57.502 - Centers for Disease Control and Prevention



*required for saving Patient InformationFacility ID:Event ID #:*Patient ID:Social Security #:Secondary ID #:Medicare #:Patient Name, Last:First:Middle:*Gender: F M Other*Date of Birth:Sex at Birth: M F OtherGender Identity:MaleFemaleFemale-to-Male TransgenderMale-to-Female TransgenderIdentifies as non-conformingOtherAsked but UnknownEthnicity (Specify): Race (Specify):Event Information*Event Type: DE – Dialysis Event*Date of Event:*Location:*Was the patient admitted/readmitted to the dialysis facility on this dialysis event date? Yes No*Transient Patient Yes NoRisk Factors*All Vascular Access: Types Present: (check all that apply) *Access placement date (mm/yyyy): Fistula _____ /_________ Unknown Buttonhole? Yes No Graft_____ /_________ Unknown Tunneled central line_____ /_________ Unknown Non-tunneled central line_____ /_________ Unknown Other vascular access device _____ /_________ UnknownIs this a catheter-graft hybrid? Yes No Vascular access comment: __________________________________________________________Access used for dialysis at the time of the event: (if more than one access was used for the dialysis treatment, please indicate the access with the higher risk of infection) Fistula Non-tunneled central line Graft Other vascular access device Tunneled central lineEvent Details*Specify Dialysis Event: (check at least one) IV antimicrobial start *Date of IV antimicrobial start: _____*Was vancomycin the antimicrobial used for this start? Yes No*Was this a new outpatient dialysis facility start or a continuation of a course initiated outside of the dialysis facility? New antimicrobial start Continuation of antimicrobial *If new antimicrobial start, was a blood sample collected for culture? Yes No Positive blood culture *Date of Positive blood culture: _____(*specify organism and antimicrobial susceptibilities on pages 2-3)*Suspected source of positive blood culture (check one): Vascular access A source other than the vascular access Contamination Uncertain*Where was this positive blood culture collected? Dialysis clinic Hospital (on the day of or the day following admission) or E.D. Other location Pus, redness, or increased swelling at vascular access site *Date of pus, redness, and increased swelling: _____ *Check the access site(s) with pus, redness, or increased swelling: Fistula Graft Tunneled central line Non-tunneled central line Other vascular access device*Specify Problem(s): (check one or more) Fever ≥ 37.8°C (100°F) oral Chills or rigors Drop in blood pressure Wound (NOT related to vascular access) with pus or increased redness Urinary tract infection Cellulitis (skin redness, heat, or pain without open wound) Pneumonia or respiratory infection Other problem (specify): _________________________________ None*Specify Outcomes:Loss of vascular access Yes No UnknownHospitalization Yes No UnknownDeath Yes No UnknownAssurance 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 25 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 57.502 (Front) Rev 10, v8.6Pathogen #Gram-positive Organisms_______Staphylococcus coagulase-negative VANCCEFOX/OXS I R N S R N(specify species if available): ______________________Enterococcus faecium____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level) DAPTOS S-DD NS NGENTHL§S R NLNZS I R NVANCS I R N_______Staphylococcus aureusCIPRO/LEVO/MOXIS I R NCLINDS I R NDAPTOS NS NDOXY/MINOS I R NERYTHS I R NGENTS I R NLNZS R NOX/CEFOX/METHS I R NRIFS I R NTETRAS I R NTIGS NS NTMZS I R NVANCS I R NCEFTARS S-DD I RPathogen #Gram-negative Organisms_______Acinetobacter (specify species)____________AMKS I R NAMPSULS I R NAZTS I R NCEFEPS I R NCEFTAZ/CEFOT/CEFTRXS I R NCIPRO/LEVOS I R NCOL/PBS I R NGENTS I R NIMIS I R NMERO/DORIS I R NPIP/PIPTAZS I R NTETRA/DOXY/MINOS I R NTMZS I R NTOBRAS I R N_______Escherichia coliAMKS I R NAMPS I R NAMPSUL/AMXCLVS I R NAZTS I R NCEFAZS I R NCEFEPS I/S-DD R NCEFOT/CEFTRXS I R NCEFTAZS I R NCEFURS I R NCEFOX/CTETS I R NCEFTAVIS R NCEFTOTAZS I R NCIPRO/LEVO/MOXIS I R NCOL/PB?S I R NERTAS I R NGENTS I R NIMIS I R NMERO/DORIS I R NPIPTAZS I R NTETRA/DOXY/MINOS I R NTIGS I R NTMZS I R NTOBRAS I R NIMIRELS I R NMERVABS I R N_______Enterobacter (specify species)____________AMKS I R NAMPS I R NAMPSUL/AMXCLVS I R NAZTS I R NCEFAZS I R NCEFEPS I/S-DD R NCEFOT/CEFTRXS I R NCEFTAZS I R NCEFURS I R NCEFOX/CTETS I R NCIPRO/LEVO/MOXIS I R NCOL/PBS I R NCEFTAVIS R NERTAS I R NGENTS I R NIMIS I R NMERO/DORIS I R NPIPTAZS I R NTETRA/DOXY/MINOS I R NTIGS I R NTMZS I R NTOBRAS I R NCEFTOTAZS I R NIMIRELS I R NMERVABS I R N___________Klebsiella pneumonia____Klebsiella oxytoca___Klebsiella aerogenesAMKS I R NAMPS I R NAMPSUL/AMXCLVS I R NAZTS I R NCEFAZS I R NCEFEPS I/S-DD R NCEFOT/CEFTRXS I R NCEFTAZS I R NCEFURS I R NCEFOX/CTETS I R NCIPRO/LEVO/MOXIS I R NCOL/PB?S I R NCEFTAVIS R NERTAS I R NGENTS I R NIMIS I R NMERO/DORIS I R NPIPTAZS I R NTETRA/DOXY/MINOS I R NTIGS I R NTMZS I R NTOBRAS I R NCEFTOTAZS I R NIMIRELS I R NMERVABS I R NPathogen #Gram-negative Organisms_______Pseudomonas aeruginosaAMKS I R NAZTS I R NCEFEPS I R NCEFTAZS I R NCIPRO/LEVOS I R NCOL/PBS I R NGENTS I R NIMIS I R NMERO/DORIS I R NPIP/PIPTAZS I R NCEFTAVIS R NTOBRAS I R NCEFTOTAZS I R NPathogen #Fungal Organisms_______Candida (specify species if available)____________ANIDS I R NCASPOS NS NFLUCOS S-DD R NFLUCYS I R NITRAS S-DD R NMICAS NS NVORIS S-DD R NPathogen #Other Organisms_______Organism 1 (specify)___________________Drug 1S I R N_______ Drug 2S I R N______Drug 3S I R N_______ Drug 4S I R N_______Drug 5S I R N______ Drug 6S I R N______ Drug 7S I R N______ Drug 8S I R N______ Drug 9S I R N_______Organism 1 (specify)___________________Drug 1S I R N_______ Drug 2S I R N______Drug 3S I R N_______ Drug 4S I R N_______Drug 5S I R N______ Drug 6S I R N______ Drug 7S I R N______ Drug 8S I R N______ Drug 9S I R N_______Organism 1 (specify)___________________Drug 1S I R N_______ Drug 2S I R N______Drug 3S I R N_______ Drug 4S I R N_______Drug 5S I R N______ Drug 6S I R N______ Drug 7S I R N______ Drug 8S I R N______ Drug 9S I R NResult CodesS = 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 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 ≥ 4Drug Codes:AMK = amikacinCEFTOTAZ = ceftolozane/tazobactamFLUCY = flucytosineOX = oxacillinAMP = ampicillinGENT = gentamicinPB = polymyxin BAMPSUL = ampicillin/sulbactamCEFTRX = ceftriaxone GENTHL = gentamicin –high level testPIP = piperacillinAMXCLV = amoxicillin/clavulanic acidCEFUR= cefuroximeIMI = imipenemPIPTAZ = piperacillin/tazobactamANID = anidulafunginCTET= cefotetanIMIREL= imipenem/relebactamRIF = rifampinAZT = aztreonamCIPRO = ciprofloxacinITRA = itraconazoleTETRA = tetracyclineCASPO = caspofunginCLIND = clindamycinLEVO = levofloxacinTIG = tigecyclineCEFAZ= cefazolinCOL = colistinLNZ = linezolid TMZ = trimethoprim/sulfamethoxazoleCEFEP = cefepimeDAPTO = daptomycinMERO = meropenemCEFOT = cefotaximeDORI = doripenemMERVAB= meropenem/vaborbactamTOBRA = tobramycinCEFOX= cefoxitinDOXY = doxycycline METH = methicillinCEFTAR = CeftarolineERTA = ertapenemMICA = micafunginVANC = vancomycinCEFTAVI = ceftazidime/avibactamERYTH = erythromycinMINO = minocyclineVORI = voriconazoleCEFTAZ = ceftazidimeFLUCO = fluconazoleMOXI = moxifloxacinCustom FieldsLabelLabel____________________________/____/_______________________________/____/_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Comments ................
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