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pdfHAI & ANTIMICROBIAL USE PREVALENCE SURVEY
ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 1: CASE ELIGIBILITY
CDCID:
-
Date:
/
/
Data collector initials: _____
Instructions: Refer to question 5 on the Antimicrobial Use Form (AUF); complete each section below, or check
“Not applicable based on AUF” if the patient is not eligible based on question 5 of the AUF.
A. Patient age eligibility
1. Was the patient ≥1 year old on the survey date or day prior?
No NOT eligible for ANY AQUA Form. Go to HAI Form.
Yes MAY be eligible for one or more AQUA Forms.
B. VANCOMYCIN eligibility
Not applicable based on AUF
2. Patient ≥1 year old and received vancomycin IV for infection treatment on the survey date or day prior?
No NOT eligible for AQUA Vancomycin Form.
Yes Eligible for AQUA Vancomycin Form.
C. FLUOROQUINOLONE eligibility
Not applicable based on AUF
3. Patient ≥18 years old and received a fluoroquinolone for infection treatment on the survey date or day prior?
No NOT eligible for AQUA Fluoroquinolone Form.
Yes Eligible for AQUA Fluoroquinolone Form.
D. COMMUNITY-ACQUIRED PNEUMONIA (CAP) eligibility
Not applicable based on AUF
4. In patients ≥1 year old given an antimicrobial drug(s) for site code “PNE” with onset “C” on the survey date
or day prior, is there documentation in the medical record of any of the following conditions?
Nursing home or long term care facility or long term acute care hospital residence prior to survey hospital admission
Hospitalized ≥2 days in the 90 days prior to admission
Received IV antimicrobials in the 30 days prior to admission
Received cancer chemotherapy in the 30 days prior to admission
Received wound care in the 30 days prior to admission
Chronic hemodialysis
Home mechanical ventilation
AIDS
Solid organ, bone marrow, or stem cell transplant
Long-term (>30 days) high-dose corticosteroid or other immunosuppressive treatment
Other congenital or acquired immunodeficiency
Cystic fibrosis
None
5. Based on question 4, confirm patient eligibility for the AQUA CAP Form:
≥1 condition checked in question 4 NOT eligible for AQUA CAP Form.
“None” checked in question 4 Eligible for AQUA CAP Form.
E. URINARY TRACT INFECTION (UTI) eligibility
Not applicable based on AUF
6. Patient ≥1 year old and site code “UTI” with onset “C,” “L” or “O” for any antimicrobial drug on the survey
date or day prior?
No NOT eligible for AQUA UTI Form.
Yes Eligible for AQUA UTI Form.
F. AQUA eligibility summary
7. Check all AQUA Forms that need to be completed for this patient:
AQUA Vancomycin
AQUA Fluoroquinolone
AQUA CAP
AQUA UTI
None
8. Confirm next steps in data collection:
If “None” is checked in question 7 Antimicrobial use data collection is complete. Go to HAI Form.
If any of the AQUA Form boxes are checked in question 7 Complete AQUA Form 2: General Patient
Assessment, then complete the appropriate AQUA Forms 3a-3d. HAI Form also required.
***FORM IS COMPLETE***
AQUA Case Eligibility_20150421
Page 1 of 1
HAI & ANTIMICROBIAL USE PREVALENCE SURVEY
ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 2: GENERAL PATIENT ASSESSMENT
CDC ID:
-
/
Date:
/
Data collector initials: _____
Healthcare exposures
1. Indicate the location from which the patient was admitted to the survey hospital (check one):
Private residence
Long term care/SNF
LTACH
Another acute care hospital
Homeless
Other _________________________
Unknown
Incarcerated
2. In the 30 days prior to admission to the survey hospital, did the patient receive (check all that apply):
IV antimicrobials
Cancer chemotherapy
Wound care
Chronic hemodialysis
Surgery
None
Unknown
3. Was the patient hospitalized in an acute care hospital for ≥2 days in the 90 days prior to this admission?
Yes
No
Unknown
Antimicrobial allergies
4. Is an antimicrobial drug allergy recorded in the medical record?
Yes
No
4a. If yes, specify drug class or classes to which patient is allergic, and reaction(s):
Drug class
Nausea,
vomiting
and/or
diarrhea
Hives or
urticaria
Other
skin
rash
Wheezing,
throat
tightness,
trouble
breathing
Angioedema
or face
swelling
Anaphylaxis
Unknown
Not
specified
Other (specify)
Penicillins
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes____________
Cephalosporins
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes____________
Sulfa drugs
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes____________
Macrolides
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes____________
Fluoroquinolones
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes____________
Vancomycin
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes____________
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes____________
Other (specify):
________________
Underlying conditions
5. Check all that apply:
None:
Unknown:
AIDS
Alcoholism in past year
Asplenia
Asthma
Cerebrovascular disease/stroke (except hemiplegia)
Chronic cognitive deficit
Chronic kidney disease
Chronic liver disease
Chronic obstructive pulmonary disease (COPD)/emphysema
Chronic lung disease (other than COPD/emphysema, asthma)
Chronic steroid or other immunosuppressive therapy
Congenital urinary tract abnormality (not VUR)
Congenital heart disease
Congestive heart failure
Connective tissue disease
Cystic fibrosis
Dementia
Diabetes mellitus with complications
Diabetes mellitus without complications
Hemiplegia
HIV without AIDS
IVDU in past year
AQUA General Patient Assessment_20150331
Kidney stones/nephrolithiasis
Leukemia
Lymphoma or multiple myeloma
MRSA colonization or infection history
Myocardial infarction
Neutropenia (absolute neutrophil count <500 cells / µL)
Peptic ulcer disease
Peripheral vascular disease
Pregnancy
Recurrent cystitis or urinary tract infection
Sickle cell disease
Smoking in home or living environment (other than patient)
Smoking in past year (patient)
Solid tumor malignancy, metastatic (not urologic/renal)
Solid tumor malignancy, not metastatic (not urologic/renal)
Spinal cord injury or paraplegia or quadriplegia
Transplant, hematopoietic stem cell or bone marrow
Transplant, solid organ
Ureteral stent
Urinary tract abnormality, not otherwise specified
Urostomy or nephrostomy
Urologic or renal malignancy
Vesicoureteral reflux (VUR)
Page 1 of 2
-
CDCID:
Infections present during the hospitalization
6. Complete table:
No.
Infection
(code)
Before hospitalization
Hospital days 1-2
On/after hosp day 3
In hospital, day unk
Unknown
Before hospitalization
Hospital days 1-2
On/after hosp day 3
In hospital, day unk
Unknown
Before hospitalization
Hospital days 1-2
On/after hosp day 3
In hospital, day unk
Unknown
Before hospitalization
Hospital days 1-2
On/after hosp day 3
In hospital, day unk
Unknown
1
Y
________
2
SSI?
Y
________
3
SSI?
Y
________
4
SSI?
Y
Was infection
treated with
antimicrobials?
Signs and symptoms documented in medical record
(check all that apply)
Onset date
________
SSI?
No infections:
Cough or dyspnea
Diarrhea
Fever
Hypotension
Unknown
Cough or dyspnea
Diarrhea
Fever
Hypotension
Unknown
Cough or dyspnea
Diarrhea
Fever
Hypotension
Unknown
Cough or dyspnea
Diarrhea
Fever
Hypotension
Unknown
Mental status change
Nausea or vomiting
Pain at infection site
Positive imaging
None
Mental status change
Nausea or vomiting
Pain at infection site
Positive imaging
None
Mental status change
Nausea or vomiting
Pain at infection site
Positive imaging
None
Mental status change
Nausea or vomiting
Pain at infection site
Positive imaging
None
Pus, drainage, abscess
Redness or swelling
Urinary frequency
Urinary urgency
Other____________
Pus, drainage, abscess
Redness or swelling
Urinary frequency
Urinary urgency
Other____________
Pus, drainage, abscess
Redness or swelling
Urinary frequency
Urinary urgency
Other____________
Pus, drainage, abscess
Redness or swelling
Urinary frequency
Urinary urgency
Other____________
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
More infections than fit in the table:
Infection codes: BJI, BSI, CDI, CNS, CVI, DIS, ENT, GTI, HEB, IAB, LRI, PNE, REP, SST, UND, UNK, UTI
Severity of illness
7. Was the patient in an ICU at any time during the hospitalization? Yes
No
Unknown
7a. If yes, enter the dates of the first ICU admission during the hospitalization:
ICU admission date: ____ / ____ /____ or Unknown
ICU discharge date: ____ / ____ /____ or
Unknown
8. Complete the table using data from the first 24-hour period of treatment during the hospitalization:
First day, CAP treatment:
First day, IV vancomycin:
First day, fluoroquinolone:
____ / ____ / ____ or
____ / ____ / ____ or
First day, UTI treatment
Parameter
____ / ____ / ____ or
NA
NA
NA
____ / ____ / ____ or
NA
Temperature:
Highest:
____
°C
°F or
Unk
____
°C
°F or
Unk
____
°C
°F or
Unk
____
°C
°F or
Unk
Lowest:
____
°C
°F or
Unk
____
°C
°F or
Unk
____
°C
°F or
Unk
____
°C
°F or
Unk
Heart rate:
Highest:
____ bpm or
Unk
____ bpm or
Unk
____ bpm or
Unk
____ bpm or
Unk
Lowest:
____ bpm or
Unk
____ bpm or
Unk
____ bpm or
Unk
____ bpm or
Unk
____ bpm or
Unk
____ bpm or
Unk
____ bpm or
Unk
____ bpm or
Unk
Respiratory:
Highest resp rate:
Lowest PaCO2:
Mechanical vent:
____ mmHg or
Yes
No
Unk
Unk
____ mmHg or
Yes
No
Unk
Unk
____ mmHg or
Yes
No
Unk
Unk
____ mmHg or
Yes
No
Unk
Unk
WBC count:
Highest:
Lowest:
Highest %bands:
Blood pressure:
Lowest systolic
BP:
Lowest mean
arterial pressure:
On vasopressors:
Lactate
________ cells/mm3
or Unk
________ cells/mm3
or Unk
____ % or
Unk
________ cells/mm3
or Unk
________ cells/mm3
or Unk
____ % or
Unk
________ cells/mm3
or Unk
________ cells/mm3
or Unk
____ % or
Unk
________ cells/mm3
or Unk
________ cells/mm3
or Unk
____ % or
Unk
____ mmHg or
Unk
____ mmHg or
Unk
____ mmHg or
Unk
____ mmHg or
Unk
____ mmHg or
Unk
____ mmHg or
Unk
____ mmHg or
Unk
____ mmHg or
Unk
Yes
______
No
mg/dL
or Unk
Unk
mmol/L
Yes
______
No
mg/dL
or Unk
Unk
mmol/L
Yes
______
No
mg/dL
or Unk
Unk
mmol/L
Yes
______
No
mg/dL
or Unk
Unk
mmol/L
***FORM IS COMPLETE*** Go to AQUA Forms 3a-3d
AQUA General Patient Assessment_20150331
Page 2 of 2
HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 3a: VANCOMYCIN
CDC ID:
-
/
Date:
/
Data collector initials: _____
Laboratory testing
1. Complete the table for POSITIVE cultures collected from the date 5 days before vancomycin IV first date (5 days before: ____/____/____) through the
vancomycin IV last date (____/____/____):
No positive cultures:
Culture data unknown:
No.
1
2
3
4
5
6
7
8
9
10
Specimen
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Pathogen
susceptible to
oxacillin,
methicillin or
cefoxitin?
Pathogen
susceptible to
penicillin or
ampicillin?
Antimicrobial
drugs given on
the DAY
AFTER the test
result was final
Collect date
(mm/dd/yy)
Test result
final date
(mm/dd/yy)
Pathogens
identified
(insert code)
Pathogen
susceptible to
vancomycin?
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Were pathogens
susceptible (S) to
≥1 antimicrobial
the patient was
getting the DAY
AFTER the test
result was final?
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
More positive cultures than fit in the table:
AQUA Vancomycin_20150227
Page 1 of 2
CDC ID:
-
2. Complete the table for NEGATIVE cultures collected from 5 days before vancomycin IV first date (5 days
before: ____/____/____) through the vancomycin IV last date (____/____/____):
No negative cultures:
Culture data unknown:
No.
Collect date
(mm/dd/yy)
1
____ / ____ / ____
2
____ / ____ / ____
3
____ / ____ / ____
4
____ / ____ / ____
5
____ / ____ / ____
Specimen
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
No.
Collect date
(mm/dd/yy)
6
____ / ____ / ____
7
____ / ____ / ____
8
____ / ____ / ____
9
____ / ____ / ____
10
____ / ____ / ____
Specimen
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
More negative cultures than fit in the table:
3. Was an MRSA surveillance culture(s) done during this admission? Yes
No
Unknown
3a. If yes to question 3, were any MRSA surveillance cultures positive for MRSA during this admission?
Yes
No
Unknown
4. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before
vancomycin IV first date through the vancomycin IV last date:
No non-culture tests done:
Non-culture test data unknown:
No.
1
2
3
4
5
Collect date
(mm/dd/yy)
Specimen
Test
What pathogen(s) were tested for?
Result
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
More tests than fit in the table:
Post-discharge antimicrobial treatment
5. Was vancomycin IV prescribed at discharge (i.e., prescribed to be administered to the patient for additional
days after hospital discharge)?
Yes
No
Unknown
5a. If yes to question 5, what is the total duration of the post-discharge vancomycin IV prescription?
_____ days, OR the prescription end date is ____ / ____ / _____, OR Duration is unknown
***FORM IS COMPLETE***
AQUA Vancomycin_20150227
Page 2 of 2
HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 3b: FLUOROQUINOLONE
CDC ID:
-
Date:
/
/
Data collector initials: _____ Drugs given:
Ciprofloxacin
Levofloxacin
Moxifloxacin
Laboratory testing
1. Complete the table for POSITIVE cultures collected from the date 5 days before fluoroquinolone first date (5 days before: ____/____/____) through
the fluoroquinolone last date (____/____/____):
No positive cultures:
Culture data unknown:
No.
1
2
3
4
5
6
7
8
9
10
Test result
final date
(mm/dd/yy)
Pathogens
identified
(insert code)
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___ / ___ / ___
___ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Collect date
(mm/dd/yy)
Specimen
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Blood
Stool
Urine
Lower resp
Other _____
Pathogen
susceptible to
ciprofloxacin?
Pathogen
susceptible to
levofloxacin?
Antimicrobial
drugs given on
the DAY AFTER
the test result
was final
Pathogen
susceptible to
moxifloxacin?
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Were pathogens
susceptible (S) to
≥1 antimicrobial
the patient was
getting the DAY
AFTER the test
result was final?
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
More positive cultures than fit in the table:
AQUA Fluoroquinolone 20150227
Page 1 of 3
CDCID:
-
2. Complete the table for NEGATIVE cultures collected from 5 days before fluoroquinolone first date (5 days
before: ____/____/____) through the fluoroquinolone last date (____/____/____):
No negative cultures:
Culture data unknown:
No.
Collect date
(mm/dd/yy)
Specimen
No.
Collect date
(mm/dd/yy)
Specimen
1
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
6
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
2
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
7
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
3
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
8
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
4
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
9
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
5
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
10
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
More negative cultures than fit in the table:
3. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before
fluoroquinolone first date through the fluoroquinolone last date:
No non-culture tests done:
Non-culture test data unknown:
No.
1
2
3
4
5
Collect date
(mm/dd/yy)
Specimen
Test
What pathogen(s) were tested for?
Result
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
More tests than fit in the table:
IV to PO conversion
4. Between the fluoroquinolone first date and the fluoroquinolone last date, was there a conversion from IV to PO
fluoroquinolone administration? Check one:
Yes Date of conversion from IV to PO administration: ____/____/____ or
Date unknown
No For example, patient received only IV fluoroquinolones, or was switched from PO to IV fluoroquinolones, or was
switched from IV to PO to IV.
Not applicable Patient received only PO fluoroquinolones.
Unknown
AQUA Fluoroquinolone 20150227
Page 2 of 3
CDCID:
-
Post-discharge antimicrobial treatment
5. Was a fluoroquinolone prescribed at discharge (i.e., prescribed to be administered to the patient for additional
days after hospital discharge)?
Yes
No
Unknown
5a. If yes to question 5, what drug(s) were prescribed? Check all that apply:
Drug
Ciprofloxacin
IV route
Yes
PO route
Yes
Unknown route
Yes
Levofloxacin
Yes
Yes
Yes
Moxifloxacin
Yes
Yes
Yes
5b. If yes to question 5, what is the total duration of the post-discharge fluoroquinolone prescription?
_____ days, OR the prescription end date is ____ / ____ / _____, OR Duration is unknown
***FORM IS COMPLETE***
AQUA Fluoroquinolone 20150227
Page 3 of 3
HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA)
FORM 3c: CAP
CDC ID:
-
Date:
/
/
Data collector initials: _____
Clinical information
1. Check any of the following ICD-9 codes that were present on admission for this patient:
None
480.0
480.1
480.2
480.3
480.8
480.9
481
482.0
482.1
482.2
482.30
482.31
482.32
482.39
482.40
482.41
482.42
482.49
482.81
482.82
482.83
482.84
482.89
482.9
483.0
483.1
483.8
485
486
487.0
487.1
487.8
2. CAP onset date (mm/dd/yy): ___ / ___ /___ or
Prior to survey hospitalization but specific date unknown
Unable to determine
3. CAP signs and symptoms in first 2 hospital days; check all that apply:
None
Fever
Increased secretions/sputum production
Chills or rigors
Hemoptysis
Cough
Chest pain
Dyspnea
Mental status changes or functional decline
O2 saturation < 90%
Apnea
Sore throat
Rhinorrhea
Grunting
Nasal flaring
Head bobbing
Chest wall retractions
Wheezing
Muscle aches
4. Did the patient require mechanical ventilation during the hospitalization?
Yes
No
Unknown
4a. If yes, was the patient removed from mechanical ventilation before hospital discharge?
Yes, clinical status improved
Yes, removed from mechanical ventilation for end-of-life care (or for reasons other than improvement)
No
Unknown
5. Complete the chest imaging table, recording studies done in the first 5 hospital days (____/____/____ through
____/____/____):
No imaging studies done:
Unknown whether imaging studies were done:
Date
(mm/dd/yy)
Findings on chest imaging studies
1
___ / ___ / ___
Bronchopneumonia/pneumonia
New or worsening infiltrates
Infiltrate, single lobe
Air space density/opacity
No evidence of pneumonia
Infiltrate, multiple lobes
Consolidation
Cavitation
Pleural effusion
Cannot rule out pneumonia
None of these
2
___ / ___ / ___
Bronchopneumonia/pneumonia
New or worsening infiltrates
Infiltrate, single lobe
Air space density/opacity
No evidence of pneumonia
Infiltrate, multiple lobes
Consolidation
Cavitation
Pleural effusion
Cannot rule out pneumonia
None of these
3
___ / ___ / ___
Bronchopneumonia/pneumonia
New or worsening infiltrates
Infiltrate, single lobe
Air space density/opacity
No evidence of pneumonia
Infiltrate, multiple lobes
Consolidation
Cavitation
Pleural effusion
Cannot rule out pneumonia
None of these
4
___ / ___ / ___
Bronchopneumonia/pneumonia
New or worsening infiltrates
Infiltrate, single lobe
Air space density/opacity
No evidence of pneumonia
Infiltrate, multiple lobes
Consolidation
Cavitation
Pleural effusion
Cannot rule out pneumonia
None of these
5
___ / ___ / ___
Bronchopneumonia/pneumonia
New or worsening infiltrates
Infiltrate, single lobe
Air space density/opacity
No evidence of pneumonia
Infiltrate, multiple lobes
Consolidation
Cavitation
Pleural effusion
Cannot rule out pneumonia
None of these
Go to page 2
AQUA CAP_20150227
Page 1 of 4
CDC ID:
-
CAP treatment
6. Was the patient receiving antimicrobial treatment for this episode of CAP before the survey hospitalization?
Yes
No
Unknown
7. CAP treatment start date during the survey hospitalization (mm/dd/yy): ____ / ____ /____ or
Unknown
8. Complete the table for all antimicrobial drugs given to treat CAP during the survey hospitalization:
No.
Drug name
First date (mm/dd/yy)
First route
Last date (mm/dd/yy)
Last route
1
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
2
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
3
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
4
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
5
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
More than 5 antimicrobial drugs were given to treat CAP:
9. Were antimicrobial drugs prescribed at hospital discharge (i.e., prescribed to be administered to the patient for
additional days after hospital discharge) to treat CAP?
Yes
No
Unknown
9a. If yes to question 9, what was the total duration of the post-discharge CAP treatment?
_____ days, OR the prescription end date is ____ / ____ / _____, OR Duration is unknown
9b. If yes to question 9, what antimicrobial drugs were prescribed?
One antimicrobial drug was prescribed (enter name: ____________________)
Two or more antimicrobial drugs were prescribed
(enter up to 3 names: ____________________, ____________________, ____________________)
Unknown
Go to page 3
AQUA CAP_20150227
Page 2 of 4
CDC ID:
-
Laboratory testing
10. Complete table below for POSITIVE cultures collected in the first 5 hospital days (____/____/____ through ____/____/____):
No positive cultures:
Culture data unknown:
No.
1
2
3
4
5
6
7
8
Specimen
Sputum
ETA
BAL
Upper resp
Other _____
Sputum
ETA
BAL
Upper resp
Other _____
Sputum
ETA
BAL
Upper resp
Other _____
Sputum
ETA
BAL
Upper resp
Other _____
Sputum
ETA
BAL
Upper resp
Other _____
Sputum
ETA
BAL
Upper resp
Other _____
Sputum
ETA
BAL
Upper resp
Other _____
Sputum
ETA
BAL
Upper resp
Other _____
Collect date
(mm/dd/yy)
Antimicrobial
drugs given on
the DAY
AFTER the test
result was final
Were pathogens
susceptible (S) to
≥1 antimicrobial
the patient was
getting the DAY
AFTER the test
result was final?
Culture result final
date (mm/dd/yy)
Pathogens
identified
(insert codes)
Path1:
Path2:
Path3:
≥104 CFU/ml or similar
≥104 CFU/ml or similar
≥104 CFU/ml or similar
<104 or similar
<104 or similar
<104 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Culture growth quantity* for lower respiratory cultures
only
Blood
Urine
Stool
____ / ___ / ___
____ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Blood
Urine
Stool
____ / ___ / ___
____ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥104 CFU/ml or similar
≥104 CFU/ml or similar
≥104 CFU/ml or similar
<104 or similar
<104 or similar
<104 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
≥104 CFU/ml or similar
≥104 CFU/ml or similar
≥104 CFU/ml or similar
<104 or similar
<104 or similar
<104 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Blood
Urine
Stool
____ / ___ / ___
____ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Blood
Urine
Stool
____ / ___ / ___
____ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥104 CFU/ml or similar
≥104 CFU/ml or similar
≥104 CFU/ml or similar
<104 or similar
<104 or similar
<104 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Blood
Urine
Stool
____ / ___ / ___
____ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥104 CFU/ml or similar
≥104 CFU/ml or similar
≥104 CFU/ml or similar
<104 or similar
<104 or similar
<104 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Path1:
Path2:
Path3:
≥104 CFU/ml or similar
≥104 CFU/ml or similar
≥104 CFU/ml or similar
<104 or similar
<104 or similar
<104 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Blood
Urine
Stool
____ / ___ / ___
____ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Blood
Urine
Stool
____ / ___ / ___
____ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥104 CFU/ml or similar
≥104 CFU/ml or similar
≥104 CFU/ml or similar
<104 or similar
<104 or similar
<104 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
____ / ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥104 CFU/ml or similar
≥104 CFU/ml or similar
≥104 CFU/ml or similar
<104 or similar
<104 or similar
<104 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
Blood
Urine
Stool
____ / ___ / ___
More positive cultures than fit in the table:
ETA=endotracheal aspirate (or tracheal aspirate). BAL=bronchoalveolar lavage (includes bronchial lavage, mini-BAL).
*Check “≥104 CFU/ml or similar” if quantity of growth in the culture is reported to be as follows: moderate, many, heavy, abundant, etc. Check “<104 or similar” if quantity of growth in the culture is reported
to be <104 CFU/ml or as follows: few, scarce, scant, rare, etc. Check “unknown” if no organism quantity is noted in the culture report.
AQUA CAP_20150227
Page 3 of 4
CDC ID:
-
11. During the first 5 hospital days did the patient have a Gram stain of lower respiratory secretions (sputum,
BAL, ETA, etc.)? Yes
No
Unknown
11a. If yes, did the Gram stain report indicate the following:
Heavy, 4+, or ≥25 neutrophils (or white blood cells) per low power field [x100]
Rare, occasional, few, 1+ or 2+, or ≤10 squamous epithelial cells per low power field [x100]
Neither of the above
Unknown
12. Complete the table for NEGATIVE cultures collected during the first 5 hospital days (____/____/____ through
____/____/____):
No negative cultures:
Culture data unknown:
No.
Collect date
(mm/dd/yy)
1
____ / ___ / ___
2
____ / ___ / ___
3
____ / ___ / ___
4
____ / ___ / ___
5
____ / ___ / ___
Specimen
Collect date
(mm/dd/yy)
No.
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
6
____ / ___ / ___
7
____ / ___ / ___
8
____ / ___ / ___
9
____ / ___ / ___
10
____ / ___ / ___
Specimen
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
Blood
Lower resp
Urine
Stool
Other ______
More negative cultures than fit in the table:
13. Complete the table for non-culture microbiology tests (positive and negative) collected during the first 5
hospital days:
No non-culture tests done:
Non-culture test data unknown:
Collect Date
(mm/dd/yy)
Specimen
Test
1
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
2
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
3
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
4
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
5
____ / ___ / ___
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
PCR
DFA
Antigen test
Other_____
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
No.
What pathogen(s) were tested for?
Result
More tests than fit in the table:
14. Did the patient have any of the following blood test results during the first 2 hospital days?
Check all that apply, or None.
Arterial pH < 7.35
PaO2 < 60 mmHg
BUN > 30 mg/dL (11 mmol/L)
Sodium < 130 mmol/L
Glucose > 250 mg/dL
Hematocrit < 30%
***FORM IS COMPLETE***
AQUA CAP_20150227
Page 4 of 4
HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA)
FORM 3d: UTI
CDC ID:
-
Date:
/
/
Data collector initials: _____
Clinical information
1. Check any of the following ICD-9 codes that were present on admission for this patient:
590.10
590.11
590.2
590.3
590.80
590.81
590.9
595.0
597.0
597.80
599.0
2. UTI onset date (mm/dd/yy): ___ / ___ /___ or
Prior to survey hospitalization but specific date unknown
Unable to determine
3. UTI signs and symptoms in first 2 hospital days; check all that apply:
Fever
Nausea or vomiting
Urgency
Rigors
Frequency
Visible blood in urine
Abdominal pain
Urinary incontinence
None
None
Costovertebral angle (CVA) pain or tenderness
Suprapubic pain, swelling or tenderness
Mental status changes or functional decline
Pain or burning with urination
4. Did the patient have an indwelling urinary catheter in place for ≥2 days on the day of UTI onset or on the day
prior to UTI onset (or if onset date unknown, on the day of survey hospital admission)?
Yes
No
Unknown
4a. If yes, were any of the following done within 5 days after UTI onset date (or if onset date unknown, within 5
days after survey hospital admission)?
Catheter changed
Catheter removed
Catheter neither changed nor removed
Unknown
UTI treatment
5. Was the patient receiving antimicrobial treatment for this UTI before the survey hospitalization?
Yes
No
Unknown
6. UTI treatment start date during the survey hospitalization (mm/dd/yy): ____ / ____ /____ or
Unknown
7. Complete the table for all antimicrobial drugs given to treat UTI during the survey hospitalization:
No.
Drug name
First date (mm/dd/yy)
First route
Last date (mm/dd/yy)
Last route
1
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
2
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
3
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
4
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
5
____ / ____ / ____
IV
PO
IM
INH
____ / ____ / ____
IV
PO
IM
INH
More than 5 antimicrobial drugs were given to treat UTI:
8. Were antimicrobial drugs prescribed at hospital discharge to treat this UTI (i.e., prescribed to be administered
to the patient for additional days after hospital discharge)?
Yes
No
Unknown
8a. If yes to question 8, what is the total duration of the post-discharge UTI treatment?
_____ days, OR the prescription end date is ____ / ____ / _____, OR Duration is unknown
8b. If yes to question 8, what antimicrobial drugs were prescribed?
One antimicrobial drug was prescribed (enter name: ____________________)
Two or more antimicrobial drugs were prescribed
(enter up to 3 names: ____________________, ____________________, ____________________)
Unknown
AQUA UTI_20150331
Page 1 of 3
CDC ID:
-
Laboratory testing
9. Complete table below for POSITIVE cultures collected in the first 5 hospital days (____/____/____ through ____/____/____):
No positive cultures:
Culture data unknown:
No.
Specimen
Collect date
(mm/dd/yy)
Culture result
final date
(mm/dd/yy)
Pathogens
identified
(insert codes)
Culture growth quantity* for urine cultures only
Antimicrobial
drugs given on
the DAY
AFTER the test
result was final
Were pathogens
susceptible (S) to
≥1 antimicrobial
the patient was
getting the DAY
AFTER the test
result was final?
1
Urine CC
Lower resp
Urine cath
Stool
Urine other
Blood
Other _____
___/ ___ / ___
___/ ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥105 CFU/ml or similar
≥105 CFU/ml or similar
≥105 CFU/ml or similar
<105 or similar
<105 or similar
<105 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
2
Urine CC
Lower resp
Urine cath
Stool
Urine other
Blood
Other _____
___/ ___ / ___
___/ ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥105 CFU/ml or similar
≥105 CFU/ml or similar
≥105 CFU/ml or similar
<105 or similar
<105 or similar
<105 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
3
Urine CC
Lower resp
Urine cath
Stool
Urine other
Blood
Other _____
___/ ___ / ___
___/ ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥105 CFU/ml or similar
≥105 CFU/ml or similar
≥105 CFU/ml or similar
<105 or similar
<105 or similar
<105 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
4
Urine CC
Lower resp
Urine cath
Stool
Urine other
Blood
Other _____
___/ ___ / ___
___/ ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥105 CFU/ml or similar
≥105 CFU/ml or similar
≥105 CFU/ml or similar
<105 or similar
<105 or similar
<105 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
5
Urine CC
Lower resp
Urine cath
Stool
Urine other
Blood
Other _____
___/ ___ / ___
___/ ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥105 CFU/ml or similar
≥105 CFU/ml or similar
≥105 CFU/ml or similar
<105 or similar
<105 or similar
<105 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
6
Urine CC
Lower resp
Urine cath
Stool
Urine other
Blood
Other _____
___/ ___ / ___
___/ ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥105 CFU/ml or similar
≥105 CFU/ml or similar
≥105 CFU/ml or similar
<105 or similar
<105 or similar
<105 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
7
Urine CC
Lower resp
Urine cath
Stool
Urine other
Blood
Other _____
___/ ___ / ___
___/ ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥105 CFU/ml or similar
≥105 CFU/ml or similar
≥105 CFU/ml or similar
<105 or similar
<105 or similar
<105 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
8
Urine CC
Lower resp
Urine cath
Stool
Urine other
Blood
Other _____
___/ ___ / ___
Path1 ________
Path2 ________
Path3 ________
Path1:
Path2:
Path3:
≥105 CFU/ml or similar
≥105 CFU/ml or similar
≥105 CFU/ml or similar
<105 or similar
<105 or similar
<105 or similar
Unk
Unk
Unk
Drug1 ________
Drug2 ________
Drug3 ________
Drug4________
Path1:
Path2:
Path3:
Y
Y
Y
N
N
N
U
U
U
___/ ___ / ___
More positive cultures than fit in the table:
Urine CC=urine clean catch. Urine cath=urine collected from an indwelling urinary catheter. Urine other=urine collected via other or unspecified means.
*Check “≥105 CFU/ml or similar” if quantity of growth in the culture is reported to be as follows: moderate, many, heavy, abundant, etc;. Check “<105 or similar” if quantity of growth in the culture is reported
to be <105 CFU/ml or as follows: few, scarce, scant, rare, etc.Check “unknown” if no organism quantity is noted in the culture report.
AQUA UTI_20150331
Page 2 of 3
-
CDCID:
10. Complete the table for NEGATIVE cultures collected in the first 5 hospital days (____/____/____ through
____/____/____):
No negative cultures:
Culture data unknown:
No.
Collect date
(mm/dd/yy)
Specimen
Collect date
(mm/dd/yy)
No.
Specimen
1
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
6
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
2
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
7
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
3
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
8
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
4
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
9
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
5
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
10
____ / ___ / ___
Blood
Lower resp
Urine
Stool
Other ______
More negative cultures than fit in the table:
11. Complete the table for urinalyses collected in the first 5 hospital days:
No urinalyses done:
Unknown whether urinalyses were done:
No.
Urinalysis date
(mm/dd/yy)
Pyuria
(>5 WBCs / hpf)
1
___ / ___ / ___
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
2
___ / ___ / ___
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
3
___ / ___ / ___
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
4
___ / ___ / ___
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
5
___ / ___ / ___
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
Y
N
Unk
Nitrites
Leukocyte esterase
Bacteria
Yeast
12. Complete the table for non-culture tests (positive and negative) collected in the first 5 hospital days:
No non-culture tests done:
Non-culture test data unknown:
No.
1
Collect Date
(mm/dd/yy)
____ / ___ / ___
2
____ / ___ / ___
3
____ / ___ / ___
4
____ / ___ / ___
5
____ / ___ / ___
Specimen
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
Blood
Lower resp
Upper resp
Urine
Stool
Other ______
Test
PCR
DFA
Antigen test
Other_____
PCR
DFA
Antigen test
Other_____
PCR
DFA
Antigen test
Other_____
PCR
DFA
Antigen test
Other_____
PCR
DFA
Antigen test
Other_____
What pathogen(s) were tested for?
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
Legionella
Cdiff
Pneumococcus
Influenza
hMPV
Other ________
RSV
Adeno
Paraflu
RSV
Adeno
Paraflu
RSV
Adeno
Paraflu
RSV
Adeno
Paraflu
RSV
Adeno
Paraflu
Result
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
Negative
Unknown
Positive (insert code):
Path1_______Path2_______
Path3_______
More tests than fit in the table:
***FORM IS COMPLETE***
AQUA UTI_20150331
Page 3 of 3
| File Type | application/pdf |
| Author | Shelley Magill |
| File Modified | 2016-06-20 |
| File Created | 2016-06-20 |