OMB No. 0920-0666

NHSN           Antimicrobial Use and Resistance (AUR)         *                            *

PhariTiaCy Data – Monthly Report Form Assi PUT Publ and this CDC Facility ID:                                 *Location Code:                     *Month:                       *Year:                        *Patient Days: Parenteral Antibiotics Antibiotic “Quantity Used^f Antibiotic “Quantity Used^f amikacin

g

g

ampicillin

g

g

ampicillin**/sulbactam

g

g

azithromycin

g

g

aztreonam

g

g

cefamandole

g

g

cefazolin

g

g

cefepime

g

g

cefmetazole

g

g

cefotaxime

g

g

cefotetan

g

g

cefoxitin

g

mill. I.U.

ceftazidime

g

mill. I.U.

ceftizoxime

g

mill. I.U.

ceftriaxone

g

g

cefuroxime

g

g

cephalothin

g

g

ciprofloxacin

g

g

clindamycin

g

g

daptomycin

g

g

ertapenem

g

g

erythromycin

g

g

vancomvcin

a

Oral Antibiotics Antibiotic “Quantity Used^f Antibiotic “Quantity Used^f amoxicillin

g

g

amoxicillin**/clavulanic acid

g

g

ampicillin

g

g

azithromycin

g

g

cefaclor

g

g

cefadroxil

g

g

cefixime

g

g

cefprozil

g

g

cephalexin

g

g

ciprofloxacin

g

g

clarithromycin

g

g

clindamycin

g

g

dicloxacillin

g

g

doxycycline

g

g

Erythromycin

a

ranee of Confidentiality: The infonnation obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the jses stated, and will not otheni/ise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d». K reporting burden of this collection of infonnation is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing eviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding urden estimate or any other aspect of this collection of infonnation, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1 600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). 57.124 Rev. 1

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