Form CDC 57.120 CDC 57.120 Surgical Site Infection

[NCEZID] The National Healthcare Safety Network (NHSN)

57.120_SSI_BLANK_November_2022

57.120 Surgical Site Infection (SSI)

OMB: 0920-0666

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Form Approved

OMB No.

Exp. Date:

www.cdc.gov/nhsn

Surgical Site Infection (SSI)

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: SSI

*Date of Event:

*NHSN Procedure Code:

ICD-10-PCS or CPT Procedure Code:

*Date of Procedure:

*Outpatient Procedure: Yes No

*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:

Event Details

*Specific Event:

Superficial Incisional Primary (SIP)

Deep Incisional Primary (DIP)

Superficial Incisional Secondary (SIS)

Deep Incisional Secondary (DIS)

Organ/Space (specify site): _______________________


*Infection present at the time of surgery (PATOS): Yes No

*Specify Criteria Used (check all that apply):


Signs & Symptoms

Laboratory

Drainage or material

Sinus tract

Organism(s) identified

Pain or tenderness

Hypothermia

Culture or non-culture based testing not performed

Swelling or inflammation

Apnea

Organism(s) identified from blood specimen

Erythema or redness

Bradycardia

Organism(s) identified from ≥ 2 periprosthetic specimens

Heat

Lethargy

Fever

Cough

Other positive laboratory tests

Incision deliberately opened/drained

Nausea

Imaging test evidence of infection

Wound spontaneously dehisces

Vomiting


Abscess

Dysuria

Clinical Diagnosis

Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam

Physician diagnosis of this event type

Physician institutes appropriate antimicrobial therapy

Other signs & symptoms




per specific site criteria


*Detected:

A (During admission)

P (Post-discharge surveillance)

RF (Readmission to facility where procedure performed)

RO (Readmission to facility other than where procedure was performed)

*Secondary Bloodstream Infection: Yes No

**Died: Yes No

SSI Contributed to Death: Yes No

Discharge Date:

*Pathogens Identified: Yes No

*If Yes, specify on pages 2-3.

*COVID-19: Yes No

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 57.120 (Front) Rev 7, v8.6

Surgical Site Infection (SSI)


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


Surgical Site Infection (SSI)


Page 4 of 4

Custom Fields

Label

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.120_SSI
SubjectNHSN OMB Forms 2020
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-09-05

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