Form 57.136 Long-Term Care Facility Component – Respiratory Tract In

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/xxxx

www.cdc.gov/NHSN

Respiratory Tract Infection Event

Page 1 of 4					*Required for saving
*Facility ID:					Event #:
*Resident ID:		Secondary ID:					Medicare #:
Resident Name, Last: First: Middle:
*Gender: M F Other					*Date of Birth:
Ethnicity (Specify):					Race (Specify):
*Date of First Admission to Facility					*Date of Current Admission to Facility
Event Details
*Event Type: RTI					*Date of Event:
*Resident Care Location
*Primary Resident Service Type (check one) □ Long-term general nursing □ Long-term dementia □ Skilled nursing/Short-term rehab □ Ventilator □ Long-term psychiatric □ Bariatric □ Hospice/Palliative
*Ventilator: YES NO Date of Device Insertion: Location of Device Insertion:
*Imaging: Was a Chest X-Ray Performed: □ YES □ NO
Findings: □ New infiltrate □ New Consolidation □ Other findings consistent with pneumonia □ Negative
*Specify Criteria Used (check all that apply)
Constitutional Signs and Symptoms:
Fever: which of the following were documented □ Single temperature > 37.8o C (>100o F) □ Repeated temperatures >37.2o C (99o F) □ Single temperature >1.1o C (2o F) over baseline □ Term “fever” documented without value				Any acute change in mental status from baseline □ Fluctuating: behavior fluctuating □ Inattention: difficulty focusing attention □ Confusion/disorganized thinking □ Altered consciousness
Acute functional decline: increase in assistance with activities of daily living (ADL) from baseline: □ Bed mobility □ Dressing □ Eating □ Toilet Use □ Transfer □ Personal hygiene □ Locomotion within the facility
Leukocytosis: documentation of at least one of the following □ Neutrophilia >10,000 leukocytes per/ml3 (enter value) ____________ □ Left shift (6% bands or ≥ 1,500 bands/mm3)
Respiratory Signs and Symptoms:
Decreased oxygenation: documentation of at least one of the following □ Pulse oximetry with single O2 saturation < 94% □ Pulse oximetry with single O2 saturation with reduction of >3% □ Resident newly placed on oxygen
□ Respiratory rate >24 breaths per minute □ New onset hypotension □ Pulse >100 □ Rigors or chills □ Malaise □ New onset hypothermia □ Myalgia or body aches □ Loss of appetite or decreased oral intake
□ New or increased cough □ New or increase sputum production □ Pleuritic chest pain □ Runny nose or sneezing □ Abnormal lung exam (new or changed) □ Stuffy nose □ Sore throat, difficulty swallowing, hoarseness □ Headache or eye pain □ Swollen or tender glands in the neck □ No documented respiratory signs or symptoms
Laboratory/Diagnostic
□ Positive flu PCR □ Positive legionella urinary antigen testing □ Positive S. pneumonia urinary antigen □ Positive sputum culture
*Specific Event Type (check one): □ PNA 1 □ PNA 2 □ PNA 3 □ LRI 1 □ LRI 2
	*Secondary Bloodstream Infection: Yes No
	Died: Yes No					Event contributed to death? Yes No
	*Transferred to acute care facility within 7 days: Yes No		*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 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 57.115 (Front) Rev 6 V. 8.6

Respiratory Tract Infection Event 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

Respiratory Tract Infection Event 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

Respiratory Tract Infection Event

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