AQUA Fluoroquinolone Form

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 3b: FLUOROQUINOLONE

CDC ID: - Date: // Data collector initials: _____

Drugs given (check all that apply): Ciprofloxacin Levofloxacin Moxifloxacin Delafloxacin

Infections and other antimicrobial drugs

1. Which infections present during the hospitalization, as reported on the GPA form (question 6), were being treated with a fluoroquinolone? None

Infection no. 1 (site ______ ) Infection no. 2 (site ______ ) Infection no. 3 (site ______ )

Infection no. 4 (site ______ ) Infection not listed in table due to >4 infections (site ______ )

Unknown

2. Did the patient receive other antimicrobial drugs in the hospital during the period defined by the date that was 5 days before the first date of fluoroquinolone and the date that was 5 days after the last date of fluoroquinolone?

Yes—complete table below

No

Unknown

2a. Other antimicrobial drugs given in the hospital:

5 days before fluoroquinolone first date*: ____ / ____ / ________

5 days after fluoroquinolone last date**: ____ / ____ / ________

No.	Drug name***	First date (mm/dd/yy)	First Route	Last date (mm/dd/yy)	Last Route
1		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
2		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
3		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
4		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
5		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
6		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
7		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
8		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
9		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
10		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
11		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
12		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
13		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
14		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
15		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
*or admission date if fluoroquinolone first date ≤5 days after admission **or discharge date if fluoroquinolone last date ≤5 days before discharge ***Enter separate records for vancomycin IV and vancomycin PO More drugs than fit in the table:

Laboratory testing CDC ID: -

3. 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.	Specimen	Collect date (mm/dd/yy)	Test result final date (mm/dd/yy)	Pathogens identified (insert code)	Pathogen susceptible to ciprofloxacin?	Pathogen susceptible to levofloxacin?	Pathogen susceptible to moxifloxacin?	Pathogen susceptible to delafloxacin?	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	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
2	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
3	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
4	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
5	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
6	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
7	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
8	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
9	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U
10	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 _______ Path2 _______ Path3 _______	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 _______ Drug2 _______ Drug3 _______ Drug4 _______	Path1: Y N U Path2: Y N U Path3: Y N U

More positive cultures than fit in the table:

CDC ID: -

4. Complete the table for NEGATIVE cultures collected from 5 days before fluoroquinolone first date through the fluoroquinolone last date:

No negative cultures: Culture data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Culture result final date (mm/dd/yy)		No.	Collect date (mm/dd/yy)	Specimen	Culture result final date (mm/dd/yy)
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:

5. 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.	Collect date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

IV to PO conversion

6. 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

CDC ID: -

Post-discharge antimicrobial treatment

7. Was a fluoroquinolone prescribed at discharge (i.e., prescribed to be administered to the patient for additional days after hospital discharge)?

Yes No Unknown

7a. If yes to question 7, what drug(s) were prescribed? Check all that apply:

Drug	Route (check all that apply)
Ciprofloxacin	IV PO Unknown
Levofloxacin	IV PO Unknown
Moxifloxacin	IV PO Unknown
Delafloxacin	IV PO Unknown

7b. If yes to question 7, what is the total duration of the post-discharge fluoroquinolone prescription?

_____ days, OR the prescription end date is ____ / ____ / _____, OR Duration is unknown

7c. Were any other antimicrobial drugs prescribed at discharge?

Yes No Unknown

7d. If yes to question 7c, what drugs were prescribed?

No.	Drug name	Route (check all that apply)
1		IV IM PO INH Unknown
2		IV IM PO INH Unknown
3		IV IM PO INH Unknown
4		IV IM PO INH Unknown
5		IV IM PO INH Unknown

***FORM IS COMPLETE***

Phase 5 AQUA Fluoroquinolone 20200113 Page 1 of 4