>> Hello. My name is LaTasha Powell, one of the BSI subject matter experts here at NHSN.
I'll be providing a few updates regarding secondary BSI
and chapter 17 reporting instructions.
By the end of this section of the presentation, our viewers will be able
to apply the MBI-LCBI RIT exception
and summarize the reporting instruction updates in chapter 17.
In 2021, a revision was made to the MBI-LCBI exception to make it more reader-friendly.
At the top of the slide, you'll see how the exception was written in 2020.
In 2021, the MBI-LCBI exception reads as follows.
An MBI-LCBI designation will not change to an LCBI event if the following criteria are met.
One, the blood culture with the non-MBI organism is collected during an existing BSI RIT
of an MBI-LCBI event and two, the blood culture with the non-MBI organism is deemed secondary
to an NHSN site-specific infection.
This exception can be found on pages 2-18 and 4-41.
On the next slide, we will review again how this exception is applied.
In this example, an LCBI 1 is cited using the enterococcus faecalis blood culture
on hospital day seven.
Because the patient has two WBC levels less than 500 cells
on two separate days during the timeframe of three days before, the day of,
and three days after the eligible blood specimen, an MBI-LCBI 1 is cited.
Please note that the MBI-LCBI 1 event, date of event, remains on hospital day seven
because the WBC levels are only risk factors and are not used to determine the date of event.
The MBI-LCBI event creates a hospital day seven through hospital day 20 BSI RIT.
If the blood culture with the non-MBI organism, as seen here in red,
is collected during an existing BSI RIT of an MBI-LCBI event,
and the blood culture is deemed secondary to an NHSN site-specific infection,
the initial MBI-LCBI designation remains unchanged.
The example seen the slide can be found in chapter two on page 2-21.
So now let's move on to updates made to the chapter 17 reporting instructions.
In 2021, there were 10 reporting instruction additions
and clarifications added to chapter 17.
It is extremely important that you're using the most current chapter 17 document to ensure
that you are identifying cases correctly
and applying secondary BSI attribution appropriately.
The following reporting instruction was added under the ENDO criteria in 2021.
It reads as follows.
Cardiac vegetation can be found on a cardiac valve, pacemaker/defibrillator lead,
or ventricular assist device components within the heart.
The reporting instruction refers to the acceptable locations
of a cardiac vegetation to cite an ENDO criteria.
In 2021, the following reporting instruction was added regarding GIT 1b.
If an organism is identified on histopathologic exam,
the blood specimen must contain a matching organism.
This reporting instruction was added in an effort to make the definition a little tighter
when deeming a blood culture secondary to this definition.
So in addition to requiring the blood specimen to contain at least one MBI organism,
we also require that the blood culture match an organism identified during the
histopathologic exam.
The histopathologic finding and the blood culture must be contained in the same GIT IWP.
In case you don't have chapter 17 handy,
GIT 1b is denoted in the red box at the bottom of this slide.
We'll discuss how we should apply this reporting instruction on the next slide.
In the first example on February 2nd, the pathology report reads classical budding hyphae
and spores of Candida admixed with ulcer slough.
On February 4th, a blood culture is positive for Candida albicans.
Because the organism seen on the pathology report matches an organism in the blood culture
and Candida albicans is an MBI organism and these elements can be captured in a GIT IWP,
GIT 1b is met and the Candida blood culture is deemed secondary.
In the second example, we have the same pathology report.
However, on February 4th, a blood culture is positive for Klebsiella pneumoniae.
Because the blood culture does not match the organism seen on histopathologic exam,
GIT 1b cannot be met in the blood culture cannot be deemed secondary.
In this culture -- if this culture cannot be deemed secondary
to another NHSN site-specific infection, an LCBI 1 is cited.
Another reporting instruction was added under GIT that reads as follows.
In patients greater than one year of age,
pneumatosis intestinalis is considered an equivocal imaging finding
for a gastrointestinal tract infection.
For patients less than or equal to one year of age, please review the NEC criteria.
Here is an example of an equivocal imaging for GIT in a patient greater than one year of age.
Pneumatosis intestinalis involving the cecum, ascending and proximal transverse colon
with significant dilatation of the large bowel, recommend consultation with general surgery.
This equivocal imaging finding requires physician documentation of antimicrobial therapy
for gastrointestinal tract infection.
It is important to note here that if pneumatosis intestinalis is found on imaging
in a patient less than or equal to one year of age, you should review the NEC one criteria.
A similar reporting instruction was added under IAB regarding organism seen
on histopathologic exam and matching blood specimens.
It reads as follows.
If an organism is identified on histopathologic exam and the blood specimen must contain --
the blood specimen must contain a matching organism.
The IAB 2b criteria is denoted by the red box on the right side of the screen.
On the next slide, we will cover how this reporting instruction can be applied.
On the left side of the slide, you will find the first example.
The pathology report of the pancreas reveals fungal profiles are seen in background
with pseudohyphae and budding yeast forms suggestive of invasive Candida infection.
On 2/4, there is a blood culture collected for Candida albicans.
Because Candida was identified during the histopathologic exam,
the matching blood culture can be captured in an IAB IWP.
An IAB 2b is cited and the Candida blood culture is deemed secondary to the IAB 2b.
In the example on the right side of the slide,
you have the same pathology report seen in the first example.
However on 2/4 a blood culture is positive for Klebsiella pneumoniae.
Because the blood does not match at least one organism identified during the histopathologic
exam, IAB 2b is not cited and the blood culture is not deemed secondary.
If the blood culture cannot be deemed secondary
to an NHSN site-specific infection, it is an LCBI 1.
Under the NEC definition, we've added the following reporting instruction.
Pneumatosis is considered an equivocal abdominal imaging finding for necrotizing enterocolitis.
Examples of abdominal imaging include KUB, ultrasound, and abdominal x-ray.
This reporting instruction was added because this is common terminology used
by medical providers with this patient population when referring to NEC.
An example of an imaging test that is equivocal
for NEC is an abdominal x-ray that reads as follows.
Abnormal bowel gas pattern with irregular appearance
of bowel loops in the right lower quadrant.
Bowel wall thickening suggestive of early pneumatosis.
It is important to note that physician documentation of antimicrobial therapy for NEC
or clinical correlation is required for the imaging test to be eligible.
There clarifications made to the reporting instructions under BURN, SKIN,
and ST regarding temporary graphs and dressings and permanent graphs on burn wounds.
Under the burn definition, the reporting instruction now reads the following.
Report BURN in the setting of an infected burn covering with a temporary graft or dressing.
In the setting of a permanent skin graft, or autograft,
over a burn wound, use the SKIN or ST criteria.
The diagram on this slide provides guidance on when to use BURN versus SKIN
or ST. If the patient has an allograft, homograft, or temporary dressing
over a burn wound, you must use the burn criteria.
If the patient has an autograft over a burn wound use SKIN
or ST depending on the skin level affected.
Under the SKIN definition, we revised two reporting instructions for clarity.
They read as follows.
Report SKIN or ST in the setting of a permanent skin graft or autograft over a burn wound.
Additionally under SKIN, we added to report BURN in the setting of an infected burn covered
with a temporary graft or dressing.
Under ST, or soft tissue, two reporting instructions were added to clarify
when it is appropriate to apply BURN versus SKIN
or ST. The first reporting instruction reads as follows.
Report SKIN or ST criteria in the setting
of a permanent skin graft, or autograft, over a burn wound.
The second reporting instruction reads report BURN in the setting of an infected burn covered
with a temporary graft or dressing.
In conclusion, if you are viewing this training video during March 2021, please submit questions
to be answered during the live Q&A session by selecting the title of the presentation
and submitting your question using the form located on the 2021 NHSN training webpage.
Alternatively if you're viewing this training video after March 2021,
please submit any questions about the content of this presentation to nhsn@cdc.gov.
Thank you for taking the time to review this section of the webinar.