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.

2. Enter the first date during the hospitalization on which an antimicrobial drug was administered to the patient: ____ / ____ / ____ or Unknown.

   Drug no.	Drug name	Route	Given on:	Rationale (check all that apply)	First date (mm/dd/yy)	If Rationale=SP only: SP duration (hrs)
   1		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   2		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   3		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   4		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   5		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   6		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   7		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   8		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   9		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   10		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   11		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h Unknown
   12		IV IM PO INH	Survey date Day prior	TAI NI MP None SP (Proc: _______)	___/___/___	≤24h >24 – 48h >48h 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.

Abbreviation key: IV=Intravenous, IM=Intramuscular, PO=Oral/enteral, INH=Inhaled, MP=Medical prophylaxis, NI=Non-infectious, SP=Surgical prophylaxis, TAI=Treatment of active infection, None=None documented. Proc=NHSN Operative procedure code for which SP was given.

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 the number of therapeutic sites. Then enter up to 5 clinician-defined therapeutic site codes for each drug. Check “Y” for “SSI” if the infection at the site indicated is a surgical site infection. Otherwise check “N”. Check “Y” for “Sepsis” if there is documentation of sepsis due to the infection at the site indicated. Otherwise, check “N”. Check “Y” for “COVID-19” if the infection at the site indicated is COVID-19. Otherwise, check “N”. Check the infection onset location for each site (multiple onset locations may be checked for each site, although this is not common).

Treatment Table

Drug no.

Drug name

No. therap sites

Therapeutic site #1

Therapeutic site #2

Therapeutic site #3

Therapeutic site #4

Therapeutic site #5

Code

Onset

Code

Onset

Code

Onset

Code

Onset

Code

Onset

1

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

2

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

3

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

4

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

5

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

6

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

7

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

8

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Code: ______ SSI Y N Sepsis Y N COVID19 Y N

C O H U L

Clinician-defined therapeutic site codes: BJI=Bone and joint infection; BSI=Bloodstream infection; CDI=Clostridioides 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.

Infection onset locations: C=Community; H=Survey hospital; L=Long term care/skilled nursing facility; O=Other healthcare facility; U=Unknown onset location.

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:

Complete Antimicrobial Quality Assessment (AQUA) Eligibility Form

to determine whether additional AQUA forms are needed.

Vancomycin IV for TAI (with or without other Rationales)

Levofloxacin, ciprofloxacin, moxifloxacin, or delafloxacin 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”

***FORM IS COMPLETE***

Phase 5_AU Form_20210513 Page 3 of 3