Pneumonia (PNEU)(<18)

www.cdc.gov/nhsn
IDENTITAS PASIEN
Event Type: PNEU Tanggal Kejadian:
Post-prosedur PNEU: Ya Tidak Tgl prosedur:
Diagnosa awal:
MDRO Infection Surveillance:
□ Ya, infeksi pathogen dari lokasi □ Tidak, infeksi pathogen bukan dari lokasi
Tgl MRS Unit/Bangsal:
Faktor Resiko
Ventilator: Ya Tidak Lokasi pemasangan: ______________ Tgl pemasangan: __ /__ /_____
Untuk NICU: BB Lahir: _________grams
Event Details
Spesifik Event: □ PNU1 □ PNU2 □ PNU3 *Immunocompromised: Ya Tidak
Spesifik kriteria : (cek semua yg tercantum)
X-Ray
□ infiltrate Baru atau progressive & persistent □ Consolidation □ Cavitation □ Pneumatoceles (in ≤1 thn)
Tanda & Gejala Laboratory
□ Demam (>38°C) □ Positive blood culture
□ Leukopenia or leukocytosis (<4000 or >12000) □ Positive pleural fluid culture
□ Gangguan status mental (in ≥70 thn) □ Positive quantitative culture from LRT specimen
□ New onset/perubahan pada sputum □ ≥5% BAL cells w/ bacteria
□ New onset/batuk yg memburuk, □ Histopathologic exam w/ abscess formation, positive quantitative
dyspnea,tachypnea culture of lung parenchyma, or lung parenchyma invasion by
□ Rales atau suara nafas bronchial † fungal hyphae
□ memburuknya pertukaran gas □ Positive culture of virus or Chlamydia
□ Hemoptysis □ Positive detection of viral antigen or antibody
□ Pleuritic nyeri dada □ 4-fold rise in paired sera for pathogen
□Temperature tidak stabil □ Positive PCR for Chlamydia or Mycoplasma
□ Apnea, tachycardia, nasal flaring dg retraction pd □ Positive micro-IF test for Chlamydia
dinding dada atau mendengkur grunting □ Positive culture or micro-IF of Legionella spp.
□ Hypothermia □ L pneumophila serogroup 1 antigens in urine
□ Wheezing, rales, atau rhonchi † □ 4-fold rise in L pneumophila antibody titer
□ Batuk □ Matching positive blood & sputum cultures w/ Candida spp.
□Bradycardia atau tachycardia □ Fungi or Pneumocytis carinii from LRT specimen
† ada 2 kriteria mengarah pada rales di PNU 1 pada tanda&gejala pada daftar. Silahkan memilih salah satu yang sesuai

dengan algoritma tertentu yang digunakan untuk mengidentifikasi pneumonia ini (Setiap Kriteria Pasien atau alternatif
berdasarkan usia)..
Secondary Bloodstream Infection: Ya Tidak
Meninggal : Ya Tidak PNEU menyebabkan kematian : Ya Tidak
Tgl Pulang : *Patogen teridentifikasi : Ya Tidak Jika Ya, spesifik pd hal 2-3

Pathogen # Identifikasi Patogen

Organism 1 _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 2 _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN
 Pneumonia (PNEU)
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Pathogen
Gram-positive Organisms
#
Staphylococcus VANC
_______ SIRN
coagulase-negative
(specify): ________________________
Enterococcus AMP CIPRO/LEVO/MOXI DAPTO DOXY/MINO GENTHL§ LNZ
_______ SIRN SIRN S NS N SIRN SRN SIRN
spp.( specify):
___________ STREPHL§ TETRA TIG VANC
SRN SIRN S NS N SIRN

Enterococcus AMP CIPRO/LEVO/MOXI DAPTO DOXY/MINO GENTHL§ LNZ

_______ SIRN SIRN S NS N SIRN SRN SIRN
faecium
QUIDAL STREPHL§ TETRA TIG VANC
SIRN SRN SIRN S NS N SIRN

Staphylococcus CHLOR CIPRO/LEVO/MOXI CLIND DAPTO DOXY/MINO ERYTH GENT

_______ SIRN SIRN SIRN S NS N SIRN SIRN SIRN
aureus
LNZ OX/CEFOX/METH QUIDAL RIF TETRA TIG TMZ VANC
SRN SIRN SIRN SIRN SIRN S NS N SIRN SIRN
Pathogen
Gram-negative Organisms
#
Acinetobacter AMK AMPSUL AZT CEFEP CEFTAZ CIPRO/LEVO COL/PB
_______ SIRN SIRN SIRN SIRN SIRN SIRN SIRN
spp. (specify):
____________ GENT IMI MERO/DORI PIP/PIPTAZ TETRA/DOXY/MINO
SIRN SIRN SIRN SIRN SIRN

TMZ TOBRA
SIRN SIRN
Escherichia coli AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
_______ SIRN SIRN SIRN SIRN SIRN SIRN SIRN

CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB

SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN
TIG TMZ TOBRA
SIRN SIRN SIRN
Enterobacter AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
_______ SIRN SIRN SIRN SIRN SIRN SIRN SIRN
spp. (specify):
____________ CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN
TIG TMZ TOBRA
SIRN SIRN SIRN

Klebsiella spp. AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX

_______ SIRN SIRN SIRN SIRN SIRN SIRN SIRN
(specify):
____________ CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

TIG TMZ TOBRA

SIRN SIRN SIRN

CDC 57.111 (Back) Rev 4, v6.6

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Pathogen
Gram-negative Organisms (continued)
#
Serratia AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
_______ SIRN SIRN SIRN SIRN SIRN SIRN SIRN
marcescens
CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN
TIG TMZ TOBRA
SIRN SIRN SIRN

Pseudomonas AMK AZT CEFEP CEFTAZ CIPRO/LEVO COL/PB GENT

_______ SIRN SIRN SIRN SIRN SIRN SIRN SIRN
aeruginosa
IMI MERO/DORI PIP/PIPTAZ TOBRA
SIRN SIRN SIRN SIRN

Stenotrophomonas LEVO TETRA/MINO TICLAV TMZ

_______ SIRN SIRN SIRN SIRN
maltophilia
Pathogen
Fungal Organisms
#
Candida spp.
(specify): ANID CASPO FLUCO FLUCY ITRA MICA VORI
_______ SIRN S NS N S S-DD R N SIRN S S-DD R N S NS N S S-DD R N
____________
Pathogen
#
Other Organisms
Organism 1 _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 1 _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 1 _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Result Codes
S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested
§
GENTHL and STREPHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic

Drug Codes:
STREPHL = streptomycin –
AMK = amikacin CEFTRX = ceftriaxone ERYTH = erythromycin MICA = micafungin
high level test
AMP = ampicillin CEFUR= cefuroxime FLUCO = fluconazole MINO = minocycline TETRA = tetracycline
TICLAV = ticarcillin/clavulanic
AMPSUL = ampicillin/sulbactam CETET= cefotetan FLUCY = flucytosine MOXI = moxifloxacin
acid
CHLOR=
AMXCLV = amoxicillin/clavulanic acid GENT = gentamicin OX = oxacillin TIG = tigecycline
chloramphenicol
GENTHL = gentamicin –high TMZ =
ANID = anidulafungin CIPRO = ciprofloxacin PB = polymyxin B
level test trimethoprim/sulfamethoxazole
AZT = aztreonam CLIND = clindamycin IMI = imipenem PIP = piperacillin TOBRA = tobramycin
CASPO = caspofungin COL = colistin ITRA = itraconazole PIPTAZ = piperacillin/tazobactam VANC = vancomycin
CEFAZ= cefazolin DAPTO = daptomycin LEVO = levofloxacin QUIDAL = quinupristin/dalfopristin VORI = voriconazole
CEFEP = cefepime DORI = doripenem LNZ = linezolid RIF = rifampin
CEFOT = cefotaxime DOXY = doxycycline MERO = meropenem
CEFOX= cefoxitin ERTA = ertapenem METH = methicillin
CEFTAZ = ceftazidime

CDC 57.111 (Back) Rev 4, v6.6

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Comments

CDC 57.111 (Back) Rev 4, v6.6