Invasive Methicillin-Resistant Stafhylococcus Aureus Act

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 at time of initial 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:

8b. ETHNIC ORIGIN:
1

1

Male

2

Female

9

7a. AGE:

Day

1

White

Not Hispanic or Latino

1

Unknown

1

Black or
African American
American Indian
or Alaska Native

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

Year

1

8c. RACE: (Check all that apply)

Hispanic or Latino

2

Unknown

1

4b. HOSPITAL I.D. WHERE
PATIENT TREATED

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

Days 2

Mos. 3

Yrs.

8d. WEIGHT:
_______ lbs _______ oz OR _______ kg Unknown

1

Asian

1

Native Hawaiian
or Other Pacific Islander

1

Unknown

8e. HEIGHT:
_______ ft _______ in OR _______ cm

Unknown

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 (IHS)

1

Other: (specify) __________________________

1

Unknown

9. WAS PATIENT HOSPITALIZED?
1

Yes

2

No

9

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

Unknown

If YES: Date of admission
Mo.

Day

Year

1
Date of discharge
Mo.

Day

12. PATIENT OUTCOME:

Year

1

Survived 2

Day

No
Unknown

9

1

Yes 2

No

Year

Yes

2

No

9

Unknown

Was the culture obtained on autopsy?1

Yes

2

No

9

Unknown

1

Joint/Synovial fluid

1

CSF

1

Bone

1

Pleural fluid

1

Internal body site (specify)

1

Peritoneal fluid

1

Pericardial fluid

_____________________________
1

3

Emergency Room

9

Unknown

4

Outpatient

10

Other sterile site (specify)
_____________________________

Day

Other: (specify)

Year

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

Unknown

1

Blood

Long Term Care Facility

Mo.

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

1

5

11b. DATE OF INITIAL CULTURE:

If Died,
Date of Death:
Was MRSA contributory or causal?

Hospital Inpatient

___________________________________

2

If survived, was the patient transferred to a LTCF?
Mo.

0

Yes

9

Died

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

1

Pregnant

2

Post-partum

3

Neither

9

Unknown

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

Yes

2

No 9

Unknown

13b. If pregnant or post-partum, 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

Unknown

16. 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

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)
_______________________

CDC 52.15B Rev. 1-2012

– 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

Unknown

1

Bacteremia

1

Osteomyelitis

1

Surgical Site (internal)

1

Traumatic Wound

1

Empyema

1

Urinary Tract

1

Catheter Site Infection

1

Surgical Incision

1

Meningitis

1

Endocarditis

1

AV Fistula / Graft Infection

1

Pressure Ulcer

1

Peritonitis

1

Skin Abscess

1

Septic Arthritis

1

Septic Emboli

1

Pneumonia (If checked, go
to question 21)

1

Abscess (not skin)

1

Bursitis

1

Other: (specify)

1

Septic Shock

___________________________________

1

Cellulitis

___________________________________

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

1

1

AIDS or CD4 count<200

1

1

1

Alcohol Abuse

1

Asthma

1

Atherosclerotic Cardiovascular Disease
(ASCVD)/CAD

1

Chronic Liver Disease

1

1

1
1

1

Chronic Renal Insufficiency

1

Chronic Skin Breakdown

1
1
1

Current Smoker

1

Hemaplegea/Pareplegia

Peripheral Vascular Disease (PVD)

1

Premature Birth

1

1

Influenza (within 10 days of initial culture)

1

Sickle Cell Anemia

Dementia

1

IVDU

1

Solid Organ Malignancy

Diabetes

1

Metastatic Solid Tumor

1

Decubitus Ulcer

Rheumatoid Arthritis

Systemic Lupus Erythematosus
Other condition(s): (specify)

Obesity

Emphysema/COPD

1

Heart Failure/CHF

1

Other Drug Use

1
_________________________________________

Hematologic Malignancy

1

Peptic Ulcer Disease

_________________________________________

1

Culture collected ≥ 3 calendar days after hospital admission.

1

Hospitalized within year before initial culture date.

1

None

1

1

Surgery within year before initial culture date.

1

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

1

Year

1

Unknown

1

1

If YES:

If YES:

1

Immunosuppressive Therapy

1

Cystic Fibrosis

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

Month

None

HIV

CVA/Stroke (Not TIA)

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

1

Unknown

Unknown
Residence in a long-term care facility
1
within year before initial culture date.
Central vascular catheter in place at
any time in the 2 calendar days prior
to initial culture.

1

Current chronic dialysis
Type
Peritoneal
Hemodialysis
Type of vascular access
AV fistula / graft
Hemodialysis CVC
Unknown

20. SUSCEPTIBILITY RESULTS: [S=Sensitive (1), I = Intermediate (2), R = Resistant (3), NS = Non-susceptible (4), U = Unknown/Not reported (9)]
Ampicillin:

S

I

R

U

Gentamicin:

S

I

R

U

Quinupristin/Dalfopristin:

S

I

R

U

Cefazolin:

S

I

R

U

Imipenem:

S

I

R

U

Rifampin:

S

I

R

U

Chloramphenicol:

S

I

R

U

Levofloxacin:

S

I

R

U

Tetracycline:

S

I

R

U

Ciprofloxacin:

S

I

R

U

S

NS

Trimethoprim-sulfamethoxazole:

S

I

R

U

Clindamycin:

S

I

R

U

S

I

R

U

Vancomycin:

Daptomycin:

S

NS

Linezolid:
Moxifloxacin:
Nafcillin:

S

I

R

U

Other:

S
S

I
I

R
R

U
U

Doxycycline:

S

I

R

U

Oxacillin:

S

I

R

U

Penicillin:

S
S

I
I

R
R

U
U

__________________________

Erythromycin:
Gatifloxacin:

S

I

R

U

U

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 Radiology Results (Check all that apply)
CT
X-Ray
Type

1

MRSA pneumonia

1

Staphylococcal pneumonia

1

Pneumonia

1

Aspiration pneumonia

1
1

Hemorrhagic pneumonia
Necrotizing pneumonia

1

No pneumonia specified

b. Discharge diagnosis (Check all that apply) 1

N/A

1

1

482.40

1

482.42

1

V09.0

1

482.41

1

482.49

1

None of these listed

Unknown

1
1
1
1
1
1
d. 1

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

1
1
1
1
1

1

Not done

Consolidation
No evidence of pneumonia
None listed
Not available
Other: (specify)
______________________

MRSA positive non-sterile respiratory specimens

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

Yes

2

9

Unknown

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

2

9

Unknown

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. 1-2012

Page 2 of 2