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Urinary Tract infection (UTI)

www.cdc.gov/nhsn

IDENTITAS PASIEN
*Event Type: UTI *Tanggal Kejadian:
Post-procedure UTI: Ya Tidak Tgl prosedur:
Diagnosa :
*MDRO Infection Surveillance:
□ Ya, infeksi patogen berhubungan dengan lokasi □ Tidak, , infeksi pathogen bukan dari lokasi yang berhubungan
*Tanggal MRS : *Unit/Bangsal:
Risk Factors
Status Kateter Urine ketika semua elemen kriteria dari UTI pertama muncul bersamaan
□ terpasang □ dilepas selama periode 2 hari □ tidak terpasang dan tidak dilepas selama periode 2 hari
Unit/bangsal pemasangan : ________________________ Tanggal pemasangan: ____ /____ /_______
Jika NICU, berat lahir (gms): ____________
Detail kejadian
*Spesifik Event: □ Symptomatic UTI (SUTI) □ Asymptomatic Bacteremic UTI (ABUTI) □ lain UTI (OUTI)
*Spesifik criteria yang digunakan: (cek semua dibawah ini)
Tanda & Gejala Laboratory & Diagnostic Testing
Pasien ≤ 1 tahun
□ Demam □ Fever □ 1 positive culture with ≥ 10 5
CFU/ml with no more than
2 species of microorganisms
□ Anyang-anyangan □ Hypothermia
□ Frequency □ Apnea □ Positive dipstick for leukocyte esterase or nitrite
□ Dysuria □ Bradycardia □ Pyuria
□ Suprapubic tenderness □ Dysuria □ Microorganisms seen on Gram stain of unspun urine
□ Costovertebral angle pain or □ Lethargy □ 1 kultur positive dengan ≥ 10 CFU/ml dan < 10
3 5

tenderness CFU/ml dengan tidak lebih dari 2 species dari

microorganisms
□ Abscess □ Vomiting □ Kultur positive
□ Pain or tenderness □ Kultur darah positive
□ Purulent drainage or material □ Imaging test evidence of infection
□ Bukti lain infeksi ditemukan pada pemeriksaan
langsung, selama prosedur invasif, atau dengan tes
diagnostik ‡
per specific site criteria
*Secondary Bloodstream Infection: Ya Tidak
Meninggal : Ya Tidak UTI yang menyebabkan kematian: Ya Tidak
Tanggal Pulang: *Patogen teridentifikasi: Ya Tidak *Jika Ya, spesifik di hal2
Tanda tangan Klinisi
Pathogen # Identifikasi Patogen
Organism 1
(specify) _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 2
(specify) _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN
 Urinary Tract infection (UTI)
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Pathogen
#
Gram-positive Organisms

_______ Staphylococcus VANC

SIRN
coagulase-negative
(specify): ________________________

_______ Enterococcus AMP CIPRO/LEVO/MOXI DAPTO DOXY/MINO GENTHL§ LNZ

SIRN SIRN S NS N SIRN SRN SIRN
spp.( specify):
___________
STREPHL§ TETRA TIG VANC
SRN SIRN S NS N SIRN

_______ Enterococcus AMP CIPRO/LEVO/MOXI DAPTO DOXY/MINO GENTHL§ LNZ

SIRN SIRN S NS N SIRN SRN SIRN
faecium

QUIDAL STREPHL§ TETRA TIG VANC

SIRN SRN SIRN S NS N SIRN

_______ Staphylococcus CHLOR CIPRO/LEVO/MOXI CLIND DAPTO DOXY/MINO ERYTH GENT

SIRN SIRN SIRN S NS N SIRN SIRN SIRN
aureus

LNZ OX/CEFOX/METH QUIDAL RIF TETRA TIG TMZ VANC

SRN SIRN SIRN SIRN SIRN S NS N SIRN SIRN

Pathogen
#
Gram-negative Organisms

_______ Acinetobacter AMK AMPSUL AZT CEFEP CEFTAZ CIPRO/LEVO COL/PB

SIRN SIRN SIRN SIRN SIRN SIRN SIRN
spp. (specify):
____________
GENT IMI MERO/DORI PIP/PIPTAZ TETRA/DOXY/MINO
SIRN SIRN SIRN SIRN SIRN

TMZ TOBRA
SIRN SIRN

_______ Escherichia coli AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
SIRN SIRN SIRN SIRN SIRN SIRN SIRN

CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB

SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

TIG TMZ TOBRA

SIRN SIRN SIRN

_______ Enterobacter AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX

SIRN SIRN SIRN SIRN SIRN SIRN SIRN
spp. (specify):
____________
CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

CDC 57.114 (Back) Rev 7, v7.1

 TIG TMZ TOBRA
SIRN SIRN SIRN

_______ Klebsiella spp. AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
SIRN SIRN SIRN SIRN SIRN SIRN SIRN
(specify):
____________
CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

TIG TMZ TOBRA

SIRN SIRN SIRN
Urinary Tract infection (UTI)
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Pathogen
#
Gram-negative Organisms (continued)

_______ Serratia AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX

SIRN SIRN SIRN SIRN SIRN SIRN SIRN
marcescens

CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB

SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

TIG TMZ TOBRA

SIRN SIRN SIRN

_______ Pseudomonas AMK AZT CEFEP CEFTAZ CIPRO/LEVO COL/PB GENT

SIRN SIRN SIRN SIRN SIRN SIRN SIRN
aeruginosa

IMI MERO/DORI PIP/PIPTAZ TOBRA

SIRN SIRN SIRN SIRN

_______ Stenotrophomonas LEVO TETRA/MINO TICLAV TMZ

SIRN SIRN SIRN SIRN
maltophilia
Pathogen
#
Fungal Organisms
Candida spp.
(specify): ANID CASPO FLUCO FLUCY ITRA MICA VORI
_______
____________ SIRN S NS N S S-DD R N SIRN S S-DD R N S NS N S S-DD R N

Pathogen
#
Other Organisms
Organism 1
(specify) _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 1
(specify) _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 1
(specify) _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

CDC 57.114 (Back) Rev 7, v7.1

 Result Codes
S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested
§
GENTHL and STREPHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic

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

CDC 57.114 (Back) Rev 7, v7.1

 Urinary Tract infection (UTI)
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Custom Fields
Label Label
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Comments

CDC 57.114 (Back) Rev 7, v7.1