Form
Approved
OMB No. 0920-0666
Exp. Date: xx/xx/xxxx
www.cdc.gov/NHSN
Respiratory Tract Infection Event
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*Required for saving
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*Facility ID: |
Event #: |
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*Resident ID: |
Secondary ID: |
Medicare #: |
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Resident 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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*Date of First Admission to Facility |
*Date of Current Admission to Facility |
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Event Details |
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*Event Type: RTI |
*Date of Event: |
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*Resident Care Location |
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*Primary Resident Service Type (check one) □ Long-term general nursing □ Long-term dementia □ Skilled nursing/Short-term rehab □ Ventilator □ Long-term psychiatric □ Bariatric □ Hospice/Palliative |
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*Ventilator: YES NO Date of Device Insertion: Location of Device Insertion: |
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*Imaging: Was a Chest X-Ray Performed: □ YES □ NO |
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Findings: □ New infiltrate □ New Consolidation □ Other findings consistent with pneumonia □ Negative |
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*Specify Criteria Used (check all that apply) |
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Constitutional Signs and Symptoms: |
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Fever: which of the following were documented □ Single temperature > 37.8o C (>100o F) □ Repeated temperatures >37.2o C (99o F) □ Single temperature >1.1o C (2o F) over baseline □ Term “fever” documented without value |
Any acute change in mental status from baseline □ Fluctuating: behavior fluctuating □ Inattention: difficulty focusing attention □ Confusion/disorganized thinking □ Altered consciousness |
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Acute functional decline: increase in assistance with activities of daily living (ADL) from baseline: □ Bed mobility □ Dressing □ Eating □ Toilet Use □ Transfer □ Personal hygiene □ Locomotion within the facility |
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Leukocytosis: documentation of at least one of the following □ Neutrophilia >10,000 leukocytes per/ml3 (enter value) ____________ □ Left shift (6% bands or ≥ 1,500 bands/mm3) |
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Respiratory Signs and Symptoms: |
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Decreased oxygenation: documentation of at least one of the following □ Pulse oximetry with single O2 saturation < 94% □ Pulse oximetry with single O2 saturation with reduction of >3% □ Resident newly placed on oxygen |
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□ Respiratory rate >24 breaths per minute □ New onset hypotension □ Pulse >100 □ Rigors or chills □ Malaise □ New onset hypothermia □ Myalgia or body aches □ Loss of appetite or decreased oral intake |
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□ New or increased cough □ New or increase sputum production □ Pleuritic chest pain □ Runny nose or sneezing □ Abnormal lung exam (new or changed) □ Stuffy nose □ Sore throat, difficulty swallowing, hoarseness □ Headache or eye pain □ Swollen or tender glands in the neck □ No documented respiratory signs or symptoms |
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Laboratory/Diagnostic |
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□ Positive flu PCR □ Positive legionella urinary antigen testing □ Positive S. pneumonia urinary antigen □ Positive sputum culture |
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*Specific Event Type (check one): □ PNA 1 □ PNA 2 □ PNA 3 □ LRI 1 □ LRI 2 |
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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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*Transferred to acute care facility within 7 days: Yes No |
*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 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 57.115 (Front) Rev 6 V. 8.6 |
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Respiratory Tract 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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Respiratory Tract 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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Respiratory Tract Infection Event
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.115_CUS |
Subject | NHSN OMB Forms |
Author | CDC/NCEZID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-08-30 |