AQUA Fluoroquinolone Form

Attachment_I_b_AQUA Fluoroquinolone Form.docx

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

AQUA Fluoroquinolone Form

OMB: 0920-0852

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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***











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