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CLABSI, CAUTI, and Cases… oh my! Kari L. Kuebler RN, BSN Infection Preventionist Surveillance Specialist Infection Prevention Indiana University Health APIC Indiana NHSN Liaison
CLABSI, CAUTI, and Cases…
oh my!Kari L. Kuebler RN, BSN
Infection Preventionist Surveillance Specialist
Infection Prevention Indiana University Health
APIC Indiana NHSN Liaison
OBJECTIVES
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1. Review NHSN Central Line-Associated Bloodstream
Infection (CLABSI) criteria
2. Review NHSN Catheter-Associated Urinary Tract Infection
(CAUTI) criteria
3. Provide case studies based on participant survey sent
prior to conference. (53 responses 41 attending today)
SURVEY SAYS…CONCERNING CLABSI SURVEILLANCE, RESPONDENTS FEEL THEY…
Are a CLABSI Master
Need a lot of help
Are proficient
Get by
2%
6%
38%
42%
12%NA
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SURVEY SAYS…CONCERNING CAUTI SURVEILLANCE, RESPONDENTS FEEL THEY…
Are a CAUTI Master
Need a lot of help
Are proficient
Get by
4%
7%
53%
30%
6%NA
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SURVEY SAYS…CON CER N IN G N HS N HAI CR ITER I A , R ES PON DEN TS R EPOR TED N OT F UL LY UN DER S TAN D IN G …
Secondary BSI Attribution Period (SBAP) 72%
Repeat Infection Timeframe (RIT) 42%
Infection Window Period (IWP) 23%
Present on Admission (POA) 15%
Date of Event (DOE) 13%
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2
3
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CLABSI REVIEW• LCBI (Laboratory Confirmed Bloodstream Infection)
– LCBI 1 (Recognized Pathogen)
– LCBI 2 (Common Commensal)
– LCBI 3 (Common Commensal for patient <1)
• Must use NHSN Organism list https://www.cdc.gov/nhsn/xls/master-organism-com-commensals-lists.xlsx
• Each year, in January, list is updated. Be sure you have current list
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Step by Step1. Determine the 7 day Infection Window Period (IWP)
• Date of first positive diagnostic test that is used as an element of the site-specific criterion
• 3 days before and 3 days after diagnostic test
• In LCBI this is always the blood culture
2. Is organism a recognized pathogen or a common commensal
•
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3. Determine elements of criteria present in IWP.• Common commensal specimens represent a single element, the collection date of the first specimen is
used to determine the IWP
• ex: LCBI 2 – looking for temp >38.0, chills, hypotension
• Rule out or identify as a LCBI 1, LCBI 2, or LCBI 3
4. Determine the Date of Event (DOE)• DOE is the date the first element used to meet an NHSN site-specific infection criterion occurs for the
first time within the seven-day infection window period
• LCBI 1- this will always be the date of the culture as that is the only element of the criteria
• LCBI 2- this will be your s/s or your culture, whichever was first in the IWP
5. Determine if POA or HAI (or within a RIT for same event type)
Admission to inpatient locationIf
POA
stop
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6. Determine device association
7. Determine location of attribution• Infection is attributed to patient location on the DOE
• If patient transferred or discharged the date of the event or the day prior, event is attributed to the
transferring unit.
• If patient was in multiple locations (the day of the event and day prior), attribute the infection to the
FIRST location the patient was housed in the day before the DOE.
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8. Determine RIT
• The date of event is Day 1 of the 14-day RIT.
• If same infection type is met within the RIT, new infection cannot be called. If there is a
new / different organism, it is added to the original infection maintaining the original DOE.
• ENDO RIT is extended until discharge.
• RIT’s do not carry over to the next admission, even if it’s the same facility.
• The RIT will apply at the level of specific type of infection with the exception of BSI, UTI,
and PNEU where the RIT will apply at the major type of infection.
• BSI (LCBI 1, LCBI 2, LCBI 3, MBI-LCBI 1, MBI-LCBI 2, and MBI-LCBI 3)
• PNEU (PNEU 1, PNEU 2, and PNEU 3)
• UTI (SUTI, ABUTI, and USI)
Only one of these major type of infection can be reported in a RIT.
For example you cannot identify a LCBI 1 and then report an MBI-
LCBI 1 within the RIT set by the LCBI 1.
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10. Determine if BSI is Primary or Secondary• A BSI that is identified as secondary to another site of infection must meet one of the infection criteria
detailed in chapter 17, UTI, PNEU, SSI, or PVAP
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APPENDIX B. Secondary Bloodstream Infection (BSI) Guide
Scenario 1: At least one organism from the blood specimen matches an organism identified from the site-specific infection that is used as an element to meet the NHSN site-specific infection criterion AND the blood specimen is collected during the secondary BSI attribution period (infection window period + repeat infection timeframe).
OR
Scenario 2: An organism identified in the blood specimen is an element that is used to meet the NHSN site-specific infection criterion, and therefore is collected during the site-specific infection window period.
Determine if BSI is Primary or Secondary (continued)
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Determine if BSI is Primary or Secondary (continued)
1. Is there another suspected infection?
2. Is there a site specific specimen that can be used to meet a NHSN criteria?
STEP by STEP
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Determine if BSI is Primary or Secondary (continued)
Is there a site specific specimen
that can be used to meet a NHSN
criteria?
• If site-specific infection criteria is
met using site specific specimen,
determine SBAP.
• Does blood specimen used to
meet LCBI contain at least one
matching organism from the site
specific specimen?
• Is LCBI DOE in the SBAP?
DOE/
SUTI
67y/o Indwelling cath placed
S
B
A
P
Fever >38.0
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Determine if BSI is Primary or Secondary (continued)
3. Can the blood specimen be used as an element of the site-specific definitions below?
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Determine if BSI is Primary or Secondary (continued)
Can the blood specimen be used as an
element of the site-specific definitions?(we will be using the PNEU2 criteria for this example)
• Identify first positive diagnostic test
that is used as an element to meet
the site-specific infection criterion to
set the IWP.
• If site-specific infection criteria is
met using blood specimen, is blood
specimen is in the IWP.
• Is organism identified in the blood
specimen and element used in the
site specific criteria?
DOE /
PNUE2
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11. If a Primary LCBI 1, LCBI 2, or LCBI 3 has been identified- ensure
pt does not meet MBI- LCBI 1, MBI-LCBI 2, or MBI-LCBI 3 criteria.• The MBI-LCBI DOE will always be the date the prerequisite LCBI criteria was
met.
CASE STUDY: – Pt is admitted with abdominal Cancer on 2/2 and taken to the OR for an
exploratory lap, SC CVL is placed.
– Pt has liver resected and right nephrectomy.
– Peritoneal drains are placed. Over next several week pt has large
amount of drainage (ascites) requiring IV fluid replacement. Pt has
intermittent vomiting and difficulty tolerating feeds. NJ tube is in place.
– On 2/26 a abd CT shows diffuse bowel wall thickening. Pt is checked
for C-Diff, it is negative. Pt is intermittently febrile with t-max of 38.0
– Pt continues to deteriate. Becomes confused and pulls out SC CVL on
3/4.
– 3/5 pt becomes hypotensive, new IJ CVL is placed to start
vasopressors. Blood cultures are done. Pt is started on antibiotics.
Blood cultures are positive for E.coli.
– A repeat abd CT is done on 3/6. CT shows metastatic disease involving
the colon with a possible perforation. T-max is 38.4.
– On 3/8, peritoneal fluid is cultured from drain placed on 2/2. Fluid
culture grows E.coli.
– On 3/10 pt passes. 18
What we know:
• E.Coli is a recognized pathogen.
• If not other cause, this will meet
LCBI 1 with a DOE of 3/5 (culture
date)
• DOE is on day 3 of inpatient stay or
later= HAI
• This is the first (+) Blood specimen so
we are not in the RIT of any other BSI.
To determine still:• Is this device associated?
• Primary or Secondary BSI?
WHAT DO YOU THINK?IS THIS DEV ICE AS S OCI AT E D?
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• SC CVL is placed on 2/2
• SC CVL is pulled out by patient on 3/4
• New IJ CVL is placed on 3/5
• LCBI 1 DOE 3/5
• Is this device associated?
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• What site specific criteria do
we want to try to rule out
to based on symptoms and
site specimens?
• What symptoms do we
have?• temp >38.0
• hypotensive
• Could we use the blood
culture and radiology to
meet? • CT shows metastatic CA
and a possible perforation
• Blood culture grows E.coli
Primary or
Secondary?
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• Set IWP
• Are all elements
of criteria met
within IWP?
• Identify DOE
• Identify RIT
• Identify SBAP
• Is Blood culture
within the
SBAP?
• IAB with
secondary LCBI1
IWP
DOE
14
days
from
DOE
SBAP
=
IWP
+
RIT
CLABSI : THINGS TO REMEMBER• A secondary BSI does not set a RIT.
• Chapter 2 “Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance”
contains a section called “Pathogen Assignment Guidance” – suggested reading
• SUTI, PNEU, and VAE have excluded organisms. ENDO, GIT, and IAB have limited inclusion
organisms.
– Organisms belonging to the following genera cannot be used to meet any NHSN definition: Blastomyces,
Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus and Pneumocystis .
• When meeting the Endocarditis (ENDO) definition, the secondary BSI attribution period includes
the 21-day infection window period and all subsequent days of the patient’s current admission.
– As a result of this lengthy ENDO secondary BSI attribution period, secondary BSI pathogen
assignment for ENDO, is limited to organism(s) identified in blood specimen that match the
organism(s) used to meet the ENDO definition.
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CAUTI CRITERIA REVIEW:
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Just follow this
simple flow chart
CAUTI OVERVIEW:
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SUTI 1- WITH A DEVICE
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Patient must meet 1, 2, and 3 below:
1. Patient had an indwelling urinary catheter that had been in place for > 2 days on the date of event
AND was either:
• Present for any portion of the calendar day on the date of event
OR
• Removed the day before the date of event
2. Patient has at least one of the following signs or symptoms:
• fever (>38.0°C): To use fever in a patient > 65 years of age, the indwelling urinary catheter
needs to be in place > 2 calendar days on date of event.
• suprapubic tenderness (no other cause)
• costovertebral angle pain or tenderness (no other cause)
• urinary urgency
• urinary frequency
• dysuria
3. Patient has a urine culture with no more than two species of organisms identified, at least one of
which is a bacterium of ≥105 CFU/ml (See Comments).
All elements of the SUTI criterion must occur during the IWP
Can only use when
device is NOT in
place.
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Urine Culture Clarification
• Candida species or yeast not otherwise specified, mold, dimorphic fungi or parasites are excluded as organisms in the UTI definition therefore blood with these organisms cannot be secondary to UTI
• Urine culture with yeast can be included as long as there is at least one bacterium with ≥105CFU/ml and no more than 2 organisms (e.g., > 105CFU/ml of E. coli and > 105CFU/ml of C. albicans)
• Urine cultures with > 2 organisms are routinely regarded as contaminated cultures and not used for NHSN CAUTI surveillance. (e.g., > 105CFU/ml E. coli, S. aureus and C. albicans = 3 organisms)
• Urine culture including “mixed flora” or equivalent such as “perineal flora”, “vaginal flora”, “normal flora” cannot be used (e.g., > 105CFU/ml of E. coli and perineal flora)
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Apply SUTI criteria:
1. Identify qualifying culture
2. Set IWP
3. Identify element of criteria in
window- if criteria met set DOE
4. Determine if POA or HAI
5. Determine if device associated
• Device in >2
• Removed day prior to the
DOE
DOEDay 4 = HAI
Indwelling cath placed
Indwelling cath removed
BOOK MARK YOUR RESOURCES
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AJIC CASE STUDIES
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July 1, 2016Volume 44, Issue 7, Pages 761–763
Lab ID event
June 1, 2017Volume 45, Issue 6, Pages 612–614
PATOS
Organ space
BSI and SSI- primary or secondary
December 1, 2017Volume 45, Issue 12, Pages 1394–1395
Use of NHSN HAI and POA worksheet
Applying PNUE criteria
Secondary BSI
AJIC- Available online 12 February 2018 (In Press, Corrected Proof)
Location mapping
