Clinical Commander

Back to dossier
id.hospital-acquired-infection.v1PRODUCTION
id.hospital-acquired-infection.v1

Hospital-acquired infection (HAI) overlay — CLABSI / CAUTI / VAP-HAP / CDI / SSI

overlayacutesubacuteadult
Hard-required inputs
0 / 19
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

HAI overlay framing: ≥ 48 h post-admission, layered on top of existing primary engine (HF, post-op, ARDS, etc.). Sets HCA-acquisition flag for downstream sepsis routing.

Inputs
1
Actions
0
Advance rule
Set
Advance when

HCA-acquisition flag set + primary engine context preserved

Patient inputs (27)

Prior abx within 90 d drives ESBL + MRSA + VRE + C. diff risk-stratification; broadens empirics until culture-directed (IDSA/ATS 2016 Kalil)

CLABSI workup gate; tunneled vs non-tunneled drives line-removal threshold (Mermel IDSA 2009 PMID 19489710)

CAUTI workup gate; duration of catheterisation > 2 d substantially increases bacteriuria risk (CDC Gould 2009)

VAP workup gate; ≥ 48 h of mechanical ventilation is the canonical VAP-onset threshold (IDSA/ATS 2016 Kalil)

SSI typically ≤ 30 d post-op (≤ 90 d if prosthetic implant) per CDC NHSN definitions; informs SSI workup + biofilm-active empirics (IDSA/SHEA 2017 Berríos-Torres)

Transplant / neutropenia / biologics / steroid ≥ 20 mg/d prednisone-equivalent ≥ 14 d → broader empirics + lower escalation threshold; fungal + atypical coverage gating

ICU > 7 d → higher MDR Gram-negative + fungal + C. auris risk; drives empiric broadening (IDSA/ATS 2016 Kalil)

Documented MDRO colonisation (MRSA nares, ESBL stool, CRE rectal, VRE) → empirics targeted to known colonisation pattern

Fever > 38 °C is sentinel; hypothermia < 36 °C in critically ill / elderly is equally concerning (SSC 2026)

≥ 48 h post-admission distinguishes HAI from community-acquired (CDC NHSN definitions); informs HCA-acquisition flag in id.sepsis.core.v1 routing

Leukocytosis > 15 K is a CDI severity criterion (IDSA/SHEA 2017 McDonald); also tracks sepsis severity

Cr ≥ 1.5× baseline is a CDI severity criterion (IDSA/SHEA 2017 McDonald); informs renal-dose adjustment of vancomycin / aminoglycosides / beta-lactams (IDSA 2020 vancomycin AUC consensus)

Lactate > 2 → resuscitation; > 4 → septic shock physiology (SSC 2026 Hour-1 bundle)

Two sets from separate sites BEFORE antibiotics if no delay > 45 min (SSC 2026); differential time-to-positivity > 2 h between line and peripheral supports CLABSI (Mermel IDSA 2009)

Hypotension on adequate fluids → septic shock → routes to id.sepsis.core.v1 with HCA flag (SSC 2026)

Tachycardia is a sepsis criterion (SIRS); part of qSOFA / NEWS2 bundled screening

Tachypnea > 22 is part of qSOFA; > 30 with hypoxemia drives respiratory failure escalation

Hypoxemia escalates VAP severity; PaO2/FiO2 ≤ 250 is a SOFA respiratory point

Local resistance > 10% to monotherapy in unit antibiogram drives combination Gram-negative empirics for VAP/HAP (IDSA/ATS 2016 Kalil)

TEE for persistent S. aureus / Enterococcus / Candida bacteremia > 72 h or with risk factors; rules out endocarditis (AHA Baddour 2015)

CT abdomen for fulminant CDI (megacolon, perforation) or deep / organ-space SSI (abscess, anastomotic leak) (IDSA/SHEA 2017 McDonald + Berríos-Torres)

Catheter UA + culture for CAUTI workup; ≥ 10^3 CFU/mL with catheter is significant per IDSA Hooton 2010

Sputum / endotracheal aspirate / BAL for VAP workup; BAL ≥ 10^4 CFU/mL or endotracheal aspirate ≥ 10^5 CFU/mL supports VAP (IDSA/ATS 2016 Kalil)

C. diff toxin EIA + GDH + NAAT 2- or 3-step algorithm (IDSA/SHEA 2017 + 2021 update Johnson); NAAT-only positive without toxin EIA suggests colonisation, not infection

Deep wound or organ-space culture from operative re-exploration for SSI workup; surface swabs unreliable (IDSA/SHEA 2017 Berríos-Torres)

Chest imaging for VAP/HAP workup; new / progressive infiltrate is the radiographic anchor (IDSA/ATS 2016 Kalil)

Adjunct for de-escalation in VAP/HAP (decrease ≥ 80% over 5-7 d supports stop); not for initiation decisions (IDSA/ATS 2016 Kalil + ProGUARD-ICU 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningclabsi_with_persistent_bacteremia
    Central-line-associated bloodstream infection with repeat positive blood cultures > 72 h despite line removal + appropriate empiric antibiotics — life-threatening; rules out endocarditis + endovascular complications (Mermel IDSA 2009 PMID 19489710; AHA Baddour 2015 endocarditis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcdi_fulminant_or_severe_complicated
    Fulminant CDI: ileus / megacolon / shock / WBC > 35 K / lactate ≥ 5 / Cr ≥ 2× baseline — life-threatening; IV metronidazole + high-dose oral / rectal vancomycin + emergent surgical evaluation (IDSA/SHEA 2017 McDonald + 2021 Johnson update; Neal Ann Surg 2011 surgical strategy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningvap_with_mdro
    Ventilator-associated pneumonia with documented MDR pathogen (ESBL / CRE / CR-Acinetobacter / VRSA / MBL-producing) — life-threatening; ID + targeted regimen per susceptibility; lung-protective ventilation; source control if abscess (IDSA/ATS 2016 Kalil PMID 27418577; IDSA AMR 2024 MDRO guidance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcre_or_pan_drug_resistant_pathogen
    Confirmed carbapenem-resistant Enterobacterales (CRE) OR carbapenem-resistant Acinetobacter OR VRSA OR pan-drug-resistant Gram-negative isolated from any HAI site — life-threatening; ceftazidime-avibactam OR meropenem-vaborbactam OR cefiderocol OR sulbactam-durlobactam + ID consult + contact precautions + IPC outbreak investigation (IDSA AMR 2024 MDRO guidance; CDC/HICPAC 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnosocomial_sepsis_within_48h_of_admission
    Sepsis features (qSOFA ≥ 2 OR SOFA delta ≥ 2 OR hypotension on adequate fluids OR lactate ≥ 4) developing > 48 h after hospital admission — life-threatening; broad-spectrum empirics per local antibiogram + source control evaluation + routes to id.sepsis.core.v1 with HCA-acquisition flag (SSC 2026 Hour-1 bundle; IDSA/ATS 2016 Kalil)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveressi_deep_or_organ_space
    Deep incisional or organ-space SSI: fever + wound drainage / dehiscence / abscess / anastomotic leak post-operatively ≤ 30 d (≤ 90 d if prosthetic implant) — severe; surgical re-exploration + broad-spectrum empiric + culture-directed; orthopedic implant infection → 6 wk IV + biofilm-active agents (IDSA/SHEA 2017 Berríos-Torres Zimmerli NEJM 2004 device infection)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecauti_in_critically_ill_remove_catheter_asap
    Catheter-associated UTI in critically ill / septic patient — severe; remove urinary catheter ASAP (or replace if catheter needed for monitoring) + culture-directed therapy; routes to id.pyelonephritis.core.v1 if upper-tract involvement (CDC Gould 2009 PMID 20156062; IDSA Hooton 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprior_antibiotic_exposure_90d_drives_broader_empirics
    Prior systemic antibiotic exposure within 90 d in patient with new HAI features — moderate; broadens ESBL + MRSA + VRE + C. diff risk-stratification; expand empiric coverage until culture-directed (IDSA/ATS 2016 Kalil PMID 27418577; IDSA AMR 2024 MDRO guidance)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSrequiredDrives screening
Loading…

Recommended regimen

HAI empiric antibiotics — by site (CLABSI / CAUTI / VAP-HAP / CDI / SSI) × MDRO pattern
axis: hai_empirics_by_site_and_mdrostep clabsi_empiric - CLABSI — vancomycin + anti-Pseudomonal β-lactam ± echinocandin
Selected step "CLABSI — vancomycin + anti-Pseudomonal β-lactam ± echinocandin" — Central venous catheter in situ + new bacteremia OR fever + line-site erythema
  • vancomycin
    first line
    glycopeptide
    15-20 mg/kg IV q8-12h; target AUC 400-600 (Rybak IDSA 2020 PMID 32191793) • IV • q8-12h
    triggers: clabsi_recognition, mrsa_risk, cons_risk
    Empiric anti-MRSA / CoNS cover until cultures; AUC-target preferred over trough
    rxcui 11124
  • cefepime
    first line
    cephalosporin_4th
    2 g IV q8h (extended infusion 3-4 h preferred) • IV • q8h
    triggers: clabsi_recognition, anti_pseudomonal_cover_needed
    Empiric anti-Pseudomonal Gram-negative cover; extended infusion improves PK target attainment (Mouton)
    rxcui 20481
  • meropenem
    comorbidity specific
    carbapenem
    1 g IV q8h (2 g if meningitis or critically ill) • IV • q8h
    triggers: esbl_risk, recent_carbapenem_active_organism, critically_ill
    ESBL cover when local resistance pattern + prior abx exposure suggests ESBL Enterobacterales (MERINO trial Harris JAMA 2018)
    rxcui 29561
  • caspofungin
    add on
    echinocandin
    70 mg IV load × 1 then 50 mg IV daily • IV • daily
    triggers: candidemia_suspected, tpn_plus_broad_abx_plus_high_risk_host, yeast_on_blood_culture
    Empiric anti-fungal for candidemia in high-risk CLABSI (IDSA candidiasis 2016 Pappas PMID 26679628); routes to id.candidemia.core.v1
    rxcui 140108
  • daptomycin
    second line
    lipopeptide
    8-10 mg/kg IV q24h (higher dose for bacteremia / endocarditis) • IV • daily
    triggers: vancomycin_intolerant, vre_isolated, vrsa_isolated, persistent_mrsa_bacteremia
    High-dose daptomycin for VRE / persistent MRSA bacteremia / vancomycin failure; CPK monitoring weekly
    rxcui 22299

outpatient playbook — drug actions (3)

  1. 1. PO antibiotic continuation if course ongoing
    Per agent + indication • PO • per agent
    trigger: Discharge with PO course remaining
    Complete course; do not stop early
  2. 2. FMT for recurrent CDI (non-pharmacologic microbiome therapy)
    Per regional FMT protocol (Rebyota / Vowst FDA-approved formulations) • colonoscopy / NG / capsule • single or two-stage course
    trigger: ≥ 3 CDI episodes OR refractory to extended-pulse vancomycin
    IDSA 2021 Johnson + van Nood NEJM 2013 — FMT is non-pharmacologic microbiome therapy
  3. 3. vaccination administration
    Per ACIP age + indication • IM • per ACIP
    trigger: Vaccination status review identifies gaps
    Reduce future HAI risk + improve overall immunisation

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New fever, hypotension, leukocytosis, or sepsis features > 48 h after hospital admission — HAI screen + HCA-acquisition flag (CDC/HICPAC 2024 NHSN definitions); Central venous catheter in situ + new fever / bacteremia — CLABSI workup (Mermel IDSA 2009 PMID 19489710); Urinary catheter in situ + dysuria / suprapubic pain / fever / pyuria — CAUTI workup (CDC Gould 2009 PMID 20156062; IDSA Hooton 2010).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hospital-acquired infection (HAI) overlay — CLABSI / CAUTI / VAP-HAP / CDI / SSI** (id.hospital-acquired-infection.v1).
Phenotype framing: Distinguish HAI site, pathogen-class, resistance pattern (susceptible vs ESBL vs CRE vs CR-Acinetobacter vs VRE vs MRSA vs VRSA vs C. auris); differentiate true infection from colonisation (catheter bacteriuria without symptoms, tracheal colonisation without VAP); identify look-alikes (drug fever, atelectasis vs VAP, transfusion reaction).
Scope: HAI overlay framing: ≥ 48 h post-admission, layered on top of existing primary engine (HF, post-op, ARDS, etc.). Sets HCA-acquisition flag for downstream sepsis routing.

No severity triggers fired against current inputs.

Plan

Regimen axis: **HAI empiric antibiotics — by site (CLABSI / CAUTI / VAP-HAP / CDI / SSI) × MDRO pattern** — step "CLABSI — vancomycin + anti-Pseudomonal β-lactam ± echinocandin".
1. vancomycin 15-20 mg/kg IV q8-12h; target AUC 400-600 (Rybak IDSA 2020 PMID 32191793) IV q8-12h (glycopeptide, first line) — Empiric anti-MRSA / CoNS cover until cultures; AUC-target preferred over trough
2. cefepime 2 g IV q8h (extended infusion 3-4 h preferred) IV q8h (cephalosporin_4th, first line) — Empiric anti-Pseudomonal Gram-negative cover; extended infusion improves PK target attainment (Mouton)
3. meropenem 1 g IV q8h (2 g if meningitis or critically ill) IV q8h (carbapenem, comorbidity specific) — ESBL cover when local resistance pattern + prior abx exposure suggests ESBL Enterobacterales (MERINO trial Harris JAMA 2018)
4. caspofungin 70 mg IV load × 1 then 50 mg IV daily IV daily (echinocandin, add on) — Empiric anti-fungal for candidemia in high-risk CLABSI (IDSA candidiasis 2016 Pappas PMID 26679628); routes to id.candidemia.core.v1
5. daptomycin 8-10 mg/kg IV q24h (higher dose for bacteremia / endocarditis) IV daily (lipopeptide, second line) — High-dose daptomycin for VRE / persistent MRSA bacteremia / vancomycin failure; CPK monitoring weekly

Setting playbook (outpatient) — Post-discharge ID follow-up; complete antibiotic course if not finished; surveillance for recurrence; FMT referral for ≥ 2 CDI recurrences; vaccinations; antimicrobial stewardship feedback
6. PO antibiotic continuation if course ongoing Per agent + indication PO per agent — Discharge with PO course remaining (Complete course; do not stop early)
7. FMT for recurrent CDI (non-pharmacologic microbiome therapy) Per regional FMT protocol (Rebyota / Vowst FDA-approved formulations) colonoscopy / NG / capsule single or two-stage course — ≥ 3 CDI episodes OR refractory to extended-pulse vancomycin (IDSA 2021 Johnson + van Nood NEJM 2013 — FMT is non-pharmacologic microbiome therapy)
8. vaccination administration Per ACIP age + indication IM per ACIP — Vaccination status review identifies gaps (Reduce future HAI risk + improve overall immunisation)

Non-pharmacologic actions:
- Patient + family education on signs of recurrence, when to return to ED
- OPAT continuation if remaining IV course
- Antimicrobial stewardship feedback to discharging unit (rotational + per-encounter)
- Infection control investigation if cluster identified (≥ 3 of same MDRO in 1 unit / 1 month)
- Social work + financial counseling if affordability barriers

AVOID / contraindication checks:
- Vancomycin AUC target not trough (Rybak IDSA 2020 PMID 32191793)
- Fidaxomicin first line over vancomycin for cdi (IDSA 2021 Johnson update)
- IV vancomycin does not treat cdi (IDSA 2017 McDonald — colonic lumen unreachable)
- Metronidazole no longer first line for non severe cdi (IDSA 2021 Johnson update)
- Ceftriaxone not adequate for pseudomonas (IDSA/ATS 2016 Kalil)
- Aminoglycoside monotherapy not adequate for gram positive (IDSA/ATS 2016 Kalil)
- Linezolid monitor platelets weekly and MAOI DDI (linezolid label + IDSA/SHEA)
- Daptomycin monitor cpk weekly and not for pneumonia (DAP PNX trial — daptomycin inactivated by surfactant)
- Rifampin CYP3A4 inducer DDI screen mandatory (DailyMed rifampin label)
- Cefepime neurotoxicity in renal impairment dose adjust (cefepime label)
- Colistin nephrotoxicity monitor creatinine daily (colistin label)
- Contact precautions for confirmed or suspected MDRO (CDC/HICPAC 2024)
- Central line removal strong for non tunneled with SA Pseudo Candida (Mermel IDSA 2009 PMID 19489710)
- Catheter avoidance and early removal for cauti prevention (CDC Gould 2009 PMID 20156062)

Monitoring

Regimen monitoring:
- blood cultures repeat q24-48h until two consecutive negatives for S. aureus / Enterococcus / Candida bacteremia
- vancomycin AUC q48-72h (target 400-600) (Rybak IDSA 2020)
- aminoglycoside trough before 3rd dose (target by indication)
- daptomycin CPK weekly
- linezolid platelets weekly + serotonin-syndrome DDI screen
- procalcitonin trend in VAP/HAP for de-escalation (ProGUARD-ICU 2021)
- C. diff symptom + WBC + Cr daily during fulminant CDI
- TEE follow-up at 4-6 wk if endocarditis confirmed (AHA Baddour 2015)
- CT abdomen / pelvis follow-up if abscess / organ-space SSI
- antimicrobial stewardship daily reassessment + duration optimisation (IDSA/SHEA ASP 2016)

Setting (outpatient) monitoring:
- Monthly ID follow-up while on OPAT
- Quarterly follow-up for chronic complications (endocarditis, osteomyelitis, prosthetic implant infection)
- Annual immunisation status audit

Follow-up plan: Outpatient ID follow-up for endocarditis / osteomyelitis / MDRO; OPAT coordination for extended-duration IV therapy; antimicrobial stewardship feedback to the unit; infection control investigation for clusters / outbreaks (≥ 3 of same MDRO in 1 unit / 1 month); patient + family education on recurrence; vaccination review (PCV20, influenza, COVID-19, herpes zoster per ACIP 2024); FMT referral for ≥ 2 CDI recurrences.
- Close-out criterion: OPAT + ID + IPC + outpatient plans documented

Monitoring phase: Repeat blood cultures q24-48 h until two consecutive negatives for S. aureus / Enterococcus / Candida bacteremia; daily reassessment of antibiotic + duration (stewardship per IDSA/SHEA 2007 ASP framework); vancomycin AUC q48-72 h (Rybak IDSA 2020); procalcitonin trend for de-escalation in VAP/HAP (ProGUARD-ICU 2021); TEE follow-up if endocarditis; CT follow-up if abscess; daily C. diff symptom assessment + WBC + Cr trend.

Disposition

Current setting: outpatient — Post-discharge ID follow-up; complete antibiotic course if not finished; surveillance for recurrence; FMT referral for ≥ 2 CDI recurrences; vaccinations; antimicrobial stewardship feedback

Disposition criteria:
- Sustained recovery — no recurrence at 6 mo + immunosuppression stable + vaccinations up to date → discharge from HAI-specific surveillance

Escalation triggers (move to higher acuity):
- Recurrence of HAI features → ED + cultures + ID urgent consult
- New MDRO isolate in outpatient cultures → ID + IPC notification
- ≥ 2 CDI recurrences → FMT referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Central-line-associated bloodstream infection with repeat positive blood cultures > 72 h despite line removal + appropriate empiric antibiotics — life-threatening; rules out endocarditis + endovascular complications (Mermel IDSA 2009 PMID 19489710; AHA Baddour 2015 endocarditis)
- [LIFE_THREATENING] Fulminant CDI: ileus / megacolon / shock / WBC > 35 K / lactate ≥ 5 / Cr ≥ 2× baseline — life-threatening; IV metronidazole + high-dose oral / rectal vancomycin + emergent surgical evaluation (IDSA/SHEA 2017 McDonald + 2021 Johnson update; Neal Ann Surg 2011 surgical strategy)
- [LIFE_THREATENING] Ventilator-associated pneumonia with documented MDR pathogen (ESBL / CRE / CR-Acinetobacter / VRSA / MBL-producing) — life-threatening; ID + targeted regimen per susceptibility; lung-protective ventilation; source control if abscess (IDSA/ATS 2016 Kalil PMID 27418577; IDSA AMR 2024 MDRO guidance)

Citations

- CDC/HICPAC HAI guidance + NHSN 2024 definitions (CLABSI, CAUTI, VAE/VAP, CDI, SSI) + IDSA/ATS 2016 HAP/VAP guideline (Kalil PMID 27418577) + Mermel IDSA 2009 CRBSI guideline (PMID 19489710) + IDSA/SHEA 2017 SSI prevention (Berríos-Torres) + IDSA/SHEA 2017 CDI guideline (McDonald) + IDSA/SHEA 2021 CDI focused update (Johnson — fidaxomicin first-line) + CDC Gould 2009 CAUTI prevention (PMID 20156062) + IDSA Hooton 2010 CAUTI diagnosis and management + IDSA AMR 2024 MDRO guidance + SSC 2026 sepsis bundle + IDSA/SHEA ASP 2016 antimicrobial stewardship framework [PMID:27418577](https://pubmed.ncbi.nlm.nih.gov/27418577/)
- Cited evidence (PMID 19489710) [PMID:19489710](https://pubmed.ncbi.nlm.nih.gov/19489710/)
- Cited evidence (PMID 20156062) [PMID:20156062](https://pubmed.ncbi.nlm.nih.gov/20156062/)
- Cited evidence (PMID 29462280) [PMID:29462280](https://pubmed.ncbi.nlm.nih.gov/29462280/)
- Cited evidence (PMID 23323867) [PMID:23323867](https://pubmed.ncbi.nlm.nih.gov/23323867/)

Last reconciled with current guidelines: 2026-05-22.
References
  • CDC/HICPAC HAI guidance + NHSN 2024 definitions (CLABSI, CAUTI, VAE/VAP, CDI, SSI) + IDSA/ATS 2016 HAP/VAP guideline (Kalil PMID 27418577) + Mermel IDSA 2009 CRBSI guideline (PMID 19489710) + IDSA/SHEA 2017 SSI prevention (Berríos-Torres) + IDSA/SHEA 2017 CDI guideline (McDonald) + IDSA/SHEA 2021 CDI focused update (Johnson — fidaxomicin first-line) + CDC Gould 2009 CAUTI prevention (PMID 20156062) + IDSA Hooton 2010 CAUTI diagnosis and management + IDSA AMR 2024 MDRO guidance + SSC 2026 sepsis bundle + IDSA/SHEA ASP 2016 antimicrobial stewardship framework — PMID:27418577
  • Cited evidence (PMID 19489710) — PMID:19489710
  • Cited evidence (PMID 20156062) — PMID:20156062
  • Cited evidence (PMID 29462280) — PMID:29462280
  • Cited evidence (PMID 23323867) — PMID:23323867