# Presentation: 610416

## MDRO or CDAD Infection Event 

| * required for saving
 Facility ID: |  | ** required for completion                          
 Event #: |  |  |  |
| --- | --- | --- | --- | --- | --- |
| *Patient ID: |  | Social Security #: |  |  |  |
| Secondary ID: |  |  |  |  |  |
| Patient Name, Last:                              First:                                   Middle: |  |  |  |  |  |
| *Gender:  M     F |  |  |  |  | *Date of Birth: |
| Ethnicity (Specify): |  |  |  |  | Race (Specify): |
| Event Details |  |  |  |  |  |
| *Event Type:
[For Event Type = BSI, PNEU, SSI, or UTI use the event specific form] |  |  |  |  | *Date of Event: |
| Post Procedure Event:   Yes     No |  |  |  |  | Date of Procedure: |
| MDRO/CDAD Infection:  Yes   No | NHSN Procedure Code:  |  |  |  | ICD-9-CM Procedure Code: |
| *Specific Organism Type: (Select up to 3)  MRSA      MSSA       VRE       MDR-Klebsiella       MDR-Acinetobacter      C. difficile |  |  |  |  |  |
| *Date Admitted to Facility:      |  |  | *Location |  |  |
| *Specific Event Type (only used for CDC defined events):  |  |  |  |  |  |
| Specify Criteria Used (check all that apply)
                     Signs & Symptoms                                  
  Abscess
  Apnea
  Vomiting 
  Bradycardia
  Redness
  Cough
  Dysuria
  Fever
  Acute onset of diarrhea (liquid stools for > 12 hours)
  Purulent drainage or material 
  Pain or tenderness
  New onset/change in sputum, increased secretions
     or increased suctioning
  Localized swelling
  Persistent microscopic or gross blood in stools
  Wheezing, rales or rhonchi
  Other evidence of infection found on direct exam,
     during surgery or by diagnostic testing+
  Other signs and symptoms +  |  |  |  | 
Laboratory or Diagnostic Testing
□ Positive culture
□ Not cultured
□ Positive blood culture
□ Blood culture not done or no organisms detected
     in blood
  Positive Gram stain when culture is negative or
     not done   
  >15 colonies cultured from IV cannula tip using 
    semiquantitative culture method
  Positive culture of pathogen
  Positive culture of skin contaminant
  Other positive laboratory tests
  Radiographic evidence of infection

Clinical Diagnosis
  Physician diagnosis of this event type+

  Physician institutes appropriate antimicrobial
     therapy+
+ Per specific event criteria |  |
| Clostridium difficile-Associated Disease |  |  |  |  |  |
| *Admitted to ICU for CDAD complications: Yes     No |  |  |  | *Surgery for CDAD complications:   Yes     No |  |
| *Secondary Bloodstream Infection:   Yes     No |  |  |  |  |  |
| **Died:    Yes     No  |  |  |  | Event contributed to death?     Yes     No |  |
| Discharge Date: ____/____/________ |  |  |  | *Pathogens Identified:      Yes     No
    If Yes, specify on page 2 |  |
| Assurance of Confidentiality:  The 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 57.126 (Front)  |  |  |  |  |  |

**MDRO or CDAD Infection Event **

- Page 1 of 3

- OMB No. 0920-0666
- Exp. Date:  03-31-2011

-   Heat
-   Hypotension
-   Hypothermia
-   Lethargy
-   Nausea
-   Suprapubic tenderness

## MDRO or CDAD Infection Event 

| Drug Codes: |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
| AMK = amikacin
AMP = ampicillin
AMPSUL=ampicillin/sulbactamCEFEP = cefepime | CEFOT = cefotaxime
CEFTAZ = ceftazidime
CEFTRX = ceftriaxone CIPRO = ciprofloxacin
CLIND = clindamycin | DAPTO=daptomycin ERYTH=erythromycin
GENT=gentamicin
IMI = imipenem
LEVO = levofloxacin | LNZ = linezolid MERO = meropenem
OX = oxacillin
PENG =  penicillin G
PIP = piperacillin
 | PIPTAZ =  piperacillin/tazobactam
QUIDAL= quinupristin/dalfopristin
RIF = rifampin
TMZ =trimethoprim/sulfamethoxazole
TOBRA = tobramycin
VANC = vancomycin |  |
| Result Codes: |  |  |  |  |  |
| S = Susceptible | I = Intermediate | R = Resistant | N = not tested |  |  |

| Pathogen # | Gram-positive Organisms |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
|   _____ | Coagulase-negativestaphylococci |  |  | VANC
S I R N |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
|   _____ | Enterococcusfaecalis |  |  | AMP
S I R N |  |  |  |  | DAPTO
S I R N |  |  |  |  |  | LNZ
S I R N |  |  |  | PENG
S I R N |  |  | VANC
S I R N |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
|   _____ | Enterococcusfaecium |  |  | AMP
S I R N |  |  |  |  | DAPTO
S I R N |  |  |  |  |  | LNZ
S I R N |  |  |  | PENG
S I R N |  |  | QUIDAL
S I R N |  |  |  |  |  |  | VANC
S I R N |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
|   _____ | Staphylococcusaureus |  |  | CLIND
S I R N |  |  |  |  | DAPTO
S I R N |  |  | ERYTH
S I R N |  |  |  |  | GENT
S I R N |  |  | LNZ
S I R N |  | OX
S I R N |  |  |  | QUIDAL
S I R N |  |  |  |  |  | RIF   
S I R N |  |  |  |  |  |  | TMZ
S I R N |  |  |  | VANC
S I R N |
| Pathogen # | Gram-negative Organisms |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
|   _____ | Acinetobacter spp. (specify)
__________ | AMK
S I R N |  |  | AMPSUL
 S I R N |  |  |  |  | CEFEP
S I R N |  |  | CEFTAZ
S I R N |  |  |  |  | CIPRO  GENT
S I R N  S I R N |  |  |  |  | IMI
S I R N |  |  |  | LEVO
S I R N |  |  |  | MERO
S I R N |  |  |  |  |  |  | PIPTAZ TOBRA  
S I R N  S I R N |  |  |  |  |  |
|   _____ | Escherichia 
coli | AMK
S I R N |  |  |  |  | CEFEP
S I R N |  |  |  | CEFOT
S I R N |  |  |  |  | CEFTAZ
S I R N |  |  |  | CEFTRX
S I R N |  |  |  | CIPRO
S I R N |  |  |  |  | IMI
S I R N |  |  |  |  | LEVO
S I R N |  |  |  |  |  |  | MERO
S I R N |  |  |
|   _____ | Enterobacterspp. (specify)
__________ | AMK
S I R N |  |  |  |  | CEFEP
S I R N |  |  |  | CEFOT
S I R N |  |  |  |  | CEFTAZ
S I R N |  |  |  | CEFTRX
S I R N |  |  |  | CIPRO
S I R N |  |  |  |  | IMI
S I R N |  |  |  |  | LEVO
S I R N |  |  |  |  |  |  | MERO
S I R N |  |  |
|   _____ | Klebsiella
oxytoca | AMK
S I R N |  |  |  |  | CEFEP
S I R N |  |  |  | CEFOT
S I R N |  |  |  |  | CEFTAZ
S I R N |  |  |  | CEFTRX
S I R N |  |  |  | CIPRO
S I R N |  |  |  |  | IMI
S I R N |  |  |  |  | LEVO
S I R N |  |  |  |  |  |  | MERO
S I R N |  |  |
|   _____ | Klebsiella pneumoniae | AMK
S I R N |  |  |  |  | CEFEP
S I R N |  |  |  | CEFOT
S I R N |  |  |  |  | CEFTAZ
S I R N |  |  |  | CEFTRX
S I R N |  |  |  | CIPRO
S I R N |  |  |  |  | IMI
S I R N |  |  |  |  | LEVO
S I R N |  |  |  |  |  |  | MERO
S I R N |  |  |
|   _____ | Serratia marcescens | AMK
S I R N |  |  |  |  | CEFEP
S I R N |  |  |  | CEFOT
S I R N |  |  |  |  | CEFTAZ
S I R N |  |  |  | CEFTRX
S I R N |  |  |  | CIPRO
S I R N |  |  |  |  | IMI
S I R N |  |  |  |  | LEVO
S I R N |  |  |  |  |  |  | MERO
S I R N |  |  |
|   _____ | Pseudomonas aeruginosa | AMK
S I R N |  |  |  |  | CEFEP
S I R N |  |  |  |  |  |  |  |  | CEFTAZ
S I R N |  |  |  | CIPRO
S I R N |  |  | IMI
S I R N |  |  |  |  | LEVO
S I R N |  |  |  |  |  | MERO
S I R N |  |  |  |  |  |  | PIP
S I R N |  |  |
|   _____ | Stenotrophomonas maltophilia |  | TMZ
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 2
(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 3
(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 |  |

**MDRO or CDAD Infection Event **

- Page 2 of 3

- OMB No. 0920-0666
- Exp. Date:  03-31-2011

- (specify): _________________________

## MDRO or CDAD Infection Event 

| Custom Fields |  |
| --- | --- |
| Label
________________________   ___/___/___
________________________   ___________
________________________   ___________
________________________   ___________
________________________   ___________
________________________   ___________
________________________   ___________ |   Label
  ________________________   ___/___/___
  ________________________   ___________
  ________________________   ___________
  ________________________   ___________
  ________________________   ___________
  ________________________   ___________
  ________________________   ___________ |
| Comments |  |
| 

 |  |

**MDRO or CDAD Infection Event **

- Page 3 of 3

- OMB No. 0920-0666
- Exp. Date:  03-31-2011

- CDC 57.126 (Back)