Form 57.75DD Manual Categorization of Positive Cultures

O MB No. 0920-0666

Exp. date: XX-XX-20XX

Manual Categorization of Positive Blood Cultures

Complete one form for all isolates that are a unique species, or genus if not identified to the species level, cultured during Day 0 through Day 6.

Organism number (from List of Blood Isolates form [CDC 57.75CC]):

Organism (genus, species):

Date first positive blood culture for this organism:

Hospital-onset: Y N

ICU-associated (does not include telemetry or step-down unit): Y N

During 48 hours before the first blood culture positive for this organism, did the patient have a central line? Y N

Includes tunneled or nontunneled catheters inserted into the subclavian, jugular, or femoral veins; pulmonary artery (Swan-Ganz) catheters; hemodialysis catheter; totally implanted devices (ports); peripherally inserted central catheters (PICC lines).

Blood culture taken from (circle one):

1. Peripheral vein 2. Vascular catheter (venous or arterial) 3. Unknown

Isolate type (circle one):

1. Recognized pathogen

2. Common skin contaminant (CSC) (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci)

If isolate is a common skin contaminant (CSC), answer a-c:

a. Symptoms: fever (>38^o), chills, or hypotension: Y N

b. Physician institutes appropriate antimicrobial therapy: Y N

3. Circle one (if meets 3, circle that in preference to 1 or 2; if meets 2, circle that in preference to 1 – include all

cultures taken during Day 0 through Day 6.)

1. CSC isolated from 1 culture of 2 taken

2. CSC isolated from 1 culture of 1 taken

3. CSC isolated from 2 cultures of 2 taken

Isolate related to infection at another site: Y N If yes, answer a and b:

a. Site (circle all that apply)

1=Bone/Joint 2=CNS 3=Endocarditis

4=Intraabdominal 5=Respiratory 6=Skin and Soft tissue

7=Surgical site 8=Implanted device 9=Urinary tract

10=Other, specify_____________________

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS D-79, Atlanta, GA 30333, ATTN: PRA (0920-0666). Do not send the completed form to this address.

CDC 57.75DD (Front) Rev. 1, Effective date: xx/xx/20xx

b. Evidence for secondary infection (circle all that apply)

1=Same genus isolated from another site 2=Physician diagnosis

3=Lab evidence (NOT microbiology) 4=Radiographic evidence

5=Organism and syndrome most compatible with secondary BSI

6=Other, specify_____________________

Does this organism meet the CDC/NNIS definition for primary BSI? Y N

(Use the CDC definitions, not the reviewer’s clinical impression which may be expressed in the next question).

If yes, specify criterion 1, 2a, or 2b:

1. Meets criterion 1

Criterion 1:

Patient has a recognized pathogen cultured from one or more blood cultures

and

organism cultured from blood is not related to an infection at another site.

2a. Meets criterion 2a

Patient has at least one of the following signs or symptoms: fever (>38^o), chills, or hypotension

and

signs and symptoms and positive laboratory results are not related to an infection at another site

and

a. common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is cultured from two or more blood cultures drawn on separate occasions

2b. Meets criterion 2b

Patient has at least one of the following signs or symptoms: fever (>38^o), chills, or hypotension

and

signs and symptoms and positive laboratory results are not related to an infection at another site

and

b. common skin contaminant (e.g., diphtheroids, Bacillus sp., Propionibacterium sp., coagulase-negative staphylococci, or micrococci) is cultured from at least one blood culture from a patient with an intravascular line, and the physician institutes appropriate antimicrobial therapy

Reviewers clinical impression: Does this isolate represent a primary BSI? Y N

If reviewer’s clinical impression differs from CDC/NNIS definition, explain why: ________________________________________________________________________________________________________________________________________________________________

CDC 57.75DD (Back) Rev. 1, Effective date: xx/xx/200x