57.120_SSI

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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-10-PCS or CPT 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): _______________________

*Infection present at the time of surgery (PATOS):   □ Yes    □ No
*Specify Criteria Used (check all that apply):

Signs & Symptoms
Laboratory
□ Drainage or material†
□ Sinus tract
□ Organism(s) identified
□ Pain or tenderness
□ Hypothermia
□ Culture or non-culture based testing not performed
□ Swelling or inflammation
□ Apnea
□ Organism(s) identified from blood specimen
□ Erythema or redness
□ Bradycardia
□ Organism(s) identified from ≥ 2 periprosthetic specimens 
□ Heat
□ Lethargy

□ Fever
□ Cough
□ Other positive laboratory tests†
□ Incision deliberately opened/drained 
□ Nausea
□ Imaging test evidence of infection
□ Wound spontaneously dehisces
□ Vomiting

□ Abscess          
□ Dysuria
Clinical Diagnosis
□ Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam †
□ Physician diagnosis of this event type

□ Physician institutes appropriate antimicrobial therapy†
□ Other signs & symptoms†



†per specific site criteria

*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)
*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 35 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 7, v8.6
Surgical Site Infection (SSI)

Page 2 of 4
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/S-DD R N

CEFOT/CEFTRX
S I R N



CEFTAZ
S I R N

CEFUR
S I R N

CEFOX/CTET
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/S-DD R N

CEFOT/CEFTRX
S I R N



CEFTAZ
S I R N

CEFUR
S I R N

CEFOX/CTET
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/S-DD R N

CEFOT/CEFTRX
S I R N



CEFTAZ
S I R N

CEFUR
S I R N

CEFOX/CTET
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)
Page 3 of 4
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
CTET= 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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