January 2022

Bloodstream Infection Event (Central Line-Associated Bloodstream

Infection and Non-central Line Associated Bloodstream Infection)

Table of Contents
Introduction ................................................................................................................................................................2
Settings .......................................................................................................................................................................2
Key Terms and Abbreviations .....................................................................................................................................2
Definitions Specific to Bloodstream Infection (BSI) / Central Line Associated Bloodstream Infection (CLABSI)
Surveillance: ...............................................................................................................................................................3
Laboratory Confirmed Bloodstream Infection (LCBIs) Hierarchy; Types of LCBIs ......................................................3
Types of Central Lines for NHSN reporting purposes:................................................................................................5
Devices Not Considered CLs for NHSN Reporting Purposes: .....................................................................................6
Table 1: Laboratory-Confirmed Bloodstream Infection Criteria: ...............................................................................6
Table 2: Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infection (MBI-LCBI) ................................... 10
Reporting Instructions: See below for a Summary of CLABSI Exclusions and Reporting Requirements. ............... 12
Reporting Instructions: ............................................................................................................................................ 13
Blood Specimen Collection ...................................................................................................................................... 14
Table 3: Examples of Associating the Use of Central Lines to BSI Events (CLABSI): ............................................... 16
Pathogen Exclusions and Reporting Considerations: .............................................................................................. 18
Table 4: Reporting Speciated and Unspeciated Organisms Identified from Blood Specimens............................... 19
Table 5: Examples Illustrating the MBI-LCBI Criteria for Neutropenia .................................................................... 19
Monthly Summary Data .......................................................................................................................................... 20
Table 6: Examples of Denominator Day counts for Device Days ............................................................................ 21
Table 7: Denominator Data Collection Methods..................................................................................................... 23
Data Analyses: ......................................................................................................................................................... 26
Table 8: CLABSI Measures Available in NHSN ......................................................................................................... 29
References ............................................................................................................................................................... 30
Appendix A: Partial List of MBI-LCBI Organisms ..................................................................................................... 31
Appendix B: Secondary BSI Guide (not applicable to Ventilator-associated Events [VAE]) .................................... 32
Table B1: Secondary BSI Guide: List of all NHSN primary site-specific definitions available for making secondary
BSI determinations using Scenario 1 or Scenario 2 ................................................................................................. 36
Secondary BSI Reporting Instructions: .................................................................................................................... 37
Pathogen Assignment .............................................................................................................................................. 39
Figure B1: Secondary BSI Guide for eligible organisms* ........................................................................................ 47
Figure B2: VAE Guidance for Secondary BSI Determination .................................................................................. 48

Disclaimer: The appearance of any product or brand names in this training protocol is for educational purposes
only and is not meant to serve as an official endorsement of any such product or brand by the Centers for
Disease Control and Prevention (CDC) or the United States Government. CDC and the United States
Government, by mentioning any particular product or brand, is neither recommending that product or brand
nor recommending against the product’s or brand’s use.

4-1
January 2022 Device-associated Module
BSI

Bloodstream Infection Event (Central Line-Associated Bloodstream

Infection and Non-central Line Associated Bloodstream Infection)

Introduction
Although a 46% decrease in CLABSIs has occurred in hospitals across the U.S. from 2008-2013, an estimated
30,100 central line-associated bloodstream infections (CLABSI) still occur in intensive care units and wards of
U.S. acute care facilities each year.1 CLABSIs are serious infections typically causing a prolongation of hospital
stay and increased cost and risk of mortality.

CLABSIs 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/HICPAC)
Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011.2

Settings
Surveillance may occur in any inpatient location where denominator data can be collected, which can 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: CLABSI surveillance after patient discharge from a facility is not required. However, if discovered, any
CLABSI with a date of event (DOE) on the day of or the day after discharge is attributed to the discharging
location and should be communicated to that facility to encourage appropriate NHSN reporting of CLABSIs.
(See Transfer Rule, Chapter 2). Do not collect or report additional central line days after discharge.

Key Terms and Abbreviations

Refer to the NHSN Patient Safety Manual, Chapter 2 Identifying Healthcare Associated Infections in NHSN and
Chapter 16 NHSN Key Terms for definitions of the following universal concepts for conducting HAI surveillance.
I. Date of event (DOE)
II. Healthcare associated infection (HAI)
III. Infection window period (IWP)
IV. Present on admission (POA)
V. Repeat infection timeframe (RIT)
VI. Secondary BSI attribution period (SBAP)
VII. Location of Attribution (LOA)
VIII. Transfer rule

4-2
January 2022 Device-associated Module
BSI

Definitions Specific to Bloodstream Infection (BSI) / Central Line Associated

Bloodstream Infection (CLABSI) Surveillance:
Primary bloodstream infection (BSI): A Laboratory Confirmed Bloodstream Infection (LCBI) that is not secondary
to an infection at another body site (see Appendix B. Secondary BSI Guide and CDC/NHSN Surveillance
Definitions for Specific Types of Infection [Ch-17], UTI [Ch-7], Pneumonia (Ch-6), and SSI (Ch-9).

Laboratory Confirmed Bloodstream Infection (LCBIs) Hierarchy; Types of LCBIs

(see Table 1 and Table 2):

BSIs

LCBI 1 LCBI 2 LCBI 3

MBI-LCBI 1 MBI-LCBI 2 MBI-LCBI 3

Secondary BSI: A BSI that is thought to be seeded from a site-specific infection at another body site (see
Appendix B. Secondary BSI Guide and CDC/NHSN Surveillance Definitions for Specific Types of Infection [Ch-17],
UTI [Ch-7], Pneumonia (Ch-6), and SSI (Ch-9)

Secondary BSI Attribution Period (SBAP): The period in which a blood specimen must be collected for a
secondary BSI to be attributed to a primary site of infection. This period includes the Infection Window Period
(IWP) combined with the Repeat Infection Timeframe (RIT). It is 14-17 days in length depending upon the date of
event (see Ch. 2 pages 2-13).

Infusion: The administration of any solution through the lumen of a catheter into a blood vessel. Infusions
include continuous infusion (for example, nutritional fluids or medications), intermittent infusion (for example,
IV flush), IV antimicrobial administration, and blood transfusion or hemodialysis treatment.

Access: The performance of any of the following activities during the current inpatient admission:
• Line placement
• Use of (entering the line with a needle or needleless device) any central line for:
o Infusion
o Withdrawal of blood
• Use for hemodynamic monitoring

4-3
January 2022 Device-associated Module
BSI

Notes:
1. If a patient is admitted to an inpatient location with a central line (CL) already in place, and it is the
patient’s only CL, the day of first access in an inpatient location begins the central line day count (CL Day
for making central line-associated determinations). Note: simply “de-accessing” any type of central line
(for example, removal of port needle but port remains in body) does not remove the patient from
CLABSI surveillance nor from device day counts for reporting denominator summary data.

2. An inpatient location, for making determinations about central line access, includes but is not limited to,
any department or unit within the facility that provides service to inpatients [for example, inpatient
Dialysis, Operating Room (OR), Interventional Radiology, Gastroenterology Lab (GI), Cardiac
Catheterization lab (CC), wards, ICUs, etc.].

3. Include any inpatient receiving dialysis in CLABSI surveillance conducted in the patient’s assigned
inpatient location, regardless of whether the patient only has one CL and dialysis staff are the only
providers to access it during dialysis treatment.
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 an Unit A patient
• Patient in Unit A for inpatient care is transported to dialysis unit within the facility for
dialysis

Because CLABSI events cannot be attributed to a non-bedded inpatient location (inpatient

location where denominator data is not collected but inpatient care is provided, for example,
OR, IR, or inpatient dialysis) , such events must be attributed to the inpatient location housing
the patient.

Central line (CL): An intravascular catheter that terminates at or close to the heart, or in one of the great vessels
AND is used for infusion, withdrawal of blood, or hemodynamic monitoring. Consider the following great vessels
when making determinations about CLABSI events and counting CL device days:
• 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.

4-4
January 2022 Device-associated Module
BSI

Notes:
1. Neither the type of device nor the insertion site is used to determine if a device is considered a central
line for NHSN reporting purposes.
2. At times, a CL may migrate from its original central location after confirmation of proper placement.
NHSN does not require ongoing verification of proper line placement. Therefore, once a line has been
designated a CL it remains a CL, regardless of migration, until removed from the body or patient
discharge, whichever comes first. CL days are included for any CLABSI surveillance conducted in that
location.
3. An introducer is an intravascular catheter, and depending on the location of the tip and its use, may be
considered a CL.
4. A non-lumened intravascular catheter that terminates at or close to the heart or in a great vessel that is
not used for infusion, withdrawal of blood or hemodynamic monitoring is not considered a CL for NHSN
reporting purposes (for example, non-lumened pacemaker wires.)

Note: There are some pacemaker wires that do have lumens, which may be considered a central line.

Types of Central Lines for NHSN reporting purposes:

1. Permanent central line: Includes:
a. Tunneled catheters, including tunneled dialysis catheters
b. Implanted catheters (including ports)
2. Temporary central line: A non-tunneled, non-implanted catheter
3. Umbilical catheter: A vascular catheter inserted through the umbilical artery or vein in a neonate. All
umbilical catheters are central lines.

Eligible Central Line: A CL that has been in place for more than two consecutive calendar days (on or after CL
day 3), following the first access of the central line, in an inpatient location, during the current admission. Such
lines are eligible for CLABSI events and remain eligible for CLABSI events until the day after removal from the
body or patient discharge, whichever comes first. See Table 3 for examples.
Eligible BSI Organism: Any organism that is eligible for use to meet LCBI or MBI-LCBI criteria. In other words, an
organism that is not an excluded pathogen for use in meeting LCBI or MBI-LCBI criteria. These organisms may or
may not be included on the NHSN organism list. Contact NHSN for guidance regarding organisms that are not
included on the NHSN organism list.

Central line-associated BSI (CLABSI): A laboratory confirmed bloodstream infection where an eligible BSI
organism is identified, and an eligible central line is present on the LCBI DOE or the day before.
Central line days: The number of days a central line is accessed to determine if an LCBI is a CLABSI.

Denominator device days: The count of central lines on an inpatient unit that is recorded in the monthly
denominator summary data. This count begins on the first day the central line is present, regardless of access.

4-5
January 2022 Device-associated Module
BSI

Devices Not Considered CLs for NHSN Reporting Purposes:

• Arterial catheters unless in the pulmonary artery, aorta or umbilical artery
• Arteriovenous fistula
• Arteriovenous graft
• Atrial catheters (also known as transthoracic intra-cardiac catheters, those catheters inserted directly
into the right or left atrium via the heart wall)
• Extracorporeal life support (ECMO)
• Hemodialysis reliable outflow (HERO) dialysis catheter
• Intra-aortic balloon pump (IABP) devices
• Peripheral IV or Midlines
• Ventricular Assist Device (VAD)

Table 1: Laboratory-Confirmed Bloodstream Infection Criteria:

Must meet one of the following LCBI criteria:
Criterion Comments and reporting instructions that follow the site-specific criteria provide further
explanation and are integral to the correct application of the criteria.

Once an LCBI determination is made, proceed to the MBI-LCBI definitions, and determine if
the corresponding MBI-LCBI criteria are also met (for example, after meeting LCBI2,
investigate for potential MBI-LCBI 2)

LCBI 1 Patient of any age has a recognized bacterial or fungal pathogen, not included on the NHSN
common commensal list:
If LCBI 1 1. Identified from one or more blood specimens obtained by a culture OR
criterion is 2. Identified to the genus or species level by non-culture based microbiologic testing
met, (NCT)* methods (for example, T2 Magnetic Resonance [T2MR] or Karius
consider Test). Note: If blood is collected for culture within 2 days before, or 1 day after the
MBI-LCBI 1 NCT, disregard the result of the NCT and use only the result of the CULTURE to make
an LCBI surveillance determination. If no blood is collected for culture within this time
period, use the result of the NCT for LCBI surveillance determination.

AND

Organism(s) identified in blood is not related to an infection at another site

(See Appendix B: Secondary BSI Guide).

*For the purposes of meeting LCBI-1, NCT is defined as a methodology that identifies an
organism directly from a blood specimen without inoculation of the blood specimen to any
culture media. For instance, NCT does not include identification by PCR of an organism grown
in a blood culture bottle or any other culture media.

4-6
January 2022 Device-associated Module
BSI

Notes:
1. If a patient meets both LCBI 1 and LCBI 2 criteria, report LCBI 1 with the recognized
pathogen entered as pathogen #1 and the common commensal as pathogen #2.
2. No additional elements (in other words, no sign or symptom such as fever) are
needed to meet LCBI 1 criteria; therefore, the LCBI 1 DOE will always be the collection
date of the first positive blood specimen used to set the BSI IWP.

LCBI 2 Patient of any age has at least one of the following signs or symptoms: fever (>38.0oC), chills,
or hypotension
If LCBI 2
criterion is AND
met,
consider Organism(s) identified in blood is not related to an infection at another site
MBI-LCBI 2 (See Appendix B: Secondary BSI Guide).

AND

The same NHSN common commensal is identified by a culture from two or more blood
specimens collected on separate occasions (see Blood Specimen Collection).

Common Commensal organisms include, but are not limited to, diphtheroids
(Corynebacterium spp. not C. diphtheria), Bacillus spp. (not B. anthracis), Propionibacterium
spp., coagulase-negative staphylococci (including S. epidermidis), viridans group streptococci,
Aerococcus spp. Micrococcus spp. and Rhodococcus spp. For a full list of common
commensals, see the Common Commensal tab of the NHSN Organisms List.

Notes:
1. Criterion elements must occur within the 7-day IWP (as defined in Chapter 2) which
includes the collection date of the positive blood specimen, the 3 calendar days
before and the 3 calendar days after.
2. The two matching common commensal specimens represent a single element for use
in meeting LCBI 2 criteria and the collection date of the first specimen is used to
determine the BSI IWP.
3. At least one element (specifically, a sign or symptom of fever, chills, or hypotension)
is required to meet LCBI 2 criteria; the LCBI 2 DOE will always be the date the first
element occurs for the first time during the BSI IWP, whether that be a sign or
symptom or the positive blood specimen.

4-7
January 2022 Device-associated Module
BSI

- 6/1 Fever > 38.0 °C LCBI 2 DOE = 6/1

- 6/2 No LCBI element -
- 6/3 No LCBI element -
Single 6/4 S. epidermidis (1 of 2) Date of 1st diagnostic
element test = 6/4
6/5 S. epidermidis (2 of 2) -
- 6/6 No LCBI element -
- 6/7 No LCBI element -

LCBI 3 Patient ≤ 1 year of age has at least one of the following signs or symptoms:
fever (>38.0oC), hypothermia (<36.0oC), apnea, or bradycardia
If LCBI 3
criterion is AND
met,
consider Organism(s) identified in blood is not related to an infection at another site
MBI-LCBI 3 (See Appendix B: Secondary BSI Guide).

AND

The same NHSN common commensal is identified by a culture from two or more blood
specimens collected on separate occasions (see Blood Specimen Collection).

Common Commensal organisms include, but are not limited to, diphtheroids
(Corynebacterium spp. not C. diphtheria), Bacillus spp. (not B. anthracis), Propionibacterium
spp., coagulase-negative staphylococci (including S. epidermidis), viridans group streptococci,
Aerococcus spp. Micrococcus spp. and Rhodococcus spp. For a full list of common
commensals, see the Common Commensal tab of the NHSN Organisms List.

Notes:
1. Criterion elements must occur within the 7-day IWP (as defined in Chapter 2) which
includes the collection date of the positive blood specimen, the 3 calendar days
before and the 3 calendar days after.
2. The two matching common commensal specimens represent a single element for use
in meeting LCBI 3 criteria and the date of the first is used to determine the BSI IWP.

At least one element (specifically, a sign or symptom of fever, hypothermia, apnea or

bradycardia) is required to meet LCBI 3 criteria; the LCBI 3 DOE will always be the date the
first element occurs for the first time during the BSI IWP whether that be a sign or symptom
or the positive blood specimen.

4-8
January 2022 Device-associated Module
BSI

-- 5/31 No LCBI element --

- 6/1 No LCBI element -
- 6/2 No LCBI element -
Single 6/3 S. epidermidis (1 of 2) Date of 1st diagnostic test = 6/3
element LCBI DOE = 6/3
6/4 S. epidermidis (2 of 2) -
- 6/5 Apnea documented -
- 6/6 No LCBI element -

4-9
January 2022 Device-associated Module
BSI

Table 2: Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infection (MBI-

LCBI)

An MBI-LCBI is a subset of the LCBI criteria; therefore, a BSI event must fully meet an LCBI criterion before
evaluating for the corresponding MBI-LCBI criteria.

The MBI-LCBI DOE will always be the date the prerequisite LCBI criteria are met. Abnormal ANC and WBC
values reflect risk factors for acquiring an MBI-LCBI, not symptoms of infection and therefore are not used in
DOE determinations.

Must meet one of the following MBI-LCBI criteria

MBI-LCBI 1 MBI-LCBI 2 MBI-LCBI 3

Patient of any age fully meets LCBI 1 Patient of any age fully meets Patient <1 year of age fully meets
criterion LCBI 2 criterion LCBI 3 criterion

with at least one blood specimen with at least two matching blood specimens

with ONLY intestinal organisms from with ONLY Viridans Group Streptococcus and/or Rothia spp. alone
the NHSN MBI organism list* but no other organisms†

identified by culture or non-culture

identified by culture
based microbiologic testing method
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 specimen:
a. Grade III or IV gastrointestinal graft versus host disease [GI GVHD]
OR
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 the 7 calendar days before the date the positive blood specimen was
collected.

OR

2. Is neutropenic, defined as at least two separate days with ANC† and/or WBC values <500 cells/mm3
collected within a 7-day time period which includes the collection date of the positive blood specimen,
the 3 calendar days before and the 3 calendar days after (See Table 5).

4 - 10
January 2022 Device-associated Module
BSI

Notes:
1. If a patient meets both MBI-LCBI 1 and MBI-LCBI 2 criteria (specifically has Viridans Group Streptococcus
or Rothia spp. plus only other MBI organisms in the blood specimen), report organisms as MBI-LCBI 1
with the recognized pathogen as pathogen #1 and the common commensal as pathogen #2.
2. Any combination of ANC and/or WBC values can be used to meet neutropenic criteria provided they are
collected on separate days within the 7-day period that includes the date of the positive blood
specimen, the 3 calendar days before and the 3 calendar days after.
3. When a blood specimen positive for an organism not included on the NHSN MBI organism list is
collected during the BSI RIT of an MBI-LCBI, the initial MBI-LCBI event is edited to an LCBI and the
identified non-MBI organism is added.
*A partial list of MBI-LCBI organisms is provided in Appendix A. See MBI organism tab on the NHSN
organism list for the full list of MBI organisms.
†Eligible positive blood specimens must be collected on separate occasions and limited to the following:
• Viridans Group Streptococcus identified in at least two sets of blood specimens
• Rothia spp. identified in at least two sets of blood specimens
• Viridans Group Streptococcus and Rothia spp. identified in at least two sets of blood specimens

†
Formula for calculating ANC if not provided by your laboratory:
• The ANC is not always reported directly in the chart
• The WBC in the chart is usually reported in terms of thousand cell/mm3
ANC = Absolute Segs + Absolute Bands
OR
ANC = WBC X %Segs + %Bands ÷ 100

Example:
WBC Segs Bands
2 k/mm3 20% 20%

ANC = 2000 X (20 + 20) ÷ 100 = 800 cells/mm3

4 - 11
January 2022 Device-associated Module
BSI

Reporting Instructions: See below for a Summary of CLABSI Exclusions and

Reporting Requirements.

When a BSI event in the presence of a central line meets one of the CLABSI exclusions listed below the
following guidelines are applied:
• The event is reported to NHSN but is NOT considered central line associated.
• The Central Line field is marked “Yes” if an eligible central line has been in place for more than 2
consecutive calendar days on the BSI DOE and is still in place on the BSI DOE or the day before.
• The events do not contribute to the CLABSI SIR measure.
• In each instance where the date of event of subsequent positive blood specimens are outside of the
established BSI RIT, meeting the exclusion criteria, the subsequent positive blood must be investigated
as primary or secondary to another site-specific infection. The CLABSI exclusion criteria must be met
again in a new BSI IWP to determine if the positive blood specimen is central line associated.
Note: Meeting LCBI criteria in all situations noted below will result in setting a BSI RIT and any associated device
days should be included in counts for denominator summary data.

a. Extracorporeal life support (ECLS or ECMO): A BSI meeting LCBI criteria with an eligible central line
where extracorporeal life support (for example, extracorporeal membrane oxygenation [ECMO]) is
present for more than 2 days on the BSI DOE and is still in place on the DOE or the day before, is
considered an LCBI. Report such events, marking the ECMO field as “Yes.”

b. Ventricular Assist Device (VAD): A BSI meeting LCBI criteria with an eligible central line where a VAD is
present for more than 2 days on the BSI DOE and is still in place on the DOE or the day before, is
considered an LCBI. Report such events, marking the VAD field as “Yes.”

c. Patient Injection: A BSI meeting LCBI criteria that is accompanied by documentation of observed or
suspected patient injection into the vascular access line, within the BSI IWP, will be considered an LCBI
but not a CLABSI for NHSN reporting purposes. This exclusion is very specific to “INJECTION”.
Manipulating or tampering with the line (such as biting, picking at, sucking on, etc.) DOES NOT meet the
intent of this exclusion. The documentation must specifically state the patient was “observed
injecting…” or “suspected of injecting…” the device. Insinuations or descriptive events that suggest such
behavior DO NOT meet the intent of this exclusion. Report such events, marking the Patient Injection
field as “Yes.”

d. Epidermolysis bullosa (EB): If during the current admission, there is documentation of a diagnosis of EB
report such an event, marking the EB field as “Yes.”

Note: The Epidermolysis bullosa (EB) CLABSI exclusion is limited to the genetic forms of EB in the
pediatric population.

e. Munchausen Syndrome by Proxy (MSBP): If during the current admission, there is documentation or a
diagnosis of known or suspected MSBP, also known as factitious disorder imposed on another (FDIA),
report such an event, marking the MSBP fields as “Yes.”

4 - 12
January 2022 Device-associated Module
BSI

f. Pus at the vascular access site: Occasionally, a patient with both a central line and another vascular
access device will have pus at the other access site. If there is pus at the site of one of the following
vascular access devices and a specimen collected from that site has at least one matching organism to
an organism identified in blood report such events, marking the “pus at the vascular access site” field as
“Yes.” Vascular access devices included in this exception are limited to:

• Arterial catheters unless in the pulmonary artery, aorta or umbilical artery

• Arteriovenous fistulae
• Arteriovenous grafts
• Atrial catheters (also known as transthoracic intra-cardiac catheters, those catheters inserted
directly into the right or left atrium via the heart wall)
• Hemodialysis reliable outflow (HERO) dialysis catheters
• Intra-aortic balloon pump (IABP) devices
• Non-accessed CL (those neither inserted nor used during current admission)
• Peripheral IV or Midlines

Reporting Instructions:

1. Group B Streptococcus: Group B Streptococcus identified from blood, with a date of event during the
first 6 days of life, will not be reported as a CLABSI. A BSI RIT is set, and any associated device days
should be included in counts for denominator summary data.

2. Do not report a BSI that has a DOE within a BSI RIT. However, add additional organisms identified that
are eligible for BSI events to the initial BSI event. See RIT guidance in Chapter 2, Identifying Healthcare
associated Infections or Chapter 16, Key Terms.

3. Only primary BSIs create a 14-day BSI RIT:

Primary BSI example: Patient has a positive blood specimen identifying Staphylococcus aureus on
hospital day 6, which is not secondary to another site-specific source of infection. A subsequent positive
blood specimen is collected on hospital day 12 that identifies Pseudomonas aeruginosa. Because this
occurs in the BSI RIT, no new BSI event is reported, and Pseudomonas is added to the initial BSI event.

4. Secondary BSIs do not create a 14-day BSI RIT:

Secondary BSI example: A Symptomatic urinary tract infection (SUTI) with Enterococcus faecalis is
identified and E. faecalis is also collected from a blood specimen on hospital day 11 within the SUTI
secondary BSI attribution period. This BSI is secondary to the SUTI. Only a SUTI RIT is set, not a BSI RIT.
On hospital day 15 (also within the SUTI RIT and secondary BSI attribution period), a blood culture which
grows Staphylococcus aureus is collected. Because the blood growing S. aureus does not have at least
one pathogen that matches the urine culture used to meet the SUTI criterion, the BSI cannot be
attributed as secondary to the SUTI. There is no BSI RIT in effect, therefore the BSI will need to be
investigated as a new BSI event and either assigned as a secondary BSI to another primary site of
infection or determined to be a primary BSI.

4 - 13
January 2022 Device-associated Module
BSI

Note: The secondary BSI attribution period of a primary source of infection is not a “catch all” for
subsequent BSIs.
5. There is no expectation that positive blood specimens collected during the present on admission (POA)
timeframe are investigated. If identified, they are not reported to NHSN. However, if a subsequent
positive blood specimen is collected within 14 days of a positive blood specimen collected during the
POA timeframe, it is imperative that a determination is made for the original blood specimen in order to
make the correct determination about the subsequent blood specimen.

Example 1: A patient has a positive blood specimen with Escherichia coli (E. coli) that is a POA on 6/1.
On 6/10, a subsequent positive blood specimen with Klebsiella pneumonia is collected. The 6/1 blood
specimen is investigated and if determined to be a primary BSI sets a 14-day BSI RIT (6/1-6/14).
Therefore, the 6/10 specimen is not a new BSI event and K. pneumonia is added to the POA BSI event if
reported.

Example 2: A patient has a positive blood specimen that identifies Staphylococcus aureus present on
admission 6/1. On 6/10, a subsequent positive blood specimen with Klebsiella pneumonia is collected.
To make the correct determination about the second blood specimen, the initial POA BSI event must be
investigated to determine if it is primary or secondary to another site. In reviewing the chart, a right
elbow culture from 5/31, also positive for S. aureus, plus the symptoms needed to meet Joint or Bursa
infection (JNT) criteria 3c are documented making the 6/1 BSI secondary to JNT. The POA primary JNT
infection creates a 14-day JNT RIT (6/1-6/14), during which no new JNT infections are reported. Because
the subsequent blood specimen does not contain at least one matching pathogen to the specimen used
to meet the JNT criteria, the positive blood with K. pneumonia cannot be attributed to the original JNT
event and must be investigated as a primary or secondary BSI.

Blood Specimen Collection

1. In LCBI criteria 2 and 3, the phrase “two or more blood specimens drawn on separate occasions” means:
a. blood from at least two separate blood draws is collected on the same or consecutive calendar
days
b. two separate site preparations (decontamination steps) are performed during specimen
collection
c. the blood cultures are assigned separate accession numbers, processed individually, and are
reported separately in the final laboratory report
This will reduce misidentification of contaminated blood specimens as LCBIs. For example, aseptic technique
indicates separate site decontaminations would be performed for blood specimens drawn from different
sites (in other words; different venipunctures, a combination of venipuncture and lumen withdrawal, or
different lumens of the same central line), or at different times. Specimens collected in this manner would
therefore be considered “separate occasions”.

4 - 14
January 2022 Device-associated Module
BSI

2. Specimen Collection Considerations: Blood specimens drawn through central lines can have a higher rate of
contamination than blood specimens collected through peripheral venipuncture. 3, 4 However, all positive
blood specimens, regardless of the site from which they are drawn or the purpose for which they are
collected, must be included when conducting in-plan CLABSI surveillance (for example, weekly blood
cultures performed in hematology and oncology locations).

3. Catheter tip cultures cannot be used in place of blood specimens for meeting LCBI criteria.

4. In MBI-LCBI 1, 2 and 3, “No other organisms” means there is no identification of a non-MBI-LCBI pathogen
(such as S. aureus) or 2 matching common commensals (such as coagulase-negative staphylococci) collected
from the blood on separate occasions that would otherwise meet LCBI criteria. If this occurs, the infection
does not meet MBI-LCBI criteria.

5. When a blood specimen positive for an organism not included on the NHSN MBI organism list is collected
during the BSI RIT of an MBI-LCBI, the initial MBI-LCBI event is edited to an LCBI and the identified non-MBI
organism is added.

MBI-RIT Exception: An MBI-LCBI designation will not change to an LCBI event if the following criteria are
met:

1. The blood culture with the non-MBI organism is collected during an existing BSI (MBI-LCBI) RIT
AND
2. The blood culture with the non-MBI organism is deemed secondary to an NHSN site-specific
infection

See Example 5 in the Secondary BSI Guide section of this protocol and Chapter 2 Pathogen Assignment
(Example 2b).

4 - 15
January 2022 Device-associated Module
BSI

Table 3: Examples of Associating the Use of Central Lines to BSI Events

(CLABSI):
This table provides examples that illustrate:
• Device association as determined by the presence of an eligible CL on the BSI DOE or the day
before.
• The goal of NHSN HAI surveillance is to identify risks to the patient that are the result of device
use in general; therefore, NHSN will not require a BSI to be associated with a specific device when
more than one line is present.

Note: The procedure for de-accessing a port involves ensuring patency of the line prior to removal
of the needle which involves blood withdrawal, an IV flush and injection of an anticoagulant.

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient A:
Port Status Port in Port in Port in Port in Port in Port in Port in
Accessed No No Yes Yes Yes De-accessed* No No
Eligible for Yes-
CLABSI No No No No Yes-eligible CL Yes-eligible CL eligible
event CL

CL CL CL CL
- - CL
Day 1 Day 2 Day 3 Day 4
Day 5
Patient A becomes eligible for a CLABSI on 4/4 because an accessed port had been in place for some portion of > 2
consecutive calendar days making it an eligible CL on 4/4 (CL day 3). The port remains eligible for a CLABSI until it is
removed, or the patient is discharged, whichever comes first.

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient B:
CL in CL in CL in CL in CL in / CL out No device No device
CL Status
Accessed No No Yes Yes Removed - -
Eligible
for CLABSI No No No No Yes-eligible CL Yes-eligible CL No
event
CL CL CL
- - - -
Day 1 Day 2 Day 3
Patient B becomes eligible for a CLABSI on 4/4 (CL Day 3) through 4/5. An accessed CL had been in place > 2 consecutive
calendar days making it an eligible CL on 4/4 (CL day 3). A BSI DOE on the day of or the day after device removal or patient
discharge is considered device associated (CLABSI).

4 - 16
January 2022 Device-associated Module
BSI

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient C:
CL in CL in CL in/ CL out CL in CL in CL in/ CL out No device
CL Status
Accessed Yes Yes Removed Placed Yes Removed -
Eligible for
CLABSI Yes Yes Yes Yes Yes Yes Yes
event
CL CL CL CL CL CL
-
Day 3 Day 4 Day 5 Day 6 Day 7 Day 8
Patient C was admitted to an inpatient location on 3/29 with a central line in place. Patient C becomes eligible for a
CLABSI on 3/31 (CL Day 3) through 4/6 because an accessed CL had been in place > 2 consecutive calendar days. A BSI
DOE occurring on the day of or the day after device removal or patient discharge is considered a device-associated
infection (CLABSI). The patient remains eligible for a CLABSI event through 4/6 because a full calendar day did not pass
without a CL in place, therefore, device counts continue uninterrupted.

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient D:
CL in CL in CL in/ CL out No device CL in CL in CL in
CL Status
Accessed Yes Yes Removed - Placed Yes Yes
Eligible for
Yes- Yes-eligible Yes-eligible Yes- Yes-
CLABSI No No
eligible CL CL CL eligible CL eligible CL
event
CL CL CL CL CL CL
-
Day 3 Day 4 Day 5 Day 1 Day 2 Day 3
Patient D was admitted to an inpatient location on 3/29 with a central line in place. Patient D becomes eligible for a
CLABSI 3/31 (CL Day 3) through 4/3. An accessed CL had been in place > 2 consecutive calendar days, however, a full
calendar day passed (4/3) with no CL in place, therefore, device day counts start over at CL day 1 when a new line is
placed. After 4/3, the patient will not be eligible for a CLABSI event again until 4/6 when the new CL becomes an eligible
CL (CL day 3).

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient E:
No device CL in CL in CL in CL in CL in CL in
CL Status
Accessed - Placed Yes Yes Yes Yes Yes
Eligible for
Yes-eligible Yes-eligible
CLABSI - No No Yes-eligible CL Yes-eligible CL
CL CL
event
CL CL CL CL CL CL
-
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6
Patient E becomes eligible for a CLABSI on 4/3 (CL Day 3) through 4/6 because line placement is considered first access
which begins device day counts regardless of whether the line is being actively used or not and an accessed CL had been
in place > 2 consecutive calendar days.

BOLD = change in status

4 - 17
January 2022 Device-associated Module
BSI

Pathogen Exclusions and Reporting Considerations:

1. The term “recognized pathogen” in LCBI 1 criteria refers to any organism that is not included on the
NHSN common commensal list (see NHSN Organisms List ) for the complete list of common
commensals used for NHSN reporting purposes). Exceptions:
a. Organisms that are parasites and viruses are excluded as LCBI pathogens. This exclusion applies to
meeting a primary BSI only. Viruses and parasites are eligible for use in secondary BSI
determinations

b. Organisms belonging to the following genera are excluded as LCBI pathogens: Campylobacter,
Salmonella, Shigella, Listeria, Vibrio and Yersinia as well as C. difficile, Enterohemorrhagic E. coli,
and Enteropathogenic E. coli. These organisms are eligible for use in secondary BSI
determinations but will not be reported as the sole pathogen in a primary BSI.
c. Organisms belonging to the following genera cannot be used to meet any NHSN definition:
Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus, and Pneumocystis. These
organisms are excluded because they typically cause community-associated infections and are
rarely known to cause healthcare-associated infections.
2. Business rules written into the pathogen fields of the NHSN application prevent entry of a common
commensal as pathogen #1 when attempting to report both a recognized pathogen and commensal
identified in an LCBI 1 or MBI-LCBI 1. To save the event successfully, enter the recognized pathogen
first as pathogen # 1 and the common commensal as pathogen #2.
3. For LCBI criteria 2 and 3, if the common commensal is identified to the species level for one blood
specimen, and a companion blood specimen is identified with only a descriptive name, which is
complementary to the companion culture (in other words, to the genus level), then it is assumed the
organisms are the same. An organism identified to the species level should be reported along with
the antibiogram, if available (see Table 4). Colony morphology, biotype, and antibiogram comparisons
should not be used to determine the “sameness “of organisms because laboratory testing capabilities
and protocols vary between facilities. To reduce reporting variabilities due to differences in laboratory
practice only genus and species identification should be used, and they should only be reported once.
If antibiograms are available and the sensitivities differ for the same organisms in separate specimens,
always report the more resistant panel (see Table 4).
4. A common commensal identified in a single blood specimen is considered a contaminant. It will not
be used to meet LCBI 2 or 3 criteria, secondary BSI attribution, nor will it prevent a case from meeting
MBI-LCBI criteria when the organism requirements call for “only” a specific organism or type of
organism (for example, “only intestinal organisms from the MBI list”).

4 - 18
January 2022 Device-associated Module
BSI

Table 4: Reporting Speciated and Unspeciated Organisms Identified from Blood

Specimens
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

Note: When identification to the species level is not provided, the genus of the organism will be reported
to NHSN. When identification to the genus level is not provided, report the organism as available on the
NHSN all organism list (for example, Gram-positive bacilli).

Table 5: Examples Illustrating the MBI-LCBI Criteria for Neutropenia

- - Day Day Day Day Day Day Day Day Day Day Day
-7 -6 -5 -4 -3 -2 -1 1* 2 3 4
Pt. WBC 100 800 400 300 ND ND 320† 400† ND 550 600
A + BC* x 1
Candida spp.
Pt. ANC ND 410 130 ND ND 120† 110† ND 110 300 320
B +BC* x 2
viridans strep
plus fever
>38°C
Pt. WBC 100 800 400 300 ND ND ND 600 230† ND 400†
C + BC* x 1
Candida spp.
ND = not done; *Collection date of positive blood specimen; Italics = ANC/WBC < 500 cells/mm3; †
ANC/WBC < 500 cells/mm3 used to meet neutropenia for MBI-LCBI criteria

Rationale for Table 5:

Patient A meets MBI-LCBI 1 criteria with neutropenia: Positive blood specimen with intestinal organism
(Candida spp.) and neutropenia*. In this case, the WBC values on Day 1 = 400, and Day -1 = 320 are used.
Patient B meets MBI-LCBI 2 criteria with neutropenia: At least two positive blood specimens with viridans
group streptococci, fever >38°C and neutropenia*. In this case, the ANC values on day -1 = 110 and Day -2
= 120 are used.

4 - 19
January 2022 Device-associated Module
BSI

Note: Any two of Days -2, -1, 2, 3, and 4 could be used to meet this requirement since WBC and/or ANC
values of <500cells/mm3 were present on those days.
Patient C meets MBI-LCBI 1 criteria with neutropenia: Positive blood specimen with intestinal organism
(Candida spp.) and neutropenia*. In this case, WBC values on Day 2 = 230 and Day 4 = 400 are used.

*Neutropenia is defined as: 2 separate days of ANC or WBC <500 cells/mm3 occurring on the collection
date of the positive blood specimen (Day 1) or during the 3 days before or the 3 days after Day 1.

Monthly Summary Data

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. For CLABSI surveillance, all LCBI
and MBI-LCBI that are identified as central-line associated must be included. 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, organisms identified from
blood specimens, and the organisms’ antimicrobial susceptibilities.

Reporting Instruction:
During the month of surveillance, if no CLABSI events are identified, the “Report No Events” box must be
checked on the appropriate denominator summary screen, (for example, Denominators for Intensive Care
Unit [ICU]/other locations [not NICU or SCA], etc.

Denominator Data: Device days and patient days are used for denominator reporting. Device-day
denominator data that are collected differ according to the patient location. The following methods can
be used for the collection of denominator data:

4 - 20
January 2022 Device-associated Module
BSI

Table 6: Examples of Denominator Day counts for Device Days

This table provides examples that illustrate:
• Denominator device day counts for a central line present on an inpatient location at the time of
the device day count.

Note: If the central line is in place at the time of the denominator device count, it is included in the daily
denominator device day count.
Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr
Patient A: Inpatient
ICU ICU ICU ICU ICU ICU
Location ICU
CL in CL in CL in CL in CL in CL in
CL inserted
Denominator
Day Counts
Day 1* Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
for Device
Days
Patient A has a CL inserted in the ICU. Because the CL was inserted in an inpatient location, Day 1 will begin
the denominator day count for device days. Patient A will have 7 denominator device days for 3/31-4/6.

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient B: Patient
ED
admitted to Inpatient Inpatient
CL in place at ICU ICU ICU
inpatient Location Location
time of CL in CL in CL in
location ICU CL in CL in
admission
CL in
Denominator
Day Counts
- Day 1 Day 2 Day 3 Day 4 Day 5 Day 6
for Device
Days
Patient B has a central at the time of admission. Because Patient B is admitted to the emergency
department on 3/31, the denominator day count for device days will not begin until the patient is
transferred to the inpatient location on 4/1. Patient B will have 6 denominator device days for 4/1-4/6.

4 - 21
January 2022 Device-associated Module
BSI

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient C: Inpatient
Location ICU ICU
ICU ICU ICU ICU ICU
CL in place at No
CL in CL in/ CL out CL in CL in CL in/ CL out
time of device
admission
Denominator
Day Counts
Day 1 Day 2 Day 3* Day 4 Day 5 Day 6* -
for Device
Days
Patient C has a central at the time of admission to ICU. Because Patient C is admitted to ICU on 3/31, the
denominator day count for device days will begin on the day of admission (3/31). Because there is no
device on 4/6, the denominator device day count will end on 4/5. Patient C will have 6 denominator
device days for 3/31-4/5.

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient D: Inpatient Inpatient
ICU ICU ICU ICU ICU
Location ICU Location ICU
CL in CL in CL in CL in CL in
No device CL inserted
Denominator
Day Counts
- Day 1* Day 2 Day 3 Day 4 Day 5 Day 6
for Device
Days
Patient D does not have a central line in place at the time of admission to ICU. Because there is no central
line in place on admission, the denominator day count for device days will not begin until the central line
is placed in the inpatient location on 4/1. Patient D will have 6 denominator device days for 4/1-4/6.

Date 31-Mar 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr

Patient E: Inpatient
Location ICU
Inpatient
Patient ICU ICU ICU ICU ICU
Location ICU
admitted Port not Port Port Port Port
Port not
with non- accessed accessed accessed accessed accessed
accessed
accessed
port
Denominator
Day Counts
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
for Device
Days
Patient E has a non-accessed port at the time of admission to ICU. The denominator device day count will
begin on the date the patient is admitted to ICU (3/31). Accessing the port on 4/3 does not change the
denominator day count for device days. Patient E will have 7 denominator device days for 3/31-4/6.

4 - 22
January 2022 Device-associated Module
BSI

Table 7: Denominator Data Collection Methods

Data Collection Details
Method
Manual, Daily Denominator data (patient days and device days) should be collected at the
same time, every day, for each location performing surveillance to ensure that
differing collection methods don’t inadvertently result in device days being
greater than patient days.

• For locations other than specialty care areas/oncology (SCA/ONC) and

NICUs, the number of patients with at least one central line, of any type, is
collected daily, at the same time each day during the month and is 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.
Notes:
1. Only one central line per patient is counted per calendar day regardless
of the number of central lines present.
2. All central lines on inpatient units should be included in device day
counts regardless of access.
• For specialty care areas/oncology, the number of patients with at least one
central line are separated into those with permanent central lines and those
with temporary central lines. The number of patients with at least one
central line, of either or both type(s), is collected daily, at the same time
each day during the month and is recorded on the Denominators for
Specialty Care Area (SCA)/Oncology (ONC) form (CDC 57.117). Only the
totals for the month are entered into NHSN. Temporary and permanent lines
are reported separately in this location because permanent lines are more
commonly used in this patient population and may be associated with a
lower BSI rate when compared to temporary central lines.
Notes:
1. Only one central line per patient is counted per calendar day regardless
of the number of central lines present.
2. All central lines on inpatient units should be included in device day
counts regardless of access.
3. If a patient has both a temporary and a permanent central line, only
report the temporary line because it is associated with a higher risk of
bloodstream infection.
The Instructions for Completion of Denominators for Intensive Care Unit
(ICU)/Other Locations (Not NICU and SCA/ONC) and Instructions for

4 - 23
January 2022 Device-associated Module
BSI

Data Collection Details

Method
Completion of Denominators for Specialty Care Areas (SCA)/Oncology (ONC)
contain brief instructions for collection and entry of each data element on
the form.
• In NICUs, the number of patients with at least one central line is stratified by
birth weight in five categories because the risk of BSI varies by birth weight.
These data are reported on the Denominators for Neonatal Intensive Care
Unit (NICU) form (CDC 57.116).
Note:
1. Report only birth weight when entering BSI denominator data. The
infant’s weight at the time of BSI identification is not used and should
not be reported. For example, 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; enter the birth weight of 1006 grams on
the BSI form.
2. All central lines on inpatient units should be included in device day
counts regardless of access. 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.

Manual, sampled • To reduce staff time spent collecting surveillance data, once weekly sampling
once/week (collected of denominator data to generate estimated central line days, may be used as
at the same time on an alternative to daily collection in non-oncology ICUs and wards (see Notes
the same designated below). Sampling may not be used in SCA/ONC locations or NICUs. During
day, once per week) the month, the number of patients in the location (patient-days) and the
number of patients with at least one central line of any type (central line
days) is collected on a designated day each week (for example, every
Tuesday), and at the same time each day.

• Evaluations of this method have repeatedly shown that use of Saturday or

Sunday generate the least accurate estimates of denominator data,
therefore, weekend days should not be selected as the designated
denominator data collection day.6-8 If the designated day is missed, collect
the denominator data on the next available weekday.

• The following must be collected and entered into NHSN:

1. The monthly total for patient-days, collected daily
2. The sampled total for patient-days

4 - 24
January 2022 Device-associated Module
BSI

Data Collection Details

Method
3. The sampled total central line-days

When these data are entered, the NHSN application will calculate an
estimate of central line-days.

Notes:

1. To ensure the accuracy of estimated denominator data obtained by

sampling, only ICU and ward location types with an average of 75 or
more central line-days per month are eligible to use this method. A
review of each location’s central line denominator data for the past
twelve months in NHSN will help determine which locations are eligible.

2. The accuracy of estimated denominator data generated by sampling can

be heavily influenced by incorrect or missing data. Careful
implementation of data collection following the guidance in this protocol
is essential to avoid erroneous fluctuations in rates or SIRs.

Electronic For any location, denominator data from electronic sources (in other words,
central line days from electronic charting may be used only after a validation of a
minimum 3 consecutive months proves the data to be within 5% (+/-) of the
manually collected once-a-day counts.

When converting from one electronic counting system to another electronic

counting system, the new electronic system should be validated against manual
counts as above. If electronic counts for the new electronic system are not
within 5% of manual counts, resume manual counting and continue working with
IT staff to improve design of electronic denominator data extraction (while
reporting manual counts) until concurrent counts are within 5% for 3
consecutive months.
Note: This guideline is important because validating a new electronic counting
system against an existing electronic system can magnify errors and result in
inaccurate denominator counts.
Perform the validation of electronic counts separately for each location
conducting CLABSI surveillance.

4 - 25
January 2022 Device-associated Module
BSI

Data Analyses:
All data that are entered into NHSN can be analyzed at event or summary level. The data in NHSN can be
visualized and analyzed in various ways, for example, descriptive analysis reports for both the
denominator and numerator data.

Types of CLABSI Analysis Reports

Standardized Infection Ratio (SIR):

The standardized infection ratio (SIR) is calculated by dividing the number of observed events by the
number of predicted events. The number of predicted events is calculated using probabilities estimated
from negative binomial models constructed from 2015 NHSN data, which represents the baseline
population.
For more information on SIR and the CLABSI parameter estimates, please see the SIR guide:
https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf.

𝑂𝑏𝑠𝑒𝑟𝑣𝑒𝑑 (𝑂) 𝐻𝐴𝐼𝑠

SIR = 𝑃𝑟𝑒𝑑𝑖𝑐𝑡𝑒𝑑 (𝑃) 𝐻𝐴𝐼𝑠

While SIRs 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 can obtain one CLABSI SIR adjusting for all locations reported. Similarly, you can obtain
one CLABSI SIR for all ICUs in your facility. In addition, IRF units within Acute Care Hospitals will be
separated from all other ACH locations.

For more information on using the CLABSI SIR reports, please see the troubleshooting guide:
https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/clabsicauti_sirtroubleshooting.pdf.
For further information regarding the p-value and 95% confidence interval, see the following guide:
https://www.cdc.gov/nhsn/ps-analysis-resources/keys-to-success.html

Note: The SIR will be calculated only if the number of predicted events (numPred) is ≥1 to help enforce a
minimum precision criterion.

Standardized Utilization Ratio (SUR):

The SUR, or standardized utilization ratio, is a summary measure used to track device use at a national,
state, local, or facility level over time. The SUR adjusts for various facility and/or location-level factors that
contribute to device use. The method of calculating an SUR is similar to the method used to calculate the
Standardized Infection Ratio (SIR), a summary statistic used in NHSN to track healthcare-associated
infections (HAIs). In device-associated HAI data analysis, the SUR compares the actual number of device
days reported to what would be predicted, given the standard population (specifically, the NHSN
baseline), adjusting for several factors that have been found to be significantly associated with differences
in device utilization.

4 - 26
January 2022 Device-associated Module
BSI

In other words, an SUR greater than 1.0 indicates that more device days were observed than predicted;
conversely, an SUR less than 1.0 indicates that fewer device days were observed than predicted. SURs are
currently calculated in NHSN for the following device types: central lines, urinary catheters, and
ventilators.

More information regarding the SUR calculations can be found at:

https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sur-guide-508.pdf
https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/run-interpret-sur-reports.pdf

Rates and Ratios:

The CLABSI rate per 1000 central line days is calculated by dividing the number of CLABSIs 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, oncology units, and other locations
in the institution. Separate rates and ratios will also be calculated for different types of central lines in
specialty care areas/oncology locations and for birth weight categories in NICUs.
𝑁𝑜. 𝑜𝑓 𝐶𝐿𝐴𝐵𝐼𝑠
CLABSI Rate = * 1000
𝑁𝑜.𝑜𝑓 𝐶𝑒𝑛𝑡𝑟𝑎𝑙 𝐿𝑖𝑛𝑒 𝐷𝑎𝑦𝑠

Device Utilization Ratio

The Central Line Utilization Ratio is calculated by dividing the number of central line catheter days by the
number of patient days.
These calculations will be performed separately for the different types of ICUs, specialty care areas, and
other locations in the institution, except for neonatal locations. DURs are useful for the purposes of
tracking device use over shorter periods of time and for internal trend analyses.
𝑁𝑜. 𝑜𝑓 𝐶𝑒𝑛𝑡𝑟𝑎𝑙 𝐿𝑖𝑛𝑒 𝐷𝑎𝑦𝑠
DUR =
𝑁𝑜. 𝑜𝑓 𝑃𝑎𝑡𝑖𝑒𝑛𝑡 𝐷𝑎𝑦𝑠

Descriptive analysis
Descriptive analysis output options of numerator and denominator data, such as line listings, frequency
tables, and bar and pie charts are available in the NHSN application. CLABSI SIRs, rates, and run charts are
also available. A line list, frequency table, and rate table are also available to analyze pathogens and
antimicrobial susceptibility data reported for CLABSIs. Guides on using NHSN analysis features are
available from: https://www.cdc.gov/nhsn/ps-analysis-resources/reference-guides.html.

NHSN Group Analysis:

NHSN Group Users can perform the same analysis as facility level users in NHSN. A few helpful tools in
NHSN for groups are listed in the resources below. These tools are guides on how to start and join a

4 - 27
January 2022 Device-associated Module
BSI

Group; how to create a template to request data from facilities; how to determine the level of access
granted by the facility following the previous steps, and how to analyze the facilities data.

Group Analysis Resources:

NHSN Group Users Page: https://www.cdc.gov/nhsn/group-users/index.html
Group User’s Guide to the Membership Rights Report: https://www.cdc.gov/nhsn/pdfs/ps-analysis-
resources/GroupAnalysisWebinar.pdf
Group User’s Guide to the Line Listing- Participation Alerts: https://www.cdc.gov/nhsn/pdfs/ps-analysis-
resources/group-alerts.pdf

Additional Resources
Analysis Resources: https://www.cdc.gov/nhsn/ps-analysis-resources/index.html
Analysis Reference Guides: https://www.cdc.gov/nhsn/PS-Analysis-resources/reference-guides.html
NHSN Training: https://www.cdc.gov/nhsn/training/index.html
Data Quality Website: https://www.cdc.gov/nhsn/ps-analysis-resources/data-quality/index.html

4 - 28
 January 2022 Device-associated Module
BSI

Table 8: CLABSI Measures Available in NHSN

Measure Exclusions Calculation Application
MBI-LCBIs, ECMO,
Both location
VAD, MSBP, EB,
The number of Observed CLABSIs specific and
CLABSI SIR Patient self-
The number of Predicted CLABSIs summarized
injection, and Pus at
measure
vascular site
ECMO, VAD, MSBP, Both location
MBI-LCBI
EB, Patient self- The number of Observed MBI − LCBIs specific and
SIR
injection, and Pus at The number of Predicted MBI − LCBIs summarized
(ACH Only)
vascular site measure
MBI-LCBIs, ECMO,
VAD, MSBP, EB,
CLABSI The number of CLABSIs for a location Location specific
Patient self- (The number of Central Line Days for that location ) × 1000
Rates measure only
injection, and Pus at
vascular site
ECMO, VAD, MSBP,
MBI-LCBI EB, Patient self- The number of MBI_LCBIs for a location Location specific
(The number of Central Line Days for that location ) × 1000
Rates injection, and Pus at measure only
vascular site
Both location
Central Line The number of Observed Central Line Days specific and
SUR The number of Predicted Central Line Days summarized
measure
Central Line Days for a location Location specific
DUR
The Patient Days for that location measure only

4 - 29
January 2022 Device-associated Module
BSI

References

1
CDC National and State Healthcare-Associated Infections Progress Report, published October 2019,
available at https://www.cdc.gov/hai/data/portal/progress-report.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”.
Clinical Infectious Diseases 52 (a): (2011): 1087-99.
3
Clinical and Laboratory Standards Institute (CLSI). Principles and Procedures for
Blood Cultures; Approved Guideline. CLSI document M47-A. Wayne, PA: Clinical and Laboratory
Standards Institute; 2007.
4
Baron, EJ., Weinstein, MP., Dunne, WM., Yagupsky, P., Welch, DF., Wilson, DM.
Blood Cultures; Approved Guideline. Washington, DC: ASM Press; 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, Nov; 45(11):
(2007): 3546-8.
6
Klevens, RM., et al. “Sampling for Collection of Central Line Day Denominators in
Surveillance for Healthcare-associated Bloodstream Infections”. Infection Control Hospital
Epidemiology. 27: (2006):338-42.
7
Thompson, ND., et al.” Evaluating the Accuracy of Sampling to Estimate Central Line–Days:
Simplification of NHSN Surveillance Methods”. Infection Control Hospital Epidemiology. 34(3):
(2013): 221-228.
8
See, I., et al. ID Week 2012 (Abstract #1284): Evaluation of Sampling Denominator Data to
Estimate Urinary Catheter- and Ventilator-Days for the NHSN. San Diego, California. October 19,
2012.

4 - 30
January 2022 Device-associated Module
BSI

Appendix A: Partial List of MBI-LCBI Organisms

Abiotrophia Escherichia (E) Pantoea (+E)
Alistipes Eubacterium Parabacteroides
Alloscardovia Ewingella (E) Peptostreptococcus
Anaerobiospirillum Faecalibacterium Pichia
Anaerococcus Filifactor Porphyromonas
Anaerorhabdus Finegoldia Prevotella
Arcobacter Flavonifractor Proteus (E)
Atopobium Fusobacterium Providencia (E)
Averyella (+E) Gemella Pseudoflavonifractor
Bacteroides Geotrichum Pseudoramibacter
Bifidobacterium Granulicatella Rahnella (E)
Bilophila Hafnia (E) Raoultella (+E)
Blautia Helcococcus Rothia
Buttiauxella (E) Helicobacter Ruminococcus
Klebsiella (E) Saccharomyces
Candida Kluyvera (E) Sarcina
Capnocytophaga Kluyveromyces Serratia (E)
CDC Enteric Group 58 (+E) Lactobacillus
Cedecea (E) Leclercia (E) Slackia
Citrobacter (E) Leminorella (E) Streptococcus (VGS subset)
Clostridium Leptotrichia Tannerella
Collinsella Leuconostoc Tatumella (E)
Cronobacter (+E) Megamonas Tetragenococcus
Dialister Megasphaera Tissierella
Dichelobacter Mitsuokella Trabulsiella (E)
Edwardsiella (E) Moellerella (E) Veillonella
Eggerthella Mogibacterium Weissella
Eggerthia Morganella (E)
Enterobacter (E) Obesumbacterium (+E) Yokenella (E)
Enterococcus Odoribacter
E = Family Enterobacteriaceae

Note: See complete list of MBI Pathogens including species by selecting the MBI Organisms tab at the
bottom of the NHSN Organism List.

4 - 31
January 2022 Device-associated Module
BSI

Appendix B: Secondary BSI Guide (not applicable to Ventilator-associated

Events [VAE])
The purpose of using the CDC/NHSN infection criteria is to identify and consistently categorize infections
that are healthcare-associated into major and site-specific infection types. LCBI criteria include the caveat
that the organism(s) identified from the blood cannot be related to infection at another site (in other
words, it must be a primary BSI). One must be sure that there is no other CDC/NHSN defined primary site-
specific infection that may have seeded the bloodstream secondarily; otherwise, the bloodstream
infection may be misclassified as a primary BSI and erroneously associated with the use of a central line,
specifically called a CLABSI. For locations performing in-plan VAE surveillance, refer to Figure B2 in this
appendix, as well as the VAE chapter for specific guidance on assigning a secondary BSI to a VAE. When
conducting BSI surveillance, the PNEU definitions (as well as UTI, SSI and all definitions found in Chapter
17) are available for attributing a secondary BSI for any patient in any location. For example, a ventilated
patient in an adult location where VAE surveillance is being conducted can have a secondary BSI assigned
to VAE or PNEU. A ventilated patient in a neonatal location where in-plan PedVAP surveillance is not an
option can have a secondary BSI assigned to PNEU.
Secondary BSI Scenarios: For purposes of NHSN reporting, for a bloodstream infection to be determined
secondary to another site of infection the following requirements must be met: *

An NHSN site-specific definition must be met; either one of the CDC/NHSN Surveillance Definitions for
Specific Types of Infections (defined in Chapter 17), or UTI, PNEU or SSI definitions.
AND
One of the following scenarios must be met:

Scenario 1: At least one organism from the blood specimen matches an organism identified from the site-
specific specimen 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.
Exception Notes:
1. The necrotizing enterocolitis (NEC) definition does not include criteria for a matching site-specific
specimen, nor an organism identified from a blood specimen that can be used as an element to meet
the NEC criteria, however an * exception for assigning a BSI secondary to NEC is provided.
a. An BSI is considered secondary to NEC if the patient meets one of the two NEC criteria
AND an organism identified from a blood specimen, collected during the secondary BSI
attribution period, is an LCBI pathogen, or the same common commensal identified from
two or more blood specimens drawn on separate occasions that are on the same or
consecutive days.

4 - 32
January 2022 Device-associated Module
BSI

†
2. The endocarditis (ENDO) criteria have different rules for infection window period, RIT, pathogen
assignment and secondary BSI attribution period. (See ENDO criteria in Ch. 17).
• Below are examples with guidance on how to distinguish between the primary or secondary nature of
a BSI. The definition of “matching organisms”, important notes and reporting instructions are also
provided. See Figure B1: Secondary BSI Guide for algorithmic display of the following instructions.
Scenario 1: An organism identified from the site-specific infection is used as an element to meet the
site-specific infection criterion, AND the blood specimen contains at least one matching organism to
that site-specific specimen. The positive blood specimen must be collected during the site-specific
infection’s secondary BSI attribution period. (For your convenience, a list of infection criteria that
include a blood specimen with at least one matching pathogen to the site-specific specimen that is
used as an element to meet the definition are included in Table B1).

a. Example: Patient meets NHSN criteria for a symptomatic urinary tract infection (suprapubic
tenderness and >105 CFU/ml of E. coli) and blood specimen collected during the symptomatic
urinary tract infection (SUTI) secondary BSI attribution period is positive for Escherichia (E.
coli). This is a SUTI with a secondary BSI and the reported organism is E. coli.

b. Example: Patient meets NHSN criteria for a symptomatic urinary tract infection (suprapubic
tenderness and >105 CFU/ml of E. coli) and blood specimen collected during the SUTI
secondary BSI attribution period grows E. coli and Pseudomonas aeruginosa. This is a SUTI
with a secondary BSI and the reported organisms are E. coli and P. aeruginosa since both site
and blood specimens are positive for at least one matching pathogen.

c. Example: Patient meets NHSN criteria for a symptomatic urinary tract infection (suprapubic
tenderness and >105 CFU/ml of E. coli) and a single blood specimen collected during the SUTI
secondary BSI attribution period is positive for E. coli and Staphylococcus epidermidis (S.
epidermidis). This is a SUTI with a secondary BSI and the reported organism is only E. coli since
the single common commensal S. epidermidis positive blood specimen by itself does not meet
BSI criteria.

Scenario 2: An organism identified from a blood specimen is an element used to meet the site-specific
infection criterion and is collected during the site-specific infection window period. (For your
convenience, a list of infection criteria that include positive blood culture as an element are included
in Table B1).

a. Example: Patient becomes febrile and complains of nausea and abdominal pain. CT scan
done that day shows a fluid collection suggestive of infection. A blood specimen collected
that day results in identification of Bacteroides fragilis. Because the patient meets IAB
criterion 3b, using the identification of an organisms from the blood specimen as an element
(fever, nausea or abdominal pain, positive blood specimen and CT scan showing infection in
abdominal cavity), the BSI is considered secondary to an intra-abdominal (IAB) infection.

4 - 33
January 2022 Device-associated Module
BSI

b. Example: Patient is febrile, has a new onset of cough and has positive chest imaging test
indicating the presence of an infiltrate. Blood specimens collected identify Pseudomonas
aeruginosa. Because the patient can meet the PNU2 definition using the identification of
organisms from a blood specimen as one of the elements of the infection criterion
(specifically, infiltrate on chest imaging test, fever, new onset of cough and organism
identified from blood specimen), the BSI is considered secondary to PNEU.

Note: In situations where an NHSN infection definition can be met using more than one criterion of
the infection definition, it is possible that identification of an organism from the blood and site-
specific specimens may not match and a BSI may still be considered a secondary BSI. Consider the
following:

a. Example: During the SSI surveillance period, a postoperative patient becomes febrile and
complains of nausea and abdominal pain. CT scan done that day shows fluid collection
suggestive of infection. Culture results show Escherichia coli from the T-tube drainage
specimen and the blood specimen grows Bacteroides fragilis. Although the organisms in the
blood culture and site-specific culture do not match for at least one organism, the blood
culture is considered secondary to IAB. This is because the patient meets organ/space SSI
IAB criterion 3b, using the identification of organism in a blood specimen as an element
(fever, nausea or abdominal pain, organism identified from a blood specimen and CT scan
showing infection in abdominal cavity). This patient also meets IAB criterion 3a using the
positive site culture plus fever, and nausea or abdominal pain even though the organism
involved is different from that used for IAB criterion 3b. In this case, the BSI is considered
secondary to the organ/space SSI IAB and both organisms would be listed as IAB infection
pathogens.

b. Example: Patient is febrile, has a new onset of cough and has positive chest imaging test
indicating the presence of an infiltrate. Blood and bronchoalveolar lavage (BAL) specimens
are collected. Results identify Klebsiella pneumoniae > 104 CFU/ml from the BAL and P.
aeruginosa from the blood. Although the organisms in the blood specimen and site-specific
specimen do not match for at least one organism, because the patient can meet PNU2
definition using either the identification of organism from blood specimen or BAL specimen
as one of the elements of the infection criterion (i.e. infiltrate on chest imaging test, fever,
new onset of cough and organism identified from blood specimen or identified from BAL
specimen), the blood is considered a secondary BSI to PNEU and both organisms would be
listed as PNEU pathogens.

Note: If no matching organism is identified from the blood and the site-specific specimen, which is used
to meet the site-specific infection definition, and the organism identified from the blood specimen
cannot be used to meet the site-specific infection criteria, secondary BSI attribution cannot be assigned.
The BSI is considered primary.

a. Example: Patient has pustules on their abdomen with tenderness and swelling. Purulent
material is obtained from the pustules and is positive for Streptococcus Group B. A blood
specimen collected the same day identifies methicillin resistant Staphylococcus aureus.
Because the organisms from the site and blood specimens do not match, and there is no site-

4 - 34
January 2022 Device-associated Module
BSI

specific criterion for SKIN that includes organisms identified from blood specimen, both a
site-specific infection, SKIN (criteria 1 and 2a) and a primary BSI is reported.

b. Example: A patient has an abscess in the soft tissue around a percutaneous endoscopic
gastrostomy (PEG) tube, identified by CT scan, and there is also purulent drainage from that
site. No site-specific specimen was collected, but a blood specimen is positive for
Staphylococcus aureus. No other sites of infection are identified. Because no culture of the
site is collected, and the patient therefore cannot meet ST criterion 1, and because there is
no ST criterion which uses identification of organism from blood specimen as an element,
this patient has a an ST infection (criterion 2), and a primary BSI with the pathogen
Staphylococcus aureus for NHSN reporting purposes.

4 - 35
January 2022 Device-associated Module
BSI

Table B1: Secondary BSI Guide: List of all NHSN primary site-specific definitions
available for making secondary BSI determinations using Scenario 1 or Scenario 2
Scenario 1 Scenario 2
A positive blood specimen must contain at least one Positive blood specimen must be an element of the
eligible matching organism to the site-specific site-specific definition
specimen
And the blood specimen is collected in the site- And blood specimen is collected in the site-specific
specific secondary BSI attribution period infection window period
And an eligible organism identified from the site- And an eligible organism identified in a blood
specific specimen is used as an element to meet the specimen is used as an element to meet the site-
site-specific definition specific definition
Site Criterion Site Criterion
ABUTI ABUTI ABUTI ABUTI
BONE 1 BONE 3a
BRST 1 BURN 1
CARD 1 DISC 3a
CIRC 2 or 3 4a, 4b, 5a or 5b
CONJ 1a (specific organisms)
ENDO
DECU 1 6e or 7e plus other
DISC 1 criteria as listed
EAR 1, 3, 5 or 7 GIT 1b or 2c
EMET 1 IAB 2b or 3b
ENDO 1 JNT 3c
EYE 1 MEN 2c or 3c
GE 2a OREP 3a
GIT 2a, 2b (only yeast) PNEU 2 or 3
IAB 1 or 3a SA 3a
IC 1 UMB 1b
JNT 1 USI 3b or 4b
LUNG 1
MED 1
MEN 1
ORAL 1, 3a, 3d (only
yeast)
OREP 1
PJI 1 or 3e
PNEU 2 or 3
SA 1
SINU 1
SSI SI, DI or OS
SKIN 2a
ST 1
UMB 1a
UR 1a or 3a
USI 1
SUTI 1a, 1b or 2
VASC only as SSI 1
VCUF 3

4 - 36
January 2022 Device-associated Module
BSI

Secondary BSI Reporting Instructions:

• For reporting secondary BSI for possible VAP (PVAP), see Figure B2 and Chapter 10.
• Do not report secondary bloodstream infection for vascular (VASC) infections, Ventilator-
Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or
pneumonia 1 (PNEU 1).
• When a BSI is suspected to be secondary to a lower respiratory tract infection, the BSI can be
determined to be secondary to VAE or PNEU definitions. (See Figure B2).
• Site-specific organism exclusions apply to secondary BSI attribution as well.

A matching organism is defined as one of the following:

1. If genus and species are identified in both specimens, they must be the same.
a. Example: An intraabdominal specimen is used as an element to meet an IAB definition and is
growing Enterobacter cloacae. A blood specimen with a collection date in the IAB secondary
BSI attribution period is growing Enterobacter cloacae. These are considered matching
organisms.
b. Example: An intraabdominal specimen is used as an element to meet IAB definition and is
growing Enterobacter aerogenes. A blood specimen with a collection date in the IAB
secondary BSI attribution period is growing Enterobacter cloacae. These are NOT considered
matching organisms as the species are different.

2. If one organism is less definitively identified than the other, the lesser identified organism must be
identified at least to the genus level and at that level the organisms must be the same.
a. Example: A surgical wound growing Pseudomonas species is used to meet deep incisional SSI
criteria and a blood specimen growing Pseudomonas aeruginosa is collected in the SSI
secondary BSI attribution period. The organisms are considered matching at the genus level
and therefore the BSI is secondary to the SSI.
b. Example: PCR identifying Enterococcus faecalis in CSF meets the MEN definition. A
subsequent blood culture collected in the MEN secondary BSI attribution period is identified
as Enterococcus species. The organisms are considered matching, and therefore the BSI is
secondary to MEN.

3. There are two exceptions to the definition:

a. Infections meeting LCBI 2 criteria with Staphylococcus or Streptococcus
Example (Staphylococcus): A patient has a fever and a previous chest tube site is
reddened, swollen, and a culture is collected from the soft tissue. A culture of the chest
tube site is positive for Staphylococcus species. SST/ST definition is met. The next day, two
blood culture sets are collected. Both are positive for coagulase negative Staphylococcus.
The organisms are NOT considered matching, because Staphylococcus species could

4 - 37
January 2022 Device-associated Module
BSI

represent a coagulase negative or a coagulase positive Staphylococcus. Therefore, the BSI

is not considered secondary to SST/ST.
Example (Streptococcus): A patient has a fever and a previous chest tube site is red,
swollen, and a culture is collected from the soft tissue. The chest tube site culture is
reported positive for Streptococcus species. SST/ST definition is met. The next day 2 blood
culture sets are collected. The blood cultures are both positive for Streptococcus, viridans
group. The organisms are NOT considered matching, because Streptococcus species could
represent a Streptococcus, viridans group or non- Streptococcus, viridans group.
Therefore, the BSI is not considered secondary to SST/ST.

b. In cases where an organism is identified only as “yeast” or “yeast not otherwise specified”,
the organism can be considered a match to other yeasts, when collected during the required
timeframe, whether more fully identified or not.
Example: A culture of tissue from the ulcer margin of a decubiti reported positive for
yeast is used as an element to meet the DECU definition. A blood specimen collected in
the secondary BSI attribution period of the DECU is reported as Candida albicans. In this
example the two organisms are considered matching organisms as the organisms are
complementary (specifically, Candida is a type of yeast) and because yeasts isolated from
non-sterile sites are commonly not identified to the genus or genus and species level.
Note: This exception is limited to yeast. It does not apply to identification of organisms as
Gram positive cocci, Gram negative rods, etc.

Example: A culture of tissue from the ulcer margin of a decubiti reported positive for a
Gram negative rod is used as an element to meet DECU definition. A blood specimen
collected in the secondary BSI attribution period of the DECU is reported as E. coli. In this
example the two organisms are NOT considered matching organisms.
Notes:
1. Antibiograms of the blood and potential primary site isolates do not have to match.

2. If the blood specimen by itself does not meet BSI criteria (for example, only one blood specimen
positive for a common commensal), that specimen may not be used to meet secondary BSI criteria
(see Scenario 1c).

4 - 38
January 2022 Device-associated Module
BSI

Pathogen Assignment
• Additional pathogens identified from secondary BSIs, should be added to the pathogens reported for
the primary infection type. The Secondary BSI data collection field should be checked yes.
MBI-RIT Exception: An MBI-LCBI designation will not change to an LCBI event if the following
criteria are met:

1. The blood culture with the non-MBI organism is collected during an existing BSI (MBI-LCBI)
RIT
AND
2. The blood culture with the non-MBI organism is deemed secondary to an NHSN site-
specific infection

See Example 5 in the Secondary BSI Guide section of this protocol and Chapter 2 Pathogen
Assignment (Example 2b)

• If at least one BSI pathogen with a collection date in the secondary BSI attribution period matches an
organism from a specimen that was used to meet a site-specific infection criterion (either a site-
specific specimen or a blood specimen) the BSI is considered secondary to the event. However, if no
matching pathogen is identified, the subsequent BSI pathogen must be evaluated and deemed
primary or secondary to another site-specific infection. For example: A patient with a primary UTI
with Escherichia coli and a secondary BSI with E. coli has a subsequent positive blood specimen with
yeast. Yeast is an excluded pathogen for meeting UTI criteria; therefore, the subsequent blood must
be evaluated as primary or secondary to another site-specific infection.
• A secondary BSI pathogen may be assigned to two different primary sites of infection (for example,
UTI and an IAB infection). In Example 1 below, two primary sites of infection have been identified and
a blood culture is collected within both the SUTI and the IAB secondary BSI attribution period. The
blood culture pathogen matches the pathogens for both primary sites of infection (SUTI and IAB).
Therefore, the pathogen is reported for both primary sites of infection as a secondary bloodstream
infection.

4 - 39
January 2022 Device-associated Module
BSI

Example 1: Pathogen Assignment

Hospital UTI UTI UTI Infection IAB Infection IAB IAB
Day (HD) SBAP RIT Window Period Window Period RIT SBAP
1 Infection Window Period
2 (First positive diagnostic test, 3 days
3 before and 3 days after)

4 1 Urine culture:
>100,000 cfu/ml Repeat Infection Timeframe
K. pneumoniae
(RIT)
5 2 Fever > 38.0 C (DOE = day 1)
6 3
7 4
Secondary BSI Attribution
8 5 Fever >38.0 C,
Abdominal pain Period (SBAP) (Infection Window
Period + RIT)
9 6 CT Scan:
Abdominal
abscess Date of Event (DOE)
10 7 Blood culture: Blood culture: Date the first element occurs for the
first time within the infection window
K. pneumoniae K. pneumoniae
period
11 8
12 9
13 10
14 11
15 12
16 13
17 14
18
19
20
21
22
23
SUTI & IAB & Secondary
Secondary BSI BSI
DOE = HD 4 DOE = HD 8
Pathogen: K. Pathogen: K.
pneumoniae pneumoniae

4 - 40
January 2022 Device-associated Module
BSI

Example 2: Pathogen Assignment (continued)

Pathogens excluded from specific infection definitions (for example, yeast in UTI, or Enterococcus spp. for
PNEU) are also excluded as pathogens for BSIs secondary to that type of infection (they cannot be added
on to one of these infections as a pathogen). In example 2 below, the excluded organism must be
accounted for as either 1) a primary bloodstream infection (BSI/CLABSI) or, 2) a secondary bloodstream
infection attributed to another primary infection (for example, IAB, SINU).

A blood culture with yeast and E. faecalis is collected during the SUTI RIT. A BSI secondary to SUTI is
identified. E. faecalis is already documented as a pathogen, but the yeast will not be reported as a
secondary BSI pathogen, because yeasts are excluded as organisms in the UTI definition. Because there is
no other primary source of infection for which the yeast BSI can be assigned as secondary, a primary BSI
with yeast is identified.

Note: The Enterococcus faecalis is not reported as a pathogen for the primary BSI because if an excluded
organism had not been identified, a primary BSI would not have been reported.

4 - 41
January 2022 Device-associated Module
BSI
Hospital UTI UTI UTI Infection BSI Infection BSI
Day (HD) SBAP RIT Window Period Window Period RIT Infection Window Period
1 (First positive diagnostic test, 3 days
before and 3 days after)
2
3 1 Dysuria
Repeat Infection Timeframe
4 2 Urine culture: (RIT)
> 100,000 cfu/ml (date of event = day 1)
E. faecalis
5 3 Secondary BSI Attribution Period
6 4 (SBAP)
7 5 (Infection Window Period + RIT)
8 6
9 7 Date of Event (DOE)
10 8 Date the first element occurs for the first
time within the infection window period
11 9 Blood culture: E. Blood culture: 1
Faecalis / Yeast E. faecalis / Yeast
12 10 2
13 11 3
14 12 4
15 13 5
16 14 6
17 7
18 8
19 9
20 10
21 11
22 12
23 13
24 14
25
UTI & Secondary Primary BSI
BSI DOE = HD 11
DOE = HD 3 Pathogen: Yeast
Pathogen: E.
faecalis

4 - 42
January 2022 Device-associated Module
BSI

Example 3: Pathogen Assignment (continued)

Hospital IAB IAB IAB Infection Window IAB Infection Window
Day (HD) SBAP RIT Period Period
1 Admit Abdominal pain &
Infection Window Period
distention
(First positive diagnostic test, 3 days
2 PICC before and 3 days after)
placed
3
4 US guided drainage-5L Repeat Infection Timeframe
purulent peritoneal fluid: (RIT)
(date of event = day 1)
Klebsiella pneumoniae
and E. coli
5 Secondary BSI Attribution Period
6 (SBAP)
7 (Infection Window Period + RIT)
8
9 Date of Event (DOE)
10 Abdominal pain Date the first element occurs for the first
11 CTS multiple liver time within the infection window period

abscesses
Blood culture:
C. glabrata, L. casei
12
13 jaundice, fever
14
15
IAB 1 DOE = HD 4 IAB 3b & Secondary BSI
Pathogens: K. DOE = HD 4
pneumoniae, E. coli Pathogens: C.
glabrata, L casei

Only one infection of a specific type (or major type for BSI, UTI and pneumonia) is reported during an RIT
for that type of event. However, a new event of the same specific type (or major type for BSI, UTI and
pneumonia) can be identified during an RIT if all required elements occur within a new IWP and the DOE is
within the RIT of the initial event. In example 3, IAB criteria 1 is met on hospital day-4 using organisms
identified from purulent fluid. During the IAB RIT (hospital day 4-hospital day 17), IAB criteria 3a is met (on
hospital day 10) using two symptoms, positive imaging evidence of an abscess and a positive blood
specimen. The positive blood specimen occurs within the IAB secondary BSI attribution period; therefore,
it is considered secondary to IAB. The pathogens, in this case, do not have to match because another
definition (IAB 3b) is fully met within a new IAB IWP (hospital day 8-hospital day 14). Because the DOE
(hospital day 10) occurs within the RIT of the initial IAB 1, a new event is not reported. The DOE, RIT and
device association are not changed but any additional organisms identified (C. glabrata and L. casei) are
added to the initial IAB event if reported.

4 - 43
January 2022 Device-associated Module
BSI

Example 4: Pathogen Assignment (continued)

Hospital GIT GIT RIT GIT Infection GIT Infection Window
Day (HD) SBAP Window Period Period
1 Admit Fever & vomiting
Infection Window Period
2 PICC (First positive diagnostic test, 3 days
placed before and 3 days after)
3
4 CT bowel abscess
5 Repeat Infection Timeframe
6 Blood culture: (RIT)
(date of event = day 1)
Enterococcus faecalis
X2
7 Secondary BSI Attribution Period
8 (SBAP)
9 (Infection Window Period + RIT)

10
11 Blood culture: Date of Event (DOE)
Candida glabrata Date the first element occurs for the first
12 time within the infection window period

13 Abscess drainage:
Candida glabrata
Abdominal pain and
nausea
14
15
GIT-2c DOE & GIT-2a & Secondary BSI
Secondary BSI DOE= DOE = HD 1
HD 1 Pathogen: C. glabrata
Pathogen:
E. faecalis

Only one infection of a specific type (or major type for BSI, UTI and pneumonia) is reported during an RIT
for that type of event. However, a new event of the same specific type (or major type for BSI, UTI and
pneumonia) can be identified during an RIT if all required elements occur within a new IWP and the DOE is
within the RIT of the initial event. In example 4, GIT criterion 2c is met on hospital day-1 using two
symptoms, positive imaging evidence of an abscess and a positive blood specimen. During the GIT RIT
(hospital day 1-hospital day 14), GIT criteria 2a is met (on hospital day 11) using two symptoms and a
positive abscess culture. The positive blood specimen occurs within the GIT secondary BSI attribution
period and matches the organism identified from the abscess culture. Therefore, it is considered
secondary to the GIT infection. The pathogens, in this case, do not have to match because another
definition (GIT 2a) is fully met within a new GIT IWP (hospital day 8-hospital day 14). Because the DOE
(hospital day 11) occurs within the RIT of the initial GIT 2c, a new event is not reported. The DOE, RIT, and
device association are not changed but any additional organism identified (C. glabrata) is added to the
initial GIT event if reported. Note: This scenario is applicable to any site-specific infection definition from
Chapter 17 or major infection type including BSI, UTI or pneumonia.

4 - 44
January 2022 Device-associated Module
BSI

Example 5: Pathogen Assignment (continued)

Hospital RIT Infection Window Infection Window RIT BSI
Day Period Period
1
Infection Window Period
2 (First positive diagnostic test, 3 days
3 before and 3 days after)

4
5 WBC –
Repeat Infection Timeframe
400 cells/mm3
(RIT)
6 (date of event = day 1)
7 1 Blood culture:
E. faecalis
Secondary BSI Attribution
8 2
Period (SBAP)
9 3 (Infection Window Period + RIT)
10 4 WBC – Erythema, Pain 1
300 cells/mm3
Date of Event (DOE)
11 5 Skin culture: 2 Date the first element occurs for the first
Staphylococcus aureus time within the infection window period
12 6 3
13 7 4
14 8 5
15 9 6
16 10 7
17 11 8
18 12 9
19 13 Blood culture: 10
Staphylococcus aureus
20 14 11
21 12
22 13
23 14
24
25
26
MBI-LCBI 1 SKIN 2a & Secondary BSI
Date of Event = HD 7 Date of Event = HD 10
Pathogen: E. faecalis Pathogen: Staphylococcus
aureus

A non-MBI organism is NOT assigned to an MBI-LCBI (primary BSI) event when a blood culture with a non-
MBI organism is collected during a BSI (MBI-LCBI)-RIT and deemed secondary to an NHSN site-specific
infection. The MBI-LCBI designation will not change to an LCBI event. On day 7 of hospital admission, E.
faecalis is identified in a blood culture meeting MBI-LCBI 1 criteria. During the BSI RIT of the MBI-LCBI 1

4 - 45
January 2022 Device-associated Module
BSI

event, a blood culture with a non-MBI organism (Staphylococcus aureus) is collected but is deemed
secondary to a SKIN 2a. Because the Staphylococcus aureus (a non-MBI organism) is secondary to SKIN
2a, the MBI-LCBI 1 designation will not change to an LCBI 1.

4 - 46
January 2022 Device-associated Module
BSI

Figure B1: Secondary BSI Guide for eligible organisms*‡

(Not applicable to Ventilator-associated Events [VAE], See Figure B2)

*
Exception: The necrotizing enterocolitis (NEC) definition does not include criteria for a matching
site-specific specimen, nor an organism identified from a blood specimen, however an exception
for assigning a BSI secondary to NEC is provided. A BSI is considered secondary to NEC if the
patient meets one of the two NEC criteria AND an organism identified from a blood specimen,
collected during the secondary BSI attribution period, is an LCBI pathogen or the same common
commensal is identified from 2 or more blood specimens drawn on separate occasions but on the
same or consecutive days.

4 - 47
January 2022 Device-associated Module
BSI

Figure B2: VAE Guidance for Secondary BSI Determination

Positive blood specimen.

Lower respiratory tract infection suspected as
source.

VAC, IVAC
PVAP or
No VAE

BSI secondary to Determine if BSI is

PVAP per VAE BSI NOT
secondary to PVAP secondary to another
surveillance site-specific infection
protocol *
Refer to Figure B1

Determine if BSI is
secondary to another
site-specific infection
Refer to Figure B1

*Secondary BSIs may be reported for possible VAP (PVAP) events, provided that at least one organism
identified from the blood specimen matches an organism identified from an appropriate respiratory tract
specimen (including respiratory secretions, pleural fluid, and lung tissue). The respiratory tract specimen
must have been collected on or after the 3rd day of mechanical ventilation and within 2 calendar days
before or after the day of onset of worsening oxygenation to be considered as a criterion for meeting the
PVAP definition. In addition, the blood specimen must have been collected during the 14-day event
period, where day 1 is the day of onset of worsening oxygenation.
• In cases where PVAP is met with only the histopathology criterion and no culture or non-culture
based testing is performed on an eligible respiratory specimen, and there is also a positive blood
specimen, a secondary BSI to VAE is not reported.
• In cases where a culture or non-culture based testing of respiratory secretions, pleural fluid, or
lung tissue is performed and does not identify an organism that matches an organism identified
from blood, a secondary BSI to VAE is not reported.
Note: Any Candida species or yeast not otherwise specified, any coagulase-negative Staphylococcus
species, and any Enterococcus species identified from blood cannot be deemed secondary to a PVAP,
unless the organism was also identified from pleural fluid or lung tissue.

4 - 48