Form CDC 57.115 CDC 57.115 Custom Event

[NCEZID] The National Healthcare Safety Network (NHSN)

57.115_CUS_November_2022

57.115 Custom Event

OMB: 0920-0666

Document [docx]
Download: docx | pdf

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

Page 4 of 4

Custom Fields

Label

Label

_______________________

____/____/____

_______________________

____/____/_____

_______________________

_____________

_______________________

______________

_______________________

_____________

_______________________

______________

_______________________

______________

_______________________

______________

_______________________

______________

_______________________

______________

_______________________

______________

_______________________

______________

_______________________

______________

_______________________

______________


Comments

















































File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.115_CUS
SubjectNHSN OMB Forms 2020
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-08-04

© 2024 OMB.report | Privacy Policy