Form Approved
OMB No. 0920-0852
Exp. Date 03/31/2025
CDC ID: - Data collector initials: ___________ |
Survey date: // |
Date form completed: // |
Enter the TOTAL no. of HAIs for this patient __________. If no HAIs, check here: None and the form is complete.
HAI |
Specific site and infection data |
Event date |
Secondary BSI |
Rx start date |
Pathogens |
Location of attribution |
BJ |
Check one: BONE DISC JNT PJI |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
BSI |
Check one: LCBI MBI-LCBI Central line-associated? Yes No Check all that apply: ECMO/ECLS VAD EB Self-injection in central line Hemodialysis catheter Munchausen syndrome (factitious disorder) Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP and pus is present at ≥1 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 Peripheral IV or Midline catheter Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor inserted during the admission) None |
____/____/____ or BH Unk |
NA |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
CNS |
Check one: IC MEN SA |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
CVS |
Check one: CARD ENDO MED VASC |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
EENT |
Check one: CONJ EAR EYE ORAL SINU UR |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
GI |
Check one: CDI GE GIT IAB NEC If CDI, which C. diff tests were performed (check all that apply)? Unknown GDH EIA Positive Negative Unknown Toxin EIA Positive Negative Unknown Combined GDH EIA and Toxin EIA Positive Intermediate Negative Unknown NAAT Positive Negative Unknown Cell cytotoxicity neutralization assay (CCNA) Positive Negative Unknown Toxigenic culture Positive Negative Unknown If CDI, which test was the LAST test result placed in the medical record? GDH EIA Toxin EIA NAAT CCNA Toxigenic culture Unknown |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
LRI |
Check one: LUNG |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
PNEU |
Check one: PNU1 PNU2 PNU3 Ventilator-associated? Yes No If PNU 2/3, check specimen types that apply: BAL ETA PSB Sputum Blood Pleural fluid Lung tissue Other, specify: ____________ If PNU3: check conditions that apply: SOT, date: ___/___/___ or Date unk HSCT, date: ___/___/___ or Date unk Low-dose steroids High-dose steroids Splenectomy HIV positive with CD4 count <200 ANC or WBC <500/mm3 Cytotoxic chemotherapy |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
REPR |
Check one: EMET EPIS OREP VCUF |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
SSI
|
Proc: ______ Proc date: ____/____/____ Check one: SI DI O/S, site: ________ If SI or DI check one: Primary incision Secondary incision PATOS: Yes No |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
NA |
SST |
Check one: BRST BURN CIRC DECU SKIN ST UMB |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
UTI |
Check one: SUTI ABUTI Catheter-associated? Yes No Was fever the only sign/symptom? Yes No Unknown Not applicable |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
USI |
Check one: USI |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
If the patient had >1 HAI of the same type at the time of the survey, enter below or check Not applicable. Note: This is not common.
HAI |
Specific site and infection data |
Event date |
Secondary BSI |
Rx start date |
Pathogens |
Location of attribution |
BSI-2 |
Check one: LCBI MBI-LCBI Central line-associated? Yes No Check all that apply: ECMO VAD EB Self-injection in central line Munchausen syndrome (factitious disorder) Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP 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 Peripheral IV or Midline catheter Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor inserted during the admission) None |
____/____/____ or BH Unk |
NA |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
SSI-2 |
Proc: ______ Proc date: ____/____/____ Check one: SI DI O/S, site: ________ If SI or DI check one: Primary incision Secondary incision PATOS: Yes No |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
NA |
___-2 |
_______ |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
___-2 |
_______ |
____/____/____ or BH Unk |
Yes No Unk |
____/____/___ Unk None |
1: _______ 2: _______ 3: _______ or None |
_________ Unk |
Refer to Operational Manual for HAI type and specific site descriptions and definitions. ECMO=extracorporeal membrane oxygenation. EB=epidermolysis bullosa. VAD=ventricular assist device. Proc=NHSN operative procedure category code. Proc date=operative procedure date. Rx start date=antimicrobial treatment start date. NA=not applicable. PATOS=infection present at time of surgery. BH=before hospital admission. Unk=unknown. SOT=solid organ transplantation. HSCT=hematopoietic stem cell transplantation. IWP=infection window period. HIV=human immunodeficiency virus. ANC=absolute neutrophil count. WBC=white blood cells count.
CDC ID: -
CDCID: -
Complete the Antimicrobial Susceptibility Table below if one or more of the specified organisms is reported as a pathogen for one or more of the HAIs entered on page 1 and 2 of this form.
Enter each of the patient’s HAI codes (e.g., BSI, PNEU, GI-2, etc.) in the top row of the table in the space(s) indicated.
Check the box next to any of the organisms below reported as a pathogen for one or more of the patient’s HAIs. Antimicrobial susceptibility test results can be entered for each organism for up to 4 different HAIs.
Circle the appropriate test result for each pathogen/drug combination in the column for the HAI for which the organism was a reported pathogen (S=sensitive/susceptible, S-DD=susceptible dose-dependent, I=intermediate, R=resistant, NS=non-susceptible, N=not tested).
Antimicrobial Susceptibility Table: If NONE of the organisms below are pathogens for any of the patient’s HAIs, check here:
Organism |
HAI #1: _______, or NA |
HAI #2: _______, or NA |
HAI #3: _______, or NA |
HAI #4: _______, or NA |
Gram-negative |
||||
Acinetobacter (any species) |
AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N |
AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N |
AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N |
AMPSUL MERO/DORI S I R N S I R N CEFTAZ CEFEP S I R N S I R N COL/PB PIPTAZ S I R N S I R N IMI S I R N |
E. coli |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
Enterobacter cloacae |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
Klebsiella (Enterobacter) aerogenes
Klebsiella oxytoca
Klebsiella pneumoniae |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
ERTA PIPTAZ S I R N S I R N IMI IMIREL S I R N S I R N MERO/DORI MERVAB S I R N S I R N CEFEP S I R N CIPRO/LEVO/MOXI S I R N |
Pseudomonas aeruginosa |
CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N |
CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N |
CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N |
CEFTAZ MERO/DORI S I R N S I R N COL/PB PIP/PIPTAZ S I R N S I R N GENT TOBRA S I R N S I R N IMI S I R N |
Gram-positive |
||||
Staphylococcus aureus |
CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N |
CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N |
CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N |
CEFOX/METH/OX LNZ S I R N S R N DAPTO VANC S NS N S I R N |
Enterococcus faecalis
Enterococcus faecium |
DAPTO VANC S NS S-DD R N S I R N LNZ S I R N |
DAPTO VANC S NS S-DD R N S I R N LNZ S I R N |
DAPTO VANC S NS S-DD R N S I R N LNZ S I R N |
DAPTO VANC S NS S-DD R N S I R N LNZ S I R N |
Fungal |
||||
Candida glabrata |
ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N |
ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N |
ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N |
ANID MICA S I R N S I R N CASPO VORI S I R N S I R N FLUCO S S-DD R N |
Drug codes: AMPSUL=ampicillin/sulbactam, ANID=anidulafungin, CASPO=caspofungin, CEFOX/OX/METH=cefoxitin, oxacillin or methicillin, CEFEP=cefepime, CEFTAZ=ceftazidime, CIPRO/LEVO/MOXI=ciprofloxacin or levofloxacin or moxifloxacin, COL/PB=colistin or polymyxin B, DAPTO=daptomycin, ERTA=ertapenem, FLUCO=fluconazole, GENT=gentamicin, IMI=imipenem, IMIREL=imipenem/relebactam, LNZ=linezolid, MERO/DORI=meropenem or doripenem, MERVAB=meropenem/vaborbactam, MICA=micafungin, PIP/PIPTAZ=piperacillin or piperacillin/tazobactam, TIG=tigecycline, TOBRA=tobramycin, VANC=vancomycin, VORI=voriconazole
***FORM IS COMPLETE***
Phase5_HAI
Form_20220516
Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Shelley Magill |
File Modified | 0000-00-00 |
File Created | 2022-08-04 |