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– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Patient’s Name:
Phone No.: (
)
Patient
Chart No.:
(Last, First, MI.)
Address:
(Number, Street, Apt. No.)
(City, State)
(Zip Code)
Hospital:
– Patient identifier information is not transmitted to CDC –
Active Bacterial Core
Surveillance (ABCs) CASE REPORT
DEPARTMENT OF
HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
A CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
– SHADED AREAS FOR OFFICE USE ONLY –
2. COUNTY:
(Residence of Patient)
1. STATE:
(Residence
of Patient)
5. WAS PATIENT
HOSPITALIZED?
If YES, date of admission:
Mo.
1
Yes
2
3. STATE I.D.:
Day
Date of discharge:
Mo.
Year
Yes 2
No
4b. HOSPITAL I.D. WHERE
PATIENT TREATED:
6a. Was patient transferred
from another hospital?
6b. If YES, hospital I.D.
Year
1
No
7a. Was patient a resident of a nursing home or other
chronic care facility at the time of first positive culture?
1
Day
4a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:
9
Yes 2
Mo.
9
Unknown
9a. AGE:
8. DATE OF BIRTH:
Unknown
No
Day
9b. Is age in day/mo/yr?
Year
1
7b. If YES, name
10. SEX:
11b. RACE: (Check all that apply)
11a. ETHNIC ORIGIN:
1
Male
2
Female
1
Hispanic or Latino
2
Not Hispanic or Latino
9
Unknown
1
White
1
Black
1
1
American Indian 1
or Alaska Native
1
______lbs ________ oz OR ________ kg OR
Native Hawaiian
or Other Pacific Islander
Unknown
Indian Health Service (IHS)
1
No health care coverage
1
Military/VA
Private/HMO/PPO/managed care plan
1
Unknown
1
Medicaid/state assistance program
1
Other (specify) _____________________________________________
3
Neither
2
Postpartum
9
Unknown
15b. If postpartum, what was the outcome of fetus:
1
Survived, no apparent illness
4
Abortion/stillbirth
2
Survived, clinical infection
5
Induced abortion
3
Live birth/neonatal death
9
Unknown
17. TYPES OF INFECTION CAUSED BY ORGANISM: (Check all that apply)
1
1
Bacteremia
without Focus
1
Peritonitis
1
Endometritis
1
Pericarditis
1
STSS
1
Otitis media
1
Septic abortion
1
Necrotizing fasciitis
1
Pneumonia
1
Chorioamnionitis
1
Puerperal sepsis
1
Cellulitis
1
Septic arthritis
1
Septic shock
1
Epiglottitis
1
Osteomyelitis
1
Other (specify)
1
Hemolytic uremic
syndrome (HUS)
1
Empyema
1
Abscess (not skin) 1
1
Unknown
Meningitis
Endocarditis
19. STERILE SITES FROM WHICH ORGANISM ISOLATED: (Check all that apply)
1
Blood
1
Peritoneal fluid
1
1
CSF
1
Pericardial fluid
1
1
Unknown
14. OUTCOME:
1
Pregnant
Unknown
______ft ________ in OR _________ cm OR
1
1
Yrs.
12b. HEIGHT:
Medicare
15a. At time of first positive culture,
patient was:
Mos. 3
12a. WEIGHT:
Asian
13. TYPE OF INSURANCE: (Check all that apply)
1
Days 2
Bone
Muscle
Survived
2
Died
9
Unknown
16. If patient <1 month of age, indicate gestational age and birth
weight. If pregnant, indicate gestational age of fetus, only.
Gestational
age:
Birth weight:
(wks)
(gms)
18a. BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
1
Neisseria meningitidis
4
Listeria monocytogenes
2
Haemophilus influenzae
5
Group A Streptococcus
3
Group B Streptococcus
6
Streptococcus pneumoniae
18b. OTHER BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY
STERILE SITE: (specify)
20. DATE FIRST POSITIVE
CULTURE OBTAINED:
(Date Specimen Collected)
Mo.
Joint
1
Day
Year
21. OTHER SITES FROM WHICH ORGANISM
ISOLATED: (Check all that apply)
1
Placenta
1
Middle ear
1
Amniotic fluid
1
Sinus
1
Pleural fluid
1
Internal body site (specify)____________________________________________
1
Wound
1
Other normally sterile site (specify)_____________________________________
1
Other (specify) _________________
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Page 1 of 2
22. IF PATIENT DIED, WAS THE CULTURE OBTAINED ON AUTOPSY?
1
Yes 2
No
9
Unknown
23. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply) (if none or chart unavailable, check appropriate box) 1
None
1
Unknown
1
Current Smoker
1
Asthma
1
Alcohol Abuse
1
Cochlear Implant
1
Multiple Myeloma
1
Emphysema/COPD
1
Atherosclerotic Cardiovascular
1
Deaf/Profound Hearing Loss
1
Sickle Cell Anemia
1
Solid Organ Malignancy
Splenectomy/Asplenia
Systemic Lupus
Erythematosus (SLE)
Disease (ASCVD)/CAD
1
1
1
Solid Organ Transplant
Immunoglobulin Deficiency
Diabetes Mellitus
Heart Failure/CHF
1
1
1
1
Nephrotic Syndrome
1
Obesity
Renal Failure/Dialysis
CSF Leak
Premature Birth (specify gestational age
at birth)
(wks)
1
1
1
1
IVDU
1
Chronic Skin Breakdown
HIV Infection
1
Cerebral Vascular Accident (CVA)/Stroke
1
Other Prior Illness (specify)
1
Complement Deficiency
1
Immunosuppressive Therapy
(Steroids, Chemotherapy, Radiation)
1
Leukemia
1
1
Hodgkin’s Disease/Lymphoma
1
AIDS or CD4 count <200
1
Bone Marrow Transplant (BMT)
1
Cirrhosis/Liver Failure
– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISMS:
HAEMOPHILUS
INFLUENZAE
24a. If <15 years of age and serotype ‘b’ or ‘unknown’ did 1 Yes 2
No 9
Unknown
patient receive Haemophilus influenzae b vaccine?
If YES, please complete the list below.
DATE GIVEN
LOT NUMBER
VACCINE NAME
MANUFACTURER
DOSE
Mo.
Day
24b. Were records obtained to verify
vaccination history? (<5 years of age only)
1
Year
1
Yes
2
No
If YES, what was the source of the
information? (Check all that apply)
2
3
4
1
Vaccine Registry
1
Healthcare Provider
1
Other (specify)
24c. What was the serotype?
1
b
2
Not Typeable
NEISSERIA MENINGITIDIS
3
a
4
c
5
d
6
e
7
f
8
Other (specify)
9
1
A
3
C
5
W135
9
Unknown
2
B
4
Y
6
Not groupable
8
Other (specify)
27. Did patient receive meningococcal vaccine?
1
Yes 2
No
9
Unknown
Yes 2
No
9
Day
Unknown
LOT NUMBER
DATE GIVEN
List most recent date for each vaccine
VACCINE NAME/MANUFACTURER
Mo.
1
Not Tested or Unknown
26. Is patient currently attending college?
(15 – 24 years only)
25. What was the serogroup?
Year
Menomune, tetravalent meningococcal polysaccharide vaccine
If YES, please complete the following information:
Menactra, tetravalent meningococcal conjugate vaccine
Other (specify)
Not Known
STREPTOCOCCUS PNEUMONIAE
28. If <15 years of age, did patient receive pneumococcal conjugate vaccine?
1
Yes 2
No
9
GROUP A STREPTOCOCCUS
(#29–31 refer to the 7 days
prior to first positive culture)
30. Did the patient deliver a baby
(vaginal or C-section)?
29. Did the patient have surgery? 1
Yes 2
1
Mo.
No
Day
9
Unknown
Yes 2
No
9
Mo.
Year
If YES and between 3 and 59 months of age, please
complete the Invasive Pneumococcal Disease
in Children expanded form.
Unknown
31. Did patient have:
Unknown
Day
Year
If YES,
date of delivery:
If YES,
date of surgery:
1
Varicella
1
Penetrating trauma
1
Blunt trauma
1
Surgical wound
(post operative)
1
Burns
32. COMMENTS:
– SURVEILLANCE OFFICE USE ONLY –
33. Was case first
identified through
audit?
1
Yes 2
9
Unknown
No
34. CRF Status:
1
2
3
4
Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests
35. Does this case have
recurrent disease with
the same pathogen?
1
Yes 2
9
Unknown
36. Date reported to EIP site
If YES, previous
(1st) state I.D.
Mo.
No
Submitted By:
Phone No. : (
)
Physician’s Name:
Phone No. : (
)
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Day
37. Initials of
S.O.
Year
Date:
/
/
Page 2 of 2
| File Type | application/pdf |
| File Modified | 2009-02-02 |
| File Created | 2009-02-02 |