Page 1 of 2
2014 CAMC Infection Prevention UTI WORKSHEET
Name
DOB
Age
Attending MD
Consultants
Date Cath Inserted
MR#
Test Period
Unit
Medicare ID#
Adm date
D/C date
Date Cath d/c’d
ICU Adm date
ICU D/C date
M
F
Adm Diagnosis:
Date of Event
Culture date
Pathogen(s)
CFUs
Was there an approved indication for the catheter documented?
Culture date
Pathogen(s)
CFUs
________ yes _________ no __________ none documented
Symptomatic Urinary Tract Infection (SUTI)No more than 2 species of microorganisms
Date
>105 CFUs/ml
>103 and <105 CFUs/ml
Criterion 1 ( patient of any age)
Criterion 2 (patient of any age)
One of the following:
One of the following:
1a (cath assoc)
2a (cath assoc)
Pt had indwelling urinary cath in place for > 2
Pt had indwelling urinary cath in place for > 2
calendar days, with day of device placement being
calendar days, with day of device placement being
Day 1, and cath was in place on the date of event
Day 1, and cath was in place on the date of event
OR
1a (cath assoc)
OR
2a (cath assoc)
Pt had indwelling urinary cath in place for > 2
Pt had indwelling urinary cath in place for > 2
calendar days and had it removed the day of or the
calendar days and had it removed the day of or the
day before the date of event
day before the date of event
OR
1b (non-cath assoc)
OR
2b (non-cath assoc)
Patient did not have an indwelling urinary catheter
Patient did not have an indwelling urinary catheter in
in place at the time of or the day before the date of
place at the time of or the day before the date of
event.
event
AND
AND
At least 1 of the following with no other cause
At least 1 of the following with no other cause
Date
Fever (>38° C) (for 1B, pt is < 65yo)
Suprapubic tenderness*
Costovertebral angle pain or tenderness◊
Urgency *
Frequency*
Dysuria*
*only applies to patients without a catheter in place
◊”abdominal pain” or “back pain” is not specific enough
to meet this
AND
Fever (>38° C) (for 2B, pt is < 65yo)
Suprapubic tenderness*
Costovertebral angle pain or tenderness◊
Urgency *
Frequency*
Dysuria*
At least 1 of the following
Positive dipstick for leukocyte esterase and/or nitrite
Pyuria (>10 WBCs/mm3 of unspun urine or
Secondary BSI?
Yes
No
>5 WBCs/high power field of spun urine)
Microorganism seen on Gram stain of unspun urine
Elements of the criterion must occur within a time frame that does not exceed a gap of 1 calendar day.
Criterion 3 (Infants ≤1 year of age)
Criterion 4 (Infants ≤1 year of age)
Pt ≤1 year of age with or without an indwelling
Pt ≤1 year of age with or without an indwelling
Date
urinary cath has at least 1 of the following with
Date
urinary cath has at least 1 of the following with
no other cause
no other cause
Fever (>38° C core)
Fever (>38° C core)
Hypothermia (<36°C core)
Hypothermia (<36°C core)
Apnea
Apnea
Bradycardia
Bradycardia
Lethargy
Lethargy
Vomiting
Vomiting
Dysuria
Dysuria
AND
At least 1 of the following
Positive dipstick for leukocyte esterase and/or nitrite
Pyuria (>10 WBCs/mm3 of unspun urine or
>5 WBCs/high power field of spun urine)
Microorganism seen on Gram stain of unspun urine
Page 2 of 2
Elements of the criterion must occur within a time frame that does not exceed a gap of 1 calendar day.
Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)
(Patient of any age)
Pt of any age with* or without an indwelling urinary cath has no s/s (no fever [>38° C], urgency, frequency, dysuria,
suprapubic tenderness, or costovertebral angle pain or tenderness◊).
OR
For a pt ≤1 year of age, no fever (>38°C core), hypothermia (<36°C core), apnea, bradycardia, dysuria, lethargy, or vomiting
AND
a positive urine culture of ≥105 CFU/ml with no more than 2 species of uropathogen microorganisms**
AND
a positive blood culture with at least 1 matching uropathogen microorganism*** to the urine culture, or at least 2 matching
blood cultures*** drawn on separate occasions if the matching pathogen is a common skin commensal.
Elements of the criterion must occur within a timeframe that does not exceed a gap of 1 calendar day
*Patient had an indwelling urinary catheter in place for >2 calendar days, with day of device placement being Day 1 and catheter was in
place when all elements of this criterion were first present together.
**Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus spp., yeasts, beta-hemolytic Streptococcus spp.,
Enterococcus spp., G. vaginalis, Aerococcus urinae, and Corynebacterium (urease positive)+
***Only genus and species identification should be utilized to determine the sameness of organisms (i.e. matching organisms). No
additional comparative methods should be used (e.g., morphology or Antibiograms)because laboratory testing capabilities and
protocols may vary between facilities
+Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C. urealyticum (CORUR) if so
speciated.
◊”abdominal pain” or “back pain” is not specific enough to meet this
Date
Day
Unit
Foley
Urine Cx
Colony
Count
Temp > 38
Pain
SP
tenderness
CV angle
pain
Urgency
Frequency
Dysuria
Leuko Est
Nitrite
Pyuria
Gm stain
Blood Cx