Non PRA Applicable- EIP Supplemental Information

AttachmentG_FINAL_0920-0852_SupplementalForms_20130726.docx

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

Non PRA Applicable- EIP Supplemental Information

OMB: 0920-0852

Document [docx]
Download: docx | pdf

Shape2 Shape1

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY

EIP HEALTHCARE FACILITY ASSESSMENT—FOR EIPT USE ONLY



Hospital ID: ________________________ Survey date: //



  1. Enter the date on which you are completing this form: //



  1. Enter your initials: _________



  1. Is the hospital located in an urban or rural area?

Rural

Urban

Unknown


  1. Does the hospital have an American Medical Association (AMA)-approved residency program?

Yes

No

Unknown


  1. Is the hospital a member of the Council of Teaching Hospitals (COTH)?

Yes

No

Unknown




HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL USE FORM


CDC ID: -

Survey date: //

Date form completed: //

Initials: ______


**Check here if no antimicrobials were administered on the survey date or the calendar day prior to the survey date. If no antimicrobials were administered, data collection is complete. If one or more antimicrobials were administered, fill out pages 1 AND 2 of this form.


**Check here if >6 antimicrobial agents were administered on the survey date or the calendar day prior to the survey date, AND enter additional antimicrobial agents on another Antimicrobial Use Form (each form will accommodate 6 antimicrobial agent entries).


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.

Shape3

Enter drug name here:

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):

Start date: ___/___/___

Survey date, total dose: ____________________________


Day prior to survey, total dose: ____________________________

IV

IM

PO

INH

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

Nursing home/SNF

Other healthcare facility

Community

Unknown


Enter drug name here:

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):

Start date: ___/___/___

Survey date, total dose: ____________________________


Day prior to survey, total dose: ____________________________

IV

IM

PO

INH

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

Nursing home/SNF

Other healthcare facility

Community

Unknown


Enter drug name here:

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):

Start date: ___/___/___

Survey date, total dose: ____________________________


Day prior to survey, total dose: ____________________________

IV

IM

PO

INH

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

Nursing home/SNF

Other healthcare facility

Community

Unknown



Continued on page 2

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL USE FORM (continued)



CDC ID: -


Enter drug name here:

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):

Start date: ___/___/___

Survey date, total dose: ____________________________


Day prior to survey, total dose: ____________________________

IV

IM

PO

INH

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

Nursing home/SNF

Other healthcare facility

Community

Unknown


Enter drug name here:

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):

Start date: ___/___/___

Survey date, total dose: ____________________________


Day prior to survey, total dose: ____________________________

IV

IM

PO

INH

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

Nursing home/SNF

Other healthcare facility

Community

Unknown


Enter drug name here:

Route

(check one):

Rationale

(check all that apply):


Shape13

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):

Start date: ___/___/___

Survey date, total dose: ____________________________


Day prior to survey, total dose: ____________________________

IV

IM

PO

INH

Medical prophylaxis

Surgical prophylaxis

Shape14 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

Nursing home/SNF

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 only “Medical prophylaxis,” “Surgical prophylaxis” or “Non-infectious”

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



HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM


CDC ID: -

Survey date: //

Data collector initials: _____


Date form completed: //


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

BSI


LCBI

MBI-LCBI

Central line-associated?

2011 rule: No Yes Current rule: No Yes


PNEU

PNU1

PNU2

PNU3

Ventilator-associated?

2011 rule: No Yes Current rule: No Yes


SSI

SUP INC

DEEP INC

ORGAN/SPACE

(for ORGAN/SPACE, specify site : ___________)

Operative procedure category code: ________


Procedure date: //


Implant? No Yes


Incision closed primarily? No Yes


If DEEP INC or ORGAN/SPACE, was physician diagnosis used to meet definition? No Yes NA


UTI

SUTI

ABUTI

OUTI

Catheter-associated?

2011 rule: No Yes Current rule: No Yes



Other Healthcare-Associated Events

HAI

Specific Site

Comments


HAI

Specific Site

Comments

BJ


BONE

JNT

DISC



LRI

BRON

LUNG


CNS

IC

MEN

SA



REPR

EMET

EPIS

VCUF

OREP


CVS

VASC

ENDO

CARD

MED



SST

SKIN

ST

BURN

DECU

PUST

CIRC

BRST

UMB


EENT

CONJ

EYE

EAR

ORAL

SINU

UR



SYS

DI


GI

GE

GIT

HEP

IAB

NEC

CDI



VAE

VAC

IVAC

POVAP

PRVAP



Enter the symptom/sign onset date for this HAI: // OR Unknown—prior to admit


Enter the therapy start date for this HAI: // OR Unknown No therapy given


Enter date on which all definition criteria were fully met: // OR Unknown


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)

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM (continued)


CDC ID: - Survey date: // Data collector initials: _____



Instructions: 1) Check the appropriate box(es) to indicate which of the pathogen(s) below (if any) caused this HAI. 2) Circle the appropriate susceptibility test results for the antimicrobial agents listed: S=sensitive/susceptible, S-DD=susceptible dose-dependent, I=intermediate, R=resistant, NS=non-susceptible or not sensitive, N=not tested. 3) Where multiple antimicrobial agents are listed in a single column, circle the agent for which results are recorded. If susceptibility data are available for multiple agents listed in a single column, select and record results for the agent to which the organism is most resistant. 4) Abbreviations: AMK=amikacin, ANID=anidulafungin, CASPO=caspofungin, CEFEP=cefepime, CEFOT=cefotaxime, CEFOX/OX/METH=cefoxitin, oxacillin or methicillin, CEFTAZ=ceftazidime, CEFTRX=ceftriaxone, CEFROL=ceftaroline, CIPRO/LEVO=ciprofloxacin or levofloxacin, COL/PB=colistin or polymyxin B, DAPTO=daptomycin, DORI=doripenem, ERTA=ertapenem, FLUCO=fluconazole, GENT=gentamicin, IMI=imipenem, LNZ=linezolid, MERO=meropenem, MICA=micafungin, PIP/PIPTAZO=piperacillin or piperacillin/tazobactam, POSA=posaconazole, TOBRA=tobramycin, VANC=vancomycin, VORI=voriconazole.


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

Candida spp. susceptibility data:

Organism

ANID

CASPO

FLUCO

MICA

POSA

VORI

Candida

albicans

glabrata

parapsilosis

other


S I R NS N

S I R NS N

S I R NS N

S I R NS N


S I R NS N

S I R NS N

S I R NS N

S I R NS N


S S-DD I R NS N

S S-DD I R NS N

S S-DD I R NS N

S S-DD I R NS N


S I R NS N

S I R NS N

S I R NS N

S I R NS N


S S-DD I R NS N

S S-DD I R NS N

S S-DD I R NS N

S S-DD I R NS N


S S-DD I R NS N

S S-DD I R NS N

S S-DD I R NS N

S S-DD I R NS N

Gram-positive bacteria susceptibility data:

Organism

CEFROL

CEFOX/OX/METH

DAPTO

LNZ

VANCO

Enterococcus

faecalis

faecium

other




S I R NS N

S I R NS N

S I R NS N


S I R NS N

S I R NS N

S I R NS N


S I R N

S I R N

S I R N

Staphylococcus aureus

S I R NS N

S I R N

S I R NS N

S I R NS N

S I R N


Enterobacteriaceae susceptibility data:

Organism

CEFEP

CEFOT

CEFTAZ

CEFTRX

COL/PB

DORI

ERTA

IMI

MERO

Enterobacter

aerogenes

cloacae

other


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

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

S I R N

E. coli

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

Klebsiella

oxytoca

pneumoniae

other


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

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

S I R N


Pseudomonas aeruginosa susceptibility data:


Organism

AMK

CEFEP

CEFTAZ

CIPRO/LEVO

COL/PB

DORI

GENT

IMI

MERO

PIP/PIPTAZ

TOBRA


P. aeruginosa

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



FORM IS COMPLETE

Appropriate Antimicrobial Use: Drug-Specific Form


Check the antimicrobial agent under evaluation (AUE) (only 1 AUE per form):


Vancomycin Daptomycin Linezolid Piperacillin/tazobactam

Demographics

CDC ID: -

Survey date: //

Date form completed: //

Data collector initials: __________

Hospital admission date: // Hospital discharge date: //

Patient Admission History

Date of symptom onset: //

Patient weight (in kg): ­­­_______

Was the patient a resident of a LTCF or LTACH prior to this hospital admission? Yes No Unknown

Does this patient have any of the following drug allergies entered in the medical record? None

Penicillin TMP/Sulfa Cephalosporins Fluoroquinolones Carbapenems Other:________________

Primary admitting diagnosis:__________________________________________________________________________

Primary discharge diagnosis:__________________________________________________________________________

Did this patient have evidence of any of the following types of infection during the admission? None

Skin or soft tissue infection Prosthetic joint infection Osteomyelitis Septic arthritis Abscess

Was this patient admitted on any antimicrobial therapy? Yes No Unknown

If Yes, name of antimicrobial:______________________________________

Did this patient have any of the following comorbidities present on admission or prior to antibiotic start? (check all that apply) None


Leukemia or lymphoma Prosthetic cardiac valve or pacemaker/AICD

History of solid organ transplant or stem cell transplant Surgery in the 12 months prior to antibiotic start Colonization with VRE in the 12 months prior to antibiotic start Renal failure/Dialysis Colonization with MRSA in the 12 months prior to antibiotic start Cancer, solid tumor

Was this patient previously hospitalized in an acute care hospital for 2 days in the 12 weeks prior to this hospitalization? Yes No Unknown

Was this patient admitted to an ICU 5 days after antibiotic start? Yes No Unknown

If Yes, ICU admission date: // ICU discharge date: //

If Yes, did the patient require ventilator support? Yes No

If Yes, did the patient require vasopressors? Yes No

Did the patient receive any of the following in the 7 days prior to antibiotic start? None

IV antimicrobials Chemotherapy Wound care Hemodialysis

Did this patient have a routine surveillance culture of the nares positive for MRSA on admission?

Yes No Not Tested Unknown



Antimicrobial Administration Table: Complete the following table for all antimicrobials the patient received in the 7 days prior to and the 7 days after start of the AUE (i.e., vancomycin, daptomycin, linezolid or piperacillin/tazobactam):

  1. Enter the names of all antimicrobials given IV, IM, po/enteral (PO), via inhalation (INH), or where route of administration is unknown (U).

  2. Record the route of administration (IV, IM, PO, INH, or U).

  3. Indicate the rationale: medical prophylaxis (MP), surgical prophylaxis (SP), empiric treatment (ET), targeted treatment (TT), non-infection-related (NI), or unknown rationale (U).

  4. Enter the clinician-defined therapeutic site(s), or enter “NA” if MP, SP, NI or U. See operational manual for details.

  5. Cells for dates on which an antimicrobial was not given should be left blank.

Date (mm/dd):









Date of AUE start:










Drug Name


Day -7

Day -6

Day -5

Day -4

Day -3

Day -2

Day -1

Day 0

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7


Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Route
















Rationale
















Therapeutic site

















Treatment

Was the patient discharged on antimicrobials? Yes No Unknown NA (patient deceased)

Diagnostic testing


Were any of the following diagnostic or microbiology specimens sent in +/- 3 days of antibiotic start? None

Cultures: Blood Respiratory Urine Wound Deep surgical Abscess drain

Ascitic fluid Pleural fluid Stool Other (specify): ______________________


Diagnostics: Urinalysis C. difficile testing


If Yes, Complete the table below for each culture or diagnostic test:

Date Specimen Collected

Test Type

Date Final Result (with AST for cultures) Available

If Positive, Organism

Antimicrobial Sensitivities*

If positive, was repeat testing done for the same site ≤ 7 days after initial culture?

If yes,

were any positive with same organism?







































































*Record AST results on AST worksheets.


Did the patient have any of the following in ≤ 3 days after starting antibiotic therapy? None

Received pressors HR > 100 bpm SBP < 99 mm Hg RR ≥ 20 bpm T ≥ 100oF (37. 8oC)

Neutropenia (ANC < 500)



COMMENTS:










Appropriate Antimicrobial Use: Urinary Tract Infection Form

Demographics

CDC ID: -

Survey date: //

Date form completed: //

Data collector initials: __________

Hospital admission date:// Hospital discharge date://

Patient Admission History

Date of symptom onset: //

Was the patient a resident of a LTCF or LTACH prior to this hospital admission? Yes No Unknown

Does this patient have any of the following drug allergies entered in the medical record? None

Penicillin TMP/Sulfa Cephalosporins Fluoroquinolones Carbapenems Other:________________

Primary admitting diagnosis:__________________________________________________________________________

Primary discharge diagnosis:__________________________________________________________________________

Was this patient admitted on any antimicrobial therapy? Yes No Unknown

If Yes, name of antimicrobial:______________________________________

Did this patient have any of the following comorbities present on admission? (check all that apply) None


Kidney stones Pregnancy Neutropenia (ANC < 500)

History of renal transplant Urologic procedure in last 3 months History of renal stents

Spinal cord injury Chronic renal failure History of dialysis

Urologic abnormality, specify:_____________


Did the patient have any of the following signs or symptoms present on admission? (check all that apply) None


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)

New onset confusion/functional decline Suprapubic pain, swelling, or tenderness

New onset hypotension Purulent drainage at urinary catheter insertion site

Acute dysuria Increased urgency Visible (gross) hematuria

Increased frequency Increased incontinence Rigors

Costovertebral angle pain or tenderness Unknown

Did the patient have any of the following urinary catheters in place at the time of or in the 2 calendar days prior to symptom onset? None

Indwelling catheter Suprapubic catheter Condom catheter (males only)

Intermittent Catheterization In place, type unknown


If urinary catheter in place at the time of or 2 calendar days, was it changed or removed after the diagnosis of UTI?

Yes No Unknown

Antimicrobial Administration Table: Complete the following table for all antimicrobials the patient received in the 3 days prior to and the 7 days after symptom onset date:

  1. Enter the names of all antimicrobials given IV, IM, po/enteral (PO), via inhalation (INH), or where route of administration is unknown (U).

  2. Record the route of administration (IV, IM, PO, INH, or U).

  3. Indicate the rationale: medical prophylaxis (MP), surgical prophylaxis (SP), empiric treatment (ET), targeted treatment (TT), non-infection-related (NI), or unknown rationale (U).

  4. Enter the clinician-defined therapeutic site(s), or enter “NA” if MP, SP, NI or U. See operational manual for details.

  5. Cells for dates on which an antimicrobial was not given should be left blank.

Date (mm/dd):





Symptom onset:











Drug Name


Day -3

Day -2

Day -1

Day 0

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Was the patient discharged on this drug?


Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site















Diagnostic testing

Was a urinalysis sent ≤ 3 days of first antibiotic start with UTI rationale? Yes No Unknown

If Yes, was there evidence of pyuria (≥ 5-10 WBCs/high power field)? Yes No Unknown

Was a urine culture sent within ≤ 3 days of first antibiotic start with UTI rationale? Yes No Unknown

If Yes, date of specimen collection: //

If Yes, date final result was available: //

If Yes, was the urine culture positive? Yes No Unknown


If culture was positive, document organism, colony count, and antimicrobial sensitivity results:

Organism

Colony forming unit count

Antimicrobial sensitivities*



















*Record AST results on the AST worksheet

Did the patient have any blood cultures positive for the same organisms listed above within ≤ 3 days of the urine culture specimen collection date? Yes No Unknown

Were other urinary cultures collected >3 days after first antibiotic start with UTI rationale? Yes No Unknown

If Yes, indicate # of days after first antibiotic start with UTI rationale: _____ days




COMMENTS:























Appropriate Antimicrobial Use: Community-Onset Lower Respiratory Infection Form

Demographics

CDC ID: -

Survey date: //

Date form completed: //

Data collector initials: __________

Hospital admission date:// Hospital discharge date://

Patient Admission History

Date of symptom onset: //

Was the patient a resident of a LTCF or LTACH prior to this hospital admission? Yes No Unknown

Does this patient have any of the following drug allergies entered in the medical record? None

Penicillin TMP/Sulfa Cephalosporins Fluoroquinolones Carbapenems Other:________________

Primary admitting diagnosis:__________________________________________________________________________

Primary discharge diagnosis:__________________________________________________________________________

Was this patient admitted on any antimicrobial therapy? Yes No Unknown

If Yes, name of antimicrobial:______________________________________

Did this patient have any of the following comorbidities present on admission? (check all that apply) None


HIV+ with CD4 cell count < 200 cells/mm3 or 14% Cancer w/ Neutropenia (ANC < 500) Asthma

History of solid organ transplant or stem cell transplant Diabetes Asplenia

COPD/Emphysema Alcohol Abuse Liver Failure

Renal failure/Dialysis

Was this patient previously hospitalized in an acute care hospital for 2 days with a diagnosis of pneumonia in the 12 weeks prior to this CO-LRI diagnosis? Yes No Unknown

Was this patient admitted to an ICU within 5 days of hospital admission? Yes No Unknown

If Yes, ICU admission date: // ICU discharge date: //

If Yes, did the patient require ventilator support? Yes No Unknown

If Yes, did the patient require vasopressors? Yes No Unknown

Did the patient receive any of the following in the 7 days prior to this CO-LRI diagnosis? None

IV antimicrobials Chemotherapy Wound care Hemodialysis



Antimicrobial Administration Table: Complete the following table for all antimicrobials the patient received on the day of admission and the 10 days after admission:

  1. Enter the names of all antimicrobials given IV, IM, po/enteral (PO), via inhalation (INH), or where route of administration is unknown (U).

  2. Record the route of administration (IV, IM, PO, INH, or U).

  3. Indicate the rationale: medical prophylaxis (MP), surgical prophylaxis (SP), empiric treatment (ET), targeted treatment (TT), non-infection-related (NI), or unknown rationale (U).

  4. Enter the clinician-defined therapeutic site(s), or enter “NA” if MP, SP, NI or U. See operational manual for details.

  5. Cells for dates on which an antimicrobial was not given should be left blank.

Date (mm/dd):


Admit date:













Drug Name


Day 0

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Day 10

Was the patient discharged on this drug?


Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site














Route













Rationale













Therapeutic site













Diagnostic testing


Was a blood culture sent ≤ 3 days of admission? Yes No Unknown

If Yes, Complete the table below for each blood culture collected:

Cult. No.

Date Specimen Collected

Date Final Result (with AST) Available

If Positive, Organism

Antimicrobial sensitivities*

If positive, were repeat cultures taken ≤ 7 days after initial culture?

If yes, were any positive for same organism?

1







2







3







4







5







6








Was a sputum, ET aspirate, or BAL sent for gram stain and culture sent ≤ 3 days of admission?

Yes No Unknown

If Yes, Complete the table below for each specimen collected:

Cult. No.

Specimen Source

Date Specimen Collected

Date Final Result (with AST) Available

If Positive, Organism

Antimicrobial sensitivities*

7






8






9






10






11






12






*Record the AST results on an AST worksheet.

Urinary antigen test for Streptococcus pneumoniae: Pos. Neg. NT U

Urinary antigen test for Legionella pneumophila? Pos. Neg. NT U

Influenza testing: Pos. Neg. NT U

Other respiratory virus testing: Pos. Neg. NT U

Did this patient have a chest x-ray or CT scan performed ≤ 3 days of admission? Yes No Unknown


If Yes, did the patient have any of the following documented in the final interpretation radiology report? None listed

Bronchopneumonia/pneumonia Consolidation Air space density/opacity

No evidence of pneumonia Cavitation New or changed infiltrates

Pleural effusion Cannot rule out pneumonia

Not available


COMMENTS:







Appropriate Antimicrobial Use: Antimicrobial Susceptibility Testing (AST) Worksheet


CDCID: - Date form completed: //



Culture collection date: // Culture No. ___________

Source: ______________________________________


Organism #1: ______________________________________


Organism #2: ______________________________________


Organism #3: ______________________________________


AAU Event Type (circle only one): UTI CO-LRI VANC DAPTO LNZ PIP/TAZO


Antimicrobial Susceptibility Testing Results

Instructions: Write the appropriate susceptibility test results for the antimicrobial agents listed using the following indications: S=sensitive/susceptible, I=intermediate, NS=not susceptible, R=resistant, N=not tested.


Antimicrobial Abbreviation (Full Name)

Organism #1

Organism #2

Organism #3

AMK (Amikacin)




AMP (Ampicillin)




AMPSUL (Ampicillin/sulbactam)




CEFEP (Cefepime)




CEFOT (Cefotaxime)




CEFOX (Cefoxitin)




CEFROL (Ceftaroline)




CEFTAZ (Ceftazidime)




CEFTRX (Ceftriaxone)




CIPRO (Ciprofloxacin)




CLINDA (Clindamycin)




COL/PB (Colistin or Polymyxin B)




DAPTO (Daptomycin)




DORI (Doripenem)




DOXY (Doxycycline)




ERYTH (Erythromycin)




ERTA (Ertapenem)




GENT (Gentamicin)




IMI (Imipenem)




LEVO (Levofloxacin)




LNZ (Linezolid)




MERO (Meropenem)




METH (Methicillin)




OX (Oxacillin)




PENG (Penicillin G)




PIP (Piperacillin)




PIPTAZ (Piperacillin/tazobactam)




QUIDAL (Quinupristin/dalfopristin)




RIF (Rifampin)




TETRA (Tetracycline)




TIG (Tigecycline)




TMZ (Trimethoprim/sulfamethoxazole)




VANC (Vancomycin)




TOBRA (Tobramycin)




Other,

specify:________________




Other,

specify:________________





FORM IS COMPLETE


EIP HFA_v1_20130625

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorShelley Magill
File Modified0000-00-00
File Created2021-01-28

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