Form CDC 57.120 CDC 57.120 Surgical Site Infection

Form Approved

OMB No.

Exp. Date:

www.cdc.gov/nhsn

Surgical Site Infection (SSI)

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*required for saving **required for completion
Facility ID:				Event #:
*Patient ID:				Social Security #:
Secondary ID:				Medicare #:
Patient Name, Last:				First:					Middle:
*Gender: F M Other				*Date of Birth:
Sex at Birth: F M Unknown				Gender Identity (Specify):
Ethnicity (Specify):				Race (Specify):
*Event Type: SSI				*Date of Event:
*NHSN Procedure Code:				ICD-10-PCS or CPT Procedure Code:
*Date of Procedure:				*Outpatient Procedure: Yes No
*MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module
*Date Admitted to Facility:						Location:
Event Details
*Specific Event:
□ Superficial Incisional Primary (SIP)							□ Deep Incisional Primary (DIP)
□ Superficial Incisional Secondary (SIS)							□ Deep Incisional Secondary (DIS)
□ Organ/Space (specify site): _______________________
*Infection present at the time of surgery (PATOS): □ Yes □ No
*Specify Criteria Used (check all that apply):
Signs & Symptoms							Laboratory
□ Drainage or material†		□ Sinus tract					□ Organism(s) identified
□ Pain or tenderness		□ Hypothermia					□ Culture or non-culture based testing not performed
□ Swelling or inflammation		□ Apnea					□ Organism(s) identified from blood specimen
□ Erythema or redness		□ Bradycardia					□ Organism(s) identified from ≥ 2 periprosthetic specimens
□ Heat		□ Lethargy
□ Fever		□ Cough					□ Other positive laboratory tests†
□ Incision deliberately opened/drained		□ Nausea					□ Imaging test evidence of infection
□ Wound spontaneously dehisces		□ Vomiting
□ Abscess		□ Dysuria					Clinical Diagnosis
□ Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam †							□ Physician diagnosis of this event type
							□ Physician institutes appropriate antimicrobial therapy†
□ Other signs & symptoms†
†per specific site criteria
*Detected:	□ A (During admission)		□ P (Post-discharge surveillance)
□ RF (Readmission to facility where procedure performed)
□ RO (Readmission to facility other than where procedure was performed)
*Secondary Bloodstream Infection: Yes No					**Died: Yes No			SSI Contributed to Death: Yes No
Discharge Date:					*Pathogens Identified: Yes No					*If Yes, specify on pages 2-3.
*COVID-19: Yes No
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 57.120 (Front) Rev 7, v8.6

Surgical Site Infection (SSI)

Pathogen #

Gram-positive Organisms

Staphylococcus coagulase-negative

(specify species if available):

CEFOX/OX S R N

VANC S I R N

____Enterococcus faecium

____Enterococcus faecalis

____Enterococcus spp. (Only those not identified to the species level)

DAPTO S I/S-DD NS R N

GENTHL§ S R N

LNZ S I R N

VANC S I R N

Staphylococcus aureus

CEFOX/METH/OX S R N	CEFTAR S S-DD I R N	CIPRO/LEVO/MOXI S I R N	CLIND S I R N	DAPTO S NS N	DOXY/MINO S I R N	GENT S I R N
LNZ S R N	RIF S I R N	TETRA S I R N	TMZ S I R N	VANC S I R N

Pathogen #

Gram-negative Organisms

Acinetobacter (specify species)

____________

AMK S I R N	AMPSUL 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 R N	DORI/MERO S I R N
DOXY/MINO S I R N	GENT S I R N	IMI S I R N	PIPTAZ S I R N	TMZ S I R N	TOBRA S I R N

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
CEFTAVI S R N	CEFTAZ S I R N	CEFTOTAZ S I R N	CIPRO/LEVO/MOXI S I R N	COL/PB† I R N	DORI/IMI/MERO S I R N	DOXY/MINO/TETRA S I R N
ERTA S I R N	GENT S I R N	IMIREL S I R N	MERVAB S I R N	PIPTAZ S I R N	TIG S I R N	TMZ S I R N
TOBRA S I R N

Enterobacter (specify species)

____________

AMK S I R N	AZT S I R N	CEFEP S I/S-DD R N	CEFOT/CEFTRX S I R N	CEFTAVI S R N	CEFTAZ S I R N	CEFTOTAZ S I R N
CIPRO/LEVO/MOXI S I R N	COL/PB† I R N	DORI/IMI/MERO S I R N	DOXY/MINO/TETRA S I R N	ERTA S I R N	GENT S I R N	IMIREL S I R N
MERVAB S I R N	PIPTAZ S I R N	TIG S I R N	TMZ S I R N	TOBRA S I R N

Pathogen #

Gram-negative Organisms (continued)

____Klebsiella pneumoniae

____Klebsiella oxytoca

____Klebsiella aerogenes

AMK 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	CEFTAVI S R N
CEFTAZ S I R N	CEFTOTAZ S I R N	CIPRO/LEVO/MOXI S I R N	COL/PB† I R N	DORI/IMI/MERO S I R N	DOXY/MINO/TETRA S I R N	ERTA S I R N
GENT S I R N	IMIREL S I R N	MERVAB S I R N	PIPTAZ S I R N	TIG S I R N	TMZ S I R N	TOBRA S I R N

Pseudomonas aeruginosa

AMK S I R N	AZT S I R N	CEFEP S I R N	CEFTAVI S R N	CEFTAZ S I R N	CEFTOTAZ S I R N	CIPRO/LEVO S I R N
COL/PB S I R N	DORI/IMI/MERO S I R N	GENT S I R N	PIPTAZ S I R N	TOBRA S I R N

Pathogen #

Fungal Organisms

Candida (specify species if available) ______________

ANID S I R N

CASPO S I R N

FLUCO S S-DD R N

MICA S I R N

VORI S I R N

Pathogen #

Other Organisms

Organism 1 (specify) _____________

Drug 1 S I R N

Drug2 S I R N

Drug3 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

Organism 1 (specify) _____________

Drug 1 S I R N

Drug2 S I R N

Drug3 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

Organism 1 (specify) _____________

Drug 1 S I R N

Drug2 S I R N

Drug3 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 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

Surgical Site Infection (SSI)

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