OMB No. 0920-0666
Exp. Date: xx-xx-xxxx
www.cdc.gov/nhsn
Urinary Tract Infection (UTI) for LTCF
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*required for saving
*Facility ID: |
Event #: |
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*Resident ID: |
*Social Security #: |
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Medicare number (or comparable railroad insurance number): |
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Resident Name, Last: |
First: |
Middle: |
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*Gender: M F Other |
*Date of Birth: ___/___/____ |
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Ethnicity (specify): |
Race (specify): |
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*Resident type: |
□ Short-stay (≤90 days) |
□ Long-stay (>90 days) |
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*Date of First Admission to Facility: __/__/____ |
*Date of Current Admission to Facility: __/__/____ |
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*Event Type: UTI |
*Date of Event: __/__/____ |
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*Resident Care Location: __________________________ |
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*Primary Resident Service Type: (check one) |
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□ Long-term general nursing |
□ Long-term dementia |
□ Long-term psychiatric |
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□ Skilled nursing/Short-term rehab (subacute) |
□ Ventilator |
□ Bariatric |
□ Hospice/Palliative |
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*Has resident been transferred from an acute care facility in the past 3 months? |
Yes |
No |
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If Yes, date of last transfer from acute care to your facility: __/__/____ |
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*Urinary Catheter status at time of specimen collection (Check one): |
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□ In place |
□ Removed within 48 hours prior |
□ Not in place nor within 48 hours prior |
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If urinary catheter status In place or Removed within 48 hours prior: |
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Site where Device Inserted (Check one): |
□ Your facility |
□ Acute care hospital |
□ Other |
□ Unknown |
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Device Type (Check one): |
□ Indwelling |
□ Suprapubic |
□ Condom (males only) |
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Date of Device Insertion: ___/___/_____ |
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Event Details |
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*Specify Criteria Used: (check all that apply) |
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Signs & Symptoms |
Laboratory & Diagnostic Testing |
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□ Fever: Single temperature ≥ 37.8°C (>100°F), or > 37.2°C (>99°F) on repeated occasions, or an increase of >1.1°C (>2°F) over baseline |
□ Positive culture with ≥ 105 CFU/ml with single predominant microorganism or 2 species of gram negative microorganisms from voided specimen |
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□ Rigors |
□ New onset hypotension |
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□ New onset confusion/functional decline |
□ Positive culture with ≥ 102 CFU/ml of any microorganisms from in/out catheter specimen |
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□ Acute pain, swelling, or tenderness of the testes, epididymis, or prostate |
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□ Acute dysuria |
□ Positive culture with ≥ 105 CFU/ml of any microorganisms from newly placed indwelling catheter specimen |
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□ Purulent drainage at catheter insertion site |
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New and/or marked increase in (check all that apply): |
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□ Urgency |
□ Costovertebral angle pain or tenderness |
□ Leukocytosis (> 14,000 cells/mm3), or Left shift (> 6% or 1,500 bands/mm3) |
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□ Frequency |
□ Suprpubic tenderness |
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□ Incontinence |
□ Visible (gross) hematuria |
□ Positive blood culture with 1 matching organism in urine culture |
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*Specific Event (Check one): |
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□ Symptomatic UTI (SUTI) |
□ Symptomatic CA-UTI (CA-SUTI) |
□ Asymptomatic Bacteremic UTI (ABUTI) |
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Secondary Bloodstream Infection: Yes No |
Died within 30 days of Date of Event: Yes No |
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*Transfer to acute care facility: Yes No |
If yes, date of transfer: ___/___/_____ |
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*Pathogens identified: Yes No |
*If Yes, specify on page 2 |
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Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.140 (Front) v6.6 |
Urinary Tract Infection (UTI) for LTCF
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Pathogen # |
Gram-positive Organisms |
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_______ |
Staphylococcus coagulase-negative |
VANC S I R N |
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(specify): ________________________ |
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_______ |
Enterococcus spp.( specify): |
AMP S I R N |
CIPRO/LEVO/MOXI S I R N |
DAPTO S NS N |
DOXY/MINO S I R N |
GENTHL§ S R N |
LNZ S I R N |
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___________ |
STREPHL§ S R N
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TETRA S I R N
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TIG S NS N
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VANC S I R N
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_______
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Enterococcus faecium |
AMP S I R N |
CIPRO/LEVO/MOXI S I R N |
DAPTO S NS N |
DOXY/MINO S I R N |
GENTHL§ S R N |
LNZ S I R N |
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QUIDAL S I R N
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STREPHL§ S R N
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TETRA S I R N
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TIG S NS N
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VANC S I R N
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_______ |
Staphylococcus aureus |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
CLIND S I R N |
DAPTO S NS N |
DOXY/MINO S I R N |
ERYTH S I R N |
GENT S I R N |
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LNZ S R N
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OX/CEFOX/METH S I R N |
QUIDAL S I R N |
RIF S I R N |
TETRA S I R N |
TIG S NS N |
TMZ S I R N |
VANC S I R N |
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Pathogen # |
Gram-negative Organisms |
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_______ |
Acinetobacter spp. (specify): |
AMK S I R N |
AMPSUL S I R N |
AZT S I R N |
CEFEP S I R N |
CEFTAZ S I R N |
CIPRO/LEVO S I R N |
COL/PB S I R N |
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____________ |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIP/PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TMZ S I R N |
TOBRA S I R N |
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_______ |
Escherichia coli |
AMK S I R N |
AMP S I R N |
AMPSUL/AMXCLV S I R N |
AZT S I R N |
CEFAZ S I R N |
CEFEP S I R N |
CEFOT/CEFTRX S I R N |
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CEFTAZ S I R N |
CEFUR S I R N |
CEFOX/CETET S I R N |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
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ERTA S I R N |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
Enterobacter spp. (specify): |
AMK S I R N |
AMP S I R N |
AMPSUL/AMXCLV S I R N |
AZT S I R N |
CEFAZ S I R N |
CEFEP S I R N |
CEFOT/CEFTRX S I R N |
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____________ |
CEFTAZ S I R N |
CEFUR S I R N |
CEFOX/CETET S I R N |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
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|
ERTA S I R N |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
Klebsiella spp. (specify): |
AMK S I R N |
AMP S I R N |
AMPSUL/AMXCLV S I R N |
AZT S I R N |
CEFAZ S I R N |
CEFEP S I R N |
CEFOT/CEFTRX S I R N |
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____________ |
CEFTAZ S I R N |
CEFUR S I R N |
CEFOX/CETET S I R N |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
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ERTA S I R N |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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Urinary Tract Infection (UTI) for LTCF Page 3 of 4 |
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Pathogen # |
Gram-negative Organisms (continued) |
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_______ |
Serratia marcescens |
AMK S I R N |
AMP S I R N |
AMPSUL/AMXCLV S I R N |
AZT S I R N |
CEFAZ S I R N |
CEFEP S I R N |
CEFOT/CEFTRX S I R N |
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CEFTAZ S I R N |
CEFUR S I R N |
CEFOX/CETET S I R N |
CHLOR S I R N |
CIPRO/LEVO/MOXI S I R N |
COL/PB S I R N |
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|
ERTA S I R N |
GENT S I R N |
IMI S I R N |
MERO/DORI S I R N |
PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
Pseudomonas aeruginosa |
AMK S I R N |
AZT S I R N |
CEFEP S I R N |
CEFTAZ S I R N |
CIPRO/LEVO S I R N |
COL/PB S I R N |
GENT S I R N |
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IMI S I R N
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MERO/DORI S I R N |
PIP/PIPTAZ S I R N |
TOBRA S I R N |
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_______ |
Stenotrophomonas maltophilia |
LEVO S I R N |
TETRA/MINO S I R N |
TICLAV S I R N |
TMZ S I R N |
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Pathogen # |
Fungal Organisms |
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_______ |
Candida spp. (specify): ____________
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ANID S I R N |
CASPO S NS N |
FLUCO S S-DD R N |
FLUCY S I R N |
ITRA S S-DD R N |
MICA S NS N |
VORI S S-DD R N |
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Pathogen # |
Other Organisms |
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_______ |
Organism 1 (specify) ____________
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_______Drug 1 S I R N |
_______ Drug 2 S I R N |
______ Drug 3 S I R N |
_______ Drug 4 S I R N |
_______Drug 5 S I R N |
______ Drug 6 S I R N |
______ Drug 7 S I R N |
______ Drug 8 S I R N |
______ Drug 9 S I R N |
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_______ |
Organism 1 (specify) ____________
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_______Drug 1 S I R N |
_______ Drug 2 S I R N |
______ Drug 3 S I R N |
_______ Drug 4 S I R N |
_______Drug 5 S I R N |
______ Drug 6 S I R N |
______ Drug 7 S I R N |
______ Drug 8 S I R N |
______ Drug 9 S I R N |
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_______ |
Organism 1 (specify) ____________
|
_______Drug 1 S I R N |
_______ Drug 2 S I R N |
______ Drug 3 S I R N |
_______ Drug 4 S I R N |
_______Drug 5 S I R N |
______ Drug 6 S I R N |
______ Drug 7 S I R N |
______ Drug 8 S I R N |
______ Drug 9 S I R N |
Result Codes
S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested
§ GENTHL and STREPHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic
Drug Codes: |
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AMK = amikacin |
CEFTRX = ceftriaxone |
ERYTH = erythromycin |
MICA = micafungin |
STREPHL = streptomycin – high level test |
AMP = ampicillin |
CEFUR= cefuroxime |
FLUCO = fluconazole |
MINO = minocycline |
TETRA = tetracycline |
AMPSUL = ampicillin/sulbactam |
CETET= cefotetan |
FLUCY = flucytosine |
MOXI = moxifloxacin |
TICLAV = ticarcillin/clavulanic acid |
AMXCLV = amoxicillin/clavulanic acid |
CHLOR= chloramphenicol |
GENT = gentamicin |
OX = oxacillin |
TIG = tigecycline |
ANID = anidulafungin |
CIPRO = ciprofloxacin |
GENTHL = gentamicin –high level test |
PB = polymyxin B |
TMZ = trimethoprim/sulfamethoxazole |
AZT = aztreonam |
CLIND = clindamycin |
IMI = imipenem |
PIP = piperacillin |
TOBRA = tobramycin |
CASPO = caspofungin |
COL = colistin |
ITRA = itraconazole |
PIPTAZ = piperacillin/tazobactam |
VANC = vancomycin |
CEFAZ= cefazolin |
DAPTO = daptomycin |
LEVO = levofloxacin |
QUIDAL = quinupristin/dalfopristin |
VORI = voriconazole |
CEFEP = cefepime |
DORI = doripenem |
LNZ = linezolid |
RIF = rifampin |
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CEFOT = cefotaxime |
DOXY = doxycycline |
MERO = meropenem |
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CEFOX= cefoxitin |
ERTA = ertapenem |
METH = methicillin |
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CEFTAZ = ceftazidime |
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Urinary Tract Infection (UTI) for LTCF Page 4 of 4 |
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Comments |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Amy Schneider |
File Modified | 0000-00-00 |
File Created | 2021-01-31 |