Form CDC 57.111 CDC 57.111 Pneumonia

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2022

www.cdc.gov/nhsn

Pneumonia (PNEU)

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: PNEU

*Date of Event:

Post-procedure PNEU: 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

*Ventilator: Yes No

Location of Device Insertion: ______________

Date of Device Insertion: __ /__ /_____

For NICU only: Birth weight: _________grams

Event Details

*Specific Event:

□ PNU1

□ PNU2

□ PNU3

*Immunocompromised: Yes No

*Specific Criteria Used: (check all that apply)

Imaging Test Results

□ New or progressive and persistent infiltrate

□ Consolidation

□ Cavitation

□ Pneumatoceles (in ≤1 y.o.)

Signs & Symptoms

Laboratory

□ Fever

□ Organism(s) identified from blood specimen

□ Leukopenia or leukocytosis

□ Organism(s) identified from pleural fluid

□ Altered mental status (in ≥70 y.o.)

□ Positive quantitative culture from LRT specimen

□ New onset/change in sputum

□ ≥5% BAL cells w/ bacteria

□ New onset/worsening cough, dyspnea, tachypnea

□ Positive quantitative culture of lung tissue

□ Rales or bronchial breath sounds†

□ Histopathologic exam w/ abscess formation or lung parenchyma invasion by fungal hyphae

□ Worsening gas exchange

□ Hemoptysis

□ Virus, Bordetella, Legionella, Mycoplasma or Chlamydia identified from respiratory secretions or tissue

□ Pleuritic chest pain

□ Temperature instability

□ 4-fold rise in paired sera for pathogen

□ Apnea, tachypnea, nasal flaring with retraction of chest wall or grunting

□ 4-fold rise in L pneumophila antibody titer

□ L pneumophila serogroup 1 antigens in urine

□ Hypothermia

□ Matching Candida spp. identified from blood & sputum, endotracheal aspirate, BAL or protected specimen brushing

□ Wheezing, rales, or rhonchi†

□ Cough

□ Fungi from LRT specimen

□ Bradycardia or tachycardia

† There are two criteria referring to rales in the PNU 1 signs and symptoms list. Please choose the one that corresponds to the specific algorithm used to identify this pneumonia (Any Patient or Alternate Criteria based on age).

*Secondary Bloodstream Infection: Yes No

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

**Died: Yes No

PNEU 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 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 57.111 (Front) Rev 9, v8.6

Pneumonia (PNEU)

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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/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 ____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/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

Pneumonia (PNEU)

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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	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

Pneumonia (PNEU)

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