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

[NCEZID] The National Healthcare Safety Network (NHSN)

57.136_RTI_LTCF_BLANK

57.136 Long Term Care Facility Component - Respiratory Tract Infection

OMB: 0920-0666

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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

Page 4 of 4

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.115_CUS
SubjectNHSN OMB Forms
AuthorCDC/NCEZID/DHQP
File Modified0000-00-00
File Created2024-07-24

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