Draft AU 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

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