Form 57.129 Adult Sepsis_

[NCEZID] The National Healthcare Safety Network (NHSN)

57.129_Adult Sepsis_BLANK

57.129_Adult Sepsis_BLANK

OMB: 0920-0666

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Download: docx | pdf

Form Approved

OMB No. 0920-xxxx

Exp. Date: XX/XX/20XX

www.cdc.gov/nhsn

Adult Sepsis

Page 1 of 4

*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:

Ethnicity (Specify):

Race (Specify):

*Event Type: Adult Sepsis

*Date of Event:

Post-procedure: Yes No

Date of Procedure:

NHSN Procedure Code:

ICD-10-PCS or CPT Procedure Code:

*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

Must meet both Part A and B

*Part A: Suspected Infection

Organism identified by culture or non-culture laboratory diagnostic test

AND

□ ≥ 4 Qualifying Antimicrobial Days starting within ± 2 calendar days of the collection date for the organism identification culture or non-culture laboratory diagnostic test

AND

*Part B: Organ Dysfunction

(Any one of the following within ± 2 calendar days of date when organism identification test was collected – check all that apply)

Initiation of a new vasopressor

Acute renal failure

Initiation of invasive mechanical ventilation

Hyperbilirubinemia

Serum lactate ≥ 2 mg/dL

Thrombocytopenia


**If discharged from facility, physical location of patient after leaving facility (Check one):

Nursing home/skilled nursing facility *if yes, see following question

Personal residence/Residential care *if yes, see following question

Other short term general hospital for inpatient care

Long term acute care hospital

Hospice inpatient medical facility

Other facility not specified above

Unknown


**If discharged from the facility to either nursing home/skilled nursing facility or personal residence/residential care, were hospice services arranged for the post-discharge period?

Yes

No

**Died: Yes No

Sepsis Contributed to Death: Yes No

Discharge Date:________________

*Pathogens Identified: Yes* No *If Yes, specify on pages 2-3

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 25 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 57.129 (Front), Rev 0


Adult Sepsis

Page 2 of 4

Pathogen #

Gram-positive Organisms


_______


Staphylococcus coagulase-negative


VANC

S I R N

(specify species if available):

____________


_______


____Enterococcus faecium


____Enterococcus faecalis

____Enterococcus spp.

(Only those not identified to the species level)


DAPTO

S NS N


GENTHL§

S R N


LNZ

S I R N


VANC

S I R N




_______


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


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


Pathogen #

Gram-negative Organisms


_______


Acinetobacter

(specify species)

____________


AMK

S I R N


AMPSUL

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


IMI

S I R N



MERO/DORI

S I R N


PIP/PIPTAZ

S I R N


TETRA/DOXY/MINO

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


CEFTAZ

S I R N


CEFUR

S I R N


CEFOX/CETET

S I R N


CIPRO/LEVO/MOXI

S I R N


COL/PB

S R N


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


TIG

S I R N


TMZ

S I R N


TOBRA

S I R N



_______


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


CEFTAZ

S I R N


CEFUR

S I R N


CEFOX/CETET

S I R N


CIPRO/LEVO/MOXI

S I R N


COL/PB

S R N


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


TIG

S I R N


TMZ

S I R N


TOBRA

S I R N



_______


____Klebsiella

pneumonia


____Klebsiella

oxytoca



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


CEFTAZ

S I R N


CEFUR

S I R N


CEFOX/CETET

S I R N


CIPRO/LEVO/MOXI

S I R N


COL/PB

S R N


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


TIG

S I R N


TMZ

S I R N


TOBRA

S I R N


Adult Sepsis

Page 3 of 4

Pathogen #

Gram-negative Organisms (continued)


_______


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




IMI

S I R N



MERO/DORI

S I R N


PIP/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 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

Pathogen #

Other Organisms

_______

Organism 1 (specify)

____________


_______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

_______

Organism 1 (specify)

____________


_______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

_______

Organism 1 (specify)

____________


_______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:




AMK = amikacin

CEFTRX = ceftriaxone

FLUCY = flucytosine

OX = oxacillin

AMP = ampicillin

CEFUR= cefuroxime

GENT = gentamicin

PB = polymyxin B

AMPSUL = ampicillin/sulbactam

CETET= cefotetan

GENTHL = gentamicin –high level test

PIP = piperacillin

AMXCLV = amoxicillin/clavulanic acid

CIPRO = ciprofloxacin

IMI = imipenem

PIPTAZ = piperacillin/tazobactam

ANID = anidulafungin

CLIND = clindamycin

ITRA = itraconazole

RIF = rifampin

AZT = aztreonam

COL = colistin

LEVO = levofloxacin

TETRA = tetracycline

CASPO = caspofungin

DAPTO = daptomycin

LNZ = linezolid

TIG = tigecycline

CEFAZ= cefazolin

DORI = doripenem

MERO = meropenem

TMZ = trimethoprim/sulfamethoxazole

CEFEP = cefepime

DOXY = doxycycline

METH = methicillin

TOBRA = tobramycin

CEFOT = cefotaxime

ERTA = ertapenem

MICA = micafungin

VANC = vancomycin

CEFOX= cefoxitin

ERYTH = erythromycin

MINO = minocycline

VORI = voriconazole

CEFTAZ = ceftazidime

FLUCO = fluconazole

MOXI = moxifloxacin


Adult Sepsis

Page 4 of 4

Custom Fields

Label

Label

______________________

____/____/____

_______________________

____/____/_____

_______________________

_____________

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______________

_______________________

_____________

_______________________

______________

_________________________

______________

_______________________

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_________________________

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_______________________

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_________________________

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_______________________

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_________________________

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_______________________

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