Supplemental Resident Antimicrobial Use Form

CDC Resident ID: ___-___-_____

Nursing Home Prevalence Survey: Resident Antimicrobial Use Form

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

Complete the Antimicrobial Drug Table below for all antimicrobial drugs given on the survey date or the calendar day prior to the survey date. One record should be entered for each drug/route combination (e.g., separate entries for vancomycin IV and vancomycin PO)
Resident name:__________________ Medical Record Number: ______________ For local use only, will not be Transmitted to CDC
	Drug name	Route	Rationale	Treatment site		First date (mm/dd/yyyy)	End date (mm/dd/yyyy), or # days	Total dose
1		IV IM PO/ENT INH	Tx. active infection Medical prophylaxis Surgical prophylaxis Non-infectious Not documented	Bloodstream Bone/joint Ear, nose, mouth Eye Gastrointestinal Genital tract	Respiratory tract Sepsis Skin or wound Urinary tract Other ………………… Not documented	____/____/______	____/____/______ ______ days	___________ g mg other…..…
2		IV IM PO/ENT INH	Tx. active infection Medical prophylaxis Surgical prophylaxis Non-infectious Not documented	Bloodstream Bone/joint Ear, nose, mouth Eye Gastrointestinal Genital tract	Respiratory tract Sepsis Skin or wound Urinary tract Other ………………… Not documented	____/____/______	____/____/______ ______ days	___________ g mg other…..…
3		IV IM PO/ENT INH	Tx. active infection Medical prophylaxis Surgical prophylaxis Non-infectious Not documented	Bloodstream Bone/joint Ear, nose, mouth Eye Gastrointestinal Genital tract	Respiratory tract Sepsis Skin or wound Urinary tract Other ………………… Not documented	____/____/______	____/____/______ ______ days	___________ g mg other…..…
4		IV IM PO/ENT INH	Tx. active infection Medical prophylaxis Surgical prophylaxis Non-infectious Not documented	Bloodstream Bone/joint Ear, nose, mouth Eye Gastrointestinal Genital tract	Respiratory tract Sepsis Skin or wound Urinary tract Other ………………… Not documented	____/____/______	____/____/______ ______ days	___________ g mg other…..…
5		IV IM PO/ENT INH	Tx. active infection Medical prophylaxis Surgical prophylaxis Non-infectious Not documented	Bloodstream Bone/joint Ear, nose, mouth Eye Gastrointestinal Genital tract	Respiratory tract Sepsis Skin or wound Urinary tract Other ………………… Not documented	____/____/______	____/____/______ ______ days	___________ g mg other…..…

Using information from the table check all scenarios below that apply to this resident and follow the form completion instructions:

Any drug with the treatment site = “Urinary Tract”  Complete Resident Infection Form sections A and B

Metronidazole, Fidaxomixin, or oral (PO) Vancomycin with treatment site = Gastrointestinal  Complete Resident Infection Form sections A and E

****FORM IS COMPLETE****