Central Line-associated Bloodstream Infections (CLABSI) Case Studies


Good morning, we’re going
to extend our discussion on applying the CLABSI
surveillance definitions for NHSN to some case studies so that we can get
some experience working with the case– with
the definition. So, we’ll spend the
next hour or so going over some case studies
that we put together. I do want to make a
note as I noted it on my earlier presentation that
this recording is being made on January 24th of 2013
after several modifications to the CLABSI Surveillance,
Definitions and Protocols which occurred after the October
of 2012 NHSN training course. The slide said that
it was posted for this presentation is
the original slide set and it has some notations
made to the slides and have been updated that will
allow individuals who attended that October training to identify those
slides that have changed. I provided you a link
to that slides at here. So, for today’s recording
I have taken those notes, cards off because they’re
just kind of distracting and I didn’t really
think we needed those. When this presentation
was originally presented, it was given to a live audience and we utilize an audience
participation feature. And since today, we
don’t have an audience that feature has been disabled. Therefore, you’ll see some empty
spaces in some of the slides where we would have normally
put the audience results. So, just in case you’re
wondering why the slides might look a little lap-sided,
that’s why. And, what I envision
doing now is that during the case
presentation, I’ll pause slightly to
allow users or viewers to place the webinar
on pause if you want, after the question
to consider the case. And then, you can come up
with a proposed answer. And then, when you’re
ready to check your answer, just unpause the webinar and I’ll be presenting the
correct interpretation, okay. So, a few ground rules for
case studies which we always like to present this as
the first information. And, really the– the purposes
for these case studies are to train and the use of the
definitions as they exist. We talked a little bit about
the difference between clinical and surveillance definitions in the previous presentation
and, those will continue. You may see some cases
in here where clinically, you may disagree, but we
are training on the use of the definitions
and a surveillance for surveillance purposes and
applying them consistently as they’re supposed to
be done and we’re hoping to optimize the interrater
reliability by doing this and improving our data quality. So, just remember that
for today’s discussion, the purpose is not to debate the
correctness of the definitions but to learn how to
correctly use them. I covered this information
earlier, for those of you that did not watch that
earlier presentation, these are questions that you
might want to ask yourself as you’re working through
the determination of whether or not something it is
a healthcare-associative infection. And specifically, you
might first ask yourself, isn’t it an HAI? If not, if it was– doesn’t
meet the criteria for an HAI, then you can stop
your investigation. If it’s not– for NHSN purposes,
we wouldn’t be recording that. If it is an HAI, you
might ask yourself which site-specific
criteria is met, and then once you’ve determine
that, then you might want to ask yourself if it’s
a device-associated HAI. And, if we’re talking
specifically about CLABSIs, or LCBI, laboratory-confirmed
bloodstream infections, you might also want to ask yourself whether it’s
a primary or a secondary BSI. And then finally, whether it’s
attributable to what locations or facilities it’s attributable
to, and in the case of an SSI, what procedure would
it be attributable to. Now, if you’re only doing
CLABSI– or surveillance, you may determine to do
this in a different order. You might first want
to look to see if the patient has
central-line in place. If there was no central-line in place during the
hospitalization, then the patient
wouldn’t develop– could not develop a CLABSI,
central line-associated BSI, and you could discontinue
your investigation. Likewise, if you’re only doing
CLABSI surveillance in ICUs, if the patient had
never been in ICU, then he could not have CLABSI
that’s attributable to an ICU. And so, you may want to stop
your investigation there for an adjustment purposes,
so you may change the order of this based on your own
facility’s circumstances. So, let’s jump right
into our case studies. The first case study is
Ms. A who is transferred to your facility with
pancreatic cancer and a peripherally
inserted central catheter which is first asked
access on day 1. On the 7th of April, blood
culture was collected– that was collected on April 5th
is growing Providencia stuartii and no other organisms
are isolated. The patient started
on antibiotics. I provided to you for
you here some additional laboratory values. You can see that admission
day is listed as day– as April first here, and we have
WBCs for everyday following that and ANCs, two of the days. The blood culture was
collected on April 5th as I’ve shown you here and
it was reported on the 7th. So the first question is, does the patient meet
criteria for an HAI? The answer is yes, because
all elements of the CDC and NHSN-sites specific
infection criteria in this case, LCBI, were first
present together on or after the third hospital day. We’re identifying the day of
hospital admission as day 1. This is considered the
healthcare-associated infection. It’s also attributed to your
hospital for the same reason but we’ll talk about
that in a minute. So next question is,
what specific type of HAI does Ms. A have? An LCBI 1? LCBI 2? Or an MBI-LCBI 1 or 2? And the answer is that she
has an MBI-LCBI criterion 1. And let’s see why. Patient meets the
LCBI criterion 1 because she had a positive
blood culture with a pathogen and no other recognized source. And additionally, the patient
meets the neutropenic definition which is two values of an
ANC or WBCs less than 500, on or within three calendar
days before the positive blood culture collection. So as you can sees day of positive blood culture
collection is here, we identified that as a day 1. And, on that day she
had an ANC of 400, and on the day before,
she had a WBC of 400. So you can see that it can be a
mixture count of ANCs and WBCs. It doesn’t have to be
just all WBCs or ANCs. Additionally, the patient
had an allegeable pathogen, this was an Enterobacteriaceae, and no other pathogens
were isolated from the blood besides
an allegeable organism from MBI-LCBI 1. So the patient meets
criteria MBI-LCBI 1.2. Next question, is the CLABSI
attributed to your facility or the transferring facility? And I think I tipped
you off to this earlier. The CLABSI is attributed
to your facility because the device
was accessed there. Remember that if a
patient is admitted with a preexisting central line,
the line should be included on the central-line day count and your CLABSI surveillance
starting with the first day that the line is accessed. And BSIs with the date of event,
on or after day 3 are attributed to the admitting facility. And remember, the date of
event is the date that all of the elements are
first present together. Very good, so that’s case one. Let’s go to our second case, Mr. B. Mr. B is a 73-year-old
Caucasian male that’s admitted to the ER on 6/10 with
nausea and vomiting, abdominal pain, and fever. He has a past medical
history of hypertension, hiatal hernia, esophageal
reflux. His admission vital
signs are noted here, nothing out of the
extraordinary. His temp however, is 38.0, and
we do have some other things that may want to know
here, amylase, 4,900, Lipase 4,000, WBCs are 22.7. And they did a CT of the abdomen and it’s suggestive
of pancreatitis. He is admitted to the medical
ICU on the 10th of June with a diagnosis
of pancreatitis. And the temp, he
continues to run a fever and it actually jumps
to a 102 Fahrenheit. He has NG tube that’s placed. He’s on– he’s made NPO. He has IV fluids and
support of care began, and they derived
two blood cultures. On the 13th, because of
his poor peripheral access, they started a central
line, left subclavian, and they began him on
TPN after verifying the– by the chest x-ray the
placement of that central line. The blood culture results
from the 10th are negative. He is transferred
to 6 North Surgical. He is afebrile on the 13th. And the 15th, he
is still afebrile. His chest x-ray shows
some fluid indicative of congestive heart failure. He has some Lasix
administered to correct. On the 16th, he is afebrile. He has an increased
abdominal pain and vomiting. And they start some
Levaquin and Flagyl. Now, we’re going to jump ahead and to the 27th,
when he is afebrile. His TPNs has been discontinued because he’s tolerating
his PO intake. In three days later,
he’s still afebrile. They discontinued
his central-line and they transferred
him to 5 West Medical after discontinuing his
Levaquin and his Flagyl. On the 1st of July,
his fever is a 100.8, so he his temp has going up. He has nausea and vomiting and he has blood cultures
times two collected. The next day, his fever
is not present but one of the blood cultures and
one’s that was positive for staph epidermis,
and one bottle in the other blood
culture status positive for coag negative staph,
and they began Vancomycin. By the 4th, he is afebrile and he is actually
discharged on the 11th. So, question number one,
is there an infection? If there is an infection,
is it POA or HAI? And the answer is it’s HAI. It occurred, all
elements first occurred on or after hospital day 3. It first occurred together
on or after hospital day 3. What site-specific
criteria would you consider when you’re making
this determination? Or you’re probably
going to look at LCBI or laboratory-confirmed
bloodstream infection ’cause you have a positive blood culture. That’s– so that’s the first
place you’re going to start. And then, we’re going
to ask ourselves, is it a device-associated
infection? Well, let’s consider this. The patient was– had
his central-line inserted on the 13th of June
and it was discontinued in the 30th of June. And July 1st, we had a fever
and he had blood cultures that were collected
and they were positive for staph epidermidis
and coag negative staph. So, was the central-line
in place for greater than two days– two days,
and the day of the BSI? The answer is yes. And, was the central-line
in place at the time of the blood culture or if
it had been discontinued which is the case here, was in
criteria for LCBI met on the day of discontinuation
or the next day? And the answer to that is yes. It was on the next
day, the first. So this is considered a
device-associated BSI. Just to show you, this
is an LCBI criterion two, patient had fever and the
positive laboratory results that were not related
to an infection at another site so it’s primary. And, he– patient had two
or more blood cultures drawn on separate occasions that showed a matching common
commensal, in this case, staph epidermidis that was
described as coag negative staph in the second culture. So, if there is or was CLABSI, to which unit should
it be attributed? Choices are medical ICU, 5
West Medical, or 6 North? And the correct answer
is 6 North. And let’s see why. Remember that if all
elements of an HAI are present within two calendar
days of transfer from one end patient location
to another in the same facility, in other words, on the day
of transfer, the next day, the HAI is attributed to
the transferring location. If we go back, patient was
transferred to 5 West at 6:30, culture or the date of
infection is the next day so it’s not the day of
transfer or about the next day. Therefore, it’s– it is attributed back to 6
North transferring location. Very good! Ms. C. Ms. C is a
45-year-old female with newly diagnosed stage
IIB endometrial cancer that’s admitted to the Women’s
Center on 11/2 for a total abdominal
hysterectomy, as well as, bilateral salpingo-oophorectomy,
and removal of pelvic and abdominal lymph nodes. She is also scheduled to have
a PICC placed for participation in the clinical trial. She has a three-month
history of new onset of pelvic pain and dysmenorrhea. She has had two previous
C-sections and the last one
was 10 years ago. Her remission and vital
signs are unremarkable. They placed the PICC line in interventional
radiology on the second. She’s typed and crossmatched
for two units of packed red blood cells
for anemia and she receives that transfusion through
her PICC on that same day. She has her surgery
on the third. There was no complication. She is transported back
to the Women’s Center from a postop recovery unit. The next day, on the forth,
she is still afebrile. Her postop antibiotics
are discontinued. The dressing is changed and
the incision has no signs of erythema or drainage, and
the Foley is draining clear yellow urine. On the fifth, the patient is
ambulating with assistance. They take out her
Foley catheter. Her dressing remains
dry and intact. She has her first bowel
movement without any difficulty and she is medicated
for abdominal pain. She’s having a pain of about
an 8 on a 1 to 10 scale. On the sixth, she
is running a fever. Her fever is 38.8
degrees Celsius, maximum. She continues to complain of
abdominal pain as unresolved with pain meds and she has
a slight tenderness noted on palpation of her left
lower abdominal area. On the seventh, her
temp is 39 degrees. Her blood cultures are
collected times two. She is sent for a CT which
shows an abscess present in the left lower
abdominal cavity. They drained that and
cultured the purulent material that is sent. IV is placed and
antibiotics are started. On the eleventh, or,
I’m sorry, on the ninth, her– she is afebrile. Her blood culture
is positive for VRE and Bacteroides fragilis
times two. And the culture from
the abscess is positive for B. fragilis also. The patient reports a
decreased abdominal pain. And on the twelfth, the
patient’s drain is removed. Abdominal signs are present. She has a followup
CT scan that shows that the abscess has resolved
and she is discharged. So, the first question is,
does the patient have an HAI? And you can choose that yes,
she does; no, she does not; or C, you are not sure. The answer is that yes, the
patient does have and HAI. Remember that all
elements of ECDC, an HSN site-specific infection
criteria, were present– first present together on or
after the third hospital day. In this case, she has
met criteria for a SSI, a surgical site infection. If so, what type? Hopefully, I just didn’t
give away too much. In traces, our patient only has
an intra-abdominal infection, IAB, with B. fragilis. Two, the patient has
an organ/space SSI-IAB with B-fragilis and a CLABSI
with VRE and B. fragilis. C, the patient has an
organ/space SSI-IAB with B. fragilis and a VRE. In this case, the BSI
is secondary to the IAB. Or finally, the patient
has an organ/space SSI-IAB and a secondary BSI with B.
fragilis and a CLABSI with VRE. The answer is C, the patient
has an organ/space SSI-IAB with B. fragilis and VRE, and
the BSI is considered secondary. So, we have to go
back to Appendix 1 in the situation for guidance. And Appendix 1 is
found in chapter 4 of the CLABSI event chapter and the NHSN Patient
Safety Component Manual. The appendix is at the end. Excuse me. The appendix is a
secondary BSI guide. And what it states is that,
in a patient suspected of having an infection or blood in a site-specific specimen
are collected for culture, and both are positive for at
least one matching organism. And that’s what we have here. We have– both cultures
have B. fragilis, although the blood
culture also has VRE in it. If the site-specific
culture is an element used to meet the infection
site criterion, then the BSI is considered
secondary to that site-specific infection. So specifically, in this case,
it’s saying that if the culture from the purulent fluid is
used to meet the IAB criteria, then we’re going to identify
the BSI as secondary. In this case, that’s
exactly the case. The patient meets IAB criterion
1 which is organisms cultured from purulent material from
the intra-abdominal space by invasive procedure. A site culture is used
to meet this definition. So, this patient has an
SSI with secondary BSI with both organisms even though
the VRE was not collect– was not recovered from the IAB. But it is a logical organism
that we might expect to see in an intra-abdominal abscess. As you can see here, the patient
meets the organ/space criteria within 30 days after
the procedure. And because there was no implant
and actually, this is an old– I’m just realizing this is
an old shot from the manual. I need to update that,
but the patient– because we no longer have the
30 days with implant rule. The infection involves any
part of the body including– excluding the skin
fascia or muscle layers. It’s opened or manipulated
during the upper procedure and the patient has
organisms isolated from an aseptically
obtained culture of fluid or tissue in the organ/space. And additionally, the patient
also meets C in abscess or other evidence of infection
involving the organ/space found on direct exam during re-app
by histo or radiologic exam. In addition, to meeting
the organ/space infection, as you know, the
patient also meets– needs to meet one of the site-specific
organ/space infections. In this case, it’s the IAB,
intra-abdominal infection. And the patient has organisms
cultured from purulent material from intra-abdominal
space obtained during invasive procedure. So, that’s number one and that’s
the one that’s determining that this BSI is secondary. But you can see the patient
also meets criterion 3, fever, abdominal pain, organisms
cultured from a blood and a positive CT scan. Very good. So, we’ll move along to Mr.
D. Mr. D is a 79-year-old male admitted with gastric cancer. Has a central line placed
on the day of admission for total parenteral nutrition. On the 16th, he has a partial
gastrectomy that’s performed. Patient is progressing well
until he spikes a fever of 101.3 on the 21st, and they
sent some blood cultures. On the 22nd, he continues to
have increasing abdominal pain. They do a CT scan of the abdomen that shows a small fluid
collection that’s posterior to the stomach. Fluid collection
is fully drained by ultrasound-guided
needle aspiration, and purulent fluid
is sent for culture. And the blood cultures
are repeated. On the 23rd, the blood
cultures from May 21st are one of two positive for
Staph epidermidis. Abdominal fluid is
growing gram positive cocci and they started antibiotics. And on the 24th, the
abdominal culture is positive for E. cloacae. The blood cultures from the
22nd, two of two are positive for coag-negative staph. So, first question is,
is there an infection? If there is an infection,
is it an HAI? And the answer for this is yes. And probably by now, you
guys are getting very good at identifying that. If all elements of the infection
criteria were first present together on or after
the third hospital day, with day of hospital
admission being day 1, then the infection is considered
healthcare-associated. The second question is does
this patient have a CLABSI? Your choices are yes,
the patient has a CLABSI with Staph epidermidis. No, the BSI is secondary
to the abdominal infection. Or, you could say,
gees, I’m not just sure. And the answer is that
no, this BSI is secondary to the abdominal infection
and let’s look at why. Again, we have to go
back to Appendix 1. And when a patient suspected of
having an infection has blood in a site-specific
specimen cultured but the organisms do not
match, such as we have here, if the site-specific culture, in
this case, the abdominal fluid, is an element used to meet
the infection site criteria, and in this case it
is, IAB criteria one, and the blood isolate
is also an element used to meet another criterion
at the same infection site and in this case, it is. IAB criteria 3c as we mentioned
earlier involves the blood culture in a positive
CT scan with symptoms. Then in that case, the blood– BSI is considered secondary to
that site-specific infection. So, this is an SSI-IAB
with both E. cloacae and coag-negative staph. Now, this might be
one where you have– your clinical decision may
make you a little uncomfortable ’cause coag-negative staph
might not be the first organism that you think of when you think
of intra-abdominal infection. But this is– we’re going to
stick with the consistency of the definition and
identify it as such. Okay, Ms. E. Ms. E is a
41-year-old female that presents to the emergency in diabetic
coma and with anemia. She has a subclavian catheter
inserted in the emergency room. In the next day, in the ICU, she
has a midline catheter inserted and she received some blood
transfusions on August 14th. On the 17th, she develops
fever of 39 degrees Celsius and shaking chills and they
sent two sets of blood cultures. On the 19th, those blood
cultures are positive for Pseudomonas aeruginosa and neither insertion
site shows inflammation and there is no other
documented infection. So the question is,
is there an LCBI? Choices are no; yes,
it’s an LCBI with Pseudomonas aeruginosa;
or C, you’re not sure. The correct answer is yes,
the patient has an LCBI with Pseudomonas aeruginosa. So, let’s ask which criterion
of LCBI does this patient meet? Criterion 1, recognized
pathogen or criterion 2, two or more positive
blood cultures with a common commensal
and fever and chills. And the correct answer
is number 1, criterion 1, ’cause the patient had
Pseudomonas aeruginosa. What unit should be
indicated for the location of the device insertion field? When you enter this BSI into
NHSN, there is a field that asks for the location of
device insertion. Would you record it as the ED? Would you record it as the ICU? Would you record it as neither
of those two, something else? Or, you’re not sure. Correct answer is that
ED should be indicated as the location of
device insertion. But I do want you to remember that although the line
was inserted in the ED, the LCBI will actually
be attributed to the ICU. And that’s according to the
transfer rule, in the exception to the transfer rule,
specifically, the fact that the ED could not
have CLABSIs attributed to it because it’s not
a bedded location. There is no overnight stays
and there is no summary day such central lines or central
line days or patient days that are collected in that area. So, it has to be attributed
to the next location. This is a CLABSI because the
line was inserted on 8/15 and all elements of the BSI
criteria were first present together on 8/17 when the
central line had been in place for greater than two days. Now, I just want to
highlight that the location of insertion field
is an optional field. You do not have to fill that
in, but if it is something that you do want to
collect in this situation, ED would be the correct
location. Okay, let’s change the scenario
and say that on the 17th, the patient’s subclavian
catheter site is red and has a small amount of pus. Does this change your decision? You can say no, they still
have a CLABSI or yes, it’s no longer a CLABSI. The correct answer is that
this is still a CLABSI. I want to bring your
attention to the criteria for cardiovascular system
infection which is found in chapter 17 of
the NHSN manual. This patient meets
criteria 4 which says, the patient has purulent
drainage at the involved vascular site and the blood culture
is not done or no organism is
cultured from the blood. Actually, I’ve highlight that
because they don’t meet that. They don’t meet any
of the criteria. They specifically don’t meet
this part of the criteria because there was a
blood culture done. So, if you look at the
reporting instructions that are at the bottom of
this definition, we’ll see that the
second bullet says, report intravascular infections
with organisms cultured from the blood as BSI-LCBI. So, because the patients got
this infection that’s involving this intravascular catheter
and there’s positive BS– blood stream– blood culture, we’re going to report
it as a BSI. I do want to bring
this to your attention because sometimes people,
the first thing they think of when they have a patient that
has an infection, what appears to be an infection at a catheter
site, is that they’re trying to make– determine whether
it’s a BSI that’s secondary to a skin infection. And really, when it’s involving
a catheter, you need to look at the vascular, the
CVS-VASC criteria, not the skin infection. Moving along, Ms. F. Ms. F who
is 10 years old has been in PICU for a week with a central line
in placed the entire time. Four months ago, she received an
allopoietic stem cell transplant for AML, acute myelocytic
leukemia. She currently weighs
25 kilograms. On the 6th of April,
the line is pulled. In April 7th, she becomes
disoriented and hypotensive. Her blood cultures are
collected times two and they send urine
cultures as well. One of the blood cultures
is positive for Strep mutans and the other was
reported as positive for viridans group strep. So, the first question
is, is this a BSI and if so, which criterion? Yes, this patient has
an LCBI criterion 2. She has hypotension and
two or more blood cultures with a common commensal
that’s considered to be the same organism
and not related to an infection in another site. So, Strep mutans is included
in the viridans group strep. So, those are matching
blood cultures. Is it a central line-associated
BSI? And the answer is yes, this is
a central line-associated BSI. Remember that the device
was in place for more than two calendar
days when all elements of the CDC/NHSN site-specific
infection criterion were first present together. What organisms should
be reported? Pause ] I’m going to report S. mutans. And just to remind you that
when you have two organisms that are matching, two common
commensals that are matching, the two organisms,
and one is reported at a more detailed level
or a more specific level, you’re going to report
the more specific. In this case, Strep
mutans is more specific than viridans group strep. So, that’s why it’s
reported that way. Okay, so what happens if there
was gastrointestinal graft versus host disease
documented from Ms. F? Would that change
your determination? Well, this is actually
still an LCBI criterion 2. The description of GI GVHD
has to be very specific. It has to say that it’s
either a grade 3 or a grade 4 to meet criteria for an
MBI-LCBI criterion 2-1a. Just GI VHD is not enough. What if on April 4th she had two
or 625 milliliters of diarrhea, does that change
your determination? Well, let’s take a look here. We’ve put the information
that– unto this table. So, table 1 or I’m sorry, April
6th is identified as day 1 because that’s the day that
the first blood culture is collected. We also have one on April 7th. And then we had diarrhea with
625 milliliters on April 4th. So, does that make a
difference in our determination? And the answer is yes. So, we know that the patient
meets LCBI criterion 2 already. She has a common commensal
identified in her blood and has a match within two
days and she has no other site and she’s also had symptoms. Additionally, the patient also
meets allogenetic hematopoietic stem cell transplant definition. Specifically, that she has had
more than 20 milliliters of– per kilogram of diarrhea
in the 24 hours– within 24 hours on or
within seven days prior to the blood culture. So, let’s look at the timing. This is day– the day of the
blood culture within seven days, one, two, three, four,
she’s negative 4 that well within the seven days. And if we did the math we
would see that according to the requirements
at 25 kilograms, she would only require 20– 500 milliliters of diarrhea
at a minimum, and she had 625. Additionally, she had– the blood culture was only
growing viridians group strep and no other organisms. So therefore, she does meet
now MBI-LCBI criterion 2-1b. Now I’m giving you this
criterion listed as 2-1b. When you report it into the NHSN
system you’ll just identify it as MBI-LCBI and you will
be putting in the elements, the criteria that you meet. But I’m giving you these
further information so that you can go back
if you want to and look at the specific criteria
that are met. So, this just shows
you the criteria and where she actually
met these. I won’t spend too
much time on that. What happens if the second
blood culture in addition to the viridian group strep
also grew micrococcus, so one of the cultures, blood cultures grew
micrococcus additionally? This is still an MBI-LCBI
because that single culture of micrococcus without
a matching blood culture within two days does not
meet the LCBI criteria, so, it’s considered a contaminant and we would not exclude the
MBI-LCBI for that reason. What happens if it
was Staph aureus? So they had instead of having
just viridians group strep they also had that and Staph
aureus in their blood. In that case it couldn’t
meet MBI-LCBI criteria because remember it can only– criteria 2 can only contain
viridians group strep and criterion 1 for MBI-LCBI 1
can only include a certain set of organism which are gut
organisms, Staph aureus which is not one of those. So, this would then
be classified as an LCBI criterion
1, a pathogen, and a positive blood culture
and no other recognized cause. Okay, we’re good, moving along. Baby Z is a 1-day-old
twin male infant admitted and emergently transferred to the neonatal intensive
care unit. Intubated during transport and
admitted with a peripheral IV in the scalp that’s
infusing at 1 cc per hour with Prostene [phonetic],
started prior to the transport. And patient also has an
umbilical fetus catheter. Gestational age was term. Birth weight was 1810 grams. The APGARs were 5 and 6. An echocardiogram
showed transposition of the great vessels
of the heart. On day 3, they repaired the
patent ductus arteriosus and the atrial septal defects. And later that day the umbilical
catheter site was noted to be slightly red. On day 4, the umbilical
site continues to be red and a low grade temperature
has developed. And on the fifth day there is
one blood culture that’s drawn through the umbilical line. The line was discontinued and the catheter tip
was sent for culture. They then placed a PICC line. On day 6, the patient continued
to have elevated temps. It reached as high as 38.1
degrees Celsius, rectal, and they started antibiotics. And on the seventh day, the
blood cultures were negative but the umbilical
catheter tip was positive for Staph epidermidis,
more than 15 colonies and they adjusted
the antibiotics. So the first question is if
this patient has an infection, is it an HAI? It is an HAI, all elements of the CDC/NHSN site-specific
infection criterion were first present together on or after
the third hospital day. In which criteria would you
consider LCBI 2 or 3 babies less than a year of age so, either
one would be reasonable and this is a common
commensal organism so, those would be the
logical criteria that you would consider. Would you consider it
to be device associated? And the answer is yes. The device was in place
for more than two day– calendar days when
all of the elements of the infection criterion
were first present together. Does the patient have an LCBI? Patient does not have an LCBI. So we considered those criteria but the patient actually
did not reach them, and that’s because the catheter
tip cultures are not utilized for NHSN LCBI criteria,
only blood cultures and your blood cultures
were negative. The patient actually meets
criterion 5 of vascular if you look at that criteria. It has a fever and greater
than 15 colonies are cultured from the intravascular cannula
tip using a semi-quantitative culture method and the
blood culture was not done or in this case, there
were no organisms cultured from the blood. So, if you’re reporting or
following vascular infections, this is one that
you would report. This is just a screenshot
to show you the criteria and opposite of what
we had earlier where we had positive blood–
organisms from the blood, in this case, we actually
don’t have any and so, we’re going to report this
as CV-VASC– CVS-VASC. So, let’s change
this just a bit. What if the catheter
tip had been negative but the blood culture was
positive for Staph epidermidis? So, instead of a blood catheter
tip we have a positive Staph epidermidis in the blood one. Would the baby have an LCBI? The answer is no, because
we only have one culture from the blood that’s
positive with common commensal. We need a supportive matching
common commensal collected within two days from the blood
and we didn’t have that so, we can’t call this as an LCBI. So, let me ask you
denominator question. If the patient had both the
PICC and the umbilical line at the same time, how would her
device days be counted each day? Would you count her as
having one central line day, two central line days,
one umbilical line day, one central line day and
one umbilical line day, or you could say
you’re not sure. The correct answer is
that you would count that as one central line day. Remember that umbilical
catheters are no longer counted separately and not used
from other central lines and therefore, we only count
this as one central line day. Ms. G. Ms. G is a 7 year old
that’s admitted to the ICU from the ER on June 1st with
a five-day history of fever, vomiting and diarrhea, which
became bloody two days ago. The patient’s oral intake
has been very small, her pulse is weak and thready
and she is hypotensive. And first, a Foley
catheter is inserted as well as a right subclavian
central line in the ER. They collected urine,
stool and blood cultures and they start some
IV hydration with her. On the second, she has
occult blood in her urine and her output is decreased. Her lab– the lab reports that her stool is growing
suspected E. coli 0157:H7. On the third, she’s experiencing
very low urine output and it’s grossly bloody. She had moderate bruising, her
labs are indicative of anemia and she has an increased
reticulocyte count. Her left upper extremity
PICC line is placed, they start hemodialysis, and that hemodialysis
is administered by contract staff via
this dedicated PICC line. Fluids continue and she started
on corticosteroid therapy. On the 4th, E. coli 0157:H7
infection is confirmed and the organism is present
in the blood and stool. So, this is a BSI that’s
present on admission. Met the criteria within
the first two days of hospitalization. On the sixth, patient
is on hemodialysis and a continuing
supportive therapy. Her labs are stable except for a slight increase
in her WBCs to 117. On the tenth, she experiences
blood pressure fluctuations, pressors are instituted. Her WBCs are elevated
since yesterday at 1500. They collect blood
and urine for culture, do a UA which is negative
for both leukocyte esterase and nitrate, and has two
WBCs per high power field of spun urine. On eleventh, the blood
cultures are positive, two of two for MSSA and her
urine culture has no growth. Does Ms. G have an HAI now? And you can say yes, she
has a CLABSI with MSSA, meets LCBI criterion 1. No, the patient had
positive blood cultures on admission so,
this is not an HAI. Or no, the patient
had an infection at another site,
so, it’s not a BSI. And the correct answer is yes,
that this patient has a CLABSI with MSSA, criterion 1a. Patient had a clear
new onset of infection with blood pressure lability
and positive blood culture. There was no other
identified related infection at another site. And the central line hadn’t been
in place for more than two days at the time of the
blood culture. Is it attributed
to your facility? Now remember that you
had contracted staff that was providing
this hemodialysis to this patient via
this dedicated line. So, you can say; yeah, you still
have to call it as attributed to your facility or
no, it’s attributed to the dialysis company. The correct answer is yes, it
is attributed to your facility because facilities
are responsible for the care that’s
provided by contract of staff within our facility. If there is an equality
issue that’s related to contracted staff then
that needs to be addressed and actions taken to
prevent infections that could occur as a result. What if she had been transported
from her patient room to an inpatient dialysis,
you know, within you hospital
each day for dialysis? Probably a lot of you
have this situation, you have a dialysis
unit where patients– inpatients go, get dialyzed
and then come back to your– one of your units
for overnight stay and for the rest of their care. So, if that was taking place
instead of contracted stuff, would that make a difference? Again, would it be attributed– would you attribute that
infection to the ICU or would you now attribute
it to the dialysis unit? And in this case the CLABSI
has to be attributed to the ICU because the dialysis unit
is not a bedded location. Again, there is no central
line days that are collected on that unit nor
patient days, and so, it has to be attributed
to the ICU. Now, if you identify that
you have a lot of infections that seem to be related to
patients that are going, a lot of BSIs that are
attributed to a lot of patients that are going to the dialysis
unit, this may be something that you want to look into
so I would keep track of that in the comment section which
can be analyzed within NHSN. You can also create a custom
event in NHSN to track such events and you might call
it potential dialysis-related events or something
along that line. And then that’s another
way for you to keep track and to do some sort of
quality improvement. Okay, Mr. H. Mr. H
is a 66-year-old male that is admitted to the SICU
following a robotic-assisted LIMA harvest and
coronary bypass graft with both chest and
leg incision. During surgery, the patient
suffered a right ventricular injury which required a
pump-assisted approach repair. A left groin incision was
made for that purpose. The code for that, the ICD-9
code for that repair is 39.61 and for your purposes and
your knowledge this is not an operative procedure within NHSN. A central line was placed in
the right subclavian vein. Two days later the patient
was progressing well and was transferred to
the intermediate care with the central line. On the fifth, the
left groin incision with purulent drainage– has
purulent drainage, redness and tenderness and a temp
of 100.8 maximum is noted. An aseptically obtained
groin would drainage is sent for culture as well
as blood cultures and they began vancomyacin. The groin wound and
the blood are positive for gram-positive cocci. And on the seventh, both
cultures are identified as methicillin-sensitive
Staph aureus. The wound culture was pure. The antibiotics would change
to match the sensitivities with second generation
cephalosporin. So, which of the
following is true? A, this patient had a
superficial SSI and a CLABSI with MSSA, both should
be reported to NHSN. B, the patient has
a CLABSI with MSSA that should be reported to NHSN. Or C, the patient
has a skin infection with MSSA with a secondary BSI. The BSI would not
be reported to NHSN. Correct answer is C.
Here’s the rationale. The infection onset was greater
than two days after admission, it was actually four so
that makes it an HAI. The central line had been in
place for greater than two days at the time that all elements of the infection were
first present together. That makes this a
device-associated infection. But the patient meets criteria
for infection at another site and the organisms from the
blood and the site match. And we’ll see the next slide. Just to note that because the
ICD-9 code is a non-operative code, this– there could be no
SSI related to this infection. So the patient meets the skin
infection, purulent drainage, pustules and vesicles. Also meets criterion 2,
tenderness and redness. Organism is cultured from the
aspirate of the affected site. And also, the patient had
positive blood cultures. What if the wound drainage
was positive for MSSA but the blood cultures
were positive for Staph epidermidis,
two of two. Would the patient have an
HAI, and if so, what type? So now, we’re dealing
with a situation where we have a site-specific
culture that has one organism and the blood culture
that has another organism. There’s no matching
organisms involved. You– or traces are that patient
has a superficial SSI with MSSA and a CLABSI with Staph epi,
or the patient has a skin with secondary BSI with
both MSSA and Staph epi, or the patient has
a skin with MSSA and a CLABSI with Staph epi. Correct answer is that
the patient has a skin with secondary BSI with
both MSSA and Staph epi. And again, pulling from Appendix
1, when a patient is suspected of having an infection
in his blood and site-specific
infection culture but the organisms do not match. If the site-specific
culture is an element used to meet the infection site
criterion, in this case, it’s skin, criterion 1, and the
blood isolate is also an element used to meet another criterion
at the same infection site, and in this case, skin criterion
2a, then the BSI, a second– considered secondary to that
site-specific infection. Mr. I is a 55-year-old male
that’s brought to the ED on 6/17 with multiple injuries for
a motor vehicle accident. He has IV catheters in his right
forearm and left forearm by EMS. He got a normal saline
drip through each line and they inserted a Foley cath. He has a history of a left
inguinal hernia repair that was done two years ago and he is an insulin-dependent
diabetic. You can see from
his– his vital signs and labs are provided
here for you. Microscopic urinalysis showed 40 to 50 red blood cells
and few WBCs. Protein was slightly positive. He went to the OR on the 17th and had an open reduction
internal fixation of a left femur, splenectomy,
repair of a small bowel. It took five hours, 35
minutes to primarily close. He had general anesthesia
and an ASA class of 4E contaminated wound class. On the 17th, all dressing
is clean, dry and intact. Foley was draining. The NG tube was in place. The patient was on a pain pump. On the 18th, the temp is 99.6. Central line is inserted. The dressings are
clean, dry and intact. Foley is without issues. On the 19th, the temp is 99. They started TPN. The dressings were changed
and the wounds look okay. The Foley is draining
clear yellow urine. The patient is improving
from 620 to 625 and the maximum temperature
during that time was 99.2. But on the 26th,
the temp is 101.2. The patient is still on TPN. They pan culture the patient. The urinalysis shows 20 to
30 WBCs per high power field. Two sets of blood cultures are
drawn, one from the central line and the other from
the right arm. And they start antibiotics
and pulled the central line. The next day, temp is 100. Urine culture is positive for gram-negative rods
greater than 100,000. No culture from the
blood culture so far. The next day, the organism
in the urine is identified as Pseudomonas aeruginosa. The blood culture from the
central line is positive now for E. coli and the stent
from the right arm as well. And on the first, they
discontinued the Foley and the patient– transfer the
patient to inpatient rehab. Does this patient have an HAI? The answer is yes, the patient
has an HAI because all elements of the infection criterion
were first present together on or after the third hospital day. Which type of SSI? Correct answer is this patient
has a SUTI, a symptomatic UTI, with Pseudomonas aeruginosa
and a CLABSI with E. coli. Again, we have to go to appendix
1 in a patient suspected of having an infection
where blood and site-specific
specimen are collected but the organisms do not match. If the site-specific
culture is an element used to meet the infection
site criterion and the blood isolate is not, then the BSI is considered
a primary infection. We do not have a SUTI criterion
utilizing blood culture as one of the elements unless
it’s an ABUTI and this patient did not meet
ABUTI criterion ’cause he was not asymptomatic. Here’s your criteria. Remember that fever is a
nonspecific symptom of infection and if a fever is present
you can’t pick and choose which criteria to attribute
it to even if you think that clinically you
have a good idea of what’s causing the
fever, it has be applied to all criteria that
are eligible. Category of two more. Baby X is a two week old, 26
week gestational age infant that is transferred from another
hospital, so your level 2, 3 nursery with the right
lower extremity PICC in place on the 3rd of October. The baby was weaned from the
ventilator two days prior to transfer and now remains on
two liters of oxygen by hood. On the fifth, which is– specifically at 36 hours after
transfer the baby is irritable and his respiration rate
has slowly increased from admission rate of 46
to the current rate of 80. He’s got nasal flaring
and chest retractions, he’s got high heart rate
at 175 beats per minute, they note rales in the right
lung and DSats to 88 percent. Oxygen is increased to 4 liters. A chest x-ray reveals
pneumatoceles, probable pneumatoceles in the
lower right lung and one set of the blood cultures are
collected through the PICC line and empiric antibiotics
are began. On the sixth, another chest
x-ray still shows probable pneumatoceles in the
right lower lobe. WBCs are 3500. And on the seventh, blood cultures reveal
Acinetobacter baumannii. Which of the following is true? This is not a primary BSI, it’s
a secondary to an infection at another site,
specifically pneumonia. So no BSI would be
reported by itself. This is a primary BSI, CLABSI
and should be reported. Or, this is a secondary BSI and should be reported
to NHSN as a CLABSI. The answer is that this
is not a primary BSI. It’s an infection– I’m sorry,
it’s secondary to an infection at another site pneumonia and you would not
report any separate BSI. Specifically, you can see here
that the baby met criteria for pneumonia 2 with
pneumatoceles, leuko– I think it was leukocytosis
in this case, rales and worsening gas exchange
and positive blood culture. Should the HAI be
attributed to your hospital or to the transferring facility? HAI should be attributed
to your hospital. Remember that the transfer–
what the transfer rule states and in this case the baby
was transferred on the third and on the first day that all of the criteria were present
together is not until day 6. And as a result, the HAI–
the pneumonia is considered, it’s been– it was
on day 3 or more and so this is considered
attributable to your facility,
not the others. I was thinking here that this
is a BSI that would be here, but we’re not talking
about a BSI. We’re talking about
a pneumonia and all of those criteria
were not present until the 6th of October. Ms. Y is a 50-year-old patient
who’s been out of your unit for 7 days receiving
induction chemotherapy for diffuse large
B-cell lymphoma and has had a central
line throughout. Because of tachycardia she’s
had two blood cultures drawn, she’s got no other
signs or symptoms. Two days later on the 7th,
she’s growing Bacillus cereus from one blood culture and
Bacteroides fragilis also. And the second blood
culture is positive for Bacteroides fragilis
and E. coli. Because– we’re thinking because
this patient is a chemotherapy patient, perhaps
they meet criteria for an MBI-LCBI criteria so I
plotted out the ANCs and WBCs for you here to use and
I identify that the day 1 which is the positive blood
culture collection date which was April 5th is here
in the box and you can see that this patient had several
days where the ANC was less than 500, and a couple where the
WBCs were also less than 500. So which of the following
is true? No LCBI criteria are met. The patient has an LCBI
1 with Bacillus cereus, Bacteroides fragilis
and E. coli. The patient has an MBI-LCBI 1 with B. fragilis
and E. coli only. Or patient has an MBI-LCBI 2 with only Bacillus
cereus reported. Number 3 is correct. Remember that this
patient meets criterion 1, had a pathogen recovered
from blood culture with no other recognized
source, was neutropenic within at least two days of ANC,
her total WBC is less than 500, we identified that within
three calendar days before or on the day of blood culture
and we have identified that. The organisms were all
eligible pathogens, Bacteroides and E. coli and there were
no other organisms recovered. The single culture of
bacillus does not exclude, because it doesn’t meet
criteria for an LCBI. So this meets– this patient
meets criteria for MBI-LCBI 1. And that is the extent of
our case studies today. I hope that they’ve
been helpful to you. I know that you may want to–
or to review them in depth and hopefully, you’ll
be able to do that utilizing the
pause feature here. Thank you very much.


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