Form Approved
OMB
No. 0920-0666
Exp. Date: 01/31/2021
www.cdc.gov/nhsn
MDRO or CDI Infection Event
Page 1 of 4
*Required for saving Facility ID: |
**Required for completion Event #: |
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*Patient ID: |
Social Security #: |
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Secondary ID: |
Medicare #: |
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Patient Name, Last: First: Middle: |
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*Gender: M F Other |
*Date of Birth: |
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Ethnicity (Specify): |
Race (Specify): |
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Event Details |
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*Event Type: [For Event Type = BSI, PNEU, SSI, or UTI use the event specific from] |
*Date of Event:
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Post Procedure Event: Yes No |
Date of Procedure: |
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MDRO/CDI Infection Surveillance: Yes |
NHSN Procedure Code: |
ICD-10-PCS or CPT Procedure Code: |
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*Specific Organism Type: (Select up to 3) |
□ MRSA |
□ MSSA |
□ VRE |
□ CephR-Klebsiella |
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□ CRE-E. coli |
□ CRE-Enterobacter |
□ CRE-Klebsiella |
□ MDR-Acinetobacter |
□ C. difficile |
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*Date Admitted to Facility: |
*Location: |
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*Specific Event Type (used only for CDC defined events): |
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Specify Criteria Used (check all that apply) |
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Signs and Symptoms |
Laboratory or Diagnostic Testing |
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□ Abscess |
□ Heat |
□ Dysuria |
□ Organism(s) identified |
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□ Apnea |
□ Hypotension |
□ Fever |
□ Not cultured |
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□ Bradycardia |
□ Hypothermia |
□ Bilious aspirate |
□ Organism(s) identified from blood specimen+ |
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□ Cough |
□ Lethargy |
□ Erythema or redness |
□ Other positive laboratory tests+ |
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□ Vomiting |
□ Nausea |
□ Suprapubic tenderness |
□ > 15 colonies cultured from IV cannula tip using semiquantitative culture method |
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□ Abdominal distension |
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□ Pain or tenderness |
□ Pneumatosis intestinalis by radiograph |
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□ Drainage or material+ |
□ Portal venous gas (Hepatobiliary gas) by radiograph |
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□ Wheezing, rales or rhonchi |
□ Pneumoperitoneum by radiograph |
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□ Diarrhea+ |
□ Imaging test evidence of infection+ |
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□ Swelling or inflammation |
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□ Occult or gross blood in stools (with no rectal fissure) |
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□ Surgical evidence of extensive bowel necrosis (>2 cm of bowel affected) |
Clinical Diagnosis |
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□ Surgical evidence of pneumatosis intestinalis with or without intestinal perforation |
□ Physician diagnosis of this event type+ |
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□ Physician institutes appropriate antimicrobial therapy+ |
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□ Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam + |
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□ Other signs and symptoms+ |
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+ Per specific site criteria |
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Clostridioides difficile Infection |
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*Admitted to ICU for CDI complications: Yes No |
*Surgery for CDI complications: Yes No |
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* Secondary Bloodstream Infection: Yes No |
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**Died: Yes No |
Event contributed to death? Yes No |
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Discharge Date: ____/____/______ |
*Pathogens Identified: Yes No If yes, specify on Page 2 |
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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 57.126 (Front) Rev 6 V. 8.6 |
MDRO or CDI Infection Event
Page 2 of 4 |
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Pathogen # |
Gram-positive Organisms |
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_______ |
Staphylococcus coagulase-negative |
VANC S I R N |
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(specify species if available): ____________ |
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_______ |
____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 |
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_______ |
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 |
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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 |
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Pathogen # |
Gram-negative Organisms |
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_______ |
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 |
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GENT S I R N |
IMI S I R N
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MERO/DORI S I R N |
PIP/PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TMZ S I R N |
TOBRA S I R N |
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_______ |
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 |
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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 |
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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 |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
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 |
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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 |
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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 |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
____Klebsiella pneumonia
____Klebsiella oxytoca
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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 |
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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 |
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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 |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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MDRO or CDI Infection Event
Page 3 of 4 |
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Pathogen # |
Gram-negative Organisms (continued) |
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_______ |
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 |
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IMI S I R N
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MERO/DORI S I R N |
PIP/PIPTAZ S I R N |
TOBRA S I R N |
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Pathogen # |
Fungal Organisms |
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_______ |
Candida (specify species if available) ____________
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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 |
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Pathogen # |
Other Organisms |
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_______ |
Organism 1 (specify) ____________
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_______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 |
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_______ |
Organism 1 (specify) ____________
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_______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 |
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_______ |
Organism 1 (specify) ____________
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_______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: |
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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 |
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MDRO or CDI Infection Event
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Comments |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.129_MDRO Infection Event |
Subject | NHSN OMB FORM 2018 |
Author | CDC/NCZEID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-09-03 |