AQUA CAP Form (modified August 2022)

Form Approved

OMB No. 0920-0852

Exp. Date 03/31/2025

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

FORM 3c: CAP

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 Unknown

J09.X1 J09.X2 J09.X3 J10.00 J10.01 J10.08 J10.1 J10.2 J10.81 J10.82 J10.83 J10.89 J11.00 J11.08 J11.1 J11.2 J11.81 J11.82 J11.83 J11.89 J12.0 J12.1 J12.2 J12.3 J12.81 J12.89 J12.9 J13 J14 J15.0 J15.1 J15.3 J15.4 J15.20 J15.211 J15.212 J15.29 J15.5 J15.6 J15.7 J15.8 J15.9 J16.0 J16.8 J18.0 J18.1 J18.9 A48.1 Other (specify):_____

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

Prior to survey hospitalization but specific date unknown Unable to determine

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

Fever

Chills or rigors

Cough

Dyspnea

O₂ saturation < 90%

Sore throat

Increased secretions/sputum production

Hemoptysis

Chest pain

Mental status changes or functional decline

Apnea

Rhinorrhea

Grunting

Nasal flaring

Head bobbing

Chest wall retractions

Wheezing

Muscle aches

4. Did the patient require mechanical ventilation at any time during the hospitalization?

Yes

No

Unknown

4a. If yes, was the patient removed from mechanical ventilation before hospital discharge?

Yes, clinical status improved

Yes, removed from mechanical ventilation for end-of-life care (or for reasons other than improvement)

No

Unknown

5. Complete the chest imaging table, recording studies done in the first 5 hospital days (____/____/____ through ____/____/____):

No imaging studies done: Unknown whether imaging studies were done:

	Date (mm/dd/yy)	Findings on chest imaging studies
1	___ / ___ / ___	Bronchopneumonia/pneumonia New or worsening infiltrates Infiltrate, single lobe	Air space density/opacity No evidence of pneumonia Infiltrate, multiple lobes	Consolidation Cavitation Pleural effusion	Cannot rule out pneumonia None of these
2	___ / ___ / ___	Bronchopneumonia/pneumonia New or worsening infiltrates Infiltrate, single lobe	Air space density/opacity No evidence of pneumonia Infiltrate, multiple lobes	Consolidation Cavitation Pleural effusion	Cannot rule out pneumonia None of these
3	___ / ___ / ___	Bronchopneumonia/pneumonia New or worsening infiltrates Infiltrate, single lobe	Air space density/opacity No evidence of pneumonia Infiltrate, multiple lobes	Consolidation Cavitation Pleural effusion	Cannot rule out pneumonia None of these
4	___ / ___ / ___	Bronchopneumonia/pneumonia New or worsening infiltrates Infiltrate, single lobe	Air space density/opacity No evidence of pneumonia Infiltrate, multiple lobes	Consolidation Cavitation Pleural effusion	Cannot rule out pneumonia None of these
5	___ / ___ / ___	Bronchopneumonia/pneumonia New or worsening infiltrates Infiltrate, single lobe	Air space density/opacity No evidence of pneumonia Infiltrate, multiple lobes	Consolidation Cavitation Pleural effusion	Cannot rule out pneumonia None of these

CDC ID: -

Antimicrobial drug treatment

6. Was the patient receiving antimicrobial treatment for this episode of CAP before the survey hospitalization?

Yes No Unknown

7. CAP treatment during the survey hospitalization:

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

8. Complete the table for all antimicrobial drugs given to treat CAP 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 CAP:

8a. Did the patient receive other antimicrobial drugs in the hospital during the CAP treatment period?

Yes—complete table below in 8b. No Unknown

8b. Other antimicrobial drugs given in the hospital (during the CAP treatment period defined by the dates in #7):

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:

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

Yes No Unknown

9a. Antimicrobial drugs prescribed at discharge for CAP or other reasons (enter CAP drugs first):

No.	Drug name	Route (check all that apply)	Indication (check all that apply)
1		IV IM PO INH Unk	CAP Other Unknown
2		IV IM PO INH Unk	CAP Other Unknown
3		IV IM PO INH Unk	CAP Other Unknown
4		IV IM PO INH Unk	CAP Other Unknown
5		IV IM PO INH Unk	CAP Other Unknown

More drugs than fit in the table:

9b. If antimicrobials were prescribed at discharge for CAP, what was the total duration of the post-discharge CAP treatment?

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

Laboratory testing

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

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 lower respiratory 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	Sputum Blood ETA Urine BAL Stool Upper resp Other _____	____ / ___ / ___	____ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥104 CFU/ml or similar <104 or similar Unk Path2: ≥104 CFU/ml or similar <104 or similar Unk Path3: ≥104 CFU/ml or similar <104 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
2	Sputum Blood ETA Urine BAL Stool Upper resp Other _____	____ / ___ / ___	____ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥104 CFU/ml or similar <104 or similar Unk Path2: ≥104 CFU/ml or similar <104 or similar Unk Path3: ≥104 CFU/ml or similar <104 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
3	Sputum Blood ETA Urine BAL Stool Upper resp Other _____	____ / ___ / ___	____ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥104 CFU/ml or similar <104 or similar Unk Path2: ≥104 CFU/ml or similar <104 or similar Unk Path3: ≥104 CFU/ml or similar <104 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
4	Sputum Blood ETA Urine BAL Stool Upper resp Other _____	____ / ___ / ___	____ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥104 CFU/ml or similar <104 or similar Unk Path2: ≥104 CFU/ml or similar <104 or similar Unk Path3: ≥104 CFU/ml or similar <104 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
5	Sputum Blood ETA Urine BAL Stool Upper resp Other _____	____ / ___ / ___	____ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥104 CFU/ml or similar <104 or similar Unk Path2: ≥104 CFU/ml or similar <104 or similar Unk Path3: ≥104 CFU/ml or similar <104 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
6	Sputum Blood ETA Urine BAL Stool Upper resp Other _____	____ / ___ / ___	____ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥104 CFU/ml or similar <104 or similar Unk Path2: ≥104 CFU/ml or similar <104 or similar Unk Path3: ≥104 CFU/ml or similar <104 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
7	Sputum Blood ETA Urine BAL Stool Upper resp Other _____	____ / ___ / ___	____ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥104 CFU/ml or similar <104 or similar Unk Path2: ≥104 CFU/ml or similar <104 or similar Unk Path3: ≥104 CFU/ml or similar <104 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
8	Sputum Blood ETA Urine BAL Stool Upper resp Other _____	____ / ___ / ___	____ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥104 CFU/ml or similar <104 or similar Unk Path2: ≥104 CFU/ml or similar <104 or similar Unk Path3: ≥104 CFU/ml or similar <104 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:

ETA=endotracheal aspirate (or tracheal aspirate). BAL=bronchoalveolar lavage (includes bronchial lavage, mini-BAL).

*Check “≥10⁴ CFU/ml or similar” if quantity of growth in the culture is reported to be as follows: moderate, many, heavy, abundant, etc. Check “<10⁴ or similar” if quantity of growth in the culture is reported to be <10⁴ CFU/ml or as follows: few, scarce, scant, rare, etc. Check “unknown” if no organism quantity is noted in the culture report.

CDC ID: -

CDC ID: -

11. During the first 5 hospital days, did the patient have a Gram stain of lower respiratory secretions (sputum, BAL, ETA, etc.)? Yes No Unknown

11a. If yes, did the Gram stain report indicate the following:

Heavy, 4+, or ≥25 neutrophils (or white blood cells) per low power field [x100]

Rare, occasional, few, 1+ or 2+, or ≤10 squamous epithelial cells per low power field [x100]

Neither of the above

Unknown

12. Complete the table for NEGATIVE cultures collected during 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:

13. Complete the table for non-culture microbiology tests (positive and negative) collected during 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 ________ 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:

14. Did the patient have any of the following blood test results during the first 2 hospital days?

Check all that apply, or None.

Arterial pH < 7.35 BUN > 30 mg/dL (11 mmol/L) Glucose > 250 mg/dL

PaO₂ < 60 mmHg Sodium < 130 mmol/L Hematocrit < 30%

***FORM IS COMPLETE***

Phase 5_AQUA CAP Form_20220516 Page 1 of 4