Submitting
State Laboratory ID
|
Date alert sent
from jurisdiction to CDC
|
Which state is
submitting this alert?
|
From which
state did the isolate originate?
|
Alert type
|
Alert type
other, specify
|
Was this pan
resistant? (non-susceptible to all drugs tested thus far)
|
Was this
isolate sent to regional laboratory for testing?
|
Original
submitting State Laboratory ID
|
Specimen source
|
Patient age in
years
|
Date of
specimen collection
|
Organism
(Genera)
|
Other genus,
specify
|
Species
|
mCIM or
Carba-NP results?
|
KPC Result
|
NDM Result
|
OXA-48 Result
|
OXA-23, -24/40,
58-like Result
|
VIM Result
|
IMP Result
|
Which method(s)
was used to test IMP?
|
By which method
was IMP positive?
|
mcr-1 Result
|
mcr-2 Result
|
Other genes
detected
|
Other genes
detected, specify
|
Description of
AST for the isolate?
|
AST file from
submitting lab
|
AST from
submitting clinical lab
|
AST from
public health lab
|
Which method
was used to conduct AST at Public Health Laboratory?
|
AST result for
Amikacin
|
AST result for
Ticarcillin/clavulanic acid constant 2
|
AST result for
Aztreonam
|
AST result for
Cefepime
|
AST result for
Piperacillin/tazobactam constant 4
|
AST result for
Trimethoprim/sulfamethoxazole
|
AST result for
Gentamicin
|
AST result for
Cefepime
|
AST result for
Tobramycin
|
AST result for
Levofloxacin
|
AST result for
Doxycycline
|
AST result for
Ciprofloxacin
|
AST result for
Minocycline
|
AST result for
Meropenem
|
AST result for
Doripenem
|
AST result for
Colistin
|
AST result for
Polymixin B
|
AST result for
Ceftazidime
|
AST result for
Cefotaxime
|
AST result for
Tigecycline
|
AST result for
Ertapenem
|
AST result for
Imipenem
|
AST result for
Cefazolin
|
AST result for
Ceftriaxone
|
AST result for
Amoxicillin/Clavulanic acid
|
AST result for
Ampicillin
|
AST result for
Ampicillin/Sulbactam
|
AST result for
Nitrofurantoin
|
AST result for
Ceftazidime Avibactam
|
AST result for
Ceftolozane/tazobactam
|
AST result for
Moxifloxacin
|
AST results
from Regional lab
|
Was the
specimen detected during colonization screening?
|
State lab ID of
the Index patient (isolate)
|
Any other
information about the isolate/patient you would like to us to
know?
|