57.114 UTI form with GISAB edits in tracked changes

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):

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 I/S-DD NS R N

GENTHL§ S R N

LNZ S I R N

VANC S I R N

Staphylococcus aureus

CEFOX/METH/OX S R N	CEFTAR S S-DD I R N	CIPRO/LEVO/MOXI S 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

Acinetobacter (specify species)

____________

AMK S I R N	AMPSUL S I R N	CEFEP S I R N	CEFTAZ/CEFOT/CEFTRX 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	CEFEP S I/S-DD R N	CEFOT/CEFTRX S I R N
CEFTAVI S R N	CEFTAZ S I 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	GENT S I R N	IMIREL S I R N	MERVAB 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	CEFEP S I/S-DD R N	CEFOT/CEFTRX S I R N	CEFTAVI S R N	CEFTAZ S I 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	GENT S I R N	IMIREL S I R N
MERVAB S I R N	PIPTAZ S I R N	TIG S I R N	TMZ S I R N	TOBRA S I R N	CEFEP S I/S-DD R N

Pathogen #

Gram-negative Organisms (continued)

____Klebsiella pneumoniae

____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	CEFEP S I/S-DD R N	CEFOT/CEFTRX S I R N	CEFTAVI S R N
CEFTAZ S I 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
GENT S I R N	IMIREL S I R N	MERVAB S I R N	PIPTAZ S I R N	TIG S I R N	TMZ S I R N	TOBRA S I R N

Pseudomonas aeruginosa

AMK S I R N	AZT S I R N	CEFEP S I R N	CEFTAVI S R N	CEFTAZ S I 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	TOBRA S I R N

Pathogen #

Fungal Organisms

Candida (specify species if available) ______________

ANID S I R N

CASPO S I R N

FLUCO S S-DD R N

MICA S I R N

VORI S I R N

Pathogen #

Other Organisms

Organism 1 (specify) _____________

Drug 1 S I R N

Drug2 S I R N

Drug3 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

Drug2 S I R N

Drug3 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

Drug2 S I R N

Drug3 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	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)

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