57.126 MDRO or CDI Infection Event (with revised GISAB question

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2022

www.cdc.gov/nhsn

MDRO or CDI Infection Event

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*Required for saving Facility ID:						**Required for completion Event #:
*Patient ID:						Social Security #:
Secondary ID:						Medicare #:
Patient Name, Last: First: Middle:
*Gender: M F Other					*Date of Birth:							Sex at Birth: M F Unknown
Ethnicity (Specify):					Race (Specify):							Gender Identity (Specify):
Event Details
*Event Type: [For Event Type = BSI, PNEU, SSI, or UTI use the event specific from]												*Date of Event:
Post Procedure Event: Yes No												Date of Procedure:
MDRO/CDI Infection Surveillance: Yes			NHSN Procedure Code:									ICD-10-PCS or CPT Procedure Code:
*Specific Organism Type: (Select up to 3)							□ MRSA				□ MSSA			□ VRE	□ CephR-Klebsiella
□ CRE-E. coli		□ CRE-Enterobacter					□ CRE-Klebsiella						□ MDR-Acinetobacter		□ C. difficile
*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						□ Not cultured
□ Bradycardia	□ Hypothermia			□ Bilious aspirate						□ Organism(s) identified from blood specimen+
□ Cough	□ Lethargy			□ Erythema or redness						□ Other positive laboratory tests+
□ Vomiting	□ Nausea			□ Suprapubic tenderness						□ > 15 colonies cultured from IV cannula tip using semiquantitative culture method
□ Abdominal distension
□ Pain or tenderness										□ Pneumatosis intestinalis by radiograph
□ Drainage or material+										□ Portal venous gas (Hepatobiliary gas) by radiograph
□ Wheezing, rales or rhonchi										□ Pneumoperitoneum by radiograph
□ Diarrhea+										□ Imaging test evidence of infection+
□ Swelling or inflammation
□ 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 site criteria
Clostridioides difficile Infection
*Admitted to ICU for CDI complications: Yes No											*Surgery for CDI complications: Yes No
* 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 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 57.126 (Front) Rev 6 V. 8.6

MDRO or CDI Infection Event

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

____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

Pathogen #

Gram-Negative Organisms (continued)

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

MDRO or CDI Infection Event

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