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pdfMulti-site Gram-Negative Surveillance Initiative (MuGSI)
CRE NDM and KPC treatment data collection form
State ID: ___________ _Patient ID: ______________ Collection Date:
1. Antibiotic
(brand)
Amikacin
(Amikin)
2a.
Administered
to treat CRE
□ Yes □ No
□ Unknown
3a. Start Date
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3b. Stop Date
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Date of incident specimen collection :
3c. Start Date
3d. Stop Date
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3e. Start Date
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3f. Stop Date
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Aztreonam (Azactam)
□ Yes □ No
□ Unknown
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Aztreonam-avibactam
□ Yes □ No
□ Unknown
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Cefepime (Maxipime)
□ Yes □ No
□ Unknown
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Cefiderocol
□ Yes □ No
□ Unknown
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Ceftriaxone (Rocephin)
Cefotaxime (Claforan)
□ Yes □ No
□ Unknown
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□ Yes □ No
□ Unknown
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Ceftazidime
(Fortaz)
□ Yes □ No
□ Unknown
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Ceftazidime-avibactam
□ Yes □ No
□ Unknown
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Ceftolozane-tazobactam
□ Yes □ No
□ Unknown
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3g. Treatment
continued after
hospital discharge
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
1
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Ciprofloxacin
(Cipro)
□ Yes □ No
□ Unknown
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Colistin or Polymyxin E
(Coly-Mycin-S)
□ Yes □ No
□ Unknown
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Cefepimeenmetazobactam
□ Yes □ No
□ Unknown
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Doripenem
(Doribax)
□ Yes □ No
□ Unknown
Doxycycline
□ Yes □ No
□ Unknown
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Eravacycline
□ Yes □ No
□ Unknown
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Ertapenem
(Invanz)
□ Yes □ No
□ Unknown
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Fosfomycin (Monurol)
□ Yes □ No
□ Unknown
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Gentamicin (Garamycin)
□ Yes □ No
□ Unknown
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Imipenem
(Primaxin)
□ Yes □ No
□ Unknown
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Imipenem-relebactam
□ Yes □ No
□ Unknown
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Levofloxacin (Levaquin)
□ Yes □ No
□ Unknown
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Meropenem (Merrem)
□ Yes □ No
□ Unknown
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□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
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□ No
□ Unknown
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□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
2
Meropenemvaborbactam
□ Yes □ No
□ Unknown
Minocycline
□ Yes □ No
□ Unknown
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Nitrofurantoin
□ Yes □ No
□ Unknown
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Moxifloxacin (Avelox)
□ Yes □ No
□ Unknown
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PiperacillinTazobactam (Zosyn)
□ Yes □ No
□ Unknown
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Plazomicin
□ Yes □ No
□ Unknown
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Polymixin B
□ Yes □ No
□ Unknown
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Tigecycline
(Tygacil)
□ Yes □ No
□ Unknown
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Trimetoprimsulfamethoxazole
□ Yes □ No
□ Unknown
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Tobramycin
(Nebcin)
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
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□ Unknown
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□ Yes □ No
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
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□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
3
Other_____________
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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Other_____________
□ Yes □ No
□ Unknown
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□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
4
4a. Was ID consulted for the
4b. If Yes, report date of initial ID consult (or reconsult)
/ / .
treatment of the CRE infection?
□ Yes
□ No
□ Unknown
4c. Were there any antibiotics noted by a clinician that could not be used for CRE treatment because they were not available or not on
formulary?
□ Yes
□ No
□ Unknown
4d. If Yes, please specify antibiotics ______________________________
Testing for carbapenemase genes:
□ No testing for carbapenemase gene data available from the medical record
5b. If yes, what testing method was 5c. If yes, dates of testing
/ /__
used? (check all that apply)
□ Automated Molecular Assay
/ /__
□ Carba-R
□ Check Points
5d. If tested, what was the
□ Immunochromatographic lateral
testing result?
flow tests (ICT)
□ NDM
□ Pos □ Neg □ Ind □ Unk
□ MALDI-TOF MS
□
KPC
□ Pos □ Neg □ Ind □ Unk
□ Next Genera:on NucleicAcid
_________________________
Sequencing
□ PCR
□ Streck ARM-D
□ Other
(specify):__________________
□ Unknown
Parameters to calculate qPitt Bacteremia score:
Record the measurements that occurred within 48 hours before or on the day of the DISC.
6a. Highest body temperature(F or
6b. Lowest body temperature (F or
6c. Has the patient had an acute hypotensive event with
C
ͦ ) on the day of the DISC
C
ͦ ) on the day of the DISC
drop in systolic blood pressure >30 mm Hg and diastolic
blood pressure >20 mm Hg on the day of the DISC?
_____________ F
_____________ F
□ Yes
_____________ C
ͦ
_____________ C
ͦ
□ No
□ Unknown
6d. Systolic blood pressure (lowest
6e. Is the patient receiving
6f. Patient has a respiratory rate of >25 breaths per
value) on the day of the DISC
mechanical ventilation on the day
minute on the day of the DISC
of the DISC?
□ Yes
□ Yes
_____________ mm Hg
□ No
□ No
□ Unknown
□ Unknown
6g. Has the patient had a cardiac
6h. Is the patient receiving
6i. Mental state on the day of the DISC (check all that
arrest on the day of the DISC or
intravenous vasopressors
apply)
within 48 hours before the DISC?
(medications to help raise blood
□ Alert (normal)
pressure) on the day of the DISC?
□ Yes
□ Disoriented
□ Yes
□ No
□ Stuporous
□ No
□ Unknown
□ Comatose
□ Unknown
□ Sedated
□ Unknown
5a. Was the incident specimen tested
for carbapenemase genes?
□ Yes
□ No
□ Unknown
5
7a. Susceptibility results (AST) from the medical record:
Please complete the table based on the information found in the medical record □ No susceptibility data available from the medical record
Antibiotic
MIC or zone
Interpretation
AST result date
MIC or zone
Interpretation
AST result date
(brand)
diameter
(clinical lab)
(clinical lab)
diameter
(SPHL/ ARLN)
(SPHL/ARLN)
(clinical lab)
(SPHL/ARLN)
Amikacin
(Amikin)
Aztreonam (Azactam)
Aztreonam-avibactam
Cefepime (Maxipime)
Cefiderocol
Ceftriaxone (Rocephin)
Cefotaxime (Claforan)
Ceftazidime
(Fortaz)
Ceftazidime-avibactam
Ceftolozane-tazobactam
Ciprofloxacin
(Cipro)
Colistin or Polymyxin E
(Coly-Mycin-S)
Cefepimeenmetazobactam
Doripenem
(Doribax)
Doxycycline
Eravacycline
Ertapenem
(Invanz)
Fosfomycin (Monurol)
Gentamicin (Garamycin)
Imipenem
(Primaxin)
Imipenem-relebactam
Levofloxacin (Levaquin)
Meropenem (Merrem)
Meropenem-vaborbactam
Minocycline
Nitrofurantoin
Moxifloxacin (Avelox)
PiperacillinTazobactam (Zosyn)
Plazomicin
Polymixin B
Tigecycline
(Tygacil)
Trimetoprimsulfamethoxazole
Tobramycin
(Nebcin)
Other_____________
6
7b. Susceptibility results from the ET, KB, MS, PX, SEN, VK, APS data sources in lab reports:
Please complete the table based on the information found at laboratory reports received by EIP sites (if not available or different from
results in the medical record)
Antibiotic
MIC or zone
Interpretation
AST result date
MIC or zone
Interpretation
AST result date
(brand)
diameter
(clinical lab)
(clinical lab)
diameter
(SPHL/ ARLN)
(SPHL/ARLN)
(clinical lab)
(SPHL/ARLN)
Amikacin
(Amikin)
Aztreonam (Azactam)
Aztreonam-avibactam
Cefepime (Maxipime)
Cefiderocol
Ceftriaxone (Rocephin)
Cefotaxime (Claforan)
Ceftazidime
(Fortaz)
Ceftazidime-avibactam
Ceftolozane-tazobactam
Ciprofloxacin
(Cipro)
Colistin or Polymyxin E
(Coly-Mycin-S)
Cefepimeenmetazobactam
Doripenem
(Doribax)
Doxycycline
Eravacycline
Ertapenem
(Invanz)
Fosfomycin (Monurol)
Gentamicin (Garamycin)
Imipenem
(Primaxin)
Imipenem-relebactam
Levofloxacin (Levaquin)
Meropenem (Merrem)
Meropenem-vaborbactam
Minocycline
Nitrofurantoin
Moxifloxacin (Avelox)
PiperacillinTazobactam (Zosyn)
Plazomicin
Polymixin B
Tigecycline
(Tygacil)
Trimetoprimsulfamethoxazole
Tobramycin
(Nebcin)
Other_____________
7
8. Form completion status
□ Complete
□ Pending
11. Comments
9. Date of abstraction
/ /___
10. SO initials
SERVICES CENTERS FOR ASE CONTROL AND PREVENTION
8
| File Type | application/pdf |
| File Title | Microsoft Word - Form NDM and KPC Treatment data collection 03202025 |
| Author | NEG3 |
| File Modified | 2025-03-21 |
| File Created | 2025-03-21 |