ABCs Neonatal Infection Expanded Tracking

NEONATAL INFECTION EXPANDED TRACKING FORM
Infant’s Name: _____________________________________________

Infant’s Chart No.: _____________________

Mother’s Name: _____________________________________________
(Last, First, M.I.)

Hospital Name: ______________________________­­­­­­­­­­_______________

Mother’s Chart No.: ____________________

(Last, First, M.I.)

Culture date: _________________________

-Patient identifier information is NOT transmitted to CDCACTIVE BACTERIAL CORE SURVEILLANCE (ABCs)
NEONATAL INFECTION EXPANDED TRACKING FORM
STATEID __ __ __ __ __ __ __

HOSPITAL ID (of birth; if home birth leave blank) __ __ __ __ __

Infant Information

Were labor & delivery records available?

Yes (1)

No (0)

2. Did this birth occur outside of the hospital?
Yes (1)
No (0)
Unknown (9)
IF
YES,
please
check
one:

Home Birth (1)
Unknown (1)
En route to hospital (3)
Other (4)

1. Date of Birth: __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

Time of birth: ___ ___ ___ ___

(times in military format)

Birthing Center (2)
Unknown (9)

4. Birth weight: ___ lbs ___oz OR __ __ __ __ grams

3. Gestational age of infant at birth in completed weeks:
__ __ (do not round up)

OMB No. 0920-0802

5. Date & time of newborn discharge from hospital of birth: __ __ /__ __ /__ __ __ __ ­­__ __ __ __
month

6. Outcome:

Survived (1)

Died (2)

day

year (4 digits)

Unknown (9)

7. Was the infant discharged to home and readmitted to the birth hospital? (for GBS cases only):
IF YES, date & time of readmission: __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

AND date & time admission: __ __ /__ __ /__ __ __ __
day

year (4 digits)

Yes (1)

__ __ __ __
Yes (1)

__ __ __ __

No (0)

Unknown (1)

time

8. Was the infant admitted to a different hospital from home? (for GBS cases only):
IF YES, hospital ID: ___ ___ ___ ___ ___
month

Unknown (1)

time

No (0)

Unknown (1)

time

9. Infant discharge diagnosis (for GBS cases only):

ICD9-1 ­­­­­­­­­__ __ __.__ __
ICD9-2 __ __ __.__ __

ICD9-3 __ __ __.__ __

10. Did the baby receive breast milk from the mother? (for late-onset GBS cases only):
IF YES, did the baby receive breast milk before onset of GBS
infection (e.g., date of first positive neonatal culture):

Yes (1)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

Maternal Information
  11. Maternal admission date & time: __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

12. Maternal age at delivery (years): __ __ years

__ __ __ __
time

13. Maternal blood type:

  14. Did mother have a prior history of penicillin allergy?
IF YES, was a previous maternal history of anaphylaxis noted?
  15. Date & time membrane rupture: __ __ /__ __ /__ __ __ __

month

day

Unknown (1)

year (4 digits)

A (1)

B (2)

Yes (1)

No (0)

Yes (1)

No (0)

__ __ __ __

AB (3)

O (4)

Unknown (1)

time

 16. Was duration of membrane rupture >18 hours?

Yes (1)

No (0)

Unknown (9)

 17. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?

Yes (1)

No (0)

Unknown (9)

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, CDC/ATSDR
Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0802). Do not send the completed form to this address.
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18. Type of rupture:

Spontaneous (1)

Artificial (2)

19. Type of delivery: (Check all that apply)
Vaginal (1)

Vaginal after previous C-section (1)

Primary C-section (1)

Forceps (1)

Vacuum (1)

Unknown (1)

Repeat C-section (1)

If delivery was by C-section: Did labor or contractions begin before C-section?

Yes (1)

No (0)

Unknown (9)

Did membrane rupture happen before C-section?

Yes (1)

No (0)

Unknown (9)

20. Intrapartum fever (T > 100.4 F or 38.0 C):

Yes (1)

No (0)

Unknown (1)

IF YES, 1st recorded T > 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month

day

year (4 digits)

Yes (1)

No (0)

__ __ __ __

21.

Were antibiotics given to the mother intrapartum?

IF YES, answer a-b and Questions 22-23
a) Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __

b) Antibiotic 1: ___________________________

Start date: __ __ /__ __ /__ __ __ __

month

Start date: __ __ /__ __ /__ __ __ __

time

Unknown (9)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 6: ___________________________
Start date: __ __ /__ __ /__ __ __ __

__ __ __ __

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 5: ___________________________
Start date: __ __ /__ __ /__ __ __ __

IM (2)

year (4 digits)

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 4: ___________________________
Start date: __ __ /__ __ /__ __ __ __

day

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 3: ___________________________
Start date: __ __ /__ __ /__ __ __ __

Unknown (9)

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 2: ___________________________

IV (1)

Unknown (1)

time

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

Stop date (if applicable): __ __ /__ __ /__ __ __ __

22. Interval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)

___ ___ (minutes)

23. What was the reason for administration of intrapartum antibiotics? (Check all that apply)

GBS prophylaxis (1)

C-section prophylaxis (1)

Mitral valve prolapse prophylaxis (1)

Suspected amnionitis (1)

Other (1)

Unknown (1)

***Questions 24–32 should only be completed for early- and late-onset GBS cases***
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24. Did mother receive prenatal care?

Yes (1)

No (0)

Unknown (9)

25. Was prenatal record (even partial information) in labor and delivery chart?

Yes (1)

No (0)

Unknown (9)

IF YES: No. of visits: __ __ First visit: __ __ /__ __ /__ __ __ __ Last visit: __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

month

day

year (4 digits)

26. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
27. GBS
bacteriuria during this pregnancy?
Yes (1)
No (0)

IF YES, what order of magnitude was the colony count?
0 (1)
<10,000 (2)
10k–<25,000 (3)
25k–<50,000 (4)
50k–<75,000 (5)
>100,0000 (7)
Unknown (9)
28. Previous infant with invasive GBS disease?

Yes (1)

No (0)

29. Previous pregnancy with GBS colonization?

Yes (1)

No (0)

75k–<100,000 (6)

30a. Was maternal group B strep colonization screened for BEFORE admission (in prenatal care)?
Yes (1)
No (0)
Unknown (9)
IF YES, list dates, test type, and test results below:
Test date (list most recent first):
1. __ __ /__ __ /__ __ __ __

2. __ __ /__ __ /__ __ __ __

Test type:
Culture (1)

Rapid PCR (2)

Other (4)

Unknown (9)

Culture (1)

Rapid PCR (2)

Other (4)

Unknown (9)

Positive culture
(Do not include urine here!)

Rapid antigen (3)

Yes (1)

No (0)

Unknown (9)

Rapid antigen (3)

Yes (1)

No (0)

Unknown (9)

30b. If the most recent test was GBS positive was antimicrobial susceptibility performed BEFORE admission (in prenatal care)?
Yes (1)

No (0)

Unknown (9)

IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?

Yes (1)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

31a. Was maternal group B strep colonization screened for AFTER admission (before delivery)?

Yes (1)

No (0)

Unknown (9)

IF YES, list date of most recent test, test type and test results below:

Test date (list most recent first):
__ __ /__ __ /__ __ __ __

Test type:
Culture (1)

Rapid PCR (2)

Other (4)

Unknown (9)

Rapid antigen (3)

Positive culture
(Do not include urine here!)
Yes (1)

No (0)

Unknown (9)

31b. If the most recent test was GBS positive, was antimicrobial susceptibility performed AFTER admission?
Yes (1)

No (0)

Unknown (9)

IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?
32.

Yes (1)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

Were GBS test results available to care givers at the time of delivery?

Yes (1)

No (0)

Unknown (9)

COMMENTS: ________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

12/2009

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