Form 57.140 57.140_LTCF UTI_Form_2022

Urinary Tract Infection (UTI) for LTCF

Form Approved OMB No. 0920-0666

Exp. Date: 12/31/22 www.cdc.gov/nhsn

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*required for saving

*Facility ID:

Event #:

*Resident ID:

Medicare number (or comparable railroad insurance number):

Resident Name, Last:

First:

Middle:

*Gender: M F Other

*Date of Birth: / /

Ethnicity (specify):

Race (specify):

*Date of First Admission to Facility: / /

*Date of Current Admission to Facility: / /

*Event Type: UTI

*Date of Event: / /

*Resident Care Location:

*Primary Resident Service Type: (check one)

□ Long-term general nursing

□ Long-term dementia

□ Long-term psychiatric

□ Skilled nursing/Short-term rehab (subacute)

□ Ventilator

□ Bariatric

□ Hospice/Palliative

*Has resident been transferred from an acute care facility to your facility in the past 4 weeks?

□ Yes

□ No

If Yes, date of last transfer from acute care to your facility: / /

If Yes, did the resident have an indwelling urinary catheter at the time of transfer to your facility?

□ Yes

□ No

*Indwelling Urinary Catheter status at time of event onset (check one):

□ In place

□ Removed within last 2 calendar days

□ Not in place

If indwelling urinary catheter status in place or removed within last 2 calendar days:

Indicate site where indwelling urinary catheter was Inserted (check one):

□ Your facility

□ Acute care hospital

□ Other

□ Unknown

Date of indwelling urinary catheter Insertion: / /

If indwelling urinary catheter not in place, was another urinary device type present at the time of event onset?

□Yes

□No

If Yes, other device type:

□ Suprapubic

□ External drainage (male or female)

□ Intermittent straight catheter

Event Details

*Specify Criteria Used: (check all that apply)

Signs & Symptoms

Laboratory & Diagnostic Testing

□ Fever: Single temperature ≥ 37.8°C (>100°F), or > 37.2°C (>99°F) on repeated occasions, or an increase of >1.1°C (>2°F) over baseline

□ Rigors

□ New onset hypotension

Positive urine culture with no more than 2 species of microorganisms, at least one of which is a bacterium of ≥ 105 CFU/ml Leukocytosis (>10,000 cells/mm3), or Left shift (> 6% or 1,500 bands/mm3) Positive blood culture with at least 1 matching organism in urine culture

□ New onset confusion/functional decline

□ Acute pain, swelling, or tenderness of the testes, epididymis, or prostate

□ Acute dysuria

□ Purulent drainage at catheter insertion site

New and/or marked increase in (check all that apply):

□ Urgency

□ Costovertebral angle pain or tenderness

□ Frequency

□ Suprapubic tenderness

□ Incontinence

□ Visible (gross) hematuria

*Specific Event (Check one): Auto-populated in NHSN application

□ Symptomatic UTI (SUTI)

□ Symptomatic CA-UTI (CA-SUTI)

□ Asymptomatic Bacteremic UTI (ABUTI)

Secondary Bloodstream Infection: Yes No

Died within 7 days of date of event: Yes No

*Transfer to acute care facility within 7 days: Yes No

*Pathogens identified: Yes No

*If Yes, specify on page 2

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.140 (Front) v9.5

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Pathogen #	Gram-positive Organisms
	Staphylococcus coagulase-negative (specify species if available):			CEFOX/OX S R N		VANC S I R N
	Enterococcus faecium Enterococcus faecalis Enterococcus spp. (Only those not identified to the species level)			DAPTO S S-DD I NS R N		GENTHL§ S R N	LNZ S I R N		NIT S I R N	VANC S I R N
	Staphylococcus aureus	CIPRO/LEVO/MOXI S I R N		CEFOX/METH/OX S R N		CEFTAR S S-DD I R N	CLIND S I R N		DAPTO S NS N	DOXY/MINO S I R N
		GENT S I R N		LNZ S R N	RIF S I R N	TETRA S I R N	TMZ S I R N		VANC S I R N
Pathogen #	Gram-negative Organisms
	Proteus mirabilis	AMP S I R N	AMOX S I R N	CEFUR S I R N	CEFTRX S I R N	CEFIX S I R N	CIPRO S I R N		LEVO S I R N	ERTA/IMI/MERO S I R N
	Acinetobacter (specify species) _	AMK S I R N	AMPSUL S I R N	CEFTAZ/CEFOT/CEFTRX S I R N			CEFEP S I R N			CIPRO/LEVO S I R N
		COL/PB S R N	DORI/MERO S I R N	DOXY/ MINO S I R N		GENT S I R N	IMI S I R N		PIPTAZ S I R N	TMZ S I R N	TOBRA S I R N
	Escherichia coli	AMK S I R N	AMP S I R N	AMPSUL/AMXCLV S I R N		AZT S I R N	CEFAZ S I R N		CEFTAZ S I R N	CEFOT/CEFTRX S I R N
		CEFEP S I/S-DD R N	CEFTAVI S R N	CEFUR S I R N	CEFTOTAZ S I R N		CIPRO/LEVO/MOXI S I R N			COL/PB† I R N
		DORI / IMI / MEDRO S I R N		DOXY / MINO / TETRA S I R N		ERTA S I R N	GENT S I R N	IMIREL S I R N		MERVAB S I R N
		NIT S I R N	PIPTAZ S I R N	TIG S I R N	TMZ S I R N	TOBRA S I R N
	Enterobacter (specify species)	AMK S I R N	AZT S I R N	CEFTAZ S I R N	CEFOT/CEFTRX S I R N		CEFEP S I/S-DD R N		CEFTAVI S R N	CEFTOTAZ S I R N
		CIPRO/LEVO/MOXI S I R N		COL/PB† I R N	DORI/IMI/MERO S I R N		DOXY/MINO/TETRA S I R N			ERTA S I R N
		IMIREL S I R N	MERVAB S I R N	NIT S I R N	PIPTAZ S I R N	TIG S I R N	TMZ S I R N		TOBRA S I R N
	Klebsiella pneumonia Klebsiella oxytoca Klebsiella aerogenes	AMK S I R N	AMPSUL/AMXCLV S I R N		AZT S I R N	CEFAZ S I R N	CEFTAZ S I R N		CEFOT / CEFTRX S I R N	CEFEP S I/S-DD R N
		CEFTAVI S R N	CEFTOTAZ S I R N	CIPRO/ LEVO/ MOXI S I R N	COL/PB† I R N		DORI/IMI/MERO S I R N			DOXY/MINO/TETRA S I R N
		GENT S I R N	IMIREL S I R N	MERVAB S I R N	NIT S I R N	PIPTAZ S I R N	TIG S I R N		TMZ S I R N	TOBRA S I R N

Pathogen #

Gram-negative Organisms (continued)

Pseudomonas aeruginosa

AMK S I R N

AZT S I R N

CEFTAZ S I R N

CEFEP S I R N

CEFTAVI S R N

CEFTOTAZ S I R N

CIPRO/LEVO S I R N

COL/PB S I R N

DORI/IMI/MERO S I R N

GENT S I R N

PIPTAZ S I R N

Pathogen #

Other Organisms

Organism 1 (specify)

Drug 1 S I R N

Drug 2 S I R N

Drug 3 S I R N

Drug 4 S I R N

Drug 5 S I R N

Drug 6 S I R N

Drug 7 S I R N

Drug 8 S I R N

Drug 9 S I R N

Organism 1 (specify)

Drug 1 S I R N

Drug 2 S I R N

Drug 3 S I R N

Drug 4 S I R N

Drug 5 S I R N

Drug 6 S I R N

Drug 7 S I R N

Drug 8 S I R N

Drug 9 S I R N

Organism 1 (specify)

Drug 1 S I R N

Drug 2 S I R N

Drug 3 S I R N

Drug 4 S I R N

Drug 5 S I R N

Drug 6 S I R N

Drug 7 S I R N

Drug 8 S I R N

Drug 9 S I R N

Result Codes

S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested

^§ GENTHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic

^† Clinical breakpoints are based on CLSI M100-ED30:2020, Intermediate MIC ≤ 2 and Resistant MIC ≥ 4

Drug Codes:
AMK = amikacin	CEFTAR = ceftaroline	GENTHL = gentamicin –high level test	PB = polymyxin B
AMP = ampicillin	CEFTAVI = ceftazidime/avibactam	IMI = imipenem	PIPTAZ = piperacillin/tazobactam
AMPSUL = ampicillin/sulbactam	CEFTOTAZ = ceftolozane/tazobactam	IMIREL = imipenem/relebactam	RIF = rifampin
AMXCLV = amoxicillin/clavulanic acid	CEFTRX = ceftriaxone	LEVO = levofloxacin	TETRA = tetracycline
ANID = anidulafungin	CIPRO = ciprofloxacin	LNZ = linezolid	TIG = tigecycline
AZT = aztreonam	CLIND = clindamycin	MERO = meropenem	TMZ = trimethoprim/sulfamethoxazole
CASPO = caspofungin	COL = colistin	MERVAB = meropenem/vaborbactam	TOBRA = tobramycin
CEFAZ= cefazolin	DAPTO = daptomycin	METH = methicillin	VANC = vancomycin
CEFEP = cefepime	DORI = doripenem	MICA = micafungin	VORI = voriconazole
CEFIX = cefixime	DOXY = doxycycline	MINO = minocycline
CEFOT = cefotaxime	ERTA = ertapenem	MOXI = moxifloxacin
CEFOX= cefoxitin	FLUCO = fluconazole	NIT = nitrofurantoin
CEFTAZ = ceftazidime	GENT = gentamicin	OX = oxacillin

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