2008 Invasive MRSA Active Bacterial Core Surveillance Case Report Form

Patient ID: _____ _____ _____ _____ _____ _____ _____ _____
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Phone No.: (

Patient's Name:

(Last, First, M.I.)

Address:

)

Patient
Chart No.:

(Number, Street, Apt. No.)

Hospital:

(Zip Code)

(City, State)

– Patient identifier information is NOT transmitted to CDC –

INVASIVE METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS
ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) CASE REPORT

DEPARTMENT OF
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333

1. STATE:
(Residence of
patient)

– SHADED AREAS FOR OFFICE USE ONLY –

2. COUNTY:
(Residence of Patient)

3. STATE I.D.:

5. Where was the patient a resident prior to admission at time of first
positive culture?

6. DATE OF BIRTH:
Mo.

1

Private Residence

1

Incarcerated

1

Long Term Care Facility

1

Transferred from hospital/acute care facility

1

Homeless

1

Other __________________________

8a. SEX:

1

8b. ETHNIC ORIGIN:

1

Male

2

Female

Form Approved OMB No. 0920-0802

Unk

7a. AGE:

Day

1

Hispanic or Latino

2

Not Hispanic or Latino

1

9

Unk

1

7b. Is age in day/mo/yr?

Year

1

8c. RACE: (Check all that apply)
1

4b. HOSPITAL I.D. WHERE
PATIENT TREATED

4a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:

Days 2

Mos. 3

Yrs.

8d. WEIGHT:

Unk

_______ lbs _______ oz OR _______ kg

White

1

Asian

Black or
African American
American Indian
or Alaska Native

1

Native Hawaiian
or Other Pacific Islander

1

Unk

8e. HEIGHT:

Unk

_______ ft _______ in OR _______ cm

8f. TYPE OF INSURANCE: (Check all that apply)
1

Medicare

1

Medicaid/state assistance program

1

Private/HMO/PPO/managed care

1

No health coverage

1

Military/VA

1

Indian Health Service (HIS)

1

Other: (specify) __________________________

1

Unk

9. WAS PATIENT HOSPITALIZED?
1

Yes

2

No

9

Unk

If YES: Date of admission
Mo.

Day

Year

1
Date of discharge
Mo.

Day

11a. LOCATION OF CULTURE COLLECTION: (Check one)

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

Year

Survived

Died

2

No

9

Unk

3

Emergency Room

9

Unk

4

Outpatient

10

Other: (specify)

11b. DATE OF INITIAL CULTURE:
Mo.

Day

Yes 2

No

Year

Date of Death:
Yes

2

Day

Year

No

9

Unk

1

Pregnant

2

Post-partum

3

Neither

9

Unk

13b. If pregnant or post-partun, what was the
outcome of the fetus:
Abortion/
4
Survived,
stillbirth
1
no apparent illness
2

Survived,
clinical infection

5

Induced
abortion

3

Live birth/neonatal
death

9

Unk

Unk

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

1

Long Term Care Facility

___________________________________

If survived, was the patient transferred to a LTCF? 1

Was MRSA contributory or causal? 1
9

5

13a. At time of first positive
culture, patient was:
Mo.

2

Hospital Inpatient

Yes

12. PATIENT OUTCOME:
1

0

Blood

1

Joint/Synovial fluid

1

CSF

1

Bone

1

Pleural fluid

1

Internal body site (specify)

1

Peritoneal fluid

1

Pericardial fluid

_____________________________
1

Other sterile site (specify)
_____________________________

15. Were cultures of the SAME
sterile site(s) positive between
7 and 30 days after initial culture?
1

Yes

2

No 9

Unk

16. Were cultures of OTHER sterile site(s) positive
within 30 days of initial culture?
1

Yes

2

No 9

Unk

If Yes, list site(s):
1

Blood

1

Joint/Synovial fluid

1

CSF

1

Bone

1

Pleural fluid

1

Internal body site (specify)

1

Peritoneal fluid

1

Pericardial fluid

_______________________
1

Other sterile site (specify)
_______________________

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 (0920-0802).
CDC 52.15B Rev. 1-2008

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

Page 1 of 2

17. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply)

1

None

1

Unk

1

Bacteremia

1

Osteomyelitis

1

Surgical Site (internal)

1

Traumatic Wound

1

Empyema

1

Urinary Tract

1

Septic Arthritis

1

Surgical Incision

1

Meningitis

1

Endocarditis

1

Bursitis

1

Pressure Ulcer

1

Peritonitis

1

Skin Abscess

1

Septic Shock

1

Septic Emboli

1

Pneumonia (If checked, go
to question 21)

1

Abscess (not skin)

1

Cellulitis

1

Other: (specify)

___________________________________
___________________________________

18. UNDERLYING CONDITIONS: (Check all that apply) (if none or no chart available, check appropriate box)

1

None

1

Unk

1

Current Smoker

1

Peripheral Vascular Disease (PVD)

1

Sickle Cell Anemia

1

Decubitus Ulcer

1

Alcohol Abuse

1

Heart Failure/CHF

1

Diabetes

1

Eczema

1

IVDU

1

Atherosclerotic Cardiovascular

1

Chronic Renal Insufficiency

1

Influenza (within 10

1

Other Drug Use

Disease (ASCVD)/CAD

1

Chronic Liver Disease

1

HIV

1

CVA/Stroke (Not TIA)

1

Rheumatoid Arthritis

1

1

AIDS or CD4 count<200

1

Emphysema/COPD

1

Obesity

_________________________________________

1

Solid Organ Malignancy

1

Asthma

1

Premature Birth

1

1

Hematologic Malignancy

1

Systemic Lupus Erythematosus

1

Immunosuppressive Therapy

_________________________________________

19. CLASSIFICATION – Healthcare-associated and Community-associated: (Check all that apply)
1

1

1

Abscess/Boil

1

Psoriasis

days of initial culture)

None

Other Dermatological Condition(s): (specify)

Other condition(s): (specify)

1

Unk

Previous documented MRSA infection or colonization
Month
Year
OR previous STATE I.D.:

1

Surgery within year before index culture date.

1

Residence in a long-term care facility
within year before index culture date.

If YES:

1

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

1

Central vascular catheter in place at
time of admission/evaluation.

1

Culture collected >48 hours after hospital admission.

1

Hospitalized within year before index culture date.
Month

Year

1

If YES:

Unk

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

S

I

R

U

Oxacillin:

S

I

R

U

Cefazolin:

S

I

R

U

Clindamycin:

S

I

R

U

Penicillin:

S

I

R

U

Chloramphenicol:

S

I

R

U

Daptomycin:

S

I

R

U

Quinupristin/Dalfopristin:

S

I

R

U

Moxifloxacin:

S

I

R

U

Doxycycline:

S

I

R

U

Rifampin:

S

I

R

U

Nafcillin:

S

I

R

U

Erythromycin:

S

I

R

U

Tetracycline:

S

I

R

U

Ampicillin:

S

I

R

U

Gatifloxacin:

S

I

R

U

Trimethoprim-sulfamethoxazole:

S

I

R

U

Imipenem:

S

I

R

U

Gentamicin:

S

I

R

U

Vancomycin:

S

I

R

U

Levofloxacin:

S

I

R

U

Other:

S

I

R

U

Linezolid:

S

I

R

U

__________________________

21. SUPPLEMENTAL PNEUMONIA QUESTIONS. Please complete if the patient was determined to have pneumonia per question 17.
a. Are any of the following listed in the discharge summary narrative?

c. Chest Radiograph Results (Check all that apply) 1

1

MRSA pneumonia

1

Staphylococcal pneumonia

1

Pneumonia

1

No pneumonia specified

1

Aspiration pneumonia

b. Discharge diagnosis (Check all that apply) 1
1

482.40

1

482.41

1

482.49

N/A
1

1

V09.0

Unk
1

None listed

1
1
1
1
1
d. 1

Bronchopneumonia/pneumonia
Air space density/opacity
Cavitation
Cannot rule out pneumonia
New or changed infiltrates

1
1
1
1

Not done

Pleural effusion
Consolidation
Not available
Other: (specify)
______________________

MRSA positive non-sterile respiratory specimens

– SURVEILLANCE OFFICE USE ONLY –
22. Was case first
identified through
audit?
1

Yes

9

Unk

2

No

23. CRF status:
1
2
3
4

Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests

24. Does this case have
recurrent MRSA
disease?
1

Yes

9

Unk

2

No

If YES, previous
(1st) STATE I.D.:

25. Date reported to EIP site:
Mo.

Day

26. Initials of
S.O:

Year

27. COMMENTS:_____________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
CDC 52.15B Rev. 1-2008

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