Attachment C. ABCs MRSA. CRF

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 – 2012

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

– SHADED AREAS FOR OFFICE USE ONLY –

1. STATE:
2. COUNTY:
(Residence of patient)
(Residence of Patient)

3. STATE I.D.:

5. Where was the patient a resident prior to the date of initial culture? (See CRF Instructions)
1

Private Residence

1

Incarcerated

1

Long Term Care Facility

1

Hospital Inpatient

1

Long Term Acute Care Hospital

1

Other __________________________

1

Homeless

1

Unknown

8a. SEX:

8b. ETHNIC ORIGIN:
1

1

Male

2

Female

2
9

Yes

2

No

9

Not Hispanic or Latino

Native Hawaiian
or Other Pacific Islander

Unknown

1

1

Unknown

1

Year

16

Survived

2

Outpatient
8
Clinic/
ICU
Doctors Office
Surgery/OR
Surgery
11
Radiology
15
Dialysis/Renal Clinic
Other Unit
Other
4
Outpatient
Emergency Room

Hospital Inpatient

3

Day

Mo.

Day

No 9

Died

9

Unknown
1

Yes 2

No

Yes

2

No

9

1

Yes 2

No

Unknown

9
10

Autopsy

Unknown

Unknown

10b. DATE OF INITIAL CULTURE:

Unknown

Mo.

Other

Day

Year

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

1

Blood

1

Joint/Synovial fluid

1

CSF

1

Bone

Pleural fluid

1

Muscle

1

Internal body site (specify)

1

Pregnant

1

2

Post-partum

1

Peritoneal fluid

3

Neither

1

Pericardial fluid

9

Unknown

_____________________
1

Other sterile site (specify)
______________________

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

1

None

1

Unknown

Unknown

If yes, indicate site and date of last positive culture:
1

Blood, Date:________

1

Muscle, Date:______

1

CSF, Date:________

1

1

Pleural fluid, Date:________

Internal body site
Date:________

1

Peritoneal fluid, Date:________

1

Other sterile site
(specify)____________
Date:________

1

Pericardial fluid, Date:________

1

Joint/Synovial fluid, Date:________

1

Bone, Date:________

CDC 52.15B Rev. 1-2012

13
14

8f. BMI:
_______

LTCF
LTACH

12. At time of first positive
culture, patient was:

Year

14. Were cultures of the SAME or OTHER sterile site(s) positive
within 30 days after initial culture date?
1

5

Unknown

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

Observational Unit/Clinical Decision Unit

Was MRSA cultured from a normally sterile site, < calender day 7 before death?
Yes 2

_______ lbs _______ oz OR _______ kg

10a. LOCATION OF CULTURE COLLECTION: (Check one)

2

Yrs.

8d. WEIGHT:

1

Year

Mos. 3

7c. If case is ≤12 months of age, type of
birth hospitalization:
9
NICU/SCN
1
Unknown
Well Baby Nursery
2

Black or
African American
American Indian
or Alaska Native

7

Days 2

Year

1

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

1

Day

Asian

Unknown

If Died,
Date of Death:

Mo.

1

1
6

7b. Is age in day/mo/yr?
1

White

Day

11. PATIENT OUTCOME:

7a. AGE:

1

Date of discharge
Mo.

6. DATE OF BIRTH:

8c. RACE: (Check all that apply)

If YES: Date of admission
Mo.

4b. HOSPITAL I.D. WHERE PATIENT TREATED:

Hispanic or Latino

9. WAS PATIENT HOSPITALIZED AT THE TIME
OF, OR WITHIN 30 CALENDAR DAYS AFTER,
INITIAL CULTURE?
1

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

1

Abscess (not skin)

1

Empyema

1

1

AV Fistula/Graft Infection

1

Endocarditis

1

Skin Abscess

1

Bacteremia

1

Meninigitis

1

Surgical Incision

1

Bursitis

1

Peritonitis

1

Surgical Site (Internal)

Septic Shock

1

Catheter Site Infection

1

Pneumonia

1

Traumatic Wound

1

Cellulitis

1

Osteomyelitis

1

Urinary Tract

1

Chronic Ulcer/Wound (non-decubitus)

1

Septic Arthritis

1

Other: (specify)

1

Decubitus/Pressure Ulcer

1

Septic Emboli

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

_______________________

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

1

None

1

Unknown

1

Abscess/Boil

1

Current Smoker

1

HIV

1

Peptic Ulcer Disease

1

AIDS or CD4 count<200

1

CVA/Stroke

1

1

Peripheral Vascular Disease (PVD)

1

Chronic Liver Disease

1

Cystic Fibrosis

Influenza
(within 10 days of initial culture)

1

IVDU

Premature Birth

Chronic Pulmonary Disease

1

1

1

Chronic Renal Insufficiency

1

Dementia

Metastatic Solid Tumor

Solid Tumor (non metastatic)

1

1

1

1

Chronic Skin Breakdown

1

Diabetes

1

Myocardial Infarct

1

Other: (specify only for cases ≤ 12 months
of age) _____________________________

1

Congestive Heart Failure

1

Hematologic Malignancy

1

Obesity

1

Connective Tissue Disease

1

Hemiplegia/Paraplegia

1

Other Drug Use

Decubitus/Pressure Ulcer

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

1

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

Culture collected >3 calendar days after hospital admission.

1

Hospitalized within year before initial culture date.
Mo.

Day

Year

1

1

Unknown

Date
Surgery
1. __________________________________________ _____ /_____ / _____
2. __________________________________________ _____ /_____ / _____
3. __________________________________________ _____ /_____ / _____

Date of discharge
If YES:

None

If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the initial culture:

If YES:
1

1

Surgery within year before initial culture date.

4. __________________________________________ _____ /_____ / _____

Unknown
1

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

1

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

1

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

1

Admitted to a LTACH within year
before initial culture date.

1

Central vascular catheter in place at
any time in the 2 calendar days prior
to initial culture.

18. SUPPLEMENTAL PNEUMONIA QUESTIONS. Please complete if the patient was determined to have pneumonia per question 15a (Timeframe of interest: within +/- 3 calendar
days of initial culture).
Not done
a. Chest Radiology Results (Check all that apply) 1
b. 1
MRSA positive non-sterile respiratory specimens
Type

CT

X-Ray

1

Bronchopneumonia/pneumonia

1

Consolidation

1

Air space density/opacity

1

No evidence of pneumonia

1

Cavitation

1

None listed

1

Cannot rule out pneumonia

1

Not available

1

New or changed infiltrates

1

1

Pleural effusion

Other: (specify)
______________________

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

Yes

2

9

Unknown

No

20. CRF status:
1
2
3
4

Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests

21. Does this case have
recurrent MRSA
disease?
1

Yes

2

9

Unknown

No

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

22. Date reported to EIP site:
Mo.

Day

23. Initials of
S.O:

Year

24 COMMENTS:_____________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
CDC 52.15B Rev. 1-2012

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