Central Line-Associated Bloodstream Infection (CLABSI) Worksheet

Date of Event of the infection is date first element of the criterion is met for the first time within the 7-day Infection Window Period and must occur on or after the 3rd calendar day of admission to an inpatient location where day of admission is Day 1.

NHSN #______

Patient: / MR# / AGE: / M F / Adm: / Disch:
MC# / DOB:
ICU: / ICU ADM / ICU DISCH / Line INSERT / Days to Infection: / Line Days:
Line Type/Site: / Location of Device Insertion:
Date of Device Insertion:
MDRO Infection Surveillance: YES NO / Date of Event: / Event Location:
Culture Date: / Pathogens:
Culture Date: / Pathogens:
How was blood culture obtained? Peripheral  Central Line  IV Catheter  Other
Must have ALL
 BSI >2 calendar days after hospital admission*
 Central line catheter was in place for > 2 calendar days(see NOTES). The day of device placement is day 1.
 Central line was in place on the day of the event (DOE) or the day prior to the BSI
 Organismcultured from one or more blood cultures is not related to an NHSN-Defined Infection at another site.
Criteria 1 & 2 may be used for patients of ANY age, including those 1 year of less. Criterion 3 only applies to patient < 1 year or less.
LCBI 1 / Patient has a recognized pathogen from one or more blood cultures.
LCBI 2 / Patient has the same COMMON COMMENSAL** from two or more separate blood cultures drawn from different sites on the same or consecutive calendar days. Must have ONE:
 Fever > 38º C
 Hypotension (define)
 Chills
LCBI 3
(≤ 1 year of age) / Patient has the same COMMON COMMENSAL** from two or more separate blood cultures drawn from different sites on the same or consecutive calendar days. Must have ONE:
 fever (>38°C core) or hypothermia (<36°C core),
 apnea,
 bradycardia
Mucosal Barrier Injury (MBI) Criteria: Must meet LCBI 1 Criteria and Must have A or B
  1. Stem cell transplant (SCT) within 1 year
 Allo-SCT with Grade  3 GI GVHD(Gastrointestinal Graft versus Host Disease)
 Allo-SCT ≥1 liter diarrhea in a 24-hour period (or ≥20 mL/kg in a 24-hour period)
  1. Neutropenia: Total WBC < 500 cell/mm3on 2 separate days within a seven-day infection window (includes the 3 calendar daysbefore or after a positive blood culture)

DOE: / MBI-LCBI 1: Patient must meet LCBI 1Criteria with positive blood culture growing any of the following intestinal organisms:Bacteroides spp., Candida spp., Clostridium spp., Enterococcus spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., Veillonella spp., or Enterobacteriaceae
DOE: / MBI-LCBI 2: Same as MBI-LCBI 1 with Viridans group streptococci only positive blood culture
DOE: / MBI-LCBI 3: Patient ≤ 1 year of age - Same as MBI-LCBI 1 with Viridans group streptococci only positive blood culture

*see transfer ruleREV 4/2015

** See complete list of Common skin commensals@

NOTES: Repeat Infection Timeframe (RIT) = 14 day time frame, in which no new infections of the same type are reported. Date of Event is day 1 of the 14-day RIT. The Secondary BSI Attribution Period includes the Infection Window Period combined with the RIT. It is 14-17 days in length depending upon the date of event. Pathogens excluded from specific infection definition are also excluded for as pathogens for BSIs secondary to that type of infection. If Central Line is Removed for one (1) full calendar day and reinserted, the central line count will start anew.

REV March 2014