2013 CAMC Bloodstream Infection Worksheet
Name
MR#
DOB
Admitting Diagnosis
M
Test Period
F
Birthweight
gms.
Unit
Event Date
Admit date
D/C date
ICU Admit date
ICU D/C date
(Neonates only)
Attending physician:
Culture date
Consultants:
Organism(s)
Is patient on hemodialysis?
YES
Type of Line
Insertion Date
# Pos
NO
D/C Date
CL insertion
checklist completed
LABORATORY CONFIRMED BLOODSTREAM INFECTION (LCBI):
Criterion 1: Pt of any age
Date
Recognized pathogen cultured from one or more blood cultures
AND
organism cultured from blood is not related to infection at another
site. (see notes)
Criterion 2: Pt of any age
Date
Common commensal (e.g. diptheroids [Corynebacterium spp.],
#1_____
Bacillus [not B. anthracis] spp., Propionibacterium spp.,
coagulase-negative staphylococci [including S. epi], viridans
#2_____
group streptococci, Aerococcus spp., Micrococcus spp.) is
cultured from two or more blood cultures drawn on separate
occasions (see notes)
AND:
at least one of the following:
Fever (>38C)
Chills
Hypotension
AND:
S/S and positive lab result are not related to an infection at
another site. (see notes)
Culture date
Organism(s)
Stem cell transplant recipient?
Placement
Location of
verified by x-ray
insertion
YES
NO
Body site of
insertion
# Pos
Line inserted by
Criterion 3: Pt <1 Yr. of age (up to and including 1st birthday)
Date
Common commensal (e.g. diptheroids [Corynebacterium
#1_____
spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp.,
coagulase-negative staphylococci [including S. epi], viridans
#2_____
group streptococci, Aerococcus spp., Micrococcus spp.) is
cultured from two or more blood cultures drawn on separate
occasions (see notes)
AND:
at least one of the following:
Fever (>38C core)
Hypothermia (<36C core)
Apnea
Bradycardia
AND:
S/S and positive lab result are not related to an infection at
another site. (see notes)
MUCOSAL BARRIER INJURY LABORATORY CONFIRMED BLOODSTREAM INFECTION (MBI-LCBI):
In 2013 when reporting an LCBI, it is optional to indicate which of the underlying conditions of the MBI-LCBI criterion was met, if any.
However, all CLABSIs, whether LCBI or MBI-LCBI, must be reported if CLABSI is part of your Monthly Reporting Plan.
Criterion 1: Pt of any age
Criterion 2: Pt of any age
Date
Date
Viridans group streptococci is cultured from two or more
Recognized pathogen cultured from one or more blood cultures
#1_____
with at least one blood culture growing any of the following
blood culture draws on separate occasions (see notes)
intestinal organisms with no other organisms isolated:
Bacteroides spp., Candida spp., Prevotella spp., Veillonells
#2_____
spp., or Enterobacteriaceae
(see table)
AND:
at least one of the following:
Fever (>38C)
Chills
Hypotension
AND:
At least one of the following:
AND:
At least one of the following:
Is an allogeneic hematopoietic stem cell transplant recipient
Is an allogeneic hematopoietic stem cell transplant recipient
within the past year with one of the following documented during
within the past year with one of the following documented
same hospitalization as positive blood culture:
during same hospitalization as positive blood culture:
a. Grade III or IV gastrointestinal graft versus host
a. Grade III or IV gastrointestinal graft versus host
disease (GI-GVHD)
disease (GI-GVHD)
b. >1 liter diarrhea in 24-hr period (or >20 ml/kg in a 24-hr
b. >1 liter diarrhea in 24-hr period (or >20 ml/kg in a
period for patients <18 years of age) with onset on or
24-hr period for patients <18 years of age) with
within 7 calendar days before the date the positive
onset on or within 7 calendar days before the date
blood culture was collected.
the positive blood culture was collected.
Is neutropenic, defined as at least 2 separate days with values of
Is neutropenic, defined as at least 2 separate days with
absolute neutrophil count (ANC) or total WBC count <500
values of absolute neutrophil count (ANC) or total WBC count
cells/mm3 on or within 3 calendar days before the date the
<500 cells/mm3 on or within 3 calendar days before the date
positive blood culture was collected (Day 1).
the positive blood culture was collected (Day 1).
AND:
AND:
S/S and positive lab result are not related to an infection at
S/S and positive lab result are not related to an infection at
another site. (see notes)
another site. (see notes)
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2013 CAMC Bloodstream Infection Worksheet
Criterion 3: Pt <1 Yr. of age
Date
Viridans group streptococci is cultured from two or more blood
culture draws on separate occasions (see notes)
AND:
At least one of the following:
Hypothermia (<36C core)
Apnea
Bradycardia
AND:
At least one of the following:
Is an allogeneic hematopoietic stem cell transplant recipient
within the past year with one of the following documented during
same hospitalization as positive blood culture:
a. Grade III or IV gastrointestinal graft versus host
disease (GI-GVHD)
b. >1 liter diarrhea in 24-hr period (or >20 ml/kg in a 24-hr
period for patients <18 years of age) with onset on or
within 7 calendar days before the date the positive
blood culture was collected.
Is neutropenic, defined as at least 2 separate days with values of
absolute neutrophil count (ANC) or total WBC count <500
cells/mm3 on or within 3 calendar days before the date the
positive blood culture was collected (Day 1).
AND:
S/S and positive lab result are not related to an infection at
another site. (see notes)
Comments:
Central line: An intravascular catheter that terminates at or close to the
heart or one of the great vessels, which is used for infusion, withdrawal of
blood, or hemodynamic monitoring.
The following are considered great vessels for the purpose of reporting
central-line infections and counting central-line days :
Aorta
pulmonary artery
superior vena cava
inferior vena cava
brachiocephalic veins
internal jugular veins
subclavian veins
external iliac veins
common femoral veins

An introducer is considered an intravascular catheter.

In neonates, the umbilical artery/vein is considered a great vessel.
Neither the location of the insertion site nor the type of device may be used
to determine if a line qualifies as a central line.
Pacemaker wires and other nonlumened devices inserted into central blood
vessels or the heart are not considered central lines, because fluids are not
infused, pushed, nor withdrawn through such devices
Formula
ANC = WBC x (%segs + %bands) / 100
Table of Events
Date
Day
CL
Bld-Pathogen
Bld-Common
commensal #1
Bld-Common
commensal #2
Other Cx
Fever
Chills
Hypotension
ANC
WBC
Formula
ANC = WBC_____ x (%segs___ + %bands___) / 100
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2013 CAMC Bloodstream Infection Worksheet
Notes:
1. “One or more blood cultures” means that at least one bottle from a blood draw is growing at least one organism.
2. “Recognized pathogen” does not include common commensals.
3. “Two or more blood cultures drawn on separate occasions” means:
1) That blood from at least two blood draws was collected within two calendar days of each other (e.g., blood draws on Mon and Tues meet this,
but blood draws on Mon and Wed would be too far apart), and
2) That at least one bottle from each blood draw is growing the same common commensal.
a. For example- adult pt has blood drawn at 8 a.m. and at 8:15 a.m. Blood from each draw is inoculated into two bottles and incubated
(4 bottles total). If one bottle from each blood draw is positive for coag-neg staph, this part of the criterion is met.
b. For example- neonate has blood draws on Tues and on Thur and both grows the same common commensal. This part of the
criterion is not met since the time exceeds the 2-day period.
c. “Separate occasions” also means blood draws from separate sites or separate accesses of the same site
d. A blood culture may consist of a single bottle for a pediatric blood draw due to volume constraints. Therefore, to meet this part of
the criterion, each bottle from two or more draws would have to be culture-positive for the same commensal.
4. If the common commensal is identified to the species level from one culture, and a companion culture is identified with only a descriptive name (e.g., to
the genus level), then it is assumed that the organisms are the same. The organism identified to the species level should be reported as the infecting
organism along with its Antibiogram if available.
5. Only genus and species identification should be utilized to determine the sameness of organisms (matching organisms). No additional comparative
methods should be used (e.g., morphology or Antibiogram) because lab testing may vary between facilities. Report the organism to the genus/species
level only once, and if Antibiogram data are available, report the results from the most resistant panel.
6. Specimen Collection: Ideally, blood specimens for culture should be obtained from 2 to 4 blood draws from separate venipuncture sites; not through a
vascular catheter. These blood draws should be performed simultaneously or over a short period of time (within a few hours).
7. “No other organism isolated” means there is not isolation in a blood culture of another recognized pathogen or common commensal other than listed in
MBI-LCBI criterion 1, 2, or 3 that would otherwise meet LCBI criteria. If this occurs, the infection should not be classified as MBI-LCBI.
8. Grade III/IV GI GVHD is defined as follows:
a. In adults: >1 L diarrhea/day or ileus with abdominal pain
b. In pediatric patients: >20 cc/kg/day of diarrhea
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