CDC 57.502 Dialysis Event

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

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: F M Unknown

Gender Identity Male Female Male-to-female transgender Female-to-male transgender Identifies as non-conforming Other Asked but unknown

Race (Select all that apply): American Indian or Alaska Native Asian Black or African American Middle Eastern or North African Native Hawaiian or Pacific Islander White Unknown Declined to respond Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown Declined to respond

Preferred Language (Specify)

Interpreter Needed:  Yes  No Declined to Respond Unknown

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

 Catheter-Graft hybrid

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)

* What is the suspected source of the organism or organisms identified on the 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  Catheter-Graft Hybrid

 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 50 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 H21-8, 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

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