Form
Approved
OMB No. 0920-0666
Exp. Date: 12/31/2022
www.cdc.gov/nhsn
Urinary Tract infection (UTI)
Page 1 of 4 |
*required for saving **required for completion |
||||||||||||
Facility ID: |
Event #: |
||||||||||||
*Patient ID: |
Social Security #: |
||||||||||||
Secondary ID: |
Medicare #: |
||||||||||||
Patient Name, Last: |
First: |
Middle: |
|||||||||||
*Gender: F M Other |
*Date of Birth: |
||||||||||||
Sex at Birth: F M Unknown |
Gender Identity (Specify): |
||||||||||||
Ethnicity (Specify): |
Race (Specify): |
||||||||||||
*Event Type: UTI |
*Date of Event: |
||||||||||||
Post-procedure UTI: Yes No |
Date of Procedure: |
||||||||||||
NHSN Procedure Code: |
ICD-10-PCS or CPT Procedure Code: |
||||||||||||
*MDRO Infection Surveillance: |
|||||||||||||
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module |
|||||||||||||
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module |
|||||||||||||
*Date Admitted to Facility: |
*Location: |
||||||||||||
Risk Factors |
|||||||||||||
*Urinary Catheter status: |
|||||||||||||
□ In place – Urinary catheter in place > 2 days on the date of event or present for any portion of the calendar day |
□ Removed – Urinary catheter in place > 2 days and removed the day before the date of event |
□ Neither – Not catheter associated –Neither in place nor removed |
|||||||||||
Location of Device Insertion: ________________________ |
Date of Device Insertion: ____ /____ /_______ |
||||||||||||
If NICU, birth weight (gms): ____________ |
|
||||||||||||
Event Details |
|||||||||||||
*Specific Event: |
□ Symptomatic UTI (SUTI) |
□ Asymptomatic Bacteremic UTI (ABUTI) |
|
||||||||||
*Specify Criteria Used: (check all that apply) |
|||||||||||||
Signs & Symptoms |
|
||||||||||||
Any Patient |
≤ 1 year old |
Laboratory & Diagnostic Testing |
|||||||||||
□ Fever |
□ Urgency |
□ Fever |
□ Positive culture with no more than 2 species of organisms, at least one of which is a bacterium of ≥ 105 CFU/ml |
||||||||||
□ Frequency |
□ Dysuria |
□ Hypothermia |
|||||||||||
|
|
□ Apnea |
|
||||||||||
|
□ Bradycardia |
||||||||||||
□ Suprapubic tenderness |
□ Lethargy |
□ Organism(s) identified from blood specimen |
|||||||||||
□ Costovertebral angle pain or tenderness |
□ Vomiting |
||||||||||||
|
□ Suprapubic tenderness |
|
|||||||||||
|
|
|
|||||||||||
|
|
||||||||||||
|
|
||||||||||||
*Secondary Bloodstream Infection: Yes No |
*COVID-19: Yes No
|
||||||||||||
**Died: Yes No |
UTI Contributed to Death: Yes No |
||||||||||||
Discharge Date: |
*Pathogens Identified: Yes No *If Yes, specify on pages 2-4. |
||||||||||||
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 20 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 57.114 (Front) Rev 12, v8.8 |
Urinary Tract infection (UTI)
Pathogen # |
Gram-positive Organisms |
|||||||||||||||||||||||||||||
|
Staphylococcus coagulase-negative
(specify species if available): |
|
||||||||||||||||||||||||||||
|
____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level) |
|
||||||||||||||||||||||||||||
|
Staphylococcus aureus
|
|
||||||||||||||||||||||||||||
Pathogen # |
Gram-negative Organisms
|
|||||||||||||||||||||||||||||
|
Acinetobacter (specify species) ____________ |
|
||||||||||||||||||||||||||||
|
Escherichia coli
|
|
||||||||||||||||||||||||||||
|
Enterobacter (specify species) ____________
|
|
||||||||||||||||||||||||||||
Pathogen # |
||||||||||||||||||||||||||||||
|
____Klebsiella pneumoniae ____Klebsiella oxytoca ____Klebsiella aerogenes |
|
||||||||||||||||||||||||||||
|
Pseudomonas aeruginosa
|
|
||||||||||||||||||||||||||||
Pathogen # |
Fungal Organisms |
|||||||||||||||||||||||||||||
|
Candida (specify species if available) ______________ |
|
||||||||||||||||||||||||||||
Pathogen # |
Other Organisms |
|||||||||||||||||||||||||||||
|
Organism 1 (specify) _____________ |
|
||||||||||||||||||||||||||||
|
Organism 1 (specify) _____________ |
|
||||||||||||||||||||||||||||
|
Organism 1 (specify) _____________ |
|
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 |
GENT = gentamicin |
OX = oxacillin |
AMP = ampicillin |
CEFTAVI = ceftazidime/avibactam |
GENTHL = gentamicin –high level test |
PB = polymyxin B |
AMPSUL = ampicillin/sulbactam |
CEFTOTAZ = ceftolozane/tazobactam |
IMI = imipenem |
PIPTAZ = piperacillin/tazobactam |
AMXCLV = amoxicillin/clavulanic acid |
CEFTRX = ceftriaxone |
IMIREL = imipenem/relebactam |
RIF = rifampin |
ANID = anidulafungin |
CIPRO = ciprofloxacin |
LEVO = levofloxacin |
TETRA = tetracycline |
AZT = aztreonam |
CLIND = clindamycin |
LNZ = linezolid |
TIG = tigecycline |
CASPO = caspofungin |
COL = colistin |
MERO = meropenem |
TMZ = trimethoprim/sulfamethoxazole |
CEFAZ= cefazolin |
DAPTO = daptomycin |
MERVAB = meropenem/vaborbactam |
TOBRA = tobramycin |
CEFEP = cefepime |
DORI = doripenem |
METH = methicillin |
VANC = vancomycin |
CEFOT = cefotaxime |
DOXY = doxycycline |
MICA = micafungin |
VORI = voriconazole |
CEFOX= cefoxitin |
ERTA = ertapenem |
MINO = minocycline |
|
CEFTAZ = ceftazidime |
FLUCO = fluconazole |
MOXI = moxifloxacin |
|
Urinary Tract infection (UTI)
Page 4 of 4 |
|||
Custom Fields |
|||
Label |
Label |
||
________________________ |
____/____/____ |
_______________________ |
____/____/_____ |
________________________ |
_____________ |
_______________________ |
______________ |
________________________ |
_____________ |
_______________________ |
______________ |
________________________ |
_____________ |
_______________________ |
______________ |
________________________ |
_____________ |
_______________________ |
______________ |
________________________ |
_____________ |
_______________________ |
______________ |
________________________ |
_____________ |
_______________________ |
______________
|
Comments |
|||
|
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.114_UTI |
Subject | NHSN OMB Forms 2020 |
Author | CDC/NCZEID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-07-30 |