Att G.4_Central Line-Associated Blood Stream Infection

Device-associated Module
CLABSI

Bloodstream Infection (Central Line-Associated Bloodstream Infection
[CLABSI] and Non-central line-associated Bloodstream Infection [BSI])
Event
Introduction: An estimated 41,000 central line-associated bloodstream infections
(CLABSI) occur in U.S. hospitals each year.1 These infections are usually serious
infections typically causing a prolongation of hospital stay and increased cost and risk of
mortality.
CLABSI can be prevented through proper insertion techniques and management of the
central line. These techniques are addressed in the CDC’s Healthcare Infection Control
Practices Advisory Committee (CDC/HIPAC) Guidelines for the Prevention of
Intravascular Catheter-Related Infections, 2011.2
Settings: Surveillance will occur in any inpatient location where denominator data can be
collected, which may include critical/intensive care units (ICU), specialty care areas
(SCA), neonatal units including neonatal intensive care units (NICUs), step down units,
wards, and long term care units. A complete listing of inpatient locations and instructions
for mapping can be found in the CDC Locations and Descriptions chapter.
NOTE: Surveillance for CLABSIs after the patient is discharged from the facility is not
required. However, if discovered, any CLABSIs with event date on the day of discharge
or the next day should be reported to NHSN (see Transfer Rule). No additional central
line days are reported.
Requirements: Surveillance for HAI CLABSI is performed in at least one inpatient
location in the healthcare institution for at least one calendar month as indicated in the
Patient Safety Monthly Reporting Plan (CDC 57.106).
Definitions:
Present on Admission (POA): Infections that are POA, as defined in Chapter 2, are not
considered HAIs and therefore are never reported to NHSN.
Healthcare-associated infections (HAI): All NHSN site specific infections must first meet
the HAI definition as defined in Chapter 2 before a site specific infection (e.g., CLABSI)
can be reported to NHSN.
Primary bloodstream infections (BSI): Laboratory-confirmed bloodstream infections
(LCBI) that are not secondary to an infection at another body site (see Appendix 1.
Secondary Bloodstream Infection (BSI) Guide and Surveillance Definitions chapter).

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Date of event: For a BSI the date of event is the date when the last element used to meet
the laboratory-confirmed bloodstream infection (LCBI) criterion occurred. Synonym:
infection date.
Central line: An intravascular catheter that terminates at or close to the heart or in one of
the great vessels which is used for infusion, withdrawal of blood, or hemodynamic
monitoring. The following are considered great vessels for the purpose of reporting
central-line BSI and counting central-line days in the NHSN system:
 Aorta
 Pulmonary artery
 Superior vena cava
 Inferior vena cava
 Brachiocephalic veins
 Internal jugular veins
 Subclavian veins
 External iliac veins
 Common iliac veins
 Femoral veins
 In neonates, the umbilical artery/vein.
NOTES:
1.
Neither the insertion site nor the type of device may be used to determine if a line
qualifies as a central line. The device must terminate in one of the great vessels
or in or near the heart and be used for one of the purposes outlined above, to
qualify as a central line.
2.
An introducer is considered an intravascular catheter, and depending on the
location of its tip and use, may be a central line.
3.
Pacemaker wires and other non-lumened devices inserted into central blood
vessels or the heart are not considered central lines, because fluids are not infused,
pushed, nor withdrawn through such devices.
4.
The following devices are not considered central lines:
 Extracorporeal membrane oxygenation (ECMO)
 Femoral arterial catheters
 Intraaortic balloon pump (IABP) devices.
 Hemodialysis reliable outflow (HeRO) dialysis catheters
Infusion: The introduction of a solution through a blood vessel via a catheter lumen. This
may include continuous infusions such as nutritional fluids or medications, or it may
include intermittent infusions such as flushes, IV antimicrobial administration, or blood
transfusion or hemodialysis.
Umbilical catheter: A central vascular device inserted through the umbilical artery or vein
in a neonate.
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Temporary central line: A non-tunneled, non-implanted catheter.
Permanent central line: Includes
 Tunneled catheters, including certain dialysis catheters
 Implanted catheters (including ports)
Central line-associated BSI (CLABSI): A laboratory-confirmed bloodstream infection
(LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar
days on the date of event, with day of device placement being Day 1,
and
a CL or UC was in place on the date of event or the day before. If a CL or UC was in
place for >2 calendar days and then removed, the date of event of the LCBI must be the
day of discontinuation or the next day. If the patient is admitted or transferred into a
facility with a central line in place (e.g., tunneled or implanted central line), and that is
the patient’s only central line, day of first access as an inpatient is considered Day1.
“Access” is defined as line placement, infusion or withdrawal through the line.
Notes:
 Central lines that are removed and reinserted: If, after central line removal,
the patient is without a central line for at least 1 full calendar day (NOT to be read
as 24 hours), then the central line day count will start anew. If instead, a new
central line is inserted before a full calendar day without a central line has passed,
the central line day count will continue.
 To distinguish subsequent LCBIs from a previously unresolved LCBI, see Note
following HAI definition in Chapter 2.
 Patients suspected or known to have accessed their own IV lines are not excluded
from CLABSI surveillance. A facility must protect the line as best they can.
Prevention efforts may include providing a patient sitter and/or removal of the
catheter as soon as is clinically possible.
EXAMPLES:
 Patient in MICU has central line inserted/accessed on June 1. On June 3, the
central line is still in place and the patient has positive blood culture with S.
aureus. This is a CLABSI because the central line was in place for >2 calendar
days (June 1, 2, and 3) on the date of event (June 3).
 Patient has a central line inserted on June 1. On June 3, the central line is removed
and on June 4 the patient has a positive blood culture with S. aureus. This is a
CLABSI because the central line was in place for >2 calendar days (June 1, 2, and
3), and was in place the day before the date of event (June 3).
 A central line is placed in the facility on May 30th. On June 3, the central line is
removed and on June 5 patient spikes a fever of 38.3°C. Two blood culture sets
collected on June 6 are positive for S. epidermidis. This is may be a healthcareassociated bloodstream infection but it is not a CLABSI because the central line
was not place the day of or the day before LCBI Criterion 2 was met (June 6, the
date of the last LCBI element).
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Location of attribution: The inpatient location where the patient was assigned on the date
of the LCBI event, which is further defined as the date when the first element used to
meet the LCBI criterion occurred (see exception below).
INPATIENT DIALYSIS:
Inpatients receiving dialysis are included in any CLABSI surveillance in the location in
which they are housed, regardless of whether or not the central line is the only central
line and only accessed for dialysis. This also applies to patients in Long-Term Acute Care
(LTAC) facilities within Acute Care Facilities when dialysis is received from the Acute
Care Facility staff.
EXAMPLES: CLABSIs in the following examples will be attributed to Unit A
 Patient on Unit A receives onsite dialysis by contracted dialysis staff
 Dialysis staff travels to Unit A to provide dialysis to Unit A patient
 Patient resides on Unit A for inpatient care, but is transported to dialysis unit
within the facility for dialysis. Since CLABSIs cannot be attributed to non-bedded
locations, such an event must be attributed to the inpatient location housing the
patient.
 Facilities may choose to capture information about the presence of a dialysis
catheter in patients with LCBIs. The BSI collection form includes a data field
“Any hemodialysis catheter present,” which may be marked yes or no, and
utilized internally by facility to identify association of dialysis to LCBI.

EXCEPTION TO LOCATION OF ATTRIBUTION:
Transfer Rule: If the date of event for a CLABSI is the day of transfer or discharge, or the
next day, the infection is attributed to the transferring location.. Receiving facilities
should share information about such HAIs with the transferring facility to enable
reporting. This is called the Transfer Rule and examples are shown below:
 Patient with a central line in place in the SICU is transferred to the surgical ward.
On the next day, the patient meets criterion for an LCBI. This is reported to
NHSN as a CLABSI for the SICU.
 Patient without a central line is transferred from the medical ward on hospital day
3 to MICU. Later that day a central line is inserted. The next day, LCBI criteria
are met. This would be considered a BSI and attributed to the medical ward;
however, it is not a CLABSI because the central line was not in place >2 days on
the date of event.
 Patient with a central line in place is transferred from the medical ward to the
coronary care ICU (CCU). After 4 days in the CCU and with the central line still
in place, all elements of LCBI are met. This is reported to NHSN as a CLABSI
for the CCU.
 After a two week hospital stay, a patient on the urology ward of Hospital A has
his only central line removed and is discharged home a few hours later. The IP
from Hospital B calls the next day to report that this patient has been admitted to
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Hospital B and meets LCBI criteria. This CLABSI should be reported to NHSN
for, and by, Hospital A and attributed to the urology ward.
NOTE: Example of multiple transfers within the transfer rule time-frame:
3/22
Patient in Unit A

3/23
Patient transferred from
Unit A to Unit B.
Later that day, patient
transferred to Unit C.
(day of transfer)

3/24
Patient transferred from Unit C to Unit D.
This is also the date of event for a
CLABSI. This CLABSI is attributed to
Unit A since Unit A was the original unit
initiating the transfer in the 2 day timeframe.
(day after transfer)

Table 1. Laboratory-Confirmed Bloodstream Infection Criteria
Criterion

Laboratory-Confirmed Bloodstream Infection (LCBI)
Comments and reporting instructions that follow the site-specific
criteria provide further explanation and are integral to the correct
application of the criteria.
Must meet one of the following criteria:

LCBI 1

Patient has a recognized pathogen cultured from one or more blood
cultures
and
organism cultured from blood is not related to an infection at another
site.(See Appendix 1 Secondary BSI Guide)

LCBI 2

Patient has at least one of the following signs or symptoms: fever
(>38.0oC), chills, or hypotension
and
organism cultured from blood is not related to an infection at another
site (See Appendix 1 Secondary BSI Guide) and
the same common commensal (i.e., diphtheroids [Corynebacterium
spp. not C. diphtheriae], Bacillus spp. [not B. anthracis],
Propionibacterium spp., coagulase-negative staphylococci [including
S. epidermidis], viridans group streptococci, Aerococcus spp., and
Micrococcus spp.) is cultured from two or more blood cultures drawn
on separate occasions (see comment 3a below). Criterion elements
must occur within a timeframe that does not exceed a gap of 1
calendar day between adjacent elements.
(See complete list of common commensals at
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http://www.cdc.gov/nhsn/XLS/master-organism-Com-CommensalsLists.xlsx)
NOTE: The matching common commensals represent a single
element; therefore, the collection date of the first common
commensal is the date of the element used to determine the Date of
Event.
6/1/2013
S.
epidermi
dis (1 of
2)

LCBI 3

6/2/2013
S.
epidermidi
s (1 of 2)

6/3/2103
No LCBI
elements

6/4/2013
Fever > 38.0
°C

Date of LCBI
Event =
6/1/2013

Patient ≤ 1 year of age has at least one of the following signs or
symptoms: fever (>38.0oC core), hypothermia (<36.0oC core),
apnea, or bradycardia
and
positive laboratory results are not related to an infection at another
site (See Appendix 1 Secondary BSI Guide)
and
the same common commensal (i.e., diphtheroids [Corynebacterium
spp. not C. diphtheriae], Bacillus spp. [not B. anthracis],
Propionibacterium spp., coagulase-negative staphylococci [including
S. epidermidis], viridans group streptococci, Aerococcus spp.,
Micrococcus spp.) is cultured from two or more blood cultures drawn
on the same or consecutive days and separate occasions (see
Comment 3a below). Criterion elements must occur within a
timeframe that does not exceed a gap of 1 calendar day between
adjacent elements. (See complete list of common commensals at
http://www.cdc.gov/nhsn/XLS/master-organism-Com-CommensalsLists.xlsx)
NOTE: The matching common commensals represent a single
element; therefore, the collection date of the first common
commensal is the date of the element.
6/1/2013
S.
epidermi
dis (1 of
2)

6/2/2013
S.
epidermidi
s (1 of 2)

6/3/2103
No LCBI
elements

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6/4/2013
Fever > 38.0
°C

Date of LCBI
Event =
6/1/2013

Device-associated Module
CLABSI

Criterion

Mucosal Barrier Injury Laboratory-Confirmed Bloodstream
Infection (MBI-LCBI)
In 2014 when reporting an LCBI, it is required to indicate which of
the underlying conditions of the MBI-LCBI criterion was met, if any.
All CLABSI, whether LCBI or MBI-LCBI, must be reported if
CLABSI is part of your Monthly Reporting Plan.
Must meet one of the following criteria:

MBI-LCBI 1

Patient of any age meets criterion 1 for LCBI with at least one blood
culture growing any of the following intestinal organisms with no
other organisms isolated (See Comment #5): Bacteroides spp.,
Candida spp., Clostridium spp., Enterococcus spp., Fusobacterium
spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., or
Enterobacteriaceae*
and
patient meets at least one of the following:
1. Is an allogeneic hematopoietic stem cell transplant recipient
within the past year with one of the following documented
during same hospitalization as positive blood culture:
a. Grade III or IV gastrointestinal graft versus host
disease [GI GVHD] (See Comment #6)
b. ≥1 liter diarrhea in a 24-hour period (or ≥20 mL/kg in
a 24-hour period for patients <18 years of age) with
onset on or within 7 calendar days before the date the
positive blood culture was collected.
2. Is neutropenic, defined as at least 2 separate days with values
of absolute neutrophil count (ANC) or total white blood cell
count (WBC) <500 cells/mm3 within a seven-day time period
which includes the date the positive blood culture was
collected (Day 1), the 3 calendar days before and the 3
calendar days after (See Table 4 for example).
*See Table 3 for partial list of eligible Enterobacteriaceae genera.

MBI-LCBI 2

Patient of any age meets criterion 2 for LCBI when the blood cultures
are growing only viridans group streptococci with no other organisms
isolated
and
patient meets at least one of the following:
1. Is an allogeneic hematopoietic stem cell transplant recipient
within the past year with one of the following documented
during same hospitalization as positive blood culture:
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a. Grade III or IV gastrointestinal graft versus host
disease [GI GVHD] (See Comment #6)
b. ≥1 liter diarrhea in a 24-hour period (or ≥20 mL/kg in
a 24-hour period for patients <18 years of age) with
onset on or within 7 calendar days before the date the
first positive blood culture was collected.
2. Is neutropenic, defined as at least 2 separate days with values
of absolute neutrophil count (ANC) or total white blood cell
count (WBC) <500 cells/mm3 within a seven-day time period
which includes the date the positive blood culture was
collected (Day 1), the 3 calendar days before and the 3
calendar days after (See Table 4 for example).
MBI-LCBI 3

Patient ≤1 year of age meets criterion 3 for LCBI when the blood
cultures are growing only viridans group streptococci with no other
organisms isolated
and
patient meets at least one of the following:
1. Is an allogeneic hematopoietic stem cell transplant recipient
within the past year with one of the following documented
during same hospitalization as positive blood culture:
a. Grade III or IV gastrointestinal graft versus host
disease [GI GVHD] (See Comment #6)
b. ≥20 mL/kg diarrhea in a 24-hour period with onset on
or within 7 calendar days before the date the first
positive blood culture is collected.
2. Is neutropenic, defined as at least 2 separate days with values
of absolute neutrophil count (ANC) or total white blood cell
count (WBC) <500 cells/mm3 on or within a seven-day time
period which includes the date the positive blood culture was
collected (Day 1), the 3 calendar days before and the 3
calendar days after. (See Table 4 for example)

Comments

1. In LCBI criterion 1, the term “recognized pathogen” includes any
organism not included on the common commensal list (see
criteria 2 and 3 or Supporting Material section at
http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html
for the list of common commensals).
2. LCBI criteria 1 and 2 and MCI-LCBI criteria 1 and 2 may be
used for patients of any age, including those patients ≤1 year of
age.
3. In LCBI criteria 2 and 3, if the pathogen or common commensal
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is identified to the species level from one blood culture, and a
companion blood culture is identified with only a descriptive
name, which is complementary to the companion culture (e.g., to
the genus level), then it is assumed that the organisms are the
same. The organism identified to the species level should be
reported as the infecting organism along with its antibiogram if
available (see Table 2 below). Only genus and species
identification should be utilized to determine the sameness of
organisms (i.e., matching organisms). No additional comparative
methods should be used (e.g., morphology or antibiograms)
because laboratory testing capabilities and protocols may vary
between facilities. This will reduce reporting variability, solely
due to laboratory practice, between facilities reporting LCBIs
meeting criterion 2. Report the organism to the genus/species
level only once, and if antibiogram data are available, report the
results from the most resistant panel.
a. In LCBI criteria 2 and 3, the phrase “two or more blood
cultures drawn on separate occasions” means 1) that blood
from at least two blood draws were collected on the same
or consecutive calendar days and 2) were collected in a
manner which suggests that 2 separate blood draw site
preparations were performed. This will reduce
misidentification of contaminated blood cultures as LCBI.
For example, blood cultures drawn from different sites
(e.g., different venipunctures, a combination of
venipuncture and lumen withdrawal, or different lumens of
the same central line) should undergo separate
decontaminations and are therefore considered drawn on
“separate occasions”.
b. A blood culture may consist of a single bottle for a
pediatric blood draw due to volume constraints. Therefore,
to meet this part of the criterion, each bottle from two
single bottle blood draws would have to be culture-positive
for the same commensal.
4. Specimen Collection Considerations: Although blood cultures
drawn through central lines can have a higher rate of
contamination than blood cultures collected through peripheral
venipuncture 3, 4 all positive blood cultures, regardless of the sites
from which they were collected, must be included when
conducting in-plan CLABSI surveillance.
5. In MBI-LCBI 1, 2 and 3, “No other organisms isolated” means
there is not isolation in a blood culture of another recognized
pathogen (e.g., S. aureus) or common commensal (e.g.,
coagulase-negative staphylococci) other than listed in MBI-LCBI
criterion 1, 2 or 3 that would otherwise meet LCBI criteria. If
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this occurs, the infection should not be classified as MBI-LCBI.

REPORTING
INSTRUCTIONS

1. Report organisms cultured from blood as BSI–LCBI when no
other site of infection is evident (see Appendix 1. Secondary
Bloodstream Infection [BSI] Guide).
2. Catheter tip cultures are not used to determine whether a patient
has a primary BSI.
3. When there is a positive blood culture and clinical signs or
symptoms of localized infection at a vascular access site, but no
other infection can be found, the infection is considered a primary
BSI.
4. Purulent phlebitis confirmed with a positive semiquantitative
culture of a catheter tip, but with either negative or no blood
culture is considered a CVS-VASC, not a BSI, SST-SKIN, or a
ST infection.
5. Occasionally a patient with both peripheral and central IV lines
develops a primary bloodstream infection (LCBI) that can clearly
be attributed to the peripheral line (e.g., pus at the insertion site
and/or matching pathogen from pus and blood). In this situation,
enter “Central Line = No” in the NHSN application. You should,
however, include the patient’s central line days in the summary
denominator count.
6. If your state or facility requires that you report healthcareassociated BSIs that are not central line-associated, enter “Central
Line = No” in the NHSN application when reporting these BSIs.
You should, however, include all of the patient’s central line days
in the summary denominator count.

Table 2. Examples of How to Report Speciated and Unspeciated Organisms Isolated
from Blood Cultures
Culture Report

Companion Culture Report

Report as…

Coagulase-positive staphylococci

S. aureus

S. aureus

S. epidermidis

Coagulase-negative
staphylococci

S. epidermidis

Enterococcus spp.

E. faecium

E. faecium

Bacillus spp. (not anthracis)

B. cereus

B. cereus

S. salivarius

Strep viridans

S. salivarius

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Table 3. Partial List of Criterion 1 MBI-LCBI Eligible Enterobacteriaceae Genera
(See complete list of MBI Pathogens at http://www.cdc.gov/nhsn/XLS/master-organismCom-Commensals-Lists.xlsx)
Citrobacter
Enterobacter
Escherichia
Klebsiella
Proteus
Providencia
Salmonella
Serratia
Shigella
Yersina

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Table 4. Examples Illustrating the MBI-LCBI Criteria for Neutropenia
Day
-7
100

Day
-6
800

Day
-5
400

Day
-4
300

Day
-3
ND

Day
-2
ND

Day
-1
320

Pt.
A

WB
C

Pt.
B

ANC

ND

410

130

ND

ND

120

110

Pt.
C

WB
C

100

800

400

300

ND

ND

ND

Day
1*
400
+ BC* w/
Candida spp.
x1
ND
+BC* w/
viridans
strep x2 and
fever >38°C
600
+ BC* w/
Candida spp.
x1

Day
2
ND

Day
3
550

Day
4
600

110

300

320

230

ND

400

ND = not done
*Day the blood specimen that was positive was collected
Patient A meets MBI-LCBI criterion 1, sub-criterion 2: Positive blood culture with intestinal organism (Candida spp.) and neutropenia (2
separate days of WBC <500 cells/mm3 occurring on the date the positive blood culture was collected [Day 1] or during the 3 days before or
the 3 days after that date). In this case, the Day 1 value = 400, and Day -1 value = 320.
Patient B meets MBI-LCBI criterion 2, sub-criterion 2: At least 2 positive blood cultures with viridans group streptococci (in this case, 2
positive), and fever >38°C and neutropenia (2 separate days of ANC <500 cells/mm3 occurring on the date the positive blood culture was
collected [Day 1] or during the 3 days before or the 3 days after that date). In this case, the Day -1 value = 110 and

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Day -2 value = 120. Note: any two of Days -2,-1, 2, 3, and 4 could be used to meet this
requirement since WBC or ANC under 500 were present on those days.
Patient C meets MBI-LCBI criterion 1, sub-criterion 2: Positive blood culture with
intestinal organism (Candida spp.) and neutropenia (2 separate days of WBC <500
cells/mm3 occurring on the date the positive blood culture was collected [Day 1] or
during the 3 days before or the 3 days after that date). In this case, Day 2 value =230 and
Day 4value = 400]).
Numerator Data: The Primary Bloodstream Infection (BSI) form (CDC 57.108) is used
to collect and report each CLABSI that is identified during the month selected for
surveillance. The Instructions for Completion of Primary Bloodstream Infection (BSI)
form contains brief instructions for collection and entry of each data element on the form.
The Primary BSI form includes patient demographic information and whether a central
line was present, and, if so, the type of central line the patient had if appropriate to the
location; these data will be used to calculate line-specific infection rates. Additional data
include the specific criteria met for identifying the primary BSI, whether the patient died,
the organisms isolated from blood cultures, and the organisms’ antimicrobial
susceptibilities.

REPORTING INSTRUCTION:
 If no CLABSIs are identified during the month of surveillance, the Report No
Events box must be checked on the appropriate denominator summary screen,
e.g., Denominators for Intensive Care Unit (ICU)/Other locations (Not NICU or
SCA), etc.
Denominator Data: Device days and patient days are used for denominators (see Key
Terms chapter). Device-day denominator data that are collected differ according to the
location of the patients being monitored; however, within a location, they should be
collected at the same time each day. When denominator data are available from electronic
databases, these sources may be used as long as the counts are not substantially different
(+/- 5%) from manually-collected counts, pre-validated for a minimum of 3 months.
For locations other than specialty care areas/oncology (SCA/ONC) and NICUs, the
number of patients with one or more central lines of any type is collected daily, at the
same time each day, during the month and recorded on the Denominators for Intensive
Care Unit (ICU)/Other Locations (Not NICU or SCA/ONC) form (CDC 57.118). Only
the totals for the month are entered into NHSN. When denominator data are available
from electronic sources (e.g., central line days from electronic charting), these sources
may be used as long as the counts are not substantially different (+/- 5%) from manuallycollected counts, pre-validated for a minimum of 3 months.
For specialty care areas/oncology, the number of patients with one or more central lines
is dichotomized into those with permanent central lines and those with temporary central
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lines on the Denominators for Specialty Care Area (SCA)/Oncology (ONC) form (CDC
57.117). Each is collected daily, at the same time each day. Only the totals for the month
are entered into NHSN. This distinction in lines is made because permanent lines are
commonly used in patients frequenting these areas and may be associated with lower
rates of BSI than central lines inserted for temporary use. If a patient has both a
temporary and a permanent central line, count the day only as a temporary line day. The
Instructions for Completion of Denominators for Intensive Care Unit (ICU)/Other
Locations (Not NICU and SCA/ONC) and Instructions for Completion of Denominators
for Specialty Care Areas (SCA)/Oncology (ONC) contain brief instructions for collection
and entry of each data element on the forms.
In NICUs, the number of patients with one or more central lines is stratified by
birthweight in five categories since risk of BSI varies by birthweight. These data are
collected on the Denominators for Neonatal Intensive Care Unit (NICU) form (CDC
57.116).
NOTE: The weight of the infant at the time of BSI is not used and should not be
reported. For example, if a neonate weighs 1006 grams at birth but remains in the NICU
for two months and has a body weight of 1650 grams when a CLABSI develops, record
the birthweight of 1006 grams on the BSI form. The Instructions for Completion of
Denominators for Neonatal Intensive Care Unit (NICU) form contains brief instructions
for collection and entry of each data element on the forms.
Data Analyses: The Standardized Infection Ratio (SIR)6 is calculated by dividing the
number of observed infections by the number of predicted infections. The number of
predicted infections, is calculated using CLABSI rates from a standard population during
a baseline time period, which represents a standard population’s CLABSI experience.7
NOTE: The SIR will be calculated only if the number of expected HAIs (numExp) is ≥1
to help enforce a minimum precision criterion.
NOTE: In the NHSN application, “predicted” is referred to as “expected”.

While the CLABSI SIR can be calculated for single locations, the measure also allows
you to summarize your data across multiple locations, adjusting for differences in the
incidence of infection among the location types. For example, you will be able to obtain
one CLABSI SIR adjusting for all locations reported. Similarly, you can obtain one
CLABSI SIR for all specialty care areas in your facility.
NOTE: Only those locations for which baseline data have been published will be
included in the SIR calculations.

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The CLABSI rate per 1000 central line days is calculated by dividing the number of
CLABSI by the number of central line days and multiplying the result by 1000. The
Central Line Utilization Ratio is calculated by dividing the number of central line days by
the number of patient days. These calculations will be performed separately for different
types of ICUs, specialty care areas, and other locations in the institution. Separate rates
and ratios will also be calculated for different types of catheters in specialty care
areas/oncology locations and for birthweight categories in NICUs.
Descriptive analysis options of numerator and denominator data are available in the
NHSN application, such as line listings, frequency tables, and bar and pie charts. SIRs
and CLABSI rates and run charts are also available. Guides on using NHSN analysis
features are available from: http://www.cdc.gov/nhsn/PS-Analysis-resources/referenceguides.html.

1

CDC Vital Signs. Making healthcare safer: reducing bloodstream infections. March 2011. Available at:
http://www.cdc.gov/VitalSigns/HAI/index.html.
2

O’Grady NP, Alexander M, Burns LA,, Dellinger EP, Garland J, Heard SO, Maki DG, et al. Guidelines
for the prevention of intravascular catheter-related infections, 2011. Clinical Infectious Diseases 2011; 52
(a):1087-99.
3

Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for Blood Cultures;
Approved Guideline. CLSI document M47-A (ISBN 1-56238-641-7). Clinical and Laboratory Standards
Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania, USA, 2007.
4

Baron EJ, Weinstein MP, Dunne Jr WM, Yagupsky P, Welch DF, and Wilson DM. Cumitech IC: Blood
Cultures IV. ASM Press: Washington, DC; 2005.
5

Lee, A, Mirrett, S., Reller, LB., Weinstein, MP. Detection of bloodstream infections in adults: how many
blood cultures are needed? Journal of Clinical Microbiology, 2007; Nov;45(11): 3546-8. Epub 2007 Sep
19.
6

Your guide to the Standardized Infection Ratio (SIR). October 2010.
http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.pdf
7

Edwards et al. (2009). National Healthcare Safety Network (NHSN) report: Data summary for 2006
through 2008, issued December 2009. Available at:
http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.PDF

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Appendix 1. Secondary Bloodstream Infection (BSI) Guide (not
applicable to Ventilator-associated Events [VAE])
What is the meaning of the statement “not related to infection at another site” in
relation to a positive blood culture?
The purpose of using the CDC/NHSN infection criteria is to identify and consistently
categorize infections that are healthcare-associated into major and specific infection sites
or types. LCBI criteria include the caveat that the organism(s) cultured from the blood
cannot be related to infection at another site (i.e., must be a primary BSI). One must be
sure that there is no other CDC-defined primary site of infection that may have seeded
the bloodstream secondarily; otherwise the bloodstream infection may be misclassified as
a primary BSI or erroneously associated with the use of a central line, i.e., called a
CLABSI. For locations participating in in-plan VAE surveillance, refer to the VAE
chapter for specific guidance on assigning a secondary BSI to a VAE.
For purposes of NHSN, for a bloodstream infection to be determined to be
secondary to a primary infection site, (i.e. related to an infection at another site,
such that primary site of infection may have seeded the bloodstream secondarily)
the patient must meet one of the NHSN site specific definitions. To be considered
secondary to a site specific infection, an element of the BSI criteria must occur within a
time frame that is no more than 2 days before or 7 days after the date of the site specific
event (date of site specific event = day 1). For example, you cannot call a bloodstream
infection secondary to UTI based on a physician diagnosis of UTI alone.
Below are listed several scenarios that may occur with guidance on how to distinguish
between the primary or secondary nature of a BSI, along with the definition of “matching
organisms”, and important notes and reporting instructions.
1. Blood and site-specific specimen cultures match for at least one organism: In a
patient suspected of having an infection, blood and a site-specific specimen are
collected for culture and both are positive for at least one matching organism. then the
BSI is considered secondary to that site-specific infection.
a. Example: Patient meets HAI criteria for a symptomatic urinary tract infection
(suprapubic tenderness and >105 CFU/ml of E. coli) and blood culture from
the same date grows E. coli. This is an HAI SUTI with a secondary BSI and
the reported organism is E. coli.
b. Example: Patient meets HAI criteria for a symptomatic urinary tract infection
(suprapubic tenderness and >105 CFU/ml of E. coli) and blood culture from
the same date grows E. coli and P. aeruginosa. This is an HAI SUTI with a
secondary BSI and the reported organisms are E. coli and P. aeruginosa, since
both site and blood culture are positive for at least one matching pathogen
Example: Patient meets HAI criteria for a symptomatic urinary tract infection
(suprapubic tenderness and >105 CFU/ml of E. coli) and blood culture from
the same date grows E. coli and S. epidermidis. This is an HAI SUTI with a
secondary BSI and the reported organism is only E. coli, since the single
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common commensal S. epidermidis positive blood culture by itself does not
meet BSI criteria.
2. Blood and site-specific specimen cultures do not match: There are two scenarios
that can occur when a patient suspected of having an infection has blood and a sitespecific specimen cultured but the organisms do not match.
a. If the site-specific culture is an element used to meet the infection site
criterion and the blood isolate is also an element used to meet another
criterion at the same infection site, then the BSI is considered secondary to
that site-specific infection.
i. Example: Postoperative patient becomes febrile and complains of
nausea and abdominal pain. Blood and an aseptically-obtained Ttube drainage specimen are collected for culture. A CT scan done
that day shows fluid collection suggestive of infection. Culture
results show Escherichia coli from theT-tube drainage specimen
but the blood grows Bacteroides fragilis. Because the patient meets
IAB criteria by positive site-specific culture (IAB criterion 3a) and
by positive blood culture as an element of a different criterion of
the same infection site (IAB 3c), the blood is considered a
secondary BSI to an IAB and both organisms would be listed as
the IAB infection pathogens. No primary BSI would be reported.
b. 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.
i. Example: Postoperative patient has an intraabdominal abscess
(IAB) noted during reoperation and purulent material is obtained at
that time which grows Escherichia coli. The patient spikes a fever
two days later and blood culture shows Bacteroides fragilis.
Because the organisms from the site and blood cultures do not
match, and no site-specific criterion that includes positive blood
culture as an element is met, both a site-specific infection (GI-IAB
criteria 1 and 2) and a primary BSI would be reported.
ii. Example: Unconscious ICU patient with a Foley catheter and
central line for past 4 days spikes a fever; blood, urine and sputum
specimens are collected for culture. The urine culture grows
>100,000 CFU/ml of Escherichia coli, blood culture grows
Enterococcus faecium, and sputum shows oral flora only. Because
the organisms from the urine and blood cultures do not match, and
a UTI criterion that includes positive blood culture as an element is
not met, both a SUTI (SUTI criterion 1a) and a primary BSI would
be reported. This infection does not meet the ABUTI criterion
since that requires at least one matching uropathogen organism in
urine and blood in an asymptomatic patient.
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3. Negative or no site-specific specimen culture, only a positive blood culture: In a
patient suspected of having an infection, if the site specific specimen is negative or,
there is no site-specific specimen if a site-specific infection criterion is met, utilizing
a positive blood culture as an element, the BSI is considered secondary to that sitespecific infection. If no site specific criterion utilizing a positive blood culture is met,
then the BSI cannot be considered secondary to this specific type of infection.
a. Example: Patient has purulent material from the intra-abdominal (IAB) space
cultured and it yields no growth. The patient also has fever, abdominal pain,
a positive blood culture with Pseudomonas aeruginosa, and radiographic
evidence of IAB infection. This patient does not meet IAB criterion 1
(positive culture from purulent material) but does meet IAB criterion 3c, an
element of which is a positive blood culture (signs/symptoms plus positive
blood culture plus radiographic evidence). This BSI is considered secondary
to the IAB and P. aeruginosa is listed as the IAB infection pathogen.
b. Example: Patient has a central line in place for 10 days. Patient complains of
knee joint tenderness, in his native knee, and limited range of motion. CT
scan findings suggest joint (JNT) infection but culture of a needle-aspirated
joint fluid is negative. A blood culture from the same time period grows S.
aureus. While this patient does not meet JNT criterion 1 (positive joint fluid
culture), he does meet JNT criterion 3c (signs/symptoms plus positive blood
culture). Since a positive blood culture is part of the criterion met for JNT
infection, this BSI is considered secondary to the JNT infection and not
reported as a CLABSI. S. aureus is reported as the pathogen for the JNT
infection.
c. Example: Patient who is 4 days status post vaginal hysterectomy has
purulent drainage from the vaginal cuff seen upon pelvic exam. She also has
a blood culture positive with S. aureus. Although this patient meets criterion
1, of VCUF (vaginal cuff) infection (i.e. posthysterectomy patient has
purulent drainage from the vaginal cuff on gross anatomical exam), if there is
no other related site of infection, this BSI will be considered primary for
NHSN reporting, since there is no VCUF criterion met that includes a
positive blood culture as one of the elements.

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A matching organism is defined as one of the following:
1. If genus and species are identified in both cultures, they must be the same.
a. Example: A blood culture reported as Enterobacter cloacae and an
intraabdominal specimen of Enterobacter cloacae are matching organisms.
b. Example: A blood culture reported as Enterobacter cloacae and an
intraabdominal specimen of Enterobacter aerogenes are NOT matching
organisms as the species are different.
2. If the organism is less definitively identified in one culture than the other, the
identifications must be complementary.
a. Example: A surgical wound growing Pseudomonas spp. and a blood culture
growing Pseudomonas aeruginosa are considered a match at the genus level
and therefore the BSI is reported as secondary to the SSI.
b. Example: A blood culture reported as Candida albicans and a urine culture
reported as yeast are considered to have matching organisms because the
organisms are complementary, i.e. Candida is a type of yeast.
Notes:
1. If the blood isolate by itself does not meet BSI criteria (e.g., only one positive blood
culture of a common commensal), then that isolate may not be used to indicate the
presence of a secondary BSI (see example 1c).
2. Antibiograms of the blood and potential primary site isolates do not have to match.
3. Blood and site-specific specimens do not have to be collected on the same day but
there must be evidence of infection at the specific site at the time of blood culture
collection.
Reporting Instructions:
1. For reporting secondary BSI for possible and probable VAP, see Chapter 10.
2. Do not report secondary bloodstream infection for vascular (VASC) infections,
Ventilator-Associated Conditions (VAC), or Infection-related Ventilator-Associated
Complications (IVAC).
3. If a site-specific criterion requiring positive culture results is met, be sure to check the
positive culture box when specifying the criteria used when adding the event, even if
another criterion that does not include culture results is also met. For example, using
the scenario in 2.a.i above, the following boxes for criteria used would be checked
when entering the SSI into the NHSN application: fever, nausea, pain or tenderness,
positive culture, positive blood culture, imaging test evidence of infection.

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Instructions for Completion of Primary Bloodstream Infection (BSI)
Form (CDC 57.108)
Data Field
Facility ID
Event #
Patient ID

Social Security #
Secondary ID
Medicare #
Patient name
Gender
Date of Birth
Ethnicity
Race

Event type
Date of event

Post-procedure BSI
NHSN procedure code

January 2014

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer.
Event ID number will be auto-entered by the computer.
Required. Enter the alphanumeric patient ID number. This is the patient
identifier assigned by the hospital and may consist of any combination of
numbers and/or letters.
Optional. Enter the 9-digit numeric patient Social Security Number.
Optional. Enter the alphanumeric ID number assigned by the facility.
Optional. Enter the patient’s Medicare number.
Optional. Enter the last, first, and middle name of the patient.
Required. Check Female, Male, or Other to indicate the gender of the
patient.
Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Optional. Specify if the patient is either Hispanic or Latino, or Not
Hispanic or Not Latino.
Optional. Specify one or more of the choices below to identify the
patient’s race:
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Required. BSI.
Required. For LCBI criterion 1, the date of positive blood culture
collection. For LCBI criterion 2, the date when the first element used to
meet this criterion occurred. Enter date of this event using this format:
MM/DD/YYYY. NOTE: If a device has been pulled on the first day of
the month in a location where there are no other device days in that
month, and a device-associated infection develops after the device is
pulled, attribute the infection to the previous month.
Optional. Check Y if this event occurred after an NHSN-defined
procedure but before discharge from the facility, otherwise check N.
Conditionally required. If Post-procedure BSI = Y, enter the appropriate
NHSN procedure code.
NOTE: A BSI cannot be “linked” to an operative procedure unless that
procedure has already been added to NHSN. If the procedure was
previously added, and the “Link to Procedure” button is clicked, the fields
pertaining to the operation will be auto-entered by the computer.

CLABSI

Data Field
ICD-9-CM procedure code

Instructions for Data Collection
Optional. The ICD-9-CM code may be entered here instead of (or in
addition to) the NHSN Procedure Code. If the ICD-9-CM code is entered,
the NHSN code will be auto-entered by the computer. If the NHSN code
is entered first, you will have the option to select the appropriate ICD-9CM code. In either case, it is optional to select the ICD-9-CM code. Only
those ICD-9-CM codes identified in Table 1 of the Surgical Site Infection
Event Chapter (Chapter 9 of NHSN Manual: Patient Safety Component
Protocol) are allowed.
MDRO Infection Surveillance Required. Enter “Yes”, if the pathogen is being followed for Infection
Surveillance in the MDRO/CDI Module in that location as part of your
Monthly Reporting Plan: MRSA, MSSA (MRSA/MSSA), VRE, CephRKlebsiella, CRE-E. coli, CRE-Enterobacter, CRE-Klebsiella, MDRAcinetobacter or C. difficile.
If the pathogen for this infection happens to be an MDRO but your facility
is not following the Infection Surveillance in the MDRO/CDI Module in
your Monthly Reporting Plan, answer “No” to this question.
Location
Required. Enter the inpatient location to which the patient was assigned
on the date of the BSI event.
If the date of BSI occurs on the day of transfer or discharge from a
location or the next day, indicate the transferring/discharging location, not
the current location of the patient, in accordance with the Transfer Rule
(see Key Terms section).
Date admitted to facility
Required. Enter date patient admitted to facility using this format:
MM/DD/YYYY. An NHSN Inpatient is defined as a patient whose date of
admission to the healthcare facility and the date of discharge are different
calendar days. When determining a patient’s admission dates to both the
facility and specific inpatient location, the NHSN user must take into
account all such days, including any days spent in an inpatient location as
an “observation” patient before being officially admitted as an inpatient to
the facility, as these days contribute to exposure risk. Therefore, all such
days are included in the counts of admissions and patient days for the
facility and specific location, and facility and admission dates must be
moved back to the first day spent in the inpatient location.
NOTE Recently Discharged Patients: If a previously unreported BSI is
identified on the day of discharge or the day after discharge, enter the
previous date of admission.

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CLABSI

Data Field
Instructions for Data Collection
Risk Factors:
Required. Answer this question if the location is an intensive care unit
If ICU/Other locations, central (ICU) or location other than a specialty care area (SCA) or neonatal
line
intensive care unit (NICU). Check Y if patient had a central line (CL) for
more than 2 calendar days when the first element of the LCBI criterion
was present (date of event) and the device was in place on the date of
event or the day before,. otherwise, check N. Day of device insertion =
Day 1
NOTE: If the patient has both a peripheral and a central line and the BSI
can clearly be attributed to the peripheral line (e.g., pus at insertion site
and matching pathogen from pus and blood), check N.

Risk Factors:
If Specialty Care
Area/Oncology,
Permanent central line

Temporary central line

Risk Factors:
If NICU,

Required. Answer these questions if the location is an SCA or oncology
location:
Check Y if patient had a tunneled or implaneted central line (CL) for more
than 2 calendar days when the first element of the LCBI criterion was
present (date of event) and the device was in place on the date of event or
the day before, otherwise check N. Day of device insertion = Day 1
Check Y if patient had a non-tunneled or non-implanted central line (CL)
for more than 2 calendar days when the first element of the LCBI criterion
was present (date of event) and the device was in place on the date of
event or the day before, otherwise check N. Day of device insertion = Day
1
NOTE: If the patient has both a peripheral and a central line and the BSI
can clearly be attributed to the peripheral line (e.g., pus at insertion site
and matching pathogen from pus and blood), check N.
Required. Answer these questions if the location is an NICU:

Central line Check Y if patient had a central line (CL) or umbilical catheter (UC) for
> 2 calendar days when the first element of the LCBI criterion was present
(date of event) and the device was in place on the date of event or the day
Birthweight before, otherwise check N. Day of device insertion = Day 1
Required. Enter patient’s weight at the time of birth in grams, not the
weight on the date of event.
NOTE: If the patient has both a peripheral and a central line and the BSI
can clearly be attributed to the peripheral line (e.g., pus at insertion site
and matching pathogen from pus and blood), check N.
Any hemodialysis catheter
present
Optional. Check Y if the patient had any central line in place for the purpose
of hemodialysis. Check N if the patient had no central line in place for the
purpose of hemodialysis. If the patient has >1 central line at the time of the
January 2014

CLABSI

Data Field

Location of device insertion

Instructions for Data Collection
event, check Y if any were in place for the purpose of hemodialysis. There is
no requirement for this central line to have been accessed to check Y.
Optional. Enter the patient location where the central line was inserted.


If the patient has more than one central line, enter the location
where the first central line was inserted.



Date of device insertion

Event Details:
Specific event
Event Details:
Specify criteria used:
Event Details:
Died
Event Details:
BSI contributed to death
Event Details:
Discharge date
Event Details:
Pathogen identified

If the patient has both a permanent and a temporary central line,
enter the location where the temporary line was inserted.
Optional. Enter the date the central line was inserted. If the patient has
more than one central line, facility may choose which insertion date to
record.
Required. Check Laboratory-confirmed (LCBI).
Required. Check each of the elements of the criterion that were met.
Required. Check Y if patient died during the hospitalization, otherwise
check N.
Conditionally required if patient died. Check Y if the BSI contributed to
death, otherwise check N.
Optional. Date patient discharged from facility using this format:
MM/DD/YYYY.
Required. This field will be auto entered by the computer as Y. Specify
pathogens on reverse of form.

Pathogen # for specified Gram- Up to three pathogens may be reported. If multiple pathogens are
positive Organisms, Gramidentified, enter the pathogen judged to be the most important cause of
negative Organisms, Fungal
infection as #1, the next most as #2, and the least as #3 (usually this order
Organisms, or Other
will be indicated on the laboratory report). If the species is not given on
Organisms
the lab report or is not found on the NHSN drop down list, then select the
“spp” choice for the genus (e.g., Bacillus natto is not on the list so would
be reported as Bacillus spp.).
Antimicrobial agent and
Conditionally required if Pathogen Identified = Y.
susceptibility results
 For those organisms shown on the back of an event form,
susceptibility results are required only for the agents listed.


For organisms that are not listed on the back of an event form, the
entry of susceptibility results is optional.

Circle the pathogen’s susceptibility result using the codes on the event
forms.
Additional antimicrobial agents and susceptibility results may be reported
January 2014

CLABSI

Data Field
Custom Fields

Comments

January 2014

Instructions for Data Collection
for up to a total of 20 agents.
Optional. Up to 50 fields may be customized for local or group use in any
combination of the following formats: date (MM/DD/YYYY), numeric,
or alphanumeric.
NOTE: Each custom field must be set up in the Facility/Custom Options
section of the application before the field can be selected for use.
Optional. Enter any information on the event.