Form 57.140 Urinary Tract Infection (UTI) for LTCF

[NCEZID] The National Healthcare Safety Network (NHSN)

57.140 Urinary Tract Infection (UTI) for LTCF-Clean Version

57.140 Urinary Tract Infection (UTI) for LTCF

OMB: 0920-0666

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F orm Approved

OMB No. 0920-0666

Exp. Date: 06/30/2026

www.cdc.gov/nhsn

Urinary Tract Infection (UTI) for LTCF


*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: ___/___/____

Sex at Birth: M F Other

Gender Identity (Specify):

*Ethnicity (specify): □ Hispanic or Latino

Not Hispanic or Latino

Declined to respond □ Unknown


*Race (specify): □ American Indian/Alaska Native □ Asian □ Black or African American

Native Hawaiian/Other Pacific Islander □ White

Declined to respond □ Unknown

*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)

Laboratory & Diagnostic Testing

Signs & Symptoms

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

  • 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


Rigors

New onset hypotension

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 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



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 NS R I 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

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




Urinary Tract Infection (UTI) for LTCF


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









Urinary Tract Infection (UTI) for LTCF


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleNHSN LTCF UTI Event Form 57.140
SubjectNHSN OMB Forms & TOIs
AuthorCDC/NCEZID/DHQP
File Modified0000-00-00
File Created2024-09-16

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