Form
Approved
OMB No.
Exp. Date:
www.cdc.gov/nhsn
Primary Bloodstream Infection (BSI)
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*required for saving **required for completion |
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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: BSI |
*Date of Event: |
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Post-procedure BSI: 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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*If ICU/Other locations, Central line: Yes No |
Check all that apply: Yes□ No□ *Any hemodialysis catheter present |
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*If Specialty Care Area/Oncology, |
Yes□ No□ *Extracorporeal life support present (ECLS or ECMO) |
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Permanent central line: Yes No Temporary central line: Yes No |
Yes□ No□ *Ventricular-assist device (VAD) present |
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*If NICU, Central line, including umbilical catheter Yes No
Birth weight (grams)
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Yes□ No□ *Known or suspected Munchausen Syndrome by Proxy during current admission Yes□ No□ *Observed or suspected patient injection into vascular line(s) within the BSI infection window period Yes□ No□ *Epidermolysis bullosa during current admission Yes□ No□ *Matching organism is identified in blood and from a site-specific specimen, both collected within the infection window period 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 □ Intra-aortic balloon pump (IABP) device □ Non-accessed central line (not accessed inserted during the admission) □ Peripheral IV or Midline catheter Location of Device Insertion: _____________________ Date of Device Insertion: ___ /___ /________
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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 57.108 (Front) Rev. 11 v9.4
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Event Details |
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*Specific Event: Laboratory-confirmed |
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*Specify Criteria Used: |
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Signs & Symptoms (check all that apply) |
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Any Patient |
≤ 1 year old |
Underlying conditions for MBI-LCBI (check all that apply): |
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□ Fever |
□ Fever |
□ Allo-SCT with Grade ≥ 3 GI GVHD |
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□ Chills |
□ Hypothermia |
□ Allo-SCT with diarrhea |
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□ Hypotension |
□ Apnea |
□ Neutropenia (WBC or ANC < 500 cells mm3) |
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□ Bradycardia |
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Laboratory (check one) |
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□ Recognized pathogen from one or more blood specimens |
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□ Common commensal from ≥ 2 blood specimens |
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**Died: Yes No |
BSI 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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*COVID-19: Yes No |
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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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Primary Bloodstream Infection (BSI)
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Comments |
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CDC
57.108 (Back) Rev 11,
v9.4
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.108 |
Subject | NHSN OMB Forms 2020 |
Author | CDC/NCEZID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-11-20 |