57.126 MDRO or CDI Infection Event

OMB No. 0920-0666

Exp. Date: 05-31-2014

www.cdc.gov/nhsn

MDRO or CDI Infection Event

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*Required for saving Facility ID:

**Required for completion Event #:

*Patient ID:

Social Security #:

Secondary ID:

Medicare #:

Patient Name, Last: First: Middle:

*Gender: M F Other

*Date of Birth:

Ethnicity (Specify):

Race (Specify):

Event Details

*Event Type: [For Event Type = BSI, PNEU, SSI, or UTI use the event specific from]

*Date of Event:

Post Procedure Event: Yes No

Date of Procedure:

MDRO/CDI Infection Surveillance: Yes

NHSN Procedure Code:

ICD-9-CM Procedure Code:

*Specific Organism Type: (Select up to 3)

□ MRSA

□ MSSA

□ VRE

□ CephR-Klebsiella

□ CRE-E. coli

□ CRE-Klebsiella

□ MDR-Acinetobacter

□ C. difficile

*Date Admitted to Facility:

*Location:

*Specific Event Type (used only for CDC defined events):

Specify Criteria Used (check all that apply)

Signs and Symptoms

Laboratory or Diagnostic Testing

□ Abscess

□ Heat

□ Dysuria

□ Positive culture

□ Apnea

□ Hypotension

□ Fever

□ Not cultured

□ Bradycardia

□ Hypothermia

□ Bilious aspirate

□ Positive blood culture

□ Cough

□ Lethargy

□ Abdominal distension

□ Blood culture not done or no organisms detected in blood

□ Redness

□ Nausea

□ Vomiting

□ Positive Gram stain when culture is negative or not done

□ Abdominal distension

□ Suprapubic tenderness

□ Positive culture of pathogen

□ Pain or tenderness

□ Localized swelling

□ Positive culture of common commensals

□ Purulent drainage or material

□ Wheezing, rales or rhonchi

□ Other positive laboratory tests+

□ New onset/change in sputum, increased secretions or increased suctioning

□ > 15 colonies cultured from IV cannula tip using semiquantitative culture method

□ Acute onset of diarrhea (liquid stools for > 12 hours)

□ Pneumatosis intestinalis by radiograph

□ Occult or gross blood in stools (with no rectal fissure)

□ Portal venous gas (Hepatobiliary gas) by radiograph

□ Surgical evidence of extensive bowel necrosis (>2 cm of bowel affected)

□ Pneumoperitoneum by radiograph

□ Radiographic evidence of infection+

□ Surgical evidence of pneumatosis intestinalis with or without intestinal perforation

Clinical Diagnosis

□ Other evidence of infection found on direct exam, during surgery or by diagnostic testing+

□ Physician diagnosis of this event type+

□ Physician institutes appropriate antimicrobial therapy+

□ Other signs and symptoms+

+ Per specific criteria

Clostridium difficile Infection

*Admitted to ICU for CDI complications: Yes No

*Surgery for CDI complications: Yes No

* Secondary Bloodstream Infection: Yes No

**Died: Yes No

Event contributed to death? Yes No

Discharge Date: ____/____/______

*Pathogens Identified: Yes No If yes, specify on Page 2

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 32 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 57.126 (Front) Rev 1 v6.6

MDRO or CDI Infection Event

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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

MDRO or CDI Infection Event

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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

MDRO or CDI Infection Event

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