CDC 57.502 Dialysis Event

[NCEZID] The National Healthcare Safety Network (NHSN)

57.502 Dialysis Event Form-Clean Form

OMB: 0920-0666

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Form Approved

OMB No. 0920-0666

Exp. Date: 06/30/2026

www.cdc.gov/nhsn


Dialysis Event Surveillance Form

*required for saving

Patient Information

Facility 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 Other

Gender Identity:

*Ethnicity (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

No

Risk 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

_____ /_________

Unknown

Is 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 line






Event 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

Unknown


Hospitalization

Yes

No

Unknown


Death

Yes

No

Unknown


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 15 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, v8.6


Pathogen #

Gram-positive Organisms


_______


Staphylococcus coagulase-negative


VANC CEFOX/OX

S I R N S R N

(specify species if available):

____________


______


____Enterococcus faecium


____Enterococcus faecalis

____Enterococcus spp.

(Only those not identified to the species level)


DAPTO

S S-DD 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


CEFTAR

S S-DD I R

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/CEFOT/CEFTRX

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/CTET

S I R N

CEFTAVI

S R N

CEFTOTAZ

S I R N

CIPRO/LEVO/MOXI

S I R N

COL/PB

S I 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

IMIREL

S I R N

MERVAB

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/CTET

S I R N


CIPRO/LEVO/MOXI

S I R N


COL/PB

S I R N

CEFTAVI

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

CEFTOTAZ

S I R N

IMIREL

S I R N

MERVAB

S I R N



_______


____Klebsiella

pneumonia


____Klebsiella

oxytoca



___Klebsiella

aerogenes



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/CTET

S I R N


CIPRO/LEVO/MOXI

S I R N


COL/PB

S I R N

CEFTAVI

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

CEFTOTAZ

S I R N

IMIREL

S I R N

MERVAB

S I R N



Pathogen #

Gram-negative Organisms


_______


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

CEFTAVI

S R N

TOBRA

S I R N

CEFTOTAZ

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 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 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

CEFTOTAZ = ceftolozane/tazobactam

FLUCY = flucytosine

OX = oxacillin

AMP = ampicillin

GENT = gentamicin

PB = polymyxin B

AMPSUL = ampicillin/sulbactam

CEFTRX = ceftriaxone

GENTHL = gentamicin –high level test

PIP = piperacillin

AMXCLV = amoxicillin/clavulanic acid

CEFUR= cefuroxime

IMI = imipenem

PIPTAZ = piperacillin/tazobactam

ANID = anidulafungin

CTET= cefotetan

IMIREL= imipenem/relebactam

RIF = rifampin

AZT = aztreonam

CIPRO = ciprofloxacin

ITRA = itraconazole

TETRA = tetracycline

CASPO = caspofungin

CLIND = clindamycin

LEVO = levofloxacin

TIG = tigecycline

CEFAZ= cefazolin

COL = colistin

LNZ = linezolid

TMZ = trimethoprim/sulfamethoxazole

CEFEP = cefepime

DAPTO = daptomycin

MERO = meropenem

CEFOT = cefotaxime

DORI = doripenem

MERVAB= meropenem/vaborbactam

TOBRA = tobramycin

CEFOX= cefoxitin

DOXY = doxycycline

METH = methicillin


CEFTAR = Ceftaroline

ERTA = ertapenem

MICA = micafungin

VANC = vancomycin

CEFTAVI = ceftazidime/avibactam

ERYTH = erythromycin

MINO = minocycline

VORI = voriconazole

CEFTAZ = ceftazidime

FLUCO = fluconazole

MOXI = moxifloxacin






Custom Fields

Label

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