Clinical Commander

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id.crbsi.core.v1

Catheter-related bloodstream infection (CRBSI / CLABSI)

infectious_diseaseacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

New engine authored 2026-05-15 (shard-5-obped-id Phase C wave 3) — closes the workup.crbsi → branches_to: ['id.crbsi.core.v1'] broken reference that already existed in id.sepsis.core.v1 (line 71) and id.candidemia.core.v1 (line 65). Manifest pointer reuses prisma/seed/manifests/id.sepsis.core.v1.ts as the nearest-ID precedent per shard authoring instruction; dedicated CRBSI manifest deferred to a future Phase D wave. Backbone evidence: Mermel IDSA CRBSI 2009 (PMID 19489710) — still operative in 2026 (no IDSA CRBSI successor guideline). Supplemented by Pappas IDSA Candidiasis 2016 (PMID 26679628), Rybak ASHP/IDSA Vanco AUC 2020 (PMID 32191793), Baddour AHA Endocarditis 2015 (PMID 26373316), Kumar CCM 2006 antibiotic-delay (PMID 16625125). Pathogen-driven line-removal-vs-salvage decision is the primary clinical decision surface: mandatory removal for S. aureus / Pseudomonas / Candida / fungi / mycobacteria / non-tunneled CVC / tunnel/pocket-port infection / septic thrombophlebitis; salvage with antibiotic-lock therapy acceptable for CoNS / susceptible Enterococcus (no IE) / susceptible GNR when tunneled/port + non-toxic. Mandatory TEE within 5-7 d for S. aureus CRBSI (AHA endocarditis 2015) and mandatory ophtho fundoscopy within 1 wk for Candida CRBSI (Pappas IDSA 2016) are wired as severity_triggers + setting_playbooks. Bayesian linkage (per §5.5.2): DTP > 2 h LR+ ≈ 8 (Blot Lancet 1999); Maki tip ≥ 15 CFU + concordant peripheral LR+ ≈ 20 (Maki NEJM 1977); quantitative ratio ≥ 3:1 LR+ ≈ 7 (Raad CID 1992); new murmur + S. aureus bacteremia LR+ ≈ 6 for IE (Fowler 2003). T_treat ≈ 15-20%; T_test ≈ 5%. Cross-dossier routing edges wired to id.sepsis.core.v1, id.candidemia.core.v1, id.opportunistic-infection.hiv-transplant.v1, id.hospital-acquired-infection.v1. Pediatric / neonatal CRBSI captured via severity_trigger (crbsi_in_neutropenic_or_immunocompromised) + notes; dedicated id.crbsi.peds.v1 deferred to future shard wave. Dialysis-catheter CRBSI captured via severity_trigger (dialysis_catheter_crbsi_special_management); dedicated nephro.dialysis-access-infection.v1 deferred to future shard wave. Antibiotic-lock formulary RxCUI capture deferred — no validated RxCUI series for lock-formulation concentrations yet. Registry batch-add deferred per shard authoring instruction: this dossier is NOT yet wired into src/lib/dossiers/_registry.ts — the main session will batch-add post-wave.

Entry points (5)

  • lab_abnormality
    Positive blood culture in patient with intravascular catheter (Mermel IDSA 2009)
    positive_blood_culture_with_line_insitu
  • lab_abnormality
    Central-line blood culture flags positive ≥ 2 h before peripheral (DTP > 2 h; Mermel IDSA 2009)
    differential_time_to_positivity_gt_2h
  • symptom
    Fever, rigors, or hemodynamic decompensation in patient with line (Mermel IDSA 2009)
    fever_or_rigors_with_line_insitu
  • lab_abnormality
    Semiquantitative Maki tip ≥ 15 CFU OR quantitative ≥ 10² CFU at line removal (Mermel IDSA 2009)
    positive_catheter_tip_culture
  • problem_list
    CVC / port / dialysis catheter / PICC + sepsis workup (Mermel IDSA 2009)
    central_venous_catheter_in_situ_with_sepsis

Required inputs (21)

  • temperaturerequired
    vital • used at ENTRY
    Fever / rigors is the sentinel CRBSI sign in line-bearing patients (Mermel IDSA 2009)
  • sbprequired
    vital • used at RED_FLAGS
    Septic shock from CRBSI drives ICU disposition + emergent line removal (Mermel IDSA 2009; SSC 2026)
  • heart_rate
    vital • used at RED_FLAGS
    Tachycardia component of qSOFA / SIRS (Mermel IDSA 2009)
  • central_venous_catheterrequired
    history • used at CONTEXT
    Mandatory — defines the engine (Mermel IDSA 2009)
  • line_type_tunneled_vs_non_tunneledrequired
    history • used at CONTEXT
    Drives line-removal-vs-salvage decision (Mermel IDSA 2009)
  • line_dwell_duration
    history • used at CONTEXT
    Tip-culture LR conditional on ≥ 24 h dwell; >7 d duration favors true CRBSI over contaminant (Mermel IDSA 2009)
  • recent_broad_spectrum_abxrequired
    history • used at CONTEXT
    Drives Candida-risk → empiric echinocandin (Mermel IDSA 2009; Pappas IDSA 2016)
  • tpn
    history • used at CONTEXT
    Lipid emulsions support C. parapsilosis; high candida-CRBSI risk (Mermel IDSA 2009; Pappas IDSA 2016)
  • neutropenia_or_immunocompromisedrequired
    history • used at CONTEXT
    Drives broader empiric coverage + line-removal threshold (Mermel IDSA 2009)
  • prosthetic_valve_or_intracardiac_device
    history • used at CONTEXT
    Mandatory TEE if S. aureus CRBSI (AHA endocarditis 2015 Baddour)
  • dialysis_dependent
    history • used at CONTEXT
    Special management — line exchange via guidewire OR remove + new site (Mermel IDSA 2009; KDIGO vascular access 2019)
  • paired_blood_cultures_line_and_peripheralrequired
    lab • used at INITIAL_WORKUP
    DTP > 2 h LR+ ≈ 8 for CRBSI; quantitative ratio ≥ 3:1 LR+ ≈ 7 (Mermel IDSA 2009; Blot Lancet 1999; Raad CID 1992)
  • catheter_tip_semiquantitative_culture
    lab • used at BRANCHING_WORKUP
    Maki roll-plate ≥ 15 CFU + concordant peripheral LR+ ≈ 20 (Maki NEJM 1977)
  • creatininerequired
    lab • used at TREATMENT
    Vanco AUC dosing; daptomycin CrCl < 30 q48 h; cefepime renal adjust (Rybak ASHP/IDSA 2020)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Neutropenia / cytopenia detection; linezolid bone-marrow toxicity monitoring (Mermel IDSA 2009)
  • lft
    lab • used at MONITORING
    Daptomycin / linezolid hepatotoxicity; sepsis bilirubin component of SOFA (Mermel IDSA 2009; SSC 2026)
  • creatine_kinase
    lab • used at MONITORING
    Daptomycin weekly CK monitoring for rhabdomyolysis (DailyMed daptomycin label)
  • lactate
    lab • used at RED_FLAGS
    Septic shock screen; SSC 2026 Hour-1 bundle (Mermel IDSA 2009; SSC 2026)
  • echocardiogram_tee
    imaging • used at BRANCHING_WORKUP
    Mandatory TEE within 5-7 d for S. aureus CRBSI; persistent bacteremia; prosthetic valve; new murmur; embolic phenomena (AHA endocarditis 2015 Baddour)
  • dilated_fundoscopy
    imaging • used at BRANCHING_WORKUP
    Mandatory ophthalmologic exam within 1 wk for Candida CRBSI; repeat at 2 wk (Pappas IDSA 2016)
  • venous_doppler_thrombophlebitis
    imaging • used at BRANCHING_WORKUP
    Suppurative thrombophlebitis workup when persistent bacteremia + line tenderness / fluctuance (Mermel IDSA 2009; Crowley Chest 2008)

12-phase flow (12)

  1. 1FRAME
    Confirm catheter-related bloodstream infection scope (clinical IDSA definition vs NHSN CLABSI surveillance definition) (Mermel IDSA 2009)
    advance: scope confirmed: line in situ + bacteremia/fungemia with line implicated
  2. 2ENTRY
    Positive blood culture with line in situ OR DTP > 2 h OR persistent fever in line-bearing patient OR positive tip culture (Mermel IDSA 2009)
    inputs: temperature
    advance: entry trigger validated
  3. 3CONTEXT
    Capture line type (tunneled vs non-tunneled vs port vs PICC vs dialysis vs arterial vs PA), dwell duration, host immunosuppression, prior abx, prosthetic valve / intracardiac device (Mermel IDSA 2009)
    inputs: central_venous_catheter, line_type_tunneled_vs_non_tunneled, recent_broad_spectrum_abx, neutropenia_or_immunocompromised
    advance: line profile + host risk documented
  4. 4RED_FLAGS
    Septic shock, S. aureus, Pseudomonas, Candida, persistent bacteremia > 72 h, prosthetic valve, septic thrombophlebitis → escalate (Mermel IDSA 2009; SSC 2026)
    inputs: sbp, lactate
    actions: calc.qsofa
    advance: red-flag-stratified; ICU vs ward decision made
  5. 5INITIAL_WORKUP
    Paired blood cultures (line + peripheral, simultaneous) with DTP measurement; CBC; BMP; lactate; LFT; coagulation if shock (Mermel IDSA 2009)
    inputs: paired_blood_cultures_line_and_peripheral, cbc, creatinine
    advance: paired cultures drawn; empirics started; DTP awaited
  6. 6BRANCHING_WORKUP
    TEE for S. aureus / persistent bacteremia / prosthetic valve; ophtho fundoscopy for Candida; venous doppler if thrombophlebitis suspected; tip culture if line removed; metastatic imaging (vertebral, splenic, hepatic) if persistent positive cultures (Mermel IDSA 2009; AHA endocarditis 2015; Pappas IDSA 2016)
    inputs: catheter_tip_semiquantitative_culture
    actions: workup.fuo
    advance: metastatic + endocarditis workup complete or deferred per pathogen
  7. 7DIFFERENTIAL
    Distinguish true CRBSI from blood-culture contaminant (single CoNS bottle LR ≈ 1.2 vs 2/2 paired CoNS LR ≈ 5); distinguish alternative source (pneumonia, UTI, IAI, SSTI) (Mermel IDSA 2009)
    advance: true CRBSI confirmed or alternative source identified
  8. 8RISK_STRATIFICATION
    qSOFA / SOFA for sepsis stratification; Pitt bacteremia score for mortality risk; pathogen-driven severity (S. aureus / Pseudomonas / Candida → severe) (Mermel IDSA 2009; SSC 2026)
    inputs: sbp, heart_rate
    actions: calc.qsofa, calc.sofa
    advance: severity tier set; line management decision pending
  9. 9TREATMENT
    Empiric vancomycin AUC 400-600 + GNR cover (cefepime / pip-tazo / meropenem per antibiogram) + echinocandin if Candida-risk; pathogen-targeted de-escalation per species; line removal per pathogen (mandatory for S. aureus / Pseudomonas / Candida / mycobacteria / non-tunneled); antibiotic-lock for tunneled/port salvage (Mermel IDSA 2009; Rybak ASHP/IDSA 2020)
    inputs: creatinine
    advance: empirics active within first hour of recognition; line decision made within 24-48 h
  10. 10DISPOSITION
    ICU if septic shock; inpatient ward with ID consult otherwise; OPAT planning for extended duration (Mermel IDSA 2009)
    inputs: sbp
    advance: level of care set; ID consulted
  11. 11MONITORING
    Repeat blood cultures q48-72 h until two consecutive negatives; daily clinical reassessment; vanco AUC q3-5 d; daptomycin CK weekly; LFT q3-7 d on linezolid / dapto; ophtho repeat at 2 wk for Candida; TEE repeat at 4-6 wk if endocarditis (Mermel IDSA 2009; Rybak ASHP/IDSA 2020; AHA endocarditis 2015)
    inputs: lft, creatinine, creatine_kinase
    actions: panel.lft, panel.renal
    advance: cultures cleared at 48-72 h; otherwise re-evaluate source
  12. 12FOLLOWUP
    OPAT enrollment for prolonged-duration regimens; ID outpatient follow-up; re-line decision; prevention review (CHG bathing, daily-necessity assessment, full-barrier insertion); patient education on line care (Mermel IDSA 2009; CDC/HICPAC BSI Prevention; Norris IDSA OPAT 2018)
    advance: OPAT + ID f/u scheduled