57.108 BSI with GISAB edits in tracked changes

57.108_PrimaryBSI_November_2022.docx

[NCEZID] The National Healthcare Safety Network (NHSN)

57.108 BSI with GISAB edits in tracked changes

OMB: 0920-0666

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Form Approved

OMB No.

Exp. Date:

www.cdc.gov/nhsn


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:

YesNo *Any hemodialysis catheter present

*If Specialty Care Area/Oncology,

YesNo *Extracorporeal life support present (ECLS or ECMO)

Permanent central line: Yes No

Temporary central line: Yes No

YesNo *Ventricular-assist device (VAD) present

*If NICU, Central line, including umbilical catheter Yes No


Birth weight (grams)


YesNo *Known or suspected Munchausen Syndrome by Proxy during current admission

YesNo*Observed or suspected patient injection into vascular line(s) within the BSI infection window period

YesNo *Epidermolysis bullosa during current admission

YesNo *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



Page 2 of 5

Event Details

*Specific Event: Laboratory-confirmed

*Specify Criteria Used:

Signs & Symptoms (check all that apply)

Any Patient

1 year old

Underlying conditions for MBI-LCBI (check all that apply):

Fever

Fever

Allo-SCT with Grade ≥ 3 GI GVHD

Chills

Hypothermia

Allo-SCT with diarrhea

Hypotension

Apnea

Neutropenia (WBC or ANC < 500 cells mm3)


Bradycardia



Laboratory (check one)

Recognized pathogen from one or more blood specimens

Common commensal from ≥ 2 blood specimens

**Died: Yes No

BSI Contributed to Death: Yes No

Discharge Date:

*Pathogens Identified: Yes No

*If Yes, specify on pages 2-3.

*COVID-19: Yes No


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

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




Primary Bloodstream Infection (BSI)

Page 5 of 5

Custom Fields

Label

Label

_________________________

____/____/_____

_______________________

____/____/_____

_________________________

______________

_______________________

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_________________________

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_______________________

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_________________________

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_______________________

______________

_________________________

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_______________________

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_______________________

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CDC 57.108 (Back) Rev 11, v9.4

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.108
SubjectNHSN OMB Forms 2020
AuthorCDC/NCEZID/DHQP
File Modified0000-00-00
File Created2024-09-15

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