Form CDC 57.114 CDC 57.114 Urinary Tract Infection (UTI)

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

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:

Ethnicity (Specify):

Race (Specify):

*Event Type: UTI

*Date of Event:

Post-procedure UTI: Yes No

Date of Procedure:

NHSN Procedure Code:

ICD-9-CM 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 date of event

□ Removed – Urinary catheter in place > 2 days but removed on the date of event or the day before

□ 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)

□ Urinary System Infection (USI)

*Specify Criteria Used: (check all that apply)

Signs & Symptoms

Any Patient

≤ 1 year old

Laboratory & Diagnostic Testing

□ Fever

□ Urgency

□ Fever

□ 1 positive culture with ≥ 105 CFU/ml with no more than 2 species of microorganisms

□ Frequency

□ Dysuria

□ Hypothermia

□ Positive dipstick for leukocyte esterase or nitrite

□ Pain or tenderness

□ Abscess

□ Apnea

□ Urine not tested for WBC

□ Acute pain, swelling, or tenderness of testes, epididymis, or prostate

□ Bradycardia

□ Pyuria (≥ 10 WBC/mm3 of unspun urine or > 5 WBC/ highpower field of spun urine)

□ Lethargy

□ Suprapubic tenderness

□ Vomiting

□ Neutropenia (WBC or ANC < 500 cells/mm3)

□ Costovertebral angle pain or tenderness

□ 1 positive culture with ≥ 103 CFU/ml and < 105 CFU/ml with no more than 2 species of microorganisms

□ Purulent drainage from affected site

□ Microorganisms seen on Gram stain of unspun urine

□ Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam‡ ‡ per specific site criteria

□ Positive culture

□ Positive blood culture

□ Imaging test evidence of infection

*Secondary Bloodstream Infection: 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 30 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 8, v8.3

Urinary Tract infection (UTI)

Page 2 of 4

Pathogen #

Gram-positive Organisms

_______

Staphylococcus coagulase-negative

VANC S I R N

(specify species if available): ____________

_______

____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level)

DAPTO S NS N

GENTHL§ S R N

LNZ S I R N

VANC S I R N

_______

Staphylococcus aureus

CIPRO/LEVO/MOXI S I R N

CLIND S I R N

DAPTO S NS N

DOXY/MINO S I R N

ERYTH S I R N

GENT S I R N

LNZ S R N

OX/CEFOX/METH S I R N

RIF S I R N

TETRA S I R N

TIG S NS 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

AZT S I R N

CEFEP S I R N

CEFTAZ S I R N

CIPRO/LEVO S I R N

COL/PB S I R N

GENT S I R N

IMI S I R N

MERO/DORI S I R N

PIP/PIPTAZ S I R N

TETRA/DOXY/MINO 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

CEFTAZ S I R N

CEFUR S I R N

CEFOX/CTET S I R N

CIPRO/LEVO/MOXI S I R N

COL/PB† S R N

ERTA S I R N

GENT S I R N

IMI S I R N

MERO/DORI S I R N

PIPTAZ S I R N

TETRA/DOXY/MINO 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

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

CEFTAZ S I R N

CEFUR S I R N

CEFOX/CTET S I R N

CIPRO/LEVO/MOXI S I R N

COL/PB† S R N

ERTA S I R N

GENT S I R N

IMI S I R N

MERO/DORI S I R N

PIPTAZ S I R N

TETRA/DOXY/MINO S I R N

TIG S I R N

TMZ S I R N

TOBRA S I R N

_______

____Klebsiella pneumonia ____Klebsiella oxytoca

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

CEFTAZ S I R N

CEFUR S I R N

CEFOX/CTET S I R N

CIPRO/LEVO/MOXI S I R N

COL/PB† S R N

ERTA S I R N

GENT S I R N

IMI S I R N

MERO/DORI S I R N

PIPTAZ S I R N

TETRA/DOXY/MINO S I R N

TIG S I R N

TMZ S I R N

TOBRA S I R N

Urinary Tract infection (UTI)

Page 3 of 4

Pathogen #

Gram-negative Organisms (continued)

_______

Pseudomonas aeruginosa

AMK S I R N

AZT S I R N

CEFEP S I R N

CEFTAZ S I R N

CIPRO/LEVO S I R N

COL/PB S I R N

GENT S I R N

IMI S I R N

MERO/DORI S I R N

PIP/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 NS N

FLUCO S S-DD R N

FLUCY S I R N

ITRA S S-DD R N

MICA S NS N

VORI S S-DD R N

Pathogen #

Other Organisms

_______

Organism 1 (specify) ____________

_______Drug 1 S I R N

_______ Drug 2 S I R N

______ Drug 3 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

_______ Drug 2 S I R N

______ Drug 3 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

_______ Drug 2 S I R N

______ Drug 3 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 have not been set by FDA or CLSI, Sensitive and Resistant designations should be based upon epidemiological cutoffs of Sensitive MIC ≤ 2 and Resistant MIC ≥ 4

Drug Codes:
AMK = amikacin	CEFTRX = ceftriaxone	FLUCY = flucytosine	OX = oxacillin
AMP = ampicillin	CEFUR= cefuroxime	GENT = gentamicin	PB = polymyxin B
AMPSUL = ampicillin/sulbactam	CTET= cefotetan	GENTHL = gentamicin –high level test	PIP = piperacillin
AMXCLV = amoxicillin/clavulanic acid	CIPRO = ciprofloxacin	IMI = imipenem	PIPTAZ = piperacillin/tazobactam
ANID = anidulafungin	CLIND = clindamycin	ITRA = itraconazole	RIF = rifampin
AZT = aztreonam	COL = colistin	LEVO = levofloxacin	TETRA = tetracycline
CASPO = caspofungin	DAPTO = daptomycin	LNZ = linezolid	TIG = tigecycline
CEFAZ= cefazolin	DORI = doripenem	MERO = meropenem	TMZ = trimethoprim/sulfamethoxazole
CEFEP = cefepime	DOXY = doxycycline	METH = methicillin	TOBRA = tobramycin
CEFOT = cefotaxime	ERTA = ertapenem	MICA = micafungin	VANC = vancomycin
CEFOX= cefoxitin	ERYTH = erythromycin	MINO = minocycline	VORI = voriconazole
CEFTAZ = ceftazidime	FLUCO = fluconazole	MOXI = moxifloxacin

Urinary Tract infection (UTI)

Page 4 of 4
Custom Fields
Label		Label
________________________	____/____/____	_______________________	____/____/_____
________________________	_____________	_______________________	______________
________________________	_____________	_______________________	______________
________________________	_____________	_______________________	______________
________________________	_____________	_______________________	______________
________________________	_____________	_______________________	______________
________________________	_____________	_______________________	______________
Comments