Form 57.111 Pneumonia (PNEU)

Form Approved

OMB No.

Exp. Date:

www.cdc.gov/nhsn

Pneumonia (PNEU)

Page 1 of 4

*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: PNEU

*Date of Event:

Post-procedure PNEU: 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

*Ventilator: Yes No

Location of Device Insertion: ______________

Date of Device Insertion: __ /__ /_____

For NICU only: Birth weight: _________grams

Event Details

*Specific Event:

□ PNU1

□ PNU2

□ PNU3

*Immunocompromised: Yes No

*Specific Criteria Used: (check all that apply)

Imaging Test Results

□ New or progressive and persistent infiltrate

□ Consolidation

□ Cavitation

□ Pneumatoceles (in ≤1 y.o.)

Signs & Symptoms

Laboratory

□ Fever

□ Organism(s) identified from blood specimen

□ Leukopenia or leukocytosis

□ Organism(s) identified from pleural fluid

□ Altered mental status (in ≥70 y.o.)

□ Positive quantitative culture from LRT specimen

□ New onset/change in sputum

□ ≥5% BAL cells w/ bacteria

□ New onset/worsening cough, dyspnea, tachypnea

□ Positive quantitative culture of lung tissue

□ Rales or bronchial breath sounds†

□ Histopathologic exam w/ abscess formation or lung parenchyma invasion by fungal hyphae

□ Worsening gas exchange

□ Hemoptysis

□ Virus, Bordetella, Legionella, Mycoplasma or Chlamydia identified from respiratory secretions or tissue

□ Pleuritic chest pain

□ Temperature instability

□ 4-fold rise in paired sera for pathogen

□ Apnea, tachypnea, nasal flaring with retraction of chest wall or grunting

□ 4-fold rise in L pneumophila antibody titer

□ L pneumophila serogroup 1 antigens in urine

□ Hypothermia

□ Matching Candida spp. identified from blood & sputum, endotracheal aspirate, BAL or protected specimen brushing

□ Wheezing, rales, or rhonchi†

□ Cough

□ Fungi from LRT specimen

□ Bradycardia or tachycardia

† There are two criteria referring to rales in the PNU 1 signs and symptoms list. Please choose the one that corresponds to the specific algorithm used to identify this pneumonia (Any Patient or Alternate Criteria based on age).

*Secondary Bloodstream Infection: Yes No

*COVID-19: Yes No

**Died: Yes No

PNEU Contributed to Death: Yes No

Discharge Date:

*Pathogens Identified: Yes No *If Yes, specify on pages 2-3

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 57.111 (Front)

Pneumonia (PNEU)

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

Drug2 S I R N

Drug3 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

Drug2 S I R N

Drug3 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

Drug2 S I R N

Drug3 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

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

Pneumonia (PNEU)

Page 4 of 4
Custom Fields
Label		Label
______________________	____/____/____	_______________________	____/____/_____
_______________________	_____________	_______________________	______________
_______________________	_____________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
Comments