Form CDC 57.120 CDC 57.120 Surgical site infection

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2022

www.cdc.gov/nhsn

Surgical Site Infection (SSI)

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*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.
COVID-19: Yes No If Yes:Suspected□Confirmed □
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)

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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

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	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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