>> Good afternoon.
We're going to start our secondary BSI group exercise.
It is an ENDO and GIT case study and it is -
it has three parts, the same patient.
And you can use any of the information from any
of the parts to answer the questions.
So, what will happen, initially, before - let me just back
up for a second, you should have your group handouts, groups -
group study materials.
You should have three HAI checklists,
you should have a table B1, secondary BSI table.
And, for those that are participating via web stream,
all of those materials are available on the NHSN training
that you have been pulling your information from previously.
So, for the first part, I'm going to give you
about eight minutes to work
through the initial part of the case study.
And then we'll have about two minutes to do the rationale,
and then I need a brave soul to come up
and answer four of the questions.
If no one volunteers, we will volunteer we will
volunteer someone.
Okay, so let's get started.
So, here's part one of the case study, on 3/1, --
this is Mister Oliver Pope, on 3/1,
this 55-year-old male is admitted
with chills and fatigue.
He has a past medical history of IV drug use,
diabetes and diverticulitis.
He has a PICC placed due to poor venous access.
The blood cultures, on admission, are positive
for MRSA times four and Vanc is started.
On 3/2, he has a TEE that reveals echo density
with the tricuspid valve consistent with vegetation.
On 3/4, he has blood cultures collected again
and they are positive for MRSA times two.
On 3/9, he feels better and he wants to go home,
so the four questions that I want you to answer is,
what determination should be made in this case?
And you have your four options here,
and you also have them in your handouts.
What elements were used to make this determination?
What about the 3/4 MRSA blood cultures?
And what scenario of secondary BSI attribution was applied
in this case?
And so, I'm going to walk around to see if you have any questions
or if you need any assistance.
Oh, and I'm sorry, there's one more question,
if this patient has subsequent MRSA blood cultures,
I can add them to this ENDO S BaP.
And you may begin.
Okay, I'm - ran a little bit over time,
do we have a brave soul who wants
to provide the answers to part one?
Anyone? Okay.
Okay. All right, so, let's give her a hand.
She's a brave soul [applause].
All right, okay, so,
what determination should be made in this case?
>> B. Oh, I'm sorry, C. C, C, C.
>> Absolutely right.
ENDO four with a secondary BSI.
Okay so, here is quickly why,
so a PAO ENDO four was cited on 3/1.
We had MRSA blood cultures times four, and that created an IWP
of 227 to 311, the 3/2 TEE is captured in that IWP and so,
the POA ENDO RIT is 3/1 until the end of the admission.
And the S BaP is 227 to the end of the current admission, okay?
All right, so what about the 3/4 blood cultures?
>> B.
>> Absolutely.
It will be secondary to the POA ENDO four [applause].
And here's why, because of the result,
the lengthy SBAP that's associated
with ENDO is only limited to the organisms identified
in the blood specimen
that matched the organisms used to meet ENDO.
So, excellent.
And that's in chapter 17, page four - 17-12.
So, what scenario was applied in this case?
>> Two.
>> B.
>> Scenario two.
And, again, because the blood was used as an element
and that the blood was collected during the IWP,
it is deemed secondary using scenario two.
Last question, if this patient has subsequent MRSA blood
cultures, I can add them to the ENDO SBAP.
>> True.
>> True. Absolutely, very good.
Good job. Let's give her a hand [applause].
>> Thank you.
>> Okay so, we're going to have to breeze
through these very quickly, so I'm going to ask
that you do both part two and part three at the same time.
So, I'm going to read part two, but you're going to have
to read part three on your own, and I want you all
to just make a determination.
So, 3/10, despite Mister Pope wanting
to go home, he's still admitted.
3/12, you have blood cultures collected that are positive
for Klebsiella pneumoniae.
On 3/14, he has left lower quadrant abdominal pain that's a
seven out of ten.
He has a 103 degrees Fahrenheit temperature
and diarrhea.
On 3/15, he has CT scan
that indicates loculated fluid collection
in the bowel consistent with abscess.
So, your three questions are,
what determination should be made in this case?
What elements were used to make this determination?
And what scenario was applied in this case?
And I'm going to ask you to work on both part two and three
because I'm -- I'm running pretty low on time.
Okay? And I'm going to be walking around so,
if you need any assistance, just please pull me
or one of the BSI experts.
Okay everyone, do we have a brave soul who wishes
to share the answers for part two?
Oh, thank you.
Everyone, give her a hand [applause].
So, what determination should be made in this case?
Okay. Actually, it's 3/12 GIT 2C with a secondary BSI.
And here's why, because I think I figured
out why you decided to choose IAB.
But because the loculated fluid collection was
in the bowel wall, it was confined
in the gastrointestinal tract, we would use GIT instead of IAB,
okay, does that make sense?
Okay, so an HAI GIT 2C is cited on 3/12,
and then the Klebsiella pneumoniae creates a GIT IWP
of 3/9 to 3/15.
The fever and abdominal pain on 3/14 and the CT that's eligible
for - that's suggestive
of infection is captured in the IWP.
The GIT RIT is 3/12 to 3/25 in the GIT S BaP is 3/9 to 3/25.
So, what scenario was applied in this case?
I'm sorry, scenario two, that's correct.
So, now we have to move on to part three.
Do we have a brave soul that wishes
to share the questions for part three?
I think I have one more question.
Does anyone want to volunteer for part three?
Okay, all right, well let's just go
over them together, how's that?
>> Yeah.
>> Okay. So, what determination should be made in this case?
>> D.
>> D, both B and C, okay.
So, remember that the GIT 2C was initially met on 3/12.
But, during the GIT 2C RIT which is 3/12 to 3/25,
GIT 2C can be met again.
And what I also noticed, as I was going
through this group exercise, that it is also possible
to use some of the elements from the previous GIT
to deem a blood culture secondary.
Did everyone catch that?
Okay, all right.
So, I have here, to try to make a little bit cleaner,
that the GIT 2C was met on 3/17 and you have the blood culture,
the abdominal pain and fever,
along with the imaging and the 3/17 candida.
And then also a GIT 2A is met.
So, they had fever and abdominal pain, the IR drainage
that was positive for candida albicans,
and so the blood culture,
the 3/17 candida is actually secondary
to both the GIT 2C and the GIT 2A.
Okay? In addition, ENDO six is also met
on 3/17 during the RIT of the POA ENDO.
So, we had fever, we had the 3/17 candida albicans
blood culture.
On 3/20, we had the echo density with tricuspid valve,
that's still present and consistent with vegetation.
And we also had the IV drug history.
We chose ENDO six because it does not have any restrictions
or limitations as far as the type of organism
that you would use, whereas, with ENDO four and five,
you will have to use the typical ENDO infectious organisms.
So, what scenario would be applied in this case?
Both. So, it would be C. So, we use scenario one to apply GIT 2A
with a secondary BSI, and then we use scenario two
to apply GIT 2C with a secondary BSI and also
in ENDO six with a secondary BSI.
If the 3/17 blood cultures were positive with only pseudomonas,
would your determination remain the same, and why?
So, actually that's - I'm sorry, that's an error.
It actually would be no.
And the reason why would be that you could not meet GIT 2A
because the pseudomonas blood culture does not match the
candida, okay?
Additionally, GIT 2C cannot be met
with the pseudomonas blood culture
because pseudomonas is not an MBI organism.
However, ENDO six,
that determination would remain the same.
And I am done with my presentation,
thank you so much [applause].