2008年美国医院感染诊断标准

ddd309CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting T eresa C.Horan,MPH,Mary Andrus,RN,BA,CIC,and Margaret A.Dudeck,MPH Atlanta,GeorgiaBACKGROUNDSince1988,the Centers for Disease Control and Prevention(CDC)has published2articles in which nos­ocomial infection and criteria for specific types of nos­ocomial infection for surveillance purposes for use in acute care settings have been defined.1,2This document replaces those articles,which are now considered obso­lete,and uses the generic term‘‘health care–associated infection’’or‘‘HAI’’instead of‘‘nosocomial.’’This doc­ument reflects the elimination of criterion1of clinical sepsis(effective in National Healthcare Safety Network [NHSN]facilities since January2005)and criteria for lab­oratory–confirmed bloodstream infection(LCBI).Spe­cifically for LCBI,criterion2c and3c,and2b and3b, were removed effective in NHSN facilities since January 2005and January2008,respectively.The definition of ‘‘implant,’’which is part of the surgical site infection (SSI)criteria,has been slightly modified.No other infec­tion criteria have been added,removed,or changed. There are also notes throughout this document that reflect changes in the use of surveillance criteria since the implementation of NHSN.For example,the From the National Healthcare Safety Network,Division of Healthcare Quality Promotion,Centers for Disease Control and Prevention, Atlanta,GA.Address correspondence to T eresa C.Horan,MPH,Division of Health-care Quality Promotion,Centers for Disease Control and Prevention, Mailstop A24,1600Clifton Road,NE,Atlanta,GA30333.E-mail: thoran@.Am J Infect Control2008;36:309-32.0196-6553/$34.00Copyrightª2008by the Association for Professionals in Infection Control and Epidemiology,Inc.doi:10.1016/j.ajic.2008.03.002population for which clinical sepsis is used has been re­stricted to patients#1year old.Another example is that incisional SSI descriptions have been expanded to spec­ify whether an SSI affects the primary or a secondary in­cision following operative procedures in which more than1incision is made.For additional information about how these criteria are used for NHSN surveillance,refer to the NHSN Manual:Patient Safety Component Protocol available at the NHSN Web site(/ncidod/ dhqp/nhsn.html).Whenever revisions occur,they will be published and made available at the NHSN Web site. CDC/NHSN SURVEILLANCE DEFINITION OF HEALTH CARE–ASSOCIATED INFECTIONFor the purposes of NHSN surveillance in the acute care setting,the CDC defines an HAI as a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s)or its toxin(s). There must be no evidence that the infection was pre­sent or incubating at the time of admission to the acute care setting.HAIs may be caused by infectious agents from endogenous or exogenous sources.Endogenous sources are body sites,such as the skin, nose,mouth,gastrointestinal(GI)tract,or vagina that are normally inhabited by microorganisms.Exogenous sources are those external to the pa­tient,such as patient care personnel,visitors,pa­tient care equipment,medical devices,or the health care environment.Other important considerations include the following:Clinical evidence may be derived from direct ob­servation of the infection site(eg,a wound)or310Vol.36No.5 Horan,Andrus,and Dudeckreview of information in the patient chart or other clinical records.d For certain types of infection,a physician or sur­geon diagnosis of infection derived from direct ob­servation during a surgical operation,endoscopic examination,or other diagnostic studies or from clinical judgment is an acceptable criterion for an HAI,unless there is compelling evidence to the contrary.For example,one of the criteria for SSI is‘‘surgeon or attending physician diagnosis.’’Un­less stated explicitly,physician diagnosis alone is not an acceptable criterion for any specific type of HAI.d Infections occurring in infants that result frompassage through the birth canal are considered HAIs.d The following infections are not considered healthcare associated:s Infections associated with complications or ex­tensions of infections already present on ad­mission,unless a change in pathogen orsymptoms strongly suggests the acquisition ofa new infection;s infections in infants that have been acquiredtransplacentally(eg,herpes simplex,toxoplas­mosis,rubella,cytomegalovirus,or syphilis)and become evident#48hours after birth;ands reactivation of a latent infection(eg,herpes zos­ter[shingles],herpes simplex,syphilis,ortuberculosis).d The following conditions are not infections:s Colonization,which means the presence of mi­croorganisms on skin,on mucous membranes,in open wounds,or in excretions or secretionsbut are not causing adverse clinical signs orsymptoms;ands inflammation that results from tissue responseto injury or stimulation by noninfectiousagents,such as chemicals.CRITERIA FOR SPECIFIC TYPES OF INFECTION Once an infection is deemed to be health care associ­ated according to the definition shown above,the spe­cific type of infection should be determined based on the criteria detailed below.These have been grouped into13major type categories to facilitate data analysis. For example,there are3specific types of urinary tract infections(symptomatic urinary tract infection,asymp­tomatic bacteriuria,and other infections of the urinary tract)that are grouped under the major type of Urinary Tract Infection.The specific and major types of infec­tion used in NHSN and their abbreviated codes are listed in T able1,and the criteria for each of the specific types of infection follow E OF THESE CRITERIA FOR PUBLICLY REPORTED HAI DATANot all infections or infection criteria may be appro­priate for use in public reporting of HAIs.Guidance on what infections and infection criteria are recommen­ded is available from other sources(eg,HICPAC[http: ///ncidod/dhqp/hicpac_pubs.html];National Quality Forum[/];profes­sional organizations).UTI-URINARY TRACT INFECTIONSUTI-Symptomatic urinary tract infectionA symptomatic urinary tract infection must meet at least1of the following criteria:1.Patient has at least 1of the following signs orsymptoms with no other recognized cause:fever(.388C),urgency,frequency,dysuria,or suprapu­bic tendernessandpatient has a positive urine culture,that is,$105microorganisms per cc of urine with no morethan2species of microorganisms.2.Patient has at least2of the following signs or symp­toms with no other recognized cause:fever(.388C),urgency,frequency,dysuria,or suprapu­bic tendernessandat least1of the followinga.positive dipstick for leukocyte esterase and/or nitrateb. pyuria(urine specimen with$10whiteblood cell[WBC]/mm3or$3WBC/high­powerfield of unspun urine)c. organisms seen on Gram’s stain of unspunurined.at least2urine cultures with repeatedisolation of the same uropathogen(gram­negative bacteria or Staphylococcus sapro­phyticus)with$102colonies/mL in non-voided specimense.#105colonies/mL of a single uropathogen(gram-negative bacteria or S saprophyticus)in a patient being treated with an effectiveantimicrobial agent for a urinary tractinfectionf.physician diagnosis of a urinary tractinfectiong.physician institutes appropriate therapy fora urinary tract infection.3.Patient#1year of age has at least1of the fol­lowing signs or symptoms with no other recog­nized cause:fever(.388C rectal),hypothermiaHoran,Andrus,and Dudeck June2008311 T able1.CDC/NHSN major and specific types of healthcare–associated infectionsUTI SSI Urinary tract infectionSUTI Symptomatic urinarytract infectionASB Asymptomatic bacteriuria OUTI Other infectionsof the urinary tract Surgical site infectionSIP Superficial incisionalprimary SSISIS Superficial incisionalsecondary SSIDIP Deep incisionalprimary SSIDIS Deep incisionalsecondary SSIOrgan/space Organ/space SSI.Indicatespecific type:d BONE d LUNGd BRST d MEDd CARD d MENd DISC d ORALd EAR d OREPd EMET d OUTId ENDO d SAd EYE d SINUd GIT d URd IAB d VASCd IC d VCUFBSId JNTBloodstream infectionLCBI Laboratory-confirmedbloodstream infection CSEP Clinical sepsisPNEU PneumoniaPNU1 PNU2 PNU3Clinically defined pneumonia Pneumonia withspecific laboratoryfindings Pneumonia in immunocompromised patientBJ Bone and joint infectionBONE OsteomyelitisJNT Joint or bursaDISC Disc spaceCNS Central nervous systemIC Intracranial infectionMEN Meningitis or ventriculitisSA Spinal abscesswithout meningitisCVS Cardiovascular system infectionVASC Arterial or venous infectionENDO EndocarditisCARD Myocarditis or pericarditisMED MediastinitisContinued T able1.ContinuedEENT Eye,ear,nose,throat,or mouth infectionCONJ ConjunctivitisEYE Eye,otherthan conjunctivitisEAR Ear,mastoidORAL Oral cavity(mouth,tongue,or gums)SINU SinusitisUR Upper respiratorytract,pharyngitis,laryngitis,epiglottitisGI Gastrointestinal system infectionGE GastroenteritisGIT Gastrointestinal(GI)tractHEP HepatitisIAB Intraabdominal,not specifiedelsewhereNEC Necrotizing enterocolitisLRI Lower respiratory tract infection,otherthan pneumoniaBRON Bronchitis,tracheobronchitis,tracheitis,withoutevidence of pneumoniaLUNG Other infectionsof the lowerrespiratory tractREPR Reproductive tract infectionEMET EndometritisEPIS EpisiotomyVCUF Vaginal cuffOREP Other infectionsof the maleor female reproductivetractSST Skin and soft tissue infectionSKIN SkinST Soft tissueDECU Decubitus ulcerBURN BurnBRST Breast abscessor mastitisUMB OmphalitisPUST PustulosisCIRC Newborn circumcisionSYS Systemic InfectionDI Disseminated infection (,378C rectal),apnea,bradycardia,dysuria,leth­argy,or vomitingandpatient has a positive urine culture,that is,$105microorganisms per cc of urine with no morethan two species of microorganisms.4.Patient#1year of age has at least1of the follow­ing signs or symptoms with no other recognizedcause:fever(.388C),hypothermia(,378C),ap­nea,bradycardia,dysuria,lethargy,or vomiting312Vol.36No.5 Horan,Andrus,and Dudeckandat least1of the following:a.positive dipstick for leukocyte esterase and/or nitrateb.pyuria(urine specimen with$10WBC/mm3or$3WBC/high-powerfield of unspunurine)c. organisms seen on Gram’s stain of unspunurined.at least2urine cultures with repeatedisolation of the same uropathogen(gram­negative bacteria or S saprophyticus)with$102colonies/mL in nonvoidedspecimense.#105colonies/mL of a single uropathogen(gram-negative bacteria or S saprophyticus)in a patient being treated with an effectiveantimicrobial agent for a urinary tractinfectionf.physician diagnosis of a urinary tractinfectiong.physician institutes appropriate therapy fora urinary tract infection.ASB-Asymptomatic bacteriuriaAn asymptomatic bacteriuria must meet at least1of the following criteria:1.Patient has had an indwelling urinary catheterwithin7days before the cultureandpatient has a positive urine culture,that is,$105microorganisms per cc of urine with no morethan2species of microorganismsandpatient has no fever(.388C),urgency,frequency,dysuria,or suprapubic tenderness.2.Patient has not had an indwelling urinary cathe­ter within7days before thefirst positive cultureandpatient has had at least2positive urine cultures,that is,$105microorganisms per cc of urinewith repeated isolation of the same micro­organism and no more than2species ofmicroorganismsandpatient has no fever(.388C),urgency,frequency,dysuria,or suprapubic tenderness.Commentsd A positive culture of a urinary catheter tip is not anacceptable laboratory test to diagnose a urinary tract infection.d Urine cultures must be obtained using appropriatetechnique,such as clean catch collection or catheterization.d In infants,a urine culture should be obtained bybladder catheterization or suprapubic aspiration;a positive urine culture from a bag specimen is un­reliable and should be confirmed by a specimen aseptically obtained by catheterization or supra­pubic aspiration.OUTI-Other infections of the urinary tract (kidney, ureter, bladder, urethra, or tissue surrounding the retroperitoneal or perinephric space)Other infections of the urinary tract must meet at least1of the following criteria:1.Patient has organisms isolated from culture offluid(other than urine)or tissue from affected site.2.Patient has an abscess or other evidence of infec­tion seen on direct examination,during a surgicaloperation,or during a histopathologicexamination.3.Patient has at least 2of the following signs orsymptoms with no other recognized cause:fever(.388C),localized pain,or localized tenderness atthe involved siteandat least1of the following:a.purulent drainage from affected siteb. organisms cultured from blood that arecompatible with suspected site of infectionc. radiographic evidence of infection(eg,ab­normal ultrasound,computerized tomogra­phy[CT]scan,magnetic resonance imaging[MRI],or radiolabel scan[gallium,techne­tium],etc)d.physician diagnosis of infection of thekidney,ureter,bladder,urethra,or tissuessurrounding the retroperitoneal or peri­nephric spacee. physician institutes appropriate therapy foran infection of the kidney,ureter,bladder,urethra,or tissues surrounding the retroper­itoneal or perinephric space.4.Patient#1year of age has at least1of the follow­ing signs or symptoms with no other recognizedcause:fever(.388C rectal),hypothermia(,378Crectal),apnea,bradycardia,lethargy,or vomitingandat least1of the following:a.purulent drainage from affected siteb. organisms cultured from blood that arecompatible with suspected site of infectionHoran,Andrus,and Dudeck June2008313c. radiographic evidence of infection(eg,ab­normal ultrasound,CTscan,MRI,or radiola­bel scan[gallium,technetium])d.physician diagnosis of infection of the kid­ney,ureter,bladder,urethra,or tissues sur­rounding the retroperitoneal orperinephric spacee. physician institutes appropriate therapy foran infection of the kidney,ureter,bladder,urethra,or tissues surrounding the retroper­itoneal or perinephric space.Reporting instructiond Report infections following circumcision in new­borns as CIRC.SSI-SURGICAL SITE INFECTIONSIP/SIS-Superficial incisional surgical site infectionA superficial incisional SSI(SIP or SIS)must meet the following criterion:Infection occurs within30days after the operative procedureandinvolves only skin and subcutaneous tissue of the incisionandpatient has at least1of the following:a.purulent drainage from the superficial incisionb. organisms isolated from an aseptically obtainedculture offluid or tissue from the superficialincisionc. at least1of the following signs or symptoms ofinfection:pain or tenderness,localized swelling, redness,or heat,and superficial incision is delib­erately opened by surgeon and is culture positive or not cultured.A culture-negativefinding does not meet this criterion.d.diagnosis of superficial incisional SSI by the sur­geon or attending physician.There are2specific types of superficial incisional SSI:d Superficial incisional primary(SIP):a superficial in­cisional SSI that is identified in the primary inci­sion in a patient who has had an operation with 1or more incisions(eg,C-section incision or chest incision for coronary artery bypass graft with a do­nor site[CBGB]).d Superficial incisional secondary(SIS):a superficialincisional SSI that is identified in the secondary in­cision in a patient who has had an operation with more than1incision(eg,donor site[leg]incision for CBGB).Reporting instructionsd Do not report a stitch abscess(minimal inflamma­tion and discharge confined to the points of suture penetration)as an infection.d Do not report a localized stab wound infection asSSI,instead report as skin(SKIN),or soft tissue (ST),infection,depending on its depth.d Report infection of the circumcision site in new­borns as CIRC.Circumcision is not an NHSN oper­ative procedure.d Report infected burn wound as BURN.d If the incisional site infection involves or extendsinto the fascial and muscle layers,report as a deep incisional SSI.d Classify infection that involves both superficialand deep incision sites as deep incisional SSI. DIP/DIS-Deep incisional surgical site infectionA deep incisional SSI(DIP or DIS)must meet the fol­lowing criterion:Infection occurs within30days after the operative procedure if no implant1is left in place or within 1year if implant is in place and the infection appears to be related to the operative procedureandinvolves deep soft tissues(eg,fascial and muscle layers) of the incisionandpatient has at least1of the following:a.purulent drainage from the deep incision but notfrom the organ/space component of the surgicalsiteb. a deep incision spontaneously dehisces or is de­liberately opened by a surgeon and is culture-pos­itive or not cultured when the patient has at least1of the following signs or symptoms:fever(.388C),or localized pain or tenderness.A cul­ture-negativefinding does not meet this criterion.c.an abscess or other evidence of infection involvingthe deep incision is found on direct examination, during reoperation,or by histopathologic or radi­ologic examinationd.diagnosis of a deep incisional SSI by a surgeon orattending physician.There are2specific types of deep incisional SSI:d Deep incisional primary(DIP):a deep incisional SSIthat is identified in a primary incision in a patient1A nonhuman-derived object,material,or tissue(eg,prosthetic heart valve,nonhuman vascular graft,mechanical heart,or hip prosthesis) that is permanently placed in a patient during an operative procedure and is not routinely manipulated for diagnostic or therapeutic purposes.314Vol.36No.5 Horan,Andrus,and Dudeckwho has had an operation with one or more inci­sions(eg,C-section incision or chest incision for CBGB);andd Deep incisional secondary(DIS):a deep incisionalSSI that is identified in the secondary incision ina patient who has had an operation with morethan1incision(eg,donor site[leg]incision for CBGB).Reporting instructiond Classify infection that involves both superficialand deep incision sites as deep incisional SSI. Organ/space-Organ/space surgical site infection An organ/space SSI involves any part of the body, excluding the skin incision,fascia,or muscle layers, that is opened or manipulated during the operative procedure.Specific sites are assigned to organ/space SSI to identify further the location of the infection. Listed below in reporting instructions are the specific sites that must be used to differentiate organ/space SSI.An example is appendectomy with subsequent subdiaphragmatic abscess,which would be reported as an organ/space SSI at the intraabdominal specific site(SSI-IAB).An organ/space SSI must meet the following criterion: Infection occurs within30days after the operative procedure if no implant1is left in place or within 1year if implant is in place and the infection appears to be related to the operative procedureandinfection involves any part of the body,excluding the skin incision,fascia,or muscle layers,that is opened or manipulated during the operative procedureandpatient has at least1of the following:a.purulent drainage from a drain that is placedthrough a stab wound into the organ/spaceb. organisms isolated from an aseptically obtainedculture offluid or tissue in the organ/spacec. an abscess or other evidence of infection involv­ing the organ/space that is found on direct exam­ination,during reoperation,or by histopathologicor radiologic examinationd.diagnosis of an organ/space SSI by a surgeon orattending physician.Reporting instructionsd Specific sites of organ/space SSI(see also criteriafor these sites)s BONE s LUNGs BRST s MEDs CARD s MENs DISC s ORALs EAR s OREPs EMET s OUTIs ENDO s SAs EYE s SINUs GIT s URs IAB s VASCs IC s VCUFs JNTd Occasionally an organ/space infection drainsthrough the incision.Such infection generally does not involve reoperation and is considered a complication of the incision;therefore,classify it as a deep incisional SSI.BSI-BLOODSTREAM INFECTIONLCBI-Laboratory-confirmed bloodstream infectionLCBI criteria1and2may be used for patients of any age,including patients#1year of age.LCBI must meet at least1of the following criteria:1.Patient has a recognized pathogen cultured from1or more blood culturesandorganism cultured from blood is not related to aninfection at another site.(See Notes1and2.)2.Patient has at least 1of the following signs orsymptoms:fever(.388C),chills,or hypotensionandsigns and symptoms and positive laboratory re­sults are not related to an infection at another siteandcommon skin contaminant(ie,diphtheroids[Corynebacterium spp],Bacillus[not B anthracis]spp,Propionibacterium spp,coagulase-negativestaphylococci[including S epidermidis],viridansgroup streptococci,Aerococcus spp,Micrococcusspp)is cultured from2or more blood culturesdrawn on separate occasions.(See Notes3and4.)3.Patient#1year of age has at least1of the follow­ing signs or symptoms:fever(.388C,rectal),hy­pothermia(,378C,rectal),apnea,or bradycardiaandsigns and symptoms and positive laboratory re­sults are not related to an infection at another siteandcommon skin contaminant(ie,diphtheroids[Cor­ynebacterium spp],Bacillus[not Banthracis]spp,Propionibacterium spp,coagulase-negative staphylococci[including S epidermidis],viridans group streptococci,Aerococcus spp,Mi­crococcus spp)is cultured from2or more bloodHoran,Andrus,and Dudeck June2008315cultures drawn on separate occasions.(See Notes3and4.)Notes1.In criterion1,the phrase‘‘1or more blood cul­tures’’means that at least1bottle from a blooddraw is reported by the laboratory as havinggrown organisms(ie,is a positive blood culture).2.In criterion1,the term‘‘recognized pathogen’’does not include organisms considered commonskin contaminants(see criteria2and3for a list ofcommon skin contaminants).A few of the recog­nized pathogens are S aureus,Enterococcus spp,Ecoli,Pseudomonas spp,Klebsiella spp,Candidaspp,and others.3.In criteria2and3,the phrase‘‘2or more blood cul­tures drawn on separate occasions’’means(1)thatblood from at least2blood draws were collectedwithin2days of each other(eg,blood draws onMonday and Tuesday or Monday and Wednesdaywould be acceptable for blood cultures drawn onseparate occasions,but blood draws on Mondayand Thursday would be too far apart in time tomeet this criterion)and(2)that at least1bottlefrom each blood draw is reported by the labora­tory as having grown the same common skin con­taminant organism(ie,is a positive blood culture).(See Note4for determining sameness oforganisms.)a.For example,an adult patient has blooddrawn at8AM and again at8:15AM of thesame day.Blood from each blood draw is in­oculated into2bottles and incubated(4bot­tles total).If1bottle from each blood drawset is positive for coagulase-negative staph­ylococci,this part of the criterion is met.b. For example,a neonate has blood drawnfor culture on Tuesday and again on Satur­day,and both grow the same commonskin contaminant.Because the time be­tween these blood cultures exceeds the2-day period for blood draws stipulatedin criteria2and3,this part of the criteriais not met.c. A blood culture may consist of a single bot­tle for a pediatric blood draw because of vol­ume constraints.Therefore,to meet thispart of the criterion,each bottle from2ormore draws would have to be culture posi­tive for the same skin contaminant.4.There are several issues to consider when deter­mining sameness of organisms.a.If the common skin contaminant is identi­fied to the species level from1culture,T able2.Examples of‘‘sameness’’by organism speciation Culture Companion Culture Report as. S epidermidis Coagulase-negative S epidermidisstaphylococciBacillus spp(not anthracis)B cereus B cereusS salivarius Strep viridans S salivariusT able3.Examples of‘‘sameness’’by organism antibiogramOrganism Name Isolate A Isolate B Interpret as. S epidermidis All drugs S All drugs S SameS epidermidis OX R OX S DifferentCEFAZ R CEFAZ SCorynebacterium spp PENG R PENG S DifferentCIPRO S CIPRO RStrep viridans All drugs S All drugs S SameexceptERYTH RS,sensitive;R,resistant.and a companion culture is identified withonly a descriptive name(ie,to the genuslevel),then it is assumed that the organismsare the same.The speciated organismshould be reported as the infecting patho­gen(see examples in T able2).b. If common skin contaminant organismsfrom the cultures are speciated but no anti­biograms are done or they are done for only1of the isolates,it is assumed that the orga­nisms are the same.c. If the common skin contaminants from thecultures have antibiograms that are differ­ent for2or more antimicrobial agents,it isassumed that the organisms are not thesame(see examples in T able3).d.For the purpose of NHSN antibiogram re­porting,the category interpretation of inter­mediate(I)should not be used to distinguishwhether2organisms are the same. Specimen collection considerationsIdeally,blood specimens for culture should be ob­tained from2to4blood draws from separate veni­puncture sites(eg,right and left antecubital veins), not through a vascular catheter.These blood draws should be performed simultaneously or over a short period of time(ie,within a few hours).3,4If your facility does not currently obtain specimens using this tech­nique,you may still report BSIs using the criteria and notes above,but you should work with appropriate personnel to facilitate better specimen collection prac­tices for blood cultures.316Vol.36No.5Reporting instructionsd Purulent phlebitis confirmed with a positive semi-quantitative culture of a catheter tip,but with ei­ther negative or no blood culture is considered a CVS-VASC,not a BSI.d Report organisms cultured from blood as BSI–LCBIwhen no other site of infection is evident. CSEP-CLINICAL SEPSISCSEP may be used only to report primary BSI in ne­onates and infants.It is not used to report BSI in adults and children.Clinical sepsis must meet the following criterion: Patient#1year of age has at least1of the following clinical signs or symptoms with no other recognized cause:fever(.388C rectal),hypothermia(,378C rec­tal),apnea,or bradycardiaandblood culture not done or no organisms detected in bloodandno apparent infection at another siteandphysician institutes treatment for sepsis.Reporting instructiond Report culture-positive infections of the blood­stream as BSI-LCBI.PNEU-PNEUMONIASee Appendix.BJ–BONE AND JOINT INFECTIONBONE-OsteomyelitisOsteomyelitis must meet at least1of the following criteria:1.Patient has organisms cultured from bone.2.Patient has evidence of osteomyelitis on directexamination of the bone during a surgical opera­tion or histopathologic examination.3.Patient has at least2of the following signsor symptoms with no other recognized cause:fever(.388C),localized swelling,tenderness,heat,or drainage at suspected site of boneinfectionandat least1of the following:anisms cultured from bloodb. positive blood antigen test(eg,H influenzae,S pneumoniae)Horan,Andrus,and Dudeckc. radiographic evidence of infection(eg,ab­normalfindings on x-ray,CT scan,MRI,ra­diolabel scan[gallium,technetium,etc]).Reporting instructiond Report mediastinitis following cardiac surgerythat is accompanied by osteomyelitis as SSI-MED rather than SSI-BONE.JNT-Joint or bursaJoint or bursa infections must meet at least1of the following criteria:1.Patient has organisms cultured from jointfluid orsynovial biopsy.2.Patient has evidence of joint or bursa infectionseen during a surgical operation or histopatho­logic examination.3.Patient has at least 2of the following signs orsymptoms with no other recognized cause:jointpain,swelling,tenderness,heat,evidence of effu­sion or limitation of motionandat least1of the following:anisms and white blood cells seen onGram’s stain of jointfluidb. positive antigen test on blood,urine,or jointfluidc. cellular profile and chemistries of jointfluidcompatible with infection and not ex­plained by an underlying rheumatologicdisorderd.radiographic evidence of infection(eg,ab­normalfindings on x-ray,CT scan,MRI,ra­diolabel scan[gallium,technetium,etc]). DISC-Disc space infectionVertebral disc space infection must meet at least1of the following criteria:1.Patient has organisms cultured from vertebraldisc space tissue obtained during a surgical oper­ation or needle aspiration.2.Patient has evidence of vertebral disc space infec­tion seen during a surgical operation or histo­pathologic examination.3.Patient has fever(.388C)with no other recog­nized cause or pain at the involved vertebraldisc spaceandradiographic evidence of infection,(eg,abnormalfindings on x-ray,CT scan,MRI,radiolabel scan[gallium,technetium,etc]).。