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Fillable Printable 57.108 Primarybsi Blank

Fillable Printable 57.108 Primarybsi Blank

57.108 Primarybsi Blank

57.108 Primarybsi Blank

Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
Primary Bloodstream Infection (BSI)
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:
Ethnicity (Specify): Race (Specify):
*Event Type: BSI *Date of Event:
Post-procedure BSI: Yes No Date of Procedure:
NHSN Procedure Cod e: ICD-10-PCS or CPT Procedure Code:
*MDRO Infection S urveillance:
Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/ CDI Module
No, this infection’s pat hogen & location are not in-plan for I nfection Surveillan ce in the MDRO/CDI Mod ule
*Date Admitted to Facili t y: *Location:
Risk Factors
*If ICU/Other locati ons, Central line: Yes No
*If Specialty Care Area/Oncology, Any hemodialysis catheter present: Yes No
Permanent central li ne: Yes No
Temporary central li ne: Yes No Location of Device I nsertion: ________ _______________
*If NICU,
Central line, including umbilical catheter: Yes No Date of Device Insert ion: ___ /___ /________
Birth weight (grams):
Event Details
*Specific Event: Laboratory-confirmed
*Specify Criteria U sed:
Signs & Symptoms (check all that apply) Underlying condit i ons for MBI-LCBI (c heck all that apply):
Any Patient ≤ 1 year old
Allo-SCT with Grade ≥ 3 GI GVHD
Fever Fever
Allo-SCT with diarrhea
Chills Hypothermia
Neutropenia (WBC or ANC < 50 0 cells mm
3
)
Hypotension Apnea
Bradycardia
Laboratory
(check one)
Recognized pathogen(s) identified from one or more blood
specimens
Common commensal identified from ≥ 2 blood specimens
**Died: Yes No BSI Contributed t o Deat h: Yes No
Discharge Date: *Pathogens Ident ified: Yes No
*If Yes, speci fy 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 57.108 (Front) Rev. 11 v8.6
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
CDC 57.108 (Back) Rev 11 v8.6
Primary Bloodstream Infection (BSI)
Page 2 of 4
Pathogen
#
Gram-positive Organisms
_______
Staphylococcus coagulase-negative
VANC
S I R N
(specify species if available):
____________
_______
____Enterococ cus faecium
____Enterococ cus faecalis
____Enterococcus spp.
(Only those not identified to the
species level)
DAPTO
S NS N
GENTHL
§
S R N
LNZ
S I R N
VANC
S I R N
_______
Staphylococcus
aureus
CIPRO/LEVO/MOXI
S I R N
CLIND
S I R N
DAPTO
S NS N
DOXY/MINO
S I R N
ERYTH
S I R N
GENT
S I R N
LNZ
S R N
OX/CEFOX/METH
S I R N
RIF
S I R N
TETRA
S I R N
TIG
S NS 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
AZT
S I R N
CEFEP
S I R N
CEFTAZ
S I R N
CIPRO/LEVO
S I R N
COL/PB
S I R N
GENT
S I R N
IMI
S I R N
MERO/DORI
S I R N
PIP/PIPTAZ
S I R N
TETRA/DOXY/MINO
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
CEFTAZ
S I R N
CEFUR
S I R N
CEFOX/CETET
S I R N
CIPRO/LEVO/MOXI
S I R N
COL/PB
S R N
ERTA
S I R N
GENT
S I R N
IMI
S I R N
MERO/DORI
S I R N
PIPTAZ
S I R N
TETRA/DOXY/MINO
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
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
CEFTAZ
S I R N
CEFUR
S I R N
CEFOX/CETET
S I R N
CIPRO/LEVO/MOXI
S I R N
COL/PB
S R N
ERTA
S I R N
GENT
S I R N
IMI
S I R N
MERO/DORI
S I R N
PIPTAZ
S I R N
TETRA/DOXY/MINO
S I R N
TIG
S I R N
TMZ
S I R N
TOBRA
S I R N
_______
____Klebsiella
pneumonia
____Klebsiella
oxytoca
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
CEFTAZ
S I R N
CEFUR
S I R N
CEFOX/CETET
S I R N
CIPRO/LEVO/MOXI
S I R N
COL/PB
S R N
ERTA
S I R N
GENT
S I R N
IMI
S I R N
MERO/DORI
S I R N
PIPTAZ
S I R N
TETRA/DOXY/MINO
S I R N
TIG
S I R N
TMZ
S I R N
TOBRA
S I R N
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
CDC 57.108 (Back) Rev 11 v8.6
Primary Bloodstream Infection (BSI)
Page 3 of 4
Pathogen
#
Gram-negative Organisms (continued)
_______
Pseudomonas
aeruginosa
AMK
S I R N
AZT
S I R N
CEFEP
S I R N
CEFTAZ
S I R N
CIPRO/LEVO
S I R N
COL/PB
S I R N
GENT
S I R N
IMI
S I R N
MERO/DORI
S I R N
PIP/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 NS N
FLUCO
S S-DD R N
FLUCY
S I R N
ITRA
S S-DD R N
MICA
S NS N
VORI
S S-DD 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 Cod es
S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependen t N = Not tested
§
GENTHL results: S = Susceptible/Synerg istic and R = Resist ant/Not Synergi stic
Clinical breakpoints have not been set by FDA or CLSI, Sensitive and Resistant designations should be based upon
epidemiological cutoffs of Sensitive MIC ≤ 2 and Resistant MIC ≥ 4
Drug Codes:
AMK = amikacin CEFTRX = ceftriaxone FLUCY = flucytosine OX = oxacillin
AMP = ampicillin CEFUR= cefuroxime GENT = gentamicin PB = polymyxin B
AMPSUL = ampicillin/sulbactam CETET= cefotetan
GENTHL = gentamicin –high level
test
PIP = piperacillin
AMXCLV = amoxicillin/clavulanic acid CIPRO = ciprofloxacin IMI = imipenem PIPTAZ = piperacillin/tazobactam
ANID = anidulafungin CLIND = clindamycin ITRA = itraconazole RIF = rifampin
AZT = aztreonam COL = colistin LEVO = levofloxacin TETRA = tetracycline
CASPO = caspofungin DAPTO = daptomycin LNZ = linezolid TIG = tigecycline
CEFAZ= cefazolin DORI = doripenem MERO = meropenem
TMZ =
trimethoprim/sulfamethoxazole
CEFEP = cefepime DOXY = doxycycline METH = methicillin TOBRA = tobramycin
CEFOT = cefotaxime ERTA = ertapenem MICA = micafungin VANC = vancomycin
CEFOX= cefoxitin ERYTH = erythromycin MINO = minocycline VORI = voriconazole
CEFTAZ = ceftazidime FLUCO = fluconazole MOXI = moxifloxacin
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
CDC 57.108 (Back) Rev 11 v8.6
Primary Bloodstream Infection (BSI)
Page 4 of 4
Custom Fields
Label Label
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_________________________ ______________ _______________________ ______________
_________________________ ______________ _______________________ ______________
_________________________ ______________ _______________________ ______________
_________________________ ______________ _______________________ ______________
_________________________ ______________ _______________________ ______________
_________________________ ______________ _______________________ ______________
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