Attachment E - EIP information

AttachmentE_0920-0852_SupplementalInformationOnly.docx

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

Attachment E - EIP information

OMB: 0920-0852

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2011 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY: EIP TEAM ANTIMICROBIAL USE FORM


CDC ID: -

Survey date: //

Date form completed: //

Data collector initials: ________



**Check here if no antimicrobials were administered on the survey date or the calendar day prior to the survey date (*be sure to consider whether dialysis qualification applies—see Primary Team/EIP Team Data Collection Form). Otherwise, fill in information, complete pages 1 AND 2 of form.


**Check here if >6 antimicrobial agents administered on the survey date or the calendar day prior to the survey date (*be sure to consider whether dialysis qualification applies—see Primary Team/EIP Team Data Collection Form), AND enter additional antimicrobial agents on another Antimicrobial Use Form.


This is Antimicrobial Use Form # ______ out of a total of ______ Antimicrobial Use Form(s) for this patient.


Therapeutic site codes: BJI = Bone or joint, BSI = Bloodstream infection, CNS = Central nervous system, CVI = Cardiovascular (other than BSI), DIS = Systemic, disseminated infection, ENT = Eyes, ears, nose, throat (includes upper respiratory infection, GTI = Gastrointestinal tract, HEB = hepatic and biliary system infections (including pancreas), IAB = intraabdominal infection other than GTI and HEB (e.g., spleen abscess), LRI = Lower respiratory infection, REP = Reproductive tract infection, SST = Skin or soft tissue infection (includes muscle infection), UTI = Urinary tract infection, UND = Undetermined, Other = specify other site.

Shape1

Drug

Route

(check one):


Rationale

(check all that apply):



If Rationale is “Treatment of active infection,” then complete the following:



Clinician-defined therapeutic site

(check all that apply):



Infection onset

(check all that apply):


IV or IM

Oral/enteral

Inhaled


Medical prophylaxis

Surgical prophylaxis

Shape2 Treatment of active infection

Non-infectious

None documented


BJI

BSI

CNS

CVI

DIS

ENT

GTI

HEB

IAB

LRI

REP

SST

UTI

UND

Unknown

Other: _______




AND

Your hospital

Other healthcare facility

Community

Unknown


Drug

Route

(check one):


Rationale

(check all that apply):


Shape3

If Rationale is “Treatment of active infection,” then complete the following:



Clinician-defined therapeutic site

(check all that apply):



Infection onset

(check all that apply):


IV or IM

Oral/enteral

Inhaled


Medical prophylaxis

Surgical prophylaxis

Shape4 Treatment of active infection

Non-infectious

None documented


BJI

BSI

CNS

CVI

DIS

ENT

GTI

HEB

IAB

LRI

REP

SST

UTI

UND

Unknown

Other: _______




AND

Your hospital

Other healthcare facility

Community

Unknown


Drug

Route

(check one):


Rationale

(check all that apply):


Shape5

If Rationale is “Treatment of active infection,” then complete the following:



Clinician-defined therapeutic site

(check all that apply):



Infection onset

(check all that apply):




IV or IM

Oral/enteral

Inhaled


Medical prophylaxis

Surgical prophylaxis

Shape6 Treatment of active infection

Non-infectious

None documented


BJI

BSI

CNS

CVI

DIS

ENT

GTI

HEB

IAB

LRI

REP

SST

UTI

UND

Unknown

Other: _______




AND

Your hospital

Other healthcare facility

Community

Unknown

Continued on page 2

2011 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY: EIP TEAM ANTIMICROBIAL USE FORM (continued)



CDC ID: -


Drug

Route

(check one):


Rationale

(check all that apply):


Shape7

If Rationale is “Treatment of active infection,” then complete the following:



Clinician-defined therapeutic site

(check all that apply):



Infection onset

(check all that apply):




IV or IM

Oral/enteral

Inhaled


Medical prophylaxis

Surgical prophylaxis

Shape8 Treatment of active infection

Non-infectious

None documented


BJI

BSI

CNS

CVI

DIS

ENT

GTI

HEB

IAB

LRI

REP

SST

UTI

UND

Unknown

Other: _______




AND

Your hospital

Other healthcare facility

Community

Unknown


Drug

Route

(check one):


Rationale

(check all that apply):


Shape9

If Rationale is “Treatment of active infection,” then complete the following:



Clinician-defined therapeutic site

(check all that apply):



Infection onset

(check all that apply):




IV or IM

Oral/enteral

Inhaled


Medical prophylaxis

Surgical prophylaxis

Shape10 Treatment of active infection

Non-infectious

None documented


BJI

BSI

CNS

CVI

DIS

ENT

GTI

HEB

IAB

LRI

REP

SST

UTI

UND

Unknown

Other: _______




AND

Your hospital

Other healthcare facility

Community

Unknown


Drug

Route

(check one):


Rationale

(check all that apply):


Shape11

If Rationale is “Treatment of active infection,” then complete the following:



Clinician-defined therapeutic site

(check all that apply):



Infection onset

(check all that apply):




IV or IM

Oral/enteral

Inhaled


Medical prophylaxis

Surgical prophylaxis

Shape12 Treatment of active infection

Non-infectious

None documented


BJI

BSI

CNS

CVI

DIS

ENT

GTI

HEB

IAB

LRI

REP

SST

UTI

UND

Unknown

Other: _______




AND

Your hospital

Other healthcare facility

Community

Unknown


Check one of the boxes below and follow the corresponding instructions:


If Rationale for ANY antimicrobial drug administered to the patient is “None documented” or “Treatment of active infection” GO TO HAI FORM.


If Rationale for EVERY antimicrobial drug administered to the patient is “Medical prophylaxis,” “Surgical prophylaxis” or “Non-infectious”

DON’T fill out HAI Form. Data collection complete.

2011 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY: EIP TEAM HAI FORM


CDC ID: -


Survey date: //


Date form completed: //


Data collector initials: __________


Does the patient have an HAI (check one)?

No data collection complete Yes complete the table and questions below.


Enter only one HAI on each HAI Form. This is HAI Form # _____ out of _____ total HAI Forms for this patient.

HAI

Specific Site

Device and Procedure Information

Comments

UTI

SUTI

ABUTI

OUTI

Catheter-associated?

No Yes


PNEU

PNU1

PNU2

PNU3

Ventilator-associated?

No Yes


BSI


LCBI


Central line-associated?

No Yes


SSI

SUP INC

DEEP INC

ORGAN/SPACE

(for ORGAN/SPACE, specify site : ___________)

Operative procedure category code:




BJ


BONE

JNT

DISC




CNS

IC

MEN

SA




CVS

VASC

ENDO

CARD

MED



EENT

CONJ

EYE

EAR

ORAL

SINU

UR



GI

GE

GIT

HEP

IAB TRANS

NEC

CDI



LRI

BRON

LUNG



REPR

EMET

EPIS

VCUF

OREP



SST

SKIN

ST

BURN

DECU

BRST

UMB

PUST CIRC



SYS

DI





Enter the symptom/sign onset date for this HAI: // OR Unknown OR Not collected


Enter the therapy start date for this HAI: //

OR check one: Unknown Not collected No therapy given


Was there a Secondary Bloodstream Infection associated with this HAI? No Yes Unknown


Enter up to three pathogen codes for this HAI: 1) ________ 2)________ 3) _________ OR No pathogen identified


Enter the CDC location of attribution for this HAI: _______________ Unknown Not applicable (i.e., SSI)


Continued on page 2

2011 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY: EIP TEAM HAI FORM (continued)


CDC ID: -

Date form completed: // Data collector initials: ________




Antimicrobial Susceptibility Testing—Instructions:

  1. Check the appropriate box(es) to indicate which of the pathogen(s) below (if any) caused this HAI. “E. coli”=Escherichia coli;E. faecium”=Enterococcus faecium; “E. faecalis”=Enterococcus faecalis; “P. aeruginosa”=Pseudomonas aeruginosa; “S. aureus”=Staphylococcus aureus.

  2. Check the appropriate susceptibility test results for the antimicrobial agents listed: S=sensitive/susceptible. I=intermediate, R=resistant, N=not tested.

  3. Antimicrobial agent abbreviations: AMK=amikacin, AMP=ampicillin, AMPSUL=ampicillin/sulbactam,CEFEP=cefepime, CEFOT=cefotetan, CEFTAZ=ceftazidime, CEFTRX=ceftriaxone, CIPRO=ciprofloxacin, CLINDA=clindamycin, COL/PB=colistin or polymyxin B, DAPTO=daptomycin, DOXY=doxycycline, ERYTH=erythromycin, GENT=gentamicin, IMI=imipenem, LEVO=levofloxacin, LNZ=linezolid, MERO=meropenem, OX=oxacillin, PENG=penicillin G, PIP=piperacillin, PIPTAZ=piperacillin/tazobactam, QUIDAL=quinupristin/dalfopristin, RIF=rifampin, TETRA=tetracycline, TIG=tigecycline, TMZ=trimethoprim/sulfamethoxazole, VANC=vancomycin.


Check here if NONE of the organisms below are pathogens for this HAI (data collection is now complete).

Acinetobacter

baumannii

other

AMK

AMPSUL

CEFEP

CEFTAZ

CIPRO


COL/PB

GENT

IMI

LEVO

MERO

PIPTAZ

TOBRA

TIG

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

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N


E. coli

AMK

AZT

CEFEP

CEFOT

CEFTAZ

CEFTRX

CIPRO

GENT

IMI

LEVO

MERO

TOBRA

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

S

I

R

N

S

I

R

N

S

I

R

N

Positive test for extended-spectrum beta lactamase (ESBL) production?

Yes No Unknown

Positive test for carbapenemase production?

Yes No Unknown




E. faecium

AMP

DAPTO

LNZ

PENG

QUIDAL

VANC

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N


E. faecalis

AMP

DAPTO

LNZ

PENG

VANC

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N


Klebsiella

pneumoniae

oxytoca

other

AMK

AZT

CEFEP

CEFOT

CEFTAZ

CEFTRX

CIPRO

GENT

IMI

LEVO

MERO

TOBRA

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

S

I

R

N

S

I

R

N

S

I

R

N

Positive test for extended-spectrum beta lactamase (ESBL) production?

Yes No Unknown

Positive test for carbapenemase production?

Yes No Unknown




P. aeruginosa

AMK

AZT

CEFEP

CEFTAZ

CIPRO

GENT

IMI

LEVO

MERO

PIP

PIPTAZ

TOBRA

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

S

I

R

N

S

I

R

N

S

I

R

N


S. aureus

CLIND

DAPTO

DOXY

ERYTH

GENT

LNZ

OX

QUIDAL

RIF

TETRA

TMZ

VANC

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

S

I

R

N

S

I

R

N

S

I

R

N

Enter the vancomycin MIC (in mcg/ml):


______________ Unknown Not collected

Check vancomycin MIC test method:

E-test Vitek 2 Vitek Legacy Phoenix MicroScan dried overnight panels Unknown Not collected

Other: ___________________________


FORM IS COMPLETE

Phase3_AntimicrobialUseForm_v1_20101210 page 1 of 2


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