Criteria for Infection Report Form – Urinary Tract Infections (UTIs)
Name: __________________________ Age _____ Sex _____ Unit _________ Room_________
Date of admission/readmission_______________ Date infection was noted ______________
□ Urinary Tract Infections (UTIs)
Invasive devices (): □ Nasogastric tube □ Indwelling or suprapubic urinary catheter □ Gastric tube
□ Tracheostomy □ Peripheral IV □ Central venous catheter □ Other _____________________________
Type of
Criteria
Infection/Site
Conditions/Comments
Infection
(symptoms must be new or increased
Both criteria must be present:
UTI should be diagnosed
□ UTI in
At least 1 of the following subcriteria:
when there are localizing
resident
WITHOUT
□ Acute dysuria or acute pain, swelling, genitourinary signs and
symptoms and a positive
an
or tenderness of the testes,
urine culture result. A
indwelling
epididymis, or prostate
diagnosis of UTI can be
catheter
□ Fever or leukocytosis (See
made without localizing
Constitutional Criteria Table) AND
symptoms if a blood culture
At least 1 of the following
isolate is the same as the
subcriteria:
organism isolated from the
o Acute costovertebral angle pain
urine and there is no
or tenderness
alternate site of infection. In
o Suprapubic pain
the absence of a clear
o Gross hematuria
alternate source of
o New or marked increase in
infection, fever or rigors
incontinence
with a positive urine culture
o New or marked increase in
result in the nonurgency
catheterized resident or
o New or marked increase in
acute confusion in the
frequency
catheterized resident will
In the absence of fever or
leukocystosis, then 2 or more of the often be treated as UTI.
However, evidence suggests
following subcriteria:
that most of these episodes
o Suprapubic pain
are likely not due to
o Gross hematuria
infection of a urinary source.
o New or marked increase in
incontinence
o New or marked increase in
urgency
o New or marked increase in
frequency
AND
Urine specimens for culture
1 of the following subcriteria:
should b e processed as
□ At least 105 cfu/mL of no more than 2
soon as possible, preferably
species of microorganisms in a
within 1–2 h. If urine
voided urine sample
specimens cannot be
□ At least 102 cfu/mL of any number of
processed within 30 min of
organisms in a specimen collected by
collection, they should be
in-and-out catheter
refrigerated. Refrigerated
specimens should be
cultured within 24 h.
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Criteria for Infection Report Form – Urinary Tract Infections (UTIs)
Type of
Infection
Infection/Site
□ UTI in
resident
WITH an
indwelling
catheter
□ Urinary Tract Infections (UTIs)
Criteria
(symptoms must be new or increased
Both criteria must be present:
At least 1 of the following subcriteria:
□ Fever, rigors, or new-onset
hypotension, with no alternate site
of infection
□ Either acute change in mental status
or acute functional decline, with no
alternate site of infection
□ New-onset suprapubic pain or
costovertebral angle pain or
tenderness
□ Purulent discharge from around the
catheter or acute pain, swelling, or
tenderness of the testes, epididymis,
or prostate
AND
Must have:
□ Urinary catheter specimen culture
with at least 105 cfu/mL of any
organism(s)
Conditions/Comments
UTI should be diagnosed
when there are localizing
genitourinary signs and
symptoms and a positive
urine culture result. A
diagnosis of UTI can be
made without localizing
symptoms if a blood culture
isolate is the same as the
organism isolated from the
urine and there is no
alternate site of infection. In
the absence of a clear
alternate source of
infection, fever or rigors
with a positive urine culture
result in the noncatheterized resident or
acute confusion in the
catheterized resident will
often be treated as UTI.
However, evidence suggests
that most of these episodes
are likely not due to
infection of a urinary source.
Recent catheter trauma,
catheter obstruction, or
new-onset hematuria are
useful localizing signs that
are consistent with UTI but
are not necessary for
diagnosis.
Urinary catheter specimens
for culture should be
collected following
replacement of the catheter
(if current catheter in place
for >14 days).
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Criteria for Infection Report Form – Urinary Tract Infections (UTIs)
1. Was resident hospitalized due to this infection?
□ Yes
□ No
2. Culture results (if any):
DATE:
SITE:
ORGANISM(S):
COMMENTS:
DATE:
SITE:
ORGANISM(S):
COMMENTS:
DATE:
SITE:
ORGANISM(S):
COMMENTS:
3. Outcome; at end of infection, the resident was:
□ The same or better than before infection
□ More dependent that before infection
□ Transferred to another facility
□ Expired/deceased
4. Does resident have a multi-drug resistant organism on culture (eg, MRSA, VRE)?
□ Yes
□ No
5. If yes, type:
□ MRSA
□ VRE
□ C-Diff
□ Other:___________________________________
6. If culture positive for multi-drug resistant organism, do they meet criteria for infection
at the site of positive culture?
□ Yes
□ No (If no, resident is likely only colonized and not infected. Isolation or contact
precautions may be necessary.)
Comments:_____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Completed by:_________________________________ Title:____________ Date:___________
Source: Infection Control and Hospital Epidemiology 2012;33(10):965-977
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