Classification of infection based upon hospital discharge summaries, medical records, and physician follow-up confirmation form^a

Classification if hospital medical records were available to the physician adjudicators (note that reporting physician also had previously indicated that the patient had experienced an infection)

(i) Confirmed infection (any of these satisfy):

(a) diagnosis of infection(s) in hospital discharge summary, without any qualifier such as ‘probable’ or ‘possible’ and irrespective of any additional details of culture or radiological reports;

(b) no specific diagnosis of infection(s) in the hospital discharge summary, but mention of any positive culture report (includes bacterial, fungal or viral), unless labelled as a ‘contaminant’;a

(c) no specific diagnosis of infection(s) in the hospital discharge summary, but a description of clinical management of infection(s) with documentation of intravenous antibiotic administration.

(ii) Empirically treated infection:

(a) diagnosis of infection(s) in hospital discharge summary, with a qualifier suggesting uncertainty such as ‘probable’, ‘possible’, ‘provisional’, ‘rule-out’ or ‘working diagnosis’ and irrespective of any additional details of culture or radiological reports.a

(iii) Possible (any of these satisfy):

(a) description of clinical management in hospital discharge summary of an inflammatory condition that is often non-infectious (e.g. diverticulitis, cholecystitis, COPD exacerbation and aspiration pneumonitis) and without substantial evidence (e.g. positive culture data) for an infection;

(b) no information in the hospital discharge summary regarding any infection.

(iv) Unlikely:

(a) alternate, non-infectious aetiology was found to explain signs/symptoms of infection (e.g. pulmonary thromboembolism).

Classification if hospital discharge summary was not available to the physician adjudicators, and the patient's rheumatologist reporting the infection provided only the follow-up infection confirmation formb

(i) Confirmed infection (any of these satisfy):

(a) reporting physician took care of the patient during the hospitalization and had first-hand knowledge of the infection;

(b) reporting physician personally reviewed the hospital medical records (e.g. discharge summary) and physician also provided to the adjudicators additional documentation is provided showing either positive cultures or confirmatory radiologic findings consistent with infection.

(ii) Empirically treated infection (any of these satisfy):

(a) reporting physician reviewed hospital medical records (e.g. discharge summary) but provided no additional documentation to the adjudicators;

(b) reporting physician reviewed medical records from other physicians who took care of the patient in the hospital.

(iii) Possible (any of these satisfy):

(a) reporting physician was told by the patient that they were hospitalized with an infection, but no primary documentation was available to the physician or the adjudicators;

(b) reporting physician reviewed hospital medical records (e.g. discharge summary) and additional documentation was provided to the adjudicators showing either negative cultures or radiologic findings that were normal or inconsistent with infection.

^aDetailed description of the criteria used to define ‘contaminant’ organisms, classify radiologic findings, etc. is found in the Appendix of [2]. ^bThe infection confirmation form asked the reporting physician to describe what information he/she had access to in order to determine if there was an infection.