Dialysis Event Form Page 3
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4Form Approved
Dialysis Event
OMB No. 0920-0666
Exp. Date: 12/31/2018
Page 3 of 4
Pathogen
Gram-negative Organisms (continued)
#
AMK
AZT
CEFEP
CEFTAZ
CIPRO/LEVO
COL/PB
GENT
Pseudomonas
_______
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
aeruginosa
IMI
MERO/DORI
PIP/PIPTAZ
TOBRA
S I R N
S I R N
S I R N
S I R N
Pathogen
Fungal Organisms
#
Candida
(specify species if
ANID
CASPO
FLUCO
FLUCY
ITRA
MICA
VORI
_______
available)
S I R N
S NS N
S S-DD R N
S I R N
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
____________
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
S I R N
S I R N
Organism 1
_______
_______
______
_______
_______
______
______
______
______
(specify)
_______
Drug 1
Drug 2
Drug 3
Drug 4
Drug 5
Drug 6
Drug 7
Drug 8
Drug 9
____________
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
S I R N
S I R N
Organism 1
_______
_______
______
_______
_______
______
______
______
______
(specify)
_______
Drug 1
Drug 2
Drug 3
Drug 4
Drug 5
Drug 6
Drug 7
Drug 8
Drug 9
____________
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
S I R N
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
CEFTRX = ceftriaxone
FLUCY = flucytosine
OX = oxacillin
AMP = ampicillin
CEFUR= cefuroxime
GENT = gentamicin
PB = polymyxin B
GENTHL = gentamicin –high level
AMPSUL = ampicillin/sulbactam
CTET= cefotetan
PIP = piperacillin
test
AMXCLV = amoxicillin/clavulanic acid
CIPRO = ciprofloxacin
IMI = imipenem
PIPTAZ = piperacillin/tazobactam
ANID = anidulafungin
CLIND = clindamycin
ITRA = itraconazole
RIF = rifampin
AZT = aztreonam
COL = colistin
LEVO = levofloxacin
TETRA = tetracycline
CASPO = caspofungin
DAPTO = daptomycin
LNZ = linezolid
TIG = tigecycline
TMZ =
CEFAZ= cefazolin
DORI = doripenem
MERO = meropenem
trimethoprim/sulfamethoxazole
CEFEP = cefepime
DOXY = doxycycline
METH = methicillin
TOBRA = tobramycin
CEFOT = cefotaxime
ERTA = ertapenem
MICA = micafungin
VANC = vancomycin
CEFOX= cefoxitin
ERYTH = erythromycin
MINO = minocycline
VORI = voriconazole
CEFTAZ = ceftazidime
FLUCO = fluconazole
MOXI = moxifloxacin
CDC 57.502, Rev 9, v8.5
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