Protocol for point prevalence surveys of healthcare-associated infections and antimicrobial use in European long-term care facilities : version 2.1.
Date: 2016-06-29
Institutions: European Centre for Disease Prevention and Control
Subjects: antibiotic, data collection, health care, health control, infectious disease, research report

TECHNICAL DOCUMENT

Protocol for point prevalence 
surveys of healthcare-associated 
infections and antimicrobial 
use in European long-term care 
facilities

Version 2.1

www.ecdc.europa.eu

ECDC TECHNICAL DOCUMENT 

Protocol for point prevalence surveys of 
healthcare-associated infections and 
antimicrobial use in European long-term 
care facilities 

Version 2.1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
This protocol was commissioned by the European Centre for Disease Prevention and Control (ECDC), coordinated 
by Pete Kinross and Carl Suetens. 
Contributing authors 
Katrien Latour, Béatrice Jans (WIV-ISP, Belgium); Enrico Ricchizzi, Maria Luisa Moro (Agenzia sanitaria e sociale 
regionale; Italy); Tommi Kärki, Pete Kinross, Carl Suetens (ECDC). 

Acknowledgements  
All designated national representatives from EU/EEA Member States that attended the ‘Train-the-trainer workshop 
for surveillance of HAI and antimicrobial use in long-term care facilities’ on 1–2 December 2015 in Stockholm, 
Sweden, for their critical feedback regarding this protocol. 

Erratum: 14 June 2016 - Figure 4 (page 13) was amended to make it consistent with Annex 1. 

Suggested citation: European Centre for Disease Prevention and Control. Protocol for point prevalence surveys of 
healthcare-associated infections and antimicrobial use in European long-term care facilities – version 2.1. 
Stockholm: ECDC; 2016. 

Stockholm, May 2016 

ISBN 978-92-9193-849-0 

doi 10.2900/02719 

Catalogue number TQ-04-16-370-EN-N 

© European Centre for Disease Prevention and Control, 2016 

Reproduction is authorised, provided the source is acknowledged 

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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Contents 

Abbreviations ............................................................................................................................................... iv 
1. Introduction .............................................................................................................................................. 1 
2. Objectives ................................................................................................................................................. 2 
3. Survey design ............................................................................................................................................ 3 
4. Data collection ........................................................................................................................................... 8 
5. Data delivery ........................................................................................................................................... 30 
6. Training .................................................................................................................................................. 31 
7. On-site assessments of IPC situation and needs including a validation survey ................................................ 31 
8. Role of the national survey coordinator ...................................................................................................... 31 
9. Ethical considerations ............................................................................................................................... 32 
10. References ............................................................................................................................................ 33 
11. Contact information ................................................................................................................................ 34 
Annex 1. Institutional questionnaire ............................................................................................................... 35 
Annex 2. Ward list (for internal use only) ....................................................................................................... 40 
Annex 3. Resident questionnaire ................................................................................................................... 43 
Annex 4. Case definitions of infections ........................................................................................................... 45 
Annex 5. Code list with microorganisms ......................................................................................................... 51 

Figures 

Figure 1. HALT-3 institutional questionnaire: Part A – general information........................................................... 9 
Figure 2. HALT-3 institutional questionnaire: Part B – Denominator data ........................................................... 11 
Figure 3. HALT-3 institutional questionnaire: Part C – medical care and coordination ......................................... 11 
Figure 4. HALT-3 institutional questionnaire: Part D – infection control practice ................................................. 13 
Figure 5. HALT-3 institutional questionnaire: Part E – antimicrobial policy ......................................................... 15 
Figure 6. HALT-3 institutional questionnaire: Part F – how was the survey performed in your facility? ................. 16 
Figure 7a. HALT-3 ward list – collection of resident-level data .......................................................................... 16 
Figure 7b. HALT-3 ward list – calculation of denominators ............................................................................... 17 
Figure 8. HALT-3 resident questionnaire: resident data ................................................................................... 18 
Figure 9. HALT-3 resident questionnaire: Part A – Antimicrobial use ................................................................. 19 
Figure 10. HALT-3 resident questionnaire: Part B – Healthcare-associated infections .......................................... 20 
Figure 11. HALT-3 infection decision algorithms (page 1 of 6) .......................................................................... 22 
Figure 12. HALT-3 resident questionnaire: Part B – Healthcare-associated infections – isolated microorganism and 
its antimicrobial resistance ............................................................................................................................ 29 

Tables 

Table 1. Criteria to categorise the national representativeness of the LTCF sample for the PPS. ............................ 5 
Table 2. Number of LTCFs and residents needed to estimate a HAI prevalence of 4% with 1% precision, by country
 .................................................................................................................................................................... 6 

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TECHNICAL DOCUMENT 

Abbreviations 

AMR  
EEA 
ESAC-NH  
EU  
GP  
HAI  
HALT project 
HALT-2 project 

HALT-3 project 

IPC  
IPSE  
LTCF  
NSC  
PPS 
RTI 
SSI 
UTI 

Antimicrobial resistance 
European Economic Area 
European Surveillance of Antimicrobial Consumption in Nursing Homes  
European Union 
General practitioner 
Healthcare-associated infection 
Healthcare-associated infections in long-term care facilities project, May–September 2010  
Healthcare-associated infections and antimicrobial use in long-term care facilities project, 
April–May 2013 
Healthcare-associated infections and antimicrobial use in long-term care facilities project, 
2016–2017 
Infection prevention and control 
Improving Patient Safety in Europe project 
Long-term care facility 
National survey coordinator 
Point prevalence survey 
Respiratory tract infection 
Surgical site infection 
Urinary tract infection 

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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

1. Introduction 

In 2008, the coordination of surveillance of healthcare-associated infections (HAIs) in Europe was transferred to the 
European Centre for Disease Prevention and Control (ECDC), which created the Healthcare-Associated Infections 
Surveillance Network (HAI-Net). A feasibility study of surveillance of HAIs in European nursing homes had already been 
performed under the Improving Patient Safety in Europe (IPSE) project financed by the European Commission [1].  

In December 2008, ECDC initiated surveillance of HAIs and antimicrobial use in European long-term care facilities 
(LTCFs) under the Healthcare-Associated Infections in Long-Term Care Facilities (HALT) project. The HALT project 
integrated variables from the European Surveillance of Antimicrobial Consumption in Nursing Homes (ESAC-NH) 
subproject into a protocol for repeated point prevalence surveys (PPSs) in LTCFs, thus providing an integrated 
methodology for continued assessment of the prevalence of HAIs, antimicrobial use, and infection prevention and 
control (IPC) resources in European LTCFs.  

From May to September 2010, a first PPS in European LTCFs (HALT project, 2010) collected data from 722 LTCFs across 
25 European countries [2]. It showed a prevalence of residents with at least one HAI in participating LTCFs of 2.4%. 
The crude prevalence of residents receiving at least one antimicrobial agent was 4.3%.  

From April to May 2013, a second PPS in European LTCFs (HALT-2 project, 2013) collected data from 1 181 LTCFs in 17 
European countries [3]. The HALT-2 project showed prevalence of residents with at least one HAI of 3.4% and a 
prevalence of residents with at least one antimicrobial agent of 4.4%. The HALT-2 project also included a validation 
survey. 

In May 2015, ECDC launched the third project to support PPSs of HAIs and antimicrobial use in LTCFs (HALT-3 (2016-
2017)). The reports, protocols and survey tools from the HALT and HALT-2 projects were adapted and discussed by the 
HALT-3 management and advisory committees. On 1‒2 December 2015, the draft protocol and materials were 
presented to nominated representatives from EU/EEA Member States at a train-the-trainer workshop, thus enabling 
these representatives to train other trainers and local survey staff. 

This protocol provides national survey coordinators (NSCs) and local data collectors in the HALT-3 project with the 
methodology, data collection forms and definitions of variables to collect from LTCFs from April–June 2016, 
September-November 2016, April–June 2017 and/or September–November 2017. 

Answers to frequently asked questions (FAQs) from NSCs and local data collectors will be published on the ECDC HAI-
Net extranet throughout the HALT-3 project. 

A separate validation protocol provides the methodology, data collection forms and definitions of variables for a 
validation survey in at least one LTCF per EU/EEA Member State, performed by a national validation team on the same 
day as a primary survey, to estimate the sensitivity and specificity of data collection in that LTCF [4]. These are used to 
adjust the estimates of the burden of HAIs in European LTCFs. 

If an invitation is received by ECDC from a participating EU/EEA Member State, the Project Management Team will 
arrange a two-day onsite assessment visit together with the corresponding national team. The objectives of the visit are 
to support the completion of a questionnaire on national data and to accompany the national team during a validation 
survey [5]. The questionnaire relates to national performance indicators of IPC, the effect of repeated PPSs in LTCFs at 
national and local level, and the collection of national denominator data. The Project Management Team accompany the 
national team on a validation survey, to aid completion of the national questionnaire and to qualitatively assess the 
comparability of the national validation surveys. 

The outputs from the PPS of HAIs and antimicrobial use in European LTCFs include a European report as well as 
feedback reports for each participating LTCF, comparing their data to national and European results; both are 
distributed to national teams for onward distribution. 

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TECHNICAL DOCUMENT 

2. Objectives 

The general objectives of ECDC surveillance of HAIs and antimicrobial use in European LTCFs are:   

 

 

 

to provide EU/EEA Member States and LTCFs with a standardised tool to follow trends in HAIs and antimicrobial 
use 
to identify priorities for national and local intervention measures and evaluate their implementation in EU/EEA 
Member States and LTCFs 
to estimate and monitor the burden of HAIs and antimicrobial use in LTCFs at national and European level. 

The overall aim of the protocol is to support the implementation of a PPS of HAIs and antimicrobial use in LTCFs, in 
support of the abovementioned objectives for European surveillance. The specific objectives of the PPSs in European 
LTCFs are:  

 
 

to estimate the prevalence of HAIs and antimicrobial use in European LTCFs 
to measure structure and process indicators of IPC in these LTCFs.  

The obtained data are considered useful: 

 

 
 
 

to quantify the prevalence of HAIs and antimicrobial use in LTCFs, EU/EEA Member States and in the EU/EEA 
region  
to identify needs for intervention, training and/or additional IPC resources 
to identify priorities for national and local intervention and raise awareness 
to foster the safety of healthcare for residents in LTCFs and the ageing European population in general. 

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3. Survey design  

3.1 Time schedule for the repeated PPSs 

Ideally, data should be collected from each LTCF on one single day. In LTCFs with a large number of beds, data 
collection can be spread over two or more consecutive days. However, all beds in one ward should be surveyed on the 
same day.  

Member States can organise the PPS in LTCFs in their country during one or more of four surveillance periods. If data 
are collected from a LTCF in more than one of these periods, only data from their first participation should be included 
in the data sent to ECDC. The four surveillance periods are: 

 
 
 
 

April‒June 2016, 
September‒November 2016, 
April‒June 2017, 
September‒November 2017.  

Since data collection for the second ECDC PPS in European acute care hospitals will also take place during these four 
periods, Member States will have the option to perform both PPSs during the same period, or not. ECDC does not plan 
to analyse these acute hospital and LTCF data in the same report. 

3.2 Survey population 

3.2.1 Countries 

All EU/EEA Member States are invited to participate through ECDC's surveillance of healthcare-associated infections 
network (HAI-Net).  

3.2.2 National survey coordinators 

In each country, one or more national survey coordinators (NSCs) are responsible for the invitation of LTCFs, training 
activities for data collectors and the organisation of the PPS in participating LTCFs (see section 8: role of the national 
survey coordinator). Ideally the NSCs should be a nominated ECDC Operational Contact Points (OCP) for Healthcare-
Associated Infections in Long-Term Care Facilities (HAI-HALT), either for epidemiology or for the European Surveillance 
System (TESSy) interactions; or the National Focal Points for Healthcare-Associated infections or their alternates, as 
ECDC is only authorised by coordinating competent bodies1 in EU/EEA Member States to contact such designated 
persons2. 

3.2.3 Eligibility criteria for LTCFs 

The term ‘long-term care services’ refers to the organisation and delivery of a broad range of services and assistance to 
people who are limited in their ability to function independently on a daily basis, i.e. to autonomously perform the basic 
activities of daily living, over an extended period of time. Additionally, there is often a need for basic medical services 
(wound dressing, pain management, medication, health monitoring, prevention, rehabilitation or palliative care). Long-
term care comprises a mix of both health and social components, therefore pertaining to both health and social sectors.  

LTCFs typically have residents who: 

 
 
 

 

need constant supervision (24 hours a day) 
need ‘high-skilled nursing care’, i.e. more than ‘basic’ nursing care and assistance for daily living activities 
are medically stable and do not need constant ‘specialised medical care’ (i.e. care administered by specialised 
physicians) 
do not need invasive medical procedures (e.g. ventilation). 

1 ECDC Competent Bodies http://ecdc.europa.eu/en/aboutus/Competent%20bodies/Pages/Competent_bodies.aspx  

2 ECDC Coordinating Competent Bodies: structures, interactions and terms of reference 
http://ecdc.europa.eu/en/aboutus/Competent%20bodies/Documents/coordinating-competent-bodies-structures-terms-of-reference-
and-interactions-w-Annexes.pdf  

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LTCF types include:  

General nursing homes  

Residential homes 

Specialised LTCFs 

In these facilities, residents need medical or skilled nursing and supervision 24h a day. These 
facilities provide principally care to seniors with severe illnesses or injuries. 

In these facilities residents are unable to live independently. They require supervision and 
assistance for the activities of daily living (ADL). These facilities usually include personal care, 
housekeeping and three meals a day 

These facilities are specialised in one specific type of care for e.g. physical impairment, chronic 
diseases such as multiple sclerosis, dementia, psychiatric illnesses, rehabilitation care, palliative 
care, intensive care 

Mixed LTCFs 

These facilities provide different types of care in the same facility (a mix of the above mentioned 
LTCF types). 

Other LTCFs 

Other facilities, not classifiable among the above mentioned LTCF types. 

Remark: This classification does not imply that the characteristics of residents within each facility type are strictly homogeneous. 

All types of LTCFs are eligible to participate in the PPS. Afterwards, each participating LTCF will receive individual 
feedback of their results. To increase the comparability of national data, data from the most similar LTCF types will be 
aggregated in the main European report for most analyses, if there are sufficient numbers of LTCFs within a type (see 
3.3 Recruiting LTCFs to the PPS). In HALT-3, the main results from the LTCF types that are not included in aggregate 
analyses will be summarised in a separate chapter. In previous surveys, these were mostly ‘specialised LTCFs’. 

The following facilities should be excluded: hospital long-term care wards, hostel care (hotel without any kind of nursing 
care), sheltered care houses, day centres, home-based centres, protected living. 

3.2.4 Eligible residents 

Residents are eligible, and should therefore be included in the survey, if they are: 

 

 

 

living full-time (24 hours a day) in the LTCF  
AND 
present at 8:00 AM on the day of the PPS 
AND 
not discharged from the LTCF at the time of the survey. 

Note: Do include residents who meet these criteria and are recorded on the resident administration system if they were 
temporarily outside the LTCF (e.g. for diagnostic investigations or medical procedures; with family/friends; etc.). 

The following residents should be excluded: 

 

 

 

 

residents not living full-time in the LTCF (e.g. residents from day care centres) 
OR 
residents living full-time in the LTCF but not present at 8:00 AM (e.g. absent for leave or admitted to a hospital) 
OR 
residents hospitalised on the day of the PPS (i.e. inpatient in a hospital with a stay of at least one night) 
OR 
residents who choose not to participate. 

Note: Residents receiving chronic ambulatory care on a regular basis in an acute care hospital (e.g. haemodialysis or 
chemotherapy) should not be excluded from the PPS if they are not hospitalised on the day of the PPS (i.e. hospital 
stay of at least one night). 

3.3 Recruiting LTCFs to the PPS  

Data from the most similar LTCF types will be aggregated in the main European report, to promote comparability of 
national results. In the HALT and HALT-2 projects, the main European PPS reports aggregated data from nursing 
homes, residential homes and mixed facilities, as these types represented 96% and 89% of the LTCFs that participated 
in these surveys, respectively. The HALT-3 report will contain one chapter presenting the main results from LTCF types 
that were not included in the aggregated analyses (e.g. specialised LTCFs). National survey coordinators will receive 
reports for each participating LTCF, irrespective of their LTCF type.  

The PPS data should ideally be acquired from LTCFs that are representative for all LTCFs in the country. The preferred 
method to acquire a nationally representative sample of LCTFs is systematic random sampling using a national register 
of LTCFs. There are several published methods to achieve this. One suitable method is described in Section 3.3.2. 

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Each country may choose to collect data from LTCFs in any or all four of the surveillance periods (i.e. April‒June 2016, 
September‒November 2016, April‒June 2017 and/or September‒November 2017). If an individual LTCF performs the 
survey more than once in these surveillance periods, it is essential that data from only one of their surveys are included 
in the database sent to ECDC.  

Given the voluntary nature of the PPS, it may not be possible for Member States to recruit LTCFs nationally even though 
this is preferable. In that scenario, recruitment may be limited to LTCFs from one or more sub-national regions (i.e. 
regional data).  

3.3.1 The number of LTCFs to recruit to the PPS  

The recommended minimum number of LTCFs to the PPS recruit in each country is provided in Table 2. Preferably these 
should be recruited from a systematic random sample of a national register (see section 3.3.2). 

The estimation of the sample size residents per country assumed that LTCFs in the current PPS share attributes with 
those that participated in HALT and HALT-2 projects and the EU register of LTCFs collected for those projects.  

The sample size was calculated for each EU/EEA Member State, anticipating a national crude prevalence of four 
residents with at least one HAI per 100 LTCF beds, with a 95% confidence interval of 3‒5% (1% precision), using the 
OpenEpi3 website sample size calculator for frequency in a population 
(http://www.openepi.com/SampleSize/SSPropor.htm; Table 2).  

The design effect4 (DEFF), due to clustering of residents in LTCFs intrinsic to the survey design, was estimated from a 
dataset containing all LTCFs that participated in the HALT and/or HALT-2 projects, using the Stata 12 software package 
(survey prefix command ‘syv’). DEFF was estimated for the entire dataset (DEFF = 3.9) and for each quintile of LTCF 
size (see Table 2). The estimation of the number of LTCFs to recruit per country was the number of residents specified 
by the sample size calculation divided by the mean number of eligible residents per LTCF in each country reported in 
the register.  

If any of these data were unavailable in the register, the denominator size was imputed from the median number of 
eligible residents per population age 65 years and over (40.3 per 1 000), the number of recommended LTCFs was 
imputed from the median number of LTCFs per population age 65 years and over (68.7 per 100 000), the DEFF was 
assumed to be the overall DEFF for the previous two surveys (3.9) and the number of LTCFs to recruit to acquire data 
on the recommended number of residents was estimated from the median LTCF size in the HALT and HALT-2 projects 
i.e. 85.1 residents/LTCF.  

The national sample representativeness will be categorised in four levels (optimal, good, poor and very poor; Table 1) 
depending on compliance with the recommended sampling methodology. The evaluation will include all LTCFs for which 
all eligible residents were included.   

Table 1. Criteria to categorise the national representativeness of the LTCF sample for the PPS. 

Optimal 

Good 

Poor 

Very poor 

• 

• 

• 

• 

• 

• 

• 

Systematic random sample of at least 25 LTCFs or at least 75% of the number of LTCFs specified in 
Table 2. 
Inclusion of at least 75% of all LTCFs or occupied LTCF beds in the country and recommended 
sample size (Table 2) achieved  
Selection of at least 25 LTCFs or at least 75% of the number of LTCFs and/or residents specified in 
Table 2 using another methodology (e.g. voluntary participation); 
Recommended sample size not achieved, but inclusion of ≥75% of all LTCFs or occupied LTCF beds 
in the country. 
Between 5 and 25 LTCFs included in countries with more than 25 LTCFs and recommended sample 
size not achieved; 
Less than 5 LTCFs included in countries with more than 5 LTCFs but inclusion of 50–75% of all LTCFs 
or occupied LTCF beds in the country. 
Inclusion of less than 5 LTCFs and less than 50% of all LTCFs and less than 50% of all occupied LTCF 
beds. 

3 Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. www.OpenEpi.com, 
updated 2015/05/04, accessed 2015/11/16. 

4 The design effect (DEFF) of a statistic is the ratio of actual variance for a given sample design over the variance if the residents were 
selected randomly (i.e. from all LTCFs or from a much larger sample). The DEFF is proportionate to the size of the clusters (i.e. LTCF 
size) and to the frequency (i.e. prevalence) of the outcome under study (higher for antimicrobial use than for HAIs). Sample size 
increases proportionally to DEFF to ensure that prevalence can be estimated with same precision, despite the over-dispersion within 
clusters. 

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TECHNICAL DOCUMENT 

Table 2. Number of LTCFs and residents needed to estimate a HAI prevalence of 4% with 1% precision, 
by country 

Country 

Population 
>65yrs a 

No. of 
LTCFs 

No. of beds  Average 

LTCF size 
(beds) 

Estimated 
DEFFb 

Recommended 
sample size 
(beds) 

No. of 
LTCFs to 
recruit 

Austria 
Belgium 
Bulgaria 
Croatia 
Cyprus 
Czech Republic 
Denmark 
Estonia 
Finland 
France 
Germany 
Greece 
Hungary 
Iceland 
Ireland 
Italy 
Latvia 
Lithuania 
Luxembourg 
Malta 
The Netherlands 
Norway 
Poland 
Portugal 
Romania 
Slovakia 
Slovenia 
Spain 
Sweden 
UK – England 
UK – Northern 
Ireland 
UK – Scotland 
UK – Wales 
Total 

1 527 257 
1 959 654 
1 395 471 
773 141 
114 442 
1 767 618 
999 801 
238 053 
1 018 193 
11 511 520 
17 002 915 
2 206 710 
1 701 675 
41 677 
562 405 
12 639 829 
379 784 
542 198 
75 057 
72 278 
2 824 345 
790 614 
5 476 620 
2 032 606 
3 258 198 
710 222 
352 145 
8 262 078 
1 828 283 
9 305 300 
279 100 

946 800 
600 600 
93 196 589 

817 
1 540 
33 
361 
92 
73 
2 600 
203 
448 
7 833 
12 354 
ND 
1 177 
ND 
570 
ND 
82 
103 
60 
45 
1 700 
991 
1 906 
178 
ND 
488 
90 
5 490 
2 766 
17 473 
249 

892 
680 
63 224 

72 602 
136 272 
486 
34 540 
2 659 
17 204 
90 181 
8 449 
19 016 
589 960 
875 549 
ND 
57 929 
ND 
34 851 
285 007 
5 798 
5 484 
5 971 
4 622 
165 000 
41 415 
123 546 
4 075 
ND 
29 052 
20 777 
331 200 
101 000 
468 658 
11 708 

38 164 
22 985 
3 604 224 

89 
88 
15 
96 
29 
236 
35 
42 
42 
75 
71 
ND 
49 
ND 
61 
ND 
71 
53 
100 
103 
97 
42 
65 
23 
ND 
60 
231 
60 
37 
27 
47 

43 
34 
69 

3.1 
3.1 
2.3 
3.1 
2.3 
5.5 
2.4 
2.4 
2.4 
3.1 
2.4 
3.9 
2.4 
3.9 
2.4 
3.9 
2.4 
2.4 
3.1 
3.1 
3.1 
2.4 
2.4 
2.4 
3.9 
2.4 
3.1 
2.4 
2.4 
2.3 
2.4 

2.4 
2.4 
3.9 

4 482 
4 524 
486e 
4 386 
2 183 
7 473 
3 484 
3 015 
3 286 
4 562 
3 535 
5 662d 
3 453 
3 104de 
3 397 
5 724 
2 823 
2 791 
3 668 
3 468 
4 533 
3 419 
3 499 
2 600 
5 691d 
3 370 
4 270 
3 525 
3 490 
3 383 
3 145 

50 
51 
33 
46 
76 
32 
100 
72 
77 
61 
50 
67 c 
70 
36 c 
56 
67 c 
40 
52 
37 
34 
47 
82 
54 
114 
67 c 
57 
18 
58 
96 
126 
67 

3 409 
3 327 
123 025 

80 
98 
2 232 

LTCF: Nursing Homes, Residential Homes and Mixed Facilities (only); ND: no data; a Source: Eurostat except for UK (UK Office for 
National Statistics, mid-2013 estimates release MYE7ST2). b Design Effect (DEFF) by quintiles of LTCF size (<30 beds: 2.3; 30 to <50 
beds: 2.4; 50 to <75 beds: 2.4; 75 to <110 beds: 3.1; >=110 beds: 5.5; Overall: 3.9). c Estimated from the median number of eligible 
residents per LTCF in HALT (2010) and HALT-2 (2013), i.e. 85.1/LTCF. d Data for Greece, Iceland and Romania were estimated from 
data for countries that provided data to HALT (2010) and/or HALT-2 (2013) and those projects’ EU register of LTCFs and LTCF beds. e 
All LTCF residents should be recruited to confirm the anticipated prevalence.  

3.3.2 Obtaining a systematic random sample of LTCFs from a national 
register  

The probability sampling method described in this section, i.e. sorting a comprehensive national list of LTCFs according 
to a given attribute (e.g. the number of beds) before selection, ensures that the selected sample represents the 
national register in terms of that attribute, particularly if the next LTCF in the list is contacted to ‘replace’ those that 
decline participation. It is recommendable to sort registers according to more than one attribute, if possible, e.g. LTCF 
type and size.   

1.  Obtain a list of all eligible LTCF types (i.e. nursing homes, residential homes and/or mixed facilities) nationally that 

includes the number of LTCF beds.  
Rank the list in ascending order of the number of beds from 1 to N. 
Consult Table 2 to obtain the minimum number of LTCFs that should be recruited to the survey (n).  

2. 
3. 

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4.  Divide the total number of LTCFs (N) by the number to be sampled (n) to acquire the sampling interval (k), i.e. 

5. 
6. 
7. 
8. 

N/n=k. 
Choose a random number between 1 and k = i. 
Select LTCF i, i+k, i+2k, …, i+nk. 
Invite these selected LTCFs to participate in the PPS.  
If a LTCF declines the invitation to participate in the PPS, invite the next LTCF on the list, i.e. i+1, i+k+1, i+2k+1, 
…, i+nk+1. If that LTCF declines to participate, invite the next in the list, and so on.  

3.3.3 Non-representative samples and reporting of results 

Although representative sampling remains strongly recommended, a comprehensive register of LTCFs may not be 
available in some EU/EEA Member States. If no national or regional register is available, purposive sampling, such as 
convenience sampling may be used to recruit LTCFs. If possible, the recruited LTCFs include eligible LTCF types and 
sizes. Alternative methods to recruit LTCFs, that EU/EEA Member States may choose to follow, include ‘convenience’ 
sampling (selection of LTCFs by the PPS coordinating centre), voluntary participation after invitation of all LTCFs and 
mandatory participation. The LTCF sampling/recruitment method is recorded at the national/regional level and will be 
categorised in four levels (optimal, good, poor and very poor) during analysis according to the criteria specified in Table 
1.   

Moreover, some countries may want to perform the PPS in LTCFs from both a nationally representative sample and from 
voluntary participation, after invitation of all LTCFs. In this case, only data from a nationally representative sample will 
be included in the European report. However, if all data are submitted, ECDC will provide the national survey 
coordinators with feedback reports for all participating LTCFs by comparing their results to the total national results. A 
variable at LTCF level, entered by the national survey coordinator, records whether a LTCF belongs to the representative 
sample. This variable will aid selection of LTCFs for the European level report.  

3.4 Data collectors 

Depending on the available resources, data can be collected by local data collectors (e.g. designated physician, 
infection control doctor/nurse, head nurse, etc.) or local data collectors supported by an external data collector (i.e. 
person recruited by the national representative, e.g. doctor, infection control nurse). 

Both local and external trained data collectors should visit the facility on the day of the PPS to review each resident with 
the nurse in charge, nurses’ aide and healthcare workers of the LTCF, looking for recent symptoms suggestive of 
infection, examining charts, case notes and drug charts. Residents with suspected infection(s) and residents receiving 
antimicrobial agents should be further reviewed, and discussed with the attending physician if possible.  

It is recommended that extra staff are involved during this period to take into account the extra workload that the PPS 
is foreseen to generate. 

Training material was developed by the HALT-3 coordination group. Training of data collectors is strongly recommended 
(see section 6 Training).  

7 

 
 
 
 
 
 
 
 
 
 
 
 
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TECHNICAL DOCUMENT 

4. Data collection 

Data are collected using two questionnaires, an institutional questionnaire and a resident questionnaire. An 
institutional questionnaire (Annex 1) collects denominator data, structural and functional characteristics (e.g. 
public/private ownership, presence of qualified nurses, medical coordination) and information about antimicrobial 
policies and infection control resources in the LTCF. These data will be used for descriptive analyses of the participating 
LTCFs and their population and to make appropriate adjustments for the LTCF’s case mix during comparative analysis at 
national/regional and European level. 

A ward list (Annex 2; optional, for internal use only) is provided for data collectors to facilitate their collection of 
denominator data from the LTCF population on the day of the PPS, for subsequent entry onto the institutional 
questionnaire. 

A resident questionnaire (Annex 3) is for each resident that receives at least one antimicrobial agents and/or 
presents with at least one active infection on the PPS day. The case definitions of infections (Annex 4) should be 
used to identify active HAIs in eligible residents. A code list for microorganisms (Annex 5) should be consulted 
when completing the resident questionnaire, to identify the appropriate codes for detected microorganisms and their 
antimicrobial resistance profiles. 

4.1 Institutional questionnaire (see Annex 1) 

The institutional questionnaire (Annex 1) collects data relating to each participating LTCF with questions grouped 
into six sections:  

 
 
 
 
 
 

A – General information,  
B – Denominator data,  
C – Medical care and coordination,  
D – Infection control practice,  
E – Antimicrobial policy and  
F – How was the survey performed in you facility? 

It is recommended that the person completing this questionnaire is the person in charge of the facility. If this person 
cannot answer some of the questions or locate the relevant information, they should request assistance from persons 
who are able to answer those questions. This is especially relevant for questions relating to antimicrobial policy. 

4.1.A – General information 

Variable 

 Description/definition 

Facility survey number 

LTCF identifier; code allocated by the national coordinating centre. 

Qualified nurses available 24 
hours a day in the facility 

Qualified nurses are available day and night, i.e. physically present and/or contactable by 
phone/beeper 24 hours a day.  

Total number of FTE 
registered nurses 

Total number of FTE nursing 
assistants 

Total number of full-time equivalent registered (graduated, qualified) nurses working in the LTCF 
(not only on the day of the PPS). Provide the current situation if possible, or for the most recent 
available situation.  
A ‘registered nurse’ is a nurse who has graduated from a college’s nursing program or from a 
school of nursing and has passed a national licensing exam to obtain a nursing license.  
Do include ‘agency nurses’, ‘bank nurses’, ‘interim nurses’ or other registered nurses who are not 
permanently employed for that position in the LTCF. No distinction should be made between the 
administrative, scientific and/or clinical work of a nurse.   
Do not include students. 

Total number of full-time equivalent (FTE) nursing assistants working in the LTCF (not only on 
the day of the PPS). Provide the current situation if possible, or the most recent available 
situation.  
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 LTCF.  
Nursing assistants work under the supervision of nurses or physicians to address the most 
fundamental elements of a resident’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. No distinction should be made 
between the administrative, scientific and/or clinical work of a nursing assistant. 
Do not include other licensed health professionals such as dietitians, physiotherapists or speech 
or occupational therapists, logistic personnel, students of any kind or volunteers who provide 
basic patient care without pay.  

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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Variable 

 Description/definition 

Total number of resident 
rooms  

Sum of all resident rooms including single rooms and multi-bedded rooms. Public areas, utility 
rooms, etc. should be excluded. 

Total number of single 
occupancy rooms in the 
facility 

Total number of rooms in the facility that are designated for single occupancy (e.g. rooms with 
one bed). A room shared by partners should not be considered as a single occupancy room.  

Total number of 
single/private rooms in the 
facility with individual toilet 
and washing facilities 

Number of single occupancy rooms with individual toilet and washing facilities (sink and/or 
shower). An individual toilet alone or a commode (toilet chair) is not sufficient to qualify as a 
‘single occupancy room with individual toilet and washing facilities’. Rooms which have toilet and 
washing facilities in a communal area should not be counted.  

Figure 1. HALT-3 institutional questionnaire: Part A – general information 

DATE OF THE SURVEY IN YOUR FACILITY 

   └─┴─┘└─┴─┘ 201└─┘(dd mm yyyy) 

FACILITY STUDY NUMBER (allotted by your national HALT-3 coordinator) 

└─┴─┴─┴─┴─┴─┴─┘ 

OWNERSHIP OF THE FACILITY 

□ Public 

□ For profit  

□ Not for profit 

QUALIFIED NURSING CARE AVAILABLE 24/24h IN THE FACILITY 

□ Yes   

□ No 

IN THE FACILITY: 

Total number of FTE REGISTERED NURSES   
Total number of FTE NURSING ASSISTANTS  
Total number of RESIDENT ROOMS                            
Total number of SINGLE OCCUPANCY RESIDENT ROOMS 
Total number of SINGLE OCCUPANCY RESIDENT ROOMS WITH  
INDIVIDUAL TOILET AND WASHING FACILITIES 

└─┴─┴─┴─┘FTE registered nurses 
└─┴─┴─┴─┘FTE nursing assistants 
└─┴─┴─┴─┘Rooms 
└─┴─┴─┴─┘Single occupancy rooms 
└─┴─┴─┴─┘Rooms with individual toilet and 

        washing facilities 

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TECHNICAL DOCUMENT 

4.1.B – Denominator data 

Variable 

Description/definition 

Beds in the facility 

Occupied beds 

Eligible residents, present at 
8:00 AM and not discharged 
at the time of the survey 

The total number of resident beds in the LTCF, both occupied and unoccupied beds. Beds shared 
by partners should be counted as two beds. 

Total number of beds occupied by residents on the day of the PPS. This figure also includes beds 
occupied by residents who are absent on the day of the PPS due to hospitalisation, on holiday or 
with family, etc. Beds shared by partners should be counted as two beds. 

Total number of residents present at 8:00 AM and not discharged at the time of the survey 

Age older than 85 

Total number of eligible residents older than 85 years on the day of the PPS. 

Male resident 

Total number of eligible male residents on the day of the PPS. 

Residents receiving at least 
one antimicrobial agent 

Total number of eligible residents receiving one or more systemic antimicrobial agents (see 4.3.2) 
on the day of the PPS. 

Residents with at least one 
infection  

Residents with any urinary 
catheter 

Total number of eligible residents with one or more infections (see 4.3.3) on the day of the PPS 

Total number of eligible residents with a urinary catheter, i.e. any tube system in place to drain 
and collect urine from the bladder, e.g. an indwelling urinary catheter, suprapubic or abdominal 
wall catheter or a cystostomy. External catheters that do not drain urine directly from the bladder 
(e.g. condom catheters) should not be included. 

Residents with any vascular 
catheter 

Total number of eligible residents with a tube system in place to access the vascular system (i.e. 
venous, arterial, arteriovenous fistulae) on the PPS day, e.g. a peripheral intravenous catheter, an 
implanted vascular access system, or any other intravascular access system. 

Residents with pressure 
sores 

Total number of eligible residents with a pressure sore on the day of the PPS. All grades of 
pressure sores should be included (e.g. the lowest grade, non-blanching erythema, characterised 
by discolouration of intact skin not affected by light finger pressure).  

Residents with other 
wounds 

Total number of eligible residents with a wound other than a pressure sore on the PPS day, 
including leg ulcers, traumatic or surgical wounds and insertion sites for percutaneous endoscopic 
gastrostomy (PEG), tracheostomy, urostomy, colostomy or suprapubic and peritoneal catheters. 

Residents disoriented in 
time and/or space 

Total number of eligible residents who suffer from periods of confusion especially relating to time, 
place or identification of persons (e.g. they cannot find their room, have no idea of time and/or 
are unable to recognise persons they know very well). 

Residents using a 
wheelchair or that are 
bedridden 

Residents with surgery in 
the previous 30 days 

Residents with urinary 
and/or faecal incontinence 

Total number of eligible residents who need a wheelchair or are bedridden on the PPS day. 

Total number of eligible residents who had surgery in the 30 days preceding the PPS. Surgery is 
defined as a procedure where an incision is made (not just a needle puncture), with breach of 
mucosa and/or skin (incl. laparoscopic approaches). The procedure does not necessarily have to 
take place in operating theatres/room, but can also take place in interventional radiology rooms, 
cardiac catheterisation rooms, endoscopic rooms etc. 

Total number of eligible residents with urinary and/or faecal incontinence (i.e. lack of control of 
the bladder or bowel sphincters resulting in an uncontrolled loss of urine or faeces) necessitating 
the use of diapers in the 24 hours prior to the PPS day (during the day and/or night). 
A resident with a urinary catheter should not be considered as incontinent for urine (this indicator 
is designed to measure work load of the LTCF staff).  

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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Figure 2. HALT-3 institutional questionnaire: Part B – Denominator data 

A – GENERAL INFORMATION ABOUT THE FACILITY 

A – GENERAL INFORMATION ABOUT THE FACILITY 
B – DENOMINATOR DATA 

This table when completed will summarize the data collected in each ward (ward list) for the total population  

IN YOUR FACILITY, ON THE DAY OF THE SURVEY, TOTAL NUMBER OF: 

BEDS IN THE FACILITY (both occupied and non-occupied beds)                 

└─┴─┴─┴─┘ 

OCCUPIED BEDS   

ELIGIBLE RESIDENTS:  

└─┴─┴─┴─┘ 

PRESENT AT 8 AM AND NOT DISCHARGED AT THE TIME OF THE SURVEY 
AGE OVER 85 YEARS 
MALE RESIDENTS   
RESIDENTS RECEIVING AT LEAST ONE ANTIMICROBIAL AGENT 
RESIDENTS WITH AT LEAST ONE INFECTION  
RESIDENTS WITH ANY URINARY CATHETER   
RESIDENTS WITH ANY VASCULAR CATHETER  
RESIDENTS WITH PRESSURE SORES  
RESIDENTS WITH OTHER WOUNDS   
RESIDENTS DISORIENTED IN TIME AND/OR SPACE 
RESIDENTS USING A WHEELCHAIR OR BEDRIDDEN 
RESIDENTS WITH SURGERY IN THE PREVIOUS 30 DAYS 
RESIDENTS WITH URINARY AND/OR FAECAL INCONTINENCE   

└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 
└─┴─┴─┴─┘ 

4.1.C – Medical care and coordination 

Variable 

Personal general 
practitioner (GP) 

GP group practice 

Description/definition 

A medical doctor, chosen by the resident, who provided medical care outside of the hospital 
environment to the LTCF resident in the years before their LTCF residence. 

GPs in one GP practice or a network of single GP practices that collaborate to attend to the 
everyday medical needs of individuals within a geographical area. 

Medical staff employed by 
the facility 

Medical doctors hired by the LTCF management to provide care to the residents. These 
physicians are not the residents’ personal GPs (see above). 

Coordinating physician  

A medical doctor in charge of the coordination of medical activities and standardisation of 
practices/policies in the facility. 

Figure 3. HALT-3 institutional questionnaire: Part C – medical care and coordination 

1. Is medical resident care, including antimicrobial prescribing, in the facility provided by the: 

□ Personal general practitioners (GP) or group practice(s) only 
□ Medical staff, employed by the facility only 
□ Both personal GPs/group practice(s) and medical doctor(s) employed by the facility 

2. Are medical activities in the facility coordinated by a coordinating medical physician (CP)? 

□ No, there is no internal or external coordination of the medical activity 
□ Yes, there is a physician from inside the facility (internal) who coordinates the medical activities 
□ Yes, there is a physician from outside the facility (external) who coordinates the medical activities 
□ Yes, there is both a physician from inside and outside the facility (internal and external) who coordinates 
the medical activities 

3. Can any of the following persons consult the medical/clinical records of all residents in the facility?  

The physician(s) in charge of medical coordination in the facility?  
The nursing staff 

□ Yes  
□ Yes  

□ No 
□ No 

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TECHNICAL DOCUMENT 

4.1.D – Infection control practice 

Variable 

Description/definition 

Infection prevention and 
control policy 

A coherent series of precautions and actions to avoid infections and transmission of pathogens 
within a population. 

Person with training in 
infection prevention and 
control  

Infection prevention and 
control (IPC) committee 

‘A registered nurse, physician, epidemiologist or medical technologist who helps to prevent 
healthcare-associated infections by isolating sources of infections and limiting their spread; 
systematically collects, analyses and interprets health data in order to plan, implement, evaluate 
and disseminate appropriate public health practices; and trains healthcare staff through 
instruction and dissemination of information on infection control practices.’ (Source: Association 
for Professionals in Infection Control and Epidemiology) 
This person can work full-time on infection control and prevention activities or combine this with 
other duties such as general nursing duty, nursing supervision, quality assurance, etc. 

A multidisciplinary committee consisting of at least the person with training in infection 
prevention and control (IPC) (IPC practitioner), the administrator, the coordinating physician (if 
present at the facility), the nursing supervisor(s) or by persons they designate. IPC committee 
members could also include quality assurance personnel, risk management personnel, 
representatives from microbiology, surgery, central sterilisation, pharmacy, environmental 
services, etc. 
The IPC committee functions may be merged with the performance improvement or patient 
safety programmes, but IPC must remain identifiable as a distinct programme. The IPC 
committee should meet regularly to review infection control data, review policies, and monitor 
programme goals and activities. Written records of meetings should be kept (Source: SHEA/APIC 
guidelines: Infection prevention and control in the LTCF, 2008). 

Litres of hand alcohol 

Total number of litres used during the course of the year preceding the PPS. 

Hand hygiene training 

Education of care professionals (i.e. nurses, nurse aides, doctors, physiotherapists, cleaning staff 
etc.), especially those new to the LTCF, on at least the importance of hand hygiene, the 
indications for hand hygiene, the technique and the products to use. 

Hand hygiene opportunities  Number of hand hygiene opportunities or indications (moments) measured as part of hand 

hygiene campaigns or audits. Only the number of observed opportunities needs to be 
recorded, not how many of these opportunities were observed to be processed correctly 
(=compliance). According to the WHO, the four moments for hand hygiene in residential 
facilities should at least include (1) before touching a patient, (2) before a clean/aseptic 
procedure, (3) after a body fluid exposure risk and (4) after touching a patient. In specialized 
LTCFs, where residents are mainly cared for in dedicated space with dedicated equipment, 
moment 5 (i.e. after touching patient surroundings) also applies [6].  

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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Figure 4. HALT-3 institutional questionnaire: Part D – infection control practice 

1. Are there persons with training in infection control/prevention available to the staff of the facility? 

□ Yes 

□ No 

2. If a person with training in infection control/prevention is available, is this person: 

□ A nurse  

□ A doctor 

□ There is both a nurse and a doctor  

Is this/are these person(s): 

□ Working in the facility (internal) 
□ Not working in the facility (external) 
□ There is both an internal and an external person 

3. In the facility, is/are there:  
(Please complete this question even if there is no person with training in infection control/prevention available in the facility) 

□ Infection prevention and control training of the nursing and paramedical staff 
□ Appropriate training of general practitioners and medical staff in infection prevention and control 
□ Development of care protocols 
□ Registration of residents colonised/infected with multi-resistant microorganisms 
□ Designation of a person responsible for reporting and management of outbreaks 
□ Feedback on surveillance results to the nursing/medical staff of the facility 
□ Supervision of disinfection and sterilisation of medical and care material 
□ Decisions on isolation & additional precautions for residents colonised with resistant microorganisms  
□ Offer of annual immunisation for flu to all residents  
□ Organisation, control, feedback on hand hygiene in the facility on a regular basis 
□ Organisation, control, feedback of a process surveillance/audit of infection policies and procedures (on regular 
basis) 
□ None of the above 

4. In the facility, is there an infection control committee (internal or external)?   

□ Yes 

□ No 

5. How many infection control committee meetings were organized in the previous year? 

Total number of meetings last year?  

└─┴─┴─┘meetings previous year 

6. Can the facility ask for help and expertise from an external infection control (IC) team on a formal basis (e.g. IC team from 
a local hospital)? 

□ Yes 

□ No 

7. In the facility, is a written protocol available for: 
-the management of MRSA and/or other multidrug resistant microorganisms 
-hand hygiene 
-the management of urinary catheters     
-the management of venous catheters/lines  
-the management of enteral feeding 

□ Yes 
□ Yes 
□ Yes 
□ Yes 
□ Yes 

□ No 
□ No 
□ No 
□ No 
□ No 

8. Is a surveillance programme of healthcare-associated infections in place in the facility? (annual summary report of number 
of urinary tract infections, respiratory tract infections, etc.)   

□ Yes 

□ No 

9. In the facility, which of following products are available for hand hygiene? 
Alcohol rub solution  
Wipes (alcohol) 
Liquid soap (antiseptic/ other) 
Bar soap in clinical areas 

□ Yes 
□ Yes 
□ Yes 
□ Yes 

□ No 
□ No 
□ No 
□ No 

10. Which hand hygiene method is most frequently used in your facility when hands are not soiled (only one answer is 
possible)? 

□ Hand disinfection with an alcohol rub solution 
□ Hand washing with water and a non antiseptic soap 
□ Hand washing with water and an antiseptic soap 

11. How many litres of alcohol rub solution for hand hygiene were used last year? 

Total annual consumption in litres 

└─┴─┴─┘ Litres last year 

12. Last year, was a hand hygiene training session organized for care professionals of the facility? 

□ Yes 

□ No 

13. How many hand hygiene opportunities were there observed in your facility last year? 

Number of observed opportunities 

└─┴─┴─┴─┴─┘ Opportunities last year 

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4.1.E – Antimicrobial policy  

Variable 

Description/definition 

Restrictive list of 
antimicrobials to be 
prescribed 

Antimicrobial committee 

A list with antimicrobial agents which are authorised for prescription, those which should not be 
used or should not be used for empiric therapy of any infection in the facility. The purpose of this 
is to preserve certain antimicrobial agents for certain culture-proven infections. In some cases 
exceptions are allowed with written motivation forms, explaining the reasons for the choice of 
that antimicrobial agent. 

This committee is in charge of the development of local guidelines and protocols for antibiotic use 
in the LTCF. The team should comprise (at least) doctors prescribing antimicrobial agents to LTCF 
residents, a pharmacist, a co-ordinating physician (if present) and an infection prevention and 
control practitioner and (if possible) a microbiologist. 

Written guidelines for 
appropriate antimicrobial 
use 

Recommendations for empirical and targeted treatment of the most frequent infections, including 
dosage, administration route and duration of treatment. Commonly a first and second therapy 
choice is proposed. 

Annual antimicrobial 
consumption 

A report on the quantity of antimicrobial agents prescribed/received during the past year, 
classified by class. 

Drug resistance profiles 

Therapeutic formulary 

Urine dipstick test 

Follow-up of the evolution of antimicrobial resistance patterns for different micro-organisms in 
order to orient the choice of antimicrobial agents for treatment. Data are obtained by surveillance 
of resistance profiles provided by microbiological protocols. 

List of eligible antimicrobial agents by illness, intended as a manual for physicians to guide their 
prescriptions. The therapeutic formulary should include a specific chapter on antimicrobial 
therapy. 

Tests performed by dipping a paper or cardboard stick into urine to test it for the presence of 
white blood cells (leukocyte esterase) and/or nitrites. Results are indicated by colour changes on 
the stick.  
This test type should not be confused with ‘dip slide’ tests performed by laboratories to test for 
the presence of microorganisms in liquids by incubating ‘dip slides’.  

14 

 
 
 
 
 
 
 
 
 
 
 
 
 
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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Figure 5. HALT-3 institutional questionnaire: Part E – antimicrobial policy   

1. Does the facility use a ‘restrictive list’ of antimicrobials to be prescribed? (prescription requiring permission of a 
designated person or not to be used) 

□ Yes  □ No 

2. If a restrictive list exists, what kinds of antibiotics are restricted?  

□ Carbapenems 
□ 3rd generation cephalosporins 
□ Fluoroquinolones 
□ Vancomycin 
□ Mupirocin 
□ Glycopeptides 
□ Broad-spectrum antibiotics 
□ Intravenously administered antibiotics 

3. Which of following elements are present in the facility? 

□ An antimicrobial committee 
□ Annual regular training on appropriate antimicrobial prescribing 
□ Written guidelines for appropriate antimicrobial use (good practice) in the facility 
□ Data available on annual antimicrobial consumption by antimicrobial class 
□ A system to remind healthcare workers of the importance of microbiological samples to inform the best 
antimicrobial choice 
□ Local (i.e. for that region/locality or national if small country) antimicrobial resistance profile summaries 
available in the LTCF or in the local General Practitioner surgeries  
□ A system that requires permission from a designated person(s) for prescribing of restricted antimicrobial, 
not included in local formulary  
□ Advice from a pharmacist for antimicrobials not included in the formulary 
□ A therapeutic formulary, comprising a list of antibiotics 
□ Feedback to the local General Practitioner on antimicrobial consumption in the facility 
□ None of the above 

4. If written therapeutic guidelines are present in the facility, are they on: 

- Respiratory tract infections?  
- Urinary tract infections? 
- Wound and soft tissue infections?    

□ Yes  □ No 
□ Yes  □ No 
□ Yes  □ No 

5. Do you perform a urine dipstick test for detection of urinary tract infections in the facility? 

□ Routinely 

□ Sometimes 

□ Never 

6. Is a programme for surveillance of antimicrobial consumption and feedback in place in the facility? 

□ Yes  □ No 

7. Is a programme for surveillance of resistant microorganisms in place in the facility? (annual summary report for 
MRSA, Clostridium difficile, etc) 
□ Yes  □ No 

8. How are antimicrobials supplied to your facility? (only one answer possible)  

□ Provided by more than one pharmacy 
□ Provided by one pharmacy only 
□ This facility does not acquire antimicrobials directly from pharmacies; antimicrobials are acquired by 

residents directly (e.g. supplied by the family)  

9. How many microbiological laboratories do you work with? (only one answer possible) 

□ More than one microbiological laboratory 
□ One single microbiological laboratory 
□ This facility does not send microbiological samples to any laboratories; each visiting general practitioner 

can work with his microbiological laboratory of choice. 

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TECHNICAL DOCUMENT 

4.1.F – How was the survey performed in your facility?  

Figure 6. HALT-3 institutional questionnaire: Part F – how was the survey performed in your facility? 

1. Who collected the HALT-3 data (incl. institutional and resident questionnaires)? 

□ A physician 
□ A nurse 
□ Another person 

2. If no physician was involved in the HALT-3 data collection (institutional and resident questionnaires), did a 
physician validate the data? 

□ Yes 

 □ No 

4.2 Ward list (see Annex 2) 

The ward list is a form (Figure 7a; Annex 2) developed to aid data collectors in the collection of denominator data for 
the institutional questionnaire (Figure 2; Annex 1). Its use is not mandatory, i.e. it is optional, for internal use only.  

Data collectors should collect information from each resident living full-time in the facility, present in the ward at 
8:00am and not discharged at the time of the survey (Figure 7a). Once these data have been collected for all wards, 
data collectors can sum the denominators from each ward (Figure 7b) and transfer these totals to the institutional 
questionnaire (Figure 2; Annex 1). Facilities that do not have different wards should only complete one ward list. 

Instructions: 

 
 

 

 
 
 

 

List all residents present on the day of the survey in columns 1 and 2. 
Add a code in column 3 that is unique for every resident in the facility. Numbers and/or letters can be used. This 
survey number should be entered on all forms for that same resident.  
If the resident meets the eligibility criteria (i.e. living full-time in the facility, present at 8am and not discharged 
at the time of the survey (see 3.2.4)), complete columns 5 to 15 by writing an ‘X’ if the risk factor or care load 
indicator is present on the day of the survey. 
Sum the Xs in each column. 
Write the totals of each column in the summary table at the end of the ward list 
Sum the totals of the summary tables in the different ward lists and report the totals in part B of the institutional 
questionnaire (Figure 2; Annex 1). 
If a resident on the ward list has an X in columns 7 and/or 8b (i.e. they were receiving at least one antimicrobial 
agent and/or had at least one infection on the day of the survey, complete a resident form for this resident 
(Annex 3) 

Figure 7a. HALT-3 ward list – collection of resident-level data 

COMPLETE THIS PART OF THE LIST 
FOR ALL RESIDENTS IN THE WARD 

COMPLETE THIS PART FOR ALL ELIGIBLE RESIDENTS (residents from 
column 4) 
Write a  X  in the column if the condition is TRUE ON THE DAY OF THE 
SURVEY 

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a
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o
s
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/
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16 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Figure 7b. HALT-3 ward list – calculation of denominators  

Use this table to add the number of ‘X’ from each column from each ward list from the facility.  

Transfer the total number into Part B of the institutional questionnaire, i.e. ‘Denominator Data’ 

On the day of the PPS, TOTAL number of: 

Column 

TOTAL NUMBERS 

Total number of beds on this ward (total bed capacity) 
Occupied beds in the ward 
Eligible residents, present at 8 AM and not discharged at time of PPS 

Age over 85 years  
Male residents 
Residents receiving at least one antimicrobial agent 
Residents with at least one infection 
Residents with any urinary catheter 
Residents with any vascular catheter 
Residents with pressure sores 
Residents with other wounds 
Residents disorientated in time and/or space 
Residents using wheelchair or being bedridden 
Residents with surgery in the previous 30 days 
Residents with urinary and/or faecal incontinence 

1 
2 
4 
5 
6 
7 
8b 
9 
10 
11a 
11b 
12 
13 
14 
15 

4.3 Resident questionnaire (see Annex 3) 

A resident questionnaire has to be completed for each resident: 

 

 

receiving at least one systemic antimicrobial agent on the day of the PPS (see 4.3.2),  
AND/OR 
presenting at least one active infection on the day of the PPS (see 4.3.3) 

The form’s questions are grouped into three sections: Resident data; ‘Part A: Antimicrobial Use’ and Part B: Healthcare-
Associated Infections’. 

4.3.1 Resident data 

Variable 

Description/definition 

Resident survey number 

Unique code assigned to the resident by the local data collectors 

Gender 

Birth year 

Gender of the resident: Male or Female 

Year the resident was born (YYYY) 

Length of stay in the facility 

The resident already has lived in the facility for EITHER less than one year OR one year or longer 

Admission to a hospital in the 
last three months 

Was the resident admitted to a hospital in the three months preceding the PPS survey date? Only 
admissions to hospitals – i.e. hospitals with at least one medical or surgical ward - for at least 
one night should be considered. 

Surgery in the previous 30 days  Did the resident undergo surgery in the 30 days preceding the PPS? Surgery is defined as a 

Urinary catheter 

Vascular catheter 

Urinary and/or faecal 
incontinence 

procedure where an incision is made (not just a needle puncture), with breach of mucosa and/or 
skin (incl. laparoscopic approaches). The procedure does not necessarily have to take place in 
operating theatres/room, but can also take place in interventional radiology rooms, cardiac 
catheterisation rooms, endoscopic rooms etc. 

Any tube system placed in the body to drain and collect urine from the bladder, e.g. an 
indwelling urinary catheter, suprapubic or abdominal wall catheter, a cystostomy. External 
catheters not draining urine directly from the bladder (e.g. condom catheters) should not be 
included. 

Any tube system placed in the body to access the vascular (venous, arterial) system, (e.g. a 
peripheral intravenous catheter, an implanted vascular access system or any other intravascular 
access system (including arteriovenous fistulae).  

Lack of control of the sphincter from bladder or bowel resulting in an uncontrolled loss of urine or 
faeces and necessitating the use of diapers in the 24 hours prior to the PPS day (during the day 
and/or night). 
A resident with a urinary catheter should not be considered as incontinent for urine. 

Pressure sores 

All grades of pressure sores should be considered, even the lowest grade characterised by 
discolouration of intact skin not affected by light finger pressure (non-blanching erythema)  

17 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

Variable 

Other wounds 

Description/definition 

All wounds other than a pressure sore, including leg ulcers, traumatic or surgical wounds and 
insertion sites for percutaneous endoscopic gastrostomy, tracheostomy, urostomy, colostomy or 
suprapubic and peritoneal catheters. 

Disoriented in time and/or space  Residents who suffer from periods of confusion especially as to time, place or identification of 

persons (e.g. cognitive impairment).  

Mobility 

In general, is the resident ambulant (he/she can walk alone with or without canes, crutches, 
walkers, etc), does he/she need a wheelchair for his/her movement or is he/she bedridden on 
the PPS day? 

Figure 8. HALT-3 resident questionnaire: resident data 

GENDER 
BIRTH YEAR 
LENGTH OF STAY IN THE FACILITY 
ADMISSION TO A HOSPITAL 
    IN THE LAST 3 MONTHS 
SURGERY IN THE PREVIOUS 30 DAYS 
PRESENCE OF: 
URINARY CATHETER 
VASCULAR CATHETER 
INCONTINENCE 
    (URINARY AND/OR FAECAL) 
WOUNDS 
- 
- 

PRESSURE SORE 
OTHER WOUNDS 

DISORIENTATION 
     (IN TIME AND/OR SPACE) 
MOBILITY 

RESIDENT DATA 

 Male 

 Female 

 (YYYY) 

 Less than one year 

 One year or longer 

 Yes 

 Yes 

 Yes 
 Yes 

 Yes 

 Yes 
 Yes 

 Yes 

 No 

 No 

 No 
 No 

 No 

 No 
 No  

 No 

 Ambulant 

 Wheelchair 

 Bedridden 

4.3.2 Antimicrobial use data 

The following antimicrobial agents should be included if their route of administration is oral, parenteral (intravenous), 
intramuscular, subcutaneous, inhalation or rectally:  

 
 
 
 

antibacterial (ATC level J01), antimycotics (J02) and antifungals (D01BA) for systemic use  
antibiotics used as intestinal antiinfectives (A07AA)  
antiprotozoals (P01AB) 
antimycobacterials (J04) when used for treatment of mycobacteria including tuberculosis or as reserve treatment 
for multidrug-resistant bacteria 

The following antimicrobial agents should be excluded: 

 

Antiviral agents for systemic use; preparations of antimicrobial agents for topical use; antiseptic agents 

18 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Collect the following information for each antimicrobial agent the resident receives on the day of the survey:   

Variable 

Description/definition 

Antimicrobial name 

Administration route 

Generic or brand name of the antimicrobial. These names should be converted to ATC5 codes by 
the national survey coordinator.  

Route of administration of the antimicrobial agent; oral, parenteral (intravenous (IV), 
intramuscular (IM) or subcutaneous (SC)) or other (e.g. rectal, inhalation). 

End date/review date of 
treatment know 

The resident’s medical or nursing records clearly state the final date when the antimicrobial 
agents should be given (end date) or when the antimicrobial agents treatment should be revised 
by the prescriber (review date). 

Type of treatment 

Indication for antimicrobial use. 

Prophylactic Antimicrobial agents prescribed to prevent an infection.  

The resident presented no signs/symptoms of an infection when the antimicrobial agent(s) was 
prescribed. 

Therapeutic   Antimicrobial agents prescribed to treat an infection.  

The resident presented signs/symptoms of an infection when the treatment was prescribed. Both 
empirical treatments (i.e. initiation of treatment before the causative pathogen is known) and 
microbiologically-documented treatments (i.e. with known pathogen known) should be 
considered. 

Antimicrobial given for 

Diagnosis group by anatomical site. 

Where prescribed 

Place where the antimicrobial was prescribed: In this facility (LTCF), in the hospital or elsewhere. 

Figure 9. HALT-3 resident questionnaire: Part A – Antimicrobial use 

ANTIMICROBIAL NAME 

ADMINISTRATION ROUTE 

PARENTERAL = IM, IV OR SC 
END DATE / REVIEW DATE OF 
TREATMENT KNOWN? 
TYPE OF  TREATMENT 

ANTIMICROBIAL GIVEN FOR 

WHERE PRESCRIBED? 

PART A: ANTIMICROBIAL USE 

ANTIMICROBIAL 1 

ANTIMICROBIAL 2 

ANTIMICROBIAL 3 

ANTIMICROBIAL 4 

……………………… 
  Oral 
  Parenteral  
  Other 
  No      Yes 

……………………… 
  Oral 
  Parenteral  
  Other 
  No      Yes 

……………………… 
  Oral 
  Parenteral  
  Other 
  No      Yes 

……………………… 
  Oral 
  Parenteral  
  Other 
  No      Yes 

  Prophylactic 
  Therapeutic 
  Urinary tract 
  Genital tract 
  Skin or wound  
  Respiratory tract 
  Gastrointestinal 
  Eye 
  Ear, nose, mouth 
  Surgical site  
  Tuberculosis 
  Systemic infection  
  Unexplained fever  
  Other (specify) 
……………………… 
  In this facility 
  In the hospital 
  Elsewhere 

  Prophylactic 
  Therapeutic 
  Urinary tract 
  Genital tract 
  Skin or wound  
  Respiratory tract 
  Gastrointestinal 
  Eye 
  Ear, nose, mouth 
  Surgical site  
  Tuberculosis 
  Systemic infection  
  Unexplained fever  
  Other (specify) 
……………………… 
  In this facility 
  In the hospital 
  Elsewhere 

  Prophylactic 
  Therapeutic 
  Urinary tract 
  Genital tract 
  Skin or wound  
  Respiratory tract 
  Gastrointestinal 
  Eye 
  Ear, nose, mouth 
  Surgical site  
  Tuberculosis 
  Systemic infection  
  Unexplained fever  
  Other (specify) 
……………………… 
  In this facility 
  In the hospital 
  Elsewhere 

  Prophylactic 
  Therapeutic 
  Urinary tract 
  Genital tract 
  Skin or wound  
  Respiratory tract 
  Gastrointestinal 
  Eye 
  Ear, nose, mouth 
  Surgical site  
  Tuberculosis 
  Systemic infection  
  Unexplained fever  
  Other (specify) 
……………………… 
  In this facility 
  In the hospital 
  Elsewhere 

19 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

4.3.3 Infection data 

Recorded the following information for each infection identified using the decision algorithm (see 4.3.3.2 and Annex 4):   

Variable 

Description/definition 

Infection code 

See 4.3.3.1 and 4.3.3.2 

If ‘OTHER’, please specify 

If infection code=’OTHER’, please provide more information on the type of infection 

Infection present at (re-) 
admission 

Date of onset 

Origin of the infection 

Yes = signs/symptoms of the infection were present at admission or re-admission to the LTCF 

Date of onset of the infection (dd/mm/yyyy).  
Not to be recorded if signs/symptoms are present at admission, but should be completed if onset 
during current stay in the LTCF. 
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 the date of onset. 

See 4.3.3.3 
Infection is associated with either (1) current LTCF stay; (2) stay in another LTCF; (3) hospital 
stay or (4) unknown.  

Figure 10. HALT-3 resident questionnaire: Part B – Healthcare-associated infections 

PART B: HEALTHCARE-ASSOCIATED INFECTIONS 
INFECTION 3 
INFECTION 2 

INFECTION 1 

INFECTION 4 

INFECTION CODE 

IF ‘OTHER’, PLEASE SPECIFY 
PRESENT AT (RE-)ADMISSION  

……………………… 
  No      Yes 

………………………. 
  No      Yes 

……………………… 
  No      Yes 

……………………… 
  No      Yes 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

DATE OF ONSET (DD/MM/YY) 

ORIGIN OF INFECTION 

A. NAME OF ISOLATED 
MICROORGANISM 
(PLEASE USE CODE 
LIST) 

B. TESTED 
ANTIMICROBIAL(S) AND 
RESISTANCE 

ONLY FOR STAAUR, 
ENC***,  ACIBAU, 
PSEAER OR 

ENTEROBACTERIACEAE 
(CIT***, ENB***, 
ESCCOL, KLE***, 
MOGSPP, PRT***, 
SER***) 

1. A 

B 

2. A 

B 

3. A 

B 

└─┴─┘/└─┴─┘/└─┴─┘  └─┴─┘/└─┴─┘/└─┴─┘  └─┴─┘/└─┴─┘/└─┴─┘  └─┴─┘/└─┴─┘/└─┴─┘ 
  Current LTCF 
  Other LTCF 
  Hospital 
  Unknown 

  Current LTCF 
  Other LTCF 
  Hospital 
  Unknown 

  Current LTCF 
  Other LTCF 
  Hospital 
  Unknown 

  Current LTCF 
  Other LTCF 
  Hospital 
  Unknown 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

1Tested antibiotic(s): STAAUR: oxacillin (OXA) or glycopeptides (GLY); ENC***:  GLY only; Enterobacteriaceae: 3rd-gen cephalosporins 
(C3G) or carbapenems (CAR); PSEAER and ACIBAU: CAR only. 2 Resistance: S=sensitive, I=intermediate, R=resistant, U=unknown 

20 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

4.3.3.1 ‘Active healthcare-associated infections’ 
Data collectors must identify residents presenting signs and/or symptoms of an active infection on the day of the PPS. 
An active healthcare-associated infection (associated with a stay in a healthcare facility, e.g. LTCF or hospital) is defined 
as: 

A. signs/symptoms of the infection: 

are present on the survey date AND are new or acutely worse a  
OR  
were present in the two weeks (14 days) prior to the PPS AND were new or acutely worse a AND the resident is 
(still) receiving treatment for that infection on the survey date b  

 

 

AND 

B. the onset of symptoms occurred: 

 

 

more than 48 hours (i.e. day 3 onwards) after the resident was (re-)admitted to the current LTCF  
OR 
less than 48 hours (i.e. present on admission, on day of admission, or on day 2) after the resident was 
(re-)admitted to the current LTCF from another healthcare facility (e.g. LTCF or hospital) 

 

 

 

OR 
deep and organ/space surgical site infections occurring less than 90 days after implant surgery 
OR 
other surgical site infections occurring less than 30 days after an operation  
OR 
Clostridium difficile infections occurring less than 28 days after discharge from a healthcare facility (e.g. 
LTCF or hospital). 

Notes: a. Chronic symptoms, such as cough or urinary urgency, are commonly not associated with infection. Non-infectious causes 
should always be considered before a diagnosis of infection is made. A change in the resident’s status is an important indication that 
an infection is in development.  

b. If these signs/symptoms met a case definition for a HAI, that HAI should be recorded on the resident form. Data collectors should 
investigate the signs/symptoms in the preceding two weeks, e.g. from patient records or by consulting the resident’s physician, if 
practicable. 

21 

 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

4.3.3.2 Identifying the infection code using the decision algorithms (Annex 4) 

Figure 11. HALT-3 infection decision algorithms (page 1 of 6) 

Healthcare-associated infections and antimicrobial use 
in European long-term care facilities (HALT-3) 

CASE DEFINITIONS OF INFECTIONS 

IMPORTANT REMARK: All active infections present on the day of the survey should be reported. An infection is active 
when signs/symptoms of the infection are present on the survey date OR signs/symptoms were present in the past and 
the resident is (still) receiving treatment for that infection on the survey date. The presence of symptoms and signs in 
the two weeks (14 days) preceding the PPS day should be verified in order to determine whether the treated infection 
matches one of the case definitions. Infections can only be reported as ‘imported’ for residents recently transferred 
from another healthcare facility (i.e. hospital or other LTCF) and still treated for an infection on the PPS day in the 
absence of documentation on (all) signs/symptoms that were present in the past. 

* 

** 
§ 

§§ 

Fever: 1) single > 37.8°C oral/tympanic membrane or 2) repeated > 37.2°C oral or > 37.5°C rectal or 3) > 1.1°Cover 
baseline from any site (oral, tympanic, axillary) 
Leucocytosis: 1) Neutrophilia > 14,000 leucocytes/mm3 or 2) left shift (>6% bands or ≥ 1500 bands/mm3) 
Acute change in mental status from baseline: Acute onset + fluctuating course + inattention AND either disorganized 
thinking or altered level of consciousness 
Acute functional decline: New 3 point increase in total ADL score (Range 0-28) from baseline based on 7 ADL items (bed 
mobility, transfer, locomotion, dressing, toilet use, personal hygiene, eating) each scored from 0 (independent) - 4 (total 
dependence) OR increased dependency defined by scales other than ADL 

URINARY TRACT INFECTIONS 

 Resident without a urinary catheter 

 Resident with a urinary catheter 

SIGNS/SYMPTOMS 

SIGNS/SYMPTOMS 

AT LEAST ONE OF THE FOLLOWING (,  or ) CRITERIA: 
  Acute dysuria  OR  acute pain/swelling or tenderness of 

the testes, epididymis, or prostate 

  Fever* OR leukocytosis** 

         AND             

One or more of the following: 
 Acute costovertebral angle pain 
 Suprapubic pain/tenderness 
 Gross hematuria 
 New or marked increase in frequency 
 New or marked increase in urgency 
 New or marked increase in incontinence 

  Two or more (in the absence of fever or leucocytosis):   

 Frequency (new/increased)                 Suprapubic pain 

 Incontinence (new/increased) 

      Gross hematuria 

URINE CULTURE 

 Not Done, negative or test results unknown 
 Urine culture done AND: 

 At least 105 cfu/ml of no more than 2 species of micro-

organisms in a voided urine sample  

OR 

 At least 102 cfu/ml of any number of organisms in a 

specimen collected by in-and-out catheter 

INFECTION CONFIRMATION 

AT LEAST ONE OF THE FOLLOWING (, ,  or ) 
CRITERIA: 
  Fever*, rigors, OR new onset hypotension with NO 

alternate site of infection    

  Acute change mental status § OR acute functional 

decline §§ with NO alternate diagnosis AND 
leukocytosis**    

  New onset suprapubic or costovertebral angle pain or 

tenderness  

  Purulent discharge around catheter or acute pain, 

swelling or tenderness of testes, epididymis, or prostate    

URINE CULTURE 

 Not done, negative or test results unknown 
 Urine culture done AND: 

 At least 105 cfu/ml of any organism(s) in a urinary 

catheter specimen 





INFECTION CONFIRMED  (= UTI-C) 
Signs/symptoms AND urine culture positive:  
INFECTION PROBABLE      (= UTI-P) 
Signs/symptoms AND urine culture not done, negative or results unknown: 
Infection treated on PPS day but no documentation of signs/symptoms           INFECTION IMPORTED      (= UTI-I) 
(hospital or other LTCF infections only) 

22 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

By comparing eligible resident’s signs/symptoms with those listed in the decision algorithms (Annex 5), data collectors 
will see whether or not enough signs/symptoms are present to confirm an infection and will enter the relevant code(s) 
onto Part B of the resident questionnaire within ‘infection code’. Therefore, exhaustive searching for signs/symptoms 
present in residents is crucial. 

The decision algorithms used in this survey are based on clinical criteria, i.e. CDC/SHEA case definitions [7] which in 
turn are based on the McGeer [8] criteria for the surveillance of infections in LTCFs.  

Only results of tests/examinations that are available on the survey date should be considered when establishing 
whether the case definition criteria are fulfilled. Those that are available after the day of the survey should not be 
considered. Although this will result in some underestimation of the true number of HAI cases, it will ensure 
comparability between all participating LTCFs and countries.  

It may be difficult to locate sufficient documentation of past signs/symptoms in residents who were recently transferred 
from another healthcare facility (e.g. hospital or other LTCF) and are still receiving treatment (including but not limited 
to antimicrobial agents). In such cases, the recollection of other LTCF staff members is a sufficient alternative to the 
use of the case definition algorithms. If none have knowledge of the resident’s signs/symptoms (i.e. the condition of 
the resident prior to (re)admission), then the HAI can be reported as an ‘imported’ infection (infection code + “-I”) 
without having to meet the HAI case definitions (Annex 5). 

As European LTCFs have more limited access to microbiological and laboratory tests than institutions in Canada and the 
United States of America [7], the case definition for urinary tract infections has two levels: ‘probable’ and ‘confirmed’. 

Healthcare-associated infection codes 

Infection 

Level 

Infection code 

Urinary tract infections (UTIs) 

Confirmed / Probable / Imported 

UTI-C / UTI-P / UTI-I 

Respiratory tract infections (RTIs) 
•  Common cold syndromes/pharyngitis 
•  Influenza-like illness (‘Flu’) 
•  Pneumonia  
•  Other lower RTI 

Surgical site infections (SSIs) 
  Superficial incisional SSI 
  Deep incisional SSI 
  Organ/space SSI 

Skin infections 
•  Cellulitis/soft tissue/wound infection  
•  Scabies  
•  Herpes simplex or herpes zoster infection  
•  Fungal infection 

Gastrointestinal tract infections 
•  Gastroenteritis 
•  Clostridium difficile infection 

Eye, ear, nose and mouth infections 
•  Conjunctivitis 
•  Ear infection 
•  Sinusitis 
•  Mouth infection or oral candidiasis 

Bloodstream infections 

Unexplained febrile episode 

Other infection(s) 

Confirmed / Imported 
Confirmed / Imported 
Confirmed / Imported 
Confirmed / Imported 

Confirmed / Imported 
Confirmed / Imported 
Confirmed / Imported 

Confirmed / Imported 
Confirmed / Imported 
Confirmed / Imported 
Confirmed / Imported 

Confirmed / Imported 
Confirmed / Imported 

Confirmed / Imported 
Confirmed / Imported 
Confirmed / Imported 
Confirmed / Imported 

Confirmed / Imported 

Confirmed / Imported 

COLD-C / COLD-I 
FLU-C / FLU-I 
PNEU-C / PNEU-I 
LRTI-C / LRTI-I 

SSSI-C / SSSI-I 
DSSI-C / DSSI-I 
OSSI-C / OSSI-I 

SKIN-C / SKIN-I 
SCAB-C / SCAB-I 
HERP-C / HERP-I 
FUNG-C / FUNG-I 

GE-C / GE-I 
CDI-C / CDI-I 

CONJ-C / CONJ-I 
EAR-C / EAR-I 
SINU-C / SINU-I 
ORAL-CORAL-I 

BSI-C / BSI-I 

FUO-C / FUO-I 

OTHER 

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Definitions of key terms used in the decision algorithms (Annex 4) 

Key terms 

Fever 

Leucocytosis 

Description/definition 

1.Single >37.8°C oral/tympanic membrane* OR 2. Repeated >37.2°C oral or >37.5°C rectal 
OR 3. >1.1°C over baseline from any site (oral, tympanic, axillary) 
* tympanic membrane = membrane that separates the external ear from the middle ear. 
1. Neutrophilia > 14 000 leucocytes/mm3 OR 2. left shift (>6% bands or ≥ 1500 bands/mm³) 
{Stone, 2012 #113} 

Acute change in mental status 

Acute onset + fluctuating course + inattention AND either disorganised thinking or altered 
level of consciousness 

Acute functional decline 

New three-point increase in total ADL score (Range 0–28) from baseline based on seven ADL 
items (bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, eating) each 
scored from 0 (independent) to 4 (total dependence) OR increased dependency defined by 
scales other than ADL 

Urinary tract infection  

Can be an infection of the kidney, ureter, bladder or urethra 

Costovertebral angle pain 

Pain in the area of the back overlying the kidney (between the 12th rib and the spine) 

Suprapubic pain/tenderness 

Pain or tenderness in the area above the pubis 

Respiratory tract infection  

Can be an infection of the upper or lower respiratory tract 

Upper respiratory tract infection 

Infection of the (naso-)pharynx ((naso-)pharyngitis) or tonsils (tonsillitis) 

Lower respiratory tract infection 

Infection of the trachea and bronchus (bronchitis), bronchiole (bronchiolitis) or lung and 
alveoli (pneumonia) 

Lymphadenopathy 

Disease of the lymph nodes (swollen or enlarged) 

Infiltrate 

Sputum 

Pleuritic chest pain 

Deposition of fluid (e.g. blood, pus, etc.) in tissues and cells 

Secretion expectorated from the lower respiratory tract (not to be confused with saliva) 

Pain in the chest during inhalation which can cause fast and superficial breathing to decrease 
the pain 

Surgical site infections (SSIs) 

Infections occurring within 30 days after the operation if no implant is left in place, or deep 
and organ/space infections within three months if implant is still in place 

Superficial incisional SSI 

Infection involves only skin and subcutaneous tissue of the incision 

Deep incisional SSI 

Organ/space SSI 

Skin infections 

Cellulitis 

Soft tissues 

Maculopapular rash 

Herpes simplex 

Herpes zoster 

Infection appears to be related to the operation and infection involves deep soft tissue (e.g. 
fascia, muscle) of the incision 

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 

Infection of the connective tissue 

Tissues that connect support or surround other structures or organs (muscles, tendons, 
ligaments, nerves, blood vessels, fat, fibrous tissues, fascia and membranes) 

Rash characterised by spots and bumps 

Disease caused by a virus leading to a rash (often around the lips and nose) with groups of 
blisters containing fluid which soon dry out 

Disease caused by a virus; mostly painful blister-shaped rash in areas where many sensory 
nerves are present (e.g. face, chest, shoulders and hip) 

Scabies 

Contagious and heavy itching disease of the skin caused by a mite 

Gastrointestinal infection 

Infection of the stomach and/or intestines 

Clostridium difficile (CD) 

Toxic megacolon 

C. difficile (gram-positive sporulating bacilli); can cause persistent diarrhoea and ulcero-
haemorrhagic colitis 

Life-threatening complication that causes widening (dilation) of the large intestine and 
symptoms such as abdominal pain, distension, tenderness, fever, rapid heart rate and can 
even lead to shock 

Pseudomembranous colitis 

A cause of antibiotic-associated diarrhoea (often caused by C. difficile) characterised by 
abdominal cramps, bloody stools, fever and diarrhoea 

Eye infection 

Conjunctival erythema 

Redness of the conjunctiva (mucous membrane lining the eyelid) 

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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

4.3.3.3 Identifying the origin of infection  
The following diagrams are designed to facilitate the allocation of residents with an ‘active HAI’ to one of the four 
categories of ‘origin of the infection’.   

NOTE: 

 

 

 

 

A HAI is associated with the current LTCF if the infection started on day 3 or later after (re-)admission to the 
current LTCF (where the date of admission to the LTCF is day 1). 
According to the definition of an ‘active HAI’, infections that started on day 1 or 2 (2 calendar days) should be 
excluded if the resident is (re-)admitted to the LTCF after a community-stay 
A surgical site infection is associated with a hospital if the SSI occurred within 30 days after an operation where 
no implant was left in place, or within 90 days for deep and organ/space SSI after an operation where an 
implant was left in place. 
Clostridium difficile infections can be associated to a hospital or other LTCF if the onset of the signs/symptoms 
occurred within 28 days after (re)admission from that hospital or other LTCF. 

25 

 
 
 
 
 
 
 
 
 
 
 
 
 
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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

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4.3.4 Isolated microorganism and antimicrobial resistance (see Annex 5) 

Data on the isolated microorganism and antimicrobial resistance are collected in Part B – Healthcare-associated 
infections of the resident questionnaire. It is recognised that there is a low frequency of laboratory testing of clinical 
samples from LTCFs in Europe, and differences between the antimicrobial susceptibility testing protocols used by those 
laboratories. 

Collect microbiological results available on the survey date (do not wait for results that are unavailable on the survey 
date). Specify up to three isolated microorganisms, using the microorganism code list (Annex 4). If no microbiological 
result is available on the day of the PPS, one of the following options should be selected:   

_NOEXA 

EXAMINATION NOT DONE 

No diagnostic sample taken, no microbiological examination done 

_NA 

RESULTS NOT AVAILABLE 

_NONID 

MICROORGANISM NOT IDENTIFIED 

_STERI 

STERILE EXAMINATION 

The results of the microbiological examination are not (yet) available or 
cannot be found 

Evidence exists that a microbiological examination has been done, but the 
microorganism cannot be correctly classified 

A microbiological examination has been done, but the result was negative 
(e.g. negative culture) 

Five groups of selected bacteria (highlighted in red in the microorganism code list) should have their antimicrobial 
resistance reported according to their resistance profile as indicated in the table below. 

Antimicrobial resistance codes and profiles 

Microorganism 

Tested antibiotic 

Antimicrobial resistance 

Staphylococcus aureus 
(STAAUR) 

Enterococcus species 
(ENC***) 
Enterobacteriaceae1, including: 
Escherichia coli (ESCCOL) 
Klebsiella species (KLE***) 
Enterobacter species (ENB***) 
Proteus species (PRT***) 
Citrobacter species (CIT***) 
Serratia species (SER***) 
Morganella species  (MOGSPP) 

Pseudomonas aeruginosa 
(PSEAER) 

Acinetobacter baumannii 
(ACIBAU) 

Oxacillin (OXA) 

Susceptible (S) 

–    

Resistant (R)  Unknown (U) 

Glycopeptides (GLY) 

Susceptible (S) 

Intermediate (I)  Resistant (R)  Unknown (U) 

Glycopeptides (GLY) 

Susceptible (S) 

Intermediate (I)  Resistant (R)  Unknown (U) 

Third-generation 
cephalosporins (C3G) 

Susceptible (S) 

Intermediate (I)  Resistant (R)  Unknown (U) 

Carbapenems (CAR) 

Susceptible (S) 

Intermediate (I)  Resistant (R)  Unknown (U) 

Carbapenems (CAR) 

Susceptible (S) 

Intermediate (I)  Resistant (R)  Unknown (U) 

Carbapenems (CAR) 

Susceptible (S) 

Intermediate (I)  Resistant (R)  Unknown (U) 

1 Antimicrobial resistance markers are not collected for other Enterobacteriaceae (e.g. Hafnia spp., Salmonella spp., Shigella spp., 
Yersinia spp.)  
OXA: susceptibility to oxacillin, or other marker of meticillin-resistant S. aureus (MRSA), such as cefoxitin, cloxacillin, dicloxacillin, 
flucloxacillin, meticillin;  
GLY: susceptibility to glycopeptides: vancomycin or teicoplanin;  
C3G: susceptibility to third-generation cephalosporins: cefotaxime, ceftriaxone, ceftazidime;  
CAR: susceptibility to carbapenems: imipenem, meropenem, doripenem.  

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Figure 12. HALT-3 resident questionnaire: Part B – Healthcare-associated infections – isolated 
microorganism and its antimicrobial resistance 

A. NAME OF ISOLATED 
MICROORGANISM 
(PLEASE USE CODE 
LIST) 

B. TESTED 
ANTIMICROBIAL(S) AND 
RESISTANCE 

ONLY FOR STAAUR, 
ENC***,  ACIBAU, 
PSEAER OR 
ENTEROBACTERIACEAE 
(CIT***, ENB***, 
ESCCOL, KLE***, 
MOGSPP, PRT***, 
SER***) 

1. A 

B 

2. A 

B 

3. A 

B 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

1Tested antibiotic(s): STAAUR: oxacillin (OXA) or glycopeptides (GLY); ENC***:  GLY only; Enterobacteriaceae: 3rd-gen cephalosporins 
(C3G) or carbapenems (CAR); PSEAER and ACIBAU: CAR only. 2 Resistance: S=sensitive, I=intermediate, R=resistant, U=unknown 

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TECHNICAL DOCUMENT 

5. Data delivery 

5.1 Software 

A stand-alone software programme developed for the HALT-3 project may be used for data entry at local (LTCF 
application) or national (NSC application) level. National survey coordinators (NSCs) are encouraged to offer this 
software to LTCFs so they can enter their data into the software. A user guide provided with the application assists the 
local data collector or person designated in the LTCF during software installation and data entry.  

Once all data for an LTCF are entered into the software, a summary report with preliminary results can be automatically 
generated for that LTCF.  

All data are stored on the local computer rather than a central database. Therefore data need to be exported. By 
clicking on this function in the menu, a zip file will be created that can be sent to the NSC. 

NSCs either import all zip files received from their participating LTCFs into the software, or enter the data into the NSC 
(‘national coordination’) application themselves. NSCs can use their application to view all national data and check for 
errors. If needed, changes should be made using the software (rather than directly on the database file) and ATC codes 
can be added for the antimicrobial agents. The NSC application also allows NSCs to generate (new) LTCF summary 
reports. Once all data is checked, NSCs should create a national database using the software’s export function. 

On request, the software can be delivered in a language other than English. To achieve this, NSCs should contact ECDC 
at HAI-Net@ecdc.europa.eu and subsequently arrange to translate text in an Excel file.  

ECDC can be contacted at HAI-Net@ecdc.europa.eu regarding any problems encountered during use of the software. 

5.2 Deadline for data delivery 

The national databases should, in each Member State, be sent to the country institution designated by the country’s 
Coordinating Competent Body5. These institutions are then requested to upload the data to the European Surveillance 
System (TESSy) at ECDC, according to the same methodology used for other communicable diseases and related 
special health issues within Decision 1082/2013/EU6. The deadlines for data submission will be communicated to 
participating NSCs by ECDC. 

5.3 Data analysis and feedback 

The European database, containing data from all national databases, will be checked for errors and inconsistencies by 
ECDC. Individual feedback reports (in English) will be generated for each participating LTCF and sent to the NSC for 
further distribution (e.g. to each participating LTCF). ECDC can be contacted at HAI-Net@ecdc.europa.eu to request 
translated LTCF feedback reports, which will require the NSC to arrange translation of text in an Excel file. 

A European report will be prepared using aggregated results, sent to NSCs from each participating country for 
verification and subsequently published on the ECDC website. 

5.4 Data ownership 

NSCs are encouraged to publish their data in international peer-reviewed journals and/or present their results at 
international conferences. The work done by the NSCs and the LTCFs should be acknowledged, e.g. by adding ‘on 
behalf of the national networks’ to the author list and/or by thanking all NSCs by name in the acknowledgements 
section. ECDC should be acknowledged in all scientific publications (including posters and oral communications).  

All analyses and outputs, including data other than their own country’s data, should be performed in consultation and in 
agreement with ECDC. All scientific outputs should be communicated to ECDC in advance of publication; these may be 
referred to on the ECDC website, and/or in other public outputs.  

5 European Centre for Disease Prevention and Control. Information on the Competent Bodies. 
http://ecdc.europa.eu/en/aboutus/Competent%20bodies/Pages/Competent_bodies.aspx 
6 DECISION No 1082/2013/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 22 October 2013 on serious cross-border 
threats to health and repealing Decision No 2119/98/EC 

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Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

6. Training 

A train-the-trainer workshop was held during the first HAI-HALT network meeting (December 2015) in Stockholm, 
Sweden attended by nominated persons from 26 EU/EEA Member States. Training material for the local/external data 
collectors is available from ECDC. It is recommended that national/regional survey coordinators organise at least one 
one-day information and training session for LTCFs participating in the PPS prior to the national/regional survey. 

7. On-site assessments of IPC situation and 
needs including a validation survey 

In collaboration with the advisory committee, the project coordination group developed a methodology to: 

 

 

collect additional qualitative information on the infection prevention and control needs and challenges in LTCFs 
to allow better interpretation of the structured information collected at the institutional level during the survey, 
and on the effect of repeated point prevalence surveys of HAIs and antimicrobial use in LTCFs at national and 
local level 
perform a qualitative assessment of the validity of the survey data collected in the country, with special 
emphasis on the method of case ascertainment, diagnostic capacity in LTCFs, access to available data sources 
during the survey including the availability of microbiological results, implementation of case definitions for HAIs 
in LTCFs and validity of reported structure and process indicators on infection prevention and control and 
antimicrobial stewardship. 

EU/EEA Member States participating to the 2016–2017 PPS will be asked to participate in the on-site assessment (a 
two-day visit).  

Together with an expert, designated by the project coordination group, the national/regional PPS coordination teams 
are to meet with representatives of at least one LTCF and: 

 
 

perform a structured qualitative assessment according to the on-site assessment methodology [5] 
implement the validation methodology [4]. 

A short report of each country visit will be produced by the project coordination group and shared with the country. The 
information collected during the on-site assessments and validation survey will be put in databases and analysed. For 
more information see ‘on-site assessment and validation protocol’, available from HAI-Net@ecdc.europa.eu [5].  

8. Role of the national survey coordinator 

National survey coordinators (NSCs) are crucial determinants of the success of repeated PPSs.  

Their tasks before PPS data collection include the following: 

 
 
 
 
 
 
 

select and invite LTCFs to participate, including LTCFs to participate in the validation survey 
make a list of all participating LTCFs and to group them by LTCF type 
participate in the train-the-trainer workshop held during the first HAI-HALT network meeting 2015 
organise at least a one-day information and training session for LTCFs participating in PPS 
distribute the data collection tools (e.g. HALT software) 
assist LTCFs during data collection (helpdesk) 
(if required) translate PPS data collection tools and letters into national languages. 

Their tasks after PPS data collection include the following: 

 
 

 

 

collect and enter local LTCF data and check the national database 
export the national database and submit the data to ECDC. ECDC will convert the HALT data to the HAIHALT 
TESSy format. Data will be pre-uploaded in TESSy by ECDC, and EU Member States will receive the converted 
national data in TESSy format from ECDC to identify any necessary data updates/replacement 
distribute the feedback forms to the participating LTCF, translation of these is possible if the national 
representative provides a translated Excel file 
communicate national results, e.g. at (inter)national scientific meetings. 

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9. Ethical considerations 

Member States will have different requirements for ethical approval for a PPS in LTCFs. The experience from the HALT 
(2010) and HALT-2 (2013) projects is that some countries required approval from an ethics committee. Some of the 
committees requested that written consent be obtained from each resident with a HAI or receiving an antimicrobial 
agent on the day of the PPS, or if not possible (e.g. in case of cognitive impairment) from a ‘proxy’ such as a carer or a 
medical professional. Data collectors in these Member States found that it was relatively feasible to acquire the 
signatures, as simply explaining the necessity of the PPS to the resident or their ‘proxy’ was sufficient.  

Confidentiality of LTCF data and resident data is assured by: 

 

 

NSCs attributing an LTCF survey number to each participating LTCF. The participating LTCFs will not be 
identifiable by other LTCFs/persons since all reports and presentations will only use LTCF survey numbers and 
never LTCF names. The key to the LTCF names from the LTCF survey number will not be sent to ECDC.   
A unique resident survey number will be allocated to each resident for whom a questionnaire is completed. 
Patient identifiers are not stored in the software and should not be written on the data collection forms. 

The ward list (optional, for internal use) for the primary HALT-3 PPS protocol includes resident identifiers. It must be 
kept in the LTCF in a secure and confidential manner and should be destroyed at the end of the HALT-3 project, i.e. 
December 2018.  

Data collected within the framework of the HALT-3 project should not be used for purposes other than those described 
in the objectives of the present protocol.  

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10. References  

1. 

2. 

3. 

4. 

5. 

6. 

7.  

8.  

European Commission (DG SANCO). Improving Patient Safety in Europe Technical Implementation Report 2005-2008. ISPE, 
November 2008. Available from: http://ecdc.europa.eu/en/healthtopics/Healthcare-associated_infections/HAI-
Net/Documents/healthcare-associated-infections-IPSE-Technical-Report.pdf  

European Centre for Disease Prevention and Control (ECDC). Point prevalence survey of healthcare-associated infections and 
antimicrobial use in European long-term care facilities. May–September 2010. Stockholm: ECDC. 2014. 

European Centre for Disease Prevention and Control (ECDC). Point prevalence survey of healthcare-associated infections and 
antimicrobial use in European long-term care facilities. April–May 2013. Stockholm: ECDC. 2014. 

European Centre for Disease Prevention and Control (ECDC). Protocol for validation of point prevalence surveys of 
healthcare-associated infections and antimicrobial use in European long-term care facilities. 2016 – 2017. Version v1.1. 
Stockholm: ECDC. 2016. 

European Centre for Disease Prevention and Control (ECDC). Protocol for national onsite assessment during the HALT-3 
project. 2016-2017. Stockholm: ECDC. 2016. 

World Health Organization. Hand hygiene in outpatient and home-based care and long-term care facilities: a guide to the 
application of the WHO multimodal hand hygiene improvement strategy and the “My Five Moments For Hand Hygiene” 
approach. 2012. Available here: http://www.who.int/gpsc/5may/EN_GPSC1_PSP_HH_Outpatient_care/en/. 

Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, et al; for the Society for Healthcare Epidemiology Long-Term 
Care Special Interest Group. Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria. 
Infect Control Hosp Epidemiol. 2012;10:965-977. 

McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, et al.. Definitions of infection for surveillance in 
long-term care facilities. Am J Infect Control. 1991;19:1-7. 

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11. Contact information  

For questions relating to use of this protocol, please contact the HALT-3 Management Team (HALT@wiv-isp.be). The 
HAI-Net extranet (URL: https://extranet.ecdc.europa.eu/HAINet/) contains a Question and Answer section, particularly 
suited to those who may perform a validation survey, collect primary PPS data or provide training to primary data 
collectors. All ECDC ‘Operational Contact Points’ for ‘Healthcare-Associated Infections In Long-Term Care Facilities (HAI-
HALT)’ and ‘National Focal Point for Healthcare-associated infections (ARHAI Programme)’ do have access to the 
extranet and may request that ECDC provides access to other named individuals. 

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Annex 1. Institutional questionnaire 

Healthcare-associated infections and antimicrobial use  
in European long-term care facilities (HALT-3) 

INSTITUTIONAL QUESTIONNAIRE 

Remark: It is essential that each facility enrolled in HALT-3 completes this questionnaire as it collects vital data.  We 
recommend that the person completing this questionnaire is the person in charge of the facility. If this person cannot 
answer some of the questions or locate the relevant information, they should request assistance from persons who are 
able to answer those questions. This is especially relevant for questions relating to antimicrobial policy. 

A – GENERAL INFORMATION 

DATE OF THE SURVEY IN YOUR FACILITY 

        └─┴─┘└─┴─┘ 201└─┘(dd mm yyyy) 

FACILITY STUDY NUMBER (allotted by your national HALT-3 coordinator) 

└─┴─┴─┴─┴─┴─┴─┘ 

OWNERSHIP OF THE FACILITY 

□ Public 

QUALIFIED NURSING CARE AVAILABLE 24/24h IN THE FACILITY 

□ For profit  □ Not for profit 
□ Yes   

□ No 

IN THE FACILITY: 

Total number of FTE REGISTERED NURSES   

└─┴─┴─┴─┘FTE registered nurses 

Total number of FTE NURSING ASSISTANTS  

└─┴─┴─┴─┘FTE nursing assistants 

Total number of RESIDENT ROOMS                            

└─┴─┴─┴─┘Rooms 

Total number of SINGLE OCCUPANCY RESIDENT ROOMS 

└─┴─┴─┴─┘Single occupancy rooms 

Total number of SINGLE OCCUPANCY RESIDENT ROOMS WITH   

└─┴─┴─┴─┘Rooms with individual toilet and 

INDIVIDUAL TOILET AND WASHING FACILITIES 

        washing facilities 

A – GENERAL INFORMATION ABOUT THE FACILITY 

A – GENERAL INFORMATION ABOUT THE FACILITY 
B – DENOMINATOR DATA 

This table when completed will summarize the data collected in each ward (ward list) for the total population  

IN YOUR FACILITY, ON THE DAY OF THE SURVEY, TOTAL NUMBER OF: 

BEDS IN THE FACILITY (both occupied and non-occupied beds)                 

└─┴─┴─┴─┘ 

OCCUPIED BEDS   

ELIGIBLE RESIDENTS:  

└─┴─┴─┴─┘ 

PRESENT AT 8 AM AND NOT DISCHARGED AT THE TIME OF THE SURVEY 

└─┴─┴─┴─┘ 

AGE OVER 85 YEARS 

MALE RESIDENTS   

RESIDENTS RECEIVING AT LEAST ONE ANTIMICROBIAL AGENT 

RESIDENTS WITH AT LEAST ONE INFECTION  

RESIDENTS WITH ANY URINARY CATHETER   

RESIDENTS WITH ANY VASCULAR CATHETER  

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

35 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

RESIDENTS WITH PRESSURE SORES  

RESIDENTS WITH OTHER WOUNDS   

RESIDENTS DISORIENTED IN TIME AND/OR SPACE 

RESIDENTS USING A WHEELCHAIR OR BEDRIDDEN 

RESIDENTS WITH SURGERY IN THE PREVIOUS 30 DAYS 

RESIDENTS WITH URINARY AND/OR FAECAL INCONTINENCE   

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

└─┴─┴─┴─┘ 

C – MEDICAL CARE AND COORDINATION 

1. Is medical resident care, including antimicrobial prescribing, in the facility provided by the: 

□ Personal general practitioners (GP) or group practice(s) only 
□ Medical staff, employed by the facility only 
□ Both personal GPs/group practice(s) and medical doctor(s) employed by the facility 

2. Are medical activities in the facility coordinated by a coordinating medical physician (CP)? 
□ No, there is no internal or external coordination of the medical activity 
□ Yes, there is a physician from inside the facility (internal) who coordinates the medical activities 
□ Yes, there is a physician from outside the facility (external) who coordinates the medical activities 
□ Yes, there is both a physician from inside and outside the facility (internal and external) who coordinates the 
medical activities 

3. Can any of the following persons consult the medical/clinical records of all residents in the facility?  

The physician(s) in charge of medical coordination in the facility?  

The nursing staff 

□ Yes    
□ Yes   

□ No 
□ No 

1. Are there persons with training in infection control/prevention available to the staff of the facility? 

D – INFECTION CONTROL PRACTICE 

□ Yes    

□ No 

2. If a person with training in infection control/prevention is available, is this person: 
□ A nurse     □ A doctor     □ There is both a nurse and a doctor  

Is this/are these person(s): 

□ Working in the facility (internal) 
□ Not working in the facility (external) 
□ There is both an internal and an external person 

3. In the facility, is/are there:  
(Please complete this question even if there is no person  with training in infection control/prevention available in the 
facility) 

□ Infection prevention and control training of the nursing and paramedical staff 
□ Appropriate training of general practitioners and medical staff in infection prevention and control 

36 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

□ Development of care protocols 
□ Registration of residents colonized/infected with multi-resistant microorganisms 
□ Designation of a person responsible for reporting and management of outbreaks 
□ Feedback on surveillance results to the nursing/medical staff of the facility 
□ Supervision of disinfection and sterilization of medical and care material 
□ Decisions on isolation & additional precautions for residents colonized with resistant microorganisms  
□ Offer of annual immunisation for flu to all residents  
□ Organization, control, feedback on hand hygiene in the facility on a regular basis 
□ Organization, control, feedback of a process surveillance/audit of infection policies and procedures (on 
regular basis) 
□ None of the above 

4. In the facility, is there an infection control committee (internal or external)?   

□ Yes  □ No 

5. How many infection control committee meetings were organized in the previous year? 

Total number of meetings last year?  

└─┴─┴─┘  meetings previous year 

6. Can the facility ask for help and expertise from an external infection control (IC) team on a formal basis (e.g. IC 

team from a local hospital)? 

7. In the facility, is a written protocol available for: 

□ Yes  □ No 

- hand hygiene 

-  the management of MRSA and/or other multidrug resistant microorganisms  □ Yes  □ No 
□ Yes  □ No 
□ Yes  □ No 
□ Yes  □ No 
□ Yes  □ No 

- the management of venous catheters/lines    

- the management of urinary catheters 

- the management of enteral feeding  

8. Is a surveillance programme of healthcare-associated infections in place in the facility? (annual summary 

report of number of urinary tract infections, respiratory tract infections, etc…) 

9. In the facility, which of following products are available for hand hygiene? 

- Alcohol rub solution 

- Wipes (alcohol)  

- Liquid soap (antiseptic/ other) 

- Bar soap in clinical areas  

□ Yes  □ No 

□ Yes  □ No 
□ Yes  □ No 
□ Yes  □ No 
□ Yes  □ No 

37 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
        
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

10. Which hand hygiene method is most frequently used in your facility when hands are not soiled (only one answer is 
possible)? 

□ Hand disinfection with an alcohol rub solution 
□ Hand washing with water and a non antiseptic soap 
□ Hand washing with water and an antiseptic soap   

11. How many litres of alcohol rub solution for hand hygiene were used last year? 

Total annual consumption in litres   

└─┴─┴─┘ Litres last year 

12. Last year, was a hand hygiene training session organized for care professionals of the facility? 

□ Yes  □ No 

13. How many hand hygiene opportunities were there observed in your facility last year? 

Number of observed opportunities   

└─┴─┴─┴─┴─┘ Opportunities last year 

E – ANTIMICROBIAL POLICY 

1. Does the facility use a ‘restrictive list’ of antimicrobials to be prescribed? (prescription requiring permission of a 
designated person or not to be used) 

□ Yes  □ No 

2. If a restrictive list exists, what kinds of antibiotics are restricted?  

□ Carbapenems 
□ 3rd generation cephalosporins 
□ Fluoroquinolones 
□ Vancomycin 
□ Mupirocin 
□ Glycopeptides 
□ Broad-spectrum antibiotics 
□ Intravenously administered antibiotics 

3. Which of following elements are present in the facility? 

□ An antimicrobial committee 
□ Annual regular training on appropriate antimicrobial prescribing 
□ Written guidelines for appropriate antimicrobial use (good practice) in the facility 
□ Data available on annual antimicrobial consumption by antimicrobial class 
□ A system to remind healthcare workers of the importance of microbiological samples to inform the best 
antimicrobial choice 
□ Local (i.e. for that region/locality or national if small country) antimicrobial resistance profile summaries 
available in the LTCF or in the local General Practitioner surgeries  
□ A system that requires permission from a designated person(s) for prescribing of restricted antimicrobial, not 
included in local formulary  

38 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

□ Advice from a pharmacist for antimicrobials not included in the formulary 
□ A therapeutic formulary, comprising a list of antibiotics 
□ Feedback to the local General Practitioner on antimicrobial consumption in the facility 
□ None of the above 

4. If written therapeutic guidelines are present in the facility, are they on: 

- Respiratory tract infections?  

- Urinary tract infections? 

- Wound and soft tissue infections?    

□ Yes  □ No 
□ Yes  □ No 
□ Yes  □ No 

5. Do you perform a urine dipstick test for detection of urinary tract infections in the facility? 

□ Routinely 

□ Sometimes 

□ Never 

6. Is a programme for surveillance of antimicrobial consumption and feedback in place in the facility? 

□ Yes  □ No 

7. Is a programme for surveillance of resistant microorganisms in place in the facility? (annual summary report for 
MRSA, Clostridium difficile, etc) 
□ Yes  □ No 

8. How are antimicrobials supplied to your facility? (only one answer possible)  

□ Provided by more than one pharmacy 
□ Provided by one pharmacy only 
□ This facility does not acquire antimicrobials directly from pharmacies; antimicrobials are acquired    by 

residents directly (e.g. supplied by the family)  

9. How many microbiological laboratories do you work with? (only one answer possible) 

□ More than one microbiological laboratory 
□ One single microbiological laboratory 
□ This facility does not send microbiological samples to any laboratories; each visiting general practitioner 

can work with his microbiological laboratory of choice. 

F – HOW WAS THE SURVEY PERFORMED IN YOUR FACILITY? 

1. Who collected the HALT-3 data (incl. institutional and resident questionnaires)? 

□ A physician 
□ A nurse 
□ Another person 

2. If no physician was involved in the HALT-3 data collection (institutional and resident questionnaires), did a physician 
validate the data? 

□ Yes  □ No 

39 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

Annex 2. Ward list (for internal use only) 

HALT-3: WARD LIST  

PPS DENOMINATOR DATA BY WARD (for internal use only) 

DATE OF THE PPS IN YOUR FACILITY 

.…/…./……. 

 FACILITY STUDY NUMBER……………………………….. 

NAME OF THE WARD: …………………………………………………………………………………… 

HOW MANY BEDS IN THIS WARD? (INCLUDES BOTH OCCUPIED AND NON-OCCUPIED BEDS):………………… beds 

The ward list is a form developed to aid surveyors’ collection of denominator data for the Institutional Questionnaire. 
Its use is not mandatory, i.e. it is optional.  

The surveillance protocol specifies that surveyors should collect information from each resident eligible resident, i.e. 
those living full-time in the facility, present in the ward at 8am and not discharged at the time of the survey. This ward 
list collects data from each resident. Once these data have been collected for all wards, surveyors can sum the 
denominators from each ward and transfer these totals to the institutional questionnaire. Facilities that do not have 
different wards only need to complete one ward list. 

Instructions: 

 
 

 

 
 
 

 

List all residents present on the day of the PPS in columns 1 and 2. 
Add a code in column 3 that is unique for every resident in the facility. Numbers and/or letters can be used. This 
resident survey number should be entered on all forms for the same resident.  
If the resident meets the eligibility criteria (i.e. living full-time in the facility, present at 8:00 am and not 
discharged at the time of the survey),  
complete columns 5 to 15 by writing an ‘X’ if the risk factor or care load indicator is present on the day of the 
survey. 
Sum the Xs in each column. 
Write the totals of each column in the summary table at the end of the ward list. 
Sum the totals of the summary tables in the different ward lists and report the totals in part B of the 
institutional questionnaire. 
If a resident on the ward list has an X in columns 7 and/or 8b (i.e. they were receiving at least one antimicrobial 
agent and/or had at least one infection on the day of the survey, complete a resident form for this resident.   

40 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COMPLETE FOLLOWING LIST FOR ALL RESIDENTS PRESENT ON THE DAY OF THE PPS  

COMPLETE THIS PART OF THE LIST FOR ALL RESIDENTS IN THE WARD 

COMPLETE THIS PART FOR ALL ELIGIBLE RESIDENTS (residents from column 4) 
Write a  X  in the column if the condition is TRUE ON THE DAY OF THE SURVEY 

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15 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

SUMMARY TABLE: TOTAL NUMBERS FOR THIS WARD 

Use this table to add the number of ‘X’ from each column from each ward list from the facility.  

Transfer the total number into Part B of the institutional questionnaire, i.e. ‘Denominator Data’ 

On the day of the PPS, TOTAL number of: 

Total number of beds on this ward (total bed capacity) 

Occupied beds in the ward 

Eligible residents, present at 8 AM and not discharged at time of PPS 

Age over 85 years  

Male residents 

Residents receiving at least one antimicrobial agent 

Residents with at least one infection 

Residents with any urinary catheter 

Residents with any vascular catheter 

Residents with pressure sores 

Residents with other wounds 

Residents disorientated in time and/or space 

Residents using wheelchair or being bedridden 

Residents with surgery in the previous 30 days 

Residents with urinary and/or faecal incontinence 

Column 

TOTAL NUMBERS 

1 

2 

4 

5 

6 

7 

8b 

9 

10 

11a 

11b 

12 

13 

14 

15 

Keep this ward list safely in your LTCF until the end of the HALT-3 project (December 2018) 

42 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Annex 3. Resident questionnaire 

Healthcare-associated infections and antimicrobial use 
in European long-term care facilities (HALT-3) 

GENDER 

BIRTH YEAR 

LENGTH OF STAY IN THE FACILITY 

ADMISSION TO A HOSPITAL 
    IN THE LAST 3 MONTHS 

SURGERY IN THE PREVIOUS 30 DAYS 

PRESENCE OF: 

URINARY CATHETER 

VASCULAR CATHETER 

INCONTINENCE 
    (URINARY AND/OR FAECAL) 

WOUNDS 
- 
- 

PRESSURE SORE 
OTHER WOUNDS 

DISORIENTATION 
     (IN TIME AND/OR SPACE) 

MOBILITY 

RESIDENT QUESTIONNAIRE 

RESIDENT DATA 

 Male 

 Female 

 (YYYY) 
 Less than one year 
 Yes 
 Yes 

 Yes 
 Yes 
 Yes 

 Yes 
 Yes 
 Yes 
 Ambulant 

 One year or longer 

 No 
 No 

 No 
 No 
 No 

 No 
 No  
 No 
 Wheelchair 

 Bedridden 

On the day of the survey, the resident: 
 RECEIVES AN ANTIMICROBIAL AGENT 
      This includes:  (i) Residents receiving prophylactic antimicrobials  
     OR  (ii) Residents receiving therapeutic antimicrobials  
 PRESENTS CONFIRMED OR PROBABLE INFECTION(S)  
      Residents with infection(s) AND resident not receiving antimicrobials 
 BOTH: ANTIMICROBIAL USE AND INFECTION(S) 
                                                        COMPLETE PART A & B 
      This includes: (i) Residents with infection(s) AND receiving antimicrobials today whether or not linked to 

                                                         COMPLETE PART A 

                                                        COMPLETE PART B 

same infection site 

     OR (ii) Residents whose signs/symptoms of an infection have resolved but who are still receiving 
     antimicrobials for that infection  

43 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

PART A: ANTIMICROBIAL USE 

ANTIMICROBIAL 1 

ANTIMICROBIAL 2 

ANTIMICROBIAL 3 

ANTIMICROBIAL 4 

ANTIMICROBIAL NAME 

ADMINISTRATION ROUTE 

PARENTERAL = IM, IV OR SC 
END DATE / REVIEW DATE OF 
TREATMENT KNOWN? 
TYPE OF  TREATMENT 

ANTIMICROBIAL GIVEN FOR 

WHERE PRESCRIBED? 

………………………  ………………………  ………………………  ……………………… 
  Oral 
  Parenteral  
  Other 
  No      Yes 

  Oral 
  Parenteral  
  Other 
  No      Yes 

  Oral 
  Parenteral  
  Other 
  No      Yes 

  Oral 
  Parenteral  
  Other 
  No      Yes 

  Prophylactic 
  Therapeutic 
  Urinary tract 
  Genital tract 
  Skin or wound  
  Respiratory tract 
  Gastrointestinal 
  Eye 
  Ear, nose, mouth 
  Surgical site  
  Tuberculosis 
  Systemic infection  
  Unexplained fever  
  Other (specify) 
……………………… 
  In this facility 
  In the hospital 
  Elsewhere 

  Prophylactic 
  Therapeutic 
  Urinary tract 
  Genital tract 
  Skin or wound  
  Respiratory tract 
  Gastrointestinal 
  Eye 
  Ear, nose, mouth 
  Surgical site  
  Tuberculosis 
  Systemic infection  
  Unexplained fever  
  Other (specify) 
……………………… 
  In this facility 
  In the hospital 
  Elsewhere 

  Prophylactic 
  Therapeutic 
  Urinary tract 
  Genital tract 
  Skin or wound  
  Respiratory tract 
  Gastrointestinal 
  Eye 
  Ear, nose, mouth 
  Surgical site  
  Tuberculosis 
  Systemic infection  
  Unexplained fever  
  Other (specify) 
……………………… 
  In this facility 
  In the hospital 
  Elsewhere 

  Prophylactic 
  Therapeutic 
  Urinary tract 
  Genital tract 
  Skin or wound  
  Respiratory tract 
  Gastrointestinal 
  Eye 
  Ear, nose, mouth 
  Surgical site  
  Tuberculosis 
  Systemic infection  
  Unexplained fever  
  Other (specify) 
……………………… 
  In this facility 
  In the hospital 
  Elsewhere 

PART B: HEALTHCARE-ASSOCIATED INFECTIONS 
INFECTION 3 
INFECTION 2 
INFECTION 1 

INFECTION CODE 

IF ‘OTHER’, PLEASE SPECIFY  ……………………… 
PRESENT AT (RE-)ADMISSION     No      Yes 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 
……………………….  ……………………… 
  No      Yes 

└─┴─┴─┴─┴─┴─┘ 

  No      Yes 

INFECTION 4 

└─┴─┴─┴─┴─┴─┘ 

……………………… 
  No      Yes 

DATE OF ONSET (DD/MM/YY) 

ORIGIN OF INFECTION 

A. NAME OF 
ISOLATED 

MICROORGANISM 
(PLEASE USE CODE 
LIST) 

B. TESTED 
ANTIMICROBIAL(S) 
AND RESISTANCE 

ONLY FOR STAAUR, 
ENC***,  ACIBAU, 
PSEAER OR 

ENTEROBACTERIACEA
E (CIT***, ENB***, 
ESCCOL, KLE***, 
MOGSPP, PRT***, 
SER***) 

1. A 

B 

2. A 

B 

3. A 

B 

└─┴─┘/└─┴─┘/└─┴─┘  └─┴─┘/└─┴─┘/└─┴─┘  └─┴─┘/└─┴─┘/└─┴─┘  └─┴─┘/└─┴─┘/└─┴─┘ 
  Current LTCF 
  Other LTCF 
  Hospital 
  Unknown 

  Current LTCF 
  Other LTCF 
  Hospital 
  Unknown 

  Current LTCF 
  Other LTCF 
  Hospital 
  Unknown 

  Current LTCF 
  Other LTCF 
  Hospital 
  Unknown 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

1Tested antibiotic(s): STAAUR: oxacillin (OXA) or glycopeptides (GLY); ENC***:  GLY only; Enterobacteriaceae: 3rd-gen cephalosporins 
(C3G) or carbapenems (CAR); PSEAER and ACIBAU: CAR only. 2 Resistance: S=sensitive, I=intermediate, R=resistant, U=unknown 

44 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Annex 4. Case definitions of infections 

Healthcare-associated infections and antimicrobial use 
in European long-term care facilities (HALT-3) 

CASE DEFINITIONS OF INFECTIONS 

IMPORTANT REMARK: All active infections present on the day of the survey should be reported. An infection is active when 
signs/symptoms of the infection are present on the survey date OR signs/symptoms were present in the past and the resident is (still) 
receiving treatment for that infection on the survey date. The presence of symptoms and signs in the two weeks (14 days) preceding 
the PPS day should be verified in order to determine whether the treated infection matches one of the case definitions. Infections can 
only be reported as ‘imported’ for residents recently transferred from another healthcare facility (i.e. hospital or other LTCF) and still 
treated for an infection on the PPS day in the absence of documentation on (all) signs/symptoms that were present in the past. 

* 

** 
§ 

§§ 

Fever: 1) single > 37.8°C oral/tympanic membrane or 2) repeated > 37.2°C oral or > 37.5°C rectal or 3) > 1.1°Cover 
baseline from any site (oral, tympanic, axillary) 
Leucocytosis: 1) Neutrophilia > 14,000 leucocytes/mm3 or 2) left shift (>6% bands or ≥ 1500 bands/mm3) 
Acute change in mental status from baseline: Acute onset + fluctuating course + inattention AND either disorganized 
thinking or altered level of consciousness 
Acute functional decline: New 3 point increase in total ADL score (Range 0-28) from baseline based on 7 ADL items (bed 
mobility, transfer, locomotion, dressing, toilet use, personal hygiene, eating) each scored from 0 (independent) - 4 (total 
dependence) OR increased dependency defined by scales other than ADL 

URINARY TRACT INFECTIONS 

 Resident without a urinary catheter 

 Resident with a urinary catheter 

SIGNS/SYMPTOMS 

SIGNS/SYMPTOMS 

AT LEAST ONE OF THE FOLLOWING (1, 2 or 3) CRITERIA: 
 1 Acute dysuria  OR  acute pain/swelling or tenderness of the 

AT LEAST ONE OF THE FOLLOWING (1, 2, 3 or 4) CRITERIA: 
 1 Fever*, rigors, OR new onset hypotension with NO 

testes, epididymis, or prostate 

 2 Fever* OR leukocytosis** 

         AND             

One or more of the following: 
 Acute costovertebral angle pain 
 Suprapubic pain/tenderness 
 Gross hematuria 
 New or marked increase in frequency 
 New or marked increase in urgency 
 New or marked increase in incontinence 

 3 Two or more (in the absence of fever or leucocytosis):   

 Frequency (new/increased)                Suprapubic pain 
 Urgency  (new/increased)                  Gross hematuria 
 Incontinence (new/increased) 

URINE CULTURE 

 Not Done, negative or test results unknown 
 Urine culture done AND: 

 At least 105 cfu/ml of no more than 2 species of micro-

organisms in a voided urine sample  

OR 

 At least 102 cfu/ml of any number of organisms in a 

specimen collected by in-and-out catheter 

INFECTION CONFIRMATION 

alternate site of infection    

 2 Acute change mental status § OR acute functional 

decline §§ with NO alternate diagnosis AND 
leukocytosis**    

 3 New onset suprapubic or costovertebral angle pain or 

tenderness  

 4 Purulent discharge around catheter or acute pain, 

swelling or tenderness of testes, epididymis, or prostate    

URINE CULTURE 

 Not done, negative or test results unknown 
 Urine culture done AND: 

 At least 105 cfu/ml of any organism(s) in a urinary 

catheter specimen 





INFECTION CONFIRMED  (= UTI-C) 
Signs/symptoms AND urine culture positive:  
Signs/symptoms AND urine culture not done, negative or results unknown: 
INFECTION PROBABLE      (= UTI-P) 
Infection treated on PPS day but no documentation of signs/symptoms           INFECTION IMPORTED      (= UTI-I) 
(hospital or other LTCF infections only) 

45 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

RESPIRATORY TRACT INFECTIONS 

COMMON COLD or PHARYNGITIS 

FLU diagnosis can be made also outside the Flu season 

AT LEAST TWO OF THE FOLLOWING CRITERIA: 

BOTH OF THE FOLLOWING CRITERIA MUST BE MET: 

  Runny nose or sneezing 
  Stuffy nose (i.e. congestion) 
  Sore throat or hoarseness or difficulty in swallowing 
  Dry cough 
  Swollen or tender glands in the neck (cervical 

lymphadenopathy) 

  Fever (for definition see top of page 1) 

AND 

  At least three of the following: 

  Chills 
  New headache or eye pain 
  Myalgias or body aches 
  Malaise or loss of appetite 
  Sore throat 
  New or increased dry cough 

INFECTION CONFIRMATION 

INFECTION CONFIRMATION 

  Infection criteria fully met:         INFECTION CONFIRMED  

           (= COLD-C) 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                       INFECTION IMPORTED 
(hospital or other LTCF only)      (= COLD-I) 

  Infection criteria fully met:        INFECTION CONFIRMED 

           (= FLU-C) 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                      INFECTION IMPORTED 
(hospital or other LTCF only)      (= FLU-I) 

LOWER RESPIRATORY TRACT INFECTIONS   

 Resident with a POSITIVE chest x-ray for pneumonia or a 

 Resident without a POSITIVE chest x-ray for pneumonia 

new infiltrate 

or a new infiltrate OR chest x-ray not done 

SIGNS/SYMPTOMS 

SIGNS/SYMPTOMS 

BOTH OF THE FOLLOWING CRITERIA MUST BE MET: 

BOTH OF THE FOLLOWING CRITERIA MUST BE MET: 

 At least one of respiratory signs or symptoms: 

 At least two of respiratory signs or symptoms: 

 New or increased cough 
 New/increased sputum production 
 02 saturation < 94% or reduced >3% from baseline 
 Abnormal lung examination (new or changed) 
 Pleuritic chest pain 
 Respiratory rate ≥ 25 breaths/min 

AND 

 New or increased cough 
 New/increased sputum production 
 O2 saturation < 94% or reduced >3% from baseline 
 Abnormal lung examination (new or changed) 
 Pleuritic chest pain 
 Respiratory rate ≥ 25 breaths/min 

AND 

 One or more constitutional signs/symptoms (fever, 

leucocytosis, confusion, acute functional decline; for 
definitions see top of page 1 §§)  

 One or more constitutional signs/symptoms (fever, 

leucocytosis, confusion, acute functional decline; for 
definitions see top of page 1 §§) 

Absence of other conditions such as chronic hearth failure that could account for symptoms 

INFECTION CONFIRMATION 

INFECTION CONFIRMATION 

 Signs/symptoms criteria met AND chest x-ray positive:  

 Infection criteria fully met:      

PNEUMONIA INFECTION CONFIRMED (= PNEU-C) 

OTHER LOWER RTI CONFIRMED (= LRTI-C) 

 Infection treated on PPS day but no documentation of 
signs/symptoms (hospital or other LTCF only):            

  Infection treated on PPS day but no documentation of   
       signs/symptoms (hospital or other LTCF only):   

PNEUMONIA INFECTION IMPORTED (= PNEU-I) 

OTHER LOWER RTI IMPORTED (= LRTI-I) 

46 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

SKIN INFECTIONS 

CELLULITIS/SOFT TISSUE/WOUND INFECTIONS 

SCABIES 

ONE OF THE FOLLOWING (1 or 2) CRITERIA MUST BE MET: 
  1 Pus at a wound, skin, or soft tissue site   
  2 Four or more new or increasing signs/symptoms at  

affected site: 

  Heat                                 
  Tenderness or pain 
  Redness  
  Serous drainage                           
  Swelling 
  One constitutional sign/symptom (fever, 

leucocytosis, confusion, acute functional decline; 
for definitions see top of page 1) 

BOTH OF THE FOLLOWING CRITERIA MUST BE MET: 

  Maculopapular and/or itching rash 

AND 
  At least one of the following: 
  Physician diagnosis 
 
Laboratory confirmation (positive scraping or biopsy) 
  Epidemiological linkage to a case of scabies with lab 

confirmation 

INFECTION CONFIRMATION 

 

Infection criteria fully met:     INFECTION CONFIRMED 

      (= SKIN-C) 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                   INFECTION IMPORTED 
(hospital or other LTCF only)  (= SKIN-I) 

INFECTION CONFIRMATION 

 

Infection criteria fully met:     INFECTION CONFIRMED 

       (= SCAB-C) 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                   INFECTION IMPORTED 
(hospital or other LTCF only)  (= SCAB-I) 

NOTE: 
If the infection matches one of the Surgical Site Infection 
(SSI) definitions, please give priority to the SSI. Do not apply 
another case definition for the same infection. 

HERPES SIMPLEX OR ZOSTER INFECTION 

FUNGAL INFECTION 

BOTH OF THE FOLLOWING CRITERIA MUST BE MET: 

BOTH OF THE FOLLOWING CRITERIA MUST BE MET: 

  A vesicular rash 

AND 

  Characteristic rash or skin lesions 

AND 

  Physician diagnosis or laboratory confirmation 

  Physician diagnosis or lab confirmed fungal pathogen from 

scraping or biopsy 

INFECTION CONFIRMATION 

INFECTION CONFIRMATION 

 

Infection criteria fully met:     INFECTION CONFIRMED 

 

Infection criteria fully met:    INFECTION CONFIRMED 

       (= HERP-C) 

      (= FUNG-C) 

  Infection treated on PPS day but no documentation of 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                   INFECTION IMPORTED 
(hospital or other LTCF only)  (= HERP-I) 

signs/symptoms:                   INFECTION IMPORTED 
(hospital or other LTCF only)   (= FUNG-I) 

47 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

SURGICAL SITE INFECTIONS 

Infection occurs within 30 days after the operation if no implant is left in place, or within three months if implant is 
in place 

SUPERFICIAL INCISIONAL 

DEEP INCISIONAL 

ORGAN/SPACE 

BOTH OF THE FOLLOWING 
CRITERIA MUST BE MET: 

BOTH OF THE FOLLOWING CRITERIA 
MUST BE MET: 

BOTH OF THE FOLLOWING CRITERIA 
MUST BE MET: 

 

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: 
  Tenderness or pain 
  Localised swelling 
  Redness  
  Heat                                 
AND 
Superficial incisional SSI 
made by a surgeon or 
attending physician                     

 

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 

 

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 

INFECTION CONFIRMATION 

 

Infection criteria fully met: 

INFECTION CONFIRMED 
(= SSSI-C) 

  Infection treated on PPS day but 
no documentation of signs/ 
symptoms (hospital or other 
LTCF only): 
        INFECTION IMPORTED 
        (= SSSI-I) 

INFECTION CONFIRMATION 

INFECTION CONFIRMATION 

 

Infection criteria fully met: 

 

Infection criteria fully met: 

INFECTION CONFIRMED 
(= DSSI-C) 

  Infection treated on PPS day but 
no documentation of signs/ 
symptoms (hospital or other 
LTCF only): 
         INFECTION IMPORTED 
         (= DSSI-I) 

INFECTION CONFIRMED 
(= OSSI-C) 

  Infection treated on PPS day but 
no documentation of signs/ 
symptoms (hospital or other 
LTCF only): 
         INFECTION IMPORTED 
         (= OSSI-I) 

NOTE: 
If the infection matches one of the Surgical Site Infection (SSI) definitions, please give priority to the SSI. Do not apply another 
case definition for the same infection. 

48 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

EYE, EAR, NOSE AND MOUTH INFECTIONS 

CONJUNCTIVITIS 

EAR 

ONE OF THE FOLLOWING (1, 2 or 3) CRITERIA MUST BE 
MET: 
  1 Pus appearing from one or both eyes, present for at 

least 24 hours    

  2 New or increased conjunctival erythema, with or 

without itching 

  3 New or increased conjunctival pain, present for at 

least 24 hours 

Symptoms must not be due to allergy or trauma to the 
conjunctiva 

ONE OF THE FOLLOWING (1 or 2) CRITERIA MUST BE MET: 
  1 Diagnosis by a physician of any ear infection 
  2 New drainage from one or both ears   

(non-purulent drainage must be accompanied by additional 
symptoms, such as ear pain or redness) 

INFECTION CONFIRMATION 

 

Infection criteria fully met:     INFECTION CONFIRMED 

       (= CONJ-C) 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                   INFECTION IMPORTED 
(hospital or other LTCF only)   (= CONJ-I) 

INFECTION CONFIRMATION 

 

Infection criteria fully met:     INFECTION CONFIRMED 

       (= EAR-C) 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                   INFECTION IMPORTED 
(hospital or other LTCF only)   (= EAR-I) 

SINUSITIS  

  Sinusitis diagnosed by physician 

ORAL CANDIDIASIS 

BOTH OF THE FOLLOWING CRITERIA MUST BE MET: 
  Presence of raised white patches on inflamed mucosa OR 

plaques on oral mucosa 

                              AND 
  Diagnosed by a dentist or a physician 

INFECTION CONFIRMATION 

INFECTION CONFIRMATION 

 

Infection criteria fully met:    INFECTION CONFIRMED 

 

Infection criteria fully met:    INFECTION CONFIRMED 

      (= SINU-C) 

      (= ORAL-C) 

  Infection treated on PPS day but no documentation of 
signs/symptoms:                  INFECTION IMPORTED 
(hospital or other LTCF only)  (= SINU-I) 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                   INFECTION IMPORTED 
(hospital or other LTCF only)   (= ORAL-I) 

=  

49 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

GASTROINTESTINAL INFECTIONS 

GASTROENTERITIS 

CLOSTRIDIUM DIFFICILE INFECTION 

ONE OF FOLLOWING (1, 2 or 3) CRITERIA MUST BE MET: 
  1 Diarrhoea, three or more liquid or watery stools above 

ONE OF FOLLOWING (1, 2 or 3) CRITERIA MUST BE MET: 
  1 Diarrhoeal stools or toxic megacolon AND 

normal baseline for the resident in 24-hr period 
  2 Vomiting, two or more episodes in 24-hr period  
  3 Both of the following:  

  Positive stool specimen for bacterial or viral 

pathogen 

AND 
  At least one of the following: nausea, vomiting,  

abdominal pain or tenderness, diarrhoea 

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 

  2 Pseudomembranous colitis revealed by lower gastro-

intestinal endoscopy  

  3 Colonic histopathology characteristic of C. difficile 

infection (with or without diarrhoea) on a specimen 
obtained during endoscopy or colectomy 

INFECTION CONFIRMATION 

INFECTION CONFIRMATION 

 

Infection criteria fully met:    INFECTION CONFIRMED 

  Infection criteria fully met:       INFECTION CONFIRMED 

  Infection treated on PPS day but no documentation of 

  Infection treated on PPS day but no documentation of 

signs/symptoms:                   INFECTION IMPORTED 
(hospital or other LTCF only)   (= GE-I) 

signs/symptoms:                      INFECTION IMPORTED 
(hospital or other LTCF only)      (= CDI-I) 

(= GE-C) 

         (= CDI-C) 

BLOODSTREAM INFECTIONS    

UNEXPLAINED FEVER    

ONE OF THE FOLLOWING (1 or 2) CRITERIA MUST BE MET: 
  1 Two or more blood cultures positive for the same 

organism    

  2 A single blood culture documented with an organism 

  The resident must have documentation in the medical 

record of fever (for definition see top of page 1) on two 
or more occasions at least 12 hours apart in any 3‐day 
period, with no known infectious or non-infectious cause  

thought not to be a contaminant 

                 AND                          

At least one of the following: 
 
  New hypothermia (<34.5° C, or does not register 

Fever (for definition see top of page 1) 

on the thermometer being used) 

  A drop in systolic blood pressure of  >30 mm Hg 

from baseline  

  Worsening mental or functional status 

INFECTION CONFIRMATION 

 

Infection criteria fully met:    INFECTION CONFIRMED 

       (= FUO-C)  

  Infection treated on PPS day but no documentation of 
signs/symptoms:                  INFECTION IMPORTED 
(hospital or other LTCF only)  (= FUO-I) 

INFECTION CONFIRMATION 

 

Infection criteria fully met:    INFECTION CONFIRMED 

      (= BSI-C) 

  Infection treated on PPS day but no documentation of 
signs/symptoms:                  INFECTION IMPORTED 
(hospital or other LTCF only)  (= BSI-I) 

OTHER INFECTION(S) 

Please specify (= OTHER) 

50 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
      
 
 
       
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

Annex 5. Code list with microorganisms 

INSTRUCTIONS 
Only report microbiological results that are available on the survey date. Do not report microbiological results that 
become available after the day of the survey. This ensures comparability of data collection between LTCFs and 
countries. 

STEP ONE 
Specify up to three isolated microorganisms, using the microorganism code list (see below).  

If no microbiological result is available on the day of the PPS, one of the following options should be selected:   

_NOEXA 
_NA 

EXAMINATION NOT DONE  
RESULTS NOT AVAILABLE 

_NONID 

MICROORGANISM NOT IDENTIFIED   

_STERI 

STERILE EXAMINATION   

No diagnostic sample taken, no microbiological examination done 
The results of the microbiological examination are not (yet) available or cannot be 
found 
Evidence exists that a microbiological examination has been done, but the micro-
organism cannot be correctly classified 
A microbiological examination has been done, but the result was negative (e.g. 
negative culture) 

STEP TWO 
For each reported microorganism HIGHLIGHTED IN RED, indicate the susceptibility using the table below. 

Microorganism 
Staphylococcus aureus 
(STAAUR) 

Enterococcus species 
(ENC***) 
Enterobacteriaceae1, 
including: 
Escherichia coli (ESCCOL) 
Klebsiella species (KLE***) 
Enterobacter species (ENB***) 
Proteus species (PRT***) 
Citrobacter species (CIT***) 
Serratia species (SER***) 
Morganella species  (MOGSPP) 
Pseudomonas aeruginosa 
(PSEAER) 
Acinetobacter baumannii 
(ACIBAU) 

Tested antibiotic2 
Oxacillin (OXA) 
Glycopeptides (GLY) 
Glycopeptides (GLY) 

Third-generation 
cephalosporins (C3G) 
Carbapenems (CAR) 

Antimicrobial resistance 

Susceptible (S) 
Susceptible (S) 
Susceptible (S) 

–  
Intermediate (I) 
Intermediate (I) 

Resistant (R) 
Resistant (R) 
Resistant (R) 

Unknown (U) 
Unknown (U) 
Unknown (U) 

Susceptible (S) 

Intermediate (I) 

Resistant (R) 

Unknown (U) 

Susceptible (S) 

Intermediate (I) 

Resistant (R) 

Unknown (U) 

Carbapenems (CAR) 

Susceptible (S) 

Intermediate (I) 

Resistant (R) 

Unknown (U) 

Carbapenems (CAR) 

Susceptible (S) 

Intermediate (I) 

Resistant (R) 

Unknown (U) 

1 Antimicrobial resistance markers are not collected for other Enterobacteriaceae (e.g. Hafnia spp., Salmonella spp., Shigella spp., 
Yersinia spp.) 2OXA: susceptibility to oxacillin, or other marker of MRSA, such as cefoxitin, cloxacillin, dicloxacillin, flucloxacillin, 
meticillin; GLY: susceptibility to glycopeptides: vancomycin or teicoplanin; C3G: susceptibility to third-generation cephalosporins: 
cefotaxime, ceftriaxone, ceftazidime;  CAR: susceptibility to carbapenems: imipenem, meropenem, doripenem. 

51 

 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

EXAMPLE: 

INFECTION CODE 

A. NAME OF ISOLATED 
MICROORGANISM 
(PLEASE USE CODE 
LIST) 

B. TESTED 
ANTIMICROBIAL(S) AND 
RESISTANCE 

ONLY FOR STAAUR, 
ENC***,  ACIBAU, 
PSEAER OR 
ENTEROBACTERIACEAE 
(CIT***, ENB***, 
ESCCOL, KLE***, 
MOGSPP, PRT***, 
SER***) 

CODE 

ACHSPP 

ACIBAU 

ACICAL 

ACIHAE 

ACILWO 

ACINSP 

ACIOTH 

ACTSPP 

AEMSPP 

AGRSPP 

ALCSPP 

ANANSP 

ANAOTH 

ASPFUM 

ASPNIG 

ASPNSP 

ASPOTH 

GNBNSP 

GNBOTH 

GPBNSP 

GPBOTH 

BACSPP 

BCTOTH 

BATFRA 

BATOTH 

BURCEP 

CAMSPP 

CANALB 

CANGLA 

52 

PART B: HEALTHCARE-ASSOCIATED INFECTIONS 

INFECTION 1 
UTI-C 

INFECTION 2 
SKIN-C 

INFECTION 3 
COLD-C 

ESCCOL 

STAAUR 

_NOEXA 

INFECTION 4 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

OXA    S 

GLY    S 

STRHCG 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

1. A 

B 

C3G    S 

CAR    U 

2. A 

ENCFAE 

B 

3. A 

B 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

GLY    S 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┴─┴─┴─┘  PSEAER 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┴─┴─┴─┘ 

└─┴─┴─┘    └─┘ 

CAR    U 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

└─┴─┴─┘    └─┘ 

NAME OF THE MICROORGANISM 

- A - 

ACHROMOBACTER SPECIES 

ACINETOBACTER BAUMANNII 

ACINETOBACTER CALCOACETICUS 

ACINETOBACTER HAEMOLYTICUS 

ACINETOBACTER LWOFFII 

ACINETOBACTER SPECIES, not specified 

ACINETOBACTER SPECIES, other 

ACTINOMYCES SPECIES 

AEROMONAS SPECIES 

AGROBACTERIUM SPECIES 

ALCALIGENES SPECIES 

ANAEROBES, not specified 

ANAEROBES, other 

ASPERGILLUS FUMIGATUS 

ASPERGILLUS NIGER 

ASPERGILLUS SPECIES, not specified 

ASPERGILLUS SPECIES, other 

- B - 

BACILLI, GRAM NEGATIVE, not specified 

BACILLI, GRAM NEGATIVE, NON ENTEROBACTERIACEAE, other 

BACILLI, GRAM POSITIVE, not specified 

BACILLI, GRAM POSITIVE, other 

BACILLUS SPECIES 

BACTERIA, other 

BACTEROIDES FRAGILIS 

BACTEROIDES, other 

BURKHOLDERIA CEPACIA 

CAMPYLOBACTER SPECIES 

CANDIDA ALBICANS 

CANDIDA GLABRATA 

- C - 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

NAME OF THE MICROORGANISM 

CODE 

CANKRU 

CANPAR 

CANNSP 

CANOTH 

CANTRO 

CHLSPP 

CITFRE 

CITDIV 

CITNSP 

CITOTH 

CLODIF 

CLOOTH 

GNCNSP 

GNCOTH 

GPCNSP 

GPCOTH 

CORSPP 

ENBAER 

ENBAGG 

ENBCLO 

ENBGER 

ENBSAK 

ENBNSP 

ENBOTH 

ETBNSP 

ETBOTH 

ENCFAE 

ENCFAI 

ENCNSP 

ENCOTH 

ESCCOL 

FILOTH 

FLASPP 

FUNOTH 

CANDIDA KRUSEI 

CANDIDA PARAPSILOSIS 

CANDIDA SPECIES, not specified 

CANDIDA SPECIES, other 

CANDIDA TROPICALIS 

CHLAMYDIA SPECIES 

CITROBACTER FREUNDII 

CITROBACTER KOSERI (EX. DIVERSUS) 

CITROBACTER SPECIES, not specified 

CITROBACTER SPECIES, other 

CLOSTRIDIUM DIFFICILE 

CLOSTRIDIUM, other 

COCCI, GRAM NEGATIVE, not specified 

COCCI, GRAM NEGATIVE, other 

COCCI, GRAM POSITIVE, not specified 

COCCI, GRAM POSITIVE, other 

CORYNEBACTERIUM SPECIES 

ENTEROBACTER AEROGENES 

ENTEROBACTER AGGLOMERANS 

ENTEROBACTER CLOACAE 

ENTEROBACTER GERGOVIAE 

ENTEROBACTER SAKAZAKII 

ENTEROBACTER SPECIES, not specified 

ENTEROBACTER SPECIES, other 

ENTEROBACTERIACEAE, not specified 

ENTEROBACTERIACEAE, other 

ENTEROCOCCUS FAECALIS 

ENTEROCOCCUS FAECIUM 

ENTEROCOCCUS SPECIES, not specified 

ENTEROCOCCUS SPECIES, other 

ESCHERICHIA COLI 

FILAMENTS, other 

FLAVOBACTERIUM SPECIES 

FUNGI, other 

GARSPP 

GARDNERELLA SPECIES 

HAEINF 

HAEPAI 

HAENSP 

HAEOTH 

HAFSPP 

HELPYL 

KLEOXY 

KLEPNE 

KLENSP 

KLEOTH 

HAEMOPHILUS INFLUENZAE 

HAEMOPHILUS PARAINFLUENZAE 

HAEMOPHILUS SPECIES, not specified 

HAEMOPHILUS SPECIES, other 

HAFNIA SPECIES 

HELICOBACTER PYLORI 

KLEBSIELLA OXYTOCA 

KLEBSIELLA PNEUMONIAE 

KLEBSIELLA SPECIES, not specified 

KLEBSIELLA SPECIES, other 

- E - 

- F - 

- G - 

- H - 

- K - 

- L - 

53 

 
 
 
 
 
 
 
 
 
 
Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

TECHNICAL DOCUMENT 

NAME OF THE MICROORGANISM 

LACTOBACILLUS SPECIES 

LEGIONELLA SPECIES 

LISTERIA MONOCYTOGENES 

- M - 

MORAXELLA CATHARRALIS 

MORAXELLA SPECIES, not specified 

MORAXELLA SPECIES, other 

MORGANELLA SPECIES 

MYCOBACTERIUM, atypical 

MYCOBACTERIUM TUBERCULOSIS COMPLEX 

MYCOPLASMA SPECIES 

- N - 

- P - 

NEISSERIA MENINGITIDIS 

NEISSERIA SPECIES, not specified 

NEISSERIA SPECIES, other 

NOCARDIA SPECIES 

PARASITES, other 

PASTEURELLA SPECIES 

PREVOTELLA SPECIES 

PROPIONIBACTERIUM SPECIES 

PROTEUS MIRABILIS 

PROTEUS SPECIES, not specified 

PROTEUS SPECIES, other 

PROTEUS VULGARIS 

PROVIDENCIA SPECIES 

PSEUDOMONADACEAE FAMILY, not specified 

PSEUDOMONADACEAE FAMILY, other 

PSEUDOMONAS AERUGINOSA 

- S - 

SALMONELLA ENTERITIDIS 

SALMONELLA SPECIES, not specified 

SALMONELLA SPECIES, other 

SALMONELLA TYPHIMURIUM 

SALMONELLA TYPHI or PARATYPHI 

SERRATIA LIQUEFACIENS 

SERRATIA MARCESCENS 

SERRATIA SPECIES, not specified 

SERRATIA SPECIES, other 

SHIGELLA SPECIES 

STAPHYLOCOCCUS AUREUS 

STAPHYLOCOCCUS EPIDERMIDIS 

STAPHYLOCOCCUS HAEMOLYTICUS 

STAPHYLOCOCCI, COAGULASE-NEGATIVE, not specified 

STAPHYLOCOCCI, COAGULASE-NEGATIVE (CNS), other 

STAPHYLOCOCCUS SPECIES, not specified 

STENOTROPHOMONAS MALTOPHILIA 

STREPTOCOCCAE, HAEMOLYTIC (C, G), other 

STREPTOCOCCUS AGALACTIAE (B) 

STREPTOCOCCUS PNEUMONIAE 

STREPTOCOCCUS PYOGENES (A) 

CODE 

LACSPP 

LEGSPP 

LISMON 

MORCAT 

MORNSP 

MOROTH 

MOGSPP 

MYCATY 

MYCTUB 

MYPSPP 

NEIMEN 

NEINSP 

NEIOTH 

NOCSPP 

PAROTH 

PASSPP 

PRESPP 

PROSPP 

PRTMIR 

PRTNSP 

PRTOTH 

PRTVUL 

PRVSPP 

PSENSP 

PSEOTH 

PSEAER 

SALENT 

SALNSP 

SALOTH 

SALTYM 

SALTYP 

SERLIQ 

SERMAR 

SERNSP 

SEROTH 

SHISPP 

STAAUR 

STAEPI 

STAHAE 

STACNS 

STAOTH 

STANSP 

STEMAL 

STRHCG 

STRAGA 

STRPNE 

STRPYO 

54 

 
 
 
 
 
 
 
 
 
 
TECHNICAL DOCUMENT 

Protocol for PPS of HAI and antimicrobial use in European long-term care facilities 

CODE 

STRNSP 

STROTH 

VIRADV 

VIRCMV 

VIRENT 

VIRHAV 

VIRHBV 

VIRHCV 

VIRHIV 

VIRHSV 

VIRINA 

VIRINB 

VIRINC 

VIRNOR 

VIRPIV 

VIRRHI 

VIRROT 

VIRRSV 

VIRSAR 

VIRVZV 

VIRNSP 

VIROTH 

NAME OF THE MICROORGANISM 

STREPTOCOCCUS SPECIES, not specified 

STREPTOCOCCUS SPECIES, other 

- V - 

ADENOVIRUS 

CYTOMEGALOVIRUS (CMV) 

ENTEROVIRUS (POLIO, COXSACKIE, ECHO) 

HEPATITIS A VIRUS 

HEPATITIS B VIRUS 

HEPATITIS C VIRUS 

HUMAN IMMUNODEFICIENCY VIRUS (HIV) 

HERPES SIMPLEX VIRUS 

INFLUENZA A VIRUS 

INFLUENZA B VIRUS 

INFLUENZA C VIRUS 

NOROVIRUS 

PARAINFLUENZAVIRUS 

RHINOVIRUS 

ROTAVIRUS 

RESPIRATORY SYNCYTIAL VIRUS (RSV) 

SARS-CORONAVIRUS 

VARICELLA-ZOSTER VIRUS 

VIRUS, not specified 

VIRUS, other 

- Y - 

YEAOTH 

YERSPP 

YEASTS, other 

YERSINIA SPECIES 

55 

 
 
 
 
 
 
 
 
 
 
 
 
European Centre for Disease 
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