16

OMB No. 0920-0666
Exp. Date: 12-31-2015
www.cdc.gov/nhsn

Surgical Site Infection (SSI)
Page 1 of 4
*required for saving **required for completion

Facility ID:
Event #:
*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: SSI
*Date of Event:
*NHSN Procedure Code:
ICD-9-CM Procedure Code:
*Date of Procedure:
*Outpatient Procedure: Yes No
*MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module
*Date Admitted to Facility
Location
Event Details
*Specific Event:
□ Superficial Incisional Primary (SIP)
□ Deep Incisional Primary (DIP)

□
□

□

Superficial Incisional Secondary (SIS)

Organ/Space (specify site): _______________________
*Specify Criteria Used (check all that apply):
Signs & Symptoms
□ Purulent drainage or material

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

Laboratory
□ Positive culture

Localized swelling
Redness

□
□
□

Heat
Fever

□

Pain or tenderness

Incision deliberately opened by surgeon
Wound spontaneously dehisces
Abscess

Deep Incisional Secondary (DIS)

□
□

Not cultured
Positive blood culture
Blood culture not done or no organisms detected in
blood
Positive Gram stain when culture is negative or not
done
‡

Other positive laboratory tests
Imaging test evidence of infection

Hypothermia
Apnea
Clinical Diagnosis

Bradycardia

□
□

Lethargy
Cough

Physician diagnosis of this event type
‡
Physician institutes appropriate antimicrobial therapy

Nausea
Vomiting

Dysuria
‡
Other evidence of infection found on direct exam, during
per organ/space specific site criteria
‡
invasive procedure, or by diagnostic tests
□ Other signs & symptoms‡
*Detected:
□ A (During admission) □ P (Post-discharge surveillance) □ RF (Readmission to facility where

□ RO (Readmission to facility other than where procedure was performed)
*Secondary Bloodstream Infection: Yes
Discharge Date:

No

procedure performed)
**Died: Yes No
SSI Contributed to Death: Yes No
*Pathogens Identified: Yes No *If Yes, specify on pages 2-3.

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 57.120 (Front) Rev 5, 7.1

OMB No. 0920-0666
Exp. Date: 12-31-2015
www.cdc.gov/nhsn

Surgical Site Infection (SSI)
Page 2 of 4

Pathogen
#
_______

_______

_______

_______

Pathogen
#
_______

_______

_______

_______

Gram-positive Organisms
VANC
Staphylococcus
SIRN
coagulase-negative
(specify): ________________________

Enterococcus
spp.( specify):
___________

AMP
SIRN

Enterococcus
faecium

Staphylococcus
aureus

GENTHL§
SRN

LNZ
SIRN

DOXY/MINO
SIRN

GENTHL§
SRN

LNZ
SIRN

TETRA
SIRN

TIG
S NS N

VANC
SIRN

CIPRO/LEVO/MOXI
SIRN

CLIND
SIRN

DAPTO
S NS N

DOXY/MINO
SIRN

ERYTH
SIRN

GENT
SIRN

OX/CEFOX/METH
SIRN

QUIDAL
SIRN

RIF
SIRN

TETRA
SIRN

TIG
S NS N

TMZ
SIRN

CEFEP
SIRN

CEFTAZ
SIRN

CIPRO/LEVO
SIRN

CIPRO/LEVO/MOXI
SIRN

DAPTO
S NS N

DOXY/MINO
SIRN

TETRA
SIRN

TIG
S NS N

VANC
SIRN

AMP
SIRN

CIPRO/LEVO/MOXI
SIRN

DAPTO
S NS N

QUIDAL
SIRN

STREPHL§
SRN

CHLOR
SIRN
LNZ
SRN

STREPHL§
SRN

VANC
SIRN

Gram-negative Organisms
Acinetobacter
spp. (specify):
____________

Escherichia coli

Enterobacter
spp. (specify):
____________

Klebsiella spp.
(specify):
____________

CDC 57.120 (Back) Rev 5, 7.1

AMK
SIRN

AMPSUL
SIRN

AZT
SIRN

GENT
SIRN

IMI
SIRN

MERO/DORI
SIRN

PIP/PIPTAZ
SIRN

TMZ
SIRN

TOBRA
SIRN

AMK
SIRN

AMP
SIRN

AMPSUL/AMXCLV
SIRN

AZT
SIRN

CEFAZ
SIRN

CEFTAZ
SIRN

CEFUR
SIRN

CEFOX/CETET
SIRN

CHLOR
SIRN

CIPRO/LEVO/MOXI
SIRN

ERTA
SIRN

GENT
SIRN

IMI
SIRN

TIG
SIRN

TMZ
SIRN

TOBRA
SIRN

AMK
SIRN

AMP
SIRN

AMPSUL/AMXCLV
SIRN

CEFTAZ
SIRN

CEFUR
SIRN

CEFOX/CETET
SIRN

ERTA
SIRN

GENT
SIRN

IMI
SIRN

TIG
SIRN

TMZ
SIRN

TOBRA
SIRN

AMK
SIRN

AMP
SIRN

AMPSUL/AMXCLV
SIRN

CEFTAZ
SIRN

CEFUR
SIRN

CEFOX/CETET
SIRN

ERTA
SIRN

GENT
SIRN

IMI
SIRN

TIG
SIRN

TMZ
SIRN

TOBRA
SIRN

MERO/DORI
SIRN

COL/PB
SIRN
TETRA/DOXY/MINO
SIRN

CEFEP
SIRN

CEFOT/CEFTRX
SIRN
COL/PB
SIRN

PIPTAZ
SIRN

TETRA/DOXY/MINO
SIRN

AZT
SIRN

CEFAZ
SIRN

CEFEP
SIRN

CHLOR
SIRN

CIPRO/LEVO/MOXI
SIRN

MERO/DORI
SIRN

CEFOT/CEFTRX
SIRN
COL/PB
SIRN

PIPTAZ
SIRN

TETRA/DOXY/MINO
SIRN

AZT
SIRN

CEFAZ
SIRN

CEFEP
SIRN

CHLOR
SIRN

CIPRO/LEVO/MOXI
SIRN

MERO/DORI
SIRN

PIPTAZ
SIRN

CEFOT/CEFTRX
SIRN
COL/PB
SIRN

TETRA/DOXY/MINO
SIRN

OMB No. 0920-0666
Exp. Date: 12-31-2015
www.cdc.gov/nhsn

Surgical Site Infection (SSI)
Page 3 of 4

Pathogen
#

Gram-negative Organisms (continued)

_______

Serratia
marcescens

_______

Pseudomonas
aeruginosa

AMK
SIRN

AMP
SIRN

AMPSUL/AMXCLV
SIRN

AZT
SIRN

CEFAZ
SIRN

CEFTAZ
SIRN

CEFUR
SIRN

CEFOX/CETET
SIRN

CHLOR
SIRN

CIPRO/LEVO/MOXI
SIRN

ERTA
SIRN

GENT
SIRN

IMI
SIRN

TIG
SIRN

TMZ
SIRN

TOBRA
SIRN

AMK
SIRN

AZT
SIRN

CEFEP
SIRN

IMI
SIRN

MERO/DORI
SIRN

_______

Stenotrophomonas
maltophilia

Pathogen
#

Fungal Organisms

CEFEP
SIRN

CEFOT/CEFTRX
SIRN
COL/PB
SIRN

MERO/DORI
SIRN

PIPTAZ
SIRN

TETRA/DOXY/MINO
SIRN

CEFTAZ
SIRN

CIPRO/LEVO
SIRN

COL/PB
SIRN

GENT
SIRN

PIP/PIPTAZ
SIRN

TOBRA
SIRN

MICA
S NS N

VORI
S S-DD R N

LEVO
SIRN

TETRA/MINO
SIRN

TICLAV
SIRN

TMZ
SIRN

CASPO
S NS N

FLUCO
S S-DD R N

FLUCY
SIRN

ITRA
S S-DD R N

Candida spp.
_______
Pathogen
#

(specify):

____________

Other Organisms
Organism 1

_______

(specify)

____________
Organism 1

_______

(specify)

____________
Organism 1

_______

ANID
SIRN

(specify)

____________

_______
Drug 1
SIRN

_______
Drug 2
SIRN

______
Drug 3
SIRN

_______
Drug 4
SIRN

_______
Drug 5
SIRN

______
Drug 6
SIRN

______
Drug 7
SIRN

______
Drug 8
SIRN

______
Drug 9
SIRN

_______
Drug 1
SIRN

_______
Drug 2
SIRN

______
Drug 3
SIRN

_______
Drug 4
SIRN

_______
Drug 5
SIRN

______
Drug 6
SIRN

______
Drug 7
SIRN

______
Drug 8
SIRN

______
Drug 9
SIRN

_______
Drug 1
SIRN

_______
Drug 2
SIRN

______
Drug 3
SIRN

_______
Drug 4
SIRN

_______
Drug 5
SIRN

______
Drug 6
SIRN

______
Drug 7
SIRN

______
Drug 8
SIRN

______
Drug 9
SIRN

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

AMP = ampicillin

CEFUR= cefuroxime

FLUCO = fluconazole

MINO = minocycline

AMPSUL = ampicillin/sulbactam

CETET= cefotetan

FLUCY = flucytosine

MOXI = moxifloxacin

AMXCLV = amoxicillin/clavulanic acid

CHLOR=
chloramphenicol

GENT = gentamicin

OX = oxacillin

STREPHL = streptomycin –
high level test
TETRA = tetracycline
TICLAV = ticarcillin/clavulanic
acid
TIG = tigecycline

ANID = anidulafungin

CIPRO = ciprofloxacin

AZT = aztreonam

CLIND = clindamycin

GENTHL = gentamicin –high
level test
IMI = imipenem

PIP = piperacillin

TMZ =
trimethoprim/sulfamethoxazole
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

CDC 57.120 (Back) Rev 5, 7.1

PB = polymyxin B

OMB No. 0920-0666
Exp. Date: 12-31-2015
www.cdc.gov/nhsn

Surgical Site Infection (SSI)
Page 4 of 4

Custom Fields
Label
______________________
_______________________
_______________________
_________________________
_________________________
_________________________
_________________________
Comments

CDC 57.120 (Back) Rev 5, v7.1

____/____/____
_____________
_____________
______________
______________
______________
______________

Label
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________

____/____/_____
______________
______________
______________
______________
______________
______________