National Disease Surveillance Program - 1_ABC's Invasive MRSA Change Request

PATIENT ID: ____ ____ ____ ____ ____ ____ ____ ____

Invasive Methicillin-resistant Staphylococcus aureus

Active Bacterial Core Surveillance (ABCs) Case Report

Patient Name:___________________________________________________________________ Phone: ( ) _____________-_____________

^{(Last, First, M.I.)}

Address: _______________________________________________________________________ Chart number:_____________________________________

^{(Number, Street, Apt#)}

_______________________________________________ ___________ ___________ Hospital: _________________________________________

^{(City) (State) (Zip)}

^{- Patient Identifier Information Is Not Transmitted to CDC - -SHADED AREAS FOR OFFICE USE ONLY-}

1. STATE:

(Residence of patient)

2. COUNTY:

(Residence of Patient)

________________________

3. STATE I.D.:

4a. HOSPITAL/LAB WHERE CULTURE IDENTIFIED:

4b. HOSPITAL ID WHERE PATIENT TREATED:

5. DATE OF BIRTH:

Mo Day Year

6a. AGE:

6b. Is age in

day/mo/yr?

1 Days

2 Mos.

3 Yrs.

7a. SEX:

1 Male

2 Female

7b. ETHNIC ORIGIN:

1 Hispanic or Latino

2 Not Hispanic or Latino

9 Unknown

7c. RACE: (Check ALL that apply)

1 American Indian or Alaska Native

1 Asian

1 Black or African American

1 Native Hawaiian or Other Pacific Islander

1 White

1 Unknown

7d. WEIGHT: ________lb ________oz OR ________ kg Unk

7e. HEIGHT: ________ft ________ in OR ________cm Unk

7f. TYPE OF INSURANCE: (Check ALL that apply)

1 Medicare

1 Military/VA

1 Medicaid/state assistance program

1 No health coverage

1 Unknown

1 Indian Health Service (HIS)

1 Private/HMO/PPO/managed care plan

1 Other: (specify)__________________________________

8. WAS PATIENT HOSPITALIZED?

1 Yes 2 No 9 Unknown

If YES: Date of Admission

^{Mo Day Year}

Date of Discharge

^{Mo Day Year}

10. LOCATION OF CULTURE COLLECTION: (Check ONE)

9. WAS AN INFECTION RELATED TO THE INITIAL CULTURE INCLUDED IN THE ADMISSION DIAGNOSIS? (Was MRSA infection the reason for hospital admission?)

1 Yes

2 No

9 Unknown

0 Hospital Inpatient

3 Emergency Room

4 Outpatient

5 Long Term Care

Facility

9 Unknown

10 Other (specify)

__________________

12. DATE OF INITIAL CULTURE: ^{Mo Day Year}

11. PATIENT OUTCOME: 9 UNKNOWN

1 SURVIVED Mo Day Year

2 DIED

Was MRSA contributory or causal? 1 Yes 2 No

9 Unknown

Date of Death:

13. STERILE SITE(S) FROM WHICH MRSA WAS INITIALLY ISOLATED: (Check ALL that apply)

1 Blood

1 CSF

1 Pleural fluid

1 Peritoneal fluid

1 Pericardial fluid

1 Joint/Synovial fluid

1 Bone

1 Internal body site (specify)

_______­­­­­­­­­­­­­­­­­__________________

1 Other sterile site (specify)

_________________________

14. Were cultures of the SAME sterile site(s) positive between 7 and 30 days after initial culture?

1 Yes 2 No 9 Unknown

15. Were cultures of OTHER sterile site(s) positive within

30 days of initial culture?

1 Yes 2 No 9 Unknown

If YES, list site(s):

16. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S):

(Check ALL that apply) 1 NONE 1 UNKNOWN

15. Were cultures of OTHER sterile site(s) positive within 30 days of initial culture?

1 Yes 2 No 9 Unknown

If YES, list site(s):

1 Bacteremia

1 Empyema

1 Meningitis

1 Peritonitis

1 Pneumonia

1 Osteomyelitis

1 Urinary Tract

1 Endocarditis

1 Surgical Incision

1 Surgical Incision

1 Pressure Ulcer

1 Skin Abscess

1 Abscess (not skin)

1 Surgical site (internal)

1 Septic Arthritis

1 Bursitis

1 Septic Shock

1 Cellulitis

1 Traumatic Wound

1 Pressure Ulcer

1 Other: (specify)

________________

________________

________________

1 Blood

1 CSF

1 Pleural fluid

1 Peritoneal fluid

1 Pericardial fluid

1 Joint/Synovial fluid

1 Bone

1 Internal body site (specify)

_____________________

­­

1 Other sterile site (specify)

­­­­­­­­­­­­­­­­­­­

_____________________

1 Blood

1 CSF

1 Pleural fluid

1 Peritoneal fluid

1 Pericardial fluid

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0009). Rev 12-2006

17. UNDERLYING CONDITIONS: (Check ALL that apply) (If none or no chart available, check appropriate box) 1 NONE 1 UNKNOWN

1 Current Smoker

1 Alcohol Abuse

1 IVDU

1 Other Drug Use

1 HIV

1 AIDS or CD4 count<200

1 Solid Organ Malignancy

1 Hematologic Malignancy

1 Peripheral Vascular Disease

(PVD)

1 Heart Failure/CHF

1 Atherosclerotic Cardiovascular

Disease (ASCVD)/CAD

1 CVA/Stroke (Not TIA)

1 Emphysema/COPD

1 Asthma

1 Systemic Lupus

Erythematosus

1 Sickle Cell Anemia

1 Diabetes

1 Chronic Renal Insufficiency

1 Chronic Liver Disease

1 Rheumatoid Arthritis

1 Obesity

1 Immunosuppressive 1 Influenza (within 10

Therapy days of initial culture)

1 Decubitus Ulcer 1 Abscess/Boil

1 Eczema 1 Psoriasis

1 Other Dermatological Condition(s): (specify)

_______________________________________

1 Other condition(s): (specify)

_______________________________________

18. CLASSIFICATION – Healthcare-associated and Community-associated: (Check ALL that apply) 1 NONE 1 UNKNOWN

1 Previous documented MRSA infection or colonization 1 Surgery within year before index

If YES: ^{Month Year} OR previous STATEID: culture date.

1 Dialysis within year before index

1 Culture collected > 48 hours after hospital admission. Culture date.

1 Hospitalized within year before index culture date. (Hemodialysis or Peritoneal dialysis)

1 Residence in a long-term care facility

within year before index culture date

1 Central vascular catheter in place at

time of admission/evaluation

19. SUSCEPTIBILITY RESULTS: [S=Sensitive (1), I=Intermediate (2), R=Resistant (3), U=Unknown/Not Reported (9)]

Ciprofloxacin:

Clindamycin:

Daptomycin:

Doxycycline:

Erythromycin:

Gatifloxacin:

Gentamicin:

Levofloxacin:

Linezolid:

Oxacillin:

Penicillin:

Quinupristin/Dalfopristin:

Rifampin:

Tetracycline:

Trimethoprim-sulfamethoxazole:

Vancomycin:

Other:

___________________________________

Cefazolin:

Chloramphenicol:

Moxifloxacin:

Nafcillin:

Ampicillin:

Imipenem:

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

S I R U

-

20. Was case first identified through audit?

1 Yes

2 No

9 Unknown

21. CRF status:

1 Complete

2 Incomplete

3 Edited & Corrected

4 Chart unavailable

after 3 requests

22. Does this case If YES, previous

have recurrent (1^st) STATEID:

MRSA disease?

1 Yes

2 No

9 Unknown

23. DATE REPORTED TO EIP SITE:

Mo Day Year

24. Initials of S.O.:

_________

25. COMMENTS: _________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________

SURVEILLANCE OFFICE USE ONLY -