Form 1 2010 HAI & Antimicrobial Use Point Prevalence Survey: Pr

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

2

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

010 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY:

PRIMARY TEAM DATA COLLECTION FORM

CDC ID: - Survey date: //

I. Identifiers (for Primary Team and EIP Team use only; Identifiers are not transmitted to CDC)
Patient name: ___________________________________ (Last, First, MI)
Date of birth: //	Hospital name: __________________________________
Hospital unit name: ______________________________	Room number: __________________________________
Medical record no.: ______________________________	Data collector initials: ____________________________

II. Demographics
Age: _______ years months days	Admission date: //
Gender: M F Unknown	CDC location code: __________________________

III. Risk factors (in place on the survey date)
Urinary catheter:	No Yes Unknown
Ventilator:	No Yes Unknown
Central line:	No Yes  Unknown	If “Yes,” check all that apply: PICC Femoral line Other central line

IV. Antimicrobials
On antimicrobials on the survey date or the calendar day prior to the survey date:	No Yes Unknown
**Qualification for hemodialysis and peritoneal dialysis patients ONLY** On any of the following antimicrobials in the 4 calendar days prior to the survey date: vancomycin, amikacin, gentamicin, tobramycin, streptomycin, kanamycin 	NA, not a dialysis patient No Yes Unknown

F

Public reporting burden of this collection of information is estimated to average 5 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-xxxx.

ORM IS COMPLETE

2

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

010 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY:

EIP TEAM ANTIMICROBIAL USE FORM

Date: // Data collector initials: ________		CDC ID: -

Check here if no antimicrobials administered/scheduled to be administered. Otherwise, fill in table(s) below, for up to 6 antimicrobial agents.

Therapeutic site codes:

BJI = Bone or joint, BSI = Bloodstream infection, CNS = Central nervous system, CVI = Cardiovascular (other than BSI), DIS = Systemic, disseminated infection, ENT = Eyes, ears, nose, throat (includes upper respiratory infection, GTI = Gastrointestinal tract, HEB = hepatic and biliary system infections (including pancreas), IAB = intraabdominal infection other than GTI and HEB (e.g., spleen abscess), LRI = Lower respiratory infection, REP = Reproductive tract infection, SST = Skin or soft tissue infection (includes muscle infection), UTI = Urinary tract infection, UND = Undetermined, Other = specify other site.

C

Public reporting burden of this collection of information is estimated to average 15 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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-xxxx.

ontinued on next page 

CDC ID: -

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

If Rationale for ANY drug listed above is “None documented” or “Treatment of active infection”  GO TO HAI FORM.

If Rationale for ALL drugs listed above is “Medical prophylaxis” or “Surgical prophylaxis”  DON’T fill out HAI Form. Data collection complete.

2

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

010 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY:

EIP TEAM HAI FORM

Date: // Data collector initials: ________	CDC ID: -
Does the patient have an HAI?
No  data collection complete Yes  complete the table below.

Enter only one HAI on each HAI Form. This is HAI Form # _____ out of _____ total HAI Forms for this patient.

HAI		Specific Site		Device and Procedure Information	Comments
	UTI	SUTI ABUTI OUTI		Catheter-associated? No Yes
	PNEU	PNU1 PNU2 PNU3		Ventilator-associated? No Yes
	BSI	LCBI CSEP		Central line-associated? No Yes
	SSI	SUP INC DEEP INC ORGAN/SPACE (for ORGAN/SPACE, specify site : ___________ )		NHSN operative procedure category code : OR (if operative procedure but not NHSN) check the following: OTH
	BJ	BONE JNT DISC
	CNS	IC MEN SA
	CVS	VASC ENDO	CARD MED
	EENT	CONJ EYE EAR	ORAL SINU UR
	GI	GE GIT HEP	IAB NEC
	LRI	BRON LUNG
	REPR	EMET EPIS	VCUF OREP
	SST	SKIN ST DECU BURN	BRST UMB PUST CIRC
	SYS	DI

Was there a Secondary Bloodstream Infection associated with this HAI? No Yes Unknown

Enter up to three pathogen codes for this HAI: 1) ________ 2)________ 3) _________ OR No pathogen identified

Enter the CDC location of attribution for this HAI: _______________ Unknown Not applicable (i.e., SSI)

Date: // Data collector initials: ________

Form Approved OMB No. 0920-XXXX Exp. Date xx/xx/20xx CDC ID: -

Antimicrobial Susceptibility Testing—Instructions:

1. Check the appropriate box(es) to indicate which of the pathogen(s) below (if any) caused this HAI. “E. coli”=Escherichia coli; “E. faecium”=Enterococcus faecium; “E. faecalis”=Enterococcus faecalis; “P. aeruginosa”=Pseudomonas aeruginosa; “S. aureus”=Staphylococcus aureus.

2. Check the appropriate susceptibility test results for the antimicrobial agents listed: S=sensitive/susceptible. I=intermediate, R=resistant, N=not tested.

3. Antimicrobial agent abbreviations: AMK=amikacin, AMP=ampicillin, AMPSUL=ampicillin/sulbactam,CEFEP=cefepime, CEFOT=cefotetan, CEFTAZ=ceftazidime, CEFTRX=ceftriaxone, CIPRO=ciprofloxacin, CLINDA=clindamycin, DAPTO=daptomycin, DOXY=doxycycline, ERYTH=erythromycin, GENT=gentamicin, IMI=imipenem, LEVO=levofloxacin, LNZ=linezolid, MERO=meropenem, OX=oxacillin, PENG=penicillin G, PIP=piperacillin, PIPTAZ=piperacillin/tazobactam, QUIDAL=quinupristin/dalfopristin, RIF=rifampin, TETRA=tetracycline, TMZ=trimethoprim/sulfamethoxazole, VANC=vancomycin.

Check here if NONE of the organisms below are pathogens for this HAI (data collection is now complete).

Acinetobacter baumannii other

AMK

AMPSUL

CEFEP

CEFTAZ

CIPRO

COL/PB

GENT

IMI

LEVO

MERO

PIPTAZ

TOBRA

TIG

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

E. coli

AMK

AZT

CEFEP

CEFOT

CEFTAZ

CEFTRX

CIPRO

GENT

IMI

LEVO

MERO

TOBRA

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

Positive test for extended-spectrum beta lactamase (ESBL) production? Yes No Don’t know

Positive test for carbapenemase production? Yes No Don’t know

E. faecium

AMP

DAPTO

LNZ

PENG

QUIDAL

VANC

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

E. faecalis	AMP		DAPTO		LNZ		PENG		VANC
	S I	R N	S I	R N	S I	R N	S I	R N	S I	R N

Klebsiella pneumoniae oxytoca other

AMK

AZT

CEFEP

CEFOT

CEFTAZ

CEFTRX

CIPRO

GENT

IMI

LEVO

MERO

TOBRA

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

Positive test for extended-spectrum beta lactamase (ESBL) production? Yes No Don’t know

Positive test for carbapenemase production? Yes No Don’t know

P. aeruginosa

AMK

AZT

CEFEP

CEFTAZ

CIPRO

GENT

IMI

LEVO

MERO

PIP

PIPTAZ

TOBRA

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S. aureus

CLIND

DAPTO

DOXY

ERYTH

GENT

LNZ

OX

QUIDAL

RIF

TETRA

TMZ

VANC

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

S I

R N

FORM IS COMPLETE