57.140_UTI_LTCF

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Urinary Tract Infection (UTI) for LTCF
Page 1 of 4
*required for saving
*Facility ID:
Event #:
*Resident ID:
*Social Security #:
Medicare number (or comparable railroad insurance number):
Resident Name, Last:
First:
Middle:
*Gender:   M     F     Other
*Date of Birth: ___/___/____
Ethnicity (specify):
Race (specify):
*Resident type:
□ Short-stay
□ Long-stay
*Date of First Admission to Facility: __/__/____
*Date of Current Admission to Facility: __/__/____
*Event Type: UTI
*Date of Event: __/__/____
*Resident Care Location: __________________________
*Primary Resident Service Type: (check one)
□ Long-term general nursing
□ Long-term dementia
□ Long-term psychiatric
□ Skilled nursing/Short-term rehab (subacute)
□ Ventilator
□ Bariatric
□ Hospice/Palliative
*Has resident been transferred from an acute care facility to your facility in the past 4 weeks?
□ Yes
□ No
If Yes, date of last transfer from acute care to your facility: __/__/____
If Yes, did the resident have an indwelling urinary catheter at the time of transfer to your facility?
□ Yes
□ No
*Indwelling Urinary Catheter status at time of event onset (check one):
□ In place
□ Removed within last 2 calendar days
□ Not in place
If indwelling urinary catheter status in place or removed within last 2 calendar days:

Site where indwelling urinary catheter Inserted (check one):
□ Your facility
□ Acute care hospital
□ Other
□ Unknown

Date of indwelling urinary catheter Insertion:   ___/___/_____
If indwelling urinary catheter not in place, was another urinary device type present at the time of event onset?
□ Yes
□ No

If Yes, other device type:
□ Suprapubic
□ Condom (males only)
□ Intermittent straight catheter
Event Details
*Specify Criteria Used: (check all that apply)
Laboratory & Diagnostic Testing
Signs & Symptoms

□ 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
□ Specimen collected from clean catch voided urine and a positive culture with no more than 2 species of microorganisms, at least one of which is a bacterium of ≥ 105 CFU/ml
□ Rigors
□ New onset hypotension

□ New onset confusion/functional decline
□ Specimen collected from in/out straight catheter and a positive culture with any number of microorganisms, at least one of which is a bacterium of ≥ 102 CFU/ml
□ Acute pain, swelling, or tenderness of the testes, epididymis, or prostate

□ Acute dysuria
□ Purulent drainage at catheter insertion site
□ Specimen collected from indwelling catheter and a positive culture with any number of microorganisms,                        at least one of which is a bacterium of ≥ 105 CFU/ml
New and/or marked increase in (check all that apply):

□ Urgency
□ Costovertebral angle pain or tenderness
□ Leukocytosis (> 14,000 cells/mm3), or Left shift (> 6% or 1,500 bands/mm3)
□ Frequency
□ Suprapubic tenderness

□ Incontinence
□ Visible (gross) hematuria
□ Positive blood culture with 1 matching organism in urine culture
*Specific Event (Check one):
□ Symptomatic UTI (SUTI)
□ Symptomatic CA-UTI (CA-SUTI)
□ Asymptomatic Bacteremic UTI (ABUTI)
Secondary Bloodstream Infection:  Yes    No
Died within 7 days of date of event: Yes   No
*Transfer to acute care facility within 7 days:   Yes   No

*Pathogens identified:   Yes    No
*If Yes, specify on page 2
Assurance of Confidentiality:  The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666).
CDC 57.140 (Front) r2  v8.8
Urinary Tract Infection (UTI) for LTCF
Page 2 of 4
Pathogen #
Gram-positive Organisms

_______

Staphylococcus coagulase-negative

VANC
S I R N

(specify species if available):
____________

_______

____Enterococcus faecium

____Enterococcus faecalis

____Enterococcus spp.
          (Only those not identified  to the species level)

DAPTO
S NS N

GENTHL§
S R N

LNZ
S I R N

VANC
S I R N



_______

Staphylococcus aureus

CIPRO/LEVO/MOXI
S I R N

CLIND
S I R N

DAPTO
S NS N

DOXY/MINO
S I R N

ERYTH
S I R N

GENT
S I R N

LNZ
S R N



OX/CEFOX/METH
S I R N

RIF
S I R N

TETRA
S I R N

TIG
S NS N

TMZ
S I R N

VANC
S I R N

Pathogen #
Gram-negative Organisms

_______

Acinetobacter
(specify species)
____________

AMK
S I R N

AMPSUL
S I R N

AZT
S I R N

CEFEP
S I R N

CEFTAZ
S I R N

CIPRO/LEVO
S I R N

COL/PB
S I R N



GENT
S I R N

IMI
S I R N


MERO/DORI
S I R N

PIP/PIPTAZ
S I R N

TETRA/DOXY/MINO
S I R N



TMZ
S I R N

TOBRA
S I R N


_______

Escherichia coli

AMK
S I R N

AMP
S I R N

AMPSUL/AMXCLV
S I R N

AZT
S I R N

CEFAZ
S I R N

CEFEP
S I/S-DD R N

CEFOT/CEFTRX
S I R N



CEFTAZ
S I R N

CEFUR
S I R N

CEFOX/CETET
S I R N

CIPRO/LEVO/MOXI
S I R N

COL/PB†
S R N



ERTA
S I R N

GENT
S I R N

IMI
S I R N

MERO/DORI
S I R N

PIPTAZ
S I R N

TETRA/DOXY/MINO
S I R N



TIG
S I R N

TMZ
S I R N

TOBRA
S I R N


_______

Enterobacter
(specify species)
____________

AMK
S I R N

AMP
S I R N

AMPSUL/AMXCLV
S I R N

AZT
S I R N

CEFAZ
S I R N

CEFEP
S I/S-DD R N

CEFOT/CEFTRX
S I R N



CEFTAZ
S I R N

CEFUR
S I R N

CEFOX/CETET
S I R N

CIPRO/LEVO/MOXI
S I R N

COL/PB†
S R N



ERTA
S I R N

GENT
S I R N

IMI
S I R N

MERO/DORI
S I R N

PIPTAZ
S I R N

TETRA/DOXY/MINO
S I R N



TIG
S I R N

TMZ
S I R N

TOBRA
S I R N


_______

____Klebsiella
        pneumonia

____Klebsiella
        oxytoca


AMK
S I R N

AMP
S I R N

AMPSUL/AMXCLV
S I R N

AZT
S I R N

CEFAZ
S I R N

CEFEP
S I/S-DD R N

CEFOT/CEFTRX
S I R N



CEFTAZ
S I R N

CEFUR
S I R N

CEFOX/CETET
S I R N

CIPRO/LEVO/MOXI
S I R N

COL/PB†
S R N



ERTA
S I R N

GENT
S I R N

IMI
S I R N

MERO/DORI
S I R N

PIPTAZ
S I R N

TETRA/DOXY/MINO
S I R N



TIG
S I R N

TMZ
S I R N

TOBRA
S I R N




Urinary Tract Infection (UTI) for LTCF
Page 3 of 4
Pathogen #
Gram-negative Organisms (continued)

_______

Pseudomonas aeruginosa

AMK
S I R N

AZT
S I R N

CEFEP
S I R N

CEFTAZ
S I R N

CIPRO/LEVO
S I R N

COL/PB
S I R N

GENT
S I R N



IMI
S I R N


MERO/DORI
S I R N

PIP/PIPTAZ
S I R N

TOBRA
S I R N
Pathogen #
Fungal Organisms
_______
Candida
(specify species if available)
____________

ANID
S I R N
CASPO
S NS N
FLUCO
S S-DD R N
FLUCY
S I R N
ITRA
S S-DD R N
MICA
S NS N
VORI
S S-DD R N
Pathogen #
Other Organisms
_______
Organism 1 (specify)
____________

_______Drug 1
S I R N
_______ Drug 2
S I R N
______
Drug 3
S I R N
_______ Drug 4
S I R N
_______Drug 5
S I R N
______ Drug 6
S I R N
______ Drug 7
S I R N
______ Drug 8
S I R N
______ Drug 9
S I R N
_______
Organism 1 (specify)
____________

_______Drug 1
S I R N
_______ Drug 2
S I R N
______
Drug 3
S I R N
_______ Drug 4
S I R N
_______Drug 5
S I R N
______ Drug 6
S I R N
______ Drug 7
S I R N
______ Drug 8
S I R N
______ Drug 9
S I R N
_______
Organism 1 (specify)
____________

_______Drug 1
S I R N
_______ Drug 2
S I R N
______
Drug 3
S I R N
_______ Drug 4
S I R N
_______Drug 5
S I R N
______ Drug 6
S I R N
______ Drug 7
S I R N
______ Drug 8
S I R N
______ Drug 9
S I R N


Result Codes
S = Susceptible   I = Intermediate   R = Resistant   NS = Non-susceptible   S-DD = Susceptible-dose dependent   N = Not tested
§ GENTHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic
† Clinical breakpoints have not been set by FDA or CLSI, Sensitive and Resistant designations should be based upon epidemiological cutoffs of Sensitive MIC ≤ 2 and Resistant MIC ≥ 4

Drug Codes:



AMK = amikacin
CEFTRX = ceftriaxone
FLUCY = flucytosine
OX = oxacillin
AMP = ampicillin
CEFUR= cefuroxime
GENT = gentamicin
PB = polymyxin B
AMPSUL = ampicillin/sulbactam
CETET= cefotetan
GENTHL = gentamicin –high level test
PIP = piperacillin
AMXCLV = amoxicillin/clavulanic acid
CIPRO = ciprofloxacin
IMI = imipenem
PIPTAZ = piperacillin/tazobactam
ANID = anidulafungin
CLIND = clindamycin
ITRA = itraconazole
RIF = rifampin
AZT = aztreonam
COL = colistin
LEVO = levofloxacin
TETRA = tetracycline
CASPO = caspofungin
DAPTO = daptomycin
LNZ = linezolid
TIG = tigecycline
CEFAZ= cefazolin
DORI = doripenem
MERO = meropenem
TMZ = trimethoprim/sulfamethoxazole
CEFEP = cefepime
DOXY = doxycycline
METH = methicillin
TOBRA = tobramycin
CEFOT = cefotaxime
ERTA = ertapenem
MICA = micafungin
VANC = vancomycin
CEFOX= cefoxitin
ERYTH = erythromycin
MINO = minocycline
VORI = voriconazole
CEFTAZ = ceftazidime
FLUCO = fluconazole
MOXI = moxifloxacin


Urinary Tract Infection (UTI) for LTCF
Page 4 of 4
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