Form CDC 57.108 CDC 57.108 Primary blood stream infection

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/22

www.cdc.gov/nhsn

Primary Bloodstream Infection (BSI)

Page 1 of 5		*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: BSI	*Date of Event:
Post-procedure BSI: Yes No	Date of Procedure:
NHSN Procedure Code:	ICD-10-PCS or CPT Procedure Code:
*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:
Risk Factors
*If ICU/Other locations, Central line: Yes No		Check all that apply: Yes□ No□ *Any hemodialysis catheter present
*If Specialty Care Area/Oncology,		Yes□ No□ *Extracorporeal life support present (ECLS or ECMO)
Permanent central line: Yes No Temporary central line: Yes No		Yes□ No□ *Ventricular-assist device (VAD) present
*If NICU, Central line, including umbilical catheter Yes No Birth weight (grams)		Yes□ No□ *Known or suspected Munchausen Syndrome by Proxy during current admission Yes□ No□ *Observed or suspected patient injection into vascular line(s) within the BSI infection window period Yes□ No□ *Epidermolysis bullosa during current admission Yes□ No□ *Matching organism is identified in blood and from a site-specific specimen, both collected within the infection window period and pus is present at one of the following vascular sites from which the specimen was collected: □ Arterial catheter □ Arteriovenous fistula □ Arteriovenous graft □ Atrial lines (Right and Left) □ Hemodialysis reliable outflow (HERO) catheter □ Intra-aortic balloon pump (IABP) device □ Non-accessed central line (not accessed inserted during the admission) □ Peripheral IV or Midline catheter Location of Device Insertion: _____________________ Date of Device Insertion: ___ /___ /________
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 30 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 57.108 (Front) Rev. 11 v9.4

Page 2 of 5

Event Details

*Specific Event: Laboratory-confirmed

*Specify Criteria Used:

Signs & Symptoms (check all that apply)

Any Patient

≤ 1 year old

Underlying conditions for MBI-LCBI (check all that apply):

□ Fever

□ Fever

□ Allo-SCT with Grade ≥ 3 GI GVHD

□ Chills

□ Hypothermia

□ Allo-SCT with diarrhea

□ Hypotension

□ Apnea

□ Neutropenia (WBC or ANC < 500 cells mm3)

□ Bradycardia

Laboratory (check one)

□ Recognized pathogen from one or more blood cultures

□ Common commensal from ≥ 2 blood cultures

**Died: Yes No

BSI Contributed to Death: Yes No

Discharge Date:

*Pathogens Identified: Yes No *If Yes, specify on pages 2-3.

COVID-19: Yes No If Yes: □Confirmed □Suspected

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/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/S-DD 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 ____Klebsiella aerogenes

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/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

Primary Bloodstream Infection (BSI)

Page 4 of 5

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

Primary Bloodstream Infection (BSI)

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Comments

CDC 57.108 (Back) Rev 11, v9.4