AttachmentF_0920-0852_SupplementalInformationOnly

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

CDC ID: -	Survey date: //	Date form completed: //			Initials: ______
Hospital discharge date: // OR check one: Still in hospital Unknown Not collected			Patient outcome:	Survived Died	Unknown Not collected

**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.

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 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):		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 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):		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 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):		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 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):		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 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):		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 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, NS=non-susceptible or not sensitive, N=not tested.

3. Antimicrobial agent abbreviations: AMK=amikacin, AMP=ampicillin, AMPSUL=ampicillin/sulbactam,CEFEP=cefepime, CEFOT=cefotaxime, CEFTAZ=ceftazidime, CEFTRX=ceftriaxone, CIPRO=ciprofloxacin, CLINDA=clindamycin, COL/PB=colistin or polymyxin B, DAPTO=daptomycin, DOXY=doxycycline, ERYTH=erythromycin, GENT=gentamicin, GENTHL=gentamicin-high level test (Enterococcus only), IMI=imipenem, LEVO=levofloxacin, LNZ=linezolid, MERO=meropenem, OX=oxacillin, PENG=penicillin G, PIP=piperacillin, PIPTAZ=piperacillin/tazobactam, QUIDAL=quinupristin/dalfopristin, RIF=rifampin, STREPHL=streptomycin-high level test (Enterococcus only), 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

NS 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. faecalis

AMP

DAPTO

GENTHL

LNZ

PENG

STREPHL

TIG

VANC

S I

R N

S

NS N

S

R N

S I

R N

S I

R N

S

R N

S

NS N

S I

R N

E. faecium

AMP

DAPTO

GENTHL

LNZ

PENG

QUIDAL

STREPHL

TIG

VANC

S I

R N

S

NS N

S

R N

S I

R N

S I

R N

S I

R N

S

R N

S

NS 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

TIG

TMZ

VANC

S I

R N

S

NS 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

NS 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

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