Dialysis Event Form Page 2

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Form Approved
Dialysis Event
OMB No. 0920-0666
Exp. Date: 12/31/2018
Page 2 of 4
Pathogen
Gram-positive Organisms
#
VANC
Staphylococcus coagulase-negative
_______
S I R N
(specify species if available):
____________
§
DAPTO
GENTHL
LNZ
VANC
____Enterococcus faecium
_______
S NS N
S R N
S I R N
S I R N
____Enterococcus faecalis
____Enterococcus spp.
(Only those not identified to the
species level)
CIPRO/LEVO/MOXI
CLIND
DAPTO
DOXY/MINO
ERYTH
GENT
LNZ
Staphylococcus
_______
S I R N
S I R N
S NS N
S I R N
S I R N
S I R N
S R N
aureus
OX/CEFOX/METH
RIF
TETRA
TIG
TMZ
VANC
S I R N
S I R N
S I R N
S NS N
S I R N
S I R N
Pathogen
Gram-negative Organisms
#
AMK
AMPSUL
AZT
CEFEP
CEFTAZ
CIPRO/LEVO
COL/PB
Acinetobacter
_______
S I R N
S I R N
S I R N
S I R N
S I R N
S I R N
S I R N
(specify species)
____________
GENT
IMI
MERO/DORI
PIP/PIPTAZ
TETRA/DOXY/MINO
S I R N
S I R N
S I R N
S I R N
S I R N
TMZ
TOBRA
S I R N
S I R N
AMK
AMP
AMPSUL/AMXCLV
AZT
CEFAZ
CEFEP
CEFOT/CEFTRX
Escherichia coli
_______
S I R N
S I R N
S I R N
S I R N
S I R N
S I/S-DD R N
S I R N
†
CEFTAZ
CEFUR
CEFOX/CTET
CIPRO/LEVO/MOXI
COL/PB
S I R N
S I R N
S I R N
S I R N
S R N
ERTA
GENT
IMI
MERO/DORI
PIPTAZ
TETRA/DOXY/MINO
S I R N
S I R N
S I R N
S I R N
S I R N
S I R N
TIG
TMZ
TOBRA
S I R N
S I R N
S I R N
AMK
AMP
AMPSUL/AMXCLV
AZT
CEFAZ
CEFEP
CEFOT/CEFTRX
Enterobacter
_______
S I R N
S I R N
S I R N
S I R N
S I R N
S I/S-DD R N
S I R N
(specify species)
____________
†
CEFTAZ
CEFUR
CEFOX/CTET
CIPRO/LEVO/MOXI
COL/PB
S I R N
S I R N
S I R N
S I R N
S R N
ERTA
GENT
IMI
MERO/DORI
PIPTAZ
TETRA/DOXY/MINO
S I R N
S I R N
S I R N
S I R N
S I R N
S I R N
TIG
TMZ
TOBRA
S I R N
S I R N
S I R N
AMK
AMP
AMPSUL/AMXCLV
AZT
CEFAZ
CEFEP
CEFOT/CEFTRX
____Klebsiella
_______
S I R N
S I R N
S I R N
S I R N
S I R N
S I/S-DD R N
S I R N
pneumonia
†
CEFTAZ
CEFUR
CEFOX/CTET
CIPRO/LEVO/MOXI
COL/PB
____Klebsiella
S I R N
S I R N
S I R N
S I R N
S R N
oxytoca
ERTA
GENT
IMI
MERO/DORI
PIPTAZ
TETRA/DOXY/MINO
S I R N
S I R N
S I R N
S I R N
S I R N
S I R N
TIG
TMZ
TOBRA
S I R N
S I R N
S I R N
CDC 57.502, Rev 9, v8.5

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