AQUA Vancomycin Form (modified August 2022)

Att_I_a_AQUA Vancomycin Form_Aug22.docx

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

AQUA Vancomycin Form (modified August 2022)

OMB: 0920-0852

Document [docx]
Download: docx | pdf


Shape1

Form Approved

OMB No. 0920-0852

Exp. Date 03/31/2025


HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 3a: VANCOMYCIN

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


Infections and other antimicrobial drugs

1. Which infections present during the hospitalization, as reported on the GPA form (question 6), were being treated with vancomycin IV? 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 vancomycin IV and the date that was 5 days after the last date of vancomycin IV?

Yes—complete table below

No

Unknown

2a. Other antimicrobial drugs given in the hospital:

5 days before vancomycin IV first date*: ____ / ____ / ________

5 days after vancomycin IV 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 vancomycin IV first date ≤5 days after admission

**or discharge date if vancomycin IV last date ≤5 days before discharge

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 vancomycin IV first date (5 days before: ____/____/____) through the vancomycin IV 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 oxacillin, methicillin or cefoxitin?

Pathogen susceptible to penicillin or ampicillin?

Pathogen susceptible to vancomycin?

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

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

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

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

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

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

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

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

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

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

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

More positive cultures than fit in the table:


4. Complete the table for NEGATIVE cultures collected from 5 days before vancomycin IV first date through the vancomycin IV 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. Was a MRSA surveillance culture(s) or CIDT done during this admission?

Yes-culture Yes-CIDT No Unknown

5a. If yes to question 5, were any MRSA surveillance cultures or CIDTs positive for MRSA during this admission?

Yes-culture Yes-CIDT No Unknown

6. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before vancomycin IV first date through the vancomycin IV 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 ________ SARS-CoV-2

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 ________ SARS-CoV-2

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 ________ SARS-CoV-2

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 ________ SARS-CoV-2

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 ________ SARS-CoV-2

Negative Unknown

Positive (insert code):

Path1_______Path2_______

Path3_______

More tests than fit in the table:

CDC ID: -

CDC ID: -


Post-discharge antimicrobial treatment

7. Was vancomycin IV 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 is the total duration of the post-discharge vancomycin IV prescription?

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


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

Yes No Unknown


7c. If yes to question 7b, 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 Vancomycin Form_20220516 Page 1 of 4


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorShelley Magill
File Modified0000-00-00
File Created2022-08-04

© 2024 OMB.report | Privacy Policy