57.114 Urinary Tract Infection (UTI)

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Urinary Tract infection (UTI)

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*required for saving **required for completion
Facility ID:				Event #:
*Patient ID:				Social Security #:
Secondary ID:				Medicare #:
Patient Name, Last:				First:						Middle:
*Gender: F M Other				*Date of Birth:
Ethnicity (Specify):				Race (Specify):
*Event Type: UTI				*Date of Event:
Post-procedure UTI: Yes No				Date of Procedure:
NHSN Procedure Code:				ICD-9-CM Procedure Code:
*MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module
*Date Admitted to Facility:							*Location:
Risk Factors
*Urinary Catheter status at time of specimen collection or onset of signs or symptoms:
□ In place		□ Removed within 2 calendar days prior							□ Not in place nor within 2 calendar days prior
Location of Device Insertion: ________________________									Date of Device Insertion: ____ /____ /_______
If NICU, birth weight (gms): ____________
Event Details
*Specific Event:	□ Symptomatic UTI (SUTI)				□ Asymptomatic Bacteremic UTI (ABUTI)						□ Other UTI (OUTI)
*Specify Criteria Used: (check all that apply)
Signs & Symptoms								Laboratory & Diagnostic Testing
Any Patient			≤ 1 year old
□ Fever			□ Fever					□ 1 positive culture with ≥ 105 CFU/ml with no more than 2 species of microorganisms
□ Urgency			□ Hypothermia
□ Frequency			□ Apnea					□ Positive dipstick for leukocyte esterase or nitrite
□ Dysuria			□ Bradycardia					□ Pyuria
□ Suprapubic tenderness			□ Dysuria					□ Microorganisms seen on Gram stain of unspun urine
□ Costovertebral angle pain or tenderness			□ Lethargy					□ 1 positive culture with ≥ 103 CFU/ml and < 105 CFU/ml with no more than 2 species of microorganisms
□ Abscess			□ Vomiting					□ Positive culture
□ Pain or tenderness								□ Positive blood culture
□ Purulent drainage or material								□ Radiographic evidence of infection
□ Other evidence of infection found on direct exam, during surgery, or by diagnostic tests‡								‡ per specific site criteria
*Secondary Bloodstream Infection: Yes No
**Died: Yes No						UTI Contributed to Death: Yes No
Discharge Date:						*Pathogens Identified: Yes No *If Yes, specify on pages 2-4.
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 32 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 57.114 (Front) Rev 7, v7.2

Urinary Tract infection (UTI)

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Pathogen #	Gram-positive Organisms
_______	Staphylococcus coagulase-negative		VANC S I R N
	(specify): ________________________
_______	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
	___________	STREPHL§ S R N			TETRA S I R N	TIG S NS N	VANC S I R N
_______	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
		QUIDAL S I R N		STREPHL§ S R N		TETRA S I R N	TIG S NS N	VANC S I R N
_______	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
		LNZ S R N		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
Pathogen #	Gram-negative Organisms
_______	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
	____________	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
		TMZ S I R N		TOBRA S I R N
_______	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
		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
		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
		TIG S I R N		TMZ S I R N	TOBRA S I R N
_______	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
	____________	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
		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
		TIG S I R N		TMZ S I R N	TOBRA S I R N
_______	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
	____________	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
		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
		TIG S I R N		TMZ S I R N	TOBRA S I R N

Urinary Tract infection (UTI)

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Pathogen #

Gram-negative Organisms (continued)

_______

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

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

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

TIG S I R N

TMZ S I R N

TOBRA S I R N

_______

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

IMI S I R N

MERO/DORI S I R N

PIP/PIPTAZ S I R N

TOBRA S I R N

_______

Stenotrophomonas maltophilia

LEVO S I R N

TETRA/MINO S I R N

TICLAV S I R N

TMZ S I R N

Pathogen #

Fungal Organisms

_______

Candida spp. (specify): ____________

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

Pathogen #

Other Organisms

_______

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

_______

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

_______

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:
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
CEFOT = cefotaxime	DOXY = doxycycline	MERO = meropenem
CEFOX= cefoxitin	ERTA = ertapenem	METH = methicillin
CEFTAZ = ceftazidime

Urinary Tract infection (UTI)

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