HAI form

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM

CDC ID: - Data collector initials: ___________

Survey date: //

Date form completed: //

Enter the TOTAL no. of HAIs for this patient __________. If no HAIs, check here: None and the form is complete.

HAI	Specific site and infection data	Event date	Secondary BSI	Rx start date	Pathogens	Location of attribution
BJ	Check one: BONE DISC JNT PJI	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
BSI	Check one: LCBI MBI-LCBI Central line-associated? Yes No Check all that apply: ECMO VAD EB Self-injection in central line Munchausen syndrome (factitious disorder) Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP and pus is present at ≥1 of the following vascular sites from which the specimen was collected: Arterial catheter Arteriovenous fistula Arteriovenous graft Atrial lines (Right and Left) Hemodialysis reliable outflow (HERO) catheter Peripheral IV or Midline catheter Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor inserted during the admission) None	____/____/____ or BH Unk	NA	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
CNS	Check one: IC MEN SA	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
CVS	Check one: CARD ENDO MED VASC	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
EENT	Check one: CONJ EAR EYE ORAL SINU UR	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
GI	Check one: CDI GE GIT IAB NEC If CDI, which C. diff tests were performed (check all that apply)? Unknown GDH EIA  Positive Negative Unknown Toxin EIA  Positive Negative Unknown Combined GDH EIA and Toxin EIA  Positive Intermediate Negative Unknown NAAT  Positive Negative Unknown Cell cytotoxicity neutralization assay (CCNA)  Positive Negative Unknown Toxigenic culture  Positive Negative Unknown If CDI, which test was the LAST test result placed in the medical record? GDH EIA Toxin EIA NAAT CCNA Toxigenic culture Unknown	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
LRI	Check one: LUNG	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
PNEU	Check one: PNU1 PNU2 PNU3 Ventilator-associated? Yes No If PNU 2/3, check specimen types that apply: BAL ETA PSB Sputum Blood Pleural fluid Lung tissue Other, specify: ____________ If PNU3: check conditions that apply: SOT, date: ___/___/___ or Date unk HSCT, date: ___/___/___ or Date unk Low-dose steroids High-dose steroids Splenectomy HIV positive with CD4 count <200 ANC or WBC <500/mm3 Cytotoxic chemotherapy	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
REPR	Check one: EMET EPIS OREP VCUF	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
SSI	Proc: ______ Proc date: ____/____/____ Check one: SI DI O/S, site: ________ If SI or DI check one: Primary incision Secondary incision PATOS: Yes No	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	NA
SST	Check one: BRST BURN CIRC DECU SKIN ST UMB	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
UTI	Check one: SUTI ABUTI USI Catheter-associated? Yes No Was fever the only sign/symptom? Yes No Unknown Not applicable	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk

If the patient had >1 HAI of the same type at the time of the survey, enter below or check Not applicable. Note: This is not common.

HAI	Specific site and infection data	Event date	Secondary BSI	Rx start date	Pathogens	Location of attribution
BSI-2	Check one: LCBI MBI-LCBI Central line-associated? Yes No Check all that apply: ECMO VAD EB Self-injection in central line Munchausen syndrome (factitious disorder) Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP and pus is present at one of the following vascular sites from which the specimen was collected: Arterial catheter Arteriovenous fistula Arteriovenous graft Atrial lines (Right and Left) Hemodialysis reliable outflow (HERO) catheter Peripheral IV or Midline catheter Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor inserted during the admission) None	____/____/____ or BH Unk	NA	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
SSI-2	Check one: SI DI O/S, site: ________ If SI or DI check one: Primary incision Secondary incision PATOS: Yes No Proc: ______ Proc date: ____/____/____	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	NA
___-2	_______	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk
___-2	_______	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk

Refer to Operational Manual for HAI type and specific site descriptions and definitions. ECMO=extracorporeal membrane oxygenation. EB=epidermolysis bullosa. VAD=ventricular assist device. Proc=NHSN operative procedure category code. Proc date=operative procedure date. Rx start date=antimicrobial treatment start date. NA=not applicable. PATOS=infection present at time of surgery. BH=before hospital admission. Unk=unknown. SOT=solid organ transplantation. HSCT=hematopoietic stem cell transplantation. IWP=infection window period. HIV=human immunodeficiency virus. ANC=absolute neutrophil count. WBC=white blood cells count.

CDC ID: -

CDCID: -

1. 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 and 2 of this form.

2. Enter each of the patient’s HAI codes (e.g., BSI, PNEU, GI-2, etc.) in the top row of the table in the space(s) indicated.

3. 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.

4. 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=non-susceptible, 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: _______, or NA		HAI #2: _______, or NA		HAI #3: _______, or NA		HAI #4: _______, or NA
Acinetobacter (any species)	AMPSUL CEFTAZ COL/PB IMI MERO/DORI TIG	S I R N S I R N S I R N S I R N S I R N S I R N	AMPSUL CEFTAZ COL/PB IMI MERO/DORI TIG	S I R N S I R N S I R N S I R N S I R N S I R N	AMPSUL CEFTAZ COL/PB IMI MERO/DORI TIG	S I R N S I R N S I R N S I R N S I R N S I R N	AMPSUL CEFTAZ COL/PB IMI MERO/DORI TIG	S I R N S I R N S I R N S I R N S I R N S I R N
Candida albicans	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N
Candida glabrata	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N
Candida parapsilosis	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N	ANID CASPO FLUCO MICA	S I R N S I R N S S-DD R N S I R N
E. coli	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Enterobacter cloacae	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Enterococcus faecalis	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
Enterococcus faecium	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
Klebsiella (Enterobacter) aerogenes	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Klebsiella oxytoca	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Klebsiella pneumoniae	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N	ERTA IMI MERO/DORI	S I R N S I R N S I R N
Pseudomonas aeruginosa	CEFTAZ COL/PB GENT IMI MERO/DORI PIP/PIPTAZ TOBRA	S I R N S I R N S I R N S I R N S I R N S I R N S I R N	CEFTAZ COL/PB GENT IMI MERO/DORI PIP/PIPTAZ TOBRA	S I R N S I R N S I R N S I R N S I R N S I R N S I R N	CEFTAZ COL/PB GENT IMI MERO/DORI PIP/PIPTAZ TOBRA	S I R N S I R N S I R N S I R N S I R N S I R N S I R N	CEFTAZ COL/PB GENT IMI MERO/DORI PIP/PIPTAZ TOBRA	S I R N S I R N S I R N S I R N S I R N S I R N S I R N
Staphylococcus aureus	CEFOX/ METH/OX DAPTO LNZ VANC	S I R N S NS N S R N S I R N	CEFOX/ METH/OX DAPTO LNZ VANC	S I R N S NS N S R N S I R N	CEFOX/ METH/OX DAPTO LNZ VANC	S I R N S NS N S R N S I R N	CEFOX/ METH/OX DAPTO LNZ VANC	S I R N S NS N S R N S I R N

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

***FORM IS COMPLETE***

Phase5_HAI Form_20200113 Page 2 of 4