HAI Form (modified August 2022)

Att_E_HAI Form_Aug22.docx

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

HAI Form (modified August 2022)

OMB: 0920-0852

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Form Approved

OMB No. 0920-0852

Exp. Date 03/31/2025

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/ECLS VAD EB Self-injection in central line Hemodialysis catheter 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 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
USI	Check one: USI	____/____/____ or BH Unk	Yes No Unk	____/____/___ Unk None	1: _______ 2: _______ 3: _______ or None	_________ Unk

HAI

Specific site and infection data

Event date

Secondary BSI

Rx start date

Pathogens

Location of attribution

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/ECLS VAD EB Self-injection in central line Hemodialysis catheter

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

____/____/___

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

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

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 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

USI

Check one: USI

____/____/____

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	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
___-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

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

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

SSI-2

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

___-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: -

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.
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.
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.
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

Gram-negative

Acinetobacter (any species)

AMPSUL MERO/DORI

S I R N S I R N

CEFTAZ CEFEP

S I R N S I R N

COL/PB PIPTAZ

S I R N S I R N

IMI

S I R N

AMPSUL MERO/DORI

S I R N S I R N

CEFTAZ CEFEP

S I R N S I R N

COL/PB PIPTAZ

S I R N S I R N

IMI

S I R N

AMPSUL MERO/DORI

S I R N S I R N

CEFTAZ CEFEP

S I R N S I R N

COL/PB PIPTAZ

S I R N S I R N

IMI

S I R N

AMPSUL MERO/DORI

S I R N S I R N

CEFTAZ CEFEP

S I R N S I R N

COL/PB PIPTAZ

S I R N S I R N

IMI

S I R N

E. coli

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N CIPRO/LEVO/MOXI

S I R N

Enterobacter cloacae

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

Klebsiella (Enterobacter) aerogenes

Klebsiella oxytoca

Klebsiella pneumoniae

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

ERTA PIPTAZ

S I R N S I R N

IMI IMIREL

S I R N S I R N

MERO/DORI MERVAB

S I R N S I R N

CEFEP

S I R N

CIPRO/LEVO/MOXI

S I R N

Pseudomonas aeruginosa

CEFTAZ MERO/DORI

S I R N S I R N

COL/PB PIP/PIPTAZ

S I R N S I R N

GENT TOBRA

S I R N S I R N

IMI

S I R N

CEFTAZ MERO/DORI

S I R N S I R N

COL/PB PIP/PIPTAZ

S I R N S I R N

GENT TOBRA

S I R N S I R N

IMI

S I R N

CEFTAZ MERO/DORI

S I R N S I R N

COL/PB PIP/PIPTAZ

S I R N S I R N

GENT TOBRA

S I R N S I R N

IMI

S I R N

CEFTAZ MERO/DORI

S I R N S I R N

COL/PB PIP/PIPTAZ

S I R N S I R N

GENT TOBRA

S I R N S I R N

IMI

S I R N

Gram-positive

Staphylococcus aureus

CEFOX/METH/OX LNZ

S I R N S R N

DAPTO VANC

S NS N S I R N

CEFOX/METH/OX LNZ

S I R N S R N

DAPTO VANC

S NS N S I R N

CEFOX/METH/OX LNZ

S I R N S R N

DAPTO VANC

S NS N S I R N

CEFOX/METH/OX LNZ

S I R N S R N

DAPTO VANC

S NS N S I R N

Enterococcus faecalis

Enterococcus faecium

DAPTO VANC

S NS S-DD R N S I R N

LNZ

S I R N

DAPTO VANC

S NS S-DD R N S I R N

LNZ

S I R N

DAPTO VANC

S NS S-DD R N S I R N

LNZ

S I R N

DAPTO VANC

S NS S-DD R N S I R N

LNZ

S I R N

Fungal

Candida glabrata

ANID MICA

S I R N S I R N

CASPO VORI

S I R N S I R N

FLUCO

S S-DD R N

ANID MICA

S I R N S I R N

CASPO VORI

S I R N S I R N

FLUCO

S S-DD R N

ANID MICA

S I R N S I R N

CASPO VORI

S I R N S I R N

FLUCO

S S-DD R N

ANID MICA

S I R N S I R N

CASPO VORI

S I R N S I R N

FLUCO

S S-DD R N

Drug codes: AMPSUL=ampicillin/sulbactam, ANID=anidulafungin, CASPO=caspofungin, CEFOX/OX/METH=cefoxitin, oxacillin or methicillin, CEFEP=cefepime, CEFTAZ=ceftazidime, CIPRO/LEVO/MOXI=ciprofloxacin or levofloxacin or moxifloxacin, COL/PB=colistin or polymyxin B, DAPTO=daptomycin, ERTA=ertapenem, FLUCO=fluconazole, GENT=gentamicin, IMI=imipenem, IMIREL=imipenem/relebactam, LNZ=linezolid, MERO/DORI=meropenem or doripenem, MERVAB=meropenem/vaborbactam, MICA=micafungin, PIP/PIPTAZ=piperacillin or piperacillin/tazobactam, TIG=tigecycline, TOBRA=tobramycin, VANC=vancomycin, VORI=voriconazole

***FORM IS COMPLETE***

Phase5_HAI Form_20220516 Page 2 of 4

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