Att G_ Antimicrobial Use Form

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL USE FORM
CDC ID:

-

Survey date:

/

/

Date form completed:

/

/

Initials: ______

1) 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, and the no. of HAIs=0.
2) Enter the first date during the hospitalization on which an antimicrobial drug was administered to the patient: ____ / ____ / ____ or Unknown.
3) 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). This is AUF # ____ out of a total of ____ AUFs for this patient.
Drug
no.

Drug name

Route

Given on:

1

IV
PO

IM
INH

Survey date
Day prior

2

IV
PO

IM
INH

Survey date
Day prior

3

IV
PO

IM
INH

Survey date
Day prior

4

IV
PO

IM
INH

Survey date
Day prior

5

IV
PO

IM
INH

Survey date
Day prior

6

IV
PO

IM
INH

Survey date
Day prior

7

IV
PO

IM
INH

Survey date
Day prior

8

IV
PO

IM
INH

Survey date
Day prior

9

IV
PO

IM
INH

Survey date
Day prior

10

IV
PO

IM
INH

Survey date
Day prior

11

IV
PO

IM
INH

Survey date
Day prior

12

IV
PO

IM
INH

Survey date
Day prior

Rationale (check all
that apply)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)
TAI
NI
MP
None
SP (Proc:_______)

First date
(mm/dd/yy)

If Rationale=SP only:
SP duration (hrs)

Total dose,
survey date
(optional)

Total dose, day prior
to survey date
(optional)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

___/___/___

≤24h
>48h

>24h but ≤48h
Unknown

______

g
mg
other (____)

______

g
mg
other (____)

Abbreviation key: IV=Intravenous, IM=Intramuscular, PO=Oral/enteral, INH=Inhaled, g=grams, mg=milligrams, other=other unit (specify), MP=Medical prophylaxis, NI=Non-infectious, SP=Surgical
prophylaxis, TAI=Treatment of active infection, None=None documented. Proc=Operative procedure code for which SP was given.
Phase 4 PS AUF_20150227

Page 1 of 2

CDC ID:
4)

-

Check here
if no drug/route combinations were given for Rationale = TAI (with or without other Rationales), and go to question #5.
Otherwise, complete the Treatment Table for all drugs in the Antimicrobial Drug Table (page 1) for which the Rationale = TAI (with or without other Rationales).
Enter the drug no. and name from the Antimicrobial Drug Table. Enter up to 5 clinician-defined therapeutic site codes. Check the “SSI” box if the infection at the
site indicated is a surgical site infection. Check the infection onset location for each site (multiple onset locations may be checked for each site). If there is only 1
therapeutic site, check the “NA” box for therapeutic sites #2-#5.

Treatment Table
Drug
Drug name
no.

Therap. site #1
Code
Onset

Therap. site #2, or NA
Code
Onset

Therap. site #3, or NA
Code
Onset

Therap. site #4, or NA
Code
Onset

Therap. site #5, or NA
Code
Onset

C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
C
O
C
O
C
O
C
O
C
O
Code:______
Code:______
Code:______
Code:______
Code:______
H
U
H
U
H
U
H
U
H
U
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
SSI? Yes
L
L
L
L
L
Clinician-defined therapeutic site codes: BJI=Bone and joint infection; BSI=Bloodstream infection; CDI=Clostridium difficile infection; CNS=Central nervous system infection; CVI=Cardiovascular infection
other than BSI; DIS=Disseminated, systemic viral infection; ENT=Ears, eyes, nose, throat, mouth (includes upper respiratory) infection; GTI=Gastrointestinal tract infection other than CDI, HEB, or IAB;
HEB=Hepatobiliary infection (including pancreas); IAB=Intraabdominal infection other than CDI, GTI or HEB; LRI=Lower respiratory infection other than PNE; PNE=Pneumonia; REP=Reproductive tract
infection; SST=Skin, soft tissue or muscle infection ; UND=Undetermined infection; UNK=Unknown infection site, UTI=Urinary tract infection. SSI=Surgical site infection; check box if infection at site indicated
is an SSI. Infection onset locations: C=Community; H=Survey hospital; L=long term care/skilled nursing facility; O=Other healthcare facility; U=Unknown onset location.
Code:______
SSI? Yes

5)

Using information from the tables on pages 1 and 2, check all scenarios below that apply to this patient, and follow the form completion instructions:
Vancomycin IV for TAI (with or without other Rationales)
Levofloxacin, ciprofloxacin or moxifloxacin for TAI (with or without other Rationales)
Any drug for TAI (with or without other Rationales) with site code “PNE” with Onset “C”
Any drug for TAI (with or without other Rationales) with site code “UTI” with Onset “C,” “L” or “O”

Complete Antimicrobial Quality Assessment (AQUA) Eligibility Form
to determine whether additional AQUA forms are needed,
and complete HAI Form.

None of the above, but Rationales are TAI or None (with or without other Rationales) for any antimicrobial drug  Complete HAI Form.
None of the above; Rationales are MP, SP, NI only for all antimicrobial drugs  Do not complete AQUA forms or HAI Form. Data collection is complete; no. of HAIs = 0.
***FORM IS COMPLETE***
Phase 4 PS AUF_20150227

Page 2 of 2

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM
CDC ID:

-

Survey date:

/

/

Date form completed:

/

/

Data collector initials: _____

Complete the tables below for the HAI(s) present at the time of the survey. For SSI, PNEU, UTI, BSI and GI, indicate whether 2011 and/or current definitions are met.
Enter the TOTAL no. of HAIs for this patient using 2011 definitions _______; using current definitions _______. If no HAIs, check here: None.
HAI

SSI

PNEU

UTI

BSI

2011 HAI Definitions
Specific site and infection data
Rx start date
Check one: SI
DI
O/S, site: ______
____/____/____
Proc: ______
Proc date: ____/____/____
Unk
None
Onset date: ____/____/____or BH
Unk
2° BSI: No
Yes
Unk
Check one: PNU1
PNU2
PNU3
Ventilator-associated? No
Yes
____/____/____
Onset date: ____/____/____or BH
Unk
Unk
None
2° BSI: No
Yes
Unk
Check one: SUTI
ABUTI
Catheter-associated? No
Onset date: ____/____/____or
2° BSI: No
Yes
Unk
Check one: LCBI
Central line-associated? No
Onset date: ____/____/____or

OUTI
Yes
BH
Unk

BH

Yes
Unk

____/____/____
Unk
None

1: _______
2: _______
3: _______
or None

Check one: SUTI
ABUTI
USI
Catheter-associated? No
Yes
Onset date: ____/____/____or BH
Unk
2° BSI: No
Yes
Unk

____/____/____
Unk
None

1: _______
2: _______
3: _______
or None

____/____/____
Unk
None

1: _______
2: _______
3: _______
or None

Check one: LCBI
MBI-LCBI
Central line-associated?
No
Yes
Onset date: ____/____/____or BH
Unk

____/____/____
Unk
None

1: _______
2: _______
3: _______
or None

____/____/____
Unk
None

1: _______
2: _______
3: _______
or None

Check one:
GI

CDI
GE
GIT
HEP
IAB
NEC
Onset date: ____/____/____or BH
Unk
2° BSI: No
Yes
Unk

1: _______
2: _______
3: _______
or None

Current HAI Definitions
Specific site and infection data
Rx start date
Check one: SI
DI
O/S, site: ______
____/____/____
Proc: ______
Proc date: ____/____/____
Unk
None
Onset date: ____/____/____or BH
Unk
2° BSI: No
Yes
Unk
PATOS? Yes
Check one: PNU1
PNU2
PNU3
Ventilator-associated?
No
Yes
____/____/____
Onset date: ____/____/____or BH
Unk
Unk
None
2° BSI: No
Yes
Unk

1: _______
2: _______
3: _______
or None

LocAtt
NA

Check one:

not applicable

VAE

____*

Pathogens

Enter code: ______*
Onset date: ____/____/____or
2° BSI: No
Yes
Unk

BH

Unk

____/____/____
Unk
None

CDI
GE
GIT
HEP
IAB
NEC
Onset date: ____/____/____or BH
Unk
2° BSI: No
Yes
Unk

____/____/____
Unk
None

Check one: VAC
IVAC
Onset date: ____/____/____or
2° BSI: No
Yes
Unk

____/____/____
Unk
None

1: _______
2: _______
3: _______
or None

HAI

SSI

Pathogens
1: _______
2: _______
3: _______
or None

LocAtt

1: _______
2: _______
3: _______
or None

NA

1: _______
2: _______
3: _______
or None

1: _______
2: _______
3: _______
or None
1: _______
2: _______
3: _______
or None

not applicable

If the patient had MORE THAN ONE SSI, GI, or other HAI at the time of the survey, enter in the table below or check
2011 HAI Definitions
Specific site definition
Rx start date
Check one: SI
DI
O/S, site: ______
____/____/____
Proc: ______
Proc date: ____/____/____
Unk
None
Onset date: ____/____/____or BH
Unk
2° BSI: No
Yes
Unk
Check one: CDI
GE
GIT
HEP
IAB
NEC
____/____/____
Onset date: ____/____/____or BH
Unk
Unk
None
2° BSI: No
Yes
Unk

PVAP
BH
Unk

Pathogens

LocAtt
NA

Not applicable.

Current HAI Definitions
Specific site definition
Rx start date
Check one: SI
DI
O/S, site: ______
____/____/____
Proc: ______
Proc date: ____/____/____
Unk
None
Onset date: ____/____/____or BH
Unk
2° BSI: No
Yes
Unk
PATOS? Yes
Check one: CDI
GE
GIT
HEP
IAB
NEC
____/____/____
Onset date: ____/____/____or BH
Unk
Unk
None
2° BSI: No
Yes
Unk

Pathogens

LocAtt

1: _______
2: _______
3: _______
or None

NA

1: _______
1: _______
2: _______
2: _______
GI
3: _______
3: _______
or None
or None
1: _______
Enter code: ______*
____/____/____ 2: _______
Onset date: ____/____/____or BH
Unk
not applicable
____*
Unk
None 3: _______
2° BSI: No
Yes
Unk
or None
*Other HAI types and specific sites: BJ (BONE, JNT, DISC); CNS (IC, MEN, SA); CVS (VASC, ENDO, CARD, MED); EENT (CONJ, EYE, EAR, ORAL, SINU, UR); LRI (BRON, LUNG); REPR (EMET,
EPIS, VCUF, OREP); SST (SKIN, ST, DECU, BURN, BRST, UMB, PUST, CIRC); SYS (DI). Proc=Operative procedure category code. Proc date=Operative procedure date. 2° BSI =Secondary BSI. Rx
date=Antimicrobial treatment start date. NA=Not applicable. PATOS=Infection present at time of surgery. BH=Before hospital admission. Unk=Unknown. No rx=No treatment. LocAtt=location of attribution.
Phase4 PS HAIF_20140420

Page 1 of 2

CDCID:
1)
2)
3)
4)

-

Complete the Antimicrobial Susceptibility Table below if one or more of the specified organisms is reported as a pathogen for
one or more of the HAIs entered on page 1 of this form.
Enter each of the patient’s HAI codes (e.g., BSI, PNEU, UTI-2, etc.) in the top row of the table in the space(s) indicated.
Check the box next to any of the organisms below reported as a pathogen for one or more of the patient’s HAIs. Antimicrobial
susceptibility test results can be entered for each organism for up to 4 different HAIs.
Circle the appropriate test result for each pathogen/drug combination in the column for the HAI for which the organism was a
reported pathogen (S=sensitive/susceptible, S-DD=susceptible dose-dependent, I=intermediate, R=resistant, NS=nonsusceptible, N=not tested).

Antimicrobial Susceptibility Table: If NONE of the organisms below are pathogens for any of the patient’s HAIs, check here:
Organism

HAI #1: ______

Acinetobacter
(any species)

AMPSUL
CEFTAZ
COL/PB
IMI
MERO/DORI
TIG

S
S
S
S
S
S

I
I
I
I
I
I

Candida albicans

ANID
CASPO
FLUCO
MICA

S
S
S
S

Candida glabrata

ANID
CASPO
FLUCO
MICA

Candida
parapsilosis

HAI #2: _______, or
AMPSUL
CEFTAZ
COL/PB
IMI
MERO/DORI
TIG

S
S
S
S
S
S

I
I
I
I
I
I

I R N
I R N
S-DD R N
I R N

ANID
CASPO
FLUCO
MICA

S
S
S
S

S
S
S
S

I R N
I R N
S-DD R N
I R N

ANID
CASPO
FLUCO
MICA

ANID
CASPO
FLUCO
MICA

S
S
S
S

I R N
I R N
S-DD R N
I R N

Enterococcus
faecalis

DAPTO
LNZ
VANC

Enterococcus
faecium

NA

HAI #3: _______, or
AMPSUL
CEFTAZ
COL/PB
IMI
MERO/DORI
TIG

S
S
S
S
S
S

I
I
I
I
I
I

I R N
I R N
S-DD R N
I R N

ANID
CASPO
FLUCO
MICA

S
S
S
S

S
S
S
S

I R N
I R N
S-DD R N
I R N

ANID
CASPO
FLUCO
MICA

ANID
CASPO
FLUCO
MICA

S
S
S
S

I R N
I R N
S-DD R N
I R N

S NS N
S I R N
S I R N

DAPTO
LNZ
VANC

DAPTO
LNZ
VANC

S NS N
S I R N
S I R N

Enterobacter
aerogenes

MERO/DORI
ERTA
IMI

Enterobacter
cloacae

NA

HAI #4: _______, or

NA

AMPSUL
CEFTAZ
COL/PB
IMI
MERO/DORI
TIG

S
S
S
S
S
S

I
I
I
I
I
I

I R N
I R N
S-DD R N
I R N

ANID
CASPO
FLUCO
MICA

S
S
S
S

I R N
I R N
S-DD R N
I R N

S
S
S
S

I R N
I R N
S-DD R N
I R N

ANID
CASPO
FLUCO
MICA

S
S
S
S

I R N
I R N
S-DD R N
I R N

ANID
CASPO
FLUCO
MICA

S
S
S
S

I R N
I R N
S-DD R N
I R N

ANID
CASPO
FLUCO
MICA

S
S
S
S

I R N
I R N
S-DD R N
I R N

S NS N
S I R N
S I R N

DAPTO
LNZ
VANC

S NS N
S I R N
S I R N

DAPTO
LNZ
VANC

S NS N
S I R N
S I R N

DAPTO
LNZ
VANC

S NS N
S I R N
S I R N

DAPTO
LNZ
VANC

S NS N
S I R N
S I R N

DAPTO
LNZ
VANC

S NS N
S I R N
S I R N

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

E. coli

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

Klebsiella oxytoca

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

MERO/DORI
ERTA
IMI

S I R N
S I R N
S I R N

R
R
R
R
R
R

N
N
N
N
N
N

R
R
R
R
R
R

N
N
N
N
N
N

R
R
R
R
R
R

N
N
N
N
N
N

R
R
R
R
R
R

MERO/DORI
MERO/DORI
MERO/DORI
MERO/DORI
S I R N
S I R N
S I R N
S I R
ERTA
ERTA
ERTA
ERTA
S I R N
S I R N
S I R N
S I R
IMI
IMI
IMI
IMI
S I R N
S I R N
S I R N
S I R
CEFTAZ
CEFTAZ
CEFTAZ
CEFTAZ
S I R N
S I R N
S I R N
S I R
COL/PB
COL/PB
COL/PB
COL/PB
S I R N
S I R N
S I R N
S I R
GENT
GENT
GENT
GENT
S I R N
S I R N
S I R N
S I R
Pseudomonas
IMI
IMI
IMI
IMI
S I R N
S I R N
S I R N
S I R
aeruginosa
MERO/DORI
MERO/DORI
MERO/DORI
MERO/DORI
S I R N
S I R N
S I R N
S I R
PIP/PIPTAZ
PIP/PIPTAZ
PIP/PIPTAZ
PIP/PIPTAZ
S I R N
S I R N
S I R N
S I R
TOBRA
TOBRA
TOBRA
TOBRA
S I R N
S I R N
S I R N
S I R
CEFOX/
CEFOX/
CEFOX/
CEFOX/
S I R N
S I R N
S I R N
S I R
METH/OX
METH/OX
METH/OX
METH/OX
Staphylococcus
DAPTO
DAPTO
DAPTO
DAPTO
S NS N
S NS N
S NS N
S NS
aureus
LNZ
LNZ
LNZ
LNZ
S R
N
S R
N
S R
N
S R
VANC
VANC
VANC
VANC
S I R N
S I R N
S I R N
S I R
Drug codes: AMPSUL=ampicillin/sulbactam, ANID=anidulafungin, CASPO=caspofungin, CEFOX/OX/METH=cefoxitin, oxacillin or methicillin,
CEFTAZ=ceftazidime, COL/PB=colistin or polymyxin B, DAPTO=daptomycin, ERTA=ertapenem, FLUCO=fluconazole, GENT=gentamicin, IMI=imipenem,
LNZ=linezolid, MERO/DORI=meropenem or doripenem, MICA=micafungin, PIP/PIPTAZ=piperacillin or piperacillin/tazobactam, TIG=tigecycline,
TOBRA=tobramycin, VANC=vancomycin
Klebsiella
pneumoniae

Phase4 PS HAIF_20150420

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N
N
N
N
N
N

N
N
N
N
N
N
N
N
N
N
N
N
N
N