Form 57.150 Urinary Tract Infection (UTI) for LTCF

Form Approved

OMB No. 0920-0666

Exp. Date: 06/30/2026

www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC

Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/TOI-57.150-LTAC.pdf

*required for saving Tracking #:

Facility ID: *Survey Year:

Facility Characteristics (completed by Infection Preventionist)

*Ownership (check one):

□ For profit □ Not for profit, including church □ Government □ Veterans Affairs

*Affiliation (check one):

□ Hospital System □ Independent □ Multi-facility organization (specialty hospital network)

*Setting/classification: _____ Free-standing _____ Within a hospital

If classified as “Free-standing,” does your LTAC hospital share physical housing with one or more of the following on-site facilities or units (check all that apply)?

□ No	□ Inpatient rehabilitation facility
□ Skilled nursing facility (SNF)/nursing home	□ Neuro-behavioral unit or facility
□ Residential facility (assisted living	□ Other (specify): __________________________

If classified as “Within a hospital,” is your LTAC hospital located:

In a building that does not provide acute care services (for example, psychiatric hospital?)	□ Yes	□ No
Near (but not within) an acute care hospital?	□ Yes	□ No

In the previous calendar year, indicate:

*Number of patient days: _________________

*Number of admissions: _________________

*Average daily census: _________________

*Numbers of LTAC beds in the following categories (categories should equal total):

a. Intensive care unit (CIU) or critical care beds: _______

b. High observation/special care/high acuity beds (not ICU): _______

c. General LTAC beds: _______

*Total number of LTAC beds (licensed capacity): _______

*Number of single occupancy rooms: _______

*Number of double occupancy rooms: _______

*Number of triple occupancy rooms: _______

*Number of quadruple occupancy rooms: _______

*Total number of admissions with one of the one of the following conditions identified on admission (present of admission, not developing during LTAC stay): (Note: These categories are not mutually exclusive.)

If helpful for your facility in identifying these conditions on admission, review a list of ICD-10 and DRG codes commonly associated with these conditions found here: http://www.cdc.gov/nhsn/xls/DRGs-ICD-9s-NHSN-LTAC-Survey.xlsx

1. Ventilator dependence: _______

2. Hemodialysis: _______

Facility Microbiology Laboratory Practices (completed with input from Microbiology Laboratory Lead)

1. Does your facility have its own on-site laboratory that performs bacterial antimicrobial □ Yes □ No susceptibility testing?

   1. If No, where is your facility’s antimicrobial susceptibility testing performed: (check one)

      □ Affiliated medical center

      □ Commercial referral laboratory

      □ Other local/regional, non-affiliated reference laboratory

   2. If Yes, do you also send out any antimicrobial susceptibility testing (check one) □ Yes □ No

2. For the following organisms, indicate which methods are used for:

1. Primary susceptibility testing and

2. Secondary, supplemental, or confirmatory testing (if performed).

If your laboratory does not perform susceptibility testing, indicate the methods used at the outside laboratory.

Use the testing codes listed below the table.

Pathogen	(1) Primary		(2) Secondary		Comments
Enterobacterales	____________________		____________________		____________________
Pseudomonas aeruginosa	____________________		____________________		____________________
Acinetobacter baumanni complex	____________________		____________________		____________________
1 = Kirby-Bauer disk diffusion		4 = Sensititre		7 = Agar dilution method
2 = Vitek (Legacy)		5.1 = MicroScan WalkAway		10 = Gradient Dilution Strip (for example E test)
2.1 = Vitek 2		5.2 = MicroScan autoSCAN		13 = Other (describe in Comments section)
3.1 = BD Phoenix		6 = Other broth microdilution method

3. Does either the primary or secondary/supplemental antimicrobial susceptibility testing (AST) include the following (check all that apply):

Drug	Organism tested:
	Enterobacterales	Pseudomonas aeruginosa	Acinetobacter baumanni
Cefiderocol	□	□	□
Ceftazidime-Avibactam	□	□	□
Ceftolozane-Tazobactam	□	□	□
Colistin	□	□	□
Delafloxacin	□	□	□
Eravacycline	□	□	□
Imipenem-Relebactam	□	□	□
Meropenem-Vaborbactam	□	□	□

Facility Microbiology Laboratory Practices (continued)

4. Has the laboratory implemented revised breakpoints recommended by CLSI for the following:

1. Third Generation Cephalosporin and monobactam (that is, aztreonam) breakpoints for □ Yes □ No Enterobacterales in 2010

2. Carbapenem breakpoints for Enterobacterales in 2010 □ Yes □ No

3. Ertapenem breakpoints for Enterobacterales in 2012 □ Yes □ No

4. Carbapenem breakpoints for Pseudomonas aeruginosa in 2012 □ Yes □ No

5. Fluroquinolone breakpoints for Pseudomonas aeruginosa in 2019 □ Yes □ No

6. Fluroquinolone breakpoints for Enterobacterales in 2019 □ Yes □ No

5. Does the laboratory test bacterial isolates for presence of carbapenemase? (this does □ Yes □ No not include automated testing instrument expert rules)

   1. If Yes, indicate what is done if carbapenemase production is detected: (check one)

      • Change susceptible carbapenem results to resistant

      • Report carbapenem MIC results without an interpretation

      • No changes are made in the interpretation of carbapenems, the rest is used for epidemiological or infection control practices

   2. If Yes, which test is routinely performed to detect carbapenemase: (check all that apply)

□ NAAT (for example, PCR)	□ MLB Screen	□ mCIM/CIM
□ Modified Hodge Test	□ Carba NP	□ CARBA 5
□ Rapid CARB Blue	□ Cepheid, BioFire, Verigene, Genmark, etc
□ E test	□ Other (specify): _______________

3. If Yes, which of the following are routinely tested for the presence of carbapenemases: (check all that apply)

   • Enterobacterales spp. □ Pseudomonas aeruginosa □ Acinetobacter baumannii

1. Does your facility use commercial or laboratory developed tests for rapid molecular detection of antimicrobial resistance markers in bacterial bloodstream infections? Examples of commercially available systems include BioFire FilmArray, Luminex Verigene, etc.

□ Yes

□ No [if checked, skip questions 7 and 8]

1. If Yes, which test panel(s) does your facility use? (check all that apply)

   • Accelerate PhenoTest BC □ BioFire FilmArray BCID □ BioFire FilmArray BCID II

   • Cepheid Xpert MRSA/SA BC □ GenMark ePlex BCID-GP □ GenMark ePlex BCID-GN

   • GenMark ePlex BCID-FP □ Luminex Verigene BC-GP □ Luminex Verigene BC-GN

   • MALDI-TOF MS directly from positive blood culture (e.g., SepsiTyper)

   • MALDI-TOF MS based antimicrobial resistance detection

   • T2Biosystems T2Bacteria □ T2Biosystems T2Candida □ T2Biosystems T2Resistance

   • Other Commercial Test(s) (Leave Comment) ___________________________________

   • Other Laboratory Developed Test(s) (Leave Comment) ___________________________

Facility Microbiology Laboratory Practices (continued)

7. In a scenario where the mecA resistance marker and Staphylococcus aureus are detected by rapid molecular testing in a blood specimen, select the procedure(s) your facility conducts. (check one)

□ Our laboratory does not perform mecA testing using rapid molecular methods. [If checked, skip question 7a.]

□ Culture based phenotypic antimicrobial susceptibility testing is not performed. [If checked, skip question 7a.]

□ Culture based phenotypic antimicrobial susceptibility testing is performed. A text indicating results of the corresponding rapid molecular testing and/or the interpretation of the rapid molecular testing result is added to the phenotypic test result.

□ Culture based phenotypic antimicrobial susceptibility testing is performed. No text indicating corresponding rapid molecular testing and/or interpretation is added.

1. If both rapid molecular and culture based phenotypic antimicrobial susceptibility testing are performed for a blood specimen to detect drug resistance in Staphylococcus aureus, and discordance is found between their results, how are results reported? (check one)

   • Further testing is not pursued. Results are reported separately.

   • Further testing is not pursued. The phenotypic result is overridden by the rapid molecular test result when an antimicrobial resistance marker is detected.

   • Further testing is performed to identify the reason for the discordance. Results are modified based on the further analysis.

1. In a scenario where the bla_CTX-M (CTX-M) resistance marker and Escherichia coli are detected by rapid molecular testing in a blood specimen, select the procedure(s) your facility conducts. (check one)

□ Our laboratory does not perform bla_CTX-M (CTX-M) testing using rapid molecular methods. [If checked, skip questions 8a]

□ Culture based phenotypic antimicrobial susceptibility testing is not performed. [If checked, skip question 8a.]

□ Culture based phenotypic antimicrobial susceptibility testing is performed. A text indicating results of the corresponding rapid molecular testing and/or the interpretation of the rapid molecular testing result is added to the phenotypic test result.

□ Culture based phenotypic antimicrobial susceptibility testing is performed. No text indicating corresponding rapid molecular testing and/or interpretation is added.

1. If both rapid and culture based phenotypic antimicrobial susceptibility testing are performed for a blood specimen to detect drug resistance in Escherichia coli and discordance is found between their results, how are results reported? (check one)

   • Further testing is not pursued. Results are reported separately.

   • Further testing is not pursued. The phenotypic result is overridden by the rapid molecular test result when an antimicrobial resistance marker is detected.

   • Further testing is performed to identify the reason for the discordance. Results are modified based on the further analysis.

1. Does your facility perform extended-spectrum beta-lactamase (ESBL) testing for E. coli, Klebsiella pneumoniae, Klebsiella oxytoca, or Proteus mirabilis routinely or using a testing algorithm? □ Yes □ No

Facility Microbiology Laboratory Practices (continued)

1. If Yes, indicate what is done if ESBL is detected: (check one)

   • Change susceptible Cefotaxime/Ceftriaxone/Cefepime results to resistant

   • No changes are made in the interpretation of cephalosporins with a note of ESBL

   • Suppress cephalosporin susceptibility results

1. Where is yeast identification performed for specimens collected at your facility? (check one)

□ On-site laboratory

□ Affiliated medical center

□ Commercial referral laboratory

□ Other local/regional, non-affiliated reference laboratory

□ Yeast identification not available (specifically, yeast identification is not performed onsite or at any affiliate/commercial/other laboratory) [If checked, skip questions 11-15]

Answer questions 11-15 for the laboratory that performs yeast identification for your facility:

11. Which of the following methods are used for yeast identification? (check all that apply)

□ MALDI-TOF MS System (Vitek MS)	□ MicroScan
□ MALDI-TOF MS System (Bruker Biotyper)	□ Non-automated Manual Kit (for example, API 20C, RapID, Germ Tube, PNA-FISH, etc.)
□ Vitek-2	□ DNA sequencing
□ BD Phoenix	□ Other (specify): ______________________

12. Does the laboratory routinely use chromogenic agar for the identification or differentiation of Candida isolates?

□ Yes □ No □ Unknown

13. Candida isolated from which of the following body sites are usually fully identified to the species level? (check all that apply)

□ Blood	□ Respiratory
□ Other normally sterile body site (for example, CSF)	□ Other (specify): ______________________
□ Urine	□ None are fully identified to the species level

14. Does the laboratory employ any molecular tests to identify Candida from blood specimens?

□ Yes □ No □ Unknown

1. If yes, which molecular tests are used to identify Candida from blood specimens? (check all that apply)

   • T2Candida Panel

   • BioFire BCID

   • GenMark ePlex BCID

   • Other, specify: _________________

   • Unknown

2. If yes and you get a positive result, does this lab culture the blood to obtain an isolate?

   • Yes, always

   • Yes, with clinical order

   • No

   • Unknown

Facility Microbiology Laboratory Practices (continued)

15. Where is antifungal susceptibility testing (AFST) performed for specimens collected at your facility? (check one)

□ On-site laboratory	□ Other local/regional, non-affiliated reference laboratory
□ Affiliated medical center	□ AFST not available (specifically, AFST is not performed onsite or at any affiliate/commercial/other laboratory) [if selected, skip questions 16 -19]
□ Commercial reference laboratory

Answer questions 16-19 for the laboratory that performs AFST for your facility:

16. What method is used for antifungal susceptibility testing (AFST), excluding Amphotericin B? (check all that apply)

□ Broth microdilution with laboratory developed plates	□ YeastOne (Thermo Scientific™ Sensititre™)	□ Gradient diffusion (E test)
□ Vitek (bioMerieux)	□ Other (specify): ________________	□ Unknown

17. What method is used for antifungal susceptibility testing (AFST) of Amphotericin B? (check all that apply)

□ Broth microdilution with laboratory developed plates	□ YeastOne (Thermo Scientific™ Sensititre™)	□ Gradient diffusion (E test)
□ Vitek (bioMerieux)	□ Other (specify): ________________	□ Unknown

18. AFST is performed for which of the following antifungal drugs? (check all that apply)

□ Fluconazole	□ Voriconazole	□ Itraconazole
□ Posaconazole	□ Micafungin	□ Anidulafungin
□ Caspofungin	□ Amphotericin B	□ Flucytosine
□ Other, specify: ________________	□ Unknown

19. AFST is performed on fungal isolates in which of the following situations? (check all that apply)

	Performed automatically	Performed with a clinician’s order	Not performed	Unknown
Blood	□	□	□	□
Other normally sterile body site (for example, CSF)	□	□	□	□
Urine	□	□	□	□
Respiratory	□	□	□	□
Other (specify): _________	□	□	□	□

20. Is this laboratory developing antibiograms or other reports to track susceptibility trends for Candida spp. isolates tested in this laboratory?

□ Yes □ No □ Unknown

21. What is the primary testing method for C. difficile used most often by your facility’s laboratory or the outside laboratory where your facility’s testing is performed? (check one)

    • Enzyme immunoassay (EIA) for toxin

    • Cell cytotoxicity neutralization assay

    • Nucleic acid amplification test (NAAT) (for example, PCR, LAMP)

      Facility Microbiology Laboratory Practices (continued)

    • NAAT plus EIA, if NAAT positive (2-step algorithm)

    • Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)

    • GDH plus NAAT (2-step algorithm)

    • GDH plus EIA for toxin, followed by NAAT for discrepant results

    • Toxigenic culture (C. difficile culture followed by detection of toxins)

    • Other (specify): _______________________________

22. Indicate the primary and definitive method used to identify microbes from blood cultures collected in your facility. (check one)

    • MALDI-TOF MS System (Vitek MS)

    • MALDI-TOF MS System (Bruker Biotyper)

    • Automated Instrument (for example, Vitek, MicroScan, Phoenix, OmniLog, Sherlock, etc.)

    • Non-automated Manual Kit (for example, API, Crystal, RapID, etc.)

    • Rapid Identification (for example, Verigene, BioFire FilmArray, PNA-FISH, Gene Xpert, etc.)

    • 16S rRNA Sequencing

    • Other (specify): _________________

    • None

23. Indicate any additional secondary methods used for microbe identification from blood cultures collected in your facility (for example, a rapid method that is confirmed with the primary methods, a secondary method if the primary method fails to give an identification, or a method that is used in conjunction with the primary method). (check all that apply)

    • MALDI-TOF MS System (Vitek MS)

    • MALDI-TOF MS System (Bruker Biotyper)

    • Automated Instrument (for example, Vitek, MicroScan, Phoenix, OmniLog, Sherlock, etc.)

    • Non-automated Manual Kit (for example, API, Crystal, RapID, etc.)

    • Rapid Identification (for example, Verigene, BioFire FilmArray, PNA-FISH, Gene Xpert, etc.)

    • 16S rRNA Sequencing

    • Other (specify): _________________

    • None

Infection Control Practices (completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)

24. Number or faction of infection preventionists (IPs) in facility:

    1. Total hours per week performing surveillance: __________________

    2. Total hours per week for infection control activities other than surveillance: __________________

25. Number or fraction of full-time employees (FTEs) for a designated hospital epidemiologist (or equivalent role) affiliated with your facility: __________________

26. Is it a policy in your facility that patients infected or colonized with MRSA are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes □ No □ Not applicable: my facility never admits these patients

Infection Control Practices (continued)

1. If Yes, check the type of patients that are routinely placed in contact precautions while in your facility (check one):

   • All infected and all colonized patients

   • Only all infected patients

   • Only infected or colonized patients with certain characteristics (check all that apply)

□ Patients admitted to high risk settings

□ Patients at high risk for transmission

27. Is it a policy in your facility that patients infected or colonized with VRE are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes □ No □ Not applicable: my facility never admits these patients

1. If Yes, check the type of patients that are routinely place in contact precautions while in your facility (check one):

   • All infected and all colonized patients

   • Only all infected patients

   • Only infected or colonized patients with certain characteristics (check all that apply)

□ Patients admitted to high risk settings

□ Patients at high risk for transmission

28. Is it a policy in your facility that patients infected or colonized with CRE (regardless of confirmatory testing for carbapenemase production) are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes □ No □ Not applicable: my facility never admits these patients

1. If Yes, check the type of patients that are routinely placed in contact precautions while in your facility (check one):

   • All infected and all colonized patients

   • Only all infected patients

   • Only infected or colonized patients with certain characteristics (check all that apply)

□ Patients admitted to high risk settings

□ Patients at high risk for transmission

29. Is it a policy in your facility that patients infected or colonized with suspected or confirmed ESBL-producing or extended spectrum cephalosporin resistant Enterobacterales are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes □ No □ Not applicable: my facility never admits these patients

1. If Yes, check the type of patients that are routinely placed in contact precautions while in your facility (check one):

   • All infected and all colonized patients

   • Only all infected patients

   • Only infected or colonized patients with certain characteristics (check all that apply)

□ Patients admitted to high risk settings

□ Patients at high risk for transmission

Infection Control Practices (continued)

30. Does the facility routinely perform screening testing (culture or non-culture) for CRE? This includes screening for patients at your facility performed by public health laboratories and commercial laboratories.

□ Yes □ No

1. If Yes, in which situations does the facility routinely perform screening testing for CRE? (check all that apply)

   • Surveillance testing at admission for all patients

   • Surveillance testing of epidemiologically-linked patients of newly identified CRE patients (for example, roommates)

   • Surveillance testing at admission of high-risk patients (check all that apply)

□ Patients admitted form long-term acute care (LTAC) or long-term care facility (LTCF)

□ Patients with recent (for example, within 6 months) overnight hospital stay outside the United States

□ Patients admitted to high-risk settings (for example, ICU)

□ Other high-risk patients (specify): _________________

• Surveillance testing of all patients in the facility or in a specific high-risk settings (for example, ICU) at pre-specified intervals (for example, weekly point prevalence survey)

• Other (specify): _________________

1. If Yes, what method is routinely used by the lab conducting CRE testing of screening swabs from your facility? (check all that apply)

   • Culture-based methods □ PCR □ Other (specify): ___________________

1. Does the facility routinely perform screening testing (culture or non-culture) for Candida auris? This includes screening for patients at your facility performed by public health laboratories and commercial laboratories.

□ Yes □ No

1. If Yes, in which situations does the facility routinely perform screening testing for Candida auris? (check all that apply)

   • Surveillance testing at admission for all patients

   • Surveillance testing of epidemiologically-linked patients of newly identified Candida auris patients (for example, point prevalence surveys in response to a case, patients in the same room or unit as a case)

   • Surveillance testing at admission of high-risk patients (check all that apply)

□ Patients admitted form long-term acute care (LTAC) or long-term care facility (LTCF)

□ Patients with recent (for example, within 6 months) overnight hospital stay outside the United States

□ Patients admitted to high-risk settings (for example, ICU)

□ Other high-risk patients (specify): _________________

• Surveillance testing of all patients in the facility or in a specific high-risk setting (for example, ICU) at pre-specified intervals (for example, weekly point prevalence survey)

• Other (specify): ___________________

1. If Yes, what method is routinely used by the lab conducting Candida auris testing of screening swabs from your facility?

   • Culture-based methods □ PCR □ Other (specify): ___________________

1. Does the facility routinely perform screening testing (culture or non-culture for MRSA for any patients admitted?

□ Yes □ No

Infection Control Practices (continued)

1. If Yes, in which situations does the facility routinely perform screening testing for MRSA? (check all that apply)

   • Surveillance testing at admission for all patients

   • Surveillance testing at admission of high-risk patients (for example, admitted from long-term acute care [LTAC] or long-term care facility [LTCF], or dialysis patients)

   • Surveillance testing at admission of patients admitted to high-risk settings (for example, ICU)

   • Surveillance testing of pre-operative patients to prevent surgical site infections

   • Other (specify): ___________________

1. Does your facility have a policy to routinely use chlorhexidine bathing for any adult patients to prevent infection or transmission of MDROs at your facility?

□ Yes □ No

1. If Yes, indicate which patients: (select all that apply)

□ ICU patients: ○ All ICU patients ○ Subset of ICU patients: □ Patients with central venous catheter or midline catheters □ Other, specify: _________

□ Patients outside the ICU: ○ All ICU patients ○ Subset of ICU patients: □ Patients with central venous catheter or midline catheters □ Other, specify: _________

□ Pre-operatively for patients undergoing surgery

34. Does the facility have a policy to routinely use a combination of topical chlorhexidine AND an intranasal antistaphylococcal agent (mupirocin, iodophor, or an alcohol based intranasal agent) for any adult patients to prevent healthcare-associated infections or reduce transmission of resistant pathogens?

□ Yes □ No

Antibiotic Stewardship Practices (completed with input from Physician and Pharmacist Stewardship Leaders)

35. Did the antibiotic stewardship leader(s) participate in responding to these questions? (check one)

□ Yes, pharmacist lead	□ Yes, both pharmacist and physician leads	□ Yes, other lead
□ Yes, physician lead	□ No

36. Facility leadership has demonstrated commitment to antibiotic stewardship efforts by: (check all that apply)

□ Providing stewardship program leader(s) dedicated time to manage the program and conduct daily stewardship interventions.

□ Allocating resources (for example, IT support, training for stewardship team) to support antibiotic stewardship efforts.

□ Having a senior executive that serves as a point of contact or “champion” to help ensure the program has resources and support to accomplish its mission.

□ Presenting information on stewardship activities and outcomes to facility leadership and/or board at least annually.

□ Ensuring the stewardship program has an opportunity to discuss resource needs with facility leadership and/or board at least annually.

□ Communicating to staff about stewardship activities, via email, newsletters, events, or other avenues.

□ Providing opportunities for hospital staff training and development on antibiotic stewardship.

□ Providing a formal statement of support for antibiotic stewardship (for example, a written policy or statement approved by the board).

□ Ensuring that staff from key support departments and groups (for example, IT and hospital medicine) are contributing to stewardship activities.

□ None of the above.

Antibiotic Stewardship Practices (continued)

37. Our facility has a leader or co-leaders responsible for antibiotic stewardship program management and outcomes.

□ Yes □ No

1. If Yes, what is the position of this leader? (check one)

   □ Physician	□ Co-led by both Pharmacist and Phsyician
   □ Pharmacist	□ Other (for example, RN, PA, NP, etc.; specify): ______________

2. If Physician or Co-led is selected, which of the following describes your antibiotic stewardship physician leader? (check all that apply)

   • Has antibiotic stewardship responsibilities in their contract or job description or performance review

   • Is physically on-site in your facility (either part-time or full-time)

   • Completed an ID fellowship

   • Completed a certificate program on antibiotic stewardship

   • Completed other training(s) (for example, conferences or online modules) on antibiotic stewardship

   • None of the above.

3. If ‘Has antibiotic stewardship responsibilities in their contract or job description’ is selected (for physician (co) leader): What percentage of time for antibiotic stewardship activities is specified in the physician (co) leader’s contract or job description? (check one)

□ 1-10%	□ 11-25%	□ 26-50%
□ 51-75%	□ 76-100%	□ Not specified

4. If Physician or Co-led is selected: In an average week, what percentage of time does the physician (co) leader spend on antibiotic stewardship activities in your facility? (check one)

□ 1-10%	□ 11-25%	□ 26-50%
□ 51-75%	□ 76-100%

5. If Pharmacist or Co-led is selected, which of the following describes your antibiotic stewardship pharmacist leader? (check all that apply)

   • Has antibiotic stewardship responsibilities in their contract, job description or performance review

   • Is physically on-site in your facility (either part-time or full-time)

   • Completed a PGY2 ID residency and/or ID fellowship

   • Completed a certificate program on antibiotic stewardship

   • Completed other training(s) (for example, conferences or online modules) on antibiotic stewardship

   • None of the above

6. If ‘Has antibiotic stewardship responsibilities in their contractor or job description’ is selected (for pharmacist (co) leader): What percentage of time for antibiotic stewardship activities is specified in the pharmacist (co) leader’s contract or job description? (check one)

□ 1-10%	□ 11-25%	□ 26-50%
□ 51-75%	□ 76-100%

7. If ‘Pharmacist’ or ‘Co-led’ is selected: In an average week, what percentage of time does the pharmacist (co) leader spend on antibiotic stewardship activities in your facility? (check one)

   	□ 1-10%	□ 11-25%	□ 26-50%
   	□ 51-75%	□ 76-100%
   Antibiotic Stewardship Practices (continued)

8. If Pharmacist or Other is selected: Does your facility have a designated physician who can serve as a point of contact and support for the non-physician leader?

□ Yes □ No

9. If a pharmacist is not the leader or co-leader for the program, is there at least one pharmacist responsible for improving antibiotic use at your facility?

□ Yes □ No

38. Our facility has the following priority antibiotic stewardship interventions: (Check all that apply)

□ Prospective audit and feedback for specific antibiotic agents

1. If Prospective audit and feedback is selected: For which categories of antimicrobials? Answer for the following categories of antimicrobials, whether or not they are on formulary. (Check all that apply)

   • Cefepime, ceftazidime, or piperacillin/tazobactam

   • Vancomycin (intravenous)

   • Ertapenem, imipenem/cilastatin, or meropenem

   • Ceftazidime/avibactam, ceftolozane/tazobactam, meropenem/vaborbactam, imipenem-cilastatin/relebactam, or cefiderocol

   • Fluoroquinolones

   • Daptomycin, linezolid, or other newer anti-MRSA agents

   • Eravacycline or omadacycline

   • Lefamulin

   • Aminoglycosides

   • Colistin or polymyxin B

   • Anidulafungin, caspofungin, or micafungin

   • Isavuconazole, posaconazole, or voriconazole

   • Amphotericin B and/or lipid-based amphotericin B

   • None of the above

2. If Prospective audit and feedback is selected: Our antibiotic stewardship program monitors prospective audit and feedback interventions (for example, by tracking antibiotic use, types of interventions, acceptance of recommendations).

□ Yes □ No

□ Preauthorization for specific antibiotic agents.

3. If Preauthorization is selected: For which categories of antimicrobials? Only answer for categories of antimicrobials that are on formulary. (Check all that apply)

   • Cefepime, ceftazidime, or piperacillin/tazobactam

   • Vancomycin (intravenous)

   • Ertapenem, imipenem/cilastatin, or meropenem

   • Ceftazidime/avibactam, ceftolozane/tazobactam, meropenem/vaborbactam, imipenem-cilastatin/relebactam, or cefiderocol

   • Fluoroquinolones

   • Daptomycin, linezolid, or other newer anti-MRSA agents

   • Eravacycline or omadacycline

   • Lefamulin

     Antibiotic Stewardship Practices (continued)

   • Aminoglycosides

   • Colistin or polymyxin B

   • Anidulafungin, caspofungin, or micafungin

   • Isavuconazole, posaconazole, or voriconazole

   • Amphotericin B and/or lipid-based amphotericin B

   • None of the above

4. If Preauthorization is selected: Our antibiotic stewardship program monitors preauthorization interventions (for example, by tracking which agents are requested for which conditions).

□ Yes □ No

• Facility-specific treatment recommendations, based on national guidelines and local pathogens susceptibilities, to assist with antibiotic selections for common clinical conditions (for example, community-acquired pneumonia, urinary tract infection, skin and soft tissue infection).

1. If Facility-specific treatment recommendations is selected: For which common clinical conditions?

   • Community-acquired pneumonia

   • Urinary tract infection

   • Skin and soft tissue infection

   • None of the above

2. If Facility-specific treatment recommendations is selected: Our stewardship program monitors adherence to our facility’s treatment recommendations for antibiotic selection for common clinical conditions (for example, community-acquired pneumonia, urinary tract infection, skin and soft infections).

□ Yes □ No

7. If Yes: For which common clinical conditions?

   • Community-acquired pneumonia

   • Urinary tract infection

   • Skin and soft tissue infection

   • None of the above

1. Our facility has a policy or formal procedure for other interventions to ensure optimal use of antibiotics: (Check all that apply.)

□ Early administration of effective antibiotics to optimize the treatment of sepsis

□ Treatment protocols for Staphylococcus aureus bloodstream infection

□ Stopping unnecessary antibiotic(s) in new cases of Clostridioides difficile infection (CDI)

□ Review of culture-proven invasive (for example, bloodstream) infections

□ Review of planned outpatient parenteral antibiotic therapy (OPAT)

□ The treating team to review antibiotics 48-72 hours after initial order (specifically, antibiotic time-out)

□ Assess and clarify documented penicillin allergy

□ Using the shortest effective duration of antibiotics at discharge for common clinical conditions (for example, community-acquired pneumonia, urinary tract infection, skin and soft tissue infections)

□ None of the above

Antibiotic Stewardship Practices (continued)

1. If ‘Using the shortest effective duration of antibiotics at discharge for common clinical conditions’ is selected: Our stewardship program monitors adherence in using the shortest effective duration of antibiotics at discharge for common clinical conditions (for example, community-acquired pneumonia, urinary tract infections, skin and soft tissue infections), at least annually.

□ Yes □ No

40. Our facility has in place the following specific ‘pharmacy-based’ interventions: (Check all that apply)

□ Pharmacy-driven changes from intravenous to oral antibiotics without a physician’s order (for example, hospital-approved protocol)

□ Alerts to providers about potentially duplicative antibiotic spectra (for example, multiple antibiotics to treat anaerobes)

□ Automatic antibiotic stop orders in specific situations (for example, surgical prophylaxis)

□ None of the above

41. Our stewardship program has engaged bedside nurses in actions to optimize antibiotic use.

□ Yes □ No

1. If Yes is selected: our facility has in place the following specific ‘nursing-based’ interventions: (Check all that apply.)

   • Nurses receive training on appropriate criteria for sending urine and/or respiratory cultures.

   • Nurses initiate discussions with the treating team on switching from intravenous to oral antibiotics.

   • Nurses initiate antibiotic time-out discussions with the treating team.

   • Nurses track antibiotic duration of therapy.

   • None of the above.

2. If ‘Nurses track antibiotic duration of therapy’ is selected: Is that information available at the bedside (for example, on a whiteboard in the room)?

□ Yes □ No

42. Our stewardship program monitors: (Check all that apply.)

□ Antibiotic resistance patterns (either facility- or region-specific), at least annually

□ Clostridioides difficile infections (or C. difficile LabID events), at least annually

□ Antibiotic use in days of therapy (DOT) per 1000 patient days or days present, at least quarterly

□ Antibiotic use in defined daily doses (DDD) per 1000 patient days, at least quarterly

□ Antibiotic expenditures (specifically, purchasing costs), at least quarterly

□ Antibiotic use in some other way, at least annually (specify): ______________________

□ None of the above

43. Our stewardship team provides the following antibiotic use reports to prescribers, at least annually: (Check all that apply.)

□ Individual, prescriber-level reports

□ Unit- or service-specific reports

□ None of the above

1. If ‘Individual, prescriber-level reports’ or ‘Unit-or service-specific reports’ is selected: Our stewardship program uses these reports to target feedback to prescribers about how they can improve their antibiotic prescribing, at least annually.

□ Yes □ No

Antibiotic Stewardship Practices (continued)

44. Our facility distributes an antibiogram to prescribers, at least annually.

□ Yes □ No

45. Information on antibiotic use, antibiotic resistance, and stewardship efforts is reported to hospital staff, at least annually.

□ Yes □ No

46. Which of the following groups receive education on optimal prescribing, adverse reactions from antibiotics, an antibiotic resistance (for example, Grand Rounds, in-service training, direct instruction) at least annually? (Check all that apply.)

□ Prescribers

□ Nursing staff

□ Pharmacists

□ None of the above

47. Are patients provided education on important side effects of prescribed antibiotics?

□ Yes □ No

1. If ‘Yes’ is selected: How is education to patients on side effects shared? (Check all that apply.)

   • Discharge paperwork

   • Verbally by nurse

   • Verbally by pharmacist

   • Verbally by physician

   • None of the above

Optional Antibiotic Stewardship Practices Questions

Response to the following questions are not required to complete the annual survey.

Provide additional information about your facility antibiotic stewardship activities and leadership.

48. Antibiotic stewardship activities are integrated into quality improvement and/or patient safety initiatives.

□ Yes □ No

48. Our facility accesses targeted remote stewardship expertise (for example, tele-stewardship to obtain facility-specific support for our antibiotic stewardship efforts).

□ Yes □ No

48. Our stewardship program works with the microbiology laboratory to implement the following interventions: (Check all that apply)

□ Selective reporting of antimicrobial susceptibility testing results

□ Placing comments in microbiology reports to improve prescribing

□ None of the above

48. Which committees or leadership entities provide oversight of your facility’s antibiotic stewardship efforts? (Check all that apply)

□ Pharmacy director	□ Executive leadership (for example, CEO, CMO)
□ Pharmacy & therapeutics	□ Hospital board
□ Patient safety	□ Other (specify): _______________
□ Quality improvement	□ None

Facility Water Management Program (WMP) (Completed with input from WMP team members)

52. Does your facility have a water management program (WMP) to prevent the growth and transmission of Legionella and other opportunistic waterborne pathogens (for example, Pseudomoas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi)?

□ Yes □ No

1. If Yes, who is represented on your facility WMP team? (Check all that apply):

□ Hospital Epidemiologist/Infection Preventionist	□ Compliance/Safety Officer
□ Hospital Administrator/Leadership	□ Risk/Quality Management Staff
□ Facilities Manager/Engineer	□ Infectious Disease Clinician
□ Maintenance Staff	□ Consultant
□ Equipment/Chemical Acquistion/Supplier	□ Laboratory Staff/Leadership
□ Environmental Services	□ Other (specifiy): __________________

52. Has your facility ever conducted an environmental assessment to identify where Legionella and other opportunistic waterborne pathogens for example could grow and spread in the facility water system (for example, piping infrastructure)? This may include a description of building water systems using text or basic diagrams that map all water supply sources, treatment systems, processing steps, control measures, and end-use points.

□ Yes □ No

1. If Yes, when was the most recent assessment conducted? (Check one)

□ Within the most recent year (<1 year ago)

□ Between 1 and 3 years ago (>1 year and <3 years)

□ More than 3 years ago (>3 years)

52. Has your facility has ever conducted a water infection control risk assessment (WICRA) to evaluate water sources, modes of transmission, patient susceptibility, patient exposure, and/or program preparedness? An example WICRA tool can be assessed at https://www.cdc.gov/hai/pdfs/prevent/water-assessment-tool-508.pdf.

□ Yes □ No

1. If Yes, when was the most recent assessment conducted? (Check one)

□ Within the most recent year (<1 year ago)

□ Between 1 and 3 years ago (>1 year and <3 years)

□ More than 3 years ago (>3 years)

52. Does your facility regularly monitor the following parameters in the building water system(s)?

Disinfectant (such as residual chlorine): □ Yes □ No

1. If Yes, does your facility have a plan for corrective actions when disinfectant(s) are not within acceptable limits as determined by the water management program? □ Yes □ No

2. If Yes, where and how frequently does your facility monitor disinfectant(s)? (Check all that apply)

Facility Water Management Program (WMP) (continued)

	Entry Points	Cold Potable Water Storage Tank(s)	Hot Potable Water Storage Tank(s)	Hot Water Supply	Hot Water Return	Representative Locations Throughout Cold Potable Building Water System(s)	Representative Locations Throughout Hot Potable Building Water System(s)	Other (specify): _______
Daily	□	□	□	□	□	□	□	□
Weekly	□	□	□	□	□	□	□	□
Monthly	□	□	□	□	□	□	□	□
Quarterly	□	□	□	□	□	□	□	□
Annually	□	□	□	□	□	□	□	□
Other (specify):_________	□	□	□	□	□	□	□	□

Water temperature: □ Yes □ No

3. If Yes, does your facility have a plan for corrective actions when water temperatures are not within acceptable limits as determined by the water management program? □ Yes □ No

4. If Yes, where and how frequently does your facility monitor water temperature? (check all that apply)

	Entry Points	Cold Potable Water Storage Tank(s)	Hot Potable Water Storage Tank(s)	Hot Water Supply	Hot Water Return	Representative Locations Throughout Cold Potable Building Water System(s)	Representative Locations Throughout Hot Potable Building Water System(s)	Other (specify): _______
Daily	□	□	□	□	□	□	□	□
Weekly	□	□	□	□	□	□	□	□
Monthly	□	□	□	□	□	□	□	□
Quarterly	□	□	□	□	□	□	□	□
Annually	□	□	□	□	□	□	□	□
Other (specify):_________	□	□	□	□	□	□	□	□

Water pH: □ Yes □ No

5. If Yes, does your facility have a plan for corrective actions when water pH is not within acceptable limits as determined by the water management program? □ Yes □ No

6. If Yes, where and how frequently does your facility monitor water pH? (check all that apply)

Facility Water Management Program (WMP) (continued)

	Entry Points	Cold Potable Water Storage Tank(s)	Hot Potable Water Storage Tank(s)	Hot Water Supply	Hot Water Return	Representative Locations Throughout Cold Potable Building Water System(s)	Representative Locations Throughout Hot Potable Building Water System(s)	Other (specify): _______
Daily	□	□	□	□	□	□	□	□
Weekly	□	□	□	□	□	□	□	□
Monthly	□	□	□	□	□	□	□	□
Quarterly	□	□	□	□	□	□	□	□
Annually	□	□	□	□	□	□	□	□
Other (specify):_________	□	□	□	□	□	□	□	□

Heterotrophic plate count (HPC) testing: □ Yes □ No

7. If Yes, does your facility have a plan for corrective actions when heterotrophic plate counts are not within acceptable limits as determined by the water management program? □ Yes □ No

8. If Yes, where and how frequently does your facility perform HPC testing? (check all that apply)

	Entry Points	Cold Potable Water Storage Tank(s)	Hot Potable Water Storage Tank(s)	Hot Water Supply	Hot Water Return	Representative Locations Throughout Cold Potable Building Water System(s)	Representative Locations Throughout Hot Potable Building Water System(s)	Other (specify): _______
Daily	□	□	□	□	□	□	□	□
Weekly	□	□	□	□	□	□	□	□
Monthly	□	□	□	□	□	□	□	□
Quarterly	□	□	□	□	□	□	□	□
Annually	□	□	□	□	□	□	□	□
Other (specify):_________	□	□	□	□	□	□	□	□

Specific environmental Legionella testing: □ Yes □ No

9. If Yes, does your facility have a plan for corrective actions when environmental tests for Legionella are not within acceptable limits as determined by the water management program? □ Yes □ No

10. If Yes, where an how frequently does your facility perform Legionella testing? (check all that apply)

Facility Water Management Program (WMP) (continued)

	Entry Points	Cold Potable Water Storage Tank(s)	Hot Potable Water Storage Tank(s)	Hot Water Supply	Hot Water Return	Representative Locations Throughout Cold Potable Building Water System(s)	Representative Locations Throughout Hot Potable Building Water System(s)	Other (specify): _______
Daily	□	□	□	□	□	□	□	□
Weekly	□	□	□	□	□	□	□	□
Monthly	□	□	□	□	□	□	□	□
Quarterly	□	□	□	□	□	□	□	□
Annually	□	□	□	□	□	□	□	□
Other (specify):_________	□	□	□	□	□	□	□	□

Specific environmental Pseudomonas testing: □ Yes □ No

11. If Yes, does your facility have a plan for corrective actions when environmental tests for Pseudomonas are not within acceptable limits as determined by the water management program?

□ Yes □ No

12. If Yes, where an how frequently does your facility perform Pseudomonas testing? (check all that apply)

	Entry Points	Cold Potable Water Storage Tank(s)	Hot Potable Water Storage Tank(s)	Hot Water Supply	Hot Water Return	Representative Locations Throughout Cold Potable Building Water System(s)	Representative Locations Throughout Hot Potable Building Water System(s)	Other (specify): _______
Daily	□	□	□	□	□	□	□	□
Weekly	□	□	□	□	□	□	□	□
Monthly	□	□	□	□	□	□	□	□
Quarterly	□	□	□	□	□	□	□	□
Annually	□	□	□	□	□	□	□	□
Other (specify):_________	□	□	□	□	□	□	□	□

52. Does your facility water management program address measures to prevent transmission of pathogens from wastewater premise plumbing to patients?

□ Yes □ No □ N/A, my facility does not have a water management program

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)).

CDC 57.150 (Front). Rev 9, v12.0 Public reporting burden of this collection of information is estimated to average 89 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 H-21, Atlanta, GA 30333, ATTN: PRA (0920-0666). Page 30 of 30