AQUA Vancomycin 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 3a: VANCOMYCIN

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

Infections and other antimicrobial drugs

1. Which infections present during the hospitalization, as reported on the GPA form (question 6), were being treated with vancomycin IV? None

Infection no. 1 (site ______ ) Infection no. 2 (site ______ ) Infection no. 3 (site ______ )

Infection no. 4 (site ______ ) Infection not listed in table due to >4 infections (site ______ )

Unknown

2. Did the patient receive other antimicrobial drugs in the hospital during the period defined by the date that was 5 days before the first date of vancomycin IV and the date that was 5 days after the last date of vancomycin IV?

Yes—complete table below

No

Unknown

2a. Other antimicrobial drugs given in the hospital:

5 days before vancomycin IV first date*: ____ / ____ / ________

5 days after vancomycin IV last date**: ____ / ____ / ________

No.	Drug name	First date (mm/dd/yy)	First Route	Last date (mm/dd/yy)	Last Route
1		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
2		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
3		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
4		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
5		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
6		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
7		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
8		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
9		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
10		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
11		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
12		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
13		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
14		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
15		____ / ____ / ____ Unk	IV IM PO INH	____ / ____ / ____ Unk	IV IM PO INH
*or admission date if vancomycin IV first date ≤5 days after admission **or discharge date if vancomycin IV last date ≤5 days before discharge More drugs than fit in the table:

Laboratory testing CDC ID: -

3. Complete the table for POSITIVE cultures collected from the date 5 days before vancomycin IV first date (5 days before: ____/____/____) through the vancomycin IV last date (____/____/____): No positive cultures: Culture data unknown:

No.	Specimen	Collect date (mm/dd/yy)	Test result final date (mm/dd/yy)	Pathogens identified (insert code)	Pathogen susceptible to oxacillin, methicillin or cefoxitin?	Pathogen susceptible to penicillin or ampicillin?	Pathogen susceptible to vancomycin?	Antimicrobial drugs given on the DAY AFTER the test result was final	Were pathogens susceptible (S) to ≥1 antimicrobial the patient was getting the DAY AFTER the test result was final?
1	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
2	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
3	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
4	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
5	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
6	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
7	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
8	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
9	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U
10	Blood Stool Urine Lower resp Other _____	___ / ___ / ___	___ / ___ / ___	Path1 ________ Path2 ________ Path3 ________	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Path1: Y N U Path2: Y N U Path3: Y N U	Drug1 ________ Drug2 ________ Drug3 ________ Drug4 ________	Path1: Y N U Path2: Y N U Path3: Y N U

More positive cultures than fit in the table:

4. Complete the table for NEGATIVE cultures collected from 5 days before vancomycin IV first date through the vancomycin IV last date:

No negative cultures: Culture data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Culture result final date (mm/dd/yy)		No.	Collect date (mm/dd/yy)	Specimen	Culture result final date (mm/dd/yy)
1	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___		6	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___
2	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___		7	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___
3	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___		8	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___
4	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___		9	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___
5	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___		10	____ / ___ / ___	Blood Lower resp Urine Stool Other ___________	____ / ___ / ___

More negative cultures than fit in the table:

5. Was a MRSA surveillance culture(s) or CIDT done during this admission?

Yes-culture Yes-CIDT No Unknown

5a. If yes to question 5, were any MRSA surveillance cultures or CIDTs positive for MRSA during this admission?

Yes-culture Yes-CIDT No Unknown

6. Complete the table for non-culture microbiology tests (positive and negative) collected from 5 days before vancomycin IV first date through the vancomycin IV last date:

No non-culture tests done: Non-culture test data unknown:

No.	Collect date (mm/dd/yy)	Specimen	Test	What pathogen(s) were tested for?	Result
1	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
2	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
3	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
4	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______
5	____ / ___ / ___	Blood Lower resp Upper resp Urine Stool Other ______	PCR DFA Antigen test Other_____	Legionella Cdiff RSV Pneumococcus Adeno Influenza hMPV Paraflu Other ________ SARS-CoV-2	Negative Unknown Positive (insert code): Path1_______Path2_______ Path3_______

More tests than fit in the table:

CDC ID: -

CDC ID: -

Post-discharge antimicrobial treatment

7. Was vancomycin IV prescribed at discharge (i.e., prescribed to be administered to the patient for additional days after hospital discharge)? Yes No Unknown

7a. If yes to question 7, what is the total duration of the post-discharge vancomycin IV prescription?

_____ days, OR the prescription end date is ____ / ____ / _____, OR Duration is unknown

7b. Were any other antimicrobial drugs prescribed at discharge?

Yes No Unknown

7c. If yes to question 7b, what drugs were prescribed?

No.	Drug name	Route (check all that apply)
1		IV IM PO INH Unknown
2		IV IM PO INH Unknown
3		IV IM PO INH Unknown
4		IV IM PO INH Unknown
5		IV IM PO INH Unknown

***FORM IS COMPLETE***

Phase 5_AQUA Vancomycin Form_20220516 Page 1 of 4