Form
Approved
OMB No. 0920-0666
Exp. Date: 12/31/2022
www.cdc.gov/NHSN
Custom Event
Page 1 of 4 |
*Required for saving
|
|||||
Facility ID: |
Event #: |
|||||
*Patient ID: |
Social Security #: |
|||||
Secondary ID: |
Medicare #: |
|||||
Patient Name, Last: First: Middle: |
||||||
*Gender: M F Other |
*Date of Birth: |
|||||
Sex at Birth: F M Unknown |
Gender Identity (Specify): |
|||||
Ethnicity (Specify): |
Race (Specify): |
|||||
Event Details |
||||||
*Event Type: |
*Date of Event: |
|||||
Post Procedure Event: Yes No |
Date of Procedure: |
|||||
NHSN Procedure Code: |
ICD-10-PCS or CPT Procedure Code: |
|||||
MDRO/CDI Infection Surveillance: No |
Date Admitted to Facility: |
|||||
Location: |
||||||
Specific Event Type (used only for CDC defined events): |
||||||
Specify Criteria Used (check all that apply) |
||||||
Signs and Symptoms |
Laboratory or Diagnostic Testing |
|||||
□ Abscess |
□ Heat |
□ Dysuria |
□ Organism(s) identified |
|||
□ Apnea |
□ Hypotension |
□ Fever |
□ Culture or non-culture based testing not performed |
|||
□ Bradycardia |
□ Hypothermia |
□ Bilious aspirate |
□ Organism(s) identified from blood specimen+ |
|||
□ Cough |
□ Lethargy |
□ Erythema or redness |
□ Other positive laboratory tests+ |
|||
□ Vomiting |
□ Nausea |
□ Abdominal distension |
□ > 15 colonies cultured from IV cannula tip using semiquantitative culture method |
|||
□ Pain or tenderness |
||||||
□ Drainage or material+ |
□ Pneumatosis intestinalis by radiograph |
|||||
□ Wheezing, rales or rhonchi |
□ Portal venous gas (Hepatobiliary gas) by radiograph |
|||||
□ Diarrhea+ |
□ Pneumoperitoneum by radiograph |
|||||
□ Swelling or inflammation |
□ Imaging test evidence of infection+ |
|||||
□ Occult or gross blood in stools (with no rectal fissure) |
|
|||||
□ Surgical evidence of extensive bowel necrosis (>2 cm of bowel affected) |
Clinical Diagnosis |
|||||
□ Surgical evidence of pneumatosis intestinalis with or without intestinal perforation |
□ Physician diagnosis of this event type+ |
|||||
□ Physician institutes appropriate antimicrobial therapy+ |
||||||
□ Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam+ |
|
|||||
□ Other signs and symptoms+ |
|
|||||
+ Per specific criteria |
||||||
Secondary Bloodstream Infection: Yes No |
*COVID-19: Yes No |
|||||
Died: Yes No |
Event contributed to death? Yes No |
|||||
Discharge Date: ____/____/______ |
*Pathogens Identified: Yes No If yes, specify on Page 2 |
|||||
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 |
Custom Event
Pathogen # |
Gram-positive Organisms |
|||||||||||||||||||||||||||||
|
Staphylococcus coagulase-negative (specify species if available): |
|
||||||||||||||||||||||||||||
|
____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level) |
|
||||||||||||||||||||||||||||
|
Staphylococcus aureus
|
|
||||||||||||||||||||||||||||
Pathogen # |
Gram-negative Organisms |
|||||||||||||||||||||||||||||
|
Acinetobacter (specify species) ____________ |
|
||||||||||||||||||||||||||||
|
Escherichia coli
|
|
||||||||||||||||||||||||||||
|
Enterobacter (specify species) ____________ |
|
||||||||||||||||||||||||||||
Pathogen # |
||||||||||||||||||||||||||||||
|
____Klebsiella pneumoniae ____Klebsiella oxytoca ____Klebsiella aerogenes |
|
||||||||||||||||||||||||||||
|
Pseudomonas aeruginosa
|
|
||||||||||||||||||||||||||||
Pathogen # |
Fungal Organisms |
|||||||||||||||||||||||||||||
|
Candida (specify species if available) ______________ |
|
||||||||||||||||||||||||||||
Pathogen # |
Other Organisms |
|||||||||||||||||||||||||||||
|
Organism 1 (specify) _____________ |
|
||||||||||||||||||||||||||||
|
Organism 1 (specify) _____________ |
|
||||||||||||||||||||||||||||
|
Organism 1 (specify) _____________ |
|
Custom Event
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: |
|
|
|
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 |
|
CEFTAZ = ceftazidime |
FLUCO = fluconazole |
MOXI = moxifloxacin |
|
Custom Event
Page 4 of 4
Custom Fields |
|||
Label |
Label |
||
_______________________ |
____/____/____ |
_______________________ |
____/____/_____ |
_______________________ |
_____________ |
_______________________ |
______________ |
_______________________ |
_____________ |
_______________________ |
______________ |
_______________________ |
______________ |
_______________________ |
______________ |
_______________________ |
______________ |
_______________________ |
______________ |
_______________________ |
______________ |
_______________________ |
______________ |
_______________________ |
______________ |
_______________________ |
______________
|
Comments |
|||
|
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.115_CUS |
Subject | NHSN OMB Forms 2020 |
Author | CDC/NCZEID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-08-18 |