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57.108

ICR 202402-0920-011 · OMB 0920-0666 · Object 140109701.
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Record metadata
File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	57.108
Subject	NHSN OMB Forms 2020
Keywords	NHSN, Primary, BSI
Author	CDC/NCEZID/DHQP
Last Modified By	Writer
File Modified	2022-11-02
File Created	2026-07-22
Conversion State	complete
Extracted Text

Primary Bloodstream Infection (BSI)
Page 1 of 5  
*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: BSI
*Date of Event:
Post-procedure BSI:     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:
Risk Factors
*If ICU/Other locations, Central line:    Yes    No
Check all that apply:
Yes□ No□  *Any hemodialysis catheter present 
*If Specialty Care Area/Oncology,
Yes□ No□  *Extracorporeal life support present (ECLS or ECMO) 
Permanent central line:             Yes    No
Temporary central line:             Yes    No
Yes□ No□  *Ventricular-assist device (VAD) present 
 *If NICU, Central line, including umbilical catheter                                                                Yes    No

Birth weight (grams)

Yes□ No□  *Known or suspected Munchausen Syndrome by Proxy                       during current admission  
Yes□ No□ *Observed or suspected patient injection into vascular                       line(s) within the BSI infection window period 
Yes□ No□  *Epidermolysis bullosa during current admission 
Yes□ No□  *Matching organism is identified in blood and from a                       site-specific specimen, both collected within the                       infection window period and pus is present at one of                       the following vascular sites from which the specimen                       was collected:  
    □ Arterial catheter  
    □ Arteriovenous fistula  
    □ Arteriovenous graft 
    □ Atrial lines (Right and Left) 
   □ Hemodialysis reliable outflow (HERO)             catheter 
   □ Intra-aortic balloon pump (IABP) device    
                                        □ Non-accessed central line (not accessed      inserted during the admission)  
                                         □ Peripheral IV or Midline catheter      
Location of Device Insertion: _____________________ 
 Date of Device Insertion: ___ /___ /________



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 57.108 (Front) Rev. 11 v9.4



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
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 are based on CLSI M100-ED30:2020, Intermediate MIC ≤ 2 and Resistant MIC ≥ 4

Primary Bloodstream Infection (BSI)
Page 5 of 5
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