AQUA General Patient Assessment Form (modified August 2022)

Form Approved

OMB No. 0920-0852

Exp. Date 03/31/2025

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY

ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 2: GENERAL PATIENT ASSESSMENT

CDC ID: ___-_________ Date: ___/___/_______ Data collector initials: _____

Healthcare exposures

1. Indicate the location from which the patient was admitted to the survey hospital (check one):

Private residence Long term care/SNF LTACH Another acute care hospital Homeless Incarcerated

Other _________________________ Unknown

2. In the 30 days prior to admission to the survey hospital, did the patient receive (check all that apply):

IV antimicrobials Cancer chemotherapy Wound care Chronic hemodialysis Surgery

None Unknown COVID-19 specific treatment

3. Was the patient hospitalized in an acute care hospital for ≥2 days in the 90 days prior to this admission?

Yes No Unknown

Antimicrobial allergies

4. Is an antimicrobial drug allergy recorded in the medical record? Yes No Unknown

4a. If yes, specify drug class or classes to which patient is allergic, and reaction(s):

Drug class	Nausea, vomiting and/or diarrhea	Hives or urticaria	Other skin rash	Wheezing, throat tightness, trouble breathing	Angio-edema or face swelling	Anaphylaxis	Not specified	Other (specify)
Penicillins	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes____________
Cephalosporins	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes____________
Sulfa drugs	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes____________
Macrolides	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes____________
Fluoroquinolones	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes____________
Vancomycin	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes____________
Other (specify): ________________	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes____________

Underlying conditions

5. Check all that apply: None: Unknown:

AIDS	Kidney stones/nephrolithiasis
Alcoholism in past year	Leukemia
Asplenia	Lymphoma or multiple myeloma
Asthma	MRSA colonization or infection history
Cerebrovascular disease/stroke (except hemiplegia)	Myocardial infarction
Chronic cognitive deficit	Neutropenia (absolute neutrophil count <500 cells / µL)
Chronic kidney disease	Peptic ulcer disease
Chronic liver disease	Peripheral vascular disease
Chronic obstructive pulmonary disease (COPD)/emphysema	Pregnancy
Chronic lung disease (other than COPD/emphysema, asthma)	Recurrent cystitis or urinary tract infection
Chronic steroid or other immunosuppressive therapy	Sickle cell disease
Congenital urinary tract abnormality (not VUR)	Smoking in home or living environment (other than patient)
Congenital heart disease	Smoking in past year (patient)
Congestive heart failure	Solid tumor malignancy, metastatic (not urologic/renal)
Connective tissue disease	Solid tumor malignancy, not metastatic (not urologic/renal)
Cystic fibrosis	Spinal cord injury or paraplegia or quadriplegia
Dementia	Transplant, hematopoietic stem cell or bone marrow
Diabetes mellitus with complications	Transplant, solid organ
Diabetes mellitus without complications	Ureteral stent
Hemiplegia	Urinary tract abnormality, not otherwise specified
HIV without AIDS	Urostomy or nephrostomy
IVDU in past year	Urologic or renal malignancy
	Vesicoureteral reflux (VUR)

CDCID: ____-__________

Infections present during the hospitalization (Do not use NHSN definitions; use information documented in medical records)

6. Complete table: No infections:

No.	Infection (code)	Onset date	Signs and symptoms documented in medical record (check all that apply)			Was infection treated with antimicrobials?
1	­­­________ SSI? Y COVID-19? Y	Before hospitalization Hospital days 1-2 On/after hosp day 3 In hospital, day unk Unknown	Cough or dyspnea Diarrhea Fever Hypotension Unknown	Mental status change Nausea or vomiting Pain at infection site Positive imaging None	Pus, drainage, abscess Redness or swelling Urinary frequency Urinary urgency Other____________	Yes No Unknown
2	­­­________ SSI? Y COVID-19? Y	Before hospitalization Hospital days 1-2 On/after hosp day 3 In hospital, day unk Unknown	Cough or dyspnea Diarrhea Fever Hypotension Unknown	Mental status change Nausea or vomiting Pain at infection site Positive imaging None	Pus, drainage, abscess Redness or swelling Urinary frequency Urinary urgency Other____________	Yes No Unknown
3	­­­________ SSI? Y COVID-19? Y	Before hospitalization Hospital days 1-2 On/after hosp day 3 In hospital, day unk Unknown	Cough or dyspnea Diarrhea Fever Hypotension Unknown	Mental status change Nausea or vomiting Pain at infection site Positive imaging None	Pus, drainage, abscess Redness or swelling Urinary frequency Urinary urgency Other____________	Yes No Unknown
4	­­­________ SSI? Y COVID-19? Y	Before hospitalization Hospital days 1-2 On/after hosp day 3 In hospital, day unk Unknown	Cough or dyspnea Diarrhea Fever Hypotension Unknown	Mental status change Nausea or vomiting Pain at infection site Positive imaging None	Pus, drainage, abscess Redness or swelling Urinary frequency Urinary urgency Other____________	Yes No Unknown

More infections than fit in the table:

Infection codes: BJI, BSI, CDI, CNS, CVI, DIS, ENT, GTI, HEB, IAB, LRI, PNE, REP, SST, UND, UNK, UTI

Severity of illness

7. Was the patient in an ICU at any time during the hospitalization? Yes No Unknown

7a. If yes, enter the dates of the first ICU admission during the hospitalization:

ICU admission date: ____ / ____ /____ or Unknown ICU discharge date: ____ / ____ /____ or Unknown

8. Complete the table using data from the first 24-hour period of treatment during the hospitalization:

Parameter	First day, CAP treatment: ____ / ____ / ____ or NA	First day, IV vancomycin: ____ / ____ / ____ or NA	First day, fluoroquinolone: ____ / ____ / ____ or NA	First day, UTI treatment ____ / ____ / ____ or NA
Temperature:
Highest:	______ °C °F or Unk	______ °C °F or Unk	______ °C °F or Unk	_____ °C °F or Unk
Lowest:	______ °C °F or Unk	______ °C °F or Unk	______ °C °F or Unk	_____ °C °F or Unk
Heart rate:
Highest:	______ bpm or Unk	______ bpm or Unk	______ bpm or Unk	______ bpm or Unk
Lowest:	______ bpm or Unk	______ bpm or Unk	______ bpm or Unk	______ bpm or Unk
Respiratory:
Highest resp rate:	______ bpm or Unk	________ bpm or Unk	______ bpm or Unk	______ bpm or Unk
Lowest PaCO2:	______ mmHg or Unk	________ mmHg or Unk	______ mmHg or Unk	______ mmHg or Unk
Mechanical vent:	Yes No Unk	Yes No Unk	Yes No Unk	Yes No Unk
Blood pressure:
Lowest systolic BP:	______ mmHg or Unk	______ mmHg or Unk	______ mmHg or Unk	______ mmHg or Unk
Lowest mean arterial pressure:	______ mmHg or Unk	______ mmHg or Unk	______ mmHg or Unk	______ mmHg or Unk
On vasopressors:	Yes No Unk	Yes No Unk	Yes No Unk	Yes No Unk
WBC count:
Highest:	______ cells/mm3 or Unk	______ cells/mm3 or Unk	______ cells/mm3 or Unk	______ cells/mm3 or Unk
Lowest:	______ cells/mm3 or Unk	______ cells/mm3 or Unk	______ cells/mm3 or Unk	______ cells/mm3 or Unk
Highest %bands:	______ % or Unk	______ % or Unk	______ % or Unk	______ % or Unk
Lactate	______ mg/dL mmol/L or Unk	______ mg/dL mmol/L or Unk	______ mg/dL mmol/L or Unk	______ mg/dL mmol/L or Unk

***FORM IS COMPLETE***  Go to AQUA Forms 3a-3d

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