Neo-KISS definition for the purposes of the EU PPS.
Report the origin of the neonatal BSI in the field BSI origin.
If both the case definitions for NEO-LCBI and NEO-CNSB are matched, report NEO-LCBI.
NEO-CNSB: laboratory-confirmed BSI with coagulase-negative staphylococci
(CNS)
At least two of: temperature > 38 °C or < 36.5 °C or temperature instability, tachycardia or bradycardia,
apnoea, extended recapillarisation time, metabolic acidosis, hyperglycaemia, other sign of BSI such as
apathy;
and
CNS is cultured from blood or catheter tip;
and
patient has one of: C-reactive protein > 2.0 mg/dL, immature/total neutrophil ratio (I/T ratio) > 0.2,
leukocytes < 5/nL, platelets <100/nL.
Note: In order to be consistent with BSI reporting in adults (including secondary BSI), the criterion ‘the organism is not related to
an infection at another site’ was removed from the Neo-KISS definition for the purposes of the EU PPS.
Report the origin of the neonatal BSI in the field BSI origin.
If both the case definitions for NEO-LCBI and NEO-CNSB are matched, report NEO-LCBI.
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NEO-PNEU: pneumonia
respiratory compromise;
and
new infiltrate, consolidation or pleural effusion on chest X-ray;
and
and at least four of: temperature > 38 °C or < 36.5 °C or temperature instability, tachycardia or
bradycardia, tachypnoea or apnoea, dyspnoea, increased respiratory secretions, new onset of purulent
sputum, isolation of a pathogen from respiratory secretions, C-reactive protein > 2.0 mg/dL, I/T ratio > 0.2.
NEO-NEC: necrotising enterocolitis
Histopathological evidence of necrotising enterocolitis;
or
at least one characteristic radiographic abnormality (pneumoperitoneum, pneumatosis intestinalis,
unchanging ‘rigid’ loops of small bowel)
plus at least two of the following without other explanation:
vomiting, abdominal distention, prefeeding residuals, persistent microscopic or gross blood in stools.
Algorithm for diagnosis of catheter-related infections
Note: Arterial line is central or peripheral, depending on where it ends.
Blood
culture
criteria
Tip/
insertion site
culture
criteria
Other
criteria
HAI
type
Positive blood culture Negative blood culture
(or not done)
Positive tip
culture
Negative
tip culture
or tip
culture not
done
Positive tip culture
Clinical signs
improve
within 48
hours of
removal
Pus or
inflammation
at tunnel site
Symptoms
improve
within 48
hours of
removal
CRI2-CVC
or
CRI2-PVC
CRI1-CVC
or
CRI1-PVC
CRI3-CVC
or
CRI3-PVC
BSI, origin
C-CVC or
C-PVC
Negative
tip culture
or tip
culture not
done
Purulent
drainage at
involved
vascular
site
Hierarchy
CVS-VASC
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Microorganism code list
The microorganism code list is adapted from the original WHOCARE coding system. The current list (150 codes) is
a selection of microorganisms based on their frequency of occurrence in healthcare-associated infections in
different infection types and/or on their public health importance. Networks/countries preferring to use the
complete WHOCARE list (currently 990 codes) may obtain the database from ECDC. The minimal list (32 codes,
currently used by some countries for HAI surveillance) should not be used for the EU PPS.
Microorganism code list (PPS selection), by category
Family
Microorganism
Code
Gram + cocci
Staphylococcus aureus
STAAUR
Staphylococcus epidermidis
STAEPI
Staphylococcus haemolyticus
STAHAE
Coagulase-negative staphylococci, not specified
STACNS
Other coagulase-negative staphylococci (CNS)
STAOTH
Staphylococcus
spp., not specified
STANSP
Streptococcus pneumonia
STRPNE
Streptococcus agalactiae
(B)
STRAGA
Streptococcus pyogenes
(A)
STRPYO
Other haemolytic streptococci (C, G)
STRHCG
Streptococcus
spp., other
STROTH
Streptococcus
spp., not specified
STRNSP
Enterococcus faecalis
ENCFAE
Enterococcus faecium
ENCFAI
Enterococcus
spp., other
ENCOTH
Enterococcus
spp., not specified
ENCNSP
Gram-positive cocci, not specified
GPCNSP
Other Gram-positive cocci
GPCOTH
Gram – cocci
Moraxella catharralis
MORCAT
Moraxella
spp., other
MOROTH
Moraxella
spp., not specified
MORNSP
Neisseria meningitides
NEIMEN
Neisseria
spp., other
NEIOTH
Neisseria
spp., not specified
NEINSP
Gram-negative cocci, not specified
GNCNSP
Other gram-negative cocci
GNCOTH
Gram + bacilli
Corynebacterium
spp.
CORSPP
Bacillus
spp.
BACSPP
Lactobacillus
spp.
LACSPP
Listeria monocytogenes
LISMON
Gram-positive bacilli, not specified
GPBNSP
Other gram-positive bacilli
GPBOTH
Enterobacteriaceae
Citrobacter freundii
CITFRE
Citrobacter koseri
(e.g.
diversus
)
CITDIV
Citrobacter
spp., other
CITOTH
Citrobacter
spp., not specified
CITNSP
Enterobacter cloacae
ENBCLO
Enterobacter aerogenes
ENBAER
Enterobacter agglomerans
ENBAGG
Enterobacter sakazakii
ENBSAK
Enterobacter gergoviae
ENBGER
Enterobacter
spp., other
ENBOTH
Enterobacter
spp., not specified
ENBNSP
Escherichia coli
ESCCOL
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Family
Microorganism
Code
Klebsiella pneumonia
KLEPNE
Klebsiella oxytoca
KLEOXY
Klebsiella
spp., other
KLEOTH
Klebsiella
spp., not specified
KLENSP
Proteus mirabilis
PRTMIR
Proteus vulgaris
PRTVUL
Proteus
spp., other
PRTOTH
Proteus
spp., not specified
PRTNSP
Serratia marcescens
SERMAR
Serratia liquefaciens
SERLIQ
Serratia
spp., other
SEROTH
Serratia
spp., not specified
SERNSP
Hafnia
spp.
HAFSPP
Morganella
spp.
MOGSPP
Providencia
spp.
PRVSPP
Salmonella Enteritidis
SALENT
Salmonella Typhi
or
Paratyphi
SALTYP
Salmonella Typhimurium
SALTYM
Salmonella
spp., not specified
SALNSP
Salmonella
spp., other
SALOTH
Shigella
spp.
SHISPP
Yersinia
spp.
YERSPP
Other enterobacteriaceae
ETBOTH
Enterobacteriaceae, not specified
ETBNSP
Gram – bacilli
Acinetobacter baumannii
ACIBAU
Acinetobacter calcoaceticus
ACICAL
Acinetobacter haemolyticus
ACIHAE
Acinetobacter lwoffii
ACILWO
Acinetobacter
spp., other
ACIOTH
Acinetobacter
spp., not specified
ACINSP
Pseudomonas aeruginosa
PSEAER
Stenotrophomonas maltophilia
STEMAL
Burkholderia cepacia
BURCEP
Pseudomonadaceae family,
other
PSEOTH
Pseudomonadaceae family,
not specified
PSENSP
Haemophilus influenza
HAEINF
Haemophilus parainfluenzae
HAEPAI
Haemophilus
spp., other
HAEOTH
Haemophilus
spp., not specified
HAENSP
Legionella
spp.
LEGSPP
Achromobacter
spp.
ACHSPP
Aeromonas
spp.
AEMSPP
Agrobacterium
spp.
AGRSPP
Alcaligenes
spp.
ALCSPP
Campylobacter
spp.
CAMSPP
Flavobacterium
spp.
FLASPP
Gardnerella
spp.
GARSPP
Helicobacter pylori
HELPYL
Pasteurella
spp.
PASSPP
Gram-negative bacilli, not specified
GNBNSP
Other Gram-negative bacilli, non enterobacteriaceae
GNBOTH
Anaerobic bacilli
Bacteroïdes fragilis
BATFRA
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Family
Microorganism
Code
Bacteroïdes
other
BATOTH
Clostridium difficile
CLODIF
Clostridium
other
CLOOTH
Propionibacterium
spp.
PROSPP
Prevotella
spp.
PRESPP
Anaerobes, not specified
ANANSP
Other anaerobes
ANAOTH
Other bacteria
Mycobacterium, atypical
MYCATY
Mycobacterium tuberculosis
complex
MYCTUB
Chlamydia
spp.
CHLSPP
Mycoplasma
spp.
MYPSPP
Actinomyces
spp.
ACTSPP
Nocardia
spp.
NOCSPP
Other bacteria
BCTOTH
Fungi
Candida albicans
CANALB
Candida glabrata
CANGLA
Candida krusei
CANKRU
Candida parapsilosis
CANPAR
Candida tropicalis
CANTRO
Candida
spp., other
CANOTH
Candida
spp., not specified
CANNSP
Aspergillus fumigatus
ASPFUM
Aspergillus niger
ASPNIG
Aspergillus
spp., other
ASPOTH
Aspergillus
spp., not specified
ASPNSP
Other yeasts
YEAOTH
Fungi other
FUNOTH
Filaments other
FILOTH
Other parasites
PAROTH
Viruses
Adenovirus
VIRADV
Cytomegalovirus (CMV)
VIRCMV
Enterovirus (polio, coxsackie, echo)
VIRENT
Hepatitis A virus
VIRHAV
Hepatitis B virus
VIRHBV
Hepatitis C virus
VIRHCV
Herpes simplex virus
VIRHSV
Human immunodeficiency virus (HIV)
VIRHIV
Influenza A virus
VIRINA
Influenza B virus
VIRINB
Influenza C virus
VIRINC
Norovirus
VIRNOR
Parainfluenzavirus
VIRPIV
Respiratory syncytial virus (RSV)
VIRRSV
Rhinovirus
VIRRHI
Rotavirus
VIRROT
SARS virus
VIRSAR
Varicella-zoster virus
VIRVZV
Virus, not specified
VIRNSP
Other virus
VIROTH
Microorganism not identified
_NONID
Examination not done
_NOEXA
Sterile examination
_STERI
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Family
Microorganism
Code
Result not (yet) available or missing
_NA
Note:
Negative microorganism codes: _NONID: evidence exists that a microbiological examination has been done, but the
microorganism cannot be correctly classified; _NOEXA: no diagnostic sample taken, no microbiological examination done;
_STERI: a microbiological examination has been done, but the result was negative (e.g. negative culture); _NA: the results of the
microbiological examination are not yet available or cannot be retrieved.
If available, microbiological results should be reported for the active HAI on the survey date, covering the entire infection
episode. Results which are not available on the survey date should not be waited for.
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Antimicrobial resistance markers and codes
The method for collecting AMR marker data was modified to allow comparative analysis between ECDC ARHAI
networks EARS-Net and HAI-Net.
New method to collect AMR markers
For each antimicrobial marker, indicate whether microorganism is susceptible (S), intermediate (I), resistant (R) or
susceptibility unknown (UNK):
Staphylococcus aureus
MRSA: Resistant to oxacillin (OXA) or other markers of methicillin-resistant
S. aureus
(MRSA), such as
cefoxitin (FOX), cloxacillin (CLO), dicloxacillin (DIC), flucloxacillin (FLC), meticillin (MET)
VRSA: Resistant to glycopeptides (GLY): vancomycin (VAN) or teicoplanin (TEC)
VISA: Intermediate to glycopeptides (GLY): vancomycin (VAN) or teicoplanin (TEC)
Enterococcus
spp.
VRE: Resistant to glycopeptides (GLY): vancomycin (VAN) or teicoplanin (TEC)
Enterobacteriaceae
(
Selection:
Escherichia coli, Klebsiella
spp.
, Enterobacter
spp.
, Proteus
spp.
, Citrobacter
spp.
,
Serratia
spp.,
Morganella
spp.
)
Third-generation cephalosporins (C3G): cefotaxime (CTX), ceftriaxone (CRO), ceftazidime (CAZ)
Carbapenems (CAR): imipenem (IPM), meropenem (MEM), doripenem (DOR)
Pseudomonas aeruginosa
Carbapenems (CAR): imipenem (IPM), meropenem (MEM), doripenem (DOR)
Acinetobacter
spp.
Carbapenems (CAR): imipenem (IPM), meropenem (MEM), doripenem (DOR)
Old (PPS I) method to collect AMR markers (still allowed, but not recommended)
Microorganisms
Codes
0
1
2
9
Staphylococcus aureus
Oxa- S
MSSA
Oxa R
MRSA
Unknown
Enterococcus
spp.
Gly-S
Gly-IR
VRE
Unknown
Enterobacteriaceae:
Selection:
Escherichia coli,
Klebsiella
spp.
, Enterobacter
spp.
, Proteus
spp.
,
Citrobacter
spp.
, Serratia
spp.,
Morganella
spp.
C3G-S,
Car-S
C3G-IR,
Car-S
C3G-IR,
Car-IR
Unknown
Pseudomonas
spp.,
Acinetobacter
spp.
Car-S
Car-IR
Unknown
Oxa=Oxacillin, Gly=glycopeptides (vancomycin, teicoplanin), C3G= third-generation cephalosporins (cefotaxim, cetriaxone,
ceftazidim), Car=carbapenems (imipenem, meropenem, doripenem)
If AMR markers are collected in accordance with the PPS I protocol methodology, report S (susceptible), IR (non-
susceptible) or U (unknown), except for MRSA, report non-susceptibility to oxacillin (or equivalent) as R (resistant).
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Surgery categories
NHSN surgery codes
Reference: NHSN operative procedure category mappings to ICD-9-CM codes, October 2010. Available from:
www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf.
NHSN code
Operative
procedure
Description
ICD-9-CM Codes
NHSN-AAA
Abdominal
aortic
aneurysm
repair
Resection of abdominal aorta with
anastomosis or replacement
38.34, 38.44, 38.64
NHSN-AMP
Limb
amputation
Total or partial amputation or
disarticulation of the upper or lower
limbs, including digits
84.00-84.19, 84.91
NHSN-APPY
Appendix
surgery
Operation of appendix (not
incidental to another procedure)
47.01, 47.09, 47.2, 47.91, 47.92, 47.99
NHSN-AVSD
Shunt for
dialysis
Arteriovenostomy for renal dialysis
39.27, 39.42
NHSN-BILI
Bile duct, liver
or pancreatic
surgery
Excision of bile ducts or operative
procedures on the biliary tract, liver
or pancreas (does not include
operations only on gallbladder)
50.0, 50.12, 50.14, 50.21-50.23, 50.25, 50.26,
50.29, 50.3, 50.4, 50.61, 50.69, 51.31-51.37,
51.39, 51.41-51.43, 51.49, 51.51, 51.59, 51.61-
51.63, 51.69, 51.71, 51.72, 51.79, 51.81-51.83,
51.89, 51.9151.95, 51.99, 52.09, 52.12, 52.22,
52.3, 52.4, 52.51-52.53, 52.5952.6, 52.7, 52.92,
52.95, 52.96, 52.99
NHSN-BRST
Breast surgery
Excision of lesion or tissue of breast
including radical, modified, or
quadrant resection, lumpectomy,
incisional biopsy, or mammoplasty.
85.12, 85.20-85.23, 85.31-85.36, 85.41-85.48,
85.50, 85.53, 85.54, 85.6, 85.70-85.76, 85.79,
85.93, 85.96
NHSN-CARD
Cardiac surgery
Procedures on the valves or septum
of heart; does not include coronary
artery bypass graft, surgery on
vessels, heart transplantation, or
pacemaker implantation
35.00 - 35.04, 35.10-35.14, 35.20-35.28, 35.31-
35.35, 35.39, 35.42, 35.50, 35.51, 35.53, 35.54,
35.60-35.63, 35.7035.73, 35.81-35.84, 35.91-
35.95, 35.98-35.99, 37.10, 37.11, 37.24, 37.31-
37.33, 37.35, 37.36, 37.41, 37.49, 37.60
NHSN-CEA
Carotid
endarterectomy
Endarterectomy on vessels of head
and neck (includes carotid artery
and jugular vein)
38.12
NHSN-CBGB
Coronary artery
bypass graft
with both chest
and donor site
incisions
Chest procedure to perform direct
revascularisation of the heart;
includes obtaining suitable vein
from donor site for grafting.
36.10-36.14, 36.19
NHSN-CBGC
Coronary artery
bypass graft
with chest
incision only
Chest procedure to perform direct
vascularisation of the heart using,
for example the internal mammary
(thoracic) artery
36.15-36.17, 36.2
NHSN-CHOL
Gallbladder
surgery
Cholecystectomy and
cholecystotomy
51.03, 51.04, 51.13, 51.21-51.24
NHSN-COLO
Colon surgery
Incision, resection, or anastomosis
of the large intestine; includes
large-tosmall and small-to-large
bowel anastomosis; does not
include rectal operations
17.31-17.36, 17.39, 45.03, 45.26, 45.41, 45.49,
45.52, 45.71-45.76, 45.79, 45.81-45.83, 45.92-
45.95, 46.03, 46.04, 46.10, 46.11, 46.13, 46.14,
46.43, 46.52, 46.75, 46.76, 46.94
NHSN-CRAN
Craniotomy
Incision through the skull to excise,
repair, or explore the brain; does
not include taps or punctures
01.12, 01.14, 01.21-01.25, 01.28, 01.31, 01.32,
01.39, 01.41, 01.42, 01.51-01.53, 01.59, 02.11-
02.14, 02.91-02.93, 07.51-07.54, 07.59, 07.61-
07.65, 07.68, 07.69, 07.71, 07.72, 07.79, 38.01,
38.11, 38.31, 38.41, 38.51, 38.61, 38.81, 39.28
NHSN-CSEC
Cesarean
section
Obstetrical delivery by Cesarean
section
74.0, 74.1, 74.2, 74.4, 74.91, 74.99
NHSN-FUSN
Spinal fusion
Immobilisation of spinal column
81.00-81.08
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NHSN code
Operative
procedure
Description
ICD-9-CM Codes
NHSN-FX
Open reduction
of fracture
Open reduction of fracture or
dislocation of long bones that
requires internal or external
fixation; does not include
placement of joint prosthesis
79.21, 79.22, 79.25, 79.26, 79.31, 79.32, 79.35,
79.36, 79.51, 79.52, 79.55, 79.56
NHSN-GAST
Gastric surgery
Incision or excision of stomach;
includes subtotal or total
gastrectomy; does not include
vagotomy and fundoplication
43.0, 43.42, 43.49, 43.5, 43.6, 43.7, 43.81,
43.89, 43.91, 43.99, 44.15, 44.21, 44.29, 44.31,
44.38 - 44.42, 44.49, 44.5, 44.61-44.65, 44.68-
44.69, 44.95-44.98
NHSN-HER
Herniorrhaphy
Repair of inguinal, femoral,
umbilical, or anterior abdominal
wall hernia; does not include repair
of diaphragmatic or hiatal hernia or
hernias at other body sites.
17.11-17.13, 17.21-17.24, 53.00 - 53.05, 53.10-
53.17, 53.21, 53.29, 53.31, 53.39, 53.41-53.43,
53.49, 53.51, 53.59, 53.61-53.63, 53.69
NHSN-HPRO
Hip prosthesis
Arthroplasty of hip
00.70-00.73, 00.85-00.87, 81.51 - 81.53
NHSN-HTP
Heart
transplant
Transplantation of heart
37.51-37.55
NHSN-HYST
Abdominal
hysterectomy
Removal of uterus through an
abdominal incision
68.31, 68.39, 68.41, 68.49, 68.61, 68.69
NHSN-KPRO
Knee prosthesis
Arthroplasty of knee
00.80-00.84, 81.54, 81.55
NHSN-KTP
Kidney
transplant
Transplantation of kidney
55.61, 55.69
NHSN-LAM
Laminectomy
Exploration or decompression of
spinal cord through excision or
incision into vertebral structures
03.01, 03.02, 03.09, 80.50, 80.51, 80.53, 80.54,
80.59, 84.60-84.69, 84.80-84.85
NHSN-LTP
Liver transplant
Transplantation of liver
50.51, 50.59
NHSN-NECK
Neck surgery
Major excision or incision of the
larynx and radical neck dissection;
does not include thyroid and
parathyroid operations.
30.1, 30.21, 30.22, 30.29, 30.3, 30.4, 31.45,
40.40-40.42
NHSN-NEPH
Kidney surgery
Resection or manipulation of the
kidney with or without removal of
related structures
55.01-55.02, 55.11, 55.12, 55.24, 55.31, 55.32,
55.34, 55.35, 55.39, 55.4, 55.51, 55.52, 55.54,
55.91
NHSN-OVRY
Ovarian
surgery
Operations on ovary and related
structures
65.01, 65.09, 65.12, 65.13, 65.2165.25, 65.29,
65.31, 65.39, 65.41, 65.49, 65.51-65.54, 65.61-
65.64, 65.71-65.76, 65.79, 65.81, 65.89, 65.92-
65.95, 65.99
NHSN-PACE
Pacemaker
surgery
Insertion, manipulation or
replacement of pacemaker
00.50-00.54, 17.51, 17.52, 37.7037.77, 37.79-
37.83, 37.85-37.87, 37.89, 37.94-37.99
NHSN-PRST
Prostate
surgery
Suprapubic, retropubic, radical, or
perineal excision of the prostate;
does not include transurethral
resection of the prostate.
60.12, 60.3, 60.4, 60.5, 60.61, 60.62, 60.69
NHSN-PVBY
Peripheral
vascular bypass
surgery
Bypass operations on peripheral
arteries
39.29
NHSN-REC
Rectal surgery
Operations on rectum
48.25, 48.35, 48.40, 48.42, 48.43, 48.49-48.52,
48.59, 48.61-48.65, 48.69, 48.74
NHSN-
RFUSN
Refusion of
spine
Refusion of spine
81.30-81.39
NHSN-SB
Small bowel
surgery
Incision or resection of the small
intestine; does not include small-to-
large bowel anastomosis.
45.01, 45.02, 45.15, 45.31-45.34, 45.51, 45.61-
45.63, 45.91, 46.01, 46.02, 46.20-46.24, 46.31,
46.39, 46.41, 46.51, 46.71-46.74, 46.93
NHSN-SPLE
Spleen surgery
Resection or manipulation of spleen
41.2, 41.33, 41.41-41.43, 41.5, 41.93, 41.95,
41.99
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
80
NHSN code
Operative
procedure
Description
ICD-9-CM Codes
NHSN-THOR
Thoracic
surgery
Noncardiac, nonvascular thoracic
surgery; includes pneumonectomy
and diaphragmatic or hiatal hernia
repair.
32.09, 32.1, 32.20, 32.21-32.23, 32.25, 32.26,
32.29, 32.30, 32.39, 32.41, 32.49, 32.50, 32.59,
32.6, 32.9, 33.0, 33.1, 33.20, 33.25, 33.28,
33.31-33.34, 33.39, 33.41 - 33.43, 33.48, 33.49,
33.98, 33.99, 34.01-34.03, 34.06, 34.1, 34.20,
34.26, 34.3, 34.4, 34.51, 34.52, 34.59, 34.6,
34.81-34.84, 34.89, 34.93, 34.99, 53.80-53.84
NHSN-THYR
Thyroid and/or
parathyroid
surgery
Resection or manipulation of
thyroid and/or parathyroid
06.02, 06.09, 06.12, 06.2, 06.31, 06.39, 06.4,
06.50-06.52, 06.6, 06.7, 06.81, 06.89, 06.91-
06.95, 06.98, 06.99
NHSN-VHYS
Vaginal
hysterectomy
Vaginal hysterectomy; includes that
by laparoscope
68.51, 68.59, 68.71, 68.79
NHSN-VSHN
Ventricular
shunt
Ventricular shunt operations,
including revision and removal of
shunt
02.2, 02.31-02.35, 02.39, 02.42, 02.43, 54.95
NHSN-XLAP
Exploratory
laparotomy
Procedures involving an incision
through abdominal wall to gain
access into the abdominal cavity;
diagnostic procedure on abdominal
region
53.71-53.72, 53.75, 54.0, 54.11, 54.12, 54.19,
54.3, 54.4, 54.51, 54.59, 54.61, 54.63, 54.64,
54.71-54.75, 54.92, 54.93
Report NHSN-codes even if the incision is not entirely closed at procedure’s end (i.e. if wires or tubes extrude through the
incision).
Examples of non-NHSN surgery
Obstetrical procedures: peri-delivery/labour (one or more) ICD-9-CM 75.3 and 75.9.
Dental extraction: ICD-9-CM code 23.1 Surgical removal.
Transurethral resection of prostate
Incision and drainage of abscess with secondary closure
Any diabetic forefoot amputation with healing by secondary intention
Any other operation where healing is by secondary intention
Tonsillectomy
Application of external fixator/Olizarov
Extraventricular drain
Hysteroscopic removal of fibroids: Evacuation of retained products of conception
TECHNICAL DOCUMENT PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3
81
References
1. Improving Patient Safety in Europe (IPSE). The IPSE report 2005-2008. Lyon: Université Claude Bernard
Lyon 1; November 2009]. Available from
http://www.ecdc.europa.eu/en/activities/surveillance/HAI/Documents/0811_IPSE_Technical_Implementation_
Report
2. European Centre for Disease Prevention and Control (ECDC). Point prevalence survey of healthcare-associated
infections and antimicrobial use in European acute care hospitals. Protocol version 4.3. Full scale survey and
codebook. Stockholm: ECDC: 2012. Available from:
http://www.ecdc.europa.eu/en/activities/surveillance/HAI/about_HAI-Net/Pages/PPS.aspx
3. Council of the European Union. Council Recommendation of 9 June 2009 on patient safety, including the
prevention and control of healthcare associated infections (2009/C 151/01). Available from: http://eur-
lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2009:151:0001:0006:EN:PDF
4. Zingg W, Holmes A, Dettenkofer M, Goetting T, Secci F, Clack L, Allegranzi B, Magiorakos AP, Pittet D; for the
systematic review and evidence-based guidance on organization of hospital infection control programmes
(SIGHT) study group. Hospital organisation, management, and structure for prevention of health-care-
associated infection: a systematic review and expert consensus. Lancet Infect Dis. 2015 Feb;15(2):212-24
5. Pollack LA, Plachouras D, Sinkowitz-Cochran R, Gruhler H, Monnet DL, Weber JT; Transatlantic Taskforce on
Antimicrobial Resistance (TATFAR) Expert Panel on Stewardship Structure and Process Indicators. A concise set
of structure and process indicators to assess and compare antimicrobial stewardship programs among EU and
US hospitals: results from a multinational expert panel. Infect Control Hosp Epidemiol. 2016 Jul 15:1-11.
6. European Centre for Disease Prevention and Control. Point prevalence survey of healthcare-associated
infections and antimicrobial use in European acute care hospitals, 2011–2012. Stockholm: ECDC; 2013.
Available from: http://www.ecdc.europa.eu/en/publications/Publications/healthcare-associated-infections-
antimicrobial-use-PPS.pdf
7. WHO, Regional Office for Europe. European database on human and technical resources for health (HlthRes-
DB). Available from http://www.euro.who.int/en/data-and-evidence/databases/european-database-on-human-
and-technical-resources-for-health-hlthres-db
8. Eurostat – Health care facilities. Hospital beds by financing sector. Available from:
http://ec.europa.eu/eurostat/cache/metadata/Annexes/hlth_res_esms_an10.pdf
9. Organisation for Economic Co-operation and Development (OECD). OECD Health Statistics 2014. Definitions,
Sources and Methods. Available from http://www.oecd.org/els/health-systems/health-data.htm
10. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation
Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. Available from
http://www.ihi.org/resources/pages/ihiwhitepapers/usingcarebundles.aspx
11. Zarb P, Coignard B, Griskeviciene J, Muller A, Vankerckhoven V, Weist K, Goossens M, Vaerenberg S, Hopkins S,
Catry B, Monnet D, Goossens H, Suetens C; National Contact Points for the ECDC pilot point prevalence
survey; Hospital Contact Points for the ECDC pilot point prevalence survey. The European Centre for Disease
Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and
antimicrobial use. Euro Surveill. 2012 Nov 15;17(46).
12. Reilly JS, Price L, Godwin J, Cairns S, Hopkins S, Cookson B, Malcolm W, Hughes G, Lyytikainen O, Coignard B,
Hansen S, Suetens C; National Participants in the ECDC pilot validation study. A pilot validation in 10 European
Union Member States of a point prevalence survey of healthcare-associated infections and antimicrobial use in
acute hospitals in Europe, 2011. Euro Surveill. 2015 Feb 26;20(8).
13. HELICS surveillance of SSI protocol, version 9.1, September 2004. Available from
http:///www.ecdc.europa.eu/IPSE/helicshome.htm
14. HELICS Surveillance of Nosocomial Infections in Intensive Care Units protocol, version 6.1, September 2004.
Available from http://www.ecdc.europa.eu/IPSE/helicshome.htm
15. Kuijper EJ, Coignard B, Tüll P, the ESCMID Study Group for
Clostridium difficile
(ESGCD), EU Member States
and the European Centre for Disease Prevention and Control (ECDC). Emergence of
Clostridium difficile
-
associated disease in North America and Europe. Clin Microbiol Infect 2006;12 (Suppl 6):2-18
16. Neo-KISS. Protokoll. December 2009. Nationales Referenzzentrum für Surveillance von nosokomialen
Infektionen. Available from http://www.nrz-hygiene.de/dwnld/NEOKISSProtokoll221209.pdf
PPS of HAIs and antimicrobial use in European acute care hospitals – protocol version 5.3 TECHNICAL DOCUMENT
82
17. Geffers C, Baerwolff S, Schwab F, Gastmeier P. Incidence of healthcare-associated infections in high-risk
neonates: results from the German surveillance system for very-low-birthweight infants. J Hosp Infect. 2008
Mar;68(3):214-21.
18. CDC/NHSN surveillance definition of healthcare-associated infection and criteria for specific types of infections
in the acute-care setting, AM J Infect Control 2008; 36: 309-32.
19. Hansen S, Sohr D, Geffers C, Astagneau P, Blacky A, Koller W, Morales I, Moro ML, Palomar M, Szilagyi E,
Suetens C, Gastmeier P. Concordance between European and US case definitions of healthcare-associated
infections. Antimicrob Resist Infect Control. 2012 Aug 2;1(1):28. doi: 10.1186/2047-2994-1-28.
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