Primary Bloodstream Infection (BSI) Worksheet



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 |

|( Organism cultured 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 |Patient has the same COMMON COMMENSAL** from two or more separate blood cultures drawn from different sites on the same or consecutive calendar |

|(≤ 1 year of age) |days. Must have ONE: |

| |( fever (>38°C core) or hypothermia ( ................
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