57.111 Pneumonia (PNEU)

[NCEZID] The National Healthcare Safety Network (NHSN)

57.111_PNEU_November_2022

OMB: 0920-0666

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Form Approved

OMB No.

Exp. Date:

www.cdc.gov/nhsn

Pneumonia (PNEU)

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:

Sex at Birth: F M Unknown

Gender Identity (Specify):

Ethnicity (Specify):

Race (Specify):

*Event Type: PNEU

*Date of Event:

Post-procedure PNEU: Yes No

Date of Procedure:

NHSN Procedure Code:

ICD-10-PCS or CPT Procedure Code:

*MDRO Infection Surveillance:

Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module

No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module

*Date Admitted to Facility:

*Location:

Risk Factors

*Ventilator: Yes No

Location of Device Insertion: ______________

Date of Device Insertion: __ /__ /_____

For NICU only: Birth weight: _________grams



Event Details

*Specific Event:

PNU1

PNU2

PNU3

*Immunocompromised: Yes No

*Specific Criteria Used: (check all that apply)

Imaging Test Results

New or progressive and persistent infiltrate

Consolidation

Cavitation

Pneumatoceles (in ≤1 y.o.)

Signs & Symptoms

Laboratory

Fever

Organism(s) identified from blood specimen

Leukopenia or leukocytosis

Organism(s) identified from pleural fluid

Altered mental status (in ≥70 y.o.)

Positive quantitative culture from LRT specimen

New onset/change in sputum

□ ≥5% BAL cells w/ bacteria

New onset/worsening cough, dyspnea, tachypnea

Positive quantitative culture of lung tissue

Rales or bronchial breath sounds

Histopathologic exam w/ abscess formation or lung parenchyma invasion by fungal hyphae

Worsening gas exchange

Hemoptysis

Virus, Bordetella, Legionella, Mycoplasma or Chlamydia identified from respiratory secretions or tissue

Pleuritic chest pain

Temperature instability

4-fold rise in paired sera for pathogen

Apnea, tachypnea, nasal flaring with retraction of chest wall or grunting

4-fold rise in L pneumophila antibody titer

L pneumophila serogroup 1 antigens in urine

Hypothermia

Matching Candida spp. identified from blood & sputum, endotracheal aspirate, BAL or protected specimen brushing

Wheezing, rales, or rhonchi

Cough

Fungi from LRT specimen

Bradycardia or tachycardia


There are two criteria referring to rales in the PNU 1 signs and symptoms list. Please choose the one that corresponds to the specific algorithm used to identify this pneumonia (Any Patient or Alternate Criteria based on age).

*Secondary Bloodstream Infection: Yes No

*COVID-19: Yes No

**Died: Yes No

PNEU Contributed to Death: Yes No

Discharge Date:

*Pathogens Identified: Yes No *If Yes, specify 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 57.111 (Front)

Pneumonia (PNEU)



Pathogen #

Gram-positive Organisms


Staphylococcus coagulase-negative

(specify species if available):

CEFOX/OX

S R N

VANC

S I R N










____Enterococcus faecium

____Enterococcus faecalis

____Enterococcus spp. (Only those not identified to the species level)

DAPTO

S I/S-DD NS R N

GENTHL§

S R N

LNZ

S I R N

VANC

S I R N








Staphylococcus aureus



CEFOX/METH/OX

S R N


CEFTAR

S S-DD I R N

CIPRO/LEVO/MOXI

S I R N

CLIND

S I R N

DAPTO

S NS N

DOXY/MINO

S I R N

GENT

S I R N

LNZ

S R N

RIF

S I R N

TETRA

S I R 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

CEFEP

S I R N


CEFTAZ/CEFOT/CEFTRX

S I R N

CIPRO/LEVO

S I R N

COL/PB

S R N

DORI/MERO

S I R N

DOXY/MINO

S I R N

GENT

S I R N

IMI

S I R N

PIPTAZ

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

CEFTAVI

S R N

CEFTAZ

S I R N


CEFTOTAZ

S I R N

CIPRO/LEVO/MOXI

S I R N

COL/PB

I R N

DORI/IMI/MERO

S I R N

DOXY/MINO/TETRA

S I R N

ERTA

S I R N

GENT

S I R N

IMIREL

S I R N

MERVAB

S I R N

PIPTAZ

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

AZT

S I R N

CEFEP

S I/S-DD R N

CEFOT/CEFTRX

S I R N

CEFTAVI

S R N

CEFTAZ

S I R N

CEFTOTAZ

S I R N

CIPRO/LEVO/MOXI

S I R N

COL/PB

I R N

DORI/IMI/MERO

S I R N

DOXY/MINO/TETRA

S I R N

ERTA

S I R N

GENT

S I R N

IMIREL

S I R N

MERVAB

S I R N

PIPTAZ

S I R N

TIG

S I R N

TMZ

S I R N

TOBRA

S I R N
















Pathogen #

Gram-negative Organisms (continued)



____Klebsiella pneumoniae

____Klebsiella oxytoca

____Klebsiella aerogenes

AMK

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

CEFTAVI

S R N

CEFTAZ

S I R N

CEFTOTAZ

S I R N

CIPRO/LEVO/MOXI

S I R N

COL/PB

I R N

DORI/IMI/MERO

S I R N

DOXY/MINO/TETRA

S I R N

ERTA

S I R N

GENT

S I R N

IMIREL

S I R N

MERVAB

S I R N

PIPTAZ

S I R N

TIG

S I R N

TMZ

S I R N

TOBRA

S I R N





Pseudomonas aeruginosa



AMK

S I R N

AZT

S I R N

CEFEP

S I R N


CEFTAVI

S R N

CEFTAZ

S I R N

CEFTOTAZ

S I R N

CIPRO/LEVO

S I R N

COL/PB

S I R N

DORI/IMI/MERO

S I R N

GENT

S I R N

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 I R N

FLUCO

S S-DD R N

MICA

S I R N

VORI

S I R N





Pathogen #

Other Organisms



Organism 1 (specify) _____________

Drug 1

S I R N

Drug2

S I R N

Drug3

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

Drug2

S I R N

Drug3

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

Drug2

S I R N

Drug3

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 Codes

S = 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 are based on CLSI M100-ED30:2020, Intermediate MIC ≤ 2 and Resistant MIC ≥ 4



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


Pneumonia (PNEU)

Page 4 of 4

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.111_PNEU
SubjectNHSN OMB Forms 2020
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-09-16

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