57.140 Urinary Tract Infection (UTI) for LTCF

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Urinary Tract Infection (UTI) for LTCF

Page 1 of 4 *required for saving

*Facility ID:

Event #:

*Resident ID:

*Social Security #:

Medicare number (or comparable railroad insurance number):

Resident Name, Last:

First:

Middle:

*Gender: M F Other

*Date of Birth: ___/___/____

Ethnicity (specify):

Race (specify):

*Resident type:

□ Short-stay

□ Long-stay

*Date of First Admission to Facility: __/__/____

*Date of Current Admission to Facility: __/__/____

*Event Type: UTI

*Date of Event: __/__/____

*Resident Care Location: __________________________

*Primary Resident Service Type: (check one)

□ Long-term general nursing

□ Long-term dementia

□ Long-term psychiatric

□ Skilled nursing/Short-term rehab (subacute)

□ Ventilator

□ Bariatric

□ Hospice/Palliative

*Has resident been transferred from an acute care facility to your facility in the past 3 months?

□ Yes

□ No

If Yes, date of last transfer from acute care to your facility: __/__/____

If Yes, did the resident have an indwelling urinary catheter at the time of transfer to your facility?

□ Yes

□ No

*Indwelling Urinary Catheter status at time of event onset (check one):

□ In place

□ Removed within last 2 calendar days

□ Not in place

If indwelling urinary catheter status in place or removed within last 2 calendar days:

Site where indwelling urinary catheter inserted (check one):

□ Your facility

□ Acute care hospital

□ Other

□ Unknown

Date of indwelling urinary catheter Insertion: ___/___/_____

If indwelling urinary catheter not in place, was another urinary device type present at the time of event onset?

□ Yes

□ No

If yes, other device type:

□ Suprapubic

□ Condom (males only)

□ Intermittent straight catheter

Event Details

*Specify Criteria Used: (check all that apply)

Laboratory & Diagnostic Testing

Signs & Symptoms

□ 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

□ Specimen collected from clean catch voided urine and positive culture with ≥ 105 CFU/ml of no more than 2 species of microorganisms

□ Rigors

□ New onset hypotension

□ New onset confusion/functional decline

□ Specimen collected from in/out straight catheter and positive culture with ≥ 102 CFU/ml of any microorganisms

□ Acute pain, swelling, or tenderness of the testes, epididymis, or prostate

□ Acute dysuria

□ Purulent drainage at catheter insertion site

□ Specimen collected from indwelling catheter and positive culture with ≥ 105 CFU/ml of any microorganisms

New and/or marked increase in (check all that apply):

□ Urgency

□ Costovertebral angle pain or tenderness

□ Leukocytosis (> 14,000 cells/mm3), or Left shift (> 6% or 1,500 bands/mm3)

□ Frequency

□ Suprapubic tenderness

□ Incontinence

□ Visible (gross) hematuria

□ Positive blood culture with 1 matching organism in urine culture

*Specific Event (Check one):

□ Symptomatic UTI (SUTI)

□ Symptomatic CA-UTI (CA-SUTI)

□ Asymptomatic Bacteremic UTI (ABUTI)

Secondary Bloodstream Infection: Yes No

Died within 7 days of date of event: Yes No

*Transfer to acute care facility within 7 days: Yes No

*Pathogens identified: Yes No

*If Yes, specify on page 2

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) v7.2

Urinary Tract Infection (UTI) for LTCF

Page 2 of 4
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) for LTCF Page 3 of 4

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) for LTCF Page 4 of 4
Custom Fields
Label		Label
______________________	____/____/____	_______________________	____/____/_____
_______________________	_____________	_______________________	______________
_______________________	_____________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
Comments