Form
Approved OMB
No. 0920-0666 Exp.
Date: 06/30/2026 www.cdc.gov/nhsn
Dialysis
Event Surveillance Form
*required for saving
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Pathogen # |
Gram-positive Organisms |
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_______ |
Staphylococcus coagulase-negative |
VANC CEFOX/OX S I R N S 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 S-DD 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 |
CEFTAR S S-DD I R |
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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/CEFOT/CEFTRX 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/CTET S I R N |
CEFTAVI S R N |
CEFTOTAZ S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB† S I 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 |
IMIREL S I R N |
MERVAB 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/CTET S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
CEFTAVI 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 |
CEFTOTAZ S I R N |
IMIREL S I R N |
MERVAB S I R N |
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_______ |
____Klebsiella pneumonia
____Klebsiella oxytoca
___Klebsiella aerogenes
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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/CTET S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB† S I R N |
CEFTAVI 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 |
CEFTOTAZ S I R N |
IMIREL S I R N |
MERVAB S I R N |
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Pathogen # |
Gram-negative Organisms |
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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 |
CEFTAVI S R N |
TOBRA S I R N |
CEFTOTAZ 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 |
CEFTOTAZ = ceftolozane/tazobactam |
FLUCY = flucytosine |
OX = oxacillin |
AMP = ampicillin |
GENT = gentamicin |
PB = polymyxin B |
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AMPSUL = ampicillin/sulbactam |
CEFTRX = ceftriaxone |
GENTHL = gentamicin –high level test |
PIP = piperacillin |
AMXCLV = amoxicillin/clavulanic acid |
CEFUR= cefuroxime |
IMI = imipenem |
PIPTAZ = piperacillin/tazobactam |
ANID = anidulafungin |
CTET= cefotetan |
IMIREL= imipenem/relebactam |
RIF = rifampin |
AZT = aztreonam |
CIPRO = ciprofloxacin |
ITRA = itraconazole |
TETRA = tetracycline |
CASPO = caspofungin |
CLIND = clindamycin |
LEVO = levofloxacin |
TIG = tigecycline |
CEFAZ= cefazolin |
COL = colistin |
LNZ = linezolid |
TMZ = trimethoprim/sulfamethoxazole |
CEFEP = cefepime |
DAPTO = daptomycin |
MERO = meropenem |
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CEFOT = cefotaxime |
DORI = doripenem |
MERVAB= meropenem/vaborbactam |
TOBRA = tobramycin |
CEFOX= cefoxitin |
DOXY = doxycycline |
METH = methicillin |
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CEFTAR = Ceftaroline |
ERTA = ertapenem |
MICA = micafungin |
VANC = vancomycin |
CEFTAVI = ceftazidime/avibactam |
ERYTH = erythromycin |
MINO = minocycline |
VORI = voriconazole |
CEFTAZ = ceftazidime |
FLUCO = fluconazole |
MOXI = moxifloxacin |
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Comments |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.502 |
Author | Amy Schneider |
File Modified | 0000-00-00 |
File Created | 2023-11-20 |