Non PRA Applicable- EIP Supplemental Information

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: //

2. Enter your initials: _________

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

☐Rural

☐Urban

☐Unknown

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

☐Yes

☐No

☐Unknown

5. 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.

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 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):		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 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):		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 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):		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 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):		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 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):		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 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 ≥ 100^oF (37. 8^oC)

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