Supplemental Resident Infection Form

Resident ID: ___-___-_____

Nursing Home Prevalence Survey: Resident Infection From

Survey Date: // Date Form Completed: // Data Collected by: _____ (initials)

For local use only, will not be Transmitted to CDC

Resident Name:__________________________________ Medical Record Number: ___________________

This form is being completed because the resident (check one):	was receiving systemic antimicrobials	had condition that may indicate infection
The date of interest is:	Antimicrobial start date: / /	Prevalence survey date: / /
The time period of interest for chart review begins:	7 days before the antimicrobial start date, beginning on / /	7 days before the survey date, beginning on / /
Date of first sign or symptom onset: / / First sign or symptom onset occurred while resident was in: This facility Prior to admission

Section A: Constitutional signs and symptoms: CHECK ALL THAT APPLY
Check here if after your review NO constitutional signs or symptoms are documented
Acute change in mental status from baseline WERE ANY OF THE FOLLOWING DOCUMENTED: Fluctuating: Behavior fluctuating (e.g., coming and Going, or change in severity during assessment) Inattention: Difficulty focusing attention ( e.g., unable to keep track of discussion or easily distracted) Disorganized thinking: Thinking is incoherent (e.g., rambling conversation, unclear flow of ideas, unpredictable switched in subject) Altered consciousness: Level described as different from baseline (Hyperalert, sleepy, drowsy, difficult to arouse, nonresponsive) Confusion Other , please specify:______________________________	Acute functional decline: increase in assistance with activities of daily living (ADL) from baseline WAS AN INCREASES IN LEVEL OF ASSISTANCE REQUIRED FOR ANY OF THE FOLLOWING DOCUMENTED: Bed mobility Transfer Locomotion within the facility Dressing Toilet use Personal hygiene Eating
Rigors or chills Myalgias or body aches Malaise Loss of appetite or decreased oral intake New-onset hypotension Respiratory rate >=25 breaths per minute Decreased oxygenation Select which of the following were documented: Pulse oximetry with single O2 saturation reading of <94% Pulse oximetry with single O2 saturation reading showing reduction of 3% from baseline Resident newly placed on oxygen Leukocytosis Select which of the following were documented: Neutrophilia (>14,000 leukocytes/mm3) Left shift (6% bands or ≥1,500 bands/mm3)	Fever SELECT WHICH OF THE FOLLOWING WERE DOCUMENTED: Single temperature >37.8oC (>100oF) Repeated temperatures >37.2oC (99oF) Single temperature >1.1oC (2oF) over baseline Term “Fever” is documented, but temperature value is not recorded New hypothermia (<34.5oC, or does not register on the thermometer being used)

Section B: Urinary tract infection signs, symptoms, or tests

Check here if after your review NO urinary tract signs, symptoms or tests are documented

INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

LOCALIZING URINARY SIGNS OR SYMPTOMS
Acute dysuria (e.g., “burning or pain with urination”)	Gross hematuria
Acute pain/swelling or tenderness of the testes, epididymis, or prostate	New or marked increase in frequency
Purulent discharge around catheter	New or marked increase in urgency
Acute costovertebral angle pain or tenderness	New or marked increase in incontinence
Suprapubic pain or tenderness

INDWELLING URINARY CATHETER status at the time of urinary sign/symptom onset:

Resident without an indwelling urinary catheter Resident with an indwelling urinary catheter

URINALYSIS (U/A or Urine Test or Urine Analysis)
Was a urinalysis performed	Yes No
If yes, date performed:	//
If yes, record the following results	Positive	Negative	Not done
Nitrites:
Leukocyte esterase:
>5 White blood cells:

URINE CULTURE
Was a urine collected for culture:		Yes No
If yes, date of specimen collection:		//
How the specimen was collected:		Voided urine sample Indwelling urinary catheter specimen Straight (“In-and-out”) catheter Other…………………………………………. Not documented
Urine culture result:		Positive Negative (no growth) Result not available
If positive, report the organisms isolated from this specimen
	Organism name: Use Codes List	Number Colony forming units (CFU)/mL
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2
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This resident had documentation of provider suspected or diagnosed urinary tract infection

Enter any additional comments or information related to urinary tract signs, symptoms or tests:

Section C: Respiratory tract infection signs, symptoms or tests

Check here if after your review NO respiratory tract signs, symptoms or tests are documented

INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

RESPIRATORY SIGNS AND SYMPTOMS
Runny nose or sneezing	New / increased cough
Stuff nose (i.e. congestion)	New/increased sputum production
Sore throat or hoarseness or difficulty swallowing	Pleuritic chest pain
Headache or eye pain	Abnormal lung examination (new or changed)
Swollen or tender glands in the neck (cervical lymphadenopathy)

RESPIRATORY X-RAY IMAGINING
Was X-RAY imaging performed	Yes No
If yes, date performed:	//
If yes, record the x-ray findings
X-ray findings not available
Negative x-ray findings
POSITIVE for pneumonia or a new infiltrate
POSITIVE with findings not consistent with pneumonia or a new infiltrate
Other findings, specify:

RESPIRATORY DIAGNOSTICS
Was a respiratory specimen collected for diagnosis:		Yes No
If yes, indicate the specimen source:
If yes, date of specimen collection:		//
If yes, record respiratory culture result		Positive Negative Result not available
If positive, report the organisms isolated from this specimen
	Organism name (s): Use code list
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2
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This resident has documentation of provider suspected or diagnosed

Cold Pharyngitis

Influenza-like illness Lower respiratory infection

Pneumonia Other respiratory tract infection, please specify: ________________________

Enter any additional comments or information related to respiratory tract signs, symptoms or testing:

Section D: Skin, soft tissue, bone, joint, and mucosal infection signs, symptoms, or tests

Check here if after your review NO skin, soft tissue, bone, joint, or mucosal signs, symptoms or tests are documented

INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

Pus present at the affected wound, skin, or soft tissue site

Presence of inflammation at the affected wound or skin or soft tissue site

SELECT WHICH OF THE FOLLOWING WERE DOCUMENTED:

Heat at the affected site

Redness at the affected site

Serous drainage at the affected site

Tenderness or pain at the affected site

Swelling at the affected site

A topical antibiotic was applied at affected site (e.g., ointment or cream). Name of topical agent:________________

The affected site is:________________________

CULTURE RELATED TO THE AFFECTED WOUND OR SKIN SITE
Was a wound or skin specimen collected for culture		Yes No
If yes, indicate the specimen source:
If yes, date of specimen collection:		//
If yes, record the culture result		Positive Negative Result not available
If positive, report the organisms isolated from this specimen
	Organism name (s): Use code list
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This resident has documentation of provider suspected or diagnosed

Wound infection Cellulitis Osteomyelitis Joint infection Other, please specify: ________________________

SUSPECTED SCABIES: INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

Maculopapular and/or itching rash

Laboratory confirmation (positive scraping or biopsy)

Epidemiological linkage to a case of scabies with lab confirmation

Provider diagnosis of scabies

Scabies other:___________________________

SUSPECTED FUNGAL SKIN or ORAL/PERIORAL INFECTION: INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

Presence of raises white patches in inflamed mucosa or plaques on oral mucosa

Provider diagnosis of oral candidiasis

Characteristic skin rash or skin lesion

Lab confirmed fungal pathogen from skin scraping or biopsy

Provider diagnosis of fungal skin infection

Fungal other:___________________________

SUSPECTED HERPES SIMPLEX OR ZOSTER INFECTION: INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

Vesicular rash

Laboratory confirmation of herpes simplex or herpes zoster infection

Provider diagnosis of herpes simplex

Provider diagnosis of herpes zoster infection

Herpes other:___________________________

**Section D continues on the next page**

SUSPECTED CONJUNCTIVITIS (“Pink eye”)

INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

Pus appearing from one or both eyes, present for at least 24 hours

New or increased conjunctival erythema, with or without itching

New or increased conjunctival pain, present for at least 24 hours.

Topical antimicrobial applied to eyes (e.g., ointment or drops)

NO documentation that conjunctivitis symptoms (“pink eye”) symptoms are due of allergic reaction or trauma

Provider diagnosis of conjunctivitis

SUSPECTED EAR INFECTION

INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

New drainage from one or both ears

Ear pain

Ear tenderness

Topical antimicrobial applied to ears (e.g., ointment or drops)

Provider diagnosis of an ear infection

Enter any additional comments or information related to skin, soft tissue, bone, joint, and mucosal infection signs, symptoms, or tests

Section E: Gastrointestinal tract infection signs, symptoms or tests

Check here if after your review NO gastrointestinal signs, symptoms or tests are documented

INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

Diarrhea

Exceeds or equivalent to: 3 liquid or watery stools in 24-h period

Diarrhea is documented, but frequency and/or time-period not known

Vomiting

Exceeds or equivalent to: 2 episodes in 24-h period

Vomiting is documented but frequency and/or time-period not known

Nausea

Abdominal pain or tenderness

Documentation of a noninfectious cause of diarrhea, vomiting or nausea, Specify:_________________________________________________

ABDOMINAL X-RAY IMAGINING
Was X-RAY imaging performed	Yes No
If yes, date performed:	//
If yes, record the following findings
	X-ray result not available
	Negative x-ray findings
	POSTIVE for evidence of toxic megacolon
	Positive with findings not consistent with toxic megacolon
	Other findings, specify:

STOOL TESTING FOR CLOSTRIDIUM DIFFICILE INFECTION
Was an order written for C. difficle testing	Yes No
If yes, order date:	//
Was stool collected for C. difficile testing:	Yes No
If yes, date of specimen collection:	//
Test type:	NAAT/PCR EIA Other (specify):___________
C. difficile test result:	Positive Negative Result not available

STOOL CULTURE FOR PATHOGENS (Bacteria, Parasite, etc.)
Was a stool specimens collected		Yes No
If yes, date of specimen collection:		//
If yes, record the culture result		Positive Negative Result not available
If positive, report the organisms isolated from this specimen
	Organism name (s): Use code list
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The resident was diagnosed with pseudomembranous colitis by endoscopy, surgery or biopsy Yes No

If yes, diagnosis date: //

The resident has documentation of provider suspected or diagnosed

C. difficile infection Gastroenteritis

Enter any additional comments or information related to gastrointestinal tract signs, symptoms, or tests

Section F: Bloodstream Infection, sepsis, blood cultures

Check here if after your review NO bloodstream infection or sepsis is documented

INDICATE WHICH OF THE FOLLOWING WERE DOCUMENTED (SELECT ALL THAT APPLY):

BLOOD CULTURE
Was blood collected for culture	Yes No
If yes, date of specimen collection:	//
Blood culture test result:	Positive Negative Result unavailable
If positive, indicate if ;
A single blood culture with a NHSN-defined recognized pathogen
Two or more blood cultures positive for the same NHSN-defined commensal organism

If positive, report the organisms isolated from this specimen
	Organism name (s): Use code list
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The resident has documentation of provider suspected or diagnosed

Bloodstream infection Sepsis

Enter any additional comments or information related to bloodstream Infection, sepsis, blood cultures

Section G: Any other infections or relevant information

Section H: Selected Antimicrobial Susceptibilities

Check here if NO organisms were isolated or if the organism isolated if NOT one of those listed below - Data collection is now complete

If one or more of the organism listed below was isolated from a specimen collected, check the box for the organism(s) and report the susceptibility result for the indicated antimicrobial agents. If 2 or more strains of the same organism are identified, enter the susceptibility pattern for the first organism isolated (by date).

Organism name [code]

OX/METH

VANC

LINZ

TMZ

AMP

CEFZN

AMP-SUL

PIP-TAZO

CIPRO

LEVO

CEFTRX

CEFTAZ

CEFEP

GENT

IMI

MERO

S. aureus [SA]

 S    R   N/A

 S    R   N/A

 S    R   N/A

 S    R   N/A

 S    R   N/A

Enterococcus spp. [ENTFM or ENTFS]

 S    R   N/A

 S    R   N/A

 S    R   N/A

 S    R   N/A

E. coli [EC]

 S    R   N/A

 S    R   N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

Klebsiella pneumoniae or oxytoca [KP or KO]

 S    R   N/A

 S    R   N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

Proteus mirabilis [PM]

 S    R   N/A

 S    R   N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

Enterobacter cloacae [ENC]

 S    R   N/A

 S    R   N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S  R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

Pseudomonas aeruginosa [PA]

 S   R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

Acinetobacter baumanii [ACBA]

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

 S    R  N/A

S – Susceptible R – Intermediate or resistance N/A – Not available or not tested Antimicrobial agent abbreviations: AMP=ampicillin, AMP-SUL=ampicillin/sulbactam, CEFZN= cefazolin, CEFEP = cefepime, CEFTAZ=ceftazidime, CEFTRX=ceftriaxone, CIPRO = ciprofloxacin, GENT=gentamicin, IMI=imipenem, LEVO=levofloxacin, LINZ = linezolid, MERO = meropenem OX/METH=oxacillin or methicillin, PIP-TAZO=piperacillin/ tazobactam, TMZ=trimethoprim/sulfamethoxazole, VANC=vancomycin