Draft HAI form

Attachment_E_HAI_Draft.pdf

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

Draft HAI form

OMB: 0920-0852

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0852 can be found here:
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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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File Type	application/pdf
Author	Shelley Magill
File Modified	2015-04-20
File Created	2015-04-20