AQUA UTI 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 3d: UTI

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

N10 N11.0 N11.1 N11.8 N11.9 N12 N15.1 N15.9 N16 N28.84 N28.85 N28.86 N30.00 N30.01 N30.10 N30.11 N30.20 N30.21 N30.30 N30.31 N30.40 N30.41 N30.80 N30.81 N30.90 N30.91 N34.0 N34.1 N34.2 N39.0

R82.71 R82.90 N41.0 N41.1 N41.2 B37.49 O23.00 Other (specify): __________

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

Prior to survey hospitalization but specific date unknown Unable to determine

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

Fever

Nausea or vomiting

Urgency

Rigors

Frequency

Visible blood in urine

Abdominal pain

Urinary incontinence

Costovertebral angle (CVA) pain or tenderness

Suprapubic pain, swelling or tenderness

Mental status changes or functional decline

Pain or burning with urination

4. Did the patient have an indwelling urinary catheter in place for ≥2 days on the day of UTI onset or on the day prior to UTI onset (or if onset date unknown, on the day of survey hospital admission)?

Yes No Unknown

4a. If yes, were any of the following done within 5 days after UTI onset date (or if onset date unknown, within 5 days after survey hospital admission)?

Catheter changed Catheter removed Catheter neither changed nor removed Unknown

Antimicrobial treatment

5. Was the patient receiving antimicrobial treatment for this UTI before the survey hospitalization?

Yes No Unknown

6. Present-on-admission (POA) UTI treatment during the survey hospitalization:

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

7. Complete the table for all antimicrobial drugs given to treat POA UTI 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 POA UTI:

CDC ID: -

Antimicrobial treatment

7a. Did the patient receive other antimicrobial drugs in the hospital during the POA UTI treatment period?

Yes—complete table below in 7b. No Unknown

7b. Other antimicrobial drugs given in the hospital (during the UTI treatment period defined by the dates in #6):

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:

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

Yes No Unknown

8a. Antimicrobial drugs prescribed at discharge for POA UTI or other reasons (enter POA UTI drugs first):

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

More drugs than fit in the table:

8b. If antimicrobial drugs were prescribed at discharge for POA-UTI, what was the total duration of the post-discharge POA UTI treatment?

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

Laboratory testing

9. Complete table below for POSITIVE cultures collected in the first 5 hospital days (____/____/____ through ____/____/____): 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 urine 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	Urine CC Lower resp Urine cath Stool Urine other Blood Other __________	___/ ___ / ___	___/ ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥105 CFU/ml or similar <105 or similar Unk Path2: ≥105 CFU/ml or similar <105 or similar Unk Path3: ≥105 CFU/ml or similar <105 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
2	Urine CC Lower resp Urine cath Stool Urine other Blood Other __________	___/ ___ / ___	___/ ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥105 CFU/ml or similar <105 or similar Unk Path2: ≥105 CFU/ml or similar <105 or similar Unk Path3: ≥105 CFU/ml or similar <105 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
3	Urine CC Lower resp Urine cath Stool Urine other Blood Other __________	___/ ___ / ___	___/ ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥105 CFU/ml or similar <105 or similar Unk Path2: ≥105 CFU/ml or similar <105 or similar Unk Path3: ≥105 CFU/ml or similar <105 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
4	Urine CC Lower resp Urine cath Stool Urine other Blood Other __________	___/ ___ / ___	___/ ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥105 CFU/ml or similar <105 or similar Unk Path2: ≥105 CFU/ml or similar <105 or similar Unk Path3: ≥105 CFU/ml or similar <105 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
5	Urine CC Lower resp Urine cath Stool Urine other Blood Other __________	___/ ___ / ___	___/ ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥105 CFU/ml or similar <105 or similar Unk Path2: ≥105 CFU/ml or similar <105 or similar Unk Path3: ≥105 CFU/ml or similar <105 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
6	Urine CC Lower resp Urine cath Stool Urine other Blood Other __________	___/ ___ / ___	___/ ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥105 CFU/ml or similar <105 or similar Unk Path2: ≥105 CFU/ml or similar <105 or similar Unk Path3: ≥105 CFU/ml or similar <105 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
7	Urine CC Lower resp Urine cath Stool Urine other Blood Other __________	___/ ___ / ___	___/ ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥105 CFU/ml or similar <105 or similar Unk Path2: ≥105 CFU/ml or similar <105 or similar Unk Path3: ≥105 CFU/ml or similar <105 or similar Unk	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
8	Urine CC Lower resp Urine cath Stool Urine other Blood Other __________	___/ ___ / ___	___/ ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: ≥105 CFU/ml or similar <105 or similar Unk Path2: ≥105 CFU/ml or similar <105 or similar Unk Path3: ≥105 CFU/ml or similar <105 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:

Urine CC=urine clean catch. Urine cath=urine collected from an indwelling urinary catheter. Urine other=urine collected via other or unspecified means.

*Check “≥10⁵ CFU/ml or similar” if quantity of growth in the culture is reported to be as follows: moderate, many, heavy, abundant, etc;. Check “<10⁵ or similar” if quantity of growth in the culture is reported to be <10⁵ CFU/ml or as follows: few, scarce, scant, rare, etc.Check “unknown” if no organism quantity is noted in the culture report.

CDC ID: -

CDCID: -

10. Complete the table for NEGATIVE cultures collected in 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:

11. Complete the table for urinalyses collected in the first 5 hospital days:

No urinalyses done: Unknown whether urinalyses were done:

No.	Urinalysis date (mm/dd/yy)	Pyuria (>5 WBCs / hpf)	Nitrites	Leukocyte esterase	Bacteria	Yeast
1	___ / ___ / ___	Y N Unk	Y N Unk	Y N Unk	Y N Unk	Y N Unk
2	___ / ___ / ___	Y N Unk	Y N Unk	Y N Unk	Y N Unk	Y N Unk
3	___ / ___ / ___	Y N Unk	Y N Unk	Y N Unk	Y N Unk	Y N Unk
4	___ / ___ / ___	Y N Unk	Y N Unk	Y N Unk	Y N Unk	Y N Unk
5	___ / ___ / ___	Y N Unk	Y N Unk	Y N Unk	Y N Unk	Y N Unk

12. Complete the table for non-culture tests (positive and negative) collected in 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:

***FORM IS COMPLETE***

Phase 5_AQUA UTI Form_20220516 page 1 of 4