Form 57.602 Long-Term Care Facility Component – Respiratory Tract In

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Late Onset Sepsis/ Meningitis Event Form: Data Table for

Monthly Electronic Upload

These data will be collected in an aggregate monthly electronic file transfer from the facility to NHSN via Clinical Document Architecture (CDA).

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Table 1. CDA File Descriptors

These data elements will be transmitted with each month’s report.

Variable Name

Description of Variable

orgid

NHSN Facility ID number

eventID

Event number

patID

Patient ID

ssn

Social security number

surname

Last name

gname

First name

mname

Middle

gender

Gender

dob

Date of birth

ethnicity

Ethnicity

race

Race

language

Preferred Language

interpreter

Interpreter Needed

eventtype

Event type

eventdate

Date of event

admitdate

Date Admitted to Facility

whereBorn

Inborn / Outborn

location

Event location

centralLine

Central line present prior to event, including umbilical catheter

birthWeight

Birth weight

gesAge

Gestational age

spcevent

Event: NLCBI 1 NLCBI 2 NLCM 1 NLCM 2

eventCriteria

Recognized pathogen from one or more blood specimens

eventCriteria

Common commensal from blood specimen(s) and antibiotics for greater than or equal to 5 days

eventCriteria

Recognized pathogen from cerebrospinal fluid specimen

eventCriteria

Common commensal from cerebrospinal fluid specimen and antibiotics for greater than or equal to 5 days

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 6 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 H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666).

Table 2. List of Antimicrobial used for susceptibility Testing

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	-

Table 3. Antimicrobial Susceptibility Details

These data elements will be transmitted with each month’s report.

Variable Name

Description of Variable

Examples

antibiotic	Antibiotic used for susceptibility test	-
PBP2a-agglutination	PBP2a-agglutination	-
PCRmec-gene	PCR mec-gene	-
EtestSign	Etest sign	>, <, =
EtestValue	Etest value	-
EtestInterp	Interpretation of Etest	-
MICsign	MIC sign	-
MICinterp	Interpretation of the MIC test	-
MICvalue	MIC value	-
ZoneSign	Zone sign	-
ZoneInterp	Interpretation of zone test	-
ZoneValue	Zone value	-
FinIntrep	Final interpretation result	-

Table 4. Patient Location and Disposition

died

Died

contribdeathy

LOS contributed to death

dischargeDate

Discharge date

createUserID

The user that created the record

version

Version number of the software under which the data was collected

modifyDate

Date the record was last updated

modifyUserID

The user that last modified record

modifyVersion

Version number of the software under which the data was last updated

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