57.109 Dialysis Event

The National Healthcare Safety Network (NHSN)

57.109_DIA_BLANK

57.109 Dialysis Event

OMB: 0920-0666

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OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn



Dialysis Event


Complete this form as indicated by the Dialysis Event Protocol

Instructions for this form are available at http://www.cdc.gov/nhsn/forms/instr/57_109.pdf

Page 1 of 4

*required for saving

Facility ID:

Event ID #:

*Patient ID:

Social Security #:

Secondary ID #:

Medicare #:

Patient Name, Last:

First:

Middle:

*Gender: F M Other

*Date of Birth:

Ethnicity (Specify):

Race (Specify):

*Event Type: DE – Dialysis Event

*Date of Event:

*Location:

Was the patient admitted/readmitted to the dialysis facility on this dialysis event date?

Yes

No

Risk Factors


*Vascular accesses: (check all that apply)

*Access placement date (mm/yyyy):

Fistula

_____ /_________

Unknown

Buttonhole?

Yes

No


Graft

_____ /_________

Unknown

Tunneled central line

_____ /_________

Unknown

Nontunneled central line

_____ /_________

Unknown

Other access device

_____ /_________

Unknown

Is this a catheter-graft hybrid?

Yes

No


Vascular access comment:


Other Patient Information

*Transient Patient

Yes

No

Event Details


*Specify Dialysis Event: (check at least one)

IV antimicrobial start

*Was vancomycin the antimicrobial used for this start?

Yes

No

Positive blood culture (*specify organism and antimicrobial susceptibilities on pages 2-3)

*Suspected source of positive blood culture (check one):

Vascular access

A source other than the vascular access

Contamination

Uncertain

Pus, redness, or increased swelling at vascular access site

*Check the access site(s) with pus, redness, or increased swelling:

Fistula

Graft

Tunneled central line

Nontunneled central line

Other access device


*Specify Problem(s): (check one or more)

Fever ≥37.8°C (100°F) oral

Chills or rigors

Drop in blood pressure

Wound (NOT related to vascular access) with pus or increased redness

Cellulitis (skin redness, heat, or pain without open wound)

Pneumonia or respiratory infection

Other problem (specify): __________________________________________________________

None


*Specify Outcomes:

Hospitalization

Yes

No

Unknown


Death

Yes

No

Unknown


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 6, v7.1

Page 2 of 4

Pathogen #

Gram-positive Organisms


_______


Staphylococcus coagulase-negative


VANC

S I R N

(specify): ________________________


_______


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

___________


STREPHL§

S R N



TETRA

S I R N



TIG

S NS N



VANC

S I R N



_______



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


QUIDAL

S I R N



STREPHL§

S R N



TETRA

S I R N



TIG

S NS N



VANC

S I R N



_______


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



LNZ

S R N



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

Pathogen #

Gram-negative Organisms


_______


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

____________


GENT

S I R N


IMI

S I R N



MERO/DORI

S I R N


PIP/PIPTAZ

S I R N


TETRA/DOXY/MINO

S I R N




TMZ

S I R N


TOBRA

S I R N



_______


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



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



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




TIG

S I R N


TMZ

S I R N


TOBRA

S I R N



_______


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

____________


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



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




TIG

S I R N


TMZ

S I R N


TOBRA

S I R N



_______


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

____________


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



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



TIG

S I R N


TMZ

S I R N


TOBRA

S I R N


Page 3 of 4

Pathogen #

Gram-negative Organisms (continued)


_______


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



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



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




TIG

S I R N


TMZ

S I R N


TOBRA

S I R N



_______


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



IMI

S I R N



MERO/DORI

S I R N


PIP/PIPTAZ

S I R N


TOBRA

S I R N


_______


Stenotrophomonas maltophilia


LEVO

S I R N


TETRA/MINO

S I R N


TICLAV

S I R N


TMZ

S I R N

Pathogen #

Fungal Organisms

_______

Candida spp. (specify): ____________


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

Pathogen #

Other Organisms

_______

Organism 1 (specify)

____________


_______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

_______

Organism 1 (specify)

____________


_______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

_______

Organism 1 (specify)

____________


_______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:





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


CEFOT = cefotaxime

DOXY = doxycycline

MERO = meropenem



CEFOX= cefoxitin

ERTA = ertapenem

METH = methicillin



CEFTAZ = ceftazidime





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