Eview of The Updated Mcgreer Criteria For Infections

McGeer Criteria for Long Term Care Surveillance Definitions for Infections Updated 2012

Article on a review of the updated McGreer Criteria for Infections in LTC Facilities.
The updated criteria can be found at http://www.jstor.org/stable/10.1086/667743
Review of the Updated McGreer Criteria for Infections
Michelle Stober, RN, BSN
Director of Interim Services, Pathway Health Services

In October 2012, the Surveillance Definitions of Infections in Long-‐Term Care Facilities: Revisiting the McGreer
Criteria was released. This position paper was first released in 1991, and since has not been updated. This
criterion was determined by an expert consensus panel based on a structured review of research and
evidenced-‐based literature. The criteria that define infections were systematically reviewed and have resulted
in changes of the original consensus definitions also known as the McGreer Criteria.

Some notable changes in the criteria are the addition of definitions of constitutional criteria (Table 2.) in
residents of long term care facilities. The decision was made to use these criteria to maintain consistency across
different infection guidelines.

This Constitutional Criteria includes:
• Fever
• Leukocytosis
• Acute change in mental status from baseline (CAM criteria also found in MDS 3.0)
• Acute functional decline in activities of daily living (ADLs)
o A new 3-‐point increase in total activities of daily living (ADL) score (range, 0-‐28) from baseline,
based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence)
Bed mobility, Transfer, Locomotion within LTCF, Dressing, Toilet use, Personal hygiene, Eating
The definition of fever was changed from a temperature greater than 100.4 degrees Fahrenheit and is
consistent with the 2008 Infectious Disease of America (IDSA) guideline for evaluating fever and infection in
older adults residing in long term care facilities (LTCFs):
1. A single oral temperature greater than37.8°C(100°F) or

2. Repeated oral temperatures greater than37.2°C(99°F)orrectaltemperaturesgreaterthan37.5°C (99.5°F)or
3. A single temperature greater than 1.1°C(2°F) over baseline from any site.
Attention should be paid the new surveillance definitions, especially for respiratory tract infection and urinary
tract infections. The following are key changes to be aware of:

Respiratory Tract Infection

When reviewing for potential respiratory infection, it is important that other conditions are ruled out such as
congestive heart failure, pulmonary embolism, atelectasis, etc..
• Removal of seasonal restrictions for influenza-‐like illness

• Pneumonia and lower respiratory tract infections-‐ at least one respiratory symptom, and at least one
constitutional criteria, along with radiographic findings to define pneumonia. This should facilitate the
surveillance into three categories including radiography results, respiratory signs or symptoms and
constitutional criteria.
• For lower respiratory tract infection oxygen saturation of <94% or <3% from baseline was added.
©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 1


Urinary Tract Infections (UTI's)

For Urinary Tract Infections without a catheter the new definitions differ substantially from the original
guidelines. The definitions take into account the low probability of UTI in residents without catheters if
symptoms are not present as well as they now take into account the need for a urine culture for microbiologic
confirmation.
• Change in character of urine was removed

• Urine culture is now needed for diagnosis
New Criteria for UTI without a Catheter: (Both criteria 1 and 2 must be present)

Criteria 1

At least one of the following sign or symptom criteria:
a. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate
b. Fever or leukocytosis (See Constitutional Criteria Table) and at least one of the following localizing
urinary tract subcriteria:
i. Acute costovertebral angle pain or tenderness
ii. Suprapubic pain
iii. Gross hematuria
iv. New or marked increase in incontinence
v. New or marked increase in urgency
vi. New or marked increase in frequency
c. In the absence of fever or leukocystosis, then 2 or more of the following subcriteria:
i. Suprapubic pain
ii. Gross hematuria
iii. New or marked increase in incontinence
iv. New or marked increase in urgency
v. New or marked increase in frequency

Criteria 2
a. At least 105 cfu/mL of no more than 2 species of microorganisms in a voided urine sample
b. At least 102 cfu/mL of any number of organisms in a specimen collected by in-‐and-‐out catheter

With the new change in surveillance guidelines, it is not only important that we train our staff but that we look
at how to operationalize infection prevention strategies.

Operational strategies for consideration:

UTI's:
• Educate staff on criteria for urinary tract infections

• Provide training on pericare and catheter care
• Encourage hydration
• Obtain baseline vital signs
• Obtain protocols to notify MD with change in condition
• Review medications


• Perform through assessment of urinary incontinence
• Provide training on pain assessment and management
• Referrals as needed to urology for chronic urinary tract infections
Respiratory Tract Infections
• Obtain a complete respiratory baseline during admission including lung sounds, observation of breathing
and color as well as oxygen saturation ratings.
Source: Infection Control and Hospital Epidemiology Vol.33, No.10(October2012), pp. 965-‐977

If you want more detail to compare the old guidelines to the new guidelines, please see the table on the next page.
The items in red are new, and the items that are struck thru have been removed.
(Shared with permission from Pathway Health Services)


Type of
Infectio Criteria
Infection/Site Conditions/Comments
n (symptoms must be new or increased)
(ü)
□ Common cold MUST HAVE at least 2 of the following: Fever may or may not be present.
syndrome □ Runny nose or sneezing Symptoms must be new and not
□ Stuffy nose (nasal congestion) attributable to allergies.
□ Or Pharyngitis
□ Sore throat or hoarseness or difficulty swallowing
□ Dry cough
□ Swollen or tender glands in neck (cervical
lymphadenopathy)
□ Influenza-‐like MUST HAVE: □Fever (≥ 100˚F taken at any site) AND If criteria for influenza-‐like illness and
illness MUST HAVE: at least 3 of the following: another upper or lower RTI are met at
□ chills □ malaise or loss of appetite the same time, only the diagnosis of
Did resident
□ headache or eye pain □sore throat influenza-‐like illness should be
receive influenza
□ Mylagia/body aches □ New or increased dry cough recorded. Because of increasing
vaccine for this flu uncertainty surrounding the timing of
season? the start of influenza season, the peak
□ YES □ NO of influenza activity, and the length of
□ Respiratory Tract
the season, “seasonality” is no longer a

criterion to define influenza-‐like illness.
□ Pneumonia MUST H AVE: □ C hest x -‐ray d emonstrating p neumonia, For both pneumonia and lower RTI, the
probable pneumonia or new infiltrate. AND presence of underlying conditions that
MUST HAVE at least 2 1 of the following could mimic the presentation of a RTI
□ New or increased cough □ 02 sat<94% or < 3% baseline (eg,
c ongestive heart failure or
□ pleuritic chest pain □ fever ≥ 100˚F (see CC table 2) interstitial lung diseases) should be
□ New or increased sputum production excluded by a review of clinical records
□ crackles, rhonchi, or wheezes on chest exam □ New or and an assessment of presenting
changed lung exam abnormalities □ respiratory rate symptoms and signs.
(>25/minute)
□ MUST HAVE ≥1: Constitutional Criteria (Fever, ADL,
Mental change)
□ Other Lower MUST HAVE at least 3 of the following: NOTE: This diagnosis can be made only
respiratory 1. □ C XR n ot p erformed o r n egative r esults f or if NO Chest x-‐ray was done OR if a CXR
tract infection pneumonia o r n ew i nfiltrate fails to confirm diagnosis of pneumonia.
2. At least 2 of respiratory subcriteria above in For both pneumonia and lower RTI, the
(bronchitis,
pneumonia presence of underlying conditions that
tracheobronchitis) □ increased cough □ pleuritic chest pain could mimic the presentation of a RTI
□ increased sputum production □ fever (≥ 100˚F) (e.g. congestive heart failure or
□ crackles, rhonchi, or wheezes on chest exam interstitial lung diseases) should be
□ one or more of: shortness of breath, increased respiratory
excluded by a review of clinical records
rate (>25/minute), worsening of mental or functional status
and assessment of s/sx
3. At least 1 of the constitutional criteria (Table 2)
Include only if symptomatic regardless of UA/UC
□ UTI in resident MUST HAVE at least 3 of the following: result. Many residents have bacteria in their urine
WITHOUT □ fever (≥ 100˚F) or chills
as a baseline and are not infected. * Change in
□ Burning pain on urination, frequency, or urgency
catheter character of urine may be clinical (new bloody
□ Urinary Tract Infection
□ Flank or suprapubic pain or tenderness urine, foul smell, or increased amount of
(any previous sediment) or as reported by lab (new pyuria or
□ Change in character of urine*
catheter must microscopic hematuria). If using lab changes, a
□ Worsening of mental or functional status (may be new or
have been D/C’d previous urinalysis must have been negative.
increased incontinence)
at least 48 hrs UTI should be diagnosed when there are localizing
before symptoms Criteria 1 and 2 MUST be present genitourinary signs and symptoms and a positive
urine culture result. A diagnosis of UTI can be
began) made without localizing symptoms if a blood
Both criteria must be present: culture isolate is the same as the organism
1. At least 1 of the following sub criteria: isolated from the urine and there is no alternate
□ Acute dysuria or acute pain, swelling, or tenderness site of infection. In the absence of a clear
alternate source of infection, fever or rigors with a
of the testes, epididymis, or prostate positive urine culture result in the non-‐
□ Fever or leukocytosis (See Constitutional Criteria Table) catheterized resident or acute confusion in the


AND catheterized resident will often be treated as UTI.
However, evidence suggests that most of these
At least 1 of the following subcriteria:
episodes are likely not due to infection of a
o Acute costovertebral angle pain or tenderness urinary source.
o Suprapubic pain
o Gross hematuria Urine specimens for culture should b e processed
as soon as possible, preferably within 1–2 h. If
o New or marked increase in incontinence
urine specimens cannot be processed within 30
o New or marked increase in urgency min of collection, they should be refrigerated.
o New or marked increase in frequency Refrigerated specimens should be cultured within
In the absence of fever or leukocystosis, then 2 or 24 h.

more of the following subcriteria:
o Suprapubic pain
o Gross hematuria
o New or marked increase in incontinence
o New or marked increase in urgency
o New or marked increase in frequency
AND
2. 1 of the following subcriteria:
5
□ At least 10 cfu/mL of no more than 2 species of
microorganisms in a voided urine sample
2
□ At least 10 cfu/mL of any number of organisms in a
specimen collected by in-‐and-‐out catheter

MUST HAVE at least 2 of the following: UTI should be diagnosed when there are localizing
□ UTI in resident genitourinary signs and symptoms and a positive
WITH catheter □ Fever (≥100˚F) or chills urine culture result. A diagnosis of UTI can be
(if symptoms □ Flank or suprapubic pain or tenderness made without localizing symptoms if a blood
□ Change in character of urine* culture isolate is the same as the organism
begin within 48 isolated from the urine and there is no alternate
hrs after □ Worsening of mental or functional status site of infection. In the absence of a clear
discontinuing a alternate source of infection, fever or rigors with a
Both criteria must be present: positive urine culture result in the non-‐
catheter, count it catheterized resident or acute confusion in the
At least 1 of the following subcriteria:
as related to catheterized resident will often be treated as UTI.
□ Fever, rigors, or new-‐onset hypotension, with no However, evidence suggests that most of these
catheter) episodes are likely not due to infection of a
alternate site of infection
urinary source.
□ Either acute change in mental status or acute
functional decline, with no alternate site of infection Recent catheter trauma, catheter obstruction, or
□ New-‐onset suprapubic pain or costovertebral angle new-‐onset hematuria are useful localizing signs
that are consistent with UTI but are not necessary
pain or tenderness
for diagnosis.
□ Purulent discharge from around the catheter or
acute pain, swelling, or tenderness of the testes, Urinary catheter specimens for culture
epididymis, or prostate should be collected following replacement
AND of the catheter (if current catheter in place
for >14 days).
Must have:
5
Urinary catheter specimen culture with at least 10
cfu/mL of any organism(s)

MUST HAVE at least 1 of the following:
□
□ 2 or more loose or watery stools above what is Care must be taken to exclude
normal for resident within a 24 hr. period noninfectious causes of symptoms. For
□ 2 or more episodes of vomiting within a 24 hr. period
GastroIntestinal
instance, new medications may cause

□ BOTH of the following: diarrhea, nausea, or vomiting; initiation
r Gastroenteritis § stool culture positive for a pathogen (Slamonella, of new enteral feeding may be
Shigella, E. Coli 0157:H7, Campylobacter( or a toxin associated with diarrhea; and nausea or
assay positive for C. difficile toxin, AND at least one of
vomiting may be associated with
the following: nausea, vomiting, diarrhea, abdominal
pain or tenderness
gallbladder disease.



At least 1 criteria must be present: Presence of new GI symptoms in a
§ Diarrhea: 3 or more liquid or watery stools above single resident may prompt enhanced
what is normal for the resident within a 24-‐hour surveillance for additional cases. In the
period presence of an outbreak, stool
§ Vomiting: 2 or more episodes in a 24-‐hour period specimens should be sent to confirm
OR the presence of norovirus or other
Both of the following subcriteria: pathogens (e.g., rotavirus or E. coli
□ A stool specimen testing positive for a pathogen (eg, O157 : H7)
Salmonella, Shigella, Escherichia coli O157 : H7,
Campylobacter species, rotavirus)
□ At least one of the following subcriteria:
o Nausea
o Vomiting
o Abdominal pain or tenderness
o Diarrhea

□ Norovirus Both criteria must be present: In the absence of laboratory
Gastro-‐ At least 1 of the following subcriteria: confirmation, an outbreak (2 or more
enteritis □ Diarrhea: 3 or more liquid or watery stools above cases occurring in a long-‐term care
what is normal for the resident within a 24-‐hour facility [LTCF] ) of acute gastroenteritis
period due to norovirus infection may be
□ Vomiting: 2 or more episodes in a 24-‐hour period assumed to be present if all of the
AND following criteria are present (“Kaplan
□
Must have: Criteria”): (a) vomiting in more than half

A stool specimen for which norovirus is positively of affected persons; (b) a mean (or
Gastrointestinal Tract
detected by electron microscopy, enzyme immunoassay, median) incubation period of 24-‐48
or molecular diagnostic testing such as polymerase chain hours; (c) a mean (or median) duration
reaction (PCR) of illness of 12-‐60 hours; and (d) no
bacterial pathogen is identified in stool
culture.

Both criteria must be present:
At least 1 of the following subcriteria: A “primary episode” of C. difficile
□ Diarrhea: 3 or more liquid or watery stools above infection is defined as one that has
rClostridium what is normal for the resident within a 24-‐hour occurred without any previous history
difficile infection period of C. difficile infection or that has
□ Presence of toxic megacolon (abnormal dilatation of occurred >8weeks after the onset of a
the large bowel, documented radiologically) previous episode of C. difficile infection.

AND A “recurrent episode” of C. difficile
At least 1 of the following subcriteria: infection is defined as an episode of C.
□ A stool sample yields a positive laboratory test difficile infection that occurs 8 weeks or
result for C. difficile toxin A or B, or a toxin sooner after the onset of a previous
producing C. difficile organism is identified from a episode, provided that the symptoms
stool sample culture or by a molecular diagnostic from the earlier (previous) episode have
test such as PCR resolved. Individuals previously
□ Pseudomembranous colitis is identified during infected with C. difficile may continue to
endoscopic examination or surgery or in remain colonized even after symptoms
histopathologic examination of a biopsy specimen resolve. In the setting of an outbreak of
GI infection, individuals could have
positive test results for presence of C.
difficile toxin because of ongoing
colonization and also be coinfected with
another pathogen. It is important that
other surveillance criteria be used to
differentiate infections in this situation.


□ Cellulitis/soft At least 1 criteria must be present: Presence of organisms cultured from
NOTE: Assure that personnel wear gloves for contact with rash or skin
tissue/wound □ Pus present at a wound, skin, or soft tissue site the surface (eg, superficial swab
□ New or increasing presence of at least 4 of the sample) of a wound is not sufficient
lesions and perform hand hygiene after glove removal
following subcriteria: evidence that the wound is infected.

o Heat at the affected site More than 1 resident with streptococcal
o Redness at the affected site skin infection from the same serogroup
o Swelling at the affected site (eg, A, B, C, G) in a long-‐term care
o Tenderness of pain at the affected site facility (LTCF) may indicate an outbreak.
□
o Serous drainage at the affected site

One (1) Constitutional Criteria (see Table 2)
□ Scabies Both criteria must be present: An epidemiologic linkage to a case can
Skin
□ A maculopapular and/or itching be considered if there is evidence of

AND geographic proximity in the facility,
At least 1 of the following subcriteria: temporal relationship to the onset of
□ Physician diagnosis symptoms, or evidence of common
source of exposure (ie, shared
□ Laboratory confirmation (scraping or biopsy)
caregiver). Care must be taken to rule
□ Epidemiologic linkage to a case of scabies with
out rashes due to skin irritation, allergic
laboratory confirmation
reactions, eczema, and other
noninfectious skin conditions.
Table 2: Definitions for Constitutional Criteria in Residents of Long-‐Term Care Facilities (LTCFs)
Fever 1. Single oral temperature >100°F OR

2. Repeated oral temperatures >99°F OR
3. Single temperature >2°F over baseline from any site (oral, tympanic, axillary)
3
Leukocytosis 1. Neutrophilia (>14,000 leukocytes/mm ) OR
3
2. Left shift (>6% bands or ≥1,500 bands/mm )
Acute change in mental All criteria must be present:
status from baseline 1. Acute onset (Evidence of acute change in resident’s mental status from baseline)
2. Fluctuating course (Behavior fluctuating: eg, coming and going or changing in severity during the
assessment)
3. Inattention (Resident has difficulty focusing attention: eg, unable to keep track of discussion or
easily distracted)
4. Either disorganized thinking or altered level of consciousness
a. Disorganized thinking (Resident’s thinking is incoherent: eg, rambling conversation,
unclear flow of ideas, unpredictable switches in subject)OR
b. Altered level of consciousness (Resident’s level of consciousness is described as different
from baseline: eg, hyperalert, sleepy, drowsy, difficult to arouse, nonresponsive)
Acute functional decline 1. A new 3-‐point increase in total activities of daily living (ADL) score (range, 0-‐28) from baseline,
based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence)
Bed mobility, Transfer, Locomotion within LTCF, Dressing, Toilet use, Personal hygiene
Eating


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1. A single oral temperature greater than37.8°C(100°F) or

• Removal of seasonal restrictions for influenza-‐like illness

• Change in character of urine was removed

• Educate staff on criteria for urinary tract infections

Respiratory Tract Infections

©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 3

the season, “seasonality” is no longer a

instance, new medications may cause

©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 5

Must have: Criteria”): (a) vomiting in more than half

©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 6

following subcriteria: evidence that the wound is infected.

o Serous drainage at the affected site

□ A maculopapular and/or itching be considered if there is evidence of

Fever 1. Single oral temperature >100°F OR

©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 7

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Eview of The Updated Mcgreer Criteria For Infections

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Eview of The Updated Mcgreer Criteria For Infections

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Document Information

Original Title

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Eview of The Updated Mcgreer Criteria For Infections

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1. A single oral temperature greater than37.8°C(100°F) or

• Removal of seasonal restrictions for influenza-­‐like illness

• Change in character of urine was removed

• Educate staff on criteria for urinary tract infections

Respiratory Tract Infections

©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 3

the season, “seasonality” is no longer a

instance, new medications may cause

©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 5

Must have: Criteria”): (a) vomiting in more than half

©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 6

following subcriteria: evidence that the wound is infected.

o Serous drainage at the affected site

□ A maculopapular and/or itching be considered if there is evidence of

Fever 1. Single oral temperature >100°F OR

©Pathway Health Services – 2012 www.pathwayhealth.com 1.877.777.5463 7

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• Removal of seasonal restrictions for influenza-‐like illness