National Center for Emerging and Zoonotic Infectious Diseases

Distinguishing Primary from Secondary Bloodstream

Infections (BSIs) for the NHSN Patient Safety Component

Katherine Allen-Bridson, RN, BSN, MScPH, CIC

Lead- Protocol and Validation Team
Surveillance Branch
Division of Healthcare Quality Promotion
Centers for Disease Control & Prevention

April 26, 2018

Objectives / Agenda
1. Review important foundational concepts from Ch. 2
and Ch. 4
2. Identify the relationship between site-specific
infections and secondary bloodstream infections.
3. Review Appendix B. Secondary BSI Guide and
reference tables from Ch. 4 BSI Device-associated Module.
4. Practice/Apply Secondary BSI Guidelines to educational case studies.
Primary BSI versus Secondary BSI
Primary BSI is a laboratory confirmed bloodstream infection
(LCBI) where an eligible BSI organism is identified and the BSI
is not secondary to a site-specific infection at another body
site
Secondary BSI is a bloodstream infection that is associated
with a site-specific infection at another body site which may
have seeded the bloodstream
Refer to Ch. 4 BSI-Device-Associated Module, Appendix B. Secondary BSI Guide
and CDC/NHSN Surveillance Definitions for Specific Types of Infection Ch. 17
LCBIs Reported to NHSN

Must be primary in nature

 CANNOT be secondary to another site of infection
Why is it important to distinguish a primary BSI from a
secondary BSI when performing CLABSI surveillance?

A. Secondary BSIs are not reported to NHSN

B. Primary BSIs are more difficult to prevent than secondary BSIs
C. To identify those BSIs for which improving central line insertion and
maintenance practices may reduce the incidence.
Primary vs Secondary BSIs
Meeting Secondary BSI Requirements:

Involves a matching site-specific Involves an organism(s) identified in

specimen as an element the blood as an element
2 Secondary BSI Scenarios
 Scenario 1: At least one organism  Scenario 2: An organism identified
from the blood specimen matches in the blood specimen is an
an organism identified from the element that is used to meet the
site-specific infection that is used NHSN site-specific infection
as an element to meet the NHSN criterion, and therefore is collected
site-specific infection criterion AND during the site-specific infection
the blood specimen is collected window period.
during the secondary BSI
attribution period (SBAP=infection
window period + repeat infection
timeframe).
Secondary Bloodstream Infections
Scenario 1
Secondary BSI Scenario 1
Scenario 1: At least one organism from the blood specimen matches an
organism identified from the site-specific infection that is used as an element to
meet the NHSN site-specific infection criterion AND the blood specimen is
collected during the secondary BSI attribution period (infection window period +
repeat infection timeframe)†.

1. Blood and site-specific specimen must have at least

one eligible matching pathogen
2. That site-specific specimen is used as an element to
meet the primary-infection criterion
AND
3. Blood specimen is collected within the SBAP of the
site-specific infection
Secondary BSI Scenario 1 NOTE
The organism(s) in the blood must
be eligible for use in meeting the
site-specific infection definition

Ex: UTI
Candida are excluded pathogens that
cannot be used to meet the NHSN UTI
definition. Therefore, a BSI with Candida
cannot be deemed secondary to a UTI.
PNEU also has excluded pathogens.
Secondary BSI Scenario 1: Example SINU

Example:
1/12/18: Patient with PMH of chronic
sinusitis admitted to Medical/Surgical unit
1/15/18: Patient sent to special
procedures for functional endoscopic
sinus evaluation. Fluid aspirated from
sinus cavity sent for culture; Results:
+ S. pneumoniae
1/19/18: Fever 102 F, blood specimen x 2
o

+ S. pneumoniae
Secondary BSI
Scenario 1
Important Secondary BSI Concept
 A positive blood culture on admission does NOT necessarily set a BSI RIT.
– 1/12: Patient admitted with positive blood culture E. coli
– 1/22: Positive blood culture S. aureus

 Only primary BSIs set a 14-day BSI RIT

 Secondary BSIs do NOT- an RIT will be set for the primary type of infection

 It is necessary to determine if the E. coli BSI was primary or secondary to

determine if the S. aureus BSI must be investigated as possible LCBI.

Refer to Ch. 4 Device-associatedBSI Module page 4-13 & 4-14 for examples
 Example: POA BSI
1/12/18: 55-year-old patient
admitted with fever (102.4oF)
of unknown origin, work-up
in progress. UA, Urine for
C&S and blood cultures x 2
collected. Results:
Urine positive > 105 CFU/ml
E. coli, & 1 of 2 BCs positive
for E. coli
1/21/18: Repeat BC’s
collected positive S. aureus.
Refer to UTI in Resource Manual
Secondary Blood Stream Infections
Scenario 2
Secondary BSI Scenario 2

1. Organism in the blood is an element used

to meet the primary-site infection criterion
2. Blood specimen is collected in the IWP
(or surveillance period if SSI)
Secondary BSI Scenario 2: Example BURN

1/12/18: Patient admitted after a

fireworks accident with 1st & 2nd degree
burns to right hand. Wound assessment: Scenario 2
Pale pink to red, glistening, mild swelling An eligible organism identified in the
with small blisters between fingers. blood is used as an element to meet the
site-specific definition
1/15/18: Wound assessment: a marked
increase in swelling of fingers, purplish The blood specimen is collected in the
site-specific infection window period
eschar with right index fingertip noted to (IWP)
be black.
1/18/18: Fever 101 F, blood specimen
o

x2 positive for Pseudomonas aeruginosa.

Secondary BSI
Scenario 2
What if neither Scenario 1 nor Scenario 2 can be met?

A. No event is identified
B. It is a primary BSI
C. Email NHSN for guidance
BREAST Example: Neither Scenario 1 nor 2 can be met…

1/15/18 : Breast fluid collected during an invasive procedure + S.aureus.

o
1/18/18: Fever 100.6 F, blood cultures x 2 (+) for coagulase negative Staph (CNS
)
Breast or Mastitis Infection Criteria
Breast infection must meet one of the following criteria
 Only Exception to Meeting Scenario 1 or 2
for Making Secondary BSI Determinations
Necrotizing Enterocolitis (NEC): NHSN NEC criteria include NO elements of
 site-specific specimen OR,
 organism(s) identified in the blood

IF… Patient meets one of the 2 NEC criteria AND

– Organism(s) in the blood, collected during the SBAP, is a recognized pathogen or 2
matching common commensals collected on separate occasions (which is the
same or consecutive days)……..The BSI is considered secondary.

*Refer to Ch. 4 BSI Module page 4-38 and Ch. 17 Site-Specific Definitions page 17-22
Assigning Pathogens in Secondary BSIs
Pathogen Assignment Rules
 An organism may be attributed as secondary to more than 1 type of
infection.
 Scenario 1: Additional organisms in the blood besides the matching
organism, are considered secondary also.
– BUT
If no matching organism with the organism in the site-specific specimen
(Scenario 1) or, with the organism in the blood (Scenario 2) the BSI
cannot be considered secondary See next case

Refer to Ch. 4 BSI Module page 4-34

Case

 1/13/2018: 60-year-old patient admitted to hospital

with fever of 101⁰F. Central line and Foley placed.
 1/14/2018: Urine cx collected: final >105 CFU/ml of
E. coli. Foley removed.
 1/15/2018: Complains of dysuria. Central line
removed. Positive blood cx’s growing: E. coli, E. faecalis
 1/16 and 1/17 Patient with 2 + blood cx’s growing
E. faecalis, S. aureus.
SUTI with Subsequent + BC: Pathogen Assignment
Secondary BSI
Tools, Education & Reference
Reference Table B1: Primary Sites Eligible for Secondary BSIs

Refer to Ch. 4 Device

-associated Module-BSI page 4-27 and Resource Manual
Secondary BSI Guide

Refer to Ch. 4 BSI Device-Associated Module page 4-38

Training Resources:
https:// www.cdc.gov/nhsn/training/patient-safety-component/index.html

https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
Frequently Asked Questions
Case Studies
Case Study 1
 February 1: 35-year-old woman admitted with complaints of right
scapular pain and fever. Superficial laceration to back right scapula from
falling into outdoor grill 5 days earlier. Wound is scabbed over in places
but purulent drainage is noted from center. Admit for IV antibiotics.

 February 3: No improvement noted with broad spectrum antibiotic

coverage. Wound is swelling, red and warm to touch. Drainage from
wound is sent for culture, positive for Streptococcus pyogenes.

 February 8: Patient fever continues, and WBCs continue to increase, now

at 20,000 WBC/μL. Blood cultures are collected and final results are
positive for methicillin-resistant S. pyogenes.
Is Case Study 1 a Primary LCBI?

A. Yes. This is an primary LCBI 1 with S. pyogenes identified on

hospital day 1-Feb 1st
B. No. This is a primary SKIN infection with a secondary BSI.
 Case Study 1 - Rationale

Refer to Case Study 1, Ch. 2 page 2- for guidance on meeting more than one site-specific criterion
Case Study 1 Rationale:
Case Study 1 Rationale:

You can set the wrong DOE if the IWP that provides the earliest DOE is not used.
Refer to: Ch. 2 pages 2-5
Meeting More than One Criteria of Same
Type of Infection?
 Case Study 2
 January 16: 67-year-old female is admitted for abdominal hysterectomy.
Patient suffers an intraoperative stroke and is admitted to neuro ICU and
placed on a ventilator.
 January 31: Patient spikes a fever to 38.1⁰C and the WBCs are elevated at
15,000 WBCs/μl. Her breath sounds are coarse throughout. Chest x-rays
show pulmonary edema, but no evidence of pneumonia. Patient grimaces
on suprapubic palpation. Vaginal exam performed and purulent drainage
noted at vaginal cuff. Vaginal cuff, blood, and UA cultures are collected.
 February 2: Final results of UA cultures-negative, but blood cultures x 2
are positive for Acinetobacter baumannii, and culture of pus from vaginal
cuff is positive for Group B Streptococcus.
Which of the following is the correct attribution?

A. This patient has a VCUF (vaginal cuff) infection with

secondary BSI.
B. This patient has an LCBI.
C. This patient has both an LCBI and a surgical site infection
(organ space-VCUF).
Case Study 2 - Rationale
Case Study 3
 Jan 1: Patient admitted with abdominal pain and distension
 Jan 2: PICC placed
 Jan 4: US guided drainage of 5L purulent peritoneal fluid,
positive for K. pneumoniae and E.coli.
 Jan 10: Abdominal pain increased
 Jan 11: CTS multiple liver abscesses, blood cultures x 2
positive C. glabrata and L. casea
 Jan 13: Jaundice, fever 101.2◦F
Which of the following is the correct attribution?

A. The patient has an LCBI 1.

B. She has an SSI-IAB (intra-abdominal infection) with
secondary BSI.
C. She has an IAB with secondary BSI.
 Case Study 3 - Rationale

The pathogens don’t have to match, in this case, because another criteria (IAB 3b) is fully met within a new IWP
Because IAB 3b is met in the IAB RIT, it is attributed to the initial event and the organisms are added
Case Study 4
 Jan 4: 45-year-old with colon cancer admitted and undergoes
colectomy. Patient’s tunneled central line for hemodialysis is
accessed today in the unit.
 Jan 9: Patient has nausea, vomiting, increase in abdominal pain,
and fever of 38.3⁰C. Blood cultures are collected, and are positive
for Candida albicans.
 Jan 10: Pain and fever continue. Patient has 2 episodes of
vomiting. CT scan of abdomen shows, small bowel obstruction.
Physician documents that source of positive blood cultures is the
gastrointestinal tract.
Case Study 4: Which definition should be applied
in the case?

A. GIT (gastrointestinal infection)

B. IAB (intra-abdominal infection)
C. OREP (reproductive Infection)
D. None, this is a primary BSI
 GIT
Case Study 4 – Rationale Case info: colon cancer,
Small bowel obstruction,
MD notes GI tract source

“GIT-Gastrointestinal tract infection (esophagus, stomach, small and large bowel, and rectum)
-excluding gastroenteritis, appendicitis, and C. difficile infection

Refer to Ch. 17 NHSN Patient Safety Manual

pages 17-20)
Case Study 4
Rationale
Case Study 5
 2/14: A 41-year-old female has been in your unit for 2
weeks. She has a central line through which she has
been receiving hemodialysis since admission.
 2/17: Her central line insertion site is red, and has
purulent drainage, which is cultured and positive for
Pseudomonas aeruginosa.
 2/19: She develops fever of 39°C and shaking chills.
Two sets of blood cultures are sent.
 2/21: Final blood culture results are positive for
Pseudomonas aeruginosa.
Case Study 5 Is this an LCBI?

A. Yes, the patient has an LCBI 1 with P. aeruginosa

B. No, this patient has a primary SKIN infection with

P. aeruginosa and a secondary BSI with the same organism.

C. No. The patient has a VASC infection with P. aeruginosa and

a secondary BSI with the same organism.
Case Study 5 -
Rationale

Refer to Ch. 17 NHSN Patient Safety Manual page 17-14 & 17-26
 Case Study 5 –
Rationale

Refer to Chapter 17
NHSN Patient Safety Manual page
17-14
 VASC- Arterial or Venous Infection
Case Study 5
Rationale
Case Study 6
 February 1: Patient admitted to PICU 4 months status post allogeneic
stem cell transplant for acute myeloid leukemia. Port in place and was
accessed on admission. Her current weight is 25 kg.
 February 8: Patient becomes disoriented and hypotensive. 2 sets of
blood culture are collected. Both are positive for Enterococcus
faecium.
 February 9: Patient has nausea, emesis, diarrhea, and abdominal pain.
 February 10: She is diagnosed with Grade III graft-versus-host disease
by endoscopy.
True or False: This BSI is secondary to GIT (gastrointestinal
infection) and therefore is not an LCBI

A. True
B. False. This is an MBI-LCBI.
Case Study 6 - Rationale
 The GIT criteria reads:
– Patient has at least two of the following signs or symptoms compatible with infection of
the organ or tissue involved: fever (>38.0°C), nausea*, vomiting*, pain*or tenderness*,
odynophagia*, or dysphagia*
– And at least one of the following:
– …c. organisms identified from blood by a culture or non-culture based
microbiologic testing method which is performed for purposes of clinical diagnosis or
treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). The organism(s)
identified in the blood must contain at least one MBI organism: See Appendix A of the
BSI protocol
– AND
– imaging test evidence suggestive of gastrointestinal infection (e.g., endoscopic exam,
MRI, CT Scan), which if equivocal is supported by clinical correlation (i.e., physician
documentation of antimicrobial treatment for gastrointestinal tract infection).

* With no other recognized cause

Case Study 6 - Rationale

 LCBI criteria must be met before MBI-LCBI criteria can be met.

– This includes determining that the BSI is not related to an
infection at another site.
 The patient does not meet GIT criteria, because an infection
was not identified by the imaging test
 Additionally, GVHD, neutropenia and chemotherapy can cause
symptoms such as nausea, vomiting and abdominal pain.
Case Study 6 - Rationale
 MBI-LCBI criterion:
– Patient of any age meets criterion 1 for LCBI with at least one blood
specimen identified by a culture or non-culture based microbiologic
testing method, with ONLY intestinal organisms from the MBI-LCBI
organisms list.
– AND patient meets at least one of the following:
1. Is an allogeneic hematopoietic stem cell transplant recipient within
the past year with one of the following documented during the same
hospitalization as the positive blood specimen:
a. Grade III or IV gastrointestinal graft versus host disease [GI GVHD]

See Ch. 4 page 10 for complete MBI-LCBI requirements

One Final Pearl of Wisdom
GE criteria: “…an enteric pathogen is identified
from stool or rectal swab …”

• Enterococcus spp., Pseudomonas spp., etc. are NOT considered enteric

pathogens for NHSN reporting purposes because they are also important
environmental pathogens.
• Examples of enteric pathogens* includes: Campylobacter spp., Shigella
spp., Enterohemorrhagic E. coli, Enteropathogenic E. coli, Salmonella spp.,
Listeria spp., Yersinia spp., Vibrio spp., and Giardia.
*These are excluded from use in meeting LCBI criteria.
Therefore, do not report as a CLABSI
–
 Summary
 There are only 2 ways to make a secondary BSI determination*:
1. Scenario 1: Organism in the site-specific specimen is used to meet criteria, and the
blood, collected in the secondary BSI attribution period matches at least one site-
specific organism.
2. Scenario 2: Organism identified in the blood specimen is used as an element to meet
the site-specific infection criterion, and therefore must be collected in the IWP.
 If neither scenario is met, the BSI is a primary infection. The only exception to
this rule is when NEC criteria are met.
 POA BSIs must be investigated when a subsequent positive blood specimen is
identified within 14 days-otherwise an incorrect determination can be made.
– Only a primary BSI creates a 14 day BSI RIT
Summary continued…

• Blood specimens occurring in the SBAP must contain at least one

matching organism to the site-specific specimen that was used to meet
the definition initially, otherwise it must be investigated as being
primary or secondary in nature.
• Sometimes a patient will meet more than 1 criterion for a type of infection. If this
occurs, consider all potential IWPs to identify possible primary sites of BSIs.
• The training videos, quick reference tools and the worksheet generator
on the NHSN website are valuable resources that can improve your
understanding of HAI surveillance, the application of the NHSN
definitions and NHSN reporting.
 Table Top Group Cases
Secondary BSIs

Case #1
Case #1 Scenario
1/7/18: Admission. PMH S/P bradycardia, pacemaker placed 2016
2/4/18: +BC, Enterococcus faecium x 2
2/5/18: +BC, Enterococcus faecium
2/6/18: +BC, Enterococcus faecium x 2
2/7/18: +BC, Enterococcus faecium
2/12/18: PICC placed
2/16/18: +BC, S. aureus X1
2/22/18: Vegetation on Pacemaker lead sent for culture, + Candida albicans
2/25/18: +BC, Candida albicans
Case #1 Questions; based on the available information:
Question 1: Which definition should be used in this case?

Question 2: Is this a primary or secondary BSI?

Question 3: Which event creates a BSI RIT?

a. Primary BSI
b. Secondary BSI
c. Both

Question 4: What is the final determination for this case?

Case #1
Answers & Rationale
Case #1 Answers & Rationale
Question 1:Which definition should be applied as possible primary source of
BSI in this case?
A: ENDO-Endocarditis

Question 2: Is this a primary or secondary BSI?

A: It depends on which BSI you are investigating
(2/4 or 2/22)

Question 3: Which event creates a BSI RIT?

A: Only primary BSIs create a BSI RIT- therefore the 2/4 BSI sets a BSI RIT
Question 4: What is the final determination for this case?
Case #1 Answers & Rationale

 ENDO IWP = 21 days total (day of diagnostic test, 10 days

before and 10 days after)

 The SBAP = includes the 21-day infection window period and

all subsequent days of the patient’s current admission.

 SBAP is limited to organism(s) identified in blood specimen

that match the organism(s) used to meet the ENDO definition.
Case #1 Answers & Rationale

 There are no other elements present during an ENDO IWP set by the
2/4 BSI (1/25-2/14) to fulfill the ENDO criterion. No other type of
infection is suggested, therefore that BSI is primary.

 Consider the next positive blood culture outside the BSI RIT 2/4-2/17.

 2/22 pacemaker lead with C. albicans sets a potential ENDO IWP of

2/12-3/4.
Case #1 Question 4
Rationale
Case #2
Case #2 Scenario
 2/2/18: Admit with fever and chills of unknown origin, knee has been
sore last few days but no obvious specific symptoms.
 2/8/18: Knee fluid drained, sent for culture which grew S. aureus
 2/14/18: Increased pain Left knee, unable to bend it due to swelling
 2/17/18: +blood specimen S. aureus
 2/22/18: +blood specimen S. aureus, S. pneumoniae
 2/24/18: +blood specimen Strep pneumoniae, Neisseria gonorrhea
Case #2

 Question 1: Which definition should be used in this case?

 Question 2: What is the final determination for this case?

Case #2
Answers & Rationale
Case #2
Question 1: JNT Joint or Bursa Infection
Case #2:
Question 3 Answer & Rationale

Refer to Ch. 2 page 2-17