New Jersey Department of Health

Division of Epidemiology, Environmental and Occupational Health

PO Box 369, Trenton, NJ 08625-0369

EPIDEMIOLOGY SURVEILLANCE RECORD (Hospital-based Laboratory)

1.	Facility Code Number:
2.	Month:	Year:	(The month and year in which the isolates were obtained, e.g., the October report would be
be dated September because it reflects organisms isolated in September.)
3.	Total Number of Inpatient Blood Cultures Done During This Month:
4.	Number of Positive Inpatient Blood Culture Results During This Month:
5.	MRSA (Defined as Staphylococcus aureus that is resistant to methicillin, nafcillin, or oxacillin according to CLSI guidelines)
A.	Number of Inpatient Isolates (Number of Patients) in:
(1) blood	(	)	(3) urine	(	)	(5) other	(	)
(2) sputum	(	)	(4) wound	(	)	(6) Total	(	)
B.	Number of Inpatient MRSA Isolates Resistant to VANCOMYCIN:
6.	All Staphylococcus aureus isolates with reduced susceptibility or resistant to vancomycin should be sent to the New Jersey Public Health and Environmental Laboratories.
7.	Please identify, list, and record antimicrobial susceptibilities (using CLSI guidelines) for the following Inpatient Blood Isolates:

A.	Gram positive cocci resistant to Vancomycin.

B.	Gram negative rods resistant (not intermediate) to Imipenem.

C.	Gram negative rods resistant to Amikacin, Gentamicin, or Tobramycin.

D.	Pneumococcal/Streptococcal isolates resistant to Penicillin.

Record antimicrobial susceptibilities as follows: R=Resistant S=Susceptible I=Intermediate
Medical Record Number:
Organism #1
Organism #2
Organism #3
Organism #4
Name:
Amikacin
Ampicillin
Aztreonam
Cefazolin
Cefepime
Cefotaxime
Cefotetan
Cefoxitin
Ceftazidime
Ceftizoxime
Ceftriaxone
Cefuroxime
Cephalothin
Chloramphenicol
Ciprofloxacin
Clindamycin
Erythromycin
Gentamicin
Gentamicin 500
Imipenem
Levofloxacin
Nitrofurantoin
Oxacillin/Meth/Naf
Penicillin
Piperacillin
Rifampin
Streptomycin
Streptomycin 2000
Tetracycline
Ticarcillin
Tobramycin
Trimethoprim/Sulfamethoxazole
Vancomycin
Other

CDS-16

AUG 12

CDS-16, Epidemiology Surveillance Record

CDS-16, Epidemiology Surveillance Record, COMMUNICABLE DISEASE SERVICE, hospital based laboratory, communicable disease control

EWhite

2012-03-19

NJDOH