Form CDC 57.115 CDC 57.115 Custom Event

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2022

www.cdc.gov/NHSN

Custom Event

Page 1 of 4					*Required for saving
Facility ID:					Event #:
*Patient ID:					Social Security #:
Secondary ID:					Medicare #:
Patient Name, Last: First: Middle:
*Gender: M F Other					*Date of Birth:
Sex at Birth: F M Unknown					Gender Identity (Specify):
Ethnicity (Specify):					Race (Specify):
Event Details
*Event Type:					*Date of Event:
Post Procedure Event: Yes No					Date of Procedure:
NHSN Procedure Code:					ICD-10-PCS or CPT Procedure Code:
MDRO/CDI Infection Surveillance: No					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				□ Culture or non-culture based testing not performed
□ Bradycardia	□ Hypothermia	□ Bilious aspirate				□ Organism(s) identified from blood specimen+
□ Cough	□ Lethargy	□ Erythema or redness				□ Other positive laboratory tests+
□ Vomiting	□ Nausea	□ Abdominal distension				□ > 15 colonies cultured from IV cannula tip using semiquantitative culture method
□ Pain or tenderness
□ Drainage or material+						□ Pneumatosis intestinalis by radiograph
□ Wheezing, rales or rhonchi						□ Portal venous gas (Hepatobiliary gas) by radiograph
□ Diarrhea+						□ Pneumoperitoneum by radiograph
□ Swelling or inflammation						□ Imaging test evidence of infection+
□ 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 criteria
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 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

Custom 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

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

Custom Event

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

Custom Event

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Custom Fields
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