Form 57.120 Surgical Site Infection

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

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)

□ Deep Incisional Secondary (DIS)

□ Organ/Space (specify site): _______________________

*Specify Criteria Used (check all that apply):

Signs & Symptoms

Laboratory

□ Purulent drainage or material

□ Sinus tract

□ Positive culture

□ Pain or tenderness

□ Hypothermia

□ Not cultured

□ Localized swelling

□ Apnea

□ Positive blood culture

□ Redness

□ Bradycardia

□ Blood culture not done or no organisms detected in blood

□ Heat

□ Lethargy

□ Fever

□ Cough

□ Positive Gram stain when culture is negative or not done

□ Incision deliberately opened/drained

□ Nausea

□ Wound spontaneously dehisces

□ Vomiting

□ Positive culture from ≥ 2 separate tissue or fluid samples from affected joint

□ Abscess

□ Dysuria

□ Other positive laboratory tests‡

□ Other evidence of infection found on direct exam, during invasive procedure, or by diagnostic tests‡

□ Imaging test evidence of infection

□ Other signs & symptoms‡

Clinical Diagnosis

‡per organ/space specific site criteria

□ Physician diagnosis of this event type

□ Physician institutes appropriate antimicrobial therapy‡

*Detected:

□ A (During admission)

□ P (Post-discharge surveillance)

□ RF (Readmission to facility where procedure performed)

□ RO (Readmission to facility other than where procedure was performed)

SSI was detected using the NHSN ICD Code-based Admit and Readmit SSI Surveillance Toolkit:

□ Yes

□ No

*Secondary Bloodstream Infection: Yes No

**Died: Yes No

SSI Contributed to Death: Yes No

Discharge Date:

*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 29 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, v8.0

Surgical Site Infection (SSI)

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Pathogen #	Gram-positive Organisms
_______	Staphylococcus coagulase-negative			VANC S I R N
	(specify species if available): ____________
_______	____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level)			DAPTO S NS N	GENTHL§ S R N		LNZ S I R N	VANC S I R N
_______	Staphylococcus aureus	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		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 (specify species) ____________	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		CIPRO/LEVO/MOXI S I R N			COL/PB† S 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 (specify species) ____________	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		CIPRO/LEVO/MOXI S I R N			COL/PB† S 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 pneumonia ____Klebsiella oxytoca	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		CIPRO/LEVO/MOXI S I R N			COL/PB† S 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

Surgical Site Infection (SSI)

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Pathogen #

Gram-negative Organisms (continued)

_______

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

Pathogen #

Fungal Organisms

_______

Candida (specify species if available) ____________

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 results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic

^† Clinical breakpoints have not been set by FDA or CLSI, Sensitive and Resistant designations should be based upon epidemiological cutoffs of Sensitive MIC ≤ 2 and Resistant MIC ≥ 4

Drug Codes:
AMK = amikacin	CEFTRX = ceftriaxone	FLUCY = flucytosine	OX = oxacillin
AMP = ampicillin	CEFUR= cefuroxime	GENT = gentamicin	PB = polymyxin B
AMPSUL = ampicillin/sulbactam	CETET= cefotetan	GENTHL = gentamicin –high level test	PIP = piperacillin
AMXCLV = amoxicillin/clavulanic acid	CIPRO = ciprofloxacin	IMI = imipenem	PIPTAZ = piperacillin/tazobactam
ANID = anidulafungin	CLIND = clindamycin	ITRA = itraconazole	RIF = rifampin
AZT = aztreonam	COL = colistin	LEVO = levofloxacin	TETRA = tetracycline
CASPO = caspofungin	DAPTO = daptomycin	LNZ = linezolid	TIG = tigecycline
CEFAZ= cefazolin	DORI = doripenem	MERO = meropenem	TMZ = trimethoprim/sulfamethoxazole
CEFEP = cefepime	DOXY = doxycycline	METH = methicillin	TOBRA = tobramycin
CEFOT = cefotaxime	ERTA = ertapenem	MICA = micafungin	VANC = vancomycin
CEFOX= cefoxitin	ERYTH = erythromycin	MINO = minocycline	VORI = voriconazole
CEFTAZ = ceftazidime	FLUCO = fluconazole	MOXI = moxifloxacin

Surgical Site Infection (SSI)

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