AQUA UTI Form

Attachment_I_d_AQUA UTI_Form.docx

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

AQUA UTI Form

OMB: 0920-0852

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HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA)

FORM 3d: UTI


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



Clinical information

1. Check any of the following ICD-10 codes that were present on admission for this patient: None

N10 N11.0 N11.1 N11.8 N11.9 N12 N15.1 N15.9 N16 N28.84 N28.85 N28.86 N30.00 N30.01 N30.10 N30.11 N30.20 N30.21 N30.30 N30.31 N30.40 N30.41 N30.80 N30.81 N30.90 N30.91 N34.0 N34.1 N34.2 N39.0

R82.71 R82.90 N41.0 N41.1 N41.2 B37.49 O23.00 Other (specify): __________

2. UTI onset date (mm/dd/yy): ___ / ___ /___ or

Prior to survey hospitalization but specific date unknown Unable to determine

3. UTI signs and symptoms in first 2 hospital days; check all that apply: None

Fever

Nausea or vomiting

Urgency

Rigors

Frequency

Visible blood in urine

Abdominal pain

Urinary incontinence

Costovertebral angle (CVA) pain or tenderness

Suprapubic pain, swelling or tenderness

Mental status changes or functional decline

Pain or burning with urination

4. Did the patient have an indwelling urinary catheter in place for 2 days on the day of UTI onset or on the day prior to UTI onset (or if onset date unknown, on the day of survey hospital admission)?

Yes No Unknown


4a. If yes, were any of the following done within 5 days after UTI onset date (or if onset date unknown, within 5 days after survey hospital admission)?

Catheter changed Catheter removed Catheter neither changed nor removed Unknown

Antimicrobial treatment

5. Was the patient receiving antimicrobial treatment for this UTI before the survey hospitalization?

Yes No Unknown

6. Present-on-admission (POA) UTI treatment during the survey hospitalization:

First date (mm/dd/yy): ____ / ____ /____ or Unknown Last date (mm/dd/yy): ____ / ____ /____ or Unknown

7. Complete the table for all antimicrobial drugs given to treat POA UTI during the survey hospitalization:

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

More than 5 antimicrobial drugs were given to treat POA UTI:





CDC ID: -


Antimicrobial treatment

7a. Did the patient receive other antimicrobial drugs in the hospital during the POA UTI treatment period?

Yes—complete table below in 7b. No Unknown


7b. Other antimicrobial drugs given in the hospital (during the UTI treatment period defined by the dates in #6):

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

*Enter separate records for vancomycin IV and vancomycin PO.

More drugs than fit in the table:


8. Were antimicrobial drugs prescribed at hospital discharge (i.e., prescribed to be administered to the patient for additional days after hospital discharge) to treat POA UTI or for other reasons?

Yes No Unknown


8a. Antimicrobial drugs prescribed at discharge for POA UTI or other reasons (enter POA UTI drugs first):


No.

Drug name

Route (check all that apply)

Indication (check all that apply)

1


IV IM PO INH Unk

POA UTI Other Unk

2


IV IM PO INH Unk

POA UTI Other Unk

3


IV IM PO INH Unk

POA UTI Other Unk

4


IV IM PO INH Unk

POA UTI Other Unk

5


IV IM PO INH Unk

POA UTI Other Unk

More drugs than fit in the table:


8b. If antimicrobial drugs were prescribed at discharge for POA-UTI, what was the total duration of the post-discharge POA UTI treatment?

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





Laboratory testing

9. Complete table below for POSITIVE cultures collected in the first 5 hospital days (____/____/____ through ____/____/____): No positive cultures: Culture data unknown:

No.

Specimen

Collect date (mm/dd/yy)

Culture result final date (mm/dd/yy)

Pathogens identified

(insert codes)

Culture growth quantity* for urine cultures only

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

Urine CC Lower resp

Urine cath Stool

Urine other Blood

Other __________

___/ ___ / ___

___/ ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 105 CFU/ml or similar <105 or similar Unk

Path2: 105 CFU/ml or similar <105 or similar Unk

Path3: 105 CFU/ml or similar <105 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

2

Urine CC Lower resp

Urine cath Stool

Urine other Blood

Other __________

___/ ___ / ___

___/ ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 105 CFU/ml or similar <105 or similar Unk

Path2: 105 CFU/ml or similar <105 or similar Unk

Path3: 105 CFU/ml or similar <105 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

3

Urine CC Lower resp

Urine cath Stool

Urine other Blood

Other __________

___/ ___ / ___

___/ ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 105 CFU/ml or similar <105 or similar Unk

Path2: 105 CFU/ml or similar <105 or similar Unk

Path3: 105 CFU/ml or similar <105 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

4

Urine CC Lower resp

Urine cath Stool

Urine other Blood

Other __________

___/ ___ / ___

___/ ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 105 CFU/ml or similar <105 or similar Unk

Path2: 105 CFU/ml or similar <105 or similar Unk

Path3: 105 CFU/ml or similar <105 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

5

Urine CC Lower resp

Urine cath Stool

Urine other Blood

Other __________

___/ ___ / ___

___/ ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 105 CFU/ml or similar <105 or similar Unk

Path2: 105 CFU/ml or similar <105 or similar Unk

Path3: 105 CFU/ml or similar <105 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

6

Urine CC Lower resp

Urine cath Stool

Urine other Blood

Other __________

___/ ___ / ___

___/ ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 105 CFU/ml or similar <105 or similar Unk

Path2: 105 CFU/ml or similar <105 or similar Unk

Path3: 105 CFU/ml or similar <105 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

7

Urine CC Lower resp

Urine cath Stool

Urine other Blood

Other __________

___/ ___ / ___

___/ ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 105 CFU/ml or similar <105 or similar Unk

Path2: 105 CFU/ml or similar <105 or similar Unk

Path3: 105 CFU/ml or similar <105 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

8

Urine CC Lower resp

Urine cath Stool

Urine other Blood

Other __________

___/ ___ / ___

___/ ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 105 CFU/ml or similar <105 or similar Unk

Path2: 105 CFU/ml or similar <105 or similar Unk

Path3: 105 CFU/ml or similar <105 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

More positive cultures than fit in the table:


Urine CC=urine clean catch. Urine cath=urine collected from an indwelling urinary catheter. Urine other=urine collected via other or unspecified means.

*Check “105 CFU/ml or similar” if quantity of growth in the culture is reported to be as follows: moderate, many, heavy, abundant, etc;. Check “<105 or similar” if quantity of growth in the culture is reported to be <105 CFU/ml or as follows: few, scarce, scant, rare, etc.Check “unknown” if no organism quantity is noted in the culture report.

CDC ID: -


CDCID: -

10. Complete the table for NEGATIVE cultures collected in the first 5 hospital days:

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:

11. Complete the table for urinalyses collected in the first 5 hospital days:

No urinalyses done: Unknown whether urinalyses were done:

No.

Urinalysis date

(mm/dd/yy)

Pyuria

(>5 WBCs / hpf)

Nitrites

Leukocyte esterase

Bacteria

Yeast

1

___ / ___ / ___

Y N Unk

Y N Unk

Y N Unk

Y N Unk

Y N Unk

2

___ / ___ / ___

Y N Unk

Y N Unk

Y N Unk

Y N Unk

Y N Unk

3

___ / ___ / ___

Y N Unk

Y N Unk

Y N Unk

Y N Unk

Y N Unk

4

___ / ___ / ___

Y N Unk

Y N Unk

Y N Unk

Y N Unk

Y N Unk

5

___ / ___ / ___

Y N Unk

Y N Unk

Y N Unk

Y N Unk

Y N Unk


12. Complete the table for non-culture tests (positive and negative) collected in the first 5 hospital days:

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:



***FORM IS COMPLETE***

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