F
orm
Approved
OMB No. 0920-0666
Exp. Date: 06/30/2026
www.cdc.gov/nhsn
Urinary Tract Infection (UTI) for LTCF
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*Required for saving |
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*Facility ID: |
Event #: |
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*Resident ID: |
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Medicare number (or comparable railroad insurance number): |
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Resident Name, Last: |
First: |
Middle: |
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*Gender: M F Other |
*Date of Birth: ___/___/____ |
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Sex at Birth: M F Other |
Gender Identity (Specify): |
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*Ethnicity (specify): □ Hispanic or Latino □ Not Hispanic or Latino □ Declined to respond □ Unknown
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*Race (specify): □ American Indian/Alaska Native □ Asian □ Black or African American □ Native Hawaiian/Other Pacific Islander □ White □ Declined to respond □ Unknown |
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*Date of First Admission to Facility: __/__/____ |
*Date of Current Admission to Facility: __/__/____ |
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*Event Type: UTI |
*Date of Event: __/__/____ |
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*Resident Care Location: __________________________ |
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*Primary Resident Service Type: (check one) |
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□ Long-term general nursing |
□ Long-term dementia |
□ Long-term psychiatric |
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□ Skilled nursing/Short-term rehab (subacute) |
□ Ventilator |
□ Bariatric |
□ Hospice/Palliative |
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*Has resident been transferred from an acute care facility to your facility in the past 4 weeks? |
□ Yes |
□ No |
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If Yes, date of last transfer from acute care to your facility: __/__/____ |
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If Yes, did the resident have an indwelling urinary catheter at the time of transfer to your facility? |
□ Yes |
□ No |
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*Indwelling Urinary Catheter status at time of event onset (check one): |
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□ In place |
□ Removed within last 2 calendar days |
□ Not in place |
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If indwelling urinary catheter status in place or removed within last 2 calendar days: |
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Indicate site where indwelling urinary catheter was Inserted (check one): |
□ Your facility |
□ Acute care hospital |
□ Other |
□ Unknown |
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Date of indwelling urinary catheter Insertion: ___/___/_____ |
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If indwelling urinary catheter not in place, was another urinary device type present at the time of event onset? |
□Yes |
□ □No |
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If Yes, other device type: |
□ Suprapubic |
□ External Drainage (male or female) |
□ Intermittent straight catheter |
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Event Details |
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*Specify Criteria Used: (check all that apply) |
Laboratory & Diagnostic Testing |
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Signs & Symptoms |
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□ 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 |
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□ Rigors |
□ New onset hypotension |
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□ New onset confusion/functional decline |
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□ Acute pain, swelling, or tenderness of the testes, epididymis, or prostate |
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□ Acute dysuria |
□ Purulent drainage at catheter insertion site |
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New and/or marked increase in (check all that apply): |
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□ Urgency |
□ Costovertebral angle pain or tenderness |
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□ Frequency |
□ Suprapubic tenderness |
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□ Incontinence |
□ Visible (gross) hematuria |
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*Specific Event (Check one): Auto-populated in NHSN application |
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□ Symptomatic UTI (SUTI) |
□ Symptomatic CA-UTI (CA-SUTI) |
□ Asymptomatic Bacteremic UTI (ABUTI) |
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Secondary Bloodstream Infection: Yes No |
Died within 7 days of date of event: Yes No |
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*Transfer to acute care facility within 7 days: Yes No |
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*Pathogens identified: Yes No |
*If Yes, specify on page 2 |
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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 35 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) v12.0 |
Urinary Tract Infection (UTI) for LTCF
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Pathogen # |
Gram-positive Organisms |
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_______ |
Staphylococcus coagulase-negative
(specify species if available): |
CEFOX/OX S R N
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VANC S I R N |
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_______ |
____Enterococcus faecium
____Enterococcus faecalis
____Enterococcus spp. (Only those not identified to the species level) |
DAPTO S S-DD NS R I N
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GENTHL§ S R N |
LNZ S I R N |
NIT S I R N
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VANC S I R N
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_______ |
Staphylococcus aureus |
CIPRO/LEVO/MOXI S I R N |
CEFOX/METH/OX S R N
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CEFTAR S S-DD I R N
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CLIND S I R N
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DAPTO S NS N
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DOXY/MINO S I R N
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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
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Pathogen # |
Gram-negative Organisms |
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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 |
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_______ |
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 |
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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 |
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_______ |
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 |
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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 |
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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
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MERVAB S I R N
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NIT S I R N
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PIPTAZ S I R N |
TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
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 |
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CIPRO/LEVO/MOXI S I R N
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COL/PB† I R N |
DORI/IMI/MERO S I R N |
DOXY/MINO/TETRA S I R N |
ERTA S I R N |
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IMIREL S I R N |
MERVAB S I R N |
NIT S I R N
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PIPTAZ S I R N
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TIG S I R N |
TMZ S I R N
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TOBRA S I R N |
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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 |
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GENT S I R N |
IMIREL S I R N |
MERVAB S I R N |
NIT S I R N
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PIPTAZ S I R N
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TIG S I R N
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TMZ S I R N |
TOBRA |
Urinary Tract Infection (UTI) for LTCF
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Pathogen # |
Gram-negative Organisms (continued) |
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_______ |
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
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COL/PB S I R N |
DORI/IMI/MERO S I R N |
GENT S I R N |
PIPTAZ S I R N |
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Pathogen # |
Other Organisms |
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_______ |
Organism 1 (specify) ____________
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_______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 |
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_______ |
Organism 1 (specify) ____________
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_______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 |
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_______ |
Organism 1 (specify) ____________
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_______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: |
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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 |
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CEFOT = cefotaxime |
ERTA = ertapenem |
MOXI = moxifloxacin |
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CEFOX= cefoxitin |
FLUCO = fluconazole |
NIT = nitrofurantoin |
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CEFTAZ = ceftazidime |
GENT = gentamicin |
OX = oxacillin |
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Urinary Tract Infection (UTI) for LTCF
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | NHSN LTCF UTI Event Form 57.140 |
Subject | NHSN OMB Forms & TOIs |
Author | CDC/NCEZID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-11-19 |