2015 CAMC UTI Worksheet
Name
DOB
MR #
Account #
Adm Diagnosis
M
F
Test Period
Medicare #
Attending
Culture date
Cath Insertion Date
Age
Pathogen(s)
Cath D/C Date
Pt expire
Yes No
Urology Consult
CFUs
Location of insertion
Unit
Event Date
Adm date
D/C date
ICU Adm date
ICU D/C date
Culture date
Pathogen(s)
Bundle ordered
CFUs
Approved indication for catheter documented
All elements of the SUTI & ABUTI criterion must occur during the Infection Window Period
Symptomatic Urinary Tract Infection (SUTI) 1
Symptomatic Urinary Tract Infection (SUTI) 2 (Infants ≤1 year of age)
Patient has a urine culture with no more than two species of organisms,
at least one of which is a bacteria of ≥10⁵ CFU/ml.
One of the following:
Date

1a (cath assoc)
OR

OR

Patient has an indwelling urinary catheter in place for the
entire day on the date of event and such catheter had been in
place for >2 calendar days, on that date (day of device
placement = Day 1)
1a (cath assoc)
Date
Pt ≤1 year of age
AND
(with‡ or without an indwelling urinary catheter)
at least one of the following signs or symptoms:
Fever (>38° C core)
Hypothermia (<36°C core)
Patient had an indwelling urinary catheter in place for >2
calendar days which was removed on the day of, or day
before the date of event
1b (non-cath assoc)
Apnea*
Patient has/had an indwelling urinary catheter but it has/had
not been in place >2 calendar days,
Vomiting*
OR
AND
Patient has a urine culture with no more than two species of
organisms, at least one of which is a bacteria of ≥10⁵ CFU/ml.
Patient did not have a urinary catheter in place on the date of
event nor the day before the date of event
at least 1 of the following signs or symptoms:
Fever (>38° C) (for 1B, pt is < 65yo)
Suprapubic tenderness*
Costovertebral angle pain or tenderness*
Urinary urgency* ◊
Frequency* ◊
Dysuria* ◊
Bradycardia*
Lethargy*
Suprapubic tenderness*
Notes:

Fever and hypothermia are non-specific symptoms of infection and
cannot be excluded from UTI determination because they are clinically
deemed due to another recognized cause.

“abdominal pain” or “back pain” is not specific enough to meet criteria
Secondary BSI?
Yes
No
Did patient have an order to leave foley in place?
Yes
No
Ordered by:
Asymptomatic Bacteremic Urinary Tract Infection (ABUTI) (Patient of any age)
Date
Patient with† or without an indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age
(Note: Patients > 65 years of age with a non-catheter-associated ABUTI may have a fever and still meet the ABUTI criterion)
AND
Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of ≥10⁵ CFU/ml
AND
Patient has a positive blood culture with at least one matching bacteria to the urine culture, or meets LCBI criterion 2 (without fever) and
matching common commensal(s) in the urine.
◊ cannot be used as symptoms when catheter is in place.
‡ If patient had an indwelling urinary catheter in place for >2 calendar days, and catheter was in place on the date of event or the previous day the CAUTI criterion is
met. If no such indwelling urinary catheter was in place, UTI (non-catheter associated) criterion is met.
*With no other recognized cause
†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 on the date of event or
the day before.
2015 CAMC UTI Worksheet
Blood Cx
Dysuria
Frequency
Urgency
CV angle
pain/
tenderness
Suprapubic
tenderness
Temp > 38
Urine Cx
Foley
Unit
RIT
Infection
Window
Period
Date of
Event
Hospital
Day
Date
Table of Events
Infection Window Period (first + diagnostic test, 3 days before & 3 days after) Repeat Infection Timeframe-RIT (14 day timeframe where date of event = day 1)
Date of Event (date the first element occurs for the first time within the infection window period) Secondary BSI Attribution Period (Infection Window Period + RIT)