Form
Approved
OMB No.
Exp. Date:
www.cdc.gov/nhsn
Pneumonia (PNEU)
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Facility ID: |
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: F M Other |
*Date of Birth: |
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Sex at Birth: F M Unknown |
Gender Identity (Specify): |
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Ethnicity (Specify): |
Race (Specify): |
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*Event Type: PNEU |
*Date of Event: |
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Post-procedure PNEU: Yes No |
Date of Procedure: |
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NHSN Procedure Code: |
ICD-10-PCS or CPT Procedure Code: |
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*MDRO Infection Surveillance: |
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□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module |
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□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module |
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*Date Admitted to Facility: |
*Location: |
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Risk Factors |
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*Ventilator: Yes No |
Location of Device Insertion: ______________ |
Date of Device Insertion: __ /__ /_____ |
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For NICU only: Birth weight: _________grams |
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Event Details |
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*Specific Event: |
□ PNU1 |
□ PNU2 |
□ PNU3 |
*Immunocompromised: Yes No |
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*Specific Criteria Used: (check all that apply) |
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Imaging Test Results |
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□ New or progressive and persistent infiltrate |
□ Consolidation |
□ Cavitation |
□ Pneumatoceles (in ≤1 y.o.) |
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Signs & Symptoms |
Laboratory |
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□ Fever |
□ Organism(s) identified from blood specimen |
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□ Leukopenia or leukocytosis |
□ Organism(s) identified from pleural fluid |
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□ Altered mental status (in ≥70 y.o.) |
□ Positive quantitative culture from LRT specimen |
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□ New onset/change in sputum |
□ ≥5% BAL cells w/ bacteria |
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□ New onset/worsening cough, dyspnea, tachypnea |
□ Positive quantitative culture of lung tissue |
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□ Rales or bronchial breath sounds† |
□ Histopathologic exam w/ abscess formation or lung parenchyma invasion by fungal hyphae |
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□ Worsening gas exchange |
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□ Hemoptysis |
□ Virus, Bordetella, Legionella, Mycoplasma or Chlamydia identified from respiratory secretions or tissue |
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□ Pleuritic chest pain |
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□ Temperature instability |
□ 4-fold rise in paired sera for pathogen |
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□ Apnea, tachypnea, nasal flaring with retraction of chest wall or grunting |
□ 4-fold rise in L pneumophila antibody titer |
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□ L pneumophila serogroup 1 antigens in urine |
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□ Hypothermia |
□ Matching Candida spp. identified from blood & sputum, endotracheal aspirate, BAL or protected specimen brushing |
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□ Wheezing, rales, or rhonchi† |
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□ Cough |
□ Fungi from LRT specimen |
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□ Bradycardia or tachycardia |
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† 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). |
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*Secondary Bloodstream Infection: Yes No |
*COVID-19: Yes No |
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**Died: Yes No |
PNEU Contributed to Death: Yes No |
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Discharge Date: |
*Pathogens Identified: Yes No *If Yes, specify on pages 2-3 |
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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 57.111 (Front) |
Pneumonia (PNEU)
Pathogen # |
Gram-positive Organisms |
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Staphylococcus coagulase-negative (specify species if available): |
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____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level) |
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Staphylococcus aureus
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Pathogen # |
Gram-negative Organisms
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Acinetobacter (specify species) ____________ |
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Escherichia coli
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Enterobacter (specify species) ____________
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Pathogen # |
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____Klebsiella pneumoniae ____Klebsiella oxytoca ____Klebsiella aerogenes |
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Pseudomonas aeruginosa
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Pathogen # |
Fungal Organisms |
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Candida (specify species if available) ______________ |
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Pathogen # |
Other Organisms |
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Organism 1 (specify) _____________ |
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Organism 1 (specify) _____________ |
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Organism 1 (specify) _____________ |
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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 are based on CLSI M100-ED30:2020, Intermediate MIC ≤ 2 and Resistant MIC ≥ 4
Drug Codes: |
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AMK = amikacin |
CEFTAR = ceftaroline |
GENT = gentamicin |
OX = oxacillin |
AMP = ampicillin |
CEFTAVI = ceftazidime/avibactam |
GENTHL = gentamicin –high level test |
PB = polymyxin B |
AMPSUL = ampicillin/sulbactam |
CEFTOTAZ = ceftolozane/tazobactam |
IMI = imipenem |
PIPTAZ = piperacillin/tazobactam |
AMXCLV = amoxicillin/clavulanic acid |
CEFTRX = ceftriaxone |
IMIREL = imipenem/relebactam |
RIF = rifampin |
ANID = anidulafungin |
CIPRO = ciprofloxacin |
LEVO = levofloxacin |
TETRA = tetracycline |
AZT = aztreonam |
CLIND = clindamycin |
LNZ = linezolid |
TIG = tigecycline |
CASPO = caspofungin |
COL = colistin |
MERO = meropenem |
TMZ = trimethoprim/sulfamethoxazole |
CEFAZ= cefazolin |
DAPTO = daptomycin |
MERVAB = meropenem/vaborbactam |
TOBRA = tobramycin |
CEFEP = cefepime |
DORI = doripenem |
METH = methicillin |
VANC = vancomycin |
CEFOT = cefotaxime |
DOXY = doxycycline |
MICA = micafungin |
VORI = voriconazole |
CEFOX= cefoxitin |
ERTA = ertapenem |
MINO = minocycline |
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CEFTAZ = ceftazidime |
FLUCO = fluconazole |
MOXI = moxifloxacin |
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Pneumonia (PNEU)
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.111_PNEU |
Subject | NHSN OMB Forms 2020 |
Author | CDC/NCZEID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-08-31 |