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id.crbsi.core.v1PRODUCTION
id.crbsi.core.v1

Catheter-related bloodstream infection (CRBSI / CLABSI)

infectious_diseaseacuteadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm catheter-related bloodstream infection scope (clinical IDSA definition vs NHSN CLABSI surveillance definition) (Mermel IDSA 2009)

Inputs
0
Actions
0
Advance rule
Set
Advance when

scope confirmed: line in situ + bacteremia/fungemia with line implicated

Patient inputs (21)

Mandatory — defines the engine (Mermel IDSA 2009)

Drives line-removal-vs-salvage decision (Mermel IDSA 2009)

Drives Candida-risk → empiric echinocandin (Mermel IDSA 2009; Pappas IDSA 2016)

Drives broader empiric coverage + line-removal threshold (Mermel IDSA 2009)

Fever / rigors is the sentinel CRBSI sign in line-bearing patients (Mermel IDSA 2009)

DTP > 2 h LR+ ≈ 8 for CRBSI; quantitative ratio ≥ 3:1 LR+ ≈ 7 (Mermel IDSA 2009; Blot Lancet 1999; Raad CID 1992)

Neutropenia / cytopenia detection; linezolid bone-marrow toxicity monitoring (Mermel IDSA 2009)

Septic shock from CRBSI drives ICU disposition + emergent line removal (Mermel IDSA 2009; SSC 2026)

Vanco AUC dosing; daptomycin CrCl < 30 q48 h; cefepime renal adjust (Rybak ASHP/IDSA 2020)

Maki roll-plate ≥ 15 CFU + concordant peripheral LR+ ≈ 20 (Maki NEJM 1977)

Mandatory TEE within 5-7 d for S. aureus CRBSI; persistent bacteremia; prosthetic valve; new murmur; embolic phenomena (AHA endocarditis 2015 Baddour)

Mandatory ophthalmologic exam within 1 wk for Candida CRBSI; repeat at 2 wk (Pappas IDSA 2016)

Suppurative thrombophlebitis workup when persistent bacteremia + line tenderness / fluctuance (Mermel IDSA 2009; Crowley Chest 2008)

Tip-culture LR conditional on ≥ 24 h dwell; >7 d duration favors true CRBSI over contaminant (Mermel IDSA 2009)

Lipid emulsions support C. parapsilosis; high candida-CRBSI risk (Mermel IDSA 2009; Pappas IDSA 2016)

Mandatory TEE if S. aureus CRBSI (AHA endocarditis 2015 Baddour)

Special management — line exchange via guidewire OR remove + new site (Mermel IDSA 2009; KDIGO vascular access 2019)

Daptomycin / linezolid hepatotoxicity; sepsis bilirubin component of SOFA (Mermel IDSA 2009; SSC 2026)

Daptomycin weekly CK monitoring for rhabdomyolysis (DailyMed daptomycin label)

Tachycardia component of qSOFA / SIRS (Mermel IDSA 2009)

Septic shock screen; SSC 2026 Hour-1 bundle (Mermel IDSA 2009; SSC 2026)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threatenings_aureus_crbsi_mandatory_removal_and_tee
    Staphylococcus aureus CRBSI confirmed on culture — requires mandatory line removal + TEE within 5-7 d + 14 d treatment if uncomplicated / 4-6 wk if endocarditis / metastatic (Mermel IDSA 2009; AHA endocarditis 2015 Baddour PMID 26373316)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcandida_crbsi_line_removal_and_ophtho
    Candida species on blood culture in line-bearing patient — mandatory line removal + 14 d echinocandin + dilated fundoscopy within 1 wk + repeat at 2 wk (Mermel IDSA 2009; Pappas IDSA 2016 PMID 26679628)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpseudomonas_or_resistant_gram_negative_crbsi
    Pseudomonas aeruginosa or resistant Enterobacterales (ESBL, CRE, MDR) on culture — line removal required + targeted GNR therapy per susceptibility + ID consult (Mermel IDSA 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpersistent_bacteremia_at_72h_post_treatment
    Blood cultures still positive ≥ 72 h on appropriate empirics + line in place — re-evaluate source: metastatic seeding, endocarditis, retained line, abscess (Mermel IDSA 2009; Fowler Arch Intern Med 2003)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningseptic_thrombophlebitis
    Fever + persistent bacteremia + venous thrombus on doppler / line-site fluctuance — line removal + anticoagulation + 4-6 wk antibiotics + vascular surgery consult (Mermel IDSA 2009; Crowley Chest 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcrbsi_in_neutropenic_or_immunocompromised
    CRBSI in patient with ANC < 500 / transplant / high-dose steroids / biologics — broaden coverage + remove line generally + ID consult; route to opportunistic-infection engine if applicable (Mermel IDSA 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcentral_line_associated_endocarditis_risk
    Risk-stratification for TEE: S. aureus, Candida, persistent bacteremia, prosthetic valve, intracardiac device — mandatory TEE within 5-7 d (Mermel IDSA 2009; AHA endocarditis 2015 Baddour)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremetastatic_seeding_features
    Vertebral osteo / discitis / endocarditis / psoas abscess / brain abscess / hepatosplenic candidiasis emerging during CRBSI treatment — imaging + extended therapy (Mermel IDSA 2009; AHA endocarditis 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredialysis_catheter_crbsi_special_management
    CRBSI in dialysis tunneled catheter — vanco + cefepime per local antibiogram + line exchange via guidewire OR removal + new site; ID + nephrology + IR coordination (Mermel IDSA 2009; KDIGO vascular access 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecons_crbsi_salvage_attempt_with_lock
    Coagulase-negative staph CRBSI in tunneled line / port + non-toxic patient + susceptible → systemic vanco + antibiotic-lock therapy × 10-14 d; remove if failure-to-respond at 72 h (Mermel IDSA 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSrequiredDrives severity classification
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Recommended regimen

CRBSI empiric — vancomycin AUC + GNR cover ± echinocandin until pathogen known (Mermel IDSA 2009)
axis: crbsi_empiric
Selected axis "CRBSI empiric — vancomycin AUC + GNR cover ± echinocandin until pathogen known (Mermel IDSA 2009)" by default fallback (first axis)
  • vancomycin
    first line
    glycopeptide
    25-30 mg/kg IV load × 1 → 15-20 mg/kg IV q8-12 h targeting AUC24 400-600 mg·h/L • IV • q8-12h (AUC-titrated)
    triggers: empiric_CRBSI, MRSA_risk, CoNS_coverage
    Mermel IDSA 2009 + Rybak ASHP/IDSA 2020 — covers MRSA + CoNS + most Enterococcus; AUC-targeted dosing is the 2026 standard (PMID 32191793)
    rxcui 11124
  • cefepime
    first line
    cephalosporin_4th_gen
    2 g IV q8h (extended infusion 3-4 h preferred in shock) • IV • q8h
    triggers: empiric_CRBSI, anti_pseudomonal_coverage_required
    Mermel IDSA 2009 — anti-pseudomonal cover; most common empiric GNR partner; renal adjust for CrCl < 60
    rxcui 20481
  • piperacillin_tazobactam
    first line
    beta_lactam_BLI
    4.5 g IV q6h (extended infusion 4 h preferred) • IV • q6h
    triggers: empiric_CRBSI_alternative_GNR_cover, intra_abdominal_concurrent_source
    Mermel IDSA 2009 — alternative GNR + anti-pseudomonal + anaerobic cover; useful when concurrent intra-abdominal source
    rxcui 74169
  • meropenem
    second line
    carbapenem
    1 g IV q8h (2 g q8h CNS / severe) • IV • q8h
    triggers: ESBL_risk, recent_carbapenem_susceptibility, septic_shock_broad_coverage
    Mermel IDSA 2009 — reserve for ESBL risk, septic shock, or local antibiogram resistance pattern; spare to minimise emergence
    rxcui 29561
  • caspofungin
    add on
    echinocandin
    70 mg IV load × 1 → 50 mg IV daily • IV • daily
    triggers: candida_risk, TPN, broad_abx_ge_7d, neutropenia, hemodynamic_instability, candida_colonisation_multifocal
    Pappas IDSA 2016 — empiric echinocandin when Candida-risk factors present pending blood-culture speciation; routes to id.candidemia.core.v1 if Candida confirmed
    rxcui 140108
  • micafungin
    add on
    echinocandin
    100 mg IV daily • IV • daily
    triggers: candida_risk_alternative
    Pappas IDSA 2016 — alternative echinocandin; equivalent efficacy to caspofungin
    rxcui 325887
  • anidulafungin
    add on
    echinocandin
    200 mg IV load × 1 → 100 mg IV daily • IV • daily
    triggers: candida_risk_alternative_no_renal_or_hepatic_dose_adjust
    Pappas IDSA 2016 — alternative echinocandin; no renal or hepatic dose adjustment
    rxcui 341018
  • daptomycin
    second line
    lipopeptide
    8-10 mg/kg IV daily (12 mg/kg for VRE bacteremia per IDSA VRE 2014) • IV • daily (q48h if CrCl < 30)
    triggers: vanco_intolerance, vanco_AUC_unachievable, persistent_MRSA_bacteremia, VRE_bacteremia
    Mermel IDSA 2009 + IDSA VRE 2014 — high-dose for bacteremia/IE; weekly CK monitoring per DailyMed daptomycin label; NOT for pneumonia (surfactant inactivation)
    rxcui 22299

ed playbook — drug actions (3)

  1. 1. vancomycin
    rxcui 11124
    25-30 mg/kg IV load × 1 • IV • q8-12h (AUC-titrated thereafter)
    trigger: Suspected CRBSI within 1 h of recognition (Mermel IDSA 2009)
    Empiric MRSA + CoNS + Enterococcus cover; AUC-guided per Rybak ASHP/IDSA 2020
  2. 2. cefepime
    rxcui 20481
    2 g IV q8h • IV • q8h
    trigger: Empiric GNR + anti-pseudomonal cover (Mermel IDSA 2009)
    Most common empiric GNR partner; ESBL-cover alternative is meropenem
  3. 3. caspofungin
    rxcui 140108
    70 mg IV load × 1 → 50 mg/d • IV • daily
    trigger: Candida-risk factor present (TPN, broad abx ≥ 7 d, multifocal colonisation, neutropenia, hemodynamic instability) (Pappas IDSA 2016)
    Empiric echinocandin pending speciation; routes to id.candidemia.core.v1 if Candida confirmed

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Positive blood culture in patient with intravascular catheter (Mermel IDSA 2009); Central-line blood culture flags positive ≥ 2 h before peripheral (DTP > 2 h; Mermel IDSA 2009); Fever, rigors, or hemodynamic decompensation in patient with line (Mermel IDSA 2009).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Catheter-related bloodstream infection (CRBSI / CLABSI)** (id.crbsi.core.v1).
Phenotype framing: 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)
Scope: Confirm catheter-related bloodstream infection scope (clinical IDSA definition vs NHSN CLABSI surveillance definition) (Mermel IDSA 2009)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CRBSI empiric — vancomycin AUC + GNR cover ± echinocandin until pathogen known (Mermel IDSA 2009)**.
1. vancomycin 25-30 mg/kg IV load × 1 → 15-20 mg/kg IV q8-12 h targeting AUC24 400-600 mg·h/L IV q8-12h (AUC-titrated) (glycopeptide, first line) — Mermel IDSA 2009 + Rybak ASHP/IDSA 2020 — covers MRSA + CoNS + most Enterococcus; AUC-targeted dosing is the 2026 standard (PMID 32191793)
2. cefepime 2 g IV q8h (extended infusion 3-4 h preferred in shock) IV q8h (cephalosporin_4th_gen, first line) — Mermel IDSA 2009 — anti-pseudomonal cover; most common empiric GNR partner; renal adjust for CrCl < 60
3. piperacillin_tazobactam 4.5 g IV q6h (extended infusion 4 h preferred) IV q6h (beta_lactam_BLI, first line) — Mermel IDSA 2009 — alternative GNR + anti-pseudomonal + anaerobic cover; useful when concurrent intra-abdominal source
4. meropenem 1 g IV q8h (2 g q8h CNS / severe) IV q8h (carbapenem, second line) — Mermel IDSA 2009 — reserve for ESBL risk, septic shock, or local antibiogram resistance pattern; spare to minimise emergence
5. caspofungin 70 mg IV load × 1 → 50 mg IV daily IV daily (echinocandin, add on) — Pappas IDSA 2016 — empiric echinocandin when Candida-risk factors present pending blood-culture speciation; routes to id.candidemia.core.v1 if Candida confirmed
6. micafungin 100 mg IV daily IV daily (echinocandin, add on) — Pappas IDSA 2016 — alternative echinocandin; equivalent efficacy to caspofungin
7. anidulafungin 200 mg IV load × 1 → 100 mg IV daily IV daily (echinocandin, add on) — Pappas IDSA 2016 — alternative echinocandin; no renal or hepatic dose adjustment
8. daptomycin 8-10 mg/kg IV daily (12 mg/kg for VRE bacteremia per IDSA VRE 2014) IV daily (q48h if CrCl < 30) (lipopeptide, second line) — Mermel IDSA 2009 + IDSA VRE 2014 — high-dose for bacteremia/IE; weekly CK monitoring per DailyMed daptomycin label; NOT for pneumonia (surfactant inactivation)

Setting playbook (ed) — Recognise CRBSI in outpatient line-bearing patient (TPN, OPAT, dialysis, oncology) presenting with fever / rigors; draw paired blood cultures BEFORE first antibiotic dose; start empiric vanco + GNR cover within 1 h of recognition (or shock); admit (Mermel IDSA 2009; SSC 2026)
9. vancomycin 25-30 mg/kg IV load × 1 IV q8-12h (AUC-titrated thereafter) — Suspected CRBSI within 1 h of recognition (Mermel IDSA 2009) (Empiric MRSA + CoNS + Enterococcus cover; AUC-guided per Rybak ASHP/IDSA 2020)
10. cefepime 2 g IV q8h IV q8h — Empiric GNR + anti-pseudomonal cover (Mermel IDSA 2009) (Most common empiric GNR partner; ESBL-cover alternative is meropenem)
11. caspofungin 70 mg IV load × 1 → 50 mg/d IV daily — Candida-risk factor present (TPN, broad abx ≥ 7 d, multifocal colonisation, neutropenia, hemodynamic instability) (Pappas IDSA 2016) (Empiric echinocandin pending speciation; routes to id.candidemia.core.v1 if Candida confirmed)

Non-pharmacologic actions:
- Do NOT remove line in ED unless septic shock + no other access (defer to inpatient team after pathogen / TEE / line management plan) (Mermel IDSA 2009)
- Notify ID consult for inpatient admission (Mermel IDSA 2009)
- Source-control of secondary collections (intra-abdominal / endocarditis / osteomyelitis) deferred to inpatient (Mermel IDSA 2009)

AVOID / contraindication checks:
- Central line removal strong non tunneled (Mermel IDSA 2009)
- Line removal mandatory for pseudomonas candida fungi mycobacteria (Mermel IDSA 2009)
- Vanco auc monitoring 400 600 (Rybak ASHP/IDSA 2020 PMID 32191793)
- Dapto ck monitoring weekly (DailyMed daptomycin label)
- Dapto no pulmonary infection (DailyMed daptomycin label)
- Repeat blood cultures 48 72h to document clearance (Mermel IDSA 2009)
- Antibiotic lock only for tunneled or port salvage (Mermel IDSA 2009)
- S aureus tee within 5 7d (AHA endocarditis 2015 Baddour PMID 26373316)
- Candida crbsi ophtho exam within 1 week (Pappas IDSA 2016 PMID 26679628)
- Septic thrombophlebitis anticoag plus extended abx (Mermel IDSA 2009; Crowley Chest 2008)
- Dialysis line crbsi coordinate nephrology and IR (Mermel IDSA 2009; KDIGO vascular access 2019)

Monitoring

Regimen monitoring:
- repeat blood cultures q48 72h until two consecutive negatives (Mermel IDSA 2009)
- vanco AUC q3 5d target 400 600 (Rybak ASHP/IDSA 2020)
- creatinine q3 7d on vanco or dapto (Rybak 2020; DailyMed daptomycin)
- daptomycin CK weekly (DailyMed daptomycin label)
- LFT q3 7d on linezolid or dapto (DailyMed labels)
- ophtho repeat at 2 weeks for candida (Pappas IDSA 2016)
- TEE repeat at 4 6 weeks if endocarditis (AHA endocarditis 2015)
- duration 14d post first negative uncomplicated (Mermel IDSA 2009)
- duration 4 6wk for endocarditis or metastatic (AHA endocarditis 2015)
- duration 5 7d CoNS with line removed (Mermel IDSA 2009)

Setting (ed) monitoring:
- Vitals q30 min until disposition (SSC 2026)
- Lactate at 2-4 h to assess response (SSC 2026)

Follow-up plan: 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)
- Close-out criterion: OPAT + ID f/u scheduled

Monitoring phase: 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)

Disposition

Current setting: ed — Recognise CRBSI in outpatient line-bearing patient (TPN, OPAT, dialysis, oncology) presenting with fever / rigors; draw paired blood cultures BEFORE first antibiotic dose; start empiric vanco + GNR cover within 1 h of recognition (or shock); admit (Mermel IDSA 2009; SSC 2026)

Disposition criteria:
- All suspected CRBSI patients admitted to inpatient ward or ICU per qSOFA / shock status; NEVER discharged home from ED (Mermel IDSA 2009)

Escalation triggers (move to higher acuity):
- qSOFA ≥ 2 + hypotension + lactate > 2 → ICU; SSC Hour-1 bundle (SSC 2026)
- Suspected septic thrombophlebitis (line-site fluctuance + persistent fever) → emergent vascular surgery / IR (Mermel IDSA 2009; Crowley Chest 2008)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Staphylococcus aureus CRBSI confirmed on culture — requires mandatory line removal + TEE within 5-7 d + 14 d treatment if uncomplicated / 4-6 wk if endocarditis / metastatic (Mermel IDSA 2009; AHA endocarditis 2015 Baddour PMID 26373316)
- [LIFE_THREATENING] Candida species on blood culture in line-bearing patient — mandatory line removal + 14 d echinocandin + dilated fundoscopy within 1 wk + repeat at 2 wk (Mermel IDSA 2009; Pappas IDSA 2016 PMID 26679628)
- [LIFE_THREATENING] Pseudomonas aeruginosa or resistant Enterobacterales (ESBL, CRE, MDR) on culture — line removal required + targeted GNR therapy per susceptibility + ID consult (Mermel IDSA 2009)

Citations

- Mermel IDSA CRBSI 2009 (Mermel et al, CID 2009 PMID 19489710) — canonical guideline; still operative in 2026. Supplemented by CDC/HICPAC BSI Prevention (O'Grady), ASHP/IDSA Vancomycin AUC Consensus 2020 (Rybak PMID 32191793), IDSA Candidiasis 2016 (Pappas PMID 26679628), AHA Endocarditis 2015 (Baddour PMID 26373316). [PMID:19489710](https://pubmed.ncbi.nlm.nih.gov/19489710/)
- Cited evidence (PMID 32191793) [PMID:32191793](https://pubmed.ncbi.nlm.nih.gov/32191793/)
- Cited evidence (PMID 26679628) [PMID:26679628](https://pubmed.ncbi.nlm.nih.gov/26679628/)
- Cited evidence (PMID 26373316) [PMID:26373316](https://pubmed.ncbi.nlm.nih.gov/26373316/)
- Cited evidence (PMID 16625125) [PMID:16625125](https://pubmed.ncbi.nlm.nih.gov/16625125/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Mermel IDSA CRBSI 2009 (Mermel et al, CID 2009 PMID 19489710) — canonical guideline; still operative in 2026. Supplemented by CDC/HICPAC BSI Prevention (O'Grady), ASHP/IDSA Vancomycin AUC Consensus 2020 (Rybak PMID 32191793), IDSA Candidiasis 2016 (Pappas PMID 26679628), AHA Endocarditis 2015 (Baddour PMID 26373316). — PMID:19489710
  • Cited evidence (PMID 32191793) — PMID:32191793
  • Cited evidence (PMID 26679628) — PMID:26679628
  • Cited evidence (PMID 26373316) — PMID:26373316
  • Cited evidence (PMID 16625125) — PMID:16625125