Criteria for Infection Report Form – Respiratory Tract Infections (RTIs)
Name: __________________________ Age _____ Sex _____ Unit _________ Room_________
Date of admission/readmission_______________ Date infection was noted ______________
□ Respiratory Tract Infections (RTIs)
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
At least 2 criteria must be present:
Fever may or may not be
□ Common
present. Symptoms must
□ Runny nose or sneezing
cold
be new and not attributable
syndrome
□ Stuffy nose (i.e., congestion)
or
□ Sore throat or hoarseness or difficulty to allergies.
pharyngitis
in swallowing
□ Dry cough
□ Swollen or tender glands in the neck
(cervical lymphadenopathy)
Both
criteria must be present:
If criteria for influenza-like
□ Influenzaillness and another upper or
like illness
□ Fever (single oral temperature
lower RTI are met at the
≥100˚F, repeated oral temperatures
same time, only the
>99 ˚F, or single temperature >2 ˚F
diagnosis of influenza-like
over baseline from any site)
illness should be recorded.
AND
Because of increasing
At least 3 of the following subcriteria:
uncertainty surrounding the
Did resident
□ Chills
timing of the start of
receive
□ New headache or eye pain
influenza season, the peak
influenza
□ Myalgias or body aches
of influenza activity, and the
vaccine for this
□ Malaise or loss of appetite
length of the season,
flu season?
□
Sore
throat
“seasonality” is no longer a
□ YES □ NO
□ New or increased dry cough
criterion to define influenzalike illness.
For both pneumonia and
□ Pneumonia All 3 criteria must be present:
lower RTI, the presence of
□ Interpretation of a chest x-ray as
underlying conditions that
demonstrating pneumonia or the
could mimic the
presence of a new infiltrate
presentation of a RTI (eg,
AND
congestive heart failure or
At least 1 of the following subcriteria:
interstitial lung diseases)
□ New or increased cough
should be excluded by a
□ New or increased sputum production
review of clinical records
□ O2 saturation <94% on room air or a
and an assessment of
reduction in O2 saturation of >3%
presenting symptoms and
from baseline
signs.
□ New or changed lung examination
abnormalities
□ Pleuritic chest pain
□ Respiratory rate of ≥25 breaths/min
NOTE: this diagnosis can
AND
ONLY be made if a chest xMust have at least 1 of the CC:
ray is done and results
□ ≥1 Constitutional Criteria (see Table) support diagnosis.
©Pathway Health Services, Inc. - All Rights Reserved - Copy with Permission Only Rehospitalization Reduction Toolkit 2012 Page 1 of 3
Criteria for Infection Report Form – Respiratory Tract Infections (RTIs)
Type of
Infection
Infection/Site
□ Respiratory Tract Infections (RTIs)
□ Lower
respiratory
tract
(bronchitis or
tracheobronchitis)
Criteria
(symptoms must be new or increased
All 3 criteria must be present:
□ Chest x-ray not performed or
negative results for pneumonia or
new infiltrate
AND
At least 2 of the following subcriteria:
□ New or increased cough
□ New or increased sputum production
□ O2 saturation <94% on room air or a
reduction in O2 saturation of >3%
from baseline
□ New or changed lung examination
abnormalities
□ Pleuritic chest pain
□ Respiratory rate of ≥25 breaths/min
AND
Must have at least 1 of the CC:
□ ≥1 Constitutional Criteria (see Table)
Conditions/Comments
For both pneumonia and
lower RTI, the presence of
underlying conditions that
could mimic the
presentation of a RTI (eg,
congestive heart failure or
interstitial lung diseases)
should be excluded by a
review of clinical records
and an assessment of
presenting symptoms and
signs.
NOTE: This diagnosis can
be made only if NO Chest xray was done OR if a CXR
fails to confirm diagnosis of
pneumonia or new infiltrate.
©Pathway Health Services, Inc. - All Rights Reserved - Copy with Permission Only Rehospitalization Reduction Toolkit 2012 Page 2 of 3
Criteria for Infection Report Form – Respiratory Tract Infections (RTIs)
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
©Pathway Health Services, Inc. - All Rights Reserved - Copy with Permission Only Rehospitalization Reduction Toolkit 2012 Page 3 of 3