OMB No. 0920-0666
Exp. Date: xx-xx-xxxx
www.cdc.gov/nhsn
Dialysis Event
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*required for saving |
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Facility ID: |
Event ID #: |
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*Patient ID: |
Social Security #: |
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Secondary ID #: |
Medicare #: |
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Patient Name, Last: |
First: |
Middle: |
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*Gender: F M Other |
*Date of Birth: |
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Ethnicity (Specify): |
Race (Specify): |
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*Event Type: DE – Dialysis Event |
*Date of Event: |
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*Location: |
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Risk Factors |
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*Vascular accesses: (check all that apply) |
Access placement date (mm/yyyy): |
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□ Fistula |
____ /_______ |
□ Unknown |
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Buttonhole? |
□ Yes |
□ No |
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□ Graft |
____ /_______ |
□ Unknown |
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□ Tunneled central line |
____ /_______ |
□ Unknown |
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□ Nontunneled central line |
____ /_______ |
□ Unknown |
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□ Other access device (e.g., hybrid) |
____ /_______ |
□ Unknown |
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Other Patient Information |
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*Transient Patient? |
□ Yes |
□ No |
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Event Details |
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*Specify Event: (check one or more) |
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□ IV antimicrobial start |
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Was vancomycin the antimicrobial used for this start? |
□ Yes |
□ No |
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□ Positive blood culture (*specify pathogen on pages 2-3) |
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*Suspected source of positive blood culture (check one): |
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□ Vascular access |
□ A source other than the vascular access |
□ Contamination |
□ Uncertain |
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□ Pus, redness, or increased swelling at vascular access site |
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*Check the access site(s) with pus, redness, or increased swelling: |
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□ Fistula |
□ Graft |
□ Tunneled central line |
□ Nontunneled central line |
□ Other access device |
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*Problem(s): (check one or more) |
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□ Fever ≥37.8°C (100°F) oral |
□ Chills or rigors |
□ Drop in blood pressure |
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□ Wound (NOT related to vascular access) with pus or increased redness |
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□ Cellulitis (skin redness, heat, or pain without open wound) |
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□ Pneumonia or respiratory infection |
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□ Other problem (specify): __________________________________________________________ |
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□ None |
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*Outcome: |
Hospitalization |
□ Yes |
□ No |
□ Unknown |
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Death |
□ Yes |
□ No |
□ Unknown |
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Assurance of Confidentiality: The voluntarily provided 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 16 minutes 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.109 (Front) Rev 5, v6.6 |
Dialysis Event
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Pathogen # |
Gram-positive Organisms |
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_______ |
Staphylococcus coagulase-negative |
VANC S I R N |
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(specify): ________________________ |
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_______ |
Enterococcus spp.( specify): |
AMP S I R N |
CIPRO/LEVO/MOXI S I R N |
DAPTO S NS N |
DOXY/MINO S I R N |
GENTHL§ S R N |
LNZ S I R N |
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___________ |
STREPHL§ S R N
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TETRA S I R N
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TIG S NS N
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VANC S I R N
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_______
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Enterococcus faecium |
AMP S I R N |
CIPRO/LEVO/MOXI S I R N |
DAPTO S NS N |
DOXY/MINO S I R N |
GENTHL§ S R N |
LNZ S I R N |
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QUIDAL S I R N
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STREPHL§ S R N
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TETRA S I R N
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TIG S NS N
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VANC S I R N
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_______ |
Staphylococcus aureus |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
CLIND S I R N |
DAPTO S NS N |
DOXY/MINO S I R N |
ERYTH S I R N |
GENT S I R N |
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LNZ S R N
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OX/CEFOX/METH S I R N |
QUIDAL S I R N |
RIF S I R N |
TETRA S I R N |
TIG S NS N |
TMZ S I R N |
VANC S I R N |
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Pathogen # |
Gram-negative Organisms |
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_______ |
Acinetobacter spp. (specify): |
AMK S I R N |
AMPSUL S I R N |
AZT S I R N |
CEFEP S I R N |
CEFTAZ S I R N |
CIPRO/LEVO S I R N |
COL/PB S I R N |
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____________ |
GENT S I R N |
IMI S I R N
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MERO/DORI S I R N |
PIP/PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TMZ S I R N |
TOBRA S I R N |
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_______ |
Escherichia coli |
AMK S I R N |
AMP S I R N |
AMPSUL/AMXCLV S I R N |
AZT S I R N |
CEFAZ S I R N |
CEFEP S I R N |
CEFOT/CEFTRX S I R N |
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CEFTAZ S I R N |
CEFUR S I R N |
CEFOX/CETET S I R N |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
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ERTA S I R N |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
Enterobacter spp. (specify): |
AMK S I R N |
AMP S I R N |
AMPSUL/AMXCLV S I R N |
AZT S I R N |
CEFAZ S I R N |
CEFEP S I R N |
CEFOT/CEFTRX S I R N |
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____________ |
CEFTAZ S I R N |
CEFUR S I R N |
CEFOX/CETET S I R N |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
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ERTA S I R N |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
Klebsiella spp. (specify): |
AMK S I R N |
AMP S I R N |
AMPSUL/AMXCLV S I R N |
AZT S I R N |
CEFAZ S I R N |
CEFEP S I R N |
CEFOT/CEFTRX S I R N |
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____________ |
CEFTAZ S I R N |
CEFUR S I R N |
CEFOX/CETET S I R N |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
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ERTA S I R N |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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Dialysis Event
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Pathogen # |
Gram-negative Organisms (continued) |
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_______ |
Serratia marcescens |
AMK S I R N |
AMP S I R N |
AMPSUL/AMXCLV S I R N |
AZT S I R N |
CEFAZ S I R N |
CEFEP S I R N |
CEFOT/CEFTRX S I R N |
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CEFTAZ S I R N |
CEFUR S I R N |
CEFOX/CETET S I R N |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
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ERTA S I R N |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
Pseudomonas aeruginosa |
AMK S I R N |
AZT S I R N |
CEFEP S I R N |
CEFTAZ S I R N |
CIPRO/LEVO S I R N |
COL/PB S I R N |
GENT S I R N |
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IMI S I R N
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MERO/DORI S I R N |
PIP/PIPTAZ S I R N |
TOBRA S I R N |
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_______ |
Stenotrophomonas maltophilia |
LEVO S I R N |
TETRA/MINO S I R N |
TICLAV S I R N |
TMZ S I R N |
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Pathogen # |
Fungal Organisms |
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_______ |
Candida spp. (specify): ____________
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ANID S I R N |
CASPO S NS N |
FLUCO S S-DD R N |
FLUCY S I R N |
ITRA S S-DD R N |
MICA S NS N |
VORI S S-DD R N |
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Pathogen # |
Other Organisms |
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_______ |
Organism 1 (specify) ____________
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_______Drug 1 S I R N |
_______ Drug 2 S I R N |
______ Drug 3 S I R N |
_______ Drug 4 S I R N |
_______Drug 5 S I R N |
______ Drug 6 S I R N |
______ Drug 7 S I R N |
______ Drug 8 S I R N |
______ Drug 9 S I R N |
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_______ |
Organism 1 (specify) ____________
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_______Drug 1 S I R N |
_______ Drug 2 S I R N |
______ Drug 3 S I R N |
_______ Drug 4 S I R N |
_______Drug 5 S I R N |
______ Drug 6 S I R N |
______ Drug 7 S I R N |
______ Drug 8 S I R N |
______ Drug 9 S I R N |
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_______ |
Organism 1 (specify) ____________
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_______Drug 1 S I R N |
_______ Drug 2 S I R N |
______ Drug 3 S I R N |
_______ Drug 4 S I R N |
_______Drug 5 S I R N |
______ Drug 6 S I R N |
______ Drug 7 S I R N |
______ Drug 8 S I R N |
______ Drug 9 S I R N |
Result Codes
S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested
§ GENTHL and STREPHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic
Drug Codes: |
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AMK = amikacin |
CEFTRX = ceftriaxone |
ERYTH = erythromycin |
MICA = micafungin |
STREPHL = streptomycin – high level test |
AMP = ampicillin |
CEFUR= cefuroxime |
FLUCO = fluconazole |
MINO = minocycline |
TETRA = tetracycline |
AMPSUL = ampicillin/sulbactam |
CETET= cefotetan |
FLUCY = flucytosine |
MOXI = moxifloxacin |
TICLAV = ticarcillin/clavulanic acid |
AMXCLV = amoxicillin/clavulanic acid |
CHLOR= chloramphenicol |
GENT = gentamicin |
OX = oxacillin |
TIG = tigecycline |
ANID = anidulafungin |
CIPRO = ciprofloxacin |
GENTHL = gentamicin –high level test |
PB = polymyxin B |
TMZ = trimethoprim/sulfamethoxazole |
AZT = aztreonam |
CLIND = clindamycin |
IMI = imipenem |
PIP = piperacillin |
TOBRA = tobramycin |
CASPO = caspofungin |
COL = colistin |
ITRA = itraconazole |
PIPTAZ = piperacillin/tazobactam |
VANC = vancomycin |
CEFAZ= cefazolin |
DAPTO = daptomycin |
LEVO = levofloxacin |
QUIDAL = quinupristin/dalfopristin |
VORI = voriconazole |
CEFEP = cefepime |
DORI = doripenem |
LNZ = linezolid |
RIF = rifampin |
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CEFOT = cefotaxime |
DOXY = doxycycline |
MERO = meropenem |
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CEFOX= cefoxitin |
ERTA = ertapenem |
METH = methicillin |
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CEFTAZ = ceftazidime |
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Dialysis Event
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Comments |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Amy Schneider |
File Modified | 0000-00-00 |
File Created | 2021-01-31 |