57.114 Urinary Tract infection (UTI)

[NCEZID] The National Healthcare Safety Network (NHSN)

57.114_UTI_BLANK_November_2022

OMB: 0920-0666

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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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Custom Fields

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.114_UTI
SubjectNHSN OMB Forms 2020
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-09-16

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